View source for Cytologically Yours: Unknowns: 201401: Case 5

==Clinical History==
58 year old female with a pancreatic mass.

==Cytology==
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===Resident Questions===
* <spoiler text="Diagnosis?">__NOGLOSSARY__
* Mucinous Pancreatic Neoplasm
** Includes two diagnostic entities:
*** Mucinous Cystic Neoplasm (MCN)
**** Most arise in the body and tail of the pancreas
**** Most occur in women between the ages of 40 and 50 years old
**** Do not arise from the pancreatic main duct
*** Intraductal Papillary Mucinous Neoplasm (IPMN)
**** Most arise in the head of the pancreas
**** Most occur in men older than 60 years old
**** Connect to the pancreatic main duct or one of its branches
**** Radiology shows dilatation of the pancreatic duct and its branches
**** Endoscopy will reveal thick mucin extruding from the ampulla
** Both are considered high risk due to their association with dysplasia and underlying carcinoma
** Distinction between the two on cytology alone is not recommended
** Best diagnosis is "neoplastic cells present, pancreatic mucinous neoplasm"
</spoiler>
* <spoiler text="What are some of the cytologic features that lead you to the diagnosis?">__NOGLOSSARY__
* Abundant thick mucin that may look colloid like
* Mucin can be so thick and tenacious it may cause difficulty in aspirating and making smears
* Flat sheets and clusters of bland appearing columnar cells with abundant intracytoplasmic mucin
* Mucin fills the cytoplasm and displaces the nucleus to the periphery or base of the cell. This is unlike the apical mucin seen in gastric foveolar epithelium
* Atypia may be present depending on the presence and degree of dysplasia 
* Single cells or groups trapped in mucus
</spoiler>
* <spoiler text="Differential diagnosis?">__NOGLOSSARY__
* Contaminant gastrointestinal 
** Brush border and interspersed goblet cells is seen in duodenal epithelium
** May see abundant mucin from GI tract
** Gastric epithelium is present in tissue fragments of uniform cuboidal cells
** Punctate perinuclear staining with B72.3
* CAN NOT DIFFERENTIATE BETWEEN IPMN AND MCN ON CYTOLOGY ALONE
</spoiler>
*<spoiler text="What ancillary studies would you order?">__NOGLOSSARY__
* CEA levels are >200ng/mL in both MCN and IPMN
* Amylase will be high in IPMN and low in MCN (due to IPMN connection with the pancreatic duct)
* B72.3 has diffuse cytoplasmic staining in MCN and IPMN
</spoiler>

{{Cytologically Yours}}

[[Category:Unknowns]]