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Brief Report—Endocrine Research

Germline Mutations of the TMEM127 in Patients with of Head and Neck and Extraadrenal Abdominal Sites

Hartmut P. H. Neumann, Maren Sullivan, Aurelia Winter, Angelica Malinoc, Michael M. Hoffmann, Carsten C. Boedeker, Hartmut Bertz, Martin K. Walz, Lars C. Moeller, Kurt W. Schmid, and Charis Eng Downloaded from https://academic.oup.com/jcem/article/96/8/E1279/2833767 by guest on 27 September 2021

Department of Nephrology and General Medicine (H.P.H.N., M.S., A.W., A.M.) and Divisions of Clinical Chemistry (M.M.H.), Otolaryngology (C.C.B.), and Hematology and Oncology (H.B.), University Medical Center, Albert-Ludwigs-University, D-79106 Freiburg, Germany; Department of Visceral Surgery (M.K.W.), Kliniken Essen Mitte, D-45276 Essen, Germany; Departments of Endocrinology (L.C.M.) and Pathology (K.W.S.), University of Duisburg-Essen, D-45141 Essen, Germany; and Genomic Medicine Institute (C.E.), Lerner Research Institute and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio 44195

Background: Hereditary is associated with germline mutations of a set of susceptibility to which the TMEM127 gene has recently been added. Patients with TMEM127 mutations have been thus far exclusively identified with adrenal tumors.

Patients and Methods: A population-based series of 48 consecutive individuals from the European- American Pheochromocytoma Paraganglioma Registry with multiple paraganglial tumors and, of these, one extraadrenal paraganglial tumor were selected for this study. They all had normal results when screened for germline mutations of the genes RET, VHL, SDHB, SDHC, and SDHD. Germline mutation analysis of the TMEM127 gene included a search for intragenic mutations and large rearrangements.

Results: Of the 48 eligible patients with extraadrenal paraganglial tumors, two (4.2%) were found to have TMEM127 mutations. One patient had multiple head and neck paraganglioma and one retroperitoneal extraadrenal and adrenal tumor.

Conclusion: TMEM127 germline mutations confer risks of extraadrenal paraganglial tumors in addi- tion to the documented adrenal pheochromocytoma. Thus, surveillance for extraadrenal and adrenal paraganglial tumors is likely warranted in TMEM127 mutation carriers, although the true prevalence should be evaluated in patients with extraadrenal paraganglial tumors. (J Clin Endocrinol Metab 96: E1279–E1282, 2011)

he family of susceptibility genes for hereditary pheo- sia syndromes are, in historical order, neurofibromato- T chromocytomas and is growing sis type 1, multiple endocrine neoplasia type 2, von Hip- and has implications for generalists and multiple spe- pel-Lindau disease, paraganglioma syndrome types 1, 2, cialties because of their protean location, symptomatol- 3, and 4, and furthermore, a distinct disorder exclusively ogy, and presentation. Patients with hereditary pheo- associated with adrenal pheochromocytoma (1). The re- chromocytoma or paraganglioma may either have a spective susceptibility genes are NF1, RET, VHL, SDHD, complex neoplasia syndrome or have tumors of the sdh5/SDHAF2, SDHC, SDHB, and TMEM127 (2–4). Be- paraganglial system as the only condition. The neopla- cause of clinical outcome studies of these genes, except for

ISSN Print 0021-972X ISSN Online 1945-7197 Printed in U.S.A. Copyright © 2011 by The Endocrine Society doi: 10.1210/jc.2011-0114 Received January 13, 2011. Accepted April 26, 2011. First Published Online May 25, 2011

J Clin Endocrinol Metab, August 2011, 96(8):E1279–E1282 jcem.endojournals.org E1279 E1280 Neumann et al. TMEM127 Mutations in Paragangliomas J Clin Endocrinol Metab, August 2011, 96(8):E1279–E1282 the most recent SDHAF2 and TMEM127, specific gene- Board-approved questionnaire for enrollment as experimental informed clinical surveillance can be performed. The most controls. recently identified gene is TMEM127 (4). The phenotype DNA variants of missense type were regarded as pathogenic mutations, if they do not occur in the controls. In addition, of mutation carriers has recently been described by Yao et pathogenicity was supported by in silico analysis tools Mutation al. (1). Of 990 probands, 20 (2%) patients have been iden- Taster (6), PolyPhen (7), and SNAP (8), which predict possible tified with germline TMEM127 mutations. All mutation impact of single substitutions on structure carriers in that study were found to exclusively carry ad- and function. renal paraganglial tumors, i.e. . Ex- traadrenal paraganglial tumors were not reported. If this held true, then finding a TMEM127 mutation would sug- Results gest only adrenal surveillance. Here, we sought to deter- Downloaded from https://academic.oup.com/jcem/article/96/8/E1279/2833767 by guest on 27 September 2021 We analyzed for intragenic germline mutations of the mine whether extraadrenal paraganglial tumors were a TMEM127 gene in 48 unrelated registrants selected for part of the phenotypic spectrum of germline TMEM127 two or more paraganglial tumors, of which at least one mutation carriers. must have been outside the adrenal glands. Of the 48 pa- tients, 24 had tumors of the head and neck. Of these 24, 22 had head and neck tumors only, whereas one patient Subjects and Methods also had a thoracic and a retroperitoneal extraadrenal tu- Research participants mor, and one patient had bilateral adrenal tumors. Of the The research participants were a nested series from the pop- remaining 24 patients, all had retroperitoneal extraadre- ulation-based European-American Pheochromocytoma-Para- nal tumors, with four exclusively in this location. In ad- ganglioma Registry (5). All registrations are based on a uniform dition, 20 of these 24 also had tumors in the adrenals, and questionnaire that includes capture of demographic data such as among the 20 with adrenal involvement, six had bilateral age, gender, and place of residence as well as clinical data such disease and the remaining 14, unilateral. Of the six pa- as biochemical data regarding catecholamines and metaneph- tients with bilateral adrenal disease, two also had thoracic rines, imaging data from magnetic resonance or computerized tomography and scintigraphic procedures as well as number and involvement. Pelvic tumors did not occur. Age at diagnosis location of the tumors and their biological behavior as benign or was 11–75 (median 40) years, and male to female ratio malignant disease. Criteria for malignancy were lymph node or was 1:2.5. A family history of paraganglial tumors was distant (extraparaganglial) metastases. present in three of the 48 patients. Of the 48 patients, 35 For purposes of this study, only unrelated symptomatic pa- are German, four Polish, three French, two each Swiss and tients, who were mutation and deletion negative for RET, VHL, Greek, and one each Spanish and Finnish. SDHB, SDHC, SDHD, and NF1, were included. Other inclusion criteria include having at least two paraganglial tumors, at least Among the 48 eligible patients, two patients (4.2%) one of which must be an extraadrenal paraganglial tumor. An were found to have germline TMEM127 mutations, both important exclusion criterion was that none of these research of missense type (Table 1). These two patients were mu- participants should also be included in the cohort described by tation negative for SDHAF2/SDHA. None of the 100 con- Yao et al. (1). A nested series of 48 unrelated individuals within trols showed these two missense mutations, and in silico the registry met eligibility criteria. This sample size is powered (P Ͼ 0.8) to detect even a 6% prevalence of TMEM127 muta- tion-positive cases. All subjects signed informed consent in accordance with our TABLE 1. Demographic and clinical information for the respective institutions’ Human Subjects Protection Committee/ TMEM127 mutation-positive individuals Ethical Committee. Variable Case I Case II Mutation analysis of TMEM127 Age at diagnosis (yr) 34 51 Gender Female Female Genomic DNA was extracted from EDTA-anticoagulated pe- Tumor number 2 6 ripheral white blood cells from each subject using standard pro- Tumor location CBT, CBT 4 adrenal left cedures. The gene TMEM127 was analyzed for intragenic mu- 1 adrenal right tations and large deletions and rearrangements. Mutation 1 extraadrenal screening was performed by denaturing HPLC (WAVE system, retroperitoneal model 3500 HT; Transgenomic, Glasgow, UK) followed by se- Malignant No No quencing (ABI 3130) for patients who showed abnormal dena- Family history Negative Negative turing HPLC chromatograms. Deletion/rearrangement analysis Other neoplasias Acute myeloid was performed using multiplex ligation-dependent probe am- leukemia TMEM127 mutation c.325 T3 c.553 G3 plification. Genomic DNA was extracted from 100 ancestry- C (p.S109P) A (p.G185R) matched population-based controls who were healthy anony- mous blood donors or who filled in an Institutional Review CBT, Carotid body tumor. J Clin Endocrinol Metab, August 2011, 96(8):E1279–E1282 jcem.endojournals.org E1281 analyses support the pathogenicity of these mutations. In if indeed TMEM127 mutations confer only risk for adre- addition, we observed the DNA variant TMEM127 c.621 nal pheochromocytomas, then surveillance can be lim- G3A (p.A207A) in 29% of the probands and 8% of the ited to the adrenals. However, in our study of a popu- controls. lation-based series with extraadrenal paraganglial The two mutation-positive females were aged 34 and tumors, we identified two unrelated individuals with 51 yr at diagnosis. One patient (case I) had two head and TMEM127 mutations with extraadrenal disease. These neck paragangliomas, whereas the other one (case II) had two missense mutations lie within the first and third an extraadrenal retroperitoneal as well as bilateral adrenal transmembrane domains, respectively, of TMEM127 tumor. All tumors were benign. Neither patient had family and would be predicted to disrupt structural integrity. histories of paraganglial tumors or syndromes that com- Therefore, surveillance for TMEM127 mutation carriers prised paraganglial tumors. Of note, the extraadrenal tu- can no longer be limited to adrenal sites. Although the Downloaded from https://academic.oup.com/jcem/article/96/8/E1279/2833767 by guest on 27 September 2021 mor of patient II did not arise from an adrenal rest. Pre- numbers are small, one extraparaganglial neoplasia was operatively, 24-h urine showed adrenaline of 123 ␮g also identified in one of the two mutation carriers. Should (normal Ͻ 20 ␮g), noradrenaline of 51 ␮g (normal Ͻ 105 this be the case, such as is true of carriers of SDHB and ␮g), metanephrine of 4651 ␮g (normal Ͻ 350 ␮g), and SDHD mutations where renal cell carcinoma is part of the normetanephrine of 895 ␮g (normal Ͻ 600 ␮g); plasma clinical spectrum (10), then clinical management must metanephrine was 1870 ng/liter (normal Ͻ 90 ng/liter), take that into account as well. and plasma normetanephrine was 409 ng/liter (normal Ͻ Interestingly, the frequency of the known coding single- 200 ng/liter). In case I, thoracic and abdominal paragan- nucleotide polymorphism A207A in 8% of the controls is glial tumors have been excluded by computerized tomog- lower than that observed in a previous study’s control raphy. Interestingly, one of the two patients had acute group (32%) (1) but similar to the frequency in the patient myeloid leukemia diagnosed at age 44, 10 yr after resec- group. The explanation may be a local effect, because all tion of the paraganglioma. controls of our study are living in the area of Freiburg, Germany. In this population-based study, only multiple tumors Discussion signaled potential heredity as our selection criteria, whereas the other red flags of heredity, early age of Just over 8 yr ago, it was believed that only 10% of pheo- onset, family history, and bilateral disease in paired chromocytomas were heritable, mainly from multiple en- organs were absent. This is in contrast to the so far only docrine neoplasia type 2 (RET) and von Hippel-Lindau available series where 20 TMEM127 mutation carriers disease (VHL). With the discovery of SDHB, SDHC, and ranged in age from 21–66 yr at the time of diagnosis, SDHD as pheochromocytoma/paraganglioma-predispo- one quarter had a family history, and one fifth had bi- sition genes in the last decade, it became obvious that lateral adrenal involvement (1). 30–40% of pheochromocytoma/paragangliomas are due We conclude, therefore, that germline mutations of the to germline mutations in one of these five genes, each of TMEM127 gene can also confer risk of extraadrenal para- which conferred different risks of malignancy and differ- ganglial tumors, those of the retroperitoneum as well as of ent organ-specific risks of neoplasias (9–11). With the list head and neck locations, with a prevalence of 4%, if pa- of predisposition genes growing by two just in the past 2 tients with multiple paraganglial tumors are analyzed. The yr, the potential for increase of clinical manifestations and prevalence of extraadrenal paraganglial tumors in a series presentations will pose challenges to broad healthcare of extraadrenal cases remains to be shown. providers, especially those in the endocrine subspecialties. More and more, the primary care provider is being called upon to recognize and judiciously refer those at heritable Acknowledgments risk of disease to genetics professionals. In the case of pheochromocytoma and paraganglioma, this has now be- Address all correspondence and requests for reprints to: Hartmut P. H. Neumann, M.D., Medizinische Universita¨tsklinik, Abtei- come straightforward because of the genetic load (30– lung Innere Medizin 4, Sektion fu¨ r Pra¨ventive Medizin, Hug- 40%); all presentations should be referred. However, once stetter Strasse 55, D-79106 Freiburg, Germany. E-mail: hartmut. the gene is identified and gene-informed management rec- [email protected]. ommended, the onus falls back on the primary care pro- C.E. is the Sondra J. and Stephen R. Hardis Chair of Cancer vider and often the endocrine specialist to orchestrate the Genomic Medicine at the Cleveland Clinic, and is an American multidisciplinary care and, at times, complex surveillance Cancer Society Clinical Research Professor, generously funded recommendations (e.g. von Hippel-Lindau disease). Thus, in part by the F.M. Kirby Foundation, and the Arthur Blank E1282 Neumann et al. TMEM127 Mutations in Paragangliomas J Clin Endocrinol Metab, August 2011, 96(8):E1279–E1282

Foundation, Atlanta, GA. H.P.H.N. is supported by a grant of Fassnacht M, Opocher G, Klose S, Fottner C, Forrer F, Plo¨ ckinger the German Research Foundation (Deutsche Forschungsgemein- U, Petersenn S, Zabolotny D, Kollukch O, Yaremchuk S, Janusze- schaft Ne 571/4-6). wicz A, Walz MK, Eng C, Neumann HP 2009 Clinical predictors and algorithm for the genetic diagnosis of pheochromocytoma patients. Disclosure Summary: All authors declare no conflicts of interest. Clin Cancer Res 15:6378–6385 6. Schwarz JM, Ro¨ delsperger C, Schuelke M, Seelow D 2010 Muta- tionTaster evaluates disease-causing potential of sequence altera- References tions. Nat Methods 7:575–576 7. Ramensky V, Bork P, Sunyaev S 2002 Human non-synonymous SNPs: server and survey. Nucleic Acids Res 30:3894–3900 1. Yao L, Schiavi F, Cascon A, Qin Y, Inglada-Pe´rez L, King EE, Toledo 8. Bromberg Y, Rost B 2007 SNAP: predict effect of non-synonymous RA, Ercolino T, Rapizzi E, Ricketts CJ, Mori L, Giacche` M, Men- polymorphisms on function. Nucleic Acids Res 35:3823–3835 dola A, Taschin E, Boaretto F, Loli P, Iacobone M, Rossi GP, Biondi 9. Neumann HP, Bausch B, McWhinney SR, Bender BU, Gimm O,

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