A new form of diffuse familial polyposis: a probable genetic explanation

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.

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.

Familial polyposis of the colon with special reference to regression of rectal polyposis after subtotal colectomy

Two families with familial polyposis of the colon are reported. One family conforms to the established pattern and in the other there is a risk of an additional inheritance of sebaceous cysts and fibromata. Initially prophylactic surgery should usually consist of a one-stage subtotal colectomy with ileorectal anastomosis. Thereafter the polyps in the rectal remnant are left untreated for 6 months in the hope of spontaneous regression of some years' duration. This routine is preferable to immediate total colectomy and ileostomy for the adolescent or young adult. Fulguration of residual polyps is deferred but may be necessary if there is no spontaneous regression. A second-stage excision may be required if polyposis becomes uncontrollable or if there is malignant change. A case may be made for prophylactic rectal excision about 10 years after subtotal colectomy. The technique of ileorectal anastomosis is discussed briefly and a plan for family supervision is outlined. It is suggested that the phenomenon of spontaneous regression of polyps in the rectal remnant may be more frequent than accepted at present and that a long-term follow-up of patients with regression is required.