Carcinoma of the colon, ampulla of Vater and urinary bladder associated with familial multiple polyposis: a case report

Acute pancreatitis secondary to adenomatous transformation of the ampulla of Vater in a patient with familial adenomatous polyposis

We present an unusual case of pancreatitis secondary to a polyp obstructing the papilla, treated endoscopically. A 45-year-old woman with familial adenomatous polyposis syndrome and prior total colectomy presented with acute pancreatitis. Upper endoscopy and endoscopic retrograde cholangiopancreaticogram revealed significant periampullary tissue. Sphincterotomy and endoscopic snare resection of the polyp were performed without complications. Local, noninvasive procedures are a promising diagnostic and therapeutic modality which has significantly less morbidity and mortality than conventional surgical techniques, and may be a reasonable alternative in the management of such patients.

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

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

Familial adenomatous polyposis associated with multiple endocrine neoplasia type 1-related tumors and thyroid carcinoma: a case report with clinicopathologic and molecular analyses

We describe a sporadic case with familial adenomatous polyposis, multiple endocrine neoplasia type 1 (MEN1)-related tumors (an endocrine cell tumor of the pancreas and bilateral parathyroid tumors), and a papillary thyroid carcinoma. To clarify how mutations of the adenomatous polyposis coli ( APC ) gene and the MEN1 gene, responsible for familial adenomatous polyposis and MEN1, respectively, might have contributed to tumorigenesis in this case, we studied germline mutations in both genes and loss of heterozygosity at their genetic loci in multiple lesions. In addition, we performed immunohistochemistry for beta-catenin, associated with the function of the APC gene. A germline mutation was found in the APC gene but not in the MEN1 gene. Normal allelic loss at the APC gene locus was observed in bilateral parathyroid tumors. Immunohistochemical staining of beta-catenin demonstrated accumulation in the cytoplasm in addition to membrane staining in all analyzed tumors and a strong nuclear reaction in the endocrine cell tumor of the pancreas. The presence of normal allelic deletions of the APC gene in bilateral parathyroid tumors and nuclear staining of beta-catenin in the pancreatic tumor in addition to the germline mutations suggests that functional loss of the APC gene played an important role not only in familial adenomatous polyposis but also in the MEN1-related tumors in this case.

Molecular basis of variegate porphyria: a missense mutation in the protoporphyrinogen oxidase gene

Variegate porphyria (VP) is an autosomal dominant disorder characterised by a partial defect in the activity of protoporphyrinogen oxidase (PPO), and has recently been genetically linked to the PPO gene on chromosome 1q22-23 (Z=6.62). In this study, we identified a mutation in the PPO gene in a patient with VP and two unaffected family members. The mutation consisted of a previously unreported T to C transition in exon 13 of the PPO gene, resulting in the substitution of a polar serine by a non-polar proline (S450P). This serine residue is evolutionarily highly conserved in man, mouse, and Bacillus subtilis, attesting to the importance of this residue. Interestingly, the gene for Gardner's syndrome (FAP) also segregates in this family, independently of the VP mutation. Gardner's syndrome or familial adenomatous polyposis (FAP) is also an autosomal dominantly inherited genodermatosis, and typically presents with colorectal cancer in early adult life secondary to extensive adenomatous polyps of the colon. The specific gene on chromosome 5 that is the site of the mutation in this disorder is known as APC (adenomatous polyposis coli), and the gene has been genetically linked to the region of 5q22.

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. Flow cytometric analysis

Turcot's syndrome is a rare, genetically transmittable disease in which patients with colonic polyposis (possibly complicated by the progression to adenocarcinoma) have malignant central nervous system neoplasms. Dominant, recessive, and sporadic cases have been described. A 26-year-old man is reported with no relevant family history who had intermittent abdominal discomfort in 1986. Sigmoidoscopy revealed numerous polyps, several of which showed carcinomatous change. Dukes' Stage C colorectal carcinoma was diagnosed. Treatment consisted of total colectomy with construction of a Koch's pouch. He remained well for 3 years until onset of headache, nausea, and vomiting. Computed tomographic scan disclosed a large, circumscribed, enhancing, right frontoparietal mass. After craniotomy and partial resection, histologic review disclosed anaplastic astrocytoma. He received cranial radiation therapy, 6000 cGy, by parallel opposed ports to the tumor bed, and carmustine 200 mg/m2 intravenously every 8 weeks. Flow cytometric DNA analysis was done on the paraffin-embedded archival material from the patient's normal colon, colonic adenocarcinoma, and anaplastic astrocytoma. DNA histograms revealed diploid distributions in all three samples. The G2/M fraction of the astrocytoma was elevated at 16%, and the S-phase fraction of the colonic adenocarcinoma was 19.4%.

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

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

Carcinoma in adenoma of the ampulla of Vater synchronous with cancer of the sigmoid colon

A 58-year-old Japanese man presented with early invasive adenocarcinoma within a papillotubular adenoma of the ampulla of Vater synchronous with advanced adenocarcinoma of the sigmoid colon. The colon had two additional adenomas. This hitherto unreported concomitance in the absence of familial polyposis coli is discussed.

Turcot's syndrome with intestinal lymphoma in a child: an unusual case of triple tumor

Turcot's syndrome, the association of brain tumor (usually glioblastoma, medullo-blastoma, or astrocytoma) and colonic polyps, is a very rare condition of which about 20 cases have been reported. It has been described only once previously with cancer in a third organ system. In this paper, we report a child affected with colonic polyposis and astrocytoma (i.e., Turcot's syndrome) associated with intestinal non-Hodgkin's lymphoma.

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.

Adenomatous polyposis: an association with carcinoma of the thyroid

A review of the St Mark's Hospital Polyposis Registry has revealed an association between adenomatous polyposis (familial polyposis coli) and thyroid carcinoma. Even though full clinical information was unavailable on all patients in the registry, it is evident that young women (below 35 years of age) are at particular risk of developing thyroid cancer, mainly of a papillary type, their chances of being affected being approximately 160 times that of normal individuals. All patients with adenomatous polyposis should thus have regular thyroid examination.

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

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

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's syndrome

The first reported case of Turcot's syndrome (brain tumour with polyposis coli) in Australia is described. An awareness of the possible extracolonic concomitant conditions of polyposis coli should lead to the prompt investigation of any patient with either known polyposis or a family history of polyposis who develops a disorder of the central nervous system.

Extracolonic polyps in familial polyposis coli and Gardner's syndrome

Endoscopy and biopsy of the upper gastrointestinal tract and terminal ileum were performed in 24 patients with familial polyposis or Gardner's syndrome in order to further define the incidence of extracolonic adenomatous polyps. Polyps, usually multiple and small in size, were detected in the gastric fundus (12.5 percent), antrum (29.1 percent), duodenum (66.6 percent), and terminal ileum (41.7 percent). Histology showed hyperplasia of the fundic glands and cystic dilatation in the polyps of gastric fundus, and adenomas in several cases of antral (three patients) or duodenal polyps (14 patients). Polyps of the terminal ileum were either adenomas (five patients) or lymphoid aggregates. Patients with stigmata of Gardner's syndrome, desmoids or mesenteric fibromatosis presented a major incidence of adenomas in the duodenum, but not in other parts of the digestive tract investigated. Subsequent checkup after an average of 33 months in ten patients revealed an increase of lesions only in the duodenum in two patients. These findings confirm that adenomatous polyps are not limited to the colon and rectum, as previously believed, but can affect the whole gastrointestinal tract. Periodic surveillance of mucosa seems to be indicated, especially for the duodenum, since degeneration of adenomas into carcinoma is possible.

Time and type of prophylactic surgery for familial adenomatosis coli

Data on 61 kinds of familial adenomatosis coli registered in Finland, including 185 affected members, were collected to evaluate the chronological evolution of carcinoma in this disease. The long-term results for 52 patients undergoing colectomy and ileorectostomy were reviewed. Colorectal carcinoma occurred in 105 patients, with cumulative percentages of 1, 6, 16, 28, and 42 at 20, 25, 30, 35, and 40 years of age. Only three out of 50 call-up patients (6%) had a carcinoma, as compared with 62% in the propositi group. No cases of rectal stump carcinomas were recorded after 52 ileorectostomies in a follow-up period of up to 21 years (mean 6 +/- 5 S.D. years). It was concluded that prophylactic colectomy must usually be performed at 20 to 25 years of age, at the latest. Despite conflicting earlier evidence, colectomy and ileorectal anastomosis may still be a viable alternative, providing that the rectal stump is very short (5 to 10 cm) and the surveillance and treatment of all new adenomas is effective.

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.

The Gardner syndrome. Significance of ocular features

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

Familial multiple polyposis coli with multiple associated tumors

A case is described of familial polyposis of the colon, which combines almost every recorded manifestation of the syndrome of associated tumors; namely, carcinomatous changes in the polyps, osteomas of facial and other bones, periampullary carcinoma, transitional-cell carcinoma of the bladder, adrenal adenoma, intra-abdominal fibrous tumors with bowel obstruction, and a remarkable tendency to contain and survive the malignancies.

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

Another unusual autopsy case of the Turcot syndrome is reported in a 23-year-old woman with polyposis coli, who developed primary carcinoma of the jejunum and glioblastoma multiforme of the left frontal lobe. Previously documented cases are reviewed. Discussion focuses on the occurrence of other extracolonic abnormalities observed with the Turcot syndrome.

Turcot's syndrome. Evidence for autosomal dominant inheritance

A case of Turcot's syndrome (colonic polyposis plus a malignant central nervous system tumor) occurring in a kindred with autosomal dominant colonic polyposis is presented. It is proposed that Turcot's syndrome patients can be classified into Type I where only siblings are affected and Type II where two or more generations have colonic polyposis. A third nonfamilial group cannot be classified into Type I or II based on available information. Evidence is presented suggesting Turcot's syndrome is best considered an additional phenotype of familial polyposis and is most likely inherited in an autosomal dominant manner.

Acute leukemia after radiotherapy in a patient with Turcot's syndrome. Impaired colony formation in skin fibroblast cultures after irradiation

Colonic polyposis and carcinoma developed in a woman with Turcot's syndrome at the age of 31 years; astrocytoma developed when she was 37. Her brother and sister had died of astrocytoma at the ages of 18 and 33 years, respectively. Progressive neutropenia developed in the patient three months after radiotherapy for her brain tumor and acute myelomonocytic leukemia 19 months after treatment. Three laboratories independently evaluated cultures of her skin fibroblasts for in vitro sensitivity to cell killing (loss of colony-forming ability) by x-rays. Survival assays consistently revealed slight but significant radiosensitivity in an early-passage (six to 10 doublings) fibroblast subculture. A later subculture (21 to 29 doublings) showed no abnormality, a possible effect of selective in vitro loss of radiosensitive cells.

Gardner's syndrome associated with periampullary carcinoma, duodenal and gastric adenomatosis. Report of a case

A 48-year-old man with Gardner's syndrome, who had abdominoperineal resection for rectal carcinoma in 1962, was found to have an ulcerating growth of the duodenum, and pancreaticoduodenectomy was performed in 1979. Histologic examination by complete step-serial sectioning disclosed a well-differentiated adenocarcinoma with adenomatous remnants, a large adenoma with focal carcinoma, 256 adenomas of the duodenum, and 91 adenomas of the gastric antrum. The world medical literature was reviewed, and 29 cases of periampullary carcinoma and 12 cases of gastric carcinoma complicating familial polyposis coli or Gardner's syndrome were analyzed.

Familial polyposis coli and its extracolonic manifestations

A detailed clinical study of 30 families with familial polyposis coli is presented. Seven 'isolated' cases are also described. It was found that some families did not exhibit any extracolonic manifestations, but the majority of families showed various numbers of members who had these manifestations of differing types and degrees. In view of the great variability within the members of a family, polyposis coli and the Gardner syndrome are probably both produced by one pleiotropic gene. The occurrence of other neoplastic phenomena in association with polyposis coli has been considered. Many types of malignancy can occur in these patients and their families and the majority are probably fortuitous. The consistent finding of an association with medulloblastoma is such as to make this association of significance, but no reason is known for this. It is suggested that the term 'Turcot syndrome' should be used in a more restrictive manner than at present.

Adenomas of the small intestine: a clinicopathologic review of 51 cases and a study of their relationship to carcinoma

The authors studied 51 patients who had small bowel tumors that contained adenomatous epithelium. These rare lesions were identified among 392,000 surgical pathology cases seen during a 62-year period. Grossly and histologically, adenomas arising in the mucosa of the small intestine are similar to the adenomas found in the colon. Of the 51 patients, 18 had adenomas, and 33 had tumors that contained both adenoma and carcinoma in the same lesion, including five intramucosal and 28 invasive carcinomas. The location of the tumor usually determined which clinical problems were produced. The data indicate that adenomas originating in the small bowel mucosa probably are premalignant lesions and that many primary adenocarcinomas of the small intestine arise in adenomas. Of the authors' 130 apparently primary small bowel carcinomas (including the papilla of Vater), 33 (25%) histologically demonstrated adenomatous epithelium in the same lesion. Factors associated with an increased chance of finding carcinoma in an adenoma include adenoma type, size of lesion, location, and multicentricity. Carcinomas appear to develop more frequently in papillary (villous) adenomas than in ordinary adenomas. The larger the lesion is, the more likely carcinoma will be identified. Adenomas involving the ampulla contain carcinoma more often than do lesions found elsewhere in the duodenum and small intestine. Three patients had multiple adenomatous polyps of the small bowel; two of these individuals also had duodenal carcinomas. Various problems in pathologic diagnosis and clinical management are discussed.

Gardner's syndrome. Recent developments in research and management

In recent years, a number of comprehensive reviews have been written on inherited intestinal polyposis syndromes (1-7), but none has dealt specifically with Gardner's syndrome and none has focused on basic research being carried out in an attempt to understand this syndrome and to improve the medical management of affected patients. A better understanding of this rare genetic disorder is essential for surgeons, gastroenterologists, cancer researchers, and geneticists alike. To the clinician, it poses difficult challenges in management; to the cancer researcher, it presents a rare opportunity to study very early premalignant transformations; and to the geneticist, it poses exciting questions at the cellular, chromosomal, and molecular levels.

Gardner syndrome and periampullary malignancy

In a family with colonic polyposis and the typical associated findings of Gardner syndrome (osteomas and soft-tissue tumors), two and possibly four of the affected members developed periampullary malignancy. A review indicates that individuals with Gardner syndrome may have a 100- to 200-fold increased risk of developing periampullary carcinoma when compared to the general population. While certain families and certain individuals (those with other duodenal involvement, males and those with all of the characteristics of Gardner syndrome expressed) may be most susceptible, all patients with Gardner syndrome should be periodically endoscopically evaluated for the presence of upper gastrointestinal tract disease.

Turcot's syndrome and its mode of inheritance

Two sisters with Turcot's syndrome, in which malignant cerebral neoplasms are associated with colonic polyposis, are presented. Cases reported in the literature, including some familial cases, have also been analysed. In familial cases, sex was unrelated to the occurrence of this disease and it was found only among siblings of the same parents and not in other members of the family. There was consanguinity in the parents of the patients in two out of three families. We therefore concluded that the mode of inheritance in this condition is autosomal recessive and that it is genetically distinct from the ordinary form of familial polyposis coli. Support is lent to the absence of an association between the two disorders by a difference in the number, size, and distribution of the colonic polyps found in Turcot's syndrome as compared with familial polyposis coli.

Lymphoma of the brain associated with polyposis of the colon--report of a case and review of Turcot's syndrome

Pathological findings of a 15-year-old girl with polyposis of the colon who has subsequently developed primary lymphoma of the brain are reported. The authors consider this case to be a rare example of Turcot's syndrome although the histological typing of the brain tumor is not classical and familial background of the polyposis has not been demonstrated. Literatures on 14 previously reported cases of Turcot's syndrome are reviewed and clinical and pathological findings are summarized. The present case is the second report of Turcot's syndrome associated with lymphoma of the brain and is unique in regard to the age as cerebral lymphoma is extremely rare in the second decade.

Pancreatitis and duodenal obstruction due to periampullary carcinoma associated with familial polyposis coli

Duodenal lesions are being reported in cases with familial polyposis of the colon. A case is described presenting with duodenal obstruction and pancreatitis complicating a peri-ampullary carcinoma in a patient with familial polyposis (adenomatosis of the colon and rectum). Upper gastrointestinal lesions notably in the duodenum include duodenal polyps and carcinoma and peri-ampullary malignancy. It is suggested that endoscopy and hypotonic duodenography be considered in patients with adenomatosis of the colon and rectum presenting with non-colonic alimentary symptoms.

Small-intestinal involvement in familial polyposis diagnosed by operative intestinal fiberscopy: report of four cases

Operative intestinal fiberscopy, in which the duodenal fiberscope was introduced during laparotomy for colectomy in familial polyposis via the enterotomy opening, permitted the demonstration of small intestinal polyps in six of seven consecutive cases. Four of the six patients had adenomatous polyps in the proximal jejunum, including one patient with the concomitant presence of ileal adenomas. Polyposis due to lymphoid hyperplasia in the terminal ileum was found in three patients. Preoperative upper gastrointestinal surveys revealed adenomas in the duodenums of all seven patients, adenomas in the gastric antrum in three, and multiple hamartomas in the gastric corpus in two. Thus, in familial polyposis or Gardner's syndrome, more or less the entire gastrointestinal tract seems to be involved and the term "gastrointestinal polyposis" seems to describe these conditions.

Periampullary malignancy in Gardner's syndrome

Three cases of familial polyposis coli with associated periampullary malignancies are reported and the literature reviewed, which disclosed 16 additional cases. An additional five unreported cases are known to exist. The authors believe that the development of periampullary malignancy in FPC is a definite extracolonic manifestation of the disease and should be considered a variant of Gardner's syndrome. It is recommended that all FPC patients with colon polyps undergo routine surveillance of the upper gastrointestinal tract and that all duodenal polyps discovered be surgically removed when feasible.

Clinical and roentgen features of the intestinal polyposis syndromes

The intestinal polyposis syndromes represent a challenging diagnostic problem for the radiologist. These syndromes include: familial multiple polyposis, Gardner's, Peutz-Jeghers, Turcot's, Cronkhite-Canada and juvenile polyposis. The polyposis syndromes can usually be differentiated from one another on the basis of the clinical history, examination of the mucocutaneous tissues and roentgen findings. Numerous other conditions, however, may mimmic a polyposis syndrome, and must be considered in the differential diagnosis.

Duodenal involvement in Gardner's syndrome

It is suggested that duodenal polyps are more frequent in Gardner's syndrome than previously recognized. The polyps have a particular tendency to undergo malignant change. Two patients with Gardner's syndrome are reported in whom duodenal polyps were associated in one patient with periampullary cancer and in the other with a possible adenocarcinoma of the duodenum.

The occurrence of desmoids in patients with familial polyposis coli

Four cases of desmoid tumour are reported in conjunction with familial polyposis coli, and the salient clinical features of patients with this combination of conditions are examined in the literature and tabulated.

Desmoids occur very rarely in the general population but they are comparatively common in people with familial polyposis, in whom they may be situated in the abdominal wall, within the abdomen, or occasionally in other sites remote from the abdomen. They may antedate the discovery of polyposis by months or years. Any patient who is found to have a desmoid should therefore be examined for polyposis coli.

Intra-abdominal desmoids by virtue of their size and situation are often of serious significance to the patient, and their effects may belie the benign histological picture they present. Renal function may be impaired by pressure on the ureters, whilst surgical removal of the lesion, which is the principal method of treatment of desmoids, may be crippling to the patient or technically impossible. Radiotherapy seems to be of limited value in the management of these tumours.

No mass occurring within the abdomen or in the abdominal wall after surgery for polyposis coli should be regarded as a recurrent adenocarcinoma until proved to be so by adequate biopsy.