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Presented by Ralph Hruban, M.D. and prepared by Doreen Nguyen, M.D.
Case 1: This elderly patient presented with obstructive jaundice.
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1. Question
Week 564: Case 1
This elderly patient presented with obstructive jaundice. CT of the pancreas revealed diffuse “sausage-like” enlargement of the gland. A Whipple was performed.images/D Nguyen/9-3-13/case 1/4x_450 pixels.jpg
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images/D Nguyen/9-3-13/case 1/20x_plasma cells_450 pixels.jpg
images/D Nguyen/9-3-13/case 1/20x_PI_450 pixels.jpgCorrect
Answer: Autoimmune pancreatitis and infiltrating ductal adenocarcinoma
Histology: At low magnification the resection specimen was dominated by an intense duct-centric mixed inflammatory cell infiltrate.
This inflammation is also associated with venulitis as demonstrated on VVG stain.
Increased numbers of cells in this infiltrate labeled with antibodies to IgG4 helping to establish the diagnosis of autoimmune pancreatitis. In addition, on closer look, some of the glands are abnormal- they have a haphazard growth pattern and some even invade nerves. This establishes the second diagnosis, an infiltrating ductal adenocarcinoma.
Discussion: Rare cases of autoimmune pancreatitis and infiltrating ductal adenocarcinoma have been reported and are important reminders that patients with autoimmune pancreatitis need to be followed after treatment and rebiopsy should be considered for those who do not respond to therapy.
Reference(s):
– Witkiewicz AK, Kennedy EP, Kennyon L, Yeo CJ, Hruban RH. Synchronous autoimmune pancreatitis and infiltrating pancreatic ductal adenocarcinoma: case report and review of the literature. Hum Pathol. 2008 Oct; 39(10):1548-51.Incorrect
Answer: Autoimmune pancreatitis and infiltrating ductal adenocarcinoma
Histology: At low magnification the resection specimen was dominated by an intense duct-centric mixed inflammatory cell infiltrate.
This inflammation is also associated with venulitis as demonstrated on VVG stain.
Increased numbers of cells in this infiltrate labeled with antibodies to IgG4 helping to establish the diagnosis of autoimmune pancreatitis. In addition, on closer look, some of the glands are abnormal- they have a haphazard growth pattern and some even invade nerves. This establishes the second diagnosis, an infiltrating ductal adenocarcinoma.
Discussion: Rare cases of autoimmune pancreatitis and infiltrating ductal adenocarcinoma have been reported and are important reminders that patients with autoimmune pancreatitis need to be followed after treatment and rebiopsy should be considered for those who do not respond to therapy.
Reference(s):
– Witkiewicz AK, Kennedy EP, Kennyon L, Yeo CJ, Hruban RH. Synchronous autoimmune pancreatitis and infiltrating pancreatic ductal adenocarcinoma: case report and review of the literature. Hum Pathol. 2008 Oct; 39(10):1548-51.
