Saudi Journal of Gastroenterology
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CASE REPORT  
Year : 2015  |  Volume : 21  |  Issue : 2  |  Page : 116-118
Cytology findings in pancreatic heterotopia, a potential pitfall for malignancy: A case report and literature review


1 Division of Pathology, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
2 Division of Surgery, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
3 Division of Gastroenterology, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada

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Date of Submission11-Sep-2014
Date of Acceptance20-Nov-2014
Date of Web Publication23-Mar-2015
 

   Abstract 

Pancreatic heterotopia is a rare congenital disorder occurring at a variety of sites in the gastrointestinal tract. It is rarely symptomatic. Despite advances in diagnostic techniques, it still remains a challenge to the clinician to differentiate it from a neoplasm. Cytologic characteristics of pancreatic heterotopia in general are rarely described in the literature. We report the cytologic characteristics of heterotopic pancreatic tissue at the gastric outlet in a 48-year-old female. The patient underwent surgical excision due to symptoms related to the lesion. Endoscopic ultrasound fine-needle aspiration is increasingly used for the diagnosis of gastrointestinal tumors, which makes the recognition of certain endoscopically unreachable lesions an important step in optimal patient management.

Keywords: Cytology of heterotopic pancreas, endoscopic ultrasound-guided fine-needle aspiration, EUS-FNA, heterotopic pancreas, histopathology of ectopic pancreas

How to cite this article:
Raddaoui E, Al-Sharabi A, Almadi MA. Cytology findings in pancreatic heterotopia, a potential pitfall for malignancy: A case report and literature review. Saudi J Gastroenterol 2015;21:116-8

How to cite this URL:
Raddaoui E, Al-Sharabi A, Almadi MA. Cytology findings in pancreatic heterotopia, a potential pitfall for malignancy: A case report and literature review. Saudi J Gastroenterol [serial online] 2015 [cited 2019 Nov 12];21:116-8. Available from: http://www.saudijgastro.com/text.asp?2015/21/2/116/153841


Pancreatic heterotopia is usually an asymptomatic condition that is encountered infrequently when evaluating patients for other reasons. It is usually identified as a subepithelial lesion in the upper gastrointestinal tract. When present in a symptomatic patient, evaluation by modalities that distinguish this lesion from other pathologies that would require surgical intervention is crucial to avoid unnecessary morbidity.


   Case Report Top


A 48-year-old woman presented with a few months history of chronic dyspepsia and epigastric abdominal pain and discomfort. Her past medical history was unremarkable. Her physical examination on initial presentation revealed minimal tenderness in the epigastric region with no peritoneal signs. Vital signs were stable. Laboratory examination showed no biochemical abnormalities. A gastroscopy was performed and demonstrated a subepithelial lesion that was about 3 cm in size at the prepyloric area on the greater curvature of the stomach. Computed tomography scan of the abdomen and pelvis with oral and intravenous contrast showed an ill-defined, 3 cm, deeply seated mass at the gastric antrum. There was neither infiltration of the surrounding adipose tissue, nor perilesional lymph node enlargement.

An endoscopic ultrasound (EUS) examination demonstrated a 3 cm localized, intramural mass in the prepyloric region. It showed a heterogeneous appearance with an indistinct margin and mainly a hypoechoic parenchyma. Fine-needle aspiration cytology material was obtained.

Cytology

Air-dried slides were first examined in the endoscopy suite using the Diff-Quik method to assess for adequacy. This was followed by processing other slides for fixation with 95% ethanol and staining by the Papanicolaou method. The smears revealed plentiful clusters of benign-appearing, uniform, cohesive, medium-sized epithelial cells with moderate amounts of granular cytoplasm and small to medium slightly hyperchromatic nuclei with delicate and thin membranes, and inconspicuous nucleoli [Figure 1]a. Some clusters showed peripherally located nuclei mimicking acinar architecture [Figure 1]b. Neither frank nuclear pleomorphism, nor mitotic activity was identified. The chronicity of her symptoms and persistence of gastric wall thickening prompted a decision to proceed with surgery. The patient underwent surgery. Intraoperatively, the patient was diagnosed to be a solid deeply seated intramural lesion (3 cm in diameter) located in the distal part of the stomach, without infiltration of other organs. Regional lymph nodes revealed no abnormalities.
Figure 1: (a) Monotonous medium-sized epithelial cells with moderate amount of granular cytoplasm and bland looking nuclei and inconspicuous nucleoli (Papanicolau stain, original magnification ×400). (b) Clusters of benign-looking epithelial cells, mimicking acinar architecture (Diff Quick stain, original magnification ×400)

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Gross and histopathology

The resected specimen measured 14 × 7 × 4 cm with attached perigastric fat measuring 5 cm in maximum thickness. Cut sections revealed a subserosal, well-circumscribed tan/yellow 3 cm solid mass with central cystic change [Figure 2].
Figure 2: Gross photo shows well-circumscribed deeply seated mass (short arrows) with central cystic-like change and the outlining thickened mucosa (long arrow)

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Histopathologic examination of the hematoxylin and eosin permanent slides of the mass showed pancreatic heterotopia with ducts, acini, islets of Langerhans, and intervening connective tissue [Figure 3]. Areas of focal chronic inflammatory reaction and fibrosis were seen. The postoperative course proved uneventful.
Figure 3: Histopathologic section reveals the essential components of pancreatic heterotopia including acini, ducts (long arrows), and Islets of Langerhans (short arrows)

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   Discussion Top


Heterotopic pancreas is a rare pathological entity that poses a challenge for clinical diagnosis and management. It is defined as the growth of pancreatic tissue outside of the pancreas, with no anatomic or vascular connection with normal pancreatic tissue. [1],[2] It has been identified in a variety of sites in the gastrointestinal tract. Common locations include the gastric antrum, jejunum, and Meckel's diverticulum. [3]

It tends to present as a submucosal lesion in the majority of cases but sporadically also in the muscularis propria and subserosa. [4] Clinical differential diagnoses often include malignancy. Most of the patients with pancreatic heterotopia are asymptomatic; however, some of them may present with a variety of symptoms, most commonly epigastric pain, abdominal distention, and gastrointestinal bleeding in 60%, 15%, and 30%, respectively. [5] Symptomatic cases (obstructive, hemorrhagic, chronic pain) and neoplastic transformation requires surgical intervention. [6],[7],[8],[9]

EUS-FNA has been found to be valuable in the diagnosis of upper gastrointestinal tract lesions. [10] Described EUS features of pancreatic heterotopia include irregular borders and heterogeneous echogenicity. Cytologic characteristics of pancreatic heterotopia in general are rarely described in the medical literature and should be made separate from pancreatic acinar metaplasia.

In contrast to pancreatic heterotopia, pancreatic acinar metaplasia consists of small islands of pancreatic acini. Because pancreatic heterotopia is typically a submucosal lesion, preoperative diagnosis is technically difficult. It is crucial for the cytopathologist to become familiar with the appearance of certain benign lesions such as pancreatic heterotopia that are rarely encountered in daily practice; such lesions may be misdiagnosed as malignant on cytologic preparations. Cytologically, differential diagnoses of pancreatic heterotopia include adenocarcinoma and neuroendocrine tumors. A few cases [9],[11] of malignant transformation of heterotopic pancreas have been reported. Histopathologic examination shows pancreatic acini, ducts, islets of Langerhans, and intervening connective tissue.

In summary, we present the cytologic findings obtained by EUS-FNA of a patient with heterotopic pancreas seated deeply as a solid mass in the gastric wall. It is essential for the cytopathologist to be aware of the appearance of certain benign lesions such as pancreatic heterotopia, that are rarely encountered in daily practice, to avoid the misdiagnosis of malignancy.

 
   References Top

1.
Beltra´n MA, Barria C. Heterotopic pancreas in the gallbladder. The importance of an uncommon condition. Pancreas 2007;34:488-91.  Back to cited text no. 1
    
2.
Hsu SD, Chan DC, Hsieh HF, Chen TW, Yu JC, Chou SJ. Ectopic pancreas presenting as ampulla of Vater tumor. Am J Surg 2008;195:498-500.  Back to cited text no. 2
    
3.
Bhatia V, Tajika M, Rastogi A. Upper gastrointestinal submucosal lesions-clinical and endosonographic evaluation and management. Trop Gastroenterol 2010;31:5-29.  Back to cited text no. 3
    
4.
Owen DA. The stomach. In: Sternberg's Diagnostic Surgical Pathology. 4 th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2004. p. 1436-7.  Back to cited text no. 4
    
5.
Chen HL, Chang WH, Shih SC, Bair MJ, Lin SC. Changing pattern of ectopic pancreas: 22 years of experience in a medical center. J Formos Med Assoc 2008;107:932-6.  Back to cited text no. 5
    
6.
Ormarsson OT, Gudmundsdottir I, Mårvik R. Diagnosis and treatment of gastric heterotopic pancreas. World J Surg 2006;30:1682-9.  Back to cited text no. 6
    
7.
Weppner JL, Wilson MR, Ricca R, Lucha PA Jr. Heterotopic pancreatic tissue obstructing the gallbladder neck: A case report. JOP 2009;10:532-4.  Back to cited text no. 7
    
8.
Christodoulidis G, Zacharoulis D, Barbanis S, Katsogridakis E, Hatzitheofilou K. Heterotopic pancreas in the stomach: A case report and literature review. World J Gastroenterol 2007;13:6098-100.  Back to cited text no. 8
    
9.
Inoue Y, Hayashi M, Arisaki Y, Higuchi K, Egashira Y, Tanigawa N. Adenocarcinoma arising in a heterotopic pancreas (Heinrich type III): A case report. J Med Case Rep 2010;4:39-43.  Back to cited text no. 9
    
10.
Philipper M, Hollerbach S, Gabbert HE, Heikaus S, Böcking A, Pomjanski N, et al. Prospective comparison of endoscopic ultrasound-guided Fine-needle aspiration and surgical histology in upper gastrointestinal submucosal tumors. Endoscopy 2010;42:300-5.  Back to cited text no. 10
    
11.
Kinoshita H, Yamaguchi S, Shimizu A, Sakata Y, Arii K, Mori K, et al. Adenocarcinoma arising from heterotopic pancreas in the duodenum. Int Surg 2012;97:351-5.  Back to cited text no. 11
    

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Correspondence Address:
Dr. Emad Raddaoui
Department of Pathology, King Khalid University Hospital College Of Medicine, King Saud University, P.O. Box 2925/32, Riyadh 11461, Saudi Arabia

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.153841

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  [Figure 1], [Figure 2], [Figure 3]



 

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