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Pathology & Laboratory Medicine

URMC / Pathology & Laboratory Medicine / Education / Case of the Month / Case 39: Incidental Pancreatic Tumor

 

Case of the Month: Incidental Pancreatic Tumor

By Numbereye Numbere, MBBS (PGY-3) and Mark G. Ettel, MD

Clinical History

An asymptomatic middle-aged woman with an incidentally discovered pancreatic mass.

Past Medical History

The patient has a history of multiple endocrine neoplasia type 1 (MEN1), with a history of primary hyperparathyroidism, pituitary adenoma, mild hypercalcemia, and multiple lipomas.  

Recent History

Abdominal CT showed a hypodense lesion in the tail of the pancreas. A follow-up MRI confirmed a 2.4 cm pancreatic mass and incidental bilateral non-obstructing renal calculi. Distal pancreatectomy was performed.

Gross examination of the distal pancreatectomy and splenectomy specimen revealed a 2.6 cm firm, well-circumscribed, homogeneous, yellow/tan intrapancreatic tumor and an unremarkable spleen.

On microscopy, the tumor consisted of a monotonous population of round cells with dispersed fine chromatin, prominent central nucleoli, and a moderate amount of cytoplasm (Figures 1-5). Also, multiple small neuroendocrine lesions of similar appearance (microadenomas; Figures 6-9) were seen.

Figure 1: PanNET. Nests of tumor cells are separated by delicate vascularized fibrous stroma. Note surrounding uninvolved pancreas on the left of the field. H&E x100. Figure 2: PanNETs. High power view shows the characteristic “salt and pepper” chromatin pattern with prominent nucleoli. H&E x200. Figure 3: Chromogranin stain showing strong granular cytoplasmic staining. x200. Figure 4: The patient’s tumor was also positive for synaptophysin. x200. Figure 5: Ki67 stain. There is rare positivity (brown-staining nuclei) for Ki-67. x200. Figure 6: A microadenoma. Microadenomas have identical cytomorphology to PanNETs. Note the surrounding uninvolved pancreas. H&E x20. Figure 7: This higher power view of the microadenoma shows cells arranged in wavy trabeculae. The characteristic “salt and pepper” chromatin is discernible. Figure 8: The patient’s microadenoma showed strong positive staining for chromogranin, similar to the PanNET. x20. Figure 9: The patient’s microadenoma was also positive for synaptophysin. x20.

Next: Diagnosis