Primary Duodenal Adenocarcinoma Research Articles

S4059 Primary Duodenal Adenocarcinoma Manifesting as Gastric Outlet Obstruction

S4059 Primary Duodenal Adenocarcinoma Manifesting as Gastric Outlet Obstruction

Development and validation of lymph node ratio-based nomograms for primary duodenal adenocarcinoma after surgery.

BackgroundThe prediction models for primary duodenal adenocarcinoma (PDA) are deficient. This study aimed to determine the predictive value of the lymph node ratio (LNR) in PDA patients and to establish and validate nomograms for predicting overall survival (OS) and cancer-specific survival (CSS) for PDAs after surgical resection.MethodsWe extracted the demographics and clinicopathological information of PDA patients between 2004 and 2018 from the Surveillance, Epidemiology and End Results database. After screening cases, we randomly divided the enrolled patients into training and validation groups. X-tile software was used to obtain the best cut-off value for the LNR. Univariate and multivariate Cox analyses were used in the training group to screen out significant variables to develop nomograms. The predictive accuracy of the nomograms was evaluated by the concordance index (C-index), calibration curves, area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA). Finally, four risk groups were created based on quartiles of the model scores.ResultsA total of 978 patients were included in this study. The best cut-off value for the LNR was 0.47. LNR was a negative predictive factor for both OS and CSS. Age, sex, grade, chemotherapy and LNR were used to construct the OS nomogram, while age, grade, chemotherapy, the number of lymph nodes removed and LNR were incorporated into the CSS nomogram. The C-index, calibration curves and AUC of the training and validation sets revealed their good predictability. DCA showed that the predictive value of the nomograms was superior to that of the American Joint Committee on Cancer (AJCC) TNM staging system (8th edition). In addition, risk stratification demonstrated that patients with higher risk correlated with poor survival.ConclusionsThe LNR was an adverse prognostic determinant for PDAs. The nomograms provided an accurate and applicable tool to evaluate the prognosis of PDA patients after surgery.

S3467 Primary Duodenal Adenocarcinoma: A Rare Malignancy

Introduction: Primary duodenal adenocarcinoma (PDA) is extremely rare, representing 0.3 – 1% of all gastrointestinal malignancies. It poses a significant challenge to the physicians due to late non-specific symptoms that delays the diagnosis. Surgical resection is the only treatment option although PDA with distant or nodal metastasis have a very poor prognosis. Case Description/Methods: A 33-year-old male patient presented with epigastric abdominal pain, nausea, vomiting, lipase > 2000, elevated LFTs and hyperbilirubinemia, consistent with acute pancreatitis. CT abdomen and pelvis revealed an irregular mass in the second and third portion of the duodenum near ampulla, dilation of pancreatic and common bile duct along with multiple hepatic lesions, consistent with metastatic malignancy. EGD showed non bleeding duodenal ulcer along with enlarged lymph nodes in the peripancreatic region. Biopsy of the ulcer was suggestive of moderately differentiated invasive duodenal adenocarcinoma with background of high-grade dysplasia. Due to metastatic malignancy, patient was started on folinic acid, fluorouracil and oxaliplatin without undergoing surgery. Percutaneous biliary drain was placed with resolution of pancreatitis and hyperbilirubinemia. Patient also completed a course of antibiotics due to pseudomonas bacteremia and sepsis secondary to pancreatic phlegmon that was drained. Pain was management with fentanyl patch and oral opioids. Patient was later discharged home with outpatient follow up. Discussion: This case highlights the importance of primary duodenal adenocarcinoma (PDA) which is a very rare malignancy. Its etiology is unknown, however patients with familial adenomatosis polyposis, Peutz-Jeghers syndrome, Crohn’s and celiac disease are at higher risk. Due to non-specific symptoms including anorexia, postprandial fullness, nausea, vomiting, jaundice and abdominal pain, early diagnosis is a challenge for physicians. PDA is most commonly seen in second part of the duodenum with an incidence of 50 -70%. It can be diagnosed with the help of contrast imaging studies along with EGD and biopsy. Management is usually surgical resection with tumors of the second part of the duodenum, proximal and distal infiltrating tumors requiring pancreaticoduodenectomy to ensure radical resection. Lymphovascular invasion, lymph node metastasis and perineural invasion are features associated with poor prognosis and high mortality. For unresectable tumors, palliative surgery or endoscopic treatment is usually indicated.

S3618 Gastric Outlet Obstruction as a Presenting Symptom of Duodenal Adenocarcinoma

Introduction: Gastric outlet obstruction (GOO) can be due to benign or malignant causes. Benign etiologies of GOO have been down-trending, resulting in 50-80% of cases of GOO attributable to malignancy. Of the malignant causes leading to GOO, pancreatic adenocarcinoma with extension to the duodenum or stomach is the most common cause, followed by distal gastric cancer. However, primary duodenal adenocarcinoma as the cause of GOO is relatively rare, and we present a case of moderate to poorly differentiated duodenal adenocarcinoma leading to GOO. Case Description/Methods: An 82-year-old man with no reported past medical history presented to the hospital with epigastric abdominal pain associated with worsening distention, nausea, multiple episodes of non-bloody projectile vomiting, and associated weight loss of 12 pounds in the past 2 months. The abdominal exam was unremarkable. Labs were nonsignificant. A computer tomography (CT) scan of the abdomen and pelvis revealed a massively dilated stomach with suspected circumferential narrowing in the distal stomach suggestive of gastric outlet obstruction (Figure A). NGT was placed for decompression, with significant relief of symptoms. The patient underwent EGD, and no gross mass or obstructive etiology was noted in the entire stomach, including pylorus and antrum. There was inflammatory appearing mucosa characterized by extensive edema and contact oozing resulting in mass effect with severe luminal narrowing in the duodenal sweep/D2 regions (Figure B). Biopsies were obtained and showed moderate to poorly differentiated adenocarcinoma (Figure C, D). Subsequently patient underwent palliative duodenal stent placement with symptomatic relief. Discussion: Clinical history is important in suspecting the diagnosis of GOO. Cross-sectional imaging aids in diagnosis but sometimes does not help differentiate benign vs. malignant etiologies. EGD is helpful when imaging is inconclusive and for definitive pathological diagnosis. Most patients achieve symptomatic relief with conservative measures like NPO and NGT decompression. The definitive treatment for GOO varies based on etiology. Most patients with malignant causes need surgery for a cure if suitable candidates. Until recently, surgical gastrojejunostomy was the primary approach for palliative purposes. However, duodenal stent placement has become the primary palliative option as it is a cost-effective, minimally invasive option with adequate symptom relief, shortened hospital stay, and faster resumption of oral intake.Figure 1.: A: CT abdomen/pelvis showed massively dilated stomach with suspected circumferential narrowing in the distal stomach suggestive of gastric outlet obstruction. Circumferential thickening and narrowing of the descending duodenum. B: EGD revealing inflammatory appearing mucosa with extensive edema and contact oozing resulting in mass effect with severe luminal narrowing in the duodenal sweep/D2 regions. C: Immunohistochemistry/histology of biopsies obtained during EGD revealing duodenal adenocarcinoma with tumor glands. D: Tumor emboli in the lymphatics of the duodenal villi.

S3496 You Shall Not Pass: Rare Duodenal Bulb Adenocarcinoma Causing Gastric Outlet Obstruction

Introduction: Duodenal carcinoma accounts for only 1-2% of diagnosed gastrointestinal cancers in the United States. Due to its insidious onset, advanced disease is often established at the time of diagnosis resulting in poor outcomes for patients. Although duodenal adenocarcinomas have been found to comprise around half of all small bowel adenocarcinomas, disease arising from within the duodenal bulb in the D1 segment is a vanishingly rare phenomenon. Case Description/Methods: A 52-year old female with a past medical history of morbid obesity with placement of laparoscopic adjustable gastric band 14 years prior presented with frequent emesis, inability to tolerate oral diet and a 22kg weight loss. Recent esophagogastroduodenoscopy during a previous admission revealed a cratered ulcer in the duodenal bulb. An upper GI series was obtained, showing a 2cm mass in the bulb apex which was confirmed by computed tomography. A repeat esophagogastroduodenoscopy was performed which identified a firm and friable ulcer with contact bleeding with complete obstruction of the duodenal bulb. Subsequent histopathology confirmed the presence of invasive, moderately differentiated adenocarcinoma. (Figure) Discussion: Small bowel tumors comprise about 2% of all GI tumors. Adenocarcinoma accounts for about 30% of all small bowel tumors. The duodenum comprises 53% of all small bowel neoplasms. Of duodenal tumors, about 57% occur in the D2 segment of the duodenum. One 2014 meta-analysis of small bowel cancers between 1990-2012 from an institutional registry (excluding ampullary cancers arising from the bile duct mucosa) identified only 30 cases of primary duodenal adenocarcinoma with none arising from D1. A previous 1991 literature review cites 47 cases of primary duodenal adenocarcinoma arising from D1, however, anatomic distinction between the duodenal bulb and the distal D1 segments was not made. Although small bowel tumors are the third leading cause of gastric outlet obstruction, lesions are typically asymptomatic. In a study of 217 primary duodenal adenocarcinoma, the median survival was 20 months with 35% presenting with metastatic disease (39% present with stage III disease). Although it is difficult to distinguish the prevalence of duodenal bulb neoplasms, it has been clearly demonstrated that neoplasms arising from the D1 segment of the duodenum are extremely rare. By presenting this case, we hope to increase the index of suspicion for small bowel neoplasms as part of the differential for gastric outlet obstruction.Figure 1.: CT demonstration of duodenal bulb mass causing gastric outlet obstruction; Figure 2: Endoscopic image of duodenal bulb tumor.

S3540 An Extremely Rare Case of Primary Duodenal Bulb Adenocarcinoma Presenting as Epigastric Abdominal Pain

S3540 An Extremely Rare Case of Primary Duodenal Bulb Adenocarcinoma Presenting as Epigastric Abdominal Pain

S3437 Initial Presentation of Primary Duodenal Adenocarcinoma

S3437 Initial Presentation of Primary Duodenal Adenocarcinoma

Long-term results after resection of primary duodenal adenocarcinoma: A retrospective cohort study

BackgroundRadical resection of duodenal adenocarcinoma (DA) offers the possibility of cure. The outcome after operation and adjuvant therapy is mainly based on small numbers due to the low incidence of the disease. We examined the long-term outcome after surgical treatment of DA. Material and methodsThis was a retrospective cohort study including all patients undergoing curatively intended resection for histologically confirmed DA at a single University hospital. Long-term survival was examined by the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox proportional hazards regression analysis was applied to adjust for confounding. ResultsA total of 96 patients were included. The median follow-up was 3.7 years (IQR 2.9–4.3), during which 18 patients (18.5%) had recurrence and 35 (36.5%) patients had died. The 3- and 5-year overall survival was 66.3% (55.6–76.9%) and 58.2% (46.2–70.2%), respectively. In the multivariable analysis, adjuvant therapy was associated with decreased mortality (HR 0.29, CI 0.11–0.76, P = 0.011) whereas positive lymph node ratio >0.20 was associated with increased mortality. ConclusionRadical operation for DA has a median overall 5-year-survival of more than 50%. The indication for adjuvant chemotherapy remains to be addressed.

Prognostic factors for overall survival in patients with primary duodenal adenocarcinoma.

The complete resection of primary duodenal adenocarcinoma (PDA) offers a chance for a cure, but the clinical and pathological characteristics of survivors have not been well studied. Patients with stage I-III PDA who underwent surgical resection between 2013 and 2018 were identified retrospectively and followed until December 2019. All patients are from the Cancer Hospital Chinese Academy of Medical Sciences. The clinical and pathological information of the patients, such as age, gender, tumor location, operative procedure, pathologic features, TNM stage, common presenting symptoms, lymph node dissection status, serum tumor markers, etc., was collected in detail. The KaplanMeier method and a Cox proportional hazards model were used for the survival analysis. In total, 85 patients with PDA were eligible for this study. Among these patients, 48 were male (56.5%), 37 were female (43.5%), the median age was 59 (range, 22-79) years, 44 (51.8%) patients were aged <60 years, and 41 (48.2%) patients were aged ≥60 years. The 1-, 3-, and 5-year survival rates were 93.7%, 79.4%, and 64.9%, respectively. The median overall survival (OS) was 27 months (range, 2-82 months), and the median follow-up was 27 months (range, 3-82 months). The patients with stage III disease had the worst prognosis (P=0.001). The univariate analysis showed that lymph node positivity (P=0.000), the N stage (P=0.000), the TNM stage (P=0.001) and carbohydrate antigen 19-9 (CA19-9) positivity (P=0.038) were related to OS. However, the total number of lymph nodes (LN) retrieved (P=0.723), tumor differentiation (P=0.136), carcinoembryonic antigen (CEA) (P=0.812), gender (P=0.477), operation type (P=0.860), tumor size (P=0.869), tumor site (P=0.120), age (P=0.733), intraoperative blood loss (P=0.660), and intraoperative blood transfusion (P=0.748) were not correlated with OS. The multivariate analysis suggested that the lymph node status was an independent prognostic risk factor for OS. In our study the median OS was 27 months (range, 2-82 months), and the 5-year survival rates was 64.9%. The lymph node status was the only prognostic factor for OS in PDA.

Primary Duodenal Adenocarcinoma: Case report and literature review

Primary adenocarcinoma of the duodenum is a rare clinical condition, accounting for only 5% of all gastrointestinal neoplasms and 0.5% of all intestinal neoplasms. Nonspecific clinical presentation contributes to the majority of cases being diagnosed in advanced stages. The prognosis is poor, with a median survival of five years, varying from 23% to 57% in patients undergoing curative surgery (cephalic duodenopancreatectomy).

Factors impacting survival outcomes after curative resection for primary duodenal adenocarcinoma

Factors impacting survival outcomes after curative resection for primary duodenal adenocarcinoma

Primary Duodenal Adenocarcinoma: About Two Cases

This article focuses on the symptomatic and diagnostic problems of primary duodenal adenocarcinoma by way of two case reports and a literature review.The diagnosis of primary duodenal adenocarcinoma is often delayed because its symptoms may be absent until the tumor has progressed, thus leading to a delay of several months. Patients typically present with a long history of variable and vague symptoms, and many are diagnosed with advanced disease. As regards clinical manifestations, abdominal pain is the most frequent symptom. The majority of these tumors are found to have infiltrated the duodenal wall at presentation, with many being unresectable due to local and distal invasion.

Factors Impacting Survival Outcomes after Curative Resection for Primary Duodenal Adenocarcinoma

Factors Impacting Survival Outcomes after Curative Resection for Primary Duodenal Adenocarcinoma

A pathological complete response by chemotherapy with S-1 and oxaliplatin for a locally advanced duodenal adenocarcinoma in Lynch syndrome: a case report

BackgroundAlthough primary duodenal adenocarcinoma (DA) is a rare malignancy representing ~ 0.5% of all gastrointestinal cancers, the incidence of DA is more frequent in Lynch syndrome. Because of its rarity, treatment strategies or optimal chemotherapeutic regimens have not been clearly defined for advanced DA.Case presentationA 72-year-old woman with Lynch syndrome visited our hospital with a right upper abdominal pain. Computed tomography (CT) showed wall thickness with enhancement in the second portion of the duodenum and adjacent abdominal wall, which suggested direct tumor invasion to the abdominal wall. Upper gastrointestinal endoscopy (UGE) showed a large ulcerative tumor in the second portion of the duodenum, and histological analysis revealed a poorly differentiated adenocarcinoma. A cT4N0M0, cStage IIB (Union for International Control Cancer TNM staging) DA was diagnosed. After three courses of chemotherapy with S-1 and oxaliplatin (SOX), follow-up CT and UGE showed shrinkage of the duodenal tumor. Therefore, the patient underwent pancreaticoduodenectomy with lymph node dissection with curative intent. Histological examination showed a pathological complete response to SOX therapy. The postoperative course was uneventful, and the patient was discharged on postoperative day 29. The patient received no adjuvant chemotherapy, and there has been no evidence of recurrence 6 months after the operation.ConclusionsSOX therapy provided a remarkable response and can be an optimal chemotherapeutic regimen for advanced DA in Lynch syndrome.

Comparison of Robot and open pancreaticodenectomy for the treatment primary duodenal adenocarcinoma

Introduction: Robot surgery is a new method that maintains advantages and overcomes disadvantages of conventional methods, a surgical option for primary duodenal adenocarcinoma (PDA), is a complex procedure that has become increasing popular. However, there is no consensus as to whether this technique should be performed routinely. Our aim was to evaluate the outcomes of RPD compared with open pancreaticoduodenectomy (OPD). Method: Retrospective analysis of all pancreaticoduodenectomies at a single quaternary cancer referral center was performed, From January 2013 to March 2018, 50 RPDs were performed to treat PDA and were compared with 43 OPDs. Patients were also matched based on their demographic data and pathologic diagnosis. Demographic information, intraoperative and postoperative data, pathologic data, and follow-up evaluation data were collected at our center. And then compared using standard statistical methods. Result: The average follow-up time of all patients was 26.86 months (range 1.67 to 70.80 months). There were no significant differences in demography, short-term complications, pathological results or TNM staging between the two groups. The survival time of RPD group was slightly longer than that of OPD group (P=0.036). There were significant differences in oral time, blood loss time and hospital stay between the two groups (P < 0.05). However, there were no differences between the robotic group and the open group in terms of operation time, pancreatic texture, pancreatic anastomosis, vascular reconstruction, reoperation, 30-day readmission, chemotherapy, recurrence or R0 resection. Conclusion: This study found that RPD is a feasible, safe, and effective method for the treatment of PDA compared with OPD , may be a better preferred method for surgeons to choose for he treatment of PDA.

Incidental Finding of Primary Duodenal Adenocarcinoma Resembling a Submucosal Tumor Successfully Diagnosed and Treated With EUS FNA and EUS Guided Fiducial Placement and SBRT

Incidental Finding of Primary Duodenal Adenocarcinoma Resembling a Submucosal Tumor Successfully Diagnosed and Treated With EUS FNA and EUS Guided Fiducial Placement and SBRT

Incidental endoscopic findings of a rare gastric neuroendocrine carcinoma concurrent with an uncommon primary duodenal adenocarcinoma: A case report

Gastric neuroendocrine tumors (NETs) are rare gastric tumors. They are often found during esophagogastroduodenoscopy (EGD) as multiple small intramucosa polyps or as a single large polypoid lesion. Gastric NETs are difficult to distinguish from gastric adenocarcinoma or lymphoma. NETs are uncommon tumors, usually poorly differentiated and highly malignant. They are typically accompanied by vascular invasion and metastasis and have an extremely poor prognosis. Here, we reported an NET of the stomach concurrent with primary duodenal adenocarcinoma. A 56‐year‐old woman had underlying adenocarcinoma of the lung and received regular chemotherapy. Because of upper abdomen discomfort, EGD was performed, which showed diffuse multiple polypoid lesions over the stomach and another protruding mass over the posterior wall of the duodenal bulb. Abdomen computed tomography and the pathological report confirmed the above diagnosis.

Prognosis and nomogram for predicting postoperative survival of duodenal adenocarcinoma: A retrospective study in China and the SEER database

As primary duodenal adenocarcinoma is rare, the prognostic factors of this disease remain insufficiently explored, especially in China. We identified postoperative duodenal adenocarcinoma patients at a Chinese double-center (from 2006 to 2016) or who were registered with the Surveillance, Epidemiology, and End Results (SEER) database (from 2004 to 2014). Clinicopathological features and significant prognostic factors for cancer-specific survival (CSS) were reviewed and analyzed by using univariate and multivariate Cox proportional hazards regression. Then, a nomogram predicting CSS was constructed based on the SEER database and validated externally by using the separate Chinese cohort. Totally, 137 patients from the Chinese double-center and 698 patients from the SEER database were included for analysis. The multivariate analyses showed that age, tumor grade and TNM stage were independent prognostic factors. The nomogram constructed using these factors showed a clear prognostic superiority to the AJCC-TNM classification, 7th ed. (C-index: SEER cohort, 0.693 vs 0.625, P < 0.001; Chinese cohort, 0.677 vs 0.659, P < 0.001, respectively). In summary, the valuable prognostic factors in patients with duodenal adenocarcinoma were age, tumor grade and TNM stage. This study developed a nomogram that can precisely predict the CSS for postoperative duodenal adenocarcinoma patients.

Evaluation of disease free survival after radical resection for primary duodenal adenocarcinoma

Objective: To investigate the risk factors associated with the disease free survival (DFS) for primary duodenal adenocarcinoma patients undergoing radical resection. Methods: The clinicopathological data of 101 primary duodenal adenocarcinoma patients who underwent radical resection from January 2001 to October 2014 were retrospectively reviewed. Using SPSS 13.0 software, the survival curve was drawn by Kaplan-Meier method, and the survival rates were analyzed by Log-rank test.COX regression model was used to identify independent risk factors. Results: Among 101 patients, the main clinical manifestation were upper abdomen discomfort, abdominal pain, jaundice, gastrointestinal obstruction, hemorrhage, emaciation and so on. A total of 87 patients had the tumor located at the descending part of the duodenum. All the 101 patients underwent radical resection, and 85 patients received pancreatoduodenectomy while 16 patients underwent segmental resection. The median disease free survival time was 26 months and the postoperative 1, 3, 5 year DFS rate were 79.7%, 60.3% and 53.6%, respectively. The univariate analyses identified elevated preoperative CEA and CA19-9 level, T stage, lymph node state, vascular invasion and perineural invasion predicting a worse DFS(P<0.05). On multivariate analysis, positive lymph node state was an independent risk factor for DFS (RR=5.394, 95% CI: 1.624-17.913). Conclusion: Radical resection is the best therapeutic method for primary duodenal adenocarcinoma; the positive lymph node state is the independent risk factor affecting the disease free survival of patients after radical resection.

Prognostic Factors and Clinical Characteristics of Patients with Primary Duodenal Adenocarcinoma: A Single-Center Experience from China.

Aim. To evaluate the clinical risk factors influencing overall survival of patients with duodenal adenocarcinoma after potentially curative resection. Methods. A series of 201 patients with primary duodenal adenocarcinoma who underwent surgery from 1999 to 2014 at Chinese Medical Academic Cancer Hospital were studied by retrospective chart review and subsequent telephone follow-up. Results. Resectional surgery was performed in 138 of the 201 patients to attempt curative treatment, while 63 patients were treated with palliative surgery. Median survival of patients who underwent resectional operation was 57 months, whereas that of patients who had palliative surgery was shorter, 7 months (p < 0.001). For patients who underwent radical resection, the overall 1-, 3-, and 5-year survival rates were 87.3, 59.1, and 44.1%, respectively. Multivariate Cox regression analysis revealed that lymph node metastasis (HR 31.76, 2.14 to 470.8; p = 0.012) and vascular invasion (HR 3.75, 1.24 to 11.38; p = 0.020) were independent prognostic factors negatively associated with survival in patients undergoing curative resection. There was no survival difference between the groups treated by the pancreaticoduodenectomy (n = 20) and limited resection (n = 10) for early-stage duodenal adenocarcinoma (p = 0.704). Conclusions. Duodenal adenocarcinoma is a rare disease. Curative resection is the best treatment for appropriate patients. Lymph node metastases and vascular invasion are negative prognostic factors.