Gardner syndrome and periampullary malignancy

The Duodenal Accessory Ampulloma and the Role of Endoscopic Retrograde Cholangiopancreatography (ERCP) in Familial Adenomatous Polyposis Coli Inheritance

The adenomatous lesions, which could be benign or malignant, have been described in the duodenum and along the duodenal ampulla in individuals with familial adenomatous polyposis (FAP) post-colectomy, along with other extracolonic manifestations. To our best knowledge, we present a unique case of the involvement of the accessory duodenal ampulla in a patient who had undergone colectomy with ileorectal anastomosis with an established diagnosis of FAP. During the endoscopic examination, the patient was found to have adenomatous growth in the accessory duodenal ampulla, which was successfully removed via endoscopic retrograde cholangiopancreatography (ERCP). To prevent pancreatitis, a temporary plastic stent was inserted and successfully removed three weeks later.

A rare case of Gardner syndrome in an African adult male: A case report

Gardner's syndrome with the complete manifestation of colonic and extracolonic features is uncommon. Therefore, every clinician should view extracolonic features with a high index of suspicion. This may be key to early diagnosis, definitive management in these patients and importantly, helps prevent malignant transformation of existing colonic polyps.

Familial Adenomatous Polyposis Syndrome: An Update and Review of Extraintestinal Manifestations

CONTEXT.—

Familial adenomatous polyposis (FAP) is a rare genetic disorder with autosomal dominant inheritance, defined by numerous adenomatous polyps, which inevitably progress to colorectal carcinoma unless detected and managed early. Greater than 70% of patients with this syndrome also develop extraintestinal manifestations, such as multiple osteomas, dental abnormalities, and a variety of other lesions located throughout the body. These manifestations have historically been subcategorized as Gardner syndrome, Turcot syndrome, or gastric adenocarcinoma and proximal polyposis of the stomach. Recent studies, however, correlate the severity of gastrointestinal disease and the prominence of extraintestinal findings to specific mutations within the adenomatous polyposis coli gene (APC), supporting a spectrum of disease as opposed to subcategorization. Advances in immunohistochemical and molecular techniques shed new light on the origin, classification, and progression risk of different entities associated with FAP.

OBJECTIVE.—

To provide a comprehensive clinicopathologic review of neoplastic and nonneoplastic entities associated with FAP syndrome, with emphasis on recent developments in immunohistochemical and molecular profiles of extraintestinal manifestations in the thyroid, skin, soft tissue, bone, central nervous system, liver, and pancreas, and the subsequent changes in classification schemes and risk stratification.

DATA SOURCES.—

This review will be based on peer-reviewed literature and the authors' experiences.

CONCLUSIONS.—

In this review we will provide an update on the clinicopathologic manifestations, immunohistochemical profiles, molecular features, and prognosis of entities seen in FAP, with a focus on routine recognition and appropriate workup of extraintestinal manifestations.

Advances in diagnostic endoscopy for duodenal, including ampullary, adenoma

Currently, the strategy for real-time endoscopic diagnosis of duodenal, including ampullary, adenoma is still unclear. In the era of high-definition and magnification endoscopy, using this modality for the detection and diagnosis of these neoplasms is very challenging for endoscopists. Over the past 10 years, many instruments have been developed to improve the detection rate of duodenal and ampullary polyps and to distinguish between adenoma and non-adenoma. The present review will focus on these novel methods and their usefulness in the diagnosis of ampullary and non-ampullary adenoma.

Cost-effectiveness of prophylactic surgery for duodenal cancer in familial adenomatous polyposis

BACKGROUND

Duodenal cancer is the leading cause of cancer death in familial adenomatous polyposis after colorectal cancer. The lifetime risk for developing duodenal cancer is 4% to 10%. Current treatment guidelines recommend endoscopic surveillance with a prophylactic pancreaticoduodenectomy in advanced duodenal polyposis, defined using the Spigelman staging system. Because no clinical trials have assessed this recommendation, a modeling approach was used to evaluate the cost-effectiveness of various treatment strategies.

METHODS

A Markov model was constructed to estimate the life expectancy and cost of three different strategies: pancreaticoduodenectomy at Spigelman stage III, pancreaticoduodenectomy at Spigelman stage IV, and pancreaticoduodenectomy at cancer diagnosis. A cohort of 30-year-old familial adenomatous polyposis patients with total colectomies was simulated until age 80. The analysis was from a societal perspective. Extensive sensitivity analysis was performed to assess the impact of model uncertainty on results.

RESULTS

At all stages of polyposis and all ages <80 years, prophylactic surgery at Spigelman stage IV resulted in the greatest life expectancy. Surgery at stage IV was more effective and more expensive than surgery at cancer diagnosis, with an incremental cost of $3,200 per quality-adjusted life year gained. Surgery at stage III was not a viable option. The results were robust to wide variation in model parameters but were sensitive to the post-pancreaticoduodenectomy quality of life score.

CONCLUSIONS

Prophylactic pancreaticoduodenectomy at stage IV duodenal polyposis in familial adenomatous polyposis is a cost-effective approach that results in greater life expectancy than surgery at either stage III or cancer diagnosis.

Polipose gastroduodenal em doentes com polipose adenomatosa familiar Pós-Retocolectomia

RACIONAL: As manifestações extracólicas, como os pólipos gastroduodenais e o tumor do duodeno, são fatores que influenciam a morbimortalidade dos doentes com polipose adenomatosa familiar no seguimento pós-retocolectomia total. OBJETIVO: Investigar a freqüência destas alterações em doentes com polipose adenomatosa familiar e verificar a eficácia do rastreamento endoscópico. MÉTODO:No período de 1984 a 2005, 62 doentes com polipose adenomatosa familiar pós-retocolectomia foram estudados retrospectivamente pelo Grupo de Coloproctologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas, SP. O tempo de seguimento médio pós-operatório foi de 81,9 meses, sendo que em 53 (85,5%) foi possível analisar a ocorrência de pólipos gastroduodenais. RESULTADOS: Dos 53 doentes em seguimento, 27 (50,9%) apresentavam pólipos gastroduodenais. Em 8 (15,4%) os pólipos adenomatosos eram gástricos, 14 (27%) pólipos duodenais e 5 (9,6%) pólipos gástricos e duodenais. Dois doentes (3,8%) desenvolveram adenoma duodenal com displasia de alto grau. E outro (1,9%), adenocarcinoma em papila duodenal. CONCLUSÃO: O rastreamento endoscópico, desta forma, é de grande importância e o objetivo é detectar, o mais precocemente possível, os casos de adenocarcinoma duodenal e pólipos gastroduodenais com displasia de alto grau.

Surveillance and management of upper gastrointestinal disease in Familial Adenomatous Polyposis

Almost all patients affected by Familial Adenomatous polyposis (FAP) will develop foregut as well as hindgut polyps, and following prophylactic colectomy duodenal cancer constitutes one of the leading causes of death in screened populations. Without prophylactic colectomy, FAP patients predictably develop colorectal cancer, but the lifetime risk of upper gastrointestinal cancer is lower, estimated at approximately 5%. Management of the upper gastrointestinal cancer risk is one of the greatest challenges facing clinicians involved in the care of Polyposis families, and with improved survival following prophylactic colectomy, the burden of foregut disease (particularly duodenal adenomatosis) will increase. Until recently, the value of upper gastrointestinal surveillance in FAP populations has been contentious, but with improved understanding of the natural history coupled with developments in surgery, interventional endoscopy and medical therapy, treatment algorithms for duodenal adenomatosis in FAP are becoming clearer.

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.

Surveillance and treatment of periampullary and duodenal adenomas in familial adenomatous polyposis

Patients with familial adenomatous polyposis (FAP) have a cumulative lifetime risk of over 90% for developing duodenal adenomas, which are the precursor lesions for duodenal adenocarcinoma. Consequently, these patients have a 5% to 10% lifetime risk of periampullary or duodenal adenocarcinoma, making this the leading cause of cancer death in FAP patients who have had prophylactic colectomies. The increased relative risk of duodenal carcinoma in FAP patients and the poor outcomes associated with the treatment of advanced duodenal cancer have led to the development of prevention strategies for this cancer in the setting of FAP. It is generally accepted that surveillance for duodenal adenomas and adenocarcinomas should be included in the management of patients with FAP, although there are few data from clinical trials that demonstrate the effectiveness of surveillance strategies or chemoprevention for the prevention of death from duodenal cancer. Prospective case series have shown that endoscopic surveillance with endoscopic or surgical treatment of high-risk lesions in the duodenal or periampullary region can be performed with successful removal of the at-risk lesion(s). Surveillance should begin at about 21 years of age and should be performed using both an end-viewing and a side-viewing upper endoscope. An interval of 3 to 5 years between examinations appears to be adequate if no polyposis is evident. Once polyposis develops, an interval of 1 to 3 years between screenings for mild polyposis is appropriate. Patients with denser polyposis or larger adenomas are recommended to undergo examination every 6 to 12 months because of their increased risk of developing duodenal adenocarcinoma. Nonsteroidal anti-inflammatory drug therapy with sulindac, a nonselective cyclooxygenase (COX) inhibitor, or celecoxib, a COX-2 selective inhibitor, may be of benefit after the development of duodenal polyposis by inducing the regression or stabilization of the polyposis, although there is limited evidence from randomized, controlled trials to support its routine use. Almost all cases of adenocarcinoma occur in patients with advanced polyposis (Spigelman stage IV disease), and approximately 33% of this group will go on to develop adenocarcinoma if left untreated. The most definitive procedure for reducing the risk of adenocarcinoma is surgical resection of the ampulla and/or duodenum. Pancreaticoduodenectomy or pancreas-sparing duodenectomy are appropriate surgical therapies that are believed to substantially reduce the risk of developing periampullary adenocarcinoma. However, these procedures are associated with significant morbidity and mortality, including the risk of inducing desmoid tumor formation in FAP patients.

Worldwide survey among polyposis registries of surgical management of severe duodenal adenomatosis in familial adenomatous polyposis

BACKGROUND

The lifetime risk of developing duodenal cancer in familial adenomatous polyposis (FAP) is about 5 per cent. When and to what extent surgical intervention should be undertaken to prevent death from invasive carcinoma is controversial. The aim of this study was to determine the effectiveness of various surgical treatments for cancer and severe duodenal adenomatosis.

METHODS

A questionnaire was mailed to the members of the Leeds Castle Polyposis Group to obtain data on patients with FAP, treated for duodenal cancer or severe duodenal adenomatosis after 1990.

RESULTS

Sixty-nine patients were included. The indication for surgery was invasive cancer in 13 patients, of whom six died from metastatic disease. Fifty-six patients were initially treated for severe duodenal adenomatosis, five (9 per cent) of whom died from metastatic disease (P = 0.002). In surviving patients, adenomas recurred after ampullectomy (six of eight, at mean follow-up of 11 months), after duodenotomy with polypectomy (17 of 21, at mean 29 months) and after pancreatoduodenectomy (six of 25, at mean 47 months). None of six patients who underwent a pancreas-sparing duodenectomy had recurrence of adenoma (mean follow-up 11 months).

CONCLUSION

Surgery for duodenal adenomatosis should take place before endoscopic biopsy reveals invasive cancer. Even after extensive surgical procedures, small bowel adenomas may occur, emphasizing the need for chemoprevention.

Tumors of the ampulla of Vater

Ampullary tumors are relatively rare, but the occurrence of biliary obstruction early in the disease course facilitates diagnosis. With technologic advances, methods of diagnosis, treatment, and management of ampullary tumors are constantly evolving. However, despite rapid improvements in these areas, preoperative differentiation between adenomas and adenocarcinomas remains difficult. Forcep biopsy specimens can accurately detect the presence or absence of adenomatous changes, but they have a high false-negative rate for adenocarcinoma. Whereas it is generally agreed that all ampullary tumors should be removed or resected, patient selection for the various treatments, including pancreatoduodenectomy, local resection, and endoscopic treatment, remains controversial. Stage of disease, patient characteristics (ie, age and comorbid conditions), and local availability of expertise determine treatment options.

Synchronous primary carcinomas of the ampulla of Vater and ascending colon in a patient with multiple flat adenomas

Multiple primary cancers occurring in the same patients have been reported to represent 1.8-3.9% of all cancers. The majority of all patients reported to have had a combination of simultaneous neoplastic changes in the ampulla of Vater and the colon showed familial adenomatous polyposis (FAP) syndrome. Variants of familial adenomatous polyposis coli are: attenuated adenomatous polyposis coli (AAPC, previously also known as flat adenoma syndrome) and multiple adenoma coli. AAPC is characterized clinically by many, but usually fewer than 100, colonic lesions that are characteristically slightly elevated and plaque-like, with a reddish surface and sometimes central depression. Genetically it represents an extremely rare variant of FAP. Another group of individuals, so-called multiple adenoma patients, have a phenotype similar to AAPC, but most have no demonstrable germ-line adenomatous polyposis coli mutation, as do patients with FAP or AAPC. However, there have been only a few reports that discussed concurrent neoplastic changes in the ampulla of Vater and colon in patients with multiple colonic flat adenomas, but without the florid phenotype of classical FAP. We present rare clinical course of a patient with multiple (more than 60) flat adenomas in the proximal colon and two primary cancers: of the ampulla of Vater and of the ascending colon. This patient and his family history did not show polyposis compatible with FAP or hereditary nonpolyposis colorectal cancer (HNPCC) syndrome.

Genetic predisposition to clinical manifestations in familial adenomatous polyposis with special reference to duodenal lesions

OBJECTIVES

In familial adenomatous polyposis (FAP), genetic predisposition for duodenal adenomatosis has not been investigated precisely. The aim of this study was to investigate the correlation between adenomatous polyposis coli (APC) gene mutation and duodenal adenomatosis in FAP.

METHODS

APC gene mutation was determined by means of a protein truncation test in 34 patients from 25 families with FAP. The prevalence and grade of duodenal adenomatosis were compared among the proximal mutation group (exons 1-9), the distal mutation group (exons 10-15), and the undetermined groups. The correlation between the course of duodenal adenomatosis and APC gene mutation was retrospectively investigated in 19 patients.

RESULTS

The prevalence of duodenal adenomatosis was lower in the proximal mutation group (44%) than in the distal mutation (100%) and undetermined (83%) groups. In patients with positive duodenal adenomatosis, the endoscopic grade did not differ among the groups. The endoscopic grade increased in two of the four patients with the proximal mutation group (50%), in three of 10 patients with the distal mutation group (30%), and in two of five patients (40%) with the undetermined group.

CONCLUSIONS

Truncating APC gene mutation proximal to exon 9 may contribute to the less frequent development of duodenal adenomatosis in FAP, but severity and progression of duodenal adenomatosis do not seem to be determined by APC gene mutation alone.

Possible role of telomerase activation in the multistep tumor progression of periampullary lesions in patients with familial adenomatous polyposis

OBJECTIVES

The role of telomerase in periampullary tumor progression in patients with familial adenomatous polyposis (FAP) was investigated.

METHODS

Relative telomerase activity was measured using a telomerease amplification protocol in periampullary biopsy specimens of normal mucosa and adenoma obtained from patients with FAP, and was compared with that of periampullary normal mucosa and cancer specimens from patients without FAP.

RESULTS

None of normal mucosa from the non-FAP patients showed a telomerase ladder. Telomerase was positively detected in three of seven normal mucosa (42.9%) and in five of seven adenoma from FAP patients (62.5%). In papillary cancer from the non-FAP patients, seven of nine tissue specimens (77.8%) showed positive activity. When semiquantitatively analyzed, the relative telomerase activity increased in accordance with the progression of the diseases.

CONCLUSIONS

Telomerase is activated even in normal mucosa of FAP patients, and the intensities of telomerase may reflect the malignant potential of periampullary neoplasms.

Natural history of ampullary adenoma in familial adenomatous polyposis: reconfirmation of benign nature during extended surveillance

OBJECTIVE

Surgical or endoscopic papillectomy may be one of the therapeutic strategies for patients with familial adenomatous polyposis (FAP). To determine whether prophylactic papillectomy is necessary for FAP, we investigated the natural history of the ampullary adenoma in FAP.

METHODS

Eighteen subjects with FAP were surveyed by duodenoscopy with biopsy for >10 yr. Endoscopic appearance, histological findings, and immunohistochemical stainings for Ki-67 of ampulla were compared between initial and final endoscopic examinations.

RESULTS

The endoscopic grade in the ampulla remained unchanged in 16 subjects, whereas in two subjects an increase in the endoscopic grade was noted. In two subjects adenoma developed from an endoscopically and histologically normal ampulla. The histological grade of dysplasia increased in three of 12 subjects who initially had adenoma. The labeling index for Ki-67 was not different between initial and final examinations.

CONCLUSIONS

These data suggest that most ampullary adenoma of patients with FAP is static and that aggressive endoscopic or surgical removal is unnecessary for the adenoma.

Characteristics of small bowel carcinoma in hereditary nonpolyposis colorectal carcinoma. International Collaborative Group on HNPCC

BACKGROUND

Small bowel carcinoma is uncommon. However, hereditary nonpolyposis colorectal carcinoma (HNPCC) patients are at increased risk of small bowel carcinoma. The purpose of this study was to characterize small bowel tumors in HNPCC patients.

METHODS

A questionnaire was mailed to the members of International Collaborative Group on HNPCC (ICG-HNPCC) requesting clinicopathologic data in their registries on HNPCC patients with small bowel carcinoma. Survival was estimated utilizing the Kaplan-Meier method.

RESULTS

Forty-two individuals from 40 HNPCC families developed 42 primary and 7 metachronous small bowel tumors. There were 46 adenocarcinomas and 3 carcinoid tumors. The median age at diagnosis of the index small bowel tumor was 49 years. Mismatch repair gene mutations were present in 15 of 42 patients (36%). There were nine hMLH1 and six hMSH2 mutations. The small bowel was the first site of carcinoma in 24 patients (57%). The median survival for the 42 patients was 47 months (range, 0-447 months). The overall 5- and 10-year survival rates were 44% and 33%, respectively.

CONCLUSIONS

Small bowel tumors can be the presenting neoplasms in HNPCC patients. Similar to colorectal carcinoma in HNPCC, small bowel adenocarcinomas in HNPCC patients occur at an earlier age and appear to have a better prognosis than those occurring in the general population.

Upper gastrointestinal disease in patients with familial adenomatous polyposis

BACKGROUND

Upper gastrointestinal disease has become an important aspect in the management of patients with familial adenomatous polyposis (FAP).

METHODS

A review of the literature was carried out using Medline. Epidemiology, pathology and treatment options are considered.

RESULTS AND CONCLUSION

Despite the fact that over 90 per cent of patients with FAP develop duodenal adenomas, only 5 per cent go on to develop cancer. In the absence of methods to detect who is at risk of cancer, all patients undergo regular endoscopic surveillance at present. Chemoprevention in the form of drug therapy may be the answer to controlling the disease.

Adenoma of the common human bile duct in Gardner's syndrome may cause relapsing acute pancreatitis

Familial adenomatous polyposis of the colon, or Gardner's syndrome, is often accompanied by adenomas of the stomach and duodenum. We experienced a rare case of Gardner's syndrome, with adenomas of the common bile duct, in a patient who presented with relapsing acute pancreatitis. Our findings indicate that adenoma in the common bile duct or pancreatic duct should be considered as a possible etiology when patients with familial polyposis or Gardner's syndrome present with pancreatitis, particularly relapsing acute pancreatitis.

Ampullary carcinoma in familial adenomatous polyposis: report of a case

We report the case of a 48-year-old man with familial adenomatous polyposis (FAP) who was found to have ampullary carcinoma 6 years after undergoing total colectomy. The patient was examined periodically after colorectal surgery except for duodenoendoscopy because he had also previously undergone distal gastrectomy with gastrojejunal anastomosis for a duodenal ulcer at 27 years of age. An ampullary lesion was suspected on blood chemistry and detected by computed tomography scan and ultrasonography although the patient showed no clinical symptoms. A pancreatoduodenectomy was performed and the histological examination revealed well-differentiated adenocarcinoma with no metastasis to the regional lymphnodes. Long-term periodic surveillance of the upper gastrointestinal tract including the papilla of Vater is therefore important for FAP patients who have undergone prophylactic colectomy.

Adenoma-carcinoma sequence in the papilla of Vater

BACKGROUND

Our aims were to investigate the question as to whether the adenoma-carcinoma sequence also applies to the papilla of Vater and to determine the frequency with which a tumour of the papilla of Vater, diagnosed histologically as containing portions of an adenoma, already contains adenocarcinoma elsewhere.

METHODS

A retrospective analysis was carried out of the forceps, snare biopsy, and excised specimens obtained from the papilla of Vater in 559 patients, including 210 patients with the primary diagnosis of carcinoma and 110 patients with the diagnosis of 'portions of an adenoma'. Comparisons were made of the age distribution of patients with adenoma and those with carcinoma, and the frequency of residual adenoma in a carcinoma as a function of degree of malignancy, T stage, and UICC stage. A follow-up examination of the patients with the primary diagnosis 'parts of an adenoma of the papilla of Vater' was performed.

RESULTS

The average age of the patients with the final diagnosis adenoma was 65.2 years, and that of the carcinoma patients 73.0 years. Residual adenoma was found in 54.9% of the 51 surgical specimens and in 31.7% of the 159 biopsy specimens obtained from carcinomas. The frequency of residual adenoma in carcinomas decreased statistically significantly with increasing T stage and degree of malignancy. The follow-up examination of the 110 patients with the primary biopsy diagnosis parts of an adenoma of the papilla of Vater showed unequivocal results in 80 cases. Only in 39.7% of these cases was the primary diagnosis adenoma confirmed, whereas in 60.25%, further histologic examination showed a carcinoma.

CONCLUSIONS

An analysis of our results, together with those reported in the literature, indicates that the adenoma-carcinoma sequence also applies to the papilla of Vater and that, in a high percentage of patients with the histologic diagnosis 'parts of an adenoma, other regions of the tumour already contain a carcinoma.

Upper intestinal surveillance in familial adenomatous polyposis

Our understanding of the natural history of upper gastrointestinal (GI) involvement in familial adenomatous polyposis (FAP) is still evolving, although we know that the main cause of death after colectomy in FAP is upper GI malignancy, affecting 5% of patients. The aim of duodenal surveillance is to target high risk individuals and identify cancers early. We have screened 200 patients prospectively and have observed that duodenal polyposis progresses slowly, but there are some young people who have severe disease who merit close observation. We pay particular attention to endoscopic technique and histological detail, and use a duodenal staging system. Patients are offered randomisation to studies of chemopreventive agents, and those with advanced disease are considered for surgery. Successful management is inhibited by our deficient knowledge of the natural history of upper gastrointestinal polyposis, and by our inability to identify high risk individuals with histological markers rather than because of any technological deficiencies in endoscopic equipment.

Familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is an autosomal dominant condition resulting in the development of more than 100 adenomatous polyps in the large bowel. In addition, a number of extracolonic manifestations of the condition may occur. Recently, increasing knowledge relating to the extracolonic abnormalities, and localization and sequencing of the gene for FAP, have had important implications for screening and long-term follow-up of those affected. In this review the natural history of the disease and the extracolonic manifestations associated with it are considered. Surgical management and advances in understanding at a molecular level are discussed, as well as the problems relating to screening for FAP and the implications of the new knowledge.

Histologic follow-up of ampullary adenomas in patients with familial adenomatosis coli

BACKGROUND

The major duodenal papilla is a common site of extracolonic adenoma in patients with familial adenomatosis coli (FAC). However, there have been no reports which have systematically discussed histologic change in atypia of ampullary adenomas with time by their location in the papilla.

METHODS AND RESULTS

The major duodenal papillae of 23 patients with FAC were followed endoscopically and histologically for an average of 7.7 years (range, 1 year to 14 years 7 months). Tubular adenomas were detected histologically in 17 of the 23 patients at the first (14) or following examinations (3). They occurred in the orifice and/or ampulla in 11 patients and in the surface of the papilla in 8 patients. Three of the 11 orifice and/or ampulla adenomas contained moderate to severe atypia. There was no histologic change in atypia or malignant transformation during the follow-up period.

CONCLUSIONS

In the patients with FAC, the major duodenal papilla had adenoma, i.e., precancerous lesion, at a high incidence (74%), and it is reported that the ampulla of the papilla tended to have extracolonic carcinoma. Therefore, it is necessary to follow duodenal papillae of patients with FAC carefully and take biopsy specimens repeatedly from various sites, especially from the orifice or ampulla even if the papilla seems to be normal.

Gastroduodenal polyps in familial adenomatous polyposis

A retrospective review of the medical records of 30 patients with familial adenomatous polyposis who underwent oesophagogastroduodenoscopy was performed to evaluate the spectrum of gastroduodenal polyps. Twenty-five patients (83%) had gastroduodenal polyps. Eighteen patients (60%) had gastric polyps and 21 patients (70%) had duodenal polyps. Five patients (17%) had gastric and 20 patients (67%) had duodenal adenomatous polyps. Three patients (10%) died from an upper gastrointestinal tract adenocarcinoma. Three of nine patients with periampullary adenomas had a normal-appearing papilla of Vater. Since gastroduodenal polyps are common in familial adenomatous polyposis, oesophagogastroduodenoscopy should be performed at the time of diagnosis. Biopsy of polyps as well as biopsy of a normal-appearing papilla of Vater should be performed. Due to their malignant potential, if identified, gastroduodenal adenomatous polyps should be destroyed.

Population genetics of colonic cancer

BACKGROUND

There are several well known but rare syndromes of inherited colonic cancer. Genetic epidemiologic studies also have demonstrated that relatives of individuals with colonic cancer in general exhibit an excess risk for this malignancy.

METHODS

This report reviews the literature pertinent to genetic and familial risk for colonic cancer with emphasis on the recent work that suggests that inherited susceptibility to colonic neoplasms is common.

RESULTS

The adenomatous polyposis syndromes are rare inherited colonic cancer conditions caused by a mutant gene which recently has been characterized. Hereditary nonpolyposis colorectal cancer is likewise inherited and may account for up to 5% of cases. The molecular genetics of this disease remain to be clarified. The majority of colonic cancer cases are considered sporadic but are known to often cluster in families. Recent work suggests that inherited susceptibility may be the basis of this familial occurrence. Screening strategies based on inherited and familial risk are suggested.

CONCLUSIONS

Knowledge of the familial and inherited risk for colonic cancer is leading to a better understanding of this disease and is suggesting more directed preventive strategies.

Hereditary aspects of colorectal adenomas

BACKGROUND

Inheritance is important to the development of colonic adenomatous polyps and colon cancer. Current knowledge of inherited susceptibility to colonic neoplasms suggests that colon cancer screening strategies should consider familial and genetic risk.

METHODS

This report reviews the literature pertinent to adenomatous polyp and colon cancer inheritance and suggests polyp-cancer screening procedures based on inherited or familial risk.

RESULTS

Colorectal adenomas and cancer occur in several rare inherited syndromes and more commonly as sporadic cases. Intensive screening protocols have been suggested for the inherited syndromes because of the high associated cancer risk. Recent evidence suggests that inherited susceptibility also may be important in a large fraction of the so-called sporadic cases. Preliminary screening guidelines are suggested for this category based on the number of first-degree relatives affected with colon cancer.

CONCLUSIONS

Inherited susceptibility appears to be more important to the pathogenesis of colorectal adenomas and cancer than previously recognized. Screening strategies which consider inherited risk may increase the effectiveness of cancer detection and prevention.

Investigations on the significance of the adenoma-carcinoma sequence in the small bowel

In view of the rarity of small-bowel epithelial neoplasms as compared with the case for the large bowel, evidence for an adenoma-carcinoma sequence in the small bowel was studied based on a search for data in the medical literature for the years 1927 through 1986. Sufficiently defined data were found for comparison of 185 benign adenomas, 76 adenoma-with-carcinomas, and 1333 carcinomas in patients without familial polyposis disease and for 63, five, and 30, respectively, in patients with disease. For patients without polyposis, it was found that (1) 29.8% of all small-bowel adenomas (33.6% if those at Vater's ampulla are excluded) showed malignancy; (2) the mean and median ages were lower for benign adenoma than for adenoma-with-carcinoma and carcinoma, although the ratios by sex were the same; (3) there is a nearly identical spatial distribution of the three types of epithelial neoplasms within the small bowel; and (4) both the frequency of finding adenomatous residues existing in continuity with carcinoma and the life history of the adenoma-carcinoma sequence are similar in the small bowel as in the large. In comparing these results with those from patients with familial polyposis disease, it was particularly noted that (1) the only difference was that adenomas in familial polyposis occurred earlier and multiply, and (2) the spatial distributions of adenomas and carcinomas for both cases were closely similar. It is therefore postulated that the adenoma-carcinoma sequence is as significant in the small bowels as in the large. A hypothesis regarding the relationship of epithelial neoplasms in people with and without familial polyposis disease is suggested.

Familial adenomatous polyposis in association with thyroiditis. Report of two cases

The authors report two patients with familial adenomatous polyposis and thyroiditis. One patient was discovered at autopsy to have in addition, a follicular carcinoma of the thyroid and focal nodular hyperplasia of the liver. The other patient had a sister with familial adenomatous polyposis and a papillary carcinoma of the thyroid. The association between familial adenomatous polyposis and thyroiditis has not been previously reported.

Mesenteric desmoid tumours in Gardner's syndrome--review of medical treatments

Gardner's syndrome comprises a triad of polyposis coli, osteomata and soft tissue tumours including desmoid tumours which can often present difficult problems in management. We report a patient with Gardner's syndrome treated with tamoxifen and medroxyprogesterone acetate. The literature on this rare syndrome and its management is reviewed.

Familial colorectal cancer and familial adenomatous polyposis

Familial adenomatous polyposis (FAP) affects around 1 in 10,000 individuals; the gene for this condition was recently shown to be located on chromosome 5, and it is only a matter of time before its precise location and function are determined, making prephenotypic, and even prenatal, diagnosis more generally available and reliable. In the mean time, care of FAP families will continue to depend on careful registration of family information, prophylactic bowel surgery and surveillance for other potentially serious manifestations of the disease. Upper gastrointestinal malignancies and desmoid tumours have overtaken colorectal cancer as the leading causes of death in some centres. Other dominantly-inherited colorectal cancer syndromes produce less striking phenotypes, but affect far more individuals than FAP. It appears that there are two patterns of hereditary non-polyposis colorectal cancer (HNPCC) syndromes, one involving cases of bowel cancer alone, the other associated with breast and gynaecological cancers; these may prove to be variable expressions of a common gene abnormality. More effort is required by clinicians managing cases of colorectal cancer to identify affected families in order to offer surveillance and appropriate treatment in the hope that such measures may prevent cancer in family members.

Natural history of duodenal lesions in Japanese patients with familial adenomatosis coli (Gardner's syndrome)

The natural history of duodenal lesions was studied in 20 patients with familial adenomatosis coli/Gardner's syndrome. These patients were followed for an average of 7.1 yr (range 1 yr, 7 mo to 12 yr, 2 mo) and repeatedly examined by hypotonic duodenography, duodenofiberscopy, and biopsy. Tubular adenomas of the duodenum (less than 8 mm in diameter) were present in 18 (90%). During the follow-up period, there was a slight increase or decrease in the number of duodenal adenomas in 4 patients but no distinct change in 13. In the remaining patient (aged 49 yr), a polypoid lesion (17 mm in diameter) of the duodenal bulb, which had been overlooked at the initial examination, became an advanced cancer (50 x 30 mm in size) during 22 mo. Tubular adenomatous tissue of the duodenal papilla was detected in 11 patients (55%). Follow-up study of the lesions revealed no change in endoscopic and histologic findings in all but 1 patient, in whom there was a slight enlargement of the duodenal papilla, as seen at endoscopy. These findings suggest to us that in patients with this disease, duodenal adenomas do not require prophylactic surgery. However, careful repeated follow-up examinations with endoscopic biopsy should be performed, with endoscopic removal of larger polyps when possible.

High prevalence of adenomatous polyps of the duodenal papilla in familial adenomatous polyposis

Eighteen consecutive asymptomatic patients with familial adenomatous polyposis (both familial polyposis coli and Gardener's syndrome) were studied over a 12-month period; side-viewing upper endoscopy and biopsy were used to assess the frequency of adenomatous polyps of the duodenal papilla. Nine of the 18 patients demonstrated adenomatous polyps of the papilla, varying in size and appearance from microadenomas in normal-appearing duodenal papillae (two) to a sessile polyp 3 cm in diameter. Two were tubulovillous adenomas (0.5 cm and 2 cm in diameter) and the remainder were tubular adenomas. Severe atypia and malignancy were not encountered. These findings reveal that adenomas of the duodenal papilla are common in individuals with familial adenomatous polyposis. Because of these findings and because of the known risk of periampullary adenocarcinomas and nonmalignant complications of polyps of the duodenal papilla in patients with familial adenomatous polyposis, upper gastrointestinal screening of such patients should include examination of the duodenal papilla with a side-viewing endoscope.

Villous adenomas and carcinoma of the duodenum in Gardner's syndrome

Patients with Gardner's syndrome are increasingly found to have polyps on routine upper gastrointestinal endoscopy, and their risk of developing periampullary carcinoma is between 3-12%. We report a 45 year old man with Gardner's syndrome who presented with periampullary carcinoma 5 years after colectomy. Review of the literature amassed another 21 cases of periampullary carcinoma in patients with Gardner's syndrome.

The protean manifestations of familial polyposis coli

Although familial polyposis coli (FPC) is often thought to be a discrete disease with uniform clinical presentation and few therapeutic options, review of 16 families encountered in the last five years has shown that marked variation in the clinical manifestations of the syndrome is the rule rather than the exception. Thirty one percent of propositi had negative family histories, 67 percent of observed cancers were in the rectum, three individuals from three families developed cancer under the age of 20. In another family the only cancer was in a 67-year-old patient. Polyp growth rate varied tremendously among individuals and over time within individuals, rectal polyps did not regress after subtotal colectomy, and three patients developed rectal cancer after subtotal colectomy (18 percent). Fifty percent of propositi had cancer on presentation, while only 18 percent of screened family members had cancer. The only extracolonic tumors seen were gastroduodenal polyps and retroperitoneal desmoids in three families. The mode of inheritance of FPC causes this variation and treatment is best tailored to the individual and his family rather than uniformly applied to all patients with FPC.

Upper gastrointestinal neoplasia in familial polyposis

Upper gastrointestinal (UGI) endoscopy was performed in 41 asymptomatic American patients with familial polyposis to assess the prevalence of gastric and duodenal polyps and to characterize their pathological features. Eighteen patients (44%) had UGI endoscopic abnormalities. Six patients had both gastric and duodenal lesions. Eight patients had only gastric polyps, and four had duodenal polyps only. The presence of other extracolonic expressions of polyposis had a suggestive but statistically insignificant correlation with UGI polyps. Patients with familial polyposis and duodenal adenomatous polyps are at high risk for the development of periampullary cancer; screening and identification of these individuals is recommended.

Prevalence and importance of pigmented ocular fundus lesions in Gardner's syndrome

We examined 134 members of 16 families with Gardner's syndrome for pigmented ocular fundus lesions. Of 41 patients with documented Gardner's syndrome, 37 (90.2 percent) had such lesions. The lesions were bilateral in 32 of the patients (78.1 percent) and in 2 of 42 controls (4.8 percent). Twenty (46.5 percent) of 43 first-degree relatives at 50 percent risk for Gardner's syndrome had bilateral pigmented fundus lesions, indicating that they had probably inherited the abnormal gene. The presence of bilateral lesions, multiple lesions (more than four), or both appeared to be a specific (specificity, 0.952) and sensitive (sensitivity, 0.780) clinical marker for Gardner's syndrome. The lesions are probably congenital; they were observed in a three-month-old baby at risk. The multiplicity of the pigmented fundus lesions and their association with diffuse disturbances of the retinal pigment epithelium in the same eye suggest a widespread expression of the abnormal gene in the retinal pigment epithelial cells.

Villous adenoma of the duodenal papilla presenting as necrotizing pancreatitis in a patient with Gardner's syndrome

The majority of patients with Gardner's syndrome and familial polyposis coli develop duodenal adenomatous polyps. Duodenal cancer sometimes arises in this setting, but nonmalignant problems from duodenal polyps have not been described. This report presents a patient with Gardner's syndrome who developed hemorrhagic pancreatitis and was found to have a villous adenoma encasing the pancreatic duct at the duodenal papilla. The case is important because it suggests that patients with polyposis coli may be at risk for significant nonmalignant problems from duodenal polyps, particularly if polyps exhibit villous histology and occur at the duodenal papilla.

Unfamiliar aspects of familial polyposis coli

Patients with familial polyposis coli or Gardner's syndrome are at risk for a variety of extracolonic manifestations. In a series of patients followed at the University of Washington, we have found several recurring and unusual manifestations, including upper gastrointestinal polyposis, small bowel obstruction secondary to desmoid tumors or adhesions, recurring pancreatitis, and adenoma of the papilla of Vater. In one family with familial polyposis only, a set of twins had different manifestations; one twin had familial polyposis only, whereas the second had classic extracolonic manifestations of Gardner's syndrome. Multiple rectal adenomas developed in a woman with an ileorectal anastomosis with each of three pregnancies. Spontaneous regression occurred after each delivery. Multiple rectal adenomas developed in her daughter on two occasions while taking birth control pills. Physicians caring for these patients should look for such manifestations.

Intestinal polyposis and periampullary carcinoma--changing concepts

Adenomatous polyps lead directly to carcinoma of the colon in patients with one of the familial syndromes of intestinal polyposis. Elective colectomy is prophylactic and life-saving. A subgroup of patients will develop periampullary carcinoma, again arising from the presence of adenomatous polyps. Such a case is presented. These polyps should be surgically excised to ensure adequate pathologic examination. Yearly upper endoscopic examination is an essential element of management. Either the presence of carcinoma in situ or the recurrence of these polyps following excision is confirmation of behavior with a high propensity for the development of invasive cancer and requires aggressive treatment.

Evaluation of chromosomal diagnosis for hereditary adenomatosis of the colorectum

Hereditary adenomatosis, particularly familial polyposis coli (FPC) and Gardner's syndrome (GS), has been investigated from family pedigrees and chromosomal markers for precancer and cancer. FPC and GS are much alike in phenotypes. Studies are in progress to determine if the two adenomatous diseases are controlled by the same DNA sequence. Chromosome numerical and structural instability is a good diagnostic criterion for hereditary adenomatous diseases where risk factors are already determined to the level of 0.5 probability from pedigree analysis. This has been applied successfully at the pediatric age level to identify family members who carry the gene but have no adenomas in the colorectum. Sister chromatid exchange (SCE) did not distinguish plasma samples from FPC, GS, or solitary adenoma patients form each other or from controls with no adenomas. SCE did distinguish invasive from recurrent and noninvasive cancer. The chromosome #2 polymorphism observed at 2q-21.3 has not been confirmed as a deletion, but is under investigation with more refined methods.

The Gardner syndrome. Significance of ocular features

Gardner syndrome is a dominantly inherited familial cancer syndrome characterized by intestinal polyposis, bony hamartomata, and various soft tissue tumors. The risk of malignancy during adult life is essentially 100%, but as yet no phenotypic marker nor biochemical or serological linkage have been useful to identify the presence of the gene in early life. We studied three families in which multiple and bilateral patches of congenital hypertrophy of the retinal pigment epithelium are related uniquely to other phenotypic features of the Gardner gene. This readily identifiable characteristic may be useful to identify early in life individuals at risk for malignancy. We also suggest that the Gardner syndrome may be genetically heterogeneous.