Piera Rizzolo

Gastric cancer with high-level microsatellite instability: target gene mutations, clinicopathologic features, and long-term survival

Gastric cancer is one of the leading causes of cancer death worldwide, and although the incidence has decreased in Western countries, specific high-risk areas are present in Italy. Gastric cancer with high-level microsatellite instability (MSI-H) represents a well-defined subset of carcinomas showing distinctive clinicopathologic features. We examined clinicopathologic associations and long-term survival in a series of 159 gastric cancer cases from a high-risk population in Tuscany (central Italy). MSI-H was associated with antral location of the tumor (P = .001), intestinal type according to Lauren classification (P = .002), expanding type according to Ming classification (P = .0001), and mucinous histologic type according to the Japanese Research Society for Gastric Cancer classification (P = .002). In addition, MSI-H was strongly associated with a higher survival at 15 years (P = .01) and with loss of hMLH1 expression, evaluated by immunohistochemistry (P = .001). Multivariate analyses showed a significant association between the absence of hMLH1 reactivity and the expanding tumor type (P = .002). We also investigated the MSI-H-related genetic changes by analyzing coding repeats within target genes involved in pathways that control cell growth (TGFbetaRII, IGFIIR, RIZ, TCF4, DP2), apoptosis (BAX, BCL10, FAS, CASPASE5, APAF1), and DNA repair genes (hMSH6, hMSH3, MED1, RAD50, BLM, ATR, BRCA2, MRE11). Gastric cancer cases with MSI-H were found to accumulate heterozygous mutations affecting multiple molecular pathways and multiple genes within each pathway. Intriguingly, in this subset, TGFbetaRII mutations appeared to be inversely related to BLM mutations (P = .006), whereas RAD50 mutation carriers showed significantly reduced survival (P = .03).

BRCA1/BRCA2 rearrangements and CHEK2 common mutations are infrequent in Italian male breast cancer cases

Male breast cancer (MBC) is a rare and poorly known disease. Germ-line mutations of BRCA2 and, to lesser extent, BRCA1 genes are the highest risk factors associated with MBC. Interestingly, BRCA2 germ-line rearrangements have been described in high-risk breast/ovarian cancer families which included at least one MBC case. Germ-line mutations of CHEK2 gene have been also implicated in inherited MBC predisposition. The CHEK2 1100delC mutation has been shown to increase the risk of breast cancer in men lacking BRCA1/BRCA2 mutations. Intriguingly, two other CHEK2 mutations (IVS2+1G>A and I157T) and a CHEK2 large genomic deletion (del9-10) have been associated with an elevated risk for prostate cancer. Here, we investigated the contribution of BRCA1, BRCA2 and CHEK2 alterations to MBC predisposition in Italy by analysing a large series of MBC cases, unselected for breast cancer family history and all negative for BRCA1/BRCA2 germ-line mutations. A total of 102 unrelated Italian MBC cases were screened for deletions/duplications of BRCA1, BRCA2 and CHEK2 by multiplex ligation-dependent probe amplification. No BRCA1, BRCA2 and CHEK2 genomic rearrangements, including the CHEK2 del9-10, were found in the series analysed. Furthermore, none of the MBC cases and 263 male population controls, also included in this study, carried the CHEK2 1100delC, IVS2+1G>A and I157T common mutations. Overall, our data suggest that screening of BRCA1/2 rearrangements is not advantageous in MBC cases not belonging to high-risk breast cancer families and that common CHEK2 mutations play an irrelevant role in MBC predisposition in Italy.

FANCM c.5791C>T nonsense mutation (rs144567652) induces exon skipping, affects DNA repair activity and is a familial breast cancer risk factor

Numerous genetic factors that influence breast cancer risk are known. However, approximately two-thirds of the overall familial risk remain unexplained. To determine whether some of the missing heritability is due to rare variants conferring high to moderate risk, we tested for an association between the c.5791C>T nonsense mutation (p.Arg1931*; rs144567652) in exon 22 of FANCM gene and breast cancer. An analysis of genotyping data from 8635 familial breast cancer cases and 6625 controls from different countries yielded an association between the c.5791C>T mutation and breast cancer risk [odds ratio (OR) = 3.93 (95% confidence interval (CI) = 1.28-12.11; P = 0.017)]. Moreover, we performed two meta-analyses of studies from countries with carriers in both cases and controls and of all available data. These analyses showed breast cancer associations with OR = 3.67 (95% CI = 1.04-12.87; P = 0.043) and OR = 3.33 (95% CI = 1.09-13.62; P = 0.032), respectively. Based on information theory-based prediction, we established that the mutation caused an out-of-frame deletion of exon 22, due to the creation of a binding site for the pre-mRNA processing protein hnRNP A1. Furthermore, genetic complementation analyses showed that the mutation influenced the DNA repair activity of the FANCM protein. In summary, we provide evidence for the first time showing that the common p.Arg1931* loss-of-function variant in FANCM is a risk factor for familial breast cancer.

PALB2 mutations in male breast cancer: a population-based study in Central Italy.

To the Editor, Male breast cancer (MBC) is a rare disease compared to female breast cancer (FBC). However, MBC shares many similarities with FBC, including genetic predisposition factors such as BRCA1/2 mutations. The frequency of BRCA1/2 mutations is quite different in ethnically diverse populationand clinic-based MBC series, ranging between 4 and 40% for BRCA2 and up to 10% for BRCA1 [1]. In a population-based series of 108 MBCs from Central Italy, we reported that about 9% of MBCs were BRCA1/2 carriers [2], suggesting the contribution of additional susceptibility genes. Several studies identify PALB2 as a moderate-penetrance breast cancer (BC) susceptibility gene, accounting for about 1% of BRCA1/2 negative familial/early onset BCs [3, 4]. PALB2 mutations were found in families with both FBC and MBC cases, suggesting that PALB2 may be involved in MBC risk [3]. As for BRCA1/2, there are evidences that PALB2 might play a role in prostate cancer (PC) [5]. Interestingly, PC patients have an increased risk of BC [6] and, on the other hand, MBC patients show an increased risk of PC [7], suggesting that these tumours may share risk factors. The role of PALB2 in MBC predisposition is still largely unknown. An interesting evaluation about this latter is provided in the recent article by Sauty de Chalon et al. [8]. Yet in the above mentioned study PALB2 pathogenic mutations were not found in 25 MBCs belonging to 25 BRCA1/2 negative families and, based on PALB2 mutation frequency (*1%), it cannot be excluded that these findings may indeed be due to the small series analysed. By using direct sequencing, we performed a screen for germline mutations of PALB2 coding region and intron– exon boundaries in 97 BRCA1/2 negative MBCs, previously identified in a population-based series of 108 MBCs [2]. Age at first BC diagnosis ranged between 35 and 90 years (mean 63.9 years), 25.8% of the patients reported a first-degree family history (FH) of breast/ovarian cancer and 14.4% had a personal history of cancer(s) at sites other than breast. In particular, prostate (28.5%) and bladder (28.5%) carcinomas were the most frequently observed metachronous cancers. Table 1 shows all the PALB2 variants identified in our study. No truncating mutations were found. A novel missense variant, I1180T, was identified in a young man diagnosed with BC at 42 years of age and with negative FH. In silico analysis (PolyPhen, SIFT, Align-GVGD and Pmut) showed that I1180T is likely to be deleterious, since it occurs in the WD40-4 conserved domain that regulates PALB2 interaction with BRCA2. This variant was not found in 90 male population controls analysed (Table 1). Three additional missense variants (Q559R, E672Q and G998E) and one synonymous (T1100T) variant, all previously Valentina Silvestri and Piera Rizzolo equally contributed to the work.

Association between the BRCA2 N372H variant and male breast cancer risk: a population-based case-control study in Tuscany, Central Italy

BackgroundMale breast cancer (MBC) is a rare disease and little is known about its aetiology. Germ-line mutations of BRCA2 and, at lower frequency, of BRCA1 are implicated in a relatively small proportion of MBC cases. Common polymorphic variants in BRCA1 and BRCA2 genes may represent breast cancer (BC) susceptibility alleles and could be associated with a modestly increased risk of MBC at population level. Considering the relevant role of BRCA2 in MBC, we investigated whether the BRCA2 N372H variant, representing the only common non-synonymous polymorphism in BRCA2, might modulate the risk of BC in male populations.MethodsA case-control study was performed comparing a population-based series of 99 MBC cases, characterized for BRCA1 and BRCA2 mutations, with 261 male population controls, all residing in Tuscany, Central Italy. All MBC cases and controls were genotyped for the BRCA2 N372H allele by TaqMan allelic discrimination assays. To evaluate the genotype specific risk of the BRCA2 N372H variant, MBC carriers of germ-line BRCA1/2 mutations were excluded from the analyses.ResultsNo association emerged in univariate and age-adjusted analyses. Age-specific analyses suggested an increased risk for the HH homozygous genotype in subjects younger than 60 years. A statistically significant interaction emerged between this genotype and age (p = 0.032). When analyses were restricted to MBC cases enrolled in the first 4 years following diagnosis, a recessive model showed a significantly increased risk of MBC in HH subjects younger than 60 years (OR = 5.63; 95% CI = 1.70;18.61).ConclusionOverall, our findings, although based on a relatively small series, suggest that the BRCA2 HH homozygous genotype might be positively associated with an increased risk of MBC in men younger than 60 years.

Mutation screening of RAD51C in male breast cancer patients

We read with great interest the paper by Akbari and colleagues [1] in a recent issue of Breast Cancer Research. The authors reported on the absence of RAD51C mutations in 454 patients with BRCA1/2-negative familial breast cancer/ovarian cancer (BC/OC). In the initial report by Meindl and colleagues [2], RAD51C mutations were identified in 6 out of 480 patients with BRCA1/2-negative familial BC/OC. Interestingly, on the basis of histopathologic features, including intermediate grade (G2), estrogen receptor-positive (ER+), progesterone receptor-positive (PR+), and HER2-negative (HER2-) expression, RAD51C-associated BCs were found to be similar to BRCA2-associated BCs [2]. BRCA2 is known to play a significant role in male BC (MBC); however, no occurrence of MBC was observed in the six RAD51C families described [2]. To investigate the role of RAD51C in MBC, we screened for RAD51C mutations in 97 MBC patients selected from our population-based series of 126 cases because they were previously found negative for BRCA1/2, CHEK2, PALB2, and BRIP1 mutations [3,4]. Notably, 25.8% of cases showed a positive first-degree family history of BC or OC or both. The majority of MBCs were invasive ductal carcinomas (74.5%), G2 (53.5%), ER+ (90.7%), PR+ (82.6%), or HER2- (85.4%). Overall, 66% of the MBCs showed an ER+/PR+/HER2- phenotype. All patients provided informed consent to the study. We carried out mutation screening of the nine exons and intron/exon boundaries of RAD51C by high resolution melting (HRM) analysis, a rapid closed-tube mutation scanning method with high sensitivity and specificity. Cases displaying abnormal profiles were evaluated by direct sequencing. Primers are available upon request. We found no truncating RAD51C mutations. We identified a novel intronic variant, IVS3 c.738-16G>T, in 1 out of 97 MBCs (1%). By in silico analysis, performed with Splice Site Prediction (BDGP, Berkeley Drosophila Genome Project, Lawrence Berkeley National Laboratory, Berkeley, CA, USA) and NetGene 2 Server software (CBSA, Center for Biological Sequence Analysis, Technical University of Denmark, Lyngby, Denmark), the IVS3 c.738-16G>T variant is predicted not to affect splicing. This variant was also identified in 2 out of 173 (1.2%) population controls examined. We also found a neutral polymorphic intronic variant, IVS6 c.904+34T>C (rs28363318), in 16 out of 97 (16.5%) MBCs. Overall, our results, which are based on a relatively large MBC series, are consistent with the findings by Akbari and colleagues [1] and with data on 92 patients with hereditary gynecological cancer in which no deleterious RAD51C mutations were identified [5] and would suggest that the impact of RAD51C mutations on BC predisposition might be more limited than initially reported. In conclusion, we found no evidence that RAD51C mutations may contribute to MBC susceptibility. Further studies on larger MBC series are needed to confirm our findings.

Inherited and acquired alterations in development of breast cancer.

Breast cancer is the most common cancer among women, accounting for about 30% of all cancers. In contrast, breast cancer is a rare disease in men, accounting for less than 1% of all cancers. Up to 10% of all breast cancers are hereditary forms, caused by inherited germ-line mutations in “high-penetrance,” “moderate-penetrance,” and “low-penetrance” breast cancer susceptibility genes. The remaining 90% of breast cancers are due to acquired somatic genetic and epigenetic alterations. A heterogeneous set of somatic alterations, including mutations and gene amplification, are reported to be involved in the etiology of breast cancer. Promoter hypermethylation of genes involved in DNA repair and hormone-mediated cell signaling, as well as altered expression of micro RNAs predicted to regulate key breast cancer genes, play an equally important role as genetic factors in development of breast cancer. Elucidation of the inherited and acquired genetic and epigenetic alterations involved in breast cancer may not only clarify molecular pathways involved in the development and progression of breast cancer itself, but may also have an important clinical and therapeutic impact on improving the management of patients with the disease.

The BRCAPRO 5.0 model is a useful tool in genetic counseling and clinical management of male breast cancer cases

No study has evaluated the performance of BRCA1/2 mutations prediction models in male breast cancer (MBC) series. Although rare, MBC deserves attention because male and female breast cancers share many characteristics, including the involvement of genetic predisposition factors such as BRCA1/BRCA2 mutations. Indeed, the occurrence of MBC is a commonly used criterion to select families for BRCA mutation testing. We evaluated the performance and clinical effectiveness of four different predictive models in a population-based series of 102 Italian MBC patients characterized for BRCA1/2 mutations. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated for each risk model at the 10% threshold. The area under the ROC (AUC) curves and its corresponding asymptotic 95% CIs were calculated as a measure of the accuracy. In our study, the BRCAPRO version 5.0 had the highest combination of sensitivity, specificity, NPV and PPV for the combined probability and for the discrimination of BRCA2 mutations. In individuals with negative breast–ovarian cancer family history, BRCAPRO 5.0 reached a high discriminatory capacity (AUC=0.92) in predicting BRCA2 mutations and showed values of sensitivity, specificity, NPV and PPV of 0.5, 0.98, 0.97 and 0.67, respectively, for the combined probability. BRCAPRO version 5.0 can be particularly useful in dealing with non-familial MBC, a circumstance that often represents a challenging situation in genetic counseling.

Gene promoter methylation and DNA repair capacity in monozygotic twins with discordant smoking habits

The influence of DNA repair capacity, plasma nutrients and tobacco smoke exposure on DNA methylation was investigated in blood cells of twenty-one couples of monozygotic twins with discordant smoking habits. All study subjects had previously been characterized for mutagen sensitivity with challenge assays with ionizing radiation in peripheral blood lymphocytes. Plasma levels of folic acid, vitamin B12 and homocysteine were also available from a previous investigation. In this work DNA methylation in the promoter region of a panel of ten genes involved in cell cycle control, differentiation, apoptosis and DNA repair (p16, FHIT, RAR, CDH1, DAPK1, hTERT, RASSF1A, MGMT, BRCA1 and PALB2) was assessed in the same batches of cells isolated for previous studies, using the methylation-sensitive high-resolution melting technique. Fairly similar profiles of gene promoter methylation were observed within co-twins compared to unrelated subjects (p= 1.23 × 10(-7)), with no significant difference related to smoking habits (p = 0.23). In a regression analysis the methylation index of study subjects, used as synthetic descriptor of overall promoter methylation, displayed a significant inverse correlation with radiation-induced micronuclei (p = 0.021) and plasma folic acid level (p = 0.007) both in smokers and in non-smokers. The observed association between repair of radiation-induced DNA damage and promoter methylation suggests the involvement of the DNA repair machinery in DNA modification. Data also highlight the possible modulating effect of folate deficiency on DNA methylation and the strong influence of familiarity on the individual epigenetic profile.

HeR2-positive male breast cancer: an update

Although rare, male breast cancer (MBC) remains a substantial cause for morbidity and mortality in men. Based on age frequency distribution, age-specific incidence rate pattern, and prognostic factor profiles, MBC is considered similar to postmenopausal breast cancer (BC). Compared with female BC (FBC), MBC cases are more often hormonal receptor (estrogen receptor/progesterone receptor [ER/PR]) positive and human epidermal growth factor receptor 2 (HER2) negative. Treatment of MBC patients follows the same indications as female postmenopausal with surgery, systemic therapy, and radiotherapy. To date, ER/PR and HER2 status provides baseline predictive information used in selecting optimal adjuvant/neoadjuvant therapy and in the selection of therapy for recurrent or metastatic disease. HER2 represents a very interesting molecular target and a number of compounds (trastuzumab [Herceptin®; F. Hoffmann-La Roche, Basel, Switzerland] and lapatinib [Tykerb®, GlaxoSmithKline, London, UK]) are currently under clinical evaluation. Particularly, trastuzumab, a monoclonal antibody which selectively binds the extracellular domain of HER2, has become an important therapeutic agent for women with HER2-positive (HER2+) BC. Currently, data regarding the use of trastuzumab in MBC patients is limited and only few case reports exist. In all cases, MBC patients received trastuzumab concomitantly with other drugs and no severe toxicity above grade 3 was observed. However, MBC patients that would be candidate for trastuzumab therapy (ie, HER2+/ER+ or HER2+/ER- MBCs) represent only a very small percentage of MBC cases. This is noteworthy, when taking into account that trastuzumab is an important and expensive component of systemic BC therapy. Since there is no data supporting the fact that response to therapy is different for men or women, we concluded that systemic therapy in MBC should be considered on the same basis as for FBC. Particularly in male patients, trastuzumab should be considered exclusively for advanced disease or high-risk HER2+ early BCs. On the other hand, lapatinib (Tykerb), a novel oral dual tyrosine kinase inhibitor that targets both HER2 and epidermal growth factor receptor, may represent an interesting and promising therapeutic agent for trastuzumab-resistant MBC patients.