大障放射總醫學會찮‘ 第 25~ 第 l 號 pp. 82 - 85, 1989 Journal 01 Korean Radiological Society, 25(1) 82-85, 1989

Round Cell Anaplastic Carcinoma of the Pancreas

Jae Hoon Lim, M.D., Dong Ho Lee, M.D. ,

Young Tae Ko, M.D., and Moon Ho Yang, M.D.*

Department of Diagnostic Radiology, Kyung Hee University Hospital

〈국문초록〉

훼장의 미성숙원형세포암

경 희 대 학교의 파대 학 땅사선파학교실

임재훈 · 이동호 · 고영태 · 앙문호.

춰l 장의 마성숙원형세포암은 현마 경 적으로 원행세 포가 특정석인 육종처럼 보이는 애우 악성인

암종우로 희 귀한 종양이 다. 초음파검사와 선산화단층촬영 상에 정 활하고 주위 와 구별 이 잘되는 고

형 종괴 로 연뜻 보아 양성 종양처 럼 보여 보통의 춰l 장암이 냐 낭성 종양파는 육안소견이 다흔 암으로

이들 종양파는 땅사선학석으로도 구벨이 가능하다.

Introduction

Round cell anaplastic carcinoma is Qne of sar-

comatoid pancreatic carcinoma, microscopically characterized by monotonous sheaths of small

round plump cells with rare giant cells and thus

more or less reminiscent of malignant ly-

mphomal-4). Whether this tumor is of ductal or

acinar cell origin remains to be determined2). Cli-

nically, this tumor does not differ significantly from ordinary adenocarcinoma of the pancreas2).

This tumor is very rare. Several cases have been

reported2,4) but there have been no descriptions of

radiological findings in the literature. We report a

‘ Departm ent of Pathology, Kyung Hee University Hospital

• 경희대학교 외과대학 해부뱅리과학교실

이 논운은 1 988년 12월 20일에 접 수하여 1989년 1월 17 일에 채택되었음

• Received Dec. 20 , 1988 , Accepted J an 17, 1989

case of round cell anaplastic carcinoma and desc-

ribe the CT and sonographic findings , and discuss the differential points from other solid pancreatic

tumors.

Case Report

A 31-year-old woman presented with generali-

zed itching and jaundice of recent onse t. On

physical examination , a child-fist sized fixed slight-Iy tender mass was palpated in the right upper

abdomen. The liver and spleen were not felt

Laboratory tests showed elevation of total biliru-

bin (14.6 mg /dl) and direct bilirubin (7.9 mg/dl) , aspartate aminotransferase (233 Unit) , alanine aminotransferase (291 Unit) , and alkaline phos-phatase (432 SI Unit) .

Ultrasonography of the upper abdomen dis-

closed an oval well defined mass in the pancreas

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Jae Hoon Lim, et al. : Roun,d Cell Anaplasti c Carcinoma 01 the pancreas-

head with complete obstruction of the common

bile duct (Fig. 1 A , B) . CT showed the same homogeneous solid mass resulting in obstruction of

common bile duct (Fig. 1 C). The rest of the pan-creas was quite normaL The liver was free of

metastasis and there was no lymphnode metas-tasis ,

At surgery, a well encapsulated firm mass , measuring 8 X7 X 7 cm was found in the head of

the pancreas. The superior mesenteric vein was

pushed anteromedially. The common bile duct was

dilated down to the mass and obliterated within

the mass. Whipple ’s operation was performed.

Cut section showed a yellow , multilobulated tu-mor with some areas of myxoid degeneration.

Microscopic examination disclosed tumor tissue

consisted of partly lobulated large columns of she-

ets of undifferentiated neoplastic cells (Fig. 1 0).

The nest of tumor cells were rather small round

cells having hyperchromatic neuclei and a mode-

rate amount of pale acidophilic and occasionally

dense eosinophilic cytoplasm. Frequent prominent

nucleoli and scattered mitotic figures were seen

But in areas , some short spindle cells were also intermingled. Characteristically e ncountered were

scattered normal pancreatic acini and a few small

ducts. The tumors blended directly to normal aci-

nar epithelium , which was strongly suggestive of acinar epithe li al origin of the tumor. Ultrastructu-

ral study by electron microscope disclosed tumor

cells of rather small ovoid or polygonal in shape

having large ovoid or slightly indented nuclei with

frequent prominent nuclεoli. The cytoplasms con-

tained rather abundant rough endoplasmic reticu-

lums and mitochondria. Distinct secretory granule

or zygogen granule is not seen . The tumor stroma

is loosely textied.

Discussion

si mulating a sarcoma , Becaue of its morphologic

similarity to sarcoma , the term “ sarcomatoid car-cinoma" was coined 1,2), According to Algu-

aci l-Garcia et aL 2) , there are four distinctive his-tologic types: pleomorphic carcinoma (pleomor-

phic giant cell tumor) , malignant giant cell tumor , spindle cell carcinoma , and round cell anaplastic carcinoma. The first three types ,are considered to

be ductal in origin , whereas the origin of the round cell anaplastic carcinoma is obscure 1,2). In

our case , the tumor blended directly to normal acinar epithelium , which is strongly suggestive of acinar epithelial origin of the tumor.

Microscopic appearance is distinctive l- 3) , The

tumor is composed of small monotonous round

cells having a moderate amount of cytoplasm.

These cells were intermingled with less frequent

cells that have abundant , plump , eosinophilic cyto-plasm and with occasional giant cells . The cells are

arranged in sheets or large clusters with poor cel-

lular cohesiveness2). Overall feature simulates

malignant lymphoma 1)

Cl inical course of round cell anaplastic car-

cinoma is simi lar to that seen in ordinary pancr-

eatic carcinoma2). Short survival of this tumor may

represent agressive nature of this tumor but firm

conclusions cannot be drawn2). Our patient has

been doing well after 5 months after operation.

The CT and ultrasound findings of our case

were a large well defined solid mass. The margin

is rather smooth and there was no evide nce of

direct invasion onto adjacent organ , though the duodenal loop and the inferior vena cava were

displaced and compressed. The texture of the

tumor was homogeneous wihout hemorrhagic nec-

rosis. Although the tumor was large , there was no hepatic or lymph node metastasis. Overall feature

was those of rather benign tumor

It must be stressed that differential diagnosis

from other tumor of the pancreas remains dif-

Round ce ll anaplastic carcinoma is a ra re vari- ficul t. Adenocarcinomas from ductal epithelium

ants o f pancreatic carcinoma , microscopically are usually small but locally invasive. Nonfunctio-

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- 大혐放射線옆탱會誌 : 第 25 卷 第 l 號 1989 -

- 84

Fig. 1. A. Transverse sonogram shows a well defined oval echopoor solid mass with a little heter.

ogeneity , measuring 7 x 7 x 7.5 cm, in the head of the pancreas . The infe rior vena cava (V) is compressed by the mass but pa. tent ‘ T he mass does not demonstrate in. creased through. transmission. K =Right kidney

B. Right parasagi ttal scan with the patient left decubi tus shows the same mass (M) result. ing in di latation of the common bile duct (CD)

C. Transverse CT shows an oval mass of homogeneous de nsity possess ing a well de. fined smooth margin. The second portion of the duodenum (D) and the in fe ri or vena cava (V) are compressed a nd not separated from the mass

D. Microphotograph shows an aci nus structure (arrow) surrounded by rather monotonous ovoid undiffe rentiated tumor ce lls (H & E , X200)

c

D

J ae Hoon Lim. et al.: Round Cell Anaplastic Carcinoma 01 the pancreas -

ning islet-cell tumors may be large and solid but

usually highly enhanced on cr by contrast infu-sion. Mucinous cystadenomas or cystadenocarcino-

mas usually present with large unilocular or multi-

locular cysts containing multiple thin septi and

small mural nodules within the cysts5,6). Solid and

papillary epithelial neoplasms of the pancreas may

be large and benign looking, but it occurs in young woman and usually shows hemorrhagic nec-

rosis within the tumor7- 9). Pleomorphic carcinomas

(pleomorphic giant cell carcinomas) of the pan-

creas usually present with a large tumor and ex-

tensive peripancreatic and periaortic Iymphnode

me.tastasis \O). Similarities exist with Iymphomas .

In conclusion , if there is a well defined large pancreatic mass with homogeneously solid internal

texture without hemorrhagic necrosis with no local

invasion or extensive Iymphnode metastasis , a radiologist should keep the round cell anaplastic

carcinoma in mind.

REFERENCES

l. Rosai ]. Ackerman ’'s 5urgical Pathology, vol 1,

sixth edition, 5 t L ouis, Toronto, L ondon:The M os-

by Company, 1981 , 689

2. Alguacil -Garcia A, Weiland LH. The histologic

spectrum , prognosis, and histogenesis of the sar-

comatoid carcin oma of the pancreas. Cancer 1977;

39: 1181-1189

3. Cubilla AL , Fitzgerald P]. Morph ological patterns

of primary nonendocrine human pancreatic carcin -

oma. Cancer Res 1975: 35.2234-2241

4. Cubilla AL , Fitzgerald P]. 5 urgical pathology of

tumors of the exocrine pancreas. In :Moosa AR ed

Tum ors of the pancreas. Baltimore: Williams &

Wllkin s, 1980; 171 -188

5. Friedman AC, Lichtenstein JE , Dachman AH. Cys-

tic neoplasm of the pancreas: radiologi-

cal -pathological correlation. Radiology 1983;

149:45-50

6. Itai Y, Moss AA , Ohtomo K. Computed tomography

of cystadenoma and cystadenocarcinoma of the pan-

creas. Radiology 1982; 145:419-425

7. Friedman AC , Lichtenstein JE , Fishman EK , Oertel

JE , Dachman AH , Siegelman SS . 50lid and papil-

lary epithelial neoplasm of the pancreas. Radiology

1985: 154:333-337

8. Kim SY, Lim JH , Lee JD , Papillary carcinoma 01

the pancreas :findings 01 US and CT. Radiology

1985; 154:338

9. Choi BI , Kim KW , Han MC , Kim YI , Kim CW

50lid and papillary epithelial neoplasms of the pan-

creas ’ CT findings. Radiology 1988; 166:413-416

10. Wolfman NT , Karstaedt N, Kawamoto EH. Pleomor-

phic carcinoma of the pancreas. Computed-tomog -

raphic, sonographic and pathologic fjndings. Rad-

iology 1985; 154:329-332

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