Lymph node evaluation and survival after curative-intent resection of duodenal adenocarcinoma: A matched cohort study.
Lymph node (LN) metastasis in patients with duodenal adenocarcinoma is associated with poor prognosis; however, the optimal extent of LN assessment and the interaction between LN assessment and adjuvant systemic therapy is poorly understood.



Resected non-metastatic duodenal adenocarcinoma patients (n = 1743) were identified in the National Cancer Database (1998-2011). Logistic regression analysis identified covariates associated with LN metastasis. The influence of increasing LN cut-off points on overall survival (OS) was analysed using the log-rank test and Cox proportional hazards modelling. Adjuvant chemotherapy (AC) and surgery alone cohorts were matched (1:1) by propensity scores based on the likelihood of nodal metastasis or survival hazard on Cox modelling. OS in the matched cohort was compared by Kaplan-Meier estimates.



LN metastases were present in 865 (49.6%) patients. Increasing LN assessment was associated with an increased likelihood of nodal involvement (P = 0.008). In node-negative patients, increasing LN assessment was associated with a decreased risk of death, with the largest actuarial survival differences observed for ≥15 LN (hazard ratio [HR] 0.63, 95% confidence interval [CI] 0.48-0.82, P = 0.001). In the propensity score-matched cohort of node-negative patients, AC was associated with non-significant improvements in 5-year actuarial (66.1% versus 58.7%, HR 0.79, 95% CI 0.53-1.18, P = 0.249), and did not vary by adequacy of LN counts (<15 LNs: HR 0.79, 95% CI 0.51-1.24, P = 0.305; ≥15 LNs: HR 0.90, 95% CI 0.35-2.30, P = 0.900).



The extent of LN identification has prognostic significance in resected node-negative duodenal adenocarcinoma, but cannot be implicated in the selection of node-negative patients for AC.
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
B L
BL
Ecker
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
M T
MT
McMillan
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
J
J
Datta
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
D T
DT
Dempsey
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
G C
GC
Karakousis
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
D L
DL
Fraker
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
J A
JA
Drebin
Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
R
R
Mamtani
Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
B J
BJ
Giantonio
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA. Electronic address: robert.roses@uphs.upenn.edu.
R E
RE
Roses
D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery*; D000368:Aged; D016022:Case-Control Studies; D017024:Chemotherapy, Adjuvant; D015331:Cohort Studies; D016208:Databases, Factual; D004379:Duodenal Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008197:Lymph Node Excision / Q000379:methods*; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D011379:Prognosis; D057216:Propensity Score; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome
Adjuvant therapy; Chemotherapy; Cut-off point analysis; Lymph node staging; Propensity score; Small bowel cancer