SDH Cancer
SDH Cancer

The National Institute of Health Pediatric & Wildtype GIST Clinic



My Pediatric and Adult Rare Tumor Network (MyPART) is a team of doctors, nurses, scientists, and other staff, working together to improve the lives of children, adolescents, and young adults with rare solid tumors.

Dr. Blakely's Clinic for SDH Deficient Gists

NCI believes there is an unmet need for comprehensive assessment by a multidisciplinary surgical team able to care for tumors in the stomach, liver, and peritoneal surface.  This team provides comprehensive care of adult patients with SDH-deficient GISTs of any stage. This includes care of associated tumors such as paragangliomas, as in the case of Carney Triad and Carney Stratakis syndrome.  Of note, the use of systemic treatment was not associated with survival. Given the lifelong predisposition to developing GISTs among patients with SDH mutations, it is not uncommon for patients to require multiple surgeries to remove areas of disease.

Prospective Study of Surgery in Gastrointestinal Stromal Tumors (GISTs) for Treatment, Tumor Modeling, and Genomic Analysis. Dr. Blakely primary investigator.  Currently recruiting patients for diagnosis, DNA testing, imaging, surgery and working in tandem with NIH's "MyPart's Family History Study."

NIH Pediatric and Wildtype GIST Clinic

The National Institute of Health in Bethesda, Maryland holds a Pediatric & Wildtype GIST Clinic.  Experts from all over the world attend to share information amongst themselves as well as educate patients, caregivers and parents on how this subset of GIST is unique. The patients who attend and who have attended this Clinic donate tissue samples and DNA (saliva) that stays on file for future research.   The Clinic is held annually, usually in June. All patients with a GIST diagnosis who are 18 years or younger, or those with a "wildtype" GIST diagnosis, are encouraged to apply.  International patients as well as US patients are accepted.   Contact and application information can be found at:​  

The PAWS - GIST Clinic 

Inspired by the Pediatric and Wildtype GIST clinic at the National Institute of Health in America, the Pediatric, Adolescent, Wildtype, Syndromic GIST (PAWS-GIST) has been formed.  PAWS-GIST is a UK based alliance of medical specialists who serve patients in the UK and Europe. They hold an annual Clinic, usually in April, at Addenbrooke's Hospital, Cambridge, UK.  Contact and application information can be found at:

National Institute of Health Paraganglioma & Pheochromocytoma Clinic

Patients with known or suspected or pheochromocytomas may be seen at the NIH in Bethesda, Maryland. The NIH holds an Annual Pheo/PGL Clinic, by invitation.  Contact and application information can be found at:

Tumor Donations

Donation of tumor tissue is of upmost importance.  If you know you are having surgery for any SDH-related cancer or Wildtype GIST we would encourage you to reach out to the SDH-RA to pre-arrange to have your tumor tissue sent to researchers.   We can be reached at:


Dr. Justin Annes at Stanford created a SDHB deficient pheo mouse and discovered part of what we were thinking caused tumors is incorrect. Being born with the SDHx mutation is not enough to form tumors.  A second gene also needs to be involved to form tumors such as: p53, PTEN, H19. Watch this short video to discover more about germline SDHx mutations.  Thank you to the pheo/para alliance for presenting this.

On December 9th, 2019, Dr. Liu presented a webcast on Pancreatic Neuroendocrine tumors.  He did an excellent job explaining neuroendocrine which applies to many patients with paras and pheos.

Q & A with Dr. Gottlieb and SDH cancer

What is SDH, How Is It Related to Cancer, and What Can Be Done About It?
Webinar by Dr. Eyal Gottlieb

Questions and Answers for the SDH Webinar (Answered by Dr. Eyal Gottlieb)
September 5th Podcast with Dr. Gottlieb and Sara Rothschild from Liferaft Group 

Succinate Dehydrogenase in Cancer and Metabolism

Clinical trials for SDH-deficient GIST, Paragangliomas/Pheochromocytomas, and Renal Cell Carcinoma

Cancer Genetics Study at Huntsman, Utah
Especially looking for patients with a family history of SDHB tumors - Dr. Joshua Schiffman.

Fresh from surgery tumor donations especially desired.

Genetic Analysis of Pheochromocytomas, Paragangliomas and Associated Conditions

The aims of this proposal are to: 1) to map gene(s) involved in pheochromocytoma, and 2) identify genotype-phenotype correlations in patients with pheochromocytoma/paraganglioma of various genetic origins. 


Contact: Patricia L Dahia    210-567-4866   


A Phase II Trial of Temozolomide (TMZ) In Advanced Succinate Dehydrogenase (SDH)-Mutant/Deficient Gastrointestinal Stromal Tumor (GIST)

Follow this link to view the trial on the website:

Principal Investigator:  Adam Burgoyne, MD, PhD, Assistant Professor of Medicine, University of California, San Diego



A Phase II Trial of the Anti-cancer Drug, Rogaratinib (BAY 1163877), for Treatment of Advanced Sarcoma With Alteration in Fibroblast Growth Factor Receptor (FGFR 1-4), and in Patients With SDH-deficient Gastrointestinal Stromal Tumor (GIST)​ 

Follow this link to view the trial on the website:

Principal Investigators:  National Cancer Institute NCI and
Suzanne George Dana-Farber - Harvard Cancer Center LAO



A Phase II Trial of the DNA Methyl Transferase Inhibitor, Guadecitabine (SGI-110), in Children and Adults With Wild Type GIST, Pheochromocytoma and Paraganglioma Associated With Succinate Dehydrogenase Deficiency and HLRCC-associated Kidney Cancer  

Follow this link to view the trial on the website: 

Principal Investigator:

John W Glod, M.D.  Trial was terminated but has results


A Phase I Trial of the Glutaminase Inhibitor CB-839 on Solid Tumors

Follow this link to view the trial on  Active - not recruiting website:


Trial contact:  Trial Administrator

I think this trial has been discontinued without any long lasting results

A Phase I Trial of HIF-2a Transcription Factor Inhibitor PT2977 with Advanced Solid Tumors

Follow this link to view the trial on the clinicaltrialsgov


Trial contact:  Richard Kelley,  (972) 629-4088
This trial is for renal cell carcinoma and patients with the VHL mutation


Articles describing the rationale behind use of HIF-2a inhibitors:


New HIF2A inhibitors: implications for pheochromocytomas and paragangliomas
Rodrigo Almeida Toledo, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
 recently developed inhibitors of hypoxia-inducible factor 2-alpha (HIF2α). This Commentary is based on the recognition of similar molecular drivers in ccRCC and the endocrine neoplasias pheochromocytomas and paragangliomas (PPGLs), ultimately leading to stabilization of HIFs. HIF-stabilizing mutations have been detected in the von Hippel-Lindau (VHL) gene, as well as in other genes, such as succinate dehydrogenase (SDHx), fumarate hydratase (FH), and transcription elongation factor B subunit 1 (TCEB1), as well as the gene that encodes HIF2α itself: EPAS1HIF2α.
The now available therapeutic opportunity to successfully inhibit HIF2α pharmacologically with PT2385 and PT2399 will certainly spearhead a series of investigations in several types of cancers, including patients with SDHB-related metastatic PPGL for whom limited therapeutic options are currently available.

HIF-2alpha: Achilles' heel of pseudohypoxic subtype paraganglioma and other related conditions
Sri Harsha Tella, David Taïeb, Karel Pacak'
The main aim of this perspective is to address the possibility of HIF-2α antagonists in the management of tumours, beyond clear cell renal cell carcinoma, where the dysfunctional hypoxia-signalling pathway, especially HIF-2α, referred here as the Achilles' heel, plays a unique role in tumorigenesis and other disorders. These tumours or disorders include PGLs, somatostatinomas, hemangioblastomas, gastrointestinal stromal tumours, pituitary tumours, leiomyomas/leiomyosarcomas, polycythaemia and retinal abnormalities. We hope that HIF-2α antagonists are likely to emerge as a potential effective treatment of choice for HIF-2α–related tumours and disorders.

Hypoxia and hypoxia-inducible factors in neuroblastoma.
Påhlman S*, Mohlin, Lund University, Sweden.
Hypoxia (i.e., low oxygen levels) is a known feature of aggressive tumors. Cells, including tumor cells, respond to conditions of insufficient oxygen by activating a transcriptional program mainly driven by hypoxia-inducible factors (HIF)-1 and HIF-2.
In this review, we discuss these non-conventional actions of HIF-2α, its putative role as a therapeutic target and the constraints it carries, as well as the importance of HIF-2 activity in a vascularized setting, the so-called pseudo-hypoxic state.

A drug that inactivates HIF-2 activity by binding to the HIF-2 alpha subunit and thereby preventing its binding to the beta-subunit. The effect, seen in some renal cell carcinoma models, is the inhibition of HIF-2-driven gene transcription, which is thought to manifest an aggressive tumor phenotype.
Germline SDHB mutations will lead to an activated HIF-2 and in theory, an HIF-2 inhibitor can have positive effects on your tumor.* 

The mutated HIF-2a in paraganglioma and pheochromocytoma results in stabilization of the protein so it is not degraded in oxygenated tissues and thus can complex with the beta subunit and form a functional transcription complex. This means that the factor can work under these "normal" conditions and promote a tumor phenotype and behaviour. In theory, a HIF2a inhibitor might have a positive effect on tumor cells that carry SDHB mutations, and that the HIF-2 inhibitor in conjunction with established chemotherapy might destroy HIF-2a positive stem cell pools.*

The following organizations are good sources to learn more


GIST Support International - Wildtype/SDH GIST -


SDH-deficient/Pediatric/Wildtype GIST Listserv Group -


The Liferaft Group -


Facebook - SDH Cancer Support Group - Gists, Pheos/Paras, RCC, Rare tumors


GIST Cancer Awareness Foundation -


GIST Cancer Research Fund -


Pediatric and Wildtype GIST Clinic at NIH -

PAWS-GIST (Paediatric Adolescent Wild-type & Syndromic GIST) UK - -


Pheo-Para Coalition -


Pheo-Para Alliance -


PheoParaTroopers -


ParaDifference Foundation -


Non-Profits Providing Financial Assistance to Cancer Patients

Cancer.Net explains Familial GIST -


SDHx Deficient GIST & Para/Pheo Researchers

GIST Support International, listing of GIST Specialists


Liferaft Group, listing of GIST Specialists

Dr. Andrew Blakely, GIST surgeon, NCI, MyPART, Bethesda, Maryland


Dr. Justin Annes, SDHx researcher at Stanford, Palo Alto, California

Dr. Patricia Dahia, SDHx researcher, San Antonio, Texas


Dr. Jason Sicklick, GIST surgeon, Moores Cancer Center, UCSD La Jolla, California


Dr. Joshua Schiffman, GIST, SDH, oncologist, researcher, Huntsman Cancer Institute, Utah


Dr. Michael Heinrich, GIST oncologist, Knight Cancer Institute, OHSU, Portland, Oregon 

Dr. Kevin Billingsley, Surgeon, Yale, New Haven, Connecticut

Dr. Rodney Pommier, NET surgeon, Knight Cancer Institute, OHSU, Portland, Oregon


Dr. Jaydiro DelRivero Rare Tumors, NIH, Bethesda, Maryland


Dr. Karel Pacak, Senior Investigator Paraganglioma and Pheochromocytoma, NIH, Bethesda, Maryland


Dr. Constantine Stratakis, Senior Investigator, geneticist, NIH/NICDH, Bethesda, Maryland


Dr. Sosipatros Boikos, Wildtype GIST oncologist, Massey Center, Virginia Commonwealth University, Richmond, Virginia


Dr. Brian Van Tine, Oncologist, Siteman Cancer Center, Washington University, St. Louis, Missouri


Dr. JP Bayley, Paraganglioma Research Group, Department of Human Genetics,

Leiden University Medical Center, The Netherlands. Link is to SDHB Database of Known Germline Variances


Dr. Katherine Janeway, Pediatric Oncologist, Dana-Farber/Harvard, Boston, Massachusetts


Dr. Margaret Von Mehren, Wildtype GIST oncologist, Fox Chase Cancer Center, Philadelphia, Pennsylvania


Dr. Jonathan Trent, Wildtype GIST oncologist, Sylvester Comprehensive Cancer Center, Miami, Florida


Dr. Ron DeMatteo, GIST expert surgeon, Penn Medicine




Relevant Published Articles

NIH Pediatric Clinic Analysis of SDH deficient GIST patients - 2012, Dr. Su Young Kim

VIDEO - Analysis of the Pediatric Gist Clinic at NIH in 2012.  Nice clear explanation of SDH deficient GIST

Administrator's take: Dr. Su Young Kim, a friend to us who had the pleasure to meet him, giving a talk/analysis of Pediatric/SDH deficient GIST

Succinate dehydrogenase (SDH)-deficient neoplasia
A.J. Gill, 2018, NSW
A detailed description of SDH mutations with their prevelence in Pheo/Paras, Gists, and other tumors

Surgical Management of Adolescents and Young Adults With Gastrointestinal Stromal Tumors: 
A US Population-Based Analysis.

This study found that adolescent and young adult GIST patients are more likely to undergo surgical management than older adult patients. Operative management is associated with improved overall survival, including those with metastatic disease

Administrator's take: Surgery is still the best often for wildtype and SDH-Deficient GIST patients

Translating Genetic Data into Actionable Clinical Guidelines: Succinate Dehydrogenase Subunit A Variants of Unknown Significance in Gastrointestinal Stromal Tumors (2017). Scholar Archive. 3972 by Amber Bannon
A dissertation by Amber Bannon, OHSU.  I had the pleasure to meet Amber and this paper talks about how some gene mutations (SDHA) are more likely to produce tumors than other variances.  The key seems to be that the mutations proximity to the center of the gene which contains "Flavin" are more likely to be pathogenic.
Note, the paper is long and might take some time to load, it is worth reading.

Prognosis and management of adult wild type gastrointestinal stromal tumours (GISTs): A pooled analysis and review of literature

•Adults with WT GISTs have a similar molecular pathway to pediatric GISTs.
•Survival in both these subtypes is similar and more favourable compared to other GISTs.
Mean survival in adults was 15.7 years ± 0.78 and in children was 18.8 years ± 1.3 (p = 0.241). Median disease free survival in adults was 10 years while 5-year overall survival was 88%. Overall survival in adults with WT GISTs is favourable compared to other adult GIST subtypes likely reflects a common molecular pathway similar to pediatric GIST.

Administrator's take: Pediatric GIST and wildtype GIST patients have a longer survival rate than regular GIST

Diagnosis, Localization, Pathophysiology, and Molecular Biology of Pheochromocytoma and Paraganglioma
Karel Pacak, MD, PhD, DSc

What I found interesting:

The paper has a comparison of the Ga-Dotatate scan verse F-FDopa scan with superior clariety in the Ga-Dotatatate.

Then some things we know:
PPGLs with mutations in SDHB are the most aggressive forms of the disease, partly owing to their pseudo-hypoxic character, metabolic abnormalities, and elevated levels of reactive oxygen species (ROS).

Some tumor suppressor solutions they thought possible include two herbal:
Piperlongumine (PL), a natural product with cytotoxic properties

Topoisomerase I inhibitor, LMP-400


ATP5B antibody led to statistically significant inhibition of proliferation. 

They were able to get a working mouse model using this technique:
NOD-scid gamma (NSG) mice xenografts of primary human PGLs took

Toward an improved definition of the genetic and tumor spectrum associated with SDH germ-line mutations

Analysis of the Leiden Open Variation Database

Gists:  26 SDHA, 14 SDHB, 9 SDHC, 6 SDHD - Total SDH deficient Gist 55

Paras/Pheos:  7 SDHA, 211 SDHB, 42 SDHC, 141 SDHD - Total SDH deficient Para/Pheo 401

Familial PCC/PGL syndromes were initially thought to predispose only to PCCs and PGLs, but several tumors, including GISTs, RCCs, and PAs, have expanded the SDH-associated tumor spectrum. Extensive clinical variability can be expected, even among carriers of an identicalSDH germ-line mutation, with tumor phenotypes being only partially expressed, as in the Carney–Stratakis dyad.
These GISTs are characterized by unique clinicopathological features and biological properties: (i) female preponderance; (ii) gastric location (predilection for the distal stomach/antrum); (iii) common multifocality; (iv) a multinodular/plexiform growth pattern; (v) epithelioid cytomorphology, either pure or combined with a spindle-cell component; (vi) SDHA and/or SDHB immunonegativity; (vii) KIT (and DOG1) immunopositivity despite the lack of KIT/PDGFRA mutations; (viii) metastatic potential (often to lymph nodes); (ix) a relatively indolent clinical course, even in the presence of metastatic disease; and (x) insensitivity to imatinib

Hypoxia and 3-Nitropropionic Acid triggers to Tumors? 

The SDHD gene was discovered by Dr. Baysal who was studying people in the Andes who got paragangliomas.  An email from him two weeks ago and he again advised me not live at in high altitudes NOR fly in airplanes.  Airplanes are known to have 80% of the oxygen that is on the ground.  SDHx patients have a compromised oxygen sensor.  Resource links to follow.

There are three breeds of dogs that by nature of the breed develop chronic hypoxia and they develop chemodectomas (the old word for paragangliomas and what is on my father's death certificate).  I just found a paper confirming this theory by two researchers in The Netherlands.  I contacted Dr. Bayley there who has been doing SDHB research for years and he said it was a colleague of his that wrote the paper.  I was hoping the research over the years on these breeds of dog would produce a chemo but the recommended procedure is surgery.

I then found a paper from 1974, the year my father died, that also said chronic hypoxias as in these dog breeds and people in the Andes causes paragangliomas!  Thus this information has been written about since 1974.  

I think there are other means of hypoxia that could also eventually lead to disease such as sleep apnea, extreme sport activities, smog . . . And the wildfire smoke I have to live with for 5 weeks every summer that has air quality at "harzardous".

I also think a compromised system could be a trigger.  My own case I think comes from mold (house mold in my case) and research shows 3-NPs are "suicide" to the SDHB gene.  I had long exposure to environmental mold in a house I rented for my daughter for college as well as finding black mold inside the graphics studio I've worked in for 35 years.

Vet Comp Oncol. 2017 Jan 25. doi: 10.1111/vco.12291. [Epub ahead of print]
Pheochromocytomas and paragangliomas in humans and dogs.

Galac S1, Korpershoek E2.

Pheochromocytomas (PCCs) and paragangliomas (PGLs) are described in several species. In humans and dogs they have many similarities: the excessive catecholamine release in hormonally active PCC causes similar clinical signs, the frequency of metastasis is similar, and they are histopathologically almost identical. Surgery is curative when PCC and PGL have not metastasized, while only palliative treatment is possible for patients with metastatic disease. Mutations in succinate dehydrogenase subunit B (SDHB) are associated with metastatic behaviour in human PCC/PGL and the same mutation has been described in dogs. The dog might therefore be a suitable model for study of the pathogenesis of metastatic PCC and PGL in humans. Further molecular studies of common tumourigenic pathways and comparative studies of histopathology of human and canine PCC and PGL are warranted.

What Baysal found was a mutation in the gene, named SDHD, that makes a protein eventually transported to the mitochondria— “the powerhouse and brains of the carotid bodies,”according to Baysal. The mutation causes the mitochondria to react as if they were in an oxygen-deprived environment, even though that is not the case. Consequently—as experienced by Andean Mountain dwellers—this tissue never stops working. The number of cells increases, and the increased mass eventually results in tumors.

Chemodectomas in Dogs: Epidemiologic Comparisons With Man2
Howard M. Hayes, Jr., D. V.M.  Joseph F. Fraumeni, M.D.  

JNCI: Journal of the National Cancer Institute, Volume 52, Issue 5, 1 May 1974, Pages 1455–1458, 

Fifty dogs with a confirmed diagnosis of chemodectoma were identified at 11 veterinary school clinic-hospitals. As in man, some evidence was found of genetic determinants: 2 brachycephalic breeds (Boston terriers and boxers) had a significantly greater risk compared to all other purebred dogs combined. An excessive risk was detected in males, though it was not statistically significant, and in older dogs. There was a significantly high frequency of 4 concurrent tumors (seminoma and interstitial-cell tumors of the testis, adenomatous thyroid neoplasms, and hemangiomas); but in man, with chemodectoma, the reported tendency to multiple primary tumors has been confined to the chemoreceptor system. The etiologic role of chronic hypoxia, suggested by the high incidence of carotid body tumors among Peruvians in the Andes, may be clarified by further studies of chemodectoma in brachycephalic breeds.

Altitude chart with amount of oxygen

Succinate, an intermediate in metabolism, signal transduction, ROS, hypoxia, and tumorigenesis

Succinate is an important metabolite at the cross-road of several metabolic pathways, also involved in the formation and elimination of reactive oxygen species. However, it is becoming increasingly apparent that its realm extends to epigenetics, tumorigenesis, signal transduction, endo- and paracrine modulation and inflammation.

3-Nitropropionic Acid Is a Suicide Inhibitor of Mitochondrial Respiration That, upon Oxidation by Complex II, Forms a Covalent Adduct with a Catalytic Base Arginine in the Active Site of the Enzyme*

The plant and fungal toxin 3-nitropropionic acid, an irreversible inactivator of succinate dehydrogenase, forms a covalent adduct with the side chain of Arg297. 

The toxin 3-nitropropionic acid (3-NP) is produced by certain plants and fungi. It is a specific inhibitor of mitochondrial respiratory complex II. Fatalities after eating moldy sugarcane have been linked to 3-NP toxicity (,1, 2). Ruminants grazing in regions with 3-NP-producing plants acquire resistance because of reduction of the nitro group to an amine by ruminal bacteria.

Nitropropionic acid (3-NPA), an irreversible inhibitor of SDH activity (Huang et al., 2006).
beta-Nitropropionic acid (3-nitropropanoic acid, BPA, 3-NPA, C3H5NO4) is a mycotoxin, a potent mitochondrial inhibitor, toxic to humans. It is produced by a number of fungi, and found widely in food, in sugar cane, as well as Japanese fungally fermented staples miso, soy sauce, katsuobushi, and some traditional Chinese medicines.  Spices are susceptible substrate for growth of mycotoxigenic fungi and mycotoxin production. Red chilli, black pepper, and dry ginger were found to be the most contaminated spices.

Contents acculumlated by Cathy Freeman, SDHB Deficient Gist Patient

Searching to shed new light on this  incurable and often misdiagnosed cancer

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