CH 39

Chapter 39: Neurofibromatosis 1
PART 5: Familial Cancer Syndromes, III. Defects in Gatekeepers

David H. Gutmann, Francis S. Collins
Abstract
1. Von Recklinghausen neurofibromatosis, or neurofibromatosis type 1 (NF1), is a common autosomal
dominant disorder that affects 1 in 3000 individuals. It is characterized clinically by the finding of two
or more of the following: caf-au-lait spots, neurofibromas, freckling in non-sun-exposed areas, optic
glioma, Lisch nodules, distinctive bony lesions, and a first-degree relative with NF1. Less common
manifestations include short stature and macrocephaly. NF1 patients also can have learning
disabilities, seizures, scoliosis, hypertension, plexiform neurofibromas, or pheochromocytomas.
2. There is a high spontaneous mutation rate in NF1, with 30 to 50 percent of cases representing new
mutations. Although the penetrance of NF1 is essentially 100 percent, NF1 tends to show variable
expressivity in that there is a wide range of clinical severity and complications in patients within the
same family, who all presumably carry the same mutation.
3. Syndromes related to NF1 include neurofibromatosis type 2 (bilateral vestibular neurofibromatosis),
segmental or mosaic NF1, Watson syndrome, and neurofibromatosis 1Noonan syndrome.
4. The gene for NF1 was identified by positional cloning and resides on chromosome 17q11.2. This
gene has an open reading frame of 8454 nucleotides and spans approximately 300,000 nucleotides
of genomic DNA. The messenger RNA is 11,000 to 13,000 nucleotides and is detectable at varying
levels in all tissues examined. Germ-line mutations in the NF1 gene have been found in affected
patients and range from large (megabase) deletions to missense and nonsense mutations.
5. The protein product of the NF1 locus (neurofibromin) is 2818 amino acids and is expressed as a
250-kDa protein in brain, spleen, kidney, testis, and thymus. This protein has structural and functional
similarity to a family of GTPase-activating proteins (GAPs) that down-regulate a cellular
proto-oncogene, p21-ras. ras has been implicated in the control of cell growth and differentiation, and
the ability of neurofibromin to down-regulate p21-ras suggests that the loss of neurofibromin may lead
to uncontrolled cell growth or tumor formation. Subcellular localization and biochemical purification
experiments have demonstrated that neurofibromin is associated with cytoplasmic microtubules.
6. Somatic mutations in the NF1 gene that result in an absence of neurofibromin expression have been
described for a variety of tumor types. Loss of neurofibromin in neuro-fibrosarcomas derived from
NF1 patients results in increased p21-ras activation and presumably tumor formation. Neurofibromin
expression is also absent in non-NF1 patients tumors, including metastatic malignant melanomas
and neuroblastomas. The loss of neurofibromin in malignancy supports the notion that neurofibromin
is a tumor-suppressor gene product.
7. The diagnosis of neurofibromatosis 1 is based largely on clinical criteria despite progress in defining
the molecular genetics of the disorder. Treatment of patients with NF1 is directed at education and
genetic counseling, early detection of malignancy, and surveillance for the appearance of
complications of NF1.
Copyright The McGraw-Hill Companies, Inc. All rights reserved.
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Von Recklinghausen neurofibromatosis, or neurofibromatosis type 1 (NF1), is one of the most common
autosomal dominant disorders in humans, afflicting all ethnic groups, both sexes, and all age groups. It is
more common than Duchenne muscular dystrophy and Huntington disease combined and has a greater
prevalence in the Western world than does cystic fibrosis. Yet NF1 has received far less attention in the
public eye and the medical literature than have these other single-gene disorders. Among the multitude of
reasons for this decreased visibility, three seem to stand out: (1) The pleiotropic and variable
manifestations of NF1 affect many different organ systems and thus lead to the involvement of a multitude
of subspecialists in the care of these patients. However, until recently no single specialist or subspecialist
had considered NF1 a disease of major concern. Now this role has been taken on by medical geneticists.
(2) Until very recently, NF1 lacked a firm biologic basis, and investigations into its pathogenesis were
more descriptive than definitive. In the absence of a biologic hypothesis for the basic defect, very little
attention was given to this disorder by basic scientists. (3) It is a tragic reality that many patients with NF1
are at least to some degree disfigured. In a society that often values physical beauty more than strength of
character, such individuals have been discriminated against, either overtly or subtly, and often have
responded by remaining in the background. There have been few poster children for von Recklinghausen
neurofibromatosis, no telethons, and very little public sympathy. The learning disabilities suffered by many
individuals with NF1 have further inhibited their ability to achieve positions of power, wealth, and influence.
All these circumstances are undergoing a turnaround. The founding of the National Neurofibromatosis
Foundation (NNFF) in America in 1978, LINK (Lets Increase Neurofibromatosis Knowledge) in 1982, and
the International Neurofibromatosis Association in 1992 signifies a new determination of NF1 sufferers
and their families to increase public awareness of the disease, support research, and reach out to each
other in support groups. The clinical care of NF patients, previously fragmented and poorly coordinated,
has been greatly improved over the past 15 years by the establishment of a large number of NF specialty
clinics, which are now present in most major medical centers. The directors of such clinics are usually
pediatricians, internists, neurologists, or geneticists, and the clinics offer diagnosis, counseling, and
regular evaluation of affected individuals for complications of the disease and coordinated access to
subspecialists when the need arises. Such clinics, initially arising out of the pioneering efforts of Vincent
Riccardi at Baylor, have provided a wealth of information about the natural history of the disease and
corrected a number of misconceptions.
From the scientific point of view, identification of the NF1 gene by a positional cloning strategy 13 and
recognition that the protein product is a participant in p21-ras-mediated growth control 47 have catapulted
NF1 into the scientific spotlight, resulting in the recruitment of a significant number of basic scientists into
research on this disorder who previously would not have paid it much mind. Thus the complexion of NF1
has changed dramatically over the past 15 years, and it now seems highly appropriate to include a
chapter on this disorder in this textbook.
There are three recent excellent books 810 on neurofibromatosis, with particular emphasis on the clinical
aspects. No attempt will be made here to duplicate those sources and the wealth of clinical detail they
provide; the interested reader is referred to those sources as well as to the classic monograph of Crowe,
Schull, and Neel. 11 Furthermore, no coverage of neurofibromatosis type 2 (NF2, formerly referred to as
central neurofibromatosis or bilateral vestibular neurofibromatosis) will be attempted. 12, 13
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CLINICAL ASPECTS
Historical Perspective
Scattered descriptions of cases that almost certainly represent NF1, sometimes even including drawings,
can be found through many centuries of medical writing. 14, 15 While other writers previously had focused
on the skin tumors and occasionally had noted the familial nature of the disorder, it was von
Recklinghausen in 1882 who gave the disease its first full description, including recognition that the
tumors arose from the fibrous tissue surrounding small nerves, leading to his designation of these tumors
as neurofibromas. 16 The autosomal dominant inheritance pattern was defined early in the twentieth
century. 17 A crucial diagnostic element, the iris nodule, was defined by the Viennese ophthalmologist
Lisch in 1937, 18 although the true significance and usefulness of this observation have come to general
attention only in the past decade. 19, 20
The landmark study of Crowe, Schull, and Neel 11 brought together for the first time all the salient clinical
features of NF1, including the high incidence, the high spontaneous mutation rate, the usefulness of the
caf-au-lait spot as a diagnostic feature, and recognition of the wide range of complications that can
occur. Other important large-scale studies of the disease include those of Borberg 21 (followed up 35
years later by Sorenson et al. 22 ), Carey et al., 23 Riccardi, 9, 24 and Huson et al. 2527 While none of these
studies is completely devoid of bias of ascertainment, together they provide a wealth of information about
this pleiotropic disease.
Incidence
Because NF1 often is not diagnosed at birth, especially if the case is a new mutation, true birth incidence
rates are difficult to obtain. Population surveys in the United States, 11 Russia, 28 Denmark, 29 and
Wales 26 (Table 39-1) have resulted in an estimate of disease prevalence of approximately 1 in 2500 to 1
in 5000. A lower estimate of 1 in 7800 is provided by the Russian study, but this almost certainly
represents an underestimate. When underascertainment and increased mortality are considered, the true
birth incidence of NF1 is probably about 1 in 3000. There is no evidence that this frequency varies among
ethnic groups. This is expected for a disorder with such a high percentage of spontaneous mutations.
Table 39-1: Estimates of Prevalence and Mutation Rate of NF1
Methods of Study
(Year)
Ascertainment
Prevalence
Mutation Rate
Crowe et al. (1956)
Surveys of admissions at general hospital

and state mental institutions
1/25003000
1.42.610 4
Sergeyev (1975)
Population sample of 16-year-old

Russian youths
1/7800
4.44.910 5
Samuelsson and
Axelson (1981)
Population-based
1/4600
4.310.5 5
Huson et al. (1989)
Population-based
1/25004950
3.110.510 5
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Diagnostic Criteria
Despite opinions to the contrary in the medical literature, the diagnosis of NF1 usually is not difficult or
controversial when performed by an experienced clinician. In 1987, the National Institutes of Health (NIH)
convened a consensus panel to define diagnostic criteria for NF1, and the list that resulted (Table 39-2)
reflects extensive clinical experience and only rarely leads to a false-positive diagnosis. 30 The same
panel also set out the distinguishing features between NF1 and NF2 (see below), ending many decades of
confusion about these two disorders, which are now known to be completely distinct, both genetically and
clinically. Recently, these diagnostic criteria were updated based on a decade of improved clinical and
basic science insights. 31
The diagnostic criteria listed in Table 39-2 do not eliminate the occurrence of certain clinical dilemmas,
however. A frequent dilemma is the identification of a child under 4 years of age with six or more
caf-au-lait spots, no family history, and no other manifestations of NF1. According to the NIH criteria, this
is insufficient evidence to make a diagnosis of NF1, but such children must be followed for the
appearance of other manifestations. Most of these children will eventually turn out to have NF1 as
additional features manifest.
Defining Features Present in Most Patients
Caf-au-Lait Spots.
The caf-au-lait spot (Fig. 39-1), a flat, evenly pigmented macule, usually is not apparent at birth but
becomes visible during the first year of life. While up to 25 percent of the normal population will have one
to three caf-au-lait spots, 32 the presence of six or more is highly suspicious for NF1 11 if the size criteria
listed in Table 39-2 are closely followed. Melanocytes within a caf-au-lait spot have an increased number
of macromelanosomes, 33 although this is not diagnostic for NF1. The caf-au-lait spots tend to fade in
later life and may be difficult or impossible to identify in elderly individuals. Visualization using a Woods
lamp often reveals these macules when they are not discernible on bedside examination.
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Typical neurofibroma and a caf-au-lait spot on the skin of an adult with NF1.
Peripheral Neurofibromas.
Peripheral neurofibromas are soft, fleshy tumors (Figs. 39-1 and 39-2) that are usually not present in
childhood but make their appearance slightly before or during adolescence. 9 They tend to increase in size
and number with age, although the rate can be extremely variable. Some females affected with NF1 note
an increase in the rate of progression during pregnancy, suggesting that these tumors may be
hormone-responsive. Pathologically, these lesions arise from cells in the peripheral nerve sheath and are
made up of a mixture of cell types, including Schwann cells, fibroblasts, mast cells, and vascular
elements. 34
There are typically two types of neurofibromas: discrete and plexiform. While a discrete neurofibroma
arises from a single site along a peripheral nerve as a focal mass with well-defined margins, plexiform
neurofibromas usually involve multiple nerve fascicles (see below). A subset of patients can have firmer
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and sometimes painful neurofibromas along the course of peripheral nerves. These neurofibromas can be
quite difficult to manage surgically. Even more challenging are the spinal neurofibromas arising from
dorsal nerve roots, which can lead to pain and neurologic compromise. It should be emphasized that
dermal neurofibromas are benign tumors without a propensity for malignant transformation.
Freckling.
The occurrence of freckles in the axilla, groin, and intertriginous areas was first pointed out by Crowe 35
and is a useful diagnostic feature. Such freckling is not apparent at birth but often appears during
childhood. In adults, freckling may be seen in the neck regions or inframammary areas in women. The
occurrence of such freckling in the inframammary areas and other skin folds 36 is a curious observation
that suggests that these lesions are modulated by the local environment.
Lisch Nodules.
Raised, often pigmented nodules of the iris, pathologically representing hamartomas, are now called Lisch
nodules (Fig. 39-3) and represent an extremely important diagnostic feature of NF1. 19, 20 Like caf-au-lait
spots and freckling, Lisch nodules never result in significant disease but can be helpful in establishing the
diagnosis. While they can be seen with simple lighting in individuals with light irises, a slit-lamp
examination is usually essential to be certain of their presence and to distinguish them from iris nevi.
Typically, these lesions are not detected until after 5 years of age.
Typical Lisch nodules (hamartomas) of the iris in an adult with NF1.
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Time Course
The defining features of NF1 described earlier, while somewhat variable in appearance, tend to follow the
pattern shown in Fig. 39-4. As implied by the figure, it is unusual for an individual with NF1 to reach
adolescence without having amply satisfied the diagnostic criteria in Table 39-2.
Typical time course of appearance of the major clinical features of NF1. CAL = caf-au-lait spots.
Common but Nondiagnostic and Nonmorbid Features
While not considered specific enough for inclusion in the list of diagnostic criteria, macrocephaly 25 and
short stature 24 are common accompaniments of NF1. The macrocephaly reflects concomitant
megalencephaly. Careful studies of adult height suggest that individuals with NF1 are on average about 3
inches shorter than predicted by their family backgrounds. 9, 25 With both these circumstances, it is
important not to overlook other, more significant causes. For instance, aqueductal stenosis leading to
hydrocephalus is a known but uncommon complication of NF1 that requires surgical intervention. 37
Similarly, growth failure occasionally can arise as a result of hypothalamic involvement by optic glioma.
Variable but Significant Complications
The defining features of NF1 listed in Table 39-2 are found in most affected patients and, while often
associated with significant cosmetic concerns related to neurofibroma growth, usually are not
life-threatening. A range of other complications that are quite variable from one patient to the next can be
more serious. Approximately one-third of patients with NF1 suffer from one or more of these serious
complications during their lifetimes (Fig. 39-5).
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Age range of presentation and frequency of major NF1 complications. PNF = plexiform neurofibroma; NFS
= neurofibrosarcoma. (From Huson et al. 27 Used by permission.)
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Learning Disability.
Frank mental retardation (IQ<70) is uncommon in NF1. Recent molecular information indicates that such
patients are much more likely to have the disease because of a large deletion that removes the entire NF1
gene and considerable flanking DNA. 38 Presumably, other nearby genes are also reduced to
hemizygosity by the deletion in these patients and contribute to the retardation.
Although retardation is uncommon, standard IQ testing reveals a downward shift of performance scores
by 5 to 10 IQ points in affected individuals. 36 Approximately 40 to 60 percent of all individuals with NF1
have learning disabilities. Analysis of the specific behavioral phenotype in children with NF1 has
demonstrated a higher incidence of minor signs of neurologic impairment (motor abnormalities involving
balance and gait), lower IQ scores, and poor performance on tasks involving nonverbal learning. In
addition, children with NF1 often exhibit areas of increased T 2 signal intensity on magnetic resonance
imaging (MRI) of the brain. It has been suggested that children with such areas (unidentified bright objects
[UBOs]) have significantly lower IQ and language scores, with impaired visual motor integration and
coordination. 39 Although this hypothesis is intriguing, it has not been confirmed in all studies examining
this association. 40, 41 UBOs are seen most commonly in the basal ganglia, cerebellum, brainstem, and
subcortical white matter regions. In one pathologic study, these hyperintense foci corresponded to areas
of vacuolar and spongiotic change, with fluid-filled vacuoles surrounded by infiltrating astrocytes. 42
Recent studies have demonstrated increased neurofibromin expression in activated astrocytes both in
vivo and in vitro, suggesting that reduced NF1 gene expression may alter the normal astrogliotic response
in the brain. 43, 44 Intervention is highly warranted if the preceding problems emerge, and all children with
NF1 should be followed closely for developmental progress and subjected to a thorough educational
evaluation at age 3 or 4 if there is any indication of significant delay.
Plexiform Neurofibromas.
A plexiform neurofibroma is a much more complex, usually congenital (though often not immediately
visible) lesion that may diffusely involve nerve, muscle, connective tissue, vascular elements, and
overlying skin. 36 Such lesions, which occur in approximately 20 percent of affected individuals, commonly
lead to overgrowth of surrounding tissues during childhood and in their most severe form can lead to
massive distortion of the face or an extremity (Fig. 39-6). When these lesions occur around the orbit, they
are often associated with sphenoid wing dysplasia, and the tumor may extend inside the cranial vault,
accompanied by pulsating exophthalmos. 9 Severe plexiform lesions are almost invariably apparent by
age 4 or 5, so it is possible to reassure older individuals without plexiform lesions that they are not at
significant risk for the development of this particularly troubling and disfiguring complication.
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Massive plexiform neurofibroma of the lower extremity in an adolescent with NF1.
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Malignancy.
The frequency of malignancy in NF1 is difficult to discern accurately, since most series reflect a referral
bias and therefore overestimate the occurrence of this complication. 42 Nonetheless, there is clearly an
increased risk of specific cancers in NF1, amounting to perhaps 2 to 5 percent of affected
individuals. 9, 23, 25, 29, 46
A particularly aggressive and often fatal malignancy is the neurofibrosarcoma, or malignant peripheral
nerve sheath tumor (MPNST), which commonly arises in a plexiform neurofibroma in a young adult. Often
the first symptom is pain or rapid growth, which should always prompt rapid investigation in an individual
with a plexiform lesion. These malignancies are highly aggressive and metastatic cancers that are
relatively resistant to chemotherapy and radiation. 47 Survival remains poor when wide excision or
amputation is not possible.
A second strongly associated tumor is optic glioma. MRI scanning of affected children with NF1 has
revealed radiographic evidence of optic nerve or optic chiasm enlargement in up to 15 to 20 percent of
patients, 4850 but the vast majority of these patients have normal vision and never become symptomatic.
Most of these tumors are detected in children younger than 6 years. A small subgroup, however, presents
with progressive visual loss associated with an expanding lesion. Occasionally, optic pathway gliomas can
lead to precocious puberty when hypothalamic involvement ensues. While this occurs only in a minority of
patients with NF1, all children with NF1 should have regular ophthalmologic evaluations.
While the risk of other malignancies of the nervous system is less impressive, there appears to be a
moderately increased risk of central nervous system tumors, especially astrocytomas. 34
Pheochromocytoma is commonly quoted as a complication of NF1 but is in fact quite uncommon in this
population. 11, 45, 46
Seizures.
A seizure disorder will develop in approximately 5 percent of patients with NF1, and the onset can occur at
any time. 9 While occasionally a definable intracranial tumor will be found to be at fault, usually no cause
can be defined. In this regard, the recent advent of MRI scanning has uncovered MRI inhomogeneities in
the brains of many children with NF1 on T 2 -weighted images. These UBOs are of uncertain etiology and
generally should not be interpreted as clinically significant. 51 There is some evidence that they tend to
disappear with age, and it is not correct, on the basis of current evidence, to refer to them as hamartomas.
Scoliosis.
Vertebral defects, including scalloping from dural ectasia, 52 are extremely common in NF1, and
approximately 10 percent of affected individuals have scoliosis during late childhood and adolescence. 9 In
some instances this can be severe enough to require bracing and/or surgery and may or may not be
associated with local neurofibroma formation.
Pseudarthrosis.
A peculiar and uncommon complication that defies the classification of NF1 as a disorder purely of the
neural crest is the involvement of long bones. This often is noted first as bowing, particularly of the tibia, in
young children. This may progress to thinning of the cortex, pathologic fracture, and severe difficulties with
nonunion of the fragments. This process may go on to form a pseudarthrosis, or false joint, leaving the
limb severely compromised. The pathologic basis of this unusual process is unknown.
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Hypertension.
Hypertension is extremely common in adults with NF1, affecting perhaps one-third of these patients. 24 In
general, this proves to be essential hypertension with no underlying cause, but the new development of
hypertension always should raise the possibility of renal artery stenosis, which is particularly common in
children, 53 or pheochromocytoma, which occasionally occurs in adults with NF1 (see above).
Miscellaneous Complications.
Frequent but less well understood problems associated with neurofibromatosis 1 include headache, which
can be bothersome but usually not disabling. The new onset of headache always should trigger evaluation
for an intracranial tumor, but many patients experience lifelong stable headache patterns with no
identifiable etiology. Generalized itching or itching localized to newly developing neurofibromas is reported
by many individuals. 9 Similarly, constipation seems to be a frequent concomitant of the disease,
especially in patients who have plexiform neurofibromas in the pelvic area. 54 These complications may
interfere with autonomic innervation of the colon and produce both bowel and bladder problems.
GENETIC ASPECTS
Inheritance Pattern
Preiser and Davenport 17 surveyed the literature in 1918 and concluded that approximately 50 percent of
the children of individuals affected with NF1 also were afflicted, regardless of sex. They noted numerous
examples of male-to-male transmission, concluding that the disease follows an autosomal dominant
pattern of inheritance. In 1981, Hall suggested that the sex of the affected parent might have an impact on
the severity of the disease, 55, 56 a phenomenon we would now ascribe to parental imprinting. 57 In that
study, children of affected mothers tended to be slightly more severely affected than did children of
affected fathers. Subsequent careful analyses of this issue have failed to confirm this maternal
effect, 23, 54, 55 although a very modest effect would be difficult to exclude with such variability of the
disease. 58, 59
Mutation Rate
All large series indicate after careful examination that 30 to 50 percent of patients with NF1 do not have an
affected parent. 11, 29, 59 Such individuals presumably represent spontaneous mutations. With the cloning
of the NF1 gene, several examples have now been documented of de novo alterations in the NF1 gene in
such individuals (see below). Given that NF1 is a common disease and that so many of its sufferers have
new mutations, one cannot escape the conclusion that the mutation rate for this locus is unusually high. In
fact, calculations of this frequency (see Table 39-1) indicate a mutation rate of approximately 10 4 per
allele per generation. Evidence based on linkage analysis has indicated that the vast majority of new
mutations arise from the paternal allele, 60, 61 indicating that these mutations apparently occur during
spermatogenesis. Whether they are meiotic or mitotic errors has not been determined, although mitotic
errors are suggested by the absence of a significant paternal age effect in new mutation cases.
With such a high mutation rate, it would be predicted that the reproductive fitness of individuals with NF1
must be significantly reduced in order for the disease to be present at an equilibrium frequency. The
Welsh study 59 found a fitness of 0.31 for affected males and 0.60 for affected females (1.0 is the
expected value). A large proportion of the reduced fertility can be attributed to a failure of affected
individuals to marry, which presumably reflects the psychosocial consequences of the condition.
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Penetrance
The penetrance of NF1 is essentially 100 percent in individuals who have reached adulthood and have
been subjected to careful examination by an experienced physician, including a slit-lamp examination.
Rare cases of normal parents giving rise to two affected children have been described 62 and could be
examples of germ-line mosaicism in one of the parents, although the possibility of independent
spontaneous mutations cannot be excluded until molecular studies are carried out in such patients. The
importance of careful examination of both parents before giving genetic counseling cannot be
overemphasized, however. There are numerous reports of circumstances in which one of the parents was
sufficiently mildly affected to be unaware of his or her diagnosis.
Variable Expressivity
NF1 is a classic example of the tendency for autosomal dominant conditions to show variable expressivity,
which can at times be dramatic in NF1. Even the more constant defining features of the disease are
subject to considerable heterogeneity when considered closely. It has been known for some time that
large families with multiple afflicted individuals are likely to demonstrate a wide range of severity and
complications, and the variability within a family of significant size is similar to the variability seen in
comparisons of different families. This indicates that the specific germ-line mutation at the NF1 locus does
not accurately predict the phenotype in a specific individual, since all affected individuals in the same
family carry the same germ-line mutation.
To distinguish between genetic influences and environmental and/or chance influences, Easton and
coworkers 63 examined a series of monozygotic twins concordant for NF1 and compared them with other
pairs of first-degree affected relatives. There was a significant correlation in the number of caf-au-lait
spots and neurofibromas between identical twins, with a lower but significant correlation in first-degree
relatives and almost no correlation between more distant relatives. This suggests that these features are
controlled by other genetic influences but that the specific mutation in the NF1 gene itself plays a minor
role. Optic glioma, scoliosis, epilepsy, and learning disability were concordant in twin pairs, but plexiform
neurofibromas were not. Furthermore, there was no indication that the presence of one complication
predicted the occurrence of another except for the fact that neurofibrosarcoma has been observed
commonly to occur almost exclusively in individuals with plexiform neurofibromas.
Related Syndromes
NF1 has been described in the literature in association with almost every imaginable disorder, but most of
these reports appear to represent the coincidental occurrence of two unrelated conditions. A classification
scheme proposed by Riccardi and Eichner 9 divides the neurofibromatoses into eight syndromes, but this
scheme has not found wide application because of the blurred boundaries between several categories. A
full discussion of variant syndromes is beyond the scope of this chapter, but a few of the most relevant
conditions will be mentioned.
Neurofibromatosis Type 2.
Type 2 neurofibromatosis, formerly designated central neurofibromatosis or bilateral vestibular
neurofibromatosis, is now appreciated to be distinct, both clinically and genetically, from NF1. 64, 65 The
NF2 gene has been mapped to chromosome 22 and was identified in 1993. 12, 13 Individuals with NF2
often have a small number of caf-au-lait spots (rarely more than six) and may have one or two peripheral
neurofibromas but usually not more. They occasionally have Lisch nodules. 66 Ophthalmologic evaluation
is extremely useful because of the presence of posterior subcapsular cataracts in a sizable proportion of
these patients. 67 The hallmark of NF2 is the development of bilateral eighth cranial nerve tumors, properly
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called vestibular schwannomas rather than acoustic neuromas, in 95 percent of these patients by age 30
years. 64 Inheritance is autosomal dominant. Other tumors of cranial and cervical nerve roots are
common, and management presents great challenges for neurosurgeons and otolaryngologists. Past
statements that acoustic neuroma is a complication of NF1 are almost certainly due to the confusion
between these two entities; since more careful definitions of the two disorders have been applied, there
has been no indication that individuals with NF1 have an increased risk of eighth cranial nerve tumors
compared with the general population. NF2 is much less common than NF1, affecting approximately 1 in
40,000 individuals.
Segmental (Mosaic) NF1.
Occasionally individuals are encountered who have features of NF1 limited to one segment of the body. 68
These features may include caf-au-lait spots, freckling, and peripheral or plexiform neurofibromas, and
Lisch nodules may be seen in an individual who has that segment of the body affected. Such individuals
invariably have normal parents but on rare occasions can have a child with classic NF1. 69 There is strong
circumstantial evidence that these cases represent somatic mutation of the NF1 gene early in
embryogenesis so that derivatives of that mutant line display the features of NF1. If the mosaicism
involves the germ line, the disease can then be transmitted. Recently, germ-line mosaicism for an NF1
gene mutation was found in a clinically unaffected father of a child with new onset NF1. 70 In addition,
somatic mosaicism for an NF1 gene deletion was detected in an individual with NF1. 71 Analysis of cases
of segmental NF1 probably will demonstrate similar somatic mosaicism.
Watson Syndrome.
A variant of NF1 that appears to breed true in certain families involves multiple caf-au-lait spots, dull
intelligence, short stature, pulmonary valvular stenosis, and only a small number of neurofibromas. 72
Reevaluation of these families has indicated that they also have Lisch nodules, further contributing to the
blurring of these two phenotypes. In fact, molecular analyses have demonstrated that in at least two
families that appear to fall into the category of Watson syndrome, deletions are present in the NF1 gene.
Currently, there appears to be no distinguishing aspect between the deletions causing Watson syndrome
and those associated with more classic NF1.
NeurofibromatosisNoonan Syndrome.
The occurrence of features reminiscent of Noonan syndrome in patients with neurofibromatosis 1 has
been noted for some time, 73 raising the question of whether these could be overlapping syndromes or
even could be due to deletion of adjacent genes. In most of these families, however, individuals with
clear-cut Noonan syndrome represent only a proportion of those affected with NF1, and some of the
features associated with Noonan syndrome (such as pectus excavatum, mild hypertelorism, and short
stature) are frequently observed in NF1. 74 A linkage study of autosomal dominant Noonan syndrome
occurring in the absence of NF1 has indicated no linkage to markers in the NF1 region of chromosome 17,
casting into doubt any notion that Noonan syndrome, at least in the aggregate, could be due to a mutation
in a gene closely adjacent to NF1. At least one family with neurofibromatosisNoonan syndrome (NFNS)
has been found to harbor a deletion in the NF1 gene, but the fact that very large deletions removing
flanking regions on either side of NF1 do not consistently result in NFNS casts further doubt on the
adjacent gene theory. The most appropriate synthesis of the data at the present time indicates that the
phenotype of NF1 can include features that overlap with those described in Noonan syndrome, but these
disorders are probably genetically distinct.
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Spinal Neurofibromatosis.
Rare families have been identified with a predominance of spinal tumors and relatively few peripheral
neurofibromas. A linkage study has indicated that one such family appears to be linked to NF1, whereas
another does not, implying locus heterogeneity for this set of conditions. 75 While this condition
underscores the variable expressivity of NF1, spinal neurofibromatosis does not represent a distinct
subtype of NF1.
MOLECULAR BIOLOGY OF THE NF1 GENE
Cloning of the NF1 Gene
Since no information was available on the structure or function of the NF1 gene product before the 1980s,
the only feasible approach available to identify the gene was positional cloning. 76 The isolation of the
gene for von Recklinghausen neurofibromatosis began with an international collaboration to assemble
linkage data in families with NF1. By early 1987, this worldwide effort made possible the construction of an
exclusion map that narrowed the candidate chromosomes to a handful. 77 Examination of these selected
chromosomes with RFLP markers culminated in the establishment of linkage of NF1 to the
pericentromeric region of chromosome 17 in the late spring of 1987. 7780 No linkage disequilibrium was
ever found. One of the linked markers was an anonymous probe called pA10-41, and another was the
gene for nerve growth factor receptor (17q12-22). 81 The linkage of NF1 with the nerve growth factor
(NGF) receptor gene was exciting because of the role of NGF in neural crest tissue development. Further
analysis using RFLP markers, however, excluded the NGF receptor gene as a candidate for the NF1
gene, since numerous crossover events were identified. 82
An intense genetic mapping effort resulted in the establishment of a multipoint linkage map constructed
from data assembled by the NF1 collaborative group (Fig. 39-7). This map represented the outcome of the
study of 142 families with over 700 affected individuals and narrowed the distance between flanking
probes and the NF1 gene to 3 cM, or about 3 million bp. 83 Candidate genes in this interval, such as the
erbA1 and erbB2 proto-oncogenes, were subsequently excluded as candidate genes for NF1 by the
identification of recombinants.
- 15 -
Linkage map for chromosome 17 demonstrating the position of the NF1 locus relative to other DNA
markers linked to the disease. The map distance of the various markers is represented in centimorgans
(cM).
The discovery of two patients with NF1 and balanced translocations involving the long arm of
chromosome 17 dramatically accelerated the process. These two NF1 patients had reciprocal
translocations, one between chromosomes 1p34.3 and 17q11.2 and the other between chromosomes
17q11.2 and 22q11.2. 8488 Support for the notion that these translocations disrupt the NF1 gene was
provided by the fact that one breakpoint in each of the translocations involved 17q11.2, precisely where
the NF1 gene had been mapped by linkage analysis.
The identification of translocation breakpoints permitted analysis of the genetic region by physical
mapping techniques and bridged the gap between linkage mapping and physical mapping. 89 Using
restriction enzymes that recognize rare restriction sites in DNA, one could search for an anomalously
migrating DNA fragment resulting from the disruption of this region by the translocations. To identify the
translocation breakpoints by physical mapping, markers capable of visualizing these areas had to be
generated. Using a series of chromosome 17-specific NotI-linking clones tested against a somatic cell
hybrid mapping panel, a clone termed 17L1A was identified that detected abnormalities by pulsed-field gel
- 16 -
electrophoresis in the 1;17 translocation patient and her affected offspring (Fig. 39-8). The presence of
abnormal fragments provided conclusive evidence that the translocation breakpoints map near the 17L1A
clone.
Pulsed-field gel analysis with probe 17L1A in an NF1 patient with [1;17] translocation. Genomic DNA is
digested with a rare-cutting restriction enzyme (either BssHII or SacII), separated by pulsed-field gel
electrophoresis, and probed with 17L1A. The DNA source in each lane is 1 and 8, patients with NF1; 2
and 5, a patient with a 1;17 translocation has a unique band not seen in the other DNA samples,
indicating the presence of a rearrangemen...
The use of cosmid libraries to look for abnormal fragments on pulsed-field gel electrophoresis provided an
additional clone, called 1F10, that detected abnormal fragments in both translocation patients. These two
cloned probes were then shown to reside on the same 600-kb DNA fragment and bracketed the two
translocations. This narrowed the interval in which the NF1 gene must reside to 600 kb of DNA. 87 Of
interest was the fact that 17L1A represented a CpG island, a hypomethylated region often associated with
five regulatory sequences of active genes.
The construction of a physical map of the region around the NF1 gene laid the groundwork for identifying
candidate cDNA transcripts. Using a combination of jump library clones, yeast artificial chromosome
probes, and cosmids, candidate cDNA transcripts were identified. Unexpectedly, however, the first
candidate gene came from another route: By comparison with a syntenic region on mouse chromosome
11, the mouse evi2 gene, which is involved in virally induced murine leukemia, was found to map between
these two breakpoints. 9092 Cloning of the human EVI2A gene excluded it as a candidate for the NF1
gene in that neither translocation actually interrupted the gene and no mutations were found in it in other
- 17 -
patients with NF1. 93 A second candidate gene, EVI2B, similar to EVI2A, was identified but also was
excluded as a potential candidate. 92 The third candidate gene, OMGP (oligodendrocyte myelin
glycoprotein), which was exciting because of its almost exclusive expression in Schwann cells and
oligodendrocytes, also failed to satisfy the criteria for an NF1 gene candidate, since no mutations could be
identified in this gene in NF1 patients. 94, 95
The fourth candidate gene was much larger and was cloned and shown to be the NF1 gene in several
ways. 13 First, the transcript crossed both translocation breakpoints and would therefore be interrupted in
these unique NF1 patients. 13 Second, more subtle mutations were identified in patients with NF1 that
would alter the coding potential of this candidate transcript. 2 These included a patient with a de novo
400-nucleotide insertion that produced an abnormally large fragment on Southern blot analysis using the
NF1 cDNA as a probe and another patient with a nonsense mutation. 96 These mutations provided
conclusive evidence that the correct gene had been found.
The NF1 gene has an open reading frame of nearly 9 kb and spans approximately 300 kb of genomic
DNA 97 (Fig. 39-9). The messenger RNA has been estimated to be 11 to 13 kb and has been detected in
all tissues examined by RT-PCR and northern blot analysis. At least 57 exons have been identified, with
three additional alternatively spliced exons (see Identification of NF1 Gene Product below). The three
previous candidate genes were all found embedded in one large intron and were transcribed from the
opposite strand from the NF1 gene. 93 The predicted protein has 2818 amino acids and a molecular
weight of 327 kDa. 98 Analysis of the amino acid sequence failed to reveal any nuclear localization signals
or transmembrane domains, suggesting that the gene product resides in the cytoplasm. Comparison of
the gene with other previously identified coding sequences revealed unexpected sequence similarity
between the NF1 gene product and a family of GTPase-activating proteins (GAPs) (see Neurofibromin as
a GTPase-Activating Protein below). 4 Analyses of homologous genes from mouse, chicken, hamster,
and Drosophila species demonstrate striking species conservation and underscore the fundamental
importance of this gene. 99102
- 18 -
The genetic organization of the NF1 locus. The genomic structure of the NF1 locus demonstrates the
location of the two NotI restriction sites separated by 1300 kb. The initiation codon is located upstream of
the centromeric NotI site and is positioned within a CpG-rich area. The position of the two translocation
breakpoints [t(1;17) and t(17;22)] described in two patients with NF1 and their interruption of the NF1 gene
are illustrated. Three...
- 19 -
Further analysis of the genomic organization of the NF1 gene demonstrated that the promoter of this gene
resides within a CpG-rich region; this is consistent with the observation that most active eukaryotic gene
promoters are contained within CpG islands. 103 During the construction of a yeast artificial chromosome
contig containing the entire NF1 gene, other homologous loci were found by low-stringency hybridization
on Southern blot. 104, 105 These loci were determined by a hybrid mapping panel and fluorescent in situ
hybridization to reside on chromosomes 14, 15, and 22. At least two loci were found on chromosome 14.
These homologous loci apparently represent unprocessed pseudogenes in that their coding sequences
contain frameshift, nonsense, and missense mutations. However, these loci also may represent mutation
reservoirs that can be crossed into the NF1 locus on chromosome 17 by interchromosomal gene
conversion. This phenomenon potentially could contribute to the high rate of mutation in NF1.
Patient Mutations
Analysis of NF1 patients for mutations is still in its infancy and is hampered by the large size of the gene.
Approximately 20 mutations have been studied in some detail. Five types of NF1 gene mutations have
been described to date in patients with NF1: (1) Translocations have been described in two patients with
NF1 and were described earlier in this chapter. These balanced translocations provided some of the first
clues to the precise physical location of the NF1 gene on chromosome 17. (2) Megabase deletions have
been reported in patients with NF1. 38 These deletions extend well beyond the NF1 gene and may include
other genes on chromosome 17q11.2. These patients manifest typical NF1 but also have significant
mental retardation. (3) Large internal deletions entirely contained within the NF1 gene have been reported
in patients with NF1. One of these deletions removed 90 kb of DNA encompassing the 5 portion of the
NF1 gene, while the other deleted 40 kb of NF1 DNA. 106 The phenotypes of these patients were
indistinguishable from those of classic NF1 patients. (4) Small rearrangements within the NF1 gene have
been described. One of these rearrangements involved the insertion of a human Alu repeat in the intron
between two NF1 exons, resulting in abnormal mRNA splicing and premature termination of the NF1
mRNA coding sequence. 96 (5) Many point mutations have been described in patients with NF1. 2 These
mutations include the creation of stop codons, missense mutations, and frameshift mutations. One of
these missense mutations involves a nonconservative substitution at codon 1423 within the
NF1-GAP-related domain (NF1GRD). 107 This mutation, when expressed in insect Sf9 cells, results in a
reduced ability of the NF1GRD to accelerate the hydrolysis of ras-GTP and perhaps altered NF1 gene
product, termed neurofibromin, function. This mutation also has been observed in anaplastic astrocytomas
and colonic adenocarcinomas. Thus far there does not appear to be a hotspot for mutation within the NF1
gene, since all these mutations are randomly distributed throughout the NF1 coding sequences. 108 To this
end, the phenotypes of patients with all the preceding mutation types (except megabase deletions) are
likely to be similar in that they all result in the loss of a functional protein. The fact that mutations all result
in a loss of NF1 protein function is consistent with the notion of NF1 as a tumor-suppressor gene.
The tumor-suppressor mechanism suggests that loss of both copies of the NF1 gene would culminate in a
transformed or neoplastic phenotype. 109112 In this hypothesis, affected individuals would inherit one
mutated NF1 gene from their parents (or as a new mutation), but neurofibromas or neurofibrosarcomas
would develop only when the second gene became nonfunctional as a result of somatic mutation. This set
of events is termed the Knudson hypothesis and was first elegantly demonstrated for
retinoblastoma. 113, 114 In patients with retinoblastoma, all somatic cells contain the germ-line-inherited
mutation in one of the retinoblastoma genes. Retinoblastomas arise as a result of loss of the second copy
of the retinoblastoma gene in retinal cells.
Occasionally, the second somatic mutation in the tumor can be detected by Southern blot analysis. In
white blood cells from patients with NF1, the DNA may be heterozygous for a particular DNA marker
polymorphism on chromosome 17, but when tumor cells develop, the remaining wild-type gene is lost,
- 20 -
eliminating that particular allele (Fig. 39-10). This is termed loss of heterozygosity and is taken as proof
that a second somatic event has occurred that results in the loss of the one remaining functional NF1
gene. Interpretation of these data for chromosome 17 are confounded by the frequent loss of
heterozygosity for markers near the p53 gene on chromosome 17p as well. 115 Loss of heterozygosity
centered at the NF1 locus has been observed in selected tumors from some patients with NF1, supporting
the notion that NF1 is a tumor-suppressor gene and that the manifestations of the disease result from
somatic loss of the second NF1 gene copy. A tumor in an NF1 patient has been found to display loss of
heterozygosity for chromosome 17 markers but in addition demonstrates a large deletion in the NF1 gene
in tumor cell but not white blood cell DNA. 116 This supports the notion that a second hit occurs in the
NF1 gene during the development of neurofibrosarcomas in patients with NF1.
Illustration of loss of heterozygosity in NF1. A given DNA marker polymorphism, denoted by the filled
squares, is present in a normal NF1 chromosome 17. A germ-line mutation found in all cells in an NF1
patient would alter the NF1 gene to result in the loss of one of the DNA markers. Because the patient has
one normal chromosome 17 DNA polymorphism and one mutated chromosome 17 DNA polymorphism,
the patient is said to be heterozygous with re...
Mutations in the NF1 gene have been described in other tumor types, including malignant melanomas,
neuroblastomas, pheochromocytomas, and neurofibrosarcomas. 117, 118 Examination of a series of
malignant melanoma cell lines derived from metastatic foci demonstrated reduced or absent
neurofibromin expression in up to 25 percent of tumors. 119, 120 Similar examination of neuroblastomas
revealed that NF1 mRNA and neurofibromin expression is reduced in up to 30 percent of
neuroblastomas. 120, 121 Similarly, three neurofibrosarcomas derived from NF1 patients demonstrated
elevated levels of ras-GTP and nearly undetectable levels of neurofibromin, suggesting a relationship
between lack of neurofibromin expression and unregulated ras activity in these cells (see below). 122, 123
Abnormalities at the DNA level have been reported for pheochromocytomas from NF1 patients. 124
Examination of these fresh tumors demonstrated loss of neurofibromin expression in six of six
pheochromocytomas as well as one adrenal cortical tumor from patients with NF1. 125 It is likely that
examination of other tumors will uncover alterations in neurofibromin expression that are consistent with
its proposed role as a tumor-suppressor gene product. Consistent with the proposed role of neurofibromin
as a negative growth regulator, tumors from patients with and without NF1 have been examined for
alterations in NF1 gene expression. The hallmark of NF1 is the neurofibroma, a benign tumor composed
predominantly of Schwann cells, fibroblasts, and to a lesser extent, mast cells. It has been presumed that
the cellular defect in the neurofibroma results from abnormal Schwann cell function secondary to loss of
neurofibromin function. Malignancies in NF1 are believed to result from the constitutional inactivation of
one NF1 gene followed by a number of somatic events, including inactivation of the other NF1 allele.
Although loss of the normal allele has been proved for the malignant nerve sheath tumor
- 21 -
(neurofibrosarcoma), 116 it had not been evaluated in the etiology of the benign neurofibroma. Recent
work has demonstrated loss of heterozygosity in 22 neurofibromas from five unrelated NF1 patients. 126 In
eight of these tumors, somatic deletions involving the wild-type NF1 gene could be demonstrated,
indicating that inactivation of the normal NF1 gene is associated with the development of the
neurofibroma. In related studies on Schwann cells derived from the dorsal root ganglia of
neurofibromin-deficient mice, abnormalities in Schwann cell proliferation and high levels of activated
p21-ras were observed, as would be predicted by loss of neurofibromin GAP function. 127 In addition,
these neurofibromin-deficient Schwann cells had abnormal proliferative responses to neuronal contact. 128
Additional studies also have demonstrated abnormalities in fibroblasts derived from
neurofibromin-deficient mouse embryos. 129 These results collectively suggest that defects in both the
Schwann cells and the fibroblasts may contribute to the development of the benign neurofibroma.
Children with NF1 are at increased risk for the development of malignant myeloid disorders. Although
myeloid disorders are an uncommon complication of NF1 in childhood, NF1 constitutes as many as 10
percent of the spontaneous cases of myeloid proliferative disorders in children. Examination of bone
marrow samples from children with NF1 in whom malignant myeloid disorders developed demonstrated
loss of heterozygosity at the NF1 locus. 130 In each case, the mutant NF1 allele was inherited from the
parent with NF1, and the normal allele was deleted in the myeloid leukemic cells. These results are
consistent with the hypothesis that loss of neurofibromin expression predisposes myeloid cells to leukemic
transformation. Mice heterozygous for a germ-line NF1 mutation also develop myeloid leukemias with loss
of the wild-type NF1 allele in the leukemic cells. 131 Analysis of these myeloid leukemic cells with loss of
neurofibromin expression demonstrates an exaggerated and prolonged increase in p21-ras activation in
response to granulocyte macrophage colony stimulating factor (GM-CSF). This increased sensitivity to
GM-CSF reflects abnormal p21-ras signaling that probably leads to chronic clonal hyperproliferation and
malignant transformation. Primary leukemic cells from children with NF1 also show an exaggerated
increase in p21-ras activity in response to GM-CSF. 132
Additional support for the hypothesis that neurofibromin functions to suppress growth by regulating ras
derives from experiments on the ability of one of these neurofibrosarcoma cell lines (ST88-14) to grow in
soft agar. 133 Whereas ST88-14 cells form colonies in soft agar, ST88-14 cells treated with pharmacologic
agents that block ras function fail to grow in soft agar. These results argue that neurofibromin loss leads to
increased ras activity, which in turn is partly responsible for the abnormal growth properties of these tumor
cells.
Animal Models
The search for spontaneous animal models of NF1 was initially disappointing. Three early models of NF1
were reported. In the bicolor damselfish, spontaneous neurofibromas and hyperpigmented spots develop,
but the disorder appears to be transmissible, and these tumors tend to be more invasive and malignant
than human neurofibromas. 134 One murine model was reported as resulting from the overexpression of
the HTLV-I tat gene in mice. 135 Neurofibroma-like tumors developed in the offspring. However, other
phenotypic features of NF1 were absent, and the neurofibromas lacked Schwann cells, unlike human NF1
neurofibromas. Similarly, the relationship between HTLV-I and human NF1 is unclear, since there is no
increased incidence of HTLV-I exposure or infection in NF1 patients. 136 The third model of NF1 was
achieved by injecting N-nitroso-N-ethylurea into pregnant Syrian golden hamsters. 102, 137 The progeny
develop neurofibromas histologically identical to those observed in NF1 patients, as well as pigmented
lesions similar to caf-au-lait spots. However, these hamsters also have Wilms tumors and other
malignancies not typically seen in NF1 patients. Recently, point mutations in the neu proto-oncogene were
identified in these hamster tumors. No mutations have been identified to date in the hamster NF1 gene by
Southern or Western blot analysis. 137
- 22 -
In an effort to develop a mouse model for neurofibromatosis 1, mice were generated that carried a null
mutation at the murine NF1 locus using gene targeting in embryonic stem cells. 138, 139 Heterozygous
mutant mice containing one mutant NF1 and one wild-type allele are phenotypically normal without
evidence of neurofibromas, pigmentary abnormalities, or Lisch nodules. However, 75 percent of
heterozygous mice succumb to tumors within 27 months compared with 15 percent of wild-type
animals. 138 In addition to developing the tumor type seen in older wild-type mice, heterozygote NF1 mice
develop certain tumor types characteristic of human NF1. One animal developed a neurofibrosarcoma at
21 months of age, and 12 developed adrenal tumors at 15 to 28 months. Nine of the adrenal tumors were
pheochromocytomas. Examination of these tumors demonstrated loss of the wild-type NF1 allele and
evidence of reduction to homozygosity for the NF1 gene in the tumor DNA. These data support the
hypothesis that the loss of NF1 gene function contributes to the development of tumors.
The breeding of heterozygous knockout animals to yield mice in which both copies of the NF1 gene were
disrupted by homologous recombination (homozygous knockout mice) produced embryos that died in
utero from generalized tissue edema. 138, 139 Examination of the hearts in these mice at embryonic day
12.5 demonstrates a double-outlet right ventricle defect resulting from a failure of the aorta and pulmonary
artery to separate. Double-outlet right ventricles have been observed in developing chicks in which the
neural crest cells migrating to form elements of the cardiac vasculature are ablated. These results suggest
that neurofibromin may be critical for the function of these neural crestderived cells, although other
mechanisms are possible. In addition to the cardiac vessel defect, the skeletal musculature is hypoplastic
relative to normal mouse embryos. The existence of a muscle-specific isoform of the NF1 gene and the
observation that neurofibromin expression is increased in skeletal and cardiac muscle during embryonic
development argue that neurofibromin also may be critical for normal muscle differentiation. 140, 141
Additionally, examination of the sympathetic ganglia in these homozygous mutant mice demonstrates
hyperplasia and an increased mitotic index. 142 These neurons also exhibit a reduced requirement for
exogenous survival factors (neurotrophins), arguing that loss of neurofibromin may drive some cells to
proliferate even in the absence of survival factors. In addition, there may be some genetic cooperativity
between NF1 and p53 such that superior cervical ganglia neurons deficient in both neurofibromin and p53
have longer survival in the absence of neurotrophins. 143
Mice heterozygous for a targeted mutation in the Nf1 gene (Nf1 +/ ) have been carefully analyzed for
features seen in patients with NF1 who also are heterozygous for a mutant Nf1 allele. Nf1 +/ mice
demonstrate learning and memory deficits. 144 As observed in people with NF1, these deficits are
restricted to specific types of learning (spatial memory but not associative learning), are not fully
penetrant, and can be compensated for with extended training.
In Drosophila, the NF1 gene may function in the protein kinase A (PKA) signaling pathway. 145 Targeted
disruption of both Drosophila NF1 genes results in reductions in fly size. Whereas homozygous null
NF1 / mice are embryonic lethal, Drosophila NF1-null flies are fertile and viable. Partial rescue of the
Drosophila mutant phenotype can be obtained with activated PKA. In addition, Drosophila NF1 is essential
for the response to certain polypeptides at the neuromuscular junction in flies. 146
Identification of the NF1 Gene Product
The protein product of the NF1 locus has been identified. Using antibodies generated against fusion
proteins and synthetic peptides, a unique 250-kDa protein is identifiable in all cell lines examined. 147151
This NF1-GAP-related protein was originally termed NF1GRP to underscore its relationship to mammalian
GAP and the yeast IRA1 and IRA2 genes (see below). 4, 149 The NNFF consortium agreed to call this
protein product neurofibromin. This protein was localized to the cytoplasm by differential centrifugation,
- 23 -
glycerol gradients, and indirect immunofluorescence. 147, 150 The difference between the predicted (327
kDa) and the observed (250 kDa) molecular weights results from anomalous migration in SDS-PAGE, not
from posttranslational modifications (DH Gutmann, unpublished results). Expression of the full-length
cDNA in insect cells produces a protein that migrates at 250 kDa. 153 Similarly, antibodies directed against
both N- and C-terminal epitopes all recognize the same 250-kDa protein. 154
The tissue distribution of neurofibromin is somewhat controversial in that the mRNA appears to be present
at some level in all tissues. 1 Initial examination of whole-cell homogenates from mouse and rat tissues
suggested that neurofibromin also was ubiquitously expressed. 149 Subsequent analysis by western
blotting, immunoprecipitation, and immunohistochemistry demonstrated that the highest levels of
expression are in the brain, spleen, kidney, testis, and thymus 102, 148 (DH Gutmann, unpublished data).
Immunohistochemical analysis of tissue sections from human and rodent tissues demonstrates prominent
nervous system expression of neurofibromin. 102, 147, 148 Neurofibromin can be detected in the dendritic
processes of central nervous system neurons (pyramidal neurons in cortical layers 2 and 5 and cerebellar
Purkinje cells), peripheral nervous system neuronal axons, nonmyelinating Schwann cells,
oligodendrocytes, and dorsal root ganglia but not astrocytes, microglia, and myelinating Schwann
cells. 148, 155 Neurofibromin expression is expressed in reactive astrocytes. 156 There does not appear to
be abundant expression in adult lung, muscle, intestine, heart, or skin.
The expression of neurofibromin during embryogenesis is being studied in the avian and rodent systems.
Preliminary results suggest that neurofibromin is expressed in the developing brain and spinal
cord. 100, 101 This pattern of expression potentially could account for the described learning disabilities
previously unattributable to a purely neural crestderived tissue disorder. Neurofibromin expression
appears to rise dramatically after day 10 of mouse development. In the rat, neurofibromin is ubiquitously
expressed from days 10 through 16, after which it becomes increased in spinal cord and brain. 157 At this
time, neurofibromin can be found in skeletal muscle, skin, lung, adrenal cortex, and cartilage. By postnatal
day 6, the distribution of neurofibromin is identical to that seen in adults. These data, combined with the
observation that homozygous mouse NF1 gene knockouts exhibit developmental arrest and death around
embryonic day 13, suggest that events occurring during this time interval depend heavily on the proper
expression of neurofibromin. Future studies directed at understanding these events will provide insights
into the pathogenesis of NF1.
Neurofibromin as a GTPase-Activating Protein
As mentioned earlier, analysis of the amino acid sequence of the NF1 gene product revealed sequence
similarity between a small portion of the gene and a family of GAPs. 4, 158163 These proteins, both in
mammals and in yeast, appear to regulate the GTP state of the cellular p21-ras proto-oncogene. 164, 165
GAP molecules accelerate the hydrolysis of p21-ras-GTP to p21-ras-GDP, converting the proto-oncogene
from the active form to the inactive form. 162, 166 Although the effector of p21-ras in mammalian cells is
unknown, in yeast, p21-ras is important in cAMP regulation. 164, 167, 168 This sequence similarity was
supported by functional studies in mammalian cells and yeast, suggesting that the NF1GRD can act as a
GAP molecule in vitro and in vivo. 57, 169, 170 Recent experiments also have demonstrated that the
full-length neurofibromin molecule has GAP-like activity. 122, 123, 153
It is exciting to postulate that neurofibromin functions as a tumor-suppressor gene product by
down-regulating the normal function of the p21-ras proto-oncogene (Fig. 39-11). Previous studies
demonstrated that p21-ras functions as part of a tyrosine kinase signal transduction pathway involving
receptor tyrosine kinases such as epidermal, nerve, and platelet-derived growth factors (EGF, NGF, and
PDGF) receptors. 171173 Support for the involvement of p21-ras in such pathways derives from a large
- 24 -
number of experiments in a wide variety of signal transduction systems. First, overexpression of the active
form of p21-ras (v-ras) results in neurite extension in a rat pheochromocytoma cell line (PC12) similar to
that observed with NGF treatment. 174, 175 This effect can be reversed by injecting PC12 cells with
antibodies against p21-ras. 176 There are conflicting data regarding the existence of a separate
p21-ras-independent pathway that also culminates in neurite extension. 177 Second, overexpression of
activated p21-ras can induce morphologic transformation of fibroblast cell lines and unlimited cell
proliferation. 178, 179 Third, some fibroblast cell lines can be induced to differentiate into adipocytes with
overexpression of activated p21-ras. 180 Fourth, p21-ras is associated with surface immunoglobulin
capping as part of a signal transduction (antigen presentation) pathway in B lymphocytes. 181, 182
The p21-ras cycle of activation and inactivation by GAP-related proteins. p21-ras is inactive in the
GDP-bound state and is converted to an active GTP-bound state by guanosine nucleotide-replacing
proteins that substitute GTP for GDP. Interaction of GAP-like proteins with p21-ras accelerates the
conversion of p21-ras-GTP to p21-ras-GDP by increasing the intrinsic GTPase activity of p21-ras and
converting p21-ras to the inactive GDP-bound for...
GAP molecules such as mammalian GAP and the yeast IRA1 and IRA2 proteins may serve to regulate
p21-ras-mediated growth and differentiation pathways by maintaining p21-ras in the inactive GDP-bound
state. This model is supported by studies that demonstrate that stimulation of tyrosine kinase receptors
such as the EGF and PDGF receptors results in phosphorylation of mammalian GAP on tyrosine residues
and inactivation of its GTPase-activating properties. 172, 183, 184 This inactivation would lead to increased
- 25 -
p21-ras in the active GTP-bound state and to unregulated cell proliferation in the case of EGF and PDGF.
The role of GAP in NGF receptor signal transduction pathways leading to cell differentiation and neurite
extension is less well understood. By analogy, it is appealing to suggest that inactivation of neurofibromin
as a result of mutation results in higher levels of p21-ras-GTP within affected cells and unlimited cell
proliferation, leading to the formation of neurofibromas or neurofibrosarcomas. As was stated previously,
examination of three neurofibrosarcomas demonstrated dramatically reduced expression of neurofibromin
and elevated p21-ras-GTP levels. 122, 123 Neurofibromin is phosphorylated on serine and threonine
residues in response to EGF and PDGF stimulation but not on tyrosine residues and therefore must
involve a pathway distinct from the tyrosine phosphorylation cascade that acts on mammalian GAP. 185, 186
Recent studies have suggested that neurofibromin may suppress cell growth through mechanisms
unrelated to ras regulation. In NIH3T3 fibroblasts, overexpression of the NF1 tumor-suppressor gene
resulted in a threefold reduction in cell growth without any changes in ras activity. 187 Similarly,
overexpression of full-length neurofibromin in a human colon carcinoma cell line resulted in reduced tumor
growth in nude mice. In these experiments, the growth-suppressor activity of neurofibromin resulted from
neurofibromin interfering with ras activation of raf. 188, 189 Finally, ras activity can regulate neurofibromin
expression. 44 This finding suggests either that neurofibromin is a critical regulator of ras in some cells or
that neurofibromin may be stimulated by ras activation to perform some other function or functions within
cells. Further work will be required to distinguish between these nonmutually exclusive possibilities.
Neurofibromin Associates with Cytoplasmic Microtubules
Subcellular localization of neurofibromin demonstrated an association with cytoplasmic microtubules by
indirect immunofluorescence and biochemical purification. 150, 154, 190 Previously described
microtubule-associated proteins (MAPs) fall into three classes based on their molecular weights: MAP1
(250 kDa), MAP2 (250 kDa), and tau (35 to 65 kDa). 191194 Some of these proteins are involved in the
stabilization of microtubules through bundling, a process in which the tight association of microtubule
filaments is facilitated. 195, 196 Other MAP molecules actively promote microtubule movement, and some
are involved in microtubule-mediated intracytoplasmic transport. 197 Subpopulations of microtubules are
implicated in signal transduction pathways involving neurotransmitters and surface receptors. 198
Biochemical properties of MAP molecules include GTP and temperature-dependent microtubule
association, dissociation from microtubules by ion-exchange chromatography, improved association with
taxol treatment, and coimmunoprecipitation with tubulin. 199204 These properties have been observed
with neurofibromin and indicate that there are specific interactions between neurofibromin and
microtubules. Studies also have demonstrated that tubulin can partially inhibit the GAP activity of
neurofibromin, an effect that is reversed with antitubulin antibodies. 153 In addition, a 20-amino-acid
sequence is found in neurofibromin that is shared with two other MAP molecules (MAP2 and tau) and has
been reported to be a serine phosphorylation sequence that is important in regulating tau association with
microtubules. 150, 205 Phosphorylation of tau on that serine residue results in a conformational change and
dissociation from the microtubules.
The finding that neurofibromin associates with microtubules does not mean that neurofibromin is a MAP.
Intracytoplasmic organelles copurify with microtubules in a manner analogous to MAP molecules, yet
these organelles would not be considered MAP molecules because they lack a role in stabilizing or
facilitating microtubule-mediated functions. Further examination of the biochemical and physical nature of
this association is necessary before neurofibromin can be assigned as a member of the MAP family.
- 26 -
The discovery that neurofibromin is a GAP-like molecule that associates with microtubules suggests
several hypotheses to explain its function in cell growth and differentiation (Fig. 39-12). One model, which
fits the upstream view of p21-ras-GAP interactions, envisions that neurofibromin is regulated by
serine/threonine kinases. 206, 207 Neurofibromin would be active as a GAP while associated with
microtubules, keeping p21-ras in the inactive form and inhibiting cell division. After phosphorylation,
neurofibromin would dissociate from the microtubules, and its GAP activity would be reduced or altered.
Alternatively, neurofibromin could be compartmentalized in the microtubule compartment (perhaps
performing some other function) until it is required for the control of p21-ras. Phosphorylation of
neurofibromin on critical serine residues would release it from the microtubules to interact with p21-ras.
Support for this alternative model is provided by experiments that have failed to demonstrate any
alteration of GAP activity after neurofibromin phosphorylation in vitro. Similarly, the interaction of
neurofibromin with microtubules may actually reduce its GAP activity, as suggested by recent
experiments, 153 and its dissociation from the microtubules may allow neurofibromin to associate with and
down-regulate p21-ras. Of interest is the finding that the same domain of neurofibromin, the GAP-related
domain, is the portion of neurofibromin required for microtubule association, suggesting a direct
relationship between neurofibromin, p21-ras regulation, and microtubule association. 152, 153, 208 Further
studies have demonstrated the involvement of neurofibromin in a B-lymphocyte signal transduction
pathway involving microtubules and p21-ras. In this system, neurofibromin and p21-ras colocalize during
immunoglobulin receptor internalization, and neurofibromin is rapidly phosphorylated. 186 A second model,
which falls into the category of a downstream hypothesis for p21-ras-GAP interaction, is that
neurofibromin is induced by the process of p21-ras-GTP to p21-ras-GDP conversion to transmit a signal
through its influence on microtubule organization. Further investigations will be required to refute or
support either of these two nonmutually exclusive hypotheses unequivocally.
- 27 -
Upstream versus downstream models of p21-ras-neurofibromin interactions. A. In the upstream model,

stimulation of appropriate cells expressing growth factor receptors leads to an inactivation of
neurofibromin, perhaps through phosphorylation cascades. Inactivation of neurofibromin releases p21-ras
from its down-regulation, allowing p21-ras to predominate in the active GTP-bound form and signal other
intracellular proteins to culminate in cel...
Neurofibromin Isoforms
Several isoforms of neurofibromin have been identified that arise from alternative splicing. 2, 98 The first
inserts 21 amino acids within the NF1GRD. This type 2 isoform is expressed in tissues different from
those in which type 1 neurofibromin is expressed and may be regulated by brain-specific differentiation
events. 209 It is expressed in many species, including chickens. 210 The type 2 isoform is the predominant
mRNA species after week 22 of human fetal development and can be induced in a neuroblastoma cell line
by retinoic acid treatment. 209 Similar induction of type 2 neurofibromin expression is observed during
Schwann cell differentiations, as reflected by an increase in NF1 mRNA and neurofibromin levels as well
as a switch from type 1 to type 2 NF1 mRNA in Schwann cells stimulated to differentiate in response to
- 28 -
treatments that increase intracellular cAMP. 210, 211 In addition, NF1 isoform expression is altered during
mouse embryogenesis, with type 2 NF1 mRNA expressed before embryonic day 10 and type 1 NF1
mRNA predominating thereafter. 212 Studies in yeast demonstrate that this isoform also has GAP-like
catalytic activity, although moderately reduced from that observed with native type 1 neurofibromin. 210
Whether this isoform can associate with cytoplasmic microtubules is being investigated.
A second, less well-characterized isoform has been identified near the C-terminus of the protein and
results from an 18-amino-acid insertion. 2, 98 This isoform is detected on the RNA level predominantly in
muscle. It is expressed in cardiac muscle (both fetal and adult), skeletal muscle, and some smooth muscle
tissues. 213 Little or no expression is found in brain, spleen, or kidney. The expression of an isoform of
NF1 in muscle is intriguing in light of a small number of patients with NF1 and cardiac disease. 214, 215 In
addition, it was demonstrated recently that neurofibromin expression increases while p21-ras activity
decreases in myoblasts stimulated to differentiate in vitro. 141 Similarly, neurofibromin is transiently
expressed in developing myotomes during murine and chick embryonic development. 100, 151, 157 The
relationship between the muscle expression of this isoform and the clinical manifestations of NF1 remains
unelucidated.
Recently, an additional isoform of the NF1 gene was identified that is expressed predominantly in the
brain. 216 This alternatively spliced isoform containing exon 9a is enriched in human and rodent cerebral
cortex, where its expression correlates with cortical neuron maturation both in vitro and in vivo. 217 The
finding of a brain-specific NF1 isoform suggests that neurofibromin may play unique roles during central
nervous system development.
BIOLOGIC PROPERTIES OF NEUROFIBROMAS
Both plexiform and cutaneous neurofibromas can arise from any nerve throughout the body and at any
time, including embryonically. Neurofibromas tend to grow more rapidly during pregnancy and puberty,
implying some hormone sensitivity. 218, 219 Neurofibromas grow as a mixed population of cells that
includes fibroblasts, mast cells, Schwann cells, axons, perineural cells, and endothelial cells. 218224 The
clonal nature of neurofibromas is controversial and has not been resolved conclusively. 225, 226
Neurofibromas have been found to contain mitogens that stimulate Schwann cell and fibroblast
proliferation. 227, 228 One study using purified Schwann cells from neurofibromas demonstrated that these
NF1 Schwann cells promoted angiogenesis and could invade chick chorioallantoic membranes. 229 These
results suggest that neurofibroma Schwann cells are intrinsically different from normal Schwann cells.
NF1 fibroblasts also have been examined for evidence of abnormal growth characteristics. Although many
of these studies have been difficult to reproduce, it has been suggested that NF1 fibroblasts are more
sensitive to ionizing radiation and have an increased rate of transformation by Kirsten murine sarcoma
viruses. 230233
Diagnosis and Treatment
Conventional Treatment of NF1 Patients.
The treatment of patients affected with NF1 often requires the expertise of many medical and surgical
subspecialists coordinated by one physician or a team of physicians familiar with NF1. 234 For this reason,
we advocate the establishment of neurofibromatosis clinics staffed by physicians who regularly see NF1
patients and are familiar with the diagnosis, management, and complications of the disorder. Closely
affiliated with the clinic should be a diverse collection of other physicians and health care providers with
subspecialties in given areas of medicine or surgery. These persons include ophthalmologists,
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neurologists, plastic surgeons, neurosurgeons, otolaryngologists, psychiatrists, social workers, child

psychologists, orthopedic surgeons, dermatologists, and oncologists. The role of an NF clinic is not only to
provide coordinated care from a centralized caregiver familiar with NF1 but also to provide up-to-date
information to patients and their families about the disease through regular communication via
NNFF-sponsored newsletters and scientific symposia.
The approach to a new patient suspected of having NF1 involves careful history taking and examination.
Before the clinic appointment, it is helpful for a genetic counselor to contact the patient to review the
patients clinical features and family history. Often this phone call will precipitate further investigation on
the part of the patient and family members in an attempt to determine which other family members have
features consistent with NF1. A careful exploration of the family may uncover relatives with subtle features
of NF1; this is particularly true in light of its variable expressivity. Hospital records, autopsy reports, and
surgical pathology reports also should be requested.
Once the patient arrives in the clinic, he or she should be examined thoroughly by one of the NF1
physicians. A careful cutaneous examination is performed to look for palpable neurofibromas, axillary or
inguinal freckling, and caf-au-lait spots. The caf-au-lait spots can be better visualized under a Wood
lamp. The number of pigmented lesions and their greatest diameters are recorded. An ophthalmologic
examination with attention to measurement of visual acuity is important to rule out symptomatic optic
glioma. In individuals beyond the age of 7 to 8, inspection of the iris should reveal Lisch nodules,
especially in patients with light-colored irises. If Lisch nodules are not appreciated and diagnostic criteria
for NF1 have not been met, referral to an opthalmologist for a slit-lamp evaluation is made. During a
general physical examination, attention is focused on the detection of any curvature of the spine,
especially in young children. Severe cases are referred to an orthopedic surgeon. In addition, inspection
of the long bones of the upper and lower extremities is warranted in young children to exclude bowing and
thinning of the cortices of these bones and prevent the formation of pseudarthroses. Suspicious bones are
examined by plain x-rays, and affected patients are referred to an orthopedic surgeon knowledgeable
about the bracing and management of this problem. In children, height, weight, and head circumference
are noted during each visit and are charted to evaluate the childs growth curve. Inspection of the face and
fingers is done to look for facial dysmorphisms or dermatoglyphics suggestive of disorders besides NF1.
In addition, blood pressure should be measured during each visit. We recommend routine general medical
appointments spaced 6 months after each visit to the NF1 clinic to allow for blood pressure determinations
twice a year. Any abnormal rise in blood pressure always warrants further investigation for renal artery
stenosis or pheochromocytoma. Patients should be questioned about headache (location, frequency, and
character) and bowel or bladder difficulties to screen for deep neurofibromatous involvement of splanchnic
nerves.
A screening neurologic examination should be performed during each visit, with special attention to visual
acuity, visual fields, and funduscopic evaluation. We strongly advocate the limited and directed use of
brain imaging studies and do not obtain them unless there is a change in the symptoms or in the
neurologic examination. The limited use of brain imaging studies is based on the low yield of these studies
in detecting asymptomatic lesions that require treatment as well as the high likelihood of finding a
high-intensity lesion on T 2 -weighted MRI. These high-intensity lesions are sometimes referred to as
UBOs and can be seen in upward of 60 percent of these children. Their clinical significance is uncertain,
and their detection often raises unnecessary concern on the part of both the family and the physician.
- 30 -
During the evaluation, attention is also paid to the social history. In children, school performance is a good
reflection of overall learning ability. Formal evaluation of IQ by the school district is recommended early
(age 3 to 4) to identify children with learning disabilities. Early detection and aggressive intervention
appear to be beneficial in NF1 patients. We encourage families to communicate regularly with the school
and to obtain physical, speech, and occupational therapy as appropriate.
Patients with NF1 are seen on a yearly basis in the clinic, during which time they are educated about new
information regarding the disease; a forum is provided for a discussion of their concerns and questions. In
addition, patients are monitored for the development of new complications, and new family members are
evaluated for signs of NF1. The removal of neurofibromas that are particularly large or cosmetically
distressing or that rub on clothing straps is coordinated with a plastic surgeon. Otherwise, we encourage
patients not to have multiple neurofibromas removed solely for cosmetic reasons, since they can grow
back in these areas after surgery.
An integral part of the diagnosis and care of NF1 patients involves the genetic counselor. In our clinic,
genetic counselors explain in detail the pattern of inheritance of NF1 (autosomal dominant), its penetrance
(essentially 100 percent by 5 years of age), and its variable expressivity. Education is provided, and
common misconceptions regarding the disease are dispelled. The emotional impact of NF1 on the patient
as well as the other family members is addressed. Families are also given information about support
group resources. Explanations of the natural history of the disorder, its behavior during puberty and
pregnancy, and its unpredictability are explored. Prenatal counseling is provided for the parents and
siblings of affected patients. Prenatal testing, when appropriate, is offered to families in which linkage
analysis is informative (see below).
Molecular Genetic Approaches to NF1 Patients.
With the entire NF1 gene cloned and the protein identified, it is now theoretically possible to study gene
mutations in patients with NF1. The approaches taken to screen for mutations involve a combination of
DNA, RNA, and protein analysis. However, given the large size of the gene and the heterogeneity of the
mutations, the search for causative mutations is quite labor-intensive. In the years since cloning of the
full-length NF1 gene, only a handful of mutations have been characterized owing to the arduous task of
screening 60 exons for DNA alterations. Therefore, routine clinical application of DNA analysis in the
diagnosis of NF1 is not yet a reality. In families in which the clinical diagnosis is certain, multiple members
are affected, and closely linked polymorphic markers are informative, linkage analysis using closely
spaced markers or microsatellite repeat sequences remains the most practical application of DNA
diagnostics. 235
It is possible that mutations in different regions and/or domains of the NF1 gene will produce different
phenotypes, as has been demonstrated for mutations within the dystrophin gene. As was true with the
dystrophin gene, in which other related but distinct disorders were caused by mutations within the same
gene, it is important to study neurologic disorders with abnormalities similar to those found in NF1 for
alterations in the NF1 gene.
To date, it has not been possible to provide diagnostic information by surveying for alterations at the
protein level. No anomalously migrating protein species have been observed, as was noted for Becker
muscular dystrophy. It appears that all the mutations described so far result in a lack of neurofibromin
expression as opposed to a smaller or larger protein product. Theoretically, an assay capable of
distinguishing 100 percent levels from 50 percent levels of neurofibromin could detect most affected
individuals (since most mutations would be null at the protein level). This requires a level of reliable
- 31 -
quantification that has not been achieved, however.

NF1 remains a clinical diagnosis. Using the diagnostic criteria established in the NIH consensus
statement, the diagnosis of NF1 can be made confidently in the vast majority of individuals. For selected
individuals desiring prenatal diagnosis, genetic testing and counseling can be provided. In families with
two or more affected individuals with NF1, linkage analysis can be performed. Recently, a commercial test
for NF1 gene mutations was developed that relies on a protein truncation assay. 236 With this technique,
RNA from white blood cells is reverse transcribed and converted into overlapping NF1 cDNA fragments in
vitro. Neurofibromin proteins from individuals with NF1 that are larger or smaller than the predicted
fragment sizes are then used to direct the search for the underlying NF1 gene mutation. The advantage of
this system is the speed with which mutations potentially can be identified. However, it is unclear at this
point whether this test will identify a significant portion of NF1 gene mutations in individuals with NF1 to
warrant more widespread use.
The cloning of the NF1 gene has opened the door to a more complete understanding of NF1 pathobiology
with the eventual goal of designing specific, nonsurgical treatments for affected patients. The finding of
elevated p21-ras-GTP levels in tumors from NF1 patients suggests that drug therapies directed at
up-regulating neurofibromin GAP activity or down-regulating p21-ras activity may have a beneficial effect
on the growth of neurofibromas. A number of groups have been studying the lipid sensitivity of
neurofibromin GAP activity in vitro and have found that specific lipids preferentially alter neurofibromin
GAP activity as opposed to mammalian p120-GAP catalytic activity. 169, 237239 The discovery of a
compound capable of up-regulating or replacing neurofibromin may prove to be a useful therapy in the
future.
Similarly, drugs that interfere with p21-ras activity, such as pharmaceutical agents that block farnesylation,
a reaction necessary for p21-ras membrane localization, may have therapeutic potential in NF1. 240242
Farnesylation-blocking agents have been shown to inhibit the mitogenic effects of growth factors and the
tumorigenic properties of neuroblastoma cells. More useful therapies may involve drugs that inhibit
farnesyl transferase (the addition of farnesyl groups to the p21-ras protein) rather than lovastatin and
compactin, which are HMG-CoA reductase inhibitors that block farnesyl synthesis. Further study of these
and related drugs may uncover useful therapies for NF1 patients.
ACKNOWLEDGMENTS
We thank the members of our neurofibromatosis research group, past and present, especially Drs. Lone
Andersen, Steve Doran, Jane Fountain, R. Todd Geist, Paula Gregory, Douglas Marchuk, Anna Mitchell,
Margaret Wallace, and Susan Wilson-Gunn. We also thank our collaborators elsewhere, including Drs.
Roymarie Ballester, Dafna Bar-Sagi, Mark Boguski, Gideon Bollag, Dennis Choi, Jeff DeClue, Julian
Downward, Ab Guha, Chung Hsu, Tyler Jacks, Richard Jove, David Louis, Douglas Lowy, Frank
McCormick, Lynn Rutkowski, Gihan Tennekoon, and Michael Wigler. We also thank numerous members
of the NF1 research community for providing preprints of manuscripts and are particularly grateful to Dr.
Susan Huson for supplying drafts of several chapters on the clinical manifestations of NF1. Nancy North
provided expert assistance in the preparation of this manuscript.
- 32 -
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Chapter 39: Neurofibromatosis 1

PART 5: Familial Cancer Syndromes, III. Defects in Gatekeepers

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

Crowe et al. (1956)

Surveys of admissions at general hospital

Population sample of 16-year-old

Huson et al. (1989)

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

Typical Lisch nodules (hamartomas) of the iris in an adult with NF1.

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

Massive plexiform neurofibroma of the lower extremity in an adolescent with NF1.

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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Chapter 39: Neurofibromatosis 1

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