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Hum Pathol. 2015 Aug;46(8):1121-8. doi: 10.1016/j.humpath.2015.04.011. Epub 2015 May 6.

C-Cell Neoplasia in Asymptomatic Carriers of RET Mutation in Extracellular Cysteine-Rich and Intracellular Tyrosine Kinase Domain.

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Department of Pathology, Yale School of Medicine, New Haven, CT 06520.
Department of Surgery, Yale School of Medicine, New Haven, CT 06520.
Department of Neurology, Hartford Hospital, Hartford, CT 06102.
Department of Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH 43205.
Department of Surgery, Yale School of Medicine, New Haven, CT 06520; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC 27710.
Department of Pediatrics, University of Florida, Gainesville, FL 32610.
Department of Pathology, Yale School of Medicine, New Haven, CT 06520. Electronic address:


Germline mutations in RET proto-oncogene associated with multiple endocrine neoplasia type 2 (MEN2) may affect codons for the extracellular cysteine-rich (ECR) or the intracellular tyrosine kinase (ITK) domain of the transmembrane receptor tyrosine kinase protein. We compared C-cell pathology in asymptomatic carriers of RET mutation affecting the 2 domains. Twenty-two asymptomatic carriers (median age, 9.5 years), 10 with mutations in the ECR (codons 634, 611, 618, and 620) and 12 with mutations in the ITK domain (codons 804, 790, 891, and 918), underwent total thyroidectomy. C-cell hyperplasia was identified in 16 (73%), was multifocal and/or bilateral in 11, and was associated with medullary thyroid carcinoma (MTC) in 10 thyroids. When comparing the ECR and ITK groups in 21 carriers from MEN2A/familial MTC families, C-cell hyperplasia was more frequent in the former (90% versus 55%), as was multifocality (70% versus 27%) and MTC (60% versus 27%), despite the significantly younger median age in the former group (5 versus 23 years, P = .04). One asymptomatic carrier had de novo codon 918 mutation (MEN2B) and showed bilateral microcarcinoma with lymph node metastasis at presentation and progressive disease on follow-up. In conclusion, asymptomatic carriers of high-risk RET mutations affecting the ECR were significantly younger and frequently showed C-cell neoplasia, multifocality, and MTC when compared with mutations affecting the ITK domain in the MEN2A/familial MTC families. The presence of C-cell disease, its severity, and aggressiveness correlated with the mutated codon and with increasing age.


C-cell hyperplasia; MEN2; Medullary thyroid carcinoma; Microcarcinoma; Prophylactic thyroidectomy; RET mutation

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