Pathology of the Pancreas. A Practical Approach

438 Pages·2021·74.546 MB·English

by  Fiona Campbell, Caroline S. Verbeke

Pathology of the
Pancreas
A Practical Approach
Fiona Campbell
Caroline S. Verbeke
Second Edition
123
Pathology of the Pancreas
Fiona Campbell • Caroline S. Verbeke
Pathology of the
Pancreas
A Practical Approach
Second Edition
Fiona Campbell Caroline S. Verbeke
Department of Pathology Department of Pathology
Royal Liverpool University Hospital Oslo University Hospital
Liverpool University of Oslo
UK Oslo
Norway
ISBN 978-3-030-49847-4 ISBN 978-3-030-49848-1 (eBook)
https://doi.org/10.1007/978-3-030-49848-1
© Springer Nature Switzerland AG 2021
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Preface
There have been many advances in pancreatic pathology since we wrote the
first edition of this book. Emerging endoscopy and tissue sampling proce-
dures, such as pancreatoscopy, micro-forceps biopsies, and fine-needle biop-
sies, are now being incorporated into routine diagnostic practice, and
neoadjuvant therapy has become part of standard treatment. New diagnostic
entities have been described, classifications and international guidelines have
been updated, and molecular pathology is beginning to play a role in diagnos-
tics and patient management. All of these advances have been incorporated
into this new edition of the book.
The book covers the spectrum of pancreatic pathology from congenital
abnormalities and hereditary disorders to inflammatory disease and neopla-
sia, and it now also includes an entirely new chapter on pancreas transplant
pathology (kindly provided by René Michel). There is also limited informa-
tion on the small super-specialized area of pediatric pancreatic pathology, and
the cytology chapter has been kindly revised by M. Priyanthi Kumarasinghe
and Ian Yusoff. The book incorporates the recent WHO 2019 classification
and TNM8, and brief summaries of the main molecular alterations found in
the most common pancreatic neoplasms have also been added.
This is a practical bench book, intended for trainees in histopathology and
consultants, who deal with pancreatic specimens. It aims to provide both
practical information for all aspects of the diagnostic process and in-depth,
up-to-date knowledge that is required for the pathologist’s participation in the
multidisciplinary team meetings and discussions.
There are more than 200 new macroscopic and microscopic images,
enabling us to illustrate the wide range of appearances that the same tumor or
disease entity can exhibit. The numerous illustrations are also used to provide
a detailed, practical, step-by-step guide to macroscopic examination and
specimen handling, as well as to explain the embryology and anatomy of the
pancreas. There are more quick-reference tables, and the potential mimics
and diagnostic pitfalls are included in differential diagnoses. There is exten-
sive cross-referencing to allow the reader easy access to relevant information.
v
vi Preface
Reporting checklists are provided for the main diagnostic entities with a sum-
mary of key data items to include in the pathology report.
We do hope that the reader will enjoy reading this new edition of the book
and that it will continue to serve as a comprehensive resource in daily diag-
nostic practice and multidisciplinary team discussion.
Liverpool, UK Fiona Campbell
Oslo, Norway Caroline S. Verbeke
Acknowledgements
We are grateful to Øystein Horgmo, University of Oslo, for his professional
help with the photography. We thank Paul Brown, Specialist Medical
Illustrator, The Leeds Teaching Hospitals NHS Trust, Leeds, UK for Medical
Drawings. We would also like to thank all of our pathology and clinical col-
leagues in Liverpool, Oslo, and Stockholm who, knowingly or unknowingly,
have contributed to our knowledge and understanding of pancreatic
pathology.
Permission to use copyrighted illustrations has kindly been granted by
• Elsevier (Cancer Treatment Reviews 2015;41:17–26) for Fig. 1.27
• Elsevier (Surgical Pathology 2016;19:523–38) for Figs. 3.19 and 3.34
• Springer Nature (Springer eBook—Operative specimen handling and
evaluation of resection margins) for Fig. 3.31
• Blackwell Publishing Limited (Histopathology 2010;56:669–82) for Figs.
20.11 and 20.12
• John Wiley and Sons (American Journal of Transplantation 2003;3:599–
605) for Fig. 22.12
Chapter 22 on Pathology of Pancreas Transplantation is an updated ver-
sion of the chapter ‘Pancreas Transplantation’ in: Michel RP, Berry GJ, edi-
tors. Pathology of Transplantation A Practical Diagnostic Approach.
Switzerland: Springer; 2016. p. 265–98.
vii
Contents
Part I General Principles
1 Embryology, Anatomy, and Histology . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Embryology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.4 Histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2 Pancreatic Specimen Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.1 Pancreatoduodenectomy Specimens . . . . . . . . . . . . . . . . . . . . 25
2.2 Distal Pancreatectomy Specimens . . . . . . . . . . . . . . . . . . . . . . 26
2.3 Total Pancreatectomy Specimens . . . . . . . . . . . . . . . . . . . . . . . 27
2.4 Duodenum-Preserving Pancreatic Resection Specimens . . . . . 27
2.5 Complex Multivisceral En Bloc Resection Specimens . . . . . . 28
2.6 Central Pancreatectomy Specimens . . . . . . . . . . . . . . . . . . . . . 28
2.7 Enucleation Specimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.8 Specimens Following Frey, Beger, or Puestow Procedures . . . 29
2.9 Laparoscopic and Robot- Assisted Resection Specimens . . . . 30
2.10 Pancreas Allograft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3 Specimen Dissection and Sampling . . . . . . . . . . . . . . . . . . . . . . . . 33
3.1 Handling of Fresh Specimens . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.2 Specimen Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.3 Macroscopic Examination of Pancreatoduodenectomy
Specimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.4 Dissection of Distal Pancreatectomy Specimens . . . . . . . . . . . 55
3.5 Dissection of Total Pancreatectomy Specimens . . . . . . . . . . . 56
3.6 D issection of Multivisceral En Bloc Resection Specimens . . . . . 56
3.7 Dissection of Other Pancreatic Specimen Types . . . . . . . . . . . 56
3.8 Handling of Pancreatic Biopsies . . . . . . . . . . . . . . . . . . . . . . . 59
3.9 Reporting Checklist of Macroscopic Findings . . . . . . . . . . . . 59
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
4 The Pancreatic Multidisciplinary Team . . . . . . . . . . . . . . . . . . . . 61
4.1 Discussion of Postoperative Cases . . . . . . . . . . . . . . . . . . . . . . 61
4.2 Discussion of Pretreatment Cases . . . . . . . . . . . . . . . . . . . . . . 62
ix
x Contents
4.3 Other Roles and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . 63
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Part II E xocrine Pancreas: Non-Cystic
5 Common Minor Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.1 Acinar Cell Nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.2 Acinar Dilatation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.3 Acinar to Ductal Metaplasia . . . . . . . . . . . . . . . . . . . . . . . . . . 68
5.4 Duct Epithelial Metaplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
5.5 Lobulocentric Atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
5.6 Age-Related Alterations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
5.7 Fatty Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
5.8 Changes in Islets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
5.9 Autolytic Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6 Hereditary Exocrine Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.1 Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.2 Hereditary Hemochromatosis . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.3 Hereditary Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.4 Inherited Pancreatic Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.5 Familial Pancreatic Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
6.6 Screening High-Risk Individuals . . . . . . . . . . . . . . . . . . . . . . . 83
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
7 Inflammatory Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7.1 Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7.2 Chronic Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
7.3 Other Inflammatory Diseases of the Pancreas . . . . . . . . . . . . . 128
7.4 Pancreatitis in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
7.5 Reporting Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
8 Pancreatic Intraepithelial Neoplasia . . . . . . . . . . . . . . . . . . . . . . . 137
8.1 WHO Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
8.2 Classification and Microscopy . . . . . . . . . . . . . . . . . . . . . . . . . 138
8.3 Variants of PanIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
8.4 Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
8.5 Lobulocentric Atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
8.6 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
9 Ductal Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
9.1 Definition and Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
9.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
9.3 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
9.4 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Contents xi
9.5 Macroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
9.6 Microscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
9.7 Grading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
9.8 Morphological Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
9.9 Immunohistochemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
9.10 Tumor Propagation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
9.11 Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
9.12 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
9.13 Treatment and Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
9.14 Histological Subtypes of Ductal Adenocarcinoma . . . . . . . . . 181
9.15 Carcinoma with Mixed Differentiation . . . . . . . . . . . . . . . . . . 191
9.16 Mixed Acinar-Ductal Carcinoma . . . . . . . . . . . . . . . . . . . . . . . 191
9.17 Ductal Adenocarcinoma Following Neoadjuvant
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
9.18 Diagnostic Molecular Pathology . . . . . . . . . . . . . . . . . . . . . . . 197
9.19 Reporting Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
10 Acinar Cell Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
10.1 WHO Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
10.2 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
10.3 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
10.4 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
10.5 Macroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
10.6 Microscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
10.7 Histochemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
10.8 Immunohistochemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
10.9 Molecular Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
10.10 Variants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
10.11 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
10.12 Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
10.13 Prognosis and Management . . . . . . . . . . . . . . . . . . . . . . . . . . 213
10.14 Reporting Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
11 Non-Epithelial Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
11.1 Mesenchymal Neoplasms of the Pancreas . . . . . . . . . . . . . . . 216
11.2 Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
12 Secondary Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
12.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
12.2 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
12.3 Macroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
12.4 Microscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
12.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
12.6 Synchronous Primary and Metastatic Cancer . . . . . . . . . . . . 231
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234