Carcinoma of the pancreas Flashcards
What is the most common pancreatic neoplasm?
90% are ductal adenocarcinomas
What are the major risk factors for pancreatic cancer?
Cigarette smoking (2-3x) Chronic pancreatitis (10-15x) Diabetes Hereditary pancreatitis (50x)
Why is pancreatic cancer so lethal?
- Early diagnosis is rare. No screening methods, of diagnostic tumor marker
What determines the resectability of the pancreas?
Extension into portal vein/SMA/Nerves. Local involvement of spleen, adrenals, vertebral column, colon stomach
–>Perineural invasion is especially common in pancreatic carcinoma
What is a PanIN tumor?
Non-invasive epithelial neoplasm arising in the pancreatic ducts. Usually with varying amounts of mucin and cytologic changes.
It’s a carcinoma in situ with high rate of progression
What size ducts do PanINs show up in?
ducts <5 mm in diameter
What tumor markers are seen in PanIN-1?
K-ras mutation
PanIN-2?
p16 mutation
PanIN-3?
p53 and BRCA2 mutations. This is why there are MULTIPLE mutations at the time of diagnosis
What might give you a false positive for pancreatic cancer?
Cystic masses are often benign
Pancreatitis (esp autoimmune) can mimic pancreatic cancer
What are three main types of benign excorine tumors?
- serous cystadenoma
- Mucinous cystadenoma
- Intraductal papillary-mucinous adenoma
What type of neoplasm has a good prognosis when resected?
Intraductal papillary-mucinous neoplasm (IPMN)
Mucinous cystadenoma
What kind of neoplasm would you see in a child?
pancreatoblastoma. 5 year survival of 60%
What type of pancreatic cancer would you see in a teenage or young woman?
pseudopapillary neoplasm: excision=cure usually
What types of patients will have mucinous cystic neoplasms of the pancreas?
middle aged women. Very rare in men. 10-20% are malignant.
At what age does ductal adenocarcinoma present?
median age 66. Uncommon under the age of 50. It is BAD NEWS BEARS
Can you tell apart masses/cysts/neoplasms by imagin?
No. A histological diagnosis is important. Also, the many different types of neoplasms are treated differently.
What are the signs you would see in cancer in the head of the pancreas?
weight loss, jauncdice, pain, anorexia
What is different about cancer in the body/tail of the pancreas?
Weakness
Jaundice is RARE
What would you use to diagnose pancreatic cancer?
CT: staging info
ERCP: obtains tissue for biopsy
Serum tumor marker CA 19-9: Prognostic utility
Ultrasound: rule out gallstones and biliary ductal dilation
What percentage of pts present with resectable disease?
25% of pancreatic cancer patients. These patients do NOT have distant mets or mesenteric vessel involvement, with a fat plane buffer between the tumor an the SMA/celiac/PV/SMV
YOU CANNOT RESECT the SMA!
How do you tell if a pt is resectable?
CT
What are the palliative measures we can use in pancreatic cancer if mets seen?
biliary obstruction: stent
Celiac plexus nerve block for pain
What procedure do you use if a tumor is in the head of the pancreas? in the tail?
Head: Pancreaticoduodenectomy: Whipple
Tail: Distal pancreatectomy
What are complications from the whipple?
- Leaks from pancreaticojejunostomy
- Infections
- Poor gastric emptying
In resected patients, how many will be alive 5 years later?
25%
What can we do to prevent recurrence?
Adjuvant XRT
Even better is NEOADJUVANT XRT, which abolishes local recurrences
Why does neoadjuvant therapy work? Whats the rationale?
- Allows manifestation of distant metastases
2. Allows unresectable patients to become resectable through tumor shrinkage
What chemo do we use?
docetaxel/gemcitabine
What is the best test for detecting pancreatic cancer?
EUS is more sensitive than CT, esp small tumors
CT is helpful for staging.
Generally, you’ll ask for both.
