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Pancreas (view source)

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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.
[[Image:Gray 1100 Pancreatic duct.png|thumb|right|250px|A drawing of the pancreas. (WC/Gray's Anatomy)]]
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==
==Normal anatomy==
Divided into three portions: head, body & tail:
Divided into three portions: head, body & tail:<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/PancreasEndo_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/PancreasEndo_11protocol.pdf]. Accessed on: 29 March 2012.</ref>
*Head:
*Head:
**Includes unicate process.
**Includes unicate process.
**Extend to superior mesenteric vein (by definition).
**Extends to the left edge of the superior mesenteric vein (SMV) - by definition.
***All of the SMV is with the head.  
*Body:
*Body:
**Superior mesenteric vein to left edge of aorta (by definition).
**Right edge of the superior mesenteric vein to the left edge of aorta - by definition.
***All of the aorta is with the body.
*Tail:
*Tail:
**Remainder of pancreas.
**Remainder of pancreas.


==Three pancreatic surgeries==
==Pancreatic surgeries==
*Whipple (includes duodenum).
Common pancreatic surgeries include:
*Whipple procedure ([[AKA]] pancreaticoduodenal resection) - includes [[duodenum]] and usually the distal [[stomach]] (antrum).
*Distal pancreatectomy.  
*Distal pancreatectomy.  
**removal of tail +/- body.
**Removal of tail +/- body.
**Specimen usually comes with the [[spleen]].
**Typically done form [[islet cell tumour]]s.
*Total pancreatectomy.
*Total pancreatectomy.
**often with splenectomy.
**Specimen usually comes with the spleen.
 
===Whipple procedure===
*[[AKA]] ''pancreaticoduodenectomy''.
 
Indications:
*Head of pancreas lesions, duodenal lesions.
 
[[Margins]]:<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/SmallbowelNET_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/SmallbowelNET_11protocol.pdf]. Accessed on: 29 March 2012.</ref>
#Proximal mucosal margin (stomach or duodenum).
#Distal mucosal margin (duodenum or jejunum).
#Bile duct margin.
#Pancreatic retroperitoneal (uncinate process) margin.
#*At SB done ''on edge'' (not ''en face'').
#Pancreatic neck transection margin ([[AKA]] distal pancreatic resection margin);<ref name=pmid20485150>{{Cite journal  | last1 = Jamieson | first1 = NB. | last2 = Foulis | first2 = AK. | last3 = Oien | first3 = KA. | last4 = Going | first4 = JJ. | last5 = Glen | first5 = P. | last6 = Dickson | first6 = EJ. | last7 = Imrie | first7 = CW. | last8 = McKay | first8 = CJ. | last9 = Carter | first9 = R. | title = Positive mobilization margins alone do not influence survival following pancreatico-duodenectomy for pancreatic ductal adenocarcinoma. | journal = Ann Surg | volume = 251 | issue = 6 | pages = 1003-10 | month = Jun | year = 2010 | doi = 10.1097/SLA.0b013e3181d77369 | PMID = 20485150 }}</ref> usu. ''en face'' and ''in toto''.<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/PancreasEndo_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/PancreasEndo_11protocol.pdf]. Accessed on: 6 April 2012.</ref>
#Sometimes superior mesenteric vein (SMV).
#Rarely superior mesenteric artery (SMA) margin.
 
[[Opening]]:
#Open the proximal (stomach) and distal (small bowel) stappled margins.
#Open the duodenum along it length on the anterior aspect.
#Open the stomach along the greater curvature.
#Join the cuts that open the stomach and duodenum.


==General classification of pancreatic tumours==
==General classification of pancreatic tumours==
Line 26: Line 59:
**Exocrine.
**Exocrine.


==Most important cystic lesions==
===Pancreas neoplasms in a table===
{| class="wikitable sortable"
!| Type
!| Key feature
!| Subtypes
!| Image
!| IHC
!| Detailed microscopic
!| Usual location
!| Other
!| DDx
|-
| Serous tumours
| cuboidal cells, clear cytoplasm
| cystadenoma, borderline t., cystadenocarcinoma
| [http://commons.wikimedia.org/wiki/File:Pancreatic_serous_cystadenoma_%281%29.jpg], [http://commons.wikimedia.org/wiki/File:Pancreatic_serous_cystadenoma_%282%29.jpg (WC)], [http://commons.wikimedia.org/wiki/File:Pancreatic_serous_cystadenoma_-_intermed_mag.jpg (WC)]
| IHC?
| cuboidal cells, clear cytoplasm, central nucleus
| body or tail
| cystadenoma may be assoc. with [[von Hippel-Lindau syndrome]]
| [[clear cell renal cell carcinoma|clear cell RCC]], oligomucinous mucinous tumours
|-
| [[Intraductal papillary mucinous tumour]] (IPMT)
| mucin, no ovarian-like stroma
| clear cell variant
| [http://wjso.com/content/8/1/25/figure/F1 (wjso.com)], [http://path.upmc.edu/cases/case451/images/fig01.jpg (upmc.edu)]
| IHC?
| papillae, tall columnar mucin-producing cells
| head
| -
| mucious neoplasms (other pancreatic, duodenal), intra-ampullary papillary-tubular neoplasm (see [[ampullary carcinoma]])
|-
| Mucinous tumour
| mucin, ovarian-like stroma
| cystadenoma, borderline t., cystadenocarcinoma
| [http://commons.wikimedia.org/w/index.php?title=File:Benign_pancreatic_mucinous_cystic_neoplasm_-_intermed_mag.jpg (WC)], [http://commons.wikimedia.org/w/index.php?title=File:Benign_pancreatic_mucinous_cystic_neoplasm_-_high_mag.jpg (WC)]
| IHC?
| tall columnar mucin-producing cells, ovarian-like stroma
| body or tail
| -
| [[IPMT]], metastatic mucinous tumours
|-
| [[Solid pseudopapillary tumour|Solid pseudopapillary<br>tumour]]
| eosinophilic intracytoplasmic globules
| clear cell variant (cytoplasm clear)
| [http://commons.wikimedia.org/w/index.php?title=File:Solid_pseudopapillary_tumour_-_intermed_mag.jpg (WC)], [http://jcp.bmj.com/content/61/11/1153/F1.large.jpg (bmj.com)]
| beta-catenin +ve, E-cadherin +ve, <br>synaptophysin +ve, chromogranin -ve
| sheets of cells, focally loosely cohesive, eosinophilic cytoplasm, uniform nuclei with grooves
| none (head, body or tail)
| usu. younger women
| [[pancreatic ductal adenocarcinoma|ductal adenocarcinoma]], [[neuroendocrine tumour]]s
|-
| [[Invasive ductal carcinoma of the pancreas|Ductal adenocarcinoma]]
| irregular shaped glands, cytologic atypia
| mucinous, spindle cell, mixed ductal-endocrine
| [http://commons.wikimedia.org/wiki/File:Pancreas_adenocarcinoma_%284%29_Case_01.jpg (WC)], [http://commons.wikimedia.org/wiki/File:Pancreas_adenocarcinoma_%282%29_Case_01.jpg (WC)]
| IHC?
| glands, sheets, single cells, nuc. atypia, +/-mitoses, +/-[[necrosis]]
| head
| arises from the precursor ''PanIN''
| ampullary carcinoma, [[chronic pancreatitis]]
|-
| [[Pancreatoblastoma]]
| squamoid nests, whorling
| -
| [http://www.nature.com/modpathol/journal/v20/n1s/fig_tab/3800686f16.html#figure-title (nature.com)]
| [[CK7]] (acinar comp.), CK8, CK18, [[CK19]]
| squamoid nests of cells, whorling, nested growth, +/-keratinization
| none
| usu. paediatric population
| [[acinar cell carcinoma of the pancreas|acinar cell carcinoma]]
|-
| [[Acinar cell carcinoma of the pancreas|Acinar cell carcinoma]]
| acinar arch.
| -
| [http://commons.wikimedia.org/wiki/File:Acinar_cell_carcinoma_of_the_pancreas_-_very_high_mag.jpg (WC)], [http://www.histopathology-india.net/acinar%20cell%20ca.JPG (histopathology-india.net)]
| trypsin, lipase
| nests or [[trabeculae]], nucleolus, mod. basophilic granular cytoplasm
| head (slight predilection)
| -
| pancreatoblastoma
|-
| Undifferentiated carcinoma with osteoclast-like [[giant cell]]s
| 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.
| -
| [http://www.pathology.vcu.edu/education/gi/lab1.b.html]
| IHC?
| loss of acinar tissue with preservation of islets, fibrosis
| ?
| not a neoplasm, included here as it is in the (clinical) DDx
| [[pancreatic ductal adenocarcinoma|ductal adenocarcinoma]]
|}
 
===WHO classification===
Benign epithelial:
*[[Pancreatic serous cystadenoma|Serous cystadenoma]].
*[[Pancreatic mucinous cystadenoma|Mucinous cystadenoma]].
*[[Intraductal papillary mucinous neoplasm|Intraductal papillary mucinous adenoma]].
*[[Mature teratoma]].
 
Borderline epithelial:
*Mucinous cystic neoplasm with moderate dysplasia.
*[[Intraductal papillary mucinous neoplasm|Intraductal papillary mucinous neoplasm with moderate dysplasia]].
*[[Solid pseudopapillary neoplasm]]
 
Malignant epithelial:
*[[Pancreatic ductal adenocarcinoma|Ductal adenocarcinoma]].
**Mucinous noncystic carcinoma.
**[[Signet ring cell carcinoma]].
**[[Adenosquamous carcinoma]].
**Undifferentiated carcinoma.
**Undifferentiated carcinoma with osteoclast-like giant cells.
**Mixed ductal-endocrine carcinoma.
*[[Pancreatic serous cystadenocarcinoma|Serous cystadenocarcinoma]].
*[[Pancreatic mucinous cystadenocarcinoma|Mucinous cystadenocarcinoma]].
**Invasive.
**Noninvasive.
*[[Intraductal papillary mucinous neoplasm|Intraductal papillary mucinous carcinoma]].
**Invasive.
**Noninvasive.
*[[Acinar cell carcinoma of the pancreas|Acinar cell carcinoma]].
*[[Pancreatoblastoma]].
*[[Solid pseudopapillary neoplasm|Solid pseudopapillary carcinoma]].
 
Soft tissue tumours:
*See ''[[soft tissue lesions]]''.
 
=Ectopic pancreatic tissue=
It comes in two flavours:<ref>URL: [http://test.pathologyportal.org/newindex.htm?92nd/specgasth2.htm http://test.pathologyportal.org/newindex.htm?92nd/specgasth2.htm]. Accessed on: 14 March 2011.</ref>
*Pancreatic ectopia.
*Pancreatic (acinar) metaplasia.
 
==Pancreatic acinar metaplasia==
*Abbreviated ''PAM''.
*[[AKA]] ''pancreatic metaplasia''.<ref name=pmid8724024>{{Cite journal  | last1 = Stachura | first1 = J. | last2 = Konturek | first2 = JW. | last3 = Urbanczyk | first3 = K. | last4 = Bogdal | first4 = J. | last5 = Mach | first5 = T. | last6 = Domschke | first6 = W. | title = Endoscopic and histological appearance of pancreatic metaplasia in the human gastric mucosa: a preliminary report on a recently recognized new type of gastric mucosal metaplasia. | journal = Eur J Gastroenterol Hepatol | volume = 8 | issue = 3 | pages = 239-43 | month = Mar | year = 1996 | doi =  | PMID = 8724024 }}</ref>
 
===General===
*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>
*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/>
 
===Gross===
*May be a single lesion or a cluster of lesions.<ref name=pmid8724024/>
 
Note:
*''Not'' associated with the endoscopic diagnosis of esophagitis or [[Barrett's esophagus]].<ref name=pmid23989798/>
 
===Microscopic===
Features:
*Pancreatic acini - only.
**Intensely eosinophilic cytoplasm.
 
Negatives:
*No pancreatic ducts.
*No islets of Langerhans (pancreatic islets).
 
====Images====
<gallery>
Image:Pancreatic_acinar_metaplasia_-_high_mag.jpg | PAM - high mag. (WC/Nephron)
Image:Pancreatic_acinar_metaplasia_-_low_mag.jpg | PAM - low mag. (WC/Nephron)
</gallery>
===IHC===
Features:<ref>{{Cite journal  | last1 = Doglioni | first1 = C. | last2 = Laurino | first2 = L. | last3 = Dei Tos | first3 = AP. | last4 = De Boni | first4 = M. | last5 = Franzin | first5 = G. | last6 = Braidotti | first6 = P. | last7 = Viale | first7 = G. | title = Pancreatic (acinar) metaplasia of the gastric mucosa. Histology, ultrastructure, immunocytochemistry, and clinicopathologic correlations of 101 cases. | journal = Am J Surg Pathol | volume = 17 | issue = 11 | pages = 1134-43 | month = Nov | year = 1993 | doi =  | PMID = 8214258 }}</ref>
*Trypase +ve.
*Lipase +ve.
 
===Sign out===
It can be debated whether it is worth reporting.
<pre>
ESOPHAGUS (DISTAL), BIOPSY:
- COLUMNAR EPITHELIUM WITH MODERATE CHRONIC, FOCALLY ACTIVE, INFLAMMATION, AND
  PANCREATIC ACINAR METAPLASIA.
- REACTIVE SQUAMOUS EPITHELIUM.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>
 
==Pancreatic ectopia==
===General===
*May be confused with something pathologic.
 
===Microscopic===
Features:
*Consists of pancreatic acini ''and'' pancreatic ducts.
*+/-Islets of Langerhans.
 
=Inflammatory=
==Pancreatitis==
===Classification===
*[[Acute pancreatitis]].
*[[Chronic pancreatitis]].
 
===Etiology===
Mnemonic ''I GET SMASHED'':
*Idiopathic.
*[[Gallstones]] ~45%.
*Ethanol ~35%.
*Tumours (pancreas, ampulla).
*Scorpion bites, snake bites.
*Microbial - mumps (paramyxovirus), [[Epstein-Barr virus]] (EBV), [[cytomegalovirus]] (CMV), mycoplasma.
*Autoimmune - [[Crohn's disease]], [[polyarteritis nodosa]] (PAN), [[systemic lupus erythematosus]] (SLE).
*Surgery/trauma, e.g. ERCP, motor vehicle collision.
*Hypercalcemia, hyperlipidemia/hypertriglyceridemia, [[hypothermia]].
*Emboli, e.g. post-[[CABG]].
*Drugs - ''SAND'' = steroids & sulfonamides, azathioprine, [[NSAID]]s, diuretics, such as furosemide.
 
==Acute pancreatitis==
{{Main|Acute pancreatitis}}
 
==Chronic pancreatitis==
{{Main|Chronic pancreatitis}}
 
=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 [[Pancreatic pseudocyst|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.
*Serous.
*Mucinous.
*Mucinous.
Line 34: Line 307:
**No ovarian-like stroma.
**No ovarian-like stroma.


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


===Mucinous vs. IMPT===
====Useful stains====
*IMPT -- no ovarian-like stroma.
*PAS-D.
**IMPT usually has total pancreatectomy.


==Cystic tumors of pancreas==
====Mucinous vs. IMPT====
*Uncommon.
IMPT:
**10% of cystic lesion (90% pseudocyst).
*No ovarian-like stroma.
*Diagnostic difficulties (hard to differentiate pseudocyst & cyst).
*Usually has total pancreatectomy.


Note:
===Cystic tumours of the pancreas===
*Pseudocysts: not real cysts... as no lining epithelium.
Khalifa's table of cystic tumours:
{| class="wikitable sortable"
!Tumour
!Usual sex
!Age (years)
!Usual site
!Typical <br>size (cm)
![[Gross pathology]]
|-
|[[serous microcystic adenoma|Serous microcystic<br> adenoma]]
|female
|66
|body & tail
|11
|[http://www.joplink.net/prev/200905/25_fig06.jpg (joplink.net]<ref>URL: [http://www.joplink.net/prev/200905/25.html http://www.joplink.net/prev/200905/25.html]. Accessed on: 15 February 2012.</ref>, [http://oac.med.jhmi.edu/cpc/images/cpc5/33.jpg (jhmi.edu)]<ref name=jhmi>URL: [http://oac.med.jhmi.edu/cpc/cases/cpc5/cpc5_answer.html http://oac.med.jhmi.edu/cpc/cases/cpc5/cpc5_answer.html]. Accessed on: 15 February 2012.</ref>
|-
|[[IPMN|Intraductal papillary<br>mucinous tumour (IPMT)]]
|male
|62
|head
|4
|[http://oac.med.jhmi.edu/cpc/images/cpc5/28.jpg (jhmi.edu)]<ref name=jhmi>URL: [http://oac.med.jhmi.edu/cpc/cases/cpc5/cpc5_answer.html http://oac.med.jhmi.edu/cpc/cases/cpc5/cpc5_answer.html]. Accessed on: 15 February 2012.</ref>
|-
|Mucinous tumour
|female
|49
|body & tail
|10
|[http://radiology.rsna.org/content/251/1/77/F8.expansion.html (rsna.org)]
|-
|[[solid pseudopapillary tumour|Solid pseudopapillary<br> tumour]]
|female
|35
|any
|7.5
|[http://www.ajronline.org/content/195/4/947/F4.expansion.html (ajronline.org)], [http://www.flickr.com/photos/35441329@N05/5249538296/ (flickr.com/humpath)]
|}


==Cystic tumours==
=Cystic lesions=
General
==Serous tumours - overview==
*50% incidental finding.
===General===
*Vague Sx.
*Cell of origin: intralobular duct cells (ductular cells).
*Abdo mass.
*Glycogen rich - but do not produce mucin.
*Wt loss.
*Jaundice.


Note:
====Subclassication====
*Usually diagnosed by imaging (CT/MRI, ERCP, Endoscopic ultrasound).
*[[Serous microcystic adenoma]] ([[AKA]] serous cystadenoma<ref name=Ref_Sternberg4_1630>{{Ref Sternberg4|1630}}</ref>).
 
==Serous cystic tumours==
General
*Arise: intralobular duct cells (ductular cells).
*Glycogen rich -- but do not produce mucin.
 
===Subclassication===
*Serous microcystic adenoma.
** Many small cysts.
** Many small cysts.
*Serous oligocystic adenoma.
*Serous oligocystic adenoma.
** Large cysts.
** Large cysts.
*Serous adenocarcinoma - rare.<ref>Khalifa has never seen it.</ref>
*Serous cystadenocarcinoma - very rare.<ref name=pmid22009426>{{Cite journal  | last1 = Bano | first1 = S. | last2 = Upreti | first2 = L. | last3 = Puri | first3 = SK. | last4 = Chaudhary | first4 = V. | last5 = Sakuja | first5 = P. | title = Imaging of pancreatic serous cystadenocarcinoma. | journal = Jpn J Radiol | volume = 29 | issue = 10 | pages = 730-4 | month = Dec | year = 2011 | doi = 10.1007/s11604-011-0617-3 | PMID = 22009426 }}</ref>


Note:  
Note:  
*If one mucin +ve cell, tumour = a mucinous tumour
*If one mucin +ve cell, tumour = a mucinous tumour.
 
===Characteristics of serous microcystic adenoma===
*1-2% of all exocrine pancratic tumours.
*Female>Male.
*Mean age 66 years.
*Truly benign with no malignant potenial.
*May not require surgical resection.
*May be part of von Hippel-Lindau.
*50-70% occur in the body and tail.
*Average size 11 cm.


Imaging
==Serous cystadenoma of the pancreas==
*Honey comb appearance.
*[[AKA]] ''serous microcystic adenoma'',<ref name=Ref_Sternberg4_1630>{{Ref Sternberg4|1630}}</ref> [[AKA]] ''pancreatic serous cystadenoma''.
*"Coin lesion" - well demarcated border.
{{Main|Serous cystadenoma of the pancreas}}
*May have central scar.


Gross
==Mucinous cystic neoplasms of the pancreas==
*Bosulated surface.
**Lobulated.
*No (macroscopic) cysts apparent on gross.
 
Micro
*Cuboidal cells.
**Glycogen rich.
 
DDx
*Renal cell carcinoma.
*Lympangioma.
*Hemangiomas.
*Oligocystic - mucinous cystic tumors and pseudocysts.
**Have mucinous -- PAS-D could be used.
*Serous adenoma my coexist with aggressive tumours.
 
==Mucinous cystic tumours==
*Gastro-entero-pancreatic cell differentiation with hypercellular ovarian-type stroma.
*Gastro-entero-pancreatic cell differentiation with hypercellular ovarian-type stroma.
**Stroma --> cellular.
**Stroma --> cellular.
Line 116: Line 386:


Note:
Note:
*Looks diff. than serous tumour.
*Looks different than serous tumour.


===Classification===
===Subclassification===
*Sucinous cystadenoma.
*Mucinous cystadenoma.
*Borderline mucinous cystic tumour.
*Borderline mucinous cystic tumour.
*Mucinous cystadenocarcinoma.
*Mucinous cystadenocarcinoma.
Line 126: Line 396:
*Few mitoses in borderline.
*Few mitoses in borderline.


Imaging
===Radiology===
*Mucinous tumours: multilocular.
*Mucinous tumours: multilocular.
*Generally larger than serous.
*Generally larger than serous.
Line 134: Line 404:
*Usually tail & body.
*Usually tail & body.


===Micro===
===Microscopic===
====Mucinous cystadenoma====
====Mucinous cystadenoma====
**Like mucinous cystadenoma in the ovary.
Features:<ref name=Ref_GLP489>{{Ref GLP|489}}</ref>
**Single cell.
*Simple tall columnar epithelium with large mucin vacuole on apical aspect.
**Tall columnar epithelium.
*"Ovarian-type stroma" under epithelium.
**Mucin +ve (intracytoplasmic).
**Ovarin-type stroma: high density of small (non-wavy) spindle cells with eosinophilic cytoplasm.
 
Notes:
*Appearance similar to ''mucinous cystadenoma'' in the [[ovarian tumours|ovary]].
*Mucin stains +ve (intracytoplasmic).
 
=====Images=====
<gallery>
Image:Benign_pancreatic_mucinous_cystic_neoplasm_-_very_low_mag.jpg | Benign mucinous cystic neoplasm - very low mag. (WC)
Image:Benign_pancreatic_mucinous_cystic_neoplasm_-_low_mag.jpg | Benign mucinous cystic neoplasm - low mag.(WC)
Image:Benign_pancreatic_mucinous_cystic_neoplasm_-_intermed_mag.jpg | Benign mucinous cystic neoplasm - intermed. mag. (WC)
Image:Benign_pancreatic_mucinous_cystic_neoplasm_-_high_mag.jpg | Benign mucinous cystic neoplasm - showing stroma - high mag. (WC)
</gallery>
www:
*[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====
Features:
*May have finger like projections.
*May have finger like projections.
*Pseudostratification.
*Pseudostratification of epithelium.


Note 1:
Notes:
* Surgery does not change based on diagnosis on frozen section.
* Surgery does not change based on diagnosis on frozen section.
* Only question is "Is the margin clear?".
** Only question is "Is the margin clear?".
 
Note 2:
* Borderline tumours are rare.
* Borderline tumours are rare.


Line 155: Line 446:
*Cells floating in mucin.
*Cells floating in mucin.


====Mucinous tumour vs. pseudocyst====
====Mucinous tumour versus pseudocyst====
mucinous t pseudocyst
{| class="wikitable sortable"
amylase & lipase low high
! Finding
viscosity high low
! Mucinous tumour
CEA, CA124 high low
! Pseudocyst
|-
|Amylase & lipase || low || high
|-
|Viscosity || high || low
|-
|[[CEA]], CA125 || high || low      
|}


Prognosis:
Prognosis:
Line 167: Line 465:
*Prognosis of m. cystadenocarcinoma is slightly better than that of ductal adenocarcinoma.
*Prognosis of m. cystadenocarcinoma is slightly better than that of ductal adenocarcinoma.


==IPMT==
==Intraductal papillary mucinous tumour==
Intraductal papillary mucinous tumour (IPMT)
*Abbreviated ''IPMT''.
*Papillomatous growth pattern.
*[[AKA]] ''intraductal papillary mucinous neoplasm'', abbreviated ''IPMN''.
*Morphologically and biologically distinct from ductal adenocarcinoma, mucinous cystic tumour and ductal papillary hyperplasia.
{{Main|Intraductal papillary mucinous tumour}}
*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
 
Khalifa's theory:
*Nothing but dilation of pancreatic duct + hypersecretion.
 
Gross
*May be patchy/multifocal.
 
===Sequence===
*Hyperplasia.
*Adenomatous hyperplasia.
*Carcinoma in situ.
*Invasive carcinoma.
 
K-ras oncogene muation associated - seen in all stages of the sequence.
 
Characteristics
*Cell enlargement.
*Incr. NC ratio.
*Nuclear crowding and pleomorphism.
*Papillary tufting.
*Mitotic activity.
*Increased mucin production.
 
===classification IMPT===
*Adenoma.
*Borderline mucinous tumour.
*Carcinoma.
 
 
NB1
*No ovarian like stroma.
*In duct.
 
NB2
*Usually not jaundiced... as no obstruction.
*Often diabetes... as pancreas is destroyed.
 
Gross
*Multiple cystic spaces.
 
Micro
*Some places -- fronds of benign looking mucin producing epithelium.
*No ovarian type stroma underneath.
 
NB
*If no viable cells in the mucin then not cancer.
**Mucin under pressure can disect through the tissue.
*Borderline tumours are rare.
 
Pitfalls
*Since it is multifocal may involve large segment of the ductal system.
**Patients often get a total pancreatectomy.
**If intralobular dilated ducts... carcinoma.
*Hard to get a negative margin.
 
Prognosis: favourable.
 
NB - any margin with mucin cells -- badness!!!
*Dilated = mucin producing ducts (???).
**DDx: PAN-IN1.
***Needs a totally pancreatectomy.


==Solid pseudopapillary tumour==
==Solid pseudopapillary tumour==
===General===
*[[AKA]] ''solid pseudopapillary neoplasm'', abbreviation ''SPN''.
*Obscure cell of origin.
*[[AKA]] ''solid and papillary epithelial neoplasm'', abbreviated ''SPEN''.<ref>URL: [http://brighamrad.harvard.edu/Cases/bwh/hcache/360/full.html http://brighamrad.harvard.edu/Cases/bwh/hcache/360/full.html]. Accessed on: 31 October 2011.</ref>
*Considered low grade, i.e. prognosis is usually good.
{{Main|Solid pseudopapillary tumour}}


===Epidemiology===
=Pre-malignant lesions=
Features:<ref>GLP P.493.</ref>
==Pancreatic intraepithelial neoplasia==
*Usually females (M:F=1:9).
*Abbreviated ''PanIN''.
*Mean age of presentation third decade (20s).
{{Main|Pancreatic intraepithelial neoplasia}}


===Management===
=Solid tumours=
May be followed radiologically.
==Invasive ductal carcinoma of the pancreas==
*[[AKA]] ''ductal adenocarcinoma''.
*[[AKA]] ''pancreatic ductal adenocarcinoma''.
*[[AKA]] ''pancreatic adenocarcinoma''.
{{Main|Invasive ductal carcinoma of the pancreas}}


===Microscopic===
==Pancreatic neuroendocrine tumour==
Features:<ref>GLP P.493-5.</ref>
*Abbreviated ''PanNET''.<ref name=pmid22198808/>
*Solid sheets of cells, focally dyscohesive.
*[[AKA]] ''pancreatic islet cell tumour''<ref name=pmid22198808>{{Cite journal | last1 = Burns | first1 = WR. | last2 = Edil | first2 = BH. | title = Neuroendocrine Pancreatic Tumors: Guidelines for Management and Update. | journal = Curr Treat Options Oncol | volume = | issue = | pages = | month = Dec | year = 2011 | doi = 10.1007/s11864-011-0172-2 | PMID = 22198808 }}</ref> - considered to be an outdated term.
*Eosinophilic cytoplasm.
*[[AKA]] ''islet cell tumour'' - considered to be an outdated term.
**Occasionally clear cytoplasm.<ref name=pmid18708424>{{cite journal |author=Serra S, Chetty R |title=Revision 2: an immunohistochemical approach and evaluation of solid pseudopapillary tumour of the pancreas |journal=J. Clin. Pathol. |volume=61 |issue=11 |pages=1153–9 |year=2008 |month=November |pmid=18708424 |doi=10.1136/jcp.2008.057828 |url=http://jcp.bmj.com/content/61/11/1153}}</ref>
{{Main|Neuroendocrine tumour of the pancreas}}
**Focal eosinophilic (intracytoplasmic) globules - '''key feature'''.
*Uniform nuclei with occasional nuclear grooves.
*+/-Necrosis - creating spaces/cavities.


Image: [http://jcp.bmj.com/content/61/11/1153/F1.large.jpg Solid pseudopapillary tumour (bmj.com)].
==Acinar cell carcinoma of the pancreas==
:'''Not''' to be confused with ''[[acinic cell carcinoma]]''.
*[[AKA]] ''acinar cell carcinoma''.
*[[AKA]] ''pancreatic acinar cell carcinoma''.<ref name=pmid>{{Cite journal  | last1 = Thomas | first1 = PC. | last2 = Nash | first2 = GF. | last3 = Aldridge | first3 = MC. | title = Pancreatic acinar cell carcinoma presenting as acute pancreatitis. | journal = HPB (Oxford) | volume = 5 | issue = 2 | pages = 111-3 | month =  | year = 2003 | doi = 10.1080/13651820310001153 | PMID = 18332967 }}</ref>
{{Main|Acinar cell carcinoma of the pancreas}}


===DDx===
==Pancreatoblastoma==
*Pseudocyst.
{{Main|Pancreatoblastoma}}
*Cystadenoma.
*Cystadenocarcinoma.


==Carcinomas==
=See also=
*Usually head of pancreas.
*[[Duodenum]].
*[[Gallbladder]].
*[[Gastrointestinal pathology]].
*[[Von Hippel-Lindau syndrome]].
*[[IgG4-related systemic disease]].


DDx:
=References=
*Mucinous tumour (may be misdiagnosed as this).
{{reflist|2}}
*Serous tumour (microcystic).


===Gross===
==Further reading==
*Necrosis.
{{Cite journal  | last1 = Klimstra | first1 = DS. | last2 = Pitman | first2 = MB. | last3 = Hruban | first3 = RH. | title = An algorithmic approach to the diagnosis of pancreatic neoplasms. | journal = Arch Pathol Lab Med | volume = 133 | issue = 3 | pages = 454-64 | month = Mar | year = 2009 | doi = 10.1043/1543-2165-133.3.454 | PMID = 19260750 }}
*Capsule.
*Hemorrhage.
 
===Microscopic===
Features:
*Solid.
*Necrosis.
**Myxoid degeneration.
*Cells around vessels.
*Nuclei.
**Bland.
**Small nuclei.
**Little pleomorphism.
**Sometimes coffee-bean appearance.
*Cytoplasm - granular, abundant.
*Quasi endocrine look.
**May stain positive for endocrine markers.
 
==Cystic tumours==
*Diagnosed by imaging/with help of images.
 
===Stains===
*PAS-D
 
Prognosis: very favourable (mostly benign).
 
==Cystic tumours of the pancreas==
{| class="wikitable"
|
|Sex
|Age (years)
|Usual site
|Typical size (cm)
|-
|Microcystic
|female
|66
|B&T
|11
|-
|Mucinous
|female
|49
|B&T
|10
|-
|IPMT
|male
|62
|H
|4
|-
|Pseudopapillary
|female
|35
|any
|7.5
|}
 
==References==
{{reflist|2}}


==External links==
=External links=
*[http://pancreaticcancer2000.com/page1.htm Pancreatic cancer - PanINs - pancreaticcancer2000.com].
*[http://pancreaticcancer2000.com/page1.htm Pancreatic cancer - PanINs - pancreaticcancer2000.com].


[[Category:Gastrointestinal pathology]]
[[Category:Gastrointestinal pathology]]
Michael
48,466

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