Transcript Periampullary Tumors

Periampullary and Pancreatic
Tumors
Rod L. Flynn, M.D.
Surgical Oncologist
Mary Washington Hospital
Fredericksburg, VA
Periampullary Tumors
• Defined as those that
arise within 2 cm of the
major papilla in the
duodenum
• Classified on the basis
of their tissue of origin
• Often difficult or
impossible to
differentiate from
pancreatic head
adenocarcinoma before
performing a resection
Periampullary Tumors
• Encompass tumors of
the:
– ampulla of Vater
– distal common bile duct
(intrapancreatic distal
common bile duct),
– duodenal tumors (usually
the second part)
involving the papilla
– tumors of the pancreatic
head involving in close
proximity to the ampulla
•
Pancreatic head
adenocarcinoma accounts for
most (approximately 80%)
tumors in the periampullary
region
Periampullary Anatomy
Periampullary Tumors
• In general, the more
distal the tumor is along
the pancreatobiliary
tree, the better the
prognosis
Non-pancreatic periampullary cancers tend to have a better prognosis
than does pancreatic adenocarcinoma because they are often more
resectable
– i.e. 90% of ampullary cancers vs 15-20% of pancreatic head
cancers
– Hilar
Cholangiocarcinomas
(Klatskin Tumors) 1520% 5-year survival
– Distal bile duct cancers
20-30% 5-year survival
– Ampullary carcinomas
40-60% 5-year survival
– Duodenal carcinomas
60% -70% 5-year
survival
– Pancreatic head
adenocarcinoma 15-20%
5-year survival
Pancreatic Head
Adenocarcinoma
Pancreatic Head
Adenocarcinoma
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Demographics
Treatment poses diagnostic and therapeutic
challenge
Second most common GI malignancy in U.S.
(colorectal is the most common)
In 2006, 33,730 new cases were diagnosed
in U.S.
Accounted for about 32,300 deaths
Fourth leading cause of cancer-related
deaths (following lung, colon, breast/prostate)
Pancreatic Head
Adenocarcinoma
Demographics
• Responsible for 5% of all cancer-related
deaths
• Surgical resection provides the only
chance for cure
• 80% of patients present with advanced
disease not amenable to resection
Pancreatic Cancer
Risk Factors
• Exact cause is unknown
• Environmental exposure
– Smoking (main risk factor)
• Risk increases with dose and exposure
• Other tobacco carcinogens likely involved
– Organic and nickel-containing solvents
– Chlorinated compounds
• High BMI
– Diet -- low in vegetables and fruits, high in animal fats
and meat products Risk higher in obese individuals
– Risk higher in obese individuals
– Decreases with weight loss and exercise
Pancreatic Cancer
Risk Factors (cont’d)
• Comorbid conditions
– Chronic pancreatitis
– Diabetes mellitus, type II
• Risk doubles with > 5-year history of diabetes mellitus, type II
• Genetic factors
– Account for 15% to 20% of cases
• 1 family member affected: 18 times risk
• 3 family members affected: 57
• Familial syndromes
times risk
Familial Syndromes
Syndrome
Hereditary pancreatitis
Hereditary nonpolyposis colorectal
cancer
(Lynch syndrome II)
Hereditary breast and ovarian
cancer
Familial atypical multiple mole
melanoma (FAMM)
Peutz-Jeghers syndrome
Ataxia-telangiectasia (ATM)
syndrome
Molecular/Genetic
Defect
7q35
hMSH2, hMLH1
BRCA2
p16 (9p21)
STK11/LKB1 (19p13)
11q22-23
Pancreatic Head Adenocarcinoma
Clinical Presentation
• Most patients with periampullary cancer
present with at least one of the following
symptoms:
– Weight loss
– Jaundice (75% of patients)
– Vague epigastric/ back pain (retroperitoneal
plexus invasion)
– Fatigue
– Intestinal malabsorption
– New onset diabetes (15%)
• Symptom complex is vague, which often delays
presentation and diagnosis
• As a result about 80% of all patients present with
unresectable disease
Pancreatic Head Adenocarcinoma
Clinical Signs
• The presence of clinical
signs usually means
advanced disease
• Courvoisier’s sign
– Painless jaundice
• Palpable abdominal mass
– Large tumor or omental
cake
• Ascites
• Umbillical nodule (Sister
Mary Joseph’s node)
• Blumer’s shelf
(rectovaginal/vescicle mass)
• Virchow’s node (left
supraclavicular)
Pancreatic Cancer
Clinical Presentation
Component
Local
Constitutional
Biliary obstruction
Pancreatic insufficiency
Symptom
Epigastric/back pain
Fatigue
Anorexia
Weight loss
Jaundice
Pruritus
Pale stools
Malabsorption of fat-soluble
vitamins
Malabsorption
AJCC STAGING
Pancreatic Cancer
TUMOR
• Tis: in situ carcinoma
• T1: < 2 cm
• T2: > 2 cm
• T3: beyond pancreas
• T4: involves celiac axis or
superior mesenteric artery
(unresectable)
NODE
• N0: no lymph node metastases
• N1: regional lymph node
metastases
METASTASES
• M0: no distant metastases
• M1: distant metastases present
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
Pancreatic Cancer
Diagnosis
• The goals of evaluating patients
with periampullary cancers is to
obtain diagnosis and clinical stage
• Based on these determinations the
patient can be triaged into a
treatment category
• (operative or non-operative)
• At time of initial diagnosis, approx
50% of patients will have
metastatic disease
• 30% will have locally-advanced
disease not amenable to surgical
resection
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The superior mesenteric vein is involved
with the large pancreatic head tumor
Pancreatic Cancer
Diagnostic Tests
• Blood tests including CBC, LFTs,
amylase/lipase, CEA, CA 19-9
• Abdominal ultrasound
– A common initial test to evaluate
jaundice
• Abdominal CT scan
– Gives better anatomical information
on the source of the biliary
obstruction
– Can give information about
extrapancreatic sites of spread
(liver, peritoneal/omental surfaces,
ascites, extensive nodal
involvement, adjacent organ
involvement)
– Can assess involvent of major
blood vessels (SMA/portal vein)
• Angiography
•
? PET scan
Pancreatic Cancer
Diagnostic Tests
• ERCP
– Brush cytology
– Stenting if necessary
– Look for dilated
pancreatic duct
– Look for filling defect
within bile duct
Pancreatic Cancer
Diagnostic Tests
• Endoscopic
ultrasound
– Can detect very
small tumors (<2cm)
– Can assist in staging
by assessing
mesenteric vascular
involvement
– FNA biopsies are
relatively easy to do
– Operator dependant
Laparoscopy for staging
Looking for
1. Local involvement of
adjacent organs
2. Loco-regional extension
(lymph nodes, soft
tissue)
3. Small liver metastases
4. Peritoneal nodules
Peritoneal Nodule
Treatment Available
• Chemotherapy
• Radiation therapy
• Chemoradiation
followed by resection
• Resection
• Resection + Adjuvant
Therapy
• Palliation
– Stents
– Bypass
– Feeding tubes
Treatment Available
• Only 10-20% of
patients are eligible
for surgery
• Most have
advanced disease at
time of diagnosis
• Most common
chemo 5-FU &
Gemcitabine
Whipple Procedure
Pancreaticoduodenectomy
• The Whipple operation was
first described in the 1930’s
by Allan Whipple
• In the 1960’s and 1970’s the
mortality rate for the Whipple
operation was very high (Up
to 25% of patients died from
the surgery)
• This experience of the 1970’s
is still remembered by some
physicians who are reluctant
to recommend the Whipple
operation
•
Today the Whipple operation has
become an extremely safe operation
in the USA - At tertiary care centers
where large numbers of these
procedures are performed by
selected surgeons, the mortality rate
is less than 4%.
Most common Diagnosis of
patients undergoing Whipple
• Peripancreatic Cancer
(jaundice)
– Pancreatic head
– Ampulla
– Bile duct
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Duodenal wall
Pancreatitis
Cystic neoplasm
Carcinoid
Islet cell tumors
Surgery
1. Incisions
2. Omentum
3. Resectability
(Portal
Vein/SMA)
4. Gall Bladder
and Porta
Hepatis
5. Gastrectomy
6. Pancreas
Transection
7. Reconstruction
Surgery
1. Incisions
2. Omentum
3. Resectability
(Portal
Vein/SMA)
4. Gall Bladder
and Porta
Hepatis
5. Gastrectomy
6. Pancreas
Transection
7. Reconstruction
Surgery (cont.)
1. Pylorus
Preserving
2. Extended
Nodal
Dissection
3. Gastric
Inversion
Surgery (cont.)
• Exposure of SMV
Surgery (cont.)
• Portal Triad
– Hepatic artery
– Portal vein
– Common bile duct
Surgery (cont.)
• Division of pancreas
Surgery (cont.)
• Resected specimen
Surgery (cont.)
• Plumbing restored
Outcomes
Possible complications
44% in modern series out of Johns Hopkins;
<5% 30-day mortality; 17day LOS v. 28 for
complicated
1. Pancreatic fistula
(Leak-8%)
2. Gastro paresis
3. Nutritional
deficiencies
1. Malabsorption
2. Early satiety
3. Weight loss
4. Diabetes
Outcomes
(Johns Hopkins study, con’t)
• N= 201 patients
• The mean age of the
patients was 63 years, with a
slight male predominance
(108 men and 93 women).
• There were no differences in
survival based on age,
gender, or race.
• The actuarial one, three and
five-year survival rates for all
201 patients were 57%,
26%, and 21% respectively,
with a median survival of
15.5 months.
• 11 five-year survivors,
• 7 six-year survivors
• one fifteen-year survivor.
Summary
• Periampullary cancers include bile duct, ampulla of vater,
duodenal, pancreatic head
• Prognoses depend on relative location
• Pancreatic head adenocarcinoma carries worst prognosis
• Surgery is the only chance of cure, although a majority of
patients are unresectable at the time of diagnosis
• Better preoperative evaluation can reduce the number of
unnecessary operations
• Preoperative diagnosis is often very difficult if not
impossible to make despite a myriad of diagnostic
modalities at our disposal
• In this group of patients we surgeons sometime have to tell
the patient after a lengthy Whipple operation: “…I have
good news, you don’t have cancer…”
Bye-bye