Surveillance Rather Than Immediate Resection Appears Advisable for Most Familial Adenomatous Polyposis-Related Ampullary Adenomas

Surveillance Rather Than Immediate Resection Appears Advisable for Most Familial Adenomatous Polyposis-Related Ampullary Adenomas

Bret T. Petersen, MD, MASGE, reviewing Singh AD, et al. Gastrointest Endosc 2021 Oct 5.

Ampullary, periampullary, and duodenal adenomas commonly occur in familial adenomatous polyposis (FAP). Their detection and management are fraught with challenges related to balancing the risk of progression to carcinoma and risks of endoscopic management. In this study, the authors sought to characterize the natural history of FAP-related ampullary adenomas (AA) among patients with at least two surveillance endoscopies recorded in a hereditary cancer registry. Clinical and pathologic parameters were compared between those with versus those without clinically significant progression (SP), as reflected by the development of advanced histology or progression to size >10 mm. 

Among 143 patients followed for a median of 7.8 years, SP occurred in 28.6%, including growth in size to ≥10 mm in 15.6%, development of advanced histology in 8.5%, and changes in both histology and size in 4.9%. Ampullary cancer developed in 2 of 143 patients (1.4%). Features associated with SP included prior extracolonic malignancy, prior cholecystectomy, male gender, and abnormal papillary findings at the time of initial AA detection. Adenomatous Polyposis Coli gene variants and Spigelman stage did not correlate with progression. During 8.2 years of surveillance, 24% of patients with AA underwent either duodenectomy (n=3) or endoscopic papillectomy (n=23) for their lesions. Most patients did not require excision or ablation of ampullary adenomas, and progression to cancer was rare.

Bret T. Petersen, MD, FASGE

COMMENT

Ampullary and duodenal cancers typically occur 1 to 3 decades later than the more common colorectal carcinoma in patients with FAP. Based on these data, the authors advise ongoing endoscopic surveillance, rather than early resection, for most ampullary adenomas in those with FAP. A similar reserved approach is typically advisable for small- to medium-sized FAP-related duodenal adenomas, which tend to be more numerous as well as challenging and risky to excise.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

CITATION(S)

Singh AD, Bhatt A, Joseph A, et al. The natural history of ampullary adenomas in familial adenomatous polyposis: a long-term follow-up study. Gastrointest Endosc 2021 Oct. 5. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2021.09.036)

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