pancreatic cancer

Question 1

ampula of vater

Answer 1

ampula at junction of pancreatic and common cile ducts

Question 2

pancreatic prefered radiological exams

Answer 2

ERCP

MRCP

Question 3

pathophysiology of PDAC (pancreatic ductal adenocarcinoma)

Answer 3

panIN 1 -KRAS, telomere shortening
panIN 2- CDNK2A (P16)
panIN 3- TP53, SMAD4
pancreatic ductal adenocarcinoma

OR

CYSTIC:
IPMN +MCN

Question 4

PDAC epidemiology

Answer 4

65-85’s

western world

Question 5

PDAC etiology

Answer 5

inviromental:

smoking 25%
chronic pancreatitis (displasia)
diabetes (first onset or worsening)
 western diet
obesity
alcholol (chrinic pancreatitis)

genetic:

familial pancriatitis
syndroms (BARC2, PJS, LS, FAMM)
familial pancreatic cancer

Question 6

precursor lessions

Answer 6

Pancreatic Intraepithelial Neoplasia (PanIN)
<5mm, thus wont be found in imaging (<1cm)
not all will results in invasive malignancy

Question 7

Cystic pancreatic tumors – potential premalignant lesions

Answer 7

pseudocyts- due acute pancreatitis, bening

serus cystic neoplasm (SCN)-very small, bening

mucinous cystic neoplasm (MCN)-
big, solitary, body and tail, malignant
surgical treatment
95% female

intraductal mucinous papillary neoplasm (IPMN)-
main (usually malignant) / side branch (bening)
females

Question 8

analasis of cystic fluid

Answer 8

cytology- malignant/bening
CEA-mucinotic or serotic
viscosity
amylase lvl

Question 9

screening for PDAC

Answer 9

2 or more first degree relatives (or 1st+2nd) with pancreatic cancer

Patients with hereditary syndrome and 1 or more FDR with PDAC (in lynch and familial pancreatitis no need for PDAC in relative)

Israel
genetic panel is recommended to all patients
test for BRCA every Ashkenazi patient with PDAC

EUS OR MRI (no contrast) or MRCP (with contrast)
every year!

Question 10

PDAC - Signs and symptoms

Answer 10

Obstructive jaundice when the cancer is located in the head of the pancreas.

abdominal discomfort
pruritus
lethargy
weight loss

Question 11

PDAC diagnosis imaging

Answer 11

CT

at any doubt-
EUS-Bx

MRI-for small indeterminate liver lesions and to evaluate the cause of biliary dilatation when no obvious mass is seen

PET CT- staging mainly

Question 12

PDAC serum markers

Answer 12

CA 19-9 is elevated in approximately 70-80%

not recommended as a routine diagnostic or screening test because of its low sensitivity and specificity

post-resection CA 19-9 level has prognostic value, indicator of asymptomatic recurrence

Question 13

PDAC stages

Answer 13

Resectable
Borderline resectable

Locally advanced

Metastatic

Question 14

PDAC Criteria for resectability

Answer 14

No vascular encasement of SMA or celiac artery

Patency of superior mesenteric – portal venous confluence

No extrapancreatic disease

Question 15

PDAC treatment

Answer 15

1.Resectable
surgery + adjuvant chemo

head of pancrease- Whipple’s procedure (tough)
distal pancreatectomy

Among them, 30% will have microscopic residual disease after surgery (R1)

2. Locally advanced
   Chemo +/- radiotherapy
3. Metastatic (60%)
   Chemotherapy
   Palliation – ERCP + stent
   Median survival ~ 6 months

Question 16

Cholangiocarcinoma (CC)

Answer 16

Mucin-producing adenocarcinoma that arise from the biliary tract

intrahepatic (IHC) – the second most common primary liver tumor

perihilar (central, 65%) -
bifurcation of the common bile duct
Klatskin tumors

peripheral (or distal, 30%)

Question 17

Risk factors of Cholangiocarcinoma (CC)

Answer 17

Intrahepatic –
Cirrhosis, especially Primary Billiary Cholangitis
Hepatitis C

primary sclerosing cholangitis 20% (usually at IBD)
liver fluke in Asians

Question 18

Cholangiocarcinoma (CC) Clinical features and radiologic evaluation

Answer 18

Painless jaundice, often with pruritus or weight loss

US, CT / MRI / MRCP, ERCP

ERCP – therapeutic tool

Question 19

Cholangiocarcinoma (CC) diagnosis

Answer 19

Diagnosis is made by biopsy, percutaneously for peripheral liver lesions, or more commonly via ERCP

Question 20

Cholangiocarcinoma (CC) Treatment

Answer 20

The usual is surgical,

combination systemic chemotherapy may be effective.

Question 21

Gallbladder cancer epidemiology

Answer 21

F4:M1

Most patients have a history of antecedent gallstones

Question 22

Gallbladder cancer Clinical features and diagnosis

Answer 22

Often diagnosed unexpectedly during gallstone or cholecystitis surgery

chronic right upper quadrant pain
weight loss

CT scans or MRCP

Question 23

Gallbladder cancer Treatment and prognosis

Answer 23

surgical

radiotherapy and chemotherapy are not useful

Usually GB cancer has worse prognosis than CC, with a typical survival of 6 months or less

Question 24

Carcinoma of the ampulla of Vater

Answer 24

This tumor arises within 2 cm of the distal end of the common bile duct
90% AdenoCA