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Interest of Routine Measurement of Serum Calcitonin: Study of Thyroidectomized Patients^a

Hiroyuki Koshiyama, MD Hyogo Prefectural Amagasaki Hospital, Hyogo, Japan

Hideo Takahashi, MD

Public Toyooka Hospital, Hyogo, Japan

Kennichi Kakudo, MD

Wakayama Medical College, Wakayama, Japan

Niccoli et al. (1) concluded that basal calcitonin measurement should become a routine aspect of the diagnostic evaluation of nodular thyroid disease, because it could detect undiagnosed medullary thyroid carcinoma. An interesting point, not commented upon by the authors, was suggested in the accompanying editorial by Horvit and Gagel (2): some patients with elevated calcitonin levels were found to have differentiated thyroid carcinoma, which might be explained by C cell hyperplasia adjacent to a follicular or papillary carcinoma. We would like to add another unexpected yield of serum calcitonin measurement: the possibility of concurrent medullary and papillary thyroid carcinomas.

We here report a case of 59-yr-old woman presenting with right thyroid nodule. She had no family history of thyroid diseases. Both serum calcitonin and carcinoembryonic antigen (CEA) levels were increased (2000 pg/mL and 14.3 ng/mL, respectively), whereas thyroglobulin was normal (11.5 ng/mL). Further examinations, including fine needle aspiration and ¹³¹I-meta-iodobenzylguanidine scintigraphy, indicated a diagnosis of medullary thyroid carcinoma, and total thyroidectomy with bilateral central and right modified neck dissection was performed. Both serum calcitonin and CEA levels decreased to normal range after the operation. Pathological examinations of the resected specimen showed several foci of follicles with ground glass-like nucleus, which were surrounded by medullary carcinoma tissue. Both intrathyroidal lesion and metastatic lymph node tissue showed positive staining for both thyroglobulin and calcitonin. Therefore the diagnosis of concurrent medullary and papillary carcinomas was made.

Coexistence of medullary and papillary carcinomas has been, although rarely, reported in the literature (3, 4, 5, 6). Actually, two cases with both medullary and papillary carcinomas were described in a study by Niccoli et al. (1). It is controversial whether those cases should be regarded as concurrent or collision tumor of two distinct neoplasms derived from different origin (3, 5, 6) or true mixed carcinomas probably arising from a common stem cell (4). When serum calcitonin level is adopted as a screening for medullary thyroid carcinoma, it should be kept in mind that this unusual association may be present.

Footnotes

^a Received April 11, 1997. Address all correspondence to: Dr. Hiroaki Sato, Department of Otolaryngology, Hyogo Prefectural Amagasaki Hospital, 1–1-1 Higashi-Damitosu-cho, Amagasaki, Hyogo 660, Japan.

References

1. Niccoli P, Wion-Barbot N, Caron P, et al. 1997 Interest of routine measurement of serum calcitonin: study in a large series of thyroidectomized patients. J Clin Endocrinol Metab. 82:338- 341.[Abstract/Free Full Text]
2. Horvit PK, Gagel RF. 1997 Editorial: the goitrous patient with an elevated serum calcitonin - what to do? J Clin Endocrinol Metab. 82:335–337.[Free Full Text]
3. Ishida T, Kawai T, Iino Y, Shinozaki K, Oowada S, Izuo M. 1985 Concurrent medullary carcinoma adjacent to papillary carcinoma - a clinicopathological and electron microscopic study (in Japanese). Gan No Rinsho. 31:1814–1820.[Medline]
4. Lax SF, Beham A, Kronenberger-Schönecker D, Langsteger W, Denk H. 1994 Coexistence of papillary and medullary carcinoma of the thyroid gland - mixed or collision tumour? Clinicopathological analysis of three cases. Virchows Archiv. 424:441–447.[Medline]
5. Apel RL, Alpert LC, Rizzo A, LiVolsi VA, Asa SL. 1994 A metastasizing composite carcinoma of the thyroid with distinct medullary and papillary components. Arch Pathol Lab Med. 118:1143–1147.[Medline]
6. Pastolero GD, Coire CI, Asa SL. 1996 Concurrent medullary and papillary carcinomas of thyroid with lymph node metastases - a collision phenomenon. Am J Surg Pathol. 20:245–250.[CrossRef][Medline]

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