| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Hypertension Unit (L.A., P.-F.P.), Department of Genetics (L.A., N.B., A.-P.G.-R., X.J.), and Clinical Investigation Centre 9201 (S.P.), Hôpital Européen Georges Pompidou, 75908 Paris cedex 15, France; Departments of Endocrinology and Radiology (S.S., J.B., X.B.), Hôpital Cochin, 75679 Paris cedex 14, France; Institut Cochin-Institut National de la Santé et de la Recherche Médicale U-567 (J.B., X.B.), Faculté de Médecine René Descartes, Université Paris 5, 75270 Paris cedex, France; Institut National de la Santé et de la Recherche Médicale U772 (L.A., N.B., X.J., A.-P.G.-R., P.-F.P.), Collège de France, 75231 Paris, France; and Department of Nuclear Medicine and Endocrine Tumors (E.B., M.S.), Institut Gustave Roussy, 94805 Villejuif, France
Address all correspondence and requests for reprints to: Laurence Amar, Hypertension Unit, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75908 Paris cedex 15, France. E-mail: laurence.amar{at}egp.aphp.fr.
 |
Abstract |
|---|
 Top Abstract IntroductionPatients and MethodsResultsDiscussionReferences |
|---|
Objective: The objective was to analyze survival according to clinical characteristics at diagnosis of malignancy and the presence or absence of SDHB mutations.
Design: This was a retrospective cohort study.
Setting and Participants: A total of 54 patients with malignant tumors were included. Malignancy was scored according to the presence of metastases or histologically documented lymph node invasion.
Main Outcome Measures: The main outcome was the specific survival after the diagnosis of the first metastasis.
Results: Germline mutations were identified in SDHB (n = 23, including 21 patients with apparent sporadic tumors) and VHL (n = 1) genes, and two patients had neurofibromatosis 1. Patients were followed up from the diagnosis of primary tumor and from the diagnosis of the first metastasis to the present or to death with medians of 79 [interquartile range (IQR) 24; 190] and 39 [IQR 14; 94] months, respectively. The 5-yr probability of survival after the diagnosis of the first metastasis was 0.55 (95% confidence interval 0.39–0.69). Patients with SDHB mutations were younger, more frequently had extra-adrenal tumors, and had a shorter metanephrine excretion doubling time. The presence of SDHB mutations was significantly and independently associated with mortality (relative risk 2.7; 95% confidence interval 1.2, 6.4; P = 0.021).
Conclusion: SDHB mutations, frequent in patients with malignant pheochromocytomas or paragangliomas, are associated with shorter survival. Therefore, SDHB genetic testing may be of prognostic value for such patients, even those with an apparent sporadic and/or benign presentation at diagnosis.
|
Introduction |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
It was recently reported that patients with chromaffin tumors and mutations in the SDHB gene, encoding succinate dehydrogenase subunit B, have a greater risk than patients with no such mutations of extraadrenal and malignant tumors (14, 15, 16, 17, 18). Here, we report a comparative study of the presentation and clinical course of 54 patients with malignant PHs or PGLs with or without SDHB mutations. Our aim was to analyze survival according to clinical characteristics at diagnosis of malignancy and the presence or absence of SDHB mutations.
|
Patients and Methods |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
We reviewed the records of patients diagnosed with a metastatic PH or PGL, either at referral (malignant primary tumor) or during follow-up (subsequent malignant recurrence), in three tertiary referral centers: the Hypertension Unit in Hôpital Européen Georges Pompidou and the Department of Endocrinology in Hôpital Cochin, Paris; and the Department of Nuclear Medicine and Endocrine Tumors, Institut Gustave Roussy, Villejuif. Patients with the following criteria were included in the analysis:
1. The presence of a PH or a thoracoabdominal PGL documented by pathology examination after surgery or biopsy, except for one patient who had a urinary metanephrine excretion of 2.5 µmol/d and a [123I]metaiodobenzylguanidine (MIBG) uptake on the primary tumor associated with liver, lung, and bone metastases.
2. The presence of metastases either at presentation or during a recurrence. Distant metastases were documented by histology, or as lesions detected by computed tomography (CT) or magnetic resonance (MR) scans and exhibiting [123I]MIBG or [111In]octreotide uptake. The diagnosis of lymph node metastasis was only accepted if confirmed by histology or in patients with associated extraparaganglionic metastases.
3. The availability of leukocyte DNA and informed written consent for its use for PH/PGL genetic testing.
4. The availability of at least one abdomen or thoracic CT scan and one MIBG scan.
Diagnostic procedures and follow-up
The procedures used for PH/PGL diagnosis and treatment were in accordance with institutional guidelines and have been described previously (5, 7, 15, 17, 19, 20). The urinary excretion of total metanephrines (metanephrine plus normetanephrine) was determined by liquid chromatography, and tumors were classified as hypersecreting if metanephrine excretion was above the upper normal limit (19). In cases with hypersecreting tumors, metanephrine excretion was determined every 6 or 12 months and standardized to urinary creatinine levels to reduce intrapatient variation as a consequence of incomplete urine collection. As previously reported, the metanephrine to creatinine ratio increased exponentially with time. This made it possible to calculate a metanephrine doubling time from the diagnosis of malignancy to latest follow-up [doubling time in months is the ratio of the neperian logarithm of 2 to the slope of the individual regression line] (20). The size of primary tumors was determined from fresh specimens during histological examination when available or, if not, by CT or MR scanning.
In cases with benign primary tumors, malignant recurrence was defined as the appearance of a metastasis (documented at reintervention or by combined biochemical and imaging tests) after complete tumor eradication (documented by negative biochemical and imaging tests) (5). Time to malignant recurrence in months was counted between initial operation and documentation of the first metastasis. Follow-up imaging tests were usually performed every 6 or 12 months after the diagnosis of malignancy. The site and size of metastases were determined by CT or MR scanning and MIBG scintigraphy or [111In] octreotide scintigraphy.
Genetic testing
The PH/PGL genetic testing was performed as previously recommended (17). The diagnosis of neurofibromatosis type 1 (NF1) was based on phenotypical criteria (21). All exons of the SDHB, VHL, and SDHD genes, and exons 10, 11, 13, 14, 15, and 16 of the RET gene were directly sequenced. Cases in which no mutations were detected by direct sequencing of the coding exons were screened for large rearrangements in the SDHB, VHL, or SDHD genes by quantitative multiplex PCR of short fluorescent fragments (QMPSFs) (22, 23).
Statistical analysis
Quantitative values are reported as means ± SD or median [interquartile range (IQR)], as appropriate. Probabilities and median times of survival are reported with 95% confidence interval (CI). Differences in baseline characteristics between patients with or without SDHB mutations were assessed using the unpaired Student’s t test or Mann-Whitney U test for quantitative variables, and the 
2 test or Fisher’s exact test for qualitative variables. Survival was analyzed as the number of months from the diagnosis of the first metastasis to last follow-up (patient’s death or last visit before November 2005). The following data were recorded for all patients: age, sex, mutational status, site and grade of the primary tumor, metanephrine levels, presence of distant metastasis at diagnosis of malignancy, and number of metastatic organs. Median survival durations were estimated using the Kaplan-Meier method, and survival curves were compared between groups using the log-rank test. Variables associated with survival with a P value < 0.20 and well-documented prognostic factors, e.g. the presence of distant metastases at diagnosis of malignancy and the number of metastatic organs, were entered into a multivariate analysis using the semi-parametric Cox’s model. Variables that are collinear or for which data were incomplete were not included in the final multivariate model. Point-wise CIs for survival probabilities fitted by the Cox’s model are reported using the log-log survivorship function. All analyses were performed using SAS Statistical Software (version 8.2; SAS Institute Inc., Cary, NC). A P value < 0.05 was considered significant.
|
Results |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
Clinical characteristics
Metastases were detected when the primary tumor was diagnosed in 24 of the 54 patients, whereas 30 patients had apparent benign primary tumors and subsequent metastatic recurrence (Table 1
). For the 30 patients with an apparent benign primary tumor, the median time to the first metastasis was 52 months [IQR 38; 109]; this group included four patients who developed a first metastasis more than 20 yr after the diagnosis of the primary tumor. Patients with metastases at diagnosis of the primary tumor were older (42.1 ± 13.3 vs. 34.5 ± 13.7 yr; P = 0.044) at first operation, and more of them were men (17 of 24 vs. 12 of 30; P = 0.024) than patients with subsequent metastatic recurrences. Other bioclinical and tumoral characteristics did not differ between the two groups. Most patients had hypersecreting tumors. None of the patients had any cancer other than PHs or PGLs.
|
For five patients there was phenotypical evidence and/or a family history suggesting a genetic disease. Two patients had diagnostic criteria for NF1, one had a retinal hemangioblastoma, but no mutation or deletion of the VHL gene, and two patients had a family history of PGLs (both had SDHB mutations). Of the 49 patients with apparent sporadic tumors, 22 had a germline mutation affecting the SDHB (n = 21) or VHL (n = 1) genes. Overall, 26 patients, including 12 with a malignant primary tumor and 14 with metastatic recurrences, had germline mutations or large deletions in SDHB (n = 23) or VHL (467A>G, pY156H, n = 1) genes or phenotypical evidence of NF1 (n = 2). No mutations in the RET or SDHD genes were detected. Patients with a gene mutation, regardless of the nature of the mutation, were younger and more frequently had bilateral tumors than patients without mutation, but the two groups did not differ in metanephrine excretion, primary tumor size, or primary tumor status (benign or malignant).
The germline mutations identified in the SDHB gene are presented in Table 2. They include eight different missense mutations in 13 patients (14, 15, 17, 24, 25), one nonsense (26) and one splicing mutation (27) in one patient each, and three different frame-shift mutations in five patients (15, 16). One of these frame-shift mutations was a deletion of 19 bases in the first exon (Fig. 1A) that has never been reported previously. QMPSF detected large deletions in SDHB in three patients, two with a deletion, including the first exon (28), and one with a deletion from exons 3–8 (Fig. 1B). Clinical features according to the SDHB genetic status are given in Table 3. The SDHB mutation carriers were younger, had a shorter metanephrine excretion doubling time, and more frequently had extraadrenal tumors than the SDHB mutation-negative patients. The uptake of MIBG and radiolabeled octreotide did not differ between patients with or without SDHB mutations. A total of 54 patients underwent at least one [123I]MIBG scintigraphy; MIBG uptake was seen in 19 of 23 patients with SDHB mutations and 28 of 31 with no SDHB mutation. There were 23 patients who underwent an Octreoscan; radiolabeled octreotide was taken up in two of 16 patients with SDHB mutations and two of seven with no SDHB mutation. The median time from the diagnosis of primary tumor to the documentation of a first metastasis was 4 months in patients with SDHB mutations and 20 months in patients without. There was no difference in presentation or outcome between the 28 patients with sporadic tumors and the three patients with familial tumors, two patients with NF1 and one patient with a VHL mutation, but no SDHB mutation. We found no relevant genotype-phenotype correlation among patients with SDHB mutations.
|
|
|
The first diagnosed distant metastasis affected a single organ in 32 patients: the skeleton (n = 17, including seven patients with subsequent lymph node metastases); liver (n = 8, including three patients with subsequent lymph node metastases); lungs (n = 4, including two patients with subsequent lymph node metastases); pancreas (n = 1, patient with subsequent lymph node metastases); or were intraarterial tumor extensions (n = 2). Nine patients had multiple distant metastases at diagnosis of malignancy, and in 13 patients the malignancy was first diagnosed by observation of invasion of lymph nodes. Including all patients and all lengths of follow-up, the most frequent metastases involved lymph nodes (n = 38), the skeleton (n = 37), liver (n = 25), and lungs (n = 21). Median time from the diagnosis of primary tumor to diagnosis of metastases was 33 months [IQR 0; 64] for lymph nodes, 36 months [IQR 10; 68] for skeleton, 34 months [IQR 1; 100] for liver, and 47 months [IQR 17; 98] for lung metastases. A few patients had metastases in the brain (n = 1), peritoneum (n = 5), pancreas (n = 2), breast (n = 1), stomach (n = 1), or pituitary (n = 1). Among the 38 patients who had lymph node invasion at some time during follow-up, only three had no other metastatic invasion.
Survival
All included patients were followed up to November 2005 or death. Median times from the diagnosis of the primary tumor and from the diagnosis of the first metastasis to last follow-up were 79 [IQR 24; 190] and 39 months [IQR 14; 94], respectively. For the 26 patients who died during follow-up, median time from the diagnosis of the primary tumor to death was 76 months [IQR 10; 124] and from the diagnosis of the first metastasis to death was 38 months [IQR 10; 63]. Causes of death were progression of metastatic disease (n = 14), complications of catecholamine hypersecretion (intestinal obstruction in six, malignant hypertension in one, pulmonary edema in one), iatrogenic complications (one perioperative death, one aplasia after chemotherapy), and unknown (n = 2).
The 5-yr probability of survival after the diagnosis of the first metastasis was 0.55 (95% CI 0.39–0.69) (Table 4). It was 0.36 (0.15–0.57) in SDHB mutation carriers and 0.67 (0.47–0.81) in the absence of SDHB mutation (relative risk 2.6; P = 0.019). Median survival after the diagnosis of the first metastasis was 42 months (95% CI 35–79) for the SDHB mutation carriers and 244 months (63–244) for patients with no SDHB mutation (Fig. 2). Survival tended to be lower for patients aged 40 yr or more at diagnosis of primary tumor, and patients with hypersecreting tumors, with malignant primary tumors or with distant metastases at diagnosis of malignancy, than for patients without these characteristics. It was very similar for men and women, and for patients with adrenal (PH proper) and those with extraadrenal (PGL) primary tumors. We used multivariate analysis to test age at diagnosis, the presence of a SDHB germline mutation, malignancy at presentation, the number of metastatic sites, and the presence of distant metastases at diagnosis of malignancy. Only the presence of SDHB mutations was significantly and independently associated with survival. The relative risk of death was 2.7 (95% CI 1.2, 6.4; P = 0.021) for patients carrying SDHB mutations.
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
We describe a series of 54 patients with malignant PHs or PGLs, and this is a number of patients similar to that for all previous series combined. All were followed from the diagnosis of malignancy to November 2005 or death. Four patients had evidence of a first metastasis more than 20 yr after resection of the primary tumor, which underlines the need for a life-long follow-up of patients operated on for PHs or PGLs (3, 4, 5, 6, 7, 8). All patients had lymph node or distant metastases documented at histology, and/or, in the case of distant metastases, by imaging studies. In decreasing order of frequency and increasing order of time from diagnosis of the primary tumor, metastases were documented in lymph nodes, the skeleton, liver, and lungs. A total of 34 patients underwent at least one reintervention at the site of the primary tumor and/or at the site of metastases, 21 patients underwent metabolic radiotherapy using one or several doses of [131I]MIBG, 19 underwent at least one tumor embolization, and 12 received chemotherapy using various drug combinations. Because many patients received multiple therapies in various sequences, the therapeutic response to reinterventions, MIBG therapy, embolization, or chemotherapy could not be analyzed according to the presence or absence of SDHB mutations This series was appropriate for the analysis of survival of malignant PH/PGL patients according to clinical, tumoral, and genetic characteristics.
Of our 54 patients with malignant PH/PGL, 23 (43%) had an SDHB gene mutation, including three cases with large deletions of one or several coding exons (Table 2
and Fig. 1). The same frequency of mutations or deletions was found in patients with apparent sporadic tumors, i.e. without syndromic presentation or family history of PH/PGL (21 of 49 patients, 43%); this strongly supports the value of SDHB mutation testing in all patients with PHs or PGLs (18, 29, 30). Extraadrenal tumors at presentation were more than twice as frequent in SDHB mutation carriers than in patients without SDHB mutations (Table 3). Survival was significantly and independently related to the presence of SDHB mutations, but not to the site of the primary tumor (Table 4). This suggests that the more aggressive outcome of PGLs than PHs described in the literature reflects undiagnosed SDHB mutations. Many studies reporting this finding were conducted before the era of comprehensive genetic testing. This finding does not exclude the primary tumor site having prognostic value, with patients harboring PGLs being more prone to subsequent malignancy and having a shorter survival than those with PHs. However, our study included only patients with documented malignant tumors. A large cohort of patients with PH/PGL at risk for malignancy would be needed to assess the respective value of SDHB mutation status and primary tumor site to predict subsequent metastases. Besides, the small numbers of SDHB-negative patients with PHs (n = 22) and with PGLs (n = 9) in our study precluded a meaningful comparison of survival by tumor site independent of SDHB mutation status. SDHB mutation carriers with malignant PH/PGL were younger than patients with no SDHB mutations, but only the presence of SDHB mutations, not age at diagnosis, was significantly associated with survival (Tables 3 and 4). Median time from presentation to evidence of a first metastasis was 4 months for patients with SDHB mutations and 20 months in patients without. SDHB mutation carriers also displayed a faster progression of catecholamine hypersecretion with a shorter metanephrine excretion doubling time than SDHB mutation-negative patients (Table 3). In multivariate analysis, the presence of SDHB germline mutations was consistently and independently associated with survival. Therefore, our study demonstrates that the presence of SDHB germline mutations is associated with a poor outcome in patients with malignant PH/PGL. As far as we know, this is the first example involving endocrine tumors in which the presence of a mutation has a prognostic value independent of tumor stage or tumor burden.
Our study includes a relatively large number of patients with malignant PHs or PGLs followed up to the present or death, and uses a robust definition of malignancy and sensitive methods for PH/PGL genetic testing. However, it is retrospective, and, therefore, there are risks of referral biases and nonstandardized follow-up and therapeutic management. The constitution of a prospective cohort involving all patients with PH/PGL in a geographically defined area, regardless of tumor status at referral, is feasible. However, given the rarity of validating events, i.e. the presence of metastases at presentation or during follow-up, and the possibility of very late metastatic recurrences, it would be a very long-term project.
Our findings have important clinical implications. First, a sporadic presentation does not exclude the presence of SDHB mutations, probably because SDHB-related PH/PGL has a low penetrance (16, 23, 29), so all patients with PH/PGL should be offered genetic testing for SDHB mutations (31, 32). Second, all patients with PH/PGL, including those with apparent benign tumors at presentation, and particularly SDHB mutation carriers, should be subject to indefinite follow-up because they are exposed to the risk of malignant recurrence. Third, in cases in which malignancy is documented, either at presentation or during a recurrence, the identification of germline SDHB mutations is predictive of a rapid metastatic spread; therefore, such cases probably require aggressive management combining surgery, metabolic radiotherapy, and, possibly, chemotherapy.
|
Acknowledgments |
|---|
|
Footnotes |
|---|
Disclosure Statement: The authors have nothing to disclose.
First Published Online July 24, 2007
1 A.-P.G.-R. and P.-F.P. contributed equally to this work. 
Abbreviations: CI, Confidence interval; CT, computed tomography; IQR, interquartile range; MIBG, metaiodobenzylguanidine; MR, magnetic resonance; NF1, neurofibromatosis type 1; PGL, paraganglioma; PH, pheochromocytoma; QMPSF, quantitative multiplex PCR of short fluorescent fragment.
Received March 28, 2007.
Accepted July 12, 2007.
|
References |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
|---|
This article has been cited by other articles:
 |
|
 |
|
  Z. Erlic, L. Rybicki, M. Peczkowska, H. Golcher, P. H. Kann, M. Brauckhoff, K. Mussig, M. Muresan, A. Schaffler, N. Reisch, et al. Clinical Predictors and Algorithm for the Genetic Diagnosis of Pheochromocytoma Patients Clin. Cancer Res., October 15, 2009; 15(20): 6378 - 6385. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J.-P. Bayley, M. M Weiss, A. Grimbergen, B. T J van Brussel, F. J Hes, J. C Jansen, S. Verhoef, P. Devilee, E. P Corssmit, and A. H J T Vriends Molecular characterization of novel germline deletions affecting SDHD and SDHC in pheochromocytoma and paraganglioma patients Endocr. Relat. Cancer, September 1, 2009; 16(3): 929 - 937. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. P. H. Neumann and C. Eng The Approach to the Patient with Paraganglioma J. Clin. Endocrinol. Metab., August 1, 2009; 94(8): 2677 - 2683. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Burnichon, V. Rohmer, L. Amar, P. Herman, S. Leboulleux, V. Darrouzet, P. Niccoli, D. Gaillard, G. Chabrier, F. Chabolle, et al. The Succinate Dehydrogenase Genetic Testing in a Large Prospective Series of Patients with Paragangliomas J. Clin. Endocrinol. Metab., August 1, 2009; 94(8): 2817 - 2827. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. J L M Timmers, A.-P. Gimenez-Roqueplo, M. Mannelli, and K. Pacak Clinical aspects of SDHx-related pheochromocytoma and paraganglioma Endocr. Relat. Cancer, June 1, 2009; 16(2): 391 - 400. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Jimenez, M. E. Cabanillas, L. Santarpia, E. Jonasch, K. L. Kyle, E. A. Lano, S. F. Matin, R. F. Nunez, N. D. Perrier, A. Phan, et al. Use of the Tyrosine Kinase Inhibitor Sunitinib in a Patient with von Hippel-Lindau Disease: Targeting Angiogenic Factors in Pheochromocytoma and Other von Hippel-Lindau Disease-Related Tumors J. Clin. Endocrinol. Metab., February 1, 2009; 94(2): 386 - 391. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A Cascon, I Landa, E Lopez-Jimenez, A Diez-Hernandez, M Buchta, C Montero-Conde, S Leskela, L J Leandro-Garcia, R Leton, C Rodriguez-Antona, et al. Molecular characterisation of a common SDHB deletion in paraganglioma patients J. Med. Genet., April 1, 2008; 45(4): 233 - 238. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Lima, T. Feijao, A. Ferreira da Silva, I. Pereira-Castro, G. Fernandez-Ballester, V. Maximo, A. Herrero, L. Serrano, M. Sobrinho-Simoes, and G. Garcia-Rostan High Frequency of Germline Succinate Dehydrogenase Mutations in Sporadic Cervical Paragangliomas in Northern Spain: Mitochondrial Succinate Dehydrogenase Structure-Function Relationships and Clinical-Pathological Correlations J. Clin. Endocrinol. Metab., December 1, 2007; 92(12): 4853 - 4864. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Endocrinology | Endocrine Reviews | J. Clin. End. & Metab. |
| Molecular Endocrinology | Recent Prog. Horm. Res. | All Endocrine Journals |
