Periampullary cancer

The silent killer

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THE DEATH of actor Rodolfo “Rudy” Fernandez, who took up college units at UST, has brought to fore the unheard of fury of periampullary cancer, a rare tumor that grows in the gastrointestinal tract. With news of the actor’s death preoccupying national media, the question on the back of many minds is how exactly the unknown disease can kill.

Periampullary cancer occurs when a tumor grows around the ampulla of Vater, a duodenal duct which evolves from the meeting point of the pancreatic and bile ducts.

“Periampullary means ‘surrounding the ampulla,’ so this cancer may involve the pancreas, bile duct, and even gallbladder tumors,” said Dr. Frederick Dy, a resident physician of the UST Hospital’s Department of Gastroenterology.

Also known as the hepatopancreatic ampulla, the ampulla of Vater serves as passageway of bile and pancreatic juices from the liver, pancreas, and gallbladder to the small intestine, helping in digestion.

According to Dr. Teresa Sy Ortin, head of the Department of Radiation Oncology of the Benavides Cancer Institute, people with periampullary cancer may experience abdominal pain, indigestion, and weight loss. In the late stages, it can cause obstruction in the outflow of bile—a digestive fluid that aids in the digestion of lipids—causing painless jaundice, a condition characterized by yellow skin.

“The cancer may ultimately cause liver failure and bowel obstruction which may lead to blood infection and death,” Ortin told the Varsitarian.

Dr. Jaime Ignacio, immediate past president of the Philippine Society for Gastroenterology, described periampullary cancer as a “rare” disease which affects one in every 1,000 people (0.1 percent).

“Just like any other tumor, the exact cause of periampullary cancer is not yet known,” he said.

Ortin added that unlike other cancers, such as that of the lungs which puts smokers at high risk, periampullary cancer does not target a specific group of people.

“Anybody can contract this type of cancer,” she said.

Dy said that in a month, the department, to which small hospitals refer periampullary cancer cases, admits four or five patients positive with the disease.

Tumor-hunting

One way to confirm the cancer’s presence is through gastroscopy, a procedure performed by inserting a tube into the patient’s intestine to observe the ampulla.

Another way is by performing a computed tomography scan, which involves the use of x-rays to allow a three-dimensional assessment of the duct. Another test is the endoscopic retrograde cholangiography, which examines the pancreas and the bile ducts using a tube to view the area. It also serves as a passage for dye which makes the pancreas and bile ducts visible in an x-ray.

Meanwhile, magnetic resonance cholangiopancreatography employs magnetic resonance imaging to provide pictures of the biliary and pancreatic ducts to determine the presence of a tumor.

According to Ortin, periampullary cancer has several symptoms such as ulcer-related sensations, detected upon a certain degree of suspicion.

“Not many people who complain of these non-specific symptoms would come in to get confirmatory tests for this cancer, which yields only one out of 10 positive results. Moreover, doctors would not probably do the tests immediately,” Ortin said.

It may be difficult to distinguish periampullary from pancreatic cancer because the pancreas are near the ampulla of Vater, Ortin added.

“Sometimes, a tumor that we find in the area gets large that we cannot determine where it originated from,” Ortin told the Varsitarian.

If the cancer is detected early, a patient may be treated by surgery followed by chemotherapy, radiation therapy, and constant monitoring. However, if the cancer has spread to other organs, palliation, a treatment performed to relieve a disease’s symptoms instead of curing it, may be done.

To treat periampullary cancer, diagnosis is performed first through gastroscopy followed by a biopsy, or getting tissues from a specific body part to be examined under the microscope.

Once cancer is detected, classification of its stage is done to determine if it has spread so that treatment can be planned. After that, surgical methods are considered.

With a survival rate of four out of 10, patients are declared free from cancer if the tumor disappears within two years, according to Ignacio.

In Fernandez’ case, surgery was performed to remove the tumor. However, he opted not to take additional treatment afterwards. A year after, two tumors appeared, one on his liver and another on the site of the surgery. Additional treatments became ineffective and only alleviated the symptoms. He responded to the treatment but eventually his illness progressed due to the advanced stage of the cancer. The last treatment he underwent was gene therapy which alters a gene to make cancer cells more sensitive to other kinds of therapy.

Many of patients of the Benavides Cancer Institute have been diagnosed with the cancer in its advanced and incurable stage. The multidisciplinary approach is used 3to treat them. This approach involves the collaboration of surgeons, medical oncologists, and radiological oncologists in looking for possible procedures to remedy the patient’s illness.

“In complex situations, such as the occurrence of a rare type of cancer, we gather doctors together to devise a plan to help the family deal with the cancer patient,” Ortin said.

Vol. LXXX, No. 1 • June 30, 2008

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