Pancreas Flashcards
percent of pancreatic cancer eligible for resection
20%
Best prognostic subtype of PDAC
colloid carcinoma
Head v tail proportion of PDAC
65% head v 25% tail (rest is indeterminate)
possible cutaneous presentations of PDAC
Pemphigoid rash (cicatricial and bullous)
Imaging features of a PNET
highly vascular
early arterial enhancement
washout in the early portal phase
Sensitivity and specificity of CA 19-9
sensitivity 70 to 92%
Specificity 68 to 92%
Positive predictive value of CA19-9 in asymptomatic patient?
i.e. can we screen for PDAC with CA19-9
<1%
PMID 14731128
(no)
What is the utility of CA-19-9 to plan for surgery?
Do not use as indicator of operability (ASCO)
May become part of selection criteria for neoadjuvant therapy.
When to biopsy prior to operating on PDAC?
Concern for:
chronic pancreatitis
autoimmune pancreatitis
(eg, extreme young age, prolonged ethanol abuse, history of other autoimmune diseases),
First-line biopsy procedure (if necessary) for PDAC?
EUS-guided FNA
NCCN unresectable definition for head PDAC
- contact with SMA >180 degrees
- contact with celiac axis >180 degrees
- tumor contact with the first jejunal SMA branch
- Unreconstructable SMV or portal vein
- Contact with the most proximal draining jejunal branch into the SMV
NCCN unresectable definition for tail PDAC
- Solid tumor contact of >180 degrees with the SMA or celiac axis
- Solid tumor contact with the celiac axis and aortic involvement
- Unreconstructable SMV or portal vein due to tumor involvement or occlusion (thrombus)
NCCN borderline resectable definition for head PDAC
SMV or portal vein
>180 degrees contact with contour irregularity
or thrombosis of the vein.
inferior vena cava.
tumor contact
Solid tumor contact with the SMA ≤180 degrees.
Solid tumor contact with variable anatomy
NCCN borderline resectable definition for tail PDAC
- Solid tumor contact with the celiac axis of ≤180 degrees.
- Solid tumor contact with the celiac axis >180 degrees without involvement of the aorta and withpreserved GDA, permitting an Appleby procedure (controverisal).
Discrepancy between AJCC and “borderline resectable” PDAC in 7th edition AJCC
7th Ed AJCC uses T4 category to designate an unresectable primary tumor. However T4s (arterial involvement) are still resected with R0 margins at some centers, especially after neoadjuvant therapy.
Ability of CT scan to detect metastatic PDAC
Contrast-enhanced CT is the modality of choice to detect distant metastases (image 16). with ~90% sensitivity and specificity.
However, the sensitivity of CT for peritoneal dissemination not high to eliminate the need for diagnostic laparoscopy in equivocal cases.
Role of Chest CT and PET in PDAC
Chest CT — most centers do not perform a routine staging chest CT for patients suspected of having pancreatic cancer because in the presence of lung metastases, the primary tumor is usually unresectable for another reason.
PET scanning — Studied, and probably not useful. In uncontrolled studies and meta-analyses, the sensitivity of integrated PET/CT (which has better spatial resolution as compared to PET alone) in the initial diagnosis of pancreatic cancer has ranged from 73 to 94 percent, while specificity ranges from 60 to 89 percent.
Role of staging laparoscopy in PDAC?
Widespread acceptance, but no controlled studies demonstrate a benefit.
Some selectively perform for borderline tumors, CA19-9 >1000, and prior to neoadjuvant therapy.
Good idea to do to avoid giving RT to peritoneal disease.
Peritoneal cytology in PDAC?
Not routinely reccomended as most patients with positive cytology have additional features of unresectability.
[PMID 15055843 MEYERS paper]
summary of resectability of PDAC
Remains controversial and somewhat of a continuum:
• nodal involvement beyond the peripancreatic tissues, and/or distant metastases.
•Direct involvement of the superior mesenteric artery (SMA), CHA, Celiac, by CT scan of low density tumor.
•Encasement or occlusion/thrombus of the superior mesenteric vein (SMV) or the SMV-portal vein
in practice, most of these patients are referred for neoadjuvant therapy prior to surgery.
T Staging of Pancreatic Cancer (PDAC and PNET)
Primary tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ* T1 < 2 cm or less in greatest dimension T2 > 2 cm in greatest dimension T3 Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery T4 Tumor involves the celiac axis or the superior mesenteric artery (unresectable primary tumor)
Stage 0, IA, IB and IIA for PDAC (it’s simple!)
Anatomic stage/prognostic groups Stage 0 Tis N0 M0 Stage IA T1 N0 M0 Stage IB T2 N0 M0 Stage IIA T3 N0 M0
N Staging of Pancreatic Cancer
N0 or N1
What phase of CT scan is best for determining liver mets?
also occurs in the portal venous phase i.e. peak hepatic enhancement
Two Radiographic findings that should broaden your differential away from PDAC?
multifocal biliary strictures (autoimmune pancreatitis)
diffuse pancreatic ductal changes
Sensitivity and Specificity of FNA for PDAC?
Sensitivity of 90%
specificity of 96%
K-ras and P53 molecular analysis are emerging as a non-routine test to improve sensitivity.
What is an Appleby procedure?
Distal pancreatectomy with en-bloc resection of the celiac access.
How is perfusion to the liver maintained after an Appleby procedure?
retrograde flow from SMA, up the GDA.
What is the ARTERIAL PHASE of a triple contrast CT scan for PDAC?
The ARTERIAL PHASE of enhancement (first 30 seconds) opacifies celiac, SMA. Look for arterial involvement of tumor.
What is the PANCREATIC PHASE of a triple contrast CT scan for PDAC?
The PANCREATIC PHASE Theoretically maximal attenuation difference between tumor and normal pancreas. Occurs between peak opacification of aorta and liver.
What is the PORTAL PHASE of a triple contrast CT scan for PDAC?
The PORTAL VENOUS PHASE, (1 min post-injection) provides enhancement of the superior mesenteric vein (SMV), splenic and portal veins.
What is stage of positive peritoneal cytology for PDAC?
AJCC defines as M1 disease.
Stage IIB, III and IV for Pancreatic canacer
Stage IIB T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage III T4 Any N M0
Stage IV Any T Any N M1RECIST Complete Response
Disappearance of all target lesions
RECIST Partial Response
> 30% decrease in the sum of the largest diameter of target lesions,
RECIST Stable Disease
Neither sufficient shrinkage to qualify for PR (>30%) nor sufficient increase to qualify for PD (>20%), taking as reference the smallest sum largest diameter since the treatment started
RECIST Progressive Disease
At least a 20% increase in the sum of the LD of target lesions, taking as reference the smallest sum LD recorded since the treatment started or the appearance of one or more new lesions
Differences in 5-year survival for PDAC based on nodes.
Five-year survival after margin-negative (R0) resection: 30% node-negative
10 % node-positive disease
Stage IIB v Stage III pancreatic cancer 5-year OS
7.7% v 6.8%
Stage III is high risk for R1 resection; Stage IIB is any node positive.
Two things to do before starting chemo-first treatment for PDAC
Tissue diagnosis is required!
Needs a stent since biliary obstruction will delay neoadjuvant chemo.
Does BRCA status help select chemo for PDAC?
Not studied, but NCCN suggest consideration of gemcitabine plus cisplatin over FOLFIRINOX, for neoadjuvant chemo of PDAC that harbors a known BRCA mutation
PDAC median survival OS R0 v R1?
What if RO is defined as >1mm margin?
- 6 v 16.5 months
- 7 v 17.1 months
PMID: 28692477
What percent of R1 PDAC survive >10 years?
9%
PMID: 28692477
What percent of R0 PDAC die before 2 years?
50%
PMID: 28692477
What is the only perioperative management decision shown to change mortality following whipple?
Surgical drain placement in high risk patients
[Cameron JACS 2015; Van Buren Ann Surg 2014]
Chemo for gallbladder cancer?
Gemcitabine/Cisplatin
ABC-02 trial
ABC - Advanced Biliary Cancer
gem/cis v gem alone for metastatic biliary cancer.
11.7 months v 8.1 month survival
[Valle NEJM 2010]
Hanging Maneuver
Anterior approach to liver resection without mobilization;
Sometimes necessary for large tumors.
Glissonian approach
taking the portal triad outside the sheath, but intrahepatically.
Low CEA, Low Mucin, Low Amylase in a pancreatic cyst
Serous cystadenoma
pancreatic mass with uniform cells with large central nucleoli and eosinophilic granular cytoplasm
Pancreatic Acinar Cell Carcinoma
Acinar Cell Carcinoma is what % of pancreatic tumors?
1%
Defining presentation of Acinar Cell Carcinoma?
lipase secretion
arthralgia
eosinophilia
subcutaneous fat necrosis
Mutations for Acinar Cell Carcinoma?
APC/beta-catenin pathway
Median survival for Acinar Cell Carcinoma
30-60 months (better than PDAC)
Adjuvant therapy for Acinar Cell Carcinoma
to rare to study, so same regimens as PDAC are used.
What % of insulinomas have MEN I
5%
What % of MEN I patients get insulinomas?
20%
lab test work-up for insulinoma
insulin, pro-insulin and c-peptide
Medical management of hypoglycemia from insulinoma?
diazoxide
Contraindicated drug for insulinomas
octreotide (worsens hypoglycemia)
pancreatic cystic lesion with fine septations and thin drainage
likely a serous cyst adenoma; radiographic observation is best option.
four Ds of glucagonoma
diabetes
dermatitis
DVT
depression
Treatment for necrolytic migratory erythema
glucagonoma dermatitis
intermittent infusions of amino acids
glucagonoma’s mess up gluconeogenesis
high CEA and mucin/ viscous fluid in a pancreatic cyst
Mucinous cystic Neoplasm - resect
biopsy finding for autoimmune pancreatitis
plasmacytic infiltration
threshold for preoperative stenting of PDAC
bilirubin of 10 mg/dl or coagulopathy
Does single agent chemotherapy palliate PDAC pain?
No
Percent of PDAC that is genetic
20%
Odds ratio for PDAC with hereditary pancreatitis?
50-80 fold higher than the general population
Genetic disorder with highest risk of PDAC?
Peutz-Jeghers (STK11)
Most common access for PVE
transhepatic contralateral approach
argument against transhepatic contralateral approach to PVE
can injure the future liver remnant
how long to wait after PVE to do volumetrics
4-8 weeks
Do you need to stop chemo during PVE?
No
Bleeding from the SMV splenic confluence, what to do?
apply pressure or stuff a raytec in the tunnel or both.
resection criteria for hepatocellular adenomas?
> 5 cm in women
all in men
central scar in liver lesion
Focal Nodular Hyperplasia
How do you RFA lesion near a major liver vessel
Pringle while you RFA so as to prevent heat sink from blood flow.
Favorable criteria for RFA of liver lesions (3)
tumors <3cm
away from liver surface
away from major inflow or outflow
Pancreatic mass with low CEA, low amylase and periodic Acid Schiff positive globules
Solid pseudo-papillary tumor
Treatment for Solid pseudo-papillary tumors of the pancreas?
resection
Metastasectomy for Solid pseudo-papillary tumors of the pancreas?
Yes
Candidacy for trials on liver transplantation for neuroendocrine mets
disease stability for 6 months
less than 50% of liver parenchyma involved
metastasectomy for high grade PNET (> 20 mit/10 HPF)
no!
Chemotherapy for high grade PNET?
yes! platinum/etoposide
8th edition AJCC definition of T4 PDAC
8thEd AJCC staging system no longer classifies T4 disease as categorically unresectable. However, they do not use the term “borderline resectable” to classify any clinical stage of disease.
