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Lissing M, Wang B, Wahlin S. Liver transplantation and primary liver cancer in porphyria. Liver Int 2024. [PMID: 38456621 DOI: 10.1111/liv.15894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
The porphyrias are a heterogeneous group of metabolic disorders that result from defects in heme synthesis. The metabolic defects are present in all cells, but symptoms are mainly cutaneous or related to neuropathy. The porphyrias are highly relevant to hepatologists since patients can present with symptoms and complications that require liver transplantation (LT), and some porphyrias are associated with a high risk for primary liver cancer (PLC). Among the cutaneous porphyrias, erythropoietic protoporphyria (EPP) can lead to cholestatic liver failure where LT cures the liver disease but not the porphyria. In acute porphyria (AP), neurotoxic porphyrin precursors are produced in the liver and LT is a curative treatment option in patients with recurrent severe neuropathic attacks. Patients with AP, mainly acute intermittent porphyria, have a significantly increased risk for PLC that warrants surveillance and adequate follow-up of high-risk groups. LT is well established in both EPP with liver failure and AP with recurrent attacks, but most transplant centres have little porphyria experience and cooperation between transplant hepatologists, and porphyria experts is important in the often-difficult decisions on timing and management of comorbid conditions.
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Affiliation(s)
- Mattias Lissing
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Bruce Wang
- Department of Medicine and Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
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2
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Haverkamp T, Bronisch O, Knösel T, Mogler C, Weichert W, Stauch T, Schmid C, Rummeny C, Beykirch MK, Petrides PE. Heterogeneous molecular behavior in liver tumors (HCC and CCA) of two patients with acute intermittent porphyria. J Cancer Res Clin Oncol 2022; 149:2647-2655. [PMID: 36245063 DOI: 10.1007/s00432-022-04384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/26/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Acute intermittent porphyria (AIP) is a very rare (orphan) metabolic disorder of porphyrin biosynthesis which is characterized by elevated plasma and urine levels of 5-aminolevulinic acid (5-ALA) and porphobilinogen (PBG). Patients with this disorder which is caused by a germline mutation of the hydroxymethylbilan-synthase (HMBS)-gene have a high risk of primary liver cancer which may be determined by disease activity. The exact mechanism of carcinogenesis of this rare tumor is unknown, however. MATERIALS AND METHODS We analyzed paraffin-embedded formalin-fixed liver tumor and normal liver specimens of two female AIP patients treated at the Munich EPNET center. One patient had developed hepatocellular carcinoma (HCC), the other intrahepatic cholangiocarcinoma (CCA). Since biallelic inactivation of HMBS had been observed in one study, we used Sanger and next-generation sequencing with a 8 gene porphyria panel plus 6 potential modifier loci to search for mutations in DNA extractions. RESULTS In the patient with the HCC, we found a second inactivating mutation in the HMBS gene in the tumor but not in the adjacent normal liver tissue. No mutation could be found in the liver tissues of the patient with CCA, however. CONCLUSIONS Biallelic inactivation of HMBS or protoporphyrinogen-oxidase (PPOX), another enzyme of porphyrin biosynthesis, has been observed in patients with acute porphyrias and liver tumors. We could confirm this in our patient with HCC with a mutation in HMBS but not in the one with CCA. Since 5-ALA can be converted into carcinogenic substances such as 4,5-dioxovaleric acid (DOVA) or 3,6-dihydropyrazine-2,5-dipropanoic acid (= cyclic dimerization product of 5-ALA), local production of these metabolites in hepatic areas with complete loss of HMBS activity may contribute to liver carcinogenesis.
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Affiliation(s)
- Thomas Haverkamp
- Molecular Genetics Laboratory, MVZ Dr.Eberhard, Brauhausstr.4, 44137, Dortmund, Germany
| | - Olivia Bronisch
- Hematology Oncology Center, EPNET Clinical Center Munich, Ludwig Maximilians University (LMU) Munich, Zweibrückenstr.2, 80331, Munich, Germany
| | - Thomas Knösel
- Institute of Pathology, Ludwig Maximilians University Munich (LMU), Thalkirchner Str.36, 80337, Munich, Germany
| | - Carolin Mogler
- Institute of Pathology, Klinikum Rechts Der Isar (RDI), Technical University of Munich, Trogerstr.36, 80337, Munich, Germany
| | - Wilko Weichert
- Institute of Pathology, Klinikum Rechts Der Isar (RDI), Technical University of Munich, Trogerstr.36, 80337, Munich, Germany
| | - Thomas Stauch
- EPNET-Porphyria Specialist Laboratory MVZ PD Dr, Volkmann Kriegsstraße 99, 76133, Karlsruhe, Germany
| | - Claudia Schmid
- Institute of Radiology Dachau, Frühlingstr.33-34, 85221, Dachau, Germany
| | - Claudia Rummeny
- Institute of Radiology Munich East, Wasserburger Landstr.274-276, 81827, Munich, Germany
| | - Maria K Beykirch
- Hematology Oncology Center, EPNET Clinical Center Munich, Ludwig Maximilians University (LMU) Munich, Zweibrückenstr.2, 80331, Munich, Germany
| | - Petro E Petrides
- Hematology Oncology Center, EPNET Clinical Center Munich, Ludwig Maximilians University (LMU) Munich, Zweibrückenstr.2, 80331, Munich, Germany.
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Molina L, Zhu J, Trépo E, Bayard Q, Amaddeo G, Blanc JF, Calderaro J, Ma X, Zucman-Rossi J, Letouzé E, Chiche L, Bioulac-Sage P, Balabaud C, Possenti L, Decraecker M, Paradis V, Laurent A. Bi-allelic hydroxymethylbilane synthase inactivation defines a homogenous clinico-molecular subtype of hepatocellular carcinoma. J Hepatol 2022; 77:1038-1046. [PMID: 35636578 PMCID: PMC10061578 DOI: 10.1016/j.jhep.2022.05.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/22/2022] [Accepted: 05/10/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Acute intermittent porphyria (AIP), caused by heterozygous germline mutations of the heme synthesis pathway enzyme HMBS (hydroxymethylbilane synthase), confers a high risk of hepatocellular carcinoma (HCC) development. Yet, the role of HMBS in liver tumorigenesis remains unclear. METHODS Herein, we explore HMBS alterations in a large series of 758 HCC cases, including 4 patients with AIP. We quantify the impact of HMBS mutations on heme biosynthesis pathway intermediates and we investigate the molecular and clinical features of HMBS-mutated tumors. RESULTS We identify recurrent bi-allelic HMBS inactivation, both in patients with AIP acquiring a second somatic HMBS mutation and in sporadic HCC with 2 somatic hits. HMBS alterations are enriched in truncating mutations, in particular in splice regions, leading to abnormal transcript structures. Bi-allelic HMBS inactivation results in a massive accumulation of its toxic substrate porphobilinogen and synergizes with CTNNB1-activating mutations, leading to the development of well-differentiated tumors with a transcriptomic signature of Wnt/β-catenin pathway activation and a DNA methylation signature related to ageing. HMBS-inactivated HCC mostly affects females, in the absence of fibrosis and classical HCC risk factors. CONCLUSIONS These data identify HMBS as a tumor suppressor gene whose bi-allelic inactivation defines a homogenous clinical and molecular HCC subtype. LAY SUMMARY Heme (the precursor to hemoglobin, which plays a key role in oxygen transport around the body) synthesis occurs in the liver and involves several enzymes including hydroxymethylbilane synthase (HMBS). HMBS mutations cause acute intermittent porphyria, a disease caused by the accumulation of toxic porphyrin precursors. Herein, we show that HMBS inactivation is also involved in the development of liver cancers with distinct clinical and molecular characteristics.
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Affiliation(s)
- Laura Molina
- Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, INSERM, Paris, France; Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Junjie Zhu
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Eric Trépo
- Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, INSERM, Paris, France; Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Quentin Bayard
- Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, INSERM, Paris, France
| | - Giuliana Amaddeo
- Université Paris Est Créteil, INSERM, IMRB, Créteil, France; INSERM, U955, Equipe 18 "Physiopathologie et Thérapeutiques des Hépatites Virales Chroniques et des cancers liés", Créteil, France; Assistance Publique-Hôpitaux de Paris, Hôpital Henri Mondor, Service d'Hépatologie, Créteil, France
| | | | - Jean-Frédéric Blanc
- Department of Hepato-Gastroenterology and Digestive Oncology, CHU de Bordeaux, Haut-Lévêque Hospital, Bordeaux, Aquitaine, France; Department of Pathology, CHU de Bordeaux, Pellegrin Hospital, Bordeaux, Aquitaine, France; Bordeaux Research in Translational Oncology, Université Bordeaux, Bordeaux, Aquitaine, France
| | - Julien Calderaro
- Université Paris Est Créteil, INSERM, IMRB, Créteil, France; INSERM, U955, Equipe 18 "Physiopathologie et Thérapeutiques des Hépatites Virales Chroniques et des cancers liés", Créteil, France; Assistance Publique-Hôpitaux de Paris, Hôpital Henri Mondor, Département de Pathologie, Créteil, France
| | - Xiaochao Ma
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Jessica Zucman-Rossi
- Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, INSERM, Paris, France; Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Eric Letouzé
- Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, INSERM, Paris, France; Nantes Université, Inserm UMR 1307, CNRS UMR 6075, Université d'Angers, CRCI2NA, Nantes, France.
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Fontanellas A, Avila MA. Hydroxymethylbilane synthase (aka porphobilinogen deaminase): A novel metabolic tumor suppressor gene in hepatocellular carcinoma. J Hepatol 2022; 77:912-914. [PMID: 35798130 DOI: 10.1016/j.jhep.2022.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/20/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Antonio Fontanellas
- Program of Hepatology, CIMA, University of Navarra, Pamplona, Spain; CIBERehd, ISCIII, Madrid, Spain; IdiSNA, Pamplona, Spain.
| | - Matías A Avila
- Program of Hepatology, CIMA, University of Navarra, Pamplona, Spain; CIBERehd, ISCIII, Madrid, Spain; IdiSNA, Pamplona, Spain.
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Wang J, Miao Y, Li L, Wu Y, Ren Y, Cui Y, Cao H. Multi-omics data integration for hepatocellular carcinoma subtyping with multi-kernel learning. Front Genet 2022; 13:962870. [PMID: 36147508 PMCID: PMC9485934 DOI: 10.3389/fgene.2022.962870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/12/2022] [Indexed: 11/21/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a leading malignant liver tumor with high mortality and morbidity. Patients at the same stage can be defined as different molecular subtypes associated with specific genomic disorders and clinical features. Thus, identifying subtypes is essential to realize efficient treatment and improve survival outcomes of HCC patients. Here, we applied a regularized multiple kernel learning with locality preserving projections method to integrate mRNA, miRNA and DNA methylation data of HCC patients to identify subtypes. We identified two HCC subtypes significantly correlated with the overall survival. The patient 3-years mortality rates in the high-risk and low-risk group was 51.0% and 23.5%, respectively. The high-risk group HCC patients were 3.37 times higher in death risk compared to the low-risk group after adjusting for clinically relevant covariates. A total of 196 differentially expressed mRNAs, 2,151 differentially methylated genes and 58 differentially expressed miRNAs were identified between the two subtypes. Additionally, pathway activity analysis showed that the activities of six pathways between the two subtypes were significantly different. Immune cell infiltration analysis revealed that the abundance of nine immune cells differed significantly between the two subtypes. We further applied the weighted gene co-expression network analysis to identify gene modules that may affect patients prognosis. Among the identified modules, the key module genes significantly associated with prognosis were found to be involved in multiple biological processes and pathways, revealing the mechanism underlying the progression of HCC. Hub gene analysis showed that the expression levels of CDK1, CDCA8, TACC3, and NCAPG were significantly associated with HCC prognosis. Our findings may bring novel insights into the subtypes of HCC and promote the realization of precision medicine.
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Affiliation(s)
- Jiaying Wang
- Department of Respiratory, Gastroenterology and Oncology (West Branch), The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Yuting Miao
- Division of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Lingmei Li
- Division of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Yongqing Wu
- Division of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Yan Ren
- Department of Psychiatry, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Yan Ren, ; Yuehua Cui, ; Hongyan Cao,
| | - Yuehua Cui
- Department of Statistics and Probability, Michigan State University, East Lansing, MI, United States
- *Correspondence: Yan Ren, ; Yuehua Cui, ; Hongyan Cao,
| | - Hongyan Cao
- Division of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, China
- Shanxi Medical University-Yidu Cloud Institute of Medical Data Science, Taiyuan, China
- *Correspondence: Yan Ren, ; Yuehua Cui, ; Hongyan Cao,
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6
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Lissing M, Vassiliou D, Floderus Y, Harper P, Bottai M, Kotopouli M, Hagström H, Sardh E, Wahlin S. Risk of primary liver cancer in acute hepatic porphyria patients: A matched cohort study of 1244 individuals. J Intern Med 2022; 291:824-836. [PMID: 35112415 PMCID: PMC9311710 DOI: 10.1111/joim.13463] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The acute hepatic porphyrias (AHP) are associated with a risk of primary liver cancer (PLC), but risk estimates are unclear, and what AHP characteristics that predict PLC risk are unknown. In this register-based, matched cohort study, we assessed the PLC risk in relation to biochemical and clinical porphyria severity, genotype, age, and sex. METHODS All patients in the Swedish porphyria register with acute intermittent porphyria (AIP), variegate porphyria (VP), or hereditary coproporphyria (HCP) during 1987-2015 were included. This AHP cohort was compared with age-, sex-, and county-matched reference individuals from the general population. National register-based hospital admissions for AHP were used to indicate the clinical severity. For AIP, the most common AHP type, patients were stratified by genotype and urinary porphobilinogen (U-PBG). Incident PLC data were collected from national health registers. RESULTS We identified 1244 individuals with AHP (1063 [85%] AIP). During a median follow-up of 19.5 years, we identified 108 incident PLC cases, including 83 AHP patients (6.7%) and 25 of 12,333 reference individuals (0.2%). The adjusted hazard ratio for AHP-PLC was 38.0 (95% confidence interval: 24.3-59.3). Previously elevated U-PBG and hospitalizations for porphyria, but not AIP genotype or sex, were associated with increased PLC risk. Patients aged >50 years with previously elevated U-PBG (n = 157) had an annual PLC incidence of 1.8%. CONCLUSION This study confirmed a high PLC risk and identified a strong association with clinical and biochemical AIP activity. Regular PLC surveillance is motivated in patients older than 50 years with a history of active AIP.
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Affiliation(s)
- Mattias Lissing
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ylva Floderus
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Pauline Harper
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marianna Kotopouli
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hannes Hagström
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Unit for Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
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Saberi B, Naik H, Overbey JR, Erwin AL, Anderson KE, Bissell DM, Bonkovsky HL, Phillips JD, Wang B, K Singal A, M McGuire B, Desnick RJ, Balwani M. Hepatocellular Carcinoma in Acute Hepatic Porphyrias: Results from the Longitudinal Study of the U.S. Porphyrias Consortium. Hepatology 2021; 73:1736-1746. [PMID: 32681675 DOI: 10.1002/hep.31460] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS The risk for hepatocellular carcinoma (HCC) is increased in acute hepatic porphyrias (AHP). The aim of this study was to explore the clinicopathologic characteristics, outcomes, and frequency of HCC in patients with AHP in the United States. APPROACH AND RESULTS This cross-sectional analysis evaluated patients with HCC in a multicenter, longitudinal study of AHP. Among 327 patients with AHP, 5 (1.5%) were diagnosed with HCC. Of the 5 HCC cases, 4 had acute intermittent porphyria and 1 had variegate porphyria, confirmed by biochemical and/or genetic testing. All patients were white females, with a median age of 27 years (range 21-75) at diagnosis. The median age at HCC diagnosis was 69 years (range 61-74). AHP was asymptomatic in 2 patients; 2 reported sporadic attacks; and 1 reported recurrent attacks (>4 attacks/year). All patients had a single HCC lesion on liver imaging that was 1.8-6.5 centimeters in diameter. Serum alpha fetoprotein levels were below 10 ng/mL in all 4 patients with available results. Four patients underwent liver resection, and 1 was treated with radioembolization. No significant inflammation or fibrosis was found in adjacent liver tissues of 3 patients who underwent liver resection. Two patients developed recurrence of HCC at 22 and 26 months following liver resection. All patients are alive with survival times from HCC diagnosis ranging from 26-153 months. CONCLUSION In this U.S. study, 1.5% of patients with AHP had HCC. HCC in AHP occurred in the absence of cirrhosis, which contrasts with other chronic liver diseases. Patients with AHP, regardless of clinical attacks, should be screened for HCC, beginning at age 50. The pathogenesis of hepatocarcinogenesis in AHP is unknown and needs further investigation.
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Affiliation(s)
- Behnam Saberi
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jessica R Overbey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Karl E Anderson
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX
| | | | - Herbert L Bonkovsky
- Section on Gastroenterology and Hepatology, Department of Internal Medicine, Wake Forest/NC Baptist Medical Center, Winston-Salem, NC
| | - John D Phillips
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Bruce Wang
- Department of Medicine, University of California, San Francisco, CA
| | - Ashwani K Singal
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD.,Division of Hepatology, Avera Transplant Institute, Sioux Falls, SD
| | | | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
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Abstract
The acute hepatic porphyrias (AHP) are a group of four inherited diseases of heme biosynthesis. They present with similar severe, episodic, acute neurovisceral symptoms due to abnormally elevated levels of porphyrin precursors delta-aminolevulinic acid (ALA). Recently genetic screening indicates that the prevalence of mutation carrier state is more common than previously thought, occurring in 1 in 1,500, though the clinical penetrance of symptomatic AHP is low at ~1%. Symptomatic attacks occur primarily in females during their reproductive years. In an acute porphyria attack, the primary symptom is abdominal pain, due to intestinal dysmotility from autonomic nerve injury. Other manifestations include seizures, weakness and mood changes, point to injury involving peripheral and central nervous system. Due to the non-specific nature of the symptoms and signs in AHP, the diagnosis is often delayed by many years. The diagnosis of AHP depends on biochemical evidence of elevated ALA and PBG levels in urine during symptomatic attacks. Genetic testing is used for confirmation of the gene involved and the exact mutation. Treatment involves administration of heme, which downregulates production of ALA. Long-term management centers on educating genetic carriers on avoiding triggers that increase the risk of acute attacks and screening family members.
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Affiliation(s)
- Bruce Wang
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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9
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Ma Y, Teng Q, Zhang Y, Zhang S. Acute intermittent porphyria: focus on possible mechanisms of acute and chronic manifestations. Intractable Rare Dis Res 2020; 9:187-195. [PMID: 33139977 PMCID: PMC7586881 DOI: 10.5582/irdr.2020.03054] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/28/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022] Open
Abstract
Porphyrias are a group of inherited metabolic diseases that include eight types, each of which is caused by a mutation that affects an enzyme of the heme biosynthetic pathway. When an enzyme defect has physiological significance, it leads to overproduction of pathway precursors prior to the defective step. The partial absence of the third enzyme in the heme biosynthetic pathway, porphobilinogen deaminase (PBGD) also known as hydroxymethylbilane synthase (HMBS), results in acute intermittent porphyria (AIP), which affects mainly women. Subjects who had AIP symptoms were deemed to have manifest AIP (MAIP). Clinical manifestations are usually diverse and non-specific. Acute AIP episodes may present with abdominal pain, nausea, and vomiting, and repeated episodes may result in a series of chronic injuries. Therefore, studying the mechanisms of acute and chronic manifestations of AIP is of great significance. This review aims to summarize the possible mechanisms of acute and chronic manifestations in patients with AIP.
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Affiliation(s)
- Yuelin Ma
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Qing Teng
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yiran Zhang
- School of First Clinical Medical College, Southern Medical University, Guangzhou, Guangdong, China
| | - Songyun Zhang
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Ouyang X, Fan Q, Ling G, Shi Y, Hu F. Identification of Diagnostic Biomarkers and Subtypes of Liver Hepatocellular Carcinoma by Multi-Omics Data Analysis. Genes (Basel) 2020; 11:genes11091051. [PMID: 32899915 PMCID: PMC7566011 DOI: 10.3390/genes11091051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 12/24/2022] Open
Abstract
As liver hepatocellular carcinoma (LIHC) has high morbidity and mortality rates, improving the clinical diagnosis and treatment of LIHC is an important issue. The advent of the era of precision medicine provides us with new opportunities to cure cancers, including the accumulation of multi-omics data of cancers. Here, we proposed an integration method that involved the Fisher ratio, Spearman correlation coefficient, classified information index, and an ensemble of decision trees (DTs) for biomarker identification based on an unbalanced dataset of LIHC. Then, we obtained 34 differentially expressed genes (DEGs). The ability of the 34 DEGs to discriminate tumor samples from normal samples was evaluated by classification, and a high area under the curve (AUC) was achieved in our studied dataset and in two external validation datasets (AUC = 0.997, 0.973, and 0.949, respectively). Additionally, we also found three subtypes of LIHC, and revealed different biological mechanisms behind the three subtypes. Mutation enrichment analysis showed that subtype 3 had many enriched mutations, including tumor protein p53 (TP53) mutations. Overall, our study suggested that the 34 DEGs could serve as diagnostic biomarkers, and the three subtypes could help with precise treatment for LIHC.
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Affiliation(s)
| | | | | | | | - Fuyan Hu
- Correspondence: ; Tel.: +86-027-87108033
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11
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Peoc'h K, Manceau H, Karim Z, Wahlin S, Gouya L, Puy H, Deybach JC. Hepatocellular carcinoma in acute hepatic porphyrias: A Damocles Sword. Mol Genet Metab 2019; 128:236-241. [PMID: 30413387 DOI: 10.1016/j.ymgme.2018.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/05/2018] [Accepted: 10/05/2018] [Indexed: 02/08/2023]
Abstract
Porphyrias are inherited diseases with low penetrance affecting the heme biosynthesis pathway. Acute intermittent porphyria (AIP), variegate porphyria (VP) and hereditary coproporphyria (HCP) together constitute the acute hepatic porphyrias (AHP). These diseases have been identified as risk factors for primary liver cancers (PLC), mainly hepatocellular carcinoma (HCC: range 87-100%) but also cholangiocarcinoma, alone or combination with HCC. In AHP, HCC annual incidence rates range from 0.16 to 0.35% according to the populations studied. Annual incidence rates are higher in Swedish and Norwegian patients, due to a founder effect. It increases above age 50. The pathophysiology could include both direct toxic effects of heme precursors, particularly δ-aminolevulinic acid (ALA), compound heterozygosity for genes implied in heme biosynthesis pathway or the loss of oxidative stress homeostasis due to a relative lack of heme. The high HCC incidence justifies radiological surveillance in AHP patients above age 50. Efforts are made to find new biological non-invasive markers. In this respect, we describe here the first report of PIVKA-II clinical utility in the follow-up of an AIP patient that develop an HCC. In this manuscript we reviewed the epidemiology, the physiopathology, and the screening strategy of HCC in AHP.
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Affiliation(s)
- Katell Peoc'h
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS, Biochimie Clinique, Hôpital Beaujon, F-92110 Clichy, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Hana Manceau
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS, Biochimie Clinique, Hôpital Beaujon, F-92110 Clichy, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Zoubida Karim
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Staffan Wahlin
- Department of Gastroenterology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; Department of Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Laurent Gouya
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Hervé Puy
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France.
| | - Jean-Charles Deybach
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
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12
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Barman-Aksözen J, Suter L, Wegmann F, Meienberg J, Minder AE, Beer M, Komminoth P, Minder EI, Schneider-Yin X. A next-generation-sequencing panel for mutational analysis of dominant acute hepatic porphyrias. Scandinavian Journal of Clinical and Laboratory Investigation 2019; 79:305-313. [PMID: 31154864 DOI: 10.1080/00365513.2019.1622030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Molecular diagnosis of autosomal dominant acute hepatic porphyrias (AHPs) plays an important role in the management of these disorders. To introduce next generation sequencing (NGS) to the porphyria diagnosis, we designed a panel that contained four genes, ALAS1, HMBS, CPOX and PPOX for mutational analysis of acute intermittent porphyria (AIP), hereditary coproporphyria (HCP) and variegate porphyria (VP). To validate the AHP panel, 30 samples with known pathogenic variants as determined by Sanger sequencing, were analyzed using the Ion PGM™. Among them, nine have so far not been reported. The pathogenic variants were identified and annotated manually in IGV by three individuals who were blinded to the Sanger results. The AHP panel consists of 95 amplicons that covers 92% of the coding region of the four genes. Of the 95 amplicons, 93 had an average read-depth of >500 reads. In 29 of the 30 tested samples, pathogenic variants were correctly identified and annotated. The number of reads from the mutated alleles were approximately 50% of the total. The annotation of a 22-bp duplication with NGS differed from that of Sanger by one nucleotide. NGS showed an advantage in allelic discrimination over Sanger sequencing and was also able to detect a known somatic variant in the HMBS gene. The AHP panel will be applied in the initial diagnosis of new patients. Any sequence variations with a frequency of ≥10% will be confirmed by Sanger sequencing. The cost-effectiveness of a NGS approach for AHP in a diagnostic laboratory needs to be further assessed.
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Affiliation(s)
| | - Lukas Suter
- a Institute of Laboratory Medicine, Triemli Hospital , Zurich , Switzerland
| | - Franziska Wegmann
- a Institute of Laboratory Medicine, Triemli Hospital , Zurich , Switzerland
| | - Janine Meienberg
- b Center for Cardiovascular Genetics and Gene Diagnostics, Foundation for People with Rare Diseases , Schlieren-Zurich , Switzerland
| | - Anna Elisabeth Minder
- c Division of Endocrinology, Department of Internal Medicine, Triemli Hospital , Zurich , Switzerland
| | - Marc Beer
- d Institute of Pathology, Triemli Hospital , Zurich , Switzerland
| | - Paul Komminoth
- d Institute of Pathology, Triemli Hospital , Zurich , Switzerland
| | - Elisabeth I Minder
- c Division of Endocrinology, Department of Internal Medicine, Triemli Hospital , Zurich , Switzerland
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13
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Smith AG, Foster JR. The association between chemical-induced porphyria and hepatic cancer. Toxicol Res (Camb) 2018; 7:647-663. [PMID: 30090612 PMCID: PMC6060669 DOI: 10.1039/c8tx00019k] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/04/2018] [Indexed: 01/24/2023] Open
Abstract
The haem biosynthetic pathway is of fundamental importance for cellular metabolism both for the erythroid and nonerythroid tissues. There are several genetic variants of the pathway in the human population that cause dysfunction of one or other of the enzymes resulting in porphyrias of varying severity. Serious chronic hepatic and systemic diseases may result. Some of these can be precipitated by exposure to drugs including hormones, barbiturates and antibiotics, as well as alcohol and particular chlorinated aromatic chemicals. In experimental animals some of the steps of this pathway can also be severely disrupted by a variety of environmental chemicals, potential drugs and pesticides, especially in the liver, leading to the accumulation of uroporphyrins derived from the intermediate uroporphyrinogens or protoporphyrin IX, the immediate precursor of haem. With some of these chemicals this also leads to cholestasis and liver cell injury and eventually hepatic tumours. The review evaluates the available evidence linking hepatic porphyria with carcinogenesis in naturally occurring human genetic conditions and in chemically-induced porphyrias in laboratory animals. The existing data showing gender, strain, and species differences in sensitivity to the chemical-induced porphyrias, liver injury and liver tumours are discussed and the role that transgenically altered mouse models have played in defining the varying mechanisms. Finally, the review proposes a novel, unifying hypothesis linking the hepatotoxicity induced by the accumulation of various porphyrins, with the increased risk of developing hepatic cancer as a long term consequence.
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Affiliation(s)
- Andrew G Smith
- MRC Toxicology Unit , Hodgkin Building , University of Leicester , Lancaster Road , Leicester LE2 4UA , UK .
| | - John R Foster
- ToxPath Sciences Ltd , 1 Troutbeck Avenue , Congleton , Cheshire , CW12 4JA , UK
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14
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Abstract
The diagnosis of acute intermittent porphyria (AIP) is often overlooked. We describe a patient with this condition who had all the 'bells and whistles', in whom the diagnosis was only made after considerable delay. Far from an esoteric condition haunting examination candidates, AIP is an important cause of a broad spectrum of neurological symptoms. Its early recognition allows the astute clinician to prevent potentially devastating sequelae. We provide practical guidance on the investigation and management of this complex disorder. With a 'back to basics' approach to the underlying genetics and biochemistry, we hope to dispel some of the confusion that may obstruct a timely diagnosis.
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Affiliation(s)
- Ronan O'Malley
- Department of Neurology, Sheffield Teaching Hospitals (STH), Sheffield, UK.,Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Ganesh Rao
- Department of Neuroscience, University of Sheffield, Sheffield, UK.,Department of Neurophysiology, Sheffield Teaching Hospitals (STH), Sheffield, UK
| | - Penelope Stein
- Department of Haematological Medicine, Kings College Hospital NHS Foundation Trust, London, UK
| | - Oliver Bandmann
- Department of Neurology, Sheffield Teaching Hospitals (STH), Sheffield, UK.,Department of Neuroscience, University of Sheffield, Sheffield, UK
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15
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Acute hepatic and erythropoietic porphyrias: from ALA synthases 1 and 2 to new molecular bases and treatments. Curr Opin Hematol 2017; 24:198-207. [PMID: 28118224 DOI: 10.1097/moh.0000000000000330] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Many studies over the past decade have together identified new genes including modifier genes and new regulation and pathophysiological mechanisms in inherited inborn diseases of the heme biosynthetic pathway. A new porphyria has been characterized: X-linked protoporphyria and the perspective to have innovative treatment at very short-term became a reality. We will summarize how recent data on both ALAS1 and ALAS2 have informed our understanding of disease pathogenesis with an emphasis on how this information may contribute to new therapeutic strategies. RECENT FINDINGS The development of clinical and biological porphyria networks improved the long-term follow up of cohorts. The ageing of patients have allowed for the identification of novel recurrently mutated genes, and highlighted long-term complications in acute hepatic porphyrias. The treatment of hepatic porphyrias by an RNAi-targeting hepatic ALAS1 is actually tested and may lead to improve the management of acute attacks.In erythropoietic porphyrias, the key role of ALAS2 as a gate keeper of the heme and subsequently hemoglobin synthesis has been demonstrated. Its implication as a modifier gene in over erythroid disorders has also been documented. SUMMARY The knowledge of both the genetic abnormalities and the regulation of heme biosynthesis has increased over the last 5 years and open new avenues in the management of erythropoietic and acute hepatic porphyrias.
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16
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Baravelli CM, Sandberg S, Aarsand AK, Nilsen RM, Tollånes MC. Acute hepatic porphyria and cancer risk: a nationwide cohort study. J Intern Med 2017; 282:229-240. [PMID: 28730628 DOI: 10.1111/joim.12646] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Acute hepatic porphyria (AHP) is considered to be a risk factor for primary liver cancer (PLC), but varying risk estimates have been published. OBJECTIVES Our aim was to investigate the risk of PLC and other cancers in persons with AHP using a nationwide cohort design. Given that greater numbers of women than men tend to have manifest and more severe AHP, a further aim was to investigate sex differences in this risk. METHODS The study sample consisted of all Norwegian residents aged 18 years or older during the period 2000-2011. Persons with AHP (n = 251) were identified through the Norwegian Porphyria Centre, and patients with a cancer diagnosis were identified by linkage to the Cancer Registry of Norway. RESULTS For persons with AHP, the annual incidence rate of PLC was 0.35%. PLC risk was substantially higher for individuals with an AHP diagnosis compared to the reference population [adjusted hazard ratio (aHR) 108, 95% confidence interval (CI) 56-207]. In a meta-analysis of published studies on PLC and AHP, including ours, women had a higher risk than men. In addition, our results suggested that persons with AHP may have increased risks of kidney (aHR 7.4, 95% CI 2.4-23.1) and endometrial cancers (aHR 6.2, 95% CI 2.0-19.3). CONCLUSIONS Our findings confirmed a substantially higher risk of PLC associated with AHP compared to the general population. In a meta-analysis, the risk was shown to be greater for women than men. The novel findings of a moderate to substantial association between AHP and kidney and endometrial cancers should be investigated further.
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Affiliation(s)
- C M Baravelli
- Norwegian Porphyria Centre (NAPOS), Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway
| | - S Sandberg
- Norwegian Porphyria Centre (NAPOS), Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Norwegian Quality Improvement of Laboratory Examinations (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - A K Aarsand
- Norwegian Porphyria Centre (NAPOS), Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway.,Norwegian Quality Improvement of Laboratory Examinations (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - R M Nilsen
- Western Norway University of Applied Sciences, Bergen, Norway
| | - M C Tollånes
- Centre for Disease Burden, Domain for Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway
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17
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Alshamsan A, Khan S, Imran A, Aljuffali IA, Alsaleh K. Prediction of Chlamydia pneumoniae protein localization in host mitochondria and cytoplasm and possible involvements in lung cancer etiology: a computational approach. Saudi Pharm J 2017; 25:1151-1157. [PMID: 30166903 PMCID: PMC6111117 DOI: 10.1016/j.jsps.2017.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/30/2017] [Indexed: 01/22/2023] Open
Abstract
Collecting evidence suggests that the intercellular infection of Chlamydia pneumoniae in lungs contributes to the etiology of lung cancer. Many proteins of Chlamydia pneumoniae outmanoeuvre the various system of the host. The infection may regulate various factors, which can influence the growth of lung cancer in affected persons. In this in-silico study, we predict potential targeting of Chlamydia pneumoniae proteins in mitochondrial and cytoplasmic comportments of host cell and their possible involvement in growth and development of lung cancer. Various cellular activities are controlled in mitochondria and cytoplasm, where the localization of Chlamydia pneumoniae proteins may alter the normal functioning of host cells. The rationale of this study is to find out and explain the connection between Chlamydia pneumoniae infection and lung cancer. A sum of 183 and 513 proteins were predicted to target in mitochondria and cytoplasm of host cell out of total 1112 proteins of Chlamydia pneumoniae. In particular, many targeted proteins may interfere with normal growth behaviour of host cells, thereby altering the decision of program cell death. Present article provides a potential connection of Chlamydia pneumoniae protein targeting and proposed that various targeted proteins may play crucial role in lung cancer etiology through diverse mechanisms.
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Affiliation(s)
- Aws Alshamsan
- Nanomedicine Research Unit, Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,King Abdullah Institute for Nanotechnology, King Saud University, Riyadh, Saudi Arabia
| | - Shahanavaj Khan
- Nanomedicine Research Unit, Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ahamad Imran
- King Abdullah Institute for Nanotechnology, King Saud University, Riyadh, Saudi Arabia
| | - Ibrahim A Aljuffali
- Nanomedicine Research Unit, Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Khalid Alsaleh
- Oncology Center, King Saud Medical City, King Saud University, Riyadh, Saudi Arabia
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18
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Ripperger T, Bielack SS, Borkhardt A, Brecht IB, Burkhardt B, Calaminus G, Debatin KM, Deubzer H, Dirksen U, Eckert C, Eggert A, Erlacher M, Fleischhack G, Frühwald MC, Gnekow A, Goehring G, Graf N, Hanenberg H, Hauer J, Hero B, Hettmer S, von Hoff K, Horstmann M, Hoyer J, Illig T, Kaatsch P, Kappler R, Kerl K, Klingebiel T, Kontny U, Kordes U, Körholz D, Koscielniak E, Kramm CM, Kuhlen M, Kulozik AE, Lamottke B, Leuschner I, Lohmann DR, Meinhardt A, Metzler M, Meyer LH, Moser O, Nathrath M, Niemeyer CM, Nustede R, Pajtler KW, Paret C, Rasche M, Reinhardt D, Rieß O, Russo A, Rutkowski S, Schlegelberger B, Schneider D, Schneppenheim R, Schrappe M, Schroeder C, von Schweinitz D, Simon T, Sparber-Sauer M, Spix C, Stanulla M, Steinemann D, Strahm B, Temming P, Thomay K, von Bueren AO, Vorwerk P, Witt O, Wlodarski M, Wössmann W, Zenker M, Zimmermann S, Pfister SM, Kratz CP. Childhood cancer predisposition syndromes-A concise review and recommendations by the Cancer Predisposition Working Group of the Society for Pediatric Oncology and Hematology. Am J Med Genet A 2017; 173:1017-1037. [PMID: 28168833 DOI: 10.1002/ajmg.a.38142] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/19/2016] [Accepted: 12/30/2016] [Indexed: 12/12/2022]
Abstract
Heritable predisposition is an important cause of cancer in children and adolescents. Although a large number of cancer predisposition genes and their associated syndromes and malignancies have already been described, it appears likely that there are more pediatric cancer patients in whom heritable cancer predisposition syndromes have yet to be recognized. In a consensus meeting in the beginning of 2016, we convened experts in Human Genetics and Pediatric Hematology/Oncology to review the available data, to categorize the large amount of information, and to develop recommendations regarding when a cancer predisposition syndrome should be suspected in a young oncology patient. This review summarizes the current knowledge of cancer predisposition syndromes in pediatric oncology and provides essential information on clinical situations in which a childhood cancer predisposition syndrome should be suspected.
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Affiliation(s)
- Tim Ripperger
- Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Stefan S Bielack
- Pediatrics 5 (Oncology, Hematology, Immunology), Klinikum Stuttgart-Olgahospital, Stuttgart, Germany
| | - Arndt Borkhardt
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University Children's Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Ines B Brecht
- General Pediatrics, Hematology/Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany.,Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Birgit Burkhardt
- Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Gabriele Calaminus
- Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Klaus-Michael Debatin
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Hedwig Deubzer
- Department of Pediatric Oncology and Hematology, Charité University Medicine, Berlin, Germany
| | - Uta Dirksen
- Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Cornelia Eckert
- Department of Pediatric Oncology and Hematology, Charité University Medicine, Berlin, Germany
| | - Angelika Eggert
- Department of Pediatric Oncology and Hematology, Charité University Medicine, Berlin, Germany
| | - Miriam Erlacher
- Faculty of Medicine, Division of Pediatric Hematology and Oncology Medical Center, Department of Pediatrics and Adolescent Medicine, University of Freiburg, Freiburg, Germany
| | - Gudrun Fleischhack
- Pediatric Oncology and Hematology, Pediatrics III, University Hospital of Essen, Essen, Germany
| | - Michael C Frühwald
- Children's Hospital Augsburg, Swabian Children's Cancer Center, Augsburg, Germany
| | - Astrid Gnekow
- Children's Hospital Augsburg, Swabian Children's Cancer Center, Augsburg, Germany
| | - Gudrun Goehring
- Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Norbert Graf
- Department of Pediatric Hematology and Oncology, University of Saarland, Homburg, Germany
| | - Helmut Hanenberg
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University Children's Hospital, Heinrich Heine University, Düsseldorf, Germany.,Department of Otorhinolaryngology and Head/Neck Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Julia Hauer
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University Children's Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Barbara Hero
- Department of Pediatric Hematology and Oncology, University of Cologne, Cologne, Germany
| | - Simone Hettmer
- Faculty of Medicine, Division of Pediatric Hematology and Oncology Medical Center, Department of Pediatrics and Adolescent Medicine, University of Freiburg, Freiburg, Germany
| | - Katja von Hoff
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Horstmann
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Juliane Hoyer
- Institute of Human Genetics, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Thomas Illig
- Department of Human Genetics, Hannover Medical School, Hannover, Germany.,Hannover Unified Biobank, Hannover Medical School, Hannover, Germany
| | - Peter Kaatsch
- German Childhood Cancer Registry (GCCR), Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Roland Kappler
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Kornelius Kerl
- Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Thomas Klingebiel
- Hospital for Children and Adolescents, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Udo Kontny
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Medical Center, Aachen, Germany
| | - Uwe Kordes
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dieter Körholz
- Department of Pediatric Hematology and Oncology, Justus Liebig University, Giessen, Germany
| | - Ewa Koscielniak
- Pediatrics 5 (Oncology, Hematology, Immunology), Klinikum Stuttgart-Olgahospital, Stuttgart, Germany
| | - Christof M Kramm
- Division of Pediatric Hematology and Oncology, University Medical Center Goettingen, Goettingen, Germany
| | - Michaela Kuhlen
- Medical Faculty, Department of Pediatric Oncology, Hematology and Clinical Immunology, University Children's Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Andreas E Kulozik
- Department of Pediatric Oncology, Hematology and Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Britta Lamottke
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Ivo Leuschner
- Kiel Paediatric Tumor Registry, Department of Paediatric Pathology, University of Kiel, Kiel, Germany
| | - Dietmar R Lohmann
- Institute of Human Genetics, University Hospital Essen, Essen, Germany.,Eye Oncogenetics Research Group, University Hospital Essen, Essen, Germany
| | - Andrea Meinhardt
- Department of Pediatric Hematology and Oncology, Justus Liebig University, Giessen, Germany
| | - Markus Metzler
- Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Lüder H Meyer
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Olga Moser
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Medical Center, Aachen, Germany
| | - Michaela Nathrath
- Department of Pediatric Oncology, Klinikum Kassel, Kassel, Germany.,Clinical Cooperation Group Osteosarcoma, Helmholtz Zentrum Munich, Neuherberg, Germany.,Pediatric Oncology Center, Technical University Munich, Munich, Germany
| | - Charlotte M Niemeyer
- Faculty of Medicine, Division of Pediatric Hematology and Oncology Medical Center, Department of Pediatrics and Adolescent Medicine, University of Freiburg, Freiburg, Germany
| | - Rainer Nustede
- Department of Surgery, Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Kristian W Pajtler
- Department of Pediatric Oncology, Hematology and Immunology, Heidelberg University Hospital, Heidelberg, Germany.,Division of Pediatric Neuro-Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Claudia Paret
- Department of Pediatric Hematology/Oncology, University Medical Center Mainz, Mainz, Germany
| | - Mareike Rasche
- Pediatric Oncology and Hematology, Pediatrics III, University Hospital of Essen, Essen, Germany
| | - Dirk Reinhardt
- Pediatric Oncology and Hematology, Pediatrics III, University Hospital of Essen, Essen, Germany
| | - Olaf Rieß
- Institute of Medical Genetics and Applied Genomics, University of Tuebingen, Tuebingen, Germany
| | - Alexandra Russo
- Department of Pediatric Hematology/Oncology, University Medical Center Mainz, Mainz, Germany
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Reinhard Schneppenheim
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Schrappe
- Department of Pediatrics, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Christopher Schroeder
- Institute of Medical Genetics and Applied Genomics, University of Tuebingen, Tuebingen, Germany
| | - Dietrich von Schweinitz
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Thorsten Simon
- Department of Pediatric Hematology and Oncology, University of Cologne, Cologne, Germany
| | - Monika Sparber-Sauer
- Pediatrics 5 (Oncology, Hematology, Immunology), Klinikum Stuttgart-Olgahospital, Stuttgart, Germany
| | - Claudia Spix
- German Childhood Cancer Registry (GCCR), Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Martin Stanulla
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Doris Steinemann
- Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Brigitte Strahm
- Faculty of Medicine, Division of Pediatric Hematology and Oncology Medical Center, Department of Pediatrics and Adolescent Medicine, University of Freiburg, Freiburg, Germany
| | - Petra Temming
- Pediatric Oncology and Hematology, Pediatrics III, University Hospital of Essen, Essen, Germany.,Eye Oncogenetics Research Group, University Hospital Essen, Essen, Germany
| | - Kathrin Thomay
- Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Andre O von Bueren
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University Medical Center Goettingen, Goettingen, Germany.,Division of Pediatric Hematology and Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Peter Vorwerk
- Pediatric Oncology, Otto von Guericke University Children's Hospital, Magdeburg, Germany
| | - Olaf Witt
- Department of Pediatric Oncology, Hematology and Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marcin Wlodarski
- Faculty of Medicine, Division of Pediatric Hematology and Oncology Medical Center, Department of Pediatrics and Adolescent Medicine, University of Freiburg, Freiburg, Germany
| | - Willy Wössmann
- Department of Pediatric Hematology and Oncology, Justus Liebig University, Giessen, Germany
| | - Martin Zenker
- Institute of Human Genetics, University Hospital Magdeburg, Otto-von-Guericke University, Magdeburg, Germany
| | - Stefanie Zimmermann
- Hospital for Children and Adolescents, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Stefan M Pfister
- Department of Pediatric Oncology, Hematology and Immunology, Heidelberg University Hospital, Heidelberg, Germany.,Division of Pediatric Neuro-Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian P Kratz
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
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Abstract
Acute intermittent porphyria (AIP) is an autosomal dominant metabolic disease caused by hepatic deficiency of hydroxymethylbilane synthase (HMBS), the third enzyme of the heme synthesis pathway. The dominant clinical feature is acute neurovisceral attack associated with high production of potentially neurotoxic porphyrin precursors due to increased hepatic heme consumption. Current Standard of Care is based on a down-regulation of hepatic heme synthesis using heme therapy. Recurrent hyper-activation of the hepatic heme synthesis pathway affects about 5% of patients and can be associated with neurological and metabolic manifestations and long-term complications including chronic kidney disease and increased risk of hepatocellular carcinoma. Prophylactic heme infusion is an effective strategy in some of these patients, but it induces tolerance and its frequent application may be associated with thromboembolic disease and hepatic siderosis. Orthotopic liver transplantation is the only curative treatment in patients with recurrent acute attacks. Emerging therapies including replacement enzyme therapy or gene therapies (HMBS-gene transfer and ALAS1-gene expression inhibition) are being developed to improve quality of life, reduce the significant morbidity associated with current therapies and prevent late complications such as hepatocellular cancer or kidney failure in HMBS mutation carriers with long-standing high production of noxious heme precursors. Herein, we provide a critical digest of the recent literature on the topic and a summary of recently developed approaches to AIP treatment and their clinical implications.
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Karim Z, Lyoumi S, Nicolas G, Deybach JC, Gouya L, Puy H. Porphyrias: A 2015 update. Clin Res Hepatol Gastroenterol 2015; 39:412-25. [PMID: 26142871 DOI: 10.1016/j.clinre.2015.05.009] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/15/2015] [Accepted: 05/19/2015] [Indexed: 02/08/2023]
Abstract
The hereditary porphyrias comprise a group of eight metabolic disorders of the heme biosynthesis pathway. Each porphyria is caused by abnormal function at a separate enzymatic step resulting in a specific accumulation of heme precursors. Porphyrias are classified as hepatic or erythropoietic, based on the organ system in which heme precursors (δ-aminolevulinic acid [ALA], porphobilinogen and porphyrins) are overproduced. Clinically, porphyrias are characterized by acute neurovisceral symptoms, skin lesions or both. However, most if not all the porphyrias impair hepatic or gastrointestinal function. Acute hepatic porphyrias present with severe abdominal pain, nausea, constipation, confusion and seizure, which may be life threatening, and patients are at risk of hepatocellular carcinoma without cirrhosis. Porphyria Cutanea presents with skin fragility and blisters, and patients are at risk of hepatocellular carcinoma with liver iron overload. Erythropoietic protoporphyria and X-linked protoporphyria present with acute painful photosensitivity, and patients are at risk of acute liver failure. Altogether, porphyrias are still underdiagnosed, but once they are suspected, early diagnosis based on measurement of biochemical metabolites that accumulate in the blood, urine, or feces is essential so specific treatment can be started as soon as possible and long-term liver complications are prevented. Screening families to identify presymptomatic carriers is also crucial to prevent overt disease and chronic hepatic complications.
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Affiliation(s)
- Zoubida Karim
- INSERM U1149 CNRS ERL 8252, centre de recherche sur l'inflammation, 16, rue Henri-Huchard, 75018 Paris, France; Laboratory of excellence, GR-Ex, 24, Boulevard du Montparnasse, 75015 Paris, France
| | - Said Lyoumi
- INSERM U1149 CNRS ERL 8252, centre de recherche sur l'inflammation, 16, rue Henri-Huchard, 75018 Paris, France; Laboratory of excellence, GR-Ex, 24, Boulevard du Montparnasse, 75015 Paris, France; Université Versailles-Saint-Quentin, 55, Avenue de Paris, 78000 Versailles, France
| | - Gael Nicolas
- INSERM U1149 CNRS ERL 8252, centre de recherche sur l'inflammation, 16, rue Henri-Huchard, 75018 Paris, France; Laboratory of excellence, GR-Ex, 24, Boulevard du Montparnasse, 75015 Paris, France
| | - Jean-Charles Deybach
- INSERM U1149 CNRS ERL 8252, centre de recherche sur l'inflammation, 16, rue Henri-Huchard, 75018 Paris, France; Université Versailles-Saint-Quentin, 55, Avenue de Paris, 78000 Versailles, France; Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 75018 Paris, France; Centre français des porphyries, hôpital Louis-Mourier, AP-HP, 92701 Colombes, France
| | - Laurent Gouya
- INSERM U1149 CNRS ERL 8252, centre de recherche sur l'inflammation, 16, rue Henri-Huchard, 75018 Paris, France; Université Versailles-Saint-Quentin, 55, Avenue de Paris, 78000 Versailles, France; Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 75018 Paris, France; Centre français des porphyries, hôpital Louis-Mourier, AP-HP, 92701 Colombes, France
| | - Hervé Puy
- INSERM U1149 CNRS ERL 8252, centre de recherche sur l'inflammation, 16, rue Henri-Huchard, 75018 Paris, France; Université Versailles-Saint-Quentin, 55, Avenue de Paris, 78000 Versailles, France; Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 75018 Paris, France; Centre français des porphyries, hôpital Louis-Mourier, AP-HP, 92701 Colombes, France.
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