Post on 14-Jan-2016
Pathology of the Pathology of the Exocrine Exocrine PancreasPancreas
Tyler Verdun, PGY3 General Pathology
University of British ColumbiaNovember 5, 2013
ObjectivesObjectives Brief review of normal pancreatic anatomyBrief review of normal pancreatic anatomy Overview of acute and chronic pancreatitisOverview of acute and chronic pancreatitis Introduction to pancreatic adenocarcinomaIntroduction to pancreatic adenocarcinoma
This session will not cover: This session will not cover: Endocrine pancreas pathologyEndocrine pancreas pathology Congenital abnormalitiesCongenital abnormalities Cystic lesionsCystic lesions Benign tumors (SPPT, cystadenomas, etc.)Benign tumors (SPPT, cystadenomas, etc.) Neuroendocrine tumorsNeuroendocrine tumors
The Normal The Normal PancreasPancreas
Normal PancreasNormal Pancreas
http://upload.wikimedia.org/wikipedia/commons/f/fc/Pancreas_4.jpg
Normal PancreasNormal Pancreas
Wait! There’s something wrong with this Wait! There’s something wrong with this picture…picture… No islets: this is actually parotid salivary glandNo islets: this is actually parotid salivary gland Sourced from http://www.youtube.com/watch?v=1Kavxv3jHzASourced from http://www.youtube.com/watch?v=1Kavxv3jHzA
Dr. John Minarcik’s excellent “Shotgun Histology” seriesDr. John Minarcik’s excellent “Shotgun Histology” series
Normal PancreasNormal Pancreas
PancreatitisPancreatitis
Acute PancreatitisAcute Pancreatitis
1. The pancreas is (metaphorically) a box 1. The pancreas is (metaphorically) a box of corrosive chemicalsof corrosive chemicals
2. Damage to the pancreas by some 2. Damage to the pancreas by some etiologic factor releases these chemicals etiologic factor releases these chemicals from cellsfrom cells
3. Digestion, saponification, and 3. Digestion, saponification, and calcification of neighboring healthy calcification of neighboring healthy tissuetissue On gross examination/autopsy – greasy, On gross examination/autopsy – greasy,
chalk-white depositschalk-white deposits
Acute Pancreatitis - Acute Pancreatitis - EtiologiesEtiologies
I – IdiopathicI – Idiopathic
G – GallstonesG – Gallstones E – Ethanol abuseE – Ethanol abuse T – Trauma: anything that compromises the blood supplyT – Trauma: anything that compromises the blood supply
S – SteroidsS – Steroids M – Microbiological (bacterial, viral, or parasitic infections) M – Microbiological (bacterial, viral, or parasitic infections) A – Autoimmune diseasesA – Autoimmune diseases S – Scorpion bite: S – Scorpion bite: Tityus trinitatisTityus trinitatis in Trinidad and Tobago in Trinidad and Tobago H – Hypercalcemia or hyperlipidemiaH – Hypercalcemia or hyperlipidemia E – ERCP: endoscopic procedure; can cause pancreatitisE – ERCP: endoscopic procedure; can cause pancreatitis D – Drugs: too many to list…D – Drugs: too many to list…
FYI: in a pinch, never doubt the “The Big 3”© FYI: in a pinch, never doubt the “The Big 3”© Antibiotics, antiepileptics/antipsychotics, anti-Antibiotics, antiepileptics/antipsychotics, anti-
inflammatoriesinflammatories
II
G G EE TT
S S MM AA S S HH EE DD
Important
Not so much
Impress your staff!
Acute Pancreatitis – Acute Pancreatitis – DiagnosisDiagnosis
Clinical presentation:Clinical presentation: Moderate to severe epigastric pain radiating to Moderate to severe epigastric pain radiating to
backback Nausea and vomitingNausea and vomiting Fever, ↑HR, ↑RR, ↓BPFever, ↑HR, ↑RR, ↓BP Rarely: abdominal or flank bruising (Cullen & Rarely: abdominal or flank bruising (Cullen &
Grey-Turner)Grey-Turner) ImagingImaging
CT scan and abdominal ultrasound showing CT scan and abdominal ultrasound showing inflammation or cystic structures around pancreasinflammation or cystic structures around pancreas
LabsLabs Elevated amylase and lipaseElevated amylase and lipase Elevated glucoseElevated glucose May see elevated liver markersMay see elevated liver markers
Acute Pancreatitis – Acute Pancreatitis – Radiologic FindingsRadiologic Findings
http://upload.wikimedia.org/wikipedia/commons/9/97/Pankreatitis_exsudativ_CT_axial.jpg
Acute Pancreatitis – Acute Pancreatitis – HistologyHistology
Normal pancreas
Horror Show
Acute Pancreatitis – Acute Pancreatitis – HistologyHistology
Neutrophils
Necrosis
Background pancreas
Hemorrhage
Acute Pancreatitis - Acute Pancreatitis - PrognosisPrognosis
MildMild Resolves with minimal supportive care within daysResolves with minimal supportive care within days
SevereSevere Significant fluid depletion and electrolyte Significant fluid depletion and electrolyte
abnormalitiesabnormalities Systemic inflammatory response and disseminated Systemic inflammatory response and disseminated
coagulationcoagulation Pseudocyst formationPseudocyst formation Necrosis and hemorrhageNecrosis and hemorrhage Abscess formation and sepsisAbscess formation and sepsis May require ICU and surgical managementMay require ICU and surgical management
Chronic PancreatitisChronic Pancreatitis
Consequence of long-standing inflammationConsequence of long-standing inflammation Usually will have had recurring episodes of Usually will have had recurring episodes of
acute pancreatitisacute pancreatitis ~80% will have history of alcoholism~80% will have history of alcoholism
Clinical presentationClinical presentation Chronic epigastric painChronic epigastric pain Persistent nausea and vomitingPersistent nausea and vomiting Other common findings Other common findings
Weight lossWeight loss Fatty stoolsFatty stools Low or normal plasma amylase and lipase levelsLow or normal plasma amylase and lipase levels
Chronic Pancreatitis – Chronic Pancreatitis – Radiologic FindingsRadiologic Findings
http://upload.wikimedia.org/wikipedia/commons/7/7b/Chronische_Pankreatitis_mit_Verkalkungen_-_CT_axial.jpg
Chronic Pancreatitis – Chronic Pancreatitis – HistologyHistology
Residual pancreas
Fibrosis and lymphocytic inflammation
Chronic Pancreatitis Chronic Pancreatitis
Functional pancreatic tissue is Functional pancreatic tissue is destroyeddestroyed 1. Enzyme levels are decreased or 1. Enzyme levels are decreased or
misleadingly normalmisleadingly normal 2. Loss of enzymes 2. Loss of enzymes decreased food decreased food
digestion and nutrient absorption in digestion and nutrient absorption in small bowelsmall bowel Fatty stoolsFatty stools
3. Weight loss3. Weight loss
Pancreatic Pancreatic AdenocarcinomaAdenocarcinoma
Pancreatic Adenocarcinoma Pancreatic Adenocarcinoma – Diagnosis– Diagnosis
Risk factorsRisk factors Chronic pancreatitisChronic pancreatitis SmokingSmoking ObesityObesity
Signs and symptoms:Signs and symptoms: Painless jaundicePainless jaundice Pain that radiates to backPain that radiates to back Weight lossWeight loss
Physical examPhysical exam Sometimes no major findingsSometimes no major findings Ascites and hepatomegaly due to metastasesAscites and hepatomegaly due to metastases Abdominal and rectal nodules from metastasesAbdominal and rectal nodules from metastases
Approximately 75% will present at an advanced Approximately 75% will present at an advanced stagestage
Pancreatic Adenocarcinoma Pancreatic Adenocarcinoma – Radiologic Findings– Radiologic Findings
http://upload.wikimedia.org/wikipedia/commons/f/f6/MBq_cystic-carcinoma-pancreas.jpg
Pancreatic Adenocarcinoma Pancreatic Adenocarcinoma – Whipple Resection– Whipple Resection
http://upload.wikimedia.org/wikipedia/commons/1/17/Macroscopic_image_of_pancreas_adenocarcinoma_removed_by_Whipple_procedure.jpg
Duodenum(cut open) Common bile
duct
Head of pancreas(cut open)
Pancreatic Adenocarcinoma Pancreatic Adenocarcinoma – Histology– Histology
Cancerous glands with mucin production
Pancreatic Adenocarcinoma Pancreatic Adenocarcinoma – Histology– Histology
Residual pancreas
Tumor with mucin
Pancreatic Adenocarcinoma Pancreatic Adenocarcinoma – Histology– Histology
Pleomorphic (ugly) cells
Mitoses
Pancreatic Adenocarcinoma Pancreatic Adenocarcinoma - Prognosis- Prognosis
http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2009&chid=95&coid=927&mid
Pancreatic Adenocarcinoma Pancreatic Adenocarcinoma - Prognosis- Prognosis
Why so poor?Why so poor? Pancreatic anatomyPancreatic anatomy
Anatomically isolatedAnatomically isolated Lacks a capsule Lacks a capsule contiguous with contiguous with
surrounding fatsurrounding fat Rich vascular supplyRich vascular supply
Cancer cells respond poorly to Cancer cells respond poorly to chemotherapychemotherapy Thick connective tissue in tumor prevents Thick connective tissue in tumor prevents
diffusion of chemo drugs?diffusion of chemo drugs?
Thank You Thank You