10th Annual Canadian Endocrine Update

April 11th, 2014

Multiple Endocrine Neoplasia Type I: Diagnosis, Management and Role of DNA Analysis

Maria Luisa Brandi University of Florence

Florence, Italy

Faculty/Presenter Disclosure

•  Faculty: Maria Luisa Brandi MD, PhD

•  Relationships with commercial interests: –  Grants/Research Support: Alexion, Amgen, Eli Lilly, Glaxo, MSD,

Novartis, NPS, Roche, Servier, Shire –  Speakers Bureau/Honoraria: NPS –  Consulting Fees: Servier, Alexion

DEFINITION

A case or a family with hormone-secreting or hormone- producing neoplasia in multiple tissue types

It encompasses several types of etiology, varying from two coincidental tumors to complex patterns of tumor types. Certain patterns of tumor types recur reproducibly among unrelated cases or among unrelated families

MULTIPLE ENDOCRINE NEOPLASIA SYNDROMES

SEVEN MULTIPLE ENDOCRINE NEOPLASIA SYNDROMES AND THEIR MAIN CHARACTERISTICS

Multiple endocrine neoplasia type 4

Parathyroid hormone, growth hormone, adrenocorticotropic hormone, adrenal non-functioning, pituitary non-functioning, islet non-secreting, gastrin

Foregut carcinoid, cervical and pancreatic neuroendocrine tumors

Lipoma

Multiple endocrine neoplasia type 2 variants

Multiple endocrine neoplasia type 1

Carney complex

McCune-Albright syndrome

Von Hippel-Lindau disease

Neurofibromatosis type 1

Islet non-secreting , pituitary non-secreting, adrenal cortex, parathyroid hormone, gastrin, insulin, prolactin, growth hormone, adrenocorticotropic hormone C-cell cancer, adrenal chromaffin, calcitonin, catecholamine, parathyroid hormone

Cortisol, thyroxine, growth hormone, prolactin, androgen or oestrogen Androgen or oestrogen, growth hormone, prolactin ,cortisol, thyroxine

Catecholamine, insulin

Duodenal carcinoid, catecholamine

Syndrome Benign tumours and/or hormonal excess

Malignant tumours and/or hormonal excess

Non-hormonal neoplasia (benign or malignant)

Foregut carcinoid, gastrin, glucagon. vasoactive intestinal polypeptide, pancreatic polypeptide

C-cell cancer, adrenal chromaffin, calcitonin, catecholamine

Thyroxine

_

Catecholamine

Angiofibroma, collagenoma, lipoma, leiomyoma, meningioma, ependymomma

Neuroma (MEN2B)

Heart myxoma, lentigine schwannoma

Fibrous dysplasia of bone, cafè-au-lait spots, sarcoma (rare) Renal-cortex cancer, haemangioblastoma, retinal angioma

Neurofibroma, cafè-au-lait spots, Lisch nodules, freckling

_

Centro TEE

Endocrine Tumors Expressed in Multiple Endocrine Neoplasia Types 1 and 2

Growth Inhibitor and Growth Promoter

TUMOR SUPPRESSOR ONCOGENE

Loss of inhibition Induces tumorigenesis Suppresses tumorigenesis

Overexpression

Diesease-causing mutations

Inactivating

Inhibits proliferation Increases apoptosis

Activating

Enhances proliferation Reduces apoptosis

Centro TEE MEN1 GENE

•  Location is on chromosome 11q13 •  Consists of 10 exons that span 9 kb and encode a 610 amino acid

protein called MENIN, that is ubiquitously expressed •  Germline mutations – over 400 different mutations of which >70%

are inactivating •  Somatic mutations – loss of heterozygosity (LOH) including 11q13

occurs in >90% of MEN1 tumours

Centro TEE MENIN INTERACTS WITH SEVERAL

PROTEINS

Nf-kB

HDAC, mSin3A

CHES RPA FANCD2

NM23

ASK

Myosin

Vimentin GFAP

MLL1/2, LEDGF b-catenin

Nuclear receptors

Pem Smad

JunD

menin

Cytoskeleton Cell cycle

DNA Repair Transcription

Tumor-suppressive or Pro-oncogenic Effects of Some Menin Interactions

Tumor-suppressive Pro-oncogenic (MEN1 and related states) MLL/p18, p27 JunD/AP1 SMAD/Runx (TGF-β/BMP) Histone modifiers Erα, VDR, PPAR-γ DNA damage response β-catenin (Wnt) IQGAP1

MLL/Hox (Mixed Lineage Leukemia) Wnt: β-catenin/Myc (Colorectal cancer) Er-α (Breast cancer) ?? (Prostate cancer) HIV promoter (SKIP, Myc, MLL)

Other

Menin Perspectives on Mechanisms of Action

•  Menin is a multifunctional protein with multiple interactions in multiple pathways and regulatory processes

•  Promiscuity raise the question of specificity

•  Target gene could help determine tumor-suppressive or pro oncogene effect from specific interactions

•  Tumor suppressive effects: loss-of-function MEN1 mutations Pro-oncogenic effects: gain-of-function MEN1 mutations?

•  Development of disease inhibition assays that target particular menin interactions should also consider the effects on menin’s other (opposing) interactions

MEN1-Related Endocrine Tumors And Their Prevalence  Parathyroid Adenomas (90%) GEP Gastrinoma (40%)

Insulinoma (10%)

Others (VIPoma, PPoma, SSoma, Glucagonoma) (2%) Non-functioning (20%)

 Anterior Pituitary Functioning: PRLoma (20%)

GH-, GH/PRL-, TSH-, ACTH-secreting, or Non-functioning (17%)

Foregut Carcinoids Thymic (2%) Bronchial (2%) Gastric (ECLoma) (10%)

 Adrenal Gland Non-functioning (20%)

MEN1-Related Non-Endocrine Tumors And Their Prevalence

Cutaneous Tumors Lipomas (30%)

Facial angiofibromas (85%)

Collagenomas (70%)

Central Nervous System Meningiomas (5%)

Ependymomas (1%)

Others Leyomiomas (10%)

Basis for a diagnosis of MEN1 in individuals

Basis for MEN1 diagnosis

CLINICAL FAMILIAL GENETIC A patient with 2 or more MEN1-associated tumours

A patient with 1 MEN1-associated tumour and a first degree relative with MEN1

An individual who has an MEN1 mutation but does not have clinical or biochemical manifestations of MEN1 i.e. a mutant gene carrier

JCEM 2001

JCEM 2012

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MEN SYNDROMES AND THEIR CHARACTERISTIC TUMORS AND ASSOCIATED GENETIC ABNORMALITIES

Type (chromosome location) Tumors (estimated penetrance) Gene, most frequently

mutated codons

MEN1 (11q13)

MEN2 (10 cen -10q11.2) MEN2A

MTC only

MEN2B (also known as MEN3)

MEN4 (12p13)

Parathyroid adenoma (90%) Enteropancreatic tumor (30-70%): gastrinoma (40%), insulinoma (10%), nonfunctioning and PPoma (20-55%), glucagonoma (<1%), VIPoma (<1%) Pituitary adenoma (30-40%): prolactinoma (20%), somatotropinoma (10%), corticotropinoma (<5%), nonfunctioning (<5%) Associated tumors: adrenal cortical tumor (40%), pheochromocytoma (<1%), bronchopulmonary NET (2%), thymic NET (2%), gastric NET (10%), lipomas (30%), angiofibromas (85%), collagenomas (70%), meningiomas (8%)

MTC (90%) Pheochromocytoma (50%) Parathyroid adenoma (20-30%) MTC (100%)

MTC (>90%) Pheochromocytoma (40-50%) Associated abnormalities (40-50%) Mucosal neuromas Marfanoid habitus Medullated corneal nerve fibers Megacolon

Parathyroid adenoma Pituitary adenoma

Reproduction organ tumors (e.g. testicular cancer, neuroendocrine cervical carcinoma) ? Adrenal + renal tumors

MEN1 83/84, 4-bp del (≈4%) 119, 3-bp del (≈3%) 209-211, 4-bp del (≈8%) 418, 3-bp del (≈4%) 514-516, del or ins (≈7%) Intron 4 ss, (≈10%)

RET 634, missense e.g. Cys → Arg (≈85%) RET 618, missense (>50%) RET 918, Met → Thr (>95%)

CDKN1B No common mutations identified to date

Adapted from: JCEM 97:2990, 2012

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SUGGESTED BIOCHEMICAL AND RADIOLOGICAL SCREENING IN INDIVIDUALS AT HIGH RISK OF DEVELOPING MEN1

Paratyroid Pancreatic NET Gastrinoma Insulinoma Other pancreatic NET Anterior pituitary Adrenal Thymic and bronchial carcinoid

8

20 5

<10

5 <10

15

Calcium, PTH Gastrin (± gastric pH) Fasting glucose, insulin Chromogranin-A; pancreatic polypeptide, glucagon, VIP Prolactin, IGF-I None unless symptoms or signs of functioning tumor and/or tumor >1 cm are identified on imaging None

None None None MRI, CT, or EUS (annually) MRI (every 3 yr) MRI or CT (annually with pancreatic imaging) CT or MRI (every 1-2 yr)

Tumor Age to

begin (yr) Biochemical test

(plasma or serum) annually Imaging test (time interval)

EUS, Endoscopic ultrasound. [Adapted from P. J. Newey and R. V. Thakker: Role of multiple endocrine neoplasia type 1 mutational analysis in clinical practice. Endocr Pract 17 (Suppl 3): 8-17, 2011 (21), with permission. © American Association of Clinical Endocrinologists. And from R. V. Thakker: Multiple endocrine neoplasia type 1 (MEN1). Translational Endocrinology and Metabolism, Vol. 2 (edited by R. P. Robertson and R. V. Thakker), The Endocrine Society, Chevy Chase, MD, 2011, pp 13-44 (5), with permission.]

Adapted from: JCEM 97:2990, 2012

GENETIC DISORDERS ASSOCIATED WITH PRIMARY HYPERPARATHYROIDISM (PHPT) AND FAMILIAL HYPERCALCEMIA

Primary Hyperparathyroidism in MEN 1 Young age of onset (20-25 yr vs. 55 yr)

Hypercalcemia usually mild (parathyroid cancer and hypercalcemic crisis very rare)

Late clinical manifestations

Greater reduction in bone mineral density

All parathyroids are affected, but with an individual extent (genetic predisposition to multiglandular disease)

Single enlarged gland

Asymmetrical hyperplasia

4 gland hyperplasia

MEN1-pHPT TREATMENT

Surgery is the elective treatment

CONTROVERSIES Whether to perform

Whether surgery should be performed

Subtotal (≤ 3.5 glands) PTX Total PTX with autotransplantation

Early stage Late stage

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MEN1-pHPT: TIMING FOR SURGERY Indications for parathyroid surgery during monitoring

From: JCEM in press

Bone Complications Are More Severe in MEN1-pHPT vs. Sporadic-pHPT

Cross-sectional observational study of 469 consecutive patients with sporadic-pHPT and 64 with MEN1-pHPT

Adapted from: JBMR 24:1404, 2009; Arch Surg 134:1119, 1999

BMD at the LS and FN in patients affected with sPHPT and MEN1-related PHPT. White and gray columns, sPHPT and MEN1 patients, respectively

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Why  Skeletal  Involvement  in                                                Hereditary  Endocrine  Tumors?  

Bone tissue is the second largest connective compartment after the skin Bone tissue is highly responsive to hormonal influence Bone phenotypes were described in congenital endocrine neoplasia syndromes Molecular biology is unraveling previously unrecognized roles for suppressive genes  

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MEN1 MEN2B

Familial Isolated Pituitary

Adenomas

Cowden Syndrome

MEN4

von Hippel Lindau

Syndrome

Menin Subserves in Bone Pleiotropic Actions  

Menin plays significant roles in osteoblast differentiation through interaction BMP-Runx2, TGFβ and JunD pathways

Menin interacts with other bone-related factors, such as Rb protein, Erα, VDR, IGF-BP2 and telomerase

IF SURGERY FAILS OR IS CONTROINDICATED?

Approved by FDA and EMA for CRF, in parathyroid cancer, in patients not operable or when PTX failed

The question is: long-term effects on proliferative tissues

Cinacalcet (AMG073)

NATURE CLINICAL PRACTICE ENDOCRINOLOGY & METABOLISM 4:351, 2008

PHASE IV, OPEN, MULTICENTRIC STUDY

Primary objectives 1.

Secondary objectives 2.

Reduction or normalization of PTH and calcemia

Reduction or maintenance of parathyroid glands’ volume

Increase of BMD and reduction of bone turnover

No effects on other endocrine gland function

Well tolerated and safe

USE OF CINACALCET IN MEN 1-pHPT

Centro TEE PITUITARY ADENOMAS MEN1

Pituitary adenomas are present in 16-65% of adult symptomatic MEN1 patients

Type of adenomas Penetrance in MEN1 patients

Prolactinomas

Non-functioning pituitary adenomas

GH + prolactin, GH secreting adenomas

ACTH secreting pituitary adenomas

TSH secreting pituitary adenomas

25%

10%

5%

2%

rare

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•  Pituitary tumors in MEN1 are not multiple or multifocal (in contrast with parathyroid or enteropancreatic tumors) with few exceptions  (Sahdev  A.  AJNR  2000)  

•  High  frequency  of  co-­‐secre=ng  tumors,  with  constant  presence  of  prolac=n  posi=ve  cells

PITUITARY ADENOMAS IN MEN1: MORPHOLOGICAL CHARACTERISTICS  

Centro TEE MEN1 VS NON-MEN1 PITUITARY TUMORS

(Data from the French-Belgian network GENEM)

•  No difference in age of presentation (38 vs 36 yr) and type of tumor (PRL-oma in 62 vs 61%)

•  Mass signs more frequent in MEN 1 pts (29 vs 14%)

•  Macroadenomas more frequent (85 vs 42%) and more invasive in MEN 1 patients

•  MEN 1 patients less responsive to medical treatments; only 42% (vs 90%) normalized PRL levels during Brc or CB therapy

Adapted from: Verges et al. JCEM 2002)

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•  Early ascertainment for MEN1 carriers

•  Surveillance for pituitary tumors in MEN1 carriers

•  Need for “modified” treatment programs for MEN1 pituitary tumors

RECOMMENDATIONS  

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•  Transphenoidal surgery is taken in account in pts with macroadenoma but it generally results in postoperative persistence of the tumor  

•  PRL- and GH-secreting adenomas are effectively

treated with CAB and SSAs respectively which are able to control secreting activity and tumor growth in most of cases  

MEN1 PITUITARY ADENOMA: TREATMENT  

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Syndromic (part of genetic syndromes) Functional (with dramatic clinical symptoms) Non functional (indolent and late diagnosis)

PANCREATIC NEUROENDOCRINE TUMORS CLASSIFICATION

Centro TEE SYNDROMIC PanNETs

•  Associated with genetic syndromes

•  Recognition allow for earlier surveillance of descendants

•  Predisposition to multifocal pancreatic neoplasms

•  The genetic basis can provide insight into the pathogenesis and the natural history of these tumors

•  Specific management

•  Syndromes: MEN1, von Hipple-Lindau, Tuberous Sclerosis, NF1

Centro TEE MEN1 - PETs

Tumor Penetrance (%) Site Malignancy (%)

Non-functioning or PP-oma 60-100 Pancreas 64-92

Gastrinoma 50 Duodenum (>80%) Pancreas 60

Insulinoma 21 Pancreas 12-20

Glucagonoma 3 Pancreas 70

VIP-oma 1 Pancreas Duodenum (10%) 40

GRF-oma <1 Pancreas 30

Somatostatinoma <1 Pancreas Duodenum/jejunum (44%)

70

FOREGUT CARCINOID

Frequently hormonally silent

Difficult to detect

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MEN1 PETs: CHARACTERISTICS

1.  Early onset for tumor expression

2. Multiplicity and puzzling tumors

3.  Cancer potential

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PETs ARE THE MOST COMMON CAUSE OF DEATH IN MEN1

(MEDIAN AGE 47 YRS.)

Doherty et al. 1998

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MEN1 – GASTRINOMAS: TYPE OF TREATMENT

•  No surgery •  Exploration if pancreatic tumors > 2,5-3 cm •  Resection of gastrinoma

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•  Increase of peptide levels (Skogseid 1991)

•  Imaged lesion > 1 cm (Wiedenmann 1998; Lowney 1998; Grama 1992; Thompson 1997; Bartsch 2001)

•  Imaged lesion > 2 cm (Triponez 2006)

•  Tumor > 3 cm or growing mass (Cadiot 1999; Mignon 1995; Norton 1999)

•  No specific size cut-off (Kouvaraki 2006)

•  Imaged lesion > 2 cm (Thakker 2012)

MEN1-PETs: SURGICAL INDICATIONS

CONCLUSIONS OF SURGICAL STRATEGY FOR GASTRINOMA IN MEN1 PATIENTS

1.  Norman Thompson’s operation is indicated for MEN1 patients with single or a few duodenal gastrinoma

2.  PPTD might be indicated for MEN1 patients with considerable numbers of duodenal gastrinoma

3.  PD may be indicated for MEN1 patients with many lymph node metastases

4.  We have to keep in mind that P-gastrinoma co-existed in 13% of MEN1 patients with D-gastrinoma

MULTIPLE FACIAL AFs •  Facial papules < 5 mm •  Reddish color •  Well-circumscribed borders

Adapted from: Zeller S, et al. J Am AcadDermatol. 2009 Aug; 61 (2): 319-22 Asgharian B, et al. J ClinEndocrinolMetab. 2004Nov: 89(11); 5328-36

MOLECULAR DIAGNOSIS CAN NOW BE INCORPORATED INTO THE MANAGEMENT OF

PATIENTS WITH THESE AUTOSOMAL DOMINANT SYNDROMES

however

VALUE OF GENETIC INFORMATION IN THE CONTEXT OF CLINICAL SCREENING AND EARLY SURGERY VARIES AMONG THESE

DISORDERS

Centro TEE USES OF GENETIC TESTING

1.  Diagnostic testing

2.  Predictive testing

3.  Carrier testing

4.  Prenatal testing

5.  Preimplantation testing

6.  Newborn screening

Clinically applicable genetic tests may be used for:

DIAGNOSTIC TESTING

•  Diagnostic testing is used to confirm or rule out a known or suspected genetic disorder in a symptomatic individual

Points to consider •  DNA testing may yield diagnostic information at a lower cost and with less

risk than other procedures •  Diagnostic testing is appropriate in symptomatic individuals of any age

•  Confirming a diagnosis may alter medical management for the individual •  Diagnostic testing of an individual may have reproductive or psychosocial

implications for other family members as well •  Establishing a diagnosis may require more than one type of genetic test

DNA testing may not always be the best way to establish a clinical diagnosis

PREDICTIVE TESTING

•  Predictive testing is offered to asymptomatic individuals with a family history of a genetic disorder

PREDICTIVE TESTING IS OF TWO TYPES

•  Pre-symptomatic (eventual development of symptoms is certain when the gene mutation is present) and predispositional (eventual development of symptoms is likely but not certain when the gene mutation is present)

CARRIER TESTING

Carrier testing is performed to identify individuals who have gene mutation for a disorder inherited in an autosomal recessive or X-linked recessive manner Carriers usually do not themselves have symptoms related to the gene mutation Carrier testing is offered to individuals who have family members with a genetic condition, family members of an identified carrier, and individuals in ethnic or racial groups known to have a higher carrier rate for a particular condition

PRENATAL TESTING

•  Prenatal testing is performed during a pregnancy to assess the health status of a fetus

•  Prenatal diagnostic tests are offered when there is an increased risk of having a child with a genetic condition due to maternal age, family history, ethnicity, or suggestive multiple marker screen of fetal ultrasound examination

•  Routine prenatal diagnostic test procedures are amniocentesis and chorionic villus sampling (CVS)

•  More specialized procedures include placental biopsy, periumbilical blood sampling (PUBS), and fetoscopy with fetal skin biopsy

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ONE DECADE FOLLOWING THE CLONING OF THE MEN1 GENE 1336 mutations and 24 polymorphisms

•  12 in the coding regions •  9 in the introns

•  3 in untranslated regions

MUTATIONS (in 1091 families) POLYMORPHISMS

•  >70% lead to truncated forms of menin •  4% are large deletions

•  Four occur frequently

•  No genotype/phenotype correlations

Useful for segregation analysis if MEN1 mutation is not found

Therefore the screening becomes time consuming, arduous and expensive

Adapted from: JCEM 92:3389, 2007; Hum Mutat 29:22, 2008

in-frame del/ins 6%

splice-site 9%

gross del 1%

missense 20%

nonsense 23%

frameshift 41%

The identification of genetic phenotypic

modifiers of the disease could in the

future facilitate the outcomes of MEN1

mutation-positive patients

Centro TEE CHARACTERISTICS OF THE MUTATED

MEN1 CASES

•  Sporadic cases: 6-10% had MEN1 mutations Familial cases: 90-94% had MEN1 mutations

•  A mutation is most likely when one typical endocrine tumor and at least one of the following is present: 1.  A first degree relative with a major endocrine tumor 2.  Age of onset less than 30 yr 3.  Multiple pancreatic tumors 4.  Parathyroid hyperplasia

Adapted from: JCEM 92:3389, 2007; Exp Clin Endocrinol Diabetes 115: 509, 2007; Hum Mutat 29:22,2008

Centro TEE CAN GENE TESTING DECREASE THE MORBIDITY

AND MORTALITY ASSOCIATED WITH MEN1?

•  Asymptomatic gene carriers will NOT be treated with prophylactic or early surgery

1.  In children by the first decade 2.  Asymptomatic gene carriers are closely followed 3.  A negative test precludes from periodic screening

•  Familial screening:

The indentification of MEN1 mutations is of help in clinical management of patients and their families and in life-planning decisions of affected patients

•  Autosomal dominant inheritance of this gene makes the gene testing important for other family members

•  Identification of gene mutation is important on life-planning •  Decisions of affected patients •  Recognition of the mutation has variable weight in the clinical

management of genetic carriers •  Negative testing precludes subjects from periodic screening •  We consider of great usefulness to inform the young patients

about the possibility to perform prenatal genetic testing

RECOMMENDATIONS OUT OF OUR EXPERIENCE

An approach to screening in MEN1

Adapted from: JCEM 97:2990, 2012

“ The development of disease manifestations that are usually associated with mutations of a particular gene, but instead are due to another aetiology”

PHENOCOPY: DEFINITION

Adapted from: Turner et al; Human Mutation, 2010

Examples: Familial MEN1 context, in which a patient with one MEN1- associated tumour does not have the familial mutation Patient with two MEN1-associated tumours, who does not have MEN1 mutation, but has involvement of another gene 5% of families attributed with MEN1 have phenocopies

Five unrelated families with a 4bp (CAGT) deletion at codons 210 and 211

PHENOTYPE GENOTYPE CORRELATION NOT OBSERVED IN THE MEN1 FAMILIES

Family

Tumours

Parathyroid Gastrinoma Insulinoma Glucagonoma Prolactinoma Carcinoid

+ + - - - +

+ - + - + -

+ + - - + -

+ + - - + -

+ + - + + -

1 2 3 4 5

Adapted from: Bassett et al, 1998 Am J Hum Genet

Clinical approach to genetic testing in a patient with PHPT

Adapted from: JCEM in press

Regional Center for Hereditary Endocrine Tumors University Hospital of Florence

Surgery Unit Inpatient Clinic

Front Line Outpatient Clinic

Day Hospital

Laboratory