Peutz-Jeghers syndrome: a clinicopathologic survey of the "Harrisburg family" with a 49-year follow-up

Of the original Peutz-Jeghers families reported by Jeghers, the "Harrisburg Family" has now been followed for 49 yr. Their 12 affected family members comprise the largest Peutz-Jeghers kindred reported. The course of this family illustrates that Peutz-Jeghers syndrome is not a benign disease. One family member developed a duodenal carcinoma in a hamartoma with adenomatous changes; this progression in the duodenum has not previously been reported. Ten patients underwent 75 polypectomies. One patient developed short bowel syndrome. Three patients died in young adulthood. The development of gastrointestinal malignancy in 2 of 12 affected patients suggests that Peutz-Jeghers syndrome may be a premalignant condition. Consequently, even asymptomatic gastric, duodenal, and colonic polyps should be removed endoscopically. If surgical intervention is necessary, intraoperative endoscopy with polypectomy may prevent the development of a short bowel syndrome. Colonoscopic screening of patients and their family members may be beneficial and surveillance for extraintestinal malignancy appears to be warranted.

A solitary Peutz-Jeghers type hamartomatous polyp in the duodenum--a case report

A 56-yr-old woman with a solitary hamartomatous polyp confined to within the third portion of the duodenum, underwent a successful endoscopic polypectomy. The histological findings were identical to Peutz-Jeghers polyp but all the other clinical features of Peutz-Jeghers syndrome were absent.

Mucinous ovarian tumors associated with mucinous adenocarcinomas of the cervix. A clinicopathological analysis of 16 cases

Sixteen cases of mucinous adenocarcinoma of the cervix that were associated with a mucinous tumor of one or both ovaries are reported. The patients ranged from 25 to 70 (average, 44) years of age; two of them had the Peutz-Jeghers syndrome. Eight patients complained of abdominal swelling; most of the remainder had symptoms of uterine origin. Twelve patients had bilateral and four had unilateral ovarian tumors, which were typically large and cystic. Microscopic examination of most of the ovarian tumors revealed various combinations of benign-appearing, borderline, and carcinomatous mucinous epithelium within the same specimen. Most of the cervical tumors were deeply invasive; 10 of them were of the adenoma malignum type. Although there were varying degrees of uncertainty in individual cases, consideration of several features including the extent and distribution of disease in the abdomen, the comparative histology of the tumors, and the pattern of ovarian involvement suggested that 10 of the ovarian tumors were independent primary tumors, three were metastatic from the cervix, and in three cases the ovaries contained both primary and metastatic tumors.

Pigmentary abnormalities in genetic disorders

This article focuses on a few of the most common genetically inherited disorders of pigmentation: multiple lentigines syndromes, Peutz-Jeghers syndrome, dyskeratosis congenita, incontinentia pigmenti, tuberous sclerosis, neurofibromatosis, and Albright's polyostotic fibrous dysplasia.

[Adenocarcinoma of the cervix in Peutz-Jeghers syndrome. Case report and review of the literature]

The incidental finding of "adenoma malignum" or minimal deviation adenocarcinoma (MDA) of the cervix in a 38-year-old woman with Peutz-Jeghers syndrome (PJS) is reported and the literature is discussed. This highly differentiated form of adenocarcinoma is extremely rare but, like some other rare neoplasms, may occur more frequently in patients with PJS syndrome. Since the prognosis of MDA is considered poor and the histological diagnosis is often missed on biopsy, the importance of closely correlating clinical and pathological findings is emphasized.

Peutz-Jeghers polyposis associated with carcinoma of the digestive organs. Report of three cases and review of the literature

Three cases of Peutz-Jeghers polyposis with carcinoma of the digestive organs are studied. Although mucocutaneous pigmentation was not present in two of the three patients, the features of intestinal polyposis are consistent with those of Peutz-Jeghers syndrome. One patient had a carcinoma of the pancreas and the other two had carcinomas with colonic Peutz-Jeghers polyps. Previous reports on carcinomas associated with Peutz-Jeghers syndrome are reviewed. An unusual location in the gastrointestinal tract, together with occurrence at an early age, characterize the carcinoma in Peutz-Jeghers syndrome. In Japanese patients, the large bowel is the site of the greatest number of carcinomas. On the other hand, Western patients showed a relatively even distribution. A possible surveillance protocol for early detection of gastrointestinal carcinoma in patients with Peutz-Jeghers syndrome is discussed.

Epithelial misplacement in Peutz-Jeghers polyps. A diagnostic pitfall

Early difficulties with the interpretation of the histopathology caused overdiagnosis of cancer in the Peutz-Jeghers syndrome; and there is still controversy about the magnitude of risk of gastrointestinal carcinoma. Most workers now believe that there is a small but definite increase in the incidence of gastrointestinal carcinoma in Peutz-Jeghers polyps and most of these cancers occur in the upper gastrointestinal tract. In a review of 491 Peutz-Jeghers polyps in the records of St. Mark's Hospital Pathology department, misplacement of epithelium was found in approximately 10% of small intestinal polyps and closely mimicked adenocarcinoma. This "pseudoinvasion" was not observed in polyps of the stomach or colon. The epithelial misplacement may involve all layers of the bowel wall; and the most helpful histological discriminators include a lack of cytological atypia, the presence of the normal epithelial cell subtypes and a brush border, hemosiderin deposition, and intramural mucinous cysts. Epithelial misplacement may account for the overdiagnosis of carcinoma arising in Peutz-Jeghers polyps as reported in the literature.

Carcinoma and polyps of the gallbladder associated with Peutz-Jeghers syndrome

Peutz-Jeghers syndrome is a genetic condition characterized by mucocutaneous pigmentation and gastrointestinal polyposis. A variety of neoplasms have been found in the alimentary tract or elsewhere in patients with this entity. A 39-year-old female patient who had carcinoma and two polyps in the gallbladder in association with Peutz-Jeghers syndrome is described. Since the polyps consisted of the normal lining epithelium of the gallbladder and pseudopyloric gland-type metaplastic cells and obviously lacked cellular atypism, the authors would consider them hamartomatous. The carcinoma partly showing submucosal invasion existed in an area other than the polyps. This is the first documented case of the syndrome having gallbladder carcinoma.

Enteritis cystica profunda in Peutz-Jeghers syndrome. Report of a case and review of the literature

The hereditary condition known as Peutz-Jeghers syndrome is characterized by mucosal pigmentation and gastrointestinal polyps. The polyps, usually pedunculated hamartomas, are significant only for the symptoms they cause. Intramural lesions also have been described with gross microscopic features that are often interpreted as malignant. Careful evaluation may show most of these lesions to be enteritis cystica profunda. These rarely diagnosed but benign tumors have very different implications for treatment and prognosis.

Tumours of the small intestine

Tumours of the small intestine are a relatively unusual group of benign and malignant tumours of both epithelial and supporting tissue origin. Their pathology, associated syndromes, clinical features, diagnosis, and management are discussed.

Peutz-Jeghers syndrome with adenomas and adenocarcinomas in colonic polyps

A case of Peutz-Jeghers syndrome is reported in which 52 colonic polyps were resected endoscopically. Of these, 49 were hamartomatous and showed no adenomatous or carcinomatous changes. In the other three polyps, adenomatous change and foci of adenocarcinoma were present. The investigation of the sites of adenomas and carcinomas in this case and others previously reported indicates that such neoplastic changes are found on the luminal surfaces of the polyps of Peutz-Jeghers syndrome.

Solitary hamartomatous polyp of the duodenum in the absence of familial polyposis

A large hamartomatous polyp of the Peutz-Jegher type was discovered in the distal duodenum by endoscopy in a patient with occult gastrointestinal bleeding. There were no other polyps in the gastrointestinal tract and the patient lacked any stigmata associated with the familial polyposis syndromes. This is the second well-documented case of an isolated hamartomatous polyp of the Peutz-Jegher type in the small intestine occurring in the absence of familial polyposis.

Epithelial polyps of the large intestine. A classification based on biologic behavior

Classifications of colonic polypoid lesions are often based on their pathogenesis. Little attention is paid to the biologic behavior (or predicted behavior, based on experience) of these lesions. Classification based on biologic behavior separates these lesions, regardless of histogenesis, according to possible malignant potential. This helps the clinician to explain the implications of the histopathologic diagnosis to the patient and to understand when aggressive or prophylactic therapy should be pursued.

Female genital tract tumors in Peutz-Jeghers syndrome

Multiple genital tract tumors, including bilateral ovarian sex cord tumors with annular tubules, adenoma malignum of the cervix, and bilateral ovarian mucinous tumors, developed in a female patient with Peutz-Jeghers syndrome. Although each of these tumor types has been reported to occur in this syndrome, the present case appears to be the first in which the syndrome was complicated by tumors of all three types.

Pancreatic adenocarcinoma in a patient with Peutz-Jeghers syndrome--a case report and literature review

A variety of intestinal and extraintestinal neoplasms has been associated with Peutz-Jeghers syndrome, although to our knowledge, there has been no reported case of associated pancreatic neoplasm. We report a 38-yr-old man with Peutz-Jeghers syndrome and pancreatic adenocarcinoma and review current literature regarding a neoplastic diathesis in these patients.

Localization of Peutz-Jeghers macules to psoriatic plaques

We report a case of the Peutz-Jeghers syndrome in which the characteristic pigmented macules developed within preexisting psoriatic plaques in sites extremely unusual for the syndrome. To our knowledge, ours is the first report of such a case in the English literature.

Peutz-Jeghers syndrome: an increased risk of neoplasia

A family with Peutz-Jeghers syndrome is reported, colonic involvement having been demonstrated on several affected members. Of the 50 members of the family about whom we could get informations, 21 had the characteristic cutaneous lesions (and usually had had some manifestation of the intestinal disease). Our first patient had a colonic carcinoma, and we could detect at least another colonic carcinoma in the family. A third attained member of the family was known to have died from "throat cancer". The most frequent clinical manifestations of this family patients are intussusception related abdominal crisis of colicky pain and rectorrhagy. In Peutz-Jeghers syndrome, there is a slight increase in the risk of malignancy, and digestive cancer can arise from coexistent adenomas, from cancerous changes of hamartomas, or "de novo", i.e., appear on previously normal mucosa.

Female genital tract and Peutz-Jeghers syndrome: an immunohistochemical study

Systematic detection of endocrine cells was performed in two genital tracts from patients with Peutz-Jeghers syndrome (PJS). These tissues proved to be particularly rich in endocrine cells. The specialized cells were distributed in the cervix and fallopian tubes. In the cervix, they were confined to remarkable mucinous tumors related to "adenoma malignum." Serotonin, somatostatin, gastrin, and pancreatic polypeptide immunoreactive cells were characterized. In fallopian tubes, serotonin-storing cells and somatostatin cells were detected respectively among normal-appearing and mucinous areas of tubal epithelium; in addition, serotonin-storing cells were found in many mesonephric rests. This strongly contrasts with the usual paucity of endocrine cells in the female genital tract. However, none of the findings mentioned was really specific of PJS. In particular, endocrine cells seem to be an integral constituent of adenoma malignum, with or without PJS. These findings suggest a disturbance of tissular differentiation.

Giant hamartoma of the colon: Peutz-Jeghers type

We have seen a young man with multiple large-bowel polyps and a single immense colonic polyp of the Peutz-Jeghers type. It was completely removed primarily to control hemorrhage and to exclude focal adenomatous or carcinomatous change. We review the spectrum of colonic hamartomas.

Genetic and familial factors in colorectal cancer

Of the patients with colorectal cancer, there are some with hereditary disorders such as familial polyposis coli, Gardner's syndrome, Turcot's syndrome, and cancer family syndrome in which colorectal adenocarcinoma develops at a significantly high frequency, and these hereditary diseases are very important and interesting from the viewpoint of carcinogenesis as well as tumorigenesis. On the other hand, Peutz-Jeghers syndrome and juvenile polyposis which likewise are hereditary diseases are often considered to be accompanied with colorectal cancer. On these grounds, 49 cases of familial polyposis coli (including Gardner's syndrome), 12 cases of Peutz-Jeghers syndrome, one case of juvenile polyposis, six pedigrees of cancer family syndrome, experienced at the National Cancer Center Hospital from 1962 to 1984 were reviewed with particular emphasis placed on the recent progress and the natural history of these diseases. Furthermore, a comparative study between single colorectal cancers (1,034 cases) and multiple ones (89 cases) was carried out from the standpoint of familial aggregation and cumulative age incidence. A high association with genetic factors was found in multiple primary colorectal cancer with a family history of colorectal cancer as well as in the well-known hereditary diseases mentioned above. The author presented a conception of the relationship between the human body and tumors from the viewpoint of a comparison among infantile and childhood tumors, hereditary tumors, familial aggregative tumors and the usual tumors observed in old age.

Epithelioid leiomyosarcoma originating in a hamartomatous polyp from a patient with Peutz-Jeghers syndrome

A case of Peutz-Jeghers syndrome with long history and multiple resections is presented. Despite the large number of intestinal polyps in these patients, malignant transformations are rare. In this case, an epithelioid leiomyosarcoma developed within a single polyp. At the time of resection this tumor had already metastasized to the liver. The histology and ultrastructure of this tumor is presented. Reviews of the clinical syndrome and leiomyosarcoma are given, with discussion of the possible interaction of these two processes as presented in this patient.

Peutz-Jeghers syndrome and cancer

A 27-year-old white woman with Peutz-Jeghers syndrome (PJS) associated with a rare but distinctive ovarian tumor, the sex cord tumor with annular tubules (SCTAT), is discussed. Pertinent oral manifestations of PJS and chemotherapy complications are illustrated by the case report. Traditionally, patients exhibiting PJS have not been considered at increased risk of cancer development. This case, coupled with a review of the recent literature, suggests that these patients are, indeed, at increased risk of malignant lesions of several organ systems.

Peutz-Jeghers syndrome and metastasising colonic adenocarcinoma

A case of metastasising colonic carcinoma associated with Peutz-Jeghers syndrome in a 39 year old man is described. The caecal adenocarcinoma had metastasised widely to regional lymph nodes and was associated with several other colonic Peutz-Jeghers polyps, showing no evidence of dysplasia or malignancy. It was not possible to determine whether the carcinoma had arisen from a Peutz-Jeghers polyp. The patient also had gastric and small intestinal polyps. The serum carcinoembryonic antigen (CEA) was normal at presentation in this patient and in one other reported case. The use of this determination as a screening test for so-called high risk groups is, therefore, not supported by this report. The risk of malignancy is not known. It will only be determined by careful follow up of a defined Peutz-Jeghers syndrome population and comparison of carcinoma incidence with a matched sample of the general population. A national registry of Peutz-Jeghers syndrome patients in the United Kingdom would help to resolve this question.

Hyperplastic (metaplastic) polyps of the colon. A histologic and histochemical study

One hundred seventy-three hyperplastic polyps removed from the colon of 146 patients were carefully examined by light microscopy in order to evaluate the histologic variants. Seventy polyps were also studied histochemically in order to assess the mucin distribution. Seven polyps measured greater than 1 cm. The frequency of hyperplastic foci has been assessed in a review of 1000 colonic adenomas, 50 juvenile, 30 inflammatory, and six Peutz-Jeghers polyps. The vast majority of the hyperplastic polyps showed features similar to those of inflammatory and ischemic bowel mucosa, leading to the suggestion of an inflammatory-ischemic origin of the polyps. The frequent finding of dysplastic features within hyperplastic polyps greater than 1 cm suggests that at least the large polyps are dysplasia-prone.

Gastro-intestinal malignancy in association with Peutz-Jeghers syndrome--three further cases

Whether a relationship exists between the Peutz-Jeghers syndrome (PJS) and gastrointestinal (GIT) malignancies remains unclear. We here present three further cases of GIT malignancies in young patients with the PJS.

Peutz-Jeghers syndrome with cervical adenocarcinoma and enteritis cystica profunda

Images

Oral and perioral pigmented macules in a patient with gastric and intestinal polyposis

A case of hereditary intestinal polyposis and orofacial pigmentation is presented. Recognition of the characteristic pigmentation by dentists may lead to early diagnosis of associated hamartomatous polyps or neoplastic disease that may be life-threatening.