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Journal of Clinical Oncology, Vol 23, No 24 (August 20), 2005: pp. 5651-5659 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.14.712 Adenomatous Polyposis Families That Screen APC Mutation–Negative by Conventional Methods Are Genetically HeterogeneousFrom the Department of Medical Genetics, Institute of Dentistry, and Institute of Biotechnology, University of Helsinki; Laboratory of Molecular Genetics, Department of Oral and Maxillofacial Diseases, and Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland Address reprint requests to Päivi Peltomäki, Department of Medical Genetics, Biomedicum Helsinki, PO Box 63 (Haartmaninkatu 8), FIN-00014 University of Helsinki, Helsinki, Finland; e-mail: paivi.peltomaki{at}helsinki.fi
PURPOSE: One third of families with classical adenomatous polyposis (FAP), and a majority of those with attenuated FAP (AFAP), remain APC mutation–negative by conventional methods. Our purpose was to clarify the genetic basis of polyposis and genotype-phenotype correlations in such families. PATIENTS AND METHODS: We studied a cohort of 29 adenomatous polyposis families that had screened APC mutation–negative by the protein truncation test, heteroduplex analysis, and exon-specific sequencing. The APC gene was investigated for large genomic rearrangements by multiplex ligation-dependent probe amplification (MLPA), and for allelic mRNA expression by single nucleotide primer extension (SNuPE). The AXIN2 gene was screened for mutations by sequencing. RESULTS: Four families (14%) showed a constitutional deletion of the entire APC gene (three families) or a single exon (one family). Seven families (24%) revealed reduced or extinct mRNA expression from one APC allele in blood, accompanied by loss of heterozygosity in the APC region in six (75%) of eight tumors. In 15 families (52%), possible APC involvement could be neither confirmed nor excluded. Finally, as detailed elsewhere, three families (10%) had germline mutations in genes other than APC, AXIN2 in one family, and MYH in two families. CONCLUSION: "APC mutation–negative" FAP is genetically heterogeneous, and a combination of MLPA and SNuPE is able to link a considerable proportion (38%) to APC. Significant differences were observed in clinical manifestations between subgroups, emphasizing the importance of accurate genetic and clinical characterization for the proper management of such families.
Familial adenomatous polyposis (FAP) is an autosomal dominant syndrome characterized by the development by age 20 years of multiple colorectal polyps; one or several of these polyps progresses to cancer by approximately 40 years of age.1 In classical FAP, at least 100 (often hundreds to more than a thousand) adenomas are present, whereas polyposis with fewer than 100 adenomas per patient is referred to as attenuated polyposis (AFAP or AAPC). In addition to colorectal polyps, affected individuals may develop various extracolonic manifestations, such as desmoid tumors, duodenal adenomas, mandibular osteomas, and hypertrophic pigmentary lesions of the retina. In AFAP, the age at onset of adenomas and cancer is higher, and the lifetime risk of cancer is lower compared with classical FAP.2 While the true incidence and frequency of AFAP is unknown,3 it may account for up to 10% of adenomatous polyposis families.4 Germline mutations of the adenomatous polyposis coli (APC) tumor suppressor gene located on 5q21-22 cause both FAP and AFAP.5-7 To date, more than 800 pathogenic mutations in APC have been described.8 These are typically frameshift or nonsense changes that lead to truncated protein products,9 forming the basis for their detection by the protein truncation test (PTT).10 In classical FAP, mutations may be scattered all over the gene, with some hot spots in the somatic mutation cluster region between codons 1250 and 1450 in exon 15.11 The position of APC mutation correlates to some extent with clinical features12-14; for example, mutations between codons 1444 to 1578 are associated with classical adenomatous polyposis and multiple extracolonic manifestations.15,16 AFAP phenotype is associated with mutations in the 5' end (before codon 157 in exon 4), in the alternatively spliced part of exon 9, and in the distal 3' end of APC (beyond codon 1595).17 Conventional methods for APC mutation detection include the PTT test and various exon-specific screening methods such as single-strand conformation polymorphism assay, heteroduplex analysis, and DNA sequencing. These methods are sensitive to point mutations, but they fail to detect large genomic rearrangements as well as possible transcription defects. Conventional techniques leave approximately 30% of families with classical FAP and approximately 90% of AFAP families APC mutation–negative.12,18-22 This apparent mutation negativity may suggest either that APC has alterations that escape detection by routine techniques, or alternatively, that other (known or unknown) genes are involved in FAP predisposition. Among known genes, recent evidence implicates at least the Mut Y homolog MYH encoding a DNA glycosylase.23 Recessive inheritance and variable polyp count (lower or greater than 100) are features of MYH-associated polyposis.24,25 MYH mutations may explain up to 25% of "APC mutation–negative" FAP, leaving the majority of FAP families without identifiable APC mutations molecularly unexplained. We recently conducted a study on 65 classical FAP families from Finland, which resulted in the identification of APC germline mutations in 72%.22 The present report addresses the genetic basis of polyposis in the third (approximate) of FAP families that shows no APC mutation by conventional methods.
Subjects We investigated 29 families (38 individuals) representing the mutation-negative fraction (30%) among a total of 98 adenomatous polyposis families from the Hereditary Colorectal Cancer Registry of Finland that had been screened for APC germline mutations by common diagnostic methods (PTT for the entire coding region and heteroduplex analysis of exons 1 to 14, or sequencing of exons 1 to 15).22 Table 1 presents clinical features of the families. Eighteen FAP families with truncating mutations in APC (18 different mutations, 26 individuals) were studied for comparison. As controls, two healthy individuals (unaffected with any cancer), as well as 20 colon cancer patients from DNA mismatch repair gene mutation–negative families with hereditary nonpolyposis colorectal carcinoma (HNPCC), were tested. This study was approved by the institutional review board of the Helsinki University Central Hospital (Helsinki, Finland).
DNA and RNA Extraction DNA was extracted from cultured lymphocytes or lymphoblasts.26 Total cellular RNA was extracted according to the guanidium thiocyanate method.27 Normal and tumor DNA from paraffin-embedded tissue sections was extracted according to Isola et al.28
MLPA for Large Genomic Rearrangements
SNuPE for Allelic mRNA Expression
Analysis of APC Promoter Region for Mutations
APC Haplotype Analysis
Loss of Heterozygosity in Tumor Tissue
AXIN2 Mutation Screen
Statistical Methods
Large Genomic Rearrangements of APC By MLPA, large genomic deletions were found to underlie 4/29 (14%) of families that tested APC mutation–negative by conventional techniques (group I, Table 2). Three families (FAP5, FAP91, and FAP108) harbored a deletion of the whole APC gene in one chromosomal homolog as suggested by the consistent reduction of APC-specific peaks relative to peaks originating from control sequences (Fig 1). Moreover, samples from two polyposis patients were available from FAP5, and both showed the deletion. The results from MLPA analysis were in agreement with lack of heterozygosity for markers located within APC (listed under Haplotype analysis in Patients and Methods). Heterozygosity for flanking markers D5S1965 and D5S346 provided borders for the APC deletion in FAP5, whereas lack of heterozygosity on the centromeric side was compatible with larger deletions in the other two families. In FAP115, MLPA indicated a deletion of APC exon 4 (Fig 1). This finding was confirmed by amplifying a segment from APC exon 3 to exon 5 from cDNA, which yielded two products: a full-length fragment and a shorter fragment that was shown to lack exon 4 by sequencing (data not shown).
Unbalanced Allelic mRNA Expression of APC Our primer extension (SNuPE) experiments utilizing the C/T (G/A) polymorphism at nucleotide 1458 in exon 11 identified seven families with unbalanced allelic mRNA expression as the sole constitutional abnormality of APC (group II, seven of 29, 24%; Table 2; Fig 2). The degree of expression reduction was variable and ranged from the level of 68% relative to that of the normal allele (FAP103 with a G-A ratio of 1.46 in cDNA relative to gDNA), to complete silencing of one allele (FAP93). In contrast, families with balanced expression from the present series (indicated as "Normal" in Table 2) showed G-A ratios very close to 1 (ranging from 0.90 to 1.01). For comparison, families with truncating mutations in APC were investigated, and all nine informative patients, who carried eight different mutations, showed balanced mRNA expression in blood, with G-A ratios ranging from 0.97 to 1.07 (Table 3). The same was true for patients from mismatch repair gene mutation–negative HNPCC families with microsatellite-stable tumors (11 informative individuals with G-A ratios between 0.80 and 1.11), as well as for healthy controls as shown in the present study and elsewhere.34 These data suggested that unbalanced mRNA expression of APC was specific to FAP families from the present group II. As further proof of pathogenic significance of unbalanced expression, constitutional reduction of mRNA expression from one APC allele was accompanied by loss of heterozygosity in the APC region in six (75%) of eight informative tumors, and the lost allele was the one not involved in the constitutional abnormality in all cases in which allelic origin could be determined (Table 2). The APC promoter region was unaltered by sequencing, therefore providing no explanation for unbalanced mRNA expression.
Families With No Detectable Germline Changes in APC Besides showing no changes in the initial screen by PTT, heteroduplex analysis, and exon-specific sequencing, 18 of 29 polyposis families could not be linked to APC even in our scrutinized screen by MLPA and SNuPE. While our investigation into APC was ongoing, a mutation in the Wnt signaling regulator gene AXIN2 was identified in one of these families (FAP113) as a result of a separate effort aiming to identify the gene defect underlying severe tooth agenesis in this family.33 We subsequently screened AXIN2 for germline mutations in the remaining families, but could not find any obvious disease-associated changes. In parallel, samples from our families were also submitted to a MYH screen, and two families (FAP83 and FAP119) revealed biallelic MYH mutations.35 Families with mutations in genes other than APC form group IV in Table 2 leaving 15 (52%) of 29 families without a defined molecular etiology (group III in Table 2). In group III, APC germline involvement could not be excluded since, for example, seven families were uninformative for SNuPE, and the fact that most families were in fact solitary cases prevented genetic linkage analysis. In two families (FAP57 and FAP74), samples were available from multiple patients, and both displayed a shared disease haplotype within the family (data not shown). Strict or putative LOH in the APC region was present in 11 of 20 informative tumors from group III (55%; Table 2), and, according to Knudson's two-hit hypothesis, could serve to expose either a somatic or a hereditary "first hit." The LOH rate was higher than that seen in APC mutation-positive families (five of 16; 31%; Table 3), and it might be reasonable to expect that the first hit occurred in the germline in at least some cases (eg, FAP57) with additional linkage support. On the other hand, group III comprised some families (such as FAP92, FAP104, and FAP73), in which no APC alterations were found in constitutional or tumor tissues, which might suggest the involvement of (an) other, as yet unknown susceptibility gene(s).
Genetic Versus Clinical Features Our group I, with large genomic deletions, had clinical features similar to those previously described for FAP families with truncating APC mutations from the same population,22 including profuse polyposis, early age at onset, and frequent extracolonic manifestations. The mean age at polyposis diagnosis was remarkably low (27.3 years) in probands from families with deletion of the entire APC gene (FAP5, FAP91, FAP108). Compared with these, FAP115 with exon 4 deletion showed a milder phenotype, consistent with the location of the change in the "AFAP region" (see Introduction). Families with unbalanced mRNA expression of APC alleles (group II) all had classical FAP, but interestingly, the mean age at onset was higher, and less than half displayed extracolonic manifestations. Compared with APC mutation–positive FAP (35.6 years),22 the mean ages at onset in probands from groups II (47.3 years) and III (45.2 years) were significantly higher (with P values of .04 and .02, respectively, by two-tailed t test). The six families with attenuated/atypical polyposis in our series belonged to groups III (with no direct evidence of APC involvement) and IV (with mutations in AXIN2 or MYH). In particular, none of the patients with MYH-associated polyposis had more than 150 polyps; similarly, the highest polyp count in patients from FAP113 with the AXIN2 R656X mutation33 was 70. Consistent with previous reports,24,25 the present two families with MYH-associated polyposis were among those without clear dominant transmission.
Unlike most previous studies that have typically addressed one abnormality at a time, we applied a comprehensive approach to clarify the molecular etiology of "APC mutation–negative" FAP. The families fell into four categories: (I) families with large genomic deletions of APC (n = 4; 14%); (II) families with unbalanced allelic mRNA expression of APC (n = 7; 24%); (III) families with no evidence of genomic deletions or unbalanced mRNA but with no convincing evidence against APC, either (n = 15; 52%); and (IV) families with germline mutations in genes other than APC (AXIN2 in one family, 4%, and MYH in two families, 7%). Several techniques are available for detecting deletions or insertions of a few base pairs (common types of mutations described for APC9) or very large, cytogenetically visible deletions,36 but difficulties arise in the diagnosis of deletions or duplications of a few kilobases, such as a deletion of a single exon or a deletion of the entire predisposing gene. For this reason, the true frequency of genomic rearrangements in APC mutation–negative FAP is unknown. Based on real-time quantitative PCR or RT-PCR experiments, APC deletion frequencies of 12% to 33% were reported, and genomic deletions were almost exclusively restricted to classical FAP (as opposed to AFAP).31,37 Recently, two new methods, multiplex amplification and probe hybridization and MLPA were designed to screen up to 40 target sequences for deletions or duplications in a single reaction tube.38 Available experience suggests that MLPA provides an easy and reliable approach for the diagnosis of dosage alterations in several disease-associated genes, including HNPCC-associated DNA mismatch repair genes39-41 and the breast and ovarian cancer–associated BRCA1.42 The present data show that MLPA is also valuable for the detection of APC deletions in FAP families. The overall deletion frequency (14% among APC mutation–negative families) and type of deletions (whole gene deletion in three fourths, single exon deletion in one fourth), and association with classical FAP were compatible with results obtained from other populations using earlier methodology (see above). While our manuscript was in preparation, another MLPA study of FAP families was published reporting APC deletions in six (25%) of 24 among APC mutation–negative FAP families from Wessex, United Kingdom; the clinical features of the families were not specified.43 Alterations in one allele may occasionally be masked by the normal sequence present in the other allele, making allele-specific approaches necessary. Concurrent with the development of the PTT test for truncating APC mutations, a radioactive oligoligation-based assay was devised to detect reduced mRNA expression from one APC allele in cases not showing truncations.10 This method was able to link three (27%) of 11 FAP families without truncations to APC. Later, physical isolation of the maternal and paternal APC alleles by the newly developed Conversion technology, combined with digital single nucleotide polymorphism for mRNA quantification, confirmed these initial observations and showed that even modest decreases in transcripts (approximately 50% of that of the normal allele) can lead to FAP predisposition.44 We developed a simple semiquantitative fluorescent primer extension assay to monitor allelic mRNA expression in our families, and seven (24%) of 29 of these, all with classical FAP, exhibited a relative expression reduction varying from the level of 68% of that of the normal allele to complete silencing of one allele. Constitutionally decreased expression from one allele was accompanied by the selective loss of the wild-type allele in tumor tissue, suggesting that reduced dosage of the APC gene product contributed to tumor development in such families. The mechanism of reduced mRNA expression remains to be identified. It is not associated with apparent DNA sequence changes in the coding region or in the 5' or 3' flanking areas.44 A previously undescribed mechanism may be involved since in our investigation, unbalanced mRNA expression was specific to the subgroup of seven families, being absent in all FAP patients with truncating APC mutations (P = .022 by two-tailed Fisher's exact test) and in patients with microsatellite-stable HNPCC (P = .021). The lack of unbalanced mRNA expression of APC in mutation-positive FAP is in marked contrast to truncating HNPCC-associated DNA mismatch repair gene mutations, which we found to regularly lead to under-representation of the mutation-containing transcripts, presumably due to nonsense-mediated RNA decay.30,45 Our results suggest that MLPA and SNuPE (or direct assays for genomic changes underlying unbalanced expression if available in the future) are valuable additions to standard APC mutation diagnostics. However, as shown by the present group III, even intensive research efforts may not result in the identification of germline changes in all cases with apparent FAP phenotype. In a clinical setting, it is important to be aware that because of genetic heterogeneity, a negative test result does not rule out inherited susceptibility to polyposis and colorectal cancer. In such cases, endoscopic screening should be offered for the siblings and descendants of the affected individuals, as was done in the pretesting era.46 Previous investigations focusing on families with APC mutation–negative FAP have observed a difference in their clinical features compared with those of APC mutation–positive FAP. Two studies found a milder phenotype,20,22 whereas one study47 reported a more severe phenotype for the mutation-negative families. The recognition of genetic heterogeneity was an important advantage of the present investigation making it possible to assess genotype-phenotype correlations separately for the individual subgroups. Our group I with large genomic deletions of APC had clinical features indistinguishable from those described for FAP families with truncating APC mutations. Families with unbalanced mRNA expression of APC alleles (group II) had a generally "milder" phenotype, supporting a distinct mechanism for predisposition. The same broadly applied to group III (families with association to APC neither confirmed nor excluded). Finally, families with germline mutations in AXIN2 or MYH (group IV) often showed attenuated or atypical FAP. Our ability to stratify the original single cohort into at least four molecularly and clinically distinct subgroups significantly defines the genetic basis of FAP and facilitates the design of more tailored strategies for the management of such families.
The authors indicated no potential conflicts of interest.
We thank Daniel Fix for advice in MLPA analyses; Saila Saarinen, Marjatta Kivekäs, and Jonna Jalanka for expert technical assistance; Jinmin Miao for cell cultures; and Tuula Lehtinen and Katja Kuosa for assistance with sample collection.
Supported by grants from the Sigrid Juselius Foundation, the Academy of Finland, the Finnish Cancer Foundation, K. Albin Johansson Foundation, Helsinki University Hospital Research and Development Funds (EVO), and Helsinki Biomedical Graduate School. Authors' disclosures of potential conflicts of interest are found at the end of this article.
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47. Bisgaard ML, Ripa R, Knudsen AL, et al: Familial adenomatous polyposis patients without an identified APC germline mutation have a severe phenotype. Gut 53:266-270, 2004 Submitted February 3, 2005; accepted April 19, 2005. This article has been cited by other articles:
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
T:A mutations in colorectal tumors. Nat Genet 30:227-232, 2002
