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Dhall D, Shi J, Allende DS, Jang KT, Basturk O, Adsay NV, Kim GE. Towards a More Standardized Approach to Pathologic Reporting of Pancreatoduodenectomy Specimens for Pancreatic Ductal Adenocarcinoma: Cross-continental and Cross-specialty Survey From the Pancreatobiliary Pathology Society Grossing Working Group. Am J Surg Pathol 2021; 45:1364-1373. [PMID: 33899790 PMCID: PMC8446290 DOI: 10.1097/pas.0000000000001723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In recent literature and international meetings held, it has become clear that there are significant differences regarding the definition of what constitutes as margins and how best to document the pathologic findings in pancreatic ductal adenocarcinoma. To capture the current practice, Pancreatobiliary Pathology Society (PBPS) Grossing Working Group conducted an international multispecialty survey encompassing 25 statements, regarding pathologic examination and reporting of pancreatic ductal adenocarcinoma, particularly in pancreatoduodenectomy specimens. The survey results highlighted several discordances; however, consensus/high concordance was reached for the following: (1) the pancreatic neck margin should be entirely submitted en face, and if tumor on the slide, then it is considered equivalent to R1; (2) uncinate margin should be submitted entirely and perpendicularly sectioned, and tumor distance from the uncinate margin should be reported; (3) all other surfaces (including vascular groove, posterior surface, and anterior surface) should be examined and documented; (4) carcinoma involving separately submitted celiac axis specimen should be staged as pT4. Although no consensus was achieved regarding what constitutes R1 versus R0, most participants agreed that ink on tumor or at and within 1 mm to the tumor is equivalent to R1 only in areas designated as a margin, not surface. In conclusion, this survey raises the awareness of the discordances and serves as a starting point towards further standardization of the pancreatoduodenectomy grossing and reporting protocols.
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Affiliation(s)
- Deepti Dhall
- Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jiaqi Shi
- Department of Pathology, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Daniela S Allende
- Department of Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kee-Taek Jang
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nazmi Volkan Adsay
- Department of Pathology, Koç University and American Hospital, Istanbul, Turkey
| | - Grace E. Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA
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van Roessel S, Soer EC, van Dieren S, Koens L, van Velthuysen MLF, Doukas M, Groot Koerkamp B, Fariña Sarasqueta A, Bronkhorst CM, Raicu GM, Kuijpers KC, Seldenrijk CA, van Santvoort HC, Molenaar IQ, van der Post RS, Stommel MWJ, Busch OR, Besselink MG, Brosens LAA, Verheij J. Axial slicing versus bivalving in the pathological examination of pancreatoduodenectomy specimens (APOLLO): a multicentre randomized controlled trial. HPB (Oxford) 2021; 23:1349-1359. [PMID: 33563546 DOI: 10.1016/j.hpb.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/23/2020] [Accepted: 01/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In pancreatoduodenectomy specimens, dissection method may affect the assessment of primary tumour origin (i.e. pancreatic, distal bile duct or ampullary adenocarcinoma), which is primarily determined macroscopically. This is the first study to prospectively compare the two commonly used techniques, i.e. axial slicing and bivalving. METHODS In four centres, a randomized controlled trial was performed in specimens of patients with a suspected (pre)malignant tumour in the pancreatic head. Primary outcome measure was the level of certainty (scale 0-100) regarding tumour origin by four independent gastrointestinal pathologists based on macroscopic assessment. Secondary outcomes were inter-observer agreement and R1 rate. RESULTS In total, 128 pancreatoduodenectomy specimens were randomized. The level of certainty in determining the primary tumour origin did not differ between axial slicing and bivalving (mean score 72 [sd 13] vs. 68 [sd 16], p = 0.21), nor did inter-observer agreement, both being moderate (kappa 0.45 vs. 0.47). In pancreatic cancer specimens, R1 rate (60% vs. 55%, p = 0.71) and the number of harvested lymph nodes (median 16 vs. 17, p = 0.58) were similar. CONCLUSION This study demonstrated no differences in determining the tumour origin between axial slicing and bivalving. Both techniques performed similarly regarding inter-observer agreement, R1 rate, and lymph node harvest.
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Affiliation(s)
- Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Eline C Soer
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Susan van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Lianne Koens
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - Michael Doukas
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Arantza Fariña Sarasqueta
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - Carolien M Bronkhorst
- Department of Pathology, Pathology-DNA, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | - G Mihaela Raicu
- Department of Pathology, Pathology-DNA, St. Antonius Hospital, Regional Academic Cancer Center Utrecht (RAKU), Nieuwegein, Utrecht, the Netherlands
| | - Karel C Kuijpers
- Department of Pathology, Pathology-DNA, St. Antonius Hospital, Regional Academic Cancer Center Utrecht (RAKU), Nieuwegein, Utrecht, the Netherlands
| | - Cornelis A Seldenrijk
- Department of Pathology, Pathology-DNA, St. Antonius Hospital, Regional Academic Cancer Center Utrecht (RAKU), Nieuwegein, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Regional Academic Cancer Center Utrecht (RAKU), Nieuwegein, Utrecht, the Netherlands; Department of Surgery, University Medical Center Utrecht, Regional Academic Cancer Center Utrecht (RAKU), Nieuwegein, Utrecht, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, St. Antonius Hospital, Regional Academic Cancer Center Utrecht (RAKU), Nieuwegein, Utrecht, the Netherlands; Department of Surgery, University Medical Center Utrecht, Regional Academic Cancer Center Utrecht (RAKU), Nieuwegein, Utrecht, the Netherlands
| | - Rachel S van der Post
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Pathology, University Medical Center Utrecht, Regional Academic Cancer Center Utrecht (RAKU), Nieuwegein, Utrecht, the Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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Kabir T, Tan HL, Syn NL, Wu EJ, Kam JH, Goh BKP. Outcomes of laparoscopic, robotic, and open pancreatoduodenectomy: A network meta-analysis of randomized controlled trials and propensity-score matched studies. Surgery 2021; 171:476-489. [PMID: 34454723 DOI: 10.1016/j.surg.2021.07.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND This network meta-analysis was performed to determine the optimal surgical approach for pancreatoduodenectomy by comparing outcomes after laparoscopic pancreatoduodenectomy, robotic pancreatoduodenectomy and open pancreatoduodenectomy. METHODS A systematic search of the PubMed, EMBASE, Scopus, and Web of Science databases was conducted to identify eligible randomized controlled trials and propensity-score matched studies. RESULTS Four randomized controlled trials and 23 propensity-score matched studies comprising a total of 4,945 patients were included for analysis. Operation time for open pancreatoduodenectomy was shorter than both laparoscopic pancreatoduodenectomy (mean difference -57.35, 95% CI 26.25-88.46 minutes) and robotic pancreatoduodenectomy (mean difference -91.08, 95% CI 48.61-133.56 minutes), blood loss for robotic pancreatoduodenectomy was significantly less than both laparoscopic pancreatoduodenectomy (mean difference -112.58, 95% CI 36.95-118.20 mL) and open pancreatoduodenectomy (mean difference -209.87, 95% CI 140.39-279.36 mL), both robotic pancreatoduodenectomy and laparoscopic pancreatoduodenectomy were associated with reduced rates of delayed gastric emptying compared with open pancreatoduodenectomy (odds ratio 0.59, 95% CI 0.39-0.90 and odds ratio 0.69, 95% CI 0.50-0.95, respectively), robotic pancreatoduodenectomy was associated with fewer wound infections compared with open pancreatoduodenectomy (odds ratio 0.35, 95% CI 0.18-0.71), and laparoscopic pancreatoduodenectomy patients enjoyed significantly shorter length of stay compared with open pancreatoduodenectomy (odds ratio 0.43, 95% CI 0.28-0.95). There were no differences in other outcomes. CONCLUSION This network meta-analysis of high-quality studies suggests that when laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy are performed in high-volume centers, short-term perioperative and oncologic outcomes are largely comparable, if not slightly improved, compared with traditional open pancreatoduodenectomy. These findings should be corroborated in further prospective randomized studies.
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Affiliation(s)
- Tousif Kabir
- Department of General Surgery, Sengkang General Hospital, Singapore; Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore. https://twitter.com/KabirTousif
| | - Hwee Leong Tan
- Department of General Surgery, Sengkang General Hospital, Singapore; Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | | | | | - Juinn Huar Kam
- Department of General Surgery, Sengkang General Hospital, Singapore; Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke NUS Medical School, Singapore.
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Rodrigues V, Dopazo C, Pando E, Blanco L, Caralt M, Gómez-Gavara C, Bilbao I, Salcedo MT, Balsells J, Charco R. Is the involvement of the hepatic artery lymph node a poor prognostic factor in pancreatic adenocarcinoma? Cir Esp 2019; 98:204-211. [PMID: 31839175 DOI: 10.1016/j.ciresp.2019.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 09/18/2019] [Accepted: 09/29/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The aim of this study is to analyze the impact of hepatic artery lymph node (HALN) involvement on the survival of patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). METHODS A single-center retrospective study analyzing patients who underwent PD for PA. Patients were included if, during PD, the HALN was submitted for pathologic evaluation. Patients were stratified by node status: PPLN- (peripancreatic lymph node)/HALN-, PPLN+/HALN- and PPLN+/HALN+. Survival analysis was estimated by the Kaplan-Meier method, and Cox regression was used for risk factors analyses. RESULTS Out of the 118 patients who underwent PD for PA, HALN status was analyzed in 64 patients. The median follow-up was 20months (r: 1-159months). HALN and PPLN were negative in 12patients (PPLN-/HALN-, 19%), PPLN was positive and HALN negative in 40patients (PPLN+/HALN-, 62%), PPLN and HALN were positive in 12 patients (PPLN+/HALN+, 19%) and PPLN was negative and HALN positive in 0 patients (PPLN-/HALN+, 0%). The overall 1, 3 and 5-year survival rates were statistically better in the PPLN-/HALN- group (82%, 72%, 54%) than in the PPLN+/HALN- group (68%, 29%, 21%) and the PPLN+/HALN+ group (72%, 9%, 9%, respectively) (P=.001 vs P=.007). The 1, 3 and 5-year probabilities of cumulative recurrence were also statistically better in the PPLN-/HALN- group (18%, 46%, 55%) than in the PPLN+/HALN- group (57%, 80%, 89%) and the PPLN+/HALN+ group (46%, 91%, 100%, respectively) (P=.006 vs P=.021). In the multivariate model, the main risk factor for overall survival and recurrence was lymphatic invasion, regardless of HALN status. CONCLUSIONS In pancreatic adenocarcinoma patients with lymph node disease, survival after PD is comparable regardless of HALN status.
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Affiliation(s)
- Victor Rodrigues
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Cristina Dopazo
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España.
| | - Elizabeth Pando
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Laia Blanco
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Mireia Caralt
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Concepción Gómez-Gavara
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Itxarone Bilbao
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - María Teresa Salcedo
- Servicio de Anatomía Patológica, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Joaquim Balsells
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Ramon Charco
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
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Shi J, Basturk O. Whipple Grossing in the Era of New Staging: Should We Standardize? Diagnostics (Basel) 2019; 9:diagnostics9040132. [PMID: 31569496 PMCID: PMC6963989 DOI: 10.3390/diagnostics9040132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Whipple procedure, also known as pancreatoduodenectomy, is the most common surgery for the removal of tumors of the head of the pancreas, ampulla, distal common bile duct, or periampullary duodenum. It is also one of the most challenging resection specimens grossed by surgical pathologists. A thorough and consistent evaluation of the gross surgical specimen is the most critical first step for accurate diagnosis, determination of tumor origin, staging, and evaluation of margin status. However, there has been no standard grossing protocol for Whipple specimens, which has led to inaccurate diagnoses, staging, and inconsistent reporting. This issue has become even more challenging in the era of the size-based tumor staging systems recommended by the new 8th Edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual. Moreover, new concerns have been raised regarding how to best evaluate margin status and lymph nodes. Studies have shown that different Whipple grossing methods can significantly impact margin assessment and lymph node yield and thus affect R0/R1 status and clinical stage. Other important issues under debate include nomenclature, definitions of margin (versus surface), and R1 status. Consistent Whipple grossing and standardization of reporting will provide better communication and more accurate diagnosis and staging, as well as prognostic prediction.
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Affiliation(s)
- Jiaqi Shi
- Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
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