Beyond Spigelman: time-adaptive duodenal cancer risk in familial adenomatous polyposis – results from a retrospective two-centre study (DRACO)

Duodenal cancer is a leading cause of death in familial adenomatous polyposis, yet the Spigelman staging system—equally weighting its four components and never formally validated against progression outcomes—has limited sensitivity for identifying patients at short-term risk.

Using a retrospective, two-centre FAP cohort, Duodenal Risk assessment for APC surveillance intervals Optimisation (DRACO) derived two reweighted risk models—Spigelman 2.0 and the Milan model—that estimate 1-year, 3-year and 5-year risk of advanced duodenal neoplasia (high-grade dysplasia or carcinoma), improving short-term sensitivity and long-term specificity over the traditional Spigelman score.

DRACO offers a data-driven alternative to a three-decade-old staging system; nevertheless, its two-centre, single-country validation and modest event numbers at longer horizons mean that prospective, multicountry validation is a necessary next step before guideline adoption.