CHRONIC PANCREATITIS OR DUCTAL ADENOCARCINOMA? N. Volkan Adsay, \ MD
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1 CHRONIC PANCREATITIS OR DUCTAL ADENOCARCINOMA? N. Volkan Adsay, \ MD
2 Case for discussion 67 y/o male Back pain and weight loss CT: 4.5 cm ill-defined, solid lesion in the head FNA/Core bx: Inconclusive Pancreatoduodenectomy
3 The dichotomy in the DDx of SOLID pancreatic tumors Schirrous/ill-defined Fleshy /demarcated Chronic pancreatitis Ductal ca. (and variants)
4 Solid scirrhous lesion in the pancreas: CP vs PDAC
5
6
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8 FGP: 1) Pale/micorvesicular cytoplasm; 2) cuticle ; 3) raisonoid, hyperchromatic nuclei
9
10 Case in discussion-diagnosis Invasive ductal carcinoma (pancreatobiliarytype adenoca.) with foamy gland pattern Incidental finding: Pancreatic Intraepithelial Neoplasia
11 Invasive ductal adenocarcinoma (PDAC)
12 PDAC Epidemiology >85% of pancreatic tumors Mean age: 63 Developed >> under-developed countries Common source of carcinoma of unknown primary 5-yr survival <5%; deadliest of all cancers
13 Organ Cancer Annual deaths in US (2016) 1 Lung 160 K 2 Colo-rectal 51 K 3 Pancreas 41 K 4 Breast 40 K 5 Prostate 29 K
14 Chronic pancreatitis vs well-differentiated ductal adenocarcinoma
15 Foamy gland ca. Benign (non-invasive) ducts
16 Chronic pancreatitis (non-invasive ducts) vs (invasive ducts) ductal adenocarcinoma
17 I. Distribution of ductal structures: Is the process lobular or disorganized?
18 Lobularity (adenosis)
19 Organization; proper clustering and size associations: Benign
20 Haphazardness of ductal elements: Carcinoma
21 Lack of lobularity: Carcinoma
22 II. Abnormal localization of ductal structures: 1. Cells around the nerves?
23 Perineurial what?
24 Benign islets can wrap around nerves
25 Ducts in perineural space: carcinoma
26
27 Y.T s approach at Frozen Section: 1. Be liberal in calling things atypical and asking for more. 2. In the meantime, set the threshold high in giving them the diagnosis of carcinoma, especially if it is a diagnostic biopsy.
28 II. Abnormal localization of ductal structures: 1. Cells around the nerves? 2. The band of tissue around the ducts
29
30 Ducts in vascular spaces: Carcinoma
31
32 Ducts in vascular spaces
33 II. Abnormal localization of ductal structures: 1. Anything around the nerves? 2. The band of tissue around the ducts 3. Ducts next to medium-sized, thick-walled blood vessels
34 Duct next to a medium-sized, thick-walled vessel: CA
35 II. Abnormal localization of ductal structures: 1. Anything around the nerves? 2. The band of tissue around the ducts 3. Ducts next to medium-sized, thick-walled blood vessels 4. Individual glands in the adipose tissue?
36 Naked epithelial units in adipose tissue, what are they?
37 Normal islets are often seen in adipose tissue
38 Isolated solitary duct in adipose tissue: CA
39 III. Architecture of ductal structures
40 Benign: Smooth contours; compressed lumina CA: Irregular contours (angulated), open lumina
41 Large Duct Type Invasive Adenocarcinoma of the Pancreas with Microcystic and Papillary Patterns: a potential microscopic mimic of non-invasive ductal neoplasia. Mod Pathol, 2012: 439.
42 Irregular contours, open lumina: CA
43
44 Cribriform-vacuolated elements: Ca
45 IV. Luminal contents of ductal structures
46 Neutrophil-rich necrotic debris in the lumen
47 Neutrophil-rich necrotic debris in the lumen: CA
48 V. Stromal changes
49
50
51 VI. Cytomorphologic findings
52
53 1. Small, uniform cells with high N/C ratio 2. Numerous glands, but no lumen formation Benign atrophy
54 B9 atrophy versus Carcinoma
55 B9 atrophy versus Carcinoma Look for CYTOPLASMIC ACIDOPHILIA, paradoxical N/C (similar to prostate)
56 If glands have ATTENUATED cells: Look for GROOVEs
57 Nuclear irregularities and grooves Similar to tubular ca of the breast
58 If glands have ABUNDANT CYTOPLASM: Look for FOAMY GLAND features
59 If glands have ABUNDANT CYTOPLASM: Look for FOAMY GLAND features
60 Large (multicell-size) vacuoles: Carcinoma
61 Individual hyperchromatic cells
62 Individual hyperchromatic cells: Carcinoma
63 VI. Cytomorphologic findings Cytology at low power
64
65
66
67
68 56 y/o male Case in discussion Symptoms: Abdominal pain, jaundice and weight loss Imaging/Gross: Ill-defined mass involving the pancreatic head. Pancreatoduodenectomy was performed with the clinical diagnosis of pancreas cancer
69 Pancreas is transformed into a sclerotic mass. Rounded contour of the pancreas is preserved (not a feature of PDAC).
70 NO CARCINOMA is identified after extensive sampling and microscopic examination
71 No carcinoma!!! This is a NEGATIVE Whipple, how can that be?
72 PSEUDOTUMORAL PANCREATITIS Benign conditions that form a mass, mimic pancreas cancer, and lead to pancreatectomy 1. Not that uncommon: 4 % of the pancreatectomies 2. Not as risky for the patient as it used to be: Mortality of Whipple is now < 2% (in high volume institutions) 3. Both the incidence and case profile is changing with advancing technology 4. Any etiologic subgroup of CP can lead to PP; however, some entities are notorious
73 Common causes of pseudotumoral pancreatitis (benign lesions that clinically mimic cancer): 1. Autoimmune pancreatitis (40%) 2. Paraduodenal (groove) pancreatitis (40%) 3. Non-specific chronic fibrosing pancreatitis (10%) 4. Others/developmental/congenital lesions (10%) * The percentages reflect this speaker s personal experience
74 Case in discussion Rounded lobules (atrophy, intersitial fibrosis) Chronic inflammation
75 Periductal expansion, inflammation and sclerosis
76 Delicate, wavy sclerosis: characteristic
77 Plasma-cell rich storiform fibrosis ( inflammatory pseudotumor-like picture): Characteristic
78 Plasma cell-rich periductal chronic inflammation
79 Periphlebitis: Important sign
80 Markedly increased IgG4- positive plasma cells
81 Case - Diagnosis AUTOIMMUNE PANCREATITIS (AIP), TYPE 1 aka LYMPHOPLASMACYTIC SCLEROSING TYPE (LPSP) aka IgG4 RELATED SCLEROSING PANCREATITIS
82 Autoimmune Pancreatitis: Subtypes TYPE 1. Lymphoplasmacytic sclerosing type: IgG4- related TYPE 2. GEL (granulocytic epithelial lesion) associated: - Ulcerative colitis - IgG4 is often minimal
83 GEL -forming variant (with Granulocytic Epithelial Lesions)
84 Pseudotumoral Pancreatitis Common causes 1. Autoimmune pancreatitis 2. Paraduodenal ( groove ) pancreatitis 3. (NOS) 4. Others/developmental and congenital lesions
85 Paraduodenal pancreatitis: Pseudotumor at the accessory ampulla region of duodenal wall and pancreas
86 Paraduodenal Pancreatitis (groove pancreatitis)
87
88 Paraduodenal Pancreatitis: Myoadenomatosis type picture
89 Pseudoinfiltrative islets admixed with nerves
90 Paraduodenal Pancreatitis: cystic dystrophy of heterotopic pancreas Both pseudocysts and true cysts
91 Paraduodenal Pancreatitis Males; uncommon in females History of alcohol abuse, HTN, DM Process often centered around accessory ampulla
92 PSEUDOTUMORAL PANCREATITIS Benign conditions that form a mass, mimic pancreas cancer, and lead to pancreatectomy 1.Not that uncommon: >5 % of the pancreatectomies 2.Auotimmune pancreatitis and paraduodenal pancreatitis are the most common cause
93
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