CASE REPORT

Germline and Somatic DICER1 Mutations in a

Well-Differentiated Fetal Adenocarcinoma of the Lung
Leanne de Kock, B.Tech,a,b Ismaël Bah, MD,c Yingchen Wu, MD,d
Meiqing Xie, MD, PhD,d John R. Priest, MD,e William D. Foulkes, M.B.B.S., PhDa,b,f,g,*
a
Department of Human Genetics, McGill University, Montreal, Quebec, Canada
b
Lady Davis Institute, Segal Cancer Centre, Jewish General Hospital, Montreal, Quebec, Canada
c
Department of Pathology, McGill University Health Centre, Montreal, Quebec, Canada
d
Department of Obstetrics and Gynecology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou,
People’s Republic of China
e
Minneapolis, MN, USA
f
Department of Medical Genetics, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
g
Program in Cancer Genetics, Departments of Oncology and Human Genetics, McGill University, Montreal, Quebec, Canada

Received 31 August 2015; revised 10 September 2015; accepted 13 September 2015

ABSTRACT carrier.3 Both CTNNB1 and adenomatous polyposis coli

Germ-line DICER1 mutations predispose to a distinctive
tumour predisposition syndrome, the DICER1 syndrome,
which is associated with a spectrum of rare mainly child-
hood-onset tumours. In 2014, a case of well-differentiated
fetal adenocarcinoma of the lung (WDFA) was reported in a
16-year-old germ-line DICER1 mutation carrier. Here we
report our finding of a characteristic somatic DICER1 RNase
IIIb c.5127T>A (p.Asp1709Glu) missense mutation within
the WDFA, confirmed using laser capture microscopy. The
child has a personal history consistent with the DICER1
syndrome: she developed a multinodular goitre at age 14
years and an ovarian Sertoli-Leydig cell tumour at age 16
years, each of which were found to harbour a somatic
DICER1 RNase IIIb missense mutation. The identification of
two DICER1 “hits” in the WDFA strongly suggests that
WDFA is a rare, previously-unrecognised manifestation of
DICER1 syndrome.

2015 International Association for the Study of Lung
Cancer. Published by Elsevier Inc. All rights reserved.
gene (APC) mutations result in constitutive activation of
the wingless-type MMTV integration site family (Wnt)
signaling pathway.3 Pulmonary blastoma (PB) is a
biphasic carcinosarcoma of adults and rarely of children
that has also been shown to harbor CTNNB1 mutations.4
We report a detailed molecular investigation of the
previously published case of a 16-year-old with WDFA,
Sertoli-Leydig cell tumor (SLCT), and multinodular
goitre (MNG) from a family with a mutation in the
microRNA-processing gene, DICER1.2
Case Report
At the age of 14 years, the child had a thyroidectomy
for bilateral MNG. At the age of 16 years, an ovarian SLCT
was resected. Preoperative chest radiography revealed
an asymptomatic lung lesion that was resected and
diagnosed as WDFA (Fig. 1A). Three of the child’s rela-
tives also had MNG.2

Keywords: DICER1; Well-differentiated fetal adenocarci-

noma; b-catenin; Laser capture microdissection; Mutation
Introduction
Well-differentiated fetal adenocarcinoma (WDFA) is a
very rare tumor of the pulmonary epithelium, presenting
most commonly during the third or fourth decades of life
but also very rarely in children.1 WDFA is considered a
variant of pulmonary adenocarcinoma.2 b-Catenin gene
(CTNNB1) mutations have previously been reported in
WDFA, and WDFA has developed in one APC mutation
*Corresponding author.
Disclosure: Dr. William D. Foulkes received a grant from Alex’s
Lemonade Stand Foundation, and Leanne de Kock received the Vanier
Canada Graduate Scholarship. The remaining authors declare no
conflict of interest.
Address for correspondence: William D. Foulkes, M.B.B.S., PhD,
Department of Medical Genetics, Lady Davis Institute, Segal Cancer
Centre, Jewish General Hospital, 3755 Cote St. Catherine Road, Mon-
treal, Quebec, Canada, H3T 1E2. E-mail: william.foulkes@mcgill.ca
ª 2015 International Association for the Study of Lung Cancer.
Published by Elsevier Inc. All rights reserved.
ISSN: 1556-0864
http://dx.doi.org/10.1016/j.jtho.2015.09.012

Journal of Thoracic Oncology Vol. 11 No. 3: e31-e33

e32 de Kock et al Journal of Thoracic Oncology Vol. 11 No. 3

Figure 1. Morphological data. (A) The epithelial component of well-differentiated fetal adenocarcinoma consists of cells
harboring clear, glycogen-rich cytoplasmic vacuoles. A sparse fibrous stroma can be noted in the background (hematoxylin
and eosin stain, magnification 40). (B) The epithelium displays mostly membranous, but also multifocal, cytoplasmic and
nuclear immunohistochemical positivity for b-catenin (magnification 600). Images taken before laser capture microdis-
section of the epithelial component (C) and mesenchymal component (hematoxylin and eosin stain) (D). Images taken of the
same areas subsequent to laser capture microdissection of the epithelial component (E) and mesenchymal component
(Arcturus HistoGene stain [Arcturus Bioscience, Inc., Mountain View, CA], magnification approximately 20) (F). Black di-
amonds indicate dissected areas.

Figure 2. Sequencing of genomic DNA obtained after laser capture microdissection of the epithelial and mesenchymal
components of the well-differentiated fetal adenocarcinoma. Mutation locations are indicated by an asterisk, and the wild-
type nucleotide sequence is provided below each chromatogram. (A) The germline DICER1 mutation (c.3540C>A) is present
in both the malignant epithelium (panel I) and background benign mesenchyme (panel II). (B) The somatic DICER1 mutation
(c.5127T>A) is present only within the epithelium (panel I). (C) The somatic b-catenin gene (CTNNB1) mutation (c.98C>G) is
similarly present within the epithelium (panel I). There is a slight suggestion of the c.98C>G mutation in the mesenchymal
component (panel II); the most likely explanation for this is contamination by some interpolated malignant epithelial cells.
March 2016
The family demonstrated a typical inherited germ-
line DICER1 mutation in blood lymphocyte genomic
DNA: c.3540C>A (p.Tyr1180*) (Fig. 2A).2 Sanger
sequencing of RNase III domains in tumor genomic DNA
from the proband’s three tumors revealed an additional
somatic DICER1 mutation in each: WDFA, c.5127T>A
(p.Asp1709Glu); SLCT, c.5438A>C (p.Glu1813Ala); and
MNG, c.5126A>G (p.Asp1709Gly). These are typical
DICER1-associated somatic RNase IIIb “hotspot” muta-
tions affecting critical metal ion binding.5 Laser micro-
dissection of malignant epithelium and background
benign stroma (Figs. 1C–1F) in the WDFA detected the
somatic DICER1 mutation exclusively in the epithelium
(Fig. 2B).
Also exclusively in WDFA epithelial tissue, we
identified a CTNNB1 mutation, c.98C>G (p.Ser33Cys)
(Fig. 2C). When subjected to immunohistochemical
staining, the tumor exhibited multifocal aberrant
epithelial nuclear/cytoplasmic expression of b-catenin
(see Fig. 1B). There is a slight suggestion of this mutation
in the stromal-derived DNA (see Fig. 2C), which may be
explained either by the presence of a minor CTNNB1-
mutated clone or, more likely, contaminating malignant
epithelial cells.
Discussion
Before our earlier report of this case,2 WDFA had
not been reported within the DICER1 syndrome (OMIM
#601200), a distinctive tumor predisposition syndrome
that is caused by germline mutations in the microRNA-
processing gene DICER1 and characterized by various
rare pediatric tumors, which often include pleuro-
pulmonary blastoma (PPB), SLCT, and MNG.5 Most
DICER1-associated tumors that have been studied har-
bor somatic RNase IIIb mutations as we found here.
Two DICER1 “hits” in the WDFA strongly suggest that
WDFA is a rare manifestation of DICER1 syndrome.
Studying additional WDFAs should determine the
strength of the association between WDFA and DICER1
syndrome. The CTNNB1 mutation in the tumor is also
consistent with prior observations,4 but finding the
DICER1 and CTNNB1 mutations exclusively in WDFA
DICER1 Mutations in Fetal Lung Adenocarcinoma e33
epithelium is novel. Our results raise intriguing ques-
tions about the relationships between three rare pul-
monary tumors: PPB, which is an exclusively
mesenchymal malignancy; WDFA, which is an adeno-
carcinoma, and PB, which is a biphasic carcinosarcoma.
PB and WDFA may share CTNNB1 mutations, and our
results show that PPB and WDFA may share DICER1
mutations. Other molecular events underpinning the
malignant epithelial component of WDFA should be
investigated. Moreover, the potential role of DICER1 in
PB deserves exploration.
Acknowledgments
The authors thank Dr. Morag Park, Dr. Nicholas Bertos,
and laboratory members for assistance with the laser
capture microdissection and subsequent DNA extrac-
tions and Talia Boshari for help with sample acquisition
and associated administrative work.
References
1. Zaidi A, Zamvar V, Macbeth F, Gibbs AR, Kulatilake N,
Butchart EG. Pulmonary blastoma: medium-term results
from a regional center. Ann Thorac Surg. 2002;73:
1572–1575.
2. Wu Y, Chen D, Li Y, Bian L, Ma T, Xie M. DICER1 mutations
in a patient with an ovarian Sertoli-Leydig tumor, well-
differentiated fetal adenocarcinoma of the lung, and fa-
milial multinodular goiter. Eur J Med Genet. 2014;57:
621–625.
3. Nakatani Y, Masudo K, Miyagi Y, et al. Aberrant nuclear
localization and gene mutation of beta-catenin in low-
grade adenocarcinoma of fetal lung type: up-regulation
of the Wnt signaling pathway may be a common denom-
inator for the development of tumors that form morules.
Mod Pathol. 2002;15:617–624.
4. Nakatani Y, Miyagi Y, Takemura T, et al. Aberrant nu-
clear/cytoplasmic localization and gene mutation of
beta-catenin in classic pulmonary blastoma: beta-
catenin immunostaining is useful for distinguishing be-
tween classic pulmonary blastoma and a blastomatoid
variant of carcinosarcoma. Am J Surg Pathol. 2004;28:
921–927.
5. Foulkes WD, Priest JR, Duchaine TF. DICER1: mutations,
microRNAs and mechanisms. Nat Rev Cancer. 2014;14:
662–672.