NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Q: What is the next step? A: Klatskin tumors are associated with a poor prognosis because of the high rate of vascular inva- sion, unresectability, and metastatic disease. If no evidence for unresectability or metastasis is evident on CT, exploration with resection of the bile ducts and gallbladder is appropriate. Tumors may extend into the left or right hepatic duct, in which case a hepatic lobectomy or trisegmentectomy may be necessary. However, most tumors are unresectable. On exploration, no local metastatic disease is present. You perform a complete resection of the primary cholangiocarcinoma at the hepatic duct bifurcation. The patient recovers and asks about his prognosis. Q: What is your response? A: The survival rate for patients with Klatskin tumors is poor; most tumors are unresectable at the time of diagnosis. Although recent improvements have been made in the treatment of these tumors, the 5-year survival rate is still poor, with the best survival rates being 25%–40% for patients undergoing curative resection. Q: How would your response change if you performed only palliative stenting of the hepatic duct strictures after finding unresectable cholangiocarcinoma with local spread? A: The 5-year survival rate in patients undergoing palliative stenting for cholangiocarcinoma is less than 5% . The most common cause of death is locally invasive disease. Neither radiation nor chemotherapy has any proven long-term benefit in the treatment of cholangiocarcinoma.

Case 7.13 Other Biliary Tract Cancers

You are evaluating a 50-year-old for jaundice.

Q: How would you manage the following situations?

Case Variation 7.13.1. Diagnosis of ampullary adenocarcinoma ◆ ◆ The patient should have a complete evaluation similar to the preceding patient (see Case 7.12). If no metastases are present, exploration is necessary. Most ampullary cancers require a pancreatoduodenectomy (Whipple procedure) to remove the lesion. In contrast to pan- creatic cancer, ampullary cancer has a higher cure rate, with reported survival at 5 years as high as 65% (much higher than that for any other biliary cancer). Case Variation 7.13.2. Diagnosis of duodenal adenocarcinoma ◆ ◆ The management of duodenal tumors depends on the size and location of the lesion. If the tumor involves the ampulla, it is necessary to perform a pancreatoduodenectomy. Removal of a lesion in the first or fourth part of the duodenum may be possible with segmental re- section. Patients with duodenal cancers have a worse prognosis because their carcinomas usually involve nearby structures. Case Variation 7.13.3. A mass in the gallbladder fossa visible on ultrasound ◆ ◆ A mass in the gallbladder fossa is usually a malignant gallbladder adenocarcinoma. These tumors may cause symptoms similar to gallstones. CT is appropriate to evaluate the mass further and look for evidence of metastasis (Fig. 7-21). SAMPLE