RAPID PUBLICATION

DELETION OF PTEN IN A PATIENT WITH BANNAYAN-RILEY-RUVALCABA SYNDROME SUGGESTS ALLELISMWITH COWDEN DISEASE

E.M. Arch1,2, B.K. Goodman5, R.A. Van Wesep4,6, D. Liaw7, K. Clarke1,3, R. Parsons7, V.A. McKusick1,3, M.T. Geraghty1,2.

Center for Medical Genetics1, Dept. of Pediatrics2, Dept. of Medicine3, Dept. of Pathology4, Kennedy Krieger Institute5, The

Johns Hopkins University School of Medicine, Baltimore, MD 21287-3914. Dept. of Pathology, Sinai Hospital of Baltimore6.

Dept. of Pathology, College of Physicians and Surgeons, Columbia University NY, NY7.

We report on an 18-month-old boy with an interstitialdeletion at 10q23.2-q24.1. This region includes thePTENgene, mutations of which have been reported to causeCowden disease. Our patient presented with manifestationsof Bannayan-Riley-Ruvalcaba (BRR) syndrome. The BRRsyndrome is a rare disorder which presents most commonlyin childhood. Cowden disease is a disease of adulthood andis inadequately described in children. Because of theconsiderable phenotypic overlap between the two disorders,and the cytogenetic and molecular findings in our patient, wesuggest that BRR syndrome and Cowden disease are allelic.Am. J. Med. Genet. 71:489–493, 1997.© 1997 Wiley-Liss, Inc.

KEY WORDS

Bannayan-Riley-Ruvalcaba syndrome; Bannayan-Zonanasyndrome; Ruvalcaba-Myhre syndrome; Riley-Smith syndrome;Cowden disease;PTEN; interstitial deletion; 10q23.2-q24.1;intestinal polyps.

INTRODUCTION

The Bannayan-Riley-Ruvalcaba (BRR) syndrome is anautosomal dominant trait comprised of macrocephaly withsubcutaneous and visceral lipomas and hemangiomas [Gorlin etal., 1990]. Bannayan [1971] and Zonana et al. [1976]independently described patients with macrocephaly andsubcutaneous and visceral lipomas and hemangiomas. TheRuvalcaba-Myhre syndrome consists of macrocephaly, intestinalpolyposis and pigmented spotting of the penis [Ruvalcaba et al.,

1980]. Riley and Smith [1960] had earlier noted a similaranomaly complex in association with pseudopapilledema.Evidence of overlap of all 3 syndromes was reported later andthe designation Bannayan-Riley-Ruvalcaba (BRR) syndromewas suggested for this condition [Gorlin et al., 1992]. Cowdendisease or multiple hamartoma syndrome is a rare autosomaldominant condition comprised of macrocephaly, mucocutaneouslesions, and hamartomatous neoplasms [Lloyd and Dennis, 1963;Mallory, 1995]. There is a strong association of this disorderwith cancers of the breast and thyroid, making it the subject ofmany recent investigations into the hereditary nature ofmalignancies.

The gene for Cowden disease was localized to 10q22-q23using linkage analysis in 12 families [Nelen et al., 1996].Recently a tumour suppressor gene,PTEN, was isolated andcharacterized from this region and mutations inPTEN werereported in patients with Cowden disease [Li et al., 1997; Liawet al., 1997]. We describe a patient with an interstitial deletionof 10q23.2-q24.1 in whom absence ofPTEN was confirmed byfluorescencein situ hybridization (FISH). His manifestationsoverlap both the BRR syndrome and Cowden disease. A similarphenotype was reported in members of 2 kindreds diagnosedwith BRR syndrome, who later developed skin lesionspathognomonic of Cowden disease and, in addition, had severalmalignancies uncommon in BRR syndrome [Fargnoli et al.,1996]. The phenotypic overlap between BRR syndrome andCowden disease, the clinical and molecular cytogenetic findingsin our patient and the recent genetic findings in Cowden diseasesuggest that both disorders are caused by loss of function of thePTENgene.

METHODS

Cytogenetics: Mitosis in lymphocytes was synchronized usingstandard methods [Yunis and Chandler, 1977]. Prometaphasechromosome spreads were G-banded using trypsin pretreatmentfollowed by Wright’s staining (GTW), and analyzed at aresolution of 650 bands per haploid set. G-banded cells wereanalyzed with a Zeiss Axioskop and the Cytovision computer-assisted karyotyping system (Applied Imaging, Santa Clara,

Address reprint requests to Michael T. Geraghty, MB, MRCPI,Assist. Prof. of Pediatrics, Center for Medical Genetics, Blalock1008, Johns Hopkins University School of Medicine, 600 N.Wolfe St., Baltimore, MD 21287-4922, USA, (410) 955-3071,(410) 955-7397 (FAX), e-mail,:geraghty@welchlink.welch.jhu.edu.received on 16 June 1997accepted on 2 July 1997Contract grant sponsor: KKI/Hopkins NICH Mental Retardation

Center Core Grant; Contract grant number: HD24061.

American Journal of Medical Genetics 71:489–493 (1997)

© 1997 Wiley-Liss, Inc.

CA). FISH was performed using the BAC clone 265N13, whichcontains thePTENgene (a gift from Dr. Ramon Parsons). Theprobe was labeled with biotin-dUTP by nick translation(BioNick, GibCo, Inc.), and prepared for hybridization usingstandard methods [Lichter et al., 1991]. Hybridization wascarried out at 370C for 20 hours, followed by successive washesin 50% formamide and 2xSSC at 420C, and a final wash in4xSSC and 0.5% Tween-20 at room temperature. The probe wasdetected using FITC-avidin and one round of signalamplification with anti-avidin. A Zeiss Axioskop equipped withepiflourescence and a dual band-pass filter set was used withKodak Ektachrome Elite II 400 film.

Pathology: Endoscopically resected polyps were fixed in 10%buffered formalin, embedded in paraffin, sectioned and stainedwith hematoxylin and eosin.

CLINICAL REPORT

The propositus is an 18-month- old Caucasian boy whowas referred for a second opinion, with a diagnosis of BRRsyndrome. He was born after an uncomplicated pregnancy andwas delivered by Caesarean section at 42 weeks for failure toprogress. The mother was a 32-year-old gr3p1 woman with ahistory of two first trimester miscarriages. Both parents were ingood health and the family history was otherwise unremarkable.The patient’s birth weight was 4904 g, length 58.5 cm, and OFC42 cm, all >95th centile. During the first year, he was followedas an outpatient for macrosomia. Weight and length for ageslowly approached the 75th centile. Head circumferenceremained markedly elevated, a pattern typical of the BRRsyndrome. He presented at 18 months of age with a recenthistory of hematochezia which required endoscopic intervention.

On examination at 18 months height and weight were atthe 75th to 90th centile, while OFC was 58 cms, 7SD above themean for age. Rate of head growth based on previous recordswas normal. He had evident brachycephaly, a prominentforehead, hypertelorism, and mild mid-face hypoplasia (Fig. 1).A 3x4 cm lipoma was present on the right abdomen, and another,measuring 1x1/2 cm, was found on the right thumb. Two smallhemangiomas were present on the back and shoulder, and twoskin tags were noted at the base of the spine and in the groinarea. Axial hypotonia was present, with otherwise normalneurologic findings. Cardiorespiratory and abdominal status waswithin normal. He had an undescended right testicle.Development was delayed, with an approximate motordevelopmental quotient of 60%, and language developmentalquotient of 90%. Hearing was normal as were brain auditoryevoked responses. Ophthalmologic examination showedbilateral pseudopapilledema and anisometropia. Neither parenthad any signs of Cowden disease or BRR syndrome. Their headcircumferences were at the 98th-99th centile.

Previous investigations in this patient included a CT scanof the brain which showed normal structure and ventricles ofnormal size. Upper and lower GI endoscopy demonstratedmultiple sessile hamartomatous polyps throughout the duodenumand large intestine (Fig 2). Small bowel follow-through wasnormal. Muscle biopsy showed no evidence of myoliposis.Blood was taken for general biochemical studies, plasma aminoacid, plasma free fatty acid and plasma carnitine levels and anacyl-carnitine profile. All results were normal. Qualitative urineorganic acid analysis was normal. Results of thyroid functiontests were also normal. Muscle carnitine was not measured. Thelymphocyte karyotype was 46,XY,del(10)(q23.2q24.1); in eachof 22 cells examined one copy of chromosome 10 had aninterstitial deletion of the long arm resulting in loss of thematerial from band q23.2 to the interface between bands q23.3and q24.1 (Fig. 3). FISH, using a probe specific for thePTENgene, demonstated the absence ofPTEN from the deletedchromosome 10. The patient’s parents had normalchromosomes.

Fig. 1: Patient at age 18 months, showing macrocephaly, promi-nent forehead, depressed nasal root and lipoma on right abdomen(photograph courtesy of the mother).

490 Arch, et al.

DISCUSSION

Clinically, this patient fits the BRR phenotype. Thisincludes macrosomia at birth with isolated persistentmacrocephaly, developmental delay, hamartomatousgastrointestinal polyps, l ipomas, hemangiomas, andpseudopapilledema. Gastrointestinal polyps are common in theBRR syndrome. They are usually hamartomatous, but aregenerally confined to the distal ileum and colon [Gorlin et al.,1992]. Cowden disease is inadequately described in infants andchildren. In adults, pathognomonic criteria for this disorderinclude facial tricholemmas, present in nearly all cases, acralkeratosis, papillomatous lesions and mucosal lesions [Nelen etal., 1996]. However, these lesions are rarely present before thesecond to third decade making it difficult to diagnose thiscondition in children. Other signs of Cowden disease include GIpolyps, which are often hamartomatous and distributedthroughout the bowel, macrocephaly, mental retardation, andmalignancy reported in several tissues [Marra et al., 1994].Thus, BRR syndrome and Cowden disease share manymanifestations [see Table I]. Our patient fits the clinicaldiagnosis of BRR syndrome but clearly he has anomalies

common to both disorders.

Interstitial deletions of the region of chromosome 10 seenin our patient are rare, only 3 cases having been reported.. Twopatients were described independently in 1985 by Shapiro et al.and Morey et al. The deletion in the first patient involvedthe region 10q22.3-q24, while the second patient’s deletion wasidentical to that observed in our patient del(10)(q23.2q24.1).Both children were reported to have minor anomalies. The firstwas macrosomic at birth and had a flat nasal bridge, apparentlylow set ears and telecanthus. Few clinical findings are given onthe second patient. Significantly, both children had rectalprolapse but no gastrointestinal endoscopic or radiologicinvestigations were reported. The third patient described byMori et al. [1988] had macrocephaly at the age of 6 months, adeletion at 10q22-q24 and was also said to have a flat nasalbridge, hypertelorism, and apparently low set ears. Nogastrointestinal investigations were reported in this patient. Thepatient we describe has an interstitial deletion of 10q23.2-24.1and is clearly deleted for more than just thePTEN gene.However, all of the clinical anomalies found in our patient arealso seen in BRR syndrome and Cowden disease. This suggeststhat hemizygosity forPTEN is the most important factor indetermining the phenotype in our patient.

Cowden disease was mapped to 10q23.1-q24.1 by Nelenet al., [1996]. Loss of heterozygosity at this locus was reportedin sporadic tumors of the thyroid and prostate [Gray et al., 1995;Ittman, 1996; Marsh et al., 1997]. Li et al. [1997] isolated andcharacterized a gene from this region and called itPTEN. Theyproposed that the protein product ofPTEN is a tumor suppressorand demonstrated mutations inPTEN in breast, prostate andglioblastoma tumour cell lines. A second group of investigatorsalso isolated this gene (but called itMMAC1) and identified

Fig. 2: Resected hamartomatous polyp showing an admixture ofbenign epithelial and stromal elements as described previously inCowden disease and BRR syndrome [Hizawa et al., 1994;Carlson et al., 1984]. Focal erosion and inflammation is alsopresent (hematoxylin and eosin, original magnification 22x).

Fig. 3: Panel A shows a chromosome ideogram at 550 bandlevel on the left and the patient’s normal (center) and deletedchromosomes 10 to the right. Panel B shows a representativemetaphase cell and interphase nucleus hybridized withBAC265N13 containingPTEN,showing only one signal on thenormal chromosome 10.

Deletion of PTEN in BRR Syndrome 491

mutations in this gene in DNA from glioma, prostate, kidney andbreast tumor samples [Steck et al., 1997]. Subsequentlygermline point mutations inPTEN were reported in familialcases of Cowden disease [Liaw et al., 1997]. Our patient isdeleted forPTEN on FISH analysis. Clinically he fits thediagnosis of the BRR syndrome. We have described above thesubstantial overlap between BRR syndrome and Cowden diseaseand the lack of information on the latter disorder in childhood.Based on the above evidence, we suggest that the Bannayan-Riley-Ruvalcaba syndrome and Cowden disease are allelic. We

further suggest that all patients with a diagnosis of the BRRsyndrome be tested for mutations at thePTEN locus, so thatappropriate anticipatory guidance can be given to patients andfamilies concerning tumor risk and management.

Acknowledgments This work was in part supported byKKI/Hopkins NICHD Mental Retardation Center Core GrantHD24061. We would like to thank Dr. R. Parsons for thegenerous gift of the BAC clone 265N13.

Table I: Comparison of clinical manifestations of BRR syndrome, Cowden Disease and the Patient

Cowden disease BRR syndrome Patient

Inheritance Autosomal dominant Autosomal dominant Sporadic

Mucocutaneous TricholemmaOral papillomasAcral keratosis

Palmoplantar keratosisHemangiomas

Multiple skin tags

LipomasAngiolipomasHemangiomas

Penile lentigines

LipomasHemangiomas

Skin tags

Gastrointestinal Polyps-varied histology-entire GI tract

Polyps-hamartomas-distal ileum and colon

Polyps-hamartomas-entire GI tract

Thyroid Goiter/AdenomaHyper/Hypothroidism

Thyroid carcinoma

Anomalies Macrocephaly MacrocephalyMacrosomia

HypertelorismDown slanting palpebral

fissures

MacrocephalyMacrosomia

Hypertelorism

CNS Mental retardationLhermitte-Duclos disease

Mental retardationLearning disabilities

SeizuresLipoid myopathy

Developmental delay

Ophthalmologic PseudopapilledemaProminent Schwalbe linesStrabismus / Amblyopia

PseudopapilledemaAnisometropia

Skeletal KyphoscoliosisPectus excavatum

ScoliosisPectus excavatum

Joint hyperextensibility

Joint hyperextensibility

Malignancy Carcinoma of breastthyroid, cervix, bladder.,

liver, GI and lung.Basal cell carcinoma

Squamous cell carcinomaMelanoma

Non-Hodgkins lymphomaAcute myeloid leukemia

Liposarcoma

Breast (1 patient) Unknown

[Gorlin et al., 1992; Hanssen and Fryns, 1995; Marra et al., 1994; Vinchon et al., 1994; Wells et al., 1994; Albrecht et al., 1992]

492 Arch, et al.

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