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Curr Pathobiol Rep. 2018 Sep;6(3):193-198. doi: 10.1007/s40139-018-0176-8. Epub 2018 Jul 16.

Evolutionary Stem Cell Poker and Cancer Risks: The Paradox of The Large And Small Intestines.

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Department of Pathology, University of Southern California Keck School of Medicine,


Purpose of review:

Recent studies demonstrate that normal human tissues accumulate substantial numbers of somatic mutations with aging, to levels comparable to their corresponding cancers. If mutations cause cancer, how do tissues avoid cancer when mutations are unavoidable?

Recent findings:

The small intestines (SI) and colon accumulate similar numbers of replication errors, but SI adenocarcinoma is much rarer than colorectal cancer. Both the small and large intestines are subdivided into millions of small neighborhoods (crypts) that are maintained by small numbers of stem cells. To explain the SI cancer paradox, four fundamental evolution parameters (mutation, drift, selection, and population size) are translated to crypts.


The accumulations of driver mutations in a single stem cell may be analogous to an evolutionary poker game. The rarity of SI cancer may reflect that SI crypts are smaller and have fewer stem cells than the colon, which reduces the numbers of cells at risk for mutation and perhaps selection efficiency. Tissue microarchitecture may physically modulate cancer evolution by controlling the numbers of directly competing neighboring cells. A better understanding of the SI cancer paradox may illuminate how tissues naturally avoid cancers when mutations are unavoidable.


neutral evolution; replication errors; selection efficiency; small intestinal adenocarcinoma; somatic mutation; stem cell niche

Conflict of interest statement

Compliance with Ethical Guidelines Conflict of Interest: Darryl Shibata declares no conflict of interest.

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