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Is Uterine Serous Papillary Carcinoma a BRCA1-Related Disease? Case Report and Review of the Literature
Gynecologic Oncology 75, 300 –304 (1999) Article ID gyno.1999.5568, available online at http://www.idealibrary.com on
CASE REPORT Is Uterine Serous Papillary Carcinoma a BRCA1-Related Disease? Case Report and Review of the Literature Gila Hornreich, M.D.,* Uziel Beller, M.D.,* Ofer Lavie, M.D.,* Paul Renbaum, Ph.D.,† Yoram Cohen, M.D.,* and Ephrat Levy-Lahad, M.D.† *Division of Gynecologic Surgery & Oncology and †Department of Medicine A and Genetics Laboratory, Shaare Zedek Medical Center, Jerusalem 91031, Israel Received January 22, 1999
Objectives. Type II endometrial carcinomas are estrogen-independent and have adverse histologic features and a substantially poorer prognosis. No risk factors have been identified. Interestingly, there is a striking clinical and histopathological similarity between serous papillary carcinomas of the ovary (OSPC), endometrium, and peritoneal cavity, suggesting a common oncogenic mechanism. Several common molecular alterations were found using molecular comparative analysis of OSPC and uterine serous papillary carcinoma (USPC). Germline mutations in the BRCA1 tumor suppressor gene predispose to breast and ovarian cancer but no association with sporadic endometrial cancer has been found. A family of Ashkenazi Jewish origin, in which one sister was first diagnosed with USPC and the second diagnosed with OSPC, led to the hypothesis that a BRCA mutation may contribute to USPC. Methods. Genomic DNA from both patients as well as two unaffected siblings was analyzed for the three mutations common in Ashkenazi Jews. Loss of heterozygosity (LOH) analysis was performed on DNA extracted from USPC tumor tissue. Results. Both affected sisters tested positive for BRCA1 5382insC germline mutation. LOH analysis confirmed the results. Conclusions. We present a breast– ovarian cancer family including two sisters with advanced serous papillary carcinomas of endometrial and ovarian origins, carrying the same BRCA1 mutation (5382insC). LOH analysis on USPC tumor DNA showed loss of the wild-type allele, suggesting a causal relationship between the germline BRCA1 mutation and USPC. We believe a study examining BRCA1 mutations in a large cohort of women with this high-risk endometrial carcinoma is warranted. A positive finding may have implications for surveillance and prophylactic surgery in carriers of BRCA1 mutations. © 1999 Academic Press
INTRODUCTION Endometrial cancer is the fourth most frequent cancer in women and the most curable among the gynecologic cancers. Risk factors well established to date include exposure to un-
0090-8258/99 $30.00 Copyright © 1999 by Academic Press All rights of reproduction in any form reserved.
opposed estrogen, obesity, diabetes mellitus, and hypertension [1]. The genetic basis of endometrial cancer has not yet been extensively investigated. In 1966, Lynch et al. first suggested that inheritance of certain genetic factors might also contribute to the development of endometrial cancer [2] and went on to describe the Lynch type II familial cancer syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC), which consists of uterine, colon, ovarian, and other multiple malignancies [3– 6]. Two major variants of endometrial cancer are well recognized, one that tends to be estrogen-dependent (type I) and the other that is estrogen-independent (type II). The two types have distinctly different prognoses. Tumors associated with the well-known risk factors and which tend to be estrogen-dependent usually demonstrate favorable characteristics, including lower grade, earlier stage at diagnosis, and fewer instances of myometrial invasion and distant metastases. Women with type II endometrial cancer, on the other hand, have adverse histologic features, including poorly differentiated tumors, papillary serous and clear-cell types, deep myometrial invasion, and extrauterine disease. Risk factors for type II endometrial cancer, which has a substantially poorer prognosis, have not been identified [1]. Sherman et al. [7] suggested a concept of two distinct pathways for endometrial carcinogenesis: a highly aggressive p53 mutation-driven serous carcinoma and a relatively indolent estrogen-driven endometrioid carcinoma. Certainly, a better understanding of the molecular biology of endometrial cancer will provide insights into the variable behavior of this disease. Previous studies have suggested that family history may be a risk factor for adverse features of endometrial cancer. Boltenberg et al. [8] noted in 1990 that endometrial carcinomas, occurring in conjunction with multiple neoplasia and other “familial” expressions of cancer predisposition, were associated with anaplastic, poorly differentiated tumors, advanced
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stage, and poor prognosis. Sandles et al. [9] reported that familial cases of endometrial adenocarcinoma, most likely due to an inherited predisposition, are associated with a more advanced stage at presentation and/or a poorer prognosis compared to sporadic cases. These groups suggested the existence of at least two distinct genetic models playing a role in the development of endometrial adenocarcinomas: HNPCC (Lynch II syndrome) and site-specific endometrial adenocarcinoma. Taken together, these studies suggest that family history may be a more important risk factor for aggressive, i.e., type II, uterine cancer, which is therefore more likely to have a genetic basis. Hereditary ovarian cancer has been researched extensively over the past few years. Before identification of specific genes conferring susceptibility, it was known to be predominantly of the serous papillary type, occurring at a significantly early age and associated with an excess of breast, colorectal, and endometrial cancers in first-degree relatives [10]. Since 1994, it has been established that germline mutations in BRCA1, a tumor suppressor gene on chromosome 17q21, account for a large proportion of inherited predispositions to breast and ovarian cancer [11]. Although an excess of endometrial cancer has not been observed in BRCA1 pedigrees [11, 12], the striking similarity in clinical presentation, histopathologic appearance, and poor prognosis between serous papillary carcinomas of the endometrium, ovary, and peritoneal cavity suggests possible common oncogenic mechanisms [13]. Indeed, a high frequency of BRCA1 mutations (11%) has been observed in women with papillary serous carcinoma of the peritoneum, and a causal relationship was suggested by demonstrating loss of heterozygosity for the BRCA1 region in the tumors [14]. The following case report provides the first evidence of a possible genetic association between a germline BRCA1 mutation and serous papillary carcinoma of endometrial origin. This finding may be significant both in delineating a further manifestation of the BRCA1 cancer syndrome and in providing additional insight into the pathogenesis of endometrial and ovarian malignancies. CASE REPORT Patient 1 is a 53-year-old woman, who presented to our department following an episode of postmenopausal bleeding. She had entered natural menopause at the age of 46 and had never received hormone-replacement therapy. An endometrial biopsy was performed, which revealed serous papillary endometrial carcinoma. She underwent surgical staging, including total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), and pelvic and para-aortic lymph node sampling. Final pathology confirmed the diagnosis of serous papillary endometrial carcinoma invading over 50% of the myometrium and involving the upper cervix, the left ovary, and
para-aortic lymph nodes (stage IIIC). The patient was treated by six courses of adjuvant platinum-based combination chemotherapy regimen (CAP) and 20 months later she is free of disease. Nine months following the diagnosis in patient 1, her sister, a 48-year-old woman, married with 5 children, began complaining of lower abdominal pain. She underwent a full gynecologic evaluation, which revealed an enlarged, left ovarian complex mass 5 3 3.2 cm. Tumor markers were elevated: CA-1255336 IU/ml and CA-15-35113 IU/ml. An exploratory laparotomy demonstrated extensive peritoneal carcinomatosis and she underwent TAH, BSO, omentectomy, lymph node sampling, and resection of the sigmoid colon. The pathological report showed moderately to poorly differentiated serous papillary adenocarcinoma of the ovary involving ovaries, omentum, and serosa of the descending colon (stage IIIC). Following optimal debulking surgery, she has completed six cycles of combination chemotherapy (paclitaxel-carboplatin) and has no evidence of disease. The patients are of Ashkenazi Jewish descent. Their family history includes ovarian cancer in another sister recently diagnosed (unavailable for testing), one second-degree relative with breast cancer (diagnosed at age 48), and one seconddegree relative with colon cancer (age 60), as well as four third-degree relatives with breast cancer, all first manifested premenopausaly in their thirties. Both sisters received genetic counseling and gave informed consent to testing for BRCA1 and BRCA2 germline mutations common in Ashkenazi Jews. METHODS Mutation Analysis Genomic DNA was extracted from peripheral blood samples by a standard salting out procedure [15]. In addition to the two above-mentioned patients, we tested two unaffected siblings (a brother and sister). Mutation analysis was performed for the three mutations common in Ashkenazi Jews (BRCA1185delAG and -5382insC, and BRCA2-6174delT). This was done by “mismatch” PCR: one of each pair of primers includes one or more mismatched nucleotide(s), which creates a restriction site in combination with the wild-type allele, but not with the mutant allele. Mutant alleles are therefore observed as uncut bands. Suspected mutations were confirmed with a second mismatch PCR, in which a restriction site is created in combination with the mutant allele, but not the wild-type allele. Primer sequences for detection of the BRCA1-5382insC mutation are F1: 59 CCA AAG CGA GCA AGC CAA TCC C 39 R1: 59 ACA AAA TGA AGC GGC CCA TCT C 39 The F1 primer in combination with the wild-type sequence
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creates a BslI site. PCR conditions were 94°C for 2 min followed by 35 cycles of 94°C for 20 s, 66°C for 1 min. Products were digested with BslI and run on 4% NuSieve 3:1 (FMC Bioproducts) agarose gels. Confirmation of the BRCA1-5382insC mutation was performed with the following primers: F2: AGT GAT CTG CCT GCC TCA GTC T 39 R2: GAC GGG AAT CCA AAT TAC ACA G 59. The F2 primer in combination with 5382insC creates an MvaI restriction site. PCR conditions were 95°C for 2 min followed by 35 cycles of 94°C for 20 s, 56°C for 20 s, and 72°C for 40 s. Loss of Heterozygosity Analysis DNA was extracted from paraffin-embedded tumor sample, using the MasterPure DNA purification kit (Epicentre Technologies, WI). Both tumor and genomic DNA samples were analyzed for D17S855, an intragenic BRCA1 dinucleotide repeat marker (Genome Database). The AFM248yg9m primer was 59 end-labeled with 32P using polynucleotide kinase (MBI Fermentas). Amplification was performed with 1 mM labeled AFM248yg9m and 1 mM unlabeled AFM248yg9a primers. PCR conditions were 95°C for 2 min followed by 35 cycles of 94°C for 20 s, 52°C for 20 s, and 72°C for 40 s. Genomic and tumor PCR products were run in tandem on 6% acrylamide denaturing gels containing 7 M urea and 30% formamide. Alleles were detected by autoradiography. RESULTS Mutation Analysis Both sisters were found to carry the BRCA1 5382insC germline mutation, which occurs in 0.1% of Ashkenazi Jews [12, 16]. Loss of Heterozygosity Analysis Of the two unaffected siblings, one was found to be a BRCA1 5382insC carrier, and one was not. Comparing segregation of D17S855 alleles with BRCA1-5382insC status allowed identification of the mutant and wild-type D17S855 alleles among these siblings. Uterine serous papillary carcinoma (USPC) tumor DNA from patient 1 exhibited loss of the wild-type allele. DISCUSSION We report a family with BRCA1-related breast– ovarian cancer syndrome, in which a BRCA1 mutation carrier developed USPC. Ashkenazi Jews are known to have a high population frequency of both BRCA1 and BRCA2 mutations (;2.5% combined frequency) [17]. As such, the association we report could be a chance coincidence. However, the uterine
tumor showed loss of the wild-type BRCA1 allele, as expected from Knudson’s “two-hit” hypothesis. This strongly supports a causal relationship between BRCA1 and USPC. To the best of our knowledge this is the first clinical evidence of this association. USPC, serous papillary peritoneal carcinoma (SPPC), and serous papillary carcinoma of the ovary share both morphological and biochemical features. All three neoplasms have a similar aggressive biological behavior and are typically diagnosed at an advanced stage. It has been observed that these tumors typically behave as intra-abdominal multifocal processes and progress accordingly [18, 19]. Since BRCA1 is clearly implicated in ovarian cancer and has recently been reported to play a role in SPPC [14], an association of BRCA1 with USPC is consistent with the similarity between these tumors. Caduff et al. [20] compared molecular alterations in histologically homologous ovarian and uterine carcinomas, among them allelic loss of markers on 17q (within and distal to BRCA1) and p53 overexpression. They compared both endometrioid and serous papillary carcinomas of ovarian and uterine origin. Both p53 expression and loss of heterozygosity on 17q were seen in similarly high proportions of uterine (75 and 43%, respectively) and ovarian (62 and 64%, respectively) serous papillary carcinomas, unlike their endometrioid-type counterparts. A particularly noteworthy finding in this study was a high frequency of specific loss of heterozygosity of 17q21 in the serous papillary carcinomas of the endometrium, contrasting with its absence in the endometrioid-type carcinomas of the endometrium. They concluded that endometrioid tumors of the ovary and endometrium, although histologically similar, might arise from different genetic events, whereas uterine serous papillary carcinoma shares with its ovarian counterpart several molecular alterations that may account for its aggressive clinical behavior. This is consistent with the results of Liu et al. [21], who analyzed 33 endometrioid adenocarcinomas and could not document an association between alteration of BRCA1 and sporadic endometrial cancers. They concluded that there was no association between the two. Thus, BRCA1 is most likely not involved in endometrioid uterine adenocarcinoma, but there is indirect evidence that it may contribute to USPC. The case we describe offers further evidence for the role of BRCA1 in the pathogenesis of USPC. Direct molecular analysis of BRCA1 in multiple cases of USPC is yet to be performed. There is epidemiological evidence for an inherited predisposition to endometrial cancer, both from pedigree studies in endometrial cancer patients [8, 9] and from population-based studies [22]. The Cancer and Steroid Hormone Study Group [22] found that history of endometrial cancer in a first-degree relative increased endometrial cancer risk by 2.8 (95% CI 1.9 – 4.2). Furthermore, in different studies, up to 16% of endometrial cancer patients were found to have multiple ma-
CASE REPORT
lignancies [23, 24]. At least half of this familial risk is not related to HNPCC [25]. However, it should be noted that in families segregating BRCA1 and BRCA2 mutations, no excess of uterine cancer has been observed [11, 12]. Our observation of USPC in a BRCA1 carrier may represent a rare manifestation of the BRCA1 cancer syndrome or one that is specific to the mutation observed in this family, namely 5382insC. Another possibility, although less likely, is that a true excess of USPC in BRCA1 carriers has been obscured by lumping USPC with the much more common endometrioid uterine cancers or from misclassification of USPC as ovarian carcinoma, particularly in families with ovarian cancer history. These issues can be addressed by large-scale studies both in families segregating BRCA1 mutations and in patients with USPC. Screening and prevention are major issues being raised today as we uncover the genetic basis for many diseases. Watson et al. [26], when investigating the risk of endometrial cancer in hereditary nonpolyposis colorectal cancer, concluded that interventions to reduce endometrial cancer morbidity and mortality are justified by the risk levels observed in specific families. They further went on to state that prophylactic TAH and BSO should be recommended to certain women in HNPCC families. It has become common practice today to recommend that women with a strong family history of breast– ovarian cancer or with a confirmed mutation in the BRCA1 gene undergo prophylactic BSO [27–29]. Though we estimate that this procedure provides up to 98% protection from future development of ovarian cancer, we believe that it is the best we have to offer these women at high risk [29]. However, the findings presented here raise the issue of including total hysterectomy as part of a prophylactic procedure. We believe that the possible association of serous papillary carcinoma of the endometrium with a BRCA1 mutation should be investigated in a large cohort of women. If this association proves to be valid, women undergoing counseling for prophylactic surgery should also be provided with information concerning their risk of developing high-risk endometrial cancer. ACKNOWLEDGMENTS We thank Ms. Gaya Klein for excellent technical assistance. This study was supported in part by a grant from ICRF (Israel Cancer Research Fund) (to ELL) and by a gift from the Basker family in loving memory of Eileen Basker.
REFERENCES 1. Rose PG: Medical progress, endometrial carcinoma. N Engl J Med 335: 640 – 649, 1996 2. Lynch HT, Krush AJ, Larsen AL, Magnuson CW: Endometrial carcinoma: multiple primary malignancies, constitutional factors, and heredity. Am J Med Sci 252:381–390, 1966 3. Lynch HT, Lanspa S, Smyrk T, Boman B, Watson P, Lynch J: Hereditary nonpolyposis colorectal cancer (Lynch syndromes I & II). Genetics, pathology, natural history, and cancer control, Part I. Cancer Genet Cytogenet 53:143–160, 1991
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4. Lynch HT, Krush AJ, Larsen AL: Heredity and endometrial carcinoma. South Med J 60:231–235, 1967 5. Hakala T, Mecklin JP, Forss M, Jarvinen H, Lehtovirta P: Endometrial carcinoma in the cancer family syndrome. Cancer 68:1656 –1659, 1991 6. Watson P, Lynch HT: Extracolonic cancer in hereditary nonpolyposis colorectal cancer. Cancer 71:677– 685, 1993 7. Sherman ME, Bur ME, Kurman RJ: p53 in endometrial cancer and its putative precursors: evidence for diverse pathways of tumorigenesis. Hum Pathol 26:1268 –1274, 1995 8. Boltenberg A, Furgyik S, Kullander S: Familial cancer aggregation in cases of adenocarcinoma corporis uteri. Acta Obstet Gynecol Scand 69: 249 –258, 1990 9. Sandles LG, Shulman LP, Elias S, Photopulos GJ, Smiley LM, Posten WM, Simpson JL: Endometrial adenocarcinoma: genetic analysis suggesting heritable site-specific uterine cancer. Gynecol Oncol 47:167–171, 1992 10. Bewtra C, Watson P, Conway T, Read-Hippee C, Lynch HT: Hereditary ovarian cancer: a clinicopathological study. Int J Gynecol Pathol 11:180 – 187, 1992 11. Ford D, Easton DF, Bishop DT, Narod SA, Goldgar DE: Risks of cancer in BRCA1-mutation carriers. Breast Cancer Linkage Consortium. Lancet 343:692– 695, 1994 12. Struewing JP, Hartge P, Wacholder S, Baker SM, Berlin M, McAdams M, Timmerman MM, Brody LC, Tucker MA: The risk of cancer associated with specific mutations of BRCA1 and BRCA2 among Ashkenazi Jews [see comments]. N Engl J Med 336:1401–1408, 1997 13. Moll UM, Valea F, Chumas J: Role of p53 alteration in primary peritoneal carcinoma. Int J Gynecol Pathol 16:156 –162, 1997 14. Bandera CA, Muto MG, Schorge JO, Berkowitz RS, Rubin SC, Mok SC: BRCA1 gene mutations in women with papillary serous carcinoma of the peritoneum. Obstet Gynecol 92:596 – 600, 1998 15. Miller SA, Dykes DD, Polesky HF: A simple salting out procedure for extracting DNA from human nucleated cells. Nucleic Acids Res 16:1215, 1988 16. Levy-Lahad E, Catane R, Eisenberg S, Kaufman B, Hornreich G, Lishinsky E, Shohat M, Weber BL, Beller U, Lahad A, Halle D: Founder BRCA1 and BRCA2 mutations in Ashkenazi Jews in Israel: frequency and differential penetrance in ovarian cancer and in breast– ovarian cancer families [see comments]. Am J Hum Genet 60:1059 –1067, 1997 17. Roa BB, Boyd AA, Volcik K, Richards CS: Ashkenazi Jewish population frequencies for common mutations in BRCA1 and BRCA2. Nat Genet 14:185–187, 1996 18. Sherman ME, Bitterman P, Rosenshein NB, Delgado G, Kurman RJ: Uterine serous carcinoma. A morphologically diverse neoplasm with unifying clinicopathologic features. Am J Surg Pathol 16:600 – 610, 1992 19. Muto MG, Welch WR, Mok SC, Bandera CA, Fishbaugh PM, Tsao SW, Lau CC, Goodman HM, Knapp RC, Berkowitz RS: Evidence for a multifocal origin of papillary serous carcinoma of the peritoneum. Cancer Res 55:490 – 492, 1995 20. Caduff RF, Svoboda-Newman SM, Bartos RE, Ferguson AW, Frank TS: Comparative analysis of histologic homologues of endometrial and ovarian carcinoma. Am J Surg Pathol 22:319 –326, 1998 21. Liu FS, Ho ESC, Shih RT, Shih A: Mutational analysis of the BRCA1 tumor suppressor gene in endometrial carcinoma. Gynecol Oncol 66:449 – 453, 1997 22. Gruber SB, Thompson WD: A population-based study of endometrial cancer and familial risk in younger women. Cancer and Steroid Hormone Study Group. Cancer Epidemiol Biomarkers Prev 5:411– 417, 1996
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23. Annegers JF, Malkasian GD Jr: Patterns of other neoplasia in patients with endometrial carcinoma. Cancer 48:856 – 859, 1981 24. Schwartz Z, Ohel G, Birkenfeld A, Anteby SO, Schenker JG: Second primary malignancy in endometrial carcinoma patients. Gynecol Oncol 22:40 – 45, 1985 25. Sandles LG: Familial endometrial adenocarcinoma. Clin Obstet Gynecol 41:167–171, 1998 26. Watson P, Vasen HF, Mecklin JP, Jarvinen H, Lynch HT: The risk of endometrial cancer in hereditary nonpolyposis colorectal cancer. Am J Med 96:516 –520, 1994
27. Tobacman JK, Greene MH, Tucker MA, Costa J, Kase R, Fraumeni JF Jr: Intra-abdominal carcinomatosis after prophylactic oophorectomy in ovarian-cancer-prone families. Lancet 2:795–797, 1982 28. Schrag D, Kuntz KM, Garber JE, Weeks JC: Special Report: Decision analysis— effects of prophylactic mastectomy and oophorectomy on life expectancy among women with BRCA1 or BRCA2 mutations. N Engl J Med 336:1464 –1471, 1997 29. Piver MS, Jishi MF, Tsukada Y, Nava G: Primary peritoneal carcinoma after prophylactic oophorectomy in women with a family history of ovarian cancer. A report of the Gilda Radner Familial Ovarian Cancer Registry. Cancer 71:2751–2755, 1993
CASE REPORT Is Uterine Serous Papillary Carcinoma a BRCA1-Related Disease? Case Report and Review of the Literature Gila Hornreich, M.D.,* Uziel Beller, M.D.,* Ofer Lavie, M.D.,* Paul Renbaum, Ph.D.,† Yoram Cohen, M.D.,* and Ephrat Levy-Lahad, M.D.† *Division of Gynecologic Surgery & Oncology and †Department of Medicine A and Genetics Laboratory, Shaare Zedek Medical Center, Jerusalem 91031, Israel Received January 22, 1999
Objectives. Type II endometrial carcinomas are estrogen-independent and have adverse histologic features and a substantially poorer prognosis. No risk factors have been identified. Interestingly, there is a striking clinical and histopathological similarity between serous papillary carcinomas of the ovary (OSPC), endometrium, and peritoneal cavity, suggesting a common oncogenic mechanism. Several common molecular alterations were found using molecular comparative analysis of OSPC and uterine serous papillary carcinoma (USPC). Germline mutations in the BRCA1 tumor suppressor gene predispose to breast and ovarian cancer but no association with sporadic endometrial cancer has been found. A family of Ashkenazi Jewish origin, in which one sister was first diagnosed with USPC and the second diagnosed with OSPC, led to the hypothesis that a BRCA mutation may contribute to USPC. Methods. Genomic DNA from both patients as well as two unaffected siblings was analyzed for the three mutations common in Ashkenazi Jews. Loss of heterozygosity (LOH) analysis was performed on DNA extracted from USPC tumor tissue. Results. Both affected sisters tested positive for BRCA1 5382insC germline mutation. LOH analysis confirmed the results. Conclusions. We present a breast– ovarian cancer family including two sisters with advanced serous papillary carcinomas of endometrial and ovarian origins, carrying the same BRCA1 mutation (5382insC). LOH analysis on USPC tumor DNA showed loss of the wild-type allele, suggesting a causal relationship between the germline BRCA1 mutation and USPC. We believe a study examining BRCA1 mutations in a large cohort of women with this high-risk endometrial carcinoma is warranted. A positive finding may have implications for surveillance and prophylactic surgery in carriers of BRCA1 mutations. © 1999 Academic Press
INTRODUCTION Endometrial cancer is the fourth most frequent cancer in women and the most curable among the gynecologic cancers. Risk factors well established to date include exposure to un-
0090-8258/99 $30.00 Copyright © 1999 by Academic Press All rights of reproduction in any form reserved.
opposed estrogen, obesity, diabetes mellitus, and hypertension [1]. The genetic basis of endometrial cancer has not yet been extensively investigated. In 1966, Lynch et al. first suggested that inheritance of certain genetic factors might also contribute to the development of endometrial cancer [2] and went on to describe the Lynch type II familial cancer syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC), which consists of uterine, colon, ovarian, and other multiple malignancies [3– 6]. Two major variants of endometrial cancer are well recognized, one that tends to be estrogen-dependent (type I) and the other that is estrogen-independent (type II). The two types have distinctly different prognoses. Tumors associated with the well-known risk factors and which tend to be estrogen-dependent usually demonstrate favorable characteristics, including lower grade, earlier stage at diagnosis, and fewer instances of myometrial invasion and distant metastases. Women with type II endometrial cancer, on the other hand, have adverse histologic features, including poorly differentiated tumors, papillary serous and clear-cell types, deep myometrial invasion, and extrauterine disease. Risk factors for type II endometrial cancer, which has a substantially poorer prognosis, have not been identified [1]. Sherman et al. [7] suggested a concept of two distinct pathways for endometrial carcinogenesis: a highly aggressive p53 mutation-driven serous carcinoma and a relatively indolent estrogen-driven endometrioid carcinoma. Certainly, a better understanding of the molecular biology of endometrial cancer will provide insights into the variable behavior of this disease. Previous studies have suggested that family history may be a risk factor for adverse features of endometrial cancer. Boltenberg et al. [8] noted in 1990 that endometrial carcinomas, occurring in conjunction with multiple neoplasia and other “familial” expressions of cancer predisposition, were associated with anaplastic, poorly differentiated tumors, advanced
300
301
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stage, and poor prognosis. Sandles et al. [9] reported that familial cases of endometrial adenocarcinoma, most likely due to an inherited predisposition, are associated with a more advanced stage at presentation and/or a poorer prognosis compared to sporadic cases. These groups suggested the existence of at least two distinct genetic models playing a role in the development of endometrial adenocarcinomas: HNPCC (Lynch II syndrome) and site-specific endometrial adenocarcinoma. Taken together, these studies suggest that family history may be a more important risk factor for aggressive, i.e., type II, uterine cancer, which is therefore more likely to have a genetic basis. Hereditary ovarian cancer has been researched extensively over the past few years. Before identification of specific genes conferring susceptibility, it was known to be predominantly of the serous papillary type, occurring at a significantly early age and associated with an excess of breast, colorectal, and endometrial cancers in first-degree relatives [10]. Since 1994, it has been established that germline mutations in BRCA1, a tumor suppressor gene on chromosome 17q21, account for a large proportion of inherited predispositions to breast and ovarian cancer [11]. Although an excess of endometrial cancer has not been observed in BRCA1 pedigrees [11, 12], the striking similarity in clinical presentation, histopathologic appearance, and poor prognosis between serous papillary carcinomas of the endometrium, ovary, and peritoneal cavity suggests possible common oncogenic mechanisms [13]. Indeed, a high frequency of BRCA1 mutations (11%) has been observed in women with papillary serous carcinoma of the peritoneum, and a causal relationship was suggested by demonstrating loss of heterozygosity for the BRCA1 region in the tumors [14]. The following case report provides the first evidence of a possible genetic association between a germline BRCA1 mutation and serous papillary carcinoma of endometrial origin. This finding may be significant both in delineating a further manifestation of the BRCA1 cancer syndrome and in providing additional insight into the pathogenesis of endometrial and ovarian malignancies. CASE REPORT Patient 1 is a 53-year-old woman, who presented to our department following an episode of postmenopausal bleeding. She had entered natural menopause at the age of 46 and had never received hormone-replacement therapy. An endometrial biopsy was performed, which revealed serous papillary endometrial carcinoma. She underwent surgical staging, including total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), and pelvic and para-aortic lymph node sampling. Final pathology confirmed the diagnosis of serous papillary endometrial carcinoma invading over 50% of the myometrium and involving the upper cervix, the left ovary, and
para-aortic lymph nodes (stage IIIC). The patient was treated by six courses of adjuvant platinum-based combination chemotherapy regimen (CAP) and 20 months later she is free of disease. Nine months following the diagnosis in patient 1, her sister, a 48-year-old woman, married with 5 children, began complaining of lower abdominal pain. She underwent a full gynecologic evaluation, which revealed an enlarged, left ovarian complex mass 5 3 3.2 cm. Tumor markers were elevated: CA-1255336 IU/ml and CA-15-35113 IU/ml. An exploratory laparotomy demonstrated extensive peritoneal carcinomatosis and she underwent TAH, BSO, omentectomy, lymph node sampling, and resection of the sigmoid colon. The pathological report showed moderately to poorly differentiated serous papillary adenocarcinoma of the ovary involving ovaries, omentum, and serosa of the descending colon (stage IIIC). Following optimal debulking surgery, she has completed six cycles of combination chemotherapy (paclitaxel-carboplatin) and has no evidence of disease. The patients are of Ashkenazi Jewish descent. Their family history includes ovarian cancer in another sister recently diagnosed (unavailable for testing), one second-degree relative with breast cancer (diagnosed at age 48), and one seconddegree relative with colon cancer (age 60), as well as four third-degree relatives with breast cancer, all first manifested premenopausaly in their thirties. Both sisters received genetic counseling and gave informed consent to testing for BRCA1 and BRCA2 germline mutations common in Ashkenazi Jews. METHODS Mutation Analysis Genomic DNA was extracted from peripheral blood samples by a standard salting out procedure [15]. In addition to the two above-mentioned patients, we tested two unaffected siblings (a brother and sister). Mutation analysis was performed for the three mutations common in Ashkenazi Jews (BRCA1185delAG and -5382insC, and BRCA2-6174delT). This was done by “mismatch” PCR: one of each pair of primers includes one or more mismatched nucleotide(s), which creates a restriction site in combination with the wild-type allele, but not with the mutant allele. Mutant alleles are therefore observed as uncut bands. Suspected mutations were confirmed with a second mismatch PCR, in which a restriction site is created in combination with the mutant allele, but not the wild-type allele. Primer sequences for detection of the BRCA1-5382insC mutation are F1: 59 CCA AAG CGA GCA AGC CAA TCC C 39 R1: 59 ACA AAA TGA AGC GGC CCA TCT C 39 The F1 primer in combination with the wild-type sequence
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creates a BslI site. PCR conditions were 94°C for 2 min followed by 35 cycles of 94°C for 20 s, 66°C for 1 min. Products were digested with BslI and run on 4% NuSieve 3:1 (FMC Bioproducts) agarose gels. Confirmation of the BRCA1-5382insC mutation was performed with the following primers: F2: AGT GAT CTG CCT GCC TCA GTC T 39 R2: GAC GGG AAT CCA AAT TAC ACA G 59. The F2 primer in combination with 5382insC creates an MvaI restriction site. PCR conditions were 95°C for 2 min followed by 35 cycles of 94°C for 20 s, 56°C for 20 s, and 72°C for 40 s. Loss of Heterozygosity Analysis DNA was extracted from paraffin-embedded tumor sample, using the MasterPure DNA purification kit (Epicentre Technologies, WI). Both tumor and genomic DNA samples were analyzed for D17S855, an intragenic BRCA1 dinucleotide repeat marker (Genome Database). The AFM248yg9m primer was 59 end-labeled with 32P using polynucleotide kinase (MBI Fermentas). Amplification was performed with 1 mM labeled AFM248yg9m and 1 mM unlabeled AFM248yg9a primers. PCR conditions were 95°C for 2 min followed by 35 cycles of 94°C for 20 s, 52°C for 20 s, and 72°C for 40 s. Genomic and tumor PCR products were run in tandem on 6% acrylamide denaturing gels containing 7 M urea and 30% formamide. Alleles were detected by autoradiography. RESULTS Mutation Analysis Both sisters were found to carry the BRCA1 5382insC germline mutation, which occurs in 0.1% of Ashkenazi Jews [12, 16]. Loss of Heterozygosity Analysis Of the two unaffected siblings, one was found to be a BRCA1 5382insC carrier, and one was not. Comparing segregation of D17S855 alleles with BRCA1-5382insC status allowed identification of the mutant and wild-type D17S855 alleles among these siblings. Uterine serous papillary carcinoma (USPC) tumor DNA from patient 1 exhibited loss of the wild-type allele. DISCUSSION We report a family with BRCA1-related breast– ovarian cancer syndrome, in which a BRCA1 mutation carrier developed USPC. Ashkenazi Jews are known to have a high population frequency of both BRCA1 and BRCA2 mutations (;2.5% combined frequency) [17]. As such, the association we report could be a chance coincidence. However, the uterine
tumor showed loss of the wild-type BRCA1 allele, as expected from Knudson’s “two-hit” hypothesis. This strongly supports a causal relationship between BRCA1 and USPC. To the best of our knowledge this is the first clinical evidence of this association. USPC, serous papillary peritoneal carcinoma (SPPC), and serous papillary carcinoma of the ovary share both morphological and biochemical features. All three neoplasms have a similar aggressive biological behavior and are typically diagnosed at an advanced stage. It has been observed that these tumors typically behave as intra-abdominal multifocal processes and progress accordingly [18, 19]. Since BRCA1 is clearly implicated in ovarian cancer and has recently been reported to play a role in SPPC [14], an association of BRCA1 with USPC is consistent with the similarity between these tumors. Caduff et al. [20] compared molecular alterations in histologically homologous ovarian and uterine carcinomas, among them allelic loss of markers on 17q (within and distal to BRCA1) and p53 overexpression. They compared both endometrioid and serous papillary carcinomas of ovarian and uterine origin. Both p53 expression and loss of heterozygosity on 17q were seen in similarly high proportions of uterine (75 and 43%, respectively) and ovarian (62 and 64%, respectively) serous papillary carcinomas, unlike their endometrioid-type counterparts. A particularly noteworthy finding in this study was a high frequency of specific loss of heterozygosity of 17q21 in the serous papillary carcinomas of the endometrium, contrasting with its absence in the endometrioid-type carcinomas of the endometrium. They concluded that endometrioid tumors of the ovary and endometrium, although histologically similar, might arise from different genetic events, whereas uterine serous papillary carcinoma shares with its ovarian counterpart several molecular alterations that may account for its aggressive clinical behavior. This is consistent with the results of Liu et al. [21], who analyzed 33 endometrioid adenocarcinomas and could not document an association between alteration of BRCA1 and sporadic endometrial cancers. They concluded that there was no association between the two. Thus, BRCA1 is most likely not involved in endometrioid uterine adenocarcinoma, but there is indirect evidence that it may contribute to USPC. The case we describe offers further evidence for the role of BRCA1 in the pathogenesis of USPC. Direct molecular analysis of BRCA1 in multiple cases of USPC is yet to be performed. There is epidemiological evidence for an inherited predisposition to endometrial cancer, both from pedigree studies in endometrial cancer patients [8, 9] and from population-based studies [22]. The Cancer and Steroid Hormone Study Group [22] found that history of endometrial cancer in a first-degree relative increased endometrial cancer risk by 2.8 (95% CI 1.9 – 4.2). Furthermore, in different studies, up to 16% of endometrial cancer patients were found to have multiple ma-
CASE REPORT
lignancies [23, 24]. At least half of this familial risk is not related to HNPCC [25]. However, it should be noted that in families segregating BRCA1 and BRCA2 mutations, no excess of uterine cancer has been observed [11, 12]. Our observation of USPC in a BRCA1 carrier may represent a rare manifestation of the BRCA1 cancer syndrome or one that is specific to the mutation observed in this family, namely 5382insC. Another possibility, although less likely, is that a true excess of USPC in BRCA1 carriers has been obscured by lumping USPC with the much more common endometrioid uterine cancers or from misclassification of USPC as ovarian carcinoma, particularly in families with ovarian cancer history. These issues can be addressed by large-scale studies both in families segregating BRCA1 mutations and in patients with USPC. Screening and prevention are major issues being raised today as we uncover the genetic basis for many diseases. Watson et al. [26], when investigating the risk of endometrial cancer in hereditary nonpolyposis colorectal cancer, concluded that interventions to reduce endometrial cancer morbidity and mortality are justified by the risk levels observed in specific families. They further went on to state that prophylactic TAH and BSO should be recommended to certain women in HNPCC families. It has become common practice today to recommend that women with a strong family history of breast– ovarian cancer or with a confirmed mutation in the BRCA1 gene undergo prophylactic BSO [27–29]. Though we estimate that this procedure provides up to 98% protection from future development of ovarian cancer, we believe that it is the best we have to offer these women at high risk [29]. However, the findings presented here raise the issue of including total hysterectomy as part of a prophylactic procedure. We believe that the possible association of serous papillary carcinoma of the endometrium with a BRCA1 mutation should be investigated in a large cohort of women. If this association proves to be valid, women undergoing counseling for prophylactic surgery should also be provided with information concerning their risk of developing high-risk endometrial cancer. ACKNOWLEDGMENTS We thank Ms. Gaya Klein for excellent technical assistance. This study was supported in part by a grant from ICRF (Israel Cancer Research Fund) (to ELL) and by a gift from the Basker family in loving memory of Eileen Basker.
REFERENCES 1. Rose PG: Medical progress, endometrial carcinoma. N Engl J Med 335: 640 – 649, 1996 2. Lynch HT, Krush AJ, Larsen AL, Magnuson CW: Endometrial carcinoma: multiple primary malignancies, constitutional factors, and heredity. Am J Med Sci 252:381–390, 1966 3. Lynch HT, Lanspa S, Smyrk T, Boman B, Watson P, Lynch J: Hereditary nonpolyposis colorectal cancer (Lynch syndromes I & II). Genetics, pathology, natural history, and cancer control, Part I. Cancer Genet Cytogenet 53:143–160, 1991
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4. Lynch HT, Krush AJ, Larsen AL: Heredity and endometrial carcinoma. South Med J 60:231–235, 1967 5. Hakala T, Mecklin JP, Forss M, Jarvinen H, Lehtovirta P: Endometrial carcinoma in the cancer family syndrome. Cancer 68:1656 –1659, 1991 6. Watson P, Lynch HT: Extracolonic cancer in hereditary nonpolyposis colorectal cancer. Cancer 71:677– 685, 1993 7. Sherman ME, Bur ME, Kurman RJ: p53 in endometrial cancer and its putative precursors: evidence for diverse pathways of tumorigenesis. Hum Pathol 26:1268 –1274, 1995 8. Boltenberg A, Furgyik S, Kullander S: Familial cancer aggregation in cases of adenocarcinoma corporis uteri. Acta Obstet Gynecol Scand 69: 249 –258, 1990 9. Sandles LG, Shulman LP, Elias S, Photopulos GJ, Smiley LM, Posten WM, Simpson JL: Endometrial adenocarcinoma: genetic analysis suggesting heritable site-specific uterine cancer. Gynecol Oncol 47:167–171, 1992 10. Bewtra C, Watson P, Conway T, Read-Hippee C, Lynch HT: Hereditary ovarian cancer: a clinicopathological study. Int J Gynecol Pathol 11:180 – 187, 1992 11. Ford D, Easton DF, Bishop DT, Narod SA, Goldgar DE: Risks of cancer in BRCA1-mutation carriers. Breast Cancer Linkage Consortium. Lancet 343:692– 695, 1994 12. Struewing JP, Hartge P, Wacholder S, Baker SM, Berlin M, McAdams M, Timmerman MM, Brody LC, Tucker MA: The risk of cancer associated with specific mutations of BRCA1 and BRCA2 among Ashkenazi Jews [see comments]. N Engl J Med 336:1401–1408, 1997 13. Moll UM, Valea F, Chumas J: Role of p53 alteration in primary peritoneal carcinoma. Int J Gynecol Pathol 16:156 –162, 1997 14. Bandera CA, Muto MG, Schorge JO, Berkowitz RS, Rubin SC, Mok SC: BRCA1 gene mutations in women with papillary serous carcinoma of the peritoneum. Obstet Gynecol 92:596 – 600, 1998 15. Miller SA, Dykes DD, Polesky HF: A simple salting out procedure for extracting DNA from human nucleated cells. Nucleic Acids Res 16:1215, 1988 16. Levy-Lahad E, Catane R, Eisenberg S, Kaufman B, Hornreich G, Lishinsky E, Shohat M, Weber BL, Beller U, Lahad A, Halle D: Founder BRCA1 and BRCA2 mutations in Ashkenazi Jews in Israel: frequency and differential penetrance in ovarian cancer and in breast– ovarian cancer families [see comments]. Am J Hum Genet 60:1059 –1067, 1997 17. Roa BB, Boyd AA, Volcik K, Richards CS: Ashkenazi Jewish population frequencies for common mutations in BRCA1 and BRCA2. Nat Genet 14:185–187, 1996 18. Sherman ME, Bitterman P, Rosenshein NB, Delgado G, Kurman RJ: Uterine serous carcinoma. A morphologically diverse neoplasm with unifying clinicopathologic features. Am J Surg Pathol 16:600 – 610, 1992 19. Muto MG, Welch WR, Mok SC, Bandera CA, Fishbaugh PM, Tsao SW, Lau CC, Goodman HM, Knapp RC, Berkowitz RS: Evidence for a multifocal origin of papillary serous carcinoma of the peritoneum. Cancer Res 55:490 – 492, 1995 20. Caduff RF, Svoboda-Newman SM, Bartos RE, Ferguson AW, Frank TS: Comparative analysis of histologic homologues of endometrial and ovarian carcinoma. Am J Surg Pathol 22:319 –326, 1998 21. Liu FS, Ho ESC, Shih RT, Shih A: Mutational analysis of the BRCA1 tumor suppressor gene in endometrial carcinoma. Gynecol Oncol 66:449 – 453, 1997 22. Gruber SB, Thompson WD: A population-based study of endometrial cancer and familial risk in younger women. Cancer and Steroid Hormone Study Group. Cancer Epidemiol Biomarkers Prev 5:411– 417, 1996
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23. Annegers JF, Malkasian GD Jr: Patterns of other neoplasia in patients with endometrial carcinoma. Cancer 48:856 – 859, 1981 24. Schwartz Z, Ohel G, Birkenfeld A, Anteby SO, Schenker JG: Second primary malignancy in endometrial carcinoma patients. Gynecol Oncol 22:40 – 45, 1985 25. Sandles LG: Familial endometrial adenocarcinoma. Clin Obstet Gynecol 41:167–171, 1998 26. Watson P, Vasen HF, Mecklin JP, Jarvinen H, Lynch HT: The risk of endometrial cancer in hereditary nonpolyposis colorectal cancer. Am J Med 96:516 –520, 1994
27. Tobacman JK, Greene MH, Tucker MA, Costa J, Kase R, Fraumeni JF Jr: Intra-abdominal carcinomatosis after prophylactic oophorectomy in ovarian-cancer-prone families. Lancet 2:795–797, 1982 28. Schrag D, Kuntz KM, Garber JE, Weeks JC: Special Report: Decision analysis— effects of prophylactic mastectomy and oophorectomy on life expectancy among women with BRCA1 or BRCA2 mutations. N Engl J Med 336:1464 –1471, 1997 29. Piver MS, Jishi MF, Tsukada Y, Nava G: Primary peritoneal carcinoma after prophylactic oophorectomy in women with a family history of ovarian cancer. A report of the Gilda Radner Familial Ovarian Cancer Registry. Cancer 71:2751–2755, 1993