VHL germline mutation carriers who had an ophthalmologic examination at the Erasmus Medical Centre or the Rotterdam Eye Hospital between 1984 and 2017, and were diagnosed with retinal hemangioblastoma (RH) were included in this study. A diagnosis of RH was based on the clinical appearance of a vasoproliferative retinal tumour. Peripheral blood samples from every member that had clinically suspected VHL disease of each family were collected for VHL mutation analysis. A total of 21 patients from 10 families were included on the basis of both a VHL germline mutation and ocular manifestations. Copy number analyses were carried out by multiplex ligation dependent probe amplification (MLPA) and fluorescence in situ hybridization (FISH). Mutations were described as one of the following two groups: truncating (complete deletion, partial deletion, nonsense mutation, splice site mutation, duplication and insertion) or missense. Ocular manifestations were not reported on an individual level, but rather were broken down based on the two groups. From Pedigree (family) 14, two individuals were suspected of VHL disease and mutational analysis revealed a R64P(c.191G>C) missense variant. Both individuals from this family did not develop RH.

GroupID: 14

DiseaseAssertion: VHL

Group size: 2

GroupNumberMales: N/A

GroupNumberFemales: N/A

GroupEthnicity: N/A

GroupAgeRange: N/A

Group Info: Retrospective analysis of a longitudinal cohort of 21 VHL germline mutation carriers and retinal haemangioblastomas. All patients were categorized in two genotypic categories: missense mutations and truncating mutations. From this family, two individual was suspected of VHL disease, but neither developed RH.

GroupPresentingHPOs: N/A

GroupHPOFreeText: N/A

GroupNotHPOs: HP:0009711 (retinal capillary hemangioma)

GroupNotHPOFreeText: This VHL patients did not present with retinal capillary hemangioma.

GroupPreviousTesting: N/A

PreviouslyPublished: N/A

SupplementalData: Table S1

Variant: p.R64P (c.191G>C)

CaseProblemVariantFreeText: N/A

LegacyVariant: N/A

ClinVarID: 2226, https://www.ncbi.nlm.nih.gov/clinvar/variation/2226/

CAID: N/A

gnomAD: N/A

VariantEvidence: Chr3(GRCh37): g.10183722G>C

MutationType: missense_variant; transversion

CivicName: R64P (c.191G>C)

MultipleGeneVariants: N/A

A 17-year-old girl was referred to the Department of Endocrinology at La Rabta University Hospital for the investigation of a newly diagnosed diabetes mellitus and a severe arterial hypertension. The patient is the first child of consanguineous parents and has a family history of type 2 diabetes and dyslipidemia, but no conditions that may suspect VHL disease. Blood tests disclosed hypercalcemia and abdominal computed tomography showed bilateral adrenal tumors. A clinical diagnosis of multiple endocrine neoplasia type 2a (MEN2A) was originally suspected but genetic analysis (not further detailed) revealed the missense mutation c.191G > C (p.Arg64Pro) in exon 1 of the VHL gene. The authors concluded that the presence of pheochromocytomas and the missense mutation in VHL gene suggests type 2 VHL disease. She was further diagnosed with dyslipidemia and primary hyperparathyroidism. The patient underwent a bilateral adrenalectomy marked by normalization of blood pressure, blood glucose, calcium, and PTH levels.

A study investigated paraganglioma/pheochromocytoma tumors in a retrospective cohort and a prospective cohort. Tumour tissue samples were sequenced by next-generation sequencing using a custom gene panel. In some cases, Sanger sequencing was used to detect germline mutations. Some of these tumors were found with germline VHL mutations. Patient ID 100, from the prospective cohort, presented with multiple paragangliomas and a germline mutation in the VHL gene c.191G>C. Other phenotypic and demographic information was not available. The paper performed carbonic anhydrase IX immunohistochemistry and immunostaining with CA9 was observed in patient 100.

PatientID: 5

KindredID: 5

Case: Sex Unknown, Age Unknown, Ethnicity Unknown

DiseaseAssertion: VHL - asymptomatic

FamilyInfo: N/A

CasePresentingHPOs: N/A

CaseHPOFreeText: No tumors were reported in this patient: it was stated that they present an additional rare disease: the patient is heterozygous for CLN5protein in the neuronal ceroid lipofuscinosis rare disease. It is thus hypothesized that the CLN5 mutation in this VHL patient offers a protective effect to prevent tumors.

CaseNotHPOs: N/A

CaseNotHPOFreeText: N/A

CasePreviousTesting: CLN5

PreviouslyPublished: N/A

SupplementalData: Yes

Variant: p.R64P(c.191G>C)

LegacyVariant: N/A

CaseProblemVariantFreeText: N/A

ClinVarID: 2226 https://www.ncbi.nlm.nih.gov/clinvar/variation/2226/

CAID: N/A

gnomAD: N/A

VariantEvidence: N/A

MutationType: missense_variant;transversion

CivicName: R64P (c.191G>C)

MultipleGeneVariants: N/A

PatientID: 4

KindredID: 4

Case: F, 23Y0M, Ethnicity Unknown

DiseaseAssertion: VHL

FamilyInfo: The patient had a family specific p.Arg64Pro mutation, and VHL disease had a heterogeneous presentation in the family. The patient’s father initially presented with bilateral pheochromocytomas and clear cell renal carcinoma, and the patient’s son underwent unilateral adrenalectomy for pheochromocytoma at the age of 7.

CasePresentingHPOs: HP:0002668 (Paraganglioma)

CaseHPOFreeText: The patient was asymptomatic and presented with a palpable mass on the left side of the neck during a routine check-up. Somatostatin receptor scintigraphy revealed a hotspot near the left carotid artery, which indicated a paraganglioma. The paraganglioma was 2.5cm in size, and histological examination of it post-resection confirmed it was a paraganglioma. The patient did not present with any later tumors, although the length of follow-up is not specified.

CaseNotHPOs: N/A

CaseNotHPOFreeText: N/A

CasePreviousTesting: N/A

PreviouslyPublished: N/A

SupplementalData: N/A

Variant: p.R64P (c.191G>C)

ClinVarID: 2226, https://www.ncbi.nlm.nih.gov/clinvar/variation/2226/

gnomAD: N/A

VariantEvidence: N/A

MutationType: missense_variant;transversion

CivicName: R64P(c.191G>C)

MultipleGeneVariants: N/A

An Israeli specialized centre identified 32 VHL patients belonging to 16 different kindreds. This retrospective collection and analysis of clinical, laboratory and imaging data of VHL patients involved one individual belonging to kindred VIII. Genetic analysis via direct VHL gene sequencing and quantitative Southern blot identified the R64P (c.191G>C) mutation. This individual (20Y, M) had bilateral adrenal pheochromocytoma, and epididymal cyst. He had no family history reported.

PatientID: 1

KindredID: 1

Case: Sex Unknown, Age Unknown, Ethnicity Unknown

DiseaseAssertion: VHL

FamilyInfo: No family information provided.

CasePresentingHPOs: HP:0002666; HP:0002668 (Pheochromocytoma; paraganglioma)

CaseHPOFreeText: Patient had pheochromocytoma and/or paraganglioma (table 2).

CaseNotHPOs: N/A

CaseNotHPOFreeText: N/A

CasePreviousTesting: N/A

PreviouslyPublished: N/A

SupplementalData: N/A

Variant: p.R64P (c.191G>C)

LegacyVariant: N/A

CaseProblemVariantFreeText: N/A

ClinVarID: 2226, /www.ncbi.nlm.nih.gov/clinvar/variation/2226/

CAID: N/A

gnomAD: N/A

VariantEvidence: N/A

MutationType: missense_variant, transversion

CivicName: R64P (c.191G>C)

MultipleGeneVariants: N/A

A study retrospectively reviewed medical records of 710 patients diagnosed with PC/PGL for associated renal neoplasia and primary renal PGLs, at Mayo Clinic, Rochester, MN. Three patients that met inclusion criteria were found with VHL mutations, only 2 of which had documented pathogenic mutations in the VHL gene. One patient (Patient 13) was a 33 year old male with a germline c.191G>C transversion resulting in a p.Arg64Pro protein change presenting with bilateral pheochromocytoma, and ccRCC.

A retrospective analysis of pheochromocytoma tissue samples from the Department of Pathology of the Erasmus MC (Rotterdam) revealed an 18Y female patient (ID #F119) with a confirmed germline mutation in the VHL gene, p.Arg64Pro. The patient had pheochromocytoma but other phenotypes were not described. Family history was not described. Pheochromocytoma is highly specific to VHL disease (PP4) and disease-causing missense variants are common in VHL disease (PP2).

PatientID: F119

KindredID: 1

Case: F, 20Y0M, Ethnicity Unknown

DiseaseAssertion: VHL

FamilyInfo: N/A

CasePresentingHPOs: HP:0002666 (pheochromocytoma)

CaseHPOFreeText: The patient had a pheochromocytoma in the left adrenal gland. It was measured to be 3 cm in size and 23 grams in weight.

CaseNotHPOs: N/A

CaseNotHPOFreeText: N/A

CasePreviousTesting: RET/SDHB/SDHD

PreviouslyPublished: N/A

SupplementalData: N/A

Variant: p.R64P(c.191G>C)

LegacyVariant: N/A

CaseProblemVariantFreeText: N/A

ClinVarID: 2226 https://www.ncbi.nlm.nih.gov/clinvar/variation/2226/

CAID: N/A

gnomAD: N/A

VariantEvidence: N/A

MutationType: missense_variant;transversion

CivicName: R64P(c.191G>C)

MultipleGeneVariants: N/A

PatientID: 552

KindredID: 1

Case: F, 7Y4M, Ethnicity Unknown

DiseaseAssertion: VHL

FamilyInfo: The patient’s mother had pheochromocytoma, and the patient’s maternal second-degree relatives had renal cell carcinoma and systemic lupus erythematosus/rheumatoid arthritis.

CasePresentingHPOs: HP:0002666; HP:0001085 (Pheochromocytoma, papilledema)

CaseHPOFreeText: N/A

CaseNotHPOs: N/A

CaseNotHPOFreeText: N/A

CasePreviousTesting: N/A

PreviouslyPublished: N/A

SupplementalData: N/A

Variant: p.R64P (c.191G>C)

ClinVarID: 2226, https://www.ncbi.nlm.nih.gov/clinvar/variation/2226/

gnomAD: N/A

VariantEvidence: N/A

MutationType: missense_variant;transversion

CivicName: R64P(c.191G>C)

MultipleGeneVariants: N/A

PatientID: III-4

KindredID: 1

Case: 34Y0M, Sex and Ethnicity Unknown

DiseaseAssertion: pheochromocytoma

FamilyInfo: Family suggesting incomplete penetrance of a VHL gene germline mutation. Mutation (p.R64P) was found in a family with 6 patients total with three generations. The earliest patient described (I-1) presented with renal cell carcinoma (age at diagnosis 48 years), 1 of their 6 children (II-1) at age 59 had no typical VHL manifestations after annual clinical monitoring and suggest non-penetrance in the patient; the second of 6 children (II-3), then aged 51, had bilateral pheochromocytoma diagnosed age 14. Their only child (III-5) had a paraganglioma with an age of diagnosis of 29 years, and a renal cyst. Patient II-1 had 4 children - one (III-1; aged 40) who presented as a carrier with no typical VHL manifestations after annual clinical monitoring; and another 32 years old presenting with pheochromocytoma. (See Figure 2 for pedigree)

CasePresentingHPOs: HP:0002666 (pheochromocytoma)

CaseHPOFreeText: Bilateral pheochromocytoma diagnosed at age 34

CaseNotHPOs: N/A

CaseNotHPOFreeText: Unclear as to whether testing for other manifestations was conducted

CasePreviousTesting: N/A

PreviouslyPublished: Previously reported, HGMD (Human Gene Mutation Database: http://uwcmml1s.uwcm.ac.uk/uwcm/mg/search/120488.html)

SupplementalData: N/A

Variant: p.R64P (c.191G>C)

CaseProblemVariantFreeText: N/A

LegacyVariant: N/A

ClinVarID: 2226 https://www.ncbi.nlm.nih.gov/clinvar/variation/2226/

CAID: CA020089 http://reg.clinicalgenome.org/redmine/projects/registry/genboree_registry/allele?hgvsOrDescriptor=NM_000551.3%3Ac.191G%3EC

gnomAD: N/A

VariantEvidence: N/A

MutationType: missense_variant;transversion

CivicName: R64P (c.191G>C)

MultipleGeneVariants: N/A

In a study of 426 unrelated VHL patients, 111 were discovered to have alterations in the VHL gene. 18 novel variants were identified in VHL patients, but none were present in 200 unaffected control individuals. DNA samples from peripheral blood leukocytes underwent polymerase chain reaction (PCR) amplification, denaturing high-performance liquid chromatography (DHPLC), and direct sequence analysis of the entire coding sequence and intron-exon boundaries. This missense mutation, c.191G>C, was found in a 26 year old VHL patient with pheochromocytoma and no family history (index case 123). Only supporting evidence for pathogenicity because patient's phenotype is highly specific for a disease with a single genetic etiology.

Medical records of patients with PPGLs between 2005 and 2016 were reviewed. Diagnosis was confirmed histologically and stratified into sporadic or familial/syndromic. Patients underwent next‐generation whole exome sequencing. A 35 year old patient presented with unifocal adrenal pheochromocytoma. Genetic testing confirmed a familial missense mutation at c.191G>C of the VHL gene.

Tissue specimens were retrieved from the archives of the Department of Pathology of the Erasmus MC (Rotterdam, The Netherlands), The University Medical Center St Radboud (Nijmegen, The Netherlands), and the University Hospital Zürich (Zürich, Switzerland). The samples were sequenced using Bigdye Terminator V3.1 cycle sequencing kit (Applied Biosystems, Foster City, CA, USA). Products were analyzed on the ABI Prism 3100 genetic analyzer (Applied Biosystems).The mutation analysis of pheochromocytoma tissue samples showed two patients, 31 year-old (F6) and 24 year-old (F87) males, with R64P germline mutations in exon 1 of the VHL tumor suppressor gene and both had no metastasis. Patient F87 was followed up 11 years later and patient F6 was followed up 21 years later. These patients belonged to the same family (family A). Besides bilateral pheochromocytoma, the paper does not provide any other phenotypic information.

Thirteen patients from four families (A, B, C and D) with known VHL disease and known mutations in the VHL gene were examined. MLPA using venous blood showed 4 variants. Family D was found with a p.R64P mutation in the VHL gene, only confirmed in patient II-1 (female) and neither parent or sibling, suggested a de novo mutation. Patient II-1 presented with pheochromocytoma in the right adrenal gland at age 37, and by age 45, she showed no signs of metastases or other VHL-associated tumors.

PatientID: N/A (case)

KindredID: 1

Case: F, 18Y0M, Ethnicity Unknown

DiseaseAssertion: VHL

FamilyInfo: Not relevant - She was the first child of consanguineous parents. Her family history was notable for type 2 diabetes and dyslipidemia but no history of pheochromocytoma, paraganglioma, unexplained sudden death, or condition relevant to VHL. However, the family screening for VHL has not been performed.

CasePresentingHPOs: HP:0006748; HP:0000819; HP:0008200 (adrenal pheochromocytoma; Diabetes mellitus; hyperparathyroidism)

CaseHPOFreeText: First brought to clinic for newly diagnosed diabetes mellitus and severe arterial hypertension. As symptoms, the patient complained of headaches, palpitations, diaphoresis, and hot flashes since one month. She reported also asthenia and body weight loss of five kilograms in two weeks. Pheochromocytoma was confirmed. CT showed adrenal masses: Right measuring 35×55×70mm, and left measuring 24×27mm. She underwent a bilateral adrenalectomy in two steps. Pathological examination confirmed bilateral adrenal pheochromocytomas. 12 months post, follow up is clear.

CaseNotHPOs: N/A

CaseNotHPOFreeText: Thyroid, abdominal, and neurological examinations were normal.

CasePreviousTesting: RET

PreviouslyPublished: N/A

SupplementalData: N/A

Variant: p.R64P (c.191G>C)

LegacyVariant: N/A

CaseProblemVariantFreeText: N/A

ClinVarID: 2226 https://www.ncbi.nlm.nih.gov/clinvar/variation/2226/

CAID: N/A

gnomAD: N/A

VariantEvidence: N/A

MutationType: missense_variant;transversion

CivicName: R64P (c.191G>C)

MultipleGeneVariants: N/A

PatientID: 100

KindredID: 100

Case: Sex Unknown, Age Unknown, Ethnicity Unknown

DiseaseAssertion: Paraganglioma

FamilyInfo: N/A

CasePresentingHPOs: HP:0002668 (paraganglioma)

CaseHPOFreeText: The patient had multiple paragangliomas.

CaseNotHPOs: N/A

CaseNotHPOFreeText: N/A

CasePreviousTesting: N/A

PreviouslyPublished: N/A

SupplementalData: Patient information pulled from Supplemental Table 1. There is additional tumour specific information in Supplemental Table 2.

Variant: p.R64P (c.191G>C)

ClinVarID: 2226 https://www.ncbi.nlm.nih.gov/clinvar/variation/2226/

gnomAD: N/A

VariantEvidence: Membrane CA9 immunostaining was observed (supplemental table 1).

MutationType: missense_variant;transversion

CivicName: R64P(c.191G>C)

MultipleGeneVariants: N/A