Contributed by Zhengbin Lu, MD, Anthony J. Demetris, MD
Published on line in February 2003
The patient was 56 year old female with a pancreatic mass, who had undergone a Whipple procedure to remove the tumor. A more detailed clinical history is not available.
This was a Whipple's procedure specimen (Figs. G1 and G2), which consisted of a segment of duodenum, 25 cm in length, and a portion of pancreas, 8 x 7.5 x 4.5 cm. There was a large mass, 5.0 x 4.5 x 3.0 cm, occupied the head of pancreas, which otherwise was tan-pink, rubbery with no apparent necrosis on the cut surface. The tumor extended into the adjacent duodenum but did not directly invade the mucosal surface grossly. The common bile duct was grossly probe-patent and of normal caliber. Seven peripancreatic lymph nodes were identified. All surgical margins appeared to be free of tumor.
: The tumor was well demarcated from the adjacent pancreatic tissue on low-power examination (Fig. 1). In most areas, tumor cells grew around the vessels with significant amount of perivascular edema, hyalinization and myxoid degeneration. (Figs. 2, 3 and 4). In some of these areas, tumor cells formed perivascular "ependymal"-like rosette or pseudopapillary structures (Figs. 5, 6 and 7). In other areas tumor cells showed glandular (Figs. 8 and 9), solid (Figs. 9 and 10) and gyriform patterns (Fig. 11). The cystic degeneration was also noted (Fig. 2). The tumor invaded the duodenal mucosa (Fig. 12) and showed focal angiolymphatic invasion with three positive lymph nodes (images not shown). Most of the tumor was composed of ovoid to cuboidal cells with mild to moderate slightly granular cytoplasm and enlarged nuclei with inconspicuous nucleoli (Figs. 4, 5, 6 and 7).
The tumor cells were strongly positive for AE1/AE3 (Fig. 13), chromogranin (Fig. 14), synaptophysin (Fig. 15), CD56 (Fig. 16), alpha-1-antitrypsin (Fig. 17) and weakly positive for neuron-specific enolase (Fig. 18), and negative for CD10 (Fig. 19), vimentin (Fig. 20). The tumor cells were also negative for the major pancreatic hormone markers including insulin, glucagon, somatostatin and ACTH (images are shown). The results of these immunohistochemical stains are summarized as below:
SYN, synaptophysin; CGA, chromogranin; NSE, neuron-specific enolase; AAT, alpha-1-antitrypsin; VIM, vimentin.