Objective: To investigate somatic pathogenic variants (PVs) in the TERT promoter region and variants in the ATRX gene, both related to telomere maintenance in cancer, in a Brazilian cohort of adrenal and extra-adrenal paragangliomas (PPGLs), and to correlate these with metastatic disease as well as with clinical, radiological, and pathological characteristics. Materials and methods: The TERT promoter was analyzed by automated Sanger sequencing or whole-exome somatic sequencing in a cohort of 79 patients with PPGLs (53 non-metastatic and 26 metastatic), encompassing a total of 81 tumors. ATRX was assessed through whole-exome somatic sequencing in 26 patients from this cohort. Results: Germline PVs in Cluster 1A genes were identified in 28 of 79 patients (35.4%), including 20 patients harboring PVs in the Succinate Dehydrogenase Complex Iron Sulfur Subunit B gene (SDHB) (25.3%) and 8 patients (10.1%) with PVs in other Cluster 1A genes. Somatic PVs in the TERT promoter (c.-124C>T/ C228T) were detected in two metastatic PPGLs (2.5% of the total cohort). Three PPGLs (two metastatic), among the 26 patients studied, harbored somatic ATRX variants classified as likely benign (11.5%). Somatic PVs in the TERT promoter were identified in patients with germline SDHB PVs. Among metastatic patients with germline SDHB PVs, the frequency of somatic PVs in the TERT promoter was 16.7%. Conclusion: This study expands the understanding of telomere maintenance mechanisms in PPGLs in a Brazilian cohort enriched for SDHB alterations. Somatic variants in the TERT promoter were associated with aggressive tumor features, such as extra-adrenal location, germline SDHB PVs, and metastatic disease.

BACKGROUND:Elevated parathyroid hormone (PTH) levels have been linked to higher cardiovascular (CV) and all-cause mortality in individuals with hyperparathyroidism or high-risk conditions (individuals with a mean age of 75-85 years and patients undergoing coronary angiography). However, it remains uncertain whether sex- and age-related differences influence these associations among normocalcemic and middle-aged adults from the general population. METHODS:We analyzed 4736 participants from the ELSA-Brasil study (mean age, 51.7 years; 55% females), followed for a median of 11.2 years. Baseline serum PTH was measured by electrochemiluminescence immunoassay. Associations of PTH with outcomes were assessed using Cox regression for all-cause mortality, reporting hazard ratios (HRs), and Fine-Gray models for CV mortality, accounting for competing risks and reporting subdistribution hazard ratios (sHRs), adjusted for total calcium, and other relevant covariates. RESULTS:A baseline PTH concentration >56 pg/mL was independently associated with higher CV mortality (sHR 1.92; 95% CI 1.22-3.01) and all-cause mortality (HR 1.61; 95% CI 1.25-2.07). Sex- and age-stratified analyses showed that females with elevated PTH had a 179% increased CV mortality risk (sHR 2.79; 95% CI 1.37-5.70), whereas no significant association was seen in males. Elevated PTH was also associated with increased CV mortality in adults ≤64 years (sHR 1.80; 95% CI 1.05-3.09) but not in older individuals. For all-cause mortality, PTH >56 pg/mL conferred a higher risk in both females (HR 1.75; 95% CI 1.15-2.66) and males (HR 1.59; 95% CI 1.16-2.19), with consistent associations across both age groups (≤64 and >64 years). CONCLUSION:In this large, community-based cohort, PTH levels at the upper end of the reference range were associated with greater CV and all-cause mortality. The excess CV risk was restricted to females and younger adults, suggesting that PTH may serve as an early, sex-sensitive biomarker of cardiometabolic risk.

CONTEXT:Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of ACTH-independent Cushing syndrome (CS), occurring in isolation or as part of Carney complex (CNC); its phenotypic and molecular spectra remain incompletely defined. OBJECTIVE:To characterize phenotypic variability, genotype-phenotype correlations, and molecular findings in PPNAD through integrated clinical, histopathological, and genetic analyses. METHODS:We evaluated 18 index patients with PPNAD (15 with CNC, 3 isolated) and performed cascade genetic screening in relatives (20 variants-positive). Clinical, hormonal, imaging and histopathological data were reviewed; germline and somatic analyses employed targeted next-generation sequencing and copy-number assessment. RESULTS:Overt CS was present in 83% of index cases; 17% had cyclic hypercortisolism. Pathogenic or likely-pathogenic germline PRKAR1A variants were identified in 70.6% probands, including four novel variants; germline PRKACA duplications were detected in two cases. Cascade screening identified eight asymptomatic variant-positive relatives, in whom mild autonomous cortisol secretion (MACS) was observed. Somatic second-hit alterations in tumor tissue included PRKACA duplication, a PRKAR1A frameshift deletion, and 17q24.2 loss of heterozygosity. Histology most often showed classic PPNAD but also nonclassical patterns, expanding the morphological spectrum. Extra-adrenal manifestations were frequent (lentigines 61%, cardiac myxomas 22%). CONCLUSION:In this referral cohort, PPNAD/CNC displays marked phenotypic variability, incomplete penetrance with subclinical cortisol excess, and diverse molecular mechanisms, including novel germline variants and somatic second hits. Some cases lacked identifiable drivers, suggesting additional uncharacterized mechanisms. Systematic genetic screening and recognition of MACS are important for early diagnosis and long-term management.

BACKGROUND:The Brazilian population represents a mosaic of genetic diversity resulting from admixture ancestries. Given reported disparities in primary aldosteronism (PA) genetics across ethnicities, we investigated the genetic spectrum of aldosterone-producing adenomas (APAs) and nodules (APNs) with classical histology in a Brazilian cohort. METHODS:We included 62 lesions (1 case with bilateral APAs) from 61 consecutive patients (median age at PA diagnosis 49 years, 59% women) with PA and classical histology, defined by CYP11B2 immunostaining (HISTALDO consensus). Somatic DNA was extracted from CYP11B2-positive areas of the dominant lesions. Hotspot regions of KCNJ5, ATP1A1, ATP2B3, CACNA1D, and CTNNB1 were initially analyzed by Sanger sequencing. Whole-exome sequencing of paired somatic and germline DNA was subsequently performed in cases without driver variants. RESULTS:Histopathology showed combined APA + aldosterone-producing micronodules as the most frequent subtype (n = 29, 47.54%), followed by isolated APA (n = 20, 32.79%) and APN (n = 5, 8.2%). Somatic pathogenic variants were identified in 82.26% of lesions: KCNJ5 (n = 35, 56.45%), ATP2B3 (n = 7, 11.29%), CACNA1D (n = 5, 8.06%), and ATP1A1 (n = 4, 6.45%). Nine novel variants were identified, including 3 in ATP2B3 (2 exon 8 in-frame deletions and 1 missense), 3 in KCNJ5, 2 in CACNA1D, and 1 in CTNNB1. The frequency of ATP2B3 variants (11.29%) was significantly higher than that reported in other cohorts (4.06%) from different ethnicities (p = .0053). ATP2B3-mutated tumors occurred predominantly in older men and were smaller in size compared with wild-type tumors. Rare germline CACNA1H variants were also detected in 3 patients. CONCLUSION:We confirmed the predominance of known somatic drivers and identified a uniquely high frequency of ATP2B3 variants, refining their clinical phenotype. These findings underscore the influence of population-specific genetic backgrounds and expand the global understanding of PA genetics.

Congenital hypogonadotropic hypogonadism (CHH) is a rare genetic disorder characterized by absent or incomplete pubertal development due to impaired production, secretion, or action of gonadotropin-releasing hormone (GnRH). When associated with anosmia or hyposmia, it is termed Kallmann syndrome. CHH exhibits striking clinical and genetic heterogeneity, encompassing either sporadic or familial cases, with inheritance patterns that include X-linked, autosomal dominant, and autosomal recessive transmission. Over the past few decades, major advances uncovered the molecular basis of CHH, shedding light on the intricate neuroendocrine regulation of human reproduction. A growing repertoire of genes has been implicated in CHH molecular pathogenesis, encoding proteins involved in the ontogeny and function of GnRH neurons. Notably, pathogenic variants in genes typically associated with complex syndromes have also been identified in patients with isolated CHH or subtle syndromic manifestations, suggesting a wide spectrum of expressivity and incomplete penetrance. Furthermore, spontaneous hypogonadism reversal, either permanent or temporary, may occur in some patients, suggesting a potential neuroplasticity within the GnRH neuronal network. This review summarizes recent advances in the molecular genetics of CHH, emphasizing the expanding spectrum of causative genes and their inheritance patterns.

CONTEXT:Bilateral macronodular adrenocortical disease (BMAD) is a rare and often underdiagnosed cause of adrenal Cushing syndrome (CS), with manifestations ranging from mild autonomous cortisol secretion (MACS) to overt CS. ARMC5 and KDM1A are the most frequently implicated genes in familial BMAD; however, long-term follow-up data on affected patients remain limited. OBJECTIVE:This retrospective study assessed the clinical and hormonal variability, genetic profiles, treatment approaches, and outcomes of 17 familial and 9 sporadic BMAD cases over a follow-up period ranging from 8 to 410 months at a Brazilian tertiary center. METHODS:A total of 250 individuals (50 index cases and 200 relatives) were included. Clinical, hormonal, and imaging data, along with histological and genetic analyses of ARMC5 and KDM1A, were evaluated. RESULTS:Among 250 individuals, 104 (26 index and 78 relatives) carried germline pathogenic/likely pathogenic ARMC5 variants. No KDM1A (likely) pathogenic variants were identified in ARMC5-wild-type patients. ARMC5-positive index cases exhibited severe clinical manifestations, evidenced by elevated cortisol levels (urinary, salivary, and post-dexamethasone suppression test) and reduced ACTH and DHEAS levels (P = .005, P = .042, P = .005, P = .041, and P = .007, respectively). Index cases had larger adrenal nodules (P < .0001). Adrenal-sparing surgery achieved 100% remission vs a 40% remission rate for unilateral adrenalectomy. Central nervous system meningiomas were observed in BMAD patients independent of ARMC5 status. Interestingly, malignant neoplasms were notably prevalent among ARMC5-altered individuals. CONCLUSION:The proposed management flowchart highlights the importance of genetic screening and continuous monitoring to mitigate the adrenal insufficiency, MACS recurrence, and tumor risk, while underscoring the need for tailored therapeutic strategies in BMAD, adapted to genetic alterations and ARMC5 status.

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is one of the most technically challenging monogenic conditions for molecular diagnosis, owing to the complex genomic architecture of the CYP21A2 locus and the extensive homology between the functional gene and its pseudogene. Over the past decades, diagnostic approaches have evolved from locus-specific assays, such as allele-specific polymerase chain reaction, to the combined use of Sanger sequencing and multiplex ligation-dependent probe amplification (MLPA), which together constituted the historical gold-standard approach strategy capable of identifying pathogenic variants, deletions and chimeric alleles. Although short-read next-generation sequencing expanded variant detection and enabled simultaneous analysis of multiple adrenal genes, its performance remains limited within the RCCX region due to misalignment artefacts and inability to resolve complex structural rearrangements. Recently, long-read sequencing (LRS) has emerged as a single-platform technology capable of resolving the CYP21A2–CYP21A1P module, accurately detecting all variant classes and directly determining cis/trans phase. Comparative studies demonstrated complete concordance with standard methods while revealing additional rearrangements previously undetectable, positioning LRS as a future reference method for high-resolution genotyping. These advances extend beyond diagnostic refinement to impact population-level strategies, where integration of molecular testing into newborn screening algorithms reduces false positives, accelerates referral pathways, and enhances salt-wasting risk prediction. In this review, we summarized the historical development, technical limitations, and clinical implications of current and emerging molecular approaches for CAH diagnosis. We highlight how LRS and integrative analytical tools are reshaping clinical practice, refining genetic counselling, and guiding personalized therapeutic strategies. Collectively, these innovations represent a decisive step toward precision Endocrinology.

Background:The germline genetic basis of bilateral primary aldosteronism (PA) remains poorly understood, particularly in apparently sporadic disease. We investigated rare germline variants in canonical and candidate genes in patients with bilateral PA associated with resistant hypertension and/or hypertension diagnosed before 40 years of age. Methods:We studied 53 individuals with bilateral PA after exclusion of familial PA types 1 and 3. Whole-exome sequencing was performed in 52 probands and 1 affected relative. Variant prioritization was restricted to genes with direct or indirect evidence linking them to PA using a virtual panel approach. Clinical, biochemical, and imaging data were compared between carriers and noncarriers. Results:Nine of 53 patients (17%) harbored at least one rare germline candidate variant. Variants in canonical PA genes were identified in 5 patients (9.6%), including CACNA1H (n = 4) and CACNA1D (n = 1). In 4 patients (7.5%), rare variants were identified in plausible candidate genes (ANO1, KCNK3, CASZ1, and STRN). All prioritized variants were classified as variants of uncertain significance. Compared with noncarriers, carriers showed a lower frequency of hypokalemia (P < .0001), higher prevalence of family history of hypertension (P < .0001), higher frequency of resistant hypertension (P < .0001), required more antihypertensives (P = .0264), and had more frequent adrenal computed tomography abnormalities, particularly bilateral involvement (P < .0001). Conclusion:Rare germline variants in canonical and candidate genes were identified in a subset of patients with apparently sporadic bilateral PA. Variants in established genes, particularly CACNA1H, were relatively frequent, with additional variants in biologically plausible candidates.

Context Central precocious puberty (CPP) has strong genetic and epigenetic influences. MECP2, an X-linked gene, encodes a DNA methylation reader with a role in gene transcription regulation. MECP2 loss-of-function mutations are linked to neurodevelopmental disorders, particularly with Rett syndrome, a severe disorder that may be associated with early puberty. MECP2 variants were identified in girls with CPP with or without neurodevelopmental disorders.Objective This work aimed to investigate potential MECP2 variants in boys with idiopathic CPP at 3 academic hospitals.Methods MECP2 DNA sequencing was performed in 10 boys with idiopathic CPP to screen for coding variants (5 exome; 5 Sanger sequencing). There were no mutations in other CPP-causing genes (MKRN3 and DLK1). MECP2 protein levels of wild-type and identified variants were assessed in a gonadotropin-releasing hormone neuronal cell line.Results We identified 2 hemizygous missense MECP2 variants in 2 unrelated boys. Patient 1 had very early sporadic CPP, speech delay, and autism. He harbored a p.Val312Ile variant, an extremely rare variant located in a critical MECP2 domain. Patient 2 had sporadic CPP with no apparent neurodevelopmental disorders. He harbored a rare variant, p.Arg366Cys. Both MECP2 variants were inherited from mothers with normal puberty. Neither patient had features of Rett syndrome. Both variants had reduced MECP2 protein levels, suggesting a potential deleterious effect.Conclusion MECP2 rare variants were identified in boys with sporadic CPP, expanding this association as previously described in girls. Our findings provide additional evidence for a role of MECP2, an epigenetic factor, in hypothalamic control of pubertal timing.

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting women of reproductive age. Its diagnosis during adolescence is particularly challenging, as physiological pubertal changes overlap with key features of PCOS; nevertheless, this developmental stage often represents the earliest window for clinical manifestation. Accordingly, a definitive diagnosis should be established only in the presence of clear and persistent evidence of both hyperandrogenism and menstrual irregularity. Adolescents presenting with a single feature should be considered at increased risk for PCOS and followed longitudinally in order to minimize both underdiagnosis and overdiagnosis. Careful exclusion of alternative diagnoses is essential, as several conditions may mimic PCOS. Importantly, PCOS extends beyond reproductive dysfunction and constitutes a chronic condition associated with long-term metabolic risk and adverse mental health outcomes. This broader disease spectrum underscores adolescence as a critical period for early risk stratification and preventive interventions. Management should prioritize lifestyle modification as the foundation of therapy, with pharmacological treatment individualized according to clinical presentation, metabolic profile, contraindications, and patient preferences. Combined oral contraceptive pills remain the first-line therapy for menstrual irregularity and hyperandrogenism and provide an important opportunity for counseling on sexual and reproductive health, including pregnancy prevention and protection against sexually transmitted infections. Metformin is recommended as first-line therapy for metabolic comorbidities, mirroring its established role in adult populations. All these considerations highlight adolescence as an important stage for accurate diagnosis, comprehensive risk assessment, and timely intervention in PCOS, with potential implications for long-term reproductive, metabolic, and psychosocial health.

Loss-of-function mutations in DLK1, encoding Delta Like Non-Canonical Notch Ligand 1, have been linked to central precocious puberty (CPP) and increased body fat in girls, suggesting a role in the connection between metabolism and reproduction. DLK1 is located in the imprinted region of human chromosome 14, and mice lacking Dlk1 exhibit growth retardation and metabolic changes, phenotypes that overlap with Temple syndrome, an imprinting disorder associated with precocious puberty. However, the mechanisms by which DLK1 influences pubertal timing remain unclear. We investigated pubertal timing in Dlk1 knockout (KO) mice with either global or selective central nervous system (CNS) deletion of Dlk1, compared with control mice. Puberty onset and body weight were assessed, along with potential mediators of pubertal timing, including leptin and kisspeptin. Dlk1KO females reached puberty at the same age as controls, despite lower body weight. Dlk1KO males had delayed preputial separation but, like females, reached puberty at significantly lower body weight. Serum leptin and hypothalamic Socs3 mRNA, a downstream leptin effector, were lower peri-pubertally in Dlk1KO females than in controls. Kiss1 mRNA levels in the mediobasal hypothalamus were significantly lower in Dlk1KO females at puberty onset. Selective Dlk1 deletion in neurons and glial cells did not affect pubertal timing. These findings suggest that peripheral sources of Dlk1 contribute to the metabolic and endocrine regulation of pubertal timing. The absence of Dlk1 appears to alter the metabolic milieu in which puberty occurs, allowing activation of the reproductive axis despite low body weight and reduced hypothalamic kisspeptin expression.

CONTEXT:Central precocious puberty (CPP). OBJECTIVE:To summarize the available supporting evidence for the Endocrine Society guidelines about the management of CPP. METHODS:Multiple databases (MEDLINE, EMBASE, Scopus) were searched to identify studies that addressed the Endocrine Society Guideline Development Panel's 10 clinical questions. Identified studies were selected and appraised, and data were extracted by pairs of independent trained reviewers. RESULTS:The systematic review yielded 3796 citations, of which 32 citations were included. The systematic review and meta-analysis demonstrate that in children with CPP, with no central nervous system symptoms, the rate of magnetic resonance imaging identification of pathogenic lesions (ie, hamartomas and brain tumors) was 6% (35 noncomparative studies with 5541 children with CPP). For girls with idiopathic CPP, gonadotropin-releasing hormone agonist (GnRHa) treatment was associated with +2.7 cm adult height gain compared to those who did not receive treatment (21 comparative observational studies with 1835 girls [mean age 8.20 ± 1.08 years]). The review did not identify any studies that assessed the clinical questions on: benefits of additional evaluation in cases of early thelarche, differentiation of slowly vs rapidly progressing CPP, order of biochemical testing to establish and monitor the diagnosis of CPP, genetic testing for individuals diagnosed with CPP, and chronological age and/or bone age for discontinuation of GnRHa treatment. CONCLUSION:This systematic review addresses various aspects of CPP evaluation and treatment of CPP and will support the development of the Endocrine Society guidelines.

BACKGROUND:Central precocious puberty (CPP), which is traditionally defined as the development of secondary sexual characteristics before age 8 years in girls and age 9 years in boys, results from the premature activation of the hypothalamic-pituitary-gonadal (HPG) axis. CPP can be associated with short adult stature, adverse psychosocial outcomes, and increased cardiometabolic and cancer risks in adulthood. Gonadotropin-releasing hormone (GnRH) agonists can effectively suppress premature activation of the HPG axis and have the potential to increase adult height as well as improve psychosocial and long-term health outcomes among patients with CPP. However, as secular trends have continued to shift toward earlier age of pubertal onset, some subpopulations of children with CPP, as it is currently defined, may not require the same extent of diagnostic evaluation and treatment. OBJECTIVE:Develop evidence-based recommendations related to the diagnosis and treatment of CPP. METHODS:A multidisciplinary panel of clinical experts, along with experts in guideline methodology and systematic literature review, used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to address 10 clinical questions related to the diagnosis and treatment of CPP. Systematic reviews of health-related benefits and harms were conducted for each clinical question. The guideline development panel (GDP) also used the GRADE evidence-to-decision (EtD) framework to address stakeholder values and preferences, costs and required resources, cost-effectiveness, acceptability, feasibility, and potential impacts on health equity. RESULTS:In girls with thelarche (Tanner stage B2) between ages 7.0 and 8.0 years, the GDP suggests watchful waiting via periodic physical examinations (every 4-6 months) rather than immediately performing evaluation with laboratory testing or radiologic imaging. In addition, the GDP suggests that all girls with breast development (ie, Tanner stage B2) before age 7 years should first be observed for 4 to 6 months to differentiate unsustained or slowly progressive puberty vs rapidly progressive puberty. These recommendations are largely based on evidence that girls with slowly progressive puberty attain a normal adult height without treatment. When hormonal evaluation is performed to confirm central (GnRH-dependent) activation as the cause of precocious puberty, the GDP suggests starting the evaluation with ultrasensitive basal luteinizing hormone (LH) concentration rather than routine GnRH/GnRH agonist (GnRHa) stimulation testing for all patients. While brain magnetic resonance imaging has been a traditional part of CPP evaluation, the GDP suggests that it should not be routinely performed in girls ages 6.0 to 8.0 years and boys ages 8.0 to 9.0 years without central nervous system (eg, neuro-ophthalmologic) symptoms, largely based on a low prevalence of pathologic intracranial findings in these age groups. The GDP suggests against routine genetic testing for patients with CPP, although they judged that genetic testing (eg, MKRN3 sequencing) should be considered for patients with familial CPP through a shared decision-making process. The GDP suggests GnRHa treatment for many children with CPP, although available evidence suggests that some patient subgroups (eg, older girls with slowly progressive CPP) may be less likely to receive a net benefit with this treatment. Rather than always starting GnRHa treatment with a monthly injectable formulation, the GDP suggests that treatment should be initiated with the formulation (such as a longer-acting formulation) that is anticipated to be used long-term. The GDP suggests against routine addition of growth hormone therapy to increase adult height. They also suggest against the routine biochemical testing (eg, LH, sex steroids) to monitor pubertal suppression while receiving GnRHa, instead reserving biochemical testing to confirm clinically suspected treatment failure. Finally, the GDP suggests against routinely continuing GnRHa treatment beyond chronologic age 10.0 to 11.0 years (girls) or 11.0 to 12.0 years (boys) and/or bone age 11.0 to 12.0 years (girls) or 12.0 to 13.0 years (boys). CONCLUSION:These clinical recommendations were developed to address important uncertainties in the diagnosis and treatment of children with CPP. They are based on the best available scientific evidence regarding clinical outcomes judged to be most important to patients and families. The GDP's overarching goal was to suggest diagnostic and therapeutic strategies that will most likely provide net clinical benefits while simultaneously considering important contextual factors such as cost and feasibility. The guideline-development process highlighted important knowledge gaps and the substantial need for additional research.

Pubertal onset is driven by the reactivation of the hypothalamic-pituitary-gonadal (HPG) axis, a process orchestrated by a complex interplay of stimulatory and inhibitory factors and influenced strongly by genetic regulation. In this study, we assessed the expression patterns of 3 genes associated with central precocious puberty (CPP) in humans-Mkrn3, Dlk1, and Mecp2-across pubertal maturation in male and female mice. Hypothalamic regions were collected for mRNA quantification by reverse transcription and real time quantitative polymerase chain reaction and protein measurement by Western blot for all 3 genes; in addition, serum samples were used for Dlk1 quantification by enzyme-linked immunosorbent assay. Hypothalamic levels of Mkrn3 mRNA and protein, a well-established inhibitor of pubertal onset, were high in early postnatal life and declined prior to puberty onset, consistent with its role in suppressing HPG axis activation. In contrast, Dlk1 mRNA and protein levels were higher in adults than younger mice-an unexpected finding since loss of DLK1 expression advances puberty onset. Conversely, serum Dlk1 decreased progressively with age, suggesting a role for peripheral Dlk1 in pubertal regulation. Mecp2, a key epigenetic regulator implicated recently in puberty regulation, had lower hypothalamic mRNA levels after PND10, whereas protein levels remained unchanged, possibly reflecting splice variant-specific expression or post-transcriptional regulation. These distinct age-dependent expression patterns suggest that Mkrn3 and Mecp2 likely contribute primarily to central HPG axis regulation, whereas Dlk1 originating peripherally may act as a central regulator of puberty. Defining these trajectories offers insights into the molecular control of pubertal timing and potential therapeutic targets for pubertal disorders.

Carney-Stratakis syndrome (CSS), a rare condition characterized by paragangliomas and/or pheochromocytomas and gastrointestinal stromal tumors (GIST), is caused by germline heterozygous pathogenic variants in the succinate dehydrogenase subunit genes (SDHB, SDHC, SDHD). Histological, genetic, and functional analyses were conducted in a 59-year-old female with CSS (9 cm left pheochromocytoma, 4.8 cm paraganglioma, and 9.3 cm GIST). Whole-exome sequencing (WES) of germline DNA paired with tumor DNA was performed. WES identified a rare heterozygous germline variant (c.293G>A/p.Arg98His) in the mitochondrial 2-oxoglutarate/malate carrier gene (SLC25A11). This variant, located in a highly conserved residue of the SLC25A11 mitochondrial carrier domain, is predicted to be deleterious in silico (REVEL score = 0.81). WES of pheochromocytoma, paraganglioma, and GIST did not reveal somatic pathogenic variants in genes previously associated with these tumors. A significant reduction in SLC25A11 expression was observed in the tumors of this patient with the SLC25A11 c.293G>A variant (0.69 ± 0.003) compared to tumors from cluster 1 (1.39 ± 0.45; P = 0.0229) and cluster 2 (1.79 ± 0.71; P = .0154). Consistent with the mRNA findings, SLC25A11 protein levels were markedly reduced in the pheochromocytoma and paraganglioma compared to other tumors. Negative staining for 5-hydroxymethylcytosine in all 3 tumors suggests a DNA hypermethylation profile characteristic of cluster 1A, despite normal SDHB expression levels. However, genome-wide copy number variation analysis did not reveal any loss of heterozygosity at the SLC25A11 locus. The loss of SLC25A11 expression in tumors, the absence of somatic drivers, and the hypermethylation status strongly support the role of SLC25A11 in CSS pathogenesis.