EXAM #3: PANCREATIC CANCER Flashcards
Where is pancreatic cancer more prevalent geographically?
In well developed countries
What is the mortality associated with pancreatic cancer in the US?
4th leading cause of cancer mortality in the US
*Note that is also has the poorest prognosis of all cancers
Where is the pancreas located?
Retroperitoneal in close proximity to the duodenum
What are the two types of cells in the exocrine pancreas?
Acinar cells and duct cells
What is the most common type of pancreatic cancer?
Adenocarcinoma arising from the exocrine pancreas (90%)
How would you describe the histopathology of an adenocarcinoma?
- Well differentiated cuboidal cells
- Duct-like structures that contain mucin
What oncogene is highly associated with pancreatic carcinoma?
K-ras (90%)
What diseases are associated with pancreatic adenocarcinoma?
- FAP
- Peutz-Jeghers
- Von Hippel-Lindau
- MEN1
- HNPCC
- BRCA
- Familial atypical multiple mole melanoma (FAMMM)
What are the non-genetic risk factors for pancreatic cancer?
- Age older than 45
- Chronic pancreatitis
- Smoking
- DM
- Diet high in fat/meat
What chemical exposures are risk factors for pancreatic cancer?
B-naphthylamine
Benzidine
What surgical history is a risk factor for pancreatic cancer?
Partial gastrectomy
How does pancreatic cancer typically present?
1) Abdominal pain
2) Weight loss
3) Jaundice
4) Steatorrhea
5) Pruritus
Elderly patient that develops glucose intolerance
How is pancreatic cancer diagnosed?
1) Spiral CT with IV contrast
- Determines mets and resectability
2) Confirm with biopsy
What are the determinants of resectablilty in pancreatic cancer?
1) No extrapancreatic disease
2) No direct tumor extension into the celiac axis and SMA
What is the utility of ERCP in pancreatic cancer?
1) Detection of small tumors not seen on CT
2) Palliation of biliary obstruction
What sign on imaging is pathognomonic for pancreatic adenocarcinoma?
“Double-duct” sign
What is EUS?
Endoscopic US
What is the utility of EUS in pancreatic cancer?
1) Aid in diagnosis and characterization of lesion
2) Biopsy
EUS biopsy is associated with LESS peritoneal seeding compared to percutaneous CT guided biopsy
What are the most common sites of metastasis for pancreatic adenocarcinoma?
- Lung
- Liver
- Peritoneum
What stage are patients in when they start to experience symptoms of pancreatic cancer?
T3= local invasion of bowel, bile duct, and major vessels
What is the tumor marker for pancreatic cancer?
CA19-9
Localization of pnacreatic cancer to which region of the pancreas is associated with earlier diagnosis?
Head of the pancreas
What is associated with decreased serial CA 19-9 levels following treatment?
Increased survival
What is the primary goal of treatment in pancreatic cancer?
Symptom control
- Pain
- Weight loss
- Pruritus
How is pain controlled in pancreatic cancer?
1) Opiates
2) Celiac plexus neurolysis
How is weight loss managed?
Replacement of pancreatic enzymes
How is pruritus managed?
Anti-histamines
SSRI
Bile-acid binding resins
What procedure is used to resect the pancreas?
“Whipple procedure” or pancreaticoduodenectomy
Note that b/c of late stage diagnosis, 80-85% are NOT amenable to resection
How is pancreatic cancer medically managed?
Chemotherapy
1) 5-FU
2) Gemcitabine
*Note that 5-FU + Radiation was just as good as 5-FU alone
Generally speaking, what is the impact of intervention in the prognosis for pancreatic cancer?
Minimal–surgery buys more months than chemo, but both are only getting the patient more MONTHS
How common are cystic neoplasms?
Rare
What are the symptoms of a cystic neoplasm?
- Bloating
- Weight loss
- Obstructive jaundice
What is the most common type of cystic neoplasm?
Mucinous cystadenomas and Cystadenocarcinomas
What are the clinical features of Mucinous cystadenomas and Cystadenocarcinomas?
- More common in middle aged women
- Usually in body or tail of pancreas
What is intraductal papillary mucinous neoplasm?
Pancreatic precursor tumor
What are the clinical features of Intraductal papillary mucinous neoplasms?
- Men 60+
- Recurrent pancreatitis from mucin obstructing the pancreatic duct
How are Cystic Neoplasms worked up?
1) Abdominal CT
2) EUS
3) Biopsy
What is the treatment for symptomatic, malignant or potentially malignant cystic neoplasms?
Surgical resection
List the various types of endocrine tumors.
- Insulinoma
- Gastrinoma
- Glucagonoma
- VIPoma
- Somatostatinoma
What is the most common type of endocrine tumor?
Insulinoma
What type of symptoms are seen with Insulinomas?
Generally, hypoglycemia in younger individuals
What is Whipple’s Triad in Insulinomas?
1) Hypoglycemic sx.
2) Serum glucose less than 50 mg/dL
3) Relief with glucose adminstration
How is an Insulinoma diagnosed?
- 72 hour fast with insulin measurement
- Elevated c-peptide and proinsulin are confirmatory
What is the gold standard for imaging an insulinoma?
Intraoperative US and palpation
What is the typical presentation for Gastrinomas?
- Abdominal pain
- PUD
- GERD
- Diarrhea
How are Gastrinomas diagnosed?
1) Elevated serum gastrin
2) Secretin stimulation test
Where is the Gastrinoma triangle?
1) superior= cystic and common bile ducts
2) inferior= second and third parts of duodenum
3) medial= neck and body of the pancreas
How are Gastrinomas treated?
PPIs and surgical resection
