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Therapeutics/Pancreatic Cancer and Cystic Pancreatic Neoplasms

Case

Therapeutics/Pancreatic Cancer and Cystic Pancreatic NeoplasmsA 59-year-old African American man presents with a history of progressive jaundice and recent-onset depression. He is a former smoker. He has a family history of pancreatic cancer. His blood sugar is elevated. Computed tomography scan of the abdomen and pelvis reveals a 2.3-cm mass in the head of the pancreas. There is regional lymphadenopathy.

Therapeutics

Surgical resection is the only potentially curative option in the management of pancreatic cancer. Because the stage is typically advanced at presentation, surgery is only considered in a minority of cases. Approx imately 20% of patients will be operative candidates at the time of diagnosis.

Table Differential diagnosis of mass lesions in the pancreas

Pathologic diagnosis Tumor type
Pancreatic adenocarcinoma Malignant
Pancreatic neuroendocrine Malignant
tumor
Acinar cell carcinoma Malignant
Metastatic tumor to thepancreas Malignant
Lymphoma Variable malignant grade
Cystic lesion of the pancreas Benign, premalignant, or malignant
Focal pancreatitis Benign
Autoimmune pancreatitis Benign

Even with appropriate patient selection and complete surgical resection, only a subset of resected patients will achieve a cure. ERCP has a role in the palliation of obstructive jaundice. External beam radiation therapy with concomitant chemotherapy (5-fluorouracil, gemcitabine, paclitaxel) is primarily used for symptom palliation with modest improvements in mean survival.

Table Absolute and relative contraindications to surgical resection of pancreatic cancer. The range is represented from top (absolute) to bottom (relative) of the table

Metastases to the liver, peritoneum, omentum, or any extra-abdominal site
Encasement of celiac axis, hepatic artery, or superior mesenteric artery
Involvement of splenoportal confluence
Involvement of bowel mesentery
Involvement of superior mesenteric vein or portal vein

Case continued

The patient is not a candidate for resection due to involvement of the superior mesenteric artery (stage T4) and is referred to oncology. Oncology recommends chemoradiation therapy for palliation of symptoms. The patient undergoes chemoradiation therapy with initial improvement in his symptoms. His cancer progresses and he elects hospice care.

Case

A 76-year-old woman with congestive heart failure and hematuria undergoes a computed tomography scan to rule out nephrolithiasis. A 2-cm cystic lesion is noted in the tail of the pancreas. She denies any history of pancreatitis or heavy alcohol consumption. She denies abdominal pain or discomfort. There is mild dilatation of the main pancreatic duct.

Therapeutics/Pancreatic Cancer and Cystic Pancreatic NeoplasmsTherapeutics

Because of the risk of malignancy, surgical resection of suspected malignant cystic neoplasms may be indicated. A dilated main pancreatic duct, mural nodules, size greater than 3 cm, dysplasia on a biopsy, and the presence of pancreatic symptoms are indications for resection. Small incidental pancreatic cysts may enlarge over a prolonged period, and morbidity or mortality due to these cysts is low; therefore, observation may be a safe management option in some cases. The decision to monitor high-risk patients with small (<2 cm) incidental cystic neoplasms should follow a discussion regarding the low risk of cancer (3.5%) but high risk of progression to malignancy (50%).

Table Features and characteristics of common cystic lesions of the pancreas. Other less common cystic lesions include cystic endocrine neoplasm, ductal adenocarcinoma with cystic degeneration, lymphoepithelial cyst, and acinar cell cystadenocarcinoma

Cyst type Pathology Aspirate Carcinoem bryonic antigen ng/mL Amylase Management
Pseudocyst: no true epithelial lining, walls are of Develops as a result of pancreatic Thin, dark, opaque,non-mucinous, with

inflammatory cells

Low High No malignant potential,resection or

endoscopic

management

indicated for

adjacent structures nflammation and necrosis,
Frequently associated with pain communicates with the ductal system
Look for gland atrophy, duct dilatation,calcification of the parenchyma, calculi in

pancreatic duct

Contains high concentrations of amylase
Lining is fibrous with granulation tissue
Lacks an epithelial lining symptoms
Mucinous cystadenoma: most common cysticneoplasm Dense mesenchymal ovarian-like stroma Viscous, clear, variablecellularity, positive for

mucin

High>200 Low After resection,non-invasive MCN-no

recurrence

Lack communication with pancreatic duct
Typically occurs in middle-aged women May have 1 or more macrocystic spacesined by mucous-secreting cells
Typically solitary97% are distal (body and tail)
Peripheral eggshell calcification issuggestive of malignancy
May be malignant at time of diagnosis
Serous cystadenoma: 2nd most common cystictumor of the pancreas Typically composed of multiple, small cystsined by glycogen-rich cuboidal

epithelium

Less viscous, thin, clear,non-mucinous, may be

bloody

Low<5 Low Resection is curative
Middle-aged women
Typically solitary Chromosomal alterations of gene for von
Very LOW malignant potential Hippel-Lindau locus 3p25 found inmajority
Central scar highly suggestive but found in -20%
Intraductal papillary mucinous neoplasm (sidebranch or main duct) Consists of dilated ductal segments,usually within the head of the pancreas,

ined by mucous-secreting cells

Viscous, clear, with mucin High(>1000 concerning

for malignancy)

High Resection (especially forpatients with nodules

or symptoms)

Patients may have multiple cysts
More common in men Main duct Intraductal papillary mucinous neoplasms has greater malignantpotential Serial imaging forhigh-risk patients

with low-risk features

A dilated pancreatic duct implies a main duct
Intraductal papillary mucinous neoplasms Mural nodules and a segmental or diffusedilatation of the pancreatic duct >15 mm

are worrisome for malignancy

Mucin extrusion from widely patent ampulla (fishmouth deformity) is pathognomonic
Side branch Intraductal papillary mucinous neoplasms is more common

Most mucinous cystic neoplasms are located in the tail of the pancreas. The risk of progression can be weighed against the risk of postoperative pancreatic fistula (29%) and mortality (0.8%) with distal pancreatectomy. Surveillance can be performed with computed tomography, magnet resonance imaging (magnetic resonance imaging), or Endoanal ultrasound-FNA. Resection may be readdressed if imaging demonstrates a significant change in diameter or morphology.

Case continued

The patient is referred for Endoanal ultrasound with FNA. Endoanal ultrasound-FNA reveals a 2-cm lesion with a mural nodule and mild main pancreatic ductal dilation. A distal pancreatectomy is performed, revealing Intraductal papillary mucinous neoplasms. The patient develops a postoperative pancreatic leak but recovers and is discharged home.

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