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Periampullary and Pancreatic Tumors. Rod L. Flynn, M.D. Surgical Oncologist Mary Washington Hospital Fredericksburg, VA. Defined as those that arise within 2 cm of the major papilla in the duodenum Classified on the basis of their tissue of origin

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Periampullary and Pancreatic Tumors

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Periampullary and pancreatic tumors l.jpg

Periampullary and Pancreatic Tumors

Rod L. Flynn, M.D.

Surgical Oncologist

Mary Washington Hospital

Fredericksburg, VA


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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


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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 Tumors


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Periampullary Anatomy


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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

In general, the more distal the tumor is along the pancreatobiliary tree, the better the prognosis

Hilar Cholangiocarcinomas(Klatskin Tumors) 15-20% 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

Periampullary Tumors


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Pancreatic Head Adenocarcinoma


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Pancreatic Head AdenocarcinomaDemographics

  • 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)


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Pancreatic Head AdenocarcinomaDemographics

  • 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


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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


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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 times risk

  • Familial syndromes


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Familial Syndromes


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Pancreatic Head AdenocarcinomaClinical 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


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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 Head AdenocarcinomaClinical Signs


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Pancreatic Cancer Clinical Presentation


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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

AJCC STAGINGPancreatic Cancer


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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

The superior mesenteric vein is involved with the large pancreatic head tumor

Pancreatic CancerDiagnosis


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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 CancerDiagnostic Tests


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ERCP

Brush cytology

Stenting if necessary

Look for dilated pancreatic duct

Look for filling defect within bile duct

Pancreatic CancerDiagnostic Tests


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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

Pancreatic CancerDiagnostic Tests


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Laparoscopy for staging

  • Looking for

    • Local involvement of adjacent organs

    • Loco-regional extension (lymph nodes, soft tissue)

    • Small liver metastases

    • Peritoneal nodules

Peritoneal Nodule


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Treatment Available

  • Chemotherapy

  • Radiation therapy

  • Chemoradiation followed by resection

  • Resection

  • Resection + Adjuvant Therapy

  • Palliation

    • Stents

    • Bypass

    • Feeding tubes


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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


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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%.


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Most common Diagnosis of patients undergoing Whipple

  • Peripancreatic Cancer (jaundice)

    • Pancreatic head

    • Ampulla

    • Bile duct

  • Duodenal wall

  • Pancreatitis

  • Cystic neoplasm

  • Carcinoid

  • Islet cell tumors


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Surgery

  • Incisions

  • Omentum

  • Resectability (Portal Vein/SMA)

  • Gall Bladder and Porta Hepatis

  • Gastrectomy

  • Pancreas Transection

  • Reconstruction


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Surgery

  • Incisions

  • Omentum

  • Resectability (Portal Vein/SMA)

  • Gall Bladder and Porta Hepatis

  • Gastrectomy

  • Pancreas Transection

  • Reconstruction


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Surgery (cont.)

  • Pylorus Preserving

  • Extended Nodal Dissection

  • Gastric Inversion


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Exposure of SMV

Surgery (cont.)


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Portal Triad

Hepatic artery

Portal vein

Common bile duct

Surgery (cont.)


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Division of pancreas

Surgery (cont.)


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Resected specimen

Surgery (cont.)


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Plumbing restored

Surgery (cont.)


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Outcomes

Possible complications44% in modern series out of Johns Hopkins; <5% 30-day mortality; 17day LOS v. 28 for complicated

  • Pancreatic fistula (Leak-8%)

  • Gastro paresis

  • Nutritional deficiencies

    • Malabsorption

    • Early satiety

    • Weight loss

  • Diabetes


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(Johns Hopkins study, con’t)

Outcomes

  • 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.


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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…”


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Bye-bye


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