Neurofibromatosis

I/ Introduction :
Definition of neurofibromatosis 6 subtypes of genetic disorders (NF1-6) Affecting all cells derived from the embryonic neural tube Predispose patients to nervous system tumors. Inheritance: autosomal dominant (drawing a parallel to familial cancer inheritance) Most common forms : NF1 (Neurofibromatosis type 1 = Von Recklinghausen disease) NF2 (Neurofibromatosis type 2 = Schwannomatosis) Prevalence: NF1 : 1/3000 to 1/4000 NF2 : 1/50 000 High penetrance (almost 100% at the age of 5) High variability in clinical expression within population and families Prognosis : hardly depending on location of tumors (poor if compressing nerves) Clinical features: NF1: Caf-au-lait spots Cutaneous neurofibroma (often benigns) Plexiform neurofibroma Lisch nodules Bony dysplasia Axillary lentigins Optic nerve glioma Most common complication: learning disabilities NF2: nerves) Subcutaneous schwannoma Meningioma Neurofibroma Cataract (lens opacities) Most common complication (severity and frequence + +) : neurological symptoms by cranial nerve compression. Schwannoma +++ (bilateral and often on cranial

II/ Molecular disorder

A/ NF1 Genes
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NF1 (17q11.2) Encompassing 3 genes (EV12A/B, CMPG and AK3) 350 kb, 59 exons Produces an RNA of 11-13 kb Codes for neurofibromin TP53 (17p) also involved in NF1

Neurofibromin Ubiquitous 2812 AA Contains a particular region : GRD (GAP related domain) GAP plays an inhibitory role in the RAS activation pathway GRD is therefore important in signal transduction (interaction with RAS) Loss of heterozygosity observed in several malignant tumors in patients with NF1 NF1 has a tumor suppressor action Protein truncation

Type of mutation -

50% de novo, proving that the gene is prone to be mutated (unstable) Mostly private mutations described in only one family Absence of hot spot regions (higher frequency of mutations) Deletions, point substitutions, insertions, duplications Nonsense and frameshift mutations : premature STOP codon Most leading to severe truncation or complete loss of gene expression Somatic mosaicism is rare and has many clinical manifestations Germinal mosaicism coul explain very rare situations in which healthy parents have several affected children

Genotype-Phenotype correlation Little evidence Because of non systematic search for mutations and lack of reliable and complete informations Deletion containing the entire gene leads to most severe cases with:

o Intellectual impairement o Facial dysmorphism o More cutaneous neurfibromas Except for this, no familial and molecular element can predict the severity of the disease A specific deletion (3bp inframe) in exon 17 with no cutaneous fibromas B/ NF2

Gene called schwannomin (22q11.13.1) 110kb, 17 exons Cytoskeleton protein with a tumor suppressor function

III/ Diagnosis for Nf1

Clinical Diagnostic Criteria for Nf1: Six or more cafe au lait patches >15 mm in adults and > 5 mm in children Two or more neurofibromas or one plexiform neurofibroma Axillary or groin freckling Lisch nodules (iris hamartomas) Optic pathway glioma A first degree relative with Nf1 A distinctive osseous lesion such as sphenoid wing dysplasia or thinning of the long bone cortex with or without pseudoarthrosis

Molecular diagnosis Confirmatory diagnostic testing suspected but (National Institutes of Health) criteria. indicated for individuals in whom NF1 is who do not fulfill the NIH diagnostic

A multi-step mutation detection protocol that identifies more than 95% of pathogenic NF1 mutations in individuals fulfilling the NIH (National Institutes of Health) diagnostic criteria is available. This protocol (analysis of both mRNA and genomic DNA) includes: RT-PCR direct sequencing microsatellite marker analysis MLPA interphase FISH.

Testing for whole-gene deletions. Testing is sometimes performed to look for whole NF1 gene deletions alone when the "large deletion phenotype" is suspected clinically. Whole NF1 gene deletions occur in 4%5% of individuals with NF1. Whole NF1 gene deletions can be identified by FISH, MLPA, or testing for multiple SNPs.

Diagnostic methods for Nf2 Clinical and family history Examination including cutaneous and ophthalmic (Slit lamp) Cranio-spinal MRI Molecular analysis Molecular diagnosis Cytogenetics -gross chromosomal changes detectable on normal cytogenetic analysis are fairly uncommon. Cytogenetically visible deletions Ring chromosome 22 Apparently balanced chromosomal translocations Fluorescence in situ hybridization analysis. Smaller deletions that remove multiple exons of NF2 or the whole gene can also be identified by FISH analysis. To confirm/establish the diagnosis in a proband, one of two sample types is used: Leukocyte DNA from an individual who has an affected parent Tumor DNA from an individual who reperesents a simplex case Differential diagnosis Nf1-Nf2 Confusion between Nf1 and Nf2, But also with other diseases, like Nf5, Watson syndrome, Noonan syndrom for Nf1, and Schwannomatosis for Nf2 Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies are available, but require prior identification of the disease-causing mutation in the family. Availability of genetic testing There are 34 laboratories that perform genetic testing, concerning NF1, and 20 laboratories, concerning Nf2, most of them carrying out sequence analysis of the entire coding region, deletion/duplication analysis and prenatal diagnosis.

IV/ Treatment
Nf1 No specific treatment for the disease exists at present. Management correspond to regular monitoring, primarily clinical, and treatment of the complications when they appear, involving the eye, central or peripheral nervous system, cardiovascular system, spine, or long bones; surgical removal of neurofibromas.

Various medical treatments for plexiform and spinal neurofibromas are being evaluated in clinical trials. Radiofrequency therapy has shown some promise for treatment of facial diffuse plexiform neurofibromas and caf-au-lait spots in small clinical series. The use of statins for treatment of learning disabilities in children with NF1 is being evaluated in clinical trials. Nf2 Treatment of vestibular schwannoma is primarily surgical. Treatment for hearing loss includes referral to an audiologist, lip-reading and sign language instruction, and possibly hearing aids and/or cochlear or brain stem implants. For affected or at-risk individuals: annual MRI beginning at approximately age ten to 12 years and continuing until at least the fourth decade of life; hearing evaluation, including BAER testing BAER= auditory brainstem response or auditory evoked response The most promising results have come from short- to medium-term treatment with avastin, which seems to have efficacy against rapidly growing schwannomas and possibly ependymomas. Further development of treatment trials is underway. Recently drug trials have identified bevacizumab as a potential treatment.