Workup/Staging Flashcards
What is the DDx of a pancreatic mass?
The DDx of a pancreatic mass includes exocrine cancer, islet cell/neuroendocrine cancer, cystic adenomas, papillary cystic neoplasms (e.g., intraductal papillary mucinous tumor), lymphoma, acinar cell carcinoma, and metastatic cancer.
What is the initial workup for suspected PCA?
Suspected PCA workup includes a focused H&P, labs including CBC, CMP, and CA 19-9, and abdominal CT scan.
In what circumstance will a PCA pt not excrete any CA 19-9?
If a pt is red cell Lewis antigen A–B negative, then the pt cannot excrete CA 19-9. The Lewis antigen– phenotype is present in 5%–10% of the population.
What is the appropriate imaging for suspected PCA?
Dual-phase thin-sliced (preferably submillimeter) CT abdomen, with images obtained in the pancreatic parenchymal and portal venous phases of enhancement.
Name 4 appropriate procedures for obtaining tissue from a suspicious pancreatic mass.
Procedures to obtain tissue from a suspicious pancreatic mass:
- EUS-guided FNA
- CT-guided FNA
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Pancreatic resection (i.e., histologic Dx is not required before Sg)
When is it appropriate to obtain tissue prior to Sg for lesions suspicious on imaging?
Tissue Dx prior to Sg is not routinely necessary, except for: (1) clinical trial enrollment, (2) prior to neoadj therapy, or (3) prior to chemo/CRT in unresectable pts.
What is the major advantage of EUS-guided FNA over CT-guided FNA of a pancreatic mass?
EUS-guided FNA is associated with lower risk of peritoneal seeding (2% vs. 16%).
When is ERCP indicated instead of EUS?
ERCP carries a higher risk of iatrogenic pancreatitis, so it is reserved for cases where PCA is causing biliary obstruction and cholangitis requiring stenting.
What is the NCCN 2018 classification scheme for PCA?
PCA are classified into 4 categories
- Resectable (T1–3N0 or N+)
- Borderline resectable (T1–4Nany)
- Locally advanced unresectable (T4Nany)
- Metastatic (TanyNanyM1)
What 3 criteria are necessary for a primary pancreatic tumor to be resectable (per NCCN)?
NCCN resectability for PCA is defined as:
- No distortion of superior mesenteric vein (SMV) or portal vein (PV) & ≤180-degree contact
- Clear fat plane around celiac artery, SMA, and common hepatic artery (CHA)
- No distant mets or mets to nodes beyond field of resection
What characteristics make a primary pancreatic tumor unresectable (per NCCN)?
Unresectable characteristics include:
- > 180-degree encasement of SMA, celiac axis, first jejunal branch of SMA for head lesions
- > 180-degree encasement of the SMA, celiac axis, or abutment of CA w/ aortic involvement for body/tail lesions
- Unreconstructable SMV/PV occlusion, contact w/ most proximal draining jejunal branch of SMV
- Aortic invasion/encasement
What are the characteristics of borderline resectable pancreatic head/body tumors (per NCCN)?
The definitions vary, but NCCN definition of borderline resectability for PCA are:
- SMV/PV involvement (distortion, narrowing or occlusion) that can be resected and reconstructed using nearby vessels.
- Tumor abutment on SMA ≤180 degrees, CHA abutment without extension to celiac axis or hepatic bifurcation.
- Gastroduodenal artery encasement up to the hepatic artery, including up to short segment encasement or direct abutment of the hepatic artery, without celiac axis involvement.
What pancreatic tail lesions are considered “borderline resectable”?
Invasion into the adrenal gland, colon, mesocolon, or kidney are considered borderline resectable for PCA tail lesions.
What location of PCA is associated with higher rates of resectability: head, body, or tail?
PCA head tumors are more resectable b/c they cause Sx early (and therefore present with earlier-stage Dz).
At presentation, what % of PCA pts are resectable?
10%–20% of PCA pts are potentially resectable at presentation.
