Superior Prognostic Importance of Perineural Invasion vs. Lymph Node Involvement After Curative Resection of Duodenal Adenocarcinoma
Stefano Cecchini*1,3, Camilo Correa-Gallego1, Vikram Deshpande2,4, Abdulmetin Dursun1, Jennifer a. Wargo1,4, Carlos Fernandez Del-Castillo1,4, Andrew L. Warshaw1,4, Cristina R. Ferrone1,4
1General Surgery, Massachusetts General Hospital, Boston, MA; 2Pathology, Massachusetts General Hospital, Boston, MA; 3General Surgery, Parma University, Parma, Italy; 4Surgery, Harvard Medical School, Boston, MA
BACKGROUND: Lymph node involvement has not been consistently shown to be a negative prognostic index for survival of patients with duodenal adenocarcinoma. Our aim is to identify stronger prognostic factors in survival of patients after resection of duodenal adenocarcinoma. METHODS: Of 102 patients with duodenal adenocarcinoma evaluated between 1/1993-1/2010, 72 underwent curative resection and 30 were explored and bypassed. Clinico-pathologic factors were evaluated in resected patients.RESULTS: The 72 patients (33 females and 39 males) had a median age of 67 years. An R0 resection was performed in 62 patients. The majority of patients (51.6%) had Stage III disease (anyT, N1). Median tumor size was 38 mm (range 2-130 mm) and a median of 13 (1-38) lymph nodes was examined. Perineural invasion was identified in 18 patients (29%). Median follow up was 25 months. The 5-year disease specific survival (DSS) was 78% vs 54% for pN0 and pN+ patients (p<.001) and 78% vs 13% for absence and presence of perineural invasion (p<.001) respectively. Lymph node ratio (LNR), type of resection (whipple vs. segmental resection), and size of tumor failed to stratify prognosis. Multivariate analysis indentified perineural invasion as the most powerful significant independent predictor of survival (HR 5.8, p=.003 CI: 1.792 - 18.749).CONCLUSIONS: Perineural invasion is a stronger predictor for survival than tumor size, T stage, lymph node involvement, LNR and type of resection.
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