|Ahead of print publication
A case of duodenal adenocarcinoma treated with primary chemoradiation
Janaki Gururajachar Manur, Harshitha M Jain
Department of Radiation Oncology, Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
|Date of Submission||03-Sep-2019|
|Date of Acceptance||08-Jan-2020|
|Date of Web Publication||05-Nov-2020|
Janaki Gururajachar Manur,
Department of Radiation Oncology, Ramaiah Medical College and Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Duodenal adenocarcinoma represents <1% of total gastrointestinal malignancies. Given the rarity of the disease, a definitive treatment guideline is lacking. Surgery plays a major role and radiotherapy was not included in the treatment due to the presence of many critical structures near the vicinity of the duodenum such as the liver, kidneys, and bowel. However, with the advent of newer techniques, adjuvant chemoradiation has shown a promising result with improvement in locoregional control by 20%. We are herewith presenting the details of the radiation planning of a patient treated with chemoradiation who had good long-term outcome.
Keywords: Chemoradiation, duodenal adenocarcinoma, inoperable
| > Introduction|| |
Among small bowel neoplasms, which constitute only 3% of all gastrointestinal tumors, benign tumors are more frequent. Common malignant tumors are neuroendocrine tumors, gastrointestinal stromal tumors, lymphomas, adenocarcinomas, and sarcomas constituting up to 40%. Fifty-seven percent of the duodenal adenocarcinoma (DA) are seen in the 2nd part suggesting mixing up of carcinogen with pancreaticobiliary secretion as an etiological factor Ross et al. Surgery is the primary modality of treatment and cloyd et al., in a comprehensive review of duodenal cancer, have described the details of the surgery. They have suggested that tumors in the 2nd part require Whipples, whereas in the rest of the duodenum segmental resection can be considered to get adequate margins. For inoperable tumors, palliative chemotherapy could be tried. The addition of adjuvant chemoradiation improves local control by 20%–23% compared to surgery alone as shown in studies done at John Hopkins and Duke University.,
We are herewith presenting a case of locally advanced duodenal cancer treated with chemotherapy and radiation who survived for more than 5 years without the surgery.
| > Case Report|| |
A 55-year-old aged female known hypertensive on medication for the past 1 year presented with a history of pain abdomen and dyspepsia for the past 4 months. There were no positive findings on examination, endoscopy revealed an ulceroproliferative growth at the second and third part of duodenum with narrowing of the lumen. Biopsy revealed a poorly differentiated carcinoma suggestive of neuroendocrine carcinoma. Immunohistochemistry ruled out neuroendocrine carcinoma with neoplastic cells expressing CDX2 and not expressing synaptophysin and chromogranin and hence, the final diagnosis was adenocarcinoma with ki-67%–90%. Positron-emission tomography(PET) computed tomography(CT) revealed metabolically active wall thickening of the third part of duodenum with few periduodenal lymphadenopathies. After preoperative workup, the patient underwent exploratory laparotomy, adhesiolysis with triple bypass which included cholecystojejunostomy, gastrojejunostomy, and jejunojejunostomy using double stapler technique on March 10, 2014.
The patient received six cycles of the FOLFOX regimen with a radiological response of >50%. The patient was given two options of close observation versus adjuvant radiation, given the paucity of data for concurrent chemoradiation and few reports showing a trend toward prolonged disease control. After taking informed consent, the patient was treated with intensity-modulated radiation therapy to a dose of 45 Gy/25fr/5 Fr week/41 days between September 24, 2014, and November 4, 2014, with initial 3 days and later weekly once EPID verification. PET CT detected lesion was contoured as gross tumor volume which was expanded by 1 cm to get clinical target volume. This was trimmed from the right kidney and liver [Figure 1]. Seven mm margin was given to get PTV to which 45 Gy/25Fr was prescribed. Coverage of 94% versus 95% was accepted, which reduced the mean dose to the right kidney from 24 Gy to 15 Gy [Table 1]. The patient withstood the treatment well with Grade I enteritis. She is on regular follow-up and at 5 years, the PET-CT has shown no evidence of any disease.
|Figure 1: Axial CT cut (a) at the level of hilum of the kidneys and (b) showing positronemission tomography detected gross tumor volume (red), clinical target volume trimmed from the right kidney (blue), and 45 Gy primary target volume coverage (orange color wash)|
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| > Discussion|| |
The most common presenting symptoms of duodenal cancer are abdominal pain, weight loss and in particular gastric outlet obstruction for duodenal tumors. Our patient had a lesion in the third part of the duodenum and so did not have obstruction as presenting symptoms. Since it is rare and if obstructive symptoms are not present, they are usually diagnosed in advanced stages in 58% of the patients.
Tumors located in the second part of the duodenum typically require Whipple resection due to proximity to the pancreas, bile duct, and ampulla of Vater. Tumors from the rest of the duodenum can be managed with segmental resection if wider margins can be obtained. When the two procedures were compared as far as outcome, there was no significant difference. Cloyd et al. in their study of 1611 patients between 1988 and 2010, found that more lymph nodes were dissected in pancreaticoduodenectomy versus segmental resection, but it did not improve survival. If negative margins can be obtained, segmental resection should be preferred. Margin positivity brings down 5 year overall survival from 58% to 0%. Historically, patients who are not fit for radical treatment are treated with bypass surgery to relieve obstruction, as in our patient. Surgery remains the main modality for DA with a 5-year survival rate of up to 55% and as high as 75% of patients fail locoregionally. With this background, adjuvant chemotherapy ± radiation has been tried.
In their institutional study of 24 patients, mostly locally advanced duodenal cancer, Kim et al. studied the role of adjuvant chemoradiation and found that overall survival was inferior with chemoradiation (30% vs. 47%) probably because node-positive patients were more. However, the locoregional relapse decreased from 71% to 20% with the addition of chemoradiation. The Grade II bowel toxicities were seen in 33% of patients. Pancreatic invasion, advanced T and N status were poor prognostic indicators. None of the patients in the non chemoradiation group survived beyond 3 years. In contrast, our patient underwent only bypass surgery and was treated with FOLFOX chemotherapy followed by radiation and is surviving without disease beyond 5 years. In a study at mayo clinic on 17 patients treated with 45–56 Gy with 5FU, radiation was given as spilt course to a dose of 40 Gy/2 Gy/Fr/20 Fr over 6 weeks with a 2 weeks gap in the middle of the course.
As far as radiation is considered, the present technology of IMRT with image-guided verification has the advantages of delivering required dose to the tumor, especially in the upper abdomen where a lot of critical structures such as the liver, bowel, kidney, and stomach are located. With more and more data available on dose, volume, and toxicities, a radiation oncologist can confidently treat a tumor in a location such as the duodenum. In the adjuvant setting, chemoradiation using 5FU with radical intent is shown to improve local control from 49%–67% to 70%–93%, but 5 years overall survival was similar., Our patient did not undergo resection and we treated with chemoradiation.
| > Conclusion|| |
Although rare and mostly advanced at presentation, primary DA does respond to chemoradiation with a long-term disease control. In patients with inoperable cancers, chemoradiation with advanced radiation techniques is not only useful but also is safe.
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Conflicts of interest
There are no conflicts of interest.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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