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Written Boards - Final > Pancreas > Flashcards

Pancreas Flashcards

1
Q

Describe chronic panc procedures

A
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2
Q

What does pancreatic mass bx with diffuse lymphocytic invasion indicate

A

Autoimmune panc

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3
Q

How did the Halsted 1898 operation differ from WHipple in 1935

A

just the 2nd portion of the duo

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4
Q

Original periop mortality? for periampullary ca
after tert centers
and now

A

20-40
5
2

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5
Q

4 risk for pancreatic cancer

A

Smoking, obesity, DM2, and 1st degree relatives

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6
Q

5 y survival for PDAC

A

7%

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7
Q

how many are surgical candidates for PDAC? how many of those make 5 years

A

20%; 20%

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8
Q

2 risk factors for distal cholangio

A

liver flukes
PSC

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9
Q

Only good thing about ampullary ACA

A

early obstruction

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10
Q

Duodenal adeno is what % of SB CA; associated syndrome

A

56; FAP

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11
Q

tumor marker for panc

A

cA 19-9

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12
Q

What is the imaging modality of choice for PDAC? How does it appear?

CholangioCA?

A

Hypodensity surrounded by normal appearing tissue

OFten not seen —>CBD thickening seen

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13
Q

What ‘sign’ can be seen radiologically for periampullary ca

A

double duct — PD and CBD

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14
Q

T staging for periampullary CA

A

0-2
2-4
>4
local vessels

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15
Q

Periampullary ca stage 2b - 3 diff

A

N2

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16
Q

What defines abuttment

A

loss of fat plane on imaging

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17
Q

Whipple 6 big steps

A

1 - Met eval, full kocher to L renal v, expose Portal and SMV, LN harvest
2- Lesser sac,

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18
Q

3 post operative tenets for whipple

A

Early feeding, early drain removal(3days), zero fluid balance

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19
Q

3 major complications following whipple early post op

A

DGE, POPF, PPH

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20
Q

Post op whipple hemorrhage causes eary v late

A

technical error

inflammation from panc leak —-> GDA PSA

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21
Q

POPF grading scale

A
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22
Q

5 year survival rate for all panc adenoca

A

7%

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23
Q

3 methods of non op biliary obstruction managmennt

A

endo stent> perc stent> perc drain

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24
Q

difference in biliary stents

A

plastic temp

metal long term 12m, covered stents have better patency against overgrowth but can migrate

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25
Q

non op options for GOO do to panc adenoca, what type of patient
success rate?

A

stent if less than 6 months predicted
96%

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26
Q

3 operative palliative procedures for panc adenoca

A

roux choledocho
GJJ
Celiac neurolysis

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27
Q

Describe celiac neurolysis procedure

A

50% ethanol injection either side of aorta

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28
Q

Side effects folfirinox v gemcit

A
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29
Q

Why does all panc adeno get systemic therapy at some point

A

It is considered systemic disease at dg

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30
Q

Borderline cutoffs: artery, vein and extrapancreatic

A

Artery: <180 abuttment sma and celiac, short encasement CHA

Vein:>180 SMV/PV; < 190 with contour irreg or thrombosis

Extra: Suspicious mets(10-20% will have radiographically occult disease

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31
Q

2 arguments against the conko 001 adjuvant trial

A

Heavy bias
only 50% received it

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32
Q

5 Neo adjuvant for PDAC pros and 3 cons

A

Pros:
-all pts treated
-aggressive tumors identified by response
incs rads efficacy
-dec fistula
dec pos margins

Cons:
- Needs endo bx
- possible endo stent
- possible loss of “window” (2%)

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33
Q

how long is neo chemo for pdac

A

2 months

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34
Q

Schedule for resectable pdac including neo

what is included in restaging

A

neo 2 m, RS, surgery, RS, adj 4 months

CTDP
CA19-9
ECOG

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35
Q

ECOG scale

A
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36
Q

Describe a serous cystadenoma

Appearance on CT

FNA results

A

benign, true epithelial lining with glyogen rich cuboidal cells

starburst, honeycomb

low cea, low mucin, atypia on FNA

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37
Q

Tx for serous cystadenoma

A

AS: obs
Sympt/growing: resect

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38
Q

What radiologic characteristic of some serous cystad may cause dg confusion

What additional test do we perform

A

multicystic

FNA

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39
Q

describe rads findings for mucinous cystic neoplasm

typical pt demographic

Cell type found

A

singular, thick walled, large

female 9:1

ovarian type stroma

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40
Q

ovarian type stroma is dg for what panc mass

A

mucinous cystic neo

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41
Q

what is often radiographically confused with mucinous cystadenoma

What 2 labs can diff on fna

A

pseudocyst

amy up in pseudo
CEA above 200 is pathognomonic for mucinous cystic ne

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42
Q

Tx for mucinous cystic neo

A

resection

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43
Q

This panc pathology mimics PDAC radiographically and clinically

A

Autoimmune panc

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44
Q

IgG4 s serology used to dg what

A

autoimmune panc

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45
Q

Describe the histopathology findings for AIP

A

periductal lymphoplasmocytic infiltration with obliterative phlebitis

Lymph infilt w/ storiform fibrosis and Igg4 cells

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46
Q

Tx for AIP

What to monitor for after starting tx

A

steroids

watch IgG4 and CA19-9 (occult malign monitoring)

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47
Q

how does acinar cell ca differ from pdac radiologically

A

hyperenhancing borders rather than discrete

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48
Q

What fna finding separates acinar cell ca

tx?

A

lipaase

resection

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49
Q

What is Schmid’s triad

A

eosinophilia, polyarthralgia and eerythema nodosum found in acinar cell ca

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50
Q

Elevated LDH found on FNA with lobulated panc mass

what is needed for treatment

what is tx

A

lymphoma

tissue

CHOP

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51
Q

CHOP regimen and side effects

A
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52
Q

MC origin of met disease in panc, apearance on CT

A

RCC

hypervasce

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53
Q

who revolutionized vascular transplant techniques and when

A

Alexs Carrell of France in 1300

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54
Q

4 selection criteria for panc transplant

A

under 55
not obese
brittle diabetics with end stage dyfunction
Failed medical tx

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55
Q

preferred procurement host

preferred specimen on gross

A

bmi less than 30
under 50

soft
pink

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56
Q

Ransons criteria

A
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57
Q

Atlanta Criteria

A
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58
Q

abx tenets for AP

A

hold unless obvious infection

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59
Q

decision algorithm for chol mild gs panc vs severe

A

chole same stay vs 6 weeks for severe

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60
Q

what is the mortality % for sev panc with more than 48h of SIRS

A

25

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61
Q

What percent of panc resections does IPMN account for

A

25

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62
Q

Cytology for IPMN

A

inc CEA and amylase

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63
Q

oncogenes for ipmn
fam hx for ipmn

A

KRAS/GNAS
Panc CA hx

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64
Q

3 high risk stigmata for ipmn

A

jaundice
10mm pd
mural nodule>5mm

65
Q

7 worrisome features for ipmn

A

mural nodule <5mm, PD 5-9mm, >3cm, thick wall, LN involv, inc CA19-9, grows >5mm in 2y, abrupt caliber change in PD

66
Q

Observation of ipmn by size classification

A

<1cm: 6m then q2y
1-2cm: 6 6 1 1 2
2-3cm: EUS 3-6m, then MRI q1y
>3cm : push surgery, EUS q 3-6m

67
Q

How many people with IPMN resections are symptomatic

what is a major associated comorbidity

A

50

DM

68
Q

cancer and dyplasia rates for bd v md ipmns

A

BD: 15 and 9
MD 44 and 33

69
Q

What CA19 9 level is concerning for IPMN, what is the ppv at this pointq

A

100

92%

70
Q

What is the imaging modality and what might be even better for ipmn

A

MDCT panc protocol

MRI/MRCP

71
Q

epithelial types for BD and MD Ipmn

A

gastric

intestinal

72
Q

Post resection 5 y survival invasive v non for ipmn

A

47
93

73
Q

margins for ipmn?

A

controversial

74
Q

most common functional pnet
s/s
tx

A

insulinoma
hypoglycemia
enucleation

75
Q

vipoma triad

A

diarrhea acholorydria hypokalemia

76
Q

pnet for necroltyic migratory erythema

management

A

glucagonoma

lanreotide then surgery(aggressive)

77
Q

What s/s show up for SSoma

A

cholelithiasis
dm2
steatorrhea

78
Q

what testing is done for insulinoma dg and what 3 criteria are met

A

72h fast
gluc<45
insulin>5inc proinsuilin and c pep

79
Q

imaging modality of choice for pnet

what did it used to be

A

PET DOTATATE 68 GA DOTA peptide

SS scan

80
Q

2 metastatc pnet treatments and their receptor types

when can mets be operated on

A

everolimus(mtor)
sunitinib(rtki)

iso liver

81
Q

pnet size cutoff for aggressive surgical resection

A

2-3cm

82
Q

Describe Appleby procedure

A
83
Q

what is the initial insult starting acute panc

then what 2 additional things happen

A

edema/microangiopathic change

dec blood flow

cell death and exocrine release

84
Q

Main goal of initial resus in severe panc

A

hydrate till they piss

10-20 ml/kg/h of LAR for 24-48h

plus goal directed

85
Q

chronic panc mutations

A

PRSS1 - trypsin
CFTR - CF
SPINK1 - trypsin inhib gene

86
Q

acute panc causes:

meds?

A

sulfanomides, azothiaprine, thiazides

87
Q

Bimodal mortality distribution with severe pancreatitis

A

earlier than 2 weeks = MSOF
Later = infection

88
Q

exocrine syfunction s/s

A

steatorrhea, weight loss, cramping with fat intake

89
Q

what are the grades of pancreatitis determined by?

classes and timing cutoff?

A

organ dysfunction

none
48h
Ongoing

90
Q

Ranson criteria?

A
91
Q

What bx finding is dg for autoimmune panc

A

lymphocyte only infiltration

92
Q

Tx for autoimmune panc?

A

Corticosteroids

93
Q

Odds of recurrent GS panc if no chole?

A

25% within 3 months

94
Q

symptoms of insulinoma(triad)

A
95
Q

Diseases associated with MEN 1?

What is the gene involved and its inheritance pattern?

4 people to screen

A

parath, pnet, pituitary

menin, AD

fam hx, MENi lesion plus adrenal, prolactinoma, primary hyperpth at young age and normal kidneys

96
Q

Alpha cells produce….

A

glucagon

97
Q

beta cells produce…

D….

D2…..

A

insulin

gastrin and ss

vip

98
Q

4 VHL diseases

inh pattern?

A

Pheo, pnet, RCC, hemangioplastomas

AD

99
Q

Labs for all PNETs

A

Insulinoma - fasting glu < 50, increased insulin with equivalent c peptide

glucagonoma - gluc> 1,000

gastrinoma - gastrin>1,000, ph<2 2 weeks off PPI
confirm: secretin stim

VIPoma - VIP 225-2000 overnight

Somatostatinoma - Fasting SS >160

NF - chromogranin A and panc PP

100
Q

s/s for all pnets

A

insulinoma - whipples

gastrinoma r PUD

glucagonoma - diabetes, necrolytic migratory erythema, dermatitis, DVT

SS - diarrhea, gallstones, diabetes, hypochlor

VIP - watery diahrea, achlorydria, hypok, met acidosis

101
Q

2 ddg to keep in mind for eval for insulinoma

A

gastric surgery history and exogenous use

102
Q

exogenous insulin lab make up?

A

elevated c peptide compared to insulin

103
Q

CT findings differentiating PNET from adenoCA? Why is that?

A

Pnet is hypervascular in arterial phase while adeno is not– hypoattenuating

104
Q

What is a PNET specific scan? The exception?

A

PET DOTATATE

insulinoma

105
Q

how is malignancy determined for PNETs?

2 categories for pnet grading and values

A

absence or presence of malignancy

106
Q

metastatic incidence upon pnet dg and survival rates

A

Life expectancy with various PNETs:

Insulinoma
Possible short-lived hyperglycemia on successful resection of insulinoma
Normal life expectancy in benign disease

Gastrinoma
Metastatic on presentation: 50%
10-year survival
Nonaggressive forms: may be 90%
Aggressive forms: may be 30%

VIPoma
Metastatic on presentation: more than 70%
5-year survival: approximately 70%

Somatostatinoma
Metastatic on presentation: 90%
5-year survival: 30% to 60%

Glucagonoma
5-year survival: 85%
5-year survival with metastatic disease: 60%

107
Q

treatment for localized pnets?

A

enucleate insulinomas if 2mm away from MPD, otherwise formally resect

gastrinoma - duodenotomy if not obvious to look for mass, usually in duo

108
Q

treatment for metastatic pnet disease in general

A

SS analogues
everolimus for insulinoma

liver embo?

109
Q

Panc 5 year survival rates

A

Resectability

5-year observed survival

Resectable

15% to 20%

Locally advanced

11

Metastatic

2%

110
Q

PDAC hereditary RFs

A
111
Q

PDAC staging

A

+/- dg lap ——for borderline, tumors>3cm, CA19-9 >150

CT CAP always

EUS maybe, need tissue for adjuvant

112
Q

4 possible solidpanc masses

A

PDAC, acinar cell, pseudopapillary, net

113
Q

RFs for PDAC non her

A

smoking, etoh, chronic panc , hep b

114
Q

3 s/s of PDAC

A

LUQ pain
painless jaundice
weight loss!!!

115
Q

border line resectable PDAC

A

> 180 smv/pv without distortion
<180 smv/pv with distortion

CHA

SMA<180

116
Q

non resectable PDAC

A

> 180 veins with distortion
180SMA
celiac
ascites
mets

117
Q

resectable pdac

A

<180 smv/pv without distortion

118
Q

Who should get neo for pdac?

Regimen options?

A

all, better compliance, stress test, tumor bio, better results

Folfirinox for strong patients or borderline

Gem/cap for weaker – better tolerated

119
Q

FOLFIRINOX MOAS and main adverse effects

A

5FU - pyrimidine analogue RNA - myelosuppression
Irinotecan - topoisomerase inhib
Oxiplatin - myelosuppression, periph neuro

120
Q

Preffered adjuvant chemo for pdac

A

gem and acp —-ESPAC 4

121
Q

2 procedures for chronic panc head disease plus ductal dilation

procedure for isolated ductal dilation

procedure for head only disease

What is the indication for a total

A

frey and beger

peustow

whipple

minimal change or small duct

122
Q

describe frey

A
123
Q

describe beger

A
124
Q

success rates of chronic panc drainage procedures?

A

60-70%

125
Q

new onset chances after beger or frey

A

25%

126
Q

acinar panc cells secrete these 2

what are the stimulated by

A

trypsin and lipase

cck, secretin

127
Q

alcohol effect on acinar panc cells

A

ROS, ethyl ester direct damage
protein precip leads to ductal obstruction and damage
acetaldehyde damages cells

128
Q

percent etoh chronic panc patients

A

70%

129
Q

combined risk factors for chrnic panc

A

smoking and etoh

130
Q

4 chronic panc complications

A

ascites, pleural, thrombosis, pseudocyst

131
Q

hereditary panc number one gene

A

PRSS1

132
Q

2 panc insuff tests

A

elastase 1 <100 in stool
fat >7g/d in stool

133
Q

imaging or diagnostics from chronic panc

A

CT
ERCP

134
Q

non op tx for chronic panc

nutritional support for chronic panc?

A

zenpep
vitamins
plexus block

TPN v enteral(better)

135
Q

Panc cyst chart:
Amylase
mucin
cyto
cea

cyst appearance on imaging
distribution
ages?

A
136
Q

central starburst calcs on imaging of pancreas

A

SCN

137
Q

: thick walled, septated macrocyst with smooth contours with or without a solid component; eggshell calcifications

in pancreas

malignants

A

MCN

mostly benign but malign potential

138
Q

poorly demarcated, lobulated, polycystic mass with dilation of main or branch/side ducts; communication with ducts

cea and amylase levels

age

A

ipmn

high for both

60s

139
Q

malignant risk in ipmn branch v main

A

15% v 30-50%

140
Q
A
141
Q

subtypes of ipmn and their MD v BD prevalence

MC type

A

intestinal mainly MD
gastric mainly SB
PB - mixed

gastric - SB

142
Q
A
143
Q

how does ipn usually present

A

incidental finding

144
Q

IPMN imaging

A

MRCP, CT panc, EUS

145
Q

IPM high risk sequelae

A

jaundice
1cm MPD
enhancing solid component in cyst

146
Q

Worrisome IPMN features

A

3 cm cyst
thick wall
MPD5-9mm
Pancreatitis
Lymph
sharp change in duct caliber
nonenhancing mural nodule

147
Q

SCN treatment

A

resect if symptomatic

148
Q

MCN tx

A

resect always

149
Q

IPMN surgical management indications

A

High-grade dysplasia or invasive cancer

Surgical resection (recommended)
Extent of resection: determined by the location, number, and size of lesions

No confirmed malignancy or invasive cancer

Resection for MD-IPMN
Main duct greater than 10 mm
Main duct 5 to 9 mm if good surgical candidate and life expectancy greater than 10 years

Resection for BD-IPMN
Main duct greater than 10 mm
Jaundice
Worrisome features

150
Q
A

Invasive IPMN

Necessity for consideration of adjuvant therapy (medical oncology) with chemotherapy with or without radiation therapy
Risk of recurrence of 25% to 50% * Imaging at 3 to 6 months and then every 3 to 9 months

Noninvasive IPMN
Risk of recurrence of 5%
Imaging yearly

150
Q

for MD Ipmn resection what should be sent durign resection

A

frzen

151
Q

IPMN low risk non op surveillance schedule per size

A

Less than 1 cm: MRI or CT in 6 months, then every 2 years if no change

1 to 2 cm: MRI or CT every 6 months for 1 year and then yearly for 2 years. If there is no change, lengthen the interval up to 2 years.

2 to 3 cm: EUS in 3 to 6 months. Then lengthen the interval up to 1 year, alternating MRI with EUS as appropriate. Consider surgery in young, fit patients with a need for prolonged surveillance.

More than 3 cm: close surveillance alternating MRI with EUS every 3 to 6 months. Strongly consider surgery in young, fit patients.

152
Q

op ipmn surveillance

A

Invasive IPMN

Necessity for consideration of adjuvant therapy (medical oncology) with chemotherapy with or without radiation therapy
Risk of recurrence of 25% to 50% * Imaging at 3 to 6 months and then every 3 to 9 months

Noninvasive IPMN

Risk of recurrence of 5%
Imaging yearly

153
Q

MC congenital pancreatic anomaly/

what is it?

A

divisum

154
Q

endo tx for divisum

surgical?

A

minor sphincterotomy

sphincterotomy or peustow

155
Q

7 main causes of splenomegaly

A

Hereditary spherocytosis
Sickle cell disease
Thalassemia
Hodgkins lymphoma and non-Hodgkins lymphoma
Acute myeloid leukemia, chronic myeloid leukemia, and chronic lymphocytic leukemia
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
Immune (idiopathic) thrombocytopenic purpura (ITP)

156
Q

Ethnic descents and inh patterns:
SSD
B thal
her sphero

A

african - AR
mediteranean - AD
european - AD

157
Q

new medical ITP treatment

A

thrombopoeitn agonists

158
Q
A

Written Boards - Final (21 decks)

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