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Tumor Grade, Not Extent of Resection, Is Associated With Recurrence-Free Survival in Patients With Duodenal Neuroendocrine Tumors
Brian Untch*, Laura H. Tang, Keisha Bonner, Kevin K. Roggin, Michael D'Angelica, Ronald P. Dematteo, William R. Jarnagin, T. P. Kingham
Surgery, Memorial Sloan-Kettering Cancer Center, New York, IL
Background: Duodenal neuroendocrine tumors are rare and few studies exist to guide surgical management. Endoscopic mucosal resection (EMR), local duodenal resection (LR), and pancreaticoduodenectomy (PD) are typically performed as primary treatment. This study identifies factors associated with recurrence after resection.
Methods: A retrospective, single institution review was performed between 1987 and 2011 on patients with a pathologic diagnosis of duodenal neuroendocrine tumor. Biopsy and surgical specimens were independently reviewed by a pathologist. Tumor grade was assigned based on WHO 2010 criteria (KI-67 and/or mitoses per high power field).
Results: Seventy-seven patients with a median age of 60 had resectable duodenal neuroendocrine tumors. Based on pathologic review, there were 9 somatostatinomas, 18 gastrinomas, and 49 not otherwise specified. In the entire group, 12 underwent EMR, 35 had LR, and 30 underwent PD (Table). Tumors were graded as low (77%), intermediate (10%), or high (13%). Positive margins for EMR, LR, and PD were identified in 66%, 29% and 3%, respectively. Median follow-up was 27 months. The 3 year recurrence-free survival (RFS) rate was 83% and there were no differences in RFS between the three different treatment groups. Tumors were smaller in the EMR group (p= 0.005) and more likely to have a positive margin compared to the LR and PD group (p<0.001). In all patients, RFS was better in low grade tumors as compared to those that were high or intermediate (p=0.04). Negative margin status and negative lymph nodes were not associated with better RFS. Morbidity after EMR, LR, and PD was 0%, 24%, and 41% respectively.
Conclusions: EMR, LR, and PD are all effective treatment approaches for duodenal neuroendocrine tumors. Tumor grade is associated with recurrence-free survival but not lymph node or margin status. When feasible, a less aggressive surgical approach to treat duodenal neuroendocrine tumors should be considered.
Table I
| Variable | EMR (n=12) | LR (n=35) | PD (n=30) | p value | | Tumor Size (cm) | 0.6+0.5 | 1.8+1.4 | 1.9+1.1 | 0.005 | | Low Grade Tumor* | 9/10 (90%) | 28/33 (84%) | 18/28 (64%) | NS | | Positive Resection Margin | 8/12 (66%) | 9/31 (29%) | 1/30 (3%) | <0.001 | | Positive Lymph Nodes | NA | 5/17 (29%) | 18/29 (62%) | 0.03 | | Recurrence | 1/12 (8%) | 6/35 (17%) | 5/30 (17%) | NS |
*pathology specimens were unavailable for review of grade in 6 patients
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