Treatment of Duodenal Cancer in Germany

Duodenal cancer is a rare tumor of the gastrointestinal tract. Its treatment requires major surgery. Doctors in medical hospitals in Germany remove tumors not only through a large abdominal incision, but also with a minimally invasive, laparoscopic technique. Doctors successfully cope with even the advanced stages of the disease. To reduce the risk of recurrence after surgery, specialists use radiation therapy, chemotherapy, and, in the advanced stages of cancer, doctors in modern medical hospitals use intraperitoneal chemotherapy and immunotherapy.

Content

1. What is duodenal cancer?
2. Principles of treatment
3. Surgical treatment
4. Radiation therapy
5. Chemotherapy
6. Why is it worth undergoing treatment in Germany?

What is duodenal cancer?

The duodenum is the first part of the small intestine. It is located just behind the stomach. This is the most important "node" of the digestive system. A food bolus from the stomach, pancreatic juice with enzymes from the pancreas, and bile from the liver enter the duodenum.

Not all duodenal tumors are primary. The duodenum may be affected with gastric cancer, pancreatic, or extrahepatic bile duct cancer.

Primary duodenal malignant tumors are rare and account for 0.5% of intestinal neoplasms. Most often they are formed in the descending part of the intestine. Adenocarcinoma is more common among all histological types – 80% of cases.

Clinical forms of the disease: 

• stenosing form – causes gastrointestinal obstruction, disrupts the advancement of the food bolus;
• infiltrative ulcerative form – the tumor grows mainly towards the intestinal wall, and it is often complicated by bleeding and perforation;
• polyposis form – grows mainly in the duodenal cavity. 

At the time of detection, 60% of duodenal neoplasms have already spread to regional lymph nodes or the liver. Patients do not have severe symptoms.  It takes an average of 6-12 months from the manifestation of the first signs of the disease, to the performance of a radical surgery.

The main symptoms are as follows: 

• pain in the upper abdomen; 
• jaundice;
• nausea;
• vomiting.

To diagnose the disease, an esophagogastroduodenoscopy is performed. This is an endoscopic examination, involving the insertion of a tube with a video camera into the duodenum through the mouth, esophagus and stomach. If the doctor sees a suspicious formation, he can immediately perform a biopsy.

Principles of treatment

Duodenal cancer is a rare disease, so the standards for the treatment of this disease have not been finalized. Different hospitals use different approaches to treatment.

In any case, surgery is considered a priority to fight cancer. The cancer that can be removed is considered resectable. If radical surgical intervention cannot be performed, it is called unresectable.

Resectable tumors must be removed completely – this is the only way to cure cancer. The standard operation is pancreaticoduodenal resection. It involves the removal of the duodenum, a large part of the pancreas and the adjacent organs and tissues. But, very rarely, and only at an early stage of the disease, the doctor may limit himself to removing a small portion of the duodenum.

After surgery, patients may require radiation therapy, chemotherapy, or a combination of them both in the following cases: 

• metastases detected in the distant lymph nodes; 
• cancer invasion through the wall of the organ. 

So far, standard recommendations for postoperative treatment have not been developed. There is evidence that adjuvant radiation therapy and chemotherapy reduce the risk of tumor recurrence, but it is not yet clear whether they increase patient survival. Therefore, different hospitals have different opinions about the need and scope of postoperative treatment.

Some hospitals in Germany offer neoadjuvant therapy. This is  irradiation of the tumors and chemotherapy, and these are carried out before surgery. It is known that they allow doctors to precisely reduce the tumor size, eliminate some metastases, lower the stage of the disease, and also make the tumor removal surgery less traumatic for the patient. However, there is no conclusive evidence that preoperative treatment improves patient survival.

Some patients are diagnosed with an unresectable tumor. It cannot be removed, at least, not immediately. Therefore, patients receive radiation therapy and chemotherapy. Many undergo palliative surgery to relieve symptoms and prevent complications. In some cases, the tumor shrinks enough that the doctor may try to remove it during radical surgery.

Should the tumor be detected at a metastatic stage, the disease is considered incurable. Radical operations cannot be performed in such situations. Doctors are limited to palliative interventions. Distant metastatic foci in the bones, lungs, and brain are controlled with radiation therapy. All patients with advanced cancer receive chemotherapy. Some hospitals in Germany also use immunotherapy with checkpoint inhibitors.

Surgical treatment

Surgery is performed for most patients with duodenal cancer. Whenever possible, doctors seek to perform the radical operation. It aims to completely remove the tumor and has the potential to cure cancer. If the cancer is detected late, or the health condition of the patient does not allow radical surgery, doctors perform palliative surgical interventions: these relieve symptoms and create conditions for the use of other treatment methods, such as chemotherapy.

Here are some of the operations to be performed for the treatment of duodenal cancer: 

Segmental duodenal resection is the most sparing surgery and is performed in the early stages of the disease. The doctor removes part of the intestine and sutures the ends together to restore the integrity of the digestive tract.

Pancreaticoduodenectomy (Whipple procedure, pancreaticoduodenal resection) is the main operation for cancer treatment for patients in whom the tumor could not be detected at an early stage. This is the most frequently performed intervention. The doctor removes the duodenum completely, along with the head of the pancreas and regional lymph nodes. It is often necessary to remove part of the stomach, the gallbladder, and part of the common bile duct.

This is a complex operation, which is unsafe for health. It lasts for several hours. The doctor needs not only to remove the organs involved in the tumor process, but also to restore the functions of the digestive system. To this end, a reconstructive stage of surgical intervention is performed. The doctor connects the stomach to the small intestine and connects the bile and pancreatic ducts to it.

Pancreatoduodenectomy often causes complications. The mortality rate in the world, during and after this surgery, averages 5%. Nonetheless, in specialized hospitals in Germany, the mortality rate does not exceed 1%.

The Whipple procedure is usually performed through a large abdominal incision. Surgeons in some medical hospitals in Germany also perform the operation using a laparoscopic technique. The surgery through short incisions is less traumatic. Patients lose less blood, recover faster, and spend less time in hospital.

Palliative surgery is performed in cases where radical tumor removal is not possible. Palliative surgical interventions aim to restore the patency of the digestive tract and eliminate obstructive jaundice. The doctor can remove part of the intestine, implant a stent in the site of ​​tumor stenosis, and perform a bypass, namely, attach the part of the small intestine located below the duodenum to the stomach so that the food bolus can bypass the stenosed site. Some patients also require bile relieving surgery.

Radiation therapy

Radiation therapy for the treatment of duodenal cancer can be used in the following cases: 

• after surgery – to reduce the risk of recurrence; 
• instead of surgery – if surgery cannot be performed due to the advanced stage of the disease, or the patient has medical contraindications for surgical treatment; 
• as the main method of local control of the tumor and metastatic foci in the advanced stage of the disease. 

Doctors use external beam radiation therapy. The hospitals in Germany use the very latest methods, which are safer for a patient’s health. These methods are very accurate and deliver beams to the target from different sides, so the healthy tissues receive a minimum amount of radiation. This results in a reduced risk of post-radiation complications.

Chemotherapy

For the treatment of patients with duodenal cancer, drugs are usually used systemically, less often local application of drugs is applied – hyperthermic intraperitoneal chemotherapy (HIPEC).

In Germany, systemic chemotherapy is used in the following cases: 

• advanced stage of cancer – as the main treatment option; 
• after tumor removal surgery, to reduce the risk of recurrence; 
• with recurrence of the neoplasm after primary treatment. 

The main combinations for chemotherapy: CAPOX, FOLFOX, FOLFIRI. As a rule, two or three drugs are used at the same time. The choice of the scheme is determined not only by the stage of the disease, but also by the state of the patient's health. More effective therapy usually turns out to be more toxic.

The HIPEC technique is used after surgery to reduce the risk of tumor recurrence after its removal. Doctors wash the patient's abdomen with a heated solution of chemotherapy drugs to kill any remaining cancer cells in the abdomen. The perfusion lasts 1-1.5 hours. The solution temperature of 40-42 degrees allows cytostatics to better penetrate into tissues, destroying tumor foci to a depth of 2-3 mm. In Germany, the HIPEC technique is used for many oncological diseases: for the treatment of stomach cancer, colon cancer, ovarian cancer, and other abdominal neoplasms. With duodenal cancer, the method is used infrequently. As a rule, the HIPEC procedure is used if the tumor has spread to the peritoneum.

For the treatment of the advanced stages of duodenal cancer, doctors in Germany use immunotherapy. The specialists use immune checkpoint inhibitors. These drugs have a low toxicity and a minimum number of medical contraindications, so they can be used even in patients who are weakened by the disease. The drugs do not have a direct cytotoxic effect, but provide a reduction in tumor foci by enhancing antitumor immunity.

Why is it worth undergoing treatment in Germany?

Many medical tourists prefer to undergo duodenal cancer treatment in German hospitals, as this country offers advanced medicine. There are a few reasons for you to receive medical care in one of the German hospitals:

• the early stages of cancer can be treated with a minimally traumatic, laparoscopic duodenal resection;
• extensive experience in performing complex surgical interventions – pancreaticoduodenal resection, which is used in most patients for the treatment of duodenal cancer;
• the mortality rate of surgical operations for cancer removal is less than 1%, while the global average is 5%, and, in countries with poorly developed medicine, the mortality rate reaches 9%;
• some patients can undergo laparoscopic surgery;
• an operation is followed by the very latest options for cancer irradiation – very accurate, with a minimum dose of radiation for the tissues adjacent to the tumor;
• when cancer spreads to the peritoneum, doctors in some medical hospitals in Germany use hyperthermic intraoperative chemotherapy to reduce the risk of recurrence of the disease;
• the use of modern schemes of drug therapy for cancer, including immunotherapy.

To undergo treatment of duodenal cancer in Germany, please use the Booking Health service. On our website you have the opportunity to get up-to-date and accurate information about the cost of treatment in Germany, compare prices in different German hospitals and book a medical care program at a favorable price. Cancer treatment will be easier and faster for you, and the cost of treatment in Germany will be lower.

You are welcome to leave your request on the Booking Health website. Our employee will contact you, consult with you, and answer all your questions. We will take care of the organization of your trip abroad. We will provide the following benefits for you:

• We will select the best German hospital, whose doctors specialize in the treatment of stomach cancer and duodenal cancer, as well as achieve the best results.
• We will help you to overcome the language barrier and establish your communication with a doctor at the German hospital.
• The waiting period for your cancer screening and treatment will be reduced, and you will receive medical care on the most suitable dates for you.
• We will reduce the price. The cost of treatment in Germany will be lower than usual due to the elimination of overpricing and coefficients for medical tourists. 
• Our specialists will solve any organizational issues: paperwork, transfers from the airport to the German hospital and back, hotel booking, and interpreting services.
• We will prepare your medical documents and translate them into English or German. You do not have to repeat the previously performed diagnostic procedures.
• We will stay in contact with the German hospital after the completion of your treatment.
• We will arrange additional medical examinations and treatment, if necessary.
• We will buy medicines in the other country and forward them to your native country.

While the best specialists in the world are taking care of your health, the Booking Health staff will help to reduce the cost of treatment in Germany and take care of all your travel arrangements.

Authors: 

The article was edited by medical experts, board certified doctors Dr. Vadim Zhiliuk and Dr. Sergey Pashchenko. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

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Sources:

National Library of Medicine

Web MD

Verywell Health