Cytologically Yours: Unknowns: 201401: Case 4

Clinical History

74 year old male with a pancreatic mass.

Cytology

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Resident Questions

• Diagnosis?

• Lymphoma
  • Occurs in elderly
  • Diffuse large B cell lymphoma is the most common
  • Presentation includes abdominal pain and jaundice due to bile duct obstruction
  • Pancreatic primary lymphoma accounts for less than 0.5% of all pancreatic malignancies and 1% of extranodal lymphomas
  • Secondary involvement of the pancreas by lymphoma has been reported to occur in 5-30% of all lymphomas.

• What are some of the cytologic features that lead you to the diagnosis?

• Cellular specimen
• Monotonous population of cells that are discohesive
• Look for lymphoglandular bodies in the background
• Cells will have high N/C ratios with round nuclei
• Mitosis
• Karryorrhexis
• Lack nuclear molding
• Rare tissue fragments

• Differential diagnosis?

• Pancreatic neuroendocrine tumor
  • Uniform, small/medium sized, round, plasmacytoid cells
  • Cells in groups
  • Scant cytoplasm
  • Salt and pepper chromatin
  • Positive CD56, Synaptophysin, Chromogranin
• Pancreatic duct adenocarcinoma (small cell pattern)
  • Generally cellular
  • Groups and single small/medium cells
  • Irregular nuclear membranes and variable cytoplasm (scant/moderate, vacuolated/dense)
  • Positive CEA, Cytokeratin, EMA
• Lymphoepithelial cyst
  • Rare benign cystic lesion with lymphocytes
  • Most occur in male patients who are in the 5th decade
  • Unilocular or multilocular lined by squamous epithelium and have numerous lymphocytes
  • Cytology will have many lymphocytes and squamous cells
  • Not associated with immunosuppression
• Flow cytometry is helpful when lymphoma is suspected

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Additional Images

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