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Molecular mechanisms of RET receptor-mediated oncogenesis in multiple endocrine neoplasia 2
Simona M. Wagner, ShuJun Zhu, Adrian C. Nicolescu, Lois M Mulligan
Corresponding author
mulligal@queensu.ca

Tel.: 1 613 533 6000 ext.77475
Division of Cancer Biology and Genetics, Cancer Research Institute and Department of Pathology & Molecular Medicine, Queen′s University, Kingston, ON, Canada.
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">The RET receptor&#58; structure&#44; activation&#44; and oncogenic mutations&#46; &#40;A&#41; Schematic diagram depicting RET tyrosine kinase receptor domains and the location of recurrent oncogenic mutations&#46; The RET protein has a large extracellular domain containing a cysteine-rich region and a series of cadherin homology domains&#44; a transmembrane domain&#44; and an intracellular tyrosine kinase domain&#46; The positions of the most common mutations found in patients with multiple endocrine neoplasia type 2 &#40;MEN 2&#41; are shown&#46; &#40;B&#41; Mechanism of RET activation&#46; Wild-type RET activation requires the dimerization of RET&#44; mediated through formation of a multicomponent complex&#46; RET is activated by binding both a soluble ligand &#40;glial cell-line-derived neurotrophic factor&#59; GDNF&#41; and a non-signaling extracellular co-receptor &#40;GDNF family receptor&#59; GFR&#945;&#41;&#46; Upon activation of RET&#44; phosphorylation of multiple intracellular tyrosines leads to stimulation of downstream signaling pathways&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Multiple endocrine neoplasia type 2 &#40;MEN 2&#41; is an inherited cancer syndrome&#44; characterized by medullary thyroid carcinoma &#40;MTC&#41;&#46; The disease has three clinically defined subtypes&#44; as described elsewhere in this volume&#46; Briefly&#44; familial MTC &#40;FMTC&#41;&#44; considered the least aggressive form of MEN 2&#44; exhibits MTC without additional tumors or phenotypes&#44; and frequently shows later onset than other disease subtypes&#46; MEN 2A is characterized by MTC with pheochromocytoma&#44; which occurs in approximately 50&#37; of cases&#44; and parathyroid hyperplasia or adenoma in 10&#8211;35&#37;&#46; Finally&#44; MEN 2B is also characterized by MTC and pheochromocytoma&#44; but parathyroid hyperplasia is rare&#46; This is the most aggressive subtype&#44; with earliest onset of disease and metastasis&#44; and poorest prognosis&#46; In MEN 2B&#44; MTC has been documented in patients as young as 2 months &#40;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#41;&#46; In addition&#44; patients with MEN 2B frequently present with other non-tumor features including ganglioneuromatosis of the mouth and gut&#44; corneal nerve thickening&#44; delayed puberty&#44; and a marfanoid habitus &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#41;&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">MEN 2 is dominantly inherited&#44; and its genetic cause&#44; mutations of the <span class="elsevierStyleItalic"><span class="elsevierStyleUnderline">RE</span>arranged during <span class="elsevierStyleUnderline">T</span>ransfection</span> &#40;<span class="elsevierStyleItalic">RET</span>&#41; proto-oncogene&#44; was first recognized nearly 20 years ago &#40;<a class="elsevierStyleCrossRefs" href="#bib4">4&#8211;6</a>&#41;&#46; Since then&#44; the range of mutations identified&#44; their potential for predicting clinical course&#44; and the underlying functional effects have been explored&#46; Detection of <span class="elsevierStyleItalic">RET</span> mutations in MEN 2 represents a paradigm for genetically guided patient management&#44; and genotype&#8211;phenotype correlations in this disease now inform recommended interventions&#44; patient and family screening&#44; and long-term follow-up &#40;<a class="elsevierStyleCrossRef" href="#bib7">7</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41;&#46; Functional characterization of these mutations also has the potential to define optimal therapeutic regimens&#44; and may identify additional phenotypic implications that have not been broadly recognized&#46; Here&#44; we discuss our current understanding of the molecular mechanisms for the more common <span class="elsevierStyleItalic">RET</span> mutations and their potential significance&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RET RECEPTOR</span><p id="para30" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">RET</span> proto-oncogene encodes a receptor tyrosine kinase that is required for the development of neural-crest-derived cells&#44; the urogenital system&#44; and the central and peripheral nervous systems&#44; notably the enteric nervous system &#40;<a class="elsevierStyleCrossRef" href="#bib9">9</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#41;&#46; The RET protein has a large extracellular domain containing a cysteine-rich region and a series of cadherin homology domains&#44; a transmembrane domain&#44; and an intracellular tyrosine kinase domain&#44; required for RET phosphorylation and downstream signaling &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1A</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib11">11</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#41;&#46; The RET kinase is structurally similar to other tyrosine kinases&#44; sharing many conserved functional motifs and regulatory residues that have been shown to have importance for kinase enzyme function &#40;<a class="elsevierStyleCrossRef" href="#bib13">13</a>&#41;&#46; RET is activated by binding of a multi-protein ligand complex&#46; RET binds a soluble ligand of the glial cell-line-derived neurotrophic factor &#40;GDNF&#41; family but also requires a co-receptor of the GDNF family receptors &#945; &#40;GFR&#945;&#41;&#44; which is tethered to the cell membrane via glycosylphosphatidylinositol linkage &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1B</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#41;&#46; Initially&#44; GDNF binds to GFR&#945;&#44; and these complexes are then able to recruit RET to form heterohexamers that are concentrated in regions of the cell membrane called lipid rafts &#40;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib16">16</a>&#41;&#46; These are membrane domains enriched in glycosylphosphatidylinositol-linked proteins and signaling molecules that provide a platform not only for enhanced cell signaling&#44; but also for regulation of receptor kinase activity and downregulation &#40;<a class="elsevierStyleCrossRef" href="#bib17">17</a>&#41;&#46; Activation of RET leads to stimulation of multiple downstream pathways&#44; including mitogen-activated protein kinase and extracellular signal-regulated kinase&#44; phosphoinositide 3-kinase and protein kinase B&#44; signal transducer and activator of transcription 3&#44; proto-oncogene tyrosine-protein kinase Src1&#44; and focal adhesion kinase &#40;<a class="elsevierStyleCrossRef" href="#bib18">18</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib19">19</a>&#41;&#44; that promote cell growth&#44; proliferation&#44; survival&#44; and&#47;or differentiation&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">THE <span class="elsevierStyleItalic">RET</span> PROTO-ONCOGENE IN MEN 2</span><p id="para40" class="elsevierStylePara elsevierViewall">MEN 2 is associated with point mutations of RET&#44; predictably leading to its activation in the absence of ligands and co-receptors&#46; Mutations are primarily amino acid substitutions affecting a very small number of <span class="elsevierStyleItalic">RET</span> codons in either the extracellular domain or within the kinase domain &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#59; <a class="elsevierStyleCrossRef" href="#fig1">Figure 1A</a>&#46; Mutations are dominant&#44; requiring only a single mutant allele to confer the disease phenotype&#46; Summaries of MEN 2 <span class="elsevierStyleItalic">RET</span> mutation occurrence are well reviewed elsewhere &#40;<a class="elsevierStyleCrossRefs" href="#bib20">20&#8211;23</a>&#41; or are available online &#40;<a href="http://www.arup.utah.edu/database/MEN2/MEN2_welcome.php">http&#58;&#47;&#47;www&#46;arup&#46;utah&#46;edu&#47;database&#47;MEN2&#47;MEN2&#95;welcome&#46;php</a>&#41;&#46; Together&#44; these data suggest strong overall themes as to functional effects of these mutations&#44; but also as to their clinical significance&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para50" class="elsevierStylePara elsevierViewall">Strong associations of disease subtype&#44; and also specific disease phenotypes&#44; with individual RET mutations have made it possible to stratify risk of MEN 2 by genotype &#40;<a class="elsevierStyleCrossRef" href="#bib7">7</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41;&#46; The management guidelines of the American Thyroid Association &#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41; base the recommendations for initial diagnosis&#44; therapeutic intervention&#44; and long-term follow-up on patient genotype and the current understanding of the natural history of the disease associated with each <span class="elsevierStyleItalic">RET</span> mutation&#46; Mutations of cysteine residues &#40;primarily cysteines 609&#44; 611&#44; 618&#44; 620&#44; 630&#44; and 634&#41; in the RET extracellular domain account for the majority of MEN 2A cases&#44; and are also common in patients with FMTC&#46; Intracellular kinase domain mutations are mainly associated with FMTC and MEN 2B&#46; Mutations in the intracellular codons 768&#44; 790&#44; 791&#44; 804&#44; and 891 underlie FMTC&#44; and occur less commonly in patients with MEN 2A &#40;<a class="elsevierStyleCrossRef" href="#bib20">20</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib24">24</a>&#41;&#44; while specific mutations of codon 918 &#40;M918T&#41; or 883 &#40;A883F&#41; account for the vast majority of MEN 2B cases&#44; and are exclusive to the subtype &#40;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib25">25</a>&#41;&#46; In addition to association with disease subtype&#44; significant correlations of specific mutations with disease features are reported&#46; For example&#44; RET codon 634 mutations carry a greater patient risk for pheochromocytoma and parathyroid hyperplasia &#40;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRefs" href="#bib26">26&#8211;28</a>&#41;&#44; and are associated with a higher frequency of detection of MTC at the time of early thyroidectomy &#40;<a class="elsevierStyleCrossRef" href="#bib29">29</a>&#41;&#46; Variation in clinical presentation has even been observed with different codon 634 substitutions&#46; The specific substitution of an arginine at codon 634 &#40;C634R&#41; is strongly associated with increased risk of parathyroid hyperplasia &#40;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRefs" href="#bib26">26&#8211;28</a>&#41;&#44; increased frequency of distant metastases&#44; earlier onset of both lymph node and distant metastases&#44; and bilaterality of pheochromocytoma &#40;<a class="elsevierStyleCrossRef" href="#bib30">30</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib31">31</a>&#41;&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle50">MOLECULAR MECHANISMS OF RET MUTATIONS</span><p id="para60" class="elsevierStylePara elsevierViewall">Evidence-based assessment of MEN 2 genotypic data demonstrate that not all RET mutations have equivalent clinical significance&#44; although all reported mutations are thought to lead to ligand-independent constitutive activation of the RET receptor&#44; autophosphorylation of RET&#44; and aberrant stimulation of downstream signaling pathways&#46; It follows that the molecular mechanisms of mutations associated with these different phenotypes may also be distinct and that these mechanisms may provide clues to disease origin and&#44; potentially&#44; treatment for patients with these mutations&#46; Here&#44; we discuss some of the current understanding of the mechanisms of RET dysfunction seen in MEN 2&#44; and explore the potential implications of these mechanisms&#46;</p><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">RET Extracellular Domain Cysteine Residues</span><p id="para70" class="elsevierStylePara elsevierViewall">The most frequently identified <span class="elsevierStyleItalic">RET</span> mutations in MEN 2 affect cysteines in the extracellular cysteine-rich region &#40;primarily residues between Cys515 and Cys634&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1A</a>&#41;&#59; <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#46; In the normal protein&#44; intramolecular cysteine&#8211;cysteine disulfide bonds contribute to the tertiary structure of the RET extracellular domain&#46; Correct positioning of residues in this region is critical to interactions with GDNF&#8211;GFR&#945; ligand complexes &#40;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib32">32</a>&#41;&#46; Amino acid substitutions&#44; resulting in replacement of a normal cysteine with any amino acid&#44; lead to loss of intramolecular bonds and to an unpaired cysteine that is available for intermolecular interactions with other mutant RET proteins &#40;<a class="elsevierStyleCrossRef" href="#fig2">Figure 2A</a>&#41; &#40;<a class="elsevierStyleCrossRefs" href="#bib33">33&#8211;35</a>&#41;&#46; These mutant RET dimers are constitutively active in the absence of ligands&#46; Furthermore&#44; mutant dimers are not recruited to lipid rafts through GFR&#945; interactions&#44; and may be activated in other membrane compartments&#44; which can affect the nature and intensity of the resultant downstream signals &#40;<a class="elsevierStyleCrossRef" href="#bib36">36</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib37">37</a>&#41;&#46; Downstream signaling regulation&#44; via interactions with ubiquitin ligases such as CasitasB-lineage lymphoma proto-oncogene &#40;CBL&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib38">38</a>&#41;&#44; or with cellular phosphatases such as SHP1 and SHP2 &#40;<a class="elsevierStyleCrossRef" href="#bib39">39</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib40">40</a>&#41; that are involved in limiting or terminating signals&#44; differ from that of the raft-associated wild-type receptor&#44; enhancing the effect of the oncogenic mutation&#46;</p><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para80" class="elsevierStylePara elsevierViewall">Although the molecular mechanisms of activation are similar&#44; cysteine RET mutations also vary in impact&#46; In general&#44; mutations located closer to the RET transmembrane domain have greater transforming ability and are linked to increased risks of more aggressive MEN 2 disease &#40;<a class="elsevierStyleCrossRef" href="#bib41">41</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46; Codon 634 mutations confer the greatest degree of RET activation&#44; with higher levels of autophosphorylation and transforming ability than the other cysteine mutations&#44; and are linked to broader phenotypes and more severe disease&#44; as described above&#46; Interestingly&#44; mutations of other cysteine residues are believed to affect the efficiency of RET protein folding and maturation&#44; and to impair transport to the cell membrane&#44; resulting in decreased levels of cell surface protein and weaker signaling capability &#40;<a class="elsevierStyleCrossRefs" href="#bib33">33&#8211;35&#44;42&#44;43</a>&#41;&#46; In fact&#44; a subset of RET cysteine mutations&#44; sometimes referred to as Janus mutations&#44; can lead to a partial loss-of-function phenotype&#44; as well as to oncogenic effects&#46; These mutations&#44; generally affecting codons 609&#44; 611&#44; 618 or 620&#44; are thought to confer cell-type-specific decreases in functional protein on the cell surface&#46; Inactivating mutations of RET can lead to the congenital abnormality Hirschsprung disease&#44; which is characterized by the absence of the enteric neurons from the distal colon &#40;<a class="elsevierStyleCrossRef" href="#bib44">44</a>&#41;&#46; Janus mutations have been linked to an insufficiency of mature RET protein in the gut&#44; resulting in the Hirschsprung phenotype&#44; yet at the same time&#44; risks remain high for MEN 2 phenotypes&#44; as sufficient mature protein is expressed in the thyroid for development of MTC &#40;<a class="elsevierStyleCrossRefs" href="#bib45">45&#8211;47</a>&#41;&#46;</p></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">RET Intracellular Domain Mutations</span><p id="para90" class="elsevierStylePara elsevierViewall">Intracellular RET kinase mutations fall into two groups&#58; high-penetrance mutations causing MEN 2B&#44; and less aggressive mutations that lead to FMTC or&#44; more rarely&#44; MEN 2A &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46; These RET mutations fall within the N-terminal and C-terminal lobes of the kinase &#40;<a class="elsevierStyleCrossRef" href="#fig3">Figure 3</a>&#41;&#46; Although the mutations are spread out along the linear protein sequence &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1A</a>&#41;&#44; they appear to cluster on either the ATP-binding face or substrate-binding&#47;autoinhibitory face of the protein tertiary structure&#44; suggesting some common themes in their functional effects &#40;<a class="elsevierStyleCrossRef" href="#fig3">Figure 3</a>&#41;&#59; <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#46; The precise mechanisms by which these intracellular mutations activate RET are various&#44; but it is suggested that they all do so through destabilizing the inactive form of RET&#44; and shifting the equilibrium of RET receptors towards the active state &#40;<a class="elsevierStyleCrossRef" href="#bib48">48</a>&#41;&#46;</p><elsevierMultimedia ident="fig3"></elsevierMultimedia></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">MEN 2B Mutations</span><p id="para100" class="elsevierStylePara elsevierViewall">Over 95&#37; of MEN 2B cases are associated with the same methionine to threonine change at codon 918 &#40;M918T&#41; in the RET kinase domain &#40;<a class="elsevierStyleCrossRef" href="#fig3">Figure 3</a>&#41;&#46; Structurally&#44; this residue lies in the substrate-binding pocket of the kinase&#44; and the M918T mutation appears to increase RET&#8211;ATP binding affinity and the stability of the active ATP-bound form&#44; effectively making RET more active&#44; more of the time &#40;<a class="elsevierStyleCrossRefs" href="#bib48">48&#8211;51</a>&#41;&#46; The M918T mutation appears to increase the stability of monomeric active forms of RET&#44; but activation of these mutants can also be further enhanced by binding of GDNF&#8211;GFR&#945; complexes&#44; suggesting that these mutant RET forms may induce signal transduction from both within and outside the lipid rafts&#44; perhaps via distinct signaling complexes &#40;<a class="elsevierStyleCrossRef" href="#fig2">Figure 2B</a>&#41;&#46; As a result&#44; RET downstream signals are enhanced&#44; and activation of targets is increased&#44; notably including upregulation of gene transcripts that contribute to cell proliferation or to metastasis-promoting cell behaviors &#40;<a class="elsevierStyleCrossRef" href="#bib52">52</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib53">53</a>&#41;&#46; Although it has been postulated that the M918T mutation alters the preferred substrates of the mutant RET protein with respect to both autophosphorylation of RET tyrosine residues&#44; and phosphorylation of downstream signaling molecules &#40;<a class="elsevierStyleCrossRef" href="#bib54">54</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib55">55</a>&#41;&#44; novel downstream targets that cannot also be stimulated at lower levels by other less active RET mutants or by ligand activation of wild-type RET have not been broadly identified &#40;<a class="elsevierStyleCrossRefs" href="#bib48">48&#8211;51&#44;53</a>&#41;&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">An intriguing finding has been that activation of M918T RET begins before the receptor arrives at the cell surface&#44; stimulating signaling pathways from the endoplasmic reticulum before the receptor reaches its fully glycosylated mature form &#40;<a class="elsevierStyleCrossRef" href="#bib56">56</a>&#41;&#44; which has not been observed for other mutants&#46; RET signaling from intracellular compartments may differ &#40;in intensity or otherwise&#41; from that at the plasma membrane&#44; which has been shown to be the case when wild-type RET is internalized into endosomes following ligand stimulation &#40;<a class="elsevierStyleCrossRef" href="#bib57">57</a>&#41; and for cytosolic RET mutants found in papillary thyroid carcinoma &#40;<a class="elsevierStyleCrossRef" href="#bib37">37</a>&#41;&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">An alanine to phenylalanine substitution at codon 883 &#40;A883F&#41; is the only other recurring MEN 2B mutation &#40;<a class="elsevierStyleCrossRef" href="#bib58">58</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib59">59</a>&#41;&#46; Structurally&#44; this residue lies between the activation and catalytic loops of the kinase &#40;<a class="elsevierStyleCrossRef" href="#fig3">Figure 3</a>&#41;&#44; and would be predicted to increase the flexibility of these domains&#44; so destabilizing the inactive form of the protein and promoting its activation&#46; Although generally considered a high-risk mutation&#44; some studies suggest that it may have a lesser effect than the M918T mutation &#40;<a class="elsevierStyleCrossRef" href="#bib60">60</a>&#41;&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">A handful of instances of double mutations in MEN 2B have also been reported&#58; V804M&#47;E805K &#40;<a class="elsevierStyleCrossRef" href="#bib51">51</a>&#41;&#44; V804M&#47;Y806C &#40;<a class="elsevierStyleCrossRef" href="#bib61">61</a>&#41;&#44; and V804M&#47;S904C &#40;<a class="elsevierStyleCrossRef" href="#bib62">62</a>&#41;&#46; It appears that the combination of two mild intracellular mutations can cooperate to produce a more severe mutant&#46; Each mutation alone &#40;V804M&#44; E805K&#44; Y806C&#44; S904C&#41; has low or no transforming ability&#44; consistent with the observation that V804M generally leads to FMTC &#40;discussed below&#41;&#44; but when coupled together&#44; they exert a synergistic effect on the transforming ability of mutated RET &#40;<a class="elsevierStyleCrossRef" href="#bib51">51</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib63">63</a>&#41;&#46;</p></span><span id="cesec80" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">Lower Risk Intracellular Domain Mutations</span><p id="para140" class="elsevierStylePara elsevierViewall">Recurrent mutations in the intracellular codons 768&#44; 790&#44; 791&#44; 804&#44; and 891 are found in patients with FMTC and&#44; less commonly&#44; MEN 2A &#40;<a class="elsevierStyleCrossRef" href="#bib20">20</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib64">64</a>&#41;&#46; This group of mutations is the most diverse in functional effects&#44; phenotypic variability&#44; and long-term clinical implications&#46;</p><p id="para150" class="elsevierStylePara elsevierViewall">Mutations of glutamic acid 768 occur almost exclusively in patients with FMTC&#44; whereas leucine 790 mutations have been recognized in both FMTC and MEN 2A families &#40;<a class="elsevierStyleCrossRefs" href="#bib20">20&#8211;23</a>&#41;&#46; These are considered lower penetrance mutations&#44; associated with later-onset disease&#44; as reflected by evidence-based clinical management recommendations suggesting that delayed prophylactic surgery may be acceptable &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41;&#46; The E768 and L790 residues lie close to the ATP binding site &#40;<a class="elsevierStyleCrossRef" href="#fig3">Figure 3</a>&#41; and may alter interactions in this region&#44; and&#47;or increase flexibility of domains&#44; making the transition to an active conformation relatively easy&#46;</p><p id="para160" class="elsevierStylePara elsevierViewall">Mutation of serine 891 to an alanine was initially recognized as an FMTC mutation&#44; but more recently has been linked to MEN 2A features &#40;<a class="elsevierStyleCrossRef" href="#bib65">65</a>&#41;&#46; Codon 891 lies in a conserved region of the RET protein&#44; and its mutation appears to alter protein autoinhibition and ATP binding&#44; favoring an active conformation&#46; Interestingly&#44; S891A and Y791F mutations are functionally unique in that they do not require RET dimerization for full activation&#44; and so RET autophosphorylation and downstream signaling are not further enhanced by ligand binding &#40;<a class="elsevierStyleCrossRef" href="#fig2">Figure 2C</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib66">66</a>&#41;&#46; As for other RET mutants&#44; this means that RET is not recruited into lipid rafts by GFR&#945;&#44; and hence it is likely that the nature&#44; intensity&#44; and duration of signaling is altered for these mutants &#40;<a class="elsevierStyleCrossRefs" href="#bib36">36&#8211;40</a>&#41;&#46;</p><p id="para170" class="elsevierStylePara elsevierViewall">The most common of these lower-risk mutations is substitution of valine 804 &#40;<a class="elsevierStyleCrossRef" href="#bib67">67</a>&#41;&#46; This residue lies in the sequence linking the N-terminal and C-terminal lobes of the kinase domain&#44; in a conserved region critical for RET&#8211;ATP binding&#44; which is required for activation of the kinase&#46; Substitution of valine 804 for a leucine &#40;V804L&#41; or methionine &#40;V804M&#41; changes the conformation of the ATP binding pocket&#44; making it more permissive for binding ATP&#44; and thus enhancing RET activation &#40;<a class="elsevierStyleCrossRef" href="#bib51">51</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib68">68</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib69">69</a>&#41;&#46; Residue 804 represents a classical gatekeeper residue &#40;<a class="elsevierStyleCrossRef" href="#bib51">51</a>&#41;&#44; positioned so as to regulate access to the ATP-binding site&#46; Competitive binding to this region is the mechanism of action of multikinase inhibitors such as vandetanib&#44; which has recently been approved for treatment of advanced MTC &#40;<a class="elsevierStyleCrossRef" href="#bib70">70</a>&#41;&#46; Although vandetanib effectively inhibits wild-type and other mutant RET forms&#44; the V804L or V804M mutations confer resistance to the drug &#40;<a class="elsevierStyleCrossRef" href="#bib48">48</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib68">68</a>&#41;&#46; As other kinase inhibitors &#40;such as sorafenib&#44; which is currently under review for managing advanced thyroid carcinoma &#40;<a class="elsevierStyleCrossRef" href="#bib71">71</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib72">72</a>&#41; are not affected by codon 804 mutations &#40;<a class="elsevierStyleCrossRef" href="#bib68">68</a>&#41;&#44; <span class="elsevierStyleItalic">RET</span> mutation status can have profound clinical importance for optimizing treatment regimens&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">The molecular effects of substitution of phenylalanine for tyrosine at codon 791 &#40;Y791F&#41; of RET are not clearly defined&#46; This residue is not a known site of tyrosine phosphorylation &#40;<a class="elsevierStyleCrossRef" href="#bib73">73</a>&#41;&#44; so direct protein interactions of RET with other molecules are unlikely to be altered by this mutation&#46; The position of the residue&#44; close to the ATP binding pocket&#44; may enhance ATP access&#44; or may again alter protein flexibility&#44; favoring the active conformation&#46; <span class="elsevierStyleItalic">In vitro</span>&#44; Y791F mutations have been shown to enhance signal transducer and activator of transcription 3 &#40;STAT3&#41; signaling &#40;<a class="elsevierStyleCrossRef" href="#bib74">74</a>&#41;&#46; Like S891A mutants&#44; the Y791F form of RET appears to exist as an active monomer as it does not require dimerization to be activated&#44; and ligand binding does not further enhance autophosphorylation or downstream signaling &#40;<a class="elsevierStyleCrossRef" href="#bib66">66</a>&#41;&#46; The significance of the Y791F mutation remains somewhat controversial&#46; Reports have identified this mutation&#44; alone or in combination with other mutations&#44; in MEN 2A and FMTC&#44; and in sporadic MTC and pheochromocytoma tumors &#40;<a class="elsevierStyleCrossRef" href="#bib24">24</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib75">75</a>&#41;&#46; Co-occurrence of Y791F and codon 634 mutations has been shown to increase the risk of pheochromocytoma in some families &#40;<a class="elsevierStyleCrossRef" href="#bib76">76</a>&#41;&#44; whereas other studies have concluded that this mutation is not pathogenic &#40;<a class="elsevierStyleCrossRef" href="#bib77">77</a>&#41;&#46; Interestingly&#44; a clue is perhaps provided by studies identifying Y791F and Y791N mutations in patients with Hirschsprung disease &#40;<a class="elsevierStyleCrossRef" href="#bib75">75</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib78">78</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib79">79</a>&#41;&#44; possibly suggesting that mutations of tyrosine 791 may act as modifiers of multiple phenotypes&#46;</p></span></span><span id="cesec90" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">CONCLUSIONS AND PERSPECTIVES</span><p id="para190" class="elsevierStylePara elsevierViewall">The landscape of MEN 2 disease management has been transformed by the identification and cataloguing of its underlying genetic causes&#46; Mutation genotype has guided the evidence-based diagnosis&#44; prediction&#44; and management of MEN 2 as for few other diseases&#46; However&#44; we are only beginning to reap the benefits of functional characterization of <span class="elsevierStyleItalic">RET</span> mutations&#46; The new crop of anti-RET therapeutics being developed has implications not just for MEN 2&#44; but for thyroid cancer in general&#44; and for other diseases that have recently been linked to RET activity including pancreatic and breast cancers &#40;<a class="elsevierStyleCrossRefs" href="#bib80">80&#8211;82</a>&#41;&#46; Conversely&#44; mutations or altered expression of RET that result in decreased receptor function have been linked to developmental defects&#44; such as Hirschsprung disease &#40;<a class="elsevierStyleCrossRef" href="#bib44">44</a>&#41; and kidney anomalies &#40;<a class="elsevierStyleCrossRef" href="#bib83">83</a>&#41;&#44;&#40;<a class="elsevierStyleCrossRef" href="#bib84">84</a>&#41;&#44; and current research also links GDNF and survival of dopaminergic neurons in Parkinson disease &#40;<a class="elsevierStyleCrossRef" href="#bib85">85</a>&#41;&#46; Together&#44; these studies clearly indicate that understanding of the normal functions and physiological role of RET are essential in assessing the short-term and long-term benefits and potential harms of novel RET-targeted therapeutics&#46;</p></span></span>"
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          "titulo" => "INTRODUCTION"
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          "titulo" => "RET RECEPTOR"
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          "titulo" => "THE RET PROTO-ONCOGENE IN MEN 2"
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          "titulo" => "MOLECULAR MECHANISMS OF RET MUTATIONS"
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              "titulo" => "RET Extracellular Domain Cysteine Residues"
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              "titulo" => "RET Intracellular Domain Mutations"
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              "titulo" => "MEN 2B Mutations"
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              "titulo" => "Lower Risk Intracellular Domain Mutations"
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            1 => "Multiple Endocrine Neoplasia Type 2"
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        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">Multiple endocrine neoplasia type 2 is an inherited cancer syndrome characterized by tumors of thyroid and adrenal tissues&#46; Germline mutations of the <span class="elsevierStyleItalic">REarranged during Transfection</span> &#40;RET&#41; proto-oncogene&#44; leading to its unregulated activation&#44; are the underlying cause of this disease&#46; Multiple endocrine neoplasia type 2 has been a model in clinical cancer genetics&#44; demonstrating how knowledge of the genetic basis can shape the diagnosis and treatment of the disease&#46; Here&#44; we discuss the nature and effects of the most common recurrent mutations of <span class="elsevierStyleItalic">RET</span> found in multiple endocrine neoplasia type 2&#46; Current understanding of the molecular mechanisms of <span class="elsevierStyleItalic">RET</span> mutations and how they alter the structure and function of the RET protein leading to its aberrant activation&#44; and the effects on <span class="elsevierStyleItalic">RET</span> localization and signaling are described&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">Wagner SM prepared the figures and was also responsible for the manuscript writing&#46; Zhu S contributed to the manuscript writing&#46; Nicolescu A prepared the models and figures&#46; Mulligan LM is the senior author who prepared the final manuscript version&#46; Wagner SM and Zhu S contributed equally to the study&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="cenpara20">contributed equally to the study</p>"
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">The RET receptor&#58; structure&#44; activation&#44; and oncogenic mutations&#46; &#40;A&#41; Schematic diagram depicting RET tyrosine kinase receptor domains and the location of recurrent oncogenic mutations&#46; The RET protein has a large extracellular domain containing a cysteine-rich region and a series of cadherin homology domains&#44; a transmembrane domain&#44; and an intracellular tyrosine kinase domain&#46; The positions of the most common mutations found in patients with multiple endocrine neoplasia type 2 &#40;MEN 2&#41; are shown&#46; &#40;B&#41; Mechanism of RET activation&#46; Wild-type RET activation requires the dimerization of RET&#44; mediated through formation of a multicomponent complex&#46; RET is activated by binding both a soluble ligand &#40;glial cell-line-derived neurotrophic factor&#59; GDNF&#41; and a non-signaling extracellular co-receptor &#40;GDNF family receptor&#59; GFR&#945;&#41;&#46; Upon activation of RET&#44; phosphorylation of multiple intracellular tyrosines leads to stimulation of downstream signaling pathways&#46;</p>"
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          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Molecular mechanisms of pathogenic RET activation&#46; Schematic diagrams showing mechanisms of RET activation in the presence of various multiple endocrine neoplasia type 2 &#40;MEN 2&#41; mutations&#46; &#40;A&#41; Substitutions of extracellular cysteines lead to formation of intermolecular disulfide bonds and to constitutive RET dimerization and activation&#46; &#40;B&#41; The MEN 2B mutation&#44; M918T &#40;star&#41; in the kinase domain&#44; leads to a conformational change with multiple effects including an increase in RET kinase activity and activation of receptors in either dimeric or monomeric form&#46; &#40;C&#41; Intracellular kinase domain mutations asterisk implicated in familial medullary thyroid carcinoma &#40;FMTC&#41; &#40;e&#46;g&#46; residues 791 and 891&#41;&#44; permit activation of monomeric RET&#44; allowing for a partially active conformation&#46;</p>"
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          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Structure of the RET tyrosine kinase domain&#46; Ribbon diagrams of the intracellular regions of activated RET&#44; in two orientations&#44; showing the positions of key functional features of the kinase&#58; the ATP binding pocket&#59; the activation or autoinhibitory loop&#59; and the substrate binding pocket&#46; Two orientations of the model&#44; displaying the autoinhibitory&#47;substrate binding face &#40;left&#41; and the ATP-binding face &#40;right&#41;&#44; are shown&#46; Amino acid residues that are mutated in patients with multiple endocrine neoplasia type 2 &#40;MEN 2&#41; are represented in the stick form&#46; The three-dimensional representation was based on the crystal structure of the phosphorylated &#40;activated&#41; RET tyrosine kinase domain &#40;residues 709&#8211;990&#41;&#46;</p>"
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          "leyenda" => "<p id="spara50" class="elsevierStyleSimplePara elsevierViewall">FMTC&#44; familial medullary thyroid carcinoma&#59; MEN 2&#44; multiple endocrine neoplasia 2&#59; RET&#44; <span class="elsevierStyleUnderline">RE</span>arranged during <span class="elsevierStyleUnderline">T</span>ransfection&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="top" scope="col">Mutation location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Affected RET Codons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Putative function of thewild-type residue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Predicted mutation effects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Recommendedintervention &#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Extracellular- cysteine rich domain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">C609C611C618C620C630&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Contributes to tertiary structure of RET through the formation of intramolecular disulfide bonds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Weakly activating&#46; Alteration in protein folding and maturation&#46;Formation of mutant RET dimers that are constitutively active in the absence of ligands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">MEN 2A and FMTC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Prophylactic thyroid surgery before the age of 5&#46; Under some conditions may delay beyond 5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">C634&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Role in formation of intramolecular disulfide bonds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Strongly activating&#46; Ligand-independent dimerization of receptor molecules&#44; enhanced phosphorylation of intracellular substrates&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">MEN 2A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Surgery before age 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">Intracellular tyrosine kinase domain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">L790&#44; Y791&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">In the N-terminal lobe of the RET kinase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Moderately activating&#46; Affects ATP binding and inter-lobe flexibility&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">MEN 2A and FMTC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">May delay surgery beyond 5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">E768&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">In close proximity with the ATP binding site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Alters interactions within the region and facilitates the transition to an active conformation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">FMTC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">V804&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">A gatekeeper residue which regulates access to the ATP binding site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Alters hinge flexibility and positioning of RET helices for catalysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">FMTC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">S891&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">C-terminal lobe of the kinase&#44; adjacent to the activation loop of the kinase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Alters activation loop conformation and promotes monomeric RET activation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">MEN 2A and FMTC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">A883&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Situated next to activation loop&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Strongly activating&#46; Local conformational change which destabilizes the inactive form of the protein and promotes its activation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">MEN 2B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">As early as possible &#40;within first year of life&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">M918&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Lies in the substrate-binding pocket of the kinase and plays a role in stabilizing the receptor&#8211;ATP complex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Strongly activating&#46; Alters protein conformation and substrate specificity&#46; The mutant can dimerize and become phosphorylated in the absence of ligand stimulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">MEN 2B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Molecular effects of RET mutations in multiple endocrine neoplasia 2&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "REFERENCES"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec10"
          "bibliografiaReferencia" => array:85 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medullary thyroid carcinoma as part of a multiple endocrine neoplasia type 2B syndrome&#58; influence of the stage on the clinical course"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              S Leboulleux \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              JP Travagli \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              B Caillou \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              A Laplanche \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              JM Bidart \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              M Schlumberger \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Cancer"
                        "fecha" => "2002"
                        "volumen" => "94"
                        "numero" => "1"
                        "paginaInicial" => "50"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multiple endocrine neoplasia 2B syndrome due to codon 918 mutation&#58; clinical manifestation and course in early and late onset disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              M Brauckhoff \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              O Gimm \n
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                              """
                            2 => """
                              CL Weiss \n
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                              """
                            3 => """
                              J Ukkat \n
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                              """
                            4 => """
                              C Sekulla \n
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                              """
                            5 => """
                              K Brauckhoff \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "World J Surg"
                        "fecha" => "2004"
                        "volumen" => "28"
                        "numero" => "12"
                        "paginaInicial" => "11"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Premonitory symptoms preceding metastatic medullary thyroid cancer in MEN 2B&#58; An exploratory analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              M Brauckhoff \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              A Machens \n
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                              """
                            2 => """
                              S Hess \n
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                              """
                            3 => """
                              K Lorenz \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              O Gimm \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              K Brauckhoff \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Surgery"
                        "fecha" => "2008"
                        "volumen" => "144"
                        "numero" => "6"
                        "paginaInicial" => "50"
                      ]
                    ]
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            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Specific mutations of the RET proto-oncogene are related to disease phenotype in MEN 2A and FMTC"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              LM Mulligan \n
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                              """
                            1 => """
                              C Eng \n
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                              """
                            2 => """
                              CS Healey \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              D Clayton \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              JBJ Kwok \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              E Gardner \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ng0194-4"
                      "Revista" => array:5 [
                        "tituloSerie" => "Nature Genet"
                        "fecha" => "1994"
                        "volumen" => "6"
                        "paginaInicial" => "4"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8136832"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Germ-line mutations of the RET proto-oncogene in multiple endocrine neoplasia type 2A"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              LM Mulligan \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              JBJ Kwok \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              CS Healey \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              MJ Elsdon \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              C Eng \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              E Gardner \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Nature"
                        "fecha" => "1993"
                        "volumen" => "363"
                        "paginaInicial" => "60"
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            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mutations in the RET proto-oncogene are associated with MEN 2A and FMTC"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              H Donis-Keller \n
                              \t\t\t\t\t\t\t\t
                              """
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es en pt

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