User Name Password Sign In. Imaging and Pathology of Pancreatic Neoplasms. A Pictorial Atlas. Edited by M. D'Onofrio , P. Major criteria for malignancy include: 1 nuclear size variation anisonucleosis greater than 4-to-1 between ductal epithelial cells; 2 incomplete ductal lumens: nests of cells, ducts with gaps, or cribriformed glands; and 3 disorganized duct distribution.
Minor criteria include: 1 huge, irregular nucleoli; 2 necrotic glandular debris; 3 glandular mitotic figures; 4 glands unaccompanied by connective tissue stroma within smooth muscle bundles in periampullary biopsies; and 5 perineural invasion. Hyperchromasia was not found to be a useful characteristic due to frozen section artifact. Additional useful findings for malignancy were single-cell infiltration and disorganized desmoplastic stroma. There are many pitfalls in the frozen section diagnosis of pancreatic lesions. In chronic pancreatitis, the ducts occasionally have a slightly irregular distribution.
However, necrotic glandular debris and mitotic figures are not typical, and most importantly the duct distribution should maintain some lobular organization. Additionally, islet cell hyperplasia is frequent and isolated larger islet cells may demonstrate a greater than 4-to-1 nuclear size variation. Knowledge of this variant, with its typical pale cytoplasm and frequently prominent apical brush border and careful attention to the above described diagnostic features of ductal adenocarcinoma should ensure correct diagnosis.
The differential features of CP and ductal adenocarcinoma at frozen section are depicted in Image 1. Frequently, the frozen section diagnosis of small liver lesions in the setting of a pancreatic head mass is the most important determinant of the surgical procedure. If ductal adenocarcinoma is found outside of the typical resection zone, pancreaticoduodenectomy is deferred and a palliative bypass procedure may be performed.
Bile duct adenomas represent an often-encountered mimic of metastatic pancreatic adenocarcinoma. These liver lesions commonly occur in a subcapsular location readily identified intraoperatively and may be multiple. Although cellular glandular lesions, they should not show significant cytologic atypia or mitotic activity.
This lesion may be confused with a bile duct adenoma if cytologically bland or an adenocarcinoma if more atypical. In difficult cases, without a preoperative tissue diagnosis, sampling of the tumor in the pancreas for comparison may be helpful. The distinction is important, as the surgeon may proceed with pancreatic resection in the face of metastatic pancreatic endocrine tumor. Frozen section diagnosis of chronic pancreatitis versus ductal adenocarcinoma. C At higher power, chronic pancreatitis reveals limited nuclear size variation.
There is slight nuclear irregularity and nucleoli are inconspicuous. Attributable, at least in part, to increased utilization of diagnostic abdominal imaging, pancreatic cystic lesions are increasingly encountered in clinical practice. Their differential diagnosis consists of an array of neoplastic and non-neoplastic entities with varying biologic potentials.
Nonoperative diagnosis may be possible in some instances, with careful attention to some combination of clinical, radiologic, laboratory, and cytologic features. Resection remains the mainstay of therapy in most cases that are suspicious for neoplasm. Correct classification has significant prognostic and therapeutic implications. They are considered here together because they have similar histologic features and tumor biologies and may not be separable on FNA.
IPMNs have a propensity to involve the pancreatic head of older men. Main duct IPMNs generally produce radiologically detectable ductal dilatation. Intraductal papillary mucinous neoplasm. B Abrupt transitions from low-grade left to higher-grade right dysplasias are not uncommon. Cytology can be performed transabdominally under ultrasound or computed tomographic guidance or as an adjunct to EUS. EUS provides the advantage of superior, real-time imaging and relative ease of multiple-needle passes. Papillary clusters of mucinous epithelium of variable cytologic-grade are characteristic, but are less frequently encountered than pathologic mucous.
Cyst fluid analysis for analytes including CEA and amylase plays a complementary role in diagnosis. The mucin-producing cystic neoplasms are characterized by elevated CEA with higher values roughly correlating with malignancy. Various cutoffs have been reported.
Imaging and Pathology of Pancreatic Neoplasms
On gross examination, IPMNs demonstrate prominent ductal dilatation. As they tend to extensively involve the duct system, frozen section is often utilized to examine margin status. Low-grade and moderate dysplasia at the margin may be indistinguishable from PanIN-1 and -2 the grading systems for IPMN and PanIN are analogous and the significance of this distinction is not clear. MCNs tend to involve the pancreatic body or tail and occur almost exclusively in women. As a rule, they do not involve the ductal system, although rare exceptions have been reported.
Imaging and Pathology of Pancreatic Neoplasms - A Pictorial Atlas | Mirko D'Onofrio | Springer
The histologic hallmark of MCN is the presence of supporting ovarian-type stroma similar to that seen in biliary cystadenoma and cystic nephroma Image 3A. They are classically sponge-like microcystic with a central stellate scar. An association with von Hippel Lindau syndrome has been reported, although most cases are sporadic.
Small, asymptomatic lesions with typical clinical, radiologic features have been safely followed. Very rare malignant examples ie, serous cystadenocarcinomas , cytologically indistinguishable from adenomas, have been reported. Serous cystadenocarcinoma is defined by the presence of metastasis typically to liver or lymph nodes. Rare serous tumors demonstrate vascular or perineural invasion or involve the tubular gastrointestinal tract or spleen by direct extension; these findings are insufficient for a diagnosis of malignancy, although these patients should be followed closely metachronous metastases have been reported.
Pseudocysts present in the backdrop of pancreatitis. Atypical clinically or radiologically examples may be aspirated. Cytology demonstrates abundant inflammatory cells and granular debris; again, GI contamination represents a potential pitfall. Resected cases should be carefully sampled to ensure this. Other rarely encountered lesions include congenital including ciliated examples , retention, and squamous-lined ie, lymphoepithelial, accessory-splenic epidermoid, and dermoid cysts Image 3D.
Finally, diagnostic consideration should be given to cystic degeneration in a typically solid lesion eg, ductal adenocarcinoma, pancreatic endocrine tumor. Other cystic lesions.
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A Mucinous cystic neoplasm. B Serous microcystic adenoma. C Pseudocyst. Lack of an epithelial lining is the defining feature. Cyst contents include histiocytes, giant cells, and calcific debris. D Ciliated foregut cyst. This simple cyst is lined by pseudostratified ciliated epithelium.
The tumors tend to have an indolent behavior and long-term survival is common. Patients can be asymptomatic or present with symptoms due to hormonal excess or a local mass effect. Tumors in those with hormonal excess and an associated endocrine syndrome are considered functional while those without an associated syndrome are nonfunctional. Functional tumors are classified by the hormones they produce and the associated endocrine syndrome.
Associated genetic syndromes include multiple endocrine neoplasia type 1, von Hippel-Lindau disease, von Recklinghausen disease, and tuberous sclerosis. Pancreatic endocrine tumor and mimics.
A The tumor is composed of nests and cords of cells with abundant amphophilic cytoplasm. C Chromogranin immunohistochemistry supports the neuroendocrine nature of this lymph node metastasis IP, x. Most PETs are solitary and well circumscribed. The most frequent growth patterns are solid, nested, trabecular, ribbon-like, tubuloacinar, and glandular Image 4A. Mixed patterns may be seen in the same tumor. Tumor cells are round or polygonal and usually fairly uniform in size and shape.
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