1. CASE STUDY
Dr. Alireza Azimi
92/10/21

2. Case presentation:
A 58 y/o man with pancreatic mass was admitted and pancreaticoduodenectomy performed.
There was a 1.5 cm mass in ampullary region.

8. DDx ??? Ductal adenocarcinoma Acinar cell carcinoma
Neuroendocrine tumor
Solid-pseudopapillary tumor

9. CK

10. Chromogranin

11. NSE

12. Vimentin

13. CD56

14. Ki67

15. Immunohistochemical study
NSE : negative
CD56: negative
Vimentin: negative
Chromogranin: negative
CK : positive
Ki67 index: about 15%

16. Final diagnosis:
Adenocarcinoma with mixed mucinous and acinar like feature

17. Pancreas ductal adenocarcinoma
About 85% of all of pancreatic malignancies.
Location: In the head of the pancreas in two-thirds of the patients and in the body or tail in the other third.
Multiple tumors are found in about 20% of the cases.
Histology:
well, moderately and poorly differentiated.
Their pattern of growth is papillary in a minority of the cases.

18. MUC1 is expressed in over 60% of ductal carcinomas.
Immunohistochemical findings:
MUC1 is expressed in over 60% of ductal carcinomas.
(In contrast to the intraductal papillary carcinomas, mucinous carcinomas, ampullary carcinomas and colorectal carcinomas, which are more often positive for MUC2).
Keratins: such as 7, 8, 18, 19, 15/16, 17, 20, and - in a lesser percentage - 5/6, 10, and 13.
EMA, CEA, CA 19-9, chromogranin !

21. Acinar cell carcinoma:
a cellular neoplasm that characteristically lacks the desmoplastic stroma commonly seen with ductal carcinomas.
The pattern of growth may be solid, trabecular, glandular, papillary, or it may reproduce the normal acinar structure.
IHC: trypsin, lipase, chymotrypsin and amylase.
and new marker: BCL10

24. Solid-pseudopapillary tumor
Most cases are found in young women. The most common clinical sign is a palpable abdominal mass.
cross section it often contains areas of hemorrhage and necrosis.
very cellular and simulates the appearance of endocrine neoplasm. Its most distinctive feature is the presence of pseudopapillae covered by several layers of epithelial cells.

25. IHC findings of SPPT : keratin (usually focal and faint)
vimentin, desmoplakin, trypsin,
chymotrypsin, amylase,
CD10 and CD56.
focal positivity has been found for NSE and other neuroendocrine markers.

28. Endocrine tumors
A significant number of cases occur in the setting of MEN syndromes, von Hippel-Lindau disease, neurofibromatosis type 1 or tuberous sclerosis.
these tumors are usually composed of small, relatively uniform cuboidal cells with centrally located nuclei and acidophilic or amphophilic, finely granular cytoplasm. Nuclear enlargement and other aberrations are common.
Pancreatic endocrine tumors may be nonfunctioning.

29. IHC findings: keratin 7, CEA,
NSE, chromogranin A and B,synaptophysin, opioid peptides.
markers specific for the various peptide hormones. (insulin...)

32. Thank you