Endoscopic resection, surveillance recommended for ampullary adenomas in FAP syndrome

Last Updated: 2020-03-12

By Reuters Staff

NEW YORK (Reuters Health) - Ampullary adenomas in patients with familial adenomatous polyposis (FAP) syndrome should be managed by endoscopic ampullectomy followed by careful surveillance for recurrence, according to the authors of a new study.

Ampullary adenomas are premalignant lesions that can progress to adenocarcinoma, but there are currently no consensus recommendations on their optimal management and surveillance. The current approach to ampullary adenomas associated with FAP is intensive endoscopic surveillance followed by resection when the adenoma grows beyond 10 mm or if there is presence of high-grade dysplasia.

Dr. Jeffrey H. Lee of the University of Texas MD Anderson Cancer Center, in Houston, and colleagues evaluated the outcome of all patients with a pathology-confirmed ampullary adenoma who were referred to their institution for treatment from 2002 to 2018.

Among the 137 patients included in the study, 95 FAP patients with ampullary adenoma underwent initial interval surveillance endoscopy with biopsy and 42 patients with sporadic ampullary adenoma underwent immediate resection.

Twelve of the 95 FAP patients subsequently developed an advanced ampullary adenoma and required endoscopic (n=10) or surgical (n=2) resection a median 4.7 years after the first endoscopy. None of the patients in the surveillance group developed ampullary adenocarcinoma.

Survival rates and survival times did not differ significantly between the surveillance-only group and the advanced-adenoma group, the researchers report in Gastrointestinal Endoscopy.

Among the 10 FAP patients and 19 with sporadic ampullary adenoma who underwent endoscopic ampullectomy, 21 were treated with endoscopy only and eight ultimately required surgery after a median 132 days. None of the patients who were originally in the surveillance group and underwent endoscopic ampullectomy subsequently needed surgical resection or developed ampullary cancer.

Ten FAP patients underwent pancreaticoduodenectomy for advanced adenoma, residual/recurrent adenoma after endoscopic ampullectomy, recurrence after surgical ampullectomy, or adenocarcinoma detected after endoscopic ampullectomy.

Postoperative adverse events occurred following 10.3% of endoscopic ampullectomies, 50% of surgical ampullectomies and 29% of pancreaticoduodenectomies.

"The management of ampullary lesions is difficult with no clear consensus on its approach," the authors conclude. "Due to their more indolent nature, patients with FAP can potentially be managed with surveillance alone in the case of nonadvanced ampullary lesions."

"For patients with sporadic lesions or advanced adenomas, every effort should be made to refer for endoscopic resection, due to their high technical success and low adverse event rates, but intensive follow-up is paramount due to the high rates of recurrence," they note. "Finally, the use of pancreaticoduodenectomy should be reserved as either second-line therapy or in patients with malignancy due to its invasive nature."

Dr. Lee did not respond to a request for comments.

SOURCE: https://bit.ly/38DS1jr Gastrointestinal Endoscopy, online March 4, 2020.