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Adrenal Ganglioneuromas in Children with Multiple Endocrine Neoplasia Type 2: A Report of Two Cases

Department of Pediatrics, Section of Endocrinology and Diabetology, Indiana University School of Medicine, Riley Hospital for Children (M.S.L., E.C.W.), Indianapolis, Indiana 46202; Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas M. D. Anderson Cancer Center (S.G.W.), Houston, Texas 77030; and Department of Surgical Endocrinology and Oncology, Washington University School of Medicine (J.F.M.), St. Louis, Missouri 63110

Address all correspondence and requests for reprints to: Dr. Emily C. Walvoord, 702 Barnhill Drive, Room 5960, Indianapolis, Indiana 46202. E-mail: ewalvoor{at}iupui.edu.

Context: Pheochromocytomas of the adrenal gland are a common component of the multiple endocrine neoplasia type 2 (MEN2) syndromes. However, pure adrenal ganglioneuromas, an extremely rare pediatric tumor of neural crest origin composed of mature ganglion cells, have never been reported in association with MEN2 in humans. MEN2A is comprised of medullary thyroid carcinoma (MTC), pheochromocytoma, and parathyroid hyperplasia. MEN2B is characterized by MTC, pheochromocytoma, neural abnormalities of the gastrointestinal tract, and mucosal neuromas.

Evidence Acquisition: We report two pediatric patients, one with MEN2A and one with MEN2B, who developed isolated adrenal ganglioneuromas without evidence of pheochromocytomas.

Evidence Synthesis: MEN2A and MEN2B are caused by activating mutations in the RET proto-oncogene, which encodes a tyrosine kinase receptor essential for signal transduction in neural crest-derived tissues, including the peripheral and enteric nervous systems, C cells of the thyroid gland, and chromaffin cells of the adrenal gland. Both pheochromocytomas and ganglioneuromas originate from neural crest cells. Interestingly, two mouse models of MEN2B exhibit adrenal ganglioneuroma formation. One mouse model develops only ganglioneuromas (but not pheochromocytomas) and expresses only one of the oncogenic RET isoforms. The other mouse model, created by site-directed mutagenesis to simulate the most common human mutation, develops both ganglioneuromas and pheochromocytomas.

Conclusions: Given our two cases, our current understanding of the mouse models, and the common origins of all these tumor cell types, we recommend including ganglioneuromas as a rare, but not unexpected, component of the MEN2 syndromes.