About the Program
Next opening: 2027-2028
Number of positions: 1
Length: 1 year
This ACGME-accredited fellowship provides robust training in disorders of the luminal GI tract, pancreas and hepatic pathology (medical liver including liver transplantation), preparing trainees for a career in an academic or private practice setting. Five GI pathologists provide clinical service, contribute to the research program of the GI section, and support the GI Pathology training program across four distinct hospital and outpatient settings.
The GI pathology fellow will get exposure to a comprehensive spectrum of gastrointestinal surgical specimens, ranging from small biopsies to complex procedures, as well as hepatobiliary specimens. Training also includes reviewing consult digital slides from community practices in Texas. The fellow will have graduated responsibility in performing operating room consultations (frozen sections and gross examination). The fellow is expected to closely interact with surgeons/clinicians and pathology colleagues from community practice, actively participate in tumor boards, IBD/liver conferences, participate in research projects and will have the opportunity to attend and contribute to numerous didactic and clinical conferences.
Rotations
The fellow will rotate across two institutions: Baylor St. Luke’s Medical Center and Texas Children’s Hospital, with a one-month rotation at MD Anderson Cancer Center. Program strengths include extensive experience in routine and complex gastrointestinal pathology, pancreatic pathology, medical liver biopsies, liver transplantation, and pediatric pathology.
A one-week rotation in clinical gastroenterology is included, during which the fellow may observe advanced endoscopic procedures such as EMR/ESD and EUS-guided FNA/FNB performed by experienced gastroenterologists.
Stipends and Benefits
Visit the Graduate School of Biomedical Sciences page on stipends and benefits for fellows.
Admissions
Candidates must be board certified or eligible for certification in anatomic pathology or AP/CP.
All application materials, including recommendation letters, must be submitted online, and include the following:
- Completed online House Staff Application
- Current Curriculum Vitae
- Personal Statement
- Transcript from Medical School(s)
- Three Recommendation Letters
Applications are accepted from mid-April to July 31 for positions beginning July 1 two years later. Interviews are conducted starting in July or August and are completed by the end of August of the application year.
Case of the Month
Dr. Katie Hogan, M.D., Ph.D., PGY1
Dr. Roshan Raza
A 72-year-old with GERD and epigastric/RUQ pain with alternating nausea, vomiting, and diarrhea versus constipation. An ultrasound was performed to investigate the RUQ pain.
- US findings: Ill-defined 4 cm mass in approximate position of pancreatic head. MRI evaluation recommended.
- MRI findings: Enhancing 2.2 x 1.9 cm pancreatic body mass concerning for primary pancreatic malignancy; 3.4 cm heterogeneous left adrenal lesion. PET evaluation recommended.
- PET findings: Hypermetabolic pancreatic mass (max Maxey value 8); 2.5 cm adrenal mass (max Maxey value 4).
The patient had no documented history of hypertension, palpitations, hyperhidrosis, or severe headache. Upper endoscopic ultrasound with fine needle aspiration of pancreatic mass was performed.
On first assessment, the mass was found to have epithelioid cells with granular, eosinophilic cytoplasm and regular, central nuclei without nucleoli. Initial immunohistochemical staining showed positive synaptophysin, chromogranin, and INSM1 staining with negative AE1-AE3, CAM5.2, β-catenin, inhibin, CD-10 and a low Ki-67.
Question
Q1: Which of the following immunohistochemical stains may be used to differentiate between a neuroendocrine tumor (NET) and a paraganglioma within the pancreas?
a) Chromogranin
b) GATA3
c) Synaptophysin
d) Inhibin
e) CD-10
Answer
The best answer is B.
Explanation
Distinguishing stains for paraganglioma include GATA3 and S-100, which should stain positive in sustentacular cells. Paragangliomas should also stain positive for common neuroendocrine markers including chromogranin and synaptophysin alongside NETs. However, cytokeratins (AE1-AE3, CAM5.2) will be negative in paragangliomas compared to positive staining in epithelial-derived NETs. Inhibin and CD-10 may be used to rule out pancreatic serous cystadenoma and solid pseudopapillary neoplasm, respectively.
In this case, upon seeing negative cytokeratin markers in the lesional tissue, additional staining for S-100 and GATA3 was performed and shown to be positive, confirming a diagnosis of a rare pancreatic paraganglioma.
Discussion
Pancreatic/peripancreatic Paraganglioma
Paragangliomas are uncommon neuroendocrine tumors (NETs) originating from extra-adrenal chromaffin cells of the autonomic nervous system. Paragangliomas rarely arise within the pancreas and, when they occur, have been most commonly reported in the pancreatic head but do not commonly cause dilatation or obstruction of biliary or pancreatic ducts. In contrast to adrenal pheochromocytomas, pancreatic paragangliomas are less likely to produce catecholamines leading to functional symptoms. On imaging, these lesions may appear hyper-enhancing and cystic and mimic other pancreatic neoplasms, chiefly pancreatic NETs.
Pancreatic paragangliomas may therefore provide a diagnostic challenge, as imaging may indicate a primary neoplasm of the pancreas such as an adenocarcinoma or NET. As in this case, particularly on fine needle aspiration where material is scarce, it is key to consider a broad differential that may include pancreatic paraganglioma and to assay for both neuroendocrine markers and keratins. The lack of keratin staining alongside positive neuroendocrine markers can distinguish pancreatic paraganglioma from the more common pancreatic NET. While most pancreatic paragangliomas are benign, a high mitotic index, evidence of vascular invasion, and necrosis may indicate a higher risk of malignancy. Nuclear pleomorphism may be present but is not predictive of tumor behavior. Patients with a pancreatic paraganglioma should be screened for additional paragangliomas and other endocrine neoplasms to investigate potential genetic syndromes.
References
Zhang L, Liao Q, Hu Y, Zhao Y. Paraganglioma of the pancreas: a potentially functional and malignant tumor. World J Surg Oncol. 2014 Jul 17;12:218. doi: 10.1186/1477-7819-12-218. PMID: 25030833; PMCID: PMC4132206.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4132206/
Borgohain M, Gogoi G, Das D, Biswas M. Pancreatic paraganglioma: An extremely rare entity and crucial role of immunohistochemistry for diagnosis. Indian J Endocrinol Metab. 2013 Sep;17(5):917-9. doi: 10.4103/2230-8210.117217. PMID: 24083178; PMCID: PMC3784880.
https://pmc.ncbi.nlm.nih.gov/articles/PMC3784880/
Tumuluru S, Mellnick V, Doyle M, Goyal B. Pancreatic Paraganglioma: A Case Report. Case Rep Pancreat Cancer. 2016 Dec 1;2(1):79-83. doi: 10.1089/crpc.2016.0016. PMID: 30631823; PMCID: PMC6319695.
https://pmc.ncbi.nlm.nih.gov/articles/PMC6319695/
Al-Jiffry BO, Alnemary Y, Khayat SH, Haiba M, Hatem M. Malignant extra-adrenal pancreatic paraganglioma: case report and literature review. BMC Cancer. 2013 Oct 20;13:486. doi: 10.1186/1471-2407-13-486. PMID: 24138700; PMCID: PMC4015757.