Pancreatic Malignancy

Question 1

Who gets pancreatic cancer?

most common type?

Intraductal Pancreatic Mucinous Neoplasm (IPMN) increaes risk for?

Answer 1

higher risk in AA male

Ductal adenocarcinoma = 85% pancreatic cancers

with associated invasive carcinoma: 2-3%

Question 2

What is the outcome like for pancreatic pts?

Answer 2

5%, five-year survival without surgery (most
patients not candidates)

Question 3

lesion located in the head of the pancreas commonly obstructs the common bile duct; pt is jaundice adn lots of CONJUGATED bilirubin

Answer 3

Exocrine pancreatic cancer

Question 4

Risk factors of exocrine pancreatic cancer

Answer 4

• Cigarette smoking: approximately 1.5 times increased relative risk
• Chronic pancreatitis: 1.8% at 10 years, 4% at 20 years

Question 5

What are some key features in the pathogenesis of pancreatic cancer?

Answer 5

Telomere shortening, mutation of oncogenes, gradual forming cancer till becomes invasive

Question 6

Features of pancreatic cancer

Answer 6

• Asthenia (weakness), weight loss,
anorexia, abdominal pain, jaundice
(approximately 50%), back pain
(approximately 50%)

Question 7

Painless jaundice, steatorrhea, and weight
loss more frequently for pancreatic cancers in the

Answer 7

pancreatic head

Question 8

How do you Dx pts with exocrine pancreatic cancer

Answer 8

• 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

Question 9

What is the use of CARBONIC ANHYDRASE (CA) 19-9 in diagnosing exocrine pancreatic cancer?

Answer 9

• Often normal in early stages so not useful for screening purposes
• Increased values may help differentiate benign disease from cancer

Question 10

EXOCRINE PANCREATIC CANCER:
TREATMENT

Answer 10

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

Question 11

Other Tx options for exocrine pancreatic cancer

Answer 11

• 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

Question 13

 mucinous cystic neoplasm
 intraductal papillary mucinous neoplasm (IPMN)

are both:

Answer 13

• Mucinous neoplasms; pancreatic cystic neoplasm

Question 14

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

Answer 14

women

mucin

body or tail

Question 15

Symptoms associated with mucinous Cystic neoplasms

Answer 15

• 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

Question 16

If you find a mucionous cystic neoplasm, what do we need to do?

Answer 16

• Surgical resection regardless of size due to
risk of malignancy

Question 17

• Mucin-producing papillary neoplasms of the pancreatic duct
• Equal sex distribution
• Incidence peaking over age 50
• No specific predilection for location

Answer 17

INTRADUCTAL PAPILLARY
MUCINOUS NEOPLASM (IPMN)

Question 18

What type of IPMN is most common?

Answer 18

Main duct: 70%

(branch duct involves the side ducts)

looks like a squid eye

Question 19

how does IPMN cauase pancreatitis

Answer 19

Mucus can obstruct the duct causing pancreatitis.

Question 20

• 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

Answer 20

INTRADUCTAL PAPILLARY
MUCINOUS NEOPLASM

Question 21

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?

Answer 21

• 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)

Question 22

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

Answer 22

pancreatic acinar cells

women

Question 23

25% of pancreatic cystic neoplasms

Malignant degeneration very rare

Answer 23

SEROUS CYSTADENOMA

Question 24

On a biopsy we see a central scar with a Central Stellate lesion. Pt was asymptomatic. What is this?

Answer 24

SEROUS CYSTADENOMA

Question 25

How does Serous Cystadenoma present

Answer 25

• Symptoms
 Usually asymptomatic
 Can present with abdominal pain, palpable
mass, biliary obstruction, or gastric outlet obstruction when large

Question 26

What is the management for serous cystadenoma?

Answer 26

• Management
 Conservative
 Surgical resection if symptomatic

Question 27

How do we tell the difference between mucinous versus serous cystic lesion?

Answer 27

Endoscopic ultrasound; has a thin needle at the end

Question 28

• Gastrinomas
• Insulinomas
• Somatostatinomas
• Glucagonomas
• VIPomas

All examples of:

Answer 28

PANCREATIC
NEUROENDOCRINE TUMORS

Question 29

• Incidence of 1 in 100,000 individuals per year
• Typically diagnosed from ages 40-60
• Mostly sporadic, but can be associated with inherited syndromes

Answer 29

PANCREATIC
NEUROENDOCRINE TUMORS

Question 30

most common NET taht causes episodic HYPOglycemia

Answer 30

Insulinoma

Question 31

Pt has hyperglycemia a rash all over his mouth, chelitis and venous thrombosis. What type of tumor could cause this?

Answer 31

Glucagonoma

Question 32

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)

Answer 32

Somatostatinomas NET

Question 33

NET causes watery diarrhea, hyokalema adn Acholorrdria

Answer 33

VIPoma

Question 34

How do you diagnose pancreatic NETs

Answer 34

• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Endoscopic ultrasound: high sensitivity
• Somatostatin-receptor scintigraphy

Question 35

Why are somtatostatin-receptor scintigraphy a useful dx tool for NETs?

Answer 35

• 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

Question 36

Tx for NETs

Answer 36

Surgical resection of primary tumor and/or liver metastases:
• Metastatic disease present frequently for
glucagonomas (50-100%), somatostatinomas
(75%), and VIPomas (60-80%)

Question 37

• Well differentiated pancreatic NET are
generally indolent
 VIPomas:____% 5-year survival
 Gastrinomas:____% 15-year survival without liver metastases,___% 10-year survival with
liver metastases

Answer 37

• 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