Portland Mutant Meeting Review

At 6pm on Friday, October 17th, 2014,  mutants gathered in the Pine Room at the Embassy Suites in Portland, Oregon. As they munched on crudités and exchanged hugs, laughter spilled out into the hallway. While most would find the subject of hereditary cancer to be anything but laughable, this group of cancer fighting warriors knows that laughter truly is the best medicine. This is especially true when you get to laugh with others who know what it is like to live with Li Fraumeni Syndrome.

A round of Mutant Speed Dating got the evening started and gave everyone a chance to spend a few minutes one-on-one with someone else who has been touched by LFS. We shared stories of scars and scares,  recovery and hope. There were spouses who got to meet other spouses for the first time. After the common topics of football and occupations were adequately explored, they ventured into other areas of conversation, the ones not usually touched upon, as the menfolk recognized that they were in the company of others who truly understood the fears of walking alongside someone who is living LFS.

A mini mutant found friendship with two other children, whose mother has LFS.  They played hide and seek while the moms discussed reconstruction and testing and the particular issues of parenting with LFS.  Young adults discussed the unique challenges of having multiple cancers by their early 20’s. Despite the unusual topics of conversation, it felt more like a family reunion than a support group social. The evening ended with everyone looking forward to seeing their new friends the next morning.

Bright and early, the Mutants congregated for breakfast. Everyone trickled into the meeting room excited to learn what was in store for Living LFS.  Of all the luck, I had gotten a cold and had all but lost my voice for the meeting. I did the best that I could to explain how Living LFS had come about.
In 2008, my daughter Lily was diagnosed with Adrenocortical Carcinoma and a sarcoma. I began reading papers online and researching what our best treatment option was. It was very disheartening, as everything I read carried the words “poor prognosis” and “poor survival”. However, I noticed that there was a name that kept popping up over and over- Dr. Raul Ribeiro from St. Jude’s. If I found a paper about pediatric adrenal tumors, he was usually associated with it.
As a resident, while studying medicine in  Brazil, Dr. Ribeiro noticed there was a higher than average incidence of adrenocortical carcinoma. He and his team found a cohort, a genetic link and eventually a specific TP53 mutation that is associated with these families. I figured if anyone could answer my questions about LFS and my daughter’s chances, it would be this man. So, I found his office number online and left him a message. No more than a few hours later, Dr. Ribeiro called me back and we discussed his experiences with LFS, adrenal tumors and the registry he had created for these tumors- IPACTR- International Pediatric AdrenoCortical Tumor Registry. He took the time to talk to me during a very scary point in our lives and I have always appreciated this and respected him for it.
In 2009, while my daughter was in chemotherapy, a regimen that Dr. Ribeiro had helped me to decide on, I started looking for other survivors of adrenal tumors. My other children had tested positive for the mutation, so we had officially become a family of mutants. A friend directed me to Facebook, and when I searched Li Fraumeni Syndrome- there was nothing but a page with 6 followers. I knew there were other families out there like mine and social media seemed like it might just be the way to find them. I started a Li Fraumeni Syndrome group and invited my family. I then invited friends I had met on MD Junction.
Every few months we would get a new person looking for support and by 2013, over 300 members gathered online, asking questions, sharing experiences and helping each other make some of the toughest decisions of their lives. Many of us got to meet in person, in Boston at the LFS conference last year. We were excited for more meetings. We decided the best way to make sure that we got our mutant fix was to arrange these meeting ourselves. Thus, the Portland Mutant Mixer was born.
At this point, a few of the amazing women who are helping to make Living LFS a reality took turns introducing themselves. Trishia Shelly-Stephens is an active supporter of the LFS community and serves as our Vice President.  We honored our Secretary/Treasurer, RD Mooney who, due to a recent diagnosis and surgery, was unable to be with us despite being a driving force behind our incorporation and filing of non profit paperwork.  Courtney Ma’at, a Social Worker, is helping us with Psychosocial Support.  Jennifer Mills, an RN, is serving as our Medical Liaison. Ann Ramer, is our Research Liaison and self proclaimed medical information hound. D’Ana Reed is providing us with technical support. Mostly, each one of the Board Members has intimate experiences with LFS and wants to help bring the LFS community together.

When we decided to meet in Portland, we thought it would be great to have a speaker for the group. I immediately thought of Dr. Ribeiro.  Dr. Ribeiro graciously accepted our invitation to speak via conference call and prepared an amazing 30 minute presentation on Pediatric Adrenocortical Tumors as Sentinel Tumors for Detecting Germline TP53 Mutations. A summary of his talk and slides from the presentation can be found HERE. Dr. Ribeiro went on to spend another half an hour expertly answering questions from the group. His work is an excellent example of how screening and early detection can save lives.

Dr. Raul Ribeiro’s Slide Show

After Dr. Ribeiro’s talk, we broke for coffee, tea and fruit, then heard from Courtney Ma’at who spoke about Stress and LFS. She made profound comparisons between Post Traumatic Stress Syndrome and LFS. She also shared some tips on how to identify and to cope with the stress of LFS and will be sharing those with us in a future blog post!

We ended the meeting with an open discussion about future meetings(we are looking at October 2015- location to be determined) and possible fundraisers. We quickly posed for a group picture and I for one had a tough time saying goodbye- so, many of us caught a train to town and had a final dinner together!

I can not thank the Mutants enough for making this such a special weekend. It was an honor to be able to hear your stories and experiences.  Thank you for traveling to share them with us.  To the Mutant supporters- whether you are a spouse or family or a friend- we could not do any of this without you.  To the Board Members of Living LFS, you are phenomenal and I am so impressed with the event that you pulled together in a few short weeks and I am excited to watch this grow. Thank you from the bottom of my heart for helping make this a reality. To Dr. Ribeiro who shared with us his time, experience and an amazing presentation, we are supremely grateful and indebted to you. To the Embassy Suites, who really worked with us to make this a great experience, we are thankful. And to Ami- whose knowledge and skills made this weekend one I know several mini mutants and mutants alike will always remember- THANK YOU!  Jennifer Mallory


Dr. Ribeiro Speaks to Living LFS in Portland

On October 18, 2014, Dr. Raul Ribeiro of St. Jude’s Research Hospital addressed a meeting of those with Li Fraumeni Syndrome in Portland, Oregon. Dr. Ribeiro has been honored with many awards and works tirelessly to ease the burden of cancer on children around the world. He leads many research efforts at St. Jude, spearheads programs such as the Cure4Kids(www.cure4kids.org) online continuing education resource, IPACTR(International Pediatric Adrenocortical Tumor Registry) and World Child Cancer(promotes cancer treatment in areas with poor resources).

Dr. Ribeiro’s research interests include acute myeloid leukemia, acute lymphoblastic leukemia and adrenocortical carcinoma. He has been an invited speaker to many universities, institutions and we were honored to have him speak for the first Mutant Meeting. Right away, you could see Dr. Ribeiro’s passion and sincerity. His enthusiasm was infectious and we left feeling his dedication to not only research and care of children with rare cancers but that his work would directly impact LFS as well.

Pediatric Adrenocortical Tumors are one of the core LFS tumors. There is a high correlation between adrenocortical tumors in children and germ line TP53 mutations. So even though these tumors are not seen very often, if they are seen, there is a relatively high chance that the child with the adrenal tumor could have a syndrome like LFS.

Dr. Ribeiro began by explaining how he became interested in the very rare pediatric adrenocortical tumors(ACT). A bit of that story can be found HERE. Adrenal tumors in children are very rare- the incidence is less than 1 per million. Over a 30 year period in the US, only 85 cases of adrenocortical carcinoma were reported. Yet in Brazil over the past 30 years, there were 350 cases of ACT. Further research found a specific mutation of the TP53 gene was responsible, the R337H mutation. It also revealed the greatest risk for pediatric ACT was before age 7. Although the risk of ACT is very high for this R337H mutation, the risk of other LFS tumors seems to be lower. This information lead to a study of newborn screening for ACT from years 2005-2010. By looking at various syndromes and mutations that exhibit ACT, they found that different mutations have different penetrance. Some TP53 mutations cause LFS and multiple tumor types as well as ACT, the R337H mutation causes adrenal tumors and they are seen generation after generation.

Even though the incidence of ACT in the general population is still very low, the screening in Brazil detected tumors in children who did not have symptoms. Of 378 children who tested positive for the mutation(carriers) and were screened, 8 cases of ACT were found. All tumors were stage 1. All children were still alive in 2013. Of the 321 carriers who did not screen for ACT, there were 11 cases of ACT, 3 were stage 1, 3 were stage 2 and 5 were stage 3. Of those children, 2 relapsed and 1 died. This shows how important screening can be for even rare syndromes.

In the meantime, Dr. Ribeiro’s team began looking into possible causes of ACT. Besides LFS, there are several syndromes that have increased risk of developing ACT. One of these syndromes is Beckwith-Wiedemann Syndrome(BWS) that is caused by mutations on Chromosome 11p15.  This mutation is linked to an over expression of IGF-2– which is Insulin-like Growth Factor 2. IGF-2 promotes growth in cells. So if it is over active, too much tissue can turn into tumors.

Dr. Ribeiro began wondering if there was a link between BWS adrenal tumors and LFS adrenal tumors and as it turns out, one of the links is IGF-2. Pediatric ACT results from too much IGF-2 and this can be caused by different events that lead to genomic instability, one of which is TP53 mutations. Essentially, genomic instability is a major problem TP53 runs across, it is another way of saying high rate of mutation or DNA damage. This damage can result in aneuploidy(having a different number of chromosomes than normal cells) that is present in virtually all cancers. Our bodies are constantly being bombarded with damaging forces and for those of us with TP53 mutations, we know what happens when the damage cannot be repaired, tumors develop.  Next is to see if steps can be taken to prevent the events(DNA damage and aneuploidy) that are caused by the mutations such as those in TP53.

This is a great example of how international cooperation and communication can lead to information that is useful for many diseases.  Pediatric Adrenocortical Tumor is the prototype of TP53 related cancers recently linked to over expression of IGF-2.  There are a variety of mutations to TP53 that can result in ACT, some of which are more severe and predispose the carrier to more cancers than others. Dr. Ribeiro is hopeful that therapeutic efforts for TP53 cancers that focus on treat genomic instability will have positive results.

Resources
Dr. Ribeiro’s slides
www.St.Jude.org
Genetics Home Reference– IGF2