Carcinoma of the Ampulla of Vater This tumor arises within 2 cm of the distal end of the common bile duct, and is mainly (90%) an adenocarcinoma. Locoregional lymph nodes are commonly involved (50%), and the liver is the most frequent site for metastases. The commonest clinical presentation is jaundice, and many patients also have pruritus, weight loss, and epigastric pain. Initial evaluation is performed with an abdominal ultrasound to assess vascular involvement, biliary dilatation, and liver lesions. This is followed by a CT scan, or MRI and especially MRCP. The most effective therapy is resection by pylorus-sparing pancreaticoduodenectomy,. | Chapter 088. Hepatocellular Carcinoma Part 11 Carcinoma of the Ampulla of Vater This tumor arises within 2 cm of the distal end of the common bile duct and is mainly 90 an adenocarcinoma. Locoregional lymph nodes are commonly involved 50 and the liver is the most frequent site for metastases. The commonest clinical presentation is jaundice and many patients also have pruritus weight loss and epigastric pain. Initial evaluation is performed with an abdominal ultrasound to assess vascular involvement biliary dilatation and liver lesions. This is followed by a CT scan or MRI and especially MRCP. The most effective therapy is resection by pylorus-sparing pancreaticoduodenectomy an aggressive procedure resulting in better survival rates than local resection. Survival rates are 25 at 5 years in operable patients with involved lymph nodes and 50 in patients without involved nodes. Unlike CCC 80 of patients are thought to be resectable at diagnosis. Adjuvant chemotherapy or radiotherapy has not been shown to be useful in enhancing survival. For metastatic tumors chemotherapy is currently experimental. Tumors Metastatic to the Liver These are predominantly from colon pancreas and breast primary tumors but can originate from any organ primary. Ocular melanomas are prone to liver metastasis. Tumor spread to the liver normally carries a poor prognosis for that tumor type. Colorectal and breast hepatic metastases were previously treated with continuous hepatic arterial infusion chemotherapy. However more effective systemic drugs for these cancers especially the addition of oxaliplatin to colorectal cancer regimens have reduced the use of hepatic artery infusion therapy. In a large randomized study of systemic versus infusional plus systemic chemotherapy for resected colorectal metastases to the liver the patients receiving infusional therapy had no survival advantage mainly due to extrahepatic tumor spread. 90Yttrium resin beads are approved in the United States for treatment .
