Vandetanib successfully controls medullary thyroid cancer-related Cushing syndrome in an adolescent patient

CONTEXT

Ectopic Cushing syndrome due to ACTH secretion from metastatic medullary thyroid cancer (MTC) is associated with significant morbidity and mortality.

OBJECTIVE

The aim of the study was to describe the first case of Cushing syndrome associated with MTC in a pediatric patient and the successful reversal of Cushing syndrome with tyrosine kinase inhibitor (vandetanib) therapy.

PATIENT AND METHODS

A 17-year-old Brazilian adolescent presented with metastatic MTC and associated ACTH-dependent ectopic Cushing syndrome in the context of multiple endocrine neoplasia type 2B. When the patient was treated with the tyrosine kinase inhibitor vandetanib, rapid decrease in serum cortisol and improvement of clinical symptoms were observed.

CONCLUSION

We describe the first pediatric case of clinical and biochemical improvement of paraneoplastic MTC-related Cushing syndrome after treatment with vandetanib. Vandetanib and possibly other tyrosine kinase inhibitors may be a novel beneficial option in patients with neuroendocrine tumor-related ectopic Cushing syndrome.

Cell cycle aberrations by alpha-synuclein over-expression and cyclin B immunoreactivity in Lewy bodies

alpha-Synuclein is a presynaptic protein that accumulates abnormally in Lewy bodies of Parkinson's disease (PD) and dementia with Lewy bodies (DLB). Its physiological function and role in neuronal death remain poorly understood. Recent immunohistochemical studies suggest that cell cycle-related phenomena may play a role in the pathogenesis of Alzheimer's disease and perhaps other neurodegenerative disorders. In this investigation, we examined the effects of alpha-synuclein expression levels on cell cycle indices in PC12 cells engineered to conditionally induce alpha-synuclein expression upon withdrawal of doxycycline. Over-expression of alpha-synuclein resulted in enhanced proliferation rate and enrichment of cells in the S phase of the cell cycle. This was associated with increased accumulation of the mitotic factor cyclin B and down-regulation of the tumor suppressor retinoblastoma 2. Additionally, ERK1/2, key molecules in proliferation signaling, were highly phosphorylated. Immunohistochemical studies on postmortem brains revealed intense cyclin B immunoreactivity in Lewy bodies in cases with DLB and to a lesser extent in PD. We propose that elevated expression of alpha-synuclein causes changes in cell cycle regulators through ERK activation leading to apoptosis of postmitotic neurons. These changes in cell cycle proteins are also associated with ectopic expression of cyclin B in Lewy bodies.

Ewing's family of tumors involving structures related to the central nervous system: a review

This review consolidates information gleaned from several case reports and larger series on Ewing's sarcoma family of tumors (EFT) involving structures related to and found in the central nervous system (CNS). These tumors involve the skull, the spinal column, adjacent soft tissues, the meninges, and the brain. We have separated the cases by skull region and spinal column level, and we discuss the attendant differences in prognosis following treatment by neurosurgery, radiation, and chemotherapy. Light and electron microscopic features can be used to differentiate EFT from other small round blue cell tumors that involve the CNS (central primitive neuroectodermal tumor, lymphoma, etc.). Recent molecular and genetic findings in EFT provide new diagnostic methods. We conclude that EFT involving the CNS and adjacent structures is not so rare as previously stated and that the prognosis is more favorable, as a rule, than for the more common examples arising in the long bones and pelvis.

Loss of heterozygosity in P53, BRCA1, and estrogen receptor genes and correlation to expression of p53 protein in ovarian epithelial tumors of different cell types and biological behavior

Loss of heterozygosity (LOH) of tumor suppressor genes (TSGs) in ovarian epithelial tumors of differing cell types and biological behavior has not been thoroughly investigated. Moreover, there have been conflicting reports correlating LOH of the p53 gene to overexpression of p53 protein. This study evaluated 34 formalin-fixed, paraffin-embedded ovarian epithelial tumors for LOH by polymerase chain reaction (PCR) for the following microsatellite markers: TP53(17p13.1/p53 gene), D17S579(17q/BRCA1 gene), and ESR (6q24-27/estrogen receptor gene). LOH of the TP53 marker was detected in 4 (44%) of 9 informative serous cystadenocarcinomas (SCa) but in 0 of 4 informative clear cell carcinomas (CCa) and 0 of 5 informative serous tumors of low malignant potential (SLMP). LOH of the BRCA1 marker was detected in 5 (83%) of 6 informative SCa, but in 1 (13%) of 8 informative CCa and 1 (14%) of 7 informative SLMP. LOH of the ESR marker was detected in 4 (50%) of 8 informative SCa, but in 0 of 4 informative CCa and 1 (16%) of 6 informative SLMP. p53 protein overexpression was present in 8 of 12 SCa but did not correlate to TP53 LOH. LOH for TP53, D17S579/ BRCA1, and ESR is common in ovarian SCa, and is observed in primary tumors as well as metastases. In contrast, these genetic alterations are less common in CCa and in the biologically less aggressive SLMP tumors. These data suggest different mechanisms of oncogenesis in ovarian epithelial tumors of different cell types and biological behavior.

Incidence of loss of heterozygosity at p53 and BRCA1 loci in serous surface carcinoma

Serous surface carcinoma (SSC) is a neoplasm histologically indistinguishable from typical serous carcinomas that arise from the ovary but has a distinct clinical presentation. It is characterized by widespread peritoneal dissemination at presentation, but the ovaries are grossly normal in size and shape. If the carcinoma involves the ovaries microscopically, the tumor is confined to the surface or is minimally invasive. The recognition of this entity is important, because in some studies it appears to have a poorer prognosis than stage-matched serous cancers of the ovary. Loss of heterozygosity (LOH) of the p53 (17p) and BRCA1 (17q) tumor suppressor genes has been frequently identified in sporadic ovarian carcinomas. Although 17p LOH is correlated with common p53 gene mutations, inactivating mutations of the BRCA1 gene are uncommon in sporadic ovarian cases. In contrast, germline BRCA1 mutations are responsible for some hereditary forms of ovarian cancer, where it has been suggested that germline BRCA1 mutations confer a more favorable prognosis. In this study, 12 sporadic SSC were assessed for the presence of allelic deletions on the p53 and BRCA1 gene loci. DNA from both tumor and normal cells was obtained for LOH studies using tissue microdissection. Polymerase chain reaction (PCR) amplification was performed with the polymorphic DNA markers TP53 (17p13.1/p53 gene) and D17S579 (17q/BRCA1 gene). LOH in the p53 and BRCA1 loci was detected in 62.5% and 66.6% of the cases, respectively. In 50% of tumors informative for both markers, it is possible that an entire chromosome may be lost. In conclusion, we have shown that LOH of the p53 and BRCA1 loci is a frequent event in sporadic SSC, similar to what has been described in the usual form of serous ovarian carcinoma. Mutational analysis will be necessary to determine the exact role of these genes in this group of tumors.

Morphologic diversity in malignant melanoma: the potential use of microdissection and the polymerase chain reaction for diagnosis

Malignant melanoma (MM) can mimic soft tissue (ST) and epithelial neoplasms. An immunoperoxidase (IP) panel and a morphologic comparison of the primary are used in diagnosis, which can be difficult when the morphologic and IP profiles of a metastatic lesion simulate those of an ST neoplasm. Through the comparison of known genetic abnormalities in primary and metastatic neoplasms, a definitive diagnosis can be suggested on the basis of the finding of identical allelic losses through the use of microdissection (MD) and the polymerase chain reaction (PCR). Genetic alterations involving the p16 gene on chromosome 9p21 have been observed in MM. We present the case of a 56-year-old man with known MM in whom multiple metastatic lesions to the skin and an adrenal gland developed during a 5-year period. A fine-needle aspiration (FNA) of a new ST buttock lesion was performed; the specimen had cytologic features different from those of the primary neoplasm and simulated a possible primary ST neoplasm. We attempted to make a definitive diagnosis of MM in the FNA of the ST buttock lesion through a genetic comparison with the primary neoplasm as well as with the other metastatic sites. Direct-visualization MD was performed on histologic glass slides of the primary and adjacent tissue (normal control), and the metastatic lesions, along with malignant cell clusters from the buttock lesion FNA. DNA was extracted and PCR amplified with primers D9S171 and IFNA for the p16 locus at the 9p21-22 region. Loss of heterozygosity for the D9S171 marker at the p16 gene locus was identified in all of the neoplastic tissue tested. Normal skin elements did not show deletion. The combination of MD and PCR are powerful tools that can be used for the comparison of genetic abnormalities in primary and metastatic neoplasms with unusual morphologic features to help support a diagnosis with a noncontributory IP.

Allelic loss on chromosome 22q in epithelioid sarcomas

Epithelioid sarcomas are soft tissue tumors with an indolent, but potentially aggressive, clinical behavior. Distinction from other benign and malignant entities may be a diagnostic dilemma. In this study, we evaluate the presence of loss of heterozygosity (LOH) of chromosome 22q in tumor DNA from 13 epithelioid sarcomas, four epithelioid angiosarcomas, and two epithelioid hemangioendotheliomas, and investigate its possible role in diagnosis. LOH was detected in 6 of 10 (60%) of the informative epithelioid sarcomas. No allele loss was detected in the informative vascular tumors, three angiosarcomas, and two hemangioendotheliomas. Chromosome 22q carries the locus of a tumor suppressor gene, the neurofibromatosis 2 (NF2) gene, which has been shown to be lost or mutated in some NF2-related tumors, sporadic meningiomas, and vestibular schwannomas, as well as a few other tumors. Our data suggest that a region of chromosome 22q may be the locus of a tumor suppressor gene involved in the tumorigenesis of these neoplasms. Genetic alterations of yet-unknown tumor suppressor genes in this region, or even the NF2 tumor suppressor gene, may play a role in epithelioid sarcomas tumorigenesis. The fact that LOH was only detected in epithelioid sarcomas and not in the vascular tumors studied suggests a possible role for this marker in diagnosis.

The MDM2 oncoprotein is overexpressed in rhabdomyosarcoma cell lines and stabilizes wild-type p53 protein

MDM2 gene overexpression has been implicated in the pathogenesis of human neoplasia via inhibition of the p53 tumor-suppressor function. To investigate the potential involvement of the MDM2 oncogene in the pathogenesis of childhood rhabdomyosarcoma (RMS) we studied MDM2 abnormalities in six RMS cell lines in correlation with the p53 status. Three showed overexpression of MDM2 mRNA and protein, one with concomitant MDM2 gene amplification. All three lacked p53 mutation and expressed low levels of p53 mRNA but exhibited elevated p53 proteins. Double immunostaining revealed that the overexpressed MDM2 and p53 proteins were co-localized to the same cell nuclei. Furthermore, the two proteins were physically associated, as shown by co-immunoprecipitation and Western blot analysis. The half-life of the p53 protein was prolonged in the MDM2-expressing RMS cells. The extended half-life wildtype p53 protein and its complex formation with the elevated MDM2 suggest that the underlying mechanism for p53 protein accumulation in these cell lines is p53 stabilization by an overabundant MDM2 protein. The overexpressed MDM2 protein had a short half-life. The three remaining RMS cell lines exhibited low MDM2 mRNA and protein levels and carried p53 mutations. This study suggest that MDM2 overexpression represents an alternative mechanism for p53 inactivation in a subset of childhood RMS without p53 mutations. The results further indicate that the elevated MDM2 protein is responsible for wildtype p53 protein accumulation via stabilization.