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%