Gynecologic and reproductive health in patients with pathogenic germline variants in DICER1.

Sixty-four DICER1 -carrier female patients from 32 predominantly non-Hispanic white families were confirmed to have a heterozygous germline DICER1 pathogenic variant and ranged in age from 2–72 years (median: 31 years). Of these, 15 DICER1 -carriers were age 11 years or younger, 38 were aged 12–50 years, and 11 were over age 50 years. Three females including one adolescent with a history of embryonal rhabdomyosarcoma and one woman who had recently undergone miscarriage did not undergo speculum exam; one other adolescent refused gynecology visit altogether but underwent study laboratory testing. The mean age of menarche was 12.7 years (range 10–16 years), the same as the general population ( 16 , 17 ). Those patients who survived pleuropulmonary blastoma, developed embryonal rhabdomyosarcoma, or developed ovarian Sertoli-Leydig cell tumors also had a similar age of menarche. No patient reported precocious puberty and most reported regular menstrual cycles with normal flow. Peripubertal gynecologic issues included embryonal rhabdomyosarcoma of the cervix (n=3; table 1 ), ovarian Sertoli-Leydig cell tumor (SLCT) (n=1), and unilateral, asymmetric breast development (n=1). Two patients with embryonal rhabdomyosarcoma of the cervix presented with vaginal bleeding prior to menarche and vaginal mass which was described as a “grape-like mass” protruding from the vagina in one. The third patient presented with heavy vaginal discharge two years after menarche. Pathologic evaluation of all three tumors revealed embryonal rhabdomyosarcoma of the cervix, botryoid type; initial treatment for each patient included chemotherapy and vaginal trachelectomy. One of these patients whose initial tumor was diagnosed at age 7 years, developed recurrence at age 12 years which was successfully treated with surgical resection, chemotherapy and vaginal vault brachytherapy. This patient subsequently was diagnosed with an ovarian Sertoli-Leydig cell tumor at age 18 years. An individual with post-pubertal embryonal rhabdomyosarcoma ultimately underwent a hysterectomy for treatment of local disease. One individual who experienced asymmetric breast development during puberty had undergone chest radiotherapy for pleuropulmonary blastoma at age 2 years; she was treated with breast augmentation and contralateral breast reduction. In these females, 15 of 64 DICER1 -carriers had a history of pleuropulmonary blastoma requiring surgical resection. All of these presented under age eight years, of whom 11 were age three years or younger. Despite 11 of 15 children being treated with a combination of surgical resection and chemotherapy with or without radiation (four with radiation versus seven without), those who were adolescents or older had an age of menarche similar to the general population( 18 ). Of nine individuals with a history of DICER1 -related ovarian tumors, five initially had Sertoli-Leydig cell tumors, two had gynandroblastomas and two were of unknown tumor type as their pathology specimens could not be centrally reviewed. Eight occurred in adolescence (median age 16 years: range 8.5–18.3). All nine women presented with virilization and/or amenorrhea ( Table 2 ). Two of these individuals developed a metachronous Sertoli-Leydig cell tumor in the contralateral ovary 6 and 46 years after their original diagnosis ( Table 2 ). A small asymptomatic ovarian carcinoid tumor was identified in a third woman when she underwent laparoscopic hysterectomy and contralateral oophorectomy three months after oophorectomy for ovarian Sertoli-Leydig cell tumor. The relationship of the carcinoid to DICER1 remains unclear. Treatment of all nine individuals comprised unilateral oophorectomy of the affected ovary with three of nine having chemotherapy treatment (age 14, 16, and 61 years). Five of these women bore children (one before and four after). One woman who also had prior cervical embryonal rhabdomyosarcoma treated with chemotherapy and low-dose brachytherapy had primary infertility. Three others have not yet attempted childbearing including one who underwent bilateral oophorectomy before age 25 years. All 64 DICER1 -carriers had a female phenotype and normal Tanner staging for age. Of 40 individuals with a cervix who underwent pelvic examinations, all but one had a normal-appearing cervix; the one exception had mild unilateral vaginal scarring after two surgical resections of embryonal rhabdomyosarcoma and vaginal brachytherapy. Male hormone testing including DHEA, DHEAS, androstenedione, 17-OH progesterone and free/total testosterone were elevated in 9 women; none had evidence of a gynecologic tumor at time of exam ( Table 3 ). Four of these nine women had prior diagnosis of polycystic ovarian disease (PCOS) based on standard criteria( 19 ). One woman who also had PCOS, had signs of virilization and amenorrhea. Generally, follicle-stimulating hormone, luteinizing hormone, estradiol, prolactin, inhibin A and B, carcinoembryonic antigen, AFP, and tumor β-hCG were in the normal range and appropriate for age. All DICER1 -carrier females over age 16 years were diagnosed with multinodular goiter (n=42) or well-differentiated thyroid carcinoma (n=4, ages 13, 20, 30, 41). Of these, 25 of 46 (54.3%) women have undergone partial or complete thyroidectomy at a median age of 20 years (range 12–60) and thus needed thyroid hormone replacement. Thirty-two of 33 DICER1 -carrier women who tried to conceive successfully delivered liveborn children. Six of these 33 reported a history of infertility with three undergoing in vitro fertilization for male factor infertility. Nine women had their first pregnancy after thyroidectomy as adolescents or young adults. These 32 women conceived a total of 111 pregnancies (median 3.0, range 1–9). Four (3.6%) pregnancies ended in first trimester termination, one (0.9%) was an ectopic pregnancy, and 23 (20.7%) resulted in spontaneous miscarriage, 21 in the first trimester and two in second trimester. Of 83 completed pregnancies (median 3, range 1–5), 71 (85.5%) resulted in vaginal deliveries and 12 (14.5%) in Cesarean births. Four (4.8%) pregnancies resulted in preterm delivery. Because of known maternal DICER1 -carrier status, an asymptomatic lung tumor was diagnosed at 3 months in a newborn, enabling early diagnosis of pleuropulmonary blastoma prior to developing symptoms( 20 ). This child is now doing well. In a second woman, a cystic lung lesion was detected by fetal ultrasound at 38 weeks, monitored postnatally and a pleuropulmonary blastoma was resected in the child at age three months. No other abnormalities in prenatal screening were reported. Ten women underwent thyroid surgery soon after pregnancy for enlarged thyroid and thyroid nodules, only one had thyroid carcinoma. Other complications of pregnancy were uncommon ( Table 4 ). Of those who were post-menarche, seven women reported dysmenorrhea, two had endometriosis. Of 26 DICER1 -carrier women aged 16 to 45 with both ovaries and available testing, anti-Müllerian hormone levels were lower than expected (median 2.94: range 0.2–10); in general, these women were fertile despite these lower anti-Müllerian hormone levels. Nine women had undergone natural menopause at a median age of 52 years (45–53) and two others had surgical menopause. Six other women had undergone hysterectomy for various benign indications including three with leiomyomata with menorrhagia (n=2) or post-menopausal bleeding (n=1), and one each with postpartum hemorrhage, endometriosis and post-menopausal endometrial polyp. One woman had breast cancer at age 29 years: a HER2+ ductal carcinoma in situ was surgically treated by mastectomy followed by breast reconstruction and neoadjuvant chemotherapy.

Participants (and/or their guardians for those < 18 years) provided written informed consent and were evaluated at the National Institutes of Health (NIH) Clinical Center as part of an Institutional Review Board-approved Natural History protocol, 11-C-0034 ( ClinicalTrials.gov Identifier: NCT01247597 ). This study recruits subjects with known DICER1 -related tumors (generally pleuropulmonary blastoma but also ovarian Sertoli-Leydig cell tumors and cystic nephroma) and their family members, as previously described ( 15 ). All females recruited from November 2011 to July 2018 with germline pathogenic DICER1 variants were included in this analysis. Those with DICER1 -associated tumors but who lacked pathogenic germline DICER1 variants (putative mosaic DICER1 or tumor-confined variants) were excluded. Pathologic materials and associated medical records were systematically obtained on all participants and were centrally reviewed by study pathologists. The general obstetric/gynecologic history was reviewed for all participants with emphasis on presenting symptoms, occurrence and treatment for DICER1 -related tumors, especially gynecologic tumors, the timing of puberty, menarche and menopause, description of menstrual cycle duration and occurrence of symptoms of virilization as the primary outcomes of interest. For this paper, multinodular goiter included self-report and study ultrasound findings of any thyroid nodule rather than more stringent criteria of thyromegaly and multiple solid nodules used in our previous report( 15 ). Antenatal and birth history was obtained for children and younger women. For women of reproductive age, fertility-infertility status, antenatal history and assessment, and pregnancy outcomes were reviewed as additional outcomes of interest. Transvaginal or abdominal pelvic ultrasound was obtained on all DICER1 -carriers to assess for current ovarian or cervical tumors. Measured reproductive hormones included follicle-stimulating hormone, luteinizing hormone, prolactin, estradiol, inhibin A and B, 17-OH progesterone, androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), and free/total testosterone and were compared to normal ranges. Reproductive tumor markers included β-hCG tumor marker, carcinoembryonic antigen and alpha-fetoprotein (AFP). In January 2013, anti-Müllerian hormone was added to the laboratory testing performed through the NIH Clinical Center laboratory. Those DICER1 -carrier patients seen prior to that time had anti-Müllerian hormone testing at home when possible (n=8). For analysis of anti-Müllerian hormone levels, only those aged 16 to 45 years with both ovaries who had undergone menarche were included. Menstrual cycle regularity defined as those occurring every 21–35 days by patient history was assessed for women of reproductive age. Gynecologic physical examination evaluated for signs of virilization and Tanner staging to characterize cohort-wide abnormalities. Females > 12 years with a cervix underwent speculum and bimanual examination to determine whether the cervix appeared normal in size and shape as an outcome of interest. Assent for pelvic exam was obtained for all post-pubertal adolescents < 18 years. Medical records were obtained whenever possible to confirm diagnoses and data abstracted.

Among these 64 girls and women with germline pathogenic DICER1 variation, nine women had a history of ovarian Sertoli-Leydig cell tumors or gynandroblastoma; three had a history of cervical embryonal rhabdomyosarcoma. Fifteen are survivors of pleuropulmonary blastoma that included surgical resection and often also included subsequent chemotherapy and radiation. Some females had a history of two different DICER1 -related tumors. Ovarian tumors generally presented with virilization and amenorrhea during adolescence. Metachronous ovarian tumors developed later in three individuals. Among all female DICER1 -carriers, including those with a unilateral ovarian tumor, pubertal development, menarche, and menopause occurred at the same age as the general population.( 18 , 21 ) Peripartum diagnosis of an affected fetus was facilitated by known maternal DICER1 status. Adult women experienced a high rate of thyroid disease resulting in thyroidectomy. Thyroid disease often worsened around pregnancy and included an increased risk of thyroid cancer. Thirty-two of 33 DICER1 -carrier women who desired childbearing had at least one liveborn child and the rate of miscarriage was similar to the general population( 22 ). Prior to attempting pregnancy, one female underwent hysterectomy, and another underwent bilateral oophorectomy. In those undergoing only unilateral oophorectomy, subsequent fertility was not compromised. Nearly all liveborn pregnancies continued to term and pregnancy complications were rare. Known maternal DICER1 status enabled peripartum diagnosis of an asymptomatic pleuropulmonary blastoma in one. Post-pubertal females who had not developed ovarian tumors generally had normal hormone levels and experienced normal menstrual cycles suggesting normal ovarian function. Of 9 DICER1 -carrier women with mildly elevated androgens, four had PCOS, one of whom had virilization. No one had ultrasound findings suggestive of a newly diagnosed tumor. Those adolescents and adult women without rhabdomyosarcoma history had a normal-appearing uterine cervix. Anti-Müllerian hormone levels, a marker of ovarian reserve, may be lower in these otherwise fertile women. Low AMH levels have been reported in women prior to and after chemotherapy, other cancer predisposition disorders, and the general population( 23 – 28 ). These reproductive-aged DICER1 -carriers did not appear to have any risk factors for lower AMH levels. This finding may warrant investigation. Thyroid abnormalities occurred in all females over age 16 years with a significant number undergoing thyroidectomy before or within a year of childbearing resulting in thyroidectomy among 59% of the childbearing-aged women. This high rate of DICER1 -related multinodular thyroid disease is much higher than the 6% rate observed in the female family control subjects under age 40( 15 ). While the thyroid is known to increase in size during pregnancy, the occurrence of thyroid surgery soon after pregnancy is noteworthy( 16 ). Thyroid hormone testing prior to and during pregnancy for those with thyroid disease or surgical hypothyroidism is recommended to enable optimizing thyroid hormone levels and is important for both maternal and fetal wellbeing ( 16 , 29 , 30 ). Since risk of DICER1 -associated tumors is a dominant trait, there is a 50% chance of transmitting the pathogenic allele to the fetus in each pregnancy regardless of whether the mother or the father harbors a pathogenic germline variant. Recently published surveillance guidelines suggest third-trimester ultrasound and chest x-ray at birth( 31 ). As illustrated by one infant in this study, evidence of a cystic lung lesion on third trimester fetal ultrasound may enable subsequent postpartum diagnosis of DICER1 -related pleuropulmonary blastoma. Suggested topics discussed with the family during genetic counseling during pregnancy include genetic testing of the child from cord blood or after birth for the parental DICER1 variant, low penetrance for the most serious DICER1 -associated phenotypes and initiation of surveillance guidelines for identification and treatment of malignancies which may improve outcomes( 31 , 32 ). Generally, if the child has a pathogenic DICER1 variant, surveillance chest CT is recommended in infancy. Routine gynecology care for DICER1 -carriers includes individual and parent education regarding symptoms of abdominal or pelvic mass, changes in menstrual cycle or signs of virilization. Surveillance for either embryonal rhabdomyosarcoma or ovarian tumors may be best accomplished by gynecologic history and pelvic ultrasound every 6–12 months to facilitate early diagnosis and treatment( 31 ). Clinical, laboratory (including AFP and male hormone testing) and ultrasound evaluation is recommended for female DICER1 -carriers who present with virilization, amenorrhea or abdominal pain/distention or mass( 1 , 33 ). Particular vigilance using ultrasound and laboratory surveillance may be indicated for those using hormonal contraceptive methods that alter menstrual cycle events( 31 ). The strengths of this study include the thorough phenotyping of subjects, enrollment of a kindred of affected individuals enabling detailed medical histories and central pathology review. The limitations of this study include small numbers, incomplete data as life-long medical records could not be obtained and participation/ascertainment bias increasing the number of females with DICER1 -related tumors, limiting the participation of those who may have milder phenotypes or those with more severe phenotypes who did not survive childhood. The number of infertile women may be limited as mothers of children with pleuropulmonary blastoma were enrolled. Despite an elevated risk both of gynecologic tumors and other DICER1 -related tumors, many women with DICER1 pathogenic variants experience healthy reproductive lives. Importantly, we did not observe an increased risk of pubertal, menstrual or fertility issues among DICER1 carriers. Surveillance and individual and family education for signs and symptoms of gynecologic tumors is warranted. The high rate of developing DICER1 -related multinodular goiter was associated with high rates of thyroidectomy and underscores the importance of thyroid hormone monitoring and assessment in DICER1 -carriers, especially during pregnancy.

Individuals who harbor germline pathogenic variants in DICER1 (MIM #601200) have an increased risk for a variety of benign and malignant tumors. The hallmark cancer of the autosomal dominant disorder, pleuropulmonary blastoma, is one of several neoplasms that may affect children and young adults. DICER1 -related gynecologic cancers include ovarian sex-cord stromal tumors, particularly Sertoli-Leydig cell tumors and gynandroblastomas often presenting during adolescence and embryonal rhabdomyosarcoma of the uterine cervix in children and adolescents( 1 , 2 ). Other clinical features include more common problems such as multinodular goiter, cystic nephroma, and differentiated thyroid carcinoma as well as less common entities like nasal chondromesenchymal hamartoma, ocular medulloepithelioma, pineoblastoma, pituitary blastoma, Wilms tumor and renal sarcoma ( 1 , 3 – 12 ). The increased risk of neoplasms is associated with heterozygous germline pathogenic variants in DICER1 , a gene which encodes an endoribonuclease crucial to processing microRNAs and is the first tumor predisposition disorder known to be caused by altered microRNA biogenesis( 7 ). The pleuropulmonary blastoma locus was mapped to chromosome 14q using linkage analysis in families with multiple cases of pleuropulmonary blastoma, resulting in the identification of heterozygous germline variants in DICER1 ( 7 ). Health care providers may consider the presence of DICER1 pathogenic variants when a female presents with a personal or family history of ovarian sex cord-stromal tumor (especially Sertoli-Leydig cell tumor, gynandroblastoma or tumors with a variable morphologic appearance that are difficult to classify), genitourinary sarcoma or other established DICER1 associations such as macrocephaly or multinodular goiter at a young age( 13 , 14 ). Likewise, a prenatal ultrasound showing a fetal lung cyst may suggest the presence of a DICER1 mutation and prompt a careful maternal and paternal family history. In these circumstances, the genetic evaluation of an individual and her family should be considered. As affected females with germline pathogenic variants in DICER1 (hereafter, DICER1 -carriers) are at risk of developing gynecologic tumors, we sought to describe the presenting symptoms, age, treatment, and effects of these DICER1 -related tumors. We also hypothesized that DICER1 -carrier females might 1) differ in the age at puberty or menarche, or report irregular menstrual cycles compared to the general population; 2) report peripubertal gynecologic issues due to DICER -related tumors; 3) experience adverse effects on their gynecologic and reproductive health after surviving a pediatric DICER1 -related tumor 4) display abnormal Tanner staging, an atypical cervical appearance, an atypical pattern of reproductive hormone levels or other endocrine disorders compared to the general population; 5) might be less fertile, have a higher rate of recurrent pregnancy loss, or adverse pregnancy outcomes; 6) experience a higher rate of gynecologic diseases or a difference in age of menopause. We sought to determine whether antenatal diagnosis of affected fetuses might occur in offspring of DICER1 -carrier women. We evaluated the gynecologic and reproductive health of a large group of thoroughly phenotyped DICER1 -carrier females.