A genome-wide scan identifies mutations in the gene encoding phosphodiesterase 11A4 (PDE11A) in individuals with adrenocortical hyperplasia Anelia Horvath 1 , Sosipatros Boikos 1 , Christoforos Giatzakis 1 , Audrey Robinson-White 1 , Lionel Groussin 4 , Kurt J Griffin 1,2 , Erica Stein 1 , Elizabeth Levine 1 , Georgia Delimpasi 1 , Hui Pin Hsiao 1 , Meg Keil 2 , Sarah Heyerdahl 1 , Ludmila Matyakhina 1 , Rossella Libe ` 4 , Amato Fratticci 4 , Lawrence S Kirschner 5 , Kevin Cramer 6 , Rolf C Gaillard 7 , Xavier Bertagna 4 , J Aidan Carney 3 , Je ´ro ˆme Bertherat 4 , Ioannis Bossis 1 & Constantine A Stratakis 1,2 Phosphodiesterases (PDEs) regulate cyclic nucleotide levels. Increased cyclic AMP (cAMP) signaling has been associated with PRKAR1A or GNAS mutations and leads to adrenocortical tumors and Cushing syndrome 1–7 . We investigated the genetic source of Cushing syndrome in individuals with adrenocortical hyperplasia that was not caused by known defects. We performed genome-wide SNP genotyping, including the adrenocortical tumor DNA. The region with the highest probability to harbor a susceptibility gene by loss of heterozygosity (LOH) and other analyses was 2q31–2q35. We identified mutations disrupting the expression of the PDE11A isoform-4 gene (PDE11A) in three kindreds. Tumor tissues showed 2q31–2q35 LOH, decreased protein expression and high cyclic nucleotide levels and cAMP-responsive element binding protein (CREB) phosphorylation. PDE11A codes for a dual-specificity PDE that is expressed in adrenal cortex and is partially inhibited by tadalafil and other PDE inhibitors 8,9 ; its germline inactivation is associated with adrenocortical hyperplasia, suggesting another means by which dysregulation of cAMP signaling causes endocrine tumors. Aberrant cAMP signaling has been linked to genetic forms of cortisol excess 1,2 . Somatic GNAS mutations are associated with macronodular adrenocortical hyperplasia in McCune-Albright syn- drome (MAS) 2 . Micronodular adrenocortical hyperplasia and its pigmented variant, primary pigmented nodular adrenocortical disease (PPNAD) may be caused by germline inactivating mutations of the PRKAR1A gene 3–6 . Most affected individuals have PPNAD as a component of Carney complex (CNC), an autosomal dominant multiple neoplasia syndrome that is also caused mostly by PRKAR1A mutations 5 . Over the last several years, it has become apparent that there is more than one form of micronodular adrenocortical hyperplasia 7 . We identified a total of ten other individuals with Cushing syndrome and adrenocortical hyperplasia who did not have PRKAR1A muta- tions. In most of these individuals, the adrenal glands had an overall normal size and weight and featured multiple small yellow-to-dark brown nodules surrounded by a cortex with a uniform appearance (Fig. 1a). Microscopically, there was moderate diffuse cortical hyper- plasia with mostly nonpigmented nodules, multiple capsular deficits and massive circumscribed and infiltrating extra-adrenal cortical excrescences with micronodules (Fig. 1b). Although overall there was no pigmentation by regular microscopy, electron micro- scopy did show granules of lipofuscin and features of a cortisol- producing adrenocortical hyperplasia (Fig. 1c). In other cases, the features of the disease were consistent with those of PPNAD caused by PRKAR1A mutations 1 . The mode of inheritance of this apparently genetic form of bilateral adrenocortical hyperplasia was uncertain: only one of the ten kindreds demonstrated clear inheritance from an affected mother to her affected daughter. All other individuals studied were the only affected individuals within their families. Preliminary studies using compara- tive genomic hybridization and BAC microarray hybridization of the tumor samples did not show any abnormalities (data not shown). We hypothesized that areas of the genome that are linked to the disease could be identified in a genome-wide scan: smaller-scale allelic losses © 2006 Nature Publishing Group http://www.nature.com/naturegenetics Received 13 December 2005; accepted 26 April 2006; published online 11 June 2006; doi:10.1038/ng1809 1 Section on Endocrinology & Genetics, and 2 Pediatric Endocrinology Training Program, Developmental Endocrinology Branch, US National Institute of Child Health and Human Development, US National Institutes of Health, Bethesda, Maryland 20892, USA. 3 Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA. 4 De ´ partement Endocrinologie, Me ´tabolisme & Cancer, Institut Cochin, Institut National de la Sante ´ et de la Recherche Me ´ dicale (INSERM) U567 and Centre National de la Recherche Scientifique (CNRS) UMR 8104, and Centre de Re ´fe ´rence des Maladies Rares de la Surre ´ nale, Service d’Endocrinologie, Ho ˆ pital Cochin, Universite ´ Paris 5, Paris, 75679, France. 5 Divisions of Endocrinology and Human Cancer Genetics, Ohio State University, Columbus, Ohio 43210, USA. 6 Sapio Sciences, LLC, York, Pennsylvania 17402, USA. 7 Division d’ Endocrinologie, Diabetologie et Metabolisme, Centre Hospitalier Universitaire Vaudois-CHUV, CH-1011 Lausanne, Switzerland. Correspondence should be addressed to C.A.S. (stratakc@mail.nih.gov). NATURE GENETICS ADVANCE ONLINE PUBLICATION 1 LETTERS