Genetic, Structural, and Functional Characterization of POLE Polymerase Proofreading Variants Allows Cancer Risk Prediction
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© American College of Medical Genetics and Genomics ARTICLE Genetic, structural, and functional characterization of POLE polymerase proofreading variants allows cancer risk prediction Nadim Hamzaoui, MD, PhD 1, Flora Alarcon, PhD2, Nicolas Leulliot, PhD3, Rosine Guimbaud, MD, PhD4, Bruno Buecher, MD, PhD5, Chrystelle Colas, MD, PhD6, Carole Corsini, MD7, Gregory Nuel, PhD8, Benoît Terris, MD, PhD9, Pierre Laurent-Puig, MD, PhD10, Stanislas Chaussade, MD11, Marion Dhooge, MD11, Clément Madru, PhD3 and Eric Clauser, MD, PhD1,12 Purpose: Polymerase proofreading-associated polyposis is a found in ten families. The estimated cumulative risk of CRC at 30, dominantly inherited colorectal cancer syndrome caused by 50, and 70 years was 11.1% (95% confidence interval [CI]: exonuclease domain missense variants in the DNA polymerases 4.2–17.5), 48.5% (33.2–60.3), and 74% (51.6–86.1). Cumulative POLE and POLD1. Manifestations may also include malignancies at risk of glioblastoma was 18.7% (3.2–25.8) at 70 years. Variants extracolonic sites. Cancer risks in this syndrome are not yet interfering with DNA binding (P286L and N363K) had a accurately quantified. significantly higher mutagenic effect than variants disrupting ion Methods: We sequenced POLE and POLD1 exonuclease domains metal coordination at the exonuclease site. in 354 individuals with early/familial colorectal cancer (CRC) or Conclusion: The risk estimates derived from this study provide a adenomatous polyposis. We assessed the pathogenicity of POLE rational basis on which to provide genetic counseling to POLE variants with yeast fluctuation assays and structural modeling. We variant carriers. estimated the penetrance function for each cancer site in variant carriers with a previously published nonparametric method Genetics in Medicine (2020) 22:1533–1541; https://doi.org/10.1038/s41436- based on survival analysis approach, able to manage unknown 020-0828-z genotypes. Results: Pathogenic POLE exonuclease domain variants P286L, Keywords: colorectal cancer; glioblastoma; penetrance; POLE; M294R, P324L, N363K, D368N, L424V, K425R, and P436S were polymerase proofreading-associated polyposis INTRODUCTION often show an “ultramutator” phenotype characterized by – Polymerase proofreading-associated polyposis (PPAP; OMIM mutational loads exceeding 100 variants per megabase2 5. 61259 and 615083), is an autosomal dominant cancer Knowledge of the age-specific cumulative cancer risks syndrome caused by the inability of the main replicative associated with PPAP could lead to improved cancer screen- DNA polymerases, POLE and POLD1, to proofread newly ing strategies and risk-reducing treatments. So far, only synthesized DNA strands1. Individuals with PPAP carry one publication has attempted to give colorectal cancer germline variants of the 3´–5´ proofreading exonuclease penetrance estimates in PPAP6. In the present study, we domain of POLE or POLD1 and are at increased risk of analyze the structural and functional consequences of eight colorectal cancer and adenoma. Several other tumor types, different POLE exonuclease variants found in ten new PPAP including endometrial, ovarian, duodenal, and brain cancers, families and give new estimates of the cumulative cancer risks have also been described in these families2. These tumors associated with PPAP. 1Service de Génétique et Biologie Moléculaires, Hôpital Cochin, APHP Centre Université de Paris and Inserm UMR_S1016, Institut Cochin, Université de Paris, Paris, France; 2Mathématiques appliquées Paris 5 (MAP5) CNRS: UMR8145, Université de Paris, Paris, France; 3Laboratoire de Cristallographie et RMN Biologiques, UMR CNRS 8015, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Pharmacie de Paris, Paris, France; 4Unité d’oncogénétique, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France; 5Department of Medical Oncology, Institut Curie, Paris Sciences Lettres Research University, Paris, France; 6Department of Genetics, Institut Curie, Paris Sciences Lettres Research University, Paris, France; 7Medical Genetics Department, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, Languedoc-Roussillon, France; 8Institute of Mathematics, National Center for French Research, Laboratory of Probability, University Pierre et Marie Curie, Sorbonne University, Paris, France; 9Department of Pathology, Cochin Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France; 10Department of Biochemistry, Unit of Pharmacogenetics and Molecular Oncology, Georges Pompidou European Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France; 11Department of gastroenterology, Cochin hospital, assistance publique–Hôpitaux de Paris, Paris Descartes university, Paris, France; 12INSERM U970, Paris Descartes University, Paris, France. Correspondence: Nadim Hamzaoui (nadim. [email protected]) Submitted 4 December 2019; revised 27 April 2020; accepted: 27 April 2020 Published online: 19 May 2020 GENETICS in MEDICINE | Volume 22 | Number 9 | September 2020 1533 ARTICLE HAMZAOUI et al MATERIALS AND METHODS is taken into account as described12. The method has been Patients described in detail elsewhere13. Analysis was performed by We recruited 354 consecutive patients exhibiting features of using R software. In the present study, the covariate tested was early-onset/familial colorectal cancer (CRC) (218 individuals) gender and a difference between groups was tested using a and/or attenuated adenomatous polyposis (136 individuals) likelihood ratio test. between 2014 and 2017. Early-onset/familial CRC patients met the revised Bethesda criteria for microsatellite instability Strains and plasmid construction (MSI) testing7. Multiple colonic adenomas patients met the The Saccharomyces cerevisiae (MATa ade5-1 lys2-InsEA14 French National Cancer Institute criteria for MUTYH trp1-289 his7-2 leu2-3,112 ura3-52) yeast strain used in the screening8. We also included in this group patients for whom study is isogenic to E13414. Nucleotides 372–6669 of POL2 endoscopy and pathology reports gave descriptions like (the yeast homolog of human POLE) were amplified, cloned “polyposis” or “multiple polyps” rather than the exact number in pGEMT (Promega) and assembled in the pFA6a-KanMX6 of adenomas. A group of 253 patients were analyzed for the integration plasmid by restriction enzyme cloning. Exonu- first time, whereas 101 patients had been previously tested clease domain variants Pol2-P301L, Pol2-M309R, Pol2- negative for Lynch syndrome or adenomatous polyposis at P339L, Pol2-N378K, Pol2-D383N, Pol2-L439V, Pol2-K440R, other institutions. Written informed consent was obtained Pol2-A445T, and Pol2-P451S (encoding variants equivalent to from all subjects and the study received the approval of the human POLE P286L, M294R, P324L, N363K, D368N, L424V, Ethical Review Committee of the Cochin University Hospital. K425R, A430T, and P436S) were created with the Quik- Change Lightning Site-Directed Mutagenesis Kit (Agilent). Variant detection Plasmids were integrated into the POL2 locus after lineariza- A custom-made Ion Torrent Ion AmpliSeq panel (Thermo tion with Bsu36I and selection for G418 resistance, following 1234567890():,; Fisher Scientific, Waltham, MA) and a Ion PGM system the protocol described by Gietz and Schiestl15. Constructs (Thermo Fisher) were used to sequence the entire coding were verified by sequencing. Two control strains were also regions of 11 genes associated with hereditary digestive constructed using the same procedure, a negative control cancers (APC, MUTYH, AXIN2, MLH1, MSH2, MSH6, Pol2-wt (wild-type) strain and a positive control Pol2-AIA CDH1, STK11, PTEN, SMAD4, BMPR1A) and the exons strain defective in 3’–5’ proofreading exonuclease by variants coding the exonuclease domains of POLE and POLD1 of the highly conserved Exo I motif DIE into an AIA motif (codons 268–471 of POLE and 304–517 of POLD1). A search (residues 290–292). for large rearrangements in the genes APC, MLH1, MSH2, MSH6, and EPCAM was done by multiplex ligation- Fluctuation assays dependent probe amplification (MLPA) (MRC Holland). The spontaneous variant rate was measured by fluctuation Cases with loss of MLH1 protein expression in the tumor by analysis according to Lang and Murray16. For mutant immunohistochemistry and without germline MLH1 deleter- selection, yeast cultures were plated onto two types of ious variants were further studied by methylation-specific selective media: CAN10X (synthetic complete medium with- MLPA (MRC Holland) searching for constitutional epimuta- out arginine, 0.5 g/liter of L-canavanine) and HIS- (synthetic tion of MLH1. complete medium without histidine). Canavanine is a toxic arginine analog, whose uptake requires the arginine trans- Estimation of penetrance porter encoded by the CAN1 gene. The Canr forward variant The objective was to estimate the penetrance function in the assay selects for loss-of-function mutants of this transporter, context where most genotypes are unobserved. For this which occur through a variety of base substitutions, frame- purpose, we use a nonparametric method based on a survival shifts, and larger rearrangements. The his7-2 reporter is a -1 analysis approach. Since many genotypes are unobserved, we frameshift variant creating a run of 7 adenines. Gain-of- + use a classical expectation–maximization (EM) algorithm9 to function mutants selected by the His reverse variant assay estimate iteratively both the penetrance function and the occur primarily by +1 or -2 indel changes. All experiments posterior carrier probability.