Identification of a second genetic alteration in patients with SHOX deficiency individuals: a potential explanation for phenotype variability

OBJECTIVE

Our study aimed to assess the impact of genetic modifiers on the significant variation in phenotype that is observed in individuals with SHOX deficiency, which is the most prevalent monogenic cause of short stature.

DESIGN AND METHODS

We performed a genetic analysis in 98 individuals from 48 families with SHOX deficiency with a target panel designed to capture the entire SHOX genomic region and 114 other genes that modulate growth and/or SHOX action. We prioritized rare potentially deleterious variants.

RESULTS

We did not identify potential deleterious variants in the promoter or intronic regions of the SHOX genomic locus. In contrast, we found eight heterozygous variants in 11 individuals from nine families in genes with a potential role as genetic modifiers. In addition to a previously described likely pathogenic (LP) variant in CYP26C1 observed in two families, we identified LP variants in PTHLH and ACAN, and variants of uncertain significance in NPR2, RUNX2, and TP53 in more affected individuals from families with SHOX deficiency. Families with a SHOX alteration restricted to the regulatory region had a higher prevalence of a second likely pathogenic variant (27%) than families with an alteration compromising the SHOX coding region (2.9%, P = .04).

CONCLUSION

In conclusion, variants in genes related to the growth plate have a potential role as genetic modifiers of the phenotype in individuals with SHOX deficiency. In individuals with SHOX alterations restricted to the regulatory region, a second alteration could be critical to determine the penetrance and expression of the phenotype.

Retrospective Analysis of Prognostic Factors in Pediatric Patients with Adrenocortical Tumor from Unique Tertiary Center with Long-Term Follow-Up

Pediatric adrenocortical tumors (PACTs) represent rare causes of malignancies. However, the south/southeast regions of Brazil are known to have a high incidence of PACTs because of the founder effect associated with a germline pathogenic variant of tumor suppressor gene TP53. We aimed to retrospectively analyze the types of variables among hormone production, radiological imaging, tumor staging, histological and genetic features that were associated with the occurrence of malignancy in 95 patients (71% females) with PACTs from a unique center. The worst prognosis was associated with those aged > 3 years (p < 0.05), high serum levels of 11-desoxicortisol (p < 0.001), tumor weight ≥ 200 g (p < 0.001), tumor size ≥ 5 cm (p < 0.05), Weiss score ≥ 5 (p < 0.05), Wieneke index ≥ 3 (p < 0.001) and Ki67 ≥ 15% (p < 0.05). Furthermore, patients with MacFarlane stage IV had an overall survival rate almost two times shorter than patients with other stages (p < 0.001). Additionally, the subtractions of BUB1B-PINK1 (<6.95) expression (p < 0.05) and IGF-IR overexpression (p = 0.0001) were associated with malignant behavior. These results helped identify patients who are likely to have an aggressive course; further multicenter prospective studies are required to confirm our results. In conclusion, PACTs with these patterns of prognostic factors could be treated using an adjuvant approach that may improve the overall survival in such patients.

RF02 | PMON189 Temporal and Social trends towards sex assignment and gender change in the 5α-reductase type 2 deficiency

 

5α-reductase type 2 (5αR2) deficiency is an autosomal recessive inherited condition affecting 46,XY individuals resulting from the inability to convert testosterone into dihydrotestosterone. Affected individuals present a range of external genitalia undervirilization at birth and pronounced masculinization at puberty. Unlike most other 46,XY DSD, the frequency of gender change among 5αR2 deficiency is high.

Objective

to analyze the 451 individuals carrying pathogenic 5αR2 variants in the SRD5A2 gene in both alleles (in homozygous or compound heterozygous state) in the literature (Pubmed, EMBASE, Medline) and websites (ensemble, HGMD, ClinVar) regarding sex assignment, external genitalia virilization (1-5 Sinnecker score), and gender change accordingly country income

Methods

A total of 357 cases out of 451 had clinical information. All patients included were divided between those born before or after 2006 (the DSD consensus year). Country income was based on the 2018 World Bank classification, classifying income into four categories: low, lower-middle, upper-middle, and high (www.worldbank.org). Categorical variables were analyzed using the Chi-square test followed by the Cramer's V. Continuous variables were analyzed either by Student t-test or ANOVA one way. A binary logistic regression was built using sex assignment and gender change as categorical dependent variables. A p<.05 was considered significant.

Results

When we divided the individuals into those diagnosed after and before 2006, the percentage of female sex assignments dropped from 72% to 56% (p<.0001), followed by an odds ratio reduction (from 2.52 to 1.65) for female sex assignment. Country income did not impact sex assignment (p=.21). However, most cases (86%) were reported from countries with high and upper-middle economies. The absence of reports from low-income countries may be due to several reasons, such as barriers to molecular diagnosis, scientific access, and specialized medical assistance. Most cases were assigned as female (69%). The overall rate of gender change was 25% (89 out 357). All but one changed their gender from female to male. The rate of gender change was significantly different across all countries (V=0.46; p<.001), but it ranged from 16% to 70%, and gender change was lower among those diagnosed after 2006 (p=.01). The association between less external genitalia virilization and female sex assignment was significant (p<.001). On the other hand, the virilization score was similar between those who kept or changed gender (p=.37). Neither the type of SRD5A2 variant (missense, nonsense, indel) nor zygosity (homo/hetero) impacted sex assignment or gender change.

Conclusion

An apparent temporal trend indicates an increased likelihood of affected 5αR2 deficiency individuals being raised as boys, providing a gender change drop. The external virilization degree influenced sex assignment, but it does not affect gender change. There is no correlation between either both sex assignment and gender development with 5αR2 genetics.

Presentation: Saturday, June 11, 2022 1:06 p.m. - 1:11 p.m., Saturday, June 11, 2022 1:06 p.m. - 1:11 p.m., Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

RF34 | PMON203 Copy Number Variant Analysis Reveals Novel Candidate Genes Associated with Primary Ovarian Insufficiency

 

Primary ovarian insufficiency (POI) is characterized by a heterogeneous genetic background. Moreover, the etiology of most POI cases remains unclear. Herein, our goal was to investigate the presence of rare deletions or duplications in patients presenting with POI, which could lead to identification of novel chromosomal regions and/or genes potentially associated with disease risk.

Patients and Methods

Sixty-six patients presenting idiopathic POI were evaluated; 44 had primary amenorrhea and 22 secondary amenorrhea. Chromosomal microarray analysis was performed to detect copy number variants (CNVs) using array-CGH or SNP-array. Identified CNVs were validated by population databases of either health individuals (Database of Genomic Variants - DGV) or patients carrying chromosomal structural alterations (DECIPHER). A set of rare CNVs was selected and annotated in regard to gene content and clinical associations using bioinformatic tools (RefSeq, OMIM, PubMed, Ovarian Kaleidoscope Database, and Mouse Genome Informatics).

Results

Fifteen rare CNVs were found in 13 patients, ten of them with primary amenorrhea. The identified CNVs comprised four deleted and 11 duplicated regions, in which the break points occurred intragenic in 8 of them. Most of the CNVs were mapped in the autosomes. Seven CNVs identified in 5 patients were classified as pathogenic or probably pathogenic; three were novel variants containing candidate genes associated with ovarian development [19q13.43 (NLRP5) and Xq13.2 (XIST)] or function [(2q37.3 (PER2)]. The other pathogenic CNVs were previously implicated in POI etiology; two of them [Xq27.2q28 del (14.5 Mb) and Xq22.1q27.1 dup (41.4 Mb)] were encompassed in a complex chromosome rearrangement, associated with 20p13 dup (2.7 Mb), and the last region was 15q25.2 deletion. Four VUS containing genes associated with ovarian development [2p23.1 (XDH and EHD3), 9p24.1 (KDM4C), 22q12.1 (ZNRF3)] or function [1p31.1 (PTGFR)] were identified.

Conclusion

CNVs analysis indicated a genetic etiology in 10% of these POI patients. New candidate genes associated with ovarian development and function were revealed.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:54 p.m. - 12:59 p.m.

Novel OTX2 loss of function variant associated with congenital hypopituitarism without eye abnormalities

OBJECTIVES

The normal development of the pituitary gland requires multiple induction signals and transcription factors encoded by more than 30 genes, including OTX2. OTX2 mutations have been described with eye abnormalities and variable congenital hypopituitarism, but rarely with hypopituitarism without ocular manifestations.

CASE PRESENTATION

We report a girl with hypopituitarism associated with pituitary hypoplasia and pituitary stalk atrophy, without ocular manifestations. NGS revealed a novel heterozygous mutation in OTX2 c.426dupC:p.(Ser143Leufs*2).

CONCLUSIONS

Mutations in the transcription factor OTX2 have been associated with ocular, craniofacial, and pituitary development anomalies. Here we describe a novel mutation in OTX2 associated with hypopituitarism without an ocular phenotype.

Adult Height in 299 Patients with Turner Syndrome with or without Growth Hormone Therapy: Results and Literature Review

CONTEXT

Treatment with growth hormone (GH) is considered effective in improving adult height (AH) in Turner syndrome (TS). However, there are few studies comparing AH between treated patients and a concurrent untreated group.

OBJECTIVE

To assess the efficacy of GH treatment in improving AH in TS and to review previous published studies with treated and untreated groups.

PARTICIPANTS AND METHODS

We retrospectively analyzed clinical data and AH of a large cohort of GH-treated (n = 168) and untreated (n = 131) patients with TS. Data are shown as median and interquartile range (IQR). We assessed pretreatment variables related with AH and compared our results with 16 studies that also included an untreated group.

RESULTS

The GH-treated group was 6.2 cm taller than the untreated group (AH = 149 cm [IQR 144.5-152.5 cm] vs. 142.8 cm [IQR 139-148 cm], p < 0.001) after 4.9 years of GH treatment with a dose of 0.35 mg/kg/week. AH SDS corrected for target height (TH) was 7.2 cm higher in GH-treated patients. AH SDS ≥-2 was more frequent in GH-treated patients (43%) than in untreated patients (16%, p < 0.001). AH SDS was also more frequently within the TH range in the GH-treated group (52%) than in the untreated group (15%, p < 0.001). Height SDS at start of GH therapy and TH SDS were positively correlated with AH (p < 0.001; R2 = 0.375). Considering the current result together with previous similar publications, a mean AH gain of 5.7 cm was observed in GH-treated (n = 696) versus untreated (n = 633) patients.

CONCLUSIONS

Our study strengthens the evidence for efficacy of GH therapy in patients with TS from different populations.

Mutations in MAP3K1 that cause 46,XY disorders of sex development disrupt distinct structural domains in the protein

Missense mutations in the gene, MAP3K1, are a common cause of 46,XY gonadal dysgenesis, accounting for 15-20% of cases [Ostrer, 2014, Disorders of sex development (DSDs): an update. J. Clin. Endocrinol. Metab., 99, 1503-1509]. Functional studies demonstrated that all of these mutations cause a protein gain-of-function that alters co-factor binding and increases phosphorylation of the downstream MAP kinase pathway targets, MAPK11, MAP3K and MAPK1. This dysregulation of the MAP kinase pathway results in increased CTNNB1, increased expression of WNT4 and FOXL2 and decreased expression of SRY and SOX9. Unique and recurrent pathogenic mutations cluster in three semi-contiguous domains outside the kinase region of the protein, a newly identified N-terminal domain that shares homology with the Guanine Exchange Factor (residues Met164 to Glu231), a Plant HomeoDomain (residues Met442 to Trp495) and an ARMadillo repeat domain (residues Met566 to Glu862). Despite the presence of the mutation clusters and clinical data, there exists a dearth of mechanistic insights behind the development imbalance. In this paper, we use structural modeling and functional data of these mutations to understand alterations of the MAP3K1 protein and the effects on protein folding, binding and downstream target phosphorylation. We show that these mutations have differential effects on protein binding depending on the domains in which they occur. These mutations increase the binding of the RHOA, MAP3K4 and FRAT1 proteins and generally decrease the binding of RAC1. Thus, pathologies in MAP3K1 disrupt the balance between the pro-kinase activities of the RHOA and MAP3K4 binding partners and the inhibitory activity of RAC1.

SUN-359 Preserved Bone Mineral Density In Adults With Classical Forms Of Congenital Adrenal Hyperplasia Submitted To Long-term Low Glucocorticoid Doses

The impact of long-term and supposedly physiological doses of corticosteroids on bone mineral density (BMD) in congenital adrenal hyperplasia (CAH) remains unknown. There are few studies with discordant results performed with mixed clinical forms and glucocorticoid (GC) regimens. Additionally, the effect of mineralocorticoid (MC) therapy has rarely been evaluated. Objective: To evaluate the BMD in adults with classical forms of CAH receiving the same GC regimen and to correlate with cumulative GC and MC doses since diagnosis. Methods: 34 adults (20 simple virilizing-SV/ 21 females) with good compliance (normal serum androgens levels for sex/age), who used cortisone acetate during childhood (16±3.3mg/m²/d) and dexamethasone after final height achievement (0.19±0.07mg/m²/d). The cumulative cortisone acetate, dexamethasone, total GC and MC doses (mg/m²) were calculated from diagnosis until the last evaluation. BMD was evaluated by z-scores (z) in the first and last densitometry. Physical activity and calcium intake were assessed by questionnaires; PTH and 25OH-Vitamin D levels were measured in the latter evaluation. GC/MC doses, clinical/laboratory data were correlated with z scores by linear regression, chi-square and t-tests. Results: The mean age in the last evaluation was 26±6yrs, duration of cortisone acetate therapy in the salt-wasting (SW) and SV forms was 14.8±4.2 and 10.5±4.3 yrs, respectively (p<0.01). The mean total femur z score was lower in the SW than SV form (p=0.04). The cumulative cortisone acetate dose had an inverse correlation with femoral neck z score (p<0.01). The total cumulative GC/MC doses had an inverse correlation with total femur z score (p<0.01). Low BMD (z<-2) was observed in 4 patients, 2/4 were recently pregnant. Serum vitamin D and PTH levels, frequency of physical activity, and calcium intake did not influence BMD. In the analysis of sequential BMD, during dexamethasone therapy, the mean interval between exams was 10.5±6yrs, and no association was found between dexamethasone cumulative dose and delta of lumbar z score. Conclusions: In this low GC dose regimen, CAH young adults do not present higher frequency of low BMD. In spite of a preserved BMD, cortisone acetate therapy during growth period in addition to MC replacement appear to have a synergistic negative effect on BMD at femoral sites. Low dexamethasone dose was not deleterious for bone health in adulthood.

SUN-382 Heterogeneous Clinical Presentation In Familial Cases Of Primary Macronodular Adrenal Hyperplasia (PMAH): The Influence Of Somatic Event Of ARMC5

Background: PMAH is a cause of adrenal hypercortisolism and it is a genetic disease linked to ARMC5 gene in most cases. Heterogenous phenotypes due to cortisol secretion and also due to different germline mutations in the ARMC5 have been described in around the world. The diversity of the molecular second hits in adrenal nodules may be able to justify different clinical outcome in the same family. We report two sisters with the same germline mutation and different clinical outcome. Case: A 45-year-old female patient presented with clinical evidence of hypercortisolism. Metabolic syndrome has been evidenced since the age of 35. Hormonal data confirmed an autonomous cortisol secretion. Abdominal CT revealed a bilateral enlargement of adrenal glands with multiples nodules (up to 2 cm, with 10 Housfield Units). ¹⁸F-FDG-PET/CT identified a slight SUV (left SUV 3.4 and right SUV 2.7). A heterozygous germline pathogenic variant of ARMC5 was identified at exon 1: c.165_166insG, p.Ile58Asnfs*45 at BTB (POZ) domain associated with a somatic LOH of the germline mutation. In 2013, the patient underwent Adrenal Sparing Surgery (ASS). She presented an excellent control of metabolic syndrome associated with adrenal insufficiency (AI) for 12 months. After 2 years a clinical recurrence of hypercortisolism was observed and confirmed by laboratory data. A new abdominal ¹⁸F-FDG-PET/CT and CT showed an increase of SUV and enlargement of the right residual adrenal gland (SUV - 3.4). The patient was submitted to a partial right adrenalectomy. Interesting, she did not present total or partial AI after the second surgical procedure. Inversely, her sister (46 years of age), with classical Cushing´s syndrome and carrier of same germline mutation (with similar hormonal data and SUV of ¹⁸F-FDG-PET/CT), presented a long-term remission of hypercortisolism after ASS. The analysis of somatic mutation of ARMC5 revealed a new event c.2082_2088delCCCGCTC, p.Pro695Serfs*20 in heterozygous status at exon 6. Analysis of PMAH sections HE stained showed a different pattern in the proportion and distribution of clusters of compact cells (60%) relative to clear spongiocytic cells. Her sister presented 13% of compact cells, similar to the PMAH pattern. Discussion: The macronodules of PMAH are composed of clear spongiocytic cells which preferentially express 3βHSD steroidogenic enzyme, and small or compact cells, which differentially express CYP17A1 steroidogenic enzyme and are located in dispersed clusters among the clear cells. CYP17A1 has both 17α-hydroxylase activity and 17,20-lyase activity. Conclusion: The somatic events of ARMC5 should be considered and could be involved in heterogeneous cortisol secretion and clinical presentation in familial cases with different outcome. Further familial cohorts and functional studies should increase our understanding of this challenged adrenal disorder.

SAT-320 A Synonymous Pathogenic Variant (p.l180=) in SDHB Gene Identified in a Young Patient with Abdominal Paraganglioma

Background: Pheochromocytomas and paragangliomas (PPGLs) are neuroendocrine tumors derived from chromaffin cells. More than 30% of patients with PPGL have a hereditary predisposition. To date, at least 14 tumor susceptibility genes have been described. Mutations in the succinate dehydrogenase complex iron sulfur subunit B gene (SDHB) are more associated with paragangliomas and metastatic disease. Patients who are young, with larger tumors (>6 cm), positive genetic testing (especially SDHB) or paraganglioma have a higher risk of metastasis development. Case Report: A 14-yr-old boy was referred to investigate severe hypertension and paroxysmal headache, pallor and tachycardia. Biochemical testing for catecholamine-secreting PPGLs showed: 24h urine metanephrines 1.9 µg (normal range, 0.05 to 1.2), plasma normetanephrine 13.3 nmol/L (<0.9 nmol/L), plasma metanephrine <0.2 nmol/L (<0.5 nmol/L), 24h urine norepinephrine 987 µg (14 to 80), 24h urine epinephrine 0 (0.5 to 20 µg) and 24h urine dopamine 391 µg (65 to 400). Magnetic resonance imaging (MRI) revealed a 6.5 cm heterogenous and high-vascular mass in right adrenal gland topography. A strong positive uptake was evidenced in the metaiodobenzylguanidine (MIBG) scintigraphy. A selective α₁-receptor blocker (prazosin) was started to control blood pressure and adrenergic symptoms. The patient underwent laparoscopic surgery and anatomopathological analysis revealed a 5.5 cm paraganglioma (PASS criteria= 3). The normal right adrenal gland was identified in the histopathology and there was no continuity between normal adrenal gland and neoplasia. After one year of follow-up, the patient is in complete remission. Genetic analysis by Sanger automated sequencing revealed no pathogenic variants in VHL and SDHD genes. We identified a heterozygous germline synonymous variant c.540 G>A (p.L180=), involving a G>A transition in the last nucleotide of SDHB exon 5. This synonymous variant results in alternative splicing of the SDHB primary transcript. This germline variant was previously reported in a 12-yr-old patient with isolated jugulotympanic paraganglioma, but it has not been associated with catecolamine-secreting paraganglioma. Neck MRI revealed no abnormalities in our patient. Conclusion: We report here a synonymous pathogenic variant in SDHB exon 5 associated with an abdominal functioning paraganglioma. Annual screening for multifocal disease (abdominal and neck PPGLs) and malignancy should be performed.

SUN-041 Estrogen Pharmacogenetics in Patients with Turner Syndrome

Background: Turner syndrome (TS) is a disorder characterized by complete or partial absence of the second sexual chromosome and the most commonly found abnormalities are short stature and gonadal failure. Most TS patients need estrogen replacement but individual outcomes on uterine volume, breast development and vertebral bone density are highly variable. To our knowledge, the impact of polymorphisms in estrogen receptor 1 (ESR1) over the variability in the development of secondary sexual characteristics and in adult height has not yet been evaluated in TS patients. Objective: To investigate the association among five ESR1 polymorphisms (rs543650, rs1038304, rs2046210, rs2234693 and rs9340799) and breast development, uterine volume, vertebral bone density, FSH and LH levels and adult height in TS patients. Methods: We selected 80 TS patients receiving adult estrogen dose for a minimum period of one year. Patients who had spontaneous complete pubertal development or who have Y chromosome material in karyotype were excluded from analysis. They were submitted to clinical and laboratory evaluation, pelvic ultrasound, bone densitometry and genotyping of the five chosen ESR1 polymorphisms through real time PCR. These polymorphisms were selected through active search in Pubmed and in GWAS catalogs, based on the following criteria: recurrence in studies, being Tag-single nucleotide polymorphisms (Tag-SNPs) or having a minor allele frequency (MAF) which allowed the present study with the available sample. Results: 61% of patients had 45,X karyotype and their mean target height was 158.9cm. 82% of them were treated with rhGH for 5 years on average and they reached a mean adult height of 149cm. Their average age of puberty onset was 14.4 years old and 10% of them had spontaneous thelarche. Their mean uterine volume was 30.1cc but ranged from 5.9 to 83cc. 91% attained adult breast development (Tanner 5) and 93% had normal vertebral bone mass after correction for height (by using the online calculator from University of Washington: courses.washington.edu/bonephys). Only 15% had FSH and/or LH lower than 10 IU/L in two or more measurements. Considering the ESR1 polymorphisms, all of them were in Hardy-Weinberg equilibrium. Statistical analysis with multiple linear regression showed that none of the studied polymorphisms was able to predict any of the above estrogen therapy outcomes in an isolated manner. Conclusion: We could not find a relationship among the studied ESR1 polymorphisms and estrogen therapy outcomes in patients with TS. However, the high variability in estrogen replacement results suggests that genetic variants play an important role. Other efforts to identify polymorphisms associated to estrogen outcomes may allow for individualization of treatment in TS.

MON-247 Clinical Characterization of Female Peripheral Precocious Puberty Due to McCune-Albright Syndrome

Background: McCune-Albright syndrome (MAS) is a rare and sporadic disease caused by a post-zygotic mutation in GNAS1 gene. It is characterized by the classical triad of polyostotic fibrous dysplasia, café-au-lait skin spots and peripheral precocious puberty (PPP). However, clinical presentation of MAS is highly variable depending on mosaic tissue distribution of mutant-bearing cells. Due to the low prevalence of MAS, detailed data of clinical and laboratory presentation are scarce. Aim: To describe the clinical and hormonal features of PPP due to MAS from a single tertiary center. Patients and Methods: The medical records of girls with PPP due to MAS diagnosed and treated from 1990 and 2018 were systematically revised. We analyzed initial clinical presentation, Tanner stage, gonadotropins and estradiol levels, and pelvic ultrasound findings of a MAS cohort. Results: From a total of 37 patients (35 girls and 2 boys) with clinical diagnosis of MAS, 14 (37.8%) female patients presented PPP. The first clinical manifestation was thelarche in 12/14 (85.7%), followed by vaginal bleeding in 7/14 (50%), and pubarche in 5/14 (35.7%). The mean height (SDS) was 109 ± 35 cm (SDS: 1.3 ± 1.6). All girls had Tanner-staging ≥ B2 (ranging from B2-B4) and 8/14 (57.1%) had pubarche. Fibrous bone dysplasia was detected in 9/14 (64.2%) by bone scintigraphy and café-au-lait skin spots were found in 10/14 (71.4%) of these girls. Menarche occurred at mean age of 3.75 ± 2 yr (2 - 7.2 yr). Mean basal LH and FSH were 0.36 ± 0.24 IU/L and 1.27± 1.0 IU/L, respectively. Estradiol levels ranged from < 13 to 783 pg/mL (mean 96.8 pg/mL). Basal estradiol levels were at prepubertal range in 8/14 (57%) on several occasions. All girls underwent a GnRH-analogue stimulated test showing a prepubertal LH response (2.9 ± 2.1 IU/L); 2 patients showed completely suppressed basal and stimulated gonadotropin levels. Uni- or bilateral ovarian cysts were identified in 9/14 patients (64.2%) being bilateral in 50% of them. Mean ovarian volumes were 2.63 ± 1.4 cm³ for right and 2.05 ± 1.9 cm³ for left ovarian, with mean cyst volumes ranging from 2.7 to 45 cm³. Other endocrine hyperfunctions were not identified in this MAS cohort. Conclusion: PPP in girls with MAS has a heterogeneous clinical presentation. It was characterized by menarche at very early age as a first sign associated with variable values of estradiol levels (pre- and pubertal) and ovarian sizes. Pediatric endocrinologists must be aware of atypical clinical and laboratory presentation of PPP due to MAS.

SUN-018 Epigenetic Loss of the PIWI/piRNA Machinery in Gonadal Tumors in Androgen Insensitivity Syndrome

Abstract: There is a high frequency of Testicular Germ Cell Tumors (TGCT) in 46,XY individuals with disorders of sexual development (46,XY DSD), which include Androgen Insensitivity Syndrome (AIS). That TGCT risk leads to pragmatic gonadectomy in these patients with several further implications. A better knowledge of TGCT tumorigenesis would be helpful either for alternative treatments or tumoral markers. Retrotransposons are mobile DNA elements that duplicate by retrotransposition, a “copy and paste” mechanism using an RNA intermediate. They composed around 50% of whole human genome. Retrotransposition has been proven as a tumorigenic mechanism in several human cancer cases due to its ability to cause genomic instability. Despite of that high frequency, they are repressed by DNA methylation through the piRNA pathway. The loss of that methylation could cause retrotransposons derepression and further tumor development. In order to analyze a possible role for epigenetic loss of piRNA machinery in seminomas from AIS patients, we performed a methylation analyses using bisulfite modification coupled to pyrosequencing of the 5’ end promoter CpG islands of the main PIWI protein genes (PIWI1, PIWI2 and PIWI4) and of the transposable element LINE-1 (long intersped element - 1) in gonads samples with anatomopathological seminoma from patients with proved AIS (AR mutations: c.2521C>G and c.384_385delGA; both with complete AIS). As control, we used the contralateral gonad of those patients, without any evidence of gonadal tumor. All samples were analyzed in quintuplicate. The methylation status was analyzed using QUMA webtool. The methylation of each CpG island was compared between tumoral versusnon-tumoral gonads. There was a hypermethylation of the PIWI protein genes (1, 2 and 4; p=0.03, 0.001, and 0.01 respectively). RT-PCR of PIWI genes showed a reduced expression of PIWI genes in tumoral samples in comparison with non-tumoral samples (1, 2, and 4; p=0.01, 0.02, and 0.0005 respectively). The opposite (hypomethylation) occurred with LINE-1 sequencing in tumoral samples (p<0.001). PIWI-family genes, together with the piRNAs are able to provoke DNA methylation leading to transposons silencing and genome integrity. In semonima from AIS, the PIWI genes hypermethylation reduced the PIWI genes expression which was related with transposable LINE-1 hypomethylation. These epigenetic alterations suggest LINE-1 as a possible mechanism for testicular tumors in AIS through PIWI/piRNA pathway disruption. As it happened in a context without any androgen action (complete AIS), it’s possible that epigenetic loss is an androgen-independent mechanism. These results open possibilities for further research on treatment based on transposable elements (as reverse transcriptase inhibitors) and for serum markers derivate from LINE-1 proteins and/or RNA.

OR13-5 The Molecular Landscape of Osteogenesis Imperfecta in a Brazilian Tertiary Service Cohort

Osteogenesis imperfecta (OI) is clinically and genetically heterogeneous. Defects in collagen type 1 are reportedly the main cause of OI (85-90%), but most available data has arisen from developed countries. Massively parallel sequencing (MPS) technologies now allow for systematic and comprehensive analysis of OI genes simultaneously. Our objective was to obtain the molecular diagnosis of OI through targeted MPS in a single tertiary center cohort of Brazilian adults with OI. After informed consent, DNA samples were obtained from 52 cases of OI (9 families and 43 sporadic; total of 64 sequenced individuals, 96% adults). Sixty-nine percent of the cohort had moderate to severe OI, and consanguinity was common (22%). Coding regions and 25-bp boundaries of 15 OI genes (COL1A1, COL1A2, IFITM5 [plus 5’UTR], SERPINF1, CRTAP, P3H1, PPIB, SERPINH1, FKBP10, PLOD2, BMP1, SP7, TMEM38B, WNT1, CREB3L1) were captured with Agilent SureSelectXT and sequenced in Illumina NextSeq. Identified variants were classified according to ACMG/AMP guidelines and those considered to be disease-causing were confirmed by Sanger sequencing. Segregation analysis was pursued when familial samples were available. A molecular diagnosis was obtained in 92% of cases. Altogether, 55 variants were identified, 21 of which had never been previously reported in international databases. Variants in COL1A1 or COL1A2 were identified in 77%, whereas 23% had variants in other candidate genes. Amongst these, variants in SERPINF1, FKBP10 and PLOD2 were more prevalent. Only one case had the previously described IFITM5 c.-14C>T variant. A peculiar combination of four heterozygous P3H1 and WNT1 variants was detected in a non-consanguineous case, where one variant in each gene was inherited from each parent. In two cases, potentially modifier variants in LRP5 were identified. Surprisingly, in four consanguineous families the molecular cause was still related to COL1A1 or COL1A2, and two non-consanguineous cases had compound heterozygous PLOD2 variants. In conclusion, targeted MPS has effectively allowed establishing the molecular basis of OI in this Brazilian cohort, unraveling novel disease-causing variants in 29% of cases, and potentially reflecting new aspects of OI pathogenesis in Brazil. Non-collagen defects were found in 23% of cases, with a higher prevalence of P3H1, FKBP10, PLOD2 and SERPINF1 defects, with potential digenic interactions, and a lower prevalence of IFITM5-related OI. Inferring the molecular diagnosis from a family history of consanguinity was misleading in this setting. Obtaining a precise diagnosis of OI in underrepresented populations allows expanding our understanding of its molecular landscape and may lead to improved personalized care in the future.

SUN-246 Low Frequency of Pathogenic Allelic Variants in the Disorders of Sex Development Related Genes in Small for Gestational Age Children with Hypospadias

Background: Small for gestational age (SGA) children are defined as the one with birth weight and/or length 2 or more standard deviations below the population mean for gestational age. The underlying causes of pre and postnatal growth failure are diverse¹. SGA boys present a high frequency of hypospadias (15 to 30%) of unknown etiology². Objective: To analyze the prevalence of SGA individuals with hypospadias in a large cohort of 46, XY disorders of sex development (DSD) patients (n=272) followed in a tertiary center and to search for a molecular etiology associated with this phenotype. Patients and methods: We evaluated 30 SGA children with medium or proximal hypospadias, four of them presented syndromic characteristics associated. DNA samples of 24 patients were studied by target massively parallel sequencing (TPMS) using an amplicon-based capture panel of 63 genes related to DSD, and one by whole exome sequencing (WES). TPMS and WES were performed in the Illumina MiSEQ/HiSEQ platforms, respectively. Paired-end reads were aligned to the hg19 assembly of the human genome with BWA-MEM. Variants were called and annotated with Platypus and ANNOVAR. Results: The prevalence of SGA individuals with hypospadias in the 46, XY DSD cohort was 11%. Two children had clinical features of Silver-Russell syndrome and their diagnosis was confirmed (11p15 LOM) by MLPA. The two other syndromic patients were suspected with three M syndrome and Mulibrey Nanism. The TPMS study identified three likely pathogenic variants in these patients: p.Trp1538* and p.Gln813fs variants in compound heterozygosis in CUL7 gene and the homozygous p.Gly340fs variant in TRIM37. Seven heterozygous variants with uncertain significance in 5 DSD related genes were identified: two in the DHX37, p.V717I and p.A737T, associated with GATA4 p.P407R variant and with WWOX p.Y85D, respectively; the WT1 p.C350R variant, the IGF1R p.R1337C variant, and the BMP8B p. Arg116Cys variant. The frequency of likely pathogenic variants in SGA children with hypospadias was 10%. Conclusion: The low frequency of pathogenic allelic variants identified in SGA children with hypospadias indicates that other mechanisms, as epigenetic changes, may be involved in the etiology of this condition. ¹ CLAYTON, P. E. et al. Management of the Child Born Small for Gestational Age through to Adulthood: A Consensus Statement of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society. The Journal Of Clinical Endocrinology & Metabolism, [s.l.], v. 92, n. 3, p.804-810, mar. 2007. The Endocrine Society. http://dx.doi.org/10.1210/jc.2006-2017. ² MOREL, Y et al. Aetiological diagnosis of male sex ambiguity: a collaborative study. European Journal Pediatric, [s. L.], v. 161, n. 1, p.49-59, jan. 2002.

SAT-288 Successful Virilization of a PAIS Patient with a Missense Mutation In The Ligand-binding Domain Of The Androgen Receptor with Combined High-dose Testosterone and Aromatase Inhibitor

The main complain of patients with partial androgen insensitivity patients (PAIS) is undervirilization signs and the small penile length. Supplemental androgen therapy has enhanced virilization in only a few patients with PAIS. Aromatase inhibitors as anastrozole and letrozole are nonsteroidal inhibitors able to bind reversibly to the heme group of cytochrome P450 reducing estrogen and estrone levels and increasing LH and FSH levels and consequently testosterone levels. We hypothesized that the combination of high-dose testosterone with anastrozole can maintain a sustained elevated testosterone levels and also deviated testosterone metabolization from estrogen to DHT, therefore increasing penile length. Case Report This experimental treatment was proposed and both patient and parents willing to participate. Patient was firstly evaluated at 7 yrs of age. The hemizygous c.2599G>C; p.V867L AR in the ligand-binding domain (LBD) was found in both affected siblings. He was previously submitted to three unsuccessful genital masculinizing surgeries and bilateral orchidopexia. The external genitalia presented a microphalus (penile length of 2 cm, -4.5 SDS), perineal hypospadias and bilateral topic testis. He received testosterone cypionate (50 mg IM injections monthly, for 3 times at age of 7 and 200 mg IM injections monthly, for 4 times at age of 8); topic DHT gel (5-10 g/daily for three months at age of 7 yrs). At age of 12.3 yrs, the genital masculinization surgeries were completed, penile length was 3.5 cm (-2.6 SDS), testicular size of 2.6x1.5 cm and pubic hair Tanner II stage. LH and FSH levels were (9.4 and 3.2 IU/L respectively), testosterone (304 ng/dL), DHT (26 ng/dL) and estradiol (<17 pg/mL). The effect of 200 mg of testosterone cypionate weekly associated to 1 mg of anastrozole daily was evaluated. After 6 months of treatment, he presented enlargement of penile length (7.0 cm, -1 SDS), and testicular size (3.0x2.0 cm) and Tanner IV of pubic hair. Gynecomastia was absent. The hormonal profile showed: decreased values of LH and FSH (0.8 and 1.1 IU/L respectively), and estradiol (<17 pg/mL) levels, and increased testosterone and DHT levels (1753 and 167 ng/dL, respectively). Bone age did not advance during treatment. Conclusion This is the first documentation of successful virilization in a PAIS boy with androgen insensitivity due to a hemizygous missense mutation in AR with a combination of high-dose testosterone and aromatase inhibitor.

MON-245 Sexuality and Fertility Issues in 46,XY Disorders of Sex Development Individuals

Abstract: The sexuality of 46,XY DSD individuals can be affected by several factors as external genitalia appearance, negative body image, traumas, social stigma, and previous genital surgery. Previous studies has been reported an impaired sexual quality of life (SexQoL) in 46,XY DSD individuals in comparison with controls. To observe aspects regarding sexual life, 144 individuals with 46,XY DSD (100 female; 44 male) were enrolled in this study. All of them were adults (>16 years old) and had completed all surgical treatments. Sexual life and fertility issues were assessed using self-developed questionnaire with likert-scale questions. Sexual orientation was assessed on the basis of orientation, sexual behavior and sexual attraction. For comparison, the cohort was divided into 3 subgroups (A: gender at adulthood; B: genitalia appearance at birth; and C: male individuals at adulthood who were assigned as male versus who changed from female to male). About fertility issues, 12 individuals (8%) had children (7 male; 5 female). 10 out of 12 were adopted children and 2 patients had children by Intravaginal insemination (IVI). Desire of fertility was similar in women and men (78.3%, 80.7% respectively; p = NS). Fear of rejection due to infertility was reported by 28% (34 out of 117). More women than men considered infertility a barrier to a steady relationship (p=0.04). Regarding sexual orientation, more than 90% referred themselves as heterosexual. Homosexuality was reported by 4% in both genders. Most 46,XY DSD women reported androphilic sexual attraction and female sexual behavior (have sex with male partners), regardless of the appearance of external genitalia. The opposite (gynephilic sexual attraction and male sexual behavior) was observed in most male patients either in individuals who were assigned male at birth and in individuals who changed from female to male. Regarding sexual life, there was significant difference between males and females on sexual fantasies, masturbation practice and fixed sexual partner, which were more frequent in males. Nevertheless, both gender reported a similar sexual life satisfaction (76% and 80%). All sexual parameters were similar comparing individuals who changed from female to male and who were assigned as male. In conclusion, sexual life satisfaction was reported by the majority of adult patients with 46,XY DSD in both gender. Among female patients, the appearance of external genitalia did not influence on sexuality, once the surgical correction of atypical genitalia have been performed. In male individuals, the sexual life was similar either if they were assigned as male or changed for that gender later. Fertility desire was common among 46,XY DSD people, regardless of gender or 46,XY etiology, which should be taken into consideration in the 46,XY DSD management.

SUN-241 Understanding and Communication of DSD in Patients' Perspectives

Communication in DSD is complex: it involves diagnosis and treatment aspects, psychological status of the pantients and cultural context. An adequate understanding by patients is essential for approach and communication in DSD. Objective: Evaluating the DSD care setting in two tertiary centers in order to identify the barriers to the adequate understanding and optimal communication. Methods: Specific questionnaire (69 questions), assessing the knowledge level, the main doubts and difficulties in DSD communication was developed and applied to DSD patients. The main doubts were clarified and a self assessment was requested for the patients before and after the interview. Results: 40 patients were interviewed. Mean patients age was 36,2y (SD: 13,7) and 54% finished at least hight school. When asked about their condition understanding, although 55% (p: 0,073) of them was satisfied, 62% doesn’t know the condition name, 53% doesn’t know the main condition characteristics and why they’re were affected and 57% still had any doubt. Doubts were related to diagnosis, drugs, surgery, appearance of the genitália, karyotype and fertility. Positevely, 77% (p < 0,01) knows the necessary treatment. The mais barriers to full understandig reported were: scientific terms used in the approach, the complexity of the conditions, the absence of dialogue about the condition at home and patient's choice not to want to know. When asked about how they were informed, 26% of them were informed in infancy, 58% in adolescence and 16% in adulthood (mean age: 14,7y SD: 7,3). 68% of them were informed by doctors. 35,5% (p: 0,01) was insatisfied with the first approach and 79% (p < 0,01) of them would prefer to know early in childhood for better adaptation. They suggested as an ideal approach to avoid omission and difficult terms, to explain gradually, clearly, using visual aids and with psychological support. Concerning communication about DSD in society, 86,5% (p < 0,01) doens’t feel conforttable talking to people about their condition and 58% suffered negative comments in family, school, work and social environment. Only 24% (p:0,064) of them doens’t bother with the judgment of other people. For better communication, among the terms (disease, clinical condition, genitalia malformation, ambiguous genitalia and disorders of sex development), 35% considered genitália malformation as the best for clarity and objectivity, and for 40% of them. disease was the worst for stigma. Their self assessment 1 to 10) improved from 6 before to 9 after the interview (t(38): 7,8, d: 1,52, IC 95%: 2,2-3,69; p< 0,01), with a positive impact on the patients knowledge. Conclsuion: Communication iabout DSD is prejudiced by the stigma and lack of knowledge. The choice of the term to refer to DSD conditions should consider the patient perspectives. Thus continued educational actions must be instituted to modify this scenario.

SUN-265 Performance of Basal and GnRH Analog-Stimulated LH Levels Assessed by an Electrochemiluminescence Assay in Girls with Central Precocious Puberty

Background: The laboratory evaluation of patients with precocious puberty is useful to differentiate central precocious puberty (CPP) from isolated thelarche (IPT) and peripheral precocious puberty (PPP). Ultrasensitive immunoassays, such as electrochemiluminescence (ECLIA), improved sensitivity and specificity of basal and GnRH-stimulated LH levels to establish the differential diagnosis among these conditions. Aim: To establish the diagnostic value of basal and GnRHa-stimulated LH values and basal estradiol assessed by ECLIA in pubertal disorders. Patients and Methods: We included 38 girls with pubertal disorders (28 CPP, 8 IPT, and 2 PPP). Their medical records were systematically revised. Clinical and hormonal data [basal and GnRH analog -stimulated LH levels (2 hs after leuprorrelin 3.75 mg) and basal estradiol] were analyzed. Gonadotropins and estradiol levels were assessed by ECLIA (Roche, Cobas e 6000). The functional sensitivity of the assays was 0.15 IU/L for LH, FSH 0.6 IU/L for FSH and 17 pg/mL for estradiol. Basal gonadotropins and estradiol were also assessed in a control group composed by 16 prepubertal and 19 pubertal girls. The cutoff values for basal and GnRH analog- stimulated LH for diagnosis of CPP was set at < 0.3 IU/L and 8 IU/L, respectively (1). Results: The mean age of girl with CPP, IPT, and PPP at the first clinical visit was 8 ± 0.9yr (5.25- 9.6 yr), 4.25± 2.6 (0.7-7.8 yr), and 5.12±2.9 (3.1 -7.1 yr), respectively. All CPP girls presented breast development ranging from B2 to B5, whereas IPT group B2-B4 and PPP group (B2). Pubarche was presented in 86% of girls with CPP (PH 2- PH 5). Only one girl in IPT group also presented pubarche (PH3), associated to zinc oxide cream use and none in PPP group presented pubarche. The mean basal LH was 3.4 ± 1.6 (<0.1- 8.6 IU/L), 0.15 ± 0.03 (< 0.15-0.2 IU/L), and <0.15 IU/L for CPP, IPT, and PPP, respectively. In CPP group, GnRHa- stimulated LH and basal estradiol levels were 6 ± 2.8 (4-61.4 IU/L) and 21 ± 17 (<17- 90 pg/ml), respectively. The sensitivity and specificity of basal and GnRHa-stimulated LH values for diagnosis of CPP was 64.7 % and 100%, respectively. However, the cutoff of 5 IU/L for GnRHa-stimulated LH improved sensitivity to 87.5% but with lower specificity of 67%. Estradiol was undetectable (<17 pg/ml) in 48% girls with CPP. In the IPT and PPP groups, basal LH <0.3 IU/L was detected in all patients. In the control group, all but one prepubertal girl had basal LH <0.15 IU/L. In addition, basal estradiol > 17 pg/ml was present in two girls from control prepubertal group. In the control pubertal group (B3-B4), mean basal LH was 4.2± 2.3 (<015- 8.8 IU/L) and basal estradiol was 61 ± 34 (<17-135pg/mL). Conclusion: The diagnostic value of basal and GnRH-stimulated LH levels assessed by ECLIA to diagnosis CPP is limited and must be interpreted together with clinical data. Reference: (1) Freire AV et al, Clin Endocrinol (Oxf), 2013.

SUN-034 Genetic Diagnosis of Congenital Isolated or Combined Growth Hormone Deficiency by Massive Parallel Sequencing Using a Target Gene Panel

Background: Congenital GH deficiency (GHD) can be isolated (IGHD) or combined with other pituitary hormone deficiencies (CPHD). The identification of mutations has clinical implications for the management of patients and genetic counseling. Objective: to conduct a prospective molecular-genetic analysis in genes associated with IGHD or CPHD. Method: 119 patients (65 males) with IGHD (n= 27) or CPHD (n= 92) were studied using target gene approach. Targeted regions (involving 26 genes associated with GHD) were captured using Agilent Sure Select technology. Sequencing was performed with Illumina NextSeq. All variants were absent or extremely rare in public databases and were classified according to the American College of Medical Genetics and Genomics/Association for Molecular Pathology (ACMG/AMP). Results: Eight patients (6.7%) had variants classified as pathogenic (n = 7) or likely pathogenic (n = 4). Two loss of function mutations were found in homozygous state in GHRHR receptor [c.57+1G>A];[c.57+1G>A] and [c.820_821insC];[c.820_821insC]. Two nonsense variants were in heterozygous state in GLI2 [c.1681G>T] and OTX2 [c.319C>T] and two heterozygous missense variants were identified in TGIF1 [c.260A>T] and GHSR [c.545T>C] - the last variant was present in two different individuals. A compound heterozygous variant in PROP1 [c.301_302del];[ c.109+1G>A] was previously published with a cohort of PROP1 Brazilian patients. Conclusion: The panel established the diagnosis of 8 patients and the patients with negative results are candidates for whole exome sequencing.

SAT-070 Clinical and Imaging Characteristics of Primary Unilateral Adrenal Hyperplasia in Primary Aldosteronism

Primary aldosteronism (PA) is the most common cause of endocrine hypertension (HT) with an estimated prevalence of 10% in referred populations and 15–20% in patients with resistant HT. Aldosterone-producing adenomas are the most common cause of unilateral PA. Primary unilateral adrenal hyperplasia (PUH) is a rare cause of PA, but is probably underestimated. PUH can be diffuse or nodular, with poorly capsulated micronodules. To date, there is a paucity of data characterizing this condition. In this study, our aim was to report the clinical and imaging features of patients with PA caused by PUH. We retrospectively evaluated clinical, imaging and histopathological data of 183 PA patients. PUH was diagnosed in 9 out of 183 patients (5%). All patients had biochemical cure of PA after unilateral adrenalectomy and anatomopathological analysis showed micronodular adrenal hyperplasia in all cases. At the diagnosis, median age was 52 yrs, ranging from 33 and 74 yrs (6 men and 3 women). Hypokalemia was reported in 63% of the cases. Aldosterone/plasmatic renin activity ratio was 123.6 (range, 52 to 379). The median duration of HT was 18 yrs (range, 1 to 52). Because of HT duration before diagnosis, only a patient had HT cure after adrenalectomy. The median follow-up was 46 months (7 to 117 months). Computed tomography (CT) accuracy to determine the lateralization was 67%. The adrenal CT findings were: normal adrenals (n= 1), bilateral hyperplasia (n= 1; right incidentaloma 1.9 cm and left PUH 1.4 cm), unilateral hyperplasia (n= 1), bilateral nodules (n= 1) and unilateral nodules (n= 5; median 1.3 cm, from 0.9 to 1.5). Adrenal venous sampling was performed in 5 patients (successful rate 80%). In the remaining cases, surgery was guided by CT. PUH was in the left adrenal in 7 out of 9 cases (78%). Hot spot somatic mutations in aldosterone-driver genes (KCNJ5, ATP1A1, ATP2B3 and CTNNB1) were excluded by Sanger automated sequencing and the presence of chimeric CYP11B1/CYP11B2 gene was ruled out by long-PCR in all cases. In conclusion, PUH prevalence in our cohort was higher than previously reported. PUH was more frequent in men and in the left adrenal. The most common CT finding was a unilateral nodule smaller than 1.5 cm. However, CT accuracy was low and AVS should be the gold standard to define lateralization. Support: CNPq (403256/2016-0) to MQA; FAPESP (2017/13394-8) to MRC.

OR04-6 Predictors of Clinical Outcome after Adrenalectomy for Unilateral Primary Aldosteronism

Primary aldosteronism (PA) is the most common cause of endocrine hypertension (HT) with an estimated prevalence of 10% in referred populations and 15-20% in patients with resistant hypertension. The most common cause of unilateral PA is aldosterone-producing adenomas (APAs). HT and hypokalemia improve in nearly 100% of patients with unilateral PA after unilateral adrenalectomy. However, complete clinical success (defined as blood pressure ≤130x80 mmHg without anti-hypertensive drugs) has been reported in about 50% (range, 35-80%) of patients with unilateral PA after surgery. HT duration and severity have been associated with clinical outcome after adrenalectomy, but few reports with a limited number of cases evaluated the prognostic role of somatic KCNJ5 mutations. In this study, our aim was to determine clinical and molecular features associated with complete clinical success after unilateral adrenalectomy in unilateral PA patients. We retrospectively evaluated 103 PA patients (42 males; median age 49 yrs, 20-74) with a median follow-up of 25 months. Hypokalemia was present in 78% of the cases. Anatomopathological analysis revealed 94 APAs and 9 unilateral adrenal hyperplasias. All patients had biochemical cure after unilateral adrenalectomy. KCNJ5 mutations were identified in 27 out of 67 (40%) tumors: p.Gly151Arg (n= 13), p.Leu168Arg (n= 13) and p.Glu145Gln (n= 1). Complete clinical success was reported in 32 out of 103 (31%) patients. In univariate analysis, HT duration, body mass index (BMI kg/m²), female sex and somatic KCNJ5mutations were associated with HT resolution after adrenalectomy. Complete clinical success was reported in 50% of patients with HT duration ≤5 yrs (vs. 24% with HT duration >5 yrs; p= 0.011), in 40% of patients with BMI <25 (vs. 22% with BMI ≥25; p= 0.042), in 38% of women (vs. 21% of men; p= 0.079) and in 70% of the patients with tumors harboring KCNJ5 somatic mutations (vs. 30% with WT tumors; p= 0.003). According to a stepwise multivariate logistic regression analysis, only the presence of a somatic KCNJ5 mutation was an independent predictor of complete success after adrenalectomy (relative risk 4.8, 95% confidence interval 1.24 to 19.21; p= 0.023). In conclusion, the presence of a somatic KCNJ5 mutation was an independent predictor of complete clinical success after unilateral adrenalectomy in patients with unilateral PA.

OR17-2 Comprehensive Genetic Investigation of Patients with Central Precocious Puberty Associated with Complex Phenotypes

Background: Idiopathic central precocious puberty (CPP) is mostly described as an isolated entity. A few studies have shown its association with clinical syndromes and rare cases of chromosomal abnormalities. Objective: To clinically characterize and to genetically investigate a cohort of patients with CPP associated with complex phenotypes. Patients and methods: Two hundred patients with idiopathic CPP were retrospectively evaluated, including phenotypic, metabolic and hormonal characterization. Thirty-two of them presented at least 3 other clinical features and conditions, characterizing complex phenotypes. Genomic microarray was performed in all sporadic and index cases, and MLPA and whole-exome sequencing were performed in a subset of cases. Results: In the group of 32 idiopathic CPP patients with complex phenotypes (28 girls, 4 boys; 16 sporadic, 16 familial), mean age at puberty onset was 6.2 yr (±1.9) for girls and 8 yr (±0.1) for boys. There was a wide phenotypic spectrum. The more prevalent clinical features described included metabolic, neurocognitive and growth phenotypes; less prevalent features included dysmorphic features and congenital anomalies. Genetic investigation resulted as follows: 3 sporadic cases with maternal uniparental disomy of chromosome 14 (Temple syndrome), with disruption at the imprinted locus of DLK1; 1 sporadic patient with a 7q11.23 deletion (Williams syndrome); 7 patients from 3 unrelated families with Xp22.33 deletions, including SHOX, upstream regulatory regions, and 3 other coding-genes. Moreover, whole-exome sequencing analysis revealed candidate pathogenic variants in 2 CPP cases. One girl with sporadic CPP associated with imperforate anus and learning difficulties presented rare frameshift variants in a dominant de novo mode in 2 genes: AREL1 (14:75142990; p.S229fs) coding an ubiquitin ligase; and TNRC6B (22:40662223-40662224; p.S663fs) coding a molecule with a role in RNA-mediated gene silencing. Both genes are expressed in hypothalamus. In addition, one boy with maternal familial CPP and autism had 2 rare potentially pathogenic variants in a dominant autosomal inheritance mode: a frameshift deletion in MKKS (20:10393728-10393731; p.F144fs) coding a protein with a role in cytokinesis; and a missense variant (4:70359481; p.P267L) in UGT2B4, coding a protein involved in estrogen hydroxylation and related to menarche timing in genome-wide association studies. Conclusion: CPP might be associated with additional clinical conditions, characterizing complex phenotypes. Two chromosomal regions, Xp22.33 and 7q11.23, represent novel candidate loci implicated in CPP. In addition, distinct novel genetic abnormalities were identified in CPP patients with complex phenotypes.

SUN-503 Hyperparathyroidism and Turner Syndrome: A Rare, Overlooked Association?

Background: Primary hyperparathyroidism (PHPT) is a relative common endocrine disease, affecting typically postmenopausal women. Turner syndrome (TS) promotes an hypogonadal state starting usually since adolescence and it is not reported a higher risk of PHPT in TS, although a few case reports were published throughout the years. Here we present two cases of PHPT concurrent with TS in women less than 50 years of age. Clinical cases: The first case is a 20-year-old women with karyotype 45,X developed nephrolithiasis needing urological intervention with normal calcium levels. After two years of follow-up, despite an adequate estrogen replacement, her bone densitometry showed a 9.1% bone loss in total hip and she had new episodes of nephrolithiasis. Her laboratory work-up revealed a serum calcium level of 10.9mg/dL (normal values 8.6-10.0mg/dL), phosphorus level of 3.6 mg/dL (normal values 2.5-4.8mg/dL), PTH level of 78.6pg/mL (normal values 14-72pg/mL) and 25-hydroxivitamin D levels of 19ng/mL. Her neck ultrasound revealed a hypoechoic nodule with 24x10x9mm behind the right thyroid lobe compatible with an enlarged parathyroid. The second case is a 40-year-old women with karyotype 45,X who was only diagnosed with TS at 37 years despite primary amenorrhea. She has type 2 diabetes and poor compliance to her medications, including estrogen replacement. During follow-up, she developed asymptomatic nephrolithiasis detected during abdominal ultrasound to assess hepatic periportal fibrosis. Her bone densitometry shows progressive bone loss. Her laboratory work-up showed an elevated serum calcium (11.1mg/dL), normal phosphorus (3.4mg/dL), an inappropriate normal PTH (50.1pg/mL), normal 25-hydroxivitamin D (21.8ng/mL). Her neck ultrasound revealed a hypoechoic nodule with 8mm behind the right thyroid lobe and parathyroid scintigraphy with Sestamibi corroborates this image as an enlarged parathyroid gland. Conclusion: PHPT is an unusual diagnosis before 50 years of age and can aggravate the bone loss caused by the hypogonadal state in TS. Here, we present two cases of young women with PHPT and TS, which may be a rare and often undiagnosed association.

SUN-250 Natural History of Growth in Patients with SHOX Gene Haploinsufficiency and Impact of Treatment with rhGH in Adult Height

Introduction: The SHOX gene haploinsufficiency is the main monogenic cause of short stature, being observed in 56% to 100% of patients with Leri-Weill dyschondrosthosis (LWD) and in 1% to 14% of children with idiopathic short stature (ISS). The diagnosis allows the establishment of a suitable prognosis for adult height, indication of rhGH treatment and genetic counseling. Objectives: To describe a cohort of 45 children (24 female) with molecular diagnosis of heterozygous SHOX defects, focusing on achievement of adult height. Materials and Methods: We analyzed retrospective data from 37 families in that defects in the SHOX gene were identified. The molecular study was performed by MLPA followed by gene sequencing. Results: In 64% of the families there was deletions in SHOX gene, 20% deletions in SHOX expression regulatory region and 16% point mutations. Among the 45 patients diagnosed during childhood, 14 were identified by family screening and 31 were index case. The mean age at diagnosis was 10.2 ± 3.2y, BMI SDS = 0.9 ± 0.8, height SDS of affected parent -2.4 ± 1.1 and height SDS of non-affected parent was -1.1 ± 1.2. The index cases were shorter than the children diagnosed by screening (Height SDS of -2.2 ± 1.0 vs. -1.5 ± 0.7, respectively; p 0.038). The majority (80%) of these children had disproportionate short stature (Sitting height by total height SDS = 3.5 ± 1.7), and 47% had Madelung deformity. Twenty-six patients reached adult height, 16 of them were treated with rhGH (mean duration of treatment = 4.8 ± 3.0 y, mean dose: 50 µg/kg/d). Eight patients (3 boys and 5 girls) were also treated with GnRH analog due to a low predicted adult height (mean duration of GnRHa was 3.1 ± 1.7y). At the first evaluation, treated patients were shorter than untreated ones (Height SDS = -2.3 ± 1.1 vs. -1.5 ± 0.6, respectively; p = 0.059). Mean adult height SDS was similar between treated and non-treated patients (height SDS -2.0 ± 1.2 vs. -2.6 ± 0.7, respectively, p = 0.179). Treated patients showed a slighted improvement of height SDS from the start the therapy to adult height (∆Height SDS = 0.3 ± 0.7), while untreated patients had loss of height SDS (∆Height SDS -1.2 ± 0.7 p <0.001). Of the treated patients 63% reached normal height (Height SDS >-2) whereas 75% of untreated patients had short stature at adult height (Z <-2). Conclusion: Treatment with rhGH promotes stature gain in patients with SHOX haploinsufficiency. Genetic screening in children with short stature allows the identification of new carriers of SHOX defect and precocious rhGH therapy can avoid the lost of 1 SDS of height between childhood and adult life.

MON-207 Identification of Monogenic Causes of Polycystic Ovary Syndrome by High Throughput Sequencing

BACKGROUND: Polycystic ovary syndrome (PCOS) is a common complex endocrine disorder, whose etiology remains to be elucidated. PCOS has a strong heritable component. Genome-wide association studies have identified several risk loci for PCOS; however, the identified candidate genes could explain less than 5% of PCOS heritability. This missing heritability might be explained by the presence of rare genetic variants with larger biological impact. High throughput sequencing (HTS) could be an interesting tool to identify these rare variants. OBJECTIVE: To identify rare genetic variants through HTS in a selection of patients with PCOS clinical relevant phenotypes or familial PCOS clusters. METHODS: Among a cohort of 130 PCOS patients, we selected 32 women presenting one or more of the following phenotypes: 1. adrenal hyperandrogenism (DHEA and/or DHEAS levels 1.5 higher the upper limit of the normal range); 2. primary amenorrhea; 3. severe insulin resistance (IR) (basal insulin >50 mUi/mL and/or after OGTT >300 mUI/mL); 4. normal androgen levels (total and free testosterone, androstenedione, DHEA and DHEAS in the normal range measured by gold standard methods). This group was studied through targeted gene sequencing panels (Miseq Illumina) including 50 genes involved in ovarian folliculogenesis, steroid hormone synthesis, gonadotropin action and insulin-signaling pathway, and genes suggested by monogenic/dygenic PCOS causes. Additional 2 families, with two PCOS sisters and their unaffected mother, were studied by exome sequencing (Hiseq Illumina). Allelic variants were considered pathogenic/potential pathogenic if they had a MAF<0.01 (Gnom AD and ExAC databases), were classified deleterious/probably deleterious by several prediction sites (i.e. SIFT, PolyPhen 2, Mutation Taster) and affect amino acids that are highly conserved among homologues (GERP scores). RESULTS: Among the 34 PCOS index patients studied, the phenotype was distributed as following: 15 with severe IR, 10 with adrenal hyperandrogenism, 2 normoandrogenic, 3 with primary amenorrhea and 4 familial cases. Twelve variants were identified in 10 patients (29.4%), affecting 6 genes: INSR, LMNA, POMC, GATA4, FSHR, H6PD, DLK1 and SCN1A. All genes were found once, except LMNA that was found in 4 different PCOS patients with severe IR. The variants in INSR, POMC and FSHR genes were found in the severe IR group, and in GATA4 in the adrenal hyperandrogenism group. The DLK1 and SCN1A variants were found in the two families studied through exome. CONCLUSION: High throughput sequencing allowed the identification of monogenic forms of PCOS, especially in patients with severe insulin resistance. The identification of rare genetic variants in PCOS patients might increase our comprehension of the pathogenesis of this disease, with positive clinical implications in patient’s treatment and genetic counseling.

OR29-3 Targeted Assessment of G0S2 Methylation Identifies a Rapidly Recurrent, Routinely Fatal Molecular Subtype of Adrenocortical Carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with frequently dismal prognosis and few therapies. Patients with locoregional ACC routinely receive surgery and adjuvant mitotane, but >50% recur with metastases even after complete resection. Histological grade (Ki67>10% or >20 mitoses/50 HPF) is the strongest clinical predictor of recurrence, but time to recurrence in patients with high grade disease is variable and patients with low grade disease frequently recur. Recent molecular profiling studies suggest risk stratification by DNA methylation may better identify patients with homogenously dismal outcomes; in The Cancer Genome Atlas study on ACC (ACC-TCGA), we similarly identified that patients with tumors bearing CpG island hypermethylation (CIMP-high) exhibit rapid recurrence and early death. However, clinical translation of this complex molecular signature remains challenging. Here, we reanalyzed ACC-TCGA data and show that CIMP-high ACC is characterized by upregulation of cell cycle and DNA damage response programs, and identify that hypermethylation and silencing of G0S2 distinguishes this subgroup. We evaluated G0S2 methylation in a multi-institutional retrospective cohort of treatment-naive primary ACC (n=80) and adrenocortical adenomas (n=22) using a straightforward, overnight restriction digest/qPCR-based assay, validated by targeted bisulfite sequencing. We identified that G0S2 hypermethylation is exclusive to a subset of ACC (40%). G0S2 hypermethylation is associated with decreased disease-free survival (median DFS=14 mo., HR=6.91, p<0.0001; Cox regression) and overall survival (median OS=17 mo., HR=2.65, p<0.005; Cox regression). These observations remain significant in multivariate analyses, demonstrating that G0S2 hypermethylation independently predicts rapidly recurrent and fatal ACC. Our data suggests that prospective targeted assessment of G0S2 methylation may enable clinicians to identify patients with CIMP-high ACC, unlikely to exhibit durable response to standard of care. Ultimately, we hope that improved identification of this subgroup will facilitate the evaluation of more aggressive adjuvant therapies for these patients, and increase patient survival in the face of this devastating disease.

SUN-035 Performance of Mutation Pathogenicity Prediction Tools on Missense Variants Associated with 46XY Disorders of Sex Development

INTRODUCTION: Single nucleotide variants (SNV) are the most common type of genetic variation among humans. The high-throughput sequencing methods increase the number of identified variants in the human genome but functional studies for disease-associated variants is laborious and time consuming. Different computational methods have been developed to predict SNP pathogenicity and phenotypic effect. They are based on different variant parameters, such as sequence homology, proteins structure and evolutionary conservation. OBJECTIVE/METHODS: To evaluate the performance of the 10 widely used pathogenicity prediction tools available in the internet in relation with functional studies: Fathmn, Mutation Acessor, Phanter and Sift sites (based on evolutionary information) and Mutation Taster, Polyphen-2, Align GVGD, CAAD, Provean and SNP-and-Go sites (based in a combination of protein structural, functional parameters and evolutionary information). We analyzed 40 described pathogenic mutation in 4 different genes associated with disorder of sex development (DSD): 17β-hydroxysteroid dehydrogenase (HSD17B3), Steroidogenic factor 1 (SF-1/NR5A1), Androgen receptor (AR) and Luteinizing hormone/chorionic gonadotropin receptor (LHCGR). All mutations are already published and functional studies showed loss of function proteins. To evaluate the false discovery rate of each tool, we analyzed 36 frequent (MAF >0.01) benign SNVs described in the same 4 DSD. The quality of the predictions was analyzed by five parameters: accuracy, precision, sensitivity, specificity and Matthews correlation coefficient (MCC). RESULTS: No method was in full accordance with the functional study. The best accuracy was observed in the Polyphen-2 and SNP-and-Go programs (0.81 and 0.82); the best precision was observed in Mutation Accessor and SNP-and-Go (0.96 and 0.84). The best specificity was observed for Mutation Accessor and SNP-and-GO (0.96 and 0.83). Five programs (Phanter, Sift, Mutation Taster, Polyphen-2 and CAAD) showed sensitivity > 0.80, but only SNP-and-GO program had specificity of 0.83. Performance ranged from poor (Align GVGD - MCC 0.13) to reasonably good (SNP-and-GO - MCC 0.63). CONCLUSION: Computational algorithms are important tools for SNV analysis but their correlation with functional studies is extremely variable. The overall best performing methods among the 10 prediction tools was SNP-and-GO, with accuracy reaching 0.82.

SAT-064 Validation of Furosemide Upright Test in Primary Aldosteronism Diagnosis Using Direct Renin Assay

Primary aldosteronism (PA) is the most common cause of endocrine hypertension. The 2016 Endocrine Society’s Guideline for PA management recommend that patients with a positive screening undergo one or more confirmatory tests to definitively confirm or exclude the diagnosis. Confirmatory testing procedures include oral sodium loading, saline infusion test (SIT), fludrocortisone suppression, captopril test (CT) and furosemide upright test (FUT). The FUT, mainly proposed by the Japan Endocrine Society, does not have limitation in patients with severe uncontrolled hypertension and heart failure. A positive FUT is defined as a plasma renin activity (PRA) <2 ng/mL/h after 2h, but it has not been standardized using a direct renin assay. The aim of this prospective study was to evaluate the FUT positive rate in a Brazilian cohort of PA patients and to establish a cut-off level to confirm PA diagnosis using direct renin concentration (DRC). We performed the FUT in 45 consecutive patients (25 males; median age 50 yrs, from 31 to 67 yrs) with PA diagnosis confirmed by biochemical cure after unilateral adrenalectomy or by adrenal venous sampling. Patients received furosemide 40 mg iv and stayed in upright position for 2h, starting at 8-9.30 AM. Blood samples for DRC, aldosterone, and potassium were drawn at time zero and after 2h. Aldosterone and DRC were measured by a chemiluminescent immunoassay (LIAISON®). Median A/DRC ratio was 10.3 (range, 2.54 to 66.4). Hypokalemia was evidenced in 27 out of 45 (60%) patients. Median DRC before and after 2h FUT was 2.8 uUI/mL (1.2 to 8.3) and 3.0 uUI/mL (0.5 to 19), respectively. Using the conversion factor of 12 to calculate PRA, FUT was positive (DRC/12= PRA <2 ng/mL/h) in all patients. Based on the highest renin level after FUT, the most suitable cut-off of direct renin concentration to confirm PA diagnosis was 20 uUL/mL. Additionally, potassium levels did not significantly change after FUT. Among these 45 PA patients, 39 performed an additional confirmatory test (recumbent SIT in 24 and CT in 15 patients). The positive rate for SIT was 83% using an aldosterone cut-off of 10 ng/dL and 100% using a cut-off of 6.8 ng/dL. CT and FUT were positive in all PA patients. In conclusion, FUT was a safe and reliable test for PA confirmation. In addition, we suggest a renin cut-off <20 uUI/mL after FTU to confirm PA diagnosis. Support: CNPq (403256/2016-0) to MQA

SUN-252 Comparison of Sitting Height/Height Ratio for Age in Children with Short Stature Caused by Defects in Growth Plate Genes

Introduction: Abnormal body proportion disclosed by sitting height/height ratio for age and sex (SH/H SDS) > 2 indicates an impairment of appendicular growth. This is frequently observed in patients with skeletal dysplasia and can be the only clinical sign in nonsyndromic short stature children that harbor heterozygous defects in genes expressed in growth plate. The aim of the present study is to compare the degree of body disproportion among children with different genetic cause of growth impairment. Methods: We evaluated 75 children with short stature caused by defects in known growth plate genes, including FGFR3 gene (16 mutations in 7 patients with achondroplasia - ACH and in 9 patients with hypochondroplasia - HCH), SHOX gene (35 defects in 15 patients with Leri-weill dyschondrosteosis - DLW and in 20 patients with isolated short stature, defined as absence of Madelung deformity clinically and radiologically), NPR2 gene (8 heterozygous mutations) and IHH gene (16 heterozygous mutations). Variants in NPR2 and IHH genes were identified in children with isolated short stature or with nonspecific skeletal abnormalities. Results: At first evaluation, patients had a mean age of 8.7±4.9 years. Children with ACH were significantly shorter than those of the other groups (mean height SDS: -4.4 vs -2.5, p<0.05). All patients with clinically recognizable skeletal dysplasia (ACH, HCH and DLW) had abnormal body proportion (SH/H SDS >2). The frequency of abnormal body proportion observed in children initially classified as idiopathic short stature (ISS) was 85% for SHOX defects and 56% for IHH mutations (p = 0.073). None children with heterozygous mutations in NPR2 presented abnormal body proportion, though 62.5% had SH/H SDS >1. Children with ACH had SH/H SDS higher than all other groups (mean: 9.9±2.8; p<0.001). The degree of abnormal body proportion observed in children with HCH was similar to that of DLW (mean: 5.7±1.1 and 4.6±2.3, respectively; p = 0.14) and was higher than in children with isolated short stature, independently of the genetic defect (p=0.003 for SHOX and p<0.001 for IHH and NPR2). The mean SH/H SDS observed in children initially classified as ISS was similar between SHOX and IHH groups (mean: 2.9 ± 0.9 and 2.3 ± 1.4, respectively; p = 0.26), which was significantly higher in comparison to NPR2 group (mean: 0.7 ± 1.3; p = 0.004 for SHOX and p=0.024 for IHH). Conclusion: All patients with ACH, HCH and DLW had abnormal body proportion and their SH/H SDS were significantly higher than that observed in ISS children with SHOX, IHH or NPR2 defects. Furthermore, among nonsyndromic children with short stature, abnormal body proportion is associated with SHOX and IHH defects, but not with NPR2 defects. The authors have nothing to disclose.

SAT-355 Comparison of Two Serum Cortisol Immunoassays versus Liquid Chromatography: Tandem Mass Spectrometry (LC-MS/MS)

Accurate measurement of serum cortisol is required to diagnose and treat adrenal disorders. The most widely used methods in clinical laboratories for serum cortisol measurement are immunoassays which are offered in numerous commercial kits and on automated platforms. The LC-MS/MS is the gold-standard method to quantify serum steroids due its highest specificity, however it is a laborious methodology. Objective: to compare serum cortisol levels measured by two immunoassays versus LC-MS/MS. Methods: 35 routine serum samples (range: 1.1 to 50.0 ug/dL) were measured by Access Cortisol in Unicel DxI800 (Beckman Coulter), Architect Cortisol in i2000 Architect (Abbott) and LC-MS/MS in Xevo-TQ-S (Waters). Results were compared by Deming regression analysis and mean bias were used to describe the relationship between LC-MS/MS and Access and Abbott immunoassays, respectively. Results: Beckman and Abbott immunoassays showed similar cortisol concentrations (mean bias: 0.366%). Both immunoassays showed close agreement with LC-MS/MS results. Deming regression analysis showed a slope of 0.99 (0.85 to 1.134) an intercept of 1.334 (-1.345 to 4.014) in LC-MS/MS vs Beckman comparison; a slope of 1.008 (0.906 to 1.110) an intercept of 1.164 (-0.766 to 3.094) in LC-MS/MS vs Abbott comparison. The mean positive bias of Beckman and Abbott versus LC-MS/MS were 8.38% e 8.78%, respectively. Conclusion:Both Beckman and Abbott Cortisol immunoassays presented similar results in comparison of cortisol LC-MS/MS measurement, which evidence that these assays are suitable and reasonable methods for routine serum cortisol determination.

OR06-6 Whole-Exome Sequencing of Patients with Pituitary Stalk Interruption Syndrome (PSIS) Reveals Probably Pathogenic Variants in Novel Candidate Genes

Background: Pituitary Stalk Interruption Syndrome (PSIS) is characterized by&nbsp;the presence of a thin or absent pituitary stalk, usually associated with an ectopic posterior pituitary, hypoplasia of the anterior pituitary and pituitary hormone deficiencies. The identification of pathogenic variants in novel genes has clinical implications for the management of the patients and genetic counseling. Objective: to identify pathogenic variants in patients with PSIS using whole-exome sequencing (WES) (trio approach). Method: We performed whole exome sequencing in eleven patients (trio approach) with PSIS using Agilent Sure Select and Illumina NextSeq technology. The patients had been screened for genes previously associated to hypopituitarism by Sanger or Target gene panel. We searched for pathogenic variants considering de novo, homozygous, compound heterozygous and X- linked inheritance. Results: We identified 116 rare allelic variants (excluding synonymous) located in exons or splice sites: 47 de novo, 20 homozygous, 48 compound heterozygous and 1 X-linked. All variants were expressed in pituitary and/or hypothalamus. Of these, 11 variants were highlighted because the genes had correlation to malformations of central nervous system, midline defects or hormonal deficiencies: LCMT1, PCDHB14, ATXN1, ATXN7, KRT18, SYNE1, WDR27, CC2D2A, HAUS5, IFT140 and ELF4. Among them, five were de novo: two were found in genes associated to cleft palate (LCMT1 and KRT18), two in genes previously associated to neurological phenotype (ATXN7 and ATXN1), one in a gene related to organization of neural cadherin-like cell adhesion (PCDHB14).ELF4 was X-linked and was previously associated with isolated growth hormone deficiency. Conclusion: The WES identified 11 potentially pathogenic variants in new candidate genes for PSIS.

SUN-031 Quantification of Pooled Libraries for Optimizing Cluster Density in Next Generation Sequencing

Background: Next-generation sequencing (NGS) consists of massive parallel processing libraries where millions of reads are generated in a single sequencing run. To ensure efficient sequencing, the amount of DNA pool libraries must be measured precisely because it influences the density of the clusters formation. There are different quantification methods aiming to obtain high density clusters with Q30>80%, avoiding the negative effects of overclustering. Our aim was to compare the density of the clusters in exome libraries quantified by two different methodologies qPCR and MiSeq Nano V2 method. Exome libraries were prepared using SureSelect Human All Exons kits (Agilent Technology) and sequenced on Illumina HiSeq2500 platform (Illumina) using the V4 high output sequencing kit. The pools were prepared in equimolar concentrations using qPCR (KAPA Library Quantification Kit), to achieve final pool library concentration of 10 nM. Three groups were defined: the original 10 nM group (n=16); a qPCR group (n=16) in which the pool concentrations were corrected by qPCR and the MiSeq Nano V2 group (n=12) where pool concentrations were corrected by clustering data of MiSeq Nano in a direct linear proportion. The statistics analysis was performed by Kruskal-Wallis followed by Dunn test. Cluster density values are reported as the absolute distance from the optimal density (1000 k/mm² of flow cell) specified for V4 kit. Results: The 10 nM group showed a median of 191, iqr (interquartile range) = 48-273, the qPCR group the median was 80, iqr = 30-135 and the MiSeq Nano V2 group the median was 46, iqr = 13-78. Therefore, the MiSeq NanoV2 method was significantly better than the other groups at either generating closer distances from the target cluster density value (Kruskal-Wallis test, p<0.05, H=7.967, p=0.02 with Dunn’s test, mean rank difference=13.84, p=0.01). The rate of success in the generation of data without overclustering effects was also better in Miseq Nano V2 group (Kruskal-Wallis test, p<0.05, H=7.525, p=0.02, Dunn’s multiple comparison test, mean rank difference=-9.625, p=0.01. Conclusion: The MiSeq Nano V2 method is significantly more precise to quantify the pool library concentration, increasing data yield per run, reducing potential loss of data due to inadequate clustering and covering, saving time and money in clinical research laboratories.

SUN-361 Reproductive Outcomes in Females with Virilizing Forms of Congenital Adrenal Hyperplasia

Subfertility rate has been observed in women with classical CAH, being inversely correlated with the severity of enzymatic defect. Psychosexual behaviors, genital abnormalities, chronic anovulation and/or excessive androgen exposure could corroborate for this finding. However, there are scarce data in the literature evaluating reproductive outcomes in CAH women. Objective: To evaluate the reproductive outcomes in women with classical CAH. Patients: 84 females with 33±11yrs old: 80 with 21-hydroxylase deficiency and 4 with 11β-hydroxylase deficiency (11OHD), were selected. Methods: Data of Prader score, age at first genitoplasty, sexual activity, sexual orientation, desire to conceive, fecundity rate and pregnancy outcomes were analyzed. Chi-square and T tests were used. Results: Prader score and age at feminizing genitoplasty (3.4±3yrs) did not differ between patients with and without desire to conceive. Among the 84 patients, 27% have never tried sexual activity, due to shame of their genitalia. Homosexual and bisexual orientations were identified in 15% and 1.2% of patients, respectively; 38% of all patients were engaged in stable relationships. Desire to conceive was expressed by 26/84 of patients, being lower in salt wasters-SW (28%) than simple virilizers (67%), and the reference population (76%, p<0.05). Fertility was achieved in 21/26 patients; the mean time to conceive was 2.2±4 yrs. Two patients were submitted to in vitro fertilization. The mean age of the first pregnancy was 29.8±6.4yrs and in the reference population was 21yrs. Full-term pregnancy occurred in 20/21 cases, one 11OHD patient had premature labor due to hypertension. Gestational diabetes was observed in only one case. Glucocorticoid doses remained stable during pregnancy, but were increased in 8% of patients in the last trimester; fludrocortisone was administered only to the SW patients. No patient had adrenal crises during gestation and all of them received stress glucocorticoid doses during delivery. All patients, except one, was submitted to cesarean section. The fecundity rate was 1.3 child/patient, lower than the reference population (1.7), p<0.05. Conclusion: We observed that the low fertility rate in CAH females is mainly secondary to lower desire to conceive, psychosexual behaviors and genital abnormalities. Regarding the fertility rate considering only those women who wanted to conceive, most of them succeed spontaneously, with low frequency of comorbidities.

SUN-351 Are We Underestimating The Role Of Systemic Chemotherapy In The Treatment Of Localized And Advanced Adrenocortical Carcinoma?

Background: Adrenocortical carcinoma (ACC) is a rare and, in the vast majority of cases, aggressive neoplasia. Even in cases of localized disease at the diagnosis in which complete surgical resection of the tumor is performed, rates of local and distant recurrence are very high. Aim: To retrospectively analyze the management and outcomes of cases that presented localized disease (Group 1) and metastatic disease at diagnosis (Group 2) followed in a single Institution. Results: Group 1 was formed by 23 cases and group 2 by 7 cases. In group 1, adjuvant treatment was initiated in 17 patients: 9 received adjuvant radiotherapy (ARDT) associated with mitotane and 8 patients received mitotane alone; six patients have been followed expectantly. Recurrence of the disease was observed in 70% of the cases (n=16). All had distant metastasis and 6 out of 16 also had local recurrence. Most frequent sites of metastasis were lung, liver and peritoneum, including a rare case of heart metastasis. All patients with recurrence received systemic chemotherapy. No patient who was followed without adjuvant treatment has recurred so far. The median recurrence free survival (RFS) and overall survival (OS) were 13 and 30 months, respectively. In group 2, 5 patients had only one site of metastasis at diagnosis (all of them presented lung metastases) and the remaining cases had two (lung and liver) or three sites (lung, liver and bone). In only one case neoadjuvant chemotherapy was the treatment of choice. In the remaining patients, primary tumor was resected and systemic chemotherapy and mitotane started after surgery. The number of chemotherapy regimens ranged from one to four. Median progression free survival (PFS) was 2 months (range, 0.9 to 11 months) and OS was 11 months (range, 0.9 to 30 months). Patients who had more than one metastatic site at diagnosis had a lower survival rate and the patient who underwent neoadjuvant chemotherapy presented the longest PFS (11 months). Conclusions: Group 1 cases analysis reinforces the high rate of disease recurrence in patients with localized disease despite adjuvant treatment with ARDT and mitotane. These findings support the need for multicenter clinical trials to investigate the benefit of systemic chemotherapy in an adjuvant setting in patients at high risk of recurrence. Regarding the metastatic patients at diagnosis, we emphasize the importance of a greater experience with neoadjuvant chemotherapy.

SAT-217 A Spontaneous and Uneventful Pregnancy in a Turner Syndrome Patient with 45,X[22]/46,X,+Mar[2]/46,Xx[1] Mosaicism: Case Report and Literature Review

Case report: Our patient was first evaluated at 5 years old (yo) because of short stature (height standard deviation score (SDS) -2.4) and recurrent acute otitis media. Her karyotype was 45,X and she did not have cardiac or renal malformations. She was treated with oxandrolone 0.0625 mg/kg/d for 20 months starting at chronological age (CA) 9y 8mo and then with growth hormone (GH) 50 µg/kg/d for 3 years starting at 12 yo, reaching an adult height of 146 cm. She had spontaneous thelarche with CA 11y 11mo and spontaneous menarche at 14y 6mo of age. Her menstrual periods, which were initially regular, became irregular and at 19 yo she started to use contraceptive pills to regulate them. She got married at 25 yo and adopted her first daughter when she was 29 yo. Since her LH and FSH had always been normal before anticonceptional use and became suppressed after its start, we discontinued it when she was 29 yo to reevaluate her ovarian function and asked for a new karyotype. Her LH, FSH and her menstrual periods went back to normal and she decided to try for a spontaneous pregnancy. Cardiac /aortic MRI was normal and pregnancy was allowed. Her new karyotype was 45,X[22]/46,X,+mar[2]/46,XX[1] and Y chromosomal material was not detected. At 32 yo she became pregnant. Standard blood examination and first trimester ultrasonography were performed without abnormal findings. She was then monitored by a high-risk pregnancy team and cardiologist. At 38 weeks of gestation, a cesarean section was performed because of cephalopelvic disproportion. She delivered a healthy female infant with a 46,XX karyotype. Literature review: More than a 100 cases of spontaneous pregnancies in patients with Turner syndrome (TS) were reported in literature. These patients had spontaneous thelarche and menarche and most of them had mosaicisms involving a 46,XX lineage, although there are reports of spontaneous pregnancies in patients with 45,X monosomy, isochromosome or ring X and mosaicisms for other cell lineages. Most newborns have a normal 46,XX or 46,XY karyotype and no abnormalities in physical examination. However, there is a higher risk of miscarriage especially during the first trimester of gestation (between 30 and 45%) and a higher prevalence of Turner syndrome in the offspring. Furthermore, other unfavorable outcomes apparently unexplained by the presence of Turner syndrome in the mother were described such as Down syndrome, atypical genitalia, cerebral palsy, hydrocephalus, cleft lift and palate and congenital tumors. There are also risks for the mother, especially involving pregnancy-induced hypertensive disorders, which can increase the risk of aortic dissection, but also a higher risk of gestational diabetes. Conclusion: Spontaneous pregnancies in TS patients occur mainly in patients with mosaicisms and should be monitored by obstetricians and cardiologists with experience in dealing with these patients.

MON-251 Clinical Features of a Large Cohort of Patients with Familial Central Precocious Puberty Caused by Loss-of-Function Mutations in MKRN3

Context: Loss-of-function mutations in Makorin RING-finger 3 (MKRN3), a maternal imprinted gene located on the long arm of chromosome 15, are the most prevalent cause of familial central precocious puberty (CPP). Objectives: To describe the clinical and hormonal features of 70 patients with CPP due to MKRN3 mutations and to establish the phenotype-genotype correlation. Setting and Participants: We studied 70 individuals from 31 families originating from different ethnic backgrounds. DNA sequencing analysis of MKRN3 coding region by Sanger method was performed and loss-of-function MKRN3 mutations were identified in all of them. Results: The genetic analysis of MKRN3 revealed 15 different mutations in 70 affected patients with CPP (27 boys; 43 girls) who were studied in two university centers from 2013 to 2018. We identified frameshift (61%), missense (26%) and nonsense mutations (13%). Frameshift mutations affecting codon 162 were the most frequent. Female patients developed thelarche at a mean age of 5.9 ± 1.2 years, adrenarche at 6.4 ± 0.9 years, had bone age advance of 2.3 ± 1.6 years, a height standard deviation score (SDS) of 1.6 ± 1.2, and a BMI-SDS in the overweight range (1.05 ± 0.7) in the initial diagnosis. Eight patients (11%) developed thelarche and adrenarche simultaneously. Male patients developed pubertal signs at a median age of 8.0 years (range 5.9-8.5 years) and had a bone age advance of 1.7 years (0-2.7). Girls who harbored frameshift mutations were more likely to have simultaneous thelarche and adrenarche and had a more advanced bone age (2.7 ± 1.6 vs 1.3 ± 1.1 years, p = 0.003), but were otherwise unremarkable. Notably, 74% of the male patients were diagnosed in adulthood, during familial segregation analysis, suggesting that male CPP was under-diagnosed. Basal laboratory evaluation showed LH levels of 1.8 ± 1.5 IU/L and FSH levels of 4.4 ± 2.4 IU/L (n=37). GnRH stimulation tests resulted in a LH peak of 25 ± 24 IU/L and a FSH peak of 13.2 ± 9.5 IU/L. Nineteen patients were treated with depot GnRH analogue for 3.3 ± 0.8 years, achieving a final height of -0.6 ± 1.1 SDS, within their target height of -1.1 ± 1.0 SDS. Among the 7 untreated adult patients, height SDS was -1.8 ± 1.1, noticeably lower than that of treated patients, although not statistically significant (p=0.06). Conclusions: Deleterious MKRN3 mutations represent a frequent genetic cause of non-syndromic familial CPP in both sexes. Clinical and hormonal features of CPP caused by these mutations are indistinguishable from idiopathic CPP.

No evidence of somatic activating mutations on gonadotropin receptor genes in sex cord stromal tumors

OBJECTIVE

To search for somatic activating mutations of gonadotropin receptor (FSH-R and LH/chorionic gonadotropin receptor [CG-R]) genes as a cause of sex cord stromal tumors.

DESIGN

Molecular studies in human tissue.

SETTING

University hospital. SPECIMEN(S): Eight granulosa cell tumors collected from paraffin-embedded tissue, eight Leydig cell tumors, and three thecomas collected from fresh-frozen or paraffin-embedded tissue.

INTERVENTION(S)

Tumor samples were used for DNA extraction. The entire exon 11 of the LH/CG-R gene and a hot spot for gonadotropin receptor activating mutations on exon 10 of the FSH-R gene were amplified by polymerase chain reaction. The former was analyzed by denaturing gradient gel electrophoresis and automatic direct sequencing, and the latter by automatic direct sequencing.

MAIN OUTCOME MEASURE(S)

Results of denaturing gradient gel electrophoresis and automatic direct sequencing.

RESULT(S)

No somatic activating mutation was detected in exon 11 of the LH/CG-R gene in eight Leydig cell tumors and three thecomas. In addition, no mutations were detected in eight granulosa cell tumors in the hot spot for activating mutations in exon 10 of the FSH-R gene.

CONCLUSION(S)

Somatic activating mutations of gonadotropin receptors seem to play no relevant role in the development of sex cord stromal tumors.