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Objective:To investigate the value of the extrahepatic bile duct and main pancreatic duct segment patterns on magnetic resonance cholangiopancreatography (MRCP) for differentiating the periampullary carcinoma (PAC).Methods:The clinicopathologic data of 125 patients with PAC who were admitted to Wuxi No.2 People’s Hospital from June 2013 to December 2021 were retrospectively analyzed, including 72 males and 53 females, aged (64.9±8.6) years. According to its anatomy, the extrahepatic bile duct (B) was divided into suprapancreatic and intrapancreatic (including ampullary) segments, and the main pancreatic duct (P) was divided into tail-body and head segments. MRCP patterns: i. the extrahepatic bile duct or main pancreatic duct visible without dilatation, ii. cutoff of the distal extrahepatic bile duct or main pancreatic duct with upstream dilatation, iii. cutoff of the intrapancreatic or head segment with upstream dilatation and remnant intrapancreatic or head segments invisible, iv. cutoff of the intrapancreatic or head segment with upstream dilatation and nondilated remnant intrapancreatic or head segments, were represented as 0, 1, 2, and 3, respectively. Segment patterns of B1/P0+ B1/P1, B0/P2+ B0/P3+ B2/P2+ B2/P3+ B3/P3, B3/P0, and B0/P0+ B2/P0 on MRCP were compared in PAC patients.Results:Of the 125 patients, there were 57 (45.6%) with pancreatic head carcinoma, 36 (28.8%) with ampullary carcinoma, 20 (16.0%) with distal cholangiocarcinoma, and 12 (9.6%) with periampullary duodenal carcinoma. Segment patterns of B0/P2+ B0/P3+ B2/P2+ B2/P3+ B3/P3 were found in 52 patients with pancreatic head carcinoma (91.2%, 52/57), with a significant difference between PAC (χ 2=110.66, P<0.001). Segment patterns of B1/P0+ B1/P1were found in 36 patients with ampullary carcinoma (100.0%, 36/36), fallowed by 11 (91.7%, 11/12) with periampullary duodenal carcinoma, with a significant difference between PAC (χ 2=129.95, P<0.001). Segment pattern of B3/P0 presented in 16 patients with distal cholangiocarcinoma (80.0%, 16/20), with a significant difference between PAC (χ 2=62.45, P<0.001). The segment patterns of B0/P0+ B2/P0 were only seen in 3 of 57(5.3%) patients with pancreatic head carcinoma. Conclusion:On MRCP, cutoff of the head segment with upstream dilatation and remnant head segment invisible or nondilated indicates the pancreatic head carcinoma. Cutoff of the intrapancreatic segment with upstream dilatation, remnant intrapancreatic segment visible, and main pancreatic duct nondilated, indicates the distal cholangiocarcinoma. And cutoff of the distal extrahepatic segment with upstream dilatation and main pancreatic duct dilatation or not, indicates the ampullary or periampullary duodenal carcinoma.
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Context: Incidence of periampullary carcinoma is low, approximately 0.5–2% of all gastrointestinal malignancies. Histologic subtyping has a prognostic bearing. The purpose of this study is to differentiate periampullary carcinomas based on immunohistochemistry (IHC) by using cytokeratin 7 (CK7), cytokeratin 20 (CK20), caudal type homeobox 2 (CDX2). Aims: To analyze the usefulness of IHC as single/panel of markers that included CK7, CK20, and CDX2. Settings and Design: This was a prospective study done from January 2017 to September 2018. Subjects and Methods: A total 50 pancreaticoduodenectomy specimens were evaluated and classified as intestinal (INT) and pancreaticobiliary (PB) types based on their morphological and immunohistochemical features, respectively. The morphologic subtypes, expression of IHC markers were correlated with different histologic parameters. Statistical Analysis: Chi-square test was used to study the association between different IHC markers with histologic parameters. Probability (P) values <0.05 were regarded as statistically significant. Results: The expression of CK7, CK20, CDX2 were studied in 50 cases to classify them as INT and pancreatobiliary subtypes. CK7 has high sensitivity (88.2%), CDX2 has high specificity (96.4%), CK20+/CDX2+ has both high sensitivity (94.2 percent) and specificity (89.2 percent) in differentiating INT from pancreatobiliary subtypes. The morphologic subtypes showed correlation with two variables (tumor grade, pathologic T stage). CK20 and CK20/CDX2 expression showed a positive correlation with tumor grade, pathologic T staging, and lymphovascular invasion. Conclusions: In conclusion, morphological classification can significantly discriminate histologic types, IHC plays a moderate role. However, the combined expression of CK20 and CDX2 is helpful in subtyping.
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The occurrence of synchronous pancreatic cancer and other primary cancer is not frequent and reaches about 5.6% as reported in autoptic studies. Double resections of the pancreas with another organ due to synchronous malignancies have been published only in quite sporadic sets of cases or individual case reports. We present a case report of a 40 years lady who presented with intermittent pain, fever and jaundice for 15 days. Examination revealed a palpable gall bladder, firm in consistency and tender to touch. She was admitted with a provisional diagnosis of cholangitis and started on intravenous antibiotics. Patient’s clinical condition improved and she was planned for a CECT and MRCP which revealed an heterogenously enhancing mass lesion in upper pole of left kidney, s/o of renal cell carcinoma (RCC) and an enhancing lesion in periampullary region s/o periampullary carcinoma with no evidence of free fluid or metastasis. ERCP guided biopsy revealed moderately differentiated adenocarcinoma and USG guided renal biopsy revealed clear cell carcinoma. Whipple’s procedure with left nephrectomy was performed. Intra operative findings revealed post-operative course and hospital stay was uneventful. Biopsy revealed poorly differentiated pancreaticobiliary adenocarcinoma with no lympho vascular or lymph nodal invasion (pT3aN0) and left sided clear cell renal carcinoma with no lympho vascular invasion (pT1N0). Synchronous malignancy of pancreas and kidney is a very rare presentation. Literature describes presence of RCC with periampullary metastasis and patients presenting with RCC post whipple’s procedure but only a handful of case reports describe presence of dual malignancy as reported above.
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Background: The morbidity rates for Whipple’s procedure has remained high even as mortality rates were coming down. This study was intended to assess postoperative morbidity rates in a tertiary care centre and to compare it with other centres.Methods: Data was collected from various registers and medical records for this retrospective cohort study. All Whipple’s procedures for 5 years were included in the study. Statistical analysis was done using R statistical software and the results were tabulated.Results: There were 48 patients and half of them developed morbidity. Surgical site infection was the most common complication (18.8%) followed by pulmonary complications (12.5%) and bile leak (6.25%). Half of the patients having pulmonary complications died while nobody with surgical site infection or bile leak died.Conclusions: In this study the morbidity rates were comparable to other centres. Hypoalbuminemia is a significant predictor of morbidity. Surgical site infection was the most common morbidity. Pulmonary complications were the most common cause for death. Morbidity rate is comparable to other centres and Whipple’s procedure is a safe surgery in the tertiary centre where the study was conducted.
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The mortality rates for Whipple’s procedure has come down during the last few years. This study was intended to assess perioperative mortality rates in a tertiary care centre and to compare it with other centres. Methods: Data was collected from various registers and medical records for this retrospective cohort study. All Whipple’s procedures for 5 years were included in the study. Statistical analysis was done using R statistical software and the results were tabulated. Results: There were 48 patients and 8 of them died. A median serum bilirubin level of 16.9 mg% was found statistically significant with respect to mortality. Similarly placed was median serum albumin levels of 2.71 gm% and poor differentiation of tumour. Conclusion: In this study the mortality rates were comparable to other centres. Hypoalbuminaemia is a significant predictor of mortality. Tumour size of more than 3 cm is associated with high mortality. High serum bilirubin levels is an independent predictor of mortality. Several studies also show similar predictors of death in Whipple’s procedure. Pulmonary complications were the most common cause for death. Mortality rate is comparable to other centres and Whipple’s procedure is a safe surgery in the tertiary centre where it was studied.
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Periampullary carcinoma includes carcinoma of head of pancreas, carcinoma of lower common bile duct, ampullary carcinoma and adenocarcinoma of duodenum. Most of the periampullary cancers shows the same clinical symptoms their imaging manifestations are overlapping or non-specific. Accurate qualitative positioning and staging of periampullary cancers are of great value in guiding of treatment plan and evaluate postoperative outcomes. CT and MRI examination have made progress in the diagnosis of periampullary carcinoma. CT scan has a good spatial and temporal resolution, while MRI has a good tissue resolution. CT and MRI examination can be used for preoperative assessment of tumor resectability and invasion range, which is of certain value.
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Periampullary carcinoma includes carcinoma of head of pancreas, carcinoma of lower common bile duct, ampullary carcinoma and adenocarcinoma of duodenum. Most of the periampullary cancers shows the same clinical symptoms their imaging manifestations are overlapping or non-specific . Accurate qualitative positioning and staging of periampullary cancers are of great value in guiding of treatment plan and evaluate postoperative outcomes. CT and MRI examination have made progress in the diagnosis of periampullary carcinoma. CT scan has a good spatial and temporal resolution, while MRI has a good tissue resolution. CT and MRI examination can be used for preoperative assessment of tumor resectability and invasion range, which is of certain value.
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Objective:To investigate the recent and long-term efficacy and safety of pancreaticoduodenectomy for pancreatic head carcinoma and periampullary carcinoma.Methods:82 cases of pancreatic cancer combined with periampullary carcinoma patients admit ted in our hospital from August 2009 to June 2013 were selected and randomly divided into the control group and the observation group With 41 patients in each group.The control group received palliative surgical treatment,while the observation group underwent pancreatoduodenectomy.The operation time,hospitalization time,intraoperative bleeding volume and the incidence of complications,1,2,3-year survival rate and the recurrence rate at 1 year after operation and tumor eradication rate were compared between twp groups.Results:The amount of bleeding,operation time of observation group were significantly higher than those of the control group(P＜0.01),no signif icant difference was found in the hospitalization time between the two groups(P＞0.05);the incidence of complications in the observation group (41.46％) was significantly higher than the control group (22.96％)(P=0.03);the 2-year and 3-year survival rate of observation group were significantly higher than those of the control group (P＜0.05),the recurrence rate at 1 year after operation of observation group was significantly lower than that of the control group (P=0.04),the tumor eradication rate was significantly higher in the observation group than that of the control group (P=0.04).Conclusion:Though pancreaticoduodenectomy could prolong the operation time,increase the risk of bleeding and complications for pancreatic head carcinoma and periampullary carcinoma,but it could effectively reduce the possibility of recurrence after operation,significantly improve the long-term survival rate.
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Periampullary carcinoma metastases are usually located at regional nodes, adjacent organs, liver or lung. On the other hand, metastatic penile cancer is uncommon. Penile metastasis usually originates from pelvic region with prostate and bladder being the most frequent primary location. We present a very rare case of periampullary carcinoma with penile metastasis in a 49-year-old man. He initially presented with early ampullary type periampullary carcinoma and had pyloric preserving pancreatoduodenectomy and adjuvant chemotherapy. However, after six years of uneventful follow up, he presented with a penile lesion which was confirmed to be pancreatic metastasis. He was started on chemotherapy but passed away two months later. Ampullary carcinoma type of periampullary carcinoma usually presents early with favourable prognosis. However, tumour recurrence can present much later after definitive treatment and at a rare site such as penis with generally poor outcome.
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Objective To investigate the survival of advanced stage periampullary carcinoma and its prognostic factors.Methods The clinical data and follow up of 134 patients with advanced stage periampullary carcinoma admitted to our hospital between January 2007 and December 2010 were retrospectively collected and analyzed.Results Of 134 patients,there were 83 males and 51 females.The mean age±S.D.was 62.49±11.41 (28-83).For the 86 patients who underwent surgery,32 had extensive peritoneal metastases on surgical exploration,27 had metastases/involvement of the liver or stomach,and 27 had major vessel infiltration.For these 86 patients,55 received surgical exploration,whereas 31 had surgical exploration plus bypass anastomosis. 45 patients received chemotherapy,while 67 received chemotherapy plus radiotherapy.The improvements in quality of life and in clinical response rate after concurrent chemoradiotherapy or chemotherapy alone were 73.1％ and 57.8％,respectively.The overall survival was 14.27±1.06 months.The median survival time was 11 (8.95±13.05) months.The 1- and 3-year survival rates were 43％ and 10％,respectively.Karnofsky performance status,and the presence or absence of jaundice co-related with poor prognosis on single factor analysis.The Karnofsky performance status was an independent survival predictor on multifactor analysis.Conclusions The prognosis of patients with advanced stage periampullary carcinoma was poor.Chemotherapy with or without radiotherapy had similar impact on overall survival,Karnofsky performance status was an independent survival predictor.
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Objective To explore the value of magnetic resonance cholangiopancreatography (MRCP) and MRI in the diagnosis and differential diagnosis of periampullary carcinoma. Methods Plain and dynamic multi-phase enhanced MRI data of 54 patients with periampullary carcinoma proved by pathology were retrospectively analysed. χ~2 test and two independent samples t test were used to examine the relative results. The results of MRI were compared with that of pathology. Results Of 32 cases with carcinoma of head of pancreas, 7 cases (21.9%) exhibited "four-duct sign". 16 cases were carcinomas of the lower part of common bile ducts, 9 cases (56.3%) showed "three-duct sign". The difference between carcinomas of head of pancreas and carcinomas of the lower part of common bile ducts was significant (P<0.05). Additionally, the ratio of the largest area of masses and the diameter of com-mon bile duct in pancreatic cancer tumors was larger than that in common bile duct cancer (P<0.05) for whether the intraoperative or MRI measurement. Conclusion MRI and MRCP are very helpful in diagnosis of periampullary carcinoma.
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Objective To compare the value of conventional ultrasound,hydrosonography and double-contrast enhanced ultrasound in the display capacity of periampullary carcinoma and its relationship with the surrounding tissue.Methods A total of 18 patients with the periampullary carcinoma were diagnosed pathologically or by endoscopic biopsy.Each patient had three imaging modalities by conventional ultrasound,hydrosonography and double-contrast enhanced ultrasound.The display capacity and the relationship between the mass and surrounding tissue were compared with three modalities.Results The display rates of limpid visibilities of carcinoma on conventional ultrasound,hydrosonography and double-contrast enhanced ultrasound were 16.7%(3/18),22.2%(4/18) and 94.4%(17/18),respectively;The display rates of duodenum protrusion on three modalities were 0(0/18),38.9% (7/18) and 72.2% (13/18),respectively,with significant differences among conventional ultrasound,hydrosonography and double-contrast enhanced ultrasound.The double-contrast enhanced ultrasound showed two cases of peripheral vascular invasion and one case of intrahepatic metastasis.Conclusion The double-contrast enhanced ultrasound can increase the display capacity of periampullary carcinoma as a new diagnostic modality for periampullary carcinoma.
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Objective To investigate the effect of the operational treatment for periampullary carcinoma.Methods The data of 53 operative patients were retrospectively analyzed. Among the 24radical operations, PD was performed in 23 cases ,PPPD in 1 ;the palliative operation was performed in 29 cases. Results Among the 24 radical operaions, the overall mortality was 8.3% (2/24), no operational death. The postoperative morbidity was 15 cases,including 5 cases of pancreatic fistula. Median length of hospital stay was 26 days. Conclusion Continual improvement of operative technique and sufficient perioperative management were the keys to increasing the effect of the operational treatment.
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Objective To explore the clinical characteristics of periampullary carcinoma in the prejaundice stage and improve early diagnosis rate and operative effects.Methods Clinical data of 27 cases with periampullary carcinoma in the prejaundice stage in our institute during the period of Jan 1998 to Dec 2005were analyzed retrospectively.Results The clinical symptom was mostly nonspecific, mainly included abdominal discomfort ( 92.6% ), abdominal pain ( 55.6% ), and irregular fever ( 29.6% ).The positive diagnosis rate with US, CT, MRCP, ERCP and EUS was 75.6%, 85.2%, 83.3%, 84.6%, and 88.9%,respectively, and they were helpful for early diagnosis.Among these 27 patients, 19 cases received regional pancreaticoduodenectomy, and 5 cases received pancreaticoduodenectomy in combination with vessel resection,3 cases received bile duct or gallbladder jejunal Roux-en-Y anastomosis, the overall resection rate was 88.9% with no operative mortality, and the post-operation complication rate was 7.4%.The 1,3, and 5 year survival rates were 100%, 70.8% and 41.7%, respectively.Conclusions The periampullary carcinoma in the prejaundice stage has its own clinical characteristics and abnormal image changes.If the diagnosis can be confirmed in the prejaundice stage, it is still an important method to improve the resection rate and prognosis.
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BACKGROUND/AIMS: Periampullary carcinoma could recur early even after curative resection in the small-sized lesion. The aim of this study is to clarify the clinicopathologic features of early recurrence cases after pancreatoduodenectomy in periampullary carcinoma. METHODS: 15 cases (group I) of recurrence within 6 months after pancreatoduodenectomy were compared clinicopathologically with 17 cases (group II) of no recurrence until 2 years after pancreatoduodenectomy between 1991 and 2000 in Hallym medical center. RESULTS: There were no differences in sex and age distri- butions between two groups (M/F ratio=8/7 vs 8/9, and average age=56.9 vs 57.5). The distributions of primary lesions were 4 cases of ampulla of Vater, 6 cases of common bile duct, 5 cases of pancreatic head in group I; 7 cases of ampulla of Vater, 8 cases of common bile duct, 2 cases of pancreatic head in group II, respectively. There were no differences in tumor size (2.8+/-1.1 cm vs. 2.4+/-1.5 cm), the number of lymph node metastasis, AJCC tumor stage, histological differentiation, neural or lymphatic invasion between two groups. The number of direct invasion to adjacent organs in group I was more than that in group II (p<0.05). CONCLUSION: The increased number of direct invasion to adjacent organs could be an important prognostic factor of early recurrence after pancreatoduodenectomy even in small-sized or no lymph node-metastasized periampullary carcinoma.
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Ampulla of Vater , Common Bile Duct , Head , Lymph Nodes , Neoplasm Metastasis , Pancreaticoduodenectomy , RecurrenceABSTRACT
The distinction of carcinomas involving periampullary region is often difficult, even in the surgically resected specimens. To examine the differences in the expressions of cytokeratin (CK) 7 and 20 in the periampullary carcinomas, we performed immunohistochemical studies on surgically resected 20 pancreatic duct adenocarcinomas (PDA), 13 distal bile duct adenocarcinomas (DBA), 10 duodenal adenocarcinomas (DA), and 18 ampulla of Vater adenocarcinomas (AVA). We analyzed the relationships between CK 7/CK 20 immunoprofile, and tumor cell differentiation and tumor size. We interpreted diffuse cytoplasmic reactivity found in > or =5% of tumor cells as positive. In the majority of cases, PDA were CK 7 /20 (95%), DBA CK 7 /20 (92.3%), DA either CK 7 /20 (40%) or CK 7 /20 (30%), AVA either CK 7 /20 (50%) or CK 7 /20 (44.4%). In DA, there was an increased CK 20 negativity in less differentiated (moderately or poorly differentiated) cases (p or =5 cm) tumor size (p=0.049). In AVA, there was a tendency of increased CK 20 positivity in less differentiated cases (p=0.10). In conclusion, the CK 7/CK 20 immunophenotype is useful in the differentiation of periampullary carcinomas: the CK 7 /CK 20 immunophenotype strongly suggests DA or AVA, whereas the CK 7 /CK 20 immunophenotype suggests PDA or DBA.
Subject(s)
Adenocarcinoma , Ampulla of Vater , Bile Ducts , Cell Differentiation , Cytoplasm , Keratin-20 , Keratin-7 , Keratins , Pancreatic DuctsABSTRACT
Objective To study significance of anicteric biliary tract dilatation in early diagnosis and treatment of patients with periampullary carcinoma.Method Review the resection rate and survival rate of 16 periampullary carcinoma patients with anicteric biliary tract obstruction found out by B-ultrasound,CT or PTC during 13 years(1986-1999).Result The operative resection rate was 87.50%(14/16) ,5-year survival rate was 43.75%(7/16),3-year survival rate was 62.50%(10/16).Conclusions Biliary tract dilatation existed before icterus occurred,while syndromes such as upset of upper abdomen,reclusion, epigastralgia distention and anorexia, may occur 1-3 months ahead of icterus occurred in patients with periampullary carcinoma. If the patient has syndromes mentioned above, more than 40 years of age and biliary tract dilatation found by B-ultrasound, CT,PTC or ERCP, periampullary carcinoma should be considered. The patients should be checked by operation,so as to raise the operative resection rate and survival rate.
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Objective To summarize early complications and treatment after regional pancreatectomy for periampullary carcinoma. Methods Clinical data of 325 periampullary carcinoma cases in our hospital from Dec 1997 to Jul 2004 were collected. Postoperative early complications were analyzed. Results There were 109 cases from Dec 1997 to Dec 2001 and 216 cases from Jan 2002 to Jul 2004. Early complications rate were 21/109( 19. 3% ) and 18/216(8. 3% ) respectively (P