What is the recommended surveillance strategy for patients with duodenal adenomas?

Duodenal Adenoma Surveillance Strategy

Surveillance of duodenal adenomas should follow the Spigelman classification system, with intervals ranging from every 6 months to 5 years depending on the stage of duodenal polyposis. 1

Surveillance Protocol Based on Spigelman Classification

The Spigelman classification is the cornerstone of duodenal adenoma surveillance, as it stratifies risk based on number, size, histology, and degree of dysplasia of duodenal polyps:

Spigelman Stage	Points	Surveillance Interval	Risk Level
Stage 0	0 points	Every 5 years	Low risk
Stage I	1-4 points	Every 5 years	Low risk
Stage II	5-6 points	Every 3 years	Moderate risk
Stage III	7-8 points	Every 1-2 years	High risk
Stage IV	9-12 points	Every 6 months or consider surgery	Very high risk

Spigelman Scoring System

• Number of polyps: 1-4 (1 point), 5-20 (2 points), >20 (3 points)
• Polyp size: 1-4mm (1 point), 5-10mm (2 points), >10mm (3 points)
• Histology: Tubular (1 point), Tubulovillous (2 points), Villous (3 points)
• Dysplasia: Mild (1 point), Moderate (2 points), Severe (3 points)

Endoscopic Technique

For optimal surveillance:

• Begin surveillance at age 25-30 years or at the time of diagnosis of colonic polyposis 1
• Use both front-view and side-view endoscopes with special attention to the papillary area 1
• Obtain biopsies from visible lesions and normal-appearing papillae 2
• Consider EUS for ampullary adenomas to determine dimensions and resectability 2

Management Based on Findings

For Advanced Adenomas (≥10mm, villous histology, high-grade dysplasia):

• Endoscopic management is first-line for most cases:
  • Endoscopic polypectomy for non-ampullary adenomas
  • Endoscopic ampullectomy for ampullary adenomas 2
  • Consider APC (argon plasma coagulation) or EMR (endoscopic mucosal resection) for appropriate lesions 3

For Spigelman Stage IV Disease:

• Consider surgical options including:
  • Duodenotomy with polypectomy
  • Pancreas-sparing duodenectomy
  • Duodenal-pancreatectomy 1

Rationale for Intensive Surveillance

The importance of strict surveillance is supported by evidence showing:

• Patients with FAP have >90% lifetime risk of developing duodenal adenomas 4
• 5-10% lifetime risk of periampullary or duodenal adenocarcinoma 4
• High cumulative risk (42.9% at age 60,50% at age 70) of developing stage IV duodenal polyposis 5
• Almost all cases of adenocarcinoma occur in patients with Spigelman stage IV disease 4

Adjunctive Therapy

For patients with established duodenal polyposis, consider chemoprevention:

• NSAIDs (sulindac 300mg) or COX-2 inhibitors (celecoxib) may reduce number and extent of duodenal adenomas 1
• However, cardiovascular side effects with COX-2 inhibitors warrant caution 1

Important Caveats

• Recurrence after endoscopic treatment is common, necessitating ongoing surveillance 3
• EUS can significantly alter management by more accurately staging ampullary adenomas 2
• Intensive surveillance with appropriate intervention can prevent progression to cancer 2, 4
• The risk of duodenal cancer is the leading cause of cancer death in FAP patients who have had prophylactic colectomies 4

By following this surveillance strategy based on the Spigelman classification, clinicians can effectively monitor duodenal adenomas and intervene appropriately to reduce morbidity and mortality from duodenal cancer.