Pancreatic Malignancy Flashcards by Meghan May

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%

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What is the outcome like for pancreatic pts?

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

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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

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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

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

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

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Features of pancreatic cancer

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

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

pancreatic head

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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

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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

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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

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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

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

are both:

• Mucinous neoplasms; pancreatic cystic neoplasm

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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

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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

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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