Clinical characteristics and adequate treatment of familial adenomatous polyposis combined with desmoid tumors

Updated European guidelines for clinical management of familial adenomatous polyposis (FAP), MUTYH-associated polyposis (MAP), gastric adenocarcinoma, proximal polyposis of the stomach (GAPPS) and other rare adenomatous polyposis syndromes: a joint EHTG-ESCP revision

BACKGROUND

Hereditary adenomatous polyposis syndromes, including familial adenomatous polyposis and other rare adenomatous polyposis syndromes, increase the lifetime risk of colorectal and other cancers.

METHODS

A team of 38 experts convened to update the 2008 European recommendations for the clinical management of patients with adenomatous polyposis syndromes. Additionally, other rare monogenic adenomatous polyposis syndromes were reviewed and added. Eighty-nine clinically relevant questions were answered after a systematic review of the existing literature with grading of the evidence according to Grading of Recommendations, Assessment, Development, and Evaluation methodology. Two levels of consensus were identified: consensus threshold (≥67% of voting guideline committee members voting either 'Strongly agree' or 'Agree' during the Delphi rounds) and high threshold (consensus ≥ 80%).

RESULTS

One hundred and forty statements reached a high level of consensus concerning the management of hereditary adenomatous polyposis syndromes.

CONCLUSION

These updated guidelines provide current, comprehensive, and evidence-based practical recommendations for the management of surveillance and treatment of familial adenomatous polyposis patients, encompassing additionally MUTYH-associated polyposis, gastric adenocarcinoma and proximal polyposis of the stomach and other recently identified polyposis syndromes based on pathogenic variants in other genes than APC or MUTYH. Due to the rarity of these diseases, patients should be managed at specialized centres.

Giant desmoid tumour mimicking recurrent uterine myoma in a nulliparous young Nigerian: a case report

BACKGROUND

Desmoid tumors are rare lesions. Although they demonstrate tumor characteristics, such as infiltrative growth and tendency towards local recurrence, they lack the ability to metastasize. To date, the cause of desmoid tumors is unknown. They can occur in both sexes, but predominant slightly in women, including nulliparous women, of reproductive age, but mostly during and after pregnancy.

CASE PRESENTATION

A 36-year-old nulliparous Nigerian woman presented with a large desmoid tumor of the anterior abdominal wall, mimicking recurrent leiomyoma. At presentation, she had a painless abdominal mass for 1 year, which was first noticeable as a small induration that progressively increased in size. The patient had a previous surgical history of open myomectomy for symptomatic fibroids of 3 years duration, prior to presentation. Treatment comprised a complete excision of the tumor with a wide margin and partial omentectomy and the anterior abdominal wall closed in layers, though without prosthesis. The patient subsequently developed incisional hernia.

CONCLUSIONS

Large desmoid tumors may be misdiagnosed or mistaken for uterine leiomyoma or other abdominal or pelvic tumors. Attention should therefore be paid to detailed patient history and systematic clinical evaluation. To guard against incisional hernia associated with surgical resection of huge desmoid tumors, mesh reconstruction is recommended.

Entirely Robot-assisted Total Colectomy/Total Proctocolectomy Compared With a Laparoscopic Approach

PURPOSE

Previous robot-assisted total colectomy/total proctocolectomy (TC/TPC) has been mostly confined to completion proctectomy combined with open or laparoscopic colon dissection. This study describes an integrative method of entirely robot-assisted maintaining anatomical dissection with single docking and one-off arm placement.

MATERIALS AND METHODS

Twenty patients who underwent robot-assisted TC/TPC and 36 who underwent laparoscopic procedures at the Asan Medical Center (Seoul, Korea) were enrolled.

RESULTS

Mean operation time was ∼1 hour longer in the robot-assisted than in the laparoscopic group (P=0.003), due primarily to the extra time required for instrument installation and more frequent transient ileal diversion. Three patients (8%) in the laparoscopic group required conversion to open surgery, compared with none in the robot-assisted group. Rates of postoperative adverse events did not differ in the 2 groups (P=0.063). Short (8 cm) ileal pouches were applied to all patients who underwent robot-assisted TPC/ileal-pouch anal anastomosis, but to one patient who underwent laparoscopic surgery. There were no discrepancies of mean daily bowel movement between patients with short and long ileal pouches 6 months after surgery (P=0.694), showing 5 times per day (range: 1 to 10).

CONCLUSION

The advantages of the boom system and motion-sensitive table were successfully utilized to integrate anatomical dissection with the multiquadrant procedures of TC/TPC, with none of these patients requiring conversion to open surgery. Refinement of these techniques may overcome some of the technical and time-related and cost-related concerns of the robotic approach.

Large desmoid tumors in familial adenomatous polyposis: a successful outcome

Desmoid tumors develop from connective tissue, fasciae, and aponeuroses, and may occur in the context of familial adenomatous polyposis or may arise sporadically; also, they may be extra-abdominal, intra-abdominal, or located in the abdominal wall. These benign tumors have a great aggressiveness with a high rate of local recurrence. Familial adenomatous polyposis is an inherited condition with autosomal dominant transmission, and is characterized by the development of multiple colonic and rectal adenomatous polyps, as well as desmoid tumors. We present the case of a 54-year-old woman with germline APC gene mutation, who underwent a total colectomy, subsequently developing two large infiltrative solid intra-abdominal lesions consistent with desmoid tumors. Medical treatment with Cox-2 inhibitors was initiated without result. She was submitted to resection for intestinal obstruction, but developed local recurrence. The lesions were also unresponsive to tamoxifen, and chemotherapy was initiated with dacarbazine plus doxorubicin, switching to vinorelbine plus methotrexate, achieving a good response in all lesions after 12 months. The approach to these intra-abdominal lesions should be progressive, beginning with observation, then a medical approach with non-steroidal anti-inflammatory drugs or with an anti-hormonal agent. Afterwards, if progression is still evident, chemotherapy should be started. Surgery should be reserved for resistance to medical treatment, in palliative situations, or for extra-abdominal or abdominal wall desmoids tumors.

[Desmoid tumors in an adolescent girl with familial adenomatous polyposis]

Desmoid tumors (DT) are rare and nonmetastasizing fibroblastic neoplasms, characterized by local invasiveness. They occur sporadically or arise in the context of familial adenomatous polyposis (FAP; 5-10% of cases). Most cases develop sporadically in young adults, but some cases also occur in children. We report the case of an adolescent girl with FAP and DT, and we discuss the therapeutic strategies. An adolescent girl with FAP underwent surgery at the age of 14 years with total proctocolectomy. She had a neo-mutation in the APC gene at codon 1068, which is not usually associated with DT. Three years later, she had painful defecations. Imaging showed two abdominal DT. After a multidisciplinary team meeting, the patient was refused for surgery, and medical treatment with antihormonal agents and nonsteroidal anti-inflammatory drugs was started. Imaging 18 months later showed DT stabilization, but the patient had difficulties to control chronic pains, which required morphine treatment, hypnotic sessions, and transcutaneous electric nerve stimulation. This case highlights the importance of DT screening in patients with FAP, mainly after surgery, regardless of their age and genetic mutation. Progress remains to be made in determining DT risk factors and in developing treatment. DT are still difficult to cure because of their potential for local invasion and local recurrence, and need to be managed by a multidisciplinary team.

Clinicopathological features of familial adenomatous polyposis in Korean patients

AIM: To identify prognostic factors and to correlate APC mutations with clinical features, including extracolic manifestations.

METHODS: One hundred thirty-five patients who underwent surgical procedures for familial adenomatous polyposis (FAP) were included. FAP was diagnosed when the number of adenomatous polyps was > 100. Data related to patient, extracoloic manifestations, cancer characteristics, operative procedure, follow up and surveillance were collected. APC mutation testing was performed in the 30 most recent patients. DNA was extracted from peripheral blood and polymerase chain reaction products using 31 primer pairs on APC gene were sequenced. A retrospective study was performed to investigate a causal relationship between prognosis and feature of patient.

RESULTS: The mean age of the 51 patients with colorectal cancer (CRC) was older than that of those without CRC (30.5 vs 36.9, P = 0.002). Older individuals were more likely to have colon cancer at the time of FAP diagnosis [odds ratio, 4.75 (95%CI: 1.71-13.89) and 5.91(1.76-22.12) for 40-49 years and age > 50 vs age < 30). The number of confirmed deaths was 13 and the median age at death was 40 years (range, 27 to 85 years). Ten of the deaths (76.9%) were from CRC. Another cause of two cases of death were desmoid tumors (15.4%). Development of cancer on remnant rectal or ileal mucosa after surgery was not observed. The APC mutation testing revealed 23 pathogenic mutations and one likely pathogenic mutation, among which were four novel mutations. The correlation between mutational status and clinical manifestations was investigated. Mutations that could prodict poor prognosis were at codon 1309 which located on mutation cluster region, codon 1465 and codon 1507.

CONCLUSION: Identification of APC mutations should aid in the diagnosis and counseling of family members in terms of early diagnosis and management of FAP.