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Presented by Elizabeth Montgomery, M.D. and prepared by Maryam Farinola M.D.
Case 2: This slide was prepared from a pancreatic resection in an adult.
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Question 1 of 1
1. Question
Week 192: Case 2
This slide was prepared from a pancreatic resection in an adult. Grossly, the pancreatic duct appeared normal, but in one area towards the tail of the pancreas there was a small, dilated area approximately 3mm in association with a firm apparent tumor. The slide is from this cystically dilated area which was not in communication with the main pancreatic duct.images/PanIN 1.jpg
images/PanIN 2.jpg
images/PanIN 3.jpg
images/PanIN 4.jpgCorrect
Answer: High grade PanIn with associated ductal carcinoma of the pancreas
Histology: This slide shows a dilated small duct in which the epithelium is replaced by a papillary atypical columnar proliferation showing all the features of high grade columnar epithelial dysplasia. Pancreatitis is certainly present in the tissue in this slide, but an area of unequivocal infiltrating adenocarcinoma with single cells each surrounded by desmoplastic stroma is present.
Discussion: The epithelium of the dilated small duct is replaced by a papillary atypical columnar proliferation showing all the features of high grade columnar epithelial dysplasia. As such, this is probably best regarded as carcinoma in situ. However, according to the current classification, since this duct does not communicate with the main pancreatic duct, this is not an intraductal papillary mucinous neoplasm with high grade dysplasia but instead pancreatic intraepithelial neoplasia (PanIN). As is sometimes the case, this high grade PanIN is associated with an infiltrating ductal adenocarcinoma. The epithelium lining the cystically dilated area shows sufficiently striking cytologic alteration that this could not be regarded as a strictly benign cyst. There is chronic pancreatitis surrounding this area which has resulted in depletion of all but the islets (the endocrine cells) which can impart an appearance somewhat akin to an endocrine neoplasm. Pancreatitis is certainly present in the tissue in this slide, but an area of unequivocal infiltrating adenocarcinoma with single cells each surrounded by desmoplastic stroma is present. Although the low power appearance of this particular lesion suggests the possibility of an intraductal papillary mucinous neoplasm, since this lesion was not in continuity with the main pancreatic duct, it is therefore best classified as PanIN. In assessing such pancreatic neoplasms, both the location in the pancreas and the macroscopic appearance are extremely important.
Incorrect
Answer: High grade PanIn with associated ductal carcinoma of the pancreas
Histology: This slide shows a dilated small duct in which the epithelium is replaced by a papillary atypical columnar proliferation showing all the features of high grade columnar epithelial dysplasia. Pancreatitis is certainly present in the tissue in this slide, but an area of unequivocal infiltrating adenocarcinoma with single cells each surrounded by desmoplastic stroma is present.
Discussion: The epithelium of the dilated small duct is replaced by a papillary atypical columnar proliferation showing all the features of high grade columnar epithelial dysplasia. As such, this is probably best regarded as carcinoma in situ. However, according to the current classification, since this duct does not communicate with the main pancreatic duct, this is not an intraductal papillary mucinous neoplasm with high grade dysplasia but instead pancreatic intraepithelial neoplasia (PanIN). As is sometimes the case, this high grade PanIN is associated with an infiltrating ductal adenocarcinoma. The epithelium lining the cystically dilated area shows sufficiently striking cytologic alteration that this could not be regarded as a strictly benign cyst. There is chronic pancreatitis surrounding this area which has resulted in depletion of all but the islets (the endocrine cells) which can impart an appearance somewhat akin to an endocrine neoplasm. Pancreatitis is certainly present in the tissue in this slide, but an area of unequivocal infiltrating adenocarcinoma with single cells each surrounded by desmoplastic stroma is present. Although the low power appearance of this particular lesion suggests the possibility of an intraductal papillary mucinous neoplasm, since this lesion was not in continuity with the main pancreatic duct, it is therefore best classified as PanIN. In assessing such pancreatic neoplasms, both the location in the pancreas and the macroscopic appearance are extremely important.
