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    Pancreas resection

    Background

    Total resections of the pancreas are undertaken to remove benign and malignant tumours.

    Examples of benign tumours are cystadenomas and intraductal adenomas. Examples of malignant tumours are cystadenocarcinomas, intraductal carcinomas, acinar cell carcinomas and ductal adenocarcinomas. The majority of periampullary cancers are adenocarcinomas.1 Specimens from the head of the pancreas are more common because malignancies in the body or tail of the pancreas not causing obstruction can be difficult to detect until too advanced for surgical resection.2

    Subtotal pancreatectomy includes the body of the pancreas with or without stomach. Distal pancreatectomy includes the body and tail of the pancreas with or without spleen.2

    Total pancreatoduodenectomy (Kausch-Whipple’s resection) includes a partial pancreatectomy (head of pancreas), cholecystectomy, common bile duct and dudoenectomy; generally with partial gastrectomy (without gastrectomy is described as pylorus-preserving).2,3

    Total pancreatoduodenectomy may be required for tumours located close to the Ampulla of Vater. Tumours can arise from exocrine pancreas (mostly adenocarcinomas)1 or endocrine tissue (neuroendocrine, islet cell tumours).4

    Lymphoma and secondary tumours may also occur in pancreas. Although microscopic reporting requires different protocols, macroscopic cut-up is similar for all types of tumours.4

    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    Frozen sections are frequently undertaken to assess the pancreatic neck and/or proximal bile duct margins.1

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Describe the following features of the specimen:

    Procedure2

    ​Record as stated by the clinician.
    • Total pancreatoduodenectomy
    • Pylorus preserving pancreatoduodenectomy
    • Subtotal pancreatectomy
    • Other, specify

    Transduodenal or endoscopic ampullectomies are specialist procedures undertaken for ampullary adenocarcinoma. Optimally they should be received pinned out on a board with orientation by the clinician to identify the ampullary duct and the deep margin.1

    Specimen integrity

    • Intact
    • Opened, describe

    Specimen orientation

    Orientate and identify the anatomical features of the specimen.

    Pancreatoduodenectomy

    • Anterior surface
    • Pancreatic transection margin (neck or body)
    • Superior mesenteric artery margin (uncinate margin)
    • Superior mesenteric vein margin (vascular groove margin)
    • Posterior pancreatic margin
    • Bile duct margin
    • Proximal gastric or duodenal margin
    • Distal duodenal or jejunal margin(s)

    Subtotal pancreatectomy

    • Anterior surface
    • Posterior margin
    • Cut margin

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Featured denoted

    Photograph the intact specimen, including the medial aspect and Ampulla of Vater.

    Anatomical components included (more than one may apply) and dimensions (mm)

    Describe and measure the anatomical components present.1

    • Pancreas, in three dimensions, inclusive of:
      • Head
      • Tail
      • Body
      • Uncinate process
    • Bile duct, length and diameter
    • Mesenteric vessels/portion of vessel, length and diameter. (Large vessels should be measured in three dimensions if a tangential resection has been performed or length x diameter if the whole circumference is present).
    • Spleen, in three dimensions and weight (g)
    • Omentum, in three dimensions
    • Stomach, length along lesser and greater curves
    • Duodenum, length
    • Gallbladder, in two dimensions
    • Other, describe

    Stent1,2

    Describe if a stent is in place.
    • Not present
    • Present

    Dissection

    Pancreatoduodenectomy

    Several methods are available for the dissection of pancreatoduodenectomy (PD) specimens.1

    1. Sectioning the entire pancreatic head and duodenum perpendicular to the long axis of the duodenum (‘axial sectioning’).5,6
    2. Sectioning perpendicular to the common bile duct, followed by sectioning along the plane of the ampullary duct in the immediate periampullary region.
    3. Sectioning along the plane of the pancreatic and common bile duct.
    4. Sectioning perpendicular to the main pancreatic duct or ‘bread-loaf’ slicing.

    After sufficient fixation, paint the surfaces and surgical margins listed below with different inks as illustrated and record the colours applied. Terminology of the circumferential margins varies between institutions and the following nomenclature is not prescriptive.

    • Superior mesenteric vein margin margin (medial circumferential resection/vascular groove)
    • Pancreatic transection margin (neck or body margin)
    • Superior mesenteric artery margin (uncinate margin/posterior circumferential margin)
    • Anterior surface and posterior margin

    If a vessel is adherent to the resection margin the sides of the vessel wall should be painted to facilitate measurement to the closest edge.

    Cut ends of a segment of superior mesenteric vein or portal vein attached to the vascular groove represent true resection margins. Where only a portion of the circumference of the vessel is included (tangential resection), the sides are also resection margins.1 Note that prior frozen section assessment may have included "en face" sampling of the transected bile duct and/or pancreatic (neck/body) margins.1 However, when the tumour infiltrates through the vessel wall to the endothelium of attached superior meseneteric or portal vein (i.e. bordering vascular space rather than retroperitoneal soft tissue) this is surface not margin involvement.

    Open the duodenum along the lateral antimesenteric border enabling identification of the ampulla of Vater and allow to fix.

    Commonly, the "axial sectioning" technique is used.5,6 Serially section the whole pancreatic head in the axial plane at 5mm intervals, i.e. perpendicular to the longitudinal axis of the duodenum to produce 10-13 slices. Optimally one slice should be through the ampulla. Slices will include cross sections of the duodenum. See diagrams and photos provided.

    Advantages and disadvantages exist for all the aforementioned techniques. Importantly, the dissection method and subsequent blocking of specimens should be standardised by individual departments.5 The selected technique should allow detailed viewing of tumour relationship to key anatomical structures as well as resection margins and surfaces. Recent studies have highlighted the value of standardised macroscopic dissection for improved recognition of tumour origin and R1 rates in PD specimens.4,5

    Distal PD specimens can be serially sectioned in the sagittal plane after painting and fixation.5 Total pancreatectomy specimens can be handled by a combination of the technique adopted for PD followed by serial sagittal sectioning of the distal pancreas. Serial sagittal sections of ampullectomy specimens with attention to demonstrating the ampullary duct extending to the deep margin is recommended.5

    Recording of the depth of portal vein invasion also provides useful feedback to surgeons.6

    After opening, the specimen will require longer fixation in larger quantity of formalin before further dissection.

    Serially section the spleen (if present).

    After sufficient fixation, paint the following surfaces and surgical margins with different inks and record the colours applied:

    • Anterior surface
    • Posterior margin
    • Transection margin

    Serially section the pancreas along the long axis from the proximal (cut end) to distal (tail) aspect. Paint the proximal surgical margin and close pancreatic surfaces with ink.

    Specimens can be dissected using a combination of the technique described above for subtotal pancreatectomy followed by serial sagittal sectioning of the distal pancreas.1,5


    Internal Inspection

    Describe the internal appearance including the following items:

    Tumour

    • Absent
    • Present, number; if more than one tumour, designate and describe each tumour separately

    Tumour size (mm)1,7,8

    • Maximum dimension1
    • Other dimensions

    Tumour site

    Describe the location of the tumour macroscopically (more than one may apply)1,2,9

    • Pancreas
      • Head
      • Body
      • Tail
      • Uncinate process
    • Duodenum
    • Ampulla of Vater
    • Common bile duct
      • Intrapancreatic
      • Extrapancreatic
    • Other, specify

    See the Structured Reporting pancreas protocol for more information on definitions and limitations of macroscopic assessement of tumour site.1

    Tumour appearance (more than one may apply)

    • Solid
    • Exophytic
    • Cystic,1 describe configuration and contents:
      • Microcystic
      • Complex
      • Simple
      • Serous fluid
      • Mucinous
    • Colour, if applicable
    • Border, if applicable

    Describe relationship of the tumour to the following structures, or surfaces and/or surgical margins:1,4,8,9,10,11,12

    • Appearance
      • Flat
      • Polypoid
    • Relationship to ampulla1
      • Intra-ampullary
      • Peri-ampullary
      • Mixed intra- and peri-ampullary
    • Distance of tumour to ampulla (mm)

    Ampullary carcinomas appear to be a histologically heterogeneous group of cancers that display differences in macroscopic appearance as well as immunophenotype and behaviour.1

    Distance of tumour (mm) to:

    • Anterior pancreatic surface
    • Pancreatic neck margin
    • Superior mesenteric vein margin
    • Superior mesenteric artery margin
    • Posterior pancreatic margin (if applicable)
    • Duodenal/stomach margin (if applicable)

    Distance of tumour (mm) to:

    • Proximal resection margin
    • Closest pancreatic surface/margin
      • Anterior
      • Retroperitoneal
      • Superior
      • Inferior
    • Describe relationship with main pancreatic duct

    Non-tumour lesion1

    Describe lesion as for tumour noting:

    • Presence of bile duct obstruction and level of obstruction
    • Stones present

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved

    Separately submitted

    • For each container, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of grossly identified lymph nodes submitted
    • Maximum diameter of each (mm)

    Photograph the dissected specimen.

    Note photographs taken, diagrams recorded and markings used for identification.


    Processing

    Dissect the specimen further and submit sections for processing according to the diagrams and illustrations provided.

    Submit representative sections demonstrating:

    • Bile duct margin and duodenal resection margins
      • Shave sections to be embedded en-face
    • Superior mesenteric/portal vein (if present)
      • Proximal and distal shave sections should be taken in addition to transverse sections
    • Tumour at closest distance to each of the pancreatic margins/surfaces
    • Tumour entering mesenteric vessel (if present)
    • Complete full face of tumour
    • Ampulla of Vater, longitudinal section
    • Invasion into duodenum/bile duct and pancreatic fat
    • Submit a shave section from the proximal cut-end margin (to be embedded en-face)
      OR perpendicular sections from the proximal margin.
    • Submit representative sections of tumour

    Cystic lesions should be sampled extensively, focussing on any solid areas to exclude invasion. Submit sections to demonstrate relationship of cyst to the main pancreatic duct.

    Submit representative sections of spleen including hilar lymph node, if present.

    Surrounding soft tissues should be examined carefully for lymph nodes. Submit all lymph nodes and designate peripancreatic (regional) from splenic and other (non-regional) lymph nodes as location of lymph node spread affects prognosis.


    Record details of each cassette.

    An illustrated block key similar to the one below may be useful.

    Block allocation key

    Cassette id
    Site
    No. of pieces
    A
    Bile duct margin
     
    B
    Duodenal/gastric margin
     
    C
    Pancreatic neck margin
     
    D
    Distal duodenal/small bowel margin
     
    E-L
    Composite whole tumour blocks to anterior, posterior surfaces, medial and posterior circumferential margins, duodenal wall  and mesenteric vessel
     
    M
    Spleen (not shown in diagram)
     
    N-P
    Regional lymph nodes (not shown in diagram)
     
    Q+
    Non-regional lymph nodes (if relevant)
     
    Cassette id
    Site
    No. of pieces
    A
    Peripheral shave margin
     
    B-H
    Tumour, representative sections focussing on visible solid areas
     
    I-J
    Lymph nodes (not shown in photo)
     
    K-M
    Representative sections of spleen including hilar lymph node (not shown in photo)
     

    Acknowledgements

    Dr Siaw Ming Chai for her contribution in reviewing and editing this protocol.


    References

    1. Chai SM, Brown I, de Boer B, Epari K, Gill A, Jasas K, et al. Cancer of the Exocrine Pancreas, Ampulla of Vater and Distal Common Bile Duct Structured Reporting Protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2014.
    2. Campbell F, Foulis AK and Verbeke CS . Dataset for the histopathological reporting of carcinomas of the pancreas, ampulla of Vater and common bile duct, The Royal College of Pathologists, London, 2010.
    3. Tsao JI, Rossi RL and Lowell JA. Pylorus-preserving pancreatoduodenectomy. Is it an adequate cancer operation. Arch Surg 1994;129(4):405-412.
    4. Stephenson TJ, Cross SS and Chetty R. Dataset for neuroendocrine tumours of the gastrointestinal tract including pancreas, The Royal College of Pathologists, London, 2012.
    5. Verbeke CS (2008). Resection margins and R1 rates in pancreatic cancer--are we there yet? Histopathology 2008;52(7):787-796.
    6. Menon KV, Gomez D, Smith AM, Anthoney A, Verbeke CS. Impact of margin status on survival following pancreatoduodenectomy for cancer: the Leeds Pathology Protocol (LEEPP). HPB (Oxford) 2009;11(1):18-24.
    7. Yamaguchi K, Mizumoto K, Noshiro H, Sugitani A, Shimizu S, Chijiiwa K and Tanaka M. Pancreatic carcinoma: < or = 2 cm versus > 2 cm in size. Int Surg 1999;84(3):213-219.
    8. Benassai G, Mastrorilli M, Quarto G, Cappiello A, Giani U, Forestieri P and Mazzeo F. Factors influencing survival after resection for ductal adenocarcinoma of the head of the pancreas. J Surg Oncol 2000;73(4):212-218.
    9. Fisher WE and Bakey ME (2007). Differences between Ampullary, Periampullary and Pancreatic Cancer. World Journal of Surgery 2007;31(1):144-146.
    10. Moon HJ, An JY, Heo JS, Choi SH, Joh JW and Kim YI. Predicting survival after surgical resection for pancreatic ductal adenocarcinoma. Pancreas 2006;32(1):37-43.
    11. Howe JR, Klimstra DS, Moccia RD, Conlon KC and Brennan MF. Factors predictive of survival in ampullary carcinoma. Ann Surg 1998;228(1):87-94.
    12. Khalifa MA, Maksymov V and Rowsell C. Retroperitoneal margin of the pancreaticoduodenectomy specimen: anatomic mapping for the surgical pathologist. Virchows Arch 2009;454(2):125-131.
    13. Han SS, Jang JY, Kim SW, Kim WH, Lee KU and Park YH. Analysis of long-term survivors after surgical resection for pancreatic cancer. Pancreas 2006;32(3):271-275.

    Jump To

      Pan 5

      Pancreatoduodenectomy

      Pan 6

      Pancreatoduodenectomy dissection

      Pan 1

      Pancreatoduodenectomy, anterior aspect

      Pan 2

      Pancreatoduodenectomy, medial aspect

      Pan 3

      Pancreatoduodenectomy with inked margins

      Pan 4

      Pancreatoduodenectomy, dissected

      Pan 7

      Subtotal pancreatectomy

      Pan 8

      Subtotal pancreatectomy, dissected


      Pancreas identification

      Pancreas identification

      RCPA | 26 September 2014

      Pancreas orientation

      Pancreas orientation

      RCPA | 26 September 2014

      Pancreas dissection

      Pancreas dissection

      RCPA | 27 August 2013

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      25-Mar-2019
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