The Spectrum of Cardiac Anomalies in Noonan Syndrome As a Result of Mutations in the PTPN11 Gene
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ARTICLE The Spectrum of Cardiac Anomalies in Noonan Syndrome as a Result of Mutations in the PTPN11 Gene Yves Sznajer, MDa, Boris Keren, MDa, Clarisse Baumann, MDa, Sabrina Pereiraa, Corinne Alberti, PhDb, Jacques Elion, MD, PhDa, He´le`ne Cave´,MDa, Alain Verloes, MD, PhDa,c aDepartment of Medical Genetics, bClinical Epidemiology Unit, and cInstitut National de la Sante´et de la Recherche Me´dicale INSERM U676, AP-HP Robert Debre´ University Hospital, Paris, France The authors have indicated they have no financial relationships relevant to this article to disclose. ABSTRACT OBJECTIVE. Noonan syndrome is a clinically homogeneous but genetically heteroge- neous condition. Type 1 Noonan syndrome is defined by the presence of a mutation in the PTPN11 gene, which is found in ϳ40% of the cases. Phenotype www.pediatrics.org/cgi/doi/10.1542/ peds.2006-0211 descriptions and cardiac defects from cohorts with Noonan syndrome were delin- doi:10.1542/peds.2006-0211 eated in the “pregenomic era.” We report the heart defects and links to gene Dr Sznajer’s current affiliation is Clinical dysfunction in cardiac development in a large cohort of patients with type 1 Genetics Unit, Hoˆpital Universitaire des Noonan syndrome. Enfants Reine-Fabiola, Universite´Libre de Bruelles, Brussels, Belgium. METHODS. This was a retrospective, multicenter study based on clinical history, Key Words pictures, and medical and cardiologic workup over time. Data were collected by Noonan syndrome, cardiac defect, PTPN11 gene, phenotype, genotype referral geneticists. Mutation screening was performed by direct sequencing of Abbreviations exons 2, 3, 4, 7, 8, 12, and 13 and their intron-exon boundaries, which harbor NS—Noonan syndrome 98% of identified mutations the PTPN11 gene. CHD—congenital heart defect PVS—pulmonary valve stenosis RESULTS. A PTPN11 gene mutation was identified in 104 (38.25%) of 274 patients HCM—hypertrophic cardiomyopathy ASD-OS—atrial septal defect of ostium with Noonan syndrome. Heart defect was present in 85%. The most prevalent secundum type congenital heart defects were pulmonary valve stenosis (60%), atrial septal defect, VSD—ventricular septal defect RAS—rat sarcoma viral oncogene ostium secundum type (25%), and stenosis of the peripheral pulmonary arteries homolog (in at least 15%). Pulmonary valve stenosis and atrial septal defect, ostium secun- MAPK—mitogen-activated protein kinase dum type, were significantly associated with the identification of a mutation in the Egfr—epithelial growth factor receptor NFAT—nuclear factor of activated T cell PTPN11 gene. Ventricular septal defect and most left-sided heart defects showed a LEOPARD—lentigines, EKG anomalies, trend toward overrepresentation in the group without a mutation. ocular hypertelorism, pulmonary stenosis, abnormal genitalia, deafness CONCLUSION. We compared our data with previous series and integrated the compre- Accepted for publication Dec 12, 2006 hension of molecular PTPN11 gene dysfunction in heart development. Address correspondence to Alain Verloes, MD, PhD, Clinical Genetics Unit, 48 Boulevard Se´rurier, 75019 Paris Cedex 19, France. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2007 by the American Academy of Pediatrics PEDIATRICS Volume 119, Number 6, June 2007 e1325 Downloaded from by guest on January 27, 2017 OONAN SYNDROME (NS) is an autosomal dominant pered by the impossibility to check retrospectively for Nmultiple congenital anomalies syndrome that is the presence of valvular dysplasia in patients for whom characterized by minor facial anomalies (hypertelorism, only pulmonary stenosis was mentioned. For this rea- downward slant of the palpebral fissures with ptosis, and son, we decided to merge the 2 anomalies under the low-set posteriorly angulated ears), short stature, con- term PVS. genital heart defects (CHDs), and variable learning dis- Mutation screening focused on hot-spot locations in abilities. With an estimated incidence of 1 in 2000,1 NS the PTPN11 gene, which covered 98% of identified mu- turned out to be 1 of the most common genetic condi- tations.6–9 Exons 2, 3, 4, 7, 8, 12, and 13 of the PTPN11 tion in pediatrics and the second most common syndro- gene and their intron-exon boundaries were sequenced mal form of CHD, after trisomy 21.2 Type 1 NS corre- on both strands from genomic DNA for each patient on sponds to the causally homogeneous subgroup of an ABI 3100 Genetic Analyzer (Applied Biosystems, Fos- patients who have NS and are molecularly defined by ter City, CA). Mutations were identified using ABI the presence of a mutation in the PTPN11 gene. Muta- PRISM SeqScape 2.0 (Applied Biosystems) by compari- tions in PTPN11 are responsible for ϳ40% of the cases of son with the reference sequence for genomic and com- NS and for Ͼ95% of patients with LEOPARD syndrome plementary DNA sequence (GenBank accession Nos. (lentigines, EKG anomalies, ocular hypertelorism, pul- NT009775.14 and NM002834). monary stenosis, abnormal genitalia, deafness). The Statistical analysis for qualitative data and compari- penetrance of the mutations of PTPN11 is 100%, but son used 2 and exact Fisher test. Significance was de- their expressivity is variable even within families. Very termined as P Ͻ .05. Informed consent was obtained for recently, mutations in KRAS3 and SOS14,5 were shown in, inclusion and DNA screening. The ethics committee of respectively, Ͻ5% and 15% of PTPN11-negative patients AP-HP Bichat University Hospital (Paris, France) ap- with NS. PTPN11, SOS1, and KRAS are part of the RAS proved the study. signaling pathway. The causative gene(s) remains to be found for roughly half of patients with NS. RESULTS A broad spectrum of cardiac phenotypes has been A total of 291 patients with NS or LEOPARD syndrome recognized in NS. Pulmonary valve stenosis (PVS), hy- were initially enrolled in the study. The 19 patients who pertrophic cardiomyopathy (HCM) and atrial septal de- presented with cafe´-au-lait spots and/or lentigines were fect of ostium secundum type (ASD-OS) are the most found to share a small number of specific mutations. common defects in NS, but ventricular septal defect Because their clinical and molecular diagnosis was (VSD), peripheral pulmonary stenosis, atrioventricular LEOPARD syndrome, they were studied and published canal, aortic stenosis, mitral regurgitation, aortic coarc- separately.12 The final cohort of patients with NS com- tation, and coronary anomalies can also be seen in NS. prises 149 boys and 123 girls. The mean age in the cohort Previous studies of cohorts of patients with NS suggested is 7 years for the groups both with and without mutation that the prevalence of specific types of CHD was different (lower quartile: 2 years; upper quartile: 13 years). in type 1 NS and in NS without PTPN11 mutation.6–11 We A mutation in the PTPN11 gene was identified in 104 report the cardiac anomalies in a large cohort of patients (38.25%) patients. Table 1 summarizes the cardiologic with type 1 NS to delineate the spectrum of cardiac findings in patients. The c.922A3G (p.N308D) nucleo- defects that are caused by PTPN11 mutations and better tide substitution represents the most prevalent mutation understand the role of PTPN11 in heart development. (18.25%) in our patients. Table 2 presents the spectrum of CHD by functional domain, by exon, and, specifically, METHODS by those observed with the p.N308D mutation. Patients with NS or LEOPARD syndrome were recruited Among patients with a mutation, the apparent rate of through a multicenter network of clinical geneticists heart defect is 85%. Because the selection criteria for from France, Switzerland, and Belgium for molecular offering molecular testing were clinically based and po- analysis of the PTPN11 gene. The patients were entered tentially biased toward overrepresentation of CHD-bear- systematically in the study, on the basis of the order by ing patients, the true penetrance of CHDs in type 1 NS which samples arrived in the laboratory for diagnosis. can nevertheless not be established objectively. The most Checklists were systematically sent to referring geneti- prevalent CHD in type 1 NS are PVS (60%), ASD-OS cists independently and before completion of the DNA (25%), and stenosis of the peripheral pulmonary arteries screening. Call for supplementary data was not based on (in at least 15.4%). PVS and ASD-OS are significantly the identification (or not) of a mutation. Specific cardi- associated with the presence of a mutation (P Ͻ .01), ologic data were derived from records of transthoracic and coarctation of aorta and HCM are associated with echocardiography and, when available, from cardiac the absence of mutation. VSD and most left-sided heart catheterization and/or heart surgery. Because the data defects show a trend toward overrepresentation in the were mainly retrospective, distinction between PVS with group without a mutation. Comparison with previously normal valves and pulmonary valve dysplasia was ham- reported series of genotyped NS is difficult. We summa- e1326 SZNAJER et al Downloaded from by guest on January 27, 2017 TABLE 1 Comparison of CHD Frequency Between PTPN11-Positive (Type 1 NS) and PTPN11-Negative Patients in Our Cohort CHD Patient With an Patient Without an P Identified Identified PTPN11 Mutation PTPN11 Mutation (n ϭ 104), n (%) (n ϭ 168), n (%) PVS 62 (59.60) 53 (31.55) Ͻ.0001 ASD 26 (26.90) 22 (13.10) Ͻ.012 Atrioventricular canal 2 (1.90) 3 (1.80) NS HCM 12 (10.60) 38 (22.60) .022 Coarctation of aorta 1 (0.96) 10