Hepatobiliary and Pancreatic Staging

What determines the type of pancreatic surgery performed?

Tumor location

Common procedures include:

• Whipple procedure / pancreaticoduodenectomy

• Distal pancreatectomy

What procedure is this showing?

Whipple procedure

Are all Whipple procedures done for the same reason?

NO!

• Not all have pancreatic origin

• Not all are adenocarcinomas

• Many different staging protocols

Where might a tumor be located in a whipple specimen?

A Whipple may contain tumors arising from:

• Pancreas

• Distal common bile duct

• Ampulla/periampullary region

• Duodenum

Do not assume the tumor is pancreatic in origin

How do you determine the likely primary site of a tumor in a Whipple specimen?

Determine the epicenter/bulk of the tumor

• Approximate 75% of the tumor bulk as the localization concept

What are two approaches to sectioning a pancreaticoduodenectomy specimen discussed in the lecture?

Bivalving (more common) — Better identify tumor origin

Axial/Serial sectioning — More accurate margin assessment

What is the pancreatic duct like grossly compared with the common bile duct?

Pancreatic duct — Narrow, tan-white, smooth/glistening lumen

CBD — Has numerous punctate orifices from peribiliary glands

What are some pancreatic tumores?

Pancreatic ductal (or acinar) adenocarcinoma

Pancreatic neuroendocrine tumor

Pancreatic neuroendocrine carcinoma (small/large cell)

Pancreatic mixed neuroendocrine/adenocarcinoma

Which pancreatic tumors can become carcinoma of the pancreas?

Pancreatic ductal (or acinar) adenocarcinoma

Pancreatic neuroendocrine carcinoma (small/large cell)

Pancreatic mixed neuroendocrine/adenocarcinoma

What are some bile duct - distal CBD tumors?

Biliary cholangiocarcinoma

What are some ampullary/periampullary tumors?

Ampullary/periampullary adenocarcinoma

Ampullary neuroendocrine tumor

Ampullary neuroendocrine carcinoma (small/large cell)

Ampullary/periampullary mixed neuroendocrine/adenocarcinoma

Which ampullary/periampullary tumors can become carcinoma of the ampulla of vater?

Ampullary/periampullary adenocarcinoma

Ampullary neuroendocrine carcinoma (small/large cell)

Ampullary/periampullary mixed neuroendocrine/adenocarcinoma

What are some duodenal tumors?

Duodenal adenocarcinoma

Duodenal neuroendocrine tumor

Duodenal neuroendocrine carcinoma (small/large cell)

Duodenal mixed neuroendocrine/adenocarcinoma

Duodenal GIST or sarcomas..

Which duodenal tumors can become carcinoma of the small intestine?

Duodenal adenocarcinoma

Duodenal neuroendocrine carcinoma (small/large cell)

Duodenal mixed neuroendocrine/adenocarcinoma

What are the pancreatic carcinoma T categories based primarily on?

Tumor size, except for T4, which is based on involvement of major arteries

What defines pT1 pancreatic carcinoma?

Tumor ≤2 cm in greatest dimension

Subcategories:

• T1a: ≤ 0.5 cm

• T1b: 0.5 < X < 1 cm

• T1c: 1–2 cm

What defines pT2 pancreatic carcinoma?

2 cm < X ≤ 4 cm

What defines pT3 pancreatic carcinoma?

Tumor >4 cm

What defines pT4 pancreatic carcinoma?

Tumor involves:

• Celiac axis, and/or

• Superior mesenteric artery (SMA), and/or

• Common hepatic artery

Regardless of tumor size

What is the most important pancreatic T-stage cutoff to memorize?

≤2 cm → T1

>2–4 cm → T2

>4 cm → T3

Major arterial involvement → T4 regardless of size

What defines pN1 pancreatic carcinoma?

Metastasis in 1–3 regional lymph nodes

What defines pN2 pancreatic carcinoma?

Metastasis in ≥4 regional lymph nodes

What defines pT1a ampullary carcinoma?

Tumor is limited to the ampulla of Vater or sphincter of Oddi

What defines pT1b ampullary carcinoma?

Tumor:

• Extends beyond the sphincter of Oddi (perisphincteric invasion), and/or

• Invades the duodenal submucosa

What defines pT2 ampullary carcinoma?

Tumor invades the muscularis propria of the duodenum

What defines pT3a ampullary carcinoma?

Tumor directly invades the pancreas up to 0.5 cm

What defines pT3b ampullary carcinoma?

Tumor:

• Extends >0.5 cm into the pancreas, OR

• Invades peripancreatic tissue, OR

• Invades periduodenal tissue, OR

• Invades duodenal serosa

without celiac axis or SMA involvement

What defines pT4 ampullary carcinoma?

Involvement of:

• Celiac axis

• SMA

• Common hepatic artery

Regardless of size

What are the ampullary N categories?

N0: no regional node metastasis

N1: 1–3 positive regional nodes

N2: ≥4 positive regional nodes

What is the “groove” region?

The posterior aspect of the ampulla where there is no pancreatic tissue covering the ampulla with the periduodenal soft tissues/serosa

What defines pTis duodenal carcinoma?

High-grade dysplasia/carcinoma in situ

What defines pT1 duodenal carcinoma?

Tumor invades:

• Lamina propria, or

• Submucosa

Subcategories:

• T1a: lamina propria

• T1b: submucosa

What defines pT2 duodenal carcinoma?

Tumor invades the muscularis propria

What defines pT3 duodenal carcinoma?

Tumor extends:

• Through muscularis propria into subserosa, or

• Into nonperitonealized perimuscular tissue such as mesentery/retroperitoneum

without serosal penetration

What defines pT4 duodenal carcinoma?

Tumor:

• Perforates the visceral peritoneum, and/or

• Directly invades another organ/structure

For the duodenum specifically, invasion of the pancreas or bile duct qualifies

What are the duodenal N categories?

N0: no regional node metastasis

N1: 1–2 positive nodes

N2: ≥3 positive nodes

What defines pTis distal bile duct carcinoma?

Carcinoma in situ / high-grade dysplasia

What defines pT1 pancreas NET?

Limited to pancreas

≤2 cm

What defines pT2 pancreas NET?

Limited to pancreas

2 < X ≤ 4 cm

What defines pT3 pancreas NET?

Limited to pancreas, >4 cm, OR

Invading:

• Duodenum

• Ampulla of Vater

• Common bile duct

What defines pT4 pancreas NET?

Tumor invading:

• Adjacent structures, OR

  • Stomach

  • Spleen

  • Colon

  • Adrenal glands

• Wall of large vessels

What defines pT1 ampulla/duodenum NET?

Duodenal tumors:

• Invades mucosa or submucosa ONLY

• ≤1 cm

Ampullary tumors:

• Confined within the sphincter of Oddi

• ≤1 cm

What defines pT2 ampulla/duodenum NET?

Duodenal tumors:

• Invades muscularis propria, OR

• >1 cm

Ampullary tumors:

• Invades through the sphincter of Oddi into the duodenal submucosa or muscularis propria, OR

• >1 cm

What defines pT3 ampulla/duodenum NET?

Invades the pancreas or peripancreatic adipose tissue

What defines pT4 ampulla/duodenum NET?

Invades the visceral peritoneum (serosa) or other organs

What are some biliary origins for CA?

Intrahepatic

Perihilar

Distal extrahepatic

What defines pTis distal bile duct carcinoma?

Carcinoma in situ / high-grade dysplasia

What defines pT1 distal bile duct carcinoma?

Tumor invades the bile duct wall to a depth <5 mm

What defines pT2 distal bile duct carcinoma?

Tumor invades the bile duct wall 5–12 mm

What defines pT3 distal bile duct carcinoma?

Tumor invasion into the bile duct wall >12 mm

What defines pT4 distal bile duct carcinoma?

Tumor involves:

• Celiac axis

• SMA

• Common hepatic artery

What are the distal bile duct N categories?

N0: no regional node metastasis

N1: 1–3 positive nodes

N2: ≥4 positive nodes

What additional gross measurement should be reported for distal cholangiocarcinoma?

Lesion size correlates better with prognosis for intrapancreatic cholangiocarcinoma

What is this showing?

Distal cholangiocarcinoma — Segmental resection

What is a low union?

The common hepatic duct and cystic bile duct did not join until both were within the pancreas

• Create a short and entirely intrapancreatic common bile duct

What defines pT1 gallbladder carcinoma?

Tumor invades:

• Lamina propria, or

• Muscular layer

Subdivided into:

• T1a: lamina propria

• T1b: muscular layer

What defines pT2 gallbladder carcinoma?

Tumor invades the perimuscular connective tissue

• WITHOUT serosal involvement or extension into the liver

Two subcategories:

• T2a → peritoneal side

  • WITHOUT serosal involvement

• T2b → hepatic side

  • NO extension into the liver

What defines pT3 gallbladder carcinoma?

Tumor:

• Perforates the serosa, and/or

• Directly invades the liver, and/or

• Directly invades one other adjacent organ/structure

  • Stomach

  • Duodenum

  • Colon

  • Pancreas

  • Omentum

  • Extrahepatic bile ducts

What defines pT4 gallbladder carcinoma?

Tumor:

• Invades the main portal vein or hepatic artery, OR

• Invades two or more extrahepatic organs/structures

What are the gallbladder N categories?

N0: no regional node metastasis

N1: 1–3 positive nodes

N2: ≥4 positive nodes

What is M1 gallbladder carcinoma?

Distant metastasis

What is the anatomic location of perihilar cholangiocarcinoma?

The tumor arises in the hilar/proximal extrahepatic bile duct region

What does "second-order bile ducts" refer to in perihilar cholangiocarcinoma?

The more proximal intrahepatic biliary branches beyond the primary hilar ducts

What defines pT1 perihilar cholangiocarcinoma?

Confined to bile duct

• With extension to the muscle layer/fibrous tissue

What defines pT2 perihilar cholangiocarcinoma?

T2a — Beyond bile duct wall into surrounding adipose tissue

T2b — Invasion of adjacent hepatic parenchyma

What defines pT3 perihilar cholangiocarcinoma?

Tumor invades:

• Unilateral branches of the portal vein, OR

• Hepatic artery

What defines pT4 perihilar cholangiocarcinoma?

Tumor invades

• Main portal vein or its branches bilaterally, or the common hepatic artery; OR

• Unilateral second-order biliary radicals with contralateral portal vein, OR

• Hepatic artery involvement

What are the perihilar cholangiocarcinoma N categories?

N0: no regional node metastasis

N1: 1–3 positive regional nodes

N2: ≥4 positive regional nodes

What is pM1 in perihilar cholangiocarcinoma?

Distant metastasis

• Include lymph nodes outside the specified regional nodal sites

What is this?

Perihilar cholangiocarcinoma

What are the three gross growth patterns of intrahepatic cholangiocarcinoma?

Intraductal (ID)

Periductal infiltrating (PI)

Mass-forming (MF)

What defines pT1 hepatocellular carcinoma?

pT1a — Solitary tumor, ≤2 cm

pT1b — Solitary tumor, >2cm, without vascular invasion

What defines pT2 hepatocellular carcinoma?

Tumor:

• >2cm WITH vascular invasion

• Multiple tumors, <5 cm

What defines pT3 hepatocellular carcinoma?

Multiple tumors, at least one >5cm

What defines pT4 hepatocellular carcinoma?

Single tumor or multiple tumors of ANY size, involving:

• Major branch of portal vein, OR

• Hepatic vein

OR tumor(s) with direct invasion of:

• Adjacent structures other than the gallbladder, OR

• With perforation of visceral peritoneum

What defines pN1 hepatocellular carcinoma lymph nodes?

Regional LN mets

What defines pM1 hepatocellular carcinoma mets?

Distant metastasis

What defines pTis intrahepatic cholangiocarcinoma?

Carcinoma in situ (intraductal tumor)

What defines pT1 intrahepatic cholangiocarcinoma?

• pT1a — Solitary tumor, ≤5 cm

• pT1b — Solitary tumor, >5cm

Without vascular invasion

What defines pT2 intrahepatic cholangiocarcinoma?

Solitary tumor with intrahepatic vascular invasion, OR

Multiple tumors, WITH or WITHOUT vascular invasion

What defines pT3 intrahepatic cholangiocarcinoma?

Tumor perforating the visceral peritoneum

What defines pT4 intrahepatic cholangiocarcinoma?

Tumor involving local extrahepatic structures by direct invasion

What define pN1 intrahepatic cholangiocarcinoma lymph nodes?

Regional lymph nodes mets present

What define pM1 intrahepatic cholangiocarcinoma lymph nodes?

Distant metastasis

Left to right: What is this showing?

Periductal infiltrating ICC

Intraductal ICC

Mass-forming ICC

ICC vs HCC locations