A 2017 SURVEY OF THE CLINICAL PRACTICE PATTERNS IN THE MANAGEMENT OF RELAPSING GRAVES DISEASE.

OBJECTIVE: Previous surveys from different world regions have demonstrated variations in the clinical management of Graves disease (GD). We aimed to investigate the clinical approach to GD relapse among endocrinologists. METHODS: Electronic questionnaires were e-mailed to all members of the Israeli Endocrine Society. Questionnaires included demographic data and different scenarios regarding treatment and follow-up of patients with GD relapse. RESULTS: The response rate was 49.4% (98/198). For a young male with GD relapse, 68% would restart antithyroid drug (ATD) (98% methimazole), while 32% would refer to radioactive iodine (RAI) treatment. Endocrinologists who treat >10 thyroid patients a week tended to choose ATDs over RAI ( P = .04). In the case of GD relapse with ophthalmopathy, 50% would continue ATDs, whereas 22.4% would recommend RAI treatment and 27.6% surgery. Most endocrinologists (56%) would continue ATDs for 12 to 24 months. Seventy-five percent would monitor complete blood count and liver function (39% for the first month and 36% for 6 months), and 44% would recommend a routine neck ultrasound. In a case of thyrotoxicosis due to a 3-cm hot nodule, most endocrinologists (70%) would refer to RAI ablation, 46.4% without and 23.7% with a previous fine-needle aspiration. No significant differences were found regarding gender, year of board certification, or work environment. CONCLUSION: Our survey demonstrates diverging patterns in the diagnosis and management of GD relapse that correlate well with previous surveys from other countries on GD-naïve patients and a less than optimal adherence to recently published clinical guidelines. ABBREVIATIONS: ATA = American Thyroid Association; ATD = antithyroid drug; CBC = complete blood count; GD = Graves disease; GO = Graves ophthalmopathy; LFT = liver function test; MMI = methimazole; PTU = propylthiouracil; RAI = radioactive iodine; TSI = thyroid-stimulating immunoglobulin.

Thyroid Disease in Pregnancy: A Clinical Survey among Endocrinologists, Gynecologists, and Obstetricians in Israel.

OBJECTIVES: To study the current practices in the management of subclinical hypothyroidism (SCH) and thyroid nodules during pregnancy of obstetricians/gynecologists (OB/GYNs) and endocrinologists in Israel. METHODS: An electronic questionnaire was sent by email to all members of the Israeli Endocrine Society and the Israel Society of Obstetrics and Gynecology. Questionnaires included demographic data and clinical scenarios with questions regarding the screening and management of pregnant women with SCH, hypothyroxinemia, and a palpable thyroid nodule. The questionnaire for OB/GYNs was slightly modified. RESULTS: We received 90 responses from endocrinologists and 42 responses from OB/GYNs. Among endocrinologists, 39% would repeat a thyroid-stimulating hormone (TSH) test of 2.9 mU/L with normal free thyroxine and treat with thyroxine if the second result was above 2.5 mU/L. Among OB/GYNs, 73% would manage a woman with SCH at the beginning of her pregnancy by themselves and only 22% would start thyroxine after a first TSH result above 2.5 mU/L. Concerning screening, 57% endocrinologists and 71% OB/GYNs recommended screening for thyroid dysfunction in every woman at the beginning of her pregnancy. Among endocrinologists, 54% would order an ultrasound for a palpable thyroid nodule and perform a fine needle aspiration only for suspicious lesions. CONCLUSIONS: The medical approach to thyroid disease in pregnant women remains a matter of controversy. Our results support the need for larger and prospective clinical studies.

LONG-TERM OUTCOMES AND PROGNOSTIC FACTORS IN PATIENTS WITH DIFFERENTIATED THYROID CANCER AND DISTANT METASTASES.

OBJECTIVE: Distant metastatic spread is the most frequent cause of thyroid cancer-related death. The objective of this study was to evaluate overall and disease-related survival of patients with differentiated thyroid cancer (DTC) and distant metastases (DM) attending a single medical center and to investigate variables predictive of better long-term outcomes. METHODS: The Rabin Medical Center Thyroid Cancer Registry was searched for patients with DM from DTC. RESULTS: The cohort included 138 patients (58.7% female) diagnosed at age 54.7 ± 19.5 years. Mean primary tumor size was 33.9 ± 26 mm. Most patients (57.7%) were stage T3/T4; 48.7% had extrathyroidal extension; 53.5% had lymph node metastases. Histopathology yielded papillary and follicular thyroid carcinoma in 66.7% and 13.8%, respectively, and intermediate/poorly differentiated carcinoma in 19.6%. All but 2 patients underwent total thyroidectomy, and 133/138 (96.4%) received radioactive iodine (RAI) therapy. DM were synchronous in 55.1%. The mean follow-up was 8.2 years from detection of metastases. The common sites of metastases were the lungs (85.6% of patients), bones (39.9%), brain (5.8%) and liver (3.6%). At last follow-up, resolution was documented in 24.6% of patients, improvement/stable disease in 31.6%, and structurally progressive disease in 43.4%. By the end of the study, 40.6% of patients died, 23.2% of DTC. Improved overall survival and disease progression were associated with younger age, lung-only DM, and metastatic RAI avidity. CONCLUSION: Patients with DTC and DM treated by standard-of-care approaches frequently achieve favorable long-term outcomes. Novel therapies might be necessary in only a minority of these patients, and the reported prognostic factors can aid in their identification. ABBREVIATIONS: CR = complete response; DM = distant metastases; DTC = differentiated thyroid cancer; ETE = extra-thyroidal extension; M0 = detected during follow-up; M1 = detected at diagnosis; MSKCC = Memorial Sloan Kettering Cancer Center; NED = no evidence of disease; OS = overall survival; PFS = progression free survival; PTC = papillary thyroid cancer; RAI = radioactive iodine; Tg = thyroglobulin.

Clinical course and outcome of nonfunctioning pituitary adenomas in the elderly compared with younger age groups.

OBJECTIVE: Nonfunctioning pituitary adenomas (NFPAs) are the most common type of pituitary adenomas diagnosed in older patients. However, there are insufficient data regarding the clinical course, risk of regrowth, and long-term prognosis in elderly versus younger patients. METHODS: This retrospective cohort study observed 105 adult patients with NFPAs diagnosed between 1995 and 2012. Patients were stratified into 3 age groups: 18 to 44 years (29 patients), 45 to 64 years (38 patients), and 65 years and over (38 patients). The impact of age on presenting symptoms, disease course, and outcome was analyzed. RESULTS: Adenoma size was larger in patients <45 years (mean, 2.9 ± 1.2 cm) compared to patients aged 45 to 64 years and those ≥65 years old (2.3 ± 0.9 and 2.5 ± 0.8 cm, respectively; P = .05), with transsphenoidal surgery being the treatment of choice in all 3 groups (83, 92, and 84%, not significant). After a mean follow-up of 6 years, there were higher recovery rates from hypopituitarism in patients <45 years old (58% vs. 27% and 24%; P = .04). Visual fields improved in most affected patients in each group following surgery (74, 94, and 86%), with a trend toward more full normalization in the youngest age group (58% vs. 44% and 41%; P = .09). There were no significant differences in the risk of remnant growth (29 to 39%), rates of radiation therapy, or need for repeated surgeries. There was no disease-related mortality. CONCLUSION: Elderly patients with NFPA have lower rates of recovery from hypopituitarism after treatment compared to younger patients, but the rates of regrowth and need for salvage surgery are similar.

Natural history of Graves' Ophthalmopathy.

Almost two centuries after having first been described, GO remains a challenging disease, and despite a tremendous improvement in the understanding of this condition; areas of uncertainty still exist regarding its physiopathology and treatment. In this article we describe some highlights in the history of GO and provide a review of our knowledge about its natural history.

Endoscopic Ultrasound-Guided Radiofrequency Ablation: A New Therapeutic Approach for Pancreatic Neuroendocrine Tumors.

CONTEXT: Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is rapidly emerging as feasible therapy for patients with pancreatic neuroendocrine tumors (pNETs) in selected cases, as a result of its favorable safety profile. OBJECTIVE: To assess the feasibility, safety, and efficacy of EUS-RFA in a cohort of patients with functional and nonfunctional pNETs (NF-pNETs). DESIGN: Data on pNET patients treated with EUS-RFA between March 2017 and October 2018 at two tertiary centers was retrospectively analyzed. RESULTS: The cohort included 18 adults (eight women, 10 men), aged 60.4 ± 14.4 years (mean ± SD), seven insulinoma patients, and 11 patients with NF-pNETs. Twenty-seven lesions with a mean diameter of 14.3 ± 7.3 mm (range 4.5 to 30) were treated. Technical success defined as typical postablative changes on a surveillance imaging was achieved in 26 out of 27 lesions. Clinical response with normalization of glucose levels was observed in all (seven of seven) insulinoma cases within 24 hours of treatment. Overall, there were no major complications 48 hours postprocedure. No clinically significant recurrences were observed during mean follow-up of 8.7 ± 4.6 months (range 2 to 21 months). CONCLUSIONS: EUS-guided RFA of pNETs is a minimally invasive, safe, and technically feasible procedure for selected patients.

Humoral hypercalcemia of pregnancy treated with bisphosphonates.

Hypercalcemia can be hazardous during pregnancy, most cases being due to primary hyperparathyroidism. We report a case of hypercalcemia with suppressed PTH levels necessitating treatment with bisphosphonates during pregnancy. A 38-year-old woman at the 26th week gestation was admitted because of symptomatic hypercalcemia. She did not take any medication that could influence her calcium levels. Physical examination was unremarkable. Laboratory tests on admission were: calcium 12.7 mg/dL (8.5-10.5 mg/dL), phosphorus 1.8 mg/dL (2.5-4.5 mg/dL) and PTH on 3 consecutive tests 1.2, 1.3 and 1.2 pg/mL (15-65 pg/mL). Her 24h urine calcium was 900 mg, 25-OH-D 40 ng/mL (30-58 ng/mL) and 1,25-OH-D 99 pg/mL (80-146 for women in the third trimester). Abdominal ultrasound revealed multiple hypervascular liver lesions consistent with hemangiomas by MRI. Breast and neck ultrasound were normal, and chest CT revealed few non-significant 0.3-0.7 cm pulmonary nodules with no change after an interval of 3 months. She was treated with isotonic saline, loop diuretics and calcitonin. Despite this treatment, calcium levels remained high (14.1 mg/dL), and pamidronate was initiated. On 35th week gestation, she underwent a cesarean section complicated by hypocalcemia of the newborn. Eight weeks after delivery, her calcium levels are 9.4 mg/dL and PTH 18 mg/dL. According to the extensive workup and the post-partum normalization of PTH and calcium levels, we conclude that excessive secretion of placental PTHrP was the cause of hypercalcemia in this patient. No significant adverse effect of bisphosphonate on the mother or baby were seen at the short term follow up.

Medullary thyroid cancer: a retrospective analysis of a cohort treated at a single tertiary care center between 1970 and 2005.

OBJECTIVE: To identify prognostic factors of clinical outcome and long-term survival in medullary thyroid cancer (MTC). DESIGN: Retrospective case series of 51 consecutive patients (mean age 46.9 years, 57% female) treated at a single tertiary university medical center from 1970 to 2005. Medical records were reviewed for demographic data, laboratory and clinical course, treatment, and long-term outcome. MAIN OUTCOME: At presentation, 25 patients (49%) had local disease and 26 (51%) had metastatic disease (three with distant metastases). RET mutations were identified in nine of 23 patients tested. The patients with hereditary disease were younger than the patients with sporadic disease (p < 0.001) and had lower calcitonin levels at diagnosis (p = 0.004) and more multicentric tumors (p = 0.02). Initial surgery consisted of total thyroidectomy in 47 patients, with neck dissection in 26; 22 patients achieved long-term remission. The 5-, 10- and 15-year survival rates were 88%, 85%, and 77%, respectively. On univariate analysis, distant metastases during the course of the disease and elevated calcitonin levels postoperatively were significant prognostic factors of reduced survival (p = 0.001 and 0.016, respectively). Lymph node involvement at initial surgery was associated with a lower remission rate (p = 0.016) but had no impact on long-term survival (p = 0.269). CONCLUSION: Patients with MTC have a generally favorable outcome, perhaps owing to recent advances in diagnosis and treatment. Although postoperative serum calcitonin level and distant metastases are the only determinants of long-term survival, the presence of cervical metastases is predictive of a higher risk of recurrent or persistent disease.

Effect of alendronate on bone mineral density in adult patients with Laron syndrome (primary growth hormone insensitivity).

Severe short stature resulting from a deficiency in insulin-like growth factor-I (IGF-I) is a prominent feature of Laron syndrome (LS). Whether patients with LS are osteopenic or not, and whether they need treatment with bisphosphonates, remains uncertain. The aim of this study was to investigate the action of alendronate on the IGF-I-deficient bones of adult patients with LS and osteoporosis, as determined by dual X-ray absorptiometry . Seven patients (5 women and 2 men) of mean age 40.8+/-7.6 years and mean bone mass density (BMD) 0.843+/-0.06 g/cm2 (T score -2.9+/-0.5) at the lumbar spine and 0.734+/-0.11 g/cm2 (T score -2.2+/-0.9) at the femoral neck were treated with alendronate 70 mg once/weekly over a 12-month period. Treatment led to an increase of 5.3% in BMD (p=0.038) at the femoral neck. There was a similar trend at the lumbar spine, but the difference was not statistically significant (2.3%, p=0.34). Mean total alkaline phosphatase decreased by 14% from normal range at baseline (p=0.007). Urinary deoxypyridinoline levels, which were elevated at baseline (10+/-2.3 nM/mMcre), showed a nonsignificant change during treatment. Our study suggests that treatment with alendronate may have positive effects in patients with LS and low BMD on dual X-ray absorptiometry.

Kallmann Syndrome: Eugenics and the Man behind the Eponym.

Kallmann syndrome is named after Franz Joseph Kallmann, a German-born psychiatrist who described in 1944 twelve subjects from three families who presented with a syndrome of missed puberty, anosmia, and color blindness. Yet, several other eponyms for the same syndrome can be found in the literature. Despite the fact that Kallmann syndrome is the most recognized eponym, very little is known about the man for whom the syndrome is named. A biographical note on Franz Joseph Kallmann and his historical context is presented.

Are adult patients with Laron syndrome osteopenic? A comparison between dual-energy X-ray absorptiometry and volumetric bone densities.

Severe short stature resulting from a deficiency in IGF-I is a prominent feature of Laron syndrome (LS). Although low bone mineral density (BMD) has been noted in LS patients examined by dual energy x-ray absorptiometry (DEXA), this technique does not take volume into account and may therefore underestimate the true bone density in patients with small bones. The aim of the present study was to evaluate the BMD yielded by DEXA in our LS patients using estimated volumetric values. Volumetric density was calculated with the following formulas: bone mineral apparent density (BMAD) = bone mineral content (BMC)/(area)(3/2) for the lumbar spine and BMAD = BMC/area(2) for the femoral neck. The study sample included 12 patients (mean age, 43.9 yr; mean height, 123.7 cm). Findings were compared with 10 osteopenic subjects without developmental abnormalities (mean age, 56 yr; mean height, 164.8 cm) and 10 healthy control subjects matched for sex and age to the LS patients (mean height, 165.5 cm). BMAD in the LS group was 0.201 +/- 0.02 g/cm(3) at the lumbar spine and 0.201 +/- 0.04 g/cm(3) at the femoral neck; corresponding values for the osteopenic group were 0.130 +/- 0.01 and 0.140 +/- 0.01 g/cm(3), and for the controls, 0.178 +/- 0.03 and 0.192 +/- 0.02 g/cm(3). Although areal BMD was significantly lower in the LS and osteopenic subjects compared with controls (P < 0.02) at both the lumbar spine and femoral neck, BMAD was low (P < 0.01) in the osteopenic group only. In conclusion, DEXA does not seem to be a reliable measure of osteoporosis in patients with LS.

[Cushing disease: long-term follow-up after transsphenoidal surgery].

BACKGROUND: Cushing's syndrome due to an ACTH-secreting pituitary tumor is associated with serious morbidity and mortality. As there is no definitive medical treatment, surgical removal of the tumor via the transsphenoidal route remains the first choice. Postoperative hypocortisolemia is recognized as the best indicator of cure. OBJECTIVE: To report the postoperative outcome and long-term follow-up of patients with surgically treated Cushing disease at the Rabin Medical Center. METHODS: We reviewed the medical records of 27 patients with Cushing disease operated on between the period 1990 and 2003. The same experienced surgeon performed all surgeries. RESULTS: Cushing disease accounted for 15% of all pituitary surgeries in our center. The mean age was 46 years, and the female to male ratio was 25:2. Macroadenomas were found in 19% of cases, and a negative MRI in another 19%. The cure rate was 70% overall and 80% when only microadenomas were considered. There were no major perioperative complications. Four out of 8 surgical failures were re-operated, and three achieved cure. After a mean follow-up period of 5.9 years, there was only one recurrence. CONCLUSION: Our results are in accordance with those reported by others and confirm that in the hands of an experienced neurosurgeon, pituitary surgery constitutes an effective treatment for Cushing disease.

Papillary thyroid cancer: factors involved in restaging N1 disease after total thyroidectomy and radioactive iodine treatment.

CONTEXT: The presence of cervical lymph node metastases is a strong predictor of persistent disease in papillary thyroid cancer (PTC). OBJECTIVE: The objective of the study was to investigate factors associated with improved outcome in patients with PTC and lymph node metastases. DESIGN: Retrospective Cohort Setting: The study was conducted at a tertiary university-affiliated medical center. PATIENTS: PATIENTS treated for PTC and N1 disease since 1995 participated in the study. Partial thyroidectomy, distant metastases, and poor differentiation were the exclusion criteria. INTERVENTIONS: The intervention was a data search of the Thyroid Registry. MAIN OUTCOME MEASURES: Significant association of clinical and disease-related factors with persistent disease was measured. RESULTS: Of 800 patients treated for PTC during the study period, 182 (69% female; mean age at diagnosis 46.5 ± 15 y) had N1 disease (47% N1a, 53% N1b). Most (93.4%) had a classical/follicular variant; 65% had T1-2 disease; and 42.6% had extrathyroid extension. All patients were treated with total thyroidectomy and radioactive iodine (mean first dose 147 ± 26 mCi). Lateral neck dissection was performed in 53% patients. Mean follow-up was 9.2 ± 4.5 years. On regression analysis, factors significantly and independently associated with persistent disease at 1 year (94 of 182, 52%; 40% of N1a group, 59% of N1b group) were primary tumor size, focality, and extrathyroid extension and at the last follow-up (62 of 182, 34%; 27% of N1a group, 33% of N1b group), primary tumor size, 1-year stimulated thyroglobulin level, and cumulative I(131) dose. Stimulated thyroglobin less than 2.1 ng/mL at 1 year predicts the absence of disease at the last follow-up with an 86% negative predictive value. CONCLUSION: PATIENTS with PTC and N1 disease treated with total thyroidectomy and radioactive iodine have a significant risk of persistent disease at early and late follow-up. The extension of the primary tumor at diagnosis appears to be the only significant predictor of persistency in these patients.

Humoral hypercalcemia of pregnancy treated with bisphosphonates

SUMMARY Hypercalcemia can be hazardous during pregnancy, most cases being due to primary hyperparathyroidism. We report a case of hypercalcemia with suppressed PTH levels necessitating treatment with bisphosphonates during pregnancy. A 38-year-old woman at the 26th week gestation was admitted because of symptomatic hypercalcemia. She did not take any medication that could influence her calcium levels. Physical examination was unremarkable. Laboratory tests on admission were: calcium 12.7 mg/dL (8.5-10.5 mg/dL), phosphorus 1.8 mg/dL (2.5-4.5 mg/dL) and PTH on 3 consecutive tests 1.2, 1.3 and 1.2 pg/mL (15-65 pg/mL). Her 24h urine calcium was 900 mg, 25-OH-D 40 ng/mL (30-58 ng/mL) and 1,25-OH-D 99 pg/mL (80-146 for women in the third trimester). Abdominal ultrasound revealed multiple hypervascular liver lesions consistent with hemangiomas by MRI. Breast and neck ultrasound were normal, and chest CT revealed few non-significant 0.3-0.7 cm pulmonary nodules with no change after an interval of 3 months. She was treated with isotonic saline, loop diuretics and calcitonin. Despite this treatment, calcium levels remained high (14.1 mg/dL), and pamidronate was initiated. On 35th week gestation, she underwent a cesarean section complicated by hypocalcemia of the newborn. Eight weeks after delivery, her calcium levels are 9.4 mg/dL and PTH 18 mg/dL. According to the extensive workup and the post-partum normalization of PTH and calcium levels, we conclude that excessive secretion of placental PTHrP was the cause of hypercalcemia in this patient. No significant adverse effect of bisphosphonate on the mother or baby were seen at the short term follow up.

Differentiated thyroid cancer is associated with less aggressive disease and better outcome in patients with coexisting Hashimotos thyroiditis.

BACKGROUND: Evaluation of surgical specimens suggests that patients with Hashimoto thyroiditis (HT) have a higher prevalence of differentiated thyroid cancer. Although patients with HT are reported to present with earlier stage disease, there is controversy as to whether these patients have better prognosis when adjusted for histology and stage at presentation. OBJECTIVES: To investigate differences between patients with differentiated thyroid cancer patients and without HT for aggressiveness of disease and clinical outcome, and the decline rate of antithyroglobulin antibodies titers over time. METHODS: A retrospective study using the Rabin Medical Center Thyroid Cancer Registry. Seven hundred fifty-three patients were included and divided into 2 groups of patients with and without HT at diagnosis. Disease severity at presentation was evaluated using the entire cohort, whereas a control group matched for age, gender, histology, and stage was used to evaluate disease course and outcome. RESULTS: HT was present in 14.2% (n = 107) of included patients and was associated with smaller primary tumor (17.9 vs 21.2 mm, P = .01) and less lymph node involvement (23% vs 34%, P = .02) at presentation. When matched groups were compared, patients with HT received less additional radioactive iodine (RAI) treatments (1.24 vs 1.45, P = .03) and showed lower rates of persistence at 1 year (13% vs 26%, P = .04) and higher rates of disease remission at the end of follow-up (90% vs 79%, P = .05). On multivariate analysis HT was predictive of a lower rate of lymph nodes involvement (odds ratio 0.34, 95% confidence interval 0.17-0.66) and persistent disease at the end of follow-up (odds ratio 0.48, 95% confidence interval 0.24-0.93). Antithyroglobulin antibodies slowly disappeared in most patients with no evidence of disease. CONCLUSION: Our study demonstrates that HT is associated with a less aggressive form of differentiated thyroid cancer and a better long-term outcome.

Clinicopathological characteristics and long-term outcome in patients with distant metastases from differentiated thyroid cancer.

BACKGROUND: Distant metastases are seen in a minority of patients with differentiated thyroid carcinoma (DTC) but account for most of its disease-specific mortality. Studies on the long-term outcome of patients with distant metastases are controversial. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 660 patients with differentiated thyroid carcinoma followed at our institution from 1994 to 2004. Forty-four patients (6.7%) had distant metastases, with a prevalence of 4.8% for papillary thyroid cancer, 21% for follicular thyroid cancer, and 10% for Hurthle cell cancer. Primary near-total thyroidectomy followed by I(131) radiation was performed in 97% of patients with metastases (86% operated on in 1980-2003). Mean age at thyroidectomy was 49+/-19 years, and the female-to-male ratio was 1.9:1. RESULTS: The distant metastasis occurred synchronously with the primary tumor in 45.5% and after a median follow-up of 9 years in the others. Affected sites were lungs (n=24), bones (n=11), lungs and bones (n=9), brain (n=3), and uterus (n=1). Median duration of follow-up was 12 years (range: 1-42 years) from thyroidectomy and 5.5 years (range: 1-24 years) from diagnosis of distant metastases. The 5- and 10-year survival rates (all causes) after diagnosis of distant metastases were 88% and 77%, respectively. No significant differences in survival curves were found by age, sex, metastasis site, histopathology, or interval to distant metastasis. CONCLUSIONS: We conclude that complete resection of the thyroid gland at diagnosis and high-dose adjuvant radioactive iodine are associated with improved survival in patients with metastatic DTC.

Prolactinoma and other head and neck tumors after scalp irradiation.

Tumors of the thyroid and parathyroid glands may develop together or separately in patients who previously have been exposed to head and neck irradiation. Whether cranial irradiation confers an increased risk for pituitary adenoma remains unknown. We report the case of a 52-year-old woman who was treated during childhood for tinea capitis with scalp irradiation and later in life developed a prolactin-secreting tumor, a parathyroid adenoma, a benign thyroid lesion, and a basal cell carcinoma of the skin. She was treated successfully with bromocriptine and surgical removal of the parathyroid adenoma. Molecular analysis of the parathyroid tissue failed to demonstrate any abnormality of the multiple endocrine neoplasia Type 1 gene. This case report is the first to describe a prolactin-secreting tumor that developed in association with other endocrine neoplasia after head and neck irradiation. Our case suggests that multiple endocrine neoplasia may develop in a sporadic pattern after scalp irradiation.