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Kaya M, Post CCB, Tops CM, Nielsen M, Crosbie EJ, Leary A, Mileshkin LR, Han K, Bessette P, de Boer SM, Jürgenliemk-Schulz IM, Lutgens L, Jobsen JJ, Haverkort MAD, Nout RA, Kroep J, Creutzberg CL, Smit VTHBM, Horeweg N, van Wezel T, Bosse T. Molecular and Clinicopathologic Characterization of Mismatch Repair-Deficient Endometrial Carcinoma Not Related to MLH1 Promoter Hypermethylation. Mod Pathol 2024; 37:100423. [PMID: 38191122 DOI: 10.1016/j.modpat.2024.100423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/08/2023] [Accepted: 01/03/2024] [Indexed: 01/10/2024]
Abstract
Universal tumor screening in endometrial carcinoma (EC) is increasingly adopted to identify individuals at risk of Lynch syndrome (LS). These cases involve mismatch repair-deficient (MMRd) EC without MLH1 promoter hypermethylation (PHM). LS is confirmed through the identification of germline MMR pathogenic variants (PV). In cases where these are not detected, emerging evidence highlights the significance of double-somatic MMR gene alterations as a sporadic cause of MMRd, alongside POLE/POLD1 exonuclease domain (EDM) PV leading to secondary MMR PV. Our understanding of the incidence of different MMRd EC origins not related to MLH1-PHM, their associations with clinicopathologic characteristics, and the prognostic implications remains limited. In a combined analysis of the PORTEC-1, -2, and -3 trials (n = 1254), 84 MMRd EC not related to MLH1-PHM were identified that successfully underwent paired tumor-normal tissue next-generation sequencing of the MMR and POLE/POLD1 genes. Among these, 37% were LS associated (LS-MMRd EC), 38% were due to double-somatic hits (DS-MMRd EC), and 25% remained unexplained. LS-MMRd EC exhibited higher rates of MSH6 (52% vs 19%) or PMS2 loss (29% vs 3%) than DS-MMRd EC, and exclusively showed MMR-deficient gland foci. DS-MMRd EC had higher rates of combined MSH2/MSH6 loss (47% vs 16%), loss of >2 MMR proteins (16% vs 3%), and somatic POLE-EDM PV (25% vs 3%) than LS-MMRd EC. Clinicopathologic characteristics, including age at tumor onset and prognosis, did not differ among the various groups. Our study validates the use of paired tumor-normal next-generation sequencing to identify definitive sporadic causes in MMRd EC unrelated to MLH1-PHM. MMR immunohistochemistry and POLE-EDM mutation status can aid in the differentiation between LS-MMRd EC and DS-MMRd EC. These findings emphasize the need for integrating tumor sequencing into LS diagnostics, along with clear interpretation guidelines, to improve clinical management. Although not impacting prognosis, confirmation of DS-MMRd EC may release patients and relatives from burdensome LS surveillance.
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Affiliation(s)
- Merve Kaya
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cathalijne C B Post
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Carli M Tops
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje Nielsen
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Emma J Crosbie
- Department of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Alexandra Leary
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - Linda R Mileshkin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Kathy Han
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Paul Bessette
- Department of Obstetrics and Gynaecology, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Stephanie M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Ludy Lutgens
- Department of Radiation Oncology, MAASTRO Clinic, Maastricht, The Netherlands
| | - Jan J Jobsen
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Marie A D Haverkort
- Department of Radiation Oncology, Radiotherapiegroep, Arnhem, The Netherlands
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nanda Horeweg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom van Wezel
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tjalling Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands.
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Jonnagadla S, Joseland SL, Saya S, den Elzen N, Isbister J, Winship IM, Buchanan DD. Heterogeneity in the psychosocial and behavioral responses associated with a diagnosis of suspected Lynch syndrome in women with endometrial cancer. Hered Cancer Clin Pract 2022; 20:27. [PMID: 35840994 PMCID: PMC9284782 DOI: 10.1186/s13053-022-00233-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background A suspected Lynch syndrome (SLS) diagnosis is made when a tumor exhibits DNA mismatch repair deficiency but cannot be definitively assigned to an inherited or non-inherited etiology. This diagnosis poses challenges for healthcare professionals, patients, and their families in managing future cancer risks and clinical care. Methods This qualitative study aimed to explore the psychosocial and behavioral responses of endometrial cancer (EC) patients receiving a SLS diagnosis (EC-SLS). Semi-structured telephone interviews were conducted with 15 EC-SLS women, transcribed, and thematically analyzed. Results Most who interpreted their result as negative for Lynch syndrome (LS) believed they were at population-level risk of cancer and felt happy and relieved. Many participants who interpreted their result as inconclusive/not definitive for LS were confused about their cancer risk and experienced negative emotions of anger and frustration. Despite variation in colorectal cancer screening recommendations reported by participants, most adhered to the advice given. Almost all participants communicated their genetic test result to immediate family members; however, communication of family cancer risk management advice was more limited due to most participants reporting not receiving family screening advice. A family history of cancer and a professional healthcare background influenced participants’ engagement in regular cancer screening. Conclusion These findings highlight variability in the psychosocial and behavioral responses associated with EC-SLS, providing insight into how healthcare professionals can optimally manage and support such individuals. Supplementary Information The online version contains supplementary material available at 10.1186/s13053-022-00233-1.
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Affiliation(s)
- Sowmya Jonnagadla
- Department of Clinical Pathology, Colorectal Oncogenomics Group, Melbourne Medical School, The University of Melbourne, Victorian Comprehensive Cancer Centre, 305 Grattan Street, Parkville, Victoria, 3010, Australia.,The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, 3000, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Sharelle L Joseland
- Department of Clinical Pathology, Colorectal Oncogenomics Group, Melbourne Medical School, The University of Melbourne, Victorian Comprehensive Cancer Centre, 305 Grattan Street, Parkville, Victoria, 3010, Australia.,The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, 3000, Australia
| | - Sibel Saya
- The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, 3000, Australia.,Department of General Practice, The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Nicole den Elzen
- Department of Clinical Pathology, Colorectal Oncogenomics Group, Melbourne Medical School, The University of Melbourne, Victorian Comprehensive Cancer Centre, 305 Grattan Street, Parkville, Victoria, 3010, Australia.,The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, 3000, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Joanne Isbister
- Genomic Medicine and Family Cancer Clinic, The Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia
| | - Ingrid M Winship
- Genomic Medicine and Family Cancer Clinic, The Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia.,Department of Medicine, The Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia
| | - Daniel D Buchanan
- Department of Clinical Pathology, Colorectal Oncogenomics Group, Melbourne Medical School, The University of Melbourne, Victorian Comprehensive Cancer Centre, 305 Grattan Street, Parkville, Victoria, 3010, Australia. .,The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, 3000, Australia. .,Genomic Medicine and Family Cancer Clinic, The Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia.
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den Elzen N, Joseland SL, Saya S, Jonnagadla S, Isbister J, Winship I, Buchanan DD. "Left in limbo": Exploring how patients with colorectal cancer interpret and respond to a suspected Lynch syndrome diagnosis. Hered Cancer Clin Pract 2021; 19:43. [PMID: 34656160 PMCID: PMC8520179 DOI: 10.1186/s13053-021-00201-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/01/2021] [Indexed: 12/30/2022] Open
Abstract
Background A diagnosis of suspected Lynch syndrome (SLS) is given when a tumour displays characteristics consistent with Lynch syndrome (LS), but no germline pathogenic variant is identified. This inconclusive diagnosis results in uncertainty around appropriate cancer risk management. This qualitative study explored how patients with CRC interpret and respond to an SLS diagnosis. Methods Semi-structured telephone interviews were conducted with 15 patients with CRC who received an SLS diagnosis, recruited from cancer genetics services across Australia. Interviews were transcribed verbatim and analysed using thematic analysis. Participant responses were compared with appointment summary letters from cancer genetics services. Results Participants’ interpretations of genetic test results were found to vary widely. While this variation often aligned with variation in interpretations by cancer genetics services, participants also had difficulties with the complexity and recall of genetic test results. Participants had a range of psychological responses to the uncertainty that their results presented, from relief to disappointment and doubt. Cancer risk perceptions also varied widely, with participants’ interpretations of their genetic test results just one of several influencing factors. Despite this variability, almost all participants adhered to cancer risk management advice, although different participants received different advice. All participants also communicated any cancer risk management advice to first-degree relatives, motivated by protecting them, but information communicated was not always consistent with advice received. Conclusions Our study findings highlight the variability in patients’ interpretations of their diagnosis, cancer risk management and family communication when a diagnosis of SLS is received, and provide novel insights into how healthcare professionals can better support patients with SLS.
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Affiliation(s)
- Nicole den Elzen
- Colorectal Oncogenomics Group, Department of Clinical Pathology, Melbourne Medical School, The University of Melbourne, 305 Grattan Street, Parkville, Victoria, 3010, Australia.,The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Sharelle L Joseland
- Colorectal Oncogenomics Group, Department of Clinical Pathology, Melbourne Medical School, The University of Melbourne, 305 Grattan Street, Parkville, Victoria, 3010, Australia.,The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
| | - Sibel Saya
- The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia.,Department of General Practice, The University of Melbourne, Parkville, Victoria, Australia
| | - Sowmya Jonnagadla
- Colorectal Oncogenomics Group, Department of Clinical Pathology, Melbourne Medical School, The University of Melbourne, 305 Grattan Street, Parkville, Victoria, 3010, Australia.,The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Joanne Isbister
- Genomic Medicine and Family Cancer Clinic, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Ingrid Winship
- Genomic Medicine and Family Cancer Clinic, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Daniel D Buchanan
- Colorectal Oncogenomics Group, Department of Clinical Pathology, Melbourne Medical School, The University of Melbourne, 305 Grattan Street, Parkville, Victoria, 3010, Australia. .,The University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia. .,Genomic Medicine and Family Cancer Clinic, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Therkildsen C, Jensen LH, Rasmussen M, Bernstein I. An Update on Immune Checkpoint Therapy for the Treatment of Lynch Syndrome. Clin Exp Gastroenterol 2021; 14:181-197. [PMID: 34079322 PMCID: PMC8163581 DOI: 10.2147/ceg.s278054] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/15/2021] [Indexed: 12/12/2022] Open
Abstract
During the recent years, immune checkpoint-based therapy has proven highly effective in microsatellite instable (MSI) solid tumors irrespective of organ site. MSI tumors are associated with a defective mismatch repair (MMR) system and a highly immune-infiltrative tumor microenvironment—both characteristics of Lynch syndrome. Lynch syndrome is a multi-tumor syndrome that not only confers a high risk of colorectal and endometrial cancer but also cancer in, eg the upper urinary tract, ovaries, and small bowel. Since the genetic predisposition for Lynch syndrome are pathogenic variants in one of the four MMR genes, MLH1, MSH2, MSH6 or PMS2, most of the Lynch syndrome cancers show MMR deficiency, MSI, and activation of the immune response system. Hence, Lynch syndrome cancer patients may be optimal candidates for immune checkpoint-based therapies. However, molecular differences have been described between sporadic MSI tumors (developed due to MLH1 promoter hypermethylation) and Lynch syndrome tumors, which may result in different treatment responses. Furthermore, the response profile of the rare Lynch syndrome cases may be masked by the more frequent cases of sporadic MSI tumors in large clinical trials. With this review, we systematically collected response data on Lynch syndrome patients treated with FDA- and EMA-approved immune checkpoint-based drugs (pembrolizumab, atezolizumab, durvalumab, avelumab, ipilimumab, and nivolumab) to elucidate the objective response rate and progression-free survival of cancer in Lynch syndrome patients. Herein, we report Lynch syndrome-related objective response rates between 46 and 71% for colorectal cancer and 14–100% for noncolorectal cancer in unselected cohorts as well as an overview of the Lynch syndrome case reports. To date, no difference in the response rates has been reported between Lynch syndrome and sporadic MSI cancer patients.
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Affiliation(s)
- Christina Therkildsen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Copenhagen, Denmark.,The Danish HNPCC Register, Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Copenhagen, Denmark
| | - Lars Henrik Jensen
- Department of Oncology, University Hospital of Southern Denmark, Vejle Hospital, Vejle, Denmark
| | - Maria Rasmussen
- The Danish HNPCC Register, Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Copenhagen, Denmark
| | - Inge Bernstein
- Department of Gastroenterology, Aalborg Hospital, Aalborg, Denmark.,Faculty of Medicine, Aalborg University, Aalborg, Denmark
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Zhang M, Chen T. Overview on population screening for carriers with germline mutations in mismatch repair (MMR) genes in China. Hered Cancer Clin Pract 2021; 19:26. [PMID: 33933134 PMCID: PMC8088635 DOI: 10.1186/s13053-021-00182-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/20/2021] [Indexed: 11/11/2022] Open
Abstract
DNA mismatch repair (MMR) genes play an important role in maintaining genome stability. Germline mutations in MMR genes disrupt the mismatch repair function and cause genome instability. Carriers with MMR germline mutations are more likely to have MMR deficiency and microsatellite instability (MSI) than non-carriers and are prone to develop colorectal cancer (CRC) and extracolorectal malignancies, known as Lynch syndrome (LS). MMR gene testing for suspected mutation carriers is a reliable method to identify the mutation types and to discover mutation carriers. Given that carriers of MMR germline mutations have a higher risk of LS-related cancers (LS-RC) and a younger age at onset than non-carriers, early surveillance and regular screening of relevant organs of carriers are very important for early detection of related cancers. This review mainly focuses on the general status of MMR carriers, the approaches for early detection and screening, and the surveillance of MMR mutation carriers in China. Population screening of MMR germline mutation carriers in China will be helpful for early detection, early diagnosis and treatment of MMR mutation carriers, which may improve the 5-year survival, and reduce mortality and incidence rate in the long term.
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Affiliation(s)
- Min Zhang
- School of Public Health, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Tianhui Chen
- Department of Cancer Prevention/Experimental Research Center, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China.
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