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The Journal of Surgical Research Aug 2020Proximal (duodenal) small bowel adenocarcinomas have a worse prognosis than distal (jejuno-ileal) tumors, but differences in patient, tumor, and treatment factors... (Comparative Study)
Comparative Study
BACKGROUND
Proximal (duodenal) small bowel adenocarcinomas have a worse prognosis than distal (jejuno-ileal) tumors, but differences in patient, tumor, and treatment factors between locations remain unclear.
METHODS
Patients in the National Cancer Database with surgically resected pathologic stage I-IV small bowel adenocarcinomas between 2004 and 2015 were analyzed. Clinical stage IV patients were excluded.
RESULTS
Proximal tumors (n = 3767) were more likely to be higher grade (OR 1.52, CI 1.22-1.85 for moderately; OR 1.83, CI 1.49-2.33 for poorly differentiated, P < 0.01 for both) and have positive lymph nodes (OR 2.04, CI 1.30-3.23, P < 0.01), while distal tumors (n = 3252) were likely to be larger (OR 1.31, CI 1.07-1.60 for size > 5 cm, P < 0.01). Proximal tumors were associated with worse overall survival (OS) and stage-specific survival compared with distal tumors (all P < 0.01). Cox regression analysis of the entire cohort showed worse survival with community versus academic cancer programs, higher comorbidity scores, pathologic stage IV, poorly differentiated histology, positive nodal or margin status, and proximal location, while female gender, larger tumor size, and chemotherapy predicted better survival. On separate Cox regression analyses of each location, neoadjuvant chemotherapy was associated with better OS in the proximal cohort (HR 0.70, CI 0.55-0.88, P < 0.01), while adjuvant chemotherapy was associated with better OS for both proximal (HR 0.49, CI 0.42-0.57, P < 0.01) and distal tumors (HR 0.68, CI 0.57-0.81, P < 0.01).
CONCLUSIONS
Proximal small bowel adenocarcinomas are associated with worse overall and stage-specific survival. This may be due to tumor biologic differences as proximal tumors were more likely to have higher grade. Future studies should further investigate differences between proximal and distal tumors to guide targeted treatment algorithms.
Topics: Adenocarcinoma; Aged; Chemoradiotherapy, Adjuvant; Duodenal Neoplasms; Duodenum; Female; Humans; Ileal Neoplasms; Ileum; Jejunal Neoplasms; Jejunum; Kaplan-Meier Estimate; Male; Margins of Excision; Middle Aged; Neoadjuvant Therapy; Neoplasm Grading; Neoplasm Staging; Prognosis; Retrospective Studies; Risk Factors; Sex Factors; Survival Rate; Treatment Outcome
PubMed: 32278965
DOI: 10.1016/j.jss.2020.03.017 -
Digestive Diseases (Basel, Switzerland) 2019The increasing incidence of duodenal neoplasm has underlined different methods of resection depending on the clinical presentation, endoscopic features and...
BACKGROUND
The increasing incidence of duodenal neoplasm has underlined different methods of resection depending on the clinical presentation, endoscopic features and histopathology. In this comprehensive review, we systematically describe the current knowledge concerning the diagnosis and management of duodenal adenomas (DAs) and discuss data considering all possible therapeutic approaches.
SUMMARY
Among a variety of duodenal lesions, including neuroendocrine tumors and gastrointestinal stromal tumors, DAs present precancerous lesions of the duodenal papilla or non-ampullary region necessitating removal. DAs can occur sporadically (SDA) as rare lesions or relatively common in polyposis syndromes. The endoscopic resections of DA are associated with an increased degree of complexity due to distinctive anatomical properties of the duodenal wall, luminal diameter and the presence of ampulla with pancreatic and biliary drainage. The endoscopic techniques including cold snare polypectomy (CSP), endoscopic mucosal resection (EMR), and argon plasma coagulation ablation are suggested to be less invasive than surgical treatment, associated with shorter hospital stay and lower cost. According to the current clinical practice, surgery has been accepted as standard therapeutic approach in familial adenomatous polyposis patients with severe polyposis or DA not amenable to endoscopic resection. Key Messages: The strategy for endoscopic resection of DAs depends on the lesion size, morphology, location, and histopathology findings. Small adenomas are most frequently diagnosed and removed by standard CSP techniques, while large laterally spreading lesions and ampullary adenoma are referred for EMR or endoscopic papillectomy respectively. Screening colonoscopy is indicated in patients with SDA. Additional studies for new endoscopic strategies and techniques for curative therapy of DAs are needed to refine future management decisions. Complete resection of DA is considered curative, but nevertheless, long-term endoscopic follow-up is still required to detect and treat any recurrent arising lesions.
Topics: Adenoma; Adenomatous Polyposis Coli; Colonoscopy; Duodenal Neoplasms; Humans; Retrospective Studies
PubMed: 30921797
DOI: 10.1159/000496697 -
The American Journal of Surgical... Feb 2022Patients with multiple endocrine neoplasia 1 syndrome (MEN1) often develop multifocal duodenopancreatic neuroendocrine tumors (dpNETs). Nonfunctional pancreatic...
Patients with multiple endocrine neoplasia 1 syndrome (MEN1) often develop multifocal duodenopancreatic neuroendocrine tumors (dpNETs). Nonfunctional pancreatic neuroendocrine tumors (PanNETs) and duodenal gastrinomas are the most frequent origins of metastasis. Current guidelines recommend surgery based on tumor functionality, size ≥2 cm, grade or presence of lymph node metastases. However, in case of multiple primary tumors it is often unknown which specific tumor metastasized. This study aims to unravel the relationship between primary dpNETs and metastases in patients with MEN1 by studying endocrine differentiation. First, it was shown that expression of the endocrine differentiation markers ARX and PDX1 was concordant in 18 unifocal sporadic neuroendocrine tumors (NETs) and matched metastases. Thereafter, ARX, PDX1, Ki67 and gastrin expression, and the presence of alternative lengthening of telomeres were determined in 137 microscopic and macroscopic dpNETs and 36 matched metastases in 10 patients with MEN1. ARX and PDX1 H-score clustering was performed to infer relatedness. For patients with multiple metastases, similar intrametastases transcription factor expression suggests that most metastases (29/32) originated from a single NET of origin, while few patients may have multiple metastatic primary NETs. In 6 patients with MEN1 and hypergastrinemia, periduodenopancreatic lymph node metastases expressed gastrin, and clustered with minute duodenal gastrinomas, not with larger PanNETs. PanNET metastases often clustered with high grade or alternative lengthening of telomeres-positive primary tumors. In conclusion, for patients with MEN1-related hypergastrinemia and PanNETs, a duodenal origin of periduodenopancreatic lymph node metastases should be considered, even when current conventional and functional imaging studies do not reveal duodenal tumors preoperatively.
Topics: Adult; Aged; Biomarkers, Tumor; Carcinoma, Neuroendocrine; Databases, Factual; Duodenal Neoplasms; Female; Gastrins; Homeodomain Proteins; Humans; Ki-67 Antigen; Lymphatic Metastasis; Male; Middle Aged; Multiple Endocrine Neoplasia Type 1; Neoplasm Grading; Pancreatic Neoplasms; Trans-Activators; Transcription Factors
PubMed: 34560682
DOI: 10.1097/PAS.0000000000001811 -
Scandinavian Journal of Gastroenterology May 2021Though superficial non-ampullary duodenal epithelial tumors (SNADETs) have been traditionally considered rare, there is a growing detection under the development and... (Review)
Review
Though superficial non-ampullary duodenal epithelial tumors (SNADETs) have been traditionally considered rare, there is a growing detection under the development and widespread of endoscopic techniques in recent times. Many case studies have revealed early manifestations of lesions through advanced endoscopic technology, however, because of the low incidence of duodenal tumors and challenges in diagnosing, the preoperative diagnosis criteria have not been established so far. In spite of this, recently the increasing detection rate of early duodenal epithelial lesions enhances the demand for minimally invasive treatment as well. The most suitable therapeutic endoscopic modality to remove duodenal lesions should be selected according to the size, location and histological invasive depth of duodenal lesions. Nevertheless, due to the special anatomical structure of the duodenum, the incidence of complications is much higher than in any other part of the digestive tract. To prevent these adverse events prophylactically, a few novel strategies have been applied effectively after resection. This review describes the current status of preoperative endoscopic diagnosis and endoscopic resection approaches, as well as countermeasures for avoiding procedure-related complications.
Topics: Duodenal Neoplasms; Duodenoscopy; Duodenum; Endoscopy; Humans; Neoplasms, Glandular and Epithelial
PubMed: 33730963
DOI: 10.1080/00365521.2021.1900384 -
Neuroendocrinology 2021The characteristics, prognostic factors, and management of duodenal neuroendocrine neoplasms (dNEN) are ill-defined, given their rarity. Whether nonsurgical management...
INTRODUCTION
The characteristics, prognostic factors, and management of duodenal neuroendocrine neoplasms (dNEN) are ill-defined, given their rarity. Whether nonsurgical management might be appropriate for patients with nonmetastatic dNEN and a good prognosis, as is the case for pancreatic NEN (pNEN), is unknown. We aimed to describe the management and prognosis of nonmetastatic dNEN patients.
METHODS
All consecutive patients with nonmetastatic dNEN managed between 1981 and 2018 in 2 expert centers were included. Recurrence-free survival (RFS) and factors associated with recurrence were estimated.
RESULTS
A total of 145 patients with dNEN were included. Twenty-eight patients with sporadic, nonfunctioning, small (median 7 mm) dNEN underwent endoscopic resection, with a 5-year RFS rate of 89.4%. Local recurrence occurred in 2 patients, who underwent surgery with no new events. The 5-year RFS rate was 87.9% in patients who underwent surgery. Upon univariate analysis, age, size, Ki67 index, and lymph node involvement (LN+) were significantly associated with worse RFS for all dNEN treated (endoscopy/surgery); multivariate analysis found that age, size, and LN+ were associated with worse RFS.
CONCLUSION
Selected nonmetastatic dNEN had a favorable outcome, and a less invasive therapeutic strategy appeared more suitable than oncological surgery.
Topics: Adult; Aged; Aged, 80 and over; Disease-Free Survival; Duodenal Neoplasms; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neuroendocrine Tumors; Outcome and Process Assessment, Health Care; Retrospective Studies
PubMed: 32335556
DOI: 10.1159/000508102 -
Expert Review of Gastroenterology &... Jun 2022Endoscopic mucosal resection of duodenal polyps (EMR) is a challenging intervention. The aim of this study was to review the patient characteristics, techniques,...
BACKGROUND
Endoscopic mucosal resection of duodenal polyps (EMR) is a challenging intervention. The aim of this study was to review the patient characteristics, techniques, procedure outcomes, adverse events, and recurrence of duodenal polyps.
RESEARCH DESIGN AND METHODS
Patients were included if they had pathologically confirmed non-ampullary duodenal polyps and had received EMR with at least one follow-up EGD for surveillance. Descriptive statistics were employed to report the findings.
RESULTS
A total of 65 patients underwent a total of 90 EMRs for duodenal polyps. The mean age was 65.4 years, and 29 of the patients were female. Complete resection of the visible mass was achieved in 96.9% of cases. Endoscopic hemostasis was required in 18.5% of patients. Delayed bleeding occurred in 9%, and delayed perforations requiring surgical intervention occurred in 2.2% of patients with no mortality. Surgery after EMR was needed in 12.7% of cases. Eleven (16.9%) patients had recurrent duodenal adenoma on follow-up EGD.
CONCLUSION
Duodenal polyps can be safely resected and have a notable recurrence rate. This is particularly true for adenomas, warranting post-resection endoscopic surveillance. The appropriate interval for post-resection surveillance of duodenal adenomas should be a focus of future study.
Topics: Adenoma; Aged; Duodenal Diseases; Duodenal Neoplasms; Endoscopic Mucosal Resection; Female; Humans; Intestinal Polyps; Male; Neoplasm Recurrence, Local; Retrospective Studies; Treatment Outcome
PubMed: 35687675
DOI: 10.1080/17474124.2022.2088508 -
Japanese Journal of Clinical Oncology Aug 2018Non-ampullary duodenal adenocarcinoma, excluding carcinoma in the ampulla of Vater, is a rare disease. Although several prognostic factors have been reported, they...
BACKGROUND
Non-ampullary duodenal adenocarcinoma, excluding carcinoma in the ampulla of Vater, is a rare disease. Although several prognostic factors have been reported, they remain controversial due to the rarity of non-ampullary duodenal adenocarcinoma. The aims of this study were to investigate prognostic factors in patients with non-ampullary duodenal adenocarcinoma and to assess chemotherapy in patients with recurrence.
PATIENTS AND METHODS
Records of 25 patients who underwent surgical treatment for non-ampullary duodenal adenocarcinoma from 2004 to 2016 were retrospectively reviewed. The relationship between the clinicopathological factors and outcomes was investigated.
RESULTS
Serum level of CA19-9, gross appearance, tumor size, tumor invasion, lymph node metastases, TNM stage and lymphatic and vascular invasion were significant risk factors of recurrence. Patients with recurrence who received chemotherapy according to regimens used to treat colorectal cancer had a better prognosis than those without chemotherapy (P = 0.016).
CONCLUSION
Advanced non-ampullary duodenal adenocarcinoma has a poor prognosis, but chemotherapy possibly improves the prognosis in the patients with recurrent non-ampullary duodenal adenocarcinoma.
Topics: Adenocarcinoma; Ampulla of Vater; CA-19-9 Antigen; Duodenal Neoplasms; Female; Humans; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Recurrence, Local; Prognosis; Retrospective Studies; Risk Factors; Survival Analysis
PubMed: 29931295
DOI: 10.1093/jjco/hyy086 -
World Journal of Gastroenterology Sep 2014Because of the low prevalence of non-ampullary duodenal epithelial tumors (NADETs), standardized clinical management of sporadic superficial NADETs, including diagnosis,... (Review)
Review
Because of the low prevalence of non-ampullary duodenal epithelial tumors (NADETs), standardized clinical management of sporadic superficial NADETs, including diagnosis, treatment, and follow-up, has not yet been established. Retrospective studies have revealed certain endoscopic findings suggestive of malignancy. Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery. The use of endoscopic treatment including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for the treatment for superficial NADETs is increasing. EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection. ESD provides an excellent complete resection rate, however it remains a challenging method, considering the high risk of intraoperative or delayed perforation. Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment. Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion, which presents a risk of lymph node metastasis. Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory. Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.
Topics: Adenoma; Carcinoma; Dissection; Duodenal Neoplasms; Duodenoscopy; Humans; Lymphatic Metastasis; Neoplasm Invasiveness; Pancreaticoduodenectomy; Treatment Outcome
PubMed: 25253950
DOI: 10.3748/wjg.v20.i35.12501 -
Acta Gastro-enterologica Belgica 2019This retrospective study purports to examine these characteristics and compare the surgical procedures available and appropriate for the treatment of patients affected... (Comparative Study)
Comparative Study
BACKGROUND AND STUDY AIMS
This retrospective study purports to examine these characteristics and compare the surgical procedures available and appropriate for the treatment of patients affected by duodenal GISTs.
PATIENTS AND METHODS
A retrospective examination of reports and studies carried out between May 2012 and March 2017, and covering patients with primary GISTs of the duodenum was performed using modules from the SPSS package. Comparisons of treatment effects resulting from the administration of two differential methods of surgical treatment namely pancreaticoduodenectomy (PD), and limited resection (LR), were effected on the reports of the GIST patients thus selected.
RESULTS
Out of these 62 patients who had undergone resection of duodenal GISTs, 47 (76%) had limited resection (LR) and 15 (24%) underwent pancreaticoduodenectomy (PD). In Multivariate analyses, tumor size was an independent predictive factor for recurrence (p=0.008). ASA, tumor size, and PD were independent and significant prognostic factors on OS (p=0.021, p=0.024, and p=0.030, respectively). In the very low and low risk group, and high-risk group, there were no significant differences in the RFS (recurrence-free survival) and OS (overall survival) between the LR and PD groups.
CONCLUSIONS
When technically feasible, LR should be given due consideration as a reliable and curative option for duodenal GISTs achieving satisfactory RFS and OS.
Topics: Duodenal Neoplasms; Duodenum; Gastrointestinal Stromal Tumors; Humans; Neoplasm Recurrence, Local; Pancreaticoduodenectomy; Prognosis; Retrospective Studies; Treatment Outcome
PubMed: 30888748
DOI: No ID Found -
The Turkish Journal of Gastroenterology... Jul 2023Duodenal lipomas are rarely found in the gastrointestinal tract. Most published literature referring to the tumors is limited to case series. There remained issues about...
BACKGROUND/AIMS
Duodenal lipomas are rarely found in the gastrointestinal tract. Most published literature referring to the tumors is limited to case series. There remained issues about the understanding and management of duodenal lipomas to be clarified. We aimed to investigate the clinical and endoscopic features of duodenal lipomas. Additionally, outcomes of endoscopic resection for duodenal lipomas were evaluated.
MATERIALS AND METHODS
A total of 29 duodenal lipomas resected endoscopically from December 2011 to October 2021 were included. Clinical characteristics, endoscopic features, and endoscopic ultrasound findings were analyzed retrospectively. The endoscopic resection was performed in 3 ways: hot snare polypectomy, endoscopic mucosa resection, and endoscopic submucosal dissection.
RESULTS
Of the 29 duodenal lipomas, 21 were located at the second portion with a mean size of 25.8 mm (range, 7-60 mm). Yamada type IV was the most common macroscopic type in 14 lesions, exhibiting a tendency of forming large peduncles. Seven patients had digestive symptoms. The occurrence of symptoms is associated with the tumor size. Endoscopic ultrasound was performed on 23 duodenal lipomas, of which 20 demonstrated homogenous echogenicity and 3 presented heterogeneous with tubular anechoic region. The endoscopic resection operation was successfully conducted on 29 patients without severe adverse events. The rate of en bloc and endoscopic complete resection was 93.1% and 86.2%, respectively. Recurrence was noted in 1 patient.
CONCLUSIONS
Clinical characteristics with typical endoscopic ultrasound features are helpful in duodenal lipomas diagnosis. The endoscopic resection is a safe and effective treatment for duodenal lipomas with considerable long-term outcomes.
Topics: Humans; Endoscopic Mucosal Resection; Endosonography; Lipoma; Retrospective Studies; Treatment Outcome; Duodenal Neoplasms
PubMed: 37326152
DOI: 10.5152/tjg.2023.22617