Duodenal adenocarcinoma: Advances in diagnosis and surgical management

Table 1 Histopathologic subtypes of duodenal adenocarcinoma

Phenotype	Histological characteristics	Histologically similar	Immunophenotype markers	Prognosis
Intestinal	Tubular/cribiforming glands lined by columnar neoplastic cells	Colonic adenocarcinoma	MUC2, CD10, CDX2	+
Gastric	Tubular/papillary proliferation with foveolar or pyloric-type differentiation	Gastric adenocarcinoma	MUC5AC, MUC6	-
Pancreaticobiliary	Simple glands of cuboidal/columnar cells with rounded pleomorphic nuclei; prominent desmoplastic stroma	Pancreatic and Extrahepatic bile duct adenocarcinoma	MUC1	-
Indeterminate	Poor differentiation	None	MUC1	-

Adapted from Ushiku et al[22].

Table 2 7^th edition of the American Joint Committee on Cancer’s staging system for small bowel adenocarcinoma

Primary tumor (T)	Regional lymph nodes (N)			Distant metastases (M)
Tx - Primary tumor cannot be assessed	Nx - Regional lymph nodes cannot be assessed			Mx - Distant metastases not assessed
Tis - Carcinoma in situ	N0 - No regional node metastasis			M0 - Distant metastases not present
T1a - Tumor invades lamina propria	N1 - Metastasis in 1-3 regional nodes			M1 - Distant metastases present
T1b - Tumor invades submucosa	N2 - Metastasis in 4 or more regional nodes
T2 - Tumor invades muscularis propria	Stage grouping
T3 - Tumor invades into the subserosa	Stage 0	Tis	N0	M0
	Stage I	T1-T2	N0	M0
T4 - Tumor perforates visceral peritoneum; or invades pancreas/bile duct	Stage IIA	T3	N0	M0
	Stage IIB	T4	N0	M0
	Stage IIIA	Any T	N1	M0
	Stage IIIB	Any T	N2	M0
	Stage IV	Any T	Any N	M1

Table 3 Series reporting factors associated with worse survival in duodenal adenocarcinoma

Ref.	Study period	Total No. of patients	No. of patients resected (%)	PD	5-year overall survivalafter resection (%)	Negative predictors of survival
						Non-predictor	Univariate	Multivariate
Solaini et al[48]	2000-2013	178	150 (84.2)	132	43	T stage, grade, AJCC stage, perineural invasion, size, age	-	Lymphovascular invasion, nodal metastasis
Poultsides et al[50]	1984-2006	122	122 (100)	122	48	T stage, tumor grade	Tumor grade, positive margins, perineural invasion, nodal metastasis, vascular invasion	Nodal metastasis
Onkendi et al[79]	1994-2009	124	99 (79.8)	70	37	Tumor size, positive nodes, surgical approach, adjuvant therapy	-	T stage and pathologic grade
Cecchini et al[80]	1982-2010	169	103 (60.9)	87	42	T stage, nodal metastasis, grade, AJCC stage, lymphovascular invasion, size, age	-	Perineural invasion
Liang et al[77]	1993-2010	36	36 (100)	31	NA	T stage, grade, AJCC stage, lymphovascular invasion, perineural invasion, size	Age > 75, body weight loss, nodal metastasis	Nodal metastasis
Malleo et al[73]	2000-2009	37	25 (67)	25	711	T stage, nodal metastasis, AJCC stage, lymphovascular invasion, perineural invasion, size, age	-	Tumor grade, lack of post-operative complications
Zhang et al[16]	1995-2008	91	59 (65)	NA	491	T stage, grade, AJCC stage, lymphovascular invasion, perineural invasion, size, age	-	Nodal metastasis, positive margins
Han et al[81]	1990-2006	32	28 (88)	18	30	-	Positive margins	-
Struck et al[78]	1989-2006	30	30 (100)	25	332	Positive margins, T stage, adjuvant therapy		Nodal metastasis, stage
Lee et al[74]	1995-2007	53	28 (53)	26	44	Age, gender, weight loss, CA19-9, grade, tumor size	T stage, nodal metastasis, AJCC stage	Nodal metastasis
Hurtuk et al[82]	1984-2005	52	35 (67)	24	NA	Grade, positive margins, nodal metastasis, venous or perineural invasion	Stage T4, tumor size < 3.5 cm	-
Hu et al[47]	NA	43	28 (65)	11	27	-	Positive margins	-
Sarela et al[51]	1983-2000	137	72 (52.5)	56	711	Gender, grade, T stage	Age, nodal metastasis	Age, nodal metastasis
Tocchi et al[13]	1980-2000	47	25 (53)	9	23	T stage, grade, AJCC stage, lymphovascular invasion, perineural invasion, positive margins, size, age	-	Nodal metastasis
Ryder et al[83]	1957-1998	49	31 (63)	27	43	Nodal metastases, location in duodenum, type of resection, adjuvant chemoradiation	-	Tumor size, histologic grade, transmural invasion
Kaklamanos et al[43]	1978-1998	63	37 (59)	26	30	Age, gender, grade, T stage	Nodal metastasis	Nodal metastasis
Bakaeen et al[44]	1976-1996	101	68 (67)	50	54	Histologic grade, tumor size, location in duodenum, adjuvant chemoradiation	Age, weight loss, T stage, nodal metastasis, AJCC stage	Weight loss, positive margins, nodal metastasis, AJCC stage
Sohn et al[35]	1984-1996	55	48 (87)	35	53	Nodal metastasis, adjuvant chemoradiation, tumor size, histologic grade	Positive margins, segmental resection, tumor in third/fourth portion of duodenum	-
Sexe et al[76]	1987-1991	85	34 (40)	31	23	AJCC Stage	-	-
Rotman et al[84]	1978-1988	66	46 (70)	38	45	Gender, age, weight loss, jaundice, T stage, tumor size, pancreatic invasion nodal metastasis, location of metastatic nodes	-	-
Delcore et al[85]	1960-1990	35	28 (80)	21	60	-	GI bleeding, symptomatic > 4 mo, nodal metastasis	-
Barnes et al[40]	1967-1991	67	36 (54)	27	54	Nodal metastasis	Stage
Lowell et al[42]	1970-1991	17	17 (100)	8	45	-	First/second portion of the duodeum	-
Ouriel et al[33]	1950-1981	65	19 (29)	1	30	-	Histologic grade, nodal metastasis	-

Values in parentheses are percentages.

¹R0 resection only;

²Three-year survival. PD: Pancreaticoduodenectomy; AJCC: American Joint Committee on Cancer; NA: Not available.