Dr. Emilia Modolo Pinto Answers Questions About Cancer Predisposition Genes and Childhood Cancer in LFS and Beyond.

Research articles often are difficult for the average person to understand. One of our goals at living LFS is to help make this information easier to understand so everyone can benefit from the exciting advances in science and medicine. In November, The New England Journal of Medicine published an article about childhood cancer, hereditary cancer genes and predisposition to cancer.   Dr. Emilia Modolo Pinto graciously agreed to answer a few questions to help us better understand the article and what it means for not only the LFS community, but for the public in general.

Emilia Modolo Pinto, Ph.D., is a researcher at St. Jude Children’s Research Hospital. She studies adrenal tumors in children, which are often associated with Li-Fraumeni Syndrome and TP53 mutations. In this interview, she talks about her work studying Li-Fraumeni syndrome.

Dr. Pinto, please tell us a little about yourself and how you became interested in hereditary cancers.
EMP: I finished my Ph.D. in Brazil in 2005. Since then, I have been studying tumors of the adrenal gland in children – adrenocortical tumors. Specifically, I study the molecular biology of these tumors – how they happen at the most basic level, the cell. Pediatric adrenocortical tumor is a rare disease, but there are many cases in southeast Brazil. In this area, it is strongly associated with a mutation in a gene called TP53. For families who are interested, the mutation is called R337H. When I was doing research for my Ph.D., I had the opportunity to study several families who have this mutation. For some families, I was able to study 3 or more generations. I learned that the mutation in the TP53 gene was passed down, without change, in every generation I studied. I also found that this mutant gene was the same in other families. The Brazilian families who have this TP53 mutation all have a history of many different cancers. Some families have a child with adrenocortical tumor, and other families have different tumors in all generations and in all ages. The situation in Brazil caught my attention and gave me an interest in hereditary cancer.

 

Recently, the New England Journal of Medicine published an article about germline mutations in predisposition genes in pediatric cancer. Can you tell us what germline mutations in predisposition genes are, and briefly summarize what this article was about?
EMP: Yes. The cells in eggs and sperm are called “germ cells.” What scientists call “germline mutations” are mutations in these specific cells. When a germ cell with a mutation joins with another germ cell to form an embryo, every cell in the embryo will carry the mutation. Now, some of these mutations affect genes called “predisposition genes.” If these genes have a mutation, they make a person more likely to develop cancer. So if a germ cell mutation affects 1 (one) of these predisposition genes, it can increase the chance of developing 1 (one) or more cancers. It’s important to stress that everyone responds differently to gene mutations. Even if everyone in a family has the same mutation, affecting the same predisposition gene, some family members will get cancer and some will not. In the New England Journal of Medicine article, the authors studied 1,120 children with cancer. They carefully examined the germline sequence of 565 genes reported be associated with cancer, and paid close attention to 60 predisposition genes that are known to increase cancer risk if 1 (one) copy of the gene is changed. Remember, a child gets 1 (one) copy of each gene from the mother and 1 (one) from the father. So, these particular predisposition genes are known to increase cancer risk if just 1 parent has a mutation. In this study, almost 9 percent of patients had germline mutations in 21 of those 60 genes that scientists paid close attention to.

 

People with Li-Fraumeni syndrome, or LFS, have mutations in their germline TP53 gene. In this article, researchers studied those mutations and several others. The results of the mutations and cancer types in the study seemed to be somewhat unexpected. What were the main things researchers learned from this study?
EMP: Researchers studied several predisposition genes, not just TP53. They chose which genes to study by reviewing the medical literature, what is already known. They also reviewed genetic databases. Usually, patients who have a lot of cancer in their families, or what we call a strong family history, have genetic testing. They get tested for a mutation in a cancer predisposition gene. But in this study, the researchers found that more than half of children with germline mutations in predisposition genes did not have a lot of cancer in the family – or any at all. They had what we call a negative family history of cancer, meaning cancer did not seem to run in the family. The results of this study will help researchers find more people with mutations in certain families. These people can benefit from genetic counseling, examinations, and tests to check for cancer. The study results will also affect how doctors take care of people with Li-Fraumeni syndrome. They will be able to find and keep track of these patients and families better.

 

Some mutations were “deemed to be pathogenic or probably pathogenic.” What does this mean?
EMP: There has been a lot of progress in genetics since the early 2000s, and scientists have found many mutations. Some of them are what scientists call “pathogenic” mutations. This means they lead to disease, such as cancer. Scientists have studied these mutations in animals, and they know having the mutation keeps cells from developing normally. Other mutations are what we call “probably pathogenic.” We can find a mutation that probably keeps cells from developing normally. But studies in animals have not yet shown that the mutation definitely causes disease. In other words, we do not know enough about those mutations yet. Even though the “probably pathogenic” mutations are associated with cancer, we need to learn more about how they cause it.

 

Why do you think the study group included more patients with leukemia and adrenocortical tumors than expected?
EMP:  This study was part of the St. Jude -Washington University Pediatric Cancer Genome Project. The cancers studied in that project are difficult to treat. Or scientists don’t yet understand how these cancers develop. Adrenocortical tumors and the types of leukemia in this study fall into these categories. For people who are interested in comparing studies, this study was able to analyze more cases of leukemia and adrenocortical tumors, compared the Surveillance, Epidemiology, and End Results (SEER) program.

 

The article says, “Discovery of 4 germline mutations in the TP53 and RB indicates that a fraction of the mutations in this study were de novo.” What are de novo mutations? Does this mean that some children in this study had a hereditary mutation, but did not actually inherit it from their parents?
EMP:  “De novo” mutations are mutations that are found for the first time in 1 (one) family member, but not in either of their parents. A de novo mutation can come from a mutation in an egg or sperm cell from 1 (one) parent. Or it can come from the fertilized egg itself. To learn if a mutation is inherited or “de novo” the parents of a child with the mutation should be tested, to see if they also have it. However, it’s important to know another reason that we sometimes cannot find a mutation in the parents. A condition called ”mosaicism” ,means they have the mutation in some of their cells, but not all of them. This can make a mutation difficult to find with common genetic tests.

 

I have Li-Fraumeni Syndrome and so do my children. What do the results of this study mean for us?
EMP:  Mutations in the TP53 gene are probably the most common cause of cancer in children. So there are probably many more children with LFS than we know about right now. Children and adults with germline TP53 mutations need regular examinations and tests to screen for cancer. This can help find tumors as early as possible, when they are most likely to be cured.

 

What does this study mean for the public?
EMP:  Scientists are learning more about what having a germline predisposition mutation means for childhood cancer. Knowing this type of mutation is present will help doctors care for patients more effectively. It will also help doctors care for family members of people with mutations. We know more about the risk of cancer, and knowing the mutation is there helps us decide on care and treatment for patients with mutations. Also, regular examinations and tests for patients with mutations will improve cancer care, because doctors can find and treat tumors earlier. Perhaps in the future, it will even be possible to prevent tumors from forming.

 

There are some very valuable take away points from this article. Children shouldn’t get cancer and when they do, researchers are now finding that family history isn’t always the only indication of a possible germline mutation. To serve the pediatric population better, to find better treatment and screening, genomics and genetics will play an even more important role as we go forward. The hope is that some day we will be able to prevent these mutations and the cancers they cause. We’d like to thank Dr. Pinto for sharing her time and knowledge with us.

 

The study referenced in this interview is from the St. Jude Children’s Research Hospital — Washington University Pediatric Cancer Genome Project and appeared in the November 18 edition of the New England Journal of Medicine.

 

Journal Reference:

Zhang et al. Germline Mutations in Predisposition Genes in Pediatric Cancer. New England Journal of Medicine., Nov. 18, 2015 DOI: 10.1056/NEJMoa1508054


Four Stories of LFS and Pediatric Adrenocortical Carcinoma, Rare Hope

-Adrenocortical tumors are very rare, seen in about 0.2 percent of all childhood cancers.-More girls are affected by adrenocortical carcinoma than boys.-It is usually seen in children between  the ages 1 and 4 years old-The tendency to develop adrenocortical tumors may be inherited, like with LFS.

These are the stories of 4 young ladies who faced adrenocortical carcinoma.  Since adrenal tumors are so rare and linked to the germline TP53 mutation that causes LFS, many face a double whammy, cancer and a diagnosis of a hereditary cancer syndrome.
Gwendolyn- A New Kind of Crisis.
Gwendolyn was diagnosed around 18 months with Adrenocortical Carcinoma, a very rare adrenal tumor. Her symptoms were precocious puberty, but nothing else. We were rushed to Sick Kids in Toronto, Ontario where they did a MRI and CT scan to confirm the tumor. We then found the tumor on her adrenal gland was roughly 8 cms and it had spread to her lungs. There were 11 spots on her lungs. Because of this type of cancer, they also did genetic testing for LFS, which it was positive. What we thought we knew and what we now know has changed drastically. 


 Chemotherapy wasn’t the worst hurdle we would experience, nor was the vomiting as her ECG(electrocardiogram that measures the heart) showed a prolonged QT which meant goodbye to her one anti nausea medication- that meant she spent the first night of cycle 4, 5, and 6 throwing up. After Cycle 4, they removed the tumor and her left adrenal gland.  Which left her with her right adrenal gland that is no longer functioning due to Mitotane. I think we were shocked more than anything as she was the first in our family with a genetic mutation. It has changed a lot of things in our family and having more children is  probably not going to happen. We worry way too much about her, as the adrenal insufficiency is a big deal. 


Nobody could predict or even expect what would happen after cycle 6. We were home for a week after her cycle when we experienced our first adrenal crisis. I drove up to Orillia Ontario (our satellite oncology clinic) , she spent 5 hours there to stabilize her and air lifted her to SickKids, where we spent 1 week. Gwen experienced 2 more crises after chemo, which was scary beyond belief. All her doctors were shocked how she goes from her normal self to a full blown adrenal crisis. So all her medications were increased including hydrocortisone, fludrocortisone, calcium and she was also put on an oral sodium which she takes very well. She was put on overnight hydration, as her body became very dehydrated very quickly. 


She makes it difficult for the doctors as she isn’t textbook, so they are hesitant in changing medication or protocol for her. We have learned the signs and symptoms of adrenal crisis rather quickly and don’t hesitate to make a trip to our clinic. The first time she had a bad adrenal crisis, if we had waited another couple hours we would not have her here today. We have learned so much over the last 15 months of diagnosis and we still learn things today. The frustration is her not being symptomatic and not stress dosing before her body is looking for the extra help. We do feel alone at times because of the adrenal cancer and LFS, we are very few in Canada and there might be more but they might not want to have others seek them out. It’s hard at times to relate to others with “normal” cancers, as ours is rare and not heard of. I refer to 1 person in Toronto, Ontario having ACC. 
– shared by Gwendolyn’s mom
 
Lily-Celebrating Normal

Lily is 10 and remembers that she had cancer but she really doesn’t remember going through chemotherapy or how sick she was and for that we are grateful. At the age of 3, Lily started going through puberty. I had brain tumors in my family, so I immediately worried that she had a rare pituitary tumor. I took her in to a pediatrician who ran some bloodwork, but otherwise didn’t seem too concerned that a preschooler was “developing” early. 


Even though I knew my dad had LFS, I worried about the tumors I knew we had in our family,  brain tumors, breast cancer, sarcomas, but adrenal cancer wasn’t on my radar. An attentive physician got us into an endocrinologist who immediately discovered Lily’s adrenocortical carcinoma- an 8 cm, softball sized tumor in my 3 year old’s abdomen. It was a “core” LFS tumor. Kids who have no family history of cancer who turn up with this tumor, usually get tested for LFS. 

After her diagnosis, I learned how rare adrenal cancer is. I remember my mom talking with Dr. Li when my brother was diagnosed with a brain tumor, so I looked for the leading specialist in pediatric adrenocortical carcinoma. I found Dr. Raul Ribeiro at St. Jude’s, who not only immediately returned my call but spent and an inordinate amount of time discussing LFS, adrenal tumors, treatment and a scared mom’s fears. 


Treatment was all we were promised, she was miserable, we hit hurdles and we learned a lot about side effect management. I learned that it was a completely different ballgame than when my dad and brother had brain tumors. But she would still put on her little tap shoes because she liked the way they clicked on the hospital linoleum and she would dance through treatments. 

Adrenal cancers have a poor prognosis. Especially tumors as big as Lily’s. We dealt with weight loss and mood swings and adrenal crises, a result of the chemotherapy drug mitotane- which not only kills off adrenal cancer cells, it kills off healthy adrenal cells too. We replaced the hormone her adrenals produced with pills and readied ourselves with shots in case of sickness or emergency- her body won’t make enough cortisol to protect her. Lily went back to school. We celebrated, even though we had to fight with the school over what appropriate precautions were. We wanted her to have the normal school experience, with a safety net. We celebrated birthdays. We celebrated holidays. We did 6 month screenings and had a few shadows and scares along the way. But that is Living LFS. Mostly we have been living. 


Lily’s 5th cancerversary came and went. So did the 6th. I remember during her treatments thinking we would throw a big party every year, but as they approached and we were busy with other things, it didn’t seem as important. Birthdays were far more important and normal. So as we sneak up on her 7th cancerversary, for a rare adrenal tumor with a poor prognosis, I am grateful. I am happy she is still here. I am happy she does’t remember all that she went through that year. I am grateful for each additional day we have been given. – shared by Lily’s mom



As a result of hormones generated by adrenal tumors, subsequent removal of adrenal glands and sometime chemotherapy, many survivors of adrenocortical tumors suffer long term effects. 

-Adrenal Insufficiency is one of the most common treatment side effects of adrenocortical carcinoma. 

-For more information on adrenal cancer and LFS refer to the previous Blog:

-Unfortunately, children with LFS are at risk for having multiple cancers.



Loraine- Long Term Effects
I am now 31 and I remember almost nothing about that period so I don’t think I can help you with telling things about that period. I was 9 months old when I was diagnosed and they removed the adrenal when I was 10 months old in Radboud UMC, a university hospital in Nijmegen, the Netherlands.

What I know is that I have a lot of bonding issues, which started in that period (you hear it a lot when little children are separated from their parents that they develop bonding issues) and that my hormones were acting really weird when I grew up.

Last year the surgeon removed my ovaries after my hormones stabilized with medication (which are downgrading the oestrogen levels) and since then I’m doing so much better, I’m not depressed any more and I’m not having heavy moodswings any more.


But I have to say that the other adrenal is producing almost no cortisol, it’s about the zero-line and every 6 months they check if I can go on the way it is or if I need medication.



Lainie- Living Every Day Like It’s Her First.

I had adrenal cancer as an infant in 1985, I was too young to remember what I went thru but growing up always knew I had adrenal cancer as a baby. I would get routine check-ups,CT Scans, and ultrasounds yearly until I was about 15. Keep in mind I never knew I had Li-Fraumeni Syndrome.
 
At around 15 years old, I was told that given I had not had a recurrence and everything had been fine for 14 years, that scans were no longer needed. I still got check ups regularly, but since I didn’t know I had Li-Fraumeni Syndrome I never thought I could get cancer again. I think the only thing that saved my life is wanting to become a nurse. It turned me into a hypochondriac which ended up benefiting me in the long run.
 
After being diagnosed with my 4th cancer, my breast surgeon and endocrinologist suggested that I go to M.D. Anderson given that surgery was more complicated and it was the best place to be. The best is an understatement! This is where I was TRUTHFULLY tested for Li-Fraumeni Syndrome and sure enough was positive.
 
Since going to M.D. Anderson my screening has been very aggressive. I have had a recurrence of breast cancer 3 times and have also done radiation when was beneficial for the breast cancer but caused sarcoma that was caught very early.
 
I am now 32 and I get scans every 3-6 months and ultrasounds. I am also on Herceptin for the rest of my life. I am very comfortable with my doctors and always make sure they understand my genetic disorder. The most important thing to remember when you have Li-Fraumeni Syndrome is that you are not like every other cancer patient but unique in your own way. You know your body so you need to be your own advocate or your child’s advocate when something isn’t right. Live every day like it’s your first. 


I would like to sincerely thank Melissa, Loraine, and Lainie for sharing their heartfelt experiences with me. It was very lonely when Lily was diagnosed and information was tough to come by. Hearing other stories of success and survival give me hope. Thank You, Jen Mallory


References

https://www.stjude.org/disease/adrenocortical-tumors.html