Carcinoma of the Ampulla of Vater

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Carcinoma of the ampulla of Vater, shown in the image below, is a rare malignant tumor arising within 2 cm of the distal end of the common bile duct, where it passes through the wall of the duodenum and ampullary papilla.

The common bile duct merges with the pancreatic duct of Wirsung to form a common channel that exits through the ampulla into the duodenum. The most distal portion of the common bile duct is dilated (ie, forms the ampulla of Vater) and is surrounded by the sphincter of Oddi, which spirals upward around the terminal portion of the duct.

Carcinoma of the ampulla of Vater tends to manifest early due to biliary outflow obstruction, as opposed to pancreatic neoplasms that often are advanced at the time of diagnosis. Clinically, however, ampullary tumors can be virtually indistinguishable from tumors of the distal bile duct or pancreatic head; the point of origin of tumors in this region is typically not determined until the patient undergoes surgery.

Pancreaticoduodenectomy is the standard resection procedure for ampullary carcinoma. When preoperative endoscopic biopsy identifies a lesion as an ampullary adenoma with no high-risk features (eg, high-grade dysplasia), treatment with local resection (ampullectomy) may be considered, if the patient is not a candidate for pancreaticoduodenectomy. However, such patients require surveillance endoscopy to monitor for recurrence.

Surgical resection with curative intent is the only option for long-term survival. Surgical, endoscopic, or radiologic biliary decompression; relief of gastric outlet obstruction; and adequate pain control may improve the quality of life but do not affect overall survival rate.

Periampullary carcinoma includes tumors arising in the head, neck, or uncinate process of the pancreas, tumors arising in the distal common bile duct, tumors arising in the duodenum, as well as tumors arising from the ampulla of Vater.

Review of the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute indicates adenocarcinoma is the most frequently identified histology for ampullary cancer. Adenocarcinoma (not otherwise specified [NOS]) was reported in 65% of cases. Carcinoma (NOS) was reported in 8.1%; adenocarcinoma arising from adenoma (adenocarcinoma in villous adenoma, in tubulovillous adenoma, in adenomatous polyp and villous adenocarcinoma) was third most common in 7.5%. Other pathologic diagnoses reported included papillary adenocarcinoma (5.6%), mucinous adenocarcinoma (4.7%), and signet ring cell carcinoma (2%). [1, 2, 3]

Lymph nodes metastases are present in as many as half of patients. Pericanalicular lymph nodes usually are the first to be involved. Nodes along the superior mesenteric, gastroduodenal, common hepatic, and splenic arteries, as well as the celiac trunk, are the second station of lymph nodes. Perineural, vascular, and lymphatic invasion are associated with a poor prognosis. Liver is the most common site (66%) of distant metastasis, followed by lymph nodes (22%). In advanced cases, lung metastasis also may occur.

The concept of ampullary carcinoma as a distinct entity is challenged by the categorization of tumors into intestinal type and biliopancreatic type histologically. A review of 118 adenocarcinomas revealed that the biliopancreatic type had a worse prognosis while the intestinal type may behave more like duodenal carcinoma. [4]

United States

Carcinoma of the ampulla of Vater is an uncommon tumor. Between 1973 and 2005, 5,625 cases were recorded in the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. Ampullary cancer accounts for approximately 0.5% of all gastrointestinal tract malignancies. [1] The incidence has been increasing since 1973 at an annual percentage rate of 0.9%. [1] Prior to the recently reported increase, the quoted incidence for ampullary carcinoma was 0.2% of all gastrointestinal malignancies and 6% of all periampullary tumors. [5]

International

Worldwide incidence is not known.

Most of these tumors are resectable for cure at diagnosis; however, the 5-year survival rate is only approximately 40% [6, 7, 8] to 67% at best. [5]

Operative mortality rates have decreased significantly over the last decade because of increased surgical experience, improved anesthesia, better preoperative imaging, and better postoperative management.

Pancreatic fistulas, prolonged gastric emptying, wound complications, intra-abdominal sepsis, thrombophlebitis, and marginal ulceration are the most common complications.

Postoperative mortality rates in the best centers are 1-2%.

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Nafisa K Kuwajerwala, MD Staff Surgeon, Breast Care Center, William Beaumont Hospital

Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Breast Disease

Disclosure: Nothing to disclose.

Pankaj Chaturvedi, MBBS, MS, FACS Professor of Head and Neck Surgery, Department of Head and Neck Surgery, Tata Memorial Hospital, India

Pankaj Chaturvedi, MBBS, MS, FACS is a member of the following medical societies: American Association for the Advancement of Science, American Head and Neck Society, Association of Surgeons of India

Disclosure: Nothing to disclose.

Ronald S Chamberlain, MD Chairman, Surgeon-in-Chief, Department of Surgery, Director, Gastrointestinal Care Center, Medical Student Clerkship Director, Medical Executive Committee Member, St Barnabas Medical Center; Associate Professor of Surgery, New York College of Osteopathic Medicine; Associate Professor of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Ronald S Chamberlain, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Study of Liver Diseases, American College of Surgeons, American Medical Association, Phi Beta Kappa, Society for Surgery of the Alimentary Tract, Society of Surgical Oncology

Disclosure: Received honoraria from Wyeth for speaking and teaching; Received honoraria from Pfizer for speaking and teaching; Received honoraria from Sanofi Aventis for speaking and teaching.

Venkata Subramanian Kanthimathinathan, MD Fellow in Bariatric/Advanced Laparoscopic Surgery, University of Missouri Healthcare

Disclosure: Nothing to disclose.

Uma Chaturvedi, MD, MBBS, DPB Lecturer, Department of Pathology, KJ Somaiya Hospital and Research Center, India

Disclosure: Nothing to disclose.

Gunateet Goswami, MD Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital

Gunateet Goswami, MD is a member of the following medical societies: American Medical Association, American Society of Echocardiography, Michigan State Medical Society

Disclosure: Nothing to disclose.

Julie A Stein, MD Clinical Faculty, Hepatobiliary and Pancreatic Surgery, Department of Surgery, William Beaumont Hospital

Julie A Stein, MD is a member of the following medical societies: American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, Pancreas Club, American College of Surgeons Oncology Group

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Benjamin Movsas, MD 

Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, American Society for Radiation Oncology

Disclosure: Nothing to disclose.

N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center

N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, Surgical Infection Society

Disclosure: Nothing to disclose.

Carcinoma of the Ampulla of Vater

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