Prevention and management of duodenal polyps in familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is one of two well described forms of hereditary colorectal cancer. The primary cause of death from this syndrome is colorectal cancer which inevitably develops usually by the fifth decade of life. Screening by genetic testing and endoscopy in concert with prophylactic surgery has significantly improved the overall survival of FAP patients. However, less well appreciated by medical providers is the second leading cause of death in FAP, duodenal adenocarcinoma. This review will discuss the clinicopathological features, management, and prevention of duodenal neoplasia in patients with familial adenomatous polyposis. FAP is an autosomal dominant disorder caused by a germline mutation in the adenomatous polyposis coli ( APC ) gene. FAP is characterised by the development of multiple (⩾100) adenomas in the colorectum. Colorectal polyposis develops by age 15 years in 50% and age 35 years in 95% of patients. The lifetime risk of colorectal carcinoma is virtually 100% if patients are not treated by colectomy.1 Patients with FAP can also develop a wide variety of extraintestinal findings. These include cutaneous lesions (lipomas, fibromas, and sebaceous and epidermoid cysts), desmoid tumours, osteomas, occult radio-opaque jaw lesions, dental abnormalities, congenital hypertrophy of the retinal pigment epithelium, and nasopharyngeal angiofibroma. In addition, FAP patients are at increased risk for several malignancies, such as hepatoblastoma, pancreatic, thyroid, biliary-tree, and brain tumours.1 Other gastrointestinal manifestations commonly found in FAP patients are duodenal adenomas, and gastric fundic gland and adenomatous polyps. Of concern, duodenal cancer is the second leading cause of death after colorectal cancer in these individuals. After the colorectum, the duodenum is the second most commonly affected site of polyp development in FAP (fig 1).2,3 Duodenal adenomas can be found in 30–70% of FAP patients2–4 and the lifetime risk of these lesions approaches 100%.4,5 …