Lymph node retrieval in pancreaticoduodenectomy specimens: does educating the pathologist matter?

BACKGROUND: Many previous studies have suggested that the number of lymph nodes retrieved should serve as a benchmark for assessing the adequacy of the resection. The aim was to retrospectively observe the impact of nodal retrieval after educating the pathologist. METHODS: Patients undergoing a pancreaticoduodenectomy (PD) between September 2005 and March 2009 were included in the study. The PDs performed between September 2005 and March 2008 were designated as Group A. The pathologists were educated regarding the importance of nodal counts in PD by the surgeon on the 1st April 2008. PDs performed between April 2008 and March 2009 were designated as Group B. RESULTS: Ninety-eight PDs performed by a single surgeon (D.R.J.) for peri-ampullary malignancy were evaluated. The median number of lymph nodes retrieved in Group A was 11(3-32) nodes. The median number of lymph nodes retrieved in Group B was 22 (10-29) nodes (P < 0.001).The lymph node ratio (positive/total nodes), median number of positive nodes retrieved, and the node positivity (node positive compared to node negative) rate did not change. DISCUSSION: A single intervention with the pathologists did impact the number of lymph nodes retrieved from PD specimens. However, the lymph node ratio and lymph node positivity rate remained unchanged. The pathologist is critical to nodal retrieval in PD, but the use of this lymph node number for benchmark of surgical adequacy may be simplistic.

Do General Pathologists Assess Gastric and Duodenal Eosinophilia?

CONTEXT.­: Eosinophilic diseases of the gastrointestinal tract (EGIDs), eosinophilic gastritis (EoG), and eosinophilic duodenitis (EoD) are rarely suspected clinically and infrequently detected by pathologists. OBJECTIVE.­: To determine whether histories of allergic or eosinophilic disorders and requests to rule out EoG and EoD affect pathologists' awareness of eosinophils in gastrointestinal biopsies. DESIGN.­: Thirty-one community-based pathologists were given 16 sets of biopsies from gastric and duodenal mucosa with elevated eosinophils, Helicobacter pylori gastritis, atrophic gastritis, normal stomach and duodenum, lymphocytosis, and celiac disease. Participants were assigned to 3 groups: group A did not receive histories of allergic or eosinophilic conditions; group B received similar histories plus a clue of possible allergic or eosinophilic conditions; and group C received the same histories as B and was asked to rule out EoG/EoD. A list of gastric and duodenal diagnoses and a space for comments were provided. Results were analyzed descriptively. RESULTS.­: Pathologists correctly diagnosed most noneosinophilic gastrointestinal disorders, indicating competence in gastrointestinal pathology. With respect to EoG and EoD, pathologists in group C performed significantly better that those in groups A and B. The combined odds ratio with 95% CI was 12.34 (2.87-53.04), P < .001, for A versus C and 4.02 (1.60-10.09), P < .02, for B versus C. CONCLUSIONS.­: Most pathologists neither reported gastric/duodenal eosinophilia nor diagnosed EoG/EoD, even when provided histories of eosinophilic disorders. Requests to rule out EoG/EoD resulted in only 4 of 11 participants evaluating and counting eosinophils in some cases. Simple evidence-based histopathologic criteria are needed before pathologists can be expected to consider and diagnose EGIDs.

Feasibility of pancreaticoduodenectomy in a nonuniversity tertiary care center: what are the key elements of success?

It is advocated that a favorable outcome for pancreaticoduodenectomy (PD) is related to a high volume at university centers. This article examines the specific elements that allow an equivalent outcome from PD in a nonuniversity tertiary care center (NUTCC). The study was performed to: (1) evaluate the outcome of PDs done at a NUTCC; (2) study the components of the process that are required to attain success in a NUTCC; and (3) provide a new look at the volume-outcome relationships in complex surgeries in a novel nonuniversity setting. Medical records of patients who underwent PD by a single surgeon between September 2005 and August 2008 at a high-volume NUTCC were analyzed. The records were reviewed with respect to preoperative and postoperative data, 30-day mortality, morbidity, and histopathology data. A total of 122 patients underwent PD. The mean age was 68.2 years. Jaundice was the most common presenting symptom in 57 per cent (69 patients). Thirty-nine patients (32%) underwent a pylorus-preserving PD. The mean operative time was 237 minutes. The mean estimated blood loss was 480 mL. The mean length hospital stay was 13 days. Thirty-day mortality was 3.2 per cent (four patients) and overall morbidity was 49 per cent. The key factors in developing a team dedicated to the care of the patient undergoing PD are discussed. A center of excellence can be developed in a NUTCC resulting in outcomes that meet and indeed may exceed nationally reported benchmarks. The key elements to success include a team approach to the patient undergoing PD.

Accuracy and cost-effectiveness of core needle biopsy in the evaluation of suspected lymphoma: a study of 101 cases.

CONTEXT: Lymphomas have traditionally been diagnosed on excisional biopsies of lymph nodes in order to evaluate tissue architecture and cytomorphology. Recent lymphoma classification schemes emphasize immunophenotypic, genetic, and molecular aspects in addition to morphology as diagnostic features. Core needle biopsies are increasingly being used to obtain tissue for diagnosis in patients with lymphadenopathy and a clinical suspicion of lymphoma. These procedures are rapid, minimally invasive, well tolerated, and may provide some architectural framework (unlike fine-needle aspirations), as well as material for ancillary studies. OBJECTIVE: To explore the accuracy, utility, and cost-effectiveness of this technique. DESIGN: Core needle biopsies of 101 consecutive patients from 2 large community hospitals who were suspected of having primary or recurrent lymphomas were retrospectively reviewed. All patients had hematoxylin-eosin-stained sections of needle cores. Specimens morphologically suspicious for lymphoma were subjected to ancillary studies, including immunohistochemistry, flow cytometry, and/or molecular studies. Core needle biopsy diagnoses were correlated with subsequent excisional biopsies, if performed. RESULTS: Core needle biopsies established a definitive pathologic diagnosis for the vast majority of cases. A diagnosis was considered sufficient to begin treatment for primary and recurrent lymphomas in most cases. Compared with an open biopsy, there is a cost savings of greater than 75%. CONCLUSION: The accuracy of this technique, along with the cost savings and decreased morbidity, suggest that this method may be used safely and reliably as a first-line diagnostic technique.

Nodal sampling in pancreaticoduodenectomy: does it change our management?

BACKGROUND: Lymph node involvement in periampullary malignancy is the single most important factor in predicting survival in pancreaticoduodenectomy (PD). The role of nodal sampling in PD has not been well evaluated. This study evaluates the utility of nodal sampling of nodal stations 8 and 12, which are easily dissected early in PD, in overall final nodal status. PATIENTS AND METHODS: Fifty patients underwent PD at a single institution by a one surgeon over a 15 month period. Nodal stations 8 and 12 were sent separately for pathologic evaluation. Twenty-eight patients had a final diagnosis of periampullary malignancy. Demographic and pathologic data were collected retrospectively from patient charts. Positive and negative predictive values of nodes 8 and 12 were evaluated. RESULTS: Eighteen of 28 patients with a diagnosis of periampullary malignancy had pathologically negative nodes 8 and 12, and a final nodal status (all peripancreatic lymph nodes) negative for nodal involvement. Nine of 28 patients had a negative nodal sampling result, but a positive final nodal status for metastatic tumor. The remaining four patients had both positive nodal sampling and final nodal status for metastatic tumor. The negative predictive value of negative nodes 8 and 12 was 0.625. CONCLUSION: The negative predictive of a negative node 8 and 12 of 0.625 suggests that the decision to proceed with or abort PD should not be based on intraoperative evaluation of these nodes. Performance of PD should be undertaken if technically feasible, and not based on intraoperative nodal assessment.