PANCREATIC NEOPLASMS

Dr SMITHA.M

MALIGNANT NEOPLASMS


DUCT CELL ORIGIN

      

Ductal adenocarcinoma Mucin hypersecreting carcinoma Mucinous macrocystic neoplasm Giant cell carcinoma Adenosquamous carcinoma Mucinous colloid carcinoma Solid and papillary epithelial neoplasm

CLASSIFICN


CONNECTIVE TISSUE ORIGIN

      

Leiomyosarcoma Malignant fibrous histiocytoma Malignant hemangiopericytoma osteogenic sarcoma Rhabdomyosarcoma Malignant neurilemmoma Liposarcoma

ACINAR CELL ORIGIN

 

Acinar cell carcinoma Acinar cell cystadenocarcinoma Pancreaticoblastoma

UNCERTAIN HISTIOGENESIS


DUCTAL ADENOCARCINOMA
      

MOST COMMON NEOPLASM >75% OF PAN. TUMORS ANY AGE { 60-80 YEARS } 60MEN > WOMEN CIGARETTE SMOKING FAMILIAL C/c PANCREATITIS HERITABLE SYNDROMES

INVASIVE DUCTAL CA

AMPULLARY CA A

    

DISMAL PROGNOSIS POOR RESPONSE TO CHEMO & RT SURGICAL RESECTIONRESECTION<10<10-20% ARE RESECTABLE AT DIAGNOSIS 5 YEAR SURVIVAL RATE
 

WITH SURGERY : 20% WITHOUT SURGERY : <5%

MIN IMPROVT IN SURVIVAL ;SAFETY OF WHIPPLES OPERN

GOOD PROGNOSTIC FACTORS

    

SMALL TUMOR SIZE { <3 cm } NO LYMPHNODE METS NEGATIVE SURGICAL MARGINS DIPLOID > ANEUPLOID ADJUVANT CHEMORADIOTHERAPY

CLINICAL MANIFESTNS
      

VAGUE ABD. PAIN WT. LOSS Upper abd pain ; radn to back Obstructive jaundice { in Ca HOP } Venous thrombosis Pancreatitis Elevated CA 19-9 [ not for small tumors ] 19-

GROSS PATHOLOGY


LOCN
   

HEAD : 60% BODY : 13% TAIL :5% DIFFUSE : 22%

   

FOCAL MASS; 2-3 cm AV: DIAMETER 2HYPOVASCULAR ; LOCALLY INVASIVE DESMOPLASTIC RESPONSE PAN DUCT OBSTRUCTN >>PROX: DILN& PARENCHYMAL ATROPHY CBD OBSTRUCTN In Ca HOP

TUMOR SPREAD


 

EARLY LOCAL INVASION BY PERIVASCULAR,PERINEURAL &LYMPHATIC SPREAD VASCULAR : SMA , CELIAC TRUNK, SMV,SPLENIC & PORTAL VEIN ADJ: DUODENUM,STOMACH &SPLEEN DISTANT METS :LIVER,PERITONEUM,LN


ADRENALS,BONES,LUNGS,PLEURA

MICROSCOPY


MUCINOUS ADENOCARCINOMA

STAGING


 

STAGE 1 : tumor limited to pancreas or ext directly to duodenum,BD or peripancreatic tissues only, no e/o LN or distant mets STAGE 2 :tumor spread into stomach ,spleen colon or nearby large bv without LN or distant mets STAGE 3 :any T lesion with reg LN mets STAGE 4 :distant mets

IMAGING
   

CT & USG : NONINVASIVE DIAGNOSIS To direct percutaneous biopsy To assess feasibility of surgical resection CECT : most popular means to assess local extent of tumor & candidacy for resection

BARIUM STUDIES
   

HOP MASSES :WIDENING OF DUO: LOOP TAIL MASSES :ELEVATE ESOPHAGUS DEFORMITY IN MUCOSAL PATTERN ONLY INDENTN :SPLAYING OF MUCOSAL FOLDS REVERSED 3 SIGN OF FROSTBERG

ELEVATING ESOPHAGUS

INDENTN OF POSTR WALL OF S T O

DEFORMITY OF MUCOSAL PATTERN

DOUBLE CONTOUR OF DUO

REVERSED 3 SIGN OF FROSTBER

ULTRASONOGRAPHY
         

INITIAL INV IN OBS: JAUNDICE IN BD OBSTRUCTN, LOOK FOR CAUSE 55% OF TUMORS : Homo HYPOECHOIC 3% : Homo HYPERECHOIC 2% : ISOECHOIC 40% : HETERO,1*ly HYPOECHOIC MOST OVOID/SPHERICAL,REST IRREGULAR VASCULAR OCCLUSION& ENCASEMENT HEPATIC METS ASCITES

IHBRD

ABRUPT TERMN OF CBD;MASS IN

COMPUTED TOMOGRAPHY
 

DIAGNOSIS & STAGING DUAL PHASE,CONTRAST ENHANCED ,THIN SECTION,HELICAL CT

 

DIAGNOSIS & STAGING SURGICAL RESECTION ;SUITABILITY

   

150 mL of 300 mg of Iodine /mL ARTERIAL &PORTAL VENOUS PHASES THIN COLLIMATION 3-5mm: SMALL LESIONS 3WATER FOR BOWEL OPACIFICN

CT FEATURES
 

 

SMALL FOCAL HYPOVASCULAR MASS FOCAL CONTOUR CHANGES WITH/OUT DEFINITE DISCRETE MASS FOCAL S.T.D LESION IN A FATTY REPLACED GLAND SPHERICAL ENLARGT OF GLAND CONVEX ROUNDED BORDERS OF UNCINATE PROCESS

CONTD


  

DILN OF MAIN PD & CBD PROX. TO MASS CBD & PD DILN WITHOUT MASS :THIN ABRUPT TAPERING OF CBD FALSE +VE : FOCAL PARENCHYMAL ENLARGT IN C/C PANCREATITIS FALSE VE : SMALL LESIONS

ABRUPT TERMN OF CBD;MASS IN HOP;SMA INFILTRN

INFILTRN OF CELIAC AXIS

MASS IN HOP

PD DILN,ATROPHY-BODY &TAIL

ABRUPT TERMN AT HOP,ENLARGED HEAD

PV IRREGULARITY,CBD STENT

SURGICAL RESECTION


HOP Lesions : PANCREATICODUODENECTOMY UNRESECTABILITYUNRESECTABILITY- CRITERIA

  

 

Tr diameter 5 cm or more Invasn of adj tissues & organs except duodenum Occlusn,stenosis or encasement of vessels portal vein,SMA &celiac branches Distant nodal mets Hematogenous mets

METASTASIS
  

 

TYPICALLY LIVER REASON FOR UNRESECTABILITY HYPOVASCULAR LESIONS BEST SEEN IN PORTAL VENOUS PHASE PERITONEAL & LYMPH METS COMMON OTHER SITES : ADRENALS ,BONES ,LUNGS ,PLEURA

VASCULAR INVOLVT


 

Change in calibre or contour deformity of the vessel & soft tissue infiltrn of perivascular fat Venous invlvt more difficult to diag than arterial>>just adj to parenchyma ,no fat Prox distensn of aff: veins Multiple venous collaterals
 

IN HEPATODUODENAL LGT[PV OCCLUSN] SHORT GASTRIC & GASTROEPIPLOIC VARICES[SV OCCLUSN]

HOP MASS;SMA ENCASEMENT;CBD&CyD DILN

PV NARROWING

SMA

LYMPHNODE INVOLVT
 

+VE LN : >1 1.5 cm diameter PROBLEM : METS IN NORMAL SIZED LN

LOCAL INVASN


 

 

INVASN OF DUODENUM,STOMACH & TRANSVERSE COLON WATER AS ORAL CONTRAST INTERRUPTN OF NORMAL ENHANCING WALL OF STOMACH & DUODENUM ADRENALS & SPLEEN LESS COMMON SPLENIC INVASION : ALONG SPLENORENAL LGT FROM TAIL

IN 1 STUDY,72% OF PTS HAD UNRESECTABLE D/S +VE PREDICTIVE VALUE OF CT FOR UNRESECTABILITY > 100% -VE PREDICTIVE VALUE IS LESS IMPRESSIVE AS 1/3 OF TRS RESECTABLE BY CT ARE SURGICALLY UNRESECTABLE
   

UNDETECTED LIVER METS PERITONEAL IMPLANTS LN INVOLVT TR INVASN OF ADJ VASCULAR STRUCTURES

MAGNETIC RESONANCE
   

TR DETECTN LEVEL OF DISTAL OBSTRUCTN SITE OF UNDERLYING TR VASCULAR INVASN

 

T1 WTED SPIN ECHO GRADIENT ECHO T1 WTED SPIN ECHO T2 WTED SEQ

LYMPHADENOPATHY


HEPATIC METS


MRI


 

LOW SIGNAL INTENSITY REL TO PAN PARENCHYMA ON T1FIBROUS T1 POOR OR NO CONTRAST ENHANCT,IMPROVING TR:PANCREAS CONTRAST DYNAMIC MR SUPR TO CT FOR TR MASS,PERIPAN: EXTENSN& VASCULAR INVOLVT FAT SUPPRESSED T1 WTED MR IMAGES MRCP : NONINVASIVE ;BILE DUCTS &PD

PD DILN %TORTUOSITY;MESENTERIC BV INFILTRN..ADENOCA +PANCREATITIS

UNCINATE PROCESS MASS

MRI: HYPOINTENSE MASS

ERCP


INDICNS
  

CT & USG FINDINGS UNCLEAR DUCTAL DILN WITH IDENTIFICN OF MASS D/d b/w DUODENAL or AMPULLARY AND PERIAMPULLARY TRS IN HOP

ERCPERCP- FINDINGS


OBSTRUCTN OR STENOSIS OF PD WITH/OUT OBSTRUCTN OF CBD STENOSIS OF PD :

 

CONCENTRIC/ECCENTRIC SMOOTH/REGULAR

DILN OF MAIN PD PROX TO NARROWING ABRUPT TERMN OF DUCT IN COMPLETE OBSTRUCTN

D O U

D O U B L E D U C T S I G N

DILN OF PD &CBD

HOP MASS

ENDOSCOPIC ULTRASOUND
 

SMALL TRS :HIGH ACCURACY ADV:



VISUALISE PANCREAS & SURR: STRUCTURES WITH HIGH FREQ TRANSDUCER IDENTIFY PTS WITH VASCULAR INVOLVT &CHARACTERISE LOCAL INVASN OF NORMAL SIZED NODES GUIDE F.N.A OF SUSPECTED MALIGNANT LESIONS

DISADV :ENDO USG

  

INABILITY TO DETECT DISTANT METS MARKED OPERATOR DEPENDENCE RISKS & COSTS OF INVASIVE PROCEDURE UNSUITABLE AS SCREENING TEST

INTRADUCTAL PAPILLARY MUCINOUS TUMORS



ALSO CALLED
  

INTRADUCTAL PAPILLARY ADENOCA MUCIN HYPERSECRETING CA DUCT ECTATIC MUCINOUS CYSTADENOMA & CYSTADENOCA ABD PAIN R/C PANCREATITIS WT LOSS DIABETES STEATORRHEA

C/F :
    

MUCIN HYPERSECRETING CA-PD DILN;FIBROSIS ;ATROPHY

CONTD


MAIN DUCT TRS



DIFFUSE/SEGTL DUCTAL DILN MOSTLY UNCINATE PROCESS FOCAL DILN OF AFF: BRANCHES CLUSTERS OF MULTIPLE 5-20mm CYSTS 5

BRANCH DUCT TRS

  

BUNCH OF GRAPES

NO/MILD DIFFUSE DILN OF MAIN PD PAPILLARY LESIONS WITH VARIABLE DYSPLASIA &INSITU CANCER

PATHO:


 

INVASIVE CA : POORER PROGNOSIS COMPLETE RESECTN OF INVOLVED PANCREAS ;INTRAOP FROZEN SECTIONS OF MARGINS ONLY 2* DUCT DILN MAY BE IMAGED DUE SMALL SIZE OF MASS ERCP : PD DILN WITH MUCUS SPILLING FROM DILATED AMPULLA MULTIPLE FILLING DEFECTS WITHIN THE DIL.DUCTS MUCIN /MASS CT,ERCP ,EUS ARE INADEQUATE FOR PREOP ASSESST OF FOCAL INVASN.

IPMT..DISTAL PD DILN WITH SOFT TISSUE MASSES

ERCP..PD DILN WITH FILLING DEFECTS

CYSTIC NEOPLASMS
 

RARE 2 GROUPS


MUCINOUS MACROCYSTIC NEOPLASM

  

CYSTADENOMA CYSTADENOCARCINOMA MACROCYSTIC ADENOMA MICROCYSTIC ADENOMA SEROUS CYSTADENOMA GLYCOGEN RICH CYSTADENOMA

SEROUS MICROCYSTIC NEOPLASM

  

MUCINOUS MACROCYSTIC NEOPLASM

    

CYSTIC TR WITH ABUNDANT MUCIN > IN FEMALES YOUNGER PTS C/F : EPIGASTRIC PAIN,ABD. MASS > IN TAIL

MMN
  

OFTEN LARGE AT DGNIS [2-19cm] [2UNI/MULTI LOCULAR LARGE CYSTIC SPACES WITH THICK MUCOID SUB ;CLOUDY BROWN/HAGIC CYST SEPTNS :CALCIFICNS,SMALLER CYSTS OR SOFT TISSUE NODULES

MUCINOUS CYSTADENOMA

MUCINOUS CYSTADENOCARCINOMA

MMNIMAGING
 

XRAY : CALCIFICN IN 16% USG :SEPTNS IN CYSTIC CAVITIES & NODULAR,PAPILLARY MURAL EXCRESCENCES CT : CYSTIC MASS WITH ENHANCING WALLS &INTERNAL SEPTNS ; CYST WITH MURAL PAP PROJECTNS MRI : CYSTS HAVE HIGH INTENSITY ON T2WI & LOW ON T1WIPROTEIN D/d OF UNILOCULAR MMN :PSEUDOCYST

TAIL OF PANCREAS MASS,SEPTNS &CALCIFICN

CYSTIC LESION IN TAIL

MMN IN TAILNODULAR COMP WITH SEPTNS

SEROUS MICROCYSTIC NEOPLASM

      

 

CONSIDERED BENIGN 1 CASE WITH METS F : M =1.5 : 1 MIDDLE AGED & ELDERLY SURGICAL RESECTN ABD PAIN & / MASS WELL CIRCUMSCRIBED ,ROUND/OVOID ,MULTILOCULAR CYSTIC TRS CTSTS SMALL,UNIFORM SIZED WITH THIN WATERY FLUID RICH IN GLYCOGEN SPONT. BLEEDING INTO CYST FLUID FIBROUS BANDS WITHIN

MICROCYSTIC ADENOMA

SMN--IMAGING SMN--IMAGING
 

XRAY : CALCIFICN IN 38% CENTRAL DYSTROPHIC CALCIFICN IN CENTRAL SCAR USG :



MULTIPLE,TINY CYSTS :HOMO,HYPERECHOIC,SOLID,ENCAPSULATED MASS LARGER CYSTS : DISCRETE ANECHOIC STRUCTURES WITH REGULAR,THIN WALLS CENTRAL CALCIFICN

SMNSMN-CNTD


CT : HYPODENSE ,ENCAPSULATED, LOBULATED ,LOBULATED MASSES DIFFUSE HOMO or LOCALISED ENHANCT OF SOLID PORTIONS & RAD : FIBROTIC BANDS MRI : MULTIPLE CYSTS WITH HIGH INTENSITYON T2WI
 

BLEED INTO CYSTS :HYPERINTENSE ON T1 SCAR HYPO ON T1

ANGIO :HIGHLY VASCULAR TRS

SMN..MULTILOCULARED TR IN NECK;ENHANCING FIBROUS SEPTA

SMN IN TAIL

ENDOCRINE TUMORS


LOCN
  

B Cells : INSULIN ; CENTRAL A Cells : GLUCAGON ; SURR B Cells D cells & PP cells : scattered INSULINOMA,GLUCOGONOMA,GASTRINOMA,SOM ATOSTATINOMA,VIPOMA,PPOMA,CARCINOID MASS,GI HAGE ,METS

FUNCTIONAL


HYPOFUNCTIONING or C/L SILENT TRS



ISLET CELL TR.PARTIALLY CYSTIC

ISLET CELL TR :MULTICENTRIC

INSULINOMA
 

MOST COMMON ISLET CELL TR WHIPPLE TRIAD

  

HYPOGLYCEMIA LOW FBS RELIEF WITH GLUCOSE

  

HIGH INSULIN LEVELS & LOW GLUCOSE LEVELS OFTEN SMALL [<2cm] AT C/L PRESN MOST SOLITARY INTRAPANCREATIC MOSTLY BENIGN

CONTD
  

   

ASSO : MEN type 1 AUTO DOMINANT ALSO PARATHYROID,PITUITARY,ADR CORTEX & THYROID MALIGNANT & MULTIPLE HELICAL CT IN ARTERIAL PHASE MRI :HYPERINTENSE ON T2WI RING LIKE PERIPHERAL ENHANCT

INSULINOMA--TAIL

MRI T2WI

;INSULINOMA TAIL

T1WI ;RING ENHANCTOF TAIL

CT..HOP INSULINOMA

T2WI :HYPERINTENSE

CONTD
 

EUS : FOR LOCALISN OF SMALL TRS REL HYPOECHOIC TO PAN ;SMOOTH or SLIGHTLY IRREGULAR,WELLDEFINED MARGINS INTRAOP USG

GASTRINOMA
 

     

2nd MOST COMMON HIGH GASTRIN,ACID SECRN &ZOLLINGER ELLISON SYNDROME 60% MULTIPLE ;60% MALIGNANT 2020-60% IN ASSOSN WITH MEN 1 50% PTS HAVE METS AT DGNS OFTEN SMALL & DIFFICULT TO IMAGE HYPERVASCULAR THIN SECTION CT IN ARTERIAL PHASE

GASTRINOMAGASTRINOMA-CONTD
  

MRI : HYPO ON T1 AND HYPER ON T2 ENHANCT LESS THAN INSULINOMA GASTRINOMA TRIANGLE
  

SUPR : JN OF CyD & CBD INFR : D2 & D3 MED : JN b/w NECK & BODY

MALIGNANT BUT SLOWGROWING

OTHER ENDOCRINE TRS

   

MOSTLY MALIGNANT & LARGE AT DGS GLUCOGONOMA VIPOMA SOMATOSTATINOMA

GLUCOGONOMA
     

VERY RARE 70% MALIGNANT GLUCOSE INTOLERANCE WT LOSS ANEMIA NECROLYTIC MIGRATORY ERYTHEMA

GLUCOGONOMA

GLUCOGONOMA:HAGE & NECROSIS

VIPoma
  

RARE HIGH VIP LEVELS WDHA Syndrome : WATERY DIARRHEA, HYPOKALEMIA,HYPOCHLORHYDRIA, ACIDOSIS 50% MALIGNANT

SOMATOSTATINOMA
    

VERY RARE GALLSTONES,DIABETES,DIARRHEA MOSTLY MALIGNANT INTRAPANCREATIC MOSTLY MAY ARISE IN SMALL BOWEL OR AMPULLA DGNS

NONFUNCTIONING TRS
  

LARGE SIZE METS R^

  

RESECTION CHEMOEMBOLISN ABLATN OF HEP METS

NONSECRETING ISLET CELL TR

SOLID & PAPILLARY EPITHELIAL NEOPLASM



    

P.E.N,S&PN, PAP CYSTIC CA,SOLID & CYSTIC TR OF PANCREAS RARE YOUNG WOMEN AV: SIZE 10 cm MORE BODY & TAIL GOOD PROG FOLL: RESECTN

SPEN


PATHO: FIBROUS CAPSULE WITH INTERNAL SOLID& CYSTIC AREAS AREAS OF HAGE & NECROSIS SURR: BY SOLID & PSEUDO PAPILLARY STR. CT: Well demarcated mass with low density areas hagic necrosis


Thick enhancing capsule

MR: well demarcated mass with central hypo & hyper intense areas


Hage : hyperintense on T1

SOLID & PAPILLARY EPI NEOPLASM IN HOP,HYPERVASCULAR CAPSULE

SPEN

SECONDARY NEOPLASMS


DIRECT INVASN


STOMACH,COLON,DUODENUM BREAST,LUNG,MELANOMA

METS


 

LYMPHOMA LEUKEMIA

PAN METS ; LEFT ADRENAL MASS