02-21 Pancreatic Cancer + Surgery Flashcards
At the end of this lecture, the learner should be able to: • Describe the clinical presentation of pancreatic cancer • Explain the appropriate work up and management of a patient with pancreatic cancer • Discuss the epidemiology and risk factors of pancreatic neoplasms • Describe the surgical procedures utilized in patients presenting with pancreatic cancer • Define what is meant by neo-adjuvant therapy, define the role of the medical oncologist, radiation oncologist and interdi
<p>
PanIN?</p>
<p>
Pancreatic intraepithelial neoplasm —microscopic papillary or flat non-invasive epithelial neoplasm arising in the pancreatic ducts. PanINs are characterized by columnar to cuboidal cells with varying amounts of mucin and degrees of cytologic and architectural atypia. PanINs usually involve ducts </p>
<p>
What are more favorable DDx for pancreatic cancer?</p>
<p>
Cystic masses in the pancreas</p>
<ul>
<li>
Many cystic neoplasms are benign or borderline.</li>
<li>
Serous cystadenoma</li>
<li>
Intraductal papillary-mucinous neoplasms**</li>
<li>
Mucinous cystic neoplasms**</li>
<li>
Some are pseudocysts (not neoplastic).</li>
</ul>
<p>
**Neoplasms with moderate dysplasia</p>
<p>
Pancreatitis can cause localized enlargement that looks like a neoplasm in imaging studies.</p>
<ul>
<li>
Autoimmune pancreatitis</li>
<li>
Paraduodenal pancreatitis (groove pancreatitis), involves head and duodenal wall.</li>
</ul>
<p>
List some of the less common pancreatic cancers (by benign, borderline and maligant) and give a few identifying features.</p>
<p>
BENIGN</p>
<ol>
<li>
Serous cystadenoma</li>
<li>
Mucinous cystadenoma</li>
<li>
Intraductal papillary-mucinous adenoma</li>
</ol>
<p>
UNCERTAIN MALIG/BORDERLINE</p>
<ul>
<li>
think mucus</li>
<li>
Good prognosis when resected.</li>
</ul>
<ol>
<li>
Intraductal papillary-mucinous neoplasm (IPMN) w/ mod. dysplasia</li>
<li>
Mucinous cystic neoplasm</li>
</ol>
<p>
MALIGANT </p>
<ol>
<li>
Ductal adenocarcinoma (~85%)
<ul>
<li>
Signet ring cell carcinoma</li>
<li>
Adenosquamous carcinoma (4%)</li>
<li>
Undifferentiated (anaplastic) carcinoma</li>
<li>
Mucinous non-­cystic carcinoma (a.k.a. colloid carcinoma)</li>
</ul>
</li>
<li>
Mucinous cystadenocarcinoma (1%)</li>
<li>
Intraductal papillary mucinous carcinoma (gone malig) (2-­3%)</li>
<li>
Acinar cell carcinoma (<1%) </li>
<li>
Pancreatoblastoma (<1%)</li>
<li>
Solid-­pseudopapillary carcinoma (<1%)</li>
</ol>
<p>
Pancreatic cancer in kids?</p>
<ul>
<li>
5-yr survival?</li>
<li>
histo appearance?</li>
</ul>
<p>
Pancreatoblastoma is the most common pancreatic neoplasm in young children (qqf chez adults)</p>
<ul>
<li>
Rare low-grade malignant tumor
<ul>
<li>
malignant but <strong>only ~35% metastatic</strong> at time of diagnosis.</li>
</ul>
</li>
<li>
5-year survival ~60%</li>
<li>
stem cell origin → Composed of primitive small cells mixed with acinar, ductal or islet cells.</li>
</ul>
<p>
Mostly dx of panc tumor in 20 y/o female?</p>
<p>
Solid-pseudopapillary neoplasm is characteristically found in teen-age or young women.<br></br>
Low grade malignant neoplasm<br></br>
Excision usually yields a cure.</p>
<p>
What if the patient is a 49 year-old female with a cystic mass in the tail of the pancreas?</p>
<p>
What if the patient is a 49 year-old female with a cystic mass in the <u><strong>tail</strong></u> of the pancreas?</p>
<p>
Mucinous cystic neoplasms (one of our moderately dysplastic ones)</p>
<ul>
<li>
have peak incidence in 45-50 yr-old women.</li>
<li>
Tend to occur in the tail</li>
<li>
Very rare in men.</li>
<li>
10-20% are malignant.</li>
<li>
generally good prognosis</li>
</ul>
<p>
Serous cystadenoma</p>
<ul>
<li>
Degree of malig?</li>
<li>
path/histo appearance?</li>
<li>
Age of onset?</li>
<li>
Where in pancreas?</li>
</ul>
<ul>
<li>
Most common <strong>benign</strong> tumor of the pancreas.
<ul>
<li>
Very few become malignant.</li>
</ul>
</li>
<li>
Multiple small cysts lined w/ cuboidal epithelium & classic <strong>honeycom</strong>b appearance</li>
<li>
Occur in adults of any age, but are <strong>most common in</strong>♀<strong>~66 yrs.</strong></li>
<li>
Most (50-70%) occur in the <strong>body or tail</strong> of the pancreas</li>
</ul>
<p>
Acinar Cell Carcinoma</p>
<ul>
<li>
Most common in</li>
<li>
Prognosis</li>
<li>
unique feature?</li>
</ul>
<ul>
<li>
Occurs at any age; p<strong>redominantly males</strong>.</li>
<li>
Aggressive but less so than ductal carcinomas;
<ul>
<li>
median survival 18 months (5-­ yr survival 10%)</li>
</ul>
</li>
<li>
Tumor cells produce exocrine enzymes, e.g. trypsin, chymotrypsin, lipase
<ul>
<li>
Lipase hypersecretion syndrome: 0-­15% of patients (with hepatic metastases)</li>
<li>
Subcutaneous fat necrosis, polyarthralgias </li>
</ul>
</li>
</ul>
<p>
Solid Pseudopapillary Tumor (aka Solid-­Cystic Tumor) </p>
<ul>
<li>
uncertain histogenesis</li>
<li>
primitive epithel cells (small, uniform cells w/ finely granular eosinophilic cytoplasm).</li>
<li>
Most common in <strong>young females</strong> (adol-35 yrs).</li>
<li>
<strong>Most are benign</strong>, but a few are invasive and more aggressive.</li>
<li>
Necrosis → cyst → forms pseudopapillary projections where tumor cells survive around blood vessels. </li>
</ul>
<p>
Mucinous cystic neoplasms (MCN):</p>
<ul>
<li>
Cystic neoplasm lined by mucin-­secreting epithelium, most often in body or tail.</li>
<li>
Almost always in <strong>women</strong>, usually age 40-­50. </li>
<li>
Graded into benign, borderline, malignant non-­invasive, and malignant invasive groups on the basis of the degree of epithelial dysplasia (mild, moderate, severe). </li>
</ul>
<p>
Intraductal papillary mucinous neoplasms (IPMN)</p>
<ul>
<li>
Intraductal mucin-secreting neoplasms that can become cystic.</li>
<li>
Arise throughout the pancreas, median age about 65, <strong>men>women.</strong></li>
<li>
Graded into benign, borderline, malignant non-invasive, and malignant invasive groups on the basis of the degree of epithelial dysplasia (mild, moderate, severe).</li>
<li>
becomes malignant (30-40%) >> MCN.</li>
</ul>
<p>
Generally speaking, how does age affect your guess as to what tumor a pancreatic neoplasm is? </p>
<p>
Ductal adenocarcinoma</p>
<ul>
<li>
Median age 66 years</li>
<li>
Uncommon under age 50</li>
<li>
Still: odds are that a mass found in older person's pancreas is ductal carcinoma</li>
</ul>
<p>
In patients </p>
<ul>
<li>
Think of other types of neoplasm, pancreatitis, pseudocyst</li>
<li>
If ductal ca, think of genetic predisposition</li>
</ul>
<p>
Major Points to Review</p>
<ol>
<li>
Pancreatic neoplasms occur in both sexes at any age.</li>
<li>
There are many types of pancreatic neoplasms, some are benign or in situ and curable.</li>
<li>
Accurate diagnosis guides management.</li>
<li>
Pancreatitis can cause masses and cysts that are indistinguishable from neoplasms by imaging.</li>
<li>
Histologic diagnosis is important.</li>
<li>
A diagnosis of pancreatic ductal adenocarcinoma remains bad news.</li>
</ol>
<p>
</p>
<p>
Resources to review</p>
<ol>
<li>
PPT for this lecture</li>
<li>
Notes, on Blackboard</li>
<li>
UpToDate - Wolters Kluwer
<ul>
<li>
Pathology of exocrine pancreatic neoplasms-I</li>
<li>
Pathology of exocrine pancreatic neoplasms-II</li>
</ul>
</li>
<li>
Netpath</li>
<li>
Robbins and Cotran, pathology textbook.</li>
</ol>
<p>
</p>
<p>
PResenting S/Sx of Pancreatic Cancer</p>
<p>
Cancer in head of panc</p>
<ul>
<li>
92% wt loss</li>
<li>
80% jaundice (b/c CBD blocked)</li>
<li>
72% pain</li>
<li>
64% anorexia</li>
</ul>
<p>
Cancer in the body/tail</p>
<ul>
<li>
100% weight loss</li>
<li>
87% pain</li>
<li>
43% weakness</li>
<li>
7% jaundice</li>
</ul>
