13. Path Lab: Pancreas and Gallbladder

Question 1

What was the goal of this lab?

Answer 1

To distinguish between chronic pancreatitis and ductal adenocarcinoma of the pancreas.

Question 2

What are some histo features of ductal adenocarcinoma?

Answer 2

• infiltrative growth pattern
• poorly-formed glands
• perineural/angiolymphatic invasion
• cytologic atypia (Anisonucleosis, hyperchromasia, nuclear pleomorphism, prominent nucleoli)

Question 3

Carcinoma or chronic pancreatitis?

Answer 3

Carcinoma.

Question 4

carcinoma or chronic pancreatitis?

Answer 4

Carcinoma

Question 5

Carcinoma or chronic pancreatitis?

Notable features? arrows?

Answer 5

Carcinoma.

Less differentiated, ductal adenocarcinoma
Note clusters of cells at arrows.
Middle/left structure: nerve.
Sometimes see glandular structures around and in nerve -> perineural invasion, way to identify cancer.

Question 6

Carcinoma or chronic pancreatitis? notable?

Answer 6

Carcinoma

No lobular arrangement of the glandular compartment.
Different from chronic pancreatitis: ductal structures arranged in lobules.

Question 7

Chronic pancreatitis: what are the features?

Answer 7

• Fibrous tissue replaces exocrine tissue.
• Some lobules show atrophy of acinar parenchyma.
• A sparse lymphocytic infiltrate may be present
• Remnant ducts in lobular, orderly, well-circumscribed arrangement, surrounded by fibrosis.
• Islets tend to remain longer than acinar cells

Question 8

carcinoma or chronic pancreatitis?

Answer 8

Chronic pancreatitis.

Lobule with some residual acinar tissue, but some atrophy
Overall lobular arrangement, central duct (biggest white)

Question 9

carcinoma or chronic pancreatitis?

Answer 9

Chronic pancreatitis

Note ducts more resistant to atrophy than surroundings.

Question 10

Carcinoma or chronic pancreatitis?

Answer 10

Chronic pancreatitis.

Note atrophic lobule.
Islets survive longer than acinar tissue

Question 11

carcinoma or chronic pancreatitis?

Answer 11

chronic pancreatitis.

Islets can condense, look like neuroendogrine tumors but it’s just condensed islets.
Residual acinar tissue here between islets

Question 12

severe acute pancreatitis: features?

Answer 12

• acinar necrosis
• peripancreatic fat necrosis

Question 13

what is this?

Answer 13

severe acute pancreatitis

note necrosis of pancreatic tissue, liquefaction

(general features: Acinar necrosis, Peripancreatic fat necrosis)

Question 14

What is this? what’s in the middle?

Answer 14

severe acute pancreatitis

Middle = area of necrosis

(general features: Acinar necrosis, Peripancreatic fat necrosis)

Question 15

what is this? what is the upper left area?

Answer 15

severe acute pancreatitis.

upper left is fat necrosis.

(general features: Acinar necrosis, Peripancreatic fat necrosis)

Question 16

Acute cholecystitis: how would it appear on histo?

Answer 16

PMNs, edema, hemorrhage, mucosal ulceration.

Question 17

What is this? notable?

Answer 17

acute cholecystitis.

Note destruction of gallbladder wall by acute inflammation. Top - necrosis of GB wall, no normal epithelium. Mucosa are destroyed, inflammation goes deeper into muscularis propria (can’t tell that from this pic)

Question 18

what is this? notable?

Answer 18

acute cholecystitis.

Fibrosis in the wall suggests an ongoing process (acute to chronic transition)

Healing can occur: this is an area of developing fibrosis, attempt to heal acute necrosis due to acute inflammation.
Fibrosis seen as proliferation of spindle cells (fibroblasts) and lots of connective type tissue (collagen, stains pink, amorphous material here.)

Question 19

Features of chronic cholecystitis?

Answer 19

Fibrosis in the wall, mild chronic inflammation, Rokitansky-Aschoff sinuses

Question 20

what is this? arrow points to what?

Answer 20

Chronic cholecystitis (mild)

arrow points to Rokitansky-Aschoff sinus

RA sinus: mucosa prolapses deep into the subserosal space. could be confused with an invasion, but here it is a benign prolapse.

Question 21

What is this? arrows point to what?

Answer 21

Chronic cholecystitis (mild)
Histiocytes acquiring lipids, infiltrating mucosal folds
Right pic: pale cyto, central nuclei. Cholesterolosis.

Arrows: Foamy Macrophages

Question 22

What is this? notable?

Answer 22

gallbladder adenocarcinoma
Haphazard arraangement, small glands,
Glands not arranged into lobules. May also see benign glands that are arranged.

Question 23

What is this? notable?

Answer 23

Gallbladder adenocarcinoma

GB wall is thick because of chronic cholecystitis.
Infiltrating atypical glands, haphazard arrangement.
Stromal arrangement: desmoplasia. Reaction to infiltrating glands of adenocarcinoma.

Question 24

What is this? notable? arrows?

Answer 24

gallbladder adenocarcimona.

Arrows to abnormal glands (due to invastion by adenocarcinoma)

Sig cytological differences, large nuclei, clumpy chromatin, crowding, loss of nuclear polarity.

Question 25

What is this? notable?

Answer 25

Chronic pancreatitis. Areas of necrosis from acute pancreatitis have been replaced by fibrotic tissue (pink, wavy) L side of the pic: normal acinar cells, preserved normal tissue. Middle of the pic: ductal cells are preserved, though acini have atrophied. **Ductal cells are NOT invading the islets so this is NOT carcinoma.**

Question 26

From the lab sheet: what am I looking for in chronic pancreatitis?

Answer 26

- atrophy of some lobules of acinar tissue - scarring, i.e., replacement by fibrous tissue - "plugs" in ducts (but these are not always present) - lymphocytic infiltrate in scattered areas - Islets and ducts may persist in areas of scarring.

Question 27

From the lab sheet: what am I looking for with pancreatic ductal carcinoma?

Answer 27

- neoplastic ducts usually associated with desmoplasia (growth of fibrous or connective tissue, secondary to insult) - invasion of adjacent tissue (fat or duodenum) - lymph node metastasis, and perineural invasion - Chronic pancreatitis may be present adjacent to a carcinoma because of duct obstruction by the tumor.

Question 28

What organ, what's going on?

Answer 28

Gallbladder. Invagination in the middle of the slide, due to mechanical pressure (possibly gallstones). Benign. Lumen of the gallbladder is to the L side, R side is serosa/fat external to the gallbladder.

Question 29

what organ, what's going on?

Answer 29

gallbladder. Cholesterol-filled macrophages in upper left: often seen in pts with high chol, or chol stones. Macrophages are in the lamina propria.

Question 30

what organ, what's going on?

Answer 30

gallbladder, adenocarcinoma. The wall is invaded by neoplastic glands. This cancer can look very similar to carcinoma of the pancreas, i.e. a ductal adenocarcinoma. The prognosis is poor because many of these carcinomas extend directly through the thin gallbladder wall into the liver. The pic below is a higher power: shows glands in the muscularis of the GB. should never see glands here so these are neoplastic.