10th Annual Canadian Endocrine Update
April 11th, 2014
Multiple Endocrine Neoplasia Type I: Diagnosis, Management and Role of DNA Analysis
Maria Luisa Brandi University of Florence
Florence, Italy
Faculty/Presenter Disclosure
• Faculty: Maria Luisa Brandi MD, PhD
• Relationships with commercial interests: – Grants/Research Support: Alexion, Amgen, Eli Lilly, Glaxo, MSD,
Novartis, NPS, Roche, Servier, Shire – Speakers Bureau/Honoraria: NPS – Consulting Fees: Servier, Alexion
DEFINITION
A case or a family with hormone-secreting or hormone- producing neoplasia in multiple tissue types
It encompasses several types of etiology, varying from two coincidental tumors to complex patterns of tumor types. Certain patterns of tumor types recur reproducibly among unrelated cases or among unrelated families
MULTIPLE ENDOCRINE NEOPLASIA SYNDROMES
SEVEN MULTIPLE ENDOCRINE NEOPLASIA SYNDROMES AND THEIR MAIN CHARACTERISTICS
Multiple endocrine neoplasia type 4
Parathyroid hormone, growth hormone, adrenocorticotropic hormone, adrenal non-functioning, pituitary non-functioning, islet non-secreting, gastrin
Foregut carcinoid, cervical and pancreatic neuroendocrine tumors
Lipoma
Multiple endocrine neoplasia type 2 variants
Multiple endocrine neoplasia type 1
Carney complex
McCune-Albright syndrome
Von Hippel-Lindau disease
Neurofibromatosis type 1
Islet non-secreting , pituitary non-secreting, adrenal cortex, parathyroid hormone, gastrin, insulin, prolactin, growth hormone, adrenocorticotropic hormone C-cell cancer, adrenal chromaffin, calcitonin, catecholamine, parathyroid hormone
Cortisol, thyroxine, growth hormone, prolactin, androgen or oestrogen Androgen or oestrogen, growth hormone, prolactin ,cortisol, thyroxine
Catecholamine, insulin
Duodenal carcinoid, catecholamine
Syndrome Benign tumours and/or hormonal excess
Malignant tumours and/or hormonal excess
Non-hormonal neoplasia (benign or malignant)
Foregut carcinoid, gastrin, glucagon. vasoactive intestinal polypeptide, pancreatic polypeptide
C-cell cancer, adrenal chromaffin, calcitonin, catecholamine
Thyroxine
_
Catecholamine
Angiofibroma, collagenoma, lipoma, leiomyoma, meningioma, ependymomma
Neuroma (MEN2B)
Heart myxoma, lentigine schwannoma
Fibrous dysplasia of bone, cafè-au-lait spots, sarcoma (rare) Renal-cortex cancer, haemangioblastoma, retinal angioma
Neurofibroma, cafè-au-lait spots, Lisch nodules, freckling
_
Centro TEE
Endocrine Tumors Expressed in Multiple Endocrine Neoplasia Types 1 and 2
Growth Inhibitor and Growth Promoter
TUMOR SUPPRESSOR ONCOGENE
Loss of inhibition Induces tumorigenesis Suppresses tumorigenesis
Overexpression
Diesease-causing mutations
Inactivating
Inhibits proliferation Increases apoptosis
Activating
Enhances proliferation Reduces apoptosis
Centro TEE MEN1 GENE
• Location is on chromosome 11q13 • Consists of 10 exons that span 9 kb and encode a 610 amino acid
protein called MENIN, that is ubiquitously expressed • Germline mutations – over 400 different mutations of which >70%
are inactivating • Somatic mutations – loss of heterozygosity (LOH) including 11q13
occurs in >90% of MEN1 tumours
Centro TEE MENIN INTERACTS WITH SEVERAL
PROTEINS
Nf-kB
HDAC, mSin3A
CHES RPA FANCD2
NM23
ASK
Myosin
Vimentin GFAP
MLL1/2, LEDGF b-catenin
Nuclear receptors
Pem Smad
JunD
menin
Cytoskeleton Cell cycle
DNA Repair Transcription
Tumor-suppressive or Pro-oncogenic Effects of Some Menin Interactions
Tumor-suppressive Pro-oncogenic (MEN1 and related states) MLL/p18, p27 JunD/AP1 SMAD/Runx (TGF-β/BMP) Histone modifiers Erα, VDR, PPAR-γ DNA damage response β-catenin (Wnt) IQGAP1
MLL/Hox (Mixed Lineage Leukemia) Wnt: β-catenin/Myc (Colorectal cancer) Er-α (Breast cancer) ?? (Prostate cancer) HIV promoter (SKIP, Myc, MLL)
Other
Menin Perspectives on Mechanisms of Action
• Menin is a multifunctional protein with multiple interactions in multiple pathways and regulatory processes
• Promiscuity raise the question of specificity
• Target gene could help determine tumor-suppressive or pro oncogene effect from specific interactions
• Tumor suppressive effects: loss-of-function MEN1 mutations Pro-oncogenic effects: gain-of-function MEN1 mutations?
• Development of disease inhibition assays that target particular menin interactions should also consider the effects on menin’s other (opposing) interactions
MEN1-Related Endocrine Tumors And Their Prevalence Parathyroid Adenomas (90%) GEP Gastrinoma (40%)
Insulinoma (10%)
Others (VIPoma, PPoma, SSoma, Glucagonoma) (2%) Non-functioning (20%)
Anterior Pituitary Functioning: PRLoma (20%)
GH-, GH/PRL-, TSH-, ACTH-secreting, or Non-functioning (17%)
Foregut Carcinoids Thymic (2%) Bronchial (2%) Gastric (ECLoma) (10%)
Adrenal Gland Non-functioning (20%)
MEN1-Related Non-Endocrine Tumors And Their Prevalence
Cutaneous Tumors Lipomas (30%)
Facial angiofibromas (85%)
Collagenomas (70%)
Central Nervous System Meningiomas (5%)
Ependymomas (1%)
Others Leyomiomas (10%)
Basis for a diagnosis of MEN1 in individuals
Basis for MEN1 diagnosis
CLINICAL FAMILIAL GENETIC A patient with 2 or more MEN1-associated tumours
A patient with 1 MEN1-associated tumour and a first degree relative with MEN1
An individual who has an MEN1 mutation but does not have clinical or biochemical manifestations of MEN1 i.e. a mutant gene carrier
JCEM 2001
JCEM 2012
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MEN SYNDROMES AND THEIR CHARACTERISTIC TUMORS AND ASSOCIATED GENETIC ABNORMALITIES
Type (chromosome location) Tumors (estimated penetrance) Gene, most frequently
mutated codons
MEN1 (11q13)
MEN2 (10 cen -10q11.2) MEN2A
MTC only
MEN2B (also known as MEN3)
MEN4 (12p13)
Parathyroid adenoma (90%) Enteropancreatic tumor (30-70%): gastrinoma (40%), insulinoma (10%), nonfunctioning and PPoma (20-55%), glucagonoma (<1%), VIPoma (<1%) Pituitary adenoma (30-40%): prolactinoma (20%), somatotropinoma (10%), corticotropinoma (<5%), nonfunctioning (<5%) Associated tumors: adrenal cortical tumor (40%), pheochromocytoma (<1%), bronchopulmonary NET (2%), thymic NET (2%), gastric NET (10%), lipomas (30%), angiofibromas (85%), collagenomas (70%), meningiomas (8%)
MTC (90%) Pheochromocytoma (50%) Parathyroid adenoma (20-30%) MTC (100%)
MTC (>90%) Pheochromocytoma (40-50%) Associated abnormalities (40-50%) Mucosal neuromas Marfanoid habitus Medullated corneal nerve fibers Megacolon
Parathyroid adenoma Pituitary adenoma
Reproduction organ tumors (e.g. testicular cancer, neuroendocrine cervical carcinoma) ? Adrenal + renal tumors
MEN1 83/84, 4-bp del (≈4%) 119, 3-bp del (≈3%) 209-211, 4-bp del (≈8%) 418, 3-bp del (≈4%) 514-516, del or ins (≈7%) Intron 4 ss, (≈10%)
RET 634, missense e.g. Cys → Arg (≈85%) RET 618, missense (>50%) RET 918, Met → Thr (>95%)
CDKN1B No common mutations identified to date
Adapted from: JCEM 97:2990, 2012
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SUGGESTED BIOCHEMICAL AND RADIOLOGICAL SCREENING IN INDIVIDUALS AT HIGH RISK OF DEVELOPING MEN1
Paratyroid Pancreatic NET Gastrinoma Insulinoma Other pancreatic NET Anterior pituitary Adrenal Thymic and bronchial carcinoid
8
20 5
<10
5 <10
15
Calcium, PTH Gastrin (± gastric pH) Fasting glucose, insulin Chromogranin-A; pancreatic polypeptide, glucagon, VIP Prolactin, IGF-I None unless symptoms or signs of functioning tumor and/or tumor >1 cm are identified on imaging None
None None None MRI, CT, or EUS (annually) MRI (every 3 yr) MRI or CT (annually with pancreatic imaging) CT or MRI (every 1-2 yr)
Tumor Age to
begin (yr) Biochemical test
(plasma or serum) annually Imaging test (time interval)
EUS, Endoscopic ultrasound. [Adapted from P. J. Newey and R. V. Thakker: Role of multiple endocrine neoplasia type 1 mutational analysis in clinical practice. Endocr Pract 17 (Suppl 3): 8-17, 2011 (21), with permission. © American Association of Clinical Endocrinologists. And from R. V. Thakker: Multiple endocrine neoplasia type 1 (MEN1). Translational Endocrinology and Metabolism, Vol. 2 (edited by R. P. Robertson and R. V. Thakker), The Endocrine Society, Chevy Chase, MD, 2011, pp 13-44 (5), with permission.]
Adapted from: JCEM 97:2990, 2012
GENETIC DISORDERS ASSOCIATED WITH PRIMARY HYPERPARATHYROIDISM (PHPT) AND FAMILIAL HYPERCALCEMIA
Primary Hyperparathyroidism in MEN 1 Young age of onset (20-25 yr vs. 55 yr)
Hypercalcemia usually mild (parathyroid cancer and hypercalcemic crisis very rare)
Late clinical manifestations
Greater reduction in bone mineral density
All parathyroids are affected, but with an individual extent (genetic predisposition to multiglandular disease)
Single enlarged gland
Asymmetrical hyperplasia
4 gland hyperplasia
MEN1-pHPT TREATMENT
Surgery is the elective treatment
CONTROVERSIES Whether to perform
Whether surgery should be performed
Subtotal (≤ 3.5 glands) PTX Total PTX with autotransplantation
Early stage Late stage
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MEN1-pHPT: TIMING FOR SURGERY Indications for parathyroid surgery during monitoring
From: JCEM in press
Bone Complications Are More Severe in MEN1-pHPT vs. Sporadic-pHPT
Cross-sectional observational study of 469 consecutive patients with sporadic-pHPT and 64 with MEN1-pHPT
Adapted from: JBMR 24:1404, 2009; Arch Surg 134:1119, 1999
BMD at the LS and FN in patients affected with sPHPT and MEN1-related PHPT. White and gray columns, sPHPT and MEN1 patients, respectively
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Why Skeletal Involvement in Hereditary Endocrine Tumors?
Bone tissue is the second largest connective compartment after the skin Bone tissue is highly responsive to hormonal influence Bone phenotypes were described in congenital endocrine neoplasia syndromes Molecular biology is unraveling previously unrecognized roles for suppressive genes
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MEN1 MEN2B
Familial Isolated Pituitary
Adenomas
Cowden Syndrome
MEN4
von Hippel Lindau
Syndrome
Menin Subserves in Bone Pleiotropic Actions
Menin plays significant roles in osteoblast differentiation through interaction BMP-Runx2, TGFβ and JunD pathways
Menin interacts with other bone-related factors, such as Rb protein, Erα, VDR, IGF-BP2 and telomerase
IF SURGERY FAILS OR IS CONTROINDICATED?
Approved by FDA and EMA for CRF, in parathyroid cancer, in patients not operable or when PTX failed
The question is: long-term effects on proliferative tissues
Cinacalcet (AMG073)
NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM 4:351, 2008
PHASE IV, OPEN, MULTICENTRIC STUDY
Primary objectives 1.
Secondary objectives 2.
Reduction or normalization of PTH and calcemia
Reduction or maintenance of parathyroid glands’ volume
Increase of BMD and reduction of bone turnover
No effects on other endocrine gland function
Well tolerated and safe
USE OF CINACALCET IN MEN 1-pHPT
Centro TEE PITUITARY ADENOMAS MEN1
Pituitary adenomas are present in 16-65% of adult symptomatic MEN1 patients
Type of adenomas Penetrance in MEN1 patients
Prolactinomas
Non-functioning pituitary adenomas
GH + prolactin, GH secreting adenomas
ACTH secreting pituitary adenomas
TSH secreting pituitary adenomas
25%
10%
5%
2%
rare
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• Pituitary tumors in MEN1 are not multiple or multifocal (in contrast with parathyroid or enteropancreatic tumors) with few exceptions (Sahdev A. AJNR 2000)
• High frequency of co-‐secre=ng tumors, with constant presence of prolac=n posi=ve cells
PITUITARY ADENOMAS IN MEN1: MORPHOLOGICAL CHARACTERISTICS
Centro TEE MEN1 VS NON-MEN1 PITUITARY TUMORS
(Data from the French-Belgian network GENEM)
• No difference in age of presentation (38 vs 36 yr) and type of tumor (PRL-oma in 62 vs 61%)
• Mass signs more frequent in MEN 1 pts (29 vs 14%)
• Macroadenomas more frequent (85 vs 42%) and more invasive in MEN 1 patients
• MEN 1 patients less responsive to medical treatments; only 42% (vs 90%) normalized PRL levels during Brc or CB therapy
Adapted from: Verges et al. JCEM 2002)
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• Early ascertainment for MEN1 carriers
• Surveillance for pituitary tumors in MEN1 carriers
• Need for “modified” treatment programs for MEN1 pituitary tumors
RECOMMENDATIONS
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• Transphenoidal surgery is taken in account in pts with macroadenoma but it generally results in postoperative persistence of the tumor
• PRL- and GH-secreting adenomas are effectively
treated with CAB and SSAs respectively which are able to control secreting activity and tumor growth in most of cases
MEN1 PITUITARY ADENOMA: TREATMENT
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Syndromic (part of genetic syndromes) Functional (with dramatic clinical symptoms) Non functional (indolent and late diagnosis)
PANCREATIC NEUROENDOCRINE TUMORS CLASSIFICATION
Centro TEE SYNDROMIC PanNETs
• Associated with genetic syndromes
• Recognition allow for earlier surveillance of descendants
• Predisposition to multifocal pancreatic neoplasms
• The genetic basis can provide insight into the pathogenesis and the natural history of these tumors
• Specific management
• Syndromes: MEN1, von Hipple-Lindau, Tuberous Sclerosis, NF1
Centro TEE MEN1 - PETs
Tumor Penetrance (%) Site Malignancy (%)
Non-functioning or PP-oma 60-100 Pancreas 64-92
Gastrinoma 50 Duodenum (>80%) Pancreas 60
Insulinoma 21 Pancreas 12-20
Glucagonoma 3 Pancreas 70
VIP-oma 1 Pancreas Duodenum (10%) 40
GRF-oma <1 Pancreas 30
Somatostatinoma <1 Pancreas Duodenum/jejunum (44%)
70
FOREGUT CARCINOID
Frequently hormonally silent
Difficult to detect
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MEN1 PETs: CHARACTERISTICS
1. Early onset for tumor expression
2. Multiplicity and puzzling tumors
3. Cancer potential
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PETs ARE THE MOST COMMON CAUSE OF DEATH IN MEN1
(MEDIAN AGE 47 YRS.)
Doherty et al. 1998
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MEN1 – GASTRINOMAS: TYPE OF TREATMENT
• No surgery • Exploration if pancreatic tumors > 2,5-3 cm • Resection of gastrinoma
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• Increase of peptide levels (Skogseid 1991)
• Imaged lesion > 1 cm (Wiedenmann 1998; Lowney 1998; Grama 1992; Thompson 1997; Bartsch 2001)
• Imaged lesion > 2 cm (Triponez 2006)
• Tumor > 3 cm or growing mass (Cadiot 1999; Mignon 1995; Norton 1999)
• No specific size cut-off (Kouvaraki 2006)
• Imaged lesion > 2 cm (Thakker 2012)
MEN1-PETs: SURGICAL INDICATIONS
CONCLUSIONS OF SURGICAL STRATEGY FOR GASTRINOMA IN MEN1 PATIENTS
1. Norman Thompson’s operation is indicated for MEN1 patients with single or a few duodenal gastrinoma
2. PPTD might be indicated for MEN1 patients with considerable numbers of duodenal gastrinoma
3. PD may be indicated for MEN1 patients with many lymph node metastases
4. We have to keep in mind that P-gastrinoma co-existed in 13% of MEN1 patients with D-gastrinoma
MULTIPLE FACIAL AFs • Facial papules < 5 mm • Reddish color • Well-circumscribed borders
Adapted from: Zeller S, et al. J Am AcadDermatol. 2009 Aug; 61 (2): 319-22 Asgharian B, et al. J ClinEndocrinolMetab. 2004Nov: 89(11); 5328-36
MOLECULAR DIAGNOSIS CAN NOW BE INCORPORATED INTO THE MANAGEMENT OF
PATIENTS WITH THESE AUTOSOMAL DOMINANT SYNDROMES
however
VALUE OF GENETIC INFORMATION IN THE CONTEXT OF CLINICAL SCREENING AND EARLY SURGERY VARIES AMONG THESE
DISORDERS
Centro TEE USES OF GENETIC TESTING
1. Diagnostic testing
2. Predictive testing
3. Carrier testing
4. Prenatal testing
5. Preimplantation testing
6. Newborn screening
Clinically applicable genetic tests may be used for:
DIAGNOSTIC TESTING
• Diagnostic testing is used to confirm or rule out a known or suspected genetic disorder in a symptomatic individual
Points to consider • DNA testing may yield diagnostic information at a lower cost and with less
risk than other procedures • Diagnostic testing is appropriate in symptomatic individuals of any age
• Confirming a diagnosis may alter medical management for the individual • Diagnostic testing of an individual may have reproductive or psychosocial
implications for other family members as well • Establishing a diagnosis may require more than one type of genetic test
DNA testing may not always be the best way to establish a clinical diagnosis
PREDICTIVE TESTING
• Predictive testing is offered to asymptomatic individuals with a family history of a genetic disorder
PREDICTIVE TESTING IS OF TWO TYPES
• Pre-symptomatic (eventual development of symptoms is certain when the gene mutation is present) and predispositional (eventual development of symptoms is likely but not certain when the gene mutation is present)
CARRIER TESTING
Carrier testing is performed to identify individuals who have gene mutation for a disorder inherited in an autosomal recessive or X-linked recessive manner Carriers usually do not themselves have symptoms related to the gene mutation Carrier testing is offered to individuals who have family members with a genetic condition, family members of an identified carrier, and individuals in ethnic or racial groups known to have a higher carrier rate for a particular condition
PRENATAL TESTING
• Prenatal testing is performed during a pregnancy to assess the health status of a fetus
• Prenatal diagnostic tests are offered when there is an increased risk of having a child with a genetic condition due to maternal age, family history, ethnicity, or suggestive multiple marker screen of fetal ultrasound examination
• Routine prenatal diagnostic test procedures are amniocentesis and chorionic villus sampling (CVS)
• More specialized procedures include placental biopsy, periumbilical blood sampling (PUBS), and fetoscopy with fetal skin biopsy
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ONE DECADE FOLLOWING THE CLONING OF THE MEN1 GENE 1336 mutations and 24 polymorphisms
• 12 in the coding regions • 9 in the introns
• 3 in untranslated regions
MUTATIONS (in 1091 families) POLYMORPHISMS
• >70% lead to truncated forms of menin • 4% are large deletions
• Four occur frequently
• No genotype/phenotype correlations
Useful for segregation analysis if MEN1 mutation is not found
Therefore the screening becomes time consuming, arduous and expensive
Adapted from: JCEM 92:3389, 2007; Hum Mutat 29:22, 2008
in-frame del/ins 6%
splice-site 9%
gross del 1%
missense 20%
nonsense 23%
frameshift 41%
The identification of genetic phenotypic
modifiers of the disease could in the
future facilitate the outcomes of MEN1
mutation-positive patients
Centro TEE CHARACTERISTICS OF THE MUTATED
MEN1 CASES
• Sporadic cases: 6-10% had MEN1 mutations Familial cases: 90-94% had MEN1 mutations
• A mutation is most likely when one typical endocrine tumor and at least one of the following is present: 1. A first degree relative with a major endocrine tumor 2. Age of onset less than 30 yr 3. Multiple pancreatic tumors 4. Parathyroid hyperplasia
Adapted from: JCEM 92:3389, 2007; Exp Clin Endocrinol Diabetes 115: 509, 2007; Hum Mutat 29:22,2008
Centro TEE CAN GENE TESTING DECREASE THE MORBIDITY
AND MORTALITY ASSOCIATED WITH MEN1?
• Asymptomatic gene carriers will NOT be treated with prophylactic or early surgery
1. In children by the first decade 2. Asymptomatic gene carriers are closely followed 3. A negative test precludes from periodic screening
• Familial screening:
The indentification of MEN1 mutations is of help in clinical management of patients and their families and in life-planning decisions of affected patients
• Autosomal dominant inheritance of this gene makes the gene testing important for other family members
• Identification of gene mutation is important on life-planning • Decisions of affected patients • Recognition of the mutation has variable weight in the clinical
management of genetic carriers • Negative testing precludes subjects from periodic screening • We consider of great usefulness to inform the young patients
about the possibility to perform prenatal genetic testing
RECOMMENDATIONS OUT OF OUR EXPERIENCE
An approach to screening in MEN1
Adapted from: JCEM 97:2990, 2012
“ The development of disease manifestations that are usually associated with mutations of a particular gene, but instead are due to another aetiology”
PHENOCOPY: DEFINITION
Adapted from: Turner et al; Human Mutation, 2010
Examples: Familial MEN1 context, in which a patient with one MEN1- associated tumour does not have the familial mutation Patient with two MEN1-associated tumours, who does not have MEN1 mutation, but has involvement of another gene 5% of families attributed with MEN1 have phenocopies
Five unrelated families with a 4bp (CAGT) deletion at codons 210 and 211
PHENOTYPE GENOTYPE CORRELATION NOT OBSERVED IN THE MEN1 FAMILIES
Family
Tumours
Parathyroid Gastrinoma Insulinoma Glucagonoma Prolactinoma Carcinoid
+ + - - - +
+ - + - + -
+ + - - + -
+ + - - + -
+ + - + + -
1 2 3 4 5
Adapted from: Bassett et al, 1998 Am J Hum Genet
Clinical approach to genetic testing in a patient with PHPT
Adapted from: JCEM in press
Regional Center for Hereditary Endocrine Tumors University Hospital of Florence
Surgery Unit Inpatient Clinic
Front Line Outpatient Clinic
Day Hospital
Laboratory