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J Clin Endocrinol Metab. May 2009; 94(5): 1826–1834.
Published online Jan 13, 2009. doi:  10.1210/jc.2008-2083
PMCID: PMC2684477

Rare Germline Mutations in Cyclin-Dependent Kinase Inhibitor Genes in Multiple Endocrine Neoplasia Type 1 and Related States

Abstract

Context: Germline mutation in the MEN1 gene is the usual cause of multiple endocrine neoplasia type 1 (MEN1). However, the prevalence of identifiable germline MEN1 mutations in familial MEN1 cases is only 70%. Some cases may have a germline mutation in another gene such as the p27 cyclin-dependent kinase inhibitor (CDKI).

Objective: The aim of the study was to investigate cases of MEN1 or related states for germline mutations in all CDKI genes.

Methods: A total of 196 consecutive index cases were selected with clear or suspected MEN1 and no identifiable germline MEN1 mutation. Every case was analyzed for germline mutation in each of the seven CDKI genes.

Results: We identified benign polymorphisms of the CDKI genes and also 15 other initially unclassified sequence variants. After detailed gene/protein analysis, seven of these 15 variants were classified as probably pathological mutations. Three of these seven were probable mutations of p27. The remaining four were probable pathological mutations in three of the other CDKI genes, thereby implicating these three genes in the germline of human tumors. The identification rates for probably pathological mutations among the 196 index cases were similarly low for each of four CDKI genes: p15 (1%), p18 (0.5%), p21 (0.5%), and p27 (1.5%). No characteristic clinical subtype related to MEN1 was identified among the seven index cases and their families.

Conclusion: Rare germline mutation in any among four (p15, p18, p21, and p27) of the seven CDKIs is a probable cause of MEN1 or of some related states.

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant syndrome with tumors of many characteristic endocrine and nonendocrine tissues. The standard clinical criteria for a case of MEN1 are tumors in two of the three main associated endocrine tissues (parathyroid, duodenopancreas, and anterior pituitary) (1). By extension, familial MEN1 is defined clinically as an index case with MEN1 and at least one first-degree relative with tumor in one or more of these three tissues. The prevalence of identifiable heterozygous germline mutations in the MEN1 gene is only 70% in index cases with familial MEN1 and considerably lower in sporadic MEN1 (2). Similarly, some other related states have only rare germline MEN1 mutations. For instance, MEN1 mutations have been identified in only 10% of index cases with familial primary hyperparathyroidism (1°HPT) and in less than 1% of index cases with familial pituitary tumor (3,4,5). Some MEN1 and MEN1-like patients without an identifiable germline MEN1 mutation may have an MEN1 mutation that is undetectable by the methods used. However, among the possible mechanisms for nondetection, promoter mutations of the MEN1 gene have not been reported, and large deletions of MEN1 seem rare (6,7). An important possibility is germline mutation of a different gene.

In mouse models, interactions of some cell cycle regulators can cause endocrine tumors. In particular, double knockouts combining germline losses of p27 or p21 with loss of p18 resulted in endocrine tumors characteristic of both MEN1 and MEN2 (8) (Fig. 11).). Despite their central roles in the cell cycle and in tumors of genetically engineered mice, most of these CDKIs have rarely been shown to cause tumors by germline mutation in man (see Discussion) [Online Mendelian Inheritance in Man (OMIM) numbers 116899, 600778, 600856, 600431, 603369, and 600927).

Figure 1
Molecular pathways distal to CDKIs. Mitogenic signals promote entry into the G1 phase through assembly and activation of cyclinD-CDK4 or cyclinD-CDK6 complexes. Subsequent progression through G1/S transition and S phase is dependent on active cyclinE-CDK2 ...

Recently, a syndrome that combined MEN1 and MEN2 (named MENX) was reported in a strain of rat (10); a germline homozygous frameshift mutation in p27 caused this phenotype (11). A heterozygous germline nonsense mutation in p27 was in parallel identified as the cause of MEN1 in one human index case and in two of his other affected family members (11). A heterozygous germline frameshift mutation in p27 was later reported in another MEN1 case (12). Among these four affected human cases, two had parathyroid tumor and three had pituitary tumor, secreting GH or ACTH. p27 germline mutation was not found in three subsequent studies analyzing 34, 69, and 21 MEN1 or MEN1-like index cases without identified MEN1 mutations, emphasizing the rarity of p27 mutation in MEN1 (2,13,14). MEN1-like state caused by p27 mutation in man was termed MEN4 (OMIM no. 610755). We have now tested for germline mutation in all of the CDKI genesa, and we have examined these in a larger series of index cases with MEN1 and related states.

Patients and Methods

Patients

The study was approved by the Institutional Review Board of the National Institute of Diabetes and Digestive and Kidney Diseases. Each patient gave written informed consent.

DNA from each case had been referred for MEN1 sequencing. Each of the 196 index cases [including the 34 cases analyzed previously for p27 mutation (2)] had been tested through the National Institutes of Health (NIH) between 1997 and 2007, and each had no identified germline MEN1 mutation. The criteria for MEN1 testing were broad. In general, a sporadic case or a familial index case was tested if there was likely multigland parathyroid hyperfunction or parathyroid hyperfunction plus another likely MEN1-related tumor. Each case was triaged by one of the same six senior staff members. Most cases were characterized from available clinical information. The amount of additional testing among cases depended partly on whether they were ever evaluated as in-patients or out-patients at NIH or elsewhere. No more than one member of a family was accepted as an index case. Extra effort was made in cases and relatives of cases with probable mutation of a CDKI gene. During this time, a total of 347 index cases suspected of MEN1 had sequencing of MEN1 plus or minus other genes. CASR or HRPT2 tests were used selectively. The prevalences of identified mutations were: MEN1, 128 of 347 (37%), CASR, 13 of 347 (4%), and HRPT2, 10 of 347 (3%). Index cases with identified mutation of MEN1, CASR, or HRPT2 were excluded from the analysis of the CDKI genes; analyses of CDKI germline mutation in this separate group will be of interest in the future but seem unlikely to uncover pathological CDKI mutations.

The distribution of nonoverlapping pretest diagnoses among the 196 index cases was: MEN1, 35%; familial MEN1, 7%; 1°HPT, 11%; multigland 1°HPT, 8%; familial 1°HPT, 17%; HPT-jaw tumor syndrome or parathyroid cancer, 7%; pituitary tumor, 1%; familial pituitary tumor, 4%; and other, 10%.

Isolation of genomic DNA and total RNA

Genomic DNA was isolated from peripheral blood, using the blood and cell culture genomic DNA maxi kit (QIAGEN, Valencia, CA). Total RNA from blood was isolated using the PaxGene blood RNA isolation kit (QIAGEN).

Parathyroid tumors (n = 5) were slowly frozen, stored under liquid nitrogen, and sectioned (8–10 μm thickness) (15). Portions were scraped from slides for DNA and RNA isolation using the Picopure system for DNA or RNA (Arcturus, MountainView, CA).

DNA sequence analysis

Primers were designed to amplify and sequence 16 coding exons, including the exon-intron boundaries, of CDKIs p15, p16/p14, p18, p19, p21, p27, and p57 (Supplemental Table 1, which is published as supplemental data on The Endocrine Society’s Journals Online web site at http://jcem.endojournals.org). The 3′ part of the first coding exon of p57 was not analyzed due to its highly variable PAPA (proline and alanine) repeats. PCR products were amplified using standard conditions with AmpliTaq Gold (ABI, Foster City, CA), purified, and sequenced (MWG Biotech, High Point, NC). Sequences were analyzed for variants by comparison with sequences obtained from normal control individuals (and with CDKI sequences deposited in GenBank), using MacVector (Oxford Molecular, Ltd., Cambridge, UK). Each sequence trace was visually analyzed.

Each DNA sample with a sequence variant was reamplified and resequenced. Sequence variants were also confirmed by independent PCR amplification using restriction enzyme digest (Supplemental Table 2).

Evaluation of CDKI sequence variants in controls

Two human random control DNA panels (HRC1 and HRC2), each consisting of genomic DNA from 96 healthy UK Caucasian blood donors were used (ECACC/Sigma-Aldrich, St. Louis, MO). These 192 control DNA samples were analyzed by PCR and sequencing for each of the 15 uncategorized sequence variants identified in the CDKI genes (Polymorphic DNA Technologies, Inc., Alameda, CA). For each of the 15 sequence variants, the same single nucleotide polymorphism was also searched in the HapMap database (hapmap.org), in the JSNPs database (snp.ims.u- tokyo.ac.jp), and in the GeneSNPs database (www.genome.utah.edu/genesnps).

Function analysis of CDKI variants

Quantitative analysis of protein expression (Western blot) and glutathione S-transferase (GST) pull-down assay was carried out using Alpha Innotech quantitation software. Further analyses of CDKI variants were with other methods (see Supplemental Methods, included in supplemental data on The Endocrine Society’s Journals Online web site at http://jcem.endojournals.org).

We only scored a mutation as probably pathological if at least one relevant test showed a substantial defect in a function of the encoded CDKI protein. The criterion for such an effect to be judged probably pathological was a decrease to less than 11% (median = 0.1%) of control in a relevant bioassay and similar results at least three separate times.

Results

CDKI sequence variants and control sequences

Among the 196 index cases tested for the seven CDKI genes, we identified 15 germline heterozygous sequence variants (initially and temporarily scored as unclassified) (Table 11)) and 15 common benign polymorphisms (10 previously known) (Supplemental Table 3).

Table 1
Summary of CDKI sequence variants and data to distinguish probably pathological from benign variants

Twelve of the 15 unclassified variants were not found in any among 192 control DNA samples, or in the HapMap database of 418 DNA samples, or in the JSNPs database of 934 DNA samples, or in the GeneSNPs database of 95 DNA samples.

However, the p21 missense variant R84Q was seen in one of 192 controls, and two of the p21 missense variants P4L and F63L were each found once in the HapMap database. Each of the three CDKI variants found in one among many apparently normal persons (an in-house control or a case in the HapMap database) was thus scored as a rare benign polymorphism.

Sequence homologies among CDKI variants

The sequence variants in the INK4 CDKI subfamily were compared with known germline or somatic disease-causing mutations of p16 (Table 11,, and Supplemental Table 4) (18). Also, see supplemental Results (supplemental Table 5). No comparable analysis was possible in the Cip/Kip subfamily because analogous mutations were not reported previously for these. Both of the p15 variants (n = 2) and the p19 variant (n = 1) corresponded to previously identified and probably pathological somatic mutations in homologous amino acids of p16 (18). Similar to our data about the two p15 variants, the p16 variants had also been shown previously to impair the binding of p16 to CDK4/CDK6 (18). This abnormality was confirmed by us for both p15 variants in the GST pull-down assays here, thereby extending evidence (see CKDI binding by CDKI variants) that both p15 variants were probably pathological. The p16 mutation that was similar to the p19 variant has not been shown to affect p16 activity (19). Therefore, this p19 variant was of uncertain significance and was classified conservatively as benign.

Defects in functions of p27 due to sequence variants

The nucleotide at the −7 position in the Kozak sequence affected by one p27 DNA variant (ATG-7G>C) is conserved among vertebrate species (Supplemental Fig. 1). RT-PCR revealed similar expression of p27 RNA from cells transfected with wild-type or variant-containing plasmid (Fig. 2A2A).). However, the concentration of p27 protein was reduced (6 ± 2%) in lysates of cells transfected with the variant-containing plasmid, suggesting deficient translation of p27 protein (Fig. 2B2B).). Thus this variant was scored as a probably pathological mutation.

Figure 2
Function assays of p27 variants among index cases. A, mRNA. RT-PCR of HEK293 cells untransfected or transfected with wild-type or p27 variant (ATG-7G>C) genomic constructs. Top panel shows RT-PCR products (at 30 cycles) with p27 primers, and ...

p27 inhibits Ras activation by p27 binding to growth factor receptor-bound protein 2 (GRB2), an adaptor protein involved in activation of Ras (21). p27 contains a proline-rich region at amino acids 91 to 95 similar to that used by son of sevenless to bind the SH3 domain of GRB2. p27 competes with SOS for binding to GRB2 at this region. In GST pull-down assays, the p27 missense variant P95S had reduced (0.1 ± 0.05%) binding to GRB2 (Fig. 2C2C).). Thus this variant was scored as a probably pathological mutation.

Expression analysis of the p27 stop>Q variant protein showed a higher molecular weight than wild-type p27, as predicted from the extension of the open reading frame by 60 amino acids to the next in-frame stop codon; however, the protein was expressed at a lower level (6 ± 2%) (Fig. 2D2D).). RT-PCR revealed similar expression of p27 RNA from plasmids expressing wild-type or stop>Q variant (Fig. 2E2E).). MG132, which blocks proteasomal degradation, brought expression of stop>Q protein to wild-type levels (Fig. 2D2D).). Therefore, the p27 stop>Q variation results in an unstable protein in vitro, prone to degradation by the proteasomal pathway. Thus, it was scored as a probably pathological mutation.

Protein expression from 11 other CDKI variants

Protein expression of missense variants of other CDKIs was analyzed as for two variants of p27 (ATG-7G>C and stop>Q) in transiently transfected HEK293 cells. No abnormality in protein expression was detected for missense variants of p16 (and its alternative reading frame p14), p19, two for p21, and one for p27 (Fig. 3B3B,, and Supplemental Fig. 2, A–D). The protein expression of p18 V31L and p21 R67L was decreased (25 ± 2% and 11 ± 2%) (Fig. 33,, A and B) indicating likely underexpression or instability. Thus, protein expression analysis for two among these 11 missense variants contributed to their scores as probably pathological mutations.

Figure 3
Expression and interaction assays of several CDKI missense variants. A and B, Protein. Western blot of whole cell lysates from HEK293 cells transfected with wild-type or mutagenized cDNA expression constructs. Top panels were probed with the indicated ...

The expression of p21 R84Q was increased (Fig. 3B3B),), indicating that the variant was more stable or was produced more efficiently than the wild-type protein. More importantly, this was not scored as a probably pathological mutation because this sequence change was also detected in one of 192 in-house control samples (Table 11).

Cyclin-dependent kinase (CDK) binding by CDKI variants

To examine the possible consequence of CDKI sequence change on binding to CDKs, GST pull-down assays were performed. The variants of p21 and p27 were analyzed for binding to GST-CDK2, and the variants of p15, p16, p18, and p19 were analyzed for binding to GST-CDK6. No abnormality in binding was observed for the missense variants of p16, p21, or p27 (Supplemental Fig. 2, E–I). However, missense variants of p15 (N41D and L64R) and p18 (V31L) were deficient in binding to GST-CDK6 (0.1 ± 0.05%) (Fig. 33,, C and D). Thus these three were scored as probably pathological mutations. This confirmed and strengthened the protein expression data of p18 V31L.

CDKI variants in family members

Germline DNA from five first-degree relatives of four index cases with probably pathological CDKI variants was sequenced. Two affected relatives aged 47 and 48 had the appropriate variant. No affected relative tested negative for the appropriate variant. Two unaffected relatives tested positive for a variant, and one tested negative for a variant. Small size of each family precluded testing for genetic linkage to any of the probably pathological CDKI variants (Fig. 44).). Thus family patterns were not used as a main criterion for assigning probably pathological roles of the CDKI variants.

Figure 4
Pedigrees and tumors of index cases with probably pathological CDKI mutations, their affected relatives, and all of their other first-degree relatives (see Table 22 for details). Germline heterozygous CDKI mutation is shown above each pedigree. ...

Clinical characteristics

Based on biochemical analyses of CDKI variants, seven index cases and their families had probably pathological mutations that supported the reported tumorigenic implication of p27, or that newly implicated three other CDKI genes in endocrine tumors (Table 11).). The seven index cases and five of their relatives (two affected, one unaffected, and two asymptomatic carriers) were tabulated separately by CDKI gene and were also examined clinically as one large group. We did not tabulate data about skin tumors of MEN1 because these data were too incomplete. Cases were classified as four index cases with sporadic or familial MEN1, two index cases with familial isolated 1°HPT, and one index case with the MEN1-associated combination of sporadic multigland 1°HPT and meningioma (22) (Fig. 44 and Table 22).). Endocrine tumor onset ages seemed similar to those for MEN1. We did not encounter pituitary tumor from p27 germline mutation although it had been reported in three of four affected cases with proven or likely p27 mutation previously (11,12). There were two prolactinomas in one family (with p21 R67L). Two cases (p15 L64R and p27 P95S) had Zollinger-Ellison syndrome that had not been previously reported with p27 mutation. Tumors of uncertain importance in affected cases or in their possibly affected first-degree relatives included esophageal carcinoid, prostate cancer, and cutaneous schwannoma.

Table 2
Clinical characteristics with probably pathological CDKI mutations in index cases and families, including two published

Discussion

CDKI mutations

Among 196 index cases of MEN1 or related states, without identifiable germline MEN1 mutations, seven showed probably pathological germline mutations in four CDKI genes (Supplemental Fig. 1); identification ratesb of probably pathological mutation among these 196 index cases were similarly low for each of these four CDKIs: p15 (1%), p18 (0.5%), p21 (0.5%), and p27 (1.5%). Eight CDKI variants of the initially unclassified 15 were scored here as benign variants (Table 11);); it remains possible that one or more of these eight might eventually prove to be a pathological mutation.

No mutation herein of a CDKI gene predicted truncation of a CDKI protein, so possible pathology from mutation needed careful scrutiny. Easton et al. (23) analyzed 1433 such BRCA1 and BRCA2 variants of unknown clinical significance. Typically, the DNA variations judged to be pathological predicted defective splicing, were located in highly conserved positions, were located in likely functional domains, segregated with disease in pedigrees, or affected the protein in assays of function. If the assay of function is relevant and the measured impairment is significant, then the defect caused by the missense mutation is probably important and pathological. Our expression studies were done in a heterologous nonendocrine cell line (HEK293 cells); human islet or parathyroid cell lines could be even more informative, but such lines are not available.

Prior reports of the effects of CDKI mutation offered aspects for comparisons to our study. In vitro CDK binding studies using amino acid substitutions in CDKIs have identified amino acids critical for optimal CDKI-CDK binding and for kinase inhibitor activity (24,25). Furthermore, several missense variants of p16 associated with a tumor phenotype have been shown to impair its CDK binding activity or to affect its expression/stability in vitro (16,17,18). Results from similar assays helped us to identify several variants of homologous CDKIs (p15 and p18) as probably pathological. We also analyzed variants by sequence homology to p16 mutations. The many sequence homologies in the INK4 family and the extended data on mutations of p16 combined to help categorize two variants (p15 N41D and p15 L64R) as probably pathological and to categorize another (p19 V102M) as probably benign.

Our analyses of CDKI function cannot be exhaustive because some aspects of CDKI function are unknown. Furthermore, some known aspects were not studied, e.g. interaction with CDK-cyclin complex or effect on CDK activity (26,27).

The seven probably pathological CDKI gene mutations predict functional impairment by combinations among protein expression, protein interaction, and absence of mutation in controls. This adds three new CDKI genes as a likely cause in MEN1 and related states. Six of the seven CDKI genes are now implicated by germline mutation in one tumor syndrome (see Clinical features of tumors associated with CDKI mutation). With likely pathological CDKI gene mutation identified in only 4% of our index cases, other unidentified genes/proteins in the cell cycle pathway may also cause a similar syndrome among some of the remaining cases. Another interpretation of the 4% rate of total identified mutations is that additional mutations of these CDKI genes were not identified by our methods. In particular, large deletions are undetected by sequencing, and this is a major mechanism for mutation of p16 (28).

The implication of germline mutations in four CDKIs in MEN1 and related syndromes (see Clinical features of tumors associated with CDKI mutation) raises the possibility that one or more CDKI could contribute by mutation or inactivation mechanisms in common sporadic endocrine tumors. It is thus relevant that some CDKIs (p16, p18, p21, and p27) have previously been analyzed for mutation and expression in sporadic endocrine tumors (Refs. 29,30,31 and references therein). Expression changes of uncertain importance were identified, but mutations were not found.

Loss of wild-type CDKI allele in tumors

Although tumorigenesis herein seems likely to be caused by the loss of CDKI gene function (32), three of four CDKIs affected by probably pathological mutations could not be tested for the loss of the wild-type allele due to the unavailability of tumors. Unfortunately, tumor was available from only one case with a probably pathological germline variant p27 (ATG-7G>C); there was no loss of the wild-type DNA copy in that tumor. For this variant, there was a reduction in p27 protein amount (analyzed by transient transfection assay in HEK293 cells; Fig. 2B2B)) that might initiate tumors by a haploinsufficiency expression (33).

Prior mutation analyses of p27 in human and rodent tumors, in particular those from germline heterozygous knockout mice, have usually not shown biallelic p27 inactivation in the tumor (33,34). This is similar to much data on p27 somatic mutations in several nonendocrine human tumors (35).

Inactivation of a single allele of p18, p21, or p27 has been shown to be sufficient to sensitize mice to radiation-induced or carcinogen-induced tumors (33,36,37). Among the CDKIs, only p16 was found previously to have consistent biallelic inactivation in a variety of human cancers (32,38). Among other CDKIs, mutation with a parallel loss of heterozygosity (LOH) has seldom been seen in human tumors (28,38). Considering prior reports, CDKIs may sometimes function as tumor suppressor genes via haploinsufficiency or via silencing of the wild-type allele without LOH, e.g. by promoter methylation.

Clinical features of tumors associated with CDKI mutation

The clinical phenotype of previously reported human tumors from proven or likely germline p27 mutation has so far been based on only four affected cases (and two silent carriers). We have now extended this via six more cases (four affected and two asymptomatic carriers) with probable p27 mutation. We also identified five cases affected with probable mutation in any one of three other CDKI genes (p15, p18, and p21). Because no specific phenotype for mutation of any one CDKI gene was evident, these were all pooled with p27 for preliminary examinations of phenotype in the CDKI gene family. Further studies will be required to determine age-related penetrance of tumors for each CDKI gene. In particular, penetrance could be determined in the future in part from larger kindreds than we have encountered. The overall features here and in two previous reports with germline p27 mutation (11,12) were those of MEN1, including that of the closely related familial or multigland 1°HPT. Among the pretest diagnoses for index cases, probable CDKI mutations were most prevalent (10%; P < 0.05; χ2) in familial 1°HPT. Such features may typify the full tumor spectrum of the mutant CDKIs; however, they might also reflect our own referral biases toward MEN1 or 1°HPT.

The current phenotype (MEN1 or related states) from mutation in one of four CDKI genes contrasts with two other phenotypes from other CDKI genes (Supplemental Fig. 4). First, familial melanomas with pancreatic ductal adenocarcinomas can arise from inactivating mutation of p16. Secondly, tumors (Wilms’ tumor, adrenocortical carcinoma, and rhabdomyosarcoma) in the Beckwith-Wiedemann syndrome arise from inactivation by mutation or other changes of p57 (39,40). Tumor specificity in the latter two phenotypes is robust from the p16 or p57 gene, respectively, although with unknown details of the relationship to that gene. It may explain why a mutation in the p16 or the p57 CDKI gene was not found in any of our index cases that had been selected for a different or MEN1-related tumor spectrum. The predominance of MEN1-associated tumors in our series may also explain why CDKI mutations (except p16) were not previously found in many common nonendocrine tumors (32,38). It is notable that we did not find C cell or chromaffin tumors of MEN2 in any family with probable CDKI mutation, although tumors of MEN2 and MEN1 were seen in both rat and mouse models of CDKI mutation (8,11).

In conclusion, we confirm and extend reports that germline p27 mutations account for a small but important fraction of cases with MEN1 and related states. Germline mutations in three of six other CDKI genes (p15, p18, and p21) are also shown for the first time as a probable cause of MEN1 or related states. The rarity of p15, p18, and p21 mutations in these cases and the lack of unequivocal pathological features of the identified mutations indicate that further research will be needed before applying these findings to the clinic. The involvement of three previously unimplicated CDKIs may indicate a broad relevance of this gene family to endocrine tumors.

Supplementary Material

[Supplemental Data]

Acknowledgments

The authors thank the patients, referring physicians, and staff of the National Institutes of Health Inter-Institute Endocrine Training Program. We thank Dr. H. C. Shen and Dr. S. K. Libutti for providing parathyroid tumor DNA and RNA, and Dr. A. B. Hickman, Dr. A. Horvath, and Dr. C. A. Stratakis for advice. We also express our gratitude to Dr. A. M. Spiegel and Dr. F. S. Collins for guidance and suggestions.

Footnotes

This work was supported by the intramural program of the National Institute of Diabetes and Digestive and Kidney Diseases.

Disclosure Summary: The authors have nothing to disclose.

First Published Online January 13, 2009

For editorial see page 1518

Abbreviations: CDK, Cyclin-dependent kinase; CDKI, CDK inhibitor; GRB2, growth factor receptor-bound protein 2; GST, glutathione S-transferase; 1°HPT, primary hyperparathyroidism; LOH, loss of heterozygosity; MEN1, multiple endocrine neoplasia type 1.

aThe INK4 CDKI family members specifically bind and inhibit cyclinD-CDK4 and cyclinD-CDK6; the genes in this family include CDKN2A, CDKN2B, CDKN2C, and CDKN2D encoding p16Ink4a, p15Ink4b, p18Ink4c, and p19Ink4d, respectively. The INK4 members are referred to here as p16, p15, p18, and p19. An alternate reading frame (ARF) of CDKN2A encodes p14ARF (p19ARF in mouse); this is not a CDKI and is referred to here as p14.

The Cip/Kip family members of CDKIs bind and inhibit a broad spectrum of cyclins-CDKs (cyclinD-CDK4, cyclinD-CDK6, cyclinE-CDK2, and cyclinA-CDK2); the genes in this family include CDKN1A, CDKN1B, and CDKN1C encoding p21Cip1, p27Kip1, and p57Kip2, respectively. The Cip/Kip members are referred to here as p21, p27, and p57.

bThe overall identification rates of probably pathological mutations in the CDKI genes among all of our 347 MEN1 or MEN1-like index cases with or without identified MEN1 mutation were the following: p15 (0.58%), p18 (0.29%), p21 (0.29%), and p27 (0.86%).

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