Difference between revisions of "Chronic pancreatitis"

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#redirect [[Pancreas#Chronic_pancreatitis]]
'''Chronic pancreatitis''' is a relatively common pathology of the [[pancreas]] that can be confused for a [[pancreatic cancer]].
 
==General==
*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-related systemic diseases|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.
 
==See also==
*[[Acute pancreatitis]].
 
==References==
{{Reflist|1}}


[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Gastrointestinal pathology]]

Latest revision as of 04:11, 21 May 2016

Chronic pancreatitis is a relatively common pathology of the pancreas that can be confused for a pancreatic cancer.

General

Complications:[1]

Autoimmune pancreatitis

Histologic subtypes of autoimmune pancreatitis:[2]

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

Lymphoplasmacytic sclerosing pancreatitis

General:

  • Serum IgG4 +ve.[5]

Microscopic:

  • Lymphoplasmacytic infiltrate.

IHC:

  • Plasma cells IgG4 +ve.

Radiology

Plain film findings:

  • Calcifications.

Microscopic

Features of chronic pancreatitis:[6]

  • 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.[7]
  • Intraluminal mucoprotein plugs.

Images:

Adenocarcinoma versus pancreatitis

This contrasts with the features of adenocarcinoma:[6]

  • 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

Positive in pancreatic carcinoma:[8]

  • p53.
  • Mesothelin.

See also

References

  1. ↑ 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.
  2. ↑ URL: http://path.upmc.edu/cases/case651/dx.html. Accessed on: 28 January 2012.
  3. ↑ 3.0 3.1 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 6.0 6.1 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.
  7. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 225. ISBN 978-1416002741.
  8. ↑ 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.
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