Small Bowel Adenocarcinoma: Understaged and Undertreated?

Nicholl, Michael B.; Ahuja, Vanita; Conway, William G.; Vu, Vu D.; Sim, Myung‐Shin; Singh, Gaurav

doi:10.1245/s10434-010-1109-x

Cited by 56 publications

(51 citation statements)

References 30 publications

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“…10 Similarly, a recent population study on small bowel adenocarcinoma showed that retrieval of at least 10 lymph nodes enhanced the prognostic ability of the AJCC staging system. 26 Our study is the first to demonstrate that the actual number of involved lymph nodes with metastasis is associated with survival, validating the current AJCC staging system, which stratifies N stage as N0 (no lymph node metastasis), N1 (1–3 positive lymph nodes), and N2 (4 or more positive lymph nodes). However, the AJCC guidelines set as the minimum number of regional lymph nodes that need to be assessed pathologically for duodenal or small bowel adenocarcinoma to 6 only.…”

Section: Discussionsupporting

confidence: 78%

Duodenal Adenocarcinoma: Clinicopathologic Analysis and Implications for Treatment

et al. 2011

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Background Duodenal adenocarcinoma is a rare cancer usually studied as a group with periampullary or small bowel adenocarcinoma; therefore, its natural history is poorly understood. Methods Patients with duodenal adenocarcinoma were identified from a single-institution pancreaticoduodenectomy database. Patients with adenocarcinoma arising from the ampulla of Vater were excluded. Univariate and multivariate analyses were performed to identify clinicopathologic variables associated with survival and recurrence after resection. Results From 1984 to 2006, a total of 122 patients with duodenal adenocarcinoma underwent pancreaticoduodenectomy. Overall survival after resection was 48% at 5 years and 41% at 10 years. Five-year survival decreased as the number of lymph nodes involved by metastasis increased from 0 to 1–3 to ≥4 (68%, 58%, 17%, respectively, P < 0.01) and as the lymph node ratio increased from 0 to >0–0.2 to >0.2–0.4 to >0.4 (68%, 57%, 14%, 14%, respectively, P < 0.01). Lymph node metastasis was the only independent predictor of decreased survival in multivariate analysis. Recurrence after resection was predominantly distant (81%). Adjuvant chemoradiation did not decrease local recurrence or prolong overall survival; however, patients who received chemoradiation more commonly had nodal metastasis (P = 0.03). Conclusions The prognostic significance of both the absolute number and ratio of involved lymph nodes emphasizes the need for adequate lymphadenectomy to accurately stage duodenal adenocarcinoma. The mostly distant pattern of recurrence underscores the need for the development of effective systemic therapies.

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Section: Discussionsupporting

confidence: 78%

Duodenal Adenocarcinoma: Clinicopathologic Analysis and Implications for Treatment

et al. 2011

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“…This finding is consistent with a prior study. 37 However, in our analysis we found that the understaging of SBA was strongly dependent upon small bowel subsite, with duodenal subsite being predominantly responsible for this effect. In fact, for the jejunal/ileal subsite the selection of ≥8 LNs assessed, had minimal impact on stage I disease (relative reduction in CSS of 1.5%) and similar impact for stage II and III disease (relative reduction in CSS of 10.7% and 11.6%, respectively).…”

Section: Discussionmentioning

confidence: 45%

A Population-Based Comparison of Adenocarcinoma of the Large and Small Intestine: Insights Into a Rare Disease

et al. 2011

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Background Because of its rarity, adenocarcinoma of the small intestine is frequently compared to adenocarcinoma of the colon, though the validity of this comparison is not known. Methods Patients with small (SBA) and large bowel adenocarcinoma (LBA) diagnosed between 1988–2007 were identified from the SEER registry. Age-standardized incidence and mortality rates were determined. Cancer-specific survival (CSS) stratified by stage and by number of assessed lymph nodes was calculated. Results A total of 4,518 and 261,521 patients with SBA and LBA, respectively, were identified. In comparison to LBA, patients with SBA were younger and presented with higher stage and histological grade. The age-standardized incidence rates decreased for LBA (−1.24%/year) but increased for SBA (+1.47%/year). While age-standardized mortality rates decreased for both LBA and SBA, the decreases were more pronounced for LBA. Five-year cancer-specific survival (CSS) was worse for resected SBA compared with resected LBA, though this difference diminished when comparing cases having ≥8 lymph nodes assessed. The relative reduction in CSS when selecting ≥8 lymph nodes was much greater for duodenal as opposed to jejunal/ileal subsite of the small bowel. With nodal selection the absolute difference in CSS between LBA and SBA for stages I, II, and III was 13%, 15.9%, and 18.5%, respectively. Conclusions Adequate nodal assessment is much less common in SBA than LBA; and it appears that SBA, in particular duodenal adenocarcinoma, is understaged. Even after corrections to minimize the effect of stage migration and inadequate lymph node evaluation, SBA demonstrated distinctly worse CSS than LBA.

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“…Durch Lymph adenektomie sollten mindestens 6 Lymphknoten entfernt werden [7]. Der therapeutische Wert der Lymphadenektomie ist nicht abschließend geklärt, jedoch ist die lymphogene Metastasierung ein unabhängiger negativer Prognosefaktor [9,14].…”

Section: Therapieunclassified

“…Ähnlich wie in vorliegender Untersuchung, konnten auch andere Autoren durch multivariate Analyse ein fortgeschrittenes Tumorstadium neben der chirurgischen Entfernung des Karzinoms als unabhängige Prognosefaktoren sichern [14,28,30]. 5JÜR 5-Jahres-Überleben, n.a.…”

Section: Therapieunclassified

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et al. 2011

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Small Bowel Adenocarcinoma: Understaged and Undertreated?

Abstract: We have found SBA staging is largely inadequate. Our results suggest recovery of ≥10 LNs ensures accurate staging. Improvement in stage II SBA OS after adequate LN may reflect a high degree of understaging in this dataset rather than a therapeutic effect of LAD.

Cited by 56 publications

References 30 publications

Duodenal Adenocarcinoma: Clinicopathologic Analysis and Implications for Treatment

Duodenal Adenocarcinoma: Clinicopathologic Analysis and Implications for Treatment

A Population-Based Comparison of Adenocarcinoma of the Large and Small Intestine: Insights Into a Rare Disease

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