Neuraxial dysraphism in EPAS1- associated syndrome due to improper mesenchymal transition

Jared S Rosenblum; Anthony J Cappadona; Davis P Argersinger; Ying Pang; Herui Wang; Matthew A Nazari; Jeeva P Munasinghe; Danielle R Donahue; Abhishek Jha; James G Smirniotopoulos; Markku M Miettinen; Russell H Knutsen; Beth A Kozel; Zhengping Zhuang; Karel Pacak; John D Heiss

doi:10.1212/NXG.0000000000000414

Neuraxial dysraphism in EPAS1- associated syndrome due to improper mesenchymal transition

Neurol Genet. 2020 Apr 1;6(3):e414. doi: 10.1212/NXG.0000000000000414. eCollection 2020 Jun.

Authors

Jared S Rosenblum¹, Anthony J Cappadona¹, Davis P Argersinger¹, Ying Pang¹, Herui Wang¹, Matthew A Nazari¹, Jeeva P Munasinghe¹, Danielle R Donahue¹, Abhishek Jha¹, James G Smirniotopoulos¹, Markku M Miettinen¹, Russell H Knutsen¹, Beth A Kozel¹, Zhengping Zhuang¹, Karel Pacak¹, John D Heiss¹

Affiliation

¹ National Institutes of Health (J.S.R., A.J.C., H.W., Z.Z.), National Cancer Institute Neuro-Oncology Branch; National Institutes of Health (D.P.A., J.D.H.), National Institute of Neurological Disorders and Stroke, Surgical Neurology Branch; National Institutes of Health (Y.P., A.J., K.P.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Section on Medical Neuroendocrinology; Georgetown Hospital (M.A.N.), Internal Medicine and Pediatrics, Washington DC; National Institutes of Health (J.P.M., D.R.D.), National Institute of Neurological Disorders and Stroke, Mouse Imaging Facility, Bethesda, MD; George Washington University (J.G.S.), Radiology, Washington DC; National Library of Medicine (J.G.S.), MedPix®; National Institutes of Health (M.M.M.), Center for Cancer Research, National Cancer Institute, Laboratory of Pathology; and National Institutes of Health (R.H.K., B.A.K.), National Heart Lung and Blood Institute, Translational Vascular Medicine Branch, Bethesda, MD.

Abstract

Objective: To investigate the effect of somatic, postzygotic, gain-of-function mutation of Endothelial Per-Arnt-Sim (PAS) domain protein 1 (EPAS1) encoding hypoxia-inducible factor-2α (HIF-2α) on posterior fossa development and spinal dysraphism in EPAS1 gain-of-function syndrome, which consists of multiple paragangliomas, somatostatinoma, and polycythemia.

Methods: Patients referred to our institution for evaluation of new, recurrent, and/or metastatic paragangliomas/pheochromocytoma were confirmed for EPAS1 gain-of-function syndrome by identification of the EPAS1 gain-of-function mutation in resected tumors and/or circulating leukocytes. The posterior fossa, its contents, and the spine were evaluated retrospectively on available MRI and CT images of the head and neck performed for tumor staging and restaging. The transgenic mouse model underwent Microfil vascular perfusion and subsequent intact ex vivo 14T MRI and micro-CT as well as gross dissection, histology, and immunohistochemistry to assess the role of EPAS1 in identified malformations.

Results: All 8 patients with EPAS1 gain-of-function syndrome demonstrated incidental posterior fossa malformations-one Dandy-Walker variant and 7 Chiari malformations without syringomyelia. These findings were not associated with a small posterior fossa; rather, the posterior fossa volume exceeded that of its neural contents. Seven of 8 patients demonstrated spinal dysraphism; 4 of 8 demonstrated abnormal vertebral segmentation. The mouse model similarly demonstrated features of neuraxial dysraphism, including cervical myelomeningocele and spinal dysraphism, and cerebellar tonsil displacement through the foramen magnum. Histology and immunohistochemistry demonstrated incomplete mesenchymal transition in the mutant but not the control mouse.

Conclusions: This study characterized posterior fossa and spinal malformations seen in EPAS1 gain-of-function syndrome and suggests that gain-of-function mutation in HIF-2α results in improper mesenchymal transition.