Pancreatic Neoplasm

This is my disclaimer for this talk. OK. So let’s go ahead and jump right in. So this is my pancreatic neoplasm algorithm. And as you can see, this algorithm is going to help us look over the types of pancreatic neoplasms, and also what is the best way to arrive at a proper diagnosis.

So right off the bat, pancreatic neoplasms can be divided into three broad categories. There are pancreatic cystic tumors, and pancreatic exocrine tumors, and pancreatic neuroendocrine tumors. Pancreatic neuroendocrine tumors were previously called islet cell tumors. But the nomenclature has now changed.

So let’s take a moment and first look at pancreatic cystic tumors. So basically, pancreatic cystic tumors can be divided into two categories. Non-mucin producing cysts and mucin producing cysts. So the non-mucin producing cysts, these are non-malignant tumors. They’re benign. And the most common is serous cystadenoma. Whereas the mucin producing cysts are the ones that have a malignant potential. And the mucin producing cysts are further divided into two different categories. Here we have indraductal papillary mucinous neoplasms and mucinous cystic neoplasms.

Now let’s talk first about the intraductal papillary mucinous neoplasms. These are the most common in this category of cystic neoplasms. And basically, if the intraductal papillary mucinous neoplasm, if it involves the main pancreatic duct, there is a 65% malignant potential. And the mucinous cystic neoplasms are actually mostly found in women. But they also can have a very distinctive malignant potential.

And so the best way that a diagnosis can be made is doing an MRCP Magnetic resonance cholangiopancratography. And if you do the MRCP, and it shows you a cyst that has the characteristic features that may be concerning for one of these types of neoplasms, then obviously the next step is to proceed with an endoscopic ultrasound and obtain a tissue biopsy by fine needle aspiration. And once the biopsy has been obtained, then the pathologist is able to examine the biopsy and finalize the diagnosis.

And even though it’s not part of this algorithm, basically, if there is a cyst that has a high malignant potential or is malignant, then obviously cyst removal and cyst resection is one of the cornerstones of treatment of that condition.

So let’s shift our focus, and move over to the pancreatic exocrine tumors. And the most common is the adenocarcinoma of the pancreas. And let’s talk about the pancreatic neuroendocrine tumors. And I’ve actually listed two of them here. Insulinoma and Gastrinoma. But there are actually other neuroendocrine tumors too. A couple of other ones that are important– one of them is a glucagonoma. And one of them is a VIPoma. Vasoactive intestinal peptide-oma.

And these neuroendocrine tumors have very characteristic symptoms. So insulinoma is associated with an exaggerated insulin production that is not in response to an increase in blood glucose levels because these are autonomous functioning tumors. And that can lead to some pretty significant hypoglycemia and hypoglycemic complications. Similarly, a gastrinoma is associated with an increased gastrin production, which can actually lead to Zollinger Ellison Syndrome. And it can lead to peptic ulcer disease, and increased acid production, and symptoms associated with that.

Similarly, a glucagonoma is a type of neuroendocrine tumor that’s associated with increased glucagon production, which is the enzyme that’s totally opposite to insulin. And it can also lead to impaired glucose tolerance. And lastly, vasoactive intestinal peptide secretion can lead to symptoms such as diarrhea and other symptoms associated with it like flushing, tachycardia. So these are some of the neuroendocrine tumors.

Let’s take a moment and also talk about adenocarcinoma of the pancreas, which usually results in symptoms such as abdominal pain, back pain, weight loss. And there’s always the possibility of painless jaundice, especially if the tumor is compressing the common bile duct. And the way that these conditions can be accurately diagnosed is you can either do a CT scan of the abdomen and pelvis or you can do an MRI scan.

But what has to be kept in mind is that whenever any kind of scans are being done for these conditions, the scans have to be highly specialized with special protocols, which are specific for the pancreas. Because when it comes to scanning the different organs in the abdominal cavity, nowadays we have such good techniques that we have developed protocols that can look at a particular organ in very, very deep detail. We have protocols to look at liver, kidneys, pancreas. So it’s not going to be just a general nonspecific CT scan of the abdomen or MRI scan of the abdomen. It’s going to be a pancreas specific imaging test.

And based upon those tests, a diagnosis can be made because most likely what the test is going to show is a lesion in the pancreas or a tumor in the pancreas. And then in order to further solidify the diagnosis, ultimately an endoscopic ultrasound with fine needle aspiration biopsy is absolutely necessary because we obviously want to use a tissue. We obviously want to make a tissue diagnosis.

And once we have the fine-needle aspiration biopsy, then the pathologist can examine it and make a tissue diagnosis. Also there are tumor markers that are associated with pancreatic neoplasms. One of the tumor marker that’s associated with pancreatic neoplasm is CA 19-9. And that level can be checked. And if it is elevated, that’s another thing that goes in favor of having a pancreatic malignancy.

But to wrap up this conversation, this is a broad overview of how I approach a patient that’s suspected of having a pancreatic neoplasm. I hope you found this explanation helpful, and you can put some of these clues and hints into active practice when you are taking care of your patients. I appreciate you looking at this video. And I hope to see you in one of my future videos. Thank you so much.