0021-972X/04/$15.00/0
Printed in U.S.A.
The Journal of Clinical Endocrinology & Metabolism 89(1):362–367
Copyright © 2004 by The Endocrine Society
doi: 10.1210/jc.2003-031236
A Novel Succinate Dehydrogenase Subunit B Gene
Mutation, H132P, Causes Familial Malignant
Sympathetic Extraadrenal Paragangliomas
MARGARETE MAIER-WOELFLE, MICHAEL BRÄNDLE, PAUL KOMMINOTH, PARVIN SAREMASLANI,
SONJA SCHMID, TAMARA LOCHER, PHILIPP U. HEITZ, INA KRULL, RENATO L. GALEAZZI,
CHRISTOPH SCHMID, AND AUREL PERREN
Department of Internal Medicine (M.M.-W., C.S.), Division of Endocrinology and Diabetology, and Institute of Clinical
Pathology, Department of Pathology (P.S., S.S., T.L., P.U.H., A.P.), University Hospital Zurich, CH-8091 Zurich,
Switzerland; Department of Internal Medicine (M.M.-W., M.B., I.K., R.L.G.), Kantonsspital St. Gallen, CH-9007 St. Gallen,
Switzerland; and Institute of Pathology (P.K.), Kantonsspital Baden, CH-5405 Baden, Switzerland
We report a family with malignant sympathetic paragangliomas (PGL) exhibiting a new type of germline mutation in the
succinate dehydrogenase subunit B (SDHB) gene. Two affected brothers, presenting with symptoms at the ages of 25
and 52 yr, suffered from malignant abdominal extraadrenal
sympathetic PGL. They died of their disease at ages 43 and 61
yr. Their mother had the same history of signs and symptoms,
suggesting a catecholamine-producing tumor at the age of 55
yr. Analysis of the germline DNA from these three patients
revealed a novel mutation in exon 4 (H132P) of the SDHB gene.
This mutation was absent in 160 control chromosomes. Loss of
heterozygosity analysis of the tumors showed a loss of one
SDHB allele, and RT-PCR-based expression analysis confirmed the exclusive expression of the mutated allele in both
tumors. A review of the published PGL families revealed malignant tumors in seven of 12 well-documented families with
SDHB mutation-associated extraadrenal PGL. These findings,
as well as findings of the family reported here, suggest a
strong causal relationship of SDHB germline mutations with
malignant extraadrenal abdominal PGL and imply the necessity of a close follow-up of affected individuals and family
members. (J Clin Endocrinol Metab 89: 362–367, 2004)
P
HEOCHROMOCYTOMA (PCC) AND extraadrenal
sympathetic paraganglioma (PGL) are phenotypically
highly similar tumors of chromaffin cells that may produce
and secrete catecholamines. However, possible differences
between these tumors have been reported at the molecular
level (1). Therefore, we will hereafter classify all extraadrenal
tumors as PGL (synonym for sympathetic tumors: extraadrenal PCC; and synonyms for parasympathetic tumors: carotid body tumor and chemodectoma) and strictly reserve
the term PCC for tumors of the adrenal medulla. Up to 90%
of PCC are noninherited and sporadic, whereas germline
mutations in the familial syndromes of multiple endocrine
neoplasia type 2, von Hippel-Lindau disease (VHL), and
neurofibromatosis type 1 (NF1) account for at least 9.5% of
PCC (2). More recently, it has been shown that germline
mutations of the mitochondrial complex II genes for succinate dehydrogenase subunits B, C, and D (SDHB, SDHC, and
SDHD) cause hereditary PGL (3). Although familial adrenal
PCCs are caused by mutations of Ret (multiple endocrine
neoplasia type 2, OMIM 164761), VHL (VHL, OMIM 193300),
or NF1 (NF1, OMIM 162200), familial PGLs are caused by
SDHD and rarely SDHC mutations (3–5), as well as by SDHB
mutations (6).
The incidence of malignancy in abdominal extraadrenal
PGLs has been reported to range between 14% and 50% (7–9).
However, the evaluation of malignancy in PGLs poses serious problems to the pathologist, and the only reliable criterion for malignancy are metastases, which can occur late in
the course of the disease. Therefore, a careful clinical follow
up of patients is necessary. Histological characteristics, such
as atypia of tumor cells, necrosis, size, weight, and presence
of vascular invasion are not reliable criteria of malignancy
(10). To date, the occurrence of malignant tumors in a familial
setting has not been assessed systematically.
We report here a family suffering from malignant abdominal sympathetic PGLs associated with a novel SDHB mutation, and we review the relevant publications dealing with
SDHB-, SDHC-, and SDHD-associated familial PGLs with
respect to malignant behavior.
Subjects and Methods
Subjects
Abbreviations: DGGE, Denaturing gradient gel electrophoresis;
LOH, loss of heterozygosity; MIBG, metaiodobenzylguanidine; NF1,
neurofibromatosis type 1; PCC, pheochromocytoma; PGL, paraganglioma; SDHB, succinate dehydrogenase subunit B; SDHC, succinate dehydrogenase subunit C; SDHD, succinate dehydrogenase subunit D;
VHL, von Hippel-Lindau.
JCEM is published monthly by The Endocrine Society (http://www.
endo-society.org), the foremost professional society serving the endocrine community.
We investigated three generations of a family (Fig. 1) with two brothers (two of eight members of generation II) suffering from malignant
abdominal extraadrenal PGL of the organ of Zuckerkandl. VHL or Ret
germline mutations had been excluded. In generation I, members I.1 and
I.2 died before our investigations. They did not suffer from symptoms
or signs, suggesting a catecholamine-producing tumor. In generation II,
five of eight members were examined (II.2, II.4, II.5, II.6, and II.8); the
remaining three members (II.1, II.3, and II.7) declined an evaluation for
catecholamine-secreting tumors. Until now, only one member of the
362
Maier-Woelfle et al. • SDHB Mutation in Familial Malignant PGLs
J Clin Endocrinol Metab, January 2004, 89(1):362–367 363
FIG. 1. Pedigree of the family.
third generation (III.3) was examined, revealing no clinical signs suggestive of PGL.
In 1969, at the age of 12 yr, patient II.8 (Fig. 1) suffered from episodic
headaches, truncal sweating, palpitations, and pallor, suggesting a catecholamine-secreting tumor. At the age of 25 yr, he presented with
hypertension (systolic blood pressure ⬎ 200 mm Hg, diastolic blood
pressure ⬎ 110 mm Hg). Urinary excretion of norepinephrine was increased during a hypertensive attack as well as in a 24-h collection.
Preoperative abdominal ultrasonography and computed tomography
revealed a left-sided abdominal mass. At laparotomy, an extraadrenal
paraaortal PGL (8.5 ⫻ 5.5 ⫻ 3.5 cm) with local lymph node metastasis
was removed. Postoperatively, the 24-h urinary excretion of norepinephrine dropped to the normal range. At the age of 42, patient II.8
presented with lower back pain and a new history of episodes of headaches, sweating, and palpitations. The 24-h urinary excretion of norepinephrine was elevated and consistent with recurrent PGL. Magnetic
resonance imaging showed lytic lesions within the lumbar vertebra 2.
After corporectomy of the lumbar vertebra 2, the 24-h urinary secretion of norepinephrine normalized, but 123I-metaiodobenzylguanidine
(MIBG) scintigraphy revealed an increased uptake in the proximal right
femur and in the frontal skull. One year later, the metastatic PGL progressed clinically and biochemically. Therapeutic administration of 131IMIBG was unsuccessful; the only effective treatment was blood pressure
control with phenoxybenzamine, with relief from symptoms. The patient died 1 yr after the primary manifestation of bone metastases at the
age of 43.
Patient II.4 had a history of a duodenal ulcer at the age of 20 yr and
headaches, stress, and palpitations since the age of 45 yr. In 1991, at the
age of 52, he presented with attacks of sweating, pallor, weight loss, and
psychiatric disorders as episodes of anxiety, nervousness, and panic.
Because of the family history of extraadrenal PGL, biochemical and
radiological evaluation was initiated and confirmed the diagnosis of an
extraadrenal PGL secreting norepinephrine. At laparotomy, an extraadrenal PGL (5.3 ⫻ 2.2 ⫻ 1.7 cm) was removed. Six years after this
operation, intraabdominal and bone metastases (cervical and thoracic
spine and in the proximal right femur) were detected. The patient died
3 yr later at the age of 61 yr due to extensive bone metastases that was
unresponsive to the 131I-MIBG therapy.
Patient I.3, the aunt of the two brothers, had been successfully operated for a symptomatic, adrenal PCC at the age of 50 yr, without
evidence for recurrence during the following 43 yr; she is alive and well.
Patient I.4, the mother of patients II.8 and II.4, showed signs and
symptoms consistent with a catecholamine-secreting tumor. Since the
age of 55 yr, she presented with episodes of sweating and pallor. She
suffered from hypertension resistant to combination therapy with verapamil, furosemide, reserpine, clopamide, and dihydroergocristine and
had a high consumption of nonsteroidal antiinflammatory drugs because of forceful attacks of headaches. She died at the age of 67 yr of
bleeding duodenal ulcers. Unfortunately, an autopsy has not been
performed.
Patient II.6, the 61-yr-old sister of patients II.4 and II.8, is well and
does not present any symptoms suggesting PCC besides very rare episodes of headaches. Her blood pressure and the 24-h urinary excretion
of norepinephrine, epinephrine, and dopamine are normal.
The siblings II.2, II.5, and III.3, the daughter of patient II.8, do not
show clinical signs of having catecholamine-secreting tumors. The 24-h
urinary excretion of norepinephrine, epinephrine, and dopamine is normal in III.3.
Methods
Blood and tumor samples. Peripheral blood for germline DNA analysis
was drawn from the family members after obtaining informed consent.
A paraffin block from a gastrectomy specimen was the only available
source of DNA from patient I.4, the mother with clinical symptoms of
a catecholamine-secreting tumor. Paraffin blocks of the tumors of the
affected individuals, II.4 and II.8, were obtained from the Pathology
Departments of the University Hospital Zurich and Kantonsspital St.
Gallen. The samples had been fixed in 4% buffered formalin and embedded in paraffin according to standard protocols.
Controls. Blood samples of 80 unrelated Swiss individuals without endocrine disease were used as normal controls.
Denaturing gradient gel electrophoresis (DGGE)-based mutation analysis.
DNA from peripheral blood was extracted using the Purgene kit (GentraSystems, Minneapolis, MN) according to the manufacturer’s instructions. When no blood was available (patients I.4 and II.4), normal tissue
was microdissected from 10-␮m tissue sections of the paraffin blocks,
and the DNA was extracted as previously described (11). The same
procedure was applied for the tumor samples.
Primers for PCR have been designed based on GenBank sequences
using the Primer 3 software (Whitehead Institute for Biomedical Research, Cambridge, MA) (12), and intron-exon boundaries have been
364
J Clin Endocrinol Metab, January 2004, 89(1):362–367
included. PCR using genomic DNA as template was carried out in a
50-␮l mixture of 1⫻ PCR buffer (Perkin-Elmer Europe, Rotkreuz, Switzerland) containing 400 ng of template DNA, 200 ␮m deoxynucleotide
triphosphate (Roche Diagnostics, Rotkreuz, Switzerland), 1 ␮m of each
primer and 1 ␮l of Taq polymerase (Ampli Taq Gold, Perkin-Elmer
Europe). A touch-down procedure was used consisting of 5 sec at 95 C,
annealing for 60 sec at temperatures decreasing from 60 to 55 C during
the first 11 cycles (with 0.5-C decremental steps in cycles two to 11), and
ending with an extension step at 72 C for 60 sec. Ten cycles with an
annealing temperature of 55 C and 15 cycles with an annealing temperature of 45 C were followed with extension times of 90 sec. After a
step of final extension for 10 min at 72 C, heteroduplex formation was
induced after 10-min denaturation at 98 C by incubations at 55 C for 30
min and 37 C for 30 min. For DGGE analysis, 10 ␮l of the PCR product
was loaded with 3 ␮l of Ficoll-based loading buffer onto 10% polyacrylamide gels containing a urea-formamide gradient (available upon request) in 0.5 ⫻ Tris acetate-EDTA. The amplicons were electrophoresed
at 60 C and 100 V for 16 h. The fragments were visualized using silver
staining as described (13). Samples exhibiting additional bands were
cycle sequenced. Because only highly fragmented paraffin DNA was
available for patient I.4, a PCR spanning codon 132 was designed to yield
a small amplification product of 81 bp.
Loss of heterozygosity (LOH) analysis. The genomic DNA obtained from
the microdissected tumor samples and adjacent nonneoplastic tissue of
patient II.4 and the peripheral blood of patient II.8 were used to amplify
the polymorphic markers D1S402 (telomeric) and D1S199 and D1S2644
(centromeric) flanking the SDHB gene. The forward primers were
5⬘ labeled with either 5⬘ hexachloro fluorescein phosphoramidite (HEX)
or 5⬘ fluorescein phosphoramidite (6-FAM) fluorescent dyes. Fragment
size analysis was performed with the 3100 Genetic Analyzer, Applied
Biosystems/Hitachi and Gene-Scan software (Applied Biosystems,
Foster City, CA).
Expression analysis. RNA was extracted from microdissected 10-␮m paraffin sections of tumor tissue using a commercial kit (RNeasy Mini Kit;
Qiagen, Basel, Switzerland) according to the manufacturer’s recommendation. After removal of remaining DNA by DNase digestion (DNAfreeKit; Ambion, Austin, TX), 1 ␮g of RNA was reverse transcribed using
oligo-p(dt) primers and the First Strand cDNA Synthesis Kit (Roche
Diagnostics). To assure that only cDNA and not genomic DNA could be
amplified, primers for RT-PCR were designed to span intron 4 and to
yield a small product of 78 bp. This PCR product was then gel purified
on 1% agarose gels, extracted from the agarose using the QIAEX II
Extraction Kit (Qiagen), and cycle sequenced.
Results
DNA analysis was performed in eight of the 15 family
members. DGGE analysis of the germline DNA revealed a
polymorphism in exon 2 of the SDHD gene in five family
members (II.4, II.5, II.6, II.8, and III.3) and a new germline
variant in exon 4 of the SDHB gene in four family members
(I.4, II.4, II.6, and II.8) (Fig. 1). Three of the members (I.4, II.4,
and II.8) had classic clinical symptoms of a catecholaminesecreting tumor, and two of them (II.4 and II.8) had histologically proven malignant sympathetic PGL (Fig. 1). In patient I.3, who had a history of adrenal PCC, DGGE analysis
of the germline DNA excluded the polymorphism in exon 2
of the SDHD gene and the new variant in exon 4 of the SDHB
gene.
Sequencing of the exon 4 variant of the SDHB gene showed
a nucleotide exchange a⬎c in codon 132, resulting in an
amino acid change H132P (Fig. 2, top). This variant was
absent in all 160 control chromosomes examined but present
in both affected individuals (II.4 and II.8), as well as in their
mother (I.4). No DGGE variants were detected in the SDHC
gene.
One of the microsatellite markers (D1S199) showed two
Maier-Woelfle et al. • SDHB Mutation in Familial Malignant PGLs
distinct products and was informative for the brothers (II.4
and II.8). In both of their tumors, the larger allele of the
D1S199 was lost, whereas the allele of 90 bp was retained
(Fig. 2, middle). The marker D1S2644 was not informative,
and D1S402 could not be amplified in the tumor tissues
because of its large size of 230 bp.
RT-PCR of parts of exons 4 and 5 of the SDHB gene showed
loss of the wild-type allele in both tumors, resulting in sole
expression of the allele carrying the a⬎c transition, indicating that H132P is not a polymorphism but a true germline
mutation (Fig. 2, bottom).
Discussion
We identified a nucleotide exchange a⬎c in codon 132 of
the SDHB gene, resulting in an exchange of the neutral hydrophilic histidine by a hydrophobic proline in the germline
DNA of two brothers (patients II.4 and II.8) who suffered
from metastasizing extraadrenal sympathetic PGL. The same
nucleotide exchange was present in the germline DNA of
their mother (patient I.4), who suffered from the same disease, and of the sister (patient II.6), who does not present
clear-cut signs of the disease. This variant was absent in 160
control chromosomes, arguing against a polymorphism. This
histidine residue is conserved among human, rat, Drosophila,
and yeast, and the glycine at the corresponding residue of the
Escherichia coli homolog is also a neutral hydrophilic amino
acid.
According to the two-hit hypothesis of Knudson et al. (14),
both alleles of a tumor suppressor gene are impaired in
familial tumors. PGLs occurring in families with SDHD
germline mutations (PGL1, OMIM 168000) have been shown
to have an allelic loss of the 11q23 region (4). The status of
the second allele in tumors of patients with SDHB germline
mutations has also been assessed. Although Young et al. (15)
showed LOH of the flanking microsatellite marker D1S507,
sequencing of the mutated codon 242 in exon 7 suggested the
retention of the wild-type allele. This result could suggest
(15) that other tumor suppressor genes on 1p35–36 are involved. Alternatively, a partial loss of the SDHB wild-type
allele may have occurred. Gimenez-Roqueplo et al. (16) have
shown LOH in tumor tissue of a SDHB-associated PCC. This
tumor was malignant and showed extensive local invasion
into the vena cava and right auricle to such an extent that a
distinction of an adrenal PCC from a juxtaadrenal sympathetic PGL becomes difficult. These authors also showed the
functional consequence of a complete loss of malonatesensitive cytochrome c activity.
In the tumors of the patients presented here, the sequencing results provided evidence for LOH of the SDHB locus,
because only the mutant cytosine was amplified from the
tumor DNA (Fig. 2, top). In addition, using the flanking
microsatellite marker D1S199, we showed allelic loss centromeric of SDHB in both tumors. Furthermore, the same
allele of 90 bp of the microsatellite marker D1S199 was retained, whereas the alleles of 98 bp (patient II.4) and 92 bp
(patient II.8) were lost in the tumors. Expression analysis was
performed to demonstrate the loss of the wild-type allele.
Sequencing of the RT-PCR products showed expression of
the H132P variant but not of the wild-type sequence in both
Maier-Woelfle et al. • SDHB Mutation in Familial Malignant PGLs
J Clin Endocrinol Metab, January 2004, 89(1):362–367 365
FIG. 2. Top, SDHB exon 4 sequence analysis of the genomic DNA reveals the H132P mutation in a heterozygous form in both affected brothers
as well as their mother. Middle, LOH analysis using microsatellite markers; D1S402 is not informative in patient II.4, D1S199 shows loss of
one allele in the tumors of patients II.4 and II.8 (arrow). Bottom, SDHB exon 4 sequence analysis of cDNA reverse transcribed from tumor tissue
RNA. Control cDNA shows the wild-type sequence, and tumors of patients II.4 and II.8 show exclusive expression of the allele carrying the H132P
mutation. No, Nonneoplastic tissue; Tu, tumor tissue.
tumors. Thus, we have shown that in the tumors one allele
carries the H132P variant in presence of the loss of the wildtype allele. We conclude that this variant represents a true
germline mutation. Intriguingly, patient I.3 who had a sympathetic tumor did not carry this germline variant. However,
the phenotype was different; she suffered from a clinically
benign adrenal PCC, and we consider it a sporadic tumor.
Studies on SDHB and SDHD mutation-associated PGLs
reveal an emerging genotype-phenotype correlation. Baysal
(17) noted that families with SDHD mutations most often
exhibit cervical parasympathetic PGLs but rarely suffer from
abdominal sympathetic PGLs. In contrast, the phenotype of
25 (89%) of 28 independent germline SDHB mutation-associated tumors was characterized by abdominal, mostly sympathetic extraadrenal PGLs (Table 1). Abdominal extraadrenal PGLs are known to be the most aggressive PGLs of the
sympathoadrenal neuroendocrine system, with an incidence
of malignancy of 15% (7) to 50% (9).
366
J Clin Endocrinol Metab, January 2004, 89(1):362–367
Maier-Woelfle et al. • SDHB Mutation in Familial Malignant PGLs
TABLE 1. Summary of reported SDHB mutations and associated phenotype
Genotype
Location
No.a
Behaviorb
Ref.c
R46Q
R46X
L56H
c.88delC
R90X
R91X
H132P
IVS4-1G⬎A
P198R
R242H
R27X
A29-Q30 insQ
R46G
Q59X
M71fs
C101Y
P131R
C192R
C196Y
P197fs
L240fs
R242H
C249X
Abdominal
Abdominal
Abdominal
Abdominal
Abdominal
Abdominal
Abdominal
Abdominal
Abdominal
Abdominal
Abdominal
Abdominal
Abdominal
Cervical
Cervical
Abdominal
Cervical
Abdominal
Abdominal
Abdominal
Abdominal
Not indicated
Abdominal
2
1
1
1
1
3
1
1
1
1
1
1
2
1
1
2
1
1
1
1
1
1
1
Malignant (1)
Benign
Malignant
Malignant
Malignant
Malignant (1)
Malignant
Benign
Benign
Malignant
Not given
Not given
Not given
Not given
Not given
Not given
Not given
Not given
Not given
Not given
Not given
Not given
Not given
16, 18
18
18
18
18
6, 5
Present study
18
6
15
5
5
5
3
3
5
3
5
5
6
5
5
5
a
Number of unrelated individuals with the germline mutation.
Number of malignant tumors indicated in parentheses.
c
References with detailed clinical data are in bold.
b
To date, 24 different SDHB mutations have been described in 28 unrelated individuals or families (3, 5, 6, 15,
16, 18), including the present report (Table 1). Based on the
studies with detailed clinical information, an additional
phenotype-genotype correlation emerges. Ten (90%) of 12
SDHB-associated families were characterized by the exclusive occurrence of extraadrenal sympathetic PGLs (6,
15, 18), including the family reported here. Only one tumor
was reported to have occurred in the adrenal gland (16),
and one family was reported to suffer from both extraadrenal PGLs and a PCC (18). It is important to realize that
seven (58%) of 12 of these well-documented families carrying SDHB germline mutations exhibited a malignant
phenotype (Table 1). Interestingly, the clinical course of
one patient reported by Young et al. (15) with a 30-yr
survival of a malignant catecholamine-secreting tumor resembles the family reported here. Patient II.8 died 18 yr
after the diagnosis of a malignant extraadrenal PGL, and
patient II.4 retrospectively most probably suffered from
this disease for 16 yr. Unfortunately, most multicenter
studies consist of groups of patients and include neither
follow-up data nor the precise location of the tumors or a
malignant phenotype. To our knowledge, no PGL family
with SDHD mutation was reported to harbor malignant
tumors.
Although Ret, NF1, and VHL are genes that primarily
cause adrenal PCCs, the SDHB gene appears to cause extraadrenal PGLs with a high rate of malignant behavior.
Therefore, SDHB mutation analysis should be recommended
for patients presenting with familial extraadrenal PGLs.
Identification of a SDHB mutation may then warrant a close
follow up of affected patients and of germline mutationcarrying children.
Acknowledgments
We thank Dr. R. Schmid, Pathology, St. Gallen, Switzerland, for
providing tissue blocks.
Received August 1, 2003. Accepted September 29, 2003.
Address all correspondence and requests for reprints to: Aurel Perren,
M.D., Department of Pathology, University Hospital Zurich, Schmelzbergstr 12, CH-8091 Zurich, Switzerland. E-mail: [email protected].
This work was supported by Swiss Cancer League Grant SKL-99702-2000 and Swiss National Science Foundation Grant 31-618845.00.
References
1. Lam KY, Lo CY, Wat NM, Luk JM, Lam KS 2001 The clinicopathological
features and importance of p53, Rb, and mdm2 expression in phaeochromocytomas and paragangliomas. J Clin Pathol 54:443– 448
2. Grufferman S, Gillman MW, Pasternak LR, Peterson CL, Young Jr WG 1980
Familial carotid body tumors: case report and epidemiologic review. Cancer
46:2116 –2122
3. Baysal BE, Willett-Brozick JE, Lawrence EC, Drovdlic CM, Savul SA,
McLeod DR, Yee HA, Brackmann DE, Slattery III WH, Myers EN, Ferrell RE,
Rubinstein WS 2002 Prevalence of SDHB, SDHC, and SDHD germline mutations in clinic patients with head and neck paragangliomas. J Med Genet
39:178 –183
4. Baysal BE, Ferrell RE, Willett-Brozick JE, Lawrence EC, Myssiorek D, Bosch
A, van der Mey A, Taschner PE, Rubinstein WS, Myers EN, Richard III CW,
Cornelisse CJ, Devilee P, Devlin B 2000 Mutations in SDHD, a mitochondrial
complex II gene, in hereditary paraganglioma. Science 287:848 – 851
5. Neumann HP, Bausch B, McWhinney SR, Bender BU, Gimm O, Franke G,
Schipper J, Klisch J, Altehoefer C, Zerres K, Januszewicz A, Smith WM,
Munk R, Manz T, Glaesker S, Apel TW, Treier M, Reineke M, Walz MK,
Hoang-Vu C, Brauckhoff M, Klein-Franke A, Klose P, Schmidt H, MaierWoelfle M, Peczkowska M, Szmigielski C, Eng C 2002 Germ-line mutations
in nonsyndromic pheochromocytoma. N Engl J Med 346:1459 –1466
6. Astuti D, Latif F, Dallol A, Dahia PL, Douglas F, George E, Skoldberg F,
Husebye ES, Eng C, Maher ER 2001 Gene mutations in the succinate dehydrogenase subunit SDHB cause susceptibility to familial pheochromocytoma
and to familial paraganglioma. Am J Hum Genet 69:49 –54
7. Hayes WS, Davidson AJ, Grimley PM, Hartman DS 1990 Extraadrenal retroperitoneal paraganglioma: clinical, pathologic, and CT findings. Am J Roentgenol 155:1247–1250
8. O’Riordain DS, Young JR WF, Grant CS, Carney JA, van Heerden JA 1996
Maier-Woelfle et al. • SDHB Mutation in Familial Malignant PGLs
9.
10.
11.
12.
13.
Clinical spectrum and outcome of functional extraadrenal paraganglioma.
World J Surg 20:916 –921; discussion 922
Sclafani LM, Woodruff JM, Brennan MF 1990 Extraadrenal retroperitoneal
paragangliomas: natural history and response to treatment. Surgery 108:1124 –
1129; discussion 1129 –1130
Linnoila RI, Keiser HR, Steinberg SM, Lack EE 1990 Histopathology of
benign versus malignant sympathoadrenal paragangliomas: clinicopathologic
study of 120 cases including unusual histologic features. Hum Pathol 21:1168 –
1180
Perren A, Roth J, Muletta-Feurer S, Saremaslani P, Speel EJ, Heitz PU,
Komminoth P 1998 Clonal analysis of sporadic pancreatic endocrine tumours.
J Pathol 186:363–371
Rozen S, Skaletsky HJ 2000 Primer3 on the WWW for general users and for
biologist programmers. In: Krawetz S, Misener S, eds. Bioinformatics methods
and protocols: methods in molecular biology. Totowa, NJ: Humana Press;
365–386
Komminoth P, Kunz E, Hiort O, Schroder S, Matias-Guiu X, Christiansen G,
Roth J, Heitz PU 1994 Detection of RET proto-oncogene point mutations in
paraffin-embedded pheochromocytoma specimens by nonradioactive single-
J Clin Endocrinol Metab, January 2004, 89(1):362–367 367
14.
15.
16.
17.
18.
strand conformation polymorphism analysis and direct sequencing. Am J
Pathol 145:922–929
Knudson Jr AG, Hethcote HW, Brown BW 1975 Mutation and childhood
cancer: a probabilistic model for the incidence of retinoblastoma. Proc Natl
Acad Sci USA 72:5116 –5120
Young AL, Baysal BE, Deb A, Young Jr WF 2002 Familial malignant catecholamine-secreting paraganglioma with prolonged survival associated with
mutation in the succinate dehydrogenase B gene. J Clin Endocrinol Metab
87:4101– 4105
Gimenez-Roqueplo AP, Favier J, Rustin P, Rieubland C, Kerlan V, Plouin
PF, Rotig A, Jeunemaitre X 2002 Functional consequences of a SDHB gene
mutation in an apparently sporadic pheochromocytoma. J Clin Endocrinol
Metab 87:4771– 4774
Baysal BE 2002 Hereditary paraganglioma targets diverse paraganglia. J Med
Genet 39:617– 622
Benn DE, Croxson MS, Tucker K, Bambach CP, Richardson AL, Delbridge
L, Pullan PT, Hammond J, Marsh DJ, Robinson BG 2003 Novel succinate
dehydrogenase subunit B (SDHB) mutations in familial phaeochromocytomas
and paragangliomas, but an absence of somatic SDHB mutations in sporadic
phaeochromocytomas. Oncogene 22:1358 –1364
JCEM is published monthly by The Endocrine Society (http://www.endo-society.org), the foremost professional society serving the
endocrine community.