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World J Gastroenterol. Nov 28, 2011; 17(44): 4839-4844
Published online Nov 28, 2011. doi: 10.3748/wjg.v17.i44.4839
Juvenile polyposis syndrome
Lodewijk AA Brosens, Danielle Langeveld, W Arnout van Hattem, Francis M Giardiello, G Johan A Offerhaus
Lodewijk AA Brosens, Danielle Langeveld, G Johan A Offerhaus, Department of Pathology, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
Danielle Langeveld, W Arnout van Hattem, G Johan A Offerhaus, Department of Pathology, Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands
Francis M Giardiello, Division of Gastroenterology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
Author contributions: Brosens LAA designed and wrote the paper; Langeveld D, van Hattem WA, Giardiello FM and Offerhaus GJA provided significant intellectual content and critically revised the manuscript.
Correspondence to: Dr. Lodewijk AA Brosens, Department of Pathology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. l.a.a.brosens@umcutrecht.nl
Telephone: +31-88-7551682 Fax: +31-30-2544990
Received: January 28, 2011
Revised: June 9, 2011
Accepted: June 16, 2011
Published online: November 28, 2011


Juvenile polyposis syndrome is a rare autosomal dominant syndrome characterized by multiple distinct juvenile polyps in the gastrointestinal tract and an increased risk of colorectal cancer. The cumulative life-time risk of colorectal cancer is 39% and the relative risk is 34. Juvenile polyps have a distinctive histology characterized by an abundance of edematous lamina propria with inflammatory cells and cystically dilated glands lined by cuboidal to columnar epithelium with reactive changes. Clinically, juvenile polyposis syndrome is defined by the presence of 5 or more juvenile polyps in the colorectum, juvenile polyps throughout the gastrointestinal tract or any number of juvenile polyps and a positive family history of juvenile polyposis. In about 50%-60% of patients diagnosed with juvenile polyposis syndrome a germline mutation in the SMAD4 or BMPR1A gene is found. Both genes play a role in the BMP/TGF-beta signalling pathway. It has been suggested that cancer in juvenile polyposis may develop through the so-called “landscaper mechanism” where an abnormal stromal environment leads to neoplastic transformation of the adjacent epithelium and in the end invasive carcinoma. Recognition of this rare disorder is important for patients and their families with regard to treatment, follow-up and screening of at risk individuals. Each clinician confronted with the diagnosis of a juvenile polyp should therefore consider the possibility of juvenile polyposis syndrome. In addition, juvenile polyposis syndrome provides a unique model to study colorectal cancer pathogenesis in general and gives insight in the molecular genetic basis of cancer. This review discusses clinical manifestations, genetics, pathogenesis and management of juvenile polyposis syndrome.

Key Words: Juvenile polyposis syndrome, Hamartoma, Colorectal cancer, SMAD4, BMPR1A


Juvenile polyposis syndrome (JPS) is a rare autosomal dominant hereditary disorder characterized by multiple distinct juvenile polyps in the gastrointestinal tract and an increased risk of colorectal cancer. Sporadic solitary colorectal juvenile polyps occur in approximately 2% of the paediatric population but these polyps are not associated with an increased risk of gastrointestinal cancer[1,2]. Juvenile polyposis syndrome is defined by the presence of five or more juvenile polyps in the colorectum, juvenile polyps throughout the gastrointestinal tract or any number of juvenile polyps, and a positive family history of juvenile polyposis[1,3]. About 50%-60% of JPS patients have a germline mutation in the SMAD4 or BMPR1A gene[4-6].


The juvenile polyp is a histopathological entity first reported by Diamond[7] in 1939 and later described in more detail by Helwig[8]. Macroscopically, juvenile polyps vary in size from 5 mm to 50 mm, and typically have a spherical, lobulated and pedunculated appearance with surface erosion (Figure 1A and B). Microscopically, a juvenile polyp is characterized by an abundance of edematous lamina propria with inflammatory cells and cystically dilated glands lined by cuboidal to columnar epithelium with reactive changes (Figure 2A and B). The distinction between an inflammatory and a juvenile polyp is often difficult. In essence, juvenile polyps in juvenile polyposis syndrome appear similar to sporadic solitary juvenile polyps, although syndromic polyps often have a frond-like growth pattern with fewer stroma, fewer dilated glands and more proliferative smaller glands[9]. In addition, polyps in juvenile polyposis syndrome frequently show neoplastic changes to the epithelium not found in sporadic solitary juvenile polyps. Colorectal polyps from individuals with a SMAD4 germline mutation often have a more proliferative epithelial phenotype and fewer stroma compared to those from patients with a BMPR1A germline mutation (Figure 2A and B)[10]. In addition, absence of the SMAD4 protein on immunohistochemistry of a juvenile polyp indicates that the patient carries a germline SMAD4 mutation (Figure 2C)[11].

Figure 1
Figure 1 Macroscopic appearance of juvenile polyposis. A: Bowel resection of a patient with juvenile polyposis syndrome showing multiple spherical pedunculated polyps with a smooth surfaces; B: Gross appearance of a juvenile polyp from a patient with juvenile polyposis syndrome. Note the smooth surface, in contrast with a Peutz-Jeghers polyp.
Figure 2
Figure 2 Histological appearance of juvenile polyposis. A: Histological section of a juvenile polyp from a juvenile polyposis patient with a germline mutation of BMPR1A. Typically, juvenile polyps are characterized by prominent lamina propria with edema and inflammatory cells, and cystically dilated glands lined by cuboidal to columnar epithelium with reactive changes; B: Histological section of a juvenile polyp from a juvenile polyposis patient with a germline mutation of SMAD4. This polyp shows relatively fewer stroma, fewer dilated glands and more proliferative smaller glands; C: SMAD4 immunohistochemistry on a juvenile polyp showing absent SMAD4 expression in the epithelium, indicating that this patient carries a germline SMAD4 mutation.

Small intestinal polyps in JPS have been classified as juvenile[12,13], hyperplastic and/or inflammatory polyps[14-16], and as lymphoid hyperplasia[15,17]. The larger small intestinal polyps resemble juvenile polyps in the colon[17]. In addition, juvenile/hamartomatous polyps with dysplastic changes and adenomas have been found in the duodenum, jejunum, and ileum of patients with JPS[12,14,16]. Moreover, we have seen a Brunner gland hamartoma in the duodenum of a juvenile polyposis patient with a SMAD4 germline mutation. Most gastric polyps in JPS patients have been diagnosed as hyperplasic polyps[14] and are indistinguishable from gastric hyperplastic polyps[18].


A germline mutation in the SMAD4 or BMPR1A gene is found in about 50%-60% of JPS patients[4-6]. Both genes are involved in the BMP/TGF-beta signalling pathway. Most germline defects are point mutations or small base pair deletions in the coding regions of SMAD4 or BMPR1A that can be identified by conventional sequence analysis. About 15% of the germline genetic defects are deletions of one or more exons, or the entire SMAD4 or BMPR1A coding sequence, which necessitates identification by techniques that analyze large genomic deletions, such as multiplex ligation-dependent probe amplification (MLPA)[4,6]. Recently, previously unknown mutations in the BMPR1A promoter region were found in about 10% of JPS patients[19].

About 30%-40% of JPS patients have no germline mutation; therefore, a number of candidate genes, mostly involved in the transforming growth factor β (TGF-β)/bone morphogenetic proteins (BMP) pathway, have been investigated for a role in JPS pathogenesis. Although not confirmed, and questioned by others, germline mutations of the TGB-β co-receptor Endoglin has been reported in two JPS patients[4,20]. In addition, SMAD1, SMAD2, SMAD3, SMAD5, SMAD7, BMPR2, BMPR1B, ACVRL1, TGFBRII and CDX2 have been analyzed; however, no germline mutations have been found in these genes[20]. In addition, PTEN, the gene linked to Cowden (CS) and Bannayan-Riley-Ruvalcaba syndrome (BRRS), has been suggested as a JPS gene. However, PTEN mutations in patients with juvenile polyps likely represent CS or BRRS patients that have not (yet) developed extraintestinal clinical features specific to these conditions[21]. A recent study involving a large number of PTEN germline-mutation positive Cowden syndrome patients substantiated this notion by showing that both upper- and lower gastrointestinal polyps are a common manifestation of this syndrome[22]. Patients afflicted by Cowden syndrome may develop colorectal juvenile polyps indistinguishable from those in juvenile polyposis syndrome. Therefore, although the exact gastrointestinal manifestations of Cowden syndrome remain to be clarified, particularly with respect to the upper gastrointestinal tract, Cowden syndrome should be part of the differential diagnosis in a patient presenting with a juvenile polyp.


Clinically, juvenile polyposis can present in two forms. The first is called juvenile polyposis of infancy. This is a generalized form occurring in infants with polyps in the stomach, small bowel and colon. The polyps vary in size from 1 to 30 mm and may be sessile or pedunculated. These infants suffer from diarrhoea, haemorrhage, malnutrition and intussusception. Death usually occurs at an early age. In addition, many of these patients have congenital abnormalities, including macrocephaly and generalized hypotonia[23]. Some investigators suggest that this rare form of juvenile polyposis is caused by continuous deletion of BMPR1A and PTEN genes located on chromosome 10q23.2 and 10q23.3 respectively, although others disagree[24,25].

In addition, generalized juvenile polyposis and juvenile polyposis coli (juvenile polyps restricted to the colorectum) have been defined[26]. However, these forms appear to be variable expressions of the same disease, because patients of both forms have been reported to segregate according to a dominant mode in the same family[24,27]. These forms may be sporadic, i.e., ‘de novo’, or inherited, and usually present later in childhood or in adult life. They are characterized by the presence of gastrointestinal juvenile polyposis and an increased risk of gastrointestinal cancer[28]. A variety of extra-intestinal manifestations have been reported in these patients[23]. In approximately 50% of juvenile polyposis coli or generalized JPS cases, a heterozygous germline mutation in the SMAD4 or BMPR1A gene is identified[24]. Several differences in phenotypic expression between carriers of a SMAD4 and BMPR1A mutations have been noted. SMAD4 mutations are associated with a more aggressive gastrointestinal phenotype, involving higher incidence of colonic adenomas and carcinomas and more frequent upper gastrointestinal polyps and gastric cancer than patients with a BMPR1A mutation[6,29,30]. Also, the combined syndrome of JPS and hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) is associated with germline mutations in SMAD4[31].


Polyps in JPS predominantly occur in the colorectum, varying in number from five to several hundred. In addition, polyps can be found in the stomach, duodenum, jejunum, and ileum, although the incidence of upper gastrointestinal tract polyps in JPS is less well studied. Rarely, profuse gastric juvenile polyposis is found in the absence colonic polyps[32]. As noted above, upper gastrointestinal polyposis and gastric cancer has been associated with SMAD4 germline mutation[6,29,30].

Few studies systematically examined upper gastrointestinal tract involvement in juvenile polyposis[12,14,33]. One investigation found gastric polyps in 10 out of 12 (83%) patients, mostly located in the antrum, but throughout the stomach in six individuals. Rarely, profuse gastric juvenile polyposis is found in the absence of colonic polyps. Duodenal polyps were found in four out of 12 (33%) JPS patients, with two having multiple polyps ranging in size from 0.5 to 1.5 cm. and two others with minute polyps[14]. Using capsule endoscopy, small-bowel polyps beyond the range of standard gastroscopy were found in 2 of 10 (20%) patients and duodenal polyps in 4 others (40%)[33]. Another study reported small bowel polyps in 8 of 56 JPS patients (14%)[12]. Moreover, a number of case reports of duodenal, jejunal, and ileal polyps in JPS patients exist[13,15-17,34], In addition, juvenile polyps are frequently found in the ileal pouch of juvenile polyposis patients who have undergone proctocolectomy[35,36].


Juvenile polyposis is associated with an increased risk of gastrointestinal cancer. A recent cancer risk analysis calculated a cumulative life-time risk for colorectal cancer in JPS of 39% and a relative risk of colorectal cancer of 34[37]. However, this may be a conservative estimate, because some patients in this study had already undergone prophylactic colectomy. Jass reported a 68% cumulative risk of colorectal cancer in patients from the St Mark’s Registry, but details were not provided[38]. In addition, several cases of stomach, duodenal, and pancreatic cancer in JPS have been described in the literature, but no formal risk analysis for these malignancies exists[28]. One study found small bowel carcinoma in six out of 56 (11%) JPS patients, but four of these cancers occurred in one family[12]. Evaluation of literature reports suggests that gastric and small bowel carcinoma, together, occur at about one-fifth the frequency of colorectal cancers in this patient group[37].


Cancer pathogenesis in juvenile polyposis has not yet been unravelled and may develop through the so-called “landscaper mechanism”. The landscaper model was proposed after the observation that the genetic alterations at chromosome 10q22 (BMPR1A locus) occurred predominantly in the stroma of juvenile polyps. This paradigm postulates that cancer develops as a result of an abnormal stromal environment, which leads to neoplastic transformation of the adjacent epithelium[39]. Support for a “landscaper” defect triggering juvenile polyposis came from a study in which disrupted BMP signalling, through expression of a natural pathway inhibitor, resulted in development a juvenile polyposis-like phenotype in mice[40]. BMP-4 expression is normally limited to the mesenchymal compartment of the murine intestine, suggesting that disruption of this mesenchymal signal is involved in mediating juvenile polyposis.

Notwithstanding the concept that faulty transmission or receipt of mesenchymal signals by the epithelium may trigger juvenile changes, others have found that homozygous SMAD4 deletions are limited to the epithelium of juvenile polyps from JPS patients with germline SMAD4 mutations and in Smad4 knockout mice[11,41]. Although further studies are needed, this suggests that SMAD4 may act as a “gatekeeper”, instead of a “landscaper” in JPS pathogenesis, consistent with the role of SMAD4 in other cancer types[42].


Management of JPS is mainly based on expert opinion[23,43-45]. Patients at risk or with a high suspicion of JPS should have endoscopic screening of the colon and upper gastrointestinal tract at age 15 or at the time of first symptoms[44]. At diagnosis of JPS, the entire gastrointestinal tract should be examined for the presence of polyps[23]. Genetic testing can be useful for at-risk members from families, where germline mutations have been identified. If no germline mutation is found in at-risk persons, then they do not have JPS and can be followed according to the guidelines for screening programs for the general population[44].

Endoscopic examination of the colon and upper gastrointestinal tract is recommended every two to three years in patients with JPS. In patients with polyps, endoscopic screening should be performed yearly, until the patient is deemed polyp-free. Patients with mild polyposis can be managed by frequent endoscopic examinations and polypectomy[23,36,44]. Intraoperative enteroscopy to evaluate small intestinal polyps can be considered at the time of colorectal surgery[16]. Endoscopic treatment of gastric polyps can be difficult, and patients with symptomatic gastric polyposis (e.g., severe anaemia) may need subtotal or total gastrectomy.

Prophylactic surgery is considered in patients with colorectal polyposis unmanageable by endoscopy (> 50-100 polyps), those with severe gastrointestinal bleeding or diarrhoea, juvenile polyps with dysplasia, and patients with a strong family history of colorectal cancer[35-37]. Surgical options include subtotal colectomy with ileorectal anastomosis, or total proctocolectomy with pouch[35,36]. Analogous to familial adenomatous polyposis, surgical type may depend on the extent of rectal polyposis. Recurrence of rectal polyps in patients with subtotal colectomy is frequent, and about half of these individuals require subsequent proctectomy[35,36]. Therefore, total proctocolectomy has been advocated as the initial surgery for patients with massive juvenile polyposis, who are unable to be managed endoscopically[36]. Although the surgery of choice in JPS remains debatable, patients need frequent post-operative endoscopic surveillance because of the high recurrence rates of polyps in the remnant rectum and the pouch[35].

In JPS patients with a germline SMAD4 mutation, screening should be considered for signs of hereditary hemorrhagic teleangiectasia, including chest radiography for arteriovenous malformations, magnetic resonance imaging of the brain, and liver sonography[31]. Digital clubbing and pulmonary osteoarthropathy are frequently described in combination with arteriovenous malformations[17].

COX-2 expression is higher in JPS polyps than in sporadic juvenile polyps and correlates with polyp size and dysplasia[46]. This observation suggests that chemoprevention using selective or non-selective COX-2 inhibitors could be beneficial in JPS. Currently, nonsteroidal anti-inflammatory drugs (NSAID) chemoprevention in JPS has not been systematically studied; however, two JPS patients who had undergone proctocolectomy with pouch reconstruction and subsequent polypectomy from the pouch had no further polyp development in the pouch while on sulindac[35]. However, the value of NSAID chemoprevention in JPS requires further investigation.


JPS is a rare hamartomatous polyposis syndrome characterized by the presence of multiple distinct juvenile polyps in the gastrointestinal tract. The primary defect in JPS may be stromal rather than epithelial. This so-called ‘landscaper’ defect may ultimately lead to neoplastic transformation in the overlying epithelium, although the polyps are not neoplastic per se. On the contrary, juvenile polyps may be considered true hamartomas, i.e., anomalies in the developmental patterning of the gut. Juvenile polyposis syndrome is, therefore, a unique model for studying carcinogenesis in the gastrointestinal tract.

Although rare, recognition of this condition is important in view of the consequences for patients and their families. Each clinician confronted with the diagnosis of a juvenile polyp should consider the possibility of juvenile polyposis syndrome. The number of juvenile polyps should be documented, along with the family history of gastrointestinal polyps and cancer. If a patient fulfils the clinical criteria of JPS, further diagnostic evaluation is indicated.

Future studies on the molecular and clinical aspects of JPS will result in a better understanding of gastrointestinal carcinogenesis and improved management of patients afflicted by this disorder.


Peer reviewer: Zoran V Krivokapic, Professor, First Surgical Clinic, Third Department, Clinical Center of Serbia, 6, Dr Koste Todorovica, Belgrade, 11000 Serbia, Republic of Ireland

S- Editor Wu X L- Editor Stewart GJ E- Editor Xiong L

1.  Giardiello FM, Hamilton SR, Kern SE, Offerhaus GJ, Green PA, Celano P, Krush AJ, Booker SV. Colorectal neoplasia in juvenile polyposis or juvenile polyps. Arch Dis Child. 1991;66:971-975.  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Nugent KP, Talbot IC, Hodgson SV, Phillips RK. Solitary juvenile polyps: not a marker for subsequent malignancy. Gastroenterology. 1993;105:698-700.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Jass JR, Williams CB, Bussey HJ, Morson BC. Juvenile polyposis--a precancerous condition. Histopathology. 1988;13:619-630.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  van Hattem WA, Brosens LA, de Leng WW, Morsink FH, Lens S, Carvalho R, Giardiello FM, Offerhaus GJ. Large genomic deletions of SMAD4, BMPR1A and PTEN in juvenile polyposis. Gut. 2008;57:623-627.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 104]  [Cited by in F6Publishing: 106]  [Article Influence: 6.9]  [Reference Citation Analysis (0)]
5.  Calva-Cerqueira D, Chinnathambi S, Pechman B, Bair J, Larsen-Haidle J, Howe JR. The rate of germline mutations and large deletions of SMAD4 and BMPR1A in juvenile polyposis. Clin Genet. 2009;75:79-85.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 72]  [Cited by in F6Publishing: 82]  [Article Influence: 4.8]  [Reference Citation Analysis (0)]
6.  Aretz S, Stienen D, Uhlhaas S, Stolte M, Entius MM, Loff S, Back W, Kaufmann A, Keller KM, Blaas SH. High proportion of large genomic deletions and a genotype phenotype update in 80 unrelated families with juvenile polyposis syndrome. J Med Genet. 2007;44:702-709.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 152]  [Cited by in F6Publishing: 164]  [Article Influence: 9.5]  [Reference Citation Analysis (0)]
7.  Diamond M. Adenoma of the rectum in childrenreport of a case in a thirty month old girl. Am J Dis Child. 1939;57:360-367.  [PubMed]  [DOI]  [Cited in This Article: ]
8.  HELWIG EB. Adenomas of the large intestine in children. Am J Dis Child. 1946;72:289-295.  [PubMed]  [DOI]  [Cited in This Article: ]
9.  Aaltonen LA, Jass JR, Howe JR. Juvenile Polyposis. Pathology and genetics of tumours of the digestive system. Lyon: IARC Press 2000; 130-132.  [PubMed]  [DOI]  [Cited in This Article: ]
10.  van Hattem WA, Langeveld D, de Leng WW, Morsink FH, van Diest PJ, Iacobuzio-Donahue CA, Giardiello FM, Offerhaus GJ, Brosens LA. Histological variations in juvenile polyp phenotype correlate with genetic defect underlying juvenile polyposis. Am J Surg Pathol. 2011;35:530-536.  [PubMed]  [DOI]  [Cited in This Article: ]
11.  Langeveld D, van Hattem WA, de Leng WW, Morsink FH, Ten Kate FJ, Giardiello FM, Offerhaus GJ, Brosens LA. SMAD4 immunohistochemistry reflects genetic status in juvenile polyposis syndrome. Clin Cancer Res. 2010;16:4126-4134.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 37]  [Cited by in F6Publishing: 42]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
12.  Woodford-Richens K, Bevan S, Churchman M, Dowling B, Jones D, Norbury CG, Hodgson SV, Desai D, Neale K, Phillips RK. Analysis of genetic and phenotypic heterogeneity in juvenile polyposis. Gut. 2000;46:656-660.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 93]  [Cited by in F6Publishing: 86]  [Article Influence: 4.0]  [Reference Citation Analysis (0)]
13.  Bentley E, Chandrasoma P, Radin R, Cohen H. Generalized juvenile polyposis with carcinoma. Am J Gastroenterol. 1989;84:1456-1459.  [PubMed]  [DOI]  [Cited in This Article: ]
14.  Järvinen HJ, Sipponen P. Gastroduodenal polyps in familial adenomatous and juvenile polyposis. Endoscopy. 1986;18:230-234.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 55]  [Cited by in F6Publishing: 56]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
15.  Sassatelli R, Bertoni G, Serra L, Bedogni G, Ponz de Leon M. Generalized juvenile polyposis with mixed pattern and gastric cancer. Gastroenterology. 1993;104:910-915.  [PubMed]  [DOI]  [Cited in This Article: ]
16.  Rodriguez-Bigas MA, Penetrante RB, Herrera L, Petrelli NJ. Intraoperative small bowel enteroscopy in familial adenomatous and familial juvenile polyposis. Gastrointest Endosc. 1995;42:560-564.  [PubMed]  [DOI]  [Cited in This Article: ]
17.  Cox KL, Frates RC, Wong A, Gandhi G. Hereditary generalized juvenile polyposis associated with pulmonary arteriovenous malformation. Gastroenterology. 1980;78:1566-1570.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Lam-Himlin D, Park JY, Cornish TC, Shi C, Montgomery E. Morphologic characterization of syndromic gastric polyps. Am J Surg Pathol. 2010;34:1656-1662.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 32]  [Cited by in F6Publishing: 36]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
19.  Calva-Cerqueira D, Dahdaleh FS, Woodfield G, Chinnathambi S, Nagy PL, Larsen-Haidle J, Weigel RJ, Howe JR. Discovery of the BMPR1A promoter and germline mutations that cause juvenile polyposis. Hum Mol Genet. 2010;19:4654-4662.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 26]  [Cited by in F6Publishing: 27]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
20.  Brosens LA, van Hattem WA, Kools MC, Ezendam C, Morsink FH, de Leng WW, Giardiello FM, Offerhaus GJ. No TGFBRII germline mutations in juvenile polyposis patients without SMAD4 or BMPR1A mutation. Gut. 2009;58:154-156.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 5]  [Article Influence: 0.2]  [Reference Citation Analysis (0)]
21.  Eng C, Ji H. Molecular classification of the inherited hamartoma polyposis syndromes: clearing the muddied waters. Am J Hum Genet. 1998;62:1020-1022.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 53]  [Cited by in F6Publishing: 60]  [Article Influence: 2.1]  [Reference Citation Analysis (0)]
22.  Heald B, Mester J, Rybicki L, Orloff MS, Burke CA, Eng C. Frequent gastrointestinal polyps and colorectal adenocarcinomas in a prospective series of PTEN mutation carriers. Gastroenterology. 2010;139:1927-1933.  [PubMed]  [DOI]  [Cited in This Article: ]
23.  Brosens LA, van Hattem WA, Jansen M, de Leng WW, Giardiello FM, Offerhaus GJ. Gastrointestinal polyposis syndromes. Curr Mol Med. 2007;7:29-46.  [PubMed]  [DOI]  [Cited in This Article: ]
24.  Delnatte C, Sanlaville D, Mougenot JF, Vermeesch JR, Houdayer C, Blois MC, Genevieve D, Goulet O, Fryns JP, Jaubert F. Contiguous gene deletion within chromosome arm 10q is associated with juvenile polyposis of infancy, reflecting cooperation between the BMPR1A and PTEN tumor-suppressor genes. Am J Hum Genet. 2006;78:1066-1074.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 97]  [Cited by in F6Publishing: 106]  [Article Influence: 5.7]  [Reference Citation Analysis (0)]
25.  Menko FH, Kneepkens CM, de Leeuw N, Peeters EA, Van Maldergem L, Kamsteeg EJ, Davidson R, Rozendaal L, Lasham CA, Peeters-Scholte CM. Variable phenotypes associated with 10q23 microdeletions involving the PTEN and BMPR1A genes. Clin Genet. 2008;74:145-154.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 42]  [Cited by in F6Publishing: 47]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
26.  Sachatello CR, Griffen WO. Hereditary polypoid diseases of the gastrointestinal tract: a working classification. Am J Surg. 1975;129:198-203.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 51]  [Cited by in F6Publishing: 50]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
27.  Stemper TJ, Kent TH, Summers RW. Juvenile polyposis and gastrointestinal carcinoma. A study of a kindred. Ann Intern Med. 1975;83:639-646.  [PubMed]  [DOI]  [Cited in This Article: ]
28.  Howe JR, Mitros FA, Summers RW. The risk of gastrointestinal carcinoma in familial juvenile polyposis. Ann Surg Oncol. 1998;5:751-756.  [PubMed]  [DOI]  [Cited in This Article: ]
29.  Handra-Luca A, Condroyer C, de Moncuit C, Tepper M, Fléjou JF, Thomas G, Olschwang S. Vessels' morphology in SMAD4 and BMPR1A-related juvenile polyposis. Am J Med Genet A. 2005;138A:113-117.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 38]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
30.  Friedl W, Uhlhaas S, Schulmann K, Stolte M, Loff S, Back W, Mangold E, Stern M, Knaebel HP, Sutter C. Juvenile polyposis: massive gastric polyposis is more common in MADH4 mutation carriers than in BMPR1A mutation carriers. Hum Genet. 2002;111:108-111.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 119]  [Cited by in F6Publishing: 98]  [Article Influence: 5.7]  [Reference Citation Analysis (0)]
31.  Gallione CJ, Repetto GM, Legius E, Rustgi AK, Schelley SL, Tejpar S, Mitchell G, Drouin E, Westermann CJ, Marchuk DA. A combined syndrome of juvenile polyposis and hereditary haemorrhagic telangiectasia associated with mutations in MADH4 (SMAD4). Lancet. 2004;363:852-859.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 491]  [Cited by in F6Publishing: 536]  [Article Influence: 25.8]  [Reference Citation Analysis (0)]
32.  Watanabe A, Nagashima H, Motoi M, Ogawa K. Familial juvenile polyposis of the stomach. Gastroenterology. 1979;77:148-151.  [PubMed]  [DOI]  [Cited in This Article: ]
33.  Postgate AJ, Will OC, Fraser CH, Fitzpatrick A, Phillips RK, Clark SK. Capsule endoscopy for the small bowel in juvenile polyposis syndrome: a case series. Endoscopy. 2009;41:1001-1004.  [PubMed]  [DOI]  [Cited in This Article: ]
34.  Sachatello CR, Pickren JW, Grace JT. Generalized juvenile gastrointestinal polyposis. A hereditary syndrome. Gastroenterology. 1970;58:699-708.  [PubMed]  [DOI]  [Cited in This Article: ]
35.  Oncel M, Church JM, Remzi FH, Fazio VW. Colonic surgery in patients with juvenile polyposis syndrome: a case series. Dis Colon Rectum. 2005;48:49-55; discussion 55-6.  [PubMed]  [DOI]  [Cited in This Article: ]
36.  Scott-Conner CE, Hausmann M, Hall TJ, Skelton DS, Anglin BL, Subramony C. Familial juvenile polyposis: patterns of recurrence and implications for surgical management. J Am Coll Surg. 1995;181:407-413.  [PubMed]  [DOI]  [Cited in This Article: ]
37.  Brosens LA, van Hattem A, Hylind LM, Iacobuzio-Donahue C, Romans KE, Axilbund J, Cruz-Correa M, Tersmette AC, Offerhaus GJ, Giardiello FM. Risk of colorectal cancer in juvenile polyposis. Gut. 2007;56:965-967.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 168]  [Cited by in F6Publishing: 164]  [Article Influence: 10.5]  [Reference Citation Analysis (0)]
38.  Jass J. Pathology of polyposis syndromes with special reference to juvenile polyposis. Hereditary colorectal cancer. Tokyo: Springer-Verlag 1990; 343-350.  [PubMed]  [DOI]  [Cited in This Article: ]
39.  Kinzler KW, Vogelstein B. Landscaping the cancer terrain. Science. 1998;280:1036-1037.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 325]  [Cited by in F6Publishing: 347]  [Article Influence: 13.0]  [Reference Citation Analysis (0)]
40.  Haramis AP, Begthel H, van den Born M, van Es J, Jonkheer S, Offerhaus GJ, Clevers H. De novo crypt formation and juvenile polyposis on BMP inhibition in mouse intestine. Science. 2004;303:1684-1686.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 563]  [Cited by in F6Publishing: 583]  [Article Influence: 29.6]  [Reference Citation Analysis (0)]
41.  Woodford-Richens K, Williamson J, Bevan S, Young J, Leggett B, Frayling I, Thway Y, Hodgson S, Kim JC, Iwama T. Allelic loss at SMAD4 in polyps from juvenile polyposis patients and use of fluorescence in situ hybridization to demonstrate clonal origin of the epithelium. Cancer Res. 2000;60:2477-2482.  [PubMed]  [DOI]  [Cited in This Article: ]
42.  Schutte M, Hruban RH, Hedrick L, Cho KR, Nadasdy GM, Weinstein CL, Bova GS, Isaacs WB, Cairns P, Nawroz H. DPC4 gene in various tumor types. Cancer Res. 1996;56:2527-2530.  [PubMed]  [DOI]  [Cited in This Article: ]
43.  Dunlop MG. Guidance on gastrointestinal surveillance for hereditary non-polyposis colorectal cancer, familial adenomatous polypolis, juvenile polyposis, and Peutz-Jeghers syndrome. Gut. 2002;51 Suppl 5:V21-V27.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 154]  [Cited by in F6Publishing: 151]  [Article Influence: 7.3]  [Reference Citation Analysis (0)]
44.  Howe JR, Ringold JC, Hughes JH, Summers RW. Direct genetic testing for Smad4 mutations in patients at risk for juvenile polyposis. Surgery. 1999;126:162-170.  [PubMed]  [DOI]  [Cited in This Article: ]
45.  Larsen Haidle J, Howe JR. Juvenile Polyposis Syndrome. Editors. GeneReviews. Seattle (WA): University of Washington, Seattle 1993; .  [PubMed]  [DOI]  [Cited in This Article: ]
46.  van Hattem WA, Brosens LA, Marks SY, Milne AN, van Eeden S, Iacobuzio-Donahue CA, Ristimäki A, Giardiello FM, Offerhaus GJ. Increased cyclooxygenase-2 expression in juvenile polyposis syndrome. Clin Gastroenterol Hepatol. 2009;7:93-97.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 11]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]