56-year-old female with obstructive jaundice, distal biliary stricture and pancreatic head mass.

Procedure: Whipple resection (partial gastrectomy, duodenectomy, and partial pancreatectomy).

Gross: The specimen consists of an en-bloc of whipple specimen, including a portion of the distal stomach, duodenum, gallbladder, and head portion of pancreas with the common bile duct. The entire specimen weighs 310 gms. The stomach measures 12 cm. in length of the great curvature, and 7 cm. in length of the lesser curvature. The proximal gastric resection margin measures 12 cm. in circumference. Along the greater and lesser curvature, there is adherent mesenteric tissue, measuring 14 x 5 x 2 cm. along the great curvature, and 8 x 5 x 2 cm. along the lesser curvature. The duodenum measures 21 cm. in length, and the diameter varying from 2.5 to 4 cm. The proximal portion of the duodenum measures 2.5 cm., and the diameter at the ampulla measures 4 cm. The distal portion of the duodenum measures 3 cm. in diameter. The pancreas measures 5 x 4.5 x 4 cm., which is firmly adherent to the wall of the stomach and duodenum. The common bile duct (CBD) measures 1.7 cm. in length and .8 cm. in diameter. The mucosal surface of CBD appears patchy hemorrhagic, and slightly granular in appearance. The gallbladder measures 8 cm. in length and 3 cm. in diameter with a small portion of disrupted cystic duct,with a diameter of 3 mm. Opening of the stomach shows a pink-red mucosa with a granular surface and loss of rugal folds. The wall measures up to .8 cm. in thickness. The mucosa is otherwise intact. Opening of the duodenum shows the usual mucosal folds. The mucosa is tan-brown. The ampulla is narrowed but patent, measuring up to 0.3 cm. in diameter. The ampulla probes approximately 3.7 cm. proximally. Probing from the common bile duct through the pancreatic duct to the ampulla is narrowed, but is patent. Sectioning through the pancreas shows gray-white firm mass involving almost the entire pancreatic tissue with granular white cut surface, and a faintly lobulated. The tumor measures 3.5 x 3 x 3.5 cm. Tumor appears to extend to uncinate. The superior, anterior and posterior sufaces of pancreas are covered by adipose fibrous tissue in which several lymph nodes are identified especially along the superior aspect of the pancreas and pericommon bile duct area. The gall baldder shows grey tan granular mucosal surface and focally disrupted cystic duct. No gall stone is noted. Representative sections are submitted.

Micro: Sections of whipple show an extensively invasive ductal adenocarcinoma, well to focally poorly differentiated, involving a fairly large area of the pancreatic head tissue. The tumor is composed of varying sized, and the appearance of large to medium and small glands that are associated with extensive desmoplastic reaction. The tumor cells range from benign bland appearing glandular cells to poorly oriented cells infiltrating a few cell clusters or poorly formed glands. Poorly oriented tumor cells show enlarged pyknotic and pleomorphic nuclei. In reas, tumor shows production of mucinous material. The malignant glands that are present away from the main pancreatic tissue in the parapancreatic adipose tissue near the vascular structure, and also perineural involvement. There is foci of vascular/lymphatic invasion. The major vessels, however, are not invaded by the tumor. There is remaining pancreatic tissue with features of atrophic chronic pancreatitis. In areas, there is atrophic acini and fairly well preserved remaining islet cells. The tumor closely extends to the anterior and posterior margin, and close to the uncinate margin as well as the common bile duct margin. However, the very margin of common bile duct, uncinate is spared from tumor extension. The proximal gastric margin, distal duodenal margin is negative. Eleven parapancreatic lymph nodes are identified, and eight of these show metastatic carcinoma. Five lymph nodes from the perigastric nodes are negative of metastatic tumor. Sections of bile duct and pancreatic duct show severe associated inflammatory reaction with periductular fibrosis, obliteration of the ductular lumen. The lining epithelium shows mild to moderate atypia, and the deeper portion of the lumen is lined by malignant epithelial cells. Sections of gallbladder show features of moderate/severe chronic cholecystitis with fibrosis of the wall. The cystic duct shows an obliterated lumen with fibrosis and a thickened wall. H & E stain.

IHC stains: The tumor shows a strong positive reaction with CA 19-9, and positive reaction with CK-7, and a negative reaction with CK-20.