FAMILIAL COLORECTAL CANCER. Lyn Schofield Manager Familial Cancer Registry

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1 FAMILIAL COLORECTAL CANCER Lyn Schofield Manager Familial Cancer Registry

2 Cancer in WA ASPR, rate per 100, Male incidence Female incidence Male mortality Female mortality Age (years) Source: Western Australian State Cancer Registry, 2004

3 Familial Colorectal Cancer 1% - 5% of CRCs will have genetic predisposition 4% Lynch Syndrome 1% FAP

4 CRC in Western Australia Male incidence Female incidence Male mortality Female mortality yrs 5-9yrs 10-14yrs yrs 25-29yrs 30-34yrs 35-39yrs 40-44yrs 45-49yrs 50-54yrs 55-59yrs 60-64yrs 65-69yrs 70-74yrs 75-79yrs 80-84yrs 85+yrs

5 Familial Adenomatous Polyposis (FAP) First identified in the 1850s APC gene discovery 1991 Accounts for less than 1% of CRC Autosomal dominant Almost 100% will develop CRC by age 50

6 DIAGNOSIS Colonic polyps, usually > 100 adenomas Development of CRC at relatively early age Family history, but not always Consider Attenuated FAP (AFAP), MYH mutations Hyperplastic polyposis syndrome

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8 Hill Robina Hill Redmond Hill Hill Beryl Marion Hill Douglas Hill Victoria Colin Hill Sidney Hill Vietnam Hill + Jennifer Jones Powell + Clinton Powell 10/7/1978 Magdalena Zylinski Kelly Edwards Suzanne Wright Rachel Rimer Ronda Jaykub Wright 27/5/1998 Joshua Edwards 13/9/1998 Angelique Zylinski 12/6/1999 Jordyn Powell 1/2/2002 Tzaynia 1/8/2003 Stuart Moffat + Scott Moffat 22/2/ Graham Moffat 17/1/ Stacey Moffat 5/10/1988 Martika Moffat 10/8/1995 Fox + Jake Fox 15/1/ Janet + Greta 2/11/ David Fox 21/7/187 - Julie + Timothy 23/8/ Melissa 19/6/1994 Mitchell 10/6/ Roland 23/7/1964 Benjamin 3/7/ Michael ? Suicide Hill Hill Hill Hill Hill

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12 Management Recommendations: Gene testing where possible Colonoscopy from age yrs Surgery - determined by polyp number & distribution Lifetime surveillance scopes, chemoprevention Specialists who see lots of pts with FAP

13 Lynch Syndrome (Hereditary non-polyposis colorectal cancer) Autosomal dominant Contributes 1% - 4% of all CRC 70% will develop cancer by age 65

14 Lynch Syndrome - characteristics Early age of onset of CRC Proximal colonic malignancy Multiple colorectal cancers Extra colonic cancers ovary, uterus, renal tract, stomach, brain, skin

15 Mismatch repair genes MLH1 PMS2 MSH2 MSH6

16 I:1 9 I:2 10 Bowel cancer age 45 II:3 II: Bowel cancer age 40s II:4 12 II:5 13 II:8 16 II:6 14 Bowel cancer age 40s II:9 17 II:1 2 Bowel cancer age 40 II:2 3 III:1 1 Bowel cancer age 37 III:2 4 III:3 5 III:4 6 III:5 7 Bowel cancer age Bowel 35 cancer age 33 III:6 8 Bowel polyps age 30

17 Advances in Diagnosis Family history issues Immunohistochemistry Microsatellite instability

18 Name: UMRN: Date of Birth: Age at diagnosis: 55 Tumour site: Rectum Grade: Moderately differentiated Stage: 1 TILS/mucinous: No BAT26 Tumour: Normal MLH1 IHC Tumour: Normal MSH2 Conclusion: MSI likely to be due to polymorphism, due to the nature of the altered migration pattern and normal expression of all four MMR genes in the tumour cells.

19 Defects in MMR genes Absent or non-functional proteins MLH-1 staining positive (MLH-1 expressed in tumour) MSH-2 staining negative (MSH-2 not expressed in tumour)

20 Name: Date of Birth: Age at diagnosis: 50 Tumour site: Transverse/Splenic flexure Grade: Moderately differentiated Stage: 2 TILS/mucinous: Mucinous BAT26 Tumour: Normal MSH2 IHC Tumour: loss of MSH6 Conclusion: Tumour shows MSI and loss of expression of MSH6. Refer to GSWA.

21 Name: UMRN: Date of Birth: Age at diagnosis: 52 Tumour site: Caecum Grade: Moderately differentiated Stage: 2 TILS/mucinous: No BAT26 Tumour: loss of MLH1 IHC Tumour: loss of PMS2 Conclusion: Tumour shows MSI and loss of expression on MLH1 and PMS2. Refer to GSWA.

22 Knowing your mutation status Endometrial Ca. in 2006 Colorectal Ca. in 2007 Mutation carrier No mutation

23 Management Annual colonoscopy from 25 yrs or 5 years younger than the earliest diagnosis of CRC in the family Second yearly upper GI endoscopy + helicobacter testing Prophylactic HBSO Site specific depending on family history

24 Familial cancer tests currently provided by Familial Cancer Program in WA Condition Genetic test Potential population risk Estimated mutation detection rate FAP APC <0.5% 80% Lynch Syndrome Familial breast cancer MLH1, MSH2, MSH6, PMS2 BRCA 1 BRCA2 1 5% 50% 5% 30%

25 Referral to GSWA Self referral Gastroenterologist Directly from the surgeon following abnormal MSI or IHC results Other sources eg ophthalmologist, oncologist GP referral include FH + any pathology or colonoscopy reports

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27 Thank you Ph