AJCP / REPORTING RECOMMENDATIONS FOR PANCREATIC SPECIMENS CONTAINING MALIGNANT TUMORS Recommendations for the Reporting of Pancreatic Specimens Containing Malignant Tumors Jorge AlboresSaavedra, David Klimstra, MD,4 MD,1 Clara Heffess, MD,2 and Daniel Longnecker, Ralph H. Hruban, MD,3 MD5 Key Words: Pancreas; Malignant tumors; Reporting Abstract The Association of Directors of Anatomic and Surgical Pathology has developed recommendations for the surgical pathology report for common malignant tumors. The recommendations for malignant tumors of the pancreas are reported herein. The Association of Directors of Anatomic and Surgical Pathology has named several committees to develop recommendations about the content of the surgical pathology report for common malignant tumors. A committee of persons with special interest and expertise write the recommendations, and they are reviewed and approved by the council of the Association of Directors of Anatomic and Surgical Pathology and subsequently by the entire membership. The recommendations have been divided into 4 major areas: (1) items that provide an informative gross description, (2) additional diagnostic features that are recommended for inclusion in every report if possible, (3) optional features that may be included in the final report, and (4) a checklist. The purpose of these recommendations is to provide an informative report for the clinician. The recommendations are intended as suggestions, and adherence to them is completely voluntary. In special clinical circumstances, the recommendations may not be applicable. The recommendations are intended as an educational resource rather than a mandate. Surgical pathology reports for biopsied or resected malignant tumors of the pancreas should incorporate the following information: A. General 1. How the specimen was identified: labeled with information such as name and medical record number. 2. How the specimen was received, eg, fresh, in fixative. 3. The exact anatomic site of the tumor. 4. The type of surgical procedure: biopsy, local excision, standard pancreaticoduodenectomy (Whipple procedure), pylorus-preserving pancreaticoduode-nectomy, total 304 Am J Clin Pathol 1999; 111:304-307
AJCP / SPECIAL ARTICLE pancreatectomy, distal pancreatectomy stating specifically which organs have been removed. B. Gross Description 1. Describe and measure (3 dimensions) the entire surgical specimen, eg, biopsy, local excision, standard pancreaticoduodenectomy (Whipple procedure), pyloruspreserving pancreaticoduodenectomy, total pancreatectomy, distal pancreatectomy. Describe and measure each component of the specimen. 2. Describe the gross features of the tumor: color, consistency, size, location within the pancreas (head, body, tail, or diffusely throughout the gland); encapsulated or nonencapsulated; relationship to the pancreatic and bile ducts; multicentricity; abnormalities of the pancreatic ducts including stricture, ductal dilatation; grossly visible mucin; unilocular or multilocular neoplastic cysts; cyst contents; nonneoplastic cysts in pancreatic tissue adjacent to tumor; secondary cyst formation due to tumor necrosis. 3. For Whipple distal or total pancreatectomy specimens, describe all applicable items, eg, status of the main pancreatic duct, accessory ducts, common bile duct, cystic duct, ampulla of Vater, duodenum, stomach, spleen, portal, superior mesenteric and splenic veins, common hepatic artery. Describe direct extension to duodenum, stomach, spleen, or colon. Report involvement of vessels; portal, superior mesenteric, and splenic veins; common hepatic artery; any other large vessel adjacent to tumor. Identify and describe surgical margins for adequacy of excision. Comment if the tumor is grossly identifiable at the margins. Describe the location, number, and consistency of lymph nodes. 4- Paraffin block key. 5. When ink is used, give code. C. Diagnostic Information 1. The type of malignancy should be recorded. The following classification of pancreatic malignant tumors is recommended.1-7 a. Type of neoplasm I Carcinoma in situ I Infiltrating ductal carcinoma I Adenosquamous carcinoma I Mucinous noncystic carcinoma I Signet-ring cell carcinoma I Undifferentiated carcinoma I Spindle and giant cell type I With osteoclast-like giant cells I Small cell carcinoma I Mucinous cystadenocarcinoma I Mucinous cystic neoplasm of low malignant potential (borderline) I Mucinous cystic neoplasm with sarcomatous transformation of the stroma I Intraductal mucinous papillary carcinoma with an invasive component I Intraductal mucinous papillary carcinoma without an invasive component I Serous cystadenocarcinoma I Solid pseudopapillary and cystic carcinoma (malignant solid papillary and cystic tumor) I Acinar cell carcinoma I Acinar cell cystadenocarcinoma I Endocrine neoplasm (eg, insulin, glucagon, somatostatin, gastrin, pancreatic polypeptide and vasoactive-intestinal peptide secreting, multihormonal) I Mixed acinar and endocrine carcinoma I Mixed ductal and endocrine carcinoma I Pancreatoblastoma b. Mesenchymal tumors I Leiomyosarcoma I Osteosarcoma c. Lymphoma d. Others 2. Tumor grade. The following grading system is suggested for infiltrating ductal carcinomas: grade 1 (well differentiated), more than 95% of the tumor is composed of glands; grade 2 (moderately differentiated), 50% to 95% of the tumor is composed of glands; grade 3 (poorly differentiated), 5% to 49% of the tumor is composed of glands; and grade 4 (undifferentiated), less than 5% of the tumor is composed of glands. For papillary intraductal carcinomas, grading is optional. The grading system designed by Albores-Saavedra, et al6 is recommended. It is based on nuclear atypia and mitotic figures. High-grade tumors are characterized by cells with vesicular or hyperchromatic nuclei and prominent nucleoli. Mitotic figures are common (more than 5 per 10 high-power fields). Low-grade neoplasms are composed of cuboidal or columnar pseudostratified cells with ovoid or elongated vesicular or hyperchromatic nuclei but without nucleoli and without mitotic activity. Tumors with moderate nuclear atypia and very few mitotic figures (<5 per 10 high-power fields) are included in the intermediate category. Because of the poor correlation of cytologic features, pattern of growth, and biologic behavior in most endocrine tumors, they are not graded. Am J Clin Pathol 1999; 111:304-307 305
Albores-Saavedra et al / REPORTING RECOMMENDATIONS FOR PANCREATIC SPECIMENS CONTAINING MALIGNANT TUMORS Table II Pancreatic Tumors Checklist Specimen Type Biopsy Local excision Distal pancreatectomy Standard pancreaticoduodenectomy Pylorus-preserving pancreaticoduodenectomy Total pancreatectomy Diagnosis Section: Pathology report should address all applicable items Tumor type Grade No stromal invasion Invasion confined to the pancreas (include size) Invasion of: (check all applicable) Peripancreatic soft tissues Cystic duct Adjacent large vessels Portal vein Mesenteric Common hepatic artery Invasion of any or all of the following (check all applicable) Ampulla of Vater Colon Spleen Invasion of: Small vessels Large vessels Perineural invasion Other pancreatic epithelial abnormalities, such as atypical ductal hyperplasia and papillary hyperplasia, should be recorded. Pathology in Other Organs Cystic duct Ampulla of Vater Spleen Involvement of Surgical Margins Pancreas neck Pancreas uncinate Posterior (retroperitoneal) pancreas Other soft tissue margins Lymph Nodes Number of lymph nodes sampled and number of lymph nodes with metastasis 8 Extent of tumor a. Tumor size b. No stromal invasion present c. Invasion confined to the pancreas (include size) d. Direct extension into ampulla e. Invasion of peripancreatic soft tissues, common bile duct, cystic duct, duodenum, or invasion of 306 Am J Clin Pathol 1999;111:304-307 4-5. 6. 7. 8. adjacent large vessels (eg, portal vein, mesenteric, or common hepatic artery) f. Invasion of spleen, colon, stomach g. Presence or absence of lymphatic or microvascular invasion h. Perineural invasion Intraductal lesions. Report papillary hyperplasia, ductal hyperplasia, or carcinoma in situ adjacent to tumor. Report dysplasia or carcinoma in situ in common bile duct or ampulla of Vater. Other lesions a. Acute or chronic pancreatitis b. Pancreatic cysts c. Calculi d. Other Surgical margins. Report involved or uninvolved surgical resection margins of the pancreas (eg, neck, uncinate, posterior), bile duct, duodenum, stomach, and soft tissues, including retroperitoneal margin. Lymph nodes. Report presence or absence of metastases in regional lymph nodes. State the number of lymph nodes sampled and the number of lymph nodes involved. Report separately submitted lymph nodes. Report results of immunoperoxidase stains and electron microscopy in endocrine and acinar neoplasms and in combined exocrine and endocrine tumors. D. Optional Features Features considered optional in the final report include: a. Ploidy b. Nuclear morphometry c. Genetic abnormalities d. Growth factors e. Receptors f. Stage ITable II shows a checklist for the reporting of pancreatic malignant neoplasms. From the 'University of Texas, Southwestern Medical Center, Dallas, TX; 2Armed Forces Institute of Pathology, Washington, DC; 3Johns Hopkins University Hospital, Baltimore, MD; 4 Memorial Sloan-Kettering Cancer Center, New York, NY; ^Dartmouth University Medical Center, Lebanon, NH. Address reprint requests to Dr V. A. LiVolsi: Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, 3400 Spruce St, 6 Founders Pavilion, Philadelphia, PA 19104.
AJCP / SPECIAL ARTICLE References 1. Solcia E, Capella C, Kloppel G. Tumors of the Pancreas. Atlas of Tumor Pathobgy. Fascicle 20. 3rd ed. Washington, DC: Armed Forces Institute of Pathology; 1997. 2. Longnecker DS, Turhune PG. The case of parallel classification of biliary tract and pancreatic neoplasms. Mod Pathol. 1996;9:828-837. 3. Albores-Saavedra J, Gould EW, Angeles-Angeles A, et al. Cystic tumors of the pancreas. Pathol Annu. 1990;25(pt 2):19-50. 4. Sessa F, Solcia E, Capella C, et al. Intraductal papillarymucinous tumours represent a distinct group of pancreatic neoplasms: an investigation of tumour cell differentiation and K-ras, p53 and c-erb-b-2 abnormalities in 26 patients. Virchows Arch. 1994;425:357-367. 5. Wenig BM, Albores-Saavedra], Buetow PC, et al. Pancreatic mucinous cystic neoplasm with sarcomatous stroma. Am ] SurgPathol. 1997;21:70-80. 6. Albores-Saavedra J, Henson DE, Milchgrub S. Intraductal papillary carcinoma of the main pancreatic duct. Int J Pancreatol. 1994;16:223-224- 7. Klimstra DS, Wenig BM, Adair CF, et al. Pancreatoblastoma: a clinicopathologic study and review of the literature. Am] SurgPathol. 1995;19:1371-1389. 8. Hruban RH, Westra WA, Phelps TH, et al. Surgical Pathology Dissection: An Illustrated Guide. New York, NY: Springer 1996:72-76. Am J Clin Pathol 1999; 111:304-307 307
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