Whipple Made Simple For Surgical Pathologists Orientation, Dissection, and Sampling of Pancreaticoduodenectomy Specimens For a More Practical and Accurate Evaluation of Pancreatic, Distal Common Bile Duct, and Ampullary Tumors
Whipple Made Simple For Surgical Pathologists Orientation, Dissection, and Sampling of Pancreaticoduodenectomy Specimens For a More Practical and Accurate Evaluation of Pancreatic, Distal Common Bile Duct, and Ampullary Tumors
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DOI：
10.1097/pas.0000000000000165
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发表时间：
2014-04-01
影响因子：
5.6
通讯作者：
Weaver, Donald W.
中科院分区：
文献类型：
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作者：
Adsay, N. Volkan;Basturk, Olca;Weaver, Donald W.
胰腺癌切除术（PD）标本的外科病理学家提出了一个挑战，因为这些标本的相对罕见，结合解剖结构的复杂性。在这里，我们描述了我们的经验，定位，解剖和采样的PD标本更实际和准确的评价胰腺，远端胆总管（CBD）和壶腹肿瘤。对于PD的方向，识别由中心血管床、左侧胰腺颈边缘和右侧钩突边缘形成的“梯形”对于找到所有相关边缘（包括标本）至关重要。位于该梯形右上边缘的CBD。定向后，可以对所有边缘进行采样。我们将钩突缘完全作为一个垂直的墨迹边缘，因为这个脂肪组织丰富的区域经常显示肉眼不可见的细微卫星癌，并且，在我们的经验中，使用这种方法，R1切除的数量增加了一倍。然后，为了确保正确识别所有淋巴结（LN），我们使用了橙色剥离方法，其中在7个任意定义的区域中剃掉胰头周围的软组织，这些区域也用作所谓的“胰腺周围软组织”的剃光样本，该组织在当前的美国癌症联合委员会TNM中定义了pT3。通过这种方法，我们的LN计数从6增加到14，LN阳性率从50%增加到73%。此外，在90%的胰腺导管腺癌中，存在肉眼未检测到的癌微灶。为了确定肿瘤的原发部位和范围，我们认为胰头二分切片，而不是轴向（横向）切片，是最具揭示性的方法。此外，壶腹十二指肠表面的发现文件是至关重要的壶腹癌和他们最近的网站具体分为4类。因此，我们从壶腹远端探测CBD和胰管，并在穿过两个导管的平面上切割胰头到壶腹。然后，我们根据病例的发现对被一分为二的胰头进行取样。例如，为了对壶腹癌进行正确的分期，必须在“沟”区取垂直于十二指肠浆膜的切片，因为壶腹癌经常延伸到这个区域。壶腹的切断（轴向）切片虽然有利于壶腹内肿瘤的Oddi周围扩散的记录，但不幸的是不能记录Vater乳头瘤（从壶腹边缘产生的肿瘤，导管过渡到十二指肠粘膜并延伸）进入相邻的十二指肠。轴向切片也常常不能证明肿瘤扩散到“凹槽”区域。总之，了解解剖标志的大体特征对于正确解剖PD标本至关重要。上述方法允许胰腺、远端CBD和壶腹癌的实用和准确的记录和分期。
Pancreaticoduodenectomy (PD) specimens present a challenge for surgical pathologists because of the relative rarity of these specimens, combined with the anatomic complexity. Here, we describe our experience on the orientation, dissection, and sampling of PD specimens for a more practical and accurate evaluation of pancreatic, distal common bile duct (CBD), and ampullary tumors. For orientation of PDs, identification of the "trapezoid," created by the vascular bed at the center, the pancreatic neck margin on the left, and the uncinate margin on the right, is of outmost importance in finding all the pertinent margins of the specimen including the CBD, which is located at the upper right edge of this trapezoid. After orientation, all the margins can be sampled. We submit the uncinate margin entirely as a perpendicular inked margin because this adipose tissue-rich area often reveals subtle satellite carcinomas that are grossly invisible, and, with this approach, the number of R1 resections has doubled in our experience. Then, to ensure proper identification of all lymph nodes (LNs), we utilize the orange-peeling approach, in which the soft tissue surrounding the pancreatic head is shaved off in 7 arbitrarily defined regions, which also serve as shaved samples of the so-called "peripancreatic soft tissue" that defines pT3 in the current American Joint Committee on Cancer TNM. With this approach, our LN count increased from 6 to 14 and LN positivity rate from 50% to 73%. In addition, in 90% of pancreatic ductal adenocarcinomas there are grossly undetected microfoci of carcinoma. For determination of the primary site and the extent of the tumor, we believe bisectioning of the pancreatic head, instead of axial (transverse) slicing, is the most revealing approach. In addition, documentation of the findings in the duodenal surface of the ampulla is crucial for ampullary carcinomas and their recent site-specific categorization into 4 categories. Therefore, we probe both the CBD and the pancreatic duct from distal to the ampulla and cut the pancreatic head to the ampulla at a plane that goes through both ducts. Then, we sample the bisected pancreatic head depending on the findings of the case. For example, for proper staging of ampullary carcinomas, it is imperative to take the sections perpendicular to the duodenal serosa at the "groove" area, as ampullary carcinomas often extend to this region. Amputative (axial) sectioning of the ampulla, although good for documentation of the peri-Oddi spread of the intra-ampullary tumors, unfortunately disallows documentation of mucosal spread of the papilla of Vater tumors (those arising from the edge of the ampulla, where the ducts transition to duodenal mucosa and extending) into the neighboring duodenum. Axial sectioning also often fails to document tumor spread to the "groove" area. In conclusion, knowledge of the gross characteristics of the anatomic hallmarks is essential for proper dissection of PD specimens. The approach described above allows practical and accurate documentation and staging of pancreas, distal CBD, and ampullary cancers.