Fabiano Sandrini

An inherited p53 mutation that contributes in a tissue-specific manner to pediatric adrenal cortical carcinoma

The incidence of pediatric adrenal cortical carcinoma (ACC) in southern Brazil is 10–15 times higher than that of pediatric ACC worldwide. Because childhood ACC is associated with Li-Fraumeni syndrome, we examined the cancer history and p53 status of 36 Brazilian patients and their families. Remarkably, 35 of 36 patients had an identical germ-line point mutation of p53 encoding an R337H amino acid substitution. Differences within intragenic polymorphic markers demonstrated that at least some mutant alleles arose independently, thus eliminating a founder effect. In tumor cells, the wild-type allele was deleted, and mutant p53 protein accumulated within the nuclei. Although these features are consistent with Li-Fraumeni syndrome-associated adrenal tumors, there was no history of increased cancer incidence among family members. Therefore, this inherited R337H p53 mutation represents a low-penetrance p53 allele that contributes in a tissue-specific manner to the development of pediatric ACC.

Penetrance of adrenocortical tumours associated with the germline TP53 R337H mutation

Background: An inherited germline P53 mutation has been identified in cases of childhood adrenocortical carcinoma (ACT), a neoplasm with a high incidence in southern Brazil. The penetrance of ACT in carriers of the point mutation, which encodes an arginine-to-histidine substitution at codon 337 of TP53 (R337H), has not been determined. Objective: To investigate the penetrance of childhood ACT in carriers of the R337H TP53 mutation. Methods: The family histories of 30 kindreds of 41 southern Brazilian children with ACT were obtained. A PCR based assay was used to detect this P53 mutation in a large number of relatives of children with ACT. In all, 927 individuals were tested for the mutation, 232 from the non-carrier and 695 (including the 40 probands) from the carrier parental lines. Results: 40 children with ACT carried the TP53 R337H mutation; the remaining child with ACT was not tested. There was no evidence of Li-Fraumeni syndrome in any of the kindreds; however, seven met the criteria for Li-Fraumeni-like syndrome. The carrier parental line was identified in each kindred. Of the 695 individuals tested in the carrier parental line, 240 (34.5%) were positive for the mutation, while none of the 232 individuals in the other parental line carried the mutation. The penetrance of ACT was 9.9% (95% confidence interval, 8.7% to 11.1%). Conclusions: The TP53 R337H mutation dramatically increases predisposition to childhood ACT but not to other cancers, and explains the increased frequency of ACT observed in this geographic region.

Adrenocortical tumors in children

Childhood adrenocortical tumors (ACT) are rare. In the USA, only about 25 new cases occur each year. In Southern Brazil, however, approximately 10 times that many cases are diagnosed each year. Most cases occur in the contiguous states of São Paulo and Paraná. The cause of this higher rate has not been identified. Familial genetic predisposition to cancer (p53 mutations) and selected genetic syndromes (Beckwith-Wiedemann syndrome) have been associated with childhood ACT in general but not with the Brazilian counterpart. Most of the affected children are young girls with classic endocrine syndromes (virilizing and/or Cushing). Levels of urinary 17-ketosteroids and plasma dehydroepiandrosterone sulfate (DHEA-S), which are abnormal in approximately 90% of the cases, provide the pivotal clue to a diagnosis of ACT. Typical imaging findings of pediatric ACT consist of a large, well-defined suprarenal tumor containing calcifications with a thin capsule and central necrosis or hemorrhage. The pathologic classification of pediatric ACT is troublesome. Even an experienced pathologist can find it difficult to differentiate carcinoma from adenoma. Surgery is the single most important procedure in the successful treatment of ACT. The role of chemotherapy in the management of childhood ACT has not been established although occasional tumors are responsive to mitotane or cisplatin-containing regimens. Because of the heterogeneity and rarity of the disease, prognostic factors have been difficult to establish in pediatric ACT. Patients with incomplete tumor resection or with metastatic disease at diagnosis have a dismal prognosis. In patients with localized and completely resected tumors, the size of the tumor has predictive value. Patients with large tumors have a much higher relapse rate than those with small tumors.

Fatores de risco no desenvolvimento da aterosclerose na infância e adolescência

Cardiovascular diseases (CVD) are a major cause of death in developed countries as well as in developing countries. In general, the clinical manifestations of CVD, such as myocardial infarction, stroke and peripheral vascular disease, are caused by an atherosclerotic process with onset as from the middle age. However, current studies indicate that the atherosclerotic process starts to develop in childhood. The pathogenesis of atherosclerosis has been studied as to its inflammatory aspect. Among the inflammatory markers, C-reactive protein (CRP) has been extensively studied in individuals with CVD, including those apparently healthy. High CRP levels have been related to risk factors for atherosclerosis: family history of coronary artery disease (CAD), dyslipidemia, hypertension, diabetes mellitus, obesity, smoking and sedentary lifestyle. A great part of these risk factors may be influenced by lifestyle modifications, such as changes in eating habits and engagement in physical activities. The effects of physical activity on CRP levels in adulthood are documented in the literature, however little is known on the influence of an active or sedentary lifestyle of children and adolescents on CRP levels. Thus, the objective of this study is to review the impact of physical activity of children and adolescents on CRP levels and the risk factors for the development of CVD.

Clinical and molecular genetics of Carney complex

Carney complex (CNC) is a multiple endocrine neoplasia (MEN) syndrome characterized by lentigines, cardiac myxomas and tumors, including primary pigmented adrenocortical disease (PPNAD). In the present report we review the main clinical manifestations of this disorder. We also discuss some of the newest molecular information regarding CNC. The complex has been mapped to 2p16 and 17q22-24, and a third locus appears likely. The gene coding for the protein kinase A (PKA) type I-a regulatory subunit (RIa), PRKAR1A, had been mapped to 17q. Cloning of the PRKAR1A genomic structure and its sequencing showed mutations in CNC patients. So far, among 57 kindreds, PRKAR1A mutations have been found in 28. In almost all the mutations, the sequence change is predicted to lead to a premature stop codon; 1 mutation altered the initiator ATG codon. Analysis of mRNA transcripts in patient lymphocytes treated with cycloheximide showed that mutant mRNAs containing a premature stop codon were degraded, due to nonsense-mediated mRNA decay--the predicted mtPRKAR1A protein products were absent in these cells. In CNC tumors, PKA activity showed increased stimulation by cAMP, whereas PKA activity ratio was decreased. To date, mutations in the PRKAR1A gene have been described in CNC patients and in some sporadic endocrine tumors. LOH of the normal allele and increased PKA activity in response to cAMP are found in these tumors, suggesting that normal PRKAR1A (largely responsible for PKA type I activity) is implicated more widely in endocrine tumorigenesis. CNC is the first human disease caused by mutations of one of the subunits of the PKA holoenzyme, a critical component of numerous cellular signaling systems.

Molecular cloning, chromosomal localization of human peripheral-type benzodiazepine receptor and PKA regulatory subunit type 1A (PRKAR1A)-associated protein PAP7, and studies in PRKAR1A mutant cells and tissues

A mouse protein that interacts with the peripheral‐type benzodiazepine receptor (PBR) and cAMP‐dependent protein kinase A (PKA) regulatory subunit RIα (PRKAR1A), named PBR and PKA‐associated protein 7 (PAP7), was identified and shown to be involved in hormone‐induced steroid biosynthesis. We report the identification of the human PAP7 gene, its expression pattern, genomic structure, and chromosomal mapping to 1q32–1q41. Human PAP7 is a 60‐kDa protein highly homologous to the rodent protein. PAP7 is widely present in human tissues and highly expressed in seminal vesicles, pituitary, thyroid, pancreas, renal cortex, enteric epithelium, muscles, myocardium and in steroidogenic tissues, including the gonads and adrenal cortex. These tissues are also targets of Carney complex (CNC), a multiple neoplasia syndrome caused by germline inactivating PRKAR1A mutations (PRKAR1A‐mut) and associated with primary pigmented nodular adrenocortical disease (PPNAD) and increased steroid synthesis. PAP7 and PRKAR1A expression were studied in PPNAD and in lymphoblasts from patients bearing PRKARlA‐mut. Like PRKAR1A, PAP7 was decreased in CNC lymphocytes and PPNAD nodules, but not in the surrounding cortex. These studies showed that, like in the mouse, human PAP7 is highly expressed in steroidogenic tissues, where it follows the pattern of PRKAR1A expression, suggesting that it participates in PRKAR1A‐mediated tumorigenesis and hypercortisolism.

Tumores do córtex adrenal na infância

Adrenocortical tumors (ACT) in children are uncommon. However, the incidence of these tumors in Parana, Brazil, is 15 times higher than that worldwide. We describe the clinical, laboratory and treatment characteristics and outcome of 125 patients treated in a single institution in the State of Parana. The median age at diagnosis was 4.3 years, with a female:male ratio of 2.6:1. The most common forms of presentation were isolated virilization (51.2%) and virilization and Cushings syndrome (42%). Nonfunctioning tumors comprised 4.8% of the cases. Two patients (1.6%) had isolated Cushings syndrome and 1 (0.8%) had Conns syndrome. Fifty-six percent presented hypertension. Surgery is the only curative treatment. Our data show that disease stage 1, absence of spillage during surgery and absence of intravenous thrombus were associated with better survival rates.

Childhood adrenocortical tumours: a review.

Childhood adrenocortical tumour (ACT) is not a common disease, but in southern Brazil the prevalence is 15 times higher than in other parts of the world. One hundred and thirty-seven patients have been identified and followed by our group over the past four decades. Affected children are predominantly girls, with a female-to-male ratio of 3.5:1 in patients below 4 years of age. Virilization alone (51.6%) or mixed with Cushings syndrome (42.0%) was the predominant clinical picture observed in these patients. Tumours are unilateral, affecting both glands equally. TP53 R337H germline mutations underlie most childhood ACTs in southern Brazil. Epidemiological data from our casuistic studies revealed that this mutation has ~10% penetrance for ACT. Surgery is the definitive treatment, and a complete resection should always be attempted. Although adjuvant chemotherapy has shown some encouraging results, its influence on overall outcome is small. The survival rate is directly correlated to tumour size; patients with small, completely excised tumours have survival rates close to 90%, whereas in those patients with inoperable tumours and/or metastatic disease it is less than 10%. In the group of patients with large, excisable tumours, half of them have an intermediate outcome. Recent molecular biology techniques and genomic approaches may help us to better understand the pathogenesis of ACT, the risk of developing a tumour when TP53 R337H is present, and to predict its outcome. An ongoing pilot study consisting of close monitoring of healthy carriers of the TP53 R337H mutation - siblings and first-degree relatives of known affected cases - aims at the early detection of ACTs and an improvement of the cure rate.

Clinical and molecular genetics of primary pigmented nodular adrenocortical disease

Carney complex (CNC) is a multiple endocrine neoplasia (MEN) syndrome associated with other, non-endocrine manifestations such as lentigines, cardiac myxomas and schwannomas. Primary pigmented nodular adrenocortical disease (PPNAD), leading to corticotrophin-independent Cushings syndrome is the most frequent endocrine lesion in CNC. The complex has been mapped to 2p16 and 17q22-24, although additional heterogeneity may exist. The gene coding for the protein kinase A (PKA) type I-a regulatory subunit (RIa), PRKAR1A, had been mapped to 17q. Cloning of the PRKAR1A genomic structure and its sequencing showed mutations in CNC-, CNC with PPNAD- and sporadic PPNAD-patients. In CNC tumors, PKA activity showed increased stimulation by cAMP, whereas PKA activity ratio was decreased, and in CNC tumors, there is LOH of the normal allele, suggesting that normal PRKAR1A may be a tumor suppressor in these tissues. CNC is the first human disease caused by mutations of one of the subunits of the PKA enzyme, a critical component of the cAMP signaling system and a potential participant in many other signaling pathways.