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Northern California SGNA Fall Conference 2010 Pancreas Neoplasms

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.

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Northern California SGNA Fall Conference 2010 Pancreas Neoplasms

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  1. Northern California SGNAFall Conference 2010Pancreas Neoplasms Randall E Lee, MD, FACP Gastroenterologist, VA NCHCS Associate Clinical Professor of Medicine, UC Davis

  2. Disclaimer • No financial conflicts of interest or sponsorships

  3. Pancreas neoplasms • Pancreas anatomy, embryology, physiology • Pancreas endocrine neoplasms • Pancreatic adenocarcinoma • Pancreas cystic neoplasms

  4. Pancreas anatomy

  5. Pancreas Embryology

  6. Pancreas physiology • Exocrine • Endocrine

  7. Pancreas physiology • Exocrine • Secretion into a duct • Endocrine

  8. Pancreas physiology • Exocrine • Secretion into a duct • Endocrine • Secretion directly into the bloodstream

  9. Pancreas structure • Acini • Islets

  10. Pancreas structure • Acini • Connected to ducts • Exocrine function • Islets

  11. Acini • Connected to ducts • Exocrine function • “acinarization” • Islets

  12. Pancreas structure • Acini • Islets • Not connected to ducts • Endocrine function

  13. Pancreas structure • Acini • Connected to ducts • Exocrine function • “acinarization” • Islets • Not connected to ducts • Endocrine function

  14. Pancreas physiology • Exocrine • Amylase: carbohydrate • Lipases: fat • Proteases: protein • Endocrine

  15. Pancreas physiology • Exocrine • Amylase: carbohydrate • Lipases: fat • Proteases: protein • Endocrine

  16. Pancreas physiology • Exocrine • Endocrine • Insulin (beta cells) • Glucagon (alpha cells) • Pancreatic polypeptide (PP cells) • Somatostatin (D cells)

  17. Pancreas neoplasms

  18. Pancreatic endocrine neoplasms • Insulinoma • Gastrinoma • Glucagonoma • VIPoma

  19. Pancreas endocrine neoplasms • Insulinoma • hypoglycemia • Gastrinoma • Glucagonoma • VIPoma

  20. Pancreas endocrine neoplasms • Insulinoma • Gastrinoma • “Zollinger-Ellison Syndrome” • Peptic ulcer, GERD, diarrhea • Gastrin is not normally produced in the pancreas! • Glucagonoma • VIPoma

  21. Pancreas endocrine neoplasms • Insulinoma • Gastrinoma • Glucagonoma • Hyperglycemia • Weight loss • Rash • VIPoma

  22. Glucagonoma rash: Necrolytic migratory erythema

  23. Pancreas endocrine neoplasms • Insulinoma • Gastrinoma • Glucagonoma • VIPoma • Severe diarrhea • Hypokalemia • Volume depletion

  24. Pancreatic endocrine neoplasm localization: CT SR scintigraphy “Octreoscan” EUS

  25. Pancreas endocrine neoplasm: treatment • Medical suppression of symptoms • Surgical resection

  26. Pancreas neoplasms

  27. 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

  28. Pancreas adenocarcinoma: perspective

  29. Pancreas adenocarcinoma: perspective National Cancer Institute, 2010

  30. Pancreas adenocarcinoma: risks

  31. Pancreas adenocarcinoma: clinical presentation • Location! • Location! • Location!

  32. Pancreas adenocarcinoma: clinical presentation • Symptoms occur late in disease course. • Head of pancreas: • Jaundice • Palpable non-tender gallbladder (Courvoisier’s sign) • Advanced: • Fat malabsorption: steatorrhea • Pain • Fatigue, anorexia, weight loss

  33. Pancreas adenocarcinoma: diagnosis • CT +/- biopsy • MRCP • ERCP & brushing / biopsy • EUS & FNA

  34. Pancreas adenocarcinoma: CT

  35. ERCP: “Double-duct” sign

  36. Pancreas malignancy: ERCP • Sphincterotomy • Grounding pad, generator, sphincterotome • Strictures • Guidewire(s), dilators, stents • Cytology brush, glass slides, fixative

  37. Pancreas malignancy: EUS • Fine-needle aspiration & biopsy • Coordinate with pathologist • Cytology fixative, glass slides

  38. Pancreas adenocarcinoma: treatment • Curative resection • Palliative therapy

  39. “Whipple procedure” = pancreaticoduodenectomy

  40. Pancreas adenocarcinoma: survival after Whipple

  41. Pancreas adenocarcinoma: treatment • Curative resection • Palliative therapy

  42. ERCP • cannulation

  43. ERCP • sphincterotomy

  44. CBD stent

  45. Pancreas Adenocarcinoma: survival

  46. Pancreas neoplasms

  47. Pancreas neoplasms: cystic • Mucinous cystic neoplasms • Serous cystadenomas • IPMNs

  48. Mucinous cystic neoplasm • Cystic tumors filled with mucin • Women > men • Body & tail of pancreas • Always considered premalignant / malignant • Surgical resection

  49. Serous cystadenoma • Cystic tumor filled with serous fluid • Women > men • Body & tail of pancreas • Generally benign, but can cause complications

  50. I P M N

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