2478 American Cancer Society Second National Conference on Cancer Genetics Supplement to Cancer Von Hippel-Lindau Syndrome A Pleomorphic Condition Christopher A. Friedrich, M.D., Ph.D. Von Hippel-Lindau (VHL) syndrome (OMIM 193300) is an autosomal dominant disorder caused by deletions or mutations in a tumor suppressor gene mapped to Division of Medical Genetics, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. human chromosome 3p25. It is characterized clinically by vascular tumors, including retinal and central nervous system hemangioblastomas (cerebellar, spinal, and brain stem). Hemangioblastomas are benign and do not metastasize. Other features include cysts of the kidneys, liver, and pancreas. Clear cell renal cell carcinoma occurs in up to 70% of patients with VHL and is a frequent cause of death. Pheochromocytomas occur in association with specific alleles of the VHL gene; therefore, a family history of pheochromocytoma in association with VHL is an indication for thorough surveillance for pheochromocytoma in affected family members. Recently, it has been appreciated that patients with VHL may develop endolymphatic sac tumors, which can cause tinnitus or deafness. The diagnosis of VHL may be made in a patient with a family history of VHL based on a single retinal or cerebellar hemangioblastoma, renal cell carcinoma or pheochromocytoma, and, possibly, multiple pancreatic cysts. Renal and epididymal cysts are not sufficient to make the diagnosis of VHL. In the absence of a family history of VHL the presence of two or more retinal or cerebellar hemangioblastomas, or one hemangioblastoma with one visceral tumor, is required for diagnosis. Studies of the natural history of VHL showed a life expectancy less than 50 years before surveillance protocols were developed. Annual assessments (physical and ophthalmologic examinations) should begin in infancy. Imaging of abdominal organs and the brain and spine should be added in teenagers and adults. Renal cysts and tumors should be monitored by computed tomography every 6 months. Mutation analysis has allowed presymptomatic identification of affected family members; those found not to have inherited the gene do not need to be monitored. The VHL gene coding sequence contains three exons, and two isoforms of mRNA exist, reflecting the presence or absence of exon 2. Tumors arise after the loss or inactivation of the wild type allele in a cell. About 20% of patients have large germline mutations detectable by Southern blot analysis, 27% have missense mutations, and 27% have nonsense or frameshift mutations. In about 20% of VHL families no deletion or mutation can be detected. Families may be characterized by the presence (type 2; 7% to 20% of families) or absence (type 1) of pheochromocytomas. Most type 2 families have missense mutations, whereas most type 1 Presented at the American Cancer Society Second National Conference on Cancer Genetics, San Francisco, CA, June 26 –28, 1998. families are affected by deletions or premature termination mutations. Prognostic counseling regarding the lifetime risk of pheochromocytoma can be aided by determination of the underlying mutation in patients without family histories of VHL. Cancer 1999;86:2478 – 82. © 1999 American Cancer Society. Address for reprints: Christopher A. Friedrich, M.D., Ph.D., Division of Medical Genetics, Maloney 1, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104-4283. Received May 25, 1999; accepted June 3, 1999. © 1999 American Cancer Society KEYWORDS: von Hippel-Lindau syndrome, cancer genetics, presymptomatic diagnosis, molecular diagnosis, genetic counseling, medical oncology, medical genetics. Von Hippel-Lindau Syndrome/Friedrich TABLE 1 Age of Onset of Characteristic Tumors Retinal lesions Cerebellar lesions Renal cell carcinoma Mean age (yrs) (range) Percentage of patients 25 30 37 (1–67) (11–78) (16–67) 45%–59% 44%–72% 40%–70% 2479 Freiburg.4 The northwest England VHL registry found the prevalence to be 1 in 85,000 and the incidence to be 1 in 45,500.10 The life expectancy of affected individuals has been less than 50 years. The prognosis may be improved because of earlier diagnosis and the recent development of surveillance protocols emphasizing regular monitoring for predictable complications and early interventions. BACKGROUND The von Hippel-Lindau (VHL) syndrome is a rare autosomal dominant condition characterized by the development of specific tumors, both benign and malignant. It is caused by deletions or point mutations in a tumor suppressor gene. Those who inherit a mutated gene are at greatly increased risk for retinal hemangioblastoma; cerebellar hemangioblastoma; pheochromocytoma; pancreatic and renal cysts; spinal hemangioblastoma; renal cell carcinoma (RCC); hemangiomas of the adrenals, liver, and lungs; endolymphatic sac tumors; and papillary cystadenoma of the epididymis or broad ligament.1–3 Up to 50% of patients in VHL families show only one manifestation of the syndrome.4,5 Expressivity is variable among families; however, some clinical features are similar within families. Clear cell RCC has been found to occur in up to 70% of patients.5 In early studies the most common causes of death were complications of cerebellar hemangioblastoma (53%) and metastatic RCC (32%).5– 8 The retinal lesions may cause retinal detachment or hemorrhage, leading to blindness, but they usually respond to treatment with laser therapy or cryotherapy if detected early. The ages of onset of typical findings are listed in Table 1.5,9 If pheochromocytoma is present in the family it may be the initial presentation. A registry started in northwest England in 1990 has registered 83 patients.10 In that population the mean age of onset of the first sign or symptom was 26.25 years, with a mean age at diagnosis of 30.87 years. The most common initial manifestation was cerebellar hemangioblastoma (34.9%). The mean age at death was 40.9 years, and the most common cause of death was complications of cerebellar hemangioblastoma (47.7%). In this population the cumulative occurrence of cerebellar hemangioblastoma was 60.2%, that of retinal hemangioblastoma was 41%, that of RCC was 25.3%, that of spinal hemangioblastoma was 14.5%, and that of pheochromocytoma was 14.5%. Family studies have shown reduced penetrance of the expression of the gene. Three lesion-free obligate carriers were found in the northwest England registry.10 The prevalence of VHL disease has been estimated at 1 in 53,000 in East Anglia, with an incidence of 1 in 36,000;1 the prevalence was 1 in 38,951 in CLINICAL DIAGNOSIS The diagnosis of VHL may be made on clinical grounds. In a patient with a positive family history of VHL, the finding of a single retinal or cerebellar hemangioblastoma, pheochromocytoma, or RCC is sufficient to make the diagnosis.11 Some have argued that the presence of multiple pancreatic cysts is also sufficient. Renal or epididymal cysts alone are not sufficient because they occur frequently in the general population.12 If no known family history of VHL exists, two or more retinal or cerebellar hemangioblastomas or one hemangioblastoma plus one visceral tumor must be present to justify the diagnosis. New mutations are thought to account for 1% to 3% of VHL cases.13,14 Symptoms of cerebellar hemangioblastoma may include headache, vomiting, wide-based gait, slurred speech, nystagmus, labile hypertension (without pheochromocytoma), positional vertigo, and dysmetria.15 Erythrocytosis occurs in 5% to 20% of patients.16 Up to 30% of patients with cerebellar hemangioblastoma have VHL disease.5,17 Spinal hemangioblastomas are more specific for VHL disease, and about 80% are caused by VHL disease. They occur in 13% to 59% of VHL patients.5,7,18 Renal cell carcinomas may occur in renal cysts. The tumors tend to grow slowly, less than 2 cm per year, and it has been recommended they by followed with computed tomography scans every 6 months.19 When they reach 3 cm nephron-sparing surgery may preserve renal function and postpone the need for dialysis.20,21 GENE IDENTIFICATION Based on family linkage studies, the gene responsible for VHL disease was mapped to chromosome 3p25.22 Pulsed-field gel electrophoresis revealed nested constitutional deletions in three unrelated patients.23 The gene was identified by positional cloning using overlapping yeast artificial chromosomes and cosmidphage contigs.13 The gene coding sequence involves three exons containing 712 nucleotides, including 70 base pairs of 59 untranslated sequence in exon 1.3 Two mRNA 2480 CANCER Supplement December 1, 1999 / Volume 86 / Number 11 TABLE 2 Recommendations for Monitoring Patients with von Hippel-Lindau Syndrome and Family Members Age (yrs) Recommendation Infancy (birth–23 mos) 2 11 Annual examinations (physical examinations including ophthalmologic examination) Urinary catecholamines every 1–2 years Biannual MRI of brain and spine; annual ultrasound examination of abdomen; if renal cysts or tumor present, CT scans every 6 months Change annual abdominal ultrasound examination to annual CT scan If no evidence of von Hippel-Lindau syndrome, change MRI of brain and spine to every 3 to 5 years; change CT scan of abdomen to every other year 20 60 CT: computed tomography; MRI: magnetic resonance imaging. Table adapted from Choyke et al.16 isoforms exist, differing based on the presence or absence of exon 2.24 Tumors may arise after inactivation, e.g., deletion or hypermethylation, of the remaining wild-type allele in a cell (i.e., loss of heterozygosity).25–27 Although it was predicted originally that the VHL gene product (pVHL) would contain 284 amino acids,13 it was later shown that the resulting protein contained 213 amino acid residues, and the numbering scheme was updated.28,29 The apparent molecular weight of pVHL is 28 to 30 kD.28,29 The VHL gene product binds to two transcription factors, elongin B and elongin C, and its binding site is mutated frequently in VHL disease.30 –32 The normal function of this protein seems to involve inhibition of transcription elongation.30,31 Introduction of wild-type, but not mutant, VHL protein into clear cell RCC cell lines lacking functioning VHL genes suppressed their ability to form tumors in nude mouse xenograft assays, confirming that the VHL gene product functions as a tumor suppressor.29,33 CLINICAL APPLICATION OF MOLECULAR CHARACTERISTICS Mutation analysis has revealed the proportions of specific molecular changes. About 15% to 20% of patients have large germline deletions, 27% have missense mutations, 27% have nonsense or frameshift mutations, and the remainder have no deletion or mutation detected.3 The identification of a mutation in an index patient allows the identification of other mutation carriers among family members who may not yet exhibit any manifestation of disease.34 Surveillance protocols for monitoring these high-risk patients have been developed by several groups, and the recommendations of the National Institutes of Health (NIH) group are listed in Table 2.16 Those family members who did not inherit the mutation and previously had an empiric risk of 50% for being affected do not need regular monitoring. Prenatal diagnosis is possible. Genotype-phenotype correlation studies have been useful in prognostic counseling, especially as regards the risk of pheochromocytoma. Mutation analysis studies of 55 unrelated VHL kindreds showed the presence of an arg238gln mutation in five of the kindreds and that of an arg238trp mutation in four of them. Large deletions or premature truncation mutations were identified in 36 of 53 families without a history of pheochromocytoma but in only 2 of 12 families with pheochromocytoma. In 10 of 12 families with pheochromocytoma missense mutations were identified, whereas only 13 of 53 families without pheochromocytomas had missense mutations. The arg238trp and arg238gln mutations were associated with a 62% risk of pheochromocytoma.35 This was confirmed in subsequent studies. Families without a history of pheochromocytomas are labeled type 1, and families with a history of pheochromocytoma (7% to 20% of families) are designated type 2.5,36 In type 2 families renal and pancreatic cysts are rarely present. Deletions or premature termination mutations affect 56% of type 1 families, whereas 96% of type 2 families are affected by missense mutations, 43% at nucleotide 238.37 Prognostic counseling regarding pheochromocytoma may be possible based on molecular results even if the family history is negative for VHL disease. Similar results were found in a large study of 469 families from North America, Europe, and Japan.38 The authors of the study also examined additional phenotypes: families with RCC but not pheochromocytoma, those with RCC and hemangioblastoma plus pheochromocytoma, and those with pheochromocytoma alone. They identified mutations in 63% of families and found a total of 137 mutations, most occurring in one or two families. It is essential patients or family members receive genetic counseling before and after undergoing molecular testing. The physician or genetic counselor must ensure that those considering being tested are Von Hippel-Lindau Syndrome/Friedrich aware of the potential benefits and disadvantages of learning that they have a gene mutation that places them at high risk for developing tumors. This includes preparing them for common reactions that other patients and families have experienced after receiving a diagnosis, including isolation, guilt, anxiety, denial, and overprotectiveness.39 Some may be concerned about the potential effect of carrying such a gene on their ability to obtain insurance or employment. 9. 10. 11. 12. CONCLUSIONS The protein encoded by the VHL gene is unique and inhibits transcription elongation. Loss of this function allows the unregulated growth of vascular tumors in multiple tissues. Patients with tumors characteristic of VHL, e.g., retinal or cerebellar hemangioblastomas, should be evaluated formally for the possibility of VHL disease. This includes a detailed family history focused on tumors in relatives. In most patients with VHL, a deletion or significant mutation can be identified, allowing confirmation of the diagnosis. Prognosis for individual patients can be affected by mutation analysis results. Families may benefit from presymptomatic detection of affected gene carriers or the exclusion of at-risk family members by negative test results. Those who are found to carry the gene may suffer psychological and financial difficulties (e.g., insurability, employability) because of the likelihood they will develop clinical disease in the future. All patients and family members being tested for VHL gene mutations should receive genetic counseling before testing and after test results return, and they should give informed consent before being tested. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. Maher ER, Iselius L, Yates JR, Littler M, Benjamin C, Harris R, et al. Von Hippel-Lindau disease: a genetic study. 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