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Case History

72 years female with a history of acral melanoma presented with loss of appetite, a mass in pancreatic head and multiple small nodules in peripancreatic fat.  Endoscopic ultrasound fine needle aspiration was performed.

  1. Based on Diff-Quick stain smears rank the following diagnosis from most likely to unlikely:
  • -Solid pseudopapillary carcinoma
  • -Carcinoid tumor
  • -Islet cell tumor 
  • -Acinar carcinoma
  • -Poorly differentiated ductal carcinoma
  1. Positive staining for neuroendocrine markers likely exclude (mark true or false):
  • -Solid pseudopapillary carcinoma
  • -Carcinoid tumor
  • -Islet cell tumor 
  • -Acinar carcinoma
  • -Poorly differentiated ductal carcinoma
  1. Although not frequently used, electron microscopy can differentiate between (mark true or false):
  • -Insulinoma and carcinoid
  • -Acinar carcinoma and ductal carcinoma
  • -Solid pseudopapillary carcinoma and Islet cell tumor
  • -Acinar carcinoma and carcinoid 
  • -Metastatic melanoma and poorly differentiated carcinoma

 Case_1111.jpegCase_11115.jpegdiff quik stained smear x40

 Case_11112.jpegIHC positive staining for trypsin

Electron microscopy image showing zymogen granules
 Case_11114.jpegH&E-stained section showing metastatic acinar carcinoma in lymph node

  1. Answers:

    1- Acinic carcinoma
    2- Carcinoid tumor
    3- Islet cell tumor
    4- SPN
    5- Poorly differentiated carcinoma

  2. 2:
    1- False
    2- False
    3- False
    4- False
    5- True

  3. 3:
    1- True
    2- True

  4. Stains for endocrine markers were negative.  Stain for trypsin was positive.  Electron microscopic examination shows classical zymogen granules.   Final diagnosis acinic carcinoma with metastasis to lymph nodes.


Case contributed by: Isam-Eldin Eltoum, M.D., M.B.A., Professor, Vice Chair, Quality and Patient Safety, Anatomic Pathology