Clinicopathological Analysis of Whipple’s Pancreaticoduodenectomy Specimens in a Tertiary Care Hospital with Special Emphasis on Grossing

Abstract

Introduction: Pancreaticoduodenectomy (PD) is done for a myriad of tumours as well as inflammatory condition affecting the duodenum, common bile duct, ampulla of vater and the head of pancreas. The diagnostic accuracy of the histopathology report is largely determined by the preliminary meticulous gross examination of the specimen. Aim: To comprehensively analyse the clinicopathological parameters of Whipple’s specimen and thus evaluate the trends in indication of Whipple’s procedure in Southern India.Materials and Methods: This was an observational time bound descriptive study done in the Department of Pathology, Father Muller Medical College Hospital, Mangalore, Karnataka from May 2014 to April 2019 wherein histopathological and clinical data of all the patients who underwent Whipple’s procedure were retrieved and analysed. The gross specimens were retrieved from the museum and records were assessed for the type of grossing method employed. The H&E slides were reassessed for the tumour type, grade, margins, perineural and angioinvasion, lymph node status and staging. Immunohistochemical marker (CD 117) and cytochemical like Mucicarmine and Alcian blue were employed wherever required. Descriptive analysis of the data involved calculating percentage, mean, median and range. The p-value was calculated using Fischer-Exact test with statistical significance level at <0.05.results: Total of 45 patients underwent Whipple’s procedure, of which 28 (62.2%) were males and 17 (37.8%) were females with a ratio of 1.6:1. The most common symptom was jaundice (33cases-73.3%) followed by pain abdomen (7 cases-15.6%). The mean age was 56.2 years. The mean tumour size was 2.8cm. Malignancy was seen in (43 cases- 95.6%). The others being, inflammatory lesions (2 cases-2.2%). The most common site of localisation of tumours was periampullary (16 cases-37.2%) followed by pancreatic head (15 cases-34.9%).The most common histological subtype was adenocarcinoma (40cases-93%). There were two cases of grade 2 neuroendocrine tumours (2 cases-4.7%) and one case (2.3%) of malignant Gastrointestinal Stromal Tumour (GIST). Lymph node positivity was most commonly seen in pancreatic cancers (7 cases-46.7%) with a significant p-value of 0.001. Lymphovascular invasion were seen in 16 cases (37.2%) and perineural invasion in 23 cases (53.5%). The most common tumour stage was T2 (16 cases-37.2%) followed by T3 (12 cases-27.9%). Margins were free in most of the malignant tumours (37 cases-86.04%).conclusion: Thorough gross inspection of the Whipple’s specimen along with sound knowledge of the anatomy of the region is of utmost importance. The present analysis showed that periampullary adenocarcinoma was the most common subtype, many of the cases being diagnosed at an advanced stage, emphasising on early diagnosis through clinicoradiological modalities and guided biopsies. A meticulous and careful evaluation of the Whipple’s specimen is a pre-requisite for accurate histopathological differentiation of tumours originating in this anatomical region. Subtyping the tumor,reporting margin clearance, lymphovascular and perineural invasion, also has prognostic implications. Whipple’s PD may rarely be done for non-neoplastic conditions like chronic pancreatitis.

Keywords

• ampullary
• pancreas
• periampullary