Macroscopy: A. Labelled "Lymph node from porta hepatis. For frozen section". A piece of tan soft tissue. Half on for frozen section. Frozen Section Diagnosis: Granulomatous, consistent with sarcoid. No malignancy. B. Labelled "Pancreatic margin". An irregular fragment of tan congested tissue. All on for frozen section. Frozen Section Diagnosis: No evidence of malignancy. C. Labelled "Whipple's procedure". The specimen consists of duodenum and head of the pancreas. There is a small amount of fibroadipose tissue at the anterior and posterior adventitial margin. There is an ill-defined, firm, infiltrative lesion within the head of the pancreas. The lesion is located medial to the common bile duct but does not appear to have invaded into the common bile duct. The entire length of the common bile duct is patent, with a circumference of up to 10 mm. The lesion adheres to the serosal surface of the duodenum but does not appear to have infiltrated the duodenum. The proximal 22 mm of the pancreatic duct is patent. The distal 20 mm of the pancreatic duct appears to be obstructed by the lesion, however, the ampulla of Vater is patent. The lesion abuts the anterior adventitial resection margin. The lesion is 6 mm from the closest posterior adventitial resection margin. Three posterior pancreaticoduodenal lymph nodes are identified, 2-18 mm in greatest dimension. Representative sections. D. Labelled "Hepatic artery node". A piece of fibrofatty tissue within which there is a lymph node. The specimen is bisected longitudinally.
Microscopy: A. The sections show lymph node within which there are numerous non-necrotic bare histiocytic granulomas. There is no evidence of metastatic malignancy. Some of the granulomas show multinucleated giant cells. B. Sections show unremarkable pancreas. C. Sections through the pancreas show a florid granulomatous inflammatory reaction with loss of pancreatic acinar tissue. The granulomata are composed of histiocytic cells, with scattered multinucleated giant cells and clusters of giant cells are seen within the pancreatic interstitium. There is no evidence of any malignant infiltrate. The bile duct and pancreatic duct epithelium are unremarkable. The small bowel epithelium is unremarkable. There is no necrosis within the granulomata. Further lymph nodes from the Whipple's resection show extensive replacement by epithelioid granulomata with no evidence of necrosis and multinucleated giant cells. Resection margins are unremarkable. D. Lymph node, showing sarcoidal granulomata.
Conclusion: A. Lymph node porta hepatis - granulomatous inflammation, consistent with sarcoid. B. Pancreatic margin - unremarkable pancreatic tissue. C. Whipple's resection - extensive non-necrotising granulomatous inflammation of head of the pancreas with granulomatous inflammation of lymph nodes. No evidence of malignancy. D. Lymph node, showing sarcoidal granulomata. Comment - the findings raise the possibility of pancreatic sarcoidosis. There are rare documented findings of this. I can see no evidence of a malignancy.