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Undifferentiated pancreatic carcinoma with osteoclast-like giant cells.

Dear Editor,

I read with great interest pictorial essay entitled "Pancreas ductal adenocarcinoma with cystic features on cross-sectional imaging: radiologic-pathologic correlation" by Seo Yeon Youn et al. (1) in the February 2018 issue of Diagnostic and Interventional Radiology. The author described the radiologic features of pancreatic ductal adenocarcinomas (PDAC) with cystic appearance. We would like to share a very rare subtype of PDAC, undiferentiated pancreatic carcinoma with osteoclast-like giant cells (UPC-OGC) presenting as a cystic mass.

A 57-year-old male was admitted with epigastric pain and weight loss for one month. Most indices of laboratory tests were normal except for slight anemia. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed an approximately 12 cm x 9 cm x 8 cm, round-like, well-defined and cystic mass with inhomogeneous enhancement in the left upper abdomen (Fig. a-d). The tumor appeared to originate from the pancreatic tail with invasion to the spleen, abutting parts of the stomach and colon. The patient underwent complete resection. Grossly, a 12 cm x 9 cm x 9 cm multilocular mass was located in the tail of pancreas with adhesion to the surrounding tissue. There were cysts filled with hemorrhagic and necrotic contents on the cut surface. Microscopically, the tumor was found to have pleomorphic mononuclear cells with multinucleated OGC (Fig. e). Immunohistology revealed that OGCs were positive for CD 68, which is a characteristic histiocytic marker of OGC (Fig. f). However, follow-up CT discovered a huge and recurrent mass in the left abdomen, surrounding the left kidney with partial invasion to the kidney 6 months after the operation.

UPC-OGC is a rare and peculiar pancreatic tumor known to originate from pancreatic ductal epithelium and categorized as a variant subtype of PDAC (2). Most UPC-OGCs have an insidious onset and are found as large tumors upon detection with a tendency towards early recurrence, even after surgical removal. Since the tumor progresses rapidly, UPC-OGC often appears as a heterogeneous cystic mass with hemorrhage and necrosis. CT and MRI demonstrated a well-demarcated, cystic tumor with obvious enhancement of septations and capsule within the tumor in our case. Hence, an inhomogeneous mass with cystic structures and nonuniform enhancement is a typical radiologic finding of UPCOGC. However, the definite diagnosis of UPC-OGC could be obtained through histopathology and immunohistochemistry. The presence of OGC is the histologically distinguishing feature of UPC-OGC (3). OGC lacks morphologic atypia and typically stains for histomonocytic markers (CD68).

It has been reported that small-sized UPC-OGC without invasion to the surrounding tissues may have a more favorable prognosis after complete excision (4). Therefore, an early diagnosis is the key concern for UPC-OGC. Fine needle aspiration is recommended as an efective modality to achieve a precise diagnosis. In our case, although the tumor was huge and invaded abutting organs, complete resection of tumor and involved organs was still the optimal treatment for this patient. However, the patient was found to have recurrence at nearly the same location within 6 months. Since the recurrent tumor was more invasive than the original one, the patient lost his second chance of surgery.

Conflict of interest disclosure

The author declared no conflicts of interest.

References

(1.) Youn SY, Rha SE, Jung ES, Lee IS. Pancreas ductal adenocarcinoma with cystic features on cross-sectional imaging: radiologic-pathologic correlation. Diagn Interv Radiol 2018; 24:5-11.

[CrossRef]

2 Bosman FT, Carneiro F, Hruban RH, Theise ND. WHO Classification of Tumors of the Digestive System. 4th ed. Lyon: International Agency for Research on Cancer (IARC) 2010:281-295.

3 Reid MD, Muraki T, HooKim K, et al. Cytologic Features and clinical implications of undifferentiated carcinoma with osteoclastic giant cells of the pancreas: An analysis of 15 cases. Cancer Cytopathol 2017; 125:563-575. [CrossRef]

4 Muraki T, Reid MD, Basturk O, et al. Undifferentiated carcinoma with osteoclastic giant cells of the pancreas: clinicopathologic analysis of 38 cases highlights a more protracted clinical course than currently appreciated. Am J Surg Pathol 2016;40:1203-1216. [CrossRef]

Received 27 May 2018; revision requested 28 May 2018; last revision received 9 July 2018; accepted 17 July 2018.

Published online 8 January 2019. DOI 10.5152/dir.2019.18261

You may cite this article as: Zhang L. Undifferentiated pancreatic carcinoma with osteoclast-like giant cells. Diagn Interv Radiol 2019; 25:173-174.

Lan Zhang

From the Department of MRI (L.Z. [??] 13837187787@163.com), the First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China.
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Author:Zhang, Lan
Publication:Diagnostic and Interventional Radiology
Article Type:Letter to the editor
Date:Mar 1, 2019
Words:728
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