Pancreas

Question 1

Most common NET tumours of pancreas

Answer 1

1) Insulinoma
2) Gastrinoma
3) Non-functional

*Insulinoma has lowest malignant potential (10%), gastrinoma (60%), glucagonoma/VIPoma up to 80%

Question 2

Imaging findings NET (US, CT, MR)

Answer 2

US: well circumscribed, hypoechoic mass
CT: early arterial enhancement, larger tumours can have necrosis, displace but don’t invade adjacent structures, can be cystic (esp if MEN1); include in ddx for cystic pancreatic lesion
MRI: T1 hypo, T2 bright, arterial enhancing

Increased uptake on Octreotide-111 (80% sensitivity) - not as sensitive for insulinomas

Question 3

Causes of pancreatic lipomatosis

Answer 3

• CF
• Schwann-Diamond (kids, short stature)
• Cushings
• Chronic steroid
• Hyperlipidemia

Question 4

What are the collections in AIEP? Necrotic pancreatitis?

Answer 4

AIEP:
<4 weeks, APFC
>4 weeks pseudocyst

Necrotizing pancreatitis:
<4 weeks, ANC
>4 weeks, WON

Question 5

Most common anatomic variant of pancreas

Answer 5

Divisum (main pancreatic duct drains into minor Papilla)

Normally should drain inferiorly via Wirsung to major papilla

Question 6

Most common imaging findings in chronic pancreatitis

Answer 6

Dilation and beading of panc duct, calcs, decreased T1 signal and enhancement and atrophy

Question 7

Constellation of findings in IgG4 disease

Answer 7

Autoimmune pancreatitis
Retroperitoneal fibrosis
Fibrosing mediastinitis
Sclerosing cholangitis
Inflammatory pseudotumour
Riedel's Thyroiditis 
Sialadenitis

Question 8

Imaging features in serous versus mucinous cystadenoma

Answer 8

Serous - grandma, benign, panc head, microcystic (can appear solid), central scar +/- calcs
Mucinous - mother, panc body or tail, PRE-MALIGNANT,, unilocular (or a few large cystic spaces), peripheral calcs are highly specific

Question 9

Which pancreatic lesion is seen in VHL?

Answer 9

Serous cystadenoma and NETs

Question 10

Imaging findings SPEN tumour

Answer 10

Young patient, tail, solid/cystic (progressive enhancement), thick capsule T1/T2, hemorrhage**
Low grade malignancy* usually removed

Question 11

Features concerning for malignancy in IPMN

Answer 11

*International consensus guidelines (2017)- Tanaka

High risk stigmata: main duct> 1 cm, enhancing nodule >5 mm, obstructive jaundice

Worrisome features: main duct 5-10 mm, cyst > 3 cm, enhancing nodule <5 mm, thickened enhancing wall, change in size > 5 mm in 2 years, lymphadenopathy, elevated CA 19-9

• Main branch have up to 60% risk malignancy (Remove these); side branch only worry if >3 cm

Question 12

Management of incidental pancreatic cyst on CT

Answer 12

<1.5 cm

• age <65, re-image q1 years x 5 - then q2 x 2
• age>65, re-image q2 years x 5 (stop if stable over 10 years)

*if grows >1.5cm, then proceed to EUS or FNA, OR if any other worrisome features or high risk stigmata

different guidelines for 1.5-2.5 cm, depending on presence of absence of connection to duct

Question 13

Genetic syndromes with increased risk of panc adenoCa

Answer 13

Peutz-Jeghers, HNPCC, VHL

Question 14

Genetic syndromes associated with pancreatic NETs

Answer 14

VHL, MEN1, NF1 (often multiple)

Gastrinoma most common in MEN1

Question 15

Boundaries of gastrinoma triangle

Answer 15

2nd/3rd duodenum, cystic duct confluence, head of pancreas

Question 16

Lipase hypersecretion syndrome

Answer 16

Acinar cell Ca

- Subcut fat necrosis, bone infarct, polyarthritis

Question 17

Branch duct IPMN associated with increased risk of:

Answer 17

synchronous adenocarcinoma

Question 18

Risk of malignancy with branch duct vs. main duct IPMN

Answer 18

Branch = 5%
Main = 35-50%