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Knoblauch AL, Blaß BI, Steiert C, Neidert N, Puzik A, Neumann-Haefelin E, Ganner A, Kotsis F, Schäfer T, Neumann HPH, Elsheikh S, Beck J, Klingler JH. Screening and surveillance recommendations for central nervous system hemangioblastomas in pediatric patients with Von Hippel-Lindau disease. J Neurooncol 2024; 168:537-545. [PMID: 38647646 PMCID: PMC11186940 DOI: 10.1007/s11060-024-04676-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/05/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Von Hippel-Lindau (VHL) disease is an autosomal-dominantly inherited tumor predisposition syndrome. One of the most common tumors are central nervous system (CNS) hemangioblastomas. Recommendations on the initiation and continuation of the screening and surveillance program for CNS tumors in pediatric VHL patients are based on small case series and thus low evidence level. To derive more robust screening recommendations, we report on the largest monocentric pediatric cohort of VHL patients. METHODS We performed a retrospective analysis on a pediatric cohort of 99 VHL patients consulted at our VHL center from 1992 to 2023. Clinical, surgical, genetic, and imaging data were collected and statistically analyzed. RESULTS 42 patients (50% male) developed CNS hemangioblastomas, of whom 18 patients (56% male) underwent hemangioblastoma surgery (mean age at first surgery: 14.9 ± 1.9 years; range 10.2-17). The first asymptomatic patient was operated on at the age of 13.2 years due to tumor progress. Truncating VHL mutation carriers had a significantly higher manifestation rate (HR = 3.7, 95% CI: 1.9-7.4, p < 0.0001) and surgery rate (HR = 3.3, 95% CI: 1.2-8.9, p = 0.02) compared with missense mutation carriers. CONCLUSION We recommend starting MRI imaging at the age of 12 years with examination intervals every (1-) 2 years depending on CNS involvement. Special attention should be paid to patients with truncating variants. Affected families should be educated regularly on potential tumor-associated symptoms to enable timely MRI imaging and eventually intervention, as CNS hemangioblastoma may develop before screening begins. GERMAN CLINICAL TRIALS REGISTER REGISTRATION NUMBER DRKS00029553, date of registration 08/16/2022, retrospectively registered.
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Affiliation(s)
- Anna Laura Knoblauch
- Department of Neurosurgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - B-I Blaß
- Department of Neurosurgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - C Steiert
- Department of Neurosurgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - N Neidert
- Department of Neurosurgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
- Berta-Ottenstein-Programme for Clinician Scientists, Medical Center - University of Freiburg, Freiburg, Germany
| | - A Puzik
- Department of Pediatric Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - E Neumann-Haefelin
- Renal Division, Department of Medicine, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - A Ganner
- Renal Division, Department of Medicine, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - F Kotsis
- Renal Division, Department of Medicine, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - T Schäfer
- Renal Division, Department of Medicine, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - H P H Neumann
- Renal Division, Department of Medicine, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - S Elsheikh
- Department of Neuroradiology, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - J Beck
- Department of Neurosurgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - J-H Klingler
- Department of Neurosurgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
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Daniels AB, Chang EY, Chew EY, Gombos DS, Gorin MB, Shields CL, Wiley HE. Consensus Guidelines for Ocular Surveillance of von Hippel-Lindau Disease. Ophthalmology 2024; 131:622-633. [PMID: 38092079 DOI: 10.1016/j.ophtha.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 03/21/2024] Open
Abstract
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.
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Affiliation(s)
- Anthony B Daniels
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, and Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee.
| | | | - Emily Y Chew
- Division of Epidemiology and Clinical Applications, National Eye Institute, Bethesda, Maryland
| | - Dan S Gombos
- Section of Ophthalmology, Department of Head & Neck Surgery, Division of Surgery, University of Texas-MD Anderson Cancer Center, Houston, Texas
| | - Michael B Gorin
- Jules Stein Eye Institute, University of California-Los Angeles School of Medicine, Los Angeles, California
| | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
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3
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Shamim SA, Arora G, Kumar N, Hussain J, Gupta SD, ST AR, Shankar K, Goyal A, Khadgawat R, Sagar S, Bal C. 68Ga-DOTANOC PET/CT for Screening and Surveillance of Von Hippel-Lindau (VHL) disease. Nucl Med Mol Imaging 2023; 57:235-242. [PMID: 37720877 PMCID: PMC10504222 DOI: 10.1007/s13139-023-00810-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 09/19/2023] Open
Abstract
Purpose Hereditary tumor syndrome Von Hippel-Lindau (VHL) disease is characterized by various benign and malignant tumors that are known to express somatostatin receptors (SSTR). We evaluated the role of 68Ga-DOTANOC PET/CT scan in patients with positive germline mutation of the VHL gene, presented initially or on follow-up, for the detection of recurrent or synchronous/metachronous lesions. Methods Fourteen patients (8 males; 6 females) with mean age 30 ± 9.86 years were retrospectively analyzed, were tested positive for VHL on gene dosage analysis, and underwent 68 Ga-DOTANOC PET/CT scan for disease evaluation. The number and site of lesions were determined. The tracer uptake was analyzed semi-quantitatively by calculating the maximum standardized uptake values (SUVmax) of lesion. Results Four of the 14 patients underwent scan for initial diagnosis as baseline, 6 patients for post-therapy disease status, and 4 patients for initial diagnosis as well as follow-up evaluation of the disease. A total of 67 lesions were detected in 14 patients. The sites of lesions were cerebellar/vertebral/spinal (17; mean SUVmax = 7.85); pancreatic neuroendocrine tumor (NET) (11; mean SUVmax = 20.64); retina (3; mean SUVmax = 10.46); pheochromocytoma (10; mean SUVmax = 16.32); paragangliomas (3; mean SUVmax = 10.65); pancreatic cyst (9; mean SUVmax = 2.54); and renal cyst (8; mean SUVmax = 1.56) and miscellaneous lesions constituted 6 lesions. Conclusion Our results show that 68 Ga-DOTANOC PET/CT may be a useful modality for screening and follow-up of associated tumors in patients with germline gene mutation for VHL. It can be used as a one-stop imaging modality for VHL patients and may substitute for separate radiological investigations, making it more convenient for patients in terms of time and cost.
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Affiliation(s)
- Shamim Ahmed Shamim
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Geetanjali Arora
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Naresh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Jhangir Hussain
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Shreya Datta Gupta
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Arun Raj ST
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Kritin Shankar
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Alpesh Goyal
- Department of Endocrinology, Metabolism & Diabetes, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology, Metabolism & Diabetes, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sambit Sagar
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Chandrasekhar Bal
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
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Daniels AB, Tirosh A, Huntoon K, Mehta GU, Spiess PE, Friedman DL, Waguespack SG, Kilkelly JE, Rednam S, Pruthi S, Jonasch EA, Baum L, Chahoud J. Guidelines for surveillance of patients with von Hippel-Lindau disease: Consensus statement of the International VHL Surveillance Guidelines Consortium and VHL Alliance. Cancer 2023; 129:2927-2940. [PMID: 37337409 DOI: 10.1002/cncr.34896] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/17/2023] [Accepted: 04/26/2023] [Indexed: 06/21/2023]
Abstract
Von Hippel‐Lindau disease is a rare inherited cancer‐predisposition syndrome. The authors report the updated recommendations for the multiorgan surveillance protocols.
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Affiliation(s)
- Anthony B Daniels
- Division of Ocular Oncology and Pathology, Department of Ophthalmology & Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amit Tirosh
- Neuroendocrine Tumors Service, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kristin Huntoon
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Tennessee, USA
| | | | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Debra L Friedman
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Texas, USA
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jill E Kilkelly
- Division of Pediatric Anesthesia, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Surya Rednam
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Sumit Pruthi
- Division of Pediatric Neuroradiology, Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric A Jonasch
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Laura Baum
- Division of Hematology/Oncology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jad Chahoud
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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Wolters WPG, Dreijerink KMA, Giles RH, van der Horst‐Schrivers ANA, van Nesselrooij B, Zandee WT, Timmers HJLM, Seute T, de Herder WW, Verrijn Stuart AA, Kilic E, Brinkman WM, Zondervan PJ, Vandertop WP, Daniels AB, Wolbers T, Links TP, van Leeuwaarde RS. Multidisciplinary integrated care pathway for von Hippel-Lindau disease. Cancer 2022; 128:2871-2879. [PMID: 35579632 PMCID: PMC9542729 DOI: 10.1002/cncr.34265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical pathways are care plans established to describe essential steps in the care of patients with a specific clinical problem. They translate (inter)national guidelines into local applicable protocols and clinical practice. The purpose of this article is to establish a multidisciplinary integrated care pathway for specialists and allied health care professionals in caring for individuals with von Hippel-Lindau (VHL) disease. METHODS Using a modified Delphi consensus-making process, a multidisciplinary panel from 5 Dutch University Medical Centers produced an integrated care pathway relating to the provision of care for patients with VHL by medical specialists, specialized nurses, and associated health care professionals. Patient representatives cocreated the pathway and contributed quality criteria from the patients' perspective. RESULTS The panel agreed on recommendations for the optimal quality of care for individuals with a VHL gene mutation. These items were the starting point for the development of a patient care pathway. With international medical guidelines addressing the different VHL-related disorders, this article presents a patient care pathway as a flowchart that can be incorporated into VHL expertise clinics or nonacademic treatment clinics. CONCLUSIONS Medical specialists (internists, urologists, neurosurgeons, ophthalmologists, geneticists, medical oncologists, neurologists, gastroenterologists, pediatricians, and ear-nose-throat specialists) together with specialized nurses play a vital role alongside health care professionals in providing care to people affected by VHL and their families. This article presents a set of consensus recommendations, supported by organ-specific guidelines, for the roles of these practitioners in order to provide optimal VHL care. This care pathway can form the basis for the development of comprehensive, integrated pathways for multiple neoplasia syndromes.
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Affiliation(s)
- Wendy P. G. Wolters
- Department of Endocrine OncologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Koen M. A. Dreijerink
- Department of EndocrinologyAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Rachel H. Giles
- Dutch VHL OrganizationUtrechtthe Netherlands,International Kidney Cancer CoalitionAmsterdam‐Duivendrechtthe Netherlands
| | | | | | - Wouter T. Zandee
- Department of EndocrinologyUniversity Medical Center GroningenGroningenthe Netherlands
| | | | - Tatjana Seute
- Department of NeurologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Wouter W. de Herder
- Department of Internal MedicineErasmus Medical CenterRotterdamthe Netherlands
| | | | - Emine Kilic
- Department of OphthalmologyErasmus Medical CenterRotterdamthe Netherlands
| | - Willem M. Brinkman
- Department of Oncological UrologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | | | - W. Peter Vandertop
- Department of NeurosurgeryAmsterdam NeuroscienceAmsterdamthe Netherlands
| | - Anthony B. Daniels
- Division of Ocular Oncology and PathologyDepartment of Ophthalmology and Visual Sciences, Vanderbilt‐Ingram Cancer CenterVanderbilt University Medical CenterNashvilleTennessee
| | | | - Thera P. Links
- Department of EndocrinologyUniversity Medical Center GroningenGroningenthe Netherlands
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von Hippel-Lindau disease: Updated guideline for diagnosis and surveillance. Eur J Med Genet 2022; 65:104538. [PMID: 35709961 DOI: 10.1016/j.ejmg.2022.104538] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/29/2022] [Accepted: 06/06/2022] [Indexed: 11/21/2022]
Abstract
von Hippel Lindau disease (vHL) is caused by a hereditary predisposition to multiple neoplasms, especially hemangioblastomas in the retina and CNS, renal cell carcinomas (RCC), pheochromocytomas, neuroendocrine pancreatic tumours (PNET) and endolymphatic sac tumours. Evidence based approaches are needed to ensure an optimal clinical care, while minimizing the burden for the patients and their families. This guideline is based on evidence from the international vHL literature and extensive research of geno- and phenotypic characteristics, disease progression and surveillance effect in the national Danish vHL cohort. We included the views and preferences of the Danish vHL patients, ensured consensus among Danish experts and compared with international recommendations. RECOMMENDATIONS: vHL can be diagnosed on clinical criteria, only; however, in most cases the diagnosis can be supported by identification of a pathogenic or likely pathogenic variant in VHL. Surveillance should be initiated in childhood in persons with, or at risk of, vHL, and include regular examination of the retina, CNS, inner ear, kidneys, neuroendocrine glands, and pancreas. Treatment of vHL manifestations should be planned to optimize the chance of cure, without unnecessary sequelae. Most manifestations are currently treated by surgery. However, belzutifan, that targets HIF-2α was recently approved by the U.S. Food and Drug Administration (FDA) for adult patients with vHL-associated RCC, CNS hemangioblastomas, or PNETs, not requiring immediate surgery. Diagnostics, surveillance, and treatment of vHL can be undertaken successfully by experts collaborating in multidisciplinary teams. Systematic registration, collaboration with patient organisations, and research are fundamental for the continuous improvement of clinical care and optimization of outcome with minimal patient inconvenience.
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Savatt JM, Ortiz NM, Thone GM, McDonald WS, Kelly MA, Berry ASF, Alvi MM, Hallquist MLG, Malinowski J, Purdy NC, Williams MS, Sturm AC, Buchanan AH. Observational study of population genomic screening for variants associated with endocrine tumor syndromes in a large, healthcare-based cohort. BMC Med 2022; 20:205. [PMID: 35668420 PMCID: PMC9172012 DOI: 10.1186/s12916-022-02375-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/12/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In current care, patients' personal and self-reported family histories are primarily used to determine whether genetic testing for hereditary endocrine tumor syndromes (ETS) is indicated. Population genomic screening for other conditions has increased ascertainment of individuals with pathogenic/likely pathogenic (P/LP) variants, leading to improved management and earlier diagnoses. It is unknown whether such benefits occur when screening broader populations for P/LP ETS variants. This manuscript assesses clinical utility outcomes of a large, unselected, healthcare-based genomic screening program by describing personal and family history of syndrome-related features, risk management behaviors after result disclosure, and rates of relevant post-disclosure diagnoses in patient-participants with P/LP ETS variants. METHODS Observational study of individuals informed of a P/LP variant in MEN1, RET, SDHAF2, SDHB, SDHC, SDHD, or VHL through Geisinger's MyCode Community Health Initiative between June 2016 and October 2019. Electronic health records (EHRs) of participants were evaluated for a report of pre-disclosure personal and self-reported family histories and post-disclosure risk management and diagnoses. RESULTS P/LP variants in genes of interest were identified in 199 of 130,490 (1 in 656) adult Geisinger MyCode patient-participants, 80 of which were disclosed during the study period. Eighty-one percent (n = 65) did not have prior evidence of the result in their EHR and, because they were identified via MyCode, were included in further analyses. Five participants identified via MyCode (8%) had a personal history of syndrome-related features; 16 (25%) had a positive self-reported family history. Time from result disclosure to EHR review was a median of 0.7 years. Post-disclosure, 36 (55.4%) completed a recommended risk management behavior; 11 (17%) were diagnosed with a syndrome-related neoplasm after completing a risk management intervention. CONCLUSIONS Broader screening for pathogenic/likely pathogenic variants associated with endocrine tumor syndromes enables detection of at-risk individuals, leads to the uptake of risk management, and facilitates relevant diagnoses. Further research will be necessary to continue to determine the clinical utility of screening diverse, unselected populations for such variants.
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Affiliation(s)
| | - Nicole M Ortiz
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | | | | | | | | | - Madiha M Alvi
- Endocrinology, Diabetes, and Metabolism, Geisinger, Danville, PA, USA.,Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | | | | | - Nicholas C Purdy
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA.,Otolaryngology, Geisinger, Danville, PA, USA
| | - Marc S Williams
- Genomic Medicine Institute, Geisinger, Danville, PA, USA.,Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Amy C Sturm
- Genomic Medicine Institute, Geisinger, Danville, PA, USA.,Geisinger Commonwealth School of Medicine, Scranton, PA, USA.,Heart and Vascular Institute, Geisinger, Danville, PA, USA
| | - Adam H Buchanan
- Genomic Medicine Institute, Geisinger, Danville, PA, USA.,Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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8
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Fugaru I, Goudie C, Capolicchio JP. Von Hippel-Lindau disease and rapidly progressing pheochromocytomas in siblings. Fam Cancer 2021; 21:229-233. [PMID: 33877494 DOI: 10.1007/s10689-021-00252-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
Von Hippel-Lindau (VHL) disease is an autosomal dominant inherited condition with a predisposition to the development of a variety of tumors including pheochromocytomas. A number of cancer surveillance protocols for patients with VHL have been developed, all of which are based on expert opinion. We report a case of two brothers with a strong family history of VHL type 2 due to a pathogenic germline VHL variant, specifically, a surface missense substitution, with a rapidly progressive clinical course that both presented with a large adrenal mass. Both brothers presented with large pheochromocytomas, the earliest presentation being at age 7, despite routine screening. The rapid progression and early presentation of these patients raises an important discussion around the commonly used surveillance protocols for pheochromocytoma in pediatric patients with VHL and missense mutations. We conclude that a more accelerated surveillance protocol may be adequate for VHL families with a high pheochromocytoma risk.
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Affiliation(s)
- Ioana Fugaru
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Catherine Goudie
- Division of Hematology-Oncology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - John-Paul Capolicchio
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada. .,Division of Pediatric Urology, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, 1001 Decarie blvd., Suite B4.2916, Montreal, QC, H4A 3J1, Canada.
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9
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Khan HA, Shahzad MA, Iqbal F, Awan MA, Khan QA, Saatci AO, Abbass A, Hussain F, Hussain SA, Ali A, Ali W. Ophthalmological Aspects of von-Hippel-Lindau Syndrome. Semin Ophthalmol 2021; 36:531-540. [PMID: 33780299 DOI: 10.1080/08820538.2021.1897851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: von Hippel-Lindau (VHL) syndrome is a multisystem neoplastic disorder involving eyes, central nervous system, kidneys, spine, and other tissues. A retinal capillary hemangioma (RCH) is the earliest manifestation of the VHL disease in most cases.Areas covered:This paper aims to provide an up-to-date review of the current literature about von Hippel-Lindau syndrome. Molecular background, systemic and ocular features of the diseases as well as the utility of newer imaging modalities in diagnosis and monitoring of ocular VHL disease have been described. Besides, we have discussed newer treatment modalities and therapeutic targets.Conclusion: Modern imaging technologies like optical coherence tomography and optical coherence tomography angiography are tools of the trade, in making an appropriate diagnosis and monitoring disease activity and response to treatment. Peripheral RCH may be treated using laser photocoagulation in tumors up to 3000 µm. Vascular endothelial growth factor suppression can help in reducing tumor activity and stabilize the tumor size; however, it does not regress the RCH.
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Affiliation(s)
- Hashim Ali Khan
- Ophthalmology department, SEHHAT Foundation Hospital, Danyore, Gilgit, Pakistan.,School of Optometry & Department of Ophthalmology, The University of Faisalabad, Faisalabad, Pakistan
| | | | - Fatima Iqbal
- School of Optometry & Department of Ophthalmology, The University of Faisalabad, Faisalabad, Pakistan.,School of Optometry and Vision Science - University of New South Wale, Sydney, Australia
| | - Muhammad Amer Awan
- Ophthalmology department, Shifa College of Medicine, Islamabad, Pakistan
| | - Qaim Ali Khan
- Ophthalmology department, Punch Medical College, AJK, Pakistan
| | | | - Ahmed Abbass
- Ophthalmology department, Shalamar Medical and Dental College, Lahore, Pakistan
| | - Fazil Hussain
- Department of General Medicine PHQ Hospital, Gilgit, Pakistan
| | - Syed Arif Hussain
- Neurosurgery department, Pakistan Institute of Medical Science (PIMS), Islamabad, Pakistan
| | - Atif Ali
- Department of Acute Medicine, Luton & Dunstable Hospital, Luton, UK
| | - Wajahat Ali
- Department of Internal Medicine, King's Mill Hospital, Sutton-in-Ashfield, Nottinghamshire, UK
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Szalat A, Oleinikov K, Nahmias A, Meiner V, Ben-Haim S, Atlan K, Lev-Cohain N, Appelbaum L, Gomori M, Mazeh H, Khalaileh A, Pe'er J, Lossos A, Shoshan Y, Grozinsky-Glasberg S, Gross DJ. VHL-Related Neuroendocrine Neoplasms And Beyond: An Israeli Specialized Center Real-Life Report. Endocr Pract 2020; 26:1131-1142. [PMID: 33471715 DOI: 10.4158/ep-2020-0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/18/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Von Hippel-Lindau (VHL) syndrome is a rare and complex disease. In 1996, we described a 3 generation VHL 2A kindred with 11 mutation carriers. We aim to share our experience regarding the long-term follow-up of this family and the management of all our other VHL patients focusing on frequently encountered neuroendocrine neoplasms: pheochromocytoma/paraganglioma and pancreatic neuroendocrine neoplasms (PNEN). METHODS All VHL patients in follow-up at our tertiary center from 1980 to 2019 were identified. Clinical, laboratory, imaging, and therapeutic characteristics were retrospectively analyzed. RESULTS We identified 32 VHL patients in 16 different families, 7/16 were classified as VHL 2 subtype. In the previously described family, the 4 initially asymptomatic carriers developed a neuroendocrine tumor; 7 new children were born, 3 of them being mutation carriers; 2 patients died, 1 due to metastatic PNEN-related liver failure. Pheochromocytoma was frequent (22/32), bilateral (13/22;59%), often diagnosed in early childhood when active screening was timely performed, associated with paraganglioma in 5/22, rarely malignant (1/22), and recurred after surgery in some cases after more than 20 years. PNEN occurred in 8/32 patients (25%), and was metastatic in 3 patients. Surgery and palliative therapy allowed relatively satisfactory outcomes. Severe disabling morbidities due to central-nervous system and ophthalmologic hemangiomas, and other rare tumors as chondrosarcoma in 2 patients and polycythemia in 1 patient were observed. CONCLUSION A multidisciplinary approach and long-term follow-up is mandatory in VHL patients to manage the multiple debilitating morbidities and delay mortality in these complex patients.
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Affiliation(s)
- Auryan Szalat
- From the Neuroendocrine Tumor Unit, Department of Endocrinology, ENETS Centre of Excellence.
| | - Kira Oleinikov
- From the Neuroendocrine Tumor Unit, Department of Endocrinology, ENETS Centre of Excellence
| | - Avital Nahmias
- From the Neuroendocrine Tumor Unit, Department of Endocrinology, ENETS Centre of Excellence
| | | | | | | | | | | | | | | | | | | | - Alexander Lossos
- the Leslie and Michael Gaffin Center for Neuro-Oncology, Departments of Oncology and Neurology
| | - Yigal Shoshan
- the Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - David J Gross
- From the Neuroendocrine Tumor Unit, Department of Endocrinology, ENETS Centre of Excellence
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11
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Chahoud J, McGettigan M, Parikh N, Boris RS, Iliopoulos O, Rathmell WK, Daniels AB, Jonasch E, Spiess PE. Evaluation, diagnosis and surveillance of renal masses in the setting of VHL disease. World J Urol 2020; 39:2409-2415. [PMID: 32936333 DOI: 10.1007/s00345-020-03441-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/03/2020] [Indexed: 01/06/2023] Open
Abstract
This brief report focuses on the evaluation and diagnosis of clinically localized renal masses in children and adults with Von Hippel-Lindau (VHL) disease. Counseling considerations pertinent to the urologists, medical oncologists, and multidisciplinary teams involved in the care of these patients are addressed. As practice patterns regarding the evaluation and management of VHL tumors can vary considerably, this report aims to provide guidance on some of the controversies associated with the diagnostic evaluation and initial management of localized renal masses in VHL patients.
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Affiliation(s)
- Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL, 33612, USA.
| | - Melissa McGettigan
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Nainesh Parikh
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL, 33612, USA
| | - Ronald S Boris
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Othon Iliopoulos
- Center for Cancer Research, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, 02139, USA
| | - W Kimryn Rathmell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Anthony B Daniels
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, UT MD Anderson Cancer Center, 1515 Holcombe Ave, Houston, TX, 77030, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL, 33612, USA
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12
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Därr R, Kater J, Sekula P, Bausch B, Krauss T, Bode C, Walz G, Neumann HP, Zschiedrich S. Clinical decision making in small non-functioning VHL-related incidentalomas. Endocr Connect 2020; 9:834-844. [PMID: 32869749 PMCID: PMC7487196 DOI: 10.1530/ec-20-0208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 01/26/2023]
Abstract
The optimal treatment strategy for patients with small non-functioning VHL-related incidentalomas is unclear. We searched the Freiburg VHL registry for patients with radiologic evidence of pheochromocytoma/paraganglioma (PHEO/PGL). In total, 176 patients with single, multiple, and recurrent tumours were identified (1.84 tumours/patient, range 1-8). Mean age at diagnosis was 32 ± 16 years. Seventy-four percent of tumours were localised to the adrenals. Mean tumour diameter was 2.42 ± 2.27 cm, 46% were <1.5 cm. 24% of tumours were biochemically inactive. Inactive tumours were significantly smaller than active PHEO/PGL at diagnosis (4.16 ± 2.80 cm vs 1.43 ± 0.45 cm; P < 0.025) and before surgery (4.89 ± 3.47 cm vs 1.36 ± 0.43 cm; P < 0.02). Disease was stable in 67% of 21 patients with evaluable tumours ≤1.5 cm according to RECIST and progressed in 7. Time till surgery in these patients was 29.5 ± 20.0 months. A total of 155 patients underwent surgery. PHEO/PGL was histologically excluded in 4 and proven in 151. Of these, one had additional metastatic disease, one harboured another tumour of a different type, and in 2 a second surgery for suspected disease recurrence did not confirm PHEO/PGL. Logistic regression analysis revealed 50% probability for a positive/negative biochemical test result at 1.8 cm tumour diameter. Values of a novel symptom score were positively correlated with tumour size (Rs = 0.46, P < 0.0001) and together with a positive biochemistry a linear size predictor (P < 0.01). Results support standardised clinical assessment and measurement of tumour size and metanephrines in VHL patients with non-functioning incidentalomas <1.5 cm at one year following diagnosis and at individualised intervals thereafter depending on evolving growth dynamics, secretory activity and symptomatology.
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Affiliation(s)
- Roland Därr
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Correspondence should be addressed to R Därr:
| | - Jonas Kater
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peggy Sekula
- Institute of Genetic Epidemiology, University Medical Center Freiburg, Freiburg, Germany
| | - Birke Bausch
- Department of Medicine II, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Krauss
- Department of Radiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerd Walz
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hartmut P Neumann
- Section for Preventive Medicine, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Zschiedrich
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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13
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Wang J, Peng X, Chen C, Ning X, Peng S, Li T, Liu S, Hong B, Zhou J, Ma K, Cai L, Gong K. Intra-Familial Phenotypic Heterogeneity and Telomere Abnormality in von Hippel- Lindau Disease: Implications for Personalized Surveillance Plan and Pathogenesis of VHL-Associated Tumors. Front Genet 2019; 10:358. [PMID: 31068970 PMCID: PMC6491623 DOI: 10.3389/fgene.2019.00358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/03/2019] [Indexed: 01/10/2023] Open
Abstract
von Hippel-Lindau (VHL) disease is a hereditary cancer syndrome with poor survival. The current recommendations have proposed uniform surveillance strategies for all patients, neglecting the obvious phenotypic varieties. In this study, we aim to confirm the phenotypic heterogeneity in VHL disease and the underlying mechanism. A total of 151 parent-child pairs were enrolled for genetic anticipation analysis, and 77 sibling pairs for birth order effect analysis. Four statistical methods were used to compare the onset age of patients among different generations and different birth orders. The results showed that the average onset age was 18.9 years earlier in children than in their parents, which was statistically significant in all of the four statistical methods. Furthermore, the first-born siblings were affected 8.3 years later than the other ones among the maternal patients. Telomere shortening was confirmed to be associated with genetic anticipation in VHL families, while it failed to explain the birth order effect. Moreover, no significant difference was observed for overall survival between parents and children (p = 0.834) and between first-born patients and the other siblings (p = 0.390). This study provides definitive evidence and possible mechanisms of intra-familial phenotypic heterogeneity in VHL families, which is helpful to the update of surveillance guidelines.
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Affiliation(s)
- Jiangyi Wang
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiang Peng
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Department of Urology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Cen Chen
- School of Statistics, Renmin University, Beijing, China
| | - Xianghui Ning
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuanghe Peng
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Teng Li
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Department of Urology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shengjie Liu
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China.,Department of Urology, Beijing Hospital, Beijing, China
| | - Baoan Hong
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Jingcheng Zhou
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Kaifang Ma
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Lin Cai
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Kan Gong
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
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14
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Rednam SP, Erez A, Druker H, Janeway KA, Kamihara J, Kohlmann WK, Nathanson KL, States LJ, Tomlinson GE, Villani A, Voss SD, Schiffman JD, Wasserman JD. Von Hippel-Lindau and Hereditary Pheochromocytoma/Paraganglioma Syndromes: Clinical Features, Genetics, and Surveillance Recommendations in Childhood. Clin Cancer Res 2018; 23:e68-e75. [PMID: 28620007 DOI: 10.1158/1078-0432.ccr-17-0547] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/24/2017] [Accepted: 04/27/2017] [Indexed: 11/16/2022]
Abstract
Von Hippel-Lindau disease (vHL) is a hereditary tumor predisposition syndrome that places affected individuals at risk for multiple tumors, which are predominantly benign and generally occur in the central nervous system or abdomen. Although the majority of tumors occur in adults, children and adolescents with the condition develop a significant proportion of vHL manifestations and are vulnerable to delayed tumor detection and their sequelae. Although multiple tumor screening paradigms are currently being utilized for patients with vHL, surveillance should be reassessed as the available relevant clinical information continues to expand. We propose a new vHL screening paradigm similar to existing approaches, with important modifications for some tumor types, placing an emphasis on risks in childhood. This includes advancement in the timing of surveillance initiation and increased frequency of screening evaluations. Another neuroendocrine-related familial condition is the rapidly expanding hereditary paraganglioma and pheochromocytoma syndrome (HPP). The tumor spectrum for patients with HPP syndrome includes paragangliomas, pheochromocytomas, renal cancer, and gastrointestinal stromal tumors. The majority of patients with HPP syndrome harbor an underlying variant in one of the SHDx genes (SDHA, SDHB, SDHC, SDHD, SDHA, and SDHAF2), although other genes also have been described (MAX and TMEM127). Annual screening for elevated plasma or urine markers along with complete blood count and biennial whole-body MRI accompanied by focal neck MRI is recommended for older children and adults with HPP syndrome to detect tumors early and to decrease morbidity and mortality from HPP-related tumors. Clin Cancer Res; 23(12); e68-e75. ©2017 AACRSee all articles in the online-only CCR Pediatric Oncology Series.
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Affiliation(s)
- Surya P Rednam
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | - Ayelet Erez
- Department of Biological Regulation, Weizmann Institute of Science, Rehovot, Israel
| | - Harriet Druker
- Division of Haematology/Oncology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine A Janeway
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts
| | - Junne Kamihara
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts
| | - Wendy K Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Katherine L Nathanson
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lisa J States
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gail E Tomlinson
- Department of Pediatrics, Division of Hematology and Oncology and Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Anita Villani
- Division of Haematology/Oncology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Stephan D Voss
- Department of Radiology, Children's Hospital, Boston, Massachusetts
| | - Joshua D Schiffman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.,Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jonathan D Wasserman
- Division of Endocrinology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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15
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Feletti A, Anglani M, Scarpa B, Schiavi F, Boaretto F, Zovato S, Taschin E, Gardi M, Zanoletti E, Piermarocchi S, Murgia A, Pavesi G, Opocher G. Von Hippel-Lindau disease: an evaluation of natural history and functional disability. Neuro Oncol 2016; 18:1011-20. [PMID: 26763786 DOI: 10.1093/neuonc/nov313] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/16/2015] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Although many studies have been published about specific lesions characterizing von Hippel-Lindau(VHL) disease, none have dealt with the natural history of the whole disease and the consequent disabilities. We aim to define the comprehensive natural history of VHL disease and to describe the functional disabilities and their impact upon patients' quality of life, thereby tailoring the follow-up schedule accordingly. METHODS We performed a prospective analysis on 128 VHL-affected patients beginning in 1996. For each affected organ, we defined intervals between the first and subsequent VHL-related manifestations and compared them with current VHL surveillance protocols. We looked for any association of the number of involved organs with age, sex, type of VHL gene mutation, and functional domain mutation. Ultimately, we assessed the organ-specific disabilities caused by VHL disease. RESULTS Hemangioblastomas show different patterns of progression depending on their location, whereas both renal cysts and carcinomas have similar progression rates. Surgery for pheochromocytoma and CNS hemangioblastoma is performed earlier than for pancreatic or renal cancer. The number of involved organs is associated with age but not with sex, type of VHL gene mutation, or functional domain mutation. A thorough analysis of functional disabilities showed that age is related to the first-appearing functional impairment, but it is not predictive of the final number of disabilities. CONCLUSIONS Our study defines the disease progression and provides a comprehensive view of the syndrome over time. We analyzed for the first time the functional disability of VHL patients, assessing the progression for each function.
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Affiliation(s)
- Alberto Feletti
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Mariagiulia Anglani
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Bruno Scarpa
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Francesca Schiavi
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Francesca Boaretto
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Stefania Zovato
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Elisa Taschin
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Mario Gardi
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Elisabetta Zanoletti
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Stefano Piermarocchi
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Alessandra Murgia
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Giacomo Pavesi
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
| | - Giuseppe Opocher
- Department of Neurosciences, Neurosurgery Unit, NOCSAE Modena Hospital, Modena, Italy (A.F., G.P.); Department of Medicine-DIMED, Section of Radiology, University of Padova, Italy (M.A.); Department of Statistical Sciences, University of Padova, Italy (B.S.); Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padova, Italy (F.S., F.B., S.Z., E.T., G.O.); Department of Urology, Ospedale Sant'Antonio, Padova, Italy (M.G.); Department of Neurosciences, Otosurgery Unit, University of Padova, Italy (E.Z.); Department of Neurosciences, Ophthalmology Unit, University of Padova, Italy (S.P.); Department of Women's and Children's Health, Pediatric Neurology Unit, University of Padova, Italy (A.M.); Department of Medicine-DIMED, University of Padova, Italy (G.O.)
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Manuel N, Ricardo P, Pilar GP, Miguel RM. Perspectives in Pediatric Pathology, Chapter 12. Congenital Epididymal Anomalies. Pediatr Dev Pathol 2016; 19:12-23. [PMID: 25119979 DOI: 10.2350/14-04-1473-pb.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Nistal Manuel
- 1 Department of Pathology, Hospital La Paz, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo No. 2, Madrid 28029, Spain
| | - Paniagua Ricardo
- 2 Department of Cell Biology, Universidad de Alcala, Madrid, Spain
| | - González-Peramato Pilar
- 1 Department of Pathology, Hospital La Paz, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo No. 2, Madrid 28029, Spain
| | - Reyes-Múgica Miguel
- 3 Department of Pathology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, One Children's Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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Billen P, Vanderschueren D, Blockmans D. HYPOCALCEMIA: A RARE COMPLICATION OF VON HIPPEL-LINDAU DISEASE. Acta Clin Belg 2014; 60:201-4. [PMID: 16279402 DOI: 10.1179/acb.2005.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
von Hippel-Lindau disease is a hereditary neoplastic syndrome, characterized by malignant and benign lesions in multiple organs. Pancreatic involvement is very common and is in general asymptomatic. We describe a case of malabsorption with severe hypocalcemia in a patient with von Hippel-Lindau disease, caused by exocrine pancreatic insufficiency, probably due to severe cystic transformation of the pancreas.
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Affiliation(s)
- P Billen
- Dienst Algemeen Inwendige Geneeskunde, Universitair Ziekenhuis Gasthuisberg, Leuven, België
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18
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Familial syndromes associated with intracranial tumours: a review. Childs Nerv Syst 2014; 30:47-64. [PMID: 24193148 DOI: 10.1007/s00381-013-2309-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 10/15/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Most cancers of the central nervous system (CNS) occur sporadically in the absence of any known underlying familial disorder or multi-systemic syndrome. Several syndromes are associated with CNS malignancies, however, and their recognition has significant implications for patient management and prognosis. Patients with syndrome-associated CNS malignancies often have multiple tumours (either confined to one region or distributed throughout the body), with similar or different histology. OBJECTIVE This review examines syndromes that are strongly associated with CNS cancers: the phakomatosis syndromes, familial syndromes such as Li-Fraumeni and familial polyposis syndromes and dyschondroplasia.
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A Detailed Immunohistochemical Analysis of 2 Cases of Papillary Cystadenoma of the Broad Ligament. Int J Gynecol Pathol 2012; 31:133-40. [DOI: 10.1097/pgp.0b013e318228f577] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Pazopanib therapy for cerebellar hemangioblastomas in von Hippel-Lindau disease: case report. Target Oncol 2012; 7:145-9. [PMID: 22374327 DOI: 10.1007/s11523-012-0214-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 02/17/2012] [Indexed: 10/28/2022]
Abstract
von Hippel-Lindau (VHL) disease is a genetically acquired multisystem tumor syndrome of the viscera and central nervous system (CNS). The most common tumors associated with this disease are histologically benign, slow-growing CNS hemangioblastomas affecting the retina, cerebellum, brainstem, spinal cord or nerve roots. With mean age at diagnosis of 30 years, CNS hemangioblastomas are usually the first manifestation of the disease. Ongoing clinical and radiological surveillance is required, with symptomatic lesions necessitating treatment. As tumor growth is inevitable during the lifetime of most VHL patients, and the multiplicity of tumors may preclude surgical cure, the search for effective therapies is ongoing. Here we provide the first report demonstrating clinical and radiological anti-tumor response using pazopanib, a small molecule multi-receptor tyrosine kinase inhibitor, in a patient with treatment-refractory VHL-associated CNS hemangioblastoma. Treatment initiation with daily oral pazopanib (800 mg/day) resulted in significant neurologic improvement and radiologic tumor volume reduction.
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Bertelsen M, Kosteljanetz M. An evaluation of the Danish national clinical guidelines for von Hippel-Lindau (VHL). Acta Neurochir (Wien) 2011; 153:35-41; discussion 41. [PMID: 20865287 DOI: 10.1007/s00701-010-0786-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 08/23/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE Von Hippel-Lindau (VHL) is a rare hereditary and potentially fatal cancer syndrome. Because of its unpredictable manifestations in various organ systems, surveillance is not linked to a single department and may therefore be incomplete. Denmark published national guidelines for the surveillance of patients with manifest and possible VHL in 2005 and was one of the first countries to do so. The present study is the first of its kind; patients with suspected and manifest VHL were followed at a single institution according to the national guidelines. The purpose was to evaluate (1) to what extent the guidelines were being followed and (2) what findings were disclosed. METHODS The study included 27 individuals with diagnosed (14 patients) or suspected (13 patients) VHL, observing the Danish VHL guidelines at the Department of Neurosurgery, Rigshospitalet, Denmark, from October 2002 to April 2008. The data were collected by reviewing patient records. RESULTS Manifestations that influenced the treatment were revealed in 48% of the patients, and 26% of the patients demonstrated asymptomatic manifestations. All investigations were conducted at a lower frequency than recommended. Individuals diagnosed with VHL were subjected to more clinical testing than individuals with suspected VHL. CONCLUSIONS This study shows that the national clinical guidelines were not being fully complied with. The investigations revealing the most serious VHL manifestations were those carried out with a frequency closest to the recommendations. Many investigations led to clinical consequences. Therefore, we recommend that all patients with suspected or manifest VHL are monitored according to structured clinical guidelines.
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Affiliation(s)
- Mette Bertelsen
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.
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23
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Abstract
Verbeke C S (2010) Histopathology 56, 669-682 Endocrine tumours of the pancreas Histopathology reporting of pancreatic endocrine neoplasms is complex. The tumours can exhibit a variety of morphological appearances, which often require careful differential diagnostic consideration. Prediction of tumour behaviour and clinical outcome is based on the World Health Organization classification and TNM staging and grading system, which share some criteria and premises, but differ significantly in others. Clinicopathological correlation through discussion at multidisciplinary team meetings is of paramount importance. In this review special emphasis is given to the items of information that can and should be provided by the pathologist to allow optimal patient management. The review further discusses areas of current controversy and uncertainty, of which pathologists participating in multidisciplinary discussions should be aware.
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Abstract
Endocrine and neuroendocrine cells form a large and diverse array of cell types. They are present in the form of specialized organs, such as the pituitary, parathyroid, thyroid, and adrenal gland, or in the form of the diffuse neuroendocrine system in the respiratory and digestive tracts. Neuroendocrine tumors are a heterogeneous group of neoplasms, yet they present certain unifying features. These include frequent hormonal overproduction that leads to specific symptoms and a typical immunohistochemical staining profile with chromogranin A and synaptophysin reactivity. Over the past decades, many neuroendocrine tumors have been described in the context of heritable tumor syndromes, and there exist several syndromes that are almost entirely composed of neuroendocrine tumors. Tumors occurring as part of these hereditary syndromes are characterized by specific genetic abnormalities that have helped our understanding of tumorigenesis, and they frequently appear at a young age. It is therefore important for the pediatric pathologist to be aware of specific histologic characteristics of neuroendocrine tumors in childhood and of their association with specific tumor syndromes. This may alert other clinicians to the possibility of multiple tumors in the patient or his family members. This review focuses on hereditary syndromes with neuroendocrine tumors, including multiple endocrine neoplasia types 1 and 2, Von Hippel-Lindau disease, neurofibromatosis type 1, Carney complex, pheochromocytoma-paraganglioma syndrome, and familial nonmedullary thyroid carcinoma. In addition, several individual neuroendocrine tumors are described, such as medullary thyroid carcinoma, gastroenteropancreatic tumors, pheochromocytoma, and paraganglioma, emphasizing specific histopathologic characteristics.
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Affiliation(s)
- José Gaal
- Department of Pathology, Josephine Nefkens Institute, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
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Bilateral papillary cystadenoma of the mesosalpinx: a rare manifestation of Von Hippel-Lindau disease. Arch Gynecol Obstet 2010; 282:343-6. [PMID: 20157715 DOI: 10.1007/s00404-010-1386-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 01/25/2010] [Indexed: 02/07/2023]
Abstract
We report a rare case of a woman with bilateral papillary cystadenomata of the broad ligament with von Hippel-Lindau disease (VHL) (other manifestations: capillary hemangioblastomas of the spinal cord). Patient surveillance is important, because in the course of VHL-associated tumors malignant lesions may arise that are relevant for the prognosis.
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Abstract
von Hippel-Lindau disease (vHL) is a hereditary multisystem cancer syndrome requiring lifelong prophylactic surveillance. Current surveillance recommendations rely on best medical judgement and no evidence of effect exists. We aimed to evaluate the capability of surveillance in manifestation detection, before these turn symptomatic, in order to prevent disabling or even fatal outcomes. We focus on surveillance of central nervous system (CNS) hemangioblastomas, retinal hemangiomas and renal cell carcinoma (RCC) as these have the most severe consequences. On the basis of full medical records from 54 living vHL-mutation carriers, risks of intercurrent manifestations in-between surveillance examinations were determined and clinical consequences of surveillance findings evaluated. Current recommendations of annual ophthalmic and abdominal examinations corresponded to acceptably low intercurrent manifestation risks (1.7% and 1.2%, respectively), whereas recommendations of biennial CNS imaging corresponded to a risk of 7.2%. Annual CNS examinations, however, significantly reduces this risk to 2.7%. Furthermore, most CNS manifestations found due to surveillance (71%, 106 of 150) had clinical consequence for the patient. Also, pre-symptomatic surveillance increased cumulative incidence of clinical vHL diagnosis from 46% to 72% and from 89% to 94% by age 30 and 50 years, respectively. The present results promote optimization of surveillance, expectantly improving clinical vHL outcomes.
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Affiliation(s)
- M L M Poulsen
- Institute of Cellular and Molecular Medicine, Copenhagen University, Denmark.
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27
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Ercolino T, Becherini L, Valeri A, Maiello M, Gaglianò MS, Parenti G, Ramazzotti M, Piscitelli E, Simi L, Pinzani P, Nesi G, Degl'Innocenti D, Console N, Bergamini C, Mannelli M. Uncommon clinical presentations of pheochromocytoma and paraganglioma in two different patients affected by two distinct novel VHL germline mutations. Clin Endocrinol (Oxf) 2008; 68:762-8. [PMID: 18031321 DOI: 10.1111/j.1365-2265.2007.03131.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
CONTEXT The von Hippel-Lindau (VHL) syndrome is an inherited multitumour disorder characterized by clinical heterogeneity and high penetrance. Pheochromocytoma (Pheo) is present in 10%-15% of cases and can be isolated or associated with other lesions such as haemangioblastomas, kidney cysts or cancer and pancreatic lesions. In VHL patients, Pheos generally secrete norepinephrine and are located in the adrenals. Extra-adrenal Pheos (paragangliomas, PGLs) are rare. OBJECTIVE While performing genetic testing in patients affected by apparently sporadic Pheos or PGLs, we found two novel different VHL germline mutations in two females who presented with two distinct very uncommon clinical pictures. One patient was studied for the presence of an adrenal incidentaloma and the other for the presence of a neck tumour. METHODS AND RESULTS Patients coding regions and exon-intron boundaries of RET (exons 10, 11, 13-15), VHL, SDHD, SDHB and SDHC genes were amplified and sequenced. We identified two novel VHL point mutations: a L198V missense mutation in a 32-year-old female affected by a right adrenal compound and mixed tumour constituted by an epinephrine secreting Pheo, a ganglioneuroma and an adrenocortical adenoma, and a T152I missense mutation in a 24-year-old female affected by a left carotid body tumour. No other lesions were found in the patients or in the VHL mutation positive relatives. CONCLUSIONS These cases enlarge the list of VHL mutations and add new insights in the clinical variability of VHL disease, thus confirming the importance of genetic testing in patients affected by apparently sporadic Pheos or PGLs.
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Affiliation(s)
- Tonino Ercolino
- Department of Clinical Physiopathology, Division of Endocrinology, University of Florence, Florence, Italy
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A patient with bilateral pheochromocytoma as part of a Von Hippel-Lindau (VHL) syndrome type 2C. World J Surg Oncol 2007; 5:112. [PMID: 17922902 PMCID: PMC2169240 DOI: 10.1186/1477-7819-5-112] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Accepted: 10/08/2007] [Indexed: 11/24/2022] Open
Abstract
Background Von Hippel-Lindau (VHL) disease is an autosomal dominant inherited disease. It is relatively recent that type 2C was identified as a separate group solely presenting with pheochromocytomas. As an illustration, an interesting case is presented of a pregnant woman with refractory hypertension. It proved to be the first manifestation of bilateral pheochromocytomas. The family history may indicate the diagnosis, but only identification of a germ line mutation in the DNA of a patient will confirm carriership. Case presentation A 27 year pregnant patient with intra uterine growth retardation presented with hypertension and pre-eclampsia. Magnetic resonance imaging revealed bilateral adrenal pheochromocytoma. She underwent laparoscopic adrenelectomy and a missense mutation (Gly93Ser) in exon 1 of the VHL gene on chromosome 3 (p25 – p26) was shown in the patient, her father and her daughter confirming the diagnosis of VHL. Conclusion In almost all VHL families molecular genetic analysis of DNA will demonstrate an inherited mutation. Because of the involvement in several organs, periodic clinical evaluation should take place in a well coordinated, multidisciplinary setting. VHL disease can be classified into several subtypes. VHL type 2C patients present with pheochromocytomas without evidence of haemangioblastomas in the central nervous system and/or retina and a low risk of renal cell carcinoma. Therefore, in such families, periodic clinical screening can be focussed on pheochromocytomas.
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Langrehr JM, Bahra M, Kristiansen G, Neumann HPH, Neumann LM, Plöckinger U, Lopez-Hänninen E. Neuroendocrine tumor of the pancreas and bilateral adrenal pheochromocytomas. A rare manifestation of von Hippel-Lindau disease in childhood. J Pediatr Surg 2007; 42:1291-4. [PMID: 17618900 DOI: 10.1016/j.jpedsurg.2007.02.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND A 12-year-old girl presenting with intermittent epigastric pains and diarrhea was referred to our clinic. Diagnostic workup revealed nonfunctional bilateral adrenal pheochromocytomas as well as a neuroendocrine tumor of the pancreatic head. This is the first report on the combination of a neuroendocrine pancreatic tumor with adrenal pheochromocytoma in a pediatric patient with von Hippel-Lindau (VHL) disease. METHODS von Hippel-Lindau disease was confirmed by molecular genetic analysis of peripheral blood lymphocytes, which revealed the mutation VHL c. 695 G > A. The family history showed also VHL disease in the mother who carried the same mutation. RESULTS AND CONCLUSION Open laparotomy, organ-sparing enucleation of pheochromocytoma, and pylorus-preserving resection of the pancreatic head tumor were successfully performed. After an uneventful postoperative course, the child fully recovered. She was free of further manifestations of VHL disease 30 months after surgery.
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Affiliation(s)
- Jan M Langrehr
- Department for General, Visceral and Transplantation Surgery, Charité, Campus Virchow Clinic, 13353 Berlin, Germany.
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Petrella BL, Brinckerhoff CE. Tumor cell invasion of von Hippel Lindau renal cell carcinoma cells is mediated by membrane type-1 matrix metalloproteinase. Mol Cancer 2006; 5:66. [PMID: 17140440 PMCID: PMC1764426 DOI: 10.1186/1476-4598-5-66] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Accepted: 12/01/2006] [Indexed: 12/21/2022] Open
Abstract
Background Metastatic renal cell carcinoma (RCC) remains the leading cause of mortality in patients with clear cell RCC arising from mutations in the von Hippel Lindau (VHL) tumor suppressor. Successful RCC tumor suppression by VHL requires the negative regulation of hypoxia inducible factor alpha (HIF alpha) protein and its downstream targets. Thus, identification of HIF target genes responsible for RCC tumor progression will aid in the development of therapies for this disease. We previously identified membrane type-1 matrix metalloproteinase (MT1-MMP) as a transcriptional target of HIF-2alpha in RCC cells null for VHL and showed that MT1-MMP is overexpressed in these cells. MT1-MMP is a key regulator of tumor progression through its functions as a matrix-degrading enzyme, as well as its ability to cleave factors, such as adhesion molecules and other MMPs. The aim of this study was to investigate the contribution of MT1-MMP to the invasive potential of RCC cells using in vitro type I collagen degradation and invasion assays. Results We evaluated RCC cells wild-type (WT8) and null (pRc-9) for VHL for invasive characteristics and showed that the pRc-9 cells demonstrated a greater propensity for both invasion and degradation of a type I collagen matrix. Furthermore, overexpression of either HIF-2alpha or MT1-MMP in the poorly invasive cell line, WT8, promoted collagen degradation and invasion of these cells. Finally, using RNAi, we show that inhibition of MT1-MMP suppresses tumor cell invasion of RCC cells. Conclusion Our results suggest that MT1-MMP is a major mediator of tumor cell invasiveness and type I collagen degradation by VHL RCC cells that express either MT1-MMP or HIF-2alpha. As such, MT1-MMP may represent a novel target for anti-invasion therapy for this disease.
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Affiliation(s)
- Brenda L Petrella
- Department of Medicine, Norris Cotton Cancer Center, Dartmouth Medical School, Lebanon, NH, USA
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Muzumdar DP, Goel A, Fattepurkar S, Goel N. Endolymphatic sac carcinoma of the right petrous bone in Von Hippel–Lindau disease. J Clin Neurosci 2006; 13:471-4. [PMID: 16678727 DOI: 10.1016/j.jocn.2005.04.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2005] [Accepted: 04/27/2005] [Indexed: 11/22/2022]
Abstract
A large endolymphatic sac papillary adenocarcinoma in a patient with Von Hippel-Lindau (vHL) disease is reported. A 31-year-old man was treated for a left eye retinal angioma 10 years previously and had been blind in that eye since. He was admitted with progressive tinnitus, lower cranial nerve paresis and ataxia. Investigations revealed a vascular and bone-eroding petrous tumour. The entirely extradural tumour involved a large part of the petrous bone and extended into the cerebellopontine angle. The vascular tumour was radically resected using a presigmoid approach after feeding vessel embolisation. The literature on this rare clinical entity is briefly discussed.
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Affiliation(s)
- D P Muzumdar
- Department of Neurosurgery, King Edward VII Memorial Hospital, Seth G.S. Medical College, Parel, Mumbai 400012, India
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Medlej-Hashim M, Mégarbané A. [Pre-symptomatic diagnosis of severe hereditary diseases with late onset in Lebanon: a choice or a necessity?]. SANTE PUBLIQUE 2006; 17:617-26. [PMID: 16485442 DOI: 10.3917/spub.054.0617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Progress achieved in the field of molecular genetics has opened the door to pre-symptomatic diagnosis tests of several severe hereditary disease, a majority of which are dominant and appear later in life. Given the importance of diagnosis in some of the cases where medical supervision and prevention are possible, there are a number of ethical dilemmas with regards to most of these diseases that, unfortunately, do not have a cure or any preventive treatment available. Above and beyond the capacity for medical care provision, there is a very high level of pressure and anxiety felt by every member of a family who has someone affected by one of these diseases in that they might be a carrier of a mutated gene which could be the cause or source of illness. They carry the burden of uncertainty that they may have already transmitted this gene or could give it to any of their children, and often there is also a significant level of guilt when one is the carrier but not to be affected by the disease itself. More and more frequently in these types of cases, there is a strong desire to know--in order to better organise and plan one's life and that of one's potential future family in the instance where one wishes to found one. This article discusses these problems based upon the consideration of four examples of such diseases with late onset: Huntington's disease, the common forms of thyroid cancer, the familiar forms of a predisposition to breast and ovarian cancer, and von Hippel-Lindau syndrome. However, regardless of the type of disease, the decision to take a genetic test is solely the choice of the individual in question, and the person should be accompanied and guided in his or her reflection by a multi-disciplinary team who can advise him or her and initiate useful deliberations on the various possibilities, their advantages and their disadvantages.
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Affiliation(s)
- M Medlej-Hashim
- Université Saint Joseph, Faculté de Médecine, Unité de Génétique Médicale, BP 11-5076 Riad El Solh, Beyrouth 1107 2180, Liban
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Catapano D, Muscarella LA, Guarnieri V, Zelante L, D'Angelo VA, D'Agruma L. Hemangioblastomas of Central Nervous System: Molecular Genetic Analysis and Clinical Management. Neurosurgery 2005; 56:1215-21; discussion 1221. [PMID: 15918937 DOI: 10.1227/01.neu.0000159646.15026.d6] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Accepted: 01/13/2005] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Hemangioblastomas of the central nervous system (CNS) are benign neoplasms that may occur sporadically or in association with von Hippel-Lindau (VHL) disease. The proportion of primary symptomatic hemangioblastomas associated with VHL disease is estimated to be from 10 to 40%, but it seems to be underestimated. We investigated the frequency of VHL germline mutation in patients with symptomatic CNS hemangioblastoma without evidence of VHL disease to define the role of molecular genetic analysis in the management of such patients and their relatives. METHODS We analyzed 14 patients (6 female and 8 male; mean age, 43.5 yr) with no family history and no other clinical manifestations of VHL disease who had been operated on for symptomatic CNS hemangioblastoma. Exons 1, 2, and 3 of the VHL gene and their immediately flanking sequences were amplified by use of polymerase chain reaction followed by analysis with denaturing high-performance liquid chromatography and sequencing the anomalous samples. RESULTS Germline mutations of the VHL gene were identified in 2 (14%) of 14 patients. VHL gene mutation analysis was performed in both patients' family members, which showed another affected asymptomatic subject for VHL disease. The affected subjects were recommended for VHL disease surveillance protocol. CONCLUSION Molecular genetic analysis is a safer and more specific instrument to confirm or exclude VHL disease in patients with CNS hemangioblastoma, a negative family history, or absence of other known manifestations of the disease. Early identification of VHL mutation gene carriers is important for reducing disease morbidity and mortality. Nonsymptomatic family members will benefit from early VHL disease diagnosis or by being excluded as at-risk subjects, reducing the psychological and economic burden of screening and surveillance protocols.
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Affiliation(s)
- Domenico Catapano
- Casa Sollievo della Sofferenza Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy.
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Rankin EB, Higgins DF, Walisser JA, Johnson RS, Bradfield CA, Haase VH. Inactivation of the arylhydrocarbon receptor nuclear translocator (Arnt) suppresses von Hippel-Lindau disease-associated vascular tumors in mice. Mol Cell Biol 2005; 25:3163-72. [PMID: 15798202 PMCID: PMC1069599 DOI: 10.1128/mcb.25.8.3163-3172.2005] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Patients with germ line mutations in the VHL tumor suppressor gene are predisposed to the development of highly vascularized tumors within multiple tissues. Loss of pVHL results in constitutive activation of the transcription factors HIF-1 and HIF-2, whose relative contributions to the pathogenesis of the VHL phenotype have yet to be defined. In order to examine the role of HIF in von Hippel-Lindau (VHL)-associated vascular tumorigenesis, we utilized Cre-loxP-mediated recombination to inactivate hypoxia-inducible factor-1alpha (Hif-1alpha) and arylhydrocarbon receptor nuclear translocator (Arnt) genes in a VHL mouse model of cavernous liver hemangiomas and polycythemia. Deletion of Hif-1alpha did not affect the development of vascular tumors and polycythemia, nor did it suppress the increased expression of vascular endothelial growth factor (Vegf) and erythropoietin (Epo). In contrast, phosphoglycerokinase (Pgk) expression was substantially decreased, providing evidence for target gene-dependent functional redundancy between different Hif transcription factors. Inactivation of Arnt completely suppressed the development of hemangiomas, polycythemia, and Hif-induced gene expression. Here, we demonstrate genetically that the development of VHL-associated vascular tumors in the liver depends on functional ARNT. Furthermore, we provide evidence that individual HIF transcription factors may play distinct roles in the development of specific VHL disease manifestations.
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Affiliation(s)
- Erinn B Rankin
- Department of Medicine, 700 Clinical Research Bldg., 415 Curie Blvd., Philadelphia, PA 19104-6144, USA
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Joerger M, Koeberle D, Neumann HPH, Gillessen S. Von Hippel-Lindau disease--a rare disease important to recognize. Oncol Res Treat 2005; 28:159-63. [PMID: 15772467 DOI: 10.1159/000083860] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Von Hippel-Lindau disease (VHL) is an autosomal dominant multisystemic cancer syndrome due to a mutation of the VHL tumor suppressor gene on chromosome 3, region p25-26, with an incidence of 1/36,000 in newborns. Patients are at risk of developing cerebellar, spinal and retinal hemangioblastoma, renal cell carcinoma, pheochromocytoma, pancreatic neuroendocrine tumors, pancreatic and renal cysts, and epididymal cystadenoma. The most common causes of death from VHL are metastases from renal cell carcinoma and neurological complications from cerebellar hemangioblastomas. Molecular analysis of the VHL gene is clinically available and indicated in patients with known or suspected VHL. CASE REPORT A 19-year-old woman was surgically treated for cerebellar hemangioblastoma in 1998 and for renal cell carcinoma of the right side in 2002. Familial VHL was subsequently diagnosed as the patient's mother was found to be affected with bilateral polycystic kidney disease with chronic renal failure as well as hemangioblastoma of the retina and medulla oblongata. The mother underwent surgery for bilateral renal cell carcinoma in 2003. CONCLUSION The multitude of VHL-associated tumors and intra-familial variability in clinical expressivity render early diagnosis of VHL difficult. We therefore shortly illustrate the spectrum of clinical phenotypes and the VHL screening and surveillance guidelines.
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Affiliation(s)
- Markus Joerger
- Department of Medical Oncology, Antoni van Leeuwenhoek Hospital / The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Petrella BL, Lohi J, Brinckerhoff CE. Identification of membrane type-1 matrix metalloproteinase as a target of hypoxia-inducible factor-2 alpha in von Hippel-Lindau renal cell carcinoma. Oncogene 2005; 24:1043-52. [PMID: 15592504 PMCID: PMC1847637 DOI: 10.1038/sj.onc.1208305] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Metastatic renal cell carcinoma (RCC) resulting from the hereditary loss of the von Hippel-Lindau (VHL) tumor suppressor gene is the leading cause of death in VHL patients due to the deleterious effects of the metastatic tumor(s). VHL functions in the destruction of the alpha subunits of the heterodimeric transcription factor, hypoxia-inducible factor (HIF-1 alpha and HIF-2 alpha), in normoxic conditions. When VHL function is lost, HIF-alpha protein is stabilized, and target hypoxia-inducible genes are transcribed. The process of tumor invasion and metastasis involves the destruction of the extracellular matrix, which is accomplished primarily by the matrix metalloproteinase (MMP) family of enzymes. Here, we describe a connection between the loss of VHL tumor suppressor function and the upregulation of membrane type-1 MMP (MT1-MMP) gene expression and protein. Specifically, MT1-MMP is upregulated in VHL-/- RCC cells through an increase in gene transcription, which is mediated by the cooperative effects of the transcription factors, HIF-2 and Sp1. Further, we identify a functional HIF-binding site in the proximal promoter of MT1-MMP. To our knowledge, this is the first report to show direct regulation of MT1-MMP by HIF-2 and to provide a direct link between the loss of VHL tumor suppressor function and an increase in MMP gene and protein expression.
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Affiliation(s)
- Brenda L. Petrella
- Department of Biochemistry, Dartmouth Medical School, Lebanon, NH 03756, USA
| | - Jouko Lohi
- Department of Pathology, Haartman Institute, University of Helsinki and Helsinki University Central Hospital, Helsinki, FIN-00014, Finland
| | - Constance E. Brinckerhoff
- Department of Biochemistry, Dartmouth Medical School, Lebanon, NH 03756, USA
- Department of Medicine, Norris Cotton Cancer Center, Dartmouth Medical School, Lebanon, NH 03756, USA
- *To whom correspondence should be addressed. Constance E. Brinckerhoff, Ph.D. Norris Cotton Cancer Center, Dartmouth Medical School, Department of Medicine, 1 Medical Center Drive, Rubin Building, HB#7936, Lebanon, NH 03756, Telephone: (603)653-9957, Fax: (603)653-9952,
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Alexakis N, Connor S, Ghaneh P, Lombard M, Smart HL, Evans J, Hughes M, Garvey CJ, Vora J, Vinjamuri S, Sutton R, Neoptolemos JP. Hereditary pancreatic endocrine tumours. Pancreatology 2004; 4:417-33; discussion 434-5. [PMID: 15249710 DOI: 10.1159/000079616] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The two main types of hereditary pancreatic neuroendocrine tumours are found in multiple endocrine neoplasia type 1 (MEN-1) and von Hippel-Lindau disease (VHL), but also in the rarer disorders of neurofibromatosis type 1 and tuberous sclerosis. This review considers the major advances that have been made in genetic diagnosis, tumour localization, medical and surgical treatment and palliation with systemic chemotherapy and radionuclides. With the exception of the insulinoma syndrome, all of the various hormone excess syndromes of MEN-1 can be treated medically. The role of surgery however remains controversial ranging from no intervention (except enucleation for insulinoma), intervening for tumours diagnosed only by biochemical criteria, intervening in those tumours only detected radiologically (1-2 cm in diameter) or intervening only if the tumour diameter is > 3 cm in diameter. The extent of surgery is also controversial, although radical lymphadenectomy is generally recommended. Pancreatic tumours associated with VHL are usually non-functioning and tumours of at least 2 cm in diameter should be resected. Practice guidelines recommend that screening in patients with MEN-1 should commence at the age of 5 years for insulinoma and at the age of 20 years for other pancreatic neuroendocrine tumours and variously at 10-20 years of age for pancreatic tumours in patients with VHL. The evidence is increasing that the life span of patients may be significantly improved with surgical intervention, mandating the widespread use of tumour surveillance and multidisciplinary team management.
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Affiliation(s)
- N Alexakis
- Department of Surgery, Royal Liverpool University Hospital, Liverpool, UK
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Tseng BS, Haas-Kogan D. Neurocutaneous Syndromes and Associated CNS Tumors. PEDIATRIC ONCOLOGY 2004. [DOI: 10.1007/978-3-662-09227-9_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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