1
|
Liu C, Lele SM, Goodenberger MH, Reiser GM, Christiansen AJ, Padussis JC. Malignant tumors in tuberous sclerosis complex: a case report and review of the literature. BMC Med Genomics 2024; 17:144. [PMID: 38802873 PMCID: PMC11129476 DOI: 10.1186/s12920-024-01913-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare, autosomal dominant genetic disease that arises from TSC1 or TSC2 genetic mutations. These genetic mutations can induce the development of benign tumors in any organ system with significant clinical implications in morbidity and mortality. In rare instances, patients with TSC can have malignant tumors, including renal cell carcinoma (RCC) and pancreatic neuroendocrine tumor (PNET). It is considered a hereditary renal cancer syndrome despite the low incidence of RCC in TSC patients. TSC is typically diagnosed in prenatal and pediatric patients and frequently associated with neurocognitive disorders and seizures, which are often experienced early in life. However, penetrance and expressivity of TSC mutations are highly variable. Herein, we present a case report, with associated literature, to highlight that there exist undiagnosed adult patients with less penetrant features, whose clinical presentation may contain non-classical signs and symptoms, who have pathogenic TSC mutations. CASE PRESENTATION A 31-year-old female with past medical history of leiomyomas status post myomectomy presented to the emergency department for a hemorrhagic adnexal cyst. Imaging incidentally identified a renal mass suspicious for RCC. Out of concern for hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome, the mass was surgically removed and confirmed as RCC. Discussion with medical genetics ascertained a family history of kidney cancer and nephrectomy procedures and a patient history of ungual fibromas on the toes. Genetic testing for hereditary kidney cancer revealed a 5'UTR deletion in the TSC1 gene, leading to a diagnosis of TSC. Following the diagnosis, dermatology found benign skin findings consistent with TSC. About six months after the incidental finding of RCC, a PNET in the pancreatic body/tail was incidentally found on chest CT imaging, which was removed and determined to be a well-differentiated PNET. Later, a brain MRI revealed two small cortical tubers, one in each frontal lobe, that were asymptomatic; the patient's history and family history did not contain seizures or learning delays. The patient presently shows no evidence of recurrence or metastatic disease, and no additional malignant tumors have been identified. CONCLUSIONS To our knowledge, this is the first report in the literature of a TSC patient without a history of neurocognitive disorders with RCC and PNET, both independently rare occurrences in TSC. The patient had a strong family history of renal disease, including RCC, and had several other clinical manifestations of TSC, including skin and brain findings. The incidental finding and surgical removal of RCC prompted the genetic evaluation and diagnosis of TSC, leading to a comparably late diagnosis for this patient. Reporting the broad spectrum of disease for TSC, including more malignant phenotypes such as the one seen in our patient, can help healthcare providers better identify patients who need genetic evaluation and additional medical care.
Collapse
Affiliation(s)
- Cassie Liu
- Disivion of Surgical Oncology, Department of Surgery, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Subodh M Lele
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Gwendolyn M Reiser
- Genetic Medicine, Munroe-Meyer Institute, University of Nebraska Medical Center, Omaha, NE, USA
| | - Andrew J Christiansen
- Division of Urologic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - James C Padussis
- Disivion of Surgical Oncology, Department of Surgery, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA.
| |
Collapse
|
2
|
Snyder HE, Pai N, Meaney B, Sloan Birbeck C, Whitney R, Johnson N, Rosato L, Jones K. Significant vomiting and weight loss in a pediatric epilepsy patient secondary to vagus nerve stimulation: A case report and review of the literature. Epilepsy Behav Rep 2023; 24:100626. [PMID: 37867486 PMCID: PMC10585338 DOI: 10.1016/j.ebr.2023.100626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/29/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023] Open
Abstract
Vagus nerve stimulation is a neuromodulatory treatment option for individuals with drug resistant epilepsy who are not resective surgical candidates. As the vagus nerve has widespread neural connections, stimulation can lead to an array of adverse effects. While vomiting and weight loss are known side effects of vagus nerve stimulation, these are typically transient, mild, and do not limit the ability to continue treatment. We describe a 17-year-old female with drug resistant focal epilepsy secondary to tuberous sclerosis complex, who began to experience daily emesis and significant weight loss approximately 2.5 years after VNS device insertion. Her body mass index progressively fell from between the 75th-85th percentiles to less than the first percentile. She underwent extensive workup by neurology, gastroenterology, and adolescent medicine services with no obvious cause identified. Prior to the insertion of an enteral tube for feeding support and urgent weight restoration, her vagus nerve stimulator was switched off, resulting in immediate cessation of her vomiting and a dramatically rapid recovery of weight over the ensuing few months. This case emphasizes the need to consider adverse effects of vagus nerve stimulation in the differential diagnosis of patients with otherwise unexplained new medical sequelae, and provides evidence potentially linking vagal stimulation to significant malnutrition-related complications. Outside of GI-related effects, few studies have shown late-onset adverse effects from VNS, including laryngeal and facial pain as well as bradyarrhythmia. Further research is needed to elucidate the exact mechanisms of vagus nerve stimulation to better anticipate and mitigate adverse effects, and to understand the pathophysiology of late-onset adverse effects in previously tolerant VNS patients.
Collapse
Affiliation(s)
- Hannah E. Snyder
- Division of Pediatric Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Nikhil Pai
- Division of Pediatric Gastroenterology, Department of Pediatrics, McMaster University, Hamilton, Ontario L8S 4K1, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Brandon Meaney
- Division of Pediatric Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Cynthia Sloan Birbeck
- Division of Pediatric Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Robyn Whitney
- Division of Pediatric Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Natasha Johnson
- Division of Adolescent Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Laura Rosato
- Division of Child Psychiatry, Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton West 5 Campus, Hamilton, Ontario L8N 3K7, Canada
| | - Kevin Jones
- Division of Pediatric Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| |
Collapse
|
3
|
Powell RM, Pattison S, Moravec JC, Bhat B, Guirguis N, Markie D, Jones GT, Copedo J, Print CG, Morison IM, Gavryushkin A, Gray B, Wyeth LJ, Eccles MR, Macaulay EC. Tuberous sclerosis complex: a complex case. Cold Spring Harb Mol Case Stud 2022; 8:mcs.a006182. [PMID: 35483879 PMCID: PMC9059781 DOI: 10.1101/mcs.a006182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/14/2022] [Indexed: 10/31/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an inheritable disorder characterized by the formation of benign yet disorganized tumors in multiple organ systems. Germline mutations in the TSC1 (hamartin) or more frequently TSC2 (tuberin) genes are causative for TSC. The malignant manifestations of TSC, pulmonary lymphangioleiomyomatosis (LAM) and renal angiomyolipoma (AML), may also occur as independent sporadic perivascular epithelial cell tumor (PEComa) characterized by somatic TSC2 mutations. Thus, discerning TSC from the copresentation of sporadic LAM and sporadic AML may be obscured in TSC patients lacking additional features. In this report, we present a case study on a single patient initially reported to have sporadic LAM and a mucinous duodenal adenocarcinoma deficient in DNA mismatch repair proteins. Moreover, the patient had a history of Wilms' tumor, which was reclassified as AML following the LAM diagnosis. Therefore, we investigated the origins and relatedness of these tumors. Using germline whole-genome sequencing, we identified a premature truncation in one of the patient's TSC2 alleles. Using immunohistochemistry, loss of tuberin expression was observed in AML and LAM tissue. However, no evidence of a somatic loss of heterozygosity or DNA methylation epimutations was observed at the TSC2 locus, suggesting alternate mechanisms may contribute to loss of the tumor suppressor protein. In the mucinous duodenal adenocarcinoma, no causative mutations were found in the DNA mismatch repair genes MLH1, MSH2, MSH6, or PMS2 Rather, clonal deconvolution analyses were used to identify mutations contributing to pathogenesis. This report highlights both the utility of using multiple sequencing techniques and the complexity of interpreting the data in a clinical context.
Collapse
Affiliation(s)
- Ryan M. Powell
- Department of Pathology, University of Otago, Dunedin 9016, New Zealand;,Tuberous Sclerosis Complex—New Zealand, New Zealand;,The New Zealand LAM Charitable Trust, New Zealand
| | - Sharon Pattison
- Department of Medicine, University of Otago, Dunedin 9016, New Zealand
| | - Jiri C. Moravec
- Department of Computer Sciences, University of Otago, Dunedin 9016, New Zealand
| | - Basharat Bhat
- Department of Surgical Sciences, University of Otago, Dunedin School of Medicine, Dunedin 9016, New Zealand
| | - Nada Guirguis
- Department of Pathology, University of Otago, Dunedin 9016, New Zealand
| | - David Markie
- Department of Pathology, University of Otago, Dunedin 9016, New Zealand
| | - Greg T. Jones
- Department of Surgical Sciences, University of Otago, Dunedin School of Medicine, Dunedin 9016, New Zealand
| | - Jason Copedo
- Grafton Clinical Genomics, University of Auckland, Auckland 1023, New Zealand
| | - Cristin G. Print
- Department of Molecular Medicine and Pathology, University of Auckland, Auckland 1023, New Zealand
| | - Ian M. Morison
- Department of Pathology, University of Otago, Dunedin 9016, New Zealand
| | - Alex Gavryushkin
- School of Mathematics and Statistics, University of Canterbury, Canterbury 8140, New Zealand
| | - Bronwyn Gray
- Tuberous Sclerosis Complex—New Zealand, New Zealand
| | - Lisa J. Wyeth
- Tuberous Sclerosis Complex—New Zealand, New Zealand;,The New Zealand LAM Charitable Trust, New Zealand
| | - Mike R. Eccles
- Department of Pathology, University of Otago, Dunedin 9016, New Zealand
| | - Erin C. Macaulay
- Department of Pathology, University of Otago, Dunedin 9016, New Zealand
| |
Collapse
|