AFIP images
Cut surface displays large nodules
Contributed by Claudio Luchini, M.D., Ph.D.
Typical histology
Intraductal growth
Cell detail
Association with neuroendocrine tumors
BCL10 expression pattern
Trypsin expression pattern
Contributed by Claudio Luchini, M.D., Ph.D.
Cytological aspects
Contributed by Wei Chen, M.D., Ph.D.
Unilocular ACT
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Multiple cystic lesions
Raw specimen
and fixed and
cut specimen
Contributed by Vidya Arole, M.D. and Wei Chen, M.D., Ph.D.
Incidental microscopic ACT
Multilocular cystic structure
Club-like pseudopapillae
Microscopic ACT CK19 immunostain
Microscopic ACT trypsin immunostain
Large unilocular ACT
ACT cyst epithelium
Large ACT CK7 immunostain
Large ACT trypsin immunostain
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Pancreatic tail / body mass
Images hosted on other servers:
Pancreatic tail mass
AFIP images
ACTH producing tumor with Cushing syndrome
Images hosted on other servers:
Typical neuroendocrine tumor appearance
66 year old man with ultrasound guided biopsy: H&E and ACTH antibody
Images hosted on other servers:
Scattered neuroendocrine cells
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Overview of pathogenesis
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CT scan
Necrotizing pancreatitis
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Intraoperative findings of necrotizing pancreatitis
Images hosted on other servers:
Acute pancreatitis with fat necrosis
Acute hemorrhagic pancreatitis
Contributed by Beena Ashan, M.D. and Sarah Kisha, M.D.
Acute interstitial pancreatitis
Hemorrhagic pancreatitis
Fat necrosis with hemosiderin disposition
Contributed by Beena Ashan, M.D. and Sarah Kisha, M.D.
Dense inflammatory infiltrate
Pancreas: acute pancreatitis, gross and microscopy
Contributed by Orhun Çığ Taşkın, M.D.
Cystic and necrotic changes
Contributed by Orhun Çığ Taşkın, M.D., Raul S. Gonzalez, M.D. and AFIP
Glandular and squamous components
p63
Adenocarcinoma and squamous carcinoma
Squamous components
Mucoepidermoid pattern
CAM5.2
CK13
Contributed by Orhun Çığ Taşkın, M.D.
Pap stain
Cell block
Cell block, p40
Images hosted on other servers:
Ultrasound guided biopsy
Contributed by Alexei Mikhailov, M.D., Ph.D. and Cinthia Drachenberg, M.D.
Inactive lymphocytes
Active acinar inflammatory infiltrate
Ductitis, no duct damage
Ductitis with epithelial damage
Venulitis
Neural inflammation
Cellular rejection grade 1
Cellular rejection grade 2
Cellular rejection grade 3
Graft fibrosis stage 2
Graft fibrosis stage 3
Chronic active cellular rejection
Antibody mediated rejection
Irregular fibrosis in peripancreatitis
Contributed by Jan Hrudka, M.D., Ph.D.
Normal pancreas histology
Normal pancreas histology
Chromogranin A IHC
Glucagon IHC
Insulin IHC
Contributed by Grigory Demyashkin, M.D., Ph.D. and AFIP images
10 week old fetus
Islets in newborn
Adult pancreas: distribution of islet cell types
6 - 8 week embryo
AFIP images
Normal pancreatic acinar cells
Normal ductal cells in sheet arrangement
AFIP images
38 / 39 week old fetus
Adult pancreatic islet cells
2 centroacinar cells with electron lucent cytoplasm
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Zymogen granules
Images hosted on other servers:
CT
PET
Endoscopic ultrasound
ERCP with stricture
Ultrasound
MRI
Mass forming autoimmune pancreatitis (CT)
Mass forming autoimmune pancreatitis (PET)
Contributed by Aaron R. Huber, D.O.
Ill defined fibrosis
Images hosted on other servers:
Nodular lesions
Ill defined pancreatic head mass
Contributed by Aaron R. Huber, D.O. and @RaulSGonzalezMD on Twitter
Fibrosis and inflammation
Inflammation
Fibrosis
Phlebitis
Phlebitis
Autoimmune pancreatitis type 1
Elastic stain
IgG4
Images hosted on other servers:
Type 1 FNA
Images hosted on other servers:
Diffuse pancreas enlargement
Contributed by David J. Escobar, M.D., Ph.D.
Granulocyte epithelial lesion
IgG4-
Contributed by Claudio Luchini, M.D., Ph.D. and Gaetano Paolino, M.D.
Head transverse section
Contributed by Claudio Luchini, M.D., Ph.D. and Gaetano Paolino, M.D.
Cardinal triad
Duct dilation
Lipomatous atrophy
Chronic inflammation
Squamous metaplasia
Perivenulitis
Residual Langerhans islets
Paraduodenal (groove) pancreatitis
Contributed by Claudio Luchini, M.D., Ph.D. and Gaetano Paolino, M.D.
Fibrous stromal elements and inflammatory cells
Contributed by Aatur Singhi, M.D., Ph.D.
Nests of tumor cells
Clear, vacuolated cytoplasm
Salt and pepper chromatin
Synaptophysin positivity
Image hosted on other servers:
Papanicolaou stain of FNA
Pancreatic neuroendocrine neoplasms: overview
Images hosted on other servers:
CT scan
AFIP images
Whipple resection specimen
Contributed by Jennifer Vazzano, D.O., M.S. and Wei Chen, M.D., Ph.D.
Large mucin pools
Images hosted on other servers:
Cystic pancreas lesion on CT scan
AFIP images
Large cystic tumor
Images hosted on other servers:
Cystic pancreas mass
Large spherical lesion with multiple loculations arising from head of pancreas
Cystic pancreatic endocrine neoplasm
Contributed by Raul S. Gonzalez, M.D.
Fibrous wall
Cyst lining
Unilocular lesion
Neuroendocrine cells within fibrosis
Images hosted on other servers:
Cystic pancreatic neuroendocrine tumor
Images hosted on other servers:
Plasmacytoid cells on FNA
Conventional smear
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At autopsy, pancreas
is mucoid and
slightly smaller
than normal
Histopathology pancreas: cystic fibrosis
Contributed by Maria Luisa C. Policarpio-Nicolas, M.D.
Ductal cells with bland nuclei
Ductal cells with tubule formation
Ductal epithelium cell block
Clusters of acinar cells
Acini in grape-like arrangement
Acinar and ductal cells histology
Gastric epithelium
Duodenal epithelium with goblet cells
Hepatocytes with intracytoplasmic pigment
Hepatocytes with bile
Mesothelial cells in sheets
Mesothelial cells with intercellular windows
Histopathology pancreas: type 2 diabetes mellitus
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Axial CT pancreas
Contributed by Wei Chen, M.D., Ph.D.
Arising in IPMN
Arising in high grade PanIN
Contributed by Wei Chen, M.D., Ph.D.
Anisonucleosis
Glands next to vessel
Perineural invasion
Gland in adipose tissue
Moderately differentiated
Poorly differentiated
Foamy gland pattern
Vacuolated pattern
Clear cell pattern
Large duct pattern
Post therapy tumor bed
Post therapy eosinophilic change
Post therapy dystrophic tumor glands
Perineural residual tumor glands
Post therapy vascular change
Contributed by Regina Plummer, D.O., Victoria Saksenberg, M.D. and AFIP images
Abundant inspissated mucin
Transition into drunken honeycomb
Anisonucleosis (4:1 variation)
Signet ring cells
Moderately
differentiated
ductal
adenocarcinoma
AFIP images
Well differentiated
Images hosted on other servers:
CT of pancreatic gastrinoma
AFIP images
Lymph node gastrinoma
Contributed by Raul S. Gonzalez, M.D. and AFIP images
Nests and cords of cells
Malignant tumor has trabecular pattern
Lobular trabecular pattern
AFIP images
Pancreatic gastrinoma
Images hosted on other servers:
CT
MRI
Liver metastases
AFIP images
Necrolytic migratory erythema
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Necrolytic migratory erythema
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H&E and immunostains
H&E and glucagon
Liver metastasis
Chromogranin
Contributed by Olca Basturk, M.D.
Trapezoid and important structures
Inked margins and vascular groove
Anterior free surface
Posterior free surface
Common bile duct margin
Pancreatic neck / duct margin
Uncinate margin
Minor (accessory) ampulla
Bivalving and sectioning
Cut surface of the pancreatic head
Low union
Peripancreatic lymph nodes
Lymph node dissection (orange peeling)
Anterior surface of distal pancreatectomy
Posterior surface of distal pancreatectomy
Serially sectioned distal pancreatectomy
Bivalved distal pancreatectomy
Total pancreatectomy
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Gastric submucosal mass
Duodenal and gastric lesions
MRI lesion in duodenum
Contributed by Kenechukwu Ojukwu, M.D., M.P.P. and Stephanie Dreikorn, M.D.
Endoscopy, subtle ectopic pancreas
Images hosted on other servers:
Single balloon
enteroscopy
showing
submucosal lesion
Contributed by Kenechukwu Ojukwu, M.D., M.P.P. and Danielle Hutchings, M.D.
Heterotopic pancreas in Meckel diverticulum
Heterotopic pancreas in stomach
Contributed by Kenechukwu Ojukwu, M.D., M.P.P. and Danielle Hutchings, M.D.
Pancreatic heterotopia in the stomach
Submucosal lesion, lobular architecture
Pancreatic acini and ducts
Heterotopic pancreas predominantly ducts
Branching ectopic pancreatic ducts
Ducts, acini and islets
Intraductal papillary mucinous neoplasm (IPMN)
Gastric type IPMN
IPMN, low grade dysplasia
Meckel diverticulum with heterotopia
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Cell block with normal pancreatic acini
Benign pancreatic
acinar cells and
ductal epithelium
(Diff-Quik)
Contributed by Irene Y. Chen, M.D.
CT abdomen
MRI abdomen
Contributed by Irene Y. Chen, M.D. and Dennis R. Dening, PA (ASCP)
Pancreatic head tumor
Pancreatic tail tumor
Contributed by Diana Agostini-Vulaj, D.O.
Nested pattern
Synaptophysin
Insulin
Contributed by @liverwei on Twitter
Intraductal oncocytic papillary neoplasm
Contributed by Gokce Askan, M.D. and Olca Basturk, M.D.
Unilocular or multilocular cystic lesion
Papillae lined by oncocytic epithelium
Intracytoplasmic vacuoles
MUC6
Pseudoinvasion
Tubular invasion pattern
Mucinous invasion pattern
Contributed by @liverwei on Twitter
Contributed by @liverwei on Twitter (see original post here)">
Intraductal oncocytic papillary neoplasm
Images hosted on other servers:
Oncocytic cell sheets with prominent nucleoli
Punched out spaces, intracytoplasmic mucin
Images hosted on other servers:
MRCP demonstrating various types of IPMN
MRCP demonstrating side branch IPMNs
Differing radiologic
modalities demonstrating
various types of
IPMN and MCN
Images hosted on other servers:
Mucin extrusion from duodenal papilla
Contributed by Dennis R. Dening, PA (ASCP)
Main duct IPMN
Contributed by Diana Agostini-Vulaj, D.O.
IPMN intestinal subtype with low grade dysplasia
IPMN gastric subtype with low grade dysplasia
IPMN with high grade dysplasia
MUC1
MUC2
Images hosted on other servers:
Low grade epithelial atypia
High grade epithelial atypia with necrotic debris
Images hosted on other servers:
Polypoid mass within dilated main pancreatic duct
Contributed by Gokce Askan, M.D. and Olca Basturk, M.D.
Nodules of back to back tubular glands
Intraductal growth pattern
Sharply circumscribed nest formation
Tightly packed tubules lined by atypical cuboidal epithelium
Comedo-like necrosis
Clear cell changes
Osseous metaplasia
Invasion
MUC1 expression
MUC6 expression
Images hosted on other servers:
CT
Large cystic mass
Mimicking serous / mucinous cystadenoma
Images hosted on other servers:
Intraoperative view
Contributed by Jen Rytych, M.D.
Sections of lymphoepithelial cyst
Images hosted on other servers:
Well demarcated cysts
Pancreas tail
Contributed by Jen Rytych, M.D. and Katrina Krogh, M.D.
Squamous lined cyst
Cyst with lymphoid cuff
Abundant keratin debris
Simple columnar and stratified squamous linings
Squamous lined lymphoid tissue
Contributed by Jen Rytych, M.D.
Degenerated squamous epithelial cells
Images hosted on other servers:
Squamous epithelium,
keratinaceous debris
and lymphocytes
Keratinaceous debris
Contributed by Rong Xia, M.D., Ph.D. and Beena Ahsan, M.D.
Circumscribed borders
Sheet-like growth pattern
Syncytial growth pattern
Positive p63 immunostain
Images hosted on other servers:
Location of tumors in patients with MEN1
AFIP images
Intramucosal tumor nodules
Zollinger-Ellison syndrome
AFIP images
Pancreatic microadenomas in patients with MEN1
Duodenal gastrinoma in the mucosa and submucosa
Hypertrophic and eroded mucosa
Images hosted on other servers:
MiNEN in the head of the pancreas on CT
MiNEN in pancreas head with portal vein narrowing on CT
Images hosted on other servers:
Mixed ductal neuroendocrine carcinoma
Contributed by Jennifer Ziebell, M.D. and Ashwini Esnakula, M.D., M.S.
Mixed ductal neuroendocrine carcinoma
Neuroendocrine carcinoma component
Ductal adenocarcinoma component
Chromogranin A
Ki67 neuroendocrine carcinoma component
MiNEN basics
Contributed by Claudio Luchini, M.D., Ph.D.
Medullary histology
Mucinous colloid histology
Adenosquamous histology
Contributed by Diana Agostini-Vulaj, D.O. and AFIP images
MCN with no connection to main duct
Unilocular cyst
Conspicuous, irregular, solid protuberances
Multiloculated cystic lesion
36 year old
woman: large
cyst with
solid tumor
Images hosted on other servers:
39 year old man with multilocular cyst with thick mucin
Contributed by Raul S. Gonzalez, M.D. and Matthew W. Rosenbaum, M.D.
Spindled ovarian type stroma
Focal minute papillation
Foveolar mucinous epithelium
Classic ovarian type stroma
MCN with invasion
Estrogen receptor
Contributed by Matthew W. Rosenbaum, M.D.
Cytology of mucinous cystic neoplasm
Contributed by Katrina Krogh, M.D.
PDA: ill defined white lesion
MCN: unilocular cyst with thick wall
IPMN: small cysts with smooth linings
MNC: unilocular
simple cyst with
smooth thin lining
Contributed by Jen Rytych, M.D. and Katrina Krogh, M.D.
Mucinous pancreatic adenocarcinoma
Pancreatic adenocarcinoma, grade 2
MCN: ovarian type stroma
IPMN, gastric type
IPMN, intestinal type
MNC
Images hosted on other servers:
20 day old girl with persistent hypoglycemia and seizures
23 year old man with hypoglycemia mimicking an insulinoma
Images hosted on other servers:
MRI demonstrating small WDNET
CT and Gallium 68 Dotatate PET showing WDNET
Contributed by Danielle Hutchings, M.D.
Well circumscribed, solid tumor in pancreatic tail
Tumor with hemorrhage
Invasion into spleen
Large vessel invasion
Pancreatic duct obstruction
Cystic degeneration
Contributed by Danielle Hutchings, M.D. and Sabrina Sopha, M.D.
Amyloid deposition
Poorly differentiated neuroendocrine carcinoma, small cell type
Poorly differentiated
neuroendocrine
carcinoma, large
cell type
Calcification
Cribriform pattern
Pseudoacinar pattern
Organoid pattern
Ki67 staining
INSM1 immunostain
Spread to duodenum (H&E and synaptophysin)
Synaptophysin staining
Synaptophysin staining
Chromogranin staining
Well differentiated pancreatic neuroendocrine tumor
(cell block, synaptophysin, chromogranin)
Contributed by Sabrina Sopha, M.D. and AFIP images
Well differentiated pancreatic neuroendocrine tumor
(pap stained smears)
Round nuclei and scanty cytoplasm
AFIP images
Enterochromaffin cell tumor: irregularly shaped
Solid tumors of the pancreas
Images hosted on other servers:
CT scan
Images hosted on other servers:
Nests of small, uniform polygonal cells
Pushing margin
Spindle cell component
Chromogranin
Desmin
Topoisomerase II alpha
Images hosted on other servers:
CT and ultrasound
with pancreatic
head mass
AFIP images
Trabecular growth
Pancreatic endocrine tumor with PP expression
Images hosted on other servers:
Chromogranin and PP
Images hosted on other servers:
Abundant basal accumulation of secretory granules
Images hosted on other servers:
Pancreatoblastoma,
CT scan
Images hosted on other servers:
Pancreatoblastoma,
body / tail mass
Contributed by Lizhi Zhang, M.D.
Geographic tumor lobules
Lobulated tumor nests
Acinar differentiation
Squamoid nests
Squamoid nests with keratinization
Neuroendocrine component
Ductal component
Primitive component
Stroma
Keratin immunostain
Trypsin immunostain
Beta catenin immunostain
CK5 immunostain
Synaptophysin immunostain
Images hosted on other servers:
Classification
Contributed by Ayşe Armutlu, M.D.
Normal
Low grade / PanIN 1A
Low grade / PanIN 1B
Low grade / PanIN 2
High grade / PanIN 3
Images hosted on other servers:
Survival curves for
well differentiated
tumors and
carcinomas
Images hosted on other servers:
Small cell carcinoma
Contributed by Claudio Luchini, M.D., Ph.D. and AFIP images
General morphological appearance
Tumor necrosis
Large cell PanNEC
Small cell PanNEC
Nodal metastasis of PanNEC
Synaptophysin positivity
Chromogranin A positivity
Typical p53 expression
Rb loss
Focal necrosis
Intense immunostaining for NSE
Solid diffuse pattern
Scattered somatostatin immunoreactive cells
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Overlapping pancreatic cells
Contributed by Aatur D. Singhi, M.D., Ph.D.
Gross parenchymal atrophy
Contributed by Aatur D. Singhi, M.D., Ph.D.
Early microscopic changes
Residual islets of Langerhans
Progressive replacement by fibrosis and fat
Near complete replacement
Low grade PanIN
Contributed by Paola Mattiolo, M.D. and Claudio Luchini, M.D., Ph.D.
Large pancreatic pseudocyst
Fibrous wall of pseudocyst
Large pseudocyst of the pancreatic head
Cut surface of the pseudocyst of figure 3
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Multiseptated lesion filled with fluid
Encapsulated cystic lesion with yellow-green material
Resembling cystic neoplasm
Contributed by Paola Mattiolo, M.D., Claudio Luchini, M.D., Ph.D. and AFIP images
Absence of an epithelial lining
Inflammation of pseudocyst wall
Fibrotic reaction
Hemorrhagic modifications
Patient with chronic pancreatitis and pseudocyst
Images hosted on other servers:
Well circumscribed solid lesion
Contributed by Olca Basturk, M.D.
Overall appearance
Well circumscribed lesion
Peripheral dense lymphoid aggregates
Entrapped pancreatic parenchyma
Hypercellular and hypocellular areas
Sheets of epithelioid cells
Atypical spindle cells
Dense hyaline fibrosis
Membranous CD99 expression
Dot-like CK18 expression
Images hosted on other servers:
Genomic and transcriptomic characterization
Contributed by Pınar Bulutay, M.D.
Central scar
Thin fibrous septa
Macrocystic and solid variant
Images hosted on other servers:
Solid variant
Contributed by Pınar Bulutay, M.D.
Innumerable submillimeter cysts
Prominent capillary network
Cellular details
Intracystic papillary projections
Macrocystic type
Cellular details, macrocystic type
Papillary projections, macrocystic type
Contributed by Amanda Kitson, M.D. and Jiaqi Shi, M.D., Ph.D.
CT: abdomen coronal
CT abdomen, transverse section
T2 MRI: abdomen coronal
Images hosted on other servers:
Hematochezia and active bleeding from ampulla
Pancreatic cyst and elevated posterior wall of gastric body
Contributed by Amanda Kitson, M.D. and Jiaqi Shi, M.D., Ph.D.
Multiloculated cyst in pancreatic head
Cyst in pancreatic body
Contributed by Amanda Kitson, M.D. and Jiaqi Shi, M.D., Ph.D.
Cuboidal to columnar epithelium
Gastric type mucinous epithelium
Hypocellular stroma
Focal atypia
Contributed by Omid Savari, M.D.
MR of abdomen
Images hosted on other servers:
Hypodense lesion
Endoscopic ultrasound
Multiple metastases
Contributed by Omid Savari, M.D., Dr. Andreas Schulz, Manfred Stolte, M.D., Dr. Helmut Luchtrath and Case #121
Predominately solid tumor
Partially necrotic tumor
Invasion of spleen
Cystic lesion
Multilocular cystic mass
Contributed by Monika Vyas, M.D., Omid Savari, M.D. and Raul S. Gonzalez, M.D.
Pleomorphism and cytologic atypia
Intracytoplasmic eosinophilic hyaline globules
Tumor infiltration by foamy histiocytes
Solid pseudopapillary neoplasm
Solid pattern
Clear cell changes
Cholesterol cleft, scattered giant cells
Tumor invading parenchyma
Beta catenin
CD10
Ki67
Metastasis to liver
Contributed by Omid Savari, M.D. and @ThatGlassTho on Twitter
Diff-Quik
Pap
Cell block
Solid pseudopapillary neoplasm
Contributed by Dr. H.D. John, Mainz
Abundant mitochondria
Granules
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CT pancreas mass
PET with metastases
Images hosted on other servers:
Pancreatic and duodenal tumors
Contributed by Raul S. Gonzalez, M.D.
Nests and cords of cells
AFIP image
D cell granules
Contributed by Claudio Luchini, M.D., Ph.D. and AFIP
Ductal
adenocarcinoma
with undifferentiated
component
Ill demarcated tumor in head of pancreas
Extensive hemorrhagic necrosis
Contributed by Claudio Luchini, M.D., Ph.D. and AFIP
Anaplastic undifferentiated carcinoma
Massive perineural invasion
Massive vascular invasion
Association with ductal adenocarcinoma
Invasion of duodenum
Rhabdoid aspects
Biopsy
Details on biopsy
Spindle cell sarcomatoid features
Pleomorphic large cells
Engulfment of red blood cells
Glandular differentiation
Tumor is keratin+
Tumor is CEA+ in glandular portions
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Ultrasound
CT
Contributed by Claudio Luchini, M.D., Ph.D.
Cystic tumor
Images hosted on other servers:
Hemorrhagic mass
Macrophotograph revealing cystic mass
Cystic mass with gastric invasion
Contributed by Claudio Luchini, M.D., Ph.D.
Associated conventional adenocarcinoma
Ductal tree involvement
Microhemorrhagic foci
Extensive necrotic hemorrhage
CK8/18+
Focal CK8/18+
CK8/18-
Images hosted on other servers:
Romanowsky stain
Papanicolaou stain
Images hosted on other servers:
Neoplastic cell
Giant cell
Images hosted on other servers:
Pancreatic tail mass
Liver metastasis
Contributed by Raul S. Gonzalez, M.D.
Nests and cords of cells
AFIP images
Pancreatic VIPoma
Images hosted on other servers:
Large mass in pancreas tail
Contributed by Katrina Krogh, M.D.
Well circumscribed mass
Cut surface of mass
Images hosted on other servers:
Invasion of large vessel
Tumor in isthmus / body
Contributed by Katrina Krogh, M.D.
Trabecular growth
Neuroendocrine nuclei
PanNET (VIPoma) metastatic to liver
Ki67
Synaptophysin
Chromogranin
Contributed by @RaulSGonzalezMD on Twitter
Contributed by @RaulSGonzalezMD on Twitter (see original post here)">
bit.ly/3zIR8Xf for a nice review). Here's a great example of the ductulo-insular subtype, with admixed benign glandular structures. Good prognosis. #pathology #gipath #PathTwitter #PathOutPic"Contributed by @RaulSGonzalezMD on Twitter (see original post here)">
bit.ly/3zIR8Xf for a nice review). Here's a great example of the ductulo-insular subtype, with admixed benign glandular structures. Good prognosis. #pathology #gipath #PathTwitter #PathOutPic"Contributed by @RaulSGonzalezMD on Twitter (see original post here)">
Well differentiated neuroendocrine tumor
Contributed by Katrina Krogh, M.D.
Diff-Quik
Images hosted on other servers:
MEN1 mutation
Table 1: Papanicolaou reporting system for pancreaticobiliary cytology
| Diagnostic categories | Average risk of malignancy | Examples of entities | Selected ancillary testing | Management |
I. Nondiagnostic | 23.1% | • Cellular artifact, obscuring hemorrhage or necrosis • Pure GI contamination • Acellular cyst aspirate with no evidence of mucinous etiology • Benign pancreatic parenchyma with clearly defined mass on imaging | Cyst fluid analysis: CEA and amylase (no mucinous etiology = lack of mucin, lack of elevated CEA, lack of KRAS or GNAS mutations) | Reassess / repeat |
II. Negative | 8.2% | • Pancreatitis • Pseudocyst • Lymphoepithelial cyst • Splenule / accessory spleen • Benign pancreatic parenchyma with no mass on imaging | Pseudocyst: high amylase + low CEA | Conservative |
III. Atypical | 46.8% (range: 28 - 100) |
• Ductal cells with indeterminate atypia (reactive versus low grade dysplasia, versus scant lesional tissue) • Abundant intracytoplasmic mucin in the epithelium | Cyst fluid analysis: CEA and amylase | Conservative, repeat or surgery |
IV. Neoplastic: benign | 20.2% |
• Serous cystadenoma (SCA) • Lymphangioma • Cystic teratoma • Schwannoma | SCA: low amylase + low CEA, VHL mutation, positive inhibin staining | Conservative |
IV. Neoplastic: other | 37.5% |
• GIST • Extra-adrenal paraganglioma • Pancreatic solitary fibrous tumor Premalignant • IPMN with dysplasia • IPNB • MCN with dysplasia Low grade malignant • PanNET • Solid pseudopapillary neoplasm (SPN) |
Solitary fibrous tumor: STAT6 mutation Intraductal papillary mucinous neoplasm: KRAS, RNF43, GNAS (specific), TP53, SMAD4 mutations Solid pseudopapillary neoplasm: CTNNB1 (beta catenin) mutation | Surgery with an option for conservative management in select scenarios |
V. Suspicious | 92.1% |
• Pancreatic ductal adenocarcinoma (PDAC) • PanNET • Acinar cell carcinoma • Pancreatoblastoma • Solid pseudopapillary neoplasm • Cyst aspirate with solid mural nodule or cyst wall mass • Lymphoma • Metastases • High grade BilIN | Immunocytochemistry, FISH molecular analysis Cyst fluid analysis: CEA and amylase | Surgery |
VI. Positive | 99.6% | • PDAC and variants • Cholangiocarcinoma • Acinar cell carcinoma • Small and large cell neuroendocrine carcinoma • Pancreatoblastoma • Lymphomas • Sarcomas • Metastases to the pancreas | Immunocytochemistry patterns in malignancy: • Positive: S100P, IMP3, MUC4, mesothelin • Negative: pVHL, CD10, clusterin beta, SMAD4 FISH significantly improves diagnostic sensitivity of adenocarcinoma (copy number abnormalities in CEP3, CEP7, CEP17 and of band 9p21) | Surgery or neoadjuvant therapy / clinical trials |
- Reference: Diagn Cytopathol 2020;48:494
Contributed by Derek Allison, M.D.
Duodenal contaminant only
GI contaminant only
Benign pancreatic parenchyma
Pancreatic splenule
Pancreatic splenule (CD8+)
Pancreatic splenule (CD45+)
Lymphoepithelial cyst
Clean mucin
IPMN with cytologic atypia
Reactive atypia; chronic pancreatitis
Biliary brush stricture
Serous cystadenoma
Serous cystadenoma: inhibin
Well differentiated
NET, WHO grade 1
Solid pseudopapillary neoplasm
Mucinous cystic neoplasm
Suspicious for pancreatic adenocarcinoma
Pancreatic ductal adenocarcinoma
Well differentiated pancreatic adenocarcinoma
PDAC by biliary brush
Bekaii-Saab: 2017
Campbell: 2020
Casillas: 2015
Centeno: 2015
Cheng: 2023
D'Onofrio: 2015
Greenson: 2019
Husain: 2021
IAC-IARC-WHO: 2023
IARC: 2017
IARC: 2019
Jiang: 2023
Klimstra: 2023
La Rosa: 2015
Lamps: 2021
Mody: 2022
Nosé: 2022
Odze: 2022
Srivastava: 2023
Thompson: 2021
Wood: 2017
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