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Mu D, Liu HQ. [Research progress on the pathogenic mechanisms, diagnosis and treatment of McCune-Albright syndrome]. Zhonghua Yu Fang Yi Xue Za Zhi 2024; 58:183-190. [PMID: 38387948 DOI: 10.3760/cma.j.cn112150-20231008-00242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
McCune-Albright syndrome is a rare chimeric disorder due to mutations in the postzygotic GNAS gene. It belongs to the group of guanine nucleotide-binding protein diseases, affecting a wide range of individuals. It is characterized by fibrous dysplasia, café-au-lait skin macules, and precocious puberty with other variable clinical manifestations. At present, there are difficulties in the molecular diagnosis of McCune-Albright syndrome, and there is a lack of effective clinical treatments to halt or reverse the course and regression of the disease. This article summarizes the clinical manifestations, diagnosis, pathogenic molecular mechanisms, treatment and relevant fertility guidelines of McCune-Albright syndrome, with a view to further research and therapy of McCune-Albright syndrome.
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Affiliation(s)
- D Mu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan Uniersity/Department of Medical Genetics/Prenatal Diagnostic Center, West China Second University Hospital, Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu 610041, China
| | - H Q Liu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan Uniersity/Department of Medical Genetics/Prenatal Diagnostic Center, West China Second University Hospital, Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu 610041, China
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Vado Y, Manero-Azua A, Pereda A, Perez de Nanclares G. Choosing the Best Tissue and Technique to Detect Mosaicism in Fibrous Dysplasia/McCune-Albright Syndrome (FD/MAS). Genes (Basel) 2024; 15:120. [PMID: 38255009 PMCID: PMC10815810 DOI: 10.3390/genes15010120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 01/24/2024] Open
Abstract
GNAS-activating somatic mutations give rise to Fibrous Dysplasia/McCune-Albright syndrome (FD/MAS). The low specificity of extra-skeletal signs of MAS and the mosaic status of the mutations generate some difficulties for a proper diagnosis. We studied the clinical and molecular statuses of 40 patients referred with a clinical suspicion of FD/MAS to provide some clues. GNAS was sequenced using both Sanger and Next-Generation Sequencing (NGS). We were able to identify the pathogenic variants in 25% of the patients. Most of them were identified in the affected tissue, but not in blood. Additionally, NGS demonstrated the ability to detect more patients with mosaicism (8/34) than Sanger sequencing (4/39). Even if in some cases, the clinical information was not complete, we confirmed that, as in previous works, when the patients were young children with a single manifestation, such as hyperpigmented skin macules or precocious puberty, the molecular diagnosis was usually negative. In conclusion, as FD/MAS is caused by mosaic variants, it is essential to use sensitive techniques that allow for the detection of low percentages and to choose the right tissue to study. When not possible, and due to the low positive genetic rate, patients with FD/MAS should only be genetically tested when the clinical diagnosis is really uncertain.
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Affiliation(s)
| | | | | | - Guiomar Perez de Nanclares
- Rare Disease Research Group, Molecular (Epi) Genetics Laboratory, Bioaraba Health Research Institute, Araba University Hospital, 01009 Vitoria-Gasteiz, Spain; (Y.V.); (A.M.-A.); (A.P.)
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Tuñón Álvarez MT, Ruiz Calleja A, Pérez de Nanclares G. [The enigma of Henry IV's disease: Did he suffer from McCune-Albright syndrome/fibrous dysplasia?]. Rev Esp Patol 2023; 56:243-251. [PMID: 37879821 DOI: 10.1016/j.patol.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Henry IV King of Castile, last king of the Trastámara dynasty, was the brother of Isabella the Catholic. He is known as "the impotent". Based on previous descriptions by historians and biographers, Gregorio Marañón in 1922 described him as "eunuchoid dysplastic with acromegalic reaction and clear schizoid features". METHODS In 1946, a post-mortem inspection was carried out on the mummified corpse found in the Monastery of Guadalupe. A written document and some photographs were recorded. We have collected the signs and symptoms described and applied the international classification of diseases recommended by the World Health Organisation, ICD11-2023. We have relied on the coins issued in the money of Henry IV, on which we have identified enlargement of the thyroid gland. RESULTS With the data available at this time, we suggest that Henry IV most probably suffered from: facial and polyostotic bone dysplasia, kyphosis, limb limping, multiple endocrine disorders, acromegaly with macrognatia, nodular thyroid disease, malodorous diaphoresis, erectile dysfunction, hypospadias, abnormal sexual development, "feminoid pelvis", abdominal colic, oligodontia and dental displacement. It is possible that he also suffered from: precocious puberty, renal lithiasis with debilitating phosphaturia, carpal tunnel, thrombopenia and growth hormone-producing pituitary hyperplasia or adenoma. CONCLUSION We suggest that Henry IV may have suffered from McCune-Albrigth syndrome associated with fibrous dysplasia, a rare disease due to gain-of-function mutations in the GNAS gene.
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Affiliation(s)
- M Teresa Tuñón Álvarez
- Anatomía Patológica, Hospital Universitario de Navarra (HUN), Universidad de Navarra (UN), Pamplona, Navarra, España.
| | | | - Guiomar Pérez de Nanclares
- Grupo de Investigación en Enfermedades Raras, Laboratorio de (Epi)Genética Molecular, Instituto de Investigación Sanitaria Bioaraba, Hospital Universitario Araba, Vitoria-Gasteiz, Álava, España
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Pirtea P, Heggarty E, Hagege E, Tran C, de Ziegler D, Farabet C, Filali M, Poulain M, Ayoubi JM. Successful ART outcome in a woman with McCune-Albright syndrome: a case report and literature review. J Assist Reprod Genet 2023; 40:1669-1675. [PMID: 37278881 PMCID: PMC10352189 DOI: 10.1007/s10815-023-02844-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/29/2023] [Indexed: 06/07/2023] Open
Abstract
McCune-Albright syndrome (MAS) is a rare genetic disease affecting multiple organs, including endocrine tissues. This endocrinopathy is sometimes responsible for infertility, as it may induce an independent functioning of the ovaries leading to anovulatory cycles. This case report describes the infertility journey of a 22-year-old female who had early puberty and irregular periods with high estrogen and progesterone levels, low FSH and LH (on day 3 of her menstrual cycle), and a multi-cystic right ovary. She received several infertility treatments: initially in vitro oocyte maturation (IVM) followed by cyst transvaginal ultrasound-guided aspiration, all unsuccessful. A right hemi-ovariectomy was performed that eventually restored regular cycles and made it possible to perform ovarian stimulation (OS) and in vitro fertilization (IVF). Live birth was obtained after the first embryo transfer.
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Affiliation(s)
- Paul Pirtea
- Department of Obstetrics, Gynecology and Reproductive Medicine, Foch Hospital, 92150, Suresnes, France.
| | - Estelle Heggarty
- Department of Obstetrics, Gynecology and Reproductive Medicine, Foch Hospital, 92150, Suresnes, France
| | - Estelle Hagege
- Department of Obstetrics, Gynecology and Reproductive Medicine, Foch Hospital, 92150, Suresnes, France
| | - Chloe Tran
- Department of Obstetrics, Gynecology and Reproductive Medicine, Foch Hospital, 92150, Suresnes, France
| | - Dominique de Ziegler
- Department of Obstetrics, Gynecology and Reproductive Medicine, Foch Hospital, 92150, Suresnes, France
| | - Clemence Farabet
- Department of Obstetrics, Gynecology and Reproductive Medicine, Foch Hospital, 92150, Suresnes, France
| | - Meryem Filali
- Department of Obstetrics, Gynecology and Reproductive Medicine, Foch Hospital, 92150, Suresnes, France
| | - Marine Poulain
- Department of Obstetrics, Gynecology and Reproductive Medicine, Foch Hospital, 92150, Suresnes, France
| | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Foch Hospital, 92150, Suresnes, France
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Hagelstein-Rotman M, Appelman-Dijkstra NM, Boyce AM, Chapurlat R, Dur NBJ, Gensburger D, Majoor BCJ, van de Sande MAJ, Dijkstra PDS. Extent of Extraskeletal Manifestations of Fibrous Dysplasia/McCune-Albright Syndrome in Patients with Mazabraud's Syndrome. Calcif Tissue Int 2022; 110:334-340. [PMID: 34854944 DOI: 10.1007/s00223-021-00918-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/20/2021] [Indexed: 11/27/2022]
Abstract
Mazabraud's syndrome (MZB) is a rare condition in which fibrous dysplasia of bone/the McCune-Albright syndrome (FD/MAS) co-exists with intramuscular myxomas. Both FD and the myxomas harbor the GNAS-mutation. Recent studies have shown that extraskeletal, GNAS-related features are associated with a more severe phenotype of FD/MAS. However, patients with MZB are often only seen by orthopedic surgeons. We therefore evaluated MZB patients seen in tertiary referral centers from the Netherlands (LUMC), USA (National Institutes of Health) and France (INSERM UMR 1033 (Lyos), Hôpital Edouard Herriot). All FD/MAS patients known in these centers with an additional diagnosis of a myxoma were included. Demographic information and data on disease extent and extraskeletal manifestations of FD/MAS such as precocious puberty (PP) or café-au-lait patches (CAL) were retrieved from patient's medical records. Thirty MZB patients were included: 20 women (67%) and 10 men (33%). Patients received a diagnosis of MZB (median 42 years, range 16-19) significantly later than the diagnosis of FD/MAS (median 30 years, range 0-60), p < 0.01. Twenty-six patients were diagnosed with polyostotic disease (87%). In 97% the myxoma was located near the skeletal FD lesion. The combination of MZB and MAS was made in 13 patients in whom PP (n = 7), CAL (n = 7), GH-excess (n = 3) and hyperthyroidism (n = 3) were present. Other extraskeletal features were (multinodular) goiter (n = 2) and thyroid cysts (n = 1). Furthermore, in this cohort of patients with MZB several (pre-)malignant tumors were observed; ductal carcinoma in situ of the breast in 3 patients (10%), breast cancer in 1 patient (3.3%), intra pancreatic mucinous neoplasms in 3 patients (10%) and liver adenomas in 2 patients (6.6%). A total of 47% of patients with MZB had an additional extraskeletal feature such as an endocrinopathy. In MZB, 87% of patients suffer from polyostotic FD, 43% of patients have extraskeletal GNAS-features such as an hyperfunctioning endocrinopathy and 30% (pre-)malignant tumors. We therefore advocate that MZB patients should undergo a complete screening and long-term follow-up for extent of bone disease, but also extraskeletal GNAS features of FD/MAS.
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Affiliation(s)
- M Hagelstein-Rotman
- Department of Medicine: Division of Endocrinology, Centre for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands.
- Department of Orthopaedic Surgery, Centre for Bone Quality, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - N M Appelman-Dijkstra
- Department of Medicine: Division of Endocrinology, Centre for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
| | - A M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - R Chapurlat
- UMR 1033, INSERM, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - N B J Dur
- Department of Orthopaedic Surgery, Centre for Bone Quality, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - D Gensburger
- UMR 1033, INSERM, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - B C J Majoor
- Department of Orthopaedic Surgery, Centre for Bone Quality, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - M A J van de Sande
- Department of Orthopaedic Surgery, Centre for Bone Quality, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - P D S Dijkstra
- Department of Orthopaedic Surgery, Centre for Bone Quality, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
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Ninomiya H, Ozeki M, Nozawa A, Yasue S, Endo S, Inuzuka M, Obara N, Mochizuki K, Kawaguchi M, Kaneko Y, Ohe N, Aoki Y, Matsuo M, Iwama T, Ohnishi H. A rare pediatric case of McCune-Albright syndrome with acute visual disturbance: Case report. Medicine (Baltimore) 2022; 101:e28815. [PMID: 35147121 PMCID: PMC8830878 DOI: 10.1097/md.0000000000028815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/25/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE McCune-Albright syndrome (MAS) is a rare disorder characterized by clinical findings, which includes fibrous dysplasia (FD). FD is a benign tumor that leads to increased rates of bone fracture. In some MAS cases with FD, facial deformities, severe pain, and orbital neuropathies are complicated. Aneurysmal bone cyst (ABC) is a benign bone tumor and rare complication of FD. PATIENT CONCERNS A 9-year-old boy was admitted to our hospital because of acute visual disturbance. DIAGNOSIS AND INTERVENTIONS The patient was clinically diagnosed as ABC complicated with MAS, and he underwent surgery. OUTCOMES After the surgery, his sight became normal. Recurrence of ABC and visual disturbance was not observed in 3 years. Genetic analysis of a tissue sample from the ABC lesion by next-generation sequencing revealed a somatic activating GNAS mutation. LESSONS To the best of our knowledge, this is the first case report of MAS causing optic neuropathy complicated with ABC. ABC complicated with MAS is extremely rare, but it should be considered as a possible diagnosis in patients with acute visual loss and facial swelling. In addition, our case had OAS, which is an uncommon syndrome and a rare complication in ABC with MAS, and rapid decompression of the ABC was effective in improving the patient's eyesight.
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Affiliation(s)
- Hiroshi Ninomiya
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Akifumi Nozawa
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
- Department of Medical Genetics, Tohoku University School of Medicine, Sendai, Japan
| | - Shiho Yasue
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Saori Endo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Masayuki Inuzuka
- Department of Ophthalmology, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Natsuko Obara
- Department of Otorhinolaryngology, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Kiyofumi Mochizuki
- Department of Ophthalmology, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Masaya Kawaguchi
- Department of Radiology, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Yo Kaneko
- Department of Radiology, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Naoyuki Ohe
- Department of Neurosurgery, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Yoko Aoki
- Department of Medical Genetics, Tohoku University School of Medicine, Sendai, Japan
| | - Masayuki Matsuo
- Department of Radiology, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Toru Iwama
- Department of Neurosurgery, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
| | - Hidenori Ohnishi
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido, Gifu, Gifu, Japan
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Shi R, Li X, Zhang J, Chen F, Ma M, Feng Y, Li T. Clinicopathological and genetic study of a rare occurrence: Malignant transformation of fibrous dysplasia of the jaws. Mol Genet Genomic Med 2022; 10:e1861. [PMID: 34989160 PMCID: PMC8801143 DOI: 10.1002/mgg3.1861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 11/01/2021] [Accepted: 12/14/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Malignant transformation of fibrous dysplasia (FD) is very rare and little is known about this occurrence. METHODS We present the detailed clinical course of three cases of osteosarcoma arising from FD of the jaws and explore the genetic aberrations by Sanger sequencing, whole-exome sequencing (WES) and immunohistochemistry (IHC). A literature review of important topics related to this occurrence was also performed. RESULTS It was observed that patients with secondary sarcoma from FD showed a wide range of ages, with most during the third decade. Female and males were equally affected. Craniofacial bones and femurs were the most affected sites. High-risk factors for this occurrence included polyostotic FD, McCune-Albright syndrome and excess growth hormone. Notably, a potential relationship between thyroid hormones and sarcoma development was suggested in one patient, who began to show malignant features after hypothyroidism correction. Sanger sequencing revealed GNAS mutations of FD retained in all malignant tissues. Additionally, abnormal TP53 was demonstrated in all three cases by WES and IHC. WES also revealed two other driver mutations, ROS1 and CHD8, and large amounts of somatic copy number alterations (CNAs) where various oncogenes and tumour suppressors are located. CONCLUSION This study demonstrated and reviewed the clinical features and risk factors for a rare occurrence, secondary sarcoma from FD, and provided important new knowledge about its genetics.
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Affiliation(s)
- Ruirui Shi
- Central LaboratoryPeking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental MaterialsBeijingPR China
- Research Unit of Precision Pathologic Diagnosis in Tumors of the Oral and Maxillofacial RegionsChinese Academy of Medical Sciences (2019RU034)BeijingChina
| | - Xuefen Li
- Central LaboratoryPeking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental MaterialsBeijingPR China
- Research Unit of Precision Pathologic Diagnosis in Tumors of the Oral and Maxillofacial RegionsChinese Academy of Medical Sciences (2019RU034)BeijingChina
| | - Jianyun Zhang
- Research Unit of Precision Pathologic Diagnosis in Tumors of the Oral and Maxillofacial RegionsChinese Academy of Medical Sciences (2019RU034)BeijingChina
- Department of Oral PathologyPeking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental MaterialsBeijingPR China
| | - Feng Chen
- Central LaboratoryPeking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental MaterialsBeijingPR China
| | - Ming Ma
- Research Unit of Precision Pathologic Diagnosis in Tumors of the Oral and Maxillofacial RegionsChinese Academy of Medical Sciences (2019RU034)BeijingChina
- Department of Oral PathologyPeking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental MaterialsBeijingPR China
| | - Yanrui Feng
- Central LaboratoryPeking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental MaterialsBeijingPR China
| | - Tiejun Li
- Research Unit of Precision Pathologic Diagnosis in Tumors of the Oral and Maxillofacial RegionsChinese Academy of Medical Sciences (2019RU034)BeijingChina
- Department of Oral PathologyPeking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental MaterialsBeijingPR China
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Takedani K, Yamamoto M, Tanaka S, Ishihara S, Taketani T, Kanasaki K. ACTH-independent Cushing's syndrome due to ectopic endocrinologically functional adrenal tissue caused by a GNAS heterozygous mutation: a rare case of McCune-Albright syndrome accompanied by central amenorrhea and hypothyroidism: a case report and literature review. Front Endocrinol (Lausanne) 2022; 13:934748. [PMID: 35966069 PMCID: PMC9373900 DOI: 10.3389/fendo.2022.934748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
In a small number of cases, the development of ectopic residual adrenal lesions during embryogenesis causing Cushing's syndrome due to the production of excess cortisol has been reported. A 29-year-old woman was admitted to our hospital for fatigue and recent amenorrhea. Her plasma ACTH was <1.5 pg/mL, and her serum cortisol was 21.4 pg/mL after the 8 mg dexamethasone suppression test, revealing the presence of ACTH-independent Cushing's syndrome; however, her bilateral adrenal glands were atrophied. Abdominal CT revealed a 40-mm round tumor on the right renal hilum and remarkably accumulated 131I-labelled adosterol. CT and bone scintigraphy showed that 99mTc-methylene diphosphonate had accumulated in her dissymmetric skull at the right-frontoparietal region. The tumor on the right renal hilum was laparoscopically removed. Her cortisol levels rapidly decreased to below the normal range, and glucocorticoids were administered to rescue adrenal insufficiency. The resected tumor was yellowish in appearance and 4.5×3.0×2.8 cm in size. Immunohistochemical staining for SF-1, P450scc, CYP17A, CYP21A, and CYP11B1 indicated that this tumor produced cortisol. Exome sequencing analysis revealed that the GNAS heterozygous mutation (c.601C>T, p. Arg201Cys; accession number, NM_000516.5) was found in approximately 20% of the adrenal tumor sample. A mutation of GNAS, encoding the Gsα subunit that mediates GPCR signaling, causes the constitutive activation of adenylyl cyclase, resulting in hypersecretion of hormones regulated by the GPCR. GNAS mutation is one of the major genetic causes of cortisol-producing adrenal tumors independent of ACTH secretion. Considering the combination of GNAS mutation with one of the typical clinical triad characteristics, fibrous dysplasia of bone, we diagnosed this patient with McCune-Albright syndrome accompanied by ACTH-independent Cushing's syndrome caused by an ectopic residual adrenal tumor due to GNAS mutation. This case highlights that GNAS involves a previously unknown pathological mechanism in which inhibition of the natural elimination of remnant tissue leads to ectopic endocrine hypersecretion.
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Affiliation(s)
- Kai Takedani
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo, Japan
| | - Masahiro Yamamoto
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo, Japan
- *Correspondence: Masahiro Yamamoto,
| | - Sayuri Tanaka
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo, Japan
| | | | - Takeshi Taketani
- Department of Pediatrics, Shimane University Faculty of Medicine, Izumo, Japan
| | - Keizo Kanasaki
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo, Japan
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Tiemann‐Boege I, Mair T, Yasari A, Zurovec M. Pathogenic postzygotic mosaicism in the tyrosine receptor kinase pathway: potential unidentified human disease hidden away in a few cells. FEBS J 2021; 288:3108-3119. [PMID: 32810928 PMCID: PMC8247027 DOI: 10.1111/febs.15528] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 07/17/2020] [Accepted: 08/14/2020] [Indexed: 01/19/2023]
Abstract
Mutations occurring during embryonic development affect only a subset of cells resulting in two or more distinct cell populations that are present at different levels, also known as postzygotic mosaicism (PZM). Although PZM is a common biological phenomenon, it is often overlooked as a source of disease due to the challenges associated with its detection and characterization, especially for very low-frequency variants. Moreover, PZM can cause a different phenotype compared to constitutional mutations. Especially, lethal mutations in receptor tyrosine kinase (RTK) pathway genes, which exist only in a mosaic state, can have completely new clinical manifestations and can look very different from the associated monogenic disorder. However, some key questions are still not addressed, such as the level of mosaicism resulting in a pathogenic phenotype and how the clinical outcome changes with the development and age. Addressing these questions is not trivial as we require methods with the sensitivity to capture some of these variants hidden away in very few cells. Recent ultra-accurate deep-sequencing approaches can now identify these low-level mosaics and will be central to understand systemic and local effects of mosaicism in the RTK pathway. The main focus of this review is to highlight the importance of low-level mosaics and the need to include their detection in studies of genomic variation associated with disease.
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Affiliation(s)
| | - Theresa Mair
- Institute of BiophysicsJohannes Kepler UniversityLinzAustria
| | - Atena Yasari
- Institute of BiophysicsJohannes Kepler UniversityLinzAustria
| | - Michal Zurovec
- Biology Centre of the Czech Academy of SciencesInstitute of EntomologyCeske BudejoviceCzech Republic
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Zhadina M, Roszko KL, Geels RES, de Castro LF, Collins MT, Boyce AM. Genotype-Phenotype Correlation in Fibrous Dysplasia/McCune-Albright Syndrome. J Clin Endocrinol Metab 2021; 106:1482-1490. [PMID: 33512531 PMCID: PMC8522305 DOI: 10.1210/clinem/dgab053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare bone and endocrine disorder resulting in fractures, pain, and disability. There are no targeted or effective therapies to alter the disease course. Disease arises from somatic gain-of-function variants at the R201 codon in GNAS, replacing arginine by either cysteine or histidine. The relative pathogenicity of these variants is not fully understood. OBJECTIVE This work aimed 1) to determine whether the most common GNAS variants (R201C and R201H) are associated with a specific clinical phenotype, and 2) to determine the prevalence of the most common GNAS variants in a large patient cohort. METHODS This retrospective cross-sectional analysis measured the correlation between genotype and phenotype characterized by clinical, biochemical, and radiographic data. RESULTS Sixty-one individuals were genotyped using DNA extracted from tissue or circulating cell-free DNA. Twenty-two patients (36.1%) had the R201C variant, and 39 (63.9%) had the R201H variant. FD skeletal disease burden, hypophosphatemia prevalence, fracture incidence, and ambulation status were similar between the 2 groups. There was no difference in the prevalence of endocrinopathies, ultrasonographic gonadal or thyroid abnormalities, or pancreatic involvement. There was a nonsignificant association of cancer with the R201H variant. CONCLUSION There is no clear genotype-phenotype correlation in patients with the most common FD/MAS pathogenic variants. The predominance of the R201H variant observed in our cohort and reported in the literature indicates it is likely responsible for a larger burden of disease in the overall population of patients with FD/MAS, which may have important implications for the future development of targeted therapies.
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Affiliation(s)
- Maria Zhadina
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Kelly L Roszko
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Raya E S Geels
- Department of Medicine, Division of Endocrinology, Centre for Bone Quality, Leiden University Medical Centre, ZA Leiden, the Netherlands
| | - Luis F de Castro
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland 20892, USA
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland , USA
- Correspondence: Alison Boyce, MD, Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health, 30 Convent Dr, Bldg 30, Rm 228, MSC 4320, Bethesda, MD 20892, USA.
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de Castro LF, Ovejero D, Boyce AM. DIAGNOSIS OF ENDOCRINE DISEASE: Mosaic disorders of FGF23 excess: Fibrous dysplasia/McCune-Albright syndrome and cutaneous skeletal hypophosphatemia syndrome. Eur J Endocrinol 2020; 182:R83-R99. [PMID: 32069220 PMCID: PMC7104564 DOI: 10.1530/eje-19-0969] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Abstract
Fibrous dysplasia/McCune-Albright Syndrome (FD/MAS), arising from gain-of-function mutations in Gαs, and cutaneous skeletal hypophosphatemia syndrome (CSHS), arising from gain-of-function mutations in the Ras/MAPK pathway, are strikingly complex, mosaic diseases with overlapping phenotypes. Both disorders are defined by mosaic skin and bone involvement, and both are complicated by increased FGF23 production. These similarities have frequently led to mis-diagnoses, primarily in patients with CSHS who are often assumed to have FD/MAS. The intriguing similarities in skeletal involvement in these genetically distinct disorders have led to novel insights into FGF23 physiology, making an understanding of FD/MAS and CSHS relevant to both clinicians and researchers interested in bone and endocrine disorders. This review will give an overview of FD/MAS and CSHS, focusing on the roles of mosaicism and FGF23 in the pathogenesis and clinical presentation of these disorders.
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Affiliation(s)
- Luis F de Castro
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Diana Ovejero
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
- Musculoskeletal Research Unit, Hospital del Mar Institute of Medical Investigation (IMIM), Barcelona, Spain
- National Research Council, Institute of Clinical Physiology, Lecce, Italy
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
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Abstract
Café au lait macules (CALMs) are a common, isolated dermatologic finding in the general population. But when do these irregularly shaped, jagged-edged, flat, hyperpigmented birthmarks suggest something that may warrant referral? Most pediatric providers are familiar with the association of CALMs and neurofibromatosis type 1. There are, however, other genetic conditions associated with these seemingly benign skin spots. This article provides an overview of CALMs, followed by a summary of several conditions associated with CALMs ranging from the most common (neurofibromatosis type 1) to rare, ring chromosome syndromes. It reviews the associated gene(s), pattern of inheritance, incidence, presenting symptoms, diagnosis, and management for these genetic conditions.
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Gaujoux S, Pasmant E, Silve C, Mehsen-Cetre N, Coriat R, Rouquette A, Douset B, Prat F, Leroy K. McCune Albright syndrome is a genetic predisposition to intraductal papillary and mucinous neoplasms of the pancreas associated pancreatic cancer in relation with GNAS somatic mutation - a case report. Medicine (Baltimore) 2019; 98:e18102. [PMID: 31852070 PMCID: PMC6922479 DOI: 10.1097/md.0000000000018102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE Intraductal papillary and mucinous neoplasms of the pancreas (IPMN) are preneoplastic lesions diagnosed with an increasing incidence. Recently, several groups have described, in up to 70% of IPMN, activating mutations of the G-protein alpha stimulatory sub-unit (Gsα subunit) gene (GNAS). GNAS-activating somatic, post-zygotic, mutations are also associated with McCune-Albright syndrome (MCAS) characterized by fibrous dysplasia, precocious puberty, and café-au-lait spots. PATIENT CONCERNS We herein report a patient with McCune Albright Syndrome that presented with malignant IPMN and underwent pancreatic resection. DIAGNOSES AND INTERVENTIONS Leucocyte and duodenum juice DNA analysis, endoscopically collected from secretin-stimulated pancreatic juice revealed the same (GNAS) activating mutation also found in the invasive pancreatic colloid adenocarcinoma arising from intestinal subtype IPMN. OUTCOMES Thirty months after surgery, the patient was alive with recurrence (bone only metastasis). LESSONS In this observation, we show that MCAS should be view as a new genetic predisposition to IPMN associated pancreatic cancer, and consequently a targeted screening in this high-risk population might be proposed.
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MESH Headings
- Adenocarcinoma, Mucinous/diagnosis
- Adenocarcinoma, Mucinous/etiology
- Adenocarcinoma, Mucinous/genetics
- Biopsy, Needle
- Carcinoma, Pancreatic Ductal/diagnosis
- Carcinoma, Pancreatic Ductal/etiology
- Carcinoma, Pancreatic Ductal/genetics
- Chromogranins/genetics
- Chromogranins/metabolism
- DNA Mutational Analysis
- DNA, Neoplasm/genetics
- Endosonography
- Female
- Fibrous Dysplasia, Polyostotic/complications
- Fibrous Dysplasia, Polyostotic/diagnosis
- Fibrous Dysplasia, Polyostotic/genetics
- GTP-Binding Protein alpha Subunits, Gs/genetics
- GTP-Binding Protein alpha Subunits, Gs/metabolism
- Genetic Predisposition to Disease
- Humans
- Middle Aged
- Mutation
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/etiology
- Pancreatic Neoplasms/genetics
- Tomography, X-Ray Computed
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Affiliation(s)
- Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Pancreatic Surgery, Cochin Hospital, APHP
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité
- INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin
| | - Eric Pasmant
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité
- Service de Génétique et Biologie Moléculaires, Hôpital Cochin
- EA7331, Université Paris Descartes
| | - Caroline Silve
- Service de Génétique et Biologie Moléculaires, Hôpital Cochin
- INSERM U1169, Hôpital Bicêtre
- Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphore / Filière OSCAR
| | | | - Romain Coriat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité
- Department of Gastroenterology, Cochin Hospital, APHP
| | | | - Bertrand Douset
- Department of Digestive, Hepato-biliary and Pancreatic Surgery, Cochin Hospital, APHP
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité
- INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin
| | - Frédéric Prat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité
- Department of Gastroenterology, Cochin Hospital, APHP
| | - Karen Leroy
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité
- Service de Génétique et Biologie Moléculaires, Hôpital Cochin
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Hartley I, Zhadina M, Collins MT, Boyce AM. Fibrous Dysplasia of Bone and McCune-Albright Syndrome: A Bench to Bedside Review. Calcif Tissue Int 2019; 104:517-529. [PMID: 31037426 PMCID: PMC6541017 DOI: 10.1007/s00223-019-00550-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
Abstract
Fibrous dysplasia is an uncommon mosaic disorder in which bone is replaced by structurally unsound fibro-osseous tissue. It is caused by the sporadic post-zygotic activating mutations in GNAS, resulting in dysregulated GαS-protein signaling in affected tissues. This manifests on a broad clinical spectrum ranging from insignificant solitary lesions to severe disease with deformities, fractures, functional impairment, and pain. Fibrous dysplasia may present in isolation or in association with hyperfunctioning endocrinopathies and café-au-lait macules, known as McCune-Albright Syndrome. This review summarizes the current understanding of pathophysiology in fibrous dysplasia, describes key pre-clinical and clinical investigations, and details the current approach to diagnosis and management.
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Affiliation(s)
- Iris Hartley
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Building 30 Room 228 MSC 4320, Bethesda, MD, 20892, USA
- Interinstitute Endocrine Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Maria Zhadina
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Building 30 Room 228 MSC 4320, Bethesda, MD, 20892, USA
- Pediatric Endocrinology Training Program, Eunice Kennedy Shriver National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, USA
| | - Micheal T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Building 30 Room 228 MSC 4320, Bethesda, MD, 20892, USA
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Building 30 Room 228 MSC 4320, Bethesda, MD, 20892, USA.
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15
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Robinson C, Estrada A, Zaheer A, Singh VK, Wolfgang CL, Goggins MG, Hruban RH, Wood LD, Noë M, Montgomery EA, Guthrie LC, Lennon AM, Boyce AM, Collins MT. Clinical and Radiographic Gastrointestinal Abnormalities in McCune-Albright Syndrome. J Clin Endocrinol Metab 2018; 103:4293-4303. [PMID: 30124968 PMCID: PMC6194803 DOI: 10.1210/jc.2018-01022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/09/2018] [Indexed: 12/12/2022]
Abstract
CONTEXT McCune-Albright syndrome (MAS) is a rare disorder characterized by fibrous dysplasia of bone, café-au-lait macules, and hyperfunctioning endocrinopathies. It arises from somatic gain-of-function mutations in GNAS, which encodes the cAMP-regulating protein Gαs. Somatic GNAS mutations have been reported in intraductal papillary mucinous neoplasms (IPMNs) and various gastrointestinal (GI) tumors. The clinical spectrum and prevalence of MAS-associated GI disease is not well established. OBJECTIVE Define the spectrum and prevalence of MAS-associated GI pathology in a large cohort of patients with MAS. DESIGN Cross-sectional study. SETTING National Institutes of Health Clinical Center and The Johns Hopkins Hospital. METHODS Fifty-four consecutive subjects with MAS (28 males; age range, 7 to 67 years) were screened with magnetic resonance cholangiopancreatography (MRCP). RESULTS Thirty of 54 subjects (56%) had radiographic GI abnormalities. Twenty-five (46%) of the screened subjects had IPMNs (mean age of 35.1 years). Fourteen of the 25 had IPMNs alone, and 11 had IPMNs and abnormal hepatobiliary imaging. The 30 patients with MAS-associated GI pathology had a higher prevalence of acute pancreatitis, diabetes mellitus, and skeletal disease burden of fibrous dysplasia than patients without GI disease. CONCLUSIONS A broad spectrum of GI pathology is associated with MAS. IPMNs are common and occur at a younger age than in the general population. Patients with MAS should be considered for screening with a focused GI history and baseline MRCP. Further determination of the natural history and malignant potential of IPMNs in MAS is needed.
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Affiliation(s)
- Cemre Robinson
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
- Program in Developmental Endocrinology and Genetics, The Eunice Kennedy Shriver Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Department of Pediatrics, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Andrea Estrada
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
- Division of Endocrinology and Diabetes, Children’s National Health System, Washington, DC
| | - Atif Zaheer
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher L Wolfgang
- Departments of Surgery, Radiology, and Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Goggins
- Division of Gastroenterology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura D Wood
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michaël Noë
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth A Montgomery
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lori C Guthrie
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Anne Marie Lennon
- Division of Gastroenterology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Surgery, Radiology, and Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
- Division of Endocrinology and Diabetes, Children’s National Health System, Washington, DC
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
- Correspondence and Reprint Requests: Michael T. Collins, MD, Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive, Building 30, Room 228, MSC 4320, Bethesda, Maryland 20892-4320. E-mail:
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Lo FS, Chen TL, Chiou CC. Detection of Rare Somatic GNAS Mutation in McCune-Albright Syndrome Using a Novel Peptide Nucleic Acid Probe in a Single Tube. Molecules 2017; 22:molecules22111874. [PMID: 29104223 PMCID: PMC6150203 DOI: 10.3390/molecules22111874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/23/2017] [Accepted: 10/30/2017] [Indexed: 02/07/2023] Open
Abstract
McCune-Albright syndrome (MAS) is characterized by the triad of precocious puberty, café au lait pigmentation, and polyostotic fibrous dysplasia (FD) of bone, and is caused by post-zygotic somatic mutations-R201H or R201C-in the guanine nucleotide binding protein, alpha stimulating (GNAS) gene. In the present study, a novel peptide nucleic acid (PNA) probe with fluorescent labeling was designed to detect trace amounts of somatic mutant GNAS in a single tube reaction. The method was applied to screen GNAS mutations in six patients with MAS/FD. The results showed that the PNA probe assay could detect low abundant mutants in 200-fold excess of wild-type alleles. The GNAS mutation was found in three patients with severe disease (MAS) by using the assay. The other three patients with mild disease (having only FD) showed a wild-type result. This study has provided a simple method to detect trace amounts of GNAS mutants with high sensitivity in large amounts of wild-type DNA.
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Affiliation(s)
- Fu-Sung Lo
- Division of Pediatric Endocrinology & Genetics, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan.
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Tai-Long Chen
- Molecular Medicine Research Center, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Chiuan-Chian Chiou
- Molecular Medicine Research Center, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
- Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan.
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Abstract
Fibrous dysplasia (FD) is an uncommon and debilitating skeletal disorder resulting in fractures, deformity, functional impairment, and pain. It arises from post-zygotic somatic activating mutations in GNAS, in the cAMP-regulating transcript α-subunit, Gsα. Constitutive Gs signaling results in activation of adenylyl cyclase and dysregulated cAMP production. In the skeleton, this leads to the development of FD lesions with abnormal bone matrix, trabeculae, and collagen, produced by undifferentiated mesenchymal cells. FD may occur in isolation or in combination with extraskeletal manifestations, including hyperfunctioning endocrinopathies and café-au-lait macules, termed McCune-Albright syndrome (MAS). This review summarizes current clinical and translational perspectives in FD/MAS, with an emphasis on FD pathogenesis, natural history, pre-clinical and clinical investigation, and future directions.
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Affiliation(s)
- Cemre Robinson
- Section on Skeletal Disorders and Mineral Homeostasis, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive Room 228 MSC 4320, Bethesda, MD, 20892, USA
| | - Michael T Collins
- Section on Skeletal Disorders and Mineral Homeostasis, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive Room 228 MSC 4320, Bethesda, MD, 20892, USA
| | - Alison M Boyce
- Section on Skeletal Disorders and Mineral Homeostasis, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive Room 228 MSC 4320, Bethesda, MD, 20892, USA.
- Division of Endocrinology and Diabetes, Children's National Health System, Washington, DC, USA.
- Bone Health Program, Division of Orthopaedics and Sports Medicine, Children's National Health System, Washington, DC, USA.
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Abstract
Growth hormone (GH) secreting pituitary tumors may be caused by genetic abnormalities in a variety of genes including AIP, MEN1, CDKN1B, and PRKAR1A. These can lead to GH secreting pituitary adenomas as an isolated occurrence (e.g. as aggressive sporadic adenomas or in familial isolated pituitary adenomas (FIPA)) or as part of syndromic conditions such as MEN1 or Carney complex. These tumors have more aggressive features than sporadic acromegaly, including a younger age at disease onset and larger tumor size, and they can be challenging to manage. In addition to mutations or deletions, copy number variation at the GPR101 locus may also lead to mixed GH and prolactin secreting pituitary adenomas in the setting of X-linked acrogigantism (X-LAG syndrome). In X-LAG syndrome and in McCune Albright syndrome, mosaicism for GPR101 duplications and activating GNAS1 mutations, respectively, contribute to the genetic pathogenesis. As only 5% of pituitary adenomas have a known cause, efficient deployment of genetic testing requires detailed knowledge of clinical characteristics and potential associated syndromic features in the patient and their family.
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Affiliation(s)
- Liliya Rostomyan
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
| | - Albert Beckers
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium.
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Abstract
There are many etiologies of peripheral precocious puberty (PPP) with diverse manifestations resulting from exposure to androgens, estrogens, or both. The clinical presentation depends on the underlying process and may be acute or gradual. The primary goals of therapy are to halt pubertal development and restore sex steroids to prepubertal values. Attenuation of linear growth velocity and rate of skeletal maturation in order to maximize height potential are additional considerations for many patients. McCune-Albright syndrome (MAS) and familial male-limited precocious puberty (FMPP) represent rare causes of PPP that arise from activating mutations in GNAS1 and the LH receptor gene, respectively. Several different therapeutic approaches have been investigated for both conditions with variable success. Experience to date suggests that the ideal therapy for precocious puberty secondary to MAS in girls remains elusive. In contrast, while the number of treated patients remains small, several successful therapeutic options for FMPP are available.
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Gérard C, Jedidi H, Petrossians P, Krzesinski F, Daly A, Beckers A. [Old phenotype and new genotypes. Pituitary adenomas]. Rev Med Liege 2015; 70:569-574. [PMID: 26738269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Gigantism and acromegaly, usually caused by a pituitary adenoma linked inappropriate secretion of growth hormone (GH), are generally considered as very rare diseases, even if, according to some authors, their cumulative prevalence is about 1/5000. Starting from the historical case of a giant from Liège we shall describe the different types of GH pituitary adenomas and their pathophysiology. We shall particularly discuss rare forms of inherited GH secreting pituitary adenomas like the FIPA (familial inherited isolated pituitary adenomas) and the X-LAG (X linked acrogigantism), both described for the first time in Liège, in 2000 and 2014, respectively.
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Angelousi A, Fencl F, Faucz FR, Malikova J, Sumnik Z, Lebl J, Stratakis CA. McCune Albright syndrome and bilateral adrenal hyperplasia: the GNAS mutation may only be present in adrenal tissue. Hormones (Athens) 2015; 14:447-50. [PMID: 26188235 PMCID: PMC6341467 DOI: 10.14310/horm.2002.1578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 04/24/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Corticotropin (ACTH)-independent hypercortisolism due to bilateral adrenocortical hyperplasia (BAH) in infancy is an extremely rare condition that is often caused by McCune Albright syndrome (MAS). MAS is caused by an activating mutation of the GNAS gene which leads to increased cyclic (c) adenosine monophosphate (AMP) signaling. Most forms of BAH are linked to increased cAMP signaling. We report the case of an infant with MAS who had BAH. METHODS Genomic DNA fragments from blood and adrenal tissue encompassing regions (exons 8 and 9) with the hot spot activating missense GNAS mutations were amplified by classical bidirectional Sanger sequencing. RESULTS The infant was found to carry the most common GNAS mutation, in exon 8 (c.602G >A, p. R201H), only in her adrenocortical tissue, despite extensive skin and other findings. CONCLUSIONS We conclude that infants with MAS, despite absence of the GNAS activating mutation in blood, may still have significant clinical findings, including ACTH-independent hypercortisolism. Molecular confirmation of the diagnosis should be sought at the tissue level in these patients.
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Affiliation(s)
- Anna Angelousi
- Section on Endocrinology & Genetics, Program on Developmental Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Bethesda, USA
| | - Filip Fencl
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Fabio R. Faucz
- Section on Endocrinology & Genetics, Program on Developmental Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Bethesda, USA
| | - Jana Malikova
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Zdenek Sumnik
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Jan Lebl
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Constantine A. Stratakis
- Section on Endocrinology & Genetics, Program on Developmental Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Bethesda, USA
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Sato T, Muroya K, Asakura Y, Yachie A, Nishimura G, Aida N, Machida J, Tanaka Y, Hasegawa T, Adachi M. Polyostotic osteolysis and hypophosphatemic rickets with elevated serum fibroblast growth factor 23: A case report. Am J Med Genet A 2015; 167A:2430-4. [PMID: 26059403 DOI: 10.1002/ajmg.a.37193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/20/2015] [Indexed: 11/07/2022]
Abstract
We report on a boy who presented with hypophosphatemic rickets with elevated serum fibroblast growth factor 23 (FGF23) and polyostotic osteolytic lesions at age 2 years. Tumor-induced hypophosphatemic rickets was suspected; however, bone biopsy for osteolytic changes revealed no tumorous change, except for irregularly dilated vessels associated with osteoclasts and fibrous proliferation. Venous sampling failed to point to FGF23-producing foci. After alfacalcidol and phosphate supplementation, the rachitic skeletal changes improved, but FGF23 increased and new osteolytic lesions developed. Serum levels of neopterin and a few cytokines, including plasma transforming growth factor-β and soluble tumor necrosis factor receptor type II, were elevated. At age 4 years, high doses of phosphate resulted in increased serum phosphate levels, decreased neopterin and cytokines, decreased FGF23, and stabilization of osteolysis. We excluded germline mutations in PHEX, FGF23, DMP1, and ENPP1 (genes for hereditary hypophosphatemic rickets) and somatic mutations in the GNAS and HRAS/KRAS (the disease-causing genes for McCune-Albright syndrome and linear nevus sebaceous syndrome, respectively). We could not perform octreotide scintigraphy or fluorodeoxyglucose-positron emission tomography, and thus could not completely exclude occult FGF23-producing tumors. However, considering the course of the disease, it is intriguing to assume that dysregulation of osteoclast-macrophage lineage may have induced increased neopterin levels, increased cytokine levels, osteolytic process, and possibly FGF23 overproduction.
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MESH Headings
- Cell Proliferation
- Child, Preschool
- Cytokines/blood
- Cytokines/genetics
- Fibroblast Growth Factor-23
- Fibroblast Growth Factors/blood
- Fibroblast Growth Factors/genetics
- Fibroblasts/drug effects
- Fibroblasts/metabolism
- Fibroblasts/pathology
- Fibrous Dysplasia, Polyostotic/blood
- Fibrous Dysplasia, Polyostotic/drug therapy
- Fibrous Dysplasia, Polyostotic/genetics
- Fibrous Dysplasia, Polyostotic/pathology
- Gene Expression Regulation
- Humans
- Hydroxycholecalciferols/therapeutic use
- Male
- Neopterin/blood
- Neopterin/genetics
- Osteoclasts/drug effects
- Osteoclasts/metabolism
- Osteoclasts/pathology
- Osteolysis/blood
- Osteolysis/drug therapy
- Osteolysis/genetics
- Osteolysis/pathology
- Phosphates/therapeutic use
- Receptors, Tumor Necrosis Factor, Type II/blood
- Receptors, Tumor Necrosis Factor, Type II/genetics
- Rickets, Hypophosphatemic/blood
- Rickets, Hypophosphatemic/drug therapy
- Rickets, Hypophosphatemic/genetics
- Rickets, Hypophosphatemic/pathology
- Transforming Growth Factor beta/blood
- Transforming Growth Factor beta/genetics
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Affiliation(s)
- Takeshi Sato
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Yokohama, Japan
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Koji Muroya
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yumi Asakura
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Akihiro Yachie
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Gen Nishimura
- Department of Radiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Noriko Aida
- Department of Radiology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Jiro Machida
- Department of Orthopedic Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yukichi Tanaka
- Department of Pathology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Masanori Adachi
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Yokohama, Japan
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Zhou SH, Yang WJ, Liu SW, Li J, Zhang CY, Zhu Y, Zhang CP. Gene expression profiling of craniofacial fibrous dysplasia reveals ADAMTS2 overexpression as a potential marker. Int J Clin Exp Pathol 2014; 7:8532-8541. [PMID: 25674217 PMCID: PMC4314047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 10/17/2014] [Indexed: 06/04/2023]
Abstract
Fibrous dysplasia (FD) as an abnormal bone growth is one of the common fibro-osseous leasions (FOL) in oral and maxillofacial region, however, its etiology still remains unclear. Here, we performed gene expression profiling of FD using microarray analysis to explore the key molecule events in FD development, and develop potential diagnostic markers or therapeutic targets for FD. We found that 1,881 genes exhibited differential expression with more than two-fold changes in FD compared to normal bone tissues, including 1,200 upregulated genes and 681 downregulated genes. Pathway analysis indicated that obviously activated pathways are Ribosome and ECM-receptor interaction pathways; downregulated pathways are "Hepatitis C" and "cancer" signaling pathways. We further validated the expression of ADAMTS2, one of most differentiated expressed genes, by Immunohistochemistry (IHC) in 40 of FD cases. Results showed that ADAMTS2 was significantly overexpressed in FD tissues, but rarely expressed in normal bone tissues, suggesting that ADAMTS2 could be a potential biomarker for FD. Thus, this study uncovered differentially expressed candidate genes in FD, which provides pilot data for understanding FD pathogenesis, and developing novel biomarkers for diagnosis and targeting of FD.
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Affiliation(s)
- Shang-Hui Zhou
- Department of Oral & Maxillofacial-Head & Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine Shanghai, China
| | - Wen-Jun Yang
- Department of Oral & Maxillofacial-Head & Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine Shanghai, China
| | - Sheng-Wen Liu
- Department of Oral & Maxillofacial-Head & Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine Shanghai, China
| | - Jiang Li
- Department of Oral Pathology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine Shanghai, China
| | - Chun-Ye Zhang
- Department of Oral Pathology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine Shanghai, China
| | - Yun Zhu
- Department of Oral & Maxillofacial-Head & Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine Shanghai, China
| | - Chen-Ping Zhang
- Department of Oral & Maxillofacial-Head & Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine Shanghai, China
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Vasilev V, Daly AF, Thiry A, Petrossians P, Fina F, Rostomyan L, Silvy M, Enjalbert A, Barlier A, Beckers A. McCune-Albright syndrome: a detailed pathological and genetic analysis of disease effects in an adult patient. J Clin Endocrinol Metab 2014; 99:E2029-38. [PMID: 25062453 DOI: 10.1210/jc.2014-1291] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT McCune Albright syndrome (MAS) is a clinical association of endocrine and nonendocrine anomalies caused by postzygotic mutation of the GNAS1 gene, leading to somatic activation of the stimulatory α-subunit of G protein (Gsα). Important advances have been made recently in describing pathological characteristics of many MAS-affected tissues, particularly pituitary, testicular, and adrenal disease. Other rarer disease related features are emerging. OBJECTIVE The objective of the investigation was to study the pathological and genetic findings of MAS on a tissue-by-tissue basis in classically and nonclassically affected tissues. DESIGN This was a comprehensive autopsy and genetic analysis. SETTING The study was conducted at a tertiary referral university hospital. PATIENTS An adult male patient with MAS and severe disease burden including gigantism was the subject of the study. INTERVENTION(S) Interventions included clinical, hormonal, and radiographic studies and gross and microscopic pathology analyses, conventional PCR, and droplet digital PCR analyses of affected and nonaffected tissues. MAIN OUTCOME MEASURE Pathological findings and the presence of GNAS1 mutations were measured. RESULTS The patient was diagnosed with MAS syndrome at 6 years of age based on the association of café-au-lait spots and radiological signs of polyostotic fibrous dysplasia. Gigantism developed and hyperprolactinemia, hypogonadotropic hypogonadism, and hyperparathyroidism were diagnosed throughout the adult period. The patient died at the age of 39 years from a pulmonary embolism. A detailed study revealed mosaiscism for the p.R201C GNAS1 mutation distributed across many endocrine and nonendocrine tissues. These genetically implicated tissues included rare or previously undescribed disease associations including primary hyperparathyroidism and hyperplasia of the thymus and endocrine pancreas. CONCLUSIONS This comprehensive pathological study of a single patient highlights the complex clinical profile of MAS and illustrates important advances in understanding the characteristics of somatic GNAS1-related pathology across a wide range of affected organs.
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Affiliation(s)
- Vladimir Vasilev
- Departments of Endocrinology (V.V., A.F.D., P.P., L.R., A.Be.) and Pathological Anatomy (A.T.), Centre Hospitalier Universitaire de Liège, University of Liège, Domaine Universitaire du Sart Tilman, 4000 Liège, Belgium; Department of Biological Oncology Transfer (F.F.), Laboratory of Medical Biology, Assistance Publique-Hôpitaux de Marseille, 13354 Marseille, France; and Laboratory of Biochemistry and Molecular Biology (M.S., A.E., A.Ba.), Centre Hospitalier Universitaire Conception, University of the Mediterranean, 13007 Marseille, France
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Turcic K, Tobar-Rubin R, Janevska D, Carroll J, Din E, Alvarez R, Haick J, Pals-Rylaarsdam R. Three intragenic suppressors of a GTPase-deficient allele of GNAS associated with McCune-Albright syndrome. J Mol Endocrinol 2014; 52:321-31. [PMID: 24850831 DOI: 10.1530/jme-13-0297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Gain-of-function mutations in heterotrimeric G-protein α subunits are associated with a variety of human diseases. McCune-Albright syndrome (MAS) is caused by mutations in GNAS, the gene encoding Gs. Alterations at Arg201 significantly reduce the GTPase activity of the protein, rendering it constitutively active. In this study, we have constructed a library of random mutations in a constitutively active yeast GPA1 gene carrying a mutation homologous to the McCune-Albright allele (Arg297His). Intragenic suppressors found at sites with homology to the human Gs protein were tested for their ability to suppress the constitutive activity of an Arg201His mutation in Gs. Three intragenic suppressors, at Phe142, Arg231, and Leu266, were able to suppress elevated basal cAMP responses caused by Arg201His when expressed in HEK293 cells. A range of amino acid substitutions was introduced at each of these sites to investigate the chemical requirements for intragenic suppression. The ability of Gs proteins carrying the suppressor mutations alone to mediate receptor-induced cAMP production was measured. These results offer potential sites on Gs that could serve as drug targets for MAS therapies.
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Affiliation(s)
- Kyle Turcic
- Department of Biological ScienceBenedictine University, 5700 College Road, Lisle, Illinois 60532, USA
| | - Raquel Tobar-Rubin
- Department of Biological ScienceBenedictine University, 5700 College Road, Lisle, Illinois 60532, USA
| | - Daniela Janevska
- Department of Biological ScienceBenedictine University, 5700 College Road, Lisle, Illinois 60532, USA
| | - Julie Carroll
- Department of Biological ScienceBenedictine University, 5700 College Road, Lisle, Illinois 60532, USA
| | - Eraj Din
- Department of Biological ScienceBenedictine University, 5700 College Road, Lisle, Illinois 60532, USA
| | - Rebecca Alvarez
- Department of Biological ScienceBenedictine University, 5700 College Road, Lisle, Illinois 60532, USA
| | - Jennifer Haick
- Department of Biological ScienceBenedictine University, 5700 College Road, Lisle, Illinois 60532, USA
| | - Robin Pals-Rylaarsdam
- Department of Biological ScienceBenedictine University, 5700 College Road, Lisle, Illinois 60532, USA
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Salpea P, Stratakis CA. Carney complex and McCune Albright syndrome: an overview of clinical manifestations and human molecular genetics. Mol Cell Endocrinol 2014; 386:85-91. [PMID: 24012779 PMCID: PMC3943598 DOI: 10.1016/j.mce.2013.08.022] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/26/2013] [Accepted: 08/27/2013] [Indexed: 12/25/2022]
Abstract
Endocrine neoplasia syndromes feature a wide spectrum of benign and malignant tumors of endocrine and non-endocrine organs associated with other clinical manifestations. This study outlines the main clinical features, genetic basis, and molecular mechanisms behind two multiple endocrine neoplasia syndromes that share quite a bit of similarities, but one can be inherited whereas the other is always sporadic, Carney complex (CNC) and McCune-Albright (MAS), respectively. Spotty skin pigmentation, cardiac and other myxomas, and different types of endocrine tumors and other characterize Carney complex, which is caused largely by inactivating Protein kinase A, regulatory subunit, type I, Alpha (PRKAR1A) gene mutations. The main features of McCune-Albright are fibrous dysplasia of bone (FD), café-au-lait macules and precocious puberty; the disease is caused by activating mutations in the Guanine Nucleotide-binding protein, Alpha-stimulating activity polypeptide (GNAS) gene which are always somatic. We review the clinical manifestations of the two syndromes and provide an update on their molecular genetics.
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Affiliation(s)
- Paraskevi Salpea
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology & Genetics (PDEGEN) & Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver, National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD 20892, USA.
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology & Genetics (PDEGEN) & Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver, National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD 20892, USA
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Gaujoux S, Salenave S, Ronot M, Rangheard AS, Cros J, Belghiti J, Sauvanet A, Ruszniewski P, Chanson P. Hepatobiliary and Pancreatic neoplasms in patients with McCune-Albright syndrome. J Clin Endocrinol Metab 2014; 99:E97-101. [PMID: 24170100 DOI: 10.1210/jc.2013-1823] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND McCune-Albright syndrome (MAS), which includes polycystic fibrous dysplasia, precocious puberty, and café au lait spots, is a rare disorder caused by somatic activating mutations of the GNAS gene. GNAS mutations have also been implicated in various sporadic tumors, including hepatobiliary and pancreatic neoplasms. AIM The aim of this study was to assess the prevalence of hepatobiliary and pancreatic neoplasms in patients with McCune-Albright syndrome. PATIENTS AND METHODS Nineteen patients diagnosed between 1995 and 2012 with MAS in a tertiary referral center for rare growth disorders were screened with dedicated gadolinium-enhanced magnetic resonance imaging for hepatobiliary and pancreatic neoplasms between June 2011 and December 2012. RESULTS Six (32%) of the 19 screened patients were found to have hepatic, pancreatic, or biliary lesions, excluding liver hemangiomas, liver cysts, and focal nodular hyperplasia. This includes pancreatic ductal lesions observed in 4 patients, including numerous branch-duct intraductal papillary mucinous neoplasms in 3 patients. Biliary lesions were observed in 1 patient, with a large choledochal cyst also involving the left biliary branch. Finally, multiple inflammatory/telangiectatic hepatic adenomas were observed in 2 patients, including 1 with proven somatic GNAS mutation. CONCLUSION We describe the first observation of syndromic intraductal papillary mucinous neoplasms and the new association between MAS and pancreatic neoplasms, namely intraductal papillary mucinous neoplasms of the pancreas but also rare hepatobiliary neoplasms including liver adenomas and choledochal cysts. These findings strongly suggest that somatic activating GNAS mutations, possibly through cAMP pathway disorders, are involved in the tumorigenesis of hepatobiliary and pancreatic tissues originating from the foregut endoderm and have led us to use a routine screening by dedicated magnetic resonance imaging including both pancreatobiliary and liver sequences in patients with MAS.
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Affiliation(s)
- Sébastien Gaujoux
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Beaujon, Departments of Hepato-Pancreato-Biliary Surgery-Pôle des Maladies de l'Appareil Digestif (PMAD) (S.G., J.B., A.S.), Radiology (M.R.), Pathology (J.C.), and Gastroenterology-PMAD (P.R.), and Inserm Centre de Recherche Biomédicale Bichat Beaujon (CRB3) Unité 773 (S.G., M.R., J.C., J.B., A.S., P.R.), Clichy F-92110, France; Faculté de Médecine, Université Paris Diderot (S.G., M.R., J.C., J.B., A.S., P.R.), F-75010 Paris, France; AP-HP, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Service d'Endocrinologie et des Maladies de la Reproduction (S.S., P.C.) and Service de Radiologie (A.-S.R.), and Université Paris-Sud 11 (P.C.), Le Kremlin Bicêtre F-94275, France; and Inserm Unité 693 (P.C.), Faculté de Médecine Paris-Sud, F-94276 Le Kremlin-Bicêtre, France
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Lietman SA, Levine MA. Fibrous dysplasia. Pediatr Endocrinol Rev 2013; 10 Suppl 2:389-396. [PMID: 23858622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Fibrous dysplasia is a developmental abnormality of bone that is characterized by a highly disorganized mixture of immature fibrous tissue and fragments of immature trabecular bone. Fibrous dysplasia may arise as a single, discrete (monostotic) lesion or can occur with a more widespread distribution with multiple lesions that affect many bones (oligo- or polyostotic). Fibrous dysplasia is usually an isolated skeletal finding but can sometimes occur as a component of a multisystem developmental disorder known as McCune-Albright syndrome (MAS) that is also associated with endocrine hyperfunction (e.g. precocious puberty) and caf au lait cutaneous macules. The identification of activating mutations in GNAS in a subset of human GH-secreting pituitary tumors and autonomously functioning human thyroid tumors provided the initial basis for understanding the molecular pathophysiology of McCune-Albright syndrome and fibrous dysplasia. These observations led to the concept that activating mutations of the GNAS gene convert it into a putative oncogene referred to as gsp (Gsa or Gas). The classic radiographic feature of fibrous dysplasia is a hazy, radiolucent, or ground-glass, pattern resulting from the defective mineralization of immature dysplastic bone; it is usually strikingly different from the radiographic appearance of normal bone, calcified cartilage, or soft tissue. The surgical approach to fibrous dysplasia should in general be conservative. Recent research suggests that the WntlB-catenin pathway may play a role in fibrous dysplasia as patients with activating GNAS mutations specifically showed that Gas mutations activated Wnt/B-catenin signaling. Thus inhibition of 8-catenin signaling or silencing GNAS alleles that encode constitutively active Gsa molecules in fibrous dysplasia and McCune-Albright syndrome offer potential therapeutic promise and deserve further study. In summary fibrous dysplasia is a developmental abnormality of bone with a known molecular etiology; Further knowledge about the molecular pathology of fibrous dysplasia may lead to improved conservative therapies in the near future.
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Affiliation(s)
- Steven A Lietman
- Musculoskeletal Tumor Center, Cleveland Clinic, Cleveland, OH 44195, USA.
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Tobar-Rubin R, Sultan D, Janevska D, Turcic K, Carroll J, Ooms L, Pals-Rylaarsdam R. Intragenic suppression of a constitutively active allele of Gsα associated with McCune-Albright syndrome. J Mol Endocrinol 2013; 50:193-201. [PMID: 23288949 PMCID: PMC3836019 DOI: 10.1530/jme-12-0087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
McCune-Albright syndrome (MAS) is a human genetic disorder caused by a mutation that constitutively activates the G(s)α subunit by abolishing GTP hydrolysis. MAS patients suffer from a range of endocrinopathies as well as polyostotic fibrous dysplasia of bone. We previously identified an intragenic suppressor of the MAS mutation in a yeast system, which substituted two residues in the GTP-binding site of Gpa1: L318P and D319V to suppress the constitutive activity of an R297H mutation, corresponding to the human F222P, D223V, and R201H mutations respectively. To extend these studies, the human GNAS gene was subjected to site-directed mutagenesis. Constructs expressing the MAS mutation (R201H), the MAS mutation plus the mutations homologous to the yeast suppressors (R201H, F222P/D223V), or the yeast suppressor mutation alone (F222P/D223V) were transfected into HEK293 cells, and basal and receptor-stimulated cAMP levels were measured. Expression of R201H increased the basal cAMP levels and decreased the EC(50) for hormone-stimulated cAMP production. These effects were dependent on the amount of R201H protein expressed. R201H, F222P/D223V abolished the constitutive activity of the MAS mutation and caused responses to hormone that were not different from those measured in cells expressing WT G(s)α. Interestingly, F222P/D223V behaved similar to R201H in causing increases in basal cAMP production, thus demonstrating constitutive activity. Substitution of another acidic (E) or polar (N, T, and G) amino acid at position 223 caused no suppression of R201H activity, while substitution of a second nonpolar amino acid (A) at this position partially suppressed, and the larger polar I residue completely suppressed the effects of R201H.
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Affiliation(s)
- Raquel Tobar-Rubin
- Department of Biological Science, Benedictine University, Lisle, Illinois 60532, USA
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Stathopoulos IP, Balanika AP, Baltas CS, Lampropoulou-Adamidou K, Koromila T, Kollia P, Tournis S, Papaioannou NA, Katsalira A. Fibrous dysplasia; confirmation of clinical diagnosis by DNA tests instead of biopsy. J Musculoskelet Neuronal Interact 2013; 13:120-123. [PMID: 23445922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- I P Stathopoulos
- Laboratory for the Research of the Musculoskeletal System Theodoros Garofalidis, University of Athens, KAT hospital, Athens, Greece.
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Boussaïd K, Meduri G, Maiza JC, Gennero I, Escourrou G, Bros A, Leguevaque P, Bennet A, Caron P. Virilizing sclerosing-stromal tumor of the ovary in a young woman with McCune Albright syndrome: clinical, pathological, and immunohistochemical studies. J Clin Endocrinol Metab 2013; 98:E314-20. [PMID: 23365131 DOI: 10.1210/jc.2012-3551] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
CONTEXT McCune-Albright syndrome (MAS) is characterized by polyostotic fibrous dysplasia, café-au-lait skin pigmentations, and gonadotropin-independent sexual precocious puberty, resulting from a somatic postzygotic activating mutation of the GNAS1 gene. SETTING We report a virilizing sclerosing-stromal tumor of the ovary in a young female with MAS. PATIENT She presented polyostotic fibrous dysplasia of the left upper and lower limbs and a café-au-lait skin spot in the posterior area of the neck. She had a history of precocious puberty, diagnosed at the age of 6 years and treated with cyproterone acetate until the age of 10 years; then she developed central puberty with severe oligomenorrhea. At the age of 23 years, she was hospitalized for a virilization syndrome including hirsutism, acne, deepening of the voice, amenorrhea, and clitoromegaly. Serum levels of T were dramatically increased (1293 ng/dl; normal range, 10-80). The abdominal computed tomography scan revealed a solid mass located on the left ovary. INTERVENTION An ovariectomy was performed, and histological examination revealed a sclerosing-stromal tumor with pseudolobular pattern. RESULTS Immunohistochemical studies revealed that the tumor cells expressed all steroidogenic enzymes involved in androgen synthesis. Molecular analysis revealed that ovarian tumor cells harbored the Arg 201 activating mutation in the GNAS1 gene. After surgery, T levels returned to normal, the patient retrieved a normal gonadal function, and she was able to become pregnant. CONCLUSION This observation extends the clinical spectrum of ovarian pathology of women with MAS. However, the mechanisms causing this ovarian tumor remain unclear, even if the gsp oncogene has been implicated in the pathogenesis of some gonadal tumors.
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Affiliation(s)
- Kahina Boussaïd
- Department of Endocrinology and Metabolic Diseases, Centre Hospitalier Universitaire Rangueil-Larrey, 24 Chemin de Pourvouville, TSA 30030, 31059 Toulouse Cedex 9, France
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Vortmeyer AO, Gläsker S, Mehta GU, Abu-Asab MS, Smith JH, Zhuang Z, Collins MT, Oldfield EH. Somatic GNAS mutation causes widespread and diffuse pituitary disease in acromegalic patients with McCune-Albright syndrome. J Clin Endocrinol Metab 2012; 97:2404-13. [PMID: 22564667 PMCID: PMC3791436 DOI: 10.1210/jc.2012-1274] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT McCune-Albright syndrome (MAS) is caused by sporadic mutations of the GNAS. Patients exhibit features of acromegaly. In most patients, GH-secreting pituitary adenomas have been held responsible for this presentation. However, surgical adenomectomy rarely eliminates excess GH production. OBJECTIVE The aim of this study was to elucidate pituitary pathology in patients with MAS and to explain the basis of failure of adenomectomy to eliminate GH hypersecretion. DESIGN AND SETTING We conducted a case series at the National Institutes of Health. INTERVENTION(S) Interventions included medical therapy and transsphenoidal surgery. PATIENTS AND MAIN OUTCOME MEASURES We studied clinical and imaging features and the histology and molecular features of the pituitary of four acromegalic MAS patients. RESULTS We identified widespread and diffuse pituitary gland disease. The primary pathological changes were characterized by hyperplastic and neoplastic change, associated with overrepresentation of somatotroph cells in structurally intact tissue areas. Genetic analysis of multiple microdissected samples of any type of histological area consistently revealed identical GNAS mutations in individual patients. The only patient with remission after surgery received complete hypophysectomy in addition to removal of multiple GH-secreting tumors. CONCLUSIONS These findings indicate developmental effects of GNAS mutation on the entire anterior pituitary gland. The pituitary of individual cases contains a spectrum of changes with regions of normal appearing gland, hyperplasia, and areas of fully developed adenoma formation, as well as transitional stages between these entities. The primary change underlying acromegaly in MAS patients is somatotroph hyperplasia involving the entire pituitary gland, with or without development of somatotroph adenoma. Thus, successful clinical management, whether it is medical, surgical, or via irradiation, must target the entire pituitary, not just the adenomas evident on imaging.
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Affiliation(s)
- Alexander O Vortmeyer
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892, USA
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Izzi B, Francois I, Labarque V, Thys C, Wittevrongel C, Devriendt K, Legius E, Van den Bruel A, D'Hooghe M, Lambrechts D, de Zegher F, Van Geet C, Freson K. Methylation defect in imprinted genes detected in patients with an Albright's hereditary osteodystrophy like phenotype and platelet Gs hypofunction. PLoS One 2012; 7:e38579. [PMID: 22679513 PMCID: PMC3367970 DOI: 10.1371/journal.pone.0038579] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 05/07/2012] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pseudohypoparathyroidism (PHP) indicates a group of heterogeneous disorders whose common feature is represented by impaired signaling of hormones that activate Gsalpha, encoded by the imprinted GNAS gene. PHP-Ib patients have isolated Parathormone (PTH) resistance and GNAS epigenetic defects while PHP-Ia cases present with hormone resistance and characteristic features jointly termed as Albright's Hereditary Osteodystrophy (AHO) due to maternally inherited GNAS mutations or similar epigenetic defects as found for PHP-Ib. Pseudopseudohypoparathyroidism (PPHP) patients with an AHO phenotype and no hormone resistance and progressive osseous heteroplasia (POH) cases have inactivating paternally inherited GNAS mutations. METHODOLOGY/PRINCIPAL FINDINGS We here describe 17 subjects with an AHO-like phenotype that could be compatible with having PPHP but none of them carried Gsalpha mutations. Functional platelet studies however showed an obvious Gs hypofunction in the 13 patients that were available for testing. Methylation for the three differentially methylated GNAS regions was quantified via the Sequenom EpiTYPER. Patients showed significant hypermethylation of the XL amplicon compared to controls (36 ± 3 vs. 29 ± 3%; p<0.001); a pattern that is reversed to XL hypomethylation found in PHPIb. Interestingly, XL hypermethylation was associated with reduced XLalphaS protein levels in the patients' platelets. Methylation for NESP and ExonA/B was significantly different for some but not all patients, though most patients have site-specific CpG methylation abnormalities in these amplicons. Since some AHO features are present in other imprinting disorders, the methylation of IGF2, H19, SNURF and GRB10 was quantified. Surprisingly, significant IGF2 hypermethylation (20 ± 10 vs. 14 ± 7%; p<0.05) and SNURF hypomethylation (23 ± 6 vs. 32 6%; p<0.001) was found in patients vs. controls, while H19 and GRB10 methylation was normal. CONCLUSION/SIGNIFICANCE In conclusion, this is the first report of methylation defects including GNAS in patients with an AHO-like phenotype without endocrinological abnormalities. Additional studies are still needed to correlate the methylation defect with the clinical phenotype.
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Affiliation(s)
- Benedetta Izzi
- Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
| | - Inge Francois
- Departement of Pediatrics, University of Leuven, Leuven, Belgium
| | - Veerle Labarque
- Departement of Pediatrics, University of Leuven, Leuven, Belgium
| | - Chantal Thys
- Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
| | | | - Koen Devriendt
- Center for Human Genetics, University of Leuven, Leuven, Belgium
| | - Eric Legius
- Center for Human Genetics, University of Leuven, Leuven, Belgium
| | | | | | | | | | - Chris Van Geet
- Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
- Departement of Pediatrics, University of Leuven, Leuven, Belgium
| | - Kathleen Freson
- Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
- * E-mail:
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Simşek-Kiper PO, Utine GE, Alanay Y, Aktaş D, Alikaşifoğlu M, Boduroğlu K. A rare case of 2q37 microdeletion with Albright hereditary osteodystrophy-like phenotype. Turk J Pediatr 2011; 53:558-560. [PMID: 22272459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Chromosome 2q37 microdeletion syndrome is a rare disorder characterized by mild-moderate psychomotor and growth retardation, autistic-like behavior, Albright hereditary osteodystrophy-like metacarpal/metatarsal shortening, and facial characteristics. We here report on a patient with 2q37 microdeletion presenting with learning difficulty, hyperactivity and attention deficit. Physical examination revealed psychomotor and growth retardation, facial dysmorphism and brachydactyly, suggestive of Albright hereditary osteodystrophy-like phenotype. Laboratory evaluation revealed 46, XX.ish subtel(2q)(D2S447-) confirming 2q37 microdeletion. Chromosome 2q37 microdeletion syndrome should be considered in the differential diagnosis of patients presenting with psychomotor and growth retardation and an Albright hereditary osteodystrophy-like phenotype, especially in the presence of brachydactyly, even if the characteristic facial features are missing.
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Affiliation(s)
- Pelin Ozlem Simşek-Kiper
- Pediatric Genetics Unit, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Abstract
McCune-Albright syndrome (polyostotic fibrous dysplasia, café-au-lait skin spots, and precocious puberty) is a genetically mosaic disorder with populations of mutant and normal cells in affected organs. Cushing syndrome, a rare feature of the condition, usually affects infants and is the result of corticotropin-independent primary bilateral adrenal disease, usually interpreted as nodular adrenocortical hyperplasia. In this study of 9 patients with Cushing syndrome and McCune-Albright syndrome, light microscopy revealed a characteristic bimorphic pattern of diffuse and nodular hyperplasia and a distinctive form of cortical atrophy with apparent zona glomerulosa hyperplasia in 8 patients, all very young. The pattern could be explained by the presence of a mosaic distribution of mutant and normal cells in the adrenal glands. The findings are different from those in inherited or other forms of genetically caused Cushing syndrome. The ninth patient, aged 17 years, had an adrenal adenoma and diffuse cortical hyperplasia in each adrenal gland.
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Affiliation(s)
- J Aidan Carney
- Department of Laboratory Medicine and Pathology, Division of Endocrinology, Diabetes, Nutrition and Metabolism, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Mariot V, Wu JY, Aydin C, Mantovani G, Mahon MJ, Linglart A, Bastepe M. Potent constitutive cyclic AMP-generating activity of XLαs implicates this imprinted GNAS product in the pathogenesis of McCune-Albright syndrome and fibrous dysplasia of bone. Bone 2011; 48:312-20. [PMID: 20887824 PMCID: PMC3021591 DOI: 10.1016/j.bone.2010.09.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 09/19/2010] [Accepted: 09/21/2010] [Indexed: 11/22/2022]
Abstract
Patients with McCune-Albright syndrome (MAS), characterized primarily by hyperpigmented skin lesions, precocious puberty, and fibrous dyslasia of bone, carry postzygotic heterozygous mutations of GNAS causing constitutive cAMP signaling. GNAS encodes the α-subunit of the stimulatory G protein (Gsα), as well as a large variant (XLαs) derived from the paternal allele. The mutations causing MAS affect both GNAS products, but whether XLαs, like Gsα, can be involved in the pathogenesis remains unknown. Here, we investigated biopsy samples from four previously reported and eight new patients with MAS. Activating mutations of GNAS (Arg201 with respect to the amino acid sequence of Gsα) were present in all the previously reported and five of the new cases. The mutation was detected within the paternally expressed XLαs transcript in five and the maternally expressed NESP55 transcript in four cases. Tissues carrying paternal mutations appeared to have higher XLαs mRNA levels than maternal mutations. The human XLαs mutant analogous to Gsα-R201H (XLαs-R543H) showed markedly higher basal cAMP accumulation than wild-type XLαs in transfected cells. Wild-type XLαs demonstrated higher basal and isoproterenol-induced cAMP signaling than Gsα and co-purified with Gβ1γ2 in transduced cells. XLαs mRNA was measurable in mouse calvarial cells, with its level being significantly higher in undifferentiated cells than those expressing preosteoblastic markers osterix and alkaline phosphatase. XLαs mRNA was also expressed in murine bone marrow stromal cells and preosteoblastic MC3T3-E1 cells. Our findings are consistent with the possibility that constitutive XLαs activity adds to the molecular pathogenesis of MAS and fibrous dysplasia of bone.
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Affiliation(s)
- Virginie Mariot
- INSERM; Université Paris Descartes. U561, Hôpital Saint Vincent de Paul, 75014 Paris, France
| | - Joy Y. Wu
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Cumhur Aydin
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Endodontics and Conservative Treatment, Gülhane Military Medical Academy, Ankara, TURKEY
| | - Giovanna Mantovani
- Department of Medical Sciences, Endocrinology and Diabetology Unit, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, ITALY
| | - Matthew J. Mahon
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Agnès Linglart
- INSERM; Université Paris Descartes. U561, Hôpital Saint Vincent de Paul, 75014 Paris, France
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Assistance Publique-Hôpitaux de Paris. Endocrinologie-diabétologie pédiatrique et Centre de référence des maladies rares du métabolisme du calcium et du phosphore, Hôpital St-Vincent de Paul, 75014 Paris, France
| | - Murat Bastepe
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Dworakowska D, Korbonits M, Aylwin S, McGregor A, Grossman AB. The pathology of pituitary adenomas from a clinical perspective. Front Biosci (Schol Ed) 2011; 3:105-116. [PMID: 21196361 DOI: 10.2741/s136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pituitary adenomas present with a variety of clinical endocrine manifestations and arise in a sporadic setting or rarely as part of hereditary genetic syndromes. Molecular analysis of familial pituitary adenomas has provided significant insight into pituitary tumorigenesis. Some specific genes have been identified that predispose to pituitary neoplasia, but these are rarely involved in the pathogenesis of sporadic tumors. The number of identified genes involved in pituitary tumorigenesis is progressively increasing. The possible resulting mechanisms of action involve abnormalities in signal transduction pathways, cell cycle regulators, growth factors, chromosome stability and others. Further studies are needed to evaluate the clinical significance of genetic alterations and their implications for patient prognosis, as well as to identify targets for existing and new therapeutic options. The aim of this review is to focus on the molecular pathology of pituitary adenomas from a practical perspective and discuss the possible clinical implications which may relate to particular molecular alterations. We have summarised familial syndromes related to pituitary adenomas and considered the prognostic value of selected molecular alterations in these tumors.
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Affiliation(s)
- Dorota Dworakowska
- Centre for Endocrinology, Barts and the London School of Medicine, EC1M 6BQ London, UK.
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Abstract
Evidence from in vitro studies and naturally occurring human diseases indicate that several endocrine cells, and particularly somatotrophs, recognize cAMP as a growth factor. Accordingly, mutations of the alpha subunit of the stimulatory G protein gene (GNAS) leading to the constitutive activation of adenylyl cyclase (the so-called gsp oncogene) have been found in a significant proportion of GH-secreting pituitary adenomas. GNAS maps within a complex region known to have more than one imprinted genes. Indeed, GNAS locus gives rise to several transcripts, all resulting from splicing of alternative first exons to exon 2 of the Gsalpha gene by a parent-specific methylation pattern of most of its different promoters. This complex tissue-specific imprinting control results in a near-exclusive expression of Gsalpha from the maternal allele in specific endocrine tissues, including the pituitary. Due to the monoallelic origin of Gsalpha in normal pituitary gsp mutations occur on a maternal allele in order to have a phenotypic effect in both sporadic GH-secreting adenomas and those associated with the McCune-Albright syndrome. Moreover, this imprinted expression pattern appears to be relaxed in the majority of tumors negative for gsp that show biallelic expression of Gsalpha transcript. Interestingly, the clinical phenotype of gsp negative tumors containing high levels of Gsalpha mRNA and protein is similar to that characterizing gsp positive tumors. Therefore, genetic and epigenetic alterations of the GNAS gene, with subsequent dysregulation of the cAMP pathway, appear, to date, the only molecular hallmark of most GH-secreting adenomas.
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Affiliation(s)
- G Mantovani
- Department of Medical Sciences, Endocrinology and Diabetology Unit, Università degli Studi di Milano, Fondazione Ca' Granda Ospedale Maggiore Policlinico IRCCS, Milan, Italy
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Fernandez-Rebollo E, García-Cuartero B, Garin I, Largo C, Martínez F, Garcia-Lacalle C, Castaño L, Bastepe M, Pérez de Nanclares G. Intragenic GNAS deletion involving exon A/B in pseudohypoparathyroidism type 1A resulting in an apparent loss of exon A/B methylation: potential for misdiagnosis of pseudohypoparathyroidism type 1B. J Clin Endocrinol Metab 2010; 95:765-71. [PMID: 20008020 PMCID: PMC2840867 DOI: 10.1210/jc.2009-1581] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Several endocrine diseases that share resistance to PTH are grouped under the term pseudohypoparathyroidism (PHP). Patients with PHP type Ia show additional hormone resistance, defective erythrocyte G(s)alpha activity, and dysmorphic features termed Albright's hereditary osteodystrophy (AHO). Patients with PHP-Ib show less diverse hormone resistance and normal G(s)alpha activity; AHO features are typically absent in PHP-Ib. Mutations affecting G(s)alpha coding exons of GNAS and epigenetic alterations in the same gene are associated with PHP-Ia and -Ib, respectively. The epigenetic GNAS changes in familial PHP-Ib are caused by microdeletions near or within GNAS but without involving G(s)alpha coding exons. OBJECTIVE We sought to identify the molecular defect in a patient who was diagnosed with PHP-Ia based on clinical presentation (hormone resistance and AHO) but displayed the molecular features typically associated with PHP-Ib (loss of methylation at exon A/B) without previously described genetic mutations. METHODS Microsatellite typing, comparative genome hybridization, and allelic dosage were performed for proband and her parents. RESULTS Comparative genome hybridization revealed a deletion of 30,431 bp extending from the intronic region between exons XL and A/B to intron 5. The same mutation was also demonstrated, by PCR, in the patient's mother, but polymorphism and allele dosage analyses indicated that she had this mutation in a mosaic manner. CONCLUSION We discovered a novel multiexonic GNAS deletion transmitted to our patient from her mother who is mosaic for this mutation. The deletion led to different phenotypic manifestations in the two generation and appeared, in the patient, as loss of GNAS imprinting.
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Mantovani G, de Sanctis L, Barbieri AM, Elli FM, Bollati V, Vaira V, Labarile P, Bondioni S, Peverelli E, Lania AG, Beck-Peccoz P, Spada A. Pseudohypoparathyroidism and GNAS epigenetic defects: clinical evaluation of albright hereditary osteodystrophy and molecular analysis in 40 patients. J Clin Endocrinol Metab 2010; 95:651-8. [PMID: 20061437 DOI: 10.1210/jc.2009-0176] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
CONTEXT The two main subtypes of pseudohypoparathyroidism (PHP), PHP-Ia and -Ib, are caused by mutations in GNAS exons 1-13 and methylation defects in the imprinted GNAS cluster, respectively. PHP-Ia patients show Albright hereditary osteodystrophy (AHO) and resistance toward PTH and additional hormones, whereas PHP-Ib patients do not have AHO, and hormone resistance appears to be limited to PTH and TSH. Recently, methylation defects have been detected in few patients with PHP and mild AHO, indicating a molecular overlap between the two forms. OBJECTIVES The aim of the study was to screen patients with clinically diagnosed PHP-Ia for methylation defects and to investigate the presence of correlations between the molecular findings and AHO severity. PATIENTS AND METHODS We investigated differential methylation of GNAS regions and STX16 microdeletions in genomic DNA from 40 patients with sporadic AHO and multihormone resistance, with no mutations in Gsalpha-coding GNAS exons. RESULTS Molecular analysis showed GNAS cluster imprinting defects in 24 of the 40 patients analyzed. No STX16 deletion was detected. The presence of imprinting defects was not associated with the severity of AHO or with specific AHO signs. CONCLUSIONS We report the largest series of the literature of patients with clinical AHO and multihormone resistance and no mutation in the Gsalpha gene. Our findings of frequent GNAS imprinting defects further confirm the existence of an overlap between molecular and clinical features of PHP-Ia and PHP-Ib and highlight the necessity of a new clinical classification of the disease that takes into account the recent knowledge on the molecular basis underlying these defects.
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Affiliation(s)
- Giovanna Mantovani
- Unità di Endocrinologia, Padiglione Granelli, Fondazione Ospedale Maggiore Instituto di Ricovero e Cura a Carattere Scientifico, Via Francesco Sforza, 35, 20122 Milano, Italy.
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Janusz L, Morawska J, Wasilewska E, Sierakowski S, Midro AT. [Genetic counseling in osteodystrophy Albright's syndrome. Part II. GNAS1 gene and encoded protein function, genetic forecast and treatment]. Przegl Lek 2010; 67:527-531. [PMID: 21387769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In this article we describe localization and structure of genes from GNAS1 cluster, which mutations are responsible for characteristic group of features described mainly as Albright's syndrome. We present the capabilities of expressions of different phenotypes depending on types of molecular changes and possibilities of genetic prognosis with problems need to be solved in interdisciplinary support.
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Affiliation(s)
- Leszek Janusz
- Studenckie Koło Naukowe przy Zakładzie Genetyki Klinicznej Uniwersytetu Medycznego w Białymstoku
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Vandeva S, Tichomirowa MA, Zacharieva S, Daly AF, Beckers A. Genetic factors in the development of pituitary adenomas. Endocr Dev 2010; 17:121-133. [PMID: 19955762 DOI: 10.1159/000262534] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Pituitary adenomas are one of the most frequent intracranial tumors. Usually, they are benign but are of great clinical significance because of tumor compression syndrome and hormone overproduction. The interest in this pathology is increasing, particularly after some recent reports on their prevalence that proved to be 3-5 times more than previously estimated. Pituitary tumors arise in a sporadic setting and rarely as part of hereditary genetic syndromes. Such rare hereditary conditions like MEN1, Carney complex and McCune-Albright syndrome give significant insight into pituitary tumorigenesis. Newer genes associated pituitary tumor development include CDKN1B (MEN4) and AIP, the latter of which is involved in the pathophysiology of 15% of FIPA kindreds. The number of genes involved in pituitary tumorigenesis is progressively increasing and the possible mechanisms of action include signal transduction pathways, cell cycle regulators, growth factors, chromosome instability and others. Nevertheless, in the majority of sporadic adenomas, the primary genetic defect remains unknown. Furthermore, there is not a well established relationship between the genotype and its influence on the protein expression, ligand-receptor interaction, tumor growth or hormone hyperproduction. Further studies should evaluate the clinical significance of genetic alterations and their implications for existing and new therapeutic options.
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44
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Morawska J, Janusz L, Wasilewska E, Sierakowski S, Midro AT. [Genetic counseling in osteodystrophy Albright syndrome. Part I. Phenotypic diagnosis and pedigree analysis]. Przegl Lek 2010; 67:523-526. [PMID: 21387768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In this article we describe problems of genetic counseling with features of morphological phenotype, biochemical and molecular changes observed in osteodystrophy Albright syndrome, inherited autosomal dominant condition.
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45
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Syryńska M, Szyszka L, Post M. [Familial fibrous dysplasia: a symptom of a syndrome or simply of cherubism?]. Ann Acad Med Stetin 2010; 56:74-80. [PMID: 21427816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Classified among non-neoplastic bone diseases, familial fibrous dysplasia is characterized by unilateral or bilateral change of shape and size in the facial part of the skull causing transposition of teeth. The aim of this study was to present two related patients with these symptoms who appeared for orthodontic consultation. MATERIALS AND METHODS The study was done in 2 related patients, C.A. aged 58 and her daughter aged 25, basing on the medical history, clinical and radiologic examination, and documentation supplied by the patients. RESULTS Extraoral clinical examination of the mother revealed structural anomalies of the mandible and maxilla in the form of asymmetry caused by a tumor localized in the alveolar process of the mandible predominantly on the left side, in the maxillary bone, and in other bones of the skeleton. Intraoral examination disclosed missing teeth, small and atypical teeth, diastemata, carious and noncarious lesions in the form of cuneiform defects, pathologic attrition, and alveolar swelling with an extensive tumor situated in the region of missing teeth 34 and 35. Panoramic radiographs revealed hyperdense foci and multiple cyst-like radiolucencies corresponding to fibrous dysplasia and located bilaterally in the maxilla and mandible. The daughter presented with hirsutism and acne rosacea. Her radiograms revealed lesions resembling periapical periodontitis corresponding to Noonan-like multiple giant-cell lesion syndrome and Gorlin and Ramon syndrome. DISCUSSION Adult patients with non-neoplastic fibro-osseous lesions accompanied by malocclusion and transposition of teeth often seek help of the orthodontist. The age of our patients (mother 58 years and daughter 25 years) not being typical for progressing cherubism, as well as radiologic findings and other systemic disorders suggest that the lesions may be due to an undiagnosed systemic disease in which familial fibrous dysplasia is one of the symptoms.
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Affiliation(s)
- Maria Syryńska
- Katedra i Zakład Ortodoncji Pomorskiej Akademii Medycznej w Szczecinie, al. Powstańców Wlkp. 72, 70-111 Szczecin
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Alvarez F, Kottler ML, Paul C, Gennero I, Salles JP, Mazereeuw-Hautier J. Albright hereditary osteodystrophy: report of a particular clinical phenotype caused by a novel GNAS mutation. J Eur Acad Dermatol Venereol 2009; 24:974-5. [PMID: 20015054 DOI: 10.1111/j.1468-3083.2009.03539.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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47
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Klaassens M, Blom EW, Schrander JJP, Ris-Stalpers C, Nieuwenhuijzen Kruseman AC, van Steensel MAM, Schrander-Stumpel CTRM. Unique skin changes in a case of Albright hereditary osteodystrophy caused by a rare GNAS1
mutation. Br J Dermatol 2009; 162:690-4. [PMID: 19863504 DOI: 10.1111/j.1365-2133.2009.09543.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M Klaassens
- Department of Pediatrics, Maastricht University Medical Center, AZ Maastricht, The Netherlands
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48
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Sun LH, Cui B, Zhao HY, Tao B, Wang WQ, Li XY, Ning G, Liu JM. Identification of a novel GNAS mutation for pseudohypoparathyroidism in a Chinese family. Endocrine 2009; 36:25-9. [PMID: 19381884 DOI: 10.1007/s12020-009-9193-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 03/13/2009] [Accepted: 04/02/2009] [Indexed: 01/27/2023]
Abstract
Pseudohypoparathyroidism (PHP) is a heterogeneous group of diseases characterized by hormone resistance to receptors that stimulate adenylate cyclase. PHP-Ia patients show specific Gs-alpha protein deficiency, PTH/TSH/gonadotropin resistance, and a phenotype characterized by Albright hereditary osteodystrophy (AHO). Many heterozygous mutations in the GNAS gene encoding the Gs protein have been identified in PHP-Ia. We describe two boys with hypocalcemia and elevated serum levels of PTH in a Chinese family. The 13 exons of the GNAS gene were amplified using 15 pairs of GNAS-specific primers and analyzed by direct sequencing. We found a novel frame shift mutation in exon 11 of the GNAS gene identified in both of the two boys and their mother. This report provides another example of a Gs-alpha mutation leading to PHP.
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Affiliation(s)
- Li-Hao Sun
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Rui-jin Hospital, Shanghai Jiao-tong University School of Medicine, Shanghai, 200025, China
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Peleg R, Luba A, Eliakim A, Israeli-Shani L, Manor E, Birk R, Parvari R. McCune-Albright syndrome in a discordant monozygotic twin. Isr Med Assoc J 2009; 11:343-347. [PMID: 19697584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND McCune-Albright syndrome is a sporadic disorder characterized by polystotic fibrous dysplasia, pigmented patches of skin, and endocrinological abnormalities. OBJECTIVES To compare the genetic characteristics of the GNAS1 gene in a monozygotic pair of twins, one of whom was diagnosed with MAS while the other had no indication of the syndrome. METHODS We performed a molecular analysis of the GNAS1 gene in DNA extracted from peripheral blood cells and quantification of mRNA extracted from lymphoblastoid cells from both twins by quantitative real-time polymerase chain reaction. RESULTS Monozygosity of the twins was confirmed by typing them to four highly polymorphic microsatellites. Molecular analysis of the GNAS1 gene extracted from both twins did not reveal the cause of this discordance. CONCLUSIONS It is possible that the exact molecular mechanism for the MAS discordance can only be determined by sampling affected tissues.
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Affiliation(s)
- Roni Peleg
- Department of Family Medicine, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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50
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Haase M, Willenberg HS. Adrenal cortical tumors and multiple endocrine neoplasia-related syndromes. MINERVA ENDOCRINOL 2009; 34:123-135. [PMID: 19471237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Relatively frequent, adrenal masses include a multitude of different tumor types: uni- or bilateral hyperplasias, adenomas, and the rare entity of adrenocortical carcinomas. With significant progress in our appreciation of their underlying molecular pathomechanisms and from analysis of affected individuals and their families, a number of inherited diseases and tumor syndromes have been linked to adrenocortical tumorigenesis. These syndromes and diseases include the Carney complex, the McCune-Albright syndrome, multiple endocrine neoplasia type 1, familial adenomatosis coli, congenital adrenal hyperplasia, familial forms of primary aldosteronism, the Beckwith-Wiedemann syndrome, and the Li-Fraumeni syndrome. The key to successful management of these syndromes is identification of patients harboring adrenal tumors within the context of hereditary diseases, since diagnostic procedures, therapy and follow-up may significantly differ from the management of sporadic, isolated adrenal tumors. This review explores the underlying genetic defects, diagnosis and therapy of the major heritable tumor syndromes associated with adrenocortical tumorigenesis.
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Affiliation(s)
- M Haase
- Department of Endocrinology, Diabetes and Rheumatology, University Hospital Duesseldorf, Duesseldorf, Germany
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