APC GENOTYPE, POLYP NUMBER, AND SURGICAL OPTIONS IN FAMILIAL ADENOMATOUS POLYPOSIS

Objective This study was performed to examine the relation between phe notypic expression in patients with familial adenomatous polyposis (FA P) and the site of mutations in the APC (adenomatous polyposis coil) g ene. The ability of APC mutations to predict surgical outcome was also investigated. Summary Background Data Germline mutations in the APC g ene cause FAP and can now be identified by direct mutational analysis. Such an analysis can identify affected persons for close surveillance and spare unaffected persons. Phenotypic expression varies within and among FAP kindreds, but certain mutations have been associated with s evere disease. Patients with severe polyposis are frequently offered t otal proctocolectomy rather than colectomy and ileorectal anastomosis out of concern for increased rectal cancer risk. Mutation analysis may offer a more rational basis for these decisions. Methods The postsurg ical courses of 58 patients from 19 FAP kindreds with identified APC g ene mutations were reviewed. APC gene mutations were identified by ana lysis of leukocyte DNA using single-strand conformational analysis and DNA sequencing. FAP severity was defined according to the number of p olyps in the colon at the time of resection (<1000, mild; >1000, sever e). Operations included subtotal colectomy with ileorectal anastomosis (IRA), total proctocolectomy with ileal pouch/anal anastomosis, total proctocolectomy with end ileostomy, and partial colectomy (PC). Resul ts Eight different APC mutations were identified. Mutations at codons 1309 and 1328 in exon 15G were associated with a uniformly severe poly posis phenotype. For other mutations, the phenotype was more variable. Patients with APC mutations: at codons 1309 and 1328 more commonly un derwent proctectomy. Among the 43 patients who initially underwent eit her IRA or PC, the rectum was later removed in 8. Seven of these patie nts had a mutation al codon 1309 or 1328. With one exception, all pati ents with mutations outside the 1389 or 1328 site who initially had IR A have retained their rectum. Conclusions Our data support an associat ion between severe polyposis phenotype and mutations at APC gene codon s 1309 and 1328. For patients with these mutations, the prognosis for retaining the rectum is poor.