The Turcot syndrome. Report of an additional case and review of the literature

Possible Considerations for the Management of Turcot’s Syndrome?

Background:

Turcot’s syndrome (TS) is a rare disease with known incidence of about 1-2 cases per year. It is, however, linked to high mortality due to the brain cancer. And because of this, we propose recommendations, aimed at preventing the mortality of the patients and to minimize the risk of undiagnosed Turcot’s syndrome.

Methods:

The authors collected the worldwide published data on TS, from the year of its definition till 2018, all of which was published on the search engines, such as Medline, Medknow, Cohraine and Wiley.

Results:

We included 97 patients, 57 from which are females and 40 males with median age of 22 years. The most common type of cancer is medulloblastoma, followed by glioblastoma and astrocytoma. We further divided the patients into two categories based on the first symptom of the disease and we made an algorithm of approaching these patients.

Conclusion:

TS is a disease that affects mostly members of families with multiple genetic mutations and types of cancers. And because of the unknown mechanisms of inheritance, it is useful to establish guidelines for the approach of those patients, in order to minimize the high mortality rate.

Familial syndromes associated with intracranial tumours: a review

BACKGROUND

Most cancers of the central nervous system (CNS) occur sporadically in the absence of any known underlying familial disorder or multi-systemic syndrome. Several syndromes are associated with CNS malignancies, however, and their recognition has significant implications for patient management and prognosis. Patients with syndrome-associated CNS malignancies often have multiple tumours (either confined to one region or distributed throughout the body), with similar or different histology.

OBJECTIVE

This review examines syndromes that are strongly associated with CNS cancers: the phakomatosis syndromes, familial syndromes such as Li-Fraumeni and familial polyposis syndromes and dyschondroplasia.

Turcot syndrome: a synchronous clinical presentation of glioblastoma multiforme and adenocarcinoma of the colon

Turcot syndrome (TS) is a rare hereditary disorder clinically characterized by the occurrence of primary tumors of the colon and the central nervous system (CNS). Here we present the case of an 11-year-old boy with a synchronous clinical presentation of both glioblastoma multiforme (GBM) and colonic adenocarcinoma. A molecular genetic study revealed microsatellite instability in the DNA mismatch repair (MMR) gene. This patient ultimately survived for 13 months after clinical presentation. Based on this case study, the synchronous presentation of glioblastoma multiforme and adenocarcinoma of the colon might suggest a shorter survival rate for patients with Turcot syndrome. A literature review complements this paper.

Turcot syndrome with colonic obstruction and small intestinal invagination: report of a case

We report herein the case of a 16-year-old boy diagnosed as having Turcot syndrome, otherwise known as glioma-polyposis syndrome. The patient was transferred from the Department of Neurosurgery where he was undergoing investigation of a brain tumor, to the Department of Medicine for investigation of gastrointestinal symptoms. The patient was diagnosed as having Turcot syndrome, and was then transferred to the Department of Surgery for treatment of an obstruction in the sigmoid colon and small intestinal invagination. A subtotal colectomy with side-to-end ileoproctostomy and release of the invaginations was carried out. Multiple polyps were found in the colon, two of which, including a large polyp that obstructed the colonic lumen, were confirmed histologically to be adenocarcinoma. The remaining polyps were adenomas. A biopsy of the brain tumor confirmed a diagnosis of astrocytoma (WHO grade II). This case report describes the characteristic features of Turcot syndrome presented by this patient.

A father and son with Turcot's syndrome: evidence for autosomal dominant inheritance: report of two cases

Typical Turcot's syndrome is characterized by the association of a brain glioma together with multiple colonic polyposis, in which the number of polypoid lesions is small and the association of colonic cancer occurs at a younger age than in familial adenomatous polyposis. We describe a family in which both the father and his son presented with typical Turcot's syndrome without parental consanguinity. This is the first report of a family that is considered to follow an autosomal dominant inheritance. After reviewing 25 documented cases in which the average age of death was 20.3 years old, it was learned that the major cause of death was brain tumor (76 percent) and the minor cause was colon cancer (16 percent). Patients were very young and, therefore, unlikely to have produced a child before their death. These facts seem to support the theory that Turcot's syndrome is an autosomal dominant disorder.

Genetic alterations in a patient with Turcot's syndrome

Turcot's syndrome (TS) is a rare disorder associated with the development of both brain and colon neoplasms. Because of the very low incidence of the disease, its molecular basis remains unclear. Presented is a TS case of a 30-year-old Japanese male with a histopathologically confirmed diagnosis of both brain tumor (glioblastoma multiforme) and colon tumor (well-differentiated adenocarcinoma). Germline mutations of the p53 gene, somatic mutations of the Ki-ras, p53 and APC genes, and microsatellite instability (MSI) was examined using polymerase chain reaction (PCR)-single strand conformation polymorphism analysis, followed by PCR-direct sequencing, and sequencing after subcloning. No germline mutations of the p53 gene were found. Somatic mutations of Ki-ras and APC genes were found in the colon adenocarcinoma but not in the brain tumor. No somatic mutation of the p53 gene was present in either colon or brain tumors. Microsatellite instability of both colon and brain tumors was positive in two of four loci. These results indicate that the colon tumor of the TS patient carries the Ki-ras and APC gene mutations. The finding of MSI in both the brain and the colon tumors may support the hypothesis that alterations of DNA repair genes are involved in the tumor development of the TS patient.

Polyposis coli, craniofacial exostosis and astrocytoma: the concomitant occurrence of the Gardner's and Turcot syndromes

BACKGROUND

Up to 60% of the patients with known adenomatous polyposis coli may present hyperostosis of the skull and facial bones, and/or a susceptibility to fibromas. This is known as the Gardner's syndrome, and is considered as an allelic variant of familial adenomatous polyposis (FAP). Also, although very rare, an adenomatous polyposis coli may occur with malignant tumors of the central nervous system, known as Turcot syndrome. If both syndromes are different phenotypic presentation of FAP, this would explain a simultaneous occurrence.

METHOD

We report the history of a patient who showed clinical signs of the simultaneous occurrence of both Gardner's and Turcot syndromes. The syndromes are compared, and in view of the literature, a genetic explanation for the concomitant occurrence is discussed.

RESULTS

Evidence obtained from the literature to consider Turcot syndrome as a phenotype of FAB is as follows: (1) The occurrence of Gardner's and Turcot syndromes in one family, but in different members; (2) The presence of congenital hypertrophic retinal pigmented epithelium (CHRPE), which correlates with the expression of polyps in FAP patients, in both syndromes; (3) Linkage of the Turcot phenotype to the adenomatous polyposis coli locus by genetic markers. Evidence obtained from this case report indicates that there is a manifestation of both syndromes in one patient together with a positive family history for FAP.

CONCLUSION

This concomitant occurrence of both Gardner's and Turcot syndromes in one patient clinically supports genetic and ophthalmic investigation to consider Turcot syndrome (like Gardner's syndrome) as a phenotypic variant of FAP. Patients with FAP should be examined for the presence of Gardner's syndrome. In case a Gardner's syndrome is suspected, a computed tomography scan of the brain is recommended because of the possible existence of a simultaneous Turcot syndrome.

Turcot's syndrome and familial adenomatous polyposis associated with brain tumor: review of related literature

We investigated clinical manifestations in 124 patients with a possible Turcot's syndrome whose data were taken from documented cases. The cases were subclassified mainly on the bases of the type of familial occurrence and listed in five Tables. We searched for differences in colonic manifestation, histologic type of glioma, mode of inheritance, frequency of parental consanguinity, skin lesions and other accompanying lesions among these five groups. The differences of these clinical findings suggested that glioma-polyposis syndrome should be classified as follows; (1) cases of Turcot's syndrome who had characteristic colonic and brain manifestations, (2) cases of FAP associated with glioma, (3) suspicious cases of glioma-polyposis, and (4) cases other than glioma-polyposis syndrome.

Turcot's syndrome

A non-familial case of cerebellar medulloblastoma associated with adenomatous polyposis coli is described and the literature is reviewed. This is the second reported case of Turcot's syndrome in Australia. A greater understanding of the genetic implications of this rare condition might be achieved through reporting of cases and long-term documentation with polyposis registries.

Synchronous double malignancy: adenocarcinoma of lung and malignant astrocytoma induced by asbestos exposure

A 54-year-old male died of cerebellar herniation induced by brain tumor. Radiological examination of this case showed two separate tumorous lesions in the brain and lung. Autopsy proved malignant astrocytoma in the brain and coincidental alveolar cell carcinoma in the lung. He had a history of asbestos exposure for 8 years doing piping work in a shipyard. Furthermore, we detected a large number of asbestos bodies in the lung and one asbestos body in the brain. Therefore, this rare case of double cancer (malignant astrocytoma and lung cancer) might have been induced by asbestos exposure.

Ocular findings in Turcot syndrome (glioma-polyposis)

Turcot syndrome is a hereditary condition characterized by multiple, adenomatous gastrointestinal polyps associated with neuroepithelial tumors of the central nervous system. The authors examined a patient with Turcot syndrome who had multiple regions of congenital hypertrophy of the retinal pigment epithelium (CHRPE) with areas of surrounding hypopigmentation in the fundi of both eyes. Multiple, bilateral patches of CHRPE have been reported in patients with familial adenomatous polyposis and Gardner syndrome. This finding is thought to be a sensitive and specific clinical marker for these conditions and useful for predicting the presence and development of colorectal polyposis. Our findings provide further evidence that familial adenomatous polyposis, Gardner syndrome, and Turcot syndrome may be related conditions representing the variable phenotypic expression of a single, autosomal dominant genetic disorder. Children and young adults with multiple patches of CHRPE and a family history of adenomatous polyposis may be at increased risk for the development of central nervous system tumors as well as gastrointestinal polyps.

Turcot's syndrome: a diagnostic consideration in a child with primary adenocarcinoma of the colon

We report the diagnosis of an adenocarcinoma of the colon in a 12-year-old girl in association with the presence of a small number of adenomatous polyps and a positive family history of a sibling with a central nervous system glioma. These findings implicate Turcot's syndrome as the cause for the development of intestinal and intracranial neoplasms in the two siblings. Since primary adenocarcinoma of the bowel is unusual in children, an underlying predisposing condition should be sought in affected cases.

Brain tumors in familial adenomatous polyposis

Familial adenomatous polyposis was always believed to be a colonic disease of genetic determination with a high risk of development of cancer of the large bowel. Over the years the list of extracolonic manifestations of this disease, both benign and malignant, has amplified. Brain tumors and, in particular, medulloblastoma have not become recognized as major malignant extracolonic manifestations of familial adenomatous polyposis. They are of particular significance because, unlike most of the other manifestations, they occur prior to or early in the development of the colonic manifestations of this disease. This report documents the investigation of 168 kindreds in The Cleveland Clinic Familial Adenomatous Polyposis Registry in a search for those at-risk individuals who developed brain tumors.

Turcot's syndrome. A review

Turcot's syndrome represents the association between familial multiple polyposis coli and neural tumors. The syndrome is reviewed with reference to genetics, colonic and central nervous system manifestations. This evidence suggests that Turcot's syndrome represents one manifestation of the pleiotropic autosomal dominant gene responsible for familial polyposis coli and the associated extracolonic manifestations of Gardner's syndrome. A diagnosis of Turcot's syndrome should be restricted to those patients with familial polyposis coli associated with gliomas or medulloblastomas. A further case is presented that is believed to be the first report of such a case in the United Kingdom.

Familial glioma: occurrence within the "familial cancer syndrome" and systemic malformations

The family pedigree across eight generations is presented with an association of osteochondrodysplasia, other skeletal abnormalities, familial glial tumours in a father and his son, colonic and other adenomatous disease, and pigment changes. This family cluster of diseases is considered to be a dysontogenetic process with blastomatous features and grouped within the phakomastoses. A review of the literature indicates that some "familial gliomas" show additional malformations, thus resembling phakomatoses. Others are found to be members within a "familial cancer syndrome". A trait of "hereditary glioma" apart from these syndromes is difficult to identify, especially if only sibships are considered which are likely to share common environmental factors.

Nonfamilial intestinal polyposis and brain tumor in a 5-year-old girl

A 5-year-old girl with glioblastoma multiforme and simultaneous adenocarcinoma in one of multiple colonic polyps is the youngest reported case of Turcot's syndrome. A literature survey and a classification based on family pedigree and pattern of inheritance are proposed.

Turcot syndrome and its characteristic colonic manifestations

The reported clinical manifestations of Turcot syndrome were studied to determine whether these corresponded to those of Turcot's original cases. Among the patients with well-documented colonic lesions, the colonic lesions were classified into three groups. First, there was a main group in which colonic lesions had the following characteristics that coincided with those of Turcot's original cases: a low number of polyps (20-100), large polyps over 3 cm in diameter, and complication by colonic cancer during the second or third decades. In the second group, the patients had too few polyps to be diagnosed as polyposis. The third group included patients with numerous colonic polyps similar to those of familial polyposis coli. The recognition of these characteristics of colonic lesions may lead to early detection of glioma in the asymptomatic period.