Phäochromozytome und Paragangliome (PPGL) sind seltene, katecholaminproduzierendeTumore des chromaffinen Gewebes. Die Erkrankung ist durch die Überproduktion von Katecholaminen gekennzeichnet und kann lebensbedrohliche Folgen haben. Die dieser Arbeit zugrunde liegende Studie untersuchte die interindividuellen Unterschiede im Metabolitenprofil bei Patient*innen mit PPGL im Vergleich zu Kontrollen mittels Flüssigchromatographie-Massenspektrometrie und einem Targeted Metabolomic Ansatz. Targeted Metabolomics beschreibt die Messung und Quantifizierung von im Voraus definierten Metaboliten in einer Probe. Von den 188 gemessenen Metaboliten zeigten vier Metabolite eine signifikanten Veränderung zwischen den Gruppen (Histidin, Threonin, LysoPC a C28:0 und Summe der Hexosen). Für alle vier Metabolite wurde ein Zusammenhang mit Katecholaminen im Urin beziehungsweise Metanephrinen im Plasma nachgewiesen. Subgruppenanalysen zeigten weitere Hinweise auf geschlechts- und phänotypspezifische Unterschiede im Metabolitenprofil zwischen Patient*innen mit PPGL und Kontrollen. / Pheochromocytomas and paragangliomas (PPGL) are rare, catecholamine-producing tumors arising from chromaffin cells. The disease is characterized by the overproduction of catecholamines and can have life-threatening consequences. The study on which this work is based investigated the interindividual differences in metabolite profiles in patients with PPGL compared to controls using liquid chromatography-mass spectrometry and a targeted metabolomics approach. Targeted metabolomics describes the measurement and quantification of predefined metabolites. Of the 188 metabolites measured, four metabolites showed a significant change between groups (histidine, threonine, LysoPC a C28:0 and sum of hexoses). A significant correlation with urinary catecholamines and/ or plasma metanephrines was identified for this metabolites. Subgroup analyses showed further evidence of sex- and phenotype-specific differences in metabolite profiles between patients with PPGL and controls.

This work summarizes the results of a research inquiring into relatively rare neuroendocrine tumors - pheochromocytomas and paragangliomas (PHEO/PGL) These tumors may arise on a hereditary genetic predisposition basis. On that account we primarily focused on a genetic examination of patients with PHEO/PGL. Methods for diagnostics of changes in SDHD, SDHB and RET genes were implemented. The number of examined genes has been (and is still being) extended. Currently we are investigating these genes: ATRX, BRAF, CDH1, CDKN2A, CDKN2B, FGFR1, FH, FHIT, GNAS, HIF2A (EPAS1), H-RAS, IDH1, IDH2, KIF1Bß, KMT2D, K-RAS, MAML3, MAX, MDH2, MET, NF1, NGFR, N-RAS, PHD2/EGLN1, RET, SDHA, SDHAF2, SDHB, SDHC, SDHD, TERT, TMEM 127, TP53 and VHL, using next generation sequencing. The number of variations of the above mentioned genes is different (23%) in Czech patients with PHEO/PGL in comparison with some foreign studies (27%, 40%). This may be caused by geographical influences or selection of patients. PHEO/PGL occur mainly (75%) in a benign form. A malignant form may be indicated by the presence of chromaffin tissue in locations where these tumors do not usually occur - liver, lungs, bones. In our study we focused on characteristics indicating the malignancy, for example, the lower age of patients with the first manifestation...

1. Abstract Pheochromocytoma/ paraganglioma (FEO/PGL) may be developed on the basis of an inherited genetic mutation of different genes. They are associated with a high risk of developing of secondary hypertension, organ damage and metastatic disease that can be fatal. The aim was to focus on the possibility of genetic testing in patients with FEO/PGL, especially in patients with malignant tumors. The issue FEO/PGL, however, concerns not only the examination and assessment of risks arising therefrom, as well as other therapies and monitoring, including appropriate recommendations for clinical practice. We demonstrated a 20% incidence of cardiovascular (CV) complications before determining the final diagnosis of FEO/PGL, mainly arrhythmic, followed by complications of myocardial ischemia and accentuate atherosclerosis. Elevated levels of vitamin C and decreased levels of malondialdehyde (MDA) following the successful removal of the tumor demonstrated reduction of oxidative stress postoperatively. We found that early postoperative testing of levels of plasma metanephrines to confirm the success of surgical removal of FEO/PGL is already possible, since there was no significant correlation between plasma levels of metanephrines and postoperative examination interval. Distribution of frequency of metastatic...

1. Abstract Pheochromocytoma/ paraganglioma (FEO/PGL) may be developed on the basis of an inherited genetic mutation of different genes. They are associated with a high risk of developing of secondary hypertension, organ damage and metastatic disease that can be fatal. The aim was to focus on the possibility of genetic testing in patients with FEO/PGL, especially in patients with malignant tumors. The issue FEO/PGL, however, concerns not only the examination and assessment of risks arising therefrom, as well as other therapies and monitoring, including appropriate recommendations for clinical practice. We demonstrated a 20% incidence of cardiovascular (CV) complications before determining the final diagnosis of FEO/PGL, mainly arrhythmic, followed by complications of myocardial ischemia and accentuate atherosclerosis. Elevated levels of vitamin C and decreased levels of malondialdehyde (MDA) following the successful removal of the tumor demonstrated reduction of oxidative stress postoperatively. We found that early postoperative testing of levels of plasma metanephrines to confirm the success of surgical removal of FEO/PGL is already possible, since there was no significant correlation between plasma levels of metanephrines and postoperative examination interval. Distribution of frequency of metastatic...

Phäochromozytome und Paragangliome (PPGL) sind seltene neuroendokrine Tumore, die von Chromaffinzellen im Nebennierenmark (Phäochromozytome, PCC) oder vom extra-adrenalen Paraganglion (Paragangliome, PGL) ausgehen. Patienten mit PPGL zeigen in der Regel Anzeichen und Symptome, die mit der Biosynthese, Speicherung und Sekretion von Katecholaminen (Dopamin, Noradrenalin, Adrenalin) zusammenhängen. Der Katecholamin-Stoffwechsel bei PPGLs wird durch den genetischen Hintergrund bestimmt. Tumoren, die auf pathogene Varianten (PVs) in Genen zurückzuführen sind, die zur Aktivierung von Hypoxie-Signalwegen führen, sind nicht in der Lage, Epinephrin zu synthetisieren, während solche, die auf PVs in Genen zurückzuführen sind, die Kinase-Signalwege aktivieren, zur Epinephrin-Synthese befähigt sind. Dieser genetisch-biochemisch-klinische Phänotyp wurde in der klinischen Forschung nachgewiesen. Der Mechanismus, der der Regulierung der Katecholamin-Biosynthese durch Tumoren aufgrund von PVs in Kinase-Signalisierungsgenen zugrunde liegt, ist jedoch nicht klar. Ziel dieser Arbeit war es, den Mechanismus der Katecholamin-Biosynthese in PPGLs aufgrund von PVs in HRAS, einem mit Kinase-Signalwegen assoziierten Gen, zu untersuchen. Darüber hinaus wurden klinische Merkmale wie Katecholamin-assoziierte Anzeichen und Symptome, die prächirurgische Diagnose und die Entwicklung einer wiederkehrenden Erkrankung bei Patienten mit PPGL untersucht. Um den Katecholamin-Stoffwechsel bei PPGL zu untersuchen, wurden Katecholamine und PNMT-Enzymaktivitäten in 251 PPGL-Geweben gemessen. Anschließend wurden zwei Hotspot-Varianten von Hras, G13R und Q61R, durch CRISPR/Cas9-basiertes Prime Editing in eine Phäochromozytom-Zelllinie (PC12) der Ratte eingeführt. Katecholamine und nachgeschaltete HRAS-Faktoren, die die Epinephrin-Biosynthese regulieren, wurden in den Zellen mit/ohne Hras-PVs gemessen. Wir fanden heraus, dass PPGLs, die auf HRAS-PVs zurückzuführen sind, einen signifikant höheren Epinephrin-Gehalt und PNMT-Enzymaktivitäten aufweisen als solche, die auf PVs in Genen zurückzuführen sind, die mit Hypoxie-Signalwegen in Verbindung stehen. In Zelllinienversuchen steigerten PVs in Hras die Pnmt-Expression zusammen mit einer erhöhten Epinephrin-Synthese. Weitere Experimente zeigten, dass Hras-PVs die Pnmt-Expression durch Phosphorylierung von SP1 über den MAPK-Signalweg hochregulieren. Darüber hinaus verringerten Hras-PVs die Glukokortikoidrezeptorspiegel, wodurch die Empfindlichkeit gegenüber der gGukokortikoid-induzierten Expression von Pnmt reduziert wurde. Drei separate klinische Projekte wurden durchgeführt, um die mit Katecholaminen verbundenen klinischen Merkmale zu verstehen. Das erste Projekt untersuchte die Unterschiede in der klinischen Behandlung und die perioperativen Komplikationen bei Patienten mit Harnblasen-Paragangliom (UBPGL), die vor der Operation diagnostiziert oder fehldiagnostiziert wurden. In diesem Projekt wurde mehr als die Hälfte (53,6 %) der Patienten mit UBPGL vor der Operation nicht diagnostiziert. Wie erwartet wurden Patienten, die vor der Operation fehldiagnostiziert wurden, kaum mit einer alpha-adrenergen Blockade behandelt, und mehr dieser Patienten erlitten während der Operation eine Bluthochdruckkrise und perioperative Komplikationen als Patienten, die vor der Operation richtig diagnostiziert wurden. Eine weitere Analyse ergab, dass bei 34,5 % der Patienten mit Katecholamin-assoziierten Symptomen und/oder Bluthochdruck vor der Operation keine UBPGL diagnostiziert wurde. Darüber hinaus wurde Bluthochdruck als unabhängiger Faktor identifiziert, der mit der präoperativen Diagnose von UBPGL assoziiert ist. Das zweite Projekt untersuchte die Unterschiede im Auftreten von Katecholamin-assoziierten Zeichen und Symptomen bei Patienten mit und ohne metastasiertem PPGL (mPPGL). Wir konnten zeigen, dass das Auftreten von Katecholamin-assoziierten Anzeichen und Symptomen bei Patienten mit mPPGL mit der Produktion von Noradrenalin verbunden war, während es bei Patienten ohne mPPGL mit Epinephrin zusammenhing. Allerdings unterschieden sich die Anzeichen und Symptome bei Patienten mit metastasiertem PPGL nicht signifikant von denen mit nicht-metastasiertem PPGL. Das dritte Projekt untersuchte das Wiederauftreten der Krankheit bei Patienten mit sporadischem PPGL. Wir konnten zeigen, dass ein noradrenerger/dopaminerger Phänotyp des Primärtumors bei Patienten mit sporadischem PPGL ein unabhängiger Prädiktor für ein Wiederauftreten der Erkrankung ist. Darüber hinaus zeigten wir, dass bei 14,7 % dieser Patienten ein Rezidiv auftrat, bei einigen sogar noch 10 oder 15 Jahre nach der Resektion des Primärtumors. Diese Arbeit zeigte anhand von klinischen Tumorgewebedaten und in vitro gentechnisch hergestellten Zellmodellen, dass die Epinephrinbiosynthese bei PPGL vorwiegend durch den genetischen Hintergrund aufgrund von PVs in HRAS reguliert wird. Klinische Studien haben gezeigt, dass das Auftreten von Anzeichen und Symptomen, die prächirurgische Diagnose und das Wiederauftreten der Erkrankung mit dem Katecholaminstoffwechsel bei Patienten mit PPGL in Zusammenhang stehen. Daher muss der Katecholaminstoffwechsel bei der klinischen Behandlung von Patienten mit PPGL unbedingt berücksichtigt werden.:Content III Abbreviations: V List of figures and tables VII Zusammenfassung 1 Summary 3 1 Introduction and outline of the thesis 5 1.1 Pheochromocytomas and paragangliomas 5 1.2 Catecholamine metabolism in PPGLs 5 1.3 Pathogenic variants in the susceptibility genes of PPGLs 7 1.4 The association between genetic pathogenic variants and catecholamine metabolism in PPGLs 8 1.5 Catecholamine-associated clinical manifestations in patients with PPGLs 12 1.6 Catecholamine metabolite testing and diagnosis of PPGLs 12 1.7 Clinical treatment of patients with PPGLs 13 1.8 Follow-up for patients with PPGL 14 1.9 Outline of the thesis 15 2 Methods and results 17 2.1 Part 1: Regulation of epinephrine biosynthesis in HRAS-mutant paragangliomas 18 2.2 Part 2: Association of catecholamine metabolism and clinical management of patients with PPGL 67 2.2.1 Publication 1: 67 Differences in clinical presentation and management between pre- and postsurgical diagnoses of urinary bladder paraganglioma: is there clinical relevance? a systematic review 67 2.2.2 Publication 2: 74 Metastatic Pheochromocytoma and Paraganglioma: Signs and Symptoms Related to Catecholamine Secretion 74 2.2.3 Publication 3: 86 Recurrent disease in patients with sporadic pheochromocytoma and paraganglioma 86 3 General discussion 95 4 Conclusion 99 5 References 100 6 Acknowledgements 108 7 List of journal articles and invited presentations 109 8 Appendix 111 / Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors derived from chromaffin cells within the adrenal medulla (pheochromocytomas, PCCs) or extra-adrenal paraganglia (paragangliomas, PGLs). Patients with PPGL normally present signs and symptoms that are associated with catecholamine (dopamine, norepinephrine, epinephrine) biosynthesis, storage, and secretion. Catecholamine metabolism in PPGLs is influenced by the genetic background. Tumors resulting from pathogenic variants (PVs) in genes that lead to activation of hypoxia signaling pathways are unable to synthesize epinephrine, whereas those resulting from PVs in genes that activate kinase signaling are capable of epinephrine synthesis. This genetic-biochemical-clinical phenotype has been revealed in clinical research. However, the mechanism behind the regulation of catecholamine biosynthesis in tumors due to PVs in kinase signaling genes remains unclear. Thus, this thesis aimed to investigate the mechanism of catecholamine biosynthesis in PPGLs due to PVs in HRAS, a gene associated with kinase signaling pathways. In addition, clinical features such as catecholamine-associated signs and symptoms, a presurgical diagnosis, and the development of recurrent disease in patients with PPGL were studied. To investigate the catecholamine metabolism in PPGLs, catecholamines and PNMT enzyme activities of 251 PPGL tissues were measured. Subsequently, two hotspot variants of Hras, G13R and Q61R, were introduced into a rat pheochromocytoma cell line (PC12) using CRISPR/Cas9-based prime editing. The levels of catecholamines and downstream factors of HRAS that regulate epinephrine biosynthesis were measured in the cells with/without Hras PVs. We found that PPGLs resulting from HRAS PVs had significantly higher epinephrine content and PNMT enzyme activities compared to those resulting from PVs in genes associated with hypoxia signaling pathways. Furthermore, in our cell line experiments, PVs in Hras increased Pnmt expression, along with increased epinephrine synthesis. Moreover, further experiments indicated that Hras PVs upregulated Pnmt expression through phosphorylation of SP1 via the MAPK pathway. In addition, Hras PVs decreased glucocorticoid receptor levels, thereby reducing sensitivity to glucocorticoid-induced expression of Pnmt. Three separate clinical projects were performed to better understand the clinical features associated with catecholamines. The first project investigated the differences in clinical management and per-operative complications between patients with urinary bladder paraganglioma (UBPGLs) who were correctly diagnosed and those who were misdiagnosed before surgery. In this project, more than half (53.6%) of the patients with UBPGL were not diagnosed before surgery. As expected, patients who were misdiagnosed before surgery received limited treatment with alpha-adrenergic blockade, resulting in a higher incidence of hypertension crisis during surgery and perioperative complications compared to patients diagnosed before surgery. Further analysis indicated that 34.5% of these patients presenting with catecholamine-associated symptoms and/or hypertension were not diagnosed with UBPGL before surgery. In addition, we identified hypertension as an independent factor associated with pre-surgical diagnosis of UBPGLs. The second project analyzed differences in the presentation of catecholamine-associated signs and symptoms in patients with and without metastatic PPGL (mPPGL). We showed that the presentation of catecholamine-associated signs and symptoms was associated with the production of norepinephrine in patients with mPPGL, whereas in non-mPPGL patients, it was associated with epinephrine. However, the signs and symptoms in patients with metastatic PPGLs did not significantly differ from those in patients with non-metastatic PPGL. The third project analyzed recurrent disease in patients with sporadic PPGL. We showed that a noradrenergic/dopaminergic phenotype of primary tumors was an independent predictor of recurrent disease among patients with sporadic PPGL. In addition, we showed that 14.7% of these patients experienced recurrent disease, with some cases occurring even 10 or 15 years after the resection of their primary tumors. This thesis, through the use of clinical tumor tissue data and in vitro genetically engineered cell models, indicated that epinephrine biosynthesis was predominantly regulated by the genetic background in PPGLs with PVs in HRAS. Additionally, clinical studies showed that the presentation of signs and symptoms, a pre-surgical diagnosis, and the presence of recurrent disease were associated with catecholamine metabolism in patients with PPGL. It is therefore imperative to consider catecholamine metabolism in the clinical management of patients with PPGL.:Content III Abbreviations: V List of figures and tables VII Zusammenfassung 1 Summary 3 1 Introduction and outline of the thesis 5 1.1 Pheochromocytomas and paragangliomas 5 1.2 Catecholamine metabolism in PPGLs 5 1.3 Pathogenic variants in the susceptibility genes of PPGLs 7 1.4 The association between genetic pathogenic variants and catecholamine metabolism in PPGLs 8 1.5 Catecholamine-associated clinical manifestations in patients with PPGLs 12 1.6 Catecholamine metabolite testing and diagnosis of PPGLs 12 1.7 Clinical treatment of patients with PPGLs 13 1.8 Follow-up for patients with PPGL 14 1.9 Outline of the thesis 15 2 Methods and results 17 2.1 Part 1: Regulation of epinephrine biosynthesis in HRAS-mutant paragangliomas 18 2.2 Part 2: Association of catecholamine metabolism and clinical management of patients with PPGL 67 2.2.1 Publication 1: 67 Differences in clinical presentation and management between pre- and postsurgical diagnoses of urinary bladder paraganglioma: is there clinical relevance? a systematic review 67 2.2.2 Publication 2: 74 Metastatic Pheochromocytoma and Paraganglioma: Signs and Symptoms Related to Catecholamine Secretion 74 2.2.3 Publication 3: 86 Recurrent disease in patients with sporadic pheochromocytoma and paraganglioma 86 3 General discussion 95 4 Conclusion 99 5 References 100 6 Acknowledgements 108 7 List of journal articles and invited presentations 109 8 Appendix 111

Pheochromocytoma and functional paraganglioma (PPGL) are rare neuroendocrine tumors characterized by catecholamines overproduction, which give a rise to disorders of glucose, lipid, and energy metabolism. The role of adipose tissue in these processes remains unclear. Our aim was to determine the gene expression profile in subcutaneous and visceral adipose tissue of patients with PPGL focusing on endocrine functions of adipose tissue, occurrence of brown (BAT) and beige adipose tissue (BeAT), all in connection with other measured metabolic and energy parameters and levels of circulating adipokines. We demonstrate signs of UCP1-dependent norepinephrine induced thermogenesis connected with overexpression of DIO2 in retroperitoneal VAT of PPGL and higher expression of key transcriptional factors of brown/beige adipogenesis, namely PPARGC1α, CEBPB and PRDM16. However, classic murine BAT or BeAT gene signature in VAT of PPGL was not detected. In subcutaneous adipose tissue (SAT) of PPGL we found signs of possible BeAT transformation, however without simultaneously undergoing UCP1-dependent thermogenesis. We also demonstrate that patients with PPGL have higher serum levels of FGF21 compared to healthy controls and these levels do not differ from obese patients. Furthermore, successful tumor removal...

Background: Medication-related interferences with measurements of catecholamines and their metabolites represent important causes of false-positive results during diagnosis of phaeochromocytomas and paragangliomas (PPGLs). Such interferences are less troublesome with measurements by liquid chromatography with tandem mass-spectrometry (LC-MS/MS) than by other methods, but can still present problems for some drugs. Levodopa, the precursor for dopamine used in the treatment of Parkinson’s disease, represents one potentially interfering medication. Methods: Plasma and urine samples, obtained from 20 Parkinsonian patients receiving levodopa, were analysed for concentrations of catecholamines and their O-methylated metabolites by LC-MS/MS. Results were compared with those from a group of 120 age-matched subjects and 18 patients with PPGLs. Results: Plasma and urinary free and deconjugated (freeþconjugated) methoxytyramine, as well as urinary dopamine, showed 22- to 148-fold higher (P<0.0001) concentrations in patients receiving levodopa than in the reference group. In contrast, plasma normetanephrine, urinary noradrenaline and urinary free and deconjugated normetanephrine concentrations were unaffected. Plasma free metanephrine, urinary adrenaline and urinary free and deconjugated metanephrine all showed higher (P<0.05) concentrations in Parkinsonian patients than the reference group, but this was only a problem for adrenaline. Similar to normetanephrine, plasma and urinary metanephrine remained below the 97.5 percentiles of the reference group in almost all Parkinsonian patients. Conclusions: These data establish that although levodopa treatment confounds identification of PPGLs that produce dopamine, the therapy is not a problem for use of LC-MS/MS measurements of plasma and urinary normetanephrine and metanephrine to diagnose more commonly encountered PPGLs that produce noradrenaline or adrenaline.