Single-stranded DNA oligonucleotides can achieve targeted base-pair substitution with modest efficiency but high precision. We show that "oligo targeting" can be used effectively to study missense mutations in DNA mismatch repair (MMR) genes. Inherited inactivating mutations in DNA MMR genes are causative for the cancer predisposition Lynch syndrome (LS). Although overtly deleterious mutations in MMR genes can clearly be ascribed as the cause of LS, the functional implications of missense mutations are often unclear. We developed a genetic screen to determine the pathogenicity of these variants of uncertain significance (VUS), focusing on mutator S homolog 2 (MSH2). VUS were introduced into the endogenous Msh2 gene of mouse embryonic stem cells by oligo targeting. Subsequent selection for MMR-deficient cells using the guanine analog 6-thioguanine allowed the detection of MMR-abrogating VUS. The screen was able to distinguish weak and strong pathogenic variants from polymorphisms and was used to investigate 59 Msh2 VUS. Nineteen of the 59 VUS were identified as pathogenic. Functional assays revealed that 14 of the 19 detected variants fully abrogated MMR activity and that five of the detected variants attenuated MMR activity. Implementation of the screen in clinical practice allows proper counseling of mutation carriers and treatment of their tumors.Lynch syndrome | DNA mismatch repair | MSH2 | variants of uncertain significance | site-directed mutagenesis T he DNA mismatch repair (MMR) system is essential for genome fidelity: It corrects mismatches that may arise during erroneous DNA replication and induces apoptosis if adducts caused by certain DNA-damaging agents cannot be repaired. Newly replicated DNA is scanned for base-base mispairings and loops of unpaired bases by heterodimers composed of MMR proteins mutator S homolog 2 and 6 (MSH2/MSH6) or mutator S homolog 2 and 3 (MSH2/MSH3), respectively. Upon encountering a mismatch, the MSH heterodimers recruit another heterodimer composed of mutator L homolog 1 and postmeiotic segregation increased 2 (MLH1/PMS2) to coordinate downstream repair events (1, 2). Exposure to certain DNA-damaging agents, such as methylating agents and the nucleotide analog 6-thioguanine (6TG), creates lesions in the genome that give rise to mismatches when replicated (3, 4). The DNA MMR system recognizes these mismatches and induces cell death to remove them. Several models propose how DNA MMR activates cell death. One model suggests that DNA MMR recognizes the mismatch and repetitively removes the incorporated nucleotide rather than the lesion itself, creating a cycle of futile repair which ultimately leads to DNA breakage and cell death (3). Another possibility is that MSH2/MSH6 and MLH1/PMS2 bind at the site of the damaged base and act as molecular scaffolds that activate downstream DNA damage-response pathways that result in apoptosis (5, 6). In the absence of a functional DNA MMR system, cells have an increased rate of spontaneous mutagenesis and elevated resistance to DNA-methyla...