Using targeted and whole-genome sequencing on precursors and advanced endometrial and colorectal cancers, Temko et al. show that somatic mutations in the POLE exonuclease domain occur early in tumorigenesis (detectable even at the precancerous stage), create pathogenic mutations in known oncogenic driver genes, and are possibly the initiating oncogenic events. Such mutations drive significant CD8+ T cell infiltration into tumors and precancerous lesions, probably due to an increased mutation burden and consequent high neoantigen frequency.
Genomic instability, a hallmark of cancer, is generally thought to occur in the mid to late stages of tumorigenesis, following the acquisition of permissive molecular aberrations such as TP53 mutation or whole genome doubling. Tumours with somatic POLE exonuclease domain mutations are notable for their extreme genomic instability (their mutation burden is among the highest in human cancer), distinct mutational signature, lymphocytic infiltrate and excellent prognosis. To what extent these characteristics are determined by the timing of POLE mutations in oncogenesis is unknown. Here, we have shown that pathogenic POLE mutations are detectable in non-malignant precursors of endometrial and colorectal cancer. Using genome and exome sequencing, we found that multiple driver mutations in POLE-mutant cancers display the characteristic POLE mutational signature, including those in genes conventionally regarded as initiators of tumorigenesis. In POLE-mutant cancers, the proportion of monoclonal predicted neoantigens was similar to other cancers, but the absolute number was much greater. We also found that the prominent CD8(+) T cell infiltrate present in POLE-mutant cancers was evident in their precursor lesions. Collectively, these data indicate that somatic POLE mutations are an early, quite possibly initiating, event in the endometrial and colorectal cancers in which they occur. The resulting early onset of genomic instability may account for the striking immune response and excellent prognosis of these tumours, as well as their early presentation.