Fast track — ArticlesAn immunohistochemical procedure to detect patients with paraganglioma and phaeochromocytoma with germline SDHB, SDHC, or SDHD gene mutations: a retrospective and prospective analysis
Introduction
Phaeochromocytomas and paragangliomas are rare, usually benign, highly vascularised tumours that both originate from neural-crest-derived chromaffin cells. The term phaeochromocytoma is reserved for intra-adrenal tumours, whereas similar but extra-adrenal tumours are termed paragangliomas. Paragangliomas are subdivided into sympathetic and parasympathetic paragangliomas, depending on their location and catecholamine production. Parasympathetic paragangliomas are located in the head and neck region, and usually do not produce catecholamines, whereas sympathetic paragangliomas are situated along the sympathetic trunk in the abdomen, and usually produce catecholamines.1
Phaeochromocytomas and paragangliomas occur sporadically and in the context of several inherited tumour syndromes, including multiple endocrine neoplasia type 2 (MEN2, with RET gene germline mutations), von Hippel–Lindau (VHL) disease (caused by germline mutations in the VHL gene), neurofibromatosis type 1 (NF1, with NF1 gene germline mutations), and the phaeochromocytoma–paraganglioma syndrome.2, 3 The latter syndrome is the most frequent hereditary condition with manifestation of paragangliomas, and is caused by germline mutations in the SDHB, SDHC, or SDHD genes. The syndrome is characterised by the familial occurrence of phaeochromocytomas or paragangliomas, usually at a young age, and often by multifocal disease with an increased risk of recurrence and an increased frequency of malignancy in the case of SDHB mutations.4 SDHB, SDHC, and SDHD encode three of four subunits of mitochondrial complex II, the succinate-ubiquinone oxidoreductase (succinate dehydrogenase) enzyme located at the crossroads between the mitochondrial aerobic electron transport chain and the tricarboxylic acid cycle.5 Recent studies showed that SDH inactivation induces angiogenesis and tumorigenesis through the inhibition of hypoxia-inducible factors (HIF)-prolyl hydroxylase.6 The SDHB, SDHC, and SDHD genes are bona fide tumour-suppressor genes, as biallelic inactivation is found in phaeochromocytoma–paraganglioma-syndrome tumours (inherited inactivating germline mutation and acquired inactivating mutation of the corresponding wild-type allele in the tumour).7
With the exception of the NF1 syndrome, where the cutaneous café-au-lait spots are characteristic,8 patients with inherited phaeochromocytomas and paragangliomas often go without clinical detection. In large published series of patients with phaeochromocytomas and paragangliomas, it has been shown that 25–30% of patients have an inherited form and 12% of patients with an apparently sporadic phaeochromocytoma and paraganglioma have unexpected germline mutations in VHL, SDHB, or SDHD genes.3, 7, 8, 9 The underdiagnosis of patients with inherited phaeochromocytoma and paraganglioma is the result of a combination of factors, including lack of family information, overlap in age distribution between hereditary and sporadic cases, de-novo mutations, incomplete penetrance (SDHB), parent-of-origin effects on penetrance (SDHD), phenotypic heterogeneity of the disease, and insufficient awareness of clinicians. There is controversy among experts as to whether RET, VHL, SDHB, SDHC, and SDHD genetic testing should be done in all patients with phaeochromocytoma and paraganglioma. Many experts have advocated that molecular genetic testing should be targeted in patients fulfilling specific clinical criteria.4, 10, 11, 12 However, reliable clinical indicators for the presence of SDHB, SDHC, and SDHD germline mutations in patients with phaeochromocytoma and paraganglioma are often absent.
Hidden heredity is most pronounced for patients with apparently sporadic parasympathetic paragangliomas, with up to 34% of cases having a germline mutation in SDHD.13 Clinical indications with high specificity but low sensitivity for the detection of phaeochromocytoma–paraganglioma syndrome (family history of phaeochromocytoma or paraganglioma, multifocal disease, younger age at onset, and malignant tumours) are insufficient for correct diagnosis of the syndrome. The detection of inherited phaeochromocytoma–paraganglioma syndrome is of major importance for patients with phaeochromocytoma and paraganglioma, as well as for their family members, since they are at an increased risk of developing multiple, various, and malignant neoplasms.4, 14, 15, 16 Additionally, after identification of an SDHB, SDHC, or SDHD germline mutation, surveillance can be offered to the individual patient with the paraganglionic tumour and to any family members who carry the mutation. Mutation analysis of SDHB, SDHC, and SDHD has been advocated to diagnose phaeochromocytoma–paraganglioma syndrome in all cases of phaeochromocytoma and paraganglioma where there are no clear clinical or family indications for the syndrome.16 Although SDH-mutation carriers will be identified frequently by mutation analysis of all patients with phaeochromocytomas and paragangliomas, most cases will be without mutation, making this genetic-screening strategy a labour-intensive and financially demanding procedure. Phaeochromocytoma–paraganglioma syndrome tumours differ from sporadic phaeochromocytomas and paragangliomas by the presence of SDHB, SDHC, or SDHD mutations, which are, except for a few incidental cases,17, 18 not found in truly sporadic phaeochromocytomas and paragangliomas. Despite this genotypic difference, no reliable phenotypic discrimination between sporadic phaeochromocytomas and paragangliomas, and phaeochromocytoma–paraganglioma syndrome-related tumours, is possible at present. In the present study we determined the value of SDHB immunohistochemistry for discriminating between SDH-related and non-SDH-related phaeochromocytomas and paragangliomas in large retrospective and prospective series in two different centres.
Section snippets
Patients
Two retrospective series of phaeochromocytomas and paragangliomas were investigated by SDHB immunohistochemistry (Erasmus MC, Rotterdam, Netherlands, 110 cases; Hôpital Européen Georges Pompidou and Hôpital Cochin, Paris, France, 65 cases). These series consisted of phaeochromocytomas diagnosed at Erasmus MC between 1982 and 2007, and diagnosed at INSERM U970 between 1995 and 2007, and of paragangliomas diagnosed in Erasmus MC between 1993 and 1998, and in INSERM U970 between 1993 and 2008. The
Results
Immunohistochemical staining was done on all 220 tumour samples. Of these tumours, 102 had a germline SDH mutation (36 SDHB, five SDHC and 61 SDHD) and all were negative for SDHB immunohistochemistry (figure 1A–C). In four SDH-mutated tumours (SDHB p.Cys98Arg and p.Pro197Arg, and SDHD p.Asp92Tyr and c.169_169+9delTGTATGTTCT) a weak and diffuse cytoplasmic SDHB immunoreactivity was seen in the tumour cells, clearly distinct from the strong speckled pattern present in normal cells of the
Discussion
The results of this study show that SDHB immunohistochemistry on routine FFPE paragangliomas and phaeochromocytomas can reveal the presence of SDHB, SDHC, and SDHD germline mutations with a high degree of reliability. The absence of SDHB staining in tumour cells was found irrespective of whether SDHB, SDHC, or SDHD is mutated, and regardless of the type of mutation, whether missense, nonsense, splice site, or frameshift. The SDHB protein-expression results obtained by immunohistochemistry using
References (33)
- et al.
Phaeochromocytoma
Lancet
(2005) Succinate:quinone oxidoreductases: an overview
Biochim Biophys Acta
(2002)- et al.
The R22X mutation of the SDHD gene in hereditary paraganglioma abolishes the enzymatic activity of complex II in the mitochondrial respiratory chain and activates the hypoxia pathway
Am J Hum Genet
(2001) - et al.
Most rare missense alleles are deleterious in humans: implications for complex disease and association studies
Am J Hum Genet
(2007) - et al.
Immunological approaches to the characterization and diagnosis of mitochondrial disease
Mitochondrion
(2004) - et al.
Phaeochromocytoma: an update on genetics and management
Endocr Relat Cancer
(2007) - et al.
Recent insights into the molecular pathogenesis of phaeochromocytoma and paraganglioma
Endocr Pathol
(2006) - et al.
Genetic testing in phaeochromocytoma or functional paraganglioma
J Clin Oncol
(2005) - et al.
Mitochondrial tumour suppressors: a genetic and biochemical update
Nat Rev
(2005) - et al.
Comprehensive mutation scanning of NF1 in apparently sporadic cases of phaeochromocytoma
J Clin Endocrinol Metab
(2006)
Germ-line mutations in nonsyndromic phaeochromocytoma
N Engl J Med
Genetic testing in phaeochromocytoma- and paraganglioma-associated syndromes
Ann N Y Acad Sci
Phaeochromocytoma, new genes and screening strategies
Clin Endocrinol (Oxf)
Clinical predictors for germline mutations in head and neck paraganglioma patients: cost reduction strategy in genetic diagnostic process as fall-out
Cancer Res
Frequent germ-line succinate dehydrogenase subunit D gene mutations in patients with apparently sporadic parasympathetic paraganglioma
Clin Cancer Res
Clinical presentation and penetrance of phaeochromocytoma/paraganglioma syndromes
J Clin Endocrinol Metab
Cited by (438)
Hereditary succinate dehydrogenase-deficient renal cell carcinoma
2024, Seminars in Diagnostic PathologyResearch progress on the pathogenesis of the SDHB mutation and related diseases
2023, Biomedicine and PharmacotherapySuccinate Dehydrogenase Mutations as Familial Pheochromocytoma Syndromes
2023, Surgical Oncology Clinics of North AmericaBack to Biochemistry: Evaluation for and Prognostic Significance of SDH Mutations in Paragangliomas and Pheochromocytomas
2023, Surgical Pathology ClinicsSurgical and postsurgical management of abdominal paragangliomas and pheochromocytomas
2023, Actas Urologicas EspanolasMethylation and hydroxymethylation in cancer
2023, Epigenetic Cancer Therapy, Second Edition
- *
These authors contributed equally to the paper
- †
Dr Verhofstad died in March, 2008
- ‡
These authors should be considered equal last authors