PROTOCOL
Familial Gastric Cancer Study
Chief Investigator:
Co-Investigators:
Professor Carlos Caldas
Professor in Cancer Medicine
Cancer Research UK Cambridge Research
Institute
Li Ka Shing Centre
Robinson Way
Cambridge
CB2 0RE
Mr. Richard Hardwick
Dept of Upper GI Surgery
Oesophago-Gastric Service
Box 201
Addenbrookes Hospital
Cambridge
CB2 0QQ
Tel: 01223 217421
Email:
richard.hardwick@addenbrookes.nhs.uk
Tel: 01223 424420
Email: cc234@cam.ac.uk
Principal Investigator:
Dr. Rebecca Fitzgerald
Hutchison-MRC Research Centre and
Dept of Gastroenterology
Box 133
Hutchison/MRC Building
Cambridge
CB2 2XZ
Dr. Paul Pharoah
Strangeways Research Laboratory
Worts Causeway
Cambridge
CB1 8BR
Tel: 01223 740166
Email: paul.pharoah@srl.cam.ac.uk
Tel: 01223 763287
Email: rcf29@cam.ac.uk
Dr. Vicki Save
Consultant Histopathologist
Dept of Pathology
Box 235
Addenbrookes Hospital
Cambridge
CB2 0QQ
Tel: 01223 596938
Email: vicki.save@addenbrookes.nhs.uk
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Collaborator:
Pathology Collaborator:
Miss Jane Blazeby
MRC Clinical Scientist
Division of Surgery
Bristol Royal Infirmary
Marlborough Street
Bristol
BS2 8HW
Prof. Fatima Carneiro
IPATIMUP
University of Porto
Rua Roberto Frias s/n
4200 Porto
Portugal
Tel: 0117 9283153
Tel 351-22-5570700
Email: fatima.carneiro@ipatimup.pt
Research Nurse:
Research Nurse:
Mrs. Sarah Dwerryhouse
University Dept of Oncology
Box 279
Addenbrookes Hospital
Cambridge
CB2 0QQ
Mrs. Isabel Caldas
University Dept of Oncology
Box 279
Addenbrookes Hospital
Cambridge
CB2 0QQ
Tel: 01223 330019
Email: sd449@medschl.cam.ac.uk
Tel: 01223 330019
Email: ic228@medschl.cam.ac.uk
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Summary of Research
Hereditary cancer syndromes have provided the samples for linkage analysis that made possible
the identification of novel cancer-causing genes. Diffuse type gastric cancer remains one of the
more common and aggressive human cancers. We propose to collect information from families
with clustered cases of gastric cancer and identify pedigrees, which suggest a pattern of
autosomal dominant inheritance. Linkage and candidate gene analysis in these pedigrees will be
used to identify a potential major susceptibility locus. Mutations have been identified rarely in
individuals under the age of 50 so it appears justified to search for germline mutations in gastric
cancer cases diagnosed under the age of 45.
In addition, the second part of the study ‘The Hereditary Diffuse Gastric Cancer Registry’ will
collect detailed molecular pathological and clinical information (including quality of life) for
cases in whom a mutation in E-cadherin (CDH1) has been identified. This is in order to inform
the future management of these families.
Background
The mortality from gastric cancer has been decreasing in most developed countries in the last
decades but still remains one of the main causes of cancer morbidity and mortality. The genetic
events underlying gastric carcinogenisis remain poorly understood and advances in screening and
treatment have been scarce. Several published studies have provided evidence that a positive
family history is a major risk factor for this disease and the relative risk for another member of
the family of a gastric cancer patient being affected is about twofold, similar to that for cases of
colon or breast cancer, suggesting that inherited factors may also be important in gastric cancer.
Moreover, some extended pedigrees suggest that a proportion of gastric cancer cases are due to
autosomal dominant high penetrance genes. This is called Hereditary Diffuse Gastric Cancer
(HDGC) syndrome, and to date mutations in the E-cadherin gene (CDH1) have been identified in
a proportion of these families. Although large high risk gastric cancer families may be quite rare,
the availability of high density microsatellite marker maps and SNP arrays means that even a
relative small number of high risk families maybe sufficient to map susceptibility genes.
Sampling such pedigrees would make possible linkage analysis to identify a major susceptibility
locus.
Aims
1- To obtain detailed family histories, blood and tumor samples on individuals from families
with a history of diffuse type gastric cancer.
2- To obtain detailed information (clinical, psychological and molecular) on individuals
undergoing clinical testing for mutations in order to assess the implications of testing,
surveillance and prophylactic surgery on these patients. To analyse and use this data in order
to provide genetic centres with up to date information and to inform the future clinical
management of these individuals.
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Inclusion Criteria
1- Any family with two documented cases of diffuse gastric cancer in first or second
degree relatives with one case under the age of 50.
2 - Three or more cases of gastric cancer in the family, diagnosed in any age, with at least
one documented case of diffuse gastric cancer.
3 - Any individual diagnosed with diffuse gastric cancer before the age of 45
4 - Any individual diagnosed with both diffuse gastric cancer and lobular breast cancer
5 - One member diagnosed with diffuse gastric cancer and another with lobular breast
cancer
6 - One family member diagnosed with diffuse gastric cancer and another with signet ring
colon cancer
However, if necessary, the research team will seek confirmation of cancer pathologies
Referral to the study
Patients currently attending the cancer genetics clinic will be invited to participate at the clinic
when they attend a routine clinic appointment for genetic counseling, to discuss their family
history.
Patients who are identified by other clinicians will be approached by the clinician (or Specialist
nurse) responsible for their clinical care, at their routine clinic appointment. They will be asked to
sign a permission slip which will allow the research team in Cambridge to contact them to
provide further information about the study.
Clinicians may also make a referral to the study by accessing the British Society of
Gastroenterology website www.bsg.org.uk. and following the links to the research section. The
Research Nurse will then send a permission slip to be given to the patient to fill in.
Individuals may also contact the Research Nurse directly by telephone (01223 330019) or email
sd449@medschl.cam.ac.uk. Details of the study are on Cancer Research UK’s website www.
cancerresearchuk.org
Second part of the study
Families who meet the criteria for Hereditary Diffuse Gastric Cancer and are undergoing clinical
testing at genetic centres will be invited to take part in the second part of the study the
‘Hereditary Diffuse Gastric Cancer Registry’. The Geneticist in charge of their clinical care will
ask if the family is willing for their information to be held on the register. The individuals will be
given an information sheet and, if agreeable, a permission slip to complete. The permission slip
would be forwarded to the Research Nurse.
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Role of the Research Nurse
Once the research team in Cambridge has received the signed permission slip the Research Nurse
will contact the individual by telephone and if they wish to participate they will be sent study
consent forms. They will also provide the opportunity for the individual to ask questions about
the study.
The research nurse will contact their GP to inform them that their patient has chosen to
participate in the study. They will also ask permission to have the blood sample taken at the
surgery. Any individual having active clinical treatment can have the blood sample taken at the
same time as the clinical sample to avoid having an added venepuncture.
If the patient/relative consents to provide a blood sample they will be sent a blood taking kit by
the research nurse in Cambridge. They will be asked to take the kit to their GP, or next hospital
clinic appointment. The sample tubes will be packaged, stamped and addressed for return to
Cambridge.
Affected and unaffected relatives will be contacted if necessary by the index patient in the first
instance. They will be sent an information sheet and permission slip by the index patient to sign
and return to the Research team. They will only be contacted directly by the research team once
they return the signed permission slip.
Members of the family may also contact the research team directly and request to participate in
the study. The same protocol of sending consents in the post will be followed and any consultant
involved in clinical care will be informed of their participation.
The Research Nurse in Cambridge will also record their family history of cancer. Confirmation of
cancers in deceased members of the family will be sought from Cancer Registries (a letter of
support from PIAG can be supplied if necessary) Histology departments at the hospitals involved
will be contacted to provide histology reports to confirm the histology of the tumours. This
information is essential to assess what mutation testing may be appropriate in the research
laboratory.
Pathology samples from each affected individual will be requested by writing to the Pathologist
concerned. Sections of tumour will be cut from the paraffin blocks for DNA analysis and to
construct a tissue microarray, and the blocks will be then returned to the Pathologist.
All individuals that agree to participate in the study will be provided with an information sheet
about the study and asked to sign a consent form. If a participant wishes to withdraw from the
study then their DNA sample and all information held on them will be destroyed.
Consent to the second part of the study the ‘Hereditary Diffuse Gastric Cancer Registry’ would
allow the Research Nurse to contact the individuals at regular intervals to obtain information
throughout the clinical testing process. It would allow access to the individual’s medical records
and their deceased relatives and to pathology specimens.
For those individuals who are found to carry a positive mutation the study will record the choices
made regarding endoscopic surveillance versus prophylactic surgery. If the individual opts for
prophylactic surgery results of surveillance endoscopy carried out pre operatively as well as
endoscopic biopsy (paraffin and snap frozen) material would be obtained. A blood sample will be
taken at the time of endoscopy for DNA/RNA extraction, Helicobacter pylori serology and the
white blood cells may be grown in tissue culture.
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Information regarding surgery and post operative complications would be sought.
Once the whole resected stomach has been processed by the local pathology department,
according to their protocol, the remainder would be requested for use in molecular studies. The
Cambridge research group is a member of a consortium set up to help in the management of these
families (The International Gastric Cancer Linkage Consortium). The pathology is reviewed by a
panel of Pathologists headed by Professor Fatima Carneiro at the University of Porto in Portugal.
The gastrectomy specimens are sent there for pathological examination and classification.
Access to archived paraffin blocks from patients who have already undergone prophylactic
surgery would also be requested.
The individual would be asked to complete a pre operative quality of life questionnaire and at
several stages post operatively. As there is very limited data on the outcome of prophylactic
gastrectomy in asymptomatic individuals the aim of the questionnaires is to measure the impact
of surgery including morbidity, quality of life and the psychological effects of surgery.
Laboratory Samples
A venous blood sample (total 20ml) will be collected into citrate 10ml and EDTA (10ml) tubes,
to extract DNA, and isolate lymphocytes for storage at –20 oC, respectively.
Tumour samples will be retrieved from Pathology departments to obtain sections and construct a
tissue microarray, and will then be returned to the originating department.
Endoscopic surveillance
There needs to be a standardized surveillance protocol. Endoscopic gastric cancer surveillance is
unproven as an effective method for detecting early lesions in patients at risk. The difficulties
arise because the lesions are frequently submucosal and the affected area may be localised so that
the early cancer may not be detected by random sampling.
The questions that need to be addressed in this area includes the frequency of surveillance, where
the biopsies should be taken from and whether the areas at risk can be targeted using adjunctive
endoscopic techniques such as magnification chromoendoscopy, auto fluorescence and narrow
band imaging . The Japanese have had success in detecting early cancerous lesions with excellent
long-term survival data. Their success seems to result from their meticulous sampling of the
mucosa by experts as well as the use of magnification and chromoendoscopy.
It is proposed that individuals participating in this study, with a significant history of two or more
histologically confirmed gastric cancers in the family, or where the genetic department involved
in their clinical care feels they are at significant risk would have an endoscopy based on the
‘Endoscopic surveillance protocol for patients fulfilling International Gastric Linkage
Consortium (IGLC) criteria for Hereditary Diffuse Gastric Cancer’ (version 2 22/5/2007)
It could be carried out either in Cambridge on a specialist gastric cancer surveillance list or their
local hospital using the protocol for guidance. The results would be recorded on the register in
Cambridge. This would be as part of their clinical care to try and detect precursory lesions. These
samples would then be analysed by a histopathologist with expertise in evaluating microscopic
foci of signet ring carcinoma (Dr. Vicki Save in Cambridge and Dr. Fatima Carneiro in Portugal).
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The data would be used to analyse the effectiveness of the surveillance protocol. It is estimated
that the endoscopy will last 20-30 minutes and involve taking approximately 30 biopsies.
This is similar to endoscopic surveillance protocols routinely used for Barrett’s oesophagus and
colonic surveillance. The risks of perforation and hemorrhage are as for routine procedures i.e. 1
in 1000
Statistical Considerations
Both parametric and non- parametric linkage analysis will be performed.
Confidentiality
Pseudo-anonymisation will be used for all patient data and samples.
All subjects will be given a numerical identification, which will be used in all day-to-day work
with the sample set. No laboratory staff working on the samples will know the patients identity.
Members of the research team, namely the research nurse, research assistant and principal
investigators will know the identity of the patient. Identifying codes will be kept in a locked
filing cabinet in the department of Oncology, Addenbrooke’s Hospital. No identification will be
used in any presentation or publication of the data. The Departments of Public Health and
Primary Care and Oncology are registered for medical research data under the Data Protection
Act 1998.
Ethical Considerations
The individuals participating in this study will be providing a blood sample for research purposes
only. However, it is recognised that as part of the research, results may be obtained which may
be of relevance to the clinical management of the patient or their relatives. In such an occurrence
we would follow our standard procedure for dealing with genetic information arising from
research studies:
1- Individuals participating in the study will be specifically asked whether they wish to be
contacted in the event of results becoming available which may be of relevance to them and
asked to complete a form indicating this.
2- In such cases the subjects would be re-contacted and invited for consultation at one of the
regional Familial Cancer Genetics Clinics, and would then be dealt with under the predictive
testing program, which provides appropriate counseling and management for individuals
wishing to undergo genetic testing.
3- Any such testing would be based on a fresh blood sample (therefore no predictive testing will
be carried out using the samples collected in this research protocol).
In addition, resources for counseling any individual in the study concerned about familial
cancer will be provided at one of the regional Familial Cancer Clinics.
4- Families undergoing clinical predictive testing for mutations in susceptibility genes would be
invited by the research nurse or their clinical geneticist, to participate in ‘The Hereditary
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Diffuse Gastric Cancer Register’, the second part of the study, in order to assess the
implications of testing, surveillance and surgery on these families. This data will be analysed
and used to provide genetic centres with up to date information to help with the management
of these families.
Financial Support
This study is being supported by a grant from Cancer Research UK to Professor Carlos Caldas.
Benefits Resulting from This Research
The main benefit from this study will be in localization and subsequent identification of new
gastric cancer predisposition genes. This study may also be direct benefit to some of the
individuals participating. For example, an individual at risk might be shown by linkage not to
have inherited the susceptibility allele and therefore, if the patient wishes to be informed of this
fact, be spared specific gastric cancer screening.
Indemnity Arrangements
The nurse involved in contact with patients and other study subjects will be covered by
professional malpractice insurance. No genetic information or “results” obtained in this study
will be used for patient care, so claims should not arise in this context. If genetic data are to be
communicated to subjects it will be through the NHS Clinical Genetics Service. Dr Joan
Patterson is the Clinical Consultant concerned in East Anglia; she is covered by MDU and Trust
indemnities. Clinical Geneticists at other centers have similar cover. Dr Rebecca Fitzgeraild
performing surveillance endoscopy is covered by MDU and Trust indemnities
Publication of the Results
Results deriving from this study will be published in peer reviewed journals.
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Publications resulting from study
Identification of Germ-line E-cadherin Mutations in Gastric cancer families of European origin.
Cancer Research Sept 15 1998
Familial gastric cancer: overview and guidelines for management.
Journal for Medical Genetics Dec 1999
Early gastric cancer in young, asymptomatic carriers of germ-line E- cadherin mutations. N Engl
J Med 2001, 344(25):1904-9.
Huntsman DG, Carneiro F, Lewis FR, MacLeod PM, Hayashi A, Monaghan KG,
Maung R, Seruca R, Jackson CE, Caldas C
Screening E-cadherin in gastric cancer families reveals germline mutations only in hereditary
diffuse gastric cancer kindred. Hum Mutat 2002 May; 19(5):510-517
Oliveira C, Bordin MC, Grehan N, Huntsman D, Suriano G, Machado JC, Kiviluoto T, Aaltonen
L, Jackson CE, Seruca R, Caldas C.
E-cadherin mutations and hereditary gastric cancer: Prevention by resection? Digestive diseases
2002; 20:23-31 RC Fitzgerald, C Caldas
Clinical implications of E-cadherin associated hereditary diffuse gastric cancer Gut 2004; 53,
775-778 R C Fitzgerald and C Caldas
Germline E-cadherin mutations in Hereditary diffuse gastric cancer: assessment of 42 new
families and review of genetic screening criteria JMG 2004; 41:508-517 Huntsman, Caldas et al
Incidence of gastric cancer and breast cancer in CDH1 (E-cadherin) mutation carriers from
hereditary diffuse gastric cancer families Gastroenterology 2001 Dec; 121(6):1348-53 Pharoah,
Guilford, Caldas
Germline E-cadherin mutations in hereditary diffuse gastric cancer: assessment of 42 new
families and review of genetic screening criteria Journal of Medical Genetics 2004; 41
Huntsman, Caldas et al
A novel mutation in the E-cadherin gene in the first family with hereditary diffuse gastric cancer
reported in Spain. European Journal of Surgical Oncology, 32: 1110-1113, 2006 RodriguezSanjuan JC, Fontalba A, Mayorga M, Bordin MC, Hyland SJ, Trugeda S, Garcia RA, GomezFleitas M, Fernandez F, Caldas C, Fernandez-Luna JL.
Familial gastric cancer- clinical management.
Best Practice & Research Clinical Gastroenterology, 20: 735-743, 2006 Fitzgerald RC and
Caldas C
Familial gastric cancer- aetiology and pathogenesis. Best Practice & Research Clinical
Gastroenterology, 20: 721-734, 2006 Barber M, Fitzgerald RC and Caldas C.
Version 7 10/9/2007
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