Pancreatico-biliary cytology: a practical approach to diagnosis. Corina Cotoi
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1 Pancreatico-biliary cytology: a practical approach to diagnosis Corina Cotoi
2 Pancreatico-biliary lesions Solid: Ductal adenocarcinoma Cholangiocarcinoma Acinar cell carcinoma Neuroendocrine tumour / carcinoma Inflammatory conditions: AIP, CP Splenunculus Lymphoma Metastatic tumours Cystic Pre-malignant: IPMN, MCN Benign: serous cystadenoma Low grade malignant potential: solid pseudopapillary neoplasm Cystic transformation of NET Lymphoepithelial cysts
3 Diagnosis of pancreatic lesions Clinical symptoms:?painless jaundice Tumour markers (eg CA19.9) Imaging: US, CT, MRI, EUS, ERCP, MRCP, functional imaging Cytology (brushings, FNAs) Cystic lesions Fluid CEA >192 ug/ml (can be falsely elevated: lymphoepithelial cysts, mesothelial inclusion cysts) Amylase: very high in pseudocysts (falsely elevated in other cystic lesions) Molecular analysis: K-Ras (IPMN, MCN), GNAS (IPMN) Biopsies Diagnostic laparoscopy
4 Solid lesions Mass on imaging Stricture of CBD, ductal dilatation, double duct sign Raised tumour markers Biliary brushings or FNA for cytology Discussion at the MDM
5 Cystic lesions MRI characterisation of the cyst? tumour markers EUS?relationship to the main pancreatic duct Worrisome features: eg mural nodule, thick wall Characterisation of fluid (?mucinous) Biochemistry: fluid CEA, amylase FNA for cytology Discussion at the MDM
6 Biliary brushings and FNAs Brushings: For investigation of biliary strictures During ERCP FNA: cystic lesions +/- solid lesions (TruCut biopsies) During EUS
7 Approach to diagnosis (RCPath guidelines) immediate on-site assessment of adequacy direct air-dried smears are preferable collection in liquid medium (saline or other liquid media for LBC or cell block preparation) cytospins are generally suitable for cyst fluid Romanowsky staining, Papanicolaou staining, H&E (no benefit over PAP) Immunohistochemistry (on cell blocks, LBC samples, cytospins) No consensus on standardised reporting (?C1-C5)
8 Pancreatic FNA - normal
9 Biliary brushing - normal
10 GI contaminant Gastric: Mucin Stripped nuclei Nuclear grooves Cup shaped mucin Duodenal: In general large sheets Brush border Goblet cells Thin mucin
11 Approach to diagnosis Clinical/radiological features are important ERCP/EUS report accompanies the cytology request form Fluid characterisation and CEA/amylase fluid analysis CytoSpin (FNA cyst) and recently ThinPrep (biliary brushings) PAP staining very useful in characterising the cellular nuclear features KRAS/GNAS mutation analysis for mucinous cystic lesions not routine practice
12 Approach to diagnosis Adequacy: the context is important, presence of epithelial cells is not always a sign of non-diagnostic sample Background o Thick mucin o Inflammation o Necrosis Epithelial cells:?double population, atypical single cells o Cytoplasm: mucinous, granular o Nuclei: anisokaryosis (more that 1:3-1:4), nuclear crowding, irregular nuclear contours, prominent nucleoli, abnormal chromatin pattern, increased nuclear:cytoplasmic ratio
13 Standardised reporting Standardized terminology and nomenclature for pancreatobiliary cytology: The Papanicolaou Society of Cytopathology Guidelines Martha B. Pitman, Barbara A. Centeno, Syed Z. Ali, Muriel Genevay, Ed Stelow, MD,Mari Mino-Kenudson, Carlos Fernandez-del Castillo, C. Max Schmidt, William R. Brugge, and Lester J. Layfield PROPOSED PANCREATOBILIARY TERMINOLOGY CLASSIFICATION SCHEME I Non-diagnostic II Negative (for malignancy) III Atypical IV Neoplastic: Benign or Other V Suspicious (for malignancy) VI Positive/malignant
14 Standardised reporting CATEGORY I Non-diagnostic no diagnostic or useful information about the solid or cystic lesion for example, an acellular aspirate of a cyst without evidence of a mucinous etiology (such as thick colloid-like mucus, elevated CEA or KRAS/GNAS mutation - see Category IV). Any cellular atypia precludes a non-diagnostic report
15 Standardised reporting CATEGORY II Negative (for malignancy) Descriptive, without a diagnosis of a specific condition such as chronic pancreatitis or pseudocyst not synonymous with a benign lesion adequate cellular and/or extracellular tissue to evaluate or define a lesion that is identified on imaging. should give a specific diagnosis when practical including: Benign pancreatobiliary tissue in the setting of vague fullness and no discrete mass Acute pancreatitis Chronic pancreatitis Autoimmune pancreatitis Pseudocyst Lymphoepithelial cyst Splenule/accessory spleen
16 Standardised reporting CATEGORY III: ATYPICAL reactive changes low cellularity premalignant changes (dysplasia, PanIN) observer caution in diagnosis. raises the possibility of a neoplasm may be suggestive of a low-grade neoplasm, but the cytological findings are insufficient to be suspicious for a high-grade malignancy / tissue is insufficient for confirmation of a specific diagnosis cytoplasmic, nuclear, or architectural features that are not consistent with normal or reactive cellular changes of the pancreas or bile ducts and are insufficient to classify them as a neoplasm or suspicious for a high-grade malignancy insufficient to explain the lesion seen on imaging Follow-up evaluation is warranted.
17 Standardised reporting CATEGORY IV: NEOPLASTIC Category IVA: Neoplastic: Benign cytological specimen sufficiently cellular and representative with or without the context of clinical, imaging and ancillary studies diagnostic of a benign neoplasm
18 Standardised reporting CATEGORY IV: NEOPLASTIC Category IVB: Neoplastic: Other pre-invasive, premalignant neoplasms (IPMN and MCN with low, intermediate or high grade dysplasia) low-grade malignant behaviour pancreatic neuroendocrine tumor (pnet) solid-pseudopapillary neoplasm (SPN) that warrant distinction from aggressive, high-grade malignancies
19 Standardised reporting CATEGORY V: SUSPICIOUS (FOR MALIGNANCY)! Suspicious for is NOT diagnostic of Correlation with the clinical and radiological findings insufficient number of the typical features of a specific malignant neoplasm qualitatively and/or quantitatively insufficient for a conclusive diagnosis of malignancy tissue is not present for ancillary studies to define a specific neoplasm malignancy is considered more probable than not
20 Standardised reporting CATEGORY VI: POSITIVE OR MALIGNANT ductal adenocarcinoma and other high-grade malignancies unequivocally display malignant cytologic characteristics includes PDAC and its variants, cholangiocarcinoma, acinar cell carcinoma, high-grade neuroendocrine carcinoma (small cell and large cell), pancreatoblastoma, lymphomas, sarcomas and metastases to the pancreas
21 Case 1 - cytology 80 y.o. female, Hilar stricture? malignancy.
22 Case 1 - cytology
23 Case 1 - diagnosis Cellular sample, satisfactory for evaluation. Negative for malignancy (reporting category II*).
24 Case 2 - cytology 53 y.o male, EUS: cystic structure with features of pseudocyst fluid amylase of 27000IU/L
25 Case 2 - cytology
26 Case 2 - diagnosis Satisfactory for evaluation. Negative for malignancy (reporting category II*). See comment. COMMENT: The findings are in keeping with the clinical impression of a pseudocyts (fluid amylase of 27000IU/L supports this diagnosis).
27 Case 3 - cytology 56 y.o. female Known PSC with biliary stricture of the right hepatic duct. ERCP and biliary brushings.
28 Case 3 - cytology
29 Case 3 - diagnosis Cellular sample, satisfactory for cytological evaluation. Atypical (reporting category III*). See comment. COMMENT: There is mild epithelial atypia, interpreted as reactive rather than neoplastic in the context of PSC Please note that chronic cholangiopaties are inflammatory conditions that lead to severe reactive atypia, sometimes difficult to differentiate from neoplasia. FISH, NGS: used in some centres, but not routine practice
30 Case 4 - cytology 75 y.o male Biliary obstruction and pancreatic mass. ERCP and brushings.
31 Case 4 - cytology
32 Case 4 - histology Mixed ductal neuroendocrine carcinoma
33 Case 4 - histology Mixed ductal neuroendocrine carcinoma
34 Case 5 - cytology Pancreatic cyst FNA Multi-cystic tumour in body of pancreas. Fluid amylase 1149 UI/l. CEA <2. EUS DG Vascular tumour - large. Suitable for resection.
35 Case 5 - diagnosis Cellular sample, satisfactory for cytological evaluation. Neoplastic: Benign (reporting category IVA*). See comment. COMMENT: The findings are in keeping with a serous cystadenoma. Low fluid CEA, lack of thick mucus and the bland epithelial cells, in places with clear cytoplasm support the diagnosis. Cytology slide circulation: 60% SCA (IVA), 40% SCA/NET (IVA-IVB)
36 Case 5 - histology Distal pancreatectomy: Pancreatic serous cystic neoplasm (microcystic serous cystadenoma).
37 Case 6 - cytology Pancreatic cyst, FNA, 16 y.o. female Endoscopic ultrasounds. 2.6 cm pancreatic cyst?debris within it?solid component. Single pass, sent for histology and cytology (transgastric approach). Fluid CEA < 2 ug/l, amylase 213 UI/l
38 Case 6 - cytology
39 Case 6 - cytology CD10 Beta-catenin Beta-catenin Synaptophysin
40 Case 6 - diagnosis Cellular sample, satisfactory for cytological evaluation. Neoplastic: Other (reporting category IVB*). See comment. COMMENT: The cytological and immunohistochemical findings are in keeping with a solid-pseudopapillary neoplasm.
41 Case 6 - histology
42 Case 6 Solid-pseudopapillary tumour Alpha 1 antitrypsin positive Differential Diagnosis: Neuroendocrine tumour Acinar cell carcinoma Serous cystadenoma Alpha 1 antichymotrypsin Neuron specfic enolase Vimentin Progesterone receptor Beta-catenin CD10 CD56 Trypsin Chymotrypsin CD117 Cytokeratins Synaptophysin CD34 Estrogen receptor Chromogranin positive positive positive positive positive positive positive negative negative positive variable ~ half of cases negative negative negative
43 Case 7 - cytology 50 y.o. male Pancreatic FNAB Uncinate process tumour, well demarcated.
44 Case 7 - cytology Synaptophysin Chromogranin
45 Case 7 - diagnosis Cellular sample, satisfactory for cytological evaluation. Neoplastic: Other (reporting category IVB*). See comment. COMMENT: The cytological and immunohistochemical findings are in keeping with a well differentiated neuroendcrine tumour.
46 Case 7 - histology Synaptophysin Ki67 Chromogranin
47 Case 8 - cytology Pancreatic cyst fluid FNA Query IPMN and dysplasia. CEA 5331 ug/l amylase 1879 UI/l, mucinous fluid aspirated
48 Case 8 - cytology
49 Case 8 - diagnosis Paucicellular sample, limiting cytological evaluation. Neoplastic: Other (reporting category IVB*). See comment. COMMENT: Although no thick mucus is seen, the high CEA and the aspirated mucinous fluid support a diagnosis of a mucinous cystic lesion. No high grade atypia is seen, but the sample is limited. Cytology slide circulation: 100% agreement in diagnosis
50 Case 8 - histology IPMN with low and intermediate grade dysplasia
51 Case 8 - histology Cytological criteria of high-grade epithelial atypia in the cyst fluid of pancreatic intraductal papillary mucinous neoplasms. Pitman MB, Centeno BA, Daglilar ES, Brugge WR, Mino-Kenudson M. Cancer Cytopathology, 2014 Agreement between cytopathologists: Significantly different between the LGD and HGD groups included: 1) cell size < a 12-μm duodenal enterocyte for HGD and equal size for LGD 2) increased nuclear-to-cytoplasmic (N/C) ratio; 3) marked nuclear membrane abnormalities; 4) abnormal chromatin pattern (hypo or hyperchromasia) 5) background necrosis
52 Case 9 - cytology 59 y.o. male Imaging revealed dilated intraphepatic ducts and hilar mass infiltrating the liver. Biliary brushing History of colon cancer
53 Case 9 - cytology
54 Case 9 - histology
55 Case 9 - histology CK7 CK20 Intestinal-type adenocarcinoma in keeping with colo-rectal metastasis CDX2
56 Case 10 - cytology 78 y.o, male Jaundice.?cholangiocarcinoma. ERCP: Mid CBD stricture. biliary brushings
57 Case 10 - cytology
58 Case 10 - diagnosis Cellular sample, satisfactory for cytological evaluation. Positive/malignant (reporting category VI*).
59 Case 10 - histology Distal cholangiocarcinoma
60 Case 10 - histology
61 THANK YOU I would like to thank: Dr Maesha Deheragoda - for clinical cover Alessandra Pacheco - for preparing the cases for today and doing an excellent job in processing and staining our cytology samples
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