Long-term survival after hepatectomy for hepatic recurrence of carcinoma of the papilla of Vater

We present herein a rare case of a long‐term survivor after major hepatectomy performed for a metastatic liver tumor from carcinoma of the papilla of Vater. A 74‐year‐old man had undergone a pancreaticoduodenectomy for carcinoma of the papilla of Vater with obstructive jaundice, in April 1995. Histologically, an exposed mass‐forming type of tumor, measuring 40 × 30 mm, was composed of mucinous and papillary adenocarcinoma, invading into the muscularis propria of the duodenum, without lymph node metastases. The patient did not receive any type of chemotherapy. In September 1999, a solitary hepatic tumor, 3.5 cm in diameter, was detected in segment VIII of the liver by computed tomography. In November 1999, right hepatic lobectomy was carried out. The anterior and posterior portal pedicles were ligated and dissected in the hepatic parenchyma so as not to compromise the hepaticojejunostomy. After the hepatectomy, the patient was treated with low‐dose tegafur/uracil/cisplatin therapy for approximately 2 years. He has been doing well, without recurrence, for 5 years after the hepatectomy. Hepatectomy for hepatic metastases from carcinoma of the papilla of Vater is thought to be a useful surgical treatment in selected patients.     

Exceptional ultra-late recurrence of papilla Vater carcinoma after pancreaticoduodenectomy: two cases at 17 and 25 years

Curative resection does not always equate with long-term survival. Cancer of the papilla Vater can remain clinically quiescent for decades prior to regional or distant recurrence. Nevertheless, late and ultra-late recurrence (respectively 10 and 15 years after initial treatment) are exceptional events. This protracted disease-free interval challenges the concept of a "cure" for cancer of the papilla Vater. In the first case reported here, a 74-year-old female underwent pancreaticoduodenectomy in 1985 for cancer of the papilla Vater revealed histologically as a well-differentiated papillotubular adenocarcinoma, stage IA (UICC classification). Multiple hepatic recurrences were found 17 years after the operation; hepatic biopsy showed histologically well to moderately differentiated papillotubular adenocarcinoma. She died about 17.5 years after the original operation. The second case is that of an 82-year-old female who underwent pancreaticoduodenectomy in 1974 for cancer of the papilla Vater, histologically a well-differentiated adenocarcinoma, stage IA. In the 25.5 years after the operation, the cancer recurred at the choledochoduodenal anastomosis and involved the liver hilus. Autopsy showed histologically well to moderately differentiated adenocarcinoma at the locations indicated, together with lung and lymph node metastases. The ultra-late recurrences (>15 years) in these cases are highly exceptional and, to our knowledge, this is the first report of such recurrences in cancer of the papilla Vater. It can occur in any patient, with or without identifiable risk factors. Because cancer of the papilla Vater can recur in many prognostically favorable cases after prolonged disease-free intervals, the possibility of delayed recurrence should not be ignored.     

Surgical treatment for carcinoma of the papilla of vater

Eighty of 89 patients who underwent radical resection (resectability 89.9%) for carcinoma of the papilla of Vater between 1976 and 1992 were retrospectively reviewed. Seventy-three patients underwent pancreaticoduodenectomy (PD) and 7 underwent pylorus-preserving pancreaticoduodenectomy (PPPD). The postoperative mortality rate was only 3.8% (3 patients). The 3- and 5-year survival rates were 63.6% and 57.4%, respectively. Important factors influencing long-term survival were Stage (clinical stage = Stage), microscopic lymph node metastasis (n), duodenal wall invasion (d), vascular invasion (v), and the epithelium of origin. Early carcinoma of the papilla of Vater is defined as tumor in which invasion is limited within the papilla of Vater; in particular, carcinomatous invasion is within the muscle of Oddi (d₀) with n₀. PD and/or PPPD with radical lymph node dissection should be performed for carcinoma of the papilla of Vater, as these procedures can be performed with low morbidity and mortality.     

A case of hepatectomy for liver metastasis after pancreatoduodenectomy for carcinoma of ampulla of Vater]

After curative resection of carcinoma of ampulla of Vater, 5-year survival rate has been reported ranging from 40% to 60%. Two major causes of the treatment failure are local recurrence and liver metastasis. Liver metastases are often multiple and are associated with poor prognosis. There have been few reports on long-term survivors after hepatectomy for metastatic liver tumors from carcinoma of ampulla of Vater. We report a 42 year-old female patient with solitary hepatic metastasis from carcinoma of ampulla of Vater, which was successfully treated by hepatectomy 69 months after curative Whipple's operation. Histologic examination of the resected specimen had revealed stage IB moderately-differentiated, intestinal type adenocarcinoma (T2N0M0). Since neither local recurrence or distant metastasis were detected, the patient underwent liver segmentectomy. Histologic study confirmed the presence of metastatic liver tumor from carcinoma of ampulla of Vater. She is doing well without evidence of recurrence at 20 months after hepatectomy.     

Prognostic factors in patients with carcinoma of the papilla of Vater

BACKGROUND/AIMS: The prognosis after curative resection for patients with carcinoma of the papilla of Vater is relatively better than that for other peripancreatic cancer. However, prognostic factors after resection of the carcinoma have not been identified. METHODOLOGY: From 1983 to 1999, 16 patients with carcinoma of the papilla of Vater underwent standard pancreatoduodenectomy and dissection of regional lymph nodes. We followed the patients for 63 days to 17 years (median, 27 months) and analyzed clinicopathologic variables in relation to prognosis. RESULTS: The survival rate at 5 years was 50.5%. The morphologic factors predicting poor outcome were macroscopic ulcer formation and microscopic pancreatic, venous, or perineural invasion. Tumors with ulcer formation tended to infiltrate into the duodenum and pancreas, but not into veins or the perineural space. Eight of 16 patients died due to recurrence of the cancer; liver metastasis (n = 6) or peritoneal dissemination (n = 2). CONCLUSIONS: Patients with carcinoma of the papilla of Vater demonstrating ulcer formation or invasion into the pancreas, vein, or perineural space may benefit from adjuvant therapy to reduce the risk of liver metastasis. Careful observation is essential for liver metastasis or peritoneal dissemination after surgery; especially in patients with ulcer formation or venous invasion.     

Pancreaticoduodenectomy for metastatic ampullary and pancreatic tumors

BACKGROUND/AIMS: To report the clinical presentation, diagnosis and results of aggressive surgical management in patients with metastatic ampullary and pancreatic tumors. METHODOLOGY: Twelve patients underwent pancreaticoduodenectomy for ampullary or pancreatic metastases from January 1, 1987, to June 30, 1998, in 2 institutions. The primary cancer was renal cell carcinoma (n = 5), melanoma (n = 2), venous leiomyosarcoma (n = 1), carcinoid tumor (n = 1), colon carcinoma (n = 1), breast carcinoma (n = 1) and small-cell lung carcinoma (n = 1). The mean interval between primary treatment and metachronous pancreatic metastasis was 88 months. In 3 cases, pancreatic metastases were synchronous with the primary tumor. The main symptoms were jaundice (n = 8) and upper gastrointestinal tract bleeding (n = 2). The principal investigations were computed tomography scan (n = 9), arteriography (n = 7), duodenoscopy (n = 6) and fine-needle aspiration (n = 4). A correct preoperative diagnosis was made for 8 patients. RESULTS: In all cases, the pancreatic tumor was resected with intention to cure or provide useful palliation, using pancreaticoduodenectomy for isolated tumors (n = 11) or total pancreatectomy for multiple lesions (n = 1). Three out of 12 patents had positive lymph nodes, and the resection margin was free of disease in all cases. There was no postoperative mortality. Survival after pancreaticoduodenectomy averaged 26 months. Overall survival of patients undergoing pancreaticoduodenectomy was 35% at 2 years and 17% at 5 years. One patient is still alive more than 10 years after pancreaticoduodenectomy. CONCLUSIONS: Pancreaticoduodenectomy can be performed safely, representing a suitable option for resection in patients with symptomatic or late isolated pancreatic metastases in the absence of widely metastatic disease. The best indications are solitary metastases from renal cell carcinoma, sarcoma and neuroendocrine tumors. However, there is no evidence of survival benefit after pancreaticoduodenectomy for synchronous tumors or metachronous tumors from melanoma or colon carcinoma.     

Cephalic duodenopancreatectomy for endocrine tumor of the ampulla of Vater and of the minor papilla]

OBJECTIVES: Endocrine tumors of the ampulla of Vater and minor papilla are rare. This study describes the mode of presentation and evaluates the correlation between pathological features and prognosis. PATIENTS: Between 1982 and 1998, 6 patients (3 M, 3 F, mean age: 47.6 years, range: 36-58) for whom a diagnosis of endocrine tumor of the ampulla of Vater or minor papilla was made between 1982 and 1998 after histological examination of an operative specimen of pancreaticoduodenectomy. RESULTS: One patient was detected incidentally, two had a Zollinger-Ellison syndrome, two had pain and one had obstructive jaundice with pain. The tumor was located in the ampulla of Vater in 5 cases and at the minor papilla in 1 case. All patients underwent a pancreaticoduodenectomy, with histological examination showing tumor diameter varying from 5 to 40 mm and positive lymph nodes. Five patients had a well differentiated endocrine tumor and one a poorly differentiated tumor. All patients had positive Grimelius staining. The secretory profile analyzed by immunohistochemistry was heterogeneous. Median duration of follow-up was 51 months (range: 6 months-16 years) with all patients currently still alive. The patient with a poorly differentiated tumor had diffuse liver metastases, the others were disease-free. CONCLUSION: This study demonstrates the frequency of metastatic spread to adjacent lymph nodes and the inconsistent secretory profiles of these tumors. Pancreaticoduodenectomy may offer long term disease-free survival in well differentiated tumors, and such histology may be useful in advising on prognosis.     

Hepatectomy for liver metastasis from ampullary cancer after pancreatoduodenectomy

A 51-year-old Japanese woman with a solitary liver metastasis originating from a carcinoma of the ampulla of Vater was successfully treated by partial hepatectomy 19 months after curative pancreatoduodenectomy with lymphadenectomy. Histologic examination revealed a stage III well-differentiated tubular adenocarcinoma (pT2, pN1, and pM0). Postoperative serum concentrations of carcinoembryonic antigen increased exponentially to 133 ng/mL. The carcinoembryonic antigen doubling time was 63 days. Computed tomography and ultrasonography of the abdomen showed a solitary metastasis in segment VI of the liver. Since neither local recurrences nor other distant metastases were detected, the patient underwent partial hepatectomy. Histologic study confirmed the presence of a metastatic liver tumor from the ampullary carcinoma. The carcinoembryonic antigen levels returned to normal immediately after the partial hepatectomy. She was well without signs of recurrence 18 months after partial hepatectomy.     

Surgical management for metastatic liver tumors

BACKGROUND/AIMS: This study investigated the results of hepatectomy for multiple liver metastases and repeated hepatectomy for recurrent hepatic metastases. A proposed treatment strategy for liver metastases is discussed. METHODOLOGY: Fifty-seven consecutive cases of liver metastases were studied. The metastases originated from colon cancer (24 cases), rectal cancer (11 cases), gastric cancer (14 cases), or gastrointestinal stromal tumors (two cases). The other cases included one each of gastric carcinoid, carcinoma of the papilla of Vater, cystic duct cancer, esophageal cancer, choriocarcinoma and breast cancer. RESULTS: The overall 5-year survival rate for the 57 cases was 45.4%; there was no significant difference between patients with colon cancer (56.3%), rectal cancer (45.5%), or gastric cancer (41.6%). The cumulative 5-year survival rates for synchronous and metachronous metastases were 38.3% and 50.8%, respectively (difference not statistically significant; NS). The survival rates for single and multiple metastases were 56.0% and 31.3% (NS), and those for monolobar and bilobar metastases were 48.5% and 40.9% (NS), respectively. Concerning the operative procedure, the survival rates for partial resection and hemi-hepatectomy were 49.5% and 26.9%, respectively (NS). The survival rates for surgical margins <4mm and >5mm were 45.9% and 45.4%, respectively (NS), and those for single and repeat hepatectomy were 40.5% and 58.2% (NS). Preoperative portal embolization was performed in seven cases because of multiple metastases or a tumor located in a deeper site in the liver. There was no hospital death among the 57 cases. CONCLUSIONS: These results show that hepatectomy may offer longer survival, even in patients with multiple or bilobar metastases. Neither the operative procedure nor the size of the surgical margin had any influence on survival after hepatectomy. The prognosis was improved not only for metastases from colorectal cancer, but also for gastric cancer. An increased survival benefit was obtained by repeat hepatectomy for recurrent hepatic metastases. Preoperative portal embolization extended the indication for hepatectomy and provided postoperative safety.     

Hepatic resection for metastatic tumors from noncolorectal carcinoma

BACKGROUND/AIMS: The role of liver resection for hepatic metastases from noncolorectal carcinomas has yet to be clarified. The present study examines a single institutional experience of hepatic resection for noncolorectal metastases. METHODOLOGY: From January 1987 to March 1999, 14 patients underwent curative resection for liver metastases from noncolorectal carcinomas. Records of these patients were reviewed. RESULTS: Resections were performed for liver metastases from gastric cancers (n = 8), pancreatic cancers (n = 2), and cancers of bile duct, the papilla of Vater, kidney, and breast (n = 1, each). Six patients (5 with gastric cancers and 1 with pancreas cancer) presented with synchronous disease and 8 with metachronous disease. In the gastric cancer patients, there are 2 disease-free survivors (26 and 53 months) in the metachronous group, though all of the 5 patients with synchronous disease died within 29 months. All of the 4 patients with pancreatobiliary carcinomas died within 2 years. One case of breast cancer and another of renal cell cancer are alive without disease at 49 and 9 months, respectively. CONCLUSIONS: For metastases from gastric cancers, better survival after hepatic resection is expected in metachronous cases than in synchronous cases. Hepatic resection may afford little benefit for patients with liver metastases from pancretobiliary cancers.     

Surgical management of recurrence after resection of colorectal liver metastases

The optimal treatment for recurrent lesions after hepatectomy for colorectal liver metastases is controversial. We report the outcome of aggressive surgery for recurrent disease after the initial hepatectomy and the influence on quality of life of such treatment. Forty-five (70%) of the 64 surviving patients developed recurrence after the initial hepatectomy for liver metastases. The determinants of hepatic recurrence were the distribution and the number of liver metastases. Twenty-eight (62%) of patients with recurrence underwent resection. A second hepatectomy was performed in 20 patients, and a third hepatectomy was done in 5 patients. Ten patients with pulmonary metastasis underwent partial lung resection on 14 occasions, while resection of brain metastases was performed in 3 patients on 5 occasions. There were no operative deaths after resection of recurrent disease. The morbidity rate was 28% after repeat hepatectomy, 21% after pulmonary resection, and 0% after resection of brain metastasis. The Karnofsky performance status (PS) after the last surgery was not significantly different from that after the initial hepatectomy. The 3- and 5-year survival rates after the second hepatectomy were 54% and 14%, respectively. The 3-and 5-year survival rates of the patients undergoing resection of extrahepatic recurrence were both 17%. The survival rate after resection of recurrent disease (n=28) was significantly better than that of patients (n=17) with unresectable recurrence (P < 0.05). For the 66 patients with colorectal liver metastases, the 5-year survival rate after initial hepatectomy was 50%. The distribution and the number of liver metastases and the presence of extrahepatic disease, as single factors, significantly affected prognosis after the initial hepatectomy. Multivariate analysis revealed that only the presence of extrahepatic metastasis and a disease-free interval of less than 6 months were independent predictors of survival after the initial and second hepatectomy, respectively. It is concluded that aggressive surgery is an effective strategy for selected patients with recurrence after initial hepatectomy. Careful selection of candidates for repeat surgery will yield increased clinical benefit, including long-term survival.     

中山医院结直肠癌MDT讨论治疗策略分析

目的分析结直肠癌多学科诊疗团队（MDT）讨论后制定的治疗策略。 方法回顾性分析2010年7月至2019年2月复旦大学附属中山医院进行MDT讨论的结直肠癌患者的临床资料,对MDT讨论结果进行统计分析。 结果结直肠癌MDT总计为1 953例结直肠癌患者进行4 535人次讨论制定个体化治疗方案。其中,553例患者肝转移灶和111例患者肺转移灶被认为可切除。另有261位最初不可切除的结直肠癌肝转移患者,在接受系统化疗联合分子靶向以及介入等综合治疗后,转化为可切除,建议接受肝转移灶切除手术。实际上总计772位结直肠癌患者接受肝转移灶切除,其中同时性肝转移患者有581例,而接受结直肠癌原发灶和肝转移灶同步切除的患者有248例。肝切除手术中仅有87例患者（11.3%）实施解剖性肝切除,绝大多数实施非解剖性肝切除。肝转移灶切除手术中联合射频消融的有62例（8.0%）。术后病理提示R1切除的有18位（2.3%）。 结论复杂结直肠癌病例推荐行MDT讨论。扩展手术适应证、应用二步肝切除术、联合射频消融等局部毁损治疗可以扩大肝转移灶手术的适应人群。初始无法手术切除的患者,如状况耐受,建议给予强烈的个体化转化治疗,争取转化后手术切除。     

Small cell neuroendocrine carcinoma of the ampulla of Vater with foci of squamous differentiation: a case report

A 54-year-old woman with obstructive jaundice was found to have a 4-cm ulcerated, elevated tumor, located at the papilla of Vater by endoscopy and radiographic investigation. Based on a clinical diagnosis of carcinoma of the ampulla of Vater, a pylorus-preserving pancreaticoduodenectomy was performed. The histologic appearance of the lesion was identical to extrapulmonary small cell carcinoma, with diffuse proliferation of small, spindle-shaped, atypical tumor cells with numerous mitoses. Neuroendocrine differentiation was demonstrated by immunoreactivity with neuron-specific enolase (NSE) and Leu-7, and by the presence of dense core granules ultrastructurally. The tumor was composed mainly of small cell neuroendocrine carcinoma, and partially of an area of squamous differentiation, showing transition from one to the other. Histopathologic investigation disclosed direct invasion deep to the lamina propria, and infiltration of the pancreatic parenchyma, duodenum, and bile duct. Lymph node metastases were present in the superior pancreaticoduodenal chain. The patient died of liver metastases 8 months later. As in previously reported cases of small cell neuroendocrine carcinoma of the ampullary region, the present case showed extremely aggressive clinical behavior with early metastases resulting in fatal outcome.     

Unusual bony colorectal metastases in post-hepatometastasectomy patients

Colorectal cancer metastases occur predominantly in the liver, with extrahepatic sites being far less common and equally distributed in the lung, brain, skin, and bone. We report two cases of unusual bony metastases of colorectal cancer. A 55‐year‐old man underwent an abdominoperineal resection for a Dukes B carcinoma of the rectum, followed 17 months later by a right hemihepatectomy for metachronous liver metastases. He subsequently presented 11 months later with a solitary metastatic deposit in the mandible. Seven months after resection and reconstruction, he remained well and disease‐free. A 67‐year‐old man underwent a right hemicolectomy and right hemihepatectomy for carcinoma of the cecum and synchronous liver metastases. He presented 16 months later with a lesion suspicious of metastases in his clavicle. He subsequently died 18 months after his original operation. The prolongation of survival after hepatic metastasectomy results in the presentation of metastases at sites not commonly seen in colorectal malignancy. Postoperative surveillance after apparently curative hepatectomy should be directed to the evaluation of any unusual new symptoms.     

Total papillectomy for borderline malignant tumor of papilla of Vater

The therapies for treating tumors of the papilla of Vater remain controversial because accurate preoperative diagnosis is difficult. Treatments include endoscopic resection, pancreaticoduodenectomy and total papillectomy. We report the case of a 69-year-old man who underwent total papillectomy for a borderline malignant tumor of the papilla of Vater. In our institution, the decision to perform a total papillectomy for borderline malignant adenoma is based on whether it is intestinal type or pancreaticobiliary type. Carcinoma of the papilla of Vater is classified into two types: an intestinal type and a pancreaticobiliary type and the prognosis of the intestinal type is much better than that of the pancreaticobiliary type. We suggest that total papillectomy can be performed for an intestinal, borderline malignant tumor.     

Successful treatment of multiple lung metastases of hepatocellular carcinoma by combined chemotherapy with docetaxel, cisplatin and tegafur/uracil

We report the successful treatment of multiple lung metastases after hepatic resection for hepatocellular carcinoma （HCC） with combined docetaxel, cisplatin （CDDP）, and enteric-coated tegafur/uracil （UFT-E）. A 68-year-old man was diagnosed with multiple lung metastases of HCC 7 mo after partial hepatectomy for HCC. Oral UFT-E was given daily and docetaxel and CDDP were given intra-arterially （administered just before the bronchial arteries） every 2 wk via a subcutaneous injection port. One month after starting chemotherapy, levels of tumor marker, protein induced by vitamin K absence Ⅱ （PIVKA-Ⅱ ）, decreased rapidly, and after a further month, chest X-ray and computed tomography revealed the complete disappearance of multiple liver metastases. Two years after the combined chemotherapy, HCC recurred in the liver and was treated but no pulmonary recurrence occurred. In the absence of a standardized highly effective therapy, this combined chemotherapy with docetaxel, CDDP and UFT-E may be an attractive option for multiple lung metastases of HCC.     

Surgical treatment of pulmonary recurrence after hepatectomy for colorectal liver metastases

BACKGROUND/AIMS: Although pulmonary recurrence is frequent among the extrahepatic recurrences after hepatectomy, the efficacy of surgical treatment for pulmonary recurrence after hepatectomy has not been confirmed. Surgical resection of pulmonary recurrence after hepatectomy for colorectal metastases was reviewed retrospectively to evaluate the survival benefit. METHODOLOGY: From 1990 to 1995, 10 of the 17 patients with pulmonary recurrence after hepatectomy for colorectal metastases underwent surgical treatment. Ten patients underwent resection of pulmonary recurrence. RESULTS: Operative mortality was 0%, and a postoperative complication was observed in 1 patient after pulmonary metastasectomy. The overall 5-year survival rate after pulmonary metastasectomy was 10.0%, and the median survival was 21.7 (range: 2.4-77.9) months. One patient underwent resection two times for remnant lung recurrence after first lung metastasectomy, and is alive with no evidence of recurrence 77.9 months after the first pulmonary resection, and 50.7 months after the third pulmonary resection. In 3 patients with well-differentiated adenocarcinoma, the median survival time was 6.2 months (range: 2.4-9.7). The other hands, 7 patients with moderately differentiated adenocarcinoma have a longer median survival time of 29.2 months (range: 16.0-77.9). CONCLUSIONS: Pulmonary metastasectomy after hepatectomy for metastases from colorectal cancer is a safe treatment, and might offer prolonged survival for highly selected patients.     

The repeated hepatectomy for frequent recurrence of hepatic metastasis from gastrointestinal stromal tumor of the stomach

Although in recent years hepatic resection has become a safe procedure, there are few data on repeat liver resection for hepatic metastases from gastrointestinal stromal tumor. A 60-year-old Japanese man underwent partial gastrectomy and extended right hepatectomy for gastrointestinal stromal tumor of the stomach with liver metastasis. However, liver metastasis recurred at the interval of less than 1 year. Therefore, the patient underwent a total of six liver resections. The liver resections comprised four R0, one R1 and one R2 resection. To our knowledge, six times for liver resection performed on one patient is a maximum. This patient survived 43 months after the first surgery. Despite frequent recurrence of hepatic metastasis from gastrointestinal stromal tumor, repeated hepatectomy provides a survival benefit if complete removal of all tumorous masses appears possible.     

Nodal involvement as an indicator of postoperative liver metastasis in carcinoma of the papilla of Vater

Background/Purpose

Although lymph node metastatic involvement is one of the most important prognostic factors for carcinoma of the papilla of Vater, a detailed analysis of this factor in relation to prognosis has not been conducted.

Methods

From 1985 to 2003, 29 patients with carcinoma of the papilla of Vater underwent pancreaticoduodenectomy and dissection of regional lymph nodes at Yamagata University Hospital. We analyzed clinicopathologic variables in relation to prognosis and precisely evaluated nodal involvement in each patient to determine lymphatic flow. Furthermore, the relationship between recurrent site and nodal involvement was investigated.

Results

The overall survival rate was 55% at 5 years. The significant prognostic factors were morphological ulcer formation (P = 0.04), histological type (P = 0.03), nodal involvement (P = 0.002), and lymphatic invasion (P = 0.03). Multivariate analysis indicated no independent factor, but nodal involvement may be the strongest prognostic factor. The overall rate of nodal involvement was 41.4% (12 of 29 patients). The metastatic rates in the superior posterior pancreaticoduodenal lymph nodes, the inferior posterior pancreaticoduodenal lymph nodes, the superior mesenteric lymph nodes, and paraaortic lymph nodes were high (31.0%, 20.7%, 17.2%, and 13.8%, respectively). Patients with nodal involvement had a significantly higher rate of liver metastasis after surgery than those without it (P = 0.02). Ulcer formation and histological type were significantly correlated with nodal involvement (P = 0.05 and P = 0.002, respectively).

Conclusions

Nodal involvement is the most important prognostic factor in patients with carcinoma of the papilla of Vater. Patients with nodal involvement are at high risk of liver metastasis; therefore, adjuvant therapy may be necessary for the control of liver metastasis. Preoperative ulcer formation and histological type in the biopsy specimen are good indicators for extended lymph node dissection and adjuvant therapy, because these variables are correlated with nodal involvement. However, our data revealed only the sites of the positive nodes, without addressing the effect of extended lymph node dissection and adjuvant chemotherapy. To date, there has been reporting of extended lymph node dissection and adjuvant chemotherapy in patients with carcinoma of the papilla of Vater. Further studies will be necessary to resolve these problems.     

Malignant carcinoid tumor in the papilla of Vater: case report and review of 25 cases reported in Japan

Carcinoid tumors in the papilla of Vater are rare. We describe a 48-year-old male who was diagnosed with a tumor consisting of atypical cells in the papilla of Vater. He underwent curative resection of the tumor by pancreatico-duodenectomy (PD), with dissection of the regional lymph nodes. Microscopic examination revealed a metastatic lymph node in the pancreatic region. Characteristic findings on histopathological and electron microscopic studies led to the final diagnosis of malignant carcinoid tumor. It is clear from the literature that carcinoid tumors in the papilla of Vater metastasize to the regional lymph nodes and the liver. However, it has been difficult to preoperatively diagnose carcinoid tumor in the papilla of Vater. Therefore, if we observe atypical cells in the papilla of Vater, malignant carcinoid tumor should be considered. If this tumor is suspected, PD or pylorus-preserving PD, together with dissection of the regional lymph nodes, at least along the hepatoduodenal ligament, should be considered as the treatment of first choice.