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7/23/2019 Periampullary Tumor
http://slidepdf.com/reader/full/periampullary-tumor 1/22
Pancreatic and peri-ampullary CA
Ductal adenoCA – most common primarymalignant disease of pancreas and peri-ampullary region
Accounts for more than 75% of all non-endocrine tumors in this region
Ranks 11th among all cancers
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Most lethal CA – overall 5-yr survival rate <3%
5th leading cause of cancer death
Ampullary, distal CBD, duodenal adenoCA – less common than pancreatic tumor; accountsfor 15-20% of all peri-ampullary malignantdisease.
Pancreatic and peri-ampullary CA
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Pancreatic and peri-ampullary CA
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Peri-ampullary CA (ampulla, distal CBD,duodenum) – associated with increased age,HNPCC, Peutz-Jeghers syndrome, familialadenomatous polyposis, Gardner’s syndrome.
Pancreatic and peri-ampullary CA
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Pancreatic and peri-ampullary CA
Can be broadly classified as primary, metastatic, orsystemic
Primary cancers can demonstrate either endocrine or
nonendocrine differentiation Most common malignant diseases that metastasize to
the pancreas are renal cell, breast, colorectal, small celllung and melanoma
Systemic malignant conditions involving the pancreasinclude leukemia and lymphoma
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Ductal AdenoCA (1o solid non-endocrineepithelial tumor)
By far the most common peri-ampullary malignant
disease
Typically aggressive; most resected adenoCA havealready metastasize to regional lymph nodes
Papillary ductal lesion are 3x more common inpatients with pancreatic CA than in normal pancreas
Display k-ras , p53, p16 mutation
Pancreatic and peri-ampullary CA
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Adenosquamous CA – variant of adenoCA; occursin patient’s with history of chemoradiation
Giant cell CA – accounts for <5% of solid
pancreatic malignant tumors Acinar cell CA – distinct histologic appearance
(often greater than 10cm)
Pancreatoblastoma – or pancreatic cancer of infancy;occur in children up to the age of 15yrs.
Pancreatic and peri-ampullary CA
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Vague symptoms early the course
Develop obstructive jaundice secondary toobstruction of the intrapancreatic portion of theCBD
Jaundice often associated with pruritus, acholicstools and dark urine
Pain described as vague upper abdominal,epigastric or back discomfort
Clinical Presentation
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Non-operative palliation Most peri-ampullary adenoCA have unresectable
tumors at presentation
Palliation is aimed at three major symptoms:obstructive jaundice, duodenal or gastric outletobstruction and tumor-associated pain
Patients found to have distant metastases,unresectable local disease, or disseminated intra-abdominal tumors are appropriate candidates fornon-operative therapy
Age alone is not a contraindication to surgicalresection or palliation
Palliative Therapy
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Biliary obstruction Biliary decompression can be achieved by either
endoscopic or percutaneous transhepatic technique
PBD first reported in 1974; catheter exchanges doneevery 3mos to prevent cholangitis and recurrentjaundice secondary to stent occlusion
Endoscopic approach is the method of choice
because of lower procedure-related morbidity andmortality; removal and replacement of stent every 3-6mos to prevent recurrent jaundice and cholangitis
Palliative Therapy
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Palliative Therapy
Pain Pain associated with pancreatic cancer is unremitting and
often poorly managed
Postulated causes include tumor infiltration into the celiacplexus, pain associated with early satiety, gastroduodenal
obstruction and gallbladder or biliary obstruction, increasedparenchymal pressure caused by pancreatic duct obstruction,and pancreatic inflammation
Tumor-associated pain is best treated with long-acting oralanalgesic in appropriate dosage, pain management specialistmay be required to help manage this problem
For pain intractable to typical narcotic regimens, CT guidedpercutaneous celiac nerve block, external beam radiationtherapy, and thoracoscopic or endoscopic chemical
splanchnicectomy maybe done.
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Palliative Therapy
Duodenal obstruction Surgical gastrojejunostomy or feeding tube insertion
maybe done
Endoluminal approaches with biliary-typeexpandable metallic stents are now being tested
Operative palliation Tertiary centers report resectability rates for peri-
ampullary cancers ranging from 67-89%
Palliative surgery is indicated in patients whosetumors are found to be unresectable at the time oflaparotomy intended for curative resection
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Operative Palliation
Obstructive jaundice
Most commonly performed surgical procedure for relief ofobstructive jaundice include hepaticojejunostomy or
choledochojejunostomy, choledochoduodenostomy andcholecystojejunostomy
Pain
Chemical splanchnicectomy can be performed to alleviate the
debilitating pain at the time of operative palliation; performedby injecting 20ml of 50% alcohol through a spinal needle oneither side of the aorta at the level of celiac plexus
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Resectional Therapy
Pancreaticoduodenectomy for peri-ampullary tumors
Halsted performed the first successful resection of a peri-ampullary tumor in 1898
Kausch performed the first successful en bloc resection usingtwo-stage approach
Whipple and colleagues popularized the procedure in the1930s and 1940s
Pylorus-preserving pancreaticoduodenectomy is now thefovored procedure because the gastric reservoir and thepyloric mechanism are kept intact
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Resectional Therapy
Operative technique
If the tumor is localized to the periampullary regionor head, neck, or uncinate process of the pancreas,
with no evidence of distant metastatic disease of thepancreas or major vascular involvement, the surgeonproceeds with resection
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Complications Operative mortality rate for pancreaticoduodenectomy is
currently less than 3% in centers specializing in pancreaticsurgery
Despite this rate, incidence of post-operative complicationsremains as high as 40-50% Two leading causes of morbidity are early delayed gastric
emptying and disruption or leak at the pancreatic anastomosis(pancreatic fistula); the cause is likely multifactorial
Erythromycin has been shown to improve gastric emptyingafter surgery By definition, pancreatic fistula occurs 7 or more days post-
op, when the drain output contains milky, amylase-rich fluidin excess of 50ml/day
Resectional Therapy
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Prognostic Factors
Prognostic factors Determined by multiple factors including tumor stage,
biologic features, molecular genetics, post-op factors and theuse of adjuvant chemoradiation
Peri-ampullary tumors including distal bile duct, ampullary,and duodenal adenoCA are less common, overall 5-yrsurvival rate is better
In long term survivors with resected peri-ampullaryadenoCA, the site specific 5-yr actual survival rates were 15%
for pancreatic CA, 27% for distal bile duct CA, 39% forampullary CA, and 59% for duodenal CA Well-differentiated tumors, negative resection margins, and
negative nodal status were indicators of a better prognosis forall peri-ampullary cancers.
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Prognostic Factors
For Pancreatic CA
Patients with diploid tumors fared significantly better thananeuploid tumors
Tumors with p53 mutations have worse prognosis Tumors with DNA mismatch repair mutations, so-called
RER+ tumors, are associated with improved prognosis
Post-op adjuvant chemotx and radiation tx has been shown
to improve survival 5-FU and external beam radiation tx appear to be indicated
after pancreaticoduodenectomy for pancreatic adenoCA
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Prognostic Factors
Bile duct CA or cholangiocarcinoma Medial survival was 22mos for distal bile duct tumors, with a
5-yr survival of 28% Surgical resection, negative microscopic margins, pre-op
nutritional status, and absence of post-op sepsis were the bestpredictors of improve outcome Adjuvant chemoradiation does not appear to prolong survival
AdenoCA of the ampulla of Vater 2nd most common peri-ampullary malignancy, has a higher
resectability rate and a better prognosis Actuarial 5-yr survival rate at 38% Favorable factors: no peri-op BT, negative lymph node
status, and well-differentiated or moderately differentiatedtumors
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Prognostic Factors
AdenoCA of the duodenum
Least common of the peri-ampullary neoplasm
Associated with the best prognosis
5-yr survival rate of 69%
Negative resection margins and tumors located inthe first and second portion of the duodenum
appear to influence survival favorably