Pancreatic Diseases & Malignancy Flashcards
What are the congenital true cysts of the pancreas?
- solitary cyst
- enterogenous cysts
- dermoid cysts
- multiple congenital pancreatic cysts -> Von Hippel Lindau syndrome
- fibrocystic disease of pancreas -> caucasians
What is the acquired true pancreatic cyst?
Retention cyst
What are the neoplastic cysts of the pancreas?
- microcystic adenoma
- mucinous cystic neoplasm
- cystic neuroendocrine tumors
- ductal adenocarcinoma with central necrosis
What is the lining of multiple congenital pancreatic cysts?
Smaller than 5cm -> lined by cuboidal epithelium
What are the clinical features of cystic neoplasms of the pancreas?
- vague abdominal pain with weight loss
- stomach or duodenal compression
- palpable epigastric mass (in tail & body retains large size)
- spontaneous hemorrhage -> papillary cystic neoplasm
What investigations are used to diagnose cystic neoplasms of the pancreas?
LAB
- serum amylase may be normal
- intracystic amylase -> if normal -> no communication with pancreatic duct -> true cyst
- CEA elevated in malignant cysts
RADIOLOGICAL
- Ultrasound & CT -> cystic & solid components of mass
- > calcifications in the wall of mass
- > internal septa & multiloculated cysts -> increase suspicion of tumor - ERCP -> true cysts do not communicate with ductal system
- Angiography -> hypervascularity or tumor vessels
- > splenic, portal or SMV obstruction
- > hemorrhage inside cyst
How should a pancreatic cystic neoplasm be treated?
COMPLETE EXCISION
- lesion in body & tail -> distal pancreatectomy with splenectomy
- lesion in the head -> Whipple (pancreaticoduodenectomy)
- debulking if inoperable
- presence of metastasis -> not contraindication to resection
- excision of isolated liver metastasis -> may be curative
What is the prognosis of pancreatic carcinoma?
- 5 years survival -> 2% or less
75% of patients > 60 years
What are the causes of pancreatic cancer?
- cigarette smoking -> carcinogenic nitrosamines
- diet high in animal fats -> cholecystokinin & pancreozymin -> ductal hyperplasia & hypertrophy of acinar cells
- diabetes -> abrupt onset of diabetes after 40 is a clue to the diagnosis
- chemical & industrial carcinogens
- polyposis of the colon (Gardner’s syndrome) -> increase in periampullary malignancy
- hereditary pancreatitis
What is the pathological classification of pancreatic exocrine carcinoma?
PRIMARY
- Duct cell origin 90% -> ductal cell adenocarcinoma, mucinous adenocarcinoma, cystadenocarcinoma
- Acinar cell origin 1% -> acinar cell carcinoma, cystadenocarcinoma (acinar cell)
METASTATIC
- 7%
What are the stages of pancreatic carcinoma?
I -> confined to gland
II -> involvement of regional lymph nodes
III -> distant metastasis to liver, regional lymph nodes, peritoneum & lungs
What are the clinical manifestations seen after micro metastasis has occurred in pancreatic carcinoma?
- obstruction of bile duct -> jaundice, pruritis
- gastric outlet obstruction -> obstruction of duodenum, or stomach
- ulceration -> GIT hemorrhage
- pain -> infiltration of peripancreatic nerve roots
non-specific tumor symptoms
- malaise, early satiety, weight loss, anorexia
- enlarged gallbladder (Courvoisier’s law)
- postprandial epigastric pain -> obstructed pancreatic or bile duct
- deep seated back pain present at night -> retroperitoneal extension of the neoplasm -> unresectable
What is abutment?
tumor-vascular contact < 180
What is encasement?
tumor-vascular contact > 180 OR vascular deformity, occlusion, or tumor thrombosis
When is pancreatic cancer considered resectable?
ARTERY
- no contact with CA, SMA, or CHA
VEIN
- no contact with SMV or PV
- abutment without vein contour irregularity
When is pancreatic cancer considered borderline resectable?
ARTERY
- head/uncinate process -> abutment or encasement to CHA without extension to CA or HA bifurcation
- > abutment to SMA - body or tail -> abutment to CA
- > encasement of CA without involvement of aorta or GDA
VEIN
- encasement of SMV or PV
- abutment to IVC
when is pancreatic cancer considered unresectable locally?
ARTERY
- encasement of the SMA or CA
- abutment of the CA + aortic involvement
VEIN
- SMV/PV un reconstructible due to tumor involvement or occlusion
when is pancreatic cancer considered unresectable (metastatic)?
distant metastasis to non regional lymph nodes
What are the physical signs of pancreatic carcinoma?
- tumor may be palpable -> hard fixed mass in the epigastrium
- palpable gallbladder (Courvoisier’s law)
- hepatomegaly -> secondary to an obstructed bile duct or metastatic carcinoma
- palpable left supraclavicular lymph node (Virchow’s node) -> due to thoracic duct involvement
- periumbilical region skin nodules (sister Joseph’s sign)
What lab studies are conclusive of pancreatic carcinoma?
- serum bilirubin > 10mg
- elevation of serum alkaline phosphatase
- anemia -> due to mucosal ulceration of periampullary tumor or varices
- silver stool
TUMOR MARKERS
- pancreatic oncofetal antigen (POA)
- CA 19-9
- CEA levels -> for follow up
What are the specific signs seen on imaging studies that indicate pancreatic carcinoma?
- Barium -> extrinsic compression of duodenum
- US, CT or MRI -> detect tumor, lymph nodes & hepatic metastasis
- ERCP -> complete pancreatic duct obstruction -> DOUBLE DUCT SIGN (diagnostic)
- PTC -> localization & decompression of site of biliary obstruction by stenting
- Angiography -> encasement or obstruction of pancreatic arteries
- > encasement, displacement or obstruction of portal or superior mesenteric vein
How is operable pancreatic carcinoma treated?
WHIPPLE’S OPERATION (head)
- pancreaticoduodenectomy -> reconstruction -> pancreatico-jejunostomy + hepatico-jejunostomy + gastro-jejunostomy
DISTAL PANCREATECTOMY + SPLENECTOMY (body/tail)
How is non operable pancreatic carcinoma treated?
PALLIATION
- bypass biliary obstruction -> cholecysto-jejunostomy OR hepatico-jejunostomy + gastrojejunostomy to guard against gastric outlet obstruction
- splanchnic block -> relieve abdominal & back pain
ADVANCED NON OPERABLE
- ERCP + biliary stent
