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Pancreas (view source)

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


A general introduction to GI pathology is in the ''[[GI pathology]]'' article.
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.
Line 15: Line 21:
==Pancreatic surgeries==
==Pancreatic surgeries==
Common pancreatic surgeries include:
Common pancreatic surgeries include:
*Whipple (includes duodenum).
*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 a [[spleen]].
**Specimen usually comes with the [[spleen]].
**Typically done form [[islet cell tumour]]s.
*Total pancreatectomy.
*Total pancreatectomy.
**Specimen usually comes with a spleen.
**Specimen usually comes with the spleen.
 
===Whipple procedure===
*[[AKA]] ''pancreaticoduodenectomy''.
 
Indications:
*Head of pancreas lesions, duodenal lesions.


===Whipple===
[[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>
Margins:
#Proximal mucosal margin (stomach or duodenum).
*Common bile duct (CBD).
#Distal mucosal margin (duodenum or jejunum).
*Uncinate process.
#Bile duct margin.
**At SB done ''on edge'' (not ''en face'').
#Pancreatic retroperitoneal (uncinate process) margin.
*Pancreatic neck transection 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>
#*At SB done ''on edge'' (not ''en face'').
*Sometimes superior mesenteric vein (SMV).
#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>
*Rarely SMA margin.
#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 40: Line 60:


===Pancreas neoplasms in a table===
===Pancreas neoplasms in a table===
{| class="wikitable"
{| class="wikitable sortable"
!| Type
!| Type
!| Key feature  
!| Key feature  
Line 54: Line 74:
| cuboidal cells, clear cytoplasm
| cuboidal cells, clear cytoplasm
| cystadenoma, borderline t., cystadenocarcinoma
| 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], [http://commons.wikimedia.org/wiki/File:Pancreatic_serous_cystadenoma_-_intermed_mag.jpg]
| [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?
| IHC?
| cuboidal cells, clear cytoplasm, central nucleus
| cuboidal cells, clear cytoplasm, central nucleus
| body or tail
| body or tail
| cystadenoma may be assoc. with [[von Hippel-Lindau syndrome]]
| cystadenoma may be assoc. with [[von Hippel-Lindau syndrome]]
| clear cell RCC, oligomucinous mucinous tumours
| [[clear cell renal cell carcinoma|clear cell RCC]], oligomucinous mucinous tumours
|-
|-
| Intraductal papillary<br>mucinous tumour (IPMT)
| [[Intraductal papillary mucinous tumour]] (IPMT)
| mucin, no ovarian-like stroma  
| mucin, no ovarian-like stroma  
| clear cell variant
| clear cell variant
| [http://wjso.com/content/8/1/25/figure/F1]
| [http://wjso.com/content/8/1/25/figure/F1 (wjso.com)], [http://path.upmc.edu/cases/case451/images/fig01.jpg (upmc.edu)]
| IHC?
| IHC?
| papillae, tall columnar mucin-producing cells
| papillae, tall columnar mucin-producing cells
| head
| head
| -
| -
| mucious neoplasms (other pancreatic, duodenal)
| mucious neoplasms (other pancreatic, duodenal), intra-ampullary papillary-tubular neoplasm (see [[ampullary carcinoma]])
|-
|-
| Mucinous tumour
| Mucinous tumour
| mucin, ovarian-like stroma  
| mucin, ovarian-like stroma  
| cystadenoma, borderline t., cystadenocarcinoma
| cystadenoma, borderline t., cystadenocarcinoma
| Image?
| [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?
| IHC?
| tall columnar mucin-producing cells, ovarian-like stroma
| tall columnar mucin-producing cells, ovarian-like stroma
| body or tail
| body or tail
| -
| -
| IPMT, metastatic mucinous tumours
| [[IPMT]], metastatic mucinous tumours
|-
|-
| Solid pseudopapillary<br>tumour
| [[Solid pseudopapillary tumour|Solid pseudopapillary<br>tumour]]
| eosinophilic intracytoplasmic globules  
| eosinophilic intracytoplasmic globules  
| clear cell variant (cytoplasm clear)
| clear cell variant (cytoplasm clear)
| [http://jcp.bmj.com/content/61/11/1153/F1.large.jpg]
| [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)]
| IHC
| beta-catenin +ve, E-cadherin +ve, <br>synaptophysin +ve, chromogranin -ve
| sheets of cells, focally loosely cohesive, eosinophilic cytoplasm, uniform nuclei with grooves
| sheets of cells, focally loosely cohesive, eosinophilic cytoplasm, uniform nuclei with grooves
| none
| none (head, body or tail)
| -
| usu. younger women
| ductal adenocarcinoma
| [[pancreatic ductal adenocarcinoma|ductal adenocarcinoma]], [[neuroendocrine tumour]]s
|-
|-
| Ductal adenocarcinoma
| [[Invasive ductal carcinoma of the pancreas|Ductal adenocarcinoma]]
| irregular shaped glands, cytologic atypia
| irregular shaped glands, cytologic atypia
| mucinous, spindle cell, mixed ductal-endocrine  
| mucinous, spindle cell, mixed ductal-endocrine  
| [http://commons.wikimedia.org/wiki/File:Pancreas_adenocarcinoma_%284%29_Case_01.jpg], [http://commons.wikimedia.org/wiki/File:Pancreas_adenocarcinoma_%282%29_Case_01.jpg]
| [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?
| IHC?
| glands, sheets, single cells, nuc. atypia, +/-mitoses, +/-necrosis
| glands, sheets, single cells, nuc. atypia, +/-mitoses, +/-[[necrosis]]
| head
| head
| arises from the precursor ''PanIN''
| arises from the precursor ''PanIN''
| ampullary carcinoma, chronic pancreatitis
| ampullary carcinoma, [[chronic pancreatitis]]
|-
|-
| Pancreatoblastoma
| [[Pancreatoblastoma]]
| squamoid nests, whorling
| squamoid nests, whorling
| -
| -
| Image?
| [http://www.nature.com/modpathol/journal/v20/n1s/fig_tab/3800686f16.html#figure-title (nature.com)]
| IHC?
| [[CK7]] (acinar comp.), CK8, CK18, [[CK19]]
| squamoid nests of cells, whorling, nested growth, +/-keratinization
| squamoid nests of cells, whorling, nested growth, +/-keratinization
| none
| none
| usu. paediatric population
| usu. paediatric population
| acinar cell carcinoma
| [[acinar cell carcinoma of the pancreas|acinar cell carcinoma]]
|-
|-
| Acinar cell carcinoma
| [[Acinar cell carcinoma of the pancreas|Acinar cell carcinoma]]
| acinar arch.
| acinar arch.
| -
| -
| [http://www.histopathology-india.net/acinar%20cell%20ca.JPG]
| [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)]
| IHC?
| trypsin, lipase
| nests or trabeculae, nucleolus, mod. basophilic granular cytoplasm
| nests or [[trabeculae]], nucleolus, mod. basophilic granular cytoplasm
| head (slight predilection)
| head (slight predilection)
| -
| -
| pancreatoblastoma
| pancreatoblastoma
|-
|-
| Undifferentiated carcinoma with osteoclast-like giant cells
| Undifferentiated carcinoma with osteoclast-like [[giant cell]]s
| giant cells
| giant cells
| -
| -
Line 131: Line 151:
| anaplastic carcinoma
| anaplastic carcinoma
|-
|-
| Chronic pancreatitis
| [[Chronic pancreatitis]]
| fibrosis, loss of acinar tissue, preservation of lobular arch.  
| fibrosis, loss of acinar tissue, preservation of lobular arch.  
| -
| -
Line 139: Line 159:
| ?
| ?
| not a neoplasm, included here as it is in the (clinical) DDx
| not a neoplasm, included here as it is in the (clinical) DDx
| ductal adenocarcinoma
| [[pancreatic ductal adenocarcinoma|ductal adenocarcinoma]]
|}
|}


==Cystic lesions of the pancreas==
===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===
===General===
*True cystic lesions are uncommon.
*True cystic lesions are uncommon.
**A true cystic lesion: ''must'' have an epithelial lining.
**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.
***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.
*It is hard to differentiate pseudocysts & cysts.


Line 179: Line 319:
===Cystic tumours of the pancreas===
===Cystic tumours of the pancreas===
Khalifa's table of cystic tumours:
Khalifa's table of cystic tumours:
{| class="wikitable"
{| class="wikitable sortable"
|
!Tumour
|Usual sex
!Usual sex
|Age (years)
!Age (years)
|Usual site
!Usual site
|Typical <br>size (cm)
!Typical <br>size (cm)
![[Gross pathology]]
|-
|-
|Serous microcystic<br> adenoma
|[[serous microcystic adenoma|Serous microcystic<br> adenoma]]
|female
|female
|66
|66
|body & tail
|body & tail
|11
|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>
|-
|-
|Intraductal papillary<br>mucinous tumour (IPMT)
|[[IPMN|Intraductal papillary<br>mucinous tumour (IPMT)]]
|male
|male
|62
|62
|head
|head
|4
|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
|Mucinous tumour
Line 203: Line 346:
|body & tail
|body & tail
|10
|10
|[http://radiology.rsna.org/content/251/1/77/F8.expansion.html (rsna.org)]
|-
|-
|Solid pseudopapillary<br> tumour
|[[solid pseudopapillary tumour|Solid pseudopapillary<br> tumour]]
|female
|female
|35
|35
|any
|any
|7.5
|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)]
|}
|}


==Serous cystic tumours==
=Cystic lesions=
==Serous tumours - overview==
===General===
===General===
*Cell of origin: intralobular duct cells (ductular cells).
*Cell of origin: intralobular duct cells (ductular cells).
*Glycogen rich - but do not produce mucin.
*Glycogen rich - but do not produce mucin.


===Subclassication===
====Subclassication====
*Serous microcystic adenoma ([[AKA]] serous cystadenoma<ref name=Ref_Sternberg4_1630>{{Ref Sternberg4|1630}}</ref>).
*[[Serous microcystic adenoma]] ([[AKA]] serous cystadenoma<ref name=Ref_Sternberg4_1630>{{Ref Sternberg4|1630}}</ref>).
** Many small cysts.
** Many small cysts.
*Serous oligocystic adenoma.
*Serous oligocystic adenoma.
** Large cysts.
** Large cysts.
*Serous adenocarcinoma - very rare.<ref name=Ref_Sternberg4_1630>{{Ref Sternberg4|1630}}</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===
==Serous cystadenoma of the pancreas==
*1-2% of all exocrine pancratic tumours.
*[[AKA]] ''serous microcystic adenoma'',<ref name=Ref_Sternberg4_1630>{{Ref Sternberg4|1630}}</ref> [[AKA]] ''pancreatic serous cystadenoma''.
*Female > male.
{{Main|Serous cystadenoma of the pancreas}}
*Mean age 66 years.
*Truly benign with no malignant potenial.
*May not require surgical resection.
*May be part of [[von Hippel-Lindau syndrome]].
*50-70% occur in the body and tail.
*Average size 11 cm.


===Radiology===
==Mucinous cystic neoplasms of the pancreas==
*Honey comb appearance.
*"Coin lesion" - well demarcated border.
*May have central scar.
 
===Gross===
*Bosulated surface.
**Lobulated.
*No (macroscopic) cysts apparent on gross.
 
===Microscopic===
Features:
*Cuboidal cells.
**Glycogen rich.
**Cilia. (???)
 
Images:
*[http://commons.wikimedia.org/wiki/File:Pancreatic_serous_cystadenoma_-_intermed_mag.jpg PSC - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Pancreatic_serous_cystadenoma_-_very_high_mag.jpg PSC - very high mag. (WC)].
 
===DDx===
*Renal cell carcinoma.
*Lympangioma.
*Hemangiomas.
*Oligocystic mucinous cystic tumors and pseudocysts.
**Have mucin; PAS-D could be used to demonstrate its presence.
 
Notes:
*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 300: Line 410:
*"Ovarian-type stroma" under epithelium.
*"Ovarian-type stroma" under epithelium.
**Ovarin-type stroma: high density of small (non-wavy) spindle cells with eosinophilic cytoplasm.
**Ovarin-type stroma: high density of small (non-wavy) spindle cells with eosinophilic cytoplasm.
Image: [http://radiology.uchc.edu/eAtlas/Images/GYN/5705b.gif Mucinous cystadenoma - ovary (uchc.edu)].


Notes:  
Notes:  
*Appearance similar to ''mucinous cystadenoma'' in the [[ovarian tumours|ovary]].
*Appearance similar to ''mucinous cystadenoma'' in the [[ovarian tumours|ovary]].
*Mucin stains +ve (intracytoplasmic).
*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====
Line 320: Line 446:
*Cells floating in mucin.
*Cells floating in mucin.


====Mucinous tumour vs. pseudocyst====
====Mucinous tumour versus pseudocyst====
{| class="wikitable"
{| class="wikitable sortable"
| || '''Mucinous tumour'''|| '''Pseudocyst'''
! Finding
! Mucinous tumour  
! Pseudocyst
|-
|-
|Amylase & lipase || low || high
|Amylase & lipase || low || high
Line 328: Line 456:
|Viscosity || high || low
|Viscosity || high || low
|-
|-
|CEA, CA125 || high || low         <!-- CA124??? was changed to CA125 -->
|[[CEA]], CA125 || high || low      
|}
|}


Line 338: Line 466:


==Intraductal papillary mucinous tumour==
==Intraductal papillary mucinous tumour==
===General===
*Abbreviated ''IPMT''.
*Often abbreviated ''IPMT''.
*[[AKA]] ''intraductal papillary mucinous neoplasm'', abbreviated ''IPMN''.
*Papillomatous growth pattern.
{{Main|Intraductal papillary mucinous tumour}}
*Morphologically and biologically distinct from ductal adenocarcinoma, mucinous cystic tumour and ductal papillary hyperplasia.
*Prognosis: favourable, if caught earlier; not much different than ductal adenocarcinoma if caught later.<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>
 
Another paper: <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>
===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.
 
Khalifa's theory:
*Nothing but dilation of pancreatic duct + hypersecretion.
 
===Gross===
*May be patchy/multifocal.
 
===Microscopic===
Features
*Cell enlargement.
*Incr. NC ratio.
*Nuclear crowding and pleomorphism.
*Papillary tufting.
*Mitotic activity.
*Increased mucin production.
 
===Classification IMPT===
*Adenoma.
*Borderline mucinous tumour.
*Carcinoma.
 
Notes:
*No ovarian like stroma.
*Tumour in duct.
*Patient usually not jaundiced... as no obstruction.
*Often diabetes... as pancreas is destroyed.
 
===Gross===
*Multiple cystic spaces.
 
===Microscopic===
Features:
*Some places -- fronds of benign looking mucin producing epithelium.
*No ovarian type stroma underneath.
 
Notes:
*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.
 
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 name=Ref_GLP493>{{Ref GLP|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>{{Ref GLP|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.


==Pancreatic intraepithelial neoplasia (PanIN)==
=See also=
*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. 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''.
 
===Histomorphology===
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.
 
Image: [http://commons.wikimedia.org/wiki/File:Pancreas_neoplasia_carcinoma_sequence.png Normal pancreas, pancreatic intraepithelial neoplasia and pancreatic carcinoma (WC)].
 
==Ductual adenoarcinomas==
===General===
*Usually in the head ~60%.
**15% in the body, 5% tail, 20% diffuse (head, body & tail).<ref name=Ref_PBoD950>{{Ref PBoD|950}}</ref>
*Abysmal prognosis.
 
===Microscopic===
Features:<ref name=Ref_PBoD951>{{Ref PBoD|951}}</ref>
*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.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Pancreas_adenocarcinoma_(3)_Case_01.jpg Pancreatic adenocarcinoma (WC)].
*[http://commons.wikimedia.org/wiki/File:Pancreas_adenocarcinoma_(2)_Case_01.jpg Pancreatic adenocarcinoma (WC)].
*[http://commons.wikimedia.org/wiki/File:Pancreas_neoplasia_carcinoma_sequence.png Normal pancreas, pancreatic intraepithelial neoplasia and pancreatic carcinoma (WC)].
 
DDx:
*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>
 
==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, [[Forensic pathology#Hypothermia|hypothermia]].
*Emboli, e.g. post-CABG.
*Drugs - ''SAND'' = steroids & sulfonamides, azathioprine, NSAIDS, diuretics, such as furosemide.
 
==Chronic pancreatitis==
===General===
*May be confused with ductal adenocarcinoma radiologically... and pathologically.
 
===Microscopic===
Features of benign:<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.
*Intraluminal mucoprotein plugs.
 
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).
 
==See also==
*[[Duodenum]].
*[[Duodenum]].
*[[Gallbladder]].
*[[Gallbladder]].
*[[Gastrointestinal pathology]].
*[[Gastrointestinal pathology]].
*[[Von Hippel-Lindau syndrome]].
*[[Von Hippel-Lindau syndrome]].
*[[IgG4-related systemic disease]].


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


==External links==
==Further reading==
{{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=
*[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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