Thyroid Carcinomas That Occur in Familial Adenomatous Polyposis Patients Recurrently Harbor Somatic Variants in <i>APC</i> , <i>BRAF</i> , and <i>KTM2D</i>

Abstract

<b><i>Background:</i></b> Familial adenomatous polyposis (FAP) is a condition typically caused by pathogenic germline mutations in the <i>APC</i> gene. In addition to colon polyps, individuals with FAP have a substantially increased risk of developing papillary thyroid cancer (PTC). Little is known about the events underlying this association, and the prevalence of somatic "second-hit" mutations in <i>APC</i> is controversial. <b><i>Methods:</i></b> Whole-genome sequencing was performed on paired thyroid tumor and normal DNA from 12 FAP patients who developed PTC. Somatic mutation profiles were compared with clinical characteristics and previously sequenced sporadic PTC cases. Germline variant profiling was performed to assess the prevalence of variants in genes previously shown to have a role in PTC predisposition. <b><i>Results:</i></b> All 12 patients harbored germline mutations in <i>APC</i>, consistent with FAP. Seven patients also had somatic mutations in <i>APC</i>, and seven patients harbored somatic mutations in <i>KMT2D</i>, which encodes a lysine methyl transferase. Mutation of these genes is extremely rare in sporadic PTCs. Notably, only two of the tumors harbored the somatic <i>BRAF</i> p.V600E mutation, which is the most common driver mutation found in sporadic PTCs. Six tumors displayed a cribriform-morular variant of PTC (PTC-CMV) histology, and all six had somatic mutations in <i>APC</i>. Additionally, nine FAP-PTC patients had rare germline variants in genes that were previously associated with thyroid carcinoma. <b><i>Conclusions:</i></b> Our data indicate that FAP-associated PTCs typically have distinct mutations compared with sporadic PTCs. Roughly half of the thyroid cancers that arise in FAP patients have somatic "second-hits" in <i>APC</i>, which is associated with PTC-CMV histology. Somatic <i>BRAF</i> p.V600E variants also occur in some FAP patients, a novel finding. We speculate that in carriers of heterozygous pathogenic mutations of tumor suppressor genes such as <i>APC</i>, a cooperating second-hit somatic variant may occur in a different gene such as <i>KTM2D</i> or <i>BRAF</i>, leading to differences in phenotypes. The role of germline variance in genes other than APC (9 of the 12 patients in this series) needs further research.