Colorectal cancer (CRC) is one of the more familial of cancers, and the presence of a family history of this malignancy is a well established risk factor. Twin studies suggest inherited and/or familial factors contribute to 25-35% of CRC cases [1]. The highly penetrant inherited colon cancer conditions including familial adenomatous polyposis, Lynch syndrome (hereditary nonpolyposis colorectal cancer), Peutz-Jeghers, Cowden syndrome and juvenile polyposis account for approximately 5% of CRCs, leaving greater than 20% without clear genetic definition [2]. An individual's risk of CRC doubles with one affected first degree relative and progressively increases with each additional affected first, second, or third degree relative [3, 4].

We have previously reported linkage of the 7q31 locus in a cohort of sibling pairs affected with CRC [5]. Other CRC and polyp-affected relative pair studies have also reported linkage to this region of chromosome 7 [6, 7]. One candidate gene in this region is the proto-oncogene and tyrosine kinase receptor, MET. MET is expressed mainly on the surface of epithelial cells. In response to binding of the MET ligand, hepatocyte growth factor (HGF), C-terminal tyrosine residues are phosphorylated followed by a cascade of intracellular signals resulting in activation of MAPK and/or PI3K/Akt pathways [8, 9] (Figure 1). In this way, aberrant activation of MET leads to increased cell proliferation, invasion, and metastasis [10, 11]. The MET gene is found to be amplified in approximately 10% of CRCs, and amplification is associated with advanced stages and worse prognoses [12–14]. Additionally, MET gene missense mutations are found in ~3% of CRCs, in particular p.R970C and p.T992I (also reported as p.R988C and p.T1010I) [15]. Specific missense mutations in the tyrosine kinase domain of MET (amino acids 1112 to 1268) lead to hereditary papillary renal carcinoma (MIM ID 164860). Individuals with this condition are usually symptomatic by their fourth decade of life due to multifocal kidney lesions.

To evaluate the possibility that germline changes in the MET gene may lead to colon cancer susceptibility in a familial setting, we scanned and sequenced all coding exons of MET in our sibling pair cohort [5]. Here we report that MET p.T992I, a non-synonymous change suggested to have oncogenic potential, is present in the germline DNA of 5.2% of this cohort and this same change is confirmed in a second familial colon cancer cohort with two affected first degree relatives at a frequency of 4.1%. This substitution is reported in <1% of the general population and has been reported in cancer cells of multiple origins, including 2.5% of colon cancers [15–18].

Because each of the families in the sibling pair cohort is of Caucasian descent, we were interested to determine whether there was evidence of a founder mutation. Using polymorphic markers surrounding the MET locus (D7S2418, D7S486 and D7S648), the haplotype segregating with the mutation in each of the 4 families was identified and found to be distinct. This suggests that this mutation arose independently.

Using tumor DNA from individuals diagnosed with CRC ≤50 years (n = 130) or individuals diagnosed with CRC and having a first degree relative with CRC (n = 169), a TaqMan assay was used to screen for the p.T992I mutation. We found that 9 of 299 tumors (3.0%) harbored the change, 1 from diagnosis ≤ 50 years (0.8%) and 8 from the two affected first-degree relative probands with CRC (4.7%). Interestingly, two of the 8 are a second-degree relative pair from a large family with excess colon cancer; one ascertained as a member of a first-degree relative pair (hr10-D on Table 2) and the other ascertained as a member of a parent-child pair also diagnosed ≤ 50 years (hr16-D on Table 2) [24]. Since these two are known to be closely related, the frequency is adjusted to 4.1% (7 of 168 families). DNA from normal tissue was available from all cases except hr16-D, and this individual was found to be an obligate carrier based on children's genotypes, thus the mutation was present in all 9 suggesting it was germline in origin. None of the 16 colorectal cancers arising in individuals with the germline p.T992I had microsatellite instability, a feature of defective mismatch repair pathway.

Because amplification of the MET gene occurs in colon cancers, we hypothesized that the allele harboring p.T992I would be preferentially amplified in colon tumors. Using cycle time from the TaqMan assay, we compared the difference of copy number of the mutant (c.2975T) from wild type (c.2975C) in tumor versus normal. Six of the 15 cases examined showed an excess of the mutant c.2975T allele over the wild type allele (Table 2), but this was not universal. This finding suggests that, in the presence of this mutation, additional amplification of the gene is not required for establishment of cancer.

Ten percent of all colon cancers arise in a familial setting when defined as two or more affected first-degree relatives [19]. There is a also two-fold increase of developing colon cancer with an affected first-degree relative [3]. Specifics of the genetic etiology of this group are not defined, leaving a gap in our knowledge of moderate risk genetic variants. A germline mutation in the MET gene, p.T992I, was identified in ~4.5% of colon cancers arising in first-degree relative pairs from two separate cohorts. The mutation was observed in less than 1% of colon cancer cases that occurred ≤ 50 years, suggesting that it does not promote very young CRC. MET p.T992I is also reported in the germline DNA of 4% of thyroid cancers [17], one endometrial and two melanoma cancer cases, and one normal individual [16]. In cancers, the p.R970C and p.T992I mutations are thought to affect phosphorylation of the serine residue (p.S985) that negatively regulates MET kinase activity [8, 25]. By comparison, the specific missense mutations reported in hereditary papillary renal carcinoma (HPRC) surround two tyrosine residues within the catalytic site (p.Y1234 and p.Y1235) that positively regulate kinase activity (Figure 1). The phenotypic differences between p.T992I and HPRC MET mutations could be explained by the difference between factors driving negative versus positive activation of MET kinase.

We propose a model whereby the p.T992I mutation functions as a progression factor rather than an initiation factor in the canonical colon cancer model [26]. Specifically, we hypothesize that an adenoma is initiated through somatic mutations in the canonical APC pathway, then the adenoma acquires other proliferative mutations, and in the presence of an underlying MET p.T992I mutation, is then able to move beyond the mucosal layer to become invasive colon cancer. This hypothesis is supported by the following observations. The individuals we identified with the MET p.T992I germline mutation do not have the hallmarks of inherited mutations in initiating factors such as multiple adenoma formation (APC gene) or microsatellite instability (mismatch repair genes). Additionally, CRC diagnosis under age 50 is infrequent. In fact, the chromosome 7q genetic locus is associated in affected relative pair studies when CRCs are included and adenomas are excluded [5–7]. The average age of CRC diagnosis in the general population is ~71 years, and it is estimated that 10 years are needed for a small polyp to progress to invasive CRC [27]. A model of rapid progression of polyp to cancer in the presence of MET p.T992I is supported in that individuals with the p.T992I mutation are diagnosed with CRC at an average age of 63 years. This would be when the general population, on average, is developing adenomas that will progress to cancer. This mutation also occurs in a variety of cancers including colon, melanoma, endometrial, thyroid, and mesothelioma [15–18] with germline confirmation in colon, thyroid, uterine, and melanoma [16, 17] suggesting that it is not a tissue-specific mechanism. MET p.T992I mutation is proposed to function through inhibition of phosphorylation of Ser985, which, when phosphorylated, corresponds with reduced MET signaling (Figure 1) [28, 29]. In cell models, the specific mutation reported here generally affects invasive behaviors including changes in cell morphology, adhesion, motility, migration and anchorage-independent growth but not proliferation, such as IL-3 independent growth in Ba/F3 cells [18, 29]. Based on these reports, it is reasonable to predict that MET p.T992I requires a growth signal (activation) but then is disabled in its ability to turn off the activation through phosphorylation of p.S985. It has also been shown that over expression of MET is an early event in the colorectal adenoma-carcinoma sequence [30]. In the context of a proliferating precancerous colonic adenoma, over expression MET p.T992I and the inability to turn off activation could allow the invasive behaviors to take place.

Although, the MET p.T992I genetic mutation has been commonly found in somatic colorectal cancer tissues, this is the first report also implicating this MET genetic mutation as a germline inherited risk factor for familial colorectal cancer. A strength of this study is the use of colorectal cancers enriched for a hereditary component. One of the limitations, however, is the small sample size and lack of a large unaffected cohort. Future independent studies on large case and carefully selected control sets are needed to replicate these results, confirm the conclusions, and provide an accurate estimate of the prevalence of this mutation in the cancer and normal populations.

We estimate that the specific germline mutation of this investigation is responsible for ~4.5% of CRCs that occur in a familial setting, defined here as two first-degree relatives with CRC. Since 10% of all CRCs occur within this definition, this would translate to 0.45% of all CRCs. Future work should be focused on measuring the precise prevalence of this mutation in a large set of cases and controls and estimation of CRC risk associated with the germline mutation. Because MET p.T992I has also been found in germline DNA of individuals diagnosed with other cancers, a large-scale study to examine the penetrance and risks of all cancers in mutation carriers will be an important advance in our understanding. Specific inhibitors of the MET protein are currently in use in human clinical trials and may have a specific utility in preventing invasion and the metastasis of early-stage cancers in individuals with the MET p.T992I mutation [8].