PTEN hamartoma tumor syndrome in children: Identification of recurrent mutations, an unpublished variant and a case of cerebral cortical dysplasia co-occurring with pleuropulmonary blastoma. Review of PTEN-related malformations of cortical development

PTEN hamartoma tumor syndrome in children: Identification of recurrent mutations, an unpublished variant and a case of cerebral cortical dysplasia co-occurring with pleuropulmonary blastoma. 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Review of PTEN-related malformations of cortical development Marinna Csenki, Tibor Kalmár, Tamás Zombori, Levente Kuthi, Viktor Vedelek, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8070330/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract PTEN hamartoma tumor syndrome (PHTS) is caused by germline heterozygous pathogenic variants of the tumor suppressor PTEN gene, crucial for the regulation of the PI3K-AKT-mTOR pathway. PHTS encompasses several different syndromes with overlapping clinical features, such as PTEN-related macrocephaly and autism syndrome, Bannayan-Riley-Ruvalcaba, Cowden, Lhermitte-Duclos, Proteus and Proteus-like syndromes. In this study, the clinical and molecular findings of five children, aged 1.5-18 years, with PHTS confirmed by clinical exome sequencing are reported. Megalencephaly, delayed development, autism spectrum disorder, and intellectual disability were the main phenotypic features in four cases with missense variants (Pro95Leu, Cys136Arg, Arg173His, and Ile253Thr). One of these variants (Ile253Thr) is still unpublished. A truncating variant (Arg335Ter), however, was associated with an extended segmental cerebral cortical dysplasia, and pleuropulmonary blastoma, neither of them reported yet in association with this pathogenic PTEN variant. DICER1 mutation was not identified in the lung tumor; however, a PTEN somatic delin variant [c.197_200delins CG p.(Lys66ThrfsTer7)] causing frameshift as a second hit in the tumor co-occurred with the germline truncating variant. Conclusion: This study expands the clinical and molecular spectrum of PHTS in childhood, highlighting a novel variant. In addition, a unique co-occurrence of segmental cerebral cortical dysplasia and pleuropulmonary blastoma in association with the pathogenic Arg335Ter PTEN variant is described. A somatic PTEN variant, as a second hit might have contributed to the genesis of the lung tumor. PTEN hamartoma tumor syndrome PTEN gene PTEN protein Macrocephaly Megalencephaly Developmental delay Intellectual disability Autism spectrum disorder Cerebral cortical dysplasia Pleuropulmonary blastoma Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 What is Known PTEN hamartoma tumor syndrome (PHTS) is caused by germline heterozygous pathogenic variants of the tumor suppressor PTEN gene, crucial for the regulation of the PI3K-AKT-mTOR pathway. PHTS encompasses several different syndromes with overlapping clinical features, such as PTEN-related macrocephaly and autism syndrome, Bannayan-Riley-Ruvalcaba, Cowden, Lhermitte-Duclos, Proteus, and Proteus-like syndromes. What is New: This study presents a series of five patients with PHTS and expands the genotypic spectrum with a novel missense variant (Ile253Thr) in the PTEN gene. The co-occurrence of segmental cerebral cortical dysplasia and pleuropulmonary blastoma in association with the germline truncating Arg335Ter variant of PTEN is reported for the first time. A somatic delin variant [c.197_200delins CG p.(Lys66ThrfsTer7)] causing frameshift in PTEN was also identified in the lung tumor as a second hit. Introduction PTEN Hamartoma Tumor Syndrome (PHTS) is a rare genetic disorder caused by heterozygous germline pathogenic variants of the tumor suppressor PTEN (Phosphatase and Tensin homolog) gene on chromosome 10 at position q23.31 (OMIM# 601728). Haploinsufficiency of PTEN may lead to an increased phosphorylation of different cellular proteins resulting in excessive activity of the PI3K-AKT-mTOR pathway leading to benign and malignant tumors and overgrowth [ 1 , 2 ]. PHTS encompasses several different syndromes with overlapping clinical features [ 3 – 5 ]. PTEN -related macrocephaly (head circumference more than + 2 SD) and autism syndrome (OMIM# 605309) can be associated with a wide range of intellectual abilities [ 6 , 7 ]. Bannayan-Riley-Ruvalcaba syndrome with manifestations in childhood and Cowden syndrome, an adult-onset condition proved to be one disorder due to pathogenic PTEN variants, though presenting variably at different ages (OMIM# 158 350) [ 8 , 9 ]. Lhermitte-Duclos syndrome (OMIM# 158310), a hamartomatous overgrowth of the cerebellum (dysplastic gangliocytoma) is deemed as a pathognomonic disorder of PHTS. A few cases of Proteus (OMIM# 176 920) and Proteus-like syndromes (OMIM# 158 350) with features of overgrowth of different body parts are also associated with PTEN mutations [ 3 – 5 , 7 ]. Studies in adult patients with PHTS indicate that germline PTEN variants are associated with increased lifetime risk of breast, endometrial, thyroid, kidney, and colorectal cancers, as well as melanoma, collectively referred to as PHTS component cancers [ 10 , 11 ]. Other cancers beyond those known to be associated with the syndrome have also been reported and called non-component cancers [ 11 ]. Cancer risk, particularly the threat of thyroid tumor is elevated also in children and young adults with PHTS [ 10 , 12 ]. While MRI findings of brain abnormalities, like enlarged perivascular (Virchow-Robin) spaces, multifocal white matter signal abnormalities, mega corpus callosum and cerebellar dysplastic gangliocytoma are well known in PHTS syndrome, the occurrence of malformations of cortical development appears quite rare [ 7 , 13 – 18 ]. Clinical presentation of pediatric patients with pathogenic PTEN mutations has been reviewed earlier [ 5 , 19 ]. We expand the genotypic and phenotypic spectrum of pediatric PTEN hamartoma tumor syndrome by reporting on a small series of five patients with de novo germline heterozygous PTEN variants. One of the variants (Ile253Thr) is still unpublished, while four of them (Pro95Leu, Cys136Arg, Arg173His, Arg335Ter) have already been described [ 20 ]. Megalencephaly, delayed development, autism spectrum disorder, and intellectual disability were the main phenotypic features in four cases with missense variants (Pro95Leu, Cys136Arg, Arg173His, and Ile253Thr). A truncating variant (Arg335Ter), however, was associated with an extended segmental cerebral cortical dysplasia, not reported yet in combination with this PTEN variant. In addition, pleuropulmonary blastoma as a non- component cancer was also found in this boy. DICER1 mutation was not identified in the lung tumor; however, a PTEN somatic delin variant [c.197_200delinsCG p.(Lys66ThrfsTer7)] causing frameshift as a second hit co-occurred with the germline truncating variant. To our knowledge pleuropulmonary blastoma has not been reported yet in combination with PHTS. A brief overview of the PTEN -related malformations of cortical development is also provided. Materials and methods This study was part of a larger research project on neurodevelopmental disorders. Clinical evaluations were performed by specialists in clinical genetics and pediatric neurology. The following tests were carried out for the patients with negative results: karyotype, MLPA, or comparative genome hybridization (aCGH), metabolic workup including plasma amino acids, urine organic acids, and plasma acylcarnitines. Endocrinology consultation and growth hormone tests were requested for patients with accelerated growth and macrosomia. Genomic DNA was extracted from peripheral blood samples with the Puregene Kit (Gentra). Clinical exom sequencing was performed by the use of either the Illumina Trusight One Exome Sequencing Panel covering the coding region of 4.813 clinically relevant genes or Illumina DNA Prep with Exome 2.5 Enrichment (both from Illumina Inc.: San Diego California, United States). Raw sequence data analysis, including base calling, de-multiplexing, alignment to the GRCh37 human reference genome, and variant calling, were performed using an in-house GATK joint model pipeline. For variant filtration, all disease-causing variants reported in HGMD, ClinVar, along with all variants with minor allele frequency (MAF) of less than 1% in the ExAc database, were considered. Variants that possibly impair the protein sequence, such as the disruption of conserved splice sites, missense, nonsense, read-throughs, or small insertions/deletions were prioritized. The large head in patients with pathogenic PTEN mutations is referred to as macrocephaly in most of the reports. In reality, these patients have megalencephaly due to an overgrowth of the brain as seen by MRI in humans and measured experimentally in mice with homozygous or heterozygous missense Pten mutations [21-23]. Macrocephaly may be related to a wide variety of causes other than megalencephaly, including hydrocephalus, enlargement of extra-axial spaces and skeletal dysplasia [23]. The term megalencephaly is used in this study. All imaging studies were retrospectively reviewed. MRI was performed on a variety of different scanners and models at different ages. MRI protocols thus also varied, although all evaluated imaging studies included at least axial and sagittal T1-weighted, axial T2-weighted, axial FLAIR, and axial DWI imaging. Neuroimaging studies were reviewed for the presence of cortical abnormalities including abnormal gyral pattern, focal cortical dysplasia, diffuse or localized pachygyria, hemimegalencephaly, polymicrogyria, or gray matter heterotopia. Gyral patterns with non-specific malformations were designated as dysgyria . In dysgyria, the imaging shows areas of variable cortical thickness and an abnormal gyral pattern characterized by irregularities of sulcal depth and orientation. The sulci are radially oriented, or narrow gyri are separated by abnormally deep or shallow sulci. The gray-white matter boundary is smooth. This imaging appearance is not typical for simplified gyral pattern, polymicrogyria, or pachygyria [23]. In a previous study, an abnormal pattern of gyrification that was suggestive of polymicrogyria in only one imaging plane in PTEN mutations was referred to as atypical gyration [15]. In another publication abnormal gyral pattern in PTEN mutations with too numerous and too shallow gyri without overt cortical thickening or saw-toothed pattern seen in polymicrogyria was called complicated gyral pattern[18]. The term dysgyria is used in this study, as it appears to cover the features described in the latter studies. Moreover, a malformation with cortical dysplasia involving several lobes is referred to as multilobar segmental cortical dysplasia in this studyinstead of (lobar) hemimegalencephaly, or dysplastic megalencephaly, designations applied by other authors [1, 15, 18]. All brain imaging studies were also assessed for the presence of other structural abnormalities described in PTEN -related disorders, such as dilated perivascular spaces (Virchow-Robin spaces), multifocal T2/FLAIR hyperintensities in the white matter, ventriculomegaly and callosal dysgenesis. Patients’ medical reports and results Patient 1 This boy was born at term by vaginal delivery as the 3 rd child from the fourth uneventful pregnancy to healthy non-consanguineous Caucasian parents. The intrauterine development of the fetus was also advanced for his gestational age. His birth weight was 4100 g (+1.1 SD) and Apgar scores were 10, 10, and 10 at 1, 5, and 10 minutes, respectively. His head circumference was 37 cm (+0.7 SD) and his length 54 cm (+1.5 SD) at birth. A younger brother of the index patient is healthy. A girl from the mother’s former relationship is healthy, however a boy from the same previous relationship has cystic fibrosis and underwent lung transplantation. The proband’s development was delayed. Unsupported gait developed by the age of 14 months. On examination at the age of 2.5 years his head circumference was 58 cm (+6.0 SD), and his height was 107 cm (+4.0 SD). Dysmorphic features in addition to megalencephaly included broad forehead, flat nasal bridge, and bilateral epicanthic folds. Vascular anomalies were not observed. Vision and hearing were normal. His speech development was also lagged behind. He was not able to keep eye contact beyond a few second. He had hand stereotypies and difficulties with his fine motor movements. He had attention deficit and poor interest in the surroundings. The Brunet-Lézine test revealed delay in all fields of development with a quotient of 47. There was a strong suspicion of autism spectrum disorder. Cranial MRI at the age of 2.5 years demonstrated bilateral dysgyria in the frontal areas. Dilated perivascular spaces were also observed in the posterior periventricular areas in addition to T2 and FLAIR hyperintensities. Clinical exome sequencing revealed a heterozygous missense variant in exon 5 of the PTEN gene: NM_000314.4:c.284C>T, NP_000305.3:p.(Pro95Leu) (Table 1, 2). This variant was de novo , not present in the parents and younger brother. It was absent from control populations (GnomAD). This variant was described as pathogenic in the literature (http://ncbi.nlm.nih.gov/clinvar/). Patient 2 This patient, a girl was born from the second pregnancy at the 36th gestational week by vaginal delivery to a drug-addicted mother. Antenatal screening tests were normal. Her birth weight was 2600 g (0.0 SD), head circumference 33 cm (+0.5 SD). Apgar scores were 9, 10 and 10 at 1, 5 and 10 minutes, respectively. Her adaptation to the extrauterine life was normal; however, her development was delayed. There was no evidence of intrauterine infection, or inborn error of metabolism. On examination, at the age of 4 years her head circumference was 58 cm (+5.5 SD), body weight 15 kg (-0.5 SD) and height 100 cm (-0.2 SD). Dysmorphic features included frontal bossing in addition to megalencephaly, low set ears, hypertelorism, and skin tags on the left little finger. She responded to elementary visual and auditory stimuli, however, she had very short attention span. Intellectual disability was obvious in association with disruptive, impulsive, poorly controlled behavior. She was able to walk without support. Muscle tone was slightly reduced with retained patella reflexes. Brain MRI at the age of 3 years revealed dysgyria mainly in the frontal and parietal areas. Dilated perivascular spaces and focal hyperintensities in the white matter on T2 and FLAIR images were also observed. Two cysts with cerebrospinal fluid signal intensity probably represented extremely dilated perivascular spaces (Fig. 1). Clinical exome sequencing revealed a heterozygous missense variant in exon 5 of the PTEN gene: NM_000314.4:c.406T>C, NP_000305.3:p.(Cys136Arg) (Table 1, 2). It was absent from control populations (GnomAD). The parents were not available for testing. This variant was described as pathogenic/likely pathogenic in the literature (http://ncbi.nlm.nih.gov/clinvar/). Patient 3 The proband, a boy, was born at term by Cesarean section for unrelated Caucasian parents. The pregnancy occurred following in vitro fertilization. Noninvasive prenatal testing (NIPT) showed no abnormalities. Fetal echocardiography revealed no cardiac abnormalities. Apgar scores were 10, 10, and 10 at 1, 5, and 10 minutes, respectively. His birth weight was 4800 g (+2.5 SD). He suffered from irritability and feeding difficulties in early infancy. At the age of 7 weeks his head circumference was 43.5 cm (+2.9 SD) and body weight 5600 g (+0.9 SD). Dysmorphic features in addition to megalencephaly included frontal bossing and small chin. He responded to visual and auditory stimuli. Moderate axial hypotonia with head lag was observed. Deep tendon reflexes were present. Head ultrasound revealed normal brain structure. Brain MRI at 7 months of age appeared to be normal. Interpretation of gyrification and white matter signal abnormalities was limited at this age. At the last follow up, at 10 months of age his gross motor development and use of hands were normal. His head circumference was 51.5 cm (+4.3 SD). He was interested in the surroundings and was able to stand up with support. The Bayley Scales of Infant and Toddler Development III test was performed at the age of 16 months and it explored a mild underachievement in the cognitive scale. Clinical exome sequencing revealed a heterozygous missense variant in exon 6 of the PTEN gene: NM_000314.4:c.518G>A, NP_000305.3:p.(Arg173His) (Table 1). This variant was de novo , not present in the parents. It was absent from control populations (GnomAD). This variant was described as pathogenic/likely pathogenic in the literature (http://ncbi.nlm.nih.gov/clinvar/). Patient 4 This boy was born at term by vaginal delivery as the second child from the 3 rd pregnancy to healthy unrelated Caucasian parents. The pregnancy was the result of insemination. Apgar scores were 10, 10, and 10 at 1, 5, and 10 minutes, respectively. His birth weight was 4500 g (+1.9 SD), length 56 cm (+2.2 SD) and head circumference 37 cm (+0.7 SD). The patient’s paternal grandfather, father, and elder brother have Asperger syndrome. The proband’s accelerated growth and delay in developmental milestones became obvious after the age of one year. Generalized reduced muscle tone and weakness were observed. He started walking at the age of 15 months. He had difficulties with speech perception and expression. On examination at the age of 14.5 years his head circumference was 61 cm (+4.2 SD) his weight 105 kg (+3.7 SD), and height 180 cm (+1.7 SD). Dysmorphic features beyond megalencephaly included narrow elongated face, prominent, protruding lower jaw (mandibular prognathism), short philtrum, and low-set ears. Obesity stretch marks (striae) were observed on the skin in the abdominal and gluteal areas. Ophthalmology and audiology wee normal. Generalized hypotonia with reduced tendon reflexes were observed, no other neurological signs were present. Intelligence quotient was 78 by the Wechsler Intelligence Scale for Children. Child psychiatry revealed autism spectrum disorder with unimpaired intelligence. Brain MRI at the age of 5 years demonstrated normal cortical architecture, while dilated perivascular spaces were observed bilaterally in the posterior periventricular area. Moderate increase in the signal intensity was also seen posteriorly in the occipital lobes on T2 and FLAIR sequences (Fig. 2). Exome sequencing revealed a heterozygous missense variant in exon 7 of the PTEN gene: NM_000314.8:c.758T>C, NP_000305.3:p.(Ile253Thr). This variant was de novo , not present in the parents (Fig. 2, Table 1). It was absent from control populations (GnomAD). In silico analysis (Varsome, Franklin database and MutationTaster) suggests that this variant is likely pathogenic. This variant has not been published yet, but is listed in ClinVar (version: 07-Jul-2025) as of uncertain significance. Patient 5 The proband, a boy was born at term from the first uneventful pregnancy by Cesarean section to unrelated, healthy Caucasian parents. His birth weight was 3850 g (+0.6 SD), length 52 cm (+0.7 SD) and head circumference 37 cm (+0.7 SD). Apgar scores were 9, 10, and 10 at 1, 5, and 10 minutes, respectively. Left sided focal seizures appeared at the age of 8 days, which were deemed to be due to neonatal infection caused by E coli . Antibiotics and phenobarbital were effective. Myoclonic jerks in the limbs, 20-30 times daily, recurred at the age of 3 months. Cranial CT suggested dysplasia of the right frontal lobe. EEG revealed almost continuous spike/polyspike discharges with maximum over the right frontal region and spreading to other areas. Vigabatrin, valproate, and carbamazepine were ineffective. The seizures subsided by the age of 1 year, although the spike discharges remained continuous over the right hemisphere despite valproate, clobazam, and levetiracetam treatment. At the age of 3 years the seizures recurred in the form of brief repetitive extensions in the arms, loss of muscle tone, and proved to be drug-resistant to various combination of antiepileptic drugs, such as vigabatrin, carbamazepine, valproate, topiramate, clobazam, lamotrigine, and levetiracetam. The EEG showed continuous spike and wave discharges in wakefulness and during sleep with maximum over the right frontal area, consistent with epilepsia partialis continua. The epilepsy proved to be drug-resistant throughout the observation period. Brain MRIat the age of 3 and 16 years revealed severe cortical dysplasia with broad, coarse gyri, shallow sulci, thickened cortex, and smooth surface in the right frontal-parietal areas. High signal intensity on T2 and FLAIR sequences was observed in the white matter underlying the dysplastic cortex (Fig. 3). Increased T2/FLAIR signal intensity was noticed also in the white matter of the left hemisphere suggestive of hypomyelination. A moderate dilatation of the right ventricle and a slight midline shift from left-to-right were observed. An apparent hemimegalencephaly defined as an overgrowth of all or part of a cerebral hemisphere was not evident, therefore the term segmental cortical dysplasia seemed to be appropriate for this malformation. Surgical removal of the focal malformation was considered but not performed because of the patient’s poor general health. The proband’s development was globally severely delayed. He was not able to roll over at the age of 8 months. Left hemiparesis with maximum in the arm became evident after the age of 6 months. Hypotonia, weakness and reduced tendon reflexes were observed. He was not able to sit or stand at the age of 1 year. Head circumference was 48 cm (-0.5 SD) at the age of 2 years. Independent gait started at the age of 5 years. Global developmental delay, intellectual disability, and failure to thrive were observed throughout his follow up; his weight was 40 kg (-2.4 SD) and height 156 cm (-1.9 SD) at the age 16 years. There was no speech at this age. Formal IQ testing was infeasible. Generalized hypotonia, weakness, reduced deep tendon reflexes, and left sided hemiparesis characterized his condition. He was wheelchair-bound. At the age of 18 years his head circumference was 47 cm (-5.4 SD), height 160 cm (-2.0 SD), and body weight 41 kg (-3.SD). Chest CT, requested for recurrent infections at the age of 15 years and MRI one and a half years later showed encapsulated mass containing contrast enhancing solid and cystic parts in the left upper and middle thoracic cavity. Rapid growth of the tumor was observed, and its size was 84x138x133 mm at the time of the MRI. The left lung with the tumor were removed at the age of 16 years. Histology revealed that the tumor was pleuropulmonary blastoma type II (Fig. 4). Chemotherapy was administered according to the CWS 2012 NRTS HR protocol. He was free of tumor recurrence in the next 4 years. The use of several antibiotics was required after the surgery. Parenteral feeding and eventually feeding through percutaneous endoscopic gastrostomy (PEG) tube became mandatory. The cranial MRI performed after the surgical procedure demonstrated a small area with high T2 signal in the right cerebellar hemisphere, ipsilaterally with the cortical dysplasia. This lesion was reported as a stroke caused by embolization during the surgery. During gastroscopy, polyposis was noticed in the stomach and duodenum. Colonoscopy revealed polyposis also in the ileum and rectum. Sequencing the PTEN gene revealed a germline heterozygous truncating variant in exon 8 of the PTEN gene: NM_000314.4:c.1003C>T, NP_000305.3:p.(Arg335Ter) (Table 1, 2, Fig 5). This variant was de novo , known as pathogenic in the literature (http://ncbi.nlm.nih.gov/clinvar/). and it was absent in the parents and the patient’s two brothers. The tumor was examined by the use of Trusight Oncology 500 panel (Illumina). The germline truncating variant was confirmed, moreover a PTEN delin somatic variant [c.197_200delinsCG p.(Lys66ThrfsTer7)] was also revealed in the tumor tissue. This somatic variant led to a frameshift, which might have a role as a second hit in the tumor genesis. DICER1 mutation was not identified in the tumor. Discussion The PTEN gene on chromosome 10q23.31 consists of 9 exons and encodes a 403 amino acid dual-specificity lipid and protein phosphatase, which is capable of dephosphorylating phospho-lipids and phospho-peptides as well. The PTEN protein embodies a phosphatase domain, a C2 lipid or membrane-binding domain, and a PDZ protein-protein interaction motif as the major functional domains. (Fig. 5 ). Exon 5 at the N terminus encodes the phosphatase domain. The PTEN protein is a negative regulator of the PI3K-AKT-mTOR pathway by dephosphorylating PIP3 at the 3’phosphate of the inositol ring resulting in PIP2 [ 24 , 25 ]. When a mutation or loss of PTEN occurs, the elevated PIP3 acts as a second messenger, promoting the subsequent activation of other kinases, which phosphorylate many proteins involved in the most important cellular functions, from proliferation to differentiation, but also apoptosis, angiogenesis and metabolism [ 24 , 25 ]. A large number of different PTEN mutations have been described [ 20 ]. These mutations include missense, nonsense, and splice site mutations, intragenic deletions or insertions, and large deletions [ 4 ]. Exons 5, 7, and 8 are overrepresented in the PTEN germline mutation spectrum. Germline pathogenic variants in PTEN are well-documented causes of PHTS, while sporadic somatic variants of PTEN make this tumor suppressor gene one of the most frequently affected in human malignancies [ 4 ]. Patients 1–3 in this study had de novo germline heterozygous missense variants in the PTEN phosphatase domain (Pro95Leu, Cys136Arg, and Arg173His) in association with megalencephaly and developmental delay. Intellectual disability was also obvious in Patients 1 and 2. These variants have previously been reported as pathogenic (Pro95Leu), or pathogenic/likely pathogenic (Cys136Arg and Arg173His) [ 19 , 20 , 21 , 26 – 44 ]. In a report on a large cohort of pediatric patients with pathogenic PTEN mutations (including Pro95Leu and Arg173His), clear genotype-phenotype relationship has not been found [ 19 ]. Developmental delay, intellectual disability and autism spectrum disorder in the presence of megalencephaly were found in 66% of these children. Only one of 47 patients did not have megalencephaly at the time of the diagnosis [ 19 ]. Dermatological features, including café-au-lait spots, skin tags, papillomatous papules, haemangioma trichilemmomas, hyperpigmented and hypopigmented lesions, lipomas, and soft tissue masses have been reported in 66% of the pediatric patients with germline PTEN mutations [ 19 ], however, mucocutaneous lesions were not noticed in our patients. Thyroid abnormalities were recognized by ultrasound only in 7 children out of 27 pediatric patients with PTEN mutations. Thyroid carcinoma was not found suggesting that this type of tumor is rare in children suffering from PTHS [ 19 ]. There were no PTHS-related tumors in Patients 1–4 in this study. In Pro95Leu mutation, the proline at position 95 has been replaced by leucine, an amino acid with similar properties. Experimental functional studies for this variant in humanized yeast-based bioassay demonstrated partially reduced phosphatase activity when compared to wild type PTEN [ 35 ]. In Cys136Arg mutation diminished cellular PTEN protein level was found in association with upregulated proteasome activity in experimental studies. The misfolded protein as a result of the Cys136Arg missense variant after conjugation with ubiquitin might induce proteotoxic stress leading to proteasome hyperactivity [ 37 ]. Loss of the unstable PTEN due to enhanced proteasomal degradation may result in functional insufficiency of the protein function. Experimental studies suggested that the Arg173His mutation leads to reduced phosphatase activity of the PTEN protein in vitro [ 27 ], however, a yeast-based bioassay demonstrated later that the phosphatase remained active [ 35 ]. Evidently, further studies are required in order to elucidate the molecular mechanisms of pathogenicity of PTEN missense mutations. The c.758T > C, p.(Ile253Thr) sequence change in Patient 4 replaces isoleucine which is neutral and non-polar, with threonine, which is neutral and polar, at codon 253 of the PTEN protein in the C2 domain. This variant is not present in population databases (gnomAD), and has not been reported yet in the literature in individuals affected with PTEN-related conditions. ClinVar contains an entry for this variant (Variation ID: 1001963), and it has been classified as a variant of uncertain significance. In silico analysis of this variant suggested that it was likely pathogenic. Two submissions to ClinVar of another variant of the same codon (c.758T > G), causing different amino acid substitution (Ile253Ser) have been classified either as likely pathogenic or a variant of uncertain significance [ 20 ]. Indeed, Patient 4, who had megalencephaly (macrocephaly), delayed development, and autism spectrum disorder with preserved cognitive functioning seems to comply with the criteria of PHTS, taking into account major and minor criteria described earlier [ 6 , 33 ]. Various abnormalities were described in the overgrowing brain in PHTS, such as cerebellar dysplastic gangliocytoma called Lhermitte-Duclos disease, low lying cerebellar tonsils (Chiari 1 malformation), meningioma, developmental venous anomalies, cavernomas, microhemorrhages, arteriovenous fistula, and pontine capillary telangiectasia [ 7 , 14 , 17 , 45 ]. The most commonly published MRI abnormalities, however, were dilated perivascular spaces and multifocal white matter abnormalities that showed hyperintensity on T2-weighted and FLAIR images [ 13 , 14 , 16 , 17 ]. It was suggested that this MRI pattern in the appropriate clinical context should prompt consideration of the diagnosis of PTEN spectrum disorders [ 13 ]. Patients 1, 2, and 4 in this study showed dilated perivascular spaces, and T2/FLAIR hyperintensities by MRI. The structural basis of cerebral overgrowth in PHTS have been studied in experimental animals and humans as well. Increased proliferation of glial cells, neuronal, and dendritic hypertrophy were observed in mouse models with germline heterozygous PTEN mutations [ 47 ]. In humans, quantitative evaluation of brain morphology and connectivity by MRI was carried out in order to designate the cerebral areas most affected by overgrowth in PHTS. Mega corpus callosum, significantly increased cortical surface area, cortical gray and white matter volumes were found in PHTS patients compared to neurotypical controls [ 46 ]. High angular resolution diffusion MRI tractography showed increased volume and length of callosal pathways and increased volume of the arcuate fasciculi connecting Broca’s and Wernicke’s areas. Increased length of various white matter tracts, such as the bilateral inferior longitudinal fasciculi, bilateral inferior fronto-occipital fasciculi, and bilateral uncinate fasciculi were also demonstrated [ 46 ]. These findings are in line with the routine MRI findings, which may show expanded white matter areas (Fig, 1A,B). Malformation of cortical development in addition to global developmental delay, intellectual disability, failure to thrive and gastrointestinal polyposis were striking abnormalities in Patient 5 with a de novo pathogenic heterozygous nonsense mutation [c.1003C > T, p.(Arg335Ter)] in PTEN . This pathogenic variant has previously been published several times, however cerebral cortical malformation has not been reported in association with this variant [ 6 , 8 , 19 , 33 , 34 , 36 , 37 , 42 , 43 , 48 , 49 – 56 ]. Moreover, Patient 5 had DICER1 negative pleuropulmonary blastoma as well, not published yet in association with pathogenic PTEN variants. The Arg335Ter variant affecting the protein in the C2 domain is the most common truncating variant [ 42 ]. Experimentally in Arg335Ter nonsense mutation cellular PTEN protein level was very low or not observable in lymphoblasts derived from PHTS patients, while significantly increased amount of truncated protein was found after proteasome inhibition suggesting that this PTEN mutant protein may undergo some proteasome degradation [ 37 ]. Similar observations were made on MCF-7 breast cancer cells and HEK-293 cells expressing this nonsense mutant PTEN. Eventually it could be hypothesized that this nonsense mutation either might cause nonsense-mediated decay, or results in a protein, which could undergo proteasomal degradation [ 37 ]. A relatively small number of patients harboring malformations of cortical development have been reported in association with PTEN mutations (Table 2 ). Atypical gyration, or complicated gyral pattern (dysgyria) [ 15 , 18 ], focal cortical dysplasia [ 17 , 18 , 57 – 59 , 60 – 62 ], gray matter heterotopia [ 15 , 16 , 19 , 46 , 60 ], and most often polymicrogyria have been documented earlier [ 14 , 15 , 17 – 19 , 46 , 55 , 61 ]. Dhamija et al [ 14 ] found only a single case with polymicrogyria out of 22 patients with Cowden syndrome whose molecular background remained unknown. In contrast in 12 patients among 22 [ 15 ] and in 8 individuals among 20 [ 18 ] carrying pathogenic PTEN variants had polymicrogyria. Hemimegalencephaly with dysgenesis of the affected hemisphere also occurred occasionally in association with PTEN mutations [ 1 , 15 , 18 , 63 ]. In Patient 5, a large dysplastic, thickened cortex and juxtacortical white matter T2 hyperintensity affecting almost half of the right cerebral hemisphere was identified. This malformation might fulfill the criteria of partial hemimegalencephaly at best, or rather multilobar segmental cortical dysplasia as the size of both hemispheres seemed to be almost the same. Epilepsy in this patient was the complication of the malformed cortex. The somatic growth of this boy severely lagged behind the typical development, and he had microcephaly using the standard calculators for percentile and SD values. The pathomechanism leading to hemimegalencephaly or multilobar segmental cortical dysplasia as seen in Patient 5 with germline PTEN mutations remained unknown. Activation state of PI3K-AKT-mTOR pathway kinases has been studied in resected hemimegalencephalic cortical tissue from a patient with germline PTEN mutation (Tyr68His) [ 1 ]. Western blotting exhibited increase in phosphorylated forms of AKT (pAKT) in the cortical homogenate and immunohistochemistry confirmed that 10% of neurons exhibited increased phospho-S6 expression. Phospho–S6 refers to the phosphorylated form of ribosomal protein S6, which is a marker of the PI3K-AKT-mTOR pathway activity. In addition, in vitro AKT kinase assay of brain extracts from the resected hemimegalencephalic brain tissue of the patient with germline PTEN mutation provided evidence of increased activity. Similarly, to the investigations in mice, the size of neurons was moderately increased in the PTEN -mutated specimen. It was concluded that very likely a second, by the authors unidentified somatic mutation might be required for the excessive PI3K-AKT pathway activation in the hemimegalencephalic cortex [ 1 ]. Brain tissue was not available from Patient 5; however, similar mechanism as discussed afore might be hypothesized. Mutations in other genes encoding components of the PI3K-AKT-mTOR pathway usually have activating effects and cause overgrowth syndromes, similarly to the loss of negative regulation in PTEN mutations. [ 1 ]. Pleuropulmonary blastoma (PPB) is the most common lung tumor of infancy and childhood. Type I PPB is a purely cystic, often multiseptated lesion with a layer of primitive, malignant cells. If those primitive cells proliferate further, this may form a mixed cystic and solid lesion termed type II PPB. Continued progression results in complete loss of the cystic spaces, leading to an entirely solid mass, termed type III PPB. A fourth type, type IR (regressed/regressing) PPB, is also seen in individuals from infancy through adulthood. The median age at diagnosis of type I PPB is 7 months, type IR is 31.2 months, type II is 35 months, and type III PPB is 39 months of age. [ 64 ]. Patient 5 had type II PPB. According to the International PPB/ DICER1 Registry 83% of of patients, suffering from this type of tumor has germline or somatic pathogenic/likely pathogenic DICER1 variant [ 64 ]. A search for pathogenic germline or somatic DICER1 variants remained unsuccessful, however, a somatic delin variant [c.197_200delinsCG p.(Lys66ThrfsTer7)] in PTEN was identified in the tumor tissue in addition to the germline PTEN variant [(c.1003C > T, p.(Arg335Ter)]. This somatic variant led to a frameshift, which might have a role as a second hit in the tumor genesis in Patient 5. In adults with PHTS lifetime risk of breast, endometrial, thyroid, kidney, and colorectal cancers, as well as melanoma has been extensively studied [ 10 , 11 ]. Risk of thyroid tumors in childhood has also been well documented [ 10 , 12 ]. These PTEN-related tumors have recently been referred to as PHTS component cancers, while other tumors that might occur in association with PTEN mutations have been called non-component cancers [ 11 ]. Pleuropulmonary blastoma can be regarded as a non-component cancer, not reported yet in combination with PTEN mutation. As pathogenic PTEN variants leads to activation of the PI3K-AKT-mTOR signaling pathway, it has been suggested that inhibition of the mTOR pathway may rescue components of the PHTS phenotype. It has been noted experimentally that in Pten knockout mice rapamycin prevented and reversed neuronal hypertrophy [ 65 ]. Further studies provided evidence that rapamycin prevents, but does not reverse aberrant migration in Pten knockout mice [ 66 ]. Moreover, pharmacologic mTOR inhibition by everolimus in Pten knockout mice led to successful downstream signaling rescue, including suppression of S6 phosphorylation, correlating with phenotypic rescue [ 67 ]. In humans, patients aged 18 years or older with Cowden syndrome due to germline PTEN mutation received sirolimus (rapamycin) for 56 days. As a result, cerebellar function improved by 1 month. Dermatologic and endoscopic examinations also showed improvement [ 68 ]. In another trial lasting for 6 months and enrolling patients with PHTS aged 5–45 years, the effect of everolimus on neurocognitive outcome was examined. The primary efficacy endpoint did not reveal improvement with everolimus, however several secondary endpoints in the fields of nonverbal IQ, verbal learning, autism symptoms, motor skills, and adaptive behavior moved in the direction of improvement [ 69 ]. Other approaches to the therapy consider that PTEN nonsense mutations, like the mutation in Patient 5 (Arg335Ter) may generate premature termination codons and produce nonfunctional truncated PTEN protein. Consequently, efforts have been made to restore full-length PTEN protein from the truncated one by translational read through [ 56 ]. The neoplastic manifestations of PHTS are rare in childhood and young adulthood with the exception of thyroid neoplasms. Therefore, recent European guidelines suggest initiating annual thyroid ultrasound surveillance at 18 years of age and younger if there is a family history of early-onset thyroid cancers [ 12 ]. Other updated aspects of surveillance recommendations and considerations for children and adolescents with PHTS have also been reviewed recently [ 12 ]. Conclusion Megalencephaly, developmental delay, autism, and intellectual disability in infancy and childhood may suggest PHTS because of an underlying pathogenic germline variant in the PTEN gene. Knowledge about the variable spectra of PHTS genotype and phenotype could help diagnostics of new patients. Variant interpretation based on large cohort studies may provide personalized healthcare of PHTS. Abbreviations aCGH Array comparative genome hybridization CT Computed tomography DWI Diffusion weighted ExAc Exome Aggregation Consortium FLAIR Fluid-attenuated inversion recovery GATK Genome analysis toolkit GnomAD Genome aggregation database GRCh37 Genome reference consortium human genome build 37 HGMD Human gene mutation database MAF Minor allele frequency MLPA Multiplex ligation-dependent probe amplification MRI Magnetic resonance imaging NIPT Non-invasive prenatal test PDZ Originated from post-synaptic density protein 95, Drosophila disc large tumor suppressor and Zona occludens-1 motif PEG Percutaneous endoscopic gastrostomy PHTS PTEN hamartoma tumor syndrome PI3K-AKT-mTOR Phosphoinositide 3 kinase-AKT-mammalian (or mechanistic) target of rapamycin PIP2 Phosphatidylinositol-4,5-bisphosphate PIP3 Phosphatidylinositol-3,4,5-triphosphate PPB Pleuropulmonary blastoma PTEN Phosphatase and tensin homolog gene PTEN PTEN protein SD Standard deviation Declarations Acknowledgements The authors thank all the patients and their parents for the invaluable participation in this study. Author’s contributions M.Cs., L.Sz.: Conceptualization, methodology, data collection, writing original draft. M.K.G.: Data collection. V.V.: Visualization. T.K., J.K,: Data interpretation, manuscript review and editing, supervision. T.Z., L.K.: Methodology, manuscript review, final approval. All authors read and approved the final manuscript. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript Data availability The data that support the findings of this study are available from the corresponding author upon request. Declarations Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Hungarian Medical Research Council (ETT TUKEB, BM/2150-1/2024). Informed consent Written informed consent to participate in the study was obtained from the parents of the patients. 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Nucleic Acids Res 45:D158-D169. https://doi.org/10.1093/nar/gkw1099 Tables Table 1 Patients with de novo heterozygous PTEN variants Patients Age (y) Gender Nucleotide refseq identifier (NM) Exon Nucleotide variation Protein refseq identifier (NP) Amino acid variation Mutational type Main clinical findings Brain MRI 1 4 M NM­_000314.4 5 c.284C>T NP_000305.3 p.(Pro95Leu) missense Megalencephaly (+6.0 SD) Macrosomia Global developmental delay Intellectual disability Dysgyria Dilated perivascular spaces Multifocal T2/FLAIR hyperintensities in the white matter 2 4 F NM_000314.4 5 c.406T>C NP_000305.3 p.(Cys136Arg) missense Megalencephaly (+5.5 SD) Global developmental delay Intellectual disability Dysgyria Dilated perivascular spaces Several cysts with CSF signal intensity Multifocal T2/FLAIR hyperintensities in the white matter 3 1,5 M NM_000314.4 6 c.518G>A NP_000305.3 p.(Arg173His) missense Megalencephaly (+4.3 SD) Delayed development (mild) Normal at 7 months of age 4 14 M NM_000314.4 7 c.758T>C UNPUBLISHED (the variant published earlier: c.758T>G) NP_000305.3 p.(Ile253Thr) UNPUBLISHED [the variant published earlier: p.(Ile253Ser )] missense Megalencephaly (+4.2 SD) Macrosomia Delayed development Autism spectrum disorder Obesitas Dilated perivascular spaces Multifocal T2/FLAIR hyperintensities in the white matter 5 18 M NM_000314.4 8 c.1003C>T NP_000305.3 p.(Arg335Ter) nonsense Microcephaly Global developmental delay Intellectual disability Failure to thrive Epilepsy Pleuropulmonary blastoma, type II Gastrointestinal polyposis) Osteoporosis Multilobar segmental cortical dysplasia M: male, F: female Table 2 Overview of PTEN-related malformations of cortical development published with genetic data 1 Malformation Exon Nucleotide variation Amino acid variation Comments Reference Dysgyria (atypical gyration 2 , or complicated gyral pattern 3 ) 1 c.7_10dupGCCA p.(Ile4SerfsTer7) presumed maternal inheritance [18] 1 c.49C>T p.(Gln17Ter) de novo [18] c.164+1G>A - de novo [15] 3 c.206A>G p.(Asn69Ser) de novo [18] 5 c.284C>T p.(Pro95Leu) de novo This study 5 c.323T>C p.(Leu108Pro) de novo [15] 5 c.368A>C p.(His123Pro) de novo [18] 5 c.395G>A p.(Gly132Asp) de novo [18] 5 c.402G>C p.Met134Ile) de novo [18] 5 c.406T>C p.(Cys136Arg) de novo This study 5 c.491delA p.(Lys164ArgfsTer3) de novo [18] 7 c.697C>T p.(Arg233Ter) de novo [18] 7 c.697C>T p.(Arg233Ter) de novo [18] deletion chr10q23 - de novo [15] Focal cortical dysplasia 4 5 c.389G>A p.(Arg130Gln) paternal inheritance [57] 5 5 c.389G>A p.(Arg130Gln) paternal inheritance [18] 6 5 c.486delC p.Asp162fsTer166 de novo [59] 8 c.1023del p.Phe341LeufsTer3 de novo [58] Multilobar segmental cortical dysplasia (large cortical dysplasia without extension to the entire hemisphere) Exon 8 c.1003C>T p.(Arg335Ter) de novo This study 3 c.202C>T p.(Tyr68His) de novo [1] [18] 5 c.388C>T p.(Arg130Ter) de novo [15] c.492+1delG - de novo [63] Loss exons 7-9 10q23.31 (89.716.106- 89.727.978)x1 Loss exons 7-9 de novo [18] Table 2 (continued) Overview of PTEN-related malformations of cortical development published with genetic data 1 Polymicrogyria 4 1 c.48T>A p.Tyr16Ter de novo [55] 2 c.139A>G p.(Arg47Gly) de novo [18] 2 c.160_162delGTA p.(Val54del) de novo [18] c.209+5G>A - de novo [15] 4 c.242T>G p.(Phe81Cys) de novo [18] c.253+1G>T - de novo [18] 5 c.380G>C p.(Gly127Ala) de novo [15] 5 c.385G>A p.(Gln129Arg) de novo Lhermitte-Duclos disease in the cerebellum [61] 5 c.388C>T p.(Arg130Ter) de novo [18] 5 c.388C>T p.(Arg130Ter) de novo [15] 5 c.389G>A p.(Arg130Gln) de novo [15] 5 c.389G>A p.(Arg130Gln) de novo [55] 5 c.406T>C p.(Cys136Arg) de novo [15] 5 c.464A>C p.(Tyr155Ser) de novo [15] c.492+1G>T - de novo [18] 6 c.521A>G p.(Tyr174Cys) de novo [15] 6 c.611delC p.(Pro204GlnfsTer17) de novo [15] 7 c.737C>T p.(Pro246Leu) de novo [15] 7 c.737C>T p.(Pro246Leu) de novo [46] 8 c.888_889delTG p.(Cys296fsTer5) de novo [18] 8 c.955insA p.(Thr319AsnfsTer6) de novo [15] 8 c.972dupT p.(Asp324fs) de novo [18] 9 c.1027delG p.(Val343Ter) de novo [15] 9 c.1085C>T p.(Ser362Leu) de novo [46] deletion chr10q23 - de novo [46] Table 2 (continued) Overview of PTEN-related malformations of cortical development published with genetic data 1 Heterotopia 4 2 c.131G>A p.(Gly44Asp) unknown [19] 5 c.266C>G p.(Pro89Arg) de novo [16] 5 c.470A>G p.(Glu157Gly de novo [19] 6 c. 605C>T p.(Thr202Ile) de novo [19] 7 c.737C>T p.(Pro246Leu) de novo [15[ c.1027-2A>G - de novo Lhermitte-Duclos disease in the cerebellum [60] 9 c.1085C>T p.(Ser362Leu) de novo [46] 1 Enlarged perivascular spaces, periventricular white matter signal abnormalities, or cysts, cerebellar tonsillar ectopia, and mega corpus callosum have not been included. Lhermitte-Duclos syndrome is listed in Table 2 only if co-occurring with malformation of cortical development 2 Terminology by Shao et al 2020 [15] – gyration is suggestive of polymicrogyria in only one imaging plane 3 Terminology by Shelkowitz et al 2023 [18] – gyri were too numerous and too shallow, but they lacked the overt cortical thickening or saw-toothed patterns typically seem in polymicrogyria 4 Classification corresponds to that of the authors’ original classification 5,6 Probably the same patients Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8070330","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":542237707,"identity":"24510926-4914-436a-ad31-1cec557da2b5","order_by":0,"name":"Marinna Csenki","email":"","orcid":"","institution":"University of Szeged, Szeged, Hungary","correspondingAuthor":false,"prefix":"","firstName":"Marinna","middleName":"","lastName":"Csenki","suffix":""},{"id":542237991,"identity":"0ed80689-0e72-437d-a885-25c70791ec63","order_by":1,"name":"Tibor Kalmár","email":"","orcid":"","institution":"University of Szeged, Szeged, Hungary","correspondingAuthor":false,"prefix":"","firstName":"Tibor","middleName":"","lastName":"Kalmár","suffix":""},{"id":542240208,"identity":"63b63b40-6f50-44f0-b27c-6ecf455db71d","order_by":2,"name":"Tamás Zombori","email":"","orcid":"","institution":"University of Szeged, Szeged, Hungary","correspondingAuthor":false,"prefix":"","firstName":"Tamás","middleName":"","lastName":"Zombori","suffix":""},{"id":542240392,"identity":"f2a26b3e-d209-4626-8961-627732ec2d0f","order_by":3,"name":"Levente Kuthi","email":"","orcid":"","institution":"National Institute of Oncology, Budapest, Hungary","correspondingAuthor":false,"prefix":"","firstName":"Levente","middleName":"","lastName":"Kuthi","suffix":""},{"id":542240653,"identity":"cebe63d2-d484-40f1-abbf-f3a99eb83a50","order_by":4,"name":"Viktor Vedelek","email":"","orcid":"","institution":"University of Szeged, Szeged, Hungary","correspondingAuthor":false,"prefix":"","firstName":"Viktor","middleName":"","lastName":"Vedelek","suffix":""},{"id":542240654,"identity":"f86e806d-7040-4dc6-8d00-2e6ab75cab24","order_by":5,"name":"Mita Krisztina Gábor","email":"","orcid":"","institution":"University of Szeged, Szeged, Hungary","correspondingAuthor":false,"prefix":"","firstName":"Mita","middleName":"Krisztina","lastName":"Gábor","suffix":""},{"id":542240778,"identity":"fe0f162e-de91-42be-a41d-f3c4f6a33b69","order_by":6,"name":"Jenő Kóbor","email":"","orcid":"","institution":"University of Szeged, Szeged, Hungary","correspondingAuthor":false,"prefix":"","firstName":"Jenő","middleName":"","lastName":"Kóbor","suffix":""},{"id":542240873,"identity":"3316b8ae-eb7b-4a62-8476-536f6346ce97","order_by":7,"name":"László Sztriha","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-8698-6514","institution":"Department of Pediatrics, University of Szeged, Szeged, Hungary","correspondingAuthor":true,"prefix":"","firstName":"László","middleName":"","lastName":"Sztriha","suffix":""}],"badges":[],"createdAt":"2025-11-09 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17:21:20","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97577,"visible":true,"origin":"","legend":"","description":"","filename":"PTENMUTATIONS.docx","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/35b045f9c5e137d32cd58d68.docx"},{"id":95670511,"identity":"7a86727c-e9fb-4a2b-bd2a-f01fe3abf51c","added_by":"auto","created_at":"2025-11-11 17:21:20","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8070330.json","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/f732d6b3cac06bfc8e74f634.json"},{"id":95670515,"identity":"b2da951e-b51b-48ff-aa1c-6ec47b78b496","added_by":"auto","created_at":"2025-11-11 17:21:20","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":235967,"visible":true,"origin":"","legend":"","description":"","filename":"rs80703300enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/f0633e6aec221360c060e0fa.xml"},{"id":95798476,"identity":"4e5bca93-c345-4553-89ec-b562c91f7e91","added_by":"auto","created_at":"2025-11-13 08:16:51","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":233028,"visible":true,"origin":"","legend":"","description":"","filename":"rs80703300structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/28fd3003fe317915960a22fa.xml"},{"id":95799044,"identity":"095de028-a8d1-4c8c-8320-e5546a6987ca","added_by":"auto","created_at":"2025-11-13 08:18:30","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":251058,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/9c0d4f8ac7015f3622c5162a.html"},{"id":95798359,"identity":"ebef7620-b717-4c96-a7ca-aca7683a9e1d","added_by":"auto","created_at":"2025-11-13 08:16:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":475063,"visible":true,"origin":"","legend":"\u003cp\u003eCranial magnetic resonance images (MRI) of Patient 2 at the age of 3 years. She had germline \u003cem\u003ePTEN\u003c/em\u003e variant c.406T\u0026gt;C p.(Cys136Arg). (A) T1-weighted parasagittal image demonstrates relatively abundant white matter compared to neurotypical control (B). This finding is in agreement with quantitative analysis providing evidence of increased volume of several pathways and fasciculi in \u003cem\u003ePTEN\u003c/em\u003e hamartoma tumor syndrome [46]. Less complexity of sulci and gyri give the impression of dysgyria in the patient (A) versus a neurotypical individual (B).\u003c/p\u003e\n\u003cp\u003e(C) T2 weighted axial image shows a cyst-like dilatation of the perivascular space in the left frontal lobe (double arrow) and several moderately dilated perivascular areas in both hypomyelinated occipital lobes (arrows).\u003c/p\u003e\n\u003cp\u003e(D) Axial FLAIR image also reveals hypomyelination in the white matter of both occipital lobes (arrows).\u003c/p\u003e","description":"","filename":"PTENFIG1.png","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/9fa6476645dbbf1f9db9827b.png"},{"id":95799508,"identity":"ad2183f1-5024-4536-921e-f8bb04ab4666","added_by":"auto","created_at":"2025-11-13 08:20:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":369051,"visible":true,"origin":"","legend":"\u003cp\u003eCranial MRI of Patient 4 at the age of 5 years. He had germline \u003cem\u003ePTEN\u003c/em\u003e variant c.758T\u0026gt;C p.(Ile253Thr).\u003c/p\u003e\n\u003cp\u003e(A) Axial T2.weighted image shows dilated perivascular spaces in both occipital lobes (arrows). (B) Axial FLAIR image depicts hypomyelination in both frontal and occipital lobes (arrows). (C) Molecular studies identified that thymine has been replaced by cytosine at the position of 758 in exon 7 and as a result, isoleucine has been replaced by threonine in the PTEN protein at position 253. The parents did not carry this variant.\u003c/p\u003e\n\u003cp\u003e(D) The pedigree of the family is also shown.\u003c/p\u003e","description":"","filename":"PTENFIG2.png","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/4fe2ae1901682e7be1d954b2.png"},{"id":95670512,"identity":"ca3b463c-ac5e-4cf4-9947-4f63925b8967","added_by":"auto","created_at":"2025-11-11 17:21:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":251849,"visible":true,"origin":"","legend":"\u003cp\u003eCranial MRI of Patient 5 at the age of 16 years. He has germline \u003cem\u003ePTEN\u003c/em\u003e variant c.1003C\u0026gt;T p.(Arg335Ter).\u003c/p\u003e\n\u003cp\u003e(A) Axial T1-weighted image shows large segmental cortical dysplasia in the right frontal-parietal area with broad, coarse gyri and shallow sulci. The cortex is thick.\u003c/p\u003e\n\u003cp\u003e(B) Axial T2 –weighted image shows high signal intensity in the white matter underlying the dysplastic cortex. The signal intensity is high also in the white matter of the left hemisphere, suggestive of hypomyelination.\u003c/p\u003e","description":"","filename":"PTENFIG3.png","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/ff71d7c3a0bcaee5c9c1290d.png"},{"id":95670518,"identity":"e71003c6-91e2-4ae7-a6d6-d00208d3f9a5","added_by":"auto","created_at":"2025-11-11 17:21:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":4518710,"visible":true,"origin":"","legend":"\u003cp\u003ePathological features of the pleuropulmonary blastoma in Patient 5. (A) Macroscopically, a relatively well-circumscribed, partly cystic and partly solid, grayish-white tumor can be observed on the cut surface of the lung. (B) On low-power view, cysts of variable diameter (black arrows) are seen, surrounded by solid tumor tissue (HE, 5x). (C) The cysts are lined by respiratory epithelium, and around them, rhabdomyoblasts of various sizes as well as spindle-shaped cells are present. In some areas, tumor cells with bizarre nuclei (yellow arrows) can also be observed (HE, 40x). The cells of the sarcomatous component are desmin-positive (insert photo).\u003c/p\u003e","description":"","filename":"PTENFIG4.png","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/ad11fcbd87269b475bc79efe.png"},{"id":95670520,"identity":"228940e0-8ac1-4ed8-8ba9-210ca2ed402a","added_by":"auto","created_at":"2025-11-11 17:21:20","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2825176,"visible":true,"origin":"","legend":"\u003cp\u003eFunctional domains of PTEN protein and localization of variants found in this study. (A) Linear model of the PTEN protein. It consists of 403 amino acids and contains a phosphatase domain, a C2 lipid or membrane binding domain and a PDZ protein-protein interaction motif as the major functional domains. Domain start and endpoints are indicated by numbering. Red lines denote point mutation sites found in this study. PDZ: \u003ca href=\"https://en.wikipedia.org/wiki/DLG4\" title=\"DLG4\"\u003epost synaptic density protein (PSD95)\u003c/a\u003e, \u003ca href=\"https://en.wikipedia.org/wiki/DLG1\" title=\"DLG1\"\u003eDrosophila disc large tumor suppressor (Dlg1)\u003c/a\u003e, and \u003ca href=\"https://en.wikipedia.org/wiki/Tight_junction_protein_1\" title=\"Tight junction protein 1\"\u003ezonula occludens-1 protein (zo-1)\u003c/a\u003e. Disordered: a functionally relevant portion of the PTEN protein lacking stable higher order structure. These domains with structural flexibility provide “hot-spots” for post-translational modifications and protein-protein interactions [70]. (B) 3D ribbon model of the PTEN protein. Domains are colored similarly as in the linear model. Mutation sites are highlighted in red. AF_AFP60484F1 Alphafold model was used for 3D visualization of the entire PTEN protein [71], ChimeraX was applied for molecule model processing [72] and Uniprot annotations were employed to visualize domains [73].\u003c/p\u003e","description":"","filename":"PTENFIG5.png","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/96019430a9df81f9940e1c80.png"},{"id":95818822,"identity":"5cf4048b-fadb-43a6-80aa-ec58a3d9c20f","added_by":"auto","created_at":"2025-11-13 10:33:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8965308,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8070330/v1/951ccdd3-9f97-4c12-8ae6-9c349fc8580d.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003ePTEN hamartoma tumor syndrome in children: Identification of recurrent mutations, an unpublished variant and a case of cerebral cortical dysplasia co-occurring with pleuropulmonary blastoma. \u003c/p\u003e\n\u003cp\u003eReview of PTEN-related malformations of cortical development\u003c/p\u003e","fulltext":[{"header":"What is Known","content":"\u003cul\u003e\n \u003cli\u003e\u003cem\u003ePTEN hamartoma tumor syndrome (PHTS) is caused by germline heterozygous pathogenic variants of the tumor suppressor PTEN gene, crucial for the regulation of the PI3K-AKT-mTOR pathway.\u0026nbsp;\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003ePHTS encompasses several different syndromes with overlapping clinical features, such as PTEN-related macrocephaly and autism syndrome, Bannayan-Riley-Ruvalcaba, Cowden, Lhermitte-Duclos, Proteus, and Proteus-like syndromes.\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is New:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003eThis study presents a series of five patients with PHTS and expands the genotypic spectrum with a novel missense variant (Ile253Thr) in the PTEN gene.\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eThe co-occurrence of segmental cerebral cortical dysplasia and pleuropulmonary blastoma in association with the germline truncating Arg335Ter variant of PTEN is reported for the first time.\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eA somatic delin variant [c.197_200delins CG p.(Lys66ThrfsTer7)] causing frameshift in PTEN was also identified in the lung tumor as a second hit.\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003ePTEN Hamartoma Tumor Syndrome (PHTS) is a rare genetic disorder caused by heterozygous germline pathogenic variants of the tumor suppressor \u003cem\u003ePTEN\u003c/em\u003e (Phosphatase and Tensin homolog) gene on chromosome 10 at position q23.31 (OMIM# 601728). Haploinsufficiency of \u003cem\u003ePTEN\u003c/em\u003e may lead to an increased phosphorylation of different cellular proteins resulting in excessive activity of the PI3K-AKT-mTOR pathway leading to benign and malignant tumors and overgrowth [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. PHTS encompasses several different syndromes with overlapping clinical features [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. \u003cem\u003ePTEN\u003c/em\u003e-related macrocephaly (head circumference more than +\u0026thinsp;2 SD) and autism syndrome (OMIM# 605309) can be associated with a wide range of intellectual abilities [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Bannayan-Riley-Ruvalcaba syndrome with manifestations in childhood and Cowden syndrome, an adult-onset condition proved to be one disorder due to pathogenic \u003cem\u003ePTEN\u003c/em\u003e variants, though presenting variably at different ages (OMIM# 158 350) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Lhermitte-Duclos syndrome (OMIM# 158310), a hamartomatous overgrowth of the cerebellum (dysplastic gangliocytoma) is deemed as a pathognomonic disorder of PHTS. A few cases of Proteus (OMIM# 176 920) and Proteus-like syndromes (OMIM# 158 350) with features of overgrowth of different body parts are also associated with \u003cem\u003ePTEN\u003c/em\u003e mutations [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudies in adult patients with PHTS indicate that germline \u003cem\u003ePTEN\u003c/em\u003e variants are associated with increased lifetime risk of breast, endometrial, thyroid, kidney, and colorectal cancers, as well as melanoma, collectively referred to as PHTS component cancers [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Other cancers beyond those known to be associated with the syndrome have also been reported and called non-component cancers [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Cancer risk, particularly the threat of thyroid tumor is elevated also in children and young adults with PHTS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile MRI findings of brain abnormalities, like enlarged perivascular (Virchow-Robin) spaces, multifocal white matter signal abnormalities, mega corpus callosum and cerebellar dysplastic gangliocytoma are well known in PHTS syndrome, the occurrence of malformations of cortical development appears quite rare [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eClinical presentation of pediatric patients with pathogenic \u003cem\u003ePTEN\u003c/em\u003e mutations has been reviewed earlier [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. We expand the genotypic and phenotypic spectrum of pediatric PTEN hamartoma tumor syndrome by reporting on a small series of five patients with \u003cem\u003ede novo\u003c/em\u003e germline heterozygous \u003cem\u003ePTEN\u003c/em\u003e variants. One of the variants (Ile253Thr) is still unpublished, while four of them (Pro95Leu, Cys136Arg, Arg173His, Arg335Ter) have already been described [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Megalencephaly, delayed development, autism spectrum disorder, and intellectual disability were the main phenotypic features in four cases with missense variants (Pro95Leu, Cys136Arg, Arg173His, and Ile253Thr). A truncating variant (Arg335Ter), however, was associated with an extended segmental cerebral cortical dysplasia, not reported yet in combination with this \u003cem\u003ePTEN\u003c/em\u003e variant. In addition, pleuropulmonary blastoma as a non- component cancer was also found in this boy. \u003cem\u003eDICER1\u003c/em\u003e mutation was not identified in the lung tumor; however, a \u003cem\u003ePTEN\u003c/em\u003e somatic delin variant [c.197_200delinsCG p.(Lys66ThrfsTer7)] causing frameshift as a second hit co-occurred with the germline truncating variant. To our knowledge pleuropulmonary blastoma has not been reported yet in combination with PHTS.\u003c/p\u003e\u003cp\u003eA brief overview of the \u003cem\u003ePTEN\u003c/em\u003e-related malformations of cortical development is also provided.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis study was part of a larger research project on neurodevelopmental disorders. Clinical evaluations were performed by specialists in clinical genetics and pediatric neurology.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The following tests were carried out for the patients with negative results: karyotype, MLPA, or comparative genome hybridization (aCGH), metabolic workup including plasma amino acids, urine organic acids, and plasma acylcarnitines. Endocrinology consultation and growth hormone tests were requested for patients with accelerated growth and macrosomia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Genomic DNA was extracted from peripheral blood samples with the Puregene Kit (Gentra). Clinical exom sequencing was performed by the use of either the Illumina Trusight One Exome Sequencing Panel covering the coding region of 4.813 clinically relevant genes or Illumina DNA Prep with Exome 2.5 Enrichment (both from Illumina Inc.: San Diego California, United States). Raw sequence data analysis, including base calling, de-multiplexing, alignment to the GRCh37 human reference genome, and variant calling, were performed using an in-house GATK joint model pipeline. For variant filtration, all disease-causing variants reported in HGMD, ClinVar, along with all variants with minor allele frequency (MAF) of less than 1% in the ExAc database, were considered. Variants that possibly impair the protein sequence, such as the disruption of conserved splice sites, missense, nonsense, read-throughs, or small insertions/deletions were prioritized.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The large head in patients with pathogenic \u003cem\u003ePTEN\u0026nbsp;\u003c/em\u003emutations is referred to as macrocephaly in most of the reports. In reality, these patients have megalencephaly due to an overgrowth of the brain as seen by MRI in humans and measured experimentally in mice with homozygous or heterozygous missense \u003cem\u003ePten\u003c/em\u003e mutations [21-23]. Macrocephaly may be related to a wide variety of causes other than megalencephaly, including hydrocephalus, enlargement of extra-axial spaces and skeletal dysplasia [23]. The term megalencephaly is used in this study. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll imaging studies were retrospectively reviewed. MRI was performed on a variety of different scanners and models at different ages. MRI protocols thus also varied, although all evaluated imaging studies included at least axial and sagittal T1-weighted, axial T2-weighted, axial FLAIR, and axial DWI imaging. Neuroimaging studies were reviewed for the presence of cortical abnormalities including abnormal gyral pattern, focal cortical dysplasia, diffuse or localized pachygyria, hemimegalencephaly, polymicrogyria, or gray matter heterotopia.\u003c/p\u003e\n\u003cp\u003eGyral patterns with non-specific malformations were designated as dysgyria\u003cstrong\u003e.\u003c/strong\u003e\u0026nbsp; In dysgyria, the imaging shows areas of variable cortical thickness and an abnormal gyral pattern characterized by irregularities of sulcal depth and orientation. The sulci are radially oriented, or narrow gyri are separated by abnormally deep or shallow sulci. The gray-white matter boundary is smooth. This imaging appearance is not typical for simplified gyral pattern, polymicrogyria, or pachygyria [23]. In a previous study, an abnormal pattern of gyrification that was suggestive of polymicrogyria in only one imaging plane in \u003cem\u003ePTEN\u003c/em\u003e mutations was referred to as atypical gyration [15]. In another publication abnormal gyral pattern in \u003cem\u003ePTEN\u003c/em\u003e mutations with too numerous and too shallow gyri without overt cortical thickening or saw-toothed pattern seen in polymicrogyria was called complicated gyral pattern[18]. The term dysgyria is used in this study, as it appears to cover the features described in the latter studies. Moreover, a malformation with cortical dysplasia involving several lobes is referred to as multilobar segmental cortical dysplasia in this studyinstead of (lobar) hemimegalencephaly, or dysplastic megalencephaly, designations applied by other authors [1, 15, 18]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll brain imaging studies were also assessed for the presence of other structural abnormalities described in \u003cem\u003ePTEN\u003c/em\u003e-related disorders, such as dilated perivascular spaces (Virchow-Robin spaces), multifocal T2/FLAIR hyperintensities in the white matter, ventriculomegaly and callosal dysgenesis. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients\u0026rsquo; medical reports and results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient 1\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;This boy was born at term by vaginal delivery as the 3\u003csup\u003erd\u003c/sup\u003e child from the fourth uneventful pregnancy to healthy non-consanguineous Caucasian parents. The intrauterine development of the fetus was also advanced for his gestational age. His birth weight was 4100 g (+1.1 SD) and Apgar scores were 10, 10, and 10 at 1, 5, and 10 minutes, respectively. His head circumference was 37 cm (+0.7 SD) and his length 54 cm (+1.5 SD) at birth.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;A younger brother of the index patient is healthy. A girl from the mother\u0026rsquo;s former relationship is healthy, however a boy from the same previous relationship has cystic fibrosis and underwent lung transplantation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The proband\u0026rsquo;s development was delayed. Unsupported gait developed by the age of 14 months. On examination at the age of 2.5 years his head circumference was 58 cm (+6.0 SD), and his height was 107 cm (+4.0 SD). Dysmorphic features in addition to megalencephaly included broad forehead, flat nasal bridge, and bilateral epicanthic folds. Vascular anomalies were not observed. Vision and hearing were normal. His speech development was also lagged behind. He was not able to keep eye contact beyond a few second. He had hand stereotypies and difficulties with his fine motor movements. He had attention deficit and poor interest in the surroundings. The Brunet-L\u0026eacute;zine test revealed delay in all fields of development with a quotient of 47. There was a strong suspicion of autism spectrum disorder.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Cranial MRI at the age of 2.5 years demonstrated bilateral dysgyria in the frontal areas. Dilated perivascular spaces were also observed in the posterior periventricular areas in addition to T2 and FLAIR hyperintensities.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Clinical exome sequencing revealed a heterozygous missense variant in exon 5 of the \u003cem\u003ePTEN\u003c/em\u003e gene: NM_000314.4:c.284C\u0026gt;T, NP_000305.3:p.(Pro95Leu) (Table 1, 2). This variant was \u003cem\u003ede novo\u003c/em\u003e, not present in the parents and younger brother. It was absent from control populations (GnomAD). This variant was described as pathogenic in the literature (http://ncbi.nlm.nih.gov/clinvar/).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient 2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;This patient, a girl was born from the second pregnancy at the 36th gestational week by vaginal delivery to a drug-addicted mother. Antenatal screening tests were normal. Her birth weight was 2600 g (0.0 SD), head circumference 33 cm (+0.5 SD). Apgar scores were 9, 10 and 10 at 1, 5 and 10 minutes, respectively. Her adaptation to the extrauterine life was normal; however, her development was delayed. There was no evidence of intrauterine infection, or inborn error of metabolism.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;On examination, at the age of 4 years her head circumference was 58 cm (+5.5 SD), body weight 15 kg (-0.5 SD) and height 100 cm (-0.2 SD). Dysmorphic features included frontal bossing in addition to megalencephaly, low set ears, hypertelorism, and skin tags on the left little finger. She responded to elementary visual and auditory stimuli, however, she had very short attention span. Intellectual disability was obvious in association with disruptive, impulsive, poorly controlled behavior. She was able to walk without support. Muscle tone was slightly reduced with retained patella reflexes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Brain MRI at the age of 3 years revealed dysgyria mainly in the frontal and parietal areas. Dilated perivascular spaces and focal hyperintensities in the white matter on T2 and FLAIR images were also observed. Two cysts with cerebrospinal fluid signal intensity probably represented extremely dilated perivascular spaces (Fig. 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical exome sequencing revealed a heterozygous missense variant in exon 5 of the \u003cem\u003ePTEN\u003c/em\u003e gene: NM_000314.4:c.406T\u0026gt;C, NP_000305.3:p.(Cys136Arg) (Table 1, 2). It was absent from control populations (GnomAD). The parents were not available for testing. This variant was described as pathogenic/likely pathogenic in the literature (http://ncbi.nlm.nih.gov/clinvar/).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient 3\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe proband, a boy, was born at term by Cesarean section for unrelated Caucasian parents. The pregnancy occurred following \u003cem\u003ein vitro\u003c/em\u003e fertilization. Noninvasive prenatal testing (NIPT) showed no abnormalities. Fetal echocardiography revealed no cardiac abnormalities. Apgar scores were 10, 10, and 10 at 1, 5, and 10 minutes, respectively. His birth weight was 4800 g (+2.5 SD). \u0026nbsp;He suffered from irritability and feeding difficulties in early infancy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the age of 7 weeks his head circumference was 43.5 cm (+2.9 SD) and body weight 5600 g (+0.9 SD). Dysmorphic features in addition to megalencephaly included frontal bossing and small chin. He responded to visual and auditory stimuli. Moderate axial hypotonia with head lag was observed. Deep tendon reflexes were present. Head ultrasound revealed normal brain structure. Brain MRI at 7 months of age appeared to be normal. Interpretation of gyrification and white matter signal abnormalities was limited at this age.\u003c/p\u003e\n\u003cp\u003eAt the last follow up, at 10 months of age his gross motor development and use of hands were normal. His head circumference was 51.5 cm (+4.3 SD). He was interested in the surroundings and was able to stand up with support. The Bayley Scales of Infant and Toddler Development III test was performed at the age of 16 months and it explored a mild underachievement in the cognitive scale.\u003c/p\u003e\n\u003cp\u003eClinical exome sequencing revealed a heterozygous missense variant in exon 6 of the \u003cem\u003ePTEN\u003c/em\u003e gene: NM_000314.4:c.518G\u0026gt;A, NP_000305.3:p.(Arg173His) (Table 1). This variant was \u003cem\u003ede novo\u003c/em\u003e, not present in the parents. It was absent from control populations (GnomAD). This variant was described as pathogenic/likely pathogenic in the literature (http://ncbi.nlm.nih.gov/clinvar/).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient 4\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis boy was born at term by vaginal delivery as the second child from the 3\u003csup\u003erd\u003c/sup\u003e pregnancy to healthy unrelated Caucasian parents. The pregnancy was the result of insemination. Apgar scores were 10, 10, and 10 at 1, 5, and 10 minutes, respectively. His birth weight was 4500 g (+1.9 SD), length 56 cm (+2.2 SD) and head circumference 37 cm (+0.7 SD).\u003c/p\u003e\n\u003cp\u003eThe patient\u0026rsquo;s paternal grandfather, father, and elder brother have Asperger syndrome. The proband\u0026rsquo;s accelerated growth and delay in developmental milestones became obvious after the age of one year. Generalized reduced muscle tone and weakness were observed. He started walking at the age of 15 months. He had difficulties with speech perception and expression. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn examination at the age of 14.5 years his head circumference was 61 cm (+4.2 SD) his weight 105 kg (+3.7 SD), and height 180 cm (+1.7 SD). Dysmorphic features beyond megalencephaly included narrow elongated face, prominent, protruding lower jaw (mandibular prognathism), short philtrum, and low-set ears. Obesity stretch marks (striae) were observed on the skin in the abdominal and gluteal areas. Ophthalmology and audiology wee normal. Generalized hypotonia with reduced tendon reflexes were observed, no other neurological signs were present. Intelligence quotient was 78 by the Wechsler Intelligence Scale for Children. Child psychiatry revealed autism spectrum disorder with unimpaired intelligence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBrain MRI at the age of 5 years demonstrated normal cortical architecture, while dilated perivascular spaces were observed bilaterally in the posterior periventricular area. Moderate increase in the signal intensity was also seen posteriorly in the occipital lobes on T2 and FLAIR sequences (Fig. 2).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Exome sequencing revealed a heterozygous missense variant in exon 7 of the \u003cem\u003ePTEN\u003c/em\u003e gene: NM_000314.8:c.758T\u0026gt;C, NP_000305.3:p.(Ile253Thr). This variant was \u003cem\u003ede novo\u003c/em\u003e, not present in the parents (Fig. 2, Table 1). It was absent from control populations (GnomAD). \u003cem\u003eIn silico\u003c/em\u003e analysis (Varsome, Franklin database and MutationTaster) suggests that this variant is likely pathogenic. This variant has not been published yet, but is listed in ClinVar (version: 07-Jul-2025) as of uncertain significance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient 5\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe proband, a boy was born at term from the first uneventful pregnancy by Cesarean section to unrelated, healthy Caucasian parents. His birth weight was 3850 g (+0.6 SD), length 52 cm (+0.7 SD) and head circumference 37 cm (+0.7 SD). Apgar scores were 9, 10, and 10 at 1, 5, and 10 minutes, respectively.\u003c/p\u003e\n\u003cp\u003eLeft sided focal seizures appeared at the age of 8 days, which were deemed to be due to neonatal infection caused by \u003cem\u003eE coli\u003c/em\u003e. Antibiotics and phenobarbital were effective. Myoclonic jerks in the limbs, 20-30 times daily, recurred at the age of 3 months. Cranial CT suggested dysplasia of the right frontal lobe. EEG revealed almost continuous spike/polyspike discharges with maximum over the right frontal region and spreading to other areas. Vigabatrin, valproate, and carbamazepine were ineffective. The seizures subsided by the age of 1 year, although the spike discharges remained continuous over the right hemisphere despite valproate, clobazam, and levetiracetam treatment. At the age of 3 years the seizures recurred in the form of brief repetitive extensions in the arms, loss of muscle tone, and proved to be drug-resistant to various combination of antiepileptic drugs, such as vigabatrin, carbamazepine, valproate, topiramate, clobazam, lamotrigine, and levetiracetam. The EEG showed continuous spike and wave discharges in wakefulness and during sleep with maximum over the right frontal area, consistent with epilepsia partialis continua. The epilepsy proved to be drug-resistant throughout the observation period. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBrain MRIat the age of 3 and 16 years revealed severe cortical dysplasia with broad, coarse gyri, shallow sulci, thickened cortex, and smooth surface in the right frontal-parietal areas. High signal intensity on T2 and FLAIR sequences was observed in the white matter underlying the dysplastic cortex (Fig. 3). Increased T2/FLAIR signal intensity was noticed also in the white matter of the left hemisphere suggestive of hypomyelination. A moderate dilatation of the right ventricle and a slight midline shift from left-to-right were observed. An apparent hemimegalencephaly defined as an overgrowth of all or part of a cerebral hemisphere was not evident, therefore the term segmental cortical dysplasia seemed to be appropriate for this malformation. Surgical removal of the focal malformation was considered but not performed because of the patient\u0026rsquo;s poor general health. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe proband\u0026rsquo;s development was globally severely delayed. He was not able to roll over at the age of 8 months. Left hemiparesis with maximum in the arm became evident after the age of 6 months. Hypotonia, weakness and reduced tendon reflexes were observed. He was not able to sit or stand at the age of 1 year. Head circumference was 48 cm (-0.5 SD) at the age of 2 years. Independent gait started at the age of 5 years. Global developmental delay, intellectual disability, and failure to thrive were observed throughout his follow up; his weight was 40 kg (-2.4 SD) and height 156 cm (-1.9 SD) at the age 16 years. There was no speech at this age. Formal IQ testing was infeasible. Generalized hypotonia, weakness, reduced deep tendon reflexes, and left sided hemiparesis characterized his condition. He was wheelchair-bound. At the age of 18 years his head circumference was 47 cm (-5.4 SD), height 160 cm (-2.0 SD), and body weight 41 kg (-3.SD).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChest CT, requested for recurrent infections at the age of 15 years and MRI one and a half years later showed encapsulated mass containing contrast enhancing solid and cystic parts in the left upper and middle thoracic cavity. Rapid growth of the tumor was observed, and its size was 84x138x133 mm at the time of the MRI. The left lung with the tumor were removed at the age of 16 years. Histology revealed that the tumor was pleuropulmonary blastoma type II (Fig. 4). Chemotherapy was administered according to the CWS 2012 NRTS HR protocol. He was free of tumor recurrence in the next 4 years. The use of several antibiotics was required after the surgery. Parenteral feeding and eventually feeding through percutaneous endoscopic gastrostomy (PEG) tube became mandatory. The cranial MRI performed after the surgical procedure demonstrated a small area with high T2 signal in the right cerebellar hemisphere, ipsilaterally with the cortical dysplasia. This lesion was reported as a stroke caused by embolization during the surgery. During gastroscopy, polyposis was noticed in the stomach and duodenum. Colonoscopy revealed polyposis also in the ileum and rectum.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSequencing the \u003cem\u003ePTEN\u003c/em\u003e gene revealed a \u003cem\u003egermline\u003c/em\u003e heterozygous truncating variant in exon 8 of the \u003cem\u003ePTEN\u003c/em\u003e gene: NM_000314.4:c.1003C\u0026gt;T, NP_000305.3:p.(Arg335Ter) (Table 1, 2, Fig 5). This variant was \u003cem\u003ede novo\u003c/em\u003e, known as pathogenic in the literature (http://ncbi.nlm.nih.gov/clinvar/). and it was absent in the parents and the patient\u0026rsquo;s two brothers. The tumor was examined by the use of Trusight Oncology 500 panel (Illumina). The germline truncating variant was confirmed, moreover a \u003cem\u003ePTEN\u0026nbsp;\u003c/em\u003edelin \u003cem\u003esomatic\u003c/em\u003e variant [c.197_200delinsCG p.(Lys66ThrfsTer7)] was also revealed in the tumor tissue. This somatic variant led to a frameshift, which might have a role as a second hit in the tumor genesis.\u003cem\u003e\u0026nbsp;DICER1\u003c/em\u003e mutation was not identified in the tumor.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe \u003cem\u003ePTEN\u003c/em\u003e gene on chromosome 10q23.31 consists of 9 exons and encodes a 403 amino acid dual-specificity lipid and protein phosphatase, which is capable of dephosphorylating phospho-lipids and phospho-peptides as well. The PTEN protein embodies a phosphatase domain, a C2 lipid or membrane-binding domain, and a PDZ protein-protein interaction motif as the major functional domains. (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Exon 5 at the N terminus encodes the phosphatase domain. The PTEN protein is a negative regulator of the PI3K-AKT-mTOR pathway by dephosphorylating PIP3 at the 3\u0026rsquo;phosphate of the inositol ring resulting in PIP2 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. When a mutation or loss of \u003cem\u003ePTEN\u003c/em\u003e occurs, the elevated PIP3 acts as a second messenger, promoting the subsequent activation of other kinases, which phosphorylate many proteins involved in the most important cellular functions, from proliferation to differentiation, but also apoptosis, angiogenesis and metabolism [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A large number of different \u003cem\u003ePTEN\u003c/em\u003e mutations have been described [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These mutations include missense, nonsense, and splice site mutations, intragenic deletions or insertions, and large deletions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Exons 5, 7, and 8 are overrepresented in the \u003cem\u003ePTEN\u003c/em\u003e germline mutation spectrum. Germline pathogenic variants in \u003cem\u003ePTEN\u003c/em\u003e are well-documented causes of PHTS, while sporadic somatic variants of \u003cem\u003ePTEN\u003c/em\u003e make this tumor suppressor gene one of the most frequently affected in human malignancies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePatients 1\u0026ndash;3 in this study had \u003cem\u003ede novo\u003c/em\u003e germline heterozygous missense variants in the PTEN phosphatase domain (Pro95Leu, Cys136Arg, and Arg173His) in association with megalencephaly and developmental delay. Intellectual disability was also obvious in Patients 1 and 2. These variants have previously been reported as pathogenic (Pro95Leu), or pathogenic/likely pathogenic (Cys136Arg and Arg173His) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In a report on a large cohort of pediatric patients with pathogenic \u003cem\u003ePTEN\u003c/em\u003e mutations (including Pro95Leu and Arg173His), clear genotype-phenotype relationship has not been found [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Developmental delay, intellectual disability and autism spectrum disorder in the presence of megalencephaly were found in 66% of these children. Only one of 47 patients did not have megalencephaly at the time of the diagnosis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Dermatological features, including caf\u0026eacute;-au-lait spots, skin tags, papillomatous papules, haemangioma trichilemmomas, hyperpigmented and hypopigmented lesions, lipomas, and soft tissue masses have been reported in 66% of the pediatric patients with germline \u003cem\u003ePTEN\u003c/em\u003e mutations [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], however, mucocutaneous lesions were not noticed in our patients. Thyroid abnormalities were recognized by ultrasound only in 7 children out of 27 pediatric patients with \u003cem\u003ePTEN\u003c/em\u003e mutations. Thyroid carcinoma was not found suggesting that this type of tumor is rare in children suffering from PTHS [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. There were no PTHS-related tumors in Patients 1\u0026ndash;4 in this study.\u003c/p\u003e\u003cp\u003eIn Pro95Leu mutation, the proline at position 95 has been replaced by leucine, an amino acid with similar properties. Experimental functional studies for this variant in humanized yeast-based bioassay demonstrated partially reduced phosphatase activity when compared to wild type PTEN [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In Cys136Arg mutation diminished cellular PTEN protein level was found in association with upregulated proteasome activity in experimental studies. The misfolded protein as a result of the Cys136Arg missense variant after conjugation with ubiquitin might induce proteotoxic stress leading to proteasome hyperactivity [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Loss of the unstable PTEN due to enhanced proteasomal degradation may result in functional insufficiency of the protein function. Experimental studies suggested that the Arg173His mutation leads to reduced phosphatase activity of the PTEN protein \u003cem\u003ein vitro\u003c/em\u003e [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], however, a yeast-based bioassay demonstrated later that the phosphatase remained active [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Evidently, further studies are required in order to elucidate the molecular mechanisms of pathogenicity of \u003cem\u003ePTEN\u003c/em\u003e missense mutations.\u003c/p\u003e\u003cp\u003eThe c.758T\u0026thinsp;\u0026gt;\u0026thinsp;C, p.(Ile253Thr) sequence change in Patient 4 replaces isoleucine which is neutral and non-polar, with threonine, which is neutral and polar, at codon 253 of the PTEN protein in the C2 domain. This variant is not present in population databases (gnomAD), and has not been reported yet in the literature in individuals affected with PTEN-related conditions. ClinVar contains an entry for this variant (Variation ID: 1001963), and it has been classified as a variant of uncertain significance. \u003cem\u003eIn silico\u003c/em\u003e analysis of this variant suggested that it was likely pathogenic. Two submissions to ClinVar of another variant of the same codon (c.758T\u0026thinsp;\u0026gt;\u0026thinsp;G), causing different amino acid substitution (Ile253Ser) have been classified either as likely pathogenic or a variant of uncertain significance [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Indeed, Patient 4, who had megalencephaly (macrocephaly), delayed development, and autism spectrum disorder with preserved cognitive functioning seems to comply with the criteria of PHTS, taking into account major and minor criteria described earlier [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eVarious abnormalities were described in the overgrowing brain in PHTS, such as cerebellar dysplastic gangliocytoma called Lhermitte-Duclos disease, low lying cerebellar tonsils (Chiari 1 malformation), meningioma, developmental venous anomalies, cavernomas, microhemorrhages, arteriovenous fistula, and pontine capillary telangiectasia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The most commonly published MRI abnormalities, however, were dilated perivascular spaces and multifocal white matter abnormalities that showed hyperintensity on T2-weighted and FLAIR images [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. It was suggested that this MRI pattern in the appropriate clinical context should prompt consideration of the diagnosis of PTEN spectrum disorders [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Patients 1, 2, and 4 in this study showed dilated perivascular spaces, and T2/FLAIR hyperintensities by MRI.\u003c/p\u003e\u003cp\u003eThe structural basis of cerebral overgrowth in PHTS have been studied in experimental animals and humans as well. Increased proliferation of glial cells, neuronal, and dendritic hypertrophy were observed in mouse models with germline heterozygous \u003cem\u003ePTEN\u003c/em\u003e mutations [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. In humans, quantitative evaluation of brain morphology and connectivity by MRI was carried out in order to designate the cerebral areas most affected by overgrowth in PHTS. Mega corpus callosum, significantly increased cortical surface area, cortical gray and white matter volumes were found in PHTS patients compared to neurotypical controls [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. High angular resolution diffusion MRI tractography showed increased volume and length of callosal pathways and increased volume of the arcuate fasciculi connecting Broca\u0026rsquo;s and Wernicke\u0026rsquo;s areas. Increased length of various white matter tracts, such as the bilateral inferior longitudinal fasciculi, bilateral inferior fronto-occipital fasciculi, and bilateral uncinate fasciculi were also demonstrated [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. These findings are in line with the routine MRI findings, which may show expanded white matter areas (Fig, 1A,B).\u003c/p\u003e\u003cp\u003eMalformation of cortical development in addition to global developmental delay, intellectual disability, failure to thrive and gastrointestinal polyposis were striking abnormalities in Patient 5 with a \u003cem\u003ede novo\u003c/em\u003e pathogenic heterozygous nonsense mutation [c.1003C\u0026thinsp;\u0026gt;\u0026thinsp;T, p.(Arg335Ter)] in \u003cem\u003ePTEN\u003c/em\u003e. This pathogenic variant has previously been published several times, however cerebral cortical malformation has not been reported in association with this variant [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50 CR51 CR52 CR53 CR54 CR55\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Moreover, Patient 5 had \u003cem\u003eDICER1\u003c/em\u003e negative pleuropulmonary blastoma as well, not published yet in association with pathogenic \u003cem\u003ePTEN\u003c/em\u003e variants.\u003c/p\u003e\u003cp\u003eThe Arg335Ter variant affecting the protein in the C2 domain is the most common truncating variant [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Experimentally in Arg335Ter nonsense mutation cellular PTEN protein level was very low or not observable in lymphoblasts derived from PHTS patients, while significantly increased amount of truncated protein was found after proteasome inhibition suggesting that this PTEN mutant protein may undergo some proteasome degradation [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Similar observations were made on MCF-7 breast cancer cells and HEK-293 cells expressing this nonsense mutant PTEN. Eventually it could be hypothesized that this nonsense mutation either might cause nonsense-mediated decay, or results in a protein, which could undergo proteasomal degradation [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA relatively small number of patients harboring malformations of cortical development have been reported in association with \u003cem\u003ePTEN\u003c/em\u003e mutations (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Atypical gyration, or complicated gyral pattern (dysgyria) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], focal cortical dysplasia [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR58\" citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan additionalcitationids=\"CR61\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e], gray matter heterotopia [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], and most often polymicrogyria have been documented earlier [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Dhamija et al [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] found only a single case with polymicrogyria out of 22 patients with Cowden syndrome whose molecular background remained unknown. In contrast in 12 patients among 22 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and in 8 individuals among 20 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] carrying pathogenic \u003cem\u003ePTEN\u003c/em\u003e variants had polymicrogyria. Hemimegalencephaly with dysgenesis of the affected hemisphere also occurred occasionally in association with \u003cem\u003ePTEN\u003c/em\u003e mutations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. In Patient 5, a large dysplastic, thickened cortex and juxtacortical white matter T2 hyperintensity affecting almost half of the right cerebral hemisphere was identified. This malformation might fulfill the criteria of partial hemimegalencephaly at best, or rather multilobar segmental cortical dysplasia as the size of both hemispheres seemed to be almost the same. Epilepsy in this patient was the complication of the malformed cortex. The somatic growth of this boy severely lagged behind the typical development, and he had microcephaly using the standard calculators for percentile and SD values.\u003c/p\u003e\u003cp\u003eThe pathomechanism leading to hemimegalencephaly or multilobar segmental cortical dysplasia as seen in Patient 5 with germline \u003cem\u003ePTEN\u003c/em\u003e mutations remained unknown. Activation state of PI3K-AKT-mTOR pathway kinases has been studied in resected hemimegalencephalic cortical tissue from a patient with germline \u003cem\u003ePTEN\u003c/em\u003e mutation (Tyr68His) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Western blotting exhibited increase in phosphorylated forms of AKT (pAKT) in the cortical homogenate and immunohistochemistry confirmed that 10% of neurons exhibited increased phospho-S6 expression. Phospho\u0026ndash;S6 refers to the phosphorylated form of ribosomal protein S6, which is a marker of the PI3K-AKT-mTOR pathway activity. In addition, \u003cem\u003ein vitro\u003c/em\u003e AKT kinase assay of brain extracts from the resected hemimegalencephalic brain tissue of the patient with germline \u003cem\u003ePTEN\u003c/em\u003e mutation provided evidence of increased activity. Similarly, to the investigations in mice, the size of neurons was moderately increased in the \u003cem\u003ePTEN\u003c/em\u003e-mutated specimen. It was concluded that very likely a second, by the authors unidentified somatic mutation might be required for the excessive PI3K-AKT pathway activation in the hemimegalencephalic cortex [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Brain tissue was not available from Patient 5; however, similar mechanism as discussed afore might be hypothesized. Mutations in other genes encoding components of the PI3K-AKT-mTOR pathway usually have activating effects and cause overgrowth syndromes, similarly to the loss of negative regulation in \u003cem\u003ePTEN\u003c/em\u003e mutations. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePleuropulmonary blastoma (PPB) is the most common lung tumor of infancy and childhood. Type I PPB is a purely cystic, often multiseptated lesion with a layer of primitive, malignant cells. If those primitive cells proliferate further, this may form a mixed cystic and solid lesion termed type II PPB. Continued progression results in complete loss of the cystic spaces, leading to an entirely solid mass, termed type III PPB. A fourth type, type IR (regressed/regressing) PPB, is also seen in individuals from infancy through adulthood. The median age at diagnosis of type I PPB is 7 months, type IR is 31.2 months, type II is 35 months, and type III PPB is 39 months of age. [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Patient 5 had type II PPB. According to the International PPB/\u003cem\u003eDICER1\u003c/em\u003e Registry 83% of of patients, suffering from this type of tumor has germline or somatic pathogenic/likely pathogenic \u003cem\u003eDICER1\u003c/em\u003e variant [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. A search for pathogenic germline or somatic \u003cem\u003eDICER1\u003c/em\u003e variants remained unsuccessful, however, a somatic delin variant [c.197_200delinsCG p.(Lys66ThrfsTer7)] in \u003cem\u003ePTEN\u003c/em\u003e was identified in the tumor tissue in addition to the germline \u003cem\u003ePTEN\u003c/em\u003e variant [(c.1003C\u0026thinsp;\u0026gt;\u0026thinsp;T, p.(Arg335Ter)]. This somatic variant led to a frameshift, which might have a role as a second hit in the tumor genesis in Patient 5. In adults with PHTS lifetime risk of breast, endometrial, thyroid, kidney, and colorectal cancers, as well as melanoma has been extensively studied [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Risk of thyroid tumors in childhood has also been well documented [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These PTEN-related tumors have recently been referred to as PHTS component cancers, while other tumors that might occur in association with PTEN mutations have been called non-component cancers [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Pleuropulmonary blastoma can be regarded as a non-component cancer, not reported yet in combination with \u003cem\u003ePTEN\u003c/em\u003e mutation.\u003c/p\u003e\u003cp\u003eAs pathogenic \u003cem\u003ePTEN\u003c/em\u003e variants leads to activation of the PI3K-AKT-mTOR signaling pathway, it has been suggested that inhibition of the mTOR pathway may rescue components of the PHTS phenotype. It has been noted experimentally that in \u003cem\u003ePten\u003c/em\u003e knockout mice rapamycin prevented and reversed neuronal hypertrophy [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Further studies provided evidence that rapamycin prevents, but does not reverse aberrant migration in \u003cem\u003ePten\u003c/em\u003e knockout mice [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Moreover, pharmacologic mTOR inhibition by everolimus in \u003cem\u003ePten\u003c/em\u003e knockout mice led to successful downstream signaling rescue, including suppression of S6 phosphorylation, correlating with phenotypic rescue [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn humans, patients aged 18 years or older with Cowden syndrome due to germline \u003cem\u003ePTEN\u003c/em\u003e mutation received sirolimus (rapamycin) for 56 days. As a result, cerebellar function improved by 1 month. Dermatologic and endoscopic examinations also showed improvement [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. In another trial lasting for 6 months and enrolling patients with PHTS aged 5\u0026ndash;45 years, the effect of everolimus on neurocognitive outcome was examined. The primary efficacy endpoint did not reveal improvement with everolimus, however several secondary endpoints in the fields of nonverbal IQ, verbal learning, autism symptoms, motor skills, and adaptive behavior moved in the direction of improvement [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOther approaches to the therapy consider that \u003cem\u003ePTEN\u003c/em\u003e nonsense mutations, like the mutation in Patient 5 (Arg335Ter) may generate premature termination codons and produce nonfunctional truncated PTEN protein. Consequently, efforts have been made to restore full-length PTEN protein from the truncated one by translational read through [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe neoplastic manifestations of PHTS are rare in childhood and young adulthood with the exception of thyroid neoplasms. Therefore, recent European guidelines suggest initiating annual thyroid ultrasound surveillance at 18 years of age and younger if there is a family history of early-onset thyroid cancers [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Other updated aspects of surveillance recommendations and considerations for children and adolescents with PHTS have also been reviewed recently [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMegalencephaly, developmental delay, autism, and intellectual disability in infancy and childhood may suggest PHTS because of an underlying pathogenic germline variant in the \u003cem\u003ePTEN\u003c/em\u003e gene. Knowledge about the variable spectra of PHTS genotype and phenotype could help diagnostics of new patients. Variant interpretation based on large cohort studies may provide personalized healthcare of PHTS.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eaCGH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Array comparative genome hybridization\u003c/p\u003e\n\u003cp\u003eCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computed tomography\u003c/p\u003e\n\u003cp\u003eDWI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Diffusion weighted\u003c/p\u003e\n\u003cp\u003eExAc\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Exome Aggregation Consortium\u003c/p\u003e\n\u003cp\u003eFLAIR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Fluid-attenuated inversion recovery\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGATK\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Genome analysis toolkit\u003c/p\u003e\n\u003cp\u003eGnomAD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Genome aggregation database \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGRCh37\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Genome reference consortium human genome build 37\u003c/p\u003e\n\u003cp\u003eHGMD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Human gene mutation database\u003c/p\u003e\n\u003cp\u003eMAF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Minor allele frequency\u003c/p\u003e\n\u003cp\u003eMLPA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Multiplex ligation-dependent probe amplification\u003c/p\u003e\n\u003cp\u003eMRI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eNIPT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non-invasive prenatal test\u003c/p\u003e\n\u003cp\u003ePDZ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Originated from post-synaptic density protein 95, \u003cem\u003eDrosophila\u003c/em\u003e disc large tumor suppressor and Zona occludens-1 motif\u003c/p\u003e\n\u003cp\u003ePEG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Percutaneous endoscopic gastrostomy\u003c/p\u003e\n\u003cp\u003ePHTS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;PTEN hamartoma tumor syndrome\u003c/p\u003e\n\u003cp\u003ePI3K-AKT-mTOR\u0026nbsp; \u0026nbsp; \u0026nbsp;Phosphoinositide 3 kinase-AKT-mammalian (or mechanistic) target of rapamycin\u003c/p\u003e\n\u003cp\u003ePIP2\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Phosphatidylinositol-4,5-bisphosphate\u003c/p\u003e\n\u003cp\u003ePIP3\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Phosphatidylinositol-3,4,5-triphosphate\u003c/p\u003e\n\u003cp\u003ePPB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Pleuropulmonary blastoma\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePTEN\u003c/em\u003e Phosphatase and tensin homolog gene\u003c/p\u003e\n\u003cp\u003ePTEN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;PTEN protein\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Standard deviation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eThe authors thank all the patients and their parents for the invaluable participation in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contributions\u0026nbsp;\u003c/strong\u003eM.Cs., L.Sz.: Conceptualization, methodology, data collection, writing original draft. M.K.G.: Data collection. V.V.: Visualization. T.K., J.K,: Data interpretation, manuscript review and editing, supervision. T.Z., L.K.: Methodology, manuscript review, final approval. All authors read and approved the final manuscript. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003eThe data that support the findings of this study are available from the corresponding author upon request. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Hungarian Medical Research Council (ETT TUKEB, BM/2150-1/2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u0026nbsp;\u003c/strong\u003eWritten informed consent to participate in the study was obtained from the parents of the patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e The authors have no relevant financial or non-financial interests to disclose\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eJansen LA, Mirzaa GM, Ishak GE et al (2015) PI3K/AKT pathway mutations cause a spectrum of brain malformations from megalencephaly to focal cortical dysplasia. Brain 138:1613-1628. https://doi.org/10.1093/brain/awv045\u003c/li\u003e\n \u003cli\u003eFruman DA, Chiu H, Hopkins BD, Bagrodia S Cantley LS, Abraham RT (2017) The PI3K pathway in human disease. 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Transl Oncol 7:196-205. https://doi.org/10.1016/jtranon.2014.02.004\u003c/li\u003e\n \u003cli\u003eSmith IN, Thacker S, Jaini R, Eng C (2019) Dynamics and structural stability effects of germline \u003cem\u003ePTEN\u003c/em\u003e mutations associated with cancer versus autism phenotypes. J Biomol Struct Dyn 37:1766-1782. https://doi.org/10.1080/07391102.2018.1465854\u003c/li\u003e\n \u003cli\u003eMighell TL, Thacker S, Fombonne E, Eng C, O\u0026rsquo;Roak BJ (2020) An integrated deep-mutational-scanning approach provides clinical insight on \u003cem\u003ePTEN\u003c/em\u003e genotype-phenotype relationships. Am J Hum Genet 106:818-829. https://doi.org/10.1016/ajhg.2020.04.014\u003c/li\u003e\n \u003cli\u003eHendricks LAJ, Hoogerbrugge N, Venselaar H, Aretz S, Spier I, Legius E, Brems H, de Putter R, Claes KBM, Evans DG et al (2022) Genotype-phenotype associations in a large PTEN hamartoma tumor syndrome (PHTS) patient cohort. Eur J Med Genet 65:104632 https://doi.org/10.1016/j.ejmg.2022.104632\u003c/li\u003e\n \u003cli\u003ePena-Couso L, Ercibengoa M, Mercadillo F, G\u0026oacute;mez-S\u0026aacute;nchez D, Inglada-P\u0026eacute;rez L, Santos M, Lanillos J, Guti\u0026eacute;rrez-Abad D, Hern\u0026aacute;ndez A, Carbonell P et al (2022) Considerations on diagnosis and surveillance measures of PTEN hamartoma tumor syndrome: clinical and genetic study in a series of Spanish patients. Orphanet J Rare Dis 17:85 https://doi.org/10.1186/s13023-021-02079-7\u003c/li\u003e\n \u003cli\u003eComeau D, Allain V, Maillet-Lebel N, Amor MB (2023) Novel dermatological and skeletal features associated with \u003cem\u003ePTEN\u003c/em\u003e variants in \u003cem\u003ePTEN\u003c/em\u003e hamartoma tumor syndrome. Eur J Med Genet 66:104798. https://doi.org/10.1016.j.ejmg.2023.104798\u003c/li\u003e\n \u003cli\u003eGambini D, Ferrero S, Bulfamante G, Pisani L Corbo M, Kuhn E (2023) Cerebellar phenotypes in germline \u003cem\u003ePTEN\u003c/em\u003e mutation carriers. Neuropathol Appl Neurobiol 50:e12970. https://doi.org/10.1111/nan.12970\u003c/li\u003e\n \u003cli\u003eShiohama T, Levman J, Vasung L, Takahashi E (2020) Brain morphological analysis in \u003cem\u003ePTEN\u003c/em\u003e hamartoma tumor syndrome. Am J Med Genet 182A:1117-1129. https://doi.org/10.1002/ajmg.a.61532\u003c/li\u003e\n \u003cli\u003eSkelton PD, Stan RV, Luikart BW (2020) The role of PTEN in neurodevelopment. Mol Neuropsychiatry 5(Suppl. 1):60-71. https://doi.org/10.1159/000504782\u003c/li\u003e\n \u003cli\u003eMarsh DJ, Coulon V, Lunetta KL, Rocca-Serra P, Dahia PLM, Zheng Z, Liaw D, Caron S, Dubou\u0026eacute; B, Lin AY et al (1998) Mutation spectrum and genotype-phenotype analysis in Cowden disease and Bannayan-Zonana syndrome, two hamartoma syndromes with germline \u003cem\u003ePTEN\u003c/em\u003e mutation. Hum Mol Genet 7:507-515. https://doi.org/10.1093/hmg/7.3.507\u003c/li\u003e\n \u003cli\u003eMester J, Eng C (2012) Estimate of \u003cem\u003ede novo\u003c/em\u003e mutation frequency in probands with \u003cem\u003ePTEN\u003c/em\u003e hamartoma tumor syndrome. Genet Med 14:819-822. https://doi.org/10.1038/gim.2012.51\u003c/li\u003e\n \u003cli\u003eHobert JA, Embacher R, Mester JL, Frazier TW II, Eng C (2014) Biochemical screening and \u003cem\u003ePTEN\u003c/em\u003e mutation analysis in individuals with autism spectrum disorders and macrocephaly. Eur J Hum Genet 22:273-276. https://doi.org/10.1038/ejhg.2013.114\u003c/li\u003e\n \u003cli\u003eNgeow J, Stanuch K, Mester JL, Barnholtz-Sloan JS, Eng C (2014) Second malignant neoplasms in patients with Cowden syndrome with underlying germline \u003cem\u003ePTEN\u0026nbsp;\u003c/em\u003emutations. J Clin Oncol 32:1818-1824. https://doi.org/10.1200/JCO.2013.53.6656\u003c/li\u003e\n \u003cli\u003eNieuwenhuis MH, Kets CM, Murphy-Ryan M, Yntema HG, Evans DG, Colas C, M\u0026oslash;ller P, Hes FJ, Hodgson SV, Olderode-Berends MJW et al (2014) Cancer risk and genotype-phenotype correlation in \u003cem\u003ePTEN\u003c/em\u003e hamartoma tumor syndrome. Fam Cancer 13:57-63. https://doi.org/10.1007/s10689-013-9674-3\u003c/li\u003e\n \u003cli\u003eBusa T, Milh M, Degardin N, Girard N, Sigaudy S, Longy M, Olshchwang S, Sobol H, Chabrol B, Philip N (2015) Clinical presentation of PTEN mutations in childhood in the absence of family history of Cowden syndrome. Eur J Paediatr Neurol 19:188-192 https://doi.org/10.1016/j.ejpn.2014.11.012\u003c/li\u003e\n \u003cli\u003eRaylor A, Delon I, Allinson K, Trotman J, Liu H, Abbs S, Tischkowitz M (2015) Malignant peripheral nerve sheath tumor in Cowden syndrome: a first report. J Neuropathol Exp Neurol 74:288-292. https://doi.org/10.1097/NEN.0000000000000178\u003c/li\u003e\n \u003cli\u003eJin SC, Dong W, Kundishora AJ, Panchagnula S, Moreno-De-Luca A, Furey CG, Allocco AA, Walker RL, Nelson-Williams C, Smith H et al (2020) Exome sequencing implicates genetic disruption of prenatal neuro-gliogenesis in sporadic congenital hydrocephalus. Nat Med 26:1754-1765. https://doi.org/10.1038/s41591-020-1090-2\u003c/li\u003e\n \u003cli\u003eLuna S, Torices L, Mingo J, Amo L, Rodr\u0026iacute;guez-Escudero I, Ruiz-Ibarlucea P, Erramuzpe A, Cort\u0026eacute;s JM Tejada MI et al (2021) A global analysis of the reconstitution of PTEN function by translational readthrough of \u003cem\u003ePTEN\u0026nbsp;\u003c/em\u003epathogenic premature termination codons. Hum Mutat 42:551-566. https://doi.org/10.1002/humu.24186\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Rourke DJ, Twomey E, Lynch SN (2012) Cortical dysplasia associated with the PTEN mutation in Bannayan Riley Ruvalcaba syndrome: a rare finding. Clin Dysmorphol 21:91-92. https://doi.org/10.1097/MCD.0b013e328351639d\u003c/li\u003e\n \u003cli\u003eCheung KM, Lam CW, Chan YK, Siu WK Yong L (2014) Atypical focal cortical dysplasia in a patient with Cowden syndrome. Hong Kong Med J 20:165-167. https://doi.org/10.12809/hkmj133863\u003c/li\u003e\n \u003cli\u003eAdachi T, Takigawa H, Nomura T, Watanabe Y, Kowa H (2018) Cowden syndrome with a novel \u003cem\u003ePTEN\u003c/em\u003e mutation presenting with partial epilepsy related to focal cortical dysplasia. Intern Med 57:97-99. https://doi.org/10.2169/internalmedicine.9052-17\u003c/li\u003e\n \u003cli\u003eKlisch J, Juenging F, Spreer J, Koch D, Tghiel T. B\u0026uuml;chert M, Arnold S, Feuerhake F, Schumacher M (2001) Lhermitte-Duclos disease: assessment with MR imaging, positron emission tomography, single-photon emission CT, and MR spectroscopy. AJNR Am J Neuroradiol 22:824-830. PMID: 11337322\u003c/li\u003e\n \u003cli\u003eElia M, Amato C, Bottitta M, Grillo L, Clabrese G, Esposito M, Carotenuto M (2012) An atypical patient with Cowden syndrome and PTEN gene mutation presenting with cortical malformation and focal epilepsy. Brain Dev 34:873-876. https://doi.org/10.1016/j.braindev.2012 .03.005\u003c/li\u003e\n \u003cli\u003eChild ND, Cascino GD (2013) Mystery case: Cowden syndrome presenting with partial epilepsy related to focal cortical dysplasia. Neurology 8:e98-99. https://doi.org/10.1212/WNL.0b013e3182a55ef0\u003c/li\u003e\n \u003cli\u003eMerks JHM, de Vries LS, Zhou XP, Nikkels P, Barth PG, Eng C, Hennekam RCM (2003) PTEN hamartoma tumour syndrome: variability of an entity. J Med Genet 40:e1111. https://doi.org/101136/jmg.40.10.e111\u003c/li\u003e\n \u003cli\u003eNelson AT, Chen KS, Schultz KAP (2025) Pleuropulmonary blastoma and \u003cem\u003eDICER1\u003c/em\u003e-related tumor predisposition: from clinicopathologic observations to clinical trial. Curr Opin Pediatr 37:48-55. https://doi.org/10.1097/MOP.0000000000001431\u003c/li\u003e\n \u003cli\u003eZhouJ, Blundell J, Ogawa S, Kwon CH, Zhang W, Sinton C, Powell CM, Parada LF. (2009) Pharmacological inhibition of mTORC1 suppresses anatomical, cellular, and behavioral abnormalities in neural-specific \u003cem\u003ePten\u003c/em\u003e knock-out mice. J Neurosci 29:1773-1783. https://doi.org/10.1523/JNEUROSCI.5685-08-2009\u003c/li\u003e\n \u003cli\u003eGetz SA, DeSpenza T Jr, Li M, Luikart BW (2016) Rapamycin prevents, but does not reverse, aberrant migration in Pten knockout neurons. Neurobiol Dis 93:12-20. https://doi.org/10.1016/j.nbd.201603.010\u003c/li\u003e\n \u003cli\u003eD\u0026rsquo;Amore, A, Sundberg M, Lin R, Lubbers ET, Winden KD, Yu L, Gawlinska K, Gawlinski D, Lopez SG, Choe Y et al (2025) Phenotypic rescue via mTOR inhibition in neuron-specific Pten knockout mice reveals AKT and mTORC1-site specific changes. Mol Psychiatry 30:3077-3089. https://doi.org/10.1038/s41380-025-02916-2\u003c/li\u003e\n \u003cli\u003eKomyia T, Blumenthal GM, DeChowdhury R, Fioravanti S, Ballas MS, Morris J, Hornyak TJ, Wank S, Hewitt SM, Morrow B et al (2019) A pilot study of sirolimus in subjects with Cowden syndrome or other syndromes characterized by germline mutations in \u003cem\u003ePTEN.\u003c/em\u003e Oncologist 24:1510-e1265. https://doi.org/10.1634/theoncologist.2019-0514\u003c/li\u003e\n \u003cli\u003eSrivastava S, Jo B, Zhang B, Frazier T, Gallagher AS, Peck F, Levin AR, Mondal S, Li Z, Filip-Dhima R et al (2022) A randomized controlled trial of everolimus for neurocognitive symptoms in PTEN hamartoma tumor syndrome. Hum Mol Genet 31:3393-3404. https://doi.org/10.1093/hmg/ddac111\u003c/li\u003e\n \u003cli\u003eMalaney P, Uversy VN Dav\u0026eacute; V (2015) Identification of intrinsically disordered regions in PTEN and delineation of its function via a network approach. Methods 77-78:69-74. https://doi.org/10.1016/j.ymeth.2014.10.005\u003c/li\u003e\n \u003cli\u003eVaradi M, Bertoni D, Magana P, Paramval U, Pidruchna I, Radhakrishnan M, TsenkovM, Nair S, Mirdita M, Yeo J et al (2024) AlphaFold protein structure database in 2024: providing structure coverage for over 214 million protein sequences. Nucleic Acids Res 52:D368-D375. https://doi.org/10.1093/nar/gkad1011\u003c/li\u003e\n \u003cli\u003eGoddard TD, Huang CC, Meng EC, Pettersen EF, Couch GS, Morris JH, Ferrin TE (2018) UCSF ChimeraX: Meeting modern challenges in visualization and analysis. Protein Sci 27:14-25. https://doi.org/10.1002/pro.3235\u003c/li\u003e\n \u003cli\u003eThe UniProt Consortium (2017) UniProt: the universal protein knowledgebase. Nucleic Acids Res 45:D158-D169. https://doi.org/10.1093/nar/gkw1099\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 \u0026nbsp;\u003c/strong\u003ePatients with \u003cem\u003ede novo\u003c/em\u003e heterozygous \u003cem\u003ePTEN\u003c/em\u003e variants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"847\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.79221%;\"\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.48642%;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eNucleotide refseq identifier\u003c/p\u003e\n \u003cp\u003e(NM)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003eExon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.098%;\"\u003e\n \u003cp\u003eNucleotide variation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eProtein refseq\u003c/p\u003e\n \u003cp\u003eidentifier\u003c/p\u003e\n \u003cp\u003e(NP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2161%;\"\u003e\n \u003cp\u003eAmino acid variation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.72963%;\"\u003e\n \u003cp\u003eMutational type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5844%;\"\u003e\n \u003cp\u003eMain clinical\u0026nbsp;\u003c/p\u003e\n \u003cp\u003efindings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9244%;\"\u003e\n \u003cp\u003eBrain MRI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.79221%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.48642%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eNM\u0026shy;_000314.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.098%;\"\u003e\n \u003cp\u003ec.284C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eNP_000305.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2161%;\"\u003e\n \u003cp\u003ep.(Pro95Leu)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.72963%;\"\u003e\n \u003cp\u003emissense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5844%;\"\u003e\n \u003cp\u003eMegalencephaly\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(+6.0 SD)\u003c/p\u003e\n \u003cp\u003eMacrosomia\u003c/p\u003e\n \u003cp\u003eGlobal developmental delay\u003c/p\u003e\n \u003cp\u003eIntellectual disability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9244%;\"\u003e\n \u003cp\u003eDysgyria\u003c/p\u003e\n \u003cp\u003eDilated perivascular spaces\u003c/p\u003e\n \u003cp\u003eMultifocal \u0026nbsp;T2/FLAIR hyperintensities in the white matter\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.79221%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.48642%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eNM_000314.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.098%;\"\u003e\n \u003cp\u003ec.406T\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eNP_000305.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2161%;\"\u003e\n \u003cp\u003ep.(Cys136Arg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.72963%;\"\u003e\n \u003cp\u003emissense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5844%;\"\u003e\n \u003cp\u003eMegalencephaly\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(+5.5 SD)\u003c/p\u003e\n \u003cp\u003eGlobal developmental delay\u003c/p\u003e\n \u003cp\u003eIntellectual disability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9244%;\"\u003e\n \u003cp\u003eDysgyria\u003c/p\u003e\n \u003cp\u003eDilated perivascular spaces\u003c/p\u003e\n \u003cp\u003eSeveral cysts with CSF signal intensity\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMultifocal \u0026nbsp;T2/FLAIR hyperintensities in the white matter\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.79221%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.48642%;\"\u003e\n \u003cp\u003e1,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eNM_000314.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.098%;\"\u003e\n \u003cp\u003ec.518G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eNP_000305.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2161%;\"\u003e\n \u003cp\u003ep.(Arg173His)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.72963%;\"\u003e\n \u003cp\u003emissense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5844%;\"\u003e\n \u003cp\u003eMegalencephaly\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(+4.3 SD)\u003c/p\u003e\n \u003cp\u003eDelayed development\u003c/p\u003e\n \u003cp\u003e(mild)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9244%;\"\u003e\n \u003cp\u003eNormal at 7 months of age\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.79221%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.48642%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNM_000314.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ec.758T\u0026gt;C\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUNPUBLISHED\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(the variant published earlier:\u003c/p\u003e\n \u003cp\u003ec.758T\u0026gt;G)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNP_000305.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2161%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep.(Ile253Thr)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUNPUBLISHED\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e[the variant published earlier:\u003c/p\u003e\n \u003cp\u003ep.(Ile253Ser\u003cstrong\u003e)]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.72963%;\"\u003e\n \u003cp\u003e\u003cstrong\u003emissense\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5844%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMegalencephaly\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(+4.2 SD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMacrosomia\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDelayed development\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAutism spectrum disorder\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eObesitas\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9244%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDilated perivascular spaces\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMultifocal \u0026nbsp; \u0026nbsp; T2/FLAIR hyperintensities in the white matter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.79221%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.48642%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eNM_000314.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.549%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.098%;\"\u003e\n \u003cp\u003ec.1003C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0354%;\"\u003e\n \u003cp\u003eNP_000305.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2161%;\"\u003e\n \u003cp\u003ep.(Arg335Ter)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.72963%;\"\u003e\n \u003cp\u003enonsense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5844%;\"\u003e\n \u003cp\u003eMicrocephaly\u003c/p\u003e\n \u003cp\u003eGlobal developmental delay\u003c/p\u003e\n \u003cp\u003eIntellectual disability\u003c/p\u003e\n \u003cp\u003eFailure to thrive\u003c/p\u003e\n \u003cp\u003eEpilepsy\u003c/p\u003e\n \u003cp\u003ePleuropulmonary \u0026nbsp;blastoma, type II\u003c/p\u003e\n \u003cp\u003eGastrointestinal polyposis)\u003c/p\u003e\n \u003cp\u003eOsteoporosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9244%;\"\u003e\n \u003cp\u003eMultilobar segmental cortical dysplasia\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eM: male, F: female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eOverview of PTEN-related malformations of cortical development published with genetic data\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eMalformation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eExon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eNucleotide variation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eAmino acid variation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eComments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"14\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDysgyria\u003c/p\u003e\n \u003cp\u003e(atypical gyration\u003csup\u003e2\u003c/sup\u003e, or complicated gyral pattern\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.7_10dupGCCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Ile4SerfsTer7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003epresumed maternal inheritance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.49C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Gln17Ter)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.164+1G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.206A\u0026gt;G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Asn69Ser)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ec.284C\u0026gt;T\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep.(Pro95Leu)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThis study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.323T\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Leu108Pro)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.368A\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(His123Pro)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.395G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Gly132Asp)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.402G\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.Met134Ile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ec.406T\u0026gt;C\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep.(Cys136Arg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThis study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.491delA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Lys164ArgfsTer3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.697C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg233Ter)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.697C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg233Ter)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003edeletion chr10q23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eFocal cortical dysplasia\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.389G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg130Gln)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003epaternal inheritance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[57]\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.389G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg130Gln)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003epaternal inheritance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.486delC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.Asp162fsTer166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[59]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.1023del\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.Phe341LeufsTer3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[58]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eMultilobar segmental cortical dysplasia\u003c/p\u003e\n \u003cp\u003e(large cortical dysplasia without extension to the entire hemisphere)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExon 8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ec.1003C\u0026gt;T\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep.(Arg335Ter)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThis study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.202C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Tyr68His)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[1]\u003c/p\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.388C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg130Ter)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.492+1delG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[63]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eLoss exons 7-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e10q23.31 (89.716.106-\u003c/p\u003e\n \u003cp\u003e89.727.978)x1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eLoss exons 7-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e(continued) Overview of PTEN-related malformations of cortical development published with genetic data\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"25\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ePolymicrogyria\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.48T\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.Tyr16Ter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[55]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.139A\u0026gt;G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg47Gly)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.160_162delGTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Val54del)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.209+5G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.242T\u0026gt;G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Phe81Cys)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.253+1G\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.380G\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Gly127Ala)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.385G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Gln129Arg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eLhermitte-Duclos disease in the cerebellum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[61]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.388C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg130Ter)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.388C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg130Ter)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.389G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg130Gln)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.389G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Arg130Gln)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[55]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.406T\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Cys136Arg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.464A\u0026gt;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Tyr155Ser)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.492+1G\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.521A\u0026gt;G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Tyr174Cys)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.611delC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Pro204GlnfsTer17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.737C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Pro246Leu)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.737C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Pro246Leu)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.888_889delTG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Cys296fsTer5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.955insA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Thr319AsnfsTer6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.972dupT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Asp324fs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.1027delG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Val343Ter)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.1085C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Ser362Leu)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003edeletion chr10q23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e (continued) Overview of PTEN-related malformations of cortical development published with genetic data\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eHeterotopia\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.131G\u0026gt;A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Gly44Asp)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003eunknown\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[19]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.266C\u0026gt;G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Pro89Arg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[16]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.470A\u0026gt;G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Glu157Gly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[19]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec. 605C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Thr202Ile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[19]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.737C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Pro246Leu)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[15[\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.1027-2A\u0026gt;G\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLhermitte-Duclos disease in the cerebellum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[60]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ec.1085C\u0026gt;T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ep.(Ser362Leu)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cem\u003ede novo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eEnlarged perivascular spaces, periventricular white matter signal abnormalities, or cysts, cerebellar tonsillar ectopia, and mega corpus callosum have not been included. Lhermitte-Duclos syndrome is listed in Table 2 only if co-occurring with malformation of cortical development\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eTerminology by Shao et al 2020 [15] \u0026ndash; gyration is suggestive of polymicrogyria in only one imaging plane\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eTerminology by Shelkowitz et al 2023 [18] \u0026ndash; gyri were too numerous and too shallow, but they lacked the overt cortical thickening or saw-toothed patterns typically seem in polymicrogyria\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eClassification corresponds to that of the authors\u0026rsquo; original classification \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5,6\u003c/sup\u003e Probably the same patients\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Department of Pediatrics, University of Szeged, Szeged, Hungary","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"PTEN hamartoma tumor syndrome, PTEN gene, PTEN protein, Macrocephaly, Megalencephaly, Developmental delay, Intellectual disability, Autism spectrum disorder, Cerebral cortical dysplasia, Pleuropulmonary blastoma ","lastPublishedDoi":"10.21203/rs.3.rs-8070330/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8070330/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePTEN hamartoma tumor syndrome (PHTS) is caused by germline heterozygous pathogenic variants of the tumor suppressor \u003cem\u003ePTEN\u003c/em\u003e gene, crucial for the regulation of the PI3K-AKT-mTOR pathway. PHTS encompasses several different syndromes with overlapping clinical features, such as PTEN-related macrocephaly and autism syndrome, Bannayan-Riley-Ruvalcaba, Cowden, Lhermitte-Duclos, Proteus and Proteus-like syndromes. In this study, the clinical and molecular findings of five children, aged 1.5-18 years, with PHTS confirmed by clinical exome sequencing are reported. Megalencephaly, delayed development, autism spectrum disorder, and intellectual disability were the main phenotypic features in four cases with missense variants (Pro95Leu, Cys136Arg, Arg173His, and Ile253Thr). One of these variants (Ile253Thr) is still unpublished. A truncating variant (Arg335Ter), however, was associated with an extended segmental cerebral cortical dysplasia, and pleuropulmonary blastoma, neither of them reported yet in association with this pathogenic \u003cem\u003ePTEN\u003c/em\u003e variant. \u003cem\u003eDICER1\u003c/em\u003e mutation was not identified in the lung tumor; however, a \u003cem\u003ePTEN\u003c/em\u003e somatic delin variant [c.197_200delins CG p.(Lys66ThrfsTer7)] causing frameshift as a second hit in the tumor co-occurred with the germline truncating variant.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion:\u003c/em\u003eThis study expands the clinical and molecular spectrum of PHTS in childhood, highlighting a novel variant. In addition, a unique co-occurrence of segmental cerebral cortical dysplasia and pleuropulmonary blastoma in association with the pathogenic Arg335Ter \u003cem\u003ePTEN\u003c/em\u003e variant is described. A somatic \u003cem\u003ePTEN\u003c/em\u003e variant, as a second hit might have contributed to the genesis of the lung tumor.\u003c/p\u003e","manuscriptTitle":"PTEN hamartoma tumor syndrome in children: Identification of recurrent mutations, an unpublished variant and a case of cerebral cortical dysplasia co-occurring with pleuropulmonary blastoma. \nReview of PTEN-related malformations of cortical development","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 17:21:16","doi":"10.21203/rs.3.rs-8070330/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5d0706b-a53e-4cee-a2bf-b997660ea97a","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-11T17:21:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-11 17:21:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8070330","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8070330","identity":"rs-8070330","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}