Howel–Evans syndrome

Howel–Evans syndrome is an extremely rare condition involving thickening of the skin in the palms of the hands and the soles of the feet (hyperkeratosis). This familial disease is associated with a high lifetime risk of esophageal cancer. For this reason, it is sometimes known as tylosis with oesophageal cancer (TOC).[1]

Tylosis with esophageal cancer
SpecialtyMedical genetics 

The condition is inherited in an autosomal dominant manner, and it has been linked to a mutation in the RHBDF2 gene. It was first described in 1958.[2]

Presentation

This condition is inherited as an autosomal dominant syndrome and characterized by palmoplantar keratoderma, oral precursor lesions particularly on the gums (leukoplakia) and a high lifetime risk of esophageal cancer (95% develop esophageal cancer by the age of 65).[3] Relapsing cutaneous horns of the lips has been reported in this condition.[4]

There are several types of this condition have been described – epidermolytic (Vörner type) and non-epidermolytic. Another classification divides these into an early onset type (type B) which occurs in the first year of life and is usually benign and a type A tylosis which occurs between the ages of 5 and 15 years and is strongly associated with esophageal cancer.[5]

Cytoglobin gene expression in oesophageal biopsies is significantly reduced (70% reduction) in this condition.[6] The mechanism of this change is not known.

Genetics

The gene responsible is RHBDF2 (Rhomboid family member 2), which is located on the long arm of chromosome 17 (at 17q25).[7] The mutation responsible for the disease was detected in Finnish, German, UK and US families. The RHBDF2 protein is a member of the intramembranous serine proteases. It is thought to play an important role in the epithelial response to injury in the esophagus and skin. RHBDF2 is involved in the regulation of the secretion of several ligands of the epidermal growth factor receptor.

Molecular biology

The rhomboid proteases – the first known intramembranous serine proteases[8] – were discovered in 1988.[9] The first rhomboid protease was cloned in 1990[10] Rhomboid proteases have a core of six transmembrane helices with the active site residues lying in a hydrophilic cavity. Rhomboid family members are widely conserved and found in all three kingdoms of life.[11]

RHBDF2 associates with the rhomboid like protease 2 (RHBDL2) and inhibits its activity.

Mutations in RHBDF2 inhibit tumour necrosis factor alpha.

RHBDL2 also acts on Epidermal growth factor and EphrinB3.

Thrombomodulin – a membrane glycoprotein – is upregulated in neoepidermis during cutaneous wound healing. RHBDL2 cleaves thrombomodulin at the transmembrane domain and causes the release of soluble thrombomodulin.

Other associations

RHBDF2 may also play a role in ovarian epithelial cancer.[12]

Possible associations with gastric cancer[13][14] and lung cancer[15][16][17][18] have been suggested. Other possible associations include corneal defects, congenital pulmonary stenosis,[19] total anomalous pulmonary venous connection[20] deafness[21] and optic atrophy.[22]

A related gene – Rhomboid domain containing 2 (RHBDD2) – appears to be important in breast cancer.[23]

A second related gene – rhomboid family 1 (RHBDF1) – appears to be important in head and neck cancer.[24]

A third member of this family – RHBDD1 – cleaves Bcl-2-interacting killer (BIK) – a proapoptotic member of the B cell lymphoma 2 (Bcl-2) family.[25]

These proteins may also have a role in diabetes.[26]

Diagnosis

Differential diagnosis

The differential diagnosis is quite extensive and includes[27][28]

Treatment

Systemic retinoids are the drugs used for tylosis.

Terminology

The condition is also referred to by several other names, including "familial keratoderma with carcinoma of the esophagus," "focal non-epidermolytic palmoplantar keratoderma with carcinoma of the esophagus,"[29] "Palmoplantar ectodermal dysplasia type III," "palmoplantar keratoderma associated with esophageal cancer," "tylosis"[30]: 213 [31]: 511  and "tylosis–esophageal cancer"[29]

See also

References
  1. "Tylosis with esophageal cancer". rarediseases.info.nih.gov. Genetic and Rare Diseases Information Center (GARD) – NIH. 18 January 2013. Retrieved 16 August 2014.
  2. Howel-Evans, W; McConnell, RB; Clarke, CA; Sheppard, PM (July 1958). "Carcinoma of the oesophagus with keratosis palmaris et plantaris (tylosis): a study of two families". Q. J. Med. 27 (107): 413–29. PMID 13579162.
  3. Marger RS, Marger D (1993) Carcinoma of the esophagus and tylosis. A lethal genetic combination. Cancer 72(1):17–19
  4. Baykal C, Savci N, Kavak A, Kurul S (2002) Palmoplantar keratoderma and oral leucoplakia with cutaneous horn of the lips. Br J Dermatol 146(4):680–683
  5. Maillefer RH, Greydanus MP (1999) To B or not to B: is tylosis B truly benign? Two North American genealogies. Am J Gastroenterol 94(3):829–834
  6. McRonald FE, Liloglou T, Xinarianos G, Hill L, Rowbottom L, Langan JE, Ellis A, Shaw JM, Field JK, Risk JM (2006) Down-regulation of the cytoglobin gene, located on 17q25, in tylosis with oesophageal cancer (TOC): evidence for trans-allele repression. Hum Mol Genet 15(8):1271–1277
  7. Saarinen S, Vahteristo P, Lehtonen R, Aittomäki K, Launonen V, Kiviluoto T, Aaltonen LA (2012) Analysis of a Finnish family confirms RHBDF2 mutations as the underlying factor in tylosis with esophageal cancer. Fam Cancer
  8. Freeman M (2009) Rhomboids: 7 years of a new protease family. Semin Cell Dev Biol 20(2):231–239
  9. Mayer U, Nüsslein-Volhard C (1988) A group of genes required for pattern formation in the ventral ectoderm of the Drosophila embryo. Genes Dev. 1988 Nov;2(11):1496–511
  10. Bier E, Jan LY, Jan YN (1990) Rhomboid, a gene required for dorsoventral axis establishment and peripheral nervous system development in Drosophila melanogaster. Genes Dev 4(2):190–203
  11. Koonin EV, Makarova KS, Rogozin IB, Davidovic L, Letellier MC, Pellegrini L (2003) The rhomboids: a nearly ubiquitous family of intramembrane serine proteases that probably evolved by multiple ancient horizontal gene transfers. Genome Biol. 2003; 4(3):R19
  12. Wojnarowicz PM, Provencher DM, Mes-Masson A-M, Tonin PN (2012) Chromosome 17q25 genes, RHBDF2 and CYGB, in ovarian cancer. Int J Oncol 40 (6) 1865-1880 Doi: 10.3892/ijo.2012.1371
  13. Wagle PK, Shetty TS, Darbari A, Tapia AA, Katrak MP, Joshi RM (2002) Carcinoma of stomach in a patient with familial tylosis. Indian J Gastroenterol 21(6):227
  14. Murata I, Ogami Y, Nagai Y, Furumi K, Yoshikawa I, Otsuki M (1998) Carcinoma of the stomach with hyperkeratosis palmaris et plantaris and acanthosis of the esophagus. Am J Gastroenterol 93(3):449–451
  15. Grundmann JU, Weisshaar E, Franke I, Bonnekoh B, Gollnick H (2003) Lung carcinoma with congenital plantar keratoderma as a variant of Clarke-Howel-Evans syndrome. Int J Dermatol 42(6):461–463
  16. Nomori H, Horio H, Iga R, Fuyuno G, Kobayashi R, Morinaga S (1996) Squamous cell carcinoma of the lung associated with palmo-plantar hyperkeratosis. Nihon Kyobu Shikkan Gakkai Zasshi 34(1):76–79
  17. Khanna SK, Agnone FA, Leibowitz AI, Raschke RA, Trehan M (1993) Nonfamilial diffuse palmoplantar keratoderma associated with bronchial carcinoma. J Am Acad Dermatol 28(2 Pt 2):295–297
  18. Murata Y, Kumano K, Tani M, Saito N, Kagotani K (1988) Acquired diffuse keratoderma of the palms and soles with bronchial carcinoma: report of a case and review of the literature. Arch Dermatol 124(4):497–498
  19. Wong ML, Tay JS (1991) Congenital heart disease in tylosis: case report. J Singapore Paediatr Soc 33(1–2):45–48
  20. Hoeger PH, Yates RW, Harper JI (1998) Palmoplantar keratoderma associated with congenital heart disease. Br J Dermatol 138(3):506–509
  21. Fitzgerald DA, Verbov JL (1996) Hereditary palmoplantar keratoderma with deafness. Br J Dermatol 134(5):939–942
  22. Dimsdale H (1949) Hereditary optic atrophy in family with keratodermia palmaris et plantaris (tylosis). Proc R Soc Med 42(10):796
  23. Abba MC, Lacunza E, Nunez MI, Colussi A, Isla-Larrain M, Segal-Eiras A, Croce MV, Aldaz CM (2009) Rhomboid domain containing 2 (RHBDD2): a novel cancer-related gene over-expressed in breast cancer. Biochim Biophys Acta 1792(10):988–997
  24. Zou H, Thomas SM, Yan ZW, Grandis JR, Vogt A, Li LY (2009) Human rhomboid family-1 gene RHBDF1 participates in GPCR-mediated transactivation of EGFR growth signals in head and neck squamous cancer cells. FASEB J 23(2):425–432
  25. Wang Y, Guan X, Fok KL, Li S, Zhang X, Miao S, Zong S, Koide SS, Chan HC, Wang L (2008) A novel member of the Rhomboid family, RHBDD1, regulates BIK-mediated apoptosis. Cell Mol Life Sci 65(23):3822–3829
  26. Walder K, Kerr-Bayles L, Civitarese A, Jowett J, Curran J, Elliott K, Trevaskis J, Bishara N, Zimmet P, Mandarino L, Ravussin E, Blangero J, Kissebah A, Collier GR (2005) The mitochondrial rhomboid protease PSARL is a new candidate gene for type 2 diabetes. Diabetologia 48(3):459–468
  27. Itin PH, Fistarol SK (2005) Palmoplantar keratodermas. Clin Dermatol 23(1):15–22
  28. Ratnavel RC, Griffiths WA (1997) The inherited palmoplantar keratodermas. Br J Dermatol 137(4):485–490
  29. Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1.
  30. James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.
  31. Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0-07-138076-0.
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