OvaNext

OvaNext is a next generation sequencing (NGS) panel that simultaneously analyzes 23 genes associated with increased risk for breast, ovarian, and/or uterine cancers.

PrintPrint

OvaNext is a next generation sequencing (NGS) panel that simultaneously analyzes 23 genes associated with increased risk for breast, ovarian, and/or uterine cancers.

Ambry utilizes next generation sequencing to offer a comprehensive hereditary gynecologic cancer panel.  Genes on this panel include ATM, BARD1, BRCA1, BRCA2, BRIP1, CDH1, CHEK2, EPCAM, MLH1, MRE11A, MSH2, MSH6, MUTYH, NBN, NF1, PALB2, PMS2, PTEN, RAD50, RAD51C, RAD51D, STK11, and TP53. Full gene sequencing is performed for 22 of the genes (excluding EPCAM). Gross deletion/duplication analysis is performed for all 23 genes. Specific-site analysis is available for individual gene mutations identified in a family.

Disease Name 
Breast Cancer
Uterine Cancer
Ovarian Cancer
Hereditary Cancer
Hereditary Breast Ovarian Cancer (HBOC)
Lynch Syndrome
Disease Information 

Breast cancer is the most common cancer in women in developed countries, affecting about 1 in 8 (12.5%) women in their lifetime.[1]  The National Cancer Institute (NCI) estimates that approximately 232,670 new cases of female breast cancer and 2,360 new cases of male breast cancer will be diagnosed in the U.S. in 2014.[2]  The majority of breast cancers are sporadic, but 5-10% are due to inherited causes.   Hereditary breast cancers tend to occur earlier in life than non-inherited sporadic cases and are more likely to occur in both breasts. The highly penetrant genes, BRCA1 and BRCA2, appear to be responsible for around half of hereditary breast cancer.[3-5]  However, additional genes have been discovered that are associated with increased breast cancer risk as well.[3-7]   Mutations in the genes on the OvaNext panel can confer an estimated 20–87% lifetime risk for breast cancer.  Some of these genes have also been associated with increased risks for other cancers, such as pancreatic cancer with PALB2, ovarian cancer with BRCA1, BRCA2, RAD51C, and others, and sarcoma with TP53.[8-12]

Ovarian cancer is the fifth most common cancer among women in developed countries, affecting approximately 1 in 71 (1.4%) women in their lifetime.[1]   The NCI estimates that approximately 21,980 new cases of ovarian cancer will be diagnosed and 14,270 ovarian cancer deaths will occur in the U.S. in 2014.[2]  It is the leading cause of death from gynecologic malignancy, usually characterized by advanced presentation with regional dissemination in the peritoneal cavity. Epithelial ovarian cancer is the most common form, and up to 25% of epithelial cases may be due to inherited gene mutations.[13, 14]  BRCA1 and BRCA2 are the most common causes of hereditary ovarian cancer, but several other genes are associated with increased ovarian cancer risk as well.[11, 13, 15, 16]

Uterine cancer affects about 1 in 38 (2.6%)  women in their lifetime.[1]  The NCI estimates that approximately 52,630 new cases of uterine cancer will be diagnosed and 8,590 uterine cancer deaths will occur in the U.S. in 2014.[2]  Increased risk for uterine cancer has been identified in a number of hereditary cancer syndromes, including Lynch syndrome and Cowden syndrome.

OvaNext Panel Genes:

ATM is a gene classically associated with an autosomal recessive condition called ataxia telangiectasia (AT). AT is characterized by progressive cerebellar ataxia with onset between ages 1 and 4, telangiectases of the conjunctivae, oculomotor apraxia, immune defects, and a predisposition to malignancy, particularly leukemia and lymphoma. Women who carry ATM mutations also have an estimated 2-4 fold increased risk for breast cancer.[17]  Cancer risk estimates for male ATM mutation carriers are not currently available. Recent studies have also reported ATM germline mutations in individuals with familial pancreatic cancer. In one of these studies, ATM mutations were identified in 4/87 (4.6%) families with more than three affected members.[18]

BRCA1 and BRCA2  are tumor suppressor genes inherited in an autosomal dominant pattern. Mutations in these two highly penetrant genes increase the chance for cancer of the breast, ovaries (including primary peritoneal and fallopian tube), pancreas and prostate. Studies suggest female BRCA1 mutation carriers have a 57-87% lifetime risk to develop breast cancer and a 39-40% lifetime risk to develop ovarian cancer by age 70.[8-10, 19-21]  Male BRCA1 mutation carriers have a cumulative breast cancer lifetime risk of about 1.2% by age 70.[22, 23] Similar studies suggest female BRCA2 mutation carriers have a 45-84% lifetime risk to develop breast cancer and an 11-18% risk to develop ovarian cancer by age 70.[8-10, 24, 25]  Male BRCA2 mutation carriers have up a 15% lifetime prostate cancer risk and a cumulative lifetime breast cancer risk of 6.8% by ages 65 and 70 respectively.[22, 23, 25, 26]  BRCA1/2 mutation carriers may also be at an increased risk for melanoma, pancreatic cancer, and potentially other cancers.[27]  BRCA2 is also known as FANCD1.  Individuals who inherit a BRCA2/FANCD1 mutation from each parent may have a rare autosomal recessive condition called Fanconi-anemia type D1 (FA-D1), which affects multiple body systems. 

BARD1, BRIP1, MRE11A, NBN, RAD50, RAD51C, and RAD51D are genes involved in the Fanconi anemia (FA)-BRCA pathway, critical for DNA repair by homologous recombination, and interact in vivo with BRCA1 and/or BRCA2.[4, 15, 28] Mutations in these genes are estimated to confer up to a three-fold increase in breast cancer risk, and mutations in each have been reported in at least one identified case of ovarian cancer to date.[11, 13, 16, 28-30]  The ovarian cancer risk associated with mutations in RAD51C and RAD51D has been estimated to be 9% and 10%, respectively.[11, 16]   BRIP1, NBN, and RAD51C are each associated with a rare autosomal recessive disorder that affects multiple body systems.  

CHEK2 is a gene that receives signals from damaged DNA, transmitted via ATM. CHEK2 interacts in vivo with BRCA1, BRCA2, and TP53, which have all been implicated in cellular processes responsible for the maintenance of genomic stability. Multiple studies indicate that mutations in CHEK2 confer an increased risk of developing many types of cancer including breast, colon, and other cancers. Mutations are more likely to be found among women with bilateral versus unilateral breast cancers. A female CHEK2 mutation carrier has approximately a two-fold increase in lifetime breast cancer risk, and has a 1% risk per year of developing a second breast primary cancer. Lifetime risks for other associated cancers are unknown.  An increased risk for ovarian cancer has also been suggested.[13, 31-33]

CDH1 germline mutations are associated with hereditary diffuse gastric cancer (HDGC) and lobular breast cancer in women. In one published study, the estimated cumulative risk of gastric cancer for CDH1 mutation carriers by age 80 years was 67% for men and 83% for women.[34]  HDGC patients typically present with diffuse-type gastric cancer, with signet ring cells diffusely infiltrating the wall of the stomach and, at advanced stages, linitis plastica. An elevated risk of lobular breast cancer in women is also associated with HDGC, with an estimated lifetime breast cancer risk of 39-52%.[35]

MLH1, MSH2, MSH6, PMS2, and EPCAM germline mutations are associated with Lynch syndrome (previously known as Hereditary Nonpolyposis Colorectal Cancer, HNPCC). Lynch syndrome is an autosomal dominant condition estimated to cause 2-5% of all colon cancer. It is associated with a significantly increased risk for colorectal cancer (up to 82% lifetime risk), uterine/endometrial cancer (25-60% lifetime risk in women), stomach cancer (6-13% lifetime risk), and ovarian cancer (4-12% lifetime risk in women). Risk for cancer of the small bowel, hepatobiliary tract, upper urinary tract (including transitional cell carcinoma of the renal pelvis), brain, and sebaceous glands may also be elevated.[36-40]

MUTYH germline mutations are known to cause MUTYH-associated polyposis (MAP), an autosomal recessive condition predisposing to gastrointestinal polyposis and colorectal cancer. Individuals who carry two MUTYH mutations on different chromosomes (in trans) have an estimated lifetime colorectal cancer risk of up to 80%.[41]  In addition, some studies suggest that MUTYH mutations confer an increased risk to develop female breast cancer, this is estimated to be a  1.5-fold lifetime increased risk within the North African Jewish population. MUTYH mutations in the carrier state may also increase lifetime risks for cancers of the duodenum, stomach, and endometrium (females),[42-44] however, these data are limited and risks may vary between populations. Two common mutations in the Caucasian population, p.Y179C and p.G396D (originally designated as p.Y165C and p.G382D), account for the majority of pathogenic MUTYH alterations reported to date. Breast cancer risk estimates for male MUTYH mutation carriers are not currently available.

NF1 mutations cause neurofibromatosis type 1 (NF1), an autosomal dominant disorder affecting multiple body systems. It is characterized by multiple café-au-lait spots, axillary and inguinal freckling, multiple cutaneous neurofibromas, and Lisch nodules. The most common neoplasms observed in individuals with NF1 include peripheral nerve sheath tumors, gastrointestinal stromal tumors (GIST), central nervous system gliomas, leukemias, paragangliomas (PGLs) and pheochromocytomas (PCCs), and breast cancer. Multiple population-based studies have demonstrated a 3 to 5-fold increase in lifetime breast cancer risk for women with NF1, with the highest risks for those less than 50 years of age. In addition, individuals with NF1 have an estimated lifetime risk for PGLs and PCCs of up to 7%.

PALB2 germline mutations have been associated with an increased lifetime risk for pancreatic cancer, breast cancer, and Fanconi-anemia type N (FA-N). Familial pancreatic and/or breast cancer due to PALB2 mutations is inherited in an autosomal dominant pattern, while FA-N is a rare autosomal recessive condition affecting multiple body systems. Females with a PALB2 mutation have a 2 to 4-fold increase in risk for breast cancer.[45, 46] A 2014 article concluded that in the context of a strong family history, mutations in PALB2 may be associated with up to a 58% risk of female breast cancer.  Without a family history, the risk for female breast cancer was estimated to be 33% (the difference attributed to genetic and/or environmental modifiers).[47]  Recent studies have identified PALB2 mutations in 1-3% of families with pancreatic cancer; however, the exact lifetime pancreatic cancer risk has not yet been established.[48, 49] Additionally, an increased risk for ovarian cancer has been suggested as well.[13]  

PTEN is a gene associated with Cowden syndrome (CS), PTEN Hamartoma Tumor syndrome (PHTS), Bannayan-Riley-Ruvalcaba syndrome, Proteus syndrome and autism spectrum disorder. CS is a multiple hamartoma syndrome with a high risk of developing tumors of the thyroid, breast, and endometrium. Mucocutaneous lesions, thyroid abnormalities, fibrocystic disease, multiple uterine leiomyomata, and macrocephaly can also be seen. Affected individuals have a lifetime risk of up to 50% for breast cancer, 10% for thyroid cancer, and 5-10% for endometrial cancer. Over 90% of individuals with CS will express some clinical manifestations by their twenties.[50, 51]  Recent studies noted increased risks for renal cell cancer, colorectal cancer, and other cancers.[52, 53]  One study quotes up to a 31-fold increase in RCC risk for PTEN mutation carriers as compared to the general population.[54]

STK11 germline mutations are associated with Peutz-Jeghers syndrome (PJS), an autosomal dominant disorder characterized by the development of gastrointestinal hamartomatous polyps, along with hyperpigmentation of the skin and mucous membranes. Overall, individuals affected with PJS have up to an 85% lifetime risk of developing cancer by the age of 70, with gastrointestinal and breast cancers being the most common.[55, 56]  Individuals with PJS are also at elevated risk for tumors of the pancreas, lung, and, in females, ovarian tumors, specifically, sex cord tumors with annular tubules (SCTATs) and mucinous ovarian tumors.

TP53 is a tumor suppressor gene, and germline mutations within it are associated with Li-Fraumeni syndrome (LFS). An individual carrying a TP53 mutation has a 21-49% lifetime risk of developing cancer by age 30 and a lifetime cancer risk of 68-93%.[57]  The most common tumor types observed in LFS families include soft tissue and osteosarcomas, breast cancer, brain tumors (including astrocytomas, glioblastomas, medulloblastomas and choroid plexus carcinomas), and adrenocortical carcinoma (ACC); other cancers, including colorectal, gastric, ovarian, pancreatic, and renal, have also been reported.[12, 58]  Studies have shown that a small percentage of women with early onset breast cancer who do not carry BRCA1 and BRCA2 mutations are identified to have mutations in TP53.[33, 59, 60]

 

Testing Benefits & Indication 

Indications for Testing

Families with a combination of the cancers below and some common red flags for hereditary cancer in the family would be appropriate to consider for OvaNext testing.

  • Ovarian cancer at any age
  • Early onset uterine cancer (diagnosed < 50 years of age)
  • Multiple primary cancers in one person (e.g. uterine and breast or thyroid cancer)
  • Multiple close family members with ovarian or uterine and other cancers (on the same side of the family)
  • Cancer histories that are suspicious for both HBOC and Lynch syndrome

Common Red Flags for Hereditary Cancer

  • Cancer diagnosed at a younger age than expected for the general population (≤ 50 years, for most cancers)
  • Cancer diagnosed across generations, and in multiple generations within a family, especially if diagnosed younger than average
  • Individual with multiple primary cancers (either in paired organs or in different organs)
  • A pattern of cancer in the family that is typical of a known cancer predisposition syndrome (for example colon and uterine cancer in Lynch syndrome, or breast and pancreatic cancer with PALB2
     
Benefits of Testing
Identifying patients with an inherited susceptibility for certain cancers can help with medical management. For example, this information can:
 
  • Modify cancer surveillance options and age of initial screening
  • Suggest specific risk-reduction measures (e.g. considering prophylactic oophorectomy, after childbearing is complete, for women with increased risk for breast/ ovarian cancer)
  • Clarify and stratify familial cancer risks, based on gene-specific cancer associations (e.g. risk for uterine, colon, and ovarian cancer with MLH1 mutations)
  • Identify other at-risk family members
  • Provide guidance with new gene-specific treatment options and risk reduction measures as they emerge

 

Test Description 

OvaNext analyzes 22 of the 23 genes (ATM, BARD1, BRCA1, BRCA2, BRIP1, CDH1, CHEK2, EPCAM, MLH1, MRE11A, MSH2, MSH6, MUTYH, NBN, NF1, PALB2, PMS2, PTEN, RAD50, RAD51C, RAD51D, STK11, and TP53) by next generation sequencing or Sanger sequencing of all coding domains and well into the flanking 5’ and 3’ ends of all the introns and untranslated regions. In addition, sequencing of the promoter region is performed for the following genes: PTEN (c.-1300 to c.-745), MLH1 (c.-337 to c.-194), and MSH2 (c.-318 to c.-65). A secondary sequencing method is performed for any regions with insufficient read depth coverage for reliable heterozygous variant detection. Suspect variant calls other than those classified as "likely benign" or "benign" are verified by Sanger sequencing in sense and antisense directions. Gene copy number analysis by a targeted microarray identifies gross deletions and duplications in all 23 genes. If a deletion is detected in exons 13, 14, or 15 of PMS2, double stranded sequencing of the appropriate exon(s) of the pseudogene PMS2CL will be performed to determine if the deletion is located in the PMS2 gene or pseudogene.  

Mutation Detection Rate 

Analytical sensitivity for all genes is estimated to be greater than 99.97% of described mutations.

Specimen Requirements 

Blood: Collect 6-10cc blood in purple top EDTA tube (preferred) or yellow top citric acetate tube.
Storage: 2-8°C. Do not freeze.
Shipment: Room temperature for two-day delivery.
For transfusion patients: Wait at least two weeks after a packed cell or platelet transfusion and at least four weeks after a whole blood transfusion prior to blood draw

DNA: Collect 20μg of DNA in TE (10mM Tris-Cl pH 8.0, 1mM EDTA); preferred at 200 ng/μl.
Quality: Please provide DNA OD 260:280 ratio (preferred 1.7-1.9) and send agarose picture with high molecular weight genomic DNA, if available.
Storage: -20°C.
Shipment: Shipment frozen on dry ice is preferred, or ship on ice.

Saliva: Collect 2 tubes with 2cc per tube in Oragene Self Collection container
Storage: At room temperature in sterile bag.
Shipment: Ship room temperature for two-day deliver

 

Turnaround Time 
TEST CODE TEST NAME TURNAROUND TIME (weeks)
8836 OvaNext (Ordered 11/3/14 or after) 2-4
  OvaNext (Ordered before 11/3/14) 8-12

 

Specialty 
References 

1. National Cancer Institute. Cancer Stat Fact Sheets.  Accessed October 22, 2014; Available from: http://seer.cancer.gov/.

2. National Cancer Institute.  Accessed October 22, 2014; Available from: http://www.cancer.gov/.

3. Castera, L., et al., Next-generation sequencing for the diagnosis of hereditary breast and ovarian cancer using genomic capture targeting multiple candidate genes. Eur J Hum Genet, 2014. 22(11): p. 1305-13.

4. Walsh, T., et al., Detection of inherited mutations for breast and ovarian cancer using genomic capture and massively parallel sequencing. Proc Natl Acad Sci U S A, 2010. 107(28): p. 12629-33.

5. van der Groep, P., E. van der Wall, and P.J. van Diest, Pathology of hereditary breast cancer. Cell Oncol (Dordr), 2011. 34(2): p. 71-88.

6. Walsh, T. and M.C. King, Ten genes for inherited breast cancer. Cancer Cell, 2007. 11(2): p. 103-5.

7. Meindl, A., et al., Hereditary breast and ovarian cancer: new genes, new treatments, new concepts. Dtsch Arztebl Int, 2011. 108(19): p. 323-30.

8. Antoniou, A., et al., Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case Series unselected for family history: a combined analysis of 22 studies. Am J Hum Genet, 2003. 72(5): p. 1117-30.

9. Chen, S. and G. Parmigiani, Meta-analysis of BRCA1 and BRCA2 penetrance. J Clin Oncol, 2007. 25(11): p. 1329-33.

10. Ford, D., et al., Genetic heterogeneity and penetrance analysis of the BRCA1 and BRCA2 genes in breast cancer families. The Breast Cancer Linkage Consortium. Am J Hum Genet, 1998. 62(3): p. 676-89.

11. Loveday, C., et al., Germline RAD51C mutations confer susceptibility to ovarian cancer. Nat Genet, 2012. 44(5): p. 475-6; author reply 476.

12. Olivier, M., et al., Li-Fraumeni and related syndromes: correlation between tumor type, family structure, and TP53 genotype. Cancer Res, 2003. 63(20): p. 6643-50.

13. Walsh, T., et al., Mutations in 12 genes for inherited ovarian, fallopian tube, and peritoneal carcinoma identified by massively parallel sequencing. Proc Natl Acad Sci U S A, 2011. 108(44): p. 18032-7.

14. Pennington, K.P., et al., Germline and somatic mutations in homologous recombination genes predict platinum response and survival in ovarian, fallopian tube, and peritoneal carcinomas. Clin Cancer Res, 2014. 20(3): p. 764-75.

15. Pennington, K.P. and E.M. Swisher, Hereditary ovarian cancer: beyond the usual suspects. Gynecol Oncol, 2012. 124(2): p. 347-53.

16. Loveday, C., et al., Germline mutations in RAD51D confer susceptibility to ovarian cancer. Nat Genet, 2011. 43(9): p. 879-82.

17. Renwick, A., et al., ATM mutations that cause ataxia-telangiectasia are breast cancer susceptibility alleles. Nat Genet, 2006. 38(8): p. 873-5.

18. Roberts NJ, J.Y., Yu J, Kopelovich L, Petersen GM, Bondy ML, Steven Gallinger, Schwartz AG, Syngal S, Cote ML, Axilbund J, Schulick R, Ali SZ, Eshleman JR, Velculescu VE, Goggins M, Bert Vogelstein, Papadopoulos M, Hruban RH, Kinzler KW,  Klein AP, ATM Mutations in Patients with hereditary Pancreatic cancer. Cancer Discovery, 2011. 2(1): p. OF1-OF6.

19. Janavicius, R., Founder BRCA1/2 mutations in the Europe: implications for hereditary breast-ovarian cancer prevention and control. EPMA J, 2010. 1(3): p. 397-412.

20. Ferla, R., et al., Founder mutations in BRCA1 and BRCA2 genes. Ann Oncol, 2007. 18 Suppl 6: p. vi93-8.

21. Tulinius, H., et al., The effect of a single BRCA2 mutation on cancer in Iceland. J Med Genet, 2002. 39(7): p. 457-62.

22. Tai, Y.C., et al., Breast cancer risk among male BRCA1 and BRCA2 mutation carriers. J Natl Cancer Inst, 2007. 99(23): p. 1811-4.

23. Thompson, D., D.F. Easton, and C. Breast Cancer Linkage, Cancer Incidence in BRCA1 mutation carriers. J Natl Cancer Inst, 2002. 94(18): p. 1358-65.

24. Folkins, A.K. and T.A. Longacre, Hereditary gynaecological malignancies: advances in screening and treatment. Histopathology, 2013. 62(1): p. 2-30.

25. Shannon, K.M. and A. Chittenden, Genetic testing by cancer site: breast. Cancer J, 2012. 18(4): p. 310-9.

26. Kote-Jarai, Z., et al., BRCA2 is a moderate penetrance gene contributing to young-onset prostate cancer: implications for genetic testing in prostate cancer patients. Br J Cancer, 2011. 105(8): p. 1230-4.

27. van Asperen, C.J., et al., Cancer risks in BRCA2 families: estimates for sites other than breast and ovary. J Med Genet, 2005. 42(9): p. 711-9.

28. Damiola, F., et al., Rare key functional domain missense substitutions in MRE11A, RAD50, and NBN contribute to breast cancer susceptibility: results from a Breast Cancer Family Registry case-control mutation-screening study. Breast Cancer Res, 2014. 16(3): p. R58.

29. Seal, S., et al., Truncating mutations in the Fanconi anemia J gene BRIP1 are low-penetrance breast cancer susceptibility alleles. Nat Genet, 2006. 38(11): p. 1239-41.

30. Meindl, A., et al., Germline mutations in breast and ovarian cancer pedigrees establish RAD51C as a human cancer susceptibility gene. Nat Genet, 2010. 42(5): p. 410-4.

31. Bahassi, E.M., et al., The checkpoint kinases Chk1 and Chk2 regulate the functional associations between hBRCA2 and Rad51 in response to DNA damage. Oncogene, 2008. 27(28): p. 3977-85.

32. Cybulski, C., et al., CHEK2 is a multiorgan cancer susceptibility gene. Am J Hum Genet, 2004. 75(6): p. 1131-5.

33. Walsh, T., et al., Spectrum of mutations in BRCA1, BRCA2, CHEK2, and TP53 in families at high risk of breast cancer. Jama, 2006. 295(12): p. 1379-88.

34. Pharoah, P.D., et al., Incidence of gastric cancer and breast cancer in CDH1 (E-cadherin) mutation carriers from hereditary diffuse gastric cancer families. Gastroenterology, 2001. 121(6): p. 1348-53.

35. Guilford, P., B. Humar, and V. Blair, Hereditary diffuse gastric cancer: translation of CDH1 germline mutations into clinical practice. Gastric Cancer, 2010. 13(1): p. 1-10.

36. Hegde, M.R. and B.B. Roa, Genetic Testing for Hereditary Nonpolyposis Colorectal Cancer (HNPCC) Current Protocols in Human Genetics, 2009. 61(Unit 10.12): p. 10.12.1-10.12.28.

37. Capelle, L.G., et al., Risk and epidemiological time trends of gastric cancer in Lynch syndrome carriers in the Netherlands. Gastroenterology, 2010. 138(2): p. 487-92.

38. Bonadona, V., et al., Cancer risks associated with germline mutations in MLH1, MSH2, and MSH6 genes in Lynch syndrome. JAMA, 2011. 305(22): p. 2304-10.

39. Engel, C., et al., Risks of less common cancers in proven mutation carriers with lynch syndrome. J Clin Oncol, 2012. 30(35): p. 4409-15.

40. Win, A.K., et al., Colorectal and other cancer risks for carriers and noncarriers from families with a DNA mismatch repair gene mutation: a prospective cohort study. J Clin Oncol, 2012. 30(9): p. 958-64.

41. Jenkins, M.A., et al., Risk of colorectal cancer in monoallelic and biallelic carriers of MYH mutations: a population-based case-family study. Cancer Epidemiol Biomarkers Prev, 2006. 15(2): p. 312-4.

42. Win, A.K., et al., Cancer risks for monoallelic MUTYH mutation carriers with a family history of colorectal cancer. Int J Cancer, 2011. 129(9): p. 2256-62.

43. Vogt, S., et al., Expanded extracolonic tumor spectrum in MUTYH-associated polyposis. Gastroenterology, 2009. 137(6): p. 1976-85 e1-10.

44. Rennert, G., et al., MutYH mutation carriers have increased breast cancer risk. Cancer, 2012. 118(8): p. 1989-93.

45. Slater, E.P., et al., PALB2 mutations in European familial pancreatic cancer families. Clin Genet, 2010. 78(5): p. 490-4.

46. Casadei, S., et al., Contribution of inherited mutations in the BRCA2-interacting protein PALB2 to familial breast cancer. Cancer Res, 2011. 71(6): p. 2222-9.

47. Antoniou, A.C., et al., Breast-cancer risk in families with mutations in PALB2. N Engl J Med, 2014. 371(6): p. 497-506.

48. Tischkowitz, M.D., et al., Analysis of the gene coding for the BRCA2-interacting protein PALB2 in familial and sporadic pancreatic cancer. Gastroenterology, 2009. 137(3): p. 1183-6.

49. Jones, S., et al., Exomic sequencing identifies PALB2 as a pancreatic cancer susceptibility gene. Science, 2009. 324(5924): p. 217.

50. Eng, C., Will the real Cowden syndrome please stand up: revised diagnostic criteria. J Med Genet, 2000. 37(11): p. 828-30.

51. Starink, T.M., et al., The Cowden syndrome: a clinical and genetic study in 21 patients. Clin Genet, 1986. 29(3): p. 222-33.

52. Heald, B., et al., Frequent gastrointestinal polyps and colorectal adenocarcinomas in a prospective series of PTEN mutation carriers. Gastroenterology, 2010. 139(6): p. 1927-33.

53. Tan, M.H., et al., Lifetime cancer risks in individuals with germline PTEN mutations. Clin Cancer Res, 2012. 18(2): p. 400-7.

54. Mester, J.L., et al., Papillary renal cell carcinoma is associated with PTEN hamartoma tumor syndrome. Urology, 2012. 79(5): p. 1187 e1-7.

55. Hearle, N., et al., Frequency and spectrum of cancers in the Peutz-Jeghers syndrome. Clin Cancer Res, 2006. 12(10): p. 3209-15.

56. Lim, W., et al., Relative frequency and morphology of cancers in STK11 mutation carriers. Gastroenterology, 2004. 126(7): p. 1788-1794.

57. Hwang, S.J., et al., Germline p53 mutations in a cohort with childhood sarcoma: sex differences in cancer risk. Am J Hum Genet, 2003. 72(4): p. 975-83.

58. Birch, J.M., et al., Prevalence and diversity of constitutional mutations in the p53 gene among 21 Li-Fraumeni families. Cancer Res, 1994. 54(5): p. 1298-304.

59. Gonzalez, K.D., et al., Beyond Li Fraumeni Syndrome: clinical characteristics of families with p53 germline mutations. J Clin Oncol, 2009. 27(8): p. 1250-6.

60. McCuaig, J.M., et al., Routine TP53 testing for breast cancer under age 30: ready for prime time? Fam Cancer, 2012. 11(4): p. 607-13.