Review R4 황은정 경희대학교 의과대학 소화기내과

Case 1 Ampulla of vater (AOV) cancer

Ampulla of vater (AOV) cancer Jaundice Abdominal pain Acute pancreatitis Bleeding …

Staging of AOV the AJCC Cancer Staging Manual, 2010;Seventh Edition Ann Surg Oncol 2008;15:1820.

Prognostic factors of AOV Required for staging : None Clinically significant : Preoperative or pre-treatment carcinoembryonic antigen (CEA) Preoperative or pre-treatment Cancer antigen (CA) 19-9 lab value Preoperative chromogranin A(CgA) the AJCC Cancer Staging Manual, 2010;Seventh Edition

AOV algorithm Recommendations for management are not included in NCCN or ESMO !

Preoperative biliary drainage Role : controversial Obstructive jaundice : 80% Impair hepatic, renal, and immune function A plastic stent or a short self-expanding metal stent Not interfere with subsequent pancreaticoduodenectomy Postoperative morbidity and mortality rates ↓

No drainage vs Preop biliary drainage Cost effective Relieve jaundice Procedure-related complications Complications d/t cholestasis Direct to Surgery Preop biliary drainage one finding neither an adverse nor a favorable impact of preoperative stenting on the incidence of postoperative morbidity or mortality another finding an overall adverse impact of stenting on the postoperative complication rate, the third, significantly fewer postoperative complications in the stented group but no impact on postsurgical mortality. Postoperative complication rate ? Postsurgical mortality ?

In studies NEJM 2010;392(2):129-132 World J Gastroenterol 2009; 15(23): 2908-2912

Pancreatic cancer로 변경

Internal vs External drainage Increased survival Decreased sepsis Decreased renal failure More rapid recovery of immune function Arch Surg 1987; 122: 731-734, Arch Surg 1990; 212: 221-227 Am J Surg 1986; 151: 476-479

Metal stent vs Plastic stent Extend the duration of stent patency Inexpensive Easily removed or exchanged Expensive Not removable Occlusion by sludge and/or bacterial biofilm Required repeated ERCP Longer patency and fewer stent-related problems Not require major decompressive surgery & additional ERCP → Adequate and durable biliary decompression Cochrane Database Syst Rev 2006;1 NEJM 2010;392(2):171-172

Conclusions Consider preoperative biliary drainage in the patients with distal malignant biliary obstruction Self expanding metal stent(SEMS) Unresectable distal malignant biliary obstruction & life expentancy < 3mon Plastic stent

Case 2 Disseminated lymphadenopathy Lymph node metastasis in early gastric cancer

Disseminated lymphadenopathy “MIAMI” Malignancies Infections Autoimmune disorders Miscellaneous and unusual conditions Iatrogenic causes → Very low, 1.1%

Tuberculous lymphadenitis Most frequent presentations of extrapulmonary tuberculosis Peak age of onset : 20 to 40 years Isolated chronic nontender lymphadenopathy, in the cervical region Diagnosis AFB smear and culture of lymph node material FNA is appropriate for initial evaluation Excisional biopsy Microscopy, culture, cytology and PCR testing Chest imaging, neck imaging Treatment Initial 2 months : rifampicin, isoniazid, ethambutol, and pyrazinamide (given daily) Next 4 months : rifampicin and isoniazid

Early gastric cancer (EGC) Adenocarcinoma confined to the mucosa or submucosa. The 5-year survival rate in EGC : > 85% Lymph node (LN) metastasis 1-3 % of intramucosal tumors 11-20 % of submucosal tumors

Risk factors of LN metastasis Undifferentiated types Ulcerated lesions Tumor size larger than 30mm Lymphatic-vascular invasion Massive submucosal penetration

Extended indications for EMR/ESD Gastric Cancer 2007;10: 1–11

EUS : no evidence of submucosal involvement EGD : irregular, slightly depressed lesion without ulceration in the antrum EUS : no evidence of submucosal involvement Bx : moderately differentiated adenocarcinoma Distal gastrectomy with D2 lymphadenectomy Macroscopic findings : 5.5 × 4.0 × 0.3 cm, EGC type IIa + IIc Histologic findings A moderately differentiated tubular adenocarcinoma, confined to the mucosa Extensive embolization of the submucosal lymphatic channels 4 of 34 dissected lymph nodes IHC staining : positively for CD-31 and D2–40

LN metastasis in intramucosal EGC

Possible mechanism of LN metastasis in intramucosal EGC Lymphatic vessels in the deep lamina propria and muscularis mucosa Efferent lymphatic channels Larger submucosal Lymphatics Deep lamina propria와 m mucosa에 lymphatic v. 존재하여 efferent ly channel이 더 큰 submucosal lymphatics로 drainage 되면서 meta 가능 Cancer 1995; 75: 926–35.

Conclusions Generalized adenopathy is occasionally seen in leukemias and lymphomas, or advanced disseminated metastatic solid tumor. Lymph node metastasis is rarely observed in Intramucosal gastric cancer. Always consider other possibilities.