{"id":47481,"date":"2026-08-14T09:40:16","date_gmt":"2026-08-14T01:40:16","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/pathweb\/?page_id=47481"},"modified":"2026-08-28T21:09:32","modified_gmt":"2026-08-28T13:09:32","slug":"pancr-fs-1","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/pancr-fs-1\/","title":{"rendered":"Short cases &#8211; Pancreas case 1 (FS)"},"content":{"rendered":"\r\n<h2>\r\n\t\t\tPancreas case 1 (FS)\t<\/h2>\r\n\t<p><em>Case writer: A\/Prof Nga Min En<\/em><\/p>\r\n\t<p><strong>Clinical history:<\/strong><\/p>\r\n<ul>\r\n<li>\r\n71M, history of pancreatic\u00a0 ductal carcinoma. Underwent neoadjuvant chemotherapy. Now undergoing Whipple resection.\r\n<\/li>\r\n<li>\r\nFrozen section performed, specimen labelled as &#8220;retroperitoneal tissue&#8221;.\r\n<\/li>\r\n<li>What are the histologic findings?<\/li>\r\n<li>What are your differential diagnoses?<\/li>\r\n<li>What clinical information would be helpful in your diagnostic workup?<\/li>\r\n<li>What ancillary tests would you do?<\/li>\r\n<\/ul>\r\n\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC1-1024x777.png\" alt=\"PANCRC1\" height=\"486\" width=\"640\" title=\"PANCRC1\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t\t\t\t<\/a>\r\n\t<\/figure>\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC2-1024x777.png\" alt=\"PANCRC2\" height=\"486\" width=\"640\" title=\"PANCRC2\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t\t\t\t<\/a>\r\n\t<\/figure>\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC3-1024x780.png\" alt=\"PANCRC3\" height=\"488\" width=\"640\" title=\"PANCRC3\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t\t\t\t<\/a>\r\n\t<\/figure>\r\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\r\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\r\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC4-1024x768.png\" alt=\"PANCRC4\" height=\"480\" width=\"640\" title=\"PANCRC4\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\r\n\t\t\t\t\t\t\t<\/a>\r\n\t<\/figure>\r\n\t<p>Click picture to enlarge<\/p>\r\n\t<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-0\" aria-controls=\"fl-accordion--content-0\" aria-expanded=\"true\" type=\"button\">Histologic Findings <i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Collapse<\/i><\/button><\/a><p>&nbsp;<\/p>\r\n<p><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC5.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC5.png\" alt=\"\" width=\"2345\" height=\"1792\" \/>(opens in new tab)<\/a><\/p>\r\n<p><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC6.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC6.png\" alt=\"\" width=\"2329\" height=\"1773\" \/>(opens in new tab)<\/a><\/p>\r\n<ul>\r\n<li>\r\nSections show large nerves (black arrows) with surrounding fibrovascular tissue\r\n<\/li>\r\n<li>\r\nSome well-formed glandular structures are seen around the nerve (red arrow)\r\n<\/li>\r\n<li>\r\nThe glandular cells have relatively bland, basal nuclei\r\n<\/li>\r\n<\/ul>\r\n<p><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC7.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/PANCRC7.png\" alt=\"\" width=\"2396\" height=\"1818\" \/>(opens in new tab)<\/a><\/p>\r\n<ul>\r\n<li>Invasive malignant glands on the left appear morphologically similar to the glands invading the smaller nerve on the right.<\/li>\r\n<\/ul>\r\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-1\" aria-controls=\"fl-accordion--content-1\" aria-expanded=\"false\" type=\"button\">Differential Diagnoses<i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\r\n<p>In the context of known malignancy, in this case pancreatic ductal adenocarcinoma, the main concern is involvement by adenocarcinoma.<\/p>\r\n<ul>\r\n<li>Hence the main differential diagnosis to consider is perineural invasion by adenocarcinoma.<\/li>\r\n<li>Very rare instances of benign perineural &#8220;pseudoinvasion&#8221; have been documented, usually in chronic pancreatitis. This would be a very unlikely differential in the context of known malignancy.<\/li>\r\n<li>At the time of the frozen section, it would be useful to know:<\/li>\r\n<li>The\u00a0<b>histologic features of the pancreatic ductal adenocarcinoma\u00a0<\/b>e.g. the\u00a0<b>histologic type and grade<\/b>. If well differentiated, this supports the histologic findings in the current sample as representing malignant glands.<\/li>\r\n<li>The imaging findings e.g. is there gross residual tumour present after chemotherapy; are there any retroperitoneal masses?<\/li>\r\n<\/ul>\r\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-2\" aria-controls=\"fl-accordion--content-2\" aria-expanded=\"false\" type=\"button\">Diagnosis and Learning Points<i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\r\n<p><u><b>Diagnosis<\/b><\/u><\/p>\r\n<ul>\r\n<li>Frozen section shows perineural involvement by adenocarcinoma<\/li>\r\n<\/ul>\r\n<p>Find this in our Virtual Pathology Museum:<\/p>\r\n<ul>\r\n<li><strong><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/virtual-pathology-museum\/00587-2\/\" target=\"_blank\" rel=\"noopener\">https:\/\/medicine.nus.edu.sg\/pathweb\/virtual-pathology-museum\/00587-2\/(opens in new tab)<\/a><\/strong><\/li>\r\n<li><strong><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/virtual-pathology-museum\/05623-2\/\" target=\"_blank\" rel=\"noopener\">https:\/\/medicine.nus.edu.sg\/pathweb\/virtual-pathology-museum\/05623-2\/(opens in new tab)<\/a><\/strong><\/li>\r\n<\/ul>\r\n<p><u><b>Learning Points<\/b><\/u><\/p>\r\n<ul>\r\n<li>When handling frozen sections of cases of known malignancy or tumours, it is useful to have an idea of the original tumour histology e.g. histologic type and grade.<\/li>\r\n<li>It would also be useful to know the stage of any known primary cancer, and margin status, as and when relevant to the current frozen section.<\/li>\r\n<li>Extremely rare instances of perineural &#8220;pseudoinvasion&#8221; have been described, sometimes by islet or benign ductal cells, often in the context of chronic pancreatitis. However, in a patient with known pancreatic malignancy, the presence of perineural glands is far more likely to represent true perineural invasion. The perineural glands must be carefully compared with the malignant glands.<\/li>\r\n<\/ul>\r\n<p><em>References:<\/em><\/p>\r\n<ol>\r\n<li><em>Goldman RL. Benign neural invasion in chronic pancreatitis.J Clin Gastroenterol. 1984;6:41-44<\/em><\/li>\r\n<li><em>Costa J. Benign epithelial inclusions in pancreatic nerves. Am J Clin Pathol. 1977;67:306-307<\/em><\/li>\r\n<li><em>Hauptmann K, Hauptmann S. Perineural pseudoinvasion in chronic pancreatitis. Pathologe. 2000;21:388-390<\/em><\/li>\r\n<\/ol>\r\n\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pathology-updates-journal-clubs\" target=\"_blank\" rel=\"noopener\">Pathology Updates &#038; Journal Clubs(opens in new tab)<\/a><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/\" target=\"_blank\" rel=\"noopener\">Short Cases(opens in new tab)<\/a><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pg-patho\/\" target=\"_blank\" rel=\"noopener\">Postgrad Pathology Home(opens in new tab)<\/a>\r\n\r\n","protected":false},"excerpt":{"rendered":"<p>Pancreas case 1 (FS) Case writer: A\/Prof Nga Min En Clinical history: 71M, history of pancreatic\u00a0 ductal carcinoma. Underwent neoadjuvant chemotherapy. Now undergoing Whipple resection. Frozen section performed, specimen labelled as &#8220;retroperitoneal tissue&#8221;. What are the histologic findings? What are your differential diagnoses? What clinical information would be helpful in your diagnostic workup? What ancillary [&hellip;]<\/p>\n","protected":false},"author":828,"featured_media":0,"parent":47288,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-47481","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\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\/short-cases\/pancr-fs-1\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:description\" content=\"Pancreas case 1 (FS) Case writer: A\/Prof Nga Min En Clinical history: 71M, history of pancreatic\u00a0 ductal carcinoma. Underwent neoadjuvant chemotherapy. 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