Peutz-Jeghers syndrome managed with a complete intraoperative endoscopy and extensive polypectomy

Inherited Predisposition to Gastric Cancer

Approximately 10% of patients with gastric cancer show familial aggregation and up to 3% are related to an inherited cancer syndrome. There are multiple germline pathogenic variants and cancer syndromes associated with an increased risk of gastric cancer. Appropriate assessment of familial and genetic risk may allow a personalized approach to gastric cancer prevention through screening and risk-reducing surgeries. The ability to better identify carriers with pathogenic genetic variants associated with gastric cancer before a diagnosis of cancer requires effective genetic risk assessment and testing, followed by optimal screening and surveillance recommendations to further reduce the morbidity and mortality.

ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes

This guideline presents recommendations for the management of patients with hereditary gastrointestinal cancer syndromes. The initial assessment is the collection of a family history of cancers and premalignant gastrointestinal conditions and should provide enough information to develop a preliminary determination of the risk of a familial predisposition to cancer. Age at diagnosis and lineage (maternal and/or paternal) should be documented for all diagnoses, especially in first- and second-degree relatives. When indicated, genetic testing for a germline mutation should be done on the most informative candidate(s) identified through the family history evaluation and/or tumor analysis to confirm a diagnosis and allow for predictive testing of at-risk relatives. Genetic testing should be conducted in the context of pre- and post-test genetic counseling to ensure the patient's informed decision making. Patients who meet clinical criteria for a syndrome as well as those with identified pathogenic germline mutations should receive appropriate surveillance measures in order to minimize their overall risk of developing syndrome-specific cancers. This guideline specifically discusses genetic testing and management of Lynch syndrome, familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (AFAP), MUTYH-associated polyposis (MAP), Peutz-Jeghers syndrome, juvenile polyposis syndrome, Cowden syndrome, serrated (hyperplastic) polyposis syndrome, hereditary pancreatic cancer, and hereditary gastric cancer.

Peutz-Jeghers syndrome: a study of long-term surgical morbidity and causes of mortality

Patients with Peutz-Jeghers syndrome (PJS) require lifelong multidisciplinary care for gastrointestinal polyposis and increased risk of cancer. Their long-term morbidities and causes of mortality are unknown. Patients with a definitive diagnosis of PJS (n = 54) were retrospectively reviewed for disease course and outcome. Operative details, pathology and complications were noted for those treated surgically (n = 33). Median follow-up was 7.0 years (interquartile range: 2-20). Two malignancies were found intra-operatively (duodenal and rectal adenocarcinoma). In the long-term, 42% underwent additional operations; 1 patient developed short bowel syndrome, while another, chronic partial bowel obstruction and pain. Twenty-one additional cancers were treated in 19 patients: gynecologic (11), lung (3), and prostate (2) being the most common. 16 patients (30%) were deceased, at a median age of 51 years. The cause of death was unknown in 4 patients, but was due exclusively to malignancies in all other patients, most commonly due to metastatic gynecologic cancer (5). The overall survival of PJS patients was significantly shorter than the expected survival of an age-and gender-matched reference population (P < 0.001). Given the morbidities associated with repeated operations and the risk for cancer-related mortality in the long-term, efforts should focus on minimizing the need for surgical intervention and optimizing cancer detection, treatment and prevention.

Successful management of intussusception with total polyp clearance in Peutz-Jeghers syndrome using a combined endoscopic and surgical approach

Intussusception due to small intestinal polyps in Peutz-Jeghers syndrome represents a significant clinical challenge. Neither pure surgical nor endoscopic approaches alone are effective in the long-term management of this problem. We describe a combined approach using both surgery and small bowel endoscopy in the management of this condition, which resulted in both immediate and long-term success. Although not new, we believe this approach remains relevant despite recent technological advancements in this area.

Endoscopy-assisted resection for multiple polyps of the small intestine in Peutz-Jeghers syndrome: a father and daughter story

Peutz-Jeghers syndrome is an infrequently encountered disease with potential complications including bleeding, intestinal obstruction, intussusception, and malignant transformation. We report on two patients, father and daughter, with Peutz-Jeghers syndrome who were admitted to hospital with similar complaints of abdominal pain. The father was 37 years old and the daughter was 17. Physical examination and laboratory tests revealed small intestinal intussusception in both patients. In the daughter, the intussuscepted segment was resected. An electrosurgical snare was also used for enteroscopic excision of multiple jejunal and ileal polyps. In the father, two 4-cm polyps were surgically resected while an enteroscopic surgical snare was used for polyps of smaller size. Both patients were discharged on postoperative day 7.

Endoscopic management of familial colonic neoplasia

Heredity plays an important causative role in a large percentage of colorectal cancers. Clinical recognition of the hereditary polyposis syndromes, hereditary nonpolyposis colorectal cancer, and common familial colorectal cancer is essential because screening, surveillance, and treatment among affected individuals and their family members differs from that recommended for the general population. More intensive cancer screening and surveillance is required if premature death is to be avoided. Genetic testing is commercially available for most of the hereditary colorectal cancer syndromes and can greatly facilitate the management of patients if properly undertaken.