Multiple endocrine neoplasia type 1 (MEN1) in two ... - Springer Link

Hum Genet (1994) 94:468472

9 Springer-Verlag 1994

B. T. T e h I 9 S. I. Hii I 9 R. David 9 V. Parameswaran S. G r i m m o n d 9 M. K. Walters 9 T. T. Tan D. J. Nancarrow 9 S. R C h a n 9 J. Mennon 9 C. Larsson A. Zaini - B. A. K. Khalid 9 J. J. Shepherd. D. R Cameron N. K. Hayward

Multiple endocrine neoplasia type 1 (MEN1) in two Asian families

Received: 15 February 1994 / Revised: 26 April 1994

A b s t r a c t Multiple endocrine neoplasia type 1 (MEN1), an autosomal dominant disease characterized by neoplasia of the parathyroid glands, anterior pituitary and endocrine pancreas, is rarely reported in Asian populations, The M E N 1 gene, mapped to c h r o m o s o m e 11 q 13 but yet to be cloned, has been found to be homogeneous in Caucasian populations through linkage analysis. Here, two previously unreported Asian kindreds with MEN I are described; linkage analysis using microsatellite polymorphic markers in the MEN1 region was carried out. The first kindred, o f Mongolian-Chinese origin, is a multigeneration family with over 150 living members, eight o f w h o m are affected to

B. T. Teh ([Y;%. D. P. Cameron Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba 4102, Australia S. I. Hii . S. Grimmond - M. K. Walters 9 D. J. Nancarrow N. K, Hayward Queensland Cancer Fund Research Unit, Joint Experimental Oncology Program, Queensland Institute of Medical Research, Herston, 4029, Australia R. David. J. J. Shepherd Department of Surgery, University of Tasmania, Hobart, Australia V. Parameswaran Department of Endocrinology, Royal Hobart Hospital, Tasmania, Australia T. T. Tan. B. A. K. Khalid Faculty of Medicine, University Kebangsaan Malaysia, Malaysia S. P. Chan. A. Zaini Faculty of Medicine, University of Malaya, Malaysia J. Mennon Queen Elizabeth Hospital, Sabah, Malaysia C. Larsson 9 B. T. Teh Department of Clinical Genetics, Karolinska Institute, Stockholm, Sweden I B. T. Teh and S. I. Hii are to be considered as joint first authors

date. The second kindred is of Chinese origin consisting of four affected members. Linkage to c h r o m o s o m e 11 q 13 was confirmed in both kindreds, supporting evidence for genetic homogeneity. A recombination in the larger kindred localizes the gene distal to marker D 11 $956, consistent with its placement from previous studies. We also show that it is feasible to use these markers for predictive testing, as four gene carriers were detected in 13 family members with unknown disease status in the first kindred.

Introduction Multiple endocrine neoplasia type 1 ( M E N I ) is an autosomal dominantly inherited disease predisposing to neoplasia o f the parathyroid glands, the anterior pituitary and the endocrine pancreas/duodenum (Wermer 1954). Other less frequently associated features include lipomata, atypical carcinoids o f the thymus and bronchus, and adenomata or carcinomas of the adrenal cortex (Wilkinson et al. 1993). The M E N 1 gene has been mapped to c h r o m o s o m e 11 q 13 (Larsson et al. 1988) by linkage analysis in families segregating the disease but is yet to be cloned. To date, several large M E N I families of Caucasian origin have been reported and linkage analysis of these families has indicated genetic homogeneity for the MEN 1 locus at 11 q 13 in this population (Larsson et al. 1988; Larsson et al. 1992; Fujimori et al. 1993; Thakker et al. 1993; Teh et al. 1994). Reports of MEN1 in Asian populations are rare. Here, we report two Asian MEN1 families, including one multi-generation family with over 150 living members, in Malaysia. We have also investigated potential ethnic heterogeneity of this disorder and the feasibility of using polymorphic c h r o m o s o m e 1 l q simple tandem repeat markers for presymptomatic diagnosis in these kindreds.

469

Materials and methods Families

East Malaysia family This family (Fig. 1) was found in the Malaysian state of Sabah in 1991. The ancestor of this family was said to have migrated from Mongolia to mainland China in the 15th century. The two parents in the first generation of this pedigree migrated to the Malaysian state of Sabah early this century. The majority of their descendants have continued to live in Sabah. The proband (IlI-7) is a 27-year-old Malaysian Chinese housewife who presented with recurrent symptoms of hypoglycaemia of eight years duration. These included attacks of dizziness, hunger, confusion, aggressive behaviour and difficulty in rousing in the morning. There was also a history of polydipsia, constipation and intermittent abdominal pains. Hypoglycaemia was confirmed and was shown to be associated with inapproriately raised serum Cpeptide. Multiple pancreatic tumours were seen over the body and tail of the pancreas on imaging with ultrasonography, computerized tomography (CT) and coeliac angiography. At the same time, hyperparathyroidism was confirmed. The tumours of the pancreas were removed and confirmed to be of endocrine origin but unfortunately immunochemical staining was not carried out. Three parathyroid glands were removed and confirmed to be hyperplastic. There was no clinical, biochemical or radiological evidence of pituitary tumour. The proband's father (II-1) was said to have had multiple operations for peptic ulcer and subsequently died from a perforated peptic ulcer. One of the proband's sisters (III-9) was subsequently confirmed to have hyperparathyroidism and is currently awaiting parathyroidectomy. Another sister (III-11) was shown to have a biochemically and radiologically proven prolactinoma. One brother (III-1), who suffered from similar hypoglycaemic attacks as the proband, was found to have hyperparatbyroidism and elevated prolactin. Unfortunately, a blood sample was not available for genetic analysis. The remaining siblings (III-3, 4, 5) were asymptomatic and were found to be normal on biochemical screening. One of the proband's paternal cousins (III-16) was found to have a prolactinoma and hyperparathyroidism and was treated with bromocriptine. One of her brothers (III- 12) was treated in western Malaysia both surgically and with radiation for a thoracic tumour, which was confirmed to be a thymic carcinoid. He was found to have hypercalcaemia and a prolactin level elevated three fold, although further radiological investigations have not been carried out. The cousin's mother (II-5) and one of her daughters (IV-10) claimed to have chronic diarrhoea and both were found to have hyperparathyrodism and elevated prolactin. Investigations for carcinoids have yet to be performed. There is no clinical data available for the proband's grandfather (1-1); thus, his disease status was considered "unknown". The proband's grandmother (I-2), aged 104, is asymptomatic and biochemical screening for MEN l was negative. In addition to the above-mentioned patients, 38 family members were investigated and were found to have no evidence of being affected, although the disease status for 25 of them is still considered "unknown" because of their young age (less than 35 years).

West Malaysia family The proband is a descendant of a Chinese migrant currently residing in western Malaysia. He first presented with a two-month history of recurrent giddiness, hunger pangs, violent behaviour and difficulty in arousal. On admission, he was found to have hypercalcaemia, and subsequently hyperparathyroidism was confirmed. CT scans of his head, neck and abdomen revealed a large pituitary tumour, a solitary tumour in the tail of the pancreas, and two enlarged parathyroid glands. Distal pancreatectomy, total parathy-

roidectomy and transphenoidal removal of the pituitary tumour were carried out. Histology of the specimens was consistent with M E N 1. On further questioning, we learned that his father bad died from lung cancer in his mid-forties and was said to have undergone two operations for renal calculi. Whereas the latter is consistent with the father having the MEN1 syndrome, more definitive signs of MENI were not reported. Thus, for the sake of analysis in this study, his disease status was considered "unknown". As part of family screening, two elder brothers and an elder sister were investigated for M E N I . The elder sister complained of frontal headaches and galactorrhoea for the past 15 years. She also claimed to have episodes of renal colic but denied passing stones or haematuria. Hyperprolactinaemia was confirmed and CT scan revealed a large hypodense tumour measuring 3 • 2.2 cm eroding the base of the pituitary fossa and extending into the sphenoid sinus. Biochemical and radiological investigations of the parathyroid and pancreatic glands revealed no abnormalities. She was treated with bromocriptine followed by transphenoidal resection of the pituitary tumour. The eldest brother had loin pains and haematuria for two years and a large staghorn calculus was seen in the right hydronephrotic kidney. His left kidney was shrunken with a calculus impacted at the pelvic-uteric junction. Hyperparathyroidism was confirmed and a CT scan of the neck showed the presence of enlarged parathyroid glands on both sides. Chest X-ray revealed a large thoracic mass that was confirmed to be a thymic carcinoid on biopsy. A C T scan of the abdomen and pituitary, and hormonal assays of pituitary and endocrine pancreas were normal. The patient underwent urgent right percutaneous nephrostomy and exploration of the parathyroid glands. Pending the improvement of his renal function, the patient is awaiting further management for the thymic carcinoid. The second brother claimed to have a history of renal calculi but biochemical and radiological investigations revealed no abnormalities. A third brother was not available for investigation.

Linkage analysis Blood samples were obtained from members of both families. Lymphoblastoid cell lines were established and DNA extracted from the harvested cells as previously described (Teh et al. 1990). The polymorphic microsatellite markers used were previously reported on chromosome 1 lq and these included Fcr (Sandford et al. 1993), D11S956 (Litt et al. 1993), D11S480 (Sandford et al. 1993), PYGM (lwasaki et al. 1992), D11S913 (Weissenbach et al. 1992), FGF3(INT2) (Fujimori et al. 1993) and D11S787 (Overbeck et al. 1993). The primers and conditions for the polymerase chain reaction (PCR) described in previous reports for each marker were used in amplifications of the specific loci using incorporation of 32P-dCTP, followed by electrophoresis and autoradiography. Allele designations in the two families were arbitrarily assigned. Two-point lod scores were generated using the MLINK program of the LINKAGE (version 5.1) software package (Lathrop et al. 1984). The criteria for scoring the disease state and the linkage model used were as described previously (Larsson et al. 1992). Briefly, asymptomatic individuals who were under the age of 35 were considered to be "unknown", whereas asymptomatic individuals older than 35 years were scored as "unaffected". The sporadic disease frequency was estimated at 5% and the frequency of the MEN 1 allele as 0.0003. Multipoint location scores were calculated using the LINKMAP program from L I N K A G E (Lathrop et al. 1984). The number of alleles for each marker was down-coded such that different alleles were only assigned for each of the four founder chromosomes in the first generation plus one additional allele for all spouse chromosomes. Haplotypes were determined in which there were the least number of recombinations in the pedigrees overall, and double recombinations around single markers were eliminated. The order of the markers used in this study and the distances between them (Fig. l) were compiled from physical (Tanigami et

470 Table 1 Two point lod scores at zero recombination fraction for linkage between seven simple tandem repeat markers and MEN I in two Asian families

FCeRI[3

D11S956 DllS480 PYGM

DllS913 FGF3

D11S787

East Malaysia family West Malaysia family

-3.86 0.04

0.88 0.19

1.29 0.59

2.91 0.34

1.81 0.13

1.05 0.15

1.74 0.23

Total

-3.28

-0.69

1.88

3.25

1.94

1.30

1.97

2

T 3.3 1.5 3.5 3.4 3.7 6.5 .1.

~

FceR1

-0

I

3 2 7 5 2 3 5

DllS956 D118480 PYGM

DllS,913 FGP3 D11S787

7 4 3 17 2 4 7

hi-.

-0'

I

" '30: 1:111 lilJl

11 3 6 17 8 2 2

5' 0 3

5 4

8 9

5

6

5 10

114111 114111

42 4 8

2 3

3 8

23 3 1

\[~r[199

5 3

55

3 1

6

6

1

2 9

3 ex

2 3 3 5

Xrrl3x

( rlio

3

3

3 1

Ni

7

i; F

74

"

10 I 191]1

7

e

5

B

3

7

7

73

7 4

417

~

3

1

~5 ~j/I "31~j

7 44

42 ~ 4 /e

4 /I

s7

1415 5 7

3 7 e , 4 9

1914 28

4 3 2 3 910 33 51 7 5

Fig. 1 Two affected branches of the East Malaysia MEN1 family showing segregation of chromosome l lq haplotypes for the marker systems listed. The eldest living member (1-2) is aged 104 and is asymptomatic. There are nine children in generation I! and 49 grandchildren in generation Ill. The number of great grandchildren in generation IV is estimated to be over 100. Unaffected branches are not shown here. The chromosome carrying the mutant allele is boxed. Recombinations are marked with a cross. Interred genotypes are shown within brackets. Orders and distances (cM) between STRP markers are indicated at the top left of the diagram

al. 1992) and linkage maps (Litt et al. 1993: Sandford et al. 1993) and from the genome database GDB, version 5.2 (Cuticchia et al. 1993).

ResuRs

The clinical data including the biochemical, radiological and surgical pathology of these two families are consistent with M E N I as in previously reported Caucasian MEN1 families. One thymic carcinoid was found in each o f these two families, in addition to the three classical M E N 1 neoplasias of parathyroid, endocrine pancreas and anterior pituitary.

5

3 3 7 3 1210 23

53 73 910 ~

81 3 5

81 35

x ~ 46 . .

63 74 , 1~ 4~ 54 54

3

3

7

6 3

'7,

4 X 54

4 4 5 B 5, 3

The f a m i l y specific and c o m b i n e d lod scores tor each m a r k e r are s u m m a r i z e d in Table 1. No r e c o m b i n a t i o n s were o b s e r v e d with markers D 11 $480, P Y G M , D 11 $913 and F G F 3 , although there were recombination events in affected individuals between F c e R I - ~ and D l 1 S 9 5 6 and between D11S956 and DI 1S480 in the larger f a m i l y (Fig. 1). These r e c o m b i n a n t s place the MEN1 locus telomeric of D1 IS956, consistent with previous reports (Larsson et al. 1988, 1992; Fujimori et al. 1993; T h a k k e r et al. 1993; Teh et al. 1994). Multipoint linkage analysis gave a peak c o m bined lod score o f 5.63 coincident with P Y G M , thus providing statistically significant evidence for linkage of the trait to this m a r k e r in these two families. It should be noted h o w e v e r that three other markers (D 11 $480, D 11 $913, F G F 3 ) were also n o n - r e c o m b i n a n t with MEN1 in these families; thus, the multipoint analysis should be interpreted with caution, since the curve (not shown) will artificially peak over the most informative m a r k e r ( P Y G M ) . Confidence limits of 95% for the position o f the M E N I gene taken from the interval defined by the peak lod - I indicate that it could lie a n y w h e r e between D 11 $480 and F G F 3 . The segregating c h r o m o s o m e l lq haplotypes in the East M a l a y s i a family are shown in Fig. 1. Individuals IV1, IV-2, IV-4, IV-9, all aged under 20, were identified as

471 gene carriers, although there is no clinical or biochemical evidence of them being affected to date. It is noteworthy that the carrier status of individual IV-7 cannot be determined unequivocally, since he had a recombination of the mutant chromosome between PYGM and D l l S 9 1 3 , the region putatively containing the MEN1 gene. In the West Malaysia family, unambiguous haplotypes could not be assigned (results not shown), thus no predictive information on the patient's eldest brother could be determined.

Discussion The incidence of MEN1 in Asian populations is unknown and, in the literature to date, only one report, which reviewed 45 MEN1 patients in 15 families between 19661989 in Japan, is available (Yoshimoto and Saito 1991). The finding of two MEN1 families in Malaysia in our study supports our previous conclusion that "MEN1 is highly unrecognised rather than uncommon" (Shepherd 1991). This is particularly true in many areas of Asian countries where the resources for investigating and screening families with MEN1 are not as readily available as in Western countries. In studying familial disease genes, kindreds of different racial origin confer opportunities for identifying heterogeneity of the disease-causing locus (Akimoto et al. 1993; Benhorin et al. 1993). The MEN1 gene was first assigned to chromosome l l q 1 3 based on allelotyping of MEN1-related pancreatic tumours and linkage analysis in two Swedish MEN1 families (Larsson et al. 1988). Subsequent confirmation studies of the same locus in Caucasian families have pointed to genetic homogeneity of the disease gene. However, as far as we are aware, the gene locus has not been tested in Asian families, including the Japanese families previously reported (Yoshimoto and Saito 1991). In this study, the highest combined multipoint lod score of 5.46 was obtained using the marker PYGM with which no recombination was found, thus confirming linkage of the MEN1 gene to chromosome 1 lq13 in these two Asian families. Together with previous studies, this points to a common genetic predisposition that is crucial in initiating tumorigenesis of MEN1. MEN1 is a complex problem with high morbidity. Although it is considered to carry a better prognosis than other forms of familial cancer, death can occur from advanced neoplasias and their complications (Shepherd 1991 ). Proper management of the disease includes family screening in the hope of early detection and intervention. In the East Malaysia family, such screening is impractical because of geographical and financial constraints. However, genetic predictive testing can obviate the need for screening of non-gene carriers, thus saving costs and offering psychological relief from uncertainty. We have previously shown that tightly linked genetic markers in chromosome 1lq13 can be used to detect gene carriers with 95%-98% confidence (Larsson et al. 1992). The confirmation of linkage to 11 q markers has made this test possible in the two Asian families in the current study.

In one family, four out of 13 members with "unknown" disease status were identified as being gene carriers, thus requiring further routine investigations. Compared with our previous experience with restriction fragment length polymorphisms (Larsson et al. 1992; Teh et al. 1994), the use of microsatellite polymorphisms offers a much greater advantage because of high polymorphicity, a requirement for minimum amounts of DNA and isotope, and the convenience of running several markers simultaneously. It is inevitable that the MEN1 gene will be cloned in the near future and mutation studies will be carried out in an effort to study the functional significance of the mutations and to correlate them with clinical phenotypes. These two Asian families will add to the repertoire of mutations identified when the gene is studied, and may help shed light on its function and mode of action. Acknowledgements We thank the enthusiastic cooperation of the medical and nursing staff of the Queen Elizabeth Hospital, Sabah, Malaysia. This study was funded by the National Health and Medical Research Council of Australia and the Swedish Cancer Foundation.

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