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Presented by Ralph Hruban, M.D. and prepared by Doreen Nguyen, M.D.
Case 3: This patient underwent a distal pancreatectomy for a mucinous cystic neoplasm.
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1. Question
Week 561: Case 3
This patient underwent a distal pancreatectomy for a mucinous cystic neoplasm. The lesion shown was found at the pancreatic parenchymal margin. The surgeon asked if she should resect additional parenchyma because of this finding.
Correct
Answer: Pancreatic intraepithelial neoplasia, don’t resect more
Histology: A small duct contains a lesion composed of cuboidal to columnar cells with only mild to moderate atypia. The glands around this duct are composed of cells with relatively uniform nuclei. The glands form a well-defined organized lobule.
Discussion: This is a nice example of lobulocentric atrophy around a pancreatic intraepithelial neoplasia (PanIN) lesion. These foci, presumably the result of focal duct-obstruction by the PanIN lesion, can mimic an invasive neoplasm. Importantly, the diagnostic features of an invasive cancer (haphazard arrangement of glands, 4 to 1 rule, glands next to muscular vessels, perineural invasion, vascular invasion, luminal necrosis, and incomplete lumina) are not present.
Reference(s):
– Detlefsen S, Sipos B, Feyerabend B, Klöppel G. Pancreatic fibrosis associated with age and ductal papillary hyperplasia. Virchows Arch. 2005 Nov; 447(5):800-5.Incorrect
Answer: Pancreatic intraepithelial neoplasia, don’t resect more
Histology: A small duct contains a lesion composed of cuboidal to columnar cells with only mild to moderate atypia. The glands around this duct are composed of cells with relatively uniform nuclei. The glands form a well-defined organized lobule.
Discussion: This is a nice example of lobulocentric atrophy around a pancreatic intraepithelial neoplasia (PanIN) lesion. These foci, presumably the result of focal duct-obstruction by the PanIN lesion, can mimic an invasive neoplasm. Importantly, the diagnostic features of an invasive cancer (haphazard arrangement of glands, 4 to 1 rule, glands next to muscular vessels, perineural invasion, vascular invasion, luminal necrosis, and incomplete lumina) are not present.
Reference(s):
– Detlefsen S, Sipos B, Feyerabend B, Klöppel G. Pancreatic fibrosis associated with age and ductal papillary hyperplasia. Virchows Arch. 2005 Nov; 447(5):800-5.
