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What are the 3 most common groups of neoplastic pancreatic cysts?
Serous, Mucinous, IPMN
Which of the following has malignant potential? (serous cystic, mucinous cystic, IPMN)? In the Pancreas.
IPMN and Mucinous; Serous has very rare malignant potential
What 2 indices are typically used when evaluating pancreatic cyst fluid?
CEA and Amylase
What information can be gathered by evaluating a pancreatic cyst's level of CEA? What levels are clinically useful?
Tell wether cyst is mucinous (>192) or a mucinous cystadenocarcinoma (> 800)
What information can be gathered by evaluating a pancreatic cyst for amylase?
This can tell if there is communication with the duct
The ERCP finding of a "fish mouth" papilla in the dudodenum thath secretes mucin is pathognomic for what pancreatic disease?
What are the primary indications for operation for pancreatic cysts?
Symptoms; Mucinous; MD-IPMN; BD-IPMN w/ worrisome/high risk stigmata
What are some symptoms associated with pancreatic cysts?
Obstruction (enteric or biliary); Early satiety; Pain; Pancreatitis
T/F; Pancreatic pseudocyst has no epithelial lining?
Pancreatic Pseudocyst amylase if higher or lower than that of serous cystic lesion?
MUCH HIGHER (10-100K)
True/False: All pancreatic pseudocysts must be treated upon finding them on CT?
False; only treat if symptomatic
T/F: Serous cystadenomas arise mostly in elderly women?
What radiological feature in the center of the serous cyst can help with diagnosis of serous cystadenoma?
Central Fibrous stellate scar
T/F: Serous cystadenomas have no malignant potential
False; Very rare malignant potential
What are the "worrisome" features for BD-IPMN currentnly being used to manage operative resection criteria?
size > 3cm, MPD size 5-9mm, non-enhancing mural nodule, abrupt change in MPD caliper with distal pancreatic atrophy, lymphadenopathy
What are "high risk" stigmata in BD-IPMN that dictate opertive resection ?
Jaundice, enhance solid component, MPD > 10mm
T/F: MCN's typically arise in women with a mean age of 48 years?
Radiologically which are more likely to present as "single" cysts (MCN or SCN)?
What radiological feature can help differentiate between a pancreatic pseudocyst and pancreatic MCN?
upstream pancreatic parenchyma lacking features of pancreatitis
What is the pathognomic finding for MCN in histopathalogic analysis?
Ovarian Stroma; which display estrogen and progesterone receptors
What percent of MCN (pancreatic) have malignant transformation?
What is the most common pancreatic cystic neoplasm?
What pancreatic cyst carries the most risk for malignant potential?
T/F: Recurrence after IPMN resection is low, and lifelong surveillance is not needed?
FALSE; (this can be the case for MCN but not for IPMN)
T/F; All pancreatic mucinous tumors are more commonly found in women?
MD-IPMN is more commen in MEN; FALSE
In which pancreatic cyst is the history of pancreatitis most common and least common (excluding pseudocyst)?
Most common IPMN (15-30%); Least common SCM
T/F: All branch-duct IPMN have high risk of malignant transformation and require operative resection?
What part of the pancreas is the majority of IPMN found? How about MCN?
What is the pathognomic finding on EGD/ERCP visualization of the papulla and ampulla of vater in MD-IPMN?
Mucin secreting from a patullous fish mouth papilla
T/F: Intraoperative frozen section analysis of IPMN is highly accurate , and a negative margin usually indicates completion?
False; Highly inaccurate
While autologous islet cell transplant has been used in patients with total pancreatectomy for chronic pancreatitis, what is the potential complication in total pancreatectomy for IPMN?
Potential of transplanting malignant cells
What extrapancreatic disease should be screened for in IPMN patients in the West/ASIA?
Colon cancer (colonoscopy); Gastric cancer (EGD)
T/F: Patients with resected pancreatic cyst with pathological analysis showing MCN require no further interval follow-up ?
TRUE; as long as the MCN has no invasive/malignant features
What is the typical patient population and presentation of the rare pancreatic pseudopapillary solid neoplasm?
Young women presenting with mass effect features as these cysts are typically Large (> 10cm)
Patients with what syndrome are at higher risk for pancreatic CNET?
MEN type 1 (pituitary, parathyroid, pancreas)
A pancreatic cyst fluid comes back positive for chromogranin A and synaptophysin, what is this cyst most likely?
When evaluating pancreatic cysts, what serum marker and cyst fluid marker are oftne used?
CA19-9 and CEA
T/F: Central pancreatectomy and enucleation carry the same risk of pancreatic fistula as does a WHIPPLE?
False; This procedure carries Increased risk (33% vs 15%)
When considering enucluation for a small pancreatic cyst, why is it so important to perform intraoperative ultrasound?
To evaluate the proximity and relationship to the main pancreatic duct, as close proximity risks a HIGH output fistula that cannot be managed with NOM
What are the 4 main cell types of the endocrine pancreas located within the islets of langerhans?
glucagon, insulin, somatostatin, and pancreatic polypeptide
What is the most common genetic syndrome associated with PNET?
Where do most malignant PNETS metastasize to?
Liver and lymph nodes
In the context of PNET metastasis, what surgery may be considered prophylactically in patients with the prognosis of likely future octreotide therapy?
cholecystectomy (bile stasis)
What medication is recommended for PNET metastasis with positive somatostatin receptor scintigraphy (SRS)?
T/F: The majority of non-functional PNETS are malignant?
TRUE; (60-90% malignant)
T/F: Most non-functional PNETS are malignant and 50% metastasize before presentation?
T/F: Enucleation is the procedure of choice for small non-functional PNETS?
False; Non-functional PNETS have a high rate of malignant potential and formal resection is warranted with LND
T/F: Whipple is usually warranted for PNET that are non-functional?
TRUE; combined with the fact that location is in the head and malignant so need formal LND
What is the most common functional PNET?
T/F: Episodes of hypoglycemia in which c-peptide is normal and insulin is increased usually means that there is factitious/exogenous soruce ?
What are the Whipple Triad of symptoms associated with Insulinoma?
Fasting hypoglycemia, neuroglycopenic symptoms, resolution with administration of glucose
What is the gold standard test for diagnosis of insulinoma?
72 hr observed fast
What is the role of SRS in insulinoma diagnosis? (In what populaiton is it useful)?
Usually no role unless MEN1, in which case you can diagnose other PNET
What is the initial preop management of insulinoma?
Stabilization of glucose, either with diet alone or Octreotide/Diazoxide
T/F: Sporadic insulinomas are typically benign and can be safely treated with enucleation?
What do Gastrinomas cause? (Name of the sayndrome)?
T/F: Most gastrinomas are benign?
FALSE; most 60-90% are malignant
T/F: Most gastrinomas arise from the G cells in the Antrum of the Stomach?
False; most arise from the duodenal and pancreas
What is the best initial diagnostic test for gastrinoma?
fasting serum gastrin
Above what level of fasting serum gastrin is gastrinoma diagnostic?
>1000 (only 1/3 will have this)
If a patient has a high clinical suspicion of gastrinoma but fasting gastrin levels are less than 1000, what tests should be considered?
Measure secretin stimulation test and calcium infusion test
What medication must be withdrawn from a patient about to take a secretin stimulation test or calcium infusion test for the correct diagnosis of gastrinoma?
PPI (at least 3 days before stimulation testing); H2 blockers at least 30 hours
For a positive secretin stimulation test to diagnose gastrinoma, what value increase in gastrin must be shown ?
What is the gastrinoma triangle?
Location of 2/3 of gastrinomas, cystic duct CBD, 2nd and 3rd duod, neck/body pamncreas
What medications are indicated for pre-operative management in gastrinoma? What surgery can help medical management in MEN1 associated gastrinoma and why?
PPI; In MEN 1 associaetd gastrinoma removal of the parathyroid can help by reducing calcium levels
T/F: Surgical exploration for gastrinoma should be performed even if localization has failed?
What are the operative approaches to gastrinoma in the duodenum? Head of pancreas? Tail of pancreas?
Enucleation w/ LND; enucleation/LND if 5cm; and distal panc
What is the most important determinant of survival in gastrinoma?
presence of liver mets
T/F: Cure rates for gastrinoma are equivalent after resection for sporadic vs MEN1?
False; much worse for MEN1
T/F: Most glucagonomas are malignant?
What are the 4 "D"s of glucagonoma?
dermatitis, diabetes, depression and DVT
What are the most common clinical manifestations of glucagonoma?
necrolytic migratory erythema and weight loss
Where are most glucagonomas located?
Tail of the pancreas
What is the preoperative management of patients with glucagonoma?
octreotide, nutrition and hydration, and DVT prophylaxis
Can enucleation be performed for glucagonoma?
No; highly malignant
What surgical procedure may be considered prophylactically in glucagonoma patients considering the possibility of future octreotide administration?
cholecystectomy (bile stasis)
T/F: Most somatistatinomas are malignant?
T/F: Most glucogonoma surgery involves distal pancreatectomy and most somatostatinoma surgery involves whipple?
What is the syndrome manifested by VIPomas?
WDHA (watery diarrhea, hypokalemia, achlorydia)
What are the most common clinical features of VIPomas?
diarrhea and hypokalemia (causing muscle weakness)
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