Cytologically Yours: Unknowns: 201401: Case 1

Clinical History

72 year old female with jaundice and a pancreatic mass.

Cytology

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Resident Questions

• Diagnosis?

• Adenocarcinoma
  • Most common malignant tumor of the pancreas
  • Accounts for approximately 85% of all pancreatic tumors
  • Patients are commonly women in the 6th and 7th decades of life
  • Prognosis is poor 90% of patients die within a year of diagnosis
  • Association with cigarette smoking, high fat diet, and diabetes mellitus
  • Triad of weight loss, pain, and jaundice
  • Usually involve the head of the pancreas
  • Can obstruct the biliary or pancreatic ducts which can cause a double duct sign on imaging and can also cause painless jaundice

• What are some of the cytologic features that lead you to the diagnosis?

• Cellular specimen
• Predominantly ductal type cells and sparse/absent acinar cells
• Pleomorphism
• Nuclear crowding and overlapping
• Nuclear enlargement (more than 2-3 times the size of red blood cells)
• Nuclear membrane irregularity
• Three dimensional configuration
• Drunken honeycomb

• Differential diagnosis?

• Chronic pancreatitis
  • Occurs in 4th and 5th decades
  • Lack of irregular nuclear contours, macronuclei, anisonucleosis
  • Monolayer fragments with honeycomb pattern
  • Cells with well defined cell borders
  • Negative staining for p53 and CDx-2
  • Positive staining for SMAD4
• Contaminant gastrointestinal epithelium
  • Gastric
    • Monolayered tissue fragments with honeycomb arrangement
    • Uniform nuclei
    • Luminal Brush border
  • Intestinal
    • Large monolayered two dimensional tissue fragments
    • Honeycomb arrangement of cells
    • Intermixed goblet cells
    • Uniform round evenly spaced nuclei
  • Positive staining for CDX-2 and SMAD4
  • Negative staining for p53
• The presence of mitotic figures does not support the diagnosis of carcinoma. Mitotic figures can be seen in chronic pancreatitis.