Northern California SGNA

Fall Conference 2010

Pancreas Neoplasms
Randall E Lee, MD, FACP
Gastroenterologist, VA NCHCS
Associate Clinical Professor of Medicine,
UC Davis
Disclaimer
No financial conflicts of interest or sponsorships
Pancreas neoplasms
Pancreas anatomy, embryology, physiology
Pancreas endocrine neoplasms
Pancreatic adenocarcinoma
Pancreas cystic neoplasms
Pancreas anatomy

Pancreas
Embryology

Pancreas physiology
Exocrine

Endocrine
Pancreas physiology
Exocrine
* Secretion into a duct

Endocrine
Pancreas physiology
Exocrine
* Secretion into a duct

Endocrine
* Secretion directly into the bloodstream
Pancreas structure
Acini

Islets


Pancreas structure
Acini
* Connected to ducts
* Exocrine function


Islets

Acini
* Connected to ducts
* Exocrine function
* acinarization

Islets

Pancreas structure
Acini

Islets
* Not connected to ducts
* Endocrine function

Pancreas structure
Acini
* Connected to ducts
* Exocrine function
* acinarization

Islets
* Not connected to ducts
* Endocrine function

Pancreas physiology
Exocrine
* Amylase: carbohydrate
* Lipases: fat
* Proteases: protein

Endocrine
Pancreas physiology
Exocrine
* Amylase: carbohydrate
* Lipases: fat
* Proteases: protein

Endocrine
Pancreas physiology
Exocrine
Endocrine
* Insulin (beta cells)
* Glucagon (alpha cells)
* Pancreatic polypeptide (PP cells)
* Somatostatin (D cells)
Pancreas neoplasms
adenocarcinoma
endocrine
cystic neoplasm
lymphoma
other
Pancreatic endocrine neoplasms
Insulinoma
Gastrinoma
Glucagonoma
VIPoma
Pancreas endocrine neoplasms
Insulinoma
* hypoglycemia
Gastrinoma
Glucagonoma
VIPoma
Pancreas endocrine neoplasms
Insulinoma
Gastrinoma
* Zollinger-Ellison Syndrome
* Peptic ulcer, GERD, diarrhea
* Gastrin is not normally produced in the pancreas!
Glucagonoma
VIPoma
Pancreas endocrine neoplasms
Insulinoma
Gastrinoma
Glucagonoma
* Hyperglycemia
* Weight loss
* Rash
VIPoma
Glucagonoma rash:

Necrolytic migratory erythema

Pancreas endocrine neoplasms
Insulinoma
Gastrinoma
Glucagonoma
VIPoma
* Severe diarrhea
* Hypokalemia
* Volume depletion
Pancreatic
endocrine neoplasm
localization:

CT
SR scintigraphy
Octreoscan
EUS


Pancreas endocrine neoplasm: treatment
Medical suppression of symptoms
Surgical resection
Pancreas neoplasms
adenocarcinoma
endocrine
cystic neoplasm
lymphoma
other
Pancreas adenocarcinoma
Usually arises from the duct
Men more than women, older than 45 years
Generally poor long-term prognosis
No good screening / early detection methods

Pancreas adenocarcinoma: perspective
0
100
200
300
400
500
600
700
H
e
a
r
t

d
i
s
e
a
s
e
C
a
n
c
e
r
S
t
r
o
k
e
C
O
P
D
A
c
c
i
d
e
n
t
A
l
z
h
e
i
m
e
r
'
s
D
i
a
b
e
t
e
s
I
n
f
l
u
e
n
z
a
2010 deaths (thousands)
Pancreas adenocarcinoma: perspective
0
50
100
150
200
250
Lung Prostate Breast Colorectal Melanoma Pancreas
New Cases 2010 Deaths 2010
National Cancer Institute, 2010
Pancreas adenocarcinoma: risks
smoking
heredity
diet
benign disease
unknown
Pancreas adenocarcinoma: clinical
presentation
Location!
Location!
Location!

Pancreas adenocarcinoma: clinical
presentation
Symptoms occur late in disease course.
Head of pancreas:
* Jaundice
* Palpable non-tender gallbladder (Courvoisiers sign)
Advanced:
* Fat malabsorption: steatorrhea
* Pain
* Fatigue, anorexia, weight loss
Pancreas adenocarcinoma: diagnosis
CT +/- biopsy
MRCP
ERCP & brushing / biopsy
EUS & FNA
Pancreas adenocarcinoma: CT

ERCP:
Double-duct
sign

Pancreas malignancy: ERCP
Sphincterotomy
* Grounding pad, generator, sphincterotome
Strictures
* Guidewire(s), dilators, stents
* Cytology brush, glass slides, fixative
Pancreas malignancy: EUS
Fine-needle aspiration & biopsy
Coordinate with pathologist
Cytology fixative, glass slides
Pancreas adenocarcinoma: treatment
Curative resection
Palliative therapy
Whipple procedure =
pancreaticoduodenectomy

Pancreas
adenocarcinoma:
survival after
Whipple

Pancreas adenocarcinoma: treatment
Curative resection
Palliative therapy
ERCP
cannulation
ERCP
sphincterotomy
CBD stent

Pancreas
Adenocarcinoma:
survival

Pancreas neoplasms
adenocarcinoma
endocrine
cystic neoplasm
lymphoma
other
Pancreas neoplasms: cystic
Mucinous cystic neoplasms
Serous cystadenomas
IPMNs
Mucinous cystic neoplasm
Cystic tumors filled with mucin
Women > men
Body & tail of pancreas
Always considered premalignant / malignant
Surgical resection
Serous cystadenoma
Cystic tumor filled with serous fluid
Women > men
Body & tail of pancreas
Generally benign, but can cause complications
I
P
M
N

Intraductal
Papillary
Mucinous
Neoplasm
IPMN
Pancreatic duct dilated, filled with mucin
Women = men
Malignant > benign
Surgical resection

Pancreas
Adenocarcinoma:
survival

IPMN
survival

Pancreas neoplasms
Pancreas anatomy, embryology, physiology
Pancreas endocrine neoplasms
Pancreatic adenocarcinoma
Pancreas cystic neoplasms