Von Hippel-Lindau syndrome (VHL) is a dominantly inherited familial cancer syndrome predisposing to a variety of malignant and benign neoplasms, most frequently retinal, cerebellar, and spinal hemangioblastoma, renal cell carcinoma (RCC), pheochromocytoma, and pancreatic tumors.
Neumann ... Von Hippel-Lindau syndrome (VHL) is a dominantly inherited familial cancer syndrome predisposing to a variety of malignant and benign neoplasms, most frequently retinal, cerebellar, and spinal hemangioblastoma, renal cell carcinoma (RCC), pheochromocytoma, and pancreatic tumors. Neumann and Wiestler (1991) classified VHL as type 1 (without pheochromocytoma) and type 2 (with pheochromocytoma). Brauch et al. (1995) further subdivided VHL type 2 into type 2A (with pheochromocytoma) and type 2B (with pheochromocytoma and renal cell carcinoma). Hoffman et al. (2001) noted that VHL type 2C refers to patients with isolated pheochromocytoma without hemangioblastoma or renal cell carcinoma. McNeill et al. (2009) proposed that patients with VHL syndrome caused by large VHL deletions that include the HSPC300 gene (C3ORF10; 611183) have a specific subtype of VHL syndrome characterized by protection from renal cell carcinoma, which the authors proposed be named VHL type 1B. Nordstrom-O'Brien et al. (2010) provided a review of the genetics of von Hippel-Lindau disease.
Seizinger et al. (1991) pointed out that visceral cysts of the kidney, pancreas, and epididymis occur not only as features of VHL but also in the general population, and that the presence of such cysts, unaccompanied by other ... Seizinger et al. (1991) pointed out that visceral cysts of the kidney, pancreas, and epididymis occur not only as features of VHL but also in the general population, and that the presence of such cysts, unaccompanied by other more typical lesions such as retinal and cerebellar hemangioblastoma, may represent a major diagnostic problem. The application of flanking markers for the VHL gene for presymptomatic diagnostic testing confirmed that epididymal cysts are indeed not suitable as a diagnostic criterion. The genetic studies suggested that VHL with or without pheochromocytomas is caused by defects within the same gene. Renal cell carcinoma occurs as part of VHL; a second more proximal region of chromosome 3, 3p14.2, is responsible for 'pure familial renal cell carcinoma' (144700). Webster et al. (2000) calculated the likelihood of VHL in an individual presenting with a single ocular angioma conditional upon the age of presentation, results of DNA analysis, family history of VHL, and results of systemic screening, and produced a risk estimate table for individuals with combinations of these variables. Hes et al. (2003) noted that in the presence of a positive family history, VHL disease can be diagnosed clinically in a patient with at least 1 typical VHL tumor. Typical VHL tumors are retinal, spinal, and cerebellar hemangioblastoma; renal cell carcinoma; and pheochromocytoma. Endolymphatic sac tumors and multiple pancreatic cysts suggest a positive carriership in the presence of a positive VHL family history because they are uncommon in the general population. In contrast, renal and epididymal cysts occur very frequently in the general population and are, as sole manifestations, not reliable indicators for VHL disease. In patients with a negative family history of VHL-associated tumors, a diagnosis of VHL disease can also be made on the basis of 2 or more hemangioblastomas or a single hemangioblastoma in association with a visceral manifestation (e.g., pheochromocytoma or renal cell carcinoma). Hes et al. (2003) suggested the following criteria for eligibility for VHL gene mutation analysis: a patient with classic VHL disease (meeting clinical diagnostic criteria) and/or first-degree family members; a person from a family in which a germline VHL gene mutation has been identified (presymptomatic test); a VHL-suspected patient, i.e., one with multicentric tumors in 1 organ, bilateral tumors, 2 organ systems affected, or 1 VHL-associated tumor at a young age (less than 50 years for hemangioblastoma and pheochromocytoma or less than 30 years for renal cell carcinoma); or a patient from a family with hemangioblastoma, renal cell carcinoma, or pheochromocytoma only. - Mutation Analysis Using DNA polymorphic markers, Glenn et al. (1992) studied 16 families with VHL disease. Of 48 asymptomatic persons at risk of developing this illness because of an affected parent or sib, DNA polymorphism analysis predicted that 9 were carriers of the disease gene and 33 had the wildtype allele. The test was not informative in 6 persons. All 9 persons predicted to carry the VHL gene had evidence of occult disease on clinical examination. There was no clinical evidence of VHL disease in 32 of 33 persons predicted to carry the wildtype allele. Richards et al. (1993, 1994) found that large germline deletions could be detected by Southern analysis and pulsed field gel electrophoresis in 19% and 3% of VHL patients, respectively. To determine whether the pheochromocytoma-associated syndromes VHL and MEN2 play a role in the development of thoracic functioning paragangliomas, Bender et al. (1997) analyzed germline DNA from 5 unselected patients with this tumor for mutations in the genes that predispose to VHL and MEN2. Molecular and clinical data revealed that 3 (60%) had VHL, with 2 different germline mutations of the VHL gene, but no individual was affected by MEN2. Two of these 3 patients with VHL did not show any additional VHL-associated lesions. Bender et al. (1997) suggested that VHL should be considered in the differential diagnosis of thoracic pheochromocytoma, and that in VHL patients suspected of a catecholamine-secreting tumor, thoracic localization should be considered if an adrenal pheochromocytoma cannot be detected. Pack et al. (1999) stated that the reported frequency of detection of VHL germline mutations had varied from 39 to 80%. Stolle et al. (1998) found that a quantitative Southern blotting procedure improved this frequency. Pack et al. (1999) reported the use of fluorescence in situ hybridization as a method to detect and characterize VHL germline deletions. They reexamined a group of VHL patients shown previously by SSCP and sequencing analysis not to harbor point mutations in the VHL locus. They found constitutional deletions in 29 of 30 VHL patients in this group, using cosmid and P1 probes that covered the VHL locus. They then tested 6 phenotypically normal offspring from 4 of these VHL families: 2 were found to carry the deletion and the other 4 were deletion-free. In addition, germline mosaicism of the VHL gene was identified in 1 family. Thus, FISH was found to be a simple and reliable method to detect VHL germline deletions and to be practically useful in cases where other methods of screening fail to detect abnormalities in the VHL gene. Hes et al. (2000) performed mutation analysis of the VHL gene in 84 patients presenting with a single CNS hemangioblastoma and 4 with multiple hemangioblastomas, but no other features of VHL. A VHL germline mutation was found in 3 of 69 (4.3%) of those with single hemangioblastomas presenting at less than 50 years of age (3 of 84 (3.6%) in total) and 2 of the 4 patients with multiple hemangioblastomas. A VHL mutation was found in a 44-year-old woman presenting with a single cerebellar hemangioblastoma, in 4 clinically unaffected relatives, and in 2 single cases presenting at 29 and 36 years. Hes et al. (2000) recommended that in addition to conventional clinical and radiologic investigations, VHL mutation analysis be offered to those presenting with CNS hemangioblastomas before the age of 50 years. Sgambati et al. (2000) presented 2 cases of VHL mosaicism. In each of 2 families, standard testing methods (Southern blot analysis and direct sequencing) identified the germline mutation in the VHL gene of the offspring, but not in their clinically affected parent. Additional methods of analysis of the affected parents' blood detected the VHL gene mutation in a portion of their peripheral blood lymphocytes. In one case, detection of the deleted allele was by FISH, and, in the second case, a 3-bp deletion was detected by conformational sensitive gel electrophoresis and DNA sequencing of cloned genomic DNA. Sgambati et al. (2000) concluded that mosaicism in VHL is important to search for and recognize when an individual without a family history of VHL has VHL. Patients diagnosed without family histories of the disease have been reported in as many as 23% of kindreds. Identification of individuals potentially mosaic for VHL will affect counseling of families, and these individuals should themselves be included in clinical screening programs for occult disease.
The cardinal features of von Hippel-Lindau syndrome are angiomata of the retina and hemangioblastoma of the cerebellum. Hemangioma of the spinal cord has also been observed. Pheochromocytoma occurs in some patients. The combination of hypertension with angioma may ... The cardinal features of von Hippel-Lindau syndrome are angiomata of the retina and hemangioblastoma of the cerebellum. Hemangioma of the spinal cord has also been observed. Pheochromocytoma occurs in some patients. The combination of hypertension with angioma may lead to subarachnoid hemorrhage. Hypernephroma-like renal tumors occur in some patients. Polycythemia may be due to either the hemangioblastoma of the cerebellum or the hypernephroma. Hemangiomas of the adrenals, lungs, and liver, and multiple cysts of the pancreas and kidneys, have been observed in some instances. Although there were many earlier reports of this syndrome (see HISTORY), Melmon and Rosen (1964) introduced the term 'von Hippel-Landau' syndrome and described a large kindred with multiple features of the disorder. The condition of arteriovenous aneurysm of retina and midbrain with facial nevus, described by Bonnet et al. (1938) and by Wyburn-Mason (1943), is of uncertain relationship to this condition. Metastatic renal cancer occurs in some instances (Kranes and Balogh, 1966). Goldberg and Duke (1968) examined the eyes of an affected 51-year-old black male whose mother died of cerebellar tumor at age 26 years. The same case was described by McKusick (1961). In addition to the association of tumors of the brain and adrenal medulla that occurs in neurofibromatosis and in von Hippel-Lindau disease, cerebellar tumors sometimes produce paroxysmal hypertension similar to that of pheochromocytoma. Urinary catecholamines are normal in such cases (Cameron and Doig, 1970). Cysts and 'hypernephroid' tumors of the epididymis have been described in VHL patients (Grossman and Melmon, 1972). Male patients may have papillary cystadenoma of the epididymis, an unusual tumor that is bilateral when it occurs in von Hippel-Lindau disease and is not familial when unilateral (Price, 1971). The experience of Lamiell (1987) differed, however; 7 of 21 affected males in 1 kindred had an epididymal mass and 5 of these were unilateral. Tsuda et al. (1976) observed the occurrence of bilateral papillary cystadenoma of the epididymis in 3 brothers with VHL syndrome. Bilateral papillary cystadenomas of the broad ligament, presumably of mesonephric origin, is the probable homologous tumor of the female (Erbe, 1978). In von Hippel-Lindau disease with pheochromocytoma, Atuk et al. (1979) reported hypercalcemia which was corrected in all by removal of the tumor. In several patients, pheochromocytoma antedated development of retinal lesions. Fishman and Bartholomew (1979) described 3 related patients with striking pancreatic involvement. One had exocrine pancreatic insufficiency. In an extensively affected kindred, Fill et al. (1979) found renal cell carcinoma in 16 of 42 cases and carcinoma of the pancreas in 4 of 42. Griffiths et al. (1987) found reports of 6 patients with von Hippel-Lindau syndrome, pheochromocytoma, and islet cell tumor. A further 11 patients showed pheochromocytoma and islet cell tumor. No patient with von Hippel-Lindau syndrome had a carcinoid tumor, which is a feature of neurofibromatosis with pheochromocytoma (see 162200). No cases of neurofibromatosis had islet cell tumor. In Cardiff, Wales, 20 patients with cerebellar hemangioblastoma were seen between 1972 and 1985. In 8 of these, Huson et al. (1986) subsequently established the diagnosis of von Hippel-Lindau disease. Although the diagnosis had not previously been considered, in retrospect, 7 of the 8 cases were known to be at risk for the syndrome. Jennings et al. (1988) demonstrated the usefulness of family studies in determining asymptomatic lesions requiring treatment, such as renal cell carcinoma. They also reported the occurrence of a spermatic cord mesenchymal hamartoma in this disorder. Lamiell et al. (1989) identified 43 affected members in a large kindred, which was exceptional for absence of pheochromocytoma and erythrocythemia, for more renal and pancreatic cysts and malignancies, and for somewhat fewer eye or central nervous system lesions. Bilateral renal adenocarcinoma was found presymptomatically in 5 young subjects who had bilateral nephrectomy and hemodialysis. Three survived long-term after renal transplants. Five members of the family had pancreatic malignancy. Horbach et al. (1989) suggested that the combination of adrenal pheochromocytoma and ipsilateral renal cell carcinoma may represent a forme fruste of von Hippel-Lindau disease. Neumann and Wiestler (1991) found a striking tendency for familial clustering of particular VHL features. Both angiomatosis retinae and hemangioblastoma of the CNS occurred in most families, whereas the occurrence of renal lesions and/or pancreatic cysts was mutually exclusive with pheochromocytoma. The authors interpreted these findings to indicate that the VHL locus is complex, with the existence of different mutations in different families or the occurrence of additional genetic lesions that cooperate with the VHL gene on chromosome 3p. They suggested a linear sequence of features as follows: pheochromocytoma, angiomatosis retinae, hemangioblastoma of the CNS, renal lesions, pancreatic cysts, and epididymal cystadenoma. In the course of an evaluation of 41 families with this disorder from the United States and Canada, Glenn et al. (1991) found 1 large family with a distinctive phenotype: the most common disease manifestation was pheochromocytoma occurring in 57% (27 of 47) of affected members; few (4 of 47) had symptomatic spinal or cerebellar hemangioblastomas; no affected family member had renal cell carcinoma or pancreatic cysts. Genetic analysis demonstrated, however, that the disorder in this family was linked to the same markers found to be linked to typical VHL. The observations are clearly relevant to the descriptions of families with 'pure' pheochromocytoma (171300); they may be instances of allelism at the VHL locus. Keeler and Klauber (1992) described renal cell carcinoma in a 16-year-old boy, probably the youngest reported example of hypernephroma in VHL disease. Lenz et al. (1992) demonstrated that norepinephrine-producing adrenal pheochromocytoma in von Hippel-Lindau disease can produce the clinical syndrome of hypertension associated with severe hypokalemia and hyperreninemic hyperaldosteronism. The hyperreninemic hyperaldosteronism was rapidly improved by beta-blockade and was completely reversed by tumor removal. Kerr et al. (1995) described hemangioblastoma of the optic nerve in a 27-year-old woman with von Hippel-Lindau syndrome, the tenth such reported case. Davies et al. (1994) described a 65-year-old woman who was an obligate carrier of the gene for von Hippel-Lindau disease. Her father, 2 brothers, 2 sisters, and 3 sons had hemangioblastomas and renal carcinomas. Careful examination of the woman showed only a small benign renal cyst. Such cysts are very common in the general population. Therefore, obligate gene carriers may not exhibit any features of the disease beyond the age of 60 years. Using a VHL register set up in the northwest of England in 1990 containing information on 83 affected persons, Maddock et al. (1996) studied population statistics, clinical features, age at onset, and survival. The mean age at onset of first symptoms was 26.25 years, with cerebellar hemangioblastoma being the most common presenting manifestation (34.9% of cases). The mean age at diagnosis of VHL was 30.87 years. Overall, 50 patients (60.2%) developed a cerebellar hemangioblastoma, 34 (41%) a retinal angioma, 21 (25.3%) a renal cell carcinoma, 12 (14.5%) a spinal hemangioblastoma, and 12 (14.5%) a pheochromocytoma. Mean age at death was 40.9 years with cerebellar hemangioblastoma being the most common cause (47.7% of deaths). In addition to the 83 clinically affected subjects, Maddock et al. (1996) identified 3 obligate carriers who were considered to be lesion free on extensive screening tests. In the regionally based cancer registry, 14% of all CNS hemangioblastomas were found to occur as part of VHL, but investigations for VHL in apparently sporadic cases appeared to have been limited. Endolymphatic sac tumors (ELSTs) are highly vascular, benign, but locally aggressive neoplasms of the endolymphactic system that often destroy the surrounding temporal bone. They are very rare and generally occur sporadically, but occur with increased frequency in patients with VHL. Manski et al. (1997) found MRI evidence of 15 ELSTs in 13 (11%) of 121 patients with VHL, but in none of 253 patients without evidence of VHL (P less than 0.001). Clinical findings in these 13 patients included hearing loss in 13, tinnitus in 12, vertigo in 8, and facial paresis in 1. Mean age at onset of hearing loss was 22 years (range, 12 to 50 years). Lonser et al. (2004) described 3 cases of von Hippel-Lindau disease that illustrated the following features of endolymphatic sac tumors: morbid hearing loss due to a radiologically undetectable microscopic tumor in the endolymphatic sac or duct; initial symptoms caused by hemorrhage, endolymphatic hydrops, or both; an origin in the endolymphatic duct or sac; and molecular evidence of an association with von Hippel-Lindau disease. Complete surgical resection of the endolymphatic sac tumors is curative and can be performed with the preservation of hearing and the alleviation of vestibular symptoms. Butman et al. (2007) reported 35 VHL patients with ELSTs; 3 had bilateral tumors. Mean age at symptom onset was 31 years (range, 11 to 63 years). In additional to hearing loss, tinnitus, and vertigo, other features included aural fullness, aural pain, and facial nerve weakness. Detailed CT and MRI studies showed that 7 (18%) ears had otic capsule invasion, which was always associated with hearing loss. Tumors with otic capsule invasion were larger (2.2 cm) than those without capsule invasion (1.2 cm). However, there was not a significant association between tumor size and hearing loss. Intralabyrinthine hemorrhage was detected in 79% of ears with sudden hearing loss. Butman et al. (2007) concluded that hearing loss associated with ELSTs can result from otic capsule invasion, intralabyrinthine hemorrhage, or endolymphatic hydrops. James (1998) tabulated reports of 4 women with VHL and broad ligament papillary cystadenoma published between 1988 and 1994 (Gersell and King, 1988; Funk and Heiken, 1989; Korn et al., 1990; Gaffey et al., 1994; Karsdorp et al., 1994) and added a fifth case. These are mesosalpinx cysts, which are the equivalent of epididymal cysts in the male. The cysts were unilateral in at least 3 of the 5 cases. They occurred along the full course of the mesonephric duct, in the mesosalpinx close to the ovary, over the uterine tubes, and near the vaginal fornix in a remnant of the Gartner duct (the female counterpart to the duct of the epididymis). At least 3 of the patients had multiple renal cysts and bilateral renal cell carcinoma. In the patient reported by Korn et al. (1990), screening for VHL after the papillary cystadenomas were diagnosed revealed pancreatic cysts and lesions of the cerebellum and kidney; renal cell carcinoma was diagnosed during follow-up surgery. The unilateral cyst in the patient reported by Gaffey et al. (1994) was preceded by the finding of a middle ear papillary tumor. The combined presentation of mesonephric cystadenoma and ear tumor was noted in reports of epididymal cysts in men (Price, 1971). Gaffey et al. (1994) suggested that the ear tumor and the adnexal tumor may represent 'major visceral manifestations of VHL.' (Nomenclature: According to the VHL Family Alliance, a genetic support group, the approved terminology is 'adnexal papillary cystadenoma of probable mesonephric origin,' abbreviated APMO (Graff, 1998).) Fukino et al. (2000) described a Japanese VHL family in which 2 of the 3 affected members developed acute occlusive hydrocephalus that necessitated emergency surgery for ventricular shunting or drainage. In both cases, the occlusion of the cerebrospinal canal was caused by cerebellar hemangioblastoma. The 2 patients with hydrocephalus were sisters aged 8 and 19 at the time of development of obstructive hydrocephalus. They inherited VHL from their mother, who also suffered from cerebellar hemangioblastoma requiring surgery as well as from retinal angiomas. McCabe et al. (2000) described the clinical features, association with von Hippel-Lindau disease, and visual acuity outcomes of patients with juxtapapillary capillary hemangioma, on or adjacent to the optic nerve. Because of their location, a hamartoma on the lesions could potentially be misdiagnosed as papilledema, papillitis, choroidal neovascularization, or choroiditis. Endophytic, exophytic, and sessile forms were described. On long-term follow-up, visual acuity generally worsened. Patients with VHL and juxtapapillary hemangioma more often presented at a younger age, had tumors with an endophytic growth pattern, and had bilateral, multiple tumors. Tumor treatment with laser photocoagulation resulted in variable visual acuity outcomes in the patients reported. Raja et al. (2004) reported that external beam radiotherapy (EBRT) was a useful option in the treatment of retinal hemangiomas secondary to VHL disease that progressed despite standard therapy. EBRT led to improvement of visual acuity, reduction in tumor volume, and stabilization of retinal detachment in most patients treated. Eisenhofer et al. (2001) examined the mechanisms linking different biochemical and clinical phenotypes of pheochromocytoma in MEN2 (171400) and VHL to underlying differences in the expression of tyrosine hydroxylase (TH; 191290), the rate-limiting enzyme in catecholamine synthesis, and of phenylethanolamine N-methyltransferase (PNMT; 171190), the enzyme that converts norepinephrine to epinephrine. Signs and symptoms of pheochromocytoma, plasma catecholamines and metanephrines, and tumor cell neurochemistry and expression of TH and PNMT were examined in 19 MEN2 patients and 30 VHL patients with adrenal pheochromocytomas. MEN2 patients were more symptomatic and had a higher incidence of hypertension (mainly paroxysmal) and higher plasma concentrations of metanephrines, but paradoxically lower total plasma concentrations of catecholamines, than VHL patients. MEN2 patients all had elevated plasma concentrations of the epinephrine metabolite metanephrine, whereas VHL patients showed specific increases in the norepinephrine metabolite normetanephrine. The above differences in clinical presentation were largely explained by lower total tissue contents of catecholamines and expression of TH and negligible stores of epinephrine and expression of PNMT in pheochromocytomas from VHL than from MEN2 patients. Taouli et al. (2003) discussed abdominal imaging findings, including pictorial images, from more than 150 patients with VHL syndrome. The most common findings were renal and pancreatic masses. In a prospective study of 406 VHL patients from 199 families seen at 1 institution in a 12-year period, Chew (2005) found that 205 of the patients had ocular involvement. Patients with complete deletion of the VHL gene were less likely to have ocular involvement than those with partial deletion, missense, or nonsense mutations (9% vs 45%; p less than 0.0001). Chew (2005) identified a previously unreported ocular feature, retinal neovascularization, in 17 patients. Chew (2005) also found 11 cases of intraorbital/intracranial hemangioblastoma, previously reported to be rare in VHL, accounting for 5.3% of all vision-threatening lesions in this study group. In surgically excised retinal hemangioblastomas associated with von Hippel-Lindau disease, Liang et al. (2007) demonstrated high levels of VEGF (192240) and CXCR4 (162643) mRNA and protein but low levels of CXCL12 (600835). Increased expression of VEGF and CXCR4 was also detected in more active hemangioblastomas.
Although pheochromocytoma occurs in only about 7% of VHL patients, marked interfamilial differences are often observed. Examining the relationship between VHL gene mutations and phenotype in 65 VHL kindreds, Crossey et al. (1994) found that large deletions or ... Although pheochromocytoma occurs in only about 7% of VHL patients, marked interfamilial differences are often observed. Examining the relationship between VHL gene mutations and phenotype in 65 VHL kindreds, Crossey et al. (1994) found that large deletions or intragenic mutations predicted to cause a truncated protein were found in 36 of 53 families without pheochromocytoma but in only 2 of 12 families with pheochromocytoma (P less than 0.01). Of 12 families with pheochromocytoma, 10 had missense mutations compared with 13 of 53 kindreds without pheochromocytoma (P less than 0.001). In particular, the arg238-to-trp and arg238-to-gln mutations were associated with a high risk (62%) of pheochromocytoma. Chen et al. (1995) identified germline mutations in 85 of 114 VHL families (75%). They found that the types of mutations responsible for VHL without pheochromocytoma (VHL type 1) differed from those responsible for VHL with pheochromocytoma (VHL type 2). Microdeletions/insertions, nonsense mutations, or deletions were found in 56% of families with VHL type 1; missense mutations accounted for 96% of those responsible for VHL type 2. Specific mutations in codon 238 accounted for 43% of the mutations responsible for VHL type 2 (see 608537.0003-608537.0005). Zbar et al. (1996) performed germline mutation analysis in 469 VHL families from North America, Europe, and Japan. Germline mutations were identified in 300 (63%) of the families tested; a total of 137 distinct intragenic germline mutations were detected. Most (124 of 137) of the mutations occurred in 1 or 2 families; a few occurred in 4 or more families. In this large series, it was possible to compare the effects of identical germline mutations in different populations. Germline VHL mutations produce similar cancer phenotypes in Caucasian and Japanese VHL families. Germline VHL mutations were identified that produced 3 distinct cancer phenotypes: (1) renal carcinoma without pheochromocytoma, (2) renal carcinoma with pheochromocytoma (e.g., 608537.0010), and (3) pheochromocytoma alone (e.g., 608537.0012). Zbar et al. (1996) provided a catalog of VHL germline mutations with associated phenotype information. In a patient with von Hippel-Lindau syndrome due to a 505T-C transition (608537.0009) in the VHL gene, Schimke et al. (1998) found a secretory carotid body paraganglioma, the first such instance; a nonfunctional malignant carotid body tumor had been described in a patient with VHL by Hull et al. (1982). Gallou et al. (1999) analyzed the occurrence of RCC in VHL families, based on the nature of the VHL mutations. They observed RCC in at least 1 member of the VHL families in 77% of cases with mutations leading to truncated proteins, and in 55% of cases with missense mutations (P less than 0.05). Thus, mutations resulting in truncated proteins may carry a higher risk of RCC in VHL patients. Bradley et al. (1999) described a family with VHL disease and a mutation in the VHL protein (608537.0017). Of 13 affected individuals, 7 had renal cell carcinoma and 1 had pheochromocytoma. The authors contrasted this family with 2 families reported by Chen et al. (1996) that had a mutation at the same position but causing a different amino acid change (608537.0012). In these families, 19 of 22 affected individuals had pheochromocytoma and none had renal cell carcinoma. Bradley et al. (1999) concluded that different amino acid changes at the same position can cause very distinct clinical phenotypes. Hes et al. (2000) described 5 VHL families in which direct sequencing of the coding region of the VHL gene failed to identify the family-specific mutation. Further molecular analysis revealed deletions involving the VHL gene in each of these families. In 4 families, partial deletions of 1 or more exons were detected by Southern blot analysis. In the fifth family, FISH analysis demonstrated the deletion of the entire VHL gene. The data supported the previously established observation that families with a germline deletion have a low risk for pheochromocytoma. Further unraveling of the genotype-phenotype correlations in VHL disease revealed that families with a full or partial deletion of the VHL gene exhibited a phenotype with a preponderance of central nervous system hemangioblastoma. Friedrich (2001) reviewed genotype/phenotype correlations in von Hippel-Lindau syndrome. Hoffman et al. (2001) noted that a type 2C VHL mutant, L188V (608537.0014), which had been associated with a pheochromocytoma-only phenotype (and had been shown to retain the ability to promote HIF (603348) ubiquitylation), retained the ability to suppress cyclin D1 (CCND1; 168461) expression, suggesting that loss of VHL-mediated suppression of cyclin D1 is not necessary for pheochromocytoma development in VHL disease. Other studies had suggested that (1) genetic modifiers influence the phenotypic expression of VHL disease (Webster et al., 1998); and (2) polymorphic variation at the CCND1 codon 242 A/G SNP (168461.0001) may influence cancer susceptibility or prognosis in some situations. Therefore, Zatyka et al. (2002) analyzed the relationship between CCND1 genotype and phenotypic expression of VHL disease. They found an association between the G allele and multiple retinal angiomas (p = 0.04), and risk of central nervous system hemangioblastoma (p = 0.05). The findings suggested that a variety of HIF-independent mechanisms may contribute to the tumor suppressor activity of the VHL protein and that polymorphic variation at one VHL protein target influences the phenotypic expression of VHL disease. In a study of 573 individuals with VHL syndrome from 200 unrelated families, Ong et al. (2007) found that age at disease onset was significantly earlier, and age-related risks of retinal angiomas and RCC were higher in individuals with nonsense or frameshift mutations compared to those with deletions or missense mutations. The results also confirmed the association of pheochromocytomas with missense mutations, particularly those that resulted in surface amino acid substitutions. Wong et al. (2007) characterized the germline mutations found in 335 patients with VHL disease associated with retinal capillary hemangioblastomas (RCHs) and sought to establish genotype-phenotype correlations between genotype category (amino acid substitutions, protein-truncating mutations, and complete deletions) and ocular phenotype. The prevalence of RCHs was lowest (14.5%) among patients with complete deletions; the overall prevalence of retinal angiomatosis was 37.2%. Genotype category had no correlation with unilaterality or bilaterality of ocular disease or with the number or extent of peripheral RCHs. The prevalence of RCHs at the juxtapapillary location was lower among patients with protein-truncating mutations than in patients with amino acid substitutions. Complete deletions were associated with the highest mean visual acuity. Franke et al. (2009) identified germline deletions in the VHL gene ranging from 0.5 to 250 kb in 54 families with VHL syndrome. In 28 of these families, at least 1 additional gene was deleted including FANCD2 (227646), HSPC300 (C3ORF10;611183), and IRAK2 (603304). The precise breakpoints were determined in 33 index patients. Of the 66 breakpoints, 90% occurred in Alu elements, indicating that Alu-mediated recombination is a major mechanism for germline deletions of the VHL gene. Among all 54 families with VHL syndrome resulting from germline deletions of the VHL gene, Franke et al. (2009) found a higher occurrence of renal cell carcinomas and CNS hemangioblastomas compared to patients with other types of mutations. There was an independent association between renal cell carcinoma and retinal angiomas and retention of the HSPC300 gene, which confirmed the findings of Cascon et al. (2007). McNeill et al. (2009) reviewed the molecular and clinical characteristics of 127 individuals from 62 kindreds with germline deletions in the VHL gene. Large VHL gene deletions associated with a contiguous loss of HSPC300 (10 patients) were associated with a significantly lower lifetime risk of RCC than deletions that did not involve HSPC300 (42 patients). The age-related risk of RCC at age 60 was 0% in the first group and 72% in the second group. Patients with exon 1 VHL deletions and retention of FANCD2 were excluded as the status of HSPC300 was uncertain. The risks of hemangioblastomas and pheochromocytomas were similar in both groups. These findings further supported the growing body of evidence indicating that patients with VHL syndrome caused by large VHL deletions that include the HSPC300 gene have a specific subtype of VHL syndrome with protection from RCC, which McNeill et al. (2009) proposed be named VHL type 1B.
In 28 of 221 kindreds with von Hippel-Lindau syndrome, Latif et al. (1993) identified rearrangements of the VHL gene. Eighteen of these rearrangements were due to deletion in the VHL gene: 1 of these was an in-frame 3-nucleotide ... In 28 of 221 kindreds with von Hippel-Lindau syndrome, Latif et al. (1993) identified rearrangements of the VHL gene. Eighteen of these rearrangements were due to deletion in the VHL gene: 1 of these was an in-frame 3-nucleotide deletion (608537.0001). In 55 of 94 unrelated VHL kindreds, Crossey et al. (1994) identified 40 different mutations in the VHL gene. The 2 most frequent mutations were arg238-to-gln (608537.0005) and arg238-to-trp (608537.0003), which were detected in 5 and 4 unrelated kindreds, respectively. Ciotti et al. (2009) identified mutations in the VHL gene in 9 (100%) of 9 unrelated families and in 16 (88.9%) of 18 isolated patients presenting with the classic phenotype of VHL syndrome. VHL mutations were also found in 2 (66.7%) of 3 patients who met the diagnostic criteria for VHL syndrome, but who also had multiple cerebellar hemangioblastomas. Of those with mutations, 6 (22%) of 27 were found to have complete or partial deletions of the gene. No VHL mutations were found in 13 additional patients who did not meet the full diagnostic criteria of the disorder, but who had some suggestive features. - Modifiers of VHL To assess the influence of variation in CCND1 (168461) on the retinal, renal, and central nervous system (CNS) manifestations of von Hippel-Lindau disease (193300), Zatyka et al. (2002) genotyped 118 patients for the codon 242 G-A SNP (168461.0001). The number of retinal angiomas was significantly higher in individuals harboring the G allele compared with AA homozygotes (p of 0.04). Possession of 1 or more G alleles was associated with earlier diagnosis of CNS hemangioblastoma by almost 2-fold, although the difference did not attain statistical significance (p of 0.05). A similar analysis for onset of renal cell carcinoma showed no evidence of an association with CCND1 genotype. In a retrospective analysis of 123 patients from 55 families with VHL, including 13 with complete germline deletion of the VHL gene and 42 with partial gene deletions, Maranchie et al. (2004) observed a paradoxically lower prevalence of renal cell carcinoma in those with complete gene deletions. RCC occurred more frequently in patients with partial germline VHL deletions relative to complete deletions (48.9% vs 22.6%, p = 0.007). This striking phenotypic dichotomy was not seen for cystic renal lesions or for CNS (p = 0.22), pancreas (p = 0.72), or pheochromocytoma (p = 0.34). Deletion mapping demonstrated that development of RCC had an even greater correlation with retention of HSPC300 (C3ORF10; 611183), located within the 30-kb region of 3p immediately telomeric to the VHL gene (52.3% vs 18.9%, p less than 0.001), suggesting the presence of a neighboring gene or genes critical to the development and maintenance of RCC. Cascon et al. (2007) found that 6 of 8 VHL patients without RCC had large germline deletion of the VHL gene including deletion of HSPC300. In contrast, 9 of the 10 with RCC had retention of the HSPC300 gene. Analysis of 9 sporadic RCC tumors showed that all retained an HSPC300 allele. Cascon et al. (2007) concluded that loss of the HSPC300 gene confers protection against renal clear cell carcinoma.
Maher et al. (1991) estimated the point prevalence of heterozygotes in East Anglia to be 1 in 53,000, with an estimated birth incidence of 1 in 36,000 live births. Reproductive fitness was 0.83. Direct and indirect estimates of ... Maher et al. (1991) estimated the point prevalence of heterozygotes in East Anglia to be 1 in 53,000, with an estimated birth incidence of 1 in 36,000 live births. Reproductive fitness was 0.83. Direct and indirect estimates of the mutation rate were 4.4 per million gametes per generation and 2.32 per million gametes per generation, respectively. No significant association was found between parental age or birth order and new mutations. In the Freiburg district of Germany, Neumann and Wiestler (1991) calculated the prevalence of this disorder to be 1 in 38,951. Maddock et al. (1996) reported on a VHL register set up in the northwest of England in 1990. There was information on 83 affected persons. In addition, the effectiveness of the screening program used and the occurrence of CNS hemangioblastomas in the general populations were examined. The diagnostic point prevalence of heterozygotes in the region was 1 in 85,000 persons, with an estimated birth incidence of 1 in 45,500 live births. The mutation rate was estimated directly to be 1.4 x 10(-6)/gene/generation (1 in 714,200). Wu et al. (2012) identified mutations in the VHL gene in 12 (75%) of 16 Chinese probands with clinically diagnosed VHL syndrome. PCR-direct sequencing detected 12 mutations, 1 of which was novel, in 12 patients (75%). Use of universal primer quantitative fluorescent multiplex PCR (UPQFM-PCR) enabled detection of 2 large deletions in 2 (12.5%) patients. The 2 remaining patients carried atypical variations in the VHL gene that could not definitively be called pathogenic. Nine (56.3%) probands did not have a family history of the disorder, suggesting a high frequency of de novo mutations among Chinese patients. Clinically, 15 families were classified as type 1 (without pheochromocytoma) and 1 as type 2 (with pheochromocytoma). The most common manifestations were CNS hemangioblastoma, clear cell renal cell carcinoma, and pancreatic cysts and tumors. Combining this information with previous reports of Chinese VHL patients indicated that the clinical features and spectrum of VHL mutations among the Chinese are comparable to those found in large-scale investigations from other countries.
The clinical diagnosis of von Hippel-Lindau (VHL) disease is established in [Lonser et al 2003, Butman et al 2008, Maher et al 2011]:...
Diagnosis
Clinical Diagnosis The clinical diagnosis of von Hippel-Lindau (VHL) disease is established in [Lonser et al 2003, Butman et al 2008, Maher et al 2011]:A simplex case (i.e., an individual with no known family history of VHL disease) presenting with two or more characteristic lesions:Two or more hemangioblastomas of the retina, spine, or brain or a single hemangioblastoma in association with a visceral manifestation (e.g., multiple kidney or pancreatic cysts)Renal cell carcinoma Adrenal or extra-adrenal pheochromocytomasLess commonly, endolymphatic sac tumors, papillary cystadenomas of the epididymis or broad ligament, or neuroendocrine tumors of the pancreasAn individual with a positive family history of VHL disease in whom one or more of the following disease manifestations is present: Retinal angiomaSpinal or cerebellar hemangioblastomaAdrenal or extra-adrenal pheochromocytomaRenal cell carcinomaMultiple renal and pancreatic cystsNote: Other lesions characteristic of VHL are endolymphatic sac tumors (ELST) and pancreatic neuroendocrine tumors; however these are not typically used to make a clinical diagnosis of VHL. The following tests are used to establish the diagnosis and determine the extent of clinical manifestations. CNS tumors may be detected with:Fundoscopy: retinal angiomasCT: cerebellar, brain stem, supratentorial and spinal hemangioblastomasMRI: cerebellar, brain stem, supratentorial and spinal hemangioblastomas, and endolymphatic sac tumors (ELST)ELST presents as a mass on the posterior wall of the petrous part of the temporal bone and can be missed on standard MRI. MRI with contrast and high signal intensity with T1, using thin slices of the internal auditory canal is recommended in symptomatic individuals.Visceral lesions may be detected with:Ultrasound: kidney and pancreatic lesions, as well as cysts of the epididymis and broad ligament CT: kidney, pancreatic, and adrenal gland lesionsMRI: kidney, pancreatic, and adrenal gland lesionsBlood or urinary catecholamine metabolites (VMA, metanephrine, and total catecholamine): pheochromocytomaMolecular Genetic TestingGene. VHL is the only gene in which mutations are known to cause VHL disease. Table 1. Summary of Molecular Genetic Testing Used in VHL DiseaseView in own windowGene SymbolTest MethodMutations DetectedMutation Detection Frequency by Test Method 1Test AvailabilityVHLSequence analysis
Sequence variants 2~72% 3Clinical Deletion / duplication analysis 4Partial- or whole- gene deletion~28% 3,51. The ability of the test method used to detect a mutation that is present in the indicated gene2. Examples of mutations detected by sequence analysis may include small intragenic deletions/insertions and missense, nonsense, and splice site mutations.3. Stolle et al [1998]4. Testing that identifies deletions/duplications not readily detectable by sequence analysis of the coding and flanking intronic regions of genomic DNA; included in the variety of methods that may be used are: quantitative PCR, long-range PCR, multiplex ligation-dependent probe amplification (MLPA), and chromosomal microarray (CMA) that includes this gene/chromosome segment.5. Hoebeeck et al [2005], Banks et al [2006]Interpretation of test results. For issues to consider in interpretation of sequence analysis results, click here.Information on specific allelic variants may be available in Molecular Genetics (see Table A. Genes and Databases and/or Pathologic allelic variants).Testing StrategyTo confirm/establish the diagnosis in a probandMolecular genetic testing is indicated in all individuals known to have or suspected of having VHL disease [Rasmussen et al 2006]. Testing may also be used to evaluate individuals with a single VHL-associated tumor and a negative family history of the disease.For individuals with manifestations of VHL disease who do not meet strict diagnostic criteria and who do not have a detectable VHL germline mutation, somatic mosaicism for a de novo VHL disease-causing mutation should be considered [Sgambati et al 2000]. In some instances, molecular genetic testing of the offspring of such individuals reveals a VHL mutation. Predictive testing for at-risk asymptomatic adult family members requires prior identification of the disease-causing mutation in the family.Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require prior identification of the disease-causing mutation in the family.Genetically Related (Allelic) DisordersVHL-associated polycythemia (familial erythrocytosis type 2 [ECYT2]; previously known as Chuvash type polycythemia (OMIM 263400). VHL-associated polycythemia, which is clinically distinct from VHL disease, is caused by homozygous or compound heterozygous mutation in VHL and is characterized by increased circulating red blood cell mass. Although thrombosis and/or hemorrhage have occurred in many individuals with VHL-associated polycythemia, no individuals with this disorder or their heterozygous relatives thus far described have developed VHL-related tumors [Gordeuk et al 2004].Of note, congenital erythrocytosis is endemic in subpopulations worldwide; mutations in VHL are the most common genetic variant causing congenital erythrocytosis [Pastore et al 2003]. In the Chuvash Republic of the Russian Federation, where this condition is endemic, Ang et al [2002] identified homozygosity for the VHL mutation p.Arg200Trp. Haplotype analysis suggested that the p.Arg200Trp mutation arose independently in at least two populations [Cario et al 2005]. A note on terminology from OMIM: “ ‘Erythrocytosis’ is the preferred term used here in order to distinguish inherited disorders characterized by increased circulating red blood cells from ‘polycythemia vera’ (PV; 263300), which is a clonal myeloproliferative disorder associated with somatic mutations in the JAK2 gene (147796).”Other. Acquired somatic mutations in VHL may give rise to sporadic VHL-type tumors (i.e., clear cell RCC and hemangioblastoma) [Iliopoulos 2001, Kim & Kaelin 2004] without other associated tumors characteristic of the hereditary disease.
Von Hippel-Lindau (VHL) disease is characterized by hemangioblastomas of the brain, spinal cord, and retina; renal cysts and renal cell carcinoma; pheochromocytoma; pancreatic cysts and neuroendocrine tumors; endolymphatic sac tumors; and epididymal and broad ligament cysts. Some clustering of tumors occurs, resulting in the designation of specific VHL disease phenotypes. The manifestations and severity are highly variable both within and between families, even among those with the same mutation....
Natural History
Von Hippel-Lindau (VHL) disease is characterized by hemangioblastomas of the brain, spinal cord, and retina; renal cysts and renal cell carcinoma; pheochromocytoma; pancreatic cysts and neuroendocrine tumors; endolymphatic sac tumors; and epididymal and broad ligament cysts. Some clustering of tumors occurs, resulting in the designation of specific VHL disease phenotypes. The manifestations and severity are highly variable both within and between families, even among those with the same mutation.Hemangioblastoma. CNS hemangioblastoma is the prototypic lesion of VHL disease [Catapano et al 2005, Glasker 2005]. Roughly 80% develop in the brain and 20% in the spinal cord. Some hemangioblastomas are not symptomatic and are discovered only on imaging. Within the brain the vast majority are infratentorial, mainly in the cerebellar hemispheres. The pituitary stalk is the most common site for the development of supratentorial hemangioblastomas in individuals with VHL disease [Lonser et al 2009]. Multiple CNS tumors, occurring either synchronously or metachronously, are common. Spinal hemangioblastomas are generally intradural, most commonly occur in the cervical or thoracic regions, and occasionally may involve the entire cord. Rarely, peripheral nerve hemangiomas may develop [Giannini et al 1998]. Hemangioblastomas are often accompanied by cysts. Cysts in the spinal cord are referred to as syrinx, which contribute to rapid growth and development of symptoms. Symptom management relies on complete removal of the hemangioblastoma causing syrinx growth.Clinical symptoms depend on the site of the tumor. With infratentorial tumors, headache, vomiting, and gait disturbances or ataxia predominate. With tumors above the tentorium, symptoms depend on the location of the lesion. Hemangioblastomas oscillate between periods of growth and stability [Wanebo et al 2003] and are generally slow growing, but on occasion include rapidly enlarging cysts that produce hydrocephaly with papilledema. Spinal hemangioblastomas usually present with pain; sensory and motor loss may develop with cord compression. Most symptom-producing spinal hemangioblastomas are associated with syringomyelia/syrinx [Wanebo et al 2003].Retinal hemangioblastoma. These retinal lesions, sometimes called retinal angiomas, are histologically identical to CNS hemangioblastomas. They may be the initial manifestations of VHL disease and may occur in childhood. About 70% of affected individuals are identified as having retinal angiomas [Webster et al 1999, Kreusel 2005] with mean age of about 25 years [Dollfus et al 2002]. The tumors are most often located in the temporal periphery of the retina with feeder and draining vessels going to and from the optic disc. However, they may develop in the posterior pole (1%) and optic disc (8%). They may be asymptomatic and may be detected on routine ophthalmoscopy. Others present with a visual field defect or a loss of visual activity resulting from retinal detachment, exudation, or hemorrhage. Tests of retinal function may be abnormal even in the presence of quiescent retinal angiomas [Kreusel et al 2006]. While the number of retinal angiomas does not appear to increase with age, the probability of vision loss increases with age [Kreusel et al 2006].Renal lesions. Multiple renal cysts are common in VHL disease [Lonser et al 2003].Renal cell carcinoma (RCC), specifically of the clear cell subtype, developing either within a cyst or in the surrounding parenchyma, occurs in about 70% of affected individuals by age 60 years, and is a leading cause of mortality in VHL disease [Maher et al 1990, Maher et al 1991]. Mutations in VHL are the most common cause of both inheritable and sporadic RCC. Pheochromocytoma may present with sustained or episodic hypertension or be totally asymptomatic, being detected incidentally by an abdominal imaging procedure. Pheochromocytomas are usually located in one or both adrenal glands. They are usually benign, but malignant behavior has been reported [Chen et al 2001, Jimenez et al 2009]. Similar in etiology, paragangliomas can develop along the sympathetic axis in the abdomen or thorax [Schimke et al 1998]; these tumors are mostly nonfunctional. Pancreatic lesions. Most pancreatic lesions are simple cysts; however, while they can be numerous in individuals with VHL, they rarely cause endocrine or exocrine insufficiency. Occasionally, cysts in the head of the pancreas cause biliary obstruction. Five to seventeen percent of individuals with VHL develop neuroendocrine tumors of the pancreas [Lonser et al 2003, Maher et al 2011]. They are not usually hormonally active and are slow growing, but malignant behavior has been observed, particularly in tumors greater than 3 cm [Marcos et al 2002, Corcos et al 2008]. Endolymphatic sac tumors. The endolymphatic sac and duct are ectodermal extensions of the membranous labyrinth. Tumors of the sac cause deafness of varying severity, often severe to profound and of sudden onset [Choo et al 2004, Kim et al 2005]. Less commonly, vertigo or tinnitus is the presenting complaint. Large tumors can involve other cranial nerves. Endolymphatic sac tumors are seen in approximately 10% of individuals with VHL disease, and in some instances the associated uni- or bilateral hearing loss is the initial feature of the disease [Kim et al 2005]. In rare cases, the tumors may be malignant [Muzumdar et al 2006]. Endolymphatic sac tumors in VHL are often misdiagnosed as Menière disease.Epididymal tumors. Epididymal or papillary cystadenomas are relatively common in males with VHL disease. They rarely cause problems, unless bilateral, in which case they may result in infertility. The equivalent, much less common, lesion in women is a papillary cystadenoma of the broad ligament.
Four general VHL disease phenotypes have been suggested based on the likelihood of pheochromocytoma or renal cell carcinoma. Many lines of research support the conclusion that the molecular etiology of pheochromocytomas appears to be distinct from other VHL lesions. Therefore, the most relevant genotype-phenotype correlations rely mostly on scoring the presence/absence of pheochromocytomas associated with a given allele. The following discussion summarizes the genotype-phenotype studies published to date, with the cautionary note that further investigation is needed. In conclusion, the patterns are not clear-cut, and genotype-phenotype correlations have no current diagnostic or therapeutic value and are used for academic purposes only. ...
Genotype-Phenotype Correlations
Four general VHL disease phenotypes have been suggested based on the likelihood of pheochromocytoma or renal cell carcinoma. Many lines of research support the conclusion that the molecular etiology of pheochromocytomas appears to be distinct from other VHL lesions. Therefore, the most relevant genotype-phenotype correlations rely mostly on scoring the presence/absence of pheochromocytomas associated with a given allele. The following discussion summarizes the genotype-phenotype studies published to date, with the cautionary note that further investigation is needed. In conclusion, the patterns are not clear-cut, and genotype-phenotype correlations have no current diagnostic or therapeutic value and are used for academic purposes only. VHL type 1. Retinal angioma, CNS hemangioblastoma, renal cell carcinoma, pancreatic cysts and neuroendocrine tumors. VHL type 1 is characterized by a low risk for pheochromocytoma. Truncating mutations or missense mutations that are predicted to grossly disrupt the folding of the VHL protein [Stebbins et al 1999] are associated with VHL type 1. VHL type 2. Pheochromocytoma, retinal angiomas and CNS hemangioblastoma. VHL type 2 is characterized by a high risk for pheochromocytoma. Individuals with VHL type 2 commonly have a missense mutation. Some missense mutations seem to correlate with a specific type 2 VHL phenotype [Weirich et al 2002, Sanso et al 2004, Abbott et al 2006, Knauth et al 2006]. (See also Molecular Genetics). Missense mutations that lead to pheochromocytoma with a low (or no) risk for RCC (types 2A and 2C) may encode a VHL protein that retains the ability to ubiquinate (and thereby downregulate) HIF1α in the presence of molecular oxygen to a greater degree than mutations that result in VHL disease with pheochromocytoma and RCC (type 2B). Furthermore, mutant pVHL may predispose to pheochromocytoma by altering the balance among a group of proteins in a molecular pathway that controls apoptosis of sympatho-adrenal precursor cells during development. Such cells may be at increased risk of developing into pheochromocytomas at a later stage [Lee et al 2005, Kaelin 2007].VHL type 2 is further subdivided:Type 2A. Pheochromocytoma, retinal angiomas and CNS hemangioblastoma; low risk for renal cell carcinoma. Type 2B. Pheochromocytoma, retinal angioma, CNS hemangioblastomas, pancreatic cysts and neuroendocrine tumor with a high risk for renal carcinomaType 2C. Risk for pheochromocytoma only Several groups report a reduced risk for renal cell carcinoma in individuals with a deletion of VHL [Cybulski et al 2002, Maranchie et al 2004, McNeill et al 2009]. In particular, individuals with a complete or partial deletion that extends 5’ of VHL to include C3orf10 have a significantly reduced risk of renal cell carcinoma [Maranchie et al 2004, McNeill et al 2009]. This genotype may constitute a distinct phenotype, VHL type 1B, characterized by a reduced risk for both renal cell carcinoma and pheochromocytoma. Some individuals within families with apparent type 2C disease have developed hemangioblastomas [Neumann & Eng 2009].
The level of mutation detection obtained by molecular genetic testing of VHL makes it possible to effectively rule out von Hippel-Lindau (VHL) disease with a high degree of certainty in individuals with (1) isolated hemangioblastoma, retinal angioma, or clear cell renal cell carcinoma and (2) no detectable VHL disease-causing germline mutation. Somatic mosaicism for VHL mutation could still be considered in such individuals. A younger individual, especially one with multiple lesions, is more likely to have a germline VHL mutation than an older individual with a single lesion [Neumann et al 2002]. ...
Differential Diagnosis
The level of mutation detection obtained by molecular genetic testing of VHL makes it possible to effectively rule out von Hippel-Lindau (VHL) disease with a high degree of certainty in individuals with (1) isolated hemangioblastoma, retinal angioma, or clear cell renal cell carcinoma and (2) no detectable VHL disease-causing germline mutation. Somatic mosaicism for VHL mutation could still be considered in such individuals. A younger individual, especially one with multiple lesions, is more likely to have a germline VHL mutation than an older individual with a single lesion [Neumann et al 2002]. Since pheochromocytoma is part of the VHL disease spectrum and may occur as the exclusive manifestation of VHL disease (type 2C), individuals with a family history of these tumors, or those in whom the disease is bilateral or multifocal, should be offered molecular genetic testing for VHL germline mutations. Germline VHL mutations are rare in simplex cases of unilateral pheochromocytoma (i.e., an affected individual with no family history of VHL disease), unless the individual is younger than age 20 years. Exceptions are those individuals with a family history that is more consistent with familial paragangliomas of the head and neck, which are caused by mutations in various subunits of the gene encoding succinic dehydrogenase (SDH) [Maher & Eng 2002, Bryant et al 2003] (see Hereditary Paraganglioma-Pheochromocytoma Syndromes), or those individuals who have features of other heritable diseases associated with pheochromocytoma including multiple endocrine neoplasia type 2A or 2B or neurofibromatosis type 1 [Neumann et al 2002]. Individuals with familial RCC should be examined for hereditary leiomyomatosis and renal cell cancer (HLRCC) and Birt-Hogg-Dubé (BHD) syndrome.Note to clinicians: For a patient-specific ‘simultaneous consult’ related to this disorder, go to , an interactive diagnostic decision support software tool that provides differential diagnoses based on patient findings (registration or institutional access required).
To establish the extent of disease in an individual diagnosed with von Hippel-Lindau (VHL) disease, the following evaluations are recommended:...
Management
Evaluations Following Initial Diagnosis To establish the extent of disease in an individual diagnosed with von Hippel-Lindau (VHL) disease, the following evaluations are recommended:Neurologic history and physical examination for evidence of CNS or peripheral nerve hemangioblastomatosis. A baseline brain and spine MRI is considered standard procedure. Ophthalmologic evaluation for retinal hemangioblastomas Audiologic evaluation for hearing loss associated with endolymphatic sac tumors Blood pressure determination, supplemented by measurement of urinary catecholamine metabolites after age five years to evaluate for pheochromocytoma Abdominal ultrasound examination after age 16 years. Suspicious lesions in the kidney, adrenal gland, or pancreas should be evaluated by more sophisticated techniques, such as CT scan or MRI. Genetics consultation Treatment of ManifestationsNo guidelines exist for the management VHL lesions.Nervous system hemangioblastoma Some advocate early surgical removal of both symptomatic and asymptomatic CNS lesions, while others follow asymptomatic lesions with yearly imaging studies. Surgical intervention of syrinx in the spinal cord is recommended.Preoperative arterial embolization may be indicated, especially for extensive spinal tumors. Gamma knife surgery may be useful with small tumors or those in inoperable sites [Asthagiri et al 2010, Simone et al 2011]. While this technique may reduce the size of the solid tumor, it does not appear to prevent cyst formation. Overall operative mortality is roughly 10%, with higher figures for brain stem tumors [Lonser et al 2003].Retinal hemangioblastoma Most ophthalmologists favor prospective treatment of retinal (but not optic nerve) angiomas to avoid blindness, although spontaneous regression has occurred. Therapeutic modalities used to treat retinal hemangioblastomas include diathermy, xenon, laser, and cryocoagulation, with variable degrees of success depending on the location, size, and number of lesions. Recurrent tumors have been noted, even after many years, but some may be new tumors in the same general area rather than recurrent disease. External beam radiotherapy has been shown to be useful when standard therapy has not prevented progression [Raja et al 2004]. Renal cell carcinoma Early surgery is the best option for renal cell carcinoma, although close monitoring only is recommended for lesions smaller than 3 cm. Depending on the size and location of the tumor, nephron-sparing or partial nephrectomy may be possible without compromising survival [Grubb et al 2005]. Nephrectomy should leave the adrenal gland in situ, as is done in individuals with RCC who do not have a confirmed diagnosis of VHL. If contralateral pheochromocytoma occurs, the remaining adrenal gland will prevent or delay steroid replacement therapy. Cryoablation is being increasingly used for small lesions or in individuals who are likely to require multiple surgical procedures [Shingleton & Sewell 2002]. Radio frequency ablation therapy is often applied to smaller tumors. However, smaller lesions treated with radio frequency need frequent intervention [Joly et al 2011] and concerns about related necrosis have not yet been adequately addressed. Renal transplantation has been successful in individuals in whom bilateral nephrectomy has been necessary. It is imperative to evaluate any living related potential donor for VHL disease and to exclude those found to have VHL disease. Pheochromocytomas Pheochromocytomas should be surgically removed. Laparoscopic approaches have been shown to be effective. Preoperative treatment with alpha-adrenergic blockade, and optional additional beta-adrenergic blockade for seven to ten days is appropriate even in individuals with no known hypertension. Partial adrenalectomy could be considered. One long-term follow-up study (9.25 years) of 36 affected individuals showed no metastatic disease; ipsilateral recurrence after partial adrenalectomy was seen in three individuals (11%) [Benhammou et al 2010].Pancreatic neuroendocrine tumor and cysts Pancreatic cysts are common, but rarely influence endocrine function and generally do not require surgical removal. Pancreatic neuroendocrine tumors need to be differentiated from cysts and serous cystadenomas. Pancreatic tumors are usually slow growing and are not hormonally active, although they can cause metastatic disease. Surgery should be considered when the risk of metastases is high. Prognostic criteria [Blansfield et al 2007]: A tumor of ≥3 cm; A mutation in exon 3; or A tumor with a doubling rate <500 days Endolymphatic sac tumors. Consideration of surgical removal of these slow-growing tumors must include discussion of the possible complication of total deafness. Early intervention with small tumors has been shown to preserve both hearing and vestibular function [Kim et al 2005].Epididymal or broad ligament papillary cyst adenomas. These generally do not require surgery, unless they are symptomatic or are threatening fertility. Prevention of Secondary ManifestationsEarly detection through surveillance and removal of tumors may prevent or minimize deficits such as hearing loss, vision loss, neurologic symptoms, and the need for renal replacement therapy.SurveillanceIndividuals with known VHL disease, individuals without clinical manifestations but identified as having a VHL mutation, and first-degree relatives who have not undergone DNA-based testing need regular clinical monitoring by a physician or medical team familiar with the spectrum of VHL disease. Physician/pediatricianAnnual evaluation starting at age one year for neurologic symptoms, vision problems or hearing disturbance Annual examination starting at age one year for signs of nystagmus, strabismus, or white pupilsAnnual blood pressure monitoring starting at age one yearMonitoring for the following complications includes:Retinal angiomas. Annual ophthalmology evaluation with indirect ophthalmoscope starting at age one yearPheochromocytoma. Annual blood or urinary fractionated metanephrines starting at age five yearsEndolymphatic sac tumors (ELST)Audiology assessment every two to three years (annually if hearing loss, tinnitus or vertigo) starting at age five yearsIf repeated ear infections are present, MRI with contrast of the internal auditory canal using thin slicesVisceral lesions. Annual abdominal ultrasound, and every other year MRI scan of the abdomen (kidney, pancreas and adrenal glands), starting at age 16 yearsCNS lesions. MRI of the brain and total spin every two years starting at age 16 years. Attention should be given to the inner ear/petrous temporal bone (for ELST) and the posterior fossa.While current medical surveillance guidelines do not address structured psychological support for individuals with VHL, their partners, and their family members, research suggests a distinct need for psychosocial support [Lammens et al 2010, Lammens et al 2011b].Note: The surveillance guidelines established for VHL are not evidence based and rely on experiential reporting, largely from North America. Guidelines may vary somewhat depending on the local standard of care. In the United States, the VHL Family Alliance has worked extensively with healthcare professionals to assemble guidelines which are generally accepted throughout the world [VHL Handbook]. Other guidelines originate from Denmark and the Netherlands. For example, Dutch guidelines recommend screening for ELST only upon indication. In addition, examination by a primary care physician and assessment of metanephrine levels start at age ten years, while ophthalmologic examination begins at age five years. Improved surveillance guidelines have increased the life expectancy of individuals with VHL by over 16 years since 1990 [Wilding et al 2012]. Two studies evaluated the implementation of national surveillance guidelines in Denmark and the Netherlands. One study showed that more than 90% of the 84 affected individuals included reported that they were familiar with their national VHL surveillance guidelines. However, daily practice showed that 64% of those individuals had received information that was only partially consistent with the Dutch guidelines [Lammens et al 2011a]. In a Danish study, compliance and frequency of follow-up was surprisingly low with regard to the national VHL guidelines for individuals with VHL and subjects at risk [Bertelsen & Kosteljanetz 2011]. These studies collectively suggest that correct implementation of surveillance guidelines through a doctor- and patient-oriented information campaign could have an immediate positive impact for individuals with VHL.Agents/Circumstances to Avoid Tobacco products should be avoided since they are considered a risk factor for kidney cancer.Chemicals and industrial toxins known to affect VHL involved organs should be avoided. Contact sports should be avoided if adrenal or pancreatic lesions are present. Evaluation of Relatives at RiskUse of molecular genetic testing for early identification of at-risk family members improves diagnostic certainty and reduces the need for screening procedures in those at-risk family members who have not inherited the disease-causing mutation [Priesemann et al 2006]. The American Society of Clinical Oncologists (ASCO) identifies VHL disease as a Group 1 disorder, i.e., a hereditary disease for which genetic testing is considered part of the standard management for at-risk family members [American Society of Clinical Oncology 2003]. However, at-risk individuals may decline genetic testing for religious or financial reasons, in which case continued screening for VHL lesions is warranted. Additionally, current DNA tests do not detect VHL mutations in all at-risk individuals. Therefore, surveillance guidelines are recommended for all individuals in whom VHL is suspected, as well as in first-degree relatives of these individuals.Early recognition of manifestations of VHL disease may allow for timely intervention and improved outcome; thus, clinical surveillance of asymptomatic at-risk individuals (including children) for early manifestations of VHL disease is appropriate.See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.Pregnancy Management Medical surveillance for pregnant women with VHL is typically stricter than in non-pregnant women. Research by the French VHL Study Group showed a significantly higher complication rate of hemangioblastomas in individuals with VHL who had had at least one pregnancy [Abadie et al 2010]. Another study concluded that pregnancy has a significant influence on cerebellar hemangioblastoma growth and causes an overall high complication rate (17%) [Frantzen et al, in press]. Intensified surveillance is recommended in a specialized medical center during preconception care and pregnancy. Special attention should be paid to pheochromocytoma and cerebellar hemangioblastoma. The VHL Handbook recommends MRI of the cerebellum without contrast at four months’ gestation.Therapies Under Investigation Certain VHL mutations fail to downregulate HIFα, leading to overexpression of vascular endothelial growth factor (VEGF). An intravitreal VEGF receptor inhibitor, ranibizumab, has been used with some success in individuals with retinal hemangioblastomas who have either failed local therapy or whose lesions are not amenable to local therapy [Wong et al 2008]. Stabilization of some, but not all, CNS hemangioblastomas has also been demonstrated [Madhusudan et al 2004]. A tyrosine kinase inhibitor, sunitinab, has had some utility in the rare unresectable malignant pheochromocytomas, but simple surgical excision is clearly preferable for these usually benign tumors [Jimenez et al 2009].Sardi et al [2009] reported three-year stabilization of previously progressive multifocal spinal hemangioblastomas with thalidomide.Gene replacement therapy and other curative treatment approaches are still in the early developmental phases. The medical and research communities are largely focused on ameliorating disease progression and on improvement of early detection methodology. Surgical techniques are rapidly improving and therapeutic options are broadening every year. Premature termination codon 124 (PTC124), also known as ataluren, may benefit a subset of affected individuals in whom nonsense mutations give rise to premature stop codons in the messenger RNA (mRNA) [Auld et al 2010]. There are three stop codons: UAA, UAG, and UGA. PTC124 promotes read-through of all three stop codons with different efficiencies. The highest read-through efficiency takes place at UGA, followed by UAG and then UAA. PTC124 has been successfully proven to promote read-through of nonsense mutations in Duchenne muscular dystrophy (DMD), cystic fibrosis (CF), and Usher syndrome type 1C. Phase 1 and 2 clinical trials have shown no serious side-effects with PTC124 treatment, even after long-term use [Wilschanski et al 2011]. Preclinical investigation of PTC124 effects on VHL is ongoing. Aminoglycosides such as gentamicin promote read-through of premature stop codons when they are supplied in high concentrations, but they have serious side effects.Search ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions.
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED....
Molecular Genetics
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.Table A. Von Hippel-Lindau Disease: Genes and DatabasesView in own windowGene SymbolChromosomal LocusProtein NameLocus SpecificHGMDVHL3p25.3
Von Hippel-Lindau disease tumor suppressorCatalogue of Somatic Mutations in Cancer (COSMIC) VHL @ LOVDVHLData are compiled from the following standard references: gene symbol from HGNC; chromosomal locus, locus name, critical region, complementation group from OMIM; protein name from UniProt. For a description of databases (Locus Specific, HGMD) to which links are provided, click here.Table B. OMIM Entries for Von Hippel-Lindau Disease (View All in OMIM) View in own window 193300VON HIPPEL-LINDAU SYNDROME; VHL 608537VHL GENE; VHLNormal allelic variants. VHL, which comprises three exons spanning about 10 kb of genomic DNA, is highly conserved among worms, flies, rodents, and humans [Kaelin 2002]. An mRNA about 4.5 kb in size is almost ubiquitously expressed and encodes proteins of 213 and 159 amino acid residues. The latter isoform is the major product in most tissues and results from initiation of translation from an internal methionine codon at position 54. Both protein isoforms appear to be functional. Pathologic allelic variants. More than 300 germline mutations have been identified in families with von Hippel-Lindau (VHL) disease (see Table A) [Beroud et al 1998]. They consist of partial- and whole-gene deletions and frameshift, nonsense, missense, and splice site mutations. Point mutations have been identified in all three exons. Codon 167 is considered a mutational "hot spot." Nordstrom-O'Brien describes detailed phenotype and gene mutation information for 945 families with VHL. The spectrum of mutations found: 52% missense, 13% frameshift, 11% nonsense, 6% in-frame deletions/insertions, 11% large/complete deletions, and 7% splice mutations. In families whose described phenotype includes pheochromocytoma, 83.5% had a missense mutation. Families without pheochromocytoma had 6.6% more truncating mutations than missense mutations [Nordstrom-O'Brien et al 2010].Normal gene product. Von Hippel-Lindau disease tumor suppressor (pVHL) has been implicated in a variety of functions including transcriptional regulation, post-transcriptional gene expression, apoptosis, extracellular matrix formation, and ubiquitinylation [Kaelin 2007, Roberts & Ohh 2008]. The role of pVHL in the regulation of hypoxia-inducible genes through the targeted ubiquitinylation and degradation of HIF1α has been described, leading to a model of how disruption of VHL results in renal cell carcinoma, hemangioblastoma, and the production of other highly vascularized tumors. Normal pVHL binds to elongin C, which forms a complex with elongin B and cullin-2 (encoded by TCEB2 and CUL2, respectively), and Rbx1 (see Figure 1). This complex resembles the SCF ubiquitin ligase or E3 complex in yeast that catalyzes the polyubiquitinylation of specific proteins and targets them for degradation by proteosomes. Under normoxic conditions, HIF1α is hydroxylated at one of two specific proline residues, catalyzed by a member of the EglN family of prolyl hydroxylase enzymes.FigureFigure 1. Schematic view of pVHL and HIF A. Normoxia in a normal cell; HIF binds to pVHL. B. Hypoxia in a normal cell; HIF does not bind to pVHL. C. Cell with VHL mutation; HIF cannot bind to pVHL, therefore the cell (more...)The VHL protein then binds to hydroxylated HIF1α and targets it for degradation. Under hypoxic conditions, HIF1α is not hydroxylated, pVHL does not bind, and HIF1α subunits accumulate. HIF1α forms heterodimers with HIF1β and activates transcription of a variety of hypoxia-inducible genes (i.e., VEGF, EPO, TGFα, PDGFβ). Likewise, when pVHL is absent or mutated, HIF1α subunits accumulate, resulting in cell proliferation and the neovascularization of tumors characteristic of VHL disease [Kaelin 2002].Abnormal gene product. Mutations in VHL either prevent its expression (i.e., deletions, frameshifts, nonsense mutations, and splice site mutations) or lead to the expression of an abnormal protein (i.e., missense mutations). The type of VHL that results from a missense mutation depends on its effect on the three-dimensional structure of the protein [Stebbins et al 1999]. Mutations in VHL cause misfolding and subsequent chaperonin-mediated breakdown [Feldman et al 2003]. Missense mutations that destabilize packing of the alpha-helical domains, decrease the stability of the alpha-beta domain interface, interfere with binding of elongin C and HIF1α, or disrupt hydrophobic core residues result in loss of HIF regulation and are more likely to result in VHL type 1. Missense mutations that result in pVHL that is normal with respect to HIF regulation are more likely to be associated with VHL type 2 (see Genotype-Phenotype Correlations).