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• Sporadic duodenal adenoma and colorectal neoplasia
  Alexander C Ford
  Published on: 24 February 2004

• Published on: 24 February 2004

  Sporadic duodenal adenoma and colorectal neoplasia

  • Alexander C Ford, Registrar in Gastroenterology
  • Other Contributors:
    • Olorunda Rotimi, Simon M Everett

  Dear Editor

  We read with great interest Murray et al’s article concerning the association between sporadic duodenal adenoma and colorectal neoplasia.[1]

  We have also noted a lack of published literature regarding sporadic duodenal adenomas, with the exception of the two reports identified by the authors,[2,3] as well as a more recent case series,[4] and therefore welcome the addition of their large ca...

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  Dear Editor

  We read with great interest Murray et al’s article concerning the association between sporadic duodenal adenoma and colorectal neoplasia.[1]

  We have also noted a lack of published literature regarding sporadic duodenal adenomas, with the exception of the two reports identified by the authors,[2,3] as well as a more recent case series,[4] and therefore welcome the addition of their large case series and comparison group. Although there is the potential for bias in the detection of colorectal neoplasia in their duodenal adenoma cases, as the indications for colonoscopy were somewhat different between cases and controls (with almost one third of cases of duodenal adenomas being endoscoped for investigation of anaemia or melaena), overall their data support a clinically relevant association between duodenal and colonic adenomas.

  These results are corroborated by our own recent experience at Leeds General Infirmary, where we have studied the natural history of duodenal adenoma. We also examined histopathology records and case notes for cases of sporadic duodenal adenoma between 1990 and 2002 (excluding familial adenomatous polyposis and hereditary non-polyposis colorectal cancer). We identified 35 cases, 16 male and 19 female with a mean age of 65. The majority of these were noted incidentally at upper gastrointestinal endoscopy or endoscopic retrograde cholangiopancreatography, with a similar range of indications for examination as those noted by Murray et al. Using the criteria stipulated by the authors 25 (71%) of the adenomas were advanced. Of the 35 patients in our series 11 underwent colonoscopic examination. This revealed a synchronous colonic adenoma in 4 patients (36%),[3] of which were tubulovillous adenomas and therefore advanced according to the aforementioned criteria, and the fourth a tubular adenoma. This compares with a reported rate of colonic neoplasia of 25.5% in a series of 1000 consecutive, unselected patients attending the Leeds General Infirmary for colonoscopy.[5] Unlike Murray et al, we did not find any colonic carcinomas in our patients. This discrepancy presumably relates to the fact that both series are relatively small and the confidence intervals are likely to be wide, much as they found.

  Unfortunately, Murray et al provide no follow-up data relating to the duodenal adenomas in their series. We have clinical data for all our cases, with a median duration of follow-up of 4 years. Seventeen of the 35 adenoma were removed (6 surgically, 4 by endoscopic mucosal resection (EMR), 3 snared, 3 during biopsy and 1 by argon photocoagulation), and of these 2 patients had a recurrence (1 treated by EMR, the other kept under surveillance), and all were alive at the time of review (median time from diagnosis 58 months). Amongst the 18 who had no therapy for their polyp, 10 had died (median length of follow-up 43 months). One patient who had a tubulovillous adenoma with high-grade dysplasia developed a 3cm adenocarcinoma of the first part of the duodenum five months after initial diagnosis and underwent a Whipple's procedure, but died 12 months later from metastatic disease. The other patients died from unrelated causes.

  Despite published literature that suggests duodenal polyps have no prognostic importance [6] we believe that the optimal management of duodenal adenomas is early excision and follow-up. We also concur that there is an association between sporadic duodenal adenomas and colonic neoplasia, and agree entirely that all patients found to have sporadic duodenal adenoma should undergo colonoscopy. However, owing to reasons of study size and bias in the comparison groups, the magnitude of this association cannot be accurately determined. Furthermore, the reasons for this association are as yet unclear, and molecular studies are required to further investigate.

  References

  (1) MA Murray, MJ Zimmerman, and HC Ee. Sporadic duodenal adenoma is associated with colorectal neoplasia. Gut 2004; 53: 261-265

  (2) Hochter W, Weingart J, Seib HJ, Ottenjann R. Duodenal polyps. Incidence, histologic substrate, and significance. Deutsche Medizinische Wochenschrift 1984; 109: 1183-6.

  (3) Jepsen JM, Persson M, Jakobsen NO, Christiansen T, Skoubo- Kristensen E, Funch-Jensen P et al. Prospective study of prevalence and endoscopic and histopathologic characteristics of duodenal polyps in patients submitted to upper endoscopy. Scandinavian Journal of Gastroenterology 1994; 29: 483-7.

  (4) Chong KC, Cheah WK, Lenzi JE, Goh PM. Benign duodenal tumors. Hepato-Gastroenterology 2000; 47: 1298-300.

  (5) Rembacken BJ, Fujji T, Cairns A, Dixon MF, Yoshida S, Chalmers DM et al. Flat and depressed colonic neoplasms: a prospective study of 1000 colonoscopies in the UK. The Lancet 2000; 35: 1211-4.

  (6) Burke CA, van Stolk RU. Diagnosis and management of gastroduodenal polyps. Surgical Oncology Clinics of North America 1996; 5: 589-607.

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  Conflict of Interest:
  None declared.

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