Reply to: Is “postoperative adjuvant chemotherapy” needed for small bowel adenocarcinoma after surgical resection?

DEAR EDITOR, We thank Dr. Yiu-Tai Li, Wen-Hsun Chang for the valuable comments1 and questions on our study named “Postoperative prognostic nutrition index predicts survival in patients with small bowel adenocarcinoma after surgical resection” published in Journal of the Chinese Medical Association in 2024 August.2 The authors’ comments are discussed below. Given the rarity of small bowel adenocarcinoma (SBA), the current international consensus on the need for postoperative adjuvant chemotherapy in these patients primarily depends on extrapolated data from studies on colorectal adenocarcinoma.3–6 Due to the complexity of the disease, treatment following tumor resection relies on multidisciplinary team discussions. Basically, indications for adjuvant chemotherapy are dictated by not only the pathological stage but also high-risk histological features of the tumor. Postoperatively, observation is appropriate in most cases of stage I SBA. Patients with stage III SBA who have undergone surgical resection potentially benefit from adjuvant chemotherapy. However, the decision regarding adjuvant chemotherapy in stage II SBA depends on certain pathological characteristics. Adjuvant chemotherapy is recommended for stage II SBA patients who exhibit high-risk features. Key factors include poorly differentiated tumor, close/positive resection margins, fewer than five lymph nodes examined if the tumor is in the duodenum, fewer than eight lymph nodes examined for other small bowel primaries, lymphovascular, or perineural invasion, and perioperative bowel perforation.3 The administration of adjuvant chemotherapy such as FOLFOX or CAPEOX may be associated with a decreased risk of recurrence and improved survival benefits. Besides traditional tumor factors such as pathological stage and high-risk features, the surgical procedures, particularly the Whipple operation, and complications like postoperative pancreatic fistula, were shown to have significant impacts on patient’s tolerance to undergo subsequent cancer treatments and overall prognosis.7,8 These postoperative factors, closely related to the nutritional and inflammatory status of the patient, could be critical in influencing overall survival. The relatively small sample size of this study (44 patients) may limit its statistical power to detect differences associated with tumor stage. With most patients (68.2%) classified as stage III and only a few in stages I and II, the uneven distribution may reduce the ability to identify stage-related differences in survival outcomes. This emphasizes both the rarity of SBA and the need for further research in this area. Indeed, postoperative adjuvant chemotherapy has become a mainstream treatment for many gastrointestinal cancers. However, due to the rarity of SBA, studies addressing the disease are still limited. Long-term clinical research and experience will be essential to developing more precise treatment plans for patients with SBA. We hope these explanations will suffice the readers’ and the authors’ expectations. Thank you for your interest again.