Hereditary pheochromocytoma (PCC) is often caused by germline mutations in one of nine susceptibility genes described to date1,2,3,4, but there are familial cases without mutations in these known genes. We sequenced the exomes of three unrelated individuals with hereditary PCC (cases) and identified mutations in MAX, the MYC associated factor X gene. Absence of MAX protein in the tumors and loss of heterozygosity caused by uniparental disomy supported the involvement of MAX alterations in the disease. A follow-up study of a selected series of 59 cases with PCC identified five additional MAX mutations and suggested an association with malignant outcome and preferential paternal transmission of MAX mutations. The involvement of the MYC-MAX-MXD1 network in the development and progression of neural crest cell tumors is further supported by the lack of functional MAX in rat PCC (PC12) cells5 and by the amplification of MYCN in neuroblastoma6 and suggests that loss of MAX function is correlated with metastatic potential.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


Gene Expression Omnibus


  1. 1.

    et al. Germ-line mutations in nonsyndromic pheochromocytoma. N. Engl. J. Med. 346, 1459–1466 (2002).

  2. 2.

    et al. SDH5, a gene required for flavination of succinate dehydrogenase, is mutated in paraganglioma. Science 325, 1139–1142 (2009).

  3. 3.

    et al. Spectrum and prevalence of FP/TMEM127 gene mutations in pheochromocytomas and paragangliomas. J. Am. Med. Assoc. 304, 2611–2619 (2010).

  4. 4.

    et al. SDHA is a tumor suppressor gene causing paraganglioma. Hum. Mol. Genet. 19, 3011–3020 (2010).

  5. 5.

    & The nerve growth factor-responsive PC12 cell line does not express the Myc dimerization partner Max. Mol. Cell. Biol. 15, 3470–3478 (1995).

  6. 6.

    et al. Transposition and amplification of oncogene-related sequences in human neuroblastomas. Cell 35, 359–367 (1983).

  7. 7.

    et al. Clinically guided genetic screening in a large cohort of Italian patients with pheochromocytomas and/or functional or nonfunctional paragangliomas. J. Clin. Endocrinol. Metab. 94, 1541–1547 (2009).

  8. 8.

    et al. Genetics of pheochromocytoma and paraganglioma in Spanish patients. J. Clin. Endocrinol. Metab. 94, 1701–1705 (2009).

  9. 9.

    et al. The Warburg effect is genetically determined in inherited pheochromocytomas. PLoS ONE 4, e7094 (2009).

  10. 10.

    et al. A HIF1α regulatory loop links hypoxia and mitochondrial signals in pheochromocytomas. PLoS Genet. 1, 72–80 (2005).

  11. 11.

    et al. Research resource: transcriptional profiling reveals different pseudohypoxic signatures in SDHB and VHL-related pheochromocytomas. Mol. Endocrinol. 24, 2382–2391 (2010).

  12. 12.

    & Myc and Max: molecular evolution of a family of proto-oncogene products and their dimerization partner. Proc. Natl. Acad. Sci. USA 92, 10217–10221 (1995).

  13. 13.

    , , & The Myc/Max/Mad network and the transcriptional control of cell behavior. Annu. Rev. Cell Dev. Biol. 16, 653–699 (2000).

  14. 14.

    , , , & Identification of casein kinase II phosphorylation sites in Max: effects on DNA-binding kinetics of Max homo- and Myc/Max heterodimers. Oncogene 8, 3211–3220 (1993).

  15. 15.

    , , & Biphasic effect of Max on Myc cotransformation activity and dependence on amino- and carboxy-terminal Max functions. Genes Dev. 6, 2429–2439 (1992).

  16. 16.

    , & c-Myc does not require max for transcriptional activity in PC-12 cells. Mol. Cell. Neurosci. 5, 277–282 (1994).

  17. 17.

    & Transforming ability of MEN2A-RET requires activation of the phosphatidylinositol 3-kinase/AKT signaling pathway. J. Biol. Chem. 275, 3568–3576 (2000).

  18. 18.

    et al. The NF1 tumor suppressor critically regulates TSC2 and mTOR. Proc. Natl. Acad. Sci. USA 102, 8573–8578 (2005).

  19. 19.

    et al. Germline mutations in TMEM127 confer susceptibility to pheochromocytoma. Nat. Genet. 42, 229–233 (2010).

  20. 20.

    , & Activation of PI3K/Akt and MAPK pathways regulates Myc-mediated transcription by phosphorylating and promoting the degradation of Mad1. Proc. Natl. Acad. Sci. USA 105, 6584–6589 (2008).

  21. 21.

    et al. Regulation of gene expression in hepatic cells by the mammalian Target of Rapamycin (mTOR). PLoS ONE 5, e9084 (2010).

  22. 22.

    et al. c-Myc inhibits Ras-mediated differentiation of pheochromocytoma cells by blocking c-Jun up-regulation. Mol. Cancer Res. 6, 325–339 (2008).

  23. 23.

    & X-ray structures of Myc-Max and Mad-Max recognizing DNA. Molecular bases of regulation by proto-oncogenic transcription factors. Cell 112, 193–205 (2003).

  24. 24.

    , , & Involvement of the 'leucine zipper' region in the oligomerization and transforming activity of human c-myc protein. Nature 337, 664–666 (1989).

  25. 25.

    et al. Genomewide single nucleotide polymorphism microarray mapping in basal cell carcinomas unveils uniparental disomy as a key somatic event. Cancer Res. 65, 8597–8603 (2005).

  26. 26.

    , , & Loss of heterozygosity associated with uniparental disomy in breast carcinoma. Mod. Pathol. 15, 1241–1250 (2002).

  27. 27.

    et al. New lesions detected by single nucleotide polymorphism array-based chromosomal analysis have important clinical impact in acute myeloid leukemia. J. Clin. Oncol. 27, 5219–5226 (2009).

  28. 28.

    et al. Paternal UPD14 is responsible for a distinctive malformation complex. Am. J. Med. Genet. 110, 268–272 (2002).

  29. 29.

    et al. The clinical phenotype of mosaicism for genome-wide paternal uniparental disomy: two new reports. Am. J. Med. Genet. A. 146A, 137–148 (2008).

  30. 30.

    et al. Mutations in SDHD, a mitochondrial complex II gene, in hereditary paraganglioma. Science 287, 848–851 (2000).

  31. 31.

    , & Molecular Cloning: A Laboratory Manual, 3 v. (Cold Spring Harbor Laboratory, Cold Spring Harbor, New York, 1989).

  32. 32.

    et al. The Sequence Alignment/Map format and SAMtools. Bioinformatics 25, 2078–2079 (2009).

  33. 33.

    , & ANNOVAR: functional annotation of genetic variants from high-throughput sequencing data. Nucleic Acids Res. 38, e164 (2010).

  34. 34.

    et al. Genome-wide SNP assay reveals structural genomic variation, extended homozygosity and cell-line induced alterations in normal individuals. Hum. Mol. Genet. 16, 1–14 (2007).

  35. 35.

    et al. Gross SDHB deletions in patients with paraganglioma detected by multiplex PCR: a possible hot spot? Genes Chromosom. Cancer 45, 213–219 (2006).

  36. 36.

    et al. Epigenetic alteration at the DLK1–GTL2 imprinted domain in human neoplasia: analysis of neuroblastoma, phaeochromocytoma and Wilms' tumour. Br. J. Cancer 92, 1574–1580 (2005).

  37. 37.

    et al. Allelic variant at -79 (C>T) in CDKN1B (p27Kip1) confers an increased risk of thyroid cancer and alters mRNA levels. Endocr. Relat. Cancer 17, 317–328 (2010).

Download references


This work was supported in part by the Fondo de Investigaciones Sanitarias (projects PS09/00942 and P1080883 to A.C. and M.R., respectively), Mutua Madrileña (project AP2775/2008 to M.R.), FP7-Grant (ENS@T-CANCER; HEALTH-F2-2010-259735) and Innovation project INTRA-706-2 ISCIII CIBER-ER (Center for Biomedical Research on Rare Diseases). I.C.-M. holds a shuttle CIBER-ER fellowship.

Author information

Author notes

    • Iñaki Comino-Méndez
    • , Francisco J Gracia-Aznárez
    •  & Francesca Schiavi

    These authors contributed equally to this work.


  1. Hereditary Endocrine Cancer Group, Spanish National Cancer Research Centre (CNIO), Madrid, Spain.

    • Iñaki Comino-Méndez
    • , Iñigo Landa
    • , Luis J Leandro-García
    • , Rocío Letón
    • , Álvaro Gómez-Graña
    • , Aguirre A de Cubas
    • , Lucía Inglada-Pérez
    • , Agnieszka Maliszewska
    • , Cristina Rodríguez-Antona
    • , Mercedes Robledo
    •  & Alberto Cascón
  2. Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain.

    • Iñaki Comino-Méndez
    • , Francisco J Gracia-Aznárez
    • , Lucía Inglada-Pérez
    • , Cristina Rodríguez-Antona
    • , Javier Benítez
    • , Mercedes Robledo
    •  & Alberto Cascón
  3. Human Genetics Group, Spanish National Cancer Research Centre, Madrid, Spain.

    • Francisco J Gracia-Aznárez
    •  & Javier Benítez
  4. Familial Cancer Clinic, Veneto Institute of Oncology, Padova, Italy.

    • Francesca Schiavi
    • , Elisa Taschin
    • , Sara Bobisse
    •  & Giuseppe Opocher
  5. Anatomical Pathology Service, Hospital de León, León, Spain.

    • Emiliano Honrado
  6. Monoclonal Antibodies Unit, Biotechnology Programme, Spanish National Cancer Research Centre, Madrid, Spain.

    • Rocío Ramos-Medina
    •  & Giovanna Roncador
  7. Human Genotyping Unit-CeGen, Human Cancer Genetics Programme, Spanish National Cancer Centre, Madrid, Spain.

    • Daniela Caronia
    • , Guillermo Pita
    •  & Anna González-Neira
  8. Endocrinology and Metabolic Diseases, University of Foggia, Foggia, Italy.

    • Giuseppe Pica
  9. Department of Endocrinology, Ospedale Niguarda Ca' Granda, Milan, Italy.

    • Paola Loli
  10. Endocrinology Section, Hospital Infanta Cristina, Badajoz, Spain.

    • Rafael Hernández-Lavado
  11. Department of Endocrinology, Hospital Universitario Clínico San Carlos, Madrid, Spain.

    • José A Díaz
  12. Department of Pathology, University Hospital, University of Granada, Granada, Spain.

    • Mercedes Gómez-Morales
  13. Department of Clinical Pathophysiology, University of Florence and Istituto Toscano Tumori, Florence, Italy.

    • Massimo Mannelli
  14. Department of Medical and Surgical Sciences, University of Padova, Padova, Italy.

    • Giuseppe Opocher


  1. Search for Iñaki Comino-Méndez in:

  2. Search for Francisco J Gracia-Aznárez in:

  3. Search for Francesca Schiavi in:

  4. Search for Iñigo Landa in:

  5. Search for Luis J Leandro-García in:

  6. Search for Rocío Letón in:

  7. Search for Emiliano Honrado in:

  8. Search for Rocío Ramos-Medina in:

  9. Search for Daniela Caronia in:

  10. Search for Guillermo Pita in:

  11. Search for Álvaro Gómez-Graña in:

  12. Search for Aguirre A de Cubas in:

  13. Search for Lucía Inglada-Pérez in:

  14. Search for Agnieszka Maliszewska in:

  15. Search for Elisa Taschin in:

  16. Search for Sara Bobisse in:

  17. Search for Giuseppe Pica in:

  18. Search for Paola Loli in:

  19. Search for Rafael Hernández-Lavado in:

  20. Search for José A Díaz in:

  21. Search for Mercedes Gómez-Morales in:

  22. Search for Anna González-Neira in:

  23. Search for Giovanna Roncador in:

  24. Search for Cristina Rodríguez-Antona in:

  25. Search for Javier Benítez in:

  26. Search for Massimo Mannelli in:

  27. Search for Giuseppe Opocher in:

  28. Search for Mercedes Robledo in:

  29. Search for Alberto Cascón in:


A.C., M.R., F.S. and G.O. conceived the project. G. Pica, P.L., R.H.-L., J.A.D., M.G.-M. and M.M. collected tumor samples. F.J.G.-A., I.C.-M. and A.C. performed next-generation sequencing analysis and filtering. I.C.-M., F.J.G.-A., F.S., I.L., L.J.L.-G., R.L., R.R.-M., D.C., A.G.-G., A.A.d.C., L.I.-P., E.T., S.B., A.M., A.G.-N. and G.R. performed additional experiments. A.C., I.C.-M., E.H. and G. Pita performed additional data analysis. A.C., I.C.-M., F.J.G.-A., M.R., C.R.-A. and J.B. wrote the manuscript. All authors approved the final draft.

Competing interests

The authors declare no competing financial interests.

Corresponding authors

Correspondence to Mercedes Robledo or Alberto Cascón.

Supplementary information

PDF files

  1. 1.

    Supplementary Text and Figures

    Supplementary Figures 1–4 and Supplementary Tables 1–3.

About this article

Publication history






Further reading