Personal View

Gardners syndrome (familial adenomatous polyposis):

a cilia-related disorder
Encarna B Gmez Garca, Nine V A M Knoers

Familial adenomatous polyposis (FAP) is an autosomal dominant form of intestinal polyposis and colorectal cancer
caused by germ-line mutations in the adenomatous polyposis coli (APC) gene. The term Gardners syndrome is used
to describe extracolonic manifestations, such as osteomas, skin cysts, congenital hypertrophy of the retinal pigmented
epithelium (CHRPE), and desmoid tumours (aggressive bromatosis), that are especially prominent in families with
FAP. We postulate that a ciliary dysfunction is the underlying pathogenetic mechanism of extraintestinal manifestations
in patients with FAP. This postulation is based on the presence of common clinical manifestations (ie, cysts, retinal
abnormalities, and brosis) in Gardners syndrome and cilia-related disorders. Additionally, both APC and the cilia
have degradation of -catenin as the common downstream target in the Wnt-signalling pathway. Mutations in APC
causing Gardners syndrome are clustered in a region encoding a series of amino-acid repeats responsible for the
binding to -catenin. Proofs of principle that -catenin could be the key mediator of the ciliary disorder also rely in the
ndings that overexpression of -catenin induces polycystic kidney disease, and CHRPE phenotypes in animal
models. Other candidates for the common link between Gardners syndrome and cilia-related disorders are the
APC-binding proteins: end-binding protein 1 (EB1) and kinesin-family-member 3a (KIF3a), both of which are ciliary
proteins involved in intraagellar transport. Finally, pathogenetic similarities between some ciliopathies and
extraintestinal tumours in FAP suggest a cilia defect. Understanding extracolonic manifestations in the context of
FAP as a ciliary disorder might add new therapeutic options for patients with Gardners syndrome.

In 1951, Eldon Gardner reported a disease in a family

from Utah (USA), characterised by diuse intestinal
polyposis, osteomas, bromas, and epidermal or
sebaceous cysts, which seemed to have an autosomal
dominant pattern of inheritance.1 The study of that
family was initiated in 1948 when a premedical student
in a genetics class called attention to a neighbour
family in his home town that seemed to have an
unusually high incidence of cancer, including several
deaths as a result of cancer of the lower digestive tract.
The family members were visited and found to be
interested in having a study made, and they were
cooperative in clinical investigations.1
Cloning of the adenomatous polyposis coli (APC) gene
in 19912 was followed by identication of mutations in
this gene in families described as having either familial
adenomatous polyposis (FAP) or Gardners syndrome.3,4
Therefore, Gardners syndrome has been deemed a
variant of FAP (OMIM:#175100), rather than a distinct
subtype of the disease, and is the term used to describe
the clinical manifestations of patients with FAP in whom
the extraintestinal features, such as osteomas, skin
tumours, and soft-tissue tumours, are especially
prominent. However, close investigation has shown that
most patients with FAP have at least subtle Gardners
manifestations.4 A review of FAP is beyond the scope of
this paper, but several excellent comprehensive reviews
are available in the published work.3,4
In this Personal View, we discuss aspects of FAP, such
as extracolonic manifestations, relevant to our postulation
that the tissues involved in Gardners syndrome have a
disorder aecting the primary cilia present in their
normal cellular counterparts (gure 1).5
www.thelancet.com/oncology Vol 10 July 2009

Department of Genetics and

Cell Biology, University Medical
Centre, and Research Institute
for Growth and Development
(GROW), Maastricht,
Netherlands
(E B Gmez Garca MD);
Department of Human
Genetics, Radboud University
Nijmegen Medical Centre,
Nijmegen, Netherlands
(Prof N V A M Knoers MD)
Correspondence to:
Dr Encarna B Gmez Garca,
Department of Clinical Genetics,
University Hospital Maastricht,
P O Box 5800,
6202 AZ Maastricht, Netherlands
Encarna.Gomezgarcia@gen.
unimaas.nl

At least 1015% of patients with FAP develop desmoid

tumours. Most of them are located in the abdominal wall
and intra-abdominally, and constitute the second most
important cause of mortality in patients with FAP
(gure 2).6,7 Current treatment options for desmoid
tumours include: non-steroidal anti-inammatory drugs
or antioestrogens, chemotherapy, surgery, or radiotherapy.
However, evidence for their ecacy is poor, partly because
it comes from small, non-controlled studies.4,10
Osteomas are usually asymptomatic and are typically
localised in the mandible, but can also appear in the skull
and long bones. Dental abnormalities, such as
supernumerary and impacted teeth, are also a common
feature (gure 2).8 Skin tumours include: epidermal
cysts, lipomas, leiomyomas, and bromas.

Elsevier Ltd

Introduction

Lancet Oncol 2009; 10: 72735

Figure 1: Immunouorescence microscopy of primary cilia in NIH3T3

broblast cells
Primary cilia were stained by use of an antibody against the cilia-specic -tubulin
isoform (red rods). Nuclei were stained by use of 4,6-diamidino-2-phenylindole
(DAPI; blue). The EB1 protein was stained by immunouorescence using an
antibody against EB1 (green). Reproduced with permission from reference 5.

727

Personal View

percentage of the general population. Therefore,

nowadays, the value of CHRPE is restricted to the
identication of aected relatives from families with FAP
and CHRPE manifestations.11

Cilia-related disorders

(A) Macmillan Publishers Ltd; (B) Lippincott Williams & Wilkins; (C) American Medical Association

Figure 2: Manifestations of Gardners syndrome

(A) Dental panoramic tomogram showing several well-dened opacities around
the periphery of the mandible corresponding to osteomas. Reproduced with
permission from reference 8. (B) Fundus showing many typical pigmented
patches of congenital hypertrophy of the retinal pigmented epithelium in a
patient with familial adenomatous polyposis. Reproduced with permission from
reference 9. (C) CT-scan showing a large (2315 cm) intra-abdominal desmoid
tumour that extends into the liver and abdominal wall. Reproduced with
permission from reference 7.

Although not initially described by Gardner, congenital

hypertrophy of the retinal pigmented epithelium
(CHRPE) is a common manifestation of FAP,3,4 and its
diagnosis by bilateral lens fundoscopic examination10 was
important in the era before DNA diagnosis (gure 2).
However, when the identication of APC mutations
became possible, CHRPE was also detected in a small
728

Cilia are hair-like cellular organelles that have motility

and sensory functions. Motile cilia are important for
moving uids and particles over epithelial cells and for
motility of sperm. Primary cilia are single non-motile
organelles found in nearly all cell types in mammals.12,13
Cilia are unique antenna-like structures, which probe
the extracellular environment for molecules recognised
by their receptors. This sensory function allows
cilia to mediate many cell-signalling pathways that
regulate growth, survival, and dierentiation of cells
during embryonic development and cell homeostasis.
Known signalling pathways mediated by ciliary activity
are the Wnt-signalling pathway, sonic-hedgehog
(Shh)-signalling pathways, and platelet-derived growthfactor receptor (PDGFR) signalling pathway. Because
protein synthesis cannot occur in cilia, all structural
and signalling components have to be actively
transported into the cilium by intraagellar transport
proteins. Intraagellar transport is bidirectional, allows
transport of axonemal components, and is part of the
sensory activity of the cilia.1214
In view of the many roles of cilia in development and
physiology, it is not surprising that defects in cilia have
been noted to be associated with a wide range of human
diseases, such as cystic kidney disease, retinal degeneration,
liver brosis, and brain malformations. Evidence suggests
that ciliary defects can lead to a broader set of developmental
and adult phenotypes, collectively called ciliopathies.
A detailed overview of known ciliopathies is provided in
the table, showing the wide range and partial overlap of
disease manifestations caused by defects in ciliary structure
or function. In general, pathogenic overlap of disease
manifestations results from homologous genes that have
similar functions or proteins that are part of the same
pathway. Indeed, several ciliary proteins shown to be
involved in nephronophthisis, Joubert syndrome,
Senior-Lken syndrome, and Meckel syndrome all interact
at the molecular level.1216
To explain how certain mutations in APC can cause a
ciliary disorder, we did a search of the published work for
common links between APC and the ciliary pathways
and for relevant genotypephenotype associations in
FAP. We summarise the ndings of both searches, the
dierent lines of evidence that support our postulation,
and the molecular candidates that link both pathways.

Signalling pathways shared by APC and cilia

Wnt pathways
Cilia act as a switch between the canonical Wnt pathway
and non-canonical (also known as planar-cell polarity
[PCP]) Wnt pathway (gure 3). In early development,
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Personal View

Primary ciliary
dyskinesia (PCD)

Primary clinical features

Gene(s) and protein(s)

Sinusitis, bronchiectasis, infertilty,

hydrocephalus, situs inversus

DNAH5, axonemal dynein Ciliary motility

DNAI1, axonemal dynein Ciliary motility

Kidney, liver, and pancreatic cysts,

Autosomal
dominant polycystic intracranial aneurysms
kidney disease
(ADPKD)
Autosomal recessive
polcystic kidney
disease (ARPKD)

Kidney cysts, liver brosis

Putative cellular function

Cellular localisation
Motile cilia
Motile cilia
Primary cilia, basal bodies, focal
adhesions, desmosomes

PKD2, polycystin-2

Cell-cell or cell-matrix interactions; mechanosensation;

interacts with polycystin 2 to produce non-selective cation
channel permeable to Ca2+
Probable channel protein; interacts with polycystin 1

PKHD1, brocystin/
polyductin

Putative receptor protein acting in collecting duct and

biliary dierentiation; interacts with polycystin 2

Primary cilia, basal bodies

PKD1, polycystin-1

Primary cilia, basal bodies, focal

adhesions, endoplasmic reticulum

Nephronophthisis (NPHP)/Senior Lken syndrome (SLS)

Juvenile, type 1

Kidney cysts, retinal degeneration

(10%), liver brosis, oculomotor
apraxia, cerebral vermis aplasia

NPHP1, nephrocystin

Adaptor protein; associates with signalling molecules in cell

adhesion and actin cytoskeletal organisation and with
-tubulin (main component of primary cilia)

Primary cilia, basal bodies,

centrosomes, focal adhesions,
adherens junctions

Infantile, type 2

Kidney cysts, retinal degeneration

(10%), situs Iiversus, liver brosis

NHP2, inversin

Primary cilia function and involved in cell-cycle; controlling

balance between dierent canonical and non-canonical
Wnt-signaling cascades; left-right axis determination

Primary cilia, basal bodies,

centrosomes, cell-cell junctions,
nucleus

NPHP3, nephrocystin-3

Might mediate, with nephrocystin and nephroretinin, a

common developmental pathway in primary cilia of
epithelial kidney cells; involved in Wnt-signalling cascades

Cilia, basal bodies, centrosomes, retinal

connecting cilium

Adolescent, type 3 Kidney cysts, retinal degeneration

(10%), liver brosis
Juvenile, type 4

Kidney cysts, retinal degeneration

NPHP4, nephroretinin
(10%), oculomotor apraxia, liver brosis

Cell-cell and cell-matrix adhesion signalling; cell division

Primary cilia, basal bodies,

centrosomes, adherens junctions

Senior Lken
syndrome

Kidney cysts, retinal degeneration with NPHP5/ICQB1,

early onset (100%)
nephrocystin-5
NPHP6/CEP290,
nephrocystin-6

Unknown, interacts with retinitis pigmentosa GTPase

regulator
Regulates intracellular protein tracking; role in cell
division?

Primary cilia, basal bodies,

centrosomes, retinal-connecting cilium
Primary cilia, centrosomes, nucleus,
retinal connecting cilium

Nephronophthisis

Kidney cysts

Transcription factor, important in sonic-hedgehog (Shh)

signalling and maintenance of renal tissue architecture
Cell-cycle regulation?

Primary cilia

Regulates intracellular protein tracking; role in cell

division?
Adaptor protein; associates with signalling molecules
involved in cell adhesion and actin cytoskeletal organisation,
and with -tubulin (a major component of primary cilia)
Signalling molecule?

Primary cilia, centrosomes, nucleus,

retinal-connecting cilium
Primary cilia, basal bodies,
centrosomes, cell-cell junctions

NPHP7/GLIS2, GLIS2
NPHP9, NEK8

Joubert syndrome
and Joubert-related
disorders
(cerebello-ocular
renal syndromes
[CORS])

Kidney cysts (nephronophthisis),

retinal degeneration (100%),
cerebellar vermis dysplasia

NPHP6/CEP290,
nephrocystin-6
NPHP1, nephrocystin

AHI1, Jouberin
NPHP8/RPGRIP1L,
RPGRIP1L

Component of cilium-related Shh-signalling; necessary for

establishment of left-right asymmetry and patterning of
neural tubes and limbs
MKS3/TMEM67, Meckelin Ciliogenesis
MeckelGruber
syndrome (MKS)
and Meckel-like
cerebro-reno-digital
syndromes

Kidney and liver cysts, polydactyly

CNS malformations, hydrocephalus

Bardet-Biedl
syndrome (BBS)

Central obesity, polydactyly,

BBS1-BBS12, BBS1-BBS12
progressive retinal degeneration,
hypogenitalism, obesity, renal
anomalies, learning disabilities/mental NPHP6/CEP290,
retardation
nephrocystin-6

MKS1, MKS1
MKS3/TMEM67, Meckelin
NPHP6/CEP290,
nephrocystin 6
NPHP8/RPGRIP1L,
RPGRIP1L

Primary cilia, basal bodies

Primary cilia, basal bodies, cell-cell

junctions
Cilia, basal bodies. Retinal-connecting
cilium
Ciliary membrane

Ciliogenesis
Ciliogenesis
Regulates intracellular protein tracking; role in cell
division?
Component of cilium-related Shh-signalling; necessary for
establishment of left-right asymmetry and patterning of
neural tubes and limbs

Basal bodies, centrosomes

Ciliary membrane
Primary cilia, centrosomes, nucleus,
retinal connecting cilium
Cilia, basal bodies, retinal-connecting
cilium

Involved in intraagellar transport; involved in

non-canonical Wnt-signalling pathway; possible role in
Shh-signalling pathway; chaperonin (BBS6, 10, 12)
Regulates intracellular protein tracking; role in cell
division?

Primary cilia (intraagellar transport

complexes), basal bodies,
retinal-connecting cilium
Primary cilia, centrosomes, nucleus

McKusick-Kaufmann Hydrometrocolpos, polydactyly,

syndrome
congenital heart malformations,
kidney cysts

BBS6, BBS6

Involved in non-canonical Wnt- signalling pathway;

chaperonin

Primary cilia, basal bodies

Alstrm syndrome
(ALMS)

Kidney cysts, retinal degeneration,

sensorineural deafness, diabetes
mellitus, mental retardation,
hypogenitalism, infertility, obesity

ALMS1, ALMS1

Ciliogenesis; mechanosensation

Centrosome, basal bodies

Jeune syndrome

Chondrodysplasia, constricted thoracic IFT80, IFT80

cage, respiratory insuciency, retinal
degeneration, Kidney cysts,
polydactyly

Intraagellar transport; essential for development and

maintenance of cilia

Basal bodies, centrosomes

(Continues on next page)

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Personal View

Primary clinical features

Gene(s) and protein(s)

Putative cellular function

Cellular localisation

NPHP6/CEP290,
nephrocystin-6
LCA5, Lebercilin

Regulates intracellular protein tracking; role in cell

division?
Unknown

Primary cilia, centrosomes, nucleus

OFD1, OFD1

Implicated in intraagellar transport

Basal bodies, centrosome

Initiation of ciliogenesis; maintenance of cilia?

Primary cilia

(Continued from previous page)

Leber congenital
amaurosis (LCA)

Retinal degeneration

Oro-facio-digital
syndrome (OFD)

Kidney cysts, mental retardation,

polydactyly, malformations in oral
cavity and face

Von Hippel-Lindau
(vHL) disease

Hemangioblastomas, CNS and retina, VHL, pVHL

kidney carcinoma, pheochromocytoma

Microtubules, centrioles, primary cilia,

retinal-connecting cilium

GLIS2=GLI similar protein 2. RPGRIP1L=retinitis pigmentosa GTPase regulator interacting protein 1-like. IFT80=Intraagellar transport protein 80.

Table: A summary of human hereditary ciliopathies

only the canonical pathway is needed, but later on during

embryogenesis, PCP is also needed to align the mitotic
orientation of proliferating cells.12
In the absence of extracellular uid ow, canonical Wnt
signalling predominates, which inhibits glycogen
synthase kinase-3- (GSK3) from activating the
-catenin degradation complex.1214 In the presence of
ow, intracellular release of calcium induces increased
expression of inversin, which in turn switches the
canonical Wnt-signalling to non-canonical Wntsignalling, favouring -catenin degradation by axin, APC
and GSK3 (the -catenin degradation complex).
Therefore, in normal conditions, both APC and cilia
restrain the canonical Wnt signalling pathway. However,
in cells with a mutated APC, the APC protein is not able
to down-regulate -catenin levels,17 and in cells with
dysrupted ciliogenesis, the absence of cilia results in
predominant canonical Wnt-signalling.18 Both situations
result in an accumulation of -catenin in the nucleus
and, therefore, overactivation of the Wnt transcriptional
activities. In polycystic kidney disease, the most common
cilia-related disease, defects in the PCP pathway are the
underlying cause of dysregulation of the growth of
epithelial kidney cells, leading to renal cysts.18 However,
abnormalities in the Wnt-signalling pathways can also
aect ciliary function, and transgenic mice overexpressing
-catenin can develop polycystic kidney disease.19,20

PDGFR pathway
PDGFR- is a tyrosine-kinase receptor located within the
ciliary membrane. In normal broblasts and in the
HT1080 brosarcoma cell line, the binding of its ligand,
PDGF, which is present in the extracellular ow, induces
downstream cellular responses via signalling pathways,
such as the MEK/ERK cascade (gure 4). These pathways
lead to cell growth, cytoskeletal changes, and cell
migration and dierentiation.13,21,22 In the PDGFR
signalling pathway, -catenin forms a complex with
PDGFR leading to cell migration.21 A connection between
the cilia and FAP is shown in a study by Signoroni and
colleagues,23 in which PDGFR activation in desmoid
tumours was noted.
730

Sonic-hedgehog (Shh) pathway

The Shh signalling pathway (gure 4) has an important
role in the embryonic development of the neural tube and
limbs.12 Primary cilia play a crucial part in mediating Shh
signalling. The transcription of Shh target genes is regulated
by the ratio of Gli (glioma) activators and repressors. In
mutant cells with aberrant or absent cilia, the the ratio of
Gli activators to repressors is changed, which can lead to
both gain-of-function and loss-of-function phenotypes.12
Mutations in SUFU, a ciliary protein that localises to
the distal tip of the primary cilia, have been shown to predispose to sporadic medulloblastoma.22 The link between
APC and cilia in the Shh pathway relies on kinesinfamily-member 3a (KIF3a), which belongs to the kinesin
super-family of microtubule transporting proteins.1214
This protein is one of four proteins that are essential for
cilia formation in Shh-dependent cells. APC and -catenin
are transported by KIF3a along the microtubules, and
accumulate in the tips of the cilia, suggesting that this
might be important for the function of APC in regulating
cell migration.24,25

APC, genotype, and phenotype correlations

The human APC gene is a tumour-suppressor gene that
consists of 8532 base pairs spanning over 15 exons; there
are also other minor isoforms that contain 21 exons.2 The
APC gene encodes a multifunctional protein, with the
most common isoform consisting of 2843-amino acids.3
APC down-regulates -catenin and is also involved in
several other fundamental cellular processes including:
adhesion, migration, organisation of the actin and microtubule networks, spindle formation, chromosome
segregation, and apoptosis.17 Two functionally distinct intracellular localisations of APC have been reported.26 One
pool is localised at the basal membrane in association with
microtubules and participates in microtubule-associated
functions. The second pool is recruited by axin and forms
the -catenin destruction complex. This APC is sequestered
in cytoplasmic punctuate structures known as axin puncta,
which prevent its microtubule-associated functions.
As shown in gure 5, APC has many domains by which
it interacts with dierent proteins, including the Wnt
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Personal View

components (-catenin, axin, and KIF3a) and the cytoskeletal regulator end-binding protein 1 (EB1), and with
microtubules.17,25 APC binds -catenin by a series of
15 and 20 amino-acid repeats. Three 15-amino-acid
repeats bind to -catenin, but do not down-regulate it.
Each of the seven 20 amino-acid repeats bind to -catenin,
but only the second one is essential for such binding.27
However, although the binding of -catenin to APC
fragments needs only a single 20 amino-acid repeat, the
presence of at least three of these repeat sequences is
needed for its downregulation. The binding domain
of APC for axin lies interspersed between these
amino-acid repeats.3 APC binds KIF3a along the entire
Armadillo repeat domain.17
APC mutations (somatic and germ-line) are mostly
located at exon 15, which is 75% of the coding sequence,
and about 60% of the these mutations are clustered in a
small region, the mutated cluster region. 95% are point
mutations (small deletions or insertions and nonsense
mutations) resulting in a truncated protein.3 The ndings
of several reports3,6,2835 aimed at the identication of
associations between the location of the mutation and
the manifestations characteristic of Gardners syndrome
are summarised in gure 5.
Miyaki and co-workers33 have shown that the number
of 20-amino-acid repeats that are conserved after two-hit
APC mutations are constant. Classic FAP has one repeat
whereas attenuated FAP has two or three. Additionally,
they showed that the number of repeats also correlated
with the risk of developing desmoid tumoursie, most
of the mutations causing desmoid tumours conserve at
least two of the seven 20-amino-acid repeats that bind
-catenin.27,33 Therefore, the number of -catenin repeats
is not only crucial for determining whether -catenin can
be downregulated, but is also dierent in the pathogenesis
of desmoid tumours compared with the pathogenesis of
colon polyps. In line with this nding, an earlier reported
variant of FAP, hereditary desmoid disease,36 which is
characterised by the presence of multifocal bromatosis,
osteomas, and epidermoid cysts, but no colon polyps, is
caused by a germline truncation mutation at codon 1914,
containing three of the seven 20-amino-acid repeats.
Colon polyps also dier from desmoid tumours in their
somatic mutations. Somatic mutations in patients with
FAP occur non-randomly, and the position of the
germline mutation is a major determinant of the somatic
mutation.34 Loss of heterozygosity in desmoid tumours is
caused by deletion of the second APC allele, therefore
leaving no intact repeats in that allele, whereas in colon
polyps it is caused by somatic recombination, which
leaves an equal number of repeats.33,34
The products of C-terminal truncated APC, resulting
from mutations causing Gardners manifestations, have
in common the loss of several amino-acid repeats
involved in the binding and downregulation of -catenin.
By use of correspondence analysis to identify associations
between the dierent manifestations of FAP, Bertario
www.thelancet.com/oncology Vol 10 July 2009

Ciliary membrane
Polycystin
IFT

NO FLOW
Canonical Wnt signalling
IFT
Axoneme
Apical plasma membrane

WNT
Frizzled
Basal
body

-cat
DSH

Nucleus

Gsk3

Centrosome

Gene X

Ca2+

FLOW
Non-canonical Wnt signalling

Ca2+
Frizzled

Ca2+

Inversin

Gardners syndrome:
overexpression of -catenin

Basal
body

DSH
Centrosome

Degraded -cat

-cat

-cat
Axin
Gsk3

Nucleus
Axin

-cat

APC

Gene X

Mutated
Gsk3 APC

Figure 3: Schematic representation of the Wnt-signalling pathway shared by APC and cilia
(A) Canonical Wnt signallingin absence of extracellular uid ow, only the canonical Wnt pathway is active. The
result is stabilisation of cytoplasmic -catenin, which translocates to the nucleus and acts as a transcriptional
coactivator. (B) Non-canonical (PCP) Wnt-signallingpresence of uid ow switches the canonical Wnt-signalling
to non-canonical Wnt-signalling, favouring -catenin degradation. Mutated APC causes loss of -catenin binding
and loss of -catenin downregulation, resulting in predominant canonical Wnt signalling. DSH=Disheveled.

and colleagues30 identied a signicant association

between mutations found beyond codon 1256 and the
occurrence of epidermoid cysts, desmoid tumours,
osteomas, and dental abnormalities.

Discussion
The molecular basis responsible for the dierent
extracolonic manifestations of FAP, resulting from
mutations in specic regions in the APC gene, has
remained elusive until now. Some postulations suggest
that the tumour-suppressor activity of APC varies
according to several factors, such as the target tissue,
the mutation site, or the length of the APC transcripts.
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Personal View

FAP and cilia disorders share phenotypic features

Ciliary membrane

EB1
SUFU
GLI A
GLI R

PDGFR

KIF3a

No Shh signalling

No PDGF signalling

Apical plasma membrane

Patched
SMO

Basal
body

GLI R

Nucleus

Centrosome

Gene X
Transcription OFF

Ciliary membrane
PDGF

PDGF signalling

SMO

Shh signalling

Shh

Apical plasma membrane

Patched
SMO

Basal
body

GLI A

MEK/ERK
Centrosome
Nucleus

Gene X

Transcription ON

Figure 4: Schematic representation of the sonic-hedgehog (Shh) and platelet-derived growth-factor receptor
(PDGFR)-signalling pathways shared by APC and cilia
(A) No signalling. (B) Signalling. Binding of Shh turns o Gli-repressive (GLI R) processing and the active form of Gli
(GLI A) activates transcription of target genes. The PDGFR-pathway is initiated with PDGF binding and induces
downstream signalling via the MEK/ERK pathways. Abnormal ciliary function in Gardners syndrome might also
rely on disrupted binding of end-binding protein 1 (EB1) or KIF3a and defective transport of APC.
SMO=Smoothened. SUFU=Suppressor of fused Drosophila homolog.

Other investigators have suggested that the

heterogeneity of clinical manifestations might be
explained by factors other than the APC gene, such as
environmental factors or independent genetic
factors.6,37
We postulate that Gardners syndrome, as it is called
the variant of FAP with prominent extracolonic
manifestations, is a cilia-related disorder. This postulation
is based on dierent lines of evidence, which will now be
discussed.
732

As shown in the table, the most frequent disease

manifestations in ciliopathies are: (renal) cysts, retinal
abnormalities, brain abnormalities, and (liver) brosis.
Cysts (skin), brosis (desmoid tumours), and retinal
abnormalities (CHRPE) are also present in Gardners
syndrome.
Defects in proteins of the photoreceptors have been
identied as the cause of the retinal degeneration present
in congenital Leber amaurosis syndrome, Senior Lken
syndrome, Bardet-Biedl syndrome, and Alstrm syndrome.13 Although CHRPE has always been believed to be a
benign disorder, evidence from studies using modern
opthalmological techniques to visualise the retina,
suggests that patients with CHRPE have retinal thinning
and photoreceptor loss.38 Therefore, as in other
ciliopathies, evidence exists for retinal degeneration.
The presence of cysts in the kidneys is not only a
feature of polycystic kidney disease, but also a feature
of most of the currently known ciliopathies. However,
cysts in the kidneys have not been described in patients
with FAP, and the same is true of epidermoid cysts in
the ciliopathies. Although localisation of the cysts might
be due to the tissue specicity of the mutant protein
involved, there is proof that either a mutated APC or
the overexpression of -catenin can induce a polycystic
renal disease phenotype in transgenic mice.19,20 Both
studies show that dysregulation of the canonical Wnt
signalling pathway can also lead to polycystic kidney
disease and can predispose to the development of renal
neoplasia.
Fibrosis of the liver is a feature of some ciliopathies,
such as autosomal recessive polycystic kidney disease
and nephronophthisis, whereas aggressive bromatosis
is a feature of both FAP-associated and sporadic (caused
by somatic mutations in -catenin) desmoid tumours.
In both of these tumour types, upregulation of
cyclooxygenase-2 (COX2) leads to a sustained autocrine
or paracrine activation of PDGFR.23 Therefore, Signoroni
and colleagues23 have proposed the use of tyrosine-kinase
inhibitors (eg, imatinib and sunitinib), in addition to
COX2 inhibitors, to block the PDGFR family for the
treatment of these tumours.
However, the question remains as to why activation of
PDGFR in desmoid tumours does not result in cell
migration and dierentiation, as opposed to what
happens in healthy broblasts.13,21,22 We postulate that the
answer to this question might be related to dierent
ligands or method of activation in normal broblasts
versus desmoid tumour cells.
Although osteomas have not been previously included
within the list of abnormalities noted in ciliopathies, it
has been shown that osteoblast dierentiation and bone
formation require that both intraagellar transport and
canonical Wnt-signaling are intact, because loss of
-catenin results in defective dierentiation of the bone
collar.39
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Personal View

-catenin binding sites

MCR (11941392)

Axin binding sites

Oligomerisation
domain

-catenin binding and down-regulating domains

Armadillo
region

15 AA repeats
6 57

453

767

Human Disc Large (HDLG)

binding site

20 AA repeats

Basic domain

1020 1170 1265

2035

2200

2400

EB1 binding site

2559

2771

2843
APC protein
wild type

200

400

600
453

800
767

1000

1200

1400

1600

1800

2000

2200

2400

2600

2800

1020 1170 1265

CHRPE (4531444)

Desmoid tumours (13102011)

Oxford University Press

Osteomas (4571513)

Dental abnormalities (4571560)

1256

Figure 5: Localisation of mutations associated with Gardners features in the APC protein
Wild-type APC protein with functional domains is shown at the top. The encompassing codon numbers are indicated between brackets. MCR=mutation cluster region. Truncated translated regions of
the protein corresponding to the dierent FAP phenotypes are shown beneath. The mutation associated regions are marked in black. The translated domains inside each region are shown in colour,
and those outside the mutation associated regions are shown in grey. CHRPE=congenital hypertrophy of the retinal pigmented epithelium. Reproduced with permission from reference 3.

APC and cilia have -catenin as a common target

Several lines of evidence point at -catenin as the
common link between Gardners syndrome and
ciliopathies. Both APC and the cilia cellular pathways
have -catenin as a common downstream link in the Wnt
signalling pathway.3,4,1214 -catenin, together with the cilia,
is also implicated in the PDGFR signalling pathway,
which modulates changes in the cytoskeleton and
regulates cell migration.20 The fact that -catenin is the
key mediator of Gardners manifestations is also
supported by experiments in Drosophila with inactivated
APC.40 Inactivation of APC resulted in overexpression of
the -catenin homologue and a phenotype comparable to
CHRPE. Conversely, when the expression of -catenin
was reduced, it induced a reversal of the CHRPE
phenotype.40 Similarly, overexpression of -catenin, either
directly19 or by inactivation of the APC gene in transgenic
mice,20 induces polycystic kidney disease.
Additionally, certain genotype and phenotype associations
in Gardners syndrome are evident. In particular, mutations
in the regions of APC causing Gardners syndrome
result in the loss of some of the amino-acid repeats involved
in -catenin binding and downregulation (amino acids
10202035).3,2832,36,37 Furthermore, the dierence in the
pathogenesis of desmoid tumours and colon polyps lies in
the dierent -catenin levels achieved with the mutated
APC proteins.27,33
www.thelancet.com/oncology Vol 10 July 2009

By considering the evidence mentioned so far, we

postulate that the presence of a mutated APC in FAP
causes an overexpression of -catenin, which, in turn,
renders the non-canonical ciliary pathway non-functional
and probably also aects ciliogenesis, resulting in
phenotypic manifestations of ciliary disease in FAP, such
as CHRPE and cysts.

Other proteins as candidate links

Other proteins that act as mediators of putative ciliary
abnormalities and the manifestations present in
Gardners syndrome might be those whose binding is
aected by a truncated APCie, axin, EB1, and KIF3a.
Therefore, the candidate APC domains that can cause
such alterations are: the region encompassing the
amino-acid repeats, the C-terminal (EB1 binding)
domain, and the armadillo region, respectively.
Axin binding sites are interspersed within the series of
20 amino-acid repeats that bind -catenin (gure 5).
Thus, axin binding is also aected by most of the APC
mutations. Additionally, axin forms part of the -catenin
degradation complex.12,13 However, axin is not a known
cilia-related protein, and, therefore, its relevance to the
function of cilia is uncertain.
The presence of EB1 has been reported in broblasts,
where its absence reduces primary cilia assembly and
inhibits ciliogenesis (gure 1),40 Additionally, EB2, the rat
733

Personal View

homologue of EB1,41 is one of the proteins present in the

photoreceptor-cell axonemes. The protein components of
the photoreceptor cell that connect the cilia of the retinal
rods and cones participate in: the intracellular transport
through the cilia; the morphogenesis of the outer segment
disc, which contains the photo pigment opsin; and in the
maintenance of discrete membrane domains.40,41
The fact that most of the mutations found in APC cause
a truncated protein without the carboxyl-terminal EB1
binding region3 might explain how mutations in APC
can cause a ciliary disorder, provided that the absence of
binding to APC results in functional abnormalities of
EB1. This notion might well be the case if the functions
so far attributed to EB1 do not rely on the protein itself,
but on the proteins that it transports, such as APC. The
review by Giardiello and colleagues37 about genotype and
phenotype associations in FAP suggests that the loss of
the EB1 functional domain plays a major part in the
development of Gardners phenotype. The researchers
showed three codons to be associated with multiplicity of
extraintestinal manifestations: 1465, 1546, and 2621.37
Whereas the rst two codons are located in the -catenin
binding domains, the predicted mutated protein resulting
from mutations in codon 2621 is located in the EB1
binding site domain, and has all the -catenin binding
domains intact. Therefore, the possibility exists that a
functional defect in EB1 as a result of defective binding to
APC, might, by itself, be responsible for CHRPE and
other extracolonic phenotypic manifestations of FAP.
Alternatively, because APC mutations that cause
Gardners syndrome can also occur at the 5 end of the
-catenin binding regions, it is possible that the cause of
Gardners manifestation might lie in the more proximal,
armadillo domain of APC. However, ndings published
by Ahmed and colleagues40 suggest otherwise. When
testing three mutant APC alleles from Drosophila (two
containing a stop codon within the armadillo region and
a third containing the whole armadillo domain and two
series of amino-acid repeats from the -catenin binding
domain) the researchers showed that all three alleles had
the same phenotypeie, retinal neuronal degeneration
and pigment-cell hypertrophy.
However, in our opinion, this nding does not exclude
an important role of the armadillo domain and its binding
protein KIF3a in the pathogenesis of other FAP manifestations, such as cerebellar medulloblastoma. Indeed,
mutations in SUFU, a ciliary protein (gure 4), have been
shown to predispose to sporadic medulloblastoma.22
Inactivating mutations in SUFU result in an illegitimate
activation of the Shh signalling pathway,22 and, therefore,
medulloblastoma belongs to the spectrum of clinical
manifestations of cilia disorders. Like SUFU, KIF3a is an
essential ciliary protein in neural cells, where it transports
APC and -catenin along the microtubules and accumulates
them in the tips of the cilia.25 A truncated APC without the
armadillo repeat could be absent from the cilia in neural
cells, which might impair cell migration and, therefore,
734

could contribute to the occurrence of medulloblastoma in

FAP. Mutations associated with medulloblastoma in FAP
are clustered in the region encompassing the codons
6791224.42 Although this region includes part of the
armadillo region, there are also mutations distal from it
within the region of 15-amino-acid repeats that cause
medulloblastoma. Therefore, a major role of KIF3a in the
development of this tumour can not be established.

Other extraintestinal tumours result from cilia disorders

We found similarities that suggest that, in addition to
desmoid tumours and medulloblastoma, other extraintestinal tumours in patients with FAP can also result
from a ciliary disorder. Indeed, as occurs in von Hippel
Lindau disease, where renal-cell carcinoma is preceded by
the formation of renal cysts,13 desmoid tumours,43 hepatoblastoma,44 papillary thyroid carcinoma,45 and periampullary
carcinoma46 have been reported to originate from cystic
lesions.
Therefore, by looking at the connections between the
oncogenic manifestations in FAP and the ciliary disease
manifestations, an exciting new perspective of the
function of the cilia takes shape: the role of cilia in
oncogenesis. In addition to VHL and SUFU, a few other
cilia-related genes have been shown to be frequently
mutated in sporadic cancer in humans.21 As Mans and
colleagues22 have proposed, the participation of cilia in
the Shh-signalling, Wnt-signalling, and PDGFR-signalling
pathways indicates an important role of the cilia in
carcinogenesis, and the possibility exists that cilia act as
tumour suppressor organelles. We propose FAP as the
disease model to study this postulation.
In this Personal View, we have provided arguments for
a new insight into the pathogenesis of FAP, explained
from the perspective of a ciliary defect. From this
perspective, the generation of Gardners manifestations,
and the extraintestinal tumours noted in patients with
this syndrome, can be understood and explained by the
many connections between APC and the cilia. Additionally,
this notion opens a new range of potential therapeutic

Search strategy and selection criteria

Data for this Personal View were obtained by a search of
PubMed using the following terms: Gardners syndrome,
Genotype AND phenotype AND correlations, APC,
Beta-catenin, EB1, ciliary disorders, primary cilia,
cysts, desmoid, osteomas, CHRPE, papillary thyroid,
medulloblastoma, and periampullary carcinoma. Only
papers published in English were used. No limitation in date
range was introduced. Information on APC and -catenin was
obtained from: OMIM, gene and protein sequences, conserved
domains, and the 3D databases from the US National Institute
of Health website. The APC mutation database was consulted
using the database at the Institute of Medical Genetics in
Cardi, Wales, UK (HGMDR, copyright Cardi University 2008).

www.thelancet.com/oncology Vol 10 July 2009

Personal View

possibilities for the treatment of patients with FAP.

Finally, as a result of the broad range of tumour types that
occur in FAP, this disease seems to be an ideal model for
explaining the role of cilia in human neoplasia.
Contributors
EG had the idea for the paper, did the literature search, writing, and
contributed some of the gures. NVAMK helped with writing and
critical review of the paper and supplied the table and gures 3 and 4.

23

24

25

26

Conicts of interest
The authors declared no conicts of interest.
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