To achieve this goal, the SMA was approached caudal to the region of the uncinate process, where a distinct fascia separates the uncinate from the mesocolon. Then, the SMA was isolated laterally right up to the vessel, and all tissues between the artery and the pancreatic parenchyma were resected. Attention was paid not to dissect it entirely from the surrounding mesenteric plexus to avoid postoperative diarrhea see Fig.
Subsequently, the peripancreatic tissue was dissected up to the portal vein. Lymph node dissection was performed up to the hepatoduodenal ligament laterally to the portal vein. Where there was evidence of tumor infiltration, the SMV was partially resected and reconstructed either by end-to-end anastomosis or insertion of a venous graft. Finally, the posterior surface of the pancreatic head specimen was assessed macroscopically for its integrity. Intraoperative view before left and after resection of the mesopancreas right. Small arrows point to the superior mesenteric artery; large arrow indicates the resection line; dashed line indicates dissection plane left ; SMV —superior mesenteric vein; SMA —superior mesenteric artery; PV —portal vein.
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For 89 of these patients In April , we introduced the modified and standardized histopathological workup and applied it prospectively until July During this month period, consecutively resected pancreatic head specimens were processed according to this protocol. Only five patients underwent a Kausch—Whipple procedure: three patients as a consequence of advanced disease, one owing to inflammatory changes of the tissue, and one owing to the intraoperative detection of a synchronous gastric neoplasia. The remaining 95 patients were treated with PPPD. For 17 patients, the operation included partial or complete resection of the SMV.
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The vena cava was partially removed once. A year-old patient who underwent head resection for ductal adenocarcinoma developed endocarditis with consecutive mitral valve regurgitation. He required replacement of the mitral valve but died postoperatively as a result of the cardiac procedure. The remaining 99 patients were discharged from hospital. Seven R1 resections revealed tumor infiltration in two stained areas.
Interestingly, the mesopancreas was the only site of infiltration in 17 of these R1 specimens In another five cases, infiltration of the mesopancreas with additional involvement of the SMV or the pancreatic transection margin was discovered. SMV margins were infiltrated in seven of the 17 specimens including partial or complete SMV resection.
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Applying the definitions of the RCP, an additional set of 13 specimens would have to be considered as R1 resections, resulting in a total percentage of Looking at each histopathological type, it became obvious that the number of R1 resections is much lower for DBD Although the total number of R1 resected specimens is too small to draw definitive conclusions, it is noteworthy that the mesopancreas is infiltrated in two of the two R1 resected PAC.
Cancer of the pancreatic head is one of the most malignant gastrointestinal tumors.
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Surgery is still considered to be the only potentially curative approach if complete resection is possible [ 6 , 20 , 23 ]. However, surgical resection in patients with localized pancreatic cancer is still underused [ 14 ]. With respect to the classification of the pancreatic head resections evaluated retrospectively, the percentage of R1 resections These data appear to indicate the possible misclassification of R1 resections as R0.
Local recurrence and disseminated cancer spread dramatically impair the prognosis of patients with pancreatic head cancer. Luettges et al. They pointed out that the retroperitoneal RM has an influence on patient survival. However, it was in when Verbeke et al. For the 54 pancreatic head resections, a color code was implemented to distinguish between the anterior, posterior, and SMV groove surface. Similar results were published by Esposito et al. As part of their protocol, they color-coded the anterior, posterior, medial margin, and groove surface of the SMV, respectively, whereas the retroperitoneal RM was not investigated separately.
The importance of the retroperitoneal resection margin was confirmed by Westgaard et al. However, it should be pointed out that all three studies classified the specimens according to the definition of The Royal College of Pathologists. Since there do not exist any general guidelines about the definition of R1 resection, we primarily applied the UICC criteria, i.
We found an R1 resection rate of Therefore, we could confirm that the number of noncurative resections is considerably higher when a modified and intensified histopathological workup is applied. Interestingly, Westgaard et al. The anterior or posterior surfaces of the pancreas were not part of the workup. We identified the mesopancreas as the primary site of positive RMs.
In total, As pointed out by other authors [ 8 , 25 ] the retroperitoneal RM is of great interest with regard to curative resection. Interestingly, there is no exact definition of the retroperitoneal RM. Some consider the complete posterior surface of the pancreas as retroperitoneal margin, while others use the term to describe just the area of sharp dissection, similar to what we call mesopancreatic RM.
Esposito et al. This diversity of definitions impairs a meaningful comparison of RMs. It was chosen because of its anatomical origin and therapeutic implication. The tissue between the pancreatic parenchyma and the SMA consists of fatty tissue and contains blood and lymphatic vessels, as well as lymph nodes draining the pancreatic head and the uncinate.
Additionally, nerve fibers are located in the mesopancreas innervating the pancreatic parenchyma. The mesopancreas rises from the embryological mesentery attaching the pancreatic bud to the abdominal wall. This leads to the consequence that the mesopancreas must be resected and removed completely in its integrity down to the mesenteric artery. Based on the embryological development and according to our experience, the pancreatic tissue is not directly adjacent to the mesenteric artery but connected by a delicate meshwork of connective tissue rich in nerve fibers mesenteric plexus.
This layer should be separated close to the mesopancreas to prevent the complications of postoperative diarrhea. As Verbeke and colleagues demonstrated [ 22 ], intensive embedding of resected tissue increases the rate of R1 resections. However, infiltration of the mesopancreas may have been misinterpreted in the past as a consequence of a cancer-induced fibrosis or disseminated cancer cells. Therefore, RMs in their integrity and numerous samples from the tumor with relation to the surfaces of the pancreas were embedded as part of this modified and standardized protocol.
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It is widely accepted that only an R0 resection is considered as a curative approach and stratification for resection status is routinely performed in clinical trials such as in the CONKO trial. However, one can speculate that in these trials the low R1 resection rates are due to a conventional pathohistological workup. Considering the mesopancreas as a structure guiding relevant vessels for lymphatic and blood drainage of the pancreatic head and the uncinate, it may be hypothesized that tumor cells drain into the lymphatic and blood vessels during manipulation of the pancreatic head e.
As in the treatment of colorectal cancer, a no-touch technique would diminish this potential influence, resulting in the need to resect the mesopancreas along the superior mesenteric artery first. Based on our data, we propose a standardized histopathological workup for pancreatic head cancer specimens, which may represent a more accurate assessment of curative and noncurative resection rates. As a consequence of this modified protocol, we demonstrate that the mesopancreas is a frequent site for positive resection margins, which has potential therapeutic implications and should be considered in clinical trials when stratifying patients into R0 and R1 resection classifications.
Owing to morphological changes during formalin fixation, it is of upmost importance to color the mesopancreatic RM directly after surgical resection. We strongly believe that the complete and meticulous surgical resection of the mesopancreas as the structure to the right of the mesenteric artery must become the standard surgical approach in pancreatic head resection. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author s and source are credited.
Langenbecks Arch Surg. Published online May 6. PMID: Gaedcke , 1 B. Gunawan , 2 M. Grade , 1 R. Liersch , 1 H. Becker , 1 and B. Ghadimi 1. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received Mar 18; Accepted Apr 7. This article has been cited by other articles in PMC. Abstract Purpose The prognosis of patients with pancreatic cancer remains poor, even after potentially curative R0 resection.
Materials and methods To test this hypothesis, color coding of all resection margins and organ surfaces as part of a standardized histopathological workup was implemented and prospectively tested on pancreatic head specimens. Results Thirty-five patients were excluded from the analysis owing to the pathohistological diagnosis; only pancreatic ductal adenocarcinoma, distal bile duct adenocarcinoma, and periampullary adenocarcinoma were included.
Conclusion Using the intensified histopathological workup for pancreatic head cancer specimens resulted in an increased rate of R1 resections and the mesopancreas represents the primary site for positive resection margins. Keywords: Pancreatic cancer, Mesopancreas, Histopathological workup, R1 resection. Introduction Due to its dismal prognosis, pancreatic cancer is the fourth most common cause of cancer death in Europe and the USA. Materials and methods Retrospective data analysis In order to test the hypothesis that an optimized and standardized histopathological workup increases the rate of R1 resections after pancreatic head resections, we first compared the rates of curative resections after conventional histopathological workup in our department.
Open in a separate window. Nonmalignant or borderline No. Malignant 7 Chronic pancreatitis 5 Neuroendocrine tumor 4 Autoimmune pancreatitis 4 Metastases to the pancreatic head 2 Periampullary adenoma 1 Duodenal adenocarcinoma 2 Periampullary adenomyoma 1 Acinar cell carcinoma 2 Serous cystadenoma 1 Non-Hodgkin lymphoma 2 Intraductal papillary mucinous neoplasia IPMN 1 Mucinous cystadenoma 1 Duodenitis 1 Simple pancreatic cyst 1 Duodenal diverticulum 23 Total 12 Total.
Discussion Cancer of the pancreatic head is one of the most malignant gastrointestinal tumors. Acknowledgment The authors thank J. Eggert and L. Schroeter for technical support.
Now featuring beautiful, useful full-color medical artwork, this book is designed as an aid for the practical application of the TNM classification system by illustrating the T and N categories in clear, easily understood graphics. The aim of this presentation is twofold: to reach a more standardized understanding and documentation of the anatomic spread of tumours, and to further enhance the dissem. The 5th edition of the TNM Atlas reflects all changes and additions of the recently published 6th edition of the TNM Classification: - numerous new figures to illustrate changes and new definitions of categories of head and neck tumours, - some digestive system tumours, - pleural mesothelioma, - malignant melanoma of skin, - breast tumours, - urological tumours, - ophthalmic tumours.
Pre-analytics of pathological specimens in oncology by Manfred Dietel 10 editions published in in English and Undetermined and held by WorldCat member libraries worldwide This book presents an overview of the most important current developments in the pre-analytical handling of tissue.
It addresses in particular potential ways to improve the situation whereby methods employed in the pre-analytical phase?
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