periampullary cancer

1. P R E S E N T E R : D R M A S T H A N B A S H A
M O D E R A T O R : D R P R A N A B A N D H U D A S
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

4. Introduction
Periampullary Carcinoma
Typeof 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%

5. 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.

6. 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.

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

8. 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 absenceof biliary obstruction,
intrinsic liver disease,or benign pancreatic disease,value> 100 U/mL
 highly specific for malignancy especiallypancreatic

9. 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.

10.  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.

11. NeedleAspiration
• Tissuediagnosis before performing
pancreatoduodenectomy is not essential
– Negativebiopsydoesn't rule out malignancy infaceof clinical and
radiologicalclues
• Tissuediagnosis mandatory if
– Neoadjuvant/adjuvant chemotherapy to begiven
– Clinical presentation more suggestive of alternative diagnosis such
aslymphoma or pancreatic islet cell tumors

12.  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.

13. AJCC 8TH

14.  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

15. Treatment
 Surgery:
 Primary mode of treatment
 Chemotherapy:
 Used 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).

16.  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.
 Can be used in metastatic setting for palliation of intractable
refractory pain

17.  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

18. WhippleProcedure
• Indicated for periampullarytumors
• Involvesremovalof
– Pancreatic headandneck
– 40%distal stomach+Cloop of duodenum +10cmproximaljejunum
– Lowerend of CBDwith gallbladder
– Peripancreatic +pericholedochal +paraduodenal +perihepatic nodes
• Contiuity maintainedby
– Choledochojejunostomy
– Pancreaticojejunostomy ( orpancreatogastrostomy)
– Gastrojejunostomy

19. WhippleProcedure

20. WhippleProcedure
• Mortality 2-8%
• Complications
– Delayed gastric emptying-25 %
• Require NGdecompression
– Pancreatic fistula -14%
– Infection- intra abdominal abscess,wound
infection, cholangitis, pancreatitis, pneumonia
– Bile/pancreatic anastomoticleak

22.  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/m2 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.

28. 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

29. 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.

30. THANK U

40. 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 .

43. 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.

44. 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.
 Many 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

45. 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
 Preliminary 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.
 Most use chemotherapy alone after resection of an ampullary
neoplasm.

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

49. 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

50.  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.

51. THANK U