Neurofibromatosis type 1 (NF1) is the most common genetic disorder with a predisposition to malignancy and affects 1 in 3500 persons worldwide. NF1 is caused by a mutation in the NF1 tumor suppressor gene that encodes the protein neurofibromin. Patients with NF1 have cutaneous, diffuse, and plexiform neurofibromas, tumors comprised primarily of Schwann cells, blood vessels, fibroblasts, and mast cells. Studies from human and murine models that closely recapitulate human plexiform neurofibroma formation indicate that tumorigenesis necessitates NF1 loss of heterozygosity in the Schwann cell. In addition, our most recent studies with bone marrow transplantation and pharmacologic experiments implicate haploinsufficiency of Nf1 (Nf1 ؉/؊ ) and ckit signaling in the hematopoietic system as required and sufficient for tumor progression. Here, we review recent studies implicating the hematopoietic system in plexiform neurofibroma genesis, delineate the physiology of stem cell factordependent hematopoietic cells and their contribution to the neurofibroma microenvironment, and highlight the application of this research toward the first successful, targeted medical treatment of a patient with a nonresectable and debilitating neurofibroma. Finally, we emphasize the importance of the tumor microenvironment hypothesis, asserting that tumorigenic cells in the neurofibroma do not arise and grow in isolation. (Blood. 2010; 116(2):157-164)
IntroductionAlthough several reports characterized neurofibromatosis type 1 (NF1) or NF1-like syndromes as early as the 18th century, [1][2][3] Friedrich von Recklinghausen did not publish his seminal, detailed case reports until 1882. 4 Von Recklinghausen observed that neurofibromas contain elements of both neuronal and fibroblastic tissue. In 1911, H. Greggio reported his observation that mast cells infiltrate the neurofibroma. 5,6 Vincent Riccardi later postulated a pivotal role for mast cells and melanocytes in NF1 pruritus, pigmentation defects, and, potentially, neurofibroma formation. 7 Today, NF1 is recognized as a common and fully penetrant genetic disease that shows variable expressivity. 6-9 The disease is transmitted in an autosomal dominant fashion as a mutation in NF1, a tumor suppressor gene encoding the protein neurofibromin. Neurofibromin functions as a p21 ras (Ras) guanosine triphosphatase (GTP)-activating protein (GAP), accelerating the hydrolysis of Ras-GTP thousands of fold and functioning at least in part to negatively regulate multiple Ras-dependent cellular signaling pathways. 6,[10][11][12][13][14][15][16] Mutations of NF1 predispose patients to variable neuronal, hematopoietic, and skeletal disorders, including myeloid leukemia, kyphoscoliosis, long bone pseudoarthrosis, and cutaneous, subcutaneous, and diffuse plexiform neurofibromas. 6,17 Neurofibromas are pathognomonic for the disease. Cutaneous neurofibromas arise from small peripheral nerves during adolescence or adulthood and are observed in greater than 95% of patients with NF1 (Figure 1 left). 18 Plexiform neu...