Pancreatic cancer

Question 1

The most common malignancy arising from the pancreas is a ductal adenocarcinoma.

Answer 1

PANCREATIC CANCER

PC is a disease of aging, with the median
age at diagnosis of 71 years, with many cases diagnosed before the
age of 65

Question 2

commonly caused by an autosomal dominant mutation in the PRSS gene, is associated with a near 50% incidence of PC by age 74.

Answer 2

Hereditary pancreatitis

Question 3

associated with an increased risk of PC

Answer 3

Diabetes mellitus

Question 4

The average size of carcinomas

Answer 4

The average size of carcinomas in the head of the pancreas is 2.5 to 3.5 cm, compared with 5 to 7 cm for tumors in the body or tail.

Question 5

Several immunohistochemical markers have diagnostic useful- ness in mucin-producing tumors, including pancreatic adenocar- cinoma.

Answer 5

MUC1, MUC3, MUC4, CEA, CA 19-9, DuPan 2, and CA 125

Question 6

Imagings

Answer 6

US is useful to evaluate the presence of gallstones and confirm biliary dilation.

CT is the method of choice for diagnosis and staging of PC.

Question 7

The pancreatic CT protocol consists of dual-phase scanning using IV and oral contrast agents.

Answer 7

The first, early arterial phase, scan is obtained at 25 seconds after IV contrast injection and offers visualization of the arterial anatomy for surgery.
The second, arterial (pancreatic) phase scan is obtained 40 seconds after administration of IV contrast agent.
At this time, maximum enhancement of the normal pancreas is obtained, allowing identification of nonenhancing neoplastic lesions
The third, portal venous phase scan is obtained 70 seconds after injection of IV contrast agent and allows accurate detection of liver metastases and assessment of tumor involvement of the portal and mesenteric veins

Question 8

Longstanding CT criteria for unresectability of a pancreatic tumor

Answer 8

1) distant metastasis (e.g., to liver, perito- neum, or other sites),
(2) encasement of the celiac axis or supe- rior mesenteric artery, and/or
(3) occlusion of the portal vein or superior mesenteric vein, although venous reconstruction is challenging this criteria.

Question 9

ERCP findings

Answer 9

A “double-duct sign” on ERCP, representing strictures in biliary and pancreatic ducts, is classically found in many patients with PC

Question 10

MRI vs CT scan

Answer 10

MRI offers
better assessment of CT isoattenuating lesions, small tumors,
hypertrophied pancreatic head, and focal infiltration of the
parenchyma.

Question 11

C19-9

Answer 11

level of 37 units/ml was the most accurate cutoff in differentiating benign from malignant pancreatic disease.

adjunct in PC for diagnosis, prognosis, and monitoring of treatment.

CA19-9 levels do have prognostic value in the setting of resectable disease.
High levels of preoperative ca 19-9 have been demonstrated to be associated with higher potential for occult metaststatic disease at the time of staging laparoscopy.

Question 12

treatment modality

Answer 12

chemotherapy is their principal treatment modality

Surgical resection is the most effective curative treatment for PC

Question 13

survival rate

Answer 13

median survival rate of a resected PC treated with adjuvant chemotherapy ranges from 20 to 23 months.

R0 resection, absence of affected lymph nodes, and tumor size represent the strongest prognostic indicators.

Question 14

The current NCCN guidelines

Answer 14

resectability as an absence of arterial (common hepatic, superior mesenteric, celiac axis) involvement with no contact with the SMV-PV or less than or equal to 180° contact with- out vein contour irregularity.

Question 15

absolute contraindication to resection.

Answer 15

Distant disease, most commonly presenting as malignant ascites or metastasis to the liver, perito- neum, or periaortic lymph nodes, is an absolute contraindication to resection.

Question 16

Relative contraindications to resection

Answer 16

encasement or occlusion of the superior mesenteric vein or portal vein, or direct extension of disease to the celiac axis, superior mesenteric artery, vena cava, or aorta.

Question 17

potential candidates for temporary biliary drainage,

Answer 17

with deep jaundice and an expected delay prior to curative-intent surgery

Question 18

Most common operation

Answer 18

The most common operation for PC is pylorus-sparing pancreaticoduodenectomy(hich removes primarily the head of the pancreas en bloc with the duodenum, distal bile duct, and proximal jejunum, with pancreaticojejunal anastomosis)

Question 19

ost common complication after the Whipple procedure, is seen in approxi- mately 22% to 26% of patients

Answer 19

Pancreatic fistula

Question 20

Nutrition

Answer 20

Enteral nutrition has demonstrated improved outcomes versus parenteral nutrition with more rapid closure of fistula, higher rate of closure, and faster recovery.

Question 21

Risk factors for recurrent disease

Answer 21

positive margins, lymph node involvement, high-grade tumors, and primary tumor size greater than 2.5 cm.

Question 22

Single agent chemotherapy has represented the mainstay of therapy for metastatic PC.

Answer 22

Gemcitabine has been shown to be a more effective drug for treating PC

Question 23

Current guidelines from the National Cancer Center Network

Answer 23

recommend adjuvant therapy with either chemotherapy alone or chemotherapy plus chemoradiation.

Question 24

Unresectable/Borderline Resectable Non-Metastatic Disease

Answer 24

avoidance of upfront surgery and multimodality therapy with neoadjuvant chemotherapy and/or chemoradiation.

Question 25

Characteristics that favor a diagnosis of pseudocyst over cystic neoplasms

Answer 25

lack of septae, loculations, solid components, or cyst wall calcifications on CT or MR

Evaluation of pseudocyst fluid reveals high levels of amylase, which is atypical for cystic tumors unless they have communication with the pancreatic duct.

Question 26

Tumors with malignant potential

Answer 26

MCN, IPMN, solid pseudopapillary tumors (SPTs), and cystic islet cell tumors.

Question 27

suspected when a CT or MRI of the abdomen shows a cyst within the body or tail of the pancreas in a middle-aged woman

Answer 27

Mucinous Cystic Neoplasms

well-defined, thin-walled solitary cysts that can be unilocular or multilocular. They lack communication with the main pancreatic duct, differentiating it from IPMN

Question 28

Cyst fluid analysis generally reveals thick and mucoid material, low fluid amylase, elevated tumor markers (CEA), and mucinous epithelial cells by cytology.

Answer 28

Mucinous Cystic Neoplasms

Question 29

Mucinous Cystic Neoplasms procedure of choice

Answer 29

Distal pancreatectomy with or without splenectomy is the procedure of choice

Question 30

predominantly benign tumors with little risk of malignant behavior.

The pathognomonic CT image is that of a spongy mass with a central “sunburst” calcification,

Answer 30

Serous Cystadenomas

Question 31

premalignant pancreatic lesions, and histologically their epithelium may demonstrate areas rang- ing from hyperplasia to carcinoma within a single tumor.

Answer 31

Intraductal Papillary Mucinous Neoplasms

occur with equal frequency in men and women, with a median age at diagnosis of approximately 65 years.

Question 32

Intraductal Papillary Mucinous Neoplasms

Answer 32

Evaluation by ERCP typically shows a patulous ampulla of Vater with extruding mucus, a finding that is pathognomonic for main duct IPMNs.

Question 33

IPMNs treatment of choice

Answer 33

Pancreaticoduodenectomy is the treatment of choice for most patients, given the predominance of IPMNs in the head of the pancreas, but distal pancreatectomy is indicated for lesions in the body or tail of the gland.

Question 34

Factors associated with worse outcome in patients with invasive histology

Answer 34

lymph node metastases, lymphovascular invasion, perineural invasion, and positive margins

Question 35

CT of acinar cell carcinomas

Answer 35

CT of acinar cell carcinomas have several features that can differentiate them from ductal adenocarcinoma, including large size without biliary or pancreatic duct dilation, exophytic morphology, and an enhancing capsule.

Question 36

Sreening

Answer 36

AGA suggests screening begins at the age of 35 in patients with hereditary pancreatitis or 10 years before the age of the index case in the setting of familial PC

Question 37

Epithelial cells

Answer 37

acinar cells, which account for approximately 80% of the gland volume;

ductal cells, comprising 10% to 15%; and

endocrine (islet) cells, comprising approximately 1% to 2%.

More than 95% of the malignant neoplasms of the pancreas arise from the exocrine elements of the gland (ductal and acinar cells) and demonstrate features consistent with adenocarcinoma

Question 38

Pancreatic pathologic changes

Answer 38

duct dilatation and fibrous atrophy of the pancreatic parenchyma.

Question 39

other useful markers in differentiating between acinar, ductal, and islet cell tumors.

Answer 39

Cytokeratins

Question 40

an oncogene where activating mutations represent the most common gene mutation present in pancreatic adenocarcinomas.

Answer 40

KRAS

KRAS targets represent a potential early detection test as well as a possible target for treatment.

Question 41

when associated with KRAS, has led to intraductal papillary mucinous neoplasm and invasive adenocarcinoma.

Answer 41

BRG1

Question 42

a tumor-suppressor gene, is an acquired mutation generally found in advanced

Answer 42

CDKN2A

Question 43

Mucinous Cystic Neoplasms

Answer 43

female predominant, with a 20:1 female-to- male ratio, and are confined to the body and tail of the gland in more than 95% of cases.

They are solitary, mucin containing, multilocular, or unilocular lesions with a thick fibrotic wall.

Mean age at presentation is 50 years.

In older series, most patients complained primarily of abdominal pain or a palpable mass.

suspected when a CT or MRI of the abdomen shows a cyst within the body or tail of the pancreas in a middle-aged woman

Question 44

If MRCP is done, there should be no communication between the pancreatic duct and the cyst itself.

Answer 44

Mucinous Cystic Neoplasms

Cyst fluid analysis generally reveals thick and mucoid material, low fluid amylase, elevated tumor markers (CEA), and mucinous epithelial cells by cytology

Question 45

Serous Cystadenomas

Answer 45

occurring mostly in the body or tail of the pancreas in women (75%) with a mean age of 62 years.

Cyst fluid analysis characteristically reveals low viscosity, low levels of CEA, and negative cytology

surgical resection is the treatment of choice for symptomatic lesions.

Options for resection depend on tumor location and include distal pancreatectomy with or without splenectomy, Whipple procedure, middle pancreatectomy, or enucleation.

Question 46

Solid Pseudopapillary Tumors

Answer 46

Women

Most (60%) pseudopapillary tumors are found in the body and tail of the pancreas.

The tumors can be quite large at presentation, with 34% of patients having masses larger than 10 cm in diameter.

Complete resection is the treatment of choice

Question 47

The lipase hypersecretion syndrome

Answer 47

present in the setting of liver metastasis and is considered an unfavorable prognostic factor.