FOLFIRINOX or FOLFOXIRI in locally advanced duodenal adenocarcinoma: are we missing out?

Small bowel adenocarcinoma, which includes duodenal adenocarcinoma, is rare and poorly represented in clinical trials exploring the role of chemotherapy in gastrointestinal tumours. Thus, current treatment recommendations are based on expert agreement and rely on extrapolated data from colon cancer. The role of triple chemotherapy (such as the FOLFIRNOX or FOLFOXIRI schedules used in pancreatic or colorectal adenocarcinoma, respectively) is unclear. No phase III studies have been performed comparing doublet and triple combinations and triple-chemotherapy is rarely used in clinical practice.

Here we present two cases of patients diagnosed with locally advanced unresectable duodenal adenocarcinoma (cytology/biopsy confirmed) who received FOLFIRINOX chemotherapy in the palliative setting. In view of radiological response to therapy, both patients were underwent curative resection. In both cases a complete pathological response was confirmed in the surgical specimen.

To the best of our knowledge, this is the first time that complete pathological responses to triple-chemotherapy in duodenal adenocarcinoma have been reported. These two cases show that FOLFIRINOX is an effective treatment for duodenal adenocarcinoma and that its use should be considered for fit patients, especially in the setting of locally advanced disease in view of its potential to downstage the disease. Even though the addition of a third drug in the metastatic scenario may be limited, we may be losing a useful combination for patients with locally advanced duodenal adenocarcinoma. We believe that the role of triple-chemotherapy in the form of FOLFIRINOX or FOLFOXIRI should be further explored in the setting of prospective clinical trials in this scenario.