Surgical pathology of whipple pancreaticoduodenectomy: A 3-year experience at a tertiary cancer care center of marathwada region of India

Abstract

The aim was to study and analyze in detail various parameters of Whipple resection specimen. Whipple procedure is a radical surgery performed for operable tumors of ampullary-periampullary region, head of pancreas, common bile duct and duodenum. Pathologic assessment of Whipple’s resection specimen needs special attention because of peculiar complex anatomy of head of pancreas and related structures, and also because of difference of opinion about grossing protocols of dissection of the specimen and confusion about terms like ‘margins’ and ‘surfaces’A histopathologist has to be aware of these intricacies so as to diagnose and accurately evaluate factors of prognostic importance.This is the first major mono-center surgical pathology study of Whipple resections reported from Department of Oncopathology, Government Cancer Hospital, Aurangabad, a newly started state level cancer hospital serving patients from Marathwada region of Maharashtra, India. This is surgical pathology study of total 31(thirty one) cases of Whipple resections performed during 2017-19. All relevant histopathologic details pertaining to grossing, microscopic diagnosis, grading and staging, and histopathologic prognostic factors were comprehensively studied. Dissection and grossing was done as per the protocols followed at Tata Memorial Hospital MumbaiOut of total 31 Whipple resections performed at this hospital, 01(one) was classical Whipple’s PD, seventeen (17) were pylorus preserving pancreaticoduodenectomy(PPPD) andthirteen (13) were of extended pancreaticoduodenectomy resections.The patients had age ranging from 38 to 76 years. There were 20 male patients and 11 female patients (M:F-2:1). As far as site of lesion is concerned 16(52%) cases had periampullary lesion. 06(19%)hadlesion in head of pancreas,07(22%) tumors were of common bile duct and there were 02(7%) cases of duodenal carcinoma. Histopathology revealed 29(94%) cases of malignant neoplasm and 02(6%) of benign lesion which included one(01) case of Brunner's gland hyperplasia withpancreatitis in adjacent pancreas, and the remaining 01 was of necrotizing pancreatitis( acute on chronic inflammation) with pseudocyst formation involving head of pancreas.Pathological stage of most of the tumors (55%) was T3, followed by T1(25%) and T2(20%)Amongst total 29 cases of malignant neoplasm, 08(28%) had well differentiated adenocarcinoma. 17 cases (58%) were of moderately differentiated adenocarcinoma and 02(7%) each were of mucinous carcinoma and neuroendocrine carcinoma. Microscopic involvement of margin/surface (CRM) was noted in 05 (17%)cases. In three(03) cases SMA surface and in 02 posterior surface were involved.PNI was noted in 12(41%) cases and LVI in 05(17%)cases. Peripancreatic lymph node metastasis was seen in 05(17%) cases. Specimens of regional lymphnodes were received separately & were negative for deposits in all the cases. Retroperitoneal lymph nodes received along with specimen of Extended Whipple’s were negative for metastasis in all the cases.From this study we conclude that important prognostic factors were location, extension, pathologic stage, histologic grade, status of margins / surfaces, LVI, PNI, and lymph node status. Therefore pathologic assessment of surgical specimen of pancreaticoduodenectomy (Whipple resection) needs special attention to evaluate these factors. To fulfill this purpose there is need of evolving standardized grossing protocols as well as uniform terminology related to terms ‘margin’ & ‘surface’.