Li KN, Chen Q, Huang CT, Liu TQ, Li HF. Long-term survival after pancreaticoduodenectomy for duodenal papillary adenocarcinoma in a patient with acquired immunodeficiency syndrome: A case report and review of literature. World J Gastrointest Surg 2026; 18(7): 117966 [DOI: 10.4240/wjgs.117966]
Corresponding Author of This Article
Tian-Qi Liu, MD, PhD, Chief Physician, Department of General Surgery, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, No. 85 Heti Road, Qingxiu District, Nanning 530021, Guangxi Zhuang Autonomous Region, China. gxljrqt@163.com
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case-report
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Li KN, Chen Q, Huang CT, Liu TQ, Li HF. Long-term survival after pancreaticoduodenectomy for duodenal papillary adenocarcinoma in a patient with acquired immunodeficiency syndrome: A case report and review of literature. World J Gastrointest Surg 2026; 18(7): 117966 [DOI: 10.4240/wjgs.117966]
World J Gastrointest Surg. Jul 27, 2026; 18(7): 117966 Published online Jul 27, 2026. doi: 10.4240/wjgs.117966
Long-term survival after pancreaticoduodenectomy for duodenal papillary adenocarcinoma in a patient with acquired immunodeficiency syndrome: A case report and review of literature
Kang-Ning Li, Chun-Tao Huang, Graduate School, Youjiang Medical University for Nationalities, Baise 533000, Guangxi Zhuang Autonomous Region, China
Qing Chen, Department of Scientific Research and Education, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
Tian-Qi Liu, Department of General Surgery, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
Hong-Fei Li, Department of Hepatobiliary Surgery, Hechi Hospital Affiliated to Youjiang Medical University for Nationalities, Hechi 547000, Guangxi Zhuang Autonomous Region, China
Co-corresponding authors: Tian-Qi Liu and Hong-Fei Li.
Author contributions: Li KN, Chen Q, and Huang CT drafted the initial manuscript; Li KN and Chen Q made equal contributions as co-first authors; Liu TQ and Li HF diagnosed and treated the patient, and reviewed and edited the manuscript as co-corresponding authors. All authors take responsibility for the final submitted version and have read and approved the final manuscript.
AI contribution statement: No generative AI was used to create any clinical or academic content. Only AI tools were employed within a limited auxiliary scope. DeepL was used to perform the initial translation of the original Chinese manuscript (written independently by us) into English during the process. DeepSeek was only used for its text proofreading function to check for basic spelling and grammar errors in the translation draft. All the content of this paper, including the complete case presentation, clinical details, and academic discussions, was independently conceived, written, and revised by the authors.
Supported by Medical and Health Appropriate Technology Development and Promotion Project of the Health Commission of Guangxi Zhuang Autonomous Region, No. S2023034.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Tian-Qi Liu, MD, PhD, Chief Physician, Department of General Surgery, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, No. 85 Heti Road, Qingxiu District, Nanning 530021, Guangxi Zhuang Autonomous Region, China. gxljrqt@163.com
Received: December 22, 2025 Revised: March 12, 2026 Accepted: April 17, 2026 Published online: July 27, 2026 Processing time: 219 Days and 2 Hours
Abstract
BACKGROUND
Duodenal papillary adenocarcinoma is exceptionally rare in patients with acquired immunodeficiency syndrome (AIDS), and while this would normally be treated by radical resection, such treatment has historically been considered high-risk in AIDS patients due to their immune deficiencies.
CASE SUMMARY
This report presents the case of a 63-year-old female with AIDS who underwent pancreaticoduodenectomy for duodenal papillary adenocarcinoma (pT2N1M0, stage IIIA) and achieved 5-year survival. Through standardized antiretroviral therapy, her CD4+ levels were maintained above 200 cells/μL. Perioperative infection prophylaxis included piperacillin-tazobactam and ornidazole. Postoperative adjuvant chemotherapy was initiated based on her absolute neutrophil count being ≥ 1.50 × 109/L but was reduced due to the occurrence of recurrent grade 3 diarrhea; ultimately, the patient could tolerate only 70% of the standard XELOX regimen over four cycles. The surgery was completed without complications. During over 5 years of follow-up, surveillance imaging showed no recurrence or metastasis, the tumor markers remained normal, and her performance status was fully recovered.
CONCLUSION
This case demonstrates that with immune optimization (CD4+ > 200 cells/μL), tailored infection prophylaxis, and neutrophil-guided chemotherapy, radical surgery can be feasible and can enable long-term survival in AIDS patients with duodenal papillary adenocarcinoma, suggesting that the CD4+ level is a potential threshold for assessing patient eligibility for surgery in comparable cases.
Core Tip: This case demonstrates that pancreaticoduodenectomy can achieve 5-year disease-free survival in patients with duodenal papillary adenocarcinoma complicated by acquired immunodeficiency syndrome, and represents the first case with comprehensive long-term prognostic outcomes documented for this specific patient population. Key factors for treatment success include effective multidisciplinary team collaborative management, tailored chemotherapy regimens guided by the patient’s absolute neutrophil count, and proactive perioperative infection prophylaxis. This case suggests that surgical eligibility should not simply be based on a CD4+ T-cell count ≥ 200 cells/μL as the absolute criterion; instead, it should be determined through comprehensive assessment incorporating the CD4+ count, viral load control, nutritional status, and tumor-specific factors.
Citation: Li KN, Chen Q, Huang CT, Liu TQ, Li HF. Long-term survival after pancreaticoduodenectomy for duodenal papillary adenocarcinoma in a patient with acquired immunodeficiency syndrome: A case report and review of literature. World J Gastrointest Surg 2026; 18(7): 117966
Since the discovery of human immunodeficiency virus (HIV) in 1981[1], it has been revealed that the virus can progressively deplete CD4+ T lymphocytes, leading to speeding up tumorigenesis through three main mechanisms: Immune surveillance defects, chronic inflammatory microenvironment formation, and latent virus reactivation[2]. The widespread use of antiretroviral therapy (ART) has transformed acquired immunodeficiency syndrome (AIDS) from a fatal disease in the early days of its discovery into a manageable chronic condition today. Furthermore, from 1996 to 2020, the all-cause mortality rate among people with HIV (PWH) decreased by over 50%, from 16.80 per 1000 person-years to 7.90 per 1000 person-years[3,4]. While the earlier initiation of ART has significantly improved life expectancy in PWH, it has also shone a spotlight on the growing importance of non-AIDS-defining cancers and their associated comorbidities[5]. Indeed, among patients treated with ART for 10 years, the cumulative incidence of non-AIDS-defining cancers was reported to be up to 6.4%, with gastrointestinal tumors accounting for up to 50% of these[6], making them now the leading cause of cancer-related deaths in PWH[7].
As an important part of the gastrointestinal tract, the duodenum accounts for only 10% of the length of the small intestine, yet it is related to 31% of small intestine tumors in non-HIV populations, with adenocarcinoma representing 55% of such cases[8]. Moreover, the duodenum is a specific target site for HIV-related damage, with cancer risk closely linked to the destruction of the intestinal mucosal immune microenvironment. HIV infects gut-associated lymphoid tissues, leading to the severe depletion of CD4+ T lymphocytes and the impaired function of intestinal resident immune cells[9,10]. It also enhances the proliferation of gastrointestinal epithelial cells, evidenced by an increased expression of proliferating cell nuclear antigens, and activates the β-catenin signaling pathway through the nuclear accumulation of β-catenin and reduction in phosphorylated β-catenin, thereby promoting tumor development and progression[11]. Furthermore, HIV infection disrupts the mucosal barrier, resulting in dysbiosis (such as the reduced abundance of butyrate-producing bacteria), alters tryptophan metabolism (e.g., by enhancing the kynurenine pathway), and induces barrier dysfunction along with the activation of pro-proliferative pathways, all of which facilitate the initiation and progression of gastrointestinal tumors[12].
Beyond signaling pathway alterations, epigenetic modifications play a crucial role in HIV-associated tumorigenesis. HIV infection induces aberrant DNA methylation patterns, including the hypermethylation of tumor suppressor gene promoters and global hypomethylation, which promotes genomic instability[13]. Additionally, HIV-induced lipid metabolic reprogramming, which is characterized by altered cholesterol homeostasis and enhanced lipogenesis, creates a tumor-promoting microenvironment by providing substrates for membrane biosynthesis and for activating oncogenic signaling cascades[14]. These epigenetic and metabolic alterations, combined with the chronic immune activation, synergistically contribute to the elevated cancer risk typically observed in PWH.
Owing to its unique anatomical location, tumors originating from the duodenal papilla in the pancreaticobiliary confluence have an annual incidence of less than 1 per 100000[15]. Pancreaticoduodenectomy (PD) remains the preferred radical treatment for tumors in this region[16-18], and its safety profile has improved significantly in recent years, with perioperative mortality declining from 25% to 1.4%. For example, in pancreatic head cancers, the R0 resection rate has increased from 66% to 81% (P = 0.0010), accompanied by a 5% improvement in 5-year survival (P = 0.020)[19]. However, the tolerability to PD of PWH remains controversial. It was reported that a CD4+ count below 200 cells/μL increases the risk of postoperative complications by 2.38 times (odds ratio = 2.38, 95% confidence interval: 1.05-5.39)[20]. Consequently, some PWH have traditionally been excluded from radical surgery for this reason.
This study reports a rare case of an AIDS patient with primary duodenal papillary adenocarcinoma who successfully underwent PD under optimized immune management, and it represents the first report of a patient achieving 5-year disease-free survival with comprehensive long-term outcome data documented. Through a systematic review of cases involving PWH who underwent radical resection for gastrointestinal tumors, we propose a perioperative management pathway guided by CD4+ threshold levels.
CASE PRESENTATION
Chief complaints
A 63-year-old woman was admitted to the Department of Hepatobiliary Surgery for jaundice of the skin and sclera accompanied by darkened urine for 2 months.
History of present illness
The patient reported having developed a yellowing of the skin and sclera accompanied by darkened urine over the past 2 months. She denied having abdominal pain, abdominal distension, vomiting, melena, or pruritus, and had no recent history of loss of appetite, changes in stool traits, or weight loss.
History of past illness
The patient was diagnosed with AIDS in 2015 through positive HIV-1/2 antibody screening (ELISA) confirmed by western blot at a designated HIV treatment center. She self-reported consistent, guideline-concordant ART at an external HIV treatment center following diagnosis, but could not provide, or declined to disclose, the full details of her specific ART regimen and serial CD4+ T lymphocyte count laboratory reports. She had been receiving standardized ART based on the “Chinese guidelines for diagnosis and treatment of HIV/AIDS (2018)”[21].
Personal and family history
The patient denied any family history of malignant tumors.
Physical examination
Physical examination revealed bilateral scleral and mucocutaneous jaundice, tenderness in the right upper quadrant, and positive hepatic percussion pain. The preoperative performance status was Eastern Cooperative Oncology Group (ECOG) score 2, and Nutritional Risk Screening score 0.
Laboratory examinations
Laboratory examinations revealed a hemoglobin level of 105.00 g/L (normal range: 110.00-150.00 g/L) and a red blood cell count of 3.24 × 1012/L (normal range: 3.50-5.00 × 1012/L). Liver function tests were abnormal, with a total bilirubin level of 118.08 μmol/L (reference: 0.00-26.00 μmol/L), direct bilirubin of 85.7 μmol/L (reference: 0.0-10.0 μmol/L), indirect bilirubin of 32.4 μmol/L (reference: 0.0-13.0 μmol/L), alanine aminotransferase of 102 U/L (reference: 0-40 U/L), and aspartate aminotransferase of 89 U/L (reference: 0-40 U/L); while a serum albumin level of 40.2 g/L (reference: 32.0-52.0 g/L). Carbohydrate antigen 19-9 (CA19-9) was elevated at 92.40 U/mL (normal: 0.00-37.00 U/mL), and the HIV antigen/antibody combo assay result was 562.94 S/CO (normal: 0.00-1.00 S/CO). Other digestive tumor markers, including alpha-fetoprotein (3.4 ng/mL; normal: 0.0-20.0 ng/mL) and carcinoembryonic antigen (2.6 ng/mL; normal: 0.0-5.0 ng/mL), were within normal limits.
Imaging examinations
Abdominal ultrasound indicated a hypoechoic mass at the distal common bile duct accompanied by intrahepatic and extrahepatic bile duct dilation. Contrast-enhanced computer tomography (CT) revealed an iso-dense nodular lesion in the duodenal papilla region with ill-defined margins and heterogeneous peripheral enhancement, more pronounced peripherally than centrally (Figure 1A and B), along with dilation of the biliary and pancreatic ducts (Figure 1C and D). Gastroscopy identified a friable mass in the mid-descending duodenum that bled readily on contact, obscuring the papillary orifice (Figure 1E and F). A pathological biopsy indicated the presence of a high-grade villous adenoma. Immunohistochemical staining showed: PCK (epithelial+), P53 (focal+), CDX-2(-), and Ki67 positivity in approximately 10% of cells.
Figure 1 Imaging features of a duodenal papillary tumor.
A and B: Axial contrast-enhanced computed tomography shows an enhancing nodular lesion (1.80 cm × 1.80 cm) in the duodenal papilla region; C and D: Note the dilated biliary and pancreatic ducts (common hepatic duct: 1.50 cm) and the double duct sign; E and F: Gastroscopy reveals a tumor (1.50 cm × 1.50 cm) in the descending duodenum obscuring the nipple opening. The discrepancy between endoscopic (1.50 cm × 1.50 cm) and pathological (1.00 cm × 1.00 cm × 0.50 cm) tumor dimensions may be attributed to tissue shrinkage during formalin fixation, partial tissue loss from preoperative biopsy, and intraoperative manipulation.
MULTIDISCIPLINARY EXPERT CONSULTATION
A multidisciplinary consultation involving specialists in infectious diseases, oncology, and anesthesiology concluded that the patient’s ART regimen was effective, with no opportunistic infections and no absolute surgical contraindications. The patient’s CD4+ T-cell count exceeded 200 cells/μL, meeting the immunological threshold for surgery.
FINAL DIAGNOSIS
Duodenal papillary adenocarcinoma (T2N1M0, stage IIIA according to the American Joint Committee on Cancer 8th edition): Confirmed by intraoperative frozen-section pathology (Figure 2).
Figure 2 Pathological findings of duodenal papillary adenocarcinoma.
A: A gray-red solid mass (1.00 cm × 1.00 cm × 0.50 cm) at the duodenal papilla with a gray-white cut surface and moderate consistency, poorly demarcated from surrounding tissues. Attached organs include the stomach (8.00 cm × 6.50 cm × 4.00 cm), duodenum (length 27.00 cm), gallbladder (11.00 cm × 4.00 cm × 3.50 cm; rough mucosa, smooth serosa), and pancreas (7.50 cm × 6.00 cm × 2.00 cm; lobulated cut surface). No tumor invasion is observed in any organ; B: Papillary adenocarcinoma infiltrating the muscularis propria. No cancer infiltration is seen in the serosa or periserosal tissues.
TREATMENT
Due to the compromised immune function in PWH, which confers a significantly elevated risk of surgical site infection, perioperative prophylactic antibiotics (piperacillin-tazobactam combined with ornidazole) were administered. Piperacillin-tazobactam was selected for its broad-spectrum coverage against Gram-negative and anaerobic bacteria commonly implicated in biliary and pancreatic infections, while ornidazole provided additional anaerobic coverage. Neither agent has significant pharmacokinetic interactions with commonly used antiretroviral drugs, as they are primarily renally excreted and do not undergo cytochrome P450 metabolism. This antibiotic combination was continued for 7 days postoperatively, and no surgical site infection or opportunistic infection occurred during hospitalization. Liver-protective therapy with magnesium isoglycyrrhizinate and ademetionine was also initiated. Prior to surgery, the patient’s direct bilirubin levels had decreased by 70.36% compared to at admission (Table 1). Owing to economic constraints, contrast-enhanced magnetic resonance imaging, magnetic resonance cholangiopancreatography, and endoscopic ultrasound were not performed. The preoperative diagnosis was high-grade villous adenoma of the descending duodenum, and the initial surgical plan was duodenal tumor resection. During intraoperative exploration, a mass was identified at the duodenal papilla with marked dilation of the common bile duct and pancreatic duct, and enlarged lymph nodes that were palpable around the pancreatic head. After incision of the descending duodenum and excision of the tumor, intraoperative frozen-section pathology revealed a well-differentiated adenocarcinoma of the duodenum. Following careful reassessment, the surgical approach was converted to PD. The total operative time was 7 hours. Intraoperative blood loss was 500 mL, and the patient received 2 units of leukocyte-reduced red blood cells and 400 mL of plasma. Postoperative pathological examination confirmed R0 resection: The papillary adenocarcinoma had infiltrated the superficial to middle muscularis propria without penetrating the serosa; no lymphovascular or perineural invasion was identified; and all the surgical margins were free of tumor. A total of 4 lymph nodes were harvested: 2 peripancreatic nodes (1 positive for metastasis), 1 greater curvature node, and 1 pericholecystic node (all negative). Besides, extended lymphadenectomy was not performed.
Table 1 Results of liver function at admission, preoperation, postoperation, and discharge.
On the 18th postoperative day, modified FOLFOX6 chemotherapy was initiated at 100% of the standard dose, specifically the intravenous administration of oxaliplatin (85 mg/m2), leucovorin (400 mg/m2), and 5-fluorouracil (400 mg/m2), followed by the continuous infusion of 5-fluorouracil (2400 mg/m2 over 46 hours). Following completion of the chemotherapy infusion, the patient was discharged in a stable condition, with an ECOG score of 2, Nutritional Risk Screening score of 1, and serum albumin level of 41.2 g/L at discharge. Six days after chemotherapy initiation, the patient developed grade 3 diarrhea (as per CTCAE v5.0 criteria)[22], with an absolute neutrophil count (ANC) of 2.63 × 109/L, hemoglobin level of 88 g/L, and platelet count of 231 × 109/L. Symptomatic treatment, including pantoprazole, probiotics, loperamide, and montmorillonite powder, was administered, leading to diarrhea resolution within 12 days. The regimen was subsequently adjusted to the XELOX protocol, comprising oxaliplatin (130 mg/m2) and capecitabine (1000 mg/m2) at 80% of the standard dose. After two cycles, grade 3 diarrhea recurred (ANC of 2.25 × 109/L, hemoglobin level of 104 g/L, platelet count of 162 × 109/L), leading to a temporary interruption of chemotherapy; this diarrhea was managed with pantoprazole and clostridium butyricum tablets, leading to its successful resolution in 16 days. When the dose was reduced to 70% during the fourth cycle, the patient experienced grade 2 diarrhea accompanied by vomiting (ANC of 3.13 × 109/L, hemoglobin level of 82 g/L, platelet count of 133 × 109/L) and declined further chemotherapy; this episode was resolved in 10 days with supportive care. This recurrent diarrhea may be attributed to HIV-related intestinal mucosal vulnerability.
OUTCOME AND FOLLOW-UP
The patient was followed for 5 years and 2 months postoperatively. Regular evaluations were performed according to the following schedule: Every 3 months for the first 2 years, and then every 6 months from 2 to 5 years, including enhanced CT of the chest and abdomen and CA19-9 testing. No evidence of local recurrence or distant metastasis was observed, and the patient’s serum CA19-9 levels remained within the normal range (Table 2). Furthermore, the immune function remained stable, with CD4+ T-cell counts consistently above 200 cells/μL and sustained viral suppression. The overall prognosis was favorable.
Table 2 Dynamics of serum carbohydrate antigen 19-9 levels of the patient.
The clinical management of PWH with duodenal papillary adenocarcinoma faces dual challenges: First, the technical complexity of PD, which involves multi-organ resection and gastrointestinal reconstruction, and second, the need for a comprehensive assessment of the infection risk under immunosuppression, ART drug interactions, and the benefits of radical resection, while meticulously assessing postoperative complications. The primary treatment for duodenal papillary tumors is surgical, with PD serving as a cornerstone procedure that can enable complete tumor excision and thorough lymph node dissection, offering a 5-year survival rate of up to 65%[18,23], providing strong justification for undertaking this high-difficulty surgery. Due to economic constraints, the patient in this case report underwent CT, gastroscopy, and tumor marker tests (e.g., CEA and CA19-9), but did not receive endoscopic ultrasound, contrast-enhanced magnetic resonance imaging, or magnetic resonance cholangiopancreatography. As a result, the depth of tumor infiltration and the extent of pancreaticobiliary duct involvement could not be precisely determined preoperatively. The preoperative biopsy indicated a high-grade villous adenoma, supporting the initial plan for local duodenal tumor resection. However, intraoperative exploration revealed marked biliary and pancreatic duct dilation with palpable enlarged peripancreatic lymph nodes, raising a suspicion of malignancy beyond the biopsy findings. Subsequent frozen-section pathology tests confirmed the existence of a well-differentiated adenocarcinoma, prompting immediate conversion to PD. This real-time pathological guidance allowed dynamic adjustment of the surgical strategy, ultimately achieving R0 resection despite the limited preoperative imaging.
Currently, clinical data on PWH undergoing PD are extremely limited, with no previous reports of HIV-positive patients with duodenal papillary adenocarcinoma receiving this procedure. Nonetheless, there are a number of common technical elements, such as vascular dissection and gastrointestinal reconstruction, shared between PD and other radical resections in PWH with carcinomas. Safety evidence from patients with periampullary carcinomas, pancreatic head cancers, and cholangiocarcinomas also offers valuable reference. Nine relevant cases have been reported in the literature, with treatment strategies based on the tumor stage and functional preservation requirements. Two cases with advanced disease received palliative procedures to alleviate symptoms[24,25], two others, with tumors confined to the ampulla and limited local invasion, underwent pylorus-preserving PD[26] and partial PD[27], respectively, to preserve their digestive function; and five other cases that underwent standard PD (Table 3)[28-32]. Existing limited evidence suggests that PD is feasible and well-tolerated in PWH who have been rigorously screened, received effective ART, and have stable immune functions. Most patients recover well in the short term postoperatively, with the incidence of postoperative complications, such as delayed gastric emptying, pancreatic fistula, and surgical site infection, comparable to those in non-HIV populations. For patients with duodenal papillary adenocarcinoma, postoperative follow-up is crucial for improving their prognosis, enabling an early identification of tumor recurrence, and for evaluating the synergistic safety of ART and adjuvant therapies. However, existing studies to date have reported a maximum follow-up of only 8 months, highlighting that there is a critical gap in long-term outcome data.
Table 3 Cases of people with human immunodeficiency virus undergoing radical resection for gastrointestinal tumors.
In assessing whether PWH can safely undergo PD, the CD4+ T lymphocyte count and continuity of ART should be core considerations. When CD4+ < 200 cells/μL, patients exhibit a significantly reduced immune function and a markedly increased risk of perioperative infections[33]; indeed, the risk of postoperative complications in such patients is 2.38 times higher than in those with CD4+ ≥ 200 cells/μL[20,34]. Additionally, PWH who do not receive ART or have CD4+ < 200 cells/μL face significantly higher surgical-related mortality risks compared to those on standardized ART or those with CD4+ ≥ 200 cells/μL[35]. Furthermore, the targeted depletion of CD4+ T lymphocytes was reported to be negatively correlated with decreased wound strength[36], further confirming the adverse impact of low CD4+ levels on surgical safety. When CD4+ < 200 cells/μL, a multidisciplinary team (MDT) led by infectious disease specialists should conduct individualized risk-benefit assessments. If the CD4+ count can be raised to ≥ 200 cells/μL through standardized ART in the short term, with sustained viral suppression, no evidence of tumor progression, and an ECOG performance status score ≤ 1, PD may be cautiously implemented under close monitoring. Conversely, PD is not recommended if the CD4+ T lymphocyte count cannot reach the threshold within a short time, the viral load remains uncontrolled, tumor progression is observed, or if the patient is in a poor general condition; in such cases, palliative treatment should be prioritized to delay disease progression and maintain the patient’s quality of life. It is noteworthy that even among gastrointestinal surgeries, the postoperative hospital stay for PWH undergoing colectomy is significantly prolonged (odds ratio = 2.61, 95% confidence interval: 1.98-3.44)[37]. This observation suggests that for more invasive procedures, such as PD, even when the CD4+ count reaches a safe threshold, an individualized risk assessment that also considers surgical complexity should be performed. The comprehensive standardized management of ART is crucial and should be implemented throughout the preoperative, intraoperative, and postoperative periods. For ART-naive patients, highly effective regimens such as integrase strand transfer inhibitor (INSTI)-based single-tablet regimens combined with long-acting fusion inhibitors can be used to rapidly suppress the virus and reduce postoperative infection risk[38]. For patients already receiving ART, it is essential to ensure treatment continuity and efficacy, and to increase the CD4+ count to ≥ 200 cells/μL to improve the quality of postoperative recovery. Studies have shown that perioperative ART is associated with reduced postoperative complications[39], whereas patients with a high baseline HIV viral load who do not receive ART have an increased risk of virological failure and significantly higher complication rates[40]. Therefore, for patients with poor perioperative viral load control or those unable to take oral ART due to fasting or other reasons, the intravenous administration of fusion inhibitors, such as albuvirtide, can be used to temporarily reduce the viral load and enhance perioperative safety[38,40]. It should be noted that some patients with CD4+ < 200 cells/μL may still benefit from radical resection[26,27,32]. As shown in Table 3, among the reported cases undergoing PD or similar procedures, three patients had CD4+ counts below 200 cells/μL (100 cells/μL, 168 cells/μL, and 123 cells/μL, respectively). While two of these patients experienced no complications during short-term follow-up, one developed sepsis at the wound and drain site, highlighting the increased infection risk at lower CD4+ levels. In contrast, patients with CD4+ ≥ 200 cells/μL generally demonstrate more favorable short-term outcomes. These observations suggest that surgical tolerance is influenced by multiple factors, including the CD4+ count, viral load, nutritional status, and individual patient characteristics. However, the limited sample sizes in previous studies preclude making definitive conclusions regarding specific CD4+ thresholds. In clinical practice, non-emergency surgeries should ideally be performed after ART initiation and when CD4+ levels have stabilized, and caution is warranted when CD4+ < 200 cells/μL in order to reduce the perioperative risks[38,41].
Setting up a MDT is central to the successful implementation of PD in PWH. Such an approach involves the coordinated participation of multiple specialties in the preoperative assessment of patients, taking into account the patient’s general condition, comorbidities, surgical complexity, wound-healing potential, CD4+ T-cell count, viral load, and immune status, along with considering nutritional indicators such as the albumin and hemoglobin levels, and body mass index. Based on these evaluations, the optimal timing of surgery and strategies for preventing infectious complications are determined[38]. Preoperative systematic monitoring of the liver and kidney functions, as well as the cardiac enzymes, is imperative. Particular attention should be given to ART-related organ toxicity. For instance, indinavir, abacavir, and didanosine are associated with an increased risk of myocardial infarction[42]; while tenofovir and efavirenz may induce hepatotoxicity[43]; and tenofovir disoproxil fumarate, ritonavir-boosted atazanavir, and ritonavir-boosted lopinavir pose risks of renal impairment[44]. Other common ART-related adverse effects include anemia, peripheral neuropathy, and lipodystrophy[45]. In cases of organ injury or the use of high-risk agents, the MDT should assess and consider transitioning the patient to a lower-toxicity regimen, preferably based on INSTIs (e.g., dolutegravir, raltegravir) or fusion inhibitors (e.g., ibalizumab). For patients with hepatic impairment, switching to tenofovir alafenamide combined with lamivudine and an INSTI is recommended. For those at high risk of renal dysfunction, tenofovir alafenamide or abacavir (in HLA-B5701-negative patients) combined with lamivudine and INSTIs is advised. After regimen adjustment, a monitoring period of 4-8 weeks is required until the HIV RNA becomes undetectable and this remains stable for at least three months, the liver and kidney functions normalize or stabilize within acceptable ranges, and the CD4+ count remains ≥ 200 cells/μL[46]. The oncology and pathology departments should collaborate to achieve accurate tumor staging information through preoperative imaging, the assessment of intraoperative frozen sections, and by standardized postoperative pathological evaluation. For patients with high-risk pathological features, such as lymph node involvement or positive margins, adjuvant systemic chemotherapy is indicated; those at a higher risk of local recurrence may require chemoradiation. For locally advanced or initially unresectable tumors, neoadjuvant therapy (chemotherapy or chemoradiation) may be attempted to downstage the tumor before reevaluating the resectability[46]. Radiotherapy and chemotherapy regimens must be formulated under MDT guidance to avoid interactions with ART. INSTI-based regimens are preferred owing to their lower risk of myelosuppression and drug interactions; treatment-related toxicity should be dynamically monitored[47]. The nutrition department should optimize the patient’s nutritional status before surgery, using albumin as a key indicator, and provide stepwise nutritional support postoperatively to address any malnutrition issues, which could otherwise impair wound healing. Studies have confirmed that hypoalbuminemia is an independent predictor of surgical site infections in PWH and that baseline malnutrition increases the risk of impaired wound healing[48,49]. The cardiology and anesthesiology departments should collaborate to mitigate the risk of perioperative hypercoagulability. PWH have a 2.16-fold higher risk of cardiovascular disease than HIV-negative individuals[50], and are also more susceptible to hypercoagulable states. Inflammatory alterations in platelet ultrastructure may also predispose patients to deep vein thrombosis[51], which is a significant perioperative risk. Therefore, preventive measures should be implemented through both pharmacological and physical means. Physical measures include intermittent pneumatic compression and early ambulation. When selecting appropriate anticoagulants, finding the right the balance between the thromboprophylactic efficacy and bleeding risk must be individualized for each patient. For example, enoxaparin is suitable for most patients with a high thrombosis risk and low bleeding risk, whereas rivaroxaban may be appropriate for those who can tolerate oral medications and prefer simplified dosing[52]. Postoperative management and follow-up should also adhere to a multidisciplinary approach. A common complication after PD is postoperative pancreatic fistula[53]. Given that PWH are at an elevated risk of postoperative complications and delayed healing due to immune dysfunction[20,34,36], it is necessary to routinely use somatostatin prophylactically[54], place a postoperative drainage tube, and dynamically monitor the amylase levels in the drainage fluid[55] to identify any issues and allow an early intervention if necessary. Follow-up should adopt a risk-stratified schedule[56]: Every three months for the first two years, every six months for years 2-5, and annually thereafter, monitoring for tumor recurrence, immune function, and nutritional status.
CONCLUSION
This report covers the case of a person with HIV who presented with duodenal papillary adenocarcinoma and who achieved long-term disease-free survival following PD. This encouraging outcome demonstrates that, with meticulous MDT collaboration, radical surgery for major malignancies can be safely performed in this patient population. Key elements of the perioperative management include: (1) Integrated evaluation by infectious disease, surgery, oncology, cardiology, nutrition, and pharmacy specialists to develop individualized risk-adapted strategies for tumor monitoring and treatment, along with the dynamic adjustment of therapeutic regimens based on toxicity responses during postoperative chemotherapy to ensure treatment safety; (2) While the widely accepted CD4+ threshold of 200 cells/μL provides a practical reference point, surgical eligibility should be determined through a more comprehensive assessment, incorporating the viral load control, nutritional status, organ function, and tumor-specific factors rather than the CD4+ count alone; while maintaining uninterrupted ART throughout the perioperative period is also essential; and (3) Proactive monitoring and management of HIV-specific risk factors, such as deep vein thrombosis and ART-related toxicities, which can help to significantly reduce perioperative complications. We propose a standardized management pathway for such cases (Figure 3), emphasizing preoperative optimization of the patient’s immune function (CD4+ ≥ 200 cells/μL) and nutritional status, ensuring ART continuity, the systematic assessment of HIV-associated comorbidities, including cardiovascular, hepatic, and renal impairments, and thorough MDT-based planning coupled with the vigilant prevention and management of postoperative complications. This case report sets a benchmark for the treatment of complex tumors in PWH, breaking the current limitations of treatment in this population during the era of effective ART. Given the scarcity of surgical data on PWH with tumors, establishing an international multi-center registry system in the future is recommended to explore the biological characteristics of tumors and the differences in treatment responses, which could provide high-level evidence-based support for standardized treatment protocols and promote more equitable and high-quality medical services.
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