title: Pancreaticoduodenectomy (Whipple resections) in patients without malignancy: are they all 'chronic pancreatitis'?
abstract: Pancreaticoduodenectomy (Whipple resection) has evolved into a safe procedure in major high-volume medical centers for the treatment of pancreatic adenocarcinoma and refractory chronic pancreatitis. However, some Whipple resections performed for a clinical suspicion of malignancy reveal only benign disease on pathologic examination. We evaluated the frequency of such Whipple resections without tumor in a large series of pancreaticoduodenectomies and classified the diverse pancreatic and biliary tract diseases present in these specimens. Of 442 Whipple resections performed during 1999-2001, 47 (10.6%) were negative for neoplastic disease and, in 40 cases, had been performed for a clinical suspicion of malignancy. Most Whipple resections revealed benign pancreatic disease, including 8 (17%) alcohol-associated chronic pancreatitis, 4 (8.5%) gallstone-associated pancreatitis, 1 (2.1%) pancreas divisum, 6 (12.8%) "ordinary" chronic pancreatitis of unknown etiology, and 11 (23.4%) lymphoplasmacytic sclerosing pancreatitis. In particular, patients with lymphoplasmacytic sclerosing pancreatitis were all thought to harbor malignancy, whereas only 13 of 19 (68.4%) of Whipple resections showing histologically "ordinary" forms of chronic pancreatitis were performed for a clinical suspicion of malignancy. Benign biliary tract disease, including three cases of primary sclerosing cholangitis, two cases of choledocholithiasis-associated chronic biliary tract disease, and four fibroinflammatory strictures isolated to the intrapancreatic common bile duct, was a common etiology for clinically suspicious Whipple resections (22.5% of cases). Pancreatic intraepithelial neoplasia (PanIN) was a common finding among all pancreata, whether involved by pancreatitis or histologically normal. Overall, PanIN 1A/1B was present in 68.1%, PanIN 2 in 40.4%, and PanIN 3 in just 2.1%. These findings indicate that "benign but clinically suspicious" Whipple resections are relatively common in high-volume centers (9.2%) and reveal a diverse group of clinicopathologically distinctive pancreatic and biliary tract disease.
authors.affiliation: Department of Pathology, Mayo Clinic, Rochester, Minnesota, 55905, USA. abraham.susan@mayo.edu
authors.forename: Susan C
authors.initials: SC
authors.lastname: Abraham
authors.forename: Robb E
authors.initials: RE
authors.lastname: Wilentz
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Yeo
authors.forename: Taylor A
authors.initials: TA
authors.lastname: Sohn
authors.forename: John L
authors.initials: JL
authors.lastname: Cameron
authors.forename: John K
authors.initials: JK
authors.lastname: Boitnott
authors.forename: Ralph H
authors.initials: RH
authors.lastname: Hruban
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001660:Biliary Tract Diseases / Q000473:pathology / Q000601:surgery*; D002278:Carcinoma in Situ / Q000473:pathology / Q000601:surgery; D002908:Chronic Disease; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery; D016577:Pancreaticoduodenectomy; D010195:Pancreatitis / Q000145:classification / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies