Review Article
Tumor-suppressor Genes, Cell Cycle Regulatory
Checkpoints, and the Skin
Ana Maria Abreu Velez1, Michael S. Howard
Departments of Dermatopathology, 1Immunodermatopathology, Georgia Dermatopathology Associates, Atlanta, Georgia, USA
The cell cycle (or cell-division cycle) is a series of events that take place in a cell, leading to its division and duplication. Cell division
requires cell cycle checkpoints (CPs) that are used by the cell to both monitor and regulate the progress of the cell cycle. Tumorsuppressor genes (TSGs) or antioncogenes are genes that protect the cell from a single event or multiple events leading to cancer.
When these genes mutate, the cell can progress to a cancerous state. We aimed to perform a narrative review, based on evaluation of
the manuscripts published in MEDLINE-indexed journals using the Medical Subject Headings (MeSH) terms “tumor suppressor’s
genes,” “skin,” and “cell cycle regulatory checkpoints.” We aimed to review the current concepts regarding TSGs, CPs, and their
association with selected cutaneous diseases. It is important to take into account that in some cell cycle disorders, multiple genetic
abnormalities may occur simultaneously. These abnormalities may include intrachromosomal insertions, unbalanced division products,
recombinations, reciprocal deletions, and/or duplication of the inserted segments or genes; thus, these presentations usually involve
several genes. Due to their complexity, these disorders require specialized expertise for proper diagnosis, counseling, personal and
family support, and genetic studies. Alterations in the TSGs or CP regulators may occur in many benign skin proliferative disorders,
neoplastic processes, and genodermatoses.
Keywords: Basal cell carcinoma (BCC), Cell cycle checkpoints (CPs), cyclins, Familial melanoma, Genetic counseling, Gorlin syndrome,
Laryngotracheal stenosis, Arthropathy, Prognathism, and short stature syndrome (LAPS), Melanoma, Myhre syndrome (MS), Neurofibromatosis
type 1 (NF-1), Oncogenes, Sézary syndrome (SS), Skin, Tumor suppressor genes (TSGs), Squamous cell carcinoma (SCC), Von Hippel-Lindau
(VHL), Werner syndrome (WS)
Address for correspondence: Dr. Ana Maria Abreu Velez, Georgia Dermatopathology Associates, 1534 North Decatur Road, NE, Suite 206,
Atlanta - 30307-1000, Georgia, USA. E-mail: [email protected]
Review objectives
To learn how to define a tumor-suppressor gene (TSG) or
A TSG is a gene that protects a cell from proceeding
toward cancer. When this gene is mutated to cause a
loss or reduction in its function, the cell can progress
to a cancerous state, usually in combination with other
genetic changes.
Access this article online
Quick Response Code:
To learn how to define CPs
There are many “points” in the cell cycle regulation
systems that control cellular transit through the
eukaryotic cell cycle; these specific points are termed CPs.
TSGs encode proteins that normally serve as a brake on
cell growth. When such genes are mutated, the brake
may be lifted, resulting in runaway cell growth known
as cancer. In contrast, oncogenes are genes that encode
proteins involved in normal cell growth. When such
genes are mutated, they may also cause cancer but they
do so by activating the growth-promoting signals. Cancer
therapies that target oncogenes usually seek to block or
reduce their action, while those aimed at TSGs seek to
restore or increase their action. In this review, we aim to
compile current data on TSGs and the skin.
The cell cycle or cell-division cycle
The cell cycle is a series of events that take place in a cell,
North American Journal of Medical Sciences | May 2015 | Volume 7 | Issue 5 |
Velez and Howard: TSGs, cell cycle regulatory checkpoints, and the skin
leading to its division and duplication.[1,2] In cells with a
nucleus (eukaryotes), the cell cycle may be divided into
the following three phases: 1) the interphase, during
which the cell grows, accumulating nutrients needed
for mitosis and duplicating its DNA, 2) the mitosis (M)
phase, during which the cell begins dividing itself into
two distinct cells, often called “daughter cells,” and
3) the final phase, cytokinesis, where the new cell is
completely divided.[1,2] The cell-division cycle is thus
the vital process via which a single-celled fertilized egg
develops into a mature organism as well as the process
by which hair, skin, blood cells, and some internal
organs are renewed.[1,2] The cell cycle is controlled by
numerous mechanisms ensuring proper cell division.
Many cells reside in a resting or quiescent state, but
can be stimulated by external signals to reenter the
cell cycle.[1,2] These external growth-promoting signals
are specifically growth factors that bind to the cell
surface receptors [Figure 1]. Most growth factors
induce the expression of genes that are referred to as
early and delayed response genes. The activation of
early response genes occurs in response to the growth
factor receptor-mediated signal transduction, resulting
in phosphorylation and activation of the transcription
factor proteins that are already present in the cell. Many
of the induced early response genes themselves encode
transcription factors, which then activate the expression
of delayed response genes. In the context of the cell cycle,
these delayed response genes encode proteins of the G1
cyclin-dependent kinases (CDKs).[1,2]
Regulation of the eukaryotic cell cycle
Cell cycle regulation directs processes crucial to cell
survival, including detection and repair of genetic
damage as well as the prevention of uncontrolled cell
division.[6] In the skin, uncontrolled cell division can
occur in diseases such as psoriasis, skin cancers, and
genodermatoses. The molecular events that control
the cell cycle are almost impossible to reverse.[6] To
be specific, there are many “parts” to the systems that
control transit through the eukaryotic cell cycle. These
“parts” include the following:
1. mechanisms to control the timing of events so that
each individual process is turned on and off at an
appropriate time;
2. Controls to ensure that events occur in a linear,
irreversible direction;
3. Redundancy, or backup systems, to ensure that the
cell cycle functions properly even in the context of
some malfunctioning parts; and
4. Adaptable system control so that the cell cycle events
may be modified in the context of different cell types
and/or environmental conditions.[6]
Many of the most important discoveries about the
The complexity of the cell cycle
The complexity of cell cycle regulation is also reflected
in the plethora of alterations leading to aberrant cell
proliferation and cancer development.[1,2] CDKs respond
to the previously described growth factor signals and
are largely responsible for pushing cells through the cell
cycle. Due to their pivotal role in cell division, nature
has evolved elaborate mechanisms to regulate the
activity of CDKs.[3] Cyclins are CDK binding partners
that are required for kinase activity and their protein
levels are directly linked to the cell cycle stage. A variety
of other CDK regulators including phosphorylation
events, natural inhibitors, and complex stability are
currently known. Phosphorylation of CDK substrates
results in diverse outcomes, including changes in gene
expression, formation of prereplicative complexes, and
breakdown of the nuclear envelope.[3] One example of the
importance of the cell cycle regulator molecules and the
skin is cyclin D1; this molecule specifically localizes to the
cytoplasms of keratinocytes during skin differentiation
and regulates cell-matrix adhesion.[4] Cyclin D1 seems to
be downregulated in specific skin cancers, especially in
squamous cell carcinoma (SCC) by an altered TSG such
as the gene Deleted in Liver Cancer 1 (DLC1).[5]
Figure 1: Displays a simplistic diagram of the cell cycle consisting of
four distinct phases: Gap1 (G1)-phase, synthesis (S)-phase, Gap2 (G2)phase (collectively known as interphase), and mitosis (M)-phase. The
M-phase is itself composed of two tightly coupled processes: mitosis,
in which the cell’s chromosomes are divided between the two daughter
cells, and cytokinesis (two cells, red arrows), in which the cell’s cytoplasm
divides in half, forming distinct cells. Growth factors, nutrients, cell size,
and DNA damage can act as possible restriction points. CPs are control
mechanisms that ensure the fidelity of cell division in eukaryotic cells.
In G1, the (restriction CP) main player is CDK inhibitor p16 (CCK p16).
This protein inhibits CDK4/6 and safeguards it so that that it can no longer
interrelate with cyclin D1 to cause cell cycle progression. The second CP
is located at the termination of G2 phase; this CP involves an activating
phosphatase known as Cdc25, which under favorable circumstances
removes the inhibitory phosphates present within the mitosis promoting
factor (a term for the cyclin B/CDK1 complex). Metaphase or spindle
phase or mitosis phase CPs require cyclin B, which harbors a destruction
box (D-box) and breaks down securin; the breakdown of securin then
allows progression of the cell cycle. Many other CPs are present in the
cell cycle but are not shown here.
mechanisms that control events of the cell cycle were
elucidated using yeast models, which are single cell
eukaryotes. Within the yeast models, pertinent discoveries
were attained by mutating genes encoding components of
cell cycle control systems. These genes were thus identified
as cell division cycle (CDC) genes. Much of the control of
the progression through the phases of a cell cycle is exerted
at specific checkpoints.[6] There are many such checkpoints
in a given cell, but the two of the most critical are:
1. Those that occur at the close of a G1 phase (prior to
S-phase entry) and
2. Those at the close of a G2 phase, preceding mitosis.[6]
For example, CPs have been shown to be downregulated
in a large proportion of basal cell carcinomas (BCCs).[7] In
addition, 14-3-3σ IkappaB kinase α (IKK-α), one of the two
catalytic subunits of the IκB kinase (IKK) complex involved
in nuclear factor kappa-light-chain-enhancer of activated
B cells (NF-κB), functions as a specific CP modulator of
epidermal development and differentiation.[7]
Other possible disruptions in skin cell cycle
regulation and their association with skin cancers
Reduced DNA repair has been linked to an increased
risk of cutaneous malignant melanoma, but insights into
the molecular mechanisms of that link are scarce. In the
skin, the INK4a/ARF cyclin-dependent kinase inhibitor
2A (CDKN2A) locus encodes two proteins that regulate
two of the most important tumor-suppressor pathways
represented by tumor protein p53 and retinoblastoma
susceptibility gene (pRB). Loss of either p16INK4a or
p19ARF was recently reported to reduce the ability of
mouse cells to repair ultraviolet (UV) induced DNA
damage and to induce a UV-mutator phenotype, as
suggested by the actions of specific regulating genes. In
other examples, loss of either p16INK4a or p19 (ARF) was
recently reported to reduce the ability of mouse cells to
repair UV-induced DNA damage. These events led to a
UV-mutator phenotype and have been suggested to play
an important role in the genesis of skin melanomas.[8]
Roles of cyclins and CDKs in cell cycle regulation
in the skin
Two key classes of regulatory molecules, cyclins and
CDKs influence a cell’s progress through the cell cycle
and this is especially important in case of skin cancers.[9,10]
Many of the genes encoding cyclins and CDKs are
conserved among all eukaryotes; however, more
complex organisms classically have more elaborate cell
cycle control systems that incorporate more individual
components. Operationally, cyclins on the skin form
the regulatory subunits and CDKs form the catalytic
subunits of an activated heterodimer. Thus, cyclins have
no catalytic activity and CDKs are inactive in the absence
of a partner cyclin. When activated by a bound cyclin,
CDKs perform a biochemical phosphorylation that
activates or inactivates target proteins and orchestrates
coordinated entry into the next phase of the cell cycle,
especially on the skin. Specific cyclin-dependent kinase
complex (cyclin-CDK) combinations determine the
specific downstream proteins targeted.[9,10] CDKs are
constitutively expressed in skin cells; in contrast, cyclins
are synthesized at specific stages of the cell cycle in
response to molecular signals. Four different classes of
cyclins have been defined, based on the stage of the cell
cycle in which they bind and activate CDKs in the skin.
These four classes are G1-cyclins, G1/S cyclins, S cyclins,
and M cyclins [Figure 1].[9,10] Although CDKs are inactive
unless bound to a cyclin, there is more to the activation
process than just the interaction of the two parts of the
complex. When cyclins bind to CDKs, they alter the
conformation of the CDKs. The conformational change
allows exposure of a domain that is the specific site of
phosphorylation; the phosphorylation is then performed
by another kinase called a CDK-activating kinase (CAK).
Following CAK phosphorylation, the cyclin-CDK
complex is fully active, especially in the skin.[9,10]
Other roles of CDKs and cell cycle regulators in the
In addition to the control of CDK kinase activity by
cyclin binding and CAK phosphorylation in the skin,
control of CDK activity may occur via interfaces with
inhibitory proteins or by inhibitory phosphorylation
procedures. Thus, there is a significant control on the
overall activity of each CDK. One of the inhibitory kinases
that phosphorylates CDKs is called Wee1.[9,10] The Wee1
inhibiting phosphorylations are in turn removed through
the action of a phosphatase called Cdc25. The action of these
two regulatory enzymes on CDK activity is very important
relative to M-CDK activity at the start of mitosis particularly
in the skin. Proteins that bind to and inhibit cyclin-CDK
complexes are called CDK inhibitory proteins or cyclindependent kinase inhibitors (CKIs).[9,10] Mammalian cells
express two classes of CKIs. These are termed:
1. CDK-interacting proteins (CIPs) or CDK inhibitory
proteins; and
2. INK4s, for inhibitors of kinase 4.
The CIPs bind and inhibit cyclin-dependent kinase 1
(CDK1), cyclin-dependent kinase 2 (CDK2), cyclindependent kinase 4 (CDK4), and cell division protein
kinase 6 (CDK6) complexes, while the INK4s bind
and inhibit only the CDK4 and CDK6 complexes.
There are at least three CIP proteins in mammalian
cells; these are identified as p21 / WAF1 / CIP1 (gene
symbol = CDKN1A), p27Kip1 (gene symbol = CDKN1B),
and p57Kip2 (gene symbol = CDKN1C). The expression
of each of these CIPs is controlled by specific events that
may have happened during the cell cycle, particularly
in the skin. For example, p21Cip1 expression is induced
in response to DNA damage.[9,10] The induction is in turn
affected by the action of the tumor-suppressor protein
(TSP) p53. INK4 is a TSG protein and is associated with
several genes including p16INK4a and p14ARF, and
with several other proteins like the Harvey rat sarcoma
viral oncogene homolog (HRAS). The INK4 proteins
are identified by their molecular weights, which are
as follows: Cyclin-dependent kinase 4 inhibitor B
(p15INK4B), p16INK4A), cyclin-dependent kinase 4
inhibitor C (p18-INK4C), and p19INK4. The p16INK4A
protein is also a TSG since loss of its function leads to
cancer particularly in the skin. All the INK4 proteins
contain four tandem repeats of a sequence of amino acids
that were first identified in ankyrin and are thus referred
to as ankyrin repeats.[9,10] An alternative model of the cell
cycle response to DNA damage has also been proposed,
known as the postreplication checkpoint model. As noted
above, p53 plays an important role in triggering control
mechanisms at both G1/S and G2/M checkpoints.
TSGs and the skin
TSGs can induce skin cancers as a result of a loss of
their normal function, i.e., these proteins suppress the
development of cancer.[1-5] A recent review documented
716 human TSG (637 coding and 79 noncoding genes),
628 mouse TSG, and 567 rat TSG.[1-7] Since a single normal
allele will express the wild-type TSG, the majority of
human TSGs are recessive; specifically, both alleles
must be defective for the cell to be susceptible to tumor
development. TSGs act as cell cycle repressors and/or
promoters of apoptosis through 1) interruption of the cell
cycle, 2) prevention of cell division, 3) halting of the cell
cycle if DNA damage is not yet repaired, 4) induction
of apoptosis if DNA damage cannot be repaired, and 5)
promotion of cell adhesion and contact inhibition. All of
these actions prevent tumor cell progression, invasion,
and metastasis.
Functions of TSGs
TSGs (or more precisely the proteins for which they
code) have 1) a dampening or repressive effect on the
cell cycle, 2) promote apoptosis, and 3) occasionally
perform both functions. The functions of TSPs fall
into several categories. First, TSPs repress genes that
are vital for continuing the cell cycle. If these genes
are not expressed, the cell cycle will not continue,
thereby effectively inhibiting cell division. Second, TSPs
decouple the cell cycle due to DNA damage.[11] If there is
a damaged DNA in the cell, TSPs prevent the cell from
dividing. If the DNA damage can be repaired, the cell
cycle is allowed to continue. Third, if the damage cannot
be repaired, TSPs initiate apoptosis (programmed
cell death) to remove the threat the cell poses to the
greater good of the organism. Fourth, some TSPs are
involved in cell adhesion and prevent tumor cells from
dispersing, block loss of cellular contact inhibition, and
inhibit metastasis.[1-10] Fifth, DNA restoration proteins
are typically classified as TSPs as well as mutations
in such genes that raise the risk of cancer; examples
include mutations in hereditary nonpolyposis colorectal
cancer (HNPCC), multiple endocrine neoplasia type 1
(MEN-1 syndrome), tumor protein 53 [TP53(p53)], breast
onset (BRCA2), adenomatous polyposis coli (APC),
and retinoblastoma protein (RB1). Further, increased
mutation rates resulting from the decreased DNA
repair lead to an increased inactivation of TSGs and the
activation of oncogenes.
All-trans retinoic acid (ATRA) and the skin
All-trans retinoic acid (ATRA) has been used for the
treatment and prevention of a number of epithelial
cancers. In the SCL-1 skin cell line of human squamous
cell carcinoma (SCC), a group of authors recently showed
that ATRA inhibited the expression of the cyclin D1/
CDK4 and cyclin E/CDK2 complexes, and also increased
the expression of the cyclin-dependent kinase inhibitors
p21 and p27.[12] ATRA has been shown to suppress signal
transducer and activator of transcription 3 (STAT3)
signaling during skin carcinogenesis.
Epigenetic regulation in the melanoma TSG
p16INK4A protein
p16INK4A protein has also been shown to be of
importance in epigenetic regulation in melanoma
via microRNAs (miRNAs). [13] miRNAs are short,
noncoding ribonucleic acid (RNA) molecules that
function as specific epigenetic regulators of the
transcriptome. miRNAs are involved in a broad
spectrum of physiological and pathological processes,
including cancer-related functions such as proliferation,
cell cycle regulation, migration, invasion, immune
evasion, and drug resistance. These functions are
primarily regulated in melanoma through four
molecular deregulated pathways, including the
rat sarcoma/mitogen-activated protein kinases
(RAS/MAPK) pathway, microphthalmia-associated
transcription factor (MITF) pathway, p16INK4A-CDK4RB pathway, and phosphatidylinositol-4,5-bisphosphate
3-kinase (PI3K)-protein kinase B (Akt) pathway.[13]
Putative therapeutic role of TSGs in skin cancer
The documentation of genes involved in chemotherapeutic
responses is critical for predicting tumor responses and
treating drug-resistant cancer patients. A group of
genes commonly lost or inactivated in cancer are TSGs,
which can thus stimulate the initiation and progression
via cell proliferation and cell migration/invasion
particularly in the skin.[11] Lately, the increasing evidence
suggests that TSG also plays an important role in the
response of cancers to a variety of chemotherapeutic
drugs.[14] Phosphatase and tensin homologue deleted
on chromosome 10 (PTEN) was identified as a TSG
through mapping of homozygous mutations occurring
in multiple sporadic tumor types, and in patients with
cancer predisposition syndromes including Cowden
syndrome.[14] Since that time, PTEN has appeared as
one of the most frequently mutated or deleted genes
in human cancers, including human skin cancers. In
particular, damage of PTEN function through mutation
or deletion has been detected in up to 70% of melanoma
cell lines and epigenetic silencing of PTEN has been
witnessed in 30-40% of malignant melanomas.[14,15]
The retinoblastoma susceptibility gene (pRB), the
p53, and the p21Cip1 TSG in the skin
Other examples of importance in the skin are the proteins
encoded by the pRB and the p53 proteins; these protein
genes are both TSGs. The function of pRB is to act as a
brake, preventing cells from exiting G1; the function of
p53 is to inhibit progression from S-phase to M-phase.[16]
One major function of the p53 protein, which is active
as a homotetrameric transcription factor, is to serve as a
component of the checkpoint that controls whether cells
enter and pass through S-phase.[16] The action of p53 is
induced in response to DNA damage. Under normal
circumstances, p53 levels remain very low due to its
interaction with a member of the ubiquitin ligase family,
mouse double minute 2 homolog (MDM2). MDM2 was
isolated as an amplified gene in the tumorigenic mouse
cell line 3T3DM.[16] In response to DNA damage, for
example, as a result of UV irradiation or γ irradiation,
cells activate several kinases including checkpoint kinase
2 (CHK2) and ataxia telangiectasia mutated (ATM)
protein. One phosphorylation target of these kinases
is p53. ATM also phosphorylates MDM2. When p53 is
phosphorylated, it is released from MDM2 and can carry
out its transcription activation functions. One target
of p53 is the cyclin inhibitor p21Cip1 gene.[16] Activation
of p21Cip1 leads to increased inhibition of the cyclin
D1-CDK4 and cyclin E-CDK2 complexes, thereby halting
progression through the cell cycle either prior to S-phase
synthesis of p21 expression, there is a convergence of the
roles of p53 and pRB (as outlined above) in the regulation
of cyclin-CDK complexes.[16] In either case, the aim is
to allow the cell to repair its damaged DNA prior to
replication or mitosis. Given our limited knowledge of
the functions of pRB and p53, it is still easy to understand
how the loss of function of either protein can lead to
aberrant cell cycle progression and the potential for the
development of cancer. In addition, a spontaneous SCC
has been shown to be induced by somatic inactivation
of retinoblastoma and transformation-related protein 53
(TRP53) TSG.[16] TSGs associated with skin conditions
include p53, pRB, and genes leading associated with
Wilms tumor, neurofibromatosis type I (NF-1), and von
Hippel-Lindau (VHL) syndrome.[16]
Inherited mutations of TSGs (germline mutations)
Inherited abnormalities of TSGs have been found in some
familial cancer syndromes particularly in the skin.[17]
These are genetic imperfections that are passed from
parents to children. Hereditary mutations are present in
individual eggs or sperm that join during fertilization.
Because the mutation is present at the zygotic stage, it
exists in all cells of the body including reproductive
cells. A hereditary mutation is a major factor in 5-10% of
all cancers.[17] They cause certain types of cancer to run
in families. There are many examples of inherited TSG
mutations and more are being discovered every year.[17]
Acquired mutations of TSGs in the skin
Most cancers are caused by DNA changes that happen
during the person’s lifetime. These are termed acquired,
sporadic, or somatic mutations. An acquired mutation can
be caused by things in the environment such as exposure
to radiation and/or toxins.[18] However, for most acquired
mutations no specific cause can be established. Unlike
inherited mutations, acquired mutations begin in one cell
of the body and are found only in the descendants of the
parent cell. They are thus not in every cell of the body.[18]
Because they are not in the reproductive cells, acquired
mutations cannot be passed on to following generations.[18]
TSG mutations have been found in many skin cancers
As previously noted, most of these mutations are acquired
and not inherited.[19] For example, abnormalities of the
TP53 gene (which codes for the p53 protein) have been
found in more than half of human cancers. Abnormalities
of the p53 gene can be inherited in Li-Fraumeni syndrome
(LFS), which increases the risk of developing various
types of cancers. An alteration associating this TSG with
melanomas has been recently described.[19] The TSG
PTEN acts by opposing the action of PI3K, which is
essential for antiapoptotic, protumorogenic Akt activation.
Other examples of TSGs associated with human cancers
include VHL, APC, cluster of differentiation 95 (CD95),
suppression of tumorigenicity 5 (ST5), Yippee-like 3
(YPEL3), suppressor of tumorigenicity protein 7 (ST7),
and suppressor of tumorigenicity 14 protein (ST14).
Some specific examples of mutated TSGs leading to
pathologic skin conditions
Activated intracellular signaling pathways based on
mutations in oncogenes and TSGs play a vital role
in a variety of malignant tumors.[20] In dermatology,
such mutations have been recognized in melanoma,
BCC, and SCC. Discovery of these associations has
led to new, targeted therapies.[20] Treatment advances
have been particularly impressive in 1) melanoma,
with small molecule inhibitors directed against the
mutated serine/threonine-protein kinase B-Raf (BRAF)
oncogene; and 2) BCCs, with inhibitors directed
against the hedgehog (Hh) signaling pathway. Novel
sequencing technologies, specifically using next
generation sequencing, have allowed a better and more
comprehensive understanding of malignant tumors. To
be specific, these studies confirmed the pathogenic roles
for BRAF and microtubule-associated protein (MAP)
kinase pathways in melanoma.[20] Simultaneously, a
series of further molecules associated with melanoma
genesis including ERBB4, GRIN2A, GRM3, PREX2,
RAC1, and TP53 have been characterized.[20]
TSG patched (PTCH) homolog 1 protein, the nevoid
BCC syndrome, and basal cell nevus syndrome
(BCNS) or Gorlin syndrome in the skin
Gorlin syndrome is a rare genodermatosis. BCC
comprises the majority of nonmelanoma skin cancers.
Dermatologists and other health professionals should
incorporate family history into clinical practice to
identify patients who may be at increased risk for
BCNS.[20] BCNS is an autosomal dominant disorder that
disposes to BCCs of the skin, ovarian fibromas, and
medulloblastomas [Table 1].[20] Additional manifestations
include palmoplantar pits, jaw cysts, and bony
deformities like kyphoscoliosis and frontal bossing.[20]
Other alterations include rib abnormalities (splaying,
synostosis, bifid, and cervical ribs), vertebral anomalies
(block vertebrae, hemivertebrae, spina bifida occulta,
and kyphoscoliosis), and shortening of the metacarpal
and the small flame lucency in phalanges. Further
abnormalities described in the reproductive system are
uterine fibromas in females and cryptorchidism and
hypogonadism in males.[20] Additional findings in BCNS
include mesenteric cysts, renal calculi, cardiac fibromas,
and a tendency to develop various other neoplastic
lesions such as melanomas, neurofibromas, and
rhabdomyosarcomas. The five primary BCNS diagnostic
criteria include multiple BCCs, odontogenic keratocysts,
palmar and plantar pits, flare calcifications, and a positive
family history. The six minor criteria include congenital
skeletal anomalies (ribs, vertebra), macrocrania,
cardiac or ovarian fibromas, medulloblastomas,
lymphomesenteric cysts, and congenital malformations
(i.e., cleft lip/palate, polydactyly, or eye anomalies).[20]
The presence of two major or one major and two minor
criteria is considered diagnostic of BCNS. In the 1990s,
a link between aberrations of the Hh signaling pathway
and BCCs in mice was confirmed. At about the same
time, multiple studies connected this pathway in
humans with both sporadic BCCs and an autosomal
dominant genetic syndrome predisposing to multiple
BCCs. The Hh signaling pathway has been identified as
important to normal embryonic development in living
organisms and is involved in processes including cell
proliferation, differentiation, and tissue patterning.
In contrast to other hereditary disorders associated
with cancer, BCNS often features widespread birth
defects. BCNS is caused by mutations in PTCH,
which is a TSG. The PTCH gene is mapped to human
chromosome 9q22.3.[21] Clinical findings are variable in
9q deletions and duplications involving PTCH, thus
influencing individual predisposition to the benign
and the malignant tumors reported in BCNS [see
Table 1].[21] Moreover, the majority of mutations in
sporadic BCCs and in Gorlin syndrome are believed
to involve PTCH. [21] Loss of heterozygosity at this
chromosomal location (primarily in hereditary tumors)
suggests that the gene is homozygously inactivated
and normally functions as a TSG.[21] Cytogenetic BCNS
studies may show intrachromosomal insertions; thus,
cytogenetic analyses are important in providing accurate
genetic counseling.[21] Early diagnosis and treatment
of this syndrome is important to reduce the severity
of complications including cutaneous and cerebral
malignancies, and oromaxillofacial deformation and
destruction due to jaw cysts. Since BCNS transmission
is autosomal dominant, any child of an affected family
is at 50% risk of carrying the affected gene. Regular
follow-up is necessary for assessing progression of
BCCs. Vismodegib is the first-in-class smooth muscle
inhibitor, approved for the treatment of locally advanced
or metastatic BCCs.[21] Tazarotene (Tazorac, Allergan,
Irvine, California, USA) is a topical retinoid with relative
specificity for retinoic acid receptor beta (RAR-β) and
retinoic acid receptor gamma (RAR-γ) receptors, and has
shown good clinical results in BCC applications. Surgical
management is also recommended in selected lesions.
TSG VHL binding protein 1 (VBP1) and the skin
VHL [Online Mendelian Inheritance in Man (OMIM)
number 193300] disease is a hereditary cancer syndrome,
characterized by the development of various tumors
including renal, pancreatic, retinal, and central
nervous system (CNS) cerebellar hemangioblastomas,
pheochromocytomas, and renal clear cell carcinomas,
and ear, nose, and throat adenomas.[22-24] The title VHL
disease was first utilized in 1936 and has been in common
use since the 1970s. VHL disease is also considered a
neurocutaneous disorder, associated with NF-1, the
tuberous sclerosis complex, incontinentia pigmenti,
Sturge-Weber syndrome, hypomelanosis of Ito, and linear
nevus sebaceous syndrome.[22-24] VHL is inherited in an
autosomal dominant manner and caused by germline
Potential TSGs; ZAC expression is present in normal skin, with a high expression level in
basal keratinocytes and a lower, more heterogeneous expression in the first suprabasal
layers of the epidermis. ZAC is a zinc finger transcription factor that induces apoptosis
and cell cycle arrest in multiple cell lines. The ZAC gene is involved in keratinocyte
differentiation and its expression is lost in BCCs.
5727, (PTCH), (PTCH1;
Gorlin syndrome is an autosomal dominant
BCCs of the skin represent the most common type of cancer in humans. The majority of these
BCNS|HPE7); protein coding
disorder that predisposes to multiple lesions,
tumors display aberrant activation of the Sonic Hedgehog (Shh)/ PTCH pathway, triggered
including BCCs of the skin, ovarian fibromas, and by mutations in the PTCH TSGs, which encode a transmembrane receptor of SHH. Also,
heterozygous mutations in PTCH incite BCC-like features in human organotypic skin cultures.
7157, (TP53), (TRP53; tumor
BCC and SS
TP53 has been implicated with polymorphisms and lack of expression in BCCs,
protein p53); protein coding
suggesting a crucial role for its expression in tumor suppression of BCCs.
8643, (PTCH2), (PTC2; patched The nevoid basal cell carcinoma syndrome (NBCCS) Mutations of TSGs in the human patched gene 2 (PTCH2) have been identified in
2); protein coding
as well as in sporadic basal cell carcinomas
individuals with NBCCS.
5925, (RB1), (pp110;
SCC, a cancer of the epidermis
Cancerous tissues from 30 patients with SCCs were confirmed for loss of heterozygosity in
4 TSGSs (p16, RB1, E-cadherin, and p53) at loci 9p21, 13q21, 6q22, and 17p13, respectively,
retinoblastoma); protein coding;
also, 7157, (TP53), (TRP53;
utilizing microsatellite markers amplified by PCR. P16 is also associated with aggressive
behavior of penile carcinomas. The p53 TSGs pathway is disrupted in most oral SCCs due
tumor protein p53); protein
to either an abnormality in p53 itself or loss of expression of p53 regulatory factors.
4851, (NOTCH1), (TAN1);
Bowen’s disease, SCCs and solar keratoses: the
The Notch 1 gene is a member of the Notch family, which undergoes downregulation
protein coding
Notch signaling pathway may play contrasting roles upon exposure to UV. In UV-related squamous cell photocarcinogenesis, Notch 1
in cancer. It can be oncosuppressive or protumoral, downregulation could perform a TSGs suppressor function via its receptor. In contrast,
contingent on the cellular and tissue setting.
Notch 1 is upregulated in sun-protected SCCs.
4763, (NF-1), (WSS;
NF1 is an inherited, autosomal dominant human
The NF1 TSGs is a modifier of carcinogen-induced pigmentation and papilloma
Neurofibromin 1); Protein
formation in experimental studies on C57BL/6 mice. NF1 patients heterozygous for
mutations in the NF1 gene are predisposed to develop benign peripheral nerve sheath
tumors, learning disabilities, bone abnormalities, certain malignant tumors, and
pigmentation defects. Pigmentation defects include patches of hyperpigmented skin
called café au lait macules, found in all NF1 patients by 5 years of age, axillary and
inguinal freckling, and altered patches of retinal melanocytes termed Lisch nodules.
2131, (EXT1), (EXT1; Exostosin WS (also known as adult progeria) is a rare,
Epigenetic loss of the familial TSG exostosin-1 (EXT1) disrupts heparan sulfate synthesis
1); Protein coding
autosomal recessive, progeroid syndrome, which
and repair in WS cancer cells. WS is specifically caused by loss of function mutations
is characterized by the appearance of premature
of the werner syndrome (WRN) gene, a RecQ family member with both helicase and
aging and associated skin cancer development
exonuclease activities. However, despite its putative tumor-suppressor function, little is
known about the contribution of WRN to human sporadic malignancies.
4089, (CDKN2A),
MS is a developmental disorder characterized by
SMAD4 has been established as a TSG and is somatically mutated in some cancers
(DPC4|JIP|SMAD4); Protein
reduced growth, generalized muscular hypertrophy, (including skin cancers). The mutations may occur as a result of germline loss-of-function
facial dysmorphism, deafness, cognitive deficits,
lesions and deletions of the gene. A restricted spectrum of mutations in the SMAD4 TSGs
joint stiffness, and skeletal anomalies.
underlies MS.
Kaposi sarcoma, the most common cancer in human TSGs genes FHIT and WWOX are also deleted in primary effusion lymphoma (PEL) cell
immunodeficiency virus (HIV) positive individuals, lines.
is caused by endothelial transformation mediated by
the Kaposi sarcoma herpes virus (KSHV)-encoded
G-protein-coupled receptor (vGPCR)
SS, a disseminated, leukemic form of cutaneous
TSG TNFAIP3 (A20) is frequently deleted in SS.
T-cell lymphoma; also in BCC
2272, fragile histidine triad
(FHIT), (FRA3B); protein coding;
also, 51741[(WW domain
containing oxidoreductase
WWOX)]; protein coding
7128, (TNFAIP3), (TNFA1P2;
tumor necrosis factor); protein
5325, (PLAGL1), (ZAC;
pleiomorphic adenoma genelike 1); protein coding
Gene ID, name, synonyms,
and gene type
Table 1: TSG and the skin
mutations in the VHL TSG. Many patients with VHL
may develop endolymphatic sac tumors, which can cause
tinnitus or deafness. The diagnosis of VHL may be made
in a patient with a family history of VHL, based on a
single retinal or cerebellar hemangioblastoma, renal cell
carcinoma or pheochromocytoma, and possibly, multiple
pancreatic cysts. Renal and epididymal cysts are not
sufficient to establish a diagnosis of VHL.[22-24] In order
to confirm a VHL diagnosis in the absence of a family
history of VHL, the presence of two or more retinal or
cerebellar hemangioblastomas, or one hemangioblastoma
and one visceral tumor are required. Studies of the natural
history of VHL had shown a life expectancy of less than
50 years before surveillance protocols were developed.
Annual assessments (physical and ophthalmologic
examinations) should begin in infancy. Imaging of the
abdominal organs and the brain and spine should be
done in teenagers and adults. Renal cysts and tumors
should be monitored by computed tomography every 6
months. Mutation analysis has allowed presymptomatic
identification of affected family members; those found not
to have inherited the gene do not need to be monitored.
VHL disease is characterized by marked phenotypic
variability and age-dependent penetrance. VHL gene
mutations have been reported in more than 900 disease
kindreds (, Last
access on January, 20, 2014). Many functions have been
assigned to the abnormal VHL normal TSG product
(pVHL), including targeting the alpha subunits of the
heterodimeric transcription factor hypoxia-inducible
factor (HIF) for destruction.[22-24] HIF, also known as
prefoldin 3, is a chaperone protein that normally binds to
VHL protein and transports it from perinuclear granules
to the nucleus or cytoplasmic sites inside the cell. HIF is
also involved in transporting normal nascent polypeptides
to cytosolic chaperonins for posttranslational folding [see
Table 1].[22-24] A second protein often damaged in VHL
disease is VBP1. VBP1 is a 197–amino acid heterohexamer,
comprising two prefoldin-α and four prefoldin-β subunits;
it is a member of the prefoldin-α subunit family.[22-24] It is
ubiquitously expressed in tissues and is located in the
cell in both the nucleus and cytoplasm. The VBP1 gene is
located at human locus Xq28. Clinical VHL disease is often
a complex multisystem disorder that needs management
from multiple medical specialties. Coordinating the
medical care of VHL families can be challenging, but is
vital to prevent avoidable morbidity and mortality.[22-24]
Recommended screening includes searching for retinal
angioma by performing annual ophthalmic examinations,
beginning in infancy or early childhood.[22-24] In addition,
CNS, and ear, and nose and throat screenings are needed,
with magnetic resonance imaging (MRI) scans of the
head every 12-36 months, beginning in adolescence.
Screening for renal cell carcinoma and pancreatic tumors
via MRI (or ultrasound) examination of the abdomen
every 12 months starting at 16 years is recommended.
Testing for pheochromocytoma is recommended, by
performing annual blood pressure monitoring and 24-h
urine studies for catecholamine metabolites.[22-24] Finally,
more intense surveillance (e.g., annual measurement of
plasma normetanephrine levels and adrenal imaging)
beginning at 8 years should be considered in families at
high-risk for pheochromocytoma. Early diagnosis of VHL
complications improves the prognosis of each patient.
All VHL patients and at-risk relatives should enter into a
comprehensive screening program in childhood (unless
VHL is excluded by molecular genetic testing).
Familial melanoma (FM) syndrome and the skin
Originally titled familial atypical multiple mole
melanoma (FAMMM) syndrome, with initial descriptions
of increased hyperdiploidy observed as an in vitro
phenomenon in cultured skin fibroblasts from highrisk and affected subjects. The FAMMM genotype was
described as complex, in that it predisposed a patient
not only to melanoma (cutaneous and intraocular
malignant melanoma) but also to other types of cancer
including lung, pancreas, and breast.[25] After recognizing
this entity, attention was initially focused on cancer
surveillance and management programs for patients
at increased risk for the several forms of hereditary
malignant melanoma.[25] Genetic analysis performed
long ago in some families with clinical and pathologic
verifications of the FM syndrome had shown some at-risk
members in these families, with a segregation ratio of
about 0.47 (consistent with an autosomal dominant mode
of inheritance). Some obligate gene carriers who lacked
any FM phenotypic manifestations were observed, and
the rate of penetrance for the FM gene was calculated
to be 0.93. The melanocytic lesions or “moles” in this
syndrome had shown to be mainly histologic compound
nevocellular nevi with varying degrees of dysplasia of
the melanocytes, an increased occurrence of fibroplasia,
and chronic inflammation within the papillary dermis. Of
further interest were findings of variation in the degree
of dysplasia in “moles” between and within families
affected by FM. These observations, when coupled with
recent reports by others, are consistent with an autosomal
dominant gene showing variable expressivity. About
5-10% of melanomas may be genetic in origin and about
2% of melanomas can be unambiguously attributed to
pathogenic germline mutations in CDKN2A.[25] Recently
another high penetrance gene, CDK4, was found to
be responsible for melanoma development in some
families. CDKN2A is a dominantly inherited gene that
is associated with mutations in the TSG CDKN2A/p16
[Table 1].[25] CDKN2A can also be altered after exposure
to UV radiation. Specifically, UV light can induce distinct
alterations in genes related to cell cycle regulation and
DNA damage responses; these same genes are also
reported to be dysregulated in patients with familial
melanoma. [25] Thus, some authors have suggested
that CDKN2A needs to be monitored for personalized
prevention strategies in high-risk populations. [25]
Presently, genetic testing is widely used for identifying
individuals with hereditary colorectal cancer and
hereditary breast/ovarian cancer, but genetic testing of
CDKN2A in the framework of melanoma prevention is
not part of the routine practice. However, there are now
several laboratories in the United States and in other
countries that offer CDKN2A testing. The likelihood
of detecting a CDKN2A mutation depends greatly on
the population being studied, which may be a result of
differences in penetrance associated with 1) variations in
melanoma predisposition phenotypes (e.g., light skin, red
hair) and 2) the local amount/intensity of UV radiation
exposure. Notably, in geographical areas with high
baseline rates of melanoma, there is greater probability
of having multiple family members with melanoma
(and individuals with multiple primary melanomas)
caused by reasons other than a CDKN2A mutation. Still,
melanoma penetrance in CDKN2A mutation carriers
is also higher in areas with higher baseline rates of
melanoma, indicating a potential interaction between
CDKN2A and other predisposing factors for melanoma
in these areas.[25] Finally, there is growing awareness
among the public about the genetic basis of cancer and
the availability of pertinent testing. Management of these
patients is difficult as one cannot be certain which moles
require biopsy and then, following histological study,
which will require wider excision. Studies of the FM
syndrome should deal carefully with its natural history,
including the patient’s lifelong susceptibility to multiply
malignant melanomas and the possibility that cancer of
other anatomic sites may be integral components of this
hereditary cancer syndrome. Dermatologists and other
health specialists should include family history and
risk assessment in clinical practice to identify patients
who may be at increased risk for familial melanoma.[25]
About 3-5% of all patients with melanoma will develop
additional primary melanomas in their lifetime. In
recognizing new familial melanoma genes using next
generation sequencing, a small number of new high
penetrance genes have been discovered. Such research
has identified the lineage including the specific oncogene
microphthalmia-associated transcription factor (MITF) as
a susceptibility gene both in melanoma families and the
general population, as well as the discovery of telomere
maintenance as a key pathway underlying melanoma
TSG tumor necrosis factor, alpha-induced protein 3
(TNFAIP3) (A20) is frequently deleted in Sézary
syndrome (SS) in the skin
SS is a disseminated form of cutaneous T cell lymphoma
(CTCL). It often presents with erythroderma, the presence
of greater than 1000 Sézary cells in the peripheral blood,
lymphadenopathy, and pruritus. Complete remission
is rare in patients with SS. According to the original
description (Sézary, 1949), the syndrome is characterized
by generalized, intensely pruritic, edematous and
pigmented erythroderma, lymphadenopathy, and large
cerebriform cells in the circulating blood. In many cases, a
fatal outcome was common 18-40 months after diagnosis.
Other symptoms and signs included palmar and plantar
hyperkeratoses with painful fissures, dystrophic nails,
patchy pigmented involvement of mucous membranes,
leonine facies, alopecia, and night sweats or chills
with normal or subfebrile body temperatures. The
histopathology of Sézary skin lesions usually reveals
irregular acanthosis with mixed hyperkeratosis and
parakeratosis, intercellular epidermal edema with
foci of frank spongiosis, small cavities containing
abnormal mononuclear cells (analogous to the Pautrier’s
microabscess of mycosis fungoides) and a dermal
mononuclear cell infiltrate of variable intensity. In all
tissues including the peripheral blood, Sézary stressed the
presence of the peculiar cerebriform cells with large, highly
irregular, and convoluted nuclei. In 1961, Taswell and
Winkelmann confirmed the presence of intracytoplasmic
periodic acid-Schiff (PAS) positive granules, an added
diagnostic feature of Sézary cells. Later, the cells were
found to have an equally characteristic ultrastructural
appearance, quite similar to that of mycosis fungoides
cells, by Lutzner and Jordan in 1968 and Brownlee and
Murad in 1970. The Sézary treatment is aimed at the
clearance of skin disease, minimization of reappearance,
prevention of disease progression, and safeguarding of
the quality of life. Other considerations include control
of symptom severity including pruritus and patient age/
comorbidities. Overall, for the limited patch and plaque
disease, patients currently have an excellent prognosis
using topical formulations, such as corticosteroids and
nitrogen mustard. The extended disease with widespread
patches/plaques often requires phototherapy. Current
Sézary therapy (especially for those with significant skin
compromise) includes combined immunomodulatory
therapy, using targeted biologic agents, and/or total
skin electron beam therapy followed by nonablative
allogeneic stem cell therapy. Other treatments such as
extracorporeal photopheresis, alpha interferon, retinoids,
antibiotics, and/or topical steroids have been utilized.
Medications such alemtuzumab, mogamulizumab, and/
or others have been utilized; however, in many cases
fatality may occur secondary to sepsis due to secondary
Mycosis fungoides (MF) and TSGs in the skin
MF is the most common clinical presentation of primary
cutaneous CTCL.[26] The CTCL entities comprise MF,
presenting with patches, plaques, and/or tumors
without a significant leukemic component; and SS,
classically presenting with erythroderma and leukemic
CTCL cells.[26] MF comprises the majority of CTCL
cases. MF patients frequently present with early phase
disease, typically associated with a favorable prognosis
and survival of 10-35 years; however, over 25% may
progress to the advanced stage of the disease, with
a median survival less than 4 years and a median
survival of a few months in patients with lymph node
involvement. SS classically presents as advanced MF
disease with erythroderma, lymphadenopathy, and
CTCL leukemia [see Table 1].[26] The Bunn and Lamberg
staging system (1979) comprises stages IA-IIA (early
stage disease) and IIB-IVB (progressive stage disease),
and provides prognostic CTCL information. Notably,
some tumor stage (IIB) patients have a worse prognosis
than erythrodermic stage patients (III). Further, plaque
stage (IB) folliculotropic MF may have a worse outcome
than tumor stage (IIB) patients. MF often advances
through the following phases. First, a premycotic phase
with a scaly, red rash appears in areas of the body that
are usually not exposed to the sun. The rash does not
cause symptoms, and may be present for months or
years.[26] It is frequently difficult to diagnose the rash
as MF during this phase. Second, a patch phase occurs
with a thin, reddened, eczema-like rash. Third, a plaque
phase occurs, manifested by small raised papules and
nodules/plaques on the skin. Fourth, the tumor phase
occurs; the skin tumors may develop ulceration and the
skin may become secondarily infected. The following
tests and procedures are utilized for the diagnosis of
MF and SS: A clinical history and physical examination
in particular; a complete blood count with differential; a
peripheral blood smear examination; and a skin biopsy
augmented with immunohistochemistry (IHC) special
stains.[26] The IHC immunophenotyping represents a
process used to identify and classify cells, based on the
specific antigens present on their surfaces or within their
cytoplasms. Other testing may include IHC staining of
leukemic cells. Other testing involves conducting a T cell
receptor (TCR) gene rearrangement test to see if genetic
changes have occurred that lead to the production of
a clonal population of T lymphocytes. Other testing
includes flow cytometric analysis that can measure:
1. The number of cells in a sample of blood,
2. The percentage of live cells in the sample,
3. Specific characteristics of the cells such as their sizes
and shapes, and
4. The presence of tumor markers on their surfaces.
In SS, multiallelic and monoallelic deletions of the
tumor necrosis TNFAIP3 have been identified. [26]
Also, A20 is a potent anti-inflammatory signaling
molecule that restricts multiple intracellular signaling
cascades. In mycosis fungoides and folliculotropic MF,
a combination of skin-directed therapy and low-dose
immunomodulators such as interferon or bexarotene
may be effective. A better understanding of the
pathogenic and biologic markers (including the altered
TSG) is needed to improve treatments directed against
other specific markers.
BCC and TSG in the skin
BCC represents the most common human neoplastic
disease. BCC is a type of skin cancer that begins in the
pluripotent basaloid cells of the epidermis. BCC often
appears as a waxy bump, though it can take other forms;
it primarily affects photoexposed areas, most often on
the head and the neck. BCC rarely appears on the genital
and the perigenital zones. A general warning sign of
skin cancer is a sore that will not heal. However, BCC
may also appear as a pearly white or waxy bump, often
with visible blood vessels on the face, ears, or neck. The
bump may bleed and develop a crust. In darker-skinned
people, this type of cancer may be brown or black. Other
forms can present as a flat, scaly, brown, or flesh-colored
patches on the chest; over time, these patches can grow
quite large. BCC may also present as a white, waxy
scar; this may be a sign of a particularly invasive and
disfiguring variant, termed morpheaform BCC. Almost
all BCCs occur on parts of the body excessively exposed
to the sun, especially the face, ears, neck, scalp, shoulders,
and back. On rare occasions, however, the tumors
develop on unexposed areas. In a few cases, contact with
arsenic, exposure to radiation, chronic inflammatory
skin conditions, and complications of burns, scars,
infections, vaccinations, or even tattoos are contributing
factors. BCC usually progresses slowly; metastases are
rare and found in less than 0.5% of the cases. However,
considerable local destruction, damage, and mutilation
may be observed if treatment is not performed. In
advanced cases, large reconstructive plastic surgeries
are needed to address the tumor.[27] Diverse histologic
variants of BCCs have been defined including nodular,
cystic, micronodular, superficial, and pigmented
presentations.[27] After the physician’s examination,
the diagnosis of BCC is confirmed with a biopsy, and a
clinical staging of BCC may be performed according to
the tumor-node-metastasis (TNM) classification system;
however, this classification is often not used in practice
due to the rarity of BCC involvement beyond the skin.
Multiple therapeutic methods have been established for
the successful treatment of BCCs. Thus, early diagnosis
leads to improved prognosis.[27] People who have had
one BCC are at risk of developing others over time, either
in the same area or elsewhere on the body. Therefore,
regular visits to a dermatologist should be kept so that
skin surface can be examined. BCCs on the scalp and
nose are especially troublesome, with reappearances
typically taking place within the first 2 years following
surgery. Should a cancer recur, the physician might
recommend a different type of treatment. Some
methods, such as Mohs micrographic surgery, may be
highly effective. In addition, topical medications such
as fluorouracil (5-FU), imiquimod 5%, and vismodegib
may be utilized. Other therapeutic modalities include
curettage and electrodissecation, laser surgery, radiation,
cryosurgery, and photodynamic therapy. Expression
of the altered TSG products B-cell lymphoma 2 gene
(Bcl-2), BCL2-associated X protein (BAX), and p53 have
been noted as BCCs; specific mutations of p53 have been
described in Korean patients with BCCs.[27] [Table 1]. In
addition, Bcl-2 and p53 expression have been negatively
correlated to clinical BCCs.[27]
NF-1 TSG and the skin
NF-1 (Online Mendelian Inheritance of Man No.
accesses February, 19, 2015), formerly known as von
Recklinghausen disease, is an autosomal dominant
disorder that affects approximately 1 in 3,500
persons.[28,29] It is caused by mutations in the NF-1 TSG,
which encodes a GTPase-Activating Protein (GAP) that
negatively regulates p21-RasNF1 in a relatively common
inherited disorder. Patients have a predisposition to
develop both benign and malignant tumors. Although
many manifestations of NF-1 affect the nervous system,
other organs and tissues can also be affected. Café au
lait spots, neurofibromas, freckles, Lisch nodules, brain
hamartomas, seizures, mental retardation, plexiform
neurofibromas, and peripheral nerve sheath tumors are
common. The development of malignant nerve tumors
and neurofibromas occurs frequently in NF1. However,
little is known about the molecular mechanisms
mediating the genesis and the progression of these
complex tumors, or the identity of the specific cell types
that give rise to dermal or cutaneous neurofibroma.
Due to the variable clinical features inherent to this
disorder, patients can present to different medical and
surgical specialists and consequently, the association
of clinical symptoms with NF1 may not be initially
easily to discern.[28,29] Accordingly, for prompt diagnosis
and providing optimum care for patients with NF1,
clinicians should be aware of the diverse clinical
features of this disorder. NF1 may present solely
with learning disabilities, speech disorders, glomus
tumors, or a variety of skeletal manifestations such as
short stature, osteopenia/osteoporosis, and lytic bone
lesions. Glomus tumors are benign but painful tumors
of the fingertips and toes. Affected individuals often
present with the triad of severe paroxysmal pain, cold
intolerance, and localized tenderness.[29] Half of the
patients with NF1 have inherited their NF1 mutation.
The NF1 gene is located on human chromosome
17q11.2, spanning approximately 280 kb of genomic
DNA. The NF1 gene also has a high frequency of de
novo mutations.[28,29] Interestingly, numerous clinical
syndromes with disease-causing mutations in genes for
proteins of the Ras signaling pathway have phenotypes
overlapping with those of NF1. These syndromes
include Noonan syndrome, LEOPARD syndrome,
cardiofaciocutaneous syndrome, Costello syndrome,
and Legius syndrome. Genetic testing is thus very
important because the eventual penetrance of NF1 is
100%, meaning that all patients with NF1 mutation
will eventually present with clinical NF1. Plexiform
neurofibromas are common NF1 tumors carrying a risk
of malignant transformation, which is typically fatal.
Some recent studies have shown a population of GAP43+
PLP+ precursors in embryonic nerve roots as the cells of
origin for these tumors. A multidisciplinary approach to
care, entailing a devoted team of specialists throughout
the lifetime of the patient is needed; knowledge of TSGs
and swift implementation of new effective treatments are
also essential.[28,29] Surgery is often utilized to remove the
NF1 tumors. NF1 has no cure; however, the quality of life
of the patients can be greatly improved. In most cases,
neurology, psychiatry, dermatology, clinical genetics,
oncology, nursing, psychology, behavioral therapy, and
internal medicine specialists are able to make a positive
impact of the quality of life of the patients and their
families. It is important to keep in mind that overall, NF1
has pronounced variability in phenotypic expression,
course progression, and multiple organ involvement.
NF1 often also requires patient group support. Finally,
the NF1 gene is genetically heterogeneous with a high
mutation detection rate.
Myhre syndrome (MS) and TSG in the skin
MS is a rare disorder whose diagnosis is primarily
clinical. MS is characterized by abnormal growth of
the skeleton, muscles, and joints and manifested by
short stature, brachydactyly, altered facial features,
pseudomuscular hypertrophy, intellectual deficiency,
joint use limitation, and hearing loss. Characteristic
facial features may include abnormally narrow skin
folds (palpebral fissures) between the upper and the
lower eyelids (blepharophimosis), underdevelopment
of the upper jaw bone (maxillary hypoplasia), and an
unusually prominent jaw (prognathism). Recently,
mutations in the mothers against decapentaplegic/
DPP homolog 4 (SMAD4) gene has been cited as the
cause of MS.[30,31] SMAD4 is a 552-amino acid protein
involved in cell signaling. It belongs to the Darwin
family of proteins, which modulate members of the
transforming growth factor beta (TGF-β) protein
superfamily. Other alterations described in MS
include delayed speech, moderate psychomotor
retardation, thick calvaria, broad ribs, hypoplastic
iliac wings, and short tubular bones. Other common
features include a “muscular” habitus and behavioral
problems. Health complications including obesity,
arterial hypertension, bronchopulmonary insufficiency,
laryngotracheal stenosis, pericarditis, and early death
may occur.[30,31] Ataxia and cerebellar atrophy may
also occur. The skin may display streaks with areas of
patchy thickening, suggestive of genetic mosaicism.
Some recent studies have also described de novo
heterozygous SMAD4 mutations, presenting with
laryngotracheal stenosis, arthropathy, prognathism,
and short stature syndrome (LAPS). Sometimes, the
presence of skewed X-chromosome inactivation in
patient DNA may be seen in MS.[30,31] Life-threatening
complications often occur in the course of the disease.
An association of MS with advanced paternal age at
patient birth suggests an autosomal dominant mutation
as the cause of MS. SMAD4 mutations have also been
identified in the primary MS differential diagnosis,
specifically LAPS. The SMAD4 data thus supports
the clinical heterogeneity in MS and a clinical overlap
with LAPS.[30,31] Most MS treatments are palliative; for
example, treatment of recurrent, progressive, proximal
tracheal stenosis required partial tracheal resection,
laser treatment, and eventually tracheotomy. Other
frequent palliative treatments include addressing
recurrent pericarditis and/or pulmonary infections.
TSGs encode proteins that decrease the risk of a
eukaryotic cell line becoming tumorigenic. When TSPs
are sequestered away from their normal functional
locations within the cell by retroviral tumor antigens, the
loss of their normal suppressor functions may result in
cellular transformation. Some common TSGs are altered
in many skin conditions and our knowledge of these
genes is constantly increasing.
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How to cite this article: Velez AM, Howard MS. Tumor-suppressor
genes, cell cycle regulatory checkpoints, and the skin. North Am J Med
Sci 2015;7:176-88.
Source of Support: Georgia Dermatopathology Associates, Atlanta,
Georgia, USA (MSH, AMAV). Conflict of Interest: None declared.

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