Pancreatic malignancy Flashcards
Stigmata on imaging of pancreatic malignancy:
main pancreatic duct >10mm, cystic lesion in pancreatic head, solid portion of cyst with enhancement
all of these in the presence of obstructive jaundice is highly suggestive of malignancy
What worrisome features of a pancreatic cyst (including branch duct IPMN) warrant EUS with FNA?
cyst >3cm thick/enhancing walls main duct 5-9mm nonenhancing mural nodule change in main pancreatic duct caliber with pancreatic atrophy distally
all pancreatic cysts with worrisome features should undergo endoscopic ultrasound
Criteria of unresectable pancreatic adenocarcinoma by NCCN guidelines:
- encirclement of the SMA or celiac axis greater than 180 degrees
- involvement of the aorta or or IVC
- involvement of SMV or portal vein to a degree that prevents reconstruction
- portal vein occlusion
Borderline resectable pancreatic adenocarcinoma (having some involvement of the great vessels but not completely excluded) management:
tissue diagnosis plus neoadjuvant prior to surgery
High risk features of a branch duct IPMN (pancreatic cyst) on imaging:
enhancing solid component (mural nodule)
main pancreatic duct >1cm
clinical signs of jaundice
all pancreatic cysts with high risk features should be resected
What type of IPMN carries the highest risk of malignancy?
main duct IPMNs
Endoscopic findings typical of main duct IPMN:
viscous fluid emanating from a patulous ampulla of vater (fish mouth ampulla)
Fluid analysis of main duct IPMN characteristics:
high amylase, high mucin, high CEA
Fluid analysis of pancreatic pseudocyst characteristics:
high amylase, low mucin (serous), low CEA
Fluid analysis of mucinous cystic neoplasms (MCNs) characteristics:
low amylase, high mucin, high CEA
CT characteristics of poorly demarcated, lobulated, polycystic masses with dilation of the main or branching pancreatic ducts is consistent with what pancreatic mass?
intraductal papillary mucinous neoplasm (IPMN)
CT characteristics of a solitary cyst with fine sepatations and a rim of calcification is consistent with what pancreatic mass?
mucinous cystic neoplasm (MCN)
CT characteristic of a well circumscribed central calcification and radiating septae (sunburst appearance) is often seen with what pancreatic mass?
serous cystic neoplasm
What size criteria of serous cystic neoplasms of the pancreas are less likely to be benign and should be considered for resection?
4cm
Indications for pancreaticoduodenectomy:
solid and cystic pancreatic neoplasms
periampullary malignancy
distal cholangiocarcinoma
Contraindications for pancreaticoduodenectomy:
- locally invasive malignancy with arterial encasement (SMA, hepatic artery)
- locally invasive malignancy with venous involvement not amenable to reconstruction
- distant metastatic disease
What amount of pancreatic tumor involvement is considered unresectable around the SMA or celiac axis?
180 degrees
What features of a neuroendocrine tumor of the pancreas may make it amenable to enucleation?
tumor <2cm that is not in communication with the main pancreatic duct; nonfunctional (except insulinoma)
What imaging is required for pancreatic cancer staging?
CT chest/ab/pelvis
Which patients with pancreatic cancer should receive chemotherapy +/- radiation?
Patient’s with borderline resectable or unresectable disease
Basic steps of a pancreaticoduodenectomy:
- right medial visceral rotation to expose the SMV
- extended kocher maneuver
- portal dissection, cholecystectomy, and CBD transection
- gastric transection (pylorus preserving vs standard)
- jejunal transection, dissection of ligament of treitz
- pancreatic transection and completion of retroperitoneal dissection
- counterclockwise reconstruction: PJ, HJ, GJ
How to diagnose a pancreatic fistula/leak after surgery:
test effluent fluid amylase (will be greater than 3 times the serum amylase)
Fluid analysis of serous cystic neoplasms characteristics:
low CEA, low amylase, serous fluid (no mucin)
Findings on labs and history for VIPoma:
achlorhydria, hypokalemia, watery diarrhea; dehydration, acidosis, hyperglycemia, hypercalcemia
IPMN with low grade dysplasia
adenoma
IPMN with moderate grade dysplasia
borderline
IPMN with high grade dysplasia
carcinoma in situ
secretin test findings for chronic pancreatitis
normal volume; normal enzyme secretion; decreased bicarbonate secretion
secretin test findings for end stage pancreatitis
low volume, low enzyme secretion, low bicarbonate secretion
secretin test findings for malnutrition
normal volume, low enzyme secretion, normal bicarbonate secretion
secretin test findings for pancreatic cancer
low volume, normal enzyme secretion, normal bicarbonate secretion
secretin test findings for Zollinger Ellison syndrome
increased volume; normal enzyme secretion, normal bicarbonate secretion
main location of VIPoma
distal pancreas
main location of somatostatinoma
head of pancreas
main location of insulinoma
evenly distributed throughout pancreas
IPMN that communicates with main duct and causes it to dilate
main duct IPMN
IPMN that communicates with branch ducts but not the main duct
branch duct IPMN
IPMN that communicates with both the branch ducts and the main duct
mixed IPMN
do mucinous cystic neoplasms of the pancreas communicate with the pancreatic ducts?
no
what operation to perform for malignancy detected in the tail of the pancreas?
take spleen with distal pancreatectomy
mucinous cystic neoplasms have what type of stroma?
ovarian
resectable pancreatic cancer features:
localized to pancreas without evidence of SMV or portal involvement and a preserved fat plane around the SMA/celiac axis and hepatic artery
borderline resectable pancreatic cancer features:
no CT evidence of extrapancreatic disease; patent SMV-portal vein confluence; no evidenc eof direct tumor extension into SMA/celiac axis; can have severe unilateral or bilateral SMV/portal impingement or SMV occlusion if reconstructible; can abut or encase hepatic artery if reconstructible; cannot abut more than 180 degrees of SMA
location of pseudocysts:
evenly distributed throughout the pancreas
location of serous cystadenomas:
evenly distributed throughout the pancreas
location of mucinous cystadenomas:
found in tail of the pancreas
location of IPMNs:
found in head of the pancreas
MCNs >____cm of the pancreas are at increased risk for malignancy.
3cm
True or false. Resection is recommended for all main duct IPMNs
true
Worrisome features of branch duct IPMNs:
> 3cm size, thickened/enhancing cyst wall, nonenhancing solid component, associated dilated main pancreatic duct, abrupt change in main pancreatic duct caliber
Most common functional pancreatic neuroendocrine tumor (PNET):
insulinoma
VIPoma electrolyte characteristics:
hypokalemia, achlorhydria (from diarrhea)
causes acidosis, hyperglycemia, and hypercalcemia
True or false. Adjuvant chemoradiation has been associated with higher toxicity but not improvement in survival for pancreatic adenocarcinoma.
True
Who should receive adjuvant chemoradiation in pancreatic adenocarcinoma?
residual microscopic disease or node positive disease
Who should receive just chemo for pancreatic adenocarcinoma?
patients with node negative disease
True or false. Adjuvant chemotherapy for pancreatic cancer has not been shown to improve survival.
false. it does improve survival
chemotherapy agents for pancreatic cancer:
gemcitabine or fluorouracil plus folinic acid
Formal pancreatic resection should be pursued for PNETs (pancreatic neuroendocrine tumors) with what features:
involvement of regional lymph nodes, tumors large than 2cm, functional PNETs (somatostatinoma, VIPoma, glucagonoma/noninsulinomas)
Treatment of PNETs that are locoregionally unresectable or patients with distant metastatic disease:
octreotide
Features of serous cystic neoplasms:
positive on periodic acid schiff stain; numerous loculations, clear fluid wihtout mucin and benign appearing epithelial cells; usually in men and women older than 50
features of solid pseudopapillary neoplasm:
diagnosed between 20-30 years; well circumscribed, encapsulated, and hetreogenous with hemorrhagic and cystic degeneration; cytology demonstrates abundant cells that are bland and uniform and staining demonstrates nuclear localization of beta catenin
