Muir–Torre syndrome

Muir–Torre syndrome
Synonyms	MTS
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Symptoms
Complications
Onset
Duration
Types
Causes
Risks
Diagnosis
Differential diagnosis
Prevention
Treatment
Medication
Prognosis
Frequency
Deaths

Muir–Torre syndrome is a rare hereditary, autosomal dominant cancer syndrome<ref name="Andrews">,

 Andrews' Diseases of the Skin: clinical Dermatology, 
  
 Saunders Elsevier, 
 2006, 
  
  
 ISBN 978-0-7216-2921-6,</ref>  that is thought to be a subtype of HNPCC. Individuals are prone to develop cancers of the colon, genitourinary tract, and skin lesions, such as keratoacanthomas and sebaceous tumors.  The genes affected are MLH1, MSH2, and more recently, MSH6, and are involved in DNA mismatch repair.

Symptoms

Muir–Torre syndrome is characterized by both:<ref name="Am Journal">,

 Association of sebaceous gland tumors and internal malignancy: The Muir–Torre syndrome, 
 The American Journal of Medicine, 
 
 Vol. 90(Issue: 5),
 pp. 606–13,
 DOI: 10.1016/S0002-9343(05)80013-0,
 PMID: 2029018,</ref>

1. At least a single sebaceous gland tumor (either an adenoma, an epithelioma, or a carcinoma)
2. A minimum of one internal malignancy

The Amsterdam criteria are frequently used to diagnose Lynch syndrome and Muir–Torre syndrome. They include the following:

• 3 or more relatives with an HNPCC-associated cancer (i.e., colorectal, cancer of the endometrium, small bowel, ureter, or renal pelvis)
• 2 or more successive generations affected by cancer
• 1 or more persons with cancer is a first-degree relative of the other 2, at least 1 case of colorectal cancer younger than age 50 years, a diagnosis of familial adenomatous polyposis has been excluded, tumors are verified by histologic examination

Muir–Torre syndrome is a genetic condition. Mutations in MLH1 and MSH2 are linked with the disease. These genes code for DNA mismatch repair genes, and mutations increase the risk of developing cancerous qualities. ^{(April 2020)}

Many patients who have sebaceous neoplasms with mutations in MSH2 and MLH1 do not in fact have Muir–Torre syndrome. The Mayo Muir–Torre risk score was devised to improve the positive predictive value of immunohistochemistry and reduce the false positive rate.<ref name="Roberts ME 2014">Roberts ME, Riegert-Johnson DL, Thomas BC,

 A clinical scoring system to identify patients with sebaceous neoplasms at risk for the Muir–Torre variant of Lynch syndrome, 
 Genetics in Medicine, 
 2014,
 Vol. 16(Issue: 9),
 pp. 711–16,
 DOI: 10.1038/gim.2014.19,
 PMID: 24603434,</ref><ref>Roberts ME, Riegert-Johnson DL, Thomas BC, 
 Screening for Muir–Torre syndrome using mismatch repair protein immunohisochemistry of sebaceous neoplasms, 
 J Genet Counsel, 
 2013,
 Vol. 22(Issue: 3),
 pp. 393–405,
 DOI: 10.1007/s10897-012-9552-4,
 PMID: 23212176,</ref> 

The Mayo Muir–Torre Risk score assigns points based several characteristics. A score of 2 or greater has a high positive predictive value of Muir–Torre syndrome. A score of 1 or lower is less likely to be Muir–Torre syndrome.<ref name="Roberts ME 2014"/>

Age of onset of first sebaceous neoplasm: <60 years = 1 point, otherwise 0 points Total number of sebaceous neoplasms: 1 = 0 points, >2 = 2 points. Personal history of Lynch related cancers: No = 0 points, Yes = 1 point Family history of Lynch-related cancer: No = 0 points, Yes = 1 point

The most common internal malignancies associated with Muir–Torre syndrome are: Colorectal (56%), Urogenital (22%), Small Intestine (4%), and Breast (4%). A variety of other internal malignancies have been reported.<ref>Akhtar S, Oza KK, Khan SA,

 Muir–Torre syndrome: a case report of a patient with concurrent jejunal and ureteral cancer and a review of the literature, 
 J Am Acad Dermatol, 
 1999,
 Vol. 41(Issue: 5),
 pp. 681–6,
 DOI: 10.1016/s0190-9622(99)70001-0,
 PMID: 10534628,</ref>

Cause

Genetic overlap with Turcot syndrome

A couple studies have been conducted on patients with both Muir–Torre syndrome and Turcot syndrome. It is thought that the two may have some genetic overlap. Both have been associated defects in MLH1 and MSH2 genes.<ref name="Dermatology Online">,

 Muir–Torre Syndrome / Turcot Syndrome overlap? A patient with sebaceous carcinoma, colon cancer, and a malignant astrocytoma, 
 Dermatology Online Journal, 
 
 Vol. 18(Issue: 5),
 pp. 3,
 
 PMID: 22630573,</ref>

In one study, a patient with defective MSH2 and MSH6 mismatch repair genes exhibited both syndromes. This is the first case where a patient with genotypic changes consistent with HNPCC has been properly diagnosed with an overlap of both syndromes. Along with neoplasms of the sebaceous gland, this patient developed cerebral neoplasms, characteristic of Turcot syndrome.<ref name="Surgical Neurology International">,

 Simultaneous Muir–Torre and Turcot's syndrome: A case report and review of the literature, 
 Surg Neurol Int, 
 
 Vol. 4(Issue: 52),
 pp. 52,
 DOI: 10.4103/2152-7806.110512,
 PMID: 23646262,
 PMC: 3640225,</ref>

Diagnosis

A person is suspected to have Muir-Torre syndrome (MTS) if he/she has one or more of the following:

• History of one or more sebaceous tumors
• Age younger than 60 years at first presentation of sebaceous tumors
• Personal history of Lynch-related cancers
• Family history of Lynch-related cancers

• The presence of specific skin tumors in MTS may lead to the correct diagnosis even in the absence of a clear family history.
• A person diagnosed with MTS can also have genetic testing to see if they have a mutation in one of the genes known to cause MTS.
• However, not everyone with Muir-Torre syndrome will have a detectable mutation in one of these genes.
• Other, unidentified genes may also play a role in the development of the condition.

Treatment

Immunohistochemistry is now being used more often to diagnose patients likely to have Muir–Torre syndrome. Sebaceous neoplasms are only infrequently encountered, and immunohistochemistry is reliable and readily available, so researchers have recommended its use. Routine immunohistochemical detection of DNA mismatch repair proteins help identify hereditary DNA mismatch repair deficiency.<ref name="Immunohistochemistry">,

 Towards identification of hereditary DNA mismatch repair deficiency: sebaceous neoplasm warrants routine immunohistochemical screening regardless of patient's age or other clinical characteristics, 
 Am J Surg Pathol, 
 2009,
 Vol. 33(Issue: 6),
 pp. 934–44,
 DOI: 10.1097/PAS.0b013e318199edca,
 PMID: 19342947,</ref>

Treatment of Muir–Torre syndrome normally consists of oral isotretinoin. The drug has been found to prevent tumor development.<ref name="Isotretinoin">,

 Muir–Torre Syndrome – Treatment with Isotretinoin and Interferon Alpha-2a Can Prevent Tumour Development, 
 Dermatology, 
 
 Vol. 200(Issue: 4),
 pp. 331–3,
 DOI: 10.1159/000018399,
 PMID: 10894967,
 
 
 Full text,</ref><ref name="Oral isotretinoin">, 
 Oral isotretinoin therapy for familial Muir–Torre syndrome, 
 J Am Acad Dermatol, 
 
 Vol. 12(Issue: 3),
 pp. 475–80,
 DOI: 10.1016/S0190-9622(85)70066-7,
 PMID: 3857234,</ref>

Patients with Muir–Torre syndrome should follow the same stringent screening for colorectal carcinoma and other malignancies as patients with Lynch syndrome. This includes frequent and early colonoscopies, mammograms, dermatologic evaluation, and imaging of the abdomen and pelvis.<ref>Ponti G, Pnz de Leon M,

 Muir–Torre syndrome, 
 Lancet Oncol, 
 2005,
 Vol. 6(Issue: 12),
 pp. 980–87,
 DOI: 10.1016/S1470-2045(05)70465-4,
 PMID: 16321766,</ref>

Incidence

Muir–Torre was observed to occur in 14 of 50 families (28%) and in 14 of 152 individuals (9.2%) with Lynch syndrome, also known as HNPCC.<ref name="Oxford Journal">,

 The Frequency of Muir–Torre Syndrome Among Lynch Syndrome Families, 
 Oxford Journal, 
 
 Vol. 100(Issue: 4),
 pp. 277–81,
 DOI: 10.1093/jnci/djm291,
 PMID: 18270343,</ref>

The 2 major MMR proteins involved are hMLH1 and hMSH2. Approximately 70% of tumors associated with the MTS have microsatellite instability. While germline disruption of hMLH1 and hMSH2 is evenly distributed in HNPCC, disruption of hMSH2 is seen in greater than 90% of MTS patients.<ref name="J Invest Dermatol">,

 Value of MLH1 and MSH2 mutations in the appearance of Muir–Torre syndrome phenotype in HNPCC patients presenting sebaceous gland tumors or keratoacanthomas. |, 
 J Invest Dermatol, 
 
 Vol. 126(Issue: 10),
 pp. 2302–7,
 DOI: 10.1038/sj.jid.5700475,
 PMID: 16826164,</ref>

Gastrointestinal and genitourinary cancers are the most common internal malignancies. Colorectal cancer is the most common visceral neoplasm in Muir–Torre syndrome patients.<ref name="PubMed">,

 Muir–Torre syndrome: a case report and review of the literature, 
 Turk J Gastroenterol, 
 
 Vol. 23(Issue: 4),
 pp. 394–8,
 DOI: 10.4318/tjg.2012.0411,
 PMID: 22965514,</ref>

Eponym

It is named for EG Muir and D Torre. A British physician, Muir noted a patient with many keratoacanthomas who went on to develop several internal malignancies at a young age. Torre presented his findings at a meeting of the New York Dermatologic Society.<ref name="pmid6020987">,

 Multiple primary carcinomata of the colon, duodenum, and larynx associated with kerato-acanthomata of the face, 
 Br J Surg, 
 
 Vol. 54(Issue: 3),
 pp. 191–5,
 DOI: 10.1002/bjs.1800540309,
 PMID: 6020987,</ref><ref name="pmid5684233">Torre D, 
 Multiple sebaceous tumors, 
 Arch Dermatol, 
 
 Vol. 98(Issue: 5),
 pp. 549–51,
 DOI: 10.1001/archderm.98.5.549,
 PMID: 5684233,</ref>

It was not until the 1980s when Creighton professor Henry Lynch noted a clustering of Muir–Torre syndrome patients in families with Lynch syndrome.<ref>Lynch HT, Fussaro RM, Roberts L,

 Muir–Torre syndrome in several members of a family with a variant of the Cancer Family Syndrome, 
 Br J Dermatol, 
 1985,
 Vol. 113(Issue: 3),
 pp. 295–301,
 DOI: 10.1111/j.1365-2133.1985.tb02081.x,
 PMID: 4063166,</ref>

See also

• List of cutaneous conditions
• List of cutaneous conditions associated with increased risk of nonmelanoma skin cancer