Multiple hepatoblastomas with positive β-catenin immunostaining as a potential indication for germline APC genetic testing: A case report

IF 1.3 4区 医学 Q3 PEDIATRICS
Takeshi Sato, Chihiro Takata, Jumpei Ito, Hiroyuki Shimada, Tomonobu Hasegawa
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His parents and elder brother, aged 3 years old, had no history of hepatoblastoma or adenomatous polyposis (Figure 1A). At the age of 1 year, he presented with abdominal distention and poor feeding. A huge mass was palpable in his upper right abdomen. The blood test showed high alpha-fetoprotein level (96,129 ng/mL, reference 10–50). Abdominal contrast-enhanced magnetic resonance imaging revealed three liver lesions, which size were almost 1.2 cm in S4 area, 13.0 cm in S5-6 area, and 3.0 cm in S7 area (Figure 1B,C). Multiple hepatoblastomas were diagnosed. No metastasis or vascular infiltrations were seen. After the chemotherapy, a right lobectomy was performed. Pathological examination of the resected main tumor showed a cord-like structure of small atypical cells, which is similar to the fetal liver cells, confirming hepatoblastoma. Immunohistochemistry staining showed positive β-catenin in the nuclei of tumor cells (Figure 1D). After obtaining written consent from the patient's parents for genetic testing, we performed next-generation sequencing in tumor samples and found a previously reported heterozygous nonsense variant, <i>APC</i> (NM_000038.6) c.3340C &gt; T, p.Arg1114*.<span><sup>2</sup></span> This variant was also identified in the peripheral blood by Sanger sequencing. This variant was not identified in either parent (Figure 1A). We shared with his parents the following information: (i) this germline <i>APC</i> variant caused hepatoblastoma in our patient, (ii) due to the potential risk for additional hepatoblastoma, regular checkups were strongly recommended, (iii) our patient may develop a less severe type of adenomatous polyposis from adolescence,<span><sup>2</sup></span> and (iv) this germline <i>APC</i> variant may cause other diseases, including brain tumors and osteoma.</p><p>Multiple lesions in identical organs are common in patients with cancer predisposing genetic background. 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First, we may assess the risk of developing additional hepatoblastomas in the residual liver after the surgical treatment for primary hepatoblastoma. Theoretically, the residual liver tissues would have much higher risk of hepatoblastoma than general population. Second, we may predict the severity of colorectal polyposis during adolescence and adulthood based on <i>APC</i> PVs, although the correlation between hepatoblastoma-associated <i>APC</i> PVs and the severity of colorectal polyposis is not fully understood. <i>APC</i> p.Gln999* causes hepatoblastoma as well as classic familial adenomatous polyposis, while the severity of colorectal polyposis of <i>APC</i> p.Arg1114* in our patient is not well known. 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Further studies and discussion are necessary to determine candidates for genetic testing and appropriate analysis method.</p><p>The work was supported by Novo Nordisk Pharma Ltd. and JCR Pharmaceuticals Co., Ltd.</p><p>The authors declare no conflict of interest.</p><p>This study has been approved by the ethical committee at Keio University School of Medicine (approval number: 20170130).</p>","PeriodicalId":10626,"journal":{"name":"Congenital Anomalies","volume":null,"pages":null},"PeriodicalIF":1.3000,"publicationDate":"2024-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/cga.12556","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Congenital Anomalies","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1111/cga.12556","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"PEDIATRICS","Score":null,"Total":0}
引用次数: 0

Abstract

Germline APC pathogenic variants (PVs) are found in around 5%–10% of patients with hepatoblastoma.1 Previous studies have shown conflicting opinion about the necessity of the routine genetic testing to identify germline APC PVs.1 To date, candidates for genetic testing and appropriate analysis method remain unknown. Here, we experienced an infantile case of multiple hepatoblastomas with β-catenin positivity and identified a germline APC PV.

Our patient was the second child of healthy parents. His parents and elder brother, aged 3 years old, had no history of hepatoblastoma or adenomatous polyposis (Figure 1A). At the age of 1 year, he presented with abdominal distention and poor feeding. A huge mass was palpable in his upper right abdomen. The blood test showed high alpha-fetoprotein level (96,129 ng/mL, reference 10–50). Abdominal contrast-enhanced magnetic resonance imaging revealed three liver lesions, which size were almost 1.2 cm in S4 area, 13.0 cm in S5-6 area, and 3.0 cm in S7 area (Figure 1B,C). Multiple hepatoblastomas were diagnosed. No metastasis or vascular infiltrations were seen. After the chemotherapy, a right lobectomy was performed. Pathological examination of the resected main tumor showed a cord-like structure of small atypical cells, which is similar to the fetal liver cells, confirming hepatoblastoma. Immunohistochemistry staining showed positive β-catenin in the nuclei of tumor cells (Figure 1D). After obtaining written consent from the patient's parents for genetic testing, we performed next-generation sequencing in tumor samples and found a previously reported heterozygous nonsense variant, APC (NM_000038.6) c.3340C > T, p.Arg1114*.2 This variant was also identified in the peripheral blood by Sanger sequencing. This variant was not identified in either parent (Figure 1A). We shared with his parents the following information: (i) this germline APC variant caused hepatoblastoma in our patient, (ii) due to the potential risk for additional hepatoblastoma, regular checkups were strongly recommended, (iii) our patient may develop a less severe type of adenomatous polyposis from adolescence,2 and (iv) this germline APC variant may cause other diseases, including brain tumors and osteoma.

Multiple lesions in identical organs are common in patients with cancer predisposing genetic background. We speculate that multiple hepatoblastomas could be also suggestive of the presence of the germline PVs. We detected positive β-catenin immunostaining in the nuclei of tumor cells in our patient. Previous studies showed (i) in hepatoblastomas with β-catenin positivity, tumor-driving CTNNB1 or APC variants were found in a mutually exclusive nature, (ii) somatic activating CTNNB1 variants are found in 60%–80% of hepatoblastomas, while somatic APC PVs are rarely found, (iii) only a few germline CTNNB1 variants have been reported in patients with colorectal adenomas, and (iv) the cases with germline APC PVs had much more lesions compared to the cases without.3 Thus, it is reasonable to examine germline APC PVs in patients who have multiple hepatoblastomas with positive β-catenin immunostaining.

There are two potential benefits of identifying an APC germline PV. First, we may assess the risk of developing additional hepatoblastomas in the residual liver after the surgical treatment for primary hepatoblastoma. Theoretically, the residual liver tissues would have much higher risk of hepatoblastoma than general population. Second, we may predict the severity of colorectal polyposis during adolescence and adulthood based on APC PVs, although the correlation between hepatoblastoma-associated APC PVs and the severity of colorectal polyposis is not fully understood. APC p.Gln999* causes hepatoblastoma as well as classic familial adenomatous polyposis, while the severity of colorectal polyposis of APC p.Arg1114* in our patient is not well known. Thus, identification of APC PVs helps us to plan management in the short and long term.

Hepatoblastoma-related variants are clustered 5′ from codon 1309 in APC4 and can be analyzed by Sanger sequencing, which is rapid and relatively low-cost, compared to next-generation sequencing. Patients with hepatoblastoma rarely have exon deletion or entire gene deletion in APC. These imply that Sanger sequencing on limited area of APC is feasible to screen germline APC PVs in hepatoblastoma.

In conclusion, patients harboring multiple hepatoblastomas with positive β-catenin immunostaining may be candidates for germline APC testing. Also, Sanger sequencing may be appropriate screening analysis method. Further studies and discussion are necessary to determine candidates for genetic testing and appropriate analysis method.

The work was supported by Novo Nordisk Pharma Ltd. and JCR Pharmaceuticals Co., Ltd.

The authors declare no conflict of interest.

This study has been approved by the ethical committee at Keio University School of Medicine (approval number: 20170130).

Abstract Image

β-catenin免疫染色阳性的多发性肝母细胞瘤是种系APC基因检测的潜在适应症:病例报告。
约有 5%-10%的肝母细胞瘤患者可发现种系 APC 致病变体(PVs)。1 先前的研究显示,对于是否有必要进行常规基因检测以识别种系 APC PVs,各方观点不一。在这里,我们经历了一例β-catenin阳性的多发性肝母细胞瘤婴儿病例,并确定了种系APC PV。他的父母和 3 岁的哥哥都没有肝母细胞瘤或腺瘤性息肉病史(图 1A)。一岁时,他出现腹胀和进食困难。他的右上腹可触及巨大肿块。血液检查显示甲胎蛋白水平较高(96 129 纳克/毫升,参考值为 10-50)。腹部造影剂增强磁共振成像显示有三个肝脏病灶,S4 区近 1.2 厘米,S5-6 区 13.0 厘米,S7 区 3.0 厘米(图 1B、C)。确诊为多发性肝母细胞瘤。未见转移或血管浸润。化疗后,患者接受了右肝叶切除术。切除的主瘤病理检查显示,小的非典型细胞呈条索状结构,与胎儿肝细胞相似,确诊为肝母细胞瘤。免疫组化染色显示肿瘤细胞核中β-catenin阳性(图1D)。在征得患者父母的书面同意进行基因检测后,我们对肿瘤样本进行了新一代测序,发现了一个之前报道过的杂合子无义变异APC (NM_000038.6) c.3340C > T, p.Arg1114*。父母双方均未发现该变异(图 1A)。我们与他的父母分享了以下信息:(i) 这个种系 APC 变异导致我们的患者患上肝母细胞瘤;(ii) 由于可能存在其他肝母细胞瘤的风险,我们强烈建议他们定期进行体检;(iii) 我们的患者可能从青春期开始患上一种不太严重的腺瘤性息肉病;2 (iv) 这个种系 APC 变异可能导致其他疾病,包括脑瘤和骨瘤。我们推测,多发性肝母细胞瘤也可能提示存在种系 PV。我们在患者的肿瘤细胞核中检测到阳性的β-catenin免疫染色。之前的研究表明:(i) 在β-catenin阳性的肝母细胞瘤中,肿瘤驱动型CTNNB1或APC变异具有相互排斥的性质;(ii) 60%-80%的肝母细胞瘤中存在体细胞活化型CTNNB1变异,而体细胞APC变异则不存在、(iii)只有少数报道在结直肠腺瘤患者中发现了种系 CTNNB1 变异,(iv)与没有发现种系 APC 变异的病例相比,有种系 APC 变异的病例的病变要多得多。3因此,在多发性肝母细胞瘤β-catenin免疫染色阳性的患者中检查种系APC PV是合理的。首先,我们可以评估原发性肝母细胞瘤手术治疗后残留肝脏中发生其他肝母细胞瘤的风险。从理论上讲,残余肝组织发生肝母细胞瘤的风险要比普通人群高得多。其次,我们可以根据 APC PV 预测青少年和成年期结直肠息肉病的严重程度,尽管肝母细胞瘤相关 APC PV 与结直肠息肉病严重程度之间的相关性尚未完全明了。APC p.Gln999*会导致肝母细胞瘤和典型的家族性腺瘤性息肉病,而我们患者的 APC p.Arg1114*的结直肠息肉病的严重程度尚不清楚。肝母细胞瘤相关变异集中在 APC4 密码子 1309 的 5′处,可通过桑格测序进行分析,与新一代测序相比,桑格测序快速且成本相对较低。肝母细胞瘤患者很少出现 APC 外显子缺失或全基因缺失。总之,携带β-catenin免疫染色阳性的多发性肝母细胞瘤患者可能是种系APC检测的候选者。此外,桑格测序也可能是合适的筛选分析方法。本研究得到了诺和诺德制药有限公司(Novo Nordisk Pharma Ltd.)和JCR制药有限公司(JCR Pharmaceuticals Co., Ltd.)的支持。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Congenital Anomalies
Congenital Anomalies PEDIATRICS-
自引率
0.00%
发文量
49
审稿时长
>12 weeks
期刊介绍: Congenital Anomalies is the official English language journal of the Japanese Teratology Society, and publishes original articles in laboratory as well as clinical research in all areas of abnormal development and related fields, from all over the world. Although contributions by members of the teratology societies affiliated with The International Federation of Teratology Societies are given priority, contributions from non-members are welcomed.
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