FAMILIAL COLORECTAL CANCER Lyn Schofield Manager Familial Cancer Registry
Cancer in WA 2004 4000 3500 ASPR, rate per 100,000 3000 2500 2000 1500 1000 Male incidence Female incidence Male mortality Female mortality 500 0 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85+ Age (years) Source: Western Australian State Cancer Registry, 2004
Familial Colorectal Cancer 1% - 5% of CRCs will have genetic predisposition 4% Lynch Syndrome 1% FAP
CRC in Western Australia 2009 140 120 Male incidence Female incidence Male mortality Female mortality 100 80 60 40 20 0 0-4yrs 5-9yrs 10-14yrs 15-19 20-24yrs 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
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
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
Hill Robina Hill Redmond Hill Hill Beryl 1940-1970 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 22/2/1982 + Graham Moffat 17/1/1983 - Stacey Moffat 5/10/1988 Martika Moffat 10/8/1995 Fox + Jake Fox 15/1/1990 - Janet + Greta 2/11/1965 + David Fox 21/7/187 - Julie + Timothy 23/8/1963 - Melissa 19/6/1994 Mitchell 10/6/2003 + Roland 23/7/1964 Benjamin 3/7/2001 + Michael 1969 -? Suicide Hill Hill Hill Hill Hill
Management Recommendations: Gene testing where possible Colonoscopy from age 10-15 yrs Surgery - determined by polyp number & distribution Lifetime surveillance scopes, chemoprevention Specialists who see lots of pts with FAP
Lynch Syndrome (Hereditary non-polyposis colorectal cancer) Autosomal dominant Contributes 1% - 4% of all CRC 70% will develop cancer by age 65
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
Mismatch repair genes MLH1 PMS2 MSH2 MSH6
I:1 9 I:2 10 Bowel cancer age 45 II:3 II:7 11 15 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
Advances in Diagnosis Family history issues Immunohistochemistry Microsatellite instability
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.
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)
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.
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.
Knowing your mutation status Endometrial Ca. in 2006 Colorectal Ca. in 2007 Mutation carrier No mutation
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
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%
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
Thank you lyn.schofield@health.wa.gov.au Ph 9340 1713