Calcifications in an endoscopic ultrasound‐guided fine‐needle aspirate of chronic pancreatitis

A 48-year-old African American man with a long history of alcoholism and major depressive disorder was admitted to the hospital for severe abdominal pain. CT scan of the abdomen showed no free fluid or air and unremarkable liver, spleen, gallbladder, kidneys, and adrenals, but showed an irregular 3.1 3 1.7 cm mass lesion extending anteriorly from the pancreatic tail and a second area of irregularity in the pancreatic body measuring 1.7 3 1.2 cm. Small adjacent lymph nodes, the largest of which measured 6 mm in the short axis were also present. No definite peripancreatic fat stranding was seen. Endosonographic imaging of the pancreas was consistent with chronic pancreatitis in head and body of the pancreas. The parenchyma showed hyperechoic strands, hyperechoic foci, and lobularity. The pancreatic duct had hyperechoic walls and measured 2.9 mm in the head and 1.4 mm in the body. The parenchyma of the pancreatic tail was diffusely and severely hypoechoic and showed multiple shadowing, echogenic foci, likely representing calcifications. There was no significant endosonographic abnormality in the common bile duct and the gallbladder was unremarkable, as was the left adrenal gland. Fineneedle aspiration of the tail mass was performed using a transgastric approach. Six passes were made with 22 and 25 gauge ultrasound biopsy needles without a stylet. The material obtained by FNA of the pancreatic tail lesion appeared pasty, chalky white, and difficult to spread on slides. Diff-Quik and Papanicolaou-stained smears and H&E-stained cellblock preparations were made. Most smears were paucicellular or acellular and consisted predominantly of abundant large calcium crystals and granular debris with occasional histiocytes. The crystals occurred singly or in larger aggregates, were rounded, barrel-shaped, fan-shaped, or rectangular with irregular jagged contours, and measured 30–100 lm in largest dimension. While some of the crystals appeared homogenous, other appeared to be composed of multiple parallel or interwoven fibrils. The crystals were best seen in Diff-Quik-stained smears, where they appeared pale blue-gray to dark blue or purple (Fig. C-1). They were difficult to visualize with Papanicolaou stains, where they appeared homogenous or fibrillary, transparent, clear, weakly cyanophilic, or pale pink, and were better seen after lowering the condenser (Fig. C-2). The crystals could not be identified as such in the H&E-stained cellblock sections, but negative images of the crystals could be focally seen against a background of pink granular material. Under polarized light, the crystals appeared blue, orange, or purple, frequently with admixtures and gradations of these colors (Fig. C-3). Smears from one of the passes showed fragments of fibrous tissue, ductal, and acinar cells and rare mixed inflammatory cells. Mild atypia was Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota *Correspondence to: Stefan E. Pambuccian, M.D., Department of Laboratory Medicine and Pathology, University of Minnesota, University of Minnesota Medical Center, Fairview, C422 Mayo MMC 76, 420 Delaware Street SE, Minneapolis, MN 55455, USA. E-mail: pambu001@umn.edu Received 4 August 2011; Revision 6 September 2011; Accepted 12 September 2011 DOI 10.1002/dc.21849 Published online 18 November 2011 in Wiley Online Library (wileyonlinelibrary.com).