Landscape of Familial Isolated and Young-Onset Pituitary Adenomas: Prospective Diagnosis in AIP Mutation Carriers

Abstract

Context: Familial isolated pituitary adenoma (FIPA) due to aryl hydrocarbon receptor interacting protein (AIP) gene mutations is an autosomal dominant disease with incomplete penetrance. Clinical screening of apparently unaffected AIP mutation (AIPmut) carriers could identify previously unrecognized disease.

Objective: To determine the AIP mutational status of FIPA and young pituitary adenoma patients, analyzing their clinical characteristics, and to perform clinical screening of apparently unaffected AIPmut carrier family members.

Design: This was an observational, longitudinal study conducted over 7 years.

Setting: International collaborative study conducted at referral centers for pituitary diseases.

Participants: FIPA families (n 216) and sporadic young-onset (30 y) pituitary adenoma patients (n 404) participated in the study.

Interventions: We performed genetic screening of patients for AIPmuts, clinical assessment of their family members, and genetic screening for somatic GNAS1 mutations and the germline FGFR4 p.G388R variant.

Main outcome measure(s): We assessed clinical disease in mutation carriers, comparison of characteristics of AIPmut positive and negative patients, results of GNAS1, and FGFR4 analysis.

Results: Thirty-seven FIPA families and 34 sporadic patients had AIPmuts. Patients with truncating AIPmuts had a younger age at disease onset and diagnosis, compared with patients with nontruncating AIPmuts. Somatic GNAS1 mutations were absent in tumors from AIPmut-positive patients, and the studied FGFR4 variant did not modify the disease behavior or penetrance in AIPmut-positive individuals. A total of 164 AIPmut-positive unaffected family members were identified; pituitary disease was detected in 18 of those who underwent clinical screening.

Conclusions: A quarter of the AIPmut carriers screened were diagnosed with pituitary disease, justifying this screening and suggesting a variable clinical course for AIPmut-positive pituitary adenomas.

Trial registration: ClinicalTrials.gov NCT00461188.

Figure 1.

Patients with truncating vs nontruncating AIPmuts. Patients with truncating AIPmuts present with a more aggressive phenotype, characterized by an earlier age at onset (A) (P = .005) and (B) at diagnosis (P = .003). C, This earlier disease onset results in a higher frequency of pediatric cases (n [total] = 131); in fact, most of the patients with truncating mutations present in childhood and adolescence. **, P < .01.

Figure 2.

Penetrance in screened AIPmut-positive carriers (n [total] = 160). The probability of detecting new cases of pituitary adenomas within apparently unaffected AIPmut carriers depends on the clinical assessment and the type of complementary biochemical/imaging studies included in the screening protocol (see text).