Diagnosis and treatment of Gardner syndrome with gastric polyposis: A case report and review of the literature

Accumulated genetic mutations leading to accelerated initiation and progression of colorectal cancer in a patient with Gardner syndrome: A case report

RATIONALE

Gardner syndrome is a rare autosomal dominant disorder with a high degree of penetrance, which is characterized by intestinal polyposis, osteomas, and dental abnormalities. Majority of patients with Gardner syndrome will develop colorectal cancer by the age of 40 to 50 years. Mutations in the adenomatous polyposis coli gene are supposed to be responsible for the initiation of Gardner syndrome.

PATIENT CONCERNS

A 22-year-old Chinese female was admitted to our hospital due to abdominal pain and bloody stool.

DIAGNOSIS

The patient presented with multiple intestinal polyposis, desmoid tumors, and dental abnormalities was diagnosed as Gardner syndrome and further examination revealed a colon tumor.

INTERVENTIONS AND OUTCOMES

Patients were implanted with stents to alleviate bowel obstruction, and were treated with oxaliplatin combined with 5-Fu for 4 cycles, but the efficacy was not good. We performed next generation sequencing of 390 genes for the tumor specimens. We detected adenomatous polyposis coli E1538Ifs∗5, KRAS G12D, NF1 R652C, loss of SMAD4, TP53 R175H, IRF2 p.R82S, TCF7L2 p.A418Tfs∗14, and SMAD4 p.L43F in this patient.

LESSONS

We reported serial mutations in key genes responsible for initiation and progression of colorectal cancer from a patient with Gardner syndrome.

Multiple osteomata from medieval Tuscany, Italy (ca. 10th-12th AD)

OBJECTIVE

To explore the possible etiology of multiple osteomata on a skull and long bones from an individual from a medieval site in Tuscany, Italy.

MATERIALS

Human skeletal remains dating to the 10^th-12^th century AD from the parish church of S. Pietro in Pava, in the province of Siena (Tuscany, Central Italy).

METHODS

Macroscopic and imaging analyses (Cone Beam Computed Tomography).

RESULTS

Nine round-shaped new bone formations are observed on a female individual aged 40-50 years. The lesions have a smooth surface and range from 2.2-6 mm in diameter.

CONCLUSIONS

Cone Beam Computed Tomography confirmed that the lesions were composed of compact bone. Macroscopic and radiological features suggest the presence of nonsyndromic multiple osteomata.

SIGNIFICANCE

Single cranial osteomata are commonly observed in osteoarchaeological remains, but multiple osteomata are rare and might assist in our understanding of neoplastic conditions in the past.

LIMITATIONS

The lack of soft tissues prevents the diagnosis of complex disorders, such as the Gardner syndrome, which is characterised by multiple osteomata and polyposis of the colon.

SUGGESTIONS FOR FURTHER RESEARCH

Careful investigation and reporting of all neoplastic lesions in ancient human remains in order to increase our knowledge about the etiology in past human populations.

Bone and dental abnormalities as first signs of familial Gardner's syndrome in a Chinese family: a literature review and a case report

Gardner's syndrome (GS) is an autosomal dominant disease characterized by the presence of familial adenomatous polyposis (FAP) as well as extraintestinal manifestations such as osteomas, dental anomalies, epidermoid cysts and ocular abnormalities. These intestinal polyps carry a 100% risk of malignant change, so early diagnosis is crucial. As craniofacial osteomas and dental anomalies of GS usually precede gastrointestinal symptoms, otolaryngologists, oral surgeons and dentists play an important role in the diagnosis of GS. GS is extensively reported in literature in the Caucasian race but not in the Mongoloid race. We report a case of a 22-year-old patient with a manifestation of three features of GS - multiple osteomas, soft tissue tumors and dental anomalies in the craniofacial region, with no intestinal polyps at the time of reporting. A family pedigree with our patient as the proband was constructed and revealed 3 consecutive generations in his lineage with GS.

Identification of a mutL‑homolog 1 mutation via whole‑exome sequencing in a Chinese family with Gardner syndrome

Gardner syndrome (GS), a variant of familial adenomatous polyposis, is a rare genetic disorder with autosomal dominant inheritance, characterized by the presence of multiple intestinal polyps, multiple osteomas, dental abnormalities and soft tissue tumors. To date, only a few gene mutations have been demonstrated to be responsible for GS. To explore potential unknown mutations responsible for GS, the present study used whole‑exome sequencing of two affected individuals from a family with GS to identify a candidate mutation in mutL‑homolog (MLH)1. The two patients with GS were diagnosed based on a combination of clinical features, family history, physical examinations and cone‑beam computed tomographic imaging. Through whole‑genome sequencing, the present study subsequently identified a missense mutation in MLH1 (NM_000249.3:p.Tyr379Ser/c.1136A>C), which was further confirmed by Sanger sequencing. Furthermore, the amino acid residue p.Tyr379 was identified to be highly conserved among different species through sequence alignment with ClustalW2. In conclusion, the results identified for the first time a MLH1 missense mutation (NM_000249.3:​p.Tyr379Ser/c.1136A>C) in a Chinese family with GS, thus broadening the range of mutated genes associated with GS. This highlights the value of whole‑exome sequencing in identifying disease mutations in a family.

Giant mediastinal thymolipoma in a patient with Gardner's syndrome

Gardner's syndrome is a hereditary disorder inherited as an autosomal dominant with high penetrance and variable expression that is caused by a mutation of the adenomatous polyposis coli gene. It is characterized by gastrointestinal polyps associated with multiple osteomas, dental anomalies, and skin and soft tissue tumors. We present a case of 30-year-old female patient with Gardner's syndrome who presented with a giant mediastinal thymolipoma. The tumor was completely excised through a bilateral posterolateral thoracotomy. There was no recurrence after 20 months of follow-up. We therefore suggest that physicians who regularly treat patients with Gardner's syndrome carefully examine for thoracic manifestations.

Multiple desmoid tumors in a patient with Gardner's syndrome - Report of a case

INTRODUCTION

Desmoid tumor (DT) is a common manifestation of Gardner's Syndrome (GS), although it is a rare condition in the general population. DT in patients with GS is usually located in the abdominal wall and/or intra-abdominal cavity.

PRESENTATION OF CASE

We report a case of a 32 years-old female patient with familial adenomatous polyposis (FAP), who was already submitted to total colectomy and developed multiple DT, located in the abdominal wall and in the left breast. The patient underwent several surgical procedures, with a multidisciplinary team of surgeons. Wide surgical resections of the left breast and the abdominal wall tumors were performed in separate steps. Polypropylene mesh reconstruction and muscle flaps were needed to cover the defects of the thoracic and abdominal walls. After partial necrosis of the adipose-cutaneous flap in the abdomen that required a new skin graft, she had a satisfactory outcome with complete healing of the surgical incisions.

DISCUSSION

DT is frequent in GS, however, breast localization is very rare, with few cases reported in the literature. Recurrence of DT is not negligible, even after a wide surgical resection. GS patients must be followed up closely, and clinical examination, associated with imaging studies, should be performed to detect any signs of tumor.

CONCLUSION

DT represents one of the most significant causes of the morbidity and mortality that affects FAP patients following colectomy. In general, the surgical procedures to excise DT are highly complex, requiring a multidisciplinary team.

Clinical significance of colonoscopy in patients with upper gastrointestinal polyps and neoplasms: a meta-analysis

BACKGROUND

Some authors have studied the relationship between the presence of polyps, adenomas and cancers of upper gastrointestinal tract (stomach and duodenum) and risk of colorectal polyps and neoplasms; however, the results are controversial, which may be due to study sample size, populations, design, clinical features, and so on. No meta-analysis, which can be generalized to a larger population and could provide a quantitative pooled risk estimate of the relationship, of this issue existed so far.

METHODS

We performed a meta-analysis to evaluate risk of colorectal polyps or neoplasms in patients with polyps, adenomas or cancers in upper gastrointestinal tract comparing with controls. A search was conducted through PubMed, EMBASE, reference lists of potentially relevant papers, and practice guidelines up to 27 November 2013 without languages restriction. Odd ratios (ORs) were pooled using random-effects models.

RESULTS

The search yielded 3 prospective and 21 retrospective case-control studies (n = 37152 participants). The principal findings included: (1) OR for colorectal polyps was 1.15 (95% CI, 1.04-1.26) in the gastric polyps group comparing with control groups; (2) Patients with gastric polyps and neoplasms have higher risk (OR, 1.31 [95% CI, 1.06-1.62], and 1.72 [95% CI, 1.42-2.09], respectively) of colorectal neoplasms comparing with their controls; and (3) Positive association was found between the presence of colorectal neoplasms and sporadic duodenal neoplasms (OR, 2.59; 95% CI, 1.64-4.11).

CONCLUSIONS

Findings from present meta-analysis of 24 case-control studies suggest that the prevalence of colorectal polyps was higher in patients with gastric polyps than in those without gastric polyps, and the risk of colorectal neoplasms increases significantly in patients with gastric polyps, neoplasms, and duodenal neoplasms. Therefore, screening colonoscopy should be considered for patients with upper gastrointestinal polyps and neoplasms.

Prosthodontic management of a patient with Gardner's syndrome: A clinical case report

Gardner's syndrome is a genetic condition demonstrating an autosomal dominant trait and characterized by the multiple colonic polyps (familial adenomatous polyposis coli) with sebaceous cysts and jaw osteomas. Various dental abnormalities present in patient's suffering with this syndrome includes multiple impacted or unerupted teeth, supernumerary teeth, hypodontia, compound odontomes and dentigerous cyst. In this case report, a patient with Gardner's syndrome who suffered from functional and psychological problems owing to multiple impacted, unerupted teeth and hypodontia was presented. Patient was treated with a maxillary conventional overdenture opposing mandibular custom bar supported overdentures.

Risk of colorectal polyps in patients with sporadic gastric polyps: A case-control study

AIM: To assess the risk of colonic polyps, adenomas and advanced neoplastic lesions (ANL) in patients with sporadic gastric polyps, especially those with fundic gland polyps (FGP).

METHODS: Clinical records of patients who had performed an upper and a lower digestive endoscopy between September 2007 and August 2008 were retrospectively analyzed. A case-control study was carried out, calling patients with gastric polyps as “cases” and patients without gastric polyps as “controls”. The risk of colonic polyps, adenomas and ANL (villous component ≥ 25%, size ≥ 10 mm, or high grade dysplasia) was assessed [odds ratio (OR) and its corresponding 95%CI].

RESULTS: Two hundred and forty seven patients were analyzed: 78 with gastric polyps (cases) and 169 without gastric polyps (controls). Among the cases, the majority of gastric polyps were FGP (80%, CI: 69-88) and hyperplastic (20%, CI: 12-31); 25% had colonic polyps (25% hyperplastic and 68% adenomas, from which 45% were ANL). Among the controls, 20% had colonic polyps (31% hyperplastic and 63% adenomas, from which 41% were ANL). The patients with sporadic FGP had an OR of 1.56 (CI: 0.80-3.04) for colonic polyps, an OR of 1.78 (CI: 0.82-3.84) for colonic adenomas, and an OR of 0.80 (CI: 0.21-2.98) for ANL. Similar results were found in patients with gastric polyps in general.

CONCLUSION: The results of this study did not show more risk of colorectal adenomas or ANL neither in patients with sporadic gastric polyps nor in those with FGP.

Gardner's Syndrome

Gardner's syndrome is an autosomal dominant disease and is a subtype of familial adenomatous polyposis. It is characterized by adenomatous intestinal polyps, multiple osteomas in the skull, maxillae, mandible, and multiple cutaneous and subcutaneous masses (epidermoids and desmoid). Intestinal polyps, if not treated, have 100% chance of becoming malignant. We report a case of a 25-year-old female patient with Gardner's syndrome, with clinical manifestations including impacted supernumerary teeth, odontomes, sebaceous cyst on the scalp, and osteomas. It is important for the general dental practitioners to be aware of the clinical and radiological characteristics of Gardner's syndrome.

Modified multivisceral transplantation with spleen-preserving pancreaticoduodenectomy for patients with familial adenomatous polyposis "Gardner's Syndrome"

BACKGROUND

Liver-sparing "modified" multivisceral transplantation (MMVTx) has recently been more used for patients with diffuse gastrointestinal disorders and preserved hepatic functions. Evisceration techniques with preservation of native spleen were also introduced to reduce risk of posttransplant lymphoproliferative disorders. This study focuses on the indications of MMVTx for patients with familial adenomatous polyposis (FAP) and the technical feasibility of performing spleen-preserving pancreaticoduodenectomy (SPPD).

METHODS

Between 1993 and 2009, 10 FAP patients required MMVTx. Nine were adults and one was a child, with a female:male ratio of 1:1.

RESULTS

Short gut with duodenal adenomatosis and extensive desmoid tumors with pancreaticoduodenal involvement dictated need for MMVTx. SPPD was technically feasible in four recipients, and conventional evisceration including splenectomy was performed in remaining six recipients. With an overall cumulative survival of 90% at 1 year and 77% at 10 years, all SPPD recipients were alive with no single example of posttransplant lymphoproliferative disorder, graft-versus-host disease, or chronic rejection. However, SPPD was associated with an increase (P>0.3) in total ischemia time, operative time, and packed red blood cells requirement but with shorter (P=0.6) length of hospital stay. With a mean follow-up of 50±45 months (range 18-128 months), none of the 10 recipients experienced intraabdominal desmoid tumor recurrence or developed de novo visceral allograft neoplasm.

CONCLUSION

MMVTx is a valuable therapeutic option for FAP patients who are in need for visceral transplantation with pathologic involvement of the pancreaticoduodenal complex. SPPD is technically feasible, and efforts should always be made to preserve native spleen because of the reported herein therapeutic advantages.

Do we need colonoscopy in patients with gastric adenomas? The risk of colorectal adenoma in patients with gastric adenomas

BACKGROUND

Gastric polyps are found frequently in various colonic polyposis syndromes. Genetic alterations of several genes occur in gastric adenomas and colorectal adenomas. However, it is unknown whether patients with gastric adenomas are at higher risk for colorectal adenomas.

OBJECTIVE

To investigate the prevalence rate of colorectal adenoma in patients with gastric adenomas and to determine the association between the presence of gastric adenomas and synchronous colorectal adenomas.

DESIGN

A retrospective, cross-sectional, case-control study.

SETTING

Single center: Center for Health Promotion of Samsung Medical Center.

PATIENTS

This study involved 87 patients with gastric adenomas and 174 sex-matched and age-matched controls among 19,019 participants who underwent EGD and colonoscopy simultaneously or within 6 months of each other from January 2001 to December 2008 at the Center for Health Promotion of Samsung Medical Center.

INTERVENTION

EGD and colonoscopy.

MAIN OUTCOME MEASUREMENTS

The prevalence rate of colorectal adenoma in patients with gastric adenomas.

RESULTS

The 87 gastric adenoma patients included 72 men and 15 women. Colorectal adenomas were identified in 42 (48.3%) of 87 cases and in 58 (33.3%) of 174 controls (P = .022). The prevalence of colorectal adenoma was significantly higher in the gastric adenoma group than in the control group. The mean size and number of colorectal adenomas were not significantly different between the two groups. The majority of colorectal adenomas were located in distal colonic segments in the gastric adenoma group in contrast with proximal colonic segments in the control group. Multivariate logistic regression analysis revealed that independent risk factors for colorectal adenoma were the presence of gastric adenomas (odds ratio [OR], .915; 95% confidence interval [CI], 1.044-3.513) and increasing age over 55 years (OR, 2.943; 95% CI, 1.558-5.560).

LIMITATIONS

Lack of data on previous colorectal adenomas and possible confounding factors such as hyperlipidemia or diabetes mellitus.

CONCLUSION

The risk of colorectal adenoma increases significantly in patients with gastric adenomas and in patients over age 55. A screening colonoscopy may be necessary for patients with gastric adenomas to detect colorectal adenomas.

Gardner syndrome complicated with hydronephrosis. A case report

Gardner syndrome is an autosomal dominant disease characterized by the presence of colonic polyposis, osteomas and soft tissue tumors. We present a case of a man who was admitted for a relapse of adenocarcinoma of the rectum. CT-staging showed multiple locations of desmoid tumors and osteomas, with final diagnosis of Gardner syndrome. The follow-up CT, after surgery and chemotherapy, showed a relapse of the lesions with hydronephrosis due to ureteral compression.

Advances in research on hereditary colorectal neoplasms

Colorectal cancer is one of the most common digestive malignant tumors in China. Its incidence and mortality rates rank top among all malignant tumors. Previous studies show that nearly one-third of colorectal cancers are associated with hereditary colorectal tumors. Hereditary colorectal tumors are mainly divided into two categories: hereditary nonpolyposis colorectal cancer and hereditary colorectal polyposis. In this article, we will review the recent advances in research on hereditary colorectal neoplasms.

[Long-term experience with therapy of a female patient with Gardner's syndrome, first presenting with extra-abdominal desmoid tumor, and review of the literature]

Gardner's syndrome is a clinical subgroup of familial adenomatous polyposis, an autosomal dominant disease. It is characterized by gastrointestinal polyps and extra-intestinal manifestations including multiple osteomas, skin and soft tissue tumours. Aggressive desmoid tumours can be very difficult to manage in patients with Gardner's syndrome. We present a case of a 17-year-old female who presented with an aggressive desmoid tumor arising of the lumbar area as part of her Gardner's syndrome. She was treated with surgery, nonsteroidal anti-inflammatory drugs, tamoxifen and radiotherapy, and was followed up for 80 months. We conclude that desmoid tumors can precede gastrointestinal manifestations of familial adenomatous polyposis or Gardner's syndrome. Such patients should be evaluated with genetic testing followed by colonoscopy. Desmoid tumours should be managed in a multidisciplinary setting, as well.