<p>Pancreatic endocrine tumors (PETs) occur sporadically or in the familial multiple endocrine neoplasia type 1 (MEN1) syndrome, whereas midgut carcinoids are nonfamilial, malignant endocrine tumors of the intestine. For these tumor entities morphological criteria are of limited use for prognostic prediction and selection of treatment. Genetic characterization may give additional information of clinical use and reveal pathways involved in tumor development.</p><p>Molecular genetic alterations in sporadic and MEN1-associated PETs and midgut carcinoids were studied with LOH and mutational analysis. In addition, immunohistochemistry was used to clarify gene expression. Detected genetic aberrations were correlated to the disease course of individual patients.</p><p>Somatic mutations of the<i> MEN1</i> gene at chromosome <i>11q13</i> were detected in 1/3 of sporadic PETs<i>. </i>Moreover, LOH was found in 70% of the lesions. All tumors with somatic <i>MEN1</i> mutations displayed loss of the remaining allele showing that the <i>MEN1</i> gene is involved in development of sporadic PETs.</p><p> Sporadic and MEN1 PETs were analyzed for LOH at <i>3p,</i> <i>11q13</i> and <i>18q</i>. A relation of LOH at <i>11q13</i> and <i>3p</i> to malignancy was found for the sporadic tumors. None of the benign tumors (all of them insulinomas) had allelic loss at <i>3p</i> or <i>11q13</i>, versus 92 % (p<0.01) of the malignant tumors (including malignant insulinomas). 1/4 of both sporadic and MEN1 lesions displayed LOH at <i>18q</i>, without altered <i>Smad4/DPC4</i>.</p><p>Genome-wide LOH screening of MEN1 PETs revealed multiple allelic deletions without general correlation to tumor size or malignancy. All tumors displayed LOH at the <i>MEN1 </i>locus, and 30% on chromosomes 3, 6, 8, 10, 18 and 21. Intratumoral heterogeneity was revealed, with chromosome 6 and 11 deletions in most tumor cells. Chromosome 6 deletions were mainly found in lesions from patients with malignant features. </p><p>A similar genome-wide LOH screening was performed on midgut carcinoids. Deletions at chromosome <i>18q</i> were found in 88% of the tumors indicating a potential tumor suppressor locus.</p>

Pancreatic endocrine tumors (PETs) occur sporadically or in the familial multiple endocrine neoplasia type 1 (MEN1) syndrome, whereas midgut carcinoids are nonfamilial, malignant endocrine tumors of the intestine. For these tumor entities morphological criteria are of limited use for prognostic prediction and selection of treatment. Genetic characterization may give additional information of clinical use and reveal pathways involved in tumor development. Molecular genetic alterations in sporadic and MEN1-associated PETs and midgut carcinoids were studied with LOH and mutational analysis. In addition, immunohistochemistry was used to clarify gene expression. Detected genetic aberrations were correlated to the disease course of individual patients. Somatic mutations of the MEN1 gene at chromosome 11q13 were detected in 1/3 of sporadic PETs. Moreover, LOH was found in 70% of the lesions. All tumors with somatic MEN1 mutations displayed loss of the remaining allele showing that the MEN1 gene is involved in development of sporadic PETs. Sporadic and MEN1 PETs were analyzed for LOH at 3p, 11q13 and 18q. A relation of LOH at 11q13 and 3p to malignancy was found for the sporadic tumors. None of the benign tumors (all of them insulinomas) had allelic loss at 3p or 11q13, versus 92 % (p&lt;0.01) of the malignant tumors (including malignant insulinomas). 1/4 of both sporadic and MEN1 lesions displayed LOH at 18q, without altered Smad4/DPC4. Genome-wide LOH screening of MEN1 PETs revealed multiple allelic deletions without general correlation to tumor size or malignancy. All tumors displayed LOH at the MEN1 locus, and 30% on chromosomes 3, 6, 8, 10, 18 and 21. Intratumoral heterogeneity was revealed, with chromosome 6 and 11 deletions in most tumor cells. Chromosome 6 deletions were mainly found in lesions from patients with malignant features. A similar genome-wide LOH screening was performed on midgut carcinoids. Deletions at chromosome 18q were found in 88% of the tumors indicating a potential tumor suppressor locus.

Le syndrome des Néoplasies Endocriniennes Multiples de type I (NEM1) est une maladie tumorale héréditaire rare caractérisée par l'apparition de tumeurs notamment du pancréas endocrine. Le gène de prédisposition est le suppresseur de tumeur MEN1, généralement retrouvé muté sur un des 2 allèles au niveau germinal chez les patients NEM1. Les tumeurs endocrines pancréatiques sont rares mais souvent métastatiques lors du diagnostic. Ces tumeurs forment un groupe hétérogène de par le type d'hormone qu'elles peuvent sécréter. Le développement et l'évolution de ces tumeurs sont encore très mal compris. L'origine cellulaire des différents types de tumeurs endocrines pancréatiques reste énigmatique, notamment en ce qui concerne les tumeurs exprimant des hormones non pancréatiques tels que les gastrinomes. Mon projet de thèse s'est articulé autour de la caractérisation d'un nouveau modèle murin d'invalidation du gène Men1 spécifiquement dans les cellules progénitrices endocrine pancréatiques Ngn3+ (PEPs), le modèle PancEndoMen1 KO. Ces travaux nous ont permis de démontrer que les gastrinomes pancréatiques liés à l'inactivation du gène Men1, avaient pour origines les cellules pancréatiques endocrines elles-mêmes. De plus, les souris PancEndoMen1 KO, développent des altérations de prolifération différentes suivant les lignages endocrines. De surcroît, l'invalidation du gène Men1 soit dans les cellules progénitrices pancréatiques, soit dans les cellules PEPs conduit au développement de tumeurs caractérisées par une altération de leur différentiation endocrine. Ainsi, mes travaux de thèse ont permis de mieux renseigner l'histogenèse des tumeurs endocrines pancréatiques en adressant le rôle dans la tumorigenèse de l'invalidation de Men1 dans les cellules PEPs au cours du développement / Multiple Endocrine Neoplasia Type I syndrome (MEN1) is a rare hereditary tumoral disease characterized by the apparition of tumors in multiple endocrine organs including the endocrine pancreas. MEN1 patients generally carry a germinal mutation on one allele of the predisposing gene to the disease, the tumor suppressor MEN1. Pancreatic endocrine tumors are rare, slowly evolving and often present with metastasis at diagnosis. These tumors constitute a heterogeneous group defined by their hormonal secretions. Evolution and development of these tumors is far from being understood. The cell of origin of the different pancreatic endocrine tumor types is enigmatic, notably for tumors secreting non-pancreatic hormones such as gastrinomas. My thesis project was structured toward the characterization of a new murine model allowing the specific disruption of the Men1 gene in Ngn3+ pancreatic endocrine progenitors, the PancEndoMen1 KO model. The combined study of this new model and previous model generated in the team, allowed us to demonstrate that pancreatic gastrinomas related to Men1 inactivation, originate from the endogenous pancreatic endocrine cells. In parallel, our results demonstrated that the mutant mice having Men1-deficient Ngn3+-progenitors resulted in differential cell proliferation alterations in different pancreatic endocrine cells. Importantly, Men1-disruption in either pancreatic endocrine or pan-pancreatic progenitors displayed tumors with impaired differentiation features. Thus, this thesis works allowed to better characterize pancreatic endocrine tumors histogenesis by addressing the role of pancreatic endocrine progenitors targeted Men1 disruption during development in tumorigenesis

Le syndrome des Néoplasies Endocriniennes Multiples de type 1 (NEM1) est une maladie à transmission autosomique dominante liée à l’inactivation du gène MEN1. Le but de mon travail de thèse était d’étudier le rôle biologique et oncosuppressif du gène Men1 dans le pancréas endocrine. La caractérisation d’un nouveau modèle m’a permis de démontrer que l’invalidation du gène Men1 spécifiquement dans les cellules alpha conduit à la fois au développement de glucagonomes et d’insulinomes par un mécanisme de transdifférenciation de cellules exprimant le glucagon en cellules exprimant l’insuline. Parallèlement, en explorant les modèles murins où le gène Men1 est invalidé respectivement dans les cellules alpha et beta Pancréatiques, j’ai pu identifier l’expression altérée de certains facteurs de transcription ayant des fonctions vitales dans ces cellules, notamment Foxa2 et MafB, dans les lésions précoces des cellules endocrines pancréatiques correspondantes. En conclusion, mon travail de thèse a permis de mieux clarifier la fonction biologique du gène Men1 dans les cellules pancréatiques endocrines et de mieux comprendre les mécanismes impliqués dans la survenue du syndrome MEN1 / Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant inherited syndrome caused by mutations of the MEN1 gene. The aim of my work is to investigate the biological and oncosuppressive roles of the Men1 gene in the pancreatic endocrine cells. The analyses carried out in a new mouse model showed that Men1 ablation in alpha cells trigged the development of both glucagonoma and insulinoma by the transdifferentiation from glucagon-producing cells to insulin-expressing cells. Furthermore, the data obtained from the characterization of both alpha- and beta-cell-specific Men1 mutant mice allowed to identify the altered expression of several important endocrine specific transcriptional factors, including Foxa2 and MafB, found in the early lesions of the corresponding pancreatic endocrine cells. Overall, my thesis work provides interesting clues for better understanding the mechanisms involved in the tumorigenesis of MEN1 syndrome

La Néoplasie Endocrinienne Multiple de type 1 (NEM1) est une maladie génétique qui associe hyperparathyroïdie primaire, tumeurs neuroendocrines digestives et adénomes hypophysaires. Elle est due à des mutations non récurrentes du gène MEN1, parfois difficile à classer. Nous avons rassemblé et analysé les données cliniques et génétiques de 1676 patients français porteurs d’une variation de MEN1 des 4 laboratoires experts du groupe TENGEN. De ce travail, nous avons alimenté une base de données de variants (UMD MEN1) et établir le profil mutationnel de MEN1 en France. Dans une seconde partie, nous avons établi des recommandations pour la classification des variants faux sens de MEN1 en adaptant les Guidelines de l’ACMG-AMP (American College of Medical Genetics).Le Syndrome de McCune-Albright (SMA) est du à des mutations postzygotiques activatrices récurrentes du gène GNAS, responsables d’un mosaïcisme somatique, souvent indétectables dans le sang. En utilisant une technique de PCR quantitative ultrasensible, le taux de détection des mutations R201C et R201H est de 50% dans le sang de 16 patients présentant 1 à 3 lésions majeures du SMA. Pour la 1ere fois, nous avons retrouvé ces mutations dans l’ADN circulant de 3/4 patients testés.Ces mutations sont retrouvées aussi dans 30 à 40% des adénomes somatotropes. Le locus GNAS est soumis à empreinte parentale, responsable d’une expression mono-allélique de GNAS dans certains tissus comme l’hypophyse. Dans une série de 57 adénomes somatotropes nous avons montré une perturbation de l’empreinte de GNAS, associée à une relâche de l’empreinte mais n’entraînait pas d’augmentation de l’expression du gène GNAS. / The Multiple Endocrine Neoplasia 1 (MEN1) is due to MEN1 mutations and characterized by a broad spectrum of lesions including hyperparathyroidism, pituitary adenomas and neuroendocrine tumors. Missense variants are frequent and could lead wrong interpretation. We collected and analyzed all the 370 variants of 1676 patients sequenced for ten years by the TENGEN network (French oncogenetics of neuroendocrine tumors). We registered them in the UMD MEN1 database. Then, consensus was reached to validate adjustments to the ACMG-AMP guidelines for MEN1 locus-specific interpretation of missense variants. The McCune-Albright syndrome (MAS) is a rare pediatric mosaic genetic disorder. MAS results from recurrent post-zygotic GNAS mutations, not detectable in blood DNA by Sanger. We develop an ultrasensitive quantitative PCR using digital droplet PCR™ (ddPCR™) in order to target the R201C and R201H GNAS mutations. After a validation study, we clinically evaluated ddPCR™ in the whole blood DNA or circulating cell-free DNA (ccfDNA) of patients presented with at least 1 MAS lesion. First we detected in ccfDNA the mosaic somatic GNAS mutant. The ddPCR™ showed a mutation detection rate of 50% in blood DNA of the 16 included patients and 3/4 in ccfDNA.GNAS mutations are also reported in 30 to 40% of somatotroph tumors. GNAS is encoded by an imprinted locus, responsible for a mono-allelic expression in pituitary. We explored the GNAS locus methylation status of 57 somatotroph adenomas and showed disturbance. We studied the impact on GNAS, SST2R and AIP expression of this disturbance. We showed an imprinting relaxation not associated with an increased expression of GNAS.

Les mutations du gène MEN1 prédisposent au syndrome des Néoplasies Endocriniennes Multiples de type 1 (NEM1), caractérisé par des tumeurs endocrines multiples. Les souris hétérozygotes pour Men1 développent des tumeurs similaires, ainsi que des cancers de la prostate et des glandes mammaires, avec une incidence faible. J'ai pu montrer que l'expression de la protéine menin, codée par ce gène, est totalement inactivée dans les carcinomes prostatiques développés chez ces souris et est associée à une dérégulation de l'expression du récepteur aux androgènes et une inactivation de l'inhibiteur des CDK p27, un gène cible connu de menin. Des souris WapCre-Men1 F/F, où le gène Men1 est invalidé dans les cellules mammaires, développent des néoplasies intraépithéliales mammaires (MIN) avec une forte incidence à partir de 9 mois. Une fuite d'expression du transgène WapCre dans l'hypophyse entraîne en plus le développement de prolactinomes chez ces souris, les conduisant à une mort prématurée. Par diverses analyses, j'ai pu déterminer que l'augmentation de l'incidence de ces lésions ne pouvait pas être seulement expliquée par l'influence des prolactinomes. De manière intéressante, j'ai pu mettre en évidence une nette diminution du marquage membranaire de beta-caténine, un partenaire connu de menin, ainsi que de E-cadhérine dans les lésions MIN, suggérant une altération de la cohésion cellulaire en absence de menin. L'ensemble des données obtenues pendant ma thèse indiquent un rôle potentiel de l'invalidation du gène Men1 dans le développement de carcinomes prostatiques et de néoplasies mammaires chez la souris

Doctor of Philosophy(PhD) / Hyperparathyroidism, a disease of the parathyroid glands, is one of the most common endocrinopathies, having a prevalence of 1 – 3 per 1000 individuals. It is characterised by calcium insensitive hypersecretion of parathyroid hormone, and increased cell proliferation. While the treatment for familial as well as many sporadic tumours associated with hyperparathyroidism includes parathyroidectomy, the extent of surgery and the follow-up monitoring regime, are dependent on accurate clinical and histopathological classification of the lesion. However, overlaps in histopathological and morphological features confound distinctions between the three main classifications of adenoma, hyperplasia and carcinoma and differential diagnosis of these lesions remains challenging. At the start of this candidature in January 2002, the genes associated with two familial syndromes in which hyperparathyroidism may feature, Multiple Endocrine Neoplasia (MEN) 1 and 2 had been identified, respectively MEN1 and RET. In addition, overexpression or translocation of cyclin D1 had been identified in both benign and malignant sporadic lesions, indicating a role for cyclin D1 in parathyroid tumorigenesis. However, the underlying events leading either directly, or indirectly, to the development of a large proportion of parathyroid lesions are still largely unknown. The work described in this thesis has contributed to the understanding of parathyroid lesions and the diagnosis and prognosis of affected individuals. During this candidature, constitutive mutation of HRPT2 was associated with Hyperparathyroidism–Jaw Tumour syndrome (HPT-JT). HRPT2 mutation analysis and loss of heterozygosity studies at 1q24-32 in parathyroid tumours presented in this thesis identified the strong association of HRPT2 mutation with sporadic parathyroid malignancy. In addition, 2-hits affecting HRPT2 were identified in several tumours suggestive of a role for HRPT2 as a tumour suppressor gene in sporadic parathyroid tumorigenesis. Microarray analysis of parathyroid tumours presented in this thesis identified three broad clusters of tumours. Cluster 1 comprised predominantly hyperplastic specimens and also included the normal tissue. Cluster 2, the most robust of the clusters, consisted of tumours harbouring HRPT2 mutations. The HPT-JT-associated tumours, both benign and malignant, and sporadic carcinomas, comprised this cluster. Cluster 3 contained the majority of the sporadic adenoma specimens, some hyperplasia, as well as all of the MEN 1-associated tumours. The cluster data is strongly suggestive that parathyroid tumours with somatic HRPT2 mutation, or tumours developing on a background of germline HRPT2 mutation, follow pathways distinct from those involved in mutant MEN 1-related parathyroid tumours. The results of this work provide strong evidence for an adenoma to carcinoma progression model for parathyroid tumorigenesis in the presence of a germline HRPT2 mutation. With the knowledge that both HRPT2 and MEN1 have significant roles in familial as well as sporadic parathyroid tumorigenesis, assays for mutation screening of these two genes have been developed as part of this thesis. These assays will facilitate a rapid molecular diagnosis for patients with one of these familial syndromes. Furthermore, novel putative biomarkers for different parathyroid tumour subtypes have also been identified. VCAM1 and UCHL1 (PGP9.5) were found to be significantly overexpressed in tumours harbouring an HRPT2 mutation at both the transcript and protein level. These two molecules are suggested as putative biomarkers for the discrimination of sporadic carcinoma or HPT-JT-associated tumours. RALDH2 transcript and protein were highly significantly overexpressed in the hyperplasia class relative to the adenoma class, and this molecule is suggested as a putative biomarker for discrimination of these classes of parathyroid tumours. These biomarkers may assist in the accurate diagnosis and prognosis of hyperparathyroidism. Large cohort studies of these putative biomarkers will be required to determine their robustness in discriminating parathyroid tumour subtypes. Further studies of their putative role in parathyroid tumorigenesis may identify them as novel molecular targets for future therapeutics to treat both hyperplastic and neoplastic parathyroid lesions.

Doctor of Philosophy(PhD) / Hyperparathyroidism, a disease of the parathyroid glands, is one of the most common endocrinopathies, having a prevalence of 1 – 3 per 1000 individuals. It is characterised by calcium insensitive hypersecretion of parathyroid hormone, and increased cell proliferation. While the treatment for familial as well as many sporadic tumours associated with hyperparathyroidism includes parathyroidectomy, the extent of surgery and the follow-up monitoring regime, are dependent on accurate clinical and histopathological classification of the lesion. However, overlaps in histopathological and morphological features confound distinctions between the three main classifications of adenoma, hyperplasia and carcinoma and differential diagnosis of these lesions remains challenging. At the start of this candidature in January 2002, the genes associated with two familial syndromes in which hyperparathyroidism may feature, Multiple Endocrine Neoplasia (MEN) 1 and 2 had been identified, respectively MEN1 and RET. In addition, overexpression or translocation of cyclin D1 had been identified in both benign and malignant sporadic lesions, indicating a role for cyclin D1 in parathyroid tumorigenesis. However, the underlying events leading either directly, or indirectly, to the development of a large proportion of parathyroid lesions are still largely unknown. The work described in this thesis has contributed to the understanding of parathyroid lesions and the diagnosis and prognosis of affected individuals. During this candidature, constitutive mutation of HRPT2 was associated with Hyperparathyroidism–Jaw Tumour syndrome (HPT-JT). HRPT2 mutation analysis and loss of heterozygosity studies at 1q24-32 in parathyroid tumours presented in this thesis identified the strong association of HRPT2 mutation with sporadic parathyroid malignancy. In addition, 2-hits affecting HRPT2 were identified in several tumours suggestive of a role for HRPT2 as a tumour suppressor gene in sporadic parathyroid tumorigenesis. Microarray analysis of parathyroid tumours presented in this thesis identified three broad clusters of tumours. Cluster 1 comprised predominantly hyperplastic specimens and also included the normal tissue. Cluster 2, the most robust of the clusters, consisted of tumours harbouring HRPT2 mutations. The HPT-JT-associated tumours, both benign and malignant, and sporadic carcinomas, comprised this cluster. Cluster 3 contained the majority of the sporadic adenoma specimens, some hyperplasia, as well as all of the MEN 1-associated tumours. The cluster data is strongly suggestive that parathyroid tumours with somatic HRPT2 mutation, or tumours developing on a background of germline HRPT2 mutation, follow pathways distinct from those involved in mutant MEN 1-related parathyroid tumours. The results of this work provide strong evidence for an adenoma to carcinoma progression model for parathyroid tumorigenesis in the presence of a germline HRPT2 mutation. With the knowledge that both HRPT2 and MEN1 have significant roles in familial as well as sporadic parathyroid tumorigenesis, assays for mutation screening of these two genes have been developed as part of this thesis. These assays will facilitate a rapid molecular diagnosis for patients with one of these familial syndromes. Furthermore, novel putative biomarkers for different parathyroid tumour subtypes have also been identified. VCAM1 and UCHL1 (PGP9.5) were found to be significantly overexpressed in tumours harbouring an HRPT2 mutation at both the transcript and protein level. These two molecules are suggested as putative biomarkers for the discrimination of sporadic carcinoma or HPT-JT-associated tumours. RALDH2 transcript and protein were highly significantly overexpressed in the hyperplasia class relative to the adenoma class, and this molecule is suggested as a putative biomarker for discrimination of these classes of parathyroid tumours. These biomarkers may assist in the accurate diagnosis and prognosis of hyperparathyroidism. Large cohort studies of these putative biomarkers will be required to determine their robustness in discriminating parathyroid tumour subtypes. Further studies of their putative role in parathyroid tumorigenesis may identify them as novel molecular targets for future therapeutics to treat both hyperplastic and neoplastic parathyroid lesions.

<p>Understanding signalling pathways that control pancreatic endocrine tumour (PET) development and proliferation may reveal novel targets for therapeutic intervention. The pathogenesis for sporadic and hereditary PETs, apart from mutations of the <i>MEN1</i> and <i>VHL</i> tumour suppressor genes, is still elusive. The protein product of the <i>MEN1</i> gene, menin, regulates many genes. The aim of this thesis was to identify genes involved in pancreatic endocrine tumourigenesis, with special reference to Notch signalling.</p><p>Messenger RNA and protein expression of NOTCH1, HES1, HEY1, ASCL1, NEUROG3, NEUROD1, DLK1, POU3F4, PDX1, RPL10, DKK1 and TPH1 were studied in human PETs, sporadic and MEN 1, as well as in tumours from heterozygous <i>Men1</i> mice. For comparison, normal and <i>MEN1</i> non-tumourous human and mouse pancreatic specimens were used. Nuclear expression of HES1 was consistently absent in PETs. In mouse tumours this coincided with loss of menin expression, and there was a correlation between <i>Men1</i> expression and several Notch signalling factors. A new phenotype consisting of numerous menin-expressing endocrine cell clusters, smaller than islets, was found in <i>Men1</i> mice. Expression of NEUROG3 and NEUROD1 was predominantly localised to the cytoplasm in PETs and islets from MEN 1 patients and <i>Men1</i> mice, whereas expression was solely nuclear in wt mice. Differences in expression levels of Pou3f4, Rpl10 and Dlk1 between islets of <i>Men1</i> and wt mice were observed.</p><p>In addition, combined RNA interference and microarray expression analysis in the pancreatic endocrine cell line BON1 identified 158 target genes of ASCL1. For two of these, DKK1 (a negative regulator of the WNT/β-catenin signalling pathway) and TPH1, immunohistochemistry was performed on PETs. In concordance with the microarray finding, DKK1 expression showed an inverse relation to ASCL1 expression.</p><p>Altered subcellular localisation of HES1, NEUROD1 and NEUROG3 and down-regulation of DKK1 may contribute to tumourigenesis.</p>

<p>Pancreatic endocrine tumors (PETs) may cause typical syndromes of hormone excess, or appear clinically non-functioning without hormonal symptoms. PETs occur sporadically, in association with the multiple endocrine neoplasia type 1 (MEN1) syndrome, or rarely the von Hippel-Lindau syndrome. Molecular genetic investigations may reveal pathways important for tumor development, and be of clinical use.</p><p>The aim of this thesis was to investigate regulation of different genes involved in cell proliferation, and relate findings to signs of malignancy in PETs.</p><p>The MEN1 gene on chromosome 11q13 was mutated in three out of eleven sporadic malignant PETs. Two nonsense mutations, causing truncation of the protein, and one missense mutation were found.</p><p>Relation of allelic loss at 11q13 and 3p25 to malignant behavior was observed in sporadic PETs. Allelic loss at 18q21 was found in a subset of sporadic and MEN1-associated PETs, and mutation analysis of Smad4 excluded a tumor suppressor gene function.</p><p>In PETs with allelic loss on chromosome 3p25, mutation analysis of WNT7A and HDAC11 excluded function as tumor suppressor genes.</p><p>Menin, encoded by the MEN1 gene, was reported to regulate expression of the cyclin-dependent kinase inhibitors CDKN2C/p18, CDKN1B/p27, and CDKN2B/p15 in mouse pancreatic islet tumor models. Here, the mRNA expression of these genes was not related to MEN1 gene mutations in human PETs.</p><p>Cyclin-dependent kinase 4 (CDK4) and the protooncogene c-Myc were found to be overexpressed regardless of MEN1 gene mutational status of the PETs. The CDK4 gene was neither amplified nor mutated. Targeting of CDK4 may present an alternative to traditional chemotherapy of PETs in the future.</p>