Solid and cystic papillary neoplasm of the pancreas: a clinico-cytopathologic and immunocytochemical study of five new cases diagnosed by fine-needle aspiration cytology and a review of the literature

PANCREATIC SOLID-PSEUDOPAPILLARY NEOPLASM IN PATIENTS WITH FAMILIAL ADENOMATOUS POLYPOSIS

BACKGROUND

Solid pseudopapillary neoplasm of the pancreas is an uncommon pancreatic tumor, which is more frequent in young adult women. Familial adenomatous polyposis is a genetic condition associated with colorectal cancer that also increases the risk of developing other tumors as well.

AIM

The aim of this study was to discuss the association of familial adenomatous polyposis with solid pseudopapillary neoplasm of the pancreas, which is very rare.

METHODS

We report two cases of patients with familial adenomatous polyposis who developed solid pseudopapillary neoplasm of the pancreas of the pancreas and were submitted to laparoscopic pancreatic resections with splenic preservation (one male and one female).

RESULTS

ß-catenin and Wnt signaling pathways have been found to play an important role in the tumorigenesis of solid pseudopapillary neoplasm of the pancreas, and their constitutive activation due to adenomatous polyposis coli gene inactivation in familial adenomatous polyposis may explain the relationship between familial adenomatous polyposis and solid pseudopapillary neoplasm of the pancreas.

CONCLUSION

Colonic resection must be prioritized, and a minimally invasive approach is preferred to minimize the risk of developing desmoid tumor. Pancreatic resection usually does not require extensive lymphadenectomy for solid pseudopapillary neoplasm of the pancreas, and splenic preservation is feasible.

Cytological Diagnosis of Pancreatic Solid-Pseudopapillary Neoplasm: A Single-Institution Community Practice Experience

Introduction. Pancreatic solid-pseudopapillary neoplasm (SPN) is a rare tumor that typically occurs in young females. Although a cytological diagnosis may be easily made in this age group when there are typical features, atypical clinical presentations and unusual cytological features may make this a challenging diagnosis. We present our single-institution experience in a cohort of these tumors, outlining both typical and atypical features. Awareness of unusual clinical and cytological features can help to avoid pitfalls during diagnosis. Methods. We performed a review of all cases of pancreatic SPNs diagnosed over a 15-year period (January 2007 to December 2021). Detailed cytological, clinical, and follow-up histological features were presented and analyzed. Results. Twenty-two cases of SPN were diagnosed at our institution during this 15-year period. Patients ranged from 12 to 73 years of age (mean 33 y, median 26 y) and included 19 females and 3 males. Seventeen patients had cytological material, and fourteen were diagnosed by EUS-FNA. Typical cytological features included papillary clusters with central capillaries, myxoid stroma, monomorphism, cercariform cells, and hyaline globules. Atypical or unusual cytological features that were seen in a few cases were multinucleated giant cells, clear cells, and/or foamy macrophages. A few cases showed features that were similar to pancreatic neuroendocrine tumors (PanNETs). Tumor cells were always positive for β-catenin, CD10, CD56, cyclin-D1, progesterone receptor (PR), and vimentin by immunohistochemistry. They were always negative for chromogranin. Pancytokeratin and synaptophysin stains were positive in 9% and 46% of cases evaluated, respectively. All cases had histological confirmation on resection. The median follow-up duration was 69 months (a range of 2–177 months), with only three cases lost to follow-up. No recurrence or metastasis was identified. Conclusions. We present our experience with cytological diagnoses of SPN in a well-characterized cohort of 22 patients with histological correlation and follow-up data. These tumors occur over a wide range and show varied cytological features. SPNs can be confidently diagnosed on limited cytological material, with limited panel immunohistochemistry aiding diagnosis in atypical cases. Recognizing the associated degenerative changes is crucial in avoiding a misdiagnosis.

Solid pseudopapillary neoplasm of the pancreas in two male patients: gender does not matter

Solid pseudopapillary tumour (SPT) is an unusual pancreatic neoplasm which predominantly affects young women. Less than 10% of patients with SPT in the reported literature were male. In this paper, the authors report two new cases of SPT that occurred in two male patients aged respectively 25 and 20 years old. Abdominal computed tomography scan showed a well-defined heterogeneous mass involving respectively the tail and the body of the pancreas with peripheral calcifications in the first case. The two patients underwent distal splenopancreatectomy. Histopathological examination of the surgical specimen coupled with immunohistochemical study was compatible with solid pseudopapillary tumour. On postoperative day 8, the first patient developed abdominal wall abscess and peritoneal collection. Postoperative course was uneventful for the second patient. In summary, a large, well-encapsulated cystic mass in the pancreas of a young man should raise suspicion of solid pseudopapillary tumour.

Solid pseudopapillary tumour (Frantz's tumour) of the pancreas in childhood

An 11-year-old girl presented with acute pancreatitis and mass in the head of the pancreas. MRI revealed a heterogeneous right-upper quadrant retroperitoneal mass measuring 6.8×6.1×5.5 cm arising from the pancreatic head. Endoscopic ultrasound with fine-needle aspirate revealed a solid pseudopapillary tumour (SPT) of the pancreas. The patient underwent a pylorus-preserving Whipple procedure. Pathology confirmed SPT. First described by Frantz, SPT represents less than 3% of all exocrine tumours. It is especially rare in children and shows different clinical features compared with adults. In our patient, tumour cells were arranged at the periphery of fibrovascular cores, but they did not show definite gland formation, keratinisation or cytoplasmic pigment accumulation. A periodic acid-Schiff stain without diastase did not show appreciable glycogen within the tumour cells, classic for Frantz's tumour. The literature, diagnosis, management and pathogenesis on this rare entity in children are reviewed and discussed.

CD 99 immunocytochemistry in solid pseudopapillary tumor of pancreas: A study on fine-needle aspiration cytology smears

BACKGROUND

Solid pseudopapillary tumor of pancreas (SPTP) is a rare pancreatic tumor of uncertain histogenesis usually affecting young women. Though these tumors have characteristic cytomorphology, it is sometimes difficult to differentiate them from neuroendocrine tumors of the pancreas. We reviewed cases of SPTP to delineate the diagnostic cytological features and also observed utility of CD 99 (MIC 2) immunostaining to aid in the diagnosis of this tumor.

AIMS

This study was designed to demonstrate the utility of CD 99 immunostaining along with cytological features for making a pre-operative diagnosis and delineating it from the neuroendocrine tumor of pancreas which is a close mimic.

MATERIALS AND METHODS

Cytomorphological features of 11 cases of solid pseudopapillary neoplasm diagnosed by pre-operative fine-needle aspiration cytology (FNAC) at our institute were reviewed. Immunocytochemistry for CD 99 was also performed on the smears.

RESULTS

All the cases had cellular smears with monomorphic cells lying singly, as loosely cohesive clusters as well as forming delicate pseudopapillae. Presence of intra and extra-cellular basement membrane material, background foamy macrophages and nuclear grooves were the other salient features. Immunocytochemistry for CD 99 could be performed on eight cases and demonstrated typical paranuclear dot-like positivity.

CONCLUSIONS

Pre-operative early diagnosis of SPTP can be made by FNAC which can further be aided by CD 99 immunocytochemistry.

Cercariform cells: another cytologic feature distinguishing solid pseudopapillary neoplasms from pancreatic endocrine neoplasms and acinar cell carcinomas in endoscopic ultrasound-guided fine-needle aspirates

BACKGROUND

Solid pseudopapillary neoplasm (SPPN) is a rare tumor of unknown origin that occurs predominantly in the body or tail of the pancreas in young women. The authors recently identified cercariform (Greek: tailed) cells, similar to those described in urothelial carcinomas, as a consistent cytologic feature in ultrasound-guided fine-needle aspiration (EUS-FNA) samples from SPPNs. The objective of the current multi-institutional study was to define the value of these cells in the differential diagnosis of SPPN with other neoplasms characterized cytologically by the presence of monotonous, uniform cells in pancreatic aspirates: pancreatic neuroendocrine tumors (Pan-NETs) and acinar cell carcinomas (ACCs).

METHODS

The files of 4 academic hospitals were searched for SPPNs, Pan-NETs, and ACCs that were diagnosed by EUS-FNA. The slides were reviewed, and several cytologic features were recorded semiquantitatively to identify discriminating features between SPPNs, Pan-NETs, and ACCs.

RESULTS

From the analysis of 18 SPPNs, 4 ACCs, and 20 Pan-NETs, the following cytologic features were identified as common to all 3 neoplasms: single cells and rosettes/acinar cell groups, round-to-plasmacytoid cells, pale-to-granular cytoplasm, fine vacuoles, and binucleated cells. Papillary structures, cercariform cells, large cytoplasmic vacuoles, reniform nuclei, hyaline globules/magenta-colored material, and degenerative features (cholesterol crystals, calcifications, foam cells, or giant cells) were significantly more common in SPPNs. Prominent nuclear grooves were encountered in only 4 of 18 SPPNs.

CONCLUSIONS

The current results indicated that the presence of cercariform cells is another useful clue for the cytologic diagnosis of SPPN in challenging cases.

Clinical and immunohistochemical features of 34 solid pseudopapillary tumors of the pancreas

BACKGROUND AND AIM

Clinicopathological data regarding pancreatic solid pseudopapillary tumors (SPT) in a multiethnic country are limited. The aim of the present study was to characterize pancreatic SPT in Australia.

METHODS

Clinicopathological features, treatment, immunohistochemical findings and outcome data of 34 patients (79% Caucasian, 12% Asian, 6% South Pacific Islander and 3% African) with pancreatic SPT were reviewed.

RESULTS

The most presenting complaint was abdominal pain. Median diameter of tumors was 60 mm (range: 20-220); predominantly located in the pancreatic tail (tail : body : head = 23:3:8). All tumors were resected and patients underwent surgery, including a liver resection for metastasis, all patients were alive after a median follow up of 70 months (IQR: 48-178). Two patients underwent repeated surgery for local recurrences with liver metastases after 8 and 18 months, which were successfully managed by surgical resection. Completeness of excision, perineural spread, vascular space invasion, mitotic rate and cellular atypia did not predict recurrence. In all cases, there was aberrant nuclear staining of beta-catenin and a loss of membranous expression of E-cadherin with aberrant nuclear localization of the cytoplasmic domain. Most pancreatic SPT were also strongly positive for CD10 (96%), progesterone receptor (79%), cytokeratin (28%), synapthophysin (26%) and chromogranin (15%).

CONCLUSIONS

Pancreatic SPT occur in all races and are uniformly indolent. Given complete resection of a pancreatic SPT is usually curative and recurrences can be treated with re-operation, correct diagnosis is important.

MR imaging features of small solid pseudopapillary tumors: retrospective differentiation from other small solid pancreatic tumors

OBJECTIVE

The purpose of this study was to describe the MRI features of small solid pseudopapillary tumors useful for differentiating these tumors from other small solid pancreatic tumors.

MATERIALS AND METHODS

Forty-five patients (18 men, 27 women; mean age, 59 ± 11.7 years) with 45 solid pancreatic tumors smaller than 3 cm in diameter registered from 2000 to 2009 were included. Twenty-two of the tumors were adenocarcinomas, 12 were endocrine tumors, and 11 were solid pseudopapillary tumors. Two radiologists analyzed the MR images for morphologic features, signal intensity of the lesion on unenhanced images, and dynamic enhancement pattern. The contrast-to-noise ratio between the lesion and the pancreas was calculated on T1- and T2-weighted images and on dynamic images.

RESULTS

Solid pseudopapillary tumors commonly had the following features: completely well-defined margin (82%), pure solid consistency (82%), low signal intensity on unenhanced T1-weighted images (100%), high signal intensity on T2-weighted images (100%), a strong predominance among women (91%), and early heterogeneous and slowly progressive enhancement (100%). The solid pseudopapillary tumors rarely had a capsule or hemorrhage. A characteristic qualitative feature of solid pseudopapillary tumors that was significantly different from the other two tumor types was very high signal intensity on T2-weighted images (p < 0.01). Quantitative analysis showed that the solid pseudopapillary tumors had a lower contrast-to-noise ratio (-16.82 ± 5.84) on T1-weighted images and a higher contrast-to-noise ratio (37.35 ± 33.59) on T2-weighted images than did the other two tumor types (p < 0.01).

CONCLUSION

Small solid pseudopapillary tumors were predominantly seen as completely well-demarcated pure solid tumors in middle-aged women. They had lower signal intensity on T1-weighted images and higher signal intensity on T2-weighted images than did the other two tumor types and had early heterogeneous and progressive enhancement.

E-cadherin/beta-catenin and CD10: a limited immunohistochemical panel to distinguish pancreatic endocrine neoplasm from solid pseudopapillary neoplasm of the pancreas on endoscopic ultrasound-guided fine-needle aspirates of the pancreas

Pancreatic endocrine neoplasm (PEN) and solid pseudopapillary neoplasm of the pancreas (SPN) frequently pose diagnostic challenges. We sought to determine which markers could provide the best immunophenotypic characterization of PEN and SPN, allowing separation on limited cytology samples. We retrieved 22 resected PEN (n = 12) and SPN (n = 10) tumors to serve as a training set for the performance of extensive immunohistochemical staining. Based on these results, we selected a subset of antibodies for application to 25 fine-needle aspiration (FNA) samples from PEN (n = 16) and SPN (n = 9). Chromogranin A, synaptophysin, CD56, and progesterone receptor (PR) highlighted PEN cases in the training set; E-cadherin was noted in a membranous pattern. SPN cases were most immunoreactive for alpha(1)-antitrypsin, vimentin, CD10, and PR, with nuclear staining for beta-catenin; E-cadherin did not show a membranous pattern. Among all FNA samples tested, the immunohistochemical staining of E-cadherin (P = .0003), beta-catenin (P = .00004), and CD10 (P = .00006) demonstrated the greatest difference between PEN and SPN. The pattern of E-cadherin/beta-catenin expression was highly specific for distinguishing PEN from SPN. On limited FNA samples, the characteristic expression of E-cadherin/beta-catenin and the expression of CD10 can be used to distinguish PEN from SPN.

Endoscopic ultrasound-guided fine-needle aspiration diagnosis of clear-cell pancreatic endocrine neoplasm in a patient with von Hippel-Lindau disease: a case report

The cytologic findings of a clear-cell pancreatic endocrine neoplasm (PEN) diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) occurring in a 29-year-old man with von Hippel-Lindau (VHL) syndrome are described. Imaging studies showed multiple pancreatic masses and cysts, a single liver lesion, and pulmonary and renal cysts. Cytologic features of this clear-cell PEN included the presence of large sheets and rounded clusters of polygonal neoplastic cells with relatively abundant cytoplasm containing numerous, small, sharply-demarcated vacuoles that occasionally indented nuclei and gave the cells a "frothy" appearance. Mild anisonucleosis was present and nucleoli were visible. Rare single cells and stripped nuclei were seen. Small vessels transgressed tumor cell sheets. These cytologic findings are distinct from those of typical endocrine neoplasms, and bear resemblance to the cytologic features of renal cell carcinoma metastatic to the pancreas. To the best of our knowledge, this is the first detailed report of the EUS-FNA cytologic findings of a clear-cell PEN associated with VHL syndrome. We believe that the distinctive and characteristic cytologic features, together with immunohistochemical studies, can allow a preoperative cytologic diagnosis of this highly unusual pancreatic lesion and avoid possible confusion with other clear-cell neoplasms in the pancreas, particularly metastatic renal cell carcinoma.

Expression pattern of claudins 5 and 7 distinguishes solid-pseudopapillary from pancreatoblastoma, acinar cell and endocrine tumors of the pancreas

Solid-pseudopapillary tumor (SPT) of the pancreas is characterized by a discohesive appearance of the neoplastic cells. This has been linked to the displacement of E-cadherin and beta-catenin from their normal membrane location, which prevents adherens junctions to form. The nuclear localization of beta-catenin is also a feature of SPT that helps in differential diagnosis. This latter includes pancreatic endocrine tumor (PET) as SPT may show neuroendocrine differentiation, and pancreatic acinar cell carcinoma (ACC) and pancreatoblastoma (PB) that may often show nuclear beta-catenin staining. However, the role of additional cell-cell adhesion systems remains to be elucidated in SPT, particularly that of claudins that are essential components of tight junctions showing modulated expression in diverse tumor types. We studied 20 SPT, 20 nonfunctioning PET, 7 ACC, 2 PB, and their matched normal pancreas for the immunohistochemical expression of claudin family members 1, 2, 3, 4, 5, and 7, beta-catenin and E-cadherin. All SPT showed intense membrane claudin 5 and cytoplasmic claudin 2 staining, lack of claudins 3 and 4, and positive cytoplasmic claudins 1 and 7 in few cases. Conversely, PET, ACC, and PB showed strong membrane expression of claudin 7 and lack of claudin 5, whereas claudins 1, 2, 3, and 4 showed variable expression among samples. All SPT showed nuclear beta-catenin and lack of E-cadherin membrane staining, whereas PET, ACC, and PB only showed nuclear beta-catenin in 1, 2, and 2 cases, respectively. SPT shows a peculiar claudin expression profile and the highly specific pattern of claudins 5 and 7 differentiates SPT from PET, ACC, and PB.

Rare pancreatic neoplasms: the utility of endoscopic ultrasound-guided fine-needle aspiration-a large single center study

BACKGROUND

Tumors other than ductal adenocarcinomas constitute 10%-15% of all pancreatic tumors. We describe the performance and pitfalls of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosis of these rare pancreatic tumors and their characteristic cytopathological features.

METHODS

The records of 455 pancreatic fine-needle aspiration procedures done between March 1997 and August 2006 at Aichi Cancer Center, Nagoya, Japan, were reviewed. Besides cytology, aspirated material was routinely submitted in formalin for cell-block analysis. The reference standard for final diagnosis was surgical pathology from resected specimens.

RESULTS

Twenty-eight rare (nonductal adenocarcinomas) pancreatic tumors were identified. Overall, EUS-FNA with the results of cytology, cell-block processing, and immunohistochemistry could correctly diagnose the type of neoplasm in 19 (67.9%) cases. EUS-FNA could distinguish benign from malignant rare tumors with a sensitivity of 69.2%, a specificity of 100%, positive predictive value of 100%, negative predictive value of 79.0%, and accuracy of 85.7%. None of three malignant pancreatic endocrine neoplasms could be diagnosed as malignant. An adequate core tissue sample could be obtained in 21 cases (75.0%) and provide a histopathological diagnosis in 19 (67.9%) cases. EUS-FNA could change the presumptive diagnosis in 11 (39.3%) cases. Specific immunochemical studies were useful adjuncts to the diagnosis. No major or minor complication was noted in any patient.

CONCLUSIONS

Pancreatic neoplasms other than ductal adenocarcinomas have diverse imaging and histopathological features. EUS-FNA is accurate and safe for their identification.

Large, clear cytoplasmic vacuolation: an under-recognized cytologic clue to distinguish solid pseudopapillary neoplasms of the pancreas from pancreatic endocrine neoplasms on fine-needle aspiration

BACKGROUND

Solid pseudopapillary neoplasm (SPN) and pancreatic endocrine neoplasm (PEN) are uncommon neoplasms that demonstrate characteristic cytologic features. It is also known that both these tumors may share similar morphologic changes. These features not uncommonly pose significant diagnostic challenge for unsuspecting cytopathologists. In the current study, the authors report that recognition of clear cytoplasmic vacuoles in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) samples from SPN serves as a useful clue that can distinguish this tumor from PEN.

METHODS

The cytologic features from 5 SPN and 20 PEN cases were evaluated. Both Diff-Quik and Papanicolaou stains from these cases were examined. A Fisher exact test of probability was performed to determine differences in the individual cytologic features noted in these 2 tumor types.

RESULTS

The results demonstrated that pseudopapillary groups (P = .004); metachromatic matrix material (P = .004); nuclear membrane irregularity (P = .004); and large, clear cytoplasmic vacuoles (P = .001) are noted significantly more frequently in SPN. The authors also demonstrated that large, clear cytoplasmic vacuoles can serve as a powerful cytologic clue for the suspicion of SPN over PEN when there is a paucity of papillary groups within the smears. Large, clear cytoplasmic vacuoles, however, were noted only in Diff-Quik-stained smears, but not in Papanicolaou-;stained smears.

CONCLUSIONS

The results of the current study highlight that large, clear cytoplasmic vacuoles can serve as a critical clue with which to distinguish SPN from PEN in diagnostically challenging cases.

Cystic and solid lesions of the pancreas

More than 95% of malignant tumours of the pancreas are exocrine carcinomas. The exocrine carcinomas have to be distinguished from benign serous cystadenomas and tumours, the latter including mucinous cystic neoplasms, serous cysts, and solid pseudopapillary neoplasms. Cystic lesions have to be separated from pseudocysts, which are the most common cysts. Pseudocysts are due to extensive confluent autodigestive tissue necrosis caused by alcoholic, biliary, or traumatic acute pancreatitis. This review focuses on the classification of the different types of solid and cystic lesions based on histological criteria. The various imaging procedures are also discussed, along with their strengths and limitations.

Endoscopic ultrasound-guided fine-needle aspiration cytology diagnosis of solid pseudopapillary tumor of the pancreas: A case report and literature review

We describe the clinical, imaging and cytopathological features of solid pseudopapillary tumor of the pancreas (SPTP) diagnosed by endoscopic ultrasound-guided (EUS-guided) fine-needle aspiration (FNA). A 17-year-old woman was admitted to our hospital with complaints of an unexplained episodic abdominal pain for 2 mo and a short history of hypertension in the endocrinology clinic. Clinical laboratory examinations revealed polycystic ovary syndrome, splenomegaly and low serum amylase and carcinoembryonic antigen (CEA) levels. Computed tomography (CT) analysis revealed a mass of the pancreatic tail with solid and cystic consistency. EUS confirmed the mass, both in body and tail of the pancreas, with distinct borders, which caused dilation of the peripheral part of the pancreatic duct (major diameter 3.7 mm). The patient underwent EUS-FNA. EUS-FNA cytology specimens consisted of single cells and aggregates of uniform malignant cells, forming microadenoid structures, branching, papillary clusters with delicate fibrovascular cores and nuclear overlapping. Naked capillaries were also seen. The nuclei of malignant cells were round or oval, eccentric with fine granular chromatin, small nucleoli and nuclear grooves in some of them. The malignant cells were periodic acid Schiff (PAS)-Alcian blue (+) and immunocytochemically they were vimentin (+), CA 19.9 (+), synaptophysin (+), chromogranin (-), neuro-specific enolase (-), a1-antitrypsin and a1-antichymotrypsin focal positive. Cytologic findings were strongly suggestive of SPTP. Biopsy confirmed the above cytologic diagnosis. EUS-guided FNA diagnosis of SPTP is accurate. EUS findings, cytomorphologic features and immunostains of cell block help distinguish SPTP from pancreatic endocrine tumors, acinar cell carcinoma and papillary mucinous carcinoma.

Central pancreatectomy with pancreaticogastrostomy in children

Children requiring surgical intervention for pancreatic disease may be at risk long term for exocrine insufficiency and glucose intolerance. Pediatric surgeons must balance the need to perform adequate surgical resection while preserving as much normal pancreatic parenchyma as possible. Neoplasms of the middle pancreatic segment with low malignant potential and isolated trauma to the pancreatic body or neck represent 2 conditions where extensive pancreatic resection is unnecessary. Central pancreatectomy for such lesions is well described in adults. Reconstruction of the distal pancreatic remnant is traditionally performed via Roux-en-Y pancreaticojejunostomy. Pancreaticogastrostomy is an alternative approach that has been used to reconstruct the distal pancreas in the adults. Pancreaticogastrostomy offers several technical advantages over pancreaticojejunostomy. Because children may be uniquely susceptible to the long-term consequences of excessive pancreatic resection, 2 cases using this technique of central pancreatectomy with pancreaticogastrostomy are described.

Malignant potential of solid pseudopapillary neoplasm of the pancreas

BACKGROUND

Solid pseudopapillary neoplasms of the pancreas are rare malignant lesions of the pancreas that typically occur in young women. Large series from any one centre are notably absent in the literature. The aim of this study was to determine long-term outcomes of operative therapy.

METHODS

The records of all 14 patients diagnosed with pseudopapillary neoplasms of the pancreas over 17 years were reviewed.

RESULTS

Thirteen of the 14 patients were female and the mean age at diagnosis was 30 years. Solid pseudopapillary neoplasm was suspected in only half of these patients before operation. On computed tomography, ultrasonography and/or magnetic resonance imaging, three lesions were solid, three were largely cystic, and five had solid and cystic components. All 14 patients underwent surgical exploration and curative resections were possible in 13, including distal pancreatectomy in nine, pancreaticoduodenectomy in three and resection of a local intraperitoneal recurrence in one patient. After follow-up ranging from 3 months to 20 years, 12 patients were alive, including one who had undergone re-exploration and resection of local and subcutaneous recurrences 9 years previously.

CONCLUSION

Solid pseudopapillary neoplasm of the pancreas should be considered in the differential diagnosis of any solid or partly cystic pancreatic mass in women aged less than 35 years. An attempt at en bloc resection without formal lymphadenectomy should be undertaken, including resection of synchronous or metachronous distant metastases.

My approach to pancreatic fine needle aspiration

Pancreatic fine needle aspiration cytopathology has earned a reputation as a rapid, safe, accurate and cost-beneficial modality of investigation of pancreatic mass lesion. Optimal results can be expected only if these procedures are undertaken regularly in gastroenterology departments processing large numbers of patients; occasional aspirators cannot exploit the technique to full potential. Professional teams following a dedicated approach to patient selection and management develop requisite expertise over time. Cytodiagnosis rests as much on morphological examination as on the milieu in which is it practised, and as much on sample quality as on cellular criteria. This article focuses attention on specimen handling, with particular reference to rapid on-site evaluation. The significance of particular cytodiagnoses in patient care is evaluated, and tumour types that may be encountered are enumerated and illustrated.

Clinical, imaging, and cytopathological features of solid pseudopapillary tumor of the pancreas: a clinicopathologic study of three cases and review of the literature

Solid pseudopapillary tumors are rare pancreatic neoplasms of uncertain pathogenesis that rarely metastasize and usually occur in young women. We describe the clinical, imaging, and cytopathological features of solid pseudopapillary tumor of the pancreas. We reviewed the clinical presentation, imaging, morphologic/immunochemical features, and follow-up of three women (age range 26-44). Cases 1, 2, and 3 presented with abdominal wall abscess, multiple endocrine neoplasia, and solid/cystic mass in the pancreatic head, respectively, and computed tomography of abdomen revealed solid/cystic masses with heterogeneous enhancement in body, tail and head of the pancreas, respectively. Case 2 also exhibited a left adrenal mass. Case 3 underwent endoscopic ultrasound of the pancreas, which showed a complex solid/cystic mass with septations. Sampling consisted of fine-needle aspiration (percutaneous or endosonography-guided), and additionally, core biopsy of the pancreatic mass and adrenal lesion in case 2. Aspirates and core biopsy revealed vascular structures with attached monotonous neoplastic cells in papillary-like arrays. Tumor cells had bland nuclear features with grooves, cytoplasmic periodic acid Schiff-positive hyaline globules, and associated myxoid/stromal fragments. Immunochemistry expressed alpha-1-antitrypsin, alpha-1-antichymotrypsin, vimentin, and focal neuron-specific enolase. Cases 1 and 3 underwent pancreatectomy with follow-up consisting of yearly imaging and no recurrences. Case 2 proved metastatic disease to adrenal gland and no follow-up was available. In the setting of typical clinical and imaging findings, an accurate preoperative diagnosis of pancreatic solid pseudopapillary tumor can be established by aspiration cytology and immunochemistry with or without concomitant core biopsy, on the basis of which clinicians decide treatment. This tumor can behave in a malignant fashion.

Fine-needle aspiration cytology of pancreatoblastoma in a young woman: report of a case and review of the literature

Pancreatoblastoma is a rare tumor and has been reported only four times in the cytologic literature, three times in fine-needle aspiration (FNA) biopsy and once in an imprint of resected tumor. We are reporting the fourth case of FNA cytology with immunohistochemical and electron microscopic studies. The patient is a 24-yr-old African American woman, who presented with a pancreatic mass, hepatic masses, and abdominal lymphadenopathy. The aspiration smears of the liver mass showed a biphasic tumor composed of bland-appearing primitive spindled stromal fragments with "spider-web"-like long fibrils interconnecting with sharply angulated islands of cohesive epithelium. At high power, the epithelium is composed of medium-sized cells with round-to-oval vesicular nuclei with fine chromatin and one-to-two small nucleoli. The neuroendocrine component was demonstrated immunohistochemically with synaptophysin and chromogranin expressions. The acinar component and squamoid component were demonstrated ultrastructurally by the presence of 400-600 nm zymogen granules and tonofilaments. The literature was reviewed and the cytological features of all the four cases of pancreatoblastoma are summarized.

Solid and papillary epithelial neoplasm of the pancreas

Solid and papillary epithelial (SPEN) is an uncommon pancreatic tumor often seen in young females. Although most of these neoplasms have a benign course, SPEN do have malignant potential. Treatment is surgical which is usually feasible either via enucleation or more radical procedures. Below we discuss diagnosis, treatment, and prognosis in detail.

Solid pseudopapillary tumour of the pancreas

BACKGROUND

Solid pseudopapillary tumour of the pancreas is a rare pancreatic tumour that occurs predominantly in women, with very few cases reported in men. This is a tumour with low malignancy potential and surgical resection usually results in cure.

METHODS

A retrospective review of our experience with solid pseudopapillary tumours between April 1992 and December 2000 was undertaken.

RESULTS

Six patients were identified including one male patient. The median age was 30 years, with four patients presenting with abdominal pain and discomfort and two patients presenting with palpable abdominal masses. The mean tumour diameter was 10.2 cm and the lesions were found mainly in the body and tail of the pancreas. Only one patient had tumour at the pancreatic head. One patient had a locally invasive disease and another had peritoneal spread. None of the patients received adjuvant therapy. The mean follow up was 3.8 years (range: 1.5-10.0) and all patients were free of recurrence to date.

CONCLUSION

SPT is a rare tumour with an unclear origin that has a distinct histology and presentation. Although preoperative diagnosis is difficult by computed tomography, magnetic resonance imaging may potentially improve this situation. In general, this is a tumour of very low malignant potential and long-term survival is excellent after resection of the tumour.

Solid-pseudopapillary tumor of the pancreas: a neoplasm with distinct and highly characteristic cytological features

The solid-pseudopapillary tumor of the pancreas (SPTP) is an unusual low-grade malignant epithelial tumor affecting predominantly adolescent girls and young women. Although approximately 500 cases of SPTP have been described in the last 40 yr, its pathogenesis remains uncertain. However, the clinical features of this neoplasm are very characteristic and SPTP must be suspected in any young woman with a cystic or partially cystic pancreatic mass. In this report, we describe the cytologic features of seven cases of SPTP investigated by preoperative fine-needle aspirates. The analysis of the cytologic features in these cases and in 43 cases collected from the literature reveals that they are highly characteristic and quite distinct from those of other cystic or solid tumors of the pancreas. On this basis, a cytologic diagnosis of SPTP may be rendered with great confidence, not only in clinically typical examples, but also in unusual presentations, such as in older patients, in males, in ectopic locations, and in metastatic sites.

Fine-needle aspiration cytology of pancreatoblastoma

Pancreatoblastoma is a rare pancreatic neoplasm seen most commonly in the pediatric age group. We report on the aspiration cytology and immunohistochemical findings of a pancreatoblastoma in a 16-yr-old male.

Giant solid cystic tumor of the pancreas with a fibrous septum caused by extracapsular growth in middle-aged woman: report of a case

We report herein the case of a 57-year-old female who was admitted to our hospital for treatment of rectal carcinoma and incidentally found to have a giant cystic tumor, 20 cm in diameter, in the body and tail of the pancreas. Several imaging procedures, including ultrasonography, computed tomography, and magnetic resonance imaging, showed that this tumor was round and hypovascular, and had a septum with protuberant lesions. The capsule was 3-4 mm thick with partial calcification. A preoperative diagnosis of a solid cystic tumor (SCT) of the pancreas was made, even though these tumors are rarely found in females in their fifties. Moreover, few reports of SCT with a septum have been described. Distal pancreatectomy and splenectomy were performed, and the tumor was found to be filled with massive necrotic tissue. Microscopically, the tumor was confirmed to be a SCT with a fibrous septum. We present this case due to the atypical findings, including the age of the patient and the existence of a septum caused by extracapsular growth.