Gastric and duodenal polyps in familial polyposis coli

Morphology and natural history of familial adenomatous polyposis-associated dysplastic fundic gland polyps

AIMS

Most patients with familial adenomatous polyposis (FAP) develop gastric fundic gland polyps, with many displaying low-grade dysplasia. This study evaluates the natural history and morphological phenotype of dysplasia in FAP-associated fundic gland polyps.

METHODS AND RESULTS

Patients with FAP and dysplastic fundic gland polyps (n = 24) were identified. Twenty-two of 24 FAP-associated dysplastic fundic gland polyps showed a gastric phenotype and two had mixed phenotype. During a mean 6.1-year follow-up (range 0.8-12.6 years) and 5.7 endoscopies (range 2-22), one patient (4%) was diagnosed with a fundic gland polyp with high-grade dysplasia, while 23 patients (96%) in this cohort had either no dysplasia or persistent low-grade dysplasia. Contemporary patients with sporadic fundic gland polyps with low-grade dyplasia had similar morphology and outcomes to the FAP-associated fundic gland polyp cohort. Dysplasia in fundic gland polyps (FAP-associated and sporadic) was associated less frequently with intestinal phenotype, high-grade dysplasia and the finding of concurrent or subsequent carcinoma compared to contemporary patients with sporadic gastric dysplasia not occurring in fundic gland polyps.

CONCLUSIONS

This cohort of patients with FAP-associated dysplastic fundic gland polyps rarely developed high-grade dysplasia and gastric adenocarcinoma was absent.

Three novel mutations of the APC gene in Korean patients with familial adenomatous polyposis

Germline mutations within the adenomatous polyposis coli (APC) gene are associated with familial adenomatous polyposis (FAP), an autosomal dominant disease predisposing individuals to colorectal cancer. Identification of APC mutations has important implications for genetic counseling and management of FAP patients. We examined the APC mutation status of 10 Korean FAP patients by polymerase chain reaction-direct sequencing method and found six APC mutations, including three novel mutations. Testing for MUTYH mutation was done for FAP patients in whom no mutation in the APC gene was identified. Three novel mutations (c.1654_1663delTCTTGGCGAG, c.3709C>T, and c.6092_6094delinsTT) and three previously reported mutations (c.3631_3632delAT, c.4438C>T, and c.4612_4613delGA) were detected. The MUTYH mutation was not detected in any of the four FAP patients without an APC mutation. This finding of three novel mutations in a group of Korean FAP patients broadens the spectrum of APC mutations.

[Intestinal and extraintestinal manifestations in familial adenomatous polyposis]

<zakljucak> U radu su opisane intestinalne i ekstraintestinalne manifestacije familijarne adenomatozne polipoze koje mogu imati dijagnosticki i prognosticki znacaj. Pojava tumora izvan kolona znacajna je za razvoj ozbiljnih simptoma bolesti (opstrukcija, krvarenje), ali i za malignu alteraciju i razvoj karcinoma, posebno u duodenumu (karcinom duodenuma i dezmoidni tumori su najcesci uzrok smrti kod bolesnika sa familijarnom adenomatoznom polipozom nakon kolekotmije). Poseban znacaj imaju dezmoidni tumori, koji su benigni po svojoj prirodi, ali koji lokalnom invazijom mogu dovesti do smrtnog ishoda, a najcesce ispoljavaju tendenciju rasta nakon hirurske resekcije creva. Kongenitalna hipertrofija pigmentnog epitela retine je prediktivni marker koji omogucava postavljanje dijagnoze familijarne adenomatozne polipoze i pre otkrivanja adenoma debelog creva.

Surveillance and management of upper gastrointestinal disease in Familial Adenomatous Polyposis

Almost all patients affected by Familial Adenomatous polyposis (FAP) will develop foregut as well as hindgut polyps, and following prophylactic colectomy duodenal cancer constitutes one of the leading causes of death in screened populations. Without prophylactic colectomy, FAP patients predictably develop colorectal cancer, but the lifetime risk of upper gastrointestinal cancer is lower, estimated at approximately 5%. Management of the upper gastrointestinal cancer risk is one of the greatest challenges facing clinicians involved in the care of Polyposis families, and with improved survival following prophylactic colectomy, the burden of foregut disease (particularly duodenal adenomatosis) will increase. Until recently, the value of upper gastrointestinal surveillance in FAP populations has been contentious, but with improved understanding of the natural history coupled with developments in surgery, interventional endoscopy and medical therapy, treatment algorithms for duodenal adenomatosis in FAP are becoming clearer.

Impact of Helicobacter pylori infection and mucosal atrophy on gastric lesions in patients with familial adenomatous polyposis

BACKGROUND AND AIMS

The role of Helicobacter pylori and atrophic gastritis in the pathogenesis of gastric lesions in familial adenomatous polyposis (FAP) has not been clarified.

PATIENTS

Thirty one patients with FAP.

METHODS

The presence of fundic gland polyposis (FGP) and gastric adenoma (GA) was determined by upper endoscopy with biopsies. The degree of gastric mucosal atrophy and H pylori status were determined by serological and histological findings. Germline mutation in the adenomatous polyposis coli (APC) gene was determined by polymerase chain reaction based single strand conformation polymorphism and direct sequencing.

RESULTS

Gastric lesions were detected in 23 patients (74%). FGP and GA were found in 52% and 39%, respectively. APC gene mutation was identified in 22 of 30 patients. Patients with FGP were less frequently infected with H pylori than those without FGP (13% v 67%). The former patients had a lower degree of atrophy than the latter. Patients with GA tended to be more frequently infected with H pylori and they had higher degrees of atrophy than those without GA. When subjects were subdivided by gastric lesions (FGP alone, FGP+GA, GA alone, and negative groups), the GA alone group had the lowest pepsinogen I/II ratio and the highest seropositivity for H pylori. GA was found more frequently in patients positive for the APC mutation whereas no such a trend was observed in FGP.

CONCLUSIONS

In FAP, H pylori associated atrophic gastritis contributes negatively to FGP. It seems to contribute positively to GA, especially in patients with truncating APC gene mutation.

Familial and inherited colorectal cancer: endoscopic screening and surveillance

Familial risk of colorectal cancer is very common. The high-risk inherited syndromes are well described and much is known about the genetics and the effectiveness of registration, endoscopic surveillance, and appropriate intervention in these patients. The inherited syndromes, however, are extremely rare. There is a large group of patients in our population who can benefit from risk stratification based on the number of their relatives with colon cancer or adenomas and the age at which those relatives developed neoplasm. The GI endoscopist has a vital role in recommending and providing colonoscopic screening for this large group of patients.

Sporadic fundic gland polyps: common gastric polyps arising through activating mutations in the beta-catenin gene

Fundic gland polyps (FGPs) are the most common gastric polyps. FGPs traditionally have been regarded as nondysplastic hamartomatous or hyperplastic lesions, but their pathogenesis remains unclear. We have recently shown that somatic adenomatous polyposis coli (APC) gene alterations are frequently present in FGPs associated with familial adenomatous polyposis (FAP), raising the possibility that mutations of the beta-catenin gene affecting the APC/beta-catenin pathway might be involved in the pathogenesis of sporadic FGPs. We analyzed somatic beta-catenin gene mutations in 57 sporadic FGPs from 40 patients without FAP and in 19 FGPs from 13 FAP patients. Direct DNA sequencing of exon 3 encompassing the glycogen synthase kinase-3beta phosphorylation region for beta-catenin was used with confirmation by HIN:fI restriction endonuclease digestion. The foveolar epithelium and dilated fundic glands of the polyps were separately microdissected and analyzed in 22 of 57 sporadic FGPs. Activating beta-catenin gene mutations were present in 91% (52 of 57) of sporadic FGPs. Both the foveolar epithelium and the dilated fundic gland epithelium comprising the polyps were shown to have the same somatic beta-catenin mutation in 21 of 22 (95%) sporadic FGPs. In contrast, beta-catenin gene mutations were not present in any of the 19 FAP-associated FGPs (P: < 0.000001). The high frequency of beta-catenin mutations in sporadic FGPs indicates that these lesions arise through activating mutations of the beta-catenin gene. Beta-catenin mutations in gastrointestinal tract polyps have previously only been demonstrated in a subset of adenomatous (dysplastic) or neoplastic polyps. Sporadic FGPs are therefore the only lesions of the gastrointestinal tract to demonstrate beta-catenin mutations while lacking dysplastic morphology.

Gastroduodenal lesions in familial adenomatous polyposis

Prophylactic colectomy is generally recommended for patients with familial adenomatous polyposis (FAP) who are inevitably affected with large bowel cancer. After prophylactic colectomy has been performed, gastrointestinal malignancy is the leading cause of death. Duodenal adenomas are found in patients with FAP and the adenoma-carcinoma sequence exists in the FAP duodenum, suggesting that treatment of duodenal polyps might be beneficial. Several methods of treatment for duodenal lesions in patients with FAP have been reported, but the current treatment options are not ideal. The nonsteroid anti-inflammatory drugs, sulindac and aspirin, are used for chemoprevention, while recently developed cyclooxygenase-2 inhibitors may be of some use in the future. Endoscopic polypectomy has been attempted for duodenal polyps and open surgical polypectomy has proven to be effective for selected patients. Photodynamic therapy and Argon plasma coagulation may be suitable to treat carpeted polyposis. New methods of duodenal resection, such as pancreas-preserving duodenectomy and pylorus-preserving pancreaticoduodenectomy, might be considered for severe duodenal polyposis; however, because prophylactic duodenal surgery has been considered too aggressive, surveillance duodenoscopy is usually performed to detect duodenal cancer at an early stage.

Fundic gland polyps in familial adenomatous polyposis: neoplasms with frequent somatic adenomatous polyposis coli gene alterations

Fundic gland polyps (FGPs) are the most common gastric polyps in patients with familial adenomatous polyposis (FAP). FGPs have traditionally been regarded as nonneoplastic, possibly hamartomatous lesions, but the pathogenesis of FGPs in both FAP and sporadic patients remains unclear. FGPs in FAP can show foveolar dysplasia, and rarely invasive gastric adenocarcinoma has been reported in patients with FAP and fundic gland polyposis. Using direct gene sequencing and allelic loss assays at 5q, we analyzed somatic adenomatous polyposis coli (APC) gene alterations in 41 FAP-associated FGPs (20 with foveolar dysplasia, six indefinite for dysplasia, and 15 nondysplastic) and 13 sporadic FGPs. The foveolar epithelium and dilated fundic glands of the polyps were separately microdissected and analyzed in 25 of 41 FAP-associated FGPs and 13 of 13 sporadic FGPs. Somatic APC gene alterations were identified frequently (21 of 41 cases, 51%) in FAP-associated FGPs. Both the foveolar epithelium and the dilated fundic gland epithelium comprising the FGPs were shown to carry the same somatic APC gene alteration in 24 (96%) of 25 cases. Furthermore, there was no difference in the frequency of somatic APC gene alterations between FGPs with foveolar dysplasia (10 of 20, 50%), indefinite for dysplasia (four of six, 67%), and nondysplastic (seven of 15, 47%) in FAP patients (P: = 0.697). In contrast, FGPs from non-FAP patients showed infrequent (one of 13, 8%) APC gene alterations (P: = 0.008). These results show that FGPs in FAP patients are pathogenetically distinct from sporadic FGPs. Somatic, second-hit APC gene alterations, which precede morphological dysplasia in many FAP-associated FGPs, indicate that FGPs arising in the setting of FAP are neoplastic lesions.

Polyposis syndromes of the gastrointestinal tract: MR findings

We describe the magnetic resonance (MR) findings in patients with gastrointestinal polyposis syndromes using breath-hold T1-weighted sequences, both standard and with fat suppression, prior to and following gadolinium administration, and breathing-independent single-shot half-Fourier RARE T2-weighted sequences. Six patients with gastrointestinal polyposis syndromes underwent MR examination to investigate for the presence of metastatic disease. The appearances of the gastrointestinal polyps on noncontrast T1-weighted spoiled gradient-echo (SGE), T2-weighted (half-Fourier RARE) images, and early and late gadolinium-enhanced SGE images were determined. Other gastrointestinal findings and extragastrointestinal disease were also evaluated. Patients with the following gastrointestinal polyposis syndromes were included: familial polyposis (n = 3), Peutz-Jeghers syndrome (n = 1), Gardner's syndrome (n = 1), and neurofibromatosis (n = 1). Polypoid lesions in all patients exhibited signal intensity comparable to bowel on noncontrast images and enhanced similar to bowel on early and late gadolinium-enhanced images. Polyps larger than 2 cm, observed in one patient with familial polyposis and the patient with Gardner's disease, showed mild heterogeneity on late gadolinium-enhanced fat-suppressed images. Multiple colonic polyps ranging from 5 mm to 3 cm in diameter were observed in patients with familial adenomatous polyposis. A solitary 1.5 cm polyp associated with entero-enteric intussusception was observed in the patient with Peutz-Jeghers syndrome. Gastric polyps ranging from 5 mm to 6 cm were observed in the stomach of the patient with Gardner's syndrome. Duodenal and jejunal neurofibromas ranging from 1 to 2 cm in diameter were present in the patient with neurofibromatosis. Extra gastrointestinal findings included an adrenal adenoma (1 patient), a pheochromocytoma (1 patient), and liver metastases (2 patients). Gastrointestinal polyps in patients with polyposis syndromes may be visualized on MR images employing breath-hold T1-weighted and breathing-independent snapshot T2-weighted techniques. Appreciation of polyp enhancement on post-gadolinium images is an important finding, which should help distinguish polyps from bowel contents.

Gastric adenocarcinoma associated with fundic gland polyps in a patient with attenuated familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is a rare autosomal dominant precancerous condition of the colon caused by mutations in the adenomatous polyposis coli (APC) tumor suppressor gene. FAP is characterized by the appearance of innumerable adenomatous polyps throughout the large bowel. Fundic gland polyps are the most common gastric lesion in FAP. It is generally believed that fundic gland polyps have little or no potential for malignant transformation in the population at large, and only a few case reports describe the development of high grade dysplasia or gastric adenocarcinoma associated with diffuse fundic gland polyposis in patients with FAP. We report the second case of gastric adenocarcinoma intimately associated with fundic gland polyposis in a family with an attenuated form of FAP. The patient had undergone routine screening per current guidelines because of his known mutation in the APC gene. This suggests that malignant transformation of fundic gland polyps in patients with FAP occur more frequently than previously believed. Current screening recommendations may not be sufficient for patients with FAP or its attenuated forms.

Upper gastrointestinal disease in patients with familial adenomatous polyposis

BACKGROUND

Upper gastrointestinal disease has become an important aspect in the management of patients with familial adenomatous polyposis (FAP).

METHODS

A review of the literature was carried out using Medline. Epidemiology, pathology and treatment options are considered.

RESULTS AND CONCLUSION

Despite the fact that over 90 per cent of patients with FAP develop duodenal adenomas, only 5 per cent go on to develop cancer. In the absence of methods to detect who is at risk of cancer, all patients undergo regular endoscopic surveillance at present. Chemoprevention in the form of drug therapy may be the answer to controlling the disease.

Nonpolypoid adenomas of the duodenum in patients with familial adenomatous polyposis (Gardner's syndrome)

BACKGROUND

Although duodenal adenomas are very common in familial adenomatous polyposis, we wished to emphasize our experience with finding nonpolypoid adenomas in the duodenum of patients with this disease.

METHODS

Duodenoscopy was performed in 23 patients with an established diagnosis of familial adenomatous polyposis or Gardner's syndrome.

RESULTS

Endoscopy revealed single or multiple nonpolypoid adenomas of the duodenum in 7 patients (30%). The lesions were smaller than 5 mm and were endoscopically recognized as flat or depressed reddish lesions; one lesion was completely flat and the remaining lesions were flat-topped elevations with a central depression. All of the lesions were histologically diagnosed as tubular adenoma with moderate epithelial atypia.

CONCLUSION

These findings suggest that duodenal nonpolypoid adenomas are common in familial adenomatous polyposis or Gardner's syndrome and that careful surveillance endoscopy seems necessary in patients with this disease.

Familial segregation in the occurrence and severity of periampullary neoplasms in familial adenomatous polyposis

BACKGROUND

Familial adenomatous polyposis (FAP) patients often develop periampullary adenomas that may progress to periampullary cancer, a common cause of death in this population. The risk of periampullary cancer in FAP is unclear, and variables that predict the occurrence and severity of periampullary tumors are not well understood. The specific aim of this study was to determine whether the risk of periampullary neoplasia segregates in specific FAP families.

MATERIALS AND METHODS

A total of 144 FAP patients from 74 families were either screened by gastroduodenoscopy (n = 132) or information was obtained from surgical or autopsy reports (n = 12). The severity of periampullary neoplasia was recorded for each patient and graded based on maximum polyp size and histology. Linear regression was used to determine the significance of a number of variables with respect to periampullary neoplasia. A blood sample was available from at least one member of 50 unrelated families and used to detect germline mutations in codons 686 through 1693 of the adenomatous polyposis coli (APC) gene.

RESULTS

Statistically significant familial segregation was found for the incidence and severity of periampullary neoplasia (P < 0.02). Age was also a statistically significant variable (P < 0.01). No correlation was observed between specific APC germline mutations and periampullary polyp frequency and severity.

CONCLUSIONS

The occurrence and severity of periampullary neoplasms in patients with FAP segregates in families. This familial association may be related to as yet unidentified modifier genes or perhaps common environmental factors. These results should prove useful in developing upper gastrointestinal screening protocols for FAP patients at risk for periampullary neoplasia.

Villous adenoma of the duodenum in a patient with familial adenomatosis coli

A case of familial adenomatosis coli with villous adenoma of the third portion of the duodenum, which falls in the category of a Gardner's syndrome, is described. The patient, who had complained of an abdominal mass which had been diagnosed as a desmoid tumor after surgical resection, had numerous adenomatous polyps throughout the colon confirmed by colonoscopy with biopsy. Endoscopic examination of the upper gastrointestinal tract revealed fundic gland polyposis in the stomach and numerous small adenomas in the duodenum. In addition, there was a pedunculated polyp in the third portion of his duodenum, measuring 30 mm in diameter, the surface of which had a cauliflowerlike appearance. The polyp was removed with the electrocautery snare and was histologically diagnosed as villous adenoma. Our case report supports the concept that villous adenoma, which possesses a high malignant potential, may occur in the upper gastrointestinal tract in patients with familial adenomatosis coli, and careful examination of the upper gastrointestinal tract including the distal duodenum seems to be necessary in the follow-up patients with this disease.

Familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is an autosomal dominant condition resulting in the development of more than 100 adenomatous polyps in the large bowel. In addition, a number of extracolonic manifestations of the condition may occur. Recently, increasing knowledge relating to the extracolonic abnormalities, and localization and sequencing of the gene for FAP, have had important implications for screening and long-term follow-up of those affected. In this review the natural history of the disease and the extracolonic manifestations associated with it are considered. Surgical management and advances in understanding at a molecular level are discussed, as well as the problems relating to screening for FAP and the implications of the new knowledge.

Three familial cases of fundic gland polyposis without polyposis coli

We report three cases of fundic gland polyposis in the stomach identified in three patients who were related. Grossly the numerous polyps covered an area limited to the body and fundus of the stomach, no polyps were found in the antrum, duodenum, colon, or rectum, and histologically, the gastric lesions consisted of numerous hamartomatous polyps, characterized by proliferation of the fundic and cystic glands. The gastric lesions were identified in families without polyposis coli. This type of fundic gland polyposis has never been documented before in the literature.

Advanced gastroduodenal polyposis with ras mutations in a patient with familial adenomatous polyposis

Upper gastrointestinal polyps are being recognized with increasing frequency in patients with familial adenomatous polyposis. Duodenal and periampullary adenomas are the most common type and have poorly understood but definite malignant potential. In contrast, the majority of polypoid lesions in the stomach are benign fundic gland polyps. We report a patient with familial adenomatous polyposis who developed dysplasia in a large exophytic hyperplastic gastric tumor that appeared to arise on a background of diffuse fundic gland polyposis and presented with anemia, hypoalbuminemia, and a protein-losing enteropathy. A large periampullary adenoma also was present. Using the polymerase chain reaction with mismatched primers, a GGT to TGT Kras codon 12 mutation was detected within areas of severe dysplasia in the gastric tumor and in the periampullary adenoma. This case serves to further highlight the spectrum of clinical, pathologic, and molecular features of premalignant upper gastrointestinal tract lesions in patients with familial adenomatous polyposis.

Multiple polyps of esophagus, stomach, colon, and rectum accompanying rectal cancer in a patient with constitutional chromosomal inversion

BACKGROUND

It has been reported that colorectal carcinomas are caused by a multistage process. In patients with familial adenomatous polyposis, carcinoma of the colorectum frequently develops and occasionally polyps develop in the upper gastrointestinal tract. Chromosomal deletion often is found for chromosomes 5, 17, and 18, on which tumor suppressor genes are located. Furthermore, loss of the alleles of loci on chromosome 3 has been reported in renal cell carcinoma, small cell lung carcinoma, and mixed salivary gland tumor in hereditary and sporadic cases. These data support the concept of a recessive mechanism for the development of human tumors.

PATIENTS AND RESULTS

The authors report the case of a 48-year-old woman with rectal cancer accompanied by multiple polyps in the esophagus, stomach, and colorectum. Histologically, the polypoid lesions in the esophagus, stomach, and colorectum showed a thickened mucosa, hyperplastic polyps, and mixed hyperplastic adenomatous polyps, respectively. Karyotype analysis showed 46, xx, inv(3)(p12.2q25.3) in all 20 inspected peripheral lymphocytes. By Southern blot with a c-raf probe, one allele of the c-raf-1 gene, which has been mapped on chromosome 3p25, was deleted from the rearranged chromosome 3 in the peripheral lymphocytes, intact colonic mucosa, and cancer tissue.

CONCLUSIONS

These results suggest that the development of hyperplastic polyps and carcinoma of the rectum results from the allelic loss in chromosome 3p, as has been reported for solid tumors at other sites.

Histologic follow-up of ampullary adenomas in patients with familial adenomatosis coli

BACKGROUND

The major duodenal papilla is a common site of extracolonic adenoma in patients with familial adenomatosis coli (FAC). However, there have been no reports which have systematically discussed histologic change in atypia of ampullary adenomas with time by their location in the papilla.

METHODS AND RESULTS

The major duodenal papillae of 23 patients with FAC were followed endoscopically and histologically for an average of 7.7 years (range, 1 year to 14 years 7 months). Tubular adenomas were detected histologically in 17 of the 23 patients at the first (14) or following examinations (3). They occurred in the orifice and/or ampulla in 11 patients and in the surface of the papilla in 8 patients. Three of the 11 orifice and/or ampulla adenomas contained moderate to severe atypia. There was no histologic change in atypia or malignant transformation during the follow-up period.

CONCLUSIONS

In the patients with FAC, the major duodenal papilla had adenoma, i.e., precancerous lesion, at a high incidence (74%), and it is reported that the ampulla of the papilla tended to have extracolonic carcinoma. Therefore, it is necessary to follow duodenal papillae of patients with FAC carefully and take biopsy specimens repeatedly from various sites, especially from the orifice or ampulla even if the papilla seems to be normal.

Gastroduodenal polyps in familial adenomatous polyposis

A retrospective review of the medical records of 30 patients with familial adenomatous polyposis who underwent oesophagogastroduodenoscopy was performed to evaluate the spectrum of gastroduodenal polyps. Twenty-five patients (83%) had gastroduodenal polyps. Eighteen patients (60%) had gastric polyps and 21 patients (70%) had duodenal polyps. Five patients (17%) had gastric and 20 patients (67%) had duodenal adenomatous polyps. Three patients (10%) died from an upper gastrointestinal tract adenocarcinoma. Three of nine patients with periampullary adenomas had a normal-appearing papilla of Vater. Since gastroduodenal polyps are common in familial adenomatous polyposis, oesophagogastroduodenoscopy should be performed at the time of diagnosis. Biopsy of polyps as well as biopsy of a normal-appearing papilla of Vater should be performed. Due to their malignant potential, if identified, gastroduodenal adenomatous polyps should be destroyed.

Overview of screening and management of familial adenomatous polyposis

The rarity of familial adenomatous polyposis (FAP) means that many clinicians may be unaware of the major advances that have taken place in screening for the condition over the past five years. This review is not only to document the current scene but also to give details of those involved in establishing registries throughout the country. FAP is a hereditary disorder which carries with it almost a 100% risk of colorectal cancer. The aim of screening is to detect gene carriers before they present with symptoms attributable to colonic polyps. In this way the incidence of colorectal cancer can be greatly reduced. The use of gene probes to identify patients with FAP is in its infancy but in selected pedigrees gene carriers can be identified using a venous blood sample. The recognition that congenital hypertrophy of the retinal pigment epithelium is an extracolonic manifestation of FAP in most pedigrees allows non-invasive ophthalmological screening of relatives at risk. The combination of these new screening methods with an effective regional registry for FAP can increase the number of patients detected by screening rather than by symptoms. This facilitates appropriate prophylactic surgery and reduces mortality related to colorectal cancer.

Upper gastrointestinal pathology in familial adenomatous polyposis: results from a prospective study of 102 patients

Multiple gastric and duodenal biopsy specimens from 102 asymptomatic patients with familial adenomatous polyposis, taken during a prospective endoscopic screening programme were examined. One hundred patients had microscopic gastroduodenal pathology, often in the absence of macroscopic lesions. Adenomas were found in 94 patients in the duodenum, in the second and third parts. Hyperplasia of villous and crypt epithelium was also seen, sometimes in the absence of adenomas: this may be a precursor of neoplastic change. In the stomach fundic gland polyps were the commonest abnormality, seen microscopically in 44 patients. Chronic antral gastritis was common in patients without fundic polyps. Gastric adenomas were present in six patients, all of whom also had duodenal adenomas. If duodenal adenomas in familial adenomatous polyposis have a similar malignant potential to those in the colorectum sequential endoscopy and biopsy are necessary to detect cancer in these patients.

Investigations on the significance of the adenoma-carcinoma sequence in the small bowel

In view of the rarity of small-bowel epithelial neoplasms as compared with the case for the large bowel, evidence for an adenoma-carcinoma sequence in the small bowel was studied based on a search for data in the medical literature for the years 1927 through 1986. Sufficiently defined data were found for comparison of 185 benign adenomas, 76 adenoma-with-carcinomas, and 1333 carcinomas in patients without familial polyposis disease and for 63, five, and 30, respectively, in patients with disease. For patients without polyposis, it was found that (1) 29.8% of all small-bowel adenomas (33.6% if those at Vater's ampulla are excluded) showed malignancy; (2) the mean and median ages were lower for benign adenoma than for adenoma-with-carcinoma and carcinoma, although the ratios by sex were the same; (3) there is a nearly identical spatial distribution of the three types of epithelial neoplasms within the small bowel; and (4) both the frequency of finding adenomatous residues existing in continuity with carcinoma and the life history of the adenoma-carcinoma sequence are similar in the small bowel as in the large. In comparing these results with those from patients with familial polyposis disease, it was particularly noted that (1) the only difference was that adenomas in familial polyposis occurred earlier and multiply, and (2) the spatial distributions of adenomas and carcinomas for both cases were closely similar. It is therefore postulated that the adenoma-carcinoma sequence is as significant in the small bowels as in the large. A hypothesis regarding the relationship of epithelial neoplasms in people with and without familial polyposis disease is suggested.

Duodenectomy without pancreatectomy for extensive benign villous adenoma of the duodenum

Villous adenomas of the duodenum are uncommon, but two have been treated recently in Blenheim. One of these was an extensive benign tumour involving most of the second part of the duodenum but causing no biliary tract obstruction. It was treated by pyloric sphincter-sparing duodenectomy without pancreatectomy, with repair by Roux loop to the bile and pancreatic ducts and proximal duodenum. This procedure does not appear to have been described previously.

Impact of a hospital-based register on the management of familial adenomatous polyposis

Colorectal cancer in familial adenomatous polyposis is a preventable disease in at-risk relatives of patients with primary cases. Until the recent establishment of a register in Western Australia, there has been no registration of pedigrees or central organization of surveillance in Australia. In the present study, the experience of 20 such families who were associated with The Royal Melbourne Hospital was documented, with an analysis of the reasons for any failure of management. The impact of a hospital-based register on the management of the disease was studied. In each family, results were categorized according to whether "at-risk" relatives had been diagnosed at surveillance examinations, and whether the Hospital register were involved. Before involvement with the register, 24 family members presented with symptomatic polyposis after the first affected case had been diagnosed. Eighteen of these had colorectal cancer at diagnosis, and 16 subjects now are dead. Identifiable reasons for the failure of surveillance were family communication failure (two cases), family denial (two cases), failure of the hospital clinic (two cases) and a failure to cover extended branches of families who were living locally (nine cases), interstate (four cases) or overseas (three cases). In contrast, only two (6%) of 33 affected cases that were identified at a planned surveillance endoscopy had colorectal cancer at diagnosis. Without the active surveillance of at-risk family members, lethal delays in diagnosis are likely to occur. Most reasons for failure potentially are correctable by a dedicated registry that is responsible for notifying clinicians and patients about the timing of surveillance procedures.

Familial colorectal cancer and familial adenomatous polyposis

Familial adenomatous polyposis (FAP) affects around 1 in 10,000 individuals; the gene for this condition was recently shown to be located on chromosome 5, and it is only a matter of time before its precise location and function are determined, making prephenotypic, and even prenatal, diagnosis more generally available and reliable. In the mean time, care of FAP families will continue to depend on careful registration of family information, prophylactic bowel surgery and surveillance for other potentially serious manifestations of the disease. Upper gastrointestinal malignancies and desmoid tumours have overtaken colorectal cancer as the leading causes of death in some centres. Other dominantly-inherited colorectal cancer syndromes produce less striking phenotypes, but affect far more individuals than FAP. It appears that there are two patterns of hereditary non-polyposis colorectal cancer (HNPCC) syndromes, one involving cases of bowel cancer alone, the other associated with breast and gynaecological cancers; these may prove to be variable expressions of a common gene abnormality. More effort is required by clinicians managing cases of colorectal cancer to identify affected families in order to offer surveillance and appropriate treatment in the hope that such measures may prevent cancer in family members.

Natural history of duodenal lesions in Japanese patients with familial adenomatosis coli (Gardner's syndrome)

The natural history of duodenal lesions was studied in 20 patients with familial adenomatosis coli/Gardner's syndrome. These patients were followed for an average of 7.1 yr (range 1 yr, 7 mo to 12 yr, 2 mo) and repeatedly examined by hypotonic duodenography, duodenofiberscopy, and biopsy. Tubular adenomas of the duodenum (less than 8 mm in diameter) were present in 18 (90%). During the follow-up period, there was a slight increase or decrease in the number of duodenal adenomas in 4 patients but no distinct change in 13. In the remaining patient (aged 49 yr), a polypoid lesion (17 mm in diameter) of the duodenal bulb, which had been overlooked at the initial examination, became an advanced cancer (50 x 30 mm in size) during 22 mo. Tubular adenomatous tissue of the duodenal papilla was detected in 11 patients (55%). Follow-up study of the lesions revealed no change in endoscopic and histologic findings in all but 1 patient, in whom there was a slight enlargement of the duodenal papilla, as seen at endoscopy. These findings suggest to us that in patients with this disease, duodenal adenomas do not require prophylactic surgery. However, careful repeated follow-up examinations with endoscopic biopsy should be performed, with endoscopic removal of larger polyps when possible.

High prevalence of adenomatous polyps of the duodenal papilla in familial adenomatous polyposis

Eighteen consecutive asymptomatic patients with familial adenomatous polyposis (both familial polyposis coli and Gardener's syndrome) were studied over a 12-month period; side-viewing upper endoscopy and biopsy were used to assess the frequency of adenomatous polyps of the duodenal papilla. Nine of the 18 patients demonstrated adenomatous polyps of the papilla, varying in size and appearance from microadenomas in normal-appearing duodenal papillae (two) to a sessile polyp 3 cm in diameter. Two were tubulovillous adenomas (0.5 cm and 2 cm in diameter) and the remainder were tubular adenomas. Severe atypia and malignancy were not encountered. These findings reveal that adenomas of the duodenal papilla are common in individuals with familial adenomatous polyposis. Because of these findings and because of the known risk of periampullary adenocarcinomas and nonmalignant complications of polyps of the duodenal papilla in patients with familial adenomatous polyposis, upper gastrointestinal screening of such patients should include examination of the duodenal papilla with a side-viewing endoscope.

Hepatocellular and gastric carcinoma associated with familial polyposis coli

A case of familial polyposis coli in association with hepatocellular and gastric carcinoma is reported. No similar case has ever been documented in the world literature. This may be surprising as it is well known that familial polyposis has a potent oncogenicity not only in the colon but also in extracolonic organs.

Villous tumors of the duodenum

Records of 32 patients with 34 villous and tubulovillous adenomas of the duodenum, treated at the Cleveland Clinic over the past 21 years, were reviewed. Twenty-two patients (69%) had complete resection of the adenoma; the incidence of malignancy was 47%. Five patients underwent a Whipple procedure; 4 patients had segmental resection of the duodenum; 12 had wide local excision of the adenoma; 1 had both a segmental resection and a local excision for two separate adenomas; and 5 patients had endoscopic excision alone. The remaining five patients underwent exploratory laparotomy alone or with palliative bypass procedures. A 28% recurrence rate was observed, all of these after segmental resection, local excision, or endoscopic excision. The highest recurrence rate was associated with local excision. The 2- and 5-year survival rates for patients with adenomas containing invasive cancer were 22% and 0%, respectively, compared to 87% and 87%, respectively, for benign adenomas (including those with carcinoma in situ). Twenty-two per cent of patients had intestinal polyposis syndromes. Duodenal adenomas were diagnosed a mean of 17 years after colectomy for polyposis, indicating the need for continued surveillance in these patients.

Natural history of gastric adenomas in patients with familial adenomatosis coli/Gardner's syndrome

The natural history of gastric adenomas was studied in 26 patients with familial adenomatosis coli (FAC)/Gardner's syndrome. The patients were followed for an average of 6.8 years (1 year, 5 months to 15 years 4 months) and examined repeatedly using gastric radiography, endoscopy, and biopsy. Gastric adenomas were present in 13 (50%). During the follow-up period, there was a new appearance of gastric adenomas in six patients but no distinct change in number, size, and histologic features in the remaining seven patients. In a 51-year-old man, an antral adenoma that measured 13 mm in diameter and had an irregular central depression did not change in size or morphology during 4 years and 1 month, but malignant change was evident at the time of endoscopic biopsy. The findings indicate that in patients with this disease, gastric adenomas require careful repeated follow-up examinations using endoscopic biopsy and, if feasible, endoscopic removal is recommended.

Upper gastrointestinal neoplasia in familial polyposis

Upper gastrointestinal (UGI) endoscopy was performed in 41 asymptomatic American patients with familial polyposis to assess the prevalence of gastric and duodenal polyps and to characterize their pathological features. Eighteen patients (44%) had UGI endoscopic abnormalities. Six patients had both gastric and duodenal lesions. Eight patients had only gastric polyps, and four had duodenal polyps only. The presence of other extracolonic expressions of polyposis had a suggestive but statistically insignificant correlation with UGI polyps. Patients with familial polyposis and duodenal adenomatous polyps are at high risk for the development of periampullary cancer; screening and identification of these individuals is recommended.

Gastric and duodenal polyps in familial adenomatous polyposis: a prospective study of the nature and prevalence of upper gastrointestinal polyps

One hundred patients with familial adenomatous polyposis have prospectively undergone gastroduodenoscopy to identify and characterise polyps found. Forty six patients had polyps in the stomach or duodenum. Thirty five patients had adenomas (33 in duodenum, two in stomach) and 26 patients had fundic gland polyps. Some of these patients had polyps in the stomach and the duodenum. Adenomas in the duodenum were present in 33% of patients studied with Gardner's syndrome variant (p = 0.04). Adenomas were also more common in older patients. As adenomas may be a precursor of adenocarcinoma, routine surveillance of the stomach and duodenum with gastroduodenoscopy is recommended in patients affected with familial adenomatous polyposis.

Villous adenoma of the duodenal papilla presenting as necrotizing pancreatitis in a patient with Gardner's syndrome

The majority of patients with Gardner's syndrome and familial polyposis coli develop duodenal adenomatous polyps. Duodenal cancer sometimes arises in this setting, but nonmalignant problems from duodenal polyps have not been described. This report presents a patient with Gardner's syndrome who developed hemorrhagic pancreatitis and was found to have a villous adenoma encasing the pancreatic duct at the duodenal papilla. The case is important because it suggests that patients with polyposis coli may be at risk for significant nonmalignant problems from duodenal polyps, particularly if polyps exhibit villous histology and occur at the duodenal papilla.

Incidence of associated diseases in familial polyposis coli

In this review we present diseases associated with hereditary polyposis syndromes. In addition to the known extracolonic manifestations of the so-called Gardner's syndrome, other important diseases are carcinomas of the thyroid and of the small bowel and bile duct adenoma. The incidence of these diseases is discussed.

Unfamiliar aspects of familial polyposis coli

Patients with familial polyposis coli or Gardner's syndrome are at risk for a variety of extracolonic manifestations. In a series of patients followed at the University of Washington, we have found several recurring and unusual manifestations, including upper gastrointestinal polyposis, small bowel obstruction secondary to desmoid tumors or adhesions, recurring pancreatitis, and adenoma of the papilla of Vater. In one family with familial polyposis only, a set of twins had different manifestations; one twin had familial polyposis only, whereas the second had classic extracolonic manifestations of Gardner's syndrome. Multiple rectal adenomas developed in a woman with an ileorectal anastomosis with each of three pregnancies. Spontaneous regression occurred after each delivery. Multiple rectal adenomas developed in her daughter on two occasions while taking birth control pills. Physicians caring for these patients should look for such manifestations.

Villous tumors of the duodenum

Nineteen cases of villous tumors of the duodenum are reported. They have a predilection for the ampullary region, tend to present with obstructive jaundice, especially if malignancy is present, and have a high prevalence of cancer (12 of 19, or 63%). Even when biopsies are available, the diagnosis of cancer is frequently missed (5 of 9 proven cancers, 56% false-negative rate), and it may be impossible to assess the presence of carcinoma in situ or invasive carcinoma without complete excision of the lesion. The authors' experience suggests that some small benign ampullary villous adenomas or those with carcinoma in situ can be excised locally but that pancreaticoduodenectomy is preferable in the fit patient for better local control both of extensive benign lesions and cancers without distant metastases.

Natural history of fundic gland polyposis in patients with familial adenomatosis coli/Gardner's syndrome

In order to study the natural history of fundic gland polyposis, 23 patients with familial adenomatosis coli/Gardner's syndrome were examined over a follow-up period ranging from 17 mo to 13 yr (average 6 yr). Examinations included gastric radiography and endoscopy with biopsy. Fundic gland polyps were found in 10 individuals. The size and number of polyps varied considerably. During the follow-up period, there was an increase in number or size of polyps, or both, in 5 patients (aged 8-27 yr), a decrease or disappearance in 2 patients (aged 36 and 41 yr), an initial decrease or disappearance followed by a late-occurring increase in 2 patients (aged 28 and 35 yr), In addition, malignant or adenomatous changes of fundic gland polyps were not observed in any patient. Therefore, fundic gland polyposis in patients with familial adenomatosis coli/Gardner's syndrome may appear as early as 8 yr of age. In some patients there is a gradual increase in number and size of polyps, whereas in others, polyp proliferation ceases and polyps may even decrease in number and size. Our findings indicate that the fundic gland polyposis does not require prophylactic surgery and that careful periodic follow-up should suffice.

Extracolonic polyps in familial polyposis coli and Gardner's syndrome

Endoscopy and biopsy of the upper gastrointestinal tract and terminal ileum were performed in 24 patients with familial polyposis or Gardner's syndrome in order to further define the incidence of extracolonic adenomatous polyps. Polyps, usually multiple and small in size, were detected in the gastric fundus (12.5 percent), antrum (29.1 percent), duodenum (66.6 percent), and terminal ileum (41.7 percent). Histology showed hyperplasia of the fundic glands and cystic dilatation in the polyps of gastric fundus, and adenomas in several cases of antral (three patients) or duodenal polyps (14 patients). Polyps of the terminal ileum were either adenomas (five patients) or lymphoid aggregates. Patients with stigmata of Gardner's syndrome, desmoids or mesenteric fibromatosis presented a major incidence of adenomas in the duodenum, but not in other parts of the digestive tract investigated. Subsequent checkup after an average of 33 months in ten patients revealed an increase of lesions only in the duodenum in two patients. These findings confirm that adenomatous polyps are not limited to the colon and rectum, as previously believed, but can affect the whole gastrointestinal tract. Periodic surveillance of mucosa seems to be indicated, especially for the duodenum, since degeneration of adenomas into carcinoma is possible.

Adrenal adenomas and adrenal carcinomas in association with hereditary adenomatosis of the colon and rectum

Hereditary adenomatosis of the colon and rectum (HACR) is associated with a wide variety of extracolonic manifestations. Two cases of neoplasia involving the adrenal gland are reported, one adenoma and one carcinoma. The literature relating these lesions to HACR and other syndromes of malignant and nonmalignant growth disturbance is reviewed. The increasing list of the extracolonic manifestations associated with HACR emphasizes the generalized nature of the growth disorder of this disease. An increased awareness of these lesions is important, as many patients with HACR now live longer by avoiding death from colorectal carcinomas due to the increasing usage of prophylactic colectomy.

Gastroduodenal polyps in familial polyposis coli

A total of 26 patients with familial polyposis coli without extracolonic manifestations were examined by gastroduodenoscopy. Histologically verified polyps were found in 18 patients (69 percent, 95 percent confidence limits 48-86). Gastric adenoma was diagnosed in one patient, fundic gland polyposis in six patients, and duodenal adenomas in 12 patients. It is concluded that the incidence of gastroduodenal polyps is independent of the clinical presence of other extracolonic manifestations. It is advisable that polyposis patients should be followed with gastroduodenoscopy and biopsy of polyps.

Adenomatous polyposis coli and multiple endocrine neoplasia type 2b. A pathogenetic relationship

A young man presenting with Cushing's syndrome was found to have multiple endocrine neoplasia type 2b MEN 2b and adenomatous colonic polyposis with duodenal and gastric polyps. The entire syndrome of MEN 2b was present, including metastatic medullary carcinoma of the thyroid, a pheochromocytoma, and peripheral nerve abnormalities. The concurrence of these two inherited multiple neoplasia syndromes may reflect a common pathogenetic step in this patient.