University of Groningen
Gynaecological malignancies in Lynch syndrome
Woolderink, Jorien Maria
DOI:
10.33612/diss.84185340
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Publication date:
2019
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Woolderink, J. M. (2019). Gynaecological malignancies in Lynch syndrome: surveillance and cancer
characteristics. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.84185340
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Jorien Woolderink
Gynaecological
malignancies
in
Lynch
Syndrome
surveillance
and cancer
characteristics
ISBN: 978-94-034-1649-6
Cover design & lay-out: Esther Beekman (www.estherontwerpt.nl) Printed by: Ipskamp Printing, Enschede
© 2019 Jorien Woolderink
All rights reserved. No part of this dissertation may be reprinted, reproduced, or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording or any information storage or retrieval system, without prior written permission of the author.
Gynaecological
malignancies in
Lynch Syndrome
surveillance and cancer
characteristics
Proefschrift
ter verkrijging van de graad van doctor aan de
Rijksuniversiteit Groningen
op gezag van de
rector Magnificus Prof. dr. E. Sterken
en volgens besluit van het college van Promoties
De openbare verdediging zal plaatsvinden op
27 november 2019 om 14.30 uur
door
Jorien Maria Woolderink
geboren op 11 maart 1975
Promotores
Prof. dr. M.J.E. Mourits, UMC Groningen Prof. dr G.H. de Bock, UMC Groningen Prof. dr. H Hollema, UMC Groningen Beoordelingscommissie
Prof. dr. C.J. van Asperen, LUMC Leiden
Prof. dr. M.Y. Bongers, Maxima MC Veldhoven, Maastricht UMC Prof. dr. H.W. Nijman, UMC Groningen
Paranimfen
Anne Uyttenboogaart Justine Briët
9
23
39
55
69
93
113
140
144
150
152
Chapter 1
General introductionChapter 2
The additional value of endometrial sampling in the early detection of endometrial cancer in women with Lynch syndrome.
Gynecol Oncol. 2013;131(2):304-8
Chapter 3
Pain evaluation during gynaecological surveillance in women with Lynch syndrome.Fam Cancer. 2017;16(2):205-210
Chapter 4
Feasibility of endometrial sampling by vaginal tampons in women with Lynch syndrome.Submitted for publication
Chapter 5
Ovarian cancer in Lynch syndrome; a systematic review.Eur J Cancer. 2016;55:65-73
Chapter 6
Characteristics of Lynch syndrome associated ovarian cancer. Gynecol Oncol. 2018;150(2):324-330Chapter 7
General discussion and future perspectivesChapter 8
Nederlandse samenvatting DankwoordCurriculum Vitae List of Publications
MLH1 M MLH1 MSH2 MSH6 PMS2 M SH2 MSH6 PMS2 EpCAM MLH1 PMS2 EpCAM MLH1 MSH2 MSH6 PM M M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 MS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M M M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH P LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM H6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH AM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 S2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS
pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 E
M H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1
SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
P MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
M 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep 6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
2 EpCA MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
M PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS
M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH
M H6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P
CAM MLH1 MSH2 MSH6 P EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
ML SH2 MSH6 PMS2 EpCAM MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 S2 EpCAM MLH1 MSH2 M
M MS2 EpCAM MLH1 MSH PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA LH1 MSH2 MSH6 PMS2 Ep
Ep MLH1 MSH2 MSH6 PM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS H6 PMS2 EpCAM MLH1
SH6 PMS2 EpCAM M MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS M MLH1 MSH2 MSH6 PM pCAM MLH1 MSH2 M EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML 2 MSH6 PMS2 EpCAM M SH2 MSH6 PMS2 Ep MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS MS2 EpCAM MLH1 6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep MLH1 MSH2 MSH6 AM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1
H6 PMS2 EpCAM SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P CAM MLH1 MSH PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM SH2 MSH6 PMS2 M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS2 EpCAM MLH1 H2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
MLH1 MSH2 MSH6 MS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 SH6 PMS2 EpCAM LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep
CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS
2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS PMS2 EpCAM MLH1 MSH2 MSH6 PM
M PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA MLH1 MSH2 MSH6 PMS2 EpCAM M
M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC M MLH1 MSH2 MSH6 PMS2 EpCA
EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS M MLH1 M
H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2EpCAM MLH1 MSH2 MSH6 PMS
6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M
P CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
H2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
S2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P
PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2EpCAM MLH1 MSH2 MS
MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
M 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6PMS2 EpCAM MLH1 MSH
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA PMS2 MS
General introduction
1
MLH1 M MLH1 MSH2 MSH6 PMS2 M SH2 MSH6 PMS2 EpCAM MLH1 PMS2 EpCAM MLH1 MSH2 MSH6 PM M M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 MS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M M M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH P LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM H6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH AM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 S2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 E
M H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1
SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
P MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
M 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep 6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
2 EpCA MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
M PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS
M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH
M H6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P
CAM MLH1 MSH2 MSH6 P EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
ML SH2 MSH6 PMS2 EpCAM MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 S2 EpCAM MLH1 MSH2 M
M MS2 EpCAM MLH1 MSH PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA LH1 MSH2 MSH6 PMS2 Ep
Ep MLH1 MSH2 MSH6 PM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS H6 PMS2 EpCAM MLH1
SH6 PMS2 EpCAM M MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS M MLH1 MSH2 MSH6 PM pCAM MLH1 MSH2 M EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML 2 MSH6 PMS2 EpCAM M SH2 MSH6 PMS2 Ep MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS MS2 EpCAM MLH1 6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep MLH1 MSH2 MSH6 AM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1
H6 PMS2 EpCAM SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P CAM MLH1 MSH PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM SH2 MSH6 PMS2 M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS2 EpCAM MLH1 H2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
MLH1 MSH2 MSH6 MS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 SH6 PMS2 EpCAM LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS
2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS PMS2 EpCAM MLH1 MSH2 MSH6 PM
M PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA MLH1 MSH2 MSH6 PMS2 EpCAM M
M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCM MLH1 MSH2 MSH6 PMS2 EpCA
EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS M MLH1 M
H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2EpCAM MLH1 MSH2 MSH6 PMS
6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M
P CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
H2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
S2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P
PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2EpCAM MLH1 MSH2 MS
MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
M 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6PMS2 EpCAM MLH1 MSH
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA PMS2 MS
Chapter 1 | General introduction
10
LYNCH SYNDROME
Lynch syndrome (LS), previously called hereditary non-polyposis colorectal cancer syndrome, is an autosomal dominant genetic predisposition for cancer, caused by mutations in the mismatch repair (MMR) genes. (1) These MMR genes in LS are MLH1 (on chromosome 3), MSH2 (on chromosome 2), MSH6 (on chromosome 2), PMS2 (on chromosome 7) and the EPCAM gene, which inactivates the MSH2 gene. (2,3) When mutations in the MMR genes will develop, disruption of the open frame of the genes involved and an accumulation of small repetitive abnormalities of the DNA (micro satellites) occur. This is called microsatellite instability (MSI-high). Cells with this DNA-repair deficient MSI-high phenotype are prone to neoplastic changes and development of cancer. (3,4) LS is associated with early onset of colorectal cancer and several extra colonic malignancies of which endometrial cancer in female LS carriers is the most frequent. (4,5) Other, less common extra colonic malignancies in LS are ovarian, stomach, small intestine, pancreas, kidney, ureter, brain, kerato-acanthoma and biliary tract cancer. (4-6) In patients with LS, mutations in MLH1 and MSH2 genes contribute to 80-90% of all gene mutations, MSH6 contributes to 5-10% and PMS2 and the EPCAM mutation causing the remaining 5%. (2,7-10)
In this introduction the criteria for referral to a clinical geneticist because of a high probability of LS will be described. Patients can be referred to the clinical geneticist when they have a LS associated tumour at a young age or a positive family history for LS associated tumours. All criteria are formulated in the Dutch guideline hereditary colon cancer (11) and are shown in Table 1. LS is highly associated with the occurrence of colon cancer and gynaecological cancers as endometrial and, to a lesser extent, ovarian cancer. The characteristics of these gynaecological cancers in women with LS and the differences with sporadic endometrial and ovarian cancer are further described in this introduction. A woman with LS or a first degree relative with 50% risk of LS, will be advised for annual gynaecological surveillance. The (dis)advantages of gynaecological surveillance in women with LS are discussed in this introduction and are subject of study in part I of this thesis.
Criteria to refer to the clinical geneticist because of high probability of LS
If a patient develops a LS associated tumour or has a family history meeting one of the LS criteria, (see Table 1), there is a suspicion of LS and these patients are eligible for genetic counselling, genetic testing and/or surveillance. (6,11)
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For patients without a malignancy, with a positive family history for LS associated tumours, or a known mutation in the family of one of the LS mismatch repair genes, counselling by a clinical geneticist and a DNA test is recommended.
Since the updated guideline in 2015, in patients diagnosed with a LS associated tumour (endometrial cancer < 70 years, colorectal cancer < 50 years), immunohistochemical (IHC) staining for four MMR proteins (MLH1, MSH2, MSH6 and PMS2) is performed. (11) IHC shows the absence of MMR protein expression in women with LS. (12) If loss of
MLH1 protein is found, a MLH1 hypermethylation test is added. Hypermethylation of MLH1 results in an inactivated MLH1 protein, which is not associated with LS. When IHC
of the tumour shows loss of MSH2, MSH6, PMS2 or MSH1 (without hypermethylation of MLH1) there is a strong suspicion of LS and a DNA test is recommended to test for a germ line mutation. When IHC is inconclusive, a microsatellite instability (MSI) test can be accomplished. MSI testing demonstrates the end-result of a deficiency in the mismatch repair genes with evaluation of the accumulation of mismatches, insertions and deletions in highly repetitive DNA segments. If the tumour displays micro satellite instability, there is also a strong suspicion of LS and a DNA test is recommended to test for a germ line mutation. Also in young patients diagnosed with a LS associated tumour (endometrial or colon cancer < 40 years of age) a DNA test is recommended regardless of the IHC/MSI results or the family history. (6,11)
Chapter 1 | General introduction
12
Endometrial cancer
Endometrial cancer is one of the most common cancers in women in the Western world. In the Netherlands, endometrial cancer is diagnosed in about 1900 women yearly and around 400 women die of this disease each year. (13) Postmenopausal bleeding is an early symptom of the disease and 75% of the patients are diagnosed with early stage endometrial cancer. Risk factors are obesity, older age, late start of the menopause, nulliparity, unopposed exogenous estrogen suppletion, use of tamoxifen or a genetic predisposition. (14) The mean age at diagnosis in the general population is 60-65 years. (13)
TABLE 1 Criteria for referral to the clinical geneticist because of suspicion of Lynch syndrome (11) 1: Patients without a malignancy and a positive
family history for malignancies 2: Patients with colorectal- or endometrial cancer with abnormal immunohistochemical (IHC) fi ndings or microsatelite instability (MSI) in the tumour
• A fi rst-degree relative with colon cancer < 50 years of age.
• Or three or more fi rst or second-degree relatives with a Lynch syndrome associated tumour < 70 years of age.
• Or a mutation in one of the LS mismatch repair genes in the family.
• < 40 years of age, regardless the IHC/MSI results.
• Or < 70 years of age with abnormal IHC/MSI results (except hypermethylation of the MLH1- promotor-gene).
3: Patients with endometrial cancer 4: Patients with colorectal- or endometrial cancer without results of IHC/MSI in the tumour • Endometrial cancer < 40 years of age, (regardless
the results of IHC/MSI
• Or endometrial cancer < 70 years of age, with occurrence of MSI/IHC (except hypermethylation of the MLH1-promotor gene).
• Or endometrial cancer and colorectal cancer, or a LS associated malignancy* in the same patient, < 70 years of age.
• Or endometrial cancer < 70 years of age and a fi rst degree relative with endometrial cancer, (or a LS associated malignancy*): both under < 70 years of age and one < 50 years of age. • Or endometrial cancer < 70 years of age and
two or more fi rst- or second degree) relatives with endometrial cancer or a LS associated malignancy*,all < 70 years of age.
• < 50 years of age.
• Or < 70 years of age and a second primary colorectal or Lynch syndrome associated malignancy* < 70 years of age, (at the same patient).
• Or < 70 years of age and a fi rst degree relative with colorectal cancer < age 70, and one of them under age 50.
• Or < 70 years of age and two or more (fi rst or second degree) relatives with colorectal cancer or a LS associated malignancy*, all under age 70. • Or < 70 years of age and many polyps or
unusual polyps:
* Or cancer of the endometrial tissue, stomach, small intestine, pancreas, biliary tract, ureter, urethra, ovary, brain or sebaceous gland adenoma (carcinoma) or kerato acanthoma. (11)
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TABLE 1 Criteria for referral to the clinical geneticist because of suspicion of Lynch syndrome (11) 1: Patients without a malignancy and a positive
family history for malignancies 2: Patients with colorectal- or endometrial cancer with abnormal immunohistochemical (IHC) fi ndings or microsatelite instability (MSI) in the tumour
• A fi rst-degree relative with colon cancer < 50 years of age.
• Or three or more fi rst or second-degree relatives with a Lynch syndrome associated tumour < 70 years of age.
• Or a mutation in one of the LS mismatch repair genes in the family.
• < 40 years of age, regardless the IHC/MSI results.
• Or < 70 years of age with abnormal IHC/MSI results (except hypermethylation of the MLH1- promotor-gene).
3: Patients with endometrial cancer 4: Patients with colorectal- or endometrial cancer without results of IHC/MSI in the tumour • Endometrial cancer < 40 years of age, (regardless
the results of IHC/MSI
• Or endometrial cancer < 70 years of age, with occurrence of MSI/IHC (except hypermethylation of the MLH1-promotor gene).
• Or endometrial cancer and colorectal cancer, or a LS associated malignancy* in the same patient, < 70 years of age.
• Or endometrial cancer < 70 years of age and a fi rst degree relative with endometrial cancer, (or a LS associated malignancy*): both under < 70 years of age and one < 50 years of age. • Or endometrial cancer < 70 years of age and
two or more fi rst- or second degree) relatives with endometrial cancer or a LS associated malignancy*,all < 70 years of age.
• < 50 years of age.
• Or < 70 years of age and a second primary colorectal or Lynch syndrome associated malignancy* < 70 years of age, (at the same patient).
• Or < 70 years of age and a fi rst degree relative with colorectal cancer < age 70, and one of them under age 50.
• Or < 70 years of age and two or more (fi rst or second degree) relatives with colorectal cancer or a LS associated malignancy*, all under age 70. • Or < 70 years of age and many polyps or
unusual polyps:
* Or cancer of the endometrial tissue, stomach, small intestine, pancreas, biliary tract, ureter, urethra, ovary, brain or sebaceous gland adenoma (carcinoma) or kerato acanthoma. (11)
In endometrial cancer several histological types are distinguished. The most frequent type is endometrioid adenocarcinoma, and less common types are mucinous adenocarcinoma, serous adenocarcinoma, clear cell adenocarcinoma, undifferentiated carcinoma and mixed type carcinoma (composed of more than one type, with at least 10% of each component). (15) These carcinomas are grouped in two different subtypes. Type 1 carcinoma; representing 80% of all endometrial carcinomas, occurs around age 60, present at an early stage with symptoms of abnormal uterine bleeding. These carcinomas are linked to unopposed estrogen stimulation, which may result in the development of simple hyperplasia of the endometrial tissue. This may progress to atypical hyperplasia, finally resulting in well-differentiated endometrioid adenocarcinoma. This type of endometrial carcinoma is characterized by good survival rates. Type 2 carcinomas often occur around age 70, representing the other 20% of the endometrial carcinomas. These tumours show non-endometrioid histology like high grade serous and clear cell carcinomas. They are not linked to estrogen stimulation, have a higher risk of lymph vascular invasion and lymphatic and metastatic spread, and behave more clinically aggressive with a decreased survival rate when compared to Type 1. (16-19)
Endometrial cancer and LS
The lifetime risk of developing endometrial cancer in LS is 15-55% depending on the type of gene mutation compared with 3% in the general population. (4,9,20-23) The mean age of women who develop endometrial cancer in LS is 50-55 years. (5,20,22,23) This is ten years earlier than in the general population. The most frequently reported symptom is irregular or postmenopausal bleeding and/or increased bleeding during menstrual periods. This can be confusing and misdiagnosed at this age, as many healthy women have this perimenopausal bleeding pattern around age 50. In 75% of the women with LS, endometrial cancer is diagnosed at an early stage, which is the same as in the general population. The five years overall survival of endometrial cancer in women with LS is around 85%, which is also comparable with the survival of endometrial cancer in the general population. (15,24-27)
Ovarian Cancer
Ovarian cancer is a less common and more lethal malignancy, with 1300 new cases in the Netherlands each year and around 1000 of these women will die of ovarian cancer. (13) Ovarian cancer is a disease with none, a-specific or late symptoms. Therefore ovarian cancer is most often diagnosed in an advantaged stage with a poor survival. Risk factors are nulliparity, no use of oral contraceptives, or a genetic predisposition
Chapter 1 | General introduction
14
of which BRCA1/2 or LS mutations are most prevalent. The mean age at diagnosis of ovarian cancer in the general population is 60-65 years. (13) The most frequent histological type of ovarian cancer in the general population is the high grade serous type. (28,29) The fallopian tube is being suggested as the primary site of origin of pelvic high grade serous ovarian cancer and non invasive serous tubal intraepithelial carcinoma’s (STICs) have been identified in prophylactically removed Fallopian tubes in BRCA carriers. (30-32) Most sporadic ovarian cancers and cancers in BRCA 1/2 mutation carriers are diagnosed as FIGO stage III-IV with a five year overall survival rate of 20-40% although a progression free survival above 50% was reported in BRCA
1-2 carriers who used Olaparib additional to standard surgical treatment and platinum
based chemotherapy after four years. (13,29,33) Ovarian cancer and LS
About 10-15% of all ovarian cancers develop in women with a BRCA1/2 or LS mutation. The majority of inherited ovarian cancers are caused by a BRCA1/2 gene mutation and ovarian cancer in LS is not a very common trait. (34-35) The lifetime risk of developing ovarian cancer in LS is 6-12% depending on the type of gene mutation. (36-42) However, in most studies on ovarian cancer, only a small number of women with LS have been included. Therefore the information about the incidence and clinical aspects of ovarian cancer in women with LS is scattered and incomplete. (21-22,36,43) The mean age of a few studies reporting on women with LS who developed ovarian cancer, was at a young age and most patients were diagnosed at an early stage (FIGO stage I/II). (44-46) Due to few studies and limited data on ovarian cancer in LS, the contribution of annual gynaecological surveillance to this early stage disease cannot be established yet.
Gynaecological surveillance and LS
Annual gynaecological surveillance in women with LS consisting of a transvaginal ultrasound and endometrial sampling in case of increased endometrial thickness to detect endometrial abnormalities in an early malignant stage is effective. (5,47-48) However the additional value of standard endometrial sampling to annual transvaginal ultrasound (irrespective of endometrial thickness), in detecting more (pre)malignant endometrial lesions in women with LS is unknown.
The value of annual gynecological surveillance for early detection of ovarian cancer in LS has never been studied systematically, due to small numbers and is still under debate. (5,48-49) In general, ovarian cancer surveillance has not been proven effective, in reducing ovarian cancer mortality in the general population (29) and not even among
15
1
women with a BRCA 1/2 mutation. (29,50-53) Even during surveillance, most ovarian cancers are found in an advanced stage and interval ovarian cancers develop between two surveillance visits. (50,52-56) As most ovarian cancers in women with LS tend to be detected at an early stage, some ascribe it to annual surveillance in LS. (57) However, there are only a few studies and no solid data to confirm this. Others assume that the good prognosis can be attributed to another biology, as the tumour type of ovarian cancer in LS (more often endometrioid or clear cell) is different from ovarian cancer in sporadic cases and BRCA1/2 mutation carriers (mostly high grade serous).
The current guideline for LS in the Netherlands advises annual endometrial surveillance by transvaginal ultrasound, measurement of the endometrial thickness and performance of a standard endometrial sampling in women from 40-60 years. (11) The choice for endometrial surveillance at this peri-menopausal age (when irregular bleeding is common and often misinterpreted) is not to miss early endometrial cancer. A surveillance advice for ovarian cancer in women with LS could not be given, due to a lack of firm data on surveillance and a certain age-range of appearance. It is advised to evaluate the ovaries while performing the transvaginal ultrasound to check the endometrial thickness for endometrial surveillance, although there is lack of evidence for annual ovarian surveillance alone in women after hysterectomy. (11)
Aim of the thesis:
The aim of this thesis is to study aspects of gynaecological surveillance in women with LS in order to improve counselling and find evidence for continuation or cessation of the various aspects of annual gynaecological surveillance in female LS carriers. In part I we evaluated the additional value of endometrial sampling to transvaginal ultrasound. We also studied the pain scores during this procedure and whether endometrial sampling can be replaced by a less invasive and less painful procedure (vaginal tampons). In part II of the thesis, the clinical and histopathological characteristics of ovarian cancer in women with LS were evaluated and the possible role of surveillance in early detection of these cancers was studied.
Chapter 1 | General introduction
16
OUTLINE OF THE THESIS
Part I: endometrial cancer and LSIn chapter two of this thesis, the additional value of standard endometrial sampling in detecting (pre)malignancies of the endometrial tissue in women with LS or first degree relatives (FDR) was evaluated. In this study, two different surveillance programs were compared. We investigated the results of annual screening in a group of women with LS or FDR who underwent annual transvaginal ultrasound and endometrial sampling in case of symptoms or a thickened endometrial response only (period I), versus women with LS or FDR who underwent transvaginal ultrasound and standard endometrial sampling at every surveillance visit, irrespective of endometrial thickness (period II). The rate of (pre)malignancies of the endometrial tissue detected in both groups was evaluated.
Endometrial sampling during annual surveillance in women with LS is an outpatient procedure, which only takes a few minutes. However, the disadvantage is that it is an invasive procedure during which many women report substantial pain and the annual repetition induces fear for this examination, although the magnitude has never been studied. Chapter three describes the perceived pain on a visual analogue scale (VAS) during repetitive annual endometrial sampling. We also studied pain scores in symptomatic women who underwent a single endometrial sampling procedure. We evaluated if asymptomatic women who underwent annual endometrial sampling reported more pain than the symptomatic group who underwent single endometrial sampling, and if the VAS score aggravated during subsequent annual procedures in women with LS. If women with LS decided for preventive surgery or to quit annual gynaecological surveillance, the reason was examined.
As endometrial sampling at annual surveillance is perceived as a painful procedure by a substantial proportion of the women with LS (median VAS score 5.0) we investigated whether a less invasive procedure would be feasible to collect endometrial cells, which is reported in chapter four. It describes a pilot study in which 25 asymptomatic women with LS or FDR were asked to insert a tampon vaginally 2-4 hours before the annual surveillance visit. At the outpatient clinic, before starting the physical examination, the tampon was removed by the patient, handed to the gynaecologist, swopped in fixation fluid and send to the pathology lab for analysis. Subsequently, the standard annual gynaecological surveillance was performed, including endometrial sampling. The aim of the study was to analyse if endometrial cells can be obtained by using
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vaginal tampons and if so, if the cells are of enough good quality to analyse. The level of pain of both procedures was evaluated with VAS scores.
Part II: ovarian cancer and LS
In chapter five of this thesis a literature review is presented about the clinical and pathological characteristics of ovarian cancer in women with LS and we evaluated the role of surveillance in the detection of ovarian cancer in LS.
In the Netherlands, a Dutch Cancer Registry (STOET) has been collecting clinical data of LS mutation carriers since 1987. Clinical data on all LS associated ovarian cancers from this registry and all LS associated ovarian cancers from the University Medical Center Groningen who were not in the STOET database, were studied in chapter six. For these women the following data was collected: data on gynaecological surveillance, age at diagnosis, mutation type, histological type, FIGO stage, treatment and follow-up data. The aim of this study was to describe clinical characteristics of LS associated ovarian cancer and the efficacy of surveillance in the early detection of these ovarian cancers.
In chapter seven, the results of the different studies are discussed and some future perspectives are given. A Dutch summary of all results is given in chapter eight.
Chapter 1 | General introduction
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MLH1 M MLH1 MSH2 MSH6 PMS2 M SH2 MSH6 PMS2 EpCAM MLH1 PMS2 EpCAM MLH1 MSH2 MSH6 PM M M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 MS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M M M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH P LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM H6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH AM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 S2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS
pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 E
M H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1
SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
P MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
M 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep 6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
2 EpCA MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
M PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS
M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH
M H6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P
CAM MLH1 MSH2 MSH6 P EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
ML SH2 MSH6 PMS2 EpCAM MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 S2 EpCAM MLH1 MSH2 M
M MS2 EpCAM MLH1 MSH PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA LH1 MSH2 MSH6 PMS2 Ep
Ep MLH1 MSH2 MSH6 PM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS H6 PMS2 EpCAM MLH1
SH6 PMS2 EpCAM M MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS M MLH1 MSH2 MSH6 PM pCAM MLH1 MSH2 M EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML 2 MSH6 PMS2 EpCAM M SH2 MSH6 PMS2 Ep MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS MS2 EpCAM MLH1 6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep MLH1 MSH2 MSH6 AM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1
H6 PMS2 EpCAM SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P CAM MLH1 MSH PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM SH2 MSH6 PMS2 M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS2 EpCAM MLH1 H2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
MLH1 MSH2 MSH6 MS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 SH6 PMS2 EpCAM LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS
2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS PMS2 EpCAM MLH1 MSH2 MSH6 PM
M PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA MLH1 MSH2 MSH6 PMS2 EpCAM M
M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC M MLH1 MSH2 MSH6 PMS2 EpCA
EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS M MLH1 M
H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2EpCAM MLH1 MSH2 MSH6 PMS
6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M
P CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
H2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
S2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P
PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2EpCAM MLH1 MSH2 MS
MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
M 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6PMS2 EpCAM MLH1 MSH
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA PMS2 MS
The additional value of
endometrial sampling
in the early detection
of endometrial cancer
in women with Lynch
syndrome
Helder-Woolderink JM
1, De Bock GH
2, Sijmons RH
3, Hollema H
4,
Mourits MJE
11 Department of Gynecologic Oncology, University Medical Center Groningen ² Department of Epidemiology, University Medical Center Groningen
3 Department of Genetics, University Medical Center Groningen 4 Department of Pathology, University Medical Center Groningen
Gynecol Oncol. 2013;131(2):304-8
2
MLH1 M MLH1 MSH2 MSH6 PMS2 M SH2 MSH6 PMS2 EpCAM MLH1 PMS2 EpCAM MLH1 MSH2 MSH6 PM M M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 MS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M M M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH P LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM H6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH AM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 S2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 E
M H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1
SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
P MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
M 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep 6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
2 EpCA MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep SH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 pCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
M PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS
M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC 2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH
M H6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P
CAM MLH1 MSH2 MSH6 P EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
ML SH2 MSH6 PMS2 EpCAM MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 S2 EpCAM MLH1 MSH2 M
M MS2 EpCAM MLH1 MSH PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA LH1 MSH2 MSH6 PMS2 Ep
Ep MLH1 MSH2 MSH6 PM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS H6 PMS2 EpCAM MLH1
SH6 PMS2 EpCAM M MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS M MLH1 MSH2 MSH6 PM pCAM MLH1 MSH2 M EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML 2 MSH6 PMS2 EpCAM M SH2 MSH6 PMS2 Ep MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS MS2 EpCAM MLH1 6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep MLH1 MSH2 MSH6 AM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1
H6 PMS2 EpCAM SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P CAM MLH1 MSH PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM SH2 MSH6 PMS2 M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS2 EpCAM MLH1 H2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
MLH1 MSH2 MSH6 MS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 SH6 PMS2 EpCAM LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 Ep CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M SH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS
2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MS PMS2 EpCAM MLH1 MSH2 MSH6 PM
M PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA MLH1 MSH2 MSH6 PMS2 EpCAM M
M MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 M
2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpC M MLH1 MSH2 MSH6 PMS2 EpCA
EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MS M MLH1 M
H1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2EpCAM MLH1 MSH2 MSH6 PMS
6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 M
P CAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6
H2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
S2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 P
PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM ML
MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2EpCAM MLH1 MSH2 MS
MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM
M 2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6PMS2 EpCAM MLH1 MSH
LH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCAM MLH1 MSH2 MSH6 PMS2 EpCA PMS2 MS
Chapter 2 | The additional value of endometrial sampling in the early detection of endometrial cancer in women with Lynch syndrome
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ABSTRACT
ObjectiveBased on previous studies, standard gynecological screening consisting of annual transvaginal ultrasonography (TVU) was extended with endometrial sampling in women with Lynch Syndrome (LS).
The aim of this study was to evaluate the additional value of endometrial sampling in detecting (pre)malignancies of the endometrium in women with LS or first-degree relatives.
Methods
All women above 30 years of age with LS or first-degree relatives at 50% risk of LS are offered annual gynecological screening in our family cancer clinic. Endometrial screening results from January 2003-December 2007 (period I: standard screening by transvaginal sonography and serum CA125) were compared with screening results from January 2008-June 2012 (period II: standard screening added with endometrial sampling).
Results
Seventy five women (300 patient years) were screened annually. There were 266 screening visits, 117 in period I and 149 in period II. In period I, four premalignant endometrial lesions were detected and one endometrial carcinoma (FIGO stage IB). In period II, two premalignancies were found. None of the lesions would have been missed without standard endometrial sampling. No interval endometrial cancers were detected in this study.
Conclusion
In this study, annual endometrial screening seems an effective screening tool in the detection of premalignancies and early endometrial cancer in women with LS. Adding standard endometrial sampling to annual TVU has no additional value in the early detection of (pre)malignant endometrial lesions in women with LS in this study.
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2
INTRODUCTION
Women with Lynch Syndrome (LS), previously called Hereditary Non Polyposis Colorectal Cancer (HNPCC), have an autosomal dominant inherited mutation in one of the DNA mismatch repair genes MLH1, MSH2, MSH6 or PMS2. LS is characterized by a high risk and early occurrence of colorectal cancer and extra colonic cancers. (1) The second most common cancer in female LS patients is endometrial cancer. The estimated cumulative lifetime risk to develop endometrial cancer in women with LS varies in different reports between 21-71%. MLH1 and MSH2 mutation carriers have a lifetime risk up to 60% to develop endometrial cancer; carriers of an MSH6 mutation have a risk up to 71%, (1,2-5) although lower risks (24%) have been reported as well. (6) For PMS2 mutation carriers, a risk of 15% has been reported. (7) However, series of
PMS2 mutation carriers are significantly smaller than those for the other mismatch repair
genes and cancer risk therefore less well established. The overall annual incidence rate of developing endometrial cancer after the age of 40 years in LS is 2,5%. (8)
The high risk of endometrial cancer in LS and the earlier age of onset, together with a well-detectable and treatable premalignant or early malignant stage, is the reason to consider endometrial cancer screening in these women and their first degree relatives at 50% risk of LS. (1-2, 9-10) A few studies have investigated the optimal gynecological screening protocol in women with LS. (1,4,11-13) Interval endometrial carcinomas occurred with annual screening of TVU alone in two studies. (4,11) In a study by Renkonen et al, mutation carriers were screened with TVU and standard endometrial sampling of the endometrial tissue at an interval of 2-3 years. (1) In their study, eight of fourteen carcinomas and premalignant lesions were diagnosed by endometrial sampling alone. However, despite endometrial sampling during most of the screening visits in this study, three interval carcinomas occurred. The tumour stage and the survival curve were more optimal in the group of patients who underwent screening than in 83 mutation positive endometrial cancers patients who had not attended screening. (1) In 2009 Gerritzen et al. also found significantly more (pre)malignancies in women with standard endometrial sampling together with annual TVU, than in women with screening by TVU alone. (12) It was concluded that TVU alone is insufficient to detect early endometrial cancer in all cases, especially among premenopausal women, and that adding endometrial sampling improves the effectiveness of gynecological screening in women with LS. (1,12) Recently Manchandra et al found four (pre) malignant lesions with TVU and outpatient hysteroscopy with endometrial sampling
Chapter 2 | The additional value of endometrial sampling in the early detection of endometrial cancer in women with Lynch syndrome
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in 41 women with LS. TVU alone detected two of four lesions. (13) In our hospital, the screening protocol was changed in women with LS or first-degree relatives at 50% risk of carrying the LS mutation and endometrial sampling was added as a standard screening tool to annual TVU from January 1st 2008. During endometrial sampling, some patients experience painful cramping but data about this symptom are lacking from other studies. Data about effectiveness of annual gynecological screening by TVU in women with LS or first degree relatives in our hospital between 1991-2002 have been published by Rijcken et al. (4) In the current study screening data were analyzed of all women with LS or first degree relatives, who were annually screened between January 2003 and June 2012.
The aim of the present study is to evaluate the additional value of endometrial sampling to annual TVU as a standard screening procedure in detecting (pre)malignant endometrial lesions in women with LS or first-degree relatives at 50% risk of carrying the LS mutation.
PATIENTS AND METHODS
SettingSince 1991, a gynecological screening program for females with LS and first-degree relatives at 50% risk of carrying the LS mutation was introduced at the Family Cancer Clinic (FCC) of the University Medical Center Groningen at a recommended age to start of 30 years. (14) In all women with LS, a pathogenic mutation in either MLH1,
MSH2, MSH6 or PMS2 had been detected using methods published previously. (15-17)
All clinical data from LS carriers and first-degree relatives at 50% risk of carrying the LS mutation are prospectively registered in a database. The first-degree relatives at 50% risk of carrying the LS mutation were women who did not wanted to be screened because of implications for life insurance. In some other patients the genetic results were not available yet. All first degree relatives at 50% of carrying the LS mutation were regarded as a carrier until the genetic test showed no genetic mutation.
During Period I (2003-2007) annual gynecological screening was performed by TVU and serum CA125 measurement. Endometrial tissue sampling by endometrial sampling or hysteroscopy and endometrial biopsy was performed only in symptomatic women (irregular, postcoïtal or postmenopausal bleeding), or in women with increased endometrial thickness on TVU (double layer above 12 mm in premenopausal women, or above 4 mm in postmenopausal women). (18,19)