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BACKGROUND: Dysregulation of the RAS-mitogen-activated protein kinase signalling pathway underlies RASopathies, a family of neurodevelopmental disorders associated with variable cancer predisposition. However, the prevalence and spectrum of solid tumours and the contribution of specific variants to tumour susceptibility remain poorly defined. METHODS: We assessed solid tumour prevalence and spectrum in the largest single-centre cohort of individuals with RASopathies (n=138), excluding neurofibromatosis type 1 and integrated these findings with a systematic literature review to evaluate tumour distribution and genotype-phenotype correlations. RESULTS: In our cohort, at least one solid tumour was identified in 10.8% of individuals with Noonan syndrome (NS), 47.8% with Costello syndrome (CS) and 7.3% with cardiofaciocutaneous syndrome (CFCS). Malignant tumours occurred in 5.4%, 30.4% and 2.4%, respectively. CS showed the highest tumour burden, frequently with multiple primary tumours, predominantly of the bladder. In NS, low-grade central nervous system (CNS) tumours were most common, particularly among individuals carrying PTPN11 variants. Tumour onset occurred with a median age of 19, 14 and 13 years in NS, CS and CFCS, respectively. Literature data analysis identified candidate variants in HRAS, PTPN11 and SOS1 genes associated with increased risk for solid tumours, which differed from mutational hotspots reported in childhood leukaemia or sporadic cancers. CONCLUSION: Solid tumour risk in RASopathies is syndrome-dependent and genotype-dependent, with CS showing a high burden of bladder tumours and NS mainly associated with CNS tumours. These findings may support tailored surveillance strategies.

BACKGROUND: Costello syndrome (CS) is a rare RASopathy, mostly caused by de novo heterozygous pathogenic variants in the HRAS gene. Over 80% of cases involve the germline p.Gly12Ser variant, resulting in a fairly uniform phenotype of neuro-cardio-facio-cutaneous involvement with an increased risk of malignancy. Consequences of other rare HRAS variants are less well understood due to the limited number of reported cases. METHODS: An adult, young woman was referred due to sparse, slow-growing scalp hair, Blaschko-linear hyperpigmentation, acanthosis nigricans, palmoplantar hyperkeratosis, and joint hyperlaxity. Molecular, imaging, and detailed laboratory studies were performed. RESULTS: Although initial clinical exome- and whole-exome sequencing (WES) were inconclusive, indicating possible mosaicism, subsequent WES from hair-derived DNA samples revealed somatic mosaicism for the rare HRAS p.Gly13Asp variant. Brain MRIs showed a cerebral cavernoma, while cardiological evaluation, urinalysis, abdominal, and pelvic ultrasound were unremarkable. Nevertheless, she remains under close follow-up. CONCLUSION: Among the ten reported individuals carrying the p.Gly13Asp variant, our patient is only the second with confirmed mosaicism and the fifth mosaic CS case described to date. This case expands the phenotypic spectrum of CS and highlights the need for multi-tissue analysis in attenuated or atypical presentations to ensure a correct diagnosis, oncological risk assessment, and informed genetic and reproductive counseling.

OBJECTIVE: Long COVID (LC) remains poorly understood, and there is a critical need for advanced computational tools to better identify and characterize patients. In this study, we use summarized symptom reports by RECOVER-Adult cohort participants linked to EHR data to characterize patients and train a computable phenotype algorithm of LC. MATERIALS AND METHODS: The study included adult participants with linked Fast Health Interoperability Resource-sourced EHR data. We characterized EHR diagnoses, procedures, medications, lab tests, and vital sign features associated with LC. A computable phenotyping algorithm was trained and validated against patient-reported symptoms. MAIN OUTCOME AND MEASURES: We assessed model discrimination and calibration in a held-out test set. We describe important model features and evaluate model discrimination and calibration. RESULTS: The study included 1501 RECOVER-Adult cohort participants with linked EHR data. 376 (25%) met criteria for highly symptomatic LC based on the RECOVER Long COVID Research Index (LCRI). EHR features associated with LC included clinician diagnosis of shortness of breath, malaise and fatigue, and cardiac dysrhythmias; documented treatment with albuterol, gabapentin, or duloxetine; or elevated heart rate. The algorithm identifying patients with highly symptomatic LC had an area under the receiver operating characteristic curve of 0.80 (95% CI 0.74-0.85), and area under the precision-recall curve of 0.58 (95% CI, 0.47-0.69). CONCLUSION AND RELEVANCE: These findings demonstrate that, using EHR data, a machine-learning model can accurately select patients with sets of self-reported LC symptoms. The model could help identify patients within a health system with the highest probability of the condition and facilitate screening, recruitment for clinical trials, and etiologic studies.

Postzygotic somatic variants affecting the Ras/MAPK signaling pathway can cause mosaic RASopathies, characterized by craniofacial abnormalities, cardiac defects, growth impairment, and various cutaneous manifestations in localized areas of the body. Herein, we present a rare case of mosaic RASopathy caused by a somatic HRAS variant. A 52-year-old Japanese patient visited our department because of skin metastasis of malignant melanoma. Besides, he had a sebaceous nevus on the forehead, linear epidermal nevus on the trunk along with the Blaschko line, and focal and linear non-epidermolytic palmoplantar keratoderma since he was young. Genetic testing revealed an HRAS missense variant c.34G>A (p.Gly12Ser) in the cells of sebaceous nevus, pigmented skin lesion, palmoplantar keratoderma, and metastatic skin lesion of melanoma. In contrast, no pathogenic HRAS variant was detected in peripheral blood leukocytes or in clinically normal skin. Somatic mutations in HRAS can cause mosaic Costello syndrome, Schimmelpenning syndrome, and woolly hair nevus. However, there is some overlap in clinical manifestations among these diseases, and no clear diagnostic criteria have been established. Therefore, we diagnosed this case as HRAS-mutant mosaic RASopathy. In addition, this is the first reported case of mosaic RASopathy concomitant with malignant melanoma. Although the occurrence of concurrent melanoma would be coincidental in this case, further investigation is necessary to evaluate the precise association between HRAS-mutant mosaic RASopathy and melanoma. The melanoma cells showed a high proportion of mutant alleles, possibly due to loss of heterozygosity. Further investigation is necessary to evaluate the precise association between HRAS-mutant mosaic RASopathy and melanoma.