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Presented by Dr. Elizabeth Thompson and prepared by Dr. Monica Butcher
This a 50 year old woman with a cystic lesion in the tail of the pancreas.
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1. Question
This a 50 year old woman with a cystic lesion in the tail of the pancreas.
Diagnosis:
Correct
Answer: B
Histologic description: H&E sections show a multiloculated cyst with a predominantly attenuated, cuboidal lining. Focally, mucin can be appreciated in the lining but it is not prominent. Condensed just below the epithelial lining is a prominent stroma comprised of plump spindled cells resembling ovarian stroma. An epithelial-lined cyst with ovarian stroma is diagnostic of a mucinous cystic neoplasm (MCN).
Differential Diagnosis: The broad differential of a cystic lesion in the pancreas includes intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystadenoma (SCA), solid-pseudopapillary neoplasm and cystic neuroendocrine tumor. Non-neoplastic cystic entities to be considered include retention cysts and acinar cystic transformation. In this case, the epithelial lining brings the focus to IPMN, MCN and SCA. SCA would have clear cytoplasm with bland, round, centrally placed nuclei. IPMN would have a collagenous stroma underlying papillary mucinous epithelium. In this case, there is extensive plump, spindled ovarian-type stroma beneath the epithelium. The epithelium is very attenuated and mucin is not prominent, but this can be seen fairly frequently in MCN and despite the name, mucinous epithelium is not required for diagnosis! Often, there are large areas of epithelial denudation with associated reactive stromal changes, foamy macrophage accumulation, cholesterol clefts and hemorrhage. These degenerative changes may obscure the ovarian-type stroma but ER and PR immunostains can help highlight it in cases where the H&E impression is equivocal.
Incorrect
Answer: B
Histologic description: H&E sections show a multiloculated cyst with a predominantly attenuated, cuboidal lining. Focally, mucin can be appreciated in the lining but it is not prominent. Condensed just below the epithelial lining is a prominent stroma comprised of plump spindled cells resembling ovarian stroma. An epithelial-lined cyst with ovarian stroma is diagnostic of a mucinous cystic neoplasm (MCN).
Differential Diagnosis: The broad differential of a cystic lesion in the pancreas includes intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystadenoma (SCA), solid-pseudopapillary neoplasm and cystic neuroendocrine tumor. Non-neoplastic cystic entities to be considered include retention cysts and acinar cystic transformation. In this case, the epithelial lining brings the focus to IPMN, MCN and SCA. SCA would have clear cytoplasm with bland, round, centrally placed nuclei. IPMN would have a collagenous stroma underlying papillary mucinous epithelium. In this case, there is extensive plump, spindled ovarian-type stroma beneath the epithelium. The epithelium is very attenuated and mucin is not prominent, but this can be seen fairly frequently in MCN and despite the name, mucinous epithelium is not required for diagnosis! Often, there are large areas of epithelial denudation with associated reactive stromal changes, foamy macrophage accumulation, cholesterol clefts and hemorrhage. These degenerative changes may obscure the ovarian-type stroma but ER and PR immunostains can help highlight it in cases where the H&E impression is equivocal.
