Prospective evaluation of molecular screening for Lynch syndrome in patients with endometrial cancer ≤ 70 years,☆☆,

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Abstract

Objective

Lynch syndrome (LS) is a hereditary syndrome that predisposes to multiple malignancies including endometrial cancer (EC). We aimed to evaluate a diagnostic strategy for LS based on routine analysis of microsatellite instability (MSI) and immunohistochemical (IHC) staining for mismatch repair (MMR) proteins in tumour tissue of all newly diagnosed EC patients ≤ 70 years.

Methods

Consecutive EC patients ≤ 70 years were included prospectively in eight Dutch centres. EC specimens were analysed for MSI, IHC of four MMR proteins, MMR gene methylation status and BRAF-mutations. tumours were classified as; 1) likely to be caused by LS, 2) sporadic MSI-H, or 3) microsatellite stable (MSS).

Results

Tumour specimens of 179 patients (median age 61 years, IQR 57–66) were analysed. In our study 92% of included patients were over 50 years of age. Eleven EC patients were found likely to have LS (6%; 95% CI 3–11%), including 1 patient suspected of an MLH1, 2 of an MSH2, 6 of an MSH6 and 2 of a PMS2 gene defect. Germline mutation analyses revealed 7 MMR gene germline mutations. Ten patients likely to have LS (92%) were older than 50 years. In addition, 31 sporadic MSI-H tumours with MLH1 promoter hypermethylation (17%; 95% CI 13–24%) were identified.

Conclusions

Molecular screening for LS in patients with EC diagnosed ≤ 70 years, leads to identification of a profile likely to have LS in 6% of cases. New screening guidelines for LS are needed, including recommendations for EC patients older than 50 years of age.

Highlights

► Tumour tissue of EC patients ≤70 years is suspected of LS in 6% of patients according to molecular screening. ► New screening guidelines for LS should include recommendations for detecting LS in EC patients older than 50 years. ► Physicians and patients have to be educated about the importance of identifying LS and genetic counselling for LS.

Introduction

Lynch syndrome (LS) is an autosomal dominant inherited syndrome that predisposes to multiple malignancies including endometrial cancer (EC). The lifetime risk of women with LS to develop EC is 40 to 60%. In addition, patients with LS carry a lifetime risk of 50 to 85% to develop colorectal cancer (CRC) and also an increased risk of up to 15% to develop other malignancies including gastric, ovarian, small bowel and urinary tract cancers [1], [2], [3], [4].

LS is caused by a mutation in one of the mismatch repair (MMR) genes; MLH1, MSH2, MSH6 or PMS2. As a consequence, LS tumours are MMR deficient and phenotypically characterised by DNA microsatellite instability (MSI). MSI can be detected in more than 90% of all ECs in LS mutation carriers [5]. Therefore, MSI analysis can be used in the diagnostic approach of LS [6]. However, MSI can also be detected in 17 to 23% of sporadic ECs [7], [8], which is mostly caused by transcriptional silencing of the MLH1 gene by promoter hypermethylation [9], [10].

In addition to MSI analysis, immunohistochemical (IHC) analyses can be performed to evaluate the expression of the four MMR proteins. Tumours showing absent MLH1 expression can be selected for MLH1 promoter methylation assay to identify sporadic MSI-H tumours. In case of MSI and loss of MMR protein expression, with exclusion of MLH1-promoter hypermethylation in MLH1 negative tumours, further germline DNA testing is indicated for LS associated MMR genes to make the final diagnosis LS.

Early detection of LS in EC patients is of great importance, since LS carriers are at risk of other cancers, especially CRC, and this risk can significantly be reduced by colonoscopic surveillance [11], [12], [13]. Selection of patients for molecular testing for LS is currently based on clinical criteria, in particular the Amsterdam II criteria and the revised Bethesda guidelines [14], [15]. In the Amsterdam II criteria EC is included as a diagnostic parameter. However, the Amsterdam II criteria lack sensitivity, particularly in cases of small families or when extensive family history information is not available [16], [17]. The revised Bethesda criteria focus primarily on patients with CRC and not with EC. Furthermore current clinical guidelines advise molecular testing for LS for patients with EC below the age of 50 years. This contributes to the concern that LS in EC patients remains undetected. Therefore the aim of this prospective multicentre study was to evaluate the feasibility and the yield of large scale molecular analyses in patients newly diagnosed with EC aged 70 years and younger.

Section snippets

Endometrial cancer patient population

All consecutive patients ≤ 70 years newly diagnosed with invasive EC of epithelial origin were included in eight Dutch hospitals, including seven regional hospitals and one academic medical centre, between May 2007 and September 2009. Patients were identified by monthly electronic searches in the pathology databases of the participating centres. Data were collected on age at diagnosis and tumour-characteristics including histological subtype and pathological tumour (T) stage.

The study was

Endometrial cancer patient population

A total of 183 EC patients were eligible to participate in the study (Fig. 1). In four cases no tumour tissue was available for molecular analyses; therefore 179 EC patients were included. The median age at EC diagnosis was 61 years (IQR 57–66). Fifteen patients were ≤ 50 years (8%) at time of diagnosis. One hundred forty-six of 179 ECs (82%) showed endometrioid type histology. The majority of included EC tumour tissues were found to be grade 1 (73 patients, 41%). Histology showed tumour confined

Discussion

In this prospective multicentre population-based study, we found that routine molecular analyses lead to the identification of 6% (95% CI 3–11%) of all newly diagnosed EC patients aged 70 years and younger as likely to have LS. Seven germline mutations in an MMR gene have been identified in eleven patients likely to have LS. The detection of LS in EC patients is of great importance since these patients are at high risk for synchronous carcinomas, especially CRC. Moreover, the diagnosis of LS is

Conflicts of interest

- None of the authors have conflicts of interest.

- None of the material in the manuscript is included in another manuscript, has been published previously, or is currently under consideration for publication elsewhere.

- Only people who contributed to the intellectual content, the analysis of data, and the writing of the manuscript are listed as authors and all authors take public responsibility for the research results being reported.

- Ethical guidelines were followed and the approval of the

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      MLH1 promoter methylation testing was conclusive in >98% of MLH1/PMS2-deficient cases (Table 2). The proportion of MMRd endometrial cancers (25.9%) in our study (Table 1) is similar to that in previous reports,9–12,14–17 and MMRd cases were present throughout all grades of endometrioid adenocarcinoma as well as high-grade carcinomas (Table 3). MMRd endometrial carcinoma is 1 of the 4 molecular subgroups of endometrial carcinoma22–24 and has an intermediate recurrence-free survival.24,25

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    The LIMO study group: P.A.A van Hagen, MD, Department of Gynaecology, IJsselland Ziekenhuis, Capelle a/d IJssel; A. Bouman, MD, PhD, Department of Gynaecology, Deventer Ziekenhuis, Deventer; P.B von Tongelen, Department of Gynaecology, MD, Ruwaard van Putten Ziekenhuis, Spijkenisse; A.M.G. Huijssoon, MD, Department of Gynaecology, Vlietland Ziekenhuis, Schiedam; L. Pijpers, MD, PhD, Department of Gynaecology, Havenziekenhuis, Rotterdam; P.J. Westenend, MD, PhD, Department of Pathology, Albert Schweitzer Ziekenhuis, Dordrecht; R.H. van Rijssel, MD, Department of Pathology, Deventer Ziekenhuis, Deventer; G. van Tilburg, Department of Pathology, Erasmus MC, Rotterdam.

    ☆☆

    Author contributions: C.H.M. Leenen: Acquisition of data, analysis and interpretation of data, drafting of the manuscript and final approval. M.G.F. van Lier: Acquisition of data, analysis and interpretation of data, revising article and final approval. H.C. van Doorn: Study design, critical revision of the data for important intellectual content, revising article and final approval. M.E. van Leerdam: Study design, critical revision of the data for important intellectual content, revising article and final approval. S.G. Kooi: Acquisition of data, revising article and final approval. J. de Waard: Acquisition of data, revising article and final approval. R.F. Hoedemaeker: Acquisition of data, revising article and final approval. A.M.W. van den Ouweland: Genetic analyses, critical revision of the data for important intellectual content, revising article and final approval. S.M. Hulspas: Molecular and immunohistochemical analyses, revising article and final approval. H.J. Dubbink: Molecular analyses, critical revision of the data for important intellectual content, revising article and final approval. E.J. Kuipers: Study design, critical revision of the data for important intellectual content, revising article and final approval. A. Wagner: Study design, genetic counselling, critical revision of the data for important intellectual content, revising article and final approval. W.N.M. Dinjens: Study design, molecular analyses, critical revision of the data for important intellectual content, revising article and final approval. E.W. Steyerberg: Study design, obtained funding, statistical analyses, critical revision of the data for important intellectual content, revising article and final approval.

    Funding: Erasmus MC Translational Medicine

    1

    On behalf of the LIMO study group.

    2

    Equal contribution.

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