Lymph Node Negative Duodenal Adenocarcinoma Is Associated with Long-termPatient Survival following Pancreaticoduodenal Resection

Abstract Background Duodenal adenocarcinoma (DA) is a rare gastrointestinal malignancy. Due to the low incidence of DA there is limited data reporting patient outcomes following radical pancreatic resection. Large retrospective single and multi-centre studies suggest that lymph node metastasis is an important factor for long-term patient survival following resection. The management of DA has tended to favour aggressive surgical resection with pancreaticoduodenectomy (PD), although a morbidity of up to 50% has been reported, mostly related to post-operative pancreatic fistulas. We assessed the disease-free (DFS) and overall survival (OS) in patients undergoing pancreaticoduodenectomy for DA in our institution. Methods We retrospectively analysed all patients undergoing pancreatic resection for DA at our institution between January 2009 – March 2020 inclusive. All DAs were cytologically or histologically proven prior to surgical resection following imaging review in a Hepato-pancreaticobiliary multidisciplinary team meeting. Patients underwent a Whipple’s with distal gastrectomy or pylorus preserving pancreaticoduodenectomy (PPPD) based on tumour size and location. Statistical analysis was performed by a Mann-Whitney U test using a p-value significance of 0.05 (SPSS, IBM, USA). DFS and OS curves were presented by Kaplan- Meier survival curves. Results 19 patients underwent pancreatic resection at our institution for DA during the study period. 12 patients underwent Whipple’s with distal gastrectomy and 9 patients underwent PPPD. The overall postoperative morbidity and mortality was 37% and 5% respectively. R0 resection was achieved in 18 patients (95%). 9 patients (47%) had no nodal involvement. Median follow up was 31 months (range 1-108 months). Median DFS was 17 months but was significantly higher in patients with no nodal metastasis [p < 0.001]. Median OS was 9.5 months for the whole cohort but was significantly higher in the patients with no nodal vs nodal metastasis (60 vs 17.5 months respectively) p < 0.003]. Conclusions DA can be resected by PD or segmental resection. PD is favoured due to improved resection margins and overall increased patient survival, despite an increased morbidity. Our series reports comparable morbidity and mortality to the published literature for DA resected by PD. This study reports a 95% R0 resection rate for DA with a 3- and 5-year survival of 50% and 30% respectively. DFS was found to be significantly higher in patients with no nodal disease, despite predominant T4 disease. This series has identified that lymph node metastasis is one of the most important prognostic determinants of long-term patient survival. Program permission yes