Abbreviations & Acronyms AMPK = adenosine monophosphate-activated protein kinase BHD syndrome = Birt-Hogg -Dub e syndrome FLCN = folliculin FNIP1 = folliculininteracting protein 1 FNIP2 = folliculininteracting protein 2 HOCT = hybrid oncocytic/ chromophobe tumors mTOR = mammalian target of rapamycin mTORC1 = mammalian target of rapamycin complex 1 VHL = von Hippel-Lindau Abstract: Birt-Hogg-Dub e syndrome is an autosomal dominantly inherited disease that predisposes patients to develop fibrofolliculoma, lung cysts and bilateral multifocal renal tumors, histologically hybrid oncocytic/chromophobe tumors, chromophobe renal cell carcinoma, oncocytoma, papillary renal cell carcinoma and clear cell renal cell carcinoma. The predominant forms of Birt-Hogg-Dub e syndrome-associated renal tumors, hybrid oncocytic/chromophobe tumors and chromophobe renal cell carcinoma are typically less aggressive, and a therapeutic principle for these tumors is a surgical removal with nephron-sparing. The timing of surgery is the most critical element for postoperative renal function, which is one of the important prognostic factors for BirtHogg-Dub e syndrome patients. The folliculin gene (FLCN) that is responsible for BirtHogg-Dub e syndrome was isolated as a novel tumor suppressor for kidney cancer. Recent studies using murine models for FLCN, a protein encoded by the FLCN gene, and its two binding partners, folliculin-interacting protein 1 (FNIP1) and folliculin-interacting protein 2 (FNIP2), have uncovered important roles for FLCN, FNIP1 and FNIP2 in cell metabolism, which include AMP-activated protein kinase-mediated energy sensing, Ppargc1a-driven mitochondrial oxidative phosphorylation and mTORC1-dependent cell proliferation. Birt-Hogg-Dub e syndrome is a hereditary hamartoma syndrome, which is triggered by metabolic alterations under a functional loss of FLCN/FNIP1/FNIP2 complex, a critical regulator of kidney cell proliferation rate; a mechanistic insight into the FLCN/ FNIP1/FNIP2 pathway could provide us a basis for developing new therapeutics for kidney cancer.Key words: Birt-Hogg-Dub e syndrome, folliculin, kidney cancer, mitochondria, mTORC1.In 1977, three Canadian physicians, Birt, Hogg and Dub e, reported kindred with skin nodules that they named fibrofolliculoma.1 In 1999, the development of lung cysts and renal tumors in this kindred were reported, and this disorder was thereafter called BHD syndrome.2 In 2002, FLCN was identified as a novel tumor suppressor gene responsible for BHD syndrome, and a genetic test of FLCN is used as a diagnostic tool for BHD syndrome.3 Among the clinical triad of BHD syndrome, the management of kidney cancer is a key for the overall survival of BHD patients. Although FLCN was a totally novel protein with unknown function and no known domains at the time of discovery, recent studies using murine models have uncovered important roles for FLCN in cell metabolism. [4][5][6][7][8][9][10] In the present review article, we describe the clinical features and management of BHD syndrome, as well ...