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Naiqiso SLS, Moses J, Tan AL, Eva L. Universal screening for Lynch syndrome in endometrial cancer diagnoses in Auckland, New Zealand: The initial experience. Aust N Z J Obstet Gynaecol 2024. [PMID: 39015010 DOI: 10.1111/ajo.13857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 06/16/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Universal mismatch repair immunohistochemistry (MMR IHC) tumour testing in endometrial cancer (EC) for Lynch syndrome (LS) was introduced in Auckland, New Zealand, in January 2017. Identifying patients with LS allows them and their families to access risk reduction strategies. Universal MMR IHC testing aids in the molecular classification of EC and has prognostic and therapeutic implications. AIM We aimed to determine the incidence of LS in women with EC in Auckland, New Zealand, following the introduction of MMR testing and the impact of universal screening on local genetic services. MATERIALS AND METHODS This is a retrospective clinicopathological evaluation of women with a new EC diagnosis referred to the Auckland Gynaecological Oncology Unit from 1/1/17 to 31/12/18. Patient data were extracted from the Gynaecological Oncology Unit database and electronic records, and analysed using descriptive statistics. RESULTS During the study period, 409 patients were diagnosed with EC, with an over-representation of Pacific Islanders (32.5%). Of these, 82.6% underwent MMR IHC testing, 20% were MMR-deficient (MMRd), and 71% had somatic hypermethylation. The Pacific Islander population had a 64% (odds ratio 0.36, P = 0.005) reduction in the odds of having MMRd tumours compared with Europeans. Of the patients who underwent MMR IHC testing, 5.5% were referred to a genetic clinic for germline testing. LS was confirmed in eight patients (2.3%). CONCLUSION LS was diagnosed in 2.3% of patients. There was an over-representation of Pacific Islanders in the EC group but not among those diagnosed with LS.
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Affiliation(s)
- Silipa Lock Sam Naiqiso
- Department of Gynaecological Oncology, National Women's Health, Te Whatu Ora, Te Toka Tumai, Auckland, Aotearoa, New Zealand
| | - Jo Moses
- Department of Histopathology, Te Whatu Ora, Te Toka Tumai, Auckland, Aotearoa, New Zealand
| | - Ai Ling Tan
- Ascot Women's Clinic, Auckland, Aotearoa, New Zealand
| | - Lois Eva
- Department of Gynaecological Oncology, National Women's Health, Te Whatu Ora, Te Toka Tumai, Auckland, Aotearoa, New Zealand
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Silva FFVE, Ballini A, Caponio VCA, Pérez-Sayáns M, Cortés MG, Rojo-Álvarez LI, García-García A, Suaréz-Peñaranda JM, Di Domenico M, Padín-Iruegas ME. Insights into MLH1 Methylation in Endometrial Adenocarcinoma through Pyrosequencing Analysis: A Retrospective Observational Study. Cancers (Basel) 2024; 16:2119. [PMID: 38893238 PMCID: PMC11171209 DOI: 10.3390/cancers16112119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/23/2024] [Accepted: 05/31/2024] [Indexed: 06/21/2024] Open
Abstract
Background: In cancer care, the MLH1 gene is crucial for DNA mismatch repair (MMR), serving as a vital tumor suppressor. Evaluating MLH1 protein expression status, followed by analysis of MLH1 promoter methylation, has become a key diagnostic and prognostic approach. Our study investigates the complex link between MLH1 methylation and prognosis in endometrial adenocarcinoma (EA) patients. Methodology: MLH1 methylation status was accessed by a Pyrosequencing (PSQ) assay. Qualitative positivity for methylation was established if it exceeded the 11% cut-off; as well, a quantitative methylation analysis was conducted to establish correlations with clinicopathological data, relapse-free survival, and disease-free survival. Results: Our study revealed that 33.3% of patients without MLH1 methylation experienced relapses, surpassing the 23.3% in patients with methylation. Furthermore, 16.7% of patients without methylation succumbed to death, with a slightly higher rate of 17.6% in methylated patients. Qualitative comparisons highlighted that the mean methylation rate in patients experiencing relapse was 35.8%, whereas in those without relapse, it was 42.2%. This pattern persisted in disease-specific survival (DSS), where deceased patients exhibited a higher mean methylation level of 49.1% compared to living patients with 38.8%. Conclusions: Our findings emphasize the efficacy of PSQ for evaluating MLH1 methylation. While unmethylation appears to be associated with a higher relapse rate, the survival rate does not seem to be influenced by methylation. Quantitative percentages suggest that elevated MLH1 methylation is linked to relapse and mortality, though a study with a larger sample size would be essential for statistically significant results.
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Affiliation(s)
- Fábio França Vieira e Silva
- Department of Medicine and Dentistry, University of Santiago de Compostela, San Francisco Street, s/n, 15782 Santiago de Compostela, Spain; (F.F.V.e.S.); (M.P.-S.); (A.G.-G.); (J.M.S.-P.)
- Health Research Institute of Santiago de Compostela (FIDIS), Santiago de Compostela University Clinical Hospital, University of Santiago de Compostela, Choupana Street, s/n, 15706 Santiago de Compostela, Spain; (M.G.C.); (L.I.R.-Á.); (M.E.P.-I.)
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Via L. De Crecchio, 7, 80138 Naples, Italy;
| | - Andrea Ballini
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Via L. De Crecchio, 7, 80138 Naples, Italy;
- Department of Clinical and Experimental Medicine, University of Foggia, Via Rovelli, 48, 71122, Foggia, Italy;
| | - Vito Carlo Alberto Caponio
- Department of Clinical and Experimental Medicine, University of Foggia, Via Rovelli, 48, 71122, Foggia, Italy;
| | - Mario Pérez-Sayáns
- Department of Medicine and Dentistry, University of Santiago de Compostela, San Francisco Street, s/n, 15782 Santiago de Compostela, Spain; (F.F.V.e.S.); (M.P.-S.); (A.G.-G.); (J.M.S.-P.)
- Health Research Institute of Santiago de Compostela (FIDIS), Santiago de Compostela University Clinical Hospital, University of Santiago de Compostela, Choupana Street, s/n, 15706 Santiago de Compostela, Spain; (M.G.C.); (L.I.R.-Á.); (M.E.P.-I.)
| | - Marina Gándara Cortés
- Health Research Institute of Santiago de Compostela (FIDIS), Santiago de Compostela University Clinical Hospital, University of Santiago de Compostela, Choupana Street, s/n, 15706 Santiago de Compostela, Spain; (M.G.C.); (L.I.R.-Á.); (M.E.P.-I.)
| | - Laura Isabel Rojo-Álvarez
- Health Research Institute of Santiago de Compostela (FIDIS), Santiago de Compostela University Clinical Hospital, University of Santiago de Compostela, Choupana Street, s/n, 15706 Santiago de Compostela, Spain; (M.G.C.); (L.I.R.-Á.); (M.E.P.-I.)
| | - Abel García-García
- Department of Medicine and Dentistry, University of Santiago de Compostela, San Francisco Street, s/n, 15782 Santiago de Compostela, Spain; (F.F.V.e.S.); (M.P.-S.); (A.G.-G.); (J.M.S.-P.)
- Health Research Institute of Santiago de Compostela (FIDIS), Santiago de Compostela University Clinical Hospital, University of Santiago de Compostela, Choupana Street, s/n, 15706 Santiago de Compostela, Spain; (M.G.C.); (L.I.R.-Á.); (M.E.P.-I.)
| | - José Manuel Suaréz-Peñaranda
- Department of Medicine and Dentistry, University of Santiago de Compostela, San Francisco Street, s/n, 15782 Santiago de Compostela, Spain; (F.F.V.e.S.); (M.P.-S.); (A.G.-G.); (J.M.S.-P.)
- Health Research Institute of Santiago de Compostela (FIDIS), Santiago de Compostela University Clinical Hospital, University of Santiago de Compostela, Choupana Street, s/n, 15706 Santiago de Compostela, Spain; (M.G.C.); (L.I.R.-Á.); (M.E.P.-I.)
| | - Marina Di Domenico
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Via L. De Crecchio, 7, 80138 Naples, Italy;
| | - María Elena Padín-Iruegas
- Health Research Institute of Santiago de Compostela (FIDIS), Santiago de Compostela University Clinical Hospital, University of Santiago de Compostela, Choupana Street, s/n, 15706 Santiago de Compostela, Spain; (M.G.C.); (L.I.R.-Á.); (M.E.P.-I.)
- Human Anatomy and Embriology Area, Departament of Funcional Biology and Health Sciences, University of Vigo, Lagoas-Marcosende, s/n, 36310 Vigo, Spain
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Olkhov-Mitsel E, Busca A, Parra-Herran C, Amemiya Y, Nofech-Mozes S, Djordjevic B, Nucci MR, Seth A, Mirkovic J. Genomic profiling of dedifferentiated endometrial carcinomas arising in the background of high-grade carcinoma: a targeted next-generation sequencing study. Histopathology 2023; 83:366-375. [PMID: 37222195 DOI: 10.1111/his.14938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/25/2023]
Abstract
AIMS Our understanding of dedifferentiated endometrial carcinoma (DEC), a rare and aggressive malignancy, mainly reflects undifferentiated carcinomas (UC) arising in the setting of low-grade endometrial cancer (DEC-LG). However, cases of UC arising in the setting of high-grade EC (DEC-HG) have been noted in the literature. Our knowledge of the genomics of DEC-HG is limited. To characterise the molecular landscape of DEC-HC, targeted genomic sequencing and immunohistochemical analysis was carried out on seven DEC-HG and four DEC-LG. METHODS AND RESULTS DEC-HG and DEC-LG, including undifferentiated and differentiated components, both showed a similar frequency and spectrum of mutations. ARID1A mutations were identified in 6/7 (86%) DEC-HG and 4/4 (100%) DEC-LG, while SMARCA4 mutations were present in 4/7 (57%) DEC-HG and in 1/4 (25%) DEC-LG. Concurrent SMARCA4/BRG1 protein loss by immunohistochemistry was observed in 3/4 and 1/1 SMARCA4 mutated DEC-HG and DEC-LG, respectively. Neither genomic alterations nor protein loss in SMARCB1/INI1 were observed in any of our cases. TP53 mutations were detected in 4/7 (57%) DEC-HG and in 2/4 (50%) DEC-LG, while mutation-pattern p53 immunohistochemistry expression was observed in 2/7 (29%) DEC-HG and none of the DEC-LG. MLH1 mutations were observed in 1/7 (14%) DEC-HG and 1/4 (25%) DEC-LG. MSH2 and MSH6 mutations were each detected in 1/7 (14%) DEC-HG, but neither was associated with corresponding loss of protein expression. CONCLUSION The findings support expanding the definition of DEC to include DEC-HG, a previously under-recognised phenomenon with genomic similarities to DEC-LG.
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Affiliation(s)
- Ekaterina Olkhov-Mitsel
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Aurelia Busca
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Carlos Parra-Herran
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital - Harvard Medical School, Boston, MA, USA
| | - Yutaka Amemiya
- Genomics Core Facility, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Sharon Nofech-Mozes
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Bojana Djordjevic
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Marisa R Nucci
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital - Harvard Medical School, Boston, MA, USA
| | - Arun Seth
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Genomics Core Facility, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
- Platform Biological Sciences, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - Jelena Mirkovic
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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Nakad Borrego S, Kurnit K, Turner LJ, Broaddus RR. Context-dependent environmental associations with endometrial cancer histotype and genotype. Int J Gynecol Cancer 2023; 33:1215-1221. [PMID: 37380216 PMCID: PMC10823374 DOI: 10.1136/ijgc-2023-004330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVE MLH1 loss due to MLH1 methylation, detected during Lynch syndrome screening, is one of the most common molecular changes in endometrial cancer. It is well established that environmental influences such as nutritional state can impact gene methylation, both in the germline and in a tumor. In colorectal cancer and other cancer types, aging is associated with changes in gene methylation. The objective of this study was to determine if there was an association between aging or body mass index on MLH1 methylation in sporadic endometrial cancer. METHODS A retrospective review of patients with endometrial cancer was performed. Tumors were screened for Lynch syndrome via immunohistochemistry, with MLH1 methylation analysis performed when there was loss of MLH1 expression. Clinical information was abstracted from the medical record. RESULTS There were 114 patients with mismatch repair deficient tumors associated with MLH1 methylation, and 349 with mismatch repair proficient tumors. Patients with mismatch repair deficient tumors were older than those whose tumors were proficient. Mismatch repair deficient tumors had a higher incidence of lymphatic/vascular space invasion. When stratified by endometrioid grade, associations with body mass index and age became apparent. Patients with endometrioid grades 1 and 2 tumors and somatic mismatch repair deficiency were significantly older, but body mass index was comparable with that of the mismatch repair intact group. For endometrioid grade 3, patient age did not significantly vary between the somatic mismatch repair deficient group and the mismatch repair intact group. In contrast, body mass index was significantly higher in the patients with grade 3 tumors with somatic mismatch repair deficiency. CONCLUSION The relationship of MLH1 methylated endometrial cancer with age and body mass index is complex and somewhat dependent on tumor grade. As body mass index is modifiable, it is possible that weight loss induces a 'molecular switch' to alter the histologic characteristics of an endometrial cancer.
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Affiliation(s)
- Sanaa Nakad Borrego
- Department of Obstetrics & Gynecology, University of Chicago Department of Medicine, Chicago, Illinois, USA
| | - Katherine Kurnit
- Section of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Laura Jane Turner
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Russell R Broaddus
- Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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5
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Correlation of PD-L1 immunohistochemical expression with microsatellite instability and p53 status in endometrial carcinoma. Eur J Obstet Gynecol Reprod Biol X 2022; 16:100172. [DOI: 10.1016/j.eurox.2022.100172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/26/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
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The Role of Immunohistochemistry Markers in Endometrial Cancer with Mismatch Repair Deficiency: A Systematic Review. Cancers (Basel) 2022; 14:cancers14153783. [PMID: 35954447 PMCID: PMC9367287 DOI: 10.3390/cancers14153783] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023] Open
Abstract
The objective of this systematic review was to summarize our current knowledge of the role of immunohistochemistry (IHC) markers for identifying mismatch repair-deficient (MMRd) tumors in endometrial cancer (EC). Identification of MMRd tumors, which occur in 13% to 30% of all ECs, has become critical for patients with colorectal and endometrial cancer for therapeutic management, clinical decision making, and prognosis. This review was conducted by two authors applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the following terms: “immunohistochemistry and microsatellite instability endometrial cancer” or “immunohistochemistry and mismatch repair endometrial cancer” or “immunohistochemistry and mismatch repair deficient endometrial cancer”. Among 596 retrieved studies, 161 fulfilled the inclusion criteria. Articles were classified and presented according to their interest for the diagnosis, prognosis, and theragnostics for patients with MMRd EC. We identified 10, 18, and 96 articles using IHC expression of two, three, or four proteins of the MMR system (MLH1, MSH2, MHS6, and PMS2), respectively. MLH1 promoter methylation was analyzed in 57 articles. Thirty-four articles classified MMRd tumors with IHC markers according to their prognosis in terms of recurrence-free survival (RFS), overall survival (OS), stage, grade, and lymph node invasion. Theragnostics were studied in eight articles underlying the important concentration of PD-L1 in MMRd EC. Even though the role of IHC has been challenged, it represents the most common, robust, and cheapest method for diagnosing MMRd tumors in EC and is a valuable tool for exploring novel biotherapies and treatment modalities.
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Li JJX, Ip PPC. Endometrial Cancer: An Update on Prognostic Pathologic Features and Clinically Relevant Biomarkers. Surg Pathol Clin 2022; 15:277-299. [PMID: 35715162 DOI: 10.1016/j.path.2022.02.006] [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] [Indexed: 06/15/2023]
Abstract
The prognosis of endometrial cancers has historically been determined by the evaluation of histologic typing, grading, and staging. Recently, molecular classification, pioneered by the 4 prognostic categories from The Cancer Genome Atlas Research Network, has been shown to independently predict the outcome, correlate with biomarker expression, and predict response to adjuvant chemotherapy. In modern-day pathology practice, it has become necessary to integrate the time-honored prognostic pathologic features with molecular classification to optimize patient management. In this review, the significance of the molecular classification of endometrioid carcinomas, the application of practical diagnostic surrogate algorithms, and interpretation of test results will be addressed. Histologic features and theragnostic biomarkers will also be discussed in relation to the molecular subtypes of endometrial cancers.
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Affiliation(s)
- Joshua J X Li
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR
| | - Philip P C Ip
- Department of Pathology, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, 102 Pok Fu Lam Road, Hong Kong SAR.
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Tsuruta T, Todo Y, Yamada R, Kuwahara K, Kurosu H, Minowa K, Minoura Y, Minobe S, Suzuki H, Kato H. Initial screening by immunohistochemistry is effective in universal screening for Lynch syndrome in endometrial cancer patients: a prospective observational study. Jpn J Clin Oncol 2022; 52:752-758. [PMID: 35438162 DOI: 10.1093/jjco/hyac058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 04/02/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few prospective reports of universal screening for Lynch syndrome exist for patients with endometrial cancer. In this study, we performed immunohistochemical staining for DNA mismatch repair-related genes (MLH1, MSH2, MSH6 and PMS2), to determine the extent to which Lynch syndrome can be diagnosed in endometrial cancer patients through universal screening. METHODS We recruited 116 consecutive patients assumed to have uterine corpus malignancy from October 2019 to February 2021 in a prospective observational study. We performed immunohistochemical for mismatch repair-related proteins on samples from 100 patients who had surgicopathologically confirmed diagnoses of endometrial cancer. Samples with missing immunohistochemical results for any of the proteins had subsequent universal screening tests for microsatellite instability, DNA methylation of the MLH1 promoter region and mismatch repair genetics. RESULTS We identified 19 (19.0%) patients with lost results for any of the proteins. All 19 patient samples had subsequent screening tests. We identified the microsatellite instability-high phenotype in 84.2% (16/19) of these patients and MLH1 methylation in 57.9% (11/19). Mismatch repair genetic testing detected two pathological variants, in MSH2 and MSH6, which indicated that the prevalence of Lynch syndrome was 2.0% in our cohort. Two cases of unclassified variant (MSH6) and one case of benign variant (PMS2) were also detected. CONCLUSIONS Initial screening by immunohistochemical is an effective method in universal screening for Lynch syndrome in endometrial cancer patients.
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Affiliation(s)
- Tomohiko Tsuruta
- Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Kagawa, Japan.,Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Yukiharu Todo
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Ryutaro Yamada
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Ken Kuwahara
- Division of Pathology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Hiroyuki Kurosu
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Kaoru Minowa
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Yuko Minoura
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Shinichiro Minobe
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Hiroaki Suzuki
- Division of Pathology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Hidenori Kato
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
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Kaneko E, Sato N, Sugawara T, Noto A, Takahashi K, Makino K, Terada Y. MLH1 promoter hypermethylation predicts poorer prognosis in mismatch repair deficiency endometrial carcinomas. J Gynecol Oncol 2021; 32:e79. [PMID: 34431253 PMCID: PMC8550932 DOI: 10.3802/jgo.2021.32.e79] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/01/2021] [Accepted: 06/15/2021] [Indexed: 11/30/2022] Open
Abstract
Objective The antitumor effects of anti-PD-1 antibody against mismatch repair deficiency (MMR-D)-associated cancers have been reported. MMR-D is found in approximately 20%–30% of endometrial carcinomas (ECs) and frequently occurs due to MLH1 promoter hypermethylation (MLH1-PHM). ECs with MLH1-PHM are classified according to the molecular screening of Lynch syndrome (LS), but few detailed reports are available. The purpose of this study was to clarify the clinical features of EC with MLH1-PHM. Methods Immunohistochemistry of MMR proteins (MLH1, MSH2, MSH6, and PMS2) was performed on specimens from 527 ECs treated at our university hospital from 2003 to 2018. MLH1 methylation analysis was added to cases with MLH1/PMS2 loss. ECs were classified as follows: cases that retained MMR proteins as “MMR-proficient;” cases with MLH1/PMS2 loss and MLH1-PHM as “met-EC;” and cases with other MMR protein loss and MLH1/PMS2 loss without MLH1-PHM as “suspected-LS.” The clinical features, including long-term prognosis, of each group, were analyzed. Results Accordingly, 419 (79.5%), 65 (12.3%), and 43 (8.2%) cases were categorized as “MMR-proficient,” “suspected-LS,” and “met-EC,” respectively. Significantly, “met-EC” had a lower proportion of grade 1 tumors (37.5%) and a higher proportion of stage III/IV tumors (37.2%) than the other groups. The overall and progression-free survival of “met-EC” were significantly worse than those of “suspected-LS” in all cases. Conclusion In ECs with MMR-D, “met-ECs” were a subgroup with a poorer prognosis than “suspected-LS.” “Met-ECs” would be the main target for anti-PD-1 antibody treatment, and its clinical susceptibility should be verified individually.
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Affiliation(s)
- Enami Kaneko
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Akita, Japan.
| | - Naoki Sato
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tae Sugawara
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Akita, Japan
| | - Aya Noto
- Department of Obstetrics and Gynecology, Akita Kousei Medical Center, Akita, Japan
| | - Kazue Takahashi
- Department of Obstetrics and Gynecology, Hiraka General Hospital, Akita, Japan
| | - Kenichi Makino
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yukihiro Terada
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Akita, Japan
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Diagnosis of Lynch Syndrome and Strategies to Distinguish Lynch-Related Tumors from Sporadic MSI/dMMR Tumors. Cancers (Basel) 2021; 13:cancers13030467. [PMID: 33530449 PMCID: PMC7865821 DOI: 10.3390/cancers13030467] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Microsatellite instability (MSI) is a hallmark of Lynch syndrome (LS)-related tumors but is not specific, as most of MSI/mismatch repair-deficient (dMMR) tumors are sporadic. Therefore, the identification of MSI/dMMR requires additional diagnostic tools to identify LS. In this review, we address the hallmarks of LS and present recent advances in diagnostic and screening strategies to identify LS patients. We also discuss the pitfalls associated with current strategies, which should be taken into account in order to improve the diagnosis of LS. Abstract Microsatellite instability (MSI) is a hallmark of Lynch syndrome (LS)-related tumors but is not specific to it, as approximately 80% of MSI/mismatch repair-deficient (dMMR) tumors are sporadic. Methods leading to the diagnosis of LS have considerably evolved in recent years and so have tumoral tests for LS screening and for the discrimination of LS-related to MSI-sporadic tumors. In this review, we address the hallmarks of LS, including the clinical, histopathological, and molecular features. We present recent advances in diagnostic and screening strategies to identify LS patients. We also discuss the pitfalls associated with the current strategies, which should be taken into account to improve the diagnosis of LS and avoid inappropriate clinical management.
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Gallon R, Gawthorpe P, Phelps RL, Hayes C, Borthwick GM, Santibanez-Koref M, Jackson MS, Burn J. How Should We Test for Lynch Syndrome? A Review of Current Guidelines and Future Strategies. Cancers (Basel) 2021; 13:406. [PMID: 33499123 PMCID: PMC7865939 DOI: 10.3390/cancers13030406] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 12/13/2022] Open
Abstract
International guidelines for the diagnosis of Lynch syndrome (LS) recommend molecular screening of colorectal cancers (CRCs) to identify patients for germline mismatch repair (MMR) gene testing. As our understanding of the LS phenotype and diagnostic technologies have advanced, there is a need to review these guidelines and new screening opportunities. We discuss the barriers to implementation of current guidelines, as well as guideline limitations, and highlight new technologies and knowledge that may address these. We also discuss alternative screening strategies to increase the rate of LS diagnoses. In particular, the focus of current guidance on CRCs means that approximately half of Lynch-spectrum tumours occurring in unknown male LS carriers, and only one-third in female LS carriers, will trigger testing for LS. There is increasing pressure to expand guidelines to include molecular screening of endometrial cancers, the most frequent cancer in female LS carriers. Furthermore, we collate the evidence to support MMR deficiency testing of other Lynch-spectrum tumours to screen for LS. However, a reliance on tumour tissue limits preoperative testing and, therefore, diagnosis prior to malignancy. The recent successes of functional assays to detect microsatellite instability or MMR deficiency in non-neoplastic tissues suggest that future diagnostic pipelines could become independent of tumour tissue.
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Affiliation(s)
| | | | | | | | | | | | | | - John Burn
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE1 3BZ, UK; (P.G.); (R.L.P.); (C.H.); (G.M.B.); (M.S.-K.); (M.S.J.)
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12
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Kim SR, Tone A, Kim RH, Cesari M, Clarke BA, Eiriksson L, Hart T, Aronson M, Holter S, Lytwyn A, Maganti M, Oldfield L, Gallinger S, Bernardini MQ, Oza AM, Djordjevic B, Lerner‐Ellis J, Van de Laar E, Vicus D, Pugh TJ, Pollett A, Ferguson SE. Performance characteristics of screening strategies to identify Lynch syndrome in women with ovarian cancer. Cancer 2020; 126:4886-4894. [PMID: 32809219 PMCID: PMC7693219 DOI: 10.1002/cncr.33144] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND For women with ovarian cancer (OC), the optimal screening strategy to identify Lynch syndrome (LS) has not been determined. In the current study, the authors compared the performance characteristics of various strategies combining mismatch repair (MMR) immunohistochemistry (IHC), microsatellite instability testing (MSI), and family history for the detection of LS. METHODS Women with nonserous and/or nonmucinous ovarian cancer were recruited prospectively from 3 cancer centers in Ontario, Canada. All underwent germline testing for LS and completed a family history assessment. Tumors were assessed using MMR IHC and MSI. The sensitivity, specificity, and positive and negative predictive values of screening strategies were compared with the gold standard of a germline result. RESULTS Of 215 women, germline data were available for 189 (88%); 13 women (7%) had pathogenic germline variants with 7 women with mutS homolog 6 (MSH6); 3 women with mutL homolog 1 (MLH1); 2 women with PMS1 homolog 2, mismatch repair system component (PMS2); and 1 woman with mutS homolog 2 (MSH2). A total of 28 women had MMR-deficient tumors (13%); of these, 11 had pathogenic variants (39%). Sequential IHC (with MLH1 promoter methylation analysis on MLH1-deficient tumors) followed by MSI for nonmethylated and/or MMR-intact patients was the most sensitive (92.3%; 95% confidence interval, 64%-99.8%) and specific (97.7%; 95% confidence interval, 94.2%-99.4%) approach, missing 1 case of LS. IHC with MLH1 promoter methylation analysis missed 2 patients of LS. Family history was found to have the lowest sensitivity at 55%. CONCLUSIONS Sequential IHC (with MLH1 promoter methylation analysis) followed by MSI was found to be most sensitive. However, IHC with MLH1 promoter methylation analysis also performed well and is likely more cost-effective and efficient in the clinical setting. The pretest probability of LS is high in patients with MMR deficiency and warrants universal screening for LS.
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Affiliation(s)
- Soyoun Rachel Kim
- Division of Gynecologic OncologyPrincess Margaret Cancer Centre, University Health NetworkSinai Health SystemsTorontoOntarioCanada
- Department of Obstetrics and GynaecologyUniversity of TorontoTorontoOntarioCanada
| | - Alicia Tone
- Division of Gynecologic OncologyPrincess Margaret Cancer Centre, University Health NetworkSinai Health SystemsTorontoOntarioCanada
| | - Raymond H. Kim
- Fred A. Litwin Family Centre for Genetic MedicineUniversity Health NetworkTorontoOntarioCanada
- Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer RegistryMount Sinai HospitalTorontoOntarioCanada
- Division of Medical Oncology and HematologyPrincess Margaret Cancer Centre, University Health NetworkSinai Health SystemsTorontoOntarioCanada
| | - Matthew Cesari
- Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoOntarioCanada
| | - Blaise A. Clarke
- Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoOntarioCanada
| | - Lua Eiriksson
- Division of Gynecologic OncologyDepartment of Obstetrics and GynecologyJuravinski Cancer Centre, McMaster UniversityHamiltonOntarioCanada
| | - Tae Hart
- Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer RegistryMount Sinai HospitalTorontoOntarioCanada
- Department of PsychologyRyerson UniversityTorontoOntarioCanada
| | - Melyssa Aronson
- Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer RegistryMount Sinai HospitalTorontoOntarioCanada
| | - Spring Holter
- Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer RegistryMount Sinai HospitalTorontoOntarioCanada
| | - Alice Lytwyn
- Division of Anatomical PathologyDepartment of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Manjula Maganti
- Department of BiostatisticsPrincess Margaret Cancer Centre, University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Leslie Oldfield
- Department of Medical BiophysicsUniversity of TorontoTorontoOntarioCanada
| | - Steven Gallinger
- Division of General SurgeryPrincess Margaret Cancer Centre, University Health NetworkSinai Health SystemsTorontoOntarioCanada
| | - Marcus Q. Bernardini
- Division of Gynecologic OncologyPrincess Margaret Cancer Centre, University Health NetworkSinai Health SystemsTorontoOntarioCanada
- Department of Obstetrics and GynaecologyUniversity of TorontoTorontoOntarioCanada
| | - Amit M. Oza
- Division of Medical Oncology and HematologyPrincess Margaret Cancer Centre, University Health NetworkSinai Health SystemsTorontoOntarioCanada
| | - Bojana Djordjevic
- Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoOntarioCanada
| | - Jordan Lerner‐Ellis
- Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoOntarioCanada
| | - Emily Van de Laar
- Division of Gynecologic OncologyPrincess Margaret Cancer Centre, University Health NetworkSinai Health SystemsTorontoOntarioCanada
| | - Danielle Vicus
- Department of Obstetrics and GynaecologyUniversity of TorontoTorontoOntarioCanada
- Division of Gynecologic OncologyDepartment of Obstetrics and GynecologySunnybrook Health Sciences Centre, University of TorontoTorontoOntarioCanada
| | - Trevor J. Pugh
- Department of Medical BiophysicsUniversity of TorontoTorontoOntarioCanada
- Ontario Institute for Cancer ResearchUniversity Health NetworkTorontoOntarioCanada
- Princess Margaret Cancer CentreUniversity Health NetworkTorontoOntarioCanada
| | - Aaron Pollett
- Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoOntarioCanada
- Pathology and Laboratory MedicineMount Sinai HospitalTorontoOntarioCanada
| | - Sarah E. Ferguson
- Division of Gynecologic OncologyPrincess Margaret Cancer Centre, University Health NetworkSinai Health SystemsTorontoOntarioCanada
- Department of Obstetrics and GynaecologyUniversity of TorontoTorontoOntarioCanada
- Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer RegistryMount Sinai HospitalTorontoOntarioCanada
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13
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Dondi G, Coluccelli S, De Leo A, Ferrari S, Gruppioni E, Bovicelli A, Godino L, Coadă CA, Morganti AG, Giordano A, Santini D, Ceccarelli C, Turchetti D, De Iaco P, Perrone AM. An Analysis of Clinical, Surgical, Pathological and Molecular Characteristics of Endometrial Cancer According to Mismatch Repair Status. A Multidisciplinary Approach. Int J Mol Sci 2020; 21:E7188. [PMID: 33003368 PMCID: PMC7582893 DOI: 10.3390/ijms21197188] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 09/25/2020] [Accepted: 09/26/2020] [Indexed: 12/17/2022] Open
Abstract
Since 2016, our hospital has applied tumor testing with immunohistochemistry (IHC) in endometrial cancer in order to detect mutations of mismatch repair genes (MMR). All cases with MMR deficiency proteins expression are sent for genetic testing, except those with MLH1 protein deficiency, in which case genetic testing is performed if negative for promoter hypermethylation. The primary aim of this study was to investigate the ability of our algorithm to identify Lynch syndrome (LS). The Secondary aims were to investigate the relationship between MMR status and clinicopathological features and prognosis of primary endometrial cancer (EC). From January 2016 to December 2018, 239 patients with EC were retrospectively analyzed and subdivided according to MMR status. Patients were divided in three groups: MMR proficient, LS and Lynch-like cancer (LLC). LS was characterized by a lower age and BMI, more use of contraceptive and less use of hormonal replacement therapy, nulliparity and a trend versus a better prognosis. LLC appeared more related to MMR proficient than LS and exhibited a more aggressive behavior. Our multidisciplinary approach permitted a correct diagnosis of germline mutation in patients with newly diagnosis EC and it confirmed clinicopathologic and prognostic characteristics of LS.
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Affiliation(s)
- Giulia Dondi
- Gynecologic Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, 40138 Bologna, Italy; (G.D.); (S.C.); (A.B.); (P.D.I.)
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy; (A.D.L.); (A.G.M.); (D.S.); (C.C.); (D.T.)
| | - Sara Coluccelli
- Gynecologic Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, 40138 Bologna, Italy; (G.D.); (S.C.); (A.B.); (P.D.I.)
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy; (A.D.L.); (A.G.M.); (D.S.); (C.C.); (D.T.)
- Center for Applied Biomedical Research, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy;
| | - Antonio De Leo
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy; (A.D.L.); (A.G.M.); (D.S.); (C.C.); (D.T.)
- Molecular Diagnostic Unit, Azienda USL Bologna, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40138 Bologna, Italy
| | - Simona Ferrari
- Unit of Medical Genetics, Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, University of Bologna, 40138 Bologna, Italy; (S.F.); (L.G.)
| | - Elisa Gruppioni
- Laboratory of Oncologic and Transplantation Molecular Pathology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40138 Bologna, Italy;
| | - Alessandro Bovicelli
- Gynecologic Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, 40138 Bologna, Italy; (G.D.); (S.C.); (A.B.); (P.D.I.)
| | - Lea Godino
- Unit of Medical Genetics, Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, University of Bologna, 40138 Bologna, Italy; (S.F.); (L.G.)
| | - Camelia Alexandra Coadă
- Center for Applied Biomedical Research, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy;
| | - Alessio Giuseppe Morganti
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy; (A.D.L.); (A.G.M.); (D.S.); (C.C.); (D.T.)
- Radiation Oncology Center, Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40138 Bologna, Italy
| | - Antonio Giordano
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA 19122, USA;
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
| | - Donatella Santini
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy; (A.D.L.); (A.G.M.); (D.S.); (C.C.); (D.T.)
- Pathology Unit Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, 40138 Bologna, Italy
| | - Claudio Ceccarelli
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy; (A.D.L.); (A.G.M.); (D.S.); (C.C.); (D.T.)
- Molecular Diagnostic Unit, Azienda USL Bologna, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40138 Bologna, Italy
| | - Daniela Turchetti
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy; (A.D.L.); (A.G.M.); (D.S.); (C.C.); (D.T.)
- Unit of Medical Genetics, Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, University of Bologna, 40138 Bologna, Italy; (S.F.); (L.G.)
| | - Pierandrea De Iaco
- Gynecologic Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, 40138 Bologna, Italy; (G.D.); (S.C.); (A.B.); (P.D.I.)
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy; (A.D.L.); (A.G.M.); (D.S.); (C.C.); (D.T.)
| | - Anna Myriam Perrone
- Gynecologic Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, 40138 Bologna, Italy; (G.D.); (S.C.); (A.B.); (P.D.I.)
- Centro di Studio e Ricerca delle Neoplasie Ginecologiche (CSR), University of Bologna, 40138 Bologna, Italy; (A.D.L.); (A.G.M.); (D.S.); (C.C.); (D.T.)
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Rosa RCA, Santis JO, Teixeira LA, Molfetta GA, Dos Santos JTT, Ribeiro VDS, Chahud F, Ribeiro-Silva A, Brunaldi MO, Silva WA, Ferraz VEDF. Lynch syndrome identification in a Brazilian cohort of endometrial cancer screened by a universal approach. Gynecol Oncol 2020; 159:229-238. [PMID: 32694065 DOI: 10.1016/j.ygyno.2020.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/07/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To report the frequency of Lynch syndrome (LS) in a cohort of patients from Southeast Brazil bearing endometrial cancer (EC), using a tumor screening universal approach. METHODS A total of 242 endometrial carcinomas were screened by immunohistochemistry (IHC) and microsatellite instability (MSI) for detection of DNA mismatch repair deficiency (dMMR). MLH1 methylation was assessed to identify sporadic cases. Patients with dMMR tumors were recruited for germline variant analysis by next-generation sequencing of the MLH1, MSH2, MSH6, PMS2, and EPCAM genes. RESULTS Ninety-three out of 242 tumors (38.5%) were classified as dMMR based on MSI and IHC results. Of these, 54 cases were selected for germline analysis, and 37/54 (68.5%) were available for sequencing. Ten patients (10/37, 27%) harbored germline pathogenic or likely pathogenic variants, most of them in the MSH6 gene (4/10, 40%). Seven variants of uncertain significance were found. Eight novel germline variants were identified. The LS prevalence in our cohort was of at least 4.1%. LS patients presented lower mean age at cancer diagnosis compared with patients diagnosed with sporadic EC. Individuals with dMMR tumors, without germline pathogenic variants detected in LS-genes ("Lynch-like" syndrome), had an intermediate mean age at cancer diagnosis between LS and sporadic cases. CONCLUSION This is the first report of the LS prevalence in EC screened by a universal approach in Brazil. Our findings contribute to a better understanding of the mutational landscape of this syndrome in Brazil, which is relevant for improved identification, genetic counseling, prevention and control of cancer in LS.
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Affiliation(s)
- Reginaldo Cruz Alves Rosa
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Regional Blood Center at University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Jessica Oliveira Santis
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Regional Blood Center at University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Lorena Alves Teixeira
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Greice Andreotti Molfetta
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Regional Blood Center at University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | | | - Vanessa Dos Santos Ribeiro
- Inter-institutional Doctoral Program in Nursing, Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, Brazil.
| | - Fernando Chahud
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Alfredo Ribeiro-Silva
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Mariângela Ottoboni Brunaldi
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Wilson Araújo Silva
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Regional Blood Center at University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Victor Evangelista de Faria Ferraz
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Center for Medical Genomics at Clinical Hospital of the Ribeirão Preto Medical School, University of São Paulo, Brazil.
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15
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Clinicopathological significance of deficient DNA mismatch repair and MLH1 promoter methylation in endometrioid endometrial carcinoma. Mod Pathol 2020; 33:1443-1452. [PMID: 32060377 DOI: 10.1038/s41379-020-0501-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 12/12/2022]
Abstract
The pathogenesis of DNA mismatch repair (MMR)-deficient endometrial carcinoma (EC) is driven by inactivating methylation or less frequently mutation of an MMR gene (MLH1, PMS2, MSH2, or MSH6). This study evaluated the prognostic and clinicopathologic differences between methylation-linked and nonmethylated MMR-deficient endometrioid ECs. We performed MMR immunohistochemistry and methylation-specific multiplex ligation-dependent probe amplification, and classified 682 unselected endometrioid ECs as MMR proficient (MMRp, n = 438) and MMR deficient (MMRd, n = 244), with the latter subcategorized as methylated (MMRd Met) and nonmethylated tumors. Loss of MMR protein expression was detected in 35.8% of the tumors as follows: MLH1 + PMS2 in 29.8%, PMS2 in 0.9%, MSH2 + MSH6 in 1.3%, MSH6 in 2.8%, and multiple abnormalities in 0.9%. Of the 244 MMRd cases, 76% were methylation-linked. MMR deficiency was associated with older age, high grade of differentiation (G3), advanced stage (II-IV), larger tumor size, abundant tumor-infiltrating lymphocytes, PD-L1 positivity in immune cells and combined positive score, wild-type p53, negative L1CAM, ARID1A loss, and type of adjuvant therapy. MMRd-Met phenotype correlated with older age and larger tumor size, and predicted diminished disease-specific survival in the whole cohort. In the MMRd subgroup, univariate analysis demonstrated an association between disease-specific survival and disease stage II-IV, high grade (G3), deep myometrial invasion, lymphovascular invasion, ER negativity, and L1CAM positivity. In conclusion, MMR methylation profile correlates with clinicopathologic characteristics of endometrioid EC, and MMRd-Met phenotype predicts lower disease-specific survival. MMR deficiency, but not MLH1 methylation status, correlates with T-cell inflammation and PD-L1 expression.
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16
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Gordhandas S, Kahn RM, Gamble C, Talukdar N, Maddy B, Baltich Nelson B, Askin G, Christos PJ, Holcomb K, Caputo TA, Chapman-Davis E, Frey MK. Clinicopathologic features of endometrial cancer with mismatch repair deficiency. Ecancermedicalscience 2020; 14:1061. [PMID: 32582376 PMCID: PMC7302890 DOI: 10.3332/ecancer.2020.1061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Indexed: 12/22/2022] Open
Abstract
The inclusion of DNA mismatch repair (MMR) evaluation as a standard of care for endometrial cancer management will result in a growing population of patients with MMR deficiency and negative germline Lynch syndrome testing (MMR-deficient). In this systematic review and study, the clinicopathologic features of endometrial cancer in patients with MMR-intact, MLH1 methylation positive, MMR-deficient or Lynch syndrome are evaluated. A systematic search of online databases between 1990 and 2018 identified studies of endometrial cancer patients with tumour testing (MMR protein immunohistochemistry or microsatellite instability) and germline assessment for Lynch syndrome. Extracted data included tumour testing, germline genetic testing, age, body mass index (BMI), family history, tumour stage, grade and histologic type. Associations between MMR-intact, MLH1 methylation positive, MMR-deficient and Lynch syndrome groups were analysed using descriptive statistics. The comprehensive search produced 4,400 publications, 29 met inclusion criteria. A total of 7,057 endometrial cancer cases were identified, 1,612 with abnormal immunohistochemistry, 977 with microsatellite instability. Nine-hundred patients underwent germline genetic testing, identifying 212 patients with Lynch syndrome. Patients in the Lynch syndrome and MMR-deficient groups were significantly younger than patients in the MMR-intact and MLH1 methylation positive groups. Patients with MMR-intact tumours had the highest BMI, followed by MMR-deficient, then Lynch syndrome. MMR-intact tumours were more likely to be grade I at diagnosis than other groups. Patients with Lynch syndrome and MMR-deficient tumours were less likely to have stage I disease as compared to patients with MMR-intact tumours. Endometrial cancer patients with MMR-deficient tumours have similar features to those with germline Lynch syndrome mutations, including age, grade, histology and stage. Even in the absence of a germline mutation, tumour evaluation for MMR status may have important clinical implications.
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Affiliation(s)
- Sushmita Gordhandas
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Ryan M Kahn
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Charlotte Gamble
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Nizam Talukdar
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Brandon Maddy
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Becky Baltich Nelson
- Department of Information Technologies and Services, Weill Cornell Medical College, New York, NY, USA
| | - Gulce Askin
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, USA
| | - Paul J Christos
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, USA
| | - Kevin Holcomb
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Thomas A Caputo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Eloise Chapman-Davis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Melissa K Frey
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
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17
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Wadee R, Grayson W. Identification of possible Lynch syndrome in endometrial carcinomas at a public hospital in South Africa. SOUTHERN AFRICAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY 2020. [DOI: 10.1080/20742835.2020.1745461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- R Wadee
- Department of Anatomical Pathology, School of Pathology, University of the Witwatersrand/National Health Laboratory Services (NHLS), Johannesburg, Republic of South Africa
| | - W Grayson
- AMPATH National Laboratories/Department of Anatomical Pathology, School of Pathology, University of the Witwatersrand, Johannesburg, Republic of South Africa
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18
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Saller J, Qin D, Felder S, Coppola D. Microsatellite Stable Colorectal Cancer With an Immunogenic Phenotype: Challenges in Diagnosis and Treatment. Clin Colorectal Cancer 2020; 19:123-131. [PMID: 32171644 DOI: 10.1016/j.clcc.2020.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 02/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with deficient microsatellite mismatch repair (dMMR) colorectal cancer (CRC) may respond to immune checkpoint inhibition (ICI), whereas patients with microsatellite-stable (MSS) CRC have not demonstrated response. However, a proportion of MSS tumors display histomorphologic features characteristic of dMMR tumors consistent with an increased antigenicity. Therefore, a subset of patients with CRC not currently receiving ICI treatment may derive benefit from ICI therapy. We review tumors in which the histologic features suggestive of dMMR were in disagreement with the DNA mismatch repair proteins obtained by immunohistochemistry (IHC). Possible causes of such disagreement are discussed. MATERIALS AND METHODS Three patients with CRC suggestive of histomorphologic immunogenicity underwent evaluation by IHC staining for mismatch repair (MMR) status, next-generation sequencing assays, and/or polymerase chain reaction. RESULTS Findings compatible with an immunogenic response were similarly observed in all patients. Case 1 highlighted the limiting factors inherent to IHC staining for MMR status: a biopsy initially interpreted as MSS was subsequently interpreted as being dMMR. Case 2 examined the challenges in reconciling histologic characteristics traditionally associated with dMMR CRCs but ultimately determined to be MSS. Case 3 examined the microsatellite instability of CRC resulting from MLH1-methylation and/or MSH6 mutation. CONCLUSIONS We demonstrated the challenges in establishing MMR status when confronted with conflicting results from histology, IHC, polymerase chain reaction, and next-generation sequencing. Given that dMMR status has been shown to be a biomarker for ICI responsiveness, the importance of accurate identification is critical.
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Affiliation(s)
- James Saller
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institution, Tampa, FL
| | - Dahui Qin
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institution, Tampa, FL
| | - Seth Felder
- Department of Gastrointestinal Surgery, H. Lee Moffitt Cancer Center and Research Institution, Tampa, FL
| | - Domenico Coppola
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institution, Tampa, FL; Florida Digestive Health Specialists, Brandenton, FL.
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Kahn RM, Gordhandas S, Maddy BP, Baltich Nelson B, Askin G, Christos PJ, Caputo TA, Chapman-Davis E, Holcomb K, Frey MK. Universal endometrial cancer tumor typing: How much has immunohistochemistry, microsatellite instability, and MLH1 methylation improved the diagnosis of Lynch syndrome across the population? Cancer 2019; 125:3172-3183. [PMID: 31150123 DOI: 10.1002/cncr.32203] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Universal tumor testing for defective DNA mismatch repair (MMR) is recommended for all women diagnosed with endometrial cancer to identify those with underlying Lynch syndrome. However, the effectiveness of these screening methods in identifying individuals with Lynch syndrome across the population has not been well studied. The aim of this study was to evaluate outcomes of MMR immunohistochemistry (IHC), mutL homolog 1 (MLH1) methylation, and microsatellite instability (MSI) analysis among patients with endometrial cancer. METHODS A complete systematic search of online databases (PubMed, EMBASE, MEDLINE, and the Cochrane Library) for 1990-2018 was performed. A DerSimonian-Laird random effects model meta-analysis was used to estimate the weighted prevalence of Lynch syndrome diagnoses. RESULTS The comprehensive search produced 4400 publications. Twenty-nine peer-reviewed studies met the inclusion criteria. Patients with endometrial cancer (n = 6649) were identified, and 206 (3%) were confirmed to have Lynch syndrome through germline genetic testing after positive universal tumor molecular screening. Among 5917 patients who underwent tumor IHC, 28% had abnormal staining. Among 3140 patients who underwent MSI analysis, 31% had MSI. Among patients with endometrial cancer, the weighted prevalence of Lynch syndrome germline mutations was 15% (95% confidence interval [CI], 11%-18%) with deficient IHC staining and 19% (95% CI, 13%-26%) with a positive MSI analysis. Among 1159 patients who exhibited a loss of MLH1 staining, 143 (13.7%) were found to be MLH1 methylation-negative among those who underwent methylation testing, and 32 demonstrated a germline MLH1 mutation (2.8% of all absent MLH1 staining cases and 22.4% of all MLH1 methylation-negative cases). Forty-three percent of patients with endometrial cancer who were diagnosed with Lynch syndrome via tumor typing would have been missed by family history-based screening alone. CONCLUSIONS Despite the widespread implementation of universal tumor testing in endometrial cancer, data regarding testing results remain limited. This study provides predictive values that will help practitioners to evaluate abnormal results in the context of Lynch syndrome and aid them in patient counseling.
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Affiliation(s)
- Ryan M Kahn
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
| | - Sushmita Gordhandas
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
| | - Brandon Paul Maddy
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
| | - Becky Baltich Nelson
- Department of Information Technologies and Services, Weill Cornell Medical College, New York, New York
| | - Gulce Askin
- Clinical and Translational Science Center, Department of Biostatistics and Epidemiology, Weill Cornell Medical College, New York, New York
| | - Paul J Christos
- Clinical and Translational Science Center, Department of Biostatistics and Epidemiology, Weill Cornell Medical College, New York, New York
| | - Thomas A Caputo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
| | - Eloise Chapman-Davis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
| | - Kevin Holcomb
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
| | - Melissa K Frey
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
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Mascarenhas L, Shanley S, Mitchell G, Spurdle AB, Macrae F, Pachter N, Buchanan DD, Ward RL, Fox S, Duxbury E, Driessen R, Boussioutas A. Current mismatch repair deficiency tumor testing practices and capabilities: A survey of Australian pathology providers. Asia Pac J Clin Oncol 2018; 14:417-425. [PMID: 30294856 DOI: 10.1111/ajco.13076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 06/17/2018] [Indexed: 12/13/2022]
Abstract
AIM & METHODS An electronic survey of the Royal College of Pathologists of Australasia accredited pathology services was conducted to assess Lynch syndrome tumor screening practices and to identify barriers and capabilities to screen newly diagnosed colorectal and endometrial tumors in Australia. RESULTS Australia lacks a national policy for universal mismatch repair-deficient (dMMR) testing of incident colorectal and endometrial tumors cases. Routine Lynch syndrome tumor screening program for colorectal and/or endometrial tumors was applied by 95% (37/39) of laboratories. Tumor dMMR screening methods varied; MMR protein immunohistochemistry (IHC) alone was undertaken by 77% of 39 laboratories, 18% performed both IHC and microsatellite instability testing, 5% did not have the capacity to perform in-house testing. For colorectal tumors, 47% (17/36) reported following a universal approach without age limit, 30% (11/36) tested only "red flag" cases; 6% (3/36) on clinician request only. For endometrial tumors, 37% (12/33) reported clinician request generated testing, 27% (9/33) were screening only "red flag" cases, and 12% (4/33) carried out universal screening without an age criteria. BRAF V600E mutation testing of colorectal tumors demonstrating aberrant MLH1 protein expression by IHC was the most common secondary tumor test, with 53% of laboratories performing the test; 15% of laboratories also applied the BRAF V600E test to endometrial tumors with aberrant MLH1 expression despite no evidence for its utility. Tumor testing for MLH1 promoter methylation was performed by less than 15% laboratories. CONCLUSION Although use of tumor screening for evidence of dMMR is widely available, protocols for its use in Australia vary widely. This national survey provides a snapshot of the current availability and practice of tumor dMMR screening and identifies the need for a uniform national testing policy.
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Affiliation(s)
- Lyon Mascarenhas
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Susan Shanley
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Gillian Mitchell
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Amanda B Spurdle
- Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Finlay Macrae
- Department of Colorectal Medicine and Genetics, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Nicholas Pachter
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia
- School of Medicine & Pharmacology, University of Western Australia, WA, Australia
| | - Daniel D Buchanan
- Colorectal Oncogenomics Group, Department of Clinical Pathology, The University of Melbourne, Parkville, Victoria, Australia
- University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
- Genomic Medicine and Family Cancer Clinic, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Robyn L Ward
- Office of Deputy Vice Chancellor (Research), University of Queensland, Brisbane, Queensland, Australia
| | - Stephen Fox
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | | | - Rebecca Driessen
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alex Boussioutas
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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Ta RM, Hecht JL, Lin DI. Discordant loss of mismatch repair proteins in advanced endometrial endometrioid carcinoma compared to paired primary uterine tumors. Gynecol Oncol 2018; 151:401-406. [PMID: 30340772 DOI: 10.1016/j.ygyno.2018.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 10/07/2018] [Accepted: 10/10/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE A subset of endometrial cancer is characterized by deficiencies in the mismatch repair (MMR) pathway. MMR testing is a well-established tool to screen for Lynch syndrome, but has also become a companion diagnostic test for immunotherapy. We compared the MMR status of primary and paired metastatic endometrial cancer to determine whether MMR deficiency can occur specifically in advanced endometrial cancer compared to primary tumor. METHODS Matched primary uterine and metastatic endometrioid adenocarcinoma from 2009 to 2018 at our institution were identified. PMS2 and MSH6 protein expression in metastatic and matched primary tumor was assessed using clinically validated immunohistochemistry methods for Lynch syndrome screening. MLH1 promoter hypermethylation and microsatellite instability (MSI) were performed in discordant cases. RESULTS 29 patients were identified with paired primary endometrial endometrioid adenocarcinoma and metastasis or recurrence after the original hysterectomy. Fourteen of 29 cases (48.2%, 14/29) were found to be MMR deficient at the metastatic or recurrent site. Two patients (6.9%, 2/29) showed discordant MMR status with PMS2 protein loss at the metastatic sites and intact expression in the primary uterine tumors. Both discordant cases exhibited abnormal subclonal loss at primary site and MLH1 promoter hypermethylation. High levels of microsatellite instability (MSI-H) was confirmed in one discordant metastatic site. CONCLUSION Advanced endometrial cancer can rarely (~7%) show somatic loss of MMR protein expression in recurrent or metastatic sites compared to matched paired primary tumor. MMR testing of recurrent or metastasis should be considered for guiding immunotherapy if primary uterine tumor exhibits abnormal subclonal MMR loss.
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Affiliation(s)
- Robert M Ta
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America
| | - Jonathan L Hecht
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America
| | - Douglas I Lin
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, United States of America.
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22
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Cory L, Morgan MA. Pathology Consultation for the Gynecologic Oncologist: What the Surgeon Wants to Know. Arch Pathol Lab Med 2018; 142:1503-1508. [PMID: 30133316 DOI: 10.5858/arpa.2018-0122-ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Clinical management of gynecologic malignancies is often multimodal. Pathologic diagnoses, patient-related factors, and disease-related factors all contribute to clinical decision making. OBJECTIVE.— To review the role of surgical pathology in treatment planning among women with gynecologic malignancies. DATA SOURCES.— An analysis of relevant literature (PubMed Plus [National Center for Biotechnology Information, Bethesda, Maryland] and Medline [Ovid, New York, New York]) and the authors' clinical practice experience were used. CONCLUSIONS.— Pathologic evaluation of gynecologic malignancies with traditional histopathology, assessment of genetic alterations, and identification of tumor biomarkers are critical to traditional treatment planning as well as for ongoing clinical trials.
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Affiliation(s)
- Lori Cory
- From the Division of Gynecologic Oncology, Hospital of the University of Pennsylvania, Philadelphia
| | - Mark A Morgan
- From the Division of Gynecologic Oncology, Hospital of the University of Pennsylvania, Philadelphia
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Importance of PCR-based Tumor Testing in the Evaluation of Lynch Syndrome-associated Endometrial Cancer. Adv Anat Pathol 2017; 24:372-378. [PMID: 28820751 DOI: 10.1097/pap.0000000000000169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Lynch syndrome (LS) is a hereditary cancer syndrome caused by a germline mutation in a DNA mismatch repair gene, usually MLH1, MSH2, MSH6, or PMS2. The most common cancers associated with LS are colorectal adenocarcinoma and endometrial carcinoma. Identification of women with LS-associated endometrial cancer is important, as these women and their affected siblings and children are at-risk of developing these same cancers. Germline testing of all endometrial cancer patients is not cost effective, and screening using young age of cancer diagnosis and/or presence of family history of syndrome-associated is underutilized and ineffective. Therefore, most groups now advocate for tumor tissue testing to screen for LS, with germline testing targeted to women with abnormal tissue testing results. Immunohistochemistry for MLH1, MSH2, MSH6, and PMS2 is used in many clinical laboratories for this tumor screening step, as immunohistochemistry is relatively inexpensive and is technically more accessible for smaller clinical labs. PCR-based tissue testing, whereas technically more challenging, does play an important role in the identification of these patients. MLH1 methylation analysis identifies women with tumor MLH1 loss who likely have sporadic endometrial cancer and do not need heightened cancer prevention surveillance. High levels of microsatellite instability have been identified in tumors with retained positive expression of mismatch repair proteins. Somatic sequencing of mismatch repair genes from tumor DNA, whereas not currently available in most clinical laboratories, is helpful in resolution of cases in which germline sequencing fails to identify a mutation in a mismatch repair gene. The tumor tissue testing approach can help to identify most women at-risk for germline mutations in a LS gene, but not all patients will be captured using this approach. Clinical suspicion can still play a pivotal role in accurately identifying a subset of these patients.
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Ritterhouse LL, Howitt BE. Molecular Pathology: Predictive, Prognostic, and Diagnostic Markers in Uterine Tumors. Surg Pathol Clin 2017; 9:405-26. [PMID: 27523969 DOI: 10.1016/j.path.2016.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article focuses on the diagnostic, prognostic, and predictive molecular biomarkers in uterine malignancies, in the context of morphologic diagnoses. The histologic classification of endometrial carcinomas is reviewed first, followed by the description and molecular classification of endometrial epithelial malignancies in the context of histologic classification. Taken together, the molecular and histologic classifications help clinicians to approach troublesome areas encountered in clinical practice and evaluate the utility of molecular alterations in the diagnosis and subclassification of endometrial carcinomas. Putative prognostic markers are reviewed. The use of molecular alterations and surrogate immunohistochemistry as prognostic and predictive markers is also discussed.
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Affiliation(s)
- Lauren L Ritterhouse
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Brooke E Howitt
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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25
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The current value of determining the mismatch repair status of colorectal cancer: A rationale for routine testing. Crit Rev Oncol Hematol 2017; 116:38-57. [PMID: 28693799 DOI: 10.1016/j.critrevonc.2017.05.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/02/2017] [Accepted: 05/15/2017] [Indexed: 02/08/2023] Open
Abstract
Colorectal Cancer (CRC) is the third most prevalent cancer in men and women. Up to 15% of CRCs display microsatellite instability (MSI). MSI is reflective of a deficient mismatch repair (MMR) system and is most commonly caused by hypermethylation of the MLH1 promoter. However, it may also be due to autosomal dominant constitutional mutations in DNA MMR, termed Lynch Syndrome. MSI may be diagnosed via polymerase chain reaction (PCR) or alternatively, immunohistochemistry (IHC) can identify MMR deficiency (dMMR). Many institutions now advocate universal tumor screening of CRC via either PCR for MSI or IHC for dMMR to guide Lynch Syndrome testing. The association of sporadic MSI with methylation of the MLH1 promoter and an activating BRAF mutation may offer further exclusion criteria for genetic testing. Aside from screening for Lynch syndrome, MMR testing is important because of its prognostic and therapeutic implications. Several studies have shown MSI CRCs exhibit different clinicopathological features and prognosis compared to microsatellite-stable (MSS) CRCs. For example, response to conventional chemotherapy has been reported to be less in MSI tumours. More recently, MSI tumours have been shown to be responsive to immune-checkpoint inhibition providing a novel therapeutic strategy. This provides a rationale for routine testing for MSI or dMMR in CRC.
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26
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Hanley KZ, Birdsong GG, Mosunjac MB. Recent Developments in Surgical Pathology of the Uterine Corpus. Arch Pathol Lab Med 2017; 141:528-541. [PMID: 28353387 DOI: 10.5858/arpa.2016-0284-sa] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There have been several updates recently on the classification of uterine tumors. Endometrial carcinomas have traditionally been divided into 2 types, but some are difficult to classify and do not fit readily into either of the currently recognized categories. The Cancer Genome Atlas Research Network has recently defined 4 new categories of endometrial cancer on the basis of mutational spectra, copy number alteration, and microsatellite instability, which might provide independent prognostic information beyond established risk factors. The Society of Gynecologic Oncology, moreover, now recommends systematic screening of every patient with endometrial cancer for Lynch syndrome. The new definition of high-grade endometrial stromal sarcoma disregards the number of mitotic figures as a primary diagnostic criterion and instead specifies moderate atypia still resembling stromal origin but lacking the pleomorphism of undifferentiated uterine sarcoma; these tumors also harbor a JAZF1-SUZ12 gene rearrangement. Mitotic count, atypia, and coagulative necrosis are the main histologic criteria that define leiomyosarcoma. Determining the type of necrosis can be very challenging in patients receiving various treatment modalities for symptomatic fibroids before myomectomy, since key histologic features of ischemic-type necrosis are often absent. Ancillary stains including p16, p53, MIB-1, trichrome, and reticulin may be helpful in tumors harboring necrosis that is difficult to classify. Minimally invasive gynecologic surgeries have introduced histologic artifacts that complicate the diagnosis. It is essential to recognize these as procedure-related artifacts to avoid upstaging tumors and triggering unnecessary adjuvant treatment.
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Affiliation(s)
| | | | - Marina B Mosunjac
- From the Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia (Dr Hanley); and the Department of Pathology and Laboratory Medicine, Grady Memorial Hospital, Atlanta, Georgia (Drs Birdsong and Mosunjac)
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Wang J, Han X, Sun Y. DNA methylation signatures in circulating cell-free DNA as biomarkers for the early detection of cancer. SCIENCE CHINA-LIFE SCIENCES 2017; 60:356-362. [DOI: 10.1007/s11427-016-0253-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/16/2016] [Indexed: 02/06/2023]
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Bruegl AS, Ring KL, Daniels M, Fellman BM, Urbauer DL, Broaddus RR. Clinical Challenges Associated with Universal Screening for Lynch Syndrome-Associated Endometrial Cancer. Cancer Prev Res (Phila) 2016; 10:108-115. [PMID: 27965287 DOI: 10.1158/1940-6207.capr-16-0219] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/21/2016] [Accepted: 11/29/2016] [Indexed: 01/12/2023]
Abstract
Universal testing for Lynch syndrome is now a routine component of the diagnostic work-up of endometrial cancer patients. The purpose of this study was to identify prospectively the barriers to universal screening based on a tissue testing approach [microsatellite instability (MSI) analysis, IHC for DNA mismatch repair proteins, and MLH1 methylation analysis]. Endometrial carcinoma patients (n = 213) prospectively underwent microsatellite instability and IHC testing for expression of DNA mismatch repair (MMR) proteins. Patients with low (MSI-L) or high (MSI-H) levels of tumor MSI or immunohistochemical loss of MLH1 (and absent MLH1 methylation), MSH2, MSH6, or PMS2 were referred to a genetic counselor for consideration of germline testing. Six discordances (3.1% of tested cases) between IHC and MSI were identified. Half of these exhibited heterogeneous immunohistochemical loss of MLH1/PMS2 and were microsatellite stable (MSS). Of the remaining cases, one was MSS with immunohistochemical loss of MSH6, one was MSS with immunohistochemical loss of MLH1/PMS2 and absent MLH1 promoter methylation, and one was MSI-H with intact expression of DNA MMR proteins. Four patients had MSI-L tumors with intact immunohistochemical protein expression; the clinical significance of MSI-L in endometrial cancer is unclear. Eight patients did not have germline mutations despite tissue testing suggesting Lynch syndrome. Including cases with insufficient tissue for testing and patients declining tissue or germline testing, we encountered significant barriers to universal screening in 13.6% of screened patients (29/213) that preclude designation of a tumor as sporadic or hereditary. Cancer Prev Res; 10(2); 108-15. ©2016 AACR.
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Affiliation(s)
- Amanda S Bruegl
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon.
| | - Kari L Ring
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia
| | - Molly Daniels
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bryan M Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diana L Urbauer
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Russell R Broaddus
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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29
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Clinicopathologic implications of DNA mismatch repair status in endometrial carcinomas. Gynecol Oncol 2016; 140:226-33. [DOI: 10.1016/j.ygyno.2015.11.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 11/24/2015] [Accepted: 11/27/2015] [Indexed: 01/11/2023]
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Sugawara T, Sato N, Shimizu D, Sato T, Makino K, Kito M, Tamura D, Kato A, Terada Y. Efficient screening strategy for Lynch syndrome in Japanese endometrial cancer. TOHOKU J EXP MED 2015; 235:117-25. [PMID: 25745978 DOI: 10.1620/tjem.235.117] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Lynch syndrome (LS) is an inherited disorder caused by a germline mutation in the DNA mismatch repair (MMR) genes and is associated with increased risk of various cancers, particularly colorectal cancer and endometrial cancer (EC). It is significant to identify LS in EC patients for prediction and prevention of the succeeding other associated cancers. However, useful LS screening guidelines for EC have not been established. The purpose of our study is to devise an efficient and practical screening strategy for LS in EC. We designed original criteria, named "APF criteria," with lenient terms (Age of onset < 50, or Personal or Family history of associated cancers) and applied it to unselected EC patients. We performed immunohistochemistry (IHC) and the methylation assay of MutL homolog 1 (MLH1) gene promoter using the tumors of patients who met our criteria, and thus selected "suspected LS" as the candidates for genetic analyses. Of 360 EC patients, 187 (51.9%) met the APF criteria, and the tumor specimens were available from 182 out of the 187 patients. IHC revealed that expression of at least one MMR protein was absent in cell nuclei of 54 (29.6%) tumors. Of 20 tumors lacking MLH1 protein expression, 14 cases were judged sporadic EC because of the hypermethylated MLH1 promoter. We thus selected 40 (11.1%) of 360 EC patients as "suspected LS." Our strategy that consists of clinical triage and the molecular analyses is expected to improve the screening efficiency and reduce the cost of LS identification in EC.
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Affiliation(s)
- Tae Sugawara
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Japan.
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Rutgers JKL. Update on pathology, staging and molecular pathology of endometrial (uterine corpus) adenocarcinoma. Future Oncol 2015; 11:3207-18. [PMID: 26551559 DOI: 10.2217/fon.15.262] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Endometrial carcinoma is comprised of two major groups: type I that is hormonally driven with a good prognosis and type II that is hormone independent with a poor prognosis. The two most common subtypes are endometrioid adenocarcinoma, the prototypic type I cancer, and uterine serous carcinoma, the prototypic type II cancer, each with their own distinct precursor lesion. The histologic type, as codified by the WHO Tumor Classification system, grade, and stage are used to guide treatment. There is an increasing interest in screening for familial risk factors, specifically Lynch syndrome. A molecular classification of endometrial cancers holds promise for future improvements in care.
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Affiliation(s)
- Joanne K L Rutgers
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
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32
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Tafe LJ. Targeted Next-Generation Sequencing for Hereditary Cancer Syndromes. J Mol Diagn 2015; 17:472-82. [DOI: 10.1016/j.jmoldx.2015.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 06/09/2015] [Accepted: 06/12/2015] [Indexed: 12/24/2022] Open
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Buchanan DD, Tan YY, Walsh MD, Clendenning M, Metcalf AM, Ferguson K, Arnold ST, Thompson BA, Lose FA, Parsons MT, Walters RJ, Pearson SA, Cummings M, Oehler MK, Blomfield PB, Quinn MA, Kirk JA, Stewart CJ, Obermair A, Young JP, Webb PM, Spurdle AB. Tumor mismatch repair immunohistochemistry and DNA MLH1 methylation testing of patients with endometrial cancer diagnosed at age younger than 60 years optimizes triage for population-level germline mismatch repair gene mutation testing. J Clin Oncol 2013; 32:90-100. [PMID: 24323032 DOI: 10.1200/jco.2013.51.2129] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Clinicopathologic data from a population-based endometrial cancer cohort, unselected for age or family history, were analyzed to determine the optimal scheme for identification of patients with germline mismatch repair (MMR) gene mutations. PATIENTS AND METHODS Endometrial cancers from 702 patients recruited into the Australian National Endometrial Cancer Study (ANECS) were tested for MMR protein expression using immunohistochemistry (IHC) and for MLH1 gene promoter methylation in MLH1-deficient cases. MMR mutation testing was performed on germline DNA of patients with MMR-protein deficient tumors. Prediction of germline mutation status was compared for combinations of tumor characteristics, age at diagnosis, and various clinical criteria (Amsterdam, Bethesda, Society of Gynecologic Oncology, ANECS). RESULTS Tumor MMR-protein deficiency was detected in 170 (24%) of 702 cases. Germline testing of 158 MMR-deficient cases identified 22 truncating mutations (3% of all cases) and four unclassified variants. Tumor MLH1 methylation was detected in 99 (89%) of 111 cases demonstrating MLH1/PMS2 IHC loss; all were germline MLH1 mutation negative. A combination of MMR IHC plus MLH1 methylation testing in women younger than 60 years of age at diagnosis provided the highest positive predictive value for the identification of mutation carriers at 46% versus ≤ 41% for any other criteria considered. CONCLUSION Population-level identification of patients with MMR mutation-positive endometrial cancer is optimized by stepwise testing for tumor MMR IHC loss in patients younger than 60 years, tumor MLH1 methylation in individuals with MLH1 IHC loss, and germline mutations in patients exhibiting loss of MSH6, MSH2, or PMS2 or loss of MLH1/PMS2 with absence of MLH1 methylation.
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Affiliation(s)
- Daniel D Buchanan
- Daniel D. Buchanan, Yen Y. Tan, Michael D. Walsh, Mark Clendenning, Alexander M. Metcalf, Kaltin Ferguson, Sven T. Arnold, Bryony A. Thompson, Felicity A. Lose, Michael T. Parsons, Rhiannon J. Walters, Sally-Ann Pearson, Joanne P. Young, Penelope M. Webb, and Amanda B. Spurdle, QIMR Berghofer Medical Research Institute, Herston; Yen Y. Tan and Andreas Obermair, University of Queensland School of Medicine, Brisbane; Margaret Cummings, University of Queensland Centre for Clinical Research, Herston, Queensland; Martin K. Oehler, Royal Adelaide Hospital, Adelaide, South Australia; Michael A. Quinn, Royal Women's Hospital, Melbourne, Victoria; Judy A. Kirk, Westmead Institute for Cancer Research, Westmead Millennium Institute, University of Sydney, Sydney, New South Wales; Colin J. Stewart, King Edward Memorial Hospital, Perth, Western Australia, Australia; and Penelope B. Blomfield, Royal Hobart Hospital, Hobart, Tasmania
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