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Last updated: 11/7/2023
Years published: 2007, 2012, 2015, 2018, 2023
NORD gratefully acknowledges Charis Eng, MD, PhD, Chair and Director, Genomic Medicine Institute, and Director, Center for Personalized Genetic Healthcare, Cleveland Clinic; Professor and Vice Chairwoman, Department of Genetics and Genome Sciences, Case Western Reserve University School of Medicine, and Lamis Yehia, PhD, Ambrose Monell Cancer Genomic Medicine Research Associate, Genomic Medicine Institute, Cleveland Clinic for assistance in the preparation of this report.
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The PTEN hamartoma tumor syndrome (PHTS) is a spectrum of disorders caused by changes (variants or mutations) of the PTEN tumor suppressor gene in egg or sperm cells (germline). These disorders are characterized by multiple hamartomas that can affect various areas of the body. Hamartoma is a general term for a benign tumor-like malformation composed of mature cells and tissue normally found in the affected area that have grown in a disorganized manner. Individuals with a variety of clinical diagnoses who ultimately have been found to carry a germline PTEN variant as the underlying cause are said to have PHTS.
Cowden syndrome (CS) is the first disorder known to be associated with germline PTEN variant. When the strictest diagnostic criteria are used, patients with a personal and family history of CS features have up to an 85% chance to have a PTEN variant. Patients with Bannayan-Riley-Ruvalcaba syndrome (BRRS) and with features reminiscent of, but not meeting, diagnostic criteria for Proteus syndrome (called Proteus-like syndrome) have also been found to have an underlying PHTS diagnosis. While these conditions were once thought to be separate, today patients with features of CS or BRRS and an underlying PTEN variant are unified as all having PHTS, with CS being a diagnosis traditionally given to adults and BRRS being first described in the pediatrics literature. This makes sense given that many of the characteristics first associated with CS tend to not appear until adulthood. PHTS is inherited in an autosomal dominant pattern, which means that each child of an affected person has a 50% chance to inherit the disease-causing variant. The symptoms vary greatly from patient to patient, even among individuals in the same family.
The primary findings in PHTS include increased risk for certain types of cancer, benign tumors and tumor-like malformations (hamartomas) and neurodevelopmental disorders. The symptoms of PHTS vary greatly from person to person and can develop at any age.
Cancer in PHTS
Previous data, which focused only on patients with a clinical diagnosis of Cowden syndrome without understanding whether an underlying PTEN variant was present, estimated lifetime breast cancer risk to be 25-50% and risk for non-medullary thyroid cancer to be 10%. Risks for uterine (endometrial) and kidney (renal cell) cancer were thought to be increased, but an exact risk level was undetermined.
Current data focusing on patients known to have PHTS provide the following lifetime risk estimates, with most diagnoses occurring after age 30:
| Cancer | Lifetime Risk with PHTS (%) | Average Age at presentation |
|---|---|---|
| Breast | 91 | 40s |
| Thyroid | 33 | 30s-40s* |
| Renal Cell | 30 | 50s |
| Endometrial | 48 | 40s-50s |
| Colon | 17 | 40s |
| Melanoma | 5 | 40s |
*Earliest age for thyroid cancer in PHTS is as early as 7 years old.
Benign tumors in PHTS
Benign skin or oral lesions are very common and tend to appear in early adulthood. The most common types of benign skin lesions seen in PHTS include:
·Lipomas – benign fatty tumors which can appear just under the skin or elsewhere (breast area, GI tract)
·Acral keratosis – rough patches of skin most often seen on the extremities (arms, hands, legs, feet)
·Papillomatous skin papules – wart-like lesions which can appear anywhere, with feet and hands commonly being affected
·Mucosal papillomas – Benign overgrowth of tissue affecting the tongue, gums, or inside the nose
·Trichilemmomas – Benign tumor of the hair follicle
·Fibromas – another kind of overgrowth involving the skin and other connective tissue; may also affect tissue covering organs, such as the ovaries
Gastrointestinal polyps are very common in adults with PHTS. Among patients who had undergone colonoscopy as part of their clinical care, >90% were found to have polyps with a mix of histological subtypes. The most common types of polyps found are hyperplastic or hamartomatous, which rarely develop into malignancy. However, adenomas, which may develop into a cancer, were also identified. Many polyps were very small and did not cause noticeable symptoms such as pain or rectal bleeding. Supported by this evidence, colorectal surveillance should be offered to people who carry a PTEN variant.
Benign breast, thyroid, and uterine lesions are also common in people with PHTS. Some females have severe breast fibrocystic disease or changes which lead to multiple breast biopsies and complications with imaging. Multinodular goiter and Hashimoto’s thyroiditis may develop in children and adults. Uterine fibroids may appear and cause bleeding or discomfort to the extent that a hysterectomy is indicated without an underlying cancer diagnosis.
Vascular tumors, including hemangiomas, arteriovenous malformations, and developmental venous anomalies, have also been observed in patients with PHTS. Treatment of some lesions has been complicated by the tendency for regrowth and scarring.
A small percentage of adults develop a rare tumor known as a cerebellar dysplastic gangliocytoma (Lhermitte-Duclos disease). Symptoms of Lhermitte-Duclos disease include increased intracranial pressure, impaired ability to coordinate voluntary movements (ataxia) and seizures. It is rare when a person with adult-onset Lhermitte-Duclos does not have an underlying PTEN variant, and observing this tumor type is an automatic indicator for PTEN genetic testing.
Neurodevelopmental concerns in PHTS
Macrocephaly (large head size) is found in 94% of measured patients with PHTS and can be a helpful screening tool to identify patients for PTEN genetic testing. In most patients, large head size is caused by overgrowth of brain tissue. The head shape may also be longer than average relative to width in some individuals (dolicocephaly).
Autism and other developmental disorders, such as intellectual disability and developmental delays, have been observed in patients with PHTS. In previous case series, up to 17% of children presenting with macrocephaly and an autism spectrum disorder alone were found to have an underlying PTEN variant.
PHTS is caused by a germline variant of PTEN, a tumor suppressor gene. PTEN stands for phosphatase and tensin homologue. A tumor suppressor is a gene that slows down cell division, repairs damage to the DNA of cells, and tells cells when to die, a normal process called apoptosis. Variants in a tumor suppressor gene often lead to uncontrolled cell growth manifesting as cancer. The PTEN gene regulates the production of an enzyme (the ‘phosphatase’ in PTEN’s name) which is believed to be important in stopping cell growth and starting apoptosis. Researchers believe that the PTEN gene plays a broad role in the development of human malignancies. More recent studies also revealed that PTEN plays an important role in brain and nervous system development and function. These studies help explain why some individuals with PHTS also have neurodevelopmental disorders, such as autism spectrum disorder.
PHTS is inherited in an autosomal dominant pattern. Dominant genetic disorders occur when only a single copy of a mutated gene is necessary to cause a particular disease. The mutated gene can be inherited from either parent or can be the result of a changed gene in the affected individual. The risk of passing the variant gene from an affected parent to a child is 50% for each pregnancy. The risk is the same for males and females.
Cowden syndrome was estimated to affect 1 in 200,000 individuals; this study was conducted just as PTEN was discovered. However, because the disorder is difficult to recognize, researchers believe it is under-diagnosed, making it difficult to determine its true frequency in the general population. Males and females are affected equally with PHTS. PHTS is not more commonly found in persons of a particular racial or ethnic group.
A diagnosis of PHTS may be suspected based upon a thorough clinical evaluation, a detailed patient history and the presence of characteristic findings. Recently, a variant risk calculator has been developed which can estimate the risk for adults to have a PTEN variant based on their personal history characteristics; this tool is available online at https://www.lerner.ccf.org/gmi/ccscore/. The diagnosis can only be confirmed when a variant of the PTEN gene is identified.
Treatment
Due to the effects on various organ systems in PHTS, it is important to involve a multidisciplinary team and offer genetic counseling to the patient and their family.
Individuals with germline PTEN variants should undergo cancer surveillance and screening following the National Comprehensive Cancer Network (NCCN) practice guidelines to enable healthcare providers to detect any tumors at the earliest, most treatable stages. For each cancer type, there are specific surveillance guidelines, including when to start screening. Screening does not start at the time of diagnosis for all cancers and depends on the patient’s age at diagnosis.
Individuals with PTEN variants should undergo cancer surveillance and screening as follows to enable healthcare providers to detect any tumors at the earliest, most treatable stages. Current suggested screening by age includes:
Children (under age 18)
• Yearly thyroid ultrasound starting at 7 years of age
• Yearly skin check with physical examination
• Consider neurodevelopmental evaluation
Adults
• Monthly breast self-examination starting at age 18 years
• Yearly thyroid ultrasound and dermatologic evaluation
• Females: breast screening (at minimum mammogram) yearly beginning at age 35; MRI may also be incorporated
• Females: consider endometrial cancer screening starting at age 35 years. Personalized management including endometrial biopsy every 1-2 years and transvaginal ultrasound as needed (postmenopausal)
• Colonoscopy beginning at age 35 (unless symptomatic or close relative with colon cancer before age 40 years); colonoscopy frequency every 5 years; more frequently if symptomatic or polyps are found
• Biannual (every other year) renal imaging (CT or MRI preferred) beginning at age 40
For patients with a family history of a particular cancer type, screening may be considered 5-10 years prior to the youngest diagnosis in the family. For example, a patient whose mother developed breast cancer at 30 may begin breast surveillance at age 25-30.
Additional treatment for PHTS is symptomatic and supportive. Various techniques may be used to treat the mucocutaneous symptoms of Cowden syndrome including topical agents, the use of extreme cold to destroy affected tissue (cryosurgery), the removal of tissue or growths through a process called curettage, in which a surgical tool shaped like a spoon (curette) is used to scrape away affected tissue or destroying affected tissue by exposing it to laser beams (laser ablation). However, surgical excision is sometimes complicated by keloid formation and recurrence (often rapid) of the lesions. It is advisable to involve a multidisciplinary team to assess the risk-to-benefit of removing such lesions.
Genetic counseling and psychosocial support are recommended for affected individuals and their families.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
A pilot clinical trial with the mTOR inhibitor Everolimus completed accrual of pediatric (over the age of 18 months old), adolescent and adult patients who have documentation of a clinical diagnosis of autism spectrum disorder and a verified PTEN variant (found in a CLIA/CAP-certified lab) from a medical or mental health professional (NCT02461446). The purpose of this pilot trial is to determine if Everolimus is safe in this population and to collect data regarding efficacy. A multi-centre trial of Sirolimus is being prepared to seek FDA approval if successful.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: [email protected]
Clinical trial information may also be found at www.clinicaltrials.gov.
Some current clinical trials also are posted on the following page on the NORD website:
https://rarediseases.org/living-with-a-rare-disease/find-clinical-trials/
For information about clinical trials sponsored by private sources, contact:
www.centerwatch.co
For information about clinical trials conducted in Europe, contact:
https://www.clinicaltrialsregister.eu/
Contact for additional information about PTEN hamartoma tumor syndrome:
Charis Eng, MD, PhD, FACP
Sondra J. & Stephen R. Hardis Chair in Cancer Genomic Medicine
Lerner Eminent Scholar
Chairwoman and Director, Genomic Medicine Institute
Director, Center for Personalized Genetic Healthcare
Medical Director, Clinical Cancer Genetics Service
Medical Director, PTEN/Cowden Multidisciplinary Clinic and National Center of Excellence, Cleveland Clinic Health System
American Cancer Society Clinical Research Professor
Cleveland Clinic Lerner Research Institute
9500 Euclid Avenue, Mailstop NE-50 (Rm NE5-314)
Cleveland, OH 44195
Tel +1 216 444 3440
Fax +1 216 636 0655
email: [email protected]
and
Lamis Yehia, PhD
Ambrose Monell Cancer Genomic Medicine Research Associate
Genomic Medicine Institute, Cleveland Clinic
Cleveland, OH 44195
Tel (lab): +1 216 445 7885
email: [email protected]
PTEN Study: [email protected]
https://my.clevelandclinic.org/departments/genomics/specialties/pten-clinic
TEXTBOOKS
Hodgson SV, Foulkes WD, Eng C, Maher ER. A Practical Guide to Human Cancer Genetics. 4th ed. London, UK: Springer; 2014: 221, & 233-239.
Behrman RE, Kliegman RM, Jenson HB. Eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, PA: Elsevier Saunders; 2005:1230.
Pilarski R, Hampel H, Eng C. PTEN Hamartoma Tumor Syndrome. NORD Guide to Rare Disorders. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:240.
Cohen MMJr, Nori G, Weksberg R. Overgrowth Syndromes. 1st ed. New York, NY: Oxford University Press; 2002:66-72.
Gorlin RJ, Cohen MMJr, Hennekam RCM. Eds. Syndromes of the Head and Neck. 4th ed. New York, NY: Oxford University Press; 2001:432-7.
JOURNAL ARTICLES
Yehia L, Plitt G, Tushar AM, Julia Joo J, Burke CA, Campbell SC, Heiden K, Jin J, Macaron C, Michener CM, Pederson HJ, Radhakrishnan K, Shin J, Tamburro J, Patil S, Eng C. Longitudinal analysis of cancer risk in children and adults with germline PTEN variants. JAMA Netw Open 2023; 6(4):e239705. doi:10.1001/jamanetworkopen.2023.9705.
Srivastava S, Jo B, Zhang B, Frazier T, Gallagher AS, Peck F, Levin AR, Mondal S, Li Z, Filip-Dhima R, Geisel G, Dies KA, Diplock A, Eng C, Hanna R, Sahin M, Hardan A; Developmental Synaptopathies Consortium. A randomized controlled trial of everolimus for neurocognitive symptoms in PTEN hamartoma tumor syndrome. Hum Mol Genet. 2022 Oct 10;31(20):3393-3404. doi: 10.1093/hmg/ddac111.
Yehia L, Keel E, Eng C. Clinical spectrum of PTEN mutations. Annu Rev Med 2020; doi: 10.1146/annurev-med-052218-125823.
Yehia L, Ngeow J and Eng C. PTEN-opathies: from biological insights to evidence-based precision medicine. JCI. 2019. 129:2.
Yehia L and Eng C. 65 YEARS OF THE DOUBLE HELIX: One gene, many endocrine and metabolic syndromes: PTEN-opathies and precision medicine. Endocrine-Related Cancer. 2018. 25:8: T121-T140.
Tan MH, Mester J, Ngeow J, Rybicki LA, Orloff MS, Eng C. Lifetime Cancer Risks in Individuals with Germline PTEN Mutations. Clin Cancer Res. 2012;18:400-7.
Tan MH, Mester J, Peterson C et al. A clinical scoring system for selection of patients for PTEN mutation testing is proposed on the basis of a prospective study of 3042 probands. Am J Hum Genet. 2011;88:42-56.
Ngeow J, Mester J, Rybicki LA, Ni Y, Milas M, Eng C. Incidence and clinical characteristics of thyroid cancer in prospective series of individuals with Cowden and Cowden-like syndrome characterized by germline PTEN, SDH, or KLLN alterations. J Clin Endo Metab. 2011;96:E2063-71.
Greene AK, Orbach DB. Management of arteriovenous malformations. Clin Plast Surg. 2011;38:95-106.
Mester J, Tilot AK, Rybicki LA, Frazier TW, Eng C. Analysis of prevalence and degree of macrocephaly in patients with germline PTEN mutations and of brain weight in Pten knock-in murine model. Eur J Hum Genet. 2011;19:763-8.
Heald B, Mester J, Rybicki L, Orloff MS, Burke CA, Eng C. Frequent gastrointestinal polyps and colorectal adenocarcinomas in a prospective series of PTEN mutation carriers. Gastro. 2010;139:1927-33.
Varga EA, Pastore M, Prior T, Herman GE, McBride KL. The prevalence of PTEN mutations in a clinical pediatric cohort with autism spectrum disorders, developmental delay, and macrocephaly. Genet Med. 2009;11:111-7.
Tan WH, Baris NH, Burrows PE et al. The spectrum of vascular anomalies in patients with PTEN mutations: implications for diagnosis and management. J Med Genet. 2007;44:594-602.
Zbuk KM, Eng C. Cancer phenomics: RET and PTEN as illustrative models. Nature Rev Cancer. 2007;7:35-45.
Robinson S, Cohen AR. Cowden disease and Lhermitte-Duclos disease: an update. Neurosurg Focus. 2006;20:E6.
Sarquis MA, Agrawal S, Shen L, Pilarski R, Zhou XP, Eng C. Distinct expression profiles for PTEN transcript and its splice variants in Cowden syndrome and Bannayan-Riley-Ruvalcaba syndrome. Am J Hum Genet. 2005;79:23-30.
Pilarski R, Eng C. Will the Cowden syndrome please stand up (again)? Expanding mutational and clinical spectra of the PTEN hamartoma tumor syndrome. J Med Genet. 2004;41:323-6.
Sansal I, Sellers WR. The biology and clinical relevance of the PTEN tumor suppressor pathway. J Clin Oncol. 2004;22:2954-63.
Merks JHM, de Vries LS, Zhou XP, et al., PTEN hamartoma tumour syndrome: variability of an entity. J Med Genet. 2003;40:e111.
Zhou XP, Hampel H, Thiele H, et al., Association of germline mutation in the PTEN tumor suppressor gene and Proteus and Proteus-like syndromes. Lancet. 2001;358:210-1.
Marsh DJ, Kum JB, Lunetta KL, et al., PTEN mutation spectrum and genotype-phenotype correlations in Bannayan-Riley-Ruvalcaba syndrome suggest a single entity with Cowden syndrome. Hum Mol Genet. 1999;8:1461-72.
INTERNET
Yehia L, Eng C. PTEN Hamartoma Tumor Syndrome. 2001 Nov 29 [Updated 2021 Feb 11]. In: Adam MP, Feldman J, Mirzaa GM, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1488/ Accessed Nov 6, 2023.
Fiala KH. Cowden Disease (Multiple Hamartoma Syndrome). Medscape. June 27, 2023. https://emedicine.medscape.com/article/1093383-overview Accessed Nov 6, 2023.
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