The Importance of Distinguishing Sporadic Cancers from Those Related to Cancer Predisposing Germline Mutations
Authors: Sorscher Steven 
Published: June 2018

Abstract

Choosing the optimal therapy for a patient's cancer has long been based on whether the cancer demonstrates a predictive marker of efficacy. The U.S. Food and Drug Administration (FDA) has now approved use of a targeted therapy based solely on tumor molecular markers (pembrolizumab for tumors with deficient mismatch repair [MMR] and high microsatellite instability [MSI]) and approved another therapy based solely on a germline mutation as the predictive marker of benefit (olaparib for BRCA carriers with ovarian or breast cancer) [New Engl J Med 2017;377:1409–1412, N Engl J Med 2012;366:1382–1392, N Eng J Med 2017;377:523–533].
Here, a patient is presented with a molecular diagnosis of Lynch syndrome and with breast cancer. Yet the breast cancer showed proficient expression of the same MMR gene found to be mutated in her germline testing. The case underscores the importance of tumor testing for MMR and MSI and of not assuming that the tumor is related to the Lynch syndrome rather than being sporadic. This is particularly true in patients with cancers (e.g., breast cancer) whose association with Lynch syndrome is not well established.
The case presented also underscores the importance of considering next-generation sequencing of the tumor when the therapies approved are based on a germline mutation being the predictive marker. For example, the FDA-approved use of the PARP inhibitor olaparib is for ovarian or breast cancers in patients harboring a BRCA germline mutation [N Engl J Med 2012;366:1382–1392, N Eng J Med 2017;377:523–533]. Yet patients with tumors lacking BRCA loss of heterozygosity (LOH) or lacking other evidence of probable loss of normal BRCA gene product expression might be less likely to benefit from PARP inhibitor therapy, because the efficacy of PARP inhibitor therapy in patients with germline BRCA mutations would likely be predicated upon BRCA LOH in their tumors.

Key Points
Cancers in patients with germline mutations may be sporadic and unrelated to the germline mutation. Lynch syndrome is due to a germline mutated mismatch repair (MMR) gene. Cancers resulting from the germline MMR gene mutation as the predisposing event would be expected to be MMR deficient (dMMR) and microsatellite instability high (MSI-H). Sporadic cancers in patients with Lynch syndrome would be expected to be MMR proficient or microsatellite stable. Pembrolizumab is only approved for solid tumors demonstrating dMMR/MSI-H. Thus, whether the cancer tissue of origin is clearly associated with Lynch syndrome or not yet clearly established as a Lynch syndrome-related cancer (e.g., breast cancer), establishing the tumor to be dMMR/MSI-H is necessary to predict possible benefit and endorse the use of pembrolizumab. Ovarian cancers that develop in BRCA germline mutation carriers are so often related to the inherited mutated BRCA as the predisposing factor that testing the tumor for the footprint of BRCA-related ovarian cancer (BRCA loss of heterozygosity) is not necessary for use of the PARP inhibitor therapy olaparib. Future studies that include tumor evaluation for normal BRCA expression or surrogates of normal BRCA gene product expression might help determine which patients harboring a germline BRCA mutation are most likely to benefit from PARP inhibitor therapy.