Ann Hepatobiliary Pancreat Surg.  2023 Feb;27(1):114-119. 10.14701/ahbps.22-069.

Pancreatoduodenectomy following neoadjuvant chemotherapy in duodenal adenocarcinoma

• Seo D
• Park BG
• Jung D
• Hwang HK
• Kim SH
• Hong SS
• Kang CM

• KMID: 2539522
• DOI: http://doi.org/10.14701/ahbps.22-069

Abstract

A 51-year-old male patient had four times of massive hematochezia episode three days before arrival. Carbohydrate antigen (CA) 19-9 level was extremely elevated. Computed tomography, magnetic resonance imaging, and positron emission tomography-computed tomography identified 5.7 cm sized periampullary duodenal cancer with regional metastatic lymph nodes and vascular invasion to aberrant right hepatic artery, main portal vein, and superior mesenteric vein. Diagnosed as duodenal adenocarcinoma through endoscopic biopsy, 16 times of FOLFIRI (5-fluorouracil, leucovorin, irinotecan) was conducted. The regimen changed to XELOX (capecitabine, oxaliplatine), four times of administration was done, and the CA19-9 level dramatically decreased. The tumor decreased to 2.1 cm. After R0 laparoscopic pylorus preserving pancreatoduodenectomy, no adjuvant therapy was given. No sign of recurrence or metastasis was reported, and the patient reached complete remission after five years. We reported a case where neoadjuvant chemotherapy for locally advanced duodenal adenocarcinoma was shown to be effective.

Keyword

Duodenal cancer; Neoadjuvant therapy; Chemotherapy; Pancreatoduodenectomy; Laparoscopy

Figure

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  Fig. 1 Preoperative findings. Computed tomography scan shows duodenal tumor arising from the duodenal 1st and 2nd portions, with direct invasion of pancreas head (white arrows) (A). Metastatic lymph nodes in hepatoduodenal ligament, around celiac axis, and in gastric pyloric areas are presented (white arrows) (B). (C) Magnetic resonance imaging shows peritumoral infiltration abutting aberrant right hepatic artery from superior mesenteric artery, and main portal vein (white arrowheads). (D) Positron emission tomography-computed tomography shows hypermetabolic lesion in the duodenal 1st and 2nd portions (white arrowheads).

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  Fig. 2 Change of tumor marker (CA19-9, CEA) during chemotherapy and after surgery. Both tumor markers decreased dramatically after changing chemotherapy regimen to XELOX from FOLFIRI. CA, carbohydrate antigen; CEA, carcinoembryonic antigen; FOLFIRI, 5-fluorouracil, leucovorin, irinotecan; XELOX, capecitabine, oxaliplatine.

Reference

1. Sabiston DC, Townsend CM. 2012. Sabiston textbook of surgery: the biological basis of modern surgical practice. 19th ed. Elsevier Saunders;Philadelphia:

2. Hong S, Won YJ, Lee JJ, Jung KW, Kong HJ, Im JS, et al. 2021; Cancer statistics in Korea: incidence, mortality, survival, and prevalence in 2018. Cancer Res Treat. 53:301–315. DOI: 10.4143/crt.2021.291. PMID: 33735559. PMCID: PMC8053867.

3. Bakaeen FG, Murr MM, Sarr MG, Thompson GB, Farnell MB, Nagorney DM, et al. 2000; What prognostic factors are important in duodenal adenocarcinoma? Arch Surg. 135:635–641. discussion 641–642. DOI: 10.1001/archsurg.135.6.635. PMID: 10843358.

4. Kelsey CR, Nelson JW, Willett CG, Chino JP, Clough RW, Bendell JC, et al. 2007; Duodenal adenocarcinoma: patterns of failure after resection and the role of chemoradiotherapy. Int J Radiat Oncol Biol Phys. 69:1436–1441. DOI: 10.1016/j.ijrobp.2007.05.006. PMID: 17689032.

5. Onkendi EO, Boostrom SY, Sarr MG, Farnell MB, Nagorney DM, Donohue JH, et al. 2012; Neoadjuvant treatment of duodenal adenocarcinoma: a rescue strategy. J Gastrointest Surg. 16:320–324. DOI: 10.1007/s11605-011-1667-7. PMID: 21956430.

6. Ji X, Bu ZD, Yan Y, Li ZY, Wu AW, Zhang LH, et al. 2018; The 8th edition of the American Joint Committee on Cancer tumor-node-metastasis staging system for gastric cancer is superior to the 7th edition: results from a Chinese mono-institutional study of 1663 patients. Gastric Cancer. 21:643–652. DOI: 10.1007/s10120-017-0779-5. PMID: 29168120. PMCID: PMC6002446.

7. Dave A, Wiseman JT, Cloyd JM. 2019; Duodenal adenocarcinoma: neoadjuvant and adjuvant therapy strategies. Expert Opin Orphan Drugs. 7:463–472. DOI: 10.1080/21678707.2019.1684257.

8. Ryder NM, Ko CY, Hines OJ, Gloor B, Reber HA. 2000; Primary duodenal adenocarcinoma: a 40-year experience. Arch Surg. 135:1070–1074. discussion 1074–1075. DOI: 10.1001/archsurg.135.9.1070. PMID: 10982512.

9. Dave A, Wiseman JT, Cloyd JM. 2018; Duodenal adenocarcinoma: more questions than answers. Laparosc Surg. 2:5. DOI: 10.21037/ls.2018.10.07.

10. Cloyd JM, George E, Visser BC. 2016; Duodenal adenocarcinoma: advances in diagnosis and surgical management. World J Gastrointest Surg. 8:212–221. DOI: 10.4240/wjgs.v8.i3.212. PMID: 27022448. PMCID: PMC4807322.

11. NCCN. Clinical practice guidelines in oncology: pancreatic adenocarcinoma. Version 1.2022 [Internet]. Available from: https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf. Plymouth Meeting: NCCN;2022. cited 2022 June 8.

12. Velandia C, Morales RD, Coello C, Mendoza AG, Pérez G, Aguero E. 2018; Neoadjuvant chemotherapy in locally advanced duodenal adenocarcinoma. Ecancermedicalscience. 12:816. DOI: 10.3332/ecancer.2018.816. PMID: 29662529. PMCID: PMC5880224.

13. Zhang GY, Mao J, Zhao B, Long B, Zhan H, Zhang JQ, et al. 2017; Duodenal bulb adenocarcinoma benefitted from neoadjuvant chemotherapy: a case report. Chemotherapy. 62:290–294. DOI: 10.1159/000469700. PMID: 28490007.

14. Kaslow SR, Prendergast K, Vitiello GA, Hani L, Berman RS, Lee AY, et al. 2022; Systemic therapy for duodenal adenocarcinoma: an analysis of the National Cancer Database (NCDB). Surgery. 172:358–364. DOI: 10.1016/j.surg.2022.03.009. PMID: 35437164.

15. Van Dam JL, Janssen QP, Besselink MG, Homs MYV, van Santvoort HC, van Tienhoven G, et al. 2022; Neoadjuvant therapy or upfront surgery for resectable and borderline resectable pancreatic cancer: a meta-analysis of randomised controlled trials. Eur J Cancer. 160:140–149. DOI: 10.1016/j.ejca.2021.10.023. PMID: 34838371.

16. Versteijne E, van Dam JL, Suker M, Janssen QP, Groothuis K, Akkermans-Vogelaar JM, et al. 2022; Neoadjuvant chemoradiotherapy versus upfront surgery for resectable and borderline resectable pancreatic cancer: long-term results of the Dutch randomized PREOPANC trial. J Clin Oncol. 40:1220–1230. DOI: 10.1200/jco.21.02233. PMID: 35084987.

17. Murphy JE, Wo JY, Ryan DP, Clark JW, Jiang W, Yeap BY, et al. 2019; Total neoadjuvant therapy with FOLFIRINOX in combination with losartan followed by chemoradiotherapy for locally advanced pancreatic cancer: a phase 2 clinical trial. JAMA Oncol. 5:1020–1027. DOI: 10.1001/jamaoncol.2019.0892. PMID: 31145418. PMCID: PMC6547247.