Involvement of the digestive tract in Cowden's disease

Pathology of Intestinal Motor Disorders in Children

Varied intestinal neuromuscular pathologies are responsible for Hirschsprung disease and other forms of chronic pseudo-obstruction that are encountered in pediatrics. Pathologically distinct subtypes discussed in this review include aganglionosis, hypoganglionosis, neuronal intranuclear inclusion disease, ganglionitis, degenerative neuropathy, diffuse ganglioneuromatosis, neuronal dysplasia, malformations of the muscularis propria, degenerative leiomyopathy, leiomyositis, and mitochondriopathies. Emphasis is given to the histopathologic features that distinguish these conditions and their differential diagnoses.

Deletion of Pten in the mouse enteric nervous system induces ganglioneuromatosis and mimics intestinal pseudoobstruction

Intestinal ganglioneuromatosis is a benign proliferation of nerve ganglion cells, nerve fibers, and supporting cells of the enteric nervous system (ENS) that can result in abnormally large enteric neuronal cells (ENCs) in the myenteric plexus and chronic intestinal pseudoobstruction (CIPO). As phosphatase and tensin homolog deleted on chromosome 10 (PTEN) is a phosphatase that is critical for controlling cell growth, proliferation, and death, we investigated the role of PTEN in the ENS by generating mice with an embryonic, ENC-selective deletion within the Pten locus. Mutant mice died 2 to 3 weeks after birth, with clinical signs of CIPO and hyperplasia and hypertrophy of ENCs resulting from increased activity of the PI3K/PTEN-AKT-S6K signaling pathway. Further analysis revealed that PTEN was only expressed in developing mouse embryonic ENCs from E15.5 and that the rate of ENC proliferation decreased once PTEN was expressed. Specific deletion of the Pten gene in ENCs therefore induced hyperplasia and hypertrophy in the later stages of embryogenesis. This phenotype was reversed by administration of a pharmacological inhibitor of AKT. In some human ganglioneuromatosis forms of CIPO, PTEN expression was found to be abnormally low and S6 phosphorylation increased. Our study thus reveals that loss of PTEN disrupts development of the ENS and identifies the PI3K/PTEN-AKT-S6K signaling pathway as a potential therapeutic target for ganglioneuromatosis forms of CIPO.

Cowden's disease—its importance for otolaryngologists

Cowden's disease is a rare predominantly inherited disease, characterized bymucocutaneous lesions, gastrointestinal polyposis and benign or malignant thyroid and breast tumours. The report deals with a typical case of this disease with emphasis on its importance forotolaryngologists.

Cowden disease: a review

Cowden disease is a genetically inherited disorder presenting with multiple hamartomatous and neoplastic lesions in various organs and tissues. We present a review of the diagnostic criteria, clinical presentation, genetics, and management of this condition.

GI polyposis and glycogenic acanthosis of the esophagus associated with PTEN mutation positive Cowden syndrome in the absence of cutaneous manifestations

A 62-yr-old man was referred for management of GI polyposis. Large bowel polyps were initially diagnosed >25 yr ago, and the patient had undergone multiple colonoscopies and polypectomies. Personal and family history were notable for thyroid goiter and hypothyroidism. Physical examination was notable for lingular papillomatosis. No cutaneous lesions were seen. Upper endoscopy revealed esophageal glycogen acanthosis. There were multiple polyps throughout the stomach and the small and large intestines. Histology of these polyps showed multiple cell types including juvenile polyps, inflammatory polyps with fibromuscular proliferation and lamina propria ganglion cells, and focal adenomatous change. A clinical diagnosis of Cowden syndrome was made. Mutation analysis revealed a variant in exon 8 of the PTEN gene. Direct sequencing revealed a germline heterozygous C.892-895InsA, which is predicted to result in a truncated PTEN protein. Cowden syndrome is an underdiagnosed, underrecognized, autosomal dominant, inherited syndrome. For the gastroenterologist, esophageal acanthosis and multiple hamartomatous polyps should suggest the diagnosis. Sensitive molecular diagnostic tests looking for mutations in the appropriate genes are clinically available. Together with genetic counseling, molecular diagnostic testing will allow more accurate risk assessment and surveillance for cancer for both the patient and family members.

Multiple hamartoma syndrome presenting with oral lesions

Multiple hamartoma syndrome (Cowden's syndrome), a rare genodermatosis with predominant mucocutaneous features, particularly hamartomas, and Cowden/Lhermitte-Duclos disease, the combination of multiple hamartomas with cerebellar hypertrophy, typically present with cutaneous and oral papillomatosis as major features of both uncommon disorders. This article details the clinical features of three patients with multiple hamartoma syndrome and one with both disorders.

Cowden's disease: report of the first case in a Chinese

A 19-year-old Chinese female presenting mucocutaneous manifestations including facial trichilemmomas, oral papillomatosis, and acral keratosis was diagnosed, according to the criteria proposed by Salem and Steck, as a definite case of Cowden's disease, although no members of her family were affected. The cutaneous reticulohistiocytic granuloma and congenital nystagmus of eyes that occurred in this case were new combinations in the syndrome. To the best of our knowledge, this is the first documented case of Cowden's disease in a Chinese.

Immunophenotypes of the palatal tonsil lymphocytes in Cowden's disease

Cowden's disease is characterized by multiple hamartomas and neoplasias of ectodermal, mesodermal and endodermal origin. A case of a 22-year-old man suffering from nocturnal dyspnoea is reported. The patient had a large number of hyperkeratotic, lichenoid papules, scattered over the right side of the trunk, back and palm. In his oral cavity, papules were present on the gingiva and hard palate. The patient was operated on for tonsillar hypertrophy and for excluding the possibility of malignant lymphoma. An examination of immunophenotypes of the palatal tonsil lymphocytes revealed B-cell proliferation and poly-clonal immunoglobulin.

Cutaneous manifestations of gastrointestinal disorders. Part I

This article reviews the cutaneous manifestations of gastrointestinal tract diseases. In part I, the gastrointestinal tract polyposis syndromes and gastrointestinal tract malignancies will be discussed. The cutaneous manifestations of inflammatory bowel disorders, vascular disorders of the gastrointestinal tract, celiac disease and bowel-associated dermatosis-arthritis syndrome will be discussed in part II. For each entity, a brief summary of the gastrointestinal tract (and other extracutaneous) manifestations is given. This is followed by a detailed discussion of the cutaneous signs. Current guidelines for the investigation and management of these diseases are presented.

Alimentary tract lesions in Cowden's disease

Cowden's disease was first recognized by its striking dermatological manifestations and subsequently by the increased incidence of neoplastic involvement of the thyroid and breast. Two cases of Cowden's disease with gastrointestinal polyps are presented to illustrate the alimentary tract involvement in this syndrome, gastrointestinal tract involvement with polyposis being seen in at least 50% of cases. As opposed to the more serious potential of neoplasia in the thyroid and breast, involvement of the alimentary tract has negligible clinical impact to the patient.

Cowden's disease--treatment of cutaneous lesions using carbon dioxide laser vaporization: a comparison of conventional and superpulsed techniques

Cowden's disease is a genodermatosis associated with both cutaneous and visceral manifestations, including cancer. Trichilemmomas represent one of the benign cutaneous lesions associated with this syndrome and may be responsible for significant cosmetic disfigurement. Using the carbon dioxide (CO2) laser in its vaporizational mode of operation, a patient with multiple trichilemmomas of the nose, previously unsuccessfully treated with multiple medical and surgical procedures, obtained excellent cosmetic results.

Cowden's disease: a case report and literature review

Cowden's disease, or multiple hamartoma syndrome, is an uncommon condition with characteristic mucocutaneous lesions associated with abnormalities of the breast, thyroid, and gastrointestinal tract. We describe a 51-year-old man with hyperplastic polyposis of the entire alimentary tract as the most prominent feature of this disease. We also present a review of 85 cases of this entity as reported in the English medical literature, and summarize the pertinent findings.

The keratotic tumors of Cowden's disease: an electronmicroscopic study

Cowden's disease is characterized by multiple hamartomas of the skin, breast, thyroid, and gastrointestinal tract. In the past, a viral hypothesis for the keratotic lesions of the skin has led to much controversy. The present study describes the results of a detailed fine structural analysis of 10 hyperkeratotic extremity lesions and 2 keratotic lesions from the face of a patient with Cowden's disease. Increases in the keratinocyte population were primarily confined to the basal and suprabasal regions. Differentiation products characteristic of keratinization were normal in both quantity and appearance. Nuclear remnants and numerous lipid droplets, markers of abnormal keratinization, were noted within horny cells. However, viral particles and/or virus-like particles were not observed in keratinocytes. Melanocytes and Langerhans cells were numerous. The latter contained membrane-bound pigment vacuoles in addition to the characteristic Birbeck granules. These unusual Langerhans cells were observed in the dermis as well as the epidermis. A large number of fully granulated "resting" mast cells was uniformly distributed throughout the dermis, associated with a prominent cellular infiltrate. Our observations do not support the concept of a viral etiology for these tumors.

Multiple hamartoma syndrome

Multiple hamartoma syndrome, also known as Cowden's disease, is a rare genodermatosis with multiple organ system involvement affecting tissues derived from ectodermal, endodermal, and mesodermal tissue layers. We describe two previously unreported cases of multiple hamartoma syndrome in a father and daughter. Both show classic features of multiple hamartoma syndrome, as well as other mucocutaneous findings. The father has been shown to have substantial cutaneous deposits of amyloid in the absence of underlying plasma cell dyscrasia or malignancy. Both individuals have undergone excision of a unique fibroma that has features that have been reported only in multiple hamartoma syndrome and should be added to the criteria used to define the entity.

Cowden's disease (multiple hamartoma syndrome)

A case report of Cowden's disease has been presented along with a discussion of its multiple system involvement. Its association with thyroid and breast malignancy make its differentiation from other or similar disease entities vital.

Oral manifestations in Cowden's syndrome. Report of four cases

Cowden's syndrome or multiple hamartoma and neoplasia syndrome is a hereditary disorder combining multiple hamartomas of many organs. These hamartomas are derived from ectodermal, mesodermal, and endodermal tissues and may undergo spontaneous malignant changes. Small papular cutaneous lesions and papillomatous outgrowth and papular lesions of the oral mucosa are the most predominant features of the syndrome. Since the orocutaneous lesions often precede the associated malignant degenerations, they may serve as a diagnostic signal for the probably developing neoplasia in other organs. The presence of extensive papillomatous and papular lesions in the oral mucosa combined with skin lesions should therefore alert the clinician to suspect the presence of Cowden's syndrome, the early diagnosis of which is important in order that the concomitant malignant changes might be discovered at the earliest possible moment. Four cases of Cowden's disease are presented, with emphasis on the oral manifestations of this syndrome.

Cowden's disease: analysis of fourteen new cases

Fourteen new patients with Cowden's disease from the Netherlands were analyzed and compared with the sixty-nine previously reported patients. The full clinical spectrum of the disease can now be fairly well delineated. Mucocutaneous lesions, especially facial trichilemmomas and other follicular malformations, acral keratoses, and oral papillomas, remain the most constant findings. The incidence of each of these mucocutaneous findings was slightly higher than reported previously, probably reflecting increasing experience with this condition. Also our patients tended to have more extensive acral keratoses and perhaps less extensive facial lesions. In one family there was an extremely high incidence of lipomas. Breast cancer was seen in three of our twelve female patients, reflecting the trend toward a lower incidence of breast cancer in the recent literature. Gastrointestinal polyps in one family were much more common than previously reported, occurring in five of seven patients. Thyroid disease was found in about two thirds of the patients and abnormalities of the female reproductive system in slightly more than half of the patients, both incidences being approximately the same as in the literature. With increased awareness of the condition it is likely that many more cases will be recognized in the future.

Cowden's disease (multiple hamartoma and neoplasia syndrome). A case report and review of the English literature

Cowden's disease is a multisystem disease complex inherited as an autosomal dominant trait with incomplete penetrance and variable expressivity. Its mucocutaneous findings are the most characteristic feature of the syndrome and the key to its diagnosis. The findings of multiple facial trichilemmomas appear to be pathognomonic of the disease. Multiple extracutaneous hamartomas are a regular feature of Cowden's disease. The most important hamartomas to recognize include fibrocystic disease of the breast, thyroid goiters or adenomas, multiple polyposis of the gastrointestinal tract, and ovarian cysts. Although many developmental anomalies have been described in these patients, only adenoid facies and high-arched palates appear significant from a statistical standpoint. The most important feature of Cowden's disease, that which makes early recognition absolutely essential, is an increased prevalence of malignant neoplasia primarily in affected female patients, and principally involving the breasts and thyroid gland. All patients, however, must be screened for occult malignancies of all types. A detailed review of the English literature offers a basis for the formation of guidelines that should be helpful in making a diagnosis of the disease.