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GS oral board > Pancreatic Neoplasms - Endocrine - Core/Disease > Flashcards

Pancreatic Neoplasms - Endocrine - Core/Disease Flashcards

1
Q

What is the workup for PNETs?

A
  • H&P
  • Biochemical workup
  • Localization imaging
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2
Q

What symptoms are associated with a nonfunctional PNET?

A
  • Often asymptomatic
  • Possible symptoms include:
    • Abdominal pain
    • Jaundice
    • Anorexia
    • Weight loss
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3
Q

What symptoms are associated with an insulinoma?

A

Classic Whipple Triad

  • Hypoglycemia
  • Neuroglycemia (diaphoresis, confusion)
  • Resolution of symptoms with eating
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4
Q

What symptoms are associated with a gastrinoma?

A
  • Abdominal pain
  • Diarrhea (70%)
  • Refractory PUD
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5
Q

What symptoms are associated with a glucagonoma?

A

The 4 Ds

  • Diabetes
  • Dermatitis
    • Necrolytic migratory erythema
  • DVT
  • Depression
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6
Q

What symptoms are associated with a somatostatinoma?

A
  • Diabetes
  • Cholelithiasis
  • Malabsorption; steatorrhea
  • Abdominal pain (39%), Jaundice (28%), GI Bleed (22%)
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7
Q

What symptoms are associated with a VIPoma?

A

Verner-Morrison Syndrome aka WDHA syndrome

  • Watery Diarrhea
    • >5L/day
  • Hypokalemia
  • Achlorhydria
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8
Q

What is the biochemical workup for a nonfunctional PNET?

A
  • Chromgranin A (>300 ng/mL)

OR

  • Pancreatic Polypeptide (>200 pg/mL)
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9
Q

What is the biochemical workup for an insulinoma?

A
  • Insulin:glucose during fasting
    • >0.3 is diagnostic
  • 72 hour fast - Gold Standard
    • Glucose < 55
    • Insulin 3+
    • C-peptide > 0.2
    • Proinsulin 5+
    • Sulfonylureas neg
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10
Q

What is the biochemical workup for a gastrinoma?

A
  • Fasing gastrin >1,000 is diagnostic
  • If <1,000 perform secretin stim test
    • Overnight fast
    • IV secretin bolus (2 IU/kg)
    • Gastrin lab obtained at 0, 2, 5, 10, 15 minutes after injection
    • Gastrin increase >200 above baseline is diagnostic

Note: Gastrin levels are affected by PPI. Stop PPI prior to testing.

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11
Q

What is the biochemical workup for a glucagonoma?

A

Fasting glucagon level

  • > 1,000 is diagnostic
    • Normal fasting level is <100
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12
Q

What is the biochemical workup for a somatostatinoma?

A

Fasting somatostatin level

  • >160 is diagnostic
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13
Q

What is the biochemical workup for a VIPoma?

A

Serum VIP level

  • 225-2,000 is diagnostic
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14
Q

How are PNETs localized preoperatively?

A
  1. CT/MRI
  2. EUS
    • Better for small lesions
    • Can perform FNA at same time
  3. Somatostatin receptor imaging (Octreoscan)
    • Does not work for insulinomas (no somatostatin receptors)
  4. SPECT/CT
  5. Angiogram
  6. Portal venous sampling
    • Ca stimulates insulin release
    • Secretin stimlates gastrin release
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15
Q

Preoperative PNET localization was unsuccessful. What can be done in the OR to help localize the lesion?

A
  1. Intraoperative US
  2. Tactile sensation
  3. Duodenotomy for direct visualization
    • Last resort for gatrinomas
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16
Q

Nonfunctional PNET Surgical Treatment

A

SAFE ANSWER: RESECT THEM ALL

  • Head: Pancreaticoduodenectomy + regional nodes
  • Distal: Distal pancreatectomy + splenectomy + regional nodes

Technically, if <2 cm can consider observation

17
Q

Insulinoma Treatment

A

Prior to surgery, stabilize glucose levels with:

  • Diet and/or
  • Diazoxide and/or
  • Everolimus

Surgery by location/depth

  • Peripheral/exophytic
    • Consider enucleation
  • Deeper/invasive
    • Head: Pancreaticoduodenectomy
    • Distal: Distal pancreatectomy
18
Q

Gastrinoma Treatment

A

Resection based on localization

  • Duodenum: Duodenotomy, local resection/enucleation, periduodenal LN
  • Head:
    • Exophytic: enucleation
    • Deeper: Pancreaticoduodenectomy
  • Distal: Distal pancreatectomy + splenectomy + regional nodes
19
Q

Somatostatinoma Treatment

A

Resection by location

  • Head: Pancreaticoduodenectomy + regional nodes
  • Distal: Distal pancreatectomy + splenectomy + regional nodes
20
Q

Glucagonoma Treatment

A

Before Surgery

  • Octreotide preoperatively
  • Symptom management

Resection based on location

  • Head: Pancreaticoduodenectomy + regional nodes
  • Distal: Distal pancreatectomy + splenectomy + regional nodes
21
Q

VIPoma Treatment

A

Before Surgery

  • Octreotide preoperatively
  • Correct dehydration and electrolyte imbalances

Resection based on location

  • Head: Pancreaticoduodenectomy + regional nodes
  • Distal: Distal pancreatectomy + splenectomy + regional nodes
22
Q

What is treatment plan in metastatic PNET?

A

IF complete resection possible

  • Resect both the primary and the metastasis

IF unresectable but asymptomatic

  • Observe (intermittent biochemical markers and imaging)
  • Consider octreotide

IF unresectable and symptomatic

  • Symptom management
  • Consider octreotide
  • Palliative options
23
Q

What is the follow-up for PNETs?

A

Standard post-op visit

THEN

  • Annually
    • H&P
    • +/- biochemical makers as indicated
    • +/- imaging as indicated

GS oral board (23 decks)

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