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ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes. Am J Gastroenterol 2015; 110:223-62; quiz 263. [PMID: 25645574 PMCID: PMC4695986 DOI: 10.1038/ajg.2014.435] [Citation(s) in RCA: 980] [Impact Index Per Article: 108.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023]
Abstract
This guideline presents recommendations for the management of patients with hereditary gastrointestinal cancer syndromes. The initial assessment is the collection of a family history of cancers and premalignant gastrointestinal conditions and should provide enough information to develop a preliminary determination of the risk of a familial predisposition to cancer. Age at diagnosis and lineage (maternal and/or paternal) should be documented for all diagnoses, especially in first- and second-degree relatives. When indicated, genetic testing for a germline mutation should be done on the most informative candidate(s) identified through the family history evaluation and/or tumor analysis to confirm a diagnosis and allow for predictive testing of at-risk relatives. Genetic testing should be conducted in the context of pre- and post-test genetic counseling to ensure the patient's informed decision making. Patients who meet clinical criteria for a syndrome as well as those with identified pathogenic germline mutations should receive appropriate surveillance measures in order to minimize their overall risk of developing syndrome-specific cancers. This guideline specifically discusses genetic testing and management of Lynch syndrome, familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (AFAP), MUTYH-associated polyposis (MAP), Peutz-Jeghers syndrome, juvenile polyposis syndrome, Cowden syndrome, serrated (hyperplastic) polyposis syndrome, hereditary pancreatic cancer, and hereditary gastric cancer.
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Abstract
Duodenal and ampullary carcinoma in familial adenomatosis (FAP) is the third leading cause of FAP related deaths. Management of this condition is a challenging. The aim of this study was to evaluate the role of multiple targeted endoscopic biopsies and macroscopic appearance as the major determinants for surgical intervention. A secondary aim was to assess histological heterogeneity through comparing endoscopic biopsies and describe the clinical outcomes of our cohort after intervention. We reviewed our FAP surveillance database of 67 patients, between January 1999--June 2011 undergoing upper GI surveillance and where indicated, subsequent surgical intervention. Among 67 patients, 11 underwent surgical resection. Pancreas-preserving duodenectomy was performed in four patients (five procedures), and Whipple's operation in seven patients. The average size of polyps was 43 mm (range 17-65 mm), and the average number of targeted endoscopic biopsies per lesion was 7.5 (range 5-10). Two cases of high-grade (severe) dysplasia were diagnosed on endoscopic biopsies each understaged compared with the subsequent surgical specimen. All carcinomas identified have been resectable with no evidence of local spread or distant metastasis. There was one postoperative death, but no cancer related deaths. We identified both cancers at an early stage and there were no missed or late diagnoses. There have been no recurrences of carcinoma in a more than 7 years follow-up. Due to the heterogeneous nature of these lesions, comprehensive macroscopic assessment should be complemented with multiple targeted biopsies to improve the chance of early detection of advanced lesions.
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Affiliation(s)
- Y Wallis
- DNA Laboratory, Regional Genetic Services, Birmingham Heartlands Hospital, Birmingham
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Jang YH, Lim SB, Kim MJ, Chung HJ, Yoo HW, Byeon JS, Myung SJ, Lee W, Chun S, Min WK. Three novel mutations of the APC gene in Korean patients with familial adenomatous polyposis. ACTA ACUST UNITED AC 2010; 200:34-9. [PMID: 20513532 DOI: 10.1016/j.cancergencyto.2010.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 03/18/2010] [Accepted: 03/22/2010] [Indexed: 12/20/2022]
Abstract
Germline mutations within the adenomatous polyposis coli (APC) gene are associated with familial adenomatous polyposis (FAP), an autosomal dominant disease predisposing individuals to colorectal cancer. Identification of APC mutations has important implications for genetic counseling and management of FAP patients. We examined the APC mutation status of 10 Korean FAP patients by polymerase chain reaction-direct sequencing method and found six APC mutations, including three novel mutations. Testing for MUTYH mutation was done for FAP patients in whom no mutation in the APC gene was identified. Three novel mutations (c.1654_1663delTCTTGGCGAG, c.3709C>T, and c.6092_6094delinsTT) and three previously reported mutations (c.3631_3632delAT, c.4438C>T, and c.4612_4613delGA) were detected. The MUTYH mutation was not detected in any of the four FAP patients without an APC mutation. This finding of three novel mutations in a group of Korean FAP patients broadens the spectrum of APC mutations.
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Affiliation(s)
- Yun Ha Jang
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Songpa-gu, Seoul, Korea
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Nagorni A, Bjelaković G, Katić V, Veselinović D. [Intestinal and extraintestinal manifestations in familial adenomatous polyposis]. VOJNOSANIT PREGL 2007; 64:475-9. [PMID: 17821923 DOI: 10.2298/vsp0707475n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
<zakljucak> U radu su opisane intestinalne i ekstraintestinalne manifestacije familijarne adenomatozne polipoze koje mogu imati dijagnosticki i prognosticki znacaj. Pojava tumora izvan kolona znacajna je za razvoj ozbiljnih simptoma bolesti (opstrukcija, krvarenje), ali i za malignu alteraciju i razvoj karcinoma, posebno u duodenumu (karcinom duodenuma i dezmoidni tumori su najcesci uzrok smrti kod bolesnika sa familijarnom adenomatoznom polipozom nakon kolekotmije). Poseban znacaj imaju dezmoidni tumori, koji su benigni po svojoj prirodi, ali koji lokalnom invazijom mogu dovesti do smrtnog ishoda, a najcesce ispoljavaju tendenciju rasta nakon hirurske resekcije creva. Kongenitalna hipertrofija pigmentnog epitela retine je prediktivni marker koji omogucava postavljanje dijagnoze familijarne adenomatozne polipoze i pre otkrivanja adenoma debelog creva.
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Ferrández A, Pho L, Solomon C, Samowitz WS, Kuwada SK, Knecht TP, Gilfeather M, Burt RW. An evidence-based, multidisciplinary approach to the clinical considerations, management, and surveillance of adrenal lesions in familial adenomatous polyposis: report of three cases. Dis Colon Rectum 2006; 49:1781-90. [PMID: 17041748 DOI: 10.1007/s10350-006-0716-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Adrenal masses are commonly discovered incidentally in patients with familial adenomatous polyposis, and adrenal malignancies have been rarely reported. Individuals with familial adenomatous polyposis frequently undergo abdominal CT-scan examinations for surveillance or symptoms. Adrenal lesions often are detected unexpectedly and are thus becoming a common clinical problem in this population. Adrenal lesions encompass a heterogeneous spectrum of pathologic entities, including primary adrenocortical and medullary tumors, benign or malignant lesions, hormonally active or inactive lesions, metastases, and infections. When an adrenal mass is detected, the clinician needs to address two crucial questions: 1) is the mass malignant? and 2) is it hormonally active? This article presents three new cases of incidental adrenal lesions in familial adenomatous polyposis, reviews the medical literature for this setting, and provides an overview of the diagnostic clinical approach and management of the adrenal findings in familial adenomatous polyposis patients.
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Affiliation(s)
- Angel Ferrández
- Department of Outreach and Prevention, Huntsman Cancer Institute, Salt Lake City, Utah, USA
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Gallagher MC, Phillips RKS, Bulow S. Surveillance and management of upper gastrointestinal disease in Familial Adenomatous Polyposis. Fam Cancer 2006; 5:263-73. [PMID: 16998672 DOI: 10.1007/s10689-005-5668-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Michelle C Gallagher
- The Polyposis Registry, Cancer Research UK Colorectal Cancer Unit, St Mark's Hospital, Northwick Park, Watford Road, HA1 3UJ, Harrow, UK
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Gusakova I, Mermershtain W, Cohen Y, Ariad S. Small bowel adenocarcinoma in crohn disease patient complicated by microangiopathic hemolytic anemia. Am J Clin Oncol 2004; 26:483-5. [PMID: 14528075 DOI: 10.1097/01.coc.0000037111.19239.fe] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Irena Gusakova
- Department of Oncology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Green PH, Jabri B. Celiac disease and other precursors to small-bowel malignancy. Hematol Oncol Clin North Am 2003. [DOI: 10.1016/s0889-8588(03)00008-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Small-intestinal malignancies are rare. Major risk factors for the development of these malignancies include celiac disease, which predisposes to both carcinoma and lymphoma. Crohn's disease patients have an increased risk of the development of adenocarcinoma, as do the inherited polyposis syndromes, FAP, and Peutz-Jehgers syndrome. Each of these conditions provides unique models for the development of malignancy.
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Affiliation(s)
- Peter H R Green
- Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave., New York, NY 10032, USA.
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Abstract
Small intestinal neoplasms are uncommonly encountered in clinical practice. They may occur sporadically, in association with genetic diseases (e.g., familial adenomatous polyposis coli or Peutz-Jeghers syndrome), or in association with chronic intestinal inflammatory disorders (e.g., Crohn's disease or celiac sprue). Benign small intestinal tumors (e.g., leiomyoma, lipoma, hamartoma, or desmoid tumor) usually are asymptomatic but may present with intussusception. Primary malignancies of the small intestine-including adenocarcinoma, leiomyosarcoma, carcinoid, and lymphoma-may present with intestinal obstruction, jaundice, bleeding, or pain. Extraintestinal neoplasms may involve the intestine via contiguous spread or peritoneal metastasis. Hematogenous metastases to the intestine from an extraintestinal primary are unusual and are most typical of melanoma. Because the small intestine is relatively inaccessible to routine endoscopy, diagnosis of small intestinal neoplasms is often delayed for months after onset of symptoms. When the diagnosis is suspected, enteroclysis is the most useful imaging study. Small bowel endoscopy (enteroscopy) is increasingly widely available and may permit earlier, nonoperative diagnosis.
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Affiliation(s)
- S S Gill
- Division of Gastroenterology, Medical College of Virginia, Commonwealth Virginia University, Richmond, Virginia, USA
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Abstract
Prophylactic colectomy is generally recommended for patients with familial adenomatous polyposis (FAP) who are inevitably affected with large bowel cancer. After prophylactic colectomy has been performed, gastrointestinal malignancy is the leading cause of death. Duodenal adenomas are found in patients with FAP and the adenoma-carcinoma sequence exists in the FAP duodenum, suggesting that treatment of duodenal polyps might be beneficial. Several methods of treatment for duodenal lesions in patients with FAP have been reported, but the current treatment options are not ideal. The nonsteroid anti-inflammatory drugs, sulindac and aspirin, are used for chemoprevention, while recently developed cyclooxygenase-2 inhibitors may be of some use in the future. Endoscopic polypectomy has been attempted for duodenal polyps and open surgical polypectomy has proven to be effective for selected patients. Photodynamic therapy and Argon plasma coagulation may be suitable to treat carpeted polyposis. New methods of duodenal resection, such as pancreas-preserving duodenectomy and pylorus-preserving pancreaticoduodenectomy, might be considered for severe duodenal polyposis; however, because prophylactic duodenal surgery has been considered too aggressive, surveillance duodenoscopy is usually performed to detect duodenal cancer at an early stage.
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Affiliation(s)
- H Kashiwagi
- Department of Surgery, Jichi Medical School, Minami-kawachi, Tochigi, Japan
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Sakorafas GH, Friess H, Dervenis CG. Villous tumors of the duodenum: biologic characters and clinical implications. Scand J Gastroenterol 2000; 35:337-44. [PMID: 10831254 DOI: 10.1080/003655200750023877] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- G H Sakorafas
- Dept. of Surgery, Hellenic Air Force Hospital, Athens, Greece
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Alarcon FJ, Burke CA, Church JM, van Stolk RU. Familial adenomatous polyposis: efficacy of endoscopic and surgical treatment for advanced duodenal adenomas. Dis Colon Rectum 1999; 42:1533-6. [PMID: 10613470 DOI: 10.1007/bf02236201] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Duodenal and periampullary cancer is the most common cause of cancer death in patients with familial adenomatous polyposis who have undergone colectomy. Endoscopic surveillance of upper gastrointestinal adenomas is recommended for patients with familial adenomatous polyposis but the timing and appropriate treatment of neoplasms is unknown. The purpose of this experiment was to report our experience with endoscopic and surgical treatment of advanced duodenal adenomas in patients with familial adenomatous polyposis. METHODS The records of all patients with familial adenomatous polyposis who had undergone surgical or endoscopic treatment for duodenal adenomas were identified. Data including endoscopic surveillance findings, type of intervention, pathology, and follow-up of the lesions were reviewed. RESULTS Ten neoplasms >1 cm were treated in eight patients (mean age at the time of diagnosis was 49 years). Nine lesions were histologically advanced. Five lesions involved the papilla. Endoscopic treatment was performed for six lesions. Four lesions recurred, and three were then treated surgically. Local resection was performed for five lesions. Four lesions recurred and two had further operative intervention. Pancreas-sparing duodenectomy was performed in three patients. At a mean follow-up period of 45.7 months, there has been no recurrence. CONCLUSIONS Endoscopic eradication is an appropriate initial treatment for histologically advanced, noncancerous neoplasms or for patients who are not surgical candidates. Pancreas-sparing duodenectomy may be the treatment of choice for patients with carcinoma and those who have failed endoscopic therapy.
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Affiliation(s)
- F J Alarcon
- Department of Internal Medicine, The Cleveland Clinic Foundation, Ohio, USA
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Hofgärtner WT, Thorp M, Ramus MW, Delorefice G, Chey WY, Ryan CK, Takahashi GW, Lobitz JR. Gastric adenocarcinoma associated with fundic gland polyps in a patient with attenuated familial adenomatous polyposis. Am J Gastroenterol 1999; 94:2275-81. [PMID: 10445562 DOI: 10.1111/j.1572-0241.1999.01312.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Familial adenomatous polyposis (FAP) is a rare autosomal dominant precancerous condition of the colon caused by mutations in the adenomatous polyposis coli (APC) tumor suppressor gene. FAP is characterized by the appearance of innumerable adenomatous polyps throughout the large bowel. Fundic gland polyps are the most common gastric lesion in FAP. It is generally believed that fundic gland polyps have little or no potential for malignant transformation in the population at large, and only a few case reports describe the development of high grade dysplasia or gastric adenocarcinoma associated with diffuse fundic gland polyposis in patients with FAP. We report the second case of gastric adenocarcinoma intimately associated with fundic gland polyposis in a family with an attenuated form of FAP. The patient had undergone routine screening per current guidelines because of his known mutation in the APC gene. This suggests that malignant transformation of fundic gland polyps in patients with FAP occur more frequently than previously believed. Current screening recommendations may not be sufficient for patients with FAP or its attenuated forms.
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Affiliation(s)
- W T Hofgärtner
- Department of Medicine, Providence St. Vincent Medical Center, Portland, Oregon, USA
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Affiliation(s)
- J G Guillem
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Abstract
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.
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Griffioen G, Bus PJ, Vasen HF, Verspaget HW, Lamers CB. Extracolonic manifestations of familial adenomatous polyposis: desmoid tumours, and upper gastrointestinal adenomas and carcinomas. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1998; 225:85-91. [PMID: 9515758 DOI: 10.1080/003655298750027281] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
It is well known that patients with familial adenomatous polyposis (FAP) are at considerable risk of developing extracolonic manifestations of the disease. Particularly, desmoid tumours of the abdominal cavity, and duodenal adenomas and carcinomas are the most serious ones. It is estimated that some 10% of the FAP patients will develop desmoids, whereas 50-90% of the FAP patients will get duodenal adenomas predominantly concentrated on or around the major papilla. Desmoid tumours and duodenal carcinomas are major causes of death in those patients in whom a prophylactic (procto)colectomy has been performed. Desmoids are histologically benign tumours, composed of mature fibroblasts. They usually grow slowly but they can become quite large and may compress or infiltrate surrounding viscera, which might cause significant morbidity as well as mortality. Successful treatment of these tumours is extremely difficult as surgical therapy often requires the removal of considerable lengths of small bowel. Moreover, surgical therapy may lead to uncontrollable bleeding and is seldom radical. Chemotherapy with cytoxic agents seems promising but so far the data are too few for firm conclusions to be drawn. The same holds true for drug regimens which interfere with the metabolic and hormonal metabolism of the tumour. Although various lines of evidence suggest that the adenoma-carcinoma sequence, which is generally accepted for colorectal adenomas, also applies for the duodenal adenomas in FAP patients, it is not clear whether we should screen these patients for upper gastrointestinal adenomas or not. As these polyps are usually small, sessile, multiple and difficult to remove, the benefit of endoscopic surveillance would be the early detection of cancer rather than eradication of the polyps. In addition, evidence that screening and early treatment leads to improvement of the prognosis is not available. Although the role of (procto)colectomy in the treatment of large-bowel polyps is well established in FAP patients, the treatment of their duodenal counterparts is still open for debate. The risk of the development of periampullary cancer is not high enough to warrant an aggressive prophylactic surgical approach, i.e. a Whipple's procedure, immediately after the discovery of duodenal adenomas. The considerable morbidity and mortality rates of this procedure must be weighted against a putative benefit of screening.
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Affiliation(s)
- G Griffioen
- Dept. of Gastroenterology-Hepatology, Leiden University Medical Center, University Hospital Leiden, The Netherlands
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Soravia C, Berk T, Haber G, Cohen Z, Gallinger S. Management of advanced duodenal polyposis in familial adenomatous polyposis. J Gastrointest Surg 1997; 1:474-8. [PMID: 9834381 DOI: 10.1016/s1091-255x(97)80136-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Patients with familial adenomatous polyposis (FAP) are at increased risk for the development of periampullary cancer. The aim of this study was to evaluate the roles of endoscopic and surgical therapy in the management of advanced duodenal polyposis in FAP. From 1990 to 1995, seventy-four FAP patients were enrolled in a prospective endoscopic surveillance protocol. Among these, 11 (14.8%) developed advanced duodenal polyposis and one had duodenal adenocarcinoma. Six patients underwent endoscopic resection of duodenal (n=5) or ampullary adenomas (n=1). The following operations were performed in the remaining six patients: ampullectomy in four, open polypectomy in one, and a Whipple procedure in one. There was one patient who died of acute pancreatitis following endoscopic ampullectomy. The patient with invasive duodenal cancer died of local recurrence. Small polyps were observed at the site of previous resection in all (9 of 9) patients undergoing repeat endoscopy during a mean follow-up of 18 months (range 4 to 34 months). An endoscopic and local surgical resectional approach to advanced duodenal polyposis in FAP is fraught with high recurrence rates, although recurrent polyps are small and may be amenable to retreatment in the future. Long-term follow-up is necessary to prove that deaths from duodenal or ampullary cancer are prevented with this strategy.
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Affiliation(s)
- C Soravia
- Department of Surgery, and Steve Atanas Stavro Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, and the Department of Medicine, University of Toronto, Ontario, Canada
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Kroser JA, Bachwich DR, Lichtenstein GR. Risk factors for the development of colorectal carcinoma and their modification. Hematol Oncol Clin North Am 1997; 11:547-77. [PMID: 9257146 DOI: 10.1016/s0889-8588(05)70451-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In this article the authors review factors determining risk for the development of colorectal cancer (CC) and their modification. Emphasis is placed on understanding the difference between average risk and high risk individuals. Risk factors including genetics, diet, environment, and coexistent diseases are discussed. The data regarding modification of risk via dietary, pharmaceutical, and prophylactic endoscopic and surgical interventions are reviewed.
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Affiliation(s)
- J A Kroser
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, USA
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Abstract
Screening and surveillance examinations are effective in lowering colorectal cancer risk. Screening tests have been demonstrated to reduce colorectal cancer mortality. Colonoscopic removal of adenomatous polyps has been determined to reduce colorectal cancer incidence. High-risk individuals and their family members should be identified and offered more aggressive recommendations for appropriate screening and surveillance guidelines. Colorectal cancer screening strategies are in an acceptable range of cost effectiveness.
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Affiliation(s)
- A J Markowitz
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Iida M, Aoyagi K, Fujimura Y, Matsumoto T, Hizawa K, Nakamura S. Nonpolypoid adenomas of the duodenum in patients with familial adenomatous polyposis (Gardner's syndrome). Gastrointest Endosc 1996; 44:305-8. [PMID: 8885351 DOI: 10.1016/s0016-5107(96)70169-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although duodenal adenomas are very common in familial adenomatous polyposis, we wished to emphasize our experience with finding nonpolypoid adenomas in the duodenum of patients with this disease. METHODS Duodenoscopy was performed in 23 patients with an established diagnosis of familial adenomatous polyposis or Gardner's syndrome. RESULTS Endoscopy revealed single or multiple nonpolypoid adenomas of the duodenum in 7 patients (30%). The lesions were smaller than 5 mm and were endoscopically recognized as flat or depressed reddish lesions; one lesion was completely flat and the remaining lesions were flat-topped elevations with a central depression. All of the lesions were histologically diagnosed as tubular adenoma with moderate epithelial atypia. CONCLUSION These findings suggest that duodenal nonpolypoid adenomas are common in familial adenomatous polyposis or Gardner's syndrome and that careful surveillance endoscopy seems necessary in patients with this disease.
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Affiliation(s)
- M Iida
- Department of Medicine, Kawasaki Medical School, Kurashiki, Japan
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Kuwada SK, Burt RW. The Clinical Features of the Hereditary and Nonhereditary Polypsis Syndromes. Surg Oncol Clin N Am 1996. [DOI: 10.1016/s1055-3207(18)30364-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Marcello PW, Asbun HJ, Veidenheimer MC, Rossi RL, Roberts PL, Fine SN, Coller JA, Murray JJ, Schoetz DJ. Gastroduodenal polyps in familial adenomatous polyposis. Surg Endosc 1996; 10:418-21. [PMID: 8661792 DOI: 10.1007/bf00191629] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Malignant degeneration of gastroduodenal polyps has been noted in patients with familial adenomatous polyposis. To evaluate this problem further, patients with familial adenomatous polyposis were contacted and offered upper gastrointestinal tract endoscopy. METHODS A prospective endoscopic examination was performed in 42 patients. RESULTS The median age of patients at endoscopy was 35 years. The duration of known familial adenomatous polyposis at the time of endoscopy was 8 years. Polyps were visualized in 21 patients (50%). Gastric polyps were seen in 14 patients (33%), duodenal polyps were seen in 11 patients (26%), and ampullary polyps were seen in 7 patients (17%). Nine patients (43%) had polyps in more than one site. Adenomatous change was noted in 73% of duodenal lesions and in only 14% of gastric polyps. Surgical intervention was required in four patients; one patient had an early ampullary carcinoma, and three patients had severe dysplasia involving the duodenum or ampulla. All four patients had undergone a previous screening examination, results of which were normal in three patients. Compared with other patients, these four patients were older (median age, 58 years; p = 0.02) and had a longer duration of disease (median duration, 25 years; p = 0.002). CONCLUSIONS All patients with familial adenomatous polyposis require lifelong endoscopic surveillance to detect malignant degeneration, which may appear later in life.
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Affiliation(s)
- P W Marcello
- Department of Colon and Rectal Surgery, Lahey Hitchcock Medical Center, Burlington, MA 01805, USA
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Sanabria JR, Croxford R, Berk TC, Cohen Z, Bapat BV, Gallinger S. Familial segregation in the occurrence and severity of periampullary neoplasms in familial adenomatous polyposis. Am J Surg 1996; 171:136-40; discussion 140-1. [PMID: 8554128 DOI: 10.1016/s0002-9610(99)80088-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Familial adenomatous polyposis (FAP) patients often develop periampullary adenomas that may progress to periampullary cancer, a common cause of death in this population. The risk of periampullary cancer in FAP is unclear, and variables that predict the occurrence and severity of periampullary tumors are not well understood. The specific aim of this study was to determine whether the risk of periampullary neoplasia segregates in specific FAP families. MATERIALS AND METHODS A total of 144 FAP patients from 74 families were either screened by gastroduodenoscopy (n = 132) or information was obtained from surgical or autopsy reports (n = 12). The severity of periampullary neoplasia was recorded for each patient and graded based on maximum polyp size and histology. Linear regression was used to determine the significance of a number of variables with respect to periampullary neoplasia. A blood sample was available from at least one member of 50 unrelated families and used to detect germline mutations in codons 686 through 1693 of the adenomatous polyposis coli (APC) gene. RESULTS Statistically significant familial segregation was found for the incidence and severity of periampullary neoplasia (P < 0.02). Age was also a statistically significant variable (P < 0.01). No correlation was observed between specific APC germline mutations and periampullary polyp frequency and severity. CONCLUSIONS The occurrence and severity of periampullary neoplasms in patients with FAP segregates in families. This familial association may be related to as yet unidentified modifier genes or perhaps common environmental factors. These results should prove useful in developing upper gastrointestinal screening protocols for FAP patients at risk for periampullary neoplasia.
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Affiliation(s)
- J R Sanabria
- Department of Surgery, Steve Atanas Stavro Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, Toronto, Ontario, Canada
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28
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Bertoni G, Sassatelli R, Nigrisoli E, Tansini P, Roncucci L, Ponz de Leon M, Bedogni G. First observation of microadenomas in the ileal mucosa of patients with familial adenomatous polyposis and colectomies. Gastroenterology 1995; 109:374-80. [PMID: 7615185 DOI: 10.1016/0016-5085(95)90323-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND & AIMS Little data are available on the type and prevalence of mucosal changes involved in the development of ileal adenomas in patients with familial adenomatous polyposis who have undergone colectomy. However, colonic metaplasia of the ileal epithelium is thought to be an important step in the development of such adenomas. METHODS Retrograde endoscopy and biopsy of the distal ileum were performed in 17 affected patients who underwent total colectomy or proctocolectomy 3-184.1 months (mean, 80.3 +/- 13.9 months) before the study. RESULTS Macroscopic ileal polyps were identified in 14 (82.4%) patients. All polyps were sessile and 1-5 mm in size. Histological analysis showed adenomas in 9 (52.9%) patients and lymphoid hyperplasia or inflammation in the others. In 1 patient, an area of colonic-type metaplasia of the ileal mucosa was found close to an adenoma. However, in 5 (29.4%) patients, random biopsy specimens of the normal-appearing mucosa showed foci of abnormal crypts in the absence of metaplasia, with histological appearance similar to the findings described in dysplastic aberrant crypt foci of the colon. Such lesions, previously observed only in colorectal mucosa and referred to as microadenomas or oligocryptal adenomas, are considered putative preneoplastic abnormalities. CONCLUSIONS Although the hypothesized sequence normal ileal mucosa leading to colonic-type metaplasia leading to adenoma cannot be excluded, our findings support the sequence normal ileal mucosa leading to microadenoma leading to gross adenoma and possibly cancer as the main histogenetic pathway, as already suggested for the large bowel.
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Affiliation(s)
- G Bertoni
- Department of Digestive Endoscopy, Ospedale S. Maria Nuova, Reggio Emilia, Italy
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29
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Doi K, Iida M, Kohrogi N, Yao T, Fujishima M. Villous adenoma of the duodenum in a patient with familial adenomatosis coli. Surg Endosc 1995; 9:512-4. [PMID: 7676373 DOI: 10.1007/bf00206838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A case of familial adenomatosis coli with villous adenoma of the third portion of the duodenum, which falls in the category of a Gardner's syndrome, is described. The patient, who had complained of an abdominal mass which had been diagnosed as a desmoid tumor after surgical resection, had numerous adenomatous polyps throughout the colon confirmed by colonoscopy with biopsy. Endoscopic examination of the upper gastrointestinal tract revealed fundic gland polyposis in the stomach and numerous small adenomas in the duodenum. In addition, there was a pedunculated polyp in the third portion of his duodenum, measuring 30 mm in diameter, the surface of which had a cauliflowerlike appearance. The polyp was removed with the electrocautery snare and was histologically diagnosed as villous adenoma. Our case report supports the concept that villous adenoma, which possesses a high malignant potential, may occur in the upper gastrointestinal tract in patients with familial adenomatosis coli, and careful examination of the upper gastrointestinal tract including the distal duodenum seems to be necessary in the follow-up patients with this disease.
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Affiliation(s)
- K Doi
- Department of Internal Medicine II, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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30
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Bülow S, Alm T, Fausa O, Hultcrantz R, Järvinen H, Vasen H. Duodenal adenomatosis in familial adenomatous polyposis. DAF Project Group. Int J Colorectal Dis 1995; 10:43-6. [PMID: 7745323 DOI: 10.1007/bf00337586] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In order to evaluate the prevalence of duodenal adenomas in familial adenomatous polyposis (FAP) and the risk of carcinoma development, a multicenter study was initiated in Denmark, Finland, Holland, Norway and Sweden, which have national polyposis registers with an almost complete registration. Patients aged 20 years or more are being examined with biennial gastroduodenoscopy during 1990-2000. Multiple duodenal biopsies are examined by one pathologist from each country, and the endoscopic and histological criteria of Spigelman have been adopted. At the end of August 1992, 312 patients with a median age of 37 years (range 20-86) had completed their first endoscopy. The duodenum was examined in 310 patients, of whom 199 (64%) had duodenal adenomas. Twenty-two patients (11% of all patients with duodenal adenomas) had no endoscopically visible polyps. One patient had an asymptomatic adenocarcinoma. The Spigelman stage worsened significantly (P < 0.05) with time from the diagnosis of FAP, which may suggest an increasing risk of carcinoma by time.
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Affiliation(s)
- S Bülow
- Danish Polyposis Register, Hvidovre Hospital, Copenhagen
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31
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Affiliation(s)
- A K Rustgi
- Gastrointestinal Unit, Massachusetts General Hospital, Boston 02114
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32
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Antonioli DA. Precursors of gastric carcinoma: a critical review with a brief description of early (curable) gastric cancer. Hum Pathol 1994; 25:994-1005. [PMID: 7927322 DOI: 10.1016/0046-8177(94)90058-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Gastric adenocarcinoma is among the most common malignancies worldwide. Its etiopathogenesis is complex and, as yet, incompletely understood; however, diet, infection with Helicobacter pylori, and genetic factors are involved. It may be classified into two main types, intestinal and diffuse. The intestinal type has decreased in incidence, whereas the diffuse tumors as well as those confined to the cardia are increasing. Numerous conditions, such as gastritis, gastric atrophy, and intestinal metaplasia (IM), are associated with intestinal type gastric cancer in retrospective studies, but only epithelial dysplasia has a positive predictive value for malignancy. These precursor conditions and lesions are analyzed for their clinicopathological significance in this review, which concludes with a brief summary of curable (early) forms of gastric cancer.
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Affiliation(s)
- D A Antonioli
- Department of Pathology, Beth Israel Hospital, Boston, MA 02115
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33
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Morales TG, Hixson LJ. Acute pancreatitis following endoscopic biopsy of the ampulla in a patient with Gardner's syndrome. Gastrointest Endosc 1994; 40:367-9. [PMID: 8056246 DOI: 10.1016/s0016-5107(94)70076-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- T G Morales
- University of Arizona Health Sciences Center, Department of Internal Medicine, Tucson 85724
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34
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Odze RD, Quinn PS, Terrault NA, Vivona AA, Ward MA, Cohen Z, Gallinger S. Advanced gastroduodenal polyposis with ras mutations in a patient with familial adenomatous polyposis. Hum Pathol 1993; 24:442-8. [PMID: 8387955 DOI: 10.1016/0046-8177(93)90095-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Upper gastrointestinal polyps are being recognized with increasing frequency in patients with familial adenomatous polyposis. Duodenal and periampullary adenomas are the most common type and have poorly understood but definite malignant potential. In contrast, the majority of polypoid lesions in the stomach are benign fundic gland polyps. We report a patient with familial adenomatous polyposis who developed dysplasia in a large exophytic hyperplastic gastric tumor that appeared to arise on a background of diffuse fundic gland polyposis and presented with anemia, hypoalbuminemia, and a protein-losing enteropathy. A large periampullary adenoma also was present. Using the polymerase chain reaction with mismatched primers, a GGT to TGT Kras codon 12 mutation was detected within areas of severe dysplasia in the gastric tumor and in the periampullary adenoma. This case serves to further highlight the spectrum of clinical, pathologic, and molecular features of premalignant upper gastrointestinal tract lesions in patients with familial adenomatous polyposis.
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Affiliation(s)
- R D Odze
- Department of Pathology, Steve Atanos Stavro FAP Registry, Mount Sinai Hospital, Toronto, Ontario, Canada
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35
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Church JM, McGannon E, Hull-Boiner S, Sivak MV, Van Stolk R, Jagelman DG, Fazio VW, Oakley JR, Lavery IC, Milsom JW. Gastroduodenal polyps in patients with familial adenomatous polyposis. Dis Colon Rectum 1992; 35:1170-3. [PMID: 1335405 DOI: 10.1007/bf02251971] [Citation(s) in RCA: 115] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A review of the endoscopy reports and pathology results from esophagogastroduodenoscopy (EGD) of all patients with familial adenomatous polyposis (FAP) undergoing such an examination was performed. Two hundred forty-seven patients were identified, with an overall prevalence of duodenal adenomas of 66 percent and of fundic gland polyps of 61 percent. Analysis of our more recent experience (1986 to 1990) shows the prevalence to be 88 percent and 84 percent, respectively. A normal-appearing papilla was adenomatous in 50 percent of cases. No case of periampullary carcinoma developed in patients under surveillance. Routine EGD is indicated for patients with FAP. Duodenal adenomas and fundic gland polyps will occur in the majority of patients.
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Affiliation(s)
- J M Church
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195
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36
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Seow-Choen F, Ho JM, Wong J, Goh HS. Gross and histological abnormalities of the foregut in familial adenomatous polyposis: a study from a South East Asian Registry. Int J Colorectal Dis 1992; 7:177-83. [PMID: 1338090 DOI: 10.1007/bf00341216] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Polyps in the stomach and duodenum are frequently found in familial adenomatous polyposis. Cancer arising from some of these polyps may be an important cause of death in patients who have had large bowel resections. This study aims to determine the nature and distribution of foregut polyps in Chinese patients. Twenty-five patients with familial adenomatous polyposis were gastroscoped by a single operator using the end viewing video-endoscopy system. Representative biopsies of normal mucosa or polyps where appropriate were taken from the gastric fundus, antrum and the duodenum. Twenty-five patients were studied. Male = 17, female = 8. Median age was 32 years (range = 17-63 yrs). Nineteen patients were found to have macroscopically visible polyps in the foregut. Ten patients had gastric polyps alone, three patients had duodenal polyps alone whilst six patients had both gastric and duodenal polyps. Twelve, one and three patients had more than 20 polyps in the gastric fundus, antrum and duodenum respectively. Only one patient had polyps which were larger than 10 mm. The commonest polyp in the gastric fundus was the fundic gland polyp whilst hyperplastic and adenomatous polyps were the commonest polyps in the gastric antrum and duodenum respectively. Five patients had adenomatous polyps of which four had duodenal adenomas alone whilst one patient had adenomas in the duodenum, gastric antrum and fundus. Seventy-six per cent of our patients with familial adenomatous polyposis had foregut polyposis. Adenomatous polyps were found in 56% of patients with duodenal polyps or 20% of patients with foregut polyps but hyperplastic and hamartomatous polyps occur commonly in patients with familial adenomatous polyposis as well.
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Affiliation(s)
- F Seow-Choen
- Dept of Colorectal Surgery, Singapore General Hospital
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37
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Goedde TA, Rodriguez-Bigas MA, Herrera L, Petrelli NJ. Gastroduodenal polyps in familial adenomatous polyposis. Surg Oncol 1992; 1:357-61. [PMID: 1341271 DOI: 10.1016/0960-7404(92)90036-k] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- T A Goedde
- Roswell Park Cancer Institute, Department of Surgical Oncology, Buffalo, New York 14263
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38
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Herman LL, Kurtz RC, Brennan MF, Shike M. Acute pancreatitis from intussusception of a gastric polyp in a patient with Gardner's syndrome. Dig Dis Sci 1992; 37:955-60. [PMID: 1587204 DOI: 10.1007/bf01300398] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gastric polyps in Gardner's syndrome are usually benign small fundic gland neoplasms with little clinical significance. We report a case of gastroduodenal intussusception secondary to a large benign gastric polyp in a 44-year-old woman with Gardner's syndrome who presented with acute pancreatitis. The intussuscepted polyp caused obstruction of the ampulla of Vater with subsequent acute pancreatitis.
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Affiliation(s)
- L L Herman
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
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39
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Affiliation(s)
- J F Morrissey
- Department of Medicine, University of Wisconsin Medical School, Madison 53792
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40
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Domizio P, Talbot IC, Spigelman AD, Williams CB, Phillips RK. Upper gastrointestinal pathology in familial adenomatous polyposis: results from a prospective study of 102 patients. J Clin Pathol 1990; 43:738-43. [PMID: 2170464 PMCID: PMC502752 DOI: 10.1136/jcp.43.9.738] [Citation(s) in RCA: 95] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Multiple gastric and duodenal biopsy specimens from 102 asymptomatic patients with familial adenomatous polyposis, taken during a prospective endoscopic screening programme were examined. One hundred patients had microscopic gastroduodenal pathology, often in the absence of macroscopic lesions. Adenomas were found in 94 patients in the duodenum, in the second and third parts. Hyperplasia of villous and crypt epithelium was also seen, sometimes in the absence of adenomas: this may be a precursor of neoplastic change. In the stomach fundic gland polyps were the commonest abnormality, seen microscopically in 44 patients. Chronic antral gastritis was common in patients without fundic polyps. Gastric adenomas were present in six patients, all of whom also had duodenal adenomas. If duodenal adenomas in familial adenomatous polyposis have a similar malignant potential to those in the colorectum sequential endoscopy and biopsy are necessary to detect cancer in these patients.
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Affiliation(s)
- P Domizio
- Department of Histopathology, St Mark's Hospital, London
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41
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Shepherd NA, Hall PA. Epithelial-mesenchymal interactions can influence the phenotype of carcinoma metastases in the mucosa of the intestine. J Pathol 1990; 160:103-9. [PMID: 2319390 DOI: 10.1002/path.1711600203] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In this paper we report two cases in which morphological differentiation of gastric adenocarcinoma has occurred when metastatic tumour was present within the lamina propria of the intestinal mucosa. In one case, there were metastases in the small intestinal mucosa and in the second case, in the mucosa of the appendix. The morphology of the intramucosal tumour simulated that of an adenomatous neoplasm. The recognition of this occurrence may be important in the differential diagnosis of primary and secondary adenocarcinomas of the gastrointestinal tract. The phenomenon is not only of diagnostic interest: the data presented here provide in vivo evidence that gastrointestinal carcinomas may differentiate in response to epithelial-mesenchymal interactions in a similar way to that seen in experimental models.
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Affiliation(s)
- N A Shepherd
- Department of Pathology, Gloucestershire Royal Hospital, U.K
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42
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Shepherd NA, Bussey HJ. Polyposis syndromes--an update. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 1990; 81:323-51. [PMID: 2155087 DOI: 10.1007/978-3-642-74662-8_15] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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43
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Dent TL, Kukora JS, Buinewicz BR. Endoscopic screening and surveillance for gastrointestinal malignancy. Surg Clin North Am 1989; 69:1205-25. [PMID: 2688151 DOI: 10.1016/s0039-6109(16)44984-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In the US, the cumulative lifetime risk of developing carcinoma of the upper gastrointestinal tract is less than 1 per cent, premalignant conditions are uncommon, and esophageal and gastric malignancies are rarely curable even when identified early. Endoscopic screening of the upper gastrointestinal tract in asymptomatic persons thus cannot be justified. Surveillance of persons with certain uncommon conditions associated with a higher risk of upper gastrointestinal cancer may be of benefit. These conditions include achalasia, Barrett's esophagus, chronic atrophic gastritis with intestinal metaplasia, familial polyposis coli, gastric polyps, lye stricture, Plummer-Vinson syndrome, and tylosis. In the lower gastrointestinal tract, however, the lifetime risk of developing carcinoma is 5 per cent, premalignant conditions and lesions are common, and carcinoma is curable when detected at an early stage. Sigmoidoscopic screening of asymptomatic adults has been advocated by the American Cancer Society but has not become widely practiced because of its cost, required physician effort, low overall yield, and poor patient compliance. Surveillance by flexible sigmoidoscopy is recommended for persons at slightly increased risk of colorectal carcinoma who have prior breast or gynecologic malignancy or a family history of colorectal malignancy. Colonoscopic surveillance is recommended for patients with high risk of colorectal cancer who have had prior colorectal carcinoma or adenoma or who have inflammatory bowel disease or a ureterosigmoidostomy.
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Affiliation(s)
- T L Dent
- Temple University School of Medicine, Philadelphia, Pennsylvania
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44
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Spigelman AD, Williams CB, Talbot IC, Domizio P, Phillips RK. Upper gastrointestinal cancer in patients with familial adenomatous polyposis. Lancet 1989; 2:783-5. [PMID: 2571019 DOI: 10.1016/s0140-6736(89)90840-4] [Citation(s) in RCA: 456] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
102 patients with familial adenomatous polyposis underwent upper gastrointestinal endoscopy as a screening test for gastroduodenal adenomas. 100 had duodenal abnormalities (dysplasia in 94, and hyperplasia in 6), usually in the second and third parts of the duodenum (91%). The periampullary area was abnormal in 87 of 97 patients who had a biopsy specimen taken from this site (dysplasia 72, hyperplasia 13, and inflammation 2). By contrast, gastric dysplasia was found in only 6 patients. Classification of duodenal polyposis on a 5-grade scale (stages 0-IV), based on polyp number, size, histology, and severity of dysplasia, showed that 11 had stage IV disease: these patients are at greatest risk of malignant change and require close surveillance. The pattern of dysplasia observed in the upper gastrointestinal tract resembled the pattern of mucosal exposure to bile.
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45
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Northover JM, Murday V. Familial colorectal cancer and familial adenomatous polyposis. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1989; 3:593-613. [PMID: 2558747 DOI: 10.1016/0950-3528(89)90019-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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46
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Iida M, Yao T, Itoh H, Watanabe H, Matsui T, Iwashita A, Fujishima M. Natural history of duodenal lesions in Japanese patients with familial adenomatosis coli (Gardner's syndrome). Gastroenterology 1989; 96:1301-6. [PMID: 2703115 DOI: 10.1016/s0016-5085(89)80017-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- M Iida
- Department of Internal Medicine II, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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47
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Alexander JR, Andrews JM, Buchi KN, Lee RG, Becker JM, Burt RW. High prevalence of adenomatous polyps of the duodenal papilla in familial adenomatous polyposis. Dig Dis Sci 1989; 34:167-70. [PMID: 2536604 DOI: 10.1007/bf01536046] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- J R Alexander
- Department of Medicine, University of Utah, Salt Lake City
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48
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Mogensen AM, Bülow S, Hage E. Duodenal adenomas in familial adenomatous polyposis: their structure and cellular composition with particular reference to endocrine hyperplasia. VIRCHOWS ARCHIV. A, PATHOLOGICAL ANATOMY AND HISTOPATHOLOGY 1989; 414:315-9. [PMID: 2540589 DOI: 10.1007/bf00734085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
134 duodenal biopsies from 14 patients with familial adenomatous polyposis were evaluated by light microscopy for the presence of adenoma. Staining reactions for endocrine cells were applied. 90 biopsies contained adenoma, almost all of the tubular type (98%) with dysplasia, ranging from mild to moderate. Accompanying hyperplasia of argyrophil and argentaffin endocrine cells was found in 91% and 64% of the adenomas, respectively. Based on histological criteria it is concluded that the risk of carcinoma development in the duodenum could equal that in colon and rectum. The observation of endocrine hyperplasia is new, and further investigations are needed before the significance of this finding can be evaluated.
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Affiliation(s)
- A M Mogensen
- Department of Pathology, Rigshospitalet, University of Copenhagen, Denmark
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