Pancreas Flashcards
Describe chronic panc procedures
What does pancreatic mass bx with diffuse lymphocytic invasion indicate
Autoimmune panc
How did the Halsted 1898 operation differ from WHipple in 1935
just the 2nd portion of the duo
Original periop mortality? for periampullary ca
after tert centers
and now
20-40
5
2
4 risk for pancreatic cancer
Smoking, obesity, DM2, and 1st degree relatives
5 y survival for PDAC
7%
how many are surgical candidates for PDAC? how many of those make 5 years
20%; 20%
2 risk factors for distal cholangio
liver flukes
PSC
Only good thing about ampullary ACA
early obstruction
Duodenal adeno is what % of SB CA; associated syndrome
56; FAP
tumor marker for panc
cA 19-9
What is the imaging modality of choice for PDAC? How does it appear?
CholangioCA?
Hypodensity surrounded by normal appearing tissue
OFten not seen —>CBD thickening seen
What ‘sign’ can be seen radiologically for periampullary ca
double duct — PD and CBD
T staging for periampullary CA
0-2
2-4
>4
local vessels
Periampullary ca stage 2b - 3 diff
N2
What defines abuttment
loss of fat plane on imaging
Whipple 6 big steps
1 - Met eval, full kocher to L renal v, expose Portal and SMV, LN harvest
2- Lesser sac,
3 post operative tenets for whipple
Early feeding, early drain removal(3days), zero fluid balance
3 major complications following whipple early post op
DGE, POPF, PPH
Post op whipple hemorrhage causes eary v late
technical error
inflammation from panc leak —-> GDA PSA
POPF grading scale
5 year survival rate for all panc adenoca
7%
3 methods of non op biliary obstruction managmennt
endo stent> perc stent> perc drain
difference in biliary stents
plastic temp
metal long term 12m, covered stents have better patency against overgrowth but can migrate
non op options for GOO do to panc adenoca, what type of patient
success rate?
stent if less than 6 months predicted
96%
3 operative palliative procedures for panc adenoca
roux choledocho
GJJ
Celiac neurolysis
Describe celiac neurolysis procedure
50% ethanol injection either side of aorta
Side effects folfirinox v gemcit
Why does all panc adeno get systemic therapy at some point
It is considered systemic disease at dg
Borderline cutoffs: artery, vein and extrapancreatic
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
2 arguments against the conko 001 adjuvant trial
Heavy bias
only 50% received it
5 Neo adjuvant for PDAC pros and 3 cons
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%)
how long is neo chemo for pdac
2 months
Schedule for resectable pdac including neo
what is included in restaging
neo 2 m, RS, surgery, RS, adj 4 months
CTDP
CA19-9
ECOG
ECOG scale
Describe a serous cystadenoma
Appearance on CT
FNA results
benign, true epithelial lining with glyogen rich cuboidal cells
starburst, honeycomb
low cea, low mucin, atypia on FNA
Tx for serous cystadenoma
AS: obs
Sympt/growing: resect
What radiologic characteristic of some serous cystad may cause dg confusion
What additional test do we perform
multicystic
FNA
describe rads findings for mucinous cystic neoplasm
typical pt demographic
Cell type found
singular, thick walled, large
female 9:1
ovarian type stroma
ovarian type stroma is dg for what panc mass
mucinous cystic neo
what is often radiographically confused with mucinous cystadenoma
What 2 labs can diff on fna
pseudocyst
amy up in pseudo
CEA above 200 is pathognomonic for mucinous cystic ne
Tx for mucinous cystic neo
resection
This panc pathology mimics PDAC radiographically and clinically
Autoimmune panc
IgG4 s serology used to dg what
autoimmune panc
Describe the histopathology findings for AIP
periductal lymphoplasmocytic infiltration with obliterative phlebitis
Lymph infilt w/ storiform fibrosis and Igg4 cells
Tx for AIP
What to monitor for after starting tx
steroids
watch IgG4 and CA19-9 (occult malign monitoring)
how does acinar cell ca differ from pdac radiologically
hyperenhancing borders rather than discrete
What fna finding separates acinar cell ca
tx?
lipaase
resection
What is Schmid’s triad
eosinophilia, polyarthralgia and eerythema nodosum found in acinar cell ca
Elevated LDH found on FNA with lobulated panc mass
what is needed for treatment
what is tx
lymphoma
tissue
CHOP
CHOP regimen and side effects
MC origin of met disease in panc, apearance on CT
RCC
hypervasce
who revolutionized vascular transplant techniques and when
Alexs Carrell of France in 1300
4 selection criteria for panc transplant
under 55
not obese
brittle diabetics with end stage dyfunction
Failed medical tx
preferred procurement host
preferred specimen on gross
bmi less than 30
under 50
soft
pink
Ransons criteria
Atlanta Criteria
abx tenets for AP
hold unless obvious infection
decision algorithm for chol mild gs panc vs severe
chole same stay vs 6 weeks for severe
what is the mortality % for sev panc with more than 48h of SIRS
25
What percent of panc resections does IPMN account for
25
Cytology for IPMN
inc CEA and amylase
oncogenes for ipmn
fam hx for ipmn
KRAS/GNAS
Panc CA hx
3 high risk stigmata for ipmn
jaundice
10mm pd
mural nodule>5mm
7 worrisome features for ipmn
mural nodule <5mm, PD 5-9mm, >3cm, thick wall, LN involv, inc CA19-9, grows >5mm in 2y, abrupt caliber change in PD
Observation of ipmn by size classification
<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
How many people with IPMN resections are symptomatic
what is a major associated comorbidity
50
DM
cancer and dyplasia rates for bd v md ipmns
BD: 15 and 9
MD 44 and 33
What CA19 9 level is concerning for IPMN, what is the ppv at this pointq
100
92%
What is the imaging modality and what might be even better for ipmn
MDCT panc protocol
MRI/MRCP
epithelial types for BD and MD Ipmn
gastric
intestinal
Post resection 5 y survival invasive v non for ipmn
47
93
margins for ipmn?
controversial
most common functional pnet
s/s
tx
insulinoma
hypoglycemia
enucleation
vipoma triad
diarrhea acholorydria hypokalemia
pnet for necroltyic migratory erythema
management
glucagonoma
lanreotide then surgery(aggressive)
What s/s show up for SSoma
cholelithiasis
dm2
steatorrhea
what testing is done for insulinoma dg and what 3 criteria are met
72h fast
gluc<45
insulin>5inc proinsuilin and c pep
imaging modality of choice for pnet
what did it used to be
PET DOTATATE 68 GA DOTA peptide
SS scan
2 metastatc pnet treatments and their receptor types
when can mets be operated on
everolimus(mtor)
sunitinib(rtki)
iso liver
pnet size cutoff for aggressive surgical resection
2-3cm
Describe Appleby procedure
what is the initial insult starting acute panc
then what 2 additional things happen
edema/microangiopathic change
dec blood flow
cell death and exocrine release
Main goal of initial resus in severe panc
hydrate till they piss
10-20 ml/kg/h of LAR for 24-48h
plus goal directed
chronic panc mutations
PRSS1 - trypsin
CFTR - CF
SPINK1 - trypsin inhib gene
acute panc causes:
meds?
sulfanomides, azothiaprine, thiazides
Bimodal mortality distribution with severe pancreatitis
earlier than 2 weeks = MSOF
Later = infection
exocrine syfunction s/s
steatorrhea, weight loss, cramping with fat intake
what are the grades of pancreatitis determined by?
classes and timing cutoff?
organ dysfunction
none
48h
Ongoing
Ranson criteria?
What bx finding is dg for autoimmune panc
lymphocyte only infiltration
Tx for autoimmune panc?
Corticosteroids
Odds of recurrent GS panc if no chole?
25% within 3 months
symptoms of insulinoma(triad)
Diseases associated with MEN 1?
What is the gene involved and its inheritance pattern?
4 people to screen
parath, pnet, pituitary
menin, AD
fam hx, MENi lesion plus adrenal, prolactinoma, primary hyperpth at young age and normal kidneys
Alpha cells produce….
glucagon
beta cells produce…
D….
D2…..
insulin
gastrin and ss
vip
4 VHL diseases
inh pattern?
Pheo, pnet, RCC, hemangioplastomas
AD
Labs for all PNETs
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
s/s for all pnets
insulinoma - whipples
gastrinoma r PUD
glucagonoma - diabetes, necrolytic migratory erythema, dermatitis, DVT
SS - diarrhea, gallstones, diabetes, hypochlor
VIP - watery diahrea, achlorydria, hypok, met acidosis
2 ddg to keep in mind for eval for insulinoma
gastric surgery history and exogenous use
exogenous insulin lab make up?
elevated c peptide compared to insulin
CT findings differentiating PNET from adenoCA? Why is that?
Pnet is hypervascular in arterial phase while adeno is not– hypoattenuating
What is a PNET specific scan? The exception?
PET DOTATATE
insulinoma
how is malignancy determined for PNETs?
2 categories for pnet grading and values
absence or presence of malignancy
metastatic incidence upon pnet dg and survival rates
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%
treatment for localized pnets?
enucleate insulinomas if 2mm away from MPD, otherwise formally resect
gastrinoma - duodenotomy if not obvious to look for mass, usually in duo
treatment for metastatic pnet disease in general
SS analogues
everolimus for insulinoma
liver embo?
Panc 5 year survival rates
Resectability
5-year observed survival
Resectable
15% to 20%
Locally advanced
11
Metastatic
2%
PDAC hereditary RFs
PDAC staging
+/- dg lap ——for borderline, tumors>3cm, CA19-9 >150
CT CAP always
EUS maybe, need tissue for adjuvant
4 possible solidpanc masses
PDAC, acinar cell, pseudopapillary, net
RFs for PDAC non her
smoking, etoh, chronic panc , hep b
3 s/s of PDAC
LUQ pain
painless jaundice
weight loss!!!
border line resectable PDAC
> 180 smv/pv without distortion
<180 smv/pv with distortion
CHA
SMA<180
non resectable PDAC
> 180 veins with distortion
180SMA
celiac
ascites
mets
resectable pdac
<180 smv/pv without distortion
Who should get neo for pdac?
Regimen options?
all, better compliance, stress test, tumor bio, better results
Folfirinox for strong patients or borderline
Gem/cap for weaker – better tolerated
FOLFIRINOX MOAS and main adverse effects
5FU - pyrimidine analogue RNA - myelosuppression
Irinotecan - topoisomerase inhib
Oxiplatin - myelosuppression, periph neuro
Preffered adjuvant chemo for pdac
gem and acp —-ESPAC 4
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
frey and beger
peustow
whipple
minimal change or small duct
describe frey
describe beger
success rates of chronic panc drainage procedures?
60-70%
new onset chances after beger or frey
25%
acinar panc cells secrete these 2
what are the stimulated by
trypsin and lipase
cck, secretin
alcohol effect on acinar panc cells
ROS, ethyl ester direct damage
protein precip leads to ductal obstruction and damage
acetaldehyde damages cells
percent etoh chronic panc patients
70%
combined risk factors for chrnic panc
smoking and etoh
4 chronic panc complications
ascites, pleural, thrombosis, pseudocyst
hereditary panc number one gene
PRSS1
2 panc insuff tests
elastase 1 <100 in stool
fat >7g/d in stool
imaging or diagnostics from chronic panc
CT
ERCP
non op tx for chronic panc
nutritional support for chronic panc?
zenpep
vitamins
plexus block
TPN v enteral(better)
Panc cyst chart:
Amylase
mucin
cyto
cea
cyst appearance on imaging
distribution
ages?
central starburst calcs on imaging of pancreas
SCN
: thick walled, septated macrocyst with smooth contours with or without a solid component; eggshell calcifications
in pancreas
malignants
MCN
mostly benign but malign potential
poorly demarcated, lobulated, polycystic mass with dilation of main or branch/side ducts; communication with ducts
cea and amylase levels
age
ipmn
high for both
60s
malignant risk in ipmn branch v main
15% v 30-50%
subtypes of ipmn and their MD v BD prevalence
MC type
intestinal mainly MD
gastric mainly SB
PB - mixed
gastric - SB
how does ipn usually present
incidental finding
IPMN imaging
MRCP, CT panc, EUS
IPM high risk sequelae
jaundice
1cm MPD
enhancing solid component in cyst
Worrisome IPMN features
3 cm cyst
thick wall
MPD5-9mm
Pancreatitis
Lymph
sharp change in duct caliber
nonenhancing mural nodule
SCN treatment
resect if symptomatic
MCN tx
resect always
IPMN surgical management indications
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
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
for MD Ipmn resection what should be sent durign resection
frzen
IPMN low risk non op surveillance schedule per size
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.
op ipmn surveillance
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
MC congenital pancreatic anomaly/
what is it?
divisum
endo tx for divisum
surgical?
minor sphincterotomy
sphincterotomy or peustow
7 main causes of splenomegaly
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)
Ethnic descents and inh patterns:
SSD
B thal
her sphero
african - AR
mediteranean - AD
european - AD
new medical ITP treatment
thrombopoeitn agonists
