Tumors of the Pancreas, Biliary Tract, and Liver of the Pancreas, Biliary Tract, ... No evidence of...

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  • VANDERBILT SURGERY

    Tumors of the Pancreas, Biliary Tract, and Liver

    Resident Teaching ConferenceMatt Landman, MD

    J. Kelly Wright, Jr. MD, Faculty Facilitator

    October 23, 2009

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    Plan

    Case presentation #1Case presentation #2Select SESAP questions

  • http://portal.surgicalcore.org/

    http://portal.surgicalcore.org/

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    Case Presentation #1

    78 y/o F Transferred to VUMC ED with:

    1 month epigastric pain48 hrs n/v10 lb weight loss over past monthOSH notes a pancreatic mass on US as well as cholelithiasis

    PMHx:HTN, ovarian tumor, urinary incontinence, goiter

    PSHx:R oopherectomy, thyroidectomy, bladder operations x4

    Meds: Premarin, Benazepril, Provera, Atenolol

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    Case Presentation #1

    Physical ExamTachycardic (110s)Right upper quadrant tenderness, negative Murphys sign

    LabsWBC 20Creatinine 0.65Tbili 1.1, AlkP 499, AST 43, Lipase 96

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    Case Presentation #1

    ManagementUnderwent perc cholecystostomy tubeEUS for pancreatic mass 4.6x4.8 simple cyst

    FNA - few inflammatory cells, no malignany

    Home with drainCytology sent from initial drain placement

    Returns carcinoma with variable squamous differentiation

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    Case Presentation #1

    ManagementNo evidence of distant diseaseTaken to OR for resection

    Cholecystectomy with en bloc segment 4b and 5 liver resectionDistal gastrectomyRight hemicolectomy

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    Case Presentation #1

    Post-operative courseFinal pathology

    Poorly differentiated cholangiocarcinoma involving adjacent colon and stomach wall (Stage IIIb)

    Home after ~3 weeks2 months post-op

    New liver lesions noted, asymptomatic PE, palliative care

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    Gallbladder Cancer

    Rare 6,000-7,000 cases annuallyPrevalence in asymptomatic patients

    80%

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    Gallbladder cancer

    Porcelain gallbladderClassically 25 60% risk of cancerMore recent series do not show this associationSlight increase risk possible with partial calcification (~7%)

    Choledochal cystsIncreased risk of cancer throughout biliary tree, especially gallbladderResection recommended

  • www.uhrad.com/ctarc/ct186a2.jpg

    www.cancernetwork.com/.../article/10162/45504

    www.uhrad.com/ctarc/ct217b2.jpg

    http://www.cancernetwork.com/liver-cancer/article/10162/45504

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    Clinical findings & diagnosis

    Mainly found during workup of right upper quadrant pain or treatment for cholelithiasis~50% not known pre-opSymptoms consistent with biliary colicMore systemic symtoms/signs (jaundice, weight loss, ascites) ominous Labwork normal or consistent with biliary obstruction

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    Gallbladder cancer

    ImagingUltrasound

    Thickened wall, mass within/replacing gallbladder50-70% will have stonesEvaluate for adenopathy, biliary obstruction as well

    CT scanAsymmetric thickening of gallbladder wall, mass or hepatic invasionPoor at evaluating nodal disease

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    Gallbladder cancer

    ImagingERCP

    Evaluate extent of biliary involvementRelieve obstruction

    MRCPComplete assessment of biliary tree, vasculature, hepatic parenchyma and nodal involvement

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    Case presentation #2

    58 y/o female presents to your clinic with the following CT scan

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    A 14x12x13cm lesion. Arterial phase shows peripheral enhancement that washes out in portal and venous contrast phases.

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    Case presentation #2

    What do you want to know about this patient?HistoryPhysical examinationLabwork

    What is the differential?Other imaging?Biopsy?

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    Case presentation #2 Diagnosis

    hepatic adenoma

    Taken to ORBilateral subcostal incisionsLesion noted segments IV, VII, VIIIAttempted enucleation, however, given adherence to right and middle hepatic veins, patient underwent right trisegmentectomyFinal pathology 19 x 15 x 7 cm hepatic adenoma

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    Which of the following is the most accurate predictor of increased risk for morbidity and mortality in a cirrhotic after abdominal operation?

    1. Childs Class2. Child-Turcotte-Pugh

    score3. MELD score4. APACHE II5. APACHE III

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    MELD score

    Developed in 2000Bilirubin, creatinine, INRSuperior to CPT score for prediction of risk in cirrhotic patients

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    Predicting mortality in cirrhosis

    Child-Pugh class (Childs class)

    A score 5-6B score 7-9C score > 9 Points Class 1-year

    Survival2-yearSurvival

    5 7 A 100% 85%

    7 9 B 81% 57%

    10 15 C 45% 35%Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R (1973). "Transection of the oesophagus for bleeding oesophageal varices". The British journal of surgery 60 (8): 6469.

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    A 70-year-old woman presents with RUQ pain. The ultrasound and CT scan shown are obtained.

  • The next procedure should be:

    1. Lap cholecystectomy2. Open cholecystectomy3. Percutaneous biopsy of

    the gallbladder4. Open cholecystectomy

    with en bloc partial hepatectomy

    5. cholecystectomy

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    A 51-year-old man has intermittent bloating and epigastric pain associated with eating friend foods. Abdominal examination is unremarkable. RUQ ultrasound examination reveals a 6-mm fixed, solitary projection in the gallbladder lacking an acoustic shadow.

    The preferred management at this time would be:

    1. Repeat US in 3 months2. Biliary excretion study, eg,

    HIDA scan3. Endoscopic ultrasound4. Lap cholecystectomy5. Open cholecystectomy

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    Name the liver lesion

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    Name the liver lesion

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    Name the liver lesion

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    Name the liver lesion

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    Name the liver lesion

  • A 36 y/o

    previously healthy woman who was wearing a seatbelt is hemodynamically normal on arrival after a MVC. CT shows a mass in her liver. The MRI show was obtained 2 days later.

  • The best recommendation would be:

    1 2 3 4 5

    20% 20% 20%20%20%1. No intervention2. Percutaneous drainage3. Colonoscopy to

    identify a primary malignancy

    4. Embolization of the right hepatic artery

    5. Resection of the right lobe of the liver

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    The single best test to determine a hepatic hemangioma is:

    1 2 3 4 5

    20% 20% 20%20%20%1. Transabdominal ultrasound

    2. Endoscopic ultrasound3. CT4. MRI5. Laparoscopy

    Tumors of the Pancreas, Biliary Tract, and LiverResident Teaching ConferencePlanSlide Number 3Slide Number 4Case Presentation #1Case Presentation #1Slide Number 7Slide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12Case Presentation #1Case Presentation #1Case Presentation #1Gallbladder CancerGallbladder cancerSlide Number 18Clinical findings & diagnosisGallbladder cancerGallbladder cancerSlide Number 22Slide Number 23Case presentation #2Slide Number 25Case presentation #2Case presentation #2Diagnosis hepatic adenomaSlide Number 28Slide Number 29Which of the following is the most accurate predictor of increased risk for morbidity and mortality in a cirrhotic after abdominal operation?MELD scorePredicting mortality in cirrhosisA 70-year-old woman presents with RUQ pain. The ultrasound and CT scan shown are obtained.The next procedure should be:A 51-year-old man has intermittent bloating and epigastric pain associated with eating friend foods. Abdominal examination is unremarkable. RUQ ultrasound examination reveals a 6-mm fixed, solitary projection in the gallbladder lacking an acoustic shadow.The preferred management at this time would be:Name the liver lesionName the liver lesionName the liver lesionName the liver lesionName the liver lesionSlide Number 41A 36 y/o previously healthy woman who was wearing a seatbelt is hemodynamically normal on arrival after a MVC. CT shows a mass in her liver. The MRI show was obtained 2 days later.The best recommendation would be:The single best test to determine a hepatic hemangioma is: