Pancreas

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The pancreas hangs-out in the upper abdomen. It occasionally is afflicited by cancers, the most common of which is very fatal.

Pancreatic cytopathology is dealt with in the gastrointestinal cytopathology article.

A general introduction to gastrointestinal pathology is in the gastrointestinal pathology article.

Introduction

Normal anatomy

Divided into three portions: head, body & tail:[1]

  • Head:
    • Includes unicate process.
    • Extends to the left edge of the superior mesenteric vein (SMV) - by definition.
      • All of the SMV is with the head.
  • Body:
    • Right edge of the superior mesenteric vein to the left edge of aorta - by definition.
      • All of the aorta is with the body.
  • Tail:
    • Remainder of pancreas.

Pancreatic surgeries

Common pancreatic surgeries include:

  • Whipple procedure (AKA pancreaticoduodenal resection) - includes duodenum +/- stomach.
  • Distal pancreatectomy.
  • Total pancreatectomy.
    • Specimen usually comes with a spleen.

Whipple procedure

Margins:[2]

  1. Proximal mucosal margin (stomach or duodenum).
  2. Distal mucosal margin (duodenum or jejunum).
  3. Bile duct margin.
  4. Pancreatic retroperitoneal (uncinate process) margin.
    • At SB done on edge (not en face).
  5. Pancreatic neck transection margin (AKA distal pancreatic resection margin);[3] usu. en face and in toto.[4]
  6. Sometimes superior mesenteric vein (SMV).
  7. Rarely superior mesenteric artery (SMA) margin.

General classification of pancreatic tumours

  • Metstatses.
    • Most common = renal cell carcinoma.
  • Primary.
    • Endocrine.
      • Usually small as hormonally active.
    • Exocrine.

Pancreas neoplasms in a table

Type Key feature Subtypes Image IHC Detailed microscopic Usual location Other DDx
Serous tumours cuboidal cells, clear cytoplasm cystadenoma, borderline t., cystadenocarcinoma [1], [2], [3] IHC? cuboidal cells, clear cytoplasm, central nucleus body or tail cystadenoma may be assoc. with von Hippel-Lindau syndrome clear cell RCC, oligomucinous mucinous tumours
Intraductal papillary
mucinous tumour (IPMT) 		mucin, no ovarian-like stroma clear cell variant (wjso.com), (upmc.edu) IHC? papillae, tall columnar mucin-producing cells head - mucious neoplasms (other pancreatic, duodenal)
Mucinous tumour mucin, ovarian-like stroma cystadenoma, borderline t., cystadenocarcinoma [4], [5] IHC? tall columnar mucin-producing cells, ovarian-like stroma body or tail - IPMT, metastatic mucinous tumours
Solid pseudopapillary
tumour 		eosinophilic intracytoplasmic globules clear cell variant (cytoplasm clear) [6], [7] beta-catenin +ve, E-cadherin +ve,
synaptophysin +ve, chromogranin -ve 		sheets of cells, focally loosely cohesive, eosinophilic cytoplasm, uniform nuclei with grooves none usu. younger women, tail of pancreas ductal adenocarcinoma, neuroendocrine tumours
Ductal adenocarcinoma irregular shaped glands, cytologic atypia mucinous, spindle cell, mixed ductal-endocrine [8], [9] IHC? glands, sheets, single cells, nuc. atypia, +/-mitoses, +/-necrosis head arises from the precursor PanIN ampullary carcinoma, chronic pancreatitis
Pancreatoblastoma squamoid nests, whorling - Image? IHC? squamoid nests of cells, whorling, nested growth, +/-keratinization none usu. paediatric population acinar cell carcinoma
Acinar cell carcinoma acinar arch. - [10] IHC? nests or trabeculae, nucleolus, mod. basophilic granular cytoplasm head (slight predilection) - pancreatoblastoma
Undifferentiated carcinoma with osteoclast-like giant cells giant cells - Image? IHC? giant cells, usu. with AIS or inv. ductal adenocarcinoma head - anaplastic carcinoma
Chronic pancreatitis fibrosis, loss of acinar tissue, preservation of lobular arch. - [11] IHC? loss of acinar tissue with preservation of islets, fibrosis ? not a neoplasm, included here as it is in the (clinical) DDx ductal adenocarcinoma

WHO classification

Benign epithelial:

Borderline epithelial:

Malignant epithelial:

Soft tissue tumours:

Ectopic pancreatic tissue

It comes in two flavours:[5]

  • Pancreatic ectopia.
  • Pancreatic (acinar) metaplasia.

Pancreatic acinar metaplasia

  • AKA pancreatic metaplasia.

General

  • Common in the GI tract.
  • Found in ~ 20% of eosphageal biopsies above the GEJ.[6]

Microscopic

Features:

  • Pancreatic acini - only.
    • Intensely eosinophilic cytoplasm.

Negatives:

  • No pancreatic ducts.
  • No islets of Langerhans (pancreatic islets).

Images:

Pancreatic ectopia

General

  • May be confused with something pathologic.

Microscopic

Features:

  • Consists of pancreatic acini and pancreatic ducts.
  • +/-Islets of Langerhans.

Inflammatory

Pancreatitis

Classification

Etiology

Mnemonic I GET SMASHED:

Acute pancreatitis

General

  • Rarely comes to pathology.
  • Usually diagnosed by abdominal CT, blood work (amylase, lipase).

Microscopic

Features:[7]

  • Loss of acini.
  • Neutrophils.
  • Hemorrhage.
  • +/-Loss of pancreatic islets.

Chronic pancreatitis

General

Complications:[8]

Autoimmune pancreatitis

Histologic subtypes of autoimmune pancreatitis:[9]

  1. Lymphoplasmacytic sclerosing pancreatitis (LPSP).
  2. Idiopathic duct-centric chronic pancreatitis (IDCP).
    • Typically IgG4 negative.
    • Approximately 20% of cases.
Lymphoplasmacytic sclerosing pancreatitis

General:

Microscopic:

  • Lymphoplasmacytic infiltrate.

IHC:

  • Plasma cells IgG4 +ve.

Radiology

Plain film findings:

  • Calcifications.

Microscopic

Features of chronic pancreatitis:[13]

  • 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.[14]
  • Intraluminal mucoprotein plugs.

Images:

Adenocarcinoma versus pancreatitis

This contrasts with the features of adenocarcinoma:[13]

  • 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:

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:[15]

  • p53.
  • Mesothelin.

Cystic lesions - overview

General

  • True cystic lesions are uncommon.
    • A true cystic lesion: must have an epithelial lining.
      • Only 10% of cystic lesions are true cystic lesions, i.e. 90% of cystic lesions are really pseudocysts.
  • It is hard to differentiate pseudocysts & cysts.

Cystic tumours - clinical

General:

  • Usually diagnosed by imaging (CT/MRI, ERCP, Endoscopic ultrasound).
    • 50% incidental finding.
  • Vague symptoms
  • Abdominal mass.
  • Weight loss.
  • Jaundice.
  • Usually favourable prognosis - mostly benign.

Most important cystic lesions

  • Serous.
  • Mucinous.
    • Ovarian-like stroma.
  • Solid pseudopapillay tumours.
  • Intraductal papillary mucinous tumour (IPMT).
    • No ovarian-like stroma.

Mnemonic SIMS: Serous, IPMT, Mucinous, Solid pseudopapillary tumour.

Useful stains

  • PAS-D.

Mucinous vs. IMPT

IMPT:

  • No ovarian-like stroma.
  • Usually has total pancreatectomy.

Cystic tumours of the pancreas

Khalifa's table of cystic tumours:

Usual sex Age (years) Usual site Typical
size (cm) 		Gross pathology
Serous microcystic
adenoma 		female 66 body & tail 11 (joplink.net[16], (jhmi.edu)[17]
Intraductal papillary
mucinous tumour (IPMT) 		male 62 head 4 (jhmi.edu)[17]
Mucinous tumour female 49 body & tail 10 (rsna.org)
Solid pseudopapillary
tumour 		female 35 any 7.5 (ajronline.org), (flickr.com/humpath)

Cystic lesions

Serous tumours - overview

General

  • Cell of origin: intralobular duct cells (ductular cells).
  • Glycogen rich - but do not produce mucin.

Subclassication

Note:

  • If one mucin +ve cell, tumour = a mucinous tumour.

Serous cystadenoma of the pancreas

  • AKA serous microcystic adenoma,[18] AKA pancreatic serous cystadenoma.

General

  • 1-2% of all exocrine pancreatic tumours.
  • Female > male.
  • Mean age 66 years.
  • Truly benign with no malignant potenial.
  • May be part of von Hippel-Lindau syndrome.

Management:

  • Observe or resect.

Gross

Features:

  • Classically has a characteristic central scar.[20]
  • Bosulated surface.
  • Lobulated.
  • No (macroscopic) cysts apparent on gross.
  • Location: 50-70% occur in the body and tail.
  • Size: average size 11 cm.

Radiologic appearance:

  • Honey comb-like appearance.
  • Well demarcated border - may be described as a "coin lesion".

Image:

Microscopic

Features:

  • Cystic spaces lined by cuboidal cells.
    • Glycogen rich.
    • Cilia. (???)

DDx:

Notes:

  • Serous adenoma my coexist with aggressive tumours.

Images:

Stains

  • PAS +ve.
  • PASD -ve.

Mucinous cystic neoplasms of the pancreas

  • Gastro-entero-pancreatic cell differentiation with hypercellular ovarian-type stroma.
    • Stroma --> cellular.
  • 2-2.5% of all exocrine pancreatic tumours.
  • Almost exclusively in women.
  • Mean age - 49 years.
  • >80% in body and tail.
  • Average size ~10 cm.

Note:

  • Looks different than serous tumour.

Subclassification

  • Mucinous cystadenoma.
  • Borderline mucinous cystic tumour.
  • Mucinous cystadenocarcinoma.

Borderline vs. Carcinoma

  • Few mitoses in borderline.

Radiology

  • Mucinous tumours: multilocular.
  • Generally larger than serous.
  • Often partially solid and cystic.
  • Often calcified.
    • Calcification rare in serous.
  • Usually tail & body.

Microscopic

Mucinous cystadenoma

Features:[22]

  • Simple tall columnar epithelium with large mucin vacuole on apical aspect.
  • "Ovarian-type stroma" under epithelium.
    • Ovarin-type stroma: high density of small (non-wavy) spindle cells with eosinophilic cytoplasm.

Images:

Notes:

  • Appearance similar to mucinous cystadenoma in the ovary.
  • Mucin stains +ve (intracytoplasmic).

Borderline mucinous cystic tumour

Features:

  • May have finger like projections.
  • Pseudostratification of epithelium.

Notes:

  • Surgery does not change based on diagnosis on frozen section.
    • Only question is "Is the margin clear?".
  • Borderline tumours are rare.

Carcinoma

  • Cells floating in mucin.

Mucinous tumour vs. pseudocyst

Mucinous tumour Pseudocyst
Amylase & lipase low high
Viscosity high low
CEA, CA125 high low

Prognosis:

  • Benign looking tumours have the potential to transform into carcinoma.
  • No report of assoc. pseudomyxoma peritonei.
    • US boards question -- it is an exception ... others one cause it.
  • Prognosis of m. cystadenocarcinoma is slightly better than that of ductal adenocarcinoma.

Intraductal papillary mucinous tumour

  • Abbreviated IPMT.
  • AKA intraductal papillary mucinous neoplasm, abbreviated IPMN.

General

  • 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.[23]
    • Dependent what is involved:[24]
      • 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:
    • Mitotic activity.

Note:

  • No ovarian type stroma underneath (as seen in mucinous tumours).

DDx:

Classification of IMPT

Commonly classified by the duct involvement:[25]

  1. Main duct type.
    • Commonly associated with invasive carcinoma.
  2. 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

  • AKA solid pseudopapillary neoplasm, abbreviation SPN.
  • AKA solid and papillary epithelial neoplasm, abbreviated SPEN.[26]

General

  • Obscure cell of origin.
  • Considered low grade, i.e. prognosis is usually good.

Epidemiology

Features:[27]

  • Usually females (M:F=1:9).
  • Mean age of presentation third decade (20s).

Management

May be followed radiologically.

Microscopic

Features:[28]

  • Solid sheets of cells, focally dyscohesive.
  • Eosinophilic cytoplasm.
    • Occasionally clear cytoplasm.[29]
    • Focal eosinophilic (intracytoplasmic) globules - key feature.
  • Uniform nuclei with occasional nuclear grooves.
  • +/-Necrosis - creating spaces/cavities.
  • +/-Cholesterol clefts.[30]

Images:

DDx

IHC

Features:[29]

  • Beta-catenin +ve ~100% (cytoplasmic & nuclear).
  • E-cadherin +ve ~100% (cytoplasmic), -ve (membrane); antibody dependent.
  • CD10 +ve ~ 80% (cytoplasmic + dot-like) key.
  • Synaptophysin +ve (weak cytoplasmic) ~70%.
  • Progesterone receptor +ve (nuclear) key.

Others:

  • CD56 +ve.
  • Chromogranin -ve.

Memory device PCB: PR (nuclear), CD10 (cytoplasmic), beta-catenin (cytoplasmic & nuclear).

Pre-malignant lesions

Pancreatic intraepithelial neoplasia

  • Abbreviated PanIN.

General

  • PanIN is thought to be the precursor lesion for pancreatic carcinoma.[31]

Overview

Putative preneoplasm-neoplasm-carcinoma sequence:

  • PanIN1a.
    • Not neoplastic, i.e. colonal.
  • PanIN1b.
    • Not neoplastic, i.e. colonal.
  • PanIN2.
    • Can be thought of as low-grade dysplasia, e.g. a (colonic) 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.[32]

Microscopic

Features:[31]

  • 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:

Solid tumours

Invasive ductal carcinoma of the pancreas

  • AKA ductal adenocarcinoma.
  • AKA pancreatic ductal adenocarcinoma.
  • AKA pancreatic adenocarcinoma.

General

  • Most common type of pancreatic cancer.[33]
  • Location: usually in the head ~60%.
    • 15% in the body, 5% tail, 20% diffuse (head, body & tail).[34]
  • Abysmal prognosis.

Risk factors:[35]

  • Smoking (RR ~ 2).
  • Pancreatitis.
  • Family history, esp. BRCA2.
  • Diabetes mellitus - modest risk increase.

Molecular characteristics:[36][37]

  1. KRAS (oncogene) mutation in ~ 90% of cases.
  2. CDKN2A[38] (AKA p16) inactivation ~ 95% of cases.
  3. TP53 (AKA p53).
  4. SMAD4.

Microscopic

Features:[39]

  • Often glandular, may be solid.
  • Nuclei.
    • May be bland - little pleomorphism.
    • Often small nuclei.
    • Sometimes coffee-bean appearance.
  • Cytoplasm - granular, abundant.
  • Quasi endocrine look.
    • May stain positive for endocrine markers.

Other features:

  • +/-Necrosis.
  • +/-Myxoid degeneration.
  • +/-Cells around vessels.

DDx:

Images:

IHC

Features:[40]

  • CD7 +ve.
  • CD20 +ve.
  • SMAD4 -ve ~55% of cases -- stomach usually +ve.
  • CDX2 -ve/+ve.
  • CEA +ve.[41]

Pancreatic neuroendocrine tumour

Main article: Neuroendocrine tumour
  • Abbreviated PanNET.[42]
  • AKA pancreatic islet cell tumour[42] - considered to be an outdated term.
  • AKA islet cell tumour - considered to be an outdated term.

General

Classification

Based on peptide produced in the pancreatic islets:

  1. Glucagon from alpha cells (glucagonoma).
  2. Insulin from beta cells (insulinoma) - most common ~ 50% of islet cell tumours.
  3. Somatostatin from D cells (somatostatinoma).
  4. Pancreatic polypeptide from PP cells.

Others:

  1. Vasoactive intestinal peptide (VIPoma).
  2. Gastrin (gastrinoma).

Microscopic

Features:

  • Nests of cells.
  • Stippled chromatin.
  • +/-Hyaline globules.

DDx:

Images:

IHC

  • CK19 +ve -- should be done as a routine in pancreatic NETs; poor prognostic factor.[46]

Note:

  • CK19 should not be confused with CA19-9.

Acinar cell carcinoma of the pancreas

Not to be confused with acinic cell carcinoma.
  • AKA acinar cell carcinoma.

General

  • Rare.
  • Solid epithelial exocrine tumour.[47]
  • Poor prognosis; mean survival of 18 months in one series.[48]

Clinical:[48]

  • Increased serum lipase.
    • Associated with arthralgias (joint pain).
  • Classic presentation - Schmid triad:[49]
    1. Subcutaneous fat necrosis.
    2. Polyarthritis.
    3. Eosinophilia.

Gross

  • Usually head of pancreas.

Microscopic

Features:[48]

  • Cells reminiscent of pancreatic acinus cells:
    • Granular, basophilic cytoplasm - usu. abundant.
    • Round/oval nucleus.
      • Nucleolus prominent.
  • Architecture:
    • Nests, sheets, trabecular, glandular.

DDx:

Images:

Stains

Features:[48]

  • PAS +ve (granular).
  • PASD +ve.

IHC

  • Trypsin +ve -- key stain.
  • Lipase +ve.
  • Chromogranin +ve (scattered, focal).
  • CD56 -ve. (?)

See also

References

  1. ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/PancreasEndo_11protocol.pdf. Accessed on: 29 March 2012.
  2. ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/SmallbowelNET_11protocol.pdf. Accessed on: 29 March 2012.
  3. ↑ Jamieson, NB.; Foulis, AK.; Oien, KA.; Going, JJ.; Glen, P.; Dickson, EJ.; Imrie, CW.; McKay, CJ. et al. (Jun 2010). "Positive mobilization margins alone do not influence survival following pancreatico-duodenectomy for pancreatic ductal adenocarcinoma.". Ann Surg 251 (6): 1003-10. doi:10.1097/SLA.0b013e3181d77369. PMID 20485150.
  4. ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/PancreasEndo_11protocol.pdf. Accessed on: 6 April 2012.
  5. ↑ URL: http://test.pathologyportal.org/newindex.htm?92nd/specgasth2.htm. Accessed on: 14 March 2011.
  6. ↑ Johansson J, Håkansson HO, Mellblom L, et al. (March 2010). "Pancreatic acinar metaplasia in the distal oesophagus and the gastric cardia: prevalence, predictors and relation to GORD". J. Gastroenterol. 45 (3): 291–9. doi:10.1007/s00535-009-0161-4. PMID 20012917.
  7. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 223. ISBN 978-1416002741.
  8. ↑ Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 469. ISBN 978-1416054542.
  9. ↑ URL: http://path.upmc.edu/cases/case651/dx.html. Accessed on: 28 January 2012.
  10. ↑ 10.0 10.1 Kamisawa, T.; Takuma, K.; Tabata, T.; Inaba, Y.; Egawa, N.; Tsuruta, K.; Hishima, T.; Sasaki, T. et al. (Jan 2011). "Serum IgG4-negative autoimmune pancreatitis.". J Gastroenterol 46 (1): 108-16. doi:10.1007/s00535-010-0317-2. PMID 20824290.
  11. ↑ Ikeura, T.; Takaoka, M.; Uchida, K.; Shimatani, M.; Miyoshi, H.; Kusuda, T.; Kurishima, A.; Fukui, Y. et al. (2012). "Autoimmune pancreatitis with histologically proven lymphoplasmacytic sclerosing pancreatitis with granulocytic epithelial lesions.". Intern Med 51 (7): 733-7. PMID 22466829.
  12. ↑ Krasinskas, AM.; Raina, A.; Khalid, A.; Tublin, M.; Yadav, D. (Jun 2007). "Autoimmune pancreatitis.". Gastroenterol Clin North Am 36 (2): 239-57, vii. doi:10.1016/j.gtc.2007.03.015. PMID 17533077.
  13. ↑ 13.0 13.1 13.2 Adsay, NV.; Bandyopadhyay, S.; Basturk, O.; Othman, M.; Cheng, JD.; Klöppel, G.; Klimstra, DS. (Nov 2004). "Chronic pancreatitis or pancreatic ductal adenocarcinoma?". Semin Diagn Pathol 21 (4): 268-76. PMID 16273946.
  14. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 225. ISBN 978-1416002741.
  15. ↑ Hornick, JL.; Lauwers, GY.; Odze, RD. (Mar 2005). "Immunohistochemistry can help distinguish metastatic pancreatic adenocarcinomas from bile duct adenomas and hamartomas of the liver.". Am J Surg Pathol 29 (3): 381-9. PMID 15725808.
  16. ↑ URL: http://www.joplink.net/prev/200905/25.html. Accessed on: 15 February 2012.
  17. ↑ 17.0 17.1 URL: http://oac.med.jhmi.edu/cpc/cases/cpc5/cpc5_answer.html. Accessed on: 15 February 2012.
  18. ↑ 18.0 18.1 Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Oberman, Harold A; Reuter, Victor E (2004). Sternberg's Diagnostic Surgical Pathology (4th ed.). Lippincott Williams & Wilkins. pp. 1630. ISBN 978-0781740517.
  19. ↑ Bano, S.; Upreti, L.; Puri, SK.; Chaudhary, V.; Sakuja, P. (Dec 2011). "Imaging of pancreatic serous cystadenocarcinoma.". Jpn J Radiol 29 (10): 730-4. doi:10.1007/s11604-011-0617-3. PMID 22009426.
  20. ↑ Kim YH, Saini S, Sahani D, Hahn PF, Mueller PR, Auh YH (2005). "Imaging diagnosis of cystic pancreatic lesions: pseudocyst versus nonpseudocyst". Radiographics 25 (3): 671–85. doi:10.1148/rg.253045104. PMID 15888617. http://radiographics.rsna.org/content/25/3/671.abstract.
  21. ↑ Vernadakis, S.; Kaiser, GM.; Christodoulou, E.; Mathe, Z.; Troullinakis, M.; Bankfalvi, A.; Paul, A. (2009). "Enormous serous microcystic adenoma of the pancreas.". JOP 10 (3): 332-4. PMID 19454830.
  22. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 489. ISBN 978-0443066573.
  23. ↑ Maire F, Hammel P, Terris B, et al. (November 2002). "Prognosis of malignant intraductal papillary mucinous tumours of the pancreas after surgical resection. Comparison with pancreatic ductal adenocarcinoma". Gut 51 (5): 717–22. PMC 1773420. PMID 12377813. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12377813.
  24. ↑ Baiocchi GL, Portolani N, Missale G, et al. (2010). "Intraductal papillary mucinous neoplasm of the pancreas (IPMN): clinico-pathological correlations and surgical indications". World J Surg Oncol 8: 25. doi:10.1186/1477-7819-8-25. PMC 2858722. PMID 20374620. http://wjso.com/content/8/1/25.
  25. ↑ Ikeuchi, N.; Itoi, T.; Sofuni, A.; Itokawa, F.; Tsuchiya, T.; Kurihara, T.; Ishii, K.; Tsuji, S. et al. (Apr 2010). "Prognosis of cancer with branch duct type IPMN of the pancreas.". World J Gastroenterol 16 (15): 1890-5. PMID PMC = 2856831 20397268 PMC = 2856831.
  26. ↑ URL: http://brighamrad.harvard.edu/Cases/bwh/hcache/360/full.html. Accessed on: 31 October 2011.
  27. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 493. ISBN 978-0443066573.
  28. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 493-5. ISBN 978-0443066573.
  29. ↑ 29.0 29.1 29.2 Serra S, Chetty R (November 2008). "Revision 2: an immunohistochemical approach and evaluation of solid pseudopapillary tumour of the pancreas". J. Clin. Pathol. 61 (11): 1153–9. doi:10.1136/jcp.2008.057828. PMID 18708424. http://jcp.bmj.com/content/61/11/1153.
  30. ↑ Abad Licham, M.; Sanchez Lihon, J.; Celis Zapata, J.. "[Pseudopapillary solid tumor of pancreas in the INEN].". Rev Gastroenterol Peru 28 (4): 356-61. PMID 19156179.
  31. ↑ 31.0 31.1 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 949. ISBN 0-7216-0187-1.
  32. ↑ Matthaei, H.; Hong, SM.; Mayo, SC.; dal Molin, M.; Olino, K.; Venkat, R.; Goggins, M.; Herman, JM. et al. (Nov 2011). "Presence of pancreatic intraepithelial neoplasia in the pancreatic transection margin does not influence outcome in patients with R0 resected pancreatic cancer.". Ann Surg Oncol 18 (12): 3493-9. doi:10.1245/s10434-011-1745-9. PMID 21537863.
  33. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 237. ISBN 978-0781765275.
  34. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 950. ISBN 0-7216-0187-1.
  35. ↑ Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 471. ISBN 978-1416054542.
  36. ↑ Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 470-1. ISBN 978-1416054542.
  37. ↑ Furukawa, T. (Nov 2009). "Molecular pathology of pancreatic cancer: implications for molecular targeting therapy.". Clin Gastroenterol Hepatol 7 (11 Suppl): S35-9. doi:10.1016/j.cgh.2009.07.035. PMID 19896096.
  38. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 600160
  39. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 951. ISBN 0-7216-0187-1.
  40. ↑ Lester, Susan Carole (2010). Manual of Surgical Pathology (3rd ed.). Saunders. pp. 94. ISBN 978-0-323-06516-0.
  41. ↑ Adsay, NV.; Basturk, O.; Cheng, JD.; Andea, AA. (Oct 2005). "Ductal neoplasia of the pancreas: nosologic, clinicopathologic, and biologic aspects.". Semin Radiat Oncol 15 (4): 254-64. doi:10.1016/j.semradonc.2005.04.001. PMID 16183479.
  42. ↑ 42.0 42.1 Burns, WR.; Edil, BH. (Dec 2011). "Neuroendocrine Pancreatic Tumors: Guidelines for Management and Update.". Curr Treat Options Oncol. doi:10.1007/s11864-011-0172-2. PMID 22198808.
  43. ↑ Charlesworth, M.; Verbeke, CS.; Falk, GA.; Walsh, M.; Smith, AM.; Morris-Stiff, G. (Feb 2012). "Pancreatic Lesions in von Hippel-Lindau Disease? A Systematic Review and Meta-synthesis of the Literature.". J Gastrointest Surg. doi:10.1007/s11605-012-1847-0. PMID 22370733.
  44. ↑ Alexakis, N.; Connor, S.; Ghaneh, P.; Lombard, M.; Smart, HL.; Evans, J.; Hughes, M.; Garvey, CJ. et al. (2004). "Hereditary pancreatic endocrine tumours.". Pancreatology 4 (5): 417-33; discussion 434-5. doi:10.1159/000079616. PMID 15249710.
  45. ↑ Zollinger RM, Ellison EH (1955). "Primary peptic ulcerations of the jejunum associated with islet cell tumors of the pancreas". Ann. Surg. 142 (4): 709–23; discussion, 724–8. doi:10.1097/00000658-195510000-00015. PMC 1465210. PMID 13259432. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1465210/.
  46. ↑ Jain, R.; Fischer, S.; Serra, S.; Chetty, R. (Jan 2010). "The use of Cytokeratin 19 (CK19) immunohistochemistry in lesions of the pancreas, gastrointestinal tract, and liver.". Appl Immunohistochem Mol Morphol 18 (1): 9-15. doi:10.1097/PAI.0b013e3181ad36ea. PMID 19956064.
  47. ↑ URL: http://brighamrad.harvard.edu/Cases/bwh/hcache/380/full.html. Accessed on: 15 January 2012.
  48. ↑ 48.0 48.1 48.2 48.3 Klimstra, DS.; Heffess, CS.; Oertel, JE.; Rosai, J. (Sep 1992). "Acinar cell carcinoma of the pancreas. A clinicopathologic study of 28 cases.". Am J Surg Pathol 16 (9): 815-37. PMID 1384374.
  49. ↑ Jang, SH.; Choi, SY.; Min, JH.; Kim, TW.; Lee, JA.; Byun, SJ.; Lee, JW. (Feb 2010). "[A case of acinar cell carcinoma of pancreas, manifested by subcutaneous nodule as initial clinical symptom].". Korean J Gastroenterol 55 (2): 139-43. PMID 20168061.

Further reading

Klimstra, DS.; Pitman, MB.; Hruban, RH. (Mar 2009). "An algorithmic approach to the diagnosis of pancreatic neoplasms.". Arch Pathol Lab Med 133 (3): 454-64. doi:10.1043/1543-2165-133.3.454. PMID 19260750.

External links

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