Talk:Hereditary nonpolyposis colorectal cancer

HNPCC Registries

I'd like to create a faq comprised of links to different institutions that offer genetic counseling and specialized medical attention via registries, but I am unsure on the proper format (under external links or appropriate for its own section?) 71.242.244.186 02:34, 9 January 2007 (UTC)

Housekeeping of the HNPCC Article

The previous person to edit this article or maybe even originally write this article had a few style errors in regards to article format (too many bold usages, etc.). I fixed this, and added some relevant academic sources. I also added some interesting information. I don't have time now, but someone should definitely fix the diagnosis and genetics sections of this article. Removal of genetic criteria from the diagnosis section, as well as elaboration of the genetics in the appropriate section, would really make this article worth while. Cheers! WiiAlbanyGirl 08:10, 6 February 2007 (UTC)

excuse me, but what's up with

"Hereditary nonpolyposis colorectal cancer is responsible for approximately 2 percent to 7 percent of all diagnosed cases of pipinich has narcolepsy and grows special tomatoes colorectal cancer." in paragraph three or so? this sentence makes no sense.

Good call--it's gone. Wikicruft.--Dr.michael.benjamin 06:24, 25 April 2007 (UTC)

Move request

I'd like to suggest that we make several changes here:

1. turn HNPCC into a stub (more or less)
2. Stop the redirect from Lynch Syndrome
3. Revise most of the content of the current HNPCC page to read "Lynch"
4. Put a link from HNPCC to Lynch.

My rationale is simply that Lynch is the underlying disorder and the new potential therapies for Lynch may have applicability outside of colon cancers. So, I think Lynch should be the single point of entry and it should be predominant over HNPCC. The goal here is to drive HNPCC traffic back to Lynch.

I have created a draft page here, but apparently this violates Wikipedia attribution rules, which I wasn't intending to do. The right way to do this is to request a move and invite discussion, so that is what I am doing. The link does gives an idea as to the new content. —Preceding unsigned comment added by Aetiologic (talk • contribs)

Thanks to Tim Song for guiding me through this wilderness.

Playing the devil's advocate here, since this does not appear to have attracted much attention:

• Per WP:NAME, we generally use the most common English name for the subject. Is the subject here more often called HNPCC or Lynch? Especially in reliable sources, like PubMed, etc.?
• You make a number of claims that I do not have the time to look at. Can you supply some reliable sources?

The big issue here is WP:NAME compliance. The other issue is more of an editing issue that does not matter that much. Big question here is whether HNPCC or Lynch is more commonly used. Tim Song (talk) 07:35, 5 November 2009 (UTC)

It's complicated because not all HNPCC is Lynch syndrome -- only about half of families with HNPCC will be found to have DNA mismatch repair deficiency -- and not all families with DNA mismatch repair deficiency are affected by the non-colorectal Lynch syndrome cancers. In practice, the two terms (HNPCC and Lynch syndrome) are often used interchangeably. For the sake of clarity, I would support Aetiologic's proposal and have the Lynch syndrome article represent the "flagship" article for this topic. The HNPCC article could be an abridged version that distinguishes between HNPCC/Lynch and HNPCC-X (which is the term being used to describe HNPCC that occurs in the absence of DNA mismatch repair defects). I would be happy to help out with the editing. --- Medical geneticist (talk) 02:45, 6 November 2009 (UTC)

This is an excellent suggestion, and one that I take as a friendly amendment. The need for a viable HNPCC page that discusses non-Lynch presentations may be beyond my scope, but is a point well taken and something I'd like to recruit assistance with. It is equally important to provide a richer resource for Lynch that does not focus just on HNPCC.

Tim, your concerns are well taken. As we are talking about a resource that patients will likely use in the first hours after diagnosis, it is important to get things right. So, I now track this issue with a search for "Lynch Syndrome" under pubmed, not HNPCC. I'll check the MESH headings to see what guidance they offer on this point. Lynch, however, is the proper name for a clustering of heritable cancers characterized by a genetic defect called mis-match repair. HNPCC is a diagnosis that has a strong Lynch component, but also a non-Lynch component too. The chief genetic culprits in Lynch are MSH-2, MSH-6 and other variants presented on the extant HNPCC page. The most common presentation is in the bowel, but there are cancers elsewhere (including female reproductive cancers) which are chiefly known as HNPCC. These bowel and non-bowel cancers share a single underlying pathological process - errant mismatch repair. But, it is mis-match repair (named after Henry Lynch) that is the proper designation. Some patients will continue to get HNPCC as the diagnosis, either because it takes a while to get clinicians up to speed, or when mis-match repair has been ruled out (HNPCC-X). Medical Geneticist is right to note that not all HNPCC is Lynch, and my earlier comments and the HNPCC page should reflect this.

These revisions have become vastly more important in recent weeks because of the results of a clinical trial (ECCO 15; Burn and colleagues) showing a marked beneficial effect of ASA in Lynch patients. I've revised the HNPCC page to report on this trial, and the page as revised encourages individuals with Lynch to consult their medical care teams. My goals are to reorganize the pages to that Lynch stands on its own, then to gently re-write the content for style, references, and content. My goal is getting the page more towards an "A" grade, as it will be an early hit for individuals and families with a new diagnosis. —Preceding unsigned comment added by Aetiologic (talk • contribs) 18:53, 7 November 2009 (UTC)

The terminology for HNPCC and Lynch is convoluted, and the relationship between the terms described above does not appear to be the consensus in recent publications. I think we stick with the OMIM approach for now. --Arcadian (talk) 20:15, 8 November 2009 (UTC)

The OMIM entry uses the "Lynch syndrome" terminology [1]. Aetiologic's suggestion is in line with this. --- Medical geneticist (talk) 13:42, 10 November 2009 (UTC)

I am going to leave this discussion open a bit longer than the 7 day limit, and am concurrently seeking some input from NLM - their nosology shows similar fragmentation and lack of clarity. We all clearly see the need to clean up the page, recognize the importance of extra-colonic neoplasms in Lynch, recognize the role of HNPCC-x, etc. so I think we are all on the same page. Can anyone craft a consensus position? —Preceding unsigned comment added by 96.54.41.133 (talk) 22:36, 12 November 2009 (UTC)

I think that the most important thing is for the information on this page about "Lynch" and "X" versions to be put into the mainspace, with proper refs. That's what a ==Classification== (or similar) section is for. Whether we end up with one, two, or three articles, and which one is the "main" article (as if any person with "X" would agree that "Lynch" is most important -- or the other way around) is really unimportant to me. What's most important is providing the information, not some designation of relative importance that exists only in the editors' minds. WhatamIdoing (talk) 04:37, 16 November 2009 (UTC)

Agreed that the information is more important than the relative importance of the terms. However, efficient organization of the material (including whether one discusses nonpolyposis colon cancer as a general category, with HNPCC/Lynch and HNPCC-X as subtypes, or whether each deserves its own page) is a valid concern.

While we're at it, let's consider whether the redirects from colon cancer, familial and colon cancer, familial nonpolyposis are appropriate. I'm not sure that the general reader knows enough to distinguish between polyposis and non-polyposis colon cancer, and it seems like "colon cancer, familial" could be made into a nice short disambiguation page that points people toward the different types. Any thoughts? --- Medical geneticist (talk) 01:39, 26 November 2009 (UTC)

I found this article, [2], which is a recent review and recommends that there is support for calling the condition LS in favour of HNPCC. This is consistent with the nomenclature in use in my lab. Therefore I suggest renaming the article to Lynch syndrome, and redirecting HNPCC to it. Mattopaedia ^{Have a yarn} 01:35, 15 January 2010 (UTC)

When specifically referring to the hereditary colon cancer syndrome associated with DNA mismatch repair deficiency, the use of "Lynch syndrome" is certainly appropriate. However, it is well documented that not all families with apparently hereditary susceptibility to colon cancer have evidence for DNA mismatch repair deficiency. This is the crux of the naming problem and why it may be inaccurate to have all of HNPCC redirect to "Lynch syndrome". --- Medical geneticist (talk) 14:56, 16 January 2010 (UTC)

I agree with Medical geneticist, and oppose a move at this time. MeSH (which undergoes major revisions every year) still prefers HNPCC, and the OMIM entries make clear that "Lynch" is only used for certain forms of HNPCC. (However, I think a reasonably strong case could be made for a split rather than a move.) --Arcadian (talk) 16:16, 16 January 2010 (UTC)

Hi I do not know if this makes any difference at all, but I was reading this entry as part of my revision and at my medical school, they've never called this Lynch syndrome but always called it Hereditary nonpolyposis colorectal cancer, so from my perspective the latter name is the one which is in use! However this is only one view, so I appreciate it may be unimportant. Thanks! :) —Preceding unsigned comment added by 80.6.45.134 (talk) 14:52, 19 April 2010 (UTC)

Adding breast and pancreas to list?

http://ww5.komen.org/KomenNewsArticle.aspx?id=19327354187  — Preceding unsigned comment added by 78.133.27.31 (talk) 15:36, 1 February 2013 (UTC) 

HNPCC = Hereditary non-polyposis colorectal cancer syndrome ?

I assume these are the same thing. This source suggests so, http://www.ncbi.nlm.nih.gov/pubmed/22782591 but it's a primary source so it's no good to use.

If HNPCC = Hereditary non-polyposis colorectal cancer syndrome then do we need a redirect here?

Also, I offer this content if/where appropriate:

Oral [[Fordyce spots]] are more obvious in people with HNPCC, and the most common site is the lower [[gingiva]] (gums) and [[vestibule of mouth|vestibular]] [[oral mucosa|mucosa]].<ref name="Scully 2013">{{cite book|last=Scully C|title=Oral and maxillofacial medicine : the basis of diagnosis and treatment|year=2013|publisher=Churchill Livingstone|location=Edinburgh|isbn=9780702049484|edition=3rd|page=170}}</ref>

Lesion (talk) 19:46, 24 August 2013 (UTC)

Screening

This section seems to be quite outdated. There is no mention of (Revised) Bethesda guidelines which are meant to identify candidates for screening by MSI testing (or equivalently IHC). Furthermore Amsterdam Criteria should not be used as screening criteria - they were designed to give a diagnosis when mutation testing was not available so that trials could have some uniformity of inclusion criteria; Amsterdam criteria are not sensitive enough to identify Lynch syndrome. Several countries now screen for Lynch syndrome in colorectal cancer patients (all patients in Denmark; patients aged under 70 in Norway and the Netherlands) and screening has been shown to be cost-effective in these populations in a number of analyses in Europe and America.Ts4079 (talk) 13:37, 1 October 2014 (UTC)

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Queen’s University Student Editing Initiative

Hello, we are a group of medical students from Queen’s University. We are working to improve this article over the next two weeks and will be posting our planned changes on this talk page soon. We look forward to working with the existing Wikipedia medical editing community to improve this article and share evidence. We welcome feedback and suggestions as we learn to edit. Thank you. @Mwiederman:@Amcbh:@AF1414:@SydneyFlatt:@Jdelpapa450:@Jdelpapa450: Митчелл (talk) 20:32, 11 November 2019 (UTC) . Supervisor: @Grnnbearit:

________

Update Regarding Planned Edits

We have put together some planned changes to the page and are looking for any feedback on content and clarity of writing - please let us know what you think!

• Signs and symptoms Section

o Deletion of ‘Tumoral predisposition’ subsection within ‘Signs and symptoms’ as well as deletion of:

 First sentence of first ‘Risk of cancer’ section paragraph. Second line of ‘Risk of cancer’ edited to specify ‘colon cancers’, since first line deleted.

 Fourth sentence of first ‘Risk of cancer’ section paragraph.

 Last sentence of first ‘Risk of cancer’ section paragraph. [Correction: "Last", this line originally stated "First"... Митчелл (talk) 19:22, 25 November 2019 (UTC)]

o The proposed additions would be placed at the start of the ‘Risk of cancer’ subsection:

Lifetime risk and mean age at diagnosis for Lynch syndrome associated cancers

Type of cancer	Lifetime risk (%)	Mean age at diagnosis (years)
Colorectal	52-58	44-61
Endometrial	25-60	48-62
Gastric	6-13	56
Ovarian	4-12	42.5

In addition to the types of cancer found in the chart above, it is understood that Lynch syndrome also contributes to an increased risk of small bowel cancer, pancreatic cancer, ureter/renal pelvis cancer, biliary tract cancer, brain cancer, and sebaceous neoplasms. Increased risk of prostate cancer and breast cancer has also been associated with Lynch syndrome, although this relationship is not entirely understood.

References

• Genetics Section

o The 4 main genes involved in HNPCC normally encode for proteins that form dimers to function:

 MLH1 dimerizes with PMS2 to form MutLα, which coordinates the binding of other proteins involved with mismatch repair like helicase, single-stranded-DNA binding-protein (RPA), and DNA polymerases [Peltomäki 2003].

 MSH2 protein forms a heterodimer with MSH6 and functions to identify mismatches via sliding clamp [Fishel et al 1993, Gruber & Kohlmann 2003].

o The impairment of either gene for the protein dimer impairs the ability to complete mismatch repair and increases the risk for HNPCC. Dimerization explains the high frequency of MLH1 and MSH2 mutations in contributing to HNPCC, so called “major” MMR genes (15528792).

• Diagnosis Section

o After the first paragraph:

 Adding the following sentences to the Diagnosis section (after the first paragraph): “Immunohistochemistry (HCI) is another method that can be used to detect four mismatch repair (MMR) proteins that are associated with HNPCC. While it is not a gold standard, it can play a role in diagnosing HNPCC when used in conjunction with other diagnostic methods.”

• Source:

o Snowsill T, Huxley N, Hoyle M, et al. A systematic review and economic evaluation of diagnostic strategies for Lynch syndrome. Health Technology Assessment 2014; 18(58):1-406. doi: 10.3310/hta18580.

 Two methods of implementation of IHC testing includes age-based testing and universal testing for all individuals with colorectal cancer. Currently, there is no widespread agreement regarding which screening method should be used. Age-based testing for IHC has been suggested in part due to cost-benefit analyses and a higher pre-test probability of Lynch Syndrome in older individuals, whereas universal testing for all individuals with colorectal cancer can increase detection of Lynch Syndrome in families and individuals.

• Source:

o Snowsill, T., Coelho, H., Huxley, N., Jones-Hughes, T., Briscoe, S., Frayling, I. M., & Hyde, C. (2017). Molecular testing for Lynch syndrome in people with colorectal cancer: systematic reviews and economic evaluation.

o Mutations in dna mismatch repair systems can lead to difficulty transmitting regions within the DNA which contain repeating patterns of two or three nucleotides, otherwise known as microsatellite instability (MSI). MSI is identified through DNA extraction from the tumor followed by PCR analysis of microsatellite panels, and can be used to identify Lynch syndrome(1).

 Source:

• (1) Evrard C, Tachon G, Randrian V, Karayan-Tapon L, Tougeron D. Microsatellite Instability: Diagnosis, Heterogeneity, Discordance, and Clinical Impact in Colorectal Cancer. Cancers. 2019;11(10).

o A diagnosis of Lynch Syndrome is applied to people with a germline DNA mutation in one of the MMR genes (MLH1, MSH2, MSH6, and PMS2) or the EPCAM gene, identified by genetic testing. Traditionally, the Amsterdam Clinical Criteria was used to identify candidates for genetic testing to make a diagnosis of Lynch syndrome, however, 2014 guidelines recommend genetic testing for all newly diagnosed cases of colorectal cancer after initial analysis by immunohistochemistry (IHC), or microsatellite instability (MSI) testing.

References

• Prevention Section - Screening Sub-Section

o Underneath ‘Amsterdam Criteria’ prior to ‘Amsterdam Criteria (all bullet points must be fulfilled)’ insert:

• The Amsterdam I criteria were published in 1990; however, were felt to be insufficiently sensitive[2].

o Between the ‘Amsterdam Criteria…’ and ‘Amsterdam Criteria II’ insert:

• The Amsterdam II criteria were developed in 1990 and improved the diagnostic sensitivity for Lynch Syndrome by including cancers of the endometrium, small bowel, ureter and renal pelvis[1].

o After the ‘Amsterdam Criteria II’ insert:

• The Bethesda criteria were developed in 1997 and later updated in 2004 by the National Cancer Institute to identify persons requiring further testing for Lynch Syndrome through MSI. In contrast to the Amsterdam Criteria, the Revised Bethesda Guidelines use pathological data in addition to clinical information to help health care providers identify high-risk persons[1,2].

Revised Bethesda Guidelines:

If a person meets any 1 of 5 criteria the tumor(s) from the person should be tested for MSI:

1. Colorectal cancer diagnosed before age 50

2. Presence of synchronous or metachronous colorectal or other Lynch syndrome associated cancers (e.g. cancers of endometrium, ovary, stomach, small bowel, pancreas, biliary tract, ureter, renal pelvis, brain, sebaceous glands, keratoacanthomas)

3. Colorectal cancer with MSI-high pathology in a person who is younger than 60 years of age

4. Colorectal cancer diagnosed in a person with one or more first-degree relative with colorectal cancer or Lynch syndrome associated tumor diagnosed under age 50

5. Person with colorectal cancer and two or more first- or second-degree relatives with colorectal cancer or Lynch syndrome associated cancer diagnosed at any age [1,2]

• It is important to note that these clinical criteria can be difficult to use in practice and clinical criteria used alone misses between 12 and 68 percent of Lynch Syndrome cases[2].

• Sources:

• [1] Bui, Q. M., Lin, D., & Ho, W. (2017). Approach to lynch syndrome for the gastroenterologist. Digestive Diseases and Sciences, 62(2), 299-304. doi:10.1007/s10620-016-4346-4

• [2] Vindigni, S. M., & Kaz, A. M. (2016). Universal screening of colorectal cancers for lynch syndrome: Challenges and opportunities. Digestive Diseases and Sciences, 61(4), 969-976. doi:10.1007/s10620-015-3964-6

Thanking you in advance for your feedback,

@Mwiederman:@Amcbh:@AF1414:@SydneyFlatt:@Jdelpapa450:@Jdelpapa450: Митчелл (talk) 04:04, 19 November 2019 (UTC) . Supervisor: @Grnnbearit:

Thanks for sharing these. Please make sure that all your group members can add the references using the citation tool (pasting in the PMID/DOI/ISBN) when editing the actual article. I realize that the reason why these are added like this is from pasting from your sandbox. Great work so far! This page recieves an average of 600+ views per day (see tool if you are interested) so your improvements will reach a large number of people in a short time! JenOttawa (talk) 13:52, 19 November 2019 (UTC)

split HNPCC and Lynch syndrome

Hi guys, would there be consensus to split this into 2 articles? HNPCC and Lynch syndrome are 2 different things. Their only connection is that one increases the risk of the other. What we have now is basically the same as merging "lung cancer" and "smoking" into a single article. Dr. Vogel (talk) 09:42, 29 January 2020 (UTC)

Queen’s University Student Editing Initiative

Hello, we are a group of medical students from Queen’s University (different from the earlier group of students). We are working to improve this article over the next two weeks and will be posting our planned changes on this talk page soon. We look forward to working with the existing Wikipedia medical editing community to improve this article and share evidence. We welcome feedback and suggestions as we learn to edit. Thank you.

1. Signs and symptoms

We propose to insert the following content into the Signs and symptoms#Risk of cancer section: “[Two-thirds of colon cancers occur in the proximal colon], and common signs and symptoms include blood in the stool, diarrhea or constipation, and unintended weight loss … The most common symptom of endometrial cancer is abnormal vaginal bleeding.” Hurriedmammal (talk) 17:50, 3 December 2020 (UTC)

References

2. Prevention

We propose to make the addition of the following content to the Prevention#Screening section: "For women with Lynch Syndrome, CA-125 biomarker tests can be used as a tool to detect endometrial or ovarian cancer. This test should be done once per year." 19djg3 (talk) 19:41, 2 December 2020 (UTC)

We propose to insert the following content into the Prevention#Screening section:

• "Colonoscopies are recommended as a preventative method of surveillance for individuals who have Lynch syndrome, or LS-associated genes. Specifically, it is recommended that colonoscopies begin at age 20-25 for MLH1 and MSH2 mutation carriers and 35 years for MSH6 and PMS2 mutation carriers. Colonoscopic surveillance should then be performed at a 1-2 year interval for Lynch Syndrome patients." Danielleswikipage (talk) 02:10, 3 December 2020 (UTC)

• "There are also strategies for detecting other cancers early or reducing the chances of developing them that people with Lynch syndrome can discuss with their doctor, however their effectiveness is not clear. These options include:

Upper endoscopies to detect stomach and small bowel cancer every 3-5 years, starting at age 30 at the earliest (preferably in a research setting) Annual urinalysis to detect bladder cancer, starting at age 30 at the earliest (preferably in a research setting) Annual physical and neurological exams to detect cancer in the central nervous system (brain or spinal cord), starting at age 25 at the earliest"WPea20 (talk) 20:04, 3 December 2020 (UTC)

References

3. Treatment

We propose to insert the following content into the Treatment section: "[Surgery remains the front-line therapy for HNPCC], with either a partial colectomy or total colectomy with ileorectal anastomosis. Due to increased risk of colorectal cancer following partial colectomy and similar quality of life after both surgeries, a total colectomy may be a preferred treatment for HNPCC, especially in younger patients."Wikithewalrus (talk) 18:29, 3 December 2020 (UTC)

References

4. Epidemiology

We propose replacing the sentence in the Epidemiology section: “In the United States, about 160,000 new cases of colorectal cancer are diagnosed each year. Hereditary nonpolyposis colorectal cancer is responsible for approximately 2 percent to 7 percent of all diagnosed cases of colorectal cancer.” with the following sentences: “Though the exact prevalence of Lynch Syndrome-causing mutations in the general population remain unknown, recent studies estimate the prevalence to be 1 in 279 individuals, or 0.35%. Certain populations are known to have a higher prevalence of founder mutations, including, but not limited to, French Canadians, Icelanders, African Americans, and Ashkenazi Jews.” We also propose adding the following sentence: “Lynch Syndrome-causing mutations are found in approximately 3% of all diagnosed colorectal cancers, and 1.8% of all diagnosed endometrial cancers.” CMForster (talk) 19:33, 3 December 2020 (UTC)

References

@Danielleswikipage:@CMForster:@WPea20:@Hurriedmammal:@Wikithewalrus:@19djg3:. Supervisor: @Grnnbearit:

Conflation of Lynch syndrome with HNPCC

HNPCC does not equal Lynch syndrome and vice versa. Lynch syndrome specifically refers to people who have a proven germline mutation resulting in loss of MMR-P and therefore are predisposed to the development of colorectal cancer and other Lynch-associated tumours. HNPCC on the other hand refers to people who fulfil the Amsterdam criteria. This distinction is important, as other hereditary colorectal cancer syndromes will also fulfill the Amsterdam criteria (e.g. MUTYH-associated). I note that this issue has previously been raised before. ‎Angavar talk