Ampullary Cancer Case Study

Cheryl Martin St. Francis Hospital

Clinical Rotation C.W. Post Dietetic Intern

�  A form of Pancreatic Cancer �  Ampullary carcinoma includes

tumors arising in the head, neck or uncinate process, distal CBD, duodenum, and/or Ampulla of Vater

�  2 types of Pancreatic Cancer �  Endocrine tumors-affect cells that

produce hormones (i.e. insulin and glucagon)

�  Exocrine tumors-affect cells that produce digestive enzymes �  Commonly called adenocarcinoma

�  Forms in the pancreas ducts

�  95% of pancreatic cancers �  Ampullary Carcinoma falls under the exocrine category

�  Pancreatic Cancer is the 10th most common site of new cancer

�  …But the 4th leading cause of cancer deaths

�  Estimated new cases and deaths in the U.S. in 2012: �  New diagnoses: 43,920 �  Deaths: 37,390

�  75% are found in the head of the pancreas, 25 % in the body and tail Global Occurrence

�  20-30% of cases are linked to

�  Age: 90% are found in ages 55 and older

�  More common in men

�  African American race

�  Obesity, physical inactivity, high-fat/cholesterol diet

�  Disease related: diabetes, chronic pancreatitis, cirrhosis of the liver

�  Helicobacter pylori (H. pylori) infection

�  Familial genetic alterations �  >10% are related to an inherited gene mutation

�  Exposure to certain pesticides, dyes, and chemicals related to gasoline

�  JAUNDICE- yellowing of the skin and white of eyes �  Most common symptom

(80%) �  Caused by malignant

cholestasis, also causing �  Clay-colored stool �  Dark urine

�  Cutaneous excoriation related to pruritus

�  Weight loss/anorexia

�  Epigastric pain

�  Swollen gallbladder

�  Nausea/Emesis/GI distress

�  Steatorrhea/bloody stool

�  Laboratory Findings �  Anemia �  Glycosuria �  Hyperglycemia �  Impaired glucose tolerance �  Hypoalbuminemia

�  Confirm diagnosis of pancreatic mass

�  Re-establish biliary tract patency

�  Determine the extent of the disease

�  Determine resectability of the primary tumor

�  Establish a histologic diagnosis

**Obtaining a history, physical examination, and noninvasive/minimally invasive imaging can

accomplish these goals

�  Blood, stool, and urine tests �  Check for tumor-associated antigens �  Elevated CA 19-9 (carbohydrate antigen 19-9) has emerged as

the most clinically useful marker �  *Not entirely reliable due to related levels in other cancers, and

falsely elevated serum levels in cholestasis

�  Abdominal Helical CT �  Evaluate presence of tumor in pancreas or periampullary area �  Identify presence of peritoneal or liver metastasis �  Evaluate relationship of tumor to local structures

�  *The CT’s sensitivity usually does not permit the visualization of small ampullary neoplasms within the duodenal lumen

�  Endoscopic Ultrasonography (EUS)

�  Sensitive for detecting small ampullary tumors

�  Identifies invasive carcinoma not evident from other imaging

�  Endoscopic Retrograde Cholangiopancreatography (ERCP) �  Preferred initial study in jaundiced patients �  Permits simultaneous:

�  Visualization of the ampulla �  Cholangiography of the pancreatic and bile

ducts �  Biopsy from segments of the CBD or pancreatic

duct �  Placement of a biliary stent, if necessary

�  *Cannot determine extent of local tumor invasion into duodenum or pancreatic parenchyma

�  Staging Laparoscopy �  Highly accurate at

predicting unresectable disease

�  Limited sensitivity for small-volume metastatic disease

AJCC TNM Staging System

�  Pancreatic Cancer is one of the most

difficult of all GI cancers to treat

�  SURGICAL RESECTION is the only potential curative treatment �  Only 15-20% of patients are candidates for resection

�  Stages I-IIB likely to be cured by radical resection

�  Those with metastatic disease are offered systemic treatment with radiation and chemotherapy

�  Options for localized disease: �  Preoperative biliary stent and drainage �  Pancreaticoduodenectomy (Whipple procedure) �  Pylorus-preserving pancreaticoduodenectomy �  Total pancreatectomy

�  Standard surgical approach for ampullary cancer �  Most common indication is the presence of a malignant

neoplasm in the head of the pancreas or other periampullary structure

�  Involves the removal of the pancreatic head, gallbladder, CBD, duodenum, first 15cm of jejunum, and distal gastrectomy

�  *If a pt’s serum albumin is <3g/dL, supplemental nutrition should be provided prior to surgery

�  Post-op Complications �  Pancreatic fistula (2-22% of operations) �  Gastroparesis �  GI tract bleeding �  Bile leaks (1-2% of cases) �  Glucose intolerance

J-tube placement optimal for post-

op nutrition support

http://www.youtube.com/watch?v=PfFZ2jsUHe0

�  Increase in nutrient and calorie needs è weight loss

�  Taste and/or smell changes

�  Loss of appetite

�  Fat malabsorption èCalcium, Vit A, D, E ,K deficiency

�  Vit B12 deficiency

�  Fluid & electrolyte imbalance

�  Inability to produce hormones: insulin & glucagon

�  Inability to produce pancreatic enzymes: amylase, protease, & lipase

� Despite advances in surgical and medical treatment, prognosis is still �  …however, Ampullary CA may have a positive prognosis

�  Survival rates: �  All stages

�  1-year- 20% �  5-years- 4%

�  s/p Whipple: �  18-20 months

�  Complete tumor resection (no metastasis): �  5-years: 20-25%