The study was approved by the Ethics Committee of Peking University First Hospital and conformed to the Helsinki Declaration.
A 40-year-old male was admitted to Peking University First Hospital in 2018 with headache and dizziness that had been ongoing for 2 months. Notably, he had undergone surgical resection for cerebellar HGBs in 2015. When he was admitted in 2018, contrast-enhanced magnetic resonance imaging (MRI) of the cerebellum (3.0 T; Signa Excite HD 3.0 T; GE Healthcare, Chicago, IL, USA) showed multiple lesions in the cerebellum with obvious enhancement, highly suggestive of HGBs (Figs. 1a–c). In addition, abdominal computed tomography (CT) scanning with contrast revealed multiple cysts in the pancreas and kidneys (Fig. 1d). Because of the obvious occupy effect and symptoms, he underwent operation again. Postoperative pathology demonstrated that both lesions resected from the cerebellum were HGBs. The patient’s symptoms improved after surgery, and at two-year follow-up (FU), his condition was found to be stable with no recurrence. Five of his family members from three generations has also undergone surgical resections for CNS-related HGBs. The patient provided written informed consent to participate in this study and for publication of this case report.
A 58-year-old female was admitted to our hospital with symptoms similar to those of the male patient. Contrast-enhanced MRI showed multiple HGBs in the cerebellum with an obvious occupy effect (Fig. 2a–c). In addition, contrast-enhanced abdominal CT showed renal cell cancer and multiple renal and pancreatic cysts (Fig. 2d). She underwent surgical resection for HGBs in the bilateral cerebellum, and her symptoms improved. At two-year FU, her condition was stable with no recurrence.
Both patients and their family members who met the clinical diagnostic criteria underwent genetic testing. Clinical, genetic, and relevant imaging data were analyzed.
Genomic DNA was extracted from peripheral blood using a QIAamp DNA Blood Mini Kit (QIAGEN, Hilden, Germany). Three coding exons and their flanking intronic regions were amplified by polymerase chain reaction (PCR) using previously described primers [5]. Direct sequencing was performed to screen missense and splicing mutations. Large exon deletions were screened using a multiplex ligation-dependent probe amplification kit (P016-C2; MRC Holland, Amsterdam, the Netherlands) and confirmed by real-time quantitative PCR with primers described by Ebenazer et al. [6]. The reaction conditions and primers used for amplification were as previously described [7].
Gene sequencing revealed a heterozygous germline mutation (NM_000551.3(VHL):c.464-1G > C) in the splice site in intron 2 of VHL in the DNA from the peripheral blood of the male patient and nine of his family members (male 4, female 5) (Fig. 3a). In total, five of these nine patients from three generations underwent a total of nine surgical resections for CNS-related HGBs, with an average of 1.8 ± 1.3 surgeries (range: 1–4). All resected lesions were located in the cerebellum. Figure 4 shows the genetic investigation used in this study. In the first, second, and third generations, the ages at which the first operation for CNS HGBs was performed were 67, 32.3, and 17 years, respectively. Notably, the age at which the first operation for CNS HGBs was performed was younger in the children (younger generation) than in their parents (older generation). Additionally, only the mother of the male patient with the NM_000551.3(VHL):c.464-1G > C variant was diagnosed with renal cell carcinoma and underwent left nephrectomy. Another intronic mutation in VHL occurred in NM_000551.3(VHL):c.464-2A > G in the 58-year-old female patient (Fig. 3b), but none of her family members showed any abnormal changes in VHL. The clinical information about the two pathogentic variants has been submitted to ClinVar database. The ClinVar accession for NM_000551.3(VHL):c.464-1G > C was SCV001371687.