Hereditary Multiple Exostoses
[Diaphyseal Aclasis,
Multiple Cartilaginous Exostoses,
Multiple Osteocartilaginous Exostoses,
Multiple Osteochondromatosis,
Osteochondromatosis.
Includes: Multiple Exostoses, Type I; Multiple Exostoses, Type II]
Authors: Initial Posting: 3 August 2000
Last Update: 20 September 2005
Gregory A Schmale, MD ; Howard A Chansky, MD ; Wendy H Raskind, MD, PhD
Summary
Disease characteristics.
Hereditary multiple exostoses (HME) is characterized by growths of multiple exostoses, benign cartilage-capped bone tumors that grow outward from the metaphyses of long bones. Exostoses can be associated with a reduction in skeletal growth, bony deformity, restricted motion of joints, shortened stature, premature osteoarthrosis, and compression of peripheral nerves. The median age of diagnosis is three years; nearly all
affected individuals are diagnosed by twelve years of age. The risk for malignant degeneration to osteochondrosarcoma increases with age, although the lifetime risk of malignant degeneration is low (~1%).
Diagnosis/testing.
The diagnosis of HME is based on clinical and/or radiographic findings of multiple exostoses in one or more members of a family.
Sequence analysis of the EXT1 and EXT2
genes is available on a clinical basis.
Management.Surgery is performed to address angular deformities; pain caused by irritation of skin, tendons, or nerves; and leg-length inequalities. Painful lesions in the absence of bone deformity are treated with surgical excision that includes the cartilage cap and overlying perichondrium to prevent recurrence; excision of exostoses may slow growth disturbance and improve cosmesis. Surgery for forearm deformity involves excision of the exostoses, corrective osteotomies, and ulnar-lengthening procedures; leg-length inequalities greater than one inch are treated with epiphyseodesis (growth plate arrest) of the longer leg or lengthening of the involved leg. Early treatment of ankle deformity may prevent or decrease later deterioration of function. Sarcomatous degeneration is treated by surgical resection.
Genetic counseling.
Hereditary multiple exostoses is inherited in an
autosomal dominant manner.
Penetrance is 95%. Ten percent of
affected individuals have hereditary multiple exostoses as the result of a de novo
gene mutation. Offspring of an
affected individual have a 50% risk of inheriting the altered
gene for hereditary multiple exostoses.
Prenatal testing is available.
Diagnosis
Clinical Diagnosis
The clinical diagnosis of hereditary multiple exostoses is established in individuals with the following:
Multiple exostoses (cartilage-capped bony growths) arising from the area of the growth plate in the juxtaphyseal region of long bones or from the surface of flat bones such as the scapula. The key radiographic and anatomic feature of an exostosis is the uninterrupted flow of cortex and medullary bone from the host bone into the exostosis. Exostoses possess the equivalent of a growth plate that ossifies and closes with the onset of skeletal maturity
Note: Approximately 70% of
affected individuals have a clinically apparent exostosis about the knee, suggesting that radiographs of the knees to detect non-palpable exotoses may be a sensitive way to detect mildly
affected individuals.
Family history consistent with
autosomal dominant inheritance
Molecular Genetic Testing
GeneReviews designates a molecular genetic test as clinically available only if the test is listed in the GeneTests Laboratory Directory by at least one US CLIA-certified laboratory or a clinical laboratory outside the US.
GeneTests does not independently verify information provided by laboratories and does not warrant any aspect of a laboratory's work; listing in GeneTests does not imply that laboratories are in compliance with accreditation, licensure, or patent laws. Clinicians must communicate directly with the laboratories to verify information. —ED.
Genes. Two
genes are known to be associated with hereditary multiple exostoses (HME):
· EXT1. Approximately 56-78% of HME.
· EXT2. Approximately 21-44% of HME.
Note: Some question remains about the relative proportion of disease related to
mutations in these two
genes.
(1) Because EXT1 was identified first, more publications describe
mutation screening for EXT1 than for EXT2.
(2) Although EXT1-related HME was reported to be less frequent in ethnic Chinese (30%) [
Xu et al 1999], confirmation of this observation is required because a
mutation was identified in fewer than half of the individuals studied.
(3) In most studies, EXT1
mutations are more frequently found than EXT2
mutations [
Dobson-Stone et al 2000 ,
Francannet et al 2001 ,
Wuyts et al 2002 ,
Porter et al 2004 ,
White et al 2004]. EXT1 accounted for 66-78% of the
mutations identified in 151
affected individuals in two clinical settings [Wuyts 2005, personal communication; Bale 2005, personal communication].
Other
locus. One group has suggested that a third
gene, EXT3, maps to
chromosome 19 [
Le Merrer et al 1994]; this
linkage association has not been corroborated.
Molecular genetic testing: Clinical uses
Confirmatory
diagnostic testingPrenatal diagnosisMolecular genetic testing: Clinical methods
·
Sequence analysis. Sequence analysis of the entire
coding regions of both EXT1 and EXT2 detects
mutations in 70-78% of
affected individuals [
Philippe et al 1997 ;
Raskind et al 1998 ;
Wuyts et al 1998 ;
Porter et al 2004 ;
White et al 2004 ; Wuyts 2005, personal communication; Bale 2005, personal communication].
· MLPA. Incorporating methods such as MLPA to detect
deletions involving complete
exons may increase the detection rate to as much as 85-90% [
White et al 2004].
Table 1 summarizes
molecular genetic testing for this disorder.
Table 1.
Molecular Genetic Testing Used in Hereditary Multiple Exostoses
Test MethodMutations Detected
Mutation Detection Rate
Test Availability
Sequence analysisEXT1
mutations85-90%% 1
Clinical
MLPA
EXT1
deletionsSequence analysisEXT2
sequence alterationsClinical
MLPA
EXT2
deletions1.
White et al 2004Interpretation of test results. For issues to consider in interpretation of sequence analysis results, click
here.
Testing Strategy for a Proband
Based on the overall experience that EXT1
mutations are more frequent than EXT2
mutations, a cost-effective testing strategy would be to sequence EXT1 first. If no
mutation is identified in EXT1, EXT2 should be sequenced.
Genetically Related Disorders
No other
phenotypes are associated with
mutations in EXT1 or EXT2.
Clinical DescriptionNatural History
The number of exostoses, number and location of involved bones, and degree of deformity vary. Exostoses grow in size and gradually ossify during skeletal development and stop growing with skeletal maturity [
Jaffe 1968], after which no new exostoses develop.
The proportion of individuals with hereditary multiple exostoses who have clinical findings increases from about 5% at birth to 96% at age 12 years [
Schmale et al 1994 ,
Legeai-Mallet et al 1997]. The median age at diagnosis is three years. By adulthood, 75% of
affected individuals have a clinically evident bony deformity. Males tend to be more severely
affected than females.
The number of exostoses that develop in an
affected person varies widely even within families. Involvement is usually symmetric. Most commonly involved bones are the humerus (50%), forearm (50%), the bones about the knee (70%) and ankle (25%) [
Schmale et al 1994], and the scapula (50%).
Hand deformity resulting from shortened metacarpals is common. Abnormal bone remodeling may result in shortening and bowing with widened metaphyses [
Sauer & Becker 1979 ,
Shapiro et al 1979 ,
Porter et al 2004].
In a study of 46
kindreds in Washington state, 39% of individuals had a deformity of the forearm, 10% had an inequality in limb length, 8% had an angular deformity of the knee, and 2% had a deformity of the ankle [
Schmale et al 1994]. Angular deformities (bowing) of the forearm and/or ankle are the most clinically significant orthopedic issues. Hip dysplasia in individuals with HME and exostoses of the proximal femur have been reported [
Malagon 2001 ,
Ofiram & Porat 2004].
It has been stated that 40% of individuals with hereditary multiple exostoses have "short stature" [
Lichenstein 1973]. Although interference with the linear growth of the long bones of the leg often results in reduction of predicted adult height, the height of most adults with EXT2
mutations and many with EXT1
mutations falls within the normal range [
Porter et al 2004]. Shortened stature is more pronounced in persons with EXT1
mutations [
Porter et al 2004].
Note: "Shortened stature" is used to indicate that although stature is often shorter than predicted based on the heights of
unaffected parents and sibs, it is usually still within the normal range.
Exostoses typically arise in the juxtaphyseal region of long bones and from the surface of flat bones (pelvis, scapula). An exostosis may be sessile or pedunculated. Sessile exostoses have a broad-based attachment to the cortex. The pedunculated variants have a pedicle arising from the cortex that is usually directed away from the adjacent growth plate. The pedunculated form is more likely to irritate overlying soft tissue, such as tendons, and compress peripheral nerves or vessels. The marrow and cancellous bone of the host bone and the exostosis are continuous.
Symptoms may also arise secondary to mass effect. Compression or stretching of peripheral nerves usually causes pain but may also cause sensory or motor deficits. Mechanical blocks to motion may result from large exostoses impinging on the adjacent bone of a joint. Overlying muscles and tendons may be irritated, resulting in pain and loss of motion. Nerves and vessels may be displaced from their normal anatomic course, complicating attempts at surgical removal of exostoses. Rarely, urinary or intestinal obstruction results from large pelvic exostoses.
The most serious complication of hereditary multiple exostoses is sarcomatous degeneration of an exostosis. Rapid growth and increasing pain, especially in a physically mature person, are signs of sarcomatous transformation [
Lange et al 1984], a potentially life-threatening condition. A bulky cartilage cap (best visualized with magnetic resonance imaging or computed tomography) thicker than two to three centimeters is highly suggestive of chondrosarcoma [
Hudson et al 1984]. After skeletal maturity, increased radionucleotide uptake on serial technetium bone scans may also be evidence of malignancy [
Lange et al 1984 ,
Bouvier et al 1986].
The reported incidence of malignant degeneration to chondrosarcoma, or less commonly to other sarcomas, has ranged from 0.5% to 20%, with more recent reports strongly favoring the lower estimates [
Voutsinas & Wynne-Davies 1983 ,
Matsuno et al 1988 ,
Hennekam 1991 ,
Schmale et al 1994 ,
Legeai-Mallet et al 1997]. However, in certain families, the rates of malignant degeneration have been reported to be as high as 6% [
Vujic et al 2004 ,
Porter et al 2004]. Malignant degeneration can occur during childhood or adolescence, but the risk increases with age.
The prevalence of chondrosarcoma in the general population is about one in 250,000 to one in 100,000 [
Garrison et al 1982 ,
Matsuno et al 1988]; however, 5% of those with a chondrosarcoma have hereditary multiple exostoses. Based on a study of HME in Washington State, it was estimated that HME increases the risk of developing a chondrosarcoma by a factor of 1000 to 2500 over the risk for individuals without hereditary multiple exostoses.
It is important to note the majority of individuals with hereditary multiple exostoses lead active, healthy lives.
Genotype-Phenotype Correlations
In a study of 172 individuals from 78 families
Porter et al (
2004) identified more severe disease in individuals with
mutations in EXT1 than in EXT2 on the basis of shortened stature, skeletal deformity (shortened forearm or bowing, knee deformity), and function (elbow, forearm, and knee range of motion). These findings support those previously reported [
Francannet et al 2001]. The risk of chondrosarcoma may also be higher in individuals with an EXT1
mutation than in those with an EXT2
mutation [
Porter et al 2004].
Penetrance
The
penetrance is estimated to be 96%. Most published instances of non-penetrance have occurred in females. However, comprehensive skeletal radiographs have not been performed in most of these instances.
Nomenclature
"Diaphyseal aclasis" is a term coined by Keith in the 1920´s to describe the abnormal bone growth through a defect in the collar of bone originating near the physis of the long bones.
"Multiple osteocartilaginous exostoses" was used to convey the observation that the growths are composed primarily of cartilage in the child and ossify as skeletal maturity is reached.
"Osteochondromatosis" is another term that has been used to describe HME.
PrevalenceThe reported prevalence of hereditary multiple exostoses ranges from as high as one in 100 in a small population in Guam to approximately one in 100,000 in European populations [
Krooth et al 1961 ,
Hennekam 1991]. The prevalence has been estimated to be at least one in 50,000 in the state of Washington [
Schmale et al 1994].
Differential Diagnosis
For current information on availability of genetic testing for disorders included in this section, see
GeneTests Laboratory Directory. —ED.
Solitary exostosis.Skeletal surveys suggest that a solitary exostosis, a common benign bone tumor, can be found in 1-2% of the population [
Mirra 1989]. Solitary exostoses demonstrate growth patterns similar to those of multiple exostoses. Conditions that may be confused with a solitary exostosis include juxtacortical osteosarcoma, soft tissue osteosarcoma, and heterotopic ossification. Plain radiography or computed tomography is often helpful in distinguishing these lesions from exostoses. Typically, none of these conditions displays the characteristic continuity of cancellous and cortical bone from the host bone to the lesion.
Three inherited conditions in which multiple exostoses occur:
· Metachondromatosis is inherited in an
autosomal dominant manner. In contrast to HME, metachondromatosis is characterized by both exostoses and intraosseous enchondromas. The exostoses of metachondromatosis occur predominantly in the digits and, unlike those of hereditary multiple exostosis, point toward the nearby joint and do not cause shortening or bowing of the long bone, joint deformity, or subluxation.
· Langer-Giedion syndrome is a
contiguous gene deletion syndrome involving EXT1.
Affected individuals have mental retardation and characteristic craniofacial and digital anomalies. Skeletal abnormalities result from
haploinsufficiency of TRPS1, the
gene responsible for trichorhinophalangeal syndrome.
· 11p11
deletion syndrome (formerly known as DEFECT 11 or Potocki-Shaffer syndrome) (
OMIM 601224) [
Wu et al 2000] is a
contiguous gene deletion syndrome involving EXT2 and ALX4 (
OMIM 168500).
Deletion of ALX4 results in parietal foramina and ossification defects of the skull (see
Enlarged Parietal Foramina/Cranium Bifidum). As-yet-unidentified
genes are responsible for the craniofacial abnormalities, syndactyly, and mental retardation seen in some cases [
Mavrogiannis et al 2001].
Management
Evaluations at Initial Diagnosis
Detailed history of symptoms from exostoses
Physical examination to document location of exostoses, functional limitations, and deformity (shortness of stature, forearm bowing and shortening, knee and ankle angular deformities)
Treatment of ManifestationsIn the absence of clinical problems, exostoses require no therapy; however, surgery is often necessary to address angular deformities, pain as a result of irritation of skin, tendons, or nerves, and leg-length inequalities. The majority of individuals with hereditary multiple exostoses have at least one operative procedure and many have multiple procedures [
Schmale et al 1994 ,
Wicklund et al 1995 ,
Porter et al 2004].
When bony deformity is absent, painful lesions can be treated with simple surgical excision [
Peterson 1989]. To avoid recurrance, excision must include the cartilage cap and overlying perichondrium. Excision of exostoses may slow the growth disturbance and improve cosmesis [
Peterson 1989].
Pain and stiffness of the elbow and wrist are common causes of disability. Surgery for forearm deformity involves excision of the exostoses, corrective osteotomies, and ulnar lengthening procedures, although more conservative management may yield satisfactory results. Leg-length inequalities greater than one inch are often treated with either epiphyseodesis (growth plate arrest) of the longer leg or lengthening of the involved leg [
Gross 1978].
In one study, ankle deformity, pain, and early arthritis were noted in approximately one-third of individuals with HME, most of whom had abnormal tibio-talar tilt. Early treatment of this deformity may prevent or decrease the incidence of late deterioration of ankle function [
Noonan et al 2002].
Hip dysplasia may result from exostoses of the proximal femur and from coxa valga.
Decreased center-edge angles and increased uncovering of the femoral heads may lead to early thigh pain and abductor weakness and late arthritis [
Malagon 2001 ,
Ofiram & Porat 2004].
Surgical resection is the treatment for sarcomatous degeneration. Adjuvant radiotherapy and chemotherapy are controversial for secondary chondrosarcoma [
Harwood et al 1980 ,
Aprin et al 1982 ,
Anract et al 1994], but are often used in the setting of a secondary osteosarcoma.
Surveillance
Axial sites, such as the pelvis, scapula, ribs, and spine, are more commonly the location of degeneration of exostoses to chondrosarcoma [
Porter et al 2004]. Monitoring of the size of adult exostoses, in particular those involving the pelvis or scapula, may aid in early identification of malignant degeneration, but at this time there are no cost/benefit analyses to support routine surveillance.
Palpable increase in size of an exostosis in an adult and increasing pain from an exostosis in an adult or child would be worrisome for malignant degeneration.
Radiography, CT scanning, magnetic resonance imaging, positron emission tomography and technicium-99 radionuclide imaging can be used to evaluate centrally located exostoses, but it is not known whether the benefits outweigh the risks of irradiation and the potential for
false positive results that lead to unnecessary interventions. In addition, optimal
screening intervals have not been determined.
Testing of Relatives at Risk
Presymptomatic testing is not warranted because the clinical diagnosis is evident at an early age and because no precipitants, protective strategies, or specific non-surgical interventions are known [
Schmale et al 1994 ,
Wicklund et al 1995].
Therapies Under Investigation
Search
ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions.
Genetic Counseling
Genetic counseling is the process of providing individuals and families with information on the nature, inheritance, and implications of genetic disorders to help them make informed medical and personal decisions.
The following section deals with genetic risk assessment and the use of family history and genetic testing to clarify genetic status for family members. This section is not meant to address all personal, cultural, or ethical issues that individuals may face or to substitute for consultation with a genetics professional. —ED.
Mode of InheritanceHereditary multiple exostoses is inherited in an
autosomal dominant manner.
Risk to Family Members
Parents of a
probandAbout 90% of individuals with HME have an
affected parent; about 10% have HME as the result of a de novo
gene mutation [
Schmale et al 1994].
Recommendations for the evaluation of parents of an individual with apparent
sporadic HME include physical examination, radiographs, and/or
molecular genetic testing if a
mutation has been identified in the
proband.
Note: Although 90% of individuals diagnosed with HME have an
affected parent, the
family history may appear to be negative because of failure to recognize the disorder in family members and/or decreased
penetrance.
Sibs of a probandThe risk to sibs depends upon the genetic status of the parents.
Because most
probands have a parent with the altered
gene, the sibs of a
proband with HME usually have a 50% risk of inheriting the
gene alteration; sibs who inherit the alteration have a 95% chance of manifesting symptoms.
When the parents are clinically
unaffected or the
disease-causing mutation cannot be detected in the
DNA of either parent, the risk to the sibs of a
proband appears to be low. No instances of
germline mosaicism have been reported, although it remains a possibility.
Offspring of a proband.The offspring have a 50% risk of inheriting the mutant
allele.
Other family members. The risk to other family members depends upon the genetic status of the proband's parents. If a parent is found to be
affected or to have a
disease-causing mutation, his or her family members are at risk.
Related Genetic Counseling IssuesConsideration in families with an apparent de novo
mutation. When neither parent of a
proband with an
autosomal dominant condition has the
disease-causing mutation or clinical evidence of the disorder, it is likely that the
proband has a de novo
mutation. However, possible non-medical explanations including
alternate paternity or undisclosed adoption could also be explored.
Family planning.The optimal time for determination of genetic risk and discussion of the availability of
prenatal testing is before pregnancy.
DNA banking.
DNA banking is the storage of
DNA (typically extracted from white blood cells) for possible future use. Because it is likely that testing methodology and our understanding of
genes,
mutations, and diseases will improve in the future, consideration should be given to banking
DNA of
affected.
DNA banking is particularly important in situations in which the
sensitivity of currently available testing is less than 100%. See
DNA Banking for a list of laboratories offering this service.
Prenatal Testing
Prenatal diagnosis for pregnancies at increased risk is possible by analysis of
DNA extracted from fetal cells obtained by amniocentesis usually performed at about 15-18 weeks' gestation or chorionic villus sampling (CVS) at about 10-12 weeks' gestation.
The disease-causing
allele of an
affected family member must be identified before
prenatal testing can be performed.
Note: Gestational age is expressed as menstrual weeks calculated either from the first day of the last normal menstrual period or by ultrasound measurements.
Requests for
prenatal testing for conditions such as HME that do not affect intellect or life span and for which some treatment exists are not common. Differences in perspective may exist among medical professionals and families regarding the use of
prenatal testing, particularly if the testing is being considered for the purpose of pregnancy termination rather than early diagnosis. Although most centers would consider decisions about
prenatal testing to be the choice of the parents, careful discussion of these issues is appropriate.
Preimplantation genetic diagnosis (PGD) using embryonic cells is available to couples at 50% risk of having a child with HME when the
disease-causing mutation of the EXT1 or EXT2
gene has been identified in the
affected parent. Achievement of pregnancy is through assisted reproductive technology and requires coordination with specialists in fertility and endocrinology. For laboratories offering PGD, see
.
Molecular Genetics
Information in the Molecular Genetics tables may differ from that in the text; tables may contain more recent information. —ED.
Molecular Genetics of Multiple Exostoses, Hereditary
Gene Symbol
Chromosomal Locus
Protein Name
EXT1: 8q24.11-q24.13; Exostosin-1
EXT2:11p12-p11; Exostosin-2
Data are compiled from the following standard references: Gene symbol from
HUGO; chromosomal locus, locus name, critical region, complementation group from
OMIM;
protein name from
Swiss-Prot.
OMIM Entries for Multiple Exostoses, Hereditary
133700 EXOSTOSES, MULTIPLE, TYPE I
133701 EXOSTOSES, MULTIPLE, TYPE II
608177 EXOSTOSIN 1; EXT1
608210 EXOSTOSIN 2; EXT2
Genomic Databases for Multiple Exostoses, Hereditary: Gene Symbol
Entrez Gene:HGMD
GeneCards:GDB
GenAtlas:EXT1
133700 :
EXT1 EXT1135994 :
EXT1EXT2
133701 :
EXT2 EXT2344921 :
EXT2For a description of the genomic databases listed, click
here.
Molecular Genetic PathogenesisAll three biochemically studied EXT
gene products are involved in the biosynthesis of heparan sulfate.
EXT1 and EXT2 encode glycosyltransferases that interact as hetero-oligomeric complexes [
McCormick et al 2000] and the related EXTL2
gene encodes an alpha-1,4-N-acetylhexosaminyltransferase [
Kitagawa et al 1999].
Mutations in EXT1 or EXT2 cause cytoskeletal abnormalities including actin accumulation, excessive bundling by alpha-actinin, and abnormal presence of muscle-specific alpha-actin [
Bernard et al 2000].
Some evidence suggests that EXT1 and EXT2 may have tumor suppressor activity [
Hecht et al 1995 ,
Raskind et al 1995 ,
Hecht et al 1997].
A two-hit mutational model was proposed for EXT1 and EXT2 in the formation of exostoses, based on the observation of
loss of heterozygosity in chondrosarcomas [
Philippe et al 1997 ,
Hecht et al 1995 ,
Hecht et al 1997].
The failure to identify two EXT
mutations or
loss of heterozygosity in exostoses of individuals with HME has been used to argue against this model [
Hall et al 2002].
It remains a possibility, however, that the second mutational hit may arise in a related
gene such as the EXT-like
genes EXTL1, EXTL2, or EXTL3, or other
genes involved in the signaling cascade of chondrocyte proliferation [
Hall et al 2002].
Epigenetic loss of EXT1 activity through hypermethylation has been observed in leukemias and other cancers, further supporting a tumor suppressor role for this
gene product [
Ropero et al 2004].
The EXTL family of
genes are related to EXT1 and EXT2 by sequence homology.
The EXTL family of
genes currently consists of three members (
Table 2).
To date, no disorder has been attributed to
mutation in any of these
genes.
Table 2. Related
GenesGeneLocusReference Comment EXTL1 1p36.1
Wise et al 1997Not associated with any disease EXTL2 1p12-p11
Wuyts et al 1997LOH in exostoses [
Bovee et al 1999] EXTL3 8p21
Van Hul et al 1998Mutations found in colorectal tumors [
Arai et al 1999]
More recent work suggests that not only do EXT1 and EXT2 code for transmembrane glycoproteins that together form a heteroligomeric heparan sulfate polymerase, but that the
protein product participates in cell signaling and chondrocyte proliferation and differentiation [
McCormick et al 2000 ,
Bernard et al 2001 ,
Senay et al 2000 ,
Hall et al 2002].
Study of heparan sulfate proteoglycan (HSPG) synthesis in Drosophila suggests that a parallel signaling pathway may exist in humans [
Bellaiche et al 1998].
Theories of osteochondroma pathogenesis are many. A routine aberrancy in the perichondrial groove of Ranvier [
Porter & Simpson 1999] may be the functional change that when coupled with haploinsufficency at EXT1 or EXT2 provides the double-hit necessary for development of an osteochondroma [
Hall et al 2002].
For individuals with HME, the
haploinsufficiency is caused by a
mutation present in all chondrocytes; for those with
isolated exostoses, the
mutation may originate in a chondrocyte residing in the abnormal region of the groove of Ranvier.
The abnormality in the groove of Ranvier may not be a chance occurrence, but rather a result of a nest of abnormally signaling chondrocytes; loss of normal signal for chondrocyte proliferation may also contribute to inadequate formation of osteoblasts from stem cells, resulting in a focal defect in the local bone collar and thereby allowing protuberant growth of a pedunculated osteochondroma [
Jones & Morcuende 2003].
The pathologic process that restricts the development of exostoses to the physeal margin is still not completely understood.
EXT1
Normal allelic variants: EXT1 contains 11
exons spanning 250 kb containing a 3166-bp
coding region.
Pathologic allelic variants: Over 100 different
mutations have been described in EXT1 (reviewed in
Wells et al 1997 ;
Wuyts & Van Hul 2000 ;
Cheung et al 2001 ;
Xiao et al 2001 ; Wuyts & Bale, personal communication).
These
mutations are dispersed throughout both
genes and most lead to premature termination of the
gene product. Only a few of the
mutations have been identified in more than one family. There are several relative hot spots for
mutations.
Exons 1 and 6 contain one and two polypyrimidine tracts, respectively. Such tracts are often sites of
frameshift mutations.
Missense mutations cluster in
codons 339 and 340.
Mutations in the carboxyterminal region are relatively sparse.
Deletion of
exon 1 (in three families) and
exons 2-11 (in one family) have been reported [
White et al 2004].
These large
deletions were not identified by
sequence analysis of individual
exons.
Normal
gene product: Exostosin-1 comprises 746 amino acids and is involved in heparan sulfate synthesis. It is a type II transmembrane glycoprotein that localizes to the endoplasmic reticulum [
McCormick et al 2000].
Exostosin-1 and Exostosin-2 form a heterooligomeric complex that accumulates in the Golgi apparatus and has substantially higher glycosyltransferase activity than Exostosin-1 or Exostosin-2 alone [
McCormick et al 2000].
Abnormal
gene product: The majority of
mutations are
insertions or
deletions that produce frame-shifts resulting in premature termination and loss of function.
Nonsense and
splice site mutations have also been observed. Most of the
missense mutations detected occur in residues that are highly conserved evolutionarily and are thought to be crucial for the activity of the
protein.
Missense mutations affecting residues that are not as tightly conserved may be rare
polymorphisms.
EXT2
Normal allelic variants: EXT2 contains 14
exons plus two alternative
exons spanning 110 kb containing a 3628-bp
coding region. Single base
polymorphisms that do not result in amino acid substitutions have been described and at least four non-synonymous changes appear to be rare
polymorphisms [
Cheung 2001].
Pathologic allelic variants:
Over 40
mutations have been found in EXT2 [
Wells et al 1997 ;
Wuyts et al 1998 ;
Wuyts & Van Hul 2000 ;
Cheung et al 2001 ;
Xiao et al 2001 ;
Wuyts & Bale, personal communications]. The
mutations are dispersed throughout EXT2 and are of all types (missense, frameshift, in-frame
deletion, nonsense, and
splice site).
Several
missense mutations and in-frame
deletions have been reported in EXT2.
Very few
mutations have been found in the carboxy-terminal region of the
gene.
Normal
gene product: The
protein comprises 718 amino acids. Exostosin 1 and exostosin 2 are both involved in heparan sulfate synthesis. Like exostosin-1, exostosin-2 is a type II transmembrane glycoprotein that localizes to the endoplasmic reticulum [
McCormick et al 2000].
Exostosin-1 and exostosin-2 form a hetero-oligomeric complex that accumulates in the Golgi apparatus and has substantially higher glycosyltransferase activity than exostosin-1 or exostosin-2 alone [
McCormick et al 2000].
Normal
gene product: The frameshift, nonsense, and
splice site mutations are predicted to result in premature chain termination and loss of
gene function. Several
missense mutations have also been described.
Some
missense mutations occur in evolutionarily conserved residues, have been seen in more than one family with HME, and are likely to be pathogenic.
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http://www.geneclinics.org/servlet/access?db=genestar&id=8888890&fcn=e&fcn2=refer&refer=http%3A%2F%2Fwww.mheresearchfoundation.org%2F&type=resource&key=jrlF0pNpxXRhqMusculoskeletal Imaging Teaching Files, Case 25 Radiographs typical of EXT
http://www.geneclinics.org/servlet/access?db=genestar&id=8888890&fcn=e&fcn2=refer&refer=http%3A%2F%2Fwww.uhrad.com%2Fmsiarc%2Fmsi025.htm&type=resource&key=jrlF0pNpxXRhqThe MHE Coalition 8838 Holly Lane Olmsted Falls OH 44138 Phone: 440-235-6325 Email: CheleZ1@aol.com
http://www.geneclinics.org/servlet/access?db=genestar&id=8888890&fcn=e&fcn2=refer&refer=http%3A%2F%2Fwww.mhecoalition.org%2F&type=resource&key=jrlF0pNpxXRhqResources Printable Copy References
Published Statements and Policies Regarding Genetic Testing
No specific guidelines regarding genetic testing for this disorder have been developed.
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Author Information:
Howard A Chansky, MD: Professor, Department of Orthopaedics and Sports Medicine University of Washington.
Gregory A Schmale, MD :Assistant Professor, Department of Orthopaedics and Sports Medicine University of Washington.
Wendy H Raskind, MD, PhD: Professor, Department of Medicine Division of Medical Genetics University of Washington.Seattle.
