Outcome Based on Management for Duodenal Adenomas: Sporadic Versus Familial Disease

Abstract

Methods of polyp resection (endoscopic, local surgical resection, or definitive surgical resection) within both sporadic and familial patient groups were compared. Patients with known cancer were excluded. Two hundred seventy-eight patients with duodenal polyps were followed during this time period: 110 patients (39.6%) with sporadic polyps and 168 (60.4%) with familial adenomatous polyposis (FAP). Sporadic patients presented at a mean age of 66.5 years. Endoscopic resection was attempted in 44 patients (40%) with morbidity in 9% and local recurrence rate of 52% with a mean follow-up of 43 months. Surgical resection was performed in 46 patients (42%): 27 by definitive resection and local resection in 19. At a mean follow-up of 41 months, there were no local recurrences in the patients treated by definitive resection and six recurrences (32%) after local resection. Morbidity was 39%. There was a significant difference in local recurrence when comparing definitive resection to both endoscopic and local resection (p<0.001, p=0.002, respectively), but no significant difference between endoscopic and local excision (p=0.13). Cancer was discovered in the surgical specimens of 11 patients (24%) with benign preoperative biopsies. FAP patients began surveillance at a mean age of 39.5 years, and mean surveillance duration was 100 months. Endoscopic resection/ablation was attempted in 40 patients (24%) with a morbidity of 7.5%. With a mean follow-up of 77.5 months, the local recurrence rate was 72.5%. Surgical resection was performed in with local recurrence rates of 9% and 100%, respectively. Surgical morbidity was 48%. Local recurrence was significantly lower following definitive resection compared to endoscopic or local resection (p<0.001), but there was no difference in local recurrence between the latter two groups (p=0.29). Four patients (8%) undergoing surgery were discovered to have invasive cancer despite benign endoscopic biopsies. In summary, endoscopic and local surgical management for both sporadic and familial duodenal polyps are associated with a high rate of local recurrence. Definitive resection in the form of pancreaticoduodenectomy, pancreas-sparing duodenectomy, or segmental duodenectomy offers the best chance for polyp eradication and prevention of carcinoma, regardless of polyp etiology.

Prevalence of Gastric and Duodenal Polyps and Risk Factors for Duodenal Neoplasm in Korean Patients with Familial Adenomatous Polyposis

“…[26][27][28] In our report, the stage II lesion in one patient removed by argon plasma coagulation was relapsed, and the stage III lesion in one patient removed by papillectomy was relapsed but stage was decreased. Therefore, follow-up endoscopy is absolutely necessary after endoscopic resection.…”

“…On the other hand, when the radical surgeries like pancreaticoduodenectomy or pylorus preserving pancreaticoduodenectomy were conducted, the recurrence rates of duodenal adenomatosis were zero or low. 25,28,29 However, high recurrence rate was reported in patients who underwent extensive surgery for invasive duodenal cancer. 30 Therefore, early detection of the lesions by the endoscopic follow-up is important, and they should be operated radically in case of high risk patients with duodenal cancer or severe dysplasia, extensive duodenal adenomatosis and Spigelman stage IV.…”

CpG island methylator phenotype and its association with malignancy in sporadic duodenal adenomas

“…The latter are reported to have much higher frequency of underlying malignancy. 6,12,13 Additional clincopathologic factors associated with an increased risk of duodenal adenocarcinoma within a duodenal adenoma include villous histological type, larger size, ampulla, or periampullary location, and multicentric origin. [8][9][10][11] Despite the presumed existence of an "adenoma-carcinoma" sequence, the molecular features leading to this malignant progression has not been extensively studied in duodenal lesions due to their rarity.…”

“…When definitive surgical resection is performed, it obviates the risk of recurrence but incurs a higher perioperative mortality and morbidity because definitive surgical resection often requires en-bloc resection of adjacent organs due to the location of the duodenum, the so-called Whipple operation. 6,35 Information regarding molecular features of duodenal adenomas has the potential to assist clinicians in the decision of whether to perform surgical resection.…”

Advanced duodenal neoplasia and carcinoma in familial adenomatous polyposis: outcomes of surgical management

“…Transduodenal resection has been exceptionally recommended because recurrence is common (32-43%), besides it may provide temporary relief of cancer threat and thus postpone definitive surgery (12,32,40). We had the opportunity to resect a 3 cm villous adenoma in a 37 years man in whom endoscopic resection was considered too risky.…”