Case Report

IDH2 and TP53 mutations are correlated withgliomagenesis in a patient with Maffucci syndrome
Kunihiko Moriya,1,6 Mika K. Kaneko,2,6 Xing Liu,2,6 Masami Hosaka,3 Fumiyoshi Fujishima,4 Jun Sakuma,5Satoshi Ogasawara,2 Mika Watanabe,4 Yoji Sasahara,1 Shigeo Kure1 and Yukinari Kato2
Departments of 1Pediatrics, 2Regional Innovation, 3Orthopedic Surgery, 4Pathology, Tohoku University Graduate School of Medicine, Sendai; 5Departmentof Neurosurgery, Fukushima Medical University School of Medicine, Fukushima, JapanKey words
Anaplastic astrocytoma, gliomagenesis, IDH2 mutation,
Maffucci syndrome, TP53
Correspondence
Kunihiko Moriya, Department of Pediatrics or YukinariKato, Department of Regional Innovation, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi,
Aoba-ku, Sendai, Miyagi 980-8574, Japan.
Tel: +81-22-717-7287; Fax: +81-22-717-7290;
E-mail: moriya-k@ped.med.tohoku.ac.jp (K. Moriya) or
yukinari-k@bea.hi-ho.ne.jp (Y. Kato)
6

We report on a 24-year-old woman who was diagnosed as having Maffucci syndrome with anaplastic astrocytoma. We analyzed the IDH1 and IDH2 mutationsof enchondroma, hemangioma and anaplastic astrocytoma tissues and the same
somatic mosaic mutation in IDH2 gene was identified in all these tissues. In addition, we identified additional mutation of the TP53 gene in anaplastic astrocytoma tissue but not in other benign tumors. This is the first report of thedetection of an identical IDH2 mutation in multiple tissues and TP53 mutation inanaplastic astrocytoma in a patient with Maffucci syndrome. This case is uniqueand supports the IDH2-dependent genetic pathway and second-hit model forgliomagenesis.

These authors contributed equally to this work.

Funding information
Platform for Drug Discovery, Informatics, and Structural
Life Science from the Ministry of Education, Culture,Sports, Science and Technology (MEXT) of Japan.
Regional Innovation Strategy Support Program fromMEXT. KAKENHI (25462242): Grant-in-Aid for Scientific
Research (C) from MEXT.
Received August 21, 2013; Revised November 12, 2013;
Accepted December 13, 2013
Cancer Sci 105 (2014) 359–362
doi: 10.1111/cas.12337

Enchondromas are benign cartilage-forming tumors within
the phalanges, metacarpals and metatarsals.(1) Individuals
with enchondromatosis syndrome, which encompasses sevenmajor subtypes, develop multiple enchondromas. The mostcommon subtypes are non-hereditary diseases, including Ollierdisease (subtype 1) and Maffucci syndrome (subtype 2); thelatter is distinguished by multiple cavernous hemangiomas that
occur in addition to the enchondromas.(1) Both conditions
generally present during childhood and can result in severe
deformity of the affected tissues, depending on the extent ofskeletal involvement. Malignant degeneration in patients with
Ollier disease is estimated to be approximately 25% at the ageof 40 years, but is uncertain in patients who have Maffucci
syndrome.(2,3) Moreover, patients with Ollier disease andMaffucci syndrome are predisposed to develop visceral andbrain tumors, such as astrocytoma, acute myeloid leukemias,and pancreatic, liver, or breast cancer.(2)Isocitrate dehydrogenase 1 (IDH1) and isocitrate dehydrogenase 2 (IDH2) are metabolic enzymes that interconvert isoci-trate and a-ketoglutarate (a-KG). In contrast, cancer-associatedpoint mutations in IDH1 and IDH2 confer a neomorphic
activity that allows reduction of a-KG to the oncometabolite
R-2-hydroxyglutarate (2-HG). Mutations in IDH1 ⁄ 2 lead to not
only a “gain of function” to catalyze the NADPH-dependent
reduction of a-KG to 2-HG but also to a “loss of function” toreduce a-KG production.(4,5) The IDH1 and IDH2 mutations
are remarkably specific to single codons: the conserved andfunctionally important Arg132 residue in IDH1 and theArg172 residue in IDH2.(6)A recent genome-wide mutational analysis identifies IDH1
⁄ 2 mutations as early and frequent genetic alterations inastrocytomas, oligodendrogliomas and oligoastrocytomas, aswell as in secondary glioblastomas.(6) Recently, it wasreported that Ollier disease and Maffucci syndrome are theresult of somatic mosaic IDH1 and IDH2 mutations.(7,8)
Here, we report on a 24-year-old female patient who wasdiagnosed as having Maffucci syndrome with anaplastic
astrocytoma. We analyzed the IDH1 and IDH2 mutations in© 2013 The Authors. Cancer Science published by Wiley Publishing Asia Pty Ltd
on behalf of Japanese Cancer Association.
This is an open access article under the terms of the Creative Commons
Attribution-NonCommercial-NoDerivs License, which permits use and distribution
in any medium, provided the original work is properly cited, the use is noncommercial and no modifications or adaptations are made.

Cancer Sci | March 2014 | vol. 105 | no. 3 | 359–362

Case Report
IDH2/TP53 mutations in Maffucci syndrome

the enchondroma, hemangioma and anaplastic astrocytoma
tissues, and the same IDH2 mutation (c.516G>T encoding
R172S) was detected in all tissues examined. Interestingly,
we also detected a TP53 mutation in the anaplastic astrocytoma tissues, but not in the enchondroma or hemangioma
tissues.
Case Report

A 24-year-old Japanese woman presented with an approximate
1-month history of headache. Her medical history included
Maffucci syndrome with multiple enchondromas of several
phalanges and metatarsal bones of the left hand (Fig. 1a,b),
combined with hemangiomas of soft tissue in the right foot(Fig. 1c). She had skeletal deformities caused by enchondromas of the phalanges of the left fingers, particularly her index
finger, appearing at 10 years of age, and hemangiomas on her

(a)

(e)

(b)

(f)(c)

(g)

(d)

(h)

Fig. 1. Clinical features of the patient with Maffucci syndrome.
(a) Deformities of the left hand caused by cartilaginous tumors.
(b) Plain X-ray image showing multiple cartilaginous tumors in manyphalanges and metacarpal bones of the left hand. (c) Hemangiomas
at the right lateral foot (arrows). (d) HE staining of cartilaginous
tumors of the left hand. (e) T1-weighted MRI imaging of brain tumor.
(f) T2-weighted MRI imaging of brain tumor. (g) Sagittal T2-weighted
MRI imaging of brain tumor. (h) HE staining of brain tissues.
© 2013 The Authors. Cancer Science published by Wiley Publishing Asia Pty Ltd
on behalf of Japanese Cancer Association.

www.wileyonlinelibrary.com/journal/cas

right foot, appearing at 16 years of age. The left-hand deformities gradually worsened, and she underwent surgical excisionof the proximal phalanx of the left index finger and complete
removal of the hemangiomas in her right foot at 21 years ofage. Pathological analysis revealed mesodermal dysplasia manifesting as a combination of enchondromatosis and hemangiomatosis. The enchondromas had a multinodular architecture
characterized by islands of cartilage (Fig. 1d).
At the time of presentation the patient was conscious but
had a severe headache. Motor function was almost normal, andher remaining cranial nerve function was otherwise intact.
There were no abnormal findings on the laboratory blood tests.
Computed tomography (CT) and MRI showed a 40 9 30-mm
mass located in the posterior fossa, which showed a low signal
on T1-weighted images (Fig. 1e) and a high signal on
T2-weighted images (Fig. 1f,g). The mass did not show anenhancement following gadolinium infusion. No distant metastatic lesion was observed on CT. Radiologically, the preoperative diagnosis was low-grade glioma. The tumor extended
from the middle cerebellar peduncle to the cerebellar vermis,
and the intraoperative pathological examination revealed diffuse astrocytoma; therefore, partial removal was performed to
avoid cerebellar ataxia or cerebellar mutism. Pathologicalexamination by HE staining demonstrated a mild focal increasein cellularity and a lack of vascular proliferation and necrosis
within the sampled tissue (Fig. 1h). The final diagnosis wasanaplastic astrocytoma. Given the patient’s consent, the relative lack of symptoms and the diffuse nature of the pathology,
the patient was administered local radiotherapy with a radiation boost to the residual tumor (50 Gy in total). Chemotherapy was not administered. The cerebellar ataxia appeared at
29 years of age. MRI showed a 16 9 7-mm lesion in the rightcerebellar hemisphere. The patient underwent endoscopic
tumor resection, followed by stereotactic radiotherapy (peripheral dose 2 Gy, total 20 Gy) and temozolomide (TMZ). TMZ
was prescribed at a dosage of 150 mg ⁄ m2 ⁄ day for 5 days
every 28 days, but the patient died at 31 years of age.
Genomic DNA was extracted from formalin-fixed, paraffinembedded tissue sections extracted by surgery using MightyAmp for FFPE (Takara Bio, Shiga, Japan) according to themanufacturer’s instructions and with the informed consent ofthe patient. We performed mutation analyses of IDH1, IDH2
and TP53 genes (Data S1). We identified the IDH2 mutation(c.516G>T encoding R172S) in the enchondroma, hemangioma
and anaplastic astrocytoma tissues, and the same IDH2-R172
mutation was detected in all these tissues (Fig. 2a). Subsequently, the PCR products were subcloned into pCR4-TOPO
vectors, and 14 clones (enchondroma), 17 clones (hemangioma) and 69 clones (astrocytoma) were sequenced to confirm
the IDH2-R172S mutations (Data S1). As a result, 28.6% (4⁄ 14), 11.8% (2 ⁄ 17) and 2.9% (2 ⁄ 69) of each tissue, respectively, were shown to carry the IDH2-R172S mutation,although these percentages do not necessarily imply those ofIDH2-R172S-possessing tumor cells (Fig. 2b). Furthermore,missense mutations (562C>A encoding L188M and 1118A>Gencoding K373R) of the TP53 gene were identified in theastrocytoma tissues, but not in the enchondroma or hemangioma tissues (Table 1, Fig. S1).
Discussion

We identified the same IDH2 (c.516G>T encoding R172S)
mutation in enchondroma, hemangioma and anaplastic astrocytoma tissues and TP53 mutation in astrocytoma taken from aCancer Sci | March 2014 | vol. 105 | no. 3 | 360

Case ReportMoriya et al.

www.wileyonlinelibrary.com/journal/cas(a)(b)Fig. 2. Mutational analysis of IDH2. (a) Direct DNA
sequencing of IDH2 was performed in theenchondroma, hemangioma and astrocytoma
tissues. (b) PCR products of IDH2 were subcloned
into pCR4-TOPO vectors, and each clone wassequenced to confirm the heterogeneous mutationof IDH2.

Table 1. Detection of IDH1 ⁄ 2 and p53 mutations in Maffucci syndrome

IDH1 ⁄ 2
IDH1
IDH2p53
Exon1
Exon2
Exon3
Exon4
Exon5
Exon6
Exon7
Exon8
Exon9
Exon10

Sense primer

Antisense primer

Enchondroma

Hemangioma

Astrocytomacggtcttcagagaagccatt
caagctgaagaagatgtggaa

gcaaaatcacattattgccaac
cagagacaagaggatggcta

Wild type
R172S

Wild type
R172S

Wild type
R172S

ctgccttccgggtcactg
ctgccttccgggtcactg
tgactgctcttttcacccatc
ctgtctccttcctcttcctacag
tgattcctcactgattgctctt
ttgggcctgtgttatctcct
ttgcttctcttttcctatcctga
tttatcacctttccttgcctct
tccccctcctctgttgct
tccctgcttctgtctcctaca

gcccaacccttgtccttac
gcccaacccttgtccttac
cccctcagggcaactgac
agccctgtcgtctctccag
gagaccccagttgcaaacc
gtggcaagtggctcctgagcttcttgtcctgcttgctt
ttgataagaggtcccaagactta
gaaggggctgaggtcactc
ggggaacaagaagtggagaa

Wild type
Wild type
ND
Wild type
Wild type
Wild type
Wild type
Wild type
Wild type
Wild type

Wild type
Wild type
Wild type
Wild type
Wild type
Wild type
Wild type
Wild type
Wild type
Wild type

Wild type
Wild type
Wild type
Wild type
L188M
Wild type
Wild type
Wild type
Wild type
K373R

ND, not detected.

patient with Maffucci syndrome. IDH mutations may be acommon genetic background in both gliomas and other tumors,
and TP53 mutation may have triggered gliomagenesis in ourpatient with Maffucci syndrome. Bathla et al. report IDH1
mutations in a case of low grade glioma with Ollier disease;
however, they did not perform mutation analyses of TP53.(9)In contrast, our case suggests that an additional acquired TP53
mutation might induce the malignant transformation in patientswith Maffucci syndrome. It is interesting to speculate that ourpatient with Maffucci syndrome, who developed an anaplastic
astrocytoma and other benign tumors with an IDH2 mutation,
represents a case of early post-zygotic genetic events, which
may have initiated the disease process. Appropriate diagnoses
of Ollier disease and Maffucci syndrome are crucial because
these diseases are associated with a significant risk of brain
tumors, as in our case, and other malignant tumors.(10,11)
Patients with Ollier disease and Maffucci syndrome have better
prognoses if the patients are diagnosed with and treated for
malignant tumors in the early stages.

Recently, we revealed that an anti-IDH1 ⁄ 2 monoclonal antibody (mAb, clone MsMab-1), which was developed against
IDH1-R132G, cross-reacts with IDH2-R172S.(12,13,14) Using
MsMab-1, we performed immunohistochemistry against anaplastic astrocytoma tissues. Although the reactivity was very
low, heterogeneity of IDH2-R172S was observed (Fig. S2).
There might be several problems about the low detection levelof IDH2-R172S in immunohistochemistry: (i) very low sensitivity of MsMab-1; (ii) low frequency of the IDH2-R172S
expression; or (iii) IDH-R172S protein degradation in a paraffin section. Although further studies are required to determine
the molecular pathogenesis of astrocytic tumors, our case isunique and supports the IDH-dependent genetic pathway andsecond-hit model for gliomagenesis.

Cancer Sci | March 2014 | vol. 105 | no. 3 | 361© 2013 The Authors. Cancer Science published by Wiley Publishing Asia Pty Ltd
on behalf of Japanese Cancer Association.

Acknowledgments
This work was supported in part by the Platform for Drug Discovery,
Informatics, and Structural Life Science from the Ministry of Educa-

Case Report
IDH2/TP53 mutations in Maffucci syndromewww.wileyonlinelibrary.com/journal/cas

tion, Culture, Sports, Science and Technology (MEXT) of Japan, byRegional Innovation Strategy Support Program from MEXT, and by
KAKENHI (25462242): Grant-in-Aid for Scientific Research (C) fromMEXT.

Disclosure Statement

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The authors have no conflict of interest.

Supporting Information
Additional supporting information may be found in the online version of this article:
Data S1. Materials and methods.
Fig. S1. Mutational analysis of TP53. Direct DNA sequencings of TP53 exon5 (a) and exon10 (b) were performed in the astrocytoma tissues.
Fig. S2. Immunohistochemical analyses against anaplastic astrocytoma tissues using MsMab-1. Mutated IDH2-R172S protein expression wasdetermined immunohistochemically in paraffin-embedded tumor specimens. Briefly, 4-lm-thick histologic sections were deparaffinized in xylene
and rehydrated. Then, they were autoclaved in citrate buffer (pH 6.0; Dako) for 20 min. Sections were incubated with 5 lg ⁄ ml of MsMab-1(A) or control (B) overnight at 4°C, followed by treatment with an LSAB kit (Dako). Color was developed using 3, 3-diaminobenzidine tetrahydrochloride (DAB; Dako) for 10 min, and counterstained with hematoxylin. Insets show that MsMab-1 stained cytoplasm. Magnification: 9200.

© 2013 The Authors. Cancer Science published by Wiley Publishing Asia Pty Ltd
on behalf of Japanese Cancer Association.

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