Cytologically Yours: Unknowns: 201401: Case 3

Clinical History

45 year old male with weight loss and jaundice.

Cytology

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Resident Questions

• Diagnosis?

• Chronic pancreatits
  • Occurs in the 4th and 5th decades
  • Clinically presents as chronic recurrent abdominal pain
  • Triad steatorrhea, diabetes mellitus, and weight loss
  • Can present as a solid mass in the head of the pancreas
  • Radiologically can appear as an ill defined lobulated mass and the periphery of the lesion can look irregular
  • Strictures of the biliary or pancreatic ducts occurs as well as calcification

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

• Variable cellularity depending on the fibrosis in the specimen, however usually low cellularity
• Smears are polymorphous (ductal cells, acinar cells, macrophages, inflammatory cells, fibrosis, debris, calcification, fat necrosis)
• Hyperplastic and atypical ductal cells can be present, and can make it difficult to distinguish from adenocarcinoma.
• Although markedly atypical cells may be present there will not be many and there will be no single atypical cells
• Reactive cells will not have anisonucleosis and will not have nuclear irregularity
• Ductal cells out number acinar cells (acinar atrophy)

• Differential diagnosis?

• Adenocarcinoma
  • Occurs later (6th and 7th decades)
  • Irregular nuclear contours, macronuclei, anisonucleosis
  • Positive staining for p53 and CDx-2
  • Negative staining for SMAD4
• The presence of mitotic figures does not support the diagnosis of carcinoma. Mitotic figures can be seen in chronic pancreatitis.
• Pancreatic cancer is often surrounded by a zone of pancreatitis, therefore pancreatits does not exclude malignancy nor does inflammation