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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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
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*
Insulin (beta cells)
Glucagon (alpha cells)
Pancreatic polypeptide (PP cells)
Somatostatin (D cells)
Pancreas neoplasms
adenocarcinoma
endocrine
cystic neoplasm
lymphoma
other
Pancreatic endocrine neoplasms
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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
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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
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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
2010 deaths (thousands)
700
600
500
400
300
200
100
0
za
en
flu
In
s
te
be
's
ia
D
er
im
he
lz
A
t
en
id
cc
A
PD
O
C
ke
ro
St
r
ce
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as
C
se
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ea
H
Pancreas adenocarcinoma: perspective
New Cases 2010
Deaths 2010
250
200
150
100
50
0
Lung
Prostate
Breast
Colorectal Melanoma
Pancreas
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 (Courvoisier’s sign)
• Advanced:
* Fat malabsorption: steatorrhea
* Pain
* Fatigue, anorexia, weight loss
Pancreas adenocarcinoma: diagnosis
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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
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Cystic tumors filled with mucin
Women > men
Body & tail of pancreas
Always considered premalignant / malignant
Surgical resection
Serous cystadenoma
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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
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Pancreatic duct dilated, filled with mucin
Women = men
Malignant > benign
Surgical resection
Pancreas
Adenocarcinoma:
survival
IPMN
survival
Pancreas neoplasms
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Pancreas anatomy, embryology, physiology
Pancreas endocrine neoplasms
Pancreatic adenocarcinoma
Pancreas cystic neoplasms