EJE
Carney complex predisposes to breast cancer: prospective study of 50 women
Patricia Vaduva,10 Florian Violon,1 Anne Jouinot, 1,2 Lucas Bouys, 1,2 Stephanie Espiard,3D Fideline Bonnet-Serrano, 40 Marie Odile North,5 Catherine Cardot-Bauters,3 Gerald Raverot, 6[D Sylvie Hieronimus,7 Herve Lefebvre,8 Marie-Laure Nunes,9 Antoine Tabarin,9[D Lionel Groussin, 1,2 Guillaume Assie, 1,2D Mathilde Sibony,1º Marie-Christine Vantyghem,3 Eric Pasmant,5 and Jérôme Bertherat1,2,*
1Genomics and Signaling of Endocrine Tumors Team, INSERM U1016, CNRS UMR8104, Cochin Institute, Paris Cité University, Paris 75005, France
2Department of Endocrinology, Reference Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris 75014, France
3Department of Endocrinology, Diabetology, Metabolism and Nutrition, Lille University Hospital, University of Lille, Inserm 1190, Lille 59000, France
4Department of Hormonology, Cochin Hospital, APHP, Paris 75014, France
5Department of Oncogenetics, Cochin Hospital, APHP, Paris 75014, France
6Department of Endocrinology, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron 69677, France
7Department of Endocrinology, Diabetology, Reproductive medicine, Nice University Hospital, Nice 06200, France
8Department of Endocrinology, Univ Rouen Normandie, INSERM, NORDIC UMR 1239, CHU Rouen, Rouen F-76000, France
9Department of Endocrinology, Diabetology and Metabolism, Bordeaux University Hospital, Pessac 33600, France
10Department of Pathology, Cochin Hospital, APHP, Paris 75014, France
*Corresponding author: Equipe Génomique et Signalisation des Tumeurs Endocrines, Bâtiment Faculté, 3ème étage, Pièce 3006, Inserm U1016-CNRS UMR8104-Université de Paris, 22, rue Méchain, Paris 75014, France. Email: jerome.bertherat@aphp.fr
Abstract
Objective: Carney complex (CNC) is a rare genetic syndrome, mostly due to germline loss-of-function pathogenic variants in PRKAR1A. Carney complex includes pigmented skin lesions, cardiac myxomas, primary pigmented nodular adrenocortical dysplasia, and various breast benign tumors.
Design: The present study was designed to describe the characteristics of breast lesions in CNC patients and their association with other manifestations of CNC and PRKAR1A genotype.
Methods: A 3-year follow-up multicenter French prospective study of CNC patients included 50 women who were analyzed for CNC manifestations and particularly breast lesions, with breast imaging, genotyping, and hormonal settings.
Results: Among the 38 women with breast imaging, 14 (39%) had breast lesions, half of them bilateral. Ten women (26%) presented with benign lesions and six with breast carcinomas (16%): one had ductal carcinoma in situ at 54, and five had invasive cancer before 50 years old, whom one with contralateral breast cancer during follow-up. The occurrence of breast cancer was more frequent in women with PRKAR1A pathogenic variant odds ratio = 6.34 (1.63-17.91) than in general population of same age. The mean age at breast cancer diagnosis was 44.7 years old: 17 years younger than in the general population. Breast cancer patients had good prognosis factors. All breast carcinomas occurred in individuals with familial CNC and PRKAR1A pathogenic variants. Loss of heterozygosity at the PRKAR1A locus in the 2 invasive breast carcinomas analyzed suggested a driver role of this tumor suppressor gene.
Conclusions: As CNC could predispose to breast carcinoma, an adequate screening strategy and follow-up should be discussed in affected women.
Clinical Trial Registration: ClinicalTrial.gov NCT00668291.
Keywords: Carney complex, PRKAR1A, breast cancer, breast lesion
Significance
Carney complex (CNC), a rare genetic syndrome caused by germline inactivating pathogenic variants of PRKAR1A, is characterized by endocrine and non-endocrine tumors, including breast lesions. The occurrence of breast cancer was more frequent in women with CNC and PRKAR1A pathogenic variants than in general population and the mean age at diagnosis younger. Moreover, the loss of heterozygosity at the PRKAR1A locus found in 2 breast carcinomas samples. This suggests that PRKAR1A inactivation could play a role in breast carcinogenesis. Thus, women with CNC are at increased risk for breast cancer and an adequate screening strategy and follow-up should be considered.
@ The Author(s) 2024. Published by Oxford University Press on behalf of European Society of Endocrinology. All rights reserved. For permissions, please e- mail: journals.permissions@oup.com
Introduction
Carney complex (CNC) is a multiple endocrine and non- endocrine neoplasia syndrome of autosomal dominant inheritance. It is a rare disease, of unknown exact prevalence,1 diagnosed more frequently in women (57%-63% of cases) ac- cording to previous studies.2,3 The CNC is familial in about 70% of the cases. Inactivating pathogenic variants in the PRKAR1A gene, coding for the type I alpha regulatory sub- unit of protein kinase A, are found in 37% of cases with spor- adic CNC presentation and more than 70% of familial cases, with almost complete penetrance.2,4,5
The diagnosis of CNC is established on the basis of the cri- teria described by Stratakis et al.3 The earliest and most fre- quent manifestations are cutaneous, followed by cardiac myxomas, and the most frequent endocrine manifestation is primary pigmented nodular adrenocortical disease. The oc- currence of thyroid lesions (cysts/adenomas/carcinomas) is frequent in CNC (5%-25%),2,3 as well as acromegaly (10%-15%) and hyperprolactinemia.2,3,6,7 Men may develop testicular lesions, in particular large cell calcifying Sertoli cell tumors3,8 and 14% of women develop ovarian lesions.2 Melanocytic psammomatous schwannomas are observed in 8%-10% of patients2,3 with 10% malignancy. Other malig- nant tumors are described: pancreatic adenocarcinomas in 2% of patients, responsible for 4%-20% of the causes of death,2,9 hepatocellular carcinomas, adrenocortical carcin- omas, or retroperitoneal fibrotic histiocytoma,10 but the speci- ficity of these lesions is debated as CNC is a rare disease and the series are of modest size.
Around 20% of female with CNC present benign breast le- sions, percentage probably underestimated in the absence of routine breast imaging.2,11 Several histological types of breast lesions are described. Breast myxoid lesions are multiple and are the first sign of the disease in 19% of patients.12 Patients are generally asymptomatic, but pain may occur in women and breast lumps in men. On mammography, the nodules are well defined, uncalcified, isodense, or hypodense respect- ing the mammary parenchyma, with rare macrocalcifications. On ultrasonography, the lesions may be solid, well circum- scribed, ovoid, and hypoechoic or may form complex cystic lumps. Magnetic resonance imaging (MRI) is the most sensi- tive imaging examination but does not present specific fea- tures.13 Microscopically accumulation of myxoid stroma is decribed.12 Ductal adenomas, occurring in about 3% of pa- tients with CNC,3,11 are often palpable and localized near the areola. In the series of six tumors described by Carney, they were solid, 1- to 5-cm diameter, covered by a thick cap- sule of hyalinized fibrous tissue, sometimes with a microcystic component or dystrophic calcifications.12 Mammography showed systematic calcifications that could lead to the suspi- cion of malignant lesions.13 For these lesions, fine needle punc- ture must be systematic, as diagnosis is difficult. However, the presence of other CNC lesions or the coexistence of homo/ contralateral myxoid fibroadenomas may guide the clinician. Mammary fibroadenomas and myxomas are benign tumors with no malignant transformation reported among CNC pa- tients for the moment. However, the benignity of these lesions does not seem to exempt patients from surveillance.
Data concerning malignant breast tumors in CNC are limited. In a literature review published by Stratakis in 2001, 1/338 patients developed breast cancer, causing death. Among the 80 women with CNC whose breast tissue was an- alyzed by Carney in 1991, one had breast cancer, but no data
concerning precise histology nor outcome was available.12 For the time being, there is no specific study allowing to determine the risk of breast cancer in patients with CNC.14 A weak asso- ciation has been found in the general population between the presence of fibroadenomas and breast cancer.15 The occur- rence of myxoid fibroadenomas in the CNC raises the question of an increased risk of breast cancer that has not been previ- ously highlighted. Breast cancer is the most frequent cancer in women (25% of cancers) and the leading cause of death from cancer worldwide.16 About 5%-10% of breast cancers are hereditary, occurring in the context of genetic predispos- ition, as germline pathogenic variants in BRCA1/2 and TP53 genes.17,18 There are many other risk factors such as per- sonal or family history of invasive breast cancer, history of high-dose chest radiation, history of ductal or lobular carcin- oma in situ, radiological breast density after menopause great- er than 75% (Breast Imaging-Reporting and Data System classification 4), history of breast lesions with atypia, and hor- mone replacement therapy for menopause.19 Breast cancer screening programs differ from country to country, but their targets are most often women aged 50 (or even 40) to 74 years. These programs exclude certain populations of high-risk women: deleterious constitutional pathogenic variant predis- posing to breast cancer, histological risk factor, and personal history of breast cancer, who benefit from specific monitoring. Breast cancer is generally of good prognosis, which is greatly influenced by the stage of the disease, the tumor size, and the age of onset.
The objective of this study was to describe in a prospective cohort of CNC women the type and characteristics of breast lesions, especially malignant and to determine the outcome of malignant lesions
Patients and methods
Patients
This French multicenter prospective study EVACARNEY (ClinicalTrial.gov registration NCT00668291) was con- ducted on 70 patients (50 women) diagnosed with CNC or presence of a germinal pathogenic variant of the PRKAR1A gene, which characteristics have been previously described.20 Ten French academic centers were involved in this study. Four evaluations were planned in the initial protocol: at base- line after inclusion, 1 year, 2 years, and 3 years after inclusion. Breast lesions management of the 50 women included in this study was analyzed prospectively during the 3 years of the an- nual systematic screening and retrospectively before inclusion and after the study up to December 31, 2022. In the analysis, no distinction was made between index cases and related sub- jects (who were therefore not excluded). There was no age lim- it for inclusion. This study was approved by the Ethics Committee of Cochin Hospital and all patients gave their writ- ten agreement to participate to the study. All research should comply with the Declaration of Helsinki.
Criteria for analysis
The different manifestations of the CNC were collected and the hormonal secretions of the different hormonal axes were analyzed. Risk factors for breast cancer were searched: per- sonal history of breast cancer, family history of breast cancer, presence of ductal/lobular hyperplasia or ductal/lobular car- cinoma in situ, breast density on mammography, history of
chest radiotherapy, and history of systemic chemotherapy, or use of hormone replacement therapy.
For each breast lesion, the clinical and imaging description, diagnostic procedure, and histological result were provided. In case of a malignant lesion, lymph node and distant metastases were searched, therapeutic methods undertaken were de- scribed, and the survival and progression-free survival was recorded.
Genetic testing
The PRKAR1A and PRKACA genes were analyzed in the Oncogenetics Department of the Cochin Hospital on leuco- cyte DNA samples. The familial or sporadic CNC status was determined. Patients were questioned for breast cancer predis- posing syndromes.19
For the breast lesions, genetic analysis was performed on formalin-fixed and paraffin-embedded material collected by macrodissection centered on the tumor areas; 10-um sections were used to extract DNA using a Maxwell16® automated sys- tem (Promega, Madison, USA) according to the manufacturer’s recommendations. Genetic analysis was performed by targeted next-generation sequencing (NGS). All exons and flanking in- tronic regions of the PRKAR1A and PRKACA genes were cap- tured with a custom-made panel (NimbleGen, Roche) and sequenced on NextSeq500 (Illumina). Sequence alignment, variant calling, and variant annotation were performed using MOABI Leaves pipeline (APHP). Variants were named at the coding DNA, RNA, and protein levels according to the Human Genome Variation Society recommendations. An as- sessment of variants’ pathogenicity was performed according to the American College of Medical Genetics and Genomics and the Association for Molecular Pathology guidelines. Assessment of variants implication was mainly performed based on population and variant databases (gnomAD and ClinVar) and predictions software (CADD, SPIP, dbscSNV, Human Splice Finder, and PROVEAN).
Statistics
The statistical analyses were performed using the R program- ming environment (R software, version 3.4.2).
Quantitative variables were described as means (standard deviations) or medians (ranges). Qualitative variables were de- scribed as numbers (percentages) and compared using Fisher’s tests were used depending on data distributions. Odds ratio (OR) with 95% confidence interval were calculated to deter- mine the risk variation for breast cancer between the individ- uals of this series and the general French population, of same age and followed up in the same time interval (women aged 15-45, followed between 1999 and 2008, reported by the French National Cancer Institute). All P-values were two- sided, and the statistical significance was defined by a P-value of ≤.05.
Results Patients
Among the 50 women analyzed, 3 died during the study, from cardiovascular causes. Seven were lost for follow-up but all 50 women had at least the initial evaluation of the prospective study. At the end of the data collection (December 2022), the 40 women had a median age of 48 years old (min-max: 13-82) and average of 47.3 years old.
Thirty-three patients had a familial form of CNC (from 12 different families). All female patients with familial form car- ried out a PRKAR1A pathogenic variant, excepting one hav- ing duplication of PRKACA. Eight patients had no genetic cause found.
All women had breast examination. Thirty-eight out of the 47 adult women (81%) performed breast imaging, over the course of the study. All had breast ultrasound (US), 13 had additional mammography, and 1 had MRI.
On imaging, 14 women (39%) had breast lesions, 10 wom- en had benign tumors (26%), and 6 women had breast carcin- omas (16%) (of which 2 also had benign lesions), representing respectively 28%, 20%, and 12% if reported to the entire co- hort (Table 1). Eight patients had bilateral breast lesions, in- cluding adenofibroma, epidermoid cysts, and fibrocystic mastopathy. The mean age of diagnosis of the first breast le- sion was 32.36 years old, with a median age of 32 years old (min-max: 16-54). At the end of the study, the patients with breast lesions had a mean age of 48.07 years old and a median age of 48.5 years old (min-max: 25-65).
Benign breast lesions
Ten women (20%) had benign breast lesions, of six different histological types (Table 1). Seven patients had adenofibromas (14%) of which 3 were bilateral, 3 patients had bilateral poly- fibromatosis (6%), 2 patients had myxoid adenofibromas, 2 patients had fibrocystic mastopathy (4%), 1 patient had bilat- eral squamous cell cysts, and 1 had ductal adenoma (2%). The mean age of onset of benign breast lesions was 27.4 years old, and the median age was 30.5 years old (min-max: 16-41). Characteristics of these lesions and their management are de- scribed in Table 1.
Breast carcinomas
In this study were found 7 breast carcinomas, in 6 patients, including 1 ductal carcinoma in situ (DCIS) (Table 1). These carcinomas were diagnosed before the inclusion in the pro- spective the study in 2 women, during the 3-year prospective follow-up in 1 woman and after the prospective follow-up for 3 of them. The DCIS occurred in a 54-year-old woman, who had also a pancreatic intraductal papillary and mucinous tumor. The other breast carcinomas were invasive and oc- curred in women, aged 36-51 years at diagnosis, without any other cancers diagnosed. One patient had breast cancer with a contralateral recurrence (asynchronous presentation), the first lesion occurring in the left breast at 49 years old and the second in the right breast at 51 years old. There was no lymph node involvement nor metastasis for this patient. Only one lesion was discovered on clinical symptoms, a pain- ful breast swelling, the others being discovered incidentally on imaging. The mean age on diagnosis of the (first) breast cancer was 44.67 years old and the median age was 45.5 years old (min-max: 36-54). Breast carcinoma occurred in 12% (6/50) of the women, 10% (5/50) of women under 50 years old, and 4% (2/50) for those under 40 years old.
Among the 6 invasive breast carcinomas: 5 were ductal adenocarcinomas and 1 was a solid intracystic papillary car- cinoma with microinfiltrating sector (Table 2). The ductal noninvasive carcinoma was macropapillary and comedonal type. Hormone receptor status was homogeneous, with all carcinomas being positive for estrogen receptor (ER+) and negative for HER2 (HER2-), and 3/6 positive for
| Patient | Histological diagnosis | Breast side | Follow-up (years) | Age at diagnosis of breast lesion (years) | If breast cancer | PRKAR1A germinal status | ||
|---|---|---|---|---|---|---|---|---|
| Alive | Overall survival (years) | Progression-free survival (years) | ||||||
| Nr 1 | Adenofibroma | R | 8 | 17 | NA | NA | NA | c.491_492delTG |
| 2 adenofibroma | L | 4.5 | 21 | NA | NA | NA | ||
| Nr 2 | Polyadenofibromatosis | R & L | 21 | 32 | NA | NA | NA | c.491_492delTG |
| Fibrocystic | R & L | 21 | 32 | NA | NA | NA | ||
| mastopathy | ||||||||
| Adenocarcinoma | L | 10 | 42 | yes | 10 | 10 | ||
| Adenofibroma | R | 5 | 48 | NA | NA | NA | ||
| Nr 3 | DCIS | R | 10 | 54 | yes | 10 | 10 | c.709-7del6 |
| Nr 4 | Adenofibroma | R | 13.5 | 33 | NA | NA | NA | wild-type |
| Adenofibroma | L | 11.5 | 34 | NA | NA | NA | ||
| Nr 5 | Myxoid adenofibroma | L | 3.5 | 32 | NA | NA | NA | c.502 + 1 G > A |
| Nr 6 | Adenofibroma | L | 19 | 16 | NA | NA | NA | c.491_492delTG |
| Epidermoid cysts | R & L | 16 | 19 | NA | NA | NA | ||
| Polyadenofibromatosis | R & L | 10.5 | 23 | NA | NA | NA | ||
| Nr 7 | Ductal adenoma | R | 32 | 32 | NA | NA | NA | c.491_492delTG |
| Fibrocystic | R | 32 | 32 | NA | NA | NA | ||
| mastopathy | ||||||||
| Adenofibroma | L | 15.5 | 49 | NA | NA | NA | ||
| Adenocarcinoma | L | 15.5 | 49 | yes | 15.5 | 15.5 | ||
| Adenocarcinoma | R | 13.5 | 51 | yes | 13.5 | 13.5 | ||
| Nr 8 | Polyadenofibromatosis | R & L | 16 | 25 | NA | NA | NA | c.124C> T |
| Nr 9 | Adenocarcinoma | L | 17 | 36 | yes | 17 | 5.5 | c.709-7del6 |
| Nr 10 | Adenocarcinoma | L | 20 | 38 | yes | 12 | 12 | c.763-764delAT |
| Nr 11 | Myxoid adenofibroma | R & L | 21 | 19 | NA | NA | NA | c.974-1G> A |
| Nr 12 | Adenocarcinoma | L | 7.5 | 49 | no | 7.5 | 7.5 | c.1131_1132delTG |
| Nr 13 | Adenofibroma | R | 14 | 29 | NA | NA | NA | c.742-752del |
| Nr 14 | Adenofibroma | R & L | 11.5 | 41 | NA | NA | NA | c.682C>T |
Breast adenocarcinoma is in bold.
Abbreviations: DCIS, ductal carcinoma in situ; NA, not applicable; R, right; L, left.
progesterone receptor (PR+). All the tumors were Luminal A type. The carcinomas were small, with a mean size of 20.6 mm and median of 16 mm (min-max: 5-45). The histo- pathological and prognostic grade was SBR-I (Scarff, Bloom et Richardson Classification21) for 3 carcinomas, SBR-II for 2 carcinomas, and SBR-IIIa for 1 carcinoma, respectively, 42.8%, 28.6%, and 14,3% of the invasive carcinomas. The Tumor Node Metastasis Classification of Malignant Tumors was TisN0M0 for 1 tumor, T1bN0M0 for 2 tumors, T1cN0M0 for 2 tumors, and T2N2aM for 1 tumor. Carcinomas had a good prognosis with 1 stage 0 tumor, 5 stage I tumors, and 1 stage IIIa tumor. Only 1 patient had lymph node involvement and distant (hepatic) metastases of breast carcinoma.
The patient with DCIS underwent lumpectomy and then right mastectomy, after pathological diagnosis, and did not re- cur (Table 2). The patient with early metastatic breast carcin- oma was treated with a first course of chemotherapy, followed by a second one, as the disease progressed. The other patients were all treated with surgery, radiotherapy, and hormonal therapy, with additional 4 courses of chemotherapy for the one who had relapsed in contralateral breast. No carcinoma was treated with targeted therapy, based on the negative HER2 status of all lesions.
All women with breast carcinoma were alive at the end of the prospective period of the study, with an observation period ranging from 7.5 to 20 years. They had an average age of 59.17 years old and a median age of 60.5 years old (min- max: 53-65). One patient progressed during follow-up, breast
lesion progression at 2.5 years, and liver metastases at 3.5 years after diagnosis, having nevertheless a long-term good survival, over 15 years. One patient died at 4.5 years from her diagnosis of breast carcinoma (in remission), of a cardio- vascular cause.
Menopause occurred in 2 patients before breast cancer diag- nosis. Only 1 patient who developed breast carcinoma had classic risk factors as family history of breast cancer for moth- er and grandmother (cancer diagnosed after 50 years old) and atypical ductal hyperplasia. All of the breast densities found in mammography were classified 2 or 3, so with no increased risk of cancer. No breast cancer predisposition syndrome was identified by familial anamnesis.
By comparing the partial prevalence of breast cancer in the French population, between 1999 and 2008, for women aged 15-45, reported by the National Cancer Institute and the preva- lence of breast cancer in women of the same age of this CNC cohort, in the same time interval, the OR was 6.15 (1.58-17.31) (P =. 006), in favor of a significant higher risk of developing breast cancer in women with CNC compared with the general population (Table 3). Moreover, cumulative risk of developing breast cancer was much higher in this CNC cohort compared with French women under 40 years old: OR = 30.25 (6.06-93.06) (P=1.67-4), or under 50 years old:
pared with women worldwide: OR = 592.08 (97.70-3817.38) (P=9.45-8) (Table 4).22
In this study, breast cancer in women with CNC was asso- ciated with PRKAR1A deletions (6 cancers/25 women)
| Patient | Histopathology | Breast side | Nodule size (mm) | IHC for HR | Classification | Treatment | Progression disease | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SBRª | TNM | Stage | Surgery | Radio therapy | Hormone therapy | Chemotherapy | Targeted therapy | Nodes | Metastasis | |||||
| Nr 2 | Solid intrakystic papillary carcinoma with microinfiltrating sector | L | 20 | ER + PR - HER2- | NA | T1cN0M0 | I | Tumorectomy then surgical resumption of breast banks and sentinel node | Breast and operating bed | Tamoxifen | No | No | No | No |
| Nr 3 | Macropapillary and comedon-like non-invasive ductal carcinoma | R | 45 | NA | I | TisN0M0 | 0 | Tumorectomy then mastectomy and sentinel node | No | No | No | No | No | No |
| Nr 7 | Papillary ductal invasive adenocarcinoma developing on a ductal papillary carcinoma | L | 6 | ER + PR + HER2- | I | T1bN0M0 | I | Tumorectomy and sentinel node | Breast. operating bed and thoracic wall | Letrozole then exemestran | No | No | No | No |
| Nr 7 | Infiltrating ductal adenocarcinoma (asynchronous presentation with L breast cancer) | R | 16 | ER + PR - HER2- | 6-II | T1cNOM | I | Tumorectomy and axillary clearance | Yes | Tamoxifen | Carboplatin- taxotere | No | No | No |
| Nr 9 | Moderately differentiated infiltrating ductal adenocarcinoma | L | 40 | ER + PR + HER2- | 6-II | T2N2aM1 | III | Mastectomy and axillary clearance | N | Tamoxifen then leuprorelin | 5-Fluorouracil- epirubicin- Cyclophosphamide then taxotere- bevacizumab | No | 4 N+/14 | Hepatic |
| Nr 10 | Infiltrating ductal adenocarcinoma | L | 12 | ER + PR- | I | T1cNOM0 | I | Mastectomy | Breast | Tamoxifen | No | No | No | No |
| Nr 12 | Infiltrating ductal adenocarcinoma | R | 5 | ER + PR + HER2- | I | T1bN0M0 | I | Tumorectomy then surgical resumption of breast banks and sentinel node | Breast and operating bed | Tamoxifen then letrozole | No | No | No | No |
Abbreviations: HR, hormone receptors; IHC, immunohistochemistry; L, left; R, right; SBR ”, Scarff-Bloom-Richardson grade; TNM, Tumor Node Metastasis Classification of Malignant Tumors. aBloom HJ, Richardson WW. Histological grading and prognosis in breast cancer; a study of 1409 cases of which 359 have been followed for 15 years. Br J Cancer. 1957; 11(3):359-377. doi:10.1038/bjc.1957.43.
| Time interval (age group) | 1999-2008 (15-45 years old) |
|---|---|
| Women followed in this time interval according to the French National Cancer Institute | 99 268 |
| Number of breast cancer according to the French National Cancer Institute | 1918 |
| Percentage of breast cancer according to the French National Cancer Institute | 1.92% |
| Breast cancer expected in CNC/PRKAR1A mutated women in the meantime | 0.71 |
| Women with CNC (and PRKAR1A mutation) followed in the meantime | 37 (36) |
| Number of breast cancers diagnosed in women with CNC (and PRKAR1A mutation) in the meantime | 4 |
| Percentage of breast cancers diagnosed in women with CNC (and PRKAR1A mutation) in the meantime | 10.8% (11.1%) |
| Odds ratio (confidence interval) (P) in women with CNC versus French women | 6.15 (1.58-17.31) (P =. 006) |
| Odds ratio (confidence interval) (P) in women with CNC and PRKAR1A mutation versus French women | 6.34 (1.63-17.91) (P =. 005) |
Abbreviation: CNC, Carney complex.
| Cumulative risk of breast cancer | Odds ratio (confidence interval) (P) Before 40 years old | |
|---|---|---|
| CNC | 3/1681 person-years | |
| France | 0.59/100 000 | 30.25 (6.06-93.06) (P = 1.67-4) Before 50 years old |
| person-years | ||
| CNC | 5/2136 person-years | |
| France | 2.4/100 000 person-years | 116.90 (19.14-1246.78) (P = 8.17-8) |
Abbreviation: CNC, Carney Complex.
(P =. 02), all breast carcinomas occurring in patients with short intragenic frameshift deletions at various genomic locations: c.491_492del, c.709(-8-3)del6, c.709(-7-2)del6, c.763_764del, and c.1131_1132del.
We collected for genetic analysis breast tumors samples from 3 patients: 2 invasive cancers (patients Nr2 and Nr7) and 1 DCIS (patient Nr3). Tumor DNA NGS was performed in those 3 breast carcinomas and showed loss of heterozygos- ity at the PRKAR1A locus in the 2 invasive breast cancers and was inconclusive for the DCIS (variant allelic frequency: 71% for breast cancer sample of patient Nr2, 73% for breast cancer sample Nr7, and 62% for sample Nr3) (Figure 1).
Breast lesions and CNC manifestations
There was no significant difference between women with be- nign breast lesions and those with breast cancer in average number of clinical manifestations of CNC (3 versus 4.5; P =. 21). Women with breast lesions had significantly more frequently osteochondromyxoma (97% versus 60%, P =. 01) compared with women with no breast lesions. Two patients had hypercorticism, 1 patient had postoperative corticotropic insufficiency, and 8 had adrenal insufficiency (6 due to adrena- lectomy, 1 due to mitotane treatment alone, and 1 due to mito- tane treatment followed by adrenalectomy). Of the 2 patients treated with mitotane with breast lesions, 1 had breast carcin- oma and 1 had breast benign lesion.
Discussion
In the current study, based on French women with CNC, with no known preexisting genetic breast cancer predisposing syn- drome, we identified 6 breast cancers among the 50 women
included (12%). Among these breast cancers, only 1 was meta- static, so there was a good overall prognosis, with no breast cancer-related deaths to be deplored.
The main limitation of this study was the small number of pa- tients included due to the rarity of CNC. Thus, it was impossible to rule with certainty whether risk factors are involved in the de- velopment of breast cancer in CNC patients. Similarly, it was impossible to propose strong recommendations on screening, given the small cohort, as well as the lack of imaging for 12 of the 50 women of the cohort, and therefore, the low power of the study. Because CNC is a rare genetic disease, women in our cohort probably benefited from more surveillance than the general population. This may lead to the more frequent and earl- ier discovery of small breast lesions. However, despite the small number of patients, this is the largest cohort of patients with CNC included in a prospective study with a precise description of breast lesions and analysis of the frequency of occurrence of breast carcinoma and its characteristics.
The largest retrospective cohort studying breast lesions in 145 patients with CNC (80 women), published by Carney in 1991 found breast lesions in 28% of the women, mainly myx- oid fibroadenoma or myxomatosis lesions (26%),12 which is consistent with the present study where 28% of women had breast lesions, mainly benign (20%). The mean age at diagnosis of myxoid lesions was 29 years old in the American cohort and 25 years old in this French cohort. The absence of breast carcin- oma described in this American cohort could be due to less per- formant and/or frequent imaging, as the breast cancers in our cohort were small (<2 cm), excepting the metastatic one.
The mean age of breast cancer diagnosis in our CNC cohort was 16.5 years younger than the general population (45.5 versus 63 years old),23 with a higher risk of breast cancer occurrence in CNC patients. This raises questions about the relevance of breast cancer screening and monitoring in patients with CNC. An annual breast clinical examination in these patients (starting after puberty) is essential, followed by systematic imaging in case of abnormality. It is also legitimate to propose a systematic im- aging screening for breast cancer in CNC patients at an early age than in general population. The NICE recommendations, for moderate-risk group (lifetime risk of breast cancer occurrence 17%-30%), appearing compatible with a 12% risk for women aged 45.5 years on average in this cohort, suggest to begin screening at age 40, with an annual mammography until age 59, and then follow the recommendations of the general popu- lation.24 Moreover, based on a recent study, in women with risk of breast cancer occurrence 2- to 4-fold higher than general population, annual mammography between the ages of 40 and 74 should be proposed.25 Another strategy can be performing
C1
C2
32 wt 79-80 del
42 wt 111 del
AGAGACTGTGA
E
T
V
PRKAR1A
AGAGACTGTGA
E
T
V
PRKAR1A
breast US or MRI, as those are more sensitive in young women and are non-irradiating. Thus, in women with CNC, we suggest imaging screening by US or MRI before the age of 40 years old in case of abnormality on breast examination. Then, systematic an- nual mammography between the age of 40 and 59 years old, then mammography every 2 years until 75 years old is suggested.
An earlier detection of breast cancer in these young women might reduce treatment modalities (surgery only, without radio- therapy and/or without antiestrogens). However, it seemed dif- ficult to give a strong recommendation on imaging screening given the relatively modest size of this cohort, even if consequent for such a rare disease.
The early occurrence of breast carcinoma in women with CNC leads us to believe that this genetic disease may predispose to breast cancer. Interestingly, all patients with breast cancer of the present study presented germline short intragenic deletions of PRKAR1A. Moreover, somatic loss of heterozygosity at the PRKAR1A locus in the 2 invasive breast carcinomas suggests an involvement of biallelic inactivation of this tumor suppressor gene in the development of breast cancer in CNC patients. Unfortunately, PRKAR1A immunohistochemistry could not be performed. According to a recent study, preferential loss of heterozygosity in breast cancer was observed (in descending or- der of significance) in specific regions of chromosomes 7q, 16q, 13q, 17p, 8p, 21q, 3p, 18q, 2q, and 19p, different from the PRKAR1A locus (17q24.2-q24.3).26 PRKAR1A germline pathogenic variants could be involved in human breast carcino- genesis, as recently shown in another endocrine tumors’ syn- drome, NEM1 (MEN1).27 However, the risk of developing breast cancer seems lower than in “classical” syndromes predis- posing to breast cancer as for BRCA1/2, TP53, or PTEN pathogenics.18 It is difficult to conclude on the potential role of mitotane therapy or immunosuppression due to hypercortis- olism in the occurrence of breast carcinoma here, given the small number of patients studied.
Cancers in young patients have particular pathological and molecular characteristics, with usually more aggressive forms.28 Due to the lack of screening and denser glandular parenchyma, cancer diagnosis at this age is often made at an advanced stage.29 The 6 invasive breast cancers of our cohort have conversely good prognosis: T1 = 83.3% and N0 = 83.3%, ie, a total of 66.6% stage I tumors, better than prog- nosis in French women under 50 years old (T1 = 63.2% and NO=60.6%).30 All of the breast carcinomas here are HR+/HER-, consistent with a recent study on women aged 20 and 49 years old, where this is the most common breast cancer subtype (58% of cases).31 The survival rate in our study is 83%, for a follow-up between 7.5 and 17 years similar to the one of the California Cancer Registry, studying 61 309 pa- tients with invasive breast cancer, showing a relative 5-year survival rate of 91.9% for ER+/PR-/HER2- tumors.32 In the ER+ patients, the good prognosis can also be explained by a more effective treatment with hormone therapy.
As the occurrence of breast cancer was more frequent in the women with PRKAR1A pathogenic variants than in general population, the mean age at diagnosis was younger, and loss of heterozygosity at the PRKAR1A locus was found in some carcinomas, we conclude that PRKAR1A could be a new pre- disposing gene for breast cancer. Early and specific screening could be proposed then to women with CNC.
Acknowledgment
We thank the physicians and nurses of the departments where the patients have been investigated, as well as pathologist proving breast tumoral tissues (Dr Anne Vincent Salomon, Dr Christine Delplanque, and Dr Jean-Michel Piquenot). We are indebted to the patients who consented to participate in this study and their relatives.
Funding
This study was funded by a research grant from the French Ministry of Health (PHRC AOM 12-002-0042, as part of a specific program of the National Plan for Rare Diseases).
Conflict of interest: The authors have no conflict of interest to declare. Co-authors G.R. and G.A. are on the editorial board of EJE. They were not involved in the review or editorial process for this paper, on which they are listed as authors.
Authors’ contributions
Patricia Vaduva (Data curation [supporting], Formal analysis [equal], Investigation [lead], Methodology [equal], Writing- original draft [lead], Writing-review & editing [equal], Florian Violon (Investigation [supporting], Resources [sup- porting], Writing-review & editing [supporting]), Anne Jouinot (Formal analysis [supporting], Methodology [equal], Software [equal], Writing-review & editing [supporting]), Lucas Bouys (Investigation [supporting], Writing-review & editing [supporting]), Stéphanie Espiard (Conceptualization [supporting], Formal analysis [supporting], Investigation [equal], Methodology [supporting], Writing-review & edit- ing [supporting]), Fidéline Bonnet-Serrano (Investigation [supporting]), Marie-Odile North (Formal analysis [support- ing], Resources [supporting]), Catherine Cardot-Bauters (Investigation [supporting], Writing-review & editing [sup- porting]), Gerald Raverot (Investigation [supporting], Validation [supporting], Writing-review & editing [supporting]), Sylvie Hieronimus (Investigation [supporting], Writing-review & editing [supporting]), Hervé Lefebvre (Investigation [supporting], Writing-review & editing [sup- porting]), Marie-Laure Nunes (Investigation [supporting]), Antoine Tabarin (Investigation [supporting]), Lionel Groussin (Investigation [supporting], Validation [supporting], Writing-review & editing [supporting]), Guillaume Assié (Investigation [supporting]), Mathilde Sibony (Methodology [supporting], Resources [supporting]), Marie-Christine Vantyghem (Investigation [supporting], Writing-review & editing [supporting]), Eric Pasmant (Investigation [support- ing], Resources [supporting], Validation [supporting], Writing-review & editing [supporting]), Jérôme Bertherat (Conceptualization [lead], Data curation [lead], Formal ana- lysis [supporting], Funding acquisition [lead], Investigation [supporting], Methodology [equal], Project administration [lead], Resources [equal], Software [lead], Supervision [lead], Validation [lead], Visualization [lead], and Writing-original draft [supporting], Writing-review & editing [lead]).
References
1. Lodish M, Stratakis CA. A genetic and molecular update on adreno- cortical causes of Cushing syndrome. Nat Rev Endocrinol. 2016;12(5):255-262. https://doi.org/10.1038/nrendo.2016.24
2. Bertherat J, Horvath A, Groussin L, et al. Mutations in regulatory subunit type 1A of cyclic adenosine 5’-monophosphate-dependent protein kinase (PRKAR1A): phenotype analysis in 353 patients and 80 different genotypes. J Clin Endocrinol Metab. 2009;94(6): 2085-2091. https://doi.org/10.1210/jc.2008-2333
3. Stratakis CA, Kirschner LS, Carney JA. Clinical and molecular features of the Carney complex: diagnostic criteria and recommen- dations for patient evaluation. J Clin Endocrinol Metab. 2001;86(9):4041-4046. https://doi.org/10.1210/jcem.86.9.7903
4. Kirschner LS, Carney JA, Pack SD, et al. Mutations of the gene en- coding the protein kinase A type I-alpha regulatory subunit in pa- tients with the Carney complex. Nat Genet. 2000;26(1):89-92. https://doi.org/10.1038/79238
5. Cazabat L, Ragazzon B, Groussin L, Bertherat J. PRKAR1A muta- tions in primary pigmented nodular adrenocortical disease.
Pituitary. 2006;9(3):211-219. https://doi.org/10.1007/s11102- 006-0266-1
6. Raff SB, Carney JA, Krugman D, Doppman JL, Stratakis CA. Prolactin secretion abnormalities in patients with the “syndrome of spotty skin pigmentation, myxomas, endocrine overactivity and schwannomas” (Carney complex). J Pediatr Endocrinol Metab JPEM. 2000;13(4):373-379. https://doi.org/10.1515/JPEM. 2000.13.4.374
7. Kirschner LS, Sandrini F, Monbo J, Lin JP, Carney JA, Stratakis CA. Genetic heterogeneity and spectrum of mutations of the PRKAR1A gene in patients with the carney complex. Hum Mol Genet. 2000;9(20):3037-3046. https://doi.org/10.1093/hmg/9.20.3037
8. Carney JA, Gordon H, Carpenter PC, Shenoy BV, Go VL. The com- plex of myxomas, spotty pigmentation, and endocrine overactivity. Medicine (Baltimore). 1985;64(4):270-283. https://doi.org/10. 1097/00005792-198507000-00007
9. Gaujoux S, Tissier F, Ragazzon B, et al. Pancreatic ductal and acinar cell neoplasms in Carney complex: a possible new association. J Clin Endocrinol Metab. 2011;96(11):E1888-E1895. https://doi. org/10.1210/jc.2011-1433
10. Bertherat J. Adrenocortical cancer in Carney complex: a paradigm of endocrine tumor progression or an association of genetic predis- posing factors? J Clin Endocrinol Metab. 2012;97(2):387-390. https://doi.org/10.1210/jc.2011-3327
11. Carney JA, Toorkey BC. Ductal adenoma of the breast with tubular features. A probable component of the complex of myxomas, spotty pigmentation, endocrine overactivity, and schwannomas. Am J Surg Pathol. 1991;15(8):722-731. https://doi.org/10.1097/ 00000478-199108000-00002
12. Carney JA, Toorkey BC. Myxoid fibroadenoma and allied condi- tions (myxomatosis) of the breast. A heritable disorder with special associations including cardiac and cutaneous myxomas. Am J Surg Pathol. 1991;15(8):713-721. https://doi.org/10.1097/00000478- 199108000-00001
13. Courcoutsakis NA, Chow CK, Shawker TH, Carney JA, Stratakis CA. Syndrome of spotty skin pigmentation, myxomas, endocrine overactivity, and schwannomas (Carney complex): breast imaging findings. Radiology. 1997;205(1):221-227. https://doi.org/10. 1148/radiology.205.1.9314989
14. Stratakis CA, Carney JA, Lin JP, et al. Carney complex, a familial multiple neoplasia and lentiginosis syndrome. Analysis of 11 kin- dreds and linkage to the short arm of chromosome 2. J Clin Invest. 1996;97(3):699-705. https://doi.org/10.1172/JCI118467
15. Dupont WD, Page DL, Parl FF, et al. Long-term risk of breast cancer in women with fibroadenoma. N Engl J Med. 1994;331(1):10-15. https://doi.org/10.1056/NEJM199407073310103
16. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012: Global Cancer Statistics, 2012. CA Cancer J Clin. 2015;65(2):87-108. https://doi.org/10.3322/caac. 21262
17. Economopoulou P, Dimitriadis G, Psyrri A. Beyond BRCA: new hereditary breast cancer susceptibility genes. Cancer Treat Rev. 2015;41(1):1-8. https://doi.org/10.1016/j.ctrv.2014.10.008
18. Lalloo F, Varley J, Moran A, et al. BRCA1, BRCA2 and TP53 mu- tations in very early-onset breast cancer with associated risks to rel- atives. Eur J Cancer Oxf Engl. 2006;42(8):1143-1150. https://doi. org/10.1016/j.ejca.2005.11.032
19. McPherson K. ABC of breast diseases: breast cancer-epidemi- ology, risk factors, and genetics. BMJ. 2000;321(7261):624-628. https://doi.org/10.1136/bmj.321.7261.624
20. Espiard S, Vantyghem MC, Assié G, et al. Frequency and incidence of Carney complex manifestations: a prospective multicenter study with a three-year follow-up. J Clin Endocrinol Metab. 2020;105(3): e436-e446. https://doi.org/10.1210/clinem/dgaa002
21. Bloom HJ, Richardson WW. Histological grading and prognosis in breast cancer; a study of 1409 cases of which 359 have been fol- lowed for 15 years. Br J Cancer. 1957;11(3):359-377. https://doi. org/10.1038/bjc.1957.43
22. Narod SA. Breast cancer in young women. Nat Rev Clin Oncol. 2012;9(8):460-470. https://doi.org/10.1038/nrclinonc.2012.102
23. Cancer Statistics Review, 1975-2014-SEER Statistics. SEER. Accessed October 15, 2019. https:/seer.cancer.gov/archive/csr/ 1975_2014/
24. National Collaborating Centre for Cancer (UK). Familial Breast Cancer: Classification and Care of People at Risk of Familial Breast Cancer and Management of Breast Cancer and Related Risks in People with a Family History of Breast Cancer. National Collaborating Centre for Cancer (UK); 2013. Accessed January 5, 2020. http://www.ncbi.nlm.nih.gov/books/NBK247567/
25. Mandelblatt JS, Stout NK, Schechter CB, et al. Collaborative mod- eling of the benefits and harms associated with different U.S. breast cancer screening strategies. Ann Intern Med. 2016;164(4):215. https://doi.org/10.7326/M15-1536
26. Miller BJ, Wang D, Krahe R, Wright FA. Pooled analysis of loss of heterozygosity in breast cancer: a genome scan provides compara- tive evidence for multiple tumor suppressors and identifies novel candidate regions. Am J Hum Genet. 2003;73(4):748-767. https:// doi.org/10.1086/378522
27. van Leeuwaarde RS, Dreijerink KM, Ausems MG, et al. MEN1-dependent breast cancer: indication for early screening? Results from the Dutch MEN1 study group. J Clin Endocrinol Metab. 2017;102(6):2083-2090. https://doi.org/10.1210/jc.2016- 3690
28. Colleoni M, Rotmensz N, Robertson C, et al. Very young women (<35 years) with operable breast cancer: features of disease at pres- entation. Ann Oncol. 2002;13(2):273-279. https://doi.org/10. 1093/annonc/mdf039
29. Di Nubila B, Cassano E, Urban LABD, et al. Radiological features and pathological-biological correlations in 348 women with breast cancer under 35 years old. Breast. 2006;15(6):744-753. https://doi. org/10.1016/j.breast.2006.02.006
30. Molinié F, Delacour-Billon S, Tretarre B, Delafosse P, Seradour B, Colonna M. Breast cancer incidence: decreasing trend in large tu- mours in women aged 50-74. J Med Screen. 2017;24(4):189-194. https://doi.org/10.1177/0969141316672894
31. Shoemaker ML, White MC, Wu M, Weir HK, Romieu I. Differences in breast cancer incidence among young women aged 20-49 years by stage and tumor characteristics, age, race, and ethni- city, 2004-2013. Breast Cancer Res Treat. 2018;169(3):595-606. https://doi.org/10.1007/s10549-018-4699-9
32. Parise CA, Bauer KR, Brown MM, Caggiano V. Breast cancer sub- types as defined by the estrogen receptor (ER), progesterone recep- tor (PR), and the human epidermal growth factor receptor 2 (HER2) among women with invasive breast cancer in California, 1999-2004. Breast J. 2009;15(6):593-602. https://doi.org/10. 1111/j.1524-4741.2009.00822.x
Downloaded from https://academic.oup.com/ejendo/article/190/2/121/7584982 by National Library of Medicine user on 03 April 2026