26427 MLH1 Hypermethylation and BRAF Mutation Analysis, Tumor (BRMLH)

​​BRAF Mutation, BRAF V600E, Hypermethylation, MLH1 Hypermethylation, Promoter Hypermethylation, MLBRF, Lynch syndrome

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

An adjunct to negative MLH1 germline testing in cases where colon tumor from the same patient demonstrates MSI-H and loss of MLH1 protein expression

If this test is ordered in conjunction with the MLH1 immunostain (IHC / Mismatch Repair [MMR] Protein Immunohistochemistry Only, Tumor) and MSI (MSI / Microsatellite Instability [MSI], Tumor), this test will only be performed when clinically indicated.

When this test is ordered, BRAF analysis and MLH1 hypermethylation analysis will always be performed. The exception would be if the tissue origin is an endometrial tumor; in those cases only the MLH1 hypermethylation analysis component will be performed.

Pathology report must accompany specimen in order for testing to be performed.

​Sections should contain both tumor and normal tissue.

Specimens that have been decalcified (all methods)

Specimens that have not been formalin-fixed

Paraffin-embedded Extracted DNA

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

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

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

Testing tumors other than colon (in the evaluation of Lynch syndrome) for BRAF and MLH1 hypermethylation has not been fully evaluated; therefore, other specimens are not accepted.

Colon cancer is relatively common and it is possible for a sporadic colon cancer to occur in a Lynch syndrome family. Therefore, evaluation of other family members should still be considered in cases with MLH1 promoter hypermethylation and absence of the BRAF V600E alteration if there is high clinical suspicion of Lynch syndrome.

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

An interpretive report will be provided.

​An interpretive report will be provided.