Term
| Most common pancreatic neoplasm is |
|
Definition
ductal adenocarcinoma (90% of pancreatic neoplasms)
Poorest survival rate of any major malignancy (5 year survival rate < 5%) |
|
|
Term
| % resectable, unresectable, metastatic |
|
Definition
Resectable disease 15%
Locally advanced/unresectable disease 50%
Metastatic disease 35% |
|
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Term
|
Definition
Cigarette smoking
Hereditary pancreatitis
Chronic pancreatitis
Type II DM
Family history of pancreatic cancer (9%)
High fat intake
Exposure to non-chlorinated solvents and DDT |
|
|
Term
| what are signs of Early invasion of surrounding structures |
|
Definition
CBD: obstructive jaundice
Duodenum: gastric outlet obstruction
Retroperitoneum: nerve invasion; pain = ominous sign!
Encasement of superior mesenteric vessels, celiac and/or hepatic artery and/or portal vein |
|
|
Term
|
Definition
Ductal phenotype
Extensive fibrotic reaction around tumor
Metastatic spread to regional lymph nodes and liver |
|
|
Term
| T/F: panc cancer is typically found before it has spread beyond the pancreas |
|
Definition
F:
Patients often have extension of tumor
beyond the confines of the pancreas at
the time of presentation. |
|
|
Term
| Where in the panc are tumors usually located: % in tail, body, head? |
|
Definition
Head 60-70%
Body 15%
Tail 10% |
|
|
Term
Series of genetic events involving
activation of oncogenes and loss of tumor
suppressor genes |
|
Definition
K-ras 85-90%
p16 80%
p53 60%
DPC4 50% |
|
|
Term
| PanIN3 vs PanIN2 lesions? |
|
Definition
PanIN2 = p16, low grade dysplasia.
PanIN3 = P53/DPC4/BCRA2…high grade…these develop sequentially over time! NOT OVERNIGHT! |
|
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Term
|
Definition
Painless jaundice
Anorexia
Weight loss
Unexplained abdominal/back pain
Recent onset of non-insulin-dependent diabetes in the non-obese adult
Episode of unexplained pancreatitis – (obstructed duct) |
|
|
Term
elderly
patient who presents with unexplained
pain, weight loss, or obstructive jaundice.
New presentation of diabetes in the
non-obese adult.
DDX? |
|
Definition
|
|
Term
| T/F: the back pain in panc cancer is responsive to pain medicines |
|
Definition
| F: pancreas is tucked away and shielded |
|
|
Term
Which tumor marker is frequently elevated in
pancreatic cancer, but is also elevated in
other GI malignancies, pancreatitis, hepatitis
and biliary obstruction.
What is the sens/spec of 15 U/ml, 37 U/ml, and 1000U/ml? |
|
Definition
CA 19-9
sensitivity specificity
15 U/ml 92% 60%
37 U/ml 81-85% 81-90%
1000 U/ml 40% 99% |
|
|
Term
| What are other common lab elevations? |
|
Definition
| Liver function tests often reveal an elevated total and conjugated bilirubin level and alkaline phosphatase consistent with biliary obstruction |
|
|
Term
| T/F: US imaging is used primarily to detect the pancreatic head mass and the enzymes are the primary determinant of obstructive jaundice |
|
Definition
F: US is the Initial test for obstructive jaundice
Determines level of biliary obstruction – combined intrahepatic and extrahepatic ductal dilation versus isolated intrahepatic ductal dilation
Evaluates CBD size
Determines if gallstones are present
Detects pancreatic head mass in only 40% of patients |
|
|
Term
| Why would you use an EUS over a CT scan? |
|
Definition
Most accurate local staging modality (can identify lesions > 0.5 cm...vs. >1cm on CT (but CT tells you about metastases)
Very sensitive for evaluating local vascular involvement (although pancreatic protocol CT as good currently)
Useful in patients with underlying pancreatic disease who have abnormal appearing glands on CT scan
Can obtain FNA of mass for diagnosis |
|
|
Term
| Upon ERCP you see a double duct sign. What does this mean? |
|
Definition
ERCP Useful for diagnosing cause of biliary obstruction when no mass is evident on CT scan or EUS
Therapeutic modality if appropriate for clinical scenario with stent placement
Brushing of pancreatic duct/CBD can be sent for cytology
Classic finding in pancreatic cancer on ERCP is the “double duct sign”
CBD left, panc duct supposed to converge here you have DILATIOn due to tumor blocking the converging site. |
|
|
Term
| Why would you put a panc canc px through surgery and what are outcomes like for head vs. body/tail lesions? |
|
Definition
Only potentially curative therapy
Only 10-20% of patients are surgical candidates
Patients with head lesions – 15% are resectable
Patients with body/tail lesions – only 5% are resectable |
|
|
Term
| CT criteria for resection |
|
Definition
No extrapancreatic disease
No extension/involvement of celiac and superior mesenteric arteries
Patent superior mesenteric and portal veins |
|
|
Term
| what is the surgery that is Used to treat cancer of the head of the pancreas (most cases of resectable tumors) and what does it involve? |
|
Definition
The Whipple (pancreaticoduodenectomy)
Remove en bloc: b/c all shared blood supply
Pancreatic head
Duodenum
Distal CBD and gallbladder
Distal part of stomach |
|
|
Term
| QUIZ: When would you do a venous resection in panc cancer? |
|
Definition
| Venous resection should be considered when there was isolated tumor involvement of the SMV or portal vein without extension to the celiac or SMA |
|
|
Term
T/F: Chemotherapy saves many lives in panc cancer since most px are not surgical candidates.
(Which agents are used?) |
|
Definition
F:
Standard adjuvant therapy
Gemcitabine chemotherapy
Radiation therapy
Chemoradiation is not curative, but may extend life by several months
Neoadjuvant chemoradiation
Focus of clinical trials
Goal is to downstage patients with borderline resectable disease or questionable functional status |
|
|
Term
| All panc cancer outcomes: |
|
Definition
Overall 5 year survival is < 5%
Survival in unresectable patients is 6 to 12 months
Survival in patients with metastatic disease is 6-8 months
“Curative” surgical resection 5 year survival is 20-25% |
|
|
Term
| Features of palliative care and what percent of the 85-90% of px with the incurable disease get these? |
|
Definition
Biliary obstruction (80%)
Endoscopic options - metallic biliary wall stent
Operative options - choledochojejunostomy
Duodenal (gastric outlet) obstruction (25%)
Endoscopic options – duodenal stent
Operative gastrojejunostomy (gastric bypass)
Pain (80%)
Narcotics stop working
Chemical splanchnicectomy – “celiac block” most effective |
|
|
Term
| The road ahead for tx panc cancer? |
|
Definition
Identify early detection biomarkers
Identify novel targets for therapeutics |
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