Duodenal adenocarcinoma: neoadjuvant and adjuvant therapy strategies

ABSTRACT

Introduction: Duodenal adenocarcinoma (DA) is a relatively rare gastrointestinal malignancy associated with poor outcomes. The mainstay of treatment is surgical resection with regional lymphadenectomy but recurrence rates remain high. Due to the relatively low incidence of DA, the lack of randomized controlled trials, and its inclusion with heterogeneous groups of periampullary and other small bowel cancers, strong evidence for the use of neoadjuvant or adjuvant treatment approaches is lacking.

Areas covered: The purpose of this article is to review the existing literature on neoadjuvant and adjuvant therapy options along with surgical options for patients with DA.

Expert opinion: The primary management of localized DA is surgical resection with negative margins and regional lymphadenectomy. Adjuvant therapy should be recommended for all patients with high-risk pathologic features such as positive lymph nodes or microscopically positive margins. The use of neoadjuvant therapy should be reserved for those patients with locally advanced disease who require downstaging to facilitate resectability. Nevertheless, given the relative rarity of DA, the available literature to guide optimal multimodality treatment decisions is minimal and additional research is needed. In the meantime, patients with DA should be treated at experienced tertiary centers by multidisciplinary oncology teams.

KEYWORDS:

• Duodenal adenocarcinoma
• pancreaticoduodenectomy
• periampullary cancer
• small bowel carcinoma
• whipple procedure

Article highlights

• Duodenal adenocarcinomas are rare tumors with vague symptoms, late diagnosis, and poor outcomes

• Surgery with curative intent that includes R0 resection and regional lymphadenectomy affords the best outcomes

• Data for adjuvant therapy are conflicting. In general, adjuvant therapy is associated with improved outcomes in patients with positive lymph nodes or resection margins

• Data for neoadjuvant therapy are limited. In general, neoadjuvant therapy should be reserved for patients with unresectable tumors that require downstaging

• New understanding on the pathophysiology of duodenal adenocarcinoma, including the ways in which it differs from other small and large bowel adenocarcinomas, is changing the landscape in the treatment options for this disease

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.