Noonan syndrome (NS) is one of the most common syndromes transmitted by a mendelian mode. In recent years, germline mutations that affect components of the RAS-MAPK (mitogen-activated protein kinase) pathway were shown to be involved in the pathogenesis of NS and four rare syndromes with clinical features overlapping with NS: Leopard syndrome, cardio-facio-cutaneous syndrome, Costello syndrome and neurofibromatosis type 1. Several hormones act through receptors that stimulate the RAS-MAPK pathway, and therefore, NS and related disorders represent a remarkable opportunity to study the implication of the RAS-MAPK pathway in different endocrine systems. Additionally, children with NS frequently are referred to the endocrinologist because of short stature, delayed puberty and/or undescended testes in males. In this paper, we review the diagnostic, clinical and molecular aspects of NS and NS-related disorders.

1.
Mendez HM, Opitz JM: Noonan syndrome: a review. Am J Med Genet 1985;21:493–506.
2.
Nora JJ, Nora AH, Sinha AK, Spangler RD, Lubs HA: The Ullrich-Noonan syndrome (Turner phenotype). Am J Dis Child 1974;127:48–55.
3.
Allanson JE: Noonan syndrome. J Med Genet 1987;24:9–13.
4.
Duncan WJ, Fowler RS, Farkas LG, Ross RB, Wright AW, Bloom KR, Huot DJ, Sondheimer HM, Rowe RD: A comprehensive scoring system for evaluating Noonan syndrome. Am J Med Genet 1981;10:37–50.
5.
Jongmans M, Sistermans EA, Rikken A, Nillesen WM, Tamminga R, Patton M, Maier EM, Tartaglia M, Noordam K, van der Burgt I: Genotypic and phenotypic characterization of Noonan syndrome: new data and review of the literature. Am J Med Genet A 2005;134:165–170.
6.
Shaw AC, Kalidas K, Crosby AH, Jeffery S, Patton MA: The natural history of Noonan syndrome: a long-term follow-up study. Arch Dis Child 2007;92:128–132.
7.
Tartaglia M, Gelb BD: Noonan syndrome and related disorders: genetics and pathogenesis. Annu Rev Genomics Hum Genet 2005;6:45–68.
8.
Schubbert S, Shannon K, Bollag G: Hyperactive Ras in developmental disorders and cancer. Nat Rev Cancer 2007;7:295–308.
9.
Binder G, Neuer K, Ranke MB, Wittekindt NE: PTPN11 mutations are associated with mild growth hormone resistance in individuals with Noonan syndrome. J Clin Endocrinol Metab 2005;90:5377–5381.
10.
Ferreira LV, Souza SA, Arnhold IJ, Mendonca BB, Jorge AA: PTPN11 (protein tyrosine phosphatase, non-receptor type 11) mutations and response to growth hormone therapy in children with Noonan syndrome. J Clin Endocrinol Metab 2005;90:5156–5160.
11.
Limal JM, Parfait B, Cabrol S, Bonnet D, Leheup B, Lyonnet S, Vidaud M, Le Bouc Y: Noonan syndrome: relationships between genotype, growth, and growth factors. J Clin Endocrinol Metab 2006;91:300–306.
12.
Legius E, Schrander-Stumpel C, Schollen E, Pulles-Heintzberger C, Gewillig M, Fryns JP: PTPN11 mutations in Leopard syndrome. J Med Genet 2002;39:571–574.
13.
Digilio MC, Conti E, Sarkozy A, Mingarelli R, Dottorini T, Marino B, Pizzuti A, Dallapiccola B: Grouping of multiple-lentigines/Leopard and Noonan syndromes on the PTPN11 gene. Am J Hum Genet 2002;71:389–394.
14.
Schubbert S, Bollag G, Shannon K: Deregulated Ras signaling in developmental disorders: new tricks for an old dog. Curr Opin Genet Dev 2007;17:15–22.
15.
Nava C, Hanna N, Michot C, Pereira S, Pouvreau N, Niihori T, Aoki Y, Matsubara Y, Arveiler B, Lacombe D, Pasmant E, Parfait B, Baumann C, Heron D, Sigaudy S, Toutain A, Rio M, Goldenberg A, Leheup B, Verloes A, Cave H: Cardio-facio-cutaneous and Noonan syndromes due to mutations in the RAS/MAPK signalling pathway: genotype-phenotype relationships and overlap with Costello syndrome. J Med Genet 2007;44:763–771.
16.
Van der Burgt I, Berends E, Lommen E, van Beersum S, Hamel B, Mariman E: Clinical and molecular studies in a large Dutch family with Noonan syndrome. Am J Med Genet 1994;53:187–191.
17.
Zenker M, Buheitel G, Rauch R, Koenig R, Bosse K, Kress W, Tietze HU, Doerr HG, Hofbeck M, Singer H, Reis A, Rauch A: Genotype-phenotype correlations in Noonan syndrome. J Pediatr 2004;144:368–374.
18.
Sharland M, Morgan M, Smith G, Burch M, Patton MA: Genetic counselling in Noonan syndrome. Am J Med Genet 1993;45:437–440.
19.
Bertola DR Pereira AC, Albano LM, De Oliveira PS, Kim CA, Krieger JE: PTPN11 gene analysis in 74 Brazilian patients with Noonan syndrome or Noonan-like phenotype. Genet Test 2006;10:186–191.
20.
Tartaglia M, Martinelli S, Stella L, Bocchinfuso G, Flex E, Cordeddu V, Zampino G, Burgt I, Palleschi A, Petrucci TC, Sorcini M, Schoch C, Foa R, Emanuel PD, Gelb BD: Diversity and functional consequences of germline and somatic PTPN11 mutations in human disease. Am J Hum Genet 2006;78:279–290.
21.
Yoshida R, Hasegawa T, Hasegawa Y, Nagai T, Kinoshita E, Tanaka Y, Kanegane H, Ohyama K, Onishi T, Hanew K, Okuyama T, Horikawa R, Tanaka T, Ogata T: Protein-tyrosine phosphatase, non-receptor type 11 mutation analysis and clinical assessment in 45 patients with Noonan syndrome. J Clin Endocrinol Metab 2004;89:3359–3364.
22.
Ferreira LV, Souza SC, Montenegro LR, Malaquias AC, Arnhold IJ, Mendonca BB, Jorge AA: Analysis of PTPN11 gene in idiopathic short stature children and Noonan syndrome patients. Clin Endocrinol (Oxf) 2008;69:426–431.
23.
Jamieson CR, van der Burgt I, Brady AF, van Reen M, Elsawi MM, Hol F, Jeffery S, Patton MA, Mariman E: Mapping a gene for Noonan syndrome to the long arm of chromosome 12. Nat Genet 1994;8:357–360.
24.
Brady AF, Jamieson CR, van der Burgt I, Crosby A, van Reen M, Kremer H, Mariman E, Patton MA, Jeffery S: Further delineation of the critical region for Noonan syndrome on the long arm of chromosome 12. Eur J Hum Genet 1997;5:336–337.
25.
Legius E, Schollen E, Matthijs G, Fryns JP: Fine mapping of Noonan/cardio-facio-cutaneous syndrome in a large family. Eur J Hum Genet 1998;6:32–37.
26.
Tartaglia M, Mehler EL, Goldberg R, Zampino G, Brunner HG, Kremer H, van der Burgt I, Crosby AH, Ion A, Jeffery S, Kalidas K, Patton MA, Kucherlapati RS, Gelb BD: Mutations in PTPN11, encoding the protein tyrosine phosphatase SHP-2, cause Noonan syndrome. Nat Genet 2001;29:465–468.
27.
Ferreira LV, Souza SA, Montenegro LR, Arnhold IJ, Pasqualini T, Heinrich JJ, Keselman AC, Mendonca BB, Jorge AA: Phenotype variability in Noonan syndrome patients with and without PTPN11 mutation (in Portuguese). Arq Bras Endocrinol Metabol 2007;51:450–456.
28.
Zenker M, Voss E, Reis A: Mild variable Noonan syndrome in a family with a novel PTPN11 mutation. Eur J Med Genet 2007;50:43–47.
29.
Bertola DR, Kim CA, Pereira AC, Mota GFA, Krieger JE, Vieira IC, Valente M, Loreto MR, Magalhães RP, Gonzáles CH: Are Noonan syndrome and Noonan-like/multiple giant cell lesion syndrome distinct entities? Am J Med Genet 2001;98:230–234.
30.
Weismann CG, Hager A, Kaemmerer H, Maslen CL, Morris CD, Schranz D, Kreuder J, Gelb BD: PTPN11 mutations play a minor role in isolated congenital heart disease. Am J Med Genet A 2005;136:146–151.
31.
Bertola DR, Pereira AC, de Oliveira PS, Kim CA, Krieger JE: Clinical variability in a Noonan syndrome family with a new PTPN11 gene mutation. Am J Med Genet 2004;130A:378–383.
32.
Kitsiou-Tzeli S, Papadopoulou A, Kanaka-Gantenbein C, Fretzayas A, Daskalopoulos D, Kanavakis E, Nicolaidou P: Does the rare A172G mutation of PTPN11 gene convey a mild Noonan syndrome phenotype? Horm Res 2006;66:124–131.
33.
Tartaglia M, Niemeyer CM, Fragale A, Song X, Buechner J, Jung A, Hahlen K, Hasle H, Licht JD, Gelb BD: Somatic mutations in PTPN11 in juvenile myelomonocytic leukemia, myelodysplastic syndromes and acute myeloid leukemia. Nat Genet 2003;34:148–150.
34.
Bentires-Alj M, Paez JG, David FS, Keilhack H, Halmos B, Naoki K, Maris JM, Richardson A, Bardelli A, Sugarbaker DJ, Richards WG, Du J, Girard L, Minna JD, Loh ML, Fisher DE, Velculescu VE, Vogelstein B, Meyerson M, Sellers WR, Neel BG: Activating mutations of the Noonan syndrome-associated SHP2/PTPN11 gene in human solid tumors and adult acute myelogenous leukemia. Cancer Res 2004;64:8816–8820.
35.
Van Vactor D, O’Reilly AM, Neel BG: Genetic analysis of protein tyrosine phosphatases. Curr Opin Genet Dev 1998;8:112–126.
36.
Niihori T, Aoki Y, Ohashi H, Kurosawa K, Kondoh T, Ishikiriyama S, Kawame H, Kamasaki H, Yamanaka T, Takada F, Nishio K, Sakurai M, Tamai H, Nagashima T, Suzuki Y, Kure S, Fujii K, Imaizumi M, Matsubara Y: Functional analysis of PTPN11/SHP-2 mutants identified in Noonan syndrome and childhood leukemia. J Hum Genet 2005;50:192–202.
37.
Schubbert S, Lieuw K, Rowe SL, Lee CM, Li X, Loh ML, Clapp DW, Shannon KM: Functional analysis of leukemia-associated PTPN11 mutations in primary hematopoietic cells. Blood 2005;106:311–317.
38.
Kim SO, Jiang J, Yi W, Feng GS, Frank SJ: Involvement of the Src homology 2-containing tyrosine phosphatase SHP-2 in growth hormone signaling. J Biol Chem 1998;273:2344–2354.
39.
Stofega MR, Herrington J, Billestrup N, Carter-Su C: Mutation of the SHP-2 binding site in growth hormone (GH) receptor prolongs GH-promoted tyrosyl phosphorylation of GH receptor, JAK2, and STAT5B. Mol Endocrinol 2000;14:1338–1350.
40.
Maile LA, Clemmons DR: Regulation of insulin-like growth factor I receptor dephosphorylation by SHPS-1 and the tyrosine phosphatase SHP-2. J Biol Chem 2002;277:8955–8960.
41.
Lima MH, Ueno M, Thirone AC, Rocha EM, Carvalho CR, Saad MJ: Regulation of IRS-1/SHP2 interaction and AKT phosphorylation in animal models of insulin resistance. Endocrine 2002;18:1–12.
42.
Carpenter LR, Farruggella TJ, Symes A, Karow ML, Yancopoulos GD, Stahl N: Enhancing leptin response by preventing SH2-containing phosphatase 2 interaction with Ob receptor. Proc Natl Acad Sci USA 1998;95:6061–6066.
43.
Schubbert S, Zenker M, Rowe SL, Boll S, Klein C, Bollag G, van der Burgt I, Musante L, Kalscheuer V, Wehner LE, Nguyen H, West B, Zhang KY, Sistermans E, Rauch A, Niemeyer CM, Shannon K, Kratz CP: Germline KRAS mutations cause Noonan syndrome. Nat Genet 2006;38:331–336.
44.
Roberts AE, Araki T, Swanson KD, Montgomery KT, Schiripo TA, Joshi VA, Li L, Yassin Y, Tamburino AM, Neel BG, Kucherlapati RS: Germline gain-of-function mutations in SOS1 cause Noonan syndrome. Nat Genet 2007;39:70–74.
45.
Tartaglia M, Pennacchio LA, Zhao C, Yadav KK, Fodale V, Sarkozy A, Pandit B, Oishi K, Martinelli S, Schackwitz W, Ustaszewska A, Martin J, Bristow J, Carta C, Lepri F, Neri C, Vasta I, Gibson K, Curry CJ, Siguero JP, Digilio MC, Zampino G, Dallapiccola B, Bar-Sagi D, Gelb BD: Gain-of-function SOS1 mutations cause a distinctive form of Noonan syndrome. Nat Genet 2007;39:75–79.
46.
Pandit B, Sarkozy A, Pennacchio LA, Carta C, Oishi K, Martinelli S, Pogna EA, Schackwitz W, Ustaszewska A, Landstrom A, Bos JM, Ommen SR, Esposito G, Lepri F, Faul C, Mundel P, Lopez Siguero JP, Tenconi R, Selicorni A, Rossi C, Mazzanti L, Torrente I, Marino B, Digilio MC, Zampino G, Ackerman MJ, Dallapiccola B, Tartaglia M, Gelb BD: Gain-of-function raf1 mutations cause Noonan and Leopard syndromes with hypertrophic cardiomyopathy. Nat Genet 2007;39:1007–1012.
47.
Razzaque MA, Nishizawa T, Komoike Y, Yagi H, Furutani M, Amo R, Kamisago M, Momma K, Katayama H, Nakagawa M, Fujiwara Y, Matsushima M, Mizuno K, Tokuyama M, Hirota H, Muneuchi J, Higashinakagawa T, Matsuoka R: Germline gain-of-function mutations in RAF1 cause Noonan syndrome. Nat Genet 2007;39:1013–1017.
48.
Shannon K, Bollag G: Sending out an SOS. Nat Genet 2007;39:8–9.
49.
Bentires-Alj M, Kontaridis MI, Neel BG: Stops along the RAS pathway in human genetic disease. Nat Med 2006;12:283–285.
50.
Keilhack H, David FS, McGregor M, Cantley LC, Neel BG: Diverse biochemical properties of SHP2 mutants. Implications for disease phenotypes. J Biol Chem 2005;280:30984–30993.
51.
Neumann TE, Allanson J, Kavamura I, Kerr B, Neri G, Noonan J, Cordeddu V, Gibson K, Tzschach A, Kruger G, Hoeltzenbein M, Goecke TO, Kehl HG, Albrecht B, Luczak K, Sasiadek MM, Musante L, Laurie R, Peters H, Tartaglia M, Zenker M, Kalscheuer V: Multiple giant cell lesions in patients with Noonan syndrome and cardio-facio-cutaneous syndrome. Eur J Hum Genet 2008; [Epub ahead of print].
52.
Chen Y, Wen R, Yang S, Schuman J, Zhang EE, Yi T, Feng GS, Wang D: Identification of SHP-2 as a STAT5A phosphatase. J Biol Chem 2003;278:16520–16527.
53.
Padidela R, Camacho-Hubner C, Attie KM, Savage MO: Abnormal growth in Noonan syndrome: genetic and endocrine features and optimal treatment. Horm Res 2008;70:129–136.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.