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Flashcards in Pancreas Deck (87)
1

percent of pancreatic cancer eligible for resection

20%

2

Best prognostic subtype of PDAC

colloid carcinoma

3

Head v tail proportion of PDAC

65% head v 25% tail (rest is indeterminate)

4

possible cutaneous presentations of PDAC

Pemphigoid rash (cicatricial and bullous)

5

Imaging features of a PNET

highly vascular
early arterial enhancement
washout in the early portal phase

6

Sensitivity and specificity of CA 19-9

sensitivity 70 to 92%
Specificity 68 to 92%

7

Positive predictive value of CA19-9 in asymptomatic patient?

(i.e. can we screen for PDAC with CA19-9)

<1%

PMID 14731128

(no)

8

What is the utility of CA-19-9 to plan for surgery?

Do not use as indicator of operability (ASCO)

May become part of selection criteria for neoadjuvant therapy.

9

When to biopsy prior to operating on PDAC?

Concern for:
chronic pancreatitis
autoimmune pancreatitis
(eg, extreme young age, prolonged ethanol abuse, history of other autoimmune diseases),

10

First-line biopsy procedure (if necessary) for PDAC?

EUS-guided FNA

11

NCCN unresectable definition for head PDAC

-contact with SMA >180 degrees
-contact with celiac axis >180 degrees
-tumor contact with the first jejunal SMA branch
-Unreconstructable SMV or portal vein
-Contact with the most proximal draining jejunal branch into the SMV

12

NCCN unresectable definition for tail PDAC

•Solid tumor contact of >180 degrees with the SMA or celiac axis
•Solid tumor contact with the celiac axis and aortic involvement
•Unreconstructable SMV or portal vein due to tumor involvement or occlusion (thrombus)

13

NCCN borderline resectable definition for head PDAC

SMV or portal vein
>180 degrees contact with contour irregularity
or thrombosis of the vein.
inferior vena cava.
tumor contact
Solid tumor contact with the SMA ≤180 degrees.
Solid tumor contact with variable anatomy

14

NCCN borderline resectable definition for tail PDAC

•Solid tumor contact with the celiac axis of ≤180 degrees.
•Solid tumor contact with the celiac axis >180 degrees without involvement of the aorta and withpreserved GDA, permitting an Appleby procedure (controverisal).

15

Discrepancy between AJCC and "borderline resectable" PDAC in 7th edition AJCC

7th Ed AJCC uses T4 category to designate an unresectable primary tumor. However T4s (arterial involvement) are still resected with R0 margins at some centers, especially after neoadjuvant therapy.

16

Ability of CT scan to detect metastatic PDAC

Contrast-enhanced CT is the modality of choice to detect distant metastases (image 16). with ~90% sensitivity and specificity.

However, the sensitivity of CT for peritoneal dissemination not high to eliminate the need for diagnostic laparoscopy in equivocal cases.

17

Role of Chest CT and PET in PDAC

Chest CT — most centers do not perform a routine staging chest CT for patients suspected of having pancreatic cancer because in the presence of lung metastases, the primary tumor is usually unresectable for another reason.

PET scanning — Studied, and probably not useful. In uncontrolled studies and meta-analyses, the sensitivity of integrated PET/CT (which has better spatial resolution as compared to PET alone) in the initial diagnosis of pancreatic cancer has ranged from 73 to 94 percent, while specificity ranges from 60 to 89 percent.

18

Role of staging laparoscopy in PDAC?

Widespread acceptance, but no controlled studies demonstrate a benefit.

Some selectively perform for borderline tumors, CA19-9 >1000, and prior to neoadjuvant therapy.

Good idea to do to avoid giving RT to peritoneal disease.

19

Peritoneal cytology in PDAC?

Not routinely reccomended as most patients with positive cytology have additional features of unresectability.

[PMID 15055843 MEYERS paper]

20

summary of resectability of PDAC

Remains controversial and somewhat of a continuum:
• nodal involvement beyond the peripancreatic tissues, and/or distant metastases.
•Direct involvement of the superior mesenteric artery (SMA), CHA, Celiac, by CT scan of low density tumor.
•Encasement or occlusion/thrombus of the superior mesenteric vein (SMV) or the SMV-portal vein

in practice, most of these patients are referred for neoadjuvant therapy prior to surgery.

21

T Staging of Pancreatic Cancer (PDAC and PNET)

Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ*
T1 < 2 cm or less in greatest dimension
T2 > 2 cm in greatest dimension
T3 Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery
T4 Tumor involves the celiac axis or the superior mesenteric artery (unresectable primary tumor)


22

Stage 0, IA, IB and IIA for PDAC (it's simple!)

Anatomic stage/prognostic groups
Stage 0 Tis N0 M0
Stage IA T1 N0 M0
Stage IB T2 N0 M0
Stage IIA T3 N0 M0

23

N Staging of Pancreatic Cancer

N0 or N1

24

What phase of CT scan is best for determining liver mets?

also occurs in the portal venous phase i.e. peak hepatic enhancement

25

Two Radiographic findings that should broaden your differential away from PDAC?

multifocal biliary strictures (autoimmune pancreatitis)
diffuse pancreatic ductal changes

26

Sensitivity and Specificity of FNA for PDAC?

Sensitivity of 90%
specificity of 96%

K-ras and P53 molecular analysis are emerging as a non-routine test to improve sensitivity.

27

What is an Appleby procedure?

Distal pancreatectomy with en-bloc resection of the celiac access.

28

How is perfusion to the liver maintained after an Appleby procedure?

retrograde flow from SMA, up the GDA.

29

What is the ARTERIAL PHASE of a triple contrast CT scan for PDAC?

The ARTERIAL PHASE of enhancement (first 30 seconds) opacifies celiac, SMA. Look for arterial involvement of tumor.

30

What is the PANCREATIC PHASE of a triple contrast CT scan for PDAC?

The PANCREATIC PHASE Theoretically maximal attenuation difference between tumor and normal pancreas. Occurs between peak opacification of aorta and liver.

31

What is the PORTAL PHASE of a triple contrast CT scan for PDAC?

The PORTAL VENOUS PHASE, (1 min post-injection) provides enhancement of the superior mesenteric vein (SMV), splenic and portal veins.

32

What is stage of positive peritoneal cytology for PDAC?

AJCC defines as M1 disease.

33

Stage IIB, III and IV for Pancreatic canacer

Stage IIB T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage III T4 Any N M0
Stage IV Any T Any N M1

34

RECIST Complete Response

Disappearance of all target lesions

35

RECIST Partial Response

>30% decrease in the sum of the largest diameter of target lesions,

36

RECIST Stable Disease

Neither sufficient shrinkage to qualify for PR (>30%) nor sufficient increase to qualify for PD (>20%), taking as reference the smallest sum largest diameter since the treatment started

37

RECIST Progressive Disease

At least a 20% increase in the sum of the LD of target lesions, taking as reference the smallest sum LD recorded since the treatment started or the appearance of one or more new lesions

38

Differences in 5-year survival for PDAC based on nodes.

Five-year survival after margin-negative (R0) resection: 30% node-negative
10 % node-positive disease

39

Stage IIB v Stage III pancreatic cancer 5-year OS

7.7% v 6.8%
Stage III is high risk for R1 resection; Stage IIB is any node positive.

40

Two things to do before starting chemo-first treatment for PDAC

Tissue diagnosis is required!

Needs a stent since biliary obstruction will delay neoadjuvant chemo.

41

Does BRCA status help select chemo for PDAC?

Not studied, but NCCN suggest consideration of gemcitabine plus cisplatin over FOLFIRINOX, for neoadjuvant chemo of PDAC that harbors a known BRCA mutation

42

PDAC median survival OS R0 v R1?

What if RO is defined as >1mm margin?

28.6 v 16.5 months

31.7 v 17.1 months

PMID: 28692477

43

What percent of R1 PDAC survive >10 years?

9%

PMID: 28692477

44

What percent of R0 PDAC die before 2 years?

50%

PMID: 28692477

45

What is the only perioperative management decision shown to change mortality following whipple?

Surgical drain placement in high risk patients

[Cameron JACS 2015; Van Buren Ann Surg 2014]

46

Chemo for gallbladder cancer?

Gemcitabine/Cisplatin

47

ABC-02 trial

ABC - Advanced Biliary Cancer

gem/cis v gem alone for metastatic biliary cancer.

11.7 months v 8.1 month survival

[Valle NEJM 2010]

48

Hanging Maneuver

Anterior approach to liver resection without mobilization;

Sometimes necessary for large tumors.

49

Glissonian approach

taking the portal triad outside the sheath, but intrahepatically.

50

Low CEA, Low Mucin, Low Amylase in a pancreatic cyst

Serous cystadenoma

51

pancreatic mass with uniform cells with large central nucleoli and eosinophilic granular cytoplasm

Pancreatic Acinar Cell Carcinoma

52

Acinar Cell Carcinoma is what % of pancreatic tumors?

1%

53

Defining presentation of Acinar Cell Carcinoma?

lipase secretion
arthralgia
eosinophilia
subcutaneous fat necrosis

54

Mutations for Acinar Cell Carcinoma?

APC/beta-catenin pathway

55

Median survival for Acinar Cell Carcinoma

30-60 months (better than PDAC)

56

Adjuvant therapy for Acinar Cell Carcinoma

to rare to study, so same regimens as PDAC are used.

57

What % of insulinomas have MEN I

5%

58

What % of MEN I patients get insulinomas?

20%

59

lab test work-up for insulinoma

insulin, pro-insulin and c-peptide

60

Medical management of hypoglycemia from insulinoma?

diazoxide

61

Contraindicated drug for insulinomas

octreotide (worsens hypoglycemia)

62

pancreatic cystic lesion with fine septations and thin drainage

likely a serous cyst adenoma; radiographic observation is best option.

63

four Ds of glucagonoma

diabetes
dermatitis
DVT
depression

64

Treatment for necrolytic migratory erythema
(glucagonoma dermatitis)

intermittent infusions of amino acids
(glucagonoma's mess up gluconeogenesis)

65

high CEA and mucin/ viscous fluid in a pancreatic cyst

Mucinous cystic Neoplasm - resect

66

biopsy finding for autoimmune pancreatitis

plasmacytic infiltration

67

threshold for preoperative stenting of PDAC

bilirubin of 10 mg/dl or coagulopathy

68

Does single agent chemotherapy palliate PDAC pain?

No

69

Percent of PDAC that is genetic

20%

70

Odds ratio for PDAC with hereditary pancreatitis?

50-80 fold higher than the general population

71

Genetic disorder with highest risk of PDAC?

Peutz-Jeghers (STK11)

72

Most common access for PVE

transhepatic contralateral approach

73

argument against transhepatic contralateral approach to PVE

can injure the future liver remnant

74

how long to wait after PVE to do volumetrics

4-8 weeks

75

Do you need to stop chemo during PVE?

No

76

Bleeding from the SMV splenic confluence, what to do?

apply pressure or stuff a raytec in the tunnel or both.

77

resection criteria for hepatocellular adenomas?

> 5 cm in women
all in men

78

central scar in liver lesion

Focal Nodular Hyperplasia

79

How do you RFA lesion near a major liver vessel

Pringle while you RFA so as to prevent heat sink from blood flow.

80

Favorable criteria for RFA of liver lesions (3)

tumors <3cm
away from liver surface
away from major inflow or outflow

81

Pancreatic mass with low CEA, low amylase and periodic Acid Schiff positive globules

Solid pseudo-papillary tumor

82

Treatment for Solid pseudo-papillary tumors of the pancreas?

resection

83

Metastasectomy for Solid pseudo-papillary tumors of the pancreas?

Yes

84

Candidacy for trials on liver transplantation for neuroendocrine mets

disease stability for 6 months
less than 50% of liver parenchyma involved

85

metastasectomy for high grade PNET (> 20 mit/10 HPF)

no!

86

Chemotherapy for high grade PNET?

yes! platinum/etoposide

87

8th edition AJCC definition of T4 PDAC

8thEd AJCC staging system no longer classifies T4 disease as categorically unresectable. However, they do not use the term "borderline resectable" to classify any clinical stage of disease.