Difference between revisions of "Pancreas"

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Pancreas (view source)

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A general introduction to GI pathology is in the ''[[GI pathology]]'' article.
A general introduction to GI pathology is in the ''[[GI pathology]]'' article.


=Introduction=
==Normal anatomy==
==Normal anatomy==
Divided into three portions: head, body & tail:
Divided into three portions: head, body & tail:
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*See ''[[soft tissue lesions]]''.
*See ''[[soft tissue lesions]]''.


==Cystic lesions of the pancreas==
=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==
*[[AKA]] pancreatic metaplasia.
 
===General===
*Common in the GI tract.
*Found in ~ 20% of [[eosphageal]] biopsies above the GEJ.<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>
 
===Microscopic===
Features:
*Pancreatic acini - only.
**Intensely eosinophilic cytoplasm.
 
Negatives:
*No pancreatic ducts.
*No islets of Langerhans (pancreatic islets).
 
Images:
*[http://commons.wikimedia.org/w/index.php?title=File:Pancreatic_acinar_metaplasia_-_high_mag.jpg PAM - high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Pancreatic_acinar_metaplasia_-_low_mag.jpg PAM - low mag. (WC)].
 
==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, NSAIDS, diuretics, such as furosemide.
 
==Acute pancreatitis==
===General===
*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==
===General===
*May be confused with ductal adenocarcinoma radiologically... and pathologically.
 
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.
 
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 and vascular invasion (rare).
**Mitosis.
**Necrotic cellular debris (intraluminal).
 
Notes:
*Memory device give 'em '''''fair'''''' chance at a benign Dx:
**Fat, adjacent to.
**Arteriole, adjacent to.
**Irregular ducts.
**Random distribution of ducts/non-lobular arrangement.
 
=Cystic lesions - overview=
===General===
===General===
*True cystic lesions are uncommon.
*True cystic lesions are uncommon.
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|}
|}


=Cystic lesions=
==Serous cystic tumours==
==Serous cystic tumours==
===General===
===General===
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Memory device ''PCB'': '''P'''R (nuclear), '''C'''D10 (cytoplasmic), '''b'''eta-catenin (cytoplasmic & nuclear).
Memory device ''PCB'': '''P'''R (nuclear), '''C'''D10 (cytoplasmic), '''b'''eta-catenin (cytoplasmic & nuclear).


=Pre-malignant lesions=
==Pancreatic intraepithelial neoplasia==
==Pancreatic intraepithelial neoplasia==


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Image: [http://commons.wikimedia.org/wiki/File:Pancreas_neoplasia_carcinoma_sequence.png Normal pancreas, pancreatic intraepithelial neoplasia and pancreatic carcinoma (WC)].
Image: [http://commons.wikimedia.org/wiki/File:Pancreas_neoplasia_carcinoma_sequence.png Normal pancreas, pancreatic intraepithelial neoplasia and pancreatic carcinoma (WC)].


=Solid tumours=
==Invasive ductal carcinoma of the pancreas==
==Invasive ductal carcinoma of the pancreas==
*[[AKA]] ''ductal adenocarcinoma''.
*[[AKA]] ''ductal adenocarcinoma''.
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*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>
*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>
*[[Cholangiocarcinoma]].
*[[Cholangiocarcinoma]].
==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, NSAIDS, diuretics, such as furosemide.
==Acute pancreatitis==
===General===
*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==
===General===
*May be confused with ductal adenocarcinoma radiologically... and pathologically.
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.
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 and vascular invasion (rare).
**Mitosis.
**Necrotic cellular debris (intraluminal).
Notes:
*Memory device give 'em '''''fair'''''' chance at a benign Dx:
**Fat, adjacent to.
**Arteriole, adjacent to.
**Irregular ducts.
**Random distribution of ducts/non-lobular arrangement.
==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==
*[[AKA]] pancreatic metaplasia.
===General===
*Common in the GI tract.
*Found in ~ 20% of [[eosphageal]] biopsies above the GEJ.<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>
===Microscopic===
Features:
*Pancreatic acini - only.
**Intensely eosinophilic cytoplasm.
Negatives:
*No pancreatic ducts.
*No islets of Langerhans (pancreatic islets).
Images:
*[http://commons.wikimedia.org/w/index.php?title=File:Pancreatic_acinar_metaplasia_-_high_mag.jpg PAM - high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Pancreatic_acinar_metaplasia_-_low_mag.jpg PAM - low mag. (WC)].
==Pancreatic ectopia==
===General===
*May be confused with something pathologic.
===Microscopic===
Features:
*Consists of pancreatic acini ''and'' pancreatic ducts.
*+/-Islets of Langerhans.


==Pancreatic neuroendocrine tumour==
==Pancreatic neuroendocrine tumour==
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*[http://path.upmc.edu/cases/case339.html Pancreatic NET with features of SPT (upmc.edu)].
*[http://path.upmc.edu/cases/case339.html Pancreatic NET with features of SPT (upmc.edu)].


==See also==
=See also=
*[[Duodenum]].
*[[Duodenum]].
*[[Gallbladder]].
*[[Gallbladder]].
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*[[Von Hippel-Lindau syndrome]].
*[[Von Hippel-Lindau syndrome]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


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{{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 }}
{{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 }}


==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
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