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Edward Chin, MD
February 3, 2005
Case
87M with scc of mouth
S/p R radical neck, partial glossectomy, mandibulectomy,
alveoloplasty, flap coverage 94
2001: elevated LFTs
U/S: intra & extrahepatic biliary dilatation, dilated CBD
CT: same
2003: CBD stones on U/S, CT
EGD ampullary mass, bxd
tubulovillous adenoma w/ foci of high-grade dysplasia
Case
Case
Ampullary Tumors
Periampullary tumors:
pancreatic
duodenal
CBD
ampulla
1o ampullary tumors:
Rare: 1 per 6 million
Benign & malignant
w/ FAP, HNPCC
Ampulla of Vater
Ampullary Tumors
Benign:
adenomas, lipoma, hamartoma, lymphangioma,
hemangioma, neurogenic tumors
Adenomas
Tubulovillous (40%)
Villous (30%)
Tubular (10%)
Non-epithelial (20%)
Malignant transformation:
adenoma dysplasia carcinoma?
Ampullary Tumors
Favorable (vs. periampullary)
Resectability > 90%
5-year survival 30-50%
Presentation
Ampullary cancers:
80% with jaundice
Adenomas (sporadic)
Typically older patients (70s)
Non-specific symptoms (mild pain, fullness, N/V, anemia, GI bleeding)
Jaundice 50-75%
Cholangitis, pancreatitis rare
CBD stones seen in 25%
Diagnosis
U/S, CT: indirect evidence (ductal dil, CBD stone)
EUS: good for staging (T > N)
Cholangiography
ERCP, MRCP, PTC for diagnosis
Intraductal extension
Indurated, rigid papilla,
ulceration seen w/ ca
Biopsies lack sensitivity
False negative < 50%
~15% of biopsies w/ adenoca
OR pathology: 30-60%
Staging
5-year survival:
Stage I: 84%
Stage II: 70%
Stage III: 27%
LN Spread
Surgical Options
Whipple procedure (pancreaticoduodenectomy)
Low mortality in large centers (< 5%)
Best survival (> 50% 5-year)
High morbidity (25-65%)
Survival
Prognostic Factors
TDE Results
Lack of high-quality studies
Largest: German study (n = 41)
TDE
26 patients underwent TDE (Duke)
Adenoca (n= 8)
Duke, TDE
Adenomas (n=18)
5 complications
5 recurrences
Mean time = 34 months
2 with Gardners syndrome
4/5 treated endoscopically, 1 whipple
No deaths
Ann Surg 1996. 224(5): 621-27
TDE indications:
Adenomas with HGD (ca in < 30%)
Large villous, TV adenomas (> 2 cm)
Low-grade, stage tumors w/ comorbidities
J Hepatobil Pancreat Surg 2004. 11: 239-44
More Data
88 patients with ampullary tumors
94% underwent surgery
92% curative resection performed
89% whipple, 3% local excision
Results
0 deaths
39% morbidity
88% malignant on
pathology
12% benign adenomas
Med survival 42 months
vs. 8 months unresectable
Br J Surgery 2004. 91(12): 1600-07
Prognostic Factors
LN spread
Resectability
Elevated bilirubin
Endoscopic Therapies
Snare resection
Laser ablation
Photodynamic irradiation
Adenomas < 4 cm
Absence of strictures or extension duct
No ulcers
Benign results of > 6 biopsies
Adjuvant Therapy
Investigational
Chemotherapy (5-FU)
+/- XRT (45 Gy)