Gastro 55 Pancreas Malignancy

  1. How to classify cystic neoplasm of pancreas? Mention treatment modalities according to its types. [TU 2072]
    • Mucinous - most common
    • Serous
    • Intraductal Papillary Mucinous Neoplasm (IPMN)
    • - Branch duct
    • - Main duct
    • - Mixed
  2. Histological finding of Mucinous Cystic Neoplasm
    • Mucin rich cells
    • MCNs contain mucin-producing epithelium and are identified histologically by the presence of mucin-rich cells and ovarian-like stroma. Staining for estrogen and progesterone is positive in most cases.
  3. CT finding of MCN?
    • Solitary cyst, which may have fine septations and surrounded by a rim of calcification.
    • Presence of eggshell calcification, larger tumor size, or a mural nodule on cross-sectional imaging is suggestive of malignancy.
  4. Treatment of MCN?
    • Pancreatic resection is the standard treatment for MCNs, given the potential for malignant transformation.
    • In the absence of invasive malignant disease, resection is curative and no further surveillance is required.
    • Adjuvant systemic chemotherapy after surgical resection, especially when node-positive disease is
    • present.
  5. Short note on Serous cystoadenoma of the pancreas. [TU 2070] 

    Histological finding of SCN
    Multiloculated, glycogen rich small cysts , positive Periodic Acid Schiff Stain
  6. CT finding of SCN
    Central calcification with radiating septa, giving sunburst appearence
  7. Treatment of SCN?
    • Although serous cystic tumors are generally considered benign, pancreatectomy is suggested when the diagnosis of malignant disease is uncertain or in symptomatic serous cystadenomas. Indications of surgery are
    • - tumor larger than 4 cm
    • - rapidly growing lesions
  8. Worrisome and High-Risk Features of Branch duct IPMN?
    • Worrisome features
    • - Main duct 5-9 mm
    • - Non enhancing mural nodule
    • - Thickened enhancing cyst wall
    • - BD-IPMN >3 cm
    • - Abrupt caliber change in mainduct with upstream atrophy
    • - Lymphadenopathy
    • - Pancreatitis

    • High Risk Factors -
    • - Main duct >1cm
    • - Enhancing solid component
    • - Jaundice

    • - All cysts with worrisome features on CT or MRI and any cyst larger than 3 cm with or without worrisome features should undergo EUS
    • - All cysts with high-risk features should be resected
    • - Definite mural nodule, Main duct features suspicious for malignancy or Cytology suspicious or positive for malignancy warrents surgery. 
    • Image Upload 1
  9. How to differentiate Nodule with Mucin?
    • Mucin moves on patient position
    • Does not have doppler flow
    • FNA - no features of malignancy
  10. Features of MD-IPMN?
    • In contrast to BD-IPMN, MD-IPMN indicates abnormal cystic dilation of the main pancreatic duct with columnar metaplasia and thick mucinous secretions. 
    • ERCP finding (Ohashi triad) - Bulging ampulla of vater, Mucin secretion and Dilated main pancreatic duct. 
    • CT findings - Dilated MPD, Cysts of varying size, mural nodules, atrophy of parenchyma. 
    • Individuals with MD-IPMN have a 30% to 50% risk of harboring invasive pancreatic cancer at the time of presentation. Thus, main duct IPMN should always be resected.
  11. Management of Mixed type IPMN?
    The biologic behavior of mixed-type IPMNs most closely resembles thatof MD-IPMNs, with a significant risk of invasive malignant disease at the time of presentation (30% to 50%). As for MD-IPMN, surgical resection is indicated for the treatment of mixed-type IPMN
  12. Mucin, CEA and Amylase in various tumor
    • SCN - mucin negative, CEA low, Amylase low
    • MCN - Mucin positive, CEA high, amylase low
    • IPMN - Mucin positive, CEA high, amylase high
    • Pseudocyst - Mucin negative, CEA low, Amylase very high
  13. What are the characteristics of cystic neoplasms of the pancreas in relation to the pseudocyst?
    • High suspicion of cystic neoplasm in following circumstances:
    • „ No history of acute pancreatitis
    • „ Internal septa or associated solid component seen in CT scan
    • „ Calcification within the cyst or its wall
    • „ Tumor marker CA 19-9 is elevated in cystic neoplasm
    • „ Recurrence or persistence of the cyst after treatment—surgical or nonsurgical
  14. Risk factors for PDAC
    • Smoking
    • Chronic Pancreatitis
    • Obesity
    • Diabetes
  15. Hereditary risk factors for PDAC
    • PRSS1 and SPINK gene mutation
    • Peutz-Jegher Syndrome
    • CFTR gene mutation
    • BRCA-2 gene mutation
    • Lynch syndrome (Mismatch repair gene mutation)
  16. Common location of carcinoma pancreas?
    • It commonly involves the head and neck of the pancreas.
    • The relative incidence is: Head and neck: body and tail = 8 : 1.
  17. Tumor markers for pancreas cancer?
    • CA 19-9
    • CEA
    • CA 494
  18. What is Trousseau’s sign and Troisier’s sign?
    Trousseau’s sign - Migratory thrombophlebitis 

    Troisier’s sign - Left supraclavicular lymph node enlargement

    Both indicate advanced disease in pancreatic malignancy.
  19. Genetic Progression in Pancreatic Malignancy
    • Normal
    • PanIN 1A - Columnar, mucin producing ductal epithelium that maintains basally located homogenous nuclei
    • PanIN IB - Papillary architecture, no nuclear atypia
    • PanIN 2 - Nuclear Atypia
    • PanIN 3 - Carcinoma in Situ (enlarged nuclei with nuclear crowding, loss of polarity)

    • Proto-oncogen - KRAS2
    • Tumor Supressor gene - p53, DPC-4, CDKN 2A
  20. CT finding of pancreatic malignancy
    Hypoattenuating lesion during the portal venous phase of imaging
  21. What is FDG-PET scan?
    • F-Fluorodeoxyglucose Positron emission tomography - cells that are actively metabolizing will preferentially take up F-labelled glucose compared to surrounding normal tissue
    • False positive in inflamatory condition
  22. TNM staging of pancreatic adenocarcinoma
    • T1 - limited to pancreas, ≤2cm in greatest diameter
    • T2 - limited to pancreas, >2cm in greatest diameter
    • T3 - Tumor extend beyond pancreas, but without involvement of celiac axis or SMA
    • T4 - Involvement of celiac axis or SMA
  23. Indication of Laparoscopy in pancreatic Ca
    • Large tumors >3cm
    • CA 19.9 >100/ml
    • Uncertain finding in CT or tumor involving body and tail of pancreas
    • Significant weight loss or Malnutrition
  24. What is Pasireotide
    • Somatostatin analogue - found to be better than octreotide
    • - Half life 11hrs vs e hrs of Octreotide
    • - Binds receptors 1,2,3,5 Vs Receptor 2,5 in Octreotide
  25. Chemotherapy for metastatic pancreatic adenocarcinoma
    • Gemcitabine
    • Gemcitabine + Nabpaclitaxel
    • Erlotinib
  26. What is FOLFIRINOX?
    • FOL – folinic acid (leucovorin), a vitamin B derivative that odulates/potentiates/reduces the side effects of fluorouracil
    • F – fluorouracil (5-FU), a pyrimidine analog and antimetabolite which incorporates into the DNA molecule and stops DNA synthesis
    • IRIN – irinotecan (Camptosar), a topoisomerase inhibitor, which prevents DNA from uncoiling and duplicating; and
    • OX – oxaliplatin (Eloxatin), a platinum-based antineoplastic agent, which inhibits DNA repair and/or DNA synthesis.
  27. Pain relief in pancreatic malignancy
    • Celiac nerve block - 3ml of 0.25% Bupivacaine and 10ml of Absolute alcohol in each celiac plexus
    • CT guided percutaneous Neurolysis
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Gastro 55 Pancreas Malignancy