Juvenile polyposis in a tropical country

Management of Juvenile Polyposis Syndrome in Children and Adolescents: A Position Paper From the ESPGHAN Polyposis Working Group

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Polyposis Working Group developed recommendations to assist clinicians and health care providers with appropriate management of patients with juvenile polyposis. This is the first juvenile polyposis Position Paper published by ESPGHAN with invited experts. Many of the published studies were descriptive and/or retrospective in nature, consequently after incorporating a modified version of the GRADE system many of the recommendations are based on expert opinion. This ESPGHAN Position Paper provides a guide for diagnosis, assessment, and management of juvenile polyposis syndrome in children and adolescents, and will be helpful in the appropriate management and timing of procedures in children and adolescents. The formation of international collaboration and consortia is proposed to monitor patients prospectively to advance our understanding of juvenile polyposis conditions.

Colonic polyposis in a 15 year-old boy: Challenges and lessons from a rural resource-poor area

INTRODUCTION

Colorectal polyps usually present with rectal bleeding and are associated with increased risk of colorectal carcinoma. Evaluation and management in resource-poor areas present unique challenges.

PRESENTATION OF CASE

This 15 year-old boy presented with 9 years of painless rectal bleeding and 2 years of a prolapsing rectal mass after passing stool. He had 3 nephews with similar symptoms. On clinical assessment and initial exam under anesthesia, an impression of a polyposis syndrome was made and a biopsy taken from the mass that revealed inflammatory polyps with no dysplasia. He was identified during a pediatric surgical outreach to a rural area with no endoscopy, limited surgical services, and no genetic testing available, even at a tertiary center. He subsequently had a three-stage proctocolectomy and ileal pouch anal anastomosis with good outcome after referral to a tertiary care center. The surgical specimen showed many polyps scattered through the colon.

DISCUSSION

In the absence of endoscopic surveillance and diagnostic services including advanced pathology and genetic testing, colorectal polyposis syndromes are a significant challenge if encountered in these settings. Reports from similar settings have not included this surgical treatment, often opting for partial colectomy. Nonetheless, good outcomes can be achieved even given these constraints. The case also illustrates the complexity of untreated chronic pediatric surgical disease in rural resource-poor areas with limited health care access.

CONCLUSION

Polyposis syndromes in children present unique challenges in rural resource-poor settings. Good outcomes can be achieved with total proctocolectomy and ileal pouch anastomosis.

Paediatric surgical pathology - a profile of cases from Western India and review of literature

AIM

The paediatric surgical pathology specimens manifest a wide spectrum of morphological and histological features. The present work has been undertaken to know the prevalence and to describe the profile of paediatric surgical pathology specimens from western India as seen in Ahmedabad, India from 2008 to 2010.

MATERIALS AND METHODS

We reviewed 140 paediatric surgical specimens, 118 specimens rendered definitive diagnosis were included for the analysis. Cases were divided in two groups, one of developmental and congenital conditions and another of acquired lesions.

RESULTS

This study included 118 patients of which 79.3 % were male and 20.7 % were female. Age range of the patients was one day to twelve years. Children of one month to one year age group (infants) were the most vulnerable (31.3% cases). Group of developmental and congenital conditions consisted of 45.7% cases where as 55.3 % cases were of acquired lesions. Gastrointestinal tract was most frequently affected organ (43.2%) followed by head and neck region (14.4%) and testis (7.6%). Hirschsprung's disease (HD) cases (6.7%) were commonest among the group of developmental and congenital conditions followed by juvenile polyps of colon (5%), Meckel's diverticulum of small intestine (5%) and neural tube defect (5%). In acquired lesions, Appendicitis was the most frequent lesion (21.2%) followed by haemorrhagic infarct of testis due to torsion (5%) and intussuception of intestine (5%). Malignant cases were (4.2%) and the most common cancer was yolk sac tumour.

CONCLUSION

Paediatric surgical specimens, unlike adults, represent significant number of developmental and congenital conditions in addition to acquired lesions; accounting for wide spectrum of morphological and histological features. Study provides insight into the trends of paediatric surgical lesions in the western region of India.

Clinical and endoscopic data in juvenile polyposis syndrome in preadolescent children: a multicenter experience from the United States

OBJECTIVES

Juvenile polyposis syndrome (JPS) is a hereditary syndrome associated with several germline mutations, and carries a significant risk for future cancer development. Clinical data of JPS in children are sparse, and clinical guidelines are mainly derived from the adult population. In the present study, we describe the largest series of children diagnosed with JPS and present clinical, endoscopical, and histologic data.

METHODS

A retrospective study of children with JPS was performed. Children were recruited from 3 academic pediatric gastroenterology centers. Clinical presentation, colonoscopic description, and histologic and demographic data were collected at initial presentation and at each future colonoscopy surveillance.

RESULTS

Thirty-six children were included in the study with a mean age of 7.35 years and male to female ratio of 1.25:1. The most common clinical presentation was gastrointestinal bleeding (100%). Family history of colon cancer was noted in 28% of children. A total of 366 polyps were removed, of which 90.5% were pedunculated and 9.5% were sessile. Up to 4 colonoscopic, follow-up surveillances were documented: 21 children had 1 surveillance, 10 children had 2 surveillances, 3 children had 3 surveillances, and 1 child had 4 surveillances. Polyps were evenly distributed throughout the colon. Most of the polyps (99.2%) had benign histology (inflammatory changes) and 3 (0.8%) involved focal adenomatous changes. No adenocarcinoma was identified in any of the 366 polyps.

CONCLUSIONS

Colonic polyps in JPS are rarely malignant during the pediatric age period. Our data suggest that the recommended colonic surveillance in children should be modified.

Juvenile Polyp in Thai Children—Clinical and Colonoscopic Presentation

BACKGROUND

The aim of this prospective study was to describe the clinical characteristics of colorectal polyp in Thai children.

METHODS

From December 2002 to February 2005, children under 15 years of age presenting with rectal bleeding were prospectively enrolled. Demographic, clinical, and laboratory information was recorded. Location, number, characteristics, and histopathology of the polyps were noted.

RESULTS

There were 32 patients with a mean age of 6.5 years. The most common presenting symptom was hematochezia, followed by prolapsing rectal mass and diarrhea. In 20 patients there was a single polyp, 6 had 2-4 polyps, and 6 were diagnosed with polyposis coli. Most of the polyps were located exclusively at the rectum and sigmoid colon. In only 7 cases were the polyps proximal to the rectosigmoid region. This included 6 patients who had polyps beyond the splenic flexure. All were juvenile polyps without evidence of adenomatous changes. Compared to those with isolated polyps, the patients with polyposis coli had a statistically significant incidence of right-sided polyps (P <0.001) and a history of prolapse of the rectal mass (P = 0.006).

CONCLUSIONS

Because of the high prevalence of right-sided polyps and the concern about malignant transformation, colonoscopy should be considered as the initial evaluation in children with rectal bleeding.

Low prevalence of loss of heterozygosity and SMAD4 mutations in sporadic and familial juvenile polyposis syndrome-associated juvenile polyps

BACKGROUND

Juvenile polyps (JP) may develop sporadically or may be associated with the familial juvenile polyposis syndrome (FJPS). In FJPS, the epithelium is susceptible to dysplasia and, ultimately adenocarcinoma. However, the mechanisms involved in this transformation are unknown. Since the epithelium in colorectal carcinogenesis undergoes a stepwise genetic progression, the purpose of this study was to determine if loss of heterozygosity (LOH) abnormalities can aid in the differentiation between sporadic and FJPS-associated polyps.

DESIGN

Ninety-one routinely-processed JP from three groups of patients were evaluated for this study. Group 1 included 39 polyps from 39 patients with a single JP and no personal or family history of FJPS; group 2 consisted of 24 polyps from 15 patients with 2-5 JP and no history of FJPS; and group 3 included 29 polyps from 22 patients with > or =5 polyps either with (7) or without (15) a family history of FJPS. Epithelium from typical, atypical, and overtly dysplastic polyps, when present (2 cases in group 3 only), were evaluated separately by microdissection and PCR analysis for LOH of APC, p53, 3p, 9p, and mutations in exon 9 of the SMAD4 gene.

RESULTS

SMAD4 mutations were observed in 3 polyps from 2 patients in group 3 (10% of informative cases; p < 0.05 vs group 1), but not in any of the polyps from the other two groups. Overall, LOH of APC, p53, 3p, and 9p were detected in 1%, 15%, 10%, and 4% of JPs, but no differences were observed between the three clinical groups. Two polyps, both in group 3, with definite dysplasia did not show any genetic alterations. The morphologic appearance of the polyps was not a reliable feature in helping to differentiate sporadic from FJPS-associated polyps.

CONCLUSIONS

LOH of APC, p53, 3p, and 9p may not be involved in the carcinogenic pathway of FJPS-associated polyps. SMAD4 gene mutations show a low sensitivity but a high specificity for FJPS.

Gastrointestinal polyposis in childhood: clinicopathologic and genetic features

Gastrointestinal polyps and certain extraintestinal lesions in children may herald a hereditary polyposis syndrome, with an increased risk of neoplasia and other health problems for both children and their relatives. The availability of molecular/genetic screening tests has increased early diagnosis of younger members of known polyposis families. This article reviews the gross and microscopic features of polyposis syndromes of childhood and summarizes the molecular/genetic advances in this field. Clinical management is also briefly discussed.