A SAMPLE FROM THE MOSS REPORTS:
TREATMENT OF CANCER
OF THE AMPULLA OF VATER
(NOTE: This is a sample section from a typical
This one happens to be on cancer of the Ampulla of Vater, a rare kind of
cancer that occurs in the small intestine. Since it is neither complete
nor up-to-date please do not try to use this information as
guidance in the treatment of this or any other kind of cancer. Moss Reports
are available on almost every kind of cancer, including both very common
and very rare situations.)
You have requested a report on the topic of cancer of the ampulla of
Vater. I will write about these tumors, but you will understand that I must
discuss this rare cancer in the context of a discussion of extra-hepatic
bile duct cancers in general.
When it comes to the alternative/complementary treatment of this disease,
I will have reference mainly to experiences with gallbladder cancer and
primary liver cancer. There simply is not a huge database available with
information on the outcome of such rare tumors using nonconventional methods.
We are mainly guided by analogy with more common, presumably similar, tumors.
Extrahepatic bile ducts are very rare, and tumors of the ampulla of Vater
are an even more unusual. How rare? On autopsy, about one in ten thousand
people is found to have a cancer of the bile duct. Fewer still have cancers
of the ampulla of Vater.
These "ampullary" tumors are obviously just a fraction of the
total. Here is a schematic diagram of the overall category of biliary tumors:
- Biliary Tract
- Bile Ducts
- Bile Ducts, Extrahepatic
- Common Bile Duct
- Vater's Ampulla
- Oddi's Sphincter
Tumors of Vater's ampulla arise from the epithelium where the whole bile
and pancreatic juice system enters the small intestines.
APPEARANCE: These tumors may be quite small, and upon operation
usually have a coarse, granular and mucosal surface. Microscopically, the
tumor is composed of malignant cells that form gland-like structures, which
is the hallmark of an "adenocarcinoma."
TUMOR TYPES: But adenocarcinoma is only one type of cancer possible
here. In fact, tumors of the hepatobiliary tree can come in a bewildering
variety of subtypes. These include carcinoma in situ; adenocarcinoma; papillary
adenocarcinoma; adenocarcinoma, intestinal type; mucinous adenocarcinoma;
clear cell adenocarcinoma; signet-ring cell carcinoma; adenosquamous carcinoma;
squamous cell carcinoma; small cell (oat cell) carcinoma; and undifferentiated
carcinoma. In addition, there can be malignant mesenchymal tumors, including
embryonal rhabdomyosarcomas, leiomyosarcomas, and malignant fibrous histiocytomas.
Some of these are so rare that if they occur (e.g. squamous cell) they warrant
an article in a medical journal!
Because of their scarcity and their complexity, really detailed and accurate
information on each one of these conditions is hard to come by; there are
few reliable statistics, and it is hard to find true "experts"
in its treatment. You also have to accept the fact that the experience with
these tumors in "alternative medicine" will of necessity be even
more limited. They will generally be treated by analogy with other, related
As stated, the ampulla of Vater is part of the extrahepatic (which means
"outside the liver") group of tubes and passages called the biliary
tract. This anatomical structure begins with the appearance of two large
ducts, called the right and left hepatic ducts, at the porta hepatis. Just
below this porta, these two ducts join to form what is called the hepatic
duct. This proceeds for another few centimeters, where it is joined by the
cystic duct, emerging from the gallbladder. The merger of the two results
is what is called the "common bile duct."
This common bile duct then continues downward through the head of the
pancreas. It is then joined by the main pancreatic duct (also called the
duct of Wirsung). The joining takes place at a slightly dilated area in
the wall (lumen) of the small intestines (the twelve-inch segment called
the "duodenum"). This dilated area is called the ampulla of Vater,
after Abraham Vater, a German anatomist of the 18th century, who first described
its structure. To confuse matters, some textbooks refuse to give Dr. Vater
his due, and call this structure that ampulla hepatopancreatica. Others
call it the duodenal ampulla. Whatever you call it, it is a well-defined
little structure which ends in a two to three centimter "nipple"
or "pimple" which goes by the name of the papilla of Vater. ("Papilla"
is Latin for nipple.)
Most people live and die without knowing they even have an ampulla or
a papilla of Vater. They generally only become an issue if they become blocked
by a stone, or if they become involved with a tumor, either malignant or
SYMPTOMS: The usual symptoms are painless jaundice, intermittent
or constant; fatigue, pruritis, fever, and nonspecific abdominal pain. Intestinal
hemorrhage or pancreatitis are also possible.
The clinical signs and symptoms of cancers of bile duct cancer (including
the ampulla of Vater) can mimic cancers of the common bile duct, the duodenum
or even the pancreas. In some ways they partake of features of each of these,
and can also involve these organs. But they have some features that set
them apart. For instance, the surface of these tumors are frequently necrotic
or ulcerated. They are occasionally infiltrating, mucous producing type,
or undifferentiated adenocarcinomas.
SPREAD: Ampulla carcinomas tend to spread by a local infiltration
of the walls of the adjacent common bile ducts, or the second portion of
the duodenum, or the head of the pancreas. If it spreads further it may
involve the portal or splenic veins, and clots within these vessels may
occur. It is said that local lymph nodes are involved in about one in every
four patients at the time of surgical diagnosis.
(There follows several pages of discussion on
EXTRAHEPATIC BILE DUCT CANCERS in general. This includes a discussion of
the pros and cons of surgery.)
TREATMENT OF INOPERABLE DISEASE: Patients who have inoperable
tumors, or tumors that have not been completely removed, are extremely unlikely
to be cured through conventional means. However, bile duct obstruction can
be relieved through surgery. This may be achieved through stents, placed
by operation, by endoscopy, or by certain "percutaneous" (through
the skin) techniques. Palliative radiation therapy may be beneficial to
some patients as well. Various clinical trials are underway on the use of
radiotherapy, with or without hyperthermia, as well as cytotoxic drugs in
the treatment of this disease. 5-FU, doxorubicin and mitomycin have been
reported to produce transient partial remissions in a minority of patients.
We shall have more to say about such trials below.
If an extra-hepatic bile duct cancer was removed surgically, but then
recurs, then the treatment options are about the same as for inoperable
disease. Prognosis is poor with conventional treatment. Relief of jaundice
will usually improve quality of life.
(Because this is a very rare kind of cancer, we
follow with a list of some international experts in its treatments. This
is not included for every kind of report, however.)
EXPERTS: This type of tumor is so rare that you certainly want
to find an expert to treat it, if possible. These are more likely to be
found at the major, comprehensive cancer centers than at local or regional
hospitals. Whenever an operative procedure has a relatively high mortality
rate this becomes extremely important. I don't think there is any single
outstanding international expert on this type of cancer. However, from my
reading and discussions I believe that the following individuals may have
considerable expertise in this disease. These are only to be taken as leads
for follow-up, not recommendations. Some of them may have retired from practice,
or only be involved in research at the moment.
U.S.A. The hospitals situated around the Harvard Medical School seem
to be prominent in this as in many other fields. For radiological diagnosis
of hepatobiliary tumors: Daniel M Chernoff, MD, Ph.D., Madeleine D Kraus,
MD and Douglass F Adams, MD at the Harvard Medical School. Rivera JA; Department
of Surgery, Harvard Medical School, Boston, Massachusetts, USA. For more
information about the Harvard Medical School you can contact Gina Mammone
by email, firstname.lastname@example.org.
(There then follows a list of three dozen international
experts on the treatment of Ampulla of Vater., giving their affiliations,
phone numbers, etc.)
After this, as in all The Moss Reports there is a discussion
of (a) clinics that provide alternative and complementary treatment
for this and related tumors; and (b) treatments that can be done at-home.
(Some of these may require the assistance of trained medical personnel.)
For more information on obtaining
a Moss Report, please contact Anne Beattie at our Brooklyn, New York office
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