Differential diagnosis of the chronic pancreatitis and the pancreatic ductal adenocarcinoma
Authors:
M. Hermanová; J. Lenz
Authors place of work:
I. patologicko-anatomický ústav LF MU a FN u sv. Anny, Brno
Published in the journal:
Čes.-slov. Patol., 48, 2012, No. 3, p. 135-140
Category:
Reviews Article
Summary
The histopathological distinction of pancreatic ductal adenocarcinoma (PDA) and chronic pancreatitis represents one of the most difficult differential diagnosis in surgical pathology, especially in small biopsy specimens and frozen sections. Practically usable morphological criteria, which allow an efficient differential diagnosis of these lesions have been determined by a number of authors. The perineural and vascular invasion represent findings, which are entirely diagnostic for PDA; however, they are rarely detectable in small biopsy specimens as well as in the presence of solitary naked ducts in fat without surrounding pancreatic elements or fibrous tissue, which also supports the diagnosis of PDA. The features that are suggestive of PDA include random haphazard distribution of ductal structures, irregular ductal contours, ruptured ducts, nuclear enlargement, pleomorphism, hyperchromatism, and mitoses. Uniterrupted proliferation of numerous ducts (>50), ducts lying adjacent to arterioles, intraluminal cellular debris, and hyperchromatic raisinoid nuclei represent less frequently displayed features that also support the diagnosis of PDA. On the contrary, the preserved lobular arrangement, clusters of uniform ductal units, smooth ductal contours, ducts related to the remaining acini and islets, and finding of intraluminnal mucoprotein plugs favor a benign process over PDA.
The combination of presented criteria and features should enable a reliable differential diagnosis of invasive pancreatic cancer and chronic pancreatitis.
Keywords:
chronic pancreatitis – pancreatic ductal adenocarcinoma – pseudotumor – differential diagnosis
Zdroje
1. Adsay NV, Bandyopadhyay S, Basturk O, et al. Chronic pancreatitis or pancreatic ductal adenocarcinoma? Semin Diagn Pathol 2004; 21(4): 268–276.
2. Klöppel G, Adsay NV. Chronic pancreatitis and the differential diagnosis versus pancreatic cancer. Arch Pathol Lab Med 2009; 133(3): 382–387.
3. Cioc AM, Ellison EC, Proca DM, Lucas JG, Frankel WL. Frozen section diagnosis of pancreatic lesions. Arch Pathol Lab Med 2002; 126(10): 1169–1173.
4. Hyland C, Kheir SM, Kashlan MB. Frozen section diagnosis of pancreatic carcinoma: a prospective study of 64 biopsies. Am J Surg Pathol 1981; 5(2): 179–191.
5. Raimondi S, Lowenfels AB, Morselli-Labate AM, Maisonneuve P, Pezzilli R. Pancreatic cancer in chronic pancreatitis; aetiology, incidence, and early detection. Best Pract Res Clin Gastroenterol 2010; 24(3): 349–358.
6. Malka D, Hammel P, Maire F, et al. Risk of pancreatic adenocarcinoma in chronic pancreatitis. Gut 2002; 51(6): 849–852.
7. Volkholz H, Stolte M, Becker V. Epithelial dysplasias in chronic pancreatitis. Virchows Arch A Pathol Anat Histol 1982; 396(3): 331–349.
8. Tannapfel A, Witzigmann H, Wittekind C. Pancreatic intraepithelial neoplasia in chronic pancreatitis. Zentralbl Chir 2001; 126(11): 879–883.
9. Ohike N, Jürgensen A, Pipeleers-Marichal M, Klöppel G. Mixed ductal-endocrine carcinomas of the pancreas and ductal adenocarcinomas with scattered endocrine cells: characterization of the endocrine cells. Virchows Arch 2003; 442(3): 258–265.
10. Lüttges J, Stigge C, Pacena M, Klöppel G. Rare ductal adenocarcinoma of the pancreas in patients younger than age 40 years. Cancer 2004; 100(1): 173–182.
11. Klöppel G, Detlefsen S, Feyerabend B. Fibrosis of the pancreas: the initial tissue damage and the resulting pattern. Virchows Arch 2004; 445(1): 1–8.
12. Ammann RW, Heitz PU, Klöppel G. Course of alcoholic chronic pancreatitis: a prospective clinicomorphological long-term study. Gastroenterology 1996; 111(1): 224–231.
13. Klöppel G, Maillet B. The morphological basis for the evolution of acute pancreatitis into chronic pancreatitis. Virchows Arch A Pathol Anat Histopathol 1992; 420(1): 1–4.
14. Klöppel G. Chronic pancreatitis, pseudotumors and other tumor-like lesions. Mod Pathol 2007; 20 Suppl 1: S113–131.
15. Zamboni G, Capelli P, Scarpa A, et al. Nonneoplastic mimickers of pancreatic neoplasms. Arch Pathol Lab Med 2009; 133(3): 439–453.
16. Adsay NV, Basturk O, Klimstra DS, Klöppel G. Pancreatic pseudotumors: non-neoplastic solid lesions of the pancreas that clinically mimic pancreas cancer. Semin Diagn Pathol 2004; 21(4): 260–267.
17. Adsay NV, Basturk O, Thirabanjasak D. Diagnostic features and differential diagnosis of autoimmune pancreatitis. Semin Diagn Pathol 2005; 22(4): 309–317.
18. Chari ST, Kloeppel G, Zhang L, Notohara K, Lerch MM, Shimosegawa T. Histopathologic and clinical subtypes of autoimmune pancreatitis: the Honolulu consensus document. Pancreatology 2010; 10(6): 664–672.
19. Sharma S, Green KB. The pancreatic duct and its arteriovenous relationship: an underutilized aid in the diagnosis and distinction of pancreatic adenocarcinoma from pancreatic intraepithelial neoplasia. A study of 126 pancreatectomy specimens. Am J Surg Pathol 2004; 28(5): 613–620.
20. Adsay VN, Bandyopadhyay S, Basturk O. Duct adjacent to a thick-walled medium-sized muscular vessel in the pancreas is often indicative of invasive adenocarcinoma. Am J Surg Pathol 2006; 30(9): 1203–1205.
21. Wachtel MS, Miller EJ. Focal changes of chronic pancreatitis and duct-arteriovenous relationships: avoiding a diagnostic pitfall. Am J Surg Pathol 2005; 29(11): 1521–1523.
22. Bandyopadhyay S, Basturk O, Coban I, Thirabanjasak D, et al. Isolated solitary ducts (naked ducts) in adipose tissue: a specific but underappreciated finding of pancreatic adenocarcinoma and one of the potential reasons of understaging and high recurrence rate. Am J Surg Pathol 2009; 33(3): 425–429.
23. Pour PM, Bell RH, Batra SK. Neural invasion in the staging of pancreatic cancer. Pancreas 2003; 26(4): 322–325.
24. Nagakawa T, Kayahara M, Ueno K, et al. A clinicopathologic study on neural invasion in cancer of the pancreatic head. Cancer 1992; 69(4): 930–935.
25. Liu B, Lu KY. Neural invasion in pancreatic carcinoma. Hepatobiliary Pancreat Dis Int 2002; 1(3): 469–476.
26. Lüttges J, Diederichs A, Menke MA, Vogel I, Kremer B, Klöppel G. Ductal lesions in patients with chronic pancreatitis show K-ras mutations in a frequency similar to that in the normal pancreas and lack nuclear immunoreactivity for p53. Cancer 2000; 88(11): 2495–2504.
27. Weger AR, Lindholm JL. Discrimination of pancreatic adenocarcinomas from chronic pancreatitis by morphometric analysis. Pathol Res Pract 1992; 188(1–2): 44–48.
28. Kosmahl M, Pauser U, Anlauf M, Klöppel G. Pancreatic ductal adenocarcinomas with cystic features: neither rare nor uniform. Mod Pathol 2005; 18(9): 1157–1164.
29. Adsay V, Logani S, Sarkar F, Crissman J, Vaitkevicius V. Foamy gland pattern of pancreatic ductal adenocarcinoma: a deceptively benign-appearing variant. Am J Surg Pathol 2000; 24(4): 493–504.
30. Klöppel G, Lüttges J. The pathology of ductal-type pancreatic carcinomas and pancreatic intraepithelial neoplasia: insights for clinicians. Curr Gastroenterol Rep 2004; 6(2): 111–118.
31. Scarpa A, Capelli P, Mukai K, et al. Pancreatic adenocarcinomas frequently show p53 gene mutations. Am J Pathol 1993; 142(5): 1534–4543.
32. Nenutil R, Smardova J, Pavlova S, et al. Discriminating functional and non-functional p53 in human tumours by p53 and MDM2 immunohistochemistry. J Pathol 2005; 207(3): 251–259.
33. Schutte M, Hruban RH, Hedrick L, et al. DPC4 gene in various tumor types. Cancer Res 1996; 56(11): 2527–2530.
34. Suda K, Takase M, Fukumura Y, Kashiwagi S. Pathology of autoimmune pancreatitis and tumor-forming pancreatitis. J Gastroenterol 2007; 42 Suppl 18: 22–27.
35. Shimosegawa T, Chari ST, Frulloni L, et al. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology. Pancreas 2011; 40(3): 352–358.
Štítky
Anatomical pathology Forensic medical examiner ToxicologyČlánok vyšiel v časopise
Czecho-Slovak Pathology
2012 Číslo 3
Najčítanejšie v tomto čísle
- Giant-cell lesions of bone and their differential diagnosis
- Sarcomatoid (metaplastic) spindle cell carcinoma arising in a phylloid tumor with massive squamous metaplasia – a case report and review of the literature
- Differential diagnosis of the chronic pancreatitis and the pancreatic ductal adenocarcinoma
- Melanocytic pseudotumors