HNPCC & FAP SIMILARITIES

& DIFFERENCES
Elaine Whitfield
Colon Cancer
Colon cancer is the third most common
form of cancer and the second leading cause
of cancer-related death in the Western
world & causes 655,000 deaths worldwide
per year.
Lifetime risk in UK is 1 in 30
Hereditary in 5-10% of cases
HNPCC causes 5% of all colorectal cancer
FAP causes 1% of all colorectal cancer

Disease Characteristics
HNPCC
Germline mutation in
mismatch repair genes
Assoc with MSI
AD with reduced penetrance
~80% lifetime risk of colon
cancer
risk of endometrial, ovary,
stomach cancer
Ave age of diagnosis = 50s
Polyps rarely seen
Slow tumour initiation & rapid
progression


FAP
Germline mutation in APC
gene Tumour suppressor
Assoc with LOH
AD fully penetrant ~100%
lifetime risk of colon cancer if
untreated
CHRPE & soft tissue &
desmoid tumours
Ave age of diagnosis = 39
100s 1000s polyps
Rapid tumour initiation and
slow progression
Inheritance & Genes Responsible
HNPCC
Autosomal dominant inheritance with reduced
penetrance (80% colon, 60% endometrial lifetime risk)
Genes mutated MSH2 (60%), MLH1 (30%), MSH6
(5%) & PMS1 & PMS2 (<2%) all genes involved in
DNA mis-match repair, found on various chromosomes
100s mutations identified (233 in MLH1 majority
point mutations esp. missense, nonsense & splicing)
Cause cancer by allowing more mutations to accumulate

Inheritance & Genes Responsible
FAP
Autosomal dominant inheritance with ~100% penetrance of colon
cancer without surgery
Gene mutated- APC (Adenomatous Polyposis Coli) gene
tumour suppressor gene 5q22
Many different mutation identified most truncating (80%)
LOH for APC adenoma (cells partially escape cell cycle
control & divide adenoma), require further mutations in
oncogene such as RAS late adenoma, then DCC mutation
late stage adenoma, then p53 mutation cancer
APC mutations also recessive at the cellular level






Normal Protein Function
HNPCC
Mismatch repair pathway proteins
Identify and remove single nucleotide mismatches or
insertion and deletion loops
At least 5 proteins involved four of which can cause
HNPCC (MSH3 not involved in HNPCC)
Mlh1 dimerises with Pms2 to co-ordinate binding of
other proteins
Msh2 forms a heterodimer with either Msh6 or Msh3
which identifies the mismatches clamp model

Normal Protein Function
FAP
APC protein product is a tumour suppressor
APC forms a complex with glycogen synthase kinase
3b (GSK-3b) which targets -catenin a protein
involved in cell adhesion & signalling
APC protein maintains normal apoptosis and may
decrease cell proliferation through its regulation of
-catenin
Abnormal APC leads to high levels of cytosolic -
catenin which binds to transcription factors and may
activate oncogenes
Also contributes to chromosome stability
Disease Diagnosis
HNPCC
Diagnosis Amsterdam II criteria
3+ relatives with HNPCC related cancers
(1 who is a 1
st
degree)
2 successive generation affected
1+ diagnosed <50 yrs
Exclusion of FAP
78 % sensitivity


Disease Identification & Progression - MSI
HNPCC
Microsatellite Instability (MSI) or molecular testing
required for accurate diagnosis
Bethesda guidelines developed to identify individuals
whose tumours are candidates for MSI
MSI microsatellites are particularly susceptible to
acquiring errors when mismatch repair gene function is
impaired
Panel of 5 markers used: MSI high = >30% show
instability, MSI low <30% and MSI stable if 0% (more
markers can be used) also RER+ or RER-
Can perform MSI on polyp biopsy but limited material
and slightly lower rate of MSI (different markers for
different tissues) also lower MSI in endometrial
carcinomas

Microsatellite Instability

Mutation Screening
HNPCC
MLH1 & MSH2 account for 90% of mutations, MSH6 ~5%,
PMS1 & PMS2 <2%
Mutation scanning DGGE, SSCP, dHPLC or direct
sequencing. MLPA up to 5% MLH1 & 20% MSH2
mutations are deletions
Targeted sequencing if familial mutation known or if belong
to ethnic group characterised by high frequency of founder
mutations (Finnish, Danish, Ashkenazi)
Mutation specific database search to investigate pathogenicity
of sequence variation detected
Immunohistochemical analysis of mismatch repair proteins in
tumour can determine which gene is involved in the
pathogenesis by detecting protein expression use as first
screen?

Disease Diagnosis
FAP
Clinically diagnosed in an individual
with >100 colorectal adenomatous polyps
or <100 polyps and a relative with FAP
Other clinically diagnostic criteria
CHRPE, soft tissue tumours, desmoid
tumours

Molecular Diagnosis
FAP
Full gene sequencing will detect ~90% mutations
Del / Dup ~10% - MLPA
~80% of mutations are truncating so can use PTT for
mutation scanning
Hypermethylation of APC promoter additional
mechanism
Immunohistochemical assessment of APC protein
expression to detect APC status regardless of
mechanism of gene inactivation also suitable for
archival tumour material

Loss of Heterozygosity
Relies on individual being heterozygous for markers close to
APC locus & comparison between normal & tumour tissue
Genotype-Phenotype Correlations
HNPCC

MSH2 mutations
greater risk for
extracolonic tumours

MSH6 tumours low
MSI, later age of
onset

FAP
Intra-familial variation
depending on location of
mutation
5 & 3 & exon 9
mutations = Attenuated
FAP (fewer polyps &
later age of onset)
Codon 1309 earlier age
and more polyps
HNPCC Variants
Muir-Torre colon cancer & sebaceous skin
neoplasms MSH2 mutations more common than
MLH1
Turcot syndrome colorectal cancer in addition to
tumours of central nervous system (can be due to
MMR gene MLH1/ PMS2 or APC gene mutation)
Early-onset haematological malignancy, brain
tumours, HNPCC-associated tumours, and signs of
neurofibromatosis type 1 homozygous MMR gene
mutation MLH1, MSH2 PMS2 carrier
consanginous parents
FAP Variants
Attenuated FAP fewer polyps, later age of
onset
Turcot syndrome

Monitoring and Treatment
HNPCC
Colonoscopy every one to two years from age
of 20-25 or ten years before earliest diagnosis
in family
If colon cancer detected full colectomy is
recommended
Prophylactic removal of the uterus and
ovaries may be considered after childbearing
is complete
Monitoring and Treatment
FAP
Sigmoidoscopy (less invasive than
colonoscopy) every one to two years from
age ten to twelve
Annual colonoscopy once polyps detected
Colectomy once 20 to 30 adenomas have
occurred

MYH- Associated Polyposis

Phenotypically similar to FAP and attenuated FAP
but inherited in Autosomal Recessive manner
MYH MutY human homologue gene chr 1p32.1-
34.3
Occassionally biallelic mutations found in
individuals with no polyps
If no APC mutation is detected in FAP consider
MYH analysis of pedigree consistent with AR
inheritance?
1/50 carrier frequency - ?increased risk for carriers
Important for counselling purposes as siblings at
25% risk, whereas FAP & HNPCC 50% risk to all
first degree relatives

MYH- Associated Polyposis
MYH protein is a base excision repair glycosylase
involved in the repair of DNA damage
If MYH is dysfunctional can cause mutations in APC
& KRAS
Dutch study of 170 CC patients found MYH mutations
in 24% of APC & HNPCC mutation negative patients
referred for testing
All mutations point mutations, no rearrangements
detected by Southern blotting
High level of breast cancer in females 18%,
significantly higher than Dutch population risk
BRCA1 & 2 also involved in base excision repair
Additional References
European Journal of Human Genetics (2008) 16, 6272;
Kruger et al Homozygous PMS2 germline mutations in
two families with early-onset haematological
malignancy, brain tumours, HNPCC-associated
tumours, and signs of neurofibromatosis type 1
Clinical Chemistry 49:4 552561 (2003) Bonk et al
Matrix-assisted Laser Desorption/Ionization Time-of-
Flight Mass Spectrometry-based Detection of
Microsatellite Instabilities in Coding DNA Sequences: A
Novel Approach to Identify DNA-Mismatch Repair-
deficient Cancer Cells
Gene Tests