Jan Peutz, Harold Jeghers and a remarkable combination of polyposis and pigmentation of the skin and mucous membranes

The Natural History of Hereditary Colorectal Cancer Syndromes: From Phenotype to Genotype? Where Do We Stand and What Does the Future Hold?

Applying the concept of a "natural history" to hereditary colorectal cancer is an interesting exercise because the way the syndromes are approached has changed so drastically. However, the exercise is instructive as it forces us to think in depth about where we are, where we have been, and, most helpfully, about where we may be going. In this article the diagnosis, along with endoscopic and surgical management of hereditary colorectal cancer are discussed in the context of their history and the changes in genomics and technology that have occurred over the last one hundred years.

Knowledge and Interdisciplinary Communication of Gastroenterologists and Dentists in the Netherlands About Gastrointestinal Diseases With Oral Manifestations

Background

Gastrointestinal diseases can have oral manifestations. The aim of this study was to investigate the knowledge of gastroenterologists and dentists about gastrointestinal diseases with oral manifestations and to assess the frequency, extent and content of communication between gastroenterologists and oral healthcare professionals.

Methods

Separate questionnaires were developed and sent to all 523 gastroenterologists and a random selection of 500 dentists in the Netherlands. Both questionnaires contained questions about demographic characteristics of the participants, 10 statements about gastrointestinal diseases with possible oral manifestations and questions about the communication between gastroenterologists and oral healthcare professionals. Additionally, the questionnaire for gastroenterologists contained 9 statements about general dentistry and the questionnaire for dentist had 9 questions about gastrointestinal diseases.

Results

Gastroenterologists answered 47.6% ± 31.9% of the questions correct about gastrointestinal diseases with possible oral manifestations and 57.5% ± 27.9% of the questions correct about general dentistry. Dentists answered 26.6% ± 20.5% of the questions correct about possible oral manifestations of gastrointestinal diseases and 50.3% ± 18.7% of the questions correct about gastrointestinal diseases. Gastroenterologists and dentists valued interdisciplinary consultation as very useful with scores of 4.07 ± 0.70 and 4.67 ± 0.49 on a 5-point Likert scale, respectively, but the frequency of consultation was considered insufficiently with a mean score of 2.88 ± 1.01 and 2.24 ± 1.05 on a 5-point Likert scale, respectively.

Conclusions

This study suggests that the knowledge of gastroenterologists and dentists about gastrointestinal diseases with oral manifestations could be improved. Interdisciplinary consultation was considered valuable for the optimal treatment of their patients but was assessed as insufficient.

Pancreatic cancer pathology viewed in the light of evolution

One way to understand ductal adenocarcinoma of the pancreas (pancreatic cancer) is to view it as unimaginably large numbers of evolving living organisms interacting with their environment. This “evolutionary view” creates both expected and surprising perspectives in all stages of neoplastic progression. Advances in the field will require greater attention to this critical evolutionary prospective.

The genetics of ductal adenocarcinoma of the pancreas in the year 2020: dramatic progress, but far to go

The publication of the "Pan-Cancer Atlas" by the Pan-Cancer Analysis of Whole Genomes Consortium, a partnership formed by The Cancer Genome Atlas (TCGA) and International Cancer Genome Consortium (ICGC), provides a wonderful opportunity to reflect on where we stand in our understanding of the genetics of pancreatic cancer, as well as on the opportunities to translate this understanding to patient care. From germline variants that predispose to the development of pancreatic cancer, to somatic mutations that are therapeutically targetable, genetics is now providing hope, where there once was no hope, for those diagnosed with pancreatic cancer.

High-grade endometrial stromal sarcoma as the initial presentation of an adult patient with Peutz-Jeghers Syndrome: a case report

A 46-year-old female presents with a pelvic mass and is diagnosed as having a high-grade endometrial stromal sarcoma. During surgery, she is noted to have areas of intussusception of the small bowel secondary to large hamartomatous polyps. The patient had a previous history of small bowel obstruction secondary to what had been thought to be hyperplastic polyps but represented hamartomatous polyps on further review. Additional examination revealed the presence of subtle hyperpigmented macules on the fingers leading to a diagnosis of Peutz-Jeghers Syndrome (PJS). The diagnosis was confirmed by the presence of a germ-line STK11 mutation. Immunohistochemistry analysis of the tumor showed decreased expression of STK-11 as compared to one of the patient's hamartomatous polyps. Next generation sequencing of the tumor specimen failed to demonstrate a "second hit" somatic mutation in STK-11. This case represents the first case of endometrial stromal sarcoma associated with PJS and illustrates the importance of increased awareness of this condition among oncologists. PJS is associated with dysregulation of the mTOR pathway; treatment with an mTOR inhibitor was not effective in this case.

Peutz-Jeghers syndrome: Diagnostic and therapeutic approach

Peutz-Jeghers syndrome (PJS) is an inherited, autosomal dominant disorder distinguished by hamartomatous polyps in the gastrointestinal tract and pigmented mucocutaneous lesions. Prevalence of PJS is estimated from 1 in 8300 to 1 in 280 000 individuals. PJS predisposes sufferers to various malignancies (gastrointestinal, pancreatic, lung, breast, uterine, ovarian and testicular tumors). Bleeding, obstruction and intussusception are common complications in patients with PJS. Double balloon enteroscopy (DBE) allows examination and treatment of the small bowel. Polypectomy using DBE may obviate the need for repeated urgent operations and small bowel resection that leads to short bowel syndrome. Prophylaxis and polypectomy of the entire small bowel is the gold standard in PJS patients. Intraoperative enteroscopy (IOE) was the only possibility for endoscopic treatment of patients with PJS before the DBE era. Both DBE and IOE facilitate exploration and treatment of the small intestine. DBE is less invasive and more convenient for the patient. Both procedures are generally safe and useful. An overall recommendation for PJS patients includes not only gastrointestinal multiple polyp resolution, but also regular lifelong cancer screening (colonoscopy, upper endoscopy, computed tomography, magnetic resonance imaging or ultrasound of the pancreas, chest X-ray, mammography and pelvic examination with ultrasound in women, and testicular examination in men). Although the incidence of PJS is low, it is important for clinicians to recognize these disorders to prevent morbidity and mortality in these patients, and to perform presymptomatic testing in the first-degree relatives of PJS patients.

LKB1 Protein Expression in Human Breast Cancer

Peutz-Jeghers syndrome is caused by germline mutations in the LKB1/STK11 gene. Peutz-Jeghers syndrome is associated with an increased risk of developing intestinal and extraintestinal cancers, including pancreatic, lung, and breast carcinomas. LKB1 gene inactivation has recently been demonstrated in a subset of sporadic pancreatic and lung carcinomas. The role of the LKB1 gene in sporadic breast carcinomas remains unclear, though recent studies suggest inactivation only within papillary carcinomas. Using a commercially available polyclonal antibody that has been shown to mirror LKB1 genetic status in gastrointestinal and pulmonary carcinomas, the authors performed IHC on a large series of breast cancers using tissue microarrays (TMAs). All abnormal TMA results were confirmed using whole sections; specifically, whole sections from the donor blocks of lesions demonstrating diminished or absent LKB1 protein expression on TMA were evaluated to compare labeling of the lesion with that of the surrounding normal breast. In all cases, normal breast epithelium demonstrated strong cytoplasmic labeling (providing an internal positive control), whereas the stroma was nonreactive. Luminal cells typically labeled more strongly than myoepithelial cells. Among 70 invasive ductal carcinomas, 3 (4.3%) showed complete loss of LKB1 labeling, whereas 6 others (8.6%) showed diminished labeling. Of the eight intraductal carcinoma lesions adjacent to these invasive carcinomas, one (12.5%) showed complete loss of LKB1 labeling and one other (12.5%) showed diminished labeling; these results were identical to those of the adjacent invasive carcinomas. One of 10 (10%) hematogenous metastases of mammary carcinoma showed loss of LKB1 labeling. Nine of the 10 invasive carcinomas and both of the ductal carcinoma in situ (DCIS) cases showing loss of or diminished LKB1 expression were of high grade. In contrast, all 13 pure nonpapillary DCIS lesions, all 5 invasive lobular carcinomas and 3 accompanying lobular carcinoma in situ lesions, all 7 papillary DCIS lesions, and all 3 papillomas evaluated showed intact LKB1 labeling. Therefore, although frequent methylation of the LKB1 gene has been reported in papillary carcinomas of the breast, the authors did not find loss of protein expression in these lesions. Instead, it was found that loss of LKB1 protein expression occurs in a subset of high-grade in situ and invasive mammary carcinomas. The authors found LKB1 gene methylation in several of these invasive carcinomas. Given recent Western blot results indicating that diminished LKB1 expression in breast carcinomas correlates with shorter relapse-free survival, LKB1 IHC merits evaluation as a potential prognostic marker for breast carcinoma.

Eponyms in Radiology of the Digestive Tract: Historical Perspectives and Imaging Appearances

Eponyms are a means of honoring individuals who have made lasting contributions to medicine. Eponyms are frequently encountered in the field of radiology, especially radiology of the digestive tract. However, the use of eponyms may fail to convey a precise meaning or definition and could result in miscommunication. Furthermore, in some instances, more than one individual may have contributed to the discovery or description of a particular structure or disease, whereas in others, an eponym may have been incorrectly applied and then propagated for years thereafter in the medical literature. Still, eponyms are a means of honoring those who have made important discoveries and observations, and familiarity with these terms is important for proper reporting and accurate communication. Moreover, the acquisition of some historical knowledge about the individuals whose names are associated with various structures or diseases helps restore some humanity to the science of medicine.

Surveillance of patients at high risk for colorectal cancer

Colorectal cancer (CRC) mortality may be greatly reduced by clinically feasible screening programs. The benefits of surveillance of high-risk programs are evident. Cancer mortality can be dramatically reduced by eradication of precursor lesions and by detection of cancer at an early and highly curable stage. Available screening methods, recommended intervals, and screening for other associated cancers are reviewed for specific high-risk groups.