Optimizing postoperative prognostication in duodenal adenocarcinoma: a multicenter study with external validation

OBJECTIVE: To develop and externally validate a prognostic nomogram for overall survival (OS) in resected duodenal adenocarcinoma (DA) using routinely available perioperative variables, thereby clarifying risk profiles and supporting clinical management. METHODS: Multicenter analysis of 2289 consecutive DA patients undergoing curative surgery (2012-2022) from China's National Cancer Center database. External validation used 335 patients from Zhejiang Provincial People's Hospital (2022-2024). LASSO-Cox regression selected variables from 89 perioperative factors to construct the nomogram, with web tool implementation. RESULTS: The LASSO-Cox model achieved 1-, 3-, and 5-year AUCs of 0.72 (95% CI, 0.68-0.77), 0.75 (95% CI, 0.72-0.77), and 0.76 (95% CI, 0.73-0.79), outperforming traditional Cox models (P < .01). External validation yielded AUCs of 0.76 (95% CI, 0.66-0.86) and 0.79 (95% CI, 0.74-0.86) for 1- and 3-year OS, and 0.81 (95% CI, 0.74-0.89) for estimated 5-year OS. The model stratified patients into low- and high-risk groups (cutoff 0.40), with low-risk patients showing superior survival. Eight predictors were selected, including modifiable surgical factors such as transfusion and operative time. CONCLUSIONS: We developed and externally validated a postoperative prognostic nomogram for DA using routinely available perioperative variables. In the present study, the model improved postoperative risk stratification and may support counseling, follow-up planning, and multidisciplinary discussion regarding adjuvant therapy; however, it should be viewed as complementary to standard staging and clinical judgment, and broader clinical implementation will require further validation.