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Trial - Ampullary Carcinoma

A Feasibility Phase II Study in the Treatment of Resected Cholangiocarcinoma, Gallbladder, Pancreatic and Ampullary Cancers

Posted: April 11th, 2008, 10:00am EDT

Conditions: Cholangiocarcinoma Cancer; Gallbladder Cancer; Pancreatic Cancer; Ampullary Cancer
Interventions: Drug: Gemcitabine and Docetaxel (Chemotherapy); Radiation: XRT at 5040 or 5400 cGy and 5FU (Radiation and Chemotherapy); Drug: Gemcitabine and Docetaxel (Chemotherapy)
Sponsor: Washington University School of Medicine
Recruiting - verified April 2008

PubMed - Ampullary Cancer

Mixed ductal-endocrine carcinoma of the pancreas with synchronous papillary carcinoma-in-situ of the common bile duct: a case report and literature review--synchronous pancreatic and bile duct tumors.

Fetched: May 6th, 2008, 9:00pm EDT

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Mixed ductal-endocrine carcinoma of the pancreas with synchronous papillary carcinoma-in-situ of the common bile duct: a case report and literature review--synchronous pancreatic and bile duct tumors.

Am Surg. 2008 Apr;74(4):338-40

Authors: Carter RR, Woodall CE, McNally ME, Talboy GE, Lankachandra KM, Van Way CW

This report is a case of a 58-year-old woman with a mixed ductal-endocrine carcinoma of the pancreas and a synchronous carcinoma-in-situ of the common bile duct. She presented with intractable itching from obstructive jaundice. Magnetic resonance imaging scan showed dilated intrahepatic biliary and common bile ducts. Endoscopic retrograde cholangiopancreatography revealed an ulcerated lesion of the ampulla. Biopsies from this lesion showed adenocarcinoma. Subsequently, pancreatoduodenectomy was performed for the diagnosis of peri-ampullary carcinoma. Gross examination revealed a 2-cm irregular, ulcerated lesion obstructing the distal 0.5 cm of the common bile duct within the head of the pancreas. On histopathological examination, it was discovered that this lesion contained two separate neoplasms: papillary carcinoma-in-situ of the intraparenchymal portion of the common bile duct and a mixed ductal-endocrine carcinoma of the pancreas. Mixed ductal-endocrine carcinoma of the pancreas is very rare. Finding it in conjunction with a synchronous, overlying papillary carcinoma carcinoma-in-situ of the common bile duct has not been previously described.

PMID: 18453301 [PubMed - in process]
Endoscopic therapy in acute recurrent pancreatitis.

Fetched: May 3rd, 2008, 9:00pm EDT

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Endoscopic therapy in acute recurrent pancreatitis.

World J Gastroenterol. 2008 Feb 21;14(7):1034-7

Authors: Baillie J

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a largely diagnostic to a largely therapeutic modality. Cross-sectional imaging, such as computed tomography (CT) and magnetic resonance imaging (MRI), and less invasive endoscopy, especially endoscopic ultrasound (EUS), have largely taken over from ERCP for diagnosis. However, ERCP remains the "first line" therapeutic tool in the management of mechanical causes of acute recurrent pancreatitis, including bile duct stones (choledocholithiasis), ampullary masses (benign and malignant), congenital variants of biliary and pancreatic anatomy (e.g. pancreas divisum, choledochoceles), sphincter of Oddi dysfunction (SOD), pancreatic stones and strictures, and parasitic disorders involving the biliary tree and/or pancreatic duct (e.g Ascariasis, Clonorchiasis).

PMID: 18286684 [PubMed - indexed for MEDLINE]
Beyond the Ivory Tower: Outcomes Following Surgery for Ampullary Cancer.

Fetched: April 22nd, 2008, 9:00pm EDT

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Beyond the Ivory Tower: Outcomes Following Surgery for Ampullary Cancer.

Ann Surg Oncol. 2008 Apr 19;

Authors: Lowy AM

PMID: 18425553 [PubMed - as supplied by publisher]
Endoscopic mucosal resection in the upper gastrointestinal tract.

Fetched: April 9th, 2008, 9:00pm EDT

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Endoscopic mucosal resection in the upper gastrointestinal tract.

World J Gastroenterol. 2008 Apr 7;14(13):1984-9

Authors: Ahmadi A, Draganov P

Endoscopic mucosal resection (EMR) is a technique used to locally excise lesions confined to the mucosa. Its main role is the treatment of advanced dysplasia and early gastrointestinal cancers. EMR was originally described as a therapy for early gastric cancer. Recently its use has expanded as a therapeutic option for ampullary masses, colorectal cancer, and large colorectal polyps. In the Western world, the predominant indication for EMR in the upper gastrointestinal tract is the staging and treatment of advance dysplasia and early neoplasia in Barrett's esophagus. This review will describe the basis, indications, techniques, and complications of EMR, and its role in the management of Barrett's esophagus.

PMID: 18395896 [PubMed - in process]
A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis.

Fetched: April 5th, 2008, 9:00pm EDT

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A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis.

Endoscopy. 2008 Apr;40(4):296-301

Authors: Bailey AA, Bourke MJ, Williams SJ, Walsh PR, Murray MA, Lee EY, Kwan V, Lynch PM

BACKGROUND AND STUDY AIMS: Inadvertent injection of contrast agent into the pancreatic duct is believed to be an important contributor to pancreatitis occurring after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis, PEP). Our aim was to examine whether primary deep biliary cannulation with a guide wire is associated with a lower rate of PEP than conventional contrast-assisted cannulation. PATIENTS AND METHODS: From August 2003 to April 2006 all patients with an intact papilla who were referred for ERCP were eligible. Patients with pancreatic or ampullary cancer were excluded. Patients were randomized to undergo sphincterotomy biliary cannulation using either contrast injection or a guide wire. The ERCP fellow attempted initially for 5 minutes. If unsuccessful, the consultant attempted for 5 minutes using the same technique, followed by crossover to the other technique in the same sequence and then needle-knife sphincterotomy where appropriate. Patients were assessed clinically after the procedure, then followed up with telephone interviews after 24 hours and 30 days, and serum amylase and lipase tests after 24 hours. RESULTS: Out of 1654 patients undergoing ERCP, 413 were included in the study. PEP occurred in 29/413 (7.0 %): 16 in the guide-wire arm, 13 in the contrast arm ( P = 0.48). The overall cannulation success rate was 97.3 %. Cannulation was successful without crossover in 323/413 patients (78.2 %): 167/202 (81.4 %) in the guide-wire arm and 156/211 (73.9 %) in the contrast arm ( P = 0.03). Multivariate analysis demonstrated female sex (OR = 2.7, P = 0.04), suspected sphincter of Oddi dysfunction (OR = 5.5, P = 0.01), and complete filling of the pancreatic duct with contrast agent (OR = 3.5, P = 0.02) to be independently associated with PEP. The risk of PEP increased incrementally with each attempt at the papilla (OR 1.4 per attempt, P = 0.04) to greater than 10 % after four or more attempts. CONCLUSIONS: The guide-wire technique improves the primary success rate for biliary cannulation during ERCP but does not reduce the incidence of PEP compared to the conventional contrast technique. The incidence of PEP increases incrementally with each attempt at the papilla.

PMID: 18389448 [PubMed - in process]
Complications and diagnostic difficulties arising from biliary self-expanding metal stent insertion before definitive histological diagnosis.

Fetched: April 4th, 2008, 9:00pm EDT

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Complications and diagnostic difficulties arising from biliary self-expanding metal stent insertion before definitive histological diagnosis.

J Gastroenterol Hepatol. 2008 Feb;23(2):315-20

Authors: Ayaru L, Kurzawinski TR, Shankar A, Webster GJ, Hatfield AR, Pereira SP

BACKGROUND: Self-expanding metal bile duct stents provide good palliation for inoperable malignant disease. However, problems may arise if metal stents are inserted before definitive histological diagnosis. The aim of this study was to evaluate the outcome of such patients. METHODS: A retrospective case note review was conducted of patients referred to a tertiary pancreaticobiliary center between 1992 and 2004 in whom a metal bile duct stent was inserted for presumed unresectable malignant disease before definitive histological diagnosis. RESULTS: There were 21 patients identified. Final diagnoses were: group 1, benign disease (n = 3); group 2, resectable malignancy (n = 2); group 3, unresectable malignancy (n = 12); and group 4, diagnosis remains uncertain (n = 4). During a follow-up of 22, 38 and 111 months, the patients in group 1 had one, eight and five episodes of stent occlusion. In group 2, both patients underwent pancreaticoduodenectomy for ampullary carcinoma, 2 and 6 months after presentation. In group 3, the median time to a confirmed malignant diagnosis was 2 months (range 1-27 months). In group 4, a median of two biopsies (range 1-4) were negative for malignancy, during a median follow up of 13 months (range 3-46). Overall in eight patients, the metal stents caused artifacts on computed tomography and/or were associated with tissue in-growth making the differentiation between benign and malignant disease difficult. CONCLUSION: These cases indicate that metal bile duct stent insertion before definitive histological diagnosis can be problematic. A proportion of cases will have benign strictures and in others the confirmation of malignancy may be made more difficult.

PMID: 18289360 [PubMed - indexed for MEDLINE]
Role of adjuvant chemoradiation therapy in adenocarcinomas of the ampulla of vater.

Fetched: April 4th, 2008, 9:00pm EDT

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Role of adjuvant chemoradiation therapy in adenocarcinomas of the ampulla of vater.

Int J Radiat Oncol Biol Phys. 2008 Mar 1;70(3):735-43

Authors: Krishnan S, Rana V, Evans DB, Varadhachary G, Das P, Bhatia S, Delclos ME, Janjan NA, Wolff RA, Crane CH, Pisters PW

PURPOSE: The role of adjuvant chemoradiation therapy (CRT) in the treatment of ampullary cancers remains undefined. We retrospectively compared treatment outcomes in patients treated with pancreaticoduodenectomy alone versus those who received additional adjuvant CRT. METHODS AND MATERIALS: Between May 1990 and January 2006, 54 of 96 patients with ampullary adenocarcinoma who underwent potentially curative pancreaticoduodenectomy also received adjuvant CRT. The median preoperative radiation dose was 45 Gy (range, 30-50.4 Gy) and median postoperative dose was 50.4 Gy (range, 45-55.8 Gy). Concurrent chemotherapy included primarily 5-fluorouracil (52%) and capecitabine (43%). Median follow-up was 31 months. Univariate and multivariate statistical methodologies were used to determine significant prognostic factors for local control (LC), distant control (DC), and overall survival (OS). RESULTS: Actuarial 5-year LC, DC, and OS were 77%, 69%, and 64%, respectively. On univariate analysis, age, gender, race/ethnicity, tumor grade, use of adjuvant treatment, and sequencing of adjuvant therapy were not significantly associated with LC, DC, or OS. However, on univariate analysis, T3/T4 tumor stage was prognostic for poorer LC and OS (p = 0.02 and p < 0.001, respectively); node-positive disease was prognostic for poorer LC (p = 0.03). On multivariate analysis, T3/T4 tumor stage was independently prognostic for decreased OS (p = 0.002). Among these patients (n = 34), those who received adjuvant CRT had a trend toward improved OS (median, 35.2 vs. 16.5 months; p = 0.06). CONCLUSIONS: Ampullary cancers have a distinctly better treatment outcome than pancreatic adenocarcinomas. Higher primary tumor stage (T3/T4), an independent adverse risk factor for poorer treatment outcomes, may warrant the addition of adjuvant CRT to pancreaticoduodenectomy.

PMID: 17980502 [PubMed - indexed for MEDLINE]
Ectopic pancreas presenting as ampulla of Vater tumor.

Fetched: April 2nd, 2008, 9:00pm EDT

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Ectopic pancreas presenting as ampulla of Vater tumor.

Am J Surg. 2008 Apr;195(4):498-500

Authors: Hsu SD, Chan DC, Hsieh HF, Chen TW, Yu JC, Chou SJ

Ectopic pancreas is relatively rare and is defined as pancreatic tissue that is situated abnormally, has no contact with the normal pancreas, and has its own ductal system and blood supply. It is usually an incidental finding in clinical practice. Most patients with an ectopic pancreas are asymptomatic, and, if present, symptoms are nonspecific and depend on the site of the lesion and the different complications encountered. Heterotopic pancreatic tissue has been found in several abdominal and intrathoracic locations, most frequently in the stomach (25%-60%) or the duodenum (25%-35%). Herein, we report a patient presenting with symptoms of ampullary tumor with obstructive jaundice, but the imaging study did not suggest the possibility of ectopic pancreas preoperatively.

PMID: 18304504 [PubMed - indexed for MEDLINE]
Survival After Resection of Ampullary Carcinoma: A National Population-Based Study.

Fetched: March 29th, 2008, 9:00pm EDT

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Survival After Resection of Ampullary Carcinoma: A National Population-Based Study.

Ann Surg Oncol. 2008 Mar 28;

Authors: O'Connell JB, Maggard MA, Manunga J, Tomlinson JS, Reber HA, Ko CY, Hines OJ

BACKGROUND: Ampullary cancer is the second most common periampullary cancer, with a resection and survival rate more favorable than that for pancreatic cancer. However, most reports have been conducted at single institutions with small sample sizes, and results may not reflect the practices and outcomes in the community. Our objective was to complete a population-based analysis of patients undergoing resection for ampullary carcinoma and compare it with outcomes in the published literature. METHODS: Patients diagnosed with ampullary cancer reported in the Surveillance, Epidemiology, and End Results program (1988-2003) were collected. Primary outcome was survival (5-year), and secondary outcome was stage at presentation. Comparisons were made with outcomes reported in the literature (resection rate, perioperative mortality, and 5-year survival). RESULTS: Of the 3292 ampullary cancer patients, 1301 (40%) underwent resection. Thirty-seven percent presented with stage I tumors. Perioperative mortality (30 day) was 7.6% after resection, and 5-year survival was 36.8%. Few patients died if they survived at least 5 years. The cancer registry data showed less early stage disease, higher perioperative mortality, and lower 5-year survival compared with published reports. CONCLUSIONS: This is the largest population-based analysis of ampullary carcinoma. Resection rates and survival at the national level are lower, in general, compared with cancer center reports, which may have implications for regionalizing these procedures. Many patients surviving at least 5 years seem to be cured by surgical resection.

PMID: 18369675 [PubMed - as supplied by publisher]
Transduodenal local resection for low-risk group ampulla of vater carcinoma.

Fetched: March 26th, 2008, 9:00pm EDT

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Transduodenal local resection for low-risk group ampulla of vater carcinoma.

J Laparoendosc Adv Surg Tech A. 2007 Dec;17(6):737-42

Authors: Park JS, Yoon DS, Park YN, Lee WJ, Chi HS, Kim BR

BACKGROUND: Carcinoma of the ampulla of Vater has a more favorable prognosis, compared to other malignant tumors of the periampullary region, because it usually presents with symptoms in the early stage. However, treatment by local resection only of the ampullary carcinoma remains controversial. The aim of this study was to evaluate the treatment results of the ampulla of Vater carcinoma according to different types of operation in low-risk-group patients. METHODS: We retrospectively reviewed the medical records of 17 low-risk-group patients among a total of 102 patients with ampulla of Vater carcinoma who had underwent curative surgery from 1992 to 2002. All specimens were critically reviewed by a single expert pathologist, and the relationship between surgical outcomes and operation type was assessed. RESULTS: The low-risk group was comprised of 10 men and 7 women with a median age of 57.8 years. Thirteen of 17 patients underwent a pancreaticoduodenectomy (PD) or a pylorus preserving pancreaticoduodenectomy (PPPD), while 4 patients underwent a transduodenal local resection (TDLR). The operation time was significantly shorter in the TDLR group, compared to the PD or PPPD groups. Among the 17 patients, there was only 1 case of recurrence in the inguinal area 33 months after the pancreaticoduodenectomy. CONCLUSIONS: Transduodenal local resection is a comparable mode of operation for low-risk-group patients with Ampulla of Vater carcinoma. In particular, it is essential to evaluate the invasion depth in preoperative endoscopic ultrasonography, cell differentiation in preoperative biopsy, and positivity of resection margin accurately by using frozen section during the operation.

PMID: 18158802 [PubMed - indexed for MEDLINE]
Variation of a variation: Case report of attenuated familial adenomatous polyposis.

Fetched: March 12th, 2008, 9:00pm EDT

Variation of a variation: Case report of attenuated familial adenomatous polyposis.

HPB (Oxford). 2006;8(2):155-6

Authors: Bhatnagar P, Tetzlaff H, Izatt L, Devlin J, Heaton ND

Background. First described in 1988, attenuated familial adenomatous polyposis (AFAP) is a rare autosomal dominant precancerous condition of the gastrointestinal tract. Few reports have described adenocarcinomatous change in the gastroduodenal region thus far. Case outlineWe report a case of AFAP presenting with extensive gastric polyposis and ampullary adenocarcinoma in absence of a positive family history of gastrointestinal cancer and a novel mutation.

PMID: 18333267 [PubMed - in process]
Papillary adenoma of the distal common bile duct associated with a synchronous carcinoma of the peri-ampullary duodenum.

Fetched: March 11th, 2008, 9:00pm EDT

Papillary adenoma of the distal common bile duct associated with a synchronous carcinoma of the peri-ampullary duodenum.

JOP. 2008;9(2):212-5

Authors: Aparajita R, Gomez D, Verbeke CS, Menon KV

CONTEXT: Benign tumours of the biliary tract are an extremely rare group of neoplasms. The diagnosis of these rare tumours is established on histopathological analysis following resection. Coincidence of a biliary adenoma of the distal common bile duct and a synchronous adenocarcinoma of the peri-ampullary duodenum has never been reported in the literature. CASE REPORT: We report a case of a papillary adenoma in the common bile duct in a 75-year-old female, who had synchronous invasive adenocarcinoma of the peri-ampullary duodenum. CONCLUSION: Isolated papillary adenoma of the bile duct is extremely rare, and in this unusual case it coincided with a peri-ampullary duodenal adenocarcinoma. However, this is a rare instance of an incidental finding within the distal bile duct following pancreaticoduodenectomy for curative treatment of a peri-ampullary adenocarcinoma.

PMID: 18326932 [PubMed - in process]
Laparoscopic deployment of biliary self-expandable metal stent (SEMS) for one-step palliation in 23 patients with advanced pancreatico-biliary tumors--a pilot trial.

Fetched: March 7th, 2008, 9:00pm EST

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Laparoscopic deployment of biliary self-expandable metal stent (SEMS) for one-step palliation in 23 patients with advanced pancreatico-biliary tumors--a pilot trial.

J Gastrointest Surg. 2007 Dec;11(12):1686-91

Authors: Artifon EL, Rodrigues AZ, Marques S, Halwan B, Sakai P, Bresciani C, Kumar A

BACKGROUND: Exploratory laparoscopy is commonly undertaken in patients with highly suspicious biliary and pancreatic lesions to facilitate diagnosis and staging cancer is present. If an unresectable tumor is identified, a second endoscopic procedure may be required do deploy a self-expandable metal stent (SEMS) for palliation. As endoscopic retrograde cholangio pancreatography (ERCP) may be unsuccessful in up to 20% of patients, we evaluated the feasibility and safety of deployment of self-expandable metal stents at the same time as the initial laparoscopy. PATIENTS AND METHODS: A total of 23 eligible patients (8 male and 15 female) with malignant obstruction of the common bile duct underwent deployment of SEMS at laparoscopy. Primary outcome measure was the successful laparoscopic deployment of stent and secondary outcome measure was complications rates. RESULTS: Indications for stent deployment were unresectable pancreatic cancer in 18, cholangiocarcinoma in two, neuroendocrine tumor in one and ampullary adenocarcinoma in two patients. The median age was 73 years (range 49-93). Twenty-two of 23 stents were deployed successfully: 17 stents were deployed transcystically and five via a choledochotomy. Median times for laparoscopic exploration and SEMS deployment were 165 min (range 105-230) and 20 min (range 10-50), respectively. Pre- and post-procedures median total bilirubin were 9.4 mg/dl (range 5.4-17.5) and 4.0 (range 2.6-7.1). The median size of the pancreatic mass was 3 cm (range 2-5 cm) and that of the common bile duct (CBD) from 9.2 mm (range 7.2-17.4). The mean duration of laparoscopy was 170 min (range 120-230 min) and that for stent deployment 23 min (range 10-50 min). Complications included bleeding, obstruction, and wound infection. Bleeding occurred on day 7 in two patients and on day 30 in one patient; bleeding occurred at the gastrojejunal anastomosis site and was successfully treated with endoscopic hemostasis. A total of three stent obstructions were identified: one each at 60, 90, and 120 days follow-up. All complications were successfully managed endoscopically. There were a total of seven deaths, six as a result of progressive cancer and one of surgical wound infection and ensuing complications. CONCLUSION: This study demonstrates that laparoscopic deployment of self-expandable metal bile duct stents is feasible and safe. This option appears to be a reasonable option in patients with inoperable malignant obstruction of the distal common bile duct.

PMID: 17906909 [PubMed - indexed for MEDLINE]
Diagnostic utility of S100P and von Hippel-Lindau gene product (pVHL) in pancreatic adenocarcinoma-with implication of their roles in early tumorigenesis.

Fetched: March 5th, 2008, 9:00pm EST

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Diagnostic utility of S100P and von Hippel-Lindau gene product (pVHL) in pancreatic adenocarcinoma-with implication of their roles in early tumorigenesis.

Am J Surg Pathol. 2008 Jan;32(1):78-91

Authors: Lin F, Shi J, Liu H, Hull ME, Dupree W, Prichard JW, Brown RE, Zhang J, Wang HL, Schuerch C

Recently, we demonstrated von Hippel-Lindau gene product (pVHL) was expressed in normal pancreatic ducts but absent in pancreatic ductal adenocarcinoma (PDA). Previous studies have suggested the diagnostic value of S100P, S100A4, and S100A6 in PDA. In this study, we evaluated pVHL, S100P, S100A4, and S100A6 as potential markers for PDA, pancreatic intraepithelial neoplasia (PanIN), ampullary adenocarcinoma (AAD), and cholangiocarcinoma (CC). Immunostains were performed on 56 PDA cases, 20 AAD cases, and 28 CC cases using antibodies against pVHL, S100P, S100A6, and S100A4. Western blots were also performed on 2 cases of PDA and the matching non-neoplastic pancreatic tissues. Of the 56 PDA cases, immunoreactivity for S100P, S100A6, and S100A4 was observed in 56, 55, and 41 cases, respectively. Non-neoplastic ductal epithelium was negative for S100P in all cases. Ninety percent of PanINs were also positive for S100P. pVHL was not detected in all PDAs and 96% of PanINs by immunohistochemistry. S100P, S100A4, and S100A6 were present in a significant number of AADs and CCs; and pVHL expression was observed in 25% of AADs and 21% of CCs. Our data indicate that (1) S100P and pVHL are a pair of sensitive and specific markers for identifying primary PDA and PanIN; (2) up-regulation of S100P and down-regulation of pVHL may play a role in early tumorigenesis in PDA; and (3) the 4 markers studied have limited value in differentiating among PDA, AAD, and CC.

PMID: 18162774 [PubMed - indexed for MEDLINE]
Contemporary results with ampullectomy for 29 "benign" neoplasms of the ampulla.

Fetched: March 1st, 2008, 9:00pm EST

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Contemporary results with ampullectomy for 29 "benign" neoplasms of the ampulla.

J Am Coll Surg. 2008 Mar;206(3):466-71

Authors: Grobmyer SR, Stasik CN, Draganov P, Hemming AW, Dixon LR, Vogel SB, Hochwald SN

BACKGROUND: Ampullectomy may be an appropriate oncologic procedure in selected patients. Sparse data exist on procedure-related complications and the relationship between histologic analysis and outcomes. STUDY DESIGN: We retrospectively reviewed our experience with ampullectomy in 29 patients with a preoperative benign histologic diagnosis over 15 years (1991 to 2006). Presenting signs, symptoms, and preoperative diagnostic studies were reviewed. Postoperative complications and followup for recurrence were recorded. The abilities of preoperative histologic biopsy, intraoperative frozen section, and final histologic analysis to guide management and predict outcomes were determined. RESULTS: Median age was 63 years. Jaundice was present in 30% of patients. Median length of hospital stay was 9 days. Forty-five percent of patients had a complication, and there was one postoperative mortality (3%). Ampullary adenomatous neoplasms were present in 89% of patients. Preoperative biopsy had complete concordance with final pathology in 76% of patients. Preoperative biopsy and intraoperative frozen section failed to identify carcinoma in four patients. Pancreaticoduodenectomy was performed within 7 days in the postoperative period in three of these patients. After ampullectomy (median followup=16 months), recurrences were identified in two patients (8%) with benign tumors. No patients with high-grade dysplasia (n=4) have had recurrence. CONCLUSIONS: Preoperative biopsy and intraoperative frozen section analysis have limitations in the management of patients undergoing ampullectomy. High-grade dysplasia on preoperative biopsy is not an absolute contraindication to ampullectomy. Morbidity of ampullectomy is significant, but longterm outcomes of this procedure, in patients without invasive malignancy, are acceptable.

PMID: 18308217 [PubMed - indexed for MEDLINE]
Polymorphisms of Genes in the Lipid Metabolism Pathway and Risk of Biliary Tract Cancers and Stones: A Population-Based Case-Control Study in Shanghai, China.

Fetched: February 26th, 2008, 9:00pm EST

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Polymorphisms of Genes in the Lipid Metabolism Pathway and Risk of Biliary Tract Cancers and Stones: A Population-Based Case-Control Study in Shanghai, China.

Cancer Epidemiol Biomarkers Prev. 2008 Feb 22;

Authors: Andreotti G, Chen J, Gao YT, Rashid A, Chen BE, Rosenberg P, Sakoda LC, Deng J, Shen MC, Wang BS, Han TQ, Zhang BH, Yeager M, Welch R, Chanock S, Fraumeni JF, Hsing AW

Biliary tract cancers, encompassing the gallbladder, extrahepatic bile duct, and ampulla of Vater, are uncommon yet highly fatal malignancies. Gallstones, the primary risk factor for biliary cancers, are linked with hyperlipidemia. We examined the associations of 12 single nucleotide polymorphisms of five genes in the lipid metabolism pathway with the risks of biliary cancers and stones in a population-based case-control study in Shanghai, China. We included 235 gallbladder, 125 extrahepatic bile duct, and 46 ampulla of Vater cancer cases, 880 biliary stone cases, and 779 population controls. Subjects completed an in-person interview and gave blood. Genotyping was conducted by TaqMan assay using DNA from buffy coats. The effects of APOE IVS1+69 (rs440446) and APOB IVS6+360C>T (rs520354) markers were limited to men. Men carrying the G allele of APOE IVS1+69 had a 1.7-fold risk of stones [95% confidence interval (95% CI), 1.2-2.4], a 1.8-fold risk of gallbladder cancer (95% CI, 1.0-3.3), a 3.7-fold risk of bile duct cancer (95% CI, 2.0-7.0), and a 4-fold risk of ampullary cancer (95% CI, 1.4-12.4). Male carriers of the T allele of APOB IVS6+360C>T had a 2-fold risk of bile duct cancer (95% CI, 1.2-3.4). The APOB T-T haplotype (APOB IVS6+360C>T, EX4+56C>T) was associated with a 1.6-fold risk of bile duct cancer (95% CI, 1.1-2.3). Male and female carriers of the T allele of LDLR IVS9-30C>T (rs1003723) had a 1.5-fold risk of bile duct cancer. Our findings suggest that gene variants in the lipid metabolism pathway contribute to the risk of biliary tract stones and cancers, particularly of the bile duct. (Cancer Epidemiol Biomarkers Prev 2008;17(3):OF1-10).

PMID: 18296645 [PubMed - as supplied by publisher]
Radiation therapy and photodynamic therapy for biliary tract and ampullary carcinomas.

Fetched: February 16th, 2008, 9:00pm EST

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Radiation therapy and photodynamic therapy for biliary tract and ampullary carcinomas.

J Hepatobiliary Pancreat Surg. 2008;15(1):63-8

Authors: Saito H, Takada T, Miyazaki M, Miyakawa S, Tsukada K, Nagino M, Kondo S, Furuse J, Tsuyuguchi T, Kimura F, Yoshitomi H, Nozawa S, Yoshida M, Wada K, Amano H, Miura F

The purpose of radiation therapy for unresectable biliary tract cancer is to prolong survival or prolong stent patency, and to provide palliation of pain. For unresectable bile duct cancer, there are a number of studies showing that radiation therapy is superior to the best supportive care. Although radiation therapy is used in many institutions, no large randomized controlled trials (RCTs) have been performed to date and the evidence level supporting the superiority of this treatment is low. Because long-term relief of jaundice is difficult without using biliary stenting, a combination of radiation therapy and stent placement is commonly used. As radiation therapy, external-beam radiation therapy is usually performed, but combined use of intraluminal brachytherapy with external beam radiation therapy is more useful for making the treatment more effective. There are many reports demonstrating improved response rates as well as extended survival and time to recurrence achieved by this combination therapy. Despite the low level of the evidence, this combination therapy is performed at many institutions. It is expected that multiinstitutional RCTs will be carried out. Unresectable gallbladder cancer with a large focus is usually extensive, and normal organs with high radio sensitivity exist contiguously with it. Therefore, only limited anticancer effects are to be expected from external beam radiation therapy for this type of cancer. The number of reports on ampullary cancer is small and the role of radiation therapy in this cancer has not been established. Combination treatment for ampullary cancer consists of either a single use of intraoperative radiation therapy, postoperative external beam radiation therapy or intraluminal brachytherapy, or a combination of two or three of these therapies. Intraoperative radiation therapy is superior in that it enables precise irradiation to the target site, thereby protecting adjacent highly radiosensitive normal tissues from irradiation. There are reports showing extended survival, although not significant, in groups undergoing intraoperative or postoperative radiation therapy compared with groups without radiation therapy. To date, there are no reports of large RCTs focusing on the significance of radiation therapy as a postoperative adjuvant treatment, so its usefulness as a postoperative adjuvant treatment is not proven. An alternative treatment is photodynamic therapy. There is an RCT demonstrating that, in unresectable bile duct cancer, extended survival and improved quality of life (QOL) have been achieved through a combination of photodynamic therapy and biliary stenting, compared with biliary stenting alone. Results from large RCTs are desired.

PMID: 18274845 [PubMed - in process]
Guidelines for chemotherapy of biliary tract and ampullary carcinomas.

Fetched: February 16th, 2008, 9:00pm EST

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Guidelines for chemotherapy of biliary tract and ampullary carcinomas.

J Hepatobiliary Pancreat Surg. 2008;15(1):55-62

Authors: Furuse J, Takada T, Miyazaki M, Miyakawa S, Tsukada K, Nagino M, Kondo S, Saito H, Tsuyuguchi T, Hirata K, Kimura F, Yoshitomi H, Nozawa S, Yoshida M, Wada K, Amano H, Miura F

Few randomized controlled trials (RCTs) with large numbers of patients have been conducted to date in patients with biliary tract cancer, and standard chemotherapy has not been established yet. In this article we review previous studies and clinical trials regarding chemotherapy for unresectable biliary tract cancer, and we present guidelines for the appropriate use of chemotherapy in patients with biliary tract cancer. According to an RCT comparing chemotherapy and best supportive care for these patients, survival was significantly longer and quality of life was significantly better in the chemotherapy group than in the control group. Thus, chemotherapy for patients with biliary tract cancer seems to be a significant treatment of choice. However, chemotherapy for patients with biliary tract cancer should be indicated for those with unresectable, locally advanced disease or distant metastasis, or for those with recurrence after resection. That is why making the diagnosis of unresectable disease should be done with greatest care. As a rule, pathological diagnosis, including cytology or histopathological diagnosis, is preferable. Chemotherapy is recommended in patients with a good general condition, because in patients with general deterioration, such as those with a performance status of 2 or 3 or those with insufficient biliary decompression, the benefit of chemotherapy is limited. As chemotherapy for unresectable biliary tract cancer, the use of gemcitabine or tegafur/gimeracil/oteracil potassium is recommended. As postoperative adjuvant chemotherapy, no effective adjuvant therapy has been established at the present time. It is recommended that further clinical trials, especially large multi-institutional RCTs (phase III studies) using novel agents such as gemcitabine should be performed as soon as possible in order to establish a standard treatment.

PMID: 18274844 [PubMed - in process]
Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment.

Fetched: February 16th, 2008, 9:00pm EST

Related Articles

Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment.

J Hepatobiliary Pancreat Surg. 2008;15(1):41-54

Authors: Kondo S, Takada T, Miyazaki M, Miyakawa S, Tsukada K, Nagino M, Furuse J, Saito H, Tsuyuguchi T, Yamamoto M, Kayahara M, Kimura F, Yoshitomi H, Nozawa S, Yoshida M, Wada K, Hirano S, Amano H, Miura F

The only curative treatment in biliary tract cancer is surgical treatment. Therefore, the suitability of curative resection should be investigated in the first place. In the presence of metastasis to the liver, lung, peritoneum, or distant lymph nodes, curative resection is not suitable. No definite consensus has been reached on local extension factors and curability. Measures of hepatic functional reserve in the jaundiced liver include future liver remnant volume and the indocyanine green (ICG) clearance test. Preoperative portal vein embolization may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate exceeding 50%-60% is planned. Postoperative complications and surgery-related mortality may be reduced with the use of portal vein embolization. Although hepatectomy and/or pancreaticoduodenectomy are preferable for the curative resection of bile duct cancer, extrahepatic bile duct resection alone is also considered in patients for whom it is judged that curative resection would be achieved after a strict diagnosis of its local extension. Also, combined caudate lobe resection is recommended for hilar cholangiocarcinoma. Because the prognosis of patients treated with combined portal vein resection is significantly better than that of unresected patients, combined portal vein resection may be carried out. Prognostic factors after resection for bile duct cancer include positive surgical margins, especially in the ductal stump; lymph node metastasis; perineural invasion; and combined vascular resection due to portal vein and/or hepatic artery invasion. For patients with suspected gallbladder cancer, laparoscopic cholecystectomy is not recommended, and open cholecystectomy should be performed as a rule. When gallbladder cancer invading the subserosal layer or deeper has been detected after simple cholecystectomy, additional resection should be considered. Prognostic factors after resection for gallbladder cancer include the depth of mural invasion; lymph node metastasis; extramural extension, especially into the hepatoduodenal ligament; perineural invasion; and the degree of curability. Pancreaticoduodenectomy is indicated for ampullary carcinoma, and limited operation is also indicated for carcinoma in adenoma. The prognostic factors after resection for ampullary carcinoma include lymph node metastasis, pancreatic invasion, and perineural invasion.

PMID: 18274843 [PubMed - in process]
Diagnosis of biliary tract and ampullary carcinomas.

Fetched: February 16th, 2008, 9:00pm EST

Related Articles

Diagnosis of biliary tract and ampullary carcinomas.

J Hepatobiliary Pancreat Surg. 2008;15(1):31-40

Authors: Tsukada K, Takada T, Miyazaki M, Miyakawa S, Nagino M, Kondo S, Furuse J, Saito H, Tsuyuguchi T, Kimura F, Yoshitomi H, Nozawa S, Yoshida M, Wada K, Amano H, Miura F

Diagnostic methods for biliary tract carcinoma and the efficacy of these methods are discussed. Neither definite methods for early diagnosis nor specific markers are available in this disease. When this disease is suspected on the basis of clinical symptoms and risk factors, hemato-biochemical examination and abdominal ultrasonography are performed and, where appropriate, enhanced computed tomography (CT) and/or magnetic resonance cholangiopancreatography (MRCP) is carried out. Diagnoses of extrahepatic bile duct cancer and ampullary carcinoma are often made based on the presence of obstructive jaundice. Although rare, abdominal pain and pyrexia, as well as abnormal findings of the hepatobiliary system detected by hemato-biochemical examination, serve as a clue to making a diagnosis of these diseases. On the other hand, the early diagnosis of gallbladder cancer is scarcely possible on the basis of clinical symptoms, so when this cancer is found with the onset of abdominal pain and jaundice, it is already advanced at the time of detection, thus making a cure difficult. When gallbladder cancer is suspected, enhanced CT is carried out. Multidetector computed tomography (MDCT), in particular - one of the methods of enhanced CT - is useful for decision of surgical criteria, because MDCT shows findings such as localization and extension of the tumor, and the presence or absence of remote metastasis. Procedures such as magnetic resonance imaging, endoscopic ultrasonography, bile duct biopsy, and cholangioscopy should be carried out taking into account indications for these procedures in individual patients. However, direct biliary tract imaging is necessary for making a precise diagnosis of the horizontal extension of bile duct cancer.

PMID: 18274842 [PubMed - in process]
Preoperative biliary drainage for biliary tract and ampullary carcinomas.

Fetched: February 16th, 2008, 9:00pm EST

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Preoperative biliary drainage for biliary tract and ampullary carcinomas.

J Hepatobiliary Pancreat Surg. 2008;15(1):25-30

Authors: Nagino M, Takada T, Miyazaki M, Miyakawa S, Tsukada K, Kondo S, Furuse J, Saito H, Tsuyuguchi T, Yoshikawa T, Ohta T, Kimura F, Ohta T, Yoshitomi H, Nozawa S, Yoshida M, Wada K, Amano H, Miura F

We posed six clinical questions (CQ) on preoperative biliary drainage and organized all pertinent evidence regarding these questions. CQ 1. Is preoperative biliary drainage necessary for patients with jaundice? The indications for preoperative drainage for jaundiced patients are changing greatly. Many reports state that, excluding conditions such as cholangitis and liver dysfunction, biliary drainage is not necessary before pancreatoduodenectomy or less invasive surgery. However, the morbidity and mortality of extended hepatectomy for biliary cancer is still high, and the most common cause of death is hepatic failure; therefore, preoperative biliary drainage is desirable in patients who are to undergo extended hepatectomy. CQ 2. What procedures are appropriate for preoperative biliary drainage? There are three methods of biliary drainage: percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD) or endoscopic retrograde biliary drainage (ERBD), and surgical drainage. ERBD is an internal drainage method, and PTBD and ENBD are external methods. However, there are no reports of comparisons of preoperative biliary drainage methods using randomized controlled trials (RCTs). Thus, at this point, a method should be used that can be safely performed with the equipment and techniques available at each facility. CQ 3. Which is better, unilateral or bilateral biliary drainage, in malignant hilar obstruction? Unilateral biliary drainage of the future remnant hepatic lobe is usually enough even when intrahepatic bile ducts are separated into multiple units due to hilar malignancy. Bilateral biliary drainage should be considered in the following cases: those in which the operative procedure is difficult to determine before biliary drainage; those in which cholangitis has developed after unilateral drainage; and those in which the decrease in serum bilirubin after unilateral drainage is very slow. CQ 4. What is the best treatment for postdrainage fever? The most likely cause of high fever in patients with biliary drainage is cholangitis due to problems with the existing drainage catheter or segmental cholangitis if an undrained segment is left. In the latter case, urgent drainage is required. CQ 5. Is bile culture necessary in patients with biliary drainage who are to undergo surgery? Monitoring of bile cultures is necessary for patients with biliary drainage to determine the appropriate use of antibiotics during the perioperative period. CQ 6. Is bile replacement useful for patients with external biliary drainage? Maintenance of the enterohepatic bile circulation is vitally important. Thus, preoperative bile replacement in patients with external biliary drainage is very likely to be effective when highly invasive surgery (e.g., extended hepatectomy for hilar cholangiocarcinoma) is planned.

PMID: 18274841 [PubMed - in process]
Risk factors for biliary tract and ampullary carcinomas and prophylactic surgery for these factors.

Fetched: February 16th, 2008, 9:00pm EST

Related Articles

Risk factors for biliary tract and ampullary carcinomas and prophylactic surgery for these factors.

J Hepatobiliary Pancreat Surg. 2008;15(1):15-24

Authors: Miyazaki M, Takada T, Miyakawa S, Tsukada K, Nagino M, Kondo S, Furuse J, Saito H, Tsuyuguchi T, Chijiiwa K, Kimura F, Yoshitomi H, Nozawa S, Yoshida M, Wada K, Amano H, Miura F

Curative resection is the only treatment for biliary tract cancer that achieves long-term survival. However, patients with advanced biliary tract cancer have only a limited prognosis even after radical surgical resection. Thus, to improve the longterm results, the early detection of biliary tract cancer and subsequent cure seem to be essential. The purpose of this study was to review the literature concerning the risk factors for cancerous and precancerous lesions of the biliary tract, and prophylactic surgery for these factors. It has been reported that pancreaticobiliary maljunction (PBM) with bile duct dilatation is a risk factor for gallbladder cancer and bile duct cancer, while PBM without bile duct dilatation is a risk factor for gallbladder cancer. Thus, in the former group, a prophylactic excision of the common bile duct and gallbladder should be recommended, while in the later group, a prophylactic cholecystectomy without bile duct resection may be the appropriate surgical procedure. It has also been reported that primary sclerosing cholangitis (PSC) is a risk factor for cholangiocarcinoma. Patients with PSC often develop advanced cholangiocarcinoma with a poor prognosis. In patients with PSC, therefore, strict follow-up should be recommended. Adenoma and dysplasia have been regarded as precancerous lesions of gallbladder cancer. A polypoid lesion of the gallbladder that is sessile, has a diameter greater than 10 mm, and /or grows rapidly, is highly likely to be cancerous and should be resected. Although gallstones seem to be closely associated with gallbladder cancer, there is no evidence of a direct causal relationship between gallstones and gallbladder cancer. Thus, a cholecystectomy is not advised for asymptomatic cholecystolithiasis. Controversy remains as to whether adenomyomatosis of the gallbladder and porcelain gallbladder are associated with gallbladder cancer. With respect to ampullary carcinoma, adenoma of the ampulla is considered to be a precancerous lesion. This article discusses the risk factors for cancerous and precancerous lesions of the biliary tract and prophylactic treatment for these factors.

PMID: 18274840 [PubMed - in process]

A 21-Year-Old Man With Chronic Pancreatitis
Journal of American Medical Association (subscription), IL - Apr 1, 2008
Structural causes include pancreatic duct obstruction due to stones, strictures, ampullary or periampullary mechanical or functional stenosis (eg, ...

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A 21-Year-Old Man With Chronic Pancreatitis - Journal of American Medical Association (subscription)

Posted: April 1st, 2008, 11:54am EDT

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Laughter, hope, friendship mark Daboy's b-day bash - ABS CBN News

Posted: March 4th, 2008, 8:48am EST

Laughter, hope, friendship mark Daboy's b-day bash
ABS CBN News, Philippines - Mar 4, 2008
Fernandez, who is being treated for ampullary cancer, appeared in good health and displayed energy and enthusiasm throughout the celebration. ...

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Ampulla Of Vater (26 unread)

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