Sugiyama Tomoko, Tajiri Takuma, Hiraiwa Shinichiro, Machida Tomohisa, Ito Hiroyuki, Yoshii Hisanori, Izumi Hideki, Nomura Eiji, Mukai Masaya, Nakamura Naoya
Department of Diagnostic Pathology, Tokai University Hachioji Hospital, Tokyo, Japan.
Department of Laboratory Medicine, Tokai University Hachioji Hospital, Tokyo, Japan.
Pathol Int. 2019 Mar;69(3):165-171. doi: 10.1111/pin.12768. Epub 2019 Feb 5.
We report a case of high-grade pancreatic intraepithelial neoplasia (PanIN) concomitant with lymphoplasmacytic sclerosing pancreatitis. The patient was an 82-year-old man in whom narrowing of the main pancreatic duct was detected incidentally by abdominal ultrasonography. Magnetic resonance cholangiopancreatography further revealed abrupt narrowing plus distal dilatation of the duct, from the pancreatic body to the tail. Distal pancreatectomy was performed under a preoperative diagnosis of intraductal papillary-mucinous neoplasm. Macroscopic examination of the surgical specimen showed an ill-demarcated, white-gray area and prominent pancreatic atrophy, while histological analysis detected small (<5 mm in diameter) cystic dilatations of the main pancreatic duct and some branch ducts plus pancreatic atrophy with fibrosis and fatty replacement of acinar cells. We also detected variously sized papillary projections, fused glands, and scattered focal papillary proliferation of columnar ductal epithelium comprising cells with elongated, mildly hyperchromatic nuclei, consistent with high-grade PanIN. In addition, we observed marked lymphoplasmacytic infiltration, periductal storiform fibrosis, and obliterative phlebitis. Immunohistochemical staining revealed abundant immunogloblin G4-positive plasma cells, indicative of type 1 autoimmune pancreatitis (AIP). The coexistence of high-grade PanIN and marked lymphoplasmacytic infiltration, typical of AIP, point to a close association between the former, as a carcinogenic process, and the latter, as an immune response.
我们报告一例高级别胰腺上皮内瘤变（PanIN）合并淋巴细胞浆细胞性硬化性胰腺炎的病例。患者为一名82岁男性，腹部超声偶然发现主胰管狭窄。磁共振胰胆管造影进一步显示，从胰体至胰尾，胰管出现突然狭窄并伴有远端扩张。术前诊断为导管内乳头状黏液性肿瘤，遂行远端胰腺切除术。手术标本的宏观检查显示界限不清的灰白色区域及明显的胰腺萎缩，而组织学分析发现主胰管及一些分支胰管有小（直径<5毫米）的囊性扩张，伴有胰腺萎缩、纤维化及腺泡细胞脂肪替代。我们还检测到大小不一的乳头状突起、融合性腺体以及由细胞核细长、轻度深染的细胞构成的柱状导管上皮散在局灶性乳头状增生，符合高级别PanIN。此外，我们观察到明显的淋巴细胞浆细胞浸润、导管周围席纹状纤维化及闭塞性静脉炎。免疫组化染色显示大量免疫球蛋白G4阳性浆细胞，提示1型自身免疫性胰腺炎（AIP）。高级别PanIN与AIP典型的明显淋巴细胞浆细胞浸润并存，表明前者作为致癌过程与后者作为免疫反应之间存在密切关联。
