Clin Genet 2011
Printed in Singapore. All rights reserved
© 2011 John Wiley & Sons A/S
De novo CDH1 mutation in a family
presenting with early-onset diffuse
Shah MA, Salo-Mullen E, Stadler Z, Ruggeri JM, Mirander M,
Pristyazhnyuk Y, Zhang L. De novo CDH1 mutation in a family
presenting with early-onset diffuse gastric cancer.
Clin Genet 2011. © John Wiley & Sons A/S, 2011
In this report, we describe the first concluded case of a de novo germline
mutation in CDH1 in a hereditary diffuse gastric cancer (HDGC) kindred.
The incident case was a woman with a personal history of Hodgkin’s
lymphoma and diffuse gastric cancer, who was then confirmed to have a
CDH1 mutation (c.1792 C>T (R598X)). The patient’s mother was found
to have the same CDH1 germline mutation; however, neither maternal
grandparent was found to carry the mutation, thus leading to a conclusion
that the proband’s mother’s mutation is of de novo origin. This case
highlights the importance of recognition of the HDGC syndrome and of
testing for CDH1 germline mutations in young individuals with diffuse
gastric cancer without a family history of the disease.
Conflict of interest
The authors confirm that there are no potential conflicts of interest
with this manuscript.
MA Shaha, E Salo-Mullenb,
Z Stadlera,b, JM Ruggeric,
M Mirandera, Y Pristyazhnyuka
and L Zhangc
aGastrointestinal Oncology Service,
bClinical Genetics Service, Department of
Medicine, andcDiagnostic Molecular
Genetics Laboratory, Department of
Pathology, Memorial Sloan-Kettering
Cancer Center, Weill Cornell Medical
College, New York, NY, USA
Key words: CDH1 – early-onset –
E-cadherin – diffuse gastric cancer –
Corresponding author: Manish A. Shah,
MD, Gastrointestinal Oncology, Division
of Hematology and Medical Oncology,
Weill Cornell Medical College, New York
Hospital, New York, NY 10021, USA.
Tel.: +1 646-962-2547;
fax: +1 646-962-1607;
Received 31 January 2011, revised and
accepted for publication 20 June 2011
Hereditary diffuse gastric cancer (HDGC) (OMIM
No. 137215) is an autosomal dominant genetic
predisposition syndrome caused by germline muta-
tions in the CDH1 gene (1, 2). E-cadherin, the
CDH1 gene product, is a calcium-dependent cell
membrane protein involved in cell–cell adhesion
and confers cell polarity (3). HDGC accounts for
1–3% of all gastric cancers (4, 5). CDH1 muta-
tions are associated with a cumulative risk for
diffuse gastric cancer, before the age of 75, of
40–67% for men and 63–83% for women (6,
7), in addition to increased risk of lobular
breast cancer and signet ring colon cancer (8).
Because of the inability to screen for early
diffuse gastric cancer, patients with germline
CDH1 mutations are recommended to undergo
risk-reducing prophylactic gastrectomy (8–10).
The CDH1 locus is 16q22.1, and is composed
of 16 exons spanning 100 kb of genomic DNA.
Germline mutations in CDH1 are identified in
30–40% of families clinically defined to have
HDGC by the International Gastric Cancer Link-
age Consortium (1, 8). Mutations have been found
in families of various ethnic backgrounds (7, 11).
To date, approximately 100 germline mutations,
including large deletions (12), in CDH1 have
been published (7, 11, 13). Additionally, a founder
mutation (2398delC), confirmed by haplotype
Shah et al.
analysis, has been identified in four families from
Newfoundland (7). At this time, CDH1 is the only
known gene associated with HDGC, and no reports
of de novo mutations in CDH1 have been pub-
lished. Herein, we report the first description of a
denovo CDH1 mutation in a woman whose daugh-
ter was diagnosed with early-onset diffuse gastric
The Memorial Sloan Kettering Cancer Cen-
ter (MSKCC) Early Onset and Familial Gas-
tric Cancer Registry (NCT00582257, www.clinical
trials.gov) was created to identify individuals with
gastric cancer at high risk for a familial predispo-
sition syndrome for gastric cancer. In this report,
the proband’s mother, maternal aunt, and maternal
grandmother were enrolled in the MSKCC Gastric
Cancer Registry. The proband and her maternal
grandfather had died prior to the family contacting
our center. This study was approved by the Institu-
tional Review Board of Memorial Sloan-Kettering
Mutation analysis of CDH1
Full gene sequencing of the CDH1 gene on
the proband and single amplicon CDH1 muta-
tion analysis on the probands mother and mater-
nal grandparents was performed at the Molecu-
lar Diagnostic Laboratory at City of Hope. Con-
firmation analysis for the presence or absence
of the familial CDH1 mutation (c.1792 C>T
(R598X)) in the proband’s mother, maternal grand-
parents, and maternal aunt was performed in
the Diagnostic Molecular Genetics Laboratory at
For confirmation analysis, peripheral blood sam-
ples were obtained from the proband’s mother,
maternal aunt, and her maternal grandparents.
Tumor tissue was also obtained from her mater-
nal grandfather’s gastroesophageal junction (GEJ)
adenocarcinoma. Genomic DNA was prepared
from 10 ml ethylenediaminetetraacetic acid blood
samples or from tumor tissue according to stan-
dard procedures. Exon 12 of the CDH1 gene was
analyzed for the c.1792 C>T (R598X) mutation.
The sequence of the forward primer (in intron 11)
is 5?-AGA CTT GGT CTG GTG GAA G-3?. The
sequence of the reverse primer (in intron 12) is 5?-
ATT GAA AGG TGG GGA TCT GG-3?. Each
polymerase chain reaction (PCR) reaction con-
tained 5 μl 10× Qiagen PCR buffer (containing
15 mM MgCl2), 1.5 unit HotStar Taq (Qiagen,
Gaithersburg MD), 2 μl 10 mM dNTPs (Invitro-
gen Co., San Diego, CA, Catalog number: 18427-
088), 4 μl 100 ng/μl primers (2 μl for each), 2 μl
genomic DNA (approximately 100 ng) and water
to make the final volume of 50 μl. Cycling condi-
tions were 95◦C for 5 min, 95◦C for 30 s (35×),
58◦C for 30 s (35×) and 72◦C for 30 s (35×)
with a final extension at 72◦C for 7 min (1×).
The PCR products were purified and subjected to
direct DNA sequencing analysis (BigDye Termi-
nator v3.1 Cycle Sequencing Kit and 3730 DNA
Analyzer, Applied Biosystems, Foster City, CA).
Paternity testing was performed in the Diagnostic
Molecular Pathology Laboratory at MSKCC using
microsatellite markers routinely employed for bone
marrow transplant engraftment studies [GenePrint
Fluorescent STR Multiplex – CSF1PO, TPOX,
TH01, vWA (Fluorescein), Cat# DC6301; Gene
Print Fluorescent STR Multiplex – Gamma STR
(Fluorescein) D16S539, D7S820, D13S317, D5S
818, Cat# DC6071; both kits were purchased from
Promega Corporation, Madison, WI]. PCR ampli-
fication and fragment analysis of STR markers
were performed according to the manufacturer’s
instructions. Markers were analyzed on an ABI
3730 DNA Analyzer and GeneMapper 4.0 soft-
ware (Applied Biosystems).
The family is a 24-member, four-generation
kindred with two mutation-positive individuals.
CDH1 full gene sequencing identified a germline
truncating mutation (c.1792 C>T (R598X)) in an
affected 25-year-old woman (proband) (Fig. 1).
This woman had a personal history of Hodgkin’s
lymphoma (syncytial variant nodular sclerosing
type) diagnosed at 14 years of age that was suc-
cessfully treated with combination chemotherapy
(adriamycin, cyclophosphamide, bleomycin, vin-
cristine, procarbazine, prednisone, and vinblastine)
and radiation to the chest, mediastinum, bilateral
supraclavicular, and bilateral neck regions (total
2100 cGy). She was subsequently diagnosed with
metastatic diffuse gastric carcinoma with signet
ring features at 25 years of age and died of this
disease at the age of 26 years.
The proband’s unaffected 50-year-old mother
was subsequently found to have the same CDH1
germline mutation as the proband upon single
De novo CDH1 mutation in an HDGC family
Small foci intra-
Fig. 1. CDH1 family pedigree.
amplicon analysis. Prophylactic gastrectomy was
performed, and surgical pathology revealed four
small foci of intramucosal signet ring adenocarci-
noma, 12 benign lymph nodes, chronic gastritis,
and gastric hyperplastic polyps; the depth of inva-
sion was to the intramucosal layer and the largest
single focus was 1 mm in size.
The proband’s 76-year-old maternal grandfather
tested negative for the familial CDH1 germline
mutation. He had a personal history of metastatic
GEJ adenocarcinoma diagnosed at 77 years of age
and a family history of esophageal cancer per
verbal report in a brother at age 76 years. Both
of these individuals had been cigarette or pipe
smokers. The proband’s maternal grandfather died
at age 77 years prior to the family joining the
MSKCC Gastric Cancer Registry.
The proband’s 73-year-old maternal grand-
mother and only maternal aunt also both tested
negative for the familial CDH1 mutation on sin-
gle amplicon analysis. The maternal aunt did have
a personal history of Wilms’ tumor diagnosed at
age 2 years per verbal report (Fig. 1).
De novo CDH1 mutation confirmation
The family history suggests that this familial
germline CDH1 mutation had occurred de novo
in the proband’s mother. Analysis of eight highly
polymorphic short tandem repeat (STR) markers
supported the claimed paternity between the
proband’s mother and her parents (Table 1). To
determine whether the mutation had occurred on
the maternal or paternal allele, we investigated sev-
eral single nucleotide polymorphisms (in Ensembl
database) located near the c. 1792 C>T (R598X)
mutation in the CDH1 gene. However, we could
not take advantage of these single nucleotide
Table 1. Results of genotype analysis using eight highly
aThe sizes (in bp) of both alleles of the corresponding STR
marker are shown for each person. The sizes of different marker
grandparents have identical allelic pattern for the D5S818 and
CSF1PO markers, and are therefore uninformative).
Shah et al.
Fig. 2. CDH1 mutation single amplicon sequencing analysis
for the proband’s mother, the proband’s maternal grandparents,
and the proband’s maternal grandfather’s gastroesophageal
polymorphisms (SNPs) because both parents were
homozygous at these locations (data not shown).
On the basis of the proband’s maternal grandfa-
ther’s personal and family history of GEJ adeno-
carcinoma and the concern for somatic mosaicism,
we performed CDH1 single amplicon analysis on
the proband’s maternal grandfather’s GEJ can-
cer tissue. The malignancy was negative for the
familial CDH1 mutation (Fig. 2). The proband’s
only maternal aunt tested negative for the famil-
ial CDH1 mutation (confirmed by single amplicon
testing at MSKCC). The proband’s only maternal
uncle did not undergo CDH1 genetic testing and
has since died at age 49 from non-cancer causes.
In this report, we describe the first case of a
concluded de novo mutation in the CDH1 gene
in a HDGC kindred. The familial CDH1 muta-
tion (c.1792C>T (R598X)) has been previously
described in two families (14, 15). In the cur-
rent family, this CDH1 mutation was initially
identified in a young woman with a personal his-
tory of Hodgkin’s lymphoma and diffuse gas-
tric cancer. The mother of this patient was also
found to have the CDH1 mutation, but neither
of the proband’s maternal grandparents had the
familial mutation. Paternity between the proband’s
mother and the maternal grandparents was con-
firmed. The proband’s maternal grandfather’s GEJ
adenocarcinoma was also negative for the familial
CDH1 mutation and thus the likelihood of somatic
mosaicism is reduced. These results lead to the
conclusion that the nonsense CDH1 germline
mutation identified in this proband and her mother
likely represents a de novo event in the proband’s
mother. The proband’s unaffected uncle died at the
age of 49 years and was not tested for the familial
CDH1 mutation prior to his passing, and there-
fore, germline mosaicism in one of the proband’s
maternal grandparents cannot be further excluded.
It is not clear whether the proband’s personal
history of Hodgkin’s lymphoma is related to her
germline CDH1 mutation. There has been one
previous report of a gastric lymphoma in the
setting of Helicobacter pylori infection reported
in a kindred with a germline CDH1 mutation (16);
however, there have been no previously reported
cases of Hodgkin’s lymphoma. The risk of a
second neoplasm following the treatment for
Hodgkin’s lymphoma is significant; as high as
5% for all survivors (17), and most frequently
include breast cancer, thyroid cancer, and bone or
soft tissue sarcoma, although gastric cancer has
also been reported (17, 18). The risk of secondary
malignancy is associated with increased dose of
mediastinal radiation (reviewed by Ng et al. (18)).
Radiation-induced genomic instability has been
showed to include DNA methylation (19), which
is a common mechanism of inactivation of the
CDH1 locus in CDH1 mutation carriers (20). It
is possible that the treatment the proband received
for her Hodgkin’s lymphoma may have resulted
in inactivation of CDH1, leading ultimately to
the initiation of her early-onset invasive diffuse
gastric adenocarcinoma. Tumor tissue from the
proband was unavailable to test this hypothesis. It
is notable that in Li-Fraumeni syndrome, another
rare cancer predisposition syndrome associated
with germline mutations within the p53 tumor
suppressor gene, an increased susceptibility to
secondary malignancies within prior radiotherapy
fields has been observed (21). This case suggests
that further assessment of the possible role of
radiation-induced carcinogenesis in patients with
HDGC is warranted.
To date, over 100 kindreds with CDH1 germline
mutations have been identified, and this kindred
is the first case of a concluded de novo CDH1
germline mutation to be reported. This suggests
that, similar to the BRCA1 and BRCA2 cancer
susceptibility genes, the rate of de novo muta-
tion in CDH1 is likely very low. In contrast, Li-
Fraumeni syndrome has a reported frequency of
de novo TP53 mutations of 7–20% (22). There are
numerous explanations for this difference, includ-
ing possibly a lack of recognition of HDGC as
De novo CDH1 mutation in an HDGC family Download full-text
a cancer predisposition syndrome and unfamiliar-
ity with criteria for CDH1 mutation analysis. The
most recent CDH1 testing criteria put forth by the
International Gastric Cancer Linkage Consortium
include: (i) two or more gastric cancer cases in the
family, with one being a confirmed diffuse gas-
tric cancer diagnosed before the age of 50 years;
(ii) three or more confirmed diffuse gastric can-
cers in first- or second-degree relatives, indepen-
dent of age; (iii) diffuse gastric cancer diagnosed
before the age of 40 years without additional fam-
ily history; and (iv) personal or family history
of diffuse gastric cancer and lobular breast can-
cer, with at least one diagnosed prior to the age
of 50 years (8). This finding further supports the
importance of testing young patients with diffuse
gastric cancer for germline CDH1 mutation, in
which the mutation detection rate is estimated to be
∼1–2% (23, 24), and highlights the significance
of the identification of CDH1 mutations in young
diffuse gastric cancer patients without an extended
family history of the disease.
In this kindred, the proband’s unaffected mother
also carried the familial CDH1 mutation, and was
confirmed to have evidence of signet ring cell
adenocarcinoma within the prophylactic gastrec-
tomy specimen. This finding, when considering
the proband’s history of early-onset metastatic
diffuse gastric cancer, also highlights the intra-
and inter-familial variability associated with CDH1
This work was supported by the DeGregorio Family Foundation
(MAS), FDA Orphan Products grant 1R01FD003755-01A1(MAS).
We would like to thank Ruben Bacares and Paulo Salazar in the
Department of Pathology for their technical assistance.
1. Caldas C, Carneiro F, Lynch HT, Yokota J, Wiesner GL,
Powell SM et al. Familial gastric cancer: overview and
guidelines for management. J Med Genet 1999: 36: 873–880.
2. Guilford P, Hopkins J, Harraway J, McLeod M, McLeod N,
Harawira P et al. E-cadherin germline mutations in familial
gastric cancer. Nature 1998: 392: 402–405.
3. Humar B, Guilford P. Hereditary diffuse gastric cancer: a
manifestation of lost cell polarity. Cancer Sci 2009: 100:
4. Lynch HT, Grady W, Suriano G, Huntsman D. Gastric cancer:
new genetic developments. J Surg Oncol 2005: 90: 114–133.
5. Oliveira C, Seruca R, Carneiro F. Genetics, pathology and
clinics of familial gastric cancer. Int J Surg Pathol 2006: 14:
6. Pharoah PD, Guilford P, Caldas C. Incidence of gastric cancer
and breast cancer in CDH1 (E-cadherin) mutation carriers from
hereditary diffuse gastric cancer families. Gastroenterology
2001: 121: 1348–1353.
7. Kaurah P, MacMillan A, Boyd N, Senz J, De Luca A, Chun N
et al. Founder and recurrent CDH1 mutations in families
with hereditary diffuse gastric cancer. JAMA 2007: 297:
8. Fitzgerald RC, Hardwick R, Huntsman D, Carneiro F, Guil-
ford P, Blair V et al. Hereditary diffuse gastric cancer: updated
consensus guidelines for clinical management and directions
for future research. J Med Genet 2010: 47: 436–444.
9. Huntsman DG, Carneiro F, Lewis FR, MacLeod PM,
Hayashi A, Monaghan KG et al. Early gastric cancer in young,
asymptomatic carriers of germ-line E-cadherin mutations. N
Engl J Med 2001: 344: 1904–1909.
10. Shaw D, Blair V, Framp A, Harawira P, McLeod M, Guil-
ford P et al. Chromoendoscopic surveillance in hereditary dif-
fuse gastric cancer: an alternative to prophylactic gastrectomy?
Gut 2005: 54: 461–468.
11. Brooks-Wilson AR, Kaurah P, Suriano G, Leach SD, Senz J,
Grehan N et al. Germline E-cadherin mutations in hereditary
diffuse gastric cancer: assessment of 42 new families and
review of genetic screening criteria. J Med Genet 2004: 41:
12. Oliveira C, Senz J, Kaurah P, Pinheiro H, Sanges R, Haegert A
et al. Germline CDH1 deletions in hereditary diffuse gastric
cancer families. Hum Mol Genet 2009: 18: 1545–1555.
13. Guilford P, Humar B, Blair V. Hereditary diffuse gastric
cancer: translation of CDH1 germline mutations into clinical
practice. Gastric Cancer 2010: 13: 1–10.
14. Gayther SA, Gorringe KL, Ramus SJ, Huntsman D,
Roviello F, Grehan N et al. Identification of germ-line E-
cadherin mutations in gastric cancer families of European
origin. Cancer Res 1998: 58: 4086–4089.
15. Humar B, Toro T, Graziano F, Muller H, Dobbie Z, Kwang-
Yang H et al. Novel germline CDH1 mutations in hereditary
diffuse gastric cancer families. Hum Mutat 2002: 19: 518–525.
16. Rodriguez-Sanjuan JC, Fontalba A, Mayorga M, Bordin MC,
Hyland SJ, Trugeda S et al. A novel mutation in the E-
cadherin gene in the first family with hereditary diffuse
gastric cancer reported in Spain. Eur J Surg Oncol 2006: 32:
17. Varady E, Deak B, Molnar ZS, Rosta A, Schneider T, Esik O.
Second malignancies after treatment for Hodgkin’s disease.
Leuk Lymphoma 2001: 42: 1275–1281.
18. Ng AK, Kenney LB, Gilbert ES, Travis LB. Secondary malig-
nancies across the age spectrum. Semin Radiat Oncol 2010:
19. Aypar U, Morgan WF, Baulch JE. Radiation-induced epige-
netic alterations after low and high LET irradiations. Mutat
Res 2010: 707: 24–33.
20. Oliveira C, Sousa S, Pinheiro H, Karam R, Bordeira-
Carrico R, Senz J et al. Quantification of epigenetic and
genetic 2nd hits in CDH1 during hereditary diffuse gastric
cancer syndrome progression. Gastroenterology 2009: 136:
21. Li FP, Fraumeni JF Jr, Mulvihill JJ et al. A cancer family
syndrome in twenty-four kindreds. Cancer Res 1988: 48:
22. Gonzalez KD, Buzin CH, Nolter KA, Gu D, Li W, Malkin D
et al. High frequency of de novo mutations in Li-Fraumeni
syndrome. J Med Genet 2009: 46: 689–693.
23. Corso G, Pedrazzani C, Pinheiro H, Fernandes E, Marrelli D,
Rinnovati C et al. E-cadherin genetic screening and clinico-
pathologic characteristics of early onset gastric cancer. Eur
J Cancer 2011: 47: 631–639.
24. Bacani JT, Soares M, Zwingerman R, di Nicola N, Senz J,
Riddell R et al. CDH1/E-cadherin germline mutations in early-
onset gastric cancer. J Med Genet 2006: 43: 867–872.