{"id":45057,"date":"2025-08-05T14:04:35","date_gmt":"2025-08-05T06:04:35","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/pathweb\/?page_id=45057"},"modified":"2026-04-23T14:20:30","modified_gmt":"2026-04-23T06:20:30","slug":"eus-fna-4","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/pathweb\/cytopath\/cyto-mystery-cases\/eus-fna-4\/","title":{"rendered":"Mystery cases &#8211; EUS-FNA 4"},"content":{"rendered":"\n<h2>\n\t\tEUS-FNA CASE 4\n\t<\/h2>\n\t<h1>Pancreatic tail nodule<\/h1>\n\t<p><strong>Clinical history:\u00a0<\/strong>A 34-year-old lady underwent EUS-FNA of a well-circumscribed pancreatic tail nodule. What are the findings from the following images?<\/p>\n\t\t\t\t<img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/eus-fna-14.jpg\" alt=\"eus-fna 14\" itemprop=\"image\" height=\"768\" width=\"1024\" title=\"eus-fna 14\" onerror=\"this.style.display='none'\"  \/>\n\t\t\t\t<img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/eus-fna-15.jpg\" alt=\"EUS-FNA case 4\" itemprop=\"image\" height=\"768\" width=\"1024\" title=\"eus-fna 15\" onerror=\"this.style.display='none'\"  \/>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-0\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-0\">Cytologic findings<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-0\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t<p>&nbsp;<\/p>\n<table>\n<tbody>\n<tr>\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/eus-fna-16.jpg\" alt=\"\" \/><\/td>\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/eus-fna-17.jpg\" alt=\"\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li>Highly cellular aspirate with papillary-like formations comprising delicate vascular cores covered by loosely adhered neoplastic epithelial cells (&#8220;spinning&#8221; off)<\/li>\n<li>Small clusters and scattered dispersed epithelial cells in the background<\/li>\n<li>Epithelial cells contain eccentric reniform nuclei with mild nuclear pleomorphism<\/li>\n<li>Nuclear grooves may be seen<\/li>\n<li>Small nucleoli may be present<\/li>\n<li>Finely distributed chromatin<\/li>\n<li>Some nuclei exhibit nuclear inclusions<\/li>\n<li>Abundant finely vacuolated cytoplasm with perinuclear vacuoles<\/li>\n<\/ul>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-1\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-1\">Differential diagnoses<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-1\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t&nbsp;<br \/>\nThe following differential diagnoses show a degree of cytomorphologic overlap and the key distinguishing features include\n<ul>\n<li>Solid pseudopapillary neoplasm\n<ul>\n<li>Low-power: Papillary-like structures with delicate to hyalinised vascular stalks (important diagnostic feature) and relative cellular discohesion<\/li>\n<li>High power: Reniform nuclei with nuclear grooves and perinuclear vacuoles<\/li>\n<\/ul>\n<\/li>\n<li>Neuroendocrine tumour\n<ul>\n<li>Low-power: Loosely cohesive groups, pseudorosettes and single plasmacytoid cells<\/li>\n<li>High-power: Round to plump oval nuclei, stippled chromatin and inconspicuous nucleoli<\/li>\n<\/ul>\n<\/li>\n<li>Acinar cell carcinoma\n<ul>\n<li>Low-power: Acinar architecture with scattered bare nuclei<\/li>\n<li>High-power: Fragile cytoplasm with spilled zymogen granules and single prominent nucleolus<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>The non-discriminating features which may be shared by these tumours include:<\/p>\n<ul>\n<li>Low-power pattern of small cell clusters and scattered single cells which appear relatively uniform<\/li>\n<li>Plasmacytoid neoplastic cells with eccentric, round to oval shaped nuclei<\/li>\n<li>Delicate cytoplasm with microvacuoles<\/li>\n<\/ul>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-2\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-2\">Histologic and immunohistochemistry<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-2\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t<p>&nbsp;<\/p>\n<table>\n<tbody>\n<tr>\n<td><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/eus-fna-18.jpg\" alt=\"\" width=\"1024\" height=\"768\" \/><\/td>\n<td><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/eus-fna-19.jpg\" alt=\"\" width=\"1024\" height=\"768\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table>\n<tbody>\n<tr>\n<td><img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2025\/06\/eus-fna-20.jpg\" alt=\"\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p>There is diffuse nuclear expression of beta-catenin and LEF1 by the tumour cells. Synaptophysin is also focally positive; this is a\u00a0potential pitfall\u00a0where the tumour may be mistaken as a neuroendocrine tumour, although the latter is likely to show diffuse positivity. Identification of pseudopapillae with hyalinised vascular stalks and nuclear expression of beta-catenin is key to the diagnosis.<\/p>\n\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--label-3\" tabindex=\"0\" aria-controls=\"fl-accordion--panel-3\">Diagnosis<\/a>\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#\" id=\"fl-accordion--icon-3\" tabindex=\"-1\"><i title=\"Expand\">Expand<\/i><\/a>\n\t\t\t\t\t&nbsp;<br \/>\n<strong>Solid pseudopapillary neoplasm<\/strong>\n<ul>\n<li>Uncommon tumour (1 to 2% of pancreatic exocrine neoplasms) of low malignant potential<\/li>\n<li>Predominantly in adolescent girls and young women<\/li>\n<li>Slight preference for pancreatic tail<\/li>\n<li>Histogenesis unclear &#8211; possible genital ridge origin<\/li>\n<li>Somatic mutation in exon 3 of\u00a0<em>CTNNB1<\/em>\u00a0gene<\/li>\n<li>A rare subset of cases may be associated with familial adenomatous polyposis<\/li>\n<li>Well-demarcated tumours with solid areas, pseudocystic spaces and haemorrhagic necrosis<\/li>\n<li>The presence of hyalinised vascular stalk with clinging neoplastic cells is a key morphologic feature<\/li>\n<li>Highly divergent immunohistochemical profile\n<ul>\n<li>Positive: Beta-catenin (nuclear), cyclin D1, alpha-1 antitrypsin, CD56, CD10, PR receptor, synaptophysin (focal and a pitfall)<\/li>\n<li>Recent studies show high rate of diffuse nuclear expression of LEF1, AR and TFE3 (1)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ol>\n<li>Kim, E. K., Jang, M., Park, M., &amp; Kim, H. (2017). LEF1, TFE3, and AR are putative diagnostic markers of solid pseudopapillary neoplasms. Oncotarget, 8(55), 93404-93413. https:\/\/doi.org\/10.18632\/oncotarget.21854<\/li>\n<\/ol>\n<p>Remaining information cited from: Kl\u00f6ppel, G., Klimstra, D. S., Basturk, O., Notohara, K. Solid pseudopapillary neoplasm. (2019). In: WHO Classification of Tumours: Digestive system tumours (5th edn). Lyon; IARC.<\/p>\n\t<p><em>Case writer: Dr Noel Chia<\/em><\/p>\n\n","protected":false},"excerpt":{"rendered":"<p>EUS-FNA CASE 4 Pancreatic tail nodule Clinical history:\u00a0A 34-year-old lady underwent EUS-FNA of a well-circumscribed pancreatic tail nodule. What are the findings from the following images? Cytologic findings Expand &nbsp; Highly cellular aspirate with papillary-like formations comprising delicate vascular cores covered by loosely adhered neoplastic epithelial cells (&#8220;spinning&#8221; off) Small clusters and scattered dispersed epithelial [&hellip;]<\/p>\n","protected":false},"author":828,"featured_media":0,"parent":44933,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-45057","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>NUS Pathweb<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/cytopath\/cyto-mystery-cases\/eus-fna-4\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:description\" content=\"EUS-FNA CASE 4 Pancreatic tail nodule Clinical history:\u00a0A 34-year-old lady underwent EUS-FNA of a well-circumscribed pancreatic tail nodule. 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