Performance of Lynch syndrome predictive models in quantifying the likelihood of germline mutations in patients with abnormal MLH1 immunoexpression


Lynch syndrome (LS) accounts for up to 4 % of all colorectal cancers (CRC). Detection of a pathogenic germline mutation in one of the mismatch repair genes is the definitive criterion for LS diagnosis, but it is time-consuming and expensive. Immunohistochemistry is the most sensitive prescreening test and its predictive value is very high for loss of expression of MSH2, MSH6, and (isolated) PMS2, but not for MLH1. We evaluated if LS predictive models have a role to improve the molecular testing algorithm in this specific setting by studying 38 individuals referred for molecular testing and who were subsequently shown to have loss of MLH1 immunoexpression in their tumors. For each proband we calculated a risk score, which represents the probability that the patient with CRC carries a pathogenic MLH1 germline mutation, using the PREMM1,2,6 and MMRpro predictive models. Of the 38 individuals, 18.4 % had a pathogenic MLH1 germline mutation. MMRpro performed better for the purpose of this study, presenting a AUC of 0.83 (95 % CI 0.67–0.9; P < 0.001) compared with a AUC of 0.68 (95 % CI 0.51–0.82, P = 0.09) for PREMM1,2,6. Considering a threshold of 5 %, MMRpro would eliminate unnecessary germline mutation analysis in a significant proportion of cases while keeping very high sensitivity. We conclude that MMRpro is useful to correctly predict who should be screened for a germline MLH1 gene mutation and propose an algorithm to improve the cost-effectiveness of LS diagnosis.

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  1. 1.

    Lynch HT, de la Chapelle A (2003) Hereditary colorectal cancer. New Engl J Med 348(10):919–932. doi:10.1056/NEJMra012242

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Chen S, Wang W, Lee S, Nafa K, Lee J, Romans K, Watson P, Gruber SB, Euhus D, Kinzler KW, Jass J, Gallinger S, Lindor NM, Casey G, Ellis N, Giardiello FM, Offit K, Parmigiani G, Colon Cancer Family R (2006) Prediction of germline mutations and cancer risk in the Lynch syndrome. JAMA 296(12):1479–1487. doi:10.1001/jama.296.12.1479

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Monteiro Santos EM, Valentin MD, Carneiro F, de Oliveira LP, de Oliveira Ferreira F, Junior SA, Nakagawa WT, Gomy I, de Faria Ferraz VE, da Silva Junior WA, Carraro DM, Rossi BM (2012) Predictive models for mutations in mismatch repair genes: implication for genetic counseling in developing countries. BMC Cancer 12:64. doi:10.1186/1471-2407-12-64

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Bronner CE, Baker SM, Morrison PT, Warren G, Smith LG, Lescoe MK, Kane M, Earabino C, Lipford J, Lindblom A et al (1994) Mutation in the DNA mismatch repair gene homologue hMLH1 is associated with hereditary non-polyposis colon cancer. Nature 368(6468):258–261. doi:10.1038/368258a0

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Leach FS, Nicolaides NC, Papadopoulos N, Liu B, Jen J, Parsons R, Peltomaki P, Sistonen P, Aaltonen LA, Nystrom-Lahti M et al (1993) Mutations of a mutS homolog in hereditary nonpolyposis colorectal cancer. Cell 75(6):1215–1225

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Peltomaki P (2003) Role of DNA mismatch repair defects in the pathogenesis of human cancer. J Clin Oncology 21(6):1174–1179

    CAS  Article  Google Scholar 

  7. 7.

    Balmana J, Balaguer F, Cervantes A, Arnold D, Group EGW (2013) Familial risk-colorectal cancer: ESMO Clinical Practice Guidelines. Ann Oncol 24(6):vi73–80. doi:10.1093/annonc/mdt209

    Google Scholar 

  8. 8.

    Vasen HF, Blanco I, Aktan-Collan K, Gopie JP, Alonso A, Aretz S, Bernstein I, Bertario L, Burn J, Capella G, Colas C, Engel C, Frayling IM, Genuardi M, Heinimann K, Hes FJ, Hodgson SV, Karagiannis JA, Lalloo F, Lindblom A, Mecklin JP, Moller P, Myrhoj T, Nagengast FM, Parc Y, Ponz de Leon M, Renkonen-Sinisalo L, Sampson JR, Stormorken A, Sijmons RH, Tejpar S, Thomas HJ, Rahner N, Wijnen JT, Jarvinen HJ, Moslein G, Mallorca G (2013) Revised guidelines for the clinical management of Lynch syndrome (HNPCC): recommendations by a group of European experts. Gut 62(6):812–823. doi:10.1136/gutjnl-2012-304356

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Dieumegard B, Grandjouan S, Sabourin JC, Le Bihan ML, Lefrere I, Bellefqih Pignon JP, Rougier P, Lasser P, Benard J, Couturier D, Bressac-de Paillerets B (2000) Extensive molecular screening for hereditary non-polyposis colorectal cancer. Br J Cancer 82(4):871–880. doi:10.1054/bjoc.1999.1014

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Jang E, Chung DC (2010) Hereditary colon cancer: lynch syndrome. Gut and liver 4(2):151–160. doi:10.5009/gnl.2010.4.2.151

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Shia J, Klimstra DS, Nafa K, Offit K, Guillem JG, Markowitz AJ, Gerald WL, Ellis NA (2005) Value of immunohistochemical detection of DNA mismatch repair proteins in predicting germline mutation in hereditary colorectal neoplasms. Am J Surg Pathol 29(1):96–104

    Article  PubMed  Google Scholar 

  12. 12.

    Shia J (2008) Immunohistochemistry versus microsatellite instability testing for screening colorectal cancer patients at risk for hereditary nonpolyposis colorectal cancer syndrome. Part I. The utility of immunohistochemistry. J Mol Diagn JMD 10(4):293–300. doi:10.2353/jmoldx.2008.080031

    Article  PubMed  Google Scholar 

  13. 13.

    Hampel H, Frankel WL, Martin E, Arnold M, Khanduja K, Kuebler P, Nakagawa H, Sotamaa K, Prior TW, Westman J, Panescu J, Fix D, Lockman J, Comeras I, de la Chapelle A (2005) Screening for the Lynch syndrome (hereditary nonpolyposis colorectal cancer). New Engl J Med 352(18):1851–1860. doi:10.1056/NEJMoa043146

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Kane MF, Loda M, Gaida GM, Lipman J, Mishra R, Goldman H, Jessup JM, Kolodner R (1997) Methylation of the hMLH1 promoter correlates with lack of expression of hMLH1 in sporadic colon tumors and mismatch repair-defective human tumor cell lines. Cancer Res 57(5):808–811

    CAS  PubMed  Google Scholar 

  15. 15.

    Parsons MT, Buchanan DD, Thompson B, Young JP, Spurdle AB (2012) Correlation of tumour BRAF mutations and MLH1 methylation with germline mismatch repair (MMR) gene mutation status: a literature review assessing utility of tumour features for MMR variant classification. J Med Genet 49(3):151–157. doi:10.1136/jmedgenet-2011-100714

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Freedman AN, Seminara D, Gail MH, Hartge P, Colditz GA, Ballard-Barbash R, Pfeiffer RM (2005) Cancer risk prediction models: a workshop on development, evaluation, and application. J Natl Cancer Inst 97(10):715–723. doi:10.1093/jnci/dji128

    Article  PubMed  Google Scholar 

  17. 17.

    Balmana J, Balaguer F, Castellvi-Bel S, Steyerberg EW, Andreu M, Llor X, Jover R, Castells A, Syngal S, Gastrointestinal Oncology Group of the Spanish Gastroenterological A (2008) Comparison of predictive models, clinical criteria and molecular tumour screening for the identification of patients with Lynch syndrome in a population-based cohort of colorectal cancer patients. J Med Genet 45(9):557–563. doi:10.1136/jmg.2008.059311

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Kastrinos F, Steyerberg EW, Balmana J, Mercado R, Gallinger S, Haile R, Casey G, Hopper JL, LeMarchand L, Lindor NM, Newcomb PA, Thibodeau SN, Syngal S, Colon Cancer Family R (2013) Comparison of the clinical prediction model PREMM(1,2,6) and molecular testing for the systematic identification of Lynch syndrome in colorectal cancer. Gut 62(2):272–279. doi:10.1136/gutjnl-2011-301265

    Article  PubMed  Google Scholar 

  19. 19.

    Win AK, Macinnis RJ, Dowty JG, Jenkins MA (2013) Criteria and prediction models for mismatch repair gene mutations: a review. J Med Genet 50(12):785–793. doi:10.1136/jmedgenet-2013-101803

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Pouchet CJ, Wong N, Chong G, Sheehan MJ, Schneider G, Rosen-Sheidley B, Foulkes W, Tischkowitz M (2009) A comparison of models used to predict MLH1, MSH2 and MSH6 mutation carriers. Ann Oncol 20(4):681–688. doi:10.1093/annonc/mdn686

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Khan O, Blanco A, Conrad P, Gulden C, Moss TZ, Olopade OI, Kupfer SS, Terdiman J (2011) Performance of Lynch syndrome predictive models in a multi-center US referral population. Am J Gastroenterol 106(10):1822–1827. doi:10.1038/ajg.2011.200 (quiz 1828)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Green RC, Parfrey PS, Woods MO, Younghusband HB (2009) Prediction of Lynch syndrome in consecutive patients with colorectal cancer. J Natl Cancer Inst 101(5):331–340. doi:10.1093/jnci/djn499

    Article  PubMed  Google Scholar 

  23. 23.

    Kastrinos F, Steyerberg EW, Mercado R, Balmana J, Holter S, Gallinger S, Siegmund KD, Church JM, Jenkins MA, Lindor NM, Thibodeau SN, Burbidge LA, Wenstrup RJ, Syngal S (2011) The PREMM(1,2,6) model predicts risk of MLH1, MSH2, and MSH6 germline mutations based on cancer history. Gastroenterology 140(1):73–81. doi:10.1053/j.gastro.2010.08.021

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Ramsoekh D, van Leerdam ME, Wagner A, Kuipers EJ, Steyerberg EW (2009) Mutation prediction models in Lynch syndrome: evaluation in a clinical genetic setting. J Med Genet 46(11):745–751. doi:10.1136/jmg.2009.066589

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Sehgal R, Sheahan K, O’Connell PR, Hanly AM, Martin ST, Winter DC (2014) Lynch syndrome: an updated review. Genes 5(3):497–507. doi:10.3390/genes5030497

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Buchanan DD, Rosty C, Clendenning M, Spurdle AB, Win AK (2014) Clinical problems of colorectal cancer and endometrial cancer cases with unknown cause of tumor mismatch repair deficiency (suspected Lynch syndrome). Appl Clin Genet 7:183–193. doi:10.2147/TACG.S48625

    PubMed  PubMed Central  Google Scholar 

  27. 27.

    Severin F, Stollenwerk B, Holinski-Feder E, Meyer E, Heinemann V, Giessen-Jung C, Rogowski W (2015) Economic evaluation of genetic screening for Lynch syndrome in Germany. Genet Med. doi:10.1038/gim.2014.190

    PubMed  Google Scholar 

  28. 28.

    Kastrinos F, Balmana J, Syngal S (2013) Prediction models in Lynch syndrome. Fam Cancer 12(2):217–228. doi:10.1007/s10689-013-9632-0

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for genetic/familial high-risk assessment: colorectal. Accessed 20 Nov 2015)

  30. 30.

    Grosse SD (2015) When is genomic testing cost-effective? testing for Lynch syndrome in patients with newly-diagnosed colorectal cancer and their relatives. Healthcare 3(4):860–878. doi:10.3390/healthcare3040860

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Ladabaum U, Wang G, Terdiman J, Blanco A, Kuppermann M, Boland CR, Ford J, Elkin E, Phillips KA (2011) Strategies to identify the Lynch syndrome among patients with colorectal cancer: a cost-effectiveness analysis. Ann Intern Med 155(2):69–79. doi:10.7326/0003-4819-155-2-201107190-00002

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Barzi A, Sadeghi S, Kattan MW, Meropol NJ (2015) Comparative effectiveness of screening strategies for Lynch syndrome. J Natl Cancer Inst 107(4). doi:10.1093/jnci/djv005

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This work was in part funded though Liga Portuguesa Contra o Cancro-Núcleo Regional do Norte (Research Scholarships to P. P. and M. P.).

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Correspondence to Manuel R. Teixeira.

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Cabreira, V., Pinto, C., Pinheiro, M. et al. Performance of Lynch syndrome predictive models in quantifying the likelihood of germline mutations in patients with abnormal MLH1 immunoexpression. Familial Cancer 16, 73–81 (2017).

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  • Lynch syndrome
  • MLH1
  • Lynch syndrome predictive models
  • Immunohistochemistry