Download 1 - 경희대학교 의과대학 내과학교실

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
Direct to
Surgery
Procedurerelated
complications
Relieve jaundice
Complications
d/t cholestasis
Postoperative complication rate ?
Postsurgical mortality ?
Preop
biliary
drainage
In studies
NEJM 2010;392(2):129-132
World J Gastroenterol 2009; 15(23): 2908-2912
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
Metal stent
Plastic stent
Extend the duration of stent
Inexpensive
patency
Easily removed or exchanged
Expensive
Occlusion by sludge and/or
Not removable
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 → Very low, 1.1%
Infections
Autoimmune disorders
Miscellaneous and unusual conditions
Iatrogenic causes
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)
• 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
•
•
•
•
•
•
•
66/F
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
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.