From the Guidelines
The next step for this 53-year-old man with familial adenomatous polyposis (FAP) and multiple small duodenal tubular adenomas is to repeat EGD in 1 year (option B). This recommendation is based on the Spigelman classification system used to stratify duodenal polyposis risk in FAP patients, as described in the guidelines for the management of hereditary colorectal cancer 1. The patient has multiple small (1-3 mm) adenomas with tubular histology, which likely represents Spigelman stage II disease. Some key points to consider in the management of this patient include:
- The Spigelman classification system is the most widely used system for staging non-ampullary duodenal disease and has been shown to correlate with cancer risk 1.
- Stage II disease carries an intermediate risk of progression to duodenal cancer and warrants annual endoscopic surveillance, although the guidelines suggest a 3-year follow-up interval for stage II disease 1, the patient's specific situation and the presence of multiple adenomas may require more frequent surveillance.
- More frequent surveillance (3-6 months) would be excessive for this presentation, while waiting 2-3 years would be too long given the risk of progression.
- Surgical referral is not indicated at this time as the adenomas are small, few in number, and were successfully removed endoscopically.
- The patient should be counseled that duodenal adenomas in FAP require lifelong surveillance as they can progress to cancer, and that surveillance intervals may change based on future findings.
- The use of non-steroidal anti-inflammatory drugs (NSAIDs) for chemoprevention has been shown to reduce the number and extent of colorectal adenomas and, less reliably, duodenal adenomas, but their use needs to be balanced with the side-effects 1.
From the Research
Next Steps for FAP Patient with Duodenal Adenomas
The patient in question has familial adenomatous polyposis (FAP) and was found to have six white lesions ranging in sizes from 1-3 mm in the duodenum, which were confirmed to be tubular adenomas. Considering the evidence from various studies, the next steps can be outlined as follows:
- Surveillance Intervals: The optimal surveillance interval for FAP patients with duodenal adenomas is not strictly defined but should reflect both Spigelman staging and ampullary disease 2.
- Endoscopic Surveillance: Regular endoscopic surveillance is crucial for the early detection and removal of adenomas to prevent cancer 3, 4, 5.
- Risk of Cancer: The risk of duodenal cancer in FAP patients is significant, and surveillance should aim to detect and remove adenomas before they progress to cancer 2, 4.
- Treatment Options: Endoscopic resection of adenomas is a key component of management, but surgery may be indicated for patients with severe polyposis or adenomas not amenable to endoscopic resection 3, 6.
Considerations for This Patient
Given that the patient has already been found to have tubular adenomas in the duodenum, the next step would likely involve:
- Close endoscopic surveillance to monitor for the development of new or advanced adenomas.
- Consideration of the Spigelman stage to guide surveillance intervals and treatment decisions.
- Removal of any advanced adenomas or those with high-grade dysplasia to prevent cancer.
Possible Answers
Based on the provided evidence:
- Repeat EGD in 1 year could be a reasonable approach, considering the need for regular surveillance in FAP patients with duodenal adenomas.
- Repeat EGD in 3-6 months might be more appropriate if there are concerns about the rapid progression of adenomas or if the patient has a high Spigelman stage.
- Repeat EGD in 2-3 years might be too long an interval, given the potential for adenomas to progress to cancer.
- Refer to a surgeon might be considered if the patient has severe polyposis or adenomas that are not amenable to endoscopic resection.