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CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON PERIAMPULLARY CANCER by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital ng Maynila Medical Center CASE MANAGEMENT, PRESENTATION, DISCUSSION O.V., 52/M LUCENA CITY CHIEF COMPLAINT: ABDOMINAL PAIN HISTORY OF PRESENT ILLNESS: 2 months PTA Px underwent cholecystectomy, IOC, and t-tube insertion in another institution HISTORY OF PRESENT ILLNESS: 6 weeks PTA the patient noted he had yellowish discoloration of his skin with associated right upper quadrant abdominal pain HISTORY OF PRESENT ILLNESS: 6 weeks PTA consultation was done in another institution where t-tube replacement was performed HISTORY OF PRESENT ILLNESS: 6 weeks PTA there was noted increase in the intensity of the abdominal pain and passage of black, tarry stool after t-tube replacement HISTORY OF PRESENT ILLNESS: 4 weeks PTA ERCP done and the noted perimampullary mass was biopsied. HISTORY OF PRESENT ILLNESS: 3 weeks PTA biopsy results revealed an adenocarcinoma HISTORY OF PRESENT ILLNESS: 3 days PTA abdominal CT Scan revealed a periampullary mass which was difficult to delineate from the pancreatic head HISTORY OF PRESENT ILLNESS: Persistence of his condition as well the results of the abovementioned diagnostics prompted consultation and subsequent admission. Pertinent (+): approximately 10% weight loss in the past 2 months PAST MEDICAL Hx: (+)HPN – UBP 130/80 HBP 160/100; maintained on Metoprolol with poor compliance FAMILY Hx: No heredofamilial disease noted PERSONAL/SOCIAL Hx: - smoking history of 2.5 pack-years - consumed 2 bottles of beer per week for the past 10 years PHYSICAL EXAMINATION: G/S: conscious, coherent, not in cardiorespiratory distress BP= 110/70 CR=80 RR= 20 T=370C SHEENT: no jaundice; pink palpebral cojunctiva,anicteric sclera, No NAD, No CLAD, No TPC PHYSICAL EXAMINATION: C/L: SCE, no retractions, clear BS CVS: adynamic precordium, NRRR, no murmur Abdomen: flabby; (+) right subcostal surgical scar with t-tube in place; soft; no palpable masses PHYSICAL EXAMINATION: Extremities: no edema, atrophy or cyanosis noted; full and equal pulses on all extremities SALIENT FEATURES: 52 y/o, M Right upper quadrant abdominal pain approximately 10% weight loss in the past 2 months underwent cholecystectomy, IOC, and t-tube insertion in another institution 2 months PTA SALIENT FEATURES: yellowish discoloration of the skin associated with right upper quadrant abdominal pain 6 weeks PTA t-tube replacement 6 weeks PTA increase in the intensity of the abdominal pain and passage of black, tarry stool after t-tube replacement RUQ abdominal pain and jaundice RUQ abdominal pain and jaundice S/P Cholecystectomy, IOC, placement of t-tube RUQ abdominal pain and jaundice Inflammatory/ Metabolic •Cirrhosis •Hepatitis Retained CBD Stone S/P Cholecystectomy, IOC, placement of t-tube Neoplastic Disease •Primary liver tumors •Metastases •Cholangiocarci noma •Klatskin tumors •GB CA •Periampullary CA Clinical Diagnosis: Diagnosis Certainty Treatment Neoplastic Disease 33% Surgical Retained CBD Stone 33% Surgical Metabolic/ Inflammatory 33% Surgical/ Medical BASES: 52 y/o, M Right upper quadrant abdominal pain underwent cholecystectomy, IOC, and ttube insertion 2 months PTA yellowish discoloration of the skin associated with right upper quadrant abdominal pain 6 weeks PTA increase in the intensity of the abdominal pain and passage of black, tarry stool after t-tube replacement Do I need a para-clinical diagnostic procedure? YES Paraclinical Diagnostic Procedures Benefit Risk Cost Availability HELICAL CT SCAN Single most valuable study for staging 1 Can provide 3D reconstruction of vascular structures surrounding the lesion1 Radiation Exposure +++ not readily available MRI Can provide 3D reconstruction of vascular structures surrounding the lesion1 Can be reconstructed to give the image of the pancreatic and bile ducts1 NONE ++++ not readily available ENDOSCOPIC UTZ with BIOPSY or FNA Can be used to establish a tissue diagnosis1 BLEEDING ++ not readily available Paraclinical Diagnostic Procedures ERCP with biopsy (9/29/07) – Normal esophagus and gastric mucosa – Fungating mass at the periampullary area. Pus noted extruding from the papilla. – Moderately dilated CBD, CHD, and right and left hepatic ducts – 0.5 filling defect at the distal CBD Paraclinical Diagnostic Procedures Biopsy result (10/5/07) – Adenocarcinoma Paraclinical Diagnostic Procedures Abdominal CT Scan (10/24/07) – Nodular soft tissue density in the periampullary region (66.1 x 49.5 x 40.6mm) – Hyperdense tubular structure, most likely a tube noted within the mass Paraclinical Diagnostic Procedures Abdominal CT Scan (10/24/07) – Head of the pancreas difficult to delineate from the mass – Body and tail of the pancreas are unremarkable – Liver and spleen normal in size and homogeneity Paraclinical Diagnostic Procedures Abdominal CT Scan (10/24/07) – GB not visualized – Biliary tree unremarkable – Kidneys normal in size, position, and configuration with good excretory function – Rest of the soft tissue, vascular, and osseous structures intact RUQ abdominal pain and jaundice Inflammatory/ Metabolic •Cirrhosis •Hepatitis Retained CBD Stone S/P Cholecystectomy, IOC, placement of t-tube Neoplastic Disease •Primary liver tumors •Metastases •Cholangiocarci noma •Klatskin tumors •GB CA •Periampullary CA RUQ abdominal pain and jaundice Inflammatory/ Metabolic •Cirrhosis •Hepatitis Retained CBD Stone S/P Cholecystectomy, IOC, placement of t-tube Neoplastic Disease •Primary liver tumors •Metastases •Cholangiocarci noma •Klatskin tumors •GB CA •Periampullary CA •Fungating mass at the periampullary region on ERCP • Nodular soft tissue density in the periampullary region on abdominal CT Scan RUQ abdominal pain and jaundice Inflammatory/ Metabolic •Cirrhosis •Hepatitis Retained CBD Stone S/P Cholecystectomy, IOC, placement of t-tube Neoplastic Disease •Primary liver tumors •Metastases •Cholangiocarci noma •Klatskin tumors •GB CA •Periampullary CA •Fungating mass at the periampullary region on ERCP • Nodular soft tissue density in the periampullary region on abdominal CT Scan Periampullary Carcinoma Pancreas Ampulla of Vater CBD Duodenum Periampullary Carcinoma Pancreas Ampulla of Vater CBD Duodenum Abdominal CT Scan –Head of the pancreas difficult to delineate from the mass –Body and tail of the pancreas are unremarkable ERCP with biopsy •Fungating mass at the periampullary region •Pus noted extruding from the papilla Periampullary Carcinoma Pancreas Ampulla of Vater CBD Duodenum Periampullary Carcinoma Pancreas Ampulla of Vater CBD Duodenum Adenocarcinoma on biopsy Ampullary Adenocarcinoma Pretreatment Diagnosis: Diagnosis Certainty Treatment Ampullary AdenoCA 90% Surgical Periampullary CA (Pancreas, CBD, Duodenum) 10% Surgical TREATMENT PRETREATMENT DIAGNOSIS: Ampullary Adenocarcinoma TREATMENT GOALS OF TREATMENT: – Curative extirpation of the tumor – Relieve biliary obstruction TREATMENT OPTIONS TREATMENT STANDARD WHIPPLE RESECTION BENEFIT Treatment of choice for resectable periampullary cancers. Applicable on tumors that appear to encroach on the proximal duodenum or the gastric antrum1 RISK COST Pncreatic fistula 14% GE Leakage 1% Bile leakage 0% Post-op bleeding 7% Intraabdominal abscess 10% Other complications 28% Relaparotomy 19% Operative Mortality 7%2 Cost of OR needs and anesthetics(P 5,000P10,000) AVAIL Available TREATMENT OPTIONS TREATMENT PPPD BENEFIT Treatment of choice for resectable periampullary cancers. RISK COST Pncreatic fistula 13% GE Leakage 0% Bile leakage 2% Post-op bleeding 7% Intraabdominal abscess 10% Other complications 22% Relaparotomy 15% Operative Mortality 3%2 Cost of OR needs and anesthetics(P 5,000P10,000) AVAIL Available TREATMENT OF CHOICE STANDARD WHIPPLE RESECTION/ PANCREATICODUODENECTOMY PREOPERATIVE PREPARATION Informed consent Psychosocial support Optimize patient’s health Screen for any condition that will interfere with treatment Prepare materials OPERATIVE TECHNIQUE Patient supine under GETA Asepsis/Antisepsis Sterile drapes placed Bilateral subcostal incision Assessment of the abdomen for metastatic disease Mobilization of the duodenum and the head of the pancreas with identification of the superior mesenteric vein • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 OPERATIVE TECHNIQUE Mobilization of the stomach and proximal duodenum with transection of the proximal duodenum (or stomach) as soon as the decision of resection has been made Skeletonization of the structures of the porta • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 OPERATIVE TECHNIQUE Cholecystectomy and division of the common bile duct Mobilization and division of the proximal duodenum Transection of the neck of the pancreas and division of the remaining attachments of the specimen to the superior mesenteric and portal veins and the superior mesenteric artery • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 OPERATIVE TECHNIQUE Reconstruction of gastrointestinal continuity Correct sponge and instrument count Layer by layer closure DSD • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 OPERATIVE FINDINGS Intraluminal mass located in the Ampulla of Vater with infiltration of the mucosal layer OPERATION DONE: STANDARD WHIPPLE RESECTION/ PANCREATICODUODENECTOMY HISTOPATHOLOGY Ampullary Adenocarcinoma, welldifferentiated arising from a villous adenoma Acute Pancreatitis Negative for tumor: – All surgical margins labelled (superior, inferior, anterior, posterior, and pancreatic surgical margins), proximal ad distal surgical margins – Pancreatic dict and CBD – All 8 lymph nodes labelled “inferior, superio, posterior pancreatic nodes and periduodenal lymph nodes” POST OPERATIVE DIAGNOSIS Ampullary Adenocarcinoma POST-OP CARE Sufficient analgesia NPO IV hydration and medication Daily wound care Monitoring of complications and treat as indicated Clear liquid diet started on the 5th POD then progression to a regular diet in the next 24-48 hours • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 POST-OP CARE Biliary drain removed the day after oral intake is started if there is no evidence of biliary leak Pancreatic drain removed on the day of discharge as long as there is no pancreatic leak • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 SHARING OF INFORMATION PERIAMPULLARY CARCINOMA Refer to cancers that arise from: – Pancreas (pancreatic adenocarcinoma is the most common periampullary CA) – Ampulla of Vater – Bile duct – Duodenum • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA similar in terms of clinical presentation, symptoms, and treatment precise tumor type is often unknown preoperatively; periampullary mass that appears to be malignant should be resected when feasible • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – – – 4th leading cause of cancer death 6% of cancer deaths in the US Most common form of pancreatic cancer • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – – – 23% 1-year survival rate after diagnosis 4% 5-year survival rate 20% 5-year survival rate for those diagnosed with local disease and underwent resection • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Symptoms: Weight loss Jaundice Abdominal or back pain Malabsorption (rarely) • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – 20% of patients will have had a new diagnosis of diabetes in the prvious 1-2 years Patients in their 50s with a new diagnosis of diabetes and no risk factors should be screened • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Evaluation: Family Hx: 10% of pancreatic cancers have a genetic basis P.E.: focus on evidence of matastasis (supraclavicular nodes, assessment of the liver) • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Evaluation: Diagnostics: – CBC – LFT – Serum albumin – Tumor markers (carbohydrate antigen 19-9, carcinogenic embryonic antigen) • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Evaluation: Helical CT Scan – Performed as a pancreatic protocol scan – Most valuable study to stage patients • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Evaluation: MRI – With newer software and protocols for imaging, may produce images as informative as those from a CT Scan • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Evaluation: CT Scan and MRI – Can provide 3D reconstruction of vascular structures surrounding the pancreatic lesion – replacing preoperative angiography • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Evaluation: Endoscopic ultrasound (EUS) – Can provide information about resectability – Needs CT Scan to corroborate the findings – Reliable in tissue diagnosis • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Evaluation: Patients with metastatic disease are not operative candidates • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Evaluation: The mass is considered unresectable if it involves: – Hepatic, celiac or superior mesenteric arteries – Celiac or periaortic nodes • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA The American Joint Committee on Cancer 6thEdition Staging System – Pancreatic Cancer Primary Tumor (T) – T1 - Tumor limited to the pancreas, 2 cm or smaller in greatest dimension – T2 - Tumor limited to the pancreas, larger than 2 cm – T3 - Tumor extension beyond the pancreas (eg, duodenum, bile duct, portal or superior mesenteric vein) but not involving the celiac axis or superior mesenteric artery – T4 - Tumor involves the celiac axis or superior mesenteric arteries (unresectable primary tumor) • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA The American Joint Committee on Cancer 6thEdition Staging System – Pancreatic Cancer Regional lymph nodes (N) – – – NX - Regional lymph nodes cannot be assessed N0 - No regional lymph node metastasis N1 - Regional lymph node metastasis • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA The American Joint Committee on Cancer 6thEdition Staging System – Pancreatic Cancer Distant metastasis (M) – – – MX - Distant metastasis cannot be assessed M0 - No distant metastasis M1 - Distant metastasis • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA The American Joint Committee on Cancer 6thEdition Staging System – Pancreatic Cancer Stage grouping for pancreatic cancer is as follows: – – – – – – – Stage 0 - Tis, N0, M0 Stage IA - T1, N0, M0 Stage IB - T2, N0, M0 Stage IIA - T3, N0, M0 Stage IIB - T1-3, N1, M0 Stage III - T4, Any N, M0 Stage IV - Any T, Any N, M1 • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Staging and resectability Stage 0, I, II – generally considered resectable Patients with tumors confined to the pancreas and lymph nodes included in the resection and who have no vascular invasion are candidates for resection • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Chemoradiation Neoadjuvant therapy – is not routinely performed – used when the tumor appears locally invasive – Downstaging in about 10% of cases which allows for resection • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA PANCREATIC ADENOCARCINOMA – Chemoradiation Adjuvant therapy – Standard of care • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA AMPULLARY CARCINOMA – Carcinoma of the Ampulla of Vater – Rare tumor – More likely to be resectable than other periampullary malignancies – jaundice presents earlier – Less aggressive than pancreatic or bile duct cancers • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA AMPULLARY CARCINOMA – Patients present with abdominal pain, jaundice and weight loss – Resection rate 80% – 30-70% 5-year survival rate • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA AMPULLARY CARCINOMA – Evaluation CT Scan EUS with biopsy or fine needle aspiration • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA AMPULLARY CARCINOMA – Evaluation EUS with biopsy or fine needle aspiration – Determine the true nature of the neoplasm and the depth of involvement into the duodenal wall • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA AMPULLARY CARCINOMA – Evaluation EUS with biopsy or fine needle aspiration – Pancreaticoduodenectomy –for patients with biopsy-proved cancers penetrating the muscularis of the duodenum • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA AMPULLARY CARCINOMA – Evaluation EUS with biopsy or fine needle aspiration – Local excision of the Ampulla of Vater – for benign lesions; a frozen section of the specimen is performed and a diagnosis of cancer requires conversion to pancreaticoduodenectomy • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA The American Joint Committee on Cancer 6thEdition Staging System – Ampulla of Vater Carcinoma Primary Tumor (T) – T1 - Tumor limited to the Ampulla of Vater or Sphincter of Oddi – T2 - Tumor invades the duodenal wall – T3 - Tumor invades the pancreas – T4 - Tumor invades peripancreatic soft tissues or other adjacent organs or structures • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA The American Joint Committee on Cancer 6thEdition Staging System – Ampulla of Vater Carcinoma Regional lymph nodes (N) – – N0 - No regional lymph node metastasis N1 - Regional lymph node metastasis • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA The American Joint Committee on Cancer 6thEdition Staging System – Pancreatic Cancer Distant metastasis (M) – – M0 - No distant metastasis M1 - Distant metastasis • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA The American Joint Committee on Cancer 6thEdition Staging System – Pancreatic Cancer Stage grouping for pancreatic cancer is as follows: – – – – – – – Stage 0 - Tis, N0, M0 Stage IA - T1, N0, M0 Stage IB - T2, N0, M0 Stage IIA - T3, N0, M0 Stage IIB - T1-3, N1, M0 Stage III - T4, Any N, M0 Stage IV - Any T, Any N, M1 • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA AMPULLARY CARCINOMA – Chemoradiation No trials indicate that chemotherapy or radiation improves survival but resection clearly does • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA CHOLANGIOCARCINOMA – – – – Involve the bile ducts More common in Asian countries Associated with chronic bile duct inflammation 25% in the distal duct • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA CHOLANGIOCARCINOMA – – – Symptoms indistinguishable from pancreatic cancer Diagnosis suspected – isolated bile duct stricture with a normal pancreatic duct Poor prognosis – 15% 5-year survival rate after resection • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA DUODENAL CARCINOMA – – – – Adenocarcinoma of the duodenum Presumed to originate from duodenal polyps 0.5% of all GI tract malignant neoplasms 45% of small bowel cancers • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 PERIAMPULLARY CARCINOMA DUODENAL CARCINOMA – – – – Can occur along the entire length of the duodenum Usually diagnosed at an advanced stage Resection is the only potetially curative treatment Up to 50% 5-year survival rate • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 MCQ 1. What is the most common periampullary carcinoma? a. Pancreatic Adenocarcinoma b. Ampullary Carcinoma c. Cholangiocarcinoma d. Duodenal Carcinoma MCQ 1. What is the most common periampullary carcinoma? a. Pancreatic Adenocarcinoma b. Ampullary Carcinoma c. Cholangiocarcinoma d. Duodenal Carcinoma MCQ 2. Which periampullary carcinoma has an 80% resection rate? a. Pancreatic Adenocarcinoma b. Ampullary Carcinoma c. Cholangiocarcinoma d. Duodenal Carcinoma MCQ 2. Which periampullary carcinoma has an 80% resection rate? a. Pancreatic Adenocarcinoma b. Ampullary Carcinoma c. Cholangiocarcinoma d. Duodenal Carcinoma MCQ 3. Which periampullary carcinoma has a 15% 5-year survival rate after resection? a. Pancreatic Adenocarcinoma b. Ampullary Carcinoma c. Cholangiocarcinoma d. Duodenal Carcinoma MCQ 3. Which periampullary carcinoma has a 15% 5-year survival rate after resection? a. Pancreatic Adenocarcinoma b. Ampullary Carcinoma c. Cholangiocarcinoma d. Duodenal Carcinoma MCR A – 1, 2, and 3 are correct B – 1 and 3 are correct C – 2 and 4 are correct D – only 4 is correct E – none are correct MCR I. Periampullary cancers arise from which of the following? 1. Pancreas 2. Ampulla of Vater 3. Bile duct 4. Liver MCR I. Periampullary cancers arise from which of the following? 1. Pancreas 2. Ampulla of Vater 3. Bile duct 4. Liver MCR II. Which is true about duodenal carcinomas 1. It is the 2nd most common periampullary carcinoma 2. It accounts for up to 45% of small bowel cancers 3. It has a 5-year survival rate of 15% 4. It represents less than 0.5% of all GI tract malignant neoplasms MCR II. Which is true about duodenal carcinomas 1. It is the 2nd most common periampullary carcinoma 2. It accounts for up to 45% of small bowel cancers 3. It has a 5-year survival rate of 15% 4. It represents less than 0.5% of all GI tract malignant neoplasms THANK YOU!!! REFERENCES Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513 Khe TC, et al: Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized multicenter analysis of 170 patients with pancreatic and perampullary tumors, Ann Surg 240(5):738-745, 2004 JOURNAL CRITICAL APPRAISAL Pylorus Preserving Pancreaticoduodenectomy Versus Standard Whipple Procedure A Prospective, Randomized, Multicenter Analysis of 170 Patients With Pancreatic and Periampullary Tumors Khe T. C. Tran, MD,* Hans G. Smeenk, MD,* Casper H. J. van Eijck, MD, PhD,* Geert Kazemier, MD,* Wim C. Hop, MSc, PhD,* Jan Willem G. Greve, MD, PhD,† Onno T. Terpstra, MD, PhD,‡ Jan A. Zijlstra, MD,§ Piet Klinkert, MD,§ and Hans Jeekel, MD, PhD* ABSTRACT Objective: – A prospective randomized multicenter study was performed to assess whether the results of pylorus-preserving pancreaticoduodenectomy (PPPD) equal those of the standard Whipple (SW) operation, especially with respect to duration of surgery, blood loss, hospital stay, delayed gastric emptying (DGE), and survival. ABSTRACT Summary Background Data: – PPPD has been associated with a higher incidence of delayed gastric emptying, resulting in a prolonged period of postoperative nasogastric suctioning. Another criticism of the pylorus-preserving pancreaticoduodenectomy for patients with a malignancy is the radicalness of the resection. On the other hand, PPPD might be associated with a shorter operation time and less blood loss. ABSTRACT Methods: – A prospective randomized multicenter study was performed in a nonselected series of 170 consecutive patients. All patients with suspicion of pancreatic or periampullary tumor were included and randomized for a SW or a PPPD resection. Data concerning patients’ demographics, intraoperative and histologic findings, as well as postoperative mortality, morbidity, and follow-up up to 115 months after discharge, were analyzed. ABSTRACT Results: – There were no significant differences noted in age, sex distribution, tumor localization, and staging. There were no differences in median blood loss and duration of operation between the 2 techniques. DGE was observed equally in the 2 groups. There was only a marginal difference in postoperative weight loss in favor of the standard Whipple procedure. Overall operative mortality was 5.3%. Tumor positive resection margins were found for 12 patients of the SW group and 19 patients of the PPPD group (P < 0.23). Long-term follow-up showed no significant statistical differences in survival between the 2 groups (P < 0.90). ABSTRACT Conclusions: – The SW and PPPD operations were associated with comparable operation time, blood loss, hospital stay, mortality, morbidity, and incidence of DGE. The overall long-term and disease-free survival was comparable in both groups. Both surgical procedures are equally effective for the treatment of pancreatic and periampullary carcinoma. Appraisal Guide: THERAPY OR PREVENTION Are the results of the study valid? Primary Guides: Was the assignment of patients to treatments randomized? – YES. The design of the study was a prospective multicenter trial which consisted of a pretreatment evaluation and a rendomized treatment with either SW or PPPD. Appraisal Guide: THERAPY OR PREVENTION Are the results of the study valid? Primary Guides: Were all patients who entered the trial properly accounted for and attributed at its conclusion? YES. Based on the final histologic diagnosis, 29 patients with benign lesions and 7 with endocrine tumors were excluded from the survival analysis. For long-term follow-up, a total of 134 patients with histologic and proven pancreatic periampullary adenocarcinoma were included and analyzed. Appraisal Guide: THERAPY OR PREVENTION Are the results of the study valid? Primary Guides: Was followup complete? YES. Appraisal Guide: THERAPY OR PREVENTION Are the results of the study valid? Primary Guides: Were patients analyzed in the groups to which they were randomized? YES. All patients with suspicion of pancreatic or periampullary tumor were included and randomized for a SW or a PPPD. Data concerning patient’s demographics, intraoperative and histologic findings as well as post-opertative mortality, morbidity, and followup up to 115 months after discharge were analyzed. Appraisal Guide: THERAPY OR PREVENTION Are the results of the study valid? Secondary Guides: Were patients, health workers, and study personnel "blind" to treatment? YES. An equal number of blind envelopes with protcols were prepared and used sequentially as patients were wnrolled in the study. Appraisal Guide: THERAPY OR PREVENTION Are the results of the study valid? Secondary Guides: Were the groups similar at the start of the trial? YES. Included were 170 patients with suspected pancreatic or periampullary cancer that were aswsumed resectable base on CT and or MRI. Patients with previous gastric resection were excluded. Appraisal Guide: THERAPY OR PREVENTION Are the results of the study valid? Secondary Guides: Aside from the experimental intervention, were the groups treated equally? YES. They were subjected to the same preoperative evaluation, exclusion criteria and post operative management.