Cowden's disease: a case report and literature review

Multiple hamartoma syndrome: clinicoradiological evaluation and histopathological correlation with brief review of literature

Cowden syndrome (CS) or multiple hamartoma syndromes (MHSs) is an uncommon condition and characterized by mucocutaneous lesions which may be associated with the lesions of breast, thyroid, gastrointestinal tract, skin, and often of central nervous system. A thorough evaluation of Cowden's disease is essential due to increased risk of malignancy in an organ or system of the affected patients. We are reporting a case of female patient who presented with multiple mucocutaneous papilloma associated with involvement of multiple organs and systems. The diagnosis was confirmed by multimodality diagnostic approach. This rare entity has not being reviewed in Indian literature till date. Being a rare case, we are discussing MHS with its clinicoradiological and histopathological correlation along with brief review of literature.

Screening for cancerous and precancerous conditions of the colon

Five points for the primary care physician: 1. Colorectal cancer (CRC) is the second leading cause of cancer-related death in both men and women in the United States. 2. Guidelines recommend initiating CRC screening in average-risk patients at age 50 years, but in African Americans at age 45 years. 3. It is preferred that an informed decision is made by the patient with the help of their clinician about the type of screening test based on the patient's personal preferences. 4. Patients with personal history of chronic ulcerative colitis and Crohn colitis have significant cancer risk 8 years after the onset of pancolitis or 12 to 15 years after the onset of left-sided colitis. Colonoscopy every 1 to 2 years should be performed, with biopsies for dysplasia. 5. Counseling to consider genetic testing and early screening recommendations for those with personal or family history of familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer.

Colonic polyposis and neoplasia in Cowden syndrome

OBJECTIVE

To identify and describe the frequency, histologic features, and clinical outcome of colon polyposis and neoplasia in Cowden syndrome--a rare familial hamartoma tumor syndrome associated with mutations in the PTEN gene.

PATIENTS AND METHODS

Patients with a clinical diagnosis of PTEN hamartoma tumor syndrome-Cowden phenotype were retrospectively identified and studied. Only those who underwent colonoscopy or colon pathologic interpretation were included in the final analysis.

RESULTS

From 1994 to 2009, 13 patients met study inclusion criteria. Of the 10 patients who underwent colonoscopy, 9 (90%; 95% confidence interval [CI], 57%-100%) had polyps, and 7 (70%; 95% CI, 39%-90%) were estimated to have more than 50 polyps. Pathologic findings of the colon were reviewed in 11 patients, and the spectrum of tumors included hamartomatous, inflammatory, adenomatous, ganglioneuromatous, hyperplastic, and juvenile polyps. Of the 13 patients, 2 (15%; 95% CI, 3%-43%) had left-sided adenocarcinoma without microsatellite instability. Five (38%) of the 13 patients underwent colectomy secondary to polyp dysplasia.

CONCLUSION

Patients with Cowden syndrome have a heavy colon polyp burden with a wide pathologic spectrum, both benign and malignant. The colon polyposis results in a previously unreported morbidity with a high colectomy rate.

Multiple primary malignancies and subtle mucocutaneous lesions associated with a novel PTEN gene mutation in a patient with Cowden syndrome: case report

Background

Cowden syndrome (CS) is a cancer predisposition syndrome associated with increased risk of breast, thyroid, and endometrial cancers, and is characterized by development of benign mucocutaneous lesions.

Case presentation

Here we report on a 58-year-old woman with multiple primary malignancies and subtle mucocutaneous lesions such as small polyps and wart-like papulas. Over a period of 23 years, she developed various malignant neoplasms including thyroid, ovarian, stomach, and colon carcinomas, and a benign meningioma. Direct sequencing analysis of the PTEN gene revealed a novel germline mutation (c.438delT, p.Leu146X).

Conclusion

This case demonstrates that Cowden syndrome is a multi-system disease that can result in the development of multiple malignant and benign tumors.

Frequent gastrointestinal polyps and colorectal adenocarcinomas in a prospective series of PTEN mutation carriers

BACKGROUND & AIMS

Germline phosphatase and tensin homolog (PTEN) mutations cause Cowden syndrome (CS), associated with breast and thyroid cancers. Case reports found 35%-85% of CS patients had gastrointestinal (GI) hamartomas. The association of benign and malignant GI neoplasias with CS remains debatable. Our goal is to describe the GI phenotype in a prospective series of PTEN mutation carriers.

METHODS

Patients who met relaxed International Cowden Consortium criteria (N = 2548) or with 5 or more GI polyps, 1 or more of which was hyperplastic or hamartomatous (N = 397), were prospectively recruited. Germline PTEN mutation/deletion analysis was performed. Of the 2945 patients, 127 (123 of 2548 and 4 of 397, respectively) patients having clear pathogenic PTEN mutations were eligible for this study. Esophagogastroduodenoscopy, colonoscopy, and pathology reports were reviewed. The Fisher 2-tailed exact test, unpaired t tests, and age- and sex-adjusted standardized incidence ratio were calculated.

RESULTS

Of 127 PTEN mutation carriers, 69 underwent 1 or more endoscopies with 64 (93%) having polyps. Of the 64, half had hyperplastic polyps. There were one to innumerable polyps in the colorectum, ileum, duodenum, stomach, and/or esophagus, with 24 subjects having both upper and lower GI polyps. Nine (13%) subjects had colorectal cancer, all younger than the age of 50. The adjusted standardized incidence ratio was 224.1 (95% confidence interval, 109.3-411.3; P < .0001).

CONCLUSIONS

PTEN-associated CS should be considered a mixed polyp syndrome, with hyperplastic polyps most prevalent, with a risk of early onset colorectal cancer. Routine colonoscopy should be considered in PTEN-associated CS, especially in the context of hyperplastic and/or adenomatous polyps.

Genetic testing for hereditary colorectal cancer

This article focuses on genetic testing for hereditary colorectal cancer syndromes. Genetic testing is now available in North America for all of the known hereditary colorectal cancer genes. In addition, most of these tests have improved significantly in the past few years with the inclusion of techniques to detect large rearrangements. As a result, clinicians are in a better position than ever to help families with these syndromes to identify the underlying genetic cause. This identification will ensure that they receive appropriate management, and will enable their relatives to determine their precise risks and to tailor their cancer surveillance.

Cowden syndrome: a critical review of the clinical literature

Cowden syndrome (CS) is a multi-system disease involving hamartomatous overgrowth of tissues of all three embryonic origins and increased risks for thyroid, breast and possibly other cancers. Benign breast, thyroid, uterine and skin lesions are also common. Approximately 80% of patients with CS have an identifiable germline mutation in the PTEN gene. The majority of the existing data on the frequencies of component clinical features have been obtained from compilations of case reports in the literature, many of which predate the establishment in 1996 of consensus diagnostic criteria. Many of these reports also suffer from ascertainment bias which emphasized the dermatologic features of the disease. This paper presents an overview of Cowden syndrome focusing on a critical evaluation of the major literature on the component cancers, benign features, and molecular findings in CS, noting the limitations of the published data.

Cowden syndrome: a critical review of the clinical literature

Cowden syndrome (CS) is a multi-system disease involving hamartomatous overgrowth of tissues of all three embryonic origins and increased risks for thyroid, breast and possibly other cancers. Benign breast, thyroid, uterine and skin lesions are also common. Approximately 80% of patients with CS have an identifiable germline mutation in the PTEN gene. The majority of the existing data on the frequencies of component clinical features have been obtained from compilations of case reports in the literature, many of which predate the establishment in 1996 of consensus diagnostic criteria. Many of these reports also suffer from ascertainment bias which emphasized the dermatologic features of the disease. This paper presents an overview of Cowden syndrome focusing on a critical evaluation of the major literature on the component cancers, benign features, and molecular findings in CS, noting the limitations of the published data.

Oral manifestations of internal malignancy and paraneoplastic syndromes

Malignant tumors of visceral organs are a fundamental feature of familial cancer and paraneoplastic syndromes. In many instances, the presence of an internal and often occult malignancy may be forewarned by various external manifestations. Several of these findings are preferentially localized to the head and neck region, including the oral cavity proper. This places the dental practitioner in a unique position to detect these "markers" of occult neoplastic involvement. Because these markers may present before an established syndrome or cancer diagnosis, even representing the first expression of disease in some cases, early recognition by a dentist may lead to timely diagnosis and management of these cancer-associated syndromes.

Cowden's disease—its importance for otolaryngologists

Cowden's disease is a rare predominantly inherited disease, characterized bymucocutaneous lesions, gastrointestinal polyposis and benign or malignant thyroid and breast tumours. The report deals with a typical case of this disease with emphasis on its importance forotolaryngologists.

Cowden disease: a review

Cowden disease is a genetically inherited disorder presenting with multiple hamartomatous and neoplastic lesions in various organs and tissues. We present a review of the diagnostic criteria, clinical presentation, genetics, and management of this condition.

Analysis of PTEN gene mutations in Korean patients with Cowden syndrome and polyposis syndrome

PURPOSE

PTEN (phosphatase and tensin homologue deleted in chromosome 10) is a candidate tumor suppressor gene. Mutations of this gene are responsible for PTEN hamartoma tumor syndromes, including Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome, Proteus syndrome, and Proteus -like syndromes. Recently, PTEN mutations were identified in several human neoplasms. We analyzed the DNA of various organs and lesions in Korean patients with Cowden syndrome, their family members, and patients with familial adenomatous polyposis for germline or somatic PTEN mutations.

METHODS

The 11 patients included in this study were 5 patients with Cowden syndrome, 4 of their family members, and 2 patients with familial adenomatous polyposis. Deletions and mutations in exons 1 to 9 of the PTEN gene were evaluated by polymerase chain reaction-single strand conformation polymorphism and sequencing analysis in esophageal acanthosis, gastric polyps, colonic polyps, skin lesions, and peripheral blood mononuclear cells. To exclude common polymorphisms, 240 controls were tested.

RESULTS

All patients with Cowden syndrome showed several to numerous polyps in the gastrointestinal tract. A missense mutation at codon 217 (GTC to GAC, Val to Asp) in exon 7 was identified in one Cowden syndrome patient, and a nonsense mutation at codon 211 (TGC to TGA, Cys to stop) in exon 6 was identified in a second patient. Identical mutations were found in all tissue samples, including colonic polyps, from each patient. No PTEN mutations were found in their family members or in any patient with familial adenomatous polyposis. None of tested controls contained a mutation.

CONCLUSIONS

We have identified two new germline PTEN mutations in Korean patients with Cowden syndrome. Mutations in the introns and regulatory regions of the PTEN gene may be present in additional patients with Cowden syndrome and polyposis syndrome.

Cowden disease: CT findings in three patients

Cowden disease, also known as multiple hamartoma syndromes, is an autosomal dominant disease characterized by numerous benign mucocutaneous tumors, hamartomas of multiple organs, and malignancies of the breast and thyroid. In this report, we present the computed tomographic findings in three patients with Cowden disease. In addition to the classic findings, the patients were diagnosed with spinal neurinoma (n=1), meningioma (n=1), and hepatic hemangioma (n=3). We also review current clinical and genetic concepts that unify Cowden disease.

Testicular hamartomas in Cowden disease

We report a case of testicular hamartomas in association with Cowden disease. Clinical examination of the patient, a 39-year-old man, revealed a palpable mass in the right side of the scrotum. Sonographic examination showed that the mass was either a spermatocele or an epididymal cyst and that multiple hyperechoic lesions were present in both testes. On subsequent MRI, the appearance of these lesions was consistent with that of fat-containing hamartomas. Testicular biopsy was not performed, but follow-up serial sonographic examination was recommended. To our knowledge, this report is the first to describe testicular hamartomas as a probable manifestation of Cowden disease.

Multigenerational familial medullary thyroid cancer (FMTC): evidence for FMTC phenocopies and association with papillary thyroid cancer

BACKGROUND

Occurrence in a familial setting is well established for medullary thyroid carcinoma (MTC) and has been more recently reported for papillary thyroid cancer (PTC). Germline mutations or rearrangements of the RET proto-oncogene are the genetic background of the majority of hereditary MTCs and of about 25-40% of PTCs.

PATIENTS

A large multigenerational familial medullary thyroid cancer (FMTC) family, comprised of four generations and a total of 60 subjects, has been fully evaluated. Studies on germline RET mutations and polymorphisms, on somatic RET activation and on haplotyping with RET-linked markers, were performed.

RESULTS

RET mutational analysis revealed a rare missense point mutation in exon 15 of RET (A891S), associated with FMTC. Haplotype analysis showed a co-segregation between the allelic variant 5 of D10S578 marker (which is tightly linked to the RET locus) and the RET mutation. Two patients, from different branches of the family, did not harbour the point mutation A891S despite histological confirmation of MTC. In these cases, haplotype analysis excluded the involvement of the RET gene itself in the pathogenesis of the MTC. In three patients, the coexistence, in different foci, of medullary and papillary thyroid cancer was documented. The genetic studies did not show ret/PTC rearrangements. The microsatellite analysis excluded co-segregation of RET locus with the MTC/PTC phenotype.

CONCLUSIONS

We report a full clinical and molecular analysis of a large FMTC kindred with an uncommon RET mutation. In two family members, phenotype and genotype were not concordant, representing the first evidence of FMTC phenocopies. Furthermore, the association of familial forms of medullary and papillary thyroid cancers has been found in 30% of patients undergoing thyroidectomy for MTC. In these situations, genetic analyses excluded the possible germline involvement of RET. Though FMTC phenocopies are likely to represent an exceptional finding, such a possibility should be taken into account in the genetic counselling for MEN 2 syndromes.

Cowden's syndrome, Lhermitte-Duclos disease, and sclerotic fibroma

The authors report a case of Lhermitte-Duclos disease, or dysplastic cerebellar gangliocytoma, in which a cutaneous sclerotic fibroma was found incidentally during the second resection of a recurrent cerebellar hamartoma. The association of Lhermitte-Duclos disease and sclerotic fibroma with Cowden's syndrome led to a dermatologic examination and confirmation of the diagnosis of Cowden's syndrome. The combination of both Lhermitte-Duclos disease and sclerotic fibroma with Cowden's syndrome has not previously been reported. A review of the 15 cases of Lhermitte-Duclos disease associated with Cowden's syndrome shows no significant gender predilection. Sclerotic fibromas, once thought to be specific for Cowden's syndrome, also are reviewed.

Familial nonmedullary thyroid carcinoma: a meta-review of case series

Familial occurrence of nonmedullary thyroid carcinoma is extremely rare but this has been increasingly recognized over the recent years. Earlier reports of such occurrence were primarily confined to individuals with previous radiation exposure, history of familial adenomatous polyposis (Gardner's syndrome) or multiple hamartomas (Cowden's syndrome), or monozygotic twins. The author reviews 15 case reports/series of familial nonmedullary thyroid carcinoma available in the literature involving kindreds with no obvious associated pathogenetic factors as mentioned above. There were a total of 87 kindreds with 178 affected individuals available for analysis, with a male to female ratio of 1:2.2. The modal age group at diagnosis was 30-39 years in both gender groups. Papillary thyroid carcinoma constituted 91% of the cases, followed by follicular (6%) and anaplastic (2%) varieties. There was one case (0.5%) each of combined papillary and medullary thyroid carcinoma and Hurthle cell carcinoma, respectively. Six of the 15 series observed that patients with familial history generally have more aggressive tumour characteristics compared to the sporadic counterparts. The incidences of multifocality, local invasion, and distant metastases at diagnosis were 49, 32, and 5%, respectively. The incidences of locoregional recurrence, distant metastases, and deaths were 29, 10, and 5.4%, respectively, at a mean follow-up period of 11 years. The actual prognostic outcome of familial nonmedullary thyroid carcinoma is still unclear in view of the limited clinical data. Although several authors have advocated an aggressive approach in managing these patients, no conclusion can be reached on the basis of this review to support this position. The author recommends that patients with familial disease should be treated according to the disease stage and other risk factors, similar to those with spontaneously occurring well-differentiated papillary or follicular thyroid carcinomas. In addition, one might consider and perform follow-up of first-degree relatives with similar degree of caution as patients who have undergone head and neck irradiation in childhood.

Alimentary tract lesions in Cowden's disease

Cowden's disease was first recognized by its striking dermatological manifestations and subsequently by the increased incidence of neoplastic involvement of the thyroid and breast. Two cases of Cowden's disease with gastrointestinal polyps are presented to illustrate the alimentary tract involvement in this syndrome, gastrointestinal tract involvement with polyposis being seen in at least 50% of cases. As opposed to the more serious potential of neoplasia in the thyroid and breast, involvement of the alimentary tract has negligible clinical impact to the patient.

Cowden's disease--treatment of cutaneous lesions using carbon dioxide laser vaporization: a comparison of conventional and superpulsed techniques

Cowden's disease is a genodermatosis associated with both cutaneous and visceral manifestations, including cancer. Trichilemmomas represent one of the benign cutaneous lesions associated with this syndrome and may be responsible for significant cosmetic disfigurement. Using the carbon dioxide (CO2) laser in its vaporizational mode of operation, a patient with multiple trichilemmomas of the nose, previously unsuccessfully treated with multiple medical and surgical procedures, obtained excellent cosmetic results.