Risk of duodenal adenomas in familial adenomatous polyposis to progress toward advanced neoplastic disease

To the Editor: In the February 1, 2004, issue of the Journal of Clinical Oncology, Saurin et al1 report that 50% of duodenal adenomas in familial adenomatous polyposis (FAP) patients progress toward more advanced disease during a mean follow-up period of 47.9 months. As the same authors observe, this value is higher than other published data. In our experience, only two (6.2%) of 32 FAP patients who are taking part of a study for identification of prognostic factors2 show an increased severity of the duodenal lesions after a mean surveillance period of 72.5 months. Moreover, until now, none of these patients have developed the most severe stage of the disease. The authors justified their results because the very accurate duodenoscopic methodology adopted in the study. This hypothesis can be shared as far as the detection of progression of the lesions is concerned, but it cannot explain the cumulative high number of high scores. At the end of the study period, the percentage of patients with severe lesions (stage IV) was 35%. High-grade dysplasia has been found in 37.1%. It is difficult to hypothesize that lesions like those described in the article could have been underestimated or missed in the available studies reporting lower percentage. The high-grade lesions are also usually detectable also by routine endoscopic examinations. To know the profile of the population under study may be crucial in these works. It may make the difference. In the Saurin et al article, we do not have the results of the molecular analysis of the patients who have progressed toward the high grade. Moreover, more information on clinical data should be available. In particular, the number of patients with ileoanal anastomosis may be of interest because they have a defective absorption of bile acids, which are involved in the risk of developing duodenal neoplasia.3 The last part of the article discusses the alternative role of endoscopy surgery in the prevention of duodenal cancer. The authors don't comment on the treatment with pharmacologic agents (ie, COX-2 inhibitors, which is a very promising field of prevention).4 Endoscopy should also be improved to increase evaluation efficiency in chemoprevention policy.