Pancreatic Malignancy Flashcards
Who gets pancreatic cancer?
most common type?
Intraductal Pancreatic Mucinous Neoplasm (IPMN) increaes risk for?
higher risk in AA male
Ductal adenocarcinoma = 85% pancreatic cancers
with associated invasive carcinoma: 2-3%
What is the outcome like for pancreatic pts?
5%, five-year survival without surgery (most
patients not candidates)
lesion located in the head of the pancreas commonly obstructs the common bile duct; pt is jaundice adn lots of CONJUGATED bilirubin
Exocrine pancreatic cancer
Risk factors of exocrine pancreatic cancer
- Cigarette smoking: approximately 1.5 times increased relative risk
- Chronic pancreatitis: 1.8% at 10 years, 4% at 20 years
What are some key features in the pathogenesis of pancreatic cancer?
Telomere shortening, mutation of oncogenes, gradual forming cancer till becomes invasive
Features of pancreatic cancer
• Asthenia (weakness), weight loss,
anorexia, abdominal pain, jaundice
(approximately 50%), back pain
(approximately 50%)
Painless jaundice, steatorrhea, and weight
loss more frequently for pancreatic cancers in the
pancreatic head
How do you Dx pts with exocrine pancreatic cancer
• Cholestatic liver pattern if biliary obstruction is present
• Abdominal ultrasound for patients with jaundice
• Computed tomography for patients with abdominal pain and weight loss
Provides staging information as well
What is the use of CARBONIC ANHYDRASE (CA) 19-9 in diagnosing exocrine pancreatic cancer?
- Often normal in early stages so not useful for screening purposes
- Increased values may help differentiate benign disease from cancer
EXOCRINE PANCREATIC CANCER:
TREATMENT
80% to 85% of pancreatic cancers are unresectable at time of diagnosis because of
distant metastases (liver) or invasion or encasement of the major blood vessels.
• Treatment of pancreatic cancer that has not metastasized nor spread to the local
vasculature is surgical resection: DO WHIPPLE if in HEAD
Other Tx options for exocrine pancreatic cancer
• Neoadjuvant therapy (before surgery)
convert patient from nonresectable to resectable
• Adjuvant therapy (after surgery): Patients with residual disease
• Palliative
surgical bypass for gastric outlet or biliaryobstruction
stents: biliary, enteral
mucinous cystic neoplasm
intraductal papillary mucinous neoplasm (IPMN)
are both:
• Mucinous neoplasms; pancreatic cystic neoplasm
MUCINOUS CYSTIC NEOPLASM
• 95% occur in____
• Typically diagnosed > age 40
• Ovarian-like stroma that secretes_____
• Typically in the pancreatic ______or _____
• No communication with the pancreatic duct
women
mucin
body or tail
Symptoms associated with mucinous Cystic neoplasms
• Symptoms
Usually asymptomatic
When symptomatic can present with abdominal pain, recurrent pancreatitis, gastric outlet obstruction, palpable mass
Jaundice and/or weight loss more common with malignancy
If you find a mucionous cystic neoplasm, what do we need to do?
• Surgical resection regardless of size due to
risk of malignancy
- Mucin-producing papillary neoplasms of the pancreatic duct
- Equal sex distribution
- Incidence peaking over age 50
- No specific predilection for location
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)
What type of IPMN is most common?
Main duct: 70%
(branch duct involves the side ducts)
looks like a squid eye
how does IPMN cauase pancreatitis
Mucus can obstruct the duct causing pancreatitis.
• Usually asymptomatic
• Chronic pancreatitis due to obstruction of pancreatic duct from mucus plugs
• Back pain, jaundice, weight loss, anorexia, diabetes mellitus, anorexia concerning for
malignancy
INTRADUCTAL PAPILLARY
MUCINOUS NEOPLASM
What is the really bad type of IPMN and what do we do to tx it?
What is less concerning and what do we do to manage?
• Main duct: surgical resection due to risk of malignancy (70%)
• Side branch: lower risk of malignancy
Safe to monitor under select circumstances (e.g. cyst
size < 3 cm, no pancreatitis)
SEROUS CYSTADENOMA
• 25% of pancreatic cystic neoplasms
• Lined by glycogen-rich cells originating from _______
• Can arise anywhere in the pancreas
• Usually diagnosed in_____ over the age of 60
• Malignant degeneration very rare
pancreatic acinar cells
women
25% of pancreatic cystic neoplasms
Malignant degeneration very rare
SEROUS CYSTADENOMA
On a biopsy we see a central scar with a Central Stellate lesion. Pt was asymptomatic. What is this?
SEROUS CYSTADENOMA
How does Serous Cystadenoma present
• Symptoms
Usually asymptomatic
Can present with abdominal pain, palpable
mass, biliary obstruction, or gastric outlet obstruction when large
What is the management for serous cystadenoma?
• Management
Conservative
Surgical resection if symptomatic
How do we tell the difference between mucinous versus serous cystic lesion?
Endoscopic ultrasound; has a thin needle at the end
- Gastrinomas
- Insulinomas
- Somatostatinomas
- Glucagonomas
- VIPomas
All examples of:
PANCREATIC
NEUROENDOCRINE TUMORS
- Incidence of 1 in 100,000 individuals per year
- Typically diagnosed from ages 40-60
- Mostly sporadic, but can be associated with inherited syndromes
PANCREATIC
NEUROENDOCRINE TUMORS
most common NET taht causes episodic HYPOglycemia
Insulinoma
Pt has hyperglycemia a rash all over his mouth, chelitis and venous thrombosis. What type of tumor could cause this?
Glucagonoma
This causes diabetes millitus d/t increased GIP, cholelithiasis from inhibited CCK adn steatorrhea from inhibited secreatin (which means can’t form bicarb in the area in duodenum = inactive pancreatic enZ)
Somatostatinomas NET
NET causes watery diarrhea, hyokalema adn Acholorrdria
VIPoma
How do you diagnose pancreatic NETs
- Computed tomography (CT)
- Magnetic resonance imaging (MRI)
- Endoscopic ultrasound: high sensitivity
- Somatostatin-receptor scintigraphy
Why are somtatostatin-receptor scintigraphy a useful dx tool for NETs?
• Somatostatin-receptor scintigraphy
Most pancreatic NETs (not insulinomas) have high
levels of somatostatin receptors
*Somatostatin analogues (e.g. octreotide):
decreases secretion of a broad range ofhormones
Tx for NETs
Surgical resection of primary tumor and/or liver metastases:
• Metastatic disease present frequently for
glucagonomas (50-100%), somatostatinomas
(75%), and VIPomas (60-80%)
• Well differentiated pancreatic NET are
generally indolent
VIPomas:____% 5-year survival
Gastrinomas:____% 15-year survival without liver metastases,___% 10-year survival with
liver metastases
• Well differentiated pancreatic NET are
generally indolent
VIPomas: 88% 5-year survival
Gastrinomas: 83% 15-year survival without liver metastases, 30% 10-year survival with
liver metastases
