Metabolomics in the Diagnosis of Pheochromocytoma and Paraganglioma

Abstract

Metabolomics refers to the detection and measurement of small molecules (metabolites) within biological systems, and is therefore a powerful tool for identifying dysfunctional cellular physiologies. For pheochromocytomas and paragangliomas (PPGLs), metabolomics has the potential to become a routine addition to histology and genomics for precise diagnostic evaluation. Initial metabolomic studies of ex vivo tumors confirmed, as expected, succinate accumulation in PPGLs associated with pathogenic variants in genes encoding succinate dehydrogenase subunits or their assembly factors (SDHx). Metabolomics has now shown utility in clarifying SDHx variants of uncertain significance, as well as the accurate diagnosis of PPGLs associated with fumarate hydratase (FH), isocitrate dehydrogenase (IDH), malate dehydrogenase (MDH2) and aspartate transaminase (GOT2). The emergence of metabolomics resembles the advent of genetic testing in this field, which began with single-gene discoveries in research laboratories but is now done by standardized massively parallel sequencing (targeted panel/exome/genome testing) in pathology laboratories governed by strict credentialing and governance requirements. In this setting, metabolomics is poised for rapid translation as it can utilize existing infrastructure, namely liquid chromatography-tandem mass spectrometry (LC-MS/MS), for the measurement of catecholamine metabolites. Metabolomics has also proven tractable to in vivo diagnosis of SDH-deficient PPGLs using magnetic resonance spectroscopy (MRS). The future of metabolomics – embedded as a diagnostic tool – will require adoption by pathologists to shepherd development of standardized assays and sample preparation, reference ranges, gold standards, and credentialing.

Key words

pheochromocytoma - paraganglioma - krebs cycle - succinate - fumarate - metabolomics

• References

• 1 Ward PD, Thompson CB. Metabolic reprograming: a cancer hallmark even Warburg did not anticipate. Cancer Cell 2012; 21: 297-308
• 2 Nicholson JK, Lindon JC, Holmes E. ‘Metabonomics’: understanding the metabolic responses of living systems to pathophysiological stimuli via multivariate statistical analysis of biological NMR spectroscopic data. Xenobiotica 1999; 29: 1181-1189
• 3 Wishart DS. Emerging applications of metabolomics in drug discovery and precision medicine. Nat Rev Drug Discov 2016; 15: 473-484
• 4 Lehotay DC, Hall P, Lepage J. et al. LC-MS/MS progress in newborn screening. Clin Biochem 2011; 44: 21-31
• 5 Baysal BE, Ferrell RE, Willett-Brozick JE. et al. Mutations in SDHD, a mitochondrial complex II gene, in hereditary paraganglioma. Science 2000; 287: 848-851
• 6 Niemann S, Muller U. Mutations in SDHC cause autosomal dominant paraganglioma, type 3. Nat Genet 2000; 26: 268-270
• 7 Astuti D, Latif F, Dallol A. et al. Gene mutations in the succinate dehydrogenase subunit SDHB cause susceptibility to familial pheochromocytoma and to familial paraganglioma. Am J Hum Genet 2001; 69: 49-54
• 8 Burnichon N, Brière JJ, Libé R. et al. SDHA is a tumor suppressor gene causing paraganglioma. Hum Mol Genet 2010; 19: 3011-3020
• 9 Hao HX, Khalimonchuk O, Schraders M. et al. SDH5, a gene required for flavination of succinate dehydrogenase, is mutated in paraganglioma. Science 2009; 325: 1139-1142
• 10 Tomlinson IP, Alam NA, Rowan AJ. et al. Germline mutations in FH predispose to dominantly inherited uterine fibroids, skin leiomyomata and papillary renal cell cancer. Nat Genet 2002; 30: 406-410
• 11 Letouzé E, Martinelli C, Loriot C. et al. SDH mutations establish a hypermethylator phenotype in paragangliomas. Cancer Cell 2013; 23: 739-752
• 12 Castro-Vega LJ, Buffet A, De Cubas AA. et al. Germline mutations in FH confer predisposition to malignant pheochromocytomas and paragangliomas. Hum Mol Genet 2014; 23: 2440-2446
• 13 Cascón A, Comino-Méndez I, Currás-Freixes M. et al. Whole-exome sequencing identifies MDH2 as a new familial paraganglioma gene. J Natl Cancer Inst 2015; 107: djv053
• 14 Calsina B, Currás-Freixes M, Buffet A. et al. Role of MDH2 pathogenic variant in pheochromocytoma and paraganglioma patients. Genet Med. 2018; 20: 1652-1662
• 15 Garg M, Nagata Y, Kanojia D. et al. Profiling of somatic mutations in acute myeloid leukemia with FLT3-ITD at diagnosis and relapse. Blood 2015; 126: 2491-2501
• 16 Parsons DW, Jones S, Zhang X. et al. An integrated genomic analysis of human glioblastoma multiforme. Science 2008; 321: 1807-1812
• 17 Mardis ER, Ding L, Dooling DJ. et al. Recurring mutations found by sequencing an acute myeloid leukemia genome. N Engl J Med 2009; 361: 1058-1066
• 18 Amary MF, Bacsi K, Maggiani F. et al. IDH1 and IDH2 mutations are frequent events in central chondrosarcoma and central and periosteal chondromas but not in other mesenchymal tumours. J Pathol 2011; 224: 334-343
• 19 Borger DR, Tanabe KK, Fan KC. et al. Frequent mutation of isocitrate dehydrogenase (IDH)1 and IDH2 in cholangiocarcinoma identified through broad-based tumor genotyping. Oncologist 2012; 17: 72-79
• 20 Dang L, White DW, Gross S. et al. Cancer-associated IDH1 mutations produce 2-oxoglutarate. Nature 2009; 462: 739-744
• 21 Gaal J, Burnichon N, Korpershoek E. et al. Isocitrate dehydrogenase mutations are rare in pheochromocytomas and paragangliomas. J Clin Endocrinol Metab 2010; 95: 1274-1278
• 22 Remacha L, Comino-Méndez I, Richter S. et al. Targeted exome sequencing of Krebs cycle genes reveals candidate cancer-predisposing mutations in pheochromocytomas and paragangliomas. Clin Cancer Res 2017; 23: 6315-6324
• 23 Buffet A, Morin A, Castro-Vega LJ. et al. Germline mutations in the mitochondrial 2-oxoglutarate/malate carrier SLC25A11 gene confer a predisposition to metastatic paragangliomas. Cancer Res 2018; 78: 1914-1922
• 24 Yang M, Soga T, Pollard PJ. Oncometabolites: linking altered metabolism with cancer. J Clin Invest 2013; 123: 3652-3658
• 25 Turcan S, Rohle D, Goenka A. et al. IDH1 mutation is sufficient to establish the glioma hypermethylator phenotype. Nature 2012; 483: 479-483
• 26 Figueroa ME, Abdel-Wahab O, Lu C. et al. Leukemic IDH1 and IDH2 mutations result in a hypermethylation phenotype, disrupt TET2 function and impair hematopoietic differentiation. Cancer Cell 2010; 18: 553-567
• 27 Xiao M, Yang H, Xu W. et al. Inhibition of α-KG-dependent histone and DNA demethylases by fumarate and succinate that are accumulated in mutations of FH and SDH tumor suppressors. Genes Dev 2012; 26: 1326-1338
• 28 Morin A, Letouzé E, Gimenez-Roqueplo AP. et al. Oncometabolites-driven tumorigenesis: from genetics to targeted therapy. Int J Cancer 2014; 135: 2237-2248
• 29 Chou AP, Chowdhury R, Li S. et al. Identification of retinol binding protein 1 promoter hypermethylation in isocitrate dehydrogenase 1 and 2 mutant gliomas. J Natl Cancer Inst 2012; 104: 1458-1469
• 30 Yang M, Ternette N, Su H. et al. The succinated proteome of FH-mutant tumours. Metabolites. 2014; 4: 640-654
• 31 Smestad J, Erber L, Chen Y. et al. Chromatin succinylation correlates with active gene expression and is perturbed by defective TCA cycle metabolism. iScience 2018; 2: 63-75
• 32 Pollard PJ, Brière JJ, Alam NA. et al. Accumulation of Krebs cycle intermediates and over-expression of HIF1alpha in tumours which result from germline FH and SDH mutations. Hum Mol Genet 2005; 14: 2231-2239
• 33 Imperiale A, Moussallieh FM, Sebag F. et al. A new specific succinate-glutamate metabolomics hallmark in SDHx-related paragangliomas. PLoS One 2013; 8: e80539
• 34 Rao JU, Engelke UF, Rodenburg RJ. et al. Genotype-specific abnormalities in mitochondrial function associate with distinct profiles of energy metabolism and catecholamine content in pheochromocytoma and paraganglioma. Clin Cancer Res 2013; 19: 3787-3795
• 35 Imperial A, Moussallieh FM, Roche P. et al. Metabolome profiling by HRMAS NMR spectroscopy of pheochromocytomas and paragangliomas detects SDH deficiency: clinical and pathophysiological implications. Neoplasia 2015; 17: 55-65
• 36 Vicha A, Taїeb D, Pacak K. Current views on cell metabolism in SDHx-related pheochromocytoma and paraganglioma. Endocr Relat Cancer 2014; 21: R261-R277
• 37 Shushan B. A review of clinical diagnostic applications of liquid chromatography-tandem mass spectrometry. Mass Spectrom Rev 2010; 29: 930-944
• 38 Vogeser M, Parhofer KG. Liquid chromatography tandem-mass spectrometry (LCMS/MS)—Technique and applications in endocrinology. Exp Clin Endocrinol Diabetes 2007; 115: 559-570
• 39 Lenders JW, Duh QY, Eisenhofer G. et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2014; 99: 1915-1942
• 40 Lendvai N, Pawlosky R, Bullova P. et al. Succinate-to-fumarate ratio as a new metabolic marker to detect the presence of SDHB/D-related paraganglioma: initial experimental and ex vivo findings. Endocrinology 2014; 155: 27-32
• 41 Richter S, Peitzsch M, Rapizzi E. et al. Krebs cycle metabolite profiling for identification and stratification of pheochromocytomas/paragangliomas due to succinate dehydrogenase deficiency. J Clin Endocrinol Metab 2014; 99: 3903-3911
• 42 Richter S, Klink B, Nacke B. et al. Epigenetic mutation of the succinate dehydrogenase c promoter in a patient with two paragangliomas. J Clin Endocrinol Metab 2016; 101: 359-363
• 43 Killian JK, Miettinen M, Walker RL. et al. Recurrent epimutation of SDHC in gastrointestinal stromal tumors. Sci Transl Med 2014; 6: 268ra177
• 44 Kim E, Wright MJ, Sioson L. et al. Utility of the succinate:fumarate ratio for assessing SDH dysfunction in different tumor types. Mol Genet Metab Rep 2016; 10: 45-49
• 45 Richter S, Gieldon L, Pang Y. et al. Metabolome-guided genomics to identify pathogenic variants in isocitrate dehydrogenase, fumarate hydratase, and succinate dehydrogenase genes in pheochromocytoma and paraganglioma. Genet Med 2018; 21: 705-717
• 46 Choi C, Ganji SK, DeBerardinis RJ. et al. 2-hydroxyglutarate detection by magnetic resonance spectroscopy in IDH-mutated patients with gliomas. Nat Med 2012; 18: 624-629
• 47 Andronesi OC, Kim GS, Gerstner E. et al. Detection of 2-hydroxyglutarate in IDH-mutated glioma patients by in vivo spectral-editing and 2D correlation magnetic resonance spectroscopy. Sci Transl Med 2012; 4: 116ra4
• 48 Varoquaux A, le Fur Y, Imperiale A. et al. Magentic resonance spectroscopy of paragangliomas: new insights into in vivo metabolomics. Endocr Relat Cancer 2015; 22: M1-M8
• 49 Lussey-Lepoutre C, Bellucci A, Morin A. et al. In vivo detection of succinate by magnetic resonance spectroscopy as a hallmark or SDHx mutations in paragangliomas. Clin Cancer Res 2016; 22: 1120-1129
• 50 Bourgeron T, Chretien D, Poggi-Bach J. et al. Mutation of the fumarase gene in two siblings with progressive encephalopathy and fumarase deficiency. J Clin Invest 1994; 93: 2514-2518
• 51 Ait-El-Mkadem S, Dayem-Quere M, Gusic M. et al. Mutations in MDH2, encoding a Krebs cycle enzyme, cause early-onset severe encephalopathy. Am J Hum Genet 2017; 100: 151-159
• 52 Di Nardo CD, Propert KJ, Loren AW. et al. Serum 2-hydroxyglutarate levels predict isocitrate dehydrogenase mutations and clinical outcome in acute myeloid leukemia. Blood 2013; 121: 4917-4924
• 53 D’Alessandro A, Moore HB, Moore EE. et al. Plasma succinate is a predictor of mortality in critically injured patients. J Trauma Acute Care Surg 2017; 83: 491-495
• 54 Hobert JA, Mester JL, Moline J. et al. Elevated plasma succinate in PTEN, SDHB, and SDHD mutation-positive individuals. Genet Med 2012; 14: 616-619
• 55 van Nederveen FH, Gaal J, Favier J. et al. An immunohistochemical procedure to detect patients with paraganglioma and pheochromocytoma with germline SDHB, SDHC or SDHD gene mutations: a retrospective and prospective analysis. Lancet Oncol 2009; 10: 764-771
• 56 Papathomas TG, Oudijk L, Persu A. et al. SDHB/SDHA immunohistochemistry in pheochromocytomas and paragangliomas: a multicentre interobserver variation analysis using virtual microscopy: a multinational study of the European Network for the Study of Adrenal Tumors (ENS@T). Mod Pathol 2015; 28: 807-821
• 57 Korpershoek E, Favier J, Gaal J. et al. SDHA immunohistochemistry detects germline SDHA gene mutations in apparently sporadic paragangliomas and pheochromocytomas. J Clin Endocrinol Metab 2011; 96: E1472-E1476
• 58 NGS in PPGL (NGSnPPGL) Study Group . Toledo RA, Burnichon N. et al. Consensus statement on next-generation-sequencing-based diagnostic testing of hereditary phaeochromocytomas and paragangliomas. Nat Rev Endocrinol 2016; 13: 233-247
• 59 Andronesi OC, Arrillaga-Romany IC, Ly KI. et al. Pharmacodynamics of mutant-IDH1 inhibitors in glioma patients probed by in vivo 3D MRS imaging of 2-hydroxyglutarate. Nat Commun 2018; 9: 1474
• 60 Kennedy AD, Wittmann BM, Evans AM. et al. Metabolomics in the clinic: a review of the shared and unique features of untargeted metabolomics for clinical research and clinical testing. J Mass Spect 2018; 53: 1143-1154