von Hippel-Lindau disease: genetic, clinical, and imaging features

Ocular von Hippel-Lindau disease: clinical update and emerging treatments

PURPOSE OF REVIEW

von Hippel-Lindau disease is an inherited, multisystemic cancer syndrome often involving the retina. This review will provide an update for the clinical characterization and treatment of ocular von Hippel-Lindau disease.

RECENT FINDINGS

A comprehensive and quantitative clinical characterization of ocular von Hippel-Lindau disease has been limited by small patient numbers and nonrepresentative sampling. Recently, a large population of patients with clinically and genetically defined von Hippel-Lindau disease was systemically characterized in a single center, enabling a quantitative evaluation of the ocular involvement of this syndrome. Correlations between the nature of von Hippel-Lindau gene mutations and the ocular phenotype were also examined, providing clues as to how disruptions in von Hippel-Lindau protein function may result in eye disease. This understanding may be relevant to the development of new therapies targeting the molecular biology of von Hippel-Lindau disease, some of which are presently being investigated.

SUMMARY

Quantitative studies enable a full characterization of the impact of von Hippel-Lindau disease on eye health and visual function. Establishing correlations between the genotype of the von Hippel-Lindau mutation and the phenotype of eye disease may inform us as to how ocular von Hippel-Lindau disease arises, and help guide molecular interventions in ocular von Hippel-Lindau disease.

Endocrine pancreatic tumors in von Hippel-Lindau disease: clinical, histological, and genetic features

OBJECTIVES

Endocrine pancreatic tumors (EPTs) in von Hippel-Lindau (VHL) disease pose difficult management problems. We aimed to assess (1) the accuracy of somatostatin receptor scintigraphy, (2) histological features with focus on malignancy and genotype-phenotype correlations, and (3) prognosis of VHL-EPT.

METHODS

Thirty-five patients with EPT-VHL (20 women; median age, 37 years) from 29 families were studied. Histological diagnosis was available in 29 patients. Endocrine pancreatic tumor patients were treated surgically (n = 22), medically (n = 8), or followed (n = 5). Somatostatin receptor scintigraphy was performed in 27 patients. Germinal alterations of the VHL gene were determined.

RESULTS

Tumors were malignant in 58% of patients. Somatostatin receptor scintigraphy was positive in 60% of cases, and weak expression of the somatostatin receptor type 2A was found in 47% of tumors. In operated patients, there was no mortality or tumor relapse (median follow-up, 5 [1-10] years). Mortality rate due to EPT was 6%. Germinal mutations were mainly located in exons 3 and 1, and a specific mutation (P86S) was identified.

CONCLUSIONS

Most EPTs in VHL patients are somatostatin receptor scintigraphy-positive and malignant, without correlation with the VHL genotype. Surgical resection is often required, but prognosis of these EPTs seems to be fairly good.

Von Hippel-Lindau (VHL) disease: an update on the clinico-pathologic and genetic aspects

von Hippel-Lindau (VHL) disease is an inherited multisystem familial cancer syndrome caused by mutations of the VHL gene on chromosome 3p25. A wide variety of neoplastic processes are known to be associated with VHL disease. The consequences of the VHL mutations and the pathway for tumor development continue to be elucidated. This paper will detail the variety of tumors associated with VHL disease and discuss the genetic mechanisms that lead to the predisposition for neoplasia.

Germline mutations in the von Hippel-Lindau disease (VHL) gene in mainland Chinese families

BACKGROUND

von Hippel-Lindau (VHL) disease is a hereditary cancer syndrome caused by germline mutations in the VHL gene. To date, more than 500 VHL families have been reported worldwide. However, few information is available about VHL germline mutations in mainland Chinese families.

OBJECTIVE

To provide some preliminary information about the germline VHL mutations in mainland Chinese population.

METHODS

A total of 27 index patients suspected of having VHL disease from unrelated Chinese families were studied by using direct DNA sequencing analysis and universal primer quantitative fluorescent multiplex polymerase chain reaction.

RESULTS

The VHL germline mutations were detected in 26 (96%) probands. A total of 20 intragenic mutations (77%) were identified consisting of 12 missenses, 5 nonsenses, 2 micro-deletions and 1 novel intron mutation (IVS1-38C>T). Six large deletions (23%) were detected including four partial deletions and two complete deletions. Furthermore, a C>T substitution at nucleotide 470 (Pro86Leu) was observed in two unrelated Chinese families. Of note, two mutations (Asn78Ser and Ser80Ile) previously characterized as VHL type I mutations in Western VHL were associated with the type II Chinese family. In addition, a VHL germline mutation was also identified in a proband who did not fulfill the clinical diagnostic criteria for VHL disease.

CONCLUSIONS

The spectrum of VHL germline mutations in mainland Chinese population is similar to that observed in Western population, and Genetic testing can be powerful in diagnosis and clinical management of VHL disease.

Clinical course of retrobulbar hemangioblastomas in von Hippel-Lindau disease

OBJECTIVE

To report clinical findings of rare retrobulbar optic nerve hemangioblastomas associated with von Hippel-Lindau disease (VHL).

DESIGN

Retrospective observational case series.

PARTICIPANTS

Nine patients with VHL.

METHODS

The clinical course and magnetic resonance imaging findings of patients with VHL and hemangioblastomas affecting the anterior visual pathway from the intraorbital optic nerve to the optic chiasm are reviewed.

MAIN OUTCOME MEASURE

Clinical course of retrobulbar optic nerve hemangioblastomas.

RESULTS

The mean age of VHL diagnosis was 24+/-14 years, and mean follow-up was 5+/-4 years. All had other CNS lesions and retinal hemangioblastomas. Approximately 50% (5/9) had a previous enucleation or had visual acuity loss (4/9), some due to other VHL ocular complications. Four patients underwent surgical resection of an intracranial hemangioblastoma. Growth patterns and pathology are similar to those of other hemangioblastomas in the CNS.

CONCLUSIONS

Although these lesions are rare, patients with VHL who present with signs of optic neuropathy should be evaluated for anterior visual pathway hemangioblastomas impinging on the optic nerve from the orbit to the chiasm. On neuroimaging, the hemangioblastomas may demonstrate chiasmal or optic tract edema, associated cysts, and T(2) flow voids. Lesions may remain radiologically and clinically stable, evolve radiographically with no visual or neurological progression, or progress clinically and radiographically. Patients at risk for visual loss should be considered for surgical resection. Close coordination among neuroradiology, neurosurgery, and ophthalmology patient care teams is advised for optimal management of these patients.

Usefulness of [111In-DTPA0] octreotide scintigraphy in a family with von Hippel-Lindau disease

The identification of patients with von Hippel-Lindau (VHL) disease dictates accurate genetic counseling of family members, whereas screening for early detection of visceral and neurological involvement is usually performed by a combination of radiological and nuclear medicine techniques such as ultrasonography or contrast-enhanced computed tomography of the upper abdomen, magnetic resonance imaging of the central nervous system and 131I-metaiodobenzylguanidine-scintigraphy. The role of 111-indium-diethylenetriaminepentaacetic acid [111In-DTPA0] octreotide scintigraphy in this clinical context has never been investigated. Here, we report imaging findings in a VHL patient and in 3 consecutive family members undergoing clinical and radiological screening that included [111In-DTPA0] octreotide scintigraphy in addition to the above-mentioned procedures. Somatostatin receptor expression was investigated in vitro by immunohistochemistry in pancreatic tumor sections. On the basis of in vivo and in vitro findings, octreotide long-acting release treatment followed by 90Y-1,4,7,10-Tetraazacyclododecane-N,N',N'',N'''-tetraacetic acid (DOTA0)-Tyr3-octreotide led to a lack of progression in this patient although this result is a possibility which needs to be proved by further investigation and longer follow-up. The results of this study suggest that [111In-DTPA0] octreotide scintigraphy may be helpful in the routine work-up of VHL patients for diagnostic and therapeutic purposes.

Clinical, genetic and radiographic analysis of 108 patients with von Hippel-Lindau disease (VHL) manifested by pancreatic neuroendocrine neoplasms (PNETs)

BACKGROUND

von Hippel-Lindau (vHL) disease is an autosomal dominant syndrome associated with neoplasms in multiple organs, which includes the pancreas. Here, we report the greatest single center experience in patients with vHL pancreatic endocrine neoplasm (PNETs).

METHODS

Between December 1998 and November 2006, 633 patients with vHL were evaluated and those with PNETs were enrolled on a prospective protocol.

RESULTS

Overall, 108 vHL patients had PNETs (17%). Nine patients had metastatic disease (8.3%) from their PNET. Patients with lesions greater than 3 cm (n = 25) were more likely to develop metastases than patients with lesions less than 3 cm (n = 83) (P < .005). Thirty-nine patients underwent resection. Germline sequencing showed that 78% of patients with metastases (7/9) had exon 3 mutations compared with 46% of patients without metastases (32/98; P < .01). Tumor doubling time was calculated for the largest PNET. The group with metastases had an average tumor doubling time of 337 days (range, 180-463 days) compared with 2630 days (range, 103-9614 days) for those without metastases (P < .0001).

CONCLUSIONS

By implementing a system of selective operative resection based on defined criteria, vHL patients with PNETs can be managed safely. For patients with small primary lesions (<3 cm), without a mutation of exon 3 and slow tumor doubling time (>500 days), a nonoperative approach may be appropriate for these nonfunctional neoplasms.

A case report of a family with 7 patients of the Von Hippel-Lindau disease

BACKGROUND

This study presents a family with hereditary cerebellar hemangioblastomas, as manifestations of the VHLD.

METHODS

In a 20-year period, 7 members of a family, in 3 generations, developed symptoms of the VHLD with very high frequency and gene penetration. Six patients were operated for cerebellar hemangioblastomas. Two had previously undergone ventriculoperitoneal shunting. There were 2 patients who developed renal and pancreatic cysts, 3 patients retinal hemangioblastoma, and 2 others epididymic cysts. A spinal cord arteriovenous malformation appeared in 1 patient who also had medulla hemangioblastoma.

RESULTS

All the patients had a satisfactory recovery after the operation. One patient now has diabetes mellitus and renal insufficiency. Another patient lost vision in the left eye due to a retinal hemangioblastoma.

CONCLUSIONS

Although rare, VHLD must always be part of the differential diagnosis of a patient with cerebellar hemangioblastoma. Timely diagnosis of the syndrome is essential for manifestations such as renal carcinoma or retinal hemangioblastoma. Organs of first-degree relatives that may be a target of the disease must thoroughly be investigated, and these relatives should be frequently followed up for the rest of their lives. Surgical resection is the gold standard, with excellent results, for hemangioblastomas of the cerebellum.

Salvage partial nephrectomy for hereditary renal cancer: feasibility and outcomes

PURPOSE

Patients with von Hippel-Lindau disease may require repeat partial nephrectomies to avoid the need for renal replacement therapy. We evaluated outcomes in patients who underwent third or fourth partial nephrectomies on the same kidney, which we call salvage partial nephrectomy.

MATERIALS AND METHODS

We retrospectively reviewed the charts of patients who underwent surgery at the National Cancer Institute from 1999 to 2006. We identified 11 of 13 patients in whom salvage partial nephrectomy was performed. Surgical outcomes were assessed by renal preservation as well as intraoperative and postoperative complications. Functional outcomes were assessed by comparing serum creatinine, 24-hour urine creatinine clearance, and nuclear renal scan before and after salvage partial nephrectomy.

RESULTS

All patients were alive and had no radiographic evidence of metastatic disease at a median followup of 25 months (range 3 to 83). Major perioperative complications occurred in 6 of 13 patients (46%) and loss of a renal unit occurred in 3 (23%). None of the patients in whom renal units were preserved required dialysis, although there was an upward trend in serum creatinine and a downward trend in creatinine clearance at postoperative followup (p = 0.07 and 0.08, respectively).

CONCLUSIONS

Although salvage partial nephrectomy is technically demanding and it has a high complication rate, it allows many patients to avoid dialysis. We believe that this experience can be used as a reference for surgeons and patients when considering the risks and benefits of salvage partial nephrectomy.

Pheochromocytoma: presentation, diagnosis and treatment

Pheochromocytomas are rare, mostly benign catecholamine-producing tumors of chromaffin cells of the adrenal medulla or of a paraganglion. Typical clinical manifestations are sustained or paroxysmal hypertension, severe headaches, palpitations and sweating resulting from hormone excess. However, their presentation is highly variable and can mimic many other diseases. If remaining unrecognized or untreated, they can be a life-threatening condition. Therefore, the most important message of this review is to think of them. The diagnosis of pheochromocytomas depends mainly upon the demonstration of catecholamine excess by 24-h urinary catecholamines and metanephrines or plasma metanephrines. They are localized by a computed tomography scan and magnetic resonance imaging of the adrenal glands and abdomen; complementary 123I-metaiodobenzylguanidine scintigraphy and 18F-dihydroxyphenylalanine-positron emission tomography are available. Because approximately one out of four pheochromocytomas turn out to be hereditary entities, screening for genetic alterations is important. Laparoscopic and adrenal sparing surgical intervention following preoperative alpha-blockade is the treatment of choice and usually curative. In malignant pheochromocytomas, radiotherapy and chemotherapy are palliative treatment options. This review provides an update on identification and management of pheochromocytomas, emphasizing current developments in diagnosis, including genetic testing, pathophysiology and treatment of pheochromocytomas.

US–MR Imaging Correlation in Pathologic Conditions of the Scrotum

Ultrasonography (US) is usually the initial imaging modality for evaluation of pathologic conditions of the scrotum. However, magnetic resonance (MR) imaging can be useful as a problem-solving tool when sonographic findings are equivocal. MR imaging allows characterization of scrotal masses as intratesticular or extratesticular and can demonstrate various types of lesions and tissue, including cysts or fluid, solid masses, fat, and fibrosis. MR imaging may be of value when the location of a scrotal mass is uncertain or when US does not allow differentiation between a solid mass and an inflammatory or vascular abnormality. Gadolinium-enhanced MR imaging can help differentiate between a benign cystic lesion and a cystic neoplasm. Gadolinium-enhanced imaging can also be used to demonstrate areas of absent or reduced testicular perfusion, such as in segmental testicular infarct. Finally, MR imaging can demonstrate an intraabdominal undescended testis, which can be difficult to detect with US, and is superior to US in differentiation between an undescended testis and testicular agenesis.

[Single-stage laparoscopic adrenalectomy and pancreatic cyst exsicion in a patient with von Hippel-Lindau disease]

INTRODUCTION

Von Hippel-Lindau disease is a dominant autosomic hereditary condition, characterized by cerebellar hemangioblastomas, retinal animas and visceral cysts and tumors. We report a case of a patient with Von Hippel-Lindau in which we performed a single-stage laparoscopic adrenalectomy for a pheochromocytoma and pancreatic cyst excision.

PATIENT AND METHOD

A 20 year old male patient with Von Hippel Lindau disease underwent laparoscopic adrenalectomy for a 5 cm left adrenal mass. A 3 cm cystic lesion was found of the tail of the pancreas and was resected completely laparoscopically during the same operative procedure.

RESULTS

Total operative time was 120 minutes. There were no operative or postoperative complications. Blood loss was < 50 mL and hospital stay was 3 days. The histopathologic result was adrenal pheochromocytoma and pancreatic mucous microcystic cystoadenoma.

CONCLUSION

Laparoscopy allows surgical approach of patients with simultaneous lesions in several abdominal solid viscera, like Von Hippel Lindau disease. This case represents the first report of one-stage laparoscopic adrenalectomy and pancreatic cyst excision.

Lesions of the Hypothalamus: MR Imaging Diagnostic Features

The hypothalamus is susceptible to involvement by a variety of processes, including developmental abnormalities, primary tumors of the central nervous system (CNS), vascular tumors, systemic tumors affecting the CNS, and inflammatory and granulomatous diseases. The hypothalamus may also be involved by lesions arising from surrounding structures such as the pituitary gland. Magnetic resonance (MR) imaging is the modality of choice for evaluating the anatomy and pathologic conditions of the hypothalamus. The MR imaging differential diagnosis depends on accurate anatomic localization and tissue characterization of hypothalamic lesions through the recognition of their signal intensity and contrast material enhancement patterns. Diffusion-weighted imaging and proton MR spectroscopy can be helpful in differentiating among various types of hypothalamic lesions. Key MR imaging features, in addition to the patient's age and clinical findings at presentation, may be helpful in developing the differential diagnosis for lesions involving the hypothalamic region.

Loss of the actin regulator HSPC300 results in clear cell renal cell carcinoma protection in Von Hippel-Lindau patients

Clear cell renal cell carcinoma (ccRCC) is the most common malignant neoplasm of the kidney. The majority of hereditary and sporadic ccRCC cases are associated with germline and somatic mutations in the Von Hippel-Lindau gene (VHL), respectively. Gross deletions at the VHL locus can result either in ccRCC or in a mild clinical phenotype, with the absence of ccRCC development. Our goal in this study was to identify the molecular basis responsible for these differences in the clinical behavior in order to predict patients' phenotype. Using multiplex ligation-dependent amplification (MLPA), we identified and characterized gross VHL deletions in Spanish VHL families. A candidate gene related to this clinical association, HSPC300, was identified and depleted by RNA interference. It was possible to narrow the susceptibility region related to the mild clinical phenotype down to approximately 14 kb that included HSPC300 (C3orf10), a regulator of actin dynamics and cytoskeleton organization. Whereas 9 out of 10 families with ccRCC retained HSPC300 in the germline, loss of the HSPC300 locus was associated with mild clinical presentation of the disease in 6 out of 8 families. In fact, genetic depletion of HSPC300 resulted in cytoskeleton abnormalities and cytokinesis arrest in several tumor cell lines including ccRCC cells, suggesting that tumor cell proliferation was compromised in the absence of HSPC300. These clinical and functional data indicate a relevant function of HSPC300 in tumor cell progression, and suggest future therapeutic strategies based upon the inhibition of HSPC300 in renal cell carcinoma and possibly on other cancers.

[Retinal angiomatosis. Ocular manifestation of von Hippel-Lindau disease]

Von Hippel-Lindau disease (VHL disease) is a rare multisystem disorder of autosomal dominant inheritance with high penetrance. Inactivation of the VHL-protein leads to an increased expression of hypoxia induced growth factors. Predilection sites for tumor growth are the retina, the central nervous system and various visceral organs. Retinal capillary hemangioblastoma is one of the earliest manifestations of VHL disease. The lifetime risk of permanent visual loss defined as a visual acuity of 0.5 or less is about 35% in gene carriers. It increases to 60% if there is already retinal capillary hemangioblastoma. If VHL disease is suspected, a careful ophthalmological examination should be included in the clinical screening program. Having confirmed the diagnosis, regular ophthalmoscopic monitoring is essential in order to detect developing tumors at an early stage. Therapeutic options for small to medium sized peripheral tumors are laser or cryocoagulation; larger- hemangioblastomas can be treated by brachytherapy using ruthenium plaques, while asymptomatic juxtapapillary tumors can be observed at regular intervals.

An 11-bp duplication in the promoter region of the VHL gene in a patient with cerebellar hemangioblastoma and renal oncocytoma

Central nervous system hemangioblastomas are benign vascular tumours that may present sporadically or as manifestation of the von Hippel-Lindau (VHL) disease. VHL Syndrome is a rare autosomal dominant disorder characterized, besides hemangioblastomas, by susceptibility to multifocal and bilateral renal cell carcinoma and cysts, retinal angiomas, pheochromocytoma, epididymis cystoadenoma, pancreatic cysts and/or islet cell tumours. Germline mutations of VHL tumour suppressor gene cause the VHL disease, while somatic mutations have been associated with sporadic hemangioblastomas and clear-cell renal carcinomas. We identified an 11-bp duplication in the promoter region of the VHL gene in a VHL-affected individual. Functional analysis revealed that this variant affects the binding or the binding affinity of one or more transcription factors that regulate the transcription of VHL in vivo, reducing the endogenous levels of VHL mRNA. Moreover, consistent with the "two hits" model, microsatellite analysis of hemangioblastoma tissue from this patient revealed Allelic Imbalance for the chromosomal region near the VHL gene. We propose that these molecular events, through a loss of pVHL function, lead to the onset of the VHL-related tumours in that individual.

CT of pheochromocytoma and paraganglioma: risk of adverse events with i.v. administration of nonionic contrast material

OBJECTIVE

When pheochromocytoma or paraganglioma is suspected, many institutions perform only unenhanced CT because of a perceived risk of inducing a hypertensive crisis with i.v. administration of contrast material. The purpose of this study was to review our experience with the use of nonionic i.v. contrast material for CT of patients with pheochromocytoma or paraganglioma. The specific goal was to determine whether adverse events occurred.

MATERIALS AND METHODS

A retrospective review of radiology records identified 25 patients (17 women, eight men; mean age, 43 years; age range, 27-70 years) with 40 pathologically proven pheochromocytomas or paragangliomas who received nonionic i.v. contrast material for CT. There were 16 adrenal pheochromocytomas, 12 abdominal paragangliomas, five neck paragangliomas, and seven metastatic lesions. Medical records were reviewed to determine whether the tumors were sporadic or associated with a syndrome, incidentally detected, or biochemically active; and whether patients were taking alpha-blocking medication at the time of CT. Adverse events were documented.

RESULTS

Nineteen patients had 23 sporadic tumors, and six patients had 17 tumors associated with a syndrome. In 12 (48%) of the 25 patients the diagnosis was clinically unsuspected at the time of CT. Elevated levels of urinary catecholamines or their metabolites were found in 19 (90%) of the 21 patients for whom this test was performed. No patients were taking alpha-blocking medication at the time of CT. No adverse events occurred in association with i.v. administration of nonionic contrast material.

CONCLUSION

I.v. administration of nonionic contrast material for CT is a safe practice for patients with pheochromocytoma and related tumors even without alpha-blocking medication.

Inherited cancer susceptibility syndromes in paediatric practice

Over the last decade there have been rapid advances in our knowledge about the molecular basis of many inherited disorders. Molecular testing is now available for many conditions and may assist in the management of the individual and their extended family. One area where the use of genetic testing has expanded rapidly is in the area of hereditary cancer, particularly in relation to hereditary breast/ovarian and hereditary bowel cancer syndromes. Although individually uncommon, there are also a number of rare cancer susceptibility syndromes affecting the paediatric population, where genetic testing may assist in patient management. The following review is a practical guide for clinicians about the role of genetic testing for some rare tumour susceptibilities pertaining to children, including retinoblastoma, familial adenomatous polyposis, juvenile polyposis syndromes, Von Hippel-Lindau disease, multiple endocrine neoplasia, Li-Fraumeni syndrome and neurofibromatosis. We concentrate on disorders where germline mutation testing is routinely available and influences patient management. We have placed specific emphasis on the paediatric presentation of these disorders and provide some guidance to clinicians about surveillance protocols in affected individuals and 'at-risk' family members.

Pituitary stalk hemangioblastoma: The fourth case report and review of the literature

Supratentorial hemangioblastomas (HBL) have been rarely described in the literature. Herein we report the fourth case of pituitary stalk HBL diagnosed concurrently with cerebellar HBLs in a 51-year-old woman with von Hippel-Lindau disease. Complete resection of the lesion was achieved using left frontopterional craniotomy and no recurrence was observed after 8 years of follow-up. The clinical presentation, radiological features, pathological findings, and the management of this particular case are discussed in the light of the available literature. To our knowledge, this case is the only pituitary stalk HBL with total resection, and a long follow-up fully documented.

Genotype-phenotype correlation in von Hippel-Lindau disease with retinal angiomatosis

OBJECTIVES

To characterize the germline mutations found in a large population of persons having von Hippel-Lindau (VHL) disease mutations with the clinical characteristics of associated retinal capillary hemangioblastomas (RCHs), to measure the prevalence of RCHs among patients with VHL disease generally and specifically for each genotype category, to establish genotype-phenotype correlations between genotype category and phenotypic features of ocular VHL disease, and to establish genotype-phenotype correlations between genotype category and visual function.

METHODS

Cross-sectional and molecular genetic study. Of 890 patients with VHL disease, 335 had ocular involvement in the form of RCHs. Statistical analysis was used to correlate the structure of the mutated VHL protein with the ocular phenotype.

RESULTS

Three genotype categories (amino acid substitutions, protein-truncating mutations, and complete deletions of VHL protein) were defined in all patients. The prevalence of RCHs was lowest (14.5%) among patients with complete deletions; the overall prevalence of retinal angiomatosis was 37.2%. Genotype category had no correlation with the unilaterality or bilaterality of ocular disease or with the number or extent of peripheral RCHs. The prevalence of RCHs at the juxtapapillary location was lower among patients with protein-truncating mutations compared with those with amino acid substitutions. Complete deletions were associated with the highest mean visual acuity compared with the other 2 genotype categories.

CONCLUSION

Patients with complete deletions of VHL protein have the lowest prevalence of ocular disease and the most favorable visual outcome.

CLINICAL RELEVANCE

The VHL mutation genotype may be used to predict the prevalence and outcome of ocular VHL disease and to guide ophthalmic follow-up.

Clinical characteristics of pancreatic neuroendocrine tumors in Japanese patients with von Hippel-Lindau disease

OBJECTIVE

The aim of this study was to elucidate the clinical characteristics of pancreatic neuroendocrine tumors (NET) in Japanese patients with von Hippel-Lindau (VHL) disease.

METHODS

We sent a questionnaire to all members of the Japan Pancreas Society in 2002 asking for the number of patients with VHL and complications of NET and/or cystic lesion in the pancreas. Furthermore, we sent a second questionnaire to obtain detailed information about the clinical characteristics of pancreatic NET.

RESULTS

A total of 58 patients with VHL were reported. Among these, 34 (59%) patients had pancreatic lesions, including 10 with pancreatic NET, 23 with a cystic lesion, and one with both. The mean age at identification of pancreatic NET was 34.6 years (range, 22-64 years). The mean diameter of the tumors was 4.3 cm (range, 1-12.5 cm). Distant metastases were found in 2 (20%) cases. During the follow-up period (3.3 years; range, 0-8 years), 7 patients are alive, and 2 patients died of hemangioblastomas.

CONCLUSIONS

Pancreatic NET in the VHL disease showed a relatively lower incidence of metastasis compared with sporadic non-functioning pancreatic NET, yielding a favorable prognosis. Because they present no hormonal syndrome, periodic screening examinations are warranted to identify pancreatic NET at an early stage.

Multimodality imaging of pancreatic and biliary congenital anomalies

A wide spectrum of anomalies of the pancreas, the pancreatic ductal system, and the biliary tree are commonly encountered at radiologic evaluation. These anomalies may simulate various neoplastic, inflammatory, and posttraumatic conditions and should be part of the differential diagnosis for a variety of abnormalities found at diagnostic imaging. Anatomic variants, developmental anomalies (eg, pancreas divisum, annular pancreas, ectopic pancreas, pancreatic agenesis and hypoplasia), and congenital diseases (congenital pancreatic cysts, von Hippel-Lindau disease, choledochal cysts), in addition to potential imaging pitfalls (uneven distribution of fat, "pseudomasses"), can all pose a diagnostic challenge for the radiologist. Familiarity with these anomalies, the imaging techniques available for their study, and their variable imaging manifestations is necessary for differentiating them from other biliary and pancreatic conditions. A basic understanding of the embryologic development and normal anatomy of the pancreas and biliary tree is also essential for identifying these anomalies.

Review: Should patients with apparently sporadic pheochromocytomas or paragangliomas be screened for hereditary syndromes?

CONTEXT

The recent identification of germline mutations of the mitochondrial complex II genes in variants of paraganglioma/pheochromocytoma syndrome has enlarged the number of known causative genes for hereditary pheochromocytoma. A question confronting clinicians is whether they should screen patients with apparently sporadic pheochromocytomas for unsuspected germline mutations of some or all of the seven genes known to cause hereditary paraganglioma or pheochromocytoma (NF1, VHL, RET, MEN1, SDHD, SDHC, and SDHB). A positive answer was suggested by a report that placed the estimate of hereditary disease in apparently sporadic pheochromocytoma as high as 24%.

EVIDENCE ACQUISITION

We applied clinically useful criteria to a review of the literature, defining cases of apparently sporadic pheochromocytoma as those without a suspicious personal or family history, with a focal, unilateral pheochromocytoma, and presenting at age less than 50 yr.

EVIDENCE SYNTHESIS

We reduced the overall estimate of unsuspected hereditary pheochromocytoma patients with apparently sporadic pheochromocytoma to approximately 17%. Mutations in only three genes (VHL, SDHB, and SDHD) accounted for almost this entire minority, and unsuspected RET mutation was rare. Costs, coverage by insurance, the potential effect on insurability, and deficient information for populations outside of referral centers should be considered before recommending genetic testing in patients with apparently sporadic presentations of pheochromocytomas.

CONCLUSION

We recommend genetic testing for patients with an apparently sporadic pheochromocytoma under the age of 20 yr with family history or features suggestive of hereditary pheochromocytoma or for patients with sympathetic paragangliomas. For individuals who do not meet these criteria, genetic testing is optional.

Molecular pathogenetics of renal cancer

Recent developments in genetics and molecular biology have led to an increased understanding of the pathobiology of renal cancer. Thorough knowledge of the molecular pathways associated with renal cancer is a prerequisite for novel potential therapeutic interventions. Studies are ongoing to evaluate novel anticancer agents that target specific molecular entities. This article reviews current knowledge on the genetics and molecular pathogenesis of sporadic and inherited forms of renal cancer.

Neuroimaging of phakomatoses

The phakomatoses are congenital disorders manifesting with central nervous system and cutaneous abnormalities. The structures predominantly affected are those of ectodermal origin, including the skin, nervous system, and eyes. The 4 most common phakomatoses are neurofibromatosis (types 1 and 2), tuberous sclerosis, Sturge-Weber disease, and von Hippel-Lindau disease. Imaging of the brain and spine in these disorders plays an important role in diagnosis, as well as determining the extent of involvement and guiding surgical interventions. This article reviews the application of x-ray computed tomography and magnetic resonance imaging to these disorders, as well as that of newer, "functional" imaging techniques such as positron emission tomography, magnetic resonance perfusion imaging, and spectroscopy.

Von Hippel–Lindau disease germline mutations in Mexican patients with cerebellar hemangioblastoma

Object

Central nervous system (CNS) hemangioblastomas are benign vascular tumors arising either sporadically or as a manifestation of von Hippel–Lindau (VHL) disease, a hereditary cancer syndrome. The authors studied a series of patients with CNS hemangioblastomas and their families to identify germline mutations in the VHL tumor suppressor gene and to establish a predictive testing and screening protocol.

Methods

Patients admitted between 2002 and 2004 to the Instituto Nacional de Neurología y Neurocirugía for hemangioblastoma were prospectively enrolled, together with their at-risk family members. The authors performed the molecular analysis of the VHL gene by using polymerase chain reaction and direct genetic sequencing. All asymptomatic mutation carriers underwent genetic counseling and tumor surveillance. Ninety-eight individuals were tested for VHL mutations—23 symptomatic and 75 asymptomatic individuals belonging to 16 families. Seven of the families had definite clinical criteria of VHL disease, five had sporadic hemangioblastoma, and four had CNS hemangioblastoma combined with minor visceral signs. Molecular genetic testing identified five germline mutations in six of the definite VHL families (sensitivity 85%), but none in the possible VHL and sporadic hemangioblastoma cases; four of these mutations had been previously described and one is a novel mutation present in two unrelated families. After patients carrying the mutation were identified, they underwent clinical screening and asymptomatic VHL-related lesions were identified in 43%.

Conclusions

Genetic testing for mutations in the VHL gene is crucial in patients with CNS hemangioblastoma. The prompt identification of patients carrying the genetic mutation allows for a multidisciplinary screening protocol to decrease morbidity and mortality rates in these patients, while avoiding costly and invasive procedures for noncarriers.

The von Hippel–Lindau (VHL) germline mutation V84L manifests as early-onset bilateral pheochromocytoma

Von Hippel-Lindau (VHL) disease is a heritable tumor susceptibility syndrome caused by germline mutations in the VHL gene. The types of tumor that can occur in affected individuals include retinal and central nervous system hemangioblastoma, renal cell carcinoma, pheochromocytoma, and others. The pattern of tumor types that develops in a VHL-affected family defines the clinical subtype (1, 2A, 2B, 2C). Generally, it is difficult to accurately predict an individual's clinical phenotype based on their VHL mutation. However, in a few specific VHL mutations, a strong genotype-phenotype correlation has been established. We report here on the clinical findings in individuals from three unrelated families with a V84L VHL germline mutation, and present follow-up information regarding the only other reported family with this missense mutation. In each of these four families, the major clinical manifestation of VHL disease is multiple early-onset pheochromocytomas (VHL type 2C). This series of eight patients strengthens the correlation between the V84L mutation and the VHL type 2C phenotype, and improves our ability to provide prognostic and management recommendations for similarly affected individuals.

Spinal hemangioblastoma containing metastatic renal cell carcinoma in von Hippel—Lindau disease

✓ The authors describe the case of a patient with von Hippel—Lindau (VHL) disease in which a spinal hemangioblastoma contained metastatic renal cell carcinoma (RCC). The literature on tumor-to-tumor metastasis associated with VHL disease of the central nervous system (CNS) is reviewed.

Midthoracic back pain developed in this 43-year-old man with a left-sided radicular component 2 years after he underwent resection of a left RCC. Radiological findings demonstrated a T6–7 intradural intramedullary lesion. A T5–8 laminectomy and gross-total resection of the spinal cord mass were performed. Light and electron microscopic examination showed features of hemangioblastoma, which contained metastatic foci of RCC. Genetic analysis demonstrated the presence of a deleting mutation in the first exon (nt. 394–406) of the VHL locus, truncating 16 amino acids (N61–77) from the first beta sheet in the VHL protein. A review of the literature revealed that RCC-to-CNS hemangioblastoma is the second most common donor—recipient tumor association among the tumor-to-tumor metastases.

Malignant mesothelioma of the tunica vaginalis testis: unusual sonographic appearance

Malignant mesothelioma of the tunica vaginalis testis is a rare and aggressive neoplasm. It is similar to malignant mesothelioma of the peritoneum, usually associated with asbestos exposure. We present an unusual case in which the tumor was a mix of a hypoechoic solid nodule and a cystic component with low-level internal echoes.

Treatment of recurrent cerebellar hemangioblastoma with external radiotherapy in a patient with von Hippel-Lindau disease: a case report and review of the literature

Von Hippel-Lindau Disease, a multisystem familial cancer syndrome, is inherited as an autosomal-dominant trait. Common manifestations of the disease are retinal, cerebellar and medullary hemangioblastomas; renal cysts and carcinomas; pancreatic cysts; pheochromocytoma; and papilllary cystadenoma of the epididym. We report the case of a 40-year-old man with type I von Hippel-Lindau disease treated with external radiotherapy for recurrent cerebellar hemangioblastoma.

Phaeochromocytoma

Phaeochromocytomas are rare neuroendocrine tumours with a highly variable clinical presentation but most commonly presenting with episodes of headaches, sweating, palpitations, and hypertension. The serious and potentially lethal cardiovascular complications of these tumours are due to the potent effects of secreted catecholamines. Biochemical testing for phaeochromocytoma is indicated not only in symptomatic patients, but also in patients with adrenal incidentalomas or identified genetic predispositions (eg, multiple endocrine neoplasia type 2, von Hippel-Lindau syndrome, neurofibromatosis type 1, and mutations of the succinate dehydrogenase genes). Imaging techniques such as CT or MRI and functional ligands such as (123)I-MIBG are used to localise biochemically proven tumours. After the use of appropriate preoperative treatment to block the effects of secreted catecholamines, laparoscopic tumour removal is the preferred procedure. If removal of phaeochromocytoma is timely, prognosis is excellent. However, prognosis is poor in patients with metastases, which especially occur in patients with large, extra-adrenal tumours.

Endolymphatic sac tumor metastatic to the spine

✓ Endolymphatic sac tumors (ELSTs) are aggressive papillary lesions of the temporal bone. Although histologically benign, they may exhibit invasive growth and destruction of the skull base. Patients generally present with symptoms referable to the lesion's location within the middle or posterior cranial fossa. Although well characterized as a distinct entity, ELSTs involved in metastatic dissemination have never been reported. In the present report the authors describe a case of ELST metastatic to the spine treated with resection.

Hemangioblastomas of Central Nervous System: Molecular Genetic Analysis and Clinical Management

OBJECTIVE

Hemangioblastomas of the central nervous system (CNS) are benign neoplasms that may occur sporadically or in association with von Hippel-Lindau (VHL) disease. The proportion of primary symptomatic hemangioblastomas associated with VHL disease is estimated to be from 10 to 40%, but it seems to be underestimated. We investigated the frequency of VHL germline mutation in patients with symptomatic CNS hemangioblastoma without evidence of VHL disease to define the role of molecular genetic analysis in the management of such patients and their relatives.

METHODS

We analyzed 14 patients (6 female and 8 male; mean age, 43.5 yr) with no family history and no other clinical manifestations of VHL disease who had been operated on for symptomatic CNS hemangioblastoma. Exons 1, 2, and 3 of the VHL gene and their immediately flanking sequences were amplified by use of polymerase chain reaction followed by analysis with denaturing high-performance liquid chromatography and sequencing the anomalous samples.

RESULTS

Germline mutations of the VHL gene were identified in 2 (14%) of 14 patients. VHL gene mutation analysis was performed in both patients' family members, which showed another affected asymptomatic subject for VHL disease. The affected subjects were recommended for VHL disease surveillance protocol.

CONCLUSION

Molecular genetic analysis is a safer and more specific instrument to confirm or exclude VHL disease in patients with CNS hemangioblastoma, a negative family history, or absence of other known manifestations of the disease. Early identification of VHL mutation gene carriers is important for reducing disease morbidity and mortality. Nonsymptomatic family members will benefit from early VHL disease diagnosis or by being excluded as at-risk subjects, reducing the psychological and economic burden of screening and surveillance protocols.

Management of von Hippel–Lindau-associated kidney cancer

Von Hippel-Lindau disease (VHL) is an autosomal-dominant inherited condition that predisposes patients to develop renal cysts and tumors, most commonly in the second to fourth decades of life. Renal cysts and tumors have historically been a major cause of disease-related morbidity and mortality, so urologists are often called on to manage patients with VHL. Knowledge of the extrarenal manifestations of VHL (hemangioblastomas of the central nervous system and retina, endolymphatic sac tumors, pancreatic cysts, epididymal and broad-ligament cysts, and pheochromocytomas) and integration of nonurologic specialties into management teams for VHL patients will help to achieve successful outcomes. Screening for renal manifestations of VHL, by regular imaging of the abdomen, begins late in the second decade of life. Because renal tumors in VHL can be multifocal and bilateral, management can be complex. Radical nephrectomy removes all tissue at risk for forming renal tumors; however, this necessitates renal replacement therapy. In an effort to control cancer effectively while preserving native renal function and minimizing intervention, some researchers have proposed an observational strategy. Patients are screened until the largest tumor reaches 3 cm in diameter, at which time operative intervention is recommended. Nephron-sparing surgery is undertaken, whenever technically feasible, with the goal of removing all tumors in that renal unit. The role of minimally invasive technologies is currently being evaluated in selected patients with VHL renal masses. Elucidation of molecular pathways associated with VHL renal tumors may facilitate development of effective medical treatments for these lesions in the future.

Clear Cell Papillary Cystadenoma of the Epididymis and Mesosalpinx

Clear cell papillary cystadenoma is a rare epithelial tumor of the epididymis, which may present as an isolated lesion or as a component of von Hippel-Lindau disease (VHLD). Recently, tumors have also been described in the female genital tract with similar histology. Recognition of clear cell papillary cystadenoma is critical because of its association with VHLD and its potential diagnostic confusion with metastatic renal cell carcinoma because of a shared architecture and clear cells. In this study, we report on the immunohistochemical differentiation of 5 clear cell papillary cystadenomas, 3 of the epididymis and 2 of the mesosalpinx, from metastatic renal cell carcinoma. In 2 cases, there was a history of renal cell carcinoma in the setting of VHLD; and in 1 of these cases, an epididymal papillary cystadenoma was initially considered to be metastatic renal cell carcinoma. Immunohistochemically, tumor cells were moderately intensely positive for cytokeratin AE1/AE3 and epithelial membrane antigen, strongly positive for CK7 and negative for CK20 and RCC. Four of 5 cases were negative for CD10. This staining profile contrasts with that reported for clear cell renal cell carcinomas, which are typically negative for CK7 and immunoreactive for renal cell carcinoma (RCC) and CD10. Our findings indicate that, in cases where there is uncertainty about the histologic diagnosis of clear cell papillary cystadenoma, the above immunohistochemical panel helps to rule out metastatic renal cell carcinoma.

The long-term results of gamma knife radiosurgery for hemangioblastomas of the brain

Object. The authors assessed the long-term result of gamma knife surgery (GKS) for hemangioblastomas of the brain (HABs) and show histopathological findings after GKS.

Methods. Thirty-five patients, 28 men and seven women, with a mean age of 36 years underwent GKS. Eighteen patients presented with multiple tumors and 17 with a solitary tumor. Twenty-one patients had von Hippel—Lindau (VHL) disease. The mean tumor diameter was 13 mm (range 5–55 mm). The mean follow up after GKS was 66 months (range 24–114 months). The mean prescription dose was 17.2 Gy (range 12–24 Gy) at the tumor margin. For tumors close to or within the brainstem a prescription dose of 12 to 13 Gy was used.

At the most recent follow up, 29 patients were alive, six were dead, and satisfactory tumor control had been achieved in 29. A stable or improved neurological status was obtained in 21 patients. Eight patients underwent open surgery because of tumor-associated cyst enlargement or the development of new tumors after GKS. Seven patients developed new tumors and five of them required a second GKS. The 1-year tumor control rate was 94%; 2 years, 85%; 3 years, 82%; 4 years, 79%; and 5 years, 71%. Histopathology showed that no tumor cells were found and there was degeneration and necrosis in a tumor nodule 48 months after GKS with a prescription dose of 18 Gy.

Conclusions. Gamma knife surgery was a useful choice for small- or medium-sized, solid HAB in the long term, especially when the tumor margin dose was 18 Gy. Although GKS can treat multiple tumors in a single session, for HABs associated with VHL disease, GKS faces the dual problems of tumor recurrence or development of a new tumor.

Hemangioblastoma of the lateral ventricle: case report and review of the literature

We report a unique case of hemangioblastoma of the lateral ventricle in a 73 year-old man with cognitive deficits and fluent dysphasia. He harboured an intraventricular tumor, placed at the trigone of the left lateral ventricle. The tumor was successfully excised, by means of a temporal craniotomy. The patient became mute in the immediate postoperative with restoration of speech within a few days. The literature has been reviewed and only three other similar cases have been reported. Discovery of lesions in such unusual location should raise a high degree of suspicion for von Hippel-Lindau disease.

The long-term results of gamma knife radiosurgery for hemangioblastomas of the brain

Object. The authors assessed the long-term result of gamma knife surgery (GKS) for hemangioblastomas of the brain (HABs) and show histopathological findings after GKS.

Methods. Thirty-five patients, 28 men and seven women, with a mean age of 36 years underwent GKS. Eighteen patients presented with multiple tumors and 17 with a solitary tumor. Twenty-one patients had von Hippel—Lindau (VHL) disease. The mean tumor diameter was 13 mm (range 5–55 mm). The mean follow up after GKS was 66 months (range 24–114 months). The mean prescription dose was 17.2 Gy (range 12–24 Gy) at the tumor margin. For tumors close to or within the brainstem a prescription dose of 12 to 13 Gy was used.

At the most recent follow up, 29 patients were alive, six were dead, and satisfactory tumor control had been achieved in 29. A stable or improved neurological status was obtained in 21 patients. Eight patients underwent open surgery because of tumor-associated cyst enlargement or the development of new tumors after GKS. Seven patients developed new tumors and five of them required a second GKS. The 1-year tumor control rate was 94%; 2 years, 85%; 3 years, 82%; 4 years, 79%; and 5 years, 71%. Histopathology showed that no tumor cells were found and there was degeneration and necrosis in a tumor nodule 48 months after GKS with a prescription dose of 18 Gy.

Conclusions. Gamma knife surgery was a useful choice for small- or medium-sized, solid HAB in the long term, especially when the tumor margin dose was 18 Gy. Although GKS can treat multiple tumors in a single session, for HABs associated with VHL disease, GKS faces the dual problems of tumor recurrence or development of a new tumor.

Differential Grading of Endolymphatic Sac Tumor Extension by Virtue of von Hippel-Lindau Disease Status

OBJECTIVE

Endolymphatic sac tumors are aggressive papillary tumors of the temporal bone frequently associated with von Hippel-Lindau disease. The goal of this study was to use a newly devised classification system as a means to analyze differences between endolymphatic sac tumor extension in von Hippel-Lindau disease and non-von Hippel-Lindau disease patients.

METHODS

Previously reported cases of endolymphatic sac tumor and two new cases were retrospectively reviewed and assigned to a new classification system consisting of four grades based on tumor extent and location.

RESULTS

Mean age of 103 patients without von Hippel-Lindau disease was 52.5 years, whereas in 46 patients with VHL the mean age was 31.3 years. Patients with von Hippel-Lindau disease were more likely to be female (female-to male ratio of 2:1 for von Hippel-Lindau disease patients versus 1:1 for non-von Hippel-Lindau disease patients). Symptoms consisted of hearing loss (100% [mean duration, 10 yr] for VHL patients versus 97% [mean duration, 7.8 yr] for non-von Hippel-Lindau disease patients), facial weakness (38% versus 49%), and tinnitus or vertigo (41% versus 60%). Bilateral tumors were common in von Hippel-Lindau disease patients (28% versus 1%). Tumors in von Hippel-Lindau disease patients were significantly more likely to be lower grade than tumors in non-von Hippel-Lindau disease patients (Grade I, 40% versus 25%; Grade II, 50% versus 58%; Grade III, 8% versus 14%; and Grade IV, 2% versus 4%; p < 0.05). Before 1988, there were relatively fewer Grade I (15% versus 33%) and relatively more Grade II (69% versus 47%) endolymphatic sac tumors in non-von Hippel-Lindau disease patients than after 1988.

CONCLUSIONS

Increased usefulness of intracranial imaging since 1988 has led to the diagnosis of sporadic endolymphatic sac tumors with lower grades. Surveillance imaging in von Hippel-Lindau disease may account for the greater proportion of endolymphatic sac tumors diagnosed with lower grades. Endolymphatic sac tumors associated with a diagnosis of von Hippel-Lindau disease appear to affect a younger population of patients than non-von Hippel-Lindau disease cases and occur in women twice as often as in men when associated with von Hippel-Lindau disease. In addition, tumors are more frequently bilateral and less advanced in the von Hippel-Lindau disease patient as opposed to the non-von Hippel-Lindau disease patient.

Long-term prognosis of hemangioblastomas of the central nervous system: Clinical and immunohistochemical study in relation to recurrence

The long-term prognosis and immunohistochemical findings for the expression of VEGF (vascular endothelial growth factor), p53 protein, and proliferative potential with MIB-1 were evaluated in six patients with VHL (von Hippel-Lindau) disease and seven patients with sporadic hemangioblastomas in relation to recurrent or new central nervous system (CNS) hemangioblastomas following treatment. Sporadic CNS hemangioblastomas were treated by total removal, and they demonstrated a good long-term prognosis without neurological deficits and no recurrence. However, even if total removal of the CNS hemangioblastomas in patients with VHL disease was performed initially, new lesions, consisting of small multiple hemangioblastomas, recurred in areas remote from the primary region in three of four patients during long-term follow-up. Such newly developed hemangioblastomas in patients with VHL disease could reflect the biological multipotentiality of CNS hemangioblastomas that were not detected during the initial operation. All of the hemangioblastomas displayed extensive overexpression of VEGF protein. The immunohistochemical findings for VEGF protein, p53 protein, and MIB-1 did not differ significantly between the sporadic and VHL disease-associated hemangioblastomas. In conclusion, since patients with VHL disease are at risk of developing new lesions, the management of hemangioblastomas in patients with VHL disease represents a more prolonged and difficult task.