1. Review
R4 황은정
경희대학교 의과대학 소화기내과

2. Case 1 Ampulla of vater (AOV) cancer

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

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

5. 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

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

7. 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 ↓

8. 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 ?

9. In studies
NEJM 2010;392(2):
World J Gastroenterol 2009; 15(23):

11. Pancreatic cancer로 변경

12. Internal vs External drainage
Increased survival
Decreased sepsis
Decreased renal failure
More rapid recovery of immune function
Arch Surg 1987; 122: , Arch Surg 1990; 212:
Am J Surg 1986; 151:

13. 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):

14. 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

15. Case 2 Disseminated lymphadenopathy Lymph node metastasis in early gastric cancer

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

19. 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

20. 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

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

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

23. 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

24. LN metastasis in intramucosal EGC

25. 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.

26. 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.