PERIAMPULLARY CARCINOMA.pptx

periampullary cancer

1. Presenter: Dr masthan basha MODERATOR: DR PRANABANDHU DAS PERIAMPULLARY CARCINOMA

2. Periampullary cancer  is a  cancer  that forms near the  ampulla of Vater , common channel formed by the confluence of the pancreatic and common bile ducts where they join and enter the  small intestine . It consists of: 1. ampullary tumour from ampulla of Vater 2. cancer of lower common bile duct 3. duodenal cancer adjacent to ampulla 4. carcinoma head of pancreas

3. 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%

4. Pancreatic carcinoma Preoperative evaluation, preparation for surgery and surgical management of these tumors mimics that of pancreatic head cancer. Duodenal Cancer and ampullary cancers have relatively better prognosis as compared to distal bile duct cancers and pancreatic head cancer among all periampullary cancers.

5. Clinical features Head of the gland typically present with jaundice, steatorrhea , weight loss, and pain. Jaundice due to biliary obstruction is often accompanied by pruritus , acholic stools, and dark urine color. Classically , pain is characterized by radiation to the back Recent onset of atypical or exacerbation of preexisting diabetes mellitus, unexplained thrombophlebitis , or history of pancreatitis is often noted.

6. Evaluation H & PE Haemogram LFT S.Amylase Tumor marker: CA 19-9

7. CA 19-9 Prognostic marker Preoperative CA 19-9 level also predicts the presence of occult metastatic disease Serial monitoring of CA 19-9 levels (once every one to three months) is useful to follow patients after potentially curative surgery and for those who are receiving chemotherapy for advanced disease . Rising CA 19-9 levels usually precede the radiographic appearance of recurrent disease. In absence of biliary obstruction, intrinsic liver disease, or benign pancreatic disease, value> 100 U/ mL  highly specific for malignancy especially pancreatic

8. Imaging Modalities Trans abdominal ultrasonography Contrast Enhanced MDCT: Present modality of choice Overall accuracy for diagnosis of pancreatic cancer is 90%. MDCT has an accuracy of 85–95% in determining resectability . Magnetic resonance cholangiopancreatography (MRCP ) : Allows non-invasive delineation of the pancreatic duct and biliary tract. its disadvantage is that it does not permit tissue sampling.

9. ERCP Endoscopic study, permits identification of the tumor , biopsy, and decompression, if needed. With availability of MDCT and dynamic contrast MRI, ERCP for diagnosis has almost become obsolete. ERCP definitely has a therapeutic role in pancreatic head cancers with biliary obstruction and a very high jaundice (>15 mg/ dL ) Endoscopic ultrasonography Endoscopic ultrasonography has a very high sensitivity and specificity for diagnosis of pancreatic cancer. EUS-guided fine-needle aspiration has a high diagnostic accuracy of more than 85–90% for pancreatic cancer.

10. Needle Aspiration Tissue diagnosis before performing pancreatoduodenectomy is not essential Negative biopsy doesn't rule out malignancy in face of clinical and radiological clues Tissue diagnosis mandatory if Neoadjuvant/adjuvant chemotherapy to be given Clinical presentation more suggestive of alternative diagnosis such as lymphoma or pancreatic islet cell tumors

11. In summary, MDCT with angiography or MRI/MRCP should constitute the first imaging modality in suspected pancreatic adenocarcinomas . EUS is recommended for assessing lesions not clearly detected, but suspected, on CT/MRI and in tumors considered ‘borderline resectable ’ on MDCT to assess vascular involvement and obtain a tissue diagnosis. PET-CT in locally advanced lesions may help rule out distant metastases.

12. AJCC 8 TH

13. Stage Grouping Stage 0 Tis N0 M0 Stage IA T1 N0 M0 Stage IB T2 N0 M0 Stage IIA T3 N0 M0 Stage IIB T1, T2, T3 N1 M0 Stage III T1, T2, T3 N2 M0 or T4 Any N M0 Stage IV Any T Any N M1

14. Treatment Surgery: Primary mode of treatment Chemotherapy : U sed in all stages of pancreatic cancer in the form of neo-adjuvant therapy (in resectable and borderline resectable tumors), as adjuvant therapy(post resections) and as palliative therapy (in locally advanced and metastatic tumors).

15. Radiation therapy: Radiation (RT) can also be used in patients with resectable , borderline resectable and locally advanced/metastatic disease . It is used concurrently with gemcitabine or 5- flurouracil based chemotherapy When used in resectable /borderline resectable disease preoperatively or as an adjuvant therapy after resection, the main goal of RT is to sterilize the vascular margins. Chemoradiation can also be given as second-line therapy in patients with locally advanced unresectable disease after initial chemotherapy . C an be used in metastatic setting for palliation of intractable refractory pain

16. Categorized into resectable , borderline resectable , or unresectable tumors based on the CT scan features depending on the abutment or involvement of major vascular structures around pancreas. Resectable tumors Primary surgery f/b adjuvant chemotherapy. Patients with R1 resection and positive LN can be considered for addition of adjuvant radiotherapy

17. Whipple Procedure Indicated for periampullary tumors Involves removal of Pancreatic head and neck 40 % distal stomach + C loop of duodenum + 10 cm proximal jejunum Lower end of CBD with gall bladder Peripancreatic + pericholedochal + paraduodenal + perihepatic nodes Contiuity maintained by Choledochojejunostomy Pancreaticojejunostomy ( or pancreatogastrostomy) Gastrojejunostomy

18. Whipple Procedure

19. Whipple Procedure Mortality 2-8 % Complications Delayed gastric emptying-25 % Require NG decompression Pancreatic fistula -14 % Infection- intra abdominal abscess, wound infection, cholangitis, pancreatitis, pneumonia Bile/pancreatic anastomotic leak

20. CONKO-001: Final results of the randomized, prospective, multicenter phase III trial of adjuvant chemotherapy with gemcitabine versus observation in patients with resected pancreatic cancer (PC ) Background : Prognosis of patients (pts) with PC is dismal, even after curatively intended resection. Whereas gemcitabine -based chemotherapy is standard in advanced PC, the role of adjuvant chemotherapy is still under discussion.  Methods : CONKO-001, a prospective, open, multicenter, controlled phase 3 study was designed to evaluate the efficacy and toxicity of gemcitabine in PC pts after complete (R0 or R1) resection. pts were randomized to receive either gemcitabine (G) (1g/m 2  d 1, 8 and 15 every 4 weeks) for 6 months or observation (O ). Primary study endpoint was disease free survival (DFS), secondary endpoints included OS and toxicity. Results : The analyses confirm the significant improvement for G in median DFS [G:13.4 months (m), O: 6.9m, p< .001]. Estimated DFS at 3 and 5 years was 23.5% and 16.0% in the G group vs. 8.5% and 6.5% in the O group, respectively. G significantly improves median OS [G:22.8m, O: 20.2m, p=.005]. Estimated survival at 3 and 5 years was 36.5% and 21.0% for G pts vs. 19.5% and 9.0% for O pts, respectively . Conclusion : Treatment with G for 6 months for pts after complete resection of PC significantly increases DFS and OS compared with O alone.

21. Borderline resectable Tumors with venous involvement of the superior mesenteric vein or portal vein, gastroduodenal artery encasement up to the hepatic artery and tumor abutment of the superior mesenteric artery of less than or equal to 180° Induction chemo followed by chemo RT (45-54 Gy ) f/b surgery assessment

22. Unresectable Tumors with more than 180° encasement of superior mesenteric artery, celiac axis, un- reconstructable superior mesenteric vein or superior mesenteric-portal vein confluence occlusion or direct involvement of the inferior vena cava and aorta are considered unresectable cancers. These patients are managed initially with chemotherapy (palliative intent) with or without radiotherapy.

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24. Ampullary Carcinoma 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 .

25. Treatment Pancreatico duodenectomy ( whipples procedure) is the primary surgical treatment option. Local ampullary excision rather than pancreatico duodenectomy for patients with noninvasive ampullary tumors. Ampullectomy is also a reasonable approach for poor surgical candidates who have a well-differentiated T1 tumor that is less than 6 mm in size However , a more aggressive surgical approach is preferred for patients who are candidates for pancreaticoduodenectomy because of better outcomes. Nonsurgical treatment modalities ( ie , endoscopic snare resection, laser ablation, photodynamic therapy) provide palliative rather than curative benefit for patients with ampullary carcinoma. These methods should be restricted to patients who are not operative candidates and those who refuse surgery.

26. Adj. treatment There is no consensus regarding the optimal management of patients after resection of an ampullary adenocarcinoma . There are scant data to guide adjuvant treatment decisions, and the true benefit of such therapy remains uncertain. M any clinicians, treat these patients in a similar manner as those with resected pancreatic head adenocarcinomas . Offer adjuvant therapy to all patients with resected ampullary cancer stage IB or higher

27. The approach differs in Europe and in the U.S ESPAC-1 trial, showed that 5-FU-containing chemotherapy prolongs survival in resected pancreatic cancer . German CONKO trial showing a survival benefit from adjuvant gemcitabine in the same patient population P reliminary report of the ESPAC-3 trial, suggesting a potentially clinically meaningful but statistically insignificant improvement in overall survival with adjuvant gemcitabine or leucovorin -modulated 5-FU in ampullary cancer. M ost use chemotherapy alone after resection of an ampullary neoplasm.

28. The American approach more often includes chemoradiotherapy as well as adjuvant chemotherapy

29. Summary Periampullary cancers : 1. Ampullary tumour from ampulla of Vater 2. Cancer of lower common bile duct 3. Duodenal cancer adjacent to ampulla 4. Carcinoma head of pancreas Duodenal Cancer and ampullary cancers have relatively better prognosis as compared to distal bile duct cancers and pancreatic head cancer among all periampullary cancers

30. Primary treatment is Pancreatico duodenectomy ( whipples procedure ). All resected pts should receive adj therapy either with chemo or chemoRT Treatment with adj chemo is recommended usually. Role of Adj ChemoRT is being evaluated in clinical studies. Pts with positive margins , positive LN , Primary tumor stage (T3,T4), high histology grade can be considered for ChemoRT .

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