Incidence and Significance of Common Bile Duct Involvement in Resected Pancreatic Ductal Adenocarcinomas: Should It Be Represented in the TNM Staging?
IV Oliva, S Bandyopadhyay, I Coban, O Basturk, D Kooby, J Sarmiento, C Staley, N Adsay. Emory University, Atlanta, GA; WSU, Detroit, MI; NYU, New York, NY
Background: It is not clear whether involvement of the common bile duct (CBD) is a parameter to be included in staging of pancreatic ductal adenocarcinoma (PDA). Current TNM defines pT3 as tumor extends beyond the pancreas. CAP and others interpret this as invasion of common bile duct &/or duodenum (including ampulla), whereas, the recent AFIP fascicle states that involvement of the bile duct should be designated as T3 only when the carcinoma extends beyond the pancreas to involve the extrapancreatic biliary tree.
Design: The incidence of extension to CBD by PDA was analyzed in 72 consecutive pancreatodudodenectomy specimens dissected carefully by a unified approach. These 72 cases were composed of only conventional PDA. Cases with neo-adjuvant therapy were excluded. CBD involvement was defined as 1) grossly identified and microscopically confirmed stricture of CBD, and 2) invasive carcinoma cells extending into the wall of the CBD. Where available, the location of the CBD involvement was also noted.
Results: CBD involvement was seen in 70 of 72 cases (97%). 34 were identified grossly with possible CBD involvement (characterized as: stricture, obstruction, dilation, encased in or abutting), and subsequently confirmed microscopically. In 37 cases with adequate documentation available, 22 involved the retroampullary CBD, and 15 involved the middle region of resected CBD. The 2 cases with no CBD involvement were women, aged 69 and 64, with tumor size 1.8 cm and 2.5 cm, respectively (slightly smaller than the average, 3.6 cm). Interestingly, one of these CBD negative patients presented with jaundice (total bilirubin 8.2 mg/dL).
Conclusions: Our study confirms that involvement of CBD is seen in virtually all cases (97%) of resectable PDA, and therefore it supports the stance taken in the recent AFIP fascicle that invasion into the CBD in a pancreatoduodenectomy specimen does not necessitate up-staging of the tumor to T3. This study also highlights the difficulty of determining the origin of some pancreatobiliary-type adenocarcinomas occupying the head of the pancreas, and whether they are arising from peribiliary ductules, CBD mucosa, or the pancreas itself.
Category: Liver & Pancreas
Monday, March 9, 2009 9:30 AM
Poster Session I Stowell-Orbison/Autopsy Award # 211, Monday Morning