Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2000  |  Volume : 6  |  Issue : 2  |  Page : 95-98
Atypical giant cells in the FNA of solitary true cyst of the pancreas: A potential diagnostic pitfall - report of case and literature review


1 Department of Pathology, King Khalid University Hospital, Riyadh, Saudi Arabia
2 Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission24-Apr-1999
Date of Acceptance04-Jul-1999
 

How to cite this article:
Al Rikabi AC, Al Bozom IA, Al Dohayan AD. Atypical giant cells in the FNA of solitary true cyst of the pancreas: A potential diagnostic pitfall - report of case and literature review. Saudi J Gastroenterol 2000;6:95-8

How to cite this URL:
Al Rikabi AC, Al Bozom IA, Al Dohayan AD. Atypical giant cells in the FNA of solitary true cyst of the pancreas: A potential diagnostic pitfall - report of case and literature review. Saudi J Gastroenterol [serial online] 2000 [cited 2019 Nov 17];6:95-8. Available from: http://www.saudijgastro.com/text.asp?2000/6/2/95/33487


Pancreatic cystic neoplasms present diagnostic challenges in cytology. Despite this, an accurate diagnosis is important since the prognosis and treatment may vary. We report the cytological features of a solitary true cyst of the pancreas which showed a large number of bizarre giant cells on fine needle aspiration (FNA) The presence of these cells is unusual and can lead to an erroneous cytologic diagnosis of anaplastic/sarcomatoid giant cell carcinoma of the pancreas. With this in mind, we discuss the possible origin of the multinucleated atypical cells and review the cytologic features and important differentiating characteristics of the most common pancreatic cystic neoplasms.


   Case Report Top


A 25-year-old Saudi male presented to our surgical clinic at King Khalid University Hospital, Riyadh with a history of upper abdominal pain of two years duration. The pain was mild in nature and localized in the epigastric region with no radiation. It was, however, aggravated by heavy meals and relieved by vomiting. The patient also recorded a loss of 6 kg. in body weight during the last one year. There was no history of change in bowel habits nor of any previous medical illnesses. On examination, the patient was found to have mild abdominal tenderness and distension in the epigastric region. The abdomen was otherwise soft and lax with no features of organomegaly. Laboratory investigations revealed normal blood counts and peripheral film. The urea, creatinine, electrolytes and liver function tests were also within normal limits. Ultrasound examination demonstrated a relatively large thick-walled cyst which was thought to arise from the pancreas. The clinical diagnosis at this stage was that of a pancreatic pseudocyst. Computed tomographic examination (CT) confirmed the presence of a large thick-walled cyst measuring 3.5 cm. in diameter and situated within the head of the pancreas [Figure - 1].

Fine needle aspiration of the cyst was performed under CT guidance, 20 ml of clear yellowish fluid were obtained and sent for cytological assessment. The patient subsequently underwent a Whipple's operation (gastroduodenopancreatectomy). The postoperative course was uneventful and the patient remained well after 6 months of follow-up.

Cytological and histological findings

The cyst fluid obtained by CT guided FNA consisted of 20 ml of yellowish and clear fluid which was processed using a Shandon Ltd. Cytospin and the cytological smears were stained using both the Diff-quick (Baxter Ltd.) and Papanicolaou staining methods. The smears revealed a large number of highly pleomorphic giant cells showing irregular nuclei with significant molding surrounded by abundant cytoplasm [Figure - 2]. Numerous foamy macrophages and several mononuclear inflammatory cells were also present in the background. A cytological diagnosis of pancreatic cystic lesion with features suspicious of malignant giant cell tumor of the pancreas was made with a clear recommendation of surgical excision. The surgical specimen consisted of a standard Whipple procedure. The pancreatic part contained a thick and fibrous walled cyst measuring 3.5 x 3.0 x 2.5 cm and containing small amount of straw colored but clear fluid. The cyst appeared to be close to the main pancreatic duct but was not grossly . connected to it. The adjacent pancreatic tissue, gastric and duodenal mucosa were unremarkable. Histological examination of the cyst showed a predominantly denuded fibrous wall which was focally lined by low cuboidal cells [Figure - 3]. There was no evidence of atypical giant cells in the cyst wall nor in the remaining little fluid which was found in the cyst lumen. A final histopathological diagnosis of benign solitary true cyst of the pancreas was made.


   Discussion Top


The role of fine needle aspiration cytology in the identification of the nature of pancreatic cysts has not been well defined[1]. Pinto and Meriano[2] published the first report on a series of pancreatic cyst aspirates, some of which were analyzed prospectively, they reported a sensitivity of 64% for the diagnosis of pancreatic carcinoma. They did, however, combine the FNA with the estimation of carcinoembryonic antigen (CEA) and amylase contents of the cyst fluid. CEA values are usually low in pseudocysts[3] and serous cystadenomas[4] but can be more than 100 ng/ml in pancreatic carcinomas[2]. Most pancreatic cystic lesions are pseudocysts[5] (90%) which are collections of pancreatic fluid enclosed by a fibrous wall without a lining[6]. FNA of pseudocyst usually lacks glandular epithelial cells and is composed of a variable mixture of inflammatory cells. We agree with Centeno et ah[7] that pseudocyst must remain a diagnosis of exclusion on cytologic grounds. Cystic epithelial neoplasms represent 5-15% of pancreatic cysts and are usually divided into microcystic adenomas (MA), mucinous cystic neoplasms (MCN) which included as advocated by Compagno and Oertel[8] mucinous cystadenomas containing foci of malignant lining, and mucinous cystadenocarcinomas and solid and papillary cystic neoplasms. Microcystic adenomas are usually multiple, evenly distributed throughout the pancreas and occur in patients in the 7th decade[9]. These lesions are usually hypocellular but may show intranuclear cytoplasmic inclusions and nuclear grooves as described by Young et al[10].

Fine needle aspiration of MCN and MCA yield cellular smears composed of mucin-secreting columnar cells with abundant background mucin while MCA usually shows malignant nuclear features; the epithelial lining of mutinous tumours in general may be heterogenous[11]. This can cause problems in the cytologic interpretation of certain pancreatic cysts since the cells that are detected in a particular specimen may come from a benign area of a malignant cyst. We agree with Centeno et al[12] that all mucinous cystic tumours should be resected to avoid this major cytologic diagnostic pitfall. Solid and cystic papillary neoplasms are rare pancreatic tumours that usually occur in young women. Cytologically, smears taken from this tumor show numerous papillary epithelial clusters with bland nuclear characteristics and a large number of capillaries [13]. This tumor can be differentiated from MCN and MCA by the lack of mucus secretion and cytological atypia, on the contrary microcystic adenoma (MA) occur in older age group and shows cytoplasmic glycogen positivity with the PAS stain in comparison with solid and cystic papillary neoplasms[13]. Giant cells can be seen in various proportions in the relatively rare anaplastic pancreatic carcinoma (also called pleomorphic, sarcomatoid or undifferentiated carcinoma)[14]. These tumors can present as large solid masses that may contain areas of central necrosis and cystic degeneration. The giant cells seen in these tumours can show two distinct morphologies: large, bizarre shaped and pleomorphic[15] or bland osteoclastic type and multinucleated cells[16]. The exact origin of these giant cells is not certain and while most authors prefer to regard them as histiocytic others favor an epithelial origin. Immunohistochemical stains for epithelial and histiocytic markers may, however, help in the identification of these cells in certain cases.

Our case is most unusual in that it showed highly pleomorphic giant cells in a non-tumourous cystic lesion. We believe that these cells represent a reaction to inspissated cyst contents. Furthermore, nuclear pleornorphism is not unusual in histiocytic and osteoclastic cells and should not be regarded, on its own, as an indicator of malignancy.

FNA of the cystic pancreatic lesions may reveal the presence of atypical giant cells. The cytopathologist should be cautioned that the presence of such cells is not necessarily an indication of malignancy as they can be seen in solitary/true cysts of the pancreas. The clinicians are also strongly advised to seek the help of all available identification stains and confirmatory tests before surgery is attempted. Surgical excision rather than drainage may be, however, the appropriate management of many such cases.


   Acknowledgement Top


The authors would like to thank Ms. Vivian Darusin for her excellent secretarial assistance.

 
   References Top

1.Lewandrowski KB, Southern JF, Pins MR et al. Cyst fluid analysis in the differential diagnosis of pancreatic cysts: A comparison of pseudocysts, serous cystadenomas, mucinous cystic neoplasms and mucinous cystadenocarcinoma. Ann Surg 1994;115:52-5.  Back to cited text no. 1    
2.Pinto MM. Meriano FV. Diagnosis of cystic pancreatic lesions by cytological examination and carcinoembryonic antigen and amylase assays of cyst contents. Acta Cytol 1991;35:456-63.  Back to cited text no. 2    
3.Kimura K, Yamanaka T, Sakai H, Ido K. Seki H, Yoshida Y. Biochemical and cytologic analysis of cystic fluid aspirated by percutaneous puncture under ultrasonic guidance in cystic disease of the pancreas. Gastroenterology (Japan) 1982, 17:4-9.  Back to cited text no. 3    
4.Fatsuta M, Lishi H, Ichii M, Noguchi S, Yamamoto R, Yamamura H, Okuda S. Values of carcinoembryonie antigen, elastica and carbohydrate antigen in aspirated pancreatic cystic fluid in the diagnosis of cysts in the pancreas. Cancer 1986;57:1836-9.  Back to cited text no. 4    
5.Sperti C, Cappellazo F, Pasquali C, Militello C. Catalini S, Bonadimani B and Pedrazzoli S. Cystic neoplasms of the pancreas: problems in differential diagnosis. Am Surg 1993;59:740-5.  Back to cited text no. 5    
6.Howard JM. Cystic neoplasms and true cysts of the pancreas. Surg Clin North Am 1989:69:651-5.  Back to cited text no. 6    
7.Centeno BA, Lewandrowski KB, Warshaw AL, Compton C and Southern JF. Cyst fluid cytologic analysis in the differential diagnosis of pancreatic cystic lesions. Am J Clin Pathol 1994:101:483-7.  Back to cited text no. 7    
8.Compagno J, Oertel JE. Mutinous cystic neoplasms of the pancreas with overt and latent malignancy (cystadenocarcinoma and cystadenoma), clinicopathological study of 41 cases. Am J Clin Pathol 1978:69:573-80.  Back to cited text no. 8    
9.Compagno J, Oertel JE. Microcystic adenomas of the pancreas (glycogen-rich cystadenoma). A clinicopathologic study of 34 cases. Am J. Clin Pathol 1978;69:289-98.  Back to cited text no. 9    
10.Young NA, Villani MA, Khoury P, Naryshkin S. Differential diagnosis of cystic neoplasms of the pancreas by fine needle aspiration. Arch Pathol Lab Med 1991;115:571-7.  Back to cited text no. 10  [PUBMED]  
11.Warshaw AL, Compton CC, Lewandrowski KB, Carclenosa G, Mueller PR. Cystic tumours of the pancreas:new clinical, radiologic and pathologic observations in 67 patients. Ann Surg 1990;212:432-45.  Back to cited text no. 11    
12.Centeno BA, Warshaw AL, Mayo-Smith W, Southern JF and Lewandrowski K. Cytologic diagnosis of pancreatic cystic lesions. A prospective study of 28 percutaneous aspirates. Acta Cytol 1997;41:972-80.  Back to cited text no. 12    
13.Katz LB, Ehya H. Aspiration cytology of papillary cystic neoplasm of the pancreas. Am J Clin Pathol 1990;94:328-33.  Back to cited text no. 13  [PUBMED]  
14.Cubilla AL, Fitzgerald PJ. Tumours of the exocrine pancreas. In: Hartmann WG, Sobin LH, eds. Atlas of tumour pathology, Second series, Fascicle 19, Washington DC. Armed Forces Institute of Pathology 1984;287.  Back to cited text no. 14    
15.Alguacil-Garcia A, Weiland LH. The histologic spectrum, prognosis and histogenesis of the sarcomatoid carcinoma of the pancreas. Cancer 1977;39:1181-9.  Back to cited text no. 15  [PUBMED]  
16.Berendt RC, Shnitka TK, Wiens E, Manickavel V, Jewell LD. The osteoclast-type giant cell tumour of the pancreas. Arch Pathol Lab Med 1987;111:43-8.  Back to cited text no. 16  [PUBMED]  

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Correspondence Address:
Ammar C Al Rikabi
Department of Pathology (32), KKUH, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864720

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