Benign variant of osteoclast-type giant cell tumor of the pancreas: importance of the lack of epithelial differentiation

Two Cases of Rare Pancreatic Malignancies

Background: Pancreatic adenocarcinoma remains one of the most lethal malignancies with little treatment advancements. Other less common pancreatic cancer histologies have different outcomes and disease course. In this article, we report two cases of rare pancreatic tumors.

Presentation: The first case is a 59-year old, who was undergoing surveillance of a known pancreatic cyst, which eventually enlarged. The mass was resected and pathology revealed undifferentiated carcinoma with osteoclast-like giant cells. The patient did not receive any adjuvant therapy and has had no recurrence. The second case is of a 60-year-old patient who presented with signs and symptoms of pancreatic insufficiency and was found to have clear cell adenocarcinoma of the pancreas. She received neoadjuvant chemoradiotherapy followed by surgical resection without complications.

Conclusion: Our article presents these rare malignancies, which had outcomes that are more encouraging than typical adenocarcinomas. Genomic sequencing can provide more insight into these tumors and potentially provide targets for therapy.

Rare pancreatic tumors

In this review, we will focus on rare pancreatic tumors. Most of these tumors do not have distinct characteristic appearances so the key to diagnosis requires a combination of imaging appearance, laboratory data, patient demographics, and associated medical syndromes in order to narrow the differential diagnosis. Nonetheless, imaging plays a vital role in narrowing the differential and guiding management. While there are many variant pathologic entities that cannot be encompassed by a single review, we aim to illustrate the imaging appearance of less common pancreatic tumors highlighting key distinctive diagnostic characteristics and discuss the implications for management. While there is overlap in the imaging appearances of many of these entities, for educational purposes, lesions will be categorized into solid (hypoenhancing and hyperenhancing), cystic lesions, mesenchymal neoplasms, and neoplasms seen in younger patients (< 40 years).

An indeterminate mucin-producing cystic neoplasm containing an undifferentiated carcinoma with osteoclast-like giant cells: a case report of a rare association of pancreatic tumors

Background

Only few case reports of mucinous cystic pancreatic neoplasm containing an undifferentiated carcinoma with osteoclast-like giant cells have been described in the literature. In the majority of cases this unusual association of tumors seems related to a favorable outcome. We present the second case of an indeterminate mucin-producting cystic neoplasm containing an area of carcinoma with osteoclast-like giant cells. The specific features of the two histotypes and the rapid course of the disease make our clinical case remarkable.

Case presentation

A 68 year old female came to our attention for a pancreatic macrocystic mass detected with ultrasonography. Her past medical history was silent. The patient reported upper abdominal discomfort for two months; nausea, vomiting or weight loss were not reported. Physical examination revealed a palpable mass in the epigastrium; scleral icterus was absent. Cross-sectional imaging showed a complex mass of the neck and body of the pancreas, characterized by multiple large cystic spaces separated by thick septa and an area of solid tissue located in the caudal portion of the lesion. The patient underwent total pancreatectomy with splenectomy. Pathological examination revealed a mucinous cystic neoplasm with a component of an undifferentiated carcinoma with osteoclast-like giant cells. Because of the absence of ovarian-type stroma, the lesion was classified as an indeterminate mucin-producing cystic neoplasm of the pancreas. The immunohistochemical studies evidenced no reactivity of osteclast-like giant cells to epithelial markers but showed a positive reactivity to histiocytic markers. Numerous pleomorphic giant cells with an immunohistochemical sarcomatoid profile were present in the undifferentiated carcinoma with osteoclast-like giant cells. A rapid tumor progression was observed: liver metastases were detected after 4 months. The patient received adjuvant chemotherapy (Gemcitabine) but expired 10 months after surgery.

Conclusion

Our case confirms that the presence of a solid area in a cystic pancreatic tumor at cross-sectional imaging should raise a suspicion of malignant transformation. The lack of ovarian-type stroma in a pancreatic mucinous cystic neoplasm and the presence of pleomorphic giant cells in an undifferentiated carcinoma with osteoclast-like giant cells could be a marker of a poor prognosis.

A case report of undifferentiated carcinoma with osteoclast-like giant cells of the pancreas and literature review

Osteoclast-like giant cell tumors rarely arise in the pancreas. Here we report the case of a 78-year-old woman who was diagnosed with a well-defined 3 cm multilocular mass in the pancreatic body by the use of ultrasonography, computed tomography and magnetic resonance imaging. The rim and the septa of the tumor were well enhanced. The distal pancreas was removed with the spleen and the peripancreatic lymph nodes. Macroscopically, the mass was composed predominantly of a multilocular cystic tumor filled with hemorrhagic necrosis, and partly composed of solid components. A histopathological study showed a proliferation of multinucleated osteoclast-like giant cells and spindle cells. Although the predominant tumor cells were strongly positive for vimentin and CD68 and negative for epithelial markers, there were some sparsely scattered cytokeratin-positive neoplastic glands. Seventeen months after surgery, the patient is still alive and has had no recurrence. Below we review 32 cases of osteoclast-like giant cell tumor of the pancreas that have been reported in English literature since 2000.

Osteoclastic and pleomorphic giant cell tumors of the pancreas: A review of clinical, endoscopic, and pathologic features

Giant cell tumors of the pancreas come in three varieties-osteoclastic, pleomorphic, and mixed histology. These tumors have distinctive endoscopic, clinical, and cytological features. Giant cell tumors have a controversial histogenesis, with some authors favoring an epithelial origin and others favoring a mesenchymal origin. The true origin of these lesions remains unclear at this time. These are also very rare tumors but proper identification and differentiation from more common pancreatic adenocarcinoma is important. The risk factors of these tumors and the prognosis may be different from those associated with standard pancreatic adenocarcinoma. Recognition of these differences can significantly affect patient care. These lesions have a unique appearance when imaged with endoscopic ultrasound (EUS), and these lesions can be diagnosed via EUS guided Fine Needle Aspiration (FNA). This manuscript will review the endoscopic, clinical, and pathologic features of these tumors.

Osteoclastic and pleomorphic giant cell tumors of the pancreas diagnosed via EUS-guided FNA: unique clinical, endoscopic, and pathologic findings in a series of 5 patients

INTRODUCTION

Osteoclastic and pleomorphic giant cell tumors of the pancreas are rare entities that have been typically described only in single case reports. We report on our experience with a series of 5 patients with pancreatic giant cell tumors seen at our institution.

METHODS

This was a retrospective study involving a search of the study institution's medical records from 2001 to 2007 for patients diagnosed with giant cell-containing neoplasms of the pancreas.

RESULTS

Five patients (2 women, 3 men) were identified. Age range was 59 to 81 years, with a mean of 70.2 years. None were current or former smokers. None had a history of alcohol abuse or preexisting pancreatitis of any kind. On EUS, tumors tended to be large, with a mean diameter of 47 mm (range 20-70 mm). All tumors had a heterogeneous echotexture and a distinct appearance when compared with the typical appearance of adenocarcinoma when viewed via EUS. The diagnosis of giant cell tumor of the pancreas, as well as the subtype, was made via EUS-guided FNA of the pancreatic lesion. Patients with pleomorphic giant cell tumors of the pancreas had a poor clinical course with a rapid decline, whereas those with mixed or osteoclastic giant cell tumors tended to have a better outcome, with a greater long-term survival. One patient is still alive more than 18 months after diagnosis.

LIMITATION

Retrospective study.

CONCLUSIONS

Giant cell tumors of the pancreas have unique clinical, endoscopic, and cytologic features. The risk factors for these lesions may be different from those associated with pancreatic adenocarcinoma. Some giant cell tumor subtypes may carry a more favorable prognosis than pancreatic adenocarcinoma, and awareness and recognition of these differences can affect patient care.

A case of osteoclast-like giant cell tumor of the pancreas associated with borderline mucinous cystic neoplasm

A 34-year-old, previously healthy female presented with severe acute upper quadrant abdominal pain and an 11-cm cystic mass in the tail of the pancreas. The patient underwent distal pancreatectomy with total gross excision of the mass. Grossly, the mass consisted of a multiloculated cystic lesion measuring 11.7 cm in its greatest dimension. An irregular solid lobulation at the lateral aspect of the cyst was visible, measuring 3 cm in the largest dimension. Histologically, there were two distinct components: a mucinous, neoplastic epithelial cyst with few foci of moderate atypia, and nodular spindle cell areas containing multinucleated tumor giant cells. Immunohistochemically, the multinucleated giant cells were positive for vimentin, CD68 and CD45, and negative for cytokeratin and epithelial membrane antigen (EMA). The spindle cells of hypercellular stroma were stained for vimentin, but not for EMA or carcinoembryonic antigen (CEA). Neuron-specific enolase (NSE), S100 and Ki-67 showed no reactivity. The histological diagnosis "osteoclast-like giant cell tumor of the pancreas associated with borderline mucinous cystic neoplasm" was made. The patient recovered and is free of disease 4 years after the diagnosis.

An unusual case of undifferentiated carcinoma in situ with osteoclast-like giant cells of the pancreas

OBJECTIVES

We report an unusual case of undifferentiated carcinoma in situ with osteoclast-like giant cells (UC with OGCs) in a 68-year-old Japanese woman.

METHODS

Preoperative examinations revealed an unidentifiable mass lesion within the main pancreatic duct (MPD) in the pancreatic head, accompanied by a dilated MPD distal to the mass lesion, which was suspected to be an intraductal papillary-mucinous neoplasm of the main-duct type with acute pancreatitis because of an increased serum amylase level. A pancreaticoduodenectomy was performed.

RESULTS

A pencil-like tumor occupied the lumen of the MPD of the pancreatic head without a visible pancreatic parenchymal mass. The intraductal tumor included a sheet of spindle cells intermingled with scattered OGCs and pleomorphic giant cells. A poorly developed glandular pattern was occasionally observed at the tumor periphery. These findings were consistent with conventional UC with OGCs. However, extraductal invasion was not found in an extensive histopathologic examination, although focal intraductal spreading into the epithelium of the first branch of the MPD was observed.

CONCLUSIONS

Undifferentiated carcinoma with OGCs usually exhibits an invasive tumor at diagnosis and is associated with a poor outcome, but the patient is alive without recurrence 22 months after surgery. To our knowledge, this is the first reported case of UC in situ without evident extraductal invasion in English literature.

Immunohistochemical and genetic analysis of osteoclastic giant cell tumor of the pancreas

Clinical, histopathologic, immunohistochemical, and genetic analyses of 2 osteoclastic giant cell tumors of the pancreas are presented. The neoplasms were composed of osteoclastic giant cells and pleomorphic cells (PCs). The tissue-specific markers gave evidence of mesenchymal nature of the osteoclastic giant cells, as well as other components of the tumor, and lacked any signs of epithelial differentiation in both patients. The nonepithelial nature of both components in the osteoclastic giant cell tumors presented may be associated with a better prognosis, which corresponds to the previous reports of similar neoplasms. A positive immunoreactivity to neuron-specific enolase was recorded in patient 2. The presence of CD68 in osteoclastic giant cells proved their histiocytic nature. Both components of the tumors showed a negative immunoreactivity to desmin and only a scattered reactivity to smooth muscle cell actin, typical markers of myofibroblastic differentiation. Mutation analysis of the tumor revealed the wild state of both p53 and K-ras oncogenes in both patients. A positive immunoreactivity for p53 in PCs of both osteoclastic giant cell tumors was recorded, whereas osteoclastic giant cells did not express this protein. The expression of p21 was recorded in osteoclastic giant cells in patient 1. The absence of Ki-67 in the osteoclastic giant cells and its expression in PCs gave evidence of a different proliferation rate of both cell populations. Different tissue-specific markers, a different proliferation rate, and a different state of oncogene activation in the osteoclastic giant cell tumors contribute to the idea that the tumor derives from a pluripotent cell that may differentiate into an array of phenotypes.

A case of osteoclast-like giant cell tumor of the pancreas with ductal adenocarcinoma: histopathological, immunohistochemical, ultrastructural and molecular biological studies

Osteoclast-like giant cell tumor of the pancreas is a very rare neoplasm, of which the histiogenesis remains controversial. A 63-yr-old woman was hospitalized for evaluation of epigastric pain. An abdominal computerized tomography revealed the presence of a large cystic mass, arising from the tail of pancreas. A distal pancreatectomy with splenectomy was performed. Histologically, the tumor was composed of mononuclear stromal cells intermingled with osteclast-like giant cells. In addition, there was a small area of moderately to well differentiated ductal adenocarcinoma. The final pathologic diagnosis was osteoclast-like giant cell tumor of the pancreas with ductal adenocarcinoma. Here, we describe the histopathological, immunohistochemical, ultrastructural and molecular biological findings of this tumor with review of the literature pertaining to this condition.

Osteoclast-like giant cell tumor of the pancreas associated with mucus-secreting adenocarcinoma. Case report and discussion of the histogenesis

BACKGROUND/AIMS

The osteoclast-like giant cell tumor of the pancreas is a rare entity that closely resembles giant cell tumor of the bone, which has also been observed in many other organs. Some tumors also contain areas of ductal adenocarcinoma. Conflicting opinions exist regarding the tumor origin, whether it is mesenchymal or epithelial, neoplastic or reactive.

METHODS

We report the case of a 69-year-old Brazilian man with a mass in the head of the pancreas, the histological examination of which revealed a predominant component of osteoclast-like giant cells within a background of pleomorphic mononuclear cells with osteoid formation and other areas composed of conventional mucus-secreting adenocarcinoma.

RESULTS

Immunohistochemistry showed that carcinoma cells of the usual type expressed epithelial antigens (EMA and cytokeratin) and lysozyme; the giant cells expressed vimentin, CD45, CD68, and lysozyme; and the mononuclear cells expressed macrophage marker (HAM56), vimentin, and lysozyme, and only some of them expressed epithelial markers, CD45, and CD68.

CONCLUSION

Our immunohistochemical findings reveal that the giant cells in this case are of mesenchymal origin may be from the bone marrow cells. We believe that it is important to determine the histogenesis in each case to carry out the pertinent adjuvant therapy.

Osteoclast-like giant cell tumor of the liver: a rare neoplasm with an aggressive clinical course

Osteoclast-like giant cell tumors (OCGTs) usually involve the bone and rarely affect the alimentary tract. Within the gastrointestinal tract the liver has been one of the most infrequently reported locations for this neoplasm to occur. In this article we report the occurrence of an OCGT arising in the liver of a 61-year-old woman. The patient presented with abdominal pain and a rapidly enlarging hepatic mass. Magnetic resonance imaging (MRI) indicated a multilocular solid lesion in the right lobe of the liver. A small extrahepatic lobulation at the lateral aspect of the lesion with penetration of the capsule was visible. Local extension into adjacent organs was not evident. Positron emission tomography (PET) did not indicate a tumor in the pancreas or elsewhere in the body. The tumor was removed by performing a formal right hepatic lobectomy. Histologic and immunohistochemical examinations revealed an OCGT. Within 3 months of the hemihepatectomy, widespread intraabdominal and pulmonary metastasis developed and the patient succumbed to her illness shortly thereafter. This report contributes further evidence to the aggressive biological behavior with regard to this rare neoplasm. The absence of metastatic disease indicated when using magnetic resonance imaging and positron emission tomography does not seem to change the overall dismal prognosis of this tumor.

Osteoclast-like giant cell tumor in mucinous cystadenocarcinoma of the pancreas: an immunohistochemical and molecular analysis

Osteoclast-like giant cell tumors (OLGT) are rare neoplasms of the pancreas and mostly associated with ductal adenocarcinomas. In this report, we present the rare case of OLGT associated with mucinous cystadenocarcinoma (MCC). We investigated the expression profile of both tumors by methods of molecular biology and immunohistochemistry. The panel of markers included osteopontin, her2/neu, mismatch repair genes, K-ras, p53, E-cadherin, VEGF-C, and podoplanin. Osteopontin was expressed by the osteoclast-like giant cells but not by the mononuclear tumor cells of the OLGT. We detected an amplification and overexpression of her2/neu in the MCC but not in the OLGT. Although we observed an immunohistochemical expression of hMSH2 and hMLH1 in the OLGT, we were not able to confirm this result by western blot analysis. We also did not find any microsatellite instability (D2S123, BAT26). While mutation of K-ras codon 12 was found in both tumor components, there was wild-type DNA of p53. E-cadherin was expressed in MCC but not in OLGT. VEGF-C was only positive in osteoclast-like giant cells and some of the mononuclear cells of OLGT. The vessel-rich stroma of OLGT did not present any podoplanin-positive lymphatic vessel. The observation of our case and others in the published literature may indicate separating OLGT with undifferentiated carcinoma from OLGT with MCC for the better clinical outcome of the latter.

A case of osteoclast-type giant cell tumor of the pancreas with high-frequency microsatellite instability

It has been reported that osteoclast-type giant cell tumor of the pancreas (OGTP) is rare, with a frequency of only 0.2% of the total reported pancreatic carcinomas. We report herein a rare case of OGTP in a 57-year-old Japanese man. Preoperative examinations showed a solid and cystic tumor, measuring 20 x 15 cm at the pancreas body. The resected specimen was a solid tumor with a giant cyst containing bloody contents. The tumor was composed of a proliferation of mononuclear cells admixed with osteoclast-type giant cells. The tumor cells were immunoreactive for vimentin, alpha1-antitrypsin, and EMA but not for CEA and cytokeratin. These findings indicated that this case was a malignant OGTP. The tumor cells showed microsatellite instability with high frequency (MSI-H). The present patient is alive 3 years after the operation, while OGTP has been reported to have a poor outcome. It has been reported that pancreatic carcinomas with MSI-H status have a favorable outcome. MSI-H might be one of the predictive markers for the long survival in OGTP.