Test Id : ML1HM

When this test is ordered, slide review will always be performed at an additional charge.

For more information see Lynch Syndrome Testing Algorithm.

This test is not recommended as a first-tier screening measure for hereditary nonpolyposis colon cancer. For more information see TMSI / Microsatellite Instability, Tumor and IHC / Mismatch Repair (MMR) Protein Immunohistochemistry Only, Tumor.

Testing will only be performed on colon or endometrial tumors demonstrating loss of MLH1 protein expression by immunohistochemistry.

Mayo Clinic's preferred screening test includes both MLH1 promoter hypermethylation and BRAF V600E testing. Order BRMLH / MLH1 Hypermethylation and BRAF Mutation Analysis, Tumor.

Extracted DNA from tissues is not an acceptable specimen type.

If the MMR immunohistochemistry (IHC) results for MLH1 and/or PMS2 suggest possible tumor heterogeneity, are ambiguous, or unusual, the physical IHC stains will be required to optimize the area of tissue selected for testing and for interpretation of the results. If IHC stains are required and not sent with the specimen, a request will be submitted to provide the IHC stains which will result in a slight delay.

Pathology report and MMR IHC results must accompany specimen in order for testing to be performed.

Specimen Type: Tissue block or slide

Collection Instructions:

1. Submit formalin-fixed, paraffin-embedded tissue block (preferred) or 1 slide stained with hematoxylin and eosin and 10 unstained, nonbaked slides (5-micron thick sections) of the tumor tissue.

2. Sections should contain tumor tissue.

• Molecular Genetics: Inherited Cancer Syndromes Patient Information
• Lynch Syndrome Testing Algorithm

1. Molecular Genetics: Inherited Cancer Syndromes Patient Information (T519)

2. If not ordering electronically, complete, print, and send 1 of the following forms with the specimen:

-Gastroenterology and Hepatology Test Request (T728)

-Oncology Test Request (T729)

See Specimen Required

An adjunct to TMSI / Microsatellite Instability, Tumor and IHC / Mismatch Repair (MMR) Protein Immunohistochemistry Only, Tumor when colon or endometrial tumor demonstrates microsatellite instability (MSI-H) and loss of MLH1 protein expression, to help distinguish a somatic versus germline event prior to performing expensive germline testing

An adjunct to negative MLH1 germline testing in cases where colon or endometrial tumor demonstrates MSI-H and loss of MLH1 protein expression

When this test is ordered, slide review will always be performed at an additional charge.

For more information see Lynch Syndrome Testing Algorithm.

Hereditary nonpolyposis colon cancer (HNPCC), also known as Lynch syndrome, is an inherited cancer syndrome caused by a germline mutation in one of several genes involved in DNA mismatch repair (MMR), including MLH1, MSH2, MSH6, and PMS2. There are several laboratory-based strategies that help establish the diagnosis of HNPCC/Lynch syndrome, including testing tumor tissue for the presence of microsatellite instability (MSI-H) and loss of protein expression for any one of the MMR proteins by immunohistochemistry (IHC). However, it is important to note that the MSI-H tumor phenotype is not restricted to inherited cancer cases; approximately 20% of sporadic colon cancers are MSI-H. Thus, MSI-H does not distinguish between a somatic (sporadic) and a germline (inherited) mutation, nor does it identify which gene is involved. Although IHC analysis is helpful in identifying the responsible gene, it also does not distinguish between somatic and germline defects.

Defective MMR in sporadic colon cancer is most often due to an abnormality in MLH1, and the most common cause of gene inactivation is promoter hypermethylation (epigenetic silencing). A specific mutation in BRAF (V600E) has been shown to be present in approximately 70% of tumors with hypermethylation of the MLH1 promoter. Importantly, the V600E mutation is rarely identified in cases with germline MLH1 mutations. Thus, direct assessment of MLH1 promoter methylation status and testing for the BRAF V600E mutation can be used to help distinguish between a germline mutation and epigenetic/somatic inactivation of MLH1. Tumors that have the BRAF V600E mutation and demonstrate MLH1 promoter hypermethylation are almost certainly sporadic, whereas tumors that show neither are most often caused by an inherited mutation.

Although testing for the BRAF V600E mutation and MLH1 promoter hypermethylation are best interpreted together, they are also available separately to accommodate various clinical situations and tumor types. These tests can provide helpful diagnostic information when evaluating an individual suspected of having HNPCC/Lynch syndrome, especially when testing is performed in conjunction with TMSI / Microsatellite Instability, Tumor and IHC / Mismatch Repair (MMR) Protein Immunohistochemistry Only, Tumor studies. It should be noted that these tests are not genetic tests but rather stratify the risk of having an inherited cancer predisposition and identify patients who may benefit from subsequent genetic testing.

An interpretative report will be provided.

An interpretive report will be provided. The likelihood of a germline (inherited) mutation is very low in those cases where the tumor demonstrates MLH1 promoter hypermethylation and the normal tissue is unmethylated. The likelihood of a germline mutation is high in those cases where the tumor and normal tissue lack MLH1 promoter hypermethylation. In cases where the tumor and normal tissue demonstrate MLH1 promoter hypermethylation, this result will be interpreted as equivocal, and a blood sample will be requested to confirm potential germline hypermethylation.

Testing tumors other than colon or endometrial for MLH1 hypermethylation has not been fully evaluated, and these specimens are not accepted for testing.

Colon cancer is relatively common, and it is possible for a sporadic colon cancer to occur in a family with hereditary nonpolyposis colorectal cancer (HNPCC). Therefore, evaluation of other family members should still be considered in cases with MLH1 promoter hypermethylation if there is high clinical suspicion of HNPCC.

1. Cunningham JM, Kim CY, Christensen ER, et al: The frequency of hereditary defective mismatch repair in a prospective series of unselected colorectal carcinomas. Am J Hum Genet. 2001 Oct;69(4):780-790

2. Wang L, Cunningham JM, Winters JL, et al: BRAF mutations in colon cancer are not likely attributable to defective DNA mismatch repair. Cancer Res. 2003 Sep;63(17):5209-5212

3. Domingo E, Laiho P, Ollikainen M, et al: BRAF screening as a low-cost effective strategy for simplifying HNPCC genetic testing. J Med Genet. 2004 Sep;41(9):664-668

4. Bettstetter M, Dechant S, Ruemmele P, et al: Distinction of hereditary nonpolyposis colorectal cancer and sporadic microsatellite-unstable colorectal cancer through quantification of MLH1 methylation by real-time PCR. Clin Cancer Res. 2007 Jun;13(11):3221-3228

5. Idos G, Valle L: Lynch syndrome. In: Adam MP, Mirzaa GM, Pagon RA, et al, eds. GeneReviews Internet). University of Washington, Seattle; 2004. Updated February 2, 2021. Accessed June 27, 2023. Available at www.ncbi.nlm.nih.gov/books/NBK1211/

A polymerase chain reaction-based assay is used to test tumor DNA for the presence of hypermethylation of the MLH1 promoter.(Modification of Grady WM, Rajput A, Lutterbaugh JD, Markowitz S: Detection of aberrantly methylated hMLH1 promoter DNA in the serum of patients with microsatellite unstable colon cancer. Cancer Res. 2001 Feb;61(3):900)

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• Clients without access to Test Prices can contact Customer Service 24 hours a day, seven days a week.
• Prospective clients should contact their account representative. For assistance, contact Customer Service.

This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. It has not been cleared or approved by the US Food and Drug Administration.

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