Functional significance of germline EPAS1 variants

A Rare Case of Paraganglioma Syndrome Associated With Polycythemia and Blindness

Pheochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumors. They can be diagnosed independently or as part of a syndrome, especially with germline mutations. Rarely, a somatic mutation can present as part of a syndrome associated with recurrent PPGL, congenital polycythemia, and vascular malformation. We report a case of a 44-year-old man with a history of congenital blindness, stroke in utero, cerebral ataxia, and polycythemia since age 12, treated with phlebotomies who presented with back pain and hypertension. Abdominal computer tomography with IV contrast showed a right adrenal enhancing lesion measuring 1.4 x 1.2 cm and a conglomerate of heterogeneously enhancing periaortic lesions measuring up to 5 cm in the mid-abdomen. Biochemical workup revealed plasma free normetanephrine 27.5 nmol/L (0.00-0.89) and plasma free metanephrine 0.49 nmol/L (0.00-0.49). Histopathology confirmed synchronous pheochromocytoma and paraganglioma. This case illustrates the importance of taking a detailed past medical history and the relevance of polycythemia in the paraganglioma workup.

Coexistence of Multiple Gene Variants in Some Patients with Erythrocytoses

Background

Erythrocytosis is a relatively common condition; however, a large proportion of these patients (70%) remain without a clear etiologic explanation.

Methods

We set up a targeted NGS panel for patients with erythrocytosis, and 118 sporadic patients with idiopathic erythrocytosis were studied.

Results

In 40 (34%) patients, no variant was found, while in 78 (66%), we identified at least one germinal variant; 55 patients (70.5%) had 1 altered gene, 18 (23%) had 2 alterations, and 5 (6.4%) had 3. An altered HFE gene was observed in 51 cases (57.1%), EGLN1 in 18 (22.6%) and EPAS1, EPOR, JAK2, and TFR2 variants in 7.7%, 10.3%, 11.5%, and 14.1% patients, respectively. In 23 patients (19.45%), more than 1 putative variant was found in multiple genes.

Conclusions

Genetic variants in patients with erythrocytosis were detected in about 2/3 of our cohort. An NGS panel including more candidate genes should reduce the number of cases diagnosed as "idiopathic" erythrocytosis in which a cause cannot yet be identified. It is known that HFE variants are common in idiopathic erythrocytosis. TFR2 alterations support the existence of a relationship between genes involved in iron metabolism and impaired erythropoiesis. Some novel multiple variants were identified. Erythrocytosis appears to be often multigenic.

E-box binding transcription factors in cancer

E-boxes are important regulatory elements in the eukaryotic genome. Transcription factors can bind to E-boxes through their basic helix-loop-helix or zinc finger domain to regulate gene transcription. E-box-binding transcription factors (EBTFs) are important regulators of development and essential for physiological activities of the cell. The fundamental role of EBTFs in cancer has been highlighted by studies on the canonical oncogene MYC, yet many EBTFs exhibit common features, implying the existence of shared molecular principles of how they are involved in tumorigenesis. A comprehensive analysis of TFs that share the basic function of binding to E-boxes has been lacking. Here, we review the structure of EBTFs, their common features in regulating transcription, their physiological functions, and their mutual regulation. We also discuss their converging functions in cancer biology, their potential to be targeted as a regulatory network, and recent progress in drug development targeting these factors in cancer therapy.

Cytoplasmic HIF-2α as tissue biomarker to identify metastatic sympathetic paraganglioma

Pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare neuroendocrine tumors. PGLs can further be divided into sympathetic (sPGLs) and head-and-neck (HN-PGLs). There are virtually no treatment options, and no cure, for metastatic PCCs and PGLs (PPGLs). Here, we composed a tissue microarray (TMA) consisting of 149 PPGLs, reflecting clinical features, presenting as a useful resource. Mutations in the pseudohypoxic marker HIF-2α correlate to an aggressive tumor phenotype. We show that HIF-2α localized to the cytoplasm in PPGLs. This subcompartmentalized protein expression differed between tumor subtypes, and strongly correlated to proliferation. Half of all sPGLs were metastatic at time of diagnosis. Cytoplasmic HIF-2α was strongly expressed in metastatic sPGLs and predicted poor outcome in this subgroup. We propose that higher cytoplasmic HIF-2α expression could serve as a useful clinical marker to differentiate paragangliomas from pheochromocytomas, and may help predict outcome in sPGL patients.

Hypoxia-inducible factor underlies von Hippel-Lindau disease stigmata

von Hippel-Lindau (VHL) disease is a rare hereditary cancer syndrome that causes a predisposition to renal clear-cell carcinoma, hemangioblastoma, pheochromocytoma, and autosomal-recessive familial polycythemia. pVHL is the substrate conferring subunit of an E3 ubiquitin ligase complex that binds to the three hypoxia-inducible factor alpha subunits (HIF1-3α) for polyubiquitylation under conditions of normoxia, targeting them for immediate degradation by the proteasome. Certain mutations in pVHL have been determined to be causative of VHL disease through the disruption of HIFα degradation. However, it remains a focus of investigation and debate whether the disruption of HIFα degradation alone is sufficient to explain the complex genotype-phenotype relationship of VHL disease or whether the other lesser or yet characterized substrates and functions of pVHL impact the development of the VHL disease stigmata; the elucidation of which would have a significant ramification to the direction of research efforts and future management and care of VHL patients and for those manifesting sporadic counterparts of VHL disease. Here, we examine the current literature including the other emergent pseudohypoxic diseases and propose that the VHL disease-phenotypic spectrum could be explained solely by the varied disruption of HIFα signaling upon the loss or mutation in pVHL.

EPAS1 Promoter Hypermethylation is a Diagnostic and Prognostic Biomarker for Non-Small Cell Lung Cancer

Background: The importance of promoter methylation in non-small cell lung cancers (NSCLCs) remains to be understood. Thus, we aimed to determine the diagnostic and prognostic value of methylation of the endothelial Per-Arnt-Sim (PAS) domain-containing protein 1 (EPAS1) promoter in NSCLC. Materials and Methods: EPAS1 promoter methylation levels were quantitated by a methylation-specific polymerase chain reaction. Furthermore, we evaluated the expression, promoter methylation, prognostic value, and impact on immune cell infiltration of EPAS1 by analyzing TCGA database or by web-based bioinformatics tools such as GEPIA, UALCAN, and MethSurv. Results: Our results demonstrated that promoter methylation of EPAS1 downregulated its expression in NSCLC tissues. Additionally, an area under the curve value of 0.772 indicated that methylation of the EPAS1 promoter is a potential diagnostic marker for NSCLC. Kaplan-Meier analysis demonstrated that high methylation levels of CpG sites in the EPAS1 promoter were indicative of worse overall survival (OS). Furthermore, EPAS1 expression levels were strongly correlated with infiltration of several types of immune cells, for instance, γδ T cells, T follicular helper cells, CD8+ T cells, and CD4+ T cells. Conclusions: Collectively, our findings demonstrated that methylation of the EPAS1 promoter is a promising prognostic biomarker for NSCLC and EPAS1 potentially plays an important role in immune cell infiltration in NSCLC.