Synchronous Periampullary Tumors in a Patient With Pancreas Divisum and Neurofibromatosis Type 1

Pathogenic germline variants in cancer predisposition genes in patients with multiple primary cancers in an Asian population and the role of extended panel genetic testing

BACKGROUND

Multiple primary cancers (MPC) are an indicator of potential hereditary cancer predisposition syndrome. There remains insufficient data on genetic testing outcomes and the optimal testing panel for MPC. We evaluated the prevalence of MPC, the spectrum of pathogenic germline variants (PGVs) and the role of extended panel testing in MPC.

METHODS

Cancer patients seen in a cancer genetics clinic in a tertiary cancer centre in Singapore from 2000 to 2023 were included. Clinical characteristics, PGV and patterns of cancer were analysed. Most patients were tested with 49 genes, but in a selected 156 patients with MPC, extended testing with 216 genes was carried out.

RESULTS

Of 3514 cancer patients (male = 17.9%, female = 82.1%), 668 (19%) had MPC (2 primaries, n = 570; 3 primaries, n = 81; ≥4 primaries, n = 17). The most common tumour pairs were breast-breast (33.2%), breast-ovary (8.9%), breast-endometrial (4.6%) and endometrial-ovary (4.6%). Patients with MPC had a younger median age of first cancer. Of the MPC patients, 29.4% tested positive for at least one PGV, with PGVs detected in BRCA1/2 (39.9%), other homologous recombination repair (HRR) genes (18.9%), mismatch repair (MMR) genes (11.2%) and TP53 (7%) genes. HRR genes included ATM, BARD1, BRIP1, CHEK2, PALB2, FANCL, RAD51C and RAD51D, while MMR genes included MLH1, MSH2, MSH6 and PMS2. MPC patients were more likely to have PGVs in TP53 and BARD1 compared with patients with single primary cancer. Extended testing detected more PGVs in MPC despite initial noninformative testing. It increased the number of PGVs detected in less established cancer predisposition genes, which include CFTR, SPINK1, TNFRSF13B, TET2, ADA, CDKN1C, CTNNA1, DDX41, HAX1, RECQL4 and MBD4.

CONCLUSION

Patients with MPC were more likely to harbour a PGV. Extended testing improved PGV detection rates, particularly for less well-known cancer predisposition genes.

Periampullary tumors in a patient with pancreatic divisum and neurofibromatosis type 1: a case report

INTRODUCTION

We present a case of a male patient with neurofibromatosis type 1 diagnosed with pancreatic divisum and several gastrointestinal tumors. A 55-year-old man was admitted to the hospital with recurrent chronic pancreatitis, indicating a large mass in the ampulla. In addition, genetic testing revealed two unique germline mutations in the neurofibromin (NF1) gene, and their potential interaction in promoting cancer was further investigated.

CONCLUSION

The first similar case was reported in 2020. The current case was distinct from other cases since an additional two NF1 mutations were found in the patient. In conjunction with prior case reports, our findings imply that genetic testing in patients diagnosed with neurofibromatosis type 1 could be helpful in the development of effective treatments.

Congenital Anomalies of the Pancreas: Various Clinical Manifestations and Their Impact on Pancreatic Diseases and Outcomes

Background and objective: Congenital anomalies of the pancreas are relatively uncommon. Most of these are asymptomatic and are detected incidentally, but can present with a variety of clinical manifestations like pancreatitis, duodenal obstruction, biliary obstruction, and rarely malignancy. Here in our study, we describe various congenital anomalies of the pancreas associated with various clinical manifestations, its management strategies, and outcomes. The aim was to study the various clinical manifestations of and management strategies for pancreatic diseases associated with congenital anomalies of the pancreas and their outcomes.

Methods: A retrospective analysis of a prospectively maintained institutional database of 14 patients, admitted over a period of three years from June 2019 to May 2022, who were treated for different clinical manifestations of various congenital anomalies of the pancreas and their outcomes was done at our institution.

Results: The total number of congenital anomalies of the pancreas in our study was 14 out of whom 7 (50%) were males and 7 (50%) females. The mean age of the patients was 37 years. The most common congenital anomaly was pancreatic divisum in six (42.9%) cases. The most common clinical manifestation was acute pancreatitis in four (28.6%) cases. One (7.1%) case was incidentally detected intraoperatively for another condition. Eight (57.1%) patients underwent surgical intervention and six (42.9%) patients were medically managed. Mortality occurred in two (14.3%) cases. Associated alcohol consumption was seen in 2 (14.3%) cases; 10 (71.4%) patients had no comorbidities while 4 (28.6%) patients had diabetes mellitus. Out of eight (57.1%) surgical patients, two (25%) had Clavien-Dindo grade I and one patient (12.5%) grade V complications.

Conclusion: Congenital anomalies of the pancreas can be associated with a variety of clinical manifestations; their management strategies and outcomes are no different from patients with the same clinical manifestations with normal pancreatic development.

Overview of the 2022 WHO Classification of Familial Endocrine Tumor Syndromes

This review of the familial tumor syndromes involving the endocrine organs is focused on discussing the main updates on the upcoming fifth edition of the WHO Classification of Endocrine and Neuroendocrine Tumors. This review emphasizes updates on histopathological and molecular genetics aspects of the most important syndromes involving the endocrine organs. We describe the newly defined Familial Cancer Syndromes as MAFA-related, MEN4, and MEN5 as well as the newly reported pathological findings in DICER1 syndrome. We also describe the updates done at the new WHO on the syndromic and non-syndromic familial thyroid diseases. We emphasize the problem of diagnostic criteria, mention the new genes that are possibly involved in this group, and at the same time, touching upon the role of some immunohistochemical studies that could support the diagnosis of some of these conditions. As pathologists play an important role in identifying tumors within a familial cancer syndrome, we highlight the most important clues for raising the suspicious of a syndrome. Finally, we highlight the challenges in defining these entities as well as determining their clinical outcome in comparison with sporadic tumors. Instead of the usual subject review, we present the highlights of the updates on familial cancer syndromes by answering select questions relevant to practicing pathologists.