Ampullary carcinoma

Nhm 8

 Definition

Lay out

Clinical manifestations,
Diagnosis and staging,

Introduction
Periampullary Carcinoma
Type of Carcinoma

Frequency

Adenocarcinoma of head of
pancreas

50 %

Tumor from ampulla of vater

30%

Distal bile duct carcinoma

10%

Duodenal carcinoma adjacent to

ampulla

10%

INTRODUCTION

INTRODUCTION

Ampullary carcinomas
are defined as those
that arise within the
ampullary complex,
distal to the confluence
of the distal common
bile duct and the
pancreatic duct .

CLINICAL MANIFESTATIONS

Most common presenting symptom of ampullary carcinoma is obstructive

jaundice (80 percent)
Additional symptoms may include diarrhea due to fat malabsorption
(steatorrhea), mild weight loss, and fatigue.
Up to one-third of patients have chronic, frequently occult gastrointestinal
blood loss with an associated microcytic anemia or heme-positive stools.

In one report, nonspecific symptoms include abdominal pain (45 percent),

fever (45 percent), mild nausea, and dyspepsia [25].
Large lesions may produce gastric outlet obstruction associated with severe
nausea and vomiting

DIAGNOSIS AND STAGING

The most commonly used staging system is the

tumor-node-metastasis (TNM) system of the combined
AJCC (American Joint Committee
onCancer)/UICC(International Union Against Cancer)
In the absence of metastases, the prognosis of an
ampullary carcinoma depends primarily upon two
factors:
the degree of local tumor invasion, as reflected by the
T stage, and the presence of lymphatic spread, as
reflected by the N stage

DIAGNOSIS AND STAGING

The diagnostic evaluation of a jaundiced

patient with a suspected malignant bile duct
obstruction is designed to
eliminate benign tumors or gallstones from
the differential,

to establish the extent of tumor invasion and

spread.

A transabdominal ultrasound (US) is a reasonable first test in

patients presenting with obstructive jaundice, but it will
generally not show the tumor.

Helical computed tomography (CT) scanning should be

obtained to visualize the pancreas and surrounding structures.

Although its spatial resolution is inadequate to determine the

degree of local tumor invasion, it is the most useful test to
exclude the presence of distant metastases.

Endoscopic retrograde cholangiopancreatography (ERCP) is

the single most useful endoscopic study since it permits
identification of the tumor, biopsy, and decompression, if
needed.


Liver biochemical tests
Blood chemistries cannot establish the diagnosis of ampullary
carcinoma, but may reflect the presence of cholestasis when an
ampullary neoplasm results in partial or complete biliary
obstruction.
Patients generally have a cholestatic pattern of liver biochemical
test abnormalities, although aminotransferases may also be
elevated .

The prothrombin time may be elevated due to impaired

absorption of fat-soluble vitamins including vitamin K .


Serum tumor markers
not specific for ampullary carcinomas and have
limited diagnostic application.
Nevertheless, some ampullary cancers are
associated with increased serum levels of
carbohydrate antigen CA 199and/orcarcinoembryonic antigen (CEA) , and serial
assay of these tumor markers may be useful for
posttreatment follow-up.

Treatment

It can be difficult to distinguish a primary ampullary carcinoma from

other periampullary tumors (mainly pancreatic carcinoma or distal
cholangiocarcinoma) preoperatively.
However, true ampullary cancers have a better prognosis than
pancreatic head cancers or distal cholangiocarcinomas.
Resectability rates are higher,
five-year survival rates are 30 to 50 percent in selected patients with
limited lymph node involvement.
Thus, an aggressive approach to diagnosis and treatment of
periampullary tumors is needed to ensure that patients with these
comparatively favorable cancers are treated optimally.