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Management of Small Bowel Adenocarcinoma

Management of Small Bowel Adenocarcinoma

Dr. Kummar and her coauthors
have tackled the difficult task
of reviewing small bowel adenocarcinoma so that we might have a better
understanding of this uncommonly encountered malignancy. The task is unusually
difficult, not because of the need to critically review reams of publications on
the topic, but rather because so little literature exists on the topic of
optimal management. Nonetheless, the authors have succeeded in educating the
reader on several important issues, including the need for close follow-up of
patients with small bowel adenocarcinoma, who are not only at risk for
recurrence but also have a relatively high risk of other gastrointestinal
tumors. Additionally, the authors identify factors associated with poor
prognosis, including age > 75 years, lack of surgical resection, advanced
disease stage, and tumor arising in the duodenum.

Pancreatic vs Duodenal Cancer

In a section entitled "Preoperative Chemoradiation," Dr. Kummar and
colleagues present the results of a study that Dr. John Hoffman and I, along
with others at the Fox Chase Cancer Center, published in 1994. In that study,
patients with adenocarcinoma of the pancreas or duodenum were treated with
preoperative chemoradiation followed by surgical resection. Only 4 of the 31
patients in that pilot study had duodenal adenocarcinoma.

Two things were remarkable about these four patients with duodenal (mostly
periampullary) cancer. First, following resection it was found that all four had
a pathologic complete response to 50 Gy and concurrent chemotherapy (fluorouracil
[5-FU] and mitomycin [Mutamycin]). In contrast, none of the 13 patients with
pancreatic cancer who underwent resection following chemoradiation had a
pathologic complete response. In fact, over 60 patients with pancreatic cancer
have been treated with chemoradiation followed by resection at the Fox Chase
Cancer Center, and none has had a pathologic complete response. It is therefore
likely that adenocarcinoma of the duodenum (particularly the periampullary
region) is much more sensitive to chemoradiation than adenocarcinoma of the
pancreas.

Second, at the time of that publication, all patients were alive, with a
median follow-up of 4.5 years. In fact, at a minimum follow-up of over 8 years
and a median follow-up of more than 12.5 years, all four patients remain alive
without recurrence. Certainly this excellent survival is not seen with
pancreatic adenocarcinoma and is better than that reported in the studies
reviewed by Kummar et al for duodenal adenocarcinoma managed by surgery alone or
surgery followed by chemoradiation.

Treatment Recommendations

Although we cannot draw conclusions from such a small number of patients
treated with preoperative chemoradiation, I would offer the following opinions
regarding management: The primary management of small bowel adenocarcinoma is
surgical resection. Chemoradiation should be a treatment option for patients
with adenocarcinoma of the duodenum—especially the periampullary region or
ampulla—who are medically inoperable or have surgically unresectable lesions.
Patients managed with chemoradiation are likely to have an objective tumor
response along with palliation of symptoms (eg, relief of pain or jaundice due
to obstruction). Furthermore, some operable patients with unresectable lesions
may have significant tumor response to chemoradiation, which may render the
lesion resectable. Resection should then be performed when possible.

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