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Sophie Norenstedt1,7, Fredrik Granath2, Anders Ekbom2, Jonas Bergh3, Mats Lambe4, Jan Adolfsson5, Fredrik Warnberg6, Jan Zedenius1,7, Inga-Lena Nilsson1,71Department of Molecular Medicine and Surgery, 2Department of Medicine, 3Department of Oncology and Pathology, Karolinska Institutet and Cancer Center Radiumhemmet, Karolinska University Hospital, Stockholm; 4Regional Oncology Centre, Uppsala; 5Oncologic Center, Karolinska University Hospital and CLINTEC Department, Karolinska Institutet, Stockholm; 6Department of Surgery, Uppsala Academic Hospital, Uppsala University; 7Endocrine Surgery Unit, Karolinska University Hospital, Stockholm, SwedenBackground: Primary hyperparathyroidism (pHPT) is associated with an increased risk of developing breast cancer, but little is known about the underlying factors. The aim of this study was to compare women with a history of pHPT and a reference population in terms of standard factors predictive of prognosis and response to therapy for breast cancer.Methods: We analyzed data collected from the National Swedish Cancer Register and from two regional oncologic center registries. Seventy-one women with breast cancer and a history of parathyroid adenomectomy were compared with 338 matched controls with breast cancer only. Tumor size, stage, hormone receptor status, lymph node status, cause of death, and cumulative survival were analyzed.Results: The mean age was 69 ± 11 years (95% confidence interval [CI]: 68–70) in both groups and the mean time interval between the parathyroid surgery and breast cancer diagnosis was 91 ± 68 months (95% CI: 72–111). There were no differences between the two groups regarding size, stage, lymph node metastases, or survival, but none of the cases with a history of pHPT were found in Stage III or IV.Conclusion: In conclusion, factors predictive of prognosis and response to therapy in women with a history of pHPT and breast cancer are similar to those in breast cancer patients without pHPT.Keywords: breast cancer, primary hyperparathyroidism, prognostic factors

Background: Transection injury to the recurrent laryngeal nerve (RLN) has been associated with permanent vocal fold palsy, and treatment has been limited to voice therapy or local treatment of vocal folds. Microsurgical repair has been reported to induce a better function. The calcium channel antagonist nimodipine improves functional recovery after experimental nerve injury and also after cranial nerve injury in patients. This study aims to present voice outcome in patients who underwent repair of the RLN and received nimodipine during regeneration.Methods: From 2002–2016, 19 patients were admitted to our center with complete unilateral injury to the RLN and underwent microsurgical repair of the RLN. After nerve repair, patients received nimodipine for 2–3 months. Laryngoscopy was performed repeatedly up to 14 months postoperatively. The Voice Handicap Index (VHI) was administered, and patients’ maximum phonation time (MPT) was recorded during the follow-up.Results: All patients recovered well after surgery, and nimodipine was well tolerated with no dropouts. None of the patients suffered from atrophy of the vocal fold, and some patients even showed a small ab/adduction of the vocal fold on the repaired side with laryngoscopy. During long-term follow-up (>3 years), VHI and MPT normalized, indicating a nearly complete recovery from unilateral RLN injury.Conclusions: In this cohort study, we report the results of the first 19 consecutive cases at our center subjected to reconstruction of the RLN and adjuvant nimodipine treatment. The outcome of the current strategy is encouraging and should be considered after iatrogenic RLN transection injuries. [ABSTRACT FROM AUTHOR]

BACKGROUND Somatic mutation of the RET proto-oncogene is thought to correlate with poor prognosis in patients with medullary thyroid carcinoma (MTC); however, data in support of this hypothesis are derived from small patient cohorts with short duration of follow-up. OBJECTIVE To evaluate the prognostic value of somatic RET mutations in a large series of sporadic cases of MTC with long follow-up. DESIGN AND INTERVENTION This study enrolled Italian patients with sporadic MTC. Diagnosis was made on the basis of lack of germline RET mutations, no family history of MTC, and negative clinical and laboratory data for other endocrine neoplasms. All patients underwent total thyroidectomy and central neck dissection. Lymphadenectomy was also performed in cases in which lymphnode metastases were diagnosed before surgery. Diagnosis of MTC was confirmed by histologic examination of paraffin-embedded tumor tissue and by immunostaining for calcitonin and chromogranin. All patients underwent pentagastrin stimulation tests and neck ultrasound during follow-up. Patients with detectable basal or stimulated calcitonin levels underwent CT or MRI to evaluate metastatic disease. Genomic DNA was isolated from peripheral blood lymphocytes or tumor tissue. Mutations in exons 10, 11, 13, 14, 15, and 16 of RET were analyzed by the polymerase chain reaction and DNA sequencing. OUTCOME MEASURES The main outcome measures included the presidence of somatic RET mutations, clinical and pathologic features of MTC, surgical response, and survival rate. RESULTS The study population comprised 43 men and 57 women. The mean age at diagnosis was 49.6 years and the mean duration of follow-up was 10.2 years. Somatic RET mutations were detected in 43 patients, 23 of whom were women. A point mutation at codon 918 of exon 16 was detected in 34 of these patients (79%), which resulted in an amino acid substitution of threonine for methionine. In addition, point mutations at codon 634 of exon 11 were detected in 7 patients (16.2%), which resulted in the substitution of arginine, tryptophan or tyrosine for cysteine. Node metastases were present in 70.0% and 26.3% of patients with and without RET mutations, respectively. Node metastases were particularly common among patients with the codon 918 mutation (76.5%). When compared with patients without somatic RET mutations, patients with mutations were more likely to have large tumors (P= 0.03), node metastases (P<0.0001), distant metastases (P= <0.02), advanced tumor stage at diagnosis (P=0.004), and poor surgical outcomes (P= 0.002). In addition, the survival rate of patients with RET mutations was lower than that of patients without RET mutations (P = 0.006). Multivariate analysis demonstrated that poor prognosis independently correlated with the presence of RET mutations (odds ratio 0.2009, 95% CI 0.0590-0.6852; P=0.01) and advanced tumor stage at diagnosis (odds ratio 0.1574, 95% CI 0.0734-0.3377; P<0.0001). CONCLUSION Somatic RET mutations were associated with poor prognosis and reduced survival in patients with sporadic MTC. [ABSTRACT FROM AUTHOR]

Introduction: Epigenetic alterations of DNA methylation are known to be associated with the clinical presentation of midgut carcinoids. Aim{s): To assess global and gene-specific promoter methylation for selected previously implicated tumor suppressors or frequently deleted loci in relation to clinical and genetic characteristics, as well as mRNA levels of the corresponding genes. Materials and methods: In total, 41 tumors and six normal tissues were analyzed by Pyrosequencing for CpG methylation of RASSFIA, CTNNB1, HIC1, P14, P16, WIF1, APC, NKX2-3, CXCL14, SMAD2, SMAD4, CDH1, CDH3, LAMA1 and LINE1. Results: Hypermetylation > 10% was observed for WIF 1, RASSF 1A, CTNNB1, NKX2-3, CXCL14, CDH1, P16 and LAMA1. Among these RASSFIA was associated with female gender (p=0.003) and alterations of the SDHD locus (p=0.002), and CTNNB1 was associated with patient outcome (p=0.01). Global LINE1 methylation was reduced in 31/40 cases especially in female cases (p=0.002) and tumors with deletion of chromosome 18 (p=0.02). Hypermethylation was associated with reduced gene expression in 83% (25/30) for WIF1 and 76% (13/17) for CTNNB1, and CTNNB1 expression was significantly increased in metastatic samples (p=0.01). Conclusion: Global hypomethylation and promoter hypermethylation were frequently observed in midgut carcinoids. Alterations affecting the CTNNB 1 gene showed effects on patient outcome. [ABSTRACT FROM AUTHOR]

Introduction: Clear cell renal cell carcinoma (ccRCC), the most common type of kidney cancer in adults, presents significant challenges owing to its resistance to conventional therapies. Standard treatment primarily revolves around surgical methods, particularly nephrectomy, which is critical for managing localized diseases. Despite recent advancements, the metastatic potential of ccRCC necessitates ongoing vigilance in postoperative monitoring to manage and detect disease recurrence. Recent shifts in treatment paradigms, especially with the integration of molecular patterns in ccRCC, have enabled the development of targeted therapies. Immune checkpoint and tyrosine kinase inhibitors (TKIs) have become central to managing metastatic ccRCC, offering new hope through improved survival outcomes. Recent studies have corroborated this by demonstrating the benefits of combining these therapies., Case Presentation: This report discusses a case study of a patient with high-grade ccRCC and thyroid metastases initially deemed non-resectable. The combination of immunotherapy and TKIs reduced tumor size, transforming the thyroid metastasis to a resectable state., Conclusion: This case highlights significant advancements in treatment approaches and the critical in the management of ccRCC, underscoring the necessity for continuous adaptation of clinical practices to incorporate new therapeutic developments., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

De-escalation of thyroid cancer treatment is crucial to prevent overtreatment of indolent disease, but it remains important to identify clinically aggressive cases. TERT promoter mutations are molecular events frequently associated with high-risk thyroid tumors with poor outcomes and may identify cases at risk of dissemination. In various international guidelines, small minimally invasive follicular thyroid carcinoma and oncocytic thyroid carcinoma (miFTC/miOTC) are classified as low-risk lesions and are not recommended adjuvant treatment. Our study aimed to explore the association between size-based risk assessment and TERT promoter mutations. Between 2019 and May 2024, 84 miFTCs/miOTCs diagnosed at our department underwent digital droplet PCR analysis targeting TERT promoter mutational hotspots C228T and C250T in clinical routine. TERT promoter mutations were found in 10 out of 84 cases (11.9%). Mutated cases were pT1 (n = 1), pT2 (n = 3), or pT3 (n = 6). Patients with mutated tumors were older compared to patients with wild-type tumors (median age of 71 years vs. 57 years, p = 0.041). There were no significant differences regarding patient sex, tumor size, Ki-67 labeling index, or the presence of distant metastases. Notably, 30% of mutations displayed variant allele frequencies < 10%, possibly suggesting subclonal events. To conclude, TERT promoter mutations in miFTCs and miOTCs were associated with higher patient age and were often suspected to be subclonal. However, they did not affect clinical outcomes, possibly due to short follow-up. Reflex testing for this genetic alteration in miFTCs and miOTCs could be justified regardless of tumor size, though the clinical benefit remains uncertain., (© 2024. The Author(s).)

Context: BRAFV600E and TERT promoter mutations in papillary thyroid carcinoma (PTC) have a synergistic effect on prognosis. This effect is believed to arise from MAPK activation triggered by BRAFV600E, leading to the upregulation of ETS transcription factors that bind to the mutant TERT promoter., Objective: To explore the role of ETS factors in relation to clinical features, BRAFV600E and TERT promoter mutations in PTC., Design: Transcriptomic data for 28 ETS factors were analyzed in the PTC cohort of The Cancer Genome Atlas (TCGA, n=399) and subsequently validated in a local cohort (n=93). In vitro experiments were performed to investigate the regulatory role in relation to BRAFV600E and TERT expression., Results: TCGA identified ETS1, ERG, FLI1, GABPA, EHF, ETV6 and SPDEF as differentially expressed genes between stages I+II and III+IV. In both cohorts, EHF was consistently associated with adverse clinical features, BRAFV600E and TERT promoter mutation/expression. Notably, in BRAFV600E mutated PTC, high EHF expression was associated with shorter disease-free survival. Cases harboring concurrent BRAFV600E, TERT promoter mutations and high EHF expression exhibited the shortest disease-free survival. In cells harboring concurrent BRAFV600E and TERT promoter mutation, over-expression of EHF significantly increased TERT expression while knockdown or pharmacological inhibition of BRAF significantly decreased both EHF and TERT expression. In addition, ChIP-qPCR analysis suggested a potential binding of EHF in TERT promoter mutant cells but not in TERT promoter wild-type cells., Conclusion: The ETS transcription factor EHF is associated with poor prognosis in PTC. This is potentially mediated by BRAF-induced upregulation of EHF which in turn increases TERT expression in TERT promoter mutated cells., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society.)

Pheochromocytoma (PCC) and abdominal paraganglioma (aPGL) (together abbreviated PPGL) frequently present with an underlying genetic event in a PPGL driver gene, and additional susceptibility genes are anticipated. Here, we re-analyzed whole-exome sequencing data for PCC patients and identified two patients with rare missense variants in the calcium voltage-gated channel subunit 1H gene (CACNA1H). CACNA1H variants were also found in the clinical setting in PCC patients using targeted sequencing and from analysis of The Cancer Genome Atlas database. In total, CACNA1H variants were found in six PCC cases. Three of these were constitutional, and two are known to have functional consequences on hormone production and gene expression in primary aldosteronism and aldosterone-producing adrenocortical adenoma. In general, PPGL exhibited reduced CACNA1H mRNA expression as compared to normal adrenal. Immunohistochemistry showed strong CACNA1H (CaV3.2) staining in adrenal medulla while PPGL typically had weak or negative staining. Reduced CACNA1H gene expression was especially pronounced in PCC compared to aPGL and in PPGL with cluster 2 kinase signaling phenotype. Furthermore, CACNA1H levels correlated with HIF1A and HIF2A. Moreover, TCGA data revealed a correlation between CACNA1H methylation density and gene expression. Expression of rCacna1h in PC12 cells induced differential protein expression profiles, determined by mass spectrometry, as well as a shift in the membrane potential where maximum calcium currents were observed, as determined by electrophysiology. The findings suggest the involvement of CACNA1H/CaV3.2 in pheochromocytoma development and establish a potential link between the etiology of adrenomedullary and adrenocortical tumor development.

Background: Mutations in micro-RNA (miRNA) regulators DICER1 and DGCR8 have recently been uncovered, revealing a potential novel mechanism driving thyroid tumor development. However, the true frequency of these hotspot mutations in follicular-patterned thyroid tumors (FTs) and their relation to established driver gene events remain elusive., Methods: A total of 440 FTs from 2 institutions were interrogated for DICER1, DGCR8, and RAS family hotspot mutations using Sanger sequencing. Whole-exome sequencing was also performed to identify additional driver gene aberrations in DICER1/DGCR8-mutant cases. Subsets of cases were further analyzed using miRNA expression profiling, and key dysregulated miRNAs were validated as markers of DICER1 mutations using quantitative RT-PCR analysis. The Cancer Genome Atlas (TCGA) database was also probed for DICER1/DGCR8 mutations and miRNA dysregulation., Results: Fourteen (3.2%) and 4 (1%) FTs harbored DICER1 and DGCR8 hotspot mutations, respectively, in the combined cohort, and no cases with normal tissue available were found to exhibit a constitutional variant. Two DGCR8-mutant cases also harbored oncogenic RAS mutations. Whole-exome sequencing analysis did not identify additional driver gene events in DICER1/DGCR8-positive cases. Comprehensive miRNA expression profiling revealed a unique pattern of dysregulated miRNAs in DICER1/DGCR8-mutant cases compared with wild-type lesions. Moreover, DICER1-mutant cases showed a remarkable reduction of 5' arm miRNAs, findings corroborated in the TCGA cohort., Conclusion: DICER1 and DGCR8 hotspot mutations are rare in unselected cohorts of FTs, and mutated cases exhibit a specific miRNA profile. Although DGCR8 mutations may coexist with established RAS gene alterations, FTs with DICER1 variants were devoid of other driver gene events., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society.)

Follicular thyroid carcinoma (FTC) is recognized by its ability to invade the tumor capsule and blood vessels, although the exact molecular signals orchestrating this phenotype remain elusive. In this study, the spatial transcriptional landscape of an FTC is detailed with comparisons between the invasive front and histologically indolent central core tumor areas. The Visium spatial gene expression platform allowed us to interrogate and visualize the whole transcriptome in 2D across formalin-fixated paraffin-embedded (FFPE) tissue sections. Four different 6 × 6 mm areas of an FTC were scrutinized, including regions with capsular and vascular invasion, capsule-near area without invasion, and a central core area of the tumor. Following successful capturing and sequencing, several expressional clusters were identified with regional variation. Most notably, invasive tumor cell clusters were significantly over-expressing genes associated with pathways interacting with the extracellular matrix (ECM) remodeling and epithelial-to-mesenchymal transition (EMT). Subsets of these genes (POSTN and DPYSL3) were additionally validated using immunohistochemistry in an independent cohort of follicular thyroid tumors showing a clear gradient pattern from the core to the periphery of the tumor. Moreover, the reconstruction of the evolutionary tree identified the invasive clones as late events in follicular thyroid tumorigenesis. To our knowledge, this is one of the first 2D global transcriptional mappings of FTC using this platform to date. Invasive FTC clones develop in a stepwise fashion and display significant dysregulation of genes associated with the ECM and EMT - thus highlighting important molecular crosstalk for further investigations., (© 2024. The Author(s).)

Anaplastic and poorly differentiated thyroid cancer (ATC, PDTC) are rare and highly aggressive tumors that historically have been associated with a short life expectancy and low chance of cure. Molecular pathology and the introduction of highly effective targeted drugs have revolutionized the possibilities of management of patients with ATC and PDTC, with BRAF and MEK inhibitors as the most prominent example. Here we provide updated recommendations regarding diagnostics and management, including primary surgical management and targeted therapies based on specific molecular pathological findings.