Rectal cancer after prolonged sulindac chemoprevention. A case report

Sulindac is reported to induce regression of colonic adenomas. However, its role as a chemoprophylactic agent for people with familial adenomatous polyposis (FAP) is under consideration.

This case report describes a patient with FAP in whom rectal adenocarcinoma developed 37 years after prophylactic colectomy and 15 months after beginning a course of sulindac. She received endoscopic follow-ups every 3 months during 15 months of 150-mg twice-daily sulindac administration. At 12 months, an endoscopic examination was unremarkable; at 15 months, endoscopic examination revealed several polyps and a flat ulcerated lesion.

Rectal carcinoma developed in a patient 15 months after beginning chemoprophylaxis: there was metastatic adenocarcinoma in 6 of 20 perirectal lymph nodes. In addition to the carcinoma, rectal mucosa contained two adenomas and multiple foci of adenomatous changes in flat mucosa.

Sulindac may not alter the pathogenesis of FAP. Patients undergoing sulindac chemoprevention must be monitored closely, including endoscopic examination. Endoscopic surveillance should include an aggressive biopsy approach because the absence of polyps does not prove the absence of neoplastic change.