Advertisement

Novel fumarate hydratase mutation in a family with atypical uterine leiomyomas and hereditary leiomyomatosis and renal cell cancer

      Objective

      To describe a novel mutation in the fumarate hydratase (FH) gene in a family with atypical uterine leiomyomas.

      Design

      Case report and review of the literature.

      Setting

      Academic community hospital.

      Patient(s)

      Three sisters who presented as nulligravidas aged 27–30 years with large atypical uterine leiomyomas.

      Intervention(s)

      Abdominal myomectomy, robotic myomectomy, hysterectomy, gene sequencing.

      Main Outcome Measure(s)

      Identification of a family with hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome and a novel mutation in the FH gene.

      Result(s)

      Two of the three sisters tested positive for a novel FH mutation p.Leu99Glufsx6. The eldest sister was clinically diagnosed with HLRCC. The patients' father also carries the same mutation in the FH gene. The patients and their father are now undergoing yearly screening for renal cancer.

      Conclusion(s)

      Patients with HLRCC are at risk for developing renal cancer as well as losing their fertility via early hysterectomy. Physicians must be aware of this condition and refer at-risk individuals for genetic testing.

      Key Words

      Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/wheelerk-novel-fh-mutation-hlrcc/
      Uterine leiomyomas are found in 25%–70% of reproductive-age women, depending on the method used for detection; most (>95%) present after the age of 30 years (
      • Marshall L.M.
      • Spiegelman D.
      • Barbieri R.L.
      • Goldman M.B.
      • Manson J.E.
      • Colditz G.A.
      • et al.
      Variation in the incidence of uterine leiomyoma among premenopausal women by age and race.
      ,
      • van Heertum K.
      • Barmat L.
      Uterine fibroids associated with infertility.
      ). Approximately 40% of uterine leiomyomas carry specific chromosomal rearrangements, including trisomy 12 or deletions and rearrangements of portions of 7q, 12q15, 6p21, or 10q22 (
      • Hodge J.C.
      • Morton C.C.
      Genetic heterogeneity among uterine leiomyomata: insights into malignant progression.
      ). There is a slight familial predisposition for the development of uterine leiomyomas, with a ∼2.5-fold risk if a first-degree relative is affected. There is, however, only one known genetic syndrome that leads to the development of uterine fibroids. Heterozygous germline mutations in the fumarate hydratase (FH) gene cause a syndrome known as hereditary leiomyomatosis and renal cell cancer (HLRCC) that puts affected individuals at risk for uterine leiomyomas, cutaneous piloleiomyomas, and type II papillary renal cell cancer.
      The pathology of a typical leiomyoma shows smooth muscle cells with bland nuclei and no increase in mitotic activity or necrosis. In contrast, malignant leiomyosarcomas have two of the following three characteristics: cytologic atypia, increased mitotic activity, and coagulative tumor cell necrosis (CTCN). Atypical leiomyomas lie in the spectrum between benign leiomyomas and malignant leiomyosarcomas. They have cytologic atypia, no CTCN, and fewer than ten mitoses per ten high-power fields (
      • Ip P.
      • Tse K.
      • Tam K.
      Uterine smooth muscle tumors other than the ordinary leiomyomas and leiomyosarcomas: a review of selected variants with emphasis on recent advances and unusual morphology that may cause concern for malignancy.
      ). Leiomyomas that develop in patients with HLRCC often have increased cellularity, cytologic atypia, and a characteristic perinuclear halo (
      • Sanz-Ortega J.
      • Vocke C.
      • Stratton P.
      • Linehan W.
      • Merino M.
      Morphologic and molecular characteristics of uterine leiomyomas in hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome.
      ).

      Materials and methods

      Three sisters each presented to a gynecologist at the ages of 27–30 years as nulligravidas with large uterine myomas. They all underwent myomectomies, and pathology was consistent with atypical myomas in each case. Owing to the familial clustering of atypical leiomyomas, they were recuited in December 2014 for more detailed investigation of possible underlying genetic disorders. The sisters were questioned regarding their family and personal history of symptoms of hereditary leiomyomatosis and renal cell cancer. Genetic testing was performed in concordance with genetic counseling. Patient III-4 had sequencing performed of her entire FH gene (Genedx). Genomic DNA was obtained via cheek swab and polymerase chain reaction amplified for exons 1–10 of the FH gene and the flanking splice sites. Bidirectional DNA sequencing was performed, compared with the published gene sequence, and confirmed with the use of repeat sequence analysis. Patients III-3 and II-2 had sequencing only of the segment of DNA that contained the p.Leu99Glufsx6 mutation (exon 3). The Leiden Open Variation Database version FH110817 was accessed to retrieve all known mutations in the FH gene (
      • Bayley J.P.
      • Launonen V.
      • Tomlinson I.P.
      The FH mutation database: an online database of fumarate hydratase mutations involved in the MCUL (HLRCC) tumor syndrome and congenital fumarase deficiency.
      ). The variant found in these patients was not identified in the SNP database. The Institutional Review Board reviewed this work, and it was considered exempt. Consent was obtained from each patient before publication.

      Results

       Case 1

      The proband (patient III-1; Fig. 1) presented as a 27-year-old nulligravida with a 6-year history of dysmenorrhea and menorrhagia. She had no significant medical history and no abdominal surgeries. At presentation her hemoglobin was 6.4 and she had an 18-week-size uterus on vaginal examination. The remainder of her physical examination was unremarkable. A pelvic ultrasound showed an enlarged myomatous uterus with multiple fibroids including a posterior fibroid measuring ∼8 × 7 cm. She was placed on continuous oral contraceptive pills and iron therapy with resulting improvement in her anemia, but she continued to experience dysmenorrhea.
      Figure thumbnail gr1
      Figure 1Pedigree of the family with novel fumarate hydratase mutation Leu99Glufsx6, showing hereditary leiomyomatosis and renal cell cancer (HLRCC)–associated conditions. NOS = not otherwise specified.
      After failing conservative management, she underwent an exploratory laparotomy and myomectomy for removal of 34 fibroids, two of which were 10 cm in size (Fig. 2). The pathology of her fibroids showed multifocal moderate to severe cytologic atypia, but no increased mitotic activity or necrosis, which was consistent with an atypical leiomyoma.
      Figure thumbnail gr2
      Figure 2(A) magnetic resonance imaging of the enlarged uterus with multiple fibroids (asterisk) of the patient in case 1 (III-1) before her second myomectomy. (B and C) Gross pathologic specimen of (B) dominant fibroid and (C) all fibroids removed from patient III-1 at her first myomectomy. (D) Cytologic atypia and the perinuclear halo (arrow) seen in the atypical leiomyoma specimen from patient 3 (III-4). Scale bar = 30 μm.
      She had initial improvement in her symptoms, but she returned 3 years later with symptoms of uterine enlargement and again was found to have an 18-week-size uterus on examination. Magnetic resonance imaging (MRI) was obtained that showed a 14 × 11 cm uterus with several large fibroids up to 7 cm in size. She was taken for a second exploratory laparotomy and myomectomy in an attempt to preserve her fertility. This time, 58 fibroids were removed, the largest a conglomeration of approximately six fibroids that was 15 cm in largest diameter. An attempt was made to remove all visible fibroids, but they invaded the uterine muscle so extensively that at the end, there were many <1-cm fibroids that could not be removed. The patient's pathology showed more diffuse cytologic atypia, but there was no mitotic activity or necrosis and she was again given the diagnosis of atypical leiomyomas.
      The patient was followed carefully with the use of serial ultrasounds, and another 3 years later, as a 33-year-old nulligravida, she showed evidence of recurrent uterine fibroids. On vaginal examination she had a 14–16-week-size uterus. Her ultrasound revealed a 12.9-cm uterus with four measurable fibroids 4–6 cm in largest dimension. At this point the patient desired definitive management and underwent a total abdominal hysterectomy. At the time of surgery, multiple adhesions were noted, but her surgery and postoperative course were uncomplicated. Her pathology again showed atypical leiomyomas. The largest fibroid in the hysterectomy specimen was 6 cm in diameter. The patient has been followed for 5 years after the hysterectomy and has shown no signs of extrauterine disease.

       Case 2

      The proband's middle sister (patient III-3; Fig. 1) presented at age 30 years with symptomatic uterine enlargement and dyspareunia. She was a nulligravida with no significant past medical or surgical history. Pelvic examination showed a 14-week-size uterus, and ultrasound identified a single 8-cm posterior myoma. The remainder of her physical examination was unremarkable. Given the presence of only a single large myoma, she was offered a minimally invasive approach. She underwent a robotic myomectomy and at the time of surgery a large posterior degenerated myoma was encountered as well as a small 1-cm anterior myoma. Final pathology showed diffuse mild and focal moderate cytologic atypia with minimal mitotic activity and no tumor-type necrosis, which was consistent with atypical leiomyoma.
      This second patient was in a long-term relationship and was counseled to consider reproduction, given her sister's history of recurrent fibroids requiring hysterectomy. She went on to conceive the following year and delivered a full-term infant via cesarean section, which was performed because of her earlier myomectomy. At the time of the cesarean section, four small ≤3-cm fibroids were seen. The patient is now approximately 1 year postpartum; serial ultrasounds have noted multiple small <3-cm myomas, but she has had no recurrent symptoms related to her fibroids.

       Case 3

      The proband's youngest sister (patient III-4; Fig. 1) presented for screening ultrasound owing to her significant family history of atypical leiomyomas. She was a 28-year-old nulligravida at time of presentation and had no symptoms of irregular or heavy menstrual bleeding and no complaints of pelvic discomfort. There was no significant medical or surgical history. Her general physical examination was normal, but she also had an enlarged fibroid uterus on pelvic examination. Imaging studies including ultrasound and MRI revealed 10-cm and 4-cm posterior myomas. Although the patient was asymptomatic, given her family history she underwent a robotic myomectomy. Final pathology was consistent with atypical leiomyoma; there was diffuse mild and focal moderate cytologic atypia with no necrosis or increased mitotic activity. Eighteen months after surgery the patient has had no symptoms of recurrent fibroids.

       HLRCC

      Because of the familial clustering of these atypical leiomyomas in three sisters at such young ages, they were questioned regarding personal and family history of cutaneous leiomyomas and renal cell cancer that would be concerning for the hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome. The youngest sister did endorse previously undiagnosed skin changes, was referred to dermatology, and had a skin biopsy that showed cutaneous leiomyomas (Fig. 3). Further investigation revealed that the patients' father had skin lesions and their paternal grandmother had a hysterectomy at an early age (Fig. 1). This side of the sisters' family is of Italian descent. On further examination the elder two sisters also had small areas suspicious for cutaneous leiomyomas.
      Figure thumbnail gr3
      Figure 3Cutaneous leiomyomas present on the forearm of patient III-4.
      The family was referred for genetic testing, and patients III-3 and III-4 were heterozygous for a novel mutation in the FH gene, p.Leu99Glufsx6 (c.295_301delTTGAAGC). This deletion of seven nucleic acid residues at 295–301 causes a frame-shift mutation that changes leucine 99 to a glutamic acid residue and creates a premature stop codon six amino acids downstream. It is unknown whether this causes production of a truncated nonfunctional protein or mRNA degradation. The truncation occurs before any of the amino acids residues that are critical for enzymatic function (Fig. 4) so is almost certainly the causative mutation for the patients' clinical features (
      • Alam N.A.
      • Rowan A.J.
      • Wortham N.C.
      • Pollard P.J.
      • Mitchell M.
      • Tyrer J.P.
      • et al.
      Genetic and functional analyses of FH mutations in multiple cutaneous and uterine leiomyomatosis, hereditary leiomyomatosis and renal cancer, and fumarate hydratase deficiency.
      ). Additionally, known disease-causing mutations have been identified in the same area of exon 3 (
      Multiple Leiomyoma Consortium T
      Germline mutations in FH predispose to dominantly inherited uterine fibroids, skin leiomyomata and papillary renal cancer.
      ). The patients' father (II-2) was also found to carry the same p.Leu99Glufsx6 mutation in FH. Because HLRCC is inherited in an autosomal dominant fashion and the patients' mother has no symptoms of the condition, she did not undergo genetic testing. The patients' brother (III-2) was tested and does not carry the FH mutation. Patient III-1 was clinically diagnosed with HLRCC because of her recurrent uterine fibroids requiring early hysterectomy and cutaneous leiomyomas, which are enough clinical features of the condition to require screening for renal cell cancer. She also has no plans for future childbearing after hysterectomy so does not require the genetic information for family planning. The three sisters and their father were referred to a urologist for screening for renal cell cancer and have each had abdominal MRIs that showed no signs of malignancy.
      Figure thumbnail gr4
      Figure 4Representation of wild-type and Leu99Gluf×6 fumarate hydratase proteins including amino acid residues critical for enzymatic function of FH.

      Discussion

      We report a family with HLRCC and a novel FH gene mutation that was detected because of the familial clustering of early-onset atypical uterine leiomyomas. HLRCC, also known as multiple cutaneous and uterine leiomyomatosis and as Reed syndrome, is caused by inactivating mutations in the FH gene. Loss of FH activity causes accumulation of fumarate, which leads to overexpression of the oncogene hypoxia-inducible factor 1α (HIF1α) (
      • O'Flaherty L.
      • Adam J.
      • Heather L.C.
      • Zhdanov A.V.
      • Chung Y.L.
      • Miranda M.X.
      • et al.
      Dysregulation of hypoxia pathways in fumarate hydratase–deficient cells is independent of defective mitochondrial metabolism.
      ). This growth signal promotes the formation of uterine leiomyomas, cutaneous leiomyomas, and type II papillary renal cancer (
      • Smit D.
      • Mensenkamp A.
      • Badeloe S.
      • Breuning M.
      • Simon M.
      • van Spaendonck K.
      • et al.
      Herediatry leiomyomatosis and renal cell cancer in families referred for fumarate hydratase germline mutation analysis.
      ). HLRCC is inherited in an autosomal dominant fashion and to date >300 patients and 155 unique mutations have been described (
      • Bayley J.P.
      • Launonen V.
      • Tomlinson I.P.
      The FH mutation database: an online database of fumarate hydratase mutations involved in the MCUL (HLRCC) tumor syndrome and congenital fumarase deficiency.
      ).
      Nearly all women with HLRCC present to their gynecologists with symptoms of uterine enlargement, dysfunctional uterine bleeding, or abdominal discomfort and are found to have uterine leiomyomas. Fibroids due to FH mutations differ from common fibroids owing to their atypical pathology and early age of onset. Therefore, a full family history should be obtained for any patient with symptomatic fibroids requiring surgical intervention before the age of 30 years or atypical fibroids before the age of 40 years. The presence of other first-degree relatives with early uterine leiomyomas (before age 40 years), cutaneous leiomyomas, or type II papillary renal cell cancer should prompt referral for genetic testing (
      • Smit D.
      • Mensenkamp A.
      • Badeloe S.
      • Breuning M.
      • Simon M.
      • van Spaendonck K.
      • et al.
      Herediatry leiomyomatosis and renal cell cancer in families referred for fumarate hydratase germline mutation analysis.
      ).
      Making the diagnosis of HLRCC is important for fertility planning because >35% of these women require surgical intervention before age 30 years and 70% before age 40 years (
      • Wei M.-H.
      • Toure O.
      • Glenn G.
      • Pithukpakorn M.
      • Neckers L.
      • Stolle C.
      • et al.
      Novel mutations in FH and expansion of the spectrum of phenotypes expressed in families with herediatary leiomyomatosis and renal cell cancer.
      ). Myomectomy is an acceptable treatment option for patients who desire fertility preservation, even for atypical leiomyomas. Atypical leiomyomas have a low risk of extrauterine recurrence (0%–3%) (
      • Ly A.
      • Mills A.M.
      • McKenney J.K.
      • Balzer B.L.
      • Kempson R.L.
      • Hendrickson M.R.
      • et al.
      Atypical leiomyomas of the uterus: a clinicopathologic study of 51 cases.
      ,
      • Bell S.
      • Kempson R.
      • Hendrickson M.
      Problematic uterine smooth muscle neoplasms.
      ), but there is a significant risk of reoperation for recurrent fibroids. Although there are no data specific to patients with FH-associated atypical leiomyomas, in a recent series of 17 patients with atypical leiomyomas not associated with HLRCC, three patients required subsequent hysterectomy and one patient required a second myomectomy (
      • Ly A.
      • Mills A.M.
      • McKenney J.K.
      • Balzer B.L.
      • Kempson R.L.
      • Hendrickson M.R.
      • et al.
      Atypical leiomyomas of the uterus: a clinicopathologic study of 51 cases.
      ). Patients with an FH mutation should consider early reproduction, if desired, owing to their significant risk of hysterectomy at an early age. Alternatively, they can be offered oocyte or embryo cryopreservation and the use of a gestational carrier. All HLRCC patients should be referred to a reproductive endocrinologist to consider preimplantation genetic diagnosis to avoid passing the mutation to their offspring.
      Cutaneous leiomyomas are found in 80%–100% of patients with an FH mutation. Renal cancers, on the other hand, are found in only ∼20% of patients, but they are particularly aggressive (
      • Launonen V.
      • Vierimaa O.
      • Kiuru M.
      • Isola J.
      • Roth S.
      • Pukkala E.
      • et al.
      Inherited susceptibility to uterine leiomyomas and renal cell cancer.
      ). The most common renal cancer pathology associated with HLRC is type II papillary, but tubulopapillary and tubular histology have also been observed (
      • Merino M.J.
      • Torres-Cabala C.
      • Pinto P.
      • Linehan W.M.
      The morphologic spectrum of kidney tumors in hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome.
      ). Women with confirmed FH mutations should be screened for renal cancer with yearly abdominal MRI owing to the ability of these cancers to metastasize early (
      • Menko F.
      • Maher E.
      • Schmidt L.
      • Middelton L.
      • Aittomaki K.
      • Tomlinson I.
      • et al.
      Hereditary leiomyomatosis and renal cell cancer (HLRCC): renal cancer risk, surveillance and treatment.
      ). There is currently no association between specific mutations in the FH gene and the risk for renal cancer, but studies are ongoing (
      • Wei M.-H.
      • Toure O.
      • Glenn G.
      • Pithukpakorn M.
      • Neckers L.
      • Stolle C.
      • et al.
      Novel mutations in FH and expansion of the spectrum of phenotypes expressed in families with herediatary leiomyomatosis and renal cell cancer.
      ).

      Conclusion

      We have described a novel mutation in the FH gene in a family with early-onset atypical leiomyomas. These patients were found to have other characteristics of the HLRCC syndrome only after specific questioning. Their diagnosis was crucial, so that they could begin screening for renal cancer as well as be counseled regarding their reproductive options. Physicians must be aware of this rare genetic condition so that patients can be identified in a timely manner.

      References

        • Marshall L.M.
        • Spiegelman D.
        • Barbieri R.L.
        • Goldman M.B.
        • Manson J.E.
        • Colditz G.A.
        • et al.
        Variation in the incidence of uterine leiomyoma among premenopausal women by age and race.
        Obstet Gynecol. 1997; 90: 967-973
        • van Heertum K.
        • Barmat L.
        Uterine fibroids associated with infertility.
        Womens Health. 2014; 10: 645-653
        • Hodge J.C.
        • Morton C.C.
        Genetic heterogeneity among uterine leiomyomata: insights into malignant progression.
        Hum Mol Genet. 2007; 16 Spec No 1: R7-R13
        • Ip P.
        • Tse K.
        • Tam K.
        Uterine smooth muscle tumors other than the ordinary leiomyomas and leiomyosarcomas: a review of selected variants with emphasis on recent advances and unusual morphology that may cause concern for malignancy.
        Adv Anat Pathol. 2010; 17: 91-112
        • Sanz-Ortega J.
        • Vocke C.
        • Stratton P.
        • Linehan W.
        • Merino M.
        Morphologic and molecular characteristics of uterine leiomyomas in hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome.
        Am J Surg Pathol. 2013; 37: 74-80
        • Bayley J.P.
        • Launonen V.
        • Tomlinson I.P.
        The FH mutation database: an online database of fumarate hydratase mutations involved in the MCUL (HLRCC) tumor syndrome and congenital fumarase deficiency.
        BMC Med Genet. 2008; 9: 20
        • Alam N.A.
        • Rowan A.J.
        • Wortham N.C.
        • Pollard P.J.
        • Mitchell M.
        • Tyrer J.P.
        • et al.
        Genetic and functional analyses of FH mutations in multiple cutaneous and uterine leiomyomatosis, hereditary leiomyomatosis and renal cancer, and fumarate hydratase deficiency.
        Hum Mol Genet. 2003; 12: 1241-1252
        • Multiple Leiomyoma Consortium T
        Germline mutations in FH predispose to dominantly inherited uterine fibroids, skin leiomyomata and papillary renal cancer.
        Nat Genet. 2002; 30: 406-410
        • O'Flaherty L.
        • Adam J.
        • Heather L.C.
        • Zhdanov A.V.
        • Chung Y.L.
        • Miranda M.X.
        • et al.
        Dysregulation of hypoxia pathways in fumarate hydratase–deficient cells is independent of defective mitochondrial metabolism.
        Hum Mol Genet. 2010; 19: 3844-3851
        • Smit D.
        • Mensenkamp A.
        • Badeloe S.
        • Breuning M.
        • Simon M.
        • van Spaendonck K.
        • et al.
        Herediatry leiomyomatosis and renal cell cancer in families referred for fumarate hydratase germline mutation analysis.
        Clin Genet. 2011; 79: 49-59
        • Wei M.-H.
        • Toure O.
        • Glenn G.
        • Pithukpakorn M.
        • Neckers L.
        • Stolle C.
        • et al.
        Novel mutations in FH and expansion of the spectrum of phenotypes expressed in families with herediatary leiomyomatosis and renal cell cancer.
        J Med Genet. 2006; 43: 18-27
        • Ly A.
        • Mills A.M.
        • McKenney J.K.
        • Balzer B.L.
        • Kempson R.L.
        • Hendrickson M.R.
        • et al.
        Atypical leiomyomas of the uterus: a clinicopathologic study of 51 cases.
        Am J Surg Pathol. 2013; 37: 643-649
        • Bell S.
        • Kempson R.
        • Hendrickson M.
        Problematic uterine smooth muscle neoplasms.
        Am J Surg Pathol. 1994; 18: 535-558
        • Launonen V.
        • Vierimaa O.
        • Kiuru M.
        • Isola J.
        • Roth S.
        • Pukkala E.
        • et al.
        Inherited susceptibility to uterine leiomyomas and renal cell cancer.
        Proc Natl Acad Sci U S A. 2001; 98: 3387-3392
        • Merino M.J.
        • Torres-Cabala C.
        • Pinto P.
        • Linehan W.M.
        The morphologic spectrum of kidney tumors in hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome.
        Am J Surg Pathol. 2007; 31: 1578-1585
        • Menko F.
        • Maher E.
        • Schmidt L.
        • Middelton L.
        • Aittomaki K.
        • Tomlinson I.
        • et al.
        Hereditary leiomyomatosis and renal cell cancer (HLRCC): renal cancer risk, surveillance and treatment.
        Fam Cancer. 2014; : 1-8