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Adenocarcinoma of the duodenum: the influence of site on survival.
TA Sohn, Lillemoe KD, Yeo CJ, Pitt HA, Kaufman HS, Hruban RH, Cameron JL.
Departments of Surgery and Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD.

This single-institution retrospective analysis reviews the management and outcome of patients with operatively managed adenocarcinoma of the duodenum. Methods: Between February 1984 and August 1996, 55 patients with adenocarcinoma of the duodenum were operatively managed and have been retrospectively reviewed. Univariate analysis was performed to identify possible prognostic indicators. Results: The patients had a mean age of 61.4±12.9 years, with 58% male and 84% white. The most common presenting signs and symptoms were abdominal pain (46%), iron-deficiency anemia (35%), and weight loss (30%). Sixty-four percent (n=35) of patients underwent a pancreaticoduodenectomy (PD) for adenocarcinoma arising in the second portion of the duodenum. Twenty-four percent (n=13) had a tumor in the third and/or fourth portion of the duodenum and underwent pancreas-sparing duodenectomy. Patients undergoing PD were comparable to those undergoing pancreas-sparing duodenectomy with respect to demographic factors, presenting symptoms and tumor pathology. The remaining 13% of patients (n=7) were deemed unresectable at the time of surgery and underwent biopsy and/or palliative bypass. The median intraoperative blood loss was 500 ml and the median number of units transfused was zero. The median operative time was 6 hours 18 minutes. The perioperative mortality rate was 3.6% (n=2); with one patient requiring reoperation in the immediate postoperative period. Of the resectable patients, 92% had negative margins, 70% had well to moderately differentiated tumors, 44% had a negative nodal status, and the average tumor diameter was 4.6 cm. Forty-six percent of patients experienced a complication in the postoperative period, with a median postoperative length of stay of 14 days. The overall five-year survival for the group was 47% (median=35 months). Negative resection margin status (p=0.007), pancreaticoduodenectomy (p=0.004) and tumors in the first and second portions of the duodenum (p=0.03) were favorable predictors of long-term survival in a univariate model. Nodal status, tumor diameter, and degree of differentiation did not influence survival. Conclusions: In patients with adenocarcinoma of the duodenum, resection offers the best opportunity for long-term survival. A negative resection margin and a periampullary location are the only pathologic factors predictive of long-term survival with tumor size and nodal status not predicting outcome. Therefore, large tumor size and the findings of positive nodes in the resection zone should not preclude resection. Patients with proximal duodenal tumors resected via pancreaticoduodenectomy fare better than those with distal tumors.