|Year : 2017 | Volume
| Issue : 4 | Page : 1254-1256
Acinar cell carcinoma of pancreas mimicking as pseudocyst – Report of an interesting case
Mandal P Kumar1, Adhikari Anindya2, Pal R Datta3, Khan Kalyan3
1 Department of Pathology, Sagar Dutta Medical College, Kolkata, India
2 Department of Pathology, Bankura Sammilani Medical College, Bankura, India
3 Department of Pathology, North Bengal Medical College, Darjeeling, West Bengal, India
|Date of Submission||14-Apr-2017|
|Date of Acceptance||19-Jul-2017|
|Date of Web Publication||04-Apr-2018|
Vil-Basudevpur, P.O. Banipur, P.S. Sankrail 711304, Howrah, West Bengal
Source of Support: None, Conflict of Interest: None
Acinar cell carcinoma of the pancreas is a rare and aggressive malignancy, comprising less than 5% of all pancreatic neoplasms. Middle-aged men are commonly affected. In our case, a 35-year-old man presented with epigastric fullness, anorexia, and weight loss for 3 months. Computed tomogram scan of the abdomen revealed a cystic lesion (93 × 83 × 62 mm) over the head of pancreas, suggestive of pancreatic pseudocyst. Serum amylase and lipase levels were 25 710 and 292.50 U/l, respectively. Excision followed by histopathological examination revealed acinar cell carcinoma of pancreas. The patient developed pancreatic fistula postoperatively. Chemotherapy with 5-fluorouracil was initiated. There was no residual tumor. The patient remained disease free for 8 months postoperatively.
Keywords: acinar cell carcinoma, pancreas, pseudocyst
|How to cite this article:|
Kumar MP, Anindya A, Datta PR, Kalyan K. Acinar cell carcinoma of pancreas mimicking as pseudocyst – Report of an interesting case. Menoufia Med J 2017;30:1254-6
|How to cite this URL:|
Kumar MP, Anindya A, Datta PR, Kalyan K. Acinar cell carcinoma of pancreas mimicking as pseudocyst – Report of an interesting case. Menoufia Med J [serial online] 2017 [cited 2020 Feb 16];30:1254-6. Available from: http://www.mmj.eg.net/text.asp?2017/30/4/1254/229214
| Introduction|| |
Pancreatic carcinoma with acinar cell differentiation is rare, comprising less than 5% of all pancreatic neoplasms. Although children may be affected, middle-aged or elderly males are mainly victimized. Usually the patient presents with abdominal mass, icterus, and weight loss. Acinar cell carcinomas (ACCs) are associated with increased serum lipase level and may manifest in the classic presentation as the Schmid triad of subcutaneous fat necrosis, polyarthritis, and eosinophilia. ACC is associated with increased levels of tumor markers such as α-fetoprotein and carcinoembryonic antigen. These are aggressive tumors with early metastasis to the regional lymph nodes and liver. However, at times, it has a benign appearance on histology as well as on radiology. This case is being reported as it presented as pancreatic pseudocyst radiologically and serologically.
| Case History|| |
A 35-year-old man presented with upper abdominal distension, anorexia, and weight loss for 3 months. On palpation, a firm mass with ill-defined borders was felt in the epigastric region. Ultrasonography showed a cystic mass over the head of pancreas. Computed tomography scan of the abdomen [Figure 1]a revealed a cystic lesion (93 × 83 × 62 mm) over the head of pancreas, suggestive of pancreatic pseudocyst. Hemogram report was within normal limits. His serum amylase level was 25 710 U/l (normal range: 22–80 U/l) and lipase level was 292.50 U/l (normal range: ≤64 U/l); both levels were markedly raised. The cyst was excised and measured 10 × 8 × 4 cm on grossing [Figure 1]b. On cut section, a partly solid cystic growth with papillary excrescences was noted. Histopathological examination of the mass [Figure 2] showed a well-circumscribed tumor with cells arranged in organoid fashion. Those cells were slightly pleomorphic, were round to oval in shape, had granular cytoplasm, and had basally placed nuclei with clumped chromatin. Clear cell changes were also noted focally. The tumor also showed a varied histopathological pattern of acinar, solid, trabecular, and papillary structures. Some of the cells showed prominent eosinophilic nucleoli. There were focal areas of hemorrhage and necrosis. Lymphovascular invasion of tumor cells was noted. The clear cells were positive for periodic acid–Schiff stain. Immunohistochemistry showed positivity for cytokeratin, whereas chromogranin A and synaptophysin were negative. The patient developed postoperative pancreatic fistula for which he underwent distal pancreatectomy with splenectomy. In total, two lymph nodes dissected were free from tumor. Chemotherapy with five cycles of 5-fluorouracil was given over a total period of 8 weeks. No residual tumor could be found. The patient remained disease free till 8 months postoperatively.
|Figure 1: (a) CT scan image of the tumor. (b) Gross appearance of the tumor.|
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|Figure 2: (a) Sheets of tumor cells with abundant cytoplasm, H and E, X10, (b) Tumor emboli within blood vessel, H and E, X10, (c) Tumor cells are separated by fibro collagenous tissue, H and E, X10, (d) Tumor cells are in sheets and syncytial pattern, H and E, X40.|
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| Discussion|| |
ACC is a rare and aggressive pancreatic neoplasm of middle-aged or elderly males which may mimic benign lesion like pancreatic pseudocyst both radiologically and serologically. These tumors may secrete lipase and other digestive enzymes, which may result in widespread subcutaneous fat necrosis and arthralgia. Our patient presented with elevated serum lipase level. Hypoglycemia may occur secondary to tumor secretion of insulin and insulin-like growth factor. Radiographic findings generally identify a solid, well-demarcated, hypovascular mass. In this patient, however, computed tomography scan showed a thick-walled cystic lesion resembling a pancreatic pseudocyst.
The neoplasm has a propensity for the pancreatic head, although rarely multifocal tumors may be present. Grossly, the tumors are usually large but well circumscribed. Microscopically, ACCs are cellular neoplasms that characteristically lack the desmoplastic stroma commonly seen with ductal adenocarcinomas. The most common histologic patterns are acinar and solid, whereas the less common patterns include glandular, trabecular, papillary, or intraductal pattern. The tumor cells are usually periodic acid–Schiff positive, diastase resistant. The neoplastic cells are immunoreactive with α1-antitrypsin, chymotrypsin, amylase, and lipases,. A minor population of endocrine cells can be seen scattered throughout the tumor which can be positive for neuroendocrine markers like chromogranin and synaptophysin. Immunohistochemistry results for chromogranin A and synaptophysin were negative in our case.
The best treatment option for localized tumors is surgical resection. However, there is a high rate of recurrence after complete surgical resection, suggesting a role of micrometastases even in localized disease. In cases of unresectable tumor with presence of distant metastases, chemotherapy with or without radiation to the pancreas has been used. In our case, although the tumor was completely resectable, adjuvant chemotherapy was administered to prevent recurrence. Present knowledge regarding the efficiency of chemoradiotherapy for ACC is limited, mainly because of its low incidence. The combination of oxaliplatin-based chemotherapy appears most effective for locally advanced or metastatic forms. For patients with unresectable yet locally confined disease, radiotherapy may be one of the treatment options. ACC is associated with a better prognosis than ductal adenocarcinoma at all stages of disease. The predictors of poor prognosis in ACC include the following: age greater than 60 years, markedly elevated serum lipase level, and tumors larger than 10 cm in diameter.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Silverman JF, Feldman PS, Covell JL, Frable WJ. Fine needle aspiration cytology of neoplasms metastatic to the breast. Acta Cytol 1987; 31
Georgianos SN, Chin J, Goode AW, Sheaff M. Secondary neoplasms of the breast: a survey of the 20th
century. Cancer 2001; 92
Alvarado CI, Carrera AM, Perez MD, Tavassoli FA. Metástases to the breast. Eur J Surg Oncol 2003; 29
Rosen PP. Metastases in the breast from non-mammary malignant neoplasms. In: Rosen PP, editor. Rosen's breast pathology
. Philadelphia, PA: Lippincott Williams and Wilkins; 2001. 689–701.
David O, Gattuso P, Razan W, Moroz K, Dhurandhar N. Unusual cases of metastases to the breast. A report of 17 cases diagnosed by fine needle aspiration. Acta Cytol 2002; 46
Lester SC. The breast. In: Kumar VK, Abbas AK, Fausto N, Aster JC, editors. Robbins and cotran pathologic basis of diseases
ed. Pensylvania: Elsevier; 2010. 1093.
Di Bonito L, Luchi M, Giarelli M, Falconieri G, Viehl P. Metastatic tumors to the female breast. An autopsy study of 12 cases. Pathol Res Pract 1991; 187
Ellis IO, Pinder SE, Lee A. Tumors of the breast. In: Fletcher CDM, editor. Diagnostic histopathology of tumors
ed. China: Churchill Livingstone Elsevier; 2007. 1
Azzopardi JG. Problems in breast pathology. In: Bennington JL, consulting editor. Major problems in pathology
. Philadelphia: W.B. Saunders 1979. 11
Toombs BD, Kalisher L. Metastatic disease in the breast; clinical, pathologic and radiographic features. Am J Roentgenol 1977; 129
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