Intraductal papillary mucinous neoplasm of the pancreas

Cytologic features predict histologic grade

Authors

  • Paul J. Michaels M.D.,

    1. James Homer Wright Pathology Laboratories and Cytopathology Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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  • Elena F. Brachtel M.D.,

    1. James Homer Wright Pathology Laboratories and Cytopathology Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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  • Brenna C. Bounds M.D.,

    1. Department of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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  • William R. Brugge M.D.,

    1. Department of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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  • Martha Bishop Pitman M.D.

    Corresponding author
    1. James Homer Wright Pathology Laboratories and Cytopathology Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
    • Department of Pathology, Warren 105-D, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114
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    • Fax: (617) 724-6564


Abstract

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) is an increasingly recognized cystic neoplasm of the pancreas, histologically classified by the degree of epithelial atypia and by the presence or absence of invasion of the cyst wall. To the authors' knowledge, the cytologic features of this neoplasm are poorly characterized, especially with respect to tumor grade.

METHODS

Thirty-three endoscopic ultrasound (EUS)-guided pancreatic fine-needle aspiration biopsy (FNAB) samples and 1 pancreatic duct brush specimen from 25 patients with a histologically confirmed IPMN were retrospectively reviewed. Blinded to tumor grade, background mucin, inflammation, necrosis, overall cellularity, the presence of gastrointestinal-contaminating epithelium, architecture of cell clusters, and nuclear and cellular morphology were evaluated. In cases in which special stains for mucin were performed, the diagnostic utility of these stains was assessed. These cytologic features were subsequently correlated with the histologic diagnosis.

RESULTS

The 34 cytology samples represented 4 adenomas, 15 IPMN-moderate dysplasias, 7 intraductal carcinomas, and 8 IPMNs with invasive carcinoma. Extracellular mucin was present in 97% of all cases; 53% had thick, viscous, “colloid-like” mucin. Special stains for mucin were positive in 6 of 11 cases (54%), helping to identify thin mucin in only 2 cases. Gastrointestinal contamination did not appear to create diagnostic difficulty due to an apparent dual (dysplastic-nondysplastic) epithelial population, but only 4 adenomas were evaluated in this study. Necrosis distinguished IPMN with carcinoma from IPMN-adenomas and IPMN with moderate dysplasia (P < .00001), and was more often observed with invasion than IPMN-carcinoma in situ (P < .05). Tight epithelial cell clusters with hyperchromatic nuclei and a high nuclear to cytoplasmic ratio was more significant in IPMN of at least moderate dysplasia (P = .03). Pale nuclei with parachromatin clearing was found to be a nuclear feature that was suspicious for at least carcinoma in situ (P < .001). In addition, significant background inflammation (neutrophils and histiocytes) was found to be more characteristic of IPMN with at least carcinoma in situ (P = .002).

CONCLUSIONS

The presence of thick, “colloid-like” mucin is noted in half of the IPMN cases, but was not found to be specific to grade. The absence of such mucin does not exclude an IPMN. The presence of tight epithelial cell clusters is consistent with a neoplasm of at least moderate dysplasia, and abundant background inflammation and parachromatin clearing correlated with the presence of at least carcinoma in situ. Necrosis was the only feature found to be strongly suggestive of invasion. Cancer (Cancer Cytopathol) 2006. © 2006 American Cancer Society.

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