ENDOSCOPIC DIAGNOSIS AND TREATMENT OF AMPULLARY NEOPLASM (WITH VIDEO)

Background and aim: For ampullary cancer, pancreaticoduodenectomy is considered to be the standard treatment. Endoscopic papillectomy (EP) has been utilized in cases of ampullary adenoma since the early 1980s. We aimed to provide a review concerning EP. Methods: We conducted a review of studies regarding EP for ampullary neoplasms. Results: Since neither lymphatic permeation, vascular invasion, nor lymph node metastasis is observed in patients with ampullary cancer limited to the mucosa, EP of such tumors without ductal infiltration into the pancreatic/bile duct can be justified as radical treatment. For its application in patients with ampullary neoplasms, accurate pretreatment staging is indispensable. EUS, which can be carried out on an outpatient basis with a low risk of complications, is useful for differential diagnosis as well as detection of periampullary tumors. Although intraductal US of the bile duct tends to result in overestimation of tumor staging in cases of ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for EP. While the technical success rate of EP is high, the complication rate and recurrence rate are not as low as a satisfactory level. Pancreatic duct stenting after EP is expected to contribute to prevention of post‐EP pancreatitis. There is no consensus regarding the mode of resection current nor the need for addition of biliary/pancreatic sphincterotomy and biliary stenting. Conclusions: EP has been reported to be useful in selected patients with ampullary neoplasms. Data on further long‐term follow up after EP are awaited.     

Ampullary neuroendocrine tumor diagnosed by endoscopic papillectomy in previously confirmed ampullary adenoma

Ampullary adenoma is a common indication for endoscopic papillectomy. Ampullary neuroendocrine tumor(NET) is a rare disease for which complete surgical resection is the treatment of choice. However, because of the morbidity and mortality associated with surgical resection, endoscopic papillectomy is increasingly used in selected cases of low grade, with no metastasis and no invasion of the pancreatic or bile duct. Also, confirmed and complete endoscopic resection of ampullary NET accompanied by adenoma has not been reported to date. We report herein a rare case of an ampullary NET accompanied with adenoma, which was successfully and completely resected via endoscopic papillectomy. Prior to papillectomy, this case was diagnosed as an ampullary adenoma.     

Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy?

BACKGROUND: Recently, the evidence has been accumulating that endoscopic resection may be curative in treating ampullary adenoma that contains high-grade intraepithelial neoplasia/in situ tumor (HGIN/Tis). However, there are only anecdotal reports of endoscopic management of "focal" T1 ampullary cancer (T1 cancer), and radical surgery is still considered the only accepted treatment modality. OBJECTIVE: To assess the possibility of endoscopic papillectomy as an alternative to radical surgery for the treatment of ampullary adenoma with HGIN/Tis or focal T1 cancer. DESIGN: Retrospective evaluation of case series of our hospital from 1996 to 2006. SETTING: Tertiary-care university teaching hospital. PATIENTS: Twenty-three patients who had HGIN/Tis or focal T1 cancer in ampullary adenoma resected by endoscopic papillectomy and 60 patients who initially underwent radical surgery for HGIN/Tis or T1 cancer of the ampulla of Vater. "Focal" was defined as a lesion involving only mucosa, with a size less than a fourth the diameter of main adenoma. INTERVENTIONS: Review of medical records and analysis of surgically or endoscopically resected specimens of ampullary tumors. MAIN OUTCOME MEASUREMENTS: Locoregional extension and follow-up data. RESULTS: Patients with HGIN/Tis of the ampulla of Vater had no lymphovascular invasion or lymph-node metastasis, and there were no occurrences of cancer or deaths during a mean (standard error [+/-SE]) 27.1 +/- 5.9 months after endoscopic papillectomy. T1 cancer was shown to have lymphovascular invasion and/or lymph-node metastasis in 10.7% and duct mucosal involvement in another 17.9%. Among them, patients with focal T1 cancer showed no lymphovascular invasion or lymph-node metastasis and no ductal involvement, and none of the patients who underwent endoscopic papillectomy alone had cancer recurrence or disease-related death for mean (+/-SE) 32.2 +/- 6.7 months. LIMITATIONS: Single-center, retrospective study, small number of patients, and medium-term follow-up period. CONCLUSIONS: Endoscopic papillectomy may be a curative treatment for ampullary adenoma with HGIN/Tis and should also be considered as an alternative to surgery in focal T1 cancer in ampullary adenoma.     

A case of ampullary cancer with pancreas divisum treated by endoscopic papillectomy

A 60's man underwent a medical check-up and esophagogastroduodenoscopy revealed an exposed-type tumor at the ampulla of Vater. Endoscopic ultrasonography and intraductal ultrasonography showed a hypoechoic mass limited to the ampulla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a slightly dilated ventral pancreatic duct not connected to the dorsal duct. Endoscopic papillectomy was performed without pancreatic stent placement and his postprocedural course was uneventful. The specimen was histologically diagnosed as well-differentiated adenocarcinoma limited to the mucosa of the ampulla of Vater. Endoscopic papillectomy without pancreatic stent placement can be performed without a risk of post-ERCP pancreatitis for ampullary tumor limited to the mucosa of the ampulla of Vater associated with pancreas divisum.     

Pathological characteristics of early to advanced gallbladder carcinoma and extrahepatic cholangiocarcinoma

Biliary tract cancer (cancer of gallbladder and extrahepatic bile duct) is the most common malignancy of the biliary tract, and is considered to be a high‐grade malignancy. In this study, we reviewed 293 gallbladder cancers and 102 bile duct cancers for clarifying growth and invasion of the extrahepatic bile duct cancer. Only 10.5% (9/86) of the early gallbladder cancers showed lymphatic invasion, but neither venous invasion nor lymph node metastasis was noted in the early cancers. 70.6% (207/293) of the gallbladder cases were pT2‐3 cancers, and frequently showed lymphatic/venous/perineural invasion and/or lymph node metastasis. 12.7% (13/102) of the extrahepatic bile duct cancers were pTis or pT1 cancers, which were categorized as early cancers. Only 15.4% (2/13) of the early cancer showed vascular/perineural invasion and/or lymph node metastasis. The majority (87.3%) of the extrahepatic bile duct cases was pT2‐3 cancers, and frequently showed vascular/perineural invasion and/or lymph node metastasis. We also examined intramural invasion patterns; i.e. intramural invasion patterns were defined as infiltrative growth (IG) type, and destructive growth (DG) type. The overall survival rate of the gallbladder cancer patients with the DG type was significantly lower than that of the patients with the IG type, associated with frequent lymphatic/venous invasion and/or lymph node metastasis. Therefore, pathological characteristics are important for clinical manifestation of the gallbladder/extrahepatic bile duct cancers.     

超声内镜对壶腹癌及肝外胆管癌术前分期诊断

超声内镜对手术前Ｖａｔｅｒ＇ｓ壶腹癌及肝外胆管癌的原发病变范围、浸润深度、是否有区域淋巴结转移及远隔转移作出诊断及分期，将有助于选择最佳治疗方案及判断预后。对２８例Ｖａｔｅｒ＇ｓ壶腹癌及１８例肝外胆管癌于手术前进行了超声内镜检查，并按照国际ＴＮＭ分期方案进行了手术前分期。其中２２例Ｖａｔｅｒ＇ｓ壶腹癌及１８例肝外胆管癌进行了根治性切除及详细的病理组织学检查，有可能将超声内镜与病理诊断结果进行对照以检验超声内镜诊断的准确性。超声内镜判断Ｖａｔｅｒ＇ｓ壶腹癌及肝外胆管癌病变范围及浸润深度的准确性分别为８１．８％及７２．２％；判断其区域淋巴结转移的准确性分别为５９％及６１．６％。Ｖａｔｅｒ＇ｓ壶腹癌伴门静脉受侵的３例中有２例于术前超声内镜检查中获得了正确诊断，但３例肝转移均未能发现。     

Surgical technique for complete resection of the extrahepatic portion of the common bile duct and the ampulla of Vater for tumors of the ampulla of Vater

Background

Ampullary tumors have to be completely resected, but substantial morbidity and mortality rates are associated with pancreaticoduodenectomy (PD). Local resection can be the procedure of choice in selected ampullary lesions for high-risk patients.

Methods

Preoperative examination indicated that the ampullary tumor extended into the common bile duct without evidence of pancreatic duct involvement and no definite invasion into either the duodenum or the pancreas. We performed a complete resection of the extrahepatic bile duct and the ampulla of Vater, including the tumor, without performing PD by dissecting the intrapancreatic bile duct from the pancreas both downward towards the ampulla of Vater and upward using a transduodenal approach.

Results

The operation was successfully completed, and the postoperative course was uneventful, with the exception of a minor pancreatic fistula from retropancreatic dissection. The final pathological examination demonstrated well-differentiated tubular adenocarcinoma limited to the mucosa with negative surgical margins.

Conclusion

Complete resection of the extrahepatic bile duct and the ampulla of Vater through a transduodenal approach can be a feasible and safe surgical procedure for selected ampullary tumors in high-risk patients.     

Indication of Endoscopic Papillectomy for Tumors of the Papilla of Vater and Its Problems

Discussions have just started in Japan as to the indication, technique and complication of endoscopic papillectomy for tumors of the papilla of Vater. We indicate endoscopic papillectomy for tumors satisfying the following:

• 1 exposed tumor‐type adenoma, or carcinoma in adenoma;
• 2 without invasion of duodenal muscularis; and
• 3 no infiltration into the pancreas or the bile duct.

Endoscopic papillectomy was performed on 12 patients with tumors of the papilla of Vater that satisfied the above criteria. En bloc snare excision was achieved in 11 out of 12 cases without endoscopic sphincterotomy (EST) or epinephrine injection. Pancreatic stenting was done in 8 cases for prevention of pancreatitis, and bile duct stenting in nine cases for prevention of cholangitis. Postoperative early complications were observed in 5 cases; pancreatitis in 2; pancreatitis and bleeding in 1; bleeding in 1; and bleeding and perforation in 1. Neither recurrence nor metastasis of tumor has been detected during the average postoperative period of 620 days. The treatment can be acknowledged as less invasive therapy. However, management of complications is important, for which further study needs to be accumulated.     

Case of early ampullary cancer treated by endoscopic papillectomy

We herein report a case of ampullary cancer in a 65‐year‐old man who underwent endoscopic papillectomy. Duodenoscopy revealed an exposed‐type tumor mass at the ampulla of Vater. Histology of the biopsy specimen demonstrated well‐differentiated adenocarcinoma. Endoscopic ultrasonography and intraductal ultrasonography showed a hypoechoic mass limited to the ampulla of Vater (clinical stage, T1). Endoscopic papillectomy was performed after informed consent was obtained. Histological examination of the resected specimen revealed adenocarcinoma limited to the ampulla of Vater (final stage, pT1). Both accurate preoperative T staging and proper histological evaluation of the resected specimen appear to justify endoscopic treatment of early ampullary cancer.     

Feasibility of endoscopic papillectomy in early stage ampulla of Vater cancer

Background and Aim:  Although endoscopic papillectomy has been attempted in early stage ampullary cancer (pTis, T1), its curative role and indications remain uncertain. The present study was designed to assess the factors that predict malignancy and lymph node metastasis and to suggest potential indications for endoscopic papillectomy by analyzing clinicopathological data.
Methods:  We performed a retrospective analysis of clinical and histopathological data of 216 patients with ampullary cancer between 1991 and 2006.
Results:  No tumor in pTis stage had metastasized to lymph nodes and only 9% of tumors in pT1 had metastasized. Tumor size ( P  = 0.018), depth of invasion ( P  = 0.021) and venous invasion ( P  = 0.014) were found to be significantly related to lymph node metastasis. Cases with early stage ampullary cancer of less than 2 cm with a well-differentiated histology and no angiolymphatic invasion ( n  = 13) showed no lymph node metastasis and no recurrence during a median follow up of 35.9 months.
Conclusion:  Endoscopic papillectomy can be adopted as a viable alternative to surgery in patients with early stage ampullary cancer of less than 2 cm in size and with a well-differentiated histology. When a resected specimen has a well-differentiated histology, and there is no resection margin involvement and no angiolymphatic invasion, our findings indicate that subsequent radical surgery is unnecessary.     

早期胃癌淋巴结转移规律及其影响因素分析

目的 探讨早期胃癌淋巴结转移规律及其影响因素,为选择合适的治疗方法提供依据.方法 对北京大学第三医院1988年3月-2009年3月于外科行胃癌根治术治疗的103例早期胃癌患者临床资料进行回顾性研究,对患者的年龄、性别,肿瘤的大小、部位、大体类型、分化程度及浸润深度与淋巴结转移的关系进行单因素及多因素分析.结果 早期胃癌的淋巴结转移率为17.5%(18/103),其中黏膜内癌的淋巴结转移率为4.1%(2/49),黏膜下层癌的淋巴结转移率为29.6%(16/54).logistic回归分析显示,浸润至黏膜下层(P=0.001)及肿瘤>2 cm(P=0.003)为早期胃癌淋巴结转移的独立危险因子.黏膜内癌发生淋巴结转移的2例均为直径>2 cm的印戒细胞癌;黏膜下层癌中,≤2 cm肿瘤的淋巴结转移率为16.1%(5/31),>2 cm肿瘤的淋巴结转移率高达47.8%(11/23)(P=0.012).高分化程度的早期胃癌的淋巴结转移率为0(0/13),中分化癌转移率为18.2%(4/22),低分化癌转移率为16.7%(5/30),印戒细胞癌转移率为23.7%(9/38),各组间差异无统计学意义(P=0.294).患者的年龄、性别、肿瘤部位(胃上部、中部、下部)和大体分型(隆起型、平坦型和凹陷型)与淋巴结转移无相关性.结论 肿瘤大小和浸润深度与早期胃癌淋巴结转移相关,决定早期胃癌治疗方案时,可参考上述因素判断淋巴结转移风险.     

Pathogenesis of carcinoma of the papilla of Vater

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7?, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20?, MUC2?). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa.     

分化不良型早期胃癌淋巴结转移的危险因素分析

目的评估分化不良型早期胃癌患者淋巴结转移的危险因素,探讨其内镜治疗的可能性。方法回顾性分析2002年9月-2008年12月经手术证实的100例分化不良型早期胃癌患者,对其年龄、性别、肿瘤大小、部位、大体类型、溃疡、组织学类型、浸润深度及淋巴管肿瘤浸润与淋巴结转移的关系进行单因素和多因素分析。结果分化不良型早期胃癌的淋巴结转移率达18．00％。多变量分析显示肿瘤大小（〉2cm）、侵犯至黏膜下层、淋巴管肿瘤浸润均是分化不良型早期胃癌淋巴结转移的独立危险因素（P〈0．05）。肿瘤大小和淋巴管肿瘤浸润是分化不良型黏膜内早期胃癌的淋巴结转移的独立危险因素。在直径≤2cm且无淋巴管肿瘤浸润的分化不良型黏膜内早期胃癌中未发现淋巴结转移。结论直径≤2cm且无淋巴管肿瘤浸润的分化不良型黏膜内癌患者可考虑内镜治疗,术后需密切随访。     

Assessment of the definition of early extrahepatic bile duct cancer through the prognosis analysis who had received curative resection]

BACKGROUND/AIMS: The definition of early extrahepatic bile duct cancer might be different from that of other gastrointestinal cancer because of the differences of histologic features including the lack of muscularis mucosa and submucosal layer in bile duct. The purpose of this study was to evaluate the concept of early extrahepatic bile duct cancer in Korea. METHODS: We evaluated seventynine cases of extrahepatic bile duct cancer who had received curative resection in Severence Hospital, Yonsei University from March 1986 to October 2005. We retrosptectively reviewed the medical records and analyzed variable prognostic factors to define early extrahepatic bile duct cancer. RESULTS: Invasion limited to the mucosa was noted in 5 cases (6.3%), fibromuscular layer in 12 cases (15.2%), adventitia of fibromuscular layer and serosa in 26 cases (32.9%), and invasion of adjacent organs in 36 cases (45.6%). Disease free 5-year survival according to the depth of invasion were 80.7% in tumor confined within mucosa, 80.0% within fibromuscular layer, 57.2% within adventitia of fibromuscular layer and serosa, and 51.5% in tumor with invasion of adjacent organ. There was no significant difference in the survival rate between patients with tumor confined to mucosa and patients with tumor invasion limited to the fibromuscular layer. However, the survival rate of patients with tumor limited to the mucosa or fibromuscular layer was significantly higher than that of patients with tumor invaded beyond fibromusular layer. In early cancer, there were more papillary polypoid type in gross finding and papillary adenocarcinoma in pathologic finding when compared to advanced cancer. CONCLUSIONS: Early extrahepatic bile duct cancer can be defined as the tumor invasion limited to the mucosa and fibromuscular layer.     

Endoscopic papillectomy: a novel approach to difficult cannulation.

BACKGROUND: Selective cannulation of the biliary and pancreatic ducts is considered to be the most difficult and rate limiting aspect of diagnostic endoscopic retrograde cholangiopancreatography (ERCP). AIMS/METHODS: A novel technique for difficult cannulation is described and its potential role in relieving malignant duodenal obstruction secondary to ampullary carcinoma. A diagnostic endoscopic papillectomy was performed in 10 patients in whom previous attempts at cannulation had failed. Five patients had exophytic ampullary carcinomas, one had carcinoma of the head of pancreas, two had an oedematous ampulla secondary to low common bile duct stones, while two had protuberant ampullae with ectopic orifices. The technique entails snaring the ampulla flush with the duodenal wall using a polypectomy snare and in a similar fashion to polypectomy removing the ensnared ampulla with diathermy using a coagulation current. The underlying exposed ducts can then be cannulated while the ensnared ampulla can be retrieved to aid histological diagnosis. RESULTS: Successful cannulation was achieved in all 10 cases with significant haemorrhage in one patient (10%). Four of the snared ampullary carcinomas (80%) were retrieved enabling a histological diagnosis to be made. CONCLUSIONS: This study demonstrates the potential role for endoscopic papillectomy as a means of cannulation in difficult circumstances, however larger comparative studies are required.     

EUS/IDUS AND ENDOSCOPIC PAPILLECTOMY

In our institute, the indication of endoscopic papillectomy is set for adenoma or early cancer without tumor growth in the bile duct or the pancreatic duct. The substantial complete excision rate was 78.8%. One out of 11 incomplete excision cases was removed surgically for tumor persistence, and, as for remaining the 10 cases without persistence had been under serial observations. One case out of the serial observations had local recurrence in 5 years 5 months after papillectomy and surgical resection was performed. Further cases and long‐term serial observations may be required to get evidence of an appropriate indication. In addition, for 60 cases experienced in our institute, the safety of this therapy was reviewed. We experienced bleeding (13.3%), pancreatitis (10%), and cholangitis (3.3%) as early complications, but all cases were successfully treated conservatively. There were no serious conditions as late complications, and endoscopic papillectomy was evaluated as a safe therapy.     

New indication for endoscopic treatment of colorectal carcinoma with submucosal invasion

BACKGROUND AND AIMS: Although an increasing number of early colorectal cancers (CRC) have been curatively treated by endoscopy, there have been no definitive criteria to decide the effectiveness of such therapy. We retrospectively analyzed clinicopathological factors to establish criteria for curative endoscopic treatment of early CRC. METHODS: First, risk factors of lymph node metastasis were analyzed in 171 patients who received surgery with postoperative histology of CRC submucosal invasion. The resultant new criteria were evaluated in another 60 patients who experienced endoscopic resection of CRC and surgery according to the current criteria most often used in Japan. RESULTS: In the first substudy, lymph node metastasis was present in 18 of 171 patients (10.5%). Lymphatic permeation, sprouting and infiltrative growth of cancer cells were identified as histological factors significantly related to lymph node metastasis, and observed in much higher rates when the depth of submucosal invasion was beyond 1,500 micron. The minimum depth with positive lymph nodes was 1,075 micron. In the second group of 60 patients, lymph node metastasis was recorded in none of nine patients who met our new criteria of complete endoscopic treatment: submucosal invasion below 1,500 micron in depth, and no lymphatic permeation, sprouting or infiltrative growth pattern on tumor histology. Lymph node metastasis was positive in three of the other cases who did not meet our new criteria. CONCLUSIONS: The present study showed that endoscopic treatment of early CRC may be considered complete when submucosal invasion beyond 1,500 micron, lymphatic permeation, sprouting, and infiltrating growth are all denied.     

Clinicopathological features associated with lymph node metastasis in early gastric cancer: Analysis of a single-institution experience in China

BACKGROUND:

An accurate assessment of potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the number of invasive procedures used in cancer therapy is critical for improving the patient’s quality of life.

OBJECTIVE:

To evaluate the clinicopathological features associated with lymph node metastasis of early gastric cancer in patients from a single institution in China.

METHODS:

A retrospective review of data from 410 patients surgically treated for early gastric cancer at the First Affiliated Hospital (Nanjing, China) between 1998 and 2007, was conducted. The clinicopathological variables associated with lymph node metastasis were evaluated.

RESULTS:

Lymph node metastasis was observed in 12.20% of patients. The macroscopic type, tumour size, location in the stomach, depth of gastric carcinoma infiltration, and presence of vascular or lymphatic invasion showed a positive correlation with the incidence of lymph node metastasis by univariate analysis. Multivariate analyses revealed histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion to be significantly and independently related to lymph node metastasis. The depth of gastric carcinoma infiltration was the strongest predictive factor for lymph node metastasis. For intramucosal cancer, tumour size was the unique risk factor for lymph node metastasis. For submucosal cancer, histological classification and tumour size were independent risk factors for lymph node metastasis.

CONCLUSIONS:

Histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion are independent risk factors for lymph node metastasis in patients with early gastric cancer in China. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible for highly selected cancers.     

Clinicopathologic features of ampullary carcinoma without jaundice

GOALS: To evaluate clinicopathological features of ampullary carcinoma without jaundice. BACKGROUND:: Obstructive jaundice is the most common symptom of patients with ampullary carcinoma. However, some patients with ampullary carcinoma do not have jaundice at the time of diagnosis. STUDY: Clinicopathologic findings of 23 patients with ampullary carcinoma showing no visible jaundice (serum total bilirubin <3.0 mg/dL) and 38 patients with ampullary carcinoma showing jaundice at the time of diagnosis were retrospectively compared. RESULTS: Fifteen of 23 patients with nonjaundiced ampullary carcinoma complained of fever and/or abdominal pain. Five asymptomatic patients were found to have a dilated bile duct on screening ultrasound or to have a tumor-like swelling of the papilla of Vater during routine upper gastrointestinal endoscopy. There was no significant difference in age, sex, size, macroscopic type, histologic type, rates of duodenal invasion, pancreatic invasion, and lymph node metastasis, and prognosis between the two groups. The cumulative 5-year and 10-year survival rates of nonjaundiced patients were 70.2% and 49.0%, compared with 33.6% and 29.4% of jaundiced patients. Ten of the 23 nonjaundiced ampullary carcinomas (43%) were in Stage I, whereas 4 of the 38 jaundiced ampullary carcinomas (11%) were in Stage I (P < 0.01). Mechanisms of nonjaundice in ampullary carcinoma were suspected to be determinant by the infiltrating pattern of the carcinoma to the lower portion of the bile duct. CONCLUSIONS: Mechanisms of nonjaundice in ampullary carcinoma might be determined by the infiltrating pattern of the carcinoma to the lower portion of the bile. As a greater number of nonjaundiced ampullary carcinomas were in an early stage, detection of them may provide an improved clinical outcome.     

Malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer

Malignant biliary obstruction generally results from primary malignancies of the pancreatic head, bile duct, gallbladder, liver, and ampulla of Vater. Metastatic lesions from other primaries to these organs or nearby lymph nodes are rarer causes of biliary obstruction. The most common primaries include renal cancer, lung cancer, gastric cancer, colorectal cancer, breast cancer, lymphoma, and melanoma. They may be difficult to differentiate from primary hepato-pancreato-biliary cancer based on imaging studies, or even on biopsy. There is also no consensus on the optimal method of treatment, including the feasibility and effectiveness of endoscopic intervention or surgery. A thorough review of the literature on pancreato-biliary metastases and malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer is presented. The diagnostic modality and clinical characteristics may differ significantly depending on the type of primary cancer. Different primaries also cause malignant biliary obstruction in different ways, including direct invasion, pancreatic or biliary metastasis, hilar lymph node metastasis, liver metastasis, and peritoneal carcinomatosis. Metastasectomy may hold promise for some types of pancreato-biliary metastases. This review aims to elucidate the current knowledge in this area, which has received sparse attention in the past. The aging population, advances in diagnostic imaging, and improved treatment options may lead to an increase in these rare occurrences going forward.