Splicing-Disrupting Mutations in Inherited Predisposition to Solid Pediatric Cancer

Abstract

The prevalence of hereditary cancer in children was estimated to be very low until recent studies suggested that at least 10% of pediatric cancer patients carry a germline mutation in a cancer predisposition gene. A significant proportion of pathogenic variants associated with an increased risk of hereditary cancer are variants affecting splicing. RNA splicing is an essential process involved in different cellular processes such as proliferation, survival, and differentiation, and alterations in this pathway have been implicated in many human cancers. Hereditary cancer genes are highly susceptible to splicing mutations, and among them there are several genes that may contribute to pediatric solid tumors when mutated in the germline. In this review, we have focused on the analysis of germline splicing-disrupting mutations found in pediatric solid tumors, as the discovery of pathogenic splice variants in pediatric cancer is a growing field for the development of personalized therapies. Therapies developed to correct aberrant splicing in cancer are also discussed as well as the options to improve the diagnostic yield based on the increase in the knowledge in splicing.

Full text

Citation: Alba-Pavón, P.; Alaña, L.;
Astigarraga, I.; Villate, O.
Splicing-Disrupting Mutations in
Inherited Predisposition to Solid
Pediatric Cancer. Cancers 2022,14,
5967. https://doi.org/10.3390/
cancers14235967
Academic Editor: Luis Franco
Received: 17 October 2022
Accepted: 28 November 2022
Published: 2 December 2022
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affil-
iations.
Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
cancers
Review
Splicing-Disrupting Mutations in Inherited Predisposition to
Solid Pediatric Cancer
Piedad Alba-Pavón1, Lide Alaña 1, Itziar Astigarraga 1,2,3 and Olatz Villate 1,*
1Pediatric Oncology Group, Biocruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain
2Pediatric Service, Hospital Universitario Cruces, 48903 Barakaldo, Spain
3Pediatric Department, Universidad del País Vasco UPV/EHU, 48940 Leioa, Spain
*Correspondence: olatz.villatebejarano@osakidetza.eus; Tel.: +34-94-6006-000 (ext. 7247)
Simple Summary:
Until recently, the prevalence of hereditary cancer in children was estimated
to be very low. However, recent studies suggest that at least 10% of pediatric cancer patients
have a germline mutation in a cancer predisposition gene. It has been shown that most of these
mutations affect splicing, a process by which different transcripts of the same gene are produced.
The splicing process is very important, as it regulates many aspects of cellular proliferation, survival,
and differentiation. Hereditary cancer genes are highly prone to splicing alterations, and among
them there are several genes that may contribute to the development of pediatric solid tumors
when mutated in the germline. In this review, we analyze the importance of the splicing-disrupting
mutations in pediatric solid cancer and inherited predisposition syndromes. The therapies developed
to correct aberrant splicing in cancer are also discussed.
Abstract:
The prevalence of hereditary cancer in children was estimated to be very low until recent
studies suggested that at least 10% of pediatric cancer patients carry a germline mutation in a cancer
predisposition gene. A significant proportion of pathogenic variants associated with an increased
risk of hereditary cancer are variants affecting splicing. RNA splicing is an essential process involved
in different cellular processes such as proliferation, survival, and differentiation, and alterations in
this pathway have been implicated in many human cancers. Hereditary cancer genes are highly
susceptible to splicing mutations, and among them there are several genes that may contribute
to pediatric solid tumors when mutated in the germline. In this review, we have focused on the
analysis of germline splicing-disrupting mutations found in pediatric solid tumors, as the discovery of
pathogenic splice variants in pediatric cancer is a growing field for the development of personalized
therapies. Therapies developed to correct aberrant splicing in cancer are also discussed as well as the
options to improve the diagnostic yield based on the increase in the knowledge in splicing.
Keywords:
cancer predisposition syndromes; solid tumors; pediatric cancer; hereditary cancer;
alternative splicing; mutations; genes
1. Alternative Splicing
Alternative splicing (AS) is a key mechanism that allows a single gene to increase its
coding capacity, enabling the synthesis of distinct mRNA and protein [
1
]. AS determines
many aspects of cellular proliferation, survival, and differentiation. Taking into account the
importance of the splicing process in gene regulation, it is not surprising that alterations in
this pathway have been implicated in several human cancers [
2
]. Analyses of more than
8000 tumors across 32 cancer types have revealed thousands of splicing variants not present in
normal tissues, which are likely to generate cancer-specific markers and neoantigens [
3
,
4
]. The
knowledge of the relationship between AS and epigenetic modifications has also enlarged
the collection of biomarkers that can be used as cancer diagnostic and/or prognostic
tools [
5
]. Moreover, aberrant splicing variants conferring drug or therapy resistance in
tumors are more common than previously estimated [6].
Cancers 2022,14, 5967. https://doi.org/10.3390/cancers14235967 https://www.mdpi.com/journal/cancers

Cancers 2022,14, 5967 2 of 23
The majority of studies on cancer and splicing have focused on the impact of somatic
variants on alternative splicing events [
3
,
7
], but the association between splicing and germline
variants in cancer predisposition genes is often overlooked. The discovery of pathogenic
splice variants in pediatric cancer is a growing field that needs further investigation.
2. Cancer Predisposition Genes
Cancer predisposition genes are those in which germline mutations confer highly or
moderately increased risks of developing neoplasms. The identification of these genes
and the pathogenic variants found in them is essential for diagnosis and personalized
treatment [
8
]. Thanks to the advances in next-generation sequencing (NGS), new cancer
predisposition genes and pathogenic variants are being identified in pediatric tumors.
The prevalence of hereditary cancer in children was generally estimated to be very
low until recent studies suggested that at least 10% of pediatric cancer patients carry a
germline mutation in a cancer predisposition gene [
9
,
10
]. A significant proportion of the
pathogenic variants associated with an increased risk of hereditary cancer are variants
affecting splicing [
11
]. The identification of the variants that disrupt AS remains a challenge,
and the consequence is that a significant proportion of patients with a possible hereditary
cancer syndrome remain without a definitive molecular diagnosis. In a recent study of
somatic mutations across 8656 tumor samples, the authors reported 1964 mutations that
had originally been incorrectly classified and had clear evidence of creating alternative
splice junctions [12].
It has recently been reported that hereditary cancer genes are highly susceptible to
splicing mutations and that three main genes responsible for Lynch Syndrome, MLH1,
MSH2, and PMS2, belong to a class of 86 disease genes that are enriched for splicing
mutations [
13
]. It was also found that the COSMIC set of cancer genes [
14
] were overrepre-
sented in these 86 splice-mutation-prone genes, with 20 of them being cancer-related genes
(Table 1). This group of genes had a higher proportion of canonical splice sites and exonic
mutations than the rest of the genes [13].
Table 1. Cancer-related genes enriched in splicing alterations.
Gene aPathway/Function Associated Cancer Predisposition Syndrome
APC Tumor suppressor Familial adenomatous polyposis
ATM Tumor suppressor Ataxia telangiectasia
BRCA1 Tumor suppressor Hereditary breast and ovarian cancer syndrome
BRCA2 Tumor suppressor Hereditary breast and ovarian cancer syndrome
COL1A1 Pro-alpha1 chains of type I collagen -
COL2A1 Pro-alpha1 chains of type II collagen -
ELN Elastic fiber formation -
EXT1 Tumor suppressor Hereditary multiple exostoses, Langer–Giedion syndrome
FANCA Fanconi anemia complementation group A Fanconi anemia
FANCD2 Fanconi anemia complementation group D2 Fanconi anemia
FANCG Fanconi anemia complementation Group G Fanconi anemia
MLH1 Tumor suppressor Lynch syndrome
MSH2 Tumor suppressor Lynch syndrome
NF1 Tumor suppressor Neurofibromatosis type 1
NF2 Tumor suppressor Neurofibromatosis type 2
PMS2 Tumor suppressor Lynch syndrome
PRKAR1A Protein Kinase CAMP-Dependent Type I
Regulatory Subunit Alpha/tumor suppressor Carney complex
RB1 Tumor suppressor Retinoblastoma
TSC2 Tumor suppressor Tuberous sclerosis type 2
WAS Effector protein for Rho-type GTPases Wiskott–Aldrich syndrome gene
aGenes predisposing to solid pediatric tumors are highlighted in grey.
On the list of hereditary cancer genes that are highly susceptible to splicing mu-
tations, there are several genes that may contribute to the development of pediatric

Cancers 2022,14, 5967 3 of 23
solid tumors when mutated in the germline: APC [
15
,
16
], ATM [
17
], BRCA1 [
18
,
19
],
BRCA2 [
20
], FANCA [
15
,
21
], FANCD2 [
19
], NF1 [
22
–
24
], NF2 [
20
,
25
], MLH1 [
26
], MSH2 [
26
],
PMS2 [22,26], RB1 [27–30], and TSC2 [20] (Table 1).
Herein, we review the importance of ASin pediatric cancers, analyzing the germline
splice variants described in genes that contribute to pediatric solid tumors and cancer
predisposition syndromes. It is important to emphasize that more research is needed in
this field since the identification of variants that affect splicing remains a challenge and most
studies focus on consensus splice-site variants. Moreover, a better understanding of splicing
biology will contribute toward the development of novel therapeutics for pediatric cancer.
To visualize the effects of the mutations that we are reporting in this review, we have
represented the sequences that can be altered in Figure 1and classified them into different
groups according to the type of altered sequence: Type I, donor site region; Type II, acceptor
site region; Type III, exonic region, including exonic splicing enhancers and silencers; and
Type IV, intronic region, including intronic splicing enhancers and silencers.
Cancers 2022, 14, x 3 of 25
PRKAR1A Protein Kinase CAMP-Dependent Type I
Regulatory Subunit Alpha/tumor suppressor Carney complex
RB1 Tumor suppressor Retinoblastoma
TSC2 Tumor suppressor Tuberous sclerosis type 2
WAS Effector protein for Rho-type GTPases Wiskott–Aldrich syndrome gene
a Genes predisposing to solid pediatric tumors are highlighted in grey.
On the list of hereditary cancer genes that are highly susceptible to splicing
mutations, there are several genes that may contribute to the development of pediatric
solid tumors when mutated in the germline: APC [15,16], ATM [17], BRCA1 [18,19],
BRCA2 [20], FANCA [15,21], FANCD2 [19], NF1 [22–24], NF2 [20,25], MLH1 [26], MSH2
[26], PMS2 [22,26], RB1 [27–30], and TSC2 [20] (Table 1).
Herein, we review the importance of ASin pediatric cancers, analyzing the germline
splice variants described in genes that contribute to pediatric solid tumors and cancer
predisposition syndromes. It is important to emphasize that more research is needed in
this field since the identification of variants that affect splicing remains a challenge and
most studies focus on consensus splice-site variants. Moreover, a better understanding of
splicing biology will contribute toward the development of novel therapeutics for
pediatric cancer.
To visualize the effects of the mutations that we are reporting in this review, we have
represented the sequences that can be altered in Figure 1 and classified them into different
groups according to the type of altered sequence: Type I, donor site region; Type II,
acceptor site region; Type III, exonic region, including exonic splicing enhancers and
silencers; and Type IV, intronic region, including intronic splicing enhancers and
silencers.
Figure 1. Schematic representation of the splicing sequences that can be altered by mutations and
their classification for this review. The DNA sequences include donor and acceptor splice sites (Type
I and Type II, respectively); exonic sequences, including exonic splicing silencers (ESS) and
enhancers (ESE) (Type III); and intronic sequences, including intronic splicing enhancers (ISE) and
silencers (ISS) (Type IV).
3. Pediatric Solid Tumors
Solid tumors represent 60% of all pediatric malignant neoplasms, and the tumor
types are very different from those found in adults. The most common pediatric tumors
include central nervous system (CNS) tumors (35%); neuroblastoma (15%); soft tissue
sarcoma (7%); Wilms tumor (6%); bone tumors, including osteosarcoma and Ewing
sarcoma (8%); retinoblastoma (5%); and other rare tumors, including hepatoblastoma,
ge rm cell tumors, and mel anoma ( 17%) [31]. In th is revi ew, we f ocus on the most pr evalen t
tumors in childhood: CNS tumors, sarcomas, and blastomas (neuroblastoma,
retinoblastoma, and Wilms tumor).
Figure 1.
Schematic representation of the splicing sequences that can be altered by mutations and
their classification for this review. The DNA sequences include donor and acceptor splice sites
(Type I and Type II, respectively); exonic sequences, including exonic splicing silencers (ESS) and
enhancers (ESE) (Type III); and intronic sequences, including intronic splicing enhancers (ISE) and
silencers (ISS) (Type IV).
3. Pediatric Solid Tumors
Solid tumors represent 60% of all pediatric malignant neoplasms, and the tumor
types are very different from those found in adults. The most common pediatric tumors
include central nervous system (CNS) tumors (35%); neuroblastoma (15%); soft tissue
sarcoma (7%); Wilms tumor (6%); bone tumors, including osteosarcoma and Ewing sar-
coma (8%); retinoblastoma (5%); and other rare tumors, including hepatoblastoma, germ
cell tumors, and melanoma (17%) [
31
]. In this review, we focus on the most prevalent tu-
mors in childhood: CNS tumors, sarcomas, and blastomas (neuroblastoma, retinoblastoma,
and Wilms tumor).
3.1. CNS Tumors
CNS tumors are the second most common type of cancer among children, and they
often occur in patients with a cancer predisposition syndrome [
21
]. The following subtypes
are discussed:
3.1.1. Medulloblastoma
Medulloblastoma (MB) is the most common malignant brain tumor in children [
32
],
and recently the World Health Organization (WHO 2021) classified MB at the molec-
ular level into four different types: MB WNT-activated, SHH-activated, group 3, and
group 4 [
33
–
35
]. MBs arise in the cerebellar vermis and spread rapidly through the cere-
brospinal pathways [
36
]. AS is especially prevalent in the mammalian nervous system,
including the cerebellum, where it modulates relevant processes (neural tube patterning,

Cancers 2022,14, 5967 4 of 23
synaptogenesis, membrane physiology, and synaptic plasticity), so a disruption of splicing
regulation can promote pathogenic events [37].
Menghi et al. investigated patterns of differential splicing between pediatric MBs and
the normal cerebellum on a genome-wide scale and concluded that inappropriate splicing
frequently occurs in human MBs and may be linked to the activation of developmental
signaling pathways and a failure of cerebellar precursor cells to differentiate [
7
]. Moreover,
splicing patterns are distinct and specific between molecular subgroups [
38
]. Subgroup-
specific splicing and alternative promoter usage were most prevalent in group 3 and SHH
MBs, while they were less frequent in WNT and group 4. AS events in MB may be partially
regulated by the correlative expression of antisense transcripts, suggesting a mechanism
affecting subgroup-specific AS [38].
Suzuki et al. discovered that approximately 50% of SHH MBs harbor a somatic
mutation in the 5
0
splice-site binding region of U1 spliceosomal small nuclear RNAs
(snRNAs). This mutation is not present across other MB subgroups. SnRNA mutant
tumors have significantly disrupted AS, and as a result aberrant AS inactivates PTCH1 and
activates oncogenes (GLI2 and CCND2), representing a novel target for therapy [39].
MB tumors may appear sporadically or as a part of an inherited syndrome. Pathogenic
germline mutations in known cancer predisposition genes have an important role, mainly
in WNT-activated and SHH-activated MB [
15
]. In a recent study, germline data in 1022
patients with MB were analyzed, and the results showed a significant excess of pathogenic
mutations in the APC,BRCA2,PALB2,PTCH1,SUFU, and TP53 genes [
15
]. Splice variants
in the canonical sites and splice regions were found in the ATM,BRCA2,FANCA,FANCC,
PALB2,PTCH1,RAD51C,SUFU,WRN,WT1, and XPC genes (Table 2).
Table 2. Germline pathogenic splice variants found in pediatric patients with CNS tumors.
Gene Diagnosis Variant Type of Mutation Reference
ATM Medulloblastoma c.6095G>A I [15]
ATM Medulloblastoma c.2921+1G>C I [15]
BRCA2 Medulloblastoma c.631+2T>G I [15]
BRCA2 Medulloblastoma c.-39-1_-39delGA II [15]
ELP1 Medulloblastoma c.3700+1G>A I [40]
ELP1 Medulloblastoma c.3572+1G>A I [40]
ELP1 Medulloblastoma c.2959-1G>T II [40]
ELP1 Medulloblastoma c.741-1G>T II [40]
ELP1 Medulloblastoma c.649G>A I [40]
ELP1 Medulloblastoma c.2959-1G>T II [40]
FANCA Medulloblastoma c.2778+1G>A I [15]
FANCC Medulloblastoma c.996+1G>T I [15]
MSH6 Medulloblastoma c.(4002-31_4002-8delins24) + (4002-
31_4002-8delins24) IV [41]
MUTYH Medulloblastoma c.925-2A>G II [22]
PALB2 Medulloblastoma c.3201+1G>C I [15]
PTCH1 Medulloblastoma c.1729-2A>G II [15]
PTCH1 Medulloblastoma c.584 +2T>G I [42]
RAD51C Medulloblastoma c.904+5G>T I [15]
SUFU Medulloblastoma c.1022 +1 G>A I [43]
SUFU Medulloblastoma c. 1365+2T>A I [44]
SUFU Medulloblastoma c.182+3A>T I [45]
SUFU Medulloblastoma c.318-10delT IV [45]
SUFU Medulloblastoma c.1297-1G>C II [45]
SUFU Medulloblastoma c.183-1G>T II [46]
SUFU Medulloblastoma c.684-2A>G II [15]

Cancers 2022,14, 5967 5 of 23
Table 2. Cont.
Gene Diagnosis Variant Type of Mutation Reference
SUFU Medulloblastoma c.455-1G>A II [15]
TP53 Medulloblastoma c.376-2A>G II [47]
WRN Medulloblastoma c.3139-1G>C II [15]
WT1 Medulloblastoma c.769+1G>C I [15]
XPC Medulloblastoma c.2251-1G>C II [15]
CHEK2 Astrocytoma c.444+1G>A I [48]
NF1 Pilocytic astrocytoma c.205_205insTC III [49]
NF1 Pilocytic astrocytoma c.1185+1G>A I [49]
NF1 Pilocytic astrocytoma c.889-2A>G II [49]
NF1 Optic pathway glioma c.2325+1G>A I [50]
NF1 Optic pathway glioma c.1260+1G>T I [49]
NF1 Low-grade glioma c.6641+1G>A I [22]
NF2 Ependymoma c.447+1G>A I [22]
ERCC2 Diffuse astrocytoma Not available [51]
MUTYH Highly infiltrative astrocytoma Not available [51]
ATM High-grade glioma c.7630-2A>C II [22]
MUTYH High-grade midline glioma c.892-2A>G II [52]
MSH6 Glioblastoma c.(4002-31_4002-8delins24) + (4002-
31_4002-8delins24) IV [41]
NF1 Glioblastoma c.1641+2T>A I [49]
NF1 Anaplastic astrocytoma c.4174-2>AG II [49]
TP53 Glioblastoma c.919+1G>A I [49]
SMARCB1 AT/RT c.501-2A>G II [53]
DICER 1 Pinealoblastoma c.4050+1G>A I [54]
TP53 Choroid plexus carcinoma c.560-2A>C II [55]
For SHH-activated MB, the Gorlin (PTCH1 and SUFU) and the Li–Fraumeni syn-
dromes (TP53) are the most common predisposition syndromes [
56
–
59
]. Additional candi-
dates for SHH-activated MB include BRCA2 and PALB2, which can be associated to Fanconi
anemia [
15
,
60
,
61
]. About 5% of patients with Gorlin syndrome (GS) develop MB, mainly
the desmoplastic form [
62
]. Between 50% and 85% of patients with GS have germline
mutations in PTCH1. In a study of GS, PTCH1 was analyzed in two familial and three
sporadic GS cases, and five germline mutations were found in PTCH1 [
42
]. One of them
was a splice-site mutation (c.584+2T>G) in an 11-year-old male patient who developed MB
at the age of 1 year (Table 2).
SUFU is also involved in the susceptibility to MB. In a report, they identified the
c.1022+1G>A SUFU germline splice mutation in a family that was PTCH1-negative but had
signs and symptoms of GS, including MB [
43
]. Another study described a family previously
diagnosed with GS with a novel SUFU splice-site pathogenic variant (c. 1365+2T>A) [
44
].
Germline SUFU mutations were analyzed in children with desmoplastic/nodular MB, and
eight germline mutations were found, with three of them being splice variants (c.182+3A>T;
c.318-10delT; and c.1297-1G>C) [
45
]. Another report showed SUFU germline mutations
in desmoplastic MBs, one of them located in the conserved splice acceptor site of exon 2
(Table 2) [46].
Li–Fraumeni syndrome (LFS) is a rare autosomal dominant form of familial cancer,
characterized by the early onset of diverse malignancies, including sarcomas, brain tumors,
and leukemias [
63
]. Germline mutations in TP53 have primarily been identified in LFS [
64
].
Mutations in splice sites are also very frequent in LFS, while missense mutations are less
common in comparison to other familial or sporadic cancers [
65
]. Several studies have
described splice-site mutations in LFS [
55
,
66
,
67
], but we have only found one study in the
IARC TP53 database, which described one splice variant in TP53 in an LFS pediatric patient
with MB (c.376-2A>G) [
47
]. Splice variants in TP53 have been found in a pediatric patient
with choroid plexus carcinoma (c.560-2A>C) [
55
] and in a pediatric glioblastoma patient
(c.919+1G>A) (Table 2) [68].

Cancers 2022,14, 5967 6 of 23
Recently, germline splice mutations in other genes such as ELP1 have been found in
two independent families with SHH-activated MB [
40
]. For WNT-activated MB, Turcot
Syndrome (APC) is the most common predisposition syndrome [
56
], a rare disorder char-
acterized by the association of colonic polyposis and primary brain tumors [
69
]. In MB
associated with APC germline pathogenic variants, no splice variants were found in this review.
Another less common MB-associated syndrome is ataxia telangiectasia (AT) [
70
].
AT is an autosomal recessive disease characterized by neurological and immunological
symptoms, radiosensitivity, and cancer predisposition. The mutated gene in AT is ATM,
and different splice variants of this gene have been described in pediatric MB (Table 2) [
15
].
Moreover, a germline splice variant of the MUTYH gene has been described in a pediatric
patient with MB (Table 2) [22].
3.1.2. Gliomas
Gliomas are CNS neoplasms that affect both the brain and spinal cord, and they are
the most common primary CNS tumors, mainly astrocytomas [71].
Low-Grade Gliomas (LGGs)
LGGs and glioneural tumors represent over 30% of pediatric CNS neoplasms [
72
,
73
].
Within the LGG category, there are different tumor types and subtypes:
a. Astrocytoma
Pilocytic astrocytoma is the most common type in children and young adults [
72
].
In relation to genetic predisposition, one study showed germline splice mutations in
the MUTYH and ERCC2 genes [
51
] in a highly infiltrative astrocytoma and a diffuse
astrocytoma, respectively, although the variants were not annotated in the manuscript
(Table 2). In a recent study, a novel CHEK2 splice variant (c.444+1G>A) was identified in
a 7-year-old child diagnosed with a subependymal giant cell astrocytoma (Table 2) [
48
].
Functional studies have shown the use of an alternative 5
0
splice site that creates a premature
stop codon. As a result of this change, the transcript is truncated, which results in reduced
CHEK2 protein levels [74].
b. Ependymoma
Ependymoma (EP) is the second most common malignant brain tumor in children, and
it originates from the walls of the ventricular system [
75
]. The etiology is largely unknown,
and germline DNA sequencing studies on pediatric EP are scarce. Pathogenic germline
variants in known cancer predisposition genes have been detected in genes such as NF2,
LZTR1,NF1, and TP53 [
76
]. EP can be associated with type 2 neurofibromatosis with a
high proportion of pathogenic mutations in NF2. The most common alterations in NF2 are
splice-site or nonsense mutations, but these are mostly found in intracranial meningiomas
and other adult nervous system cases [
77
–
79
], except the variant c.447+1G>A, which was
described in a pediatric EP (Table 2) [22].
Epigenetic alterations appear to play a central role in the development of the molecular
classification of EPs [
80
]. Recent findings have shown that posterior fossa type A (PFA)
EPs exhibit low H3K27 methylation and overexpress EZHIP (enhancer of zeste homologs
inhibitory protein), which dysregulates gene silencing to promote tumorigenesis. Genomic
dataset analyses from PFA and diffuse intrinsic pontine gliomas (DIPG) have revealed that
these two different tumors share a common dysregulated chromatin landscape [81].
c. Optic glioma
Neurofibromatosis type 1 (NF1) is one of the most frequent autosomal dominant
disorders and is caused by mutations in the NF1 gene. NF1 patients are predisposed
to develop brain tumors, among others, and gliomas are found in 15–20% of affected
individuals [
82
,
83
]. About 15% of children with NF1 develop low-grade optic pathway
gliomas (OPG) [
84
], whereas high-grade gliomas, including anaplastic astrocytomas (AA)
and glioblastomas, are less frequent in children with NF1 [23,85].

Cancers 2022,14, 5967 7 of 23
In one study, NF1 patients were analyzed (31% with OPG), and an NF1-splice germline
variant was found in a OPG patient: c.2325+1G>A, which produced exon 14 skipping
(Table 2) [
50
]. Different NF1 germline mutations in pediatric glioma patients that affected
the splicing process have been described: c.205_205insTC, c.1185+1G>A, c.889-2A>G,
c.2325+1G>A, and c.1260+1G>T in pilocytic astrocytomas and OPG [
49
]. Moreover, the
variant c.6641+1G>A has been found in a pediatric LGG (Table 2) [22].
High-Grade Gliomas (HGGs)
HGG is one of the most fatal childhood brain tumors and can be associated with
underlying cancer predisposition syndromes such as NF1 and Turcot and Li–Fraumeni
syndromes [86].
NF1 germline mutations have been described in high glioma pediatric patients, affect-
ing the splicing process as c.1641+2T>A and c.4174-2>AG in glioblastoma and anaplastic
astrocytoma (AA), respectively (Table 2) [49].
Constitutional mismatch repair deficiency (CMMRD) is a syndrome caused by biallelic
mutations in the mismatch repair pathway [
87
]. This repair system comprises different
genes, including MSH2,MSH6,MLH1, and PMS2 [
88
]. Patients with CMMRD or familial
adenomatous polyposis (FAP) who develop brain tumors were lumped together under
the term Turcot syndrome [
16
]. Biallelic germline splice mutations in MSH6 have been
reported in MB and in glioblastoma multiforme (Table 2) [
41
]. In a report, an inactivating
germline mutation in MUTYH was found in a patient with a high-grade midline glioma
(Table 2) [
52
]. A germline mutation in ATM, affecting the splicing process, was found in a
pediatric HGG patient (Table 2) [22].
3.1.3. Other CNS Tumors
Pinealoblastoma
The DICER1 syndrome is related to several benign and malignant tumors, including
rhabdomyosarcoma and pinealoblastoma [
89
]. A germline DICER1 splice-site variant
(c.4050+1G>A) was found in a 10-year-old patient with pinealoblastoma (Table 2) [54].
Atypical Teratoid/Rhabdoid Tumors
Rhabdoid tumors (RTs) are most commonly observed in the brain, where they are
called atypical teratoid/rhabdoid tumors (AT/RT) [
53
]. The majority of RTs are caused
by a loss of function in SMARCB1, and more recently mutations in SMARCB4 have been
found as a cause of RTs. Germline mutations in SMARCB1 are also associated with familial
schwannomatosis [
90
]. Deletions or truncating mutations of SMARCB1 are generally found
in AT/RT, and loss-of-function mutations in exon 1 and splice-site mutations are more
frequent in schwannomatosis [
90
]. Kordes et al. analyzed 50 patients with AR/RT, and
germline mutations in SMARCB1 were detected in 10 patients, including one splice-site
mutation: c.501-2A>G (Table 2) [53].
In another report, they showed an inherited SMARCB1 mutation in a two-generation
family that was a splice-site mutation in exon 7 [
91
]. In a recent study, they presented two
siblings with congenital AT/RT due to a germline SVA-E retrotransposon insertion into
intron 2 that disrupts the splicing between exons 2 and 3 of SMARCB1 [92].
3.2. Sarcomas
Sarcomas are tumors with a mesenchymal origin that comprise around 12% of all
neoplasms in children and adolescents. They are a very heterogeneous group of tumors,
comprising more than 70 distinct histological subtypes. Sarcomasare classified into two
main groups: bone and soft-tissue sarcomas, with osteosarcoma, Ewing sarcoma, and
rhabdomyosarcoma being the most frequent types in children and adolescents [93].

Cancers 2022,14, 5967 8 of 23
3.2.1. Osteosarcoma
Osteosarcoma is the most common primary bone tumor. The peak incidence oc-
curs during the pubertal growth spurt [
94
]. It was estimated that 10% of osteosarcoma
patients have a hereditary predisposition syndrome [
95
]. However, recent publications esti-
mated that 28% of patients diagnosed with osteosarcoma had pathogenic/likely pathogenic
germline variants [
18
]. Many different cancer predisposition syndromes are associated
with osteosarcoma development, including autosomal dominant disorders (LFS and hered-
itary retinoblastoma [
96
,
97
]) and autosomal recessive disorders (primarily DNA helicase
disorders: Rothmund–Thomson, RAPADILINO, Werner, and Bloom syndromes [98–100]).
LFS is associated with germline loss-of-function mutations in TP53. Several germline
variants have been described in TP53 affecting mRNA splicing, some of them associated
with osteosarcoma development in pediatric patients (Table 3). A rare TP53 germline
mutation, c.671+1G>A, was described in a 15-year-old patient diagnosed with osteosar-
coma in an LFS context. This variant results in a 6-amino-acid insertion between codons
224 and 225 in exon 6 [
101
]. The TP53 c.672G>A germline variant was reported in a
17-year-old male with two primary sarcomas (pleomorphic sarcoma and telangiectatic
osteosarcoma) (Table 3). This variant is a synonymous change that preserves the glutamate
in position 224, but the change results in a shift of the exon 6 splice site by five base pairs,
producing a frameshift and a premature stop codon at residue 246 in exon 7 [102].
Table 3. Germline pathogenic splice variants found in pediatric patients with sarcomas.
Gene Diagnosis Variant Type of Mutation Reference
TP53 Osteosarcoma c.671+1G>A I [101]
TP53 Osteosarcoma c.672+1G>A I [103]
TP53 Osteosarcoma c.375+1G>A I [104]
TP53 Osteosarcoma c.559+2T>G I [105]
TP53 Osteosarcoma c.672+1G>A I [101]
TP53 Osteosarcoma c.770T>A III [106]
TP53 Telangiectatic osteosarcoma c.672G>A I [102]
TP53 Osteosarcoma c.258+1G>T I [107]
RECQL4 Osteosarcoma g.2746del11 IV [108]
RECQL4 Osteosarcoma g.3685G>A I [108]
RECQL4 Osteosarcoma g.2626G>A II [108]
RECQL4 Osteosarcoma g.3712del24 IV [108]
RECQL4 Osteosarcoma c.1391-1G>A II [109]
RECQL4 Osteosarcoma c.1704-1G>A II [110]
RECQL4 Osteosarcoma c.2059-1G>C II [111]
RB1 Osteosarcoma c.940-1G>A II [22]
RB1 Osteosarcoma c.2106+2_2106+5del I [107]
NTHL1 Ewing sarcoma c.116-1G>A II [107]
SLX4 Ewing sarcoma c.1684-1G>A II [107]
FANCA Ewing sarcoma c.523-1G>C II [107]
FANCA Ewing sarcoma c.3828+1G>C I [107]
RAD51C Ewing sarcoma c.905-3_906del II [107]
RAD51C Ewing sarcoma c.1026+5_1026+7del I [107]
CHEK2 Ewing sarcoma c.812+1G>T I [107]
FANCC Ewing sarcoma c.456+4A>T I [107]
EXT2 Ewing sarcoma c.69+2insAGGG I [19]
FANCD2 Ewing sarcoma c.2715+1G>A I [19]
TP53 Rhabdomyosarcoma c.560-1G>A II [112]
TP53 Rhabdomyosarcoma c.376-1G>A II [113]
TP53 Embryonal rhabdomyosarcoma c.783-2A>G II [113]
TP53 Spindle cell rhabdomyosarcoma c.560-1G>C II [114]
NF1 Embryonal rhabdomyosarcoma c.6704+1G>T I [114]
DICER1 Embryonal rhabdomyosarcoma c.1907+1G>A I [115]

Cancers 2022,14, 5967 9 of 23
Hereditary retinoblastoma is an autosomal dominant syndrome that is linked to
RB1 germline mutations. The primary tumor developed in childhood is retinoblastoma;
however, there is an increased risk of developing various neoplasms, especially osteosar-
coma [
116
]. Atypical RB1 germline variants have been described in sarcoma patients
without retinoblastoma as a primary tumor [
117
]. Two pathogenic splice variants have been
found in the germline in two different patients diagnosed with osteosarcoma
(Table 3) [22,107].
Syndromes characterized by germline mutations in genes encoding DNA helicases
of the RecQ family have an increased risk for cancer, especially osteosarcoma. These are
Rothmund–Thomson, RAPADILINO, Werner, and Bloom syndromes [
118
]. Rothmund–
Thomson and RAPALIDINO syndromes are caused by mutations in the RECQL4 gene.
Rothmund–Thomson syndrome is a disorder characterized by poikilodermatous skin
changes, congenital skeletal abnormalities, premature aging, and an increased risk for
cancer [
119
]. RAPALIDINO is a very rare syndrome identified by radial hypoplasia,
patellae hypoplasia, a cleft or highly arched palate, diarrhea, dislocated joints, small size
and limb malformation, a slender nose, and normal intelligence. In the Human Gene
Mutation Database (HGMD), 14% of the reported variants in the RECQL4 gene are splice
variants, and 7 of the 25 splice variants are described in patients diagnosed with Rothmund–
Thomson syndrome who developed osteosarcoma (Table 3) [108–111].
Werner syndrome is a disease caused by mutations in the WRN gene, and it is asso-
ciated with the development of osteosarcoma during adult life [
95
]. Bloom syndrome is
caused by mutations in another DNA helicase gene, BLM. This syndrome is characterized by
clinical features including small stature, photosensitive rashes, and immunodeficiency [
95
].
Ten percent of BLM variants reported in the HGMD are splice variants; however, none of
these variants are associated with the development of osteosarcoma.
3.2.2. Ewing Sarcoma
Ewing sarcoma is the second most common bone and soft tissue cancer. The majority
of Ewing sarcomas arise in bone, and up to 30% arise in soft tissue. The highest incidence
is in the second decade of life. Ewing sarcoma development is uncommon in patients
younger than 5 years or older than 30 years [120–122].
Ewing sarcoma is characterized by a low somatic mutation rate, and it is mainly
caused by a chromosome rearrangement as a driver alteration. This rearrangement is
between the EWSR1 gene and members of the ETS gene family. The most common is the
EWSR1-FLI1 fusion gene [
123
]. Most of studies related to Ewing sarcoma predisposition
have focused on the identification of susceptibility loci from genome-wide association
studies (GWASs) [124].
Aberrant splicing of the EWS-FLI1 transcript alters EWS-FLI1 protein expression and
EWS-FLI1-driven expression [
125
]. Targeting EWS-FLI1 is one of the therapeutic options,
but recently epigenetic/transcriptional modulators have been proven to be promising
therapeutic strategies for indirectly altering its expression and/or function [126].
EWS-FLI1 induces the expression of a specific set of novel spliced and polyadenylated
transcripts in regions of the genome that are normally transcriptionally silent. These neo-
genes are practically undetectable in normal tissues or non-Ewing-sarcoma tumors [127].
Recently, germline pathogenic variants have been described in genes involved in
DNA damage repair in Ewing sarcoma patients [
19
,
107
]. In these studies, germline splice
variants have been found in the NTHL1,SLX4,CHEK2,EXT2,RAD51C,FANCA,FANCC,
and FANCD2 genes (Table 2), most of them described in splice sites. All of these genes,
except EXT2, are involved in the DNA repair response through different signaling pathways
such as the nucleotide-excision repair (NER) pathway, DNA double-strand break repair,
the DNA damage checkpoint, and oxidative DNA damage repair [
128
–
135
]. A loss of the
functionality of DNA repair proteins could contribute to rearrangement signatures due
to the failure of homologous recombination mechanisms [
19
,
107
]. Germline mutations

Cancers 2022,14, 5967 10 of 23
in some of these genes are associated with Fanconi anemia (SLX4,FANCA,FANCC, and
FANCD2) [136,137].
3.2.3. Rhabdomyosarcoma
Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma developed at a
pediatric age. The two main subtypes are embryonal and alveolar RMS [93,138]. Chromo-
somal translocations involving chromosomes 1 or 2 and chromosome 13 are associated
with 80% of alveolar RMS cases. These rearrangements fuse the PAX3 or PAX7 and FOXO1
genes [
139
]. Embryonal is the most common subtype, and though translocations are not ob-
served, TP53,KRAS,NRAS,HRAS,CTNNB1, and FGFR4 are the most frequently mutated
genes in this subtype [140].
Most rhabdomyosarcomas are primarily sporadic, but they can be associated with several
syndromes, including RASopathies and Li–Fraumeni and DICER1 syndromes [
141
–
143
].
Cancer predisposition syndromes are more frequent in patients with embryonal RMS than
in those with the alveolar subtype [138].
RASopathies are a group of disorders caused by germline mutations in the genes involved
in the RAS/MAPK signaling pathway with a high risk of cancer development [
144
,
145
].
NF1, Costello syndrome, and Noonan syndrome are the RASopathies most frequently
associated with the risk of RMS development [
146
,
147
]. Costello syndrome is caused by
HRAS germline mutations. Noonan syndrome is associated with mutations in the RAS
family of genes, PTPN11, and SOS1 genes. The RAS family are GTPases that catalyze
the hydrolysis of GTP, activating the MAPK signaling pathway. They are oncogenes that
exhibit activating mutations in cancer. Germline splice variants have not been described
in the KRAS,HRAS, and NRAS genes in the HGMD database. In contrast, many splice
variants have been described in the SOS1 and PTPN11 genes, but none of them were in
patients with RMS.
The DICER1 gene encodes an enzyme involved in the production of mature microR-
NAs [
148
]. DICER1 germline mutations cause a cancer predisposition syndrome with
cancer risk for pleuropulmonary blastoma, cystic nephroma, Sertoli–Leydig cell tumors,
pinealoblastoma, and embryonal RMS [
149
]. In this context, the DICER1 c.1907+1G>A
splice variant was found in the germline in a 6-month-old female with an embryonal
rhabdomyosarcoma localized in the vagina (Table 3) [115].
Many of the previously mentioned cancer predisposition syndromes are also associ-
ated with the development of rhabdomyosarcomas, in particular LFS and NF1. Different
splice variants in genes associated with these syndromes, TP53 and NF1, are described in
RMS pediatric patients in the germline, all of them described in splice sites (Table 3).
3.3. Neuroblastoma
Neuroblastoma (NB) originates from neural crest cells and affects the sympathetic
nervous system. It is characterized by an early age of onset and a high frequency of
metastatic disease at diagnosis in patients over 1 year of age. NB tumors present few
chromosomic aberrations, including MYCN amplification, 17q gain, 1p deletion, and
11q deletion [150].
NB has been associated with the following cancer predisposition syndromes: famil-
ial neuroblastoma, familial paraganglioma/pheochromocytoma, CCHS/Hirschsprung,
Beckwith–Wiedemann, Simpson–Golabi–Behmel, LFS, Sotos, Costello, Noonan, Rubinstein–
Taybi, Wolf–Hirschhorn, Weaver, NF1, ROHHAD, and Fanconi anemia [136,151–168].
The PHOX2B and ALK genes are major susceptibility genes of familial NB [
150
].
PHOX2B encodes a transcription factor promoting neural crest differentiation. NB-exclusive
mutations are mainly missense and frameshift; splicing variants of this gene have not yet
been associated with NB [
169
]. ALK was also identified as major familial neuroblastoma
predisposition gene [
170
], and as in the previous case, no NB-associated splicing variants
have been described.

Cancers 2022,14, 5967 11 of 23
For patients with sporadic disease, different studies focused on uncommon germline
variants associated with NB have been conducted, and pathogenic and likely pathogenic
variants were identified in predisposition genes such as ALK,CHEK2,BRCA2,SMARCA4,
and TP53 and in candidate genes such as AXIN2,PALB2,BARD1,PINK1,APC,BRCA1,
SDHB, and LZTR1 [
20
,
22
,
171
–
174
]. A pathogenic germline splice variant in BRCA2,
c.8488-1G>A, was identified to be associated with NB [
22
]. PALB2 also had a germline
variant that was predicted to delete a splice donor site, c.1684+1C>A [172].
3.4. Retinoblastoma
Retinoblastoma (RB) is the most common primary malignant intraocular cancer in
children, and it represents 3% of all pediatric tumors [
175
]. There are different forms of RB:
unilateral or unifocal, bilateral or multifocal, and trilateral [175].
Overall, around 90% of bilateral cases and 10–25% of unilateral cases have RB1
germline mutations [
176
]. RB1 is a tumor-suppressor gene and encodes pRB, a key regulator
of the cell cycle [
143
]. RB1 is one of the hereditary cancer genes that is highly susceptible to
splicing mutations. In fact, aberrant splicing of the RB1 gene was found to be the dominant
cause of retinoblastomas in a recent study [
177
]. In this report, they observed that, of all the
diseases collected in the HGMD, the highest proportion of splicing phenotypes seen in ex-
onic mutations was found in RB1. These data suggested that RB1 is particularly susceptible
to splicing mutations [
177
]. Consistent with the above, germline mutations affecting RB1
alternative splicing have been identified in many studies of RB patients [22,176–182].
3.5. Wilms Tumors
Wilms tumor (nephroblastoma, WT) is the most common pediatric renal malignancy,
representing 90% of renal tumors and 5–7% of all pediatric malignancies [
175
]. It is esti-
mated that about 10% of WT cases are caused by germline pathogenic variants or epigenetic
alterations occurring early during embryogenesis [
183
]. WT is primarily a nonhereditary
condition [184].
WT is associated with different hereditary cancer syndromes, including WAGR, Denys–
Drash, Bloom, Frasier, Gorlin, Beckwith–Wiedemann, Sotos, Simpson–Golabi–Behmel, Perlman,
mosaic variegated aneuploidy, Muliebry nanism, hereditary hyperparathyroidism, isolated
hemihypertrophy, LFS, DICER1, and Bohring–Opitz syndromes among others [184–207].
There are more than 20 WT predisposition genes. There is an overlap of only four
genes, WT1,IGF2,TP53, and DICER1, between the WT predisposition genes and the
somatically mutated WT driver genes [183,208].
Regarding the splicing-disrupting mutations, the variant c.1095G>T in CHEK2 was
shown to affect AS. This variant increases the expression of a transcript without exon 10,
which loses the kinase function of the protein [208].
One of the genetic syndromes associated with WT, Frasier syndrome (FS), is caused
by splicing variants that affect the balance of WT1 isoforms. Two alternative splice donor
sites in intron 9 are responsible for creating two different transcripts (with or without
lysine-threonine-serine), and an imbalance in the transcripts results in the development of
FS. Pathogenic variants in this intron have been identified in WT patients [209].
An interesting case report described a pediatric patient with no response to treatment
to a bilateral WT carrying a novel germline WT1 gene splice-site mutation in intron 6,
c.895-2A>G. The authors suggested that the correlation of this variant with response and
prognosis should be further studied [210].
A germline mutation affecting splicing in the CTR9 gene has been identified in a family
with WT [
211
]. The variant c.958-2A>G produces exon 9 skipping, and it is predicted
to encode a truncated protein. Another splice variant was found in CTR9, the splice-site
mutation c.1194+2T>C, which is predicted to disrupt the exon 9 splice site, which was analyzed
and confirmed with a minigene strategy [
212
]. A pathogenic germline splice variant has been
also found in the TRIM28 gene, a WT predisposition gene: c.840–2A>G [213].

Cancers 2022,14, 5967 12 of 23
4. Therapeutic Targeting of Splicing in Cancer
The identification of cancer-specific splice variants has increased the development
of new therapies to correct aberrant splicing. Different strategies have been used for this
purpose, such as blocking components of the spliceosome, targeting protein isoforms
produced by incorrect AS, blocking protein kinases that regulate splicing factors, and the
use of antisense oligonucleotides (ASOs), among others [214].
Small molecules that are modulators of the spliceosome have been tested in cancer
clinical trials, for example, modulating the splicing factor SF3B [
215
]. Synthetic analogues
of compounds derived from bacteria that are cytotoxic to cancer cell lines were designed
to bind SF3B [
215
]. Upon binding to the splicing factor, they prevent the assembly of the
spliceosome, thus inhibiting splicing [
216
]. Changes in splicing are mainly in genes related
to cell cycle regulation and apoptosis [215].
The application of ASOs in cancer therapy is still under intense research, but promising
preclinical results have been reported [
215
]. Results obtained in clinical trials are also
encouraging [
217
]. ASOs can correct cancer-related AS, as it has been shown in cancer cell
lines (Figure 2) [
215
,
218
]. For all these reasons, there is a growing interest in the use of ASO-
based therapeutics in cancer [
6
,
219
]. ASOs are particularly interesting in cancer therapy, as
they can be generated for specific target sequences. They can decrease the expression of
coding oncogenic drivers, and they can target noncoding RNAs. Nevertheless, ASOs have
not yet obtained marketing authorization for cancer treatment [218].
There are several challenges that may impact the therapeutic efficacy of oligonucleotide
therapeutics in cancer [
217
]. One of them is to achieve the efficient delivery of the drugs to
cancer cells in the body. Oligonucleotides need to overcome several barriers, such as the
vascular endothelial barrier or the blood–brain barrier, depending on the target tissue and
avoid rapid clearance from circulation to obtain a therapeutic effect [
220
]. The blood–brain
barrier seems to be impervious to oligonucleotides. Many attempts have been performed to
deliver oligonucleotides across this barrier, with modest success [
220
]. The most promising
involve conjugates of oligonucleotides with cell-penetrating peptides [
221
], but there are
concerns about the possible toxicities of the peptides.
Other limitations for antisense therapeutics are the complexity of cancers that some-
times involve multiple genes to target and drug interactions. It has been reported that
oligonucleotides may compete with chemotherapeutics for plasma protein binding, which
can reduce the
in vivo
efficacy of the combination compared to chemotherapeutics alone [
222
].
Cancers 2022, 14, x 13 of 25
Other limitations for antisense therapeutics are the complexity of cancers that
sometimes involve multiple genes to target and drug interactions. It has been reported
that oligonucleotides may compete with chemotherapeutics for plasma protein binding,
which can reduce the in vivo efficacy of the combination compared to chemotherapeutics
alone [222].
Figure 2. Therapeutic strategy using antisense oligonucleotides. MKNK2 encodes the kinase Mnk2,
and exon 14 is defined by two different alternative 3′ splice sites (3′SSa and 3′SSb). In glioblastoma
cells, the spliceosome binds to the 3′SSb splice site, producing the oncogenic isoform Mnk2b. Using
an ASO to block this site favors the use of 3′SSa, and the tumor-suppressive protein Mnk2a is
produced [223].
Regarding cancer pharmacogenetics, somatic mutations have become druggable
targets or biomarkers, whereas germline mutations are potentially responsible for drug
responses [224]. Primary resistance to treatments can be supported by germline splicing
variants. An example of this is the tyrosine kinase inhibitor (TKI) imatinib and BIM-γ
[225]. There is a recurrent deletion in intron 2 of the BIM gene that was found to be
associated with an increased likelihood of chronic myeloid leukemia resistance to imatinib
and second-line TKIs [225].
Research on splicing-disrupting mutations in inherited predispositions to solid
pediatric cancer and clinical trials are necessary. At this time, there are no clinical trials
registered at ClinicalTrial.gov on splicing that include pediatric patients with solid tumors
(Figure 3). At the time of this review, there are 1193 registered clinical trials in pediatric
solid tumors, but none of them are related to therapies to correct aberrant splicing.
Figure 2.
Therapeutic strategy using antisense oligonucleotides. MKNK2 encodes the kinase Mnk2,
and exon 14 is defined by two different alternative 3
0
splice sites (3
0
SSa and 3
0
SSb). In glioblastoma
cells, the spliceosome binds to the 3
0
SSb splice site, producing the oncogenic isoform Mnk2b. Using
an ASO to block this site favors the use of 3
0
SSa, and the tumor-suppressive protein Mnk2a is
produced [223].

Cancers 2022,14, 5967 13 of 23
Regarding cancer pharmacogenetics, somatic mutations have become druggable tar-
gets or biomarkers, whereas germline mutations are potentially responsible for drug
responses [
224
]. Primary resistance to treatments can be supported by germline splicing
variants. An example of this is the tyrosine kinase inhibitor (TKI) imatinib and BIM-
γ
[
225
].
There is a recurrent deletion in intron 2 of the BIM gene that was found to be associated with
an increased likelihood of chronic myeloid leukemia resistance to imatinib and second-line
TKIs [225].
Research on splicing-disrupting mutations in inherited predispositions to solid pe-
diatric cancer and clinical trials are necessary. At this time, there are no clinical trials
registered at ClinicalTrial.gov on splicing that include pediatric patients with solid tumors
(Figure 3). At the time of this review, there are 1193 registered clinical trials in pediatric
solid tumors, but none of them are related to therapies to correct aberrant splicing.
At the time of this review there are no active registered trials at ClinicalTrial.gov using
ASOs for pediatric cancer in general. There was a clinical trial that included pediatric
patients, which was already completed, to treat patients with advanced melanoma using
Bcl-2 ASOs in combination with dacarbazine (NCT00016263). However, for adult cancer
there are 18 active trials registered with ASO technology, mainly for lymphomas, leukemias,
and solid tumors.
Cancers 2022, 14, x 14 of 25
Figure 3. Clinical trials that include research on splicing in pediatric cancer. There are 429,668
registered clinical trials in the ClinicalTrial.gov database at the time of this review. The number is
minimized to 13,806 when filtering the trials by the terms cancer and solid tumor. Taking into
account the age (child: birth–17 years), there are 1193 clinical trials. When the term splicing is
included, no clinical trials are registered.
At the time of this review there are no active registered trials at ClinicalTrial.gov
using ASOs for pediatric cancer in general. There was a clinical trial that included
pediatric patients, which was already completed, to treat patients with advanced
melanoma using Bcl-2 ASOs in combination with dacarbazine (NCT00016263). However,
for adult cancer there are 18 active trials registered with ASO technology, mainly for
lymphomas, leukemias, and solid tumors.
5. Conclusions and Future Perspectives
In this review, we have shown that most of the splicing variants described in the
germline in pediatric solid tumors are located in the consensus splice sites. The
identification of variants that affect splicing remains a challenge, and most studies only
focus on consensus splice-site variants. As a result, variants in exons or deep introns are
not studied, and many patients remain undiagnosed. Moreover, it is important to
experimentally verify the impact of splicing on variants outside the canonical splice sites
to ensure the accurate classification of variants. In this regard, the identification and study
of variants for which in silico analyses predict an unknown significance but could alter the
splicing process would provide new insights into cancer pathogenesis.
To increase the diagnostic rate, RNA sequencing (RNA-seq) has a great potential for
improving diagnosis because of the splicing results generated by this analysis [226]. RNA-
seq provides an opportunity to identify pathogenic variants in the noncoding regions of
genes [227]. Several reports have also shown the benefits of RNA-seq for hereditary cancer
predisposition genes. In a recent study, RNA analyses allowed the classification of 88% of
the cancer gene splicing variants selected for analysis as either pathogenic or benign.
These studies show that patients under DNA analysis would benefit from the addition of
RNA-seq to the diagnosis [228].
The additional increase in diagnostic yield offered by RNA-seq represents an
opportunity for the development of new personalized management strategies that could
contribute to improving early detection, therapy, and prognosis [229]. Identifying a cancer
predisposition syndrome has a huge impact in the clinical management of pediatric cancer
Figure 3.
Clinical trials that include research on splicing in pediatric cancer. There are
429,668 registered clinical trials in the ClinicalTrial.gov database at the time of this review. The
number is minimized to 13,806 when filtering the trials by the terms cancer and solid tumor. Taking
into account the age (child: birth–17 years), there are 1193 clinical trials. When the term splicing is
included, no clinical trials are registered.
5. Conclusions and Future Perspectives
In this review, we have shown that most of the splicing variants described in the
germline in pediatric solid tumors are located in the consensus splice sites. The identifi-
cation of variants that affect splicing remains a challenge, and most studies only focus on
consensus splice-site variants. As a result, variants in exons or deep introns are not studied,
and many patients remain undiagnosed. Moreover, it is important to experimentally verify
the impact of splicing on variants outside the canonical splice sites to ensure the accurate
classification of variants. In this regard, the identification and study of variants for which
in silico analyses predict an unknown significance but could alter the splicing process would
provide new insights into cancer pathogenesis.

Cancers 2022,14, 5967 14 of 23
To increase the diagnostic rate, RNA sequencing (RNA-seq) has a great potential
for improving diagnosis because of the splicing results generated by this analysis [
226
].
RNA-seq provides an opportunity to identify pathogenic variants in the noncoding regions
of genes [
227
]. Several reports have also shown the benefits of RNA-seq for hereditary
cancer predisposition genes. In a recent study, RNA analyses allowed the classification of
88% of the cancer gene splicing variants selected for analysis as either pathogenic or benign.
These studies show that patients under DNA analysis would benefit from the addition of
RNA-seq to the diagnosis [228].
The additional increase in diagnostic yield offered by RNA-seq represents an opportu-
nity for the development of new personalized management strategies that could contribute
to improving early detection, therapy, and prognosis [
229
]. Identifying a cancer predisposi-
tion syndrome has a huge impact in the clinical management of pediatric cancer patients
and their families, allowing a better follow-up and adequate genetic family counselling.
Author Contributions:
Writing—original draft, P.A.-P., L.A., I.A. and O.V.; writing—review and
editing, P.A.-P., L.A., I.A. and O.V.; supervision, O.V. All authors have read and agreed to the
published version of the manuscript.
Funding:
This work was supported by the Basque Government (2021111030) and the Platform
to support research on cancer in children and adolescents from EITB Media AND BIOEF, SAU
(BIO20/CI/015/BCB). P.A.-P. is supported by a Basque Government fellowship (PRE_2021_2_0048).
Acknowledgments:
The authors thank the members of the Pediatric Oncology Group of the Biocruces
Bizkaia Health Research Institute for their daily work and involvement. The authors would like to
make a special mention to all patients and families who agree to participate in research projects and
clinical trials. Thanks to them, research in pediatric cancer is possible.
Conflicts of Interest: The authors declare no conflict of interest.
References
1. Modrek, B.; Lee, C. A Genomic View of Alternative Splicing. Nat. Genet. 2002,30, 13–19. [CrossRef] [PubMed]
2. Wang, E.; Aifantis, I. RNA Splicing and Cancer. Trends Cancer 2020,6, 631–644. [CrossRef] [PubMed]
3.
Kahles, A.; Lehmann, K.-V.; Toussaint, N.C.; Hüser, M.; Stark, S.G.; Sachsenberg, T.; Stegle, O.; Kohlbacher, O.; Sander, C.;
Rätsch, G.; et al. Comprehensive Analysis of Alternative Splicing Across Tumors from 8705 Patients. Cancer Cell
2018
,34,
211–224.e6. [CrossRef] [PubMed]
4.
Frankiw, L.; Baltimore, D.; Li, G. Alternative MRNA Splicing in Cancer Immunotherapy. Nat. Rev. Immunol.
2019
,19, 675–687.
[CrossRef]
5.
Gimeno-Valiente, F.; López-Rodas, G.; Castillo, J.; Franco, L. Alternative Splicing, Epigenetic Modifications and Cancer: A
Dangerous Triangle, or a Hopeful One? Cancers 2022,14, 560. [CrossRef] [PubMed]
6. Wang, B.-D.; Lee, N.H. Aberrant RNA Splicing in Cancer and Drug Resistance. Cancers 2018,10, 458. [CrossRef]
7.
Menghi, F.; Jacques, T.S.; Barenco, M.; Schwalbe, E.C.; Clifford, S.C.; Hubank, M.; Ham, J. Genome-Wide Analysis of Alternative
Splicing in Medulloblastoma Identifies Splicing Patterns Characteristic of Normal Cerebellar Development. Cancer Res.
2011
,71,
2045–2055. [CrossRef]
8.
Wei, R.; Yao, Y.; Yang, W.; Zheng, C.-H.; Zhao, M.; Xia, J. DbCPG: A Web Resource for Cancer Predisposition Genes. Oncotarget
2016,7, 37803–37811. [CrossRef]
9.
Johnson, L.-M.; Hamilton, K.V.; Valdez, J.M.; Knapp, E.; Baker, J.N.; Nichols, K.E. Ethical Considerations Surrounding Germline
Next-Generation Sequencing of Children with Cancer. Expert Rev. Mol. Diagn. 2017,17, 523–534. [CrossRef]
10.
Plon, S.E.; Lupo, P.J. Genetic Predisposition to Childhood Cancer in the Genomic Era. Annu. Rev. Genom. Hum. Genet.
2019
,20,
241–263. [CrossRef]
11.
Nix, P.; Mundt, E.; Coffee, B.; Goossen, E.; Warf, B.M.; Brown, K.; Bowles, K.; Roa, B. Interpretation of BRCA2 Splicing Variants: A
Case Series of Challenging Variant Interpretations and the Importance of Functional RNA Analysis. Fam. Cancer
2021
,21, 7–19.
[CrossRef] [PubMed]
12.
Jayasinghe, R.G.; Cao, S.; Gao, Q.; Wendl, M.C.; Vo, N.S.; Reynolds, S.M.; Zhao, Y.; Climente-González, H.; Chai, S.; Wang, F.; et al.
Systematic Analysis of Splice-Site-Creating Mutations in Cancer. Cell Rep. 2018,23, 270–281.e3. [CrossRef] [PubMed]
13.
Rhine, C.L.; Cygan, K.J.; Soemedi, R.; Maguire, S.; Murray, M.F.; Monaghan, S.F.; Fairbrother, W.G. Hereditary Cancer Genes Are
Highly Susceptible to Splicing Mutations. PLoS Genet. 2018,14, e1007231. [CrossRef]
14.
Forbes, S.A.; Beare, D.; Gunasekaran, P.; Leung, K.; Bindal, N.; Boutselakis, H.; Ding, M.; Bamford, S.; Cole, C.; Ward, S.; et al.
COSMIC: Exploring the World’s Knowledge of Somatic Mutations in Human Cancer. Nucleic Acids Res.
2015
,43, D805–D811.
[CrossRef] [PubMed]

Cancers 2022,14, 5967 15 of 23
15.
Waszak, S.M.; Northcott, P.A.; Buchhalter, I.; Robinson, G.W.; Sutter, C.; Groebner, S.; Grund, K.B.; Brugières, L.; Jones, D.T.W.;
Pajtler, K.W.; et al. Spectrum and Prevalence of Genetic Predisposition in Medulloblastoma: A Retrospective Genetic Study and
Prospective Validation in a Clinical Trial Cohort. Lancet Oncol. 2018,19, 785–798. [CrossRef]
16.
Hamilton, S.R.; Liu, B.; Parsons, R.E.; Papadopoulos, N.; Jen, J.; Powell, S.M.; Krush, A.J.; Berk, T.; Cohen, Z.; Tetu, B.; et al. The
Molecular Basis of Turcot’s Syndrome. N. Engl. J. Med. 1995,332, 839–847. [CrossRef]
17.
The St. Jude Children’s Research Hospital–Washington University Pediatric Cancer Genome Project. The Genomic Landscape of
Diffuse Intrinsic Pontine Glioma and Pediatric Non-Brainstem High-Grade Glioma. Nat. Genet. 2014,46, 444–450. [CrossRef]
18.
Mirabello, L.; Zhu, B.; Koster, R.; Karlins, E.; Dean, M.; Yeager, M.; Gianferante, M.; Spector, L.G.; Morton, L.M.; Karyadi, D.; et al.
Frequency of Pathogenic Germline Variants in Cancer-Susceptibility Genes in Patients with Osteosarcoma. JAMA Oncol.
2020
,6, 724.
[CrossRef]
19.
Brohl, A.S.; Patidar, R.; Turner, C.E.; Wen, X.; Song, Y.K.; Wei, J.S.; Calzone, K.A.; Khan, J. Frequent Inactivating Germline
Mutations in DNA Repair Genes in Patients with Ewing Sarcoma. Genet. Med. 2017,19, 955–958. [CrossRef]
20.
Gröbner, S.N.; Worst, B.C.; Weischenfeldt, J.; Buchhalter, I.; Kleinheinz, K.; Rudneva, V.A.; Johann, P.D.; Balasubramanian, G.P.;
Segura-Wang, M.; Brabetz, S.; et al. The Landscape of Genomic Alterations across Childhood Cancers. Nature
2018
,555, 321–327.
[CrossRef]
21.
Muskens, I.S.; Zhang, C.; de Smith, A.J.; Biegel, J.A.; Walsh, K.M.; Wiemels, J.L. Germline Genetic Landscape of Pediatric Central
Nervous System Tumors. Neuro-Oncol. 2019,21, 1376–1388. [CrossRef] [PubMed]
22.
Zhang, J.; Walsh, M.F.; Wu, G.; Edmonson, M.N.; Gruber, T.A.; Easton, J.; Hedges, D.; Ma, X.; Zhou, X.; Yergeau, D.A.; et al.
Germline Mutations in Predisposition Genes in Pediatric Cancer. N. Engl. J. Med. 2015,373, 2336–2346. [CrossRef] [PubMed]
23.
Listernick, R.; Charrow, J.; Greenwald, M.; Mets, M. Natural History of Optic Pathway Tumors in Children with Neurofibromatosis
Type 1: A Longitudinal Study. J. Pediatr. 1994,125, 63–66. [CrossRef] [PubMed]
24.
Helfferich, J.; Nijmeijer, R.; Brouwer, O.F.; Boon, M.; Fock, A.; Hoving, E.W.; Meijer, L.; den Dunnen, W.F.A.; de Bont, E.S.J.M.
Neurofibromatosis Type 1 Associated Low Grade Gliomas: A Comparison with Sporadic Low Grade Gliomas. Crit. Rev. Oncol.
/Hematol. 2016,104, 30–41. [CrossRef] [PubMed]
25.
Ruggieri, M.; Praticò, A.D.; Serra, A.; Maiolino, L.; Cocuzza, S.; Di Mauro, P.; Licciardello, L.; Milone, P.; Privitera, G.; Belfiore, G.;
et al. Childhood Neurofibromatosis Type 2 (NF2) and Related Disorders: From Bench to Bedside and Biologically Targeted
Therapies. Acta Otorhinolaryngol. Ital. 2016,36, 345–367. [CrossRef]
26.
Bouffet, E.; Larouche, V.; Campbell, B.B.; Merico, D.; de Borja, R.; Aronson, M.; Durno, C.; Krueger, J.; Cabric, V.; Ramaswamy, V.;
et al. Immune Checkpoint Inhibition for Hypermutant Glioblastoma Multiforme Resulting from Germline Biallelic Mismatch
Repair Deficiency. J. Clin. Oncol. 2016,34, 2206–2211. [CrossRef]
27.
Brichard, B.; Heusterspreute, M.; De Potter, P.; Chantrain, C.; Vermylen, C.; Sibille, C.; Gala, J.-L. Unilateral Retinoblastoma, Lack
of Familial History and Older Age Does Not Exclude Germline RB1 Gene Mutation. Eur. J. Cancer 2006,42, 65–72. [CrossRef]
28.
Broaddus, E.; Topham, A.; Singh, A.D. Incidence of Retinoblastoma in the USA: 1975–2004. Br. J. Ophthalmol.
2009
,93, 21–23.
[CrossRef]
29.
Rubenfeld, M.; Abramson, D.H.; Ellsworth, R.M.; Kitchin, F.D. Unilateral vs. Bilateral Retinoblastoma. Ophthalmology
1986
,93,
1016–1019. [CrossRef]
30. Plowman, P.N.; Pizer, B.; Kingston, J.E. Pineal Parenchymal Tumours: II. Clin. Oncol. 2004,16, 244–247. [CrossRef]
31.
Dome, J.S.; Rodriguez-Galindo, C.; Spunt, S.L.; Santana, V.M. Pediatric Solid Tumors. In Abeloff’s Clinical Oncology; Elsevier:
Amsterdam, The Netherlands, 2020; pp. 1703–1747.e11, ISBN 978-0-323-47674-4.
32.
Dubuc, A.M.; Northcott, P.A.; Mack, S.; Witt, H.; Pfister, S.; Taylor, M.D. The Genetics of Pediatric Brain Tumors. Curr. Neurol.
Neurosci. Rep. 2010,10, 215–223. [CrossRef] [PubMed]
33.
Cho, Y.-J.; Tsherniak, A.; Tamayo, P.; Santagata, S.; Ligon, A.; Greulich, H.; Berhoukim, R.; Amani, V.; Goumnerova, L.;
Eberhart, C.G.; et al. Integrative Genomic Analysis of Medulloblastoma Identifies a Molecular Subgroup That Drives Poor Clinical
Outcome. J. Clin. Oncol. 2011,29, 1424–1430. [CrossRef] [PubMed]
34.
Kool, M.; Koster, J.; Bunt, J.; Hasselt, N.E.; Lakeman, A.; van Sluis, P.; Troost, D.; Meeteren, N.S.; Caron, H.N.; Cloos, J.;
et al. Integrated Genomics Identifies Five Medulloblastoma Subtypes with Distinct Genetic Profiles, Pathway Signatures and
Clinicopathological Features. PLoS ONE 2008,3, e3088. [CrossRef] [PubMed]
35.
Northcott, P.A.; Hielscher, T.; Dubuc, A.; Mack, S.; Shih, D.; Remke, M.; Al-Halabi, H.; Albrecht, S.; Jabado, N.; Eberhart, C.G.;
et al. Pediatric and Adult Sonic Hedgehog Medulloblastomas Are Clinically and Molecularly Distinct. Acta Neuropathol.
2011
,
122, 231–240. [CrossRef] [PubMed]
36.
Roussel, M.F.; Hatten, M.E. Cerebellum. In Current Topics in Developmental Biology; Elsevier: Amsterdam, The Netherlands, 2011;
Volume 94, pp. 235–282, ISBN 978-0-12-380916-2.
37.
Farini, D.; Marazziti, D.; Geloso, M.C.; Sette, C. Transcriptome Programs Involved in the Development and Structure of the
Cerebellum. Cell. Mol. Life Sci. 2021,78, 6431–6451. [CrossRef] [PubMed]
38.
Dubuc, A.M.; Morrissy, A.S.; Kloosterhof, N.K.; Northcott, P.A.; Yu, E.P.Y.; Shih, D.; Peacock, J.; Grajkowska, W.; van Meter, T.;
Eberhart, C.G.; et al. Subgroup-Specific Alternative Splicing in Medulloblastoma. Acta Neuropathol.
2012
,123, 485–499. [CrossRef]
39.
Suzuki, H.; Kumar, S.A.; Shuai, S.; Diaz-Navarro, A.; Gutierrez-Fernandez, A.; De Antonellis, P.; Cavalli, F.M.G.; Juraschka, K.;
Farooq, H.; Shibahara, I.; et al. Recurrent Noncoding U1 SnRNA Mutations Drive Cryptic Splicing in SHH Medulloblastoma.
Nature 2019,574, 707–711. [CrossRef]

Cancers 2022,14, 5967 16 of 23
40.
Waszak, S.M.; Robinson, G.W.; Gudenas, B.L.; Smith, K.S.; Forget, A.; Kojic, M.; Garcia-Lopez, J.; Hadley, J.; Hamilton, K.V.;
Indersie, E.; et al. Germline Elongator Mutations in Sonic Hedgehog Medulloblastoma. Nature 2020,580, 396–401. [CrossRef]
41.
Ilencikova, D.; Sejnova, D.; Jindrova, J.; Babal, P. High-Grade Brain Tumors in Siblings with Biallelic MSH6 Mutations: Biallelic
MSH6 Mutations and Malignancies. Pediatr. Blood Cancer 2011,57, 1067–1070. [CrossRef]
42.
Fujii, M.; Noguchi, K.; Urade, M.; Muraki, Y.; Moridera, K.; Kishimoto, H.; Hashimoto-Tamaoki, T.; Nakano, Y. Novel PTCH1
Mutations in Japanese Nevoid Basal Cell Carcinoma Syndrome Patients: Two Familial and Three Sporadic Cases Including the
First Japanese Patient with Medulloblastoma. J. Hum. Genet. 2011,56, 277–283. [CrossRef]
43.
Pastorino, L.; Ghiorzo, P.; Nasti, S.; Battistuzzi, L.; Cusano, R.; Marzocchi, C.; Garrè, M.L.; Clementi, M.; Scarrà, G.B. Identification
of a SUFU Germline Mutation in a Family with Gorlin Syndrome. Am. J. Med. Genet.
2009
,149A, 1539–1543. [CrossRef] [PubMed]
44.
Huq, A.J.; Walsh, M.; Rajagopalan, B.; Finlay, M.; Trainer, A.H.; Bonnet, F.; Sevenet, N.; Winship, I.M. Mutations in SUFU and
PTCH1 Genes May Cause Different Cutaneous Cancer Predisposition Syndromes: Similar, but Not the Same. Fam. Cancer
2018
,
17, 601–606. [CrossRef]
45.
Brugières, L.; Remenieras, A.; Pierron, G.; Varlet, P.; Forget, S.; Byrde, V.; Bombled, J.; Puget, S.; Caron, O.; Dufour, C.; et al. High
Frequency of Germline SUFU Mutations in Children With Desmoplastic/Nodular Medulloblastoma Younger Than 3 Years of
Age. J. Clin. Oncol. 2012,30, 2087–2093. [CrossRef] [PubMed]
46.
Taylor, M.D.; Liu, L.; Raffel, C.; Hui, C.; Mainprize, T.G.; Zhang, X.; Agatep, R.; Chiappa, S.; Gao, L.; Lowrance, A.; et al. Mutations
in SUFU Predispose to Medulloblastoma. Nat. Genet. 2002,31, 306–310. [CrossRef] [PubMed]
47.
Chompret, A.; Brugières, L.; Ronsin, M.; Gardes, M.; Dessarps-Freichey, F.; Abel, A.; Hua, D.; Ligot, L.; Dondon, M.G.; Bressac-de
Paillerets, B.; et al. P53 Germline Mutations in Childhood Cancers and Cancer Risk for Carrier Individuals. Br. J. Cancer
2000
,82,
1932–1937. [CrossRef] [PubMed]
48.
Venkataramany, A.S.; Schieffer, K.M.; Lee, K.; Cottrell, C.E.; Wang, P.Y.; Mardis, E.R.; Cripe, T.P.; Chandler, D.S. Alternative RNA
Splicing Defects in Pediatric Cancers: New Insights in Tumorigenesis and Potential Therapeutic Vulnerabilities. Ann. Oncol.
2022
,
33, 578–592. [CrossRef]
49. D’Angelo, F.; Ceccarelli, M.; Tala; Garofano, L.; Zhang, J.; Frattini, V.; Caruso, F.P.; Lewis, G.; Alfaro, K.D.; Bauchet, L.; et al. The
Molecular Landscape of Glioma in Patients with Neurofibromatosis 1. Nat. Med. 2019,25, 176–187. [CrossRef]
50.
Nemethova, M.; Bolcekova, A.; Ilencikova, D.; Durovcikova, D.; Hlinkova, K.; Hlavata, A.; Kovacs, L.; Kadasi, L.; Zatkova, A.
Thirty-Nine Novel Neurofibromatosis 1 ( NF1) Gene Mutations Identified in Slovak Patients: NF1 in Slovakia. Ann. Hum. Genet.
2013,77, 364–379. [CrossRef]
51.
Kline, C.N.; Joseph, N.M.; Grenert, J.P.; van Ziffle, J.; Talevich, E.; Onodera, C.; Aboian, M.; Cha, S.; Raleigh, D.R.; Braunstein, S.;
et al. Targeted Next-Generation Sequencing of Pediatric Neuro-Oncology Patients Improves Diagnosis, Identifies Pathogenic
Germline Mutations, and Directs Targeted Therapy. Neuro-Oncol. 2016,19, 699–709. [CrossRef]
52.
Kline, C.N.; Joseph, N.M.; Grenert, J.P.; van Ziffle, J.; Yeh, I.; Bastian, B.C.; Mueller, S.; Solomon, D.A. Inactivating MUTYH
Germline Mutations in Pediatric Patients with High-Grade Midline Gliomas. Neuro Oncol. 2016,18, 752–753. [CrossRef]
53. Kordes, U.; Gesk, S.; Frühwald, M.C.; Graf, N.; Leuschner, I.; Hasselblatt, M.; Jeibmann, A.; Oyen, F.; Peters, O.; Pietsch, T.; et al.
Clinical and Molecular Features in Patients with Atypical Teratoid Rhabdoid Tumor or Malignant Rhabdoid Tumor: Molecular
Features in Patients with ATRT. Genes Chromosom. Cancer 2010,49, 176–181. [CrossRef] [PubMed]
54.
de Kock, L.; Sabbaghian, N.; Druker, H.; Weber, E.; Hamel, N.; Miller, S.; Choong, C.S.; Gottardo, N.G.; Kees, U.R.; Rednam, S.P.;
et al. Germ-Line and Somatic DICER1 Mutations in Pineoblastoma. Acta Neuropathol. 2014,128, 583–595. [CrossRef] [PubMed]
55.
Jolly, K.W.; Malkin, D.; Douglass, E.C.; Brown, T.F.; Sinclair, A.E.; Look, A.T. Splice-Site Mutation of the P53 Gene in a Family with
Hereditary Breast-Ovarian Cancer. Oncogene 1994,9, 97–102. [PubMed]
56.
Hottinger, A.F.; Khakoo, Y. Neurooncology of Familial Cancer Syndromes. J. Child Neurol.
2009
,24, 1526–1535. [CrossRef]
[PubMed]
57.
Smith, M.J.; Beetz, C.; Williams, S.G.; Bhaskar, S.S.; O’Sullivan, J.; Anderson, B.; Daly, S.B.; Urquhart, J.E.; Bholah, Z.; Oudit, D.;
et al. Germline Mutations in SUFU Cause Gorlin Syndrome–Associated Childhood Medulloblastoma and Redefine the Risk
Associated With PTCH1 Mutations. J. Clin. Oncol. 2014,32, 4155–4161. [CrossRef] [PubMed]
58.
Zhukova, N.; Ramaswamy, V.; Remke, M.; Pfaff, E.; Shih, D.J.H.; Martin, D.C.; Castelo-Branco, P.; Baskin, B.; Ray, P.N.; Bouffet, E.;
et al. Subgroup-Specific Prognostic Implications of TP53 Mutation in Medulloblastoma. J. Clin. Oncol.
2013
,31, 2927–2935.
[CrossRef] [PubMed]
59.
Kool, M.; Jones, D.T.W.; Jäger, N.; Northcott, P.A.; Pugh, T.J.; Hovestadt, V.; Piro, R.M.; Esparza, L.A.; Markant, S.L.; Remke, M.;
et al. Genome Sequencing of SHH Medulloblastoma Predicts Genotype-Related Response to Smoothened Inhibition. Cancer Cell
2014,25, 393–405. [CrossRef] [PubMed]
60. Miele, E.; Mastronuzzi, A.; Po, A.; Carai, A.; Alfano, V.; Serra, A.; Colafati, G.S.; Strocchio, L.; Antonelli, M.; Buttarelli, F.R.; et al.
Characterization of Medulloblastoma in Fanconi Anemia: A Novel Mutation in the BRCA2 Gene and SHH Molecular Subgroup.
Biomark. Res. 2015,3, 13. [CrossRef]
61.
Xu, J.; Margol, A.S.; Shukla, A.; Ren, X.; Finlay, J.L.; Krieger, M.D.; Gilles, F.H.; Couch, F.J.; Aziz, M.; Fung, E.T.; et al. Disseminated
Medulloblastoma in a Child with Germline BRCA2 6174delT Mutation and without Fanconi Anemia. Front. Oncol.
2015
,5, 191.
[CrossRef]
62.
Amlashi, S.F.A.; Riffaud, L.; Brassier, G.; Morandi, X. Nevoid Basal Cell Carcinoma Syndrome: Relation with Desmoplastic
Medulloblastoma in Infancy: A Population-Based Study and Review of the Literature. Cancer 2003,98, 618–624. [CrossRef]

Cancers 2022,14, 5967 17 of 23
63.
Li, F.P.; Fraumeni, J.F.; Mulvihill, J.J.; Blattner, W.A.; Dreyfus, M.G.; Tucker, M.A.; Miller, R.W. A Cancer Family Syndrome in
Twenty-Four Kindreds. Cancer Res. 1988,48, 5358–5362. [PubMed]
64.
Fromentel, C.C.D.; Soussi, T. TP53 Tumor Suppressor Gene: A Model for Investigating Human Mutagenesis. Genes Chromosom.
Cancer 1992,4, 1–15. [CrossRef] [PubMed]
65.
Kouidou, S.; Malousi, A.; Maglaveras, N. Li-Fraumeni and Li-Fraumeni-like Syndrome Mutations in P53 Are Associated with
Exonic Methylation and Splicing Regulatory Elements: LF/LFL SYNDROME MUTATIONS IN P53. Mol. Carcinog.
2009
,48,
895–902. [CrossRef] [PubMed]
66.
Warneford, S.G.; Witton, L.J.; Townsend, M.L.; Rowe, P.B.; Reddel, R.R.; Dalla-Pozza, L.; Symonds, G. Germ-Line Splicing
Mutation of the P53 Gene in a Cancer-Prone Family. Cell Growth Differ. 1992,3, 839–846.
67.
Felix, C.A.; Strauss, E.A.; D’Amico, D.; Tsokos, M.; Winter, S.; Mitsudomi, T.; Nau, M.M.; Brown, D.L.; Leahey, A.M.;
Horowitz, M.E. A Novel Germline P53 Splicing Mutation in a Pediatric Patient with a Second Malignant Neoplasm. Oncogene
1993,8, 1203–1210.
68.
Haque, M.M.; Kowtal, P.; Sarin, R. Identification and Characterization of TP53 Gene Allele Dropout in Li-Fraumeni Syndrome
and Oral Cancer Cohorts. Sci. Rep. 2018,8, 11705. [CrossRef]
69.
Northcott, P.A.; Buchhalter, I.; Morrissy, A.S.; Hovestadt, V.; Weischenfeldt, J.; Ehrenberger, T.; Gröbner, S.; Segura-Wang, M.;
Zichner, T.; Rudneva, V.A.; et al. The Whole-Genome Landscape of Medulloblastoma Subtypes. Nature
2017
,547, 311–317.
[CrossRef]
70.
Hart, R.M.; Kimler, B.F.; Evans, R.G.; Park, C.H. Radiotherapeutic Management of Medulloblastoma in a Pediatric Patient with
Ataxia Telangiectasia. Int. J. Radiat. Oncol. Biol. Phys. 1987,13, 1237–1240. [CrossRef]
71.
Sturm, D.; Pfister, S.M.; Jones, D.T.W. Pediatric Gliomas: Current Concepts on Diagnosis, Biology, and Clinical Management. J.
Clin. Oncol. 2017,35, 2370–2377. [CrossRef]
72.
Ostrom, Q.T.; Gittleman, H.; Fulop, J.; Liu, M.; Blanda, R.; Kromer, C.; Wolinsky, Y.; Kruchko, C.; Barnholtz-Sloan, J.S. CBTRUS
Statistical Report: Primary Brain and Central Nervous System Tumors Diagnosed in the United States in 2008-2012. Neuro Oncol.
2015,17, iv1–iv62. [CrossRef]
73.
Ostrom, Q.T.; de Blank, P.M.; Kruchko, C.; Petersen, C.M.; Liao, P.; Finlay, J.L.; Stearns, D.S.; Wolff, J.E.; Wolinsky, Y.; Letterio, J.J.;
et al. Alex’s Lemonade Stand Foundation Infant and Childhood Primary Brain and Central Nervous System Tumors Diagnosed
in the United States in 2007–2011. Neuro-Oncol. 2015,16, x1–x36. [CrossRef] [PubMed]
74.
Dong, X.; Wang, L.; Taniguchi, K.; Wang, X.; Cunningham, J.M.; McDonnell, S.K.; Qian, C.; Marks, A.F.; Slager, S.L.; Peterson, B.J.;
et al. Mutations in CHEK2 Associated with Prostate Cancer Risk. Am. J. Hum. Genet. 2003,72, 270–280. [CrossRef] [PubMed]
75. Vitanza, N.A.; Partap, S. Pediatric Ependymoma. J. Child Neurol. 2016,31, 1354–1366. [CrossRef]
76.
Foss-Skiftesvik, J.; Stoltze, U.K.; van Overeem Hansen, T.; Ahlborn, L.B.; Sørensen, E.; Ostrowski, S.R.; Kullegaard, S.M.A.;
Laspiur, A.O.; Melchior, L.C.; Scheie, D.; et al. Redefining Germline Predisposition in Children with Molecularly Characterized
Ependymoma: A Population-Based 20-Year Cohort. Acta Neuropathol. Commun. 2022,10, 123. [CrossRef] [PubMed]
77.
Baser, M.E.; Kuramoto, L.; Joe, H.; Friedman, J.M.; Wallace, A.J.; Gillespie, J.E.; Ramsden, R.T.; Evans, D.G.R. Genotype-Phenotype
Correlations for Nervous System Tumors in Neurofibromatosis 2: A Population-Based Study. Am. J. Hum. Genet.
2004
,75,
231–239. [CrossRef]
78.
Cooper, J.; Giancotti, F.G. Molecular Insights into NF2 /Merlin Tumor Suppressor Function. FEBS Lett.
2014
,588, 2743–2752.
[CrossRef]
79.
Painter, S.L.; Sipkova, Z.; Emmanouil, B.; Halliday, D.; Parry, A.; Elston, J.S. Neurofibromatosis Type 2–Related Eye Disease
Correlated With Genetic Severity Type. J. Neuro-Ophthalmol. 2019,39, 44–49. [CrossRef]
80.
Stuckert, A.; Bertrand, K.C.; Wang, P.; Smith, A.; Mack, S.C. Weighing Ependymoma as an Epigenetic Disease. J. Neurooncol.
2020
,
150, 57–61. [CrossRef]
81.
Jain, S.U.; Do, T.J.; Lund, P.J.; Rashoff, A.Q.; Diehl, K.L.; Cieslik, M.; Bajic, A.; Juretic, N.; Deshmukh, S.; Venneti, S.; et al. PFA
Ependymoma-Associated Protein EZHIP Inhibits PRC2 Activity through a H3 K27M-like Mechanism. Nat. Commun.
2019
,10, 2146.
[CrossRef]
82.
Uusitalo, E.; Rantanen, M.; Kallionpää, R.A.; Pöyhönen, M.; Leppävirta, J.; Ylä-Outinen, H.; Riccardi, V.M.; Pukkala, E.;
Pitkäniemi, J.; Peltonen, S.; et al. Distinctive Cancer Associations in Patients With Neurofibromatosis Type 1. J. Clin. Oncol.
2016
,
34, 1978–1986. [CrossRef]
83.
Seminog, O.O.; Goldacre, M.J. Risk of Benign Tumours of Nervous System, and of Malignant Neoplasms, in People with
Neurofibromatosis: Population-Based Record-Linkage Study. Br. J. Cancer 2013,108, 193–198. [CrossRef] [PubMed]
84.
Blanchard, G.; Lafforgue, M.-P.; Lion-François, L.; Kemlin, I.; Rodriguez, D.; Castelnau, P.; Carneiro, M.; Meyer, P.; Rivier, F.;
Barbarot, S.; et al. Systematic MRI in NF1 Children under Six Years of Age for the Diagnosis of Optic Pathway Gliomas. Study
and Outcome of a French Cohort. Eur. J. Paediatr. Neurol. 2016,20, 275–281. [CrossRef] [PubMed]
85.
Kaul, A.; Toonen, J.A.; Cimino, P.J.; Gianino, S.M.; Gutmann, D.H. Akt- or MEK-Mediated MTOR Inhibition Suppresses Nf1 Optic
Glioma Growth. Neuro-Oncol. 2015,17, 843–853. [CrossRef] [PubMed]
86.
Braunstein, S.; Raleigh, D.; Bindra, R.; Mueller, S.; Haas-Kogan, D. Pediatric High-Grade Glioma: Current Molecular Landscape
and Therapeutic Approaches. J. Neurooncol. 2017,134, 541–549. [CrossRef]

Cancers 2022,14, 5967 18 of 23
87.
Wimmer, K.; Kratz, C.P.; Vasen, H.F.A.; Caron, O.; Colas, C.; Entz-Werle, N.; Gerdes, A.-M.; Goldberg, Y.; Ilencikova, D.; Muleris,
M.; et al. Diagnostic Criteria for Constitutional Mismatch Repair Deficiency Syndrome: Suggestions of the European Consortium
‘Care for CMMRD’ (C4CMMRD). J. Med. Genet. 2014,51, 355–365. [CrossRef]
88.
Wimmer, K.; Etzler, J. Constitutional Mismatch Repair-Deficiency Syndrome: Have We so Far Seen Only the Tip of an Iceberg?
Hum. Genet. 2008,124, 105–122. [CrossRef]
89.
Hill, D.A.; Ivanovich, J.; Priest, J.R.; Gurnett, C.A.; Dehner, L.P.; Desruisseau, D.; Jarzembowski, J.A.; Wikenheiser-Brokamp, K.A.;
Suarez, B.K.; Whelan, A.J.; et al. DICER1 Mutations in Familial Pleuropulmonary Blastoma. Science 2009,325, 965. [CrossRef]
90.
Smith, M.J.; Wallace, A.J.; Bowers, N.L.; Eaton, H.; Evans, D.G.R. SMARCB1 Mutations in Schwannomatosis and Genotype
Correlations with Rhabdoid Tumors. Cancer Genet. 2014,207, 373–378. [CrossRef]
91.
Taylor, M.D.; Gokgoz, N.; Andrulis, I.L.; Mainprize, T.G.; Drake, J.M.; Rutka, J.T. Familial Posterior Fossa Brain Tumors of Infancy
Secondary to Germline Mutation of the HSNF5 Gene. Am. J. Hum. Genet. 2000,66, 1403–1406. [CrossRef]
92.
Sabatella, M.; Mantere, T.; Waanders, E.; Neveling, K.; Mensenkamp, A.R.; Dijk, F.; Hehir-Kwa, J.Y.; Derks, R.; Kwint, M.;
O’Gorman, L.; et al. Optical Genome Mapping Identifies a Germline Retrotransposon Insertion in SMARCB1 in Two Siblings
with Atypical Teratoid Rhabdoid Tumors. J. Pathol. 2021,255, 202–211. [CrossRef]
93.
WHO Classification of Tumours Editorial Board. Soft Tissue and Bone Tumours; International Agency for Research on Cancer: Lyon,
France, 2020; ISBN 978-92-832-4502-5.
94.
Mirabello, L.; Troisi, R.J.; Savage, S.A. International Osteosarcoma Incidence Patterns in Children and Adolescents, Middle Ages
and Elderly Persons. Int. J. Cancer 2009,125, 229–234. [CrossRef] [PubMed]
95.
Calvert, G.T.; Randall, R.L.; Jones, K.B.; Cannon-Albright, L.; Lessnick, S.; Schiffman, J.D. At-Risk Populations for Osteosarcoma:
The Syndromes and Beyond. Sarcoma 2012,2012, 152382. [CrossRef] [PubMed]
96.
Tinat, J.; Bougeard, G.; Baert-Desurmont, S.; Vasseur, S.; Martin, C.; Bouvignies, E.; Caron, O.; Bressac-de Paillerets, B.; Berthet, P.;
Dugast, C.; et al. 2009 Version of the Chompret Criteria for Li Fraumeni Syndrome. J. Clin. Oncol.
2009
,27, e108–e109. [CrossRef]
[PubMed]
97.
Chauveinc, L.; Mosseri, V.; Quintana, E.; Desjardins, L.; Schlienger, P.; Doz, F.; Dutrillaux, B. Osteosarcoma Following Retinoblas-
toma: Age at Onset and Latency Period. Ophthalmic Genet. 2001,22, 77–88. [CrossRef]
98.
Siitonen, H.A.; Sotkasiira, J.; Biervliet, M.; Benmansour, A.; Capri, Y.; Cormier-Daire, V.; Crandall, B.; Hannula-Jouppi, K.;
Hennekam, R.; Herzog, D.; et al. The Mutation Spectrum in RECQL4 Diseases. Eur. J. Hum. Genet.
2009
,17, 151–158. [CrossRef]
99.
Ishikawa, Y.; Miller, R.W.; Machinami, R.; Sugano, H.; Goto, M. Atypical Osteosarcomas in Werner Syndrome (Adult Progeria).
Jpn. J. Cancer Res. 2000,91, 1345–1349. [CrossRef]
100. German, J. Bloom’s Syndrome. XX. The First 100 Cancers. Cancer Genet. Cytogenet. 1997,93, 100–106. [CrossRef]
101.
Piao, J.; Sakurai, N.; Iwamoto, S.; Nishioka, J.; Nakatani, K.; Komada, Y.; Mizutani, S.; Takagi, M. Functional Studies of a Novel
Germline P53 Splicing Mutation Identified in a Patient with Li–F Raumeni-L Ike Syndrome. Mol. Carcinog.
2013
,52, 770–776.
[CrossRef]
102.
Austin, F.; Oyarbide, U.; Massey, G.; Grimes, M.; Corey, S.J. Synonymous Mutation in TP53 Results in a Cryptic Splice Site
Affecting Its DNA-binding Site in an Adolescent with Two Primary Sarcomas. Pediatr. Blood Cancer 2017,64, e26584. [CrossRef]
103.
Sakurai, N.; Iwamoto, S.; Miura, Y.; Nakamura, T.; Matsumine, A.; Nishioka, J.; Nakatani, K.; Komada, Y. Novel P53 Splicing
Site Mutation in Li-Fraumeni-like Syndrome with Osteosarcoma: Novel P53 Splicing Site Mutation in LFL. Pediatr. Int.
2013
,55,
107–111. [CrossRef]
104.
Renaux-Petel, M.; Charbonnier, F.; Théry, J.-C.; Fermey, P.; Lienard, G.; Bou, J.; Coutant, S.; Vezain, M.; Kasper, E.; Fourneaux, S.;
et al. Contribution of de Novo and Mosaic TP53 Mutations to Li-Fraumeni Syndrome. J. Med. Genet.
2018
,55, 173–180. [CrossRef]
[PubMed]
105.
Wong, S.S.; Lozano, G.; Gaff, C.L.; Gardner, R.J.M.; Strong, L.C.; Aittomäki, K.; Lindeman, G.J. Novel P53 Germline Mutation in a
Patient with Li−Fraumeni Syndrome: Letters to the Editor. Int. Med. J. 2003,33, 621–623. [CrossRef] [PubMed]
106.
Mazoyer, S.; Lalle, P.; Moyret-Lalle, C.; Marçais, C.; Schraub, S.; Frappaz, D.; Sobol, H.; Ozturk, M. Two Germ-Line Mutations
Affecting the Same Nucleotide at Codon 257 of P53 Gene, a Rare Site for Mutations. Oncogene 1994,9, 1237–1239. [PubMed]
107.
Gillani, R.; Camp, S.Y.; Han, S.; Jones, J.K.; Chu, H.; O’Brien, S.; Young, E.L.; Hayes, L.; Mitchell, G.; Fowler, T.; et al. Germline
Predisposition to Pediatric Ewing Sarcoma Is Characterized by Inherited Pathogenic Variants in DNA Damage Repair Genes. Am.
J. Hum. Genet. 2022,109, 1026–1037. [CrossRef]
108.
Wang, L.L.; Gannavarapu, A.; Kozinetz, C.A.; Levy, M.L.; Lewis, R.A.; Chintagumpala, M.M.; Ruiz-Maldanado, R.; Contreras-
Ruiz, J.; Cunniff, C.; Erickson, R.P.; et al. Association Between Osteosarcoma and Deleterious Mutations in the RECQL4 Gene in
Rothmund-Thomson Syndrome. JNCI J. Natl. Cancer Inst. 2003,95, 669–674. [CrossRef]
109. Lindor, N.M.; Furuichi, Y.; Kitao, S.; Shimamoto, A.; Arndt, C.; Jalal, S. Rothmund-Thomson Syndrome Due ToRECQ4 Helicase
Mutations: Report and Clinical and Molecular Comparisons with Bloom Syndrome and Werner Syndrome. Am. J. Med. Genet.
2000,90, 223–228. [CrossRef]
110.
Simon, T.; Kohlhase, J.; Wilhelm, C.; Kochanek, M.; De Carolis, B.; Berthold, F. Multiple Malignant Diseases in a Patient with
Rothmund-Thomson Syndrome with RECQL4 Mutations: Case Report and Literature Review. Am. J. Med. Genet.
2010
,152A,
1575–1579. [CrossRef]
111.
Beghini, A.; Castorina, P.; Roversi, G.; Modiano, P.; Larizza, L. RNA Processing Defects of the Helicase GeneRECQL4 in a
Compound Heterozygous Rothmund-Thomson Patient. Am. J. Med. Genet. 2003,120, 395–399. [CrossRef]

Cancers 2022,14, 5967 19 of 23
112.
Van Hest, L.P.; Ruijs, M.W.G.; Wagner, A.; van der Meer, C.A.; Verhoef, S.; van‘t Veer, L.J.; Meijers-Heijboer, H. Two TP53 Germline
Mutations in a Classical Li-Fraumeni Syndrome Family. Fam. Cancer 2007,6, 311–316. [CrossRef]
113.
Bouaoun, L.; Sonkin, D.; Ardin, M.; Hollstein, M.; Byrnes, G.; Zavadil, J.; Olivier, M. TP53 Variations in Human Cancers: New
Lessons from the IARC TP53 Database and Genomics Data. Hum. Mutat. 2016,37, 865–876. [CrossRef]
114.
Li, H.; Sisoudiya, S.D.; Martin-Giacalone, B.A.; Khayat, M.M.; Dugan-Perez, S.; Marquez-Do, D.A.; Scheurer, M.E.; Muzny, D.;
Boerwinkle, E.; Gibbs, R.A.; et al. Germline Cancer Predisposition Variants in Pediatric Rhabdomyosarcoma: A Report from the
Children’s Oncology Group. JNCI J. Natl. Cancer Inst. 2021,113, 875–883. [CrossRef]
115.
Nashed, L.M.; Mayhew, A.; Gomez-Lobo, V.; Lawlor, C. DICER1 Mutation Detected in an Infant Guides Accurate Diagnosis of
Auto-Amputated Embryonal Rhabdomyosarcoma. J. Pediatr. Adolesc. Gynecol. 2021,34, 865–868. [CrossRef] [PubMed]
116.
Dommering, C.J.; Marees, T.; van der Hout, A.H.; Imhof, S.M.; Meijers-Heijboer, H.; Ringens, P.J.; van Leeuwen, F.E.; Moll, A.C.
RB1 Mutations and Second Primary Malignancies after Hereditary Retinoblastoma. Fam. Cancer
2012
,11, 225–233. [CrossRef]
[PubMed]
117.
Imbert-Bouteille, M.; Gauthier-Villars, M.; Leroux, D.; Meunier, I.; Aerts, I.; Lumbroso-Le Rouic, L.; Lejeune, S.; Delnatte, C.;
Abadie, C.; Pujol, P.; et al. Osteosarcoma without Prior Retinoblastoma Related to RB1 Low-penetrance Germline Pathogenic
Variants: A Novel Type of RB1 -related Hereditary Predisposition Syndrome? Mol. Genet. Genom. Med.
2019
,7, e913. [CrossRef]
[PubMed]
118.
Czarnecka, A.M.; Synoradzki, K.; Firlej, W.; Bartnik, E.; Sobczuk, P.; Fiedorowicz, M.; Grieb, P.; Rutkowski, P. Molecular Biology
of Osteosarcoma. Cancers 2020,12, 2130. [CrossRef]
119. Larizza, L.; Roversi, G.; Volpi, L. Rothmund-Thomson Syndrome. Orphanet. J. Rare Dis. 2010,5, 2. [CrossRef]
120.
Esiashvili, N.; Goodman, M.; Marcus, R.B. Changes in Incidence and Survival of Ewing Sarcoma Patients Over the Past 3 Decades:
Surveillance Epidemiology and End Results Data. J. Pediatr. Hematol./Oncol. 2008,30, 425–430. [CrossRef]
121.
Choi, E.-Y.K.; Gardner, J.M.; Lucas, D.R.; McHugh, J.B.; Patel, R.M. Ewing Sarcoma. Semin. Diagn. Pathol.
2014
,31, 39–47.
[CrossRef]
122.
Choi, J.H.; Ro, J.Y. The 2020 WHO Classification of Tumors of Soft Tissue: Selected Changes and New Entities. Adv. Anat. Pathol.
2021,28, 44–58. [CrossRef]
123.
Crompton, B.D.; Stewart, C.; Taylor-Weiner, A.; Alexe, G.; Kurek, K.C.; Calicchio, M.L.; Kiezun, A.; Carter, S.L.; Shukla, S.A.;
Mehta, S.S.; et al. The Genomic Landscape of Pediatric Ewing Sarcoma. Cancer Discov.
2014
,4, 1326–1341. [CrossRef] [PubMed]
124.
Machiela, M.J.; Grünewald, T.G.P.; Surdez, D.; Reynaud, S.; Mirabeau, O.; Karlins, E.; Rubio, R.A.; Zaidi, S.; Grossetete-Lalami, S.;
Ballet, S.; et al. Genome-Wide Association Study Identifies Multiple New Loci Associated with Ewing Sarcoma Susceptibility.
Nat. Commun. 2018,9, 3184. [CrossRef] [PubMed]
125.
Grohar, P.J.; Kim, S.; Rangel Rivera, G.O.; Sen, N.; Haddock, S.; Harlow, M.L.; Maloney, N.K.; Zhu, J.; O’Neill, M.; Jones, T.L.; et al.
Functional Genomic Screening Reveals Splicing of the EWS-FLI1 Fusion Transcript as a Vulnerability in Ewing Sarcoma. Cell Rep.
2016,14, 598–610. [CrossRef] [PubMed]
126.
Mo, J.; Tan, K.; Dong, Y.; Lu, W.; Liu, F.; Mei, Y.; Huang, H.; Zhao, K.; Lv, Z.; Ye, Y.; et al. Therapeutic Targeting the Oncogenic
Driver EWSR1::FLI1 in Ewing Sarcoma through Inhibition of the FACT Complex. Oncogene
2022
,38, 307–3092. [CrossRef]
[PubMed]
127.
Vibert, J.; Saulnier, O.; Collin, C.; Petit, F.; Borgman, K.J.E.; Vigneau, J.; Gautier, M.; Zaidi, S.; Pierron, G.; Watson, S.; et al.
Oncogenic Chimeric Transcription Factors Drive Tumor-Specific Transcription, Processing, and Translation of Silent Genomic
Regions. Mol. Cell 2022,82, 2458–2471.e9. [CrossRef] [PubMed]
128.
Prasad, A.; Wallace, S.S.; Pederson, D.S. Initiation of Base Excision Repair of Oxidative Lesions in Nucleosomes by the Human,
Bifunctional DNA Glycosylase NTH1. Mol. Cell. Biol. 2007,27, 8442–8453. [CrossRef] [PubMed]
129.
Kim, Y. Nuclease Delivery: Versatile Functions of SLX4/FANCP in Genome Maintenance. Mol. Cells
2014
,37, 569–574. [CrossRef]
130. Bartek, J.; Lukas, J. Chk1 and Chk2 Kinases in Checkpoint Control and Cancer. Cancer Cell 2003,3, 421–429. [CrossRef]
131.
Ito, S.; Kuraoka, I.; Chymkowitch, P.; Compe, E.; Takedachi, A.; Ishigami, C.; Coin, F.; Egly, J.-M.; Tanaka, K. XPG Stabilizes TFIIH,
Allowing Transactivation of Nuclear Receptors: Implications for Cockayne Syndrome in XP-G/CS Patients. Mol. Cell
2007
,26,
231–243. [CrossRef]
132.
Prakash, R.; Zhang, Y.; Feng, W.; Jasin, M. Homologous Recombination and Human Health: The Roles of BRCA1, BRCA2, and
Associated Proteins. Cold Spring Harb. Perspect. Biol. 2015,7, a016600. [CrossRef]
133.
Castella, M.; Pujol, R.; Callén, E.; Trujillo, J.P.; Casado, J.A.; Gille, H.; Lach, F.P.; Auerbach, A.D.; Schindler, D.; Benítez, J.; et al.
Origin, Functional Role, and Clinical Impact of Fanconi Anemia FANCA Mutations. Blood 2011,117, 3759–3769. [CrossRef]
134.
Kitao, H.; Yamamoto, K.; Matsushita, N.; Ohzeki, M.; Ishiai, M.; Takata, M. Functional Interplay between BRCA2/FancD1 and
FancC in DNA Repair. J. Biol. Chem. 2006,281, 21312–21320. [CrossRef] [PubMed]
135.
Smogorzewska, A.; Matsuoka, S.; Vinciguerra, P.; McDonald, E.R.; Hurov, K.E.; Luo, J.; Ballif, B.A.; Gygi, S.P.; Hofmann, K.;
D’Andrea, A.D.; et al. Identification of the FANCI Protein, a Monoubiquitinated FANCD2 Paralog Required for DNA Repair. Cell
2007,129, 289–301. [CrossRef]
136.
Nalepa, G.; Clapp, D.W. Fanconi Anaemia and Cancer: An Intricate Relationship. Nat. Rev. Cancer
2018
,18, 168–185. [CrossRef]
[PubMed]
137.
Ceccaldi, R.; Sarangi, P.; D’Andrea, A.D. The Fanconi Anaemia Pathway: New Players and New Functions. Nat. Rev. Mol. Cell
Biol. 2016,17, 337–349. [CrossRef] [PubMed]

Cancers 2022,14, 5967 20 of 23
138.
Skapek, S.X.; Ferrari, A.; Gupta, A.A.; Lupo, P.J.; Butler, E.; Shipley, J.; Barr, F.G.; Hawkins, D.S. Rhabdomyosarcoma. Nat. Rev.
Dis. Prim. 2019,5, 1. [CrossRef]
139.
Parham, D.M.; Barr, F.G. Classification of Rhabdomyosarcoma and Its Molecular Basis. Adv. Anat. Pathol.
2013
,20, 387–397.
[CrossRef]
140.
Shern, J.F.; Selfe, J.; Izquierdo, E.; Patidar, R.; Chou, H.-C.; Song, Y.K.; Yohe, M.E.; Sindiri, S.; Wei, J.; Wen, X.; et al. Genomic
Classification and Clinical Outcome in Rhabdomyosarcoma: A Report From an International Consortium. J. Clin. Oncol.
2021
,39,
2859–2871. [CrossRef]
141.
Diller, L.; Sexsmith, E.; Gottlieb, A.; Li, F.P.; Malkin, D. Germline P53 Mutations Are Frequently Detected in Young Children with
Rhabdomyosarcoma. J. Clin. Investig. 1995,95, 1606–1611. [CrossRef]
142.
Doros, L.; Yang, J.; Dehner, L.; Rossi, C.T.; Skiver, K.; Jarzembowski, J.A.; Messinger, Y.; Schultz, K.A.; Williams, G.; André, N.;
et al. DICER1 Mutations in Embryonal Rhabdomyosarcomas from Children with and without Familial PPB-Tumor Predisposition
Syndrome. Pediatr. Blood Cancer 2012,59, 558–560. [CrossRef]
143.
Capasso, M.; Montella, A.; Tirelli, M.; Maiorino, T.; Cantalupo, S.; Iolascon, A. Genetic Predisposition to Solid Pediatric Cancers.
Front. Oncol. 2020,10, 590033. [CrossRef]
144.
Ney, G.M.; McKay, L.; Koschmann, C.; Mody, R.; Li, Q. The Emerging Role of Ras Pathway Signaling in Pediatric Cancer. Cancer
Res. 2020,80, 5155–5163. [CrossRef] [PubMed]
145.
Aoki, Y.; Niihori, T.; Inoue, S.; Matsubara, Y. Recent Advances in RASopathies. J. Hum. Genet.
2016
,61, 33–39. [CrossRef]
[PubMed]
146.
Hartley, A.L.; Birch, J.M.; Marsden, H.B.; Harris, M.; Blair, V. Neurofibromatosis in Children with Soft Tissue Sarcoma. Pediatr.
Hematol. Oncol. 1988,5, 7–16. [CrossRef] [PubMed]
147.
Kratz, C.P.; Rapisuwon, S.; Reed, H.; Hasle, H.; Rosenberg, P.S. Cancer in Noonan, Costello, Cardiofaciocutaneous and LEOPARD
Syndromes. Am. J. Med. Genet. 2011,157, 83–89. [CrossRef] [PubMed]
148.
Foulkes, W.D.; Priest, J.R.; Duchaine, T.F. DICER1: Mutations, MicroRNAs and Mechanisms. Nat. Rev. Cancer
2014
,14, 662–672.
[CrossRef]
149.
Schultz, K.A.P.; Williams, G.M.; Kamihara, J.; Stewart, D.R.; Harris, A.K.; Bauer, A.J.; Turner, J.; Shah, R.; Schneider, K.;
Schneider, K.W.; et al. DICER1 and Associated Conditions: Identification of At-Risk Individuals and Recommended Surveillance
Strategies. Clin. Cancer Res. 2018,24, 2251–2261. [CrossRef]
150.
Capasso, M.; Diskin, S.J. Genetics and Genomics of Neuroblastoma. In Cancer Genetics; Pasche, B., Ed.; Cancer Treatment and
Research; Springer US: Boston, MA, USA, 2010; Volume 155, pp. 65–84, ISBN 978-1-4419-6032-0.
151.
Chitayat, D.; Friedman, J.M.; Dimmick, J.E. Neuroblastoma in a Child with Wiedemann-Beckwith Syndrome. Am. J. Med. Genet.
1990,35, 433–436. [CrossRef]
152.
Maas, S.M.; Vansenne, F.; Kadouch, D.J.M.; Ibrahim, A.; Bliek, J.; Hopman, S.; Mannens, M.M.; Merks, J.H.M.; Maher, E.R.;
Hennekam, R.C. Phenotype, Cancer Risk, and Surveillance in Beckwith-Wiedemann Syndrome Depending on Molecular Genetic
Subgroups. Am. J. Med. Genet. 2016,170, 2248–2260. [CrossRef]
153.
Trochet, D.; Bourdeaut, F.; Janoueix-Lerosey, I.; Deville, A.; de Pontual, L.; Schleiermacher, G.; Coze, C.; Philip, N.; Frébourg, T.;
Munnich, A.; et al. Germline Mutations of the Paired–Like Homeobox 2B (PHOX2B) Gene in Neuroblastoma. Am. J. Hum. Genet.
2004,74, 761–764. [CrossRef]
154.
Rohrer, T.; Trachsel, D.; Engelcke, G.; Hammer, J. Congenital Central Hypoventilation Syndrome Associated with Hirschsprung’s
Disease and Neuroblastoma: Case of Multiple Neurocristopathies. Pediatr. Pulmonol. 2002,33, 71–76. [CrossRef]
155. Barr, E.; Applebaum, M. Genetic Predisposition to Neuroblastoma. Children 2018,5, 119. [CrossRef] [PubMed]
156.
Gripp, K.W.; Lin, A.E. Costello Syndrome: A Ras/Mitogen Activated Protein Kinase Pathway Syndrome (Rasopathy) Resulting
from HRAS Germline Mutations. Genet. Med. 2012,14, 285–292. [CrossRef] [PubMed]
157.
Schimke, R.N.; Collins, D.L.; Stolle, C.A. Paraganglioma, Neuroblastoma, and a SDHB Mutation: Resolution of a 30-Year-Old
Mystery. Am. J. Med. Genet. 2010,152A, 1531–1535. [CrossRef] [PubMed]
158.
Birch, J.M.; Alston, R.D.; McNally, R.J.; Evans, D.G.R.; Kelsey, A.M.; Harris, M.; Eden, O.B.; Varley, J.M. Relative Frequency and
Morphology of Cancers in Carriers of Germline TP53 Mutations. Oncogene 2001,20, 4621–4628. [CrossRef] [PubMed]
159.
Ripperger, T.; Bielack, S.S.; Borkhardt, A.; Brecht, I.B.; Burkhardt, B.; Calaminus, G.; Debatin, K.-M.; Deubzer, H.; Dirksen, U.;
Eckert, C.; et al. Childhood Cancer Predisposition Syndromes-A Concise Review and Recommendations by the Cancer Pre-
disposition Working Group of the Society for Pediatric Oncology and Hematology. Am. J. Med. Genet.
2017
,173, 1017–1037.
[CrossRef]
160. Cotton, J.L. Noonan Syndrome and Neuroblastoma. Arch. Pediatr. Adolesc. Med. 1995,149, 1280. [CrossRef]
161.
Origone, P.; Defferrari, R.; Mazzocco, K.; Cunsolo, C.L.; Bernardi, B.D.; Tonini, G.P. Homozygous Inactivation of NF1 Gene in a
Patient with Familial NF1 and Disseminated Neuroblastoma. Am. J. Med. Genet. 2003,118A, 309–313. [CrossRef]
162.
Crucis, A.; Richer, W.; Brugières, L.; Bergeron, C.; Marie-Cardine, A.; Stephan, J.-L.; Girard, P.; Corradini, N.; Munzer, M.;
Lacour, B.; et al. Rhabdomyosarcomas in Children with Neurofibromatosis Type I: A National Historical Cohort: Rhabdomyosar-
comas and NF1. Pediatr. Blood Cancer 2015,62, 1733–1738. [CrossRef]
163.
De Kort, E.; Conneman, N.; Diderich, K. A Case of Rubinstein-Taybi Syndrome and Congenital Neuroblastoma. Am. J. Med.
Genet. 2014,164, 1332–1333. [CrossRef]

Cancers 2022,14, 5967 21 of 23
164.
Berdasco, M.; Ropero, S.; Setien, F.; Fraga, M.F.; Lapunzina, P.; Losson, R.; Alaminos, M.; Cheung, N.-K.; Rahman, N.; Esteller, M.
Epigenetic Inactivation of the Sotos Overgrowth Syndrome Gene Histone Methyltransferase NSD1 in Human Neuroblastoma
and Glioma. Proc. Natl. Acad. Sci. USA 2009,106, 21830–21835. [CrossRef]
165.
Nance, M.A.; Neglia, J.P.; Talwar, D.; Berry, S.A. Neuroblastoma in a Patient with Sotos’ Syndrome. J. Med. Genet.
1990
,27,
130–132. [CrossRef] [PubMed]
166.
Tatton-Brown, K.; Murray, A.; Hanks, S.; Douglas, J.; Armstrong, R.; Banka, S.; Bird, L.M.; Clericuzio, C.L.; Cormier-Daire, V.;
Cushing, T.; et al. Weaver Syndrome and EZH2 Mutations: Clarifying the Clinical Phenotype. Am. J. Med. Genet.
2013
,161,
2972–2980. [CrossRef] [PubMed]
167.
Coulter, D.; Powell, C.M.; Gold, S. Weaver Syndrome and Neuroblastoma. J. Pediatr. Hematol./Oncol.
2008
,30, 758–760. [CrossRef]
[PubMed]
168.
Ozcan, A.; Acer, H.; Ciraci, S.; Gumus, H.; Karakukcu, M.; Patiroglu, T.; Ozdemir, M.A.; Unal, E. Neuroblastoma in a Child With
Wolf-Hirschhorn Syndrome. J. Pediatr. Hematol./Oncol. 2017,39, e224–e226. [CrossRef]
169.
Bachetti, T.; Ceccherini, I. Causative and Common PHOX2B Variants Define a Broad Phenotypic Spectrum. Clin. Genet.
2020
,97,
103–113. [CrossRef]
170.
Mossé, Y.P.; Laudenslager, M.; Longo, L.; Cole, K.A.; Wood, A.; Attiyeh, E.F.; Laquaglia, M.J.; Sennett, R.; Lynch, J.E.; Perri, P.; et al.
Identification of ALK as a Major Familial Neuroblastoma Predisposition Gene. Nature 2008,455, 930–935. [CrossRef]
171.
Parsons, D.W.; Roy, A.; Yang, Y.; Wang, T.; Scollon, S.; Bergstrom, K.; Kerstein, R.A.; Gutierrez, S.; Petersen, A.K.; Bavle, A.; et al.
Diagnostic Yield of Clinical Tumor and Germline Whole-Exome Sequencing for Children with Solid Tumors. JAMA Oncol.
2016
,
2, 616. [CrossRef]
172.
Pugh, T.J.; Morozova, O.; Attiyeh, E.F.; Asgharzadeh, S.; Wei, J.S.; Auclair, D.; Carter, S.L.; Cibulskis, K.; Hanna, M.; Kiezun, A.;
et al. The Genetic Landscape of High-Risk Neuroblastoma. Nat. Genet. 2013,45, 279–284. [CrossRef]
173.
Lasorsa, V.A.; Formicola, D.; Pignataro, P.; Cimmino, F.; Calabrese, F.M.; Mora, J.; Esposito, M.R.; Pantile, M.; Zanon, C.; De
Mariano, M.; et al. Exome and Deep Sequencing of Clinically Aggressive Neuroblastoma Reveal Somatic Mutations That Affect
Key Pathways Involved in Cancer Progression. Oncotarget 2016,7, 21840–21852. [CrossRef]
174.
Mody, R.J.; Wu, Y.-M.; Lonigro, R.J.; Cao, X.; Roychowdhury, S.; Vats, P.; Frank, K.M.; Prensner, J.R.; Asangani, I.; Palanisamy, N.;
et al. Integrative Clinical Sequencing in the Management of Refractory or Relapsed Cancer in Youth. JAMA
2015
,314, 913.
[CrossRef]
175.
Trubicka, J.; Grajkowska, W.; Dembowska-Bagi ´nska, B. Molecular Markers of Pediatric Solid Tumors—Diagnosis, Optimizing
Treatments, and Determining Susceptibility: Current State and Future Directions. Cells 2022,11, 1238. [CrossRef] [PubMed]
176.
Fang, X.; Chen, J.; Wang, Y.; Zhao, M.; Zhang, X.; Yang, L.; Ni, X.; Zhao, J.; Gallie, B.L. RB1 Germline Mutation Spectrum and
Clinical Features in Patients with Unilateral Retinoblastomas. Ophthalmic Genet. 2021,42, 593–599. [CrossRef] [PubMed]
177.
Cygan, K.J.; Soemedi, R.; Rhine, C.L.; Profeta, A.; Murphy, E.L.; Murray, M.F.; Fairbrother, W.G. Defective Splicing of the RB1
Transcript Is the Dominant Cause of Retinoblastomas. Hum. Genet. 2017,136, 1303–1312. [CrossRef] [PubMed]
178.
Alonso, J.; García-Miguel, P.; Abelairas, J.; Mendiola, M.; Sarret, E.; Vendrell, M.T.; Navajas, A.; Pestaña, A. Spectrum of Germline
RB1 Gene Mutations in Spanish Retinoblastoma Patients: Phenotypic and Molecular Epidemiological Implications: Novel RB1
Mutations in Retinoblastoma. Hum. Mutat. 2001,17, 412–422. [CrossRef]
179.
Parsam, V.L.; Ali, M.J.; Honavar, S.G.; Vemuganti, G.K.; Kannabiran, C. Splicing Aberrations Caused by Constitutional RB1 Gene
Mutations in Retinoblastoma. J. Biosci. 2011,36, 281–287. [CrossRef]
180.
Lohmann, D.R.; Brandt, B.; Höpping, W.; Passarge, E.; Horsthemke, B. The Spectrum of RB1 Germ-Line Mutations in Hereditary
Retinoblastoma. Am. J. Hum. Genet. 1996,58, 940–949.
181.
Lan, X.; Xu, W.; Tang, X.; Ye, H.; Song, X.; Lin, L.; Ren, X.; Yu, G.; Zhang, H.; Wu, S. Spectrum of RB1 Germline Mutations and
Clinical Features in Unrelated Chinese Patients With Retinoblastoma. Front. Genet. 2020,11, 142. [CrossRef]
182.
Dommering, C.J.; Mol, B.M.; Moll, A.C.; Burton, M.; Cloos, J.; Dorsman, J.C.; Meijers-Heijboer, H.; van der Hout, A.H. RB1
Mutation Spectrum in a Comprehensive Nationwide Cohort of Retinoblastoma Patients. J. Med. Genet.
2014
,51, 366–374.
[CrossRef]
183.
Mahamdallie, S.; Yost, S.; Poyastro-Pearson, E.; Holt, E.; Zachariou, A.; Seal, S.; Elliott, A.; Clarke, M.; Warren-Perry, M.; Hanks, S.;
et al. Identification of New Wilms Tumour Predisposition Genes: An Exome Sequencing Study. Lancet Child Adolesc. Health
2019
,
3, 322–331. [CrossRef]
184.
Treger, T.D.; Chowdhury, T.; Pritchard-Jones, K.; Behjati, S. The Genetic Changes of Wilms Tumour. Nat. Rev. Nephrol.
2019
,15,
240–251. [CrossRef]
185.
Cooper, W.N.; Luharia, A.; Evans, G.A.; Raza, H.; Haire, A.C.; Grundy, R.; Bowdin, S.C.; Riccio, A.; Sebastio, G.; Bliek, J.; et al.
Molecular Subtypes and Phenotypic Expression of Beckwith–Wiedemann Syndrome. Eur. J. Hum. Genet.
2005
,13, 1025–1032.
[CrossRef] [PubMed]
186.
Cairney, A.E.L.; Andrews, M.; Greenberg, M.; Smith, D.; Weksberg, R. Wilms Tumor in Three Patients with Bloom Syndrome. J.
Pediatr. 1987,111, 414–416. [CrossRef] [PubMed]
187.
Russell, B.; Johnston, J.J.; Biesecker, L.G.; Kramer, N.; Pickart, A.; Rhead, W.; Tan, W.-H.; Brownstein, C.A.; Kate Clarkson, L.;
Dobson, A.; et al. Clinical Management of Patients with ASXL1 Mutations and Bohring-Opitz Syndrome, Emphasizing the Need
for Wilms Tumor Surveillance. Am. J. Med. Genet. 2015,167, 2122–2131. [CrossRef]

Cancers 2022,14, 5967 22 of 23
188.
Pelletier, J.; Bruening, W.; Kashtan, C.E.; Mauer, S.M.; Manivel, J.C.; Striegel, J.E.; Houghton, D.C.; Junien, C.; Habib, R.;
Fouser, L. Germline Mutations in the Wilms’ Tumor Suppressor Gene Are Associated with Abnormal Urogenital Development in
Denys-Drash Syndrome. Cell 1991,67, 437–447. [CrossRef] [PubMed]
189.
Palculict, T.B.; Ruteshouser, E.C.; Fan, Y.; Wang, W.; Strong, L.; Huff, V. Identification of Germline DICER1 Mutations and Loss of
Heterozygosity in Familial Wilms Tumour. J. Med. Genet. 2016,53, 385–388. [CrossRef]
190.
Scollon, S.; Anglin, A.K.; Thomas, M.; Turner, J.T.; Wolfe Schneider, K. A Comprehensive Review of Pediatric Tumors and
Associated Cancer Predisposition Syndromes. J. Genet. Couns. 2017,26, 387–434. [CrossRef]
191.
Scott, R.H. Syndromes and Constitutional Chromosomal Abnormalities Associated with Wilms Tumour. J. Med. Genet.
2006
,43,
705–715. [CrossRef]
192.
Reid, S. Biallelic BRCA2 Mutations Are Associated with Multiple Malignancies in Childhood Including Familial Wilms Tumour. J.
Med. Genet. 2005,42, 147–151. [CrossRef]
193.
Reid, S.; Schindler, D.; Hanenberg, H.; Barker, K.; Hanks, S.; Kalb, R.; Neveling, K.; Kelly, P.; Seal, S.; Freund, M.; et al. Biallelic
Mutations in PALB2 Cause Fanconi Anemia Subtype FA-N and Predispose to Childhood Cancer. Nat. Genet.
2007
,39, 162–164.
[CrossRef]
194.
Barbaux, S.; Niaudet, P.; Gubler, M.-C.; Grünfeld, J.-P.; Jaubert, F.; Kuttenn, F.; Fékété, C.N.; Souleyreau-Therville, N.; Thibaud, E.;
Fellous, M.; et al. Donor Splice-Site Mutations in WT1 Are Responsible for Frasier Syndrome. Nat. Genet.
1997
,17, 467–470.
[CrossRef]
195.
Cajaiba, M.M.; Bale, A.E.; Alvarez-Franco, M.; McNamara, J.; Reyes-Múgica, M. Rhabdomyosarcoma, Wilms Tumor, and Deletion
of the Patched Gene in Gorlin Syndrome. Nat. Rev. Clin. Oncol. 2006,3, 575–580. [CrossRef] [PubMed]
196.
Isidor, B.; Bourdeaut, F.; Lafon, D.; Plessis, G.; Lacaze, E.; Kannengiesser, C.; Rossignol, S.; Pichon, O.; Briand, A.; Martin-
Coignard, D.; et al. Wilms’ Tumor in Patients with 9q22.3 Microdeletion Syndrome Suggests a Role for PTCH1 in Nephroblastomas.
Eur. J. Hum. Genet. 2013,21, 784–787. [CrossRef] [PubMed]
197.
Shuman, C.; Smith, A.C.; Steele, L.; Ray, P.N.; Clericuzio, C.; Zackai, E.; Parisi, M.A.; Meadows, A.T.; Kelly, T.; Tichauer, D.; et al.
Constitutional UPD for Chromosome 11p15 in Individuals with Isolated Hemihyperplasia Is Associated with High Tumor Risk
and Occurs Following Assisted Reproductive Technologies. Am. J. Med. Genet. 2006,140A, 1497–1503. [CrossRef] [PubMed]
198.
Hartley, A.L.; Birch, J.M.; Tricker, K.; Wallace, S.A.; Kelsey, A.M.; Harris, M.; Morris Jones, P.H. Wilms’ Tumor in the Li-Fraumeni
Cancer Family Syndrome. Cancer Genet. Cytogenet. 1993,67, 133–135. [CrossRef] [PubMed]
199.
Hanks, S.; Coleman, K.; Reid, S.; Plaja, A.; Firth, H.; FitzPatrick, D.; Kidd, A.; Méhes, K.; Nash, R.; Robin, N.; et al. Constitutional
Aneuploidy and Cancer Predisposition Caused by Biallelic Mutations in BUB1B. Nat. Genet. 2004,36, 1159–1161. [CrossRef]
200.
Scott, R.H.; Walker, L.; Olsen, O.E.; Levitt, G.; Kenney, I.; Maher, E.; Owens, C.M.; Pritchard-Jones, K.; Craft, A.; Rahman, N.
Surveillance for Wilms Tumour in At-Risk Children: Pragmatic Recommendations for Best Practice. Arch. Dis. Child.
2006
,91,
995–999. [CrossRef] [PubMed]
201.
Yost, S.; de Wolf, B.; Hanks, S.; Zachariou, A.; Marcozzi, C.; Clarke, M.; de Voer, R.M.; Etemad, B.; Uijttewaal, E.; Ramsay, E.;
et al. Biallelic TRIP13 Mutations Predispose to Wilms Tumor and Chromosome Missegregation. Nat. Genet.
2017
,49, 1148–1151.
[CrossRef]
202.
Karlberg, N.; Karlberg, S.; Karikoski, R.; Mikkola, S.; Lipsanen-Nyman, M.; Jalanko, H. High Frequency of Tumours in Mulibrey
Nanism. J. Pathol. 2009,218, 163–171. [CrossRef]
203.
Astuti, D.; Morris, M.R.; Cooper, W.N.; Staals, R.H.J.; Wake, N.C.; Fews, G.A.; Gill, H.; Gentle, D.; Shuib, S.; Ricketts, C.J.; et al.
Germline Mutations in DIS3L2 Cause the Perlman Syndrome of Overgrowth and Wilms Tumor Susceptibility. Nat. Genet.
2012
,
44, 277–284. [CrossRef]
204.
Gripp, K.W.; Baker, L.; Kandula, V.; Conard, K.; Scavina, M.; Napoli, J.A.; Griffin, G.C.; Thacker, M.; Knox, R.G.; Clark, G.R.;
et al. Nephroblastomatosis or Wilms Tumor in a Fourth Patient with a Somatic PIK3CA Mutation. Am. J. Med. Genet.
2016
,170,
2559–2569. [CrossRef]
205.
Cottereau, E.; Mortemousque, I.; Moizard, M.-P.; Bürglen, L.; Lacombe, D.; Gilbert-Dussardier, B.; Sigaudy, S.; Boute, O.; David, A.;
Faivre, L.; et al. Phenotypic Spectrum of Simpson-Golabi-Behmel Syndrome in a Series of 42 Cases With a Mutation in GPC 3 and
Review of the Literature: American Journal of Medical Genetics Part C (Seminars in Medical Genetics). Am. J. Med. Genet.
2013
,
163, 92–105. [CrossRef] [PubMed]
206.
Fagali, C.; Kok, F.; Nicola, P.; Kim, C.; Bertola, D.; Albano, L.; Koiffmann, C.P. MLPA Analysis in 30 Sotos Syndrome Patients
Revealed One Total NSD1 Deletion and Two Partial Deletions Not Previously Reported. Eur. J. Med. Genet.
2009
,52, 333–336.
[CrossRef] [PubMed]
207.
Breslow, N.E.; Norris, R.; Norkool, P.A.; Kang, T.; Beckwith, J.B.; Perlman, E.J.; Ritchey, M.L.; Green, D.M.; Nichols, K.E.
Characteristics and Outcomes of Children With the Wilms Tumor-Aniridia Syndrome: A Report from the National Wilms Tumor
Study Group. J. Clin. Oncol. 2003,21, 4579–4585. [CrossRef]
208.
Ciceri, S.; Gamba, B.; Corbetta, P.; Mondini, P.; Terenziani, M.; Catania, S.; Nantron, M.; Bianchi, M.; D’Angelo, P.; Torri, F.; et al.
Genetic and Epigenetic Analyses Guided by High Resolution Whole-Genome SNP Array Reveals a Possible Role of CHEK2 in
Wilms Tumour Susceptibility. Oncotarget 2018,9, 34079–34089. [CrossRef] [PubMed]
209.
Tsuji, Y.; Yamamura, T.; Nagano, C.; Horinouchi, T.; Sakakibara, N.; Ishiko, S.; Aoto, Y.; Rossanti, R.; Okada, E.; Tanaka, E.; et al.
Systematic Review of Genotype-Phenotype Correlations in Frasier Syndrome. Kidney Int. Rep.
2021
,6, 2585–2593. [CrossRef]
[PubMed]

Cancers 2022,14, 5967 23 of 23
210.
Lugtenberg, R.T.; Cransberg, K.; Loos, W.J.; Wagner, A.; Alders, M.; van den Heuvel-Eibrink, M.M. Topotecan Distribution in an
Anephric Infant with Therapy Resistant Bilateral Wilms Tumor with a Novel Germline WT1 Gene Mutation. Cancer Chemother.
Pharmacol. 2008,62, 1039–1044. [CrossRef]
211.
Martins, A.G.; Pinto, A.T.; Domingues, R.; Cavaco, B.M. Identification of a Novel CTR9 Germline Mutation in a Family with
Wilms Tumor. Eur. J. Med. Genet. 2018,61, 294–299. [CrossRef] [PubMed]
212.
Hanks, S.; Perdeaux, E.R.; Seal, S.; Ruark, E.; Mahamdallie, S.S.; Murray, A.; Ramsay, E.; Del Vecchio Duarte, S.; Zachariou, A.; de
Souza, B.; et al. Germline Mutations in the PAF1 Complex Gene CTR9 Predispose to Wilms Tumour. Nat. Commun.
2014
,5, 4398.
[CrossRef]
213.
Hol, J.A.; Diets, I.J.; Krijger, R.R.; Heuvel-Eibrink, M.M.; Jongmans, M.C.; Kuiper, R.P. TRIM28 Variants and WILMS’ Tumour
Predisposition. J. Pathol. 2021,254, 494–504. [CrossRef]
214.
Bessa, C.; Matos, P.; Jordan, P.; Gonçalves, V. Alternative Splicing: Expanding the Landscape of Cancer Biomarkers and
Therapeutics. Int. J. Mol. Sci. 2020,21, 9032. [CrossRef]
215.
Desterro, J.; Bak-Gordon, P.; Carmo-Fonseca, M. Targeting MRNA Processing as an Anticancer Strategy. Nat. Rev. Drug Discov.
2020,19, 112–129. [CrossRef] [PubMed]
216.
Effenberger, K.A.; Urabe, V.K.; Jurica, M.S. Modulating Splicing with Small Molecular Inhibitors of the Spliceosome: Modulating
Splicing with Small Molecular Inhibitors. WIREs RNA 2017,8, e1381. [CrossRef] [PubMed]
217.
Xiong, H.; Veedu, R.N.; Diermeier, S.D. Recent Advances in Oligonucleotide Therapeutics in Oncology. Int. J. Mol. Sci.
2021
,22, 3295.
[CrossRef]
218.
Quemener, A.M.; Bachelot, L.; Forestier, A.; Donnou-Fournet, E.; Gilot, D.; Galibert, M. The Powerful World of Antisense
Oligonucleotides: From Bench to Bedside. WIREs RNA 2020,11, e1594. [CrossRef]
219.
Inoue, D.; Chew, G.-L.; Liu, B.; Michel, B.C.; Pangallo, J.; D’Avino, A.R.; Hitchman, T.; North, K.; Lee, S.C.-W.; Bitner, L.; et al.
Spliceosomal Disruption of the Non-Canonical BAF Complex in Cancer. Nature 2019,574, 432–436. [CrossRef] [PubMed]
220. Juliano, R.L. The Delivery of Therapeutic Oligonucleotides. Nucleic Acids Res. 2016,44, 6518–6548. [CrossRef] [PubMed]
221.
Boisguérin, P.; Deshayes, S.; Gait, M.J.; O’Donovan, L.; Godfrey, C.; Betts, C.A.; Wood, M.J.A.; Lebleu, B. Delivery of Therapeutic
Oligonucleotides with Cell Penetrating Peptides. Adv. Drug Deliv. Rev. 2015,87, 52–67. [CrossRef]
222.
Schneider, E.K.; Huang, J.X.; Carbone, V.; Baker, M.; Azad, M.A.K.; Cooper, M.A.; Li, J.; Velkov, T. Drug-Drug Plasma Protein
Binding Interactions of Ivacaftor: Ivacaftor Plasma Protein Binding. J. Mol. Recognit. 2015,28, 339–348. [CrossRef]
223.
Mogilevsky, M.; Shimshon, O.; Kumar, S.; Mogilevsky, A.; Keshet, E.; Yavin, E.; Heyd, F.; Karni, R. Modulation of MKNK2
Alternative Splicing by Splice-Switching Oligonucleotides as a Novel Approach for Glioblastoma Treatment. Nucleic Acids Res.
2018,46, 11396–11404. [CrossRef]
224. Kaehler, M.; Cascorbi, I. Germline Variants in Cancer Therapy. Cancer Drug Resist. 2019,2, 18–30. [CrossRef]
225.
Ng, K.P.; Hillmer, A.M.; Chuah, C.T.H.; Juan, W.C.; Ko, T.K.; Teo, A.S.M.; Ariyaratne, P.N.; Takahashi, N.; Sawada, K.; Fei, Y.; et al.
A Common BIM Deletion Polymorphism Mediates Intrinsic Resistance and Inferior Responses to Tyrosine Kinase Inhibitors in
Cancer. Nat. Med. 2012,18, 521–528. [CrossRef] [PubMed]
226.
Park, E.; Pan, Z.; Zhang, Z.; Lin, L.; Xing, Y. The Expanding Landscape of Alternative Splicing Variation in Human Populations.
Am. J. Hum. Genet. 2018,102, 11–26. [CrossRef] [PubMed]
227. Scotti, M.M.; Swanson, M.S. RNA Mis-Splicing in Disease. Nat. Rev. Genet. 2016,17, 19–32. [CrossRef] [PubMed]
228.
Karam, R.; Conner, B.; LaDuca, H.; McGoldrick, K.; Krempely, K.; Richardson, M.E.; Zimmermann, H.; Gutierrez, S.; Reineke, P.;
Hoang, L.; et al. Assessment of Diagnostic Outcomes of RNA Genetic Testing for Hereditary Cancer. JAMA Netw. Open
2019
,2, e1913900.
[CrossRef] [PubMed]
229.
Landrith, T.; Li, B.; Cass, A.A.; Conner, B.R.; LaDuca, H.; McKenna, D.B.; Maxwell, K.N.; Domchek, S.; Morman, N.A.; Heinlen, C.;
et al. Splicing Profile by Capture RNA-Seq Identifies Pathogenic Germline Variants in Tumor Suppressor Genes. NPJ Precis. Oncol.
2020,4, 4. [CrossRef]