Gastric Adenomas in Familial Adenomatous Polyposis Are Common, But Subtle, and Have a Benign Course

Purpose: Patients with familial adenomatous polyposis (FAP) are known to be at increased risk for gastric adenomas. The clinical features of gastric adenomas in FAP have not been well characterized, and there is a lack of standardized approach to management of these lesions. The aim of this study was to describe the endoscopic appearance, risk factors, clinical course and response to therapy of gastric adenomas in patients with FAP. Methods: We retrospectively reviewed the records of 97 patients with FAP who underwent esophagogastroduodenoscopy (EGD) at Mayo Clinic (Florida, Rochester and Arizona) between 2004 and 2013. Results: Nine patients (9.2%) had biopsy-proven gastric adenomas. Adenomas were located in the antrum (five patients), in the body and fundus in the setting of background fundic gland polyps (FGP) (three patients), and in the body not associated with FGP (one patient). Adenoma size was 3-40 mm and the number of adenomas per patient ranged from one to 20. Adenomas in the antrum were flat and subtle, whereas those in gastric body or fundus were polypoid and difficult to differentiate from cystic FGP seen in patients with FAP. The performing endoscopists reported diffi culty in identifying adenomas, and six patients had at least one EGD within the previous three years where gastric adenomas were not reported. Adenomas were classified as tubular in eight patients, and tubulovillous in one patient. High-grade dysplasia was noted in one patient. After a follow-up of 63 months (interquartile range: 20-149), no patient in our entire cohort (with or without gastric adenomas) developed gastric cancer. The FAP patients in whom gastric adenoma developed, as compared to those without gastric adenoma, were more likely to be younger [36 ± 12 vs. 48 ± 15 years, p=0.02], have concomitant chronic gastritis [22% vs. 0%, p=0.008], and have desmoid tumors [5(56%) vs. 19(22%), p 0.04]. Conclusion: Gastric adenomas are not uncommon in patients with FAP and are often difficult to identify endoscopically. Endoscopists should have a high degree of suspicion for gastric adenomas in these patients and a low threshold to biopsy. Given the benign clinical course, recommended initial management is conservative with endoscopic therapy and periodic surveillance.