Pancreatic Pathology Online
Reporting of Pancreaticoduodenectomy (Whipple's Operation) Specimen
Pancreaticoduodenectomy is carried out for malignant tumours of the ampulla of Vater, the periampullary region and the head of the pancreas.
Benign neoplasms of the ampulla, which include hamartomatous polyps and inflammatory fibroid polyps, occur very rarely.
These are usually treated by local excision but can occasionally simulate malignancy, with involvement of deep tissues that can be mistaken for invasion, and Whipple’s operation is consequently performed.
The report should comment on the presence of :
- Type and differentiation
- Site of origin:
- Perineural and vascular invasion:
- Extent of infiltration:
1. pancreatic duct ;
2. extrapancreatic structures such as common bile duct, peritoneum, duodenum, gastric antrum ;
3. lymph nodes;
- Completeness of excision at the common bile duct, gastric, duodenal, pancreatic, posterior and peritoneal margins of excision.
In addition, other changes in the specimen (such as inflammation, haemorrhage, fibrosis etc.) should be described, as for biopsy specimens above.
Histopathological assessment of resection specimens is currently the most accurate and reliable method of confirming malignancy and determining prognosis in pancreatic neoplasia.
Although advances in radiological imaging techniques have resulted in increased preoperative diagnostic and staging accuracy, radiological assessment of some pancreatic lesions (Example: Cystic abnormalities) is still problematic.
Inaccuracies in preoperative radiological tumour staging have been reported in up to 79% of cases and definitive tumor staging still requires histopathology.
Histopathologists dealing with these specimens must therefore be certain that they assess and record the appropriate data in each case.
Major histopathological prognostic factors in pancreatic exocrine carcinoma:
Surgical margin tumour involvement;
Tumour extension beyond pancreas;
Lymph node metastasis;
Lymphovascular tumor invasion;
Perineural tumor invasion.
TNM staging system for pancreatic exocrine carcinoma :
Tis - Carcinoma in situ
T1 - Tumour limited to pancreas and 2 cm or less in greatest dimension
T2 - Tumour limited to pancreas and more than 2 cm in greatest dimension.
T3 - Tumour extends directly into the duodenum, bile duct (including ampulla) or peripancreatic tissues (retroperitoneal adipose tissue, mesentery, omentum and peritoneum).
T4 - Tumour extends directly into the stomach, spleen, colon or adjacent large vessels (portal vein, coeliac artery, superior mesenteric and common hepatic artieries/veins ; not splenic artery/vein).
N0 - No regional lymph node metastases
N1a - Metastasis in one regional lymph node
N1b - Metastasis in multiple regional lymph nodes
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