Childhood adrenocortical tumors : impact on growth and development of adrenal cortex hormones exposure, the current health status of long-term survivors and familial cancer susceptibility in carriers of the "TP53" R337H mutation

Orientadores: Antônio de Azevedo Barros Filho, Raul Correa RibeiroTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: INTRODUÇÃO: a ocorrência de tumores adrenocorticais na infância, nas regiões Sul e Sudeste do Brasil, é 18 vezes mais frequente do que em outras regiões geográficas do mundo e, em cerca de 90% dos casos, os pacientes são portadores da mutação hereditária R337H do gene TP53, que predispõe ao câncer familiar. OBJETIVOS: avaliar o comportamento clínico, o impacto da exposição hormonal no crescimento e desenvolvimento, a sobrevida e os aspectos da predisposição familiar ao câncer associada à mutação do TP53 R337H dos parentes de crianças e adolescentes tratados com tumores adrenocorticais e portadores da mutação. PACIENTES E MÉTODOS: foram elegíveis 103 pacientes tratados com tumor do córtex da adrenal (TCA) no Centro Infantil Boldrini. O estudo foi descritivo, analítico e ambispectivo. Os dados demográficos, cirúrgicos e histopatológicos foram obtidos pelos prontuários médicos; os aspectos clínicos, o crescimento, o desenvolvimento e a história familiar de câncer foram reavaliados periodicamente. As análises estatísticas descritivas e de associação entre as variáveis, entre TCA, mutação, câncer e sobrevida foram realizadas e o nível de significância foi de 5% (programa SAS v.9.4). RESULTADOS: 69 pacientes do sexo feminino e 34 masculinos, idade mediana, 26 (4¿259) meses; tempo de história, 4 (0,3-36) meses; 90,8% eram portadores da mutação; apresentação clínica: 75 (72,8%) secretores de andrógenos (virilização); 3 (2,9%) secretores de cortisol (síndrome de Cushing); 18 (17,5%) secretores de andrógenos e cortisol e 7 (6,8%) não secretores (assintomático); estádio da doença: I (n=47); II (n=28); III (n=20) IV (n=8). Houve correlação entre os sintomas endócrinos, a idade e o estadiamento (P=0,01); e entre o volume do tumor (> ou = 200 cm³) e os estádios avançados (III e IV), (P<0,0001). Na avaliação do crescimento, não houve diferença significativa para a média e mediana do peso (P=0,22), altura (P=0,28) e do índice de massa corpórea (P=0,27) entre os sexos; análise do escore-Z ficou acima da média para altura e virilização, índice de massa corpórea e secreção de cortisol (P=0,02); a sobrevida global foi de 76,7% (EP±4,2%). Houve diferença estatística para sobrevida e estádio: I (95,7%); II (75%); III (55%) e IV (25%) (P<0,001). De 69 sobreviventes, 25 (36%) apresentaram pelo menos um efeito tardio. Para o tempo de seguimento de 9,7 (3-32) anos, 10 (18,2%) de 55 genitores carreadores da mutação R337H foram diagnosticados com câncer e nenhum caso foi observado entre os não carreadores. Ocorreram 249 neoplasias em 1410 indivíduos na linhagem parental segregante da mutação e 66/984 na não segregante (P<0,0001); as famílias do estudo apresentaram maior incidência de tumores do trato gastrointestinal e baixa ocorrência de sarcomas, características que diferem das síndromes clássicas de susceptibilidade ao câncer. CONCLUSÃO: o TCA na infância está associado à mutação TP53 R337H e à história familiar de câncer. Os sinais e sintomas favorecem a detecção precoce nas consultas de puericultura. O diagnóstico de uma criança com TCA sinaliza para o estudo da mutação, orientação genética, vigilância e intervenções preventivas de câncer no paciente e nos familiaresAbstract: INTRODUCTION: the incidence of the adrenocortical tumor (ACT) in children is 18 fold higher in southeastern and southern regions of Brazil than in other regions of the world. More than 90% of children with ACT in this geographic region carry a TP53 R337H mutation. OBJECTIVES: to evaluate the clinical and biological characteristics of pediatric ACT and the impact on growth and development of early exposure to steroid hormones in these children and describe the incidence, age of onset and types of tumors in relatives of children with ACT. PATIENTS AND METHODS: in this ambiespective study, clinical, epidemiological, family history of cancer and outcome of 103 children with ACT managed at the Boldrini Medical Center were analyzed. Demographic, histopathologic, clinical and treatment data were obtained from medical records. The family history of cancer (pedigrees) and growth and development charts were updated yearly. Descriptive and analytic statistics were performed using SAS v.9.4. The level of significance was 5% considered in all analyses. RESULTS: the median age of the 69 girls and 34 boys was 24 months (4-259). The median interval time between signs and symptoms was 4 months (0.3-36). The TP53 R337H mutation was present in 90.8% of the tested children. Virilization was noted in 75 (72.8%), Cushing syndrome in 3 (2.9%), mixed (cortisol and androgen) in 18 (17.5%) and 7 (6.8%) did not have clinical evidence of endocrine abnormalities. Disease stage I in 47 children, II in 28, III in 20 and IV in 8. Virilization was strongly associated with young age and limited-stage disease (P=0.01), whereas advanced-stage disease was associated with heavy tumors (P=0.001). There was no significative difference in the median weight and height, and body mass index (BMI) at diagnosis between boys and girls. The Z-score above the median value for height was significantly associated with virilization (P=0,03), and the BMI above the median value with elevated cortisol (P=0.02). The overall survival was 76.7% (EP±4.2%). There was a significant association between survival and disease stage 95.7% in stage I, 75% in stage II, 55% in stage III and 25% in stage IV (P=0.001). At a median time of 9.7 years (3-32), 10 of 55 parents (18.2%) carrying the R337H mutation developed cancer, whereas none of 55 parents without the mutation. In lineages segregating the mutation, 249 of 1410 individuals developed cancer while 66/984 in the non-segregating lineages (P<0.0001). Among the relatives of children with ACT, breast and gastrointestinal cancers were the most common. Sarcomas were very rare, in contrast with findings in the Li-Fraumeni syndrome. CONCLUSIONS: in families of children with ACT carrying the TP53 R337H mutation, relatives in lineages segregating this mutation are at high risk of developing cancer. The diagnosis of a child with ACT in southern Brazil is an indication to perform genetic counseling followed by genetic testing for the mutation and surveillance for presymptomatic carriers. Because signs and symptoms of virilization appear early in the course of ACT, the general pediatrician should refer these children to a pediatric oncology center promptlyDoutoradoPediatriaDoutora em Ciência

Association of the germline TP53 R337H mutation with breast cancer in southern Brazil

<p>Abstract</p> <p>Background</p> <p>The germline <it>TP53</it>-R337H mutation is strongly associated with pediatric adrenocortical tumors (ACT) in southern Brazil; it has low penetrance and limited tissue specificity in most families and therefore is not associated with Li-Fraumeni syndrome. However, other tumor types, mainly breast cancer, have been observed in carriers of several unrelated kindreds, raising the possibility that the R337H mutation may also contribute to breast tumorigenesis in a genetic background-specific context.</p> <p>Methods</p> <p>We conducted a case-control study to determine the prevalence of the R337H mutation by sequencing <it>TP</it>53 exon 10 in 123 women with breast cancer and 223 age- and sex-matched control subjects from southern Brazil. Fisher's test was used to compare the prevalence of the R337H.</p> <p>Results</p> <p>The R337H mutation was found in three patients but in none of the controls (p = 0.0442). Among the carriers, two had familial history of cancer meeting the Li-Fraumeni-like criteria. Remarkably, tumors in each of these three cases underwent loss of heterozygosity by eliminating the mutant <it>TP53 </it>allele rather than the wild-type allele. Polymorphisms were identified within the <it>TP53 </it>(R72P and Ins16) and <it>MDM2 </it>(SNP309) genes that may further diminish <it>TP53 </it>tumor suppressor activity.</p> <p>Conclusion</p> <p>These results demonstrate that the R337H mutation can significantly increase the risk of breast cancer in carriers, which likely depends on additional cooperating genetic factors. These findings are also important for understanding how low-penetrant mutant <it>TP53 </it>alleles can differentially influence tumor susceptibility.</p

Crescimento compensatorio e ganho ponderal de crianças no primeiro ano apos o termino da terapia de leucenia linfoide aguda

Orientador: Antonio de Azevedo Barros FilhoDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias medicasResumo: INTRODUÇÃO: Apesar do sucesso terapêutico, o tratamento da leucemia linfóide aguda (LLA) na infância é seguido de efeitos deletérios, entre eles retardo no crescimento com prejuízo da estatura final e alta freqüência de sobrepeso e obesidade, prejudicando a qualidade de vida dos jovens e adultos sobreviventes. OBJETIVO: Estudar o crescimento linear, a velocidade de crescimento e a massa corpórea de crianças portadoras de LLA, em remissão clínica completa, no primeiro ano após o término da terapia, comparando-se três modalidades de profilaxia da infiltração leucêmica no sistema nervoso central, nas diferentes faixas etárias e sexo. METODOLOGIA: Foram analisados 311 sobreviventes a longo prazo, submetidos ao tratamento de LLA na infância, e divididos conforme a terapia profilática de infiltração meníngea instituída: Grupo I: 24Gy (n=155), Grupo II: 18Gy (n=71) e Grupo III: sem radioterapia craniana (n=85). Foram considerados idade, peso e altura ao diagnóstico, ao término da terapia e um ano após o término e calculados o escore z para altura e velocidade de crescimento e o índice relativo de massa corpórea (BMI-r) nas três ocasiões. RESULTADOS: Independente da terapia instituída, 92,1% das crianças apresentaram retardo no crescimento, sendo mais acentuada naquelas do Grupo I. A média das diferenças entre os escores z da altura ao término da terapia em relação aos do diagnóstico nos grupos I, II e III foram, respectivamente de -0,79± 0,57; -0,72± 0,68 e de -0,63± 0,55. Um ano após o término houve crescimento compensatório (p<0,001), porém sem atingir o canal de crescimento inicial. As médias das diferenças entre os escores z para altura um ano após o término e ao término da terapia, foram respectivamente de 0,08+ 0,40; 0,11± 0,32 e 0,21± 0,5 para os grupos I, II e EL Não houve diferença estatística entre os sexos, porém crianças com idade inferior a cinco anos apresentaram velocidade de crescimento inferior às maiores durante a terapia e maior recuperação após a suspensão (p=0,001). Houve elevação progressiva da massa corpórea sendo que, ao diagnóstico 88% das crianças apresentavam peso normal ou abaixo da média para a mesma idade e sexo e um ano após o término, 40% estavam com sobrepeso ou obesos. CONCLUSÕES: Independente da terapia utilizada, as crianças apresentaram retardo de crescimento durante o tratamento. A maioria apresentou recuperação estatural, porém sem alcançar os níveis iniciais. Ao término do tratamento e um ano após observou-se elevado ganho ponderal na maioria das crianças, independente da terapia, idade e sexo. Muitos dos fatores determinantes dos efeitos tardios do tratamento sobre o crescimento linear e ponderal não estão ainda esclarecidos, sendo importante a monitorização auxológica durante e após o término da terapia.Abstract: INTRODUCTION: In spite of the therapeutic success, the treatment of Acute Lymphoblastic Leukemia during childhood is followed by late effects, like growth retardation with jeopardized final height and excessive weight gain with increased frequency of obesity which can potentially impair the quality of survivors. OBJECTIVE: The goal of this study was to evaluate the impact of therapy on linear growth, velocity of growth, and body mass in children cured of Acute Lymphoblastic Leukemia. Three modalities of central nervous system treatment were compared. Variables were analyzed during the first year of treatment and after the end of treatment. METHODS: Growth data of 311 children who were long term survivors of ALL, treated between 1967 and 1983, were analyzed. Children were divided in three groups according to the prophylactic therapy used for meningeal infiltration: Group I: 24Gy (n=155), Group II: 18Gy (n=71), and Group III: no intracranial irradiation (n=85). The following variables were analyzed at the time of diagnosis, at the end of therapy, and one year after treatment: height, weight, body mass index, growth velocity, and calculated height standard deviation score (SDS). These variables were analyzed according to age, gender, and treatment group. RESULTS: Overall, 92.1% of the children presented growth retardation during therapy. One year after the end of treatment, this retardation was partially abolished, with children in Groups II and HI faring better than Group I, with no differences between boys and girls. However, children under the age of five had a slower growth rate than those older than five, regardless of treatment group. The change in height SDS between the end of treatment and the time of diagnosis was -0.79±0.57, -0.72±0.68, and -0.63±0.55 in Groups I, n, and EI, respectively. When compared to the end of treatment, the change in height SDS one year after treatment was 0.08±0.40, 0.11±0.32, and 0.21 ±0.5 in the same groups. Analysis of body mass index revealed excess weight gain during and after treatment in both boys and girls regardless of treatment group. At the time of diagnosis, 66.6% of the children had normal weight, but one year after treatment 46.9% were overweight and 20.2% obese. CONCLUSIONS: Independently of the employed therapy, children treated for ALL had growth retardation during treatment, and almost all had unsatisfactory stature recovery and did not reach the expected height for their age. Stature loss and the rate of recovery was worst in Group I (24Gy), and similarly better in Groups II (18Gy) and HI (no intracranial radiation). Young adults treated for leukemia during childhood are prone to short stature, overweight, and obesity. Auxological attention should be given to the survivors for early detection of untoward late effect so as to prevent them and to rehabilitate these patients and so to improve the quality of life of these survivors.MestradoPediatriaMestre em Saude da Criança e do Adolescent

A unique case of synchronous functional adrenocortical adenoma and myelolipoma within the ectopic adrenal cortex in a child with beckwith–wiedemann syndrome

We report a unique case of synchronous functional adrenocortical adenoma and an incidental myelolipoma within ectopic cortical adrenal tissue located in the renal hilum in a child with Beckwith–Wiedemann syndrome and review the association between adrenal gland disorders and myelolipomas. To the best of our knowledge, this is the first documented case of a simultaneous occurrence of these three conditions. A 17-month-old child with Beckwith–Wiedemann syndrome was diagnosed with a left adrenal tumor during complementary radiologic studies. Biochemical investigation before surgery showed elevated blood levels of cortisol and dehydroepiandrosterone hormones. The patient underwent a left adrenalectomy with ipsilateral renal hilar and intercaval-aortic lymph node dissection. Pathology findings revealed a left adrenocortical adenoma and an incidental myelolipoma growing within ectopic cortical adrenal tissue in the renal hilum. The patient is doing well and does not have any current health issues. Patients with adrenal cortex disorders, such as hyperplasias and neoplasms, particularly when associated with hormonal imbalances, may have an increased risk of developing myelolipomas. Whether Beckwith–Wiedemann syndrome may, by itself, contribute to simultaneous occurrence of adrenocortical adenomas and myelolipomas remains to be clarified208318919

TP53 p.Arg337His geographic distribution correlates with adrenocortical tumor occurrence

Abstract Background The p.Arg337His mutation of the TP53 is the most frequent germline missense variant associated with cancer described so far in this gene. It is mainly found in the South and Southeastern regions of Brazil, where it has been associated with a high incidence of pediatric adrenocortical (ACT) and choroid plexus tumors. The frequency and geographic distribution of this mutation is largely unknown, except for the Parana State, where a mean prevalence of 0.27% was reported. In the present study, we developed a high‐throughput method for p.Arg337His genotyping, what allowed us to determine the frequency and geographic distribution of this mutation in a cohort from the most populous state in Brazil. Methods Consecutive samples from 31,612 newborns from São Paulo State were screened for p.Arg337His. The allelic discrimination was done by real‐time polymerase chain reaction (PCR) and the presence of haplotype A3 in carriers was examined by using allele‐specific oligonucleotide PCR, followed by nested‐PCR to detect the SNP rs9894946. Results We found 67 (0.21%) samples positive for this mutation. The highest p.Arg337His frequencies were found in the cities close to the boundary between São Paulo and Minas Gerais State. No association could be found between p.Arg337His and gender, ethnicity, premature birth or twinning. Remarkably, a trend was found between the geographic distribution of p.Arg337His carriers and occurrence of ACT. Conclusion We presented for the first time the p.Arg337His frequency among individuals unselected for any disease from a subset of the São Paulo State, the most populous in Brazil. The allele discrimination assay we presented here has proven to be a reliable and efficient method for high‐throughput genotyping. ACT was found to be a good sentinel cancer to suppose p.Arg337His presence in our region

Occurrence of Neuroblastoma among <i>TP53</i> p.R337H Carriers

<div><p>The high incidence of adrenocortical tumors and choroid plexus carcinoma in children from South and Southeastern regions of Brazil is associated with the germline p.R337H mutation of <i>TP53</i> gene. The concomitant occurrence of neuroblastoma and adrenocortical tumors in pediatric patients harboring the p.R337H mutation at our institution prompted us to investigate the putative association between p.R337H and pediatric neuroblastoma. Genomic DNA samples from 83 neuroblastoma patients referred to a single institution during the period of 2000–2014 were screened for the p.R337H mutation. Available samples from carriers were investigated for both nuclear p53 accumulation and loss of heterozigosity in tumor. Clinical data were obtained from medical records in order to assess the impact of 337H allele on manifestation of the disease. Seven out 83 neuroblastoma patients (8.4%) were carriers of the <i>TP53</i> p.R337H mutation in our cohort. Immunohistochemical analysis of p.R337H-positive tumors revealed nuclear p53 accumulation. Loss of heterozigosity was not found among available samples. The presence of 337H allele was associated with increased proportion of stage I tumors. Our data indicate that in addition to adrenocortical tumors, choroid plexus carcinoma, breast cancer and osteosarcoma, genetic counseling and clinical surveillance should consider neuroblastoma as a potential neoplasia affecting p.R337H carriers.</p></div

Cancer family history of the 83 neuroblastoma patients according to p.R337H status.

<p>^a Presence of at least one member of the family with cancer, without criteria for a cancer predisposition syndrome though.</p><p>Cancer family history of the 83 neuroblastoma patients according to p.R337H status.</p

Immunohistochemical p53 staining on p.R337H positive NB tumors.

<p>A, B) Representative images of nuclear p53 accumulation on neuroblastoma cells from patients 3 and 7, respectively (100x magnification).</p

Literature review on <i>TP53</i> mutations in association with neuroblastoma.

<p>NB–neuroblastoma; LFS–Li-Fraumeni Syndrome</p><p>^a in two cases NB were concomitant with ACT</p><p>^b of these 461 carriers, 11 developed adrenocortical tumors, 2 choroid plexus tumors, 1 glioblastoma multiforme, 1 Burkitt lymphoma and 1 neuroblastoma</p><p>^c All 148 cancer cases were diagnosed in carriers of <i>TP53</i> germline mutations</p><p>^d There is no information on the total number of individuals (carriers) analyzed.</p><p>Literature review on <i>TP53</i> mutations in association with neuroblastoma.</p

Characteristics of p.R337H positive patients.

<p>NB–Neuroblastoma; ACT–adrenocortical tumor; NA–material not available for analysis; IHC–immunohistochemistry; DBD–DNA-binding domain. Immunohistochemistry was scored as 0 (no cells positive), + (up to 25% of cells positive), ++ (26% to 50% of cells positive), +++ (51% to 75% of cells positive), or ++++ (>75% of cells positive).</p><p>^a Only the mutant allele was found in this tumor. It was not possible to distinguish between homozygosity or loss of heterozygosity with retention of the mutated allele in the tumor.</p><p>Characteristics of p.R337H positive patients.</p