Pathologic staging of pancreatic, ampullary, biliary, and gallbladder cancers: pitfalls and practical limitations of the current AJCC/UICC TNM staging system and opportunities for improvement
Pathologic staging of pancreatic, ampullary, biliary, and gallbladder cancers: pitfalls and practical limitations of the current AJCC/UICC TNM staging system and opportunities for improvement
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DOI：
10.1053/j.semdp.2012.08.010
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发表时间：
2012-08-01
影响因子：
2.3
通讯作者：
Roa, Juan Carlos
中科院分区：
文献类型：
--
作者：
Adsay, N. Volkan;Bagci, Pelin;Roa, Juan Carlos
壶腹胰胆道肿瘤越来越多；然而，由于缺乏熟悉度，他们的分期可能非常具有挑战性。在这篇综述文章中，在病理水平上对这些肿瘤的分期所遇到的各种问题进行了评估，并讨论了日常实践的可能解决方案以及未来分期方案的潜在改进。虽然n分期参数现已很好地确定（胰十二指肠切除术所需的淋巴结数量为12个），但t分期有几个问题：对于胰腺，发现导管内乳头状黏液性肿瘤（ipmn）和黏液性囊性肿瘤（MCNs）中出现的小癌症需要创建T1亚期（如T1a， b和c）；由于缺乏对“胰周软组织”和“累及总胆管”（指哪一部分）的正确定义，使得T3非常主观。随着主要血管（门静脉）可切除性的增加，这类病例需要重新定义“T”。对于壶腹，由于该区域的解剖复杂性和对该区域肿瘤三维扩散的认识不足等因素（特别是，肿瘤经常延伸到十二指肠周围软组织和十二指肠浆膜，这在目前的系统中没有得到解决，需要特定的综合方法来记录），目前的t分期缺乏可重复性和临床相关性，因此需要进行重大修订。最近提出的壶腹肿瘤的细化定义和部位特异性亚分类突出了有待改进的领域。对于肝外胆管，使用侵犯深度的分期方案可能更实用，以避免胆管组织学分层的不一致；需要更好地定义像“导管内扩散”这样的术语。对于胆囊，由于许多胆囊癌是“不明显的”（在临床和完全没有怀疑的胆囊切除术中发现），建立适当的检查方案和充分的抽样是至关重要的。自
Tumors of the ampulla-pancreatobiliary tract are encountered increasingly; however, their staging can be highly challenging due to lack of familiarity. In this review article, the various issues encountered in staging of these tumors at the pathologic level are evaluated and possible solutions for daily practice as well as potential improvements for future staging protocols are discussed. While N-stage parameters have now been well established (the number of lymph nodes required in pancreatoduodenectomies is 12), the T-staging has several issues: for the pancreas, the discovery of small cancers arising in intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs) necessitates the creation of substages of T1 (as T1a, b, and c); lack of proper definition of "peripancreatic soft tissue" and "common bile duct involvement" (as to which part is meant) makes T3 highly subjective. Increasing resectability of main vessels (portal vein) brings the need to redefine a "T" for such cases. For the ampulla, due to factors like anatomic complexity of the region and the under-appreciation of three-dimensional spread of the tumors in this area (in particular, the frequent extension into periduodenal soft tissues and duodenal serosa, which are not addressed in the current system and which require specific grossing approaches to document), the current T-staging lacks reproducibility and clinical relevance, and therefore, major revisions are needed. Recently proposed refined definition and site-specific subclassification of ampullary tumors highlight the areas for improvement. For the extrahepatic bile ducts, the staging schemes that use the depth of invasion may be more practical to circumvent the inconsistencies in the histologic layering of the ducts; better definition of terms like "periductal spread" is needed. For the gallbladder, since many gallbladder cancers are "unapparent" (found in clinically and grossly unsuspected cholecystectomies), establishing proper grossing protocols and adequate sampling are crucial. Since the