Table of Contents
Definition / general | Essential features | Sites | Clinical features | Diagnosis | Cytology description | Cytology images | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Policarpio-Nicolas MLC. Cytology. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/pancreascytology.html. Accessed January 23rd, 2021.
Definition / general
- Normal and nonneoplastic findings in pancreas cytology
- Preparations:
- Conventional smears or touch preparation stained with Diff-Quik, Papanicolaou
- Liquid based (thin prep)
- Cytospin
- Cell block (for immunohistochemistry and molecular)
- Cyst fluid (chemistry, tumor markers, molecular)
Essential features
- Normal cellular elements:
- Acinar
- Ductal
- Islet cells (rare)
- Contaminants during procedure:
- Bile
- Gastric epithelium
- Duodenal epithelium
- Hepatocytes
- Mesothelial cells
- Procedures:
- Pancreas image guided fine needle aspiration (FNA)
- Bile duct brushing
- Percutaneous interventional guided FNA
Sites
- Head / uncinate, body and tail of pancreas
Clinical features
- General settings: patients with suspected neoplasia of the pancreaticobiliary tract should receive the following (Diagn Cytopathol 2014;42:325)
- Clinical history and physical examination, including identifying risk factors for malignant causes and for benign explanations for a stricture or cyst (e.g. chronic pancreatitis, primary sclerosing cholangitis / inflammatory bowel disease, autoimmune disease, etc.)
- Laboratory studies (e.g. serum bilirubin and alkaline phosphatase)
- Selective use of serum tumor markers (CA19-9 and CEA)
- Imaging studies
- Serum IgG4 when autoimmune disease is suspected
- Clinical indications for pancreas FNA
- Pancreatic mass / cyst on imaging (Diagn Cytopathol 2014;42:325)
- Unexplained acute pancreatitis in older patients
- Newly diagnosed late onset diabetes mellitus
- Jaundice, pruritus, cholestasis unexplained by underling hepatobiliary disease or choledocholithiasis
- Anorexia, weight loss, abdominal pain radiating to the back
- Clinical indications for bile duct brushing
- Obstructive jaundice (Acta Cytol 2016;60:167)
- Distal common bile duct stricture
- Proximal / complex hilar stricture
- Screening patients with primary sclerosing cholangitis for biliary neoplasia (Endoscopy 2016;48:432)
Diagnosis
- Common diagnostic procedures utilized in the procurement of pancreatic cytology samples:
- Endoscopic ultrasound (EUS) guided FNA for pancreatic mass / lesions
- Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) are used to obtain brushing or aspiration from the common bile duct and pancreatic duct stricture / mass
Cytology description
Normal
Nonneoplastic contaminants
- Bile duct
- Monolayered flat sheets arranged in honeycomb pattern
- Cuboidal to columnar cells
- Bland appearing basally located nuclei imparting a picket fence appearance
- Scant pale cytoplasm
- Acinar cells
- Pyramidal to triangle shaped cells arranged singly, in clusters or grape-like appearance occasionally embedded in fibroconnective tissue
- Abundant granular cytoplasm
- Round central to eccentric nuclei
- Occasional nucleoli
- Islet cells
- Infrequently seen in normal pancreas
Nonneoplastic contaminants
- Bile: seen in biliary specimens
- Duodenal epithelium: seen in EUS guided transduodenal FNA for lesions in pancreatic head and uncinate
- Flat sheets (honeycomb) arrangement, occasional singly scattered cells
- Uniformly round, bland appearing evenly spaced nuclei
- Scant pale cytoplasm
- Goblet cells present (Diagn Cytopathol 2005;33:381)
- Gastric epithelium: present in transgastric EUS FNA for pancreatic lesions in the body and tail
- Flat sheets arranged in monolayered (honeycomb) pattern (Diagn Cytopathol 2005;33:381)
- Cells with uniformly round, evenly spaced bland appearing nuclei
- Pale cytoplasm with well defined cell border
- Surface epithelium lined by tall columnar cells with basally located nuclei and cytoplasm filled with abundant mucin
- Hepatocytes: contaminant in procedures using percutaneous interventional guided FNA
- Polygonal cells with well defined cell borders and abundant granular cytoplasm
- May have intracytoplasmic pigment (bile, lipofuscin or iron)
- Centrally located nuclei, prominent nucleoli
- Occasional intranuclear inclusions
- Mesothelial cells: contaminant in procedures using percutaneous interventional guided FNA
- Polygonal cells arranged in flat sheets
- Moderate amount of cytoplasm (dense in the center and pale in periphery)
- Clear spaces in between cells intercellular windows
- Single to occasionally binucleated to multinucleated round to oval nuclei
Cytology images
Contributed by Maria Luisa C. Policarpio-Nicolas, M.D.
Sample pathology report
- Pancreas, head, endoscopic ultrasound guided fine needle aspiration:
- Nondiagnostic
- Normal acinar and ductal epithelium. The biopsy does not explain the well defined pancreatic mass seen on imaging (Cytojournal 2014;11:3).
Differential diagnosis
- Acinar carcinoma:
- Highly cellular, small to moderate sized loose groups, numerous single cells and stripped round nuclei, prominent acinar formation, little anisonucleosis, prominent nucleoli (Diagn Cytopathol 2006;34:367)
- Ductal adenocarcinoma:
- 3 dimensional to glandular arrangement of tumor cells, loss of polarity, moderate to marked variation in nuclear size (4:1 ratio), small to large prominent nucleoli, singly scattered tumor cells, mitotic figures (few to many)
Board review style question #1
Board review style answer #1
Board review style question #2
Which is the method used to procure a cytology sample from a bile duct stricture?
- Endoscopic ultrasound guided
- CT guided
- Endoscopic retrograde cholangiopancreatography
- MRI guided
Board review style answer #2