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Presented by Elizabeth Montgomery, M.D. and prepared by Maryam Farinola M.D.
Case 6: Incidental nodules discovered endoscopically in the pyloric antrum of an adult.
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1. Question
Week 192: Case 6
Incidental nodules discovered endoscopically in the pyloric antrum of an adult.images/pancreatic heterotopia 1.jpg
images/pancreatic heterotopia 2.jpg
images/pancreatic heterotopia 3.jpgCorrect
Answer: Pancreatic acinar cell heterotopia
Histology: The lesion is characterized by brightly eosinophilic pancreatic acinar-type cells which are shown to have zymogen granules should ultrastructure be performed. No intestinal metaplasia is seen in this specimen and there are no goblet cells. The cytologic features are too bland to regard this as metastatic carcinoma.
Discussion: Pancreatic heterotopia is a not uncommon finding in the stomach and esophagus of both children and adults. It is frequently found in biopsies for assessment of Barret metaplasia. It is of no clinical significance in either children or adults. When it occurs in the stomach, it is generally an incidental finding and again of no clinical significance. The only setting in which nodules of pancreatic heterotopia in the stomach can be significant is when they occur in the pylorus of small children. In this setting, they can result in gastric outlet obstruction and be clinically significant. They are characterized by brightly eosinophilic pancreatic acinar-type cells which are shown to have zymogen granules should ultrastructure be performed. Occasionally, these are mistaken for carcinoid tumors, in which case immunohistochemical stains for chromogranin and synaptophysin are negative, since these are of exocrine rather than endocrine pancreatic type origin. Rarely, such faux sites do contain small nodules of pancreatic islet tissue. Of course, no intestinal metaplasia is seen in this specimen and there are no goblet cells. The cytologic features are too bland to regard this as metastatic carcinoma.
Incorrect
Answer: Pancreatic acinar cell heterotopia
Histology: The lesion is characterized by brightly eosinophilic pancreatic acinar-type cells which are shown to have zymogen granules should ultrastructure be performed. No intestinal metaplasia is seen in this specimen and there are no goblet cells. The cytologic features are too bland to regard this as metastatic carcinoma.
Discussion: Pancreatic heterotopia is a not uncommon finding in the stomach and esophagus of both children and adults. It is frequently found in biopsies for assessment of Barret metaplasia. It is of no clinical significance in either children or adults. When it occurs in the stomach, it is generally an incidental finding and again of no clinical significance. The only setting in which nodules of pancreatic heterotopia in the stomach can be significant is when they occur in the pylorus of small children. In this setting, they can result in gastric outlet obstruction and be clinically significant. They are characterized by brightly eosinophilic pancreatic acinar-type cells which are shown to have zymogen granules should ultrastructure be performed. Occasionally, these are mistaken for carcinoid tumors, in which case immunohistochemical stains for chromogranin and synaptophysin are negative, since these are of exocrine rather than endocrine pancreatic type origin. Rarely, such faux sites do contain small nodules of pancreatic islet tissue. Of course, no intestinal metaplasia is seen in this specimen and there are no goblet cells. The cytologic features are too bland to regard this as metastatic carcinoma.
