General Pathology Biliary Tract and Pancreas 1 December 07

Biliary Tract Bile Two major functions o Elimination of bilirubin e!cess cholesterol and !enobiotics that are insufficiently water soluble to be e!creted in urine o Emulsification of dietary fat in the gut by bile acids "cholic acid chenodeo!ycholic acid# $nconjugated % &onjugated 'eabsorbed in terminal ileum "enterohe(atic circulation# Cholestasis )ystemic retention of not only bilirubin but also other solutes eliminated in bile (articularly bile salts and cholesterol Due to he(atocellular dysfunction or biliary obstruction *ccumulation of bile (igment within the he(atic (arenchyma + ,u(ffer cells Bile ductular (roliferation Bile la-es Portal tract fibrosis Secondary Biliary Cirrhosis .ost common cause is e!trahe(atic cholelithiasis Biliary atresia malignancies of the biliary tree and head of the (ancreas and strictures &holestasis Bile duct (roliferation with surrounding neutro(hils Peri(ortal fibrosis Primary Biliary Cirrhosis .iddle/aged women .01 2 1010 Possibly autoimmune o *utoantibodies to mitochondrial dehydrogenase 405 6nsidious onset usually (resenting with (ruritus 7y(erbilirubinemia jaundice cirrhosis late 8 al-aline (hos(hatase cholesterol Cholelithiasis :ery common &holesterol stones o Bile is su(ersaturated with cholesterol o Gallbladder stasis o 1;. o <besity o *d3ancing age Pigment stones + calcium bilirubinate salts o *sian more than =estern o &hronic hemolytic syndromes Primary Sclerosing Cholangitis 6nflammation obliterati3e onion/s-in fibrosis and segmental dilatation of the obstructed intrahe(atic and e!trahe(atic bile ducts )tring of beads on E'&P 705 associated with inflammatory bowel disease (articularly ulcerati3e colitis .01 2 901 third through fifth decades Progressi3e fatigue (ruritus jaundice &hronic course 6ncreased ris- for cholangiocarcinoma

(yru3ate

&linical 1eatures o *sym(tomatic o Biliary colic o &holecystitis o Gallstone ileus

Figure 1-Nonsuppurative, granulomatous destruction of medium-sized intrahepatic bile ducts = florid duct lesion

MR*, Mel, Eisa

(kami ba tlga trans n2?)

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General Pathology Biliary Tract and Pancreas by VGY

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Cholecystitis *cute calculous o <bstruction of GB nec- or cystic duct o '$> (ain radiating to right shoulder o 1e3er nausea leu-ocytosis o Potential surgical emergency *cute acalculous + seriously ill (ts &hronic o 'ecurrent attac-s of (ain o ?ausea and 3omiting o *ssociated with fatty meals

Choledocholithiasis )tones within the biliary tree =est + from gallbladder *sia + (rimary ductal and intrahe(atic stone formation )ym(toms due to0 o Biliary obstruction o Pancreatitis o &holangitis o 7e(atic abscess Cholangitis *cute inflammation of bile ducts Due to biliary obstruction usually choledocholithiasis Bacterial infection from gut i@e@ gram negati3e aerobes o 1e3er chills abdominal (ain jaundice Aatin *merica and ?ear East0 1asciola he(atica schistosomiasis 1ar East0 &lonorchis sinensis <(isthorchis 3i3errini *6D)0 cry(tos(oridiosis Biliary Atresia 1BC of cases of neonatal cholestasis 1 in 10 000 li3e births &om(lete obstruction of bile flow caused by destruction or absence of all or (art of the e!trahe(atic bile ducts *cDuired inflammatory disorder ?ormal stools to acholic stools Bile ductular (roliferation on li3er b! &irrhosis by C to E months of age@ 'eDuire li3er trans(lantation

General Pathology Biliary Tract and Pancreas by VGY

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Gallbladder Carcinoma )e3enth decade 1;. Disco3ered at late stage usually incidental E!o(hytic and infiltrating ty(es *denocarcinoma Aocal e!tension into li3er cystic duct (ortahe(atic A?s .ean F yr sur3i3al 15

=irsung disco3ered the (ancreatic duct in 1EH9@ Pancreas as a secretory gland was in3estigated by Graaf in 1E71@ '@ 1itI established (ancreatitis as a disease in 1GG4@ =hi((le (erformed the first (ancreatico/duodenectomy in 14CF and refined it in 14H0@

Pancreas Gland with both e!ocrine and endocrine functions E/10 inch in length E0/100 gram in weight Aocation0 retro/(eritoneumJ 9nd lumbar 3ertebral le3el E!tends in an obliDue trans3erse (osition Parts of (ancreas0 head nec- body and tail Embryology Endodermal origin De3elo(s from 3entral and dorsal (ancreatic buds :entral bud becomes the uncinate (rocess and inferior head of (ancreas Dorsal bud becomes su(erior head nec- body and tail :entral bud duct fuses with dorsal bud duct to become mail (ancreatic duct "=irsung#

Cholangiocarcinoma <lder (ts .;1 Painless jaundice ?B: weight loss <(isthorchis sinensis "li3er flu-e# inflammatory bowel disease Tumors usually small at d! yet not resectable ,lats-in tumor + arises at bifurcation *denocarcinoma .ean sur3i3al E to 1G months

Pancreas Brief History 7ero(hilus Gree- surgeon first described (ancreas@

Head of Pancreas 6ncludes uncinate (rocess 1lattened structure 9 + C cm thic *ttached to the 9nd and Crd (ortions of duodenum on the right Emerges into nec- on the left Border bBw head K nec- is determined by GD* insertion )PD* and 6PD* anastamose bBw the duodenum and the rt@ lateral border Neck of Pancreas

General Pathology Biliary Tract and Pancreas by VGY 9@F cm in length )traddles ).: and P: *ntero/su(erior surface su((orts the (ylorus )u(erior mesenteric 3essels emerge from the inferior border Posteriorly ).: and s(lenic 3ein confluence to form (ortal 3ein Posteriorly mostly no branches to (ancreas

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*nterior collateral arcade bBw anterosu(erior and anteroinferior PD* Posterior collateral arcade bBw (osterosu(erior and (osteroinferior PD* Body and tail su((lied by s(lenic artery by about 10 branches Three biggest branches are o Dorsal (ancreatic artery o Pancreatica .agna "mid(ortion of body# o &audal (ancreatic artery "tail#

Body of Pancreas Elongated long structure *nterior surface se(arated from stomach by lesser sac Posterior surface related to aorta lt@ adrenal gland lt@ renal 3essels and u((er 1BCrd of lt@ -idney )(lenic 3ein runs embedded in the (ost@ )urface 6nferior surface is co3ered by tran@ mesocolon Tail of Pancreas ?arrow short segment Aies at the le3el of the 19th thoracic 3ertebra Ends within the s(lenic hilum Aies in the s(leno(hrenic ligament *nteriorly related to s(lenic fle!ure of colon .ay be injured during s(lenectomy "fistula# Pancreatic !"ct .ain duct "=irsung# runs the entire length of (ancreas Loins &BD at the am(ulla of :ater 9 + H mm in diameter 90 secondary branches Ductal (ressure is 1F + C0 mm 7g "3s@ 7 + 17 in &BD# thus (re3enting damage to (anc@ duct Aesser duct ")antorini# drains su(erior (ortion of head and em(ties se(arately into 9nd (ortion of duodenum Arterial S"##ly of the Pancreas :ariety of major arterial sources "celiac ).* and s(lenic# &eliac &ommon 7e(atic *rtery Gastroduodenal *rtery )u(erior (ancreaticoduodenal artery which di3ides into anterior and (osterior branches ).* 6nferior (ancreaticoduodenal artery which di3ides into anterior and (osterior branches

$eno"s !rainage of Pancreas 1ollows arterial su((ly *nterior and (osterior arcades drain head and the body )(lenic 3ein drains the body and tail .ajor drainage areas are o )u(ra(ancreatic P: o 'etro(ancreatic P: o )(lenic 3ein o 6nfra(ancreatic ).: $ltimately into (ortal 3ein

%ym#hatic !rainage 'ich (eriacinar networ- that drain into F nodal grou(s o )u(erior nodes o *nterior nodes o 6nferior nodes o Posterior PD nodes o )(lenic nodes &nner'ation of Pancreas

General Pathology Biliary Tract and Pancreas by VGY Pe(tidergic neurons that secrete amines and (e(tides "somatostatin 3asoacti3e intestinal (e(tide calcitonin gene/ related (e(tide and galanin 'ich afferent sensory fiber networGanglionectomy or celiac ganglion bloc-ade interru(t these somatic fibers "(ancreatic (ainJ# Pe(tidergic neurons that secrete amines and (e(tides "somatostatin 3asoacti3e intestinal (e(tide calcitonin gene/ related (e(tide and galanin 'ich afferent sensory fiber networGanglionectomy or celiac ganglion bloc-ade interru(t these somatic fibers "(ancreatic (ainJ#

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*l-aline (7 results from secreted bicarbonate which ser3es to neutraliIe gastric acid and regulate the (7 of the intestine EnIymes digest carbohydrates (roteins and fats

Histology)E*ocrine Pancreas 9 major com(onents + acinar cells and ducts &onstitute G05 to 405 of the (ancreatic mass *cinar cells secrete the digesti3e enIymes 90 to H0 acinar cells coalesce into a unit called the acinus &entroacinar cell "9nd cell ty(e in the acinus# is res(onsible for fluid and electrolyte secretion by the (ancreas Ductular system / networ- of conduits that carry the e!ocrine secretions into the duodenum *cinus small intercalated ducts interlobular duct (ancreatic duct 6nterlobular ducts contribute to fluid and electrolyte secretion along with the centroacinar cells Histology)Endocrine Pancreas *ccounts for only 95 of the (ancreatic mass ?ests of cells / islets of Aangerhans 1our major cell ty(es o *l(ha "*# cells secrete glucagon o Beta "B# cells secrete insulin o Delta "D# cells secrete somatostatin o 1 cells secrete (ancreatic (oly(e(tide B cells are centrally located within the islet and constitute 705 of the islet mass PP * and D cells are located at the (eri(hery of the islet Physiology + E*ocrine Pancreas )ecretion of water and electrolytes originates in the centroacinar and intercalated duct cells Pancreatic enIymes originate in the acinar cells 1inal (roduct is a colorless odorless and isosmotic al-aline fluid that contains digesti3e enIymes "amylase li(ase and try(sinogen# F00 to G00 ml (ancreatic fluid secreted (er day

Bicarbonate Secretion Bicarbonate is formed from carbonic acid by the enIyme carbonic anhydrase .ajor stimulants )ecretin &holecysto-inin Gastrin *cetylcholine .ajor inhibitors *tro(ine )omatostatin Pancreatic (oly(e(tide and Glucagon )ecretin / released from the duodenal mucosa in res(onse to a duodenal luminal (7 M C En,yme Secretion *cinar cells secrete isoIymes o amylases li(ases and (roteases .ajor stimulants o &holecysto-inin *cetylcholine )ecretin :6P )ynthesiIed in the endo(lasmic reticulum of the acinar cells and are (ac-aged in the Iymogen granules 'eleased from the acinar cells into the lumen of the acinus and then trans(orted into the duodenal lumen where the enIymes are acti3ated@

En,ymes of the Pancreas *mylase o only digesti3e enIyme secreted by the (ancreas in an acti3e form o functions o(timally at a (7 of 7 o hydrolyIes starch and glycogen to glucose maltose maltotriose and de!trins Ai(ase o function o(timally at a (7 of 7 to 4 o emulsify and hydrolyIe fat in the (resence of bile salts Proteases o essential for (rotein digestion o secreted as (roenIymes and reDuire acti3ation for (roteolytic acti3ity o duodenal enIyme entero-inase con3erts try(sinogen to try(sin o Try(sin in turn acti3ates chymotry(sin elastase carbo!y(e(tidase and (hos(holi(ase =ithin the (ancreas enIyme acti3ation is (re3ented by an anti(roteolytic enIyme secreted by the acinar cells &ns"lin )ynthesiIed in the B cells of the islets of Aangerhans G05 of the islet cell mass must be surgically remo3ed before diabetes becomes clinically a((arent Proinsulin is trans(orted from the endo(lasmic reticulum to the Golgi com(le! where it is (ac-aged into granules and

General Pathology Biliary Tract and Pancreas by VGY clea3ed into insulin and a residual connecting (e(tide or & (e(tide .ajor stimulants o Glucose amino acids glucagon G6P &&, sulfonylurea com(ounds N/)ym(athetic fibers .ajor inhibitors o somatostatin amylin (ancreastatin O/sym(athetic fibers

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?onbacterial inflammatory disease caused by acti3ation interstitial liberation and autodigestion of the (ancreas by its own enIymes@ 6nconclusi3e e3idence regarding (athogenesis o Partial or intermittent ductal obstruction and increased ductal (ressure o Biliary reflu! o Duodenal juice reflu! Etiology o Gallstones and *lcohol account for 405 o 7y(erli(idemia o 7y(ercalcemia o 1amilial o Pancreatic duct obstruction Tumour Pancreas di3isum :iral infection )cor(ion 3enom Drugs 6dio(athic

Gl"cagon )ecreted by the * cells of the islet Glucagon ele3ates blood glucose le3els through the stimulation of glycogenolysis and gluconeogenesis .ajor stimulants o *minoacids &holinergic fibers N/)ym(athetic fibers .ajor inhibitors o Glucose insulin somatostatin O/sym(athetic fibers Somatostatin )ecreted by the D cells of the islet 6nhibits the release of growth hormone 6nhibits the release of almost all (e(tide hormones 6nhibits gastric (ancreatic and biliary secretion $sed to treat both endocrine and e!ocrine disorders E*ocrine Pancreas The final (roduct of the e!ocrine (ancreas is a clear isotonic solution with a (7 in the range of G@ The 9 distinct com(onents of e!ocrine secretion are enIyme secretion and waterPelectrolyte secretion@ &holecysto-inin is the most (otent endogenous hormone -nown to stimulate enIyme secretion@ )ecretin is the most (otent endogenous stimulant of (ancreatic electrolyte secretion@ Endocrine Pancreas The release of insulin into the (ortal blood is controlled by the concentration of blood glucose 3agal interactions and local concentrations of somatostatin@ The major stimulus for glucagon release is a fall in serum glucose@ Pancreatic polypeptide a((ears to function for regulation of (ancreatic e!ocrine secretion and biliary tract motility@ Somatostatin has a broad inhibitory s(ectrum of gastrointestinal acti3ity Congenital anomalies *genesis Pancreas di3isum *nnular (ancreas Ecto(ic (ancreas Ac"te Pancreatitis

o o o o

)igns and )ym(toms o .ide(igastric abdominal (ain o 'adiating to the baco ?ausea and 3omiting o 1e3er and tachycardia o E(igastric tenderness o *bdominal distention o Bluish discoloration in the flan- "Grey urner!s sign" o Bluish discoloration (eriumbilically "#ullen!s sign" Diagnosis o 6t is su((orted by a((ro(riate laboratory determinations and radiogra(hic findings o )erum amylase is the most widely used lab test o 7y(eramylasemia is commonly obser3ed within 9H hrs@ of the onset and gradually returns to normal o Persistent hy(eramylasemia beyond the initial weemay indicate the de3elo(ment of (ancreatic (seudocyst (hlegmon abscess or ongoing acute (ancreatic inflammation@ o Ele3ated amylase le3els may occur in other acute abdominal conditions though le3els rarely e!ceed F00 6$BdA o $rinary amylase e!cretion is increased and this may be 3ery hel(ful in cases where the serum amylase le3el has returned to normal@ o <ther lab@ 1indings .oderate leu-ocytosis .ild bilirubin ele3ation "M9mgBdA# 'aised 7aematocrit 7y(ocalcaemia "&alcium being com(le!ed with fatty acids#

General Pathology Biliary Tract and Pancreas by VGY

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'adiogra(hic 1indings o &Q' and P1* non/s(ecific findings )entinel loo( Pleural effusion "Aeft# *bdominal $ltrasonogra(hy Aithiasis of biliary tract Pancreatic swelling &om(uted Tomogra(hy with i3 contrast

&linical &ourse o Early identification of (atients at greater ris- of com(lications allows them to be managed more aggressi3ely which a((ears to decrease the mortality rate@ o The se3erity and (rognosis of an attac- of acute (ancreatitis can be (redicted by use of routinely a3ailable laboratory determinations@ o Lust the single finding of fluid seDuestration e!ceeding 9 ABd for more than 9 days is reasonably accurate di3iding line between se3ere and mild to moderate disease@ 'ansonRs criteria for se3erity o <n admission o *ge ;FF years =B& ;1E000 Blood Glucose ;900 mgBdA AD7 ;CF0 iuBA *)T ")G<T# ; 9F0 iuBdA

Treatment Goals of medical treatment o 'eduction of (ancreatic secretory stimuli o &orrection of fluid and electrolyte derangements &om(lications o *bscess o o o o o o Pseudocyst formation Pancreatic ascites &hronic (leural effusion Gastrointestinal bleeding *cute s(lenic 3ein thrombosis &hronic Pancreatitis

*fter 9H hours 7ematocrit fall ;105 B$? rise ;GmgBdA )erum &a MGmgBdA *rterial P< ME0 mm7g Base deficit ; HmEDBA 1luid seDuestration ;E00 mA Predicted .ortality 'ates 0/9 criteria 2 95 C or H criteria 2 1F5 F or E criteria 2 H05 7 or G criteria 2 1005 Pancreatic Pse"docyst The term (seudocyst denotes absence of an epithelial lining in contrast to true cysts Enca(sulated collections of fluid with high enIyme concentrations that arise from the (ancreas@ They are usually located either within or adjacent to the (ancreas in the lesser sac@ The walls of a (seudocyst are formed by inflammatory fibrosis of the (eritoneal mesenteric and serosal membranes which limits s(read of the (ancreatic juice as the lesion de3elo(s@ Early or late (resentation Pain is the most common finding 1e3er weight loss tenderness (al(able mass Laundice rarely Ele3ated amylase and =B& in S F05 &T scan is the in3estigation of choice DBD *bscess (hlegmon neo(lastic cysts &om(lications o o 6nfection *bscess 'u(ture )e3ere chemical (eritonitis

Glasgow (rognostic system

General Pathology Biliary Tract and Pancreas by VGY o 7aemorrhage

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Poor (rognosis "mean sur3i3al F to E months#

Chronic Pancreatitis 6s an entity encom(assing recurrent or (ersistent abdominal (ain of (ancreatic origin combined with e3idence of e!ocrine and endocrine insufficiency and mar-ed (athologically by irre3ersible (arenchymal destruction@ 6t is associated with alcohol abuse 7y(er(arathyroidism congenital anomalies of the (ancreatic duct and (ancreatic trauma@ 6t may also be idio(athic@ Neo#lasms of the Pancreas E*ocrine T"mo"rs A0 Periam#"llary Carcinoma &ancer of the head of (ancreas GF5 *m(ullary carcinoma 105 Duodenal carcinomas MF5 Distal &ommon Bile Duct &a MF5 )igns and )ym(toms o Laundice o =eight loss o *nore!ia o :ague abdominal (ain o Ele3ated bilirubin *l-@ Phos(hatase *)T *AT o Tumour mar-ers &* 14/4 not sufficiently accurate o &T scan to determine the siIe and to detect metastatic s(read o )electi3e celiac and mesenteric angiogram combined with (ortal 3enogra(hy to assess resectability@ Treatment o Palliation with Drainage of biliary tree with stents o Duodenal obstruction (oorly (alliated non/ o(erati3ely o )urgical treatment is feasible o <nly H05 of (re/o(erati3ely resectable tumours are resectable and this rate is e3en lower for adeno/&a of head of (ancreas@ o =hi((leRs (ancreaticoduodenectomy Prognosis o <3erall F year sur3i3al 9F5 o 7ead of (ancreas &a F/year sur3i3al M905 o <ther (eriam(ullary &a F year sur3i3al SE05 o &hemothera(y alone not significant benefit o &ombined 'adio/chemothera(y and local radiation thera(y ha3e shown some benefit at least in local tumour control@ Carcinoma of Body and Tail C05 of all cases of (ancreatic &ancer =eight loss and abdominal (ain &T scan and E'&P 'esectability rate M75

Neo#lasms of the Pancreas Endocrine T"mo"rs Pancreatic islet cell endocrine tumour are rare and are (resumed to originate from neural crest cells@ 1unctional endocrine tumours are con3entionally named according to the major hormone (roduced by the hormone@ .alignancy is determined by the (resence of local in3asion the s(read to regional lym(h nodes or the e!istence of he(atic or distant metastases0 $( to 9F5 of (ancreatic endocrine tumours are classified as non/functional based on the absence of a clinical syndrome and the lac- of ele3ated serum hormone le3els@ ?on/functioning tumours freDuently ha3e clinical manifestations similar to the more common e!ocrine malignancies ?on/functioning tumours are associated with a higher malignancy rate than are their functioning counter(arts@ Princi(les of .anagement o 'ecognition of the abnormal (hysiologic mechanism or characteristic syndrome o Detection of hormone ele3ations in serum by radioimmunoassay o AocaliIation and staging of the tumour in (re(aration for o(erati3e thera(y@ o Goals of treatment0 control of sym(toms due to hormone e!cess E!cision of ma!imal neo(lastic tissue Pre3ention of tumour recurrence@ Endocrine Pancreatic Tumours a@ 6nsulinoma o .ost common endocrine tumour o 405 benign solitary (ancreatic adenomas b@ Gastrinoma o )econd most common o Pe(tic ulcer disease@ o Ele3ated serum gastrin c@ :6P/oma o =atery diarrhea hy(o-alemia achlorydria d@ )omatostatinoma

B0

!"ctal Adenocarcinoma GF 5 of (ancreatic malignancies Hth most common &* in the $) 'is- factors0 o &igarette smo-ing o &hronic (ancreatitis o Pancreaticobiliary ductal anomaly o Elderly Diagnosis o &T )can o .'6 o &eliac angiogra(hy

General Pathology Biliary Tract and Pancreas by VGY o o o o o )onogra(hy E'&P )elenomethionine )can Duodenal *s(iration )erum Test0

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)(an/1 &* 14/4 &E* 9BC/head 1BC/body K tail Poorly delineated yellowish gray &) Duodenal wall direct e!tension ?on/neo(lastic area inflammation fibrosis e!tensi3e atro(hy chronic

.icrosco(ic features0 o o o =ell differentiated d! is e!tremely difficult AP< + glands are well formed 1/9 layers 7P< + mar-ed nuclear (leomor(hism loss of (olarity (rominent nucleoli Perinueral in3asion + 405 Pan 6? B &6)

o <ncocytic &* o &lear cell &* o )ignet ring o .ucinous &* .ost common )ites of .etI o (eritoneum o Aung o *drenal o Bone o Distal lym(h nodes o s-in o &?) &ytology o Duodenal secretion o Pancreatic Luice o Percutaneous 1?* o 6ntrao( 1?* Treatment0 )urgical o Body K tail + distal (ancreatectomy o 7ead + =hi((le o(eration P retro(eritoneal resection o Paliati3e by(ass o(eration

o o 67& o .ucin "gastric K )6 ty(es# o ,eratin E.* o &E* &*14/4 B79@C o Pancreatic &* *ssociated antigens o D$ P*?/9 o T Pan/1 o Tn o )ialosyl/Tn/*ntigens o D1C *ntigen o .1 o &athe(sin E o Pe(sinogen 66 o :illin o Aaminin )il3er stain &hromogranin 6slet cell hormones &ytogenetics0 o )tructural rearrangements o .utationsB accumulation of (FC o ,/ras oncogene mutation o 7E'9neu o3ere!(ression o *neu(loid :ariants o *denosDuamous &*

Giant Cell T"mor large K hemorrhagic Dual (o(ulation0 o )(indle cells o .ultinucleated giant cells )ome cases clear cut glandular a((earance

2icrocystic Cystadenoma *@-@a@glycogen/ric- cystadenoma Aarge multinucleated mass small cysts filled with clear serous fluid .icrosco(ic0 small flat to cuboidal lining Aayer of myoe(ithelium 67&0 E.* A.= -eratin Elderly

2icrocystic Adenocarcinoma

General Pathology Biliary Tract and Pancreas by VGY )imilar to microcystic adenoma but with nuclear aty(ia (leomor(hism metastasis

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2"cino"s Cystic Neo#lasm Tounger age grou( =omen Aarge multiloculated or unilocular lined by tall mucin (roducing cells 7igh le3els of &E* .ucinous &yst *denoma 3s@ .ucinous &ystadeno&* + distinction not always clear cut

.icrosco(ic0 3ery cellular simulates islet cell tumor o Pseudo(a(illae co3ered by layers of e(ithelial cells o ?uclei are o3oid and folded o Distict nucleoli few mitoses o 7yaline globules o Thic- fibro3ascular core with mucinous change $ltrastructure o *cinar ductal K endocrine differentiation 67& o ,eratin desmo(la-in try(sin chymotry(sin amylase K 3imentin o 1ocal reacti3ity0 ?)E islet cell hormones

7aay ang habaU 1eeling -o tlga ndi na -mi trans nito e@ <ist new year naV .agbagong buhay na -auV 0/(

&ntrad"ctal Neo#lasm 6ntraductal Pa(illary &arcinoma o 6n3ol3e major ducts multicentric .ucus secreting or .ucin Producing Duct/Ectatic Tumor o Dilated ducts filled with mucus o &olumnar mucin (roducing well diff o <3ere!(ression or c/erb/9 Acinar Cell T"mor 5 T"mor)like Conditions *cinar &ell 7y(er(lasia *cinar &ell *denoma *cinar &ell &arcinoma

Acinic Cell Carcinoma 67& o Try(sin o Ai(ase o &hymotry(sin o amylase *bundant E' on E. .etastasis (resent in the time of diagnosis Pa#illary 5 Solid E#ithelial Neo#lasm Toung women Aarge with areas of necrosis and hemorrhage some with well de3elo(ed ca(sule