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PANCREATIC CYTOLOGY

Mehmet Akif Demir, MD

Clinical Pathology and Genetics

Sahlgrenska University Hospital Gothenburg-Sweden

Papanicolau Society of Cytopathology5 Commities and their publications in 2014

• Adler D, Schmidt CM, Al-Haddad M, et al. Clinical evaluation, imaging studies, indications for cytologic study, and preprocedural requirements for duct brushing studies and pancreatic FNA: The Papanicolau Society of Cytopathology recommendations for pancreatic and biliary cytology. Diagnostic Cytopathology, 2014;42(4):325-332

• Brugge W, DeWitt J, Klapman JB. Techniques for cytologic sampling of pancreatic and bile duct lesions. Diagnostic Cytopathology, 2014; 42(4):333-337

• Pitman MB, Centeno BA, Ali SZ, et al. Standardized terminology and nomenclature for pancreatobiliary cytology: The Papanicolau Society of Cytopathology Guidelines. Diagnostic Cytopathology 2014;42(4):338-350.

• Layfield LJ, Ehya H, Fille AC et al. Utilisation of ancillary studies in the cytologic diagnosis of biliary tract and pancreatic lesions: The Papanicolau Society of Cytopathology Guidelines for Pancreatobiliary Cytology. 2014 Diagnostic Cytopathology, 42(4):351-362

• Kurtycz DFI, Field A, Tabatabai L, et al. Post-brushing and fine needle-aspiration biopsy follow-up and treatment options for patients with pancreatobiliary lesions: The papanicolau Society of Cytopathology Guidelines. Cytojournal 2014; 11(Suppl 1):5. Published online 2014 Jun 2. doi: 10.4103/1742-6413.133356

Other references

• Pitman MB, Layfield LJ. Guidelines for pancreaticobiliary cytology from the Papanicolau Society of Cytopathology: a review. Cancer Cytopathol 2014;122:399-411.

• Layfield LJ, Dodd L, Factor R, Schmidt RL. Malignancy risk associated with diagnostic categories defined by the Papanicolau Society of Cytopathology Pancreatobiliary Guidelines. Cancer Cytopathology 2014;122:420-427.

Benefits of a common nomenclature

• Standardization of nomenclature

• Unifies reporting of disease categories

• Contributes to evaluation of interobserver variability

• Improves intraobserver reproducibility

• Better aligns patient management options with interpretations

• Improves patient care

• Universally understanding by clinicians and pathologists

• ”Statistics” (economical aspects)

Categories

General tiered System in Cytology PSC suggestion for PB cytology

Nondiagnostic I. Nondiagnostic

Negative (Benign) II. Negative

Atypical III. Atypical

Suspicious IV. Neoplastic

-Benign

-Other

V. Suspicious

Positive VI. Positive/Malignant

Management

• Malignant ………………………..surgery

• Premalignant

• Low-intermediate grade………observation with repeat sampling

• Hig grade …………………………….surgery

• Neoplasm…………………………..surgery or observation

• Benign………………………………..medical management

• Endocrine tumors………………. surgery, chemotherapy, observation

Clinical information

• Patient age, gender

• Symptoms

• Anamnesis (important details that may effect diagnosis)

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Radiological information

• Localisation of the lesion in the pancreas

• Characteristics of the lesion• Size, growth pattern (rounded, infiltrative)

• Solid or cystic (unilocular, multilocular, solid with cystic component, thickness of the wall, calcifications)

• Vascularisation

• Cyst contents: thin, thick, mucinous, viscous, water-clear, brown,…

• NEEDLE TRACT!!! EUS Via?• Esophagus?

• Gastric wall?

• Duodenum?

Ancillary tests

• CEA

• AMYLASE

• Molecular analyses: KRAS, GNAS

• Immunocytochemistry & Immunohistochemistry (cell-block)

Differential Diagnostic Approach

SOLID

• Chronic pancreatitis

• Ductal adenocarcinoma

• Acinar cell carcinoma

• Pancreatic endocrine neoplasm

• Solid pseudopapillary tumor

• Pancreatoblastoma

• Metastasis

CYSTIC

• Pseudocyst

• Serous cyst

• Mucinous cyst (MCN, IPMN)

• Cystic degeneration of typicallysolid tumors

• Rare cystic lesions• Simple cysts

• Lymphoepthelial cyst

• Peripancreatic cysts

Important!

• DO NOT DIAGNOSE AS ”TUMOR” IF THERE IS NO RADIOLOGIC MASS LESION!!!

• NO MASS LESION: MOST PROBABLY NORMAL ACINAR CELLS/FRAGMENT, NOT ACINAR CELL CARCINOMA OR NEUROENDOCRINE TUMOR!!!

NormalNormal

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Contamination !!!

• Gastric

• Intestinal

• Contamination or a component of the tumor?

Gastric contamination, cell-block

Duodenal contamination

Cystic lesions

• Direct smears

• Other analyses on fresh undiluted cyst fluid

• CEA

• Molecular

• Cytomorphologic

• Cytospin

• Cellblock

http://www.radiologyassistant.nl/en/p4ec7bb77267de/pancreas-cystic-lesions.html

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Amylase & CEA

• Amylase levels

• High levels associated with pseudocysts

• May be increased in IPMN and LEC

• Not increased in serous cysts and MCN

• Elevated CEA: in favour of mucinous cyst

• Cannot distinguish IPMN from MCN

• No correlation with malignancy

• May be increased in duplication cysts, lymphoepithelial cysts

Molecular tests

• KRAS• supports a neoplastic mucinous cyst

• Cannot distinguish IPMN and MCN

• Does not contribute grading

• GNAS• supports IPMN over MCN

• No correlation with grade

• RNF43• Supports a mucinous cyst

• Does not distinguish IPMN and MCN

• 3p deletions• 3p25, VHL gene, and other 3p deletions supports Serous Cystic Adenoma (SCA)

• CTNNB1 (Beta-catenin) deletion• Support Solid Pseudopapillary Neoplasm (SPN)

Suggested Categories (Papanicolau Society ofCytopathologists)

• I. NONDIAGNOSTIC

• II. NEGATIVE

• III. ATYPIA

• IV. NEOPLASTIC

• BENIGN

• OTHER

• SUSPICIOUS FOR MALIGNANCY

• POSITIVE/MALIGNANT

I. Nondiagnostic

• A specimen that provides no diagnostic or useful information aboutthe lesion sampled.

• Criteria• Preparation artifact

• Obscuring artifact

• Gastrointestinal epithelium only

• Normal pancreatic tissue elements in the setting of a clearly defined mass by imaging

• Acellular aspirates of a solid mass or pancreatobiliary brushing

• Acellular aspirate of a cyst without evidence of a mucinous etiology (thickmucin, elevated CEA or KRAS mutation)

II: Negative

• Definition: A sample that contains adequate cellular and/or extracellular tissue to evaluate or define a non-neoplastic lesion thatis identified on imaging.

• Includes the presence of normal pancreatic tissue in the appropriateclinical setting such a vague fullness on imaging and no distict masslesion.

(Benign pancreas, Chronic pancreatitis, Autoimmune pancreatitis, pseudocyst, lymphoepithelial cyst, accessory spleen)

III. Atypical

• Definition: Cells with cytoplasmic, nuclear, or architectural features not consistent with normal or reactive cellular components of the pancreas or bile ducts, and insufficient features to classify them as a neoplasm or suspicious for a high grade malignancy.

• The findings do not explain a lesion identified on imaging studies

• Follow-up evaluation is warranted.

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Atypical

• Mild-moderate cellular atypia, NOS

• Mucinous/ductal epithelium with mild-moderate nuclear atypia (from a solid lesion or not clearly from a mucinous cyst)

• PanIN

• GI contamination with atypia

• Ductal atypia in bile duct samples

IV. Neoplastic

• Benign

• Other

IV. Neoplastic: Benign

• Definition: Cytological specimen sufficientlycellular and representative, with or without the context of clinical, imaging, and ancillary studies, to be diagnostic of a benign neoplasm.

• SCA (Serous cystadenoma)• Sparse cellularity

• Clean or bloody background

• Flat sheets and loose clusters

• Bland cuboidal cells

• Clear, finely vacuolated or granular cytoplasm with indistinct borders

• Associated hemosiderin-laden macrophages

• Low CEA; low amylase

• No KRAS mutation

IV. Neoplastic: Other

• Definition: A neoplasm that is either premalignant such as IPMN or MCN with low, intermediate or high grade dysplasia, or a solid-cellular neoplasmsuch as well-differentiated PanNET or SPN

• PanNET

• SPN

• Mucinous cyst (IPMN or MCN), not otherwise specified

• Mucinous cyst (IPMN or MCN), with low-grade atypia

• Mucinous cyst (IPMN or MCN) with high-grade atypia

• GIST

WHO 2010 classification of the primary neuroendocrine tumors of the gastrointestinal system

• NET G1 (carcinoid) (Neuroendocrine Tumor Gr-1)

• NET G2 (Neuroendocrine Tumor Gr-2)

• NEC (Neuroendocrine Carcinoma, large cell or small cell type)

• MANEC (Mixed Adenoneuroendocrine Carcinoma)

• Hyperplastic and preneoplastic lesions.

• NETs usually show local metastases but NECs are usually much more aggressive tumors and can show widespread metastases

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PanNET

• Almost the same classification and grading system as in gastrointestinal system

• “Pancreatic small cell NECs may not express neuroendocrine markersand this does not preclude the diagnosis so long as alternative diagnostic considerations are excluded”.

• NET usually p53(-), NEC usually p53(+)

• NET can be positive for CD99. t(11;22) translocation can be helpful in differential diagnosis of PNET.

ENETS (European Neuroendocrine Tumor Society) grading*

• G1

• mitotic count <2/10HPF and/or

• Ki 67 index 2≤ %

• G2

• mitotic count 2-20/10HPF and/or

• Ki67 index 3-20

• G3

• mitotic count >20/10HPF and/or

• Ki67 index >20

• Mitotic count in at least 50HPFs

• Ki 67 index as a percentage of 500-2000 cells counted in areas of strongest nuclear labelling (hot spots)

ENETS (European Neuroendocrine Tumor Society) gradinG

High Ki67 in FNA but about 1% in

surgical biopsy ??? 5 months interval

between biopsy & FNAC

Hot-spots and nucleolar ”hot-

spots”. How can we standardize

Ki-67 counting in cytology?

Cyto Ki67 Cyto Ki67

CASE: Scull base neuroendocrine tumour /lymph node FNAC…

IHC-panel for PanNET/NEC

• Chromogranin-A

• CK8/18

• Gastrin

• Glukagon

• Insulin

• Ki67

• Pancreatic Polypeptid

• Somatostatin

• Synaptophysin

• (Trypsin)

• (Beta-cathenin)

Case: Pancreas EUSPanNET

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GASTRIN

SYNAPTOPHYSIN

CK 8/18

CHROMOGRANIN AZES

Case-pancreas tumor: SCPPN

Onlymucin: Category?

Category?

Case:pancreas MCN?

CEA

Whipple: PanIN-I-II, IPMN borderline, kr pancreatit, squa metap

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Case: Cytologically lowgrade MCN/IPMN?Whipple: PanIn-II

V: Suspicious for malignancy

• Definition:

• A specimen is suspicious for malignancy when some but not all of the criteria of a specific malignant neoplasm are present, mainly pancreatic adenocarcinoma.

• The cytological features raise strong suspicion for malignancy, but the findings are qualitatively and/or quantitatively insufficient for a conclusive diagnosis.

VI: Positive/Malignant

• Definition: Unequivocal display of malignant cytologiccharacteristics

• Adenocarcinoma of the pancreatobiliary ducts, and variants

• Acinar cell carcinoma

• High-grade neuroendocrine carcinoma (small and large cell type)

• Pancreatoblastoma

• Lymphoma

• Metastases

Acinar cell carcinoma

Acinar cell carcinoma

TrypsinTrypsinTrypsinTrypsin (!!!positive in normal cells also)

Cell-block

Cytospin

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IHCC-panel for GIST

• ASMA

• CD34

• C-KIT

• DESMIN

• DOG-1

• Ki-67

• S100

C-kit

CD34

DOG-1

Ki-67

CASEOld man with a3 cm tumorin the pacreaticcorpus

Renal Cell Carcinoma metastasis

CD10

VIMENTIN

CARBA

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