Endoscopic Resection Versus Surgical Resection for T1/T2 Duodenal Adenocarcinoma: Considerations of Nodal Upstaging

BACKGROUND AND OBJECTIVE: Endoscopic resection (ER) is increasingly used for early-stage duodenal adenocarcinoma (DA). This study aimed to identify factors guiding ER selection for clinical T1/T2N0 DA. METHODS: A retrospective National Cancer Database analysis (2010-2021) included patients with clinical T1/T2N0M0 DA with available pathological staging among those who underwent surgical resection. Outcomes were overall survival and lymph node upstaging (LNU). Survival was evaluated using Cox proportional hazard models, and predictors of LNU were assessed using logistic regression. RESULTS: Among 527 patients, 68 underwent ER and 459 underwent a major resection. Overall survival did not differ between the two groups (HR: 0.96, 95% CI: 0.65-1.40). Among major resections, nodal upstaging occurred in about 40% of patients and was associated with worse survival (T1 HR: 1.72, 95% CI: 1.18-2.50) and (T2 HR: 2.06, 95% CI: 1.28-3.33). Poor differentiation (OR: 2.83, 95% CI: 1.08-7.45), lymphovascular invasion (OR 7.19, 95% CI: 4.48-11.53), and age (≥ 80 compared to < 65-OR: 0.40, 95% CI: 0.20-0.82) were significant predictors of LNU. CONCLUSION: Nearly 40% of clinically node-negative T1/T2 DA patients who underwent a major resection had LNU, which was associated with worse overall survival. Pathologic features should guide ER selection.