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Lauricella S, Rausa E, Pellegrini I, Ricci MT, Signoroni S, Palassini E, Cavalcoli F, Pasanisi P, Colombo C, Vitellaro M. Current management of familial adenomatous polyposis. Expert Rev Anticancer Ther 2024; 24:363-377. [PMID: 38785081 DOI: 10.1080/14737140.2024.2344649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION APC-associated polyposis is a rare hereditary disorder characterized by the development of multiple adenomas in the digestive tract. Individuals with APC-associated polyposis need to be managed by specialized multidisciplinary teams in dedicated centers. AREAS COVERED The study aimed to review the literature on Familial adenomatous polyposis (FAP) to provide an update on diagnostic and surgical management while focusing on strategies to minimize the risk of desmoid-type fibromatosis, cancer in anorectal remnant, and postoperative complications. FAP individuals require a comprehensive approach that includes diagnosis, surveillance, preventive surgery, and addressing specific extracolonic concerns such as duodenal and desmoid tumors. Management should be personalized considering all factors: genotype, phenotype, and personal needs. Total colectomy and ileo-rectal anastomosis have been shown to yield superior QoL results when compared to Restorative Procto colectomy and ileopouch-anal anastomosis with acceptable oncological risk of developing cancer in the rectal stump if patients rigorously adhere to lifelong endoscopic surveillance. Additionally, a low-inflammatory diet may prevent adenomas and cancer by modulating systemic and tissue inflammatory indices. EXPERT OPINION FAP management requires a multidisciplinary and personalized approach. Integrating genetic advances, innovative surveillance techniques, and emerging therapeutic modalities will contribute to improving outcomes and quality of life for FAP individuals.
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Affiliation(s)
- Sara Lauricella
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Emanuele Rausa
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Ilaria Pellegrini
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maria Teresa Ricci
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Signoroni
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elena Palassini
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Cavalcoli
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Patrizia Pasanisi
- Nutrition Research and Metabolomics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Chiara Colombo
- Sarcoma Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marco Vitellaro
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Shahzad MI, Pickering G, Zafar M, Hayat S, Vlavianos P. The Duodenal Accessory Ampulloma and the Role of Endoscopic Retrograde Cholangiopancreatography (ERCP) in Familial Adenomatous Polyposis Coli Inheritance. Cureus 2024; 16:e59445. [PMID: 38826909 PMCID: PMC11140427 DOI: 10.7759/cureus.59445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
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.
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Affiliation(s)
| | | | - Mansoor Zafar
- Gastroenterology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, GBR
| | - Sulaiman Hayat
- Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, GBR
| | - Panagiotis Vlavianos
- Hepatobiliary and Gastroenterology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, GBR
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Sasaki K, Kawai K, Nozawa H, Ishihara S, Ishida H, Ishibashi K, Mori Y, Shichijo S, Tani Y, Takeuchi Y, Chino A, Takao M, Fujiyoshi K, Matsubara T, Miyakura Y, Taniguchi F, Yamaguchi T, Tanakaya K, Tomita N, Ajioka Y. Risk of gastric adenoma and adenocarcinoma in patients with familial adenomatous polyposis in Japan: a nationwide multicenter study. J Gastroenterol 2024; 59:187-194. [PMID: 38263336 PMCID: PMC10904405 DOI: 10.1007/s00535-023-02074-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/26/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Patients with familial adenomatous polyposis (FAP) have an increased risk of developing gastric neoplasms. However, the clinical course of FAP with these gastric lesions has not yet been fully clarified. The present study aimed to clarify the changes in the incidence risk of developing gastric adenoma or gastric cancer during the lifespan of patients with FAP. METHODS Four hundred forty-three patients with data regarding gastric adenoma and gastric cancer retrospectively registered in a nationwide Japanese multicenter study were enrolled. The cumulative incidences and hazard rates (HRs) of gastric neoplasms were evaluated. RESULTS The cumulative incidence rates in 50-year-old patients with FAP were 22.8% for gastric adenoma and 7.6% for gastric cancer, respectively. No significant association was found between gastric neoplasms and the colonic phenotype. The peak age for the HR of gastric adenoma was 65 years, with the highest HR (0.043). Regarding the incidence of gastric cancer, the HR increased moderately up to the age of 40 years, but the increase accelerated from the age of 50 years (HR = 0.0067). CONCLUSION Careful surveillance of the upper gastrointestinal tract in elderly patients with FAP, such as shortening the interval of follow-up according to age, may be helpful for early diagnosis of gastric cancer.
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Affiliation(s)
- Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan.
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hideyuki Ishida
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Keiichiro Ishibashi
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Yoshiko Mori
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Satoki Shichijo
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yasuhiro Tani
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoji Takeuchi
- Department of Genetic Oncology, Division of Hereditary Tumors and Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Akiko Chino
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Misato Takao
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kenji Fujiyoshi
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Takaaki Matsubara
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Department of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Yasuyuki Miyakura
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Department of Surgery, Saitama Medical Center Jichi Medical University, Saitama, Japan
| | - Fumitaka Taniguchi
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Tatsuro Yamaguchi
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Department of Clinical Genetics, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kohji Tanakaya
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Naohiro Tomita
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Yoichi Ajioka
- The Committee of Hereditary Colorectal Cancer, Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan
- Division of Molecular and Diagnostic Pathology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Canovai E, Butler A, Clark S, Latchford A, Sinha A, Sharkey L, Rutter C, Russell N, Upponi S, Amin I. Treatment of Complex Desmoid Tumors in Familial Adenomatous Polyposis Syndrome by Intestinal Transplantation. Transplant Direct 2024; 10:e1571. [PMID: 38264298 PMCID: PMC10803031 DOI: 10.1097/txd.0000000000001571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/25/2023] [Indexed: 01/25/2024] Open
Abstract
Background Desmoid tumors are fibroblastic lesions which often have an unpredictable and variable clinical course. In the context of familial adenomatous polyposis (FAP), these frequently occur intra-abdominally, especially in the small-bowel mesentery resulting in sepsis, fistulation, and invasion of the abdominal wall and retroperitoneum. In selected cases where other modalities have failed, the most radical option is to perform a total enterectomy and intestinal transplantation (ITx). In this study, we present our center's experience of ITx for desmoid in patients with FAP. Methods We performed a retrospective review of our prospectively collected database between 2007 and 2022. All patients undergoing ITx for FAP-related desmoid were included. Results Between October 2007 and September 2023, 144 ITx were performed on 130 patients at our center. Of these, 15 patients (9%) were for desmoid associated with FAP (7 modified multivisceral transplants, 6 isolated ITx, and 2 liver-containing grafts). The median follow-up was 57 mo (8-119); 5-y patient survival was 82%, all with functioning grafts without local desmoid recurrence. These patients presented us with several complex surgical issues, such as loss of abdominal domain, retroperitoneal/abdominal wall involvement, ileoanal pouch-related issues, and the need for foregut resection because of adenomatous disease. Conclusions ITx is a viable treatment in selected patients with FAP and extensive desmoid disease. The decision to refer for ITx can be challenging, particularly the timing and sequence of treatment (simultaneous versus sequential exenteration). Delays can result in additional disease burden, such as secondary liver disease or invasion of adjacent structures.
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Affiliation(s)
- Emilio Canovai
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Andrew Butler
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Susan Clark
- Family Cancer & Lynch Syndrome Clinic, St Mark’s Centre for Familial Intestinal Cancer, St Mark’s Hospital, London North West University Healthcare NHS Trust, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Andrew Latchford
- Family Cancer & Lynch Syndrome Clinic, St Mark’s Centre for Familial Intestinal Cancer, St Mark’s Hospital, London North West University Healthcare NHS Trust, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Ashish Sinha
- Family Cancer & Lynch Syndrome Clinic, St Mark’s Centre for Familial Intestinal Cancer, St Mark’s Hospital, London North West University Healthcare NHS Trust, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Lisa Sharkey
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Charlotte Rutter
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Neil Russell
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Sara Upponi
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Irum Amin
- Cambridge Centre for Intestinal Rehabilitation and Transplant (CamCIRT), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
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Faul E, Xhaja X, Church J. Correlation Between the Severity of Adhesions and Desmoid Disease in Patients With Familial Adenomatous Polyposis: A Prospective Cohort Study. Dis Colon Rectum 2024; 67:273-279. [PMID: 36940315 DOI: 10.1097/dcr.0000000000002839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
BACKGROUND Clinical experience teaches that intraperitoneal adhesions are more severe in patients with familial adenomatous polyposis than in patients without it. This impression may come from the common association of familial adenomatous polyposis with desmoid disease. OBJECTIVES This study aimed to determine whether patients with familial adenomatous polyposis and desmoid disease develop more severe adhesions than those without desmoid disease. DESIGN Prospectively collected data study. SETTINGS Hereditary colorectal cancer center in a tertiary referral hospital. PATIENTS Patients undergoing first reoperative intra-abdominal surgery for familial adenomatous polyposis; controls were those having their initial abdominal surgery. INTERVENTIONS Surgery and adhesiolysis. MAIN OUTCOME MEASURES Presence and type of desmoid disease; presence and severity of nondesmoid intraperitoneal adhesions. Where patients had multiple operations, only the first reoperative surgery was chosen. Desmoid disease was noted as reaction (sheet) or mass. Adhesions were graded as none, mild (<10 min for mobilization), average (10-30 min), and severe (>30 min or significant bowel damage). Patients having their first abdominal surgery for familial adenomatous polyposis were used as a control group. RESULTS A total of 211 patients had no prior surgery; 5% had desmoids and 1% had adhesions. One hundred thirty-seven patients underwent reoperative surgery: 39% had desmoid disease ( p < 0.05 vs no prior surgery), the highest rate being in patients after IPAA (57%), and 45% had severe adhesions ( p < 0.01 vs no prior surgery), worst after Koch pouch (89%), and total proctocolectomy with ileostomy (82%). Thirty-six percent of patients without desmoid disease had severe adhesions. Desmoid reaction was associated with severe adhesions in 47% of cases and desmoid tumors in 66% of cases. LIMITATIONS Possible limitations include the potential overlap between desmoid adhesions and nondesmoid adhesions and the potential for inaccuracy in defining the time of adhesiolyses. CONCLUSIONS Familial adenomatous polyposis is associated with severe postoperative adhesions after reoperative abdominal surgery, especially in patients who develop desmoid disease. See Video Abstract . CORRELACIN ENTRE LA GRAVEDAD DE LAS ADHERENCIAS Y LA ENFERMEDAD DESMOIDEA EN PACIENTES CON POLIPOSIS ADENOMATOSA FAMILIAR ESTUDIO PROSPECTIVO DE COHORTES ANTECEDENTES:La experiencia clínica demuestra que las adherencias intraperitoneales son más graves en pacientes con poliposis adenomatosa familiar que en pacientes sin enfermedad desmoidea. Esta impresión puede provenir de la asociación común de poliposis adenomatosa familiar con enfermedad desmoidea.OBJETIVOS:Ver si los pacientes con poliposis adenomatosa familiar y enfermedad desmoidea desarrollan adherencias más graves que aquellos sin enfermedad desmoidea.DISEÑO:Estudio de datos recolectados prospectivamente.AJUSTES:Centro de cáncer colorrectal hereditario en un hospital de referencia terciario.PACIENTES:Pacientes sometidos a una primera cirugía intraabdominal de caracter reoperatorio por poliposis adenomatosa familiar: los controles fueron los que se sometieron a su cirugía abdominal inicial.INTERVENCIONES:Cirugía y adhesiolisis.PRINCIPALES MEDIDAS DE RESULTADO:Presencia y tipo de enfermedad desmoidea; presencia y severidad de adherencias intraperitoneales no desmoideas. Cuando los pacientes tenían múltiples operaciones, solo se eligió la primera cirugía reoperatoria. La enfermedad desmoidea se anotó como reacción (hoja filamentosa) o masa. Las adherencias se calificaron como ninguna, leve (<10 minutos para la movilización), promedio (10 a 30 minutos) y severa (>30 minutos o daño intestinal significativo). Los pacientes sometidos a una primera cirugía abdominal por poliposis adenomatosa familiar se utilizaron como grupo de control.RESULTADOS:211 pacientes no tenían cirugía previa: 5% desmoideos y 1% adherencias. 137 pacientes se sometieron a cirugía reoperatoria: 39% tenía enfermedad desmoidea ( p < 0,05 frente aquellos sin cirugía previa), la tasa más alta se presentó en aquellos pacientes después de una anastomosis ileoanal con reservorio (57%) donde el 45% tenía adherencias graves ( p < 0,01 frente aquellos sin cirugía previa), peores resultados se observaron después de la confección de un reservorio de Koch (89%) y luego de proctocolectomía total con ileostomía (82%). El 36% de los pacientes sin enfermedad desmoidea tenían adherencias graves. La reacción desmoidea se asoció con adherencias graves en el 47% de los casos, y los tumores desmoides se asociaron con adherencias graves en el 66% de los casos.LIMITACIONES:Superposición potencial entre adherencias desmoideas y adherencias no desmoideas. Posible inexactitud en la definición del tiempo de adhesiolisis.CONCLUSIONES:La poliposis adenomatosa familiar se asocia con adherencias postoperatorias graves después de una cirugía abdominal reoperatoria, especialmente en pacientes que desarrollan enfermedad desmoidea. (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Eleanor Faul
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
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Al-Sukhni E, Shapiro J, Suraweera H, Semotiuk K, Swallow CJ, Brar S, Razak A, Gupta AA, Gladdy RA. Desmoid Tumors in Familial Adenomatous Polyposis Patients: Favorable Outcomes with Multidisciplinary Management. Ann Surg Oncol 2023; 30:5142-5149. [PMID: 37237094 PMCID: PMC10215061 DOI: 10.1245/s10434-023-13675-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE In this study, we aimed to describe the clinical features, management, and outcomes of desmoid tumors (DTs) in familial adenomatous polyposis (FAP) patients at a high-volume sarcoma center. METHODS Consecutive patients with FAP and DTs were identified from our institutional databases (1985-2021). Patient demographics, treatment, and outcomes were described. Categorical data were compared using Fisher's exact test, and Kaplan-Meier curves were used to estimate progression-free survival (PFS). RESULTS Forty-five patients with 67 DTs were identified: 39 mesenteric or retroperitoneal (58.2%), 17 abdominal wall (25.4%), 4 extremity (6%), 4 breast (6%) and 3 back (4.4%). Severe DT symptoms were present in 12 patients (26.7%). Initial treatments per tumor were observation in 30 (44.8%) DTs, chemotherapy in 15 (22.4%) DTs, surgery in 10 (14.9%) DTs, and other systemic therapies in 10 (14.9%) DTs. The majority of DTs remained stable with observation or a single intervention (77.8%). Median PFS was 23.4 years (95% confidence interval 7.6-39.2). In the 12 severely symptomatic patients, four patients required more than two interventions for DT control. At a median follow-up of 6.0 years (range 0.7-35.8 years), 33 (73.3%) patients were alive with disease, 7 (15.6%) were alive without disease, and 5 (11.1%) died of other causes. No patients died of DT-related complications. CONCLUSIONS The majority of DTs in FAP patients remained stable with observation or a single intervention. There were no DT-related deaths; however, 12 of 45 patients (26.7%) experienced significant tumor morbidity and required more interventions for disease control. Further studies on quality of life are required.
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Affiliation(s)
- Eisar Al-Sukhni
- Division of Surgical Oncology, Mount Sinai Hospital, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Joel Shapiro
- Division of Surgical Oncology, Mount Sinai Hospital, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Harini Suraweera
- Division of Surgical Oncology, Mount Sinai Hospital, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kara Semotiuk
- Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, Toronto, ON, Canada
| | - Carol J Swallow
- Division of Surgical Oncology, Mount Sinai Hospital, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Savtaj Brar
- Division of Surgical Oncology, Mount Sinai Hospital, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Albiruni Razak
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Abha A Gupta
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Rebecca A Gladdy
- Division of Surgical Oncology, Mount Sinai Hospital, Princess Margaret Cancer Centre, Toronto, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
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Novel Endoscopic Polypectomy Surveillance Technique for Fundic Gland Polyps in Familial Adenomatous Polyposis Can Improve Early Detection of Dysplasia and Gastric Cancer. Am J Gastroenterol 2022; 117:1246-1254. [PMID: 35584332 DOI: 10.14309/ajg.0000000000001833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 05/16/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Fundic gland polyps (FGPs) are commonly found in patients with familial adenomatous polyposis (FAP) and are considered benign. Biopsies are not routinely performed, and conventional forceps may be time-consuming and/or yield nonrepresentative histology. The purpose of this study was to evaluate the role of a novel endoscopic polypectomy surveillance (EPS), a large volume cold-snare polypectomy technique of random FGPs, in the incidence of dysplasia and gastric cancer (GC) in FAP. METHODS This is a retrospective longitudinal cohort of patients with FAP referred to a tertiary care center for duodenal adenoma surveillance and who underwent EPS of FGPs between 2001 and 2019. Demographic, endoscopic, and clinicopathologic information was reviewed. RESULTS Thirty-five patients with FAP were identified at initial endoscopy by the mean age of 43.4 years (±12.8). One hundred thirteen surveillance endoscopies were performed in total using EPS. Dysplasia of FGPs was present on initial esophagogastroduodenoscopy in 7 patients (20%), and 13 additional patients (46.4%) progressed to low-grade dysplasia. Three patients (15%) who subsequently had progression to GC were found to have signet ring cell cancer within the foci of FGPs through EPS. One patient presented as metastatic GC. Progression from nondysplastic FGP to low-grade dysplasia occurred over 63 months (±46.3) with further progression to GC over 34 months (±8.5). Endoscopic risk factors for cancer were polyps >10 mm in size ( P < 0.001) and carpeting of polyps ( P < 0.001). The 5-year cumulative incidence of developing dysplasia was 35.7%. DISCUSSION We identified that the incidence of dysplasia and GC is higher than previously reported in patients with FAP. Our study used a novel EPS technique and was able to identify GC within the foci of FGPs. Upper endoscopic guidelines should include a more rigorous sampling method for FGPs, such as EPS, to optimize early detection of dysplasia and GC.
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Martin I, Roos VH, Anele C, Walton SJ, Cuthill V, Suzuki N, Bastiaansen BA, Clark SK, von Roon A, Dekker E, Latchford A. Gastric adenomas and their management in familial adenomatous polyposis. Endoscopy 2021; 53:795-801. [PMID: 32942317 PMCID: PMC8315898 DOI: 10.1055/a-1265-2716] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with familial adenomatous polyposis (FAP) are at increased risk of developing gastric adenomas. There is limited understanding of their clinical course and no consensus on management. We reviewed the management of gastric adenomas in patients with FAP from two centers. METHODS Patients with FAP and histologically confirmed gastric adenomas were identified between 1997 and 2018. Patient demographics, adenoma characteristics, and management/surveillance outcomes were collected. RESULTS Of 726 patients with FAP, 104 (14 %; 49 female) were diagnosed with gastric adenomas at a median age of 47 years (range 19 - 80). The median size of gastric adenomas was 6 mm (range 1.5 - 50); 64 (62 %) patients had adenomas located distally to the incisura. Five patients (5 %) had gastric adenomas demonstrating high-grade dysplasia (HGD) on initial diagnosis, distributed equally within the stomach. The risk of HGD was associated with adenoma size (P = 0.04). Of adenomas > 20 mm, 33 % contained HGD. Two patients had gastric cancer at initial gastric adenoma diagnosis. A total of 63 patients (61 %) underwent endoscopic therapy for gastric adenomas. Complications occurred in three patients (5 %) and two (3 %) had recurrence, all following piecemeal resection of large (30 - 50 mm) lesions. Three patients were diagnosed with gastric cancer at median follow-up of 66 months (range 66 - 115) after initial diagnosis. CONCLUSIONS We observed gastric adenomas in 14 % of patients with FAP. Of these, 5 % contained HGD; risk of HGD correlated with adenoma size. Endoscopic resection was feasible, with few complications and low recurrence rates, but did not completely eliminate the cancer risk.
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Affiliation(s)
- Isabel Martin
- The Polyposis Registry, St. Mark’s Hospital, London, United Kingdom,Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Victorine H. Roos
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Netherlands
| | - Chukwuemeka Anele
- The Polyposis Registry, St. Mark’s Hospital, London, United Kingdom,Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Sarah-Jane Walton
- Department of Surgery, Basildon and Thurrock University Hospital, Basildon, United Kingdom
| | - Victoria Cuthill
- The Polyposis Registry, St. Mark’s Hospital, London, United Kingdom
| | - Noriko Suzuki
- The Polyposis Registry, St. Mark’s Hospital, London, United Kingdom
| | - Barbara A. Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Netherlands
| | - Susan K. Clark
- The Polyposis Registry, St. Mark’s Hospital, London, United Kingdom,Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Alexander von Roon
- Department of Surgery, University College Hospital, London, United Kingdom
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Netherlands
| | - Andrew Latchford
- The Polyposis Registry, St. Mark’s Hospital, London, United Kingdom,Department of Surgery and Cancer, Imperial College London, United Kingdom
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9
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Sasaki K, Nozawa H, Kawai K, Murono K, Emoto S, Kishikawa J, Ishii H, Yokoyama Y, Abe S, Nagai Y, Anzai H, Sonoda H, Taira T, Ishihara S. Risk of extracolonic malignancies and metachronous rectal cancer after colectomy and ileorectal anastomosis in familial adenomatous polyposis. Asian J Surg 2021; 45:396-400. [PMID: 34330586 DOI: 10.1016/j.asjsur.2021.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/12/2021] [Accepted: 06/30/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Analysis of long-term clinical outcomes of patients with familial adenomatous polyposis is critical in reducing or preventing the incidence of extracolonic malignancies after initial surgery. The aim of the present study was to clarify the long-term outcomes, and establish a surveillance strategy for surgically treated familial adenomatous polyposis patients. METHODS Between January 1967 and March 2020, retrospective data were collected from 37 patients with familial adenomatous polyposis treated or monitored in our department. Occurrence of metachronous cancers, including rectal cancers and extracolonic malignancies, and other diseases was analyzed. RESULTS The median follow-up duration after the first surgery was 13.8 years. Initially, 16 patients underwent total proctocolectomy with ileal pouch-anal anastomosis, 18 underwent total colectomy with ileorectal anastomosis, and three underwent other procedures. A secondary proctectomy was performed for 9 of the 18 patients who underwent ileorectal anastomosis. Rectal cancer was diagnosed in 6 patients who underwent ileorectal anastomosis. In addition, 5 gastric cancer, 2 duodenal cancer, 1 gallbladder cancer, and 1 thyroid cancer cases were diagnosed. The age at which the extracolonic malignancies were diagnosed was >50 years. 4 patients died due to metachronous rectal cancer, gastric cancer, or gallbladder cancer. CONCLUSION Careful consideration should be paid before choosing ileorectal anastomosis as the treatment procedure for familial adenomatous polyposis patients because completion proctectomy was eventually necessary for half of the patients. Long-term surveillance, with more frequent gastric surveillance for patients over 50 years, is important for the prevention and treatment of extracolonic malignancies in familial adenomatous polyposis patients.
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Affiliation(s)
- Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan.
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Junko Kishikawa
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Hiroaki Ishii
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Shinya Abe
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Yuzo Nagai
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Hiroyuki Anzai
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Tetsuro Taira
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo, Japan
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10
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Pasquer A, Benech N, Pioche M, Breton A, Rivory J, Vinet O, Poncet G, Saurin JC. Prophylactic colectomy and rectal preservation in FAP: systematic endoscopic follow-up and adenoma destruction changes natural history of polyposis. Endosc Int Open 2021; 9:E1014-E1022. [PMID: 34222624 PMCID: PMC8211478 DOI: 10.1055/a-1467-6257] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/04/2021] [Indexed: 12/30/2022] Open
Abstract
Background and study aims Prophylactic surgery of familial adenomatous polyposis (FAP) includes total colectomy with ileorectal anastomosis (IRA) to proctocolectomy with ileoanal anastomosis (IAA). Surgical guidelines rely on studies without systematic endoscopic follow-up and treatment. Our aim was to report our experience based on a different approach: therapeutic follow-up, comparing in this setting IRA and IAA in terms of oncological safety and quality of life. Patients and methods Between January 1965 and November 2015, all patients who underwent prophylactic surgery for FAP with therapeutic endoscopic follow-up in Lyon University hospital: systematic endoscopic treatment of adenomas, were retrospectively and prospectively (since 2011) included. Results A total of 296 patients were analyzed: 92 had proctocolectomy with IAA (31.1 %), 197 total colectomy with IRA (66.5 %), and seven abdominoperineal resections (2.4 %). Median follow-up was 17.1 years (range, 0-38.1). Incidence of secondary cancer (IR vs. IAA) was 6.1 % vs. 1.1 % ( P = 0.06; 95 %CI 0.001-0.36). The 15-year cancer-free and overall survival (IR vs. IAA) were 99.5 % vs 100 % ( P = 0.09) and 98.9 % vs. 98.8 % ( P = 0.82), respectively. Postoperative morbidity occurred in 44 patients: 29 (14.7 %) in the IRA and 15 (16.3 %) in the IAA group ( P = 0.72). The mean number of stools per day in the respective groups were 4.4 (2.5) vs. 5.5 (2.6) ( P = 0.001). Fecal incontinence occurred in 14 patients (7.1 %) in the IRA vs. 16 (17.4 %) in the IAA group ( P = 0.03). Conclusions A combination of therapeutic endoscopic treatment and extended rectal preservation appears to be a safe alternative to ileoanal J-pouch anastomosis.
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Affiliation(s)
- Arnaud Pasquer
- Digestive and Oncological Surgery Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France,University Claude Bernard Lyon I, Faculté de Médecine Lyon Est, Lyon, France
| | - Nicolas Benech
- Hepato-gastroenterology Department Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Mathieu Pioche
- University Claude Bernard Lyon I, Faculté de Médecine Lyon Est, Lyon, France,Hepato-gastroenterology Department Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Antoine Breton
- Digestive and Oncological Surgery Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Jerome Rivory
- Hepato-gastroenterology Department Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Olivier Vinet
- Hepato-gastroenterology Department Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Gilles Poncet
- Digestive and Oncological Surgery Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France,University Claude Bernard Lyon I, Faculté de Médecine Lyon Est, Lyon, France
| | - Jean Christophe Saurin
- University Claude Bernard Lyon I, Faculté de Médecine Lyon Est, Lyon, France,Hepato-gastroenterology Department Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
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11
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Mehta NA, Shah RS, Yoon J, O'Malley M, LaGuardia L, Mankaney G, Bhatt A, Burke CA. Risks, Benefits, and Effects on Management for Biopsy of the Papilla in Patients With Familial Adenomatous Polyposis. Clin Gastroenterol Hepatol 2021; 19:760-767. [PMID: 32492482 DOI: 10.1016/j.cgh.2020.05.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 05/20/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Ampullary and duodenal cancer are the leading causes of death in patients with familial adenomatous polyposis (FAP) after colectomy has been performed. Risk of duodenal cancer is determined based on Spigelman stage (SS) of duodenal polyposis. Guidelines recommend endoscopic surveillance of the duodenum and visualization of the papilla to stage duodenal polyposis. There is no consensus on whether biopsies should be routinely collected from duodenal papilla and findings included in SS. Additionally, there are no data on the risk of pancreatitis after biopsy collection from papilla of patients with FAP. We studied the incidence of pancreatitis after biopsy of the papilla in patients with FAP and effects of biopsy findings on SS. METHODS We identified consecutive patients with FAP at a single center from January 2011 through December 2018 with ≥1 endoscopy with biopsy of the papilla. Patients with history of foregut surgery were excluded. We identified 273 patients with FAP who had biopsies collected from papilla over 792 EGDs, with 1-8 independent exams with biopsy per patient. We collected demographic, endoscopic, and histology data from patients and calculated SS with vs without biopsy findings. Post-procedural pancreatitis was defined by 2 of the following: abdominal pain, lipase level 3-fold the upper limit of normal, or radiography findings consistent with pancreatitis within 7 days of esophagogastroduodenoscopy (EGD). RESULTS Pancreatitis developed in 2 patients (0.73%): 1 after biopsy of a normal-appearing papilla and 1 after biopsy of an abnormal appearing papilla. Inclusions of biopsy data increased SS in 36 patients (13.2%), with consideration of prophylactic duodenectomy for 3.3%. CONCLUSIONS Pancreatitis after biopsy of the duodenal papilla is rare. Histology data obtained from biopsy of the papilla in patients with FAP can change SS and affect patient management.
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Affiliation(s)
- Neal A Mehta
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Ravi S Shah
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jiyoon Yoon
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Margaret O'Malley
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lisa LaGuardia
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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12
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Zhou J, Liang C, Qing D, Wang Y, Tan Y, Shi X. A novel large deletion in the APC gene associated with Gardner syndrome in a Chinese family. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:179-182. [PMID: 33213169 DOI: 10.17235/reed.2020.6974/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Gardner syndrome is a hereditary disease characterized by familial adenomatous polyposis (FAP), accompanied by soft tissue tumors. MATERIAL AND METHODS a Chinese FAP family was enrolled and followed-up for three years. RESULTS a novel large germline fragment deletion (EX10_16DEL) of the adenomatous polyposis coli (APC) gene was identified by multiplex ligation-dependent probe amplification (MLPA). An unexpected abdominal tumor grew two years after a subtotal colectomy of the proband. The immunohistochemistry study of the abdominal tumor showed SMA(focal+), calponin(+), β-catenin(nucleus+) and CD34(focal+), CD117(-), which was consistent with a desmoid tumor. CONCLUSION when a FAP related desmoid tumor appears, the possibility of Gardner syndrome should be considered. This is the first largest deletion of the APC gene in the Chinese population associated with Gardner syndrome.
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Affiliation(s)
- Junfeng Zhou
- Gastroenterology, The Second Xiangya Hospital. Central South University
| | - Chengbo Liang
- Medical Genetics, The Second Xiangya Hospital. Central South University
| | - Duxin Qing
- Medical Genetics, The Second Xiangya Hospital. Central South University
| | - Yongjun Wang
- Medical Genetics, The Second Xiangya Hospital. Central South University
| | - Yuyong Tan
- Medical Genetics, The Second Xiangya Hospital. Central South University
| | - Xiaoliu Shi
- Gastroenterology, second Xiangya Hospital. Central South University,
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13
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Augustin T, Moslim MA, Cengiz TB, El-Hayek K, Simon R, Bhatt A, Tang A, Burke CA, Matthew Walsh R. Survival outcomes after surgical management of sporadic or familial adenomatous polyposis associated duodenal cancer. J Surg Oncol 2020; 122:1132-1144. [PMID: 33124067 DOI: 10.1002/jso.26131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 06/08/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Duodenal cancer is the second most common cause of cancer death in familial adenomatous polyposis (FAP) patients. In this study, we compare oncologic outcomes between sporadic and FAP-associated duodenal cancer. METHODS In this retrospective study, all patients who underwent surgeries between 2000 and 2014 for either sporadic or FAP duodenal cancer were identified. The patients were grouped based on diagnoses and perioperative and survival outcomes were compared. RESULTS A total of 56 patients with duodenal cancer (43 sporadic, 13 FAP) who underwent surgery were identified. Pancreatoduodenectomy (PD) was the most common procedure performed. The overall median survival was 7.5 years (1 year: 92%; 5 years: 58.1%). FAP patients had earlier tumor, node, and metastasis stage, less margin involvement, less perineural, and angiolymphatic invasion but had a comparable survival to sporadic patients. The median survival for FAP duodenal cancer was 7.4 vs 9.6 years for sporadic (P = .97) with similar utilization of adjuvant chemotherapy. Although not statistically significant, PD had an improved median survival compared to segmental duodenal resection (SDR) (9.6 years for PD vs 3.6 years for SDR, P = .17). Non-periampullary location and presence of positive lymph nodes were significant predictors of mortality on multivariate analysis. CONCLUSIONS FAP duodenal cancer has no survival advantage compared to sporadic duodenal cancer despite an improved stage of resection with extraampullary lesions having a worse survival.
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Affiliation(s)
- Toms Augustin
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Maitham A Moslim
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Turgut Bora Cengiz
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Kevin El-Hayek
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease, and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Andrew Tang
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Digestive Disease, and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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14
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Outcome of a novel modified endoscopic papillectomy for duodenal major papilla adenoma. Surg Endosc 2020; 34:5160-5167. [PMID: 32666256 PMCID: PMC7572334 DOI: 10.1007/s00464-020-07715-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
Background and aims In recent years, with the development of endoscopic techniques, endoscopic resection is widely used for duodenal papillary adenomas, but conventional endoscopic resection has a high rate of incomplete resection and recurrence. On this basis, we have employed a novel modified endoscopic papillectomy (ESP). In this study, we evaluated the feasibility and advantages of this ESP for the treatment of duodenal major papilla adenoma. Methods A total of 56 patients with duodenal major papilla adenoma confirmed by endoscopic ultrasonography, intraluminal ultrasound and gastroscopic biopsy from October 2007 to June 2017 were collected in the Department of Gastroenterology, Nanjing Drum Tower Hospital. The diameter of the adenoma ranged from 1.41 to 2.02 cm. 16 cases were given the conventional method and 40 cases underwent the modified ESP procedure in which a small incision was made by cutting current when anchoring the snare tip on the distal side of the adenoma. Results En bloc resection rate was significantly higher in the modified group (100%, 40/40) than that in the conventional group (81.3%, 13/16; P = 0.02). However, no significance was seen between the modified group and the conventional group in complete resection rate (92.5%, 37/40 vs 93.8%, 15/16; P = 1.00). There was no significant difference in the number and difficulty of postoperative pancreatic and biliary stents placement between the two groups (P = 0.20). Total bleeding occurrence was much lower in the modified group (37.5%, 15/40 vs 87.5%, 14/16; P = 0.001), and no significant differences were found in other short-term complications and the 3, 6, 12 and 24 months recurrences rate between the conventional and modified ESP groups. Conclusions The modified ESP improves the treatment outcome of duodenal major papilla adenoma with higher en bloc resection rate and lowering bleeding rate. Electronic supplementary material The online version of this article (10.1007/s00464-020-07715-0) contains supplementary material, which is available to authorized users.
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15
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Leite JS, Tralhão JG, Manso A, Fernandes M, Cunha I, Amaro P. Pancreas- and Pylorus-Preserving Duodenectomy for Advanced Familial Duodenal Polyposis. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:185-191. [PMID: 32509924 DOI: 10.1159/000503010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 08/29/2019] [Indexed: 11/19/2022]
Abstract
Most patients with familial adenomatous polyposis (FAP) will develop duodenal polyps and 5% progress to cancer. Those with Spigelman stage IV have a 36% risk of cancer at 10 years. Endoscopic surveillance is necessary with local ablation for early disease. Unresectable duodenal disease and severe dysplasia are an indication for prophylactic radical surgery by pancreaticoduodenectomy or pancreas-sparing duodenectomy. Some preliminary results have shown better outcomes with duodenectomy. A 45-year-old female with FAP had restorative proctocolectomy at 24 years, desmoid of the mesentery with regression after sulindac, two pregnancies, and at the age of 37 years had duodenal polyposis stage III carpeting the periampullary region. Endoscopic papillectomy and extensive piecemeal mucosectomy was performed but was unsuccessful due to recurrence. After 7 years of regular endoscopic surveillance, focal high-grade dysplasia was diagnosed at the last evaluation. Some diminutive polyps were seen in the small-bowel capsule endoscopy. MRCP showed a normal biliary and pancreatic duct without visualization of the Santorini duct. A pancreas and pylorus-preserving duodenectomy was performed with 3 main steps: (1) duodenectomy with preservation of the pancreas and the pylorus; (2) reconstruction with an advanced jejunal limb and duodenojejunostomy; (3) reimplantation of the biliary and pancreatic duct in the jejunal loop. The patient was discharged on the 11th postoperative day without complications. In conclusion, pancreas- and pylorus-preserving duodenectomy is a promising alternative to pancreaticoduodenectomy for advanced duodenal polyposis that allows complete endoscopic surveillance.
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Affiliation(s)
- Júlio S Leite
- Serviço de Cirurgia Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - José Guilherme Tralhão
- Serviço de Cirurgia Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - António Manso
- Serviço de Cirurgia Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Miguel Fernandes
- Serviço de Cirurgia Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Inês Cunha
- Serviço de Gastrenterologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Amaro
- Serviço de Gastrenterologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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16
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Yang J, Gurudu SR, Koptiuch C, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Khashab MA, Jamil LH, Jue TL, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Thosani N, Wani SB, Samadder NJ. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in familial adenomatous polyposis syndromes. Gastrointest Endosc 2020; 91:963-982.e2. [PMID: 32169282 DOI: 10.1016/j.gie.2020.01.028] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 02/08/2023]
Abstract
Familial adenomatous polyposis (FAP) syndrome is a complex entity, which includes FAP, attenuated FAP, and MUTYH-associated polyposis. These patients are at significant risk for colorectal cancer and carry additional risks for extracolonic malignancies. In this guideline, we reviewed the most recent literature to formulate recommendations on the role of endoscopy in this patient population. Relevant clinical questions were how to identify high-risk individuals warranting genetic testing, when to start screening examinations, what are appropriate surveillance intervals, how to identify endoscopically high-risk features, and what is the role of chemoprevention. A systematic literature search from 2005 to 2018 was performed, in addition to the inclusion of seminal historical studies. Most studies were from worldwide registries, which have compiled years of data regarding the natural history and cancer risks in this cohort. Given that most studies were retrospective, recommendations were based on epidemiologic data and expert opinion. Management of colorectal polyps in FAP has not changed much in recent years, as colectomy in FAP is the standard of care. What is new, however, is the developing body of literature on the role of endoscopy in managing upper GI and small-bowel polyposis, as patients are living longer and improved endoscopic technologies have emerged.
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Affiliation(s)
- Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Suryakanth R Gurudu
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Cathryn Koptiuch
- Department of Population Sciences, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Deepak Agrawal
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Department of Gastroenterology, University of California, San Diego, California, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Beaumont Hospital-Royal Oak, Royal Oak, Michigan, USA
| | - Terry L Jue
- Department of Gastroenterology, The Permanente Medical Group, San Francisco, California, USA
| | - Joanna K Law
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Advent Health Medical Group, Gastroenterology/Hepatology, Advent Health Hospital Altamonte Springs, Altamonte Springs, Florida, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainsville, Florida, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - N Jewel Samadder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
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17
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Zuin M, Celotto F, Pucciarelli S, Urso EDL. Isoperistaltic Jejunal Loop Interposition after Total Gastrectomy for Gastric Cancer in Patients with Familial Adenomatous Polyposis. J Gastric Cancer 2020; 20:225-231. [PMID: 32596005 PMCID: PMC7311215 DOI: 10.5230/jgc.2020.20.e16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/12/2020] [Accepted: 04/02/2020] [Indexed: 01/09/2023] Open
Abstract
Gastric cancer is a rare condition affecting patients with familial adenomatous polyposis (FAP). The mainstay of treatment is total gastrectomy. Since duodenal cancer is the most common cause of death after total colectomy in FAP, endoscopic surveillance for duodenal cancer is mandatory. Here, we describe the use of an isoperistaltic jejunal loop interposition technique to reconstruct the digestive tract after total gastrectomy in 2 patients with FAP. There were no early or late complications. Both patients are still alive and in good clinical condition. They did not experience weight loss or symptoms of dumping syndrome. Duodenal endoscopic surveillance after this technique was easier than after the classical Roux-en-Y reconstruction. Hence, regular follow-up was possible for both patients.
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Affiliation(s)
- Matteo Zuin
- Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Clinica Chirurgica I, Azienda Ospedaliera di Padova, Università di Padova, Padova, Italy
| | - Francesco Celotto
- Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Clinica Chirurgica I, Azienda Ospedaliera di Padova, Università di Padova, Padova, Italy
| | - Salvatore Pucciarelli
- Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Clinica Chirurgica I, Azienda Ospedaliera di Padova, Università di Padova, Padova, Italy
| | - Emanuele Damiano Luca Urso
- Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Clinica Chirurgica I, Azienda Ospedaliera di Padova, Università di Padova, Padova, Italy
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Chittleborough T, Sampurno S, Carpinteri S, Lynch AC, Heriot AG, Ramsay RG. Modeling open surgery in mice to explore peritoneal damage, carbon dioxide humidification and desmoidogenesis. Pleura Peritoneum 2019; 4:20190023. [PMID: 31799374 PMCID: PMC6881699 DOI: 10.1515/pp-2019-0023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/03/2019] [Indexed: 12/31/2022] Open
Abstract
Background The exposure of the peritoneum to desiccation during surgery generates lasting damage to the mesothelial lining which impacts inflammation and tissue repair. We have previously explored open abdominal surgery in mice subjected to passive airflow however, operating theatres employ active airflow. Therefore, we sought an engineering solution to recapitulate the active airflow in mice. Similarly, to the passive airflow studies we investigated the influence of humidified-warm carbon dioxide (CO2) on this damage in the context of active airflow. Additionally, we addressed the controversial role of surgery in exacerbating desmoidogenesis in a mouse model of familial adenomatous polyposis. Methods An active airflow mouse-operating module manufactured to produce the equivalent downdraft airflow to that of a modern operating theatre was employed. We quantified mesothelial cell integrity by scanning electron microscopy (SEM) sampled from the peritoneal wall that was subjected to mechanical damage or not, with and without the delivery of humidified-warm CO2. To explore the role of open and laparoscopic surgery in the process of desmoidogenesis we crossed Apcmin/+ C57Bl/6 mice with p53+/− mice to generate animals that developed desmoid tumors with 100% penetrance. Results One hour of active airflow generates substantial damage to peritoneal mesothelial cells and their microvilli as measured at 24 h post intervention, which is significantly greater than that generated by passive airflow. Use of humidified-warm CO2 mostly protects the mesothelium that had not experienced additional mechanical (surgical) damage at 24 h. Maximal damage was evident in all treatment groups regardless of flow or use of gas. At day 10 mechanically-damaged peritoneum remains in mice but is essentially repaired in the gas-treated groups. Regarding desmoidogenesis, operating procedures did not increase the frequency of desmoid tumors but their frequency correlated with time following surgery but not age of mice. Conclusions Active airflow generates more peritoneal damage than passive airflow and is reduced significantly by the use of humidified-warm CO2. Introduced peritoneal damage is largely repaired in mice by day 10 with gas. Desmoid tumor incidence is not increased substantially by surgery itself but rises over time following surgery compared to non-surgery mice.
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Affiliation(s)
| | | | | | | | | | - Robert George Ramsay
- GI Cancer Program, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne3000, Victoria, Australia
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Wang Y, Qi M, Hao Y, Hong J. The efficacy of prophylactic pancreatic stents against complications of post-endoscopic papillectomy or endoscopic ampullectomy: a systematic review and meta-analysis. Therap Adv Gastroenterol 2019; 12:1756284819855342. [PMID: 31263509 PMCID: PMC6595661 DOI: 10.1177/1756284819855342] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/01/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endoscopic resection has been increasingly adopted for neoplasms in the major duodenal papilla. Previous studies have reached varying conclusions on whether prophylactic pancreatic stent (PS) placement is an effective measure against post-procedure complications. We aimed to investigate whether PS could reduce the incidence of post-procedure complications. METHODS The PubMed, Cochrane Library, and EMBASE databases were systematically searched from the inception dates to 25 December 2018 to identify all randomized controlled trials (RCTs) and retrospective cohort studies (RCSs) comparing prophylactic PS and no PS against post-procedure complications. The main outcomes measurements were post-procedure pancreatitis, bleeding, perforation and late papillary stenosis. RESULTS 23 RCSs (1001 subjects) and 2 RCTs met the inclusion criteria. Meta-analysis of the RCSs showed that prophylactic PS decreased the odds of post-procedure pancreatitis (OR, 0.71; 95% CI, 0.36-1.40; p = 0.325) as well as late papillary stenosis (OR, 0.35; 95% CI, 0.07-1.75; p = 0.200; I 2 =0%) and increased the odds of bleeding (OR, 1.32; 95% CI, 0.50-3.46; p = 0.572; I 2 = 0%) and perforation (OR, 2.25; 95% CI, 0.33-15.50; p = 0.412; I 2 = 0%) but not significantly. Sensitivity analysis illustrated prophylactic PS significantly decreased the risk of post-procedure pancreatitis (OR, 0.44; 95% CI, 0.24-0.80; p = 0.007). CONCLUSIONS PS placement was prophylactic against post-procedure complications although not significantly. Sensitivity analysis suggests the significant effect of prophylactic PS against post-procedure pancreatitis. More RCTs are required to validate the statistical significance of our results and potentially relevant characteristics improving the prophylactic efficacy of stents.
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Affiliation(s)
- Yining Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, and Key Laboratory of Carcinogenesis and Cancer Invasion (Ministry of Education), Fudan University, Shanghai, China,Joint Programme of Nanchang University and Queen Mary University of London, Nanchang, China
| | - Miao Qi
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,Joint Programme of Nanchang University and Queen Mary University of London, Nanchang, China
| | - Yuanzhen Hao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,Joint Programme of Nanchang University and Queen Mary University of London, Nanchang, China
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Saurin JC, Benech N, Calavas L, Pasquer A. Why not simply treat large adenomas of the rectum and ileal pouch after colectomy in familial adenomatous polyposis? Endosc Int Open 2019; 7:E699-E700. [PMID: 31074465 PMCID: PMC6506332 DOI: 10.1055/a-0890-3379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
| | - Nicolas Benech
- Gastroenterology Unit, E. Herriot Hospital. Hospices Civils de Lyon, Lyon, France
| | - Laura Calavas
- Gastroenterology Unit, E. Herriot Hospital. Hospices Civils de Lyon, Lyon, France
| | - Arnaud Pasquer
- Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon, France
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van Houdt WJ, Wei IH, Kuk D, Qin LX, Jadeja B, Villano A, Hameed M, Singer S, Crago AM. Yield of Colonoscopy in Identification of Newly Diagnosed Desmoid-Type Fibromatosis with Underlying Familial Adenomatous Polyposis. Ann Surg Oncol 2019; 26:765-771. [PMID: 30610557 PMCID: PMC6380484 DOI: 10.1245/s10434-018-07138-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Desmoid-type fibromatosis can arise in patients with familial adenomatous polyposis (FAP), therefore patients with desmoids often undergo colonoscopy to rule out FAP. Because finding FAP is uncommon, we sought to define subsets of desmoid patients in whom colonoscopy frequently identified FAP. METHODS Patients with desmoid-type fibromatosis were identified from surgery and pathology databases at a single institution, and information on colonoscopy and FAP diagnosis was collected retrospectively. CTNNB1 mutation status was defined by Sanger sequencing and digital polymerase chain reaction of archived specimens. RESULTS Among 626 patients with desmoids, 26 were diagnosed with FAP. In 20 patients, FAP diagnosis predated the desmoid diagnosis. Among patients without prior FAP diagnosis, 161 underwent colonoscopy, which identified only six cases of FAP (diagnostic yield 3.7%). Yields were substantially higher among patients with four characteristics: age < 40 years (11% yield), intra-abdominal or retroperitoneal tumors (5.4%), multifocal disease (29%), and family history (8%) (all p < 0.001). All cases of FAP were detected in patients younger than 40 years of age and with at least one of the other three characteristics. CTNNB1 mutation status was available in 82 patients with known FAP status. None of the 61 patients with CTNNB1 mutations were diagnosed with FAP, while 7 of the 21 patients with no CTNNB1 mutation detected (24%) were FAP patients. CONCLUSIONS Patients with desmoid-type fibromatosis and undiagnosed FAP generally have multiple risk factors, which may be used to selectively recommend colonoscopic screening. Routine CTNNB1 sequencing may also rule out FAP and allow for deferral of colonoscopy.
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Affiliation(s)
- Winan J van Houdt
- Sarcoma Biology Laboratory and Sarcoma Disease Management Team, Sarcoma Disease Management Program, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Iris H Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Deborah Kuk
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Li-Xuan Qin
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bhumika Jadeja
- Sarcoma Biology Laboratory and Sarcoma Disease Management Team, Sarcoma Disease Management Program, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anthony Villano
- Sarcoma Biology Laboratory and Sarcoma Disease Management Team, Sarcoma Disease Management Program, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meera Hameed
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samuel Singer
- Sarcoma Biology Laboratory and Sarcoma Disease Management Team, Sarcoma Disease Management Program, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Aimee M Crago
- Sarcoma Biology Laboratory and Sarcoma Disease Management Team, Sarcoma Disease Management Program, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
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Management of Familial Adenomatous Polyposis in Children and Adolescents: Position Paper From the ESPGHAN Polyposis Working Group. J Pediatr Gastroenterol Nutr 2019; 68:428-441. [PMID: 30585891 DOI: 10.1097/mpg.0000000000002247] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Familial adenomatous polyposis (FAP) is a well-described inherited syndrome, characterized by the development of hundreds to thousands of adenomas in the colorectum, with implications in children and adolescents. Almost all adult patients will develop colorectal cancer if they are not identified and treated early enough. Identifying and screening for FAP commences in adolescence. The syndrome is inherited as an autosomal dominant trait and caused by mutations in the adenomatous polyposis (APC) gene. This European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) position paper provides a guide for diagnosis, assessment, and management of FAP in children and adolescents.This is the first position paper regarding FAP published by ESPGHAN. Literature from PubMed, Medline, and Embase was reviewed and in the absence of evidence, recommendations reflect the opinion of paediatric and adult experts involved in the care of polyposis syndromes. Because many of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, these of the recommendations are supported on expert opinion. This position paper will instruct on the appropriate management and timing of procedures in children and adolescents with FAP.
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Genotype-Phenotype Associations of APC Mutations With Pouch Adenoma in Patients With Familial Adenomatous Polyposis. J Clin Gastroenterol 2019; 53:e54-e60. [PMID: 29099467 DOI: 10.1097/mcg.0000000000000950] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with familial adenomatous polyposis (FAP) may carry various adenomatous polyposis coli (APC) mutations. However, genotype-phenotype correlation for APC mutations is still debated and is yet to be evaluated with regard to pouch polyp formation. OBJECTIVE To evaluate the association between APC mutation type and exon location and the outcome of pouch adenoma. DESIGN SETTING AND PATIENTS Forty-five FAP patients with defined pathogenic APC mutations, who underwent total proctocolectomy and ileal pouch anal anastomosis were classified by mutation type and location. Analysis was conducted for clinical and endoscopic parameters. RESULTS Twenty patients had either indel/deletion mutations and 25 had nonsense/missense mutations. The indel/deletion group was associated with higher prevalence of preoperative hundreds of colonic adenomas (66.7% vs. 30%; P=0.030), lower rates of stapled versus sewn anastomosis (46.7% vs. 76%; P=0.060), of single stage surgery (13.3% vs. 44%; P=0.045) and with higher pouch adenoma formation rate (50% vs. 8%; P=0.002). Twenty-seven were carriers of exons 1 to 14 mutations and 18 were carriers of exon 15 mutations. Carriers of exon 15 mutations had higher prevalence of preoperative hundreds of colonic adenomas (55.6% vs. 22.2%; P=0.003) and a higher tendency for pouch and cuff adenoma formation rate. Adjusted odds ratio for pouch adenoma formation was 8.32 (1.42-48.80; P=0.019) for the indel/deletion group versus nonsense/missense, but no significant independent association was noted with mutation location. The mean number of pouch and cuff adenoma formation (per endoscopy) was higher among carriers of exon 15 mutations, but no significant independent association was noted the with mutation type. CONCLUSIONS Type and location of APC mutation are associated with colonic polyp burden, surgical outcome and likelihood of developing pouch adenomas. These findings may contribute to surgical and endoscopic surveillance decisions for FAP patients.
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Ashburn JH. Management of rectal neoplasia in hereditary colorectal cancer patients. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Yamamoto R, Mokuno Y, Matsubara H, Kaneko H, Iyomasa S. Multiple mesenteric desmoid tumors after gastrectomy for gastric cancer: A case report and literature review. Int J Surg Case Rep 2018; 50:50-55. [PMID: 30081320 PMCID: PMC6083430 DOI: 10.1016/j.ijscr.2018.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/24/2018] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Many patients with desmoids have an antecedent trauma, particularly surgical intervention for familial adenomatous polyposis. However, cases of mesenteric desmoid after gastrectomy are extremely rare. We present a case of multiple mesenteric desmoids after total gastrectomy for gastric cancer. PRESENTATION OF CASE A 70-year-old man had undergone a total gastrectomy for early stage gastric cancer. He had no other relevant medical history or family history. A year after gastrectomy, a computed tomography showed three mesenteric masses, and we performed careful observation. The 2-year postoperative examination indicated slowly growing masses. There were no other lesions except for the three masses. We decided to perform diagnostic surgery to evaluate the tumors. There were three mesenteric masses (1.5 cm, 4 cm and 1.5 cm in diameter). We performed partial small intestinal resections for each mass. Histological examination showed that the tumors were desmoids. A year after surgery, he was doing well with no evidence of recurrence of the desmoids or the gastric cancer. DISCUSSION Diagnosing intra-abdominal desmoid tumors is often difficult. Especially if a patient has a history of malignancy, it may be extremely difficult to differentiate multiple mesenteric desmoids from a cancer recurrence. In the current case, surgical resection was a useful treatment option as diagnostic therapy. CONCLUSIONS Multiple mesenteric desmoids could emerge after gastrectomy for gastric cancer, and surgical resection of the tumors is a useful option as a diagnostic therapy.
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Affiliation(s)
- Ryusei Yamamoto
- Department of Surgery, Yachiyo Hospital, 2-2-7, Sumiyoshi-cho, Anjo-shi, Aichi, 446-8510, Japan.
| | - Yasuji Mokuno
- Department of Surgery, Yachiyo Hospital, 2-2-7, Sumiyoshi-cho, Anjo-shi, Aichi, 446-8510, Japan.
| | - Hideo Matsubara
- Department of Surgery, Yachiyo Hospital, 2-2-7, Sumiyoshi-cho, Anjo-shi, Aichi, 446-8510, Japan.
| | - Hirokazu Kaneko
- Department of Surgery, Yachiyo Hospital, 2-2-7, Sumiyoshi-cho, Anjo-shi, Aichi, 446-8510, Japan.
| | - Shinsuke Iyomasa
- Department of Surgery, Yachiyo Hospital, 2-2-7, Sumiyoshi-cho, Anjo-shi, Aichi, 446-8510, Japan.
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Sulbaran M, Campos FG, Ribeiro U, Kishi HS, Sakai P, de Moura EGH, Bustamante-López L, Tomitão M, Nahas SC, Cecconello I, Safatle-Ribeiro AV. Risk factors for advanced duodenal and ampullary adenomatosis in familial adenomatous polyposis: a prospective, single-center study. Endosc Int Open 2018; 6:E531-E540. [PMID: 29713679 PMCID: PMC5909774 DOI: 10.1055/a-0577-2650] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 12/18/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND STUDY AIMS To determine the clinical features associated with advanced duodenal and ampullary adenomas in familial adenomatous polyposis. Secondarily, we describe the prevalence and clinical significance of jejunal polyposis. PATIENTS AND METHODS This is a single center, prospective study of 62 patients with familial adenomatous polyposis. Duodenal polyposis was classified according to Spigelman and ampullary adenomas were identified. Patients with Spigelman III and IV duodenal polyposis underwent balloon assisted enteroscopy. Predefined groups according to Spigelman and presence or not of ampullary adenomas were related to the clinical variables: gender, age, family history of familial adenomatous polyposis, type of colorectal surgery, and type of colorectal polyposis. RESULTS Advanced duodenal polyposis was present in 13 patients (21 %; 9 male) at a mean age of 37.61 ± 13.9 years. There was a statistically significant association between family history of the disease and groups according to Spigelman ( P = 0.03). Seven unrelated patients (6 male) presented ampullary adenomas at a mean age of 36.14 ± 14.2 years. The association between ampullary adenomas and extraintestinal manifestations was statistically significant in multivariate analysis ( P = 0.009). Five endoscopic types of non-ampullary adenoma were identified, showing that lesions larger than 10 mm or with a central depression presented foci of high grade dysplasia. Among 28 patients in 12 different families, a similar Spigelman score was identified; 10/12 patients (83.3 %) who underwent enteroscopy presented small tubular adenomas with low grade dysplasia in the proximal jejunum. CONCLUSIONS Advanced duodenal polyposis phenotype may be predictable from disease severity in a first-degree relative. Ampullary adenomas were independently associated with the presence of extraintestinal manifestations.
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Affiliation(s)
- M. Sulbaran
- Gastrointestinal Endoscopy Service, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Corresponding author Marianny Sulbaran, MD MSc Gastrointestinal Endoscopy Service, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of MedicineAv. Dr. Eneas de Carvalho Aguiar, 255 – Block 3 – Cerqueira Cesar, Sao Paulo – SP, 01246-000Brazil+55-11-31494790
| | - F. G. Campos
- Surgical Division, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - U. Ribeiro
- Surgical Division, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - H. S. Kishi
- Pathology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - P. Sakai
- Gastrointestinal Endoscopy Service, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - E. G. H. de Moura
- Gastrointestinal Endoscopy Service, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - L. Bustamante-López
- Surgical Division, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - M. Tomitão
- Pathology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - S. C. Nahas
- Surgical Division, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - I. Cecconello
- Surgical Division, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - A. V. Safatle-Ribeiro
- Gastrointestinal Endoscopy Service, Gastroenterology Department, Clinics Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
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Abstract
Gastric cancer is not a recognised extra-colonic manifestation of FAP, except in countries with a high prevalence of gastric cancer. Data regarding gastric adenomas in FAP are sparse. The aim of this study was to review the clinical characteristics of gastric tumours occurring within an FAP population from the largest European polyposis registry. All patients that developed a gastric adenoma or carcinoma were identified from a prospectively maintained registry database. The primary outcome measure was the occurrence of gastric adenoma or adenocarcinoma. Secondary outcomes included APC mutation, tumour stage, management and survival. Eight patients developed gastric cancer and 21 an adenoma (median age 52 and 44 years, respectively). Regular oesophagogastroduodenoscopy surveillance was performed in 6/8 patients who developed cancer. Half were advanced T3/4 tumours and 6/8 had nodal or metastatic spread at diagnosis. All cancer cases died within a median of 13.5 months from diagnosis. Gastric adenomas were evenly distributed: 11/21 (52%) in the distal and 10/21 (48%) proximal stomach, whereas 5/8 (63%) cancers were located proximally. An association between gastric tumour and desmoid development was observed; 7/8 (88%) cancer and 11/21 (52%) adenoma cases had a personal or family history of desmoid. It would appear from this small, retrospective study that gastric cancer is not a prominent extra-colonic feature of FAP in the Western world. It seems to present at an advanced stage with a poor prognosis. There may be an association between gastric tumour and desmoid occurrence but a large multicentre cohort is necessary to investigate this further.
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Adrenal Lesions in Patients With (Attenuated) Familial Adenomatous Polyposis and MUTYH-Associated Polyposis. Dis Colon Rectum 2017; 60:1057-1064. [PMID: 28891849 DOI: 10.1097/dcr.0000000000000809] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The reported proportion of patients with familial adenomatous polyposis who have adrenal lesions varies between 7% and 13% compared with 4% in the general population; the prevalence of adrenal lesions in patients with attenuated familial adenomatous polyposis and MUTYH-associated polyposis is unknown. Data on the clinical relevance and clinical course are limited. OBJECTIVE We aimed to report on the frequency, characteristics, and progression of adrenal lesions in polyposis patients. DESIGN This was a historical cohort study. SETTINGS The study was performed at the Academic Medical Center, Amsterdam. PATIENTS All of the patients with familial adenomatous polyposis, attenuated familial adenomatous polyposis, and MUTYH-associated polyposis were included. Medical charts and imaging reports were analyzed for data on adrenal lesions. A radiologist reassessed all of the images. Patients had not routinely been screened for adrenal lesions. MAIN OUTCOME MEASURES The frequency, characteristics, and progression of adrenal lesions in patients with polyposis who underwent abdominal imaging were assessed. Findings were compared with a reference. RESULTS A total of 39 adrenal lesions were identified in 23 (26%) of 90 patients with familial adenomatous polyposis, 2 (18%) of 11 with attenuated familial adenomatous polyposis, and 5 (24%) of 21 with MUTYH-associated polyposis. Mean age at time of detection was 50.7 years (range, 17.1-83.3 y). Median lesion size at baseline was 1.4 cm (range, 1.0-5.0 cm) versus 1.7 cm (range, 1.0-5.7 cm) after a median of 3.5 years (range, 1.0-11.4 y). Two patients were diagnosed with a hyperfunctioning lesion, and 4 underwent adrenalectomy: 3 lesions appeared benign, and 1 was oncocytic of uncertain malignant potential. The OR for detecting at least 1 lesion in a patient with polyposis versus reference was 6.2 (95% CI, 3.2-12.3), with no significant differences in ORs among the 3 syndromes. LIMITATIONS The study was limited by its retrospective design. CONCLUSIONS Adrenal lesions are frequent in patients with polyposis who undergo abdominal imaging. They appear to follow a benign and slowly progressive course and are mostly nonhyperfunctioning. See Abstract Video at http://links.lww.com/DCR/A323.
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Prognostic impact of hospital volume on familial adenomatous polyposis: a nationwide multicenter study. Int J Colorectal Dis 2017; 32:1489-1498. [PMID: 28831607 DOI: 10.1007/s00384-017-2885-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Many studies have shown that hospital volume is significantly associated with short- and long-term outcomes in various diseases, including cancer. However, there have been no reports discussing the relationship between hospital volume and familial adenomatous polyposis (FAP). This study aimed to clarify whether hospital volume affects short- and long-term outcomes in FAP patients. METHODS We established a retrospectively collected database of FAP patients who underwent initial surgical treatment at 23 Japanese institutions during 2000-2012. Factors associated with short- and long-term outcomes were analyzed. RESULTS The study cohort included 303 FAP patients. These patients were classified into tertile categories according to hospital volume: low (n = 31), middle (n = 72), and high volume (n = 200). The proportion of only adenoma/stage 0 was comparable among tertile categories. The adoption of operative procedure significantly differed among tertile categories; specifically, high-volume institutions preferred handsewn ileal pouch-anal anastomosis without diverting ileostomy (P < 0.001 and < 0.001, respectively). Nevertheless, the frequency of complications with Clavien-Dindo classification grade ≥ 3 was not significantly different among tertile categories. Functional results were acceptable in every category. Wexner scores were significantly lower in high-volume compared to low-volume institutions (P = 0.02). Multivariate analyses showed that UICC stage and hospital volume were significantly associated with overall survival (P = 0.04 and 0.03, respectively). CONCLUSIONS Hospital volume was significantly associated with short- and long-term outcomes in FAP patients.
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Pancreas-sparing total duodenectomy for Spigelman stage IV duodenal polyposis associated with familial adenomatous polyposis: experience of 10 cases at a single institution. Fam Cancer 2017; 16:91-98. [PMID: 27655252 DOI: 10.1007/s10689-016-9932-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Duodenal cancer is a leading cause of death in patients with familial adenomatous polyposis (FAP). In patients with Spigelman's classification (SC) stage IV duodenal polyposis (DP), careful endoscopic surveillance by specialists or surgical intervention is mandatory. We herein report the surgical and pathological outcomes of FAP patients with SC stage duodenal polyposis undergoing pancreas-sparing total duodenectomy (PSTD), which has been rarely reported but seems optimal in such patients. PSTD and distal gastrectomy with Billroth-I type reconstruction in ten consecutive FAP patients with SC stage IV DP are reported. The median duration of surgery was 396 min (range 314-571 min) and the median estimated blood loss was 480 mL (range 100-975 mL). Significant postoperative complications included wound infection in 1 patient, pancreatic fistula [International Study Group on Pancreatic Fistula definition (ISGPF) grade B] in 4 patients. Histopathologic examinations revealed a well-differentiated carcinoma in situ in 3 patients and others were all adenomas. Over a median follow-up period of 15 months (range 9-29 months), 1 patient developed a stomal ulcer which improved with medical treatment. There were no patients with a body weight loss of ≥10 % relative to the preoperative body weight. No recurrence were experienced during the follow up period. Patients were free from postoperative diabetes mellitus. PSTD is a feasible and acceptable procedure in FAP patients with SC stage IV DP, in terms of surgical, pathological and clinical outcome. However, accumulation of the patients and long-term follow up study is necessary.
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Gan M, Boothe D, Neklason DW, Samadder NJ, Frandsen J, Keener MB, Lloyd S. Outcomes and complications of radiation therapy in patients with familial adenomatous polyposis. J Gastrointest Oncol 2017; 8:643-649. [PMID: 28890814 DOI: 10.21037/jgo.2017.03.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The outcomes, complications, and rates of secondary malignancies from radiation therapy (RT) are not known for patients with familial adenomatous polyposis (FAP). METHODS We queried the Hereditary Gastrointestinal Cancer Registry (HGCR) for patients with FAP who received RT. Outcomes assessed included acute and late treatment toxicity and secondary malignancies. RESULTS We identified 15 patients undergoing 18 treatment courses. Median follow-up was 3.1 years after RT. Treated sites included rectal cancer, desmoid, prostate cancer, breast cancer, melanoma, medulloblastoma, gastric cancer, and glioma. Secondary tumors occurred in two patients: a medulloblastoma was diagnosed in a patient treated for glioma, and a desmoid tumor was diagnosed in a patient treated for rectal cancer. All nine patients treated with intra-abdominal or pelvic RT had prior prophylactic proctocolectomies, yet only one patient experienced grade 3 gastrointestinal toxicity. Common Terminology Criteria for Adverse Events version 4 (CTCAE v4) toxicities were grade 1 in seven treatment courses (39%), grade 2 in five courses (28%), and grade 3 in two courses (11%). CONCLUSIONS In this cohort, RT was well tolerated with adverse effects comparable with non-FAP patients. Secondary in-field tumors occurred in 2 of 15 patients and their increased risk in this cohort was likely due to prior predilection from FAP itself, although an increased role of RT cannot be ruled out.
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Affiliation(s)
- Meng Gan
- University of Utah School of Medicine; Salt Lake City, UT, USA
| | - Dustin Boothe
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah; Salt Lake City, UT, USA
| | - Deborah W Neklason
- Department of Oncological Sciences, University of Utah; Salt Lake City, UT, USA
| | - N Jewel Samadder
- Department of Internal Medicine, University of Utah; Salt Lake City, UT, USA
| | - Jonathan Frandsen
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah; Salt Lake City, UT, USA
| | - Megan B Keener
- Department of Oncological Sciences, University of Utah; Salt Lake City, UT, USA
| | - Shane Lloyd
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah; Salt Lake City, UT, USA
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de Latour RA, Kilaru SM, Gross SA. Management of small bowel polyps: A literature review. Best Pract Res Clin Gastroenterol 2017; 31:401-408. [PMID: 28842049 DOI: 10.1016/j.bpg.2017.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 06/25/2017] [Indexed: 02/07/2023]
Abstract
Despite the small bowel comprising 90% of the mucosal surface area of the gastrointestinal tract, it is a rare site for neoplasia and only accounts for a little over 3% of the tumors that arise in the digestive tract. Benign small bowel lesions include lipomas, lymphangiomas, leiomyomas, neurofibromas, nodular lymphoid hyperplasia and adenomas, many of which are precursors to malignant lesions. Several polyposis syndromes are associated with small bowel polyps as well, including familial adenomatous polyposis syndrome, lynch syndrome, Peutz-Jeghers syndrome, Cowden syndrome and juvenile polyposis syndrome. Our aim was to review non-malignant small bowel polyps and discuss the prevalence, typical location, clinical presentation, diagnosis, endoscopic and histologic description and lastly management of each of these lesions.
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Affiliation(s)
- Rabia A de Latour
- New York University School of Medicine, Department of Gastroenterology, 240 East 38th Street, 23rd Floor, New York, NY 10016, USA.
| | - Saikiran M Kilaru
- New York University School of Medicine, Department of Gastroenterology, 240 East 38th Street, 23rd Floor, New York, NY 10016, USA.
| | - Seth A Gross
- New York University School of Medicine, Department of Gastroenterology, 240 East 38th Street, 23rd Floor, New York, NY 10016, USA.
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Adenomatous Polyposis Syndromes: Familial Adenomatous Polyposis and MutYH-Associated Polyposis. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0379-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Skubitz KM. Biology and Treatment of Aggressive Fibromatosis or Desmoid Tumor. Mayo Clin Proc 2017; 92:947-964. [PMID: 28578783 DOI: 10.1016/j.mayocp.2017.02.012] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/24/2017] [Accepted: 02/16/2017] [Indexed: 12/14/2022]
Abstract
Aggressive fibromatosis, also known as desmoid-type fibromatosis (DTF) or desmoid tumor, is an uncommon locally invasive tumor. Because of its low incidence and variable behavior, DTF is often first seen by physicians who are not familiar with it, and recent advances in understanding this disease have led to changes in treatment approaches. The Wnt (β-catenin) pathway appears to play a key role in DTF pathogenesis, and recent studies of DTF biology suggest a possible model of DTF pathogenesis. Histologically, DTF shows a poorly circumscribed proliferation of myofibroblast-like cells with variable collagen deposition, similar to the proliferative phase of wound healing, and DTF has been associated with trauma and pregnancy. Desmoid-type fibromatosis may be a useful model of the tumor stroma in carcinomas as well as other fibrosing diseases such as progressive pulmonary fibrosis. The clinical course of DTF can vary greatly among patients, complicating the determination of the optimal treatment approach. Treatment options include surgery, nonsteroidal anti-inflammatory drugs with or without hormonal manipulation, chemotherapy, radiation therapy, and other forms of local therapy. Many treatments have been used, but these are not without toxicities. Because of the variable nature of the disease and the potential morbidity of treatment, some cases of DTF may do better without treatment; simple observation is often the best initial treatment. This review used a PubMed search from January 1, 1980, through October 31, 2016, using the terms fibromatosis and desmoid and discusses DTF disease characteristics, pathophysiology, and treatment options as well as examines several cases illustrating key points in the biology and treatment of this heterogeneous disease.
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Affiliation(s)
- Keith M Skubitz
- Department of Medicine, University of Minnesota Medical School, Minneapolis.
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Chittleborough TJ, Warrier SK, Heriot AG, Kalady M, Church J. Dispelling misconceptions in the management of familial adenomatous polyposis. ANZ J Surg 2017; 87:441-445. [PMID: 28266097 DOI: 10.1111/ans.13919] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 12/18/2016] [Accepted: 12/26/2016] [Indexed: 12/15/2022]
Abstract
Patients with familial adenomatous polyposis require surgical intervention at some point in their lives. The diagnosis is often apparent from their phenotype and family history, however, this is not always the case. Many factors can influence the surgical strategy although the polyposis burden and distribution remain the main consideration. While prophylactic removal of the rectum and colon is often required, sparing the rectum at the index surgery is safe in select patients. This article aims to dispel misconceptions in the diagnosis and treatment of patients with familial adenomatous polyposis.
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Affiliation(s)
- Timothy J Chittleborough
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew Kalady
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio, USA
| | - James Church
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio, USA
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Li L, Jensen JN, Szabo S, VanTuinen P, Lew SM. Recurrent giant cranial desmoid tumor in a 3-year-old boy with familial adenomatous polyposis requiring bifrontoparietal cranioplasty: case report. J Neurosurg Pediatr 2016; 25:703-707. [PMID: 27635978 DOI: 10.3171/2016.6.peds15741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Desmoid tumors, also known as aggressive fibromatosis, are locally infiltrating musculoaponeurotic neoplasms arising in connective tissues. Desmoid tumors may be associated with familial adenomatous polyposis (FAP), a genetic disorder that presents with hundreds to thousands of precancerous colorectal polyps. The authors report the case of an 18-month-old boy who underwent resection of a right temporal desmoid tumor (initially diagnosed as cranial fasciitis) and developed a bilateral frontoparietal calvarial desmoid tumor 2 years later. The patient underwent gross-total resection of the tumor that required a large cranioplasty. He was subsequently diagnosed with FAP. The patient has been without tumor recurrence for 9 years afterwards and has not required revision of his cranioplasty. This is the first report describing a recurrent cranial desmoid tumor in a pediatric patient with FAP. The authors believe, however, that some of the cases previously reported as cranial fasciitis are likely desmoid tumors pathobiologically and genetically.
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Affiliation(s)
- Luyuan Li
- Departments of 1 Neurological Surgery and
| | - John N Jensen
- Plastic Surgery, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, Wisconsin; and
| | - Sara Szabo
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Peter VanTuinen
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sean M Lew
- Departments of 1 Neurological Surgery and
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Santos M, Rocha A, Martins V, Santos M. Desmoid Tumours in Familial Adenomatous Polyposis: Review of 17 Patients from a Portuguese Tertiary Center. J Clin Diagn Res 2016; 10:PC01-PC05. [PMID: 27891388 DOI: 10.7860/jcdr/2016/19451.8596] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/27/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Desmoid Tumours (DT) are benign tumours with an estimated incidence of 2-4 per million per year. Between 7-16% of them are associated with Familial Adenomatous Polyposis (FAP) and are mostly parietal or intra-abdominal. They are a challenge in relation to their unpredictable natural course, associated complications and difficult treatment. AIM The aim of the present study was to review the occurrence, management and follow-up of DT on FAP patients treated consecutively at a tertiary care center. MATERIALS AND METHODS A retrospective review of clinical data from patients treated consecutively between 1993 and 2014. Patients' data was gathered from clinical records. Data collection included the following variables: demographic data, genotype, FAP phenotype, data on FAP related surgery, DT diagnosis, location, size and number, DT treatment, patients' status and follow-up data. RESULTS The study population consisted of 17 patients from 9 families; with a mean age of 41 years, mostly women (59%) and most with a mutation either on codon 232 or 554. Most tumours had an intra-abdominal component (59%) with a mean size of 5cm. Fifteen patients were first treated with pharmacotherapy (Non-steroidal Anti-inflammatory Drugs (NSAIDs) and Tamoxifen). Five patients (29%) underwent surgery, 4 of them for complications of intra-abdominal tumours and 1 patient for abdominal wall tumours. Two patients underwent chemotherapy in relation to aggressive intra-abdominal disease. The mean follow-up time since diagnosis of DT was 123 months. Overall, 2 patients had remission, 11 patients had regression or stabilized disease, and 2 patients had progression. One patient died due to surgical complications. CONCLUSION Diagnosis of DT is based on clinical symptoms, without the need for screening, although imaging plays an important role once diagnosis is suspected. The treatment approach is conservative on most patients, leaving surgery for DT related complications. The follow-up of patients with DT is also based on clinical symptoms.
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Affiliation(s)
- Marco Santos
- General Surgeons, Department of Surgery, General Surgery Service, Centro Hospitalar do Porto , Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - Anabela Rocha
- General Surgeons, Department of Surgery, General Surgery Service, Centro Hospitalar do Porto , Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - Vilma Martins
- General Surgeons, Department of Surgery, General Surgery Service, Centro Hospitalar do Porto , Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - Marisa Santos
- General Surgeons, Department of Surgery, General Surgery Service, Centro Hospitalar do Porto , Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
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Mesenteric Fibromatosis in Crohn's Disease as a Potential Effect of Adalimumab. ACG Case Rep J 2016; 3:184-6. [PMID: 27144199 PMCID: PMC4843151 DOI: 10.14309/crj.2016.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 12/03/2015] [Indexed: 12/24/2022] Open
Abstract
A 36-year-old woman with no medical or surgical history was evaluated for weight loss. Abdominal computed tomography (CT) showed signs of Crohn's disease, which was later confirmed endoscopically. She was started on tumor necrosis factor-α (TNF-α) inhibitor therapy. Nine months after treatment, she experienced additional weight loss and a 7 x 8 x 8-cm mass on repeat CT. Biopsy revealed retroperitoneal fibromatosis, so TNF-α was continued. Repeat CT showed an enlarged mass. TNF-α therapy had a suspected role in mass growth, therapy was discontinued, and the mass surgically resected. One year after resection, she has regained weight with no recurrence of the mesenteric fibromatosis.
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Familial adenomatous polyposis in pediatrics: natural history, emerging surveillance and management protocols, chemopreventive strategies, and areas of ongoing debate. Fam Cancer 2016; 15:477-85. [DOI: 10.1007/s10689-016-9905-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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41
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Waller A, Findeis S, Lee MJ. Familial Adenomatous Polyposis. J Pediatr Genet 2016; 5:78-83. [PMID: 27617147 DOI: 10.1055/s-0036-1579760] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/10/2015] [Indexed: 12/12/2022]
Abstract
Familial adenomatous polyposis (FAP), caused by a germline mutation in the adenomatous polyposis coli (APC) gene on chromosome 5q21, is an autosomal dominant disorder characterized by hundreds to thousands of adenomas throughout the gastrointestinal tract. A variety of extraintestinal manifestations, including thyroid, soft tissue, and brain tumors, may also be present. These patients inevitably develop colorectal carcinoma by the fourth decade of life. In this review, the pathology, epidemiology, and genetic features of FAP are discussed.
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Affiliation(s)
- Alexia Waller
- Department of Pathology, Baylor University Medical Center, Dallas, Texas, United States
| | - Sarah Findeis
- School of Medicine and Dentistry, Pennsylvania State University, Hershey, Pennsylvania, United States
| | - Michael J Lee
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, United States
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Mishra DP, Rout SS. Desmoid Tumors: A Clear Perspective or a Persisting Enigma? A Case Report and Review of Literature. World J Oncol 2016; 7:21-27. [PMID: 28983359 PMCID: PMC5624685 DOI: 10.14740/wjon961w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2016] [Indexed: 01/31/2023] Open
Abstract
Desmoid tumors are benign but locally aggressive tumors of mesenchymal origin which are poorly circumscribed, infiltrate the surrounding tissue, lack a true capsule and are composed of abundant collagen. History of trauma or surgery to the site of tumor origin is elicited in up to one in four cases and they most commonly develop in the anterior abdominal wall and shoulder girdle but they can arise in any skeletal muscle. The clinical behavior and natural history of desmoid tumors are unpredictable and management is difficult with many issues remaining controversial, mainly regarding early detection, the role, type and timing of surgery and the value of non-operative therapies. We report a case of anterior abdominal wall desmoid tumor in a 40-year-old male with a previous history of surgery.
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Affiliation(s)
- Debi Prasad Mishra
- Department of Pathology, MKCG Medical College and Hospital, Berhampur, Odisha, India
| | - Suman Saurav Rout
- Department of General Surgery, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
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Abstract
GOALS Our aim was to determine whether the screening of family members of familial adenomatous polyposis (FAP) patients significantly influences survival, and to gauge the extent of FAP-related causes of death. BACKGROUND The screening of families with FAP has been shown to be profitable in reducing colorectal cancer-related mortality, but conclusions about the screening effect on overall survival has been controversial. STUDY This is a nationwide population-based retrospective cohort study, and the primary outcome of interest was overall mortality and survival. A total of 154 families with at least 1 clinically diagnosed FAP patient between 1963 and 2015 were included. There were altogether 194 probands and 225 call-ups. During the follow-up period, 2639 person-years with 92 deaths among probands were observed and 3634 person-years and 30 deaths among call-ups. We report crude mortality rates and standardized mortality ratios together with descriptive statistics. We compared the survival of probands and call-ups to the population by relative survival method. RESULTS The crude mortality rate among probands was 34.9 per 1000 person-years and 8.3 among call-ups. The standardized mortality ratios for call-ups was 2.47 (confidence interval, 1.69-3.46) and for probands 4.07 (confidence interval, 3.29-4.96) (P=0.014). The relative survival of probands was significantly lower than call-ups (P=0.0018), and 20-year relative survival for call-ups was 94% (88% to 100%). Over two thirds of all deaths were FAP related. CONCLUSIONS Survival of screened family members of FAP patients is comparable to the general population within 20 years after diagnosis. Therefore, participation in surveillance should not be delayed when a family member with FAP has been detected.
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Desurmont T, Lefèvre JH, Shields C, Colas C, Tiret E, Parc Y. Desmoid tumour in familial adenomatous polyposis patients: responses to treatments. Fam Cancer 2015; 14:31-9. [PMID: 25315103 DOI: 10.1007/s10689-014-9760-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
No guidelines for desmoid tumors (DT) management are available and DT have now become the first cause of death in FAP patients who had restorative proctocolectomy. We aimed to assess the results of the different treatments used for DT in Familial Adenomatous Polyposis (FAP) patients. All patients followed for FAP who developed a DT between 1970 and 2010 were collated. We analysed separately the history of DT according to location: mesenteric, parietal or mixed. 79 FAP patients [45 females (56 %); mean age 33.3 ± 12.5] presented 149 DT and were included; 16(20 %) had a DT diagnosed during or before first abdominal surgery and 47 (59 %) had isolated mesenteric DT. 11 patients had only surgical treatment, 17 only medical treatments, 31 had combined treatment and 20 had no treatment with spontaneous DT regression or stabilization. Overall, 80 treatment lines were administered to patients with a progression free or regression rate of 43 % (34/80). Response rates were: chemotherapy 77 % (10/13); Sulindac + tamoxifen 50 % (6/12); Tamoxifen 40 % (6/15); Imatinib 36 % (4/11); Sulindac 28 % (8/29). Among the 42 surgical procedures, an R0 resection was performed in 26 (62 %) allowing the absence of recurrence for 54 %. After a median follow-up of 81 months, 8 patients died of their DT and 6 died of other cause. Overall and DT-specific survival at 20 years were 52 and 79 %, respectively. Chemotherapy was the most efficient treatment. For intra-abdominal DT, we consider it as a first choice treatment and reserve surgery when it is impossible or when DT are life threatening.
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Affiliation(s)
- Thibault Desurmont
- Department of Digestive Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris VI, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
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Roncucci L, Mariani F. Prevention of colorectal cancer: How many tools do we have in our basket? Eur J Intern Med 2015; 26:752-6. [PMID: 26499755 DOI: 10.1016/j.ejim.2015.08.019] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 07/16/2015] [Accepted: 08/07/2015] [Indexed: 12/18/2022]
Abstract
Prevention is the main strategy in order to reduce colorectal cancer incidence and mortality. It can be accomplished through primary prevention, using measures affecting factors known to confer higher risk of colorectal cancer, or through secondary prevention, aimed at early diagnosis of cancer or preneoplastic lesions in groups of subjects at increased risk of cancer. Although primary prevention should be the goal for future years, because it acts on the probable causes of colorectal cancer, at present it seems that secondary prevention is more effective on colorectal cancer survival, and the approaches which have yielded the most satisfying results, in terms of reduced mortality for cancer, are those aimed at detecting preneoplastic lesions, or cancer at an early stage in selected groups of subjects at average or increased risk of colorectal cancer. These groups are subjects aged 50years or older, affected individuals (gene carriers) or family members of hereditary colorectal cancer syndromes (i.e., Lynch syndrome and familial adenomatous polyposis), and patients with inflammatory bowel diseases. The most effective procedures used, though with some drawbacks, are fecal occult blood tests and colonoscopy. Future research should be addressed to find new approaches that will render preventive strategies more acceptable for the population, and more cost-effective.
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Affiliation(s)
- Luca Roncucci
- Department of Diagnostic and Clinical Medicine and Public Health, University of Modena and Reggio Emilia, Policlinico, Via Del Pozzo 71, Modena 41124, Italy.
| | - Francesco Mariani
- Department of Diagnostic and Clinical Medicine and Public Health, University of Modena and Reggio Emilia, Policlinico, Via Del Pozzo 71, Modena 41124, Italy
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Wnęk B, Strugała M, Łożyńska-Nelke A, Burdyński R, Krokowicz P. Familial Adenomatous Polyposis; 30-Year Observation of a Female Patient - Case Report. POLISH JOURNAL OF SURGERY 2015; 87:86-90. [PMID: 26146100 DOI: 10.1515/pjs-2015-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Indexed: 11/15/2022]
Abstract
Familial adenomatous polyposis (FAP) is a colorectal cancer syndrome caused by a germline mutation inherited in an autosomal-dominant pattern with a 100% penetrance. Our detailed case report presents a history of a 55-year-old FAP female patient who had been under constant clinical observation for 30 years. The disease was diagnosed at the age of 22. The patient underwent restorative proctocolectomy with ileal pouch-anal anastomosis (PRC-IPAA). During our follow-up extra-colonic manifestations occurred such as a desmoidtumour, fundic gland polyps in the stomach and duodenal polyps also in the periampullary region. Apart from disease-related symptoms the patient manifested other complications such as small bowel adhesive obstruction, benign breast tumours, uterine myomas, cholelithiasisand thyroid nodules. Our analysis of the above case presents advantages of a long-term medical observation of a FAP patient carried out by a specialist surgical medical centre.
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Rich TA, Liu M, Etzel CJ, Bannon SA, Mork ME, Ready K, Saraiya DS, Grubbs EG, Perrier ND, Lu KH, Arun BK, Woodard TL, Schover LR, Litton JK. Comparison of attitudes regarding preimplantation genetic diagnosis among patients with hereditary cancer syndromes. Fam Cancer 2015; 13:291-9. [PMID: 24072553 DOI: 10.1007/s10689-013-9685-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Preimplantation genetic diagnosis (PGD) allows couples to avoid having a child with an inherited condition, potentially reducing cancer burden in families with a hereditary cancer predisposition. This study investigated and compared awareness and acceptance of PGD among patients with different hereditary cancer syndromes. Questionnaires were mailed to 984 adults with hereditary breast and ovarian cancer, Lynch syndrome, familial adenomatous polyposis, or multiple endocrine neoplasia type 1 or 2. Associations between clinical, demographic, and psychosocial factors and awareness and acceptance of PGD were examined. Of 370 respondents (38 % return rate), 28 % felt their syndrome impacted family planning, 24 % were aware of PGD, 72 % felt that PGD should be offered, 43 % would consider using PGD, and 29 % were uncertain. Family experience and syndrome-specific characteristics, such as disease severity, quality of life and availability of medical interventions as well as gender, family planning stage, and religiosity impact perceptions of the acceptability of PGD, though a high level of uncertainty exists. Hereditary cancer patients lack awareness of PGD despite feeling that PGD should be offered, highlighting the need for education on this topic. While we found attitudes about the acceptability of PGD to be generally similar to those reported in the literature and of genetics and ethics experts, we observed similarities and differences between syndromes that provide insight into why some hereditary cancer patients may find PGD more acceptable than others.
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Affiliation(s)
- Thereasa A Rich
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA,
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Moussata D, Napoleon B, Lepilliez V, Klich A, Ecochard R, Lapalus MG, Nancey S, Cenni JC, Ponchon T, Chayvialle JA, Saurin JC. Endoscopic treatment of severe duodenal polyposis as an alternative to surgery for patients with familial adenomatous polyposis. Gastrointest Endosc 2014; 80:817-25. [PMID: 24814771 DOI: 10.1016/j.gie.2014.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 03/05/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with familial adenomatous polyposis (FAP) and severe (stage IV) duodenal polyposis are candidates for pancreaticoduodenectomy, which has high morbidity. Little information is available about the feasibility of therapeutic endoscopy for these patients. OBJECTIVE To evaluate the long-term efficiency and risks of endoscopic therapy. DESIGN Retrospective study. SETTING A 2-referral center long-term cohort study. PATIENTS Thirty-five FAP patients (15 men, mean age 48 years) presenting with stage IV duodenal polyposis were included. Patients had a mean Spigelman classification score of 9.8 points (range 9-12 points) at their first examination. INTERVENTIONS Patients underwent a surveillance endoscopy, including lateral and axial viewing with chromoendoscopy while under sedation, along with 7 ± 4.8 therapeutic endoscopic sessions during a follow-up period of 9 ± 4.5 years (range 1-19 years) after their first endoscopy. MAIN OUTCOME MEASUREMENTS Treatment modalities, adverse events, and efficiency (evolution of the Spigelman score) were reviewed. RESULTS A total of 245 therapeutic endoscopies were performed and 15 adverse events (6%) occurred. During the follow-up period, Spigelman scores decreased in 95% of patients by 6 ± 2.2 points (P = .002). Modeling analysis showed that the mean Spigelman score decreased by 60% after 150 months. LIMITATIONS Retrospective study and the duration of the follow-up, even though this is the longest follow-up reported in medical literature. CONCLUSION Endoscopic treatment of severe duodenal polyposis in patients with FAP produces few adverse events and allows efficient downstaging of the polyposis. Long-term follow-up data did not reveal a high risk of invasive duodenal cancer in these patients.
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Affiliation(s)
- Driffa Moussata
- Gastroenterology Department, Lyon Sud Hospital, Pierre Benite, France
| | | | | | - Amna Klich
- Statistics Department, Lyon Civil Hospital, Lyon, France
| | - René Ecochard
- Statistics Department, Lyon Civil Hospital, Lyon, France
| | | | - Stéphane Nancey
- Gastroenterology Department, Lyon Sud Hospital, Pierre Benite, France
| | - Jean-Claude Cenni
- Gastroenterology Department, Lyon Sud Hospital, Pierre Benite, France
| | - Thierry Ponchon
- Gastroenterology Department, Edouard Herriot Hospital, Lyon, France
| | | | - Jean-Christophe Saurin
- Gastroenterology Department, Lyon Sud Hospital, Pierre Benite, France; Gastroenterology Department, Edouard Herriot Hospital, Lyon, France
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49
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Jung WB, Kim CW, Kim JC. Clinical characteristics and adequate treatment of familial adenomatous polyposis combined with desmoid tumors. Cancer Res Treat 2014; 46:366-73. [PMID: 25152189 PMCID: PMC4206065 DOI: 10.4143/crt.2013.185] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/08/2013] [Indexed: 12/18/2022] Open
Abstract
Purpose The objective of this study was to examine the clincopathologic characteristics and outcomes of familial adenomatous polyposis (FAP) patients with and without desmoid tumors (DTs), including the risk factors for progression of FAP-related DTs. Materials and Methods We reviewed the medical records and database of all patients with FAP who were treated between January 1993 and December 2011. Results Of 75 FAP patients, 18 (24%) were FAP with DTs. Seventeen of these had intra-abdominal DTs and one had intra- and extra-abdominal DTs. We divided the patients into two groups according to type of resection; the R0 or R1 resection group, referred to as the curative resection group (eight patients), and the R2 resection/palliative operation/medical treatment group, referred to as the palliative resection group (10 patients). Two patients in the curative resection group and two patients in the palliative group had progressed to tumor growth by the follow-up (p=0.800). In univariate analysis, DT diagnosis before or simultaneously with FAP diagnosis (DTs unrelated to surgical trauma) was a significant risk factor for tumor progression at final follow-up. Conclusion A multidisciplinary approach to DT treatment is needed, including nonsteroidal antiinflammatory drugs, anti-estrogens, cytotoxic agents, and surgery. However, the role of surgery in resectable and complicated tumors may be limited. DT unrelated to surgical trauma has a relatively poor prognosis.
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Affiliation(s)
- Won Beom Jung
- Department of Surgery, Institute of Innovative Cancer Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Wook Kim
- Department of Surgery, Institute of Innovative Cancer Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Department of Surgery, Institute of Innovative Cancer Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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50
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Shim CN, Chung MJ, Bang S, Park SW, Song SY, Chung JB, Park JY. Clinicopathologic characteristics associated with complications and long-term outcomes of endoscopic papillectomy for adenoma. Yonsei Med J 2014; 55:644-50. [PMID: 24719130 PMCID: PMC3990097 DOI: 10.3349/ymj.2014.55.3.644] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/19/2013] [Accepted: 09/27/2013] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Endoscopic papillectomy (EP) is currently employed for the treatment of ampullary adenoma. This study aimed to evaluate the clinical, endoscopic, and histologic characteristics related to complications and long-term outcomes of EP. MATERIALS AND METHODS Thirty-nine patients underwent EP for ampullary adenoma. Patients were grouped according to the occurrence of procedure-related complications: no complication group (n=28) and complication group (n=11). RESULTS The overall complication rate was 28.2%. The most common complication was EP-related pancreatitis (n=7). Amylase (p=0.006) and lipase levels (p=0.007), 24 hours after EP, were significantly higher in the complication group, however, these levels did not differ at earlier times. As the tumor progressed from adenoma to cancer, the complete resection was significantly lessened (p=0.032). The duration of antiprotease injection during the hospital stay was significantly longer (p=0.017) and the transfusion requirements were significantly higher (p=0.018) in the complication group. During a median follow-up of 15 months, three lesions (10.3%) recurred among patients with complete resection (n=29) and five lesions (12.8%) recurred among enrolled patients. One patient with progressive recurrence from low-grade dysplasia to adenocarcinoma was noted during a follow-up of 22 months. CONCLUSION If symptoms are present, amylase and lipase levels, 24 hours after EP, could help predict possible EP-related pancreatitis. Histologic diagnosis through resected specimens may result in complete resection. Patients with complications need a longer duration of antiprotease injection during their hospital stay and more transfusions. The recurrence rate was not significantly high in completely resected cases, however, there was a possibility of progressive recurrence.
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Affiliation(s)
- Choong Nam Shim
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Project for Medical Science, Seoul, Korea
| | - Jae Bock Chung
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Youp Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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