How to classify cystic neoplasm of pancreas? Mention treatment modalities according to its types. [TU 2072]
- Mucinous - most common
- Intraductal Papillary Mucinous Neoplasm (IPMN)
- - Branch duct
- - Main duct
- - Mixed
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.
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.
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
Short note on Serous cystoadenoma of the pancreas. [TU 2070]
Histological finding of SCN
Multiloculated, glycogen rich small cysts , positive Periodic Acid Schiff Stain
CT finding of SCN
Central calcification with radiating septa, giving sunburst appearence
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
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.
How to differentiate Nodule with Mucin?
- Mucin moves on patient position
- Does not have doppler flow
- FNA - no features of malignancy
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.
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
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
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
Risk factors for PDAC
- Chronic Pancreatitis
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)
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.
Tumor markers for pancreas cancer?
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.
Genetic Progression in Pancreatic Malignancy
- 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
CT finding of pancreatic malignancy
Hypoattenuating lesion during the portal venous phase of imaging
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
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
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
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
Chemotherapy for metastatic pancreatic adenocarcinoma
- Gemcitabine + Nabpaclitaxel
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.
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