Transcript PastPresentFuture-2 - People at Creighton University

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HEREDITARY COLON CANCER: LYNCH
SYNDROME – PAST, PRESENT AND THE
FUTURE
HENRY T. LYNCH, MD
JANE F. LYNCH, BSN
Creighton University
School of Medicine
Omaha, Nebraska
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Problem Areas
• Dx of Lynch syndrome (LS) frequently missed.
• Classification of LS may be ambiguous.
• More than CRC (numerous extracolonic
cancers).
• Multiple molecular/phenotypic heterogeneous
concerns.
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Family History
Must be comprehensive;
Cancer of all anatomic sites, verification
whenever possible.
Why Pursue Cancer of All Anatomic Sites?
Pertinent for any hereditary cancer syndrome
Most identified by pattern of cancer expression, e.g.:
• breast and ovary (HBOC syndrome);
• CRC, endometrium, ovary, others (Lynch syndrome);
• sarcomas, breast, brain, multiple others in SBLA (LiFraumeni syndrome);
• medullary thyroid carcinoma and
pheochromocytoma (MEN-2a and MEN-2b);
• melanoma and pancreatic cancer with CDKN2A
(p16) mutation (FAMMM syndrome);
• diffuse gastric cancer and lobular breast cancer
with CDH1 mutation (HDGC syndrome);
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...and the list goes on.
Genetic Counseling
• Mandatory
• Centers of Cancer Genetic Expertise
• Physician Role, unfortunately, often
insufficient
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Patient’s Modified Nuclear Pedigree
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Colorectal Cancer
Worldwide estimates for colorectal cancer during 2008*:
Incidence – 1,233,711
Mortality –
608,644
Worldwide estimates for familial/hereditary CRC during
2008*:
Lynch syndrome 3-5% of all CRC
37,011-61,686
FAP
<1% of all CRC
<12,337
Familial
20% of all CRC
246,742
*GLOBOCAN. The International Agency for Research
on Cancer web site. URL: http://www.iarc.fr/
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Familial/Hereditary CRC in US
Annual CRC incidence in US: 142,570
Lynch syndrome 3-5% of all CRC
4,277 - 7,129
FAP
<1% of all CRC
<1,426
Familial
20% of all CRC
28,514
Jemal et al. CA Cancer J Clin 60:277-300,2010.
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Magnitude of the Problem
Question: Why are these figures of such
significant public health impact?
Answer: Each hereditary cancer comes from a
family that could benefit immensely from genetic
counseling.
DNA testing, surveillance, and highly-targeted
management are the key!
Problem: Significance of family frequently missed!
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THE
BEGINNING!
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Archives of Internal Medicine
Vol. 12, July-Dec., 1913
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Archives of Internal Medicine Vol. 12, July-Dec., 1913
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Arch Intern Med 117:206-212, 1966.
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Arch Intern Med 117:206-212, 1966.
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Arch Intern Med 141:607-611, 1981
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Cancer Research 54:4590-4594, 1994.
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Am J Gastroenterology 89:1978-1980, 1994.
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How Aggressive?
Of 225 CRC patients with LS, 10.2 % had CRC within 5 yr
of colonoscopy.
Other studies showed CRC within 3 yrs of colonoscopy.
Conclusion:
1) Accelerated carcinogenesis;
2) Need shorter colonoscopy intervals.
Am J Gastrology 89:1978-1980, 1994.
Cancer 83:259-266, 1998.
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Survival continued
Results:
Compared with the unselected series, the
HNPCC cases had lower stage
disease (P < 0.001), and fewer had
distant metastases at diagnosis (P <
0.001 in an analysis stratified by T
classification);
In stage-stratified survival analysis, the
HNPCC cases had a significant overall
survival advantage regardless of
adjustment for their younger age;
Cancer 83:259-266, 1998.
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Survival continued
Results:
A conservative estimate of the hazard
ratio (of HNPCC cases to the
unselected series) was 0.67 (P <
0.0012).
The estimated death rate for the HNPCC
cases, adjusted for stage and age
differences, was at most two-thirds of
the rate for the hospital series.
Cancer 83:259-266, 1998.
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Am. J. Hum. Genet. 72:1088-1100, 2003
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JAMA 291:718-724, 2004
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Genetic Heterogeneity in HNPCC
MSH6
MSH2
MLH1
PMS2
PMS1
Chr 7
Chr 3
Chr 2
HNPCC is associated with germline mutations in
any one of at least five genes
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FUTURE!
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Should we test all
colorectal cancer for
Lynch Syndrome?
YES! Test everybody.
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Search for LS Among CRC Affecteds*
Evidence:
Among 500 CRC patients, 18 (3.6%) had LS.
Of these 18:
 18 (100%) had MSI-H CRCs;
 17 (94%) were correctly predicted by IHC;
 only 8 (44%) were dx < 50 years;
 only 13 (72%) met the revised Bethesda guidelines;
 1/35 cases of CRC show LS.
*Hampel et al. J Clin Oncol 26:5783-5788, 2008.
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Molecular Genetic Screening for LS
Recommendation*:
All incident CRC and EC cases should be molecularly
screened for LS.
MSI highly sensitive (89.3%).
IHC equally sensitive (91.2%), is inexpensive, is more
readily available, and predicts the nonworking gene.
IHC is preferred method to screen for LS*.
*Hampel et al. J Clin Oncol 26:5783-5788, 2008.
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Increased risk for certain
extracolonic malignancies
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Endometrial
Ovary
Stomach
Small bowel
Pancreas
Liver and biliary tree
Muir-Torre cutaneous features
Brain, (glioblastoma) – Turcot’s syndrome
Possible Prostate cancer and others
Breast cancer - controversial.
Cardinal Features of Lynch Syndrome
• Differentiating pathology features of LS CRCs:
- more often poorly differentiated;
- excess of mucoid and signet-cell features;
- Crohn’s-like reaction;
- medullary features;
- significant excess of infiltrating lymphocytes
within the tumor.
• Increased survival from CRC.
• Sine qua non for diagnosis is identification of
germline mutation in MMR gene (most commonly
MLH1, MSH2, MSH6) segregating in the family.
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A
C
B
D
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Cancer 77:1836-1843, 1996.
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Breast Cancer Research and Treatment 53:87-91, 1999.
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Breast Cancer in the Danish HNPCC
Register*
20 ♀ mutation carriers dx with BC at mean age of
50 years (33-66).
Predominantly ductal carcinoma with extensive
lymphocytic reactions in 8/14 evaluated tumors.
MMR protein immunostaining showed loss of
expression of MLH1, MSH2, or MSH6
corresponding to the mutations found in 7/16
investigated cases.
*Jensen et al. Breast Cancer Res Treat 120:777782, 2010.
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Dis Colon Rectum 53:77-82, 2010.
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Times to subsequent CRC and subsequent abdominal
surgery were significantly shorter in the control group (P <
.006 and P < .04, respectively).
No significant difference was identified with respect to
survival time between the cases and controls.
Conclusion: Even though no survival benefit was identified
between the cases and controls the increased incidence of
metachronous colorectal cancer and increased abdominal
surgeries among controls warrant the recommendation of
subtotal colectomy in patients with LS.
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N Engl J Med 354: 261-269, 2006
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BRAFV600E Mutations in MSI*
The BRAFV600E mutation occurs exclusively in
sporadic forms of MSI CRC.
Combined analysis of MSI and BRAFV600E
mutation is included in current protocols of LS
since it is a reliable, fast, and low-cost strategy.
Helps identify sporadic cases and avoids timeconsuming and expensive screening of MMR
germline mutation analysis.
*Seruca et al. Expert Rev Gastroenterol Hepatol
3:5-9, 2009.
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Algorithm
1. IHC on all colorectal patients on
tumor block;
2. If positive, BRAF (if positive, then
sporadic);
3. Only do full MMR genetic tests on
patient IHC +. BRAF neg.
MORPHOLOGY
SUSPICIOUS
FOR MSI-H
Run PCR test
for MSI status
Is there
MSI-H?
NO
FAMILIAL CRC
TYPE “X”
NO
YES
Is there loss
of staining
with any of
the Abs?
Run mutation analysis
for BRAF V600E
Is there
BRAF V600E
mutation?
NO EVIDENCE OF
LYNCH
SYNDROME
NO
IHC for MLH1,
MSH2, MSH6, PMS2
YES
PUTATIVE
LYNCH
SYNDROME
MMR GENES MUTATION
ANALYSIS
YES
SPORADIC CRC
WITH MSI-H
NO
Is there
a mutation in MMR
gene?
YES
Gatalica Z, Torlakovic E. Fam Cancer 2008;7:15-26
LYNCH
SYNDROME
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MSI Analysis
A functional assay for
the MMR proteins
MSI Analysis
MSI High Data
New – Focus on Mononcleotides
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MSI and Therapeutic Implications
Pharmacogenetics:
5-FU-based chemotherapy refractory in MSI
CRCs;
possible advantage of irinotecan-based therapy;
the latter “not ready for prime time” but 5-FU
approaching clinical acceptability.
Boland and Goel. Gastroenterology 138:2073-2087, 2010.
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MSI and Therapeutic Implications
Virtually all studies show either no benefit or
adverse effects in response to 5-FU-based
adjuvant chemotherapy (reviewed by Boland
and Goel.*)
In vitro responses suggest that chemoresistance is
seen for many chemotherapeutic agents.**
*Gastroenterology 138:2073-2087, 2010.
**Aebi et al. Cancer Res 56:3087-3090, 1996.
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MSI and Therapeutic Implications*
Currently, guidelines do not recommend using MSI
status to determine whether or not to use
chemotherapy.
This recommendation merits a second look, given
the wealth of data showing the inadequacy of 5FU for CRC with MSI.
Should be tested only in the context of a
randomized clinical trial.
*Boland & Goel. Gastroenterology 138:2073-2087,
2010.
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Familial CRC Type “X”
Amsterdam Criteria positive but lacking MSI and MMR
mutations will constitute ~ 40% of those AC-I without
MMR mutations and therein referred to as familial CRC
type X.*
1) CRC > left side
2)  CRC and extra colonic CRC
3) Later age CRC onset
4) Molecular genetics (MSI and IHC or MMR
mutation) ABSENT!
*Lindor et al. JAMA 293:1979-1985, 2005.
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Epithelial Cell Adhesion Molecule (EPCAM)
Gene and Its Lynch Syndrome Connection*
A portion of this ~40% lacking MMR
mutations is caused by a mutation
mechanism in the gene known as
EPCAM.
*Kovacs et al. Hum Mutat 30:197-203, 2009.
5’ EPCAM deletion
Exons 8 and 9 and polyadenylation sequence
Polyadenylation Sequence
Transcriptional read through
Hypermethylation of the MSH2 promoter
Ligtenberg MJ, Nature Genetics 2009.
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Why LS with Site-Specific CRC?
Deletion in EPCAM results in hypermethylation
and incomplete silencing of MSH2.
EPCAM mutation carriers may have phenotypic
features that differ from carriers of MSH2
mutations – namely, an almost exclusive
expression of site-specific CRC, thereby lacking
extracolonic cancers.
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American and Dutch families have the same
deletion in the EPCAM gene
MSH2
EPCAM
Deletion
c.859-1462_*1999del
(4.9 kb, starting in intron 7
and including exons 8 & 9)
Lightenberg, Nature Genetics 2009.
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American and Dutch EPCAM mutations
originate from a common ancestor
Family R and the Dutch families share a 6.1 MB region surrounding
the same EPCAM deletion indicating a common ancestor. Based on the size of the
shared region it is estimated the deletion occurred 10 generations ago.
Chromosome 2
Chromosome 2
Deletion and Region
inherited from
common ancestor
Dutch Families
Family R
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History of Family R*
Ascertained by us in 1970 and followed continuously.
700 blood line relatives
327 individuals age ≥ 18, ≥ 25% pedigree risk
Phenotype strikingly similar to LS but integral extracolonic
cancers absent (site-specific CRCs)
*Lynch et al. Cancer 56:934-938, 1985.
Lynch et al. Cancer 56:939-951, 1985.
First patient identified with
EPCAM mutation
CRC affecteds
EPCAM results
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Family Information Service (FIS)
Cost-effective and highly efficient way of
educating and counseling all available family
members from a geographic catchment area
during a single setting.
Makes best use of physician’s time and effort,
has group therapy potential and patients
welcome it.
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Targeted CRC Screening
Screening is melded to LS’s natural history:
Proximal location  colonoscopy
Early age of onset  beginning at age 25
Accelerated carcinogenesis  every 1-2 yrs < age 40,
then annually
Pattern of extra-colonic cancers  targeted screening
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MSI/IHC in CRC*
Conclusion:
CRCs with MSI may show distinctive clinical,
pathologic features:
a) predominance of CRC in proximal colon;
b) lymphocyte infiltration within tumor;
c) poorly differentiated mucinous or signet cell
appearance;
d) better prognosis;
e) differing response to chemotherapeutics;
f) molecular screening all CRC cases.
*Boland and Goel. Gastroenterology 138:2073-2087, 2010.
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*Jensen et al. Breast Cancer Res Treat 120:777-782, 2010.
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Breast Cancer in the Danish HNPCC
Register*
Defective MMR in a substantial proportion of the
BCs studied links it to HNPCC.
While the low number does not motivate
surveillance, the observation supports a role for
defective MMR in BC progression in LS.
*Jensen et al. Breast Cancer Res Treat 120:777782, 2010.
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MSI and Therapeutic Implications*
Where did this knowledge originate?
Through DNA MMR genes first identified in
bacteria through exposure to cytotoxic mutagens
(alkylating agents) and selecting for strains
resistant to DNA damage.
*Carethers et al. J Clin Invest 98:199-206, 1996.
Ribic et al. N Engl J Med 349:247-257, 2003.
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MSI and Therapeutic Implications*
Resulting bacteria were hypermutable and
resistant to DNA alkylation.
Resistant to cytotoxic agents that acted by
damaging DNA.
Raised possibility that DNA MMR deficient cells
might be relatively resistant to some types of
cytotoxic chemotherapy.
*Carethers et al. J Clin Invest 98:199-206, 1996.
Ribic et al. N Engl J Med 349:247-257, 2003.
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Cardinal Features of Lynch Syndrome
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AD – MMR mutations
Proximal
Earlier age of onset
Accelerated carcinogenesis
Extra colonic cancers
Pathology – distinctive?
↑ survival