Li–Fraumeni syndrome

Li–Fraumeni syndrome
Classification and external resources
ICD-9-CM	758.3
OMIM	151623
DiseasesDB	7450
eMedicine	ped/1305
MeSH	D016864

Li–Fraumeni syndrome is a rare cancer predisposition hereditary disorder characterized as autosomal dominant. It was named after two American physicians, Frederick Pei Li and Joseph F. Fraumeni, Jr., who first recognized the syndrome after reviewing the medical records and death certificates of 648 childhood rhabdomyosarcoma patients.^[1] This syndrome is also known as the sarcoma, breast, leukaemia and adrenal gland (SBLA) syndrome.

The syndrome is linked to germline mutations of the p53 tumor suppressor gene,^[2] which encodes a transcription factor (p53) that normally regulates the cell cycle and prevents genomic mutations. The mutations can be inherited, or can arise from de novo mutations early in embryogenesis, or in one of the parent's germ cells.

Characteristics

Li–Fraumeni syndrome is characterized by early onset of cancer, a wide variety of types of cancers, and development of multiple cancers throughout one's life.^[3]

Epidemiology

Li–Fraumeni syndrome (LFS) is relatively rare; as of 2011, cases had been reported in more than 500 families.^[4] The syndrome was discovered using an epidemiological approach. Li and Fraumeni identified four families in which siblings or cousins of rhabdomyosarcoma patients had a childhood sarcoma, which suggested a familial cancer syndrome.^[5]^[6] Identification of TP53 as the gene affected by mutation was suggested by the same approach. Over half of the cancers in Li-Fraumeni families had been previously associated with inactivating mutations of the p53 gene, and, in one primary research study, DNA sequencing in samples taken from five Li–Fraumeni syndrome families showed autosomal dominant inheritance of a mutated TP53 gene.^[5]^[6]

Pathology

LFS1: Mutations in TP53

Normal Conditions: TP53 is a tumor suppressor gene on chromosome 17 that normally assists in the control of cell division and growth through action on the normal cell cycle. TP53 typically become expressed due to cellular stressors, such as DNA damage, and can halt the cell cycle to assist with either the repair of repairable DNA damage, or can induce apoptosis of a cell with irreparable damage. The repair of "bad" DNA, or the apoptosis of a cell, prevents the proliferation of damaged cells.
Mutant Conditions: Mutations of TP53 can inhibit its normal function, and allow cells with damaged DNA to continue to divide. If these DNA mutations are left unchecked, some cells can become immortalized, and divide in an uncontrolled manner forming tumors (cancers). Further mutations in the DNA could lead to malignant cells that can travel to, and develop cancer in different areas of the body. Many individuals with Li–Fraumeni syndrome have been shown to be heterozygous for a TP53 mutation. Recent studies have shown that 60% to 80% of classic LFS families harbor detectable germ line TP53 mutations, the majority of which are missense mutations in the DNA-binding domain.^[4] These missense mutations cause a decrease in the ability of p53 to bind to DNA, thus inhibiting the normal TP53 mechanism.
Unique Brazilian Mutation: Although other mutations leading to Li–Fraumeni syndrome have been found outside the DNA-binding domain, a mutation at codon 337 of the tetramerization domain of TP53 has shown a particularly high frequency. The tetramerization domain plays a major role in the oligomerization of the p53 protein, which exists as a tetramer.^[7] This mutation has only been found in Brazilian families, and is located in exon 10 of the TP53 gene. The mutation causes an amino acid change from arginine to histidine at codon 337. With pH in the low to normal physiological range (up to 7.5), the mutant protein forms normal oligomers and retains its suppressor function.^[4] However, at a high physiological pH, p53 is unable to assemble into a tetramer.^[4] This unique feature may contribute to why families with this particular mutation often show incomplete penetrance.
Dominant Negative Mutations: Most individuals with Li–Fraumeni syndrome are heterozygous for a mutant TP53 gene, and some p53 mutants can inhibit the function of the wild-type p53 in a dominant negative manner. Mutated p53 proteins are typically more stable than wild-type, and can inhibit the activity of the wild-type protein in suppressing cell proliferation and in inducing cell cycle arrest.^[8] Due to the mutant p53 being able to inhibit some wild-type p53, damaged cells are at an even greater susceptibility to proliferate and become transformed, resulting in cancer.

LFS2: Mutations in CHEK2

Another variant of Li–Fraumeni that remains somewhat controversial, is a mutation of the CHEK2 (or CHK2) gene.^[4] CHK2 is also a tumor suppressor gene. CHK2 regulates the action of p53. CHK2 is activated by ATM which detects DNA damage, and in this way DNA damage information can be conveyed to p53 to indirectly arrest the cell cycle at that point for DNA repair to be able to take place or to cause apoptosis (programmed cell death).

LFS-L:

Families that do not conform to the criteria of classical Li–Fraumeni syndrome have been termed "LFS-like".^[4] LFS-like individuals generally do not have any detectable p53 mutations, and tend to be diagnosed on either the Birch or Eeles criteria.

A third locus has been mapped to the long arm of chromosome 1 (1q23) but no gene has yet been identified.

Clinical

The classical LFS malignancies - sarcoma, cancers of the breast, brain and adrenal glands - comprise about 80% of all cancers that occur in this syndrome.

The risk of developing any invasive cancer (excluding skin cancer) is ~50% by age 30 (1% in the general population) and is 90% by age 70. Early onset breast cancer accounts for 25% of all the cancers in this syndrome. This is followed by soft tissue sarcomas (20%), bone sarcoma (15%) and brain tumors - especially glioblastomas - (13%). Other tumours seen in this syndrome include leukaemia, lymphoma and adrenocortical carcinoma.

~90% of females with LFS develop breast cancer by age 60 years; the majority of these occur before age 45 years. Females with this syndrome have almost a 100% lifetime risk of developing cancer. This compares with 73% for affected males. The difference may be due to much smaller breast tissue in males as well as increased estrogen levels in females.

The risks of sarcoma, female breast cancer and haematopoietic malignancies in mutation carriers are more than 100 times greater than those seen in the general population.

Other tumours reported in this syndrome but not yet proved to be linked with it include melanoma, Wilm's and other kidney tumors, hepatacellular carcinoma, gonadal germ cell, pancreatic, gastric, choroid plexus, colorectal and prostate cancers.

80% of children with adrenocortical carcinoma and 2%-10% of childhood brain tumors have p53 mutations.

2%-3% of osteosarcomas, 9% rhabdomyosarcomas and 7%-20% patients with multiple primary tumors have p53 mutations.

Although most cases of this syndrome have early onset of cancer, cases have also been reported later in life.^[9]

Diagnosis

Li–Fraumeni syndrome is diagnosed if the following three criteria are met:

the patient has been diagnosed with a sarcoma at a young age (below 45),
a first-degree relative has been diagnosed with any cancer at a young age (below 45), and
another first-degree or a second-degree relative has been diagnosed with any cancer at a young age (below 45) or with a sarcoma at any age.

Other criteria have also been proposed, such as the Birch criteria,^[10] which require:

a proband with any childhood cancer or sarcoma, brain tumor or adrenal cortical carcinoma diagnosed before age 45,
a first or second degree relative with a typical LFS malignancy (sarcoma, leukaemia, or cancers of the breast, brain or adrenal cortex) regardless of age at diagnosis, and/or
a first or second degree relative with any cancer diagnosed before age 60.

In addition, there has been suggestion of an Eeles criterion:^[11]

two first or second degree relatives with LFS-related malignancies at any age.

Management

Genetic counseling and genetic testing are used to confirm that somebody has this gene mutation. Once such a person is identified, early and regular screenings for cancer are recommended for him or her as people with Li–Fraumeni are likely to develop another primary malignancy at a future time (57% within 30 years of diagnosis).

Chompret criteria

A 2009 revision of the traditional Chompret criteria for screening has been proposed:^[12]

A proband who has:

tumor belonging to the LFS tumor spectrum - soft tissue sarcoma, osteosarcoma, pre-menopausal breast cancer, brain tumor, adrenocortical carcinoma, leukemia or lung bronchoalveolar cancer - before age 46 years;

and at least one of the following:

at least one first or second degree relative with an LFS tumour (except breast cancer if the proband has breast cancer) before age 56 years or with multiple tumours
a proband with multiple tumours (except multiple breast tumours), two of which belong to the LFS tumour spectrum and the first of which occurred before age 46 years
a proband who is diagnosed with adrenocortical carcinoma or choroid plexus tumour, irrespective of family history

Recommendations

Recommendations for individuals from families affected by the syndrome include:

Avoidance of radiation therapy to reduce risk of secondary radiation induced malignancies,
Children and adults undergo comprehensive annual physical examination,
Women undergo age specific breast cancer monitoring beginning at age 25 years, and
All patients should consult a physician promptly for evaluation of lingering symptoms and illnesses.

Suggestions

Adults undergo routine screening for colorectal cancer beginning no later than age 25 years
Individuals undergo organ targeted surveillance based on the pattern of cancer observed in their family

Prophylactic mastectomy to reduce the risk of breast cancer is an option.

References

↑ Li F.P.; Fraumeni J.F. (October 1969). "Soft-tissue sarcomas, breast cancer, and other neoplasms. A familial syndrome?". Ann. Intern. Med. 71 (4): 747–52. doi:10.7326/0003-4819-71-4-747. PMID 5360287.
↑ Varley J.M. (March 2003). "Germline TP53 mutations and Li-Fraumeni syndrome". Hum. Mutat. 21 (3): 313–20. doi:10.1002/humu.10185. PMID 12619118.
↑ Hisada, M.; Garber, J. E.; Li, F. P.; Fung, C. Y.; Fraumeni, J. F. (1998). "Multiple Primary Cancers in Families With Li-Fraumeni Syndrome". JNCI Journal of the National Cancer Institute. 90 (8): 606–611. doi:10.1093/jnci/90.8.606. ISSN 0027-8874.
1 2 3 4 5 6 Malkin, D. (2011). "Li-Fraumeni Syndrome". In Levine, Arnold J. Genes and Cancer (PDF). 2. pp. 475–484. doi:10.1177/1947601911413466. PMC 3135649. Retrieved 22 February 2016.
1 2 Malkin, D.; Li, F.P.; Strong, L.C.; Fraumeni Jr, J.F.; Nelson, C.E.; Kim, D.H.; Kassel, J.; Gryka, M.A.; Bischoff, F.Z. Tainsky, M.A. et al. (1990). "Germ Line p53 Mutations in a Familial Syndrome of Breast Cancer, Sarcomas, and Other Neoplasms". Science. 250 (4985, 30 November): 1233–1238. doi:10.1126/science.1978757. PMID 1978757.
1 2 Malkin D. & Friend, S.H. (1993). "Correction: a Li-Fraumeni syndrome p53 mutation. Erratum for "Germ Line p53 Mutations in a Familial Syndrome of Breast Cancer, Sarcomas, and Other Neoplasms"". Science. 259 (5097, 12 February): 878. PMID 8438145.
↑ Chène, P. (2001). "The Role of Tetramerization in p53 function" (online, print review). Oncogene. 20 (21): 2611–2617. doi:10.1038/sj.onc.1204373.
↑ Willis, Amy; Jung, Eun Joo; Wakefield, Therese & Chen, Xinbin (2004). "Mutant p53 Exerts a Dominant Negative Effect by Preventing Wild-Type p53 from Binding to the Promoter of its Target Genes". Oncogene. 23: 2330–2338. doi:10.1038/sj.onc.1207396. Retrieved 22 February 2016.
↑ Cho Y, Kim J, Kim Y, Jeong J, Lee KA (2013) A case of late-onset Li-Fraumeni-like syndrome with unilateral breast cancer. Ann Lab Me 33(3):212-216. doi: 10.3343/alm.2013.33.3.212.
↑ Birch JM, Hartley AL, Tricker K, Prosser J, Condie A, Kelsey A, Harries M, Jones P, Binchy A, Crowther D, Craft A, Eden O, Evans D, Thompson E, Mann J, Martin J, Mitchell E, Santibanez-Koref M (1994) Prevalence and diversity of constitutional mutations in the p53 gene among 21 Li-Fraumeni families. Cancer Res 54:1298–304.
↑ Eeles, R. (1995). "Germline mutations in the TP53 gene". Cancer Surveys. 25: 101–124. ISSN 0261-2429. PMID 8718514.
↑ Tinat J.; Bougeard G.; Baert-Desurmont, S.; Vasseur, S.; Martin, C.; Bouvignies, E.; Caron, O.; Bressac-de Paillerets, B.; Berthet, P.; Dugast, C.; Bonaiti-Pellie, C. & Stoppa-Lyonnet, D. (2009). "2009 Version of the Chompret criteria for Li Fraumeni syndrome" (research correspondence). J. Clin. Oncol. 27: 1–2. Retrieved 22 February 2016.

External links

Li–Fraumeni syndrome, in the National Library of Medicine Genetics Home Reference (an introduction to the disease)
Li–Fraumeni Syndrome by Katherine A Schneider and Frederick Li, in GeneReviews, a section of GeneTests, published online by the University of Washington with funds from the National Institutes of Health
Li–Fraumeni syndrome; LFS1, entry in Online Mendelian Inheritance in Man (OMIM), published by Johns Hopkins University and the National Institutes of Health
The George Pantziarka TP53 Trust A support group from the UK for sufferers of Li–Fraumeni Syndrome or other TP53-related disorders
Living LFS A support group that encourages, empowers, and educates those living with Li-Fraumeni Syndrome by connecting them with care, resources, and others who are Living LFS.

Metabolic disease: DNA replication and DNA repair-deficiency disorder

DNA replication

Separation/initiation: RNASEH2A
- Aicardi–Goutières syndrome 4

Termination/telomerase: DKC1
- Dyskeratosis congenita

DNA repair

Nucleotide excision repair	Cockayne syndrome/DeSanctis–Cacchione syndrome Thymine dimer Xeroderma pigmentosum IBIDS syndrome

MSI/DNA mismatch repair	Hereditary nonpolyposis colorectal cancer Muir–Torre syndrome Mismatch repair cancer syndrome

MRN complex	Ataxia telangiectasia Nijmegen breakage syndrome

Other	RecQ helicase Bloom syndrome Werner syndrome Rothmund–Thomson syndrome/Rapadilino syndrome Fanconi anemia Li-Fraumeni syndrome Severe combined immunodeficiency

Genetic disorder, protein biosynthesis: Transcription factor/coregulator deficiencies

(1) Basic domains

1.2	Feingold syndrome Saethre–Chotzen syndrome

1.3	Tietz syndrome

(2) Zinc finger
DNA-binding domains

2.1	(Intracellular receptor): Thyroid hormone resistance Androgen insensitivity syndrome PAIS MAIS CAIS Kennedy's disease PHA1AD pseudohypoaldosteronism Estrogen insensitivity syndrome X-linked adrenal hypoplasia congenita MODY 1 Familial partial lipodystrophy 3 SF1 XY gonadal dysgenesis

2.2	Barakat syndrome Tricho–rhino–phalangeal syndrome

2.3	Greig cephalopolysyndactyly syndrome/Pallister–Hall syndrome Denys–Drash syndrome Duane-radial ray syndrome MODY 7 MRX 89 Townes–Brocks syndrome Acrocallosal syndrome Myotonic dystrophy 2

2.5	Autoimmune polyendocrine syndrome type 1

(3) Helix-turn-helix domains

3.1	ARX Ohtahara syndrome Lissencephaly X2 MNX1 Currarino syndrome HOXD13 SPD1 Synpolydactyly PDX1 MODY 4 LMX1B Nail–patella syndrome MSX1 Tooth and nail syndrome OFC5 PITX2 Axenfeld syndrome 1 POU4F3 DFNA15 POU3F4 DFNX2 ZEB1 Posterior polymorphous corneal dystrophy Fuchs' dystrophy 3 ZEB2 Mowat–Wilson syndrome

3.2	PAX2 Papillorenal syndrome PAX3 Waardenburg syndrome 1&3 PAX4 MODY 9 PAX6 Gillespie syndrome Coloboma of optic nerve PAX8 Congenital hypothyroidism 2 PAX9 STHAG3

3.3	FOXC1 Axenfeld syndrome 3 Iridogoniodysgenesis, dominant type FOXC2 Lymphedema–distichiasis syndrome FOXE1 Bamforth–Lazarus syndrome FOXE3 Anterior segment mesenchymal dysgenesis FOXF1 ACD/MPV FOXI1 Enlarged vestibular aqueduct FOXL2 Premature ovarian failure 3 FOXP3 IPEX

3.5	IRF6 Van der Woude syndrome Popliteal pterygium syndrome

(4) β-Scaffold factors
with minor groove contacts

4.2	Hyperimmunoglobulin E syndrome

4.3	Holt–Oram syndrome Li–Fraumeni syndrome Ulnar–mammary syndrome

4.7	Campomelic dysplasia MODY 3 MODY 5 SF1 SRY XY gonadal dysgenesis Premature ovarian failure 7 SOX10 Waardenburg syndrome 4c Yemenite deaf-blind hypopigmentation syndrome

4.11	Cleidocranial dysostosis

(0) Other transcription factors

0.6	Kabuki syndrome

Ungrouped

Transcription coregulators

Coactivator:	CREBBP Rubinstein–Taybi syndrome

Corepressor:	HR (Atrichia with papular lesions)

Deficiencies of intracellular signaling peptides and proteins

GTP-binding protein regulators

GTPase-activating protein	Neurofibromatosis type I Watson syndrome Tuberous sclerosis

Guanine nucleotide exchange factor	Marinesco–Sjögren syndrome Aarskog–Scott syndrome Juvenile primary lateral sclerosis X-Linked mental retardation 1

G protein

Heterotrimeic	cAMP/GNAS1: Pseudopseudohypoparathyroidism Progressive osseous heteroplasia Pseudohypoparathyroidism Albright's hereditary osteodystrophy McCune–Albright syndrome CGL 2

Monomeric	RAS: HRAS Costello syndrome KRAS Noonan syndrome 3 KRAS Cardiofaciocutaneous syndrome RAB: RAB7 Charcot–Marie–Tooth disease RAB23 Carpenter syndrome RAB27 Griscelli syndrome type 2 RHO: RAC2 Neutrophil immunodeficiency syndrome ARF: SAR1B Chylomicron retention disease ARL13B Joubert syndrome 8 ARL6 Bardet–Biedl syndrome 3

MAP kinase

Cardiofaciocutaneous syndrome

Other kinase/phosphatase

Tyrosine kinase	BTK X-linked agammaglobulinemia ZAP70 ZAP70 deficiency

Serine/threonine kinase	RPS6KA3 Coffin-Lowry syndrome CHEK2 Li-Fraumeni syndrome 2 IKBKG Incontinentia pigmenti STK11 Peutz–Jeghers syndrome DMPK Myotonic dystrophy 1 ATR Seckel syndrome 1 GRK1 Oguchi disease 2 WNK4/WNK1 Pseudohypoaldosteronism 2

Tyrosine phosphatase	PTEN Bannayan–Riley–Ruvalcaba syndrome Lhermitte–Duclos disease Cowden syndrome Proteus-like syndrome MTM1 X-linked myotubular myopathy PTPN11 Noonan syndrome 1 LEOPARD syndrome Metachondromatosis

Signal transducing adaptor proteins

Other

NF2
- Neurofibromatosis type II
NOTCH3
- CADASIL
PRKAR1A
- Carney complex
PRKAG2
- Wolff–Parkinson–White syndrome
PRKCSH
- PRKCSH Polycystic liver disease
XIAP
- XIAP2

See also intracellular signaling peptides and proteins

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