Follow-up of indeterminate cytologic diagnoses of solid pancreatic lesions: atypia versus suspicious (one institution's experience)

Ikemura, Kenji; Liang, Yan; Park, Ji-Weon

doi:10.1016/j.jasc.2018.02.004

Cited by 4 publications

(14 citation statements)

References 17 publications

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“…These reactive changes were responsible for as many as 38% of atypical diagnoses (in one study), because of their resemblance to lymphoma, acinar cell carcinoma (ACC) and pancreatic ductal adenocarcinoma (PDAC). 9,11,17 Distinguishing benign acinar cells from ACC may be impossible morphologically. On low power reactive acinar cells maintain their organized lobular grape-like configuration, and lack pleomorphism or mitoses (Figure 1), while the tumor cells of ACC form ill-defined syncytial clusters or single cells and show more nuclear pleomorphism, mitoses, prominent cherry red nucleoli and necrosis.…”

Section: Technical Factorsmentioning

confidence: 99%

“…Another common cause of "atypical" diagnoses is well-differentiated or low-grade morphology as seen in well differentiated PanNET, ACC, SPN, and well-differentiated PDAC. 9,11,13,14,17,[27][28][29] PanNET and ACC often show minimal deviation from normal or reactive pancreatic islet cells and acini, making definitive diagnosis a challenge. PanNET may also mimic ACC as both can show dispersed plasmacytoid tumor cells, acinar groups or rosettes, and stripped nuclei.…”

Section: Well-differentiated and Low-grade Morphologymentioning

confidence: 99%

“…As a result the frequency of usage of the atypical category is quite variable and ranges from 0%-16%, with an average of 6%. [4][5][6][7][8][9][10][11][12][13][14] The atypical category is even more frequent in bile duct brushings, but a discussion of bile duct brushings is beyond the scope of this review. 15,16 A factor that is thought to contribute to interinstitutional variability in the frequency of "atypical" cases is the fact that some studies restricted their analyses to solid pancreatic lesions, 9,12 while others included both solid and cystic lesions.…”

mentioning

confidence: 99%

“…[4][5][6][7][8][9][10][11][12][13][14] The atypical category is even more frequent in bile duct brushings, but a discussion of bile duct brushings is beyond the scope of this review. 15,16 A factor that is thought to contribute to interinstitutional variability in the frequency of "atypical" cases is the fact that some studies restricted their analyses to solid pancreatic lesions, 9,12 while others included both solid and cystic lesions. 11,14,17 Studies that excluded cystic pancreatic lesions typically did so because indeterminate (including atypical) diagnoses in pancreatic cysts were thought to have been mostly resolved by application of the 2014 PSC guidelines, which provide objective cytologic criteria and incorporate imaging, biochemical and molecular cyst fluid analysis into final diagnoses.…”

mentioning

confidence: 99%

“…11,14,17 Studies that excluded cystic pancreatic lesions typically did so because indeterminate (including atypical) diagnoses in pancreatic cysts were thought to have been mostly resolved by application of the 2014 PSC guidelines, which provide objective cytologic criteria and incorporate imaging, biochemical and molecular cyst fluid analysis into final diagnoses. 2,3,9,12 In fact, when the PSC system was first implemented it decreased the overall number of atypical diagnoses, particularly for cystic lesions. Its' widespread usage has led to the redistribution of many originally "atypical" cases into either benign or neoplastic categories.…”

mentioning

confidence: 99%

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Atypical cells in fine needle aspiration biopsies of pancreas: Causes, work‐up, and recommendations for management

HooKim

Reid

2021

Diagnostic Cytopathology

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Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a sensitive and specific method for diagnosing cancer in solid pancreatic masses. However, some cases receive indeterminate atypical diagnoses, which creates management dilemmas. In the 2014 Papanicolaou Society of Cytopathology (PSC) standardized guidelines for pancreatobiliary cytology, specimens in the "Atypical" category show a spectrum of architectural and/or cellular changes beyond normal or reactive, but, quantitatively or qualitatively, insufficient for classification as neoplastic (benign/ other), suspicious or positive for malignancy. Implementation of the PSC system decreased atypical diagnoses, particularly for cystic lesions, and redistributed many cases into benign and neoplastic categories. Because no set cytologic criteria exist for the "Atypical" category there is wide variability in its use, and its frequency ranges from 0%-16% (mean 6%). It consists of a heterogeneous mix of cases that occur because of preanalytic, lesion-specific (low cellularity, necrosis, cystic, reactive and premalignant changes), to pathologist-dependent factors (experience, expertise, training and institutional case volume). Outcomes of atypical diagnoses in solid pancreatic masses range from benign to premalignant and malignant and include reactive atypia in pancreatitis, well differentiated adenocarcinoma, and non-ductal malignancies. The associated risk of malignancy (ROM) ranges from 28%-100%, with an overall intermediate ROM in large-scale studies. Cytopathologists and institutions should monitor and keep their personal and/or laboratory's atypical rates low by judiciously using rapid onsite evaluation, ancillary studies, consensus or expert review, as well as correlation with clinical and radiologic findings. Early repeat EUS-FNA is indicated for unresolved cases.

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Section: Technical Factorsmentioning

confidence: 99%

Section: Well-differentiated and Low-grade Morphologymentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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confidence: 99%

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Atypical cells in fine needle aspiration biopsies of pancreas: Causes, work‐up, and recommendations for management

HooKim

Reid

2021

Diagnostic Cytopathology

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The World Health Organization Reporting System for Pancreaticobiliary Cytopathology: Overview and Summary

Centeno,

Saieg,

Siddiqui

et al. 2024

Cancer Cytopathology

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The recently published WHO Reporting System for Pancreaticobiliary Cytopathology (World Health Organization [WHO] System) is an international approach to the standardized reporting of pancreaticobiliary cytopathology, updating the Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology (PSC System). Significant changes were made to the categorization of benign neoplasms, intraductal neoplasms, mucinous cystic neoplasms, and malignant neoplasms considered low grade. Benign neoplasms, such as serous cystadenoma, categorized as Neoplastic: benign in the PSC system, are categorized as Benign/negative for malignancy in the WHO system. Pancreatic neuroendocrine tumor, solid‐pseudopapillary neoplasm, and gastrointestinal stromal tumor, categorized as Neoplastic: other in the PSC system, are categorized as Malignant in the WHO System in accord with their classification in the 5th edition WHO Classification of Digestive System Tumours (2019). The two new categories of Pancreaticobiliary Neoplasm Low‐risk/grade and Pancreaticobiliary Neoplasm High‐risk/grade are mostly limited to intraductal neoplasms and mucinous cystic neoplasms. Low‐risk/grade lesions are mucinous cysts, with or without low‐grade epithelial atypia. High‐risk/grade lesions contain neoplastic epithelium with high‐grade epithelial atypia. Correlation with clinical, imaging, and ancillary studies remains a key tenet. The sections for each entity are written to highlight key cytopathological features and cytopathological differential diagnoses with the pathologist working in low resource setting in mind. Each section also includes the most pertinent ancillary studies useful for the differential diagnosis. Sample reports are provided for each category. Finally, the book provides a separate section with risk of malignancy and management recommendations for each category to facilitate decision‐making for clinicians.

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The World Health Organization Reporting System for Pancreaticobiliary Cytopathology

et al. 2022

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The World Health Organization (WHO), the International Academy of Cytology, and the International Agency for Research on Cancer, with expert contributors from around the world, present an international approach to standardized reporting of pancreaticobiliary cytopathology. This reporting system is one of the first in a series from various body sites that mirror the WHO Classification of Tumours series and provides an evidence-based terminology system with associated risk of malignancy and diagnostic management recommendation per diagnostic category. The WHO Reporting System for Pancreaticobiliary Cytopathology (WHO system) revises the Papanicolaou Society of Cytopathology (PSC) system for Reporting Pancreaticobiliary Cytology published in 2015 and replaces the six-tiered system with a seven-tiered system: “insufficient/inadequate/nondiagnostic”; “benign (negative for malignancy),” “atypical,” “pancreaticobiliary neoplasm of low risk/low grade,” “pancreatic neoplasm of high risk/high grade,” “suspicious for malignancy,” and “malignant.” The principal differences between the WHO and the PSC systems revolve around the classification of neoplasia. In the PSC system, there was a single category for “neoplastic” lesions that includes two groups, one for “benign neoplasms” [primarily serous cystadenoma] and one named “other,” dominated by premalignant intraductal neoplasms (primarily intraductal papillary mucinous neoplasms) and low-grade malignant neoplasms [pancreatic neuroendocrine tumors (PanNETs) and solid pseudopapillary neoplasms (SPNs)]. In the WHO system, benign neoplasms with virtually no risk of malignancy are included in the “benign” category and low-grade malignancies (PanNET and SPN) are included in the “malignant” category, as per the WHO Classification of Digestive System Tumours, thus leaving in the “neoplasm” category primarily those noninvasive premalignant lesions of the ductal system. These neoplasms are divided by the cytomorphological grade of the epithelium into low risk/low-grade and high risk/high-grade, with distinctly different risks of malignancy. As with the PSC system, the WHO system advocates close correlation with imaging and encourages incorporation of ancillary testing into the final diagnosis, such as biochemical (CEA and amylase) and molecular testing of cyst fluid and bile duct brushings. Key diagnostic cytopathological features of specific lesions or neoplasms, ancillary studies for diagnostic and prognostic evaluation, and implications of diagnosis for patient care and management are discussed. In addition, the WHO system includes reporting and diagnostic management options that recognize the variations in the availability of diagnostic and prognostic ancillary testing modalities in low- and middle-income countries, where cytopathology is particularly useful and is increasingly available in the absence of histopathological services.

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Follow-up of indeterminate cytologic diagnoses of solid pancreatic lesions: atypia versus suspicious (one institution's experience)

Cited by 4 publications

References 17 publications

Atypical cells in fine needle aspiration biopsies of pancreas: Causes, work‐up, and recommendations for management

Atypical cells in fine needle aspiration biopsies of pancreas: Causes, work‐up, and recommendations for management

The World Health Organization Reporting System for Pancreaticobiliary Cytopathology: Overview and Summary

The World Health Organization Reporting System for Pancreaticobiliary Cytopathology

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