Multidisciplinary integrated care pathway for von Hippel-Lindau disease

Predominantly multiple focal non-cystic renal lesions: an imaging approach

Multiple non-cystic renal lesions are occasionally discovered during imaging for various reasons and poses a diagnostic challenge to the practicing radiologist. These lesions may appear as a primary or dominant imaging finding or may be an additional abnormality in the setting of multiorgan involvement. Awareness of the imaging appearance of the various entities presenting as renal lesions integrated with associated extrarenal imaging findings along with clinical information is crucial for a proper diagnostic approach and patient work-up. This review summarizes the most relevant causes of infectious, inflammatory, vascular, and neoplastic disorders presenting as predominantly multiple focal non-cystic lesions.

Novel Von Hippel-Lindau Germline Variants in Iranian Patients with Retinal Capillary Hemangioblastoma

Introduction

The aim of this study was to determine the potential genetic cause of retinal capillary hemangioblastoma (RCH) with symptoms of Von Hippel-Lindau (VHL) disease.

Case Presentations

Three Iranian families (5 RCH patients) with novel variants are included in this study. The VHL variant analysis was performed by the Sanger sequencing technique. Molecular dynamics (MDs) simulations were conducted to analyze conformational changes resulting from variants in VHL protein structure and were compared with that of the native structure. Novel variant sites, including c.511A>C, c.511A>T, and c.514C>T in exon 3 of the VHL gene were identified. According to the American College of Medical Genetics (ACMG) classifications, c.514C>T (p.P172S) and c.511A>C (p.K171Q) are classified as variants of uncertain significance (VUS), and c.511A>T (p.K171*) is classified as a likely pathogenic variant. MD simulations demonstrated overall fluctuations of the proteins structure and a significantly lower degree of flexibility in the α-domain for the variant-encoded VHL protein structure compared to that of the native form.

Conclusion

The structural information and computational analysis of the identified variants are predicted to induce conformational changes that limit the flexibility of protein VHL interaction interface with Elongin B/C, Elongin C/B, and Cullin-2, which are necessary for hypoxia-inducible factor 1-α binding. The genetic variants identified in Iranian patients with RCH may aid in the molecular confirmation of other patients diagnosed with VHL and their at-risk family members. These pioneering results that include detailed structural and functional analysis of a variant's effect on the VHL protein may serve as a model for future studies.

Consensus Guidelines for Ocular Surveillance of von Hippel-Lindau Disease

PURPOSE

To develop guidelines for ocular surveillance and early intervention for individuals with von Hippel-Lindau (VHL) disease.

DESIGN

Systematic review of the literature.

PARTICIPANTS

Expert panel of retina specialists and ocular oncologists.

METHODS

A consortium of experts on clinical management of all-organ aspects of VHL disease was convened. Working groups with expertise in organ-specific features of VHL disease were tasked with development of evidence-based guidelines for each organ system. The ophthalmology subcommittee formulated questions for consideration and performed a systematic literature review. Evidence was graded for topic quality and relevance and the strength of each recommendation, and guideline recommendations were developed.

RESULTS

The quality of evidence was limited, and no controlled clinical trial data were available. Consensus guidelines included: (1) individuals with known or suspected VHL disease should undergo periodic ocular screening (evidence type, III; evidence strength, C; degree of consensus, 2A); (2) patients at risk of VHL disease, including first-degree relatives of patients with known VHL disease, or any patient with single or multifocal retinal hemangioblastomas (RHs), should undergo genetic testing for pathologic VHL disease gene variants as part of an appropriate medical evaluation (III/C/2A); (3) ocular screening should begin within 12 months after birth and continue throughout life (III/C/2A); (4) ocular screening should occur approximately every 6 to 12 months until 30 years of age and then at least yearly thereafter (III/C-D/2A); (5) ocular screening should be performed before a planned pregnancy and every 6 to 12 months during pregnancy (IV/D/2A); (6) ultra-widefield color fundus photography may be helpful in certain circumstances to monitor RHs, and ultra-widefield fluorescein angiography may be helpful in certain circumstances to detect small RHs (IV/D/2A); (7) patients should be managed, whenever possible, by those with subspecialty training, with experience with VHL disease or RHs, or with both and ideally within the context of a multidisciplinary center capable of providing multiorgan surveillance and access to genetic testing (IV/D/2A); (8) extramacular or extrapapillary RHs should be treated promptly (III/C/2A).

CONCLUSIONS

Based on available evidence from observational studies, broad agreement was reached for a strategy of lifelong surveillance and early treatment for ocular VHL disease. These guidelines were endorsed by the VHL Alliance and the International Society of Ocular Oncology and were approved by the American Academy of Ophthalmology Board of Trustees.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Neurocutaneous Diseases: Diagnosis, Management, and Treatment

Neurocutaneous disorders, also known as phakomatoses, are congenital and acquired syndromes resulting in simultaneous neurologic and cutaneous involvement. In several of these conditions, the genetic phenomenon is understood, providing a pivotal role in the development of therapeutic options. This review encompasses the discussion of the genetic and clinical involvement of neurocutaneous disorders, and examines clinical management and treatment options. With the current advances in genetics, the role of precision medicine and targeted therapy play a substantial role in addressing the management of these conditions. The interconnectedness between therapeutic options highlights the importance of precision medicine in treating each disorder's unique molecular pathway. This review provides an extensive synthesis of ongoing and current therapeutics in the management of such clinically unique and challenging conditions.

Current State of Genomics in Nursing: A Scoping Review of Healthcare Provider Oriented (Clinical and Educational) Outcomes (2012-2022)

In the 20 years since the initial sequencing of the human genome, genomics has become increasingly relevant to nursing. We sought to chart the current state of genomics in nursing by conducting a systematic scoping review of the literature in four databases (2012-2022). The included articles were categorized according to the Cochrane Collaboration outcome domains/sub-domains, and thematic analysis was employed to identify key topical areas to summarize the state of the science. Of 8532 retrieved articles, we identified 232 eligible articles. The articles primarily reported descriptive studies from the United States and other high-income countries (191/232, 82%). More than half (126/232, 54.3%) aligned with the "healthcare provider oriented outcomes" outcome domain. Three times as many articles related to the "knowledge and understanding" sub-domain compared to the "consultation process" subdomain (96 vs. 30). Five key areas of focus were identified, including "nursing practice" (50/126, 40%), "genetic counseling and screening" (29/126, 23%), "specialist nursing" (21/126, 17%), "nurse preparatory education" (17/126, 13%), and "pharmacogenomics" (9/126, 7%). Only 42/126 (33%) articles reported interventional studies. To further integrate genomics into nursing, study findings indicate there is a need to move beyond descriptive work on knowledge and understanding to focus on interventional studies and implementation of genomics into nursing practice.

Síndrome de von Hippel-Lindau em um Serviço Privado de Câncer em São Paulo: Relato de Caso

Introdução: A síndrome de von Hippel-Lindau (VHL) é uma patologia hereditária autossômica dominante que envolve o crescimento de tumores em diversas regiões do corpo humano em razão da mutação no gene VHL. Relato do caso: Paciente, sexo masculino, 38 anos, há três anos queixava-se de cefaleia recorrente, com piora progressiva. Foi diagnosticado com uma lesão em cerebelo cuja ressonância magnética cerebral encontrou uma formação expansiva na porção posteroinferior do hemisfério cerebelar esquerdo. Foi realizada tomografia multislice de abdome, que evidenciou formação nodular esplênica com realce marginal. A imagem da coluna cervical demonstrou pequeno nódulo localizado na medula cervical (intramedular) adjacente à vértebra cervical 3 (C3). Diante dos achados, o paciente foi submetido à ressecção macroscópica total da lesão do cerebelo, com laudo anatomopatológico de hemangioblastoma cerebelar grau 1, de acordo com a classificação da Organização Mundial da Saúde (OMS), que é um tumor benigno com baixa agressividade e recorrência. O teste imuno-histoquímico mostrou cluster of differentiation 34 (CD 34) positivo, índice de proliferação celular (Ki67) positivo (<5%), alfa inibina positiva e epithelial membrane antigen (EMA) negativo. Como o paciente não tinha história familiar de câncer, em função dos achados radiológicos, foi realizado sequenciamento de nova geração identificando a variante patogênica VHL c.292T>C, constatado em linhagem germinativa que, apesar do desconhecimento de história familiar positiva para a síndrome, confirmou o diagnóstico do paciente. Conclusão: O conjunto de achados clínicos e a variante no gene VHL confirmam o diagnóstico da síndrome.

[A Surgically Treated Depression]

A Surgically Treated Depression Abstract. We present a 64-year-old patient with an unclear deterioration of her general condition due to a suspected depression. Despite antidepressive treatment, her condition further deteriorated. The CT/MRI of the skull showed a cerebellar tumor as well as a hydrocephalus obstructivus. Together with tumor staging, the histology, which revealed a hemangioblastoma, led to the diagnosis of VHL syndrome. Patients with VHL syndrome and their families should be included in a screening program, unless molecular genetic testing has ruled out the disease.