Pathology of the Exocrine Pancreas Tyler Verdun PGY

Pathology of the Exocrine Pancreas Tyler Verdun, PGY 3 General Pathology University of British Columbia November 5, 2013

Objectives n Brief review of normal pancreatic anatomy Overview of acute and chronic pancreatitis Introduction to pancreatic adenocarcinoma n This session will not cover: n n n n Endocrine pancreas pathology Congenital abnormalities Cystic lesions Benign tumors (SPPT, cystadenomas, etc. ) Neuroendocrine tumors

The Normal Pancreas

Normal Pancreas http: //upload. wikimedia. org/wikipedia/commons/f/fc/Pancreas_4. jpg

Normal Pancreas n Wait! There’s something wrong with this picture… n n No islets: this is actually parotid salivary gland Sourced from http: //www. youtube. com/watch? v=1 Kavxv 3 j. Hz. A n Dr. John Minarcik’s excellent “Shotgun Histology” series

Normal Pancreas

Pancreatitis

Acute Pancreatitis 1. The pancreas is (metaphorically) a box of corrosive chemicals n 2. Damage to the pancreas by some etiologic factor releases these chemicals from cells n 3. Digestion, saponification, and calcification of neighboring healthy tissue n n On gross examination/autopsy – greasy, chalk -white deposits

Acute Pancreatitis - Etiologies n n n II – Idiopathic Important G G – Gallstones E E – Ethanol abuse T T – Trauma: anything that compromises the blood supply S S – Steroids M M – Microbiological (bacterial, viral, or parasitic infections) A A – Autoimmune diseases Impress your staff! S S – Scorpion bite: Tityus trinitatis in Trinidad and Tobago H H – Hypercalcemia or hyperlipidemia Not so much E E – ERCP: endoscopic procedure; can cause pancreatitis D D – Drugs: too many to list… n FYI: in a pinch, never doubt the “The Big 3”© n Antibiotics, antiepileptics/antipsychotics, anti-inflammatories

Acute Pancreatitis – Diagnosis n Clinical presentation: n n n Imaging n n Moderate to severe epigastric pain radiating to back Nausea and vomiting Fever, ↑HR, ↑RR, ↓BP Rarely: abdominal or flank bruising (Cullen & Grey. Turner) CT scan and abdominal ultrasound showing inflammation or cystic structures around pancreas Labs n n n Elevated amylase and lipase Elevated glucose May see elevated liver markers

Acute Pancreatitis – Radiologic Findings http: //upload. wikimedia. org/wikipedia/commons/9/97/Pankreatitis_exsudativ_CT_axial. jpg

Acute Pancreatitis – Histology Horror Show Normal pancreas

Acute Pancreatitis – Histology Hemorrhage Necrosis Background pancreas Neutrophils

Acute Pancreatitis Prognosis n Mild n n Resolves with minimal supportive care within days Severe n n n Significant fluid depletion and electrolyte abnormalities Systemic inflammatory response and disseminated coagulation Pseudocyst formation Necrosis and hemorrhage Abscess formation and sepsis May require ICU and surgical management

Chronic Pancreatitis n Consequence of long-standing inflammation n Usually will have had recurring episodes of acute pancreatitis ~80% will have history of alcoholism Clinical presentation n Chronic epigastric pain Persistent nausea and vomiting Other common findings n n n Weight loss Fatty stools Low or normal plasma amylase and lipase levels

Chronic Pancreatitis – Radiologic Findings http: //upload. wikimedia. org/wikipedia/commons/7/7 b/Chronische_Pankreatitis_mit_Verkalkungen__CT_axial. jpg

Chronic Pancreatitis – Histology Residual pancreas Fibrosis and lymphocytic inflammation

Chronic Pancreatitis n Functional pancreatic tissue is destroyed 1. Enzyme levels are decreased or misleadingly normal n 2. Loss of enzymes decreased food digestion and nutrient absorption in small bowel n n Fatty stools n 3. Weight loss

Pancreatic Adenocarcinoma

Pancreatic Adenocarcinoma – Diagnosis n Risk factors n n Signs and symptoms: n n Painless jaundice Pain that radiates to back Weight loss Physical exam n n Chronic pancreatitis Smoking Obesity Sometimes no major findings Ascites and hepatomegaly due to metastases Abdominal and rectal nodules from metastases Approximately 75% will present at an advanced stage

Pancreatic Adenocarcinoma – Radiologic Findings http: //upload. wikimedia. org/wikipedia/commons/f/f 6/MBq_cystic-carcinoma-pancreas. jpg

Pancreatic Adenocarcinoma – Whipple Resection Duodenum (cut open) Common bile duct Head of pancreas (cut open) http: //upload. wikimedia. org/wikipedia/commons/1/17/Macroscopic_image_of_pancreas_adenocarcinoma_removed_by_Whipple_procedure. jpg

Pancreatic Adenocarcinoma – Histology Cancerous glands with mucin production

Pancreatic Adenocarcinoma – Histology Residual pancreas Tumor with mucin

Pancreatic Adenocarcinoma – Histology Pleomorphic (ugly) cells Mitoses

Pancreatic Adenocarcinoma Prognosis http: //progressreport. cancer. gov/doc_detail. asp? pid=1&did=2009&chid=95&coid=927&mid

Pancreatic Adenocarcinoma Prognosis Why so poor? n Pancreatic anatomy n Anatomically isolated n Lacks a capsule contiguous with surrounding fat n Rich vascular supply n n Cancer cells respond poorly to chemotherapy n Thick connective tissue in tumor prevents diffusion of chemo drugs?

Thank You