Comparison of the clinical efficacy of a new prognostic stratification for duodenal adenocarcinoma with that of TNM staging: The importance of T status with regard to the prognosis

Published:August 14, 2022DOI:



      Although the current staging system and therapeutic strategy for duodenal adenocarcinoma (DA) focus on the N status, their validity has not been clarified. In this study, we evaluated the prognostic factors of DA and reviewed the current staging system.


      We included 105 patients who underwent surgical resection of DA in our department between September 2006 and October 2020. Patients with localised disease other than an early tumour (pT1a) were classified into the advanced group, and prognostic factors were compared with those for the Union for International Cancer Control (UICC) classification, 8th edition.


      The 5-year overall survival (OS) rate in the advanced group (n = 55) was 73%. Multivariate analysis revealed that pT4 and pN2 statuses were independent prognostic factors for OS. The prognosis was stratified based on the pT4 and pN2 statuses, whereas the survival curves for patients with pStage II (pN0) and pStage IIIA (pN1) DA overlapped on staging according to the UICC classification. The new classification indicated a favourable prognosis for patients classified as pT1-3N1 stage IIIA (5-year OS, 86%), whereas the prognosis of patients with pT4N0-1 DA was similar to those classified as pT1-3N2 stage IIIB. Patients with pT4N2 DA had a similar prognosis (5-year OS, 24%) as those with metastases, and 75% of these patients showed distant metastasis within one year after surgery.


      Both T and N statuses affect the prognosis of DA. Patients with pT4N2 DA may require intensive adjuvant chemotherapy. (238 words)


      CT (computed tomography), DG (distal gastrectomy), DA (duodenal adenocarcinoma), NCCN (National Comprehensive Cancer Network), OS (overall survival), PD (pancreatoduodenectomy), PPDD (pancreas-preserving distal duodenectomy), RFS (recurrence-free survival), UICC (Union for International Cancer Control)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Coupland V.H.
        • Kocher H.M.
        • Berry D.P.
        • et al.
        Incidence and survival for hepatic, pancreatic and biliary cancers in England between 1998 and 2007.
        Cancer Epidemiol. Aug 2012; 36: e207-e214
        • Bilimoria K.Y.
        • Bentrem D.J.
        • Wayne J.D.
        • Ko C.Y.
        • Bennett C.L.
        • Talamonti M.S.
        Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years.
        Ann Surg Jan. 2009; 249: 63-71
        • Legue L.M.
        • Bernards N.
        • Gerritse S.L.
        • et al.
        Trends in incidence, treatment and survival of small bowel adenocarcinomas between 1999 and 2013: a population-based study in The Netherlands.
        Acta Oncol. Sep - Oct 2016; 55: 1183-1189
        • Benson A.B.
        • Venook A.P.
        • Al-Hawary M.M.
        • et al.
        Small bowel adenocarcinoma, version 1.2020, NCCN clinical practice guidelines in oncology.
        J Natl Compr Canc Netw. Sep 1 2019; 17: 1109-1133
        • Onkendi E.O.
        • Boostrom S.Y.
        • Sarr M.G.
        • et al.
        15-year experience with surgical treatment of duodenal carcinoma: a comparison of periampullary and extra-ampullary duodenal carcinomas.
        J Gastrointest Sur. Apr. 2012; 16: 682-691
        • Augustin T.
        • Moslim M.A.
        • Cengiz T.B.
        • et al.
        Survival outcomes after surgical management of sporadic or familial adenomatous polyposis associated duodenal cancer.
        J Surg Oncol Nov. 2020; 122: 1132-1144
        • Solaini L.
        • Jamieson N.B.
        • Metcalfe M.
        • et al.
        Outcome after surgical resection for duodenal adenocarcinoma in the UK.
        Br J Surg. May 2015; 102: 676-681
        • Poultsides G.A.
        • Huang L.C.
        • Cameron J.L.
        • et al.
        Duodenal adenocarcinoma: clinicopathologic analysis and implications for treatment.
        Ann Surg Oncol. Jun 2012; 19: 1928-1935
        • Meijer L.L.
        • Alberga A.J.
        • de Bakker J.K.
        • et al.
        Outcomes and treatment options for duodenal adenocarcinoma: a systematic review and meta-analysis.
        Ann Surg Oncol Sep. 2018; 25: 2681-2692
        • Zhu Z.
        • Zhong F.
        Comparative analysis of outcomes and clinicopathological characteristics of duodenal adenocarcinoma: a SEER analysis.
        Cancer Inves. Nov. 2020; 38: 543-548
        • Sakamoto T.
        • Saiura A.
        • Ono Y.
        • et al.
        Optimal lymphadenectomy for duodenal adenocarcinoma: does the number alone matter?.
        Ann Surg Oncol. Oct 2017; 24: 3368-3375
        • Ltd K.C.
        General rules for the study of pancreatic cancer.
        seventh ed. Japan Pancreas Society, Tokyo2016
        • Kakushima N.
        • Ono H.
        • Takao T.
        • Kanemoto H.
        • Sasaki K.
        Method and timing of resection of superficial non-ampullary duodenal epithelial tumors.
        Dig Endosc Apr. 2014; 26: 35-40
        • Sarela A.I.
        • Brennan M.F.
        • Karpeh M.S.
        • Klimstra D.
        • Conlon K.C.
        Adenocarcinoma of the duodenum: importance of accurate lymph node staging and similarity in outcome to gastric cancer.
        Ann Surg Oncol Apr. 2004; 11: 380-386
        • Cecchini S.
        • Correa-Gallego C.
        • Desphande V.
        • et al.
        Superior prognostic importance of perineural invasion vs. lymph node involvement after curative resection of duodenal adenocarcinoma.
        J Gastrointest Surg Jan. 2012; 16 (; discussion 120): 113-120
        • Irino T.
        • Nunobe S.
        • Hiki N.
        • et al.
        Laparoscopic-endoscopic cooperative surgery for duodenal tumors: a unique procedure that helps ensure the safety of endoscopic submucosal dissection.
        Endoscopy Apr. 2015; 47: 349-351
        • Yamamoto Y.
        • Yoshizawa N.
        • Tomida H.
        • Fujisaki J.
        • Igarashi M.
        Therapeutic outcomes of endoscopic resection for superficial non-ampullary duodenal tumor.
        Dig Endosc Apr. 2014; 26: 50-56
        • Yoshimizu S.
        • Kawachi H.
        • Yamamoto Y.
        • et al.
        Clinicopathological features and risk factors for lymph node metastasis in early-stage non-ampullary duodenal adenocarcinoma.
        J Gastroenterol Aug. 2020; 55: 754-762
        • Ecker B.L.
        • McMillan M.T.
        • Datta J.
        • et al.
        Efficacy of adjuvant chemotherapy for small bowel adenocarcinoma: a propensity score-matched analysis.
        Cancer Mar 1. 2016; 122: 693-701
        • Nagakawa Y.
        • Sahara Y.
        • Hosokawa Y.
        • et al.
        Clinical impact of neoadjuvant chemotherapy and chemoradiotherapy in borderline resectable pancreatic cancer: analysis of 884 patients at facilities specializing in pancreatic surgery.
        Ann Surg Oncol. Jun 2019; 26: 1629-1636
        • Naito Y.
        • Ishikawa H.
        • Sadashima E.
        • et al.
        Significance of neoadjuvant chemoradiotherapy for borderline resectable pancreatic head cancer: pathological local invasion and microvessel invasion analysis.
        Mol Clin Oncol Sep. 2019; 11: 225-233
        • Macedo F.I.
        • Ryon E.
        • Maithel S.K.
        • et al.
        Survival outcomes associated with clinical and pathological response following neoadjuvant FOLFIRINOX or gemcitabine/nab-paclitaxel chemotherapy in resected pancreatic cancer.
        Ann Surg Sep. 2019; 270: 400-413
        • Assifi M.M.
        • Lu X.
        • Eibl G.
        • Reber H.A.
        • Li G.
        • Hines O.J.
        Neoadjuvant therapy in pancreatic adenocarcinoma: a meta-analysis of phase II trials.
        Surgery Sep. 2011; 150: 466-473
        • Jang J.Y.
        • Han Y.
        • Lee H.
        • et al.
        Oncological benefits of neoadjuvant chemoradiation with gemcitabine versus upfront surgery in patients with borderline resectable pancreatic cancer: a prospective, randomized, open-label, multicenter phase 2/3 trial.
        Ann Surg. Aug 2018; 268: 215-222
        • Turner K.M.
        • Delman A.M.
        • Vaysburg D.M.
        • et al.
        Systemic therapy for resected pancreatic adenocarcinoma: how much is enough?.
        Ann Surg Oncol. 2022; 29: 3463-3472
        • Borggreve A.S.
        • Goense L.
        • Brenkman H.J.F.
        • et al.
        Imaging strategies in the management of gastric cancer: current role and future potential of MRI.
        Br J Radiol May. 2019; 9220181044
        • Sun Z.
        • Li J.
        • Wang T.
        • Xie Z.
        • Jin L.
        • Hu S.
        Predicting perigastric lymph node metastasis in gastric cancer with CT perfusion imaging: a prospective analysis.
        Eur J Radiol Jan. 2020; 122108753
        • Akiyoshi T.
        • Matsueda K.
        • Hiratsuka M.
        • et al.
        Indications for lateral pelvic lymph node dissection based on magnetic resonance imaging before and after preoperative chemoradiotherapy in patients with advanced low-rectal cancer.
        Ann Surg Oncol. Dec 2015; 22: S614-S620
        • Loch F.N.
        • Asbach P.
        • Haas M.
        • et al.
        Accuracy of various criteria for lymph node staging in ductal adenocarcinoma of the pancreatic head by computed tomography and magnetic resonance imaging.
        World J Surg Oncol. Aug 18 2020; 18: 213
        • Kim H.R.
        • Seo M.
        • Nah Y.W.
        • Park H.W.
        • Park S.H.
        Clinical impact of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in patients with resectable pancreatic cancer: diagnosing lymph node metastasis and predicting survival.
        Nucl Med Commun Jul. 2018; 39: 691-698