Cancer Genetics 256–257 (2021) 26–30

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Cancer Genetics
journal homepage: www.elsevier.com/locate/cancergen

Case Report

Somatic NF1 mutations in pituitary adenomas: Report of two cases

Christopher S. Hong a, Adam J. Kundishora a, Aladine A. Elsamadicy a, Andrew B. Koo a,
Declan McGuone b, Silvio E. Inzucchi c, Sacit Bulent Omay a,∗, E. Zeynep Erson-Omay a,∗
a
Department of Neurosurgery, Yale School of Medicine, 20 York Street, LCI8, New Haven, CT 06511, United States
b
Department of Pathology, Yale School of Medicine, New Haven, CT 06511, United States
c
Section of Endocrinology, Department of Medicine, Yale School of Medicine, New Haven, CT 06511, United States

a r t i c l e i n f o

Article history:
Received 4 May 2020
Revised 26 August 2020
Accepted 26 March 2021

Keywords:
NF1
Neurofibromatosis
Pituitary
Adenoma
Cancer ontology keywords: pituitary gland
adenoma
NF1 gene

Introduction
To date, the genetic landscape of pituitary adenomas is rela-
tively not as diverse as other brain tumors, but a handful of key
mutations have been identified that correlate with tumorigene-
sis and pathological hormonal secretion [1,2]. While mutations in
the neurofibromatosis genes have been well-characterized in tu-
mor formation, particularly for patients with germ-line mutations,
their existence in pituitary adenomas has been poorly character-
ized. In this report, we describe two cases of pituitary adenomas
with rare, somatic NF1 variants.
Case presentations
Patient 1
A 59 year-old male was incidentally diagnosed with a large
sellar mass, during initial evaluation prior to undergoing surgical
repair of an aneurysm of the proximal ascending thoracic aorta.
Otherwise, there was no significant past medical or family his-
tory. Magnetic resonance imaging (MRI) revealed a homogenously
enhancing bilobed sellar mass with suprasellar extension causing
∗
Corresponding authors.
E-mail addresses: sacit.omay@yale.edu (S.B. Omay), zeynep.erson@yale.edu (E.Z.
Erson-Omay).
mass effect on the optic chiasm (Fig. 1A,B). Hormonal evaluation
demonstrated elevated thyroid-stimulating hormone (TSH), free T4,
and T3, consistent with a TSH-secreting pituitary adenoma, for
which he was prescribed octreotide injections to gain hormonal
control. Neuro-ophthalmologic evaluation was unremarkable. Af-
ter sufficient recovery from successful surgical repair of his aor-
tic aneurysm, he underwent endoscopic endonasal resection of his
pituitary macroadenoma. Histopathologic analysis confirmed a pi-
tuitary adenoma with diffuse nuclear positivity for transcription
factor PIT-1 and multiple cells staining for TSH (Fig. 1C–F). Scat-
tered SF-1 positive cells, and occasional prolactin and hGH pos-
itive cells were also present. The Ki-67 index was less than 3%.
Post-operatively, the patient recovered uneventfully and thyroid
function testing was improved, but the patient still required oc-
treotide treatment and low-dose prednisone for central adrenal in-
sufficiency at most recent follow-up.
Patient 2
A 46 year-old male with no significant past medical history ini-
tially presented to an ophthalmologist with concerns for 6 months
of progressive peripheral vision loss. Further work-up with brain
MRI revealed a large homogenously enhancing giant sellar mass
compressing the optic chiasm and extension into the third ven-
tricle (Fig. 2A,B). He was subsequently referred to our institu-
tion for further management. Formal neuro-ophthalmologic eval-

https://doi.org/10.1016/j.cancergen.2021.03.004
2210-7762/© 2021 Elsevier Inc. All rights reserved.
C.S. Hong, A.J. Kundishora, A.A. Elsamadicy et al.
Fig. 1. Imaging and histopathology of patient 1. (A) Coronal and (B) sagittal T1-weighted MRI post-contrast images demonstrate a bilobed suprasellar mass with extension
into the right cavernous sinus and displacement of the optic chiasm. (C) Hematoxylin & eosin (H&E) stained section of the pituitary adenoma showing (D) effacement of
reticulin with (E) prominent stromal fibrosis on a trichrome stain. (F) The tumor exhibits diffuse neuronal positivity for transcription factor PIT-1 with scattered TSH-positive
cells (arrowheads, inset). All images mag 200x.
uation confirmed bitemporal hemianopsia with decreased right-
sided visual acuity. Biochemical testing of neuroendocrine function
was normal. Given the considerable size of the tumor and visual
deficits, he underwent endoscopic endonasal resection of his le-
sion. Histopathologic analysis revealed a pituitary adenoma with
diffuse nuclear positivity for transcription factor SF1 (Fig. 2C,D).
Pituitary hormone expression was not detected. The Ki-67 index
was less than 3%. Post-operatively, the patient experienced subjec-
tive improvement of his visual deficits. At last follow-up, neuro-
opthalmologic evaluation demonstrated significant improvement of
right-sided visual acuity and visual field deficits. At last endocrine
follow-up, he remained on desmopressin for diabetes insipidus and
low-dose prednisone for central adrenal insufficiency.
Genetic analysis
Whole-exome sequencing was performed on the resected tu-
mors and matching blood samples from both index patients. Out
of our institutional database of WES data from 56 resected pitu-
itary adenomas, these were the only two cases, exhibiting NF1 al-
terations. For patient 1, a somatic missense single nucleotide vari-
ant (SNV) was detected in NF1 (p.M102R), which was identified to
be deleterious by MutationTaster [3]. There was an increased copy
number variation (CNV) rate, reflected in alterations of chromo-
somes 2, 5, 7, 9, 14, 15, 18, 19, 20, and 21. For patient 2, a so-
matic missense SNV was detected in NF1 (p.D1067Y), which was
identified to be deleterious by SIFT [4], Polyphen2 [5], and Muta-
27
Cancer Genetics 256–257 (2021) 26–30
tionTaster [3]. This case had no significant large scale somatic CNV
events (Table 1). Both of the identified NF1 SNVs were not identi-
fied in public databases such as gnomAD Genome, gnomAD Exome,
ExAC, 10 0 0Genomes and NHLBI. As such, they were categorized
as tier 3 (variants of unknown clinical significance), in accordance
with stated guidelines for interpretation and reporting of sequence
variants in cancer, set forth by a joint consensus recommendation
[6]. Based on interpretation guidelines set forth by the American
College of Medical Genetics and Genomics (ACMG), the NF1 vari-
ant for patient 1 (M102R) was classified as “uncertain significance,”
and the NF1 variant for patient 2 (D1067Y) was classified as “likely
pathogenic” [7].
WES and CNV analysis of the index patients revealed somatic
heterozygous loss of NF1, in contrast to the typical two-hit phe-
nomenon seen in tumors, occurring in syndromic patients with
germ-line NF1 mutations. To further investigate the concept of het-
erozygous loss of NF1 in other brain tumors, we queried 885 pa-
tients with SNV/INDEL data and CNV data from four different pri-
mary brain tumor databases (Brain Lower Grade Glioma – TCGA,
PanCancer Atlas, Glioblastoma Multiforme – TCGA, PanCancer At-
las) stored in cBioPortal [8]. In this dataset, 14% (n = 124) of
the cases had NF1 alterations, including 8% with CNVs (homozy-
gous and heteorozygous deletions) and 9% with SNV/INDELs. 20.2%
(25/124) of cases had a heterozygous mutation, accompanied by
copy number loss, while 8.1% (10/124) of cases had a homozygous
deletion. Notably, 41.1% (51/124) of cases had only a heterozygous
alteration, defined as missense, in-frame, or truncating.
 C.S. Hong, A.J. Kundishora, A.A. Elsamadicy et al.
Table 1
Summary of somatic NF1 variants from the index patients.

DNA Somatic DNA Protein Level

Genome Chromo- Position RefSeq RefSeq Classifi- Sub & Sub & Variant Variant Cancer Biomarker Therapeutic of
Version Gene some (HGVS) Transcript Protein cation Position Position Type Consequence PMIDs Type Class Context Effect Evidence

GRCh37 NF1 chr17 g.chr17: NF1:NM_ NP_000258 Somatic c.T305G p.M102R SNV Missense PMID: Neurofibromatosis, Predictive None None Tier 3
29490220 000267: 11,356,864; type 1, 162,200
T>G exon4: PMID:16,374, (3); Leukemia,
c.T305G: 483 juvenile
p.M102R myelomonocytic,
607,785 (3);
Neurofibromatosis,
familial spinal,
162,210 (3);
Neurofibromatosis-
Noonan syndrome,
28

601,321 (3); Watson

syndrome, 193,520
(3) [MIM:613,113]
GRCh37 NF1 chr17 g.chr17: NF1:NM_ NP_000258 Somatic c.G3199T p.D1067Y SNV Missense PMID:11,356, Neurofibromatosis, Predictive None None Tier 3
29559092 000267: 864; PMID:16, type 1, 162,200 (3);
G>T exon25: 374,483 Leukemia, juvenile
c.G3199T: myelomonocytic,
p.D1067Y 607,785 (3);
Neurofibromatosis,
familial spinal,
162,210 (3);
Neurofibromatosis-
Noonan syndrome,
601,321 (3); Watson
syndrome, 193,520
(3) [MIM:613,113]

Cancer Genetics 256–257 (2021) 26–30

C.S. Hong, A.J. Kundishora, A.A. Elsamadicy et al.
Fig. 2. Imaging and histopathology of patient 2. (A) Coronal and (B) sagittal T1-weighted MRI post-contrast images show a large suprasellar mass compressing the optic
chiasm with mass effect extending to the third ventricle. (C) Hematoxylin and eosin (H&E) stained section of the pituitary adenoma showing (D) effacement of reticulin. All
images mag 200x.
Discussion
Comprehensive genomic analyses of sporadic pituitary adeno-
mas have continued to demonstrate relatively few recurrent so-
matic mutations. Key mutations that have been identified corre-
late with certain subsets of hormonally active tumors, such as mu-
tations in GNAS in growth-hormone secreting tumors [2], as well
as USP8 mutations in ACTH-secreting tumors [1]. While significant
chromosomal alterations may exist within a subset of pituitary
adenomas [9], no large-scale associations have been able to asso-
ciate chromosomal instability with increased clinical aggression.
Besides the well-characterized role of germline NF1 mutations
in hereditary cancer syndromes, sporadic mutations of NF1 also
occur in a significant subset of human cancers, including those
of the breast, gastrointestinal tract, lung, ovary, skin, myeloid, and
glioblastoma. Only a few cases of NF1-mutated pituitary adeno-
mas have been reported, two in patients with an existing clin-
ical diagnosis of NF1 but without accompanying genomic analy-
ses to demonstrate whether loss of the second copy of NF1 oc-
curred [10,11]. More recently, a patient with a known germline
nonsense NF1 mutation was described who developed acromegaly
secondary to a GH-secreting pituitary adenoma [12]. The tumor did
not demonstrate loss of heterozygosity of NF1 but did reveal a so-
matic heterozygous mutation in the GNAS gene, which is a known
driver of GH-secreting pituitary adenomas [2]. As pituitary adeno-
mas and NF1 are relatively common pathologies, the finding of NF1
29
Cancer Genetics 256–257 (2021) 26–30
mutations in pituitary adenomas may be coincidental, as demon-
strated by this case. To our knowledge, the two index patients de-
scribed in this study are the first cases of somatic NF1 variants re-
ported in pituitary adenomas, notably in patients without clinical
or genetic evidence of underlying syndromic NF1 pathology.
It remains unclear whether the NF1 variants detected in the in-
dex patients represent drivers of tumor formation. Deleterious au-
tosomal dominant germline mutations in NF1, considered a tumor
suppressor, contribute to tumorigenesis in the syndromic condi-
tion via loss of negative regulation of the oncogenic Ras/MAPK/ERK
pathway, leading to dysregulated mitotic activity and cellular pro-
liferation. Within pituitary tumors, a comprehensive study of the
neurofibromatosis genes in pituitary adenomas failed to reveal ge-
netic alterations in NF1 [13]. Notably, the NF1 variants detected
in the index patients were heterozygous, in contrast to the no-
tion that a second-hit has been described in most NF1 mutated-
driven tumors. However, it is not uncommon for tumor suppressor
genes to be involved in certain cancers with only a somatic het-
erozygous mutation. Our query of four large genomic databases of
primary brain tumors revealed that 14% of cases exhibited NF1 al-
terations, among which 41% were heterozygous without loss of the
other copy. Likewise, similar large database reviews have demon-
strated NF1 mutational frequencies across various human cancers
[14]. Specifically, heterozygous loss of NF1 has been reported in
sporadic pheochromocytomas [15] and acute myeloid leukemia
[16]. Additionally, there are preclinical data to suggest enhanced
C.S. Hong, A.J. Kundishora, A.A. Elsamadicy et al.
Ras/MAPK/ERK pathway activity in pituitary tumors [17], includ-
ing previous in vitro studies that have demonstrated that NF1 het-
erozygosity may be sufficient for abnormal angiogenesis, cellular
growth, and invasion [18–20]. Further reports characterizing the
genetic landscape of sporadic pituitary tumors, as well as those in
syndromic patients, are needed to determine whether mutations
in the neurofibromatosis genes play a role in a subset of pituitary
adenoma pathogenesis.
Declaration of Competing Interest
The authors declare no conflict of interest.
Acknowledgments
None.
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