Simultaneous Adrenocortical Carcinoma and Neuroblastoma in an Infant With a Novel Germline p53 Mutation
Rachael Courtney, DO* and Sarangarajan Ranganathan, MD+
Summary: We present an infant with 2 simultaneous, but histo- logically distinct tumors with a novel germline p53 mutation. The child was found to have a paraspinal neuroblastoma, a concurrent adrenal cortical carcinoma, and an I162F p53 gene mutation. We review the associations of germline p53 mutations (or Li-Fraumeni syndrome) with both tumor types and the current research in similar germline p53 mutations. Finally, we discuss the multiple ways in which our patient is unique including the paucity of cases with simultaneous but histologically unrelated tumors and the fact that our patient is the first reported case of an I162F germline p53 mutation.
Key Words: p53, Li-Fraumeni syndrome, adrenocortical carci- noma, neuroblastoma
(J Pediatr Hematol Oncol 2015;37:215-218)
N euroblastoma is the most common tumor of infancy likely to present as mediastinal and adrenal masses in the neonatal period and as a congenital tumor. Most of these congenital tumors are of stage 4S and have a favor- able prognosis because of lack of N-myc amplification and the potential to spontaneously regress. An imaging study that reveals both a paraspinal mediastinal mass and an adrenal tumor leads to a diagnosis of neuroblastoma and subsequent treatment on one of the neuroblastoma Child- ren’s Oncology Group protocols. It is uncommon to find associations of neuroblastoma with other tumors in the neonatal period with only instances of second neoplasms developing years posttherapy as possibly a late effect.
We herein report a unique instance of a neonate pre- senting with 2 masses that turned out to be different tumors with a novel p53 gene germline mutation.
CASE REPORT
Patient Introduction
Our patient was born full term by spontaneous vaginal delivery. His prenatal care and delivery were at an outside hospital and those records are not available to us at the time of this report. During a prenatal ultrasound he was found to have a left-sided hydronephrosis. His mother had an amniocentesis performed at a different hospital which was reportedly normal. He also had a renal
Received for publication January 3, 2014; accepted October 3, 2014. From the Divisions of *Pediatric Hematology/Oncology; and Pedi- atric Pathology, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA.
The authors declare no conflict of interest.
Reprints: Rachael Courtney, DO, Division of Pediatric Hematology/ Oncology, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, 4401 Penn Ave, Pittsburgh, PA 15224 (e-mail: rachael.courtney@chp.edu).
Copyright @ 2014 Wolters Kluwer Health, Inc. All rights reserved.
ultrasound done on day one of life which was reportedly stable from his prenatal ultrasound.
At 2 months of age urology started him on prophylactic antibiotics. He was asked to come back in 6 months time for a repeat ultrasound with a voiding cystourethrogram. Therefore, at 8 months of age he had a renal ultrasound which revealed a right- sided renal mass. This was followed by a computed tomography of the chest, abdomen, and pelvis which revealed a right suprarenal mass as well as a right thoracic paraspinal soft-tissue mass. His voiding cystourethrogram was negative.
The clinical suspicion was that the patient had a multifocal neuroblastoma. There had been no family history of cancers on either side. A bone marrow aspiration was negative. A whole body bone scan showed only moderate left-sided hydronephrosis and poor visualization of the right kidney consistent with known tumor. An metaiodobenzylguanidine whole body scan showed no uptake of the tracer. Urine HVA/VMA excretion was normal.
The decision was made to resect the paraspinal mass. At 8 months of age he underwent near-complete excision of a 3 x2 x 1 cm right thoracic paraspinal mass involving the right sympathetic chain. Pathology confirmed a neuroblastoma with positive lymph nodes (a stage 2B tumor).
He developed a Horner syndrome of his right eye after his first surgery but recovered well otherwise. He underwent resection of a 6.5x6.5 x 6cm suprarenal mass within the adrenal capsule 2 weeks after his first surgery. The pathology of this specimen showed an adrenal cortical carcinoma (ACC) (stage II or T2NxM0). Subsequent laboratory work showed that he had evidence of adrenal hypersecretion with an elevated dehydroepiandrosterone at 1555 µg/dL (reference range for age 20 to 100), increased andros- tenedione at 299 ng/dL (reference range for age less than 51), and a cortisol at the high end of normal at 18 ug/dL (reference range for
age 2.1 to 18.1). Thus, the patient had 2 simultaneous but histo- logically distinct primary tumors at only 8 months of age.
Pathology
Neuroblastoma
Resection of the mediastinal mass revealed a 2.5x 1.4x 0.9 cm mass that histologically revealed small round blue cells in a fibrillary background consistent with a poorly differentiated neuroblastoma (Fig. 1). Multinucleate and polylobate cells were also present but no ganglionic differentiation was noted. Areas more consistent with an undifferentiated neuroblastoma with no neuropil in the background of small blue cells were also noted. The mitotic karyorrhectic index was assessed to be intermediate (2% to 4%) within the tumor, making this a poorly differentiated neuroblastoma, favorable histol- ogy for age (Shimada classification), N-myc nonamplified, with a DNA index of 2.4. An adjoining sympathetic ganglion was also identified as was a contiguous lymph node showing involvement by tumor. A p53 stain was negative in this tumor.
Adrenal Cortical Carcinoma
The abdominal mass measured 6.5x6.5x 6.0 cm (Fig. 2). Sections revealed portion of normal adrenal gland at the periphery. An encapsulated tumor with a multinodular appearance was seen arising in the adrenal gland. Histology revealed most of the nodules to be composed of sheets and large nests of cells showing marked nuclear pleomorphism with nuclei ranging from small ones with stippled chromatin to others that were large and polylobated with intranuclear pseudoinclusions and occasional nucleolus. Fibrovas- cular septa separate the nests of cells but no Zellballen arrangement was appreciated. Areas of hemorrhage and necrosis were evident and the tumor cells showed brisk mitoses with many atypical forms. No neuropil was identified in the tumor. The tumor cells were strongly positive for inhibin, Melan-A103, and vimentin with only rare cell showing weak PGP9.5 staining. The tumor cells were negative for synaptophysin and S100 excluding a pheochromocytoma. A Ki-67 proliferation marker showed high proliferation index of 50% to 60%. A p53 stain showed positive nuclear staining in about 60% of cells (Fig. 3). Vascular invasion by the tumor was noted histologically. A diagnosis of adrenocortical carcinoma was rendered.
Treatment
For his neuroblastoma, the patient was considered low risk and was enrolled on children’s oncology group study P9641 which, since the surgeons achieved near-complete resection, meant that he
could be observed for spontaneous resolution of his tumor. For his ACC, surgical resection with observation was considered the standard of treatment for a stage II tumor. Repeat imaging in the 6 months following surgery showed a residual adrenal mass that was markedly decreased in size and resolution of the thoracic neuro- blastoma mass. He was lost to follow-up in the 6- to 12-month postoperative period but returned for his 1-year postoperative scan. This scan showed resolution of all masses. Unfortunately the patient was lost to follow-up after this point despite many attempts to contact the family; however, distant family members report that the child, who is now age 11, is healthy.
Our patient had been referred to genetics for a tumor pre- disposition syndrome workup shortly after his diagnosis given the oddity of having 2 distinct tumors. At this point a bone marrow had already been done due to his presumed diagnosis of neuro- blastoma and his bone marrow cytogenetics revealed a normal male karyotype of 46, XY. Given the association of adrenocortical carcinoma with Beckwith-Wiedemann syndrome he had molecular testing done that returned negative. And, given his multiple tumors and the association of adrenocortical carcinoma with p53 muta- tions, testing was done to rule out germline p53 mutations. This testing returned positive for an A to T missense mutation at nucleotide 13163 resulting in an isoleucine to phenylalanine change at codon 162 (I162F) in exon 5.
DISCUSSION
Germline p53 and Li-Fraumeni Syndrome (LFS)
P53 (OMIM 191170; located on 17q13.1) and its sig- naling pathway play a role in many cell functions including promoting cell cycle arrest, initiating DNA repair, and promoting cell apoptosis. Somatic mutations in p53 and other members of its pathway are well known to play a role in many cancers.
Germline P53 mutations are also well characterized. LFS (OMIM 151623) is an autosomal dominant syndrome caused by germline mutations in p53.1 Patients with LFS are predisposed to multiple cancers with half of LFS patients developing a cancer by age 30.2,3 Of note, muta- tions in germline p53 only account for about 70% to 80% of LFS cases. There are other genes in the p53 pathway suspected to cause LFS but there are no definitive data concluding their involvement.4,5
It is well established that LFS has a strong association with breast carcinoma, soft-tissue sarcomas, adrenocortical
carcinoma, and brain tumors with these tumors composing between 50% and 80% of tumors seen in LFS.2,6,7 Given the rarity of LFS, only a few studies have looked at large numbers of LFS patients and attempted to determine the frequency of all types of cancers associated with LFS. Birch et al6 described a series of 20 families with LFS and 8 families with Li-Fraumeni-like syndrome with germline p53 mutations in each family in 2001. Another large study came from Gonzalez et al7 in 2009 where they analyzed the characteristics of 91 patients with confirmed germline p53 mutations.
Does Our Patient Have LFS?
Multiple criterions have been suggested to evaluate patients for the likelihood of LFS. These criterion known as “classic LFS,” “Birch,” “Eeles,” and “Chompret” criteria look at characteristics like tumor type and family his- tory.8-12 At the time of diagnosis, our patient’s family his- tory was negative for familial cancers so, except for the Chompret, he would not have fit most of the criterion to screen for LFS. However, it is known that not all patients with inherited germline p53 mutations have a positive family history. Malkin et al13 evaluated patients who had a history of 2 different cancerous tumors for germline p53 mutations. None, of the 59 patients tested had a family history consistent with LFS; however, 4 patients tested positive for germline p53. Subsequent testing was done of the family members in 3 of the cases and it showed that all 3 had a parent with a germline p53 mutation. Thus, it is possible that our patient could have inherited a p53/LFS mutation from his family but his family has not shown any clinical sequelae from their p53 mutation. In contrast, it is possible that our patient had a sporadic germline mutation (ie, index case) as this has been shown to occur in 7% to 20% of germline p53 mutations.14 Regardless, with his germline p53 mutation he does fit the diagnosis of LFS. Unfortunately our patient and his family was lost to follow- up before we could test his parents.
Germline p53 Mutations/LFS and ACC
ACC tumors are rare and show a bimodal age dis- tribution in the general population with peaks in the first and fifth decades of life. ACC, particularly those occurring in childhood, are well known to be associated with germline p53 mutations/LFS. In the Gonzalez et al7 study, 67% of patients of all ages with ACC were found to have a germline p53 mutation. And Birch et al6 described ACC in 7 of 148 cancers seen in LFS and Li-Fraumeni-like families. In contrast to the median age of diagnosis of mid-40’s seen in the general population, it is well established that patients with ACC secondary to germline p53 mutations/LFS present with ACC at a much younger age. More specifi- cally, multiple studies have shown that ≥ 80% of patients under the age of 15 to 18 years with ACC have germline p53 mutation with 68% presenting by 4 years of age.3,7,15
Germline p53 Mutations/LFS and Neuroblastoma
Neuroblastoma is not typically thought to be asso- ciated with germline p53 mutations/LFS. However, some authors feel there may be a weak association.6 There are scattered reports of neuroblastoma associated with germ- line p53 mutations/LFS in the literature. In Birch et al’s6 report on 20 families with LFS there were 2 cases. Others
report single case studies. Overall the relationship between neuroblastoma and p53 remains unclear.
Our Patient’s p53 Mutation
Our patient had a germline I162F mutation of his p53 gene. Codon 162 falls within the DNA-binding domain (109 to 288) of the p53 protein.16 DNA binding is vital as p53 binds DNA to activate the transcription of a number of genes to inhibit cell cycle progression, promote apoptosis, and many other functions.
Approximately 75% of mutations in p53 occur as missense mutations within the DNA-binding domain that causes a dominant negative effect by competing with or oligomerizing with the wild-type protein.4,15,17,18 Com- monly, mutations in a protein create a nonfunctional pro- tein (ie, a null mutant). However, it is important to note that not all p53 mutations cause a complete loss of function. Other mutations have been noted to cause gain of function of p53, alteration in p53 binding to transcription factors to increase or decrease their function, and alteration in p53 binding to other proteins outside of the regulation of gene transcription to increase or decrease their function. Fur- thermore, p53 mutants in yeast have been shown to have different activity levels depending on temperature and which promoters it is interacting with.19
Work in yeast has helped shed some light on the pos- sible effects of this specific I162F mutation. I162F mutants were shown to be able activate some promoters of cell cycle arrest and apoptosis normally (ie, wild-type activation) but be unable to activate other (ie, mutant activation). The degree of activation varied between the promoters as did the mutant’s response to each promoter in varied temper- atures.19-23 Thus, it appears the I162F mutation is more complex than many p53 mutations and instead functions as a “partial deficient” mutant.
The clinical sequelae of a partial deficient mutant as compared with a null mutant is still unclear but research suggests that some partial deficient mutants have better clinical outcomes with a lower incidence of multiple tumors and a milder family history.24 For example, 2 p53 mutations, R337H and R175L, have been found to be associated with adrenal cortical carcinoma but these patients and their fam- ilies have not had suffered from the other tumors seen with Li-Fraumeni syndrome. Furthermore, it was found that the R337H mutation only had a 10% penetrance for developing an ACC.25 Although our young man is only 1 single patient and we did not have the opportunity to test his parents to see if the p53 mutation truly ran through his family, one could hypothesis that his I162F mutation could be a partial defi- cient mutant with lower penetrance, a predilection for ACC, and a reprieve from other LFS-associated tumors.
What Makes Our Patient Unique
Here we present a patient who had both an adrenal cortical carcinoma as well as a simultaneous neuro- blastoma. This patient is unique for multiple reasons. First, although ACC are often associated with LFS, neuro- blastoma is rarely reported with LFS.
Second, our patient was only 8 months old when his tumors were discovered. Studies have shown the average age of onset of 29 years for females and 40 for males for a first tumor in a patient with LFS; although, adrenal tumors are known to occur in childhood and have even been shown to occur in the first year of life.7 And neuroblastoma is a malignancy of young childhood.
Third, the fact that our patient had 2 histologically unrelated tumors simultaneously is quite unique. It is well established that LFS patients can have multiple cancers with 1 study showing 15% of patients developed 2 cancers, 4% developed 3, and 2% developed 4 cancers in a life- time.26 It is felt that prior irradiation and chemotherapy plays an additional role in these patients developing addi- tional tumors. But 2 concurrent and histologically unre- lated tumors are very rarely described in the literature. In fact, a literature search revealed only rare cases of patients having compound tumors or 2 histologically different tumors in the same organ. One report by Pivnick et al27 describes a 20-month-old female with germline p53 muta- tion (R248W) and Turner syndrome found to have 2 simultaneous and distinct masses in her adrenal gland with one being a ganglioneuroblastoma and the other being an ACC with a metastatic lung nodule. Interestingly, one of the few other cases in the literature describes a 10-month- old female presenting with a composite adrenal neoplasm with ACC and neuroblastoma found to have the same R248W mutation as the child described by Pivnick et al.28
Finally, we have described a patient found to have a unique germline p53 mutation not previously described in the literature. As of December 2013 there were 729 cases of germline mutations in p53 in p53 database.19 To the best of our knowledge, our patient is only the second patient described with a germline mutation in codon 162 of p53, with the other being a case of cystosarcoma phyllodes of the breast followed by a high-grade sarcoma of the leg with an I162N mutation, and the first patient with the specific germline A13163T mutation of codon 162.29
ACKNOWLEDGMENTS
The authors thank Dr Gilberto Fronza and Dr Lak- shamanan Krishnamurti for their assistance during the preparation of this manuscript.
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