Ampullary carcinoma, also known as carcinoma of the ampulla of Vater or ampullary cancer, is an infrequent type of cancer that develops in the ampulla of Vater. The ampulla of Vater is a small, muscular structure located where the common bile duct and pancreatic duct join and empty into the duodenum, the first part of the small intestine.
Ampullary carcinoma is a type of gastrointestinal cancer, and it is considered a subset of periampullary cancers, including tumors arising from the pancreas, bile ducts, and duodenum. It accounts for only minute percentage of all gastrointestinal malignancies.
The exact cause of ampullary carcinoma is unknown, but several risk factors have been identified. These include:
Age: The risk of developing ampullary carcinoma increases with age, with majority cases occurring in individuals over 60.
Chronic inflammation: Conditions that cause chronic inflammation of the bile ducts or pancreas, such as primary sclerosing cholangitis or chronic pancreatitis, may increase the risk.
Genetic factors: Some hereditary conditions, such as familial adenomatous polyposis (FAP) and Lynch syndrome (hereditary non-polyposis colorectal cancer), are associated with an increased risk of ampullary carcinoma.
Smoking: Cigarette smoking has been identified as a risk factor for ampullary carcinoma.
Symptoms of ampullary carcinoma can vary but might include jaundice, abdominal pain, unexplained weight loss, nausea, vomiting, changes in bowel habits, and fatigue. These symptoms can be nonspecific and mimic other digestive disorders, making the diagnosis challenging.
Epidemiology
Ampullary carcinoma is relatively rare tumor, constituting nearly 0.2% of all gastrointestinal tract (GIT) malignancies and around 7% of periampullary carcinoma in the American States. A comprehensive analysis of data from the Surveillance, Epidemiology, and End Results program identified 6,803 patients diagnosed with ampullary cancer from 2004 to 2013 and the annual incidence of ampullary carcinoma has remained relatively stable since 2004.
A recent epidemiologic study conducted in the Netherlands revealed an enhance in the incidence rate of ampullary cancer over time. The study found that the incidence rate rose from 0.59 per 100,000 individuals in the period of 1989-1995 to 0.68 per 100,000 individuals in the period of 2010-2016. Furthermore, in patients diagnosed with the non-metastatic ampullary disease, the five-year overall survival rate demonstrated improvement. It enhanced from 19.8% in the years 1989-1995 to 29.1% in the years 2010-2016.
Mortality
Historically, the reported operative mortality rate for ampullary cancer was nearly 20%. However, in recent years, several medical centers have reported larger series with significantly lower perioperative mortality rates, typically around 5%.
In a population-based analysis conducted in 2008, involving 1,301 individuals who underwent resection, the perioperative mortality rate was found to be 7.6%. This suggests a notable improvement in surgical outcomes. Additionally, the 5-year survival rate for these patients was reported as 37%.
Morbidity
The surgery for ampullary cancer is associated with a considerable morbidity rate, estimated to be around 65%. In certain series, approximately 13% of patients require a repeat laparotomy to address complications arising from the procedure.
Race
Due to the relative rarity of ampullary carcinoma, investigations regarding the prevalence trends across diverse ethnicities have not been undertaken.
Sex
It is more common in the men.
Anatomy
Pathophysiology
The pathophysiology of ampullary carcinoma involves the abnormal growth and proliferation of cells in the ampulla of Vater, which can lead to the formation of a cancerous tumor. The exact mechanisms underlying the development of ampullary carcinoma are not fully understood, but several factors contribute to its pathophysiology.
Genetic alterations: Ampullary carcinoma is associated with genetic mutations that disrupt normal cellular processes. These mutations can occur spontaneously or may be inherited in some cases. Specific genetic alterations, like mutations in the APC gene (associated with familial adenomatous polyposis) or DNA mismatch repair genes, have been implicated in the development of ampullary carcinoma.
Chronic inflammation: Chronic inflammation of the ampulla, bile ducts, or pancreas is believed to play a role in the pathophysiology of ampullary carcinoma. Conditions such as primary sclerosing cholangitis and chronic pancreatitis can cause persistent inflammation, leading to cellular damage and the subsequent development of cancer.
Tumor formation: Ampullary carcinoma typically arises from the epithelial cells lining the ampulla of Vater. The exact sequence of events leading to tumor formation has yet to be fully elucidated. However, it involves genetic and molecular changes, including accumulating DNA mutations, dysregulation of cell cycle control, and alterations in cellular signaling pathways.
Tumor invasion and metastasis: As ampullary carcinoma progresses, cancer cells can invade surrounding tissues and spread to regional lymph nodes or distant organs. The process of metastasis involves the detachment of cancer cells from the primary tumor, their entry into the bloodstream or lymphatic system, and colonization at distant sites. The exact mechanisms underlying ampullary carcinoma cells’ invasiveness and metastatic potential are complex and multifactorial.
The consequences of ampullary carcinoma on the normal physiological functions of the ampulla of Vater and adjacent structures depend on the tumor’s size, location, and extent. Common complications include obstruction of the bile duct or pancreatic duct, leading to symptoms such as jaundice, abdominal pain, and digestive disturbances.
Additionally, tumor growth can cause compression and invasion of surrounding structures, further exacerbating symptoms and potentially affecting organ function. Understanding the pathophysiology of ampullary carcinoma is crucial for developing targeted therapies and improving diagnostic and treatment strategies.
Etiology
The etiology of ampullary carcinoma, or carcinoma of the ampulla of Vater, is multifactorial, involving genetic, environmental, and lifestyle factors. While the exact cause of ampullary carcinoma is not fully understood, Certain risk factors have been identified:
Age: Ampullary carcinoma is more commonly diagnosed in individuals over 60, with the incidence increasing with advancing age.
Genetic factors: Certain hereditary conditions and genetic syndromes are associated with an increased risk of ampullary carcinoma. These include familial adenomatous polyposis (FAP), Lynch syndrome (hereditary non-polyposis colorectal cancer), and Peutz-Jeghers syndrome. These genetic conditions predispose individuals to develop gastrointestinal cancers, including ampullary carcinoma.
Chronic inflammation: Chronic inflammation of the ampulla, bile ducts, or pancreas is believed to contribute to the development of ampullary carcinoma. Conditions like primary sclerosing cholangitis, chronic pancreatitis, and choledochal cysts can cause persistent inflammation, leading to cellular damage and an increased risk of cancer development.
Gallstone disease: Gallstones have been associated with an increased risk of ampullary carcinoma. Gallstones can cause inflammation and obstruction of the bile ducts, potentially leading to chronic inflammation and subsequent carcinogenesis.
Smoking: Cigarette smoking is a recognized risk factor for various cancers, including ampullary carcinoma. Smoking is thought to promote cancer development by introducing carcinogens into the body, leading to DNA damage and the initiation of malignant transformation.
Pancreaticobiliary maljunction: This congenital anomaly involves the abnormal union of the pancreatic and bile ducts outside the duodenal wall. It can result in the reflux of pancreatic juices into the biliary system, leading to chronic inflammation and an increased risk of ampullary carcinoma.
Dietary factors: Some studies suggest that a diet rich in fat and a small quantity of fruits and vegetables may enhance the risk of ampullary carcinoma.
Genetics
Prognostic Factors
Prognostic factors are variables or characteristics that can help predict the likely outcome or prognosis for individuals diagnosed with ampullary carcinoma. These factors can assist in determining the appropriate treatment approach and provide insights into disease progression and overall survival rates. The prognostic factors of ampullary carcinoma include:
Tumor stage: At the time of diagnosis, the stage of ampullary carcinoma is one of the most significant prognostic factors. Staging is depend on the extent of tumor invasion, involvement of nearby lymph nodes, and presence of distant metastasis—generally, the earlier the tumor stage, the better the prognosis.
Tumor size and extent: The size of the tumor and its extent of invasion into surrounding tissues play a role in determining the prognosis. Smaller, localized tumors generally have a better prognosis than larger, more invasive tumors.
Lymph node involvement: The existence or absence of cancer cells in the regional lymph nodes is an important prognostic factor. The extend of cancer to the lymph nodes indicates a higher likelihood of disease progression and a worse prognosis.
Histological grade: The histological grade refers to the microscopic appearance of cancer cells under a microscope and their degree of differentiation. Well-differentiated tumors, which resemble normal cells more closely, tend to have a better prognosis than poorly differentiated or undifferentiated tumors.
Resectability: The surgical resectability of the tumor is a crucial factor in determining the prognosis. If the tumor can be completely removed through surgery, it generally improves the chances of long-term survival.
Perineural invasion: Cancer cells invading the nerves in the surrounding tissues are associated with a worse prognosis. Perineural invasion indicates a higher risk of local recurrence and distant metastasis.
Vascular invasion: Cancer cells’ involvement of blood vessels or lymphatic channels is associated with a poorer prognosis. Vascular invasion increases the risk of distant metastasis and limits treatment options.
Molecular markers: Various molecular markers, such as genetic mutations or protein expression patterns, have been investigated as potential prognostic factors in ampullary carcinoma. For example, genetic alterations, such as KRAS mutations or overexpression of proteins like HER2/neu, may impact prognosis and guide targeted therapies.
Patient factors: Factors specific to the individual, such as age, overall health status, and comorbidities, can influence the prognosis of ampullary carcinoma. Generally, younger patients with better overall health tend to have better outcomes.
Clinical History
Clinical history
The clinical presentation of ampullary carcinoma can vary among individuals, and the symptoms and signs may depend on various factors, such as the tumor’s size, location, and stage. Here are the typical clinical features associated with ampullary carcinoma:
Age group: Ampullary carcinoma is more commonly diagnosed in individuals over 60.
Physical Examination
Physical examination
The physical examination findings in individuals with ampullary carcinoma can be variable, and some may not exhibit any specific physical signs. However, a thorough examination may reveal specific findings that can raise suspicion of ampullary carcinoma. Here are some aspects that may be evaluated during a physical examination:
Jaundice: Yellowing of the skin and sclera (the white part of the eyes) may be observed in individuals with obstructive jaundice due to ampullary carcinoma. This can be assessed by examining the skin and conjunctiva.
Abdominal tenderness: Palpation of the abdomen may reveal tenderness or discomfort, particularly in the upper abdomen, which can be associated with a tumor or inflammation.
Abdominal mass: A palpable mass or swelling may sometimes be felt in the upper abdomen. This may suggest a locally advanced ampullary carcinoma or the presence of associated lymphadenopathy.
Hepatomegaly or splenomegaly: In advanced cases or if there is liver or spleen involvement, enlargement of these organs may be detected on abdominal palpation.
Lymphadenopathy: Enlarged lymph nodes in the abdomen or neck may be palpable. The presence of enlarged lymph nodes might indicate regional spread of the cancer.
Signs of chronic liver disease: In individuals with underlying liver disease, like primary sclerosing cholangitis or cirrhosis, signs of chronic liver disease, such as spider nevi (spider-like blood vessels), palmar erythema (reddening of the palms), or ascites (accumulation of fluid in the abdomen), may be evident.
Age group
Associated comorbidity
Associated comorbidity or activity:
No specific comorbidity or activity is directly associated with the development of ampullary carcinoma. However, individuals with certain conditions, such as primary sclerosing cholangitis or chronic pancreatitis, may have an enhanced risk of developing this type of cancer.
Associated activity
Acuity of presentation
Acuity of presentation:
The presentation of ampullary carcinoma can vary in acuity. In certain cases, the symptoms may develop gradually over time, while in others, they may appear suddenly.
Common signs and symptoms of ampullary carcinoma include:
Jaundice: It is the yellowing of the skin and eyes due to the tumor’s bile duct obstruction. This may be accompanied by dark urine and pale stools.
Abdominal pain: Pain or discomfort in the upper abdomen, which may be persistent or intermittent. The pain can be mild-severe and may worsen after eating.
Unexplained weight loss: Significant and unintentional weight loss might occur due to a combination of factors like decreased appetite, malabsorption, and metabolic changes associated with cancer.
Nausea and vomiting: These symptoms may result from bile duct obstruction or impaired digestion due to the tumor’s location near the pancreatic duct.
Changes in bowel habits: Some individuals might experience changes in bowel movements, like diarrhea or pale, greasy stools, due to impaired digestion or blockage of the pancreatic duct.
Fatigue: Generalized weakness and fatigue can occur due to underlying cancer and associated metabolic changes.
Anemia: Ampullary carcinoma can cause chronic blood loss, leading to anemia, manifesting as fatigue, weakness, and shortness of breath.
It is key to note that the clinical presentation of ampullary carcinoma can overlap with other conditions affecting the gastrointestinal tract, making the diagnosis challenging.
Differential Diagnoses
Differential Diagnosis
The differential diagnosis of ampullary carcinoma involves considering other conditions that can exist with similar symptoms or findings. Certain conditions that may be included in the differential diagnosis of ampullary carcinoma are:
Benign ampullary tumors: Non-cancerous tumors of the ampulla, such as adenomas or hamartomas, can present with symptoms similar to ampullary carcinoma. These tumors can cause biliary obstruction, jaundice, and abdominal pain. Differentiating between benign and malignant ampullary tumors often requires histological examination of a biopsy sample.
Pancreatic cancer: Pancreatic cancer can sometimes involve Vater’s ampulla and cause symptoms similar to ampullary carcinoma. Imaging studies and biopsies may be necessary to distinguish between the two conditions.
Biliary stones: Obstruction of the bile duct due to gallstones can result in symptoms such as jaundice, abdominal pain, and changes in bowel movements. An abdominal ultrasound or other imaging modalities can help identify the presence of gallstones.
Chronic pancreatitis: Chronic pancreas inflammation can lead to symptoms similar to ampullary carcinoma, including abdominal pain, jaundice, and weight loss. Imaging tests and pancreatic enzyme levels may aid in differentiation.
Cholangiocarcinoma: This is cancer that originates in the bile ducts. It can sometimes present with similar symptoms as ampullary carcinoma due to obstruction of the bile duct. Imaging studies, such as MRCP (magnetic resonance cholangiopancreatography) and biopsy, may be necessary to differentiate between the two conditions.
Duodenal adenocarcinoma: Adenocarcinoma of the duodenum, the first part of the small intestine, can present with symptoms similar to ampullary carcinoma. Endoscopic examination and biopsy can help differentiate between the two.
Pancreatic neuroendocrine tumors: These tumors arise from the hormone-producing cells of the pancreas. Depending on the location, they can present symptoms similar to ampullary carcinoma. Imaging studies and histopathological analysis can aid in distinguishing between the two conditions.
Choledocholithiasis: Obstruction of the common bile duct due to stones can cause symptoms resembling ampullary carcinoma. Imaging tests, such as abdominal ultrasound or endoscopic retrograde cholangiopancreatography (ERCP), can help identify the presence of stones.
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Treatment
The treatment of ampullary carcinoma typically involves a multidisciplinary approach and may include a combination of surgery, chemotherapy, radiation therapy, and supportive care. The specific treatment options depend on various factors, including the stage of cancer, the overall health of the individual, and individualized treatment plans. Here is an overview of the different treatment modalities and the phase of management involved:
Modification of environment:
Lifestyle modifications: While there are no specific environmental modifications for ampullary carcinoma, maintaining a healthy lifestyle, together with a balanced diet, regular exercise, can contribute to overall well-being and support the individual during treatment.
Administration of a pharmaceutical agent:
Chemotherapy: Systemic chemotherapy may be recommended before or after surgery to help shrink the tumor, destroy cancer cells that may have spread, or improve survival rates. Commonly used chemotherapy regimens for ampullary carcinoma include gemcitabine and cisplatin.
Targeted therapy: In some cases, therapies targeting molecular abnormalities in cancer cells, such as HER2-targeted therapy or EGFR inhibitors, may be utilized. Genetic testing of the tumor can help guide the selection of targeted therapies.
Intervention with a procedure:
Surgery: The surgical resection is the primary treatment for ampullary carcinoma whenever feasible. The objective is to eliminate the tumor and surrounding tissues, such as pancreaticoduodenectomy (Whipple procedure).
Endoscopic interventions: In some cases, endoscopic procedures, such as endoscopic ampullectomy or endoscopic stenting, may relieve bile duct obstruction and alleviate symptoms, particularly in individuals who are not surgical candidates or for palliative purposes.
Phase of management:
Initial diagnosis and staging: This phase involves a comprehensive evaluation, including imaging tests (e.g., CT scan, MRI, endoscopic ultrasound) and pathological examination (biopsy) to determine the cancer stage.
Curative intent: The primary goal for individuals with resectable tumors is complete surgical removal of the tumor with negative margins. Surgery may be followed by adjuvant chemotherapy to reduce the risk of recurrence.
Palliative care: In cases where the tumor is unresectable or advanced, the focus shifts to palliative care. This involves managing symptoms, such as pain, jaundice, and improving quality of life. Palliative treatments may include stenting to relieve bile duct obstruction, pain management, nutritional support, and emotional support.
Ampullary carcinoma, also known as carcinoma of the ampulla of Vater or ampullary cancer, is an infrequent type of cancer that develops in the ampulla of Vater. The ampulla of Vater is a small, muscular structure located where the common bile duct and pancreatic duct join and empty into the duodenum, the first part of the small intestine.
Ampullary carcinoma is a type of gastrointestinal cancer, and it is considered a subset of periampullary cancers, including tumors arising from the pancreas, bile ducts, and duodenum. It accounts for only minute percentage of all gastrointestinal malignancies.
The exact cause of ampullary carcinoma is unknown, but several risk factors have been identified. These include:
Age: The risk of developing ampullary carcinoma increases with age, with majority cases occurring in individuals over 60.
Chronic inflammation: Conditions that cause chronic inflammation of the bile ducts or pancreas, such as primary sclerosing cholangitis or chronic pancreatitis, may increase the risk.
Genetic factors: Some hereditary conditions, such as familial adenomatous polyposis (FAP) and Lynch syndrome (hereditary non-polyposis colorectal cancer), are associated with an increased risk of ampullary carcinoma.
Smoking: Cigarette smoking has been identified as a risk factor for ampullary carcinoma.
Symptoms of ampullary carcinoma can vary but might include jaundice, abdominal pain, unexplained weight loss, nausea, vomiting, changes in bowel habits, and fatigue. These symptoms can be nonspecific and mimic other digestive disorders, making the diagnosis challenging.
Ampullary carcinoma is relatively rare tumor, constituting nearly 0.2% of all gastrointestinal tract (GIT) malignancies and around 7% of periampullary carcinoma in the American States. A comprehensive analysis of data from the Surveillance, Epidemiology, and End Results program identified 6,803 patients diagnosed with ampullary cancer from 2004 to 2013 and the annual incidence of ampullary carcinoma has remained relatively stable since 2004.
A recent epidemiologic study conducted in the Netherlands revealed an enhance in the incidence rate of ampullary cancer over time. The study found that the incidence rate rose from 0.59 per 100,000 individuals in the period of 1989-1995 to 0.68 per 100,000 individuals in the period of 2010-2016. Furthermore, in patients diagnosed with the non-metastatic ampullary disease, the five-year overall survival rate demonstrated improvement. It enhanced from 19.8% in the years 1989-1995 to 29.1% in the years 2010-2016.
Mortality
Historically, the reported operative mortality rate for ampullary cancer was nearly 20%. However, in recent years, several medical centers have reported larger series with significantly lower perioperative mortality rates, typically around 5%.
In a population-based analysis conducted in 2008, involving 1,301 individuals who underwent resection, the perioperative mortality rate was found to be 7.6%. This suggests a notable improvement in surgical outcomes. Additionally, the 5-year survival rate for these patients was reported as 37%.
Morbidity
The surgery for ampullary cancer is associated with a considerable morbidity rate, estimated to be around 65%. In certain series, approximately 13% of patients require a repeat laparotomy to address complications arising from the procedure.
Race
Due to the relative rarity of ampullary carcinoma, investigations regarding the prevalence trends across diverse ethnicities have not been undertaken.
Sex
It is more common in the men.
The pathophysiology of ampullary carcinoma involves the abnormal growth and proliferation of cells in the ampulla of Vater, which can lead to the formation of a cancerous tumor. The exact mechanisms underlying the development of ampullary carcinoma are not fully understood, but several factors contribute to its pathophysiology.
Genetic alterations: Ampullary carcinoma is associated with genetic mutations that disrupt normal cellular processes. These mutations can occur spontaneously or may be inherited in some cases. Specific genetic alterations, like mutations in the APC gene (associated with familial adenomatous polyposis) or DNA mismatch repair genes, have been implicated in the development of ampullary carcinoma.
Chronic inflammation: Chronic inflammation of the ampulla, bile ducts, or pancreas is believed to play a role in the pathophysiology of ampullary carcinoma. Conditions such as primary sclerosing cholangitis and chronic pancreatitis can cause persistent inflammation, leading to cellular damage and the subsequent development of cancer.
Tumor formation: Ampullary carcinoma typically arises from the epithelial cells lining the ampulla of Vater. The exact sequence of events leading to tumor formation has yet to be fully elucidated. However, it involves genetic and molecular changes, including accumulating DNA mutations, dysregulation of cell cycle control, and alterations in cellular signaling pathways.
Tumor invasion and metastasis: As ampullary carcinoma progresses, cancer cells can invade surrounding tissues and spread to regional lymph nodes or distant organs. The process of metastasis involves the detachment of cancer cells from the primary tumor, their entry into the bloodstream or lymphatic system, and colonization at distant sites. The exact mechanisms underlying ampullary carcinoma cells’ invasiveness and metastatic potential are complex and multifactorial.
The consequences of ampullary carcinoma on the normal physiological functions of the ampulla of Vater and adjacent structures depend on the tumor’s size, location, and extent. Common complications include obstruction of the bile duct or pancreatic duct, leading to symptoms such as jaundice, abdominal pain, and digestive disturbances.
Additionally, tumor growth can cause compression and invasion of surrounding structures, further exacerbating symptoms and potentially affecting organ function. Understanding the pathophysiology of ampullary carcinoma is crucial for developing targeted therapies and improving diagnostic and treatment strategies.
The etiology of ampullary carcinoma, or carcinoma of the ampulla of Vater, is multifactorial, involving genetic, environmental, and lifestyle factors. While the exact cause of ampullary carcinoma is not fully understood, Certain risk factors have been identified:
Age: Ampullary carcinoma is more commonly diagnosed in individuals over 60, with the incidence increasing with advancing age.
Genetic factors: Certain hereditary conditions and genetic syndromes are associated with an increased risk of ampullary carcinoma. These include familial adenomatous polyposis (FAP), Lynch syndrome (hereditary non-polyposis colorectal cancer), and Peutz-Jeghers syndrome. These genetic conditions predispose individuals to develop gastrointestinal cancers, including ampullary carcinoma.
Chronic inflammation: Chronic inflammation of the ampulla, bile ducts, or pancreas is believed to contribute to the development of ampullary carcinoma. Conditions like primary sclerosing cholangitis, chronic pancreatitis, and choledochal cysts can cause persistent inflammation, leading to cellular damage and an increased risk of cancer development.
Gallstone disease: Gallstones have been associated with an increased risk of ampullary carcinoma. Gallstones can cause inflammation and obstruction of the bile ducts, potentially leading to chronic inflammation and subsequent carcinogenesis.
Smoking: Cigarette smoking is a recognized risk factor for various cancers, including ampullary carcinoma. Smoking is thought to promote cancer development by introducing carcinogens into the body, leading to DNA damage and the initiation of malignant transformation.
Pancreaticobiliary maljunction: This congenital anomaly involves the abnormal union of the pancreatic and bile ducts outside the duodenal wall. It can result in the reflux of pancreatic juices into the biliary system, leading to chronic inflammation and an increased risk of ampullary carcinoma.
Dietary factors: Some studies suggest that a diet rich in fat and a small quantity of fruits and vegetables may enhance the risk of ampullary carcinoma.
Prognostic factors are variables or characteristics that can help predict the likely outcome or prognosis for individuals diagnosed with ampullary carcinoma. These factors can assist in determining the appropriate treatment approach and provide insights into disease progression and overall survival rates. The prognostic factors of ampullary carcinoma include:
Tumor stage: At the time of diagnosis, the stage of ampullary carcinoma is one of the most significant prognostic factors. Staging is depend on the extent of tumor invasion, involvement of nearby lymph nodes, and presence of distant metastasis—generally, the earlier the tumor stage, the better the prognosis.
Tumor size and extent: The size of the tumor and its extent of invasion into surrounding tissues play a role in determining the prognosis. Smaller, localized tumors generally have a better prognosis than larger, more invasive tumors.
Lymph node involvement: The existence or absence of cancer cells in the regional lymph nodes is an important prognostic factor. The extend of cancer to the lymph nodes indicates a higher likelihood of disease progression and a worse prognosis.
Histological grade: The histological grade refers to the microscopic appearance of cancer cells under a microscope and their degree of differentiation. Well-differentiated tumors, which resemble normal cells more closely, tend to have a better prognosis than poorly differentiated or undifferentiated tumors.
Resectability: The surgical resectability of the tumor is a crucial factor in determining the prognosis. If the tumor can be completely removed through surgery, it generally improves the chances of long-term survival.
Perineural invasion: Cancer cells invading the nerves in the surrounding tissues are associated with a worse prognosis. Perineural invasion indicates a higher risk of local recurrence and distant metastasis.
Vascular invasion: Cancer cells’ involvement of blood vessels or lymphatic channels is associated with a poorer prognosis. Vascular invasion increases the risk of distant metastasis and limits treatment options.
Molecular markers: Various molecular markers, such as genetic mutations or protein expression patterns, have been investigated as potential prognostic factors in ampullary carcinoma. For example, genetic alterations, such as KRAS mutations or overexpression of proteins like HER2/neu, may impact prognosis and guide targeted therapies.
Patient factors: Factors specific to the individual, such as age, overall health status, and comorbidities, can influence the prognosis of ampullary carcinoma. Generally, younger patients with better overall health tend to have better outcomes.
Clinical history
The clinical presentation of ampullary carcinoma can vary among individuals, and the symptoms and signs may depend on various factors, such as the tumor’s size, location, and stage. Here are the typical clinical features associated with ampullary carcinoma:
Age group: Ampullary carcinoma is more commonly diagnosed in individuals over 60.
Physical examination
The physical examination findings in individuals with ampullary carcinoma can be variable, and some may not exhibit any specific physical signs. However, a thorough examination may reveal specific findings that can raise suspicion of ampullary carcinoma. Here are some aspects that may be evaluated during a physical examination:
Jaundice: Yellowing of the skin and sclera (the white part of the eyes) may be observed in individuals with obstructive jaundice due to ampullary carcinoma. This can be assessed by examining the skin and conjunctiva.
Abdominal tenderness: Palpation of the abdomen may reveal tenderness or discomfort, particularly in the upper abdomen, which can be associated with a tumor or inflammation.
Abdominal mass: A palpable mass or swelling may sometimes be felt in the upper abdomen. This may suggest a locally advanced ampullary carcinoma or the presence of associated lymphadenopathy.
Hepatomegaly or splenomegaly: In advanced cases or if there is liver or spleen involvement, enlargement of these organs may be detected on abdominal palpation.
Lymphadenopathy: Enlarged lymph nodes in the abdomen or neck may be palpable. The presence of enlarged lymph nodes might indicate regional spread of the cancer.
Signs of chronic liver disease: In individuals with underlying liver disease, like primary sclerosing cholangitis or cirrhosis, signs of chronic liver disease, such as spider nevi (spider-like blood vessels), palmar erythema (reddening of the palms), or ascites (accumulation of fluid in the abdomen), may be evident.
Associated comorbidity or activity:
No specific comorbidity or activity is directly associated with the development of ampullary carcinoma. However, individuals with certain conditions, such as primary sclerosing cholangitis or chronic pancreatitis, may have an enhanced risk of developing this type of cancer.
Acuity of presentation:
The presentation of ampullary carcinoma can vary in acuity. In certain cases, the symptoms may develop gradually over time, while in others, they may appear suddenly.
Common signs and symptoms of ampullary carcinoma include:
Jaundice: It is the yellowing of the skin and eyes due to the tumor’s bile duct obstruction. This may be accompanied by dark urine and pale stools.
Abdominal pain: Pain or discomfort in the upper abdomen, which may be persistent or intermittent. The pain can be mild-severe and may worsen after eating.
Unexplained weight loss: Significant and unintentional weight loss might occur due to a combination of factors like decreased appetite, malabsorption, and metabolic changes associated with cancer.
Nausea and vomiting: These symptoms may result from bile duct obstruction or impaired digestion due to the tumor’s location near the pancreatic duct.
Changes in bowel habits: Some individuals might experience changes in bowel movements, like diarrhea or pale, greasy stools, due to impaired digestion or blockage of the pancreatic duct.
Fatigue: Generalized weakness and fatigue can occur due to underlying cancer and associated metabolic changes.
Anemia: Ampullary carcinoma can cause chronic blood loss, leading to anemia, manifesting as fatigue, weakness, and shortness of breath.
It is key to note that the clinical presentation of ampullary carcinoma can overlap with other conditions affecting the gastrointestinal tract, making the diagnosis challenging.
Differential Diagnosis
The differential diagnosis of ampullary carcinoma involves considering other conditions that can exist with similar symptoms or findings. Certain conditions that may be included in the differential diagnosis of ampullary carcinoma are:
Benign ampullary tumors: Non-cancerous tumors of the ampulla, such as adenomas or hamartomas, can present with symptoms similar to ampullary carcinoma. These tumors can cause biliary obstruction, jaundice, and abdominal pain. Differentiating between benign and malignant ampullary tumors often requires histological examination of a biopsy sample.
Pancreatic cancer: Pancreatic cancer can sometimes involve Vater’s ampulla and cause symptoms similar to ampullary carcinoma. Imaging studies and biopsies may be necessary to distinguish between the two conditions.
Biliary stones: Obstruction of the bile duct due to gallstones can result in symptoms such as jaundice, abdominal pain, and changes in bowel movements. An abdominal ultrasound or other imaging modalities can help identify the presence of gallstones.
Chronic pancreatitis: Chronic pancreas inflammation can lead to symptoms similar to ampullary carcinoma, including abdominal pain, jaundice, and weight loss. Imaging tests and pancreatic enzyme levels may aid in differentiation.
Cholangiocarcinoma: This is cancer that originates in the bile ducts. It can sometimes present with similar symptoms as ampullary carcinoma due to obstruction of the bile duct. Imaging studies, such as MRCP (magnetic resonance cholangiopancreatography) and biopsy, may be necessary to differentiate between the two conditions.
Duodenal adenocarcinoma: Adenocarcinoma of the duodenum, the first part of the small intestine, can present with symptoms similar to ampullary carcinoma. Endoscopic examination and biopsy can help differentiate between the two.
Pancreatic neuroendocrine tumors: These tumors arise from the hormone-producing cells of the pancreas. Depending on the location, they can present symptoms similar to ampullary carcinoma. Imaging studies and histopathological analysis can aid in distinguishing between the two conditions.
Choledocholithiasis: Obstruction of the common bile duct due to stones can cause symptoms resembling ampullary carcinoma. Imaging tests, such as abdominal ultrasound or endoscopic retrograde cholangiopancreatography (ERCP), can help identify the presence of stones.
Treatment
The treatment of ampullary carcinoma typically involves a multidisciplinary approach and may include a combination of surgery, chemotherapy, radiation therapy, and supportive care. The specific treatment options depend on various factors, including the stage of cancer, the overall health of the individual, and individualized treatment plans. Here is an overview of the different treatment modalities and the phase of management involved:
Modification of environment:
Lifestyle modifications: While there are no specific environmental modifications for ampullary carcinoma, maintaining a healthy lifestyle, together with a balanced diet, regular exercise, can contribute to overall well-being and support the individual during treatment.
Administration of a pharmaceutical agent:
Chemotherapy: Systemic chemotherapy may be recommended before or after surgery to help shrink the tumor, destroy cancer cells that may have spread, or improve survival rates. Commonly used chemotherapy regimens for ampullary carcinoma include gemcitabine and cisplatin.
Targeted therapy: In some cases, therapies targeting molecular abnormalities in cancer cells, such as HER2-targeted therapy or EGFR inhibitors, may be utilized. Genetic testing of the tumor can help guide the selection of targeted therapies.
Intervention with a procedure:
Surgery: The surgical resection is the primary treatment for ampullary carcinoma whenever feasible. The objective is to eliminate the tumor and surrounding tissues, such as pancreaticoduodenectomy (Whipple procedure).
Endoscopic interventions: In some cases, endoscopic procedures, such as endoscopic ampullectomy or endoscopic stenting, may relieve bile duct obstruction and alleviate symptoms, particularly in individuals who are not surgical candidates or for palliative purposes.
Phase of management:
Initial diagnosis and staging: This phase involves a comprehensive evaluation, including imaging tests (e.g., CT scan, MRI, endoscopic ultrasound) and pathological examination (biopsy) to determine the cancer stage.
Curative intent: The primary goal for individuals with resectable tumors is complete surgical removal of the tumor with negative margins. Surgery may be followed by adjuvant chemotherapy to reduce the risk of recurrence.
Palliative care: In cases where the tumor is unresectable or advanced, the focus shifts to palliative care. This involves managing symptoms, such as pain, jaundice, and improving quality of life. Palliative treatments may include stenting to relieve bile duct obstruction, pain management, nutritional support, and emotional support.
Ampullary carcinoma, also known as carcinoma of the ampulla of Vater or ampullary cancer, is an infrequent type of cancer that develops in the ampulla of Vater. The ampulla of Vater is a small, muscular structure located where the common bile duct and pancreatic duct join and empty into the duodenum, the first part of the small intestine.
Ampullary carcinoma is a type of gastrointestinal cancer, and it is considered a subset of periampullary cancers, including tumors arising from the pancreas, bile ducts, and duodenum. It accounts for only minute percentage of all gastrointestinal malignancies.
The exact cause of ampullary carcinoma is unknown, but several risk factors have been identified. These include:
Age: The risk of developing ampullary carcinoma increases with age, with majority cases occurring in individuals over 60.
Chronic inflammation: Conditions that cause chronic inflammation of the bile ducts or pancreas, such as primary sclerosing cholangitis or chronic pancreatitis, may increase the risk.
Genetic factors: Some hereditary conditions, such as familial adenomatous polyposis (FAP) and Lynch syndrome (hereditary non-polyposis colorectal cancer), are associated with an increased risk of ampullary carcinoma.
Smoking: Cigarette smoking has been identified as a risk factor for ampullary carcinoma.
Symptoms of ampullary carcinoma can vary but might include jaundice, abdominal pain, unexplained weight loss, nausea, vomiting, changes in bowel habits, and fatigue. These symptoms can be nonspecific and mimic other digestive disorders, making the diagnosis challenging.
Ampullary carcinoma is relatively rare tumor, constituting nearly 0.2% of all gastrointestinal tract (GIT) malignancies and around 7% of periampullary carcinoma in the American States. A comprehensive analysis of data from the Surveillance, Epidemiology, and End Results program identified 6,803 patients diagnosed with ampullary cancer from 2004 to 2013 and the annual incidence of ampullary carcinoma has remained relatively stable since 2004.
A recent epidemiologic study conducted in the Netherlands revealed an enhance in the incidence rate of ampullary cancer over time. The study found that the incidence rate rose from 0.59 per 100,000 individuals in the period of 1989-1995 to 0.68 per 100,000 individuals in the period of 2010-2016. Furthermore, in patients diagnosed with the non-metastatic ampullary disease, the five-year overall survival rate demonstrated improvement. It enhanced from 19.8% in the years 1989-1995 to 29.1% in the years 2010-2016.
Mortality
Historically, the reported operative mortality rate for ampullary cancer was nearly 20%. However, in recent years, several medical centers have reported larger series with significantly lower perioperative mortality rates, typically around 5%.
In a population-based analysis conducted in 2008, involving 1,301 individuals who underwent resection, the perioperative mortality rate was found to be 7.6%. This suggests a notable improvement in surgical outcomes. Additionally, the 5-year survival rate for these patients was reported as 37%.
Morbidity
The surgery for ampullary cancer is associated with a considerable morbidity rate, estimated to be around 65%. In certain series, approximately 13% of patients require a repeat laparotomy to address complications arising from the procedure.
Race
Due to the relative rarity of ampullary carcinoma, investigations regarding the prevalence trends across diverse ethnicities have not been undertaken.
Sex
It is more common in the men.
The pathophysiology of ampullary carcinoma involves the abnormal growth and proliferation of cells in the ampulla of Vater, which can lead to the formation of a cancerous tumor. The exact mechanisms underlying the development of ampullary carcinoma are not fully understood, but several factors contribute to its pathophysiology.
Genetic alterations: Ampullary carcinoma is associated with genetic mutations that disrupt normal cellular processes. These mutations can occur spontaneously or may be inherited in some cases. Specific genetic alterations, like mutations in the APC gene (associated with familial adenomatous polyposis) or DNA mismatch repair genes, have been implicated in the development of ampullary carcinoma.
Chronic inflammation: Chronic inflammation of the ampulla, bile ducts, or pancreas is believed to play a role in the pathophysiology of ampullary carcinoma. Conditions such as primary sclerosing cholangitis and chronic pancreatitis can cause persistent inflammation, leading to cellular damage and the subsequent development of cancer.
Tumor formation: Ampullary carcinoma typically arises from the epithelial cells lining the ampulla of Vater. The exact sequence of events leading to tumor formation has yet to be fully elucidated. However, it involves genetic and molecular changes, including accumulating DNA mutations, dysregulation of cell cycle control, and alterations in cellular signaling pathways.
Tumor invasion and metastasis: As ampullary carcinoma progresses, cancer cells can invade surrounding tissues and spread to regional lymph nodes or distant organs. The process of metastasis involves the detachment of cancer cells from the primary tumor, their entry into the bloodstream or lymphatic system, and colonization at distant sites. The exact mechanisms underlying ampullary carcinoma cells’ invasiveness and metastatic potential are complex and multifactorial.
The consequences of ampullary carcinoma on the normal physiological functions of the ampulla of Vater and adjacent structures depend on the tumor’s size, location, and extent. Common complications include obstruction of the bile duct or pancreatic duct, leading to symptoms such as jaundice, abdominal pain, and digestive disturbances.
Additionally, tumor growth can cause compression and invasion of surrounding structures, further exacerbating symptoms and potentially affecting organ function. Understanding the pathophysiology of ampullary carcinoma is crucial for developing targeted therapies and improving diagnostic and treatment strategies.
The etiology of ampullary carcinoma, or carcinoma of the ampulla of Vater, is multifactorial, involving genetic, environmental, and lifestyle factors. While the exact cause of ampullary carcinoma is not fully understood, Certain risk factors have been identified:
Age: Ampullary carcinoma is more commonly diagnosed in individuals over 60, with the incidence increasing with advancing age.
Genetic factors: Certain hereditary conditions and genetic syndromes are associated with an increased risk of ampullary carcinoma. These include familial adenomatous polyposis (FAP), Lynch syndrome (hereditary non-polyposis colorectal cancer), and Peutz-Jeghers syndrome. These genetic conditions predispose individuals to develop gastrointestinal cancers, including ampullary carcinoma.
Chronic inflammation: Chronic inflammation of the ampulla, bile ducts, or pancreas is believed to contribute to the development of ampullary carcinoma. Conditions like primary sclerosing cholangitis, chronic pancreatitis, and choledochal cysts can cause persistent inflammation, leading to cellular damage and an increased risk of cancer development.
Gallstone disease: Gallstones have been associated with an increased risk of ampullary carcinoma. Gallstones can cause inflammation and obstruction of the bile ducts, potentially leading to chronic inflammation and subsequent carcinogenesis.
Smoking: Cigarette smoking is a recognized risk factor for various cancers, including ampullary carcinoma. Smoking is thought to promote cancer development by introducing carcinogens into the body, leading to DNA damage and the initiation of malignant transformation.
Pancreaticobiliary maljunction: This congenital anomaly involves the abnormal union of the pancreatic and bile ducts outside the duodenal wall. It can result in the reflux of pancreatic juices into the biliary system, leading to chronic inflammation and an increased risk of ampullary carcinoma.
Dietary factors: Some studies suggest that a diet rich in fat and a small quantity of fruits and vegetables may enhance the risk of ampullary carcinoma.
Prognostic factors are variables or characteristics that can help predict the likely outcome or prognosis for individuals diagnosed with ampullary carcinoma. These factors can assist in determining the appropriate treatment approach and provide insights into disease progression and overall survival rates. The prognostic factors of ampullary carcinoma include:
Tumor stage: At the time of diagnosis, the stage of ampullary carcinoma is one of the most significant prognostic factors. Staging is depend on the extent of tumor invasion, involvement of nearby lymph nodes, and presence of distant metastasis—generally, the earlier the tumor stage, the better the prognosis.
Tumor size and extent: The size of the tumor and its extent of invasion into surrounding tissues play a role in determining the prognosis. Smaller, localized tumors generally have a better prognosis than larger, more invasive tumors.
Lymph node involvement: The existence or absence of cancer cells in the regional lymph nodes is an important prognostic factor. The extend of cancer to the lymph nodes indicates a higher likelihood of disease progression and a worse prognosis.
Histological grade: The histological grade refers to the microscopic appearance of cancer cells under a microscope and their degree of differentiation. Well-differentiated tumors, which resemble normal cells more closely, tend to have a better prognosis than poorly differentiated or undifferentiated tumors.
Resectability: The surgical resectability of the tumor is a crucial factor in determining the prognosis. If the tumor can be completely removed through surgery, it generally improves the chances of long-term survival.
Perineural invasion: Cancer cells invading the nerves in the surrounding tissues are associated with a worse prognosis. Perineural invasion indicates a higher risk of local recurrence and distant metastasis.
Vascular invasion: Cancer cells’ involvement of blood vessels or lymphatic channels is associated with a poorer prognosis. Vascular invasion increases the risk of distant metastasis and limits treatment options.
Molecular markers: Various molecular markers, such as genetic mutations or protein expression patterns, have been investigated as potential prognostic factors in ampullary carcinoma. For example, genetic alterations, such as KRAS mutations or overexpression of proteins like HER2/neu, may impact prognosis and guide targeted therapies.
Patient factors: Factors specific to the individual, such as age, overall health status, and comorbidities, can influence the prognosis of ampullary carcinoma. Generally, younger patients with better overall health tend to have better outcomes.
Clinical history
The clinical presentation of ampullary carcinoma can vary among individuals, and the symptoms and signs may depend on various factors, such as the tumor’s size, location, and stage. Here are the typical clinical features associated with ampullary carcinoma:
Age group: Ampullary carcinoma is more commonly diagnosed in individuals over 60.
Physical examination
The physical examination findings in individuals with ampullary carcinoma can be variable, and some may not exhibit any specific physical signs. However, a thorough examination may reveal specific findings that can raise suspicion of ampullary carcinoma. Here are some aspects that may be evaluated during a physical examination:
Jaundice: Yellowing of the skin and sclera (the white part of the eyes) may be observed in individuals with obstructive jaundice due to ampullary carcinoma. This can be assessed by examining the skin and conjunctiva.
Abdominal tenderness: Palpation of the abdomen may reveal tenderness or discomfort, particularly in the upper abdomen, which can be associated with a tumor or inflammation.
Abdominal mass: A palpable mass or swelling may sometimes be felt in the upper abdomen. This may suggest a locally advanced ampullary carcinoma or the presence of associated lymphadenopathy.
Hepatomegaly or splenomegaly: In advanced cases or if there is liver or spleen involvement, enlargement of these organs may be detected on abdominal palpation.
Lymphadenopathy: Enlarged lymph nodes in the abdomen or neck may be palpable. The presence of enlarged lymph nodes might indicate regional spread of the cancer.
Signs of chronic liver disease: In individuals with underlying liver disease, like primary sclerosing cholangitis or cirrhosis, signs of chronic liver disease, such as spider nevi (spider-like blood vessels), palmar erythema (reddening of the palms), or ascites (accumulation of fluid in the abdomen), may be evident.
Associated comorbidity or activity:
No specific comorbidity or activity is directly associated with the development of ampullary carcinoma. However, individuals with certain conditions, such as primary sclerosing cholangitis or chronic pancreatitis, may have an enhanced risk of developing this type of cancer.
Acuity of presentation:
The presentation of ampullary carcinoma can vary in acuity. In certain cases, the symptoms may develop gradually over time, while in others, they may appear suddenly.
Common signs and symptoms of ampullary carcinoma include:
Jaundice: It is the yellowing of the skin and eyes due to the tumor’s bile duct obstruction. This may be accompanied by dark urine and pale stools.
Abdominal pain: Pain or discomfort in the upper abdomen, which may be persistent or intermittent. The pain can be mild-severe and may worsen after eating.
Unexplained weight loss: Significant and unintentional weight loss might occur due to a combination of factors like decreased appetite, malabsorption, and metabolic changes associated with cancer.
Nausea and vomiting: These symptoms may result from bile duct obstruction or impaired digestion due to the tumor’s location near the pancreatic duct.
Changes in bowel habits: Some individuals might experience changes in bowel movements, like diarrhea or pale, greasy stools, due to impaired digestion or blockage of the pancreatic duct.
Fatigue: Generalized weakness and fatigue can occur due to underlying cancer and associated metabolic changes.
Anemia: Ampullary carcinoma can cause chronic blood loss, leading to anemia, manifesting as fatigue, weakness, and shortness of breath.
It is key to note that the clinical presentation of ampullary carcinoma can overlap with other conditions affecting the gastrointestinal tract, making the diagnosis challenging.
Differential Diagnosis
The differential diagnosis of ampullary carcinoma involves considering other conditions that can exist with similar symptoms or findings. Certain conditions that may be included in the differential diagnosis of ampullary carcinoma are:
Benign ampullary tumors: Non-cancerous tumors of the ampulla, such as adenomas or hamartomas, can present with symptoms similar to ampullary carcinoma. These tumors can cause biliary obstruction, jaundice, and abdominal pain. Differentiating between benign and malignant ampullary tumors often requires histological examination of a biopsy sample.
Pancreatic cancer: Pancreatic cancer can sometimes involve Vater’s ampulla and cause symptoms similar to ampullary carcinoma. Imaging studies and biopsies may be necessary to distinguish between the two conditions.
Biliary stones: Obstruction of the bile duct due to gallstones can result in symptoms such as jaundice, abdominal pain, and changes in bowel movements. An abdominal ultrasound or other imaging modalities can help identify the presence of gallstones.
Chronic pancreatitis: Chronic pancreas inflammation can lead to symptoms similar to ampullary carcinoma, including abdominal pain, jaundice, and weight loss. Imaging tests and pancreatic enzyme levels may aid in differentiation.
Cholangiocarcinoma: This is cancer that originates in the bile ducts. It can sometimes present with similar symptoms as ampullary carcinoma due to obstruction of the bile duct. Imaging studies, such as MRCP (magnetic resonance cholangiopancreatography) and biopsy, may be necessary to differentiate between the two conditions.
Duodenal adenocarcinoma: Adenocarcinoma of the duodenum, the first part of the small intestine, can present with symptoms similar to ampullary carcinoma. Endoscopic examination and biopsy can help differentiate between the two.
Pancreatic neuroendocrine tumors: These tumors arise from the hormone-producing cells of the pancreas. Depending on the location, they can present symptoms similar to ampullary carcinoma. Imaging studies and histopathological analysis can aid in distinguishing between the two conditions.
Choledocholithiasis: Obstruction of the common bile duct due to stones can cause symptoms resembling ampullary carcinoma. Imaging tests, such as abdominal ultrasound or endoscopic retrograde cholangiopancreatography (ERCP), can help identify the presence of stones.
Treatment
The treatment of ampullary carcinoma typically involves a multidisciplinary approach and may include a combination of surgery, chemotherapy, radiation therapy, and supportive care. The specific treatment options depend on various factors, including the stage of cancer, the overall health of the individual, and individualized treatment plans. Here is an overview of the different treatment modalities and the phase of management involved:
Modification of environment:
Lifestyle modifications: While there are no specific environmental modifications for ampullary carcinoma, maintaining a healthy lifestyle, together with a balanced diet, regular exercise, can contribute to overall well-being and support the individual during treatment.
Administration of a pharmaceutical agent:
Chemotherapy: Systemic chemotherapy may be recommended before or after surgery to help shrink the tumor, destroy cancer cells that may have spread, or improve survival rates. Commonly used chemotherapy regimens for ampullary carcinoma include gemcitabine and cisplatin.
Targeted therapy: In some cases, therapies targeting molecular abnormalities in cancer cells, such as HER2-targeted therapy or EGFR inhibitors, may be utilized. Genetic testing of the tumor can help guide the selection of targeted therapies.
Intervention with a procedure:
Surgery: The surgical resection is the primary treatment for ampullary carcinoma whenever feasible. The objective is to eliminate the tumor and surrounding tissues, such as pancreaticoduodenectomy (Whipple procedure).
Endoscopic interventions: In some cases, endoscopic procedures, such as endoscopic ampullectomy or endoscopic stenting, may relieve bile duct obstruction and alleviate symptoms, particularly in individuals who are not surgical candidates or for palliative purposes.
Phase of management:
Initial diagnosis and staging: This phase involves a comprehensive evaluation, including imaging tests (e.g., CT scan, MRI, endoscopic ultrasound) and pathological examination (biopsy) to determine the cancer stage.
Curative intent: The primary goal for individuals with resectable tumors is complete surgical removal of the tumor with negative margins. Surgery may be followed by adjuvant chemotherapy to reduce the risk of recurrence.
Palliative care: In cases where the tumor is unresectable or advanced, the focus shifts to palliative care. This involves managing symptoms, such as pain, jaundice, and improving quality of life. Palliative treatments may include stenting to relieve bile duct obstruction, pain management, nutritional support, and emotional support.
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