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You, Hong, Yun, Kim, Lee, Lee, Kim, Ha, Kim, Kim, Jung, and Lee: Primary Nonampullary Duodenal Adenocarcinoma: A Single-center Experience for 15 Years
Original Article

Korean J Gastroenterol 2015;66(4):194-201.

Published online: 4 October 2015

DOI: https://doi.org/10.4166/kjg.2015.66.4.194

Primary Nonampullary Duodenal Adenocarcinoma: A Single-center Experience for 15 Years

Hyun Seon You1, Jeong Woo Hong1, Eun Young Yun1, Jin Joo Kim1, Jae Min Lee1, Sang Soo Lee1, 2, Hong Jun Kim1, 2, Chang Yoon Ha1, 2, Hyun Jin Kim1, 2, Tae Hyo Kim1, 2, Woon Tae Jung1, 2, Ok-Jae Lee1, 2

1Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea

2Institute of Health Sciences, Gyeongsang National University, Jinju, Korea

Correspondence to: Ok-Jae Lee, Department of Internal Medicine, Gyeongsang National University School of Medicine, 15 Jinju-daero 816beon-gil, Jinju 52727, Korea. Tel: +82-55-750-8056, Fax: +82-55-758-9122, E-mail: ojlee@gnu.ac.kr

Received 20 August 2015       Revised 8 September 2015       Accepted 14 September 2015

Copyright © 2015 Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Primary non-ampullary duodenal adenocarcinomas (PNADAs) comprise <0.3% of gastrointestinal malignancies. The rarity of PNADA and poorly defined natural history often leads to a delayed correct diagnosis. This study was conducted to evaluate the clinical characteristics of PNADA and to identify its prognostic factors.

Methods

Data were collected by retrospectively reviewing the medical records of patients with PNADA managed at Gyeongsang National University Hospital from January 2000 to December 2014. Demographic, clinical, endoscopic, and pathological variables were investigated, and factors related to survival were analyzed.

Results

Twenty-seven patients with PNADA were identified, and their median age was 64.9±13.6 years with 16 (59.3%) being male. The majority of patients (25/27, 92.6%) were initially diagnosed during upper endoscopy with biopsies. The tumor was located on the 1st or 2nd portion of duodenum in 92.6% (25/27) of patients. At the time of diagnosis, 85.2% (23/27) had advanced diseases (stage III or IV); 48.2% (13/27) had distant metastasis. Median survival time was 12 months (1–93 months). One and 3-year survival rates were 48.1% and 33.3%, respectively. On multivariable analysis, total bilirubin ≥2 mg/dL (OR, 85.28; 95% CI, 3.77–1,938.79; p=0.005) and distant metastasis (OR, 26.74; 95% CI, 3.13–2,328.14; p=0.003) at the time of diagnosis were independent poor prognostic factors.

Conclusions

The majority of patients were diagnosed at an advanced stage. Presence of distant metastasis was independent prognostic factor of PNADA together with elevated total bilirubin.

Keywords: Dudenal cancer, Adenocarcinoma, Survival, Prognosis

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Fig. 1.
Overall survival curve in patients with primary non-ampullary duodenal adenocarcinoma. Overall one-year and 3-year survival rates were 48.1% and 33.3%, respectively in 27 patients with primary non-ampullary duodenal adenocacinoma.
kjg-66-194f1.tif
Fig. 2.
Cumulative survival curves in the patients with primary non-ampullary duodenal adenocarcinoma according to total bilirubin and M stage.(A) Survival rate is higher in patients with total bilirubin <2 mg/dL than those with ≥2 mg/dL (p=0.003). (B) Survival rate is higher in M1 than M0 stage (p=0.000).
kjg-66-194f2.tif
Table 1.
Baseline Characteristics of Patients with Primary non-ampullary Duodenal Adenocarcinoma (n=27)
Variable Data
Age (yr) 64.9±13.6 (34–83)
Sex, male 16 (59.3)
Smoking 8 (29.6)
Symptoms  
 Abdominal pain 13 (48.2)
 Nausea, vomiting 6 (22.2)
 Bleeding 5 (18.5)
 Jaundice 1 (3.7)
 Asymptomatic 2 (7.4)
Symptom duration (day) 7 (1–120)
Hemoglobin <10 g/dL 8 (29.6)
Total bilirubin ≥2 mg/dL 2 (7.4)
Stool hemoglobin (＋) 2/8 (25.0)
Diagnosis modality  
 Duodenoscopy 25 (92.5)
 Laparotomy 2 (7.4)
Location  
 1st portion 14 (51.9)
 2nd portion 11 (40.7)
 3rd portion, 4th portion 1 (3.7), 1 (3.7)
Other primary cancer 6 (22.2)
Stage I/II/III/IV 3 (11.1)/1 (3.7)/11 (40.7)/12 (44.4)
Treatment (＋) 21 (77.8)
Surgery 14 (51.9)
 EMR 1
 PPPD 7
 Subtotal gastrectomy 3
 Palliative gastrojejunostomy 3
Chemotherapy 14 (51.9)
Radiation therapy 7 (25.9)
Survival period (mo) 31.6 (1–93)

Values are presented as mean±SD (range), number of patients (%), n only, or median (range).

EMR, emdoscopic mucosal resection; PPPD, pylorus preserved pancreaticoduodenectomy.

Table 2.
Summary of 27 Patients with Primary Nonampullary Duodenal Adenocarcinoma
Case Age (yr) Sex Symptom Stage Management Survival time (mo) Outcome
1 61 F Bleeding I None 59 Death
2 73 M Abdominal pain I STG 63 Alive
3 75 M Asymptomatic I EMR 44 Alive
4 57 M Bleeding II PPPD 93 Alive
5 42 M Abdominal pain III Palliative CRRT 38 Death
6 34 F Abdominal pain III PPPD＋ adjuvant CCRT 26 Death
7 70 M Bleeding III PPPD＋ adjuvant CTx. 34 Death
8 41 F Abdominal pain III Palliative CRRT 7 Death
9 74 F Abdominal pain III None 3 Death
10 76 F Abdominal pain III STG 67 Alive
11 68 M Asymptomatic III STG＋ Adjuvant CCRT 67 Alive
12 48 M Bleeding III PPPD＋ palliative CTx. 12 Death
13 67 M Abdominal pain III PPPD 36 Alive
14 77 M Nausea/vomiting III PPPD＋ adjuvant CTx. 62 Alive
15 57 F Nausea/vomiting III PPPD＋ adjuvant CTx. 14 Death
16 70 M Abdominal pain IV None 1 Death
17 66 M Nausea/vomiting IV Palliative CTx. 5 Death
18 81 M Nausea/vomiting IV Palliative GJ 8 Death
19 72 F Abdominal pain IV Palliative GJ＋ CTx. 8 Death
20 79 M Abdominal pain IV Palliative GJ 1 Death
21 57 M Nausea/vomiting IV Palliative CTx. 14 Death
22 38 F jaundice IV None 2 Death
23 68 M Abdominal pain IV Palliative CTx. 5 Death
24 82 F Abdominal pain IV None 2 Death
25 66 M Nausea/vomiting IV Stent inserttion 10 Death
26 68 F Bleeding IV Palliative CTx. 12 Death
27 83 F Abdominal pain IV None 7 Death

STG, subtotal gastrectomy; EMR, endoscopic mucosal resection; CCRT, concurrent chemoradiotherapy; PPPD, pylorus preserved pancreati-coduodenectomy; CTx., chemotherapy; GJ, gastrojejunostomy.

Table 3.
Clinical Outcome of Patients with Nonampullary Primary Duodenal Adenocarcinoma according to Clinical Variables
Variable No. of patients Median survival (mo) 3-Year survival rate (%) p-value
Age (yr)       0.973
 <65 9 29 33.3  
 ≥65 18 27 33.3  
Gender       0.187
 Male 16 38 43.8  
 Female 11 19 18.2  
Smoking       0.105
 (＋) 8 47 50.0  
 (−) 19 22 26.0  
Abdominal pain       0.236
 (＋) 13 22 30.8  
 (−) 14 38 35.7  
Nausea, vomiting       0.756
 (＋) 6 23 20.0  
 (−) 22 33 36.4  
Bleeding       0.487
 (＋) 5 42 40  
 (−) 22 25 34.8  
Hemoglobin       0.874
 <10 g/dL 8 33 37.5  
 >10 g/dL 19 26 31.6  
Total bilirubin       0.003
 <2 mg/dL 25 34 36.0  
 ≥2 mg/dL 2 3 0  
CEA        
 <5 ng/mL 14 54 57.1 0.000
 ≥5 ng/mL 7 6 0  
 ND 6      
CA 19–9       0.890
 <35 U/mL 11 39 45  
 ≥35 U/mL 8 31 37  
 ND 8      
Borrmann type       0.023
 Type I 2 5 0  
 Type II 6 65 83.3  
 Type III 15 24 26.7  
 Type IV 2 7 0  
T stage       0.174
 T1＋ T2 5 50 80  
 T3＋ T4 22 26 26.1  
N stage       0.920
 N0 10 33 40  
 N1 17 26 33.3  
M stage       0.000
 M0 14 55 64.3  
 M1 13 7 0  
Surgery       0.032
 (＋) 14 44 42.9  
 (−) 13 17 23.1  
Chemotherapy       0.613
 (＋) 14 32 28.6  
 (−) 13 27 38.5  

ND, not done.

Table 4.
Prognostic Factors for Survival in Patients with Primary Nonampullary Duodenal Adenocarcinoma on Multivariate Analyses
Parameter Relative risk 95% CI p-value
Total bilirubin≥2 mg/dL 85.28 3.76–1,935.79 0.005
CEA ≥5 ng/mL 2.17 0.17–27.67 0.550
Borrmann type 1.82 0.53–6.26 0.342
M1 stage 26.74 3.13–228.14 0.003
Surgical treatment 0.55 0.16–1.94 0.353
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