Editing Periampullary cancer

== Four common types: ==

=== '''Pancreatic ductal adenocarcinoma (~80%)''' ===

** Also most aggressive of these - only 15% of patients are surgical candidates at diagnosis
** Among those who have surgery, median survival is 20 months, and 5 year survival of 20%
** Commonly 50-70yo
** RFs:
*** Smoking
*** Obesity
*** T2DM
*** Family history

=== '''Distal cholangiocarcinoma (~10%)''' ===

** Distal CCA arises in CBD between junction of cystic duct and ampulla of Vater
** RFs:
*** 60-70yo
*** PSC
*** Parasites
*** CP
*** HBV/HCV
*** Choledochal cysts
** 5 year survival: 30% for local/regional disease, 2% for distant mets at time of diagnosis

=== '''Ampullary adenocarcinoma''' ===

** Generally develop obstructive symptoms early, and therefore seen earlier
** 80% resectable disease
** There could be two different subtypes - intestinal (better) and pancreaticobiliary (worse survival)

=== '''Duodenal adenocarcinoma''' ===

** Often quite large at diagnosis, because they can have unrestricted growth before symptoms are noted
* Rarely - neuroendocrine neoplasms, pancreatic cystic neoplasms, acinar and squamous cell carcinomas, GI stromal tumours, sarcomas, lymphomas, metastases.

== Presentation ==

* Obstructive jaundice - often painless, but can have vague pain
* Cholangitis
* Pancreatic insufficiency
* GI bleeding

== Clinically ==

* Look for sister mary joseph nodule or Virchow's node
* Sometimes have Courvoisier's sign - palpable non-tender GB

== Investigation ==

* Bloods
** INR
** CA-19-9
* Imaging
** CT is best first test if suspected, with pancreas protocol
** PDAC best imaged PV phase
** Double duct is most commonly a/w PDAC

== Staging ==

* Stages I and II - Conventional resectability - localised, non-metastatic tumours without extension into major visceral vasculature
* Stage III - non-metastatic tumours with some degree of major vascular involvement
** Abutment - <180deg loss of fat separation between tumour and vessel
** Encasement >180deg
** Divide stage III into:
*** 'Borderline resectable' - technically reconstructable vascular involvement

*

* 'Locally advanced unresectable'

* Stage IV - distant mets, unresectable


Tissue biopsy/stenting

* EUS + FNA

== Treatment ==

* Resectable (stage I or II): upfront surgery followed by adjuvant CTX
** Consider neoadjuvant - gaining traction recently
* Borderline resectable - Neoadjuvant CTX +/- RTX, then re-image, and assuming no progression, can be resected
* Locally advanced unresectable - CTX, and if it rarely downstages, it may become resectable later, but this is rare
* Unresectable (stage IV) - CTX

== Surgery: ==

* Pancreaticoduodenectomy, either standard or pylorus-preserving - unclear which is superior. Minimally-invasive has equivalent oncologic results.
* Technique
** Abdominal exploration - confirm no spread
** Mobilisation of structures and formal tumour resection
** Pancreaticobiliary and GI reconstruction


[[Category:Biliary]]