DEAR DR. ROACH: My husband was diagnosed with ampullary cancer. He has a tumor the size of a marble. We are told this is an aggressive cancer. My concern is that they are giving him chemotherapy before the Whipple surgery. Is this standard practice? — P.T.
ANSWER: The ampulla of Vater is an opening in the duodenum (the first segment of the small intestine), where the common bile duct releases bile and pancreatic enzymes to aid digestion. A cancer of the ampulla can originate from the pancreas, the bile duct or the duodenum, and these can all be aggressive cancers.
The standard approach in people with the possibility to be cured is called a pancreaticoduodenectomy, otherwise known as the Whipple procedure. Although this is a complex surgery that used to have a high mortality rate, in specialized centers, the risk of death from the procedure is now about 1%.
Most people are familiar with getting chemotherapy after surgery to help remove any cancer cells that remain after surgery, a technique called “adjuvant therapy.” However, giving chemotherapy before surgery (“neoadjuvant chemotherapy”) has increasingly been used in people with ampullary cancer. The idea is to shrink the tumor to make it easier for the surgeon to remove completely. Chemotherapy may also kill any cancer cells that have already spread.
The decision of when to use chemotherapy depends on the individual person’s situation, so I can’t tell you which would be better in your husband’s case, as I lack both the details of his tumor and the expertise. I can confirm that giving chemotherapy prior to surgery is being used in regards to ampullary cancer.
DEAR DR. ROACH: I am 22. I had an electrocardiogram (EKG) last year, which indicated an incomplete right bundle branch block and early repolarization of the ventricles. Are these two related to each other? Are they serious to any extent, knowing that I have no symptoms? How can my heart rate be normal if the ventricles repolarize early? — B.A.N.
ANSWER: Both early repolarization and an incomplete right bundle branch block are common findings in young people who are getting EKGs, usually as part of a school physical and often as an evaluation for athletes. Depolarization of the heart muscle is seen on the surface electrocardiogram and corresponds to the contraction of the ventricle (called the QRS waves). The muscle cells must then “repolarize” — that is, restore their electrical potential to be ready for the next contraction.
Early repolarization is a normal variant where the ventricle gets electrically ready for the next beat faster than average. In fact, one way to be sure that the EKG finding really does show early repolarization is to put the person on a treadmill to raise their heart rate. The early repolarization will then go away, since faster repolarization is appropriate for a quicker heartbeat.
About 15% of young athletes with early repolarization will also have an incomplete right bundle branch block, which represents slowing of the electrical impulses within the ventricles and a widening of the QRS complex.
Fortunately, these findings almost never represent serious disease in people with no symptoms.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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