Case 501 -- A 46-year-old woman with constant left upper quadrant pain

Contributed by Deborah Marks-Jones, MD, Smiljana Istvanic-Zdravkovic, MD and Jagjit Singh, MD


PATIENT HISTORY:

The patient was a 46-year-old woman with constant left upper quadrant pain. The patient's past medical history is significant for a myocardial infarction in 2001 with subsequent coronary artery bypass graft. The patient also has insulin-dependent type-2 diabetes mellitus diagnosed 9 years earlier. For approximately six weeks, the patient had been experiencing constant left upper quadrant pain which radiated to her left back. A CT scan was performed which showed a 7.0 cm, partially calcified, mass in the tail of the pancreas (Figure 1). There was no vascular involvement, nor adenopathy.

GROSS DESCRIPTION:

The specimen consisted of a 10.0 x 7.0 x 4.5 cm portion of pancreas, as well as the spleen and five peripancreatic lymph nodes. Sectioning of the pancreas revealed a 5.0 x 5.0 x 4.3 cm dull, lobulated, tan-yellow mass in the distal tail of the pancreas. The mass was approximately 1.5 cm from the stapled surgical resection margin. The lymph nodes and spleen were grossly unremarkable.

MICROSCOPIC DESCRIPTION:

Microscopic examination of the neoplasm revealed nests and cords of relatively round uniform epithelial cells. These cells are separated by a minimal amount of fibrovascular stroma (Figures 2, 3 and 4). Cytologically, the cells have "salt-and-pepper" chromatin with somewhat prominent nucleoli (Figure 5). No necrosis, mitosis or cellular pleomorphism are identified. Focal calcifications are present. Multifocal angiolymphatic invasion is noted (Figure 6). An immunohistochemical stain for synaptophysin is strongly positive in the neoplastic cells (Figure 7). The neoplastic cells are negative for chromogranin, CA19.9, vimentin, insulin, glucagon, somatostatin, PAS and mucicarmine.

FINAL DIAGNOSIS


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