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Familial Atypical Multiple Mole Melanoma Syndrome

, MD, , MD, MMSc, , MD, and , MD.

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Introduction

Familial atypical multiple mole melanoma (FAMMM) syndrome is an autosomal dominant genodermatosis characterized by multiple melanocytic nevi, usually more than 50, and a family history of melanoma (Figure 1 and Figure 2). It is associated with mutations in the CDKN2A gene and shows reduced penetrance and variable expressivity. Some FAMMM kindreds show an increased risk for the development of pancreatic cancer and possibly other malignancies (1-6).

Epidemiology

An accurate estimate of the prevalence of FAMMM is difficult to make given the highly variable phenotype displayed both between and within FAMMM kindreds and the limited data available (4, 7-9). Some individuals exhibit all of the classic FAMMM characteristics while others will display few or none of the cutaneous features (4).

About 160,000 individuals were diagnosed with melanoma in 2002 (10). It is estimated that approximately 5% to 12%(11) of melanoma is hereditary, and approximately 40% of that is caused by CDKN2A mutations (7). Based on these estimates, approximately 3,200 to 6,700 cases of melanoma per year are caused by mutations in CDKN2A. However, this number is much higher than the number of CDKN2A mutation carriers diagnosed and is probably an overestimate.

Historical Background

In 1820 Norris reported the first case of what is now recognized as FAMMM (12). He described a 59-year-old man with melanoma, a high total body mole count, and family history of the same. Norris’s original report can be viewed by linking to the appendix "The first reported case of familial atypical multiple melanoma mole syndrome"

In 1968, Lynch and Krush first reported an association between pancreatic cancer and multiple nevi and melanoma (13). Ten years later, Lynch proposed the name Familial Atypical Multiple Mole Melanoma be given to the syndrome of “malignant melanoma in association with a distinguishing cutaneous phenotype characterized by multiple large moles, irregular in shape, coloured reddish-brown to pink, with evidence of pigmentary leakage, and an apparent autosomal dominant mode of inheritance.” (14) In 1978, Clark described a similar phenotype, the B-K mole syndrome, consisting of familial melanoma in the setting of numerous atypical nevi (15). By the 1980s, several published studies had verified an autosomal dominant mode of inheritance with variable expressivity and reduced penetrance (5, 8, 9, 16). At the same time, several studies established the association of pancreatic cancer with FAMMM in a subset of kindreds. These studies have also suggested an association with other systemic malignancies, although no clear neoplastic phenotype has been defined (1-4, 6, 7,11). In 1992, mutations in the CDKN2A gene were reported in FAMMM kindreds (17). To distinguish FAMMM kindreds with CDKN2A mutations and pancreatic cancer Lynch proposed the term familial atypical multiple mole melanoma-pancreatic cancer (FAMMM-PC) (4).

Pathology

The histopathologic characteristics of melanoma in FAMMM kindreds are not different from those seen in sporadic cases of melanoma and, thus, are not useful in diagnosing the syndrome. Superficial spreading melanoma (SSM) and nodular melanoma are the most frequently encountered histological melanoma subtypes in patients with CDKN2A mutations, which is consistent with the relative early age of onset. Some studies have shown a predominance of SSM in FAMMM patients compared to sporadic melanoma controls, while other studies have shown no difference between these groups.[20]

In 2002, Masback and others examined the clinical and histopathologic characteristics of cutaneous malignant melanomas in 26 individuals from nine CDKN2A mutation-positive families and compared them with cutaneous malignant melanomas from 78 age-matched controls and with cutaneous malignant melanomas from a 667-member population-based group (18). For each group, they evaluated Breslow thickness, Clark invasion level, ulceration, inflammation, regression reaction and the presence of benign dermal nevus cells. The differences seen in Breslow thickness between the groups did not reach statistical significance, which has been corroborated by some studies (19-21) and challenged by others (22-24). When comparing Clark invasion level, CDKN2A mutation cases were significantly less invasive (Clark level II versus levels III and IV) than the age-matched controls and population-based lesions. None of the histopathologic differences, however, were sufficient to establish a diagnosis between a CDKN2A-associated melanoma from a non-CDKN2A melanoma.

The Gene—CDKN2A

The CDKN2A gene is located on chromosome 9p21.3. Two main transcripts, isoforms ‘1’ and ‘4’, each contain three exons and span 7288 and 26740 bp, respectively. They encode proteins of 156 and 173 amino acids; isoform ‘1’ encodes p16(INK4a), while isoform ‘4’ encodes p14(ARF), a protein that is structurally unrelated to p16(INK4) but acts in cell cycle G1 control by stabilizing the tumor suppressor protein p53.

The first exons for p16(INK4) and p14(ARF) are coded independently. The second exons begin with the same coding sequence (Figure 3). However, they have different reading frames and thus encode different amino acid sequences. Therefore, despite having the same coding sequence for exon 2, the proteins do not have a similar amino acid sequence.

The only significant evolutionary conservation in CDKN2A is observed in exon 2, where a multispecies sequence alignment shows 76% sequence identity and 94% sequence similarity across six mammalian species (Figure 4). While exon 2 of both alternative reading frames overlaps, the drop in conservation beyond the coding region of isoform 4 (Figure 5) suggests that this isoform is more responsible for the observed conservation.

Table 3 shows the prevalence of somatic and germline CDKN2A mutations.

Table 3

Table

Table 3. Prevalence of CDKN2A mutations in different populations.

The Protein—P16(INK4a), P15(INK4b), P18(INK4c)

Germline mutations of the CDKN2A gene seen in melanoma and pancreatic cancer-prone families are typically missense or nonsense mutations that impair the inhibitor function of proteins p16(INK4), p15(INK4b), or p18(INK4c). These proteins normally act at the G1/S checkpoint in the cell cycle, where they inhibit the cyclin-dependent kinases CDK4 and CDK6, thus preventing phosphorylation of the retinoblastoma protein RB1. This inhibits the release of transcription factors that would ordinarily induce S phase progression. Thus when mutations in the CDKN2A gene disrupt the function of p16(INK4), there is improper progression from the G1 to the S phase, allowing continued, uncontrolled cell proliferation (1, 7).

And while mutations involving p16(INK4) may be present in only a portion of FAMMM kindreds, p16(INK4) is somatically inactivated in 95% of sporadic cases of pancreatic cancer (1) and 40% of familial melanoma (7).

Diagnosis

Clinical Evaluation

FAMMM is a clinical diagnosis based on numerous nevi, including atypical nevi with ABCDE (see below) characteristics resembling early melanoma, and a family history of melanoma. The diagnostic criteria for FAMMM syndrome can be seen in Table 1, as outlined by both the National Cancer Institute and the National Institutes of Health consensus paper (25, 26). An integral aspect of the diagnosis is a comprehensive cancer family history (27).

Table 1

Table

Table 1. Diagnostic criteria for Familial Atypical Multiple Mole Melanoma syndrome

The clinical and histopathologic characteristics of melanoma in FAMMM kindreds are not significantly different from those seen in sporadic cases of melanoma and, thus, are not useful in diagnosing the syndrome (See Pathology). Currently, most pigmented nevi are evaluated for melanoma on the basis of the subjective ABCDE characteristics of the nevus, referring to asymmetric shape, border irregularity, color variegation, diameter greater than 6 mm, and elevation or evolution (28). Other, more objective methods of evaluation have been employed to reduce diagnostic errors, including dermatoscopy, photography, digital dermatoscopy, and computer image analysis (29).

Genetic Testing

There is controversy regarding whether or not to use genetic testing for CDKN2A mutations for screening of patients. Benefits may include the ability to identify some high-risk kindreds and refer them to a clinical research screening program (1). However, given the lack of understanding of the genotype-phenotype relationship in CDKN2A kindreds, others argue that knowledge of the genotype would not alter the management of these individuals and that high-risk kindreds should be enrolled in research screening programs regardless of CDKN2A mutation status. In addition, it is important to note that patients with the clinical phenotype of FAMMM may have molecular defects other than CDKN2A. Therefore, negative genetic testing for this mutation does not exclude hereditary melanoma syndromes, increases cost, and may give false reassurance.

Laboratories offer clinical testing of CDKN2A by sequencing, targeted mutation analysis, and deletion/duplication testing for regular and prenatal diagnosis. A list of laboratories offering CDKN2A testing can be found at www.geneclinics.org.

CDKN2A mutations and melanoma

A recent review of 466 melanoma multiplex families (2137 patients) revealed 38% had CDKN2A mutations, though the frequency varied significantly by geography. Boston, Emilia-Romagna, Philadelphia, Brisbane, Tel Aviv, and Sydney all had CDKN2A mutation frequency of <25%, whereas Genoa, Glasgow, Leeds, Leiden, Lund, and Toronto displayed a mutation frequency of >50%. Genoa, Leiden, and Toronto all had mutation frequencies of close to 70%. One-hundred seventy-eight families had CDKN2A germline mutations involving p16(INK4) and within those families, 57 different CDKN2A mutations were detected. Thirty-five percent of the mutations were observed in more than one family. The CDKN2A mutation distribution was 65% missense, 16% deletions, 7% insertions or duplications, and splicing and nonsense mutations each accounted for 5%. Australia and United Kingdom shared the same most common mutations, as did France with Mediterranean Europe. The largest number of different mutations was seen in North America, consistent with its mixed ancestry (7).

There is limited data on CDKN2A mutations in sporadic melanoma cases. Reported studies have shown a low CDKN2A mutation rate in sporadic melanoma tumors. In one study of 48 sporadic melanomas, 2% had a point mutation and only 20% had a deletion in the CDKN2A gene (30). Another study of sporadic melanomas revealed loss of heterozygosity in 24% and homozygous deletion in 15% (31). The results of these studies suggest that loss of the CDKN2A is not likely involved in the initial formation of cutaneous malignant melanoma.

CDKN2A mutations and pancreatic cancer

There is no significant data on germline CDKN2A mutations in sporadic pancreatic cancer cases. They are assumed to be rare. Studies have shown p16(INK4a) inactivation in 95% of sporadic pancreatic cancers (1).

A study of the world’s largest familial melanoma database documented an association between pancreatic cancer and CDKN2A mutations in melanoma multiplex families (7). Twenty- eight percent of CDKN2A mutation-positive kindreds had a pancreatic cancer compared to 6% of CDKN2A mutation-negative kindreds. Seventy-four percent of families with pancreatic cancer harbored a CDKN2A mutation compared to 33% of those families with melanoma only (7). One study estimated penetrance for pancreatic cancer to be 17% in CDKN2A mutation carriers by 75 years of age (6).

The frequency of pancreatic cancer in CDKN2A mutation-positive families varied from <11% to >60% depending on the specific mutation involved. Sixty-six percent of CDKN2A mutation kindreds harbor one of the ten most common CDKN2A mutations, and pancreatic cancer frequency was evaluated for each of these ten common mutations. For mutations p.R112_L113insR and c.225_24del19 the pancreatic cancer frequency was >60% while it was 35% to 50% in p.L32P, p.V126D, and p.G101W, 15% to 25% in p.R24P and c.-34G>T, and <11% in p.M53I, c.IVS2-105A>G and c.32_33ins9-32.

Numerous other studies have documented the association between CDKN2A mutations and pancreatic cancer (1, 2, 6, 11, 32). In 1990, Bergman and others examined 200 family members from 9 well-documented FAMMM kindreds and found a significantly higher than expected incidence of pancreatic cancer (2). An increased risk of pancreatic cancer in melanoma-prone families with a known CDKN2A mutation has also been documented. (13–22—fold increase) (32). A study of 19 families with known CDKN2A mutations revealed an increased risk of pancreatic cancer and an estimated cumulative risk of developing pancreatic cancer by age 75 years of 17%(6). In 2002, Bartsch and others showed a correlation between CDKN2A germline mutations and pancreatic cancer by examining CDKN2A prevalence in pancreatic cancer-only families and in families with both pancreatic cancer and melanoma. None of the 18 pancreatic cancer-only families had CDKN2A mutations, compared to 2 of the 5 pancreatic cancer and melanoma families (1). In addition, a pedigree analysis performed on a familial melanoma kindred with known CDKN2A mutations found an observed-expected ratio of 8.9 to 12.6 for pancreatic cancer (11).

Numerous studies have verified a correlation between CDKN2A gene mutations and FAMMM syndrome, yet others illustrate the limitations of our understanding of this relationship. In 2000, Goldstein and others studied 104 melanoma patients from 17 CDKN2A kindreds and found that only six of these 17 families expressed pancreatic cancer. The specific CDKN2A mutations were determined and the same mutations were seen in families with and without pancreatic cancer (8). Gruis and others studied 7 FAMMM kindreds in 1995 with similar results (33). Six of the families harbored the same 19 base pair deletion yet between three of those families, there were five cases in which individuals expressed melanoma and other FAMMM characteristics without expressing the deletion in their genotype. Another study of eight CDKN2A kindreds revealed great diversity between and within families (4). In some families, melanoma was the predominant malignancy while, in others, pancreatic cancer predominated the cancer presentation. Some families trended toward early onset of pancreatic carcinoma while others displayed later onset. Several CDKN2A mutation positive individuals from different families did not express any of the classic FAMMM phenotype characteristics.

CDKN2A mutations and other cancers

A number of studies have addressed the concern for increased susceptibility to cancers other than pancreatic cancer in melanoma-prone, CDKN2A mutation-positive kindreds. In 1981, Lynch and others noted carcinoma of the lung, skin, larynx, and breast, as well as primary intraocular melanoma in a single FAMMM kindred in higher than expected frequencies. However, given the small size of this report, no significant patterns could be established (34). In 1983, Lynch and others documented a five-fold increase in risk of cancer at all anatomic sites in an analysis of 80 FAMMM patients, but were unable to show significance in any specific organ cancer due to study size (5). The findings of this study have been challenged (35) on the grounds of selection bias as the participants were chosen from a study of hereditary cancer syndromes.

Follow-up studies have been mixed on the risk of non-melanoma, non-pancreatic cancer in CDKN2A mutation carriers. Greene and others, in 1987, studied 14 FAMMM kindreds and found no “striking diathesis” for non-melanoma cancers in these families (35). Another study of 200 FAMMM patients revealed an excess of digestive system cancer, particularly pancreatic cancer in 9 FAMMM kindreds, but revealed no significantly increased risk for the other cancers tested, including breast and respiratory system cancer (2). A review of 19 FAMMM kindreds with a known p16 mutation found a relatively high number of lung cancer cases (6). In 2002, Bartsch and others studied 18 familial pancreatic cancer, CDKN2A/p16-mutation kindreds without a history of melanoma and 5 families with the p16 mutation and both pancreatic cancer and melanoma (1). Other tumors documented during this study were breast, prostate, lung, esophagus, stomach, and colon cancer. Eight other FAMMM kindreds studied experienced additional primaries of the lung, breast, esophagus, and endometrium, as well as sarcoma, which may represent other malignancies associated with CDKN2A mutations (4). In 2000, Borg and others also noted an increased frequency of breast cancer in CDKN2A mutation melanoma prone families (3). Table 2 shows a list of other malignancies documented in FAMMM kindreds.

Table 2

Table

Table 2. Malignancies other than pancreatic cancer and melanoma reported in FAMMM kindreds

An additional study evaluated the role of CDKN2A mutations in early-onset cancers of the breast, pancreas, and malignant melanoma. The study of 189 patients revealed infrequent alterations in the CDKN2A gene, suggesting that CDKN2A gene mutations do not play a significant role in the development of these early-onset malignancies (36).

Penetrance, expressivity, and modifiers

The penetrance for melanoma in kindreds with CDKN2A mutations is estimated at 58% to 92% by 80 years of age and varies with geography (11). The penetrance in CDKN2A mutation carriers for pancreatic cancer has been estimated to be 17% by 75 years of age (6). As noted above, there is wide variation in published estimates of the penetrance of CDKN2A mutations.

The single most important modifier in the risk of pancreatic cancer appears to be cigarette smoking. Smoking increases the risk of pancreatic cancer in the general population 1.5 to 5.5-fold (37). In 2003, Rulyak and others studied pancreatic cancer-prone families and noted that pancreatic cancer developed approximately 10 years earlier in smokers as compared to nonsmokers (38).

Natural History

Overview/Classic cutaneous findings

FAMMM is classically characterized by cutaneous findings of a high total body nevi count, usually greater than 50 and often into the hundreds, including some atypical nevi which may resemble early melanoma (14, 25, 27). The majority of the nevi will appear clinically typical (Figure 1). However, the evaluation of many FAMMM kindreds has revealed the significant heterogeneity in the cutaneous phenotype. Some family members of classic FAMMM kindreds will display only part of this phenotype, such as only atypical nevi, or will show none of the cutaneous characteristics of classic FAMMM but may harbor the CDKN2A mutation and later develop melanoma or pancreatic cancer (4). This heterogeneity also extends to the spectrum of cancer presentation, as some kindreds will show a melanoma predominance and others a pancreatic cancer predominance, while others may show an excess of an additional cancer whose pathophysiology in relation to FAMMM syndrome has not been entirely elucidated (1-6). A clear neoplastic phenotype in these families has not yet been clearly defined (9).

Melanoma in FAMMM

The penetrance of melanoma in CDKN2A mutation melanoma-prone families is estimated to be 58% to 92% (11, 39). Numerous studies have verified an earlier age of onset of melanoma in FAMMM kindreds compared with the general population, which may be related to an increased susceptibility to ultraviolet radiation (39).

One study compared melanomas from 26 CDKN2A mutation individuals to a population-based cohort of melanomas and found that CDKN2A-associated cases were diagnosed at a significantly younger age than the population cohort, with a median age of diagnosis of 42 years for the CDKN2A cases compared to 61 years for the population-based group (18). Another observed a median age at diagnosis of 33 years in patients with a germline CDKN2A mutation compared to 41 years in patients without a CDKN2A mutation but with a family history of melanoma, and 53 years in the general population (40). Bartsch and others reported similar findings in their study of 18 CDKN2A germline mutations with median age at diagnosis of 45 years for the CDKN2A kindreds versus 55 in the general population. An evaluation of 2137 patients from 466 melanoma-prone families revealed a median age at melanoma diagnosis of 9 years earlier for CDKN2A families (36 years) than for families without the mutation (45 years). This study evaluated families from North America, Europe, Australia, Asia, and the Middle East, and this trend was consistently observed in all geographic regions (7). While these studies observed a median age of melanoma diagnosis in CDKN2A kindreds to be between 33 and 45, there are several documented cases of melanoma occurring as early as the early teens and twenties within some FAMMM kindreds (4).

Significant variability has been reported regarding location of melanomas in CDKN2A mutation kindreds versus population-based controls, with some groups showing an excess on the head and neck in familial melanomas, others with an excess on the trunk of the body in familial melanomas, and yet others showing a body distribution similar to that seen in sporadic cases (18).

Additional controversy surrounds the pathologic significance of the atypical nevi seen in association with FAMMM syndrome with some arguing that they are simply markers of an increased risk of melanoma and others treating them as premalignant lesions. Part of this controversy is based on data which shows that atypical nevi are more likely to undergo malignant melanoma transformation when compared to clinically typical nevi. However, atypical nevi often regress, and melanomas in FAMMM patients often develop on normal skin (39, 41).

Pancreatic Cancer in FAMMM

Pancreatic cancer, which is seen in association with FAMMM in a subset of kindreds (1-4, 6), is the 4th most common cause of cancer death in the United States (42). Estimates for worldwide incidence and mortality of pancreatic cancer during 2002 were 232,306 and 227,023. The similarity of the numbers demonstrates the poor prognosis associated with this disease (10). An estimated 5 to 10% of pancreatic cancer patients have a family history of pancreatic cancer (43).

The risk of pancreatic cancer for a given individual increases with the number of pancreatic cancer cases in their family. There is no increased risk if only one family member was diagnosed with pancreatic cancer, but the risk increased to 18-fold when two first-degree relatives had pancreatic cancer. If three relatives had pancreatic cancer, the risk increased to 57-fold (44).

Pancreatic cancer is the second most frequent cancer diagnosed in FAMMM kindreds (2, 6, 9). One study estimated an association with pancreatic cancer in 25% of FAMMM kindreds and another observed a 13–22—fold increased risk of pancreatic cancer in CDKN2A mutation carrying members of FAMMM kindreds (32, 45). An additional study examined members of 19 FAMMM kindreds harboring a 19 base pair p16 deletion mutation and found that the cumulative risk of developing pancreatic cancer by 75 years of age was 17% (6).

The early onset of melanoma in FAMMM kindreds is well documented, while controversy exists as to whether or not pancreatic cancer is diagnosed at an earlier age in FAMMM kindreds compared to sporadic cases. In one study of eight CDKN2A FAMMM kindreds, early-onset pancreatic cancer was noted in some families, while it occurred much later in others (4). Goldstein and others observed no difference in age of diagnosis of pancreatic cancer in CDKN2A families (70.5 years) when compared with the population (71 years) in their study of 104 patients from 17 CDKN2A kindreds (8). Hruban and others reported similar findings in their study of 212 kindreds which revealed at median age at pancreatic cancer diagnosis of 65 years for both groups (44). In contrast, a recent study comparing 30 patients from CDKN2A kindreds to a sporadic cohort showed a statistically significant difference in age of pancreatic cancer diagnosis between the two groups. In the CDKN2A group, 36% of the pancreatic cancer diagnoses occurred in patients who were less than 50 years old, which was in contrast to 18.3% in the population-based group. Of note, however, 87% of the members of the familial cohorts were smokers compared to 66% of the sporadic cohort, which could significantly alter the age of pancreatic cancer presentation (46).

Screening and Management

Melanoma and pancreatic cancer cause significant morbidity and mortality in FAMMM patients. The authors support the view that all FAMMM patients be counseled on screening. Given the lack of convincing and concordant data regarding CDKN2A mutation status and cancer risk, CDKN2A mutation should not be used for risk stratification or determination of follow-up program at this time (47).

Melanoma

Screening for melanoma in FAMMM kindreds should begin at age 10 with a baseline total body skin examination including scalp, oral mucosa, genital area, and nail, as family members may develop melanoma in their early teens (4, 8, 39, 47). This screening should also be offered to all first- and some second-degree relatives. Nevi should be examined for ABCDE features of melanoma. The concept of the “ugly duckling” nevus is helpful in identifying a pigmented lesion with unusual characteristics. When an individual lesion varies significantly compared to the other nevi present, biopsy is indicated. Additionally, dermoscopy may also be a useful adjunct in the evaluation of pigmented lesions with suspicious features.

Patients with FAMMM syndrome should be examined by the health care provider every 6 months initially to ensure nevi stability. Once this is established and the patient demonstrates understanding of how to perform self-examination and the importance of such self-surveillance, these visits can be conducted annually or as needed if the patient detects an abnormality on self-exam. Thorough total body self-examination should be performed by the patient with assistance from a friend or family member every month, and patients should have quick access to the physician in the case of suspected change. Nevi may become more unstable during puberty and pregnancy and may warrant increased frequency of physician examinations during these periods (39, 47).

Suspicious macular pigmented lesions may be adequately sampled by deep shave excision. Papular or nodular lesions require a punch biopsy or excision for accurate determination of Breslow depth. Further definitive surgical treatment is dictated by histopathology.

Pancreatic Cancer

There are currently no successful screening methods to detect early, operable pancreatic carcinoma (27, 47). The anatomic location of the pancreas and late-presenting, often nonspecific, initial symptoms of pancreatic cancer hinder the ability to detect masses at an early, resectable stage. Given the low incidence of pancreatic cancer in the general population and lack of reliable screening test, there are no routine screening protocols for pancreatic cancer as there are for others such as breast and colon cancer. However, promising results have been seen with the use of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in clinical trials evaluating high-risk families (48-50). These tests are not currently considered standard of care, and patients and families at high-risk for a pancreatic cancer, such as those with FAMMM syndrome, should be referred for consideration of clinical research screening programs. The current technology of CT and MRI imaging modalities are not able to reliably detect masses in the pancreas that are less than 1-2 cm (51). ERCP has been shown to detect advanced pancreatic carcinoma with a sensitivity of 92% but is associated with a number of serious complications (52). Endoscopic ultrasound is currently the most sensitive test available for detection of small pancreatic masses (53) and is associated with significantly fewer complications than ERCP.

At Mayo Clinic, FAMMM patients with a confirmed mutation and family history of pancreatic cancer are offered screening with either high-resolution pancreatic protocol CT, MRI, or endoscopic ultrasound starting at age 50 or 10 years younger than the earliest family member with pancreas cancer. They are counseled on the lack of evidence-based data to support screening, and on the limitations of our current technology to detect a lesion at a stage amenable to therapy.

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Figure

Figure 1. Cutaneous manifestations of FAMMM. Courtesy of Jennifer Hand, MD, Mayo Clinic. Note the numerous typical nevi as well as scars from previous excisions (arrows).

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Figure

Figure 2. Summary of FAMMM diagnostic criteria, CDKN2A mutation prevalence in FAMMM and penetrance of melanoma and pancreatic cancer in CDKN2A mutation carrier and non carrier FAMMM patients. Note that cancer risks reported for FAMMM vary widely (4, 6, (more...)

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Figure

Figure 3. Genomic structure of CDKN2A isoforms. Top: exon-intron structure of isoforms 1, 3, and 4. Thick bars represent exons, thin bars untranslated regions (UTRs), and lines introns. Bottom: Despite sharing DNA sequence, exon 2 of isoform 1 and isoform (more...)

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Figure

Figure 4..A six-species alignment of the amino acid sequence of p16(INK4). Only the portion of the gene encoded by exon 2 shows significant conservation. Forward arrow: C-terminal boundary of exon 2 in both main isoforms. Left-most reverse arrow: N-terminal (more...)

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Figure 5. Evolutionary conservation at CDKN2A Exon 2. Drop in conservation score beyond coding sequence of isoform '4' suggests that its encoded protein, p14(ARF), rather than p16(INK), is responsible for evolutionary conservation at this locus. Note (more...)

Copyright © 2009-, Douglas L Riegert-Johnson.
Bookshelf ID: NBK7030PMID: 21249757

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