(NOTE: This is a sample section from a typical Moss Report. 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 tumors.

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 benign.

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, gmammone@dsg.harvard.edu.

(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 at 718-636-4433.

Ralph W. Moss, Ph.D. is director of the The Moss Reports for cancer patients. Dr. Moss is the author of eleven books and three documentaries on cancer-related topics. He is or has been an advisor on alternative cancer treatments to the National Institutes of Health, the National Cancer Institute, the American Urological Association, Columbia University, the University of Texas, the Susan G. Komen Foundation and the German Society of Oncology. He wrote the first article on alternative medicine for the Encyclopedia Britannica yearbook. He is listed in Marquis Who's Who in America, Who's Who in the World, Who's Who in the East, and Who's Who in Entertainment (as a film documentarian). This Web site does not advocate any particular treatment for cancer. We urge you to always seek competent medical advice for all health problems, especially cancer. Before consulting our site please read our full Disclaimer statement.

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