long case periampullary cancer

7/30/2019 Long Case Periampullary Cancer

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Dr Ramdip Ray MS, MRCS ( Eng) Assistant Professor Medical College, Kolkata

obstructive jaundice

Periampullary carcinomaa long case discussion


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My dear boy !

you said that the Gall bladder is firm

This is a classic case of a hard gall bladder.


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Sir !

I . felt that it is firm .


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Are you sure ?


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I think so


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Okay go on


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obstructive jaundice


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Obstructive Jaundice

yellow sclera, skin, mucosa

dark urine

clay coloured stools

itching


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why itching ?


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the itch

accumulation of bile salts in blood/ tissues

sometimes precedes jaundice


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where to look for mild jaundice ?


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early jaundice

examine posterior hard palate


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why periampullary ?


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Periampullary CA

elderly male

not known patient of gallstones

progressive jaundice

anorexia

Courvoisiers law


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Courvoisier's law : 1890

If in the presence of jaundice the

gallbladder is palpable, then the

jaundice is unlikely to be due to a stone


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Courvoisier's law : 1890

With obstruction of the common bile duct by stone,

dilatation of gallbladder is rare. The organ is usually

shrunken. With obstruction of other kinds, on the

contrary, distention is the rule, shrinking occurs in only

one twelfth of these cases


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exceptions ?


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Exceptions to Courvoisier

pancreatic calculus at ampulla

double impaction

Oriental cholangiohepatitis


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pancreatic calculus at ampulla

double impaction

Oriental cholangiohepatitis

( long standing stones in CBD + Clonorchis

sinensis from freshwater fish )


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NOT mucocele GB


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define periampullary CA


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Periampullary CA

within 2 cm of ampulla

1 pancreatic head / CA2 intrapancreatic CBD

3 ampullary

4 duodenal


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differential diagnoses ?


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Differential diagnoses

pancreatic head CA

distal cholangioCA

CA Gall bladder

HCC

CBD stone


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Other differential diagnoses

chronic pancreatitis

enlarged pericholedochal lymph nodes

sclerosing cholangitis

oriental cholangiohepatitis

hydatid cyst

choledochal cyst


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Which type of periampullary ?


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Which type of periampullary ?

difficult to say

typical ampullary :

intermittent / waxing & waning jaundice


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confirm obstructive jaundice


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confirm obstructive jaundice

hyperbilirubinemia, mainly conjugated

elevated ALP & GGT normal or mildly elevated ALT/AST

low albumin

prolongation of P time


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normal LFT values ?


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normal values

Albumin : 3.55 mg / dL

ALP : 30300 IU / L ( adults )

ALT : 335 IU / L

AST : 335 IU / L


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Why does ALP rise ?


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Why ALP / GGT rise

ALP & GGT : bile duct epithelial damage

ALT & AST : hepatocyte damage

Albumin & P time : hepatic synthetic function


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other causes of high ALP ?


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ALP rise

Obstructive Jaundice

Hepatocellular Jaundice Malignant infiltration

Pagets disease

Pregnancy

Childhood


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elevated P time


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P time

Inj Vitamin K ( Vit K dependent II, VII, IX, X )

prefer I.V. to avoid risk of intramuscular

haematoma

FFP


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after LFT ?


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Ultrasonography

organ of origin GB

hepatomegaly, any liver SOL

distented GB / absence of gallstones dilated IHBR, CHD & CBD

dilated MPD

any periampullary SOL any enlarged LN, ascites


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spleen just palpable ?


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Splenomegaly

just palpable.. One & a half times

L sided portal hypertension

splenic vein thrombosis


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father had an abdominal cancer


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familial / hereditary ?

HNPCC

Familial Breast Cancer ( BRCA2 mutation )

Peutz Jeghers

Ataxia telangiectasia

FAMMM ( Familial Atypical Multiple Mole Melanoma )


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other risk factors ?


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Risk factors Pancreatic CA

age : strongest

smoking : Nnitroso compounds

hereditary / chronic pancreatitis

cystic fibrosis

carcinogens : DDT

diabetes mellitus ??


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diabetes mellitus

diabetes or abnormal GTT in 80 % of pancreatic CA

increased insulin, but reduced peripheral sensitivity

glucagon, somatostatin & amylin increased

amylin from peritumour tissue in response to a factor

produced by the tumour. Surgical resection may

improve !


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molecular genetics


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molecular genetics

The molecular genetics of pancreatic adenocarcinoma have been well

studied. Of these tumors, 80-95% have mutations in the KRAS2 gene, and

85-98% have mutations, deletions, or hypermethylation in the CDKN2 gene.

Of these cancers, 50% have mutations in TP53 and about 55% havehomozygous deletions or mutations of Smad4. Some of these mutations

can also be found in high-risk precursors of pancreatic cancer. For

example, in chronic pancreatitis, 30% of patients have detectable

mutations in TP16 and 10% have K-ras mutations. Although studies are

underway, the genetic mutations associated with pancreaticadenocarcinoma are not yet clinically useful in screening for or

diagnosing the disease.


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molecular genetics

The molecular genetics of pancreatic adenocarcinoma have been well

studied. Of these tumors, 80-95% have mutations in the KRAS 2 gene,and 85-98% have mutations, deletions, or hypermethylation in the CDKN2

gene. Of these cancers, 50% have mutations in TP53 and about 55%have homozygous deletions or mutations of Smad4. Some of these

mutations can also be found in high-risk precursors of pancreatic cancer.

For example, in chronic pancreatitis, 30% of patients have detectable

mutations in TP16 and 10% have K-ras mutations. Although studies areunderway, the genetic mutations associated with pancreatic

adenocarcinoma are not yet clinically useful in screening foror diagnosing the disease.


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after USG ?


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CECT

confirm USG findings

liver mets, LN, distant mets

hypodense mass on venous phase

abutment, encasement or occlusion of portal

vein / SMV / SMA or coeliac axis vascular anomalies


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best imaging ?


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Current standard

helical CECT with 3D reconstruction

further imaging in equivocal cases


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other imaging options

MRCP

MR Angiography

EUS

PET

Laparoscopy


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role of EUS


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EUS

more sensitive for lesions < 2cm

better for L N mets

guided FNAC : esp for Neoadjuvant

Issues : availibility, expertise, cost, invasive


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role of ERCP


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ERCP

to visualise / biopsy ampullary / duodenal

brush cytology & delineation of cholangioCA

for stenting : plastic or metallic


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pre operative stenting

unresolved debate


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pre operative stenting

biliary tract sepsis

elderly / comorbidities very high bilirubin levels

( as per institutional policy )


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pre op biopsy


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pre operative biopsy

non issue

not required in good risk patient with double

duct sign negative bx will not change plan

positive bx may help in counselling

if neo adjuvant planned

10 % benign after Whipples


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diagnostic laparoscopy


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diagnostic laparoscopy

very large tumours

no need of palliative surgery ( stent in place )

body / tail tumours


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Pathological dilemma

abundant desmoplastic stroma

widely scattered neoplastic glands

few cancer cells in FNAC / Bx specimens !

more host tissue than cancer cells

atypia often in chronic pancreatitis


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differential behaviour

similar perioperative M & M

post operative diabetes rare .. In all

long-term survival different


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pancreatic most clinically aggressive

K ras mutations for codon 12 specific for

pancreatic

Jaundice more common in cholangio &

ampullary

Waxing & waning in ampullary

But none present at earlier stage


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Location Mediansurvival

5 yr survival L N mets Perineuralinvasion

Pancreatic 1118 mo 626 % 5679 % Most

Cholangio 2233 mo 1343 % 5669 % 86 %

Ampullary 3849 mo 3348 % 3050 % 517 %

Duodenal 86 mo 3267 % 3647 % -


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ampullary & duodenal

no ampulla in two-thirds

pathological distinction difficult

similar presentation / outcome

proposal : classified as one !


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Assessment of fitness

Hb, TLC, DLC

Sugar, Urea, Creatinine

CXRPA, ECG

Echo, Stress Echo, TMT in some centres


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Informed consent

discuss diagnosis with patient

natural course & treatment options

the surgical procedure chances of inoperability / surgical bypass

Risk of death ( < 4 % )

Risk of morbidities ( 3050 % )

Residual disease / Recurrent disease


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pre operative preparation

adequate hydration : urine output

mannitol / diuretics : unproven role

Inj Vit K 10 mg I.m. / I.v. 35 days

FFP if required

prophylactic I.v. antibiotics at induction

stenting if indicated


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Complications of obstructive jaundice ?


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Obstructive jaundice

Cholangitis : pain, fever & jaundice

Toxic cholangitis : also shock, confusion

Infective complication

Coagulopathy

Hepatorenal syndrome

Impaired immune function


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plan

Whipples operation in good risk


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signs of inoperability

liver / distant metastases

peritoneal metastases

SMVportal vein / SMA fixity


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palliative bypass

hepaticojejunostomy

NOT cholecystojejunostomy unlesslaparoscopic palliation


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margins

pancreatic parenchymal

C B D

G I mucosal

retroperitoneal / uncinate / mesenteric

vascular margin : most important


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controversies

pre op biopsy : resolved

pre op stenting

pre-op mannitol / diuretics

prophylactic octreotide

PP-PDR vs Classic PDR

Classic vs extended PDR

Adjuvant therapy

Prophylactic G J : resolved


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thank you

long case periampullary cancer

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