Juvenile polyposis of the stomach: clinicopathological features and its malignant potential

AIMS: To clarify a clinical entity of juvenile polyposis of the stomach compared with generalised juvenile gastrointestinal polyposis. METHODS: The clinicopathological features of juvenile polyposis dominantly involving the stomach at initial presentation were reviewed in 12 patients (three new patients and nine from the literature). These were compared with 29 cases of generalised juvenile gastrointestinal polyposis. RESULTS: There were three men and nine women with juvenile polyposis of the stomach, aged 10-63 years. Hypoproteinaemia was present in nine patients, anaemia in seven, and a family history of intestinal polyposis in seven. No patient presented with a congenital abnormality. During the observation period, two patients developed colonic juvenile polyps. Gastric polyps invariably affected the antrum and extended to the fundus, eventually becoming more numerous, larger, and more pedunculated. Ten patients required gastrectomy for associated malignancy or uncontrolled protein losing gastropathy. Histological examinations of the resected specimens demonstrated neoplastic tissue arising from juvenile polyps in four of the 12 patients. Atypism in these mixed polyps varied from adenoma to well or moderately differentiated adenocarcinoma. CONCLUSIONS: Juvenile polyposis of the stomach has malignant potential, and may be a separate entity from generalised juvenile gastrointestinal polyposis.     

Juvenile gastrointestinal polyposis

Two cases of juvenile gastrointestinal polyposis are described and the literature is reviewed. Despite the benign nature of the individual polyps, the disease has a poor prognosis. Of 13 reported patients, 4 had macrocephaly, and one of the authors' 2 patients had large peripheral intracranial cysts. This appears to be the first reported documentation of the etiology of macrocephaly associated with juvenile polyposis. Major clinical problems are related to severe loss of blood and protein from the gastrointestinal tract.     

Genomic organization and mutational analysis of KVLQT1, a gene responsible for familial long QT syndrome

BACKGROUND: Turcot's Syndrome is the association of multiple adenomatous polyps of the colon with a primary tumor of the central nervous system. We present the first reported case of Turcot's Syndrome in a patient with malignant ependymomas. Recent advances in the elucidation of the genetic basis for the hereditary forms of colon cancer have provided a clearer understanding of the etiology of Turcot's Syndrome. This new information is relevant to the neurosurgical community and provides updated guidelines in the diagnosis and management of patients with this complex disease process. RESULTS: Turcot's Syndrome is related to two distinct genetic errors. The first involves a germ-line mutation in the adenomatous polyposis coli (APC) gene, which is postulated to act as a tumor suppressor gene. The second is a germ-line defect in one of a group of genes responsible for DNA nucleotide mismatch repair. CONCLUSION: The elucidation of the gene defects responsible for the hereditary forms of colon cancer has provided a clearer understanding of the molecular basis of Turcot's Syndrome. Patients with hereditary forms of colon cancer and neurologic symptoms require immediate and thorough investigation because of their significantly increased risk of developing CNS tumors. Previously healthy patients diagnosed with a CNS tumor with a family history of adenomatous polyposis coli should undergo screening and surveillance colonoscopy as the CNS lesion may precede colonic symptoms. CNS screening guidelines for asymptomatic patients with adenomatous polyposis coli requires further risk analysis studies. All patients diagnosed with Turcot's Syndrome should be tested for the gene defect, including the CNS tumor tissue to provide further data on the genetic relationship between Turcot's Syndrome and the hereditary forms of colon cancer.     

Germline mutations in the 3' part of APC exon 15 do not result in truncated proteins and are associated with attenuated adenomatous polyposis coli

Familial adenomatous polyposis (FAP) is an inherited predisposition to colorectal cancer characterized by the development of numerous adenomatous polyps predominantly in the colorectal region. Germline mutations in the adenomatous polyposis coli (APC) gene are responsible for most cases of FAP. Mutations at the 5' end of APC are known to be associated with a relatively mild form of the disease, called attenuated adenomatous polyposis coli (AAPC). We identified a frameshift mutation in the 3' part of exon 15, resulting in a stop codon at 1862, in a large Dutch kindred with AAPC. Western blot analysis of lymphoblastoid cell lines derived from affected family members from this kindred, as well as from a previously reported Swiss family carrying a frameshift mutation at codon 1987 and displaying a similar attenuated phenotype, showed only the wild-type APC protein. Our study indicates that chain-terminating mutations located in the 3' part of APC do not result in detectable truncated polypeptides and we hypothesize that this is likely to be the basis for the observed AAPC phenotype.     

Cronkhite-Canada syndrome. Epidemiology, symptoms, morphology and therapy based on a case report and literature review

Juvenile polyposis was first described by Cronkhite and Canada in 1955. This disease is characterized by juvenile intestinal polyps and ectodermal abnormalities. The etiology of Cronkhite-Canada syndrome (CCS), however, is still not well understood. Interestingly among patients with CCS a significant correlation (16.5%) with intestinal carcinomas has been observed. Thus, malignant transformation and/or genetic predisposition may be involved in the initiation of the disease. In the following, epidemiology, symptoms, morphology and therapy of CCS are discussed. Our examinations are based on studies reported in the literature and on a case report of a female patient who developed a colon carcinoma 2 years after initial diagnosis of CCS.     

Evidence for inverse agonism of SR141716A at human recombinant cannabinoid CB1 and CB2 receptors

OBJECTIVES: We studied the clinical spectrum, histology, and malignant potential of colonic polyps in Indian children (< or =12 yr). METHODS: Two hundred thirty-six children with colonic polyps were studied from January 1991 to October 1996. They were evaluated clinically and colonoscopic polypectomy was done. Children with five or more juvenile polyps were labeled as having juvenile polyposis and serial colonoscopic polypectomies were done every 3 wk. Colectomy was performed when there were intractable symptoms or clearing of the polyps by colonoscopy was not possible. Histological examination of the polyps was done. Follow-up colonoscopy was done in children with juvenile polyposis only. RESULTS: The mean age of these children was 6.12 +/- 2.7 yr, with a male preponderance (3.5:1). Rectal bleeding of a mean duration of 14 +/- 16 months was the presenting symptom in 98.7%. Solitary polyps were seen in 76%, multiple polyps in 16.5%, and juvenile polyposis in 7% (n = 17) of the children. A majority (93%) of the polyps were juvenile and 85% were rectosigmoid in location. Adenomatous changes, seen in 11%, were more common in juvenile polyposis (59%) than in juvenile polyps (5%). Among those with juvenile polyposis, colon clearance was achieved in eight, six required colectomy for intractable symptoms, and three were still on the polypectomy program. Polyps recurred in 5% of children with juvenile polyps and 37.5% of those with juvenile polyposis. CONCLUSIONS: Juvenile polyps remain the most common colonic polyps in children. A significant number of cases of polyps are multiple and proximally located, which emphasizes the need for total colonoscopy in all. Juvenile polyps should be removed even if asymptomatic because of their neoplastic potential. Colonoscopic polypectomy is effective even in juvenile polyposis. Surveillance colonoscopy is required in juvenile polyposis only.     

Analysis of antigen receptor genes in Hodgkin''s disease

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.     

Colorectal cancer: future population screening for early colorectal cancer

Colorectal cancer (CRC) is one of the most frequent cancers in Western countries. The identification of individuals at risk and the early diagnosis of CRC are of critical importance since a large proportion can be prevented or cured by surgical removal before metastasis has occurred. With increasing understanding of the genetic basis of hereditary and sporadic (non-hereditary) CRC, it becomes feasible to detect genetic alterations by molecular techniques. Familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC), as well as early stages of spontaneous CRC, can be diagnosed by molecular characterisation of the adenomatous polyposis coli (APC) gene, the RAS oncogene and other genes in DNA from peripheral blood, stool or intestinal biopsies. With a better understanding of the genetic events leading to malignant transformation, molecular population screening should allow us to identify individuals at risk as well as patients with an early and potentially curable CRC. At present, careful patient and family history, physical examination and testing for occult blood as well as colonoscopy are still the key elements for clinical patient management. Molecular diagnosis will hopefully soon complement these analyses and should result in a reduction of morbidity and mortality from CRC.     

Polyposis coli. Comparison between the familial and non-familial form

Since 1970 16 patients with polyposis coli have been treated at the Department of Surgery, Medical School, Hannover. Of these, 9 patients showed the classic type of familial polyposis, while 7 patients denied a positive family history. Comparing both groups, the nonfamilial type of polyposis coli can be separated as well from the familial polyposis as from multiple adenomas of the large bowel. Operative treatment in both groups of polyposis coli and management of nonfamilial polyposis coli are discussed.     

Tumor suppressor genes with special emphasis on the APC tumor suppressor gene

Tumor suppressor genes play a central role in the genesis and progression of human cancers. Genetic alterations of tumor suppressor genes have been found in a variety of hereditary and nonhereditary cancers. Persons that carry a hereditary mutation in tumor suppressor genes are strongly predisposed to one or more kinds of cancer. This review brings current developments in the field of tumor suppressor genes. Special emphasis is dedicated to recently discovered tumor suppressor gene APC (adenomatous polyposis coli) whose mutations are responsible for familial adenomatous polyposis (FAP). The known mutations of the APC gene are described. The role of the APC gene in tumor development, as well as the possibility for presymptomatic genetic testing is also discussed in the paper.     

Replication of cytopathic and noncytopathic bovine viral diarrhea virus in zona-free and zona-intact in vitro-produced bovine embryos and the effect on embryo quality

The adenomatous polyposis coli gene is mutated in familial adenomatous polyposis and in sporadic colorectal tumours. The adenomatous polyposis coli gene product is a 300,000 mol. wt cytoplasmic protein that binds to at least three other proteins; beta-catenin, a cytoplasmic E-cadherin-associated protein; hDLG, a human homologue of the Drosophila discs large tumour suppressor protein and glycogen synthase kinase 3 beta, a mammalian homologue of the Drosophila ZESTE WHITE 3 protein. The adenomatous polyposis coli gene is highly expressed in the brain, suggesting that it may be involved in nerve function. Here we show that adenomatous polyposis coli is localized in the pericapillary astrocytic endfeet throughout the mouse central nervous system. Adenomatous polyposis coli is also localized in the astrocytic processes in the cerebellar granular layer, and displays concentrated expression in the terminal plexuses of the basket cell fibres around Purkinje cells. Adenomatous polyposis coli is further expressed in neuronal cell bodies and/or nerve fibres in the olfactory bulb, hippocampus, brain stem, spinal cord and dorsal root ganglia. Adenomatous polyposis coli is demonstrated to be co-localized with beta-catenin and/or hDLG in neurons and nerve fibres, but not in astrocytes. From these results, adenomatous polyposis coli is suggested to participate in a signal transduction pathway in astrocytes which is independent of beta-catenin and hDLG, and also in regulation of neuronal functions in association with beta-catenin and hDLG.     

Diffuse cystic glandular malformation of the stomach associated with adenocarcinoma: Case report and review of the literature

A 60-year-old man was found to have diffuse cystic glandular malformation and adenocarcinoma of the stomach. Review of the literature revealed one similar reported case and five others with diffuse heterotopic cystic malformation only. Clinically, the lesion is associated with gastrointestinal symptoms, and radiologically, it can mimic diffuse gastric carcinoma, lymphoma, and polyposis.     

Apoptosis in rat prostatic adenocarcinoma is associated with rapid infiltration of cytotoxic T-cells and activated macrophages

The laser has played a valuable primary and adjunctive role in the management of nasal and sinus disorders. When using the laser there must be appropriate knowledge about safety, instrumentation, and types of pathologic conditions in which the laser is effective. The laser is effective for turbinate dysfunction of various causes. Its coagulating, cutting, and vaporization ability make it useful in managing intranasal vascular disorders such as hereditary hemorrhagic telangiectasia and hemangioma. There is some promise in using the laser for nasal polyposis with eosinophilia.     

Enhanced intestinal adenomatous polyp formation in Pms2-/-;Min mice

Analysis of two human familial cancer syndromes, hereditary nonpolyposis colorectal cancer and familial adenomatous polyposis, indicates that mutations in either one of four DNA mismatch repair gene homologues or the adenomatous polyposis coli (APC) gene, respectively, are important for the development of colorectal cancer. To further investigate the role of DNA mismatch repair in intestinal tumorigenesis, we generated mice with mutations in both Apc and the DNA mismatch repair gene, Pms2. Whereas Pms2-deficient mice do not develop intestinal tumors, mice deficient in Pms2 and heterozygous for Min, an allele of Apc, develop approximately three times the number of small intestinal adenomas and four times the number of colon adenomas relative to Min and Pms2+/-;Min mice. Although Pms2 deficiency clearly increases adenoma formation in the Min background, histological analysis indicated no clear evidence for progression to carcinoma.     

Open heart operation in patients suffering from hereditary spherocytosis

Hereditary spherocytosis is a clinically heterogeneous, genetically determined red blood cell membrane disorder resulting in hemolytic anemia. Structural or functional disorders of the cytoskeletal proteins result in the formation of spherocytes, which lack the strength, durability, and flexibility to withstand the stresses of the circulation. This problem can be accentuated by the deleterious effects of the heart-lung machine. Three patients with hereditary spherocytosis underwent open heart operation with no deaths and no serious complications resulting from the hematologic defect. Splenectomy is recommended, although not essential, before a cardiac operation, and mechanical valves should perhaps be avoided.     

The complete mitochondrial DNA sequence of the pig (Sus scrofa)

Familial adenomatous polyposis (FAP) is an autosomal dominant hereditary disorder caused by a germline inactivating mutation of the adenomatous polyposis coli (APC) gene. Patients with FAP sometimes develop various extracolonic manifestations including adrenocortical neoplasms. We present a 14-year-old boy with FAP who had an adrenocortical tumor with atypical histopathologic features, ie, sex-cord-like differentiation. Immunohistochemical studies of adrenal 4 binding protein (Ad4BP) and steroidogenic enzymes showed the capacity of these tumor cells to produce steroids. Genetic analysis of the tumor disclosed a two-hit mutation in APC: a germline 5-base pair deletion accompanied by a loss of the normal allele. Because there were no reports of genetic alterations in adrenocortical tumors developed in FAP patients, we examined 10 sporadic adrenal tumors (four carcinomas and six adenomas) for mutations in APC. However, no mutations were found in these 10 sporadic adrenal tumors. These results suggest that mutation of APC is also responsible for some fraction of the adrenocortical tumors: the tumor in this case is included.     

APC gene messenger RNA: novel isoforms that lack exon 7

The APC gene at human chromosome 5q21 is responsible for familial adenomatous polyposis coli. Furthermore, sporadic cancers of not only colon but also other digestive organs often contain mutations in the APC gene. A dominant mouse mutation Min that was generated by chemical mutagenesis and causes polyposis in the digestive tract is in the mouse homologue of the human APC gene. The APC mRNA is generated from 15 exons. Two mRNA isoforms were reported which are produced by alternative splicing in the 9th exon. Here, we report novel mRNA isoforms that lack the 7th exon in both mouse and human cells.     

Contribution of cases to the new classification of polyposis syndrome in the gastrointestinal tract

In Schweizerische Medizinische Wochenschrift 106, 894-897 (1976) an article was published on a kinship with hereditary "minor adenomatous polyposis" of the colon with a higher than expected incidence of carcinoma of the stomach. Evidence for a genetic relationship between this family (Sch.) and another branch with an isolated case (Sch. E.) of familial polyposis of the gastrointestinal tract was found. The patient Sch. E. is presented here. The polyposis of this patient is phenotypically identical with that found in the classical familial polyposis of the colon, but also exhibits features of "minor adenomatous polyposis". A systematic clinical-endoscopic examination of ten members of the patient's family produced no further cases of gastrointestinal polyposis of carcinomata. In the case of Sch. E., therefore, a spontaneous mutation is postulated. A new classification of the various types of colonic polyposis is suggested.     

Microsatellite instability in B-cell lymphoma originating from Bloom syndrome

We present two cases of osteochondroma after total body irradiation in bone marrow recipients, the first in a 6-year-old boy with juvenile chronic myelogenous leukemia and the second in a 13-year-old boy with acute myelogenous leukemia. The patients developed multiple osteochondromas three years and seven years, respectively, after 12 Gy of total body irradiation. Neither had a family history of hereditary multiple osteochondromatosis. A review of the English literature revealed only one report describing five cases of osteochondroma after 12 Gy of total body irradiation in bone marrow transplant recipients. Osteochondroma should be considered as an additional adverse effect of total body irradiation.