GENES, CHROMOSOMES & CANCER 51:83–91 (2012)
Evidence for Breast Cancer as an Integral
Part of Lynch Syndrome
Nicole Buerki,1,2,3*†Lucienne Gautier,2,3†Michal Kovac,2,3†Giancarlo Marra,4Mauro Buser,2
Hansjakob Mueller,2,3and Karl Heinimann2,3*
1Departmentof Obstetricsand Gynecology ,Cantonal Hospitalof Liestal,Liestal,Switzerland
2Research Group HumanGenetics,Departmentof Biomedicine,Universityof Basel,Basel,Switzerland
3Divisionof Medical Genetics,University Children’s Hospital,Basel,Switzerland
4Institutefor Molecular Cancer Research,Universityof Zurich,Zurich,Switzerland
Lynch syndrome, an autosomal dominant cancer predisposition caused by mutations in DNA mismatch repair (MMR) genes,
mainly mainly mutL homolog 1, OMIM 120436 (MLH1) and mutS homolog 2, OMIM 609309 (MSH2), encompasses a tumor
spectrum including primarily gastrointestinal, endometrial, and ovarian cancer. This study aimed at clarifying the heavily
debated issue of breast cancer being part of Lynch syndrome. Detailed clinical data on cancer occurrence in Swiss female
MLH1/MSH2 mutation carriers were gathered, all available breast cancer specimens assessed for molecular evidence for
MMR deficiency (i.e., microsatellite instability (MSI), MMR protein expression, and somatic (epi)genetic MMR gene altera-
tions) and compiled with the scarce molecular data available from the literature. Seventy unrelated Swiss Lynch syndrome
families were investigated comprising 632 female family members at risk of which 92 were genetically verified mutation car-
riers (52 MLH1 and 40 MSH2). On contrast to endometrial and ovarian cancer, which occurred significantly more often and
at younger age in MLH1/MSH2 mutation carriers (median 50.5 and 49.0 years; P < 0.00001), overall cumulative breast can-
cer incidence closely mirrored the one in the Swiss population (56.5 years). Six (85.7%) of seven breast cancer specimens
available for molecular investigations displayed the hallmarks of MMR deficiency. Combined with data from the literature,
MSI was present in 26 (70.3%) of 37 and altered MMR protein expression in 16 (72.7%) of 22 breast cancer specimens
from MLH1/MSH2 mutation carriers. These findings, thus, provide strong molecular evidence for a pivotal role of MMR defi-
ciency in breast cancer development in Lynch syndrome.
C 2011 Wiley Periodicals, Inc.
Lynch syndrome, also known as hereditary
nonpolyposis colorectal cancer (CRC) syndrome,
is an autosomal dominantly inherited cancer pre-
disposition accounting for 2–5% of the total CRC
burden (Lynch et al., 2009).
General hallmarks for hereditary cancer predis-
position syndromes include young age of onset,
more than one primary cancer in one individual,
and multiple family members with the same or
related types of cancer. In Lynch syndrome, cri-
teria that are more specific have been developed
to help identify at-risk families. The original Am-
sterdam criteria were based on the occurrence of
CRC only (Vasen et al., 1991), while the modified
Amsterdam criteria (II) recognize the importance
of extracolonic cancers in identifying Lynch
syndrome families as well (Vasen et al., 1999).
However, these criteria may lack sensitivity, par-
ticularly in the case of small families or missing
family history information. The Bethesda criteria
have been developed to identify those individuals
whose tumors are candidates for microsatellite
instability (MSI) testing (Rodriguez-Bigas et al.,
guidelines, individuals diagnosed with CRC less
than age 50 years have been included into the
Revised Bethesda Guidelines (Umar et al., 2004).
In ?70% of Lynch syndrome families, a patho-
genic germ line mutation in one of four mismatch
repair (MMR) genes can be identified: mutL
homolog 1, OMIM 120436 (MLH1; about 50% of
all mutations), mutS homolog 2, OMIM 609309
(MSH2; 40%), mutS homolog 6, OMIM 600678
(MSH6; ?7–10%), and postmeiotic segregation
increased 2, OMIM 600259l (PMS2; fewer than
To increasethe sensitivityof these
Additional Supporting Information may be found in the online
version of this article.
Supported by: Krebsliga beider Basel, the Zentralschweizer
Krebsliga, and Oncosuisse.
yThese authors equally contributed to this work.
*Correspondence to: Nicole Buerki, Department of Obstetrics
and Gynecology, Cantonal Hospital of Liestal, Rheinstrasse 26,
CH-4410 Liestal, Switzerland.
Karl Heinimann, Research Group Human Genetics, Department
of Biomedicine, University of Basel, Mattenstrasse 28, CH-4058
Basel, Switzerland. E-mail: firstname.lastname@example.org
Received 10 June 2011; Accepted 5 September 2011
Published online 27 October 2011 in
Wiley Online Library (wileyonlinelibrary.com).
E-mail: email@example.com or
C 2011 Wiley Periodicals, Inc.
5%). The somatic inactivation of the remaining
wild-type allele leads to MMR deficiency and
consequently results in genomic instability with
cancer cells exhibiting the molecular hallmark of
Lynch syndrome, MSI. In about 30% of families
fulfilling the clinical criteria for Lynch syndrome,
no pathogenic MMR germ line mutation can be
identified (Liu et al., 1996; Salovaara et al., 2000;
Berends et al., 2002).
While early onset, right-sided CRC represents
the hallmark cancer of Lynch syndrome (Lynch
et al., 1993; Lynch and Smyrk, 1996; Aarnio et al.,
1999), extracolonic cancers such as tumors of the
stomach (Aarnio et al., 1997), upper urinary tract,
small bowel (Rodriguez-Bigas et al., 1998), hepa-
tobiliary tract, sebaceous gland (Muir-Torre vari-
(Turcot variant; Hamilton et al., 1995) may occur
in addition. Women from Lynch syndrome fami-
lies are at a significantly increased risk for gyneco-
logic malignancies, namely
ovarian carcinoma. In fact, the lifetime risk for en-
dometrial (Watson et al., 1994; Aarnio et al., 1995;
Aarnio et al., 1999) and ovarian cancers (Watson
et al., 2001) is estimated at 30–60% and 12%,
respectively, compared with 3 and 2%, respec-
tively, in the general population. An elevated risk
for breast cancer in Lynch syndrome has been
suggested in several studies, but the issue remains
controversial (Risinger et al., 1996; Scott et al.,
2001; Vasen et al., 2001; Muller et al., 2002; de
Leeuw et al., 2003; Oliveira Ferreira et al., 2004;
Watson and Riley, 2005; Westenend et al., 2005;
Blokhuis et al., 2008; Shanley et al., 2009).
of breast cancer belonging to the Lynch syndrome
tumor spectrum, this study systematically assessed
occurrence, age distribution and putative geno-
endometrial, ovarian, and breast cancer in a con-
secutive series of 70 Swiss Lynch syndrome fami-
lies with characterized MLH1/MSH2 germ line
mutation. Subsequently, all available breast cancer
specimens were investigated for molecular evi-
dence for MMR deficiency, including MSI analy-
sis, MMR protein expression, and presence of
somatic (epi)genetic alterations in MMR genes,
and the data compiled with the scarce molecular
information available from the pertinent literature.
PATIENTS AND METHODS
For the epidemiological analysis, a consecutive
series of 70 unrelated Swiss Lynch syndrome
families with a pathogenic germ line mutation in
either MLH1 (n ¼ 39) or MSH2 (n ¼ 31) were
investigated. Each kindred encompassed at least
three generations and comprised 632 female fam-
ily members at risk (378 associated with MLH1
and 254 with MSH2). Of these, 92 women could
be genetically verified as mutation carriers (52
MLH1 and 40 MSH2) and 61 as noncarriers (33
MLH1 and 28 MSH2; Table 1).
All patients had been referred from hospital
services and private practices throughout Switzer-
land for genetic counseling and testing from 1999
to 2007. Detailed pedigree and clinicopathological
data were obtained from index patients and/or
family members as well as from the treating physi-
cians. Whenever possible, data were verified by
reviewing medical and pathological reports as well
as death certificates (30 of 32 tumors in family
members with a known mutation could be veri-
fied). Written informed consent was obtained from
all individuals as well as ethical study approval by
the Ethikkommission beider Basel (‘‘Basler Studie
u ¨ber familiaere Tumorkrankheiten’’, Nr. 258/05).
Medical data encompassed the date of and age
at diagnosis, precise cancer location, TNM stag-
ing, histological assessment, and grading, as well
as occurrence of other synchronous and metachro-
nous malignancies. For all relatives (at least three
generations) additional data were recorded, e.g.,
their sex, age (at time of interview), age at death,
occurrence of any cancer (type, age at diagnosis)
and an estimation of how well the person is
remembered (Burki et al., 1987; Heinimann
et al., 1997). Subsequently, data were processed
for statistical evaluation (see below).
DNA Extraction from Peripheral Blood
and Tumor Tissue
For the molecular analysis, seven breast cancer
specimens from six verified MMR mutation carriers
were investigated: these encompassed all four
tumors mentioned in the epidemiological analysis
(Table 1) as well as three additional cancers from
Lynch syndrome patients referred to our group after
2007 (and therefore not included in the epidemio-
logical analysis part [1999–2007]). DNA from pe-
ripheral blood was isolated applying the salting-out
procedure described by Miller et al. (1988). Before
DNA extraction from tumor tissue, histopathological
classification of hematoxylin/eosin stained, formalin-
fixed tissue blocks was carried out, and a represen-
tative portion of the tumor with an average tumor
content of more than 70% was scraped off. DNA
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BREAST CANCER IN LYNCH SYNDROME