Neoadjuvant Therapy for Duodenal and Ampullary Adenocarcinoma: A Systematic Review

BACKGROUND

The role of systemic therapy in the management of ampullary (AA) and duodenal adenocarcinoma (DA) remains poorly understood. This study sought to synthesize current evidence supporting the use of neoadjuvant therapy (NAT) in AA and DA.

METHODS

The study searched PubMed, Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCO), and ClinicalTrials.gov databases for observational or randomized studies published between 2002 and 2022 evaluating survival outcomes for patients with non-metastatic AA or DA who received systemic therapy and surgical resection. The data extracted included overall survival, progression-free survival, and pathologic response (PR) rate.

RESULTS

From the 347 abstracts identified in this study, 29 reports were reviewed in full, and 15 were included in the final review. The selected studies published from 2007 to 2022 were retrospective. Eight were single-center studies; five used the National Cancer Database (NCDB); and two were European multicenter/national studies. Overall, no studies identified survival differences between NAT and upfront surgery (with or without adjuvant therapy). Two NCDB studies reported longer survival with NAT/AT than with surgery. Five single-center studies reported a significant portion of NAT patients who achieved PR, and one study identified major PR as an independent predictor of survival. Other outcomes associated with NAT included conversion from unresectable to resectable disease, reduced lymph node positivity, and decreased local recurrence rate.

CONCLUSION

Evidence supporting the use of NAT in AA and DA is weak. No randomized studies exist, and observational data show mixed results. For patients with DA and AA, NAT appears safe, but better evidence is needed to understand the preferred multidisciplinary management of DA and AA periampullary malignancies.

Ampullary Adenocarcinoma, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Ampullary cancers refer to tumors originating from the ampulla of Vater (the ampulla, the intraduodenal portion of the bile duct, and the intraduodenal portion of the pancreatic duct), while periampullary cancers may arise from locations encompassing the head of the pancreas, distal bile duct, duodenum, or ampulla of Vater. Ampullary cancers are rare gastrointestinal malignancies, and prognosis varies greatly based on factors such as patient age, TNM classification, differentiation grade, and treatment modality received. Systemic therapy is used in all stages of ampullary cancer, including neoadjuvant therapy, adjuvant therapy, and first-line or subsequent-line therapy for locally advanced, metastatic, and recurrent disease. Radiation therapy may be used in localized ampullary cancer, sometimes in combination with chemotherapy, but there is no high-level evidence to support its utility. Select tumors may be treated surgically. This article describes NCCN recommendations regarding management of ampullary adenocarcinoma.

Incidence and comparative outcomes of periampullary cancer: A population-based analysis demonstrating improved outcomes and increased use of adjuvant therapy from 2004 to 2012

BACKGROUND AND OBJECTIVES

Periampullary adenocarcinoma (PAC) is stratified anatomically: ampullary adenocarcinoma (AA), distal cholangiocarcinoma (DCC), duodenal adenocarcinoma (DA), and pancreatic ductal adenocarcinoma (PDAC). We aimed to determine differences in incidence, prognosis, and treatment in stage-matched PAC patients in a longitudinal study.

METHODS

PAC patients were identified in The National Cancer Database from 2004 to 2012. Clinicopathological variables were compared between subtypes. Covariate-adjusted treatment use and OS were compared.

RESULTS

The 116 705 patients with PAC were identified: 1320 (9%) AA, 3732 (3%) DCC, 7142 (6%) DA, and 95 511 (82%) PDAC. DA, DCC, and PDAC were associated with worse survival compared with AA (hazard ratio [HR], 1.10; 95% CI, 1.1-1.1; HR, 1.50; 95% CI, 1.4-1.6, and HR, 1.90; 95% CI, 1.8-1.9). Among resected patients, DA was associated with improved survival compared with AA (HR, 0.70; 95% CI, 0.67-0.75); DCC and PDAC were associated with worse survival (HR, 1.41; 95% CI, 1.31-1.53 and HR, 2.041; 95% CI, 1.07-2.12). Resected AA, PDAC, and DA, but not DCC, demonstrated significantly improved survival over the studied period. While all patients had increased adjuvant therapy (AT) receipt over time (P < 0.001), only patients with PDAC had increased neoadjuvant therapy (NAT) receipt ( P < 0.001).

CONCLUSION

Resected PDAC, AA, and DA were associated with clinically significant improved survival over time, mirroring a concurrent associated increased receipt of AT.

[A Case of Long-Term Survival after Repeated Multidisciplinary Treatment for Liver Metastasis of Ampullary Cancer]

The patient was a 79-year-old man. He underwent endoscopic papillectomy for ampullary cancer when he was 70 years old. At the ages of 71 and 73 years, liver metastasis in segment 6 was detected, and radiofrequency ablation(RFA)was performed and adjuvant chemotherapy(gemcitabine, S-1)was administered. At the age of 79 years, recurrence of liver metastasis appeared. Because there were no other metastatic lesions, we performed S6 subsegmentectomy. Five months after the surgery, no recurrence was observed. In general, the prognosis of patients with ampullary cancer with distant metastasis is very poor. This case suggested the efficacy of multidisciplinary treatment, including surgery, RFA, and chemotherapy, in a patient with ampullary cancer with distant metastasis.

Association of Adjuvant Therapy with Improved Survival in Ampullary Cancer: A National Cohort Study

BACKGROUND

There are limited data on the efficacy of adjuvant therapy in ampullary cancer. The aim of this study was to determine whether adjuvant therapy was associated with improved survival for patients with ampullary cancer.

METHODS

From the National Cancer Database, we identified ampullary cancer patients who underwent resection between 2004 and 2013. We performed 1:1 propensity score matching, comparing patients who had postoperative observation to patients who received adjuvant chemotherapy (ACT) or adjuvant chemoradiotherapy (ACRT).

RESULTS

We identified 4190 patients who fit our inclusion criteria; 63% had postoperative observation, 21% received ACT, and 16% underwent ACRT. In the matched cohorts, the use of ACT was associated with improved overall survival (HR = 0.82, 95% CI = 0.71 to 0.95). The median overall survival was 47.2 months for the ACT group and 35.5 months for the observation group. In a separate matched analysis, ACRT was also associated with improved survival (HR = 0.84, 95% CI = 0.72 to 0.98) as compared to observation. The median overall survival was 38.1 months for the ACRT group and 31.0 months for the observation group. The benefit was more pronounced in high-risk patients, such as ones with higher T and N categories.

CONCLUSIONS

In this retrospective study, the use of adjuvant therapy in ampullary cancer was associated with significantly improved overall survival. The benefit of adjuvant therapy for this disease should be confirmed in a more rigorous fashion via randomized controlled trials.

Updated therapeutic outcome for patients with periampullary and pancreatic cancer related to recent translational research

Chemotherapy with improved effect in patients with metastatic pancreatic cancer has recently been established, launching a new era for patients with this very aggressive disease. FOLFIRINOX and gemcitabine plus nab-paclitaxel are different regimens, both capable of stabilizing the disease, thus increasing the number of patients who can reach second line and even third line of treatment. Concurrently, new windows of opportunity open for nutritional support and other therapeutic interventions, improving quality of life. Also pancreatic surgery has changed significantly during the latest years. Extended operations, including vascular/multivisceral resections are frequently performed in specialized centers, pushing borders of resectability. Potentially curative treatment including neoadjuvant and adjuvant chemotherapy is offered new patient groups. Translational research is the basis for the essential understanding of the ongoing development. Even thou biomarkers for clinical management of patients with periampullary tumors have almost been lacking, biomarker driven trials are now in progress. New insight is constantly made available for clinicians; one recent example is selection of patients for gemcitabine treatment based on the expression level of the human equilibrium nucleoside transporter 1. An example of new diagnostic tools is identification of early pancreatic cancer patients by a three-biomarker panel in urine: The proteins lymphatic vessel endothelial hyaluronan receptor 1, regenerating gene 1 alpha and translation elongation factor 1 alpha. Requirement of treatment guideline revisions is intensifying, as combined chemotherapy regimens result in unexpected advantages. The European Study Group for Pancreatic Cancer 4 trial outcome is an illustration: Addition of capecitabine in the adjuvant setting improved overall survival more than expected from the effect in advanced disease. Rapid implementation of new treatment options is mandatory when progress finally extends to patients with this serious disease.

Targeted next generation sequencing of endoscopic ultrasound acquired cytology from ampullary and pancreatic adenocarcinoma has the potential to aid patient stratification for optimal therapy selection

BACKGROUND & AIMS

Less than 10% of registered drug intervention trials for pancreatic ductal adenocarcinoma (PDAC) include a biomarker stratification strategy. The ability to identify distinct mutation subsets via endoscopic ultrasound fine needle aspiration (EUS FNA) molecular cytology could greatly aid clinical trial patient stratification and offer predictive markers. We identified chemotherapy treatment naïve ampullary adenocarcinoma and PDAC patients who underwent EUS FNA to assess multigene mutational frequency and diversity with a surgical resection concordance assessment, where available.

METHODS

Following strict cytology smear screening criteria, targeted next generation sequencing (NGS) using a 160 cancer gene panel was performed.

RESULTS

Complete sequencing was achieved in 29 patients, whereby 83 pathogenic alterations were identified in 21 genes. Cytology genotyping revealed that the majority of mutations were identified in KRAS (93%), TP53 (72%), SMAD4 (31%), and GNAS (10%). There was 100% concordance for the following pathogenic alterations: KRAS, TP53, SMAD4, KMT2D, NOTCH2, MSH2, RB1, SMARCA4, PPP2R1A, PIK3R1, SCL7A8, ATM, and FANCD2. Absolute multigene mutational concordance was 83%. Incremental cytology smear mutations in GRIN2A, GATA3 and KDM6A were identified despite re-examination of raw sequence reads in the corresponding resection specimens.

CONCLUSIONS

EUS FNA cytology genotyping using a 160 cancer gene NGS panel revealed a broad spectrum of pathogenic alterations. The fidelity of cytology genotyping to that of paired surgical resection specimens suggests that EUS FNA represents a suitable surrogate and may complement the conventional stratification criteria in decision making for therapies and may guide future biomarker driven therapeutic development.

A tsunami of unmet needs: pancreatic and ampullary cancer patients' supportive care needs and use of community and allied health services

OBJECTIVE

People diagnosed with pancreatic cancer have the worst survival prognosis of any cancer. No previous research has documented the supportive care needs of this population. Our objective was to describe people's needs and use of support services and to examine whether these differed according to whether or not patients had undergone surgical resection.

METHODS

Queensland pancreatic or ampullary cancer patients (n = 136, 54% of those eligible) completed a survey, which assessed 34 needs across five domains (Supportive Care Needs Survey-Short Form) and use of health services. Differences by resection were compared with Chi-squared tests.

RESULTS

Overall, 96% of participants reported having some needs. More than half reported moderate-to-high unmet physical (54%) or psychological (52%) needs, whereas health system/information (32%), patient care (21%) and sexuality needs (16%) were described less frequently. The three most frequently reported moderate-to-high needs included 'not being able to do things they used to do' (41%), 'concerns about the worries of those close' (37%) and 'uncertainty about the future' (30%). Patients with non-resectable disease reported greater individual information needs, but their needs were otherwise similar to patients with resectable disease. Self-reported use of support was low; only 35% accessed information, 28%, 18% and 15% consulted a dietician, complementary medicine practitioner or mental health practitioner, respectively. Palliative care access was greater (59% vs 27%) among those with non-resectable disease.

CONCLUSION

Very high levels of needs were reported by people with pancreatic or ampullary cancer. Future work needs to elucidate why uptake of appropriate supportive care is low and which services are required.

Trends in incidence and management of cancer of the ampulla of Vater

AIM: To provide trends in incidence, management and survival of cancer of the ampulla of Vater in a well-defined French population.

METHODS: Data were obtained from the population-based digestive cancer registry of Burgundy over a 34-year period. Age-standardized incidence rates were computed using the world standard population. Average annual variations in incidence rates were estimated using a poisson regression. A univariate and multivariate relative survival analysis was performed.

RESULTS: Age-standardized incidence rates were 0.46 and 0.30 per 100000 inhabitants for men and women, respectively. Incidence rate increased from 0.26 (1976-1984) to 0.58 (2003-2009) for men and remained stable for women. Resection for cure was performed in 48.3% of cases. This proportion was stable over the study period. Among cases with curative resection, pancreatico-duodenectomy was performed in 94.0% of cases and ampullectomy in 6.0% of cases. A total of 50.8% of cancers of the ampulla of Vater were diagnosed at an advanced stage. Their proportion remained stable throughout the study period. The overall 1- and 5-year relative survival rates were 60.2% and 27.7%, respectively. Relative survival did not vary over time. Treatment and stage at diagnosis were the most important determinants of survival. The 5-year relative survival rate was 41.5% after resection for cure, 9.5% after palliative surgery and 6.7% after symptomatic treatment. In multivariate analysis, only stage at diagnosis significantly influenced the risk of death.

CONCLUSION: Cancer of the ampulla of Vater is still uncommon, but its incidence increased for men in Burgundy. Diagnosis is often made at an advanced stage, dramatically worsening the prognosis.

Defining the role of adjuvant therapy: ampullary and duodenal adenocarcinoma

Adenocarcinomas of the ampulla of Vater and duodenum are more rare than pancreatic cancer and have a better prognosis. However, studies conducted on the management of these cancers, such as adjuvant chemotherapy and radiation therapy, are limited by small sample sizes and series that are retrospective. This review evaluates ampullary and duodenal adenocarcinomas with regard to incidence, anatomy, prognostic features, patterns of failure, and the available literature studying adjuvant therapy.

Primary non-Hodgkin's lymphoma of the common bile duct: A case report and literature review

Hepatobiliary involvement by malignant lymphoma is usually a secondary manifestation of systemic disease, whereas primary non-Hodgkin's lymphoma of the extrahepatic biliary ducts is an extremely rare entity. We describe the case of a 57-year-old man who presented with an acute onset of obstructive jaundice and severe itching. Abdominal ultrasonography and computed tomography revealed intrahepatic and common hepatic ducts dilatation. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed a mid-common bile duct stricture. The patient was presumed to have cholangiocarcinoma of the common bile duct, and an en bloc resection of the tumor with Roux-en-Y hepaticojejunostomy and porta-hepatis lymph nodes dissection was performed. Histopathology and immunohistochemistry revealed a large B cell non-Hodgkin's lymphoma. The patient received six cycles of combination chemotherapy using cyclophosphamide, vincristine, prednisone, and rituximab (CVP-R) protocol, and after a 5-year follow-up he is still in complete remission. We also reviewed the cases published from 1982 to 2012, highlighting the challenges in reaching a correct preoperative diagnosis and the treatment modalities used in each case.

Adjuvant treatment for ampullary cancer. Highlights from the "2011 ASCO Annual Meeting". Chicago, IL, USA; June 3-7, 2011

Ampullary cancer is an uncommon tumor and tends to have a better prognosis than pancreatic cancer. However, one half of patients will die from recurrent disease suggesting the need for effective adjuvant therapy. Currently, there is lack of randomized trials to guide the use of adjuvant therapy in ampullary cancer. At the 2011 American Society of Clinical Oncology (ASCO) Annual Meeting, the largest trial (Abstract #4006) evaluating adjuvant treatment of ampullary cancer was presented.

Clinical outcomes of nitinol and stainless steel uncovered metal stents for malignant biliary strictures: is there a difference?

BACKGROUND

Self-expandable metal stents (SEMSs) made from nitinol (N) were developed as a potentially more effective alternative to conventional stainless steel (SS) stents.

OBJECTIVE

To compare clinical outcomes of N versus SS stents in the management of malignant biliary strictures.

DESIGN

Retrospective study.

SETTING

Tertiary-care cancer center.

PATIENTS

All patients with first-time N (Flexxus) and SS (Wallstent) uncovered biliary SEMSs placed between January 2006 and October 2007.

INTERVENTIONS

SEMS placement.

RESULTS

A total of 81 N and 96 SS stents were placed. The most common cancer diagnosis was pancreatic (80.2% N; 62.5% SS; P = .06). The most frequent site of stricture was the common bile duct (85.2% N; 86.5% SS; P = .31). Biliary decompression was achieved in 93.8% of the N group and 86.4% of the SS group (P = .22). Immediate stent manipulation was required in 4 patients in each group. Subsequent intervention for poor drainage was performed in 17 N (21%) and 26 SS (27%) stents at mean times of 142.1 days (range, 5-541 days; median, 77 days) and 148.1 days (range, 14-375; median, 158.5), respectively (P = .17). The occlusion rate between N and SS stents was not significant (P = .42). The overall durations of stent patency in the N and SS group were similar (median 129 and 137 days, respectively; P = .61), including the subgroup analysis performed on patients with pancreatic cancer (P = .60) and common duct strictures (P = .77). Complication rates were low in both groups (early: 3.7% N, 6.3% SS; late: 2.5% N, 3.1% SS). Ninety percent underwent chemotherapy and 38% radiation therapy in each group.

LIMITATIONS

Retrospective design.

CONCLUSION

Similar outcomes were achieved with N and SS stents regarding efficacy, duration of stent patency, occlusion rates, and complications. Our results are most applicable to patients with common duct strictures and pancreatic cancer.

Bile duct malignancies

Bile duct malignancies include intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), gall bladder carcinoma (GC) and carcinoma of Vater's ampulla (ampulloma). Bile duct neoplasms are rare tumours with overall poor prognosis. The overall incidence affects up to 12.5 per 100,000 persons in the Czech Republic. The mortality rate has risen recently to 9.5 per 100,000 persons. The incidence and mortality have been remarkably stable over the past 3 decades. The survival rate of patients with these tumours is poor, usually not exceeding 12 months. The diagnostic process is complex, uneasy and usually late. Most cases are diagnosed when unresectable, and palliative treatment is the main approach of medical care for these tumours. The treatment remains very challenging. New approaches have not brought much improvement in this field. Standards of palliative care are lacking and quality of life assessments are surprisingly not common. From the scarce data it seems, however, that multimodal individually tailored treatment can prolong patients'survival and improve the health-related quality of life. The care in specialized centres offers methods of surgery, interventional radiology, clinical oncology and high quality supportive care. These methods are discussed in the article in greater detail. Improvements in this field can be sought in new diagnostic methods and new procedures in surgery and interventional radiology. Understanding the tumour biology on the molecular level could shift the strategy to a more successful one, resulting in more cured patients. Further improvements in palliative care can be sought by defining new targets and new drug development. The lack of patients with bile duct neoplasms has been the limiting factor for any improvements. A new design of larger randomized international multicentric clinical trials with prompt data sharing could help to overcome this major problem. Defining standards of palliative care is a necessity. Addressing health-related quality of life could help to assess the real benefit of palliative treatment.

Early thrombosis of the superior vena cava in a patient with a central venous catheter and carcinoma of the ampulla of Vater

Superior vena cava syndrome results from obstruction of flow through the vessel either by external compression or thrombosis. External compression by intrathoracic neoplasms is the most common etiology. Thrombosis of the vessel most often occurs in the setting of indwelling catheters or pacemakers. The diagnosis is suggested by the clinical manifestations of facial and upper extremity swelling, dyspnea, and cough. It is confirmed by CT scan showing the development of collateral flow around the lesion. In this report, we present a patient who developed superior vena cava thrombosis after undergoing a short period of central venous catheterization and a Whipple procedure for adenocarcinoma of the ampulla of Vater. The endothelial damage caused by the catheter, the low-flow state induced by the large fluid shifts during the operation, and the hypercoagulable state induced by malignancy fulfill Virchow's triad for venous thrombosis. To our knowledge, this is the first reported case of superior vena cava syndrome after the Whipple procedure with symptoms appearing after a shorter period of catheterization than previously reported in the adult literature.

[Diagnosis of Vater's papilla cancer and its combination treatment and radiotherapy]

The paper considers the problems of enhancing the efficiency of diagnosis and treatment of Vater's papilla cancer complicated by jaundice, by maximally realizing the capacities of instrumental studies and by improving the procedures of combination treatment and radiotherapy for this disease. The achieved treatment results show it expedient to use combination treatment and, if radical surgery is contraindicated, radiotherapy for Vater's papilla cancer.

[Peroral direct cholangioscopy for diagnosis and treatment]

Peroral direct cholangioscopy (PDCS) is endoscopic method for diagnosis in the common bile duct (CBD) utilizing an ultra-slim upper endoscope. Clinical utility and problem of this method were investigated in ten patients who had stenosis or obstruction in the CBD with stones or a tumor. Scope shaft had to become the form of a U loop by counterclockwise rotation, to advance the scope in the direction of intrahepatic bile duct. As for one case, although the scope was formed alpha loop without U loop, direct observation of total CBC was possible. Large working channel of the endoscope could take adequate tissue sample by large biopsy forceps. Electrohydraulic lithotripsy and stone extraction with a basket could be accomplished easily and safely by direct visualization with a clear image. Pneumobilia was noted in all cases with insertion of PDCS. Although the abdominal pain and pyrexia with regard to PDCS did not occur, transient leukocytosis was noted.

Twelve years survival with repeated hepatectomy and lung resection for metastasis from carcinoma of the papilla of Vater after pancreaticoduodenectomy

We present a 60-year-old woman who underwent three times hepatectomy and lung resection for metastasis originating from a carcinoma of the papilla of Vater after pancreaticoduodenectomy with lymphadenectomy during 12 years. Pancreaticoduodenectomy was performed in 1980 and histological examination of original tumor revealed a stage IIA papillary adenocarcinoma (pT3, pN0, pM0). Repetitive hepatectomy underwent in 1986 (S7,8), 1988 (S2), 1991 (S4) and bilateral partial resection of lung (right S1, left S2.3) in 1990. She died from multiple skin, bone and lung metastases 12 years after pancreaticoduodenectomy. The current case is very rare, however, if patients with carcinoma of the papilla of Vater have localized liver metastases and no local recurrence, liver metastases should be resected to improve the chances for long-term survival.

Islet Cell Carcinoma: Neuroendocrine Tumors of the Pancreas and Periampullary Region

Most patients who have islet cell tumors, except those who have insulinomas, present with locally advanced or metastatic disease. In contrast with patients who have adenocarcinoma of the pancreas, those who have islet cell carcinomas can achieve long-term survival even if their disease is advanced. Liver-directed therapies, somatostatin analogs, and interferon are not curative but can be used to relieve tumor-associated symptoms. Similarly, palliative chemotherapy has been used with limited success. Advances in our understanding of the molecular mechanisms underlying tumor progression have translated into intense interest in biologically based strategies to treat this disease.

Carcinoid of the ampulla of Vater: Morphologic features and clinical implications

Carcinoids involving the ampulla of Vater are rare lesions that may produce painless jaundice. The published data indicate that these tumors, in contrast to their midgut counterparts, metastasize in approximately half of cases irrespective of primary tumor size. Therefore, radical excision in the form of pancreaticoduodenectomy is recommended regardless of tumor size. As with other gastrointestinal carcinoid tumors, biological treatment with octreotide analogues can be applied to symptomatic patients. Tumor-targeted radioactive therapy is a newly emerging treatment option. We here report case of a carcinoid tumor of the ampulla of Vater presenting as painless jaundice in a 65-year old man and review the relevant literature, giving special attention to the morphologic features, clinical characteristics, and treatment modalities associated with this disease process.

[Carcinoma of the papilla of Vater. Diagnostic and therapeutic problems. An analysis of 32 Tunisian cases]

The aim determine the clinical, morphological, endoscopical and progressive profile of patients with ampullary carcinoma.

PATIENTS AND METHODS

Thirty-two patients with a carcinoma of the ampulla of Vater, hospitalised in the Gastro-enterology service of Habib Thameur Hospital (Tunis) (1992-2002) have been analysed retrospectively.

RESULTS

Twelve men and 20 women of an average age of 66 years have been included. Twelve patients (37%) had had a cholecystectomy into the 3 years preceding the diagnosis of the ampullary carcinoma. A duodenal tumour had been found at 29 patients (91%). After endoscopical sphincterectomy, an intra-ampullar exophytic tumour had been found in I case and an infiltrated aspect of the ampulla of Vater in 2 cases. The jaundice was frequent. The use of lateral duodenoscopy allowed carrying the positive diagnosis in all cases. Five patients had metastasis at the moment of diagnosis. A DPC has been practiced at 15 patients. A palliative biliary diversion has been realized at 9 patients. Six patients had an endoscopical palliative drainage with installation of a plastic prosthesis. The rate of post- operative mortality was 20%. The rate of morbidity linked to the surgery was 21.8%.

CONCLUSION

The ampullary carcinoma is a rare tumour diagnosed belated. The postoperative mortality is raised. The identification of factors forecast and the utilization of adjuvant processing will be able to allow the improvement of the prognosis.

[Oat cell carcinoma of the common bile duct]

Oat cell tumors in the common bile duct are extremely rare. We describe the case of a 76-year-old man with skin and mucous jaundice of 15 days' duration without constitutional syndrome. A tumor was diagnosed in the mid portion of the common bile duct. After surgical resection, pathological analysis revealed small-cell (oat cell) carcinoma. The treatment of these tumors is multidisciplinary. Surgery is followed by chemo- and radiotherapy.

[A patient with bile duct cancer who showed rapid obstruction after insertion of a non covered stent, but in this case obtained a stent opening and better QOL after reinsertion of a covered stent]

A 73-year-old man is presented with jaundice. Dynamic CT showed a papillary mass in the common bile duct. Percutaneous transhepatic cholangiography revealed a filling defect in the middle common bile duct. Poorly differentiated adenocarcinoma was demonstrated from a papillary mass in the common bile duct by biopsy specimens obtained under p. ercutaneous transhepatic cholangioscopy. Based on these findings, upper to middle bile duct cancer was diagnosed. An unresectable tumor was defined by involving the main portal vein and common hepatic artery at surgical exploration. A non-covered expandable metallic stent was placed 8 days after the operation. However, since contrast radiography showed tumor protrusion in the stent next day after the insertion, a covered stent was placed. Stent obstruction did not occur, and the patient was discharged from the hospital with a good quality of life. A covered stent can be more potentially and clinically effective than a non-covered stent especially for a papillary tumor in the bile duct.

Risk factors for cholecystitis after metal stent placement in malignant biliary obstruction

BACKGROUND

Cholecystitis related to metal stent placement is a morbid event.

OBJECTIVE

This study evaluated the risk factors of cholecystitis after metal stenting for malignant biliary obstruction.

PATIENTS

Between December 1997 and April 2003, 155 patients who were treated with a metal stent for malignant biliary obstruction were retrospectively enrolled.

MAIN OUTCOME MEASUREMENTS

The incidence and characteristics of patients with cholecystitis were evaluated and compared with those of patients without cholecystitis. Patient characteristics and tumor or procedure-related data were recorded for the following variables: sex, age, tumor and stent length, stent type (covered vs uncovered), cholangitis before ERCP, degree of gallbladder filling with contrast medium during ERCP, primary disease type (Klatskin vs others), presence of gallbladder stones, and the relationship of the cystic duct orifice to the location of the tumor (across vs others).

RESULTS

There were 15 (9.7%) patients diagnosed with cholecystitis after metal stent insertion. The onset of cholecystitis was on average 4.6 days (range 1 to 26) after the procedure. We found that an obstruction across the cystic duct orifice by tumor (P < .01, odds ratio 12.7) and the presence of gallbladder stone (P = .01, odds ratio 6.6) were positively related to the cholecystitis after metal stent insertion.

LIMITATIONS

The limitations of the study were the use of multiple types of stents and the retrospective design.

CONCLUSIONS

This study demonstrated that an obstruction across the cystic duct by tumor and the presence of gallbladder stone were risk factors for the development of cholecystitis after metal stent placement.

Carcinoid tmour of the common bile duct: report of a case and a review of the literature

Carcinoid tumours of the common bile duct are extremely rare lesions. In this article we report a case with an extrahepatic bile duct carcinoid tumour. A 40-year-old woman suffered from biliary colic and jaundice. Pre-operative computed tomography demonstrated a tumour in the biliary tract. At laparotomy there was a tumour invading the common bile duct. Common bile duct resection was performed. Carcinoid tumour of the common bile duct was diagnosed histopathologically. For extrahepatic bile duct carcinoid tumours surgical resection is the only treatment modality that offers a chance to provide a cure and prolonged disease-free survival. The favourable histopathological and biological features of these tumours encouraged the surgeons to use more aggressive approaches for advanced disease.

Removal of self-expandable metallic wallstent--a case report

Self-expandable metallic stents (SEMS) have become the preferred palliative treatment for patients with malignant biliary obstruction; endoscopic stent placement is less invasive than surgery and is rapidly effective. A longer duration of patency makes SEMS superior to plastic stents for palliation of patients with malignant stricture. Few cases of removal of an uncovered SEMS are reported in case of a blocked stent. We report the first case report of removal of covered biliary SEMS from India.

Embryonal rhabdomyosarcoma of the common bile duct mimicking choledochal cyst

Embryonal rhabdomyosarcoma of the common bile duct is a very rare malignancy of childhood. The radiological appearance of the lesion is similar to that of congenital choledochal cyst if there is no local invasion to the adjacent tissues. The authors present a case of embryonal rhabdomyosarcoma of the common bile duct which was considered to be a congenital choledochal cyst preoperatively, and they discuss this very rare childhood tumor, with a brief survey of the literature. In conclusion, it is important to know that this rare tumor can simulate congenital choledochal cyst; it should be considered in the differential diagnosis of obstructive jaundice in children.

[Intratumoral injection of immature dendritic cells (DC) for cancer patients]

We proceeded with DC immunotherapy for 21 cancer patients. Immature dendric cells were injected intratumorally to the 16 patients, and three good and effective cases were obtained: case 1: A 69-year-old male patient with papilla-vater carcinoma, case 2: A 49-year-old female patient with gastric cancer, case 3: A 66-year-old male patient with malignant melanoma.

Carcinoid of the ampulla of Vater

Endocrine neoplasms only rarely occur at the ampulla of Vater, comprising mostly carcinoids and malignant carcinoids, as well as few cases of poorly differentiated endocrine carcinomas (small cell carcinomas). Only 105 cases are reported in the literature, most as single case reports. For many years, the neoplasms of the disseminated neuroendocrine cell system of the gastrointestinal tract have been subsumed as 'carcinoids'. Instead, in the latest World Health Organization (WHO) classification published in 2000, it is recommended to distinguish between (i) well-differentiated endocrine tumors (carcinoids); (ii) well-differentiated endocrine carcinomas (malignant carcinoids); and (iii) poorly differentiated endocrine carcinomas (small cell carcinomas). Patients with carcinoid tumors of the ampulla of Vater are very often free of clinical and laboratory findings that belong to the carcinoid syndrome. Approximately 26% of all patients with carcinoid tumor reported in the literature had neurofibromatosis. Besides endoscopic retrograde cholangiopancreatography, endosonography, computed tomography or magnetic resonance imaging may complete the staging approach of this tumor. The Kausch-Whipple procedure or pylorus-preserving pancreaticoduodenectomy is considered the treatment of choice for ampullary, well-differentiated carcinoids >2.0 cm and for ampullary neuroendocrine carcinomas. However, it should be considered that long-term survival of patients with ampullary carcinoids is also reported after local tumor excision (5-year survival rate of 90%). The dilemma is that the differentiation of neuroendocrine tumors cannot be assessed intraoperatively in most cases. Therefore, considering that the 5-year survival rate in patients with neuroendocrine carcinomas of the ampulla of Vater is very low without radical resection, neuroendocrine tumors of the ampulla of Vater without definite histological differentiation should undergo extended surgery.

[State of the art in therapeutic biliary endoscopy]

Almost all biliary diseases are now amenable to endoscopic treatment. Progress in therapeutic biliary endoscopy is currently focusing on identifying the best treatment options to be used in each case in relation to available evidence: how should a malignant stricture of the common bile duct or hilium be drained? How should a "difficult" biliary stone be extracted? How should an external biliary fistula be treated? What should one do with the gallbladder after extraction of common bile duct stone? Should sedation or general anesthesia be offered? Progress has been made in the technique of endoscopic ampulectomy and in developing new devices to improve the success rate of endoscopic retrograde cholangiopancreatography.

[Update on endoscopic management of malignant obstructive jaundice]

The diagnosis of bilio-pancreatic diseases is carried out when patients present symptoms of biliary obstruction. The majority of these patients cannot receive curative treatment at the time of the diagnosis. Laboratory tests can differentiate between intra- or extra-hepatic obstruction, and the different imaging techniques will establish the cause and degree of disease extension. Endoscopic cholangiography can confirm the tumor's etiology with a biopsy, cytology or aspiration at the level of the stenosis. Palliative endoscopic treatment offers good results. The decision of placing a plastic or metallic stent will depend on the probable survival rate that the patient has. In tumors in the hila a previous magnetic resonance cholangiography plays a fundamental role in the therapeutic decision.

Adjuvant chemo-radiotherapy in ampullary cancers

PURPOSE

Patterns of failure following surgical treatment of ampullary cancers indicate that up to 45% of patients develop loco-regional recurrence. The effect of adjuvant chemo-radiotherapy on survival and loco-regional control is not yet established in this malignancy.

PATIENTS AND METHODS

From January 1989 to December 2000, 113 patients underwent pancreatico-duodenectomy for ampullary cancer. One hundred and four patients who survived the operation were available for analysis to study the effect of adjuvant chemo-radiotherapy on survival and loco-regional control. Forty-nine patients received adjuvant chemo-radiotherapy (median dose 50.4 Gy with concurrent 5-Flurouracil) and long-term outcome in these patients was compared with those 55 who did not receive adjuvant therapy.

RESULTS

The overall median survival was 30.1 (range 1.6-140.0) months with actuarial 1, 3 and 5-year survival rates of 79, 43 and 33%, respectively. No significant difference in median survival (34.6 vs 24.5 months; P=0.3) and actuarial 5-year survival rates (38 vs 28%) was seen between those who received and those who did not receive adjuvant therapy. Adjuvant chemo-radiotherapy did not influence the survival in high-risk patients (P=0.84), in various T and N stages and had no impact on loco-regional recurrence (P=0.6).

CONCLUSIONS

Adjuvant chemo-radiotherapy did not improve the long-term survival or decrease recurrence rates in patients with ampullary cancers who had undergone pancreatico-duodenectomy.

Current status of laparoscopic biliary bypass in the management of non-resectable peri-ampullary cancer

BACKGROUND

In patients with non-resectable peri-ampullary cancer, optimization of quality of life is an important goal. Although endoscopic palliation is widely used, the proponents of laparoscopic biliary bypass claim that this procedure alters management towards surgery. However, the evidence base for selection of laparoscopic bypass is limited and the aim of this report is to scrutinize the available evidence in order to assess the current role of this procedure.

METHODS

A computerised literature search was made of the Medline database for the period from January 1966 to December 2004. Searches identified 12 reports of laparoscopic palliation for peri-ampullary cancer. These reports were retrieved and data analysed in the following categories: type of bypass; combination with other procedures; complication and outcome.

RESULTS

Laparoscopic cholecystoenterostomy is the commonest form of laparoscopic biliary bypass practiced. Of the 52 reported cases undergoing laparoscopic biliary bypass, 40 underwent laparoscopic cholecystojejunostomy, 6 laparoscopic choledochoduodenostomy and 6 underwent laparoscopic hepaticoje- junostomy.

CONCLUSION

Current evidence does not justify the incorporation of laparoscopic biliary bypass techniques into contemporary evidence-based management algorithms for patients with non-resectable periampullary cancer.

Carcinoid of the ampulla of Vater

Endocrine neoplasms only rarely occur at the ampulla of Vater, comprising mostly carcinoids and malignant carcinoids, as well as few cases of poorly differentiated endocrine carcinomas (small cell carcinomas). Only 105 cases are reported in the literature, most as single case reports. For many years, the neoplasms of the disseminated neuroendocrine cell system of the gastrointestinal tract have been subsumed as 'carcinoids'. Instead, in the latest World Health Organization (WHO) classification published in 2000, it is recommended to distinguish between (i) well-differentiated endocrine tumors (carcinoids); (ii) well-differentiated endocrine carcinomas (malignant carcinoids); and (iii) poorly differentiated endocrine carcinomas (small cell carcinomas). Patients with carcinoid tumors of the ampulla of Vater are very often free of clinical and laboratory findings that belong to the carcinoid syndrome. Approximately 26% of all patients with carcinoid tumor reported in the literature had neurofibromatosis. Besides endoscopic retrograde cholangiopancreatography, endosonography, computed tomography or magnetic resonance imaging may complete the staging approach of this tumor. The Kausch-Whipple procedure or pylorus-preserving pancreaticoduodenectomy is considered the treatment of choice for ampullary, well-differentiated carcinoids >2.0 cm and for ampullary neuroendocrine carcinomas. However, it should be considered that long-term survival of patients with ampullary carcinoids is also reported after local tumor excision (5-year survival rate of 90%). The dilemma is that the differentiation of neuroendocrine tumors cannot be assessed intraoperatively in most cases. Therefore, considering that the 5-year survival rate in patients with neuroendocrine carcinomas of the ampulla of Vater is very low without radical resection, neuroendocrine tumors of the ampulla of Vater without definite histological differentiation should undergo extended surgery.

Aktuelle Diagnostik und Therapie von Gallengangs- und Gallenblasenkarzinomen

Carcinoma of the biliary tree are rare tumours of the gastrointestinal tract with a rising incidence during the last years. Biliary neoplasms are classified into intra- and extrahepatic cholangiocarcinoma (Klatskin tumour, middle and distal extrahepatic tumours), gallbladder cancer, and ampullary carcinoma. Transformation of normal into malignant bile duct tissue requires a chain of consecutive gene mutations, similar to the adenoma-dysplasia-carcinoma-sequence in colon cancer. Abdominal ultrasound, combined non-invasive magnetic resonance cholangiography/tomography (MRC/MRT), and facultatively endoscopic retrograde cholangiography (ERC) for unclear diagnosis, represent the gold standard for primary diagnosis. For ampullary carcinoma, endosonography and endoscopic biopsy are the diagnostic tools of choice. Cure is attainable only by formal curative radical surgical resection. Increasing surgical radicality within the last years enabled clearly improved 5-year survival rates. In contrast, there has been no clinical benefit for adjuvant and neoadjuvant therapies. For palliation, bile duct stenting and photodynamic therapy are established methods. Radio- and chemotherapy should be reserved for clinical studies. New therapeutic approaches include brachytherapy, the use of modern chemotherapeutics, COX-2- and tyrosine kinase-receptor-inhibitors.

Homozygous deletion of the MTAP gene in invasive adenocarcinoma of the pancreas and in periampullary cancer: a potential new target for therapy

Methylthioadenosine phosphorylase (MTAP) plays an important role in the salvage pathway for the synthesis of adenosine. Novel chemotherapeutic strategies exploiting the selective loss of MTAP function in cancers have been proposed. The MTAP gene, on chromosome 9p21, is frequently included within homozygous deletions of the p16INK4A/ CDKN2A gene. Biallelic deletions of the p16INK4A/CDKN2A gene are found in 40% of pancreatic cancers, suggesting that the MTAP gene may be frequently inactivated in pancreatic cancer and that selected patients with pancreatic cancer may benefit from therapies targeting this loss. We immunolabeled six xenografted pancreatic cancers with known MTAP and p16INK4A/CDKN2A gene status and found that immunolabeling mirrored gene status. Loss of expression of both MTAP and p16 was observed only in those pancreatic cancers with homozygous deletions that encompassed both the MTAP and p16INK4A/CDKN2A genes. We then immunolabeled a series of 320 microarrayed infiltrating pancreatic adenocarcinomas, 35 biliary adenocarcinomas, 54 ampullary cancers, and 35 noninvasive intraductal papillary mucinous neoplasms. Immunolabeling for MTAP was lost in 91 of the 300 (30%) evaluable pancreatic cancers, 9 of 54 (17%) ampullary cancers, 4 of 33 (12%) biliary cancers, and in 1 of 35 (3%) IPMNs. All neoplasms with loss of MTAP labeling also demonstrated loss of p16 labeling. These results suggest that MTAP expression is lost in approximately 30% of infiltrating pancreatic cancers and in a lower percentage of other periampullary neoplasms, that this loss is the result of homozygous deletions encompassing both the MTAP and p16INK4A/CDKN2A genes. Thus, pancreatic cancer is a promising cancer type in which to explore novel chemotherapeutic strategies to exploit the selective loss of MTAP function.

An investigation of primary malignancies associated with ampullary carcinoma

BACKGROUND/AIMS

As ampullary carcinoma has a favorable prognosis, associated malignancies have potential prognostic significance in these patients. This study focused on the incidence and characteristics of preexisting, coexisting and subsequent malignancies in patients with ampullary carcinoma.

METHODOLOGY

Sixty-four cases of ampullary carcinoma were retrospectively identified. Fifty-four patients underwent surgical resection, while in the other ten, histological diagnosis was reached after biopsy and/or autopsy. Other primary malignancies associated with ampullary carcinoma, occurring in the prediagnostic or postdiagnostic period, were investigated. The mean postdiagnostic follow-up period was 3.9 years (range, 0-23 years).

RESULTS

Other malignancies occurred in 17 patients (27%), being found before (n=9), at (n=7), or after (n=5) diagnosis of ampullary carcinoma. The total number of associated lesions was 23, including one case of quadruple and four cases of triple carcinoma. The major associated malignancies were colonic carcinoma (n=9), gastric carcinoma (n=5), and uterine carcinoma (n=3). Twenty-one lesions were treated surgically or endoscopically. One patient died from synchronous extrahepatic bile duct carcinoma and one from leukemia, and one died from subsequent urinary bladder carcinoma. Development of other malignancies was related to age but not to gender, family history, adjuvant chemo/radiotherapy, or tumor pathology.

CONCLUSIONS

Ampullary carcinoma is associated with a high incidence of other malignancies, particularly colonic and gastric carcinomas. The possibility of associated malignancies should therefore be considered in preoperative screening and postoperative follow-up of patients with ampullary carcinoma.

Factors predictive of malignancy and endoscopic resectability in ampullary neoplasia

OBJECTIVE

Endoscopic treatment of ampullary lesions has been well described, though it remains uncertain if specific features predict malignancy, and whether identifiable factors are associated with successful endoscopic resection of benign lesions.

METHODS

Fifty-six consecutive patients undergoing endoscopic evaluation of ampullary neoplasia between March 2000 and May 2004 were included in the study. Clinical presentation, underlying medical conditions, endoscopic treatment, endoscopic ultrasound (EUS) to define extent of local involvement, pathology results, and outcome were documented. Data elements for analysis included EUS findings, lesion lifting with submucosal injection, age, gender, tumor size, and endoscopic intervention. Analyses were performed to determine the ability to predict malignancy and the ability to extirpate benign lesions.

RESULTS

Thirty-one males and 25 females were included; mean age was 62 yr. Final diagnoses included 29 adenomas, 20 adenocarcinomas, 4 adenomyomas, 2 paragangliomas, and 1 neuroendocrine tumor. Thirty of 35 patients with benign lesions had extirpation with a mean of two endoscopic procedures. Complications of endoscopic resection included cholangitis (1), bleeding (2), and pancreatitis (4). The presence of malignancy was associated by multivariate analysis with the inability to obtain a cleavage plane with saline injection. Univariate analysis also identified EUS T stage as a predictor of malignancy. In benign lesions, none of the analyzed variables predicted successful endoscopic resection.

CONCLUSION

In ampullary lesions, failure to achieve a cleavage plane with submucosal injection is the strongest predictor of malignancy followed by EUS T stage. Endoscopic treatment of benign ampullary neoplasia is effective; no factor was predictive of successful extirpation.

Evaluation and management of periampullary tumors

Periampullary cancers make up 5% of all gastrointestinal cancers. The complexity of the periampullary anatomy makes determination of the origin of some of these tumors difficult. However, advances in imaging have helped with diagnosis as well as defining the extent of the lesion and its potential resectability. For many of these tumors, surgery is the recommended treatment. However, endoscopic removal is being extended to different lesions with encouraging preliminary results. Improvements in overall prognosis for periampullary tumors will be limited until diagnosis can be established earlier in the course of the disease and adjuvant therapies become more effective.

[Adjuvant arterial infusion chemotherapy for patients with biliary cancer]

Although surgery is the only potentially curative treatment for biliary cancer, patients frequently develop liver metastasis, local recurrence, and peritoneal metastasis after complete resection. Liver metastasis is a common mode of progression for biliary cancer, and the prognosis is extremely poor when it occurs. Between January 2000 and December 2003, 18 out of 37 patients received adjuvant arterial infusion chemotherapy after curative resection of biliary cancer. Nine of these 18 patients had bile duct cancer, seven had gallbladder cancer, and two had cancer of the papilla of Vater. A catheter was placed using Seldinger's technique, with the tip being advanced into the common hepatic artery via the femoral artery. Then 1,000 mg/body of 5-FU was administered as a 24-hour continuous infusion on days 1-3 and 5-7. Two cycles of this chemotherapy were delivered through an angiography catheter without using a reservoir port. This treatment caused no severe systemic or abdominal complications. The two groups were well balanced with respect to prognostic factors. The 1-year survival rate was 76.2% in the adjuvant chemotherapy group versus 52.7% in the non-adjuvant chemotherapy group, while the 3-year survival rates were 47.6% and 39.5%, respectively (Wilcoxon test, p=0.048). Median overall survival was superior in the adjuvant chemotherapy group and the difference was significant. High-dose arterial infusion of 5-FU seems to be a safe, tolerable, and effective regimen for preventing the postoperative recurrence of biliary cancer.