Hereditary nonpolyposis colorectal cancer
Hereditary nonpolyposis colorectal cancer is a hereditary predisposition to colon cancer.
HNPCC includes Lynch syndrome, an autosomal dominant genetic condition that is associated with a high risk of colon cancer and endometrial cancer, as well as ovarian, stomach, small intestine, hepatobiliary tract, upper urinary tract, brain, and skin cancers. The increased risk for these cancers is due to inherited genetic mutations that impair DNA mismatch repair. It is a type of cancer syndrome.
Other HNPCC conditions include Lynch-like syndrome, polymerase proofreading-associated polyposis and familial colorectal cancer type X.
Signs and symptoms
Risk of cancer
Lifetime risk and mean age at diagnosis for Lynch syndrome–associated cancers| Type of cancer | Lifetime risk | Mean age at diagnosis |
| Colorectal | 52-58 | 44-61 |
| Endometrial | 25-60 | 48-62 |
| Gastric | 6-13 | 56 |
| Ovarian | 4-12 | 42.5 |
In addition to the types of cancer found in the chart above, it is understood that Lynch syndrome also contributes to an increased risk of small bowel cancer, pancreatic cancer, ureter/renal pelvis cancer, biliary tract cancer, brain cancer, and sebaceous neoplasms. Increased risk of prostate cancer and breast cancer has also been associated with Lynch syndrome, although this relationship is not entirely understood.
Two-thirds of colon cancers occur in the proximal colon and common signs and symptoms include blood in the stool, diarrhea or constipation, and unintended weight loss. The mean age of colorectal cancer diagnosis is 44 for members of families that meet the Amsterdam criteria. The average age of diagnosis of endometrial cancer is about 60 years. Among women with HNPCC who have both colon and endometrial cancer, about half present first with endometrial cancer, making endometrial cancer the most common sentinel cancer in Lynch syndrome. The most common symptom of endometrial cancer is abnormal vaginal bleeding. In HNPCC, the mean age of diagnosis of gastric cancer is 56 years of age with intestinal-type adenocarcinoma being the most commonly reported pathology. HNPCC-associated ovarian cancers have an average age of diagnosis of 42.5 years old; approximately 30% are diagnosed before age 40.
Significant variation in the rate of cancer has been found depending on the mutation involved. Up to the age of 75 years the risks of different cancers by the mutations are in the table below.
| Gene | colorectal cancer risk | endometrial cancer risk | ovarian cancer risk | upper gastrointestinal cancer risk | urinary tract cancer risk | prostate cancer risk | brain tumor risk |
| MLH1 | 46% | 43% | 10% | 21% | 8% | 17% | 1% |
| MSH2 | 57% | 17% | 10% | 25% | 32% | 5% | n.a. |
| MSH6 | 15% | 46% | 13% | 7% | 11% | 18% | 1% |
Genetics
Lynch syndrome is inherited in an autosomal dominant fashion. The hallmark of Lynch syndrome is defective DNA mismatch repair, which causes an elevated rate of single nucleotide changes and microsatellite instability, also known as MSI-H. MSI is identifiable in cancer specimens in the pathology laboratory. Most cases result in changes in the lengths of dinucleotide repeats of the nucleobases cytosine and adenine.The 4 main genes involved in Lynch syndrome normally encode for proteins that form dimers to function:
- MLH1 protein dimerizes with PMS2 protein to form MutLα, which coordinates the binding of other proteins involved with mismatch repair like DNA helicase, single-stranded-DNA binding-protein, and DNA polymerases.
- MSH2 protein dimerizes with MSH6 protein, which identifies mismatches via a sliding clamp model, a protein for scanning for errors.
| OMIM name | Genes implicated in HNPCC | Frequency of mutations in HNPCC families | Locus | First publication |
| HNPCC1 | MSH2/''EPCAM | approximately 60% | 2p22 | Fishel 1993 |
| HNPCC2 | MLH1 | approximately 30% | 3p21 | Papadopoulos 1994 |
| HNPCC5 | MSH6 | 7-10% | 2p16 | Miyaki 1997 |
| HNPCC4 | PMS2 | relatively infrequent | 7p22 | Nicolaides 1994 |
| HNPCC3 | PMS1 | case report | 2q31-q33 | Nicolaides 1994 |
| HNPCC6 | TGFBR2 | case report | 3p22 | |
| HNPCC7 | MLH3 | disputed | 14q24.3 |
People with MSH6'' mutations are more likely to be Amsterdam criteria II-negative. The presentation with MSH6 is slightly different from with MLH1 and MSH2, and the term "MSH6 syndrome" has been used to describe this condition. In one study, the Bethesda guidelines were more sensitive than the Amsterdam Criteria in detecting it.
Up to 39% of families with mutations in a Lynch syndrome gene do not meet the Amsterdam criteria. Therefore, families found to have a deleterious mutation in a Lynch syndrome gene should be considered to have Lynch syndrome regardless of the extent of the family history. This also means that the Amsterdam criteria fail to identify many people who are at risk for Lynch syndrome. Improving the criteria for screening is an active area of research, as detailed in the Screening Strategies section of this article.
Most people with Lynch syndrome inherit the condition from a parent. However, due to incomplete penetrance, variable age of cancer diagnosis, cancer risk reduction, or early death, not all people with a Lynch syndrome gene mutation have a parent who had cancer. Some people develop HNPCC de-novo in a new generation, without inheriting the gene. These people are often only identified after developing early-life colon cancer. Parents with HNPCC have a 50% chance of passing the genetic mutation on to each child. It is also important to note, that deleterious mutation in one of MMR genes alone is not sufficient to cause cancer, but that rather further mutations in other tumour suppressor genes need to occur.
Diagnosis
A diagnosis of Lynch syndrome is applied to people with a germline DNA mutation in one of the MMR genes or the EPCAM gene, identified by genetic testing. Candidates for germline genetic testing can be identified by clinical criteria such as the Amsterdam Clinical Criteria and Bethesda Guidelines, or through tumor analysis by immunohistochemistry, or microsatellite instability testing. In the US, professional societies recommend testing every colon cancer for MSI or IHC as screening for Lynch syndrome, but this is not always performed because of cost and resource limitations. Genetic testing is commercially available and consists of a blood test.Immunohistochemistry
is a method that can be used to detect abnormal mismatch repair protein expression in tumours that are associated with Lynch syndrome. While it is not diagnostic of a Lynch syndrome, it can play a role in identifying people who should have germline testing. Two methods of implementation of IHC testing includes age-based testing and universal testing for all people. Currently, there is no widespread agreement regarding which screening method should be used. Age-based testing for IHC has been suggested in part due to cost-benefit analyses, whereas universal testing for all people with colorectal cancer ensures people with Lynch Syndrome are not missed. To address the costs, researchers are trying to predict MSI or IHC directly from the way the tumor looks under the microscope, without doing any molecular testing.Microsatellite instability
Mutations in DNA mismatch repair systems can lead to difficulty transmitting regions within the DNA which contain repeating patterns of two or three nucleotides, otherwise known as microsatellite instability. MSI is associated with alternate sized repetitive DNA sequences that are not present in the correlated germ line DNA resulting in 15-20% of colorectal cancers. MSI is identified through DNA extraction from both a tumor tissue sample and a normal tissue sample followed by PCR analysis of microsatellite regions. MSI analysis can be used to identify people who may have Lynch syndrome and direct them for further testing. One study noted that one-third of MSI colorectal cancers showed a low immunoscore, suggesting that tumor-infiltrating lymphocytes might be a good option for therapy for these patients. High numbers of tumor-infiltrating lymphocytes were related to better survival rates and treatment responses.Classification
Three major groups of MSI-H cancers can be recognized by histopathological criteria:- right-sided poorly differentiated cancers
- right-sided mucinous cancers
- adenocarcinomas in any location showing any measurable level of intraepithelial lymphocyte
In addition, HNPCC can be divided into Lynch syndrome I and Lynch syndrome II.
Screening
and genetic testing are recommended for families that meet the Amsterdam criteria, preferably before the onset of colon cancer.Colon cancer
Colonoscopies are recommended as a preventative method of surveillance for individuals who have Lynch syndrome, or LS-associated genes. Specifically, it is recommended that colonoscopies begin at ages 20–25 for MLH1 and MSH2 mutation carriers and 35 years for MSH6 and PMS2 mutation carriers. Colonoscopic surveillance should then be performed at a 1-2 year interval for Lynch Syndrome patients.
Endometrial/ovarian cancer
A transvaginal ultrasound with or without endometrial biopsy is recommended annually for ovarian and endometrial cancer screening. For women with Lynch syndrome, a yearly CA-125 blood test can be used to screen for ovarian cancer, however there is limited data on the efficacy of this test in reducing mortality.
Other cancers
There are also strategies for detecting other cancers early or reducing the chances of developing them that people with Lynch syndrome can discuss with their doctor, however, their effectiveness is not clear. These options include:
- Upper endoscopies to detect stomach and small bowel cancer every 3–5 years, starting at age 30 at the earliest
- Annual urinalysis to detect bladder cancer, starting at age 30 at the earliest
- Annual physical and neurological exams to detect cancer in the central nervous system, starting at age 25 at the earliest