Inherited pathogenic mutations in the mismatch repair (MMR) genes, MSH2, MLH1, MSH6, and PMS2 predispose to Lynch syndrome (LS). However, the finding of a variant or variants of uncertain significance (VUS) in affected family members complicates the risk assessment. Here, we describe a putative LS family carrying VUS in both MSH2 (c.2768T>A, p.Val923Glu) and MSH6 (c.3563G>A, p.Ser1188Asn). Two colorectal cancer (CRC) patients were studied for mutations and identified as carriers of both variants. In spite of a relatively high mean age of cancer onset (59.5 years) in the family, many CRC patients and the tumor pathological data suggested that the missense variation in MSH2, the more common susceptibility gene in LS, would be the predisposing alteration. However, MSH2 VUS was surprisingly found to be MMR proficient in an in vitro MMR assay and a tolerant alteration in silico. By supplying evidence that instead of MSH2 p.Val923Glu the MSH6 p.Ser1188Asn variant is completely MMR-deficient, the present study confirms the previous findings, and suggests that MSH6 (c.3563G>A, p.Ser1188Asn) is the pathogenic mutation in the family. Moreover, our results strongly support the strategy to functionally assess all identified VUS before predictive gene testing and genetic counseling are offered to a family.
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We thank Mikko Frilander for providing the HeLa cell line and Merja Salmitie for the preparation of 5′IDL1. Friedrik Wikman at Molecular Diagnostics at Skejby Hospital and Henrik Okkels at Clinical Biochemistry at Aalborg Hospital are acknowledged for their contributions to the molecular genetics analyses. Claus Fenger at Pathologic Department at Odense University Hospital is acknowledged for performing the immunohistochemical analyses. This study was supported by grants: Sigrid Juselius Foundation; European Research Council (2008-AdG-232635); Finnish Cancer Organisations, The Biocentrum Helsinki Organisation; The Research Foundation of the University of Helsinki and Kuopio Naturalists’ Society.
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