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Rahmatinejad Z, Goshayeshi L, Bergquist R, Goshayeshi L, Golabpour A, Hoseini B. PTEN hamartoma tumour syndrome: case report based on data from the Iranian hereditary colorectal cancer registry and literature review. Diagn Pathol 2023; 18:43. [PMID: 37016356 PMCID: PMC10071641 DOI: 10.1186/s13000-023-01331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/22/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND PTEN hamartoma tumour syndrome (PHTS) is a rare hereditary disorder caused by germline pathogenic mutations in the PTEN gene. This study presents a case of PHTS referred for genetic evaluation due to multiple polyps in the rectosigmoid area, and provides a literature review of PHTS case reports published between March 2010 and March 2022. CASE PRESENTATION A 39-year-old Iranian female with a family history of gastric cancer in a first-degree relative presented with minimal bright red blood per rectum and resistant dyspepsia. Colonoscopy revealed the presence of over 20 polyps in the rectosigmoid area, while the rest of the colon appeared normal. Further upper endoscopy showed multiple small polyps in the stomach and duodenum, leading to a referral for genetic evaluation of hereditary colorectal polyposis. Whole-exome sequencing led to a PHTS diagnosis, even though the patient displayed no clinical or skin symptoms of the condition. Further screenings identified early-stage breast cancer and benign thyroid nodules through mammography and thyroid ultrasound. METHOD AND RESULTS OF LITERATURE REVIEW A search of PubMed using the search terms "Hamartoma syndrome, Multiple" [Mesh] AND "case report" OR "case series" yielded 43 case reports, predominantly in women with a median age of 39 years. The literature suggests that patients with PHTS often have a family history of breast, thyroid and endometrial neoplasms along with pathogenic variants in the PTEN/MMAC1 gene. Gastrointestinal polyps are one of the most common signs reported in the literature, and the presence of acral keratosis, trichilemmomas and mucocutaneous papillomas are pathognomonic characteristics of PHTS. CONCLUSION When a patient presents with more than 20 rectosigmoid polyps, PHTS should be considered. In such cases, it is recommended to conduct further investigations to identify other potential manifestations and the phenotype of PHTS. Women with PHTS should undergo annual mammography and magnetic resonance testing for breast cancer screening from the age of 30, in addition to annual transvaginal ultrasounds and blind suction endometrial biopsies.
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Affiliation(s)
- Zahra Rahmatinejad
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ladan Goshayeshi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Robert Bergquist
- Ingerod, Brastad, SE-454 94, Sweden
- Formerly UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
| | - Lena Goshayeshi
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amin Golabpour
- School of Allied Medical Sciences, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Benyamin Hoseini
- Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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McLean A, Alalade AF, Golash A, Gurusinghe N. De Novo Cavernoma Formation in a Patient With Cowden Syndrome and Lhermitte-Duclos Disease. World Neurosurg 2020; 143:308-314. [PMID: 32777405 DOI: 10.1016/j.wneu.2020.07.221] [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: 06/18/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cowden syndrome (CS) is an autosomal dominant genodermatosis with a predisposition for the development of multiple cancers, benign hamartomas, and extracranial vascular malformations. Rarely, intracranial lesions like meningiomas and vascular malformations can also be present with CS. These vascular malformations include developmental venous anomalies, arteriovenous fistulae and cavernomas. Most cases of cavernomas are thought to be congenital, although in recent literature they have been shown to occur de novo with other conditions (e.g., other vascular malformations, trauma, postcranial surgery, viral infection, and genetic disorders). CASE DESCRIPTION We present a 29-year-old woman who was diagnosed with Lhermitte-Duclos disease after episodes of persistent generalized headaches. She underwent a foramen magnum decompression and was subsequently diagnosed with CS. Ten years, later she was also diagnosed with 2 cerebral cavernomas that were not present on her prior monitoring scans. CONCLUSIONS We present a case of a patient with CS and LDD who had de novo cavernoma development several years after the initial diagnosis, as well as a review of the literature. We highlight the need of surveillance neuroimaging for patients with CS, as there is the risk of new development of vascular abnormalities (particularly cavernomas).
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Affiliation(s)
- Ailsa McLean
- Department of Neurosurgery, Royal Preston Hospital, United Kingdom
| | - Andrew F Alalade
- Department of Neurosurgery, Royal Preston Hospital, United Kingdom.
| | - Aprajay Golash
- Department of Neurosurgery, Royal Preston Hospital, United Kingdom
| | - Nihal Gurusinghe
- Department of Neurosurgery, Royal Preston Hospital, United Kingdom
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Hedjoudje A, Peng X, Gautam A, Pardo CA, Sciubba D, Gailloud P. Case of Cowden Syndrome with 15 Spinal Arteriovenous Fistulas. World Neurosurg 2020; 139:567-576. [PMID: 32344142 DOI: 10.1016/j.wneu.2020.04.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spinal vascular malformations are rarely multiple: fewer than 50 observations have been documented so far, with a maximum of 4 coexisting lesions per patient, always restricted to a single vertebral region (e.g., cervical or thoracic). CASE DESCRIPTION We describe the case of a 61-year-old woman with Cowden syndrome with 15 spinal arteriovenous fistulas (AVFs) at the cervical, thoracic, and lumbar levels and an adrenal AVF. She was initially referred for reevaluation of an upper cervical spinal epidural spinal arteriovenous fistula diagnosed 6 years earlier. Her history included breast carcinoma, a malignant salivary gland tumor, and removal of multiple ovarian, thyroid, and gastric hamartomas. Computed tomography and magnetic resonance imaging confirmed the presence of a prominent cervical vascular lesion. Spinal digital subtraction angiography revealed the presence of 15 additional vascular anomalies. CONCLUSIONS This multiplicity of AVFs appears to result from a combination of various factors including local regional hemodynamic changes, growth factor-mediated alterations involving notably vascular endothelial growth factor pathways, and the prothrombotic state associated with abnormalities in blood vessel structure.
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Affiliation(s)
- Abderrahmane Hedjoudje
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
| | - Xiao Peng
- Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ayushi Gautam
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Carlos A Pardo
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Sciubba
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Dhamija R, Hoxworth JM. Imaging of PTEN-related abnormalities in the central nervous system. Clin Imaging 2019; 60:180-185. [PMID: 31927175 DOI: 10.1016/j.clinimag.2019.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 11/04/2019] [Accepted: 12/09/2019] [Indexed: 11/16/2022]
Abstract
The phosphatase and tensin homolog (PTEN) located at 10q23.31 is a tumor suppressor gene expressed ubiquitously, and loss of function mutations lead to aberrant growth, angiogenesis, and an increased risk for a variety of tumors. PTEN mutations have been associated with multiple abnormalities in the central nervous system, and a number of clinical phenotypes are now attributed to germline PTEN mutations, collectively referred to as PTEN hamartoma tumor syndrome (PHTS). Most notably, these include Cowden syndrome (CS), Bannayan-Riley-Ruvalcaba syndrome (BRRS), and autism spectrum disorders with macrocephaly. It is important to recognize the neuroimaging features associated with PTEN mutations to not only avoid misdiagnosis in cases of known PHTS but also to guide genetic testing in patients who do not yet have an established diagnosis. In this review, the central nervous system imaging features of PTEN-related disorders are discussed.
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Affiliation(s)
- Radhika Dhamija
- Departments of Clinical Genomics and Neurology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Joseph M Hoxworth
- Divison of Neuroradiology, Department of Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA.
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Takei J, Tochigi S, Arai M, Tanaka T, Kajiwara I, Hatano K, Ichinose D, Sakamoto H, Hasegawa Y, Ishibashi T, Tani S, Murayama Y. Spinal Extradural Arteriovenous Fistula with Cowden Syndrome: A Case Report and Literature Review Regarding Pathogenesis and Therapeutic Strategy. NMC Case Rep J 2018; 5:83-85. [PMID: 30327747 PMCID: PMC6187262 DOI: 10.2176/nmccrj.cr.2018-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 05/02/2018] [Indexed: 11/22/2022] Open
Abstract
We report the case of a patient with a spinal extradural arteriovenous fistula (AVF) associated with Cowden syndrome (CS) that was successfully treated by endovascular surgery. CS is an autosomal dominant disorder associated with diverse symptoms caused by a deleterious mutation in the phosphatase and tensin homolog (PTEN) gene. A 67-year-old woman was diagnosed with CS based on her medical history of multiple cancers for which she underwent abdominal surgery, macrocephaly, Lhermitte-Duclos disease, and facial papules. Her genetic testing demonstrated a PTEN mutation. She presented with progressive paraparesis and her MRI of the thoracolumbar spine showed the spinal cord edema along with flow voids. A spinal angiogram demonstrated a spinal extradural AVF with the perimedullary drainage. The AVF was successfully treated by endovascular surgery. The PTEN mutation can accelerate angiogenesis; thus, vascular anomalies are one of the diagnostic criteria of CS. However, only two cases of vascular anomalies involving the spinal cord in patients with CS have been reported previously. As the present case, both cases had a history of abdominal or retroperitoneal cancer. The PTEN mutation accompanied with abdominal surgery might have caused this vascular anomaly as the consequences of venous congestion around the thoracolumbar spine. A spinal extradural AVF should be considered in patients with CS who present with myelopathy, especially when the patient has a history of abdominal or retroperitoneal surgery. Regarding the treatment strategy, endovascular surgery should be considered because surgical insult could prompt secondary vascular anomalies resulting from neovascularization due to the PTEN mutation.
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Affiliation(s)
- Jun Takei
- Department of Neurosurgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Satoru Tochigi
- Department of Neurosurgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Masami Arai
- Department of Clinical Genetic Oncology, the Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshihide Tanaka
- Department of Neurosurgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Ikki Kajiwara
- Department of Neurosurgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Keisuke Hatano
- Department of Neurosurgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Daisuke Ichinose
- Department of Neurosurgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Hiroki Sakamoto
- Department of Neurosurgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Yuzuru Hasegawa
- Department of Neurosurgery, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Satoshi Tani
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
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