Founder mutation in Lynch syndrome

El síndrome de Lynch es la más frecuente de las neoplasias colorrectales hereditarias. Se origina por mutaciones germinales deletéreas familia-específicas en los genes que codifican proteínas de reparación del ADN: MLH1 (homólogo humano de mutL), MSH2 y MSH6 (homólogo humano de mutS 2 y 6, respectivamente), PMS2 (homólogo humano de PMS1 2) y MUTYH (homólogo humano de la ADN-glycosilasa mutY). La mutación c.2252_2253delAA, p.Lys751Serfs*3 en el exón 19 del gen MLH1 segrega con un haplotipo descripto en la región norte de Italia y cuyo origen fue atribuido a un efecto fundador. Esta mutación co-segrega con características típicas del síndrome de Lynch, incluyendo afectación temprana y múltiples tumores primarios en el mismo individuo, una alta frecuencia de cáncer pancreático, elevada inestabilidad microsatelital y falta de expresión de PMS2. En el presente trabajo se comunica dicha mutación en una paciente argentina con adenocarcinoma endometroide de útero en cuya historia familiar existen antecedentes de cáncer de colon diagnosticado antes de los 50 años en familiares de primer grado, reuniendo los criterios de Ámsterdam I y síndrome de Lynch II. Los polimorfismos presentes en la paciente coinciden con el haplotipo descripto en una región del norte de Italia. El alto grado de patogenicidad asociada a esta mutación hace imprescindible el estudio de todos los integrantes de las familias con cáncer hereditario permitiendo el diagnóstico genético pre-sintomático, la instauración de tratamientos o conductas preventivas y su seguimientoLynch syndrome is the most frequent syndrome in hereditary colorectal cancer, a family-specific deleterious mutations in genes encoding DNA reparation proteins: MLH1 (mutL homolog 1), MSH2, MSH6 (mutS homolog 2 y 6, respectively), PMS2 (PMS1 homolog 2, mismatch repair system component) y MUTYH (mutY DNA glycosylase). The c.2252_2253delAA, p.Lys751Serfs*3 mutation in MLH1 gene segregates with a haplotype reported in the northern region of Italy and whose origin was attributed to a founder effect. This mutation co-segregates with typical characteristics of Lynch syndrome, including early age at onset and multiple primary tumors in the same individual, a high frequency of pancreatic cancer, high microsatellite instability and lack of PMS2 expression. This report describes a mutation in an Argentinian patient with endometrioid adenocarcinoma of uterus. Her first-degree relatives had a history of colon cancer diagnosed before 50 years, fulfilling the Amsterdam Criteria I and Lynch syndrome II. The high pathogenicity associated to this mutation makes necessary the study of all members from families with hereditary cancer, allowing pre-symptomatic genetic diagnosis, early assessment and the instauration of preventive treatments.Fil: Cajal, Andrea. Hospital Italiano. Instituto de Ciencias Básicas y Medicina Experimental; ArgentinaFil: Piñero, Tamara Alejandra. Hospital Italiano. Instituto de Ciencias Básicas y Medicina Experimental; ArgentinaFil: Verzura, Alicia. Hospital Italiano; ArgentinaFil: Santino, Juan Pablo. Hospital Italiano; ArgentinaFil: Solano, Angela Rosario. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Investigaciones Biomédicas. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Biomédicas; Argentina. Centro de Educación Médica e Investigaciones Clínicas “Norberto Quirno”; ArgentinaFil: Kalfayan, Pablo G.. Hospital Italiano; ArgentinaFil: Ferro, Fabiana Alejandra. Hospital Italiano; ArgentinaFil: Vaccaro, Carlos A.. Hospital Italiano; Argentin

Hereditary Cancer Program (ProCanHe): 21-years of experience at a referral registry in Argentina

Registries in South America were initiated in the early 90´s with thehelp of Henry T. Lynch. The Programa de Cancer Hereditario (Pro.Can.He), is a multidisciplinary program established in 1996 at theHospital Italiano, Argentina. The aim of the study is to update our 21-year experience to determine the applicability of genetic testshighlighting the most informative molecular findings in relation toLynch syndrome mostly.Materials and methods: Families undergoing genetic testing aftergenetic counselling between1996-2018 were included. Data were obtainedfrom a prospective IRB approved database. Clinicalepidemiologicaland molecular variables were analysed. Genetic testswere carried out after a genetic counselling session and obtainingthe informed consent of the patient.Molecular testingUntil 2015, the search for variants was carried out by PCR and Sangersequencing of exons and adjacent intronic regions of MLH1 andMSH2. Then, sequencing of MLH1/MSH2/MSH6/PMS2/EPCAM geneswas performed by NGS and large rearrangements were detected byMLPA. The variants were classified according to international databases.Variants with uncertain or unreported clinical significancewere analysed In-silico using the PolyPhen, SIFT and/or Human Splicingfinder 3.0 software.ResultsA total of 83 families (49 fulfilled Amsterdam Criteria [AC] and 34 BethesdaCriteria [BC]) were analysed. Pathogenic variants were foundin 26 out of 83 (31.3%) families, been 23 pathogenic and 3 likelypathogenic.Splice site and large rearrangements represented 19.2% (5/26) and11.5% (3/26) of the variants.23% (6/26) of them were originally describedin this series and 1 was a founding mutation from Piedmont,Italy. Affected genes include MSH2, MLH1, MSH6 and PMS2 (12, 11, 2and 1 cases respectively). Mutation detection rates in AC and BT familieswere 48.9% (N=24) and 5.9% (N=2), p<0.01. Among AC families,those with identified mutation had a lower median age of cancer onset and higher incidence of extra-CCR cancer than those withoutidentified mutations. Additionally, we have also studied other genesin patients with different clinical conditions included in the registry.We identified mutations in APC, MUTYH, BMPR1A, SMAD4, CDH1,BRCA1-2, CHEK2.ConclusionThe multidisciplinary approach and the international collaborationsallowed the correct implementation of the genetic tests. To ourknowledge, this study is the first Characterization of AC families accordingto genetic tests in South America. This allowed the identificationof AC families with different ages of onset and prevalence ofextra-CRC cancers, as well as several significant variant not previouslyreported in international databases.Fil: Piñero, Tamara Alejandra. Consejo Nacional de Investigaciones Cientificas y Tecnicas. Oficina de Coordinacion Administrativa Houssay. Instituto de Medicina Traslacional E Ingenieria Biomedica. - Hospital Italiano. Instituto de Medicina Traslacional E Ingenieria Biomedica. - Instituto Universitario Hospital Italiano de Buenos Aires. Instituto de Medicina Traslacional E Ingenieria Biomedica.; ArgentinaFil: Herrando, Ignacio. Hospital Italiano; ArgentinaFil: Kalfayan, Pablo Germán. Hospital Italiano; ArgentinaFil: Gonzales, M.. Hospital Italiano; ArgentinaFil: Ferro, A.. Hospital Italiano; ArgentinaFil: Santino, Juan Pablo. Hospital Italiano; ArgentinaFil: Cajal, R.. Consejo Nacional de Investigaciones Cientificas y Tecnicas. Oficina de Coordinacion Administrativa Houssay. Instituto de Medicina Traslacional E Ingenieria Biomedica. - Hospital Italiano. Instituto de Medicina Traslacional E Ingenieria Biomedica. - Instituto Universitario Hospital Italiano de Buenos Aires. Instituto de Medicina Traslacional E Ingenieria Biomedica.; ArgentinaFil: Falconi, D.. Hospital Italiano; ArgentinaFil: Guerrero, Gisella. Hospital Italiano; ArgentinaFil: Verzura, A.. Hospital Italiano; ArgentinaFil: Riggi, Maria. Hospital Italiano; ArgentinaFil: Church, James. No especifíca;Fil: Peltomäki, P.. No especifíca;Fil: Martins, Alexandra. No especifíca;Fil: Pavicic, Walter Hernan. Consejo Nacional de Investigaciones Cientificas y Tecnicas. Oficina de Coordinacion Administrativa Houssay. Instituto de Medicina Traslacional E Ingenieria Biomedica. - Hospital Italiano. Instituto de Medicina Traslacional E Ingenieria Biomedica. - Instituto Universitario Hospital Italiano de Buenos Aires. Instituto de Medicina Traslacional E Ingenieria Biomedica.; ArgentinaFil: Dominguez, M.. University of Oslo; NoruegaFil: Vaccaro, C.. Hospital Italiano; ArgentinaThe 3rd European Hereditary Tumour Group MeetingNiceFranciaEuropean Hereditary Tumour Group Meetin

Resonancia magnética e invasión vascular extramural en pacientes con cáncer rectal y metástasis hepáticas

Antecedentes. La invasión vascular extramural (IVE) en pacientes con cáncer rectal (CR) se asocia con tumores localmente avanzados siendo un factor de predicción independiente de recidiva local, recurrencia a distancia y pobre sobrevida global. Objetivo. Determinar la asociación entre IVE y metástasis hepáticas sincrónicas en pacientes con CR. Material y métodos. Se realizó un estudio de cohorte retrospectivo que incluyó una serie de pacientes con diagnóstico endoscópico e histológico de cáncer de recto medio e inferior a los cuales se les realizó un estudio de resonancia magnética (RM) para estatificación inicial desde enero de 2011 hasta enero de 2012 inclusive. A fin de evaluar la presencia o ausencia de metástasis hepáticas sincrónicas, se incluyeron únicamente a aquellos pacientes que habían realizado algún estudio por imágenes que evaluara el hígado durante 1 año posterior a la RM de inicio (enero de 2012 hasta enero de 2013 inclusive). Se realizó un análisis multivariado mediante regresión logística. Resultados. Se incluyeron 68 pacientes. Veinte pacientes desarrollaron metástasis hepáticas durante el período de observación (29,41%), de los cuales 15 presentaban signos de IVE por RM (75%). La incidencia de metástasis hepáticas sincrónicas tuvo una asociación marginalmente significativa con la presencia de IVE (RR 3,35, IC 95%: 1,0001-11,2187, P = 0,050). Conclusión. La presencia de IVE por RM es un factor de mal pronóstico dado que aumenta el riesgo de desarrollar metástasis hepáticas sincrónicas en pacientes con CR

Universal determination of microsatellite instability using BAT26 as a single marker in an Argentine colorectal cancer cohort

Microsatellite instability (MSI) is a hallmark tool for Lynch syndrome (LS) screening and a prognostic marker for sporadic colorectal cancer (CRC). In regions with limited resources and scarce CRC molecular characterization as South America, the implementation of universal MSI screening is under debate for both its purposes. We sought to estimate the frequency of BAT26 in colorectal adenocarcinomas and to determine associated clinical and histological features. Consecutive patients from a CRC registry were included. BAT26 determination was performed in all cases; if instability was found, immunohistochemistry (IHC) and BRAF mutation analyses were done, as appropriate. Differences were assessed by chi-squared or Fisher’s exact test, or by T test or Mann–Whitney. Multiple logistic regression was used to identify factors independently associated with BAT26-unstable tumors. We included 155 patients; mean age was 65.6 (SD 14.4) and 56.1% were male. The frequency of BAT26-unstable tumors was 22% (95% CI 15.7–29.3). Factors independently associated with BAT26-unstable tumors were right colon localization (OR 3.4, 95% CI 1.3–8.7), histological MSI features (OR 5.1, 95% CI 1.9–13.6) and Amsterdam criteria (OR 23.2, 95% CI 1.9–286.7). IHC was altered in 85.3% BAT26-unstable tumors and 70.6% lacked MLH1 expression; 47.8% of these harbored BRAF V600E mutation. We provide evidence to link the frequency of BAT26 to an increased diagnostic yield (up to 1.4-folds) of suspected LS cases in comparison to the revised Bethesda guidelines alone. In regions with limited resources, clinical and histological features associated with BAT26-unstable status could be useful to direct MSI screening in sporadic CRCs and may help guide clinical care and future research.Fil: González, María Laura. Hospital Italiano; ArgentinaFil: Causada Calo, Natalia. Hospital Italiano; Argentina. McMaster University; CanadáFil: Santino, Juan Pablo. Hospital Italiano; ArgentinaFil: Dominguez Valentin, Mev. The Norwegian Radium Hospital; NoruegaFil: Ferro, Fabiana Alejandra. Hospital Italiano; ArgentinaFil: Sammartino, Inés. Hospital Italiano; ArgentinaFil: Kalfayan, Pablo Germán. Hospital Italiano; ArgentinaFil: Verzura, Maria Alicia. Hospital Italiano; ArgentinaFil: Piñero, Tamara Lejandra. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Hospital Italiano; ArgentinaFil: Cajal, Andrea. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Hospital Italiano; ArgentinaFil: Pavicic, Walter Hernan. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Hospital Italiano; ArgentinaFil: Vaccaro, Carlos. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Hospital Italiano; Argentin

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)