Name: diploma approach for standardized pathology assessment of distal pancreatectomy specimens
Uploaded: 2020-02-01T13:00:00
Description: Watch this Scientific Journal Video about DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens at JoVE.com

We would like to thank Joana Ribeiro for filming of the specimen.

The protocol followed the ethical guidelines of Southampton University Hospital NHS Foundation Trust. Informed consent was obtained for the use of the tissue for teaching and research purposes.
NOTE: The relevant steps are summarized in Table 2 and the relevant materials in Table of Materials.
1. Specimen orientation
NOTE: In order to aid the histopathologist in accurate specimen orientation, ensure that th...

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Adequate histopathological assessment of a resected specimen is essential for the stratification of disease prognosis and guidance of further treatment strategies. Standardized protocols for the assessment of specimens resulting from distal pancreatectomy for PDAC are lacking. This potentially creates a considerable variability among the reported histopathological findings14. Differences in definitions and practice between centers limit the comparability of studies15. Furth...

Pancreatic ductal adenocarcinoma (PDAC) is associated with a very poor prognosis1. Surgery, in combination with (neo)adjuvant therapy remains the only curative treatment2. Following surgery, adequate histopathological assessment of the resected specimen is essential for prognostic stratification and in addition it may guide further treatment strategies3. Furthermore, the recent 8th edition of American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system for pancreatic tumors has incorporated significant changes to tumor (pT) stage, which is predominantly based on tumor size4,5. While maximum tumor size is assessed macroscopically, adequate specimen sampling is required in order to corroborate these findings, particularly as chronic pancreatitis can mimic tumor appearance with the naked eye.
As the majority of pancreatic ductal adenocarcinomas (up to 80%) are encountered in the head of the pancreas, most of the literature is based on the assessment of pancreatoduodenectomy specimens6,7. In the United Kingdom, the Royal College of Pathologists (RCPath) have published datasets that provide evidence-based guidelines on the specimen handling, dissection and reporting of pancreatic cancer, with focus placed on the more common pancreatoduodenectomy specimens8. Nonetheless, international consensus regarding specimen grossing is still lacking and practice is still highly divergent between centers6. The equivalent process of standardizing pathology assessment of specimen originating from a distal (i.e., left) pancreatectomy is now of growing clinical interest.
The Distal Pancreatectomy, Minimally Invasive or Open, for malignancy (DIPLOMA, ISRCTN44897265) trial is an international multicenter, randomized controlled trial comparing open versus minimally invasive surgical approach for the management of PDAC of the pancreatic body and tail. The DIPLOMA pathology protocol has been developed as a means of standardizing pathology assessment and reporting for this trial. The protocol describes the assessment of distal pancreatectomy specimens, including specimen orientation, inking, lymph node sampling, assessment of splenic vessel involvement (and other organs if present), and block selection.
The described method was developed during four meetings of the DIPLOMA study group (April 2015 Manchester, December 2016 Amsterdam, May 2017 Mainz, and April 2018 Amsterdam) with highly experienced 20&#8722;40 surgeons and pancreatic pathologists from 10 countries across Europe. Discussions included the relevance of the various margins, the transection plane and especially the dissection plane between the posterior part of the body and tail.
Patient characteristics
A 79-year-old woman presented with an incidental finding of a 34 mm tumor in the body of the pancreas, which was suspicious for malignancy. The CT scan showed no radiological evidence of tumor involvement of major vascular structures or the presence of (distant) metastases. Only adjacent small sized lymphadenopathy was noted. The patient was discussed in the multidisciplinary team meeting where it was decided that she was eligible for surgery. An open radical distal pancreatectomy, splenectomy and wedge resection of the stomach was performed within the DIPLOMA trial.
Macroscopic assessment of distal pancreatectomy specimens and nomenclature of margins
The relevant margins that should be assessed in a distal pancreatectomy specimen include the transection margin, splenic artery and vein margins, posterior dissection margin, and additional margins in the case of multivisceral resections as shown in Table 1.
The transection margin is the surface where the pancreatic body was separated from the neck. Mainly in laparoscopic, but also in increasing numbers of open, surgical specimens, this margin is a linear staple line. The splenic artery and vein margins are in close proximity to the stapled transection margin and are marked with vascular clips or small staples. The posterior margin is the dissection plane between the posterior part of the body and tail of the pancreas and the frontal plane of the renal fascia, within the retroperitoneum. Between the anterior and posterior renal fascia is the perirenal space, within which lie the kidney and adrenal gland in a loose fibrofatty connective tissue compartment. The posterior dissection margin varies depending on the exact surgical procedure performed. This may include the anterior renal fascia, with or without the adrenal gland and posterior renal fascia9,10. While the anterior, peritonealized surface is not considered a surgical margin, tumor breaching of this surface is associated with an increased risk of local recurrence3.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Formalin</td>
			<td>Genta</td>
			<td>BFNC50</td>
			<td></td>
		</tr>
		<tr>
			<td>Gloves</td>
			<td>Healthline</td>
			<td>FTG182, FTG183, FTG184 (depending on size)</td>
			<td></td>
		</tr>
		<tr>
			<td>Blade Handles</td>
			<td>Swann Morton</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Blades</td>
			<td>Swann Morton</td>
			<td>FSF440</td>
			<td></td>
		</tr>
		<tr>
			<td>Scales</td>
			<td>Ohaus</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Long Knives</td>
			<td>Cellpath</td>
			<td>KMY811</td>
			<td></td>
		</tr>
		<tr>
			<td>Ruler</td>
			<td>Solmedia</td>
			<td>RUL003</td>
			<td></td>
		</tr>
		<tr>
			<td>Scissors</td>
			<td>Weiss</td>
			<td>FGP8939</td>
			<td></td>
		</tr>
	</tbody>
</table>

diploma approach for standardized pathology assessment of distal pancreatectomy specimens

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. Accurate pathology assessment of the pancreatic specimen is essential for providing prognostic information and it may guide further treatment strategies. The recent 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system for pancreatic tumors has incorporated significant changes to tumor (pT) stage, which is predominantly based on tumor size. This change emphasizes the importance of careful block selection. Owing to the greater prevalence of tumors in the head of the pancreas, efforts are made to standardize the assessment of pancreatoduodenectomy specimens. However, consensus regarding the macroscopic assessment of distal (i.e., left) pancreatectomy specimens is lacking. The DIPLOMA approach includes the standardized measurement of pancreas and other resected organs, inking of relevant surgical margins and anatomical surfaces without removing covering layers of fat, measurement of tumor size (for T-stage), together with assessment of splenic vessel involvement (and other organs if present). All relevant margins are assessed, and relevant blocks are selected to confirm these parameters microscopically. The current protocol describes a standardized approach to the macroscopic assessment of distal pancreatectomy specimens. This approach was developed during several meetings with pathologists and surgeons during the preparation phase for an international multicenter trial (DIPLOMA, ISRCTN44897265), which focuses on radicality of distal pancreatectomy for pancreatic ductal adenocarcinoma. This standardized approach can be instrumental in the design of studies and will uniform reporting on the outcomes of distal pancreatectomy. The described technique is used in the DIPLOMA trial for pancreatic ductal adenocarcinoma but may also be useful for other indications.

Microscopic assessment showed a 28 x 25 x 30 mm, moderately differentiated, pancreatic ductal adenocarcinoma as shown in Table 3. There was perineural and lymphovascular invasion without splenic artery or vein involvement. In total, 17 lymph nodes were found, of which 3 were involved (1 superior border, 2 inferior border). Distant lymph nodes (station 8 and hepatic artery) showed no evidence of metastatic malignancy. All resection margins were clear of tumor: transection ...

Watch this Scientific Journal Video about DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens at JoVE.com

DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens

The current study highlights a standardized approach to the macroscopic assessment of distal pancreatectomy specimens for pancreatic ductal adenocarcinoma, with special emphasis on the measurement of pancreatic dimensions and those of other organs, inking of margins, measurement of tumor size and proximity to margins, lymph node sampling and block selection.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. ...

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