Hereditary Colorectal Cancer Syndromes: Molecular Genetics and Precision Medicine

Optimizing genetic testing strategy for suspected attenuated adenomatous polyposis: effective solutions in public health systems

BACKGROUND

APC and MUTYH genes are key in hereditary attenuated adenomatous polyposis syndromes. Guidelines recommend genetic testing based on polyp count, often overlooking age despite its impact on polyp prevalence.

AIM

To enhance genetic testing strategies for suspected attenuated adenomatous polyposis by combining polyp count and age in a probability calculator.

METHODS

Retrospective study of adult patients referred to NGS genetic testing for suspected attenuated adenomatous polyposis (accumulated history of < 100 adenomas) (discovery cohort, N = 138). Data included age, adenoma count, and test results. A multivariable logistic regression model was developed to associate positive genetic test results with age and adenoma count. The model was externally validated with 259 patients from two tertiary hospitals in our region (validation cohort, N = 259).

RESULTS

In the discovery cohort, 13 (9.4%) patients had pathogenic mutations, being younger (OR:0.91, 95%CI 0.86-0.96) and having more adenomas (OR:1.08, 95%CI 1.04-1.13) compared to negative cases. The logistic regression model combining age and polyp count demonstrated an AUC of 0.92. Using a cutoff probability of 3.5%, the model achieved 100% sensitivity and 58% specificity in identifying positive cases. In the external validation, the model accurately predicted 14 out of 16 positive cases (88%). The remaining two positive cases were a patient with an AXIN2 mutation in heterozygosis, and a patient with a NTHL1 mutation in homozygosis. Performance evaluation of both hospitals yielded AUC values of 0.77 and 0.90.

CONCLUSIONS

Older individuals with fewer polyps are less likely have hereditary syndromes. Including age in genetic testing criteria can enhance patient selection and cost-effectiveness.

Transcriptomic profiling and bioinformatics-driven statistical prioritization of CRC biomarkers: A step toward precision oncology

Colorectal adenocarcinoma (COAD) is among the most common causes of cancer-related death globally. Early detection and targeted therapy depend on identifying key molecular biomarkers that drive tumor progression. The molecular heterogeneity of COAD demands robust computational strategies to improve the accuracy of biomarker discovery.

METHODS

We developed and implemented a comprehensive, multi-step bioinformatics and statistical pipeline to systematically prioritize clinically relevant biomarkers in COAD. This pipeline integrated differential gene expression analysis, protein-protein interaction (PPI) network construction, and functional enrichment analysis to identify key hub genes associated with tumor progression. We subsequently applied principal component analysis (PCA) and overall survival modeling to evaluate the diagnostic and prognostic relevance of these candidates. Receiver operating characteristic (ROC) curve analysis was used to assess their sensitivity and specificity. Finally, experimental validation of the prioritized hub genes was conducted via qPCR across three CRC cell lines (LoVo, HCT-116, and HT-29), confirming their upregulation and supporting their clinical potential.

RESULTS

Our integrative pipeline prioritized five key hub genes (CDH3, CXCL1, MMP1, MMP3, and TGFBI) as significantly upregulated in COAD tissues compared to normal controls. Functional enrichment analysis linked these genes to extracellular matrix degradation, epithelial-mesenchymal transition (EMT), inflammatory signaling, and tumor invasion, underscoring their roles in key oncogenic processes. Survival analysis revealed varying degrees of association with patient prognosis, most notably for CXCL1. Diagnostic performance, assessed by ROC analysis, yielded moderate AUC values (0.669-0.692), supporting their potential as biomarkers. Finally, qPCR validation across three CRC cell lines confirmed robust upregulation of all five genes, reinforcing their biological relevance in COAD progression.

CONCLUSION

Our study establishes a reproducible, integrative bioinformatics and statistical framework for the systematic identification of clinically actionable biomarkers in CRC. The five hub genes prioritized (CDH3, CXCL1, MMP1, MMP3, and TGFBI) demonstrated consistent diagnostic and prognostic value, offering a solid basis for the development of non-invasive molecular diagnostics and contributing to precision oncology.

The current status of care for families with Lynch syndrome in China

Lynch syndrome is one of the most common hereditary cancer predisposition syndromes, which is caused by germline pathogenic variants in mismatch repair genes. It is associated with increased risks of colorectal cancer, endometrial cancer and various other types of cancer. With the rapid development in economy, medicine and genetic tests technology in recent decades, China had achieved significant advancements in the screening, diagnosis and treatment of Lynch syndrome. However, there are still a lot of challenges remaining unresolved. The major challenges include inconsistent access to genetic tests and counseling, regional disparities in healthcare quality, and limited implementation of clinical guidelines. This review will focus on the Chinese current status in the screening of Lynch syndrome, cancer surveillance, preventive measures, patients' willingness to take genetic tests and share genetic information, insurance coverage of medical cost, and national collaboration. At the end, we also summarize the major current research themes in Lynch syndrome in China.

Endoscopic Screening and Surveillance of Gastrointestinal Cancer

Gastrointestinal (GI) cancer is a major health concern, contributing significantly to mortality rates in many regions, including Europe. It affects millions of people worldwide and leads to hundreds of thousands of deaths each year. Early detection and treatment through endoscopic methods play a vital role, providing less invasive and more affordable options compared to traditional surgical procedures. Targeted screening is vital for conditions such as Barrett's esophagus (BE), esophageal adenocarcinoma (EAC), gastric cancer (GC), ampullary carcinoma (AC), and colorectal cancer (CRC), particularly in high-risk populations. Endoscopic surveillance significantly reduces cancer incidence and improves survival rates, highlighting the importance of continuous advancements and updated guidelines to enhance screening efficacy and patient outcomes.

Hereditary colorectal cancer syndromes and inflammatory bowel disease: results from a registry-based study

PURPOSE

In this study, we investigated the progression of high-grade dysplasia (HGD)/CRC in patients with hereditary colorectal cancer syndromes (HCSS) and concomitant inflammatory bowel diseases (IBDs).

METHODS

We described the natural history of a series of patients with confirmed diagnosis of hereditary colorectal cancer syndromes (HCCSs) and concomitant IBDs who were referred to the Hereditary Digestive Tumors Registry at the Fondazione IRCCS Istituto Nazionale dei Tumori of Milan.

RESULTS

Between January 1989 and April 2024, among 450 patients with APC-associated polyposis and 1050 patients with Lynch syndrome (LS), we identified six patients with IBDs (five with UC, one with ileal penetrating CD) and concomitant HCCSs (five with LS, one with APC-associated polyposis). Three patients developed CRC (two patients with stage IIA, and one with stage IIIA); in one patient, CRC occurred over a median follow-up of 12 months after IBD diagnosis, while in two, both conditions were diagnosed simultaneously. The median age at initial diagnosis of CRC was 33 years (range 27-41). Five patients (83.3%) underwent surgical procedures (three colonic resections for carcinoma and two for other reasons). Most of them progressed to precancerous or cancerous colonic lesions at a young age. Notably, all patients with CRC had a diagnosis of UC.

CONCLUSION

IBD patients with coexistent HCCSs can develop early CRC onset at an advanced stage. These patients should be always referred to tertiary referral centers for strict surveillance programs and early surgical management of advanced colorectal neoplastic lesions. Noninvasive biomarkers of neoplastic changes are advocated to further improve the management of IBD patients with HCCSs.

Genetic predisposition to polyposis syndromes

Hereditary polyposis syndromes are significant contributors to colorectal cancer (CRC). These syndromes are characterized by the development of various types and numbers of polyps, distinct inheritance patterns, and extracolonic manifestations. This review explores these syndromes with a focus on their genetic characteristics. Advances in diagnostics, particularly the identification of pathogenic germline variants through massive sequencing technologies, have enhanced our understanding of the genetic alterations associated with polyp formation and CRC risk. Identifying pathogenic variants beyond traditional diagnostic criteria improves the management and surveillance of these syndromes. Genetic diagnosis not only refines patient treatment and surveillance, but also informs relatives of potential risks, enabling appropriate management. However, challenges persist in determining the pathogenicity of newly discovered mutations due to their low prevalence. This review covers hereditary polyposis syndromes, from well-established to newly recognized types, providing insights into their genetic landscapes and highlighting the need for tailored surveillance based on genotype.

Potential Utility of A Proliferation-Inducing Ligand (APRIL) in Colorectal Cancer

APRIL (A proliferation-inducing ligand) is a member of the tumor necrosis factor superfamily that is overexpressed in a variety of malignant tumors, including colorectal cancer (CRC). Its key physiological roles include inducing the immunoglobulin switch and ensuring plasmocyte survival. In terms of pathological roles, APRIL antagonism has been identified as a key target in autoimmune diseases and immunoglobulin disorders. As previously demonstrated, several inflammatory processes occur at the site of neoplastic initial stages, and their local symptoms are difficult to detect, particularly in the early stages. That is why we chose to study the current literature on APRIL's role in the development of colorectal cancer. The main objective of our research was to investigate the role of APRIL in cancer initiation and its usefulness in the detection and therapy of CRC. Interestingly, the findings conducted so far show that the selected protein has a significant potential as a CRC biomarker and treatment target. Importantly, based on its concentration, it is possible to identify CRC patients, but whether the lesion has a benign or malignant nature, indicating the possibility of rapid detection of an ongoing disease process.

Utility of Stool-Based Tests for Colorectal Cancer Detection: A Comprehensive Review

Colorectal cancer (CRC) is a significant global health issue where early detection is crucial for improving treatment outcomes and survival rates. This comprehensive review assesses the utility of stool-based tests in CRC screening, including traditional fecal occult blood tests (FOBT), both chemical (gFOBT) and immunochemical techniques (FIT), as well as multitarget stool DNA (mt-sDNA) as a novel and promising biomarker. The advancements, limitations and the impact of false positives and negatives of these methods are examined. The review analyzed various studies on current screening methods, focusing on laboratory tests and biomarkers. Findings indicate that while FIT and mt-sDNA tests offer enhanced sensitivity and specificity over traditional guaiac-based FOBT, they also come with higher costs and potential for increased false positives. FIT shows better patient adherence due to its ease to use, but incorrect usage and interpretation of FOBT can lead to significant diagnostic errors. In conclusion, despite the improvements in FOBT methods like FIT in CRC detection, careful consideration of each method's benefits and drawbacks is essential. Effective CRC screening programs should combine various methods tailored to specific population needs, aiming for early detection and reduced mortality rates.

Characteristics and Outcomes of Colorectal Cancer Patients Cared for by the Multidisciplinary Team in the Reggio Emilia Province, Italy

Colorectal cancer emerged as the third most prevalent malignancy worldwide, affecting nearly 2 million individuals in the year 2020. This study elucidates the pivotal role of a multidisciplinary team (MDT) in influencing the prognosis, as measured by relative survival rates, depending upon the stage and age. Cases recorded in an Italian Cancer Registry between 2017 and 2018 were included. Relative survival was reported at 1 and 3 years after diagnosis comparing MDT vs. no-MDT approaches. During the study period, 605 CRCs were recorded while 361 (59.7%) were taken care of by an MDT. Compared to no-MDT, MDT patients were younger with earlier stages and received more surgery. One year after diagnosis, survival was 78.7% (90% in MDT vs. 62% in no-MDT); stratifying by stage, in the MDT group there was no survival advantage for stage I (97.2% vs. 89.9%) and II (96.8% vs. 89.4%), but an advantage was observed for stage III (86.4% vs. 56.9%) and stage IV (63.7% vs. 27.4%). Similar values were observed at 3 years where a marked advantage was observed for stages III (69.9% vs. 35.1%) and IV (29.2% vs. 5.1%). The univariable analysis confirmed an excess risk in the no-MDT group (HR 2.6; 95% CI 2.0-3.3), also confirmed in the multivariable regression analysis (HR 2.0; 95% CI 1.5-2.5). Despite the increase in the number of MDT patients in 2018 (from 50% to 69%), this does not correspond to an improvement in outcome.

Molecular typing guiding treatment and prognosis of endometrial cancer

Genetic abnormalities, such asPTEN, PIK3CA,CTNNB1,ARID1A, andERBB2, which frequently occur in endometrial cancer (EC), are potential therapeutic targets. In 2013, integrated genomic analysis conducted by The Cancer Genome Atlas identified four molecular subtypes, including POLE ultra-mutated, microsatellite instability hypermutated, copy-number low, and copy-number high, which strongly correlate with prognosis. Surrogate markers-based molecular classification methods have been developed to make these molecular classifications accessible and affordable, achieving classification into POLEmut, mismatch repair deficient (MMRd), p53abn, and no specific molecular profile (NSMP) with normal p53 expression. Although POLEmut EC has aggressive pathologic features, there are few cases of advanced and/or recurrence. Therefore, the possibility of de-escalating adjuvant therapy can be considered. Additionally, immune checkpoint inhibitors (ICI) may be a candidate for treating advanced and recurrent POLEmut EC because of their high immunogenicity. MMRd EC shows an intermediate prognosis between those of POLEmut and p53abn EC. MMRd EC is generally characterized by high immunogenicity similar to POLEmut EC, suggesting that ICI can also be a potential therapeutic agent. Among the four molecular subtypes, p53abn EC has the worst prognosis. However, some p53abn tumors have the molecular hallmark of homologous recombination deficiency and could be treated with poly (ADP-ribose) polymerase inhibitors. In addition, some p53abn tumors overexpress the human epidermal growth factor receptor 2, which can also be a potential therapeutic target. NSMP EC are a heterogeneous population because they lack characteristic molecular biological features. Approximately half of the NSMP EC show high expression of estrogen receptor/progesterone receptor, suggesting the possibility of hormonal therapy. In addition, the PI3K/AKT/mTOR pathway frequently altered in EC may be a therapeutic target. This review summarizes the molecular biological characteristics and potential therapeutic agents in molecularly featured EC. Several clinical trials are in progress to stratify EC into molecular classifications and demonstrate the efficacy and safety of molecularly matched treatment and management strategies.

Genetic Predisposition to Colorectal Cancer: How Many and Which Genes to Test?

Colorectal cancer is one of the most common tumors, and genetic predisposition is one of the key risk factors in the development of this malignancy. Lynch syndrome and familial adenomatous polyposis are the best-known genetic diseases associated with hereditary colorectal cancer. However, some other genetic disorders confer an increased risk of colorectal cancer, such as Li-Fraumeni syndrome (TP53 gene), MUTYH-associated polyposis (MUTYH gene), Peutz-Jeghers syndrome (STK11 gene), Cowden syndrome (PTEN gene), and juvenile polyposis syndrome (BMPR1A and SMAD4 genes). Moreover, the recent advances in molecular techniques, in particular Next-Generation Sequencing, have led to the identification of many new genes involved in the predisposition to colorectal cancers, such as RPS20, POLE, POLD1, AXIN2, NTHL1, MSH3, RNF43 and GREM1. In this review, we summarized the past and more recent findings in the field of cancer predisposition genes, with insights into the role of the encoded proteins and into the associated genetic disorders. Furthermore, we discussed the possible clinical utility of genetic testing in terms of prevention protocols and therapeutic approaches.