背景:结节性硬化症(TSC)是一种罕见的,由TSC1或TSC2基因突变引起的常染色体显性遗传病。这些基因突变可以诱导任何器官系统中良性肿瘤的发展,对发病率和死亡率具有重要的临床意义。在极少数情况下,TSC患者可能患有恶性肿瘤,包括肾细胞癌(RCC)和胰腺神经内分泌肿瘤(PNET)。尽管TSC患者中RCC的发病率较低,但仍被认为是遗传性肾癌综合征。TSC通常在产前和儿科患者中诊断,并且经常与神经认知障碍和癫痫发作有关。在生命的早期经常经历。然而,TSC突变的外显率和表达率是高度可变的。在这里,我们提供病例报告,与相关文学,为了强调存在渗透特征较小的未确诊成年患者,其临床表现可能包含非经典体征和症状,有致病性TSC突变的人。
方法:一名31岁女性,既往有平滑肌瘤病史,子宫肌瘤切除术后因出血性附件囊肿到急诊科就诊。影像学偶然发现可疑肾癌的肾脏肿块。出于对遗传性平滑肌瘤和肾细胞癌(HLRCC)综合征的关注,手术切除肿块,确认为RCC.与医学遗传学的讨论确定了肾癌和肾切除术的家族史以及脚趾上的指甲纤维瘤的患者史。遗传性肾癌的基因检测显示TSC1基因中存在5'UTR缺失,导致TSC的诊断。在诊断之后,皮肤科发现良性皮肤表现与TSC一致。偶然发现RCC大约六个月后,在胸部CT成像中偶然发现了胰腺体/尾部的PNET,将其移除并确定为分化良好的PNET。稍后,脑部核磁共振显示两个小的皮质块茎,每个额叶都有一个,无症状;患者的病史和家族史不包含癫痫发作或学习延迟。患者目前无复发或转移性疾病的证据,没有发现其他恶性肿瘤。
结论:据我们所知,这是没有神经认知障碍伴RCC和PNET病史的TSC患者的文献中的第一份报告,在TSC中都是独立罕见的。患者有很强的肾病家族史,包括碾压混凝土,还有其他几种TSC临床表现,包括皮肤和大脑的发现。RCC的偶然发现和手术切除促进了TSC的遗传评估和诊断。导致该患者的诊断相对较晚。报告TSC的广泛疾病,包括更恶性的表型,比如在我们的病人身上看到的,可以帮助医疗保健提供者更好地识别需要遗传评估和额外医疗护理的患者。
BACKGROUND: Tuberous sclerosis complex (TSC) is a rare, autosomal dominant genetic disease that arises from TSC1 or TSC2 genetic mutations. These genetic mutations can induce the development of benign tumors in any organ system with significant clinical implications in morbidity and mortality. In rare instances, patients with TSC can have malignant tumors, including renal cell carcinoma (RCC) and pancreatic neuroendocrine tumor (PNET). It is considered a hereditary renal cancer syndrome despite the low incidence of RCC in TSC patients. TSC is typically diagnosed in prenatal and pediatric patients and frequently associated with neurocognitive disorders and seizures, which are often experienced early in life. However, penetrance and expressivity of TSC mutations are highly variable. Herein, we present a
case report, with associated literature, to highlight that there exist undiagnosed adult patients with less penetrant features, whose clinical presentation may contain non-classical signs and symptoms, who have pathogenic TSC mutations.
METHODS: A 31-year-old female with past medical history of leiomyomas status post myomectomy presented to the emergency department for a hemorrhagic adnexal cyst. Imaging incidentally identified a renal mass suspicious for RCC. Out of concern for hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome, the mass was surgically removed and confirmed as RCC. Discussion with medical genetics ascertained a family history of kidney cancer and nephrectomy procedures and a patient history of ungual fibromas on the toes. Genetic testing for hereditary kidney cancer revealed a 5\'UTR deletion in the TSC1 gene, leading to a diagnosis of TSC. Following the diagnosis, dermatology found benign skin findings consistent with TSC. About six months after the incidental finding of RCC, a PNET in the pancreatic body/tail was incidentally found on chest CT imaging, which was removed and determined to be a well-differentiated PNET. Later, a brain MRI revealed two small cortical tubers, one in each frontal lobe, that were asymptomatic; the patient\'s history and family history did not contain seizures or learning delays. The patient presently shows no evidence of recurrence or metastatic disease, and no additional malignant tumors have been identified.
CONCLUSIONS: To our knowledge, this is the first report in the literature of a TSC patient without a history of neurocognitive disorders with RCC and PNET, both independently rare occurrences in TSC. The patient had a strong family history of renal disease, including RCC, and had several other clinical manifestations of TSC, including skin and brain findings. The incidental finding and surgical removal of RCC prompted the genetic evaluation and diagnosis of TSC, leading to a comparably late diagnosis for this patient. Reporting the broad spectrum of disease for TSC, including more malignant phenotypes such as the one seen in our patient, can help healthcare providers better identify patients who need genetic evaluation and additional medical care.