Pancreatic Masses
With Dr. Jamie Nathan · hosted by Dr. Rod Gerardo · StayCurrentMD
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Pancreatic Tumors 2 items
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Elevated lipase and elevated bilirubin suggest obstruction in the pancreatic head, which can be caused by neoplasms or more commonly in pediatrics by non-neoplastic findings such as autoimmune pancreatitis or complications of pancreatitis.
Pancreatoblastoma is the most common malignant pancreatic tumor in children, typically presenting in patients less than 10 years of age.
In pancreatoblastoma, alpha-fetoprotein is elevated in up to 80% of cases.
Up to 45-50% of pancreatoblastoma cases present with metastases.
Pancreatoblastomas respond well to chemotherapy with a cisplatin and doxorubicin-based regimen.
The number one prognostic factor for pancreatoblastoma is complete surgical excision, whether at initial presentation or following neoadjuvant chemotherapy.
Solid pseudopapillary neoplasms are more common in young female patients, typically in their second or third decade of life.
Solid pseudopapillary tumors are indolent and slow-growing, often presenting with very large masses in the body and tail of the pancreas.
Enucleation or simple biopsy of solid pseudopapillary neoplasms should be avoided due to high recurrence rates; complete surgical resection is required.
Solid pseudopapillary neoplasms have a recurrence rate of up to 10% but excellent long-term survival with 95% 10-year survival.
Neuroendocrine tumors make up about 1-2% of all pancreatic tumors and can be either benign adenomas or malignant carcinomas.
Neuroendocrine tumors tend to present in children over 10 years of age, though they are more common in middle-aged patients.
In 10% of patients, neuroendocrine tumors may present in the setting of multiple endocrine neoplasia type 1, von Hippel-Lindau, or tuberous sclerosis.
Insulinoma is the most common neuroendocrine tumor, accounting for almost 50% of pancreatic neuroendocrine tumors, followed by gastrinomas at 30%.
Insulinomas are typically benign; 6% can be malignant. 90% are solitary, 10% are associated with MEN1.
Insulinomas present with Whipple's triad: symptoms of hypoglycemia, low fasting blood glucose, and symptom resolution with glucose administration.
On imaging, a solid lesion in the pancreas is more worrisome than a cystic lesion when found incidentally.
Ultrasound is low cost and easily accessible but the pancreas is often suboptimally visualized and characterization of pancreatic masses is poor.
CT scan is rapidly acquired with good resolution but has downsides of radiation and need for contrast; it is often used for solid tumor staging.
MRI provides better differentiation between solid and cystic or fluid components and can better characterize components of a pancreatic mass.
Cross-sectional imaging (CT or MRI) cannot confidently differentiate a benign versus malignant pancreatic lesion.
A completely cystic pancreatic lesion is less concerning for malignancy, but if the mass has solid components, it becomes more concerning for neoplasm.
Pediatric EUS is not practical in many institutions because there are not many practitioners in the pediatric GI community comfortable with pediatric EUS.
In the pediatric realm, autoimmune pancreatitis is more common than pancreatic neoplasm.
With negative biliary cytology and after biliary and pancreatic duct stenting, a four-week steroid trial with taper can be initiated for presumed autoimmune pancreatitis, even if IgG4 findings are normal.
Type 1 autoimmune pancreatitis is IgG4-mediated; type 2 autoimmune pancreatitis is IgG4-negative.
Autoimmune pancreatitis with a pancreatic head mass is typically very steroid responsive, with rapid resolution of the mass in most cases.
For malignant pancreatic head lesions, a radical resection (Whipple pancreaticoduodenectomy) is required; for benign or borderline benign lesions, duodenum-preserving pancreatic head resections (Beger or Berne procedures) may be considered.
Studies report up to about a 10% risk of diabetes (endocrine impairment) after just a distal pancreatectomy in the setting of otherwise normal pancreas.
Enucleation may be appropriate for pancreatic neuroendocrine tumors but should be used sparingly; it is not recommended for solid pseudopapillary neoplasms due to higher recurrence risk.
Type 1 autoimmune pancreatitis is IgG4-related systemic disease involving multiple organs (sialoadenitis, sclerosing cholangitis, retroperitoneal fibrosis) and responds quickly to steroids; IgG4 levels are elevated in 90% of patients.
Type 2 autoimmune pancreatitis is pancreas-specific with normal IgG4 levels; 30% of patients also have IBD. Histology shows idiopathic duct-centric pancreatitis.
Over 90% of children with autoimmune pancreatitis present with abdominal pain; about 40% present with obstructive jaundice.
Positive serologies for IgG4 are described in only 22% of children with autoimmune pancreatitis in one study.
In pediatric autoimmune pancreatitis, focal enlargement in the pancreatic head occurs in about 50% of patients; global pancreatic enlargement in 30%; main pancreatic duct irregularity in two-thirds; common bile duct strictures in 55%; and the capsule-like rim sign in only 16%.
93% of pediatric patients with autoimmune pancreatitis respond to steroids, indicating very steroid-responsive disease.
Autoimmune pancreatitis in children more commonly follows a type 2 presentation rather than type 1 or IgG4-related presentation, based on data from the INSPIRE consortium and European pancreatic consortium.
Ideally, a tissue diagnosis should be obtained before initiating therapy for autoimmune pancreatitis, but barriers in pediatrics (limited EUS-skilled endoscopists and pathologists, inadequate biopsies) often cannot be overcome.
The diagnosis of autoimmune pancreatitis in children can be made with a combination of clinical and imaging findings because the risk of pediatric neoplasm is lower than autoimmune pancreatitis.
Clinical response to corticosteroid therapy for autoimmune pancreatitis should be seen within a few weeks; imaging response should be anticipated after about three months.