Identification of candidate genes for prostate cancer-risk SNPs utilizing a normal prostate tissue eQTL data set

Multiple studies have identified loci associated with the risk of developing prostate cancer but the associated genes are not well studied. Here we create a normal prostate tissue-specific eQTL data set and apply this data set to previously identified prostate cancer (PrCa)-risk SNPs in an effort to identify candidate target genes. The eQTL data set is constructed by the genotyping and RNA sequencing of 471 samples. We focus on 146 PrCa-risk SNPs, including all SNPs in linkage disequilibrium with each risk SNP, resulting in 100 unique risk intervals. We analyse cis-acting associations where the transcript is located within 2 Mb (±1 Mb) of the risk SNP interval. Of all SNP–gene combinations tested, 41.7% of SNPs demonstrate a significant eQTL signal after adjustment for sample histology and 14 expression principal component covariates. Of the 100 PrCa-risk intervals, 51 have a significant eQTL signal and these are associated with 88 genes. This study provides a rich resource to study biological mechanisms underlying genetic risk to PrCa.

Single nucleotide polymorphisms—SNPs—have been identified for prostate cancer but whether these SNPs alter the expression of genes is largely unknown. In this study, the authors search for genes located within 2 Mb of the SNPs and identify SNPs that influence gene expression, so called expression quantitative trait loci.

Experimental designs for array comparative genomic hybridization technology

Array comparative genomic hybridization (aCGH) technology is commonly used to estimate genome-wide copy-number variation and to evaluate associations between copy number and disease. Although aCGH technology is well developed and there are numerous algorithms available for estimating copy number, little attention has been paid to the important issue of the statistical experimental design. Herein, we review classical statistical experimental designs and discuss their relevance to aCGH technology as well as their importance for downstream statistical analyses. Furthermore, we provide experimental design guidance for various study objectives.

Abstract PD10-05: HLA-DQA1*02:01/DRB1*07:01 as a biomarker for lapatinib-induced hepatotoxicity: prospective confirmation in a large randomised clinical trial (TEACH, EGF105485)

Hepatotoxicity is associated with small molecule tyrosine kinase inhibitors (TKI) in use for the treatment of a variety of cancers. Retrospective studies have identified and confirmed that specific Class II Human Leukocyte Antigen (HLA) alleles are strongly associated with ALT elevation in women treated with the TKI lapatinib for breast cancer. This study aimed to further evaluate and validate the role of the specified HLA alleles as predictors of elevated ALT in a pre-defined analysis of a large, randomized, double-blind, placebo-controlled study of lapatinib monotherapy in early stage HER2 positive breast cancer, the TEACH study (Tykerb Evaluation After Chemotherapy, EGF105485).

This prospectively defined pharmacogenetic study compared the frequency of hepatobiliary adverse events between pre-specified Major Histocompatibility Complex (MHC) genetic variants, including the HLA alleles DQA1*02:01 and DRB1*07:01. The primary focus was on elevated ALT, as well as rare cases of concurrent ALT (>3x ULN) and bilirubin (>2x ULN) elevation, which represent possible Hy's Law cases and a high risk of acute liver failure, among 1194 patients randomized to lapatinib treatment from whom pharmacogenetic data was available.

This study prospectively validated prior reports of the association of the specified MHC variants with elevated ALT among women treated with lapatinib. The strongest effects were observed for carriers of the HLA alleles DQA1*02:01 and DRB1*07:01, with odds ratios of 20 (95% CI: 8–40) between cases (n = 34) and controls (n = 807–808). These two HLA alleles are highly correlated, inherited together in most individuals and are consistent with a single genetic association. The overall risk of patients having an ALT (>3xULN) elevation was 3.0% and 0.7% during treatment with lapatinib and placebo respectively. Carriers of either HLA allele had a 12% chance (positive predictive value) of having an elevated ALT (>3xULN), in contrast to a 0.9% risk (negative predictive value, 99.1%) for non-carriers of the specified HLA alleles. These associations were maintained for higher ALT elevation thresholds and for cases of concurrent ALT and TBL elevation, consistent with possible Hy's Law cases. These results strongly support the role of Class II HLA-modulated immune mechanisms in lapatinib-induced hepatotoxicity.

Our results validate the large strength of association of the HLA alleles DRB1*07:01 and DQA1*02:01 with hepatotoxicity and provide the possibility of managing the risk of hepatotoxicity in women receiving lapatinib for early or late stage HER2 positive breast cancer. This association with immune mechanisms may have implications for toxicities with other TKIs in current use in cancer patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD10-05.

Validity of family history data on PD: evidence for a family information bias

OBJECTIVE

To study the validity of information provided by case and control subjects (or their proxies) about PD among their first-degree relatives.

METHODS

Secondary cases of PD were assessed both through a single informant (family history method) and through the study of each relative (family study method). The family study method was considered as the standard for comparison, and the sensitivity and specificity of the family history method were studied.

RESULTS

A total of 133 population-based case subjects and their 655 relatives were recruited, and 119 population-based control subjects and their 511 relatives. Sensitivity was 68% (95% CI = 47 to 85) for cases and 45% (95% CI = 17 to 77) for controls. Specificity was 99% (95% CI = 98 to 99) for cases and 100% (95% CI = 99 to 100) for controls. The odds ratio (OR) for family history of PD was 4.34 (95% CI = 1.63 to 11.58, p = 0.003) using the family history method and 1.86 (95% CI = 0.78 to 4.44, p = 0.16) using the family study method. The former significant OR more than doubled the latter not significant OR (relative bias = 133%). Bias was more pronounced for proxy interviews and for women informants, and when the relatives were siblings, were living, and were examined or had medical record documentation.

CONCLUSIONS

Case subjects with PD (or their proxies) are more aware of PD among their first-degree relatives than control subjects (or their proxies); however, they overreport PD in relatives who are not affected. This causes a substantial family information bias.

Head trauma preceding PD: a case-control study

OBJECTIVE

To investigate the association of PD with preceding head trauma using a case-control study design.

METHODS

The medical records-linkage system of the Rochester Epidemiology Project was used to identify 196 subjects who developed PD in Olmsted County, MN, from 1976 through 1995. Each incident case was matched by age (+/-1 year) and sex to a general population control. The complete medical records of cases and controls in the system were reviewed to detect preceding episodes of head trauma.

RESULTS

The frequency of head trauma overall was significantly higher in cases than in controls (odds ratio [OR] = 4.3; 95% CI = 1.2 to 15.2). Compared with subjects who never experienced a trauma, subjects who experienced a mild head trauma with only amnesia had no increased risk; however, subjects who experienced a mild head trauma with loss of consciousness or a more severe trauma had an OR of 11.0 (95% CI = 1.4 to 85.2). Although not significant, head trauma resulting in hospitalization was more frequent in cases than in control subjects (OR = 8.0; 95% CI = 1.0 to 64.0). Whereas the OR was higher for men than women and for patients with later onset of PD than for patients with earlier onset, these differences were not significant.

CONCLUSIONS

These results suggest an association between head trauma and the later development of PD that varies with severity. Although the OR is high (4.3), the population attributable risk is only 5% because head trauma is a relatively rare event.

Confirmation of linkage of prostate cancer aggressiveness with chromosome 19q

Regions on chromosomes 7 and 19 were recently reported to contain susceptibility loci that regulate tumor aggressiveness of prostate cancer. To confirm these findings, we analyzed genome scan data from 161 pedigrees affected with prostate cancer. Using the Gleason score as a quantitative measure of tumor aggressiveness, we regressed the squared trait difference, as well as the mean-corrected cross product, on the estimated proportion of alleles shared identical-by-descent at each marker position. Our results confirm the previous linkage results for chromosome 19q (D19S902, P<.00001). In addition, we report suggestive evidence for linkage on chromosome 4 (D4S403, P=.00012). The results of previous findings, together with our results, provide strong evidence that chromosome 19 harbors a gene for tumor aggressiveness.

Efficacy of bilateral prophylactic mastectomy in BRCA1 and BRCA2 gene mutation carriers

BACKGROUND

In women with a family history of breast cancer, bilateral prophylactic mastectomy is associated with a decreased risk of subsequent breast cancer of approximately 90%. We examined the association between bilateral prophylactic mastectomy and breast cancer risk in women at high risk for breast cancer who also had mutations in BRCA1 and BRCA2 genes.

METHODS

We obtained blood samples from 176 of the 214 high-risk women who participated in our previous retrospective cohort study of bilateral prophylactic mastectomy. We used conformation-sensitive gel electrophoresis and direct sequence analysis of the blood specimens to identify women with mutations in BRCA1 and BRCA2. The carriers' probabilities of developing breast cancer were estimated from two different penetrance models.

RESULTS

We identified 26 women with an alteration in BRCA1 or BRCA2. Eighteen of the mutations were considered to be deleterious and eight to be of uncertain clinical significance. None of the 26 women has developed breast cancer after a median of 13.4 years of follow-up (range, 5.8-28.5 years). Three of the 214 women are known to have developed a breast cancer after prophylactic mastectomy. For two of these women, BRCA1 and BRCA2 screening was negative, and no blood specimen was available for the third. Estimations of the effectiveness of prophylactic mastectomy were performed, considering this woman as both a mutation carrier and a noncarrier. These calculations predicted that six to nine breast cancers should have developed among the mutation carriers, which translates into a risk reduction, after bilateral prophylactic mastectomy, of 89.5%-100% (95% confidence interval = 41.4% to 100%).

CONCLUSIONS

Prophylactic mastectomy is associated with a substantial reduction in the incidence of subsequent breast cancer not only in women identified as being at high risk on the basis of a family history of breast cancer but also in known BRCA1 or BRCA2 mutation carriers.

Case-Control study of the extended tau gene haplotype in Parkinson's disease

We investigated the association of Parkinson's disease with tau gene haplotypes. In a sample of 319 unrelated Parkinson's disease patients and 196 control subjects, we observed an increased risk of Parkinson's disease for persons with the H1/H1 genotype (odds ratio = 1.5; 95% confidence interval: 0.98-2.23); however, the finding was not statistically significant. The results remained similar after adjusting for the possible misclassification of progressive supranuclear palsy patients as Parkinson's disease, but became statistically significant after restricting the analysis to nondemented subjects.

Efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer

PURPOSE

To estimate the efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer.

PATIENTS AND METHODS

We followed the course of 745 women with a first breast cancer and a family history of breast and/or ovarian cancer who underwent contralateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. Family history information and cancer follow-up information were obtained from the medical record, a study-specific questionnaire, and telephone follow-up. Life-tables for contralateral breast cancers, which consider age at first breast cancer, current age, and type of family history, were used to calculate the number of breast cancers expected in our cohort had they not had a prophylactic mastectomy.

RESULTS

Of the 745 women in our cohort, 388 were premenopausal (age < 50 years) and 357 were post- menopausal. Eight women developed a contralateral breast cancer. Six events were observed among the premenopausal women, compared with 106.2 predicted, resulting in a risk reduction of 94.4% (95% confidence interval [CI], 87.7% to 97.9%). For the 357 postmenopausal women, 50.3 contralateral breast cancers were predicted, whereas only two were observed, representing a 96.0% risk reduction (95% CI, 85.6% to 99.5%).

CONCLUSION

The incidence of contralateral breast cancer seems to be reduced significantly after contralateral prophylactic mastectomy in women with a personal and family history of breast cancer.

Hysterectomy, menopause, and estrogen use preceding Parkinson's disease: an exploratory case-control study

We studied the association of Parkinson's disease (PD) with type of menopause (natural or surgical), age at menopause, and postmenopausal estrogen replacement therapy using a case-control design. We used the medical records-linkage system of the Rochester Epidemiology Project to identify 72 women who developed PD in Olmsted County, MN, during the twenty years 1976-1995. Each incident case was matched by age (+/- 1 year) to a general population control subject. We collected exposure data through review of the complete medical records of cases and control subjects in the system. PD cases had undergone hysterectomy (with or without unilateral oophorectomy) significantly more often than control subjects (odds ratio [OR] = 3.36; 95% confidence interval [CI] = 1.05-10.77). In addition, PD cases had experienced early menopause (< or = 46 years) more commonly than control subjects (OR = 2.18; 95% CI = 0.88-5.39). Finally, PD cases had used estrogens orally or parenterally for at least 6 months after menopause less frequently (8%) than control subjects (14%; OR = 0.47; 95% CI = 0.12-1.85). However, the findings for early menopause and estrogen replacement therapy were not statistically significant. Despite the limited sample size of this exploratory study, we hypothesize that there is an increased risk of PD in conditions causing an early reduction in endogenous estrogen. This hypothesis needs to be confirmed in a larger study.

Role of HPC2/ELAC2 in hereditary prostate cancer

The HPC2/ELAC2 gene on chromosome 17p was recently identified as a candidate gene for hereditary prostate cancer (HPC). To confirm these findings, we screened 300 prostate cancer patients (2 affected members/family) from 150 families with HPC for potential germ-line mutations using conformation-sensitive gel electrophoresis, followed by direct sequence analysis. The minimum criteria for our families with HPC was the presence of 3 affected men with prostate cancer. A total of 23 variants were identified, including 13 intronic and 10 exonic changes. Of the 10 exonic changes, 1 truncating mutation was identified, a Glu216Stop nonsense mutation. This nonsense variant was found in 2 of 3 affected men in a single family. The remaining nine alterations included five missense, three silent, and one variant in the 3' untranslated region. To additionally test for potential associations of polymorphic variants and increased risk for disease, we genotyped two common polymorphisms, Ser217Leu and Ala541Thr, in 446 prostate cancer patients from 164 families with HPC and 502 population-based controls. The frequency of the Leu217 variant was similar for patients (32.3%) and controls (31.8%), as was the frequency of the Thr541 variant (5.4% among patients versus 5.2% among controls). In contrast to previous reports, we found no association of the joint effects of Leu271 and Thr541 (odds ratio, 1.04; 95% confidence interval, 0.57-1.89). Overall, our results did not reveal any association between these two common polymorphisms and the risk for HPC. The finding of a nonsense mutation in the HPC2/ELAC2 gene confirms its potential role in genetic susceptibility to prostate cancer. However, our data also suggest that germ-line mutations of the HPC2/ELAC2 are rare in HPC and that the variants Leu217 and Thr541 do not appear to influence the risk for HPC. Cumulatively, these results suggest that alterations within the HPC2/ELAC2 gene play a limited role in genetic susceptibility to HPC.

Time trends in the incidence of parkinsonism in Olmsted County, Minnesota

OBJECTIVE

To investigate time trends in the incidence of parkinsonism and PD over a 15-year period (1976 to 1990).

METHODS

The authors used the medical records-linkage system of the Rochester Epidemiology Project to identify incidence cases of parkinsonism in Olmsted County, MN, over three 5-year periods, 1976 to 1980, 1981 to 1985, and 1986 to 1990. PD and other types of parkinsonism were classified using defined criteria. Population denominators were derived from census data and were corrected by removing prevalent cases of parkinsonism.

RESULTS

Over the 15 years of the study, 364 cases of parkinsonism were identified; 154 (42%) of them had PD. The incidence of parkinsonism remained stable over the three 5-year periods for the age classes 0 to 39, 40 to 59, and 60 to 69 years. For the age class 70 to 99 years, there was some increase over time mainly owing to an increased incidence of drug-induced parkinsonism. The incidence of PD remained stable over the three 5-year periods for all age classes. Results were similar when considering men and women separately. No birth-cohort effect was present for parkinsonism. Comparison with three previous studies in the same population did not reveal any major long-term secular trends in the incidence of parkinsonism.

CONCLUSIONS

The findings for PD over 15 years and comparison of the findings with historical data for parkinsonism over half a century suggest that no major environmental risk factors for PD (e.g., environmental toxins, drugs, diet constituents, or infectious agents) were introduced or removed from this population during these periods.

Regression models for linkage heterogeneity applied to familial prostate cancer

Linkage heterogeneity frequently occurs for complex genetic diseases, and statistical methods must account for it to avoid severe loss in power to discover susceptibility genes. A common method to allow for only a fraction of linked pedigrees is to fit a mixture likelihood and then to test for linkage homogeneity, given linkage (admixture test), or to test for linkage while allowing for heterogeneity, using the heterogeneity LOD (HLOD) score. Furthermore, features of the families, such as mean age at diagnosis, may help to discriminate families that demonstrate linkage from those that do not. Pedigree features are often used to create homogeneous subsets, and LOD or HLOD scores are then computed within the subsets. However, this practice introduces several problems, including reduced power (which results from multiple testing and small sample sizes within subsets) and difficulty in interpretation of results. To address some of these limitations, we present a regression-based extension of the mixture likelihood for which pedigree features are used as covariates that determine the probability that a family is the linked type. Some advantages of this approach are that multiple covariates can be used (including quantitative covariates), covariates can be adjusted for each other, and interactions among covariates can be assessed. This new regression method is applied to linkage data for familial prostate cancer and provides new insights into the understanding of prostate cancer linkage heterogeneity.

Analysis of the prostate cancer-susceptibility locus HPC20 in 172 families affected by prostate cancer

A recent study of hereditary prostate cancer has provided evidence for a prostate cancer-susceptibility locus, HPC20, which maps to 20q13. To assess further the potential contribution of this locus to prostate cancer susceptibility, we studied 172 unrelated families affected by prostate cancer, using 17 polymorphic markers across a 98.5-cM segment of chromosome 20 that contains the candidate region. Parametric analysis, allowing for heterogeneity, resulted in an overall HLOD score of 0.09 (P=.39) at D20S171, under the assumption of linkage in 6% of families. Mode-of-inheritance-free analysis of the entire data set resulted in a maximal Zlr score of 0.76 (LOD 0.13; P=.22) at the same location. The strongest evidence for linkage was seen in the subset of 16 black families (LOD 0.86; Zlr=1.99; P=.023) between markers D20S893 and D20S120, near the putative location of HPC20. Although some positive results were observed, our linkage study does not provide statistically significant support for the existence of a prostate cancer-susceptibility locus HPC20 at 20q13.

Smoking, alcohol, and coffee consumption preceding Parkinson's disease: a case-control study

OBJECTIVE

To study the association of PD with preceding smoking, alcohol, and coffee consumption using a case-control design.

METHODS

The authors used the medical records linkage system of the Rochester Epidemiology Project to identify 196 subjects who developed PD in Olmsted County, MN, during the years 1976 to 1995. Each incident case was matched by age (+/-1 year) and sex to a general population control subject. The authors reviewed the complete medical records of cases and control subjects to abstract exposure information.

RESULTS

For coffee consumption, the authors found an OR of 0.35 (95% CI = 0.16 to 0.78, p = 0.01), a dose-effect trend (p = 0.003), and a later age at PD onset in cases who drank coffee compared with those who never did (median 72 versus 64 years; p = 0.0002). The inverse association with coffee remained significant after adjustment for education, smoking, and alcohol drinking and was restricted to PD cases with onset at age <72 years and to men. The OR for cigarette smoking was 0.69 (95% CI = 0.45 to 1.08, p = 0.1). The authors found no association between PD and alcohol consumption. Extreme or unusual behaviors such as tobacco chewing or snuff use and a diagnosis of alcoholism were significantly more common in control subjects than cases.

CONCLUSIONS

These findings suggest an inverse association between coffee drinking and PD; however, this association does not imply that coffee has a direct protective effect against PD. Alternative explanations for the association should be considered.

Association of Peutz-Jeghers-like mucocutaneous pigmentation with breast and gynecologic carcinomas in women

Most reports describe an increased risk of malignancy in Peutz-Jeghers syndrome (PJS). We identified individuals with PJS-like pigmentation but no polyposis, designated as isolated mucocutaneous melanotic pigmentation (IMMP), and 1) characterized their clinical features, 2) assessed them for cancer events, and 3) screened a sample of these subjects for mutations in LKB1, a gene responsible for a portion of PJS cases. Review of Mayo Clinic records from 1945 to 1996 identified 26 patients with IMMP. All were then interviewed or their medical records reviewed to determine if cancer had developed. Conformation-sensitive gel electrophoresis (CSGE) screening for LKB1 mutations was followed by direct sequencing. Ten of these 26 individuals (38%) developed 12 malignancies that arose in the cervix (n = 3), endometrium (n = 3), breast (n = 1), kidney (n = 1), lung (n = 2), colon (n = 1), and lymphatic tissue (n = 1). In females with IMMP, the relative risk for cancer was 3.2 (95% CI, 1.2-6.9), while that for males was not increased. The relative risk for breast and gynecologic cancers was 7.8 (95% CI, 2.5-18.1) in affected females. Of 9 individuals tested, no LKB1 mutations were detected. Classical PJS is associated with an increased cancer risk. Our results indicate that IMMP is another lentiginosis with cancer predisposition. In particular, the relative risk for cancer in females with IMMP was significantly increased, as is true in females with PJS. However, LKB1 mutations did not contribute to the development of IMMP in the patients tested.

Influence of strict, intermediate, and broad diagnostic criteria on the age- and sex-specific incidence of Parkinson's disease

We studied the influence of three sets of diagnostic criteria on the age- and sex-specific incidence of Parkinson's disease (PD) among residents of Olmsted County, Minnesota, for the period 1976 to 1990. Incidence cases of parkinsonism were detected using the medical records-linkage system of the Rochester Epidemiology Project. PD was separated from other types of parkinsonism using strict, intermediate, and broad criteria. We found 154 incident cases of PD using the strict criteria, 215 using the intermediate criteria, and 266 using the broad criteria. The incidence rate was consistently higher for men across all ages with all three sets of criteria; however, sex differences were more striking at older ages when using the broad criteria. In men above age 79 years, the incidence rate of PD declined with strict criteria, remained stable with intermediate criteria, and increased with broad criteria. The impact of diagnostic criteria on the age-specific incidence curve was less striking for women. When using the broad criteria, the risk of PD increased constantly with age in both sexes, suggesting that PD is an aging-related disease. Our findings suggest that the diagnostic criteria used to separate PD from other types of parkinsonism influence the magnitude of PD incidence and its distribution by age and sex.

Genetic heterogeneity in Peutz-Jeghers syndrome

LKB1, the human gene encoding a serine threonine kinase, was recently identified as a susceptibility gene for Peutz-Jeghers syndrome (PJS), a disease characterized by the constellation of intestinal hamartomata, oral mucocutaneous hyperpigmentation, and an increased risk for gastrointestinal as well as extraintestinal malignancies. To date, the majority of individuals with PJS have been found to have genetic alterations in LKB1, most of which result in protein truncation. Additionally, linkage analyses have suggested a modicum of genetic heterogeneity, with the majority of PJS families showing linkage to the LKB1 locus. In this study, we evaluated five kindreds with greater than two affected family members, five PJS probands with only one other affected family member, as well as 23 individuals with sporadic PJS for mutations within the LKB1 gene. Conformation sensitive gel electrophoresis was utilized for the initial screen, followed by direct sequence analysis for characterization. Long-range PCR was used for the detection of larger genetic insertions or deletions. Mutation analysis revealed genetic alterations in LKB1 in two probands who had a family history of PJS. LKB1 mutations were detected in only four of the remaining 23 cases of sporadic PJS. These data suggest the presence of significant genetic heterogeneity for PJS and the involvement of other loci in this syndrome.

Genetic heterogeneity in Peutz-Jeghers syndrome

LKB1, the human gene encoding a serine threonine kinase, was recently identified as a susceptibility gene for Peutz-Jeghers syndrome (PJS), a disease characterized by the constellation of intestinal hamartomata, oral mucocutaneous hyperpigmentation, and an increased risk for gastrointestinal as well as extraintestinal malignancies. To date, the majority of individuals with PJS have been found to have genetic alterations in LKB1, most of which result in protein truncation. Additionally, linkage analyses have suggested a modicum of genetic heterogeneity, with the majority of PJS families showing linkage to the LKB1 locus. In this study, we evaluated five kindreds with greater than two affected family members, five PJS probands with only one other affected family member, as well as 23 individuals with sporadic PJS for mutations within the LKB1 gene. Conformation sensitive gel electrophoresis was utilized for the initial screen, followed by direct sequence analysis for characterization. Long-range PCR was used for the detection of larger genetic insertions or deletions. Mutation analysis revealed genetic alterations in LKB1 in two probands who had a family history of PJS. LKB1 mutations were detected in only four of the remaining 23 cases of sporadic PJS. These data suggest the presence of significant genetic heterogeneity for PJS and the involvement of other loci in this syndrome.

Long-term satisfaction and psychological and social function following bilateral prophylactic mastectomy

CONTEXT

Prophylactic mastectomy is a preventive option for women who wish to reduce their risk of breast cancer. There has been concern about possible negative psychological sequelae following this procedure. However, few data are available regarding long-term satisfaction and psychological and social function following this procedure.

OBJECTIVE

To evaluate patients' long-term satisfaction and psychological and social function following prophylactic mastectomy.

DESIGN, SETTING, AND PARTICIPANTS

Descriptive study of all women known to be alive (n = 609) who had a family history of breast cancer and elected to undergo bilateral prophylactic mastectomy at a large, tertiary US health care clinic between 1960 and 1993, 94% (n = 572) of whom completed a study questionnaire.

MAIN OUTCOME MEASURES

Satisfaction with procedure and effects on psychological and social function, based on responses to the study-specific questionnaire.

RESULTS

Mean time from prophylactic mastectomy to last follow-up was 14.5 years. Most women (70%) were satisfied with the procedure; 11% were neutral; and 19% were dissatisfied. Among the psychological and social variables, the most striking finding was that 74% reported a diminished level of emotional concern about developing breast cancer. The majority of women reported no change/favorable effects in levels of emotional stability (68%/23%), level of stress (58%/28%), self-esteem (69%/13%), sexual relationships (73%/4%), and feelings of femininity (67%/8%). Forty-eight percent reported no change in their level of satisfaction with body appearance; 16% reported favorable effects. However, 9%, 14%, 18%, 23%, 25%, and 36% reported negative effects in these 6 variables, respectively.

CONCLUSIONS

This study suggests that positive outcomes following prophylactic mastectomy include decreased emotional concern about developing breast cancer and generally favorable psychological and social outcomes. These must be weighed against the irreversibility of the decision, potential problems with implants and reconstructive surgery, and occurrence of adverse psychological and social outcomes in some women. JAMA. 2000;284:319-324

Anxiety disorders and depressive disorders preceding Parkinson's disease: a case-control study

We studied the association between preceding psychiatric disorders and Parkinson's disease (PD) using a case-control design. We used the medical records-linkage system of the Rochester Epidemiology Project to identify 196 subjects who developed PD in Olmsted County, Minnesota, during the years 1976-1995. Each case was matched by age (+/-1 yr) and sex to a general population control. We reviewed the complete medical records of cases and control subjects to detect preceding psychiatric disorders. The frequency of psychiatric disorders was higher in cases than in control subjects; the odds ratio was 2.2 for anxiety disorders (95% confidence interval [95% CI] = 1.4-3.4; p = 0.0003), 1.9 for depressive disorders (95% CI = 1.1-3.2; p = 0.02), and 2.4 for both anxiety disorders and depressive disorders occurring in the same individual (95% CI = 1.2-4.8; p = 0.02). When we restricted analyses to disorders present 5 years or more before the onset of motor symptoms of PD, the association with depressive disorders lost statistical significance. However, the association with anxiety disorders remained significant for disorders present 5, 10, or 20 years before onset of motor symptoms. Our results suggest that anxiety disorders and depressive disorders are associated with PD and that the causative process or the risk factors underlying PD are present many years before the appearance of motor symptoms.

Case-control study of debrisoquine 4-hydroxylase, N-acetyltransferase 2, and apolipoprotein E gene polymorphisms in Parkinson's disease

We investigated the association of Parkinson's disease (PD) with two genes encoding liver-detoxifying enzymes, debrisoquine 4-hydroxylase (CYP2D6) and N-acetyltransferase 2 (NAT2), and with one gene related to Alzheimer's disease, apolipoprotein E (APOE). In a sample of 139 unrelated PD cases and 113 control subjects, the NAT2 M3 allele was associated with PD (odds ratio = 7.9; 95% confidence interval = 1.7-36.3). Case-control analyses for CYP2D6, APOE, and NAT2 M1 or M2 did not show a significant association. However, the age at onset of PD was significantly earlier in cases with the APOE epsilon2/epsilon3 genotype than in cases with the epsilon3/epsilon3 genotype.

Microsatellite instability and hMLH1/hMSH2 expression in young endometrial carcinoma patients: associations with family history and histopathology

Endometrial cancer is the second most common malignancy in patients with hereditary nonpolyposis colorectal cancer (HNPCC). The age at diagnosis of HNPCC-associated endometrial cancer is approximately 15 years younger than for sporadic endometrial cancer. Our current study was undertaken to determine the frequency of microsatellite instability (MSI) and absence of hMLH1 or hMSH2 protein expression in young patients with endometrial carcinoma and to correlate these findings with histopathologic and clinical features. Endometrial carcinoma from 62 women (23-52 years, median age 46) were assessed for MSI. Twenty-one of the 62 (34%) tumors demonstrated MSI. Of the 21 tumors demonstrating MSI, 12 showed an absence of hMLH1 expression, 4 showed an absence of hMSH2 expression, and 5 demonstrated normal expression of both proteins. All 41 tumors without MSI demonstrated normal hMLH1 and hMSH2 expression. Two patients with MSI tumors fulfilled the Amsterdam criteria for HNPCC, while 2 had histories suggestive of HNPCC. None of the patients with tumors without MSI had a personal or family cancer history suggestive of HNPCC. The MSI phenotype was associated (p < 0.05) with high FIGO stage and grade, cribriform growth pattern, mucinous differentiation and necrosis. Our findings suggest that the frequency of HNPCC in young endometrial cancer patients is relatively low when compared with the frequency of HNPCC in young colorectal cancer patients. Defects of the MMR proteins hMSH2 or hMLH1 account for MSI in most but not all endometrial cancers from young patients.

Microsatellite instability and hMLH1/hMSH2 expression in young endometrial carcinoma patients: associations with family history and histopathology

Endometrial cancer is the second most common malignancy in patients with hereditary nonpolyposis colorectal cancer (HNPCC). The age at diagnosis of HNPCC-associated endometrial cancer is approximately 15 years younger than for sporadic endometrial cancer. Our current study was undertaken to determine the frequency of microsatellite instability (MSI) and absence of hMLH1 or hMSH2 protein expression in young patients with endometrial carcinoma and to correlate these findings with histopathologic and clinical features. Endometrial carcinoma from 62 women (23-52 years, median age 46) were assessed for MSI. Twenty-one of the 62 (34%) tumors demonstrated MSI. Of the 21 tumors demonstrating MSI, 12 showed an absence of hMLH1 expression, 4 showed an absence of hMSH2 expression, and 5 demonstrated normal expression of both proteins. All 41 tumors without MSI demonstrated normal hMLH1 and hMSH2 expression. Two patients with MSI tumors fulfilled the Amsterdam criteria for HNPCC, while 2 had histories suggestive of HNPCC. None of the patients with tumors without MSI had a personal or family cancer history suggestive of HNPCC. The MSI phenotype was associated (p < 0.05) with high FIGO stage and grade, cribriform growth pattern, mucinous differentiation and necrosis. Our findings suggest that the frequency of HNPCC in young endometrial cancer patients is relatively low when compared with the frequency of HNPCC in young colorectal cancer patients. Defects of the MMR proteins hMSH2 or hMLH1 account for MSI in most but not all endometrial cancers from young patients.

Incidence of medically recognized migraine: A 1989-1990 study in Olmsted County, Minnesota

OBJECTIVE

To investigate the incidence of medically recognized migraine in Olmsted County, Minnesota, during the years 1989 to 1990.

METHODS

We used the records-linkage system of the Rochester Epidemiology Project to identify all subjects who sought medical attention for their headache and had their initial visit for migraine within the study period. Incident cases were classified using specified criteria.

RESULTS

From 9837 records screened, we found 713 incident cases. The average annual incidence rate (new cases per 100 000 person-years) was 343.0 in both sexes combined, 481.6 in women, and 194.4 in men. In women, incidence rates were low at the extremes of age and higher among those aged between 10 and 49 years, with a striking peak at the age of 20 to 29 years. Migraine without aura was the most common type of migraine in women. Men had a more constant risk of migraine throughout life with a lesser peak at the age of 10 to 19 years, and they were equally affected by all types of migraine. Women had consistently higher incidence rates than men at all ages, and there were strikingly higher incidence rates of migraine without aura in women than in men.

CONCLUSIONS

Although our incidence rates were restricted to medically recognized cases of migraine, we confirmed previously reported epidemiological patterns.

Linkage analyses at the chromosome 1 loci 1q24-25 (HPC1), 1q42.2-43 (PCAP), and 1p36 (CAPB) in families with hereditary prostate cancer

Recent studies suggest that hereditary prostate cancer (PRCA) is a complex disease, involving multiple susceptibility genes and variable phenotypic expression. Through linkage analysis, potential prostate cancer susceptibility loci have been mapped to 3 regions on chromosome 1. To investigate the reported linkage to these regions, we conducted linkage studies on 144 PRCA families by using microsatellite markers in regions 1q24-25 (HPC1) and 1q42.2-43 (PCAP). We also examined the 1p36 (CAPB) region in 13 PRCA families with at least one case of brain cancer. No significant evidence of linkage to the HPC1 or PCAP region was found when the entire data set was analyzed. However, weak evidence for linkage to HPC1 was observed in the subset of families with male-to-male transmission (n=102; maximum multipoint nonparametric linkage [NPL] 1.99, P=.03). Weak evidence for linkage with heterogeneity within this subset was also observed (HLOD 1.21, P=.02), with approximately 20% of families linked. Although not statistically significant, suggestive evidence for linkage to PCAP was observed for the families (n=21) that met the three criteria of male-to-male transmission, average age of diagnosis <66 years, and >/=5 affected individuals (maximum multipoint NPL 1.45, P=.08). There was no evidence for linkage to CAPB in the brain cancer-prostate cancer subset. These results strengthen the argument that prostate cancer is a heterogeneous disease and that multiple genetic and environmental factors may be important for its etiology.

Case-control study of the ubiquitin carboxy-terminal hydrolase L1 gene in Parkinson's disease

We investigated the association of PD with a recently reported I93M mutation of the ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) gene, and with a new and common polymorphic variant S18Y of the same gene. We did not identify the I93M mutation in any of 139 unrelated PD cases or 113 controls. However, S18Y polymorphism carriers had significantly lower risk of PD (odds ratio = 0.53; p = 0.03), and the risk reduction was greater for younger onset cases.

Increasing incidence of medically recognized migraine headache in a United States population

OBJECTIVE

To investigate trends in the incidence of medically recognized migraine in Olmsted County, Minnesota over approximately a decade.

METHODS

The authors used the records-linkage system of the Rochester Epidemiology Project to identify individuals whose records included any diagnostic rubric related to headache for the 3-year period 1979 through 1981 and the 2-year period 1989 through 1990. A nurse abstracter and a neurologist (J.W.S.) reviewed the complete history of each potential case and assigned a diagnosis using the International Headache Society classification (IHS, modified). Only patients who consulted a doctor for their headache and had their initial visit for migraine within the study years were considered as incident cases.

RESULTS

The incidence of medically recognized migraine increased in female subjects between the 1979-through-1981 period and the 1989-through-1990 period for all ages, but particularly among those who were aged 10 to 49 years. The peak incidence rate at age 20 to 29 years increased from 634.5 new cases per 100,000 person-years in 1979 through 1981 to 986.4 in the 1989-through-1990 period (absolute increase 351.9; relative increase 56%). The rise in incidence in female subjects was most sizable for migrainous disorder (IHS code 1.7); smaller increases were noted for migraine without aura and with typical aura. Only a slight absolute increase in migraine incidence rates was observed in male subjects, restricted to those 10 to 19 years of age (absolute increase 174.7; relative increase 89%).

CONCLUSIONS

Although the incidence rates reported here are restricted to patients who consulted a doctor for their headache, the authors suggest that the incidence of migraine has increased over time in female subjects, especially those of reproductive age. The increase was most pronounced for migrainous disorder. Incidence rates were more stable in male subjects over time.

Autopsy patterns for Parkinson's disease and related disorders in Olmsted County, Minnesota

Using a records-linkage system, we determined the frequency and distribution of brain autopsies in residents of Olmsted County, Minnesota, in whom parkinsonism developed during 1976 through 1990. Of the 364 incident cases identified, 235 patients were deceased at the time of record abstraction. The overall autopsy rate was low (23%). Diagnostic certainty (for PD), diagnostic type (PD versus other parkinsonism), sex, age at death, and location at death were important selection factors for autopsy.

Microsatellite instability and 8p allelic imbalance in stage B2 and C colorectal cancers

BACKGROUND

Microsatellite instability (MSI) and allelic imbalance involving chromosome arms 5q, 8p, 17p, and 18q are genetic alterations commonly found in colorectal cancer. We investigated whether the presence or absence of these genetic alterations would allow stratification of patients with Astler-Coller stage B2 or C colorectal cancer into favorable and unfavorable prognostic groups.

METHODS

Tumors from 508 patients were evaluated for MSI and allelic imbalance by use of 11 microsatellite markers located on chromosome arms 5q, 8p, 15q, 17p, and 18q. Genetic alterations involving each of these markers were examined for associations with survival and disease recurrence. All P values are two-sided.

RESULTS

In univariate analyses, high MSI (MSI-H), i.e., MSI at 30% or more of the loci examined, was associated with improved survival (P =.02) and time to recurrence (P =.01). The group of patients whose tumors exhibited allelic imbalance at chromosome 8p had decreased survival (P =.02) and time to recurrence (P =.004). No statistically significant associations with survival or time to recurrence were observed for markers on chromosome arms 5q, 15q, 17p, or 18q. In multivariate analyses, MSI-H was an independent predictor of improved survival (hazard ratio [HR] = 0.51; 95% confidence interval [CI] = 0.31-0.82; P =.006) and time to recurrence (HR = 0.42; 95% CI = 0.24-0.74; P =.003), and 8p allelic imbalance was an independent predictor of decreased survival (HR = 1.89; 95% CI = 1.25-2.83; P =. 002) and time to recurrence (HR = 2.07; 95% CI = 1.32-3.25; P =.002).

CONCLUSIONS

Patients whose tumors exhibited MSI-H had a favorable prognosis, whereas those with 8p allelic imbalance had a poor prognosis; both alterations served as independent prognostic factors. To our knowledge, this is the first report of an association between 8p allelic imbalance and survival in patients with colorectal cancer.

Detection of preclinical Parkinson disease in at-risk family members with use of [123I]beta-CIT and SPECT: an exploratory study

OBJECTIVE

To explore whether the radioligand 2 beta-carboxymethoxy-3 beta-(4-[123I] iodophenyl) tropane ([123I]beta-CIT) and single-photon emission computed tomography (SPECT) can detect decreased striatal uptake in at-risk relatives of patients with Parkinson disease (PD).

PATIENTS AND METHODS

Ten PD patients, 10 at-risk first-degree relatives of PD patients, and 10 controls underwent [123I]beta-CIT and SPECT brain imaging. Their striatal uptake ratios were compared.

RESULTS

Age-adjusted specific to nonspecific striatal uptake ratios were lower in patients compared with controls and with relatives; however, ratios were similar in relatives and controls. Among relatives, ratios were consistently lower in subgroups postulated to be at higher risk for preclinical PD.

CONCLUSION

Our findings provide preliminary support that [123I]beta-CIT and SPECT may detect decreased striatal uptake in relatives of PD patients postulated to be at higher risk for PD.

The incidence and prevalence of myoclonus in Olmsted County, Minnesota

OBJECTIVE

To study the incidence and prevalence of diagnosed myoclonus in Olmsted County, Minnesota. Little is known about the frequency and distribution of myoclonus in the general population.

DESIGN

Descriptive study with case ascertainment through a records-linkage system.

PATIENTS AND METHODS

We used a medical records-linkage system to identify all subjects whose records contained documentation of myoclonus or of diseases known to exhibit myoclonus. The records of all potential patients were reviewed by a neurologist, and only patients with pathologic and persistent myoclonus were included. Population denominators were derived from census data.

RESULTS

The average annual incidence rate of pathologic and persistent myoclonus for 1976 through 1990 was 1.3 cases per 100,000 person-years. The rate increased with advancing age and was consistently higher in men. Symptomatic myoclonus was the most common type, followed by epileptic and essential myoclonus; dementing diseases were the most common cause of symptomatic myoclonus. The lifetime prevalence of myoclonus, as of January 1, 1990, was 8.6 cases per 100,000 population, and the prevalence increased with advancing age.

CONCLUSION

Although our figures are probably under-estimated, they are the first attempt, to our knowledge, to measure myoclonus morbidity in the general population. We found clinical features and age and sex distributions different from those previously described in clinical series.

Incidence and distribution of parkinsonism in Olmsted County, Minnesota, 1976-1990

OBJECTIVE

Limited information is available on the frequency and distribution of parkinsonism as a syndrome. We studied the incidence of parkinsonism and its specific types among residents of Olmsted County, MN, for the period from 1976 through 1990.

METHODS

We used the medical records linkage-system of the Rochester Epidemiology Project to identify all individuals whose records contained documentation of any form of parkinsonism, related neurodegenerative diseases, or tremor of any type. A nurse abstractor screened the records, and, when applicable, a neurologist reviewed them to determine the presence of parkinsonism using specified diagnostic criteria and to define the year of onset.

RESULTS

We found 364 incident cases of parkinsonism: 154 with PD (42%), 72 with drug-induced parkinsonism (20%), 61 unspecified (17%), 51 with parkinsonism in dementia (14%), and 26 with other causes (7%). The average annual incidence rate of parkinsonism (per 100,000 person-years) in the age group 50 to 99 years was 114.7; incidence increased steeply with age from 0.8 in the age group 0 to 29 years to 304.8 in the age group 80 to 99 years. The cumulative incidence of parkinsonism assuming no competing causes of death was 7.5% to age 90 years. PD was the most common type of parkinsonism, followed by parkinsonism in dementia in men and drug-induced parkinsonism in women. Men had higher incidence than women at all ages for all types of parkinsonism except drug-induced.

CONCLUSIONS

Parkinsonism is a common disease among the elderly; its incidence increases steeply with advancing age and is consistently higher in men. The distribution by type changes with age and gender.

Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer

BACKGROUND

Options for women at high risk for breast cancer include surveillance, chemoprevention, and prophylactic mastectomy. The data on the outcomes for surveillance and prophylactic mastectomy are incomplete.

METHODS

We conducted a retrospective study of all women with a family history of breast cancer who underwent bilateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. The women were divided into two groups - high risk and moderate risk - on the basis of family history. A control study of the sisters of the high-risk probands and the Gail model were used to predict the number of breast cancers expected in these two groups in the absence of prophylactic mastectomy.

RESULTS

We identified 639 women with a family history of breast cancer who had undergone bilateral prophylactic mastectomy: 214 at high risk and 425 at moderate risk. The median length of follow-up was 14 years. The median age at prophylactic mastectomy was 42 years. According to the Gall model, 37.4 breast cancers were expected in the moderate-risk group; 4 breast cancers occurred (reduction in risk, 89.5 percent; P<0.001). We compared the numbers of breast cancers among the 214 high-risk probands with the numbers among their 403 sisters who had not undergone prophylactic mastectomy. Of these sisters, 38.7 percent (156) had been given a diagnosis of breast cancer (115 cases were diagnosed before the respective proband's prophylactic mastectomy, 38 were diagnosed afterward, and the time of the diagnosis was unknown in 3 cases). By contrast, breast cancer was diagnosed in 1.4 percent (3 of 214) of the probands. Thus, prophylactic mastectomy was associated with a reduction in the incidence of breast cancer of at least 90 percent.

CONCLUSIONS

In women with a high risk of breast cancer on the basis of family history, prophylactic mastectomy can significantly reduce the incidence of breast cancer.

Reduced COX-2 protein in colorectal cancer with defective mismatch repair

Most colorectal adenomas and carcinomas arise in the setting of chromosomal instability characterized by progressive loss of heterozygosity. In contrast, approximately 15-20% of colorectal neoplasms arise through a distinct genetic pathway characterized by microsatellite instability (MSI) associated with frequent loss of expression of one of the DNA mismatch repair enzymes, most often hMLH1 or hMSH2. These distinct genetic pathways are reflected by differences in tumor histopathology, distribution in the colon, prognosis, and dwell time required for progression from adenoma to carcinoma. To determine whether these two groups of tumors differ in their expression of cyclooxygenase-2 (COX-2), a putative chemopreventative target, immunostaining for this protein was performed in colorectal cancers categorized by the presence (n = 41) and absence (n = 66) of defective mismatch repair. Defective mismatch repair was defined by the presence of tumor microsatellite instability (MSI-H, > or =40% of markers demonstrating instability) and by the absence of protein expression for either hMLH1 or hMSH2. Overall, our results showed that low or absent COX-2 staining was significantly more common among tumors with defective mismatch repair (P = 0.001). Other features predictive of low COX-2 staining included marked tumor infiltrating lymphocytosis, and solid/cribiform or signet ring histological patterns. These observations indicate that colorectal cancers with molecular and phenotypic characteristics of defective DNA mismatch repair express lower levels of COX-2. The clinical implications of this biological distinction remain unknown but should be considered when assessing the efficacy of COX-2 inhibitors for chemoprevention in patients whose tumors may arise in the setting of defective DNA mismatch repair.

Major histocompatibility complex class II alleles and the course and outcome of MS: a population-based study

BACKGROUND

The major histocompatibility complex (MHC) has been consistently associated with susceptibility to MS and the course of several other human autoimmune diseases. A putative association between the course and severity of MS and the MHC remains controversial.

METHODS

DR and DQ genotyping by either restriction fragment length polymorphism or sequence-specific PCR-based typing in 119 patients representing 73.4% of the population with MS evaluated in a cross-sectional disability survey and 100 healthy controls from Olmsted County, Minnesota.

RESULTS

We found a positive association between MS susceptibility and the DR15-DQ6 and DR13-DQ7 haplotypes, and we found a negative association with the DR1-DQ5 haplotype. We found a trend to a positive association of primary progressive MS with DR4-DQ8 and DR1-DQ5 and an association of "bout onset" MS with DR17-DQ2. We did not find an association with disease severity, as defined by EDSS/duration.

CONCLUSION

Lack of consistency between different studies may be due to regional variation in MS and limitations of power but likely indicate a minor effect of MHC class II genes on the course and severity of MS.

Evidence for autosomal dominant inheritance of prostate cancer

A family-history cancer survey was conducted on 5,486 men who underwent a radical prostatectomy, for clinically localized prostate cancer, in the Department of Urology at the Mayo Clinic during 1966-95; 4,288 men responded to the survey. Complex segregation analysis was performed to assess the genetic basis of age at diagnosis and the familial clustering of prostate cancer. For the total group, no single-gene model of inheritance clearly explained familial clustering of disease, which could be partly explained by lack of Hardy-Weinberg equilibrium, with an excess of homozygotes. After accounting for deviations from Hardy-Weinberg equilibrium, the best-fitting model that explained the familial aggregation and age at diagnosis was a rare autosomal dominant susceptibility gene, and this model fitted best when probands were diagnosed at <60 years of age. The model predicts that the frequency of the susceptibility gene in the population is .006 and that the risk of prostate cancer by age 85 years is 89% among carriers of the gene and 3% among noncarriers. A strength of our study is its large size, such that genetic models could be fitted within strata defined by the age of the proband. Although the autosomal dominant model was consistently the best model, the parameter estimates differed somewhat (P=.03) across the different age groups, suggesting genetic heterogeneity. Additional evidence that the hereditary basis of prostate cancer is likely to be genetically complex was provided by the following: (1) there was a significantly elevated age-adjusted risk of prostate cancer among brothers of probands, compared with their fathers (relative risk 1.5 [95% confidence interval 1.4-1.7]); (2) the autosomal dominant model predicted an excess of homozygotes, over that predicted by Hardy-Weinberg equilibrium; and (3) the model-predicted risk of prostate cancer among relatives was inadequate when probands were diagnosed at age >=70 years.

Increased risk for cancer in patients with the Peutz-Jeghers syndrome

BACKGROUND

Some reports describe an increased risk for cancer in patients with the Peutz-Jeghers syndrome.

OBJECTIVE

To characterize occurrences of cancer in a large cohort of patients with the Peutz-Jeghers syndrome.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care center.

PATIENTS

34 patients with the Peutz-Jeghers syndrome identified from Mayo Clinic records from 1945 to 1996.

MEASUREMENTS

Cases of cancer documented by chart review and telephone follow-up.

RESULTS

26 cases of noncutaneous cancer developed in 18 of the 34 patients: 10 cases of gastrointestinal cancer and 16 cases of extraintestinal cancer. With the use of SEER (Surveillance, Epidemiology, and End Results) data for comparison, the relative risk for cancer was 18.5 (95% CI, 8.5 to 35.2) in women with the Peutz-Jeghers syndrome and 6.2 (CI, 2.5 to 12.8) in men with the syndrome (P = 0.001). In women, the relative risk for breast and gynecologic cancer was 20.3 (CI, 7.4 to 44.2).

CONCLUSIONS

The Peutz-Jeghers syndrome is associated with an increased risk for cancer. The relative risk for breast and gynecologic cancers is particularly high.

Validation of a telephone questionnaire for Parkinson's disease

As part of a genetic study, we investigated the accuracy of a telephone questionnaire to diagnose or screen for Parkinson's disease (PD). We studied 20 PD patients randomly selected among all incident cases in Olmsted County, Minnesota, for the period 1970 through 1988. Each patient was matched by age and sex to a subject free of PD or parkinsonism residing in the same county. In addition, we studied 20 patients with PD referred to our institution from outside of Olmsted County between 1991 and 1993. Medical record documentation of disease status for both affected and unaffected subjects served as the standard for comparison. A trained interviewer kept unaware of disease status administered nine symptom questions via telephone to all study subjects (or their proxy). Seventeen PD cases from Olmsted County, all 20 referral cases, and 16 unaffected subjects participated in the interview (total = 37 with PD and 16 unaffected subjects); 36 interviews (24 PD) were with a proxy and 17 (13 PD) were direct. Questions regarding "poor balance," "trouble buttoning," and "trouble arising" had the highest sensitivity; questions regarding "shaking," "feet stuck to the floor," "softer voice," and "smaller writing" had the highest specificity. A combination of any four symptoms yielded the best balance between sensitivity (89%) and specificity (88%). Although the questionnaire appears to be useful both as a screening and as a diagnostic tool, it failed to reach complete accuracy, and it should be used in the context of a more complex case-finding strategy.

Microsatellite instability in colorectal cancer: different mutator phenotypes and the principal involvement of hMLH1

Recent studies have demonstrated the presence of microsatellite instability (MSI) in tumors from patients with hereditary nonpolyposis colorectal cancer and in a large number of sporadic tumors. To further characterize the type of alterations at these loci and their frequency of involvement in colon cancer, we studied DNA extracted from paraffin-embedded tissue from 508 patients using 11 microsatellites localized to chromosomes 5, 8, 15, 17, and 18. Overall, MSI at each locus varied in character and frequency and was observed with at least one marker in 191 cases (37.6%). Based on the number of markers displaying instability per tumor, three groups of patients were defined: those with <30% of the markers showing instability (MSI-L,, n = 109, 21.5%); those with > or = 30% (MSI-H, n = 82, 16.1%); and those showing no instability (MSS, n = 317, 62.4%). These groups were tested for correlations with a number of clinical and pathological parameters, including age, sex, stage, ploidy status, and site of tumor. Comparing across the three groups and verified by pair-wise comparisons, the MSI-H group was associated with tumor site (proximal colon, P = 0.001), sex (females, P = 0.005), stage (Dukes' B, P = 0.01), and ploidy status (diploid, P = 0.03). No significant differences were noted between the MSI-L and MSS group for any of the parameters tested. An additional 188 consecutive surgical colorectal cancer cases were examined for the presence of MSI and for the immunohistochemical expression of hMLH1 and hMSH2 proteins. Of this group, 129 (68.6%) were classified as MSS, 17 (9.0%) as MSI-L, and 42 (22.3%) as MSI-H. None of the MSS and none of the MSI-L tumors had altered expression of either hMLH1 or hMSH2. However, the majority of MSI-H (40 of 42, 95%) cases demonstrated absence of staining for these proteins. The most frequently altered protein was hMLH1, occurring in 95% of the tumors with altered expression. Cumulatively, these data suggest that the tumor phenotype MSI-H is distinct from tumor phenotypes MSI-L and MSS, with no apparent differences between MSI-L and MSS. Furthermore, altered hMLH1 protein expression appears to be responsible for the mutator phenotype in the vast majority of MSI-H tumors.

Incidence of progressive supranuclear palsy and multiple system atrophy in Olmsted County, Minnesota, 1976 to 1990

Information on the incidence of progressive supranuclear palsy (PSP) is limited; incidence rates for multiple system atrophy (MSA) are not available. We studied the incidence of PSP and MSA in Olmsted County, Minnesota, for the years 1976 to 1990. This study was part of a larger investigation of all forms of parkinsonism. We used the medical records-linkage system of the Rochester Epidemiology Project to identify all subjects whose records contained documentation of any from of parkinsonism, related neurodegenerative diseases, or tremor of any type. A nurse abstractor screened the records and, when applicable, a neurologist reviewed them to determine the presence or absence of parkinsonism. Cases of parkinsonism were classified using specified diagnostic criteria. Population denominators were derived from census data and were corrected by removing prevalent cases of parkinsonism. Over the 15 years of the study, we found 16 incident cases of PSP and nine incident cases of MSA. No cases of PSP or MSA had onset before age 50 years. The average annual incidence rate (new cases per 100,000 person-years) for ages 50 to 99 years was 5.3 for PSP and 3.0 for MSA. The incidence of PSP increased steeply with age from 1.7 at 50 to 59 years to 14.7 at 80 to 99 years, and was consistently higher in men. Median survival time from symptom onset was 5.3 years for PSP and 8.5 years for MSA. The incidence of PSP increases with age and is consistently higher in men at all ages. PSP and MSA are more common than previously recognized.

The neurologic complications of B-cell chronic lymphocytic leukemia

We performed a retrospective study to characterize the type, frequency, and timing of neurologic complications in patients with B-cell chronic lymphocytic leukemia (B-CLL). We reviewed 962 total charts with a median follow-up time of 57.5 months. There were 109 cases (11.3%) of neurologic complications, including 69 cases (7.2%) of herpes zoster infection, 17 cases (1.8%) of other opportunistic infection, 14 cases (1.5%) of treatment-related conditions, eight cases (0.8%) of direct leukemic involvement of neural tissue, and 1 case (0.1%) of intracranial hemorrhage. No cases of a non-zoster opportunistic infection presented in early-stage (Rai stage 0-2) B-CLL, and only one case of direct leukemic involvement of neural structures presented in early-stage B-CLL. Of the 25 cases of non-zoster or treatment-related complications, only 5 presented before 6 years from the initial B-CLL diagnosis. Three of these were in advanced-stage B-CLL, staging could not be determined in one, and one presented in early-stage B-CLL. We conclude that the overall neurologic complication rate of B-CLL is low, and that the Rai stage of the disease correlates best with the risk of developing neurologic complications. The occurrence of a related non-zoster neurologic complication in a patient with B-CLL stage 0-2 approaches 1:1,000.

Allelic imbalance and microsatellite instability in prostatic adenocarcinoma

Although prostate cancer is one of the most common malignancies of males in Western countries, relatively little is known about the molecular mechanisms involved in tumor initiation and progression. Allelic loss studies have suggested the involvement of multiple tumor suppressor genes (TSGs), but few detailed studies of all chromosomes have been performed. In an effort to localize and identify candidate TSGs, we performed allelic imbalance (AI) studies on 55 prostate cancers, using 135 polymorphic microsatellite markers. For the entire chromosome. AI ranged from a low of 0% on chromosomes 14 and 20 to a high of 71% on chromosome 8. Chromosomal regions demonstrating at least twice the background frequency of AI (ranging from 20 to 69%) included 5q, 6q, 7q, 8p, 13, l6q, l8q, and 21. In addition, AI was examined for association with a number of clinicopathological parameters. AI on chromosomes 7 and 16 were each associated with greater age at diagnosis (P = 0.009 and 0.001, respectively), and AI on chromosomes 10, 16, and 18 was associated with aneuploidy/tetraploidy (P = 0.037, 0.013, and 0.054, respectively). Furthermore, AI on chromosome 5 was associated with a higher pathological stage (P = 0.021) and on chromosome 8 and 16 with a higher Gleason score (P = 0.027 and 0.041, respectively). No tumor exhibited a phenotype of widespread microsatellite instability. These results indicate that there likely exist multiple sites harboring candidate TSG in prostate cancer, some of which may have important clinical implications, and which argue against widespread microsatellite instability.