Further evidence that one of the earliest alterations in colorectal carcinogenesis involves APC.

Colorectal cancer is hypothesized to arise after the accumulation of multiple mutations in critical oncogenes or tumor suppressor genes. The relative timing of each mutation is unknown because the exact number and types of mutations differ between tumors. However, for every mutation except the first, tumor heterogeneity must exist until clonal dominance is reestablished. This principle was applied to mutant APC genes in eight colorectal adenomas. The APC mutations were homogeneously present throughout the adenomas, including those less than 1 cm in size, but absent from the normal polyp stalks. In one adenoma with APC and c-K-ras mutations, both mutations were simultaneously present in only a small discrete portion, suggesting that the c-K-ras mutation was acquired after the APC mutation. These findings suggest that when mutations in APC occur, they are usually one of the first events in colorectal carcinogenesis or provide such a strong selective advantage that intratumor heterogeneity is seldom observed.