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...

<ol>
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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. ...

Standardized pathology assessment of distal pancreatectomy specimens, an explanatory video as performed in the DIPLOMA trial. Pancreatic ductal adenocarcinoma is associated with a poor prognosis. A minority of these tumors are found in the pancreatic body and tail.Accurate pathological assessment of pancreatic specimens is essential for the provision of prognostic information that may guide treatment strategies. The following protocol focuses on the assessment of left pancreatectomy specimens, including specimen orientation, inking, lymph node sampling, and block selection. A 79-year-old woman presented with an incidental finding of a 34-millimeter tumor within the body of the pancreas with adjacent lymphadenopathy suspicious for malignancy on CT scan.No distant metastases seen. A radical left pancreatectomy, splenectomy, and wedge resection of the stomach was performed. CT scan demonstrates the tumor within the pancreas.Following surgery, the specimen is fixed in formalin for 24 to 48 hours. Macroscopic assessment of left pancreatectomy specimens includes specimen orientation, measurement of pancreas, spleen, and upper organs, inking of margins and peritonealized surfaces, specimen dissection, and assessment of tumor location, size, appearance, and approximate distance to margins and tissue sampling. With regards to specimen orientation, formalin fixation may cause distortion, making it difficult to distinguish the anterior peritonealized surface from the retroperitoneal or posterior dissection margin.For these reasons, it is recommended that the operating surgeon places sutures to mark the posterior margin, as is done in this case. This is the anterior peritonealized surface and this is the stapled transection margin where the splenic vessel margins lie. This is the posterior dissection margin, which is marked with a suture.This is the superior border of the pancreas where the splenic artery and vein lie and this is the inferior border of the pancreas. This is an additional stapled gastric wall margin and this is the spleen. Specimen dimensions.The pancreas measures 95 millimeters from medial to lateral, 30 millimeters cranial to caudal, and 20 millimeters anterior to posterior. The spleen is 110 millimeters cranial to caudal, 60 millimeters anterior to posterior, and 20 millimeters medial to lateral. The wedge of stomach measures 35 by 10 by five millimeters.The specimen is inked in the following manner. The anterior peritonealized surface is inked yellow. The gastric wall margin is inked blue.The transection margin is inked red. The superior border of the pancreas is inked in green in order to identify station 11 lymph nodes. The inferior border is inked in orange in order to identify station 18 nodes and the posterior dissection margin is inked in black.Before dissecting the specimen, the transection margin and vascular resection margins are taken. The staple line of the transection margin must be removed as metal staples cannot be cut by the microtome blade. It is advised to cut closely to the staple line to preserve as much as possible the proximity to the true margin.Having removed the staple line, the transection margin can either be assessed with a single en face section or alternatively bread slices can be made perpendicular to the original staple line so as to measure exact distance of tumor to margin. The splenic artery and vein are in close proximity to the transection margin and are usually marked with clips. An en face section is taken at both artery and vein.Any additional resection margins can now be removed. In this case, we removed the staple line from the gastric wedge resection. Finally, specimen dissection can begin.The pancreas is sliced from medial to lateral at three to five-millimeter intervals towards the splenic hilum. It is strongly advised not to remove any of the posterior pancreatic fat. The slices are laid out from medial to lateral in 15 slices.And now for tumor assessment. Here we show that tumor is present in slices nine to 14. The cut surface of the tumor is pale and homogenous.Tumor measures 30 millimeters to the craniocaudal plane, 25 millimeters anterior to posterior, and 30 millimeters medial to lateral. The third measurement is based on slice thickness. Macroscopic assessment of tumor size can be challenging owing to the presence of fibrosis and chronic pancreatitis that can mimic tumor macroscopically.It is for this reason that a generous amount of tumor sampling, supported by a detailed block description with photographs of the specimen slices, can be used to achieve more accurate description of tumor size and extent, which can then be correlated microscopically. Within the specimen slices, one can see the splenic artery running along the superior border of the pancreas. The splenic vein, though harder to visualize in this image, runs along the posterior border of the pancreas, halfway through the slice.Though tumor is seen in close vicinity to the splenic vein, microscopically it was not involved. When sampling tumor, the specimen slices are geometrically divided to include surrounding peripancreatic fat and lymph nodes, demonstrating the relationship of tumor to adjacent structures and margins. Furthermore in this case, sections demonstrating the exact relationship between tumor and the gastric wall are taken.Pancreatic ductal adenocarcinomas have an infiltrative pattern of growth, where the interface between tumor and normal pancreas can be obscured by fibrosis and chronic pancreatitis. Therefore, the same rationale for thorough block taking applies for assessing margins. Spleen is now bread sliced in the craniocaudal direction at three to five-millimeter intervals.In instances where tumor is in close proximity to the spleen, it is recommended to keep the spleen intact with the specimen and take sections in continuity between tumor and spleen. Assuming there are no focal abnormalities, a representative section is taken of the spleen. Finally, we have block selections, which includes the transection margin, vascular resection margins, gastric wall margins, blocks of tumor demonstrating maximum size and distance to margins, background pancreas and a representative section of spleen, and lymph nodes.The microscopic findings were of a 30-millimeter, moderately differentiated ductal adenocarcinoma, with extension into the muscularis propria of the gastric wall. There was lymphovascular invasion without involvement of the splenic artery or splenic vein and perineural invasion. Three out of 17 lymph nodes were involved, one superior and two inferior.Staging was pT2, N1 according to TNM8, and all margins were clear by at least one millimeter. The advantages of the methodology described include the use of orientation sutures to mark the posterior dissection margin. This method of orientation is part of the standardized protocol for the DIPLOMA trial.Secondly, we strongly advised to avoid removing the posterior peripancreatic fat as this may compromise accurate margin assessment. In addition to inking the margins, using different colors to mark the superior and inferior border of the pancreas allows us to identify the station 11 and 18 lymph nodes.

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