pancreatic cancer Flashcards
ampula of vater
ampula at junction of pancreatic and common cile ducts
pancreatic prefered radiological exams
ERCP
MRCP
pathophysiology of PDAC (pancreatic ductal adenocarcinoma)
panIN 1 -KRAS, telomere shortening
panIN 2- CDNK2A (P16)
panIN 3- TP53, SMAD4
pancreatic ductal adenocarcinoma
OR
CYSTIC:
IPMN +MCN
PDAC epidemiology
65-85’s
western world
PDAC etiology
inviromental:
smoking 25% chronic pancreatitis (displasia) diabetes (first onset or worsening) western diet obesity alcholol (chrinic pancreatitis)
genetic:
familial pancriatitis
syndroms (BARC2, PJS, LS, FAMM)
familial pancreatic cancer
precursor lessions
Pancreatic Intraepithelial Neoplasia (PanIN)
<5mm, thus wont be found in imaging (<1cm)
not all will results in invasive malignancy
Cystic pancreatic tumors – potential premalignant lesions
pseudocyts- due acute pancreatitis, bening
serus cystic neoplasm (SCN)-very small, bening
mucinous cystic neoplasm (MCN)-
big, solitary, body and tail, malignant
surgical treatment
95% female
intraductal mucinous papillary neoplasm (IPMN)-
main (usually malignant) / side branch (bening)
females
analasis of cystic fluid
cytology- malignant/bening
CEA-mucinotic or serotic
viscosity
amylase lvl
screening for PDAC
2 or more first degree relatives (or 1st+2nd) with pancreatic cancer
Patients with hereditary syndrome and 1 or more FDR with PDAC (in lynch and familial pancreatitis no need for PDAC in relative)
Israel
genetic panel is recommended to all patients
test for BRCA every Ashkenazi patient with PDAC
EUS OR MRI (no contrast) or MRCP (with contrast)
every year!
PDAC - Signs and symptoms
Obstructive jaundice when the cancer is located in the head of the pancreas.
abdominal discomfort
pruritus
lethargy
weight loss
PDAC diagnosis imaging
CT
at any doubt-
EUS-Bx
MRI-for small indeterminate liver lesions and to evaluate the cause of biliary dilatation when no obvious mass is seen
PET CT- staging mainly
PDAC serum markers
CA 19-9 is elevated in approximately 70-80%
not recommended as a routine diagnostic or screening test because of its low sensitivity and specificity
post-resection CA 19-9 level has prognostic value, indicator of asymptomatic recurrence
PDAC stages
Resectable
Borderline resectable
Locally advanced
Metastatic
PDAC Criteria for resectability
No vascular encasement of SMA or celiac artery
Patency of superior mesenteric – portal venous confluence
No extrapancreatic disease
PDAC treatment
1.Resectable
surgery + adjuvant chemo
head of pancrease- Whipple’s procedure (tough)
distal pancreatectomy
Among them, 30% will have microscopic residual disease after surgery (R1)
- Locally advanced
Chemo +/- radiotherapy - Metastatic (60%)
Chemotherapy
Palliation – ERCP + stent
Median survival ~ 6 months
Cholangiocarcinoma (CC)
Mucin-producing adenocarcinoma that arise from the biliary tract
intrahepatic (IHC) – the second most common primary liver tumor
perihilar (central, 65%) -
bifurcation of the common bile duct
Klatskin tumors
peripheral (or distal, 30%)
Risk factors of Cholangiocarcinoma (CC)
Intrahepatic –
Cirrhosis, especially Primary Billiary Cholangitis
Hepatitis C
primary sclerosing cholangitis 20% (usually at IBD)
liver fluke in Asians
Cholangiocarcinoma (CC) Clinical features and radiologic evaluation
Painless jaundice, often with pruritus or weight loss
US, CT / MRI / MRCP, ERCP
ERCP – therapeutic tool
Cholangiocarcinoma (CC) diagnosis
Diagnosis is made by biopsy, percutaneously for peripheral liver lesions, or more commonly via ERCP
Cholangiocarcinoma (CC) Treatment
The usual is surgical,
combination systemic chemotherapy may be effective.
Gallbladder cancer epidemiology
F4:M1
Most patients have a history of antecedent gallstones
Gallbladder cancer Clinical features and diagnosis
Often diagnosed unexpectedly during gallstone or cholecystitis surgery
chronic right upper quadrant pain
weight loss
CT scans or MRCP
Gallbladder cancer Treatment and prognosis
surgical
radiotherapy and chemotherapy are not useful
Usually GB cancer has worse prognosis than CC, with a typical survival of 6 months or less
Carcinoma of the ampulla of Vater
This tumor arises within 2 cm of the distal end of the common bile duct
90% AdenoCA
