1. Pancreatic tumour slide seminar
Newton ACS Wong
Department of Histopathology
Bristol Royal Infirmary
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2. Report what is clinically relevant
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8. Case P3
49 Female
Classic Whipple's for cancer (stented). Tumour measuring 20 x 20 x 10 mm, which distorts the ampulla and abuts the adjacent duodenal wall.
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9. Ampullary adenocarcinoma
Case P3
Diagnosis:
Ampullary adenocarcinoma
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10. Case P5
67 Male
Likely pancreatic adeno-carcinoma. Not stented before surgery. There is a tumour within the head of pancreas measuring 28 x 26 x 22 mm. Tumour does not appear to extend to the adjacent duodenum.
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11. Pancreatic ductal adenocarcinoma
Case P3
Diagnosis:
Pancreatic ductal adenocarcinoma
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12. Case 13534/12
Diagnosis:
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13. Case 13534/12
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14. Primary duodenal adenocarcinoma
Case 13534/12
Diagnosis:
Primary duodenal adenocarcinoma
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15. Case 13534/12 Primary duodenal adenocarcinoma, exclude:
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16. Case 13534/12 Primary duodenal adenocarcinoma, exclude: FAP
Coeliac disease
Crohn’s disease
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17. Case 12664/12
Diagnosis:
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18. Case 12664/12
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19. Distal cholangiocarcinoma
Case 12664/12
Diagnosis:
Distal cholangiocarcinoma
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20. Adjuvant chemo (ESPAC4) Ampullary AdCa: Cholangioca:
Ductal AdCa:
Adjuvant chemo (ESPAC4)
Ampullary AdCa:
Cholangioca:
Chemo vs no chemo (BILCAP)
Duodenal AdCa:
Multi-national trial soon
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21. Case P7
64 Female
Pancreatic cyst with cyst fluid showing CEA 5500, no prior history of acute pancreatitis. Mainly unilocular cyst measuring 110 mm in maximum diameter. This cyst is filled with tan coloured mucoid fluid and has a rough inner lining. At its distal (splenic) and posterior aspects, the cyst wall is particularly thickened and contains numerous small daughter cysts (measuring up to 5 mm in diameter).
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22. Mucinous cystadenoma of pancreas
Case P7
Diagnosis:
Mucinous cystadenoma of pancreas
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23. Mucinous cystadenoma of pancreas
AKA:
Mucinous cystic neoplasm of pancreas
Hepatobiliary or biliary cystadenoma [with mesenchymal stroma]
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24. Mucinous cystadenoma of pancreas
Young females
Tail >>> Head
Stroma less prominent in males (liver)
Lutea-like cells
Malignant potential so complete excision
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25. Case P2
76 Female
Cystic lesion in pancreatic body. ?Mucinous at EUS. A unilocular cyst which measures 34 x 30 x 25 mm. The cyst contains mucoid material. This cyst is surrounded by numerous cystically dilated ducts.
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26. Case P2
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27. Intraductal papillary mucinous neoplasm (IPMN)
Case P2
Diagnosis:
Intraductal papillary mucinous neoplasm (IPMN)
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28. Main duct (higher malignant risk) and/or side branch Head > Tail
IPMN
Main duct (higher malignant risk) and/or side branch
Head > Tail
Epithelial type (pancreaticobiliary, foveolar, intestinal)
Grade (2 or 3 point scale)
Premalignant
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29. Intraductal oncocytic papillary neoplasm (IOPN)
Variant of IPMN
Cytology (mistaken for acinar cell carcinoma)
Gives rise to …
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30. Intraductal oncocytic papillary neoplasm (IOPN)
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31. IPMN vs. PanIN
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33. Case P8
69 Male
Main body of pancreas tumour - ?neuroendocrine. A lobulated tumour measuring 45 x 25 x 25 mm. This tumour has a central scar but shows otherwise a uniform spongy cut surface with neither haemorrhage nor necrosis.
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34. Microcystic serous cystadenoma of pancreas
Case P8
Diagnosis:
Microcystic serous cystadenoma of pancreas
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35. Serous cystadenoma of pancreas
Microcystic (1 cm) / Macro or Oligocystic / Unicystic / Solid
Clear, PAS+ve (glycogen), bland cubiodal epithelium
Central scar
‘Benign’ but malignant and locally aggressive variants
DD of unicystic is ‘retention cyst’
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36. Case P6
45 Male
Distal pancreatectomy (spleen preserving) for pancreatic cystic tumour. Cyst fluid showed raised CEA so ?mucinous cystadenoma. The distal two thirds of the tail is replaced by a complex (due to infolding of the wall) but apparently unilocular cyst which contains white material.
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37. Case P6
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38. Lymphoepithelial cyst of pancreas
Case P8
Diagnosis:
Lymphoepithelial cyst of pancreas
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39. Lymphoepithelial cyst of pancreas
Extra-pancreatic
Male 50+
Why? (Not HIV related)
Elevated cyst fluid CEA level (mesenteric/mesothelial cyst)
DD: Dermoid cyst, splenic epidermoid cyst
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40. Case P9
74 Male
Further piece of wall of cystic lesion next to pancreas. Fibrous tissue fragment measuring 10 x 9 x 3 mm.
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41. Pancreatic pseudocyst
Case P9
Diagnosis:
Pancreatic pseudocyst
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42. Pseudocyst Chronic pancreatitis Cytology How molecular tests can cli42

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44. Case P4
57 Female
Lesion on CT suggested being in distal pancreas. At surgery palpable lesion. A well circumscribed nodule within the pancreatic tail which measures 9 x 8 x 8 mm.
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45. Neuroendocrine tumour of pancreas
Case P4
Diagnosis:
Neuroendocrine tumour of pancreas
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46. Hormone IHC (insulin, glucagon, somatostatin, VIP)
Pancreatic NET
Hormone IHC (insulin, glucagon, somatostatin, VIP)
Grading and staging:
BSG guidelines 2012
RCPath MDS 2012
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53. Case P1
47 Male
Known FAP patient. ?desmoid tumour in tail of pancreas. A well circumscribed tumour measuring 9 x 8 x 6 cm. The tumour shows a white/yellow cut surface with widespread haemorrhage.
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54. Case P1
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55. Solid pseudopapillary neoplasm of pancreas
Case P1
Diagnosis:
Solid pseudopapillary neoplasm of pancreas
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56. Acinar Cell Ca Pancreatic NET Solid Pseudopapillary Neoplasm
Keratin −/+
Vimentin − − + +
Trypsin[*] − −
Chromogranin − −
Synaptophysin −
CD56 −
α1-Antitrypsin + −/
CEA − −  
Nuclear − − + +
Beta catenin
−, usually negative; −/+, usually negative, may be positive; +, often positive; + +, consistently positive.
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57. Solid Pseudopapillary Neoplasm
Younger females
10-15% metastasis
Link with FAP? (germline APC mutation vs. CTNNB1 mutation in SPPN)
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58. Case 14890/11
Diagnosis:
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59. Acinar cell carcinoma of pancreas
Case 14890/11
Diagnosis:
Acinar cell carcinoma of pancreas
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60. Acinar Cell Ca Pancreatic NET Solid Pseudopapillary Neoplasm
Keratin −/+
Vimentin − − + +
Trypsin[*] − −
Chromogranin − −
Synaptophysin −
CD56 −
α1-Antitrypsin + −/
CEA − −  
Nuclear − − + +
Beta catenin
DPAS+ cyto − −
−, usually negative; −/+, usually negative, may be positive; +, often positive; + +, consistently positive.
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61. Acinar cell cystadenoma or cystadenocarcinoma
Acinar cell carcinoma
Older males
Poor prognosis
Cystic variant:
Acinar cell cystadenoma or cystadenocarcinoma
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62. Case 16104/12
Diagnosis:
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63. Colloid/oncocytic carcinoma of pancreas
Case 16104/12
Diagnosis:
Colloid/oncocytic carcinoma of pancreas
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64. Colloid / oncocytic carcinoma
Various combinations of colloid (mucinous) and oncocytic features
Colloid arise from IPMN or MCA
Oncocytic arise from IOPN
Colloid ca – better prognosis?
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65. Case 16377/11
Diagnosis:
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66. Case 16377/11
Diagnosis:
Anaplastic (undifferentiated) carcinoma with osteoclast like giant cells
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67. Case 16377/11 Cytology Don’t mistake for sarcoma or melanoma
Poor prognosis
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68. Case P10
64 Male
Larger lesion in neck of pancreas, enucleated. Smaller lesion in tail of pancreas. A 6 mm diameter nodule is present close to the proximal end of the specimen.
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69. Metastatic renal cell carcinoma
Case P10
Diagnosis:
Metastatic renal cell carcinoma
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70. RCC (cw. Solid serous cystadenoma)
Secondary neoplasms
RCC (cw. Solid serous cystadenoma)
Melanoma
Colorectal carcinoma (CDX2, CA125, PDX1)
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