The cancer of duodenum is a rare
but aggressive disease and radical surgery to achieve complete tumor excision is
the only potentially curative treatment. Due to rarity, these tumors are often grouped
either with periampullary or small bowel cancers and therefore available literature
for their management is limited.
Traditionally pancreatoduodenectomy
or Whipple's procedure is the recommended surgical procedure for duodenal
cancers. Whipple's procedure is a complex procedure and still carries a
mortality of up to 5% and morbidity in the range of 30-50% at well endowed
centers. Moreover for non-ampullary duodenal cancers the risks associated with
Whipple's procedure are reported to be higher due to risk factors including non
dilated pancreatic duct & soft pancreas.
As per the recent NCCN guidelines while the preferred treatment for
duodenal cancers is Whipple's procedure however in select patients limited segmentectomy
with regional lymphadenectomy is an acceptable alternative. We present one such patient recently managed by our team.
Case presentation
A 57 years gentleman with a recent
history (May 2019) of coronary artery bypass graft (CABG) and aortic valve replacement
(AVR) presented in emergency room with massive upper GI bleed in August 2019.
He also had history of recurrent vomiting of 20-25 days duration and also loss
of weight of approx 15 kg over 2 months following cardiac surgery. Following
initial resuscitation in ICU and discontinuation of anti-platelet &
anti-coagulation medications, an urgent upper GI endoscopy was performed. On
endoscopy except for bleeding from stricture in fourth part of duodenum, rest
of the upper GI tract was normal (Figure 1).
Figure 1. Upper GI endoscopy - bleed from stricture duodenum
Bleeding was controlled with
injection sclerotherapy and the biopsy from the lesion was reported as tubulo-villous
adenoma with high grade dysplasia. A subsequent CECT whole abdomen was
suggestive of circumferential duodenum wall thickening in third part of
duodenum (Figure 2).
Figure 2. CECT abdomen displaying circumferential wall thickening in III part of duodenum (white arrows) & additional findings of horse shoe kidney (asterisk )
The tumor markers CEA (1.31) & Ca 19.9 (0.8) were
within normal range and colonoscopic examination did not reveal any
abnormality. After thorough work up and discontinuation of anticoagulants 12
hours prior he was taken up for surgery.
In our patient because of recent CABG and AVR surgery, early resumption
of anticoagulants & anti-platelet medications was warranted. Hence PPDD was
an obvious alternative especially because tumor was confined to the wall of
duodenum and distally located (III & IV part of duodenum).
At surgery there was stricture in
III & IV part of duodenum and enlarged regional lymph nodes. A PPDD with 5
cm proximal and 10 cm distal margin along with regional lymphadenectomy was
performed. A side to side duodeno-jejunal
anastomosis (second part of duodenum & proximal jejunum) and feeding
jejunostomy was fashioned. In post operative period injection Enoxaparin
(0.6 mg sc BD) was re-started on post operative day (POD) 1 and subsequently
anti-platelet medications were added on POD 4. Except for delayed gastric
emptying his postoperative period was uneventful. Histopathology reported well
differentiated adenocarcinoma of duodenum and tumour was invading muscularis
propria & focally into subserosa (pT3). No lympho-vacular emboli or
perineural spread was seen. All 17 lymph nodes and surgical margins (proximal, distal and
radial) were
free from tumour.
Discussion
Primary adenocarcinoma of the duodenum is an uncommon neoplasm but the
prognosis is better in comparison to cancer of pancreas or distal bile duct.
Because of the soft pancreatic texture and small size pancreatic duct,
the rate of pancreatic fistula following Whipple's procedure for non-ampullary
duodenal cancers is reported to be in the range of 28.9 – 32.5% which is almost
double in comparison to Whipple's procedure for all other pathologies.1,2
There are conflicting reports on the extent of surgery for duodenal
cancers. Some advocate PD for all duodenal cancers regardless of location while
others support segmental resection (PPDD) for distal duodenal cancers if margin
negative resection is feasible.
In one of the early study from Johns Hopkins Hospital, significant 5
year overall survival advantage with PD (69%) was reported in comparison to PPDD (0%).3
However several subsequent studies have not supported these results in
favour of PD. A study from Mayo Clinic reported comparable overall survival
between the groups of patients undergoing PD or PPDD for duodenal cancer. The 5
year survival estimate in PPDD group was 52% and in PD group was 42 % (p=0.50).4
A study of SEER database involving 1611 patients' also reported that PD does
not impact 5 year survival (37.6%) compared with segmental resection (41.3 %) for
duodenal cancers (p > 0.05).5 In a recent systematic review of
largest collective number of patients (n = 1728) authors concluded that
aggressive surgical approach to achieve complete tumor excision should be
pursued and PPDD should be considered if tumor invasion is confined to duodenal
wall especially for distal duodenal tumors.6
In summary, PPDD is an acceptable alternative
to Whipple's procedure for non ampullary duodenal cancers particularly in high
risk cases.
References
1. Le CHA, Shingler G, Mowbray NG et al. Surgical outcomes for duodenal adenoma and adenocarcinoma: a multicentre study in Australia and the United Kingdom. ANZ J Surg. 2018;88:E157-E161. Doi:10.1111/ans.13873
4. Onkendi EO, Boostrom SY, Sarr MG et al. 15-year experience with surgical treatment of duodenal carcinoma: a comparison of periampullary and extra-ampullary duodenal carcinomas. J Gastrointest Surg. 2012;16(4):682-691
5. Cloyd JM, Norton JA, Visser BC et al. Does the extent of resection impact survival for duodenal adenocarcinoma? Analysis of 1,611 cases. Ann Surg Oncol. 2015;22(2):573-580
6. Debang Li, Xiaoying Si, Tao Wan et al. Outcomes of surgical resection for primary duodenal adenocarcinoma: A systematic review. Asian J Surg. 2019;42(1):46-52
Suggested for further reading:
Authors:
Dr Nitin Vashistha, MS, FIAGES, FACS
Dr Dinesh Singhal, MS, FACS, DNB (Surg Gastro)
Department of Surgical Gastroenterology,
Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com
Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com
No comments:
Post a Comment