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Surgery for Pancreatic and Periampullary Cancer pp 247–280Cite as

Pathology Reporting of Resected Pancreatic/Periampullary Cancer Specimen

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Abstract

Pancreatic specimens have always been a great challenge for surgical pathologists due to their anatomic complexity and the difficulty of becoming familiar with these specimens. However, pancreatic specimens are becoming more and more common in many hospitals because of the improvements in surgical techniques and perioperative care that have dramatically reduced the postoperative mortality rate.

Pathological aspects are highly relevant for the management of cancer patients. However, in pancreatic cancer the discrepancies in the published data in terms of relevance have obscured their real value. This variability is mainly due to the different pathological approaches, not only in specimen handling and slicing but also in defining what should be considered as “margin” or “surface,” the nomenclature of these margins, and when we should consider that a margin is involved (0 mm versus 1 mm rule).

In the last decade, the use of standardized pathological protocols for macroscopic handling and reporting has proved to be essential for obtaining robust and reproducible data, emphasizing the fact that a good quality pathological report is required because of its prognostic relevance and implications in oncological treatment. However, some disagreements still exist regarding the most important guidelines, and this continues to be an obstacle for homogenizing and comparing studies.

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Abbreviations

AJCC:

American Joint Committee on Cancer

BDM:

Bile duct margin

CAP:

College of American Pathologists

CDP:

Cephalic duodenopancreatectomy

CRM:

Circumferential resection margin

DBDC:

Distal bile duct carcinoma

DP:

Distal pancreatectomy

IPMN:

Intraductal papillary mucinous neoplasm

ISGPS:

International Study Group of Pancreatic Surgery

ITPN:

Intraductal tubulopapillary neoplasm

JPS:

Japan Pancreas Society

LN:

Lymph node

LNR:

Lymph node ratio

PanIN:

Pancreatic intraepithelial neoplasia

PDAC:

Pancreatic ductal adenocarcinoma

PNM:

Pancreatic neck margin

PUPM:

Posterior surface of the uncinate process margin

PV-SMVM:

Portal vein-superior mesenteric vein margin

RCPA:

Royal College of Pathologists of Australasia

RCPUK:

Royal College of Pathologists of the United Kingdom

SMA:

Superior mesenteric artery

SMAM:

Superior mesenteric artery margin

SMV:

Superior mesenteric vein

SMVM:

Superior mesenteric vein margin

TP:

Total pancreatectomy

WHO:

World Health Organization

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Acknowledgments

The authors thank Ms. Landy Menzies for her review of the manuscript. The authors also thank A. Juaristi, M.J. Silva, M.C. Caballero, and M. Larzabal, specialized pathologists at the Department of Pathology, Hospital Universitario Donostia, for their collaboration.

Author information

Authors and Affiliations

  1. Department of Pathology, Hospital Universitario Donostia, Donostia, Spain

    María Carmen Gómez-Mateo

  2. Department of Surgery, Hospital Clínico, University of Valencia, Valencia, Spain

    Luis Sabater-Ortí

  3. Department of Surgery, Hospital Universitario Donostia, Donostia, Spain

    Inmaculada Ruiz-Montesinos

  4. Department of Pathology, Hospital Clínico, University of Valencia, Valencia, Spain

    Antonio Ferrández-Izquierdo

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  1. María Carmen Gómez-Mateo
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  4. Antonio Ferrández-Izquierdo
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Editor information

Editors and Affiliations

  1. Chief Hepato-Pancreato-Biliary and Gastrointestinal Division, Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P., India

    Mallika Tewari

Appendices

Appendix 1: WHO Classification of Malignant Epithelial Tumors of the Pancreas, Gallbladder and Extrahepatic Bile Ducts, Ampulla Region, and Small Intestine [97]

Pancreas

 • Ductal adenocarcinoma

  – Adenosquamous carcinoma

  – Colloid carcinoma (mucinous noncystic carcinoma)

  – Hepatoid carcinoma

  – Medullary carcinoma

  – Signet ring cell carcinoma

  – Undifferentiated (anaplastic) carcinoma

  – Undifferentiated carcinoma with osteoclast-like giant cells

 • Acinar cell carcinoma

 • Acinar cell cystadenocarcinoma

 • Intraductal papillary-mucinous neoplasm with an associated invasive carcinoma

 • Mixed acinar-ductal carcinoma

 • Mixed acinar-neuroendocrine carcinoma

 • Mixed acinar-neuroendocrine-ductal carcinoma

 • Mixed ductal-neuroendocrine carcinoma

 • Mucinous cystic neoplasm with an associated invasive carcinoma

 • Pancreatoblastoma

 • Serous cystadenocarcinoma

 • Solid-pseudopapillary neoplasm

Gallbladder and extrahepatic bile ducts

 • Adenocarcinoma

  – Adenocarcinoma, biliary type

  – Adenocarcinoma, gastric foveolar type

  – Adenocarcinoma, intestinal type

  – Clear cell adenocarcinoma

  – Mucinous adenocarcinoma

  – Signet ring cell carcinoma

 • Adenosquamous carcinoma

 • Intracystic (gallbladder) or intraductal (bile ducts) papillary neoplasm with an associated invasive carcinoma

 • Mucinous cystic neoplasm with an associated invasive carcinoma

 • Squamous cell carcinoma

 • Undifferentiated carcinoma small intestine

Ampullary region

 • Adenocarcinoma

  – Invasive intestinal type

  – Pancreatobiliary type

 • Adenosquamous carcinoma

 • Clear cell carcinoma

 • Hepatoid adenocarcinoma

 • Invasive papillary adenocarcinoma

 • Mucinous adenocarcinoma

 • Signet ring cell carcinoma

 • Squamous cell carcinoma

 • Undifferentiated carcinoma

 • Undifferentiated carcinoma with osteoclast-like giant cells

Small intestine

 • Adenocarcinoma

 • Mucinous adenocarcinoma

 • Signet ring cell carcinoma

 • Adenosquamous carcinoma

 • Medullary carcinoma

 • Squamous cell carcinoma

 • Undifferentiated carcinoma

  1. Benign and premalignant epithelial lesions and neuroendocrine tumors are not included

Appendix 2: Histopathological Grading of PDAC According to WHO Classification [97, 141]

Tumor grade

Glandular differentiation

Mucin production

Mitoses (per 10 HPF)

Nuclear features

Grade 1

Well differentiated

Intensive

5

Little polymorphism, polar arrangement

Grade 2

Moderately differentiated duct-like structures and tubular glands

Irregular

6–10

Moderate polymorphism

Grade 3

Poorly differentiated glands, abortive mucoepidermoid and pleomorphic structures

Abortive

>10

Marked polymorphism and increased size

  1. HPF high-power field

Appendix 3: Equivalences Between Lymph Node Stations According to JPS and AJCC-UICC Classification [41, 56]

JPS node stations

UICC node stations

5

Suprapyloric

6

Infrapyloric

7

Left gastric artery

8

Common hepatic artery

9

Celiac

10

Splenic hilum

11

Superior splenic artery

12

Hepatoduodenal ligament (portal/bile duct)

13

Posterior pancreaticoduodenal

14

Superior mesenteric vessel

15

Colic artery

16

Para-aortic

17

Anterior pancreaticoduodenal

18

Inferior

Appendix 4: Example of Pathologic Report of the Pancreatic and Periampullary Cancer Specimens

Pathologic report of pancreatic specimens

Patient:

– Name:

– Age:

– Affiliation number:

Identification number:

Tumor banking: Yes no

Previous diagnosis:

Photodocumentation: Yes no

Macroscopic examination

Specimen type:

Tumor location:

Macroscopic characteristics:

Tumor size: cm

Microscopic examination

Histologic type:

Invasion:

– Vascular

– Lymphatic

– Perineural

Precursor lesions:

– PanIN

– IPMN

– Other:

Histologic grade:

Microscopic tumor size: cm

Tumor extension:

Nonneoplastic lesions

– Bile duct obstruction

– Pancreatic duct obstruction

– Pancreatic calculi

– Chronic pancreatitis

– Other:

Treatment effect (neoadjuvant therapy):

– Complete response (grade 0)

– Moderate response (grade 1)

– Minimal response (grade 2)

– Poor response (grade 3)

Margins distance*:

Lymph nodes:

+

Total

– Proximal (luminal):

– Distal (luminal):

– CBD:

– PNM:

– Anterior surface:

– Posterior margin:

– SMVM:

– SMAM:

– Other:

 – Suprapyloric (S5)

  

 – Infrapyloric (S6)

  

 – Peripancreatic (S13, 17, 18)

  

 – Left gastric artery (S7)

  

 – Common hepatic artery (S8)

  

 – Celiac (S9)

  

 – Hepatoduodenal ligament (S12)

  

 – Superior mesenteric vessel (S14)

  

 – Colic artery (S15)

  

*fill in margins when applicable. If a margin is involved, indicate the distance and specify direct or indirect involvement

 – Para-aortic (S16)

  

 – Splenic hilum (S10)

  

 – Superior splenic artery (S11)

  

LNR (positive nodes/total nodes):

  

TNM classification (according to the current edition):

Comments:

Appendix 5:New Proposed TNM Classification for AJCC Staging System for Pancreatic Adenocarcinoma (Eight Edition) [100]

Primary tumor (T)

T1: Maximum tumor diameter ≤ 2 cm

T2: Maximum tumor diameter > 2 ≤ 4 cm

T3: Maximum tumor diameter > 4 cm

T4: Tumor involves the celiac axis or the superior mesenteric artery (unresectable primary tumor)

Regional lymph nodes (N)

N0: No regional lymph node metastasis

N1: Metastasis in 1–3 regional lymph nodes

N2: Metastasis in ≥4 regional lymph nodes

Distant metastases (M)

M0: No distant metastases

M1: Distant metastases

Stages

Stage IA

T1

N0

M0

Stage IB

T2

N0

M0

Stage IIA

T3

N0

M0

Stage IIB

T1–T3

N1

M0

Stage III

Any T

Any N

M0

T4

N2

M0

Stage IV

Any T

Any N

M1

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Gómez-Mateo, M.C., Sabater-Ortí, L., Ruiz-Montesinos, I., Ferrández-Izquierdo, A. (2018). Pathology Reporting of Resected Pancreatic/Periampullary Cancer Specimen. In: Tewari, M. (eds) Surgery for Pancreatic and Periampullary Cancer. Springer, Singapore. https://doi.org/10.1007/978-981-10-7464-6_26

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