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Surgical treatment of tumors of the ampulla of Vater
618
Journal of Gastrointestinal Surgery
Abstracts
Five specimens (19%) had multiple positive margins. In 7 specimens (26%), the only positive resection margins were the SMA or SMV/ PV. More limited pathologic assessment of only the pancreatic, CBD and posterior margins would have resulted in a positive margin rate of 19%. In this series, a total of 135 margins were evaluated of which 17 (13%) of them were positive, with the mesenteric margin (SMA or SMV/PV) accounting for 65% of microscopically positive margins. The mesenteric tissue is the most frequently positive resection margin in patients with pancreatic cancer undergoing pancreaticoduodenectomy. Furthermore, a limited examination would have failed to detect a positive SMA or SMV/PV margin in as many as 26% of patients. Due to the prognostic significance of microscopically involved margins (R1 resection) on clinical outcome, comprehensive examination to include the mesenteric margins is recommended.
311 THE EFFECT OF CISPLATIN INTRA-ARTERIAL INFUSION WITH RADIOTHERAPY AS A TREATMENT FOR UNRESECTABLE ADVANCED PANCREATIC CARCINOMA Yokota Tokuyasu, MD, Yuji Ishii, MD, Tatsuo Okubo, MD, Takeyuki Misawa, MD, Yuichi Ishida, MD, Yasuki Unemura, MD, Seiya Yoshida, MD, Kyonsu Son, MD, Hiroaki Shiba, MD, Ryouta Saito, MD, Susumu Kobayashi, MD, Yoji Yamazaki, MD, Katsuhiko Yanaga, MD, Jikei University School of Medicine, Tokyo, Japan Cisplatin has been reported to enhance the cell-killing effect of radiation. The purpose of this study was to evaluate the feasibility and effectiveness of radiotherapy combined with cisplatin arterial infusion in patients with unresectable advanced pancreatic carcinoma. Between June 1999 and December 2003, thirty-three patients (Stage IVa without distant metastasis: n ⫽ 19, Stage IVb with distant metastasis: n ⫽ 14, Japan Pancreas Society: the fifth edition) from our facility were enrolled in this study. Pretreatment staging included chest Xray, ultrasonography, dynamic computed tomography, and angiography of the abdomen. Causes of unresectability consisted of local invasion (obstruction or extensive invasion of the portal vein and/or tumor encasement of the celiac or superior mesenteric artery) and liver metastasis. The patients studied were treated with external beam radiation (1.8-2.0 Gy/fraction, 5 fractions/week, total: 40-50 Gy), cisplatin intra-arterial infusion (5 mg/m2/day intra-arterial infusion just before each radiation fraction) and 5-FU intravenous infusion (250 mg/m2/day). Prognosis was compared with a control group of 63 patients who had undergone pancreatectomy for stage IVa and stage IVb of pancreatic carcinoma. The major toxicity of cisplatin intraarterial infusion with radiotherapy was nausea (2/33, 6%). In patients treated by intra-arterial infusion with radiotherapy, the median survival time of the stage IVa group and the stage IVb group was
12.9 ⫾ 4.1 months (M) and 5.9 ⫾ 0.8 M, respectively, which was not statistical by different from the control groups (13.6 ⫾ 6.3 M and 6.0 ⫾ 1.1 M, respectively). The 1-year survival rate was 42% (8/19) and 21% (3/14), respectively, which was comparable to the control groups (42% [21/50] and 15% [2/13], respectively). This arterial chemo-radiation regimen is effective for locally advanced pancreatic carcinoma with acceptable toxicity.
312 SURGICAL TREATMENT OF TUMORS OF THE AMPULLA OF VATER Frank Treitschke, MD, M. H. Schoenberg, MD, Red Cross Hospital Munich, Mu¨nchen, Germany Tumors of the ampulla of Vater are rare. Ampullary carcinoma have a significantly higher resectability rate and better prognosis than other carcinoma originating in the periampullary area. The most authors suggest radical resection as treatment of choice for carcinoma of the ampulla. Alternatively some investigators have recommended local resection to reduce treatment related mortality and morbidity rates. Adequate treatment of benign tumors of the ampulla is still a matter of debate. Due to a suspected adenoma-carcinoma sequence some argue that partial pancreaticoduodenectomy is mandatory. Others believe that local excision is sufficient in these patients. The purpose of this prospective study was to evaluate clinical course, surgical management, and outcome of patients operated for malignant and benign tumors of the ampulla of Vater; 202 consecutive patients undergoing surgical treatment for ampullary tumors between 1983 and 2003 were observed; 69% of all tumors were malignant, the remaining were benign neoplasm (n ⫽ 64); and 138 patients with ampullary adenocarcinoma were treated by classical pancreaticoduodenectomy (PR) in 36% and pylorus-preserving resection (PPPR) in 31%. Ampullectomy was performed in elderly patients with high cardiac risk (8%). Palliative bypass procedures were performed in 25%. 58 patients suffering from a benign tumor underwent ampullectomy. Due to macroscopical appearance suspicious for a malignant tumor, PPPR was performed in 6 cases for benign lesions. 72% of all patients with benign neoplasm exhibited a tubulovillous or villous adenoma with medium or severe degree of dysplasia. Hospital mortality for all resected patients was 2.6%. The 1-, 3-, and 5-year survival after radical resection for patients with adenocarcinoma was 83.1%, 62.2%, and 53.8%, respectively. 62 patients with benign neoplasm are still alive without evidence of recurrent disease (97%). Radical resection for ampullary cancer can be performed with a low mortality and morbidity. PPPR is the surgical treatment of choice for carcinomas of the ampulla of vater. Ampullectomy is an adequate procedure in treating benign ampullary lesions. The decision-making should be based on pre- and even more eminent intraoperative frozen section histology. If the histology is uncertain PPPR should be performed
Journal of Gastrointestinal Surgery
Abstracts
Five specimens (19%) had multiple positive margins. In 7 specimens (26%), the only positive resection margins were the SMA or SMV/ PV. More limited pathologic assessment of only the pancreatic, CBD and posterior margins would have resulted in a positive margin rate of 19%. In this series, a total of 135 margins were evaluated of which 17 (13%) of them were positive, with the mesenteric margin (SMA or SMV/PV) accounting for 65% of microscopically positive margins. The mesenteric tissue is the most frequently positive resection margin in patients with pancreatic cancer undergoing pancreaticoduodenectomy. Furthermore, a limited examination would have failed to detect a positive SMA or SMV/PV margin in as many as 26% of patients. Due to the prognostic significance of microscopically involved margins (R1 resection) on clinical outcome, comprehensive examination to include the mesenteric margins is recommended.
311 THE EFFECT OF CISPLATIN INTRA-ARTERIAL INFUSION WITH RADIOTHERAPY AS A TREATMENT FOR UNRESECTABLE ADVANCED PANCREATIC CARCINOMA Yokota Tokuyasu, MD, Yuji Ishii, MD, Tatsuo Okubo, MD, Takeyuki Misawa, MD, Yuichi Ishida, MD, Yasuki Unemura, MD, Seiya Yoshida, MD, Kyonsu Son, MD, Hiroaki Shiba, MD, Ryouta Saito, MD, Susumu Kobayashi, MD, Yoji Yamazaki, MD, Katsuhiko Yanaga, MD, Jikei University School of Medicine, Tokyo, Japan Cisplatin has been reported to enhance the cell-killing effect of radiation. The purpose of this study was to evaluate the feasibility and effectiveness of radiotherapy combined with cisplatin arterial infusion in patients with unresectable advanced pancreatic carcinoma. Between June 1999 and December 2003, thirty-three patients (Stage IVa without distant metastasis: n ⫽ 19, Stage IVb with distant metastasis: n ⫽ 14, Japan Pancreas Society: the fifth edition) from our facility were enrolled in this study. Pretreatment staging included chest Xray, ultrasonography, dynamic computed tomography, and angiography of the abdomen. Causes of unresectability consisted of local invasion (obstruction or extensive invasion of the portal vein and/or tumor encasement of the celiac or superior mesenteric artery) and liver metastasis. The patients studied were treated with external beam radiation (1.8-2.0 Gy/fraction, 5 fractions/week, total: 40-50 Gy), cisplatin intra-arterial infusion (5 mg/m2/day intra-arterial infusion just before each radiation fraction) and 5-FU intravenous infusion (250 mg/m2/day). Prognosis was compared with a control group of 63 patients who had undergone pancreatectomy for stage IVa and stage IVb of pancreatic carcinoma. The major toxicity of cisplatin intraarterial infusion with radiotherapy was nausea (2/33, 6%). In patients treated by intra-arterial infusion with radiotherapy, the median survival time of the stage IVa group and the stage IVb group was
12.9 ⫾ 4.1 months (M) and 5.9 ⫾ 0.8 M, respectively, which was not statistical by different from the control groups (13.6 ⫾ 6.3 M and 6.0 ⫾ 1.1 M, respectively). The 1-year survival rate was 42% (8/19) and 21% (3/14), respectively, which was comparable to the control groups (42% [21/50] and 15% [2/13], respectively). This arterial chemo-radiation regimen is effective for locally advanced pancreatic carcinoma with acceptable toxicity.
312 SURGICAL TREATMENT OF TUMORS OF THE AMPULLA OF VATER Frank Treitschke, MD, M. H. Schoenberg, MD, Red Cross Hospital Munich, Mu¨nchen, Germany Tumors of the ampulla of Vater are rare. Ampullary carcinoma have a significantly higher resectability rate and better prognosis than other carcinoma originating in the periampullary area. The most authors suggest radical resection as treatment of choice for carcinoma of the ampulla. Alternatively some investigators have recommended local resection to reduce treatment related mortality and morbidity rates. Adequate treatment of benign tumors of the ampulla is still a matter of debate. Due to a suspected adenoma-carcinoma sequence some argue that partial pancreaticoduodenectomy is mandatory. Others believe that local excision is sufficient in these patients. The purpose of this prospective study was to evaluate clinical course, surgical management, and outcome of patients operated for malignant and benign tumors of the ampulla of Vater; 202 consecutive patients undergoing surgical treatment for ampullary tumors between 1983 and 2003 were observed; 69% of all tumors were malignant, the remaining were benign neoplasm (n ⫽ 64); and 138 patients with ampullary adenocarcinoma were treated by classical pancreaticoduodenectomy (PR) in 36% and pylorus-preserving resection (PPPR) in 31%. Ampullectomy was performed in elderly patients with high cardiac risk (8%). Palliative bypass procedures were performed in 25%. 58 patients suffering from a benign tumor underwent ampullectomy. Due to macroscopical appearance suspicious for a malignant tumor, PPPR was performed in 6 cases for benign lesions. 72% of all patients with benign neoplasm exhibited a tubulovillous or villous adenoma with medium or severe degree of dysplasia. Hospital mortality for all resected patients was 2.6%. The 1-, 3-, and 5-year survival after radical resection for patients with adenocarcinoma was 83.1%, 62.2%, and 53.8%, respectively. 62 patients with benign neoplasm are still alive without evidence of recurrent disease (97%). Radical resection for ampullary cancer can be performed with a low mortality and morbidity. PPPR is the surgical treatment of choice for carcinomas of the ampulla of vater. Ampullectomy is an adequate procedure in treating benign ampullary lesions. The decision-making should be based on pre- and even more eminent intraoperative frozen section histology. If the histology is uncertain PPPR should be performed