Multigenerational VHL family characterized by pathogenic germline ELOC variant: Response to belzutifan

We describe a large family of patients with canonical Von Hippel-Lindau (VHL) manifestations, including central nervous system and retinal hemangioblastomas, clear cell renal cell carcinoma (ccRCC), pancreatic neuroendocrine tumors, and pheochromocytomas, all who lacked any detectable alteration within the VHL gene. Analysis of a ccRCC demonstrated a novel p.E92G variant in the Elongin C gene, ELOC, a known ccRCC tumor suppressor gene. We aim to confirm that the ELOC variant is responsible for the VHL manifestations in this family.

Germline testing and tumor analysis were performed to assess the molecular alterations in the lesions in this family. Abdominal imaging was used to determine the sizes of VHL-related lesions.

We demonstrated this ELOC p.E92G variant was a germline alteration and was present in each affected individual that received genetic testing, demonstrating co-segregation of variant and disease. Analysis of tumors excised from 2 patients demonstrated loss of heterozygosity for the ELOC variant and single copy chromosomal loss of chromosome 8 that encodes the ELOC gene, consistent with inactivation of a tumor suppressor gene. Two patients who received Belzutifan showed a decrease in size of their kidney, pancreatic, and spinal lesions and 1 showed improvement of retinal manifestations.

These findings indicate that the p.E92G ELOC variant is responsible for the VHL manifestations in this family, and that these tumors are being driven by loss of the VCB-Cul2 E3-ubiquitin ligase complex activity.