Difference between revisions of "Pancreas"

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Pancreas (view source)

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→‎Pancreatic acinar metaplasia: fix typo
 
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| -
| -
| [http://www.nature.com/modpathol/journal/v20/n1s/fig_tab/3800686f16.html#figure-title (nature.com)]
| [http://www.nature.com/modpathol/journal/v20/n1s/fig_tab/3800686f16.html#figure-title (nature.com)]
| CK7 (acinar comp.), CK8, CK18, [[CK19]]
| [[CK7]] (acinar comp.), CK8, CK18, [[CK19]]
| squamoid nests of cells, whorling, nested growth, +/-keratinization
| squamoid nests of cells, whorling, nested growth, +/-keratinization
| none
| none
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*Common in the GI tract.
*Common in the GI tract.
*Found in ~ 17-19% of [[stomach|gastro]][[esophagus|esophageal]] junction biopsies.<ref name=pmid23989798/><ref name=pmid20012917>{{cite journal |author=Johansson J, Håkansson HO, Mellblom L, ''et al.'' |title=Pancreatic acinar metaplasia in the distal oesophagus and the gastric cardia: prevalence, predictors and relation to GORD |journal=J. Gastroenterol. |volume=45 |issue=3 |pages=291–9 |year=2010 |month=March |pmid=20012917 |doi=10.1007/s00535-009-0161-4 |url=}}</ref>
*Found in ~ 17-19% of [[stomach|gastro]][[esophagus|esophageal]] junction biopsies.<ref name=pmid23989798/><ref name=pmid20012917>{{cite journal |author=Johansson J, Håkansson HO, Mellblom L, ''et al.'' |title=Pancreatic acinar metaplasia in the distal oesophagus and the gastric cardia: prevalence, predictors and relation to GORD |journal=J. Gastroenterol. |volume=45 |issue=3 |pages=291–9 |year=2010 |month=March |pmid=20012917 |doi=10.1007/s00535-009-0161-4 |url=}}</ref>
*Associated with intestinal metaplasis.<ref name=pmid23989798>{{Cite journal  | last1 = Schneider | first1 = NI. | last2 = Plieschnegger | first2 = W. | last3 = Geppert | first3 = M. | last4 = Wigginghaus | first4 = B. | last5 = Höss | first5 = GM. | last6 = Eherer | first6 = A. | last7 = Wolf | first7 = EM. | last8 = Rehak | first8 = P. | last9 = Vieth | first9 = M. | title = Pancreatic acinar cells-a normal finding at the gastroesophageal junction? Data from a prospective Central European multicenter study. | journal = Virchows Arch | volume =  | issue =  | pages =  | month = Aug | year = 2013 | doi = 10.1007/s00428-013-1471-8 | PMID = 23989798 }}</ref>
*Associated with intestinal metaplasia.<ref name=pmid23989798>{{Cite journal  | last1 = Schneider | first1 = NI. | last2 = Plieschnegger | first2 = W. | last3 = Geppert | first3 = M. | last4 = Wigginghaus | first4 = B. | last5 = Höss | first5 = GM. | last6 = Eherer | first6 = A. | last7 = Wolf | first7 = EM. | last8 = Rehak | first8 = P. | last9 = Vieth | first9 = M. | title = Pancreatic acinar cells-a normal finding at the gastroesophageal junction? Data from a prospective Central European multicenter study. | journal = Virchows Arch | volume =  | issue =  | pages =  | month = Aug | year = 2013 | doi = 10.1007/s00428-013-1471-8 | PMID = 23989798 }}</ref>
**Not associated with changes of [[GERD]], or [[Helicobacter gastritis]].<ref name=pmid23989798/>
**Not associated with changes of [[GERD]], or [[Helicobacter gastritis]].<ref name=pmid23989798/>


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==Acute pancreatitis==
==Acute pancreatitis==
===General===
{{Main|Acute pancreatitis}}
*Rarely comes to pathology.
*Usually diagnosed by abdominal CT, blood work (amylase, lipase).
 
===Microscopic===
Features:<ref>{{Ref Klatt|223}}</ref>
*Loss of acini.
*Neutrophils.
*Hemorrhage.
*+/-Loss of pancreatic islets.


==Chronic pancreatitis==
==Chronic pancreatitis==
===General===
{{Main|Chronic pancreatitis}}
*May be confused with [[pancreatic ductal adenocarcinoma|ductal adenocarcinoma]] radiologically... and pathologically.
*Often due to [[ethanol abuse]].
 
Complications:<ref name=Ref_PCPBoD8_469>{{Ref PCPBoD8|469}}</ref>
*Malabsorption.
*[[Diabetes mellitus]].
*Pseudocysts.
 
====Autoimmune pancreatitis====
Histologic subtypes of autoimmune pancreatitis:<ref>URL: [http://path.upmc.edu/cases/case651/dx.html http://path.upmc.edu/cases/case651/dx.html]. Accessed on: 28 January 2012.</ref>
#Lymphoplasmacytic sclerosing pancreatitis (LPSP).
#*Typically IgG4 positive -- one of the ''[[IgG4-related systemic disease]]s''.
#**IgG4 negative cases reported.<ref name=pmid20824290/><ref name=pmid22466829>{{Cite journal  | last1 = Ikeura | first1 = T. | last2 = Takaoka | first2 = M. | last3 = Uchida | first3 = K. | last4 = Shimatani | first4 = M. | last5 = Miyoshi | first5 = H. | last6 = Kusuda | first6 = T. | last7 = Kurishima | first7 = A. | last8 = Fukui | first8 = Y. | last9 = Sumimoto | first9 = K. | title = Autoimmune pancreatitis with histologically proven lymphoplasmacytic sclerosing pancreatitis with granulocytic epithelial lesions. | journal = Intern Med | volume = 51 | issue = 7 | pages = 733-7 | month =  | year = 2012 | doi =  | PMID = 22466829 }}</ref>
#*Approximately 80% of cases.<ref name=pmid20824290>{{Cite journal  | last1 = Kamisawa | first1 = T. | last2 = Takuma | first2 = K. | last3 = Tabata | first3 = T. | last4 = Inaba | first4 = Y. | last5 = Egawa | first5 = N. | last6 = Tsuruta | first6 = K. | last7 = Hishima | first7 = T. | last8 = Sasaki | first8 = T. | last9 = Itoi | first9 = T. | title = Serum IgG4-negative autoimmune pancreatitis. | journal = J Gastroenterol | volume = 46 | issue = 1 | pages = 108-16 | month = Jan | year = 2011 | doi = 10.1007/s00535-010-0317-2 | PMID = 20824290 }}</ref>
#Idiopathic duct-centric chronic pancreatitis (IDCP).
#*Typically IgG4 negative.
#*Approximately 20% of cases.
 
=====Lymphoplasmacytic sclerosing pancreatitis=====
General:
*Serum IgG4 +ve.<ref name=pmid17533077>{{Cite journal  | last1 = Krasinskas | first1 = AM. | last2 = Raina | first2 = A. | last3 = Khalid | first3 = A. | last4 = Tublin | first4 = M. | last5 = Yadav | first5 = D. | title = Autoimmune pancreatitis. | journal = Gastroenterol Clin North Am | volume = 36 | issue = 2 | pages = 239-57, vii | month = Jun | year = 2007 | doi = 10.1016/j.gtc.2007.03.015 | PMID = 17533077 }}</ref>
Microscopic:
*Lymphoplasmacytic infiltrate.
IHC:
*Plasma cells IgG4 +ve.
 
===Radiology===
Plain film findings:
*Calcifications.
 
===Microscopic===
Features of chronic pancreatitis:<ref name=pmid16273946>{{Cite journal  | last1 = Adsay | first1 = NV. | last2 = Bandyopadhyay | first2 = S. | last3 = Basturk | first3 = O. | last4 = Othman | first4 = M. | last5 = Cheng | first5 = JD. | last6 = Klöppel | first6 = G. | last7 = Klimstra | first7 = DS. | title = Chronic pancreatitis or pancreatic ductal adenocarcinoma? | journal = Semin Diagn Pathol | volume = 21 | issue = 4 | pages = 268-76 | month = Nov | year = 2004 | doi =  | PMID = 16273946 }}</ref>
*Preservation of lobular architecture - evenly spaced ductal units.
*Uniformly sized ductal elements.
*Smooth ductal contours.
*Ducts surrounded by acini or islets.
**Islets usu. preserved better than acini.<ref name=Ref_Klatt225>{{Ref Klatt|225}}</ref>
*Intraluminal mucoprotein plugs.
 
Images:
*[http://path.upmc.edu/cases/case651.html Autoimmune pancreatitis / IgG4 sclerosing disease - several images (upmc.edu)].
 
====Adenocarcinoma versus pancreatitis====
This contrasts with the features of adenocarcinoma:<ref name=pmid16273946>{{Cite journal  | last1 = Adsay | first1 = NV. | last2 = Bandyopadhyay | first2 = S. | last3 = Basturk | first3 = O. | last4 = Othman | first4 = M. | last5 = Cheng | first5 = JD. | last6 = Klöppel | first6 = G. | last7 = Klimstra | first7 = DS. | title = Chronic pancreatitis or pancreatic ductal adenocarcinoma? | journal = Semin Diagn Pathol | volume = 21 | issue = 4 | pages = 268-76 | month = Nov | year = 2004 | doi =  | PMID = 16273946 }}</ref>
*Ductal architecture:
**Random distribution of ductal structures.
**Irregular ductal contours.
**"Naked ducts in fat"; ducts without surrounding pancreatic elements or fibrous tissue.
**Ducts adjacent to arterioles.
*Nuclear atypia:
**Enlargement (>3 times the size of a lymphocyte).
**Pleomorphism.
**Distinct [[nucleoli]].
**Hyperchromatic raisinoid nucleoli.
*Generally assoc. with malignancy:
**[[perineural invasion|Perineural]] and [[vascular invasion]] (rare).
**Mitosis.
**Necrotic cellular debris (intraluminal).
 
Notes:
*Memory device: ''give 'em a '''fair''' chance'' at a benign diagnosis. Features suggestive of malignant:
**Fat, adjacent to.
**Arteriole, adjacent to.
**Irregular ducts.
**Random distribution of ducts/non-lobular arrangement.
 
===IHC===
*IgG4 +ve plasma cells -- IgG4 sclerosing disease.
 
Positive in pancreatic carcinoma:<ref name=pmid15725808>{{Cite journal  | last1 = Hornick | first1 = JL. | last2 = Lauwers | first2 = GY. | last3 = Odze | first3 = RD. | title = Immunohistochemistry can help distinguish metastatic pancreatic adenocarcinomas from bile duct adenomas and hamartomas of the liver. | journal = Am J Surg Pathol | volume = 29 | issue = 3 | pages = 381-9 | month = Mar | year = 2005 | doi =  | PMID = 15725808 }}</ref>
*p53.
*Mesothelin.


=Cystic lesions - overview=
=Cystic lesions - overview=
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www:
www:
*[http://radiology.uchc.edu/eAtlas/Images/GYN/5705b.gif Mucinous cystadenoma - ovary (uchc.edu)].
*[http://radiology.uchc.edu/eAtlas/Images/GYN/5705b.gif Mucinous cystadenoma - ovary (uchc.edu)].
[[File:4 477025809 sl 1.png|Mucinous cystic neoplasm of pancreas]]
[[File:4 477025809 sl 2.png|Mucinous cystic neoplasm of pancreas]]
[[File:4 477025809 sl 3.png|Mucinous cystic neoplasm of pancreas]]
[[File:4 477025809 sl 4.png|Mucinous cystic neoplasm of pancreas]]
[[File:4 477025809 sl 5.png|Mucinous cystic neoplasm of pancreas]]
[[File:4 477025809 sl 6.png|Mucinous cystic neoplasm of pancreas]]
[[File:4 477025809 sl 7.png|Mucinous cystic neoplasm of pancreas]]<br>
Benign mucinous cystic neoplasm of pancreas in a 62 year old woman. A. CT scan showed a peripherally calcified spheroidal mass at the tail of the pancreas. Cytology only showed debris and inflammatory cells, but CEA of the fluid was 2875.2 ng/mL. B. Almost all sections of the cyst showed acellular debris topping a fibrous, often calcified wall, consistent with a pseudocyst. C. Extensive sampling, undertaken because of the high CEA, revealed rare sections with a lining. D. Lining nuclei are bland, with even chromatin. Shape and size variation, as well as darkening when shrunken, are all explicable by degeneration. E. Within distal pancreas, a focus of changes of chronic pancreatitis is seen upper left, while a pancreatic duct in lower right shows an intraductal proliferation. F. Tumor cells show mucinous vacuoles, with better preserved nuclei.  Nuclear appearances remain bland. G. Cellular ovarian stroma appeared beneath epithelium of a separate focus of the cystic neoplasm.


====Borderline mucinous cystic tumour====
====Borderline mucinous cystic tumour====
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|Viscosity || high || low
|Viscosity || high || low
|-
|-
|CEA, CA125 || high || low       
|[[CEA]], CA125 || high || low       
|}
|}


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*Abbreviated ''IPMT''.
*Abbreviated ''IPMT''.
*[[AKA]] ''intraductal papillary mucinous neoplasm'', abbreviated ''IPMN''.
*[[AKA]] ''intraductal papillary mucinous neoplasm'', abbreviated ''IPMN''.
===General===
{{Main|Intraductal papillary mucinous tumour}}
*Morphologically and biologically distinct from ductal adenocarcinoma, mucinous cystic tumour and ductal papillary hyperplasia.
*Prognosis:
**Favourable if caught early; not much different than ductal adenocarcinoma if caught late.<ref name=pmid12377813>{{cite journal |author=Maire F, Hammel P, Terris B, ''et al.'' |title=Prognosis of malignant intraductal papillary mucinous tumours of the pancreas after surgical resection. Comparison with pancreatic ductal adenocarcinoma |journal=Gut |volume=51 |issue=5 |pages=717–22 |year=2002 |month=November |pmid=12377813 |pmc=1773420 |doi= |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12377813}}</ref>
**Dependent what is involved:<ref name=pmid20374620>{{cite journal |author=Baiocchi GL, Portolani N, Missale G, ''et al.'' |title=Intraductal papillary mucinous neoplasm of the pancreas (IPMN): clinico-pathological correlations and surgical indications |journal=World J Surg Oncol |volume=8 |issue= |pages=25 |year=2010 |pmid=20374620 |pmc=2858722 |doi=10.1186/1477-7819-8-25 |url=http://wjso.com/content/8/1/25}}</ref>
***Main duct (bad prognosis).
***Branch (good prognosis).
 
Clinical:
*Patient usually not jaundiced... as no obstruction.
*Often diabetes... as pancreas is destroyed.
*Patients may get a total pancreatectomy - as the disease is often multifocal.
 
====Epidemiology====
*~1% of all exocrine pancreatic tumours.
*More common in males.
*Mean age at presentation 62 years.
*60-80% occur in the head of the pancreas.
*Average size 4 cm.
 
===Gross===
*May be patchy/multifocal.
*Multiple cystic spaces.
 
===Microscopic===
Features:
*Pancreatic duct lining cells jut into the duct lumen - papillomatous growth pattern.
*Cytology:
**Cell enlargement.
***Increased mucin production.
**Nuclear changes:
***Increased [[NC ratio]].
***Nuclear crowding and [[nuclear pleomorphism|pleomorphism]].
**Mitotic activity.
 
Note:
*No ovarian type stroma underneath (as seen in mucinous tumours).
 
DDx:
*[[PanIN]].
*[[Invasive ductal carcinoma of the pancreas]].
*Intra-ampullary papillary-tubular neoplasm -- see ''[[ampulla of Vater]]''.
 
====Classification of IMPT====
Commonly classified by the duct involvement:<ref name=pmid20397268>{{Cite journal  | last1 = Ikeuchi | first1 = N. | last2 = Itoi | first2 = T. | last3 = Sofuni | first3 = A. | last4 = Itokawa | first4 = F. | last5 = Tsuchiya | first5 = T. | last6 = Kurihara | first6 = T. | last7 = Ishii | first7 = K. | last8 = Tsuji | first8 = S. | last9 = Umeda | first9 = J. | title = Prognosis of cancer with branch duct type IPMN of the pancreas. | journal = World J Gastroenterol | volume = 16 | issue = 15 | pages = 1890-5 | month = Apr | year = 2010 | doi =  | PMID = 20397268 PMC = 2856831 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856831/}}</ref>
#Main duct type.
#*Commonly associated with invasive carcinoma.
#Branch duct type.
#*Less commonly associated with invasive carcinoma.
 
=====Behaviour - Khalifa=====
*Adenoma.
*Borderline mucinous tumour.
*Carcinoma.
 
Notes:
*Borderline tumours are rare.
*If intralobular dilated ducts... carcinoma.
*Any margin with mucin cells in thought to be badness!


==Solid pseudopapillary tumour==
==Solid pseudopapillary tumour==
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=Pre-malignant lesions=
=Pre-malignant lesions=
==Pancreatic intraepithelial neoplasia==
==Pancreatic intraepithelial neoplasia==
*Abbreviated ''PanIN''.
*Abbreviated ''PanIN''.
 
{{Main|Pancreatic intraepithelial neoplasia}}
===General===
*PanIN is thought to be the precursor lesion for pancreatic carcinoma.<ref name=Ref_PBoD949>{{Ref PBoD|949}}</ref>
 
====Overview====
Putative preneoplasm-neoplasm-carcinoma sequence:
*PanIN1a.
**Not neoplastic, i.e. clonal.
*PanIN1b.
**Not neoplastic, i.e. clonal.
*PanIN2.
**Can be thought of as ''low-grade dysplasia'', e.g. a ''(colonic) [[tubular adenoma of the gastrointestinal tract|tubular adenoma]] without high-grade dysplasia''.
*PanIN3.
**Can be thought of as ''high-grade dysplasia'', e.g. ''(colonic) villous adenoma''.
**May be referred to as ''carcinoma in situ''.<ref name=pmid21537863>{{Cite journal  | last1 = Matthaei | first1 = H. | last2 = Hong | first2 = SM. | last3 = Mayo | first3 = SC. | last4 = dal Molin | first4 = M. | last5 = Olino | first5 = K. | last6 = Venkat | first6 = R. | last7 = Goggins | first7 = M. | last8 = Herman | first8 = JM. | last9 = Edil | first9 = BH. | title = Presence of pancreatic intraepithelial neoplasia in the pancreatic transection margin does not influence outcome in patients with R0 resected pancreatic cancer. | journal = Ann Surg Oncol | volume = 18 | issue = 12 | pages = 3493-9 | month = Nov | year = 2011 | doi = 10.1245/s10434-011-1745-9 | PMID = 21537863 }}</ref>
 
===Microscopic===
Features:<ref name=Ref_PBoD949>{{Ref PBoD|949}}</ref>
*PanIN1a - increased amount of cytoplasm.
**Nuclear size & stratification perserved, arch. perserved.
*PanIN1b - increased amount of cytoplasm, folding of epithelium/moderated arch. distortion.
**Nuclear size & stratification perserved.
*PanIN2 - increased cell size, and nuclear enlargement (increased NC ratio), moderate nuclear atypia with loss of (basal) nuclear polarization.
*PanIN3 - marked nuclear atypia with increased NC ratio.
**No invasion identified.
*Pancreatic carcinoma - cytologic features of PanIN3 with definite invasion.
 
====Images====
<gallery>
Image:Pancreas_neoplasia_carcinoma_sequence.png | Normal pancreas, pancreatic intraepithelial neoplasia and pancreatic carcinoma. (WC)
</gallery>
www:
*[http://www.path.jhu.edu/pancreas/professionals/panin-3.php PanIN III - several images (jhu.edu)].


=Solid tumours=
=Solid tumours=
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==Pancreatoblastoma==
==Pancreatoblastoma==
===General===
{{Main|Pancreatoblastoma}}
*Very rare.
*Tumour of childhood - age of diagnosis ~5 years old.<ref name=pmid22525406>{{Cite journal  | last1 = Glick | first1 = RD. | last2 = Pashankar | first2 = FD. | last3 = Pappo | first3 = A. | last4 = Laquaglia | first4 = MP. | title = Management of pancreatoblastoma in children and young adults. | journal = J Pediatr Hematol Oncol | volume = 34 Suppl 2 | issue =  | pages = S47-50 | month = May | year = 2012 | doi = 10.1097/MPH.0b013e31824e3839 | PMID = 22525406 }}</ref>
*Prognosis ~80% year survival in children<ref name=pmid21696948>{{Cite journal  | last1 = Bien | first1 = E. | last2 = Godzinski | first2 = J. | last3 = Dall'igna | first3 = P. | last4 = Defachelles | first4 = AS. | last5 = Stachowicz-Stencel | first5 = T. | last6 = Orbach | first6 = D. | last7 = Bisogno | first7 = G. | last8 = Cecchetto | first8 = G. | last9 = Warmann | first9 = S. | title = Pancreatoblastoma: a report from the European cooperative study group for paediatric rare tumours (EXPeRT). | journal = Eur J Cancer | volume = 47 | issue = 15 | pages = 2347-52 | month = Oct | year = 2011 | doi = 10.1016/j.ejca.2011.05.022 | PMID = 21696948 }}</ref> more aggressive in adults.
*May be seen in adults.<ref name=pmid22572137>{{Cite journal  | last1 = Balasundaram | first1 = C. | last2 = Luthra | first2 = M. | last3 = Chavalidthamrong | first3 = D. | last4 = Chow | first4 = J. | last5 = Khan | first5 = H. | last6 = Endres | first6 = PJ. | title = Pancreatoblastoma: a rare tumor still evolving in clinical presentation and histology. | journal = JOP | volume = 13 | issue = 3 | pages = 301-3 | month = May | year = 2012 | doi =  | PMID = 22572137 }}</ref>
 
Associations:<ref name=pmid17228135/>
*[[Beckwith-Wiedemann syndrome]].
*[[Familial adenomatous polyposis]].
 
===Microscopic===
Features:<ref name=pmid17228135>{{Cite journal  | last1 = Saif | first1 = MW. | title = Pancreatoblastoma. | journal = JOP | volume = 8 | issue = 1 | pages = 55-63 | month =  | year = 2007 | doi =  | PMID = 17228135 }}</ref><ref name=pmid15943785/>
*Acinar-like structures.
*Squamoid corpuscles.
*Undifferentiated component.
 
Image:
*[http://www.nature.com/modpathol/journal/v20/n1s/fig_tab/3800686f16.html#figure-title Pancreatoblastoma (nature.com)].<ref name=pmid17486055>{{Cite journal  | last1 = Klimstra | first1 = DS. | title = Nonductal neoplasms of the pancreas. | journal = Mod Pathol | volume = 20 Suppl 1 | issue =  | pages = S94-112 | month = Feb | year = 2007 | doi = 10.1038/modpathol.3800686 | PMID = 17486055 }}</ref>
 
===IHC===
Features:<ref name=pmid15943785>{{Cite journal  | last1 = Nishimata | first1 = S. | last2 = Kato | first2 = K. | last3 = Tanaka | first3 = M. | last4 = Ijiri | first4 = R. | last5 = Toyoda | first5 = Y. | last6 = Kigasawa | first6 = H. | last7 = Ohama | first7 = Y. | last8 = Nakatani | first8 = Y. | last9 = Notohara | first9 = K. | title = Expression pattern of keratin subclasses in pancreatoblastoma with special emphasis on squamoid corpuscles. | journal = Pathol Int | volume = 55 | issue = 6 | pages = 297-302 | month = Jun | year = 2005 | doi = 10.1111/j.1440-1827.2005.01829.x | PMID = 15943785 }}</ref>
*CK7 +ve -- acinar, undifferentiated component.
*CK8 +ve -- squamous component.
*CK18 +ve -- squamous component.
*CK19 +ve -- squamous component.


=See also=
=See also=
Michael
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