Malignant tumors of the major duodenal papilla. What is bds cancer? Treatment of papilla of Vater cancer

The close location of the large duodenal papilla to the pancreatic and bile ducts makes it very vulnerable in the event of the development of a pathological process in the large pancreatic and common bile ducts, as well as in the duodenum. Regular changes in pressure in this area of ​​the duodenum additionally have a traumatic effect on the papilla.
For this reason, there is a relatively mild development of chronic and acute duodenal papillitis. With chronic papillitis, benign and, in some cases, malignant neoplasms of the BDS occur. The concept of the major duodenal papilla includes the papilla itself, the terminal section of the common bile duct and the ampulla of the papilla.

Carcinoma

Carcinoma of the major duodenal papilla is an epithelial malignant tumor initially arising from the epithelium of the duodenal mucosa, which covers the papilla and adjacent areas of the intestine, the epithelium of the pancreatic duct, the epithelium of the ampulla of the ampulla of the duodenum, and the acinar cells of the pancreas, which is adjacent to the region of the major duodenal papilla.
It is often very difficult to determine the place where the tumor began to develop. Basically, carcinoma appears as a medullary tumor or polyp. Carcinoma of acinar origin often acquires infiltrative growth. Regarding the structure, the most common are adenocarcinomas. Carcinoma, which originates from the epithelium of the ampulla of the major duodenal papilla, is distinguished by its papillary structure and relatively low malignancy. Its size, as a rule, does not exceed 3 centimeters.

Symptoms

The first symptom of the disease is often obstructive or subhepatic jaundice, which manifests itself as a result of compression of the common bile duct. Basically, jaundice develops gradually, painlessly and without a sudden disturbance in the general condition. Often, when first seeing a patient, a doctor makes an erroneous diagnosis - viral hepatitis.
Subhepatic jaundice, especially in the initial period, is incomplete. This stage is characterized by the appearance of stercobilin in the feces and urobilin in the urine, as well as slight skin itching, in comparison with carcinoma of the head of the pancreas and cholangiocarcinomas.
Occasionally, pain in the upper half of the abdomen can be observed in the early stages. 1-3 months before jaundice, the patient begins to lose weight. Significant weight loss is observed already with the appearance of jaundice. Further progression of the disease is sometimes accompanied by the development of purulent cholangitis. More common symptoms are bleeding from the tumor and compression of the duodenum.
In addition, there is an increase in aminotransferase activity and a significant increase in GGTP activity. A small proportion of patients experience an increase in leukocytes and an increase in ESR.

Diagnosis of the major duodenal papilla

X-ray examination of the duodenum of patients helps to identify a picture that raises suspicion of a tumor of the papilla of Vater: the corresponding zone has a filling defect, or a gross and persistent deformation of any wall. Usually, various disturbances in the advancement of the contrast mass in the area of ​​the nipple are always detected.
Duodenal endoscopy can also provide valuable diagnostic data. During endoscopy, a biopsy is performed on areas suspicious for the presence of a tumor. If any doubts arise or a specialist wishes to clarify the area of ​​tumor spread, ERCP can also be used. However, it is not always possible to cannulate the papilla.
During radionuclide scintigraphy, there is often a delay in the flow of bile into the duodenum; CT and ultrasound, which are performed for the first time, often do not provide significant diagnostic information. The most aggressive course of the tumor process can be observed with the atomic origin of the neoplasm. The rate of progression of this type of tumor is similar to that of the ductal type. The ampullary type is less aggressive. In addition, it can be detected the fastest because it causes jaundice to begin relatively earlier. The most slowly progressing type is considered duodenal.

Surgical treatment of the major duodenal papilla

If this is possible, then pancreatoduodenal resection is performed. Palliative operations involving the application of biliodigestive anastomoses and biliary prostheses have become quite widespread. In case of duodenal stenosis, gastroenterostomosis is applied. If necessary, chemotherapy is given.
As with other tumors, the fate of the patient depends on the time of detection of the tumor.

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Causes and predisposing factors:

1. Genetic predisposition. It is often detected in families with familial adenomatous polyposis. Also, in some patients, a cellular mutation of the K-ras gene is detected.
2. BDS adenoma is a benign tumor of the papilla that can become malignant.
3. Chronic diseases of the gallbladder and liver.
4. Chronic pancreatitis.

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Symptoms and course of the disease

Cancer of the papilla of Vater is detected in the early stages of development, due to narrowing of the final section of the biliary tract. This leads to wavy yellowing of varying intensity of the skin, which is accompanied by itching. And refusal to eat, indigestion, fever, vomiting leads to weight loss. Due to a violation of the outflow of bile, the liver becomes enlarged, and a full gallbladder can be palpated through the abdominal wall. Obstruction of the excretory ducts is also reflected in the state of the blood.

In blood plasma it is noted:

• increased activity of gamma-glutamyl and alkaline phosphatase;
• bilirubin increases significantly;
• increase in transaminase.

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Treatment of the disease

The only radical treatment method is surgery. Most often, pancreatoduodenal resection is performed - removal of part of the duodenum, stomach and part of the pancreas with adjacent lymph nodes.

They have auxiliary value radiation therapy and chemotherapy. Chemotherapy is also used for metastases.

Palliative measures are also performed endoscopic intraductal interventions with pronounced narrowing of the common bile duct, if it is impossible to perform radical intervention. This type of operation includes papillotomy (dissection of the papilla of Vater) followed by stenting. This helps normalize the passage of bile.

For effective treatment of cancer of the major duodenal papilla, high-quality early diagnosis is important.

Diagnosis of the disease

Diagnostic program:

1. Consultation with a qualified specialist.
2. Detailed blood tests, including general clinical, biochemical, electrolyte composition, lipid profile, determination of tumor markers, pancreatic enzymes, glycosylated hemoglobin.
3. Ultrasound examination of the abdominal organs with Dopplerography of the abdominal vessels; Spiral computed tomography of the abdominal cavity.
4. Combined positron emission computed tomography.
5. Endoscopic and laparoscopic ultrasonography.
6. Esophagogastroduodenoscopy with test for Helicobacter pylori (under anesthesia).
7. Tumor biopsy.
8. Urgent histopathology and histochemistry of biopsy material.
9. Magnetic resonance cholangiopancreatography (as an option).

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Major duodenal papilla cancer arises from the epithelium of the ducts (common bile, pancreatic, ampulla papilla) or

from the epithelium of the duodenal mucosa. The tumor is usually small (from 0.5 to 2–2.5 cm), has a round or

ovoid formation protruding into the lumen of the duodenum. In most cases it is exophytic(growth into the lumen of the organ),

grows slowly and for a long timedoes not extend beyond the papilla. With infiltrative growth, the surrounding environment is quickly involved in the process.

tissues (duodenumintestine, head of pancreas, common bile duct). Microscopically, the tumor is most often

is an adenocarcinoma.Metastases are found relatively rarely. Metastases affect regional lymphatic

nodes, then the liver and less often other organs.There are no gender differences in incidence.

Risk factors that can lead to the development of cancer include the presence of hyperplastic

changes in the Vater nipple area -hyperplastic ostial polyps, adenomas, glandular-cystic hyperplasia of the transitional fold

major duodenal papilla (MDP).

Biliary hypertension develops. There is a threat of cholangitis and cholangiogenic liver abscesses. Mechanisms are triggered in the liver itself

its cirrhotic transformation. Hypertension in the pancreatic ducts due to stenosis or obstruction of the main

pancreatic duct tumor of the major duodenal papilla, leads to dystrophic and inflammatory changes in the parenchyma

pancreas glands. An increase in tumor size can lead to deformation of the duodenum. However, as a rule,

in this case, small intestinal obstruction does not occur. A more common complication is tumor disintegration with intraintestinal bleeding.

Clinical picture and diagnosis of cancer of the major duodenal papilla

In the initial period, it may be accompanied by a painful attack in the epigastrium with irradiation of pain in the back, which is due to

beginning biliary and pancreatic hypertension. The pain is constant and aching or paroxysmal, reminiscent of

hepatic colic. But soon jaundice appears. In a third of patients, jaundice is the first sign of the disease. At the initial stage, jaundice

wears fickle character. Less commonly, jaundice maydecrease, which is usually associated with the disintegration of the tumor and a temporary improvement in bile outflow,

but it's late stages of the disease. But usually jaundice is progressive. This is the most common, but not early sign of cancer.

Jaundice is accompanied by discoloration of stool. hepatic-renal and multiple organ failure, itching of the skin. Often jaundice

complicated by cholangitis with high fever.

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Malignant neoplasms of the BDS are detected quite often; they account for 0.5-1.6% of all malignant tumors and more than 3% of malignant tumors of the gastrointestinal tract, 5-18% of tumors of the duodenum, including 5% of all carcinomas of the digestive organs. Men are affected somewhat more often than women, and the main age of those affected is over 50 years.

Malignant neoplasms of the bile duct can originate from the epithelium of the distal part of the common bile duct, the terminal part of the pancreatic duct, the mucous membrane of the bile duct or the wall of the duodenum in the area of ​​the papilla. In the latter case, the tumors are prone to ulceration. Sometimes it is very difficult to establish the original origin of the tumor, and sometimes this is only of academic interest, since clinically all malignant tumors of the BDS zone have the same course.

Classification and pathomorphology

Ny - the presence of lymphatic metastases is not known.
. Na—single retroduodenal lymph nodes are affected.
. Nb - parapancreatic lymph nodes are affected.
. Ne - periportal, para-aortic or mesenteric lymph nodes are affected.

M0 - no distant metastases.
. M1 - there are distant metastases.

There are several morphological types of malignant tumors of the BDS.

Adenocarcinoma of the BDS.

Papillary cancer. Exophytic growth into the lumen of the papilla and duodenum is characteristic. The tumor is represented by glandular-like complexes of small size with a well-defined stroma. The complexes are cavities lined with tall columnar epithelium with a thickened basement membrane.

Scirrhosis form. The tumor is small in size with a predominant spread along the common bile duct and into surrounding tissues. The neoplasm contains fibrous tissue rich in collagen fibers with a pronounced vascular network, among which small polymorphic cancer cells are visible, sometimes forming cavities and cysts; cell nuclei of various sizes show a large number of mitoses, including pathological ones.

Mucous cancer. Characteristic is the growth into the lumen of the papilla of glandular structures formed by prismatic cells with a large amount of pink mucus in the apical sections. The mitotic activity of cancer cells is high.

Adenocarcinoma arising from the epithelium of the duodenum. A large number of glandular structures of round, oval or convoluted shape are revealed, devoid of excretory ducts and in places overflowing with mucus. These structures infiltrate the submucosal and muscular membranes of the duodenum. The epithelium is atypical, predominantly cubic, sometimes multirow prismatic; large mast cells with pronounced granularity are present.

Of all the listed malignant neoplasms of the BDS area, adenocarcinoma develops most often. BDS carcinomas are characterized by slower growth and a more favorable prognosis than pancreatic cancer.
Macroscopically, three forms of BDS cancer are distinguished: polyposis, infiltrative and ulcerative. Usually the tumor is small (up to 1.5 cm in diameter) and has a stalk. The process does not extend beyond the papilla for a long time.

The polypous form can lead to obstruction of the lumen of the abdominal joint (see Fig. 5-45), and the infiltrative form can lead to its stenosis. In addition, the tumor can infiltrate the wall of the duodenum with the formation of a nodular form. This form of tumor is characterized by the absence of changes in the mucous membrane above the tumor, so a superficial biopsy may not yield results.

Rice. 5-45. Adenocarcinoma of the major duodenal papilla(macro specimen): a — view from the lumen of the duodenum; b - tumor on the section, the absence of invasion into the pancreatic tissue is clearly visible

A long-term tumor process is characterized by increasing cholestasis, secondary cholecystitis, development of congestive gallbladder, choledocholithiasis, cholangitis, secondary biliary hepatitis, liver cirrhosis, biliary-dependent obstructive pancreatitis.

Damage to the duodenum by the tumor process can lead to its severe deformation, the development of secondary dynamic and mechanical obstruction (duodenostasis), and ulceration can lead to bleeding. Clinical picture

Cancer of the BDS area can occur in several clinical forms:
. choleis-like variant (with typical biliary colic);
. cholangitis (without colic, with skin itching, jaundice, low-grade fever);
. gastric (dyskintic) with secondary gastric dyspepsia.

Once occurring, jaundice in BDS cancer becomes permanent with a tendency to worsen, but temporary (false) improvements are possible], mainly due to recanalization of the duct during tumor disintegration, or against the background of anti-inflammatory therapy by reducing secondary edema of the mucosa.

Characterized by a pronounced dyspeptic syndrome associated with impaired cavity digestion in the duodenum and small intestine due to impaired outflow of bile and pancreatic secretions. Patients gradually lose weight, even to the point of cachexia.

Diagnostics

X-ray examination of malignant neoplasms of the duodenum reveals a defect in the filling of the duodenum in the zone of its descending part along the internal contour. The size of the defect is usually small (up to 3 cm), its contours are uneven, and the relief of the mucous membrane is disturbed. Particular attention should be paid to the rigidity of the intestinal wall at the site of the filling defect. Diagnosis is aided by tight filling of the intestine with barium sulfate in conditions of hypotension, as well as double contrasting of the intestine.

The most common early endoscopic symptom is an increase in the size of the BDS, ulcerations in its area, papillary or tuberous formations (see Fig. 5-46). Often the papilla takes on a crimson-red color. During decay, the amount of BDS may be small, however, as a rule, a large area of ​​ulceration and infiltration of surrounding tissues is revealed.

Rice. 5-46. Adenocarcinoma of the major duodenal papilla. Endoscopic photography, view from the duodenal lumen

In some cases, ERCP, MRCP, and EUS help diagnose BDS cancer; These methods make it possible to identify damage to the ducts, the transition of the process to the pancreas.

In case of unsuccessful attempts to contrast the ducts due to tumor obstruction of the orifice of the BDS, laparoscopic or percutaneous transhepatic cholecystocholangiography is used. As a rule, dilatation of the bile ducts with a “break” of the common bile duct in the duodenum area is detected.

Differential diagnosis in the presence of obstructive jaundice syndrome is carried out with benign tumors of the obstructive jaundice, choledocholithiasis, stenotic papillitis, tumors of the head of the pancreas, autoimmune pancreatitis, etc.

With extensive tumor infiltration and ulceration of the LBD area, secondary damage to the papilla most often occurs due to the spread of cancer of the head of the pancreas. The correct diagnosis can be made by CT, MRI, ERCP, ultrasound by identifying changes in the structure of the gland, indicating its primary tumor lesion. At the same time, the exact determination of the primary location of the process does not affect the outcome and prognosis of the disease, since the possibility of radical treatment in such a situation is doubtful.

Treatment

In case of advanced tumor processes, operations to drain the ducts of the abdominal wall (EPST, application of various cholecystodigestive anastomoses) are more often performed. However, timely radical surgical treatment ensures a five-year survival rate of 40%.

For palliative purposes in patients with inoperable BDS cancer, due to its low morbidity and the possibility of re-execution in case of relapses of obstructive jaundice, the use of EPST with retrograde prosthetics (stenting) of the bile ducts is recommended.

The data presented indicate the importance of timely diagnosis of tumor lesions in the BDS area: the earlier the tumor process is verified, the more radical and less traumatic it is possible to operate on these patients.

Maev I.V., Kucheryavyi Yu.A.

Found in 0.1-1.7% of deaths from malignant tumors. In the group of patients with tumor lesions of the organs of the papcreatoduodenal zone, this localization is not uncommon and occurs in 12-20% of cases.

Pathological anatomy

Neoplasms major duodenal papilla arise from the epithelium of the ducts (common bile, pancreatic, ampulla papilla) or from the epithelium of the duodenal mucosa. The tumor is usually small (from 0.5 to 2-2.5 cm), has the appearance of a round or ovoid formation protruding into the lumen of the duodenum. In most cases, it is exophytic, grows slowly and does not extend beyond the papilla for a long time. With infiltrative cancer, the surrounding tissues (duodenum, head of the pancreas, common bile duct) are quickly involved in the process. Microscopically, the tumor most often represents an adenocarcinoma.
Metastases are found relatively rarely - in 25%. Metastases affect regional lymph nodes, then the liver and, less commonly, other organs.

Clinic

The symptomatology is similar to that of pancreatic head cancer, but the clinical course differs in features that have diagnostic significance and also influence the prognosis and choice of treatment method.
The localization of the tumor at the level of the papilla determines the relatively early appearance of jaundice. The pre-icteric period is shorter than for pancreatic cancer. Jaundice in more than half of patients has a wave-like character.
Tumors of the large duodenal papilla ulcerate quite quickly. This circumstance contributes to the penetration of infection from the duodenum into the bile ducts and pancreatic ducts. Cholangitis occurs more often than with cancer of the head of the pancreas (in 40-50% of cases), manifested by chills, high fever (up to 38-39 ° C), pain in the liver. Infection of the pancreatic duct leads to outbreaks of pancreatitis, which are confirmed by increased urine diastase levels and clinical signs: paroxysmal girdle pain, vomiting, fever and high leukocytosis.
Cancer of the major duodenal papilla is characterized by bleeding from the tumor. The degree of blood loss varies: from the presence of occult blood in the stool to significant bleeding accompanied by severe anemia.

Diagnostics

The inflammatory component in cancer of the major duodenal papilla gives rise to serious diagnostic errors. Pain, fever, and undulating jaundice give rise to diagnoses such as cholecystitis, cholangitis, and pancreatitis. After the use of antibiotics, the inflammatory phenomena are relieved, the condition of some patients improves and they are discharged, mistakenly considered to have recovered. Internal bleeding is rarely regarded as a symptom of peptic ulcer disease. As a result, despite the rather early appearance of such a clear sign of the disease as jaundice, the correct diagnosis is established after 1-3 months, and sometimes after 1-2 years. With oncological alertness of the doctor and a comprehensive assessment of data from anamnesis, clinical, radiological and endoscopic examinations, the number of diagnostic errors will be significantly reduced.
A positive Courvoisier symptom is detected in 50-75% of cases. In other patients, the gallbladder cannot be palpated due to significant enlargement of the liver or changes in the gallbladder (cholecystitis, cholelithiasis). The combination of cancer of the major duodenal papilla with cholelithiasis and cholecystitis occurred in 14% of cases. Courvoisier's sign is known to indicate distal bile duct obstruction and is equally characteristic of cancer of the major duodenal papilla, malignant tumors of the head of the pancreas and the distal common bile duct.
The method of duodenography and fibroduodenoscopy helps clarify the topical diagnosis.

Treatment

For cancer of the major duodenal papilla, pancreatoduodenal resection is performed.