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Pancreatic Tumours - Coggle Diagram
Pancreatic Tumours
Pancreas Ductal Adenocarcinoma PDAC
Epidemiology
95% malignant tumours
600 per year in IRE
7th caus eof cancer deaths
Rare below 45
Peak at 75 women, 65men
15% resectable at presentation
Presentation
80% Obstructive jaundice
80% happen in head of gland
Weightl loss
New onset Diabetes / Worsening control
Early saiety
Pain -supossedly painless - some pain but vague
If painful - local regional nerves are involve
Risk factors
Cancer syndromes
Lynch
BRA
MLH1
Smoking
Alcohol
High calory diet
Dry cleaning industry
Diagnosis
Minimum data sets - what needed to stage tumour
CA 19-9 (serum)
CT pancreas !!
EUS
ERCP - not usual unless ??
Used to relieve obstruction - stenting
Only usedful for diagnoses
Ampullary
Distal commo n bile duct colangiocarcinoma
Not so useful for head of pancreas carcinoma - in the gland not in the duct
Use
Stenting
Not so much for diagnois
Sparingly
MRCP
PET - not that useful
Laparoscopy - sparingly use CT instead
US
Laparoscopic Staging
Not used as much
Peak and shriek
Used for selective cases
CA 19-9 really high (suggests mets) but no visible mets on CT - go in and take out :)
Treatment Algorithm
Resectable
Resection
Often come back
Locally Advanced disease
Combined modality therapy
Metastatic disease
Chemotherapy
Best supportive care
Management
Surgical Therapy
Two Operations
Tail coming Away -
Distal pancreatectomy and Total Splenectomy
20% tumours in tail
Blood supply and nodes of tail implicated with tail of pancreas so spleen has to go
Leak rate - 1 in 3
Head come away - Whipple
Pancreaticoduodenectomy
3 bits of plumbing after
Stomach
Adjuvant Therapy
Treatment given after the primary treatment
Median survival - point of time of which 50% are still alive
5 Fluorouracil
Gemcitabine
mFOLF
Follow Up
Most get adjuvant
6 monthly CA19-9 and CT pancreas and thorax
Panreatic Resection Morbidity
Answer Framework
Presentation
Epidemiology
Risk factors
Diagnosis and Staging
Bloods, EUS, Radiology
Therapy
Conservative
Medical
Disease modifiying
Symptoms control
Surgical
Follow up
Prognosis
Pancreas
Endocrine
Exocrine
Majority of malignant tumours are head
Blood supply
Blood supply to spleen invloved in bodya nd tail on pancreas
Associations
HEad
Bcommon bile duct
Duodenum
Pancreas Serous Cyst Adenoma
Epidemiology
Incidental finding - not many clincal features
Women >60
VHL syndrome
Types
Oligocystic
Microcystic
Management
Conservative
Surgery
Indication
Local pressure syndrome
Prognosis
Very good
Investigation
Imaging
US - Endoccopic ultrasound and aspirate fluid - pathology
Biochemical analysis
CEA
High - mucinou
Low - serous cyst adenoma
Mucinous Cystic Neoplasma (MCNs)
Types
MCNs - no connection to pancreas
Epidmemiologicl
Incidental
Femal >40
Diagnosis
Axial immaging
CT pancreas
MRI pancreas
EUS and sampling
CEA - high mucin
String test - not done anymore
String sign
Bloods
Transformation
can
Management
Surgical Resection MCNS
IPMN Intraductal Papilary MNs
Epidemiology
Incidental finding
M=F
Older 50s 60s
Most common cyst in pancreas
Diagnosis and Staging
Bloods
EUS
Radiology
Managment
Surgical Resection
Main Duct operate (1cm)
More transform early
Side Brand if >4cm /complex
6% need resection
Follow up
Yearly MRCPs
Features for sugery indication
Size
nodules
Rind becomes more complex
Prognosis
Good if followed (6% need resection)
PNET Pancreas Neuroendocrine Tumour
Types
Function
Insulinomas - Hypoglycaemia
Gastrinomas
PUD
Zollinger-Ellison
Glucagonomas
Migratory erythema
Diarrhoea
VIPomas
Watery diarrhoea
PPoma
Diarrhoea
Non functioning
Most
Minimum work up
Serum chromogranin A and ruine 5HIAA
CT pancreas
MRI pancreas
EUS and biopsy
Octreoscan or DOTATATE-PET
Epidemiology
Usually incidental
Features
Slow growing
Incidental finding
Periferation index
Rapid dividing
Grade 1: 1-2%
Grade 2: 2-20%
Grade 3: Neuroendocrine carcinomas
Non surgical
Small cell and large cell affects regimen chemotherapy
Management
Conservative
Below 2cm
and
asymptomatic G1
Tend to be slow growing
Surgical Resection
Indications
Size >2cm
Grade 1 /2 (MIB index, <20% grade 3 NEC)
Functioning
Mets?
Medical
Landriotide
Chemo
Algorithm: ...
Other Stuff - DDX of Tumours
Solid pseudopapillary neoplasms
Young women
Good prognosis
Pseudocysts
Dont have epithelial lining
Acinar cell carcinomas
Lipas ehypersecretion
BRACA 2
Pancreaticoblastoma
Tumours / Neoplasm
Benign
Serous cysts
Mucinous cysts
Malignant
"Cancer"
Primary
PDAC
PNET
Secondary
Rare