Quarterly Journal-vf-Medicine, New Series 67, No. 252, pp.

299-308, April 1988

Family Screening in Medullary Thyroid

Carcinoma Presenting Without a Family History
B. A. J. PONDER*!, N. FINER*, R. COFFEY§, C. L. HARMER*,
M. MAISEYt, M. G. ORMERODt, M. E. PEMBREY§, M. A. PONDERf,
P. ROSSWICKU, S. SHALET** and members of the Cancer Research Campaign
Medullary Thyroid Group

From the * Royal Marsden Hospital, Downs Road, Sutton, Surrey, ^Institute of
Cancer Research, Clifton Avenue, Sutton, Surrey, $Guy's Hospital, London SE1,
^Institute of Child Health, Guilford Street, London WC1, fSf George's Hospital,
Blackshaw Road, London SW17 OQT, and * * Christie Hospital and Holt Radium
Institute, Wilmslow Road, Manchester M20 9BX

Accepted 20 November 1987

SUMMARY
Systematic screening of the families of a series of 39 patients with apparently sporadic medullary
thyroid carcinoma detected seven new cases in four families. A negative family history in a
patient presenting with medullary thyroid carcinoma is not reliable in excluding familial disease,
and family screening should be considered for new patients with medullary thyroid carcinoma.

INTRODUCTION
Medullary thyroid carcinoma arises from the calcitonin-secreting ' C cells of the thyroid. There
are about 80 new cases per year in the United Kingdom'. About 75 per cent of cases are sporadic,
but the remaining 25 per cent are familial [1]. In these families, the condition is inherited as an
autosomal dominant trait with incomplete penetrance in association with phaeochromocytoma
and hyperplasia or adenomas of the parathyroid: a combination known as multiple endocrine
neoplasia, type 2a (MEN 2a). Of those who present clinically 30 to 50 percent die of the disease,
and many more suffer significant morbidity [1]. By contrast, early diagnosis by screening of
family members allows thyroidectomy or adrenalectomy which is likely to be curative [2-7].
The decision to screen for MEN 2 in the family of a patient presenting with medullary thyroid
carcinoma is usually based on family history. This assumes that gene carriers will almost always
be recognizable because they will have developed overt disease by the age of 50 or 60, and so a
negative family history can rule out the inherited form of the disease with a high degree of
certainty. We have shown previously [8] that this assumption is incorrect, and that even by the
age of 70 approximately 40 per cent of gene carriers will not have presented with symptoms.
Family history will therefore not be reliable, because some patients with MEN 2 will have
apparently unaffected parents, and may therefore present as sporadic disease. We now show,
by systematic screening of first-degree relatives, that approximately 10 per cent of apparently
sporadic cases have familial disease. We suggest that family history must be used critically in
© Oxford University Press 1988
300 B. A. J. Ponder and others
decisions about screening for MEN 2, and that screening of the families of patients of
apparently sporadic medullary thyroid carcinoma should be undertaken more widely.

SUBJECTS AND METHODS

Index patients
The study is based on 48 consecutive patients with histologically proven medullary thyroid
carcinoma who attended one of four participating hospitals between 1975 and 1985, and in
whom the family history elicited at first attendance at the hospital did not suggest MEN 2. The
only exclusions were patients from outside the United Kingdom.

The Cancer Research Campaign Medullary Thyroid Register

In July 1986, the register contained clinical and family information on members of 47 MEN 2a
families. The register has ethical committee approval and has been notified under the Data
Protection Act.

Family screening
Systematic screening started in 1980. It was extended retrospectively to the families (all first-
degree relatives aged eight years or older) of 28 patients already diagnosed before 1980, and
prospectively to the families of 20 new cases diagnosed after that time. During the retrospective
identification of index cases it was found that the families of three had already been screened,
presumably because the index cases had presented young, even though none had a family
history suggestive of MEN 2. The data from these families have been included in the analysis.
They are, however, identified separately in the Results section.
The purpose of screening and of the study were explained to the index cases by the clinicians
responsible for their care. If they agreed to participate, the index cases were visited at home by a
family interviewer who explained the screening again, and obtained a more extensive family
history [7]. Permission was obtained to approach first-degree relatives. Where there was doubt
whether the approach would be welcome, the approach was made initially through the general
practitioner of the relative concerned. All general practitioners were contacted before screen-
ing took place. Family members not living with the index patient were contacted by letter and
the majority were visited at home before an appointment was made for screening.
Screening was a one-hour outpatient procedure. It consisted of a brief history and physical
examination, a pentagastrin stimulation test [3] for calcitonin using a dose of pentagastrin
(Ayerst) 0.5 /<g/kg body weight IV in 15 s (individuals aged eight to 65 years; over 65 years,
basal calcitonin only), and a 24-h urine collection for VMA, metanephrines and nor-
metanephrines. The same clinician directed the screening of each family. In the three families
screened before the start of the main study, the stimulus was alcohol [9] (50 ml whisky by
mouth) in two, and calcium (2 mg Ca++/kg IV as calcium gluconate in 1 min) [10] in one.
Blood samples (10 ml) were collected in heparin tubes chilled in ice, and the plasma was
separated within 30 min and stored in three aliquots at -70°C until assay. All samples were
assayed by the Supra-regional assay service at the Hammersmith Hospital [11], which at the
time of the study used a radioimmunoassay based on a rabbit anticalcitonin antibody on
unextracted samples. Duplicates were assayed either at Guy's Hospital using a Calcitonin II
RIA Test kit (Immuno Nuclear Corp, Minnesota, U.S.A.) modified to increase sensitivity and
using WHO standards 70/234 (Dr Gail Mashiter), or by Professor K. Gautvik (Oslo) [12].
 Medullary Thyroid Carcinoma 301
All pentagastrin stimulation tests at the Royal Marsden and Guy's hospitals were performed
by one of two clinicians. Evident side-effects from the pentagastrin injection were recorded,
and at the end of the test the subject was asked to rate whether the test had been not at all,
mildly, moderately or extremely unpleasant.

Histology review
Histopathological review, including immunocytochemical stains for calcitonin, was undertaken
on all cases where thyroid tissue was available.

RESULTS
COMPLETENESS OF SCREENING
Of the 48 index cases, three had no living relatives. The remaining 45 families were offered
screening, and five refused. Two refusals were in families where the original patient had
recently died, and three were because the index cases were elderly (67, 69, 81 years); two of
these had only one living relative under 75 years old. In one, family screening is still in progress.
In the 39 families in which initial screening is complete, 141 of 173 eligible first-degree relatives
were offered screening, and all but seven of these (95 per cent) accepted. The remaining 32 have
not so far been offered screening either because they have lost touch, because they live at a
distance, or because they are old and infirm and their family doctors have recommended
against.

AGE DISTRIBUTION OF INDEX CASES AND FAMILY MEMBERS

Figure 1 shows that by the criterion of age at diagnosis, the index cases in the screening series
were a typical sample of patients with medullary thyroid carcinoma. Twenty-eight parents
(median age 70 years), 78 siblings (median 43 years) and 67 children (median 20 years) were
eligible for screening. In only eight of the 39 families were both parents alive.

RESULTS OF SCREENING
The results are summarized in Table 1 and Figs. 1 and 2. Seven individuals in four families were

TABLE 1. Summary of screening results

No. of Proven Unproven Probable false positive
individuals positive ? positive Basal CT Basal CT
(and families) rf**"fl ^ i/rr/1
screened >0.5^g/l
Main study
123 4* 2 7 6
(36 families) (3 families) (1 additional
family)
Families screened before study started:
Whisky 7 0 0 2* 0
stimulus (2 families)
Ca++ 3 2* 0 0 0
stimulus (1 family) (1 family)

* Underwent thyroidectomy.
 302 B. A. J. Ponder and others
No.
individuals
16 n

12- screening series

(48)

F* * • * « ? »F *

16 -i

12-

0 10 20 30 40 50 60 70 80 90
age
FIG. 1. Age distribution of the index patients. The histograms show the age at diagnosis of the index
patients in the screening series, compared with patients with medullary thyroid carcinoma taken
from the Thames and Liverpool Cancer Registries. ' P indicates the four index cases who were found
to have familial disease, and '?' the further case in whom familial disease is suspected: '*' indicates
the ages at diagnosis of the apparently sporadic index cases in the CRC Medullary Thyroid Group
Register, whose disease has been shown to be familial by family screening.

found to have medullary thyroid carcinoma on first screening. In one of these families, a
suggestive family history was elicited by our family interviewer, although not by three clinicians
whom the index case had seen before referral. Four of the seven individuals detected on first
screening had elevated levels of basal calcitonin (without stimulation). The diagnosis has been
confirmed at thyroidectomy in all but one of the seven individuals, a 69-year-old woman (Fig.
2(a)) who refuses surgery, but who has a markedly elevated basal calcitonin, with a greater than
two-fold increment on stimulation and ultrasound and CT scan evidence of a 1.5 cm nodule in
the right lobe of the thyroid. One member of the newly-diagnosed families so far has proven
phaeochromocytoma. Four of 39 apparently sporadic index cases (10.3 per cent) have thus been
proved to be familial on initial screening. One further individual in another family has consis-
tently abnormal screening results, but has not yet undergone surgery.

Equivocal and probable false positive results

Equivocal or probable false positive results were obtained at the first screening of individuals in
 Medullary Thyroid Carcinoma 303

(a) ,69 B (b)

D <§>' O

• 35 O ®53B O

14 12 • O #28

(c) (d)
o 66jZf

1 I I
@57 S
<Du • O 0 641 (O)
, ifT
_l

• 22 36B<§> O D
25 ^1B

n
FIG. 2. Pedigrees of the four families in which medullary thyroid carcinoma was found to be familial
by screening. Key: /'=index case; 69B=abnormal calcitonin aged 69; 12s=abnormal calcitonin on
stimulation only, aged 12; ®=confirmed medullary thyroid carcinoma found by screening;
©=papillary thyroid carcinoma (see text); (O)=lost contact;i2(lZf=died (age). Both affected
individuals in family (b) also had phaeochromocytoma.

several families. They are summarized in Table 2. With one exception, these results were
excluded as indicating medullary thyroid carcinoma or C-cell hyperplasia by one or more of the
following criteria: (i) there was a less than two-fold increment of calcitonin level after pen-
tagastrin stimulation, (ii) duplicate aliquots were consistently normal when assayed in another
assay, or (iii) duplicate aliquots and repeat tests were consistently normal when assayed in the
original assay. Two false positive results which led to thyroidectomy were, however, obtained
in one of the families screened by whisky stimulation before the start of the main study. The 14-
and 19-year old sons of the index case had elevated basal levels of calcitonin (0.57 and 0.52//g/l;
normal <0.08,«g/l) which in one case showed a two-fold rise after whisky, and in the other a less
than two-fold rise. The values were consistent in two separate stimulation tests but were not
checked in another assay. The thyroidectomy specimens have been systematically sectioned
and stained by immunohistochemistry for calcitonin with no evidence of medullary thyroid
carcinoma or C-cell hyperplasia [13,14].

The age at diagnosis of medullary thyroid carcinoma which proved to be familial

Figure 1 shows the distribution of ages at diagnosis of the index cases with familial medullary
thyroid carcinoma from the screening series, and from other families in the CRC Register who
were found to have familial disease only by family screening, compared with the distribution of
age at diagnosis for all medullary thyroid carcinoma both sporadic and familial. It is clear that
age at diagnosis is not a reliable discriminator between sporadic and familial disease.
304 B. A. J. Ponder and others
TABLE 2. Equivocal and possible false positive screening results
No. of Stimulus Increment Assay of duplicate aliquots Repeat test
individuals after Original Another in original
stimulus assay
assay assay
Basal CT >0.5 /ig/1
2 Pentagastrin >2x Not done Normal Normal
2 Pentagastrin <2x Not done Normal Normal
3 Pentagastrin Not assayed All Normal Two normal
because normal one not done
basal >0.5 Mg/\
1 Ethanol 2x Not done Not done Same
1 Ethanol <2x Not done Not done Same
Basal CT 0 .15-0.5 /<g/l
6 Pentagastrin Not above Same Normal Same
0.5 Mg/\
Note that none of these ostensibly abnormal results meets both the criteria of (i) a two-fold
increment after stimulation, and (ii) reproducibility in another radioimmunoassay using a different
antibody.

C-CELL HYPERPLASIA
C-cell hyperplasia may be an indicator of the familial form of medullary thyroid carcinoma [13-
15]. All the available thyroid material from the index cases was therefore reviewed, with
immunocytochemical staining for calcitonin, by two experienced pathologists who were not
aware of the history or screening results, in an attempt to examine the concordance between
C-cell hyperplasia and the results of family screening. Clear results could not be obtained, due
largely to inadequate sampling of the residual thyroid, particularly the contralateral lobe.

THE ACCEPTABILITY OF SCREENING

The subjective responses of 83 individuals were recorded immediately after their first pen-
tagastrin stimulation test. Forty-two reported the test as not unpleasant or slightly unpleasant,
33 as moderately unpleasant, and eight (10 per cent) as very or extremely unpleasant. The main
effects were flushing, epigastric discomfort and nausea, and in a few cases, tingling in the
extremities, lasting about one minute. Children tolerated the test as well as adults (and in MEN
2 families outside this series where both stimuli have been used, it is our impression that
children prefer the pentagastrin stimulus to ethanol, contrary to some other reports [9]).
Nobody has refused to have the test a second time if it has been recommended, nor has any
parent refused for their child. The only major untoward effect was seen in a 44-year-old man
who became unrousable after the pentagastrin injection, which was given when he was lying
down. He recovered fully within two minutes. Pulse and blood pressure were not abnormal,
and no explanation for the reaction could be found.
We are not aware that any of the 48 families in this series have been distressed by our
approach. On the contrary, many have expressed strong support for the screening programme.

DISCUSSION
Our finding that four of 39 unselected and apparently sporadic cases of medullary thyroid
carcinoma had in fact familial disease, is consistent with the experience of other groups [15-17].
 Medullary Thyroid Carcinoma 305
Combined, these studies have identified a total of 20 familial index cases out of 139 who
presented with apparently sporadic disease (14.4 per cent).
Only 5 to 10 per cent of patients who present with medullary thyroid carcinoma give a family
history, and so are identified as having familial disease at presentation (refs. 1, 18-20; CRC
Medullary Thyroid Group, unpublished data). Since 10 to 15 per cent of cases are found to be
familial on screening, this leads to the rather surprising conclusion that the majority of cases of
familial medullary thyroid carcinoma will not be detected by family history. This is because of
the relatively low clinical penetrance of MEN 2a: data from the CRC Medullary Thyroid Group
register indicate that only 40 per cent of gene carriers in known families will have presented
clinically by the age of 50 [8]. Many familial cases may thus have inherited the disease from a
parent, who although elderly, has not himself manifested clinical symptoms. A contributing
factor, however, is the poor quality of most family histories which are taken as routine, as in one
of our patients and, for example, one of the three familial cases discovered in the Danish
screening series [17].
It might be argued that the families in which the gene for medullary thyroid carcinoma has
low penetrance, which will form the majority of those detected only by screening, have a less
aggressive form of the disease. In that case, screening of the families of apparently sporadic
cases might not be necessary. There is no evidence to support this argument. One of the six
family members picked up by our screening has already died of the disease aged 38 and at least
one member of each of the four families identified by screening has metastatic disease.
Unpublished data from the CRC Medullary Thyroid Group register show that in 17 other
families where screening was not done on presentation of the index case, 13 of 25 individuals
who subsequently presented with symptoms are now dead. In contrast, there is already
evidence that by regular screening of family members at risk, deaths from medullary thyroid
carcinoma can be eliminated [5, 6]. This argues strongly that apparently isolated familial
disease cannot safely be regarded as benign, and that screening is worthwhile.
In this study, screening was tolerated well and acceptance was high. A major factor was
probably the time which we were able to spend on explanation, including home visits, and the
consistent care of each family by the same clinician and family interviewer.
Thirteen out of 123 initial screening tests in the pentagastrin-stimulated series (10.6 per cent)
gave apparently false positive results. Two other apparently false-positive responses to whisky
stimulation in a family screened before the study began, led to removal of thyroids which
appeared normal. In a population at relatively low risk (seven of 133 so far found to have
medullary thyroid carcinoma), this is an unacceptably high false positive rate. Most of these
false positive results presumably arose from spurious cross reaction or interference by subs-
tances in plasma with the antibody used in the calcitonin radioimmunoassay [21], which was the
National Health Service assay for the United Kingdom. Our experience suggests that the great
majority of false positive results can be detected if the following criteria are strictly applied: (1)
there must be at least a two-fold increase of the basal calcitonin level after stimulation,
reproducible on successive stimulation tests, and (2) concordant results must be obtained when
stored duplicate samples are assayed in a second laboratory which uses a different antibody for
the calcitonin radioimmunoassay. Relatives of patients with sporadic medullary thyroid carcin-
oma have a lower genetic probability of having medullary thyroid carcinoma than the pro-
bability of 50 per cent in a known MEN 2 family. The risk of false positive results is
correspondingly higher. In our opinion, unless there is clinically evident disease, screening tests
should only be the basis for thyroidectomy in 'sporadic' families if these criteria are fulfilled.
Compared with screening in the general population, screening for medullary thyroid carcin-
oma is carried out on a relatively high-risk group, defined by the fact that one family member
has had the disease. It is therefore likely to be more efficient than population screening for
306 B. A. J. Ponder and others
cancers like cervix and breast. The costs of the initial screening of the families in the present
series, the costs (discounted at 5 per cent p.a.) of follow-up, and the costs of treatment, total
about £33 000, or £4750 per individual detected (1986 prices). Review of the case notes of the six
patients with MEN 2a who presented at the Royal Marsden Hospital between 1975 and 1980
suggests that the additional costs of treating their more advanced disease (similarly discounted,
and excluding routine outpatient follow up and up to one month inpatient stay for terminal
illness) averaged £4300 per patient. Thus, on the worst assumption that continued screening of
these families will detect no further cases of MEN 2, the net cost of screening, unselectively
applied to the family of every new case with medullary thyroid carcinoma, is of the order of £500
per patient detected. Taking the average age of clinical presentation of familial medullary
thyroid carcinoma to be 50 years [7], and assuming that one-third of these patients will die of the
disease within 10 to 15 years, this is equivalent to about £80 per year of life gained. The logistic
burden would be an increase in about 50 per cent in the current load of the National Health
Service supraregional assay service for calcitonin estimations, and about four new families to be
screened each year at each of the 17 clinical centres throughout the United Kingdom which are
represented in the Cancer Research Campaign Medullary Thyroid Group.
The foregoing discussion was based on the premise of indiscriminate screening of the family
of every new patient with medullary thyroid carcinoma. Even this extreme policy would be
logistically and economically feasible. In practice, of course, some selection of families is
possible. Although advanced age at diagnosis and apparently unaffected parents are not
reliable indicators of sporadic disease, they do provide some guidance. The ages of the
unaffected parents and other first-degree relatives of an apparently sporadic case can be used to
calculate a numerical probability that the individual has familial disease, based on the age at
onset distribution for clinical disease in MEN 2 gene carriers [8]. This probability can be used to
select families for screening. The age at onset data and the methods for estimation of familial
risk will be reported separately.
In principle, this estimate could be further refined by taking into account the presence or
absence of C-cell hyperplasia in the thyroid of the index case. Our own experience and that of
others [23, 24] suggests that this method also is not completely reliable, and that both false
positives and negatives will occur. A major problem is that the diagnosis of medullary thyroid
carcinoma in a sporadic case is often not suspected until after thyroidectomy, and the thyroid is
therefore not processed to allow C-cell hyperplasia to be assessed. Until surgeons and patholo-
gists process thyroids removed for tumour routinely in such a way that adequate tissue is
available for sampling the whole C-cell area, including the contralateral lobe, the predictive
value of a report of C-cell hyperplasia in an apparently sporadic case will not be known. The
reliance which should be placed on a report of the presence or absence of C-cell hyperplasia in
the incomplete material which is currently available from the majority of cases is not clear, but
may not be very great.
The genetic locus for MEN 2a has recently been mapped to chromosome 10 [25, 26] and
linked DN A markers for genetic counselling may soon be available. These cannot, however, be
used to distinguish the familial from the sporadic case for which identification of the defective
gene itself will be needed. The recognition of familial cases among those with apparently
sporadic disease is therefore likely to remain an important problem for some time to come.

ACKNOWLEDGEMENTS
Members of the CRC Medullary Thyroid Group and others who contributed data to the CRC
MTC Register are: R. Auden, J. J. Body, J. J. Brown, C. W. Burke, D. Chang, A. Ciavarelli,
N. Dudley, M. B. Duthie, O. Edwards, K. Emmertsen, J. R. Farndon, N. Finer, H. Gray,
 Medullary Thyroid Carcinoma 307
D. N. W. Griffith, J. F. Hale, K. Hainan, H. Hansen, C. Harmer, D. A. Heath, D. Ken, J. L.
Lindsay, J. Lynn, M. Maisey, J. Monson, D. Parker, B. A. J. Ponder, I. Ramsay, P. Rosswick,
S. Shalet, K. Sikora, J. F. B. Smith, P. Sonksen, F. T. Stathopoulos, J. Stevenson, D. Sykes,
M. Telenius-Berg, W. Vant Hoff, M. Weissel, J. Went, E. D. Williams, A. M. Zalin.
The CRC Medullary Thyroid Group is supported by the Cancer Research Campaign. R.C. is
funded by the Medical Research Council. We thank Drs J. P. Sloane and R. Poston for
pathology review, Professor E. D. Williams for discussions on C-cell hyperplasia, and Mr D. F.
Easton for valuable comments on the manuscript.

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