[Cutaneous polyposis in a female patient with an APC variant without adenomatous polyposis of the colon]

The occurrence of multiple benign skin tumors is suspicious for a hereditary tumor syndrome. Genetic investigations often clarify the molecular foundations and enable a nosological classification. In the case of a cutaneous polyposis described here, a variant in APC was detected; however, simultaneous symptoms of an adenomatous polyposis of the colon were lacking.

Gastrointestinal Polyps and Polyposis in Children: Experience of Endoscopic and Surgical Outcomes

INTRODUCTION

There are gaps in the literature regarding outcome of multiple polyps and dilemmas in the management issues in polyposis syndromes in children.

OBJECTIVE

We aimed to study the clinical behaviour of gastrointestinal (GI) polyps with emphasis on therapeutic outcomes of polyposis syndrome.

METHODS

Proven cases of GI polyp(s) on endoscopy were classified as single polyp, multiple polyps, and polyposis syndrome. Complex presentation was defined as 1 or more of the following: severe anaemia, anasarca, intussusception, rectal mucosal prolapse, and diarrhoea. A clinico-endoscopic criterion was applied in polyposis syndrome patients for the decision of surgery versus endoscopic therapy with surveillance.

RESULTS

Of total 240 patients, there were no significant differences between single (52.5%, n = 126) versus multiple polyps (27.5%, n = 66) with respect to age, symptoms, histology, and recurrence. Polyposis syndrome (20%, n = 48) presented with complex symptoms (50%), higher family history, significantly lower haemoglobin, total protein, and albumin as compared to single and multiple polyps (p < 0.01). Nineteen polyposis patients with favourable clinico-endoscopic criteria were endoscopically eradicated for polyps in 3 (1-4) sessions with sustenance of laboratory parameters at 1 year and 30% symptomatic recurrence at follow-up of 23.5 (7-40) months. There were no major endoscopic complications. Nineteen patients required proctocolectomy with improvement in laboratory parameters 6 months post-surgery.

CONCLUSIONS

Multiple polyps behave similar to single polyps in children. A clinico-endoscopic criterion may guide for optimal management of polyposis syndrome. Colectomy may be effectively deferred in a large proportion of polyposis syndrome patients if maintained on an endoscopic protocol.

A Case Report of Cronkhite-Canada Syndrome Complicated by Membranous Nephropathy

Cronkhite-Canada syndrome (CCS) is a very rare disorder with less than 500 reported cases. It is characterized by extensive gastrointestinal polyposis and ectodermal anomalies including alopecia, cutaneous hyperpigmentation, and onychodystrophy. Only 3 cases of associated kidney disease (membranous nephropathy [MN]) have been reported. A 71-year-old male with CCS was referred for further evaluation of proteinuria. The patient initially presented with abdominal discomfort, weight loss, dysgeusia, skin hyperpigmentation, alopecia, and dystrophic nails. Endoscopic evaluation showed widespread gastrointestinal nodular inflammation and polyps. Histopathology was consistent with CCS. Initial treatment was with prednisone, azathioprine, and ranitidine. He had moderate clinical improvement but developed nephrotic-range proteinuria. Renal biopsy showed MN, and cyclosporine was started. The patient had significant improvement in his CCS manifestations; however, his proteinuria and renal function worsened. Rituximab was added to his regimen of cyclosporine and azathioprine, which resulted in remission of his MN, marked improvement in his polyposis, and near resolution of his cutaneous symptoms. This case represents a unique presentation of CCS associated with MN treated with rituximab. The excellent clinical response observed for both CCS and MN advocates consideration of this treatment, especially for refractory disease.

Clinical predictors for sessile serrated polyposis syndrome: A case control study

AIM

To compared individuals with serrated polyposis syndrome (SPS) to those with sessile serrated adenoma (SSA) and adenomas in the setting of endoscopists with high adenoma detection rates at a secondary and tertiary academic centre.

METHODS

Retrospectively we collated the clinical, endoscopic and histological features of all patients with SPS at St Vincent’s public and private hospital in the last 3 years. Patients were identified by searching through 2 pathology databases. Variables explored included smoking status, symptoms, and family history of concurrent colorectal cancer, number and location of polyps. Patients with SPS were matched to two cohorts (1) patients with SSA not meeting World Health Organization (WHO) criteria for SPS over 3 years; and (2) patients with exclusively adenomas. The control cases were also matched according to gender and endoscopist. Adenoma detection rates ranged from 25% to 40%.

RESULTS

Forty patients with SPS were identified and matched with 40 patients in each control group. In total 15452 colonoscopies were performed over the study period which amounts to a prevalence of 1: 384 patients (0.26%) with SPS. Fourteen patients (35%) required more than 1 year to accumulate enough polyps to reach WHO criteria for SPS. The diagnosis of SPS was largely incidental and 5% SPS patients were diagnosed with colorectal cancer over 3 years. The chance of detecting a meta-synchronous adenoma was similar in those with SPS (42%) and those with SSA (55%), P = 0.49. The majority of patients (75%) meeting criteria for SPS were women. The mean age of those with SPS (45 years) was significantly lower than both cohorts with SSA (57 years) and adenomas (63 years), P = 0.01. On univariate analysis cigarette exposure, first-degree family history of colorectal cancer and a high BMI weren’t significantly more associated with SPS compared to patients with SSA or patients with adenomas. However, patients with SPS (97%) and patients with SSAs not meeting SPS criteria (98%) were significantly more likely to be Caucasian compared to patients with adenomas (79%), P = 0.01.

CONCLUSION

The prevalence of SPS in our study was 0.26%. The vast majority of patients diagnosed with SPS were women. As a group, they were significantly younger compared to patients with SSA not meeting WHO criteria and patients with adenomatous polyps by more than a decade. Patients with SPS were no more likely to have a first degree relative with colorectal cancer or smoking history than the other two groups. Patients with serrated polyps were more likely to be Caucasian than patients with adenomas.

Role of enhanced visibility in evaluating polyposis syndromes using a newly developed contrast image capsule endoscope

Background/Aims

A flexible spectral imaging color enhancement system was installed in new capsule software for video capsule endoscopy. Contrast image capsule endoscopy (CICE) is a novel technology using light-emitting diodes selected for the main absorption range of hemoglobin. We assessed the feasibility and diagnostic effi cacy for small bowel surveillance in patients with polyposis syndromes.

Methods

Six patients with polyposis syndromes, four with familial adenomatous polyposis and one each with Cowden syndrome (CS) and Cronkhite-Canada syndrome (CCS) were examined using CICE. We conducted three evaluations to assess the effect on the numbers of the detected polyps; compare polyp diagnostic rates between adenoma and hamartoma; and assess polyp visibility.

Results

The numbers of detected polyps and diagnostic accuracy did not differ signifi cantly between pre-contrast and contrast images. However, 50% of the adenomatous polyps displayed enhanced visibility on contrast images. CICE contrast images exhibited clearly demarcated lesions and improved the visibility of minute structures of adenomatous polyps. Hamartomatous polyp micro-structures in patients with CS and CCS were more clearly visualized on contrast than pre-contrast images.

Conclusions

CICE is an effective tool for enhancing the visibility of polyps in patients with polyposis syndrome.