The concise handbook of family cancer syndromes. Mayo Familial Cancer Program

Pooled genome linkage scan of aggressive prostate cancer: results from the International Consortium for Prostate Cancer Genetics

While it is widely appreciated that prostate cancers vary substantially in their propensity to progress to a life-threatening stage, the molecular events responsible for this progression have not been identified. Understanding these molecular mechanisms could provide important prognostic information relevant to more effective clinical management of this heterogeneous cancer. Hence, through genetic linkage analyses, we examined the hypothesis that the tendency to develop aggressive prostate cancer may have an important genetic component. Starting with 1,233 familial prostate cancer families with genome scan data available from the International Consortium for Prostate Cancer Genetics, we selected those that had at least three members with the phenotype of clinically aggressive prostate cancer, as defined by either high tumor grade and/or stage, resulting in 166 pedigrees (13%). Genome-wide linkage data were then pooled to perform a combined linkage analysis for these families. Linkage signals reaching a suggestive level of significance were found on chromosomes 6p22.3 (LOD = 3.0), 11q14.1-14.3 (LOD = 2.4), and 20p11.21-q11.21 (LOD = 2.5). For chromosome 11, stronger evidence of linkage (LOD = 3.3) was observed among pedigrees with an average at diagnosis of 65 years or younger. Other chromosomes that showed evidence for heterogeneity in linkage across strata were chromosome 7, with the strongest linkage signal among pedigrees without male-to-male disease transmission (7q21.11, LOD = 4.1), and chromosome 21, with the strongest linkage signal among pedigrees that had African American ancestry (21q22.13-22.3; LOD = 3.2). Our findings suggest several regions that may contain genes which, when mutated, predispose men to develop a more aggressive prostate cancer phenotype. This provides a basis for attempts to identify these genes, with potential clinical utility for men with aggressive prostate cancer and their relatives.

Adjustment issues related to bilateral prophylactic mastectomy in women at elevated risk of developing breast cancer

Breast cancer is the most common cancer diagnosis for North American and Western European women. Increased knowledge in availability of genetic testing has helped to identify those women at high risk of eventually developing breast cancer. This has resulted in more women considering bilateral prophylactic mastectomy as a viable preventative option. Although the efficacy of the procedure has been established, much less is known about the psychological impact of undergoing this procedure. In order to assess these factors, we reviewed what is currently known about the psychological impact of undergoing bilateral prophylactic mastectomy. Searches were conducted and inclusion criteria revealed articles that focused on the psychological components involved with undergoing a bilateral prophylactic mastectomy. The findings are summarized and fell broadly into one or more of the following three areas: (1) satisfaction or regret following the surgery, (2) psychosocial functioning after the surgery, and (3) predictors of quality of life. Plastic surgery nurses have a unique opportunity to impact important psychological considerations, such as expectations of the early postoperative period, body image concerns, and psychological distress.

Familial risk for histology-specific bone cancers: an updated study in Sweden

We used the nation-wide Swedish Family-Cancer Database to examine the familial risks of histology-specific bone cancers in offspring by parental or sibling probands. Adjusted standardised incidence ratios (SIRs) were used to measure the risk. Among the 1327 offspring bone cancers, only two parent-offspring pairs and one sibling pair were noted with concordant bone cancer but the SIRs were not significant. Significant associations were observed in specific histological types or specific age groups, some of which may be chance findings arising from multiple comparisons. However, the risk of early-onset (< 25 years) osteosarcoma in offspring was significantly increased when mothers presented with breast cancer (1.7) and melanoma (2.9), suggesting that Li-Fraumeni syndrome could partly explain this familial aggregation. Other associations, such as childhood osteosarcoma with parental liver cancer, Ewing's sarcoma with kidney cancer and giant cell sarcoma with maternal breast cancer, were novel findings and may be related to other familial diseases.

Incidence of multiple primary malignancies among patients with bone cancers in Sweden

PURPOSE

The present study aimed at quantifying risks for second malignancies in patients with bone cancers, and risks for second bone cancers after other primary tumors.

METHODS

Adjusted standardized incidence ratios (SIRs) were used as a measure of risk.

RESULTS

Among 2,546 primary bone cancer patients, a total of 171-second malignancies occurred. Besides second bone cancers, other cancer sites with an increased SIR were the soft tissues and endocrine glands. The overall risk of second malignancies following Ewing's sarcoma was 5.63, followed by chordoma (1.99), osteosarcoma (1.54), and chondrosarcoma (1.51). Patients diagnosed before age 20 years showed an increased SIR of 3.11. The increased occurrence of second bone cancers was noted after the cancer sites of upper aerodigestive tract, kidney and nervous system.

CONCLUSIONS

The incidence of second primary malignancies in bone cancer patients was moderately increased. Among histological types, Ewing's sarcoma showed the highest risk of developing second cancers. Young age was also associated with an increased risk. Besides therapeutic effects, the observed excesses of a second bone or soft tissue tumor may be related to Li-Fraumeni syndrome. Increases at other sites may be related to unknown factors or spurious findings.

Pathogenetic mechanisms in thyroid follicular-cell neoplasia

Thyroid cancer is one of the few malignancies that are increasing in incidence. Recent advances have improved our understanding of its pathogenesis; these include the identification of genetic alterations that activate a common effector pathway involving the RET-Ras-BRAF signalling cascade, and other unique chromosomal rearrangements. Some of these have been associated with radiation exposure as a pathogenetic mechanism. Defects in transcriptional and post-transcriptional regulation of adhesion molecules and cell-cycle control elements seem to affect tumour progression. This information can provide powerful ancillary diagnostic tools and can also be used to identify new therapeutic targets.

A pooled analysis of second primary pancreatic cancer

Studies of pancreatic cancer in the setting of second primary malignant neoplasms can provide etiologic clues. An international multicenter study was carried out using data from 13 cancer registries with a registration period up to year 2000. Cancer patients were followed up from the initial cancer diagnosis, and the occurrence of second primary malignant neoplasms was compared with expected values derived from local rates, adjusting for age, sex, and period of diagnosis. Results from individual registries were pooled by use of a fixed-effects model. People were at higher risk of developing pancreatic cancer within 10 years of a diagnosis of cancers of the pharynx, stomach, gallbladder, larynx, lung, cervix, corpus uteri, bladder, and eye and 10 years or later following a diagnosis of cancers of the stomach, colon, gallbladder, breast, cervix, placenta, corpus uteri, ovary, testis, bladder, kidney, and eye, as well as Hodgkin's and non-Hodgkin's lymphomas. Pancreatic cancer was connected with smoking-related cancers, confirming the etiologic role of tobacco. The associations with uterine and ovarian cancers suggest that reproductive factors might be implicated in pancreatic carcinogenesis. The elevated pancreatic cancer risk in young patients observed among several types of cancer implies a role of genetic factors. Radiotherapy is also suggested as a risk factor.

Cancer Screening in Older Adults in an Era of Genomics and Longevity

OBJECTIVES

To provide an overview of cancer genomics and cancer screening in older adults with a focus on breast, prostate, and colon cancers.

DATA SOURCES

Journal articles, research articles, and web sites.

CONCLUSION

Cancer screening in older populations is often in the context of one or more co-morbid conditions, cancer survivorship, genomic information, and competing health priorities. The field of cancer screening has outgrown the tools available to enable health care providers and older adults to make informed cancer screening decisions. Research is needed to develop clinical screening tools that integrate age, cancer risk, life expectancy, and comorbidity.

IMPLICATIONS FOR NURSING PRACTICE

Health care providers are faced with opportunities and challenges in the prevention and early detection of cancer in older Americans.

Cancer Survivorship—Genetic Susceptibility and Second Primary Cancers: Research Strategies and Recommendations

Cancer survivors constitute 3.5% of the United States population, but second primary malignancies among this high-risk group now account for 16% of all cancer incidence. Although few data currently exist regarding the molecular mechanisms for second primary cancers and other late outcomes after cancer treatment, the careful measurement and documentation of potentially carcinogenic treatments (chemotherapy and radiotherapy) provide a unique platform for in vivo research on gene-environment interactions in human carcinogenesis. We review research priorities identified during a National Cancer Institute (NCI)-sponsored workshop entitled "Cancer Survivorship--Genetic Susceptibility and Second Primary Cancers." These priorities include 1) development of a national research infrastructure for studies of cancer survivorship; 2) creation of a coordinated system for biospecimen collection; 3) development of new technology, bioinformatics, and biomarkers; 4) design of new epidemiologic methods; and 5) development of evidence-based clinical practice guidelines. Many of the infrastructure resources and design strategies that would facilitate research in this area also provide a foundation for the study of other important nonneoplastic late effects of treatment and psychosocial concerns among cancer survivors. These research areas warrant high priority to promote NCI's goal of eliminating pain and suffering related to cancer.

Second primary malignancies among patients with soft tissue tumors in Sweden

Survival from soft tissue tumors (STTs) has been improved because of the successful treatment. One of the late sequelae in STT survivors is the development of a second malignancy. The present study aimed at quantifying risks for second malignancies in patients with STTs, and risks for second STTs after other primary malignancies. Adjusted standardized incidence ratios (SIRs), calculated from the Swedish Family-Cancer Database, were used as a measure of risk. Among 6,671 primary STT patients, a total of 650 second malignancies occurred. Besides second STTs, other cancer sites with an increased SIR were the nervous system, endocrine glands, skin (melanoma and squamous cell carcinoma) and prostate; the risk for non-Hodgkin lymphoma (NHL) was also increased. The overall risk of second malignancies decreased in the following order: fibrosarocma (1.63) > myxosarcoma (1.48) > leiomyosarcoma (1.44) > liposarcoma (1.21). An increased risk of second STTs after primary cancers of the bone, ovary, nervous system, cervix, thyroid gland, skin, endometrium, breast, upper aerodigestive tract, and after Hodgkin disease, NHL and leukemia was also noted. This study showed that the incidence of second primary malignancies in patients with STTs was increased, but the SIRs varied among specific cancer sites. Besides therapeutic effects, the associations between STTs and bone and nervous system tumors suggested that cancer syndromes, such as neurofibromatosis type 1 and Li-Fraumeni syndrome, may partly explain the excesses. The associations of STTs with cancers of the skin (squamous cell carcinoma and melanoma) and with NHL may be related to immunodeficiency.

Factores de riesgo para los tumores óseos malignos pediátricos

INTRODUCTION

Cancer is the result of the interaction of two kinds of determinants: genetic (endogenous) and environmental (exogenous). In the last few decades, pediatric oncology as a whole has progressed, including knowledge of malignant osseous tumors (MOT). Although advances have been made in diagnostic and therapeutic aspects, little progress has taken place in our knowledge of the risk factors involved in their etiopathogenesis.

OBJECTIVE

This review has three objectives: a) to provide an update on MOT-related risk factors in the child and adult population; b) to disseminate knowledge of the main MOT-related risk factors among our colleagues in order to promote research into these factors, diagnosis and future prevention, and c) to request help from our colleagues in the Environment and Pediatric Cancer research project.

MATERIAL AND METHODS

We performed a systematic review of the literature published in the last 30 years on risk factors implicated in the etiopathogenesis of MOT, using Medline, Cancerlit, Science Citation Index and Embase. The search profiles used were: pediatric/childhood malignant bone tumors, pediatric/ childhood bone cancer/neoplasm, osteosarcoma/bone sarcoma/Ewing's sarcoma and risk factors/etiology/epidemiology. The most interesting articles were selected and the most relevant references contained therein were retrieved.

RESULTS

MOT represent 6-7 % of all pediatric neoplasms. The most frequent types are osteosarcoma (OS) and Ewing's sarcoma (ES), representing 56 % and 34 % respectively. OS-related risk factors are the following: a) previous osseous disease (Paget's disease); b) familial-genetic factors (hereditary retinoblastoma, Li-Fraumeni syndrome, Rothmund-Thompson syndrome, Bloom syndrome, familial OS, Diamond-Blackfan anemia); c) chemical factors (antineoplastic drugs); d) physical factors (ionizing radiation); e) biologic factors; f) parental occupation, and g) other factors (artificial osseous implants and traumatisms). ES-related risk factors are the following: a) ethnic-cultural (Caucasian race); b) genetic factors; c) parental occupation (herbicide, pesticide and fertilizer exposure); d) maternal obstetric history, and e) other factors (parental smoking and inguinal hernia).

CONCLUSIONS

Most causes of MOT are unknown. Based on different levels of scientific evidence, the main factors implicated in the etiopathogenesis of OS are: Paget's disease, hereditary retinoblastoma, Li-Fraumeni syndrome, antineoplastic drugs, and ionizing radiation. The main factors related to ES are: Caucasian race, parental occupation, parental smoking, and surgery for inguinal hernia. The main obstacles to greater knowledge of MOT-related factors are: a) their multiple origin; b) the low prevalence in the population; c) lack of environmental health training in pediatrics, and d) the low public and private investment in this research field.

Increased risk of cancer among siblings of long-term childhood cancer survivors: a report from the childhood cancer survivor study

We determined risk of cancer among first-degree relatives of 5-year survivors of childhood leukemia, lymphoma, central nervous system tumors, sarcomas, Wilms' tumor, and neuroblastoma. Subjects were 13,703 participants in the Childhood Cancer Survivor Study. Family history was collected on 56,759 first-degree relatives using a self-reported questionnaire. Incidence was compared with age- and sex-specific rates using the U.S. Surveillance, Epidemiology and End Results program. Siblings of the survivors had an increased risk of cancer [standardized incidence ratio (SIR), 1.5; 95% confidence interval (95% CI), 1.35-1.7]. Risk was elevated for siblings of probands of leukemia (SIR, 1.3; 95% CI, 1.0-1.6), Hodgkin's disease (SIR, 1.5; 95% CI, 1.2-1.9), non-Hodgkin's lymphoma (SIR, 1.8; 95% CI, 1.3-2.5), Wilms' tumor (SIR, 1.9; 95% CI, 1.2-3.2), soft tissue sarcoma (SIR, 1.5; 95% CI, 1.0-2.2), and bone tumors (SIR, 1.6; 95% CI, 1.2-2.2). Cancer risk was elevated in siblings (SIR, 2.4; 95% CI, 1.5-3.7) and offspring (SIR, 15.0; 95% CI, 5.3-42.9) of probands with second malignant neoplasms (SMN) compared with relatives of probands without SMNs. Siblings of probands with leukemia, Hodgkin's disease, neuroblastoma, and Wilms' tumor had elevated risks for the same malignancies. Parents had no increased risk (fathers' SIR, 0.7; 95% CI, 0.7-0.8; mothers' SIR, 0.9; 95% CI, 0.9-1.0). Seventy percent of siblings' cancers developed in adulthood. These findings suggest that familial cancer syndromes may be revealed as this cohort and family members age and with accrual of more offspring and subjects with SMNs.

Evaluation of breast involvement in relation to Cowden syndrome: a radiological and clinicopathological study of patients with PTEN germ-line mutations

We describe the clinical, radiological, and pathological findings of the diverse benign and malignant breast neoplasms found in association with Cowden syndrome. Patients with Cowden syndrome had a substantially increased risk of breast carcinoma. We find that 33% of the patients in our study population with Cowden disease have developed breast carcinoma to date. An association between Cowden disease and multiple tubular adenomas or breast hamartomas was found in two patients, suggesting a genetic origin. PTEN germ-line mutations were found in all four patients presenting with relevant benign or malignant breast pathology. We also assess the value of specific diagnostic tools used in the surveillance management. Screening mammography was useful in the diagnosis of small, high-grade carcinomas.

Familial risks for nonmedullary thyroid cancer

CONTEXT

Reliable data on familial risks are important for clinical counseling and cancer genetics.

OBJECTIVE

We wanted to define familial risks for histopathology-specific nonmedullary thyroid cancers through parental and sibling probands.

SETTING

The study examines the nationwide Swedish Family-Cancer Database on 10.5 million individuals, containing families with parents and offspring.

PATIENTS

Cancer data were retrieved from the Swedish Cancer Registry from years 1958 to 2002, including 3292 patients with thyroid adenocarcinoma. The Systematized Nomenclature of Medicine histology was available from 1993 onward, with 1449 papillary, 288 follicular, 148 anaplastic, and 68 Hurthle cell tumors.

MAIN OUTCOME MEASURES

Familial risk for offspring was defined through standardized incidence ratio, adjusted for many variables.

RESULTS

The familial risk for papillary carcinoma was 3.21 and 6.24 when a parent and a sibling, respectively, were diagnosed with thyroid cancers. There was an apparent gender preference, particularly among sisters, whose risk was 11.19. The risks were highest for early onset cancers. Thyroid adenocarcinoma was shown to be associated with melanoma and connective tissue tumors, and probably also with neurinomas (schwannomas). Associations found in single comparisons with papillary thyroid cancer and other sites included right-sided colon, breast, ovarian, and kidney cancers. Hurthle cell tumors were associated with Hodgkin's and non-Hodgkin's lymphoma, but the numbers of cases were small.

CONCLUSIONS

The present findings were based on a limited number of cases, but they display a complex and heterogeneous pattern of familial nonmedullary thyroid cancer. The high risk for papillary carcinoma among women requires clinical attention, although the absolute risks for this rare cancer are still low.

Familial multiple primary lung cancers: a population-based analysis from Sweden

Multiple primary cancers arise because of inherited or acquired deficiencies, and their causes may depend on the first primary cancer, or they may be entirely independent. We used a nation-wide family dataset to search for evidence for a genetic predisposition to lung cancer. The Swedish Family-Cancer Database includes all Swedes born in 1932 and later with their parents, totalling over 10.2 million individuals. Cancer cases were retrieved from the Swedish Cancer Registry up to year 2000. Standardized incidence ratios (SIR) and 95% confidence limits (CI) were calculated for first and second primary lung cancers by a family history. The incidence of second primary lung cancer was nine times higher among cases with familial lung cancer compare to that of first primary lung cancer. The proportion of multiple primary lung cancer patients with family history for lung cancer was 4.7% (9/190) for men and 6.5% (5/77) for women. Lung cancer patients with a family history of lung cancer were at a significantly increased risk for subsequent primary lung cancer among both men (SIR=9.89, 95%CI 4.48-18.66) and women (SIR=17.86, 95%CI 5.63-42.00). The corresponding SIRs in patients without a family history were 2.04 (95%CI 1.75-2.36) and 5.10 (95%CI 3.99-6.43) for men and women, respectively. The present study suggests that the development from the first primary lung cancer to the second primary lung cancer may be more strongly affected by genetic factor than the first primary lung cancer.

Endoscopic management of familial colonic neoplasia

Heredity plays an important causative role in a large percentage of colorectal cancers. Clinical recognition of the hereditary polyposis syndromes, hereditary nonpolyposis colorectal cancer, and common familial colorectal cancer is essential because screening, surveillance, and treatment among affected individuals and their family members differs from that recommended for the general population. More intensive cancer screening and surveillance is required if premature death is to be avoided. Genetic testing is commercially available for most of the hereditary colorectal cancer syndromes and can greatly facilitate the management of patients if properly undertaken.

Inherited polyposis syndromes: molecular mechanisms, clinicopathology, and genetic testing

The inherited polyposis syndromes are a group of conditions in which multiple gastrointestinal polyps occur in the lumen of the gastrointestinal tract, most exhibit an increased risk of colon cancer. Benign and malignant extraintestinal tumors might also be observed. Recent elucidation of the underlying gene mutations has contributed to our understanding of the cell biology and molecular mechanisms associated with gastrointestinal tumorigenesis. Developments have also allowed genetic testing to become an integral component in accurate diagnosis, categorization, and management of inherited polyposis syndromes. In this review, we will focus on familial adenomatous polyposis, mutY human homologue-associated polyposis, Peutz-Jeghers syndrome, juvenile polyposis, and Cowden syndrome. It is essential that both physician and patient understand the benefits and limitations of genetic testing before submission of samples to the laboratory. There are many issues accompanying molecular diagnosis of cancer syndromes, and genetic counseling is an essential prelude to genetic testing.

Effect of Helicobacter pylori infection on the expression of DNA mismatch repair protein

BACKGROUND

Helicobacer pylori infection is a major gastric cancer risk factor. Deficient DNA mismatch repair (MMR) caused by H. pylori may underlie microsatellite instability (MSI) in the gastric epithelium and may represent a major mechanism of mutation accumulation in the gastric mucosa during the early stages of H. pylori-associated gastric carcinogenesis. In this study, we examined the expression of DNA MMR protein (hMLH1 and hMSH2) in patients with chronic H. pylori infection before and after eradication of the infection.

MATERIALS AND METHODS

Gastric tissue samples were collected from 60 patients with H. pylori gastritis and peptic ulcer disease before and after eradication of the infection. The DNA MMR protein expression (hMLH1 and hMSH2) was determined by immunohistochemical staining in 60 patients before and after H. pylori eradication. The percentage of epithelial cell nuclei and intensity of staining were then compared in gastric biopsies before and after eradication.

RESULTS

The percentage of hMLH1 (76.60 +/- 20.27, 84.82 +/- 12.73, p=.01) and hMSH2 (82.36 +/- 12.86, 88.11 +/- 9.27, p<.05) positive epithelial cells significantly increased in 53 patients who became H. pylori-negative after eradication therapy. However, the intensity of hMLH1 and hMSH2 staining was not significantly different. In those 7 patients, who did not respond to the eradication therapy and were still H. pylori-positive, the percent positivity and intensity of hMLH1 and hMSH2 staining did not change.

CONCLUSIONS

The expression of DNA MMR proteins increased in the gastric mucosa after H. pylori eradication, indicating that H. pylori gastritis may be associated with a reduced DNA MMR system during infection. The effect of H. pylori infection on MMR protein expression appears to be at least partially reversible after H. pylori eradication. These data suggest that H. pylori gastritis might lead to a deficiency of DNA MMR in gastric epithelium that may increase the risk of mutation accumulation in the gastric mucosa cells during chronic H. pylori infection.

Consensus conference on cancer registration of brain and central nervous system tumors

The passage of Public Law 107-260, the Benign Brain Tumor Cancer Registries Amendment Act, in October 2002 has made the collection of all primary brain tumors a reality. However, at the first Consensus Conference on Brain Tumor Definition for Registration in 2002, and during the development of training materials for benign brain tumor collection, several issues were identified that were tabled for future discussion. These and other issues were addressed at the subsequent 2003 Consensus Conference on Cancer Registration of Brain and Central Nervous System Tumors, at which the Central Brain Tumor Registry of the United States facilitated a discussion among epidemiologists, neurosurgeons, and neuropathologists. Multidisciplinary consensus was reached on four points, for which the following recommendations were made: (1) amend the histology coding scheme for cysts and tumor-like lesions that currently have a code in the third edition of the International Classification of Disease for Oncology (ICDO), (2) collect data on all instances of specific cysts and tumor-like lesions that are located in brain and other CNS sites but currently lack ICDO codes, (3) establish a new ICDO topography site for skull base tumors for the brain and CNS, and (4) collect data on genetic syndromes in patients diagnosed with brain or CNS tumors. We view this conference as part of a continuing process. Because classification of primary intracranial and other CNS tumors is dynamic, and the registration and coding of these tumors will need to be periodically reviewed.

A prospective trial comparing wireless capsule endoscopy and barium contrast series for small-bowel surveillance in hereditary GI polyposis syndromes

BACKGROUND

Capsule endoscopy has demonstrated its clinical utility in the evaluation of the small bowel, and, accordingly, it has been suggested that it could be useful for the identification of small-intestinal polyps in patients with polyposis syndromes. The objective was to establish the effectiveness of wireless capsule endoscopy for detecting small-bowel polyps in patients with hereditary GI polyposis syndromes in comparison with barium contrast series.

METHODS

Consecutive patients with GI polyposis syndromes were included. Small-bowel follow-through series and capsule endoscopy were performed within 1 week, in a blind fashion. The number and the location of polyps were analyzed.

RESULTS

Twenty-four patients with familial adenomatous polyposis (n = 20) or Peutz-Jeghers syndrome (n = 4) were included. Capsule endoscopy detected small-bowel polyps in 7 of 24 patients (29%), whereas a barium contrast study identified small-intestinal polyps in only 3 of these 7 patients. In the 4 remaining patients, all of them with familial adenomatous polyposis, polyps detected by the capsule but missed in radiographic series were located at either ileum (2 patients), jejunum (1), or duodenum (1). No procedure-related complication was observed in any patient.

CONCLUSIONS

Wireless capsule endoscopy is a highly accurate technique for the detection of small-bowel polyps in patients with hereditary GI polyposis syndromes, and it represents a valuable alternative to barium contrast series in the surveillance of patients with Peutz-Jeghers syndrome.

Multifocal micronodular pneumocyte hyperplasia in a man with tuberous sclerosis

We report a peculiar case of multifocal micronodular pneumocyte hyperplasia (MMPH) occurring in a 43-year-old man with tuberous sclerosis. Computed tomography of the chest demonstrated multiple micronodules, measuring up to 5 mm in size, present bilaterally in the lung fields, with no cystic change. Histologically, a proliferation of type II pneumocytes without the typical nulclear atypia lined the thickened alveolar septa in an adenomatoid pattern. Proliferation of immature smooth muscle cells suggestive of LAM was not observed. The characteristic findings of the positive immunohistochemical stains for cytokeratin and surfactant apoprotein A and B, and negative stains for HMB-45, alpha-1 smooth muscle actin, desmin, p53 and carcinoembryonic antigen confirmed the presence of alveolar lining cells in each MMPH lesion. Since the MMPH was observed in a male and did not appear to possess malignant potential, the MMPH appears to be a hamartomatous proliferation occurring in a male with tuberous sclerosis that is separate from lymphangiomyomatosis (LAM) which is related to estrogen and progesterone receptors.

Peutz-Jeghers syndrome in a 14-year-old boy: case report and review of the literature

Peutz-Jeghers syndrome (PSJ) is a relatively rare but well-recognized condition, with a prevalence of approximately one in 120,000 births in the USA. It is generally inherited as an autosomal dominant trait, although 35% of cases are new mutations. This disorder is characterized by melanocytic macules on the hands, feet, peri-oral skin and oral mucosa, and multiple gastrointestinal hamartomatous polyps. People with PSJ have an increased risk for developing a variety of malignant tumours. The aim of the present study was to report one case of PSJ in a 14-year-old boy with mucocutaneous pigmentation associated with duodenal hamartomatous polyps.

Von Hippel-Lindau disease--a rare disease important to recognize

INTRODUCTION

Von Hippel-Lindau disease (VHL) is an autosomal dominant multisystemic cancer syndrome due to a mutation of the VHL tumor suppressor gene on chromosome 3, region p25-26, with an incidence of 1/36,000 in newborns. Patients are at risk of developing cerebellar, spinal and retinal hemangioblastoma, renal cell carcinoma, pheochromocytoma, pancreatic neuroendocrine tumors, pancreatic and renal cysts, and epididymal cystadenoma. The most common causes of death from VHL are metastases from renal cell carcinoma and neurological complications from cerebellar hemangioblastomas. Molecular analysis of the VHL gene is clinically available and indicated in patients with known or suspected VHL.

CASE REPORT

A 19-year-old woman was surgically treated for cerebellar hemangioblastoma in 1998 and for renal cell carcinoma of the right side in 2002. Familial VHL was subsequently diagnosed as the patient's mother was found to be affected with bilateral polycystic kidney disease with chronic renal failure as well as hemangioblastoma of the retina and medulla oblongata. The mother underwent surgery for bilateral renal cell carcinoma in 2003.

CONCLUSION

The multitude of VHL-associated tumors and intra-familial variability in clinical expressivity render early diagnosis of VHL difficult. We therefore shortly illustrate the spectrum of clinical phenotypes and the VHL screening and surveillance guidelines.

Genetic cancer risk assessment and counseling: recommendations of the national society of genetic counselors

These cancer genetic counseling recommendations describe the medical, psychosocial, and ethical ramifications of identifying at-risk individuals through cancer risk assessment with or without genetic testing. They were developed by members of the Practice Issues Subcommittee of the National Society of Genetic Counselors Cancer Genetic Counseling Special Interest Group. The information contained in this document is derived from extensive review of the current literature on cancer genetic risk assessment and counseling as well as the personal expertise of genetic counselors specializing in cancer genetics. The recommendations are intended to provide information about the process of genetic counseling and risk assessment for hereditary cancer disorders rather than specific information about individual syndromes. Key components include the intake (medical and family histories), psychosocial assessment (assessment of risk perception), cancer risk assessment (determination and communication of risk), molecular testing for hereditary cancer syndromes (regulations, informed consent, and counseling process), and follow-up considerations. These recommendations should not be construed as dictating an exclusive course of management, nor does use of such recommendations guarantee a particular outcome. These recommendations do not displace a health care provider's professional judgment based on the clinical circumstances of a client.

Genetic alterations in hereditary breast cancer

Genetic linkage studies have led to the identification of highly penetrant genes as the possible cause of inherited cancer risk in many cancer-prone families. Most women with a family history of breast/ovarian cancer have tumors characterized by alterations in particular genes, mainly BRCA1 and BRCA2, but also CHK2, ATM, STK11 and others. This paper examines the BRCA1 and BRCA2 genes, focusing on the Italian pattern of mutations. The function of these two genes, classified as tumor suppressors, is linked with key metabolic mechanisms such as DNA damage repair, regulation of gene expression and cell cycle control. The pathological BRCA allelic variants may cause alteration of protein function, transcriptional activity and DNA repair; accumulation of the defects leads to widespread chromosome instability that may be directly responsible for cancer formation. In fact, mutations in BRCA1 and BRCA2, conferring a highly increased susceptibility to breast and ovarian cancer, do not lead to cancer by themselves. The current consensus is that these are 'caretaker' genes, which, when inactivated, allow other genetic defects to accumulate. The nature of these other molecular events may define the pathway through which BRCA1 and BRCA2 act. The BRCA mutation spectrum is complex, and the significance of most nucleotide alterations is difficult to understand. Moreover, the mutation pattern seems to be related to ethnicity. The Italian Consortium of Hereditary Breast and Ovarian Cancer has reviewed 1758 families; 23% have been found to be carriers of pathogenetic mutations in BRCA1 or BRCA2. Founder mutations have been described in geographically restricted areas of Italy; a regional founder effect has been demonstrated in Italy for the mutations BRCA1 5083del19 and BRCA2 8765delAG, and a probable new founder mutation has been characterized in Tuscany. The presence of founder mutations has practical implications for genetic testing.

The risk of developing second cancers among survivors of childhood soft tissue sarcoma

BACKGROUND

Previous studies have shown that children who are treated for soft tissue sarcoma (STS) are at increased risk for developing second cancers. However, the risk for specific cancer sites and variations in risk by treatment and STS histology remain unclear.

METHODS

The study evaluated 1499 children (age < 18 years) who survived for > or = 1 year after they were diagnosed with STS and who were reported to the Surveillance, Epidemiology, and End Results (SEER) population-based cancer registries from 1973 to 2000.

RESULTS

Twenty-seven children developed 28 subsequent primary malignancies, compared with 4.5 expected malignancies based on general population rates (observed-to-expected [O/E] ratio = 6.3 (95% confidence interval [95% CI], 4.2-9.1). The risk of developing a subsequent malignancy was increased among children with rhabdomyosarcoma (observed = 11 malignancies; O/E ratio = 7.7), fibromatous neoplasms (observed = 9 malignancies; O/E ratio = 5.8), and other specified STS (observed = 7 malignancies; O/E ratio = 6.5). Initial therapy with radiation and chemotherapeutic agents was associated with a significantly higher risk of second malignancies compared with surgery alone (O/E ratio = 15.2 vs. 1.4; P < 0.0001). Elevated risks were observed for acute myeloid leukemia, cutaneous melanoma, female breast cancer, and sarcomas of the bone and soft tissue, with generally higher risks among patients who initially received combined modality therapy. Excess cancers of the oral cavity were prominent among long-term survivors. For several children, the pattern of multiple malignancies was consistent with a genetic syndrome, particularly neurofibromatosis type 1 and Li-Fraumeni syndrome.

CONCLUSIONS

The risk of second malignancies was increased for all histologic types of childhood STS and was particularly high among patients who received combined modality therapy.

LKB1, the multitasking tumour suppressor kinase

Mutations in the lkb1 gene are found in Peutz-Jeghers syndrome (PJS), with loss of heterozygosity or somatic mutations at the lkb1 locus, suggesting the gene product, the serine/threonine kinase LKB1, may function as a tumour suppressor. Patients with PJS are at a greater risk of developing cancers of epithelial tissue origin. It is widely accepted that the presence of hamartomatous polyps in PJS does not in itself lead to the development of malignancy. The signalling mechanisms that lead to these PJS related malignancies are not well understood. However, it is evident from the recent literature that LKB1 is a multitasking kinase, with unlimited potential in orchestrating cell activity. Thus far, LKB1 has been found to play a role in chromatin remodelling, cell cycle arrest, Wnt signalling, cell polarity, and energy metabolism, all of which may require the tumour suppressor function of this kinase and/or its catalytic activity.

Hereditary cancer syndromes of the skin

Hereditary cancer syndromes are a group of disorders characterized by a genetic susceptibility to the development of malignant tumors. Multiple cancers in the family or an abnormally early onset for the given cancer may suggest an underlying inherited predisposition. Awareness of their associated dermatologic manifestations can facilitate early detection of risk for neoplasms. This article provides an update on the clinical features, diagnostic criteria, and the use of genetic analysis in the detection of causative mutations of those hereditary cancer syndromes with cutaneous manifestations.

Physician exposure to and attitudes toward advertisements for genetic tests for inherited cancer susceptibility

Commercial marketing materials may serve as a source of information for physicians about genetic testing for inherited cancer susceptibility (GTICS) in addition to medical guidelines, continuing education, and journal articles. The primary purposes of this study were to: (1) determine the percentage of physicians who received advertisements for GTICS early in the diffusion of commercial GTICS (1999-2000); (2) assess associated characteristics; and (3) measure the perceived importance of commercial advertisements and promotions in physicians' decisions to recommend testing to patients. A nationally representative, stratified random sample of 1,251 physicians from the American Medical Association (AMA) Physician Masterfile completed a 15-20 min mixed mode questionnaire that assessed specialty, previous use of genetic tests, practice characteristics, age, and receipt of advertising materials (response rate = 71%). Overall, 27.4% (n = 426) had received advertisements. In multivariate analysis, factors associated with receipt of advertisements included: specialties in obstetrics/gynecology, oncology, or gastroenterology; past GTICS use, and age 50+. One of four felt that advertisements would be important in their decision to recommend GTICS. Study results indicate that physicians, particularly in oncology, obstetrics/gynecology, and gastroenterology, began receiving GTICS advertisements commensurate with the early diffusion of commercially available tests into clinical practice. At that time, one-quarter of the physicians considered advertisements to play an important role in their clinical decision making, suggesting attention to other sources of information and additional factors.

Genetics and oncology nursing

OBJECTIVES

To review oncology nursing practice in the genetic era, how genetic information is used across the cancer care continuum, practice guidelines, and opportunities for genetic nursing education.

DATA SOURCES

Published articles.

CONCLUSION

Genetic information in oncology health care is used not only to predict risk but to elucidate disease biology, explain individual variation in vulnerability to environmental carcinogens, diagnose and characterize malignancies, design treatment regimens specific to a cancer's genetic fingerprint, develop new, therapeutic modalities, and clarify modulators of drug metabolism, efficacy, and interactions.

IMPLICATIONS FOR NURSING PRACTICE

With current and emerging genetic discoveries, all oncology nurses will use genetic information in their practice.

Complete germline deletion of the STK11 gene in a family with Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS, MIM175200) is an autosomal-dominant inherited disorder characterised by multiple gastrointestinal hamartomatous polyps, melanin spots of the oral mucosa and digits, and an increased risk for various neoplasms. The PJS results from germline alterations of the STK11/LKB1 tumour suppressor gene, located on 19p13.3, and encoding a serine/threonine kinase. The detection of STK11 germline mutations, in only 50-70% of PJS families, has suggested a genetic heterogeneity of the disease. We report the case of a family with typical features of PJS, including gastrointestinal hamartomatous, breast cancers and melanin spots of the oral mucosa. Quantitative multiplex PCR of short fluorescent fragments (QMPSF) of the 19p13 region allowed us to identify an approximately 250 kb heterozygous deletion removing entirely the STK11 locus. This report, which constitutes the first description of a complete germline deletion of STK11, shows that the presence of such large genomic deletions should be considered in PJS families without detectable point mutations of STK11.

E-Cadherin (CDH1) and p53 rather than SMAD4 and Caspase-10 germline mutations contribute to genetic predisposition in Portuguese gastric cancer patients

Approximately 30% of all hereditary diffuse gastric cancer (HDGC) families carry CDH1 germline mutations. The other two thirds remain genetically unexplained and are probably caused by alterations in other genes. Using polymerase chain reaction (PCR)/single-strand conformation polymorphism (SSCP)/sequencing, we screened 32 Portuguese families with a history of gastric cancer and 23 patients with early onset gastric cancer for CDH1 germline mutations. In probands negative for CDH1 mutations, we screened genes involved in hereditary cancer syndromes in which gastric cancer may be one of the component tumours, namely p53 (Li-Fraumeni Syndrome) and hMLH1 and hMSH2 (HNPCC). We also screened in these patients for mutations in Caspase-10, a gene inactivated in sporadic gastric cancer, and SMAD4, a gene whose inactivation in mice is associated with signet-ring cell carcinoma of the stomach. One of the families fulfilling the HDGC criteria harboured a CDH1 germline mutation, and one of the families with incomplete criteria harboured a p53 germline mutation. No mutations were identified in hMLH1 and hMSH2, and only sequence variants were found in SMAD4 and Caspase-10. The present work reports for the first time CDH1 germline mutations in Portuguese gastric cancer families, and highlights the need for p53 mutation screening in families lacking CDH1 germline mutations, in a country with one of the highest incidences of gastric cancer in the world. No evidence was found for a role of germline mutations in SMAD4 and Caspase-10 in families lacking CDH1 mutations.

Epidemiology and genetics of childhood cancer

Childhood cancer is rare everywhere in the world, with age-standardized annual incidence usually between 70 and 160 per million at age 0-14 years. Greater variation is seen between populations for some specific tumour types. Some of the largest variations are geographical and are attributable to environmental factors, whereas variation mainly on ethnic lines seems likely to be a marker of genetic predisposition. A wide range of familial and genetic syndromes is associated with an increased risk of childhood cancer. Virtually all the excess risk of cancer among first-degree relatives of children with cancer can be accounted for by known hereditary syndromes. Studies of weak predisposition and gene-environment interaction have so far shown limited consistency. There are very few established environmental or exogenous risk factors and most of these are infective agents. Many putative risk factors can hardly ever be investigated epidemiologically except by interview or questionnaire studies. Some recent examples illustrate the continuing problems of participation bias and recall bias.

Cancer genetics in primary care

The cloning of two major breast cancer susceptibility genes, BRCA1 and BRCA2, in 1994 and 1995 and the subsequent development of commercial genetic testing has brought hereditary cancer genetics into the public eye. In addition to DNA-based genetic testing, new strategies and treatments have been developed to provide accurate assessment of cancer risk and to reduce the chances of cancer developing in the future. This increasing scientific and public attention has prompted some cancer patients and their families to find out whether they "have the cancer gene" and has placed more responsibility on primary care clinicians to identify people who should be referred for specialized services of hereditary cancer genetics.

Common hereditary cancer syndromes

OBJECTIVES

To review cancer risk assessment and counseling, hereditary cancer syndrome risk factors, indicators for cancer predisposition testing, and interpretation of genetic test results.

DATA SOURCES

Research studies, review articles, and authors' experience.

CONCLUSION

Approximately 10% of those with a diagnosis of cancer may have a hereditary predisposition. In many cases genetic testing for susceptibility genes may be available. Knowledge of the results of genetic testing can be helpful when developing a plan for cancer prevention and early detection, and addressing concerns associated with genetic testing with the individual and family.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to know how to access genetic resources and to identify, evaluate, and care for patients and families at risk of or diagnosed with common hereditary cancer syndromes.

Genotype-phenotype correlations in Peutz-Jeghers syndrome

BACKGROUND AND AIMS

Peutz-Jeghers syndrome (PJS) is a dominantly inherited disorder often caused by mutations in STK11. Time to onset of symptoms was characterised for a large collection of individuals with PJS who had been tested for STK11 mutations and genotype-phenotype correlations were evaluated.

METHODS

We characterised mutations in 42 independent probands and also used a historical cohort design to study 51 individuals with Peutz-Jeghers syndrome who had completed self-administered questionnaires.

RESULTS

Mutations were detected in 22/32 (69%) probands with PJS and 0/10 probands referred to rule out PJS. Real-time PCR analysis to quantitate DNA failed to detect any large deletions in PJS participants without STK11 mutations. The median time to onset for gastrointestinal symptoms or polypectomy was 13 years of age but showed a wide variability. Gastric polyps were frequent in PJS participants, with a median age at onset of 16 years. Individuals with missense mutations had a significantly later time to onset of first polypectomy (p = 0.04) and of other symptoms compared with those participants either with truncating mutations or no detectable mutation.

CONCLUSION

STK11 mutation analysis should be restricted to individuals who meet PJS criteria or their close relatives. Direct sequencing of STK11 yields a high rate of point mutations in individuals who meet phenotypic PJS criteria. Individuals with missense mutations of STK11 typically had a later time to onset for PJS symptoms. The common occurrence of gastric polyps may facilitate chemopreventive studies for this disorder.

A case-based evaluation of SRD5A1, SRD5A2, AR, and ADRA1A as candidate genes for severity of BPH

In men with a clinical diagnosis of benign prostatic hyperplasia (BPH), polytomous logistic regression analysis was conducted to evaluate associations between two silent polymorphisms in SRD5A1 (codon positions 30 and 116), two polymorphisms in SRD5A2 (Val89Leu substitution and C to T transition in intron 1), a trinucleotide (CAG)n repeat in androgen receptor (AR), and an Arg492Cys substitution in ADRA1A and clinical parameters that characterize severity of BPH. Candidate gene selection was based on two mechanistic pathways targeted by pharmacotherapy for BPH: (1) androgen metabolic loci contributing to prostate growth (static obstruction); and (2) factors affecting smooth muscle tone (dynamic obstruction). Polymorphisms in SRD5A2 were not associated with severity of BPH; however, SRD5A1 polymorphisms were associated with severity of BPH. The process(es) in which these silent single-nucleotide polymorphisms (SNPs) influence BPH phenotypes is unknown and additional studies will be needed to assess whether these SNPs have direct functional consequences. The characterization of additional molecular factors that contribute to static and dynamic obstruction may help predict response to pharmacotherapy and serve to identify novel drug targets for the clinical management of BPH.

The role of the E-cadherin gene (CDH1) in diffuse gastric cancer susceptibility: from the laboratory to clinical practice

Loss of function of the E-cadherin gene (CDH1) has been linked with diffuse gastric cancer susceptibility, and germline inactivating mutations in CDH1 characterise the hereditary diffuse gastric cancer (HDGC) syndrome. Hypermethylation in the CDH1 promoter region is a frequent phenomenon in poorly differentiated, diffuse gastric carcinomas and it was identified as the main mechanism for the inactivation of the remaining wild-type allele in HDGC cases. Specific criteria are used to identify patients with suspected HDGC and who should be investigated for CDH1 germline mutations. Accurate screening is mandatory for unaffected carriers of CDH1 mutations and selected high-risk individuals could be considered for prophylactic gastrectomy. Also, germline CDH1 mutations may predispose to lobular breast carcinoma and prostate cancer. Germline CDH1 mutations are not always detectable in patients who meet the HDGC criteria and the aetiological role of this gene is still under investigation. Families without recognised inactivating CDH1 mutations may have undisclosed CDH1 mutations or mutations in its regulatory sequences or germline mutations in unidentified genes that also contribute to the disease. In recent years, several germline missense CDH1 mutations have been identified, some of which showed a marked negative influence on E-cadherin function in experimental models. CDH1 promoter hypermethylation seems a key event in the carcinogenetic process of poorly differentiated, diffuse gastric cancer and it deserves further investigation as a new target for anticancer therapies with demethylating agents.

Melanoma hereditário: prevalência de fatores de risco em um grupo de pacientes no Sul do Brasil

FUNDAMENTOS: Aproximadamente 10% dos casos de melanoma são atribuíveis a mutações em genes de predisposição, sendo, portanto, hereditários. OBJETIVOS: Este estudo avalia a prevalência de fatores de risco para melanoma hereditário em um grupo de pacientes com melanoma no sul do Brasil. CASUÍSTICA E MÉTODOS: Foram estudados 195 pacientes com diagnóstico de melanoma admitidos consecutivamente no Hospital de Clínicas de Porto Alegre entre janeiro de 1999 e junho de 2000. RESULTADOS: A idade média ao diagnóstico de melanoma foi de 48 anos em homens e 44,9 anos em mulheres. Dos 133 pacientes cuja história familiar encontrava-se registrada no prontuário, 13 (9,8%) apresentavam história familiar de melanoma. A presença de ao menos um fator de risco importante para predisposição hereditária ao melanoma foi constatada em 31 pacientes (16%; IC 95% 10,9% - 21,1%). CONCLUSÃO: A possibilidade de influência do fator hereditário no Brasil estimula a procura ativa de fatores de risco genético em pacientes com melanoma, já que a identificação de famílias de alto risco pode ter grande impacto sobre a morbimortalidade de seus integrantes.

Second primary malignancies in thyroid cancer patients

The late health effects associated with radioiodine (¹³¹I) given as treatment for thyroid cancer are difficult to assess since the number of thyroid cancer patients treated at each centre is limited. The risk of second primary malignancies (SPMs) was evaluated in a European cohort of thyroid cancer patients. A common database was obtained by pooling the 2-year survivors of the three major Swedish, Italian, and French cohorts of papillary and follicular thyroid cancer patients. A time-dependent analysis using external comparison was performed. The study concerned 6841 thyroid cancer patients, diagnosed during the period 1934–1995, at a mean age of 44 years. In all, 17% were treated with external radiotherapy and 62% received ¹³¹I. In total, 576 patients were diagnosed with a SPM. Compared to the general population of each of the three countries, an overall significantly increased risk of SPM of 27% (95% CI: 15–40) was seen in the European cohort. An increased risk of both solid tumours and leukaemias was found with increasing cumulative activity of ¹³¹I administered, with an excess absolute risk of 14.4 solid cancers and of 0.8 leukaemias per GBq of ¹³¹I and 10⁵ person-years of follow-up. A relationship was found between ¹³¹I administration and occurrence of bone and soft tissue, colorectal, and salivary gland cancers. These results strongly highlight the necessity to delineate the indications of ¹³¹I treatment in thyroid cancer patients in order to restrict its use to patients in whom clinical benefits are expected.

Cancer genetics in primary care

Primary care physicians are in a unique position to apply recent advances in cancer genetics to the improved care of their patients. Although the impact of our burgeoning knowledge in this area is significant and growing, it is often incompletely understood by the general practitioner. In this article we review the genetic basis of cancer and focus attention on inherited forms of cancer using breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2) as examples. Specific attributes of family and personal history are the most significant indicators of an increased risk of cancer in the individual patient. Genetic testing can be used to further assess risk and guide strategies for cancer screening, prevention, and treatment. However, the decision of whether to pursue genetic testing and the interpretation of results are complex. We review factors involved in these decisions as well as the implications, risks, and benefits of genetic testing for the individual and the family.

Preventive measures in Peutz-Jeghers syndrome

Peutz-Jeghers syndrome is a rare genetic disorder characterized by mucocutaneous melanin deposition, intestinal polyposis and an increased risk of cancer, both intestinal and extra-intestinal. We describe the current status of diagnosis and the methods by which the consequences of this condition can be minimized. A surveillance program for those diagnosed is also included.

The Role of Estrogens in BRCA1/2 Mutation Carriers

Persons undergoing genetic testing for an inherited predisposition to cancer often raise questions about recommendations for follow-up care. Missing from current guidelines is consideration of the role of estrogens for BRCA1/BRCA2 mutation carriers. Potential implications of hormones for risk of cancer and effectiveness of risk-reduction strategies need to be considered in the design of comprehensive guidelines for high-risk women. Patients who are mutation carriers may ask questions about the use of oral contraceptives, hormone replacement, and utility of current screening modalities. Controversy exists, even when considering these issues for the general population, but become more imperative when considering young, unaffected women who carry an inherited genetic mutation making decisions that may have long-term health consequences. Many patients have considered estrogen ablation via prophylactic surgeries as risk-reduction interventions. This article reviews data regarding these issues, makes recommendations based on available information, and offers future perspectives for those identified at high risk for cancer because of genetic predisposition. Although questions remain regarding the potential implications of hormones for risk of cancer and effectiveness of risk-reduction strategies, all information should be considered when educating and caring for such patients.

Ampullary adenoma: clinical manifestations, diagnosis, and treatment

Ampullary adenomas occur sporadically and in the setting of familial polyposis syndromes. In either case, and whether symptomatic at presentation or found asymptomatically in the setting of endoscopic screening programs, they are premalignant lesions with risk for malignant degeneration to carcinoma following the adenoma-to-carcinoma sequence that is well recognized in colonic adenocarcinoma. Accordingly, many experts advocate excision, although others cite the low rate of histologic progression suggested by some recent studies as justification for close endoscopic surveillance rather than excision before demonstration of dysplastic change. This recommendation, however, is complicated by considerable data underscoring the limited accuracy of endoscopic forceps biopsy in detecting occult foci of carcinoma within ampullary adenoma. Thus, the optimal management of these lesions continues to generate considerable controversy. Indications for excision of an ampullary adenoma include treatment of immediate symptoms as well as prevention of malignant degeneration. Although pancreaticoduodenectomy has long been considered the standard procedure for ampullary carcinoma, much controversy exists regarding the procedure of choice for ampullary adenoma. Radical surgery (pancreaticoduodenectomy) possesses the advantage of low recurrence rate but at the expense of higher morbidity (25%-65%) and mortality (0%-10%). Local surgical excision (surgical ampullectomy) possesses the advantages of lower morbidity (0%-25%), essentially nil mortality, and possibly decreased length of hospital stay, but decidedly higher recurrence rates (generally 5%-30%) and the need for postoperative endoscopic surveillance. Snare ampullectomy is a newer endoscopic excisional technique for which limited data are available; advantages compared with radical surgery mirror those of local surgical excision, with apparent lower mortality (0%-1%) and lower morbidity (12%). Presumed advantages compared with local surgical excision include lack of necessity for general anesthesia and laparotomy with comparable morbidity. Disadvantages seem to include limited availability of experienced operators, procedural complexity sometimes requiring adjunctive modalities such as fulguration, the need for multiple procedures (mean, 2.0 procedures) to effect complete excision, and recurrence rates approaching 30%, with a requirement for continued endoscopic surveillance. Ultimately, choice is driven by availability of local expertise, patient tolerance of or expected compliance with long-term endoscopic surveillance programs, presence or absence of coexisting familial polyposis syndromes, medical comorbidities, and overall life expectancy.