[Diagnosis of adrenocortical carcinoma]

A mellékvesekéreg-carcinoma ritka, rossz prognózisú megbetegedés. Az érintett betegek kórjóslatát döntően meghatározza, hogy a betegség korán, még lokoregionális stádiumban kerüljön felismerésre, amikor a sebészi tumoreltávolítással jelentősen növelhető a gyógyulás esélye. A mellékvese-daganatok dignitásának meghatározása gyakran jelent kihívást a preoperatív kivizsgálás során, a diagnózisalkotást hagyományos radiológiai és laboratóriumi vizsgálatok segítik. Újabban igen jó diagnosztikai pontosságot mutató biomarkerek is megismerésre kerültek, klinikai használatuk a közeljövőben várható. Közülük is kiemelkednek a gáz-, illetve folyadékkromatográfián alapuló szteroidmetabolomikai vizsgálatok, valamint a miRNS-ek vizsgálata. Ebben az összefoglalóban bemutatjuk a mellékvesekéreg-carcinoma azonosítását segítő preoperatív klinikai és posztoperatív patológiai vizsgálómódszereket. Orv Hetil. 2024; 165(4): 123–131.

Whole genome sequencing resolves 10 years diagnostic odyssey in familiar myxoma

Carney complex (CNC) is an ultrarare disorder causing cutaneous and cardiac myxomas, primary pigmented nodular adrenocortical disease, hypophyseal adenoma, and gonadal tumours. Genetic alterations are often missed under routine genetic testing. Pathogenic variants in PRKAR1A are identified in most cases, while large exonic or chromosomal deletions have only been reported in a few cases. Our aim was to identify the causal genetic alteration in our kindred with a clinical diagnosis of CNC and prove its pathogenic role by functional investigation. Targeted testing of PRKAR1A gene, whole exome and whole genome sequencing (WGS) were performed in the proband, one clinically affected and one unaffected relative. WGS identified a novel, large, 10,662 bp (10.6 kbp; LRG_514t1:c.-10403_-7 + 265del; hg19, chr17:g.66498293_66508954del) deletion in the promoter of PRKAR1A in heterozygous form in the affected family members. The exact breakpoints and the increased enzyme activity in deletion carriers compared to wild type carrier were proved. Segregation analysis and functional evaluation of PKA activity confirmed the pathogenic role of this alteration. A novel deletion upstream of the PRKAR1A gene was proved to be the cause of CNC. Our study underlines the need for WGS in molecular genetic testing of patients with monogenic disorders where conventional genetic analysis fails.

[Macronodular adrenal hyperplasia causing Cushing's syndrome due to ARMC5 gene mutation.]

Our 69-year-old female patient was investigated for a 20 kg weight gain over 2 years. The patient's medical history included hypertension, hyperuricemia, bilateral cataract surgery and musculosceletal complaints. Diabetes mellitus was not found. Physical examination revealed abdominal obesity, proximal myopathy and atrophic, vulnerable skin. The "overnight", low-dose and long, low-dose dexamethasone suppression tests indicated autonomous cortisol overproduction (plasma cortisol level: 172.6 and 153.2 nmol/L, cut-off: 50 nmol/L). The suppressed ACTH (<1.11 pmol/L, normal value: 1.12-10.75 pmol/L) suggested ACTH-independent hypercortisolism. Abdominal CT described macronodular enlargement of both adrenals. The size of the largest nodule was 23 × 20 mm in the right, and 24 × 30 mm on the left side (with -33 ± 37 HU density values on native scans). The 131I-cholesterol adrenal scintigraphy and SPECT/CT showed almost equally intensive radiopharmacon uptake on both sides. Based on the clinical results, bilateral macronodular adrenal hyperplasia associated with ACTH-independent hypercortisolism was diagnosed. Genomic DNA was obtained from the peripheral blood leukocytes. Targeted sequencing of 25 genes potentially involved in adrenal tumorigenesis revealed a new disease-causing armadillo repeat-containing 5 (ARMC5) gene mutation (c.1724del28 bp, g.31,476,067-31,476,094). Because of the autosomal dominant inheritance of this genetic alteration, the patient's two children underwent genetic screening for the ARMC5 mutation. The same mutation was found in the younger child of our patient. To the best of our knowledge, this is the first published Hungarian case of ARMC5 mutation with bilateral macronodular adrenal hyperplasia and ACTH-independent Cushing's syndrome. The genetic alteration is present in two generations of the family of the index patient. Orv Hetil. 2023; 164(32): 1271-1277.

A CYP24A1-gén terhességi hypercalcaemiát okozó defektusa

Terhességben a hypercalcaemia ritka elváltozás. A leggyakrabban primer hyperparathyreosis vagy parathormon-szerű fehérjét termelő malignus daganat okozza. Ritkábban fokozott intestinalis kalciumfelszívódás, D-vitamin-intoxikáció, tejalkáli-szindróma állhat az eltérés hátterében, valamint granulomatosus betegségek és lymphomák, amelyekben a 25(OH)D-vitamin 1α-hidroxiláz enzim okozta expressziója megnövekedett. A gestatiós hypercalcaemia rendkívül ritka oka lehet ezek mellett a D-vitamin-katabolizmus zavara a CYP24A1-gén funkcióvesztő mutációi miatt. Közleményünkben egy 34 éves kaukázusi nőbeteg esetét mutatjuk be, akinél hypercalcaemia mellett normális intakt parathormon-koncentráció és bal alsó mellékpajzsmirigy-adenoma igazolódott. Malignus tumor kutatását célzó kivizsgálása kórjelző eltérést nem igazolt, ezt követően a bal alsó mellékpajzsmirigy-adenoma eltávolításra került. A posztoperatív ellenőrzések során a hypercalcaemia megszűnését észleltük. A mellékpajzsmirigy-adenoma eltávolítása után 15 hónappal 8 hetes gravidaként spontán elvetélt, ekkor a szérumkalcium értéke a referenciatartomány felső határán volt. 25 hónap múlva, 12 hetes várandósként parathormon-independens hypercalcaemia igazolódott, ekkor kórházi felvételre került. A 25(OH)D-vitamin és a parathormon-szerű fehérje koncentrációját a referenciatartományon belül regisztráltuk, míg az 1,25(OH)2D-szint kifejezetten emelkedett volt. A terhességi hypercalcaemia hátterében a CYP24A1-génnek a D-vitamin-metabolizmus zavarát okozó „compound” heterozigóta mutációját igazoltuk. A beteg konzervatív kezelése mellett a terhesség során egyéb szövődményt nem észleltünk, végül terminusban, császármetszés útján egészséges leánygyermeket szült. A közlemény bemutatja a terhesség alatt észlelt hypercalcaemia kórisméjének és terápiájának nehézségeit. Tudomásunk szerint betegünk a Magyarországon diagnosztizált első CYP24A1-hiányos eset. Orv Hetil. 2022; 163(31): 1237–1242.

Tissue miRNA Combinations for the Differential Diagnosis of Adrenocortical Carcinoma and Adenoma Established by Artificial Intelligence

Simple Summary

The histological differential diagnosis of adrenocortical adenoma and carcinoma is difficult and requires great expertise. MiRNAs were shown to be useful for the differential diagnosis of benign and malignant tumors of several organs, and several findings have suggested their utility in adrenocortical tumors as well. Here, we have selected tissue miRNAs based on the literature search, and used machine learning to identify novel clinically applicable miRNA combinations. Combinations with high sensitivity and specificity (both over 90%) have been identified that could be promising for clinical use. Besides being a useful adjunct to histological examination, these miRNA combinations could enable preoperative adrenal biopsy in patients with adrenal tumors suspicious for malignancy.

Abstract

The histological analysis of adrenal tumors is difficult and requires great expertise. Tissue microRNA (miRNA) expression is distinct between benign and malignant tumors of several organs and can be useful for diagnostic purposes. MiRNAs are stable and their expression can be reliably reproduced from archived formalin-fixed, paraffin-embedded (FFPE) tissue blocks. Our purpose was to assess the potential applicability of combinations of literature-based miRNAs as markers of adrenocortical malignancy. Archived FFPE tissue samples from 10 adrenocortical carcinoma (ACC), 10 adrenocortical adenoma (ACA) and 10 normal adrenal cortex samples were analyzed in a discovery cohort, while 21 ACC and 22 ACA patients were studied in a blind manner in the validation cohort. The expression of miRNA was determined by RT-qPCR. Machine learning and neural network-based methods were used to find the best performing miRNA combination models. To evaluate diagnostic applicability, ROC-analysis was performed. We have identified three miRNA combinations (hsa-miR-195 + hsa-miR-210 + hsa-miR-503; hsa-miR-210 + hsa-miR-375 + hsa-miR-503 and hsa-miR-210 + hsa-miR-483-5p + hsa-miR-503) as unexpectedly good predictors to determine adrenocortical malignancy with sensitivity and specificity both of over 90%. These miRNA panels can supplement the histological examination of removed tumors and could even be performed from small volume adrenal biopsy samples preoperatively.

Prognostic factors and mitotane treatment of adrenocortical cancer. Two decades of experience from an institutional case series

OBJECTIVES

This study aimed to characterise the clinicopathological features and prognostic factors of a large cohort of Hungarian patients with adrenocortical cancer diagnosed between 2000-2021.

PATIENTS AND METHODS

This retrospective study included seventy-four patients (27 men and 47 women) with histologically confirmed adrenocortical cancer in a single tertiary referral endocrine centre. Descriptive statistics were performed, providing summaries of selected clinical and pathological parameters. Clinicopathological factors contributing to overall survival were analysed.

RESULTS

The median age of patients was 48,5 years (17-84 years) at diagnosis. The majority of cases were diagnosed at ENSAT stage II (39,2%) and stage IV (33,8%). At diagnosis, the median tumour size was 9,0 cm (4,5-20 cm). In 47 patients (71,6%), the tumour was hormonally active. The median overall survival and the 5-year survival rate were 23,5 months (95% CI, 17-30,5 months) and 18,3%, respectively. Primary tumour resection was performed in 68 patients (91,8%); R0 surgical resection was achieved in 30 patients. In univariate Cox regression model, tumours with stages III and IV, high proliferative activity (Ki67-index > 10%), R1-R2 surgical resection state and hormonal activity were associated with poorer survival. Cortisol excess, both isolated and combined with androgen production, was associated with poorer survival. Fifty-five patients were treated with mitotane. The overall survival of patients achieving therapeutic mitotane plasma concentration was significantly better compared to those who never reached it [27.0 (2-175) months vs 18.0 (2-83) months; p<0.05)]. The median age, the distribution of gender, ENSAT stage, resection state and Ki67-index did not differ between these two groups. The time needed to reach the therapeutic range of serum mitotane was 96.5 days (95% CI, 75-133 days).

CONCLUSION

Our results confirm previous data that disease stage, mitotic activity, the resection state and the mitotane treatment achieving therapeutic concentration are the most critical parameters influencing the prognosis of adrenocortical cancer. Our data suggest that hormonal activity may be more frequent than described previously, and it is a strong and independent prognostic factor of overall survival. To our knowledge, this is the first single-centre study confirming the prognostic importance of achieving therapeutic mitotane concentration.

Type 3 autoimmune polyglandular syndrome with multiple genetic alterations in a young male patient with type 1 diabetes mellitus

Not required for Clinical Vignette.

Complete Remission of Advanced Adrenocortical Cancer Following Mitotane Monotherapy: A Case Report and Literature Review of Predictive Markers

Mitotane has been used for the treatment of adrenocortical cancer (ACC) for over 50 years. Despite its widespread use both in monotherapy and in combination with chemotherapeutics, our knowledge of its mechanism of action and therapeutic efficacy is scarce. The number of patients with advanced ACC who have achieved complete remission documented by detailed clinical data is below ten. We report a case of a 64-year-old woman with a non-functional ACC. Histological examination showed vascular invasion, Ki67 of 10% and a mitotic count of 3/10 high-power field. Immunohistochemistry revealed p53 positivity. Pathological TNM grade was reported as T2N0M0, ENSAT stage 2. Nine months after the initial diagnosis, re-staging CT revealed multiple peritoneal nodules, lymph node and kidney metastases confirmed by histologic examination. Mitotane monotherapy was started with a maintenance dose between 2.0 and 2.5 grams/day. Partial remission was established at six months. Subsequently, for another 12 months, each of the three-monthly CT scans confirmed complete remission. Nineteen months after the initiation of mitotane, an unexpected sudden death occurred. A detailed autopsy work-up, performed in the full awareness of oncological history, confirmed complete remission. The authors review the molecular biomarkers and clinical features reported as predictors of response to mitotane monotherapy.

Rare diseases caused by abnormal calcium sensing and signalling

The calcium-sensing receptor (CaSR) provides the major mechanism for the detection of extracellular calcium concentration in several cell types, via the induction of G-protein-coupled signalling. Accordingly, CaSR plays a pivotal role in calcium homeostasis, and the CaSR gene defects are related to diseases characterized by serum calcium level changes. Activating mutations of the CaSR gene cause enhanced sensitivity to extracellular calcium concentration resulting in autosomal dominant hypocalcemia or Bartter-syndrome type V. Inactivating CaSR gene mutations lead to resistance to extracellular calcium. In these cases, familial hypocalciuric hypercalcaemia (FHH1) or neonatal severe hyperparathyroidism (NSHPT) can develop. FHH2 and FHH3 are associated with mutations of genes of partner proteins of calcium signal transduction. The common polymorphisms of the CaSR gene have been reported not to affect the calcium homeostasis itself; however, they may be associated with the increased risk of malignancies.

A peculiar pancreatic lesion: nodular foci of trilineage differentiation and diffuse islet cell hyperplasia

Összefoglaló. A szerzők egy különleges pancreaselváltozás esetét ismertetik, melyben az acinusok neuroendokrin jellegű transzformációja diffúz, atípusos megjelenésű szigetsejtes hyperplasiával társult, valamint a pancreas mindhárom sejtvonalát (acinaris, ductalis, insularis) tartalmazó nodulusok képződtek. A komplex megjelenés ellenére a kórfolyamat nem járt endokrin tünetekkel. Esetünkben a kiváltó ok hátterében a struktúrák kóros progenitorsejt-differenciációja állhatott. Az irodalomban ilyen közlés eddig nem ismert. Orv Hetil. 2021; 162(6): 227-232. Summary. The authors present a case of a peculiar pancreatic lesion, in which the neuroendocrine transformation of the acini was associated with a diffuse, atypical insular hyperplasia, and micronodules exhibiting trilineage differentiation. Despite the complex alteration, no endocrine symptoms were noted. The case may represent the result of an abnormal pancreatic differentiation raising the possibility of reprogramming of the progenitor cells. To the best of our knowledge, this is the first report of such a lesion in the literature. Orv Hetil. 2021; 162(6): 227-232.

Case Report: Complete Necrosis of a Large Adrenocortical Cancer and Liver Metastases Achieved by Selective Arterial Embolization: A Case Study and Review of Literature

There is very limited experience regarding the interventional radiological treatment of adrenocortical cancer (ACC). We present the case of a 57-year-old female patient with a large, potentially unresectable left-sided ACC and two hepatic metastases. Both liver tumors were effectively treated by trans-arterial embolization (TAE), followed by TAE of the bulky primary tumor as a life-saving intervention necessitated by severe intratumoral bleeding. Surgical removal of the primary tumor revealed complete necrosis. The patient is considered tumor free after 3.5 years. To the best of our knowledge, this is the first report to show that even a primary ACC may be completely ablated by selective embolization, and the fourth to prove the curative potential of liver TAE for ACC metastases. This case highlights the potential of selective embolization in ACC treatment.

Changes in endogenous metal element concentrations in various aetiologies of chronic liver disease

Our body contains physiologically many metal ions used for its metabolic processes and function. Metal ion changes can start pathological processes, however, the pathological processes may also lead to changes in metal ion concentration. In this study, the authors summarize the physiologically present metal ions' change in liver diseases with various aetiologies, the consequences are discussed as well as the connections with the progression. Further, the authors point out the element concentration changes as diagnostic or prognostic values for the liver diseases as well. Orv Hetil. 2020; 161(22): 917-923.

True MEN1 or phenocopy? Evidence for geno-phenotypic correlations in MEN1 syndrome

PURPOSE

Multiple endocrine neoplasia type 1 is a rare tumor syndrome caused by germline mutations of MEN1 gene. Phenotype varies widely, and no definitive correlation with the genotype has been observed. Mutation-negative patients with MEN1-associated tumors represent phenocopies. By comparing mutation-positive and mutation-negative patients, we aimed to identify phenotype features predictive for a positive genetic test and to evaluate the role of MEN1 mutations in phenotype modulation.

METHODS

Mutation screeening of MEN1 gene by Sanger sequencing and assessment of clinical data of 189 consecutively enrolled probands and relatives were performed at our national and European Reference Center. Multiple ligation probe amplification analysis of MEN1 gene and Sanger sequencing of CDKN1B were carried out in clinically suspicious but MEN1-negative cases.

RESULTS

Twenty-seven probands and twenty family members carried MEN1 mutations. Five mutations have not been described earlier. Pronouncedly high number of phenocopies (>70%) was observed. Clinical suspicion of MEN1 syndrome emerged at significantly earlier age in MEN1-positive compared to MEN1-negative probands. Gastroenteropancreatic neuroendocrine tumors developed significantly earlier and more frequently in carriers compared to non-carriers. Probands with high-impact (frameshift, nonsense, large deletions) mutations, predicted to affect menin function significantly, developed GEP-NETs more frequently compared to low-impact (inframe and missense) mutation carriers.

CONCLUSIONS

MEN1 phenocopy is common and represents a significant confounder for the genetic testing. GEP-NET under 30 years best predicted a MEN1 mutation. The present study thus confirmed a previous proposal and suggested that GEP-NET under 30 years should be considered as a part of the indication criteria for MEN1 mutational analysis.

Diagnostic performance of a newly developed salivary cortisol and cortisone measurement using an LC-MS/MS method with simple and rapid sample preparation

BACKGROUND

Late-night salivary cortisol level is one of the first-line tests recommended by the Endocrine Society for the diagnosis of endogenous hypercortisolism. Most routine laboratories measure cortisol levels using immunoassay tests which fail to determine low cortisol levels accurately due to the numerous interfering substances. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method with simple and rapid sample preparation was developed for the simultaneous measurement of cortisol and cortisone and its performance in the diagnosis of endogenous hypercortisolism was evaluated.

METHODS

324 late-night saliva samples were analyzed from which 272 samples were derived from patients with a suspected diagnosis of endogenous hypercortisolism. Salivary cortisol levels were assayed using an electrochemiluminescent immunoassay (ECLIA, Cortisol II, Roche), and simultaneous measurement of cortisol and cortisone was performed using an LC-MS/MS method.

RESULTS

A strong correlation between cortisol results measured using ECLIA and LC-MS/MS (r ² = 0.892) was demonstrated. Receiver operating characteristics (ROC) analysis showed good diagnostic performance of cortisol and cortisone levels assayed using LC-MS/MS method and for cortisol measured using ECLIA.

CONCLUSIONS

Late-night salivary cortisol and cortisone are useful parameters for the diagnosis of hypercortisolism. Using samples obtained from patients where the diagnosis of hypercortisolism is extremely challenging cut-off values for midnight salivary cortisol and cortisone measured by LC-MS/MS method were established.

[Steroid 21-hydroxylase deficiency, the most frequent cause of congenital adrenal hyperplasia]

Congenital adrenal hyperplasia is a group of genetic diseases due to the disablement of 7 genes; one of them is steroid 21-hydroxylase deficiency. The genes of congenital adrenal hyperplasia encode enzymes taking part in the steroidogenesis of adrenal gland. Steroid 21-hydroxylase deficiency is an autosomal recessive disorder caused by mutations of the steroid 21-hydroxylase gene. The mutations of steroid 21-hydroxylase gene cause 95% of the congenital adrenal hyperplasia cases. Although the non-classic steroid 21-hydroxylase deficiency with mild symptoms is seldom diagnosed, the classic steroid 21-hydroxylase deficiency may lead to life-threatening salt-wasting and adrenal crises due to the insufficient aldosterone and cortisol serum levels. The classic type requires life-long steroid replacement which may result in cushingoid side effects, and typical comorbidities may be also developed. The patients' quality of life is decreased, and their mortality is much higher than that of the population without steroid 21-hydroxylase deficiency. The diagnosis, consequences and the patients' life-long clinical care require a multidisciplinary approach: the specialists in pediatrics, internal medicine, endocrinology, laboratory medicine, genetic diagnostics, surgery, obstetrics-gynecology and psychology need to work together. Orv Hetil. 2018; 159(7): 269-277.

Genetikai tényezők a hypopituitarismus kialakulásában. A transzkripciós faktorok szerepe az agyalapimirigy-elégtelenség hátterében

Abstract:

Developmental disorders affecting the hypothalamic-pituitary system can result in pituitary hormone deficiency showing a diverse clinical presentation. A significant majority of these disorders are closely linked to defects in transcription factor genes which play a major role in pituitary development. Those affecting the early phase of organogenesis typically lead to complex conditions affecting the pituitary as well as structures in the central nervous system. Transcription factors involved in the late phase can result in combined but rarely isolated pituitary hormone deficiency without extra-pituitary manifestation. Identifying the defects in these pituitary transcription factor genes may provide a useful tool in predicting disease progression as well as screening family members. Several pituitary transcription factors can be detected in the adult gland as well which is strongly emphasized in the World Health Organization’s most recent guideline for pituitary tumor classification. Our review summarizes the current essential knowledge relevant for clinical endocrinologists. Orv Hetil. 2018; 159(7): 278–284.

Analysis of laboratory data of 155 patients with pheochromocytoma-paraganglioma syndrome diagnosed during the past 20 years

Introduction: Laboratory diagnosis of pheochromocytoma-paraganglioma syndrome has been markedly improved during the past two decades. Aim: Retrospective assessment of diagnostic utility of urinary catecholamines and their metabolites as well as serum chromogranin A in 155 patients diagnosed at the 2nd Department of Medicine, Semmelweis University. Method: Urinary catecholamines and metabolites were measured using high-performance liquid chromatography with electrochemical detection in 155 patients with pheochromocytoma-paraganglioma (of whom 28.4% had hereditary background) and in 170 non-pheochromocytoma patients used as controls. Serum chromogranin A was measured by immunoradiometry. Results: Sensitivity (93.2%) and specificity (87.0%) of urinary fractionated metanephrines were higher than those of urinary catecholamines (90.9% vs. 85.7%, respectively) and serum chromogranin A (88.7% and 77.5%, respectively). Urinary normetanephrine and serum chromogranin A correlated positively with tumor size (r = 0.552, p<0.0001 and r = 0.618, p<0.0001, respectively). Conclusions: These data confirm the diagnostic utility of urinary catecholamines and their metabolites. Urinary normetanephrine and serum chromogranin A may help to estimate tumour mass and probably tumour progression. Orv. Hetil., 2015, 156(16), 626–635.

Significance of biochemical markers in the diagnosis of neuroendocrine tumours and in the follow-up of patients

Circulating markers of neuroendocrine tumours are useful tools in the diagnosis of these tumours. Laboratory tests for general biomarkers have acceptable sensitivity for the recognition of neuroendocrine tumours as these biologically active proteins are typically synthesized by all types of neuroendocrine cells. Measurement of chromogranin A is widely used not only in the diagnosis of neuroendocrine tumours but it may predict the prognosis of the diseases and the effect of the antitumor therapy. It is also a useful tool for the detection of residual tumours. Neurendocrine tumours represent a heterogeneous group of tumours with the ability to secrete several hormones and, therefore, measurement of these hormones can also serve as neuroendocrine cell type-specific markers in routine clinical practice. In this review the authors summarize the significance of tumour markers in the diagnosis of neuroendocrine tumours as well as in the management and follow-up of patients with this disease. Orv. Hetil., 2014, 155(45), 1775–1782.

[Effects and significance of estradiol in men]

The most important estrogen is estradiol in both men and women. In men elevated estradiol levels and associated metabolic disorders have been implicated in the development of common diseases including cardiovascular disorders, insulin resistance and type 2 diabetes mellitus, as increased estradiol associated with decreased testosterone levels increases the risk of these diseases. In this review the authors summarize the causes and consequences of androgen deficiency and estradiol excess, and they review recent studies on potential therapeutic strategies to correct increased estradiol levels in men.

Methods for the analysis of large gene deletions and their application in some monogenic disorders

Számos monogénesen öröklődő kórképben a betegséget okozó gén teljes vagy részleges deletiója, illetve kópiaszámának megváltozása patogenetikai tényezőként jön számításba. A direkt DNS-szekvenálás nem alkalmas a gén nagy deletiójának, illetve kópiaszám-változásának kimutatására. Az összefoglalóban a szerzők áttekintik a nagy géndeletio vizsgálómódszereit, és két, monogénesen öröklődő betegségben végzett saját vizsgálataik példáján keresztül bemutatják a módszerek gyakorlati alkalmazásának lehetőségeit. Vázolják a géndeletio-vizsgálat hagyományos (kromoszóma-sávtechnika, Southern-blot, fluoreszcens in situ hibridizáció) és polimeráz láncreakcióra alapozott módszereit (denaturáló nagy felbontóképességű folyadékkromatográfia, kvantitatív valós idejű polimeráz láncreakció, mikroszatellitamarker-analízis, multiplex amplifikálhatópróba-hibridizáció, multiplex ligatióspróba-analízis), valamint a technikai és informatikai haladás legújabb vívmányait (komparatív genomhibridizálás, „array” analízis). Saját vizsgálataikban von Hippel–Lindau-szindrómában szenvedő betegekben kvantitatív valós idejű polimeráz láncreakció és multiplex ligatióspróba-amplifikálás alkalmazásával bemutatják a VHL, illetve congenitalis adrenalis hyperplasiás betegekben a CYP21A2 géndeletio-vizsgálat eredményeit és ezek klinikai jelentőségét.