Presentation on theme: "TUMORS OF THE AMPULLA OF VATER"— Presentation transcript:
1 TUMORS OF THE AMPULLA OF VATER Aswad H. Al.ObeidyFICMS, FICMS GE&HepKirkuk General Hospital
2 TUMORS OF THE AMPULLA OF VATER Has the highest incidence of neoplastic transformation and malignancy.Production of local carcinogens through the combined interactions of the components of bile, pancreatic juice, and duodenal contents.Both benign and malignant tumors of the ampulla of Vater occur.The benign tumors include adenomas, gastrointestinal stromal tumors (GISTs) , lipomas, and neuroendocrine tumors.Tumors metastatic from other primary sites have also been reported
3 ADENOMA AND ADENOCARCINOMA Most common malignant tumor of the ampulla of Vaterless than 10% of all periampullary adenocarcinomasUp to 25% of such tumors that are resectable.Arise from the mucosal cells of the ampulla of Vater and undergo an adenoma–carcinoma progression sequenceBenign adenomas may become dysplastic, with subsequent progression to adenocarcinoma.80% to 90% of adenocarcinomas were surrounded by benign adenomasIn many cases evolution from benign to malignant histology was noted.Risk factors for ampullary adenocarcinoma include familial adenomatous polyposis (FAP) and Peutz-Jeghers syndrome. FAP have higher frequency of ampullary adenomas, 50% to 86%
4 Clinical FeaturesThe average age of patients with ampullary adenoma is the mid-50sFor ampullary adenocarcinoma is the mid-60s.Present most commonly with obstructive jaundice, in 80%Weight loss occurs in 75% of patientsAbdominal pain in 50%Occult gastrointestinal bleeding is common, in one third of patientsNonspecific symptoms such as anorexia, dyspepsia, and malaiseRarely, with pancreatitis secondary to pancreatic duct obstructionWith features of sphincter of Oddi dysfunctionPhysical examination include conjunctival or cutaneous icterus and, less commonly, hepatomegaly, a distended gall-bladderPositive fecal occult blood test resultVery rarely distinctive silver stools, which result from a combination of the absence of bilirubin and the presence of blood.
5 DiagnosisThe earliest and most common laboratory abnormality is an increase in the serum alkaline phosphatase levelFollowed by hyperbilirubinemia as the tumor obstructs the bile duct.No tumor markers have been identified that are either sensitive or specificThe first imaging modality should be ultrasonography or CT to determine the level of biliary obstruction.Dual-contrast helical CT is the most informative and cost-effective imaging techniqueCT can detect a periampullary mass larger than 1cm,the level of biliary obstruction, the relationship of the mass with surrounding vascular structures, and the presence or absence of liver metastases.Endoscopy to visualize duodenal mucosal abnormalitiesERCP is often the next procedure for patients with a suspected ampullary malignancyEUS has been reported to be both reliable and accurate in the diagnosis and staging
6 Staging Primary Tumor (T Stage) T1 Tumor limited to ampulla of Vater T2 Tumor invades duodenal wallT3 Tumor invades ≤2 cm into pancreasT4 Tumor invades >2 cm into pancreas and/or adjacent organsRegional Lymph Nodes (N Stage)N0 No regional lymph node metastasisN1 Regional lymph node metastasisDistant Metastasis (M Stage)M0 No distant metastasisM1 Distant metastasisTNM Stage GroupingStage I T N M0Stage II T N M0Stage III T N M0Stage IVA T N M0Stage IVB T N M1
7 Management Local Excision The first local surgical resection of an ampullary tumor was performed by William S. Halsted in 1899.Currently, local resection of ampullary tumors is reserved for patients with a benign adenoma or ampullary neuroendocrine tumor and for highly selected patients with ampullary adenocarcinomaThe options for local treatment are endoscopic snare removal, endoscopic ablation, and surgical ampullectomy.Pedunculated tubular adenomas smaller than 1 cm without severe dysplasia can be managed endoscopically, usually with snare excision, sphincterotomy, and temporary placement of a pancreatic duct stent,the risk of incomplete resection and recurrence is as high as 20% with this method.Operative resectionFor adenomas larger than 1 cm, operative resection is indicated once metastatic disease is excluded.Postoperative morbidity after local ampullectomy is low, and mortality rates lower than 2% have been reported.
8 Review of the literature Beger and colleagues identified 62 patients who had undergone ampullectomy for benign neoplasms. After a follow-up period ranging from 1 to 156 months, all were free of disease.Branum and associates reported that of 19 patients with benign neoplasms resected with ampullectomy, disease recurred in 5 at a mean of 35 months (range, 8 to 72 months); two of these patients also had FAP.Mayo Clinic suggesting that such patients may be at risk for the development of adenocarcinoma at the site of recurrence. Fifty patients with benign villous ampullary tumor were treated with local excision, and 17 tumors recurred, with actuarial recurrence rates of 32% at 5 years and 43% at 10 years. Four of the recurrences (24%) were adenocarcinomas
9 Whipple's procedureTreatment of choice for patients with ampullary adenocarcinomaClassic pancreaticoduodenectomy, which includes a distal gastrectomy, and the pylorus-preserving modificationLocal lymph node resection is adequate because there are no data to support an extended lymph node dissection for ampullary adenocarcinoma.Many centers reporting operative mortality rates of less than 5%Morbidity rates associated with this procedure remain high, from 25% to 50%In 1997, the group at the Johns Hopkins Hospital reported the largest single-institution experience in the management of adenocarcinoma of the ampulla of VaterOne hundred twenty patients with adenocarcinoma were treated over a 28-year period. Resection was performed in 106 patients (88%), 105 of whom (99%) underwent either a pancreaticoduodenectomy (n = 103) or total pancreatectomy (n = 2). The overall operative mortality rate was 3.8%. One or more complications occurred in 49 patients, for an overall morbidity rate of 47%. The most common complication was pancreatic fistula, which occurred in 23 patients (25%).
10 Chemotherapy and Radiation Therapy and palliation There are no data to support use adjuvant chemoradiation for ampullary adenocarcinoma.Limited data demonstrate that adjuvant chemotherapy with 5-FU, doxorubicin, and mitomycin C delays tumor recurrence in patients with ampullary adenocarcinomaOperative palliation of obstructive jaundice with a Roux-en-Y hepaticojejunostomy is appropriate.A gastrojejunostomy also should be performed in patients with a compromised duodenal lumen to prevent gastric outlet obstruction before death.If the tumor is determined preoperatively to be unresectable, biliary decompression can be ac-complished by means of endoscopic or percutaneous techniques.
11 PrognosisSurvival in patients with unresectable ampullary adenocarcinoma is 5 to 9 months.The overall 5-year survival rate for patients with resected ampullary cancer ranges from 25% to 55%The 5-year survival rate is significantly better than that for patients with pancreatic adenocarcinomaIn the 1997 Johns Hopkins series, lymph node status, degree of differentiation, and operative blood loss were significant predictors of survivalTumor diameter had no effect on survival, nor did adjuvant therapyIn a series of 101 patients who underwent resection for ampullary adenocarcinoma at Memorial Sloan-Kettering Cancer Center, the 5-year survival rate was 46%, and resection margin status, nodal status, and tumor differentiation were predictive of survival