Pancreas (Exocrine)

 

Protocol applies to all carcinomas of the exocrine pancreas.

 

Procedures

·         Cytology

·         Incisional Biopsy

·         Partial Pancreatectomy

·         Whipple Procedure

 

 

This protocol is intended to assist pathologists in providing clinically useful and relevant information as a result of the examination of surgical specimens. Use of this protocol is intended to be entirely voluntary. If equally valid protocols or similar documents are applicable, the pathologist is, of course, free to follow those authorities. Indeed, the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of the individual circumstances presented by a specific patient or specimen.

 

It should be understood that adherence to this protocol will not guarantee a successful result. Nevertheless, pathologists are urged to familiarize themselves with the document. Where a physician chooses to deviate from the protocol based on the circumstances of a particular patient or specimen, the physician is advised to make a contemporaneous written notation of the reason for the procedure followed.

 

The College recognizes that this document may be used by hospitals, attorneys, managed care organizations, insurance carriers, and other payers. However, the document was developed solely as a tool to assist pathologists in the diagnostic process by providing information that reflects the state of relevant medical knowledge at the time the protocol was first published. It was not developed for credentialing, litigation, or reimbursement purposes. The College cautions that any uses of the protocol for these purposes involve considerations that are beyond the scope of this document.

 

I. Cytologic material         back     Top     Main Page

      A.    Clinical Information

            1.    Patient identification

                  a.    Name

                  b     Identification Number

                  c.    Age (birth date)

                  d.    Gender

            2.    Responsible physician(s)

            3.    Date of procedure

            4.    Other clinical information

                  a.    Clinical history

                        (1)   jaundice

                        (2)   pancreatitis

                        (3)   previous pancreatic or biliary surgery

                        (4)   pseudocyst drainage

                        (5)   diabetes mellitus

                  b.    Clinical findings (e.g. ERCP and/or imaging studies)

                  c.    Clinical diagnosis

                  d.    Procedure (e.g. brushing, washing, other)

                  e.    Operative findings

 

      B.    Macroscopic Examination

            1.    Specimen

                  a.    Unfixed/fixed (specify fixative)

                  b.    Number of slides received, if appropriate

c.    Quantity and appearance of fluid specimen, if appropriate

                  d.    Other (e.g. cytologic preparation from tissue)

                  e.    Results of intraprocedural consultation

            2.    Material submitted for microscopic evaluation

3.    Special studies (specify) (e.g. cytochemistry, immunocytochemistry)

      C.    Microscopic Evaluation

1.    Adequacy of specimen (if unsatisfactory for evaluation, specify reason)

            2.    Tumor, if present (Note A)

                  a.    Histologic type, if possible (Note B)

                  b.    Histologic grade, if possible (Note C)

                  c.    Other features (e.g. necrosis)

            3.    Additional pathologic findings, if present

            4.    Results/status of special studies (specify)

            5.    Comments

a.    Correlation with intraprocedural consultation, as appropriate

                  b.    Correlations with other specimens, as appropriate

                  c.    Correlation with clinical information, as appropriate

 

 

II. Incisional biopsy         back     Top     Main Page

A.    Clinical Information

            1.    Patient identification

                  a.    Name

                  b.    Identification Number

                  c.    Age (birth date)

                  d.    Gender

            2.    Responsible physician(s)

            3.    Date of procedure

            4.    Other clinical information

                  a.    Clinical history

                        (1)   jaundice

                        (2)   pancreatitis

                        (3)   previous pancreatic or biliary surgery

                        (4)   pseudocyst drainage

                        (5)   diabetes mellitus

                  b.    Clinical findings (e.g. ERCP and/or imaging studies)

                  c.    Procedure (e.g. ERCP biopsy, wedge biopsy)

                  d.    Operative findings

                  e.    Anatomic site(s) of specimen(s)

     

      B.    Macroscopic Examination

            1.    Specimen

                  a.    Unfixed/fixed (specify fixative)

                  b.    Number of pieces

                  c.    Largest dimension of each piece

                  d.    Results of intraoperative consultation

            2.    Tissues submitted for microscopic evaluation

                  a.    Submit entire specimen

b.    Frozen section tissue fragment(s)(unless saved for special studies)

3.    Special studies (specify) (e.g. histochemistry, immunohistochemistry)

      C.    Microscopic Evaluation

            1.    Tumor (Note A)

                  a.    Histologic type (Note B)

                  b.    Histologic grade (Note C)

                  c.    Invasion

            2.    Additional pathologic findings, if present

                  a.    Dysplasia

                  b.    Metaplasia

                  c.    Pancreatitis

                  d.    Other(s)

            3.    Results/status of special studies (specify)

            4.    Comments

a.    Correlation with intraoperative consultation, as appropriate

                  b.    Correlation with other specimens, as appropriate

                  c.    Correlation with clinical information, as appropriate

 

 

III. Partial pancreatectomy         back     Top     Main Page

(Distal or left pancreatectomy)

 

A.    Clinical Information

            1.    Patient identification

                  a.    Name

                  b.    Identification Number

                  c.    Age (birth date)

                  d.    Gender

            2.    Responsible physician(s)

            3.    Date of procedure

            4.    Other clinical information

                  a.    Clinical history

                        (1)   jaundice

                        (2)   pancreatitis

                        (3)   previous pancreatic or biliary surgery

                        (4)   pseudocyst drainage

                        (5)   diabetes mellitus

                  b.    Clinical findings (e.g. ERCP and/or imaging studies)

                  c.    Clinical diagnosis

d.    Procedure (e.g. distal pancreatectomy, local excision of tumor)

                  e.    Operative findings

                  f.    Anatomic site(s) of specimen(s)

 

      B.    Macroscopic Examination

            1.    Specimen

                  a.    Organs/tissues received (specify)

                  b.    Unfixed/fixed (specify fixative)

                  c.    Number of pieces

                  d.    Dimensions

                  e.    Orientation of specimen (if indicated by surgeon)

                  f.    Results of intraoperative consultation

            2.    Tumor (Note A)

                  a.    Location (Note D)

                  b.    Configuration (Note E)

                  c.    Dimensions (best estimate) (Note F)

d.    Descriptive features (e.g. color/consistency/necrosis/hemorrhage/cavitation)

                  e.    Estimated extent of invasion (Note F)

                  f.    Distance from margins (Note G)

                        (1)   proximal

                        (2)   distal

(3)   radial (soft tissue margin closest to deepest tumor penetration)             

3.    Lesions in noncancerous pancreas

                  a.    Pancreatic duct obstruction

                  b.    Stones

                  c.    Pancreatitis

                  d.    Other(s)

4.    Regional lymph nodes (identify by location, if possible, or if specified by surgeon) (Note F)

            5.    Tissues submitted for microscopic evaluation

                  a.    Carcinoma, including:

(1)   points of deepest penetration of surrounding structures

                        (2)   interface with adjacent pancreas

                        (3)   interface with adjacent duodenum (if appropriate)

                        (4)   visceral serosa overlying tumor

                  b.    Margins (Note G)

                        (1)   proximal

                        (2)   distal

(3)   radial (posterior soft tissue margin closest to deepest tumor penetration)

                  c.    All lymph nodes (Note F):

                        (1)   specify node(s) when marked by surgeon

                  d.    Non-involved pancreas

e.    Frozen section tissue fragment(s) (unless saved for special studies)

                  f.    Other tissue(s)/organ(s)

6.    Special studies (specify) (e.g. histochemistry, immunohistochemistry, electron microscopy, DNA analysis [specify type])

 

      C.    Microscopic Evaluation

            1.    Tumor (Note A)

                  a.    Histologic type (Note B)

                  b.    Histologic grade (Note C)

                  c.    Extent of invasion (Note F)

                  d.    Blood/lymphatic vessel invasion (Note H)

                  e.    Perineural invasion (Note I)

            2.    Margins (Note G)

                  a.    Proximal

                  b.    Posterior pancreatic surface (deep radial margin)

                  c.    Distal (if appropriate)

            3.    Peritoneal surface

            4.    Regional lymph nodes (Note F)

                  a.    Number

                  b.    Number involved by tumor

            5.    Additional pathologic findings, if present

                  a.    Dysplasia

                  b.    Metaplasia

                  c.    Pancreatitis

                  d.    Other(s)

            6.    Distant metastasis (pM) (specify site)

            7.    Results/status of special studies (specify)

            8.    Comments

a.    Correlation with intraprocedural consultation, as appropriate

                  b.    Correlation with other specimens, as appropriate

                  c.    Correlation with clinical information, as appropriate

 

 

IV.  Whipple procedure        back     Top     Main Page

(Pancreaticoduodenectomy, partial or total pancreatectomy, with or without partial gastrectomy)

 

      A.    Clinical Information

            1.   Identification Number

                  a.    Name

                  b.    Patient identification

                  c.    Age (birth date)

                  d.    Gender

            2.    Responsible physician(s)

            3.    Date of procedure

            4.    Other clinical information

                  a.    Clinical history

                        (1)   jaundice

                        (2)   pancreatitis

                        (3)   previous pancreatic or biliary surgery

                        (4)   pseudocyst drainage

                        (5)   diabetes mellitus

                  b.    Clinical findings (e.g. ERCP and/or imaging studies)

                  c.    Clinical diagnosis

                  d.    Procedure (e.g. pylorus-sparing Whipple resection)

                  e.    Operative findings

                  f.    Anatomic site(s) of specimen(s)

 

      B.    Macroscopic Examination

            1.    Specimen

                  a.    Organs/tissues received (specify)

                  b.    Unfixed/fixed (specify fixative)

                  c.    Number of pieces

                  d.    Dimensions (measure attached tissues individually)

                  e.    Orientation of specimen (if indicated by surgeon)

                  f.    Results of intraoperative consultation

            2.    Tumor

                  a.    Location (Note D)

                  b.    Configuration (Note E)

                  c.    Dimensions (best estimate) (Note F)

d.    Descriptive characteristics(e.g. color, consistency, necrosis, hemorrhage, cavitation)

                  e.    Estimated extent of invasion (Note F)

            3.    Margins (Note G)

                  a.    Distal pancreas

                  b.    Common bile duct

                  c.    Posterior pancreatic surface (deep radial margin)

                  d.    Proximal (gastric)

                  e.    Distal (duodenal)

                  f.    Other(s)

            4.    Regional lymph nodes (Note F)

            5.    Additional pathologic findings, if present

                  a.    Common bile duct obstruction

                  b.    Pancreatic duct obstruction

                  c.    Calculi

                  d.    Pancreatitis

                  e.    Other(s)

            6.    Tissues submitted for microscopic evaluation

                  a.    Carcinoma, including

(1)   points of deepest penetration of surrounding structures

                        (2)   points of deepest penetration of closest margins

                        (3)   interface of tumor with adjacent tissues

                  b.    Ampulla of Vater (plus accessory papilla if present)

                  c.    Margins

                        (1)   distal pancreas

                        (2)   common bile duct

                        (3)   posterior pancreatic surface (deep radial margin)

                        (4)   proximal (gastric)

                        (5)   distal (duodenal)

                  d.    All lymph nodes

                  e.    Other lesions (e.g. pseudocysts)

                  f.    Pancreas uninvolved by tumor

g.    Frozen section tissue fragment(s) (unless saved for special studies)

                  h.    Other tissue(s)/organ(s)

7.    Special studies (specify) (e.g. histochemistry, immunohistochemistry, electron microscopy, DNA analysis[specify type])

 

      C.    Microscopic Evaluation

            1.    Tumor (Note A)

                  a.    Histologic type (Note B)

                  b.    Histologic grade (Note C)

                  c.    Extent of invasion (Note F)

                  d.    Blood/lymphatic vessel invasion (Note H)

                  e.    Perineural invasion (Note I)

            2.    Margins (Note G)

                  a.    Distal pancreas

                  b.    Common bile duct

                  c.    Posterior pancreatic surface (deep radial margin)

                  d.    Proximal (gastric) (Note J)

                  e.    Distal (duodenal)

                  f.    Other(s)

            3.    Regional lymph nodes (Note F)

                  a.    Number

                  b.    Number with metastases

            4.    Distant metastasis (specify site)

            5.    Additional pathologic findings, if present

                  a.    Chronic pancreatitis

                  b.    Dysplasia

                  c.    Metaplasia

                  d.    Other(s)

            6.    Other tissue(s)/organ(s)

            7.    Results/status of special studies (specify)

            8.    Comments

                  a.    Correlation with intraoperative consultation

                  b.    Correlation with other specimens, as appropriate

                  c.    Correlation with clinical information, as appropriate

 

 

EXPLANATORY NOTES

 

A.    Tumors            back     Top     Main Page

This protocol applies to epithelial tumors of the exocrine pancreas.(1) It excludes endocrine tumors and tumors of the ampulla of Vater. More than 90%-95% of malignant tumors of the pancreas are exocrine carcinomas.(1,2) For these tumors, surgical resection remains the only potentially curative approach, and the prognosis is primarily dependent on the anatomic extent of disease.(2)

 

B.    Histologic Type         back     Top     Main Page

A modified classification of malignant and borderline (uncertain malignant potential) epithelial tumors of the exocrine pancreas recommended by the World Health Organization (WHO) is shown below.(3) However, this protocol does not preclude the use of other histologic types or systems of classification.

 

WHO Classification of Epithelial Tumors of the Exocrine Pancreas

Malignant Tumors

·         Severe ductal dysplasia/carcinoma in situ

·         Ductal adenocarcinoma

·         Mucinous noncystic carcinoma

·         Signet ring cell carcinoma**

·         Adenosquamous carcinoma

·         Undifferentiated (anaplastic) carcinoma***

·         Mixed ductal-endocrine carcinoma

·         Osteoclast-like giant cell tumor*

·         Serous cystadenocarcinoma*

·         Mucinous cystadenocarcinoma*

·         Intraductal papillary-mucinous carcinoma*

·         Invasive papillary-mucinous carcinoma

·         Acinar cell carcinoma*

·         Acinar cell cystadenocarcinoma*

·         Mixed acinar-endocrine carcinoma*

·         Pancreaticoblastoma*

·         Solid pseudopapillary carcinoma*

·         Miscellaneous carcinomas

 

* These histologic types are not usually graded.

** By convention, signet ring cell carcinomas are assigned grade 3 (see below).

*** By definition, undifferentiated carcinomas are grade 4 (see below).

 

Borderline  (Uncertain Malignant Potential) Tumors

·         Mucinous cystic tumor with moderate dysplasia

·         Intraductal papillary-mucinous tumor with moderate dysplasia

·         Solid-pseudopapillary tumor

 

  Have a favorable prognosis compared to ductal adenocarcinoma(3)

 

C.    Histopathologic Grade        back     Top     Main Page   

For adenocarcinomas, a histologic grade based on the extent of glandular differentiation is suggested as shown below.(4,5)

 

Grade X     Cannot be assessed

Grade 1     Well differentiated (>95% of tumor composed of glands)

Grade 2     Moderately differentiated (50%-95% of tumor composed of glands)

Grade 3     Poorly differentiated (5-49% of tumor composed of glands)

Grade 4     Undifferentiated (<5% of tumor composed of glands)

 

For ductal adenocarcinoma, histologic grade has been shown to have prognostic significance with grades 3 and 4 being unfavorable prognostic factors.(6-8) In comparisons between the Klšppel grading system and the TNM grading system, no differences in predictive value have been demonstrated.(8)

 

D.    Definition of Location        back     Top     Main Page

The anatomic subdivisions defining location of tumors of the pancreas are as follows:(5)

 

1.    Tumors of the head of the pancreas are those arising to the right of the left border of the superior mesenteric vein. The uncinate process is part of the head.

2.    Tumors of the body of the pancreas are those arising between the left border of the superior mesenteric vein and the left border of the aorta.

3.    Tumors of the tail of the pancreas are those arising between the left border of the aorta and the hilum of the spleen.

 

E.    Tumor Configuration           back     Top     Main Page

Major types include intraductal, infiltrative, and circumscribed (if circumscribed: cystic or solid).

 

F.   TNM and Stage Groupings                back     Top     Main Page

The TNM Staging System for carcinoma of the exocrine pancreas of the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC) TNM is recommended and shown below.(5) The post-resection prognosis of a patient with pancreatic carcinoma is primarily determined by the anatomic extent of disease as defined by the TNM stage groupings.

 

By AJCC/UICC convention, the designation “T” refers to a primary tumor that has not been previously treated. The symbol “p” refers to the pathologic classification of the TNM, as opposed to the clinical classification and is based on gross and microscopic examination.  pT entails a resection of the primary tumor or biopsy adequate to evaluate the highest pT category; pN entails removal of nodes adequate to validate lymph node metastasis; and pM implies microscopic examination of distant lesions.  Clinical classification (cTNM) is usually carried out by the referring physician before treatment during initial evaluation of the patient or when pathologic classification is not possible.

 

Residual Tumor in the Patient

Tumor remaining in a patient after definitive therapy (e.g., surgical resection for cure) is categorized by a system known as R classification, shown below. 

 

RX    Presence of residual tumor cannot be assessed

R0    No residual tumor

R1    Microscopic residual tumor

R2    Macroscopic residual tumor.

 

For the surgeon, the R classification may be useful to indicate the known or assumed status of the completeness of a surgical excision.  For the pathologist, the R classification is relevant to the status of the margins of a surgical resection specimen.  That is, tumor involving the resection margin on pathologic examination may be assumed to correspond to residual tumor in the patient and may be classified as macroscopic or microscopic according to the findings at the specimen margin(s).

 

Residual Tumor in a Specimen

In contrast, tumor remaining in a resection specimen from a patient who has undergone previous (neoadjuvant) treatment of any type (radiation therapy alone, chemotherapy therapy alone, or any combined modality treatment) is codified by the TNM using a prescript “y” (e.g., ypT1).  Thus, yTNM indicates the post-treatment status of the tumor.  For many neoadjuvant therapies, the classification of residual disease may be a strong predictor of postoperative outcome.  In addition, the ypTNM classification provides a standardized framework for the collection of data needed to accurately evaluate new neoadjuvant therapies.

 

Locally Recurrent Tumor

In contrast to “residual” tumor, classification of a tumor as “recurrent” requires a documented disease-free interval after definitive therapy.  Recurrent tumor may also be classified according to the TNM categories, but the prefix “r” (e.g., rpT1) is used to indicate the recurrent status of the tumor. 

 

Primary Tumor* (T)

TX       Primary tumor cannot be assessed

T0       No evidence of primary tumor

Tis      Carcinoma in situ

T1       Tumor limited to the pancreas and 2 cm or less in greatest dimension**

T2       Tumor limited to the pancreas and more than 2 cm in greatest dimension**

T3       Tumor extends directly to any of the following: duodenum, bile duct, peripancreatic tissues***

T4       Tumor extends directly to any of the following: stomach, spleen, colon, adjacent large vessels****

 

* If more than one tumor is present in the pancreas, the tumor with the highest T category should be classified according to the pT definitions and either the multiplicity (“m”) or the actual number of simultaneous multiple tumors (e.g. “3”) should be indicated in parentheses following the T category of the primary tumor (e.g. pT3[m] or pT3[2]).(9) This applies only to grossly recognizable synchronous primary carcinomas and not to a single grossly detected tumor with multiple separate microscopic foci.(9)

 

Multiple synchronous carcinomas of the exocrine pancreas may be:

    • multiple noninvasive tumors

    • multiple invasive tumors

    • multiple invasive tumors with associated carcinoma in situ

    • a single invasive tumor with associated carcinoma in situ

 

** Tumor size has been shown to have independent prognostic significance.

 

*** For T3, peripancreatic soft tissues include soft tissues adjacent to the pancreas in addition to the common bile duct and duodenum (including the ampulla of Vater). Specifically, peripancreatic tissues include the surrounding retroperitoneal fat (retroperitoneal soft tissue), including mesentery (mesenteric fat), mesocolon, greater and lesser omentum, and peritoneum.(5,9) Involvement of the peripancreatic soft tissues has been shown to have independent prognostic significance as an adverse factor.(13,19,22-27)

 

**** For the T4 classification, the adjacent large vessels are the portal vein, the celiac artery, the superior mesenteric and common hepatic arteries and veins (not the splenic vessels). Invasion of the portal vein has been shown to have independent prognostic significance as an adverse factor.(13,19,26,27) Direct extension to an organ or structure not listed in T1-T4 is M1.  Peritoneal seeding is also considered M1.(9)

 

Regional Lymph Nodes (N)†

NX    Regional lymph nodes cannot be assessed

N0    No regional lymph node metastasis

N1    Regional lymph node metastasis††

N1a   Metastasis in a single regional lymph node†††

N1b   Metastasis in multiple regional lymph nodes

 

†The regional nodes may be subdivided as follows:

Superior - lymph nodes superior to head and body of pancreas.

Inferior - lymph nodes inferior to head and body of pancreas.

Anterior - anterior pancreaticoduodenal, pyloric, and proximal mesenteric lymph nodes.

Posterior - posterior pancreaticoduodenal, common bile duct or pericholedochal, and proximal mesenteric nodes.

Splenic -   (for tumors in body and tail only)nodes of the splenic hilum and tail of pancreas.

 

The following lymph nodes are also considered regional: hepatic artery nodes, infrapyloric nodes (for tumors in head only), subpyloric nodes (for tumors in head only), celiac nodes (for tumors in head only), superior mesenteric nodes, pancreaticolieno (for tumors in body and tail only), splenic nodes (for tumors in body and tail only), retroperitoneal nodes, and lateral aortic nodes. Tumor involvement of other nodal groups is considered distant metastasis.

 

†† The presence of lymph node metastases has been shown to have independent prognostic significance as an adverse factor

††† Rationale: prognostic differences between N1a and N1b have been defined as follows:(10)

 

 

The difference between pN1a and pN1b is statistically significant (p<0.01).

 

Distant Metastasis (M)

MX    Distant metastasis cannot be assessed

M0    No distant metastasis

M1    Distant metastasis

 

Stage Groupings

Stage 0   Tis    N0      M0

Stage I   T1     N0      M0

          T2     N0      M0

Stage II T3     N0      M0

Stage III T1     N1      M0

          T2     N1      M0

          T3     N1      M0

Stage IVA        T4      Any N M0

Stage IVB Any T  Any N   M1

 

 

 

G.    Margins           back     Top     Main Page

Most local recurrences of invasive pancreatic adenocarcinoma arise in the pancreatic bed corresponding to the deep radial posterior margin of the pancreas. Since this a critical margin, the protocol recommends inking the posterior surface of the pancreas and submitting sections through the tumor at its closest approach to this margin.

When dealing with an intraductal tumor, the distal resection margin, the common bile duct margin (Whipple procedure) or the proximal resection margin of the pancreas (distal pancreatectomy) are the most critical. Complete en face sections through the pancreatic margin and the common bile duct margin should be taken.

 

H.    Blood/Lymphatic Vessel Invasion     back     Top     Main Page   

Blood/lymphatic (small vessel) invasion has been shown to be an adverse prognostic factor.(23)

 

I.    Perineural Invasion     back     Top     Main Page   

Perineural invasion has been shown to be an adverse prognostic factor.(19,30)

 

J.    Other Evaluation        back     Top     Main Page

In addition to the examination of other tissues/organs that are part of pancreaticoduodenectomy specimens, pathologic evaluation may also include examination of the gastric antrum for gastritis (e.g. Helicobacter pylori gastritis or chemical gastritis) and the duodenum for duodenitis, peptic ulcer disease, and ampullitis.

 

REFERENCES        back     Top     Main Page

1.    Solcia E, Capella C, Klšppel G. Tumors of the pancreas. Atlas of Tumor Pathology. 3rd series, Fascicle 20. Washington, DC: Armed Forces Institute of Pathology; 1997.

2.    Yamamoto M, Saitoh Y, Hermanek P. Exocrine Pancreatic Carcinoma. In: Hermanek P, Gospodarowicz M, Henson DE, et al., eds. Prognostic Factors in Cancer. Berlin-New York:  Springer-Verlag; 1995.

3.    Klšppel G, Solcia E, Longnecker D, Capella C, Sobin LH. Histological typing of tumours of the exocrine pancreas. In: WHO International Histological Classification of Tumors. 2nd ed. Berlin-New York: Springer-Verlag; 1991.

4.    Sobin LH, Wittekind C, eds. TNM Classification of Malignant Tumours: International Union Against Cancer. 5th ed. New York, NY: Wiley; 1997.

5.    Fleming ID, Cooper JS, Henson DE, et al., eds. AJCC Manual for Staging of Cancer. 5th ed. Philadelphia, PA: Lippincott Raven;  1997.

6.    Klšppel G, Lindenthal G, von Bźlow M, Kern HF. Histological and fine structural features of pancreatic ductal adenocarcinoma in relation to growth and prognosis: Studies in xenografted tumours and clinico-histopathological correlation in a series of 75 cases. Histopathology. 1985;9:841-856.

7.    Bšttger TC, Stšrkel S, Wellek S, Stšrkel M, Junginger T. Factors influencing survival after resection of pancreatic cancer. Cancer. 1994:73:63-73.

8.    Giulianotti PC, Boggi U, Fornaciari G, et al. Prognostic value of histological grading in ductal adenocarcinoma of the pancreas:  Klšppel vs TNM grading. Int J Pancreatol. 1995;17:279-289.

9.    Hermanek P, Henson DE, Hutter RVP, Sobin LH. TNM Supplement. Berlin-New York: Springer-Verlag, 1993.

10.   Hermanek P. Staging of exocrine pancreatic carcinoma. Eur J Surg Oncol. 1991;17:167-172.

11.   Cancer of the Pancreas Task Force:  Staging of cancer of the pancreas. Cancer. 1981;47:1631-1637.

12.   Bšttger T, Zech WW, Sorger K, Junginger T. Relevant factors in the prognosis of  ductal pancreatic carcinoma. Acta Chir Scand. 1990;156:781-788.

13.   Tsunoda T, Ura K, Eto T, Matsumoto T, Tsuchiya R.  UICC and Japanese Stage Classifications for Carcinoma of the Pancreas. Int J Pancreatol. 1991;8:205-214.

14.   Eskelinen M, Lipponen P. A review of prognostic factors in human pancreatic adenocarcinoma. Cancer Detect Prevent. 1992;16:287-295.

15.   Bakkevold KE, Kambesta B. Staging of carcinoma of the pancreas and ampulla of Vater. Int J Pancreatol. 1995;17:249-259.

16.   Allison DC, Bose KK, Hruban RH, et al. Pancreatic cancer cell DNA content correlates with long-term survival after pancreaticoduodenectomy. Ann Surg. 1991;214:648-656.

17.   Geer RJ, Brennan MF. Prognostic indicators for survival after resection of pancreatic adenocarcinoma. Am J Surg. 1993;165:68-73.

18.   Baumel H, Huguier M, Manderscheid JC, Fabre JM, Houry S, Fagot H. Results of resection for cancer of the exocrine pancreas: A study from the French Association of Surgery. Br J Surg. 1994:81:102-107.

19.   Griffanti-Bartoli F, Arnone GB, Ceppa P, Ravera G, Carrabetta S, Civalleri D.  Malignant tumors in the head of the pancreas and the periampullary region, diagnostic and prognostic aspects. Anticancer Res. 1994;14:657-666.

20.   Fortner JG, Klimstra DS, Senie TR, Maclean BJ. Tumor size is the primary prognosticator for pancreatic cancer after regional pancreatectomy. Ann Surg. 1996;223:147-153.

21.   Yeo CJ, Cameron JL, Lillemoe KD, et al. Pancreaticoduodenectomy for cancer of the head of the pancreas. Ann Surg. 1995;221:721-723.

22.   Tsuchiya R, Oribe T, Noda T. Size of the tumor and other factors influencing prognosis of carcinoma of the head of the pancreas. Am J Gastroenterol. 1985;80:459-462.

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Pancreatoblastoma

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Acinar Cell Carcinoma and Acinar Cell Cystadenocarcinoma

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Osteoclast-like Giant-Cell Tumor

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Mucinous Non-cystic Carcinoma

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Undifferentiated (Anaplastic) Carcinoma

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Adenosquamous Carcinoma

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Mucinous Cystic Tumor

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