Flashcards in Pancreatic Malignancies Deck (29):
What are the two types of pancreatic cancer?
Ductal adenocarcinoma (85%)
Intraductal Pancreatic Mucinous Neoplasm (2-3%)
What are some risk factors for the development of exocrine pancreatic cancer?
Cigarette smoking (1.5x increased relative risk)
Chronic pancreatitis (1.8% at 10 years, 4% at 20 years)
What are some genetic changes that lead to the development of pancreatic cancer?
Mutations of K-RAS
Inactivation of p16
Inactivation of p53, SMAD4, BRCA2
How do patients with pancreatic cancer typically present?
weakness, weight loss, anorexia, abdominal pain, jaundice, back pain
What clinical symptoms are more common for cancers in the pancreatic head?
How do you diagnosis pancreatic cancer?
Cholestatic liver pattern if biliary obstruction is present
Abdominal ultrasound for patients with jaundice
CT for patients with abdominal pain and weight loss (staging information too)
Is carbonic anhydrase a helpful lab test for determining whether a patient has pancreatic cancer?
Not really -- increased values may help you differentiation benign from cancer but values are often normal in early stages
What is the treatment for pancreatic cancer?
Surgical resection -- but 80-85% are unresectable at time of diagnosis because of distant metastases (liver) or invasion or encasement of the major blood vessels
Neoadjuvant therapy (before surgery) -- converts patient from nonresectable to resectable
Adjuvent therapy (after surgery ) -- patients with residual disease
Palliative -- surgical bypass for gastric outlet or biliary obstruction; stents: biliary, enteral
What are some types of pancreatic cystic neoplasms?
Mucinous neoplasms = mucinous cystic neoplasma, Intraductal papillary mucinous neoplasm (IPMN)
Non-mucinous neoplasms = serous cystadenoma
Who gets mucinous cystic neoplasms?
95% occur in women
Typically diagnosed > 40 yo
What is a mucinous cystic neoplasm?
Ovarian-like storm that secretes mucin
Typically present in pancreatic body or tail
No communication with the pancreatic duct
What are some symptoms of mucinous cystic neoplasm?
When symptomatic, can present with abdominal pain, recurrent pancreatitis, gastric outlet obstruction, palpable mass
Jaundice or weight loss more common with malignancy
What is the treatment for mucinous cystic neoplasm?
Surgical resection regardless of size, d/t risk of malignancy
What is an intraductal papillary mucinous neoplasm (IPMN)?
Mucin-producing papillary neoplasm of pancreatic duct
No predilection for location
What are the different types of IPMN?
Main duct IPMN: involves the main pancreatic duct
Branch duct IPMN: involves the side branches of the main pancreatic duct
Mixed type IPMN: involves both the main pancreatic duct and its side branches
What are some symptoms with IPMN?
Chronic pancreatitis d/t obstruction of pancreatic duct from mucous plugs
Back pain, jaundice, weight loss, anorexia, DM, anorexia concerning for malignancy
What is the management for IPMN?
Main duct: surgical resection d/t risk of malignancy (70%)
Side branch: lower risk of malignancy, safe to monitor under 3cm, no pancreatitis
What is a serous cyst adenoma?
25% of pancreatic cystic neoplasms
Lined by glycogen-rich cells originating from pancreatic acinar cells
Can arise anywhere in the pancreas
Usually in women over the age of 60
What are some symptoms of a serous cystadenoma?
Can present with abdominal pain, palpable mass, biliary obstruction, or gastric outlet obstruction when large
How do you manage serous cystadenomas?
Surgical resection if symptomatic
What do you use to determine if a lesion is mucinous vs serous?
Endoscopic ultrasound/fine needle aspirate to sample cytology
Name some examples of pancreatic neuroendocrine tumors.
How does insulinoma present?
Episodic hypoglycemia, most common pancreatic NET
How does glucagonoma present?
Hyperglycemia, rash (necrolytic migratory erythema), chelitis, venous thrombosis
How does a somatostatinoma present?
Diabetes mellitus (gastric inhibitory peptide), cholelithiasis (CCK), steatorrhea (secretin)
How does VIPoma present?
Pancreatic cholera = watery diarrhea, hypokalemia, achlorhydria (WHDA)
VIP stimulates secretion of water into pancreatic juice and bile, inhibits gastric acid secretion
What are some ways to diagnose NET?
Imaging: CT, MRI, Endoscopic ultrasound, somatostatin-receptor scintigraphy (high levels of somatostatin receptors)
Somatostatin analogues (octreotide) decrease secretion of a broad range of hormones
Proton-pump inhibitors for gastrinomas
What is the treatment for NETs?
Surgical resection of primary tumor and/or metastases
*Metastatic disease present frequently for glucagonomas (50-100%), somatostatinomas (75%), and VIPomas (60-80%)