Solid-cystic (papillary-cystic) tumours within and outside the pancreas in men: report of two patients

Case report: A case report and literature review of extrapancreatic solid pseudopapillary neoplasm

Background

Solid pseudopapillary neoplasm (SPN) is a rare tumor with low malignant potential, which typically occurs in the pancreas. Extrapancreatic SPN is also extremely rare worldwide.

Case presentation

We report a case of a 70-year-old woman hospitalized with abdominal pain and bloating. The patient did not have any underlying diseases, such as diabetes, coronary heart disease, or hypertension. More than 30 years ago, the patient underwent surgery for “ectopic pregnancy”. The patient had no family history of hereditary disease, nor did any immediate family members have a history of cancer. Laboratory tests showed that her hemoglobin and albumin levels were low and she had a high level of cancer antigen 125 (CA125). Enhanced computed tomography (CT) showed a large tumor in the abdomen and pelvis. The patient subsequently underwent surgery, and it was found that the tumor was attached to the terminal ileum. Pathological findings suggested that the tumor was an extrapancreatic SPN, with an ectopic pancreas found in the tumor tissue. The patient did not receive chemotherapy or radiotherapy after surgery. After 13 months of follow-up, the patient was admitted again with abdominal pain. CT showed tumor recurrence with extensive systemic metastases. The patient and her family refused reoperation and biopsy, and the patient was discharged after the abdominal pain and anemia resolved.

Conclusion

We report a rare case of extrapancreatic SPN of ileal origin, which could be the first report worldwide. It had aggressive biological features, with recurrence and metastasis 13 months after surgery. For extrapancreatic SPN, the risk of recurrence should be assessed, and for tumors suspected of malignant behavior, a longer follow-up after discharge may be needed. Although SPN generally has a good prognosis after surgery, there is no consensus on whether postoperative chemotherapy and other treatments are needed for patients with high recurrence risk.

Pancreatic Solid Pseudopapillary Neoplasm: Key Pathologic and Genetic Features

CONTEXT.—

Solid pseudopapillary neoplasm of the pancreas is a low-grade malignant tumor generally associated with a good prognosis. Solid pseudopapillary neoplasms show peculiar morphologic features, but sometimes the differential diagnosis with other pancreatic neoplasms (ie, pancreatic neuroendocrine tumors) can be a challenging task, especially in cytologic or biopsy specimens. In these cases immunohistochemistry is a useful tool, but the diagnostic utility of several proposed immunohistochemical markers is questionable. In recent years, despite several attempts to characterize the pathogenetic, molecular, and prognostic features of solid pseudopapillary neoplasms, they still remain unclear.

OBJECTIVE.—

To give the reader a comprehensive update on this entity.

DATA SOURCES.—

The PubMed database (US National Library of Medicine) was searched using the following string: pseudopapillary tumor [AND/OR] neoplasm [AND/OR] pancreas. All articles written in English were included. In addition, because a heterogeneous terminology has been used in the past to define solid pseudopapillary neoplasms, the reference lists of each paper selected in the PubMed database were also reviewed.

CONCLUSIONS.—

This review gives a comprehensive update on the pathologic, clinical, and molecular features of solid pseudopapillary neoplasms, particularly addressing issues and challenges related to diagnosis. In addition, we have tried to correlate the molecular alterations with the morphologic and clinical features.

Malignant Transformation of Ectopic Pancreas

Malignant transformation of ectopic pancreas tissue is a diagnostic challenge as clinical symptoms and radiographic features of these tumors are non-specific. Given the rarity of these lesions, it is usually neither suspected nor included in the diagnostic workup of different tumors. We conducted a comprehensive literature review regarding malignancy arising from ectopic pancreas for a better understanding of its frequency, clinicopathological features, and prognosis. A literature search was performed in three major databases: PubMed, Cochrane, and Web of Science. Fifty-four well-documented cases of malignant ectopic pancreas were identified in the published literature. Our analysis provided the following observations: (1) there was a slight predominance of males over females; (2) most patients with malignant transformation of ectopic pancreas were middle-aged; (3) most commonly, the tumor was located in the stomach; (4) most tumors were adenocarcinomas; (5) most frequently, the malignancy arose within a type I heterotopia according to Heinrich classification; (6) macroscopically, a subepithelial-like appearance was most frequently observed; and (7) improved prognosis for ectopic pancreatic malignancies in comparison with reported survival data for orthotopic pancreatic cancer. Even if the majority of cases of ectopic pancreas are incidental findings and malignant transformation is a rare event, pancreatic heterotopy should be considered as a source of potentially malignant lesions.

Solid pancreatic pseudopapillary tumor managed laparoscopically: A case report and review of the literature

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Solid pancreatic pseudopapillary tumors are a rare neoplasms with not well known pathogenesis.

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Imaging is not able to provide a precise diagnostic orientation. The essential role is played by surgery and histological examination.

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Immunohistochemistry shows a possible correlation between the Beta-catenin mutations or alteration of the E-cadherin and tumor development.

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Laparoscopic technique has proven to be the gold standard for the countless advantages found compared to the open technique.

Background

Solid pancreatic pseudopapillary tumors are a rare neoplasms, about 1–3% of all pancreatic neoplasms. This cancer mainly affects women between the third and fourth decade of life.

They are not well known; the molecular origins represent a low degree of malignancy, in which the complete resection is curative. We report our experience with a case report of SPT in a young man.

Presentation of case

Thirty-six years old male patient with a mass about 10 cm in the pancreatic tail and splenic ilum. After following CT and MR, the patient was subjected to surgery. Histophatological result was solid tumor pseudopapillary of pancreas with no pathological lymph nodes.

Discussion and conclusion

Solid pseudopapillary neoplasm shows histological characteristic solid and pseudopapillary proliferation. Immunohistochemistry detects, among the causes of tumor development, a correlation between the Beta-catenin mutations, alteration of the E-cadherin. In the most cases, therapy is surgical treatment with laparoscopic.

Heterotopic Pancreas of the Gastrointestinal Tract and Associated Precursor and Cancerous Lesions: Systematic Pathologic Studies of 165 Cases

Heterotopic pancreas (HP) can be detected by accompanying symptoms or incidentally during gastrointestinal (GI) tract tumor resection. We compared clinicopathologic features among 165 resected HPs (57 gastric [35%], 56 duodenal [34%], 30 omental [18%], and 22 jejunal [13%]). Symptomatic HPs (79/135 GI tract wall HPs, 59%) were larger (P=0.05), more common in younger patients and in a gastric location (both P<0.001), and more frequently associated with lymphoid cuffs (P=0.03) than incidentally found HPs. Gastric/jejunal HPs were more frequently symptomatic (P<0.001), deeply located (P=0.03), and associated with lymphoid cuffs (P=0.008) and pancreatic intraepithelial neoplasia/intraductal papillary mucinous neoplasms (PanIN/IPMN; P=0.001) than duodenal HPs. HP was frequently associated with acinar-ductal metaplasias (117/135 GI tract wall HPs, 87%) and PanINs/IPMNs (68/135, 50%); those with PanINs/IPMNs were larger (P<0.001), more frequently located in stomach (P=0.001), had deeper wall involvement (P=0.03), and more often showed infiltrative growth (P<0.001) and lymphoid cuffs (P=0.02). Four HPs containing PanINs abutted adenocarcinomas, all expressing wild-type KRAS and intact SMAD4/DPC4 expression. Thus, symptomatic HP is associated with younger age, larger size, gastric location, and lymphoid cuffs. HPs containing PanINs/IPMNs (usually low grade) are larger and more common in stomach, have deeper wall location, and show infiltrative growth and lymphoid cuffs. Adenocarcinomas are rarely observed adjacent to HPs with PanINs/IPMNs. KRAS mutational and SMAD4/DPC4 immunohistochemical studies can discriminate between adenocarcinoma derived from HP and concurrent adenocarcinoma with HP.

An extrapancreatic solid-pseudopapillary neoplasm in the greater omentum

A solid pseudopapillary neoplasm (SPN) is an uncommon pancreatic tumour that usually occurs in young women. Tumours outside the pancreas (e.g. in the ovary, retroperitoneum or omentum) are rare. We report a case of an SPN arising from the greater omentum in a 78-year-old male who presented with a month-long history of abdominal pain and a palpable abdominal mass. Laboratory data showed inflammation and anaemia. CT and magnetic resonance imaging revealed a well-defined encapsulated mass measuring 18 cm in the upper right abdomen. The tumour was completely removed via surgery, and pathologic examination confirmed a diagnosis of an SPN in the greater omentum.

Solid Pseudopapillary Tumour of Extrapancreatic Origin Presenting as Mesenteric Cystic Mass: A Diagnostic Dilemma

Solid Pseudopapillary Tumour (SPT) is a rare and distinctive pancreatic exocrine neoplasm. Even Rarely, such primary SPT may originate from ectopic pancreatic tissues. We are hereby presenting one such unique case, where a 50-year-old female presented with pain and a mid-abdominal lump. Radiology revealed a well-defined outline located adjacent to the tail of pancreas. The excised mass was 19×14×7cm in dimension having zones of haemorrhage, necrosis and cystic spaces filled with necrotic debris. Microscopic examination confirmed the diagnosis of SPT. SPT originating in extrapancreatic location may mimic an ovarian cystic tumours or mesenteric cysts, its proper identification is crucial.

Extrapancreatic solid pseudopapillary tumors: A clinicopathological analysis of two cases

Solid pseudopapillary tumors (SPTs) are unusual neoplasms that mostly occur in the pancreas, and predominantly affect young women. As a low-grade malignant neoplasm of the exocrine pancreas, they occasionally metastasize, usually to the liver or peritoneum. It has been reported that <1% of SPTs are primary extrapancreatic SPTs. In the present study, we present two rare, but conspicuous extrapancreatic SPTs. Both occurred in young women, and showed good prognoses following surgery. One was a recurrent SPT of the pancreas that metastasized to the ovary, and the other was a distinct primary neoplasm that arose in the retroperitoneal area. The pathological features of the two tumors, including solid and pseudopapillary growth patterns with pale or eosinophilic cytoplasm, were characteristic of SPTs of the pancreas. However, in the case of the metastatic ovarian tumor, focal necrosis and an increased nuclear-to-cytoplasmic ratio were observed. The presence of positive nuclear-cytoplasmic β-catenin, the loss of membranous E-cadherin expression, and a perinuclear punctate CD99 staining pattern on immunohistochemistical analysis, were essential features for diagnosis. The aim of the present study was to compare the morphological and immunohistochemical features of these tumors with those typical of pancreatic SPTs, and to raise awareness that SPTs are able to metastasize to unusual sites, and may also arise as primary tumors outside the pancreas, which may lead to diagnostic dilemmas.

Solid-pseudopapillary neoplasm of the pancreas in children: can we predict malignancy?

PURPOSE

We aimed to review clinical and histologic findings of solid-pseudopapillary neoplasm (SPN) in children and determine the predictive factor of the malignancy.

METHOD

The records of 45 patients (9 males, 36 females) who underwent surgery for SPN in the Asan Medical Center from 1992 to 2012 were retrospectively analyzed. We analyzed the factors between histologic benign group (n=36) and malignant group (n=9).

RESULTS

The mean age of children was 14.9±3.15years (range 9-20years). Mean size of the tumor was 6.36±3.61cm, and most common site in the pancreas was the tail (n=23). Three patients had distant metastasis at initial diagnosis. The sites were the liver (n=2) and the omentum (n=1). All patients underwent complete resection, and the median follow up period was 34months. Recurrence (n=4) was more common in the malignant group (p<0.05). We calculated the proportion of solid component by manual volumetry with a CT scan. The median value was 41.5% in benign group and 88.4% in malignant group. On comparative analysis, the proportion of solid component was found to have significant association with malignancy (p<0.05).

CONCLUSION

Histologic malignant SPN has high risk of recurrence. We should consider more radical resection when finding a predominantly solid tumor in a CT scan.

Solid-pseudopapillary neoplasms of the pancreas: clinical and pathological features of 33 cases

PURPOSE

Solid-pseudopapillary neoplasms (SPNs) are rare pancreatic tumors, with a low potential for malignancy. The clinical and pathological features of 33 SPNs were reviewed.

METHODS

This study conducted a retrospective analysis of 33 patients who underwent surgery for a pathologically confirmed SPN from 2000 to 2011.

RESULTS

Thirty of the 33 patients (91 %) were female, and the median age at diagnosis was 29.2 years (range 12-59). The most common symptom was abdominal discomfort with dull pain (58 %). Others included asymptomatic lesions that were only detected incidentally during imaging (21 %), a palpable abdominal mass (15 %) and indigestion (6 %). All 33 patients underwent surgery with a curative intent and 3 (9 %) underwent laparoscopic surgery. The mean diameter of the tumors was 4.9 cm (range 2-15 cm), and they occurred in the head (9, 27 %), neck (5, 15 %), body or tail (19, 58 %) of the pancreas. One patient had lymph node metastases, one patient had portal venous invasion and 8 patients had perineural invasion. The patient follow-up ranged from 4 to 118 months, and 32 patients were alive and well without recurrence. One patient relapsed 10 months after distal pancreatectomy with splenectomy and underwent a second surgery via laparotomy. Unfortunately, the patient died of multiple organ failure 12 days after the second surgery.

CONCLUSION

SPNs are rare neoplasms with malignant potential but excellent prognosis. Adequate surgical resection, including laparoscopic surgery, may therefore be performed safely and is associated with a long-term survival, even in invasive cases.

Peritoneal and nodal recurrence 7 years after the excision of a ruptured solid pseudopapillary neoplasm of the pancreas: report of a case

A solid pseudopapillary neoplasm (SPN) of the pancreas is generally regarded as a neoplasm of low malignant potential and there is rarely recurrence of the disease. A 12-year-old female underwent a pylorus preserving pancreaticoduodenectomy for a ruptured pancreatic SPN following a blunt abdominal trauma. The tumor showed no pathological features suggesting malignant potential. Follow-up imaging studies depicted small nodules adjacent to the superior mesenteric vein 7 years after surgery. A laparotomy was performed, and exploration revealed 3 nodules adjacent to the superior mesenteric vein and 4 small nodules in the mesointestine. All of these lesions were extirpated, and were histologically confirmed to be nodal and peritoneal recurrence of SPN. This case indicates that SPN of the pancreas has a latent ability to recur, regardless of its benign pathological features, and peritoneal spread may be promoted by trauma. A close postoperative follow-up is thus mandatory in all patients with SPN even after a radical resection.

Primary solid papillary tumor of the liver

Solid papillary tumor (SPT) is an uncommon lesion of the pancreas whose origin and behavior are poorly understood. Very rare cases of primary extra-pancreatic SPTs have been described, and their clinical, histological, immunophenotypic and ultrastructural features seem to be similar to those arising in the pancreas. Here we report a case of primitive SPT of the liver, the second case described in the literature so far.

Extrapancreatic solid pseudopapillary neoplasm: report of a case of primary ovarian origin and review of the literature

Solid pseudopapillary neoplasm, an uncommon, intriguing, low-grade malignant tumor of the pancreas, can exceptionally occur in extrapancreatic sites. We report 1 such case occurring as an ovarian primary in a 25-year-old woman, who presented with abdominal fullness. She remained well 12 years after resection of the 1.7-kg right ovarian tumor. Histologically, the tumor showed a solid, dehiscent, and pseudopapillary growth, traversed by fibrous septa and arborizing blood vessels. The polygonal tumor cells had round nuclei, fine chromatin, and lightly eosinophilic granular cytoplasm. In certain areas, eosinophilic hyaline globules were present. On immunostaining, the tumor cells were positive for β-catenin (nuclear translocation), CD10, CD56, and synaptophysin (focal), and were negative for cytokeratin, E-cadherin, and chromogranin. The morphologic and immunohistochemical features were compatible with those of solid pseudopapillary neoplasm. Review of the literature uncovered 10 cases of extrapancreatic solid pseudopapillary neoplasm with adequate data for analysis. They were seen to occur predominantly in young female patients, who presented with a large tumor mass, similar to their pancreatic counterparts. The most common sites of occurrence were the mesocolon (with ectopic pancreatic tissue) and ovary. Awareness of the existence of this tumor in various extrapancreatic sites is essential to avoid misdiagnosis.

Primary malignant solid pseudopapillary tumors of the gastroduodenal area

Extrapancreatic cases of solid-pseudopapillary tumor (SPT) are exceedingly rare. We report here two cases of primary tumors located in the gastroduodenal region, morphologically identical to pancreatic SPT, but particular by their immunohistochemical features and malignant evolution. Clinical charts and all available histopathological material were reviewed; complementary immunohistochemical investigations and molecular analyses were performed. The patients were a 32-year-old female, submitted to surgical resection for a tumor of the prepyloric region, and a 73-year-old male presenting with a duodenal tumor and synchronous liver metastases. In the two cases, the primary tumor and all the metastases available for study were morphologically indistinguishable from typical pancreatic SPT. However, their immunohistochemical profile was characterized by the absence of hormone receptor expression and of nuclear localization of beta-catenin and E-cadherin. In the only case in which it was feasible, molecular analysis did not identify any mutation in the CTNNB1 gene. Both tumors had a malignant behavior, with extensive metastatic dissemination. In conclusion, we report two unusual cases of extrapancreatic SPT arising in the gastroduodenal area, associated with a malignant course and an extensive metastatic dissemination.

A solid pseudopapillary tumour arising from mesocolon without ectopic pancreas

A solid pseudopapillary tumour (SPT) is an uncommon pancreatic tumour. Very rarely it has also been described outside the pancreas, usually arising from heterotopic pancreatic tissue. In this paper, we described a case arising from the transverse mesocolon without heterotopic pancreatic tissue in an 18-year-old girl.

Solid-pseudopapillary neoplasm: a pancreatic enigma

Solid-pseudopapillary neoplasm of the pancreas is a relatively uncommon tumor. It typically affects young women, has nonspecific clinical and radiologic manifestations, and can be readily diagnosed by ultrasound-guided fine-needle aspiration and histopathologic evaluation. Histologic features characteristically show loosely cohesive, relatively uniform polygonal cells surrounding delicate capillary-sized blood vessels. Other features include cytoplasmic vacuolization, finely stippled chromatin, nuclear grooving, eosinophilic hyaline globules, and degenerative changes. Almost all solid-pseudopapillary neoplasms harbor mutations in the beta-catenin gene. They stain with beta-catenin, CD10, and focally with neuroendocrine markers. Although previously considered benign, this tumor is currently considered a low-grade malignant epithelial neoplasm with low metastatic rate and high overall survival. Most patients are cured by complete surgical excision. Despite the characterization of the morphologic and molecular features of this enigmatic neoplasm, more work is needed to uncover its cell of origin and true histogenesis.

Solid pseudopapillary tumor of the pancreas: an enigmatic tumor

Solid pseudopapillary tumor of the pancreas is a rare pancreatic tumor that predominantly occurs in young non-Caucasian women. Although most tumors show benign behavior, malignant degeneration may occur. A case of solid pseudopapillary pancreatic tumor in a Caucasian woman is presented that was investigated by endoscopic ultrasonography (EUS), computed tomography, magnetic resonance imaging and EUS-guided fine needle aspiration. The patient underwent surgery and radiological findings are correlated with histopathology. The preoperative diagnosis of solid pseudopapillary tumor of the pancreas is challenging, frequently leading to imaging by multiple different modalities.

[Solid pseudopapillary pancreas tumors--often neglected]

Solid pseudopapillary tumors of the pancreas (SPTP) are rare tumors of the pancreas with low malignancy potential and a very good prognostic outcome after surgery. They typically occur in young women or adolescents and consist of solid, cystic and cystic-hemorrhagic components.Imaging findings in these tumors are characteristic and include a fibrotic capsule with a clear delineation and exhibit solid and cystic-hemorrhagic signal and density characteristics. Calcifications may be present in the periphery of the tumor. The tumor capsule shows contrast enhancement, the solid components in the periphery enhance in the early phase and gradually and inhomogeneously in late phases. MRI is superior to CT and other imaging modalities for characterization of SPTP. Awareness and knowledge of this tumor entity with an excellent prognosis is crucial to guide the patient towards effective, predominantly organ-sparing surgical treatment.

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.

Clinical and biological behavior of pancreatic solid pseudopapillary tumors: report on 31 consecutive patients

BACKGROUND

Solid pseudopapillary tumors (SPTs) represent one of the most uncommon histotypes of all exocrine pancreatic neoplasms.

AIM

To delineate the clinical presentation and biological behavior of SPT and evaluate the efficacy of treatment.

METHODS

Retrospective analysis of 31 patients (27 female, 4 male, mean age of 34 years, (range 7-56)) who underwent surgical resection with a definitive histological diagnosis of SPT.

RESULTS

Tumor detection was incidental in the 55% of cases. Symptoms were abdominal discomfort (n=10), jaundice (n=2), weight loss (n=6), vomiting (n=5), and a palpable abdominal mass (n=4). The neoplasm was localized in the pancreatic head in 10 patients and in the body-tail in 20 cases; the main diameter ranged from 2 to 20 cm (mean 5.4). At the radiological work-up, the neoplasm was solid in 87% of cases and delimited by a capsule in 39%. An internal necrotic-hemorrhagic area was present in 29% of cases. Calcifications were noticed in two patients and septa in one. None of the patients had metastases at the time of diagnosis. In 9 cases, pancreaticoduodenectomy was performed, while 15 patients underwent a left pancreatectomy (4 spleen preserving), 6 a middle pancreatectomy, and 1 enucleation. There was no postoperative mortality with an overall morbidity of 35%. At a median follow-up of 58.2 months (12-229 range), all patients are alive without evidence of local recurrence, metastasis, diabetes, or exocrine insufficiency.

CONCLUSIONS

Solid pseudopapillary tumor (SPT) is an indolent neoplasm with low-grade biological aggressiveness, making surgical treatment successful despite its large size.

Solid-pseudopapillary neoplasm of the pancreas: Three cases with a literature review

Solid-pseudopapillary neoplasm of the pancreas is a very rare tumor. It most commonly occurs in young women and has unique pathologic features. Previous immunohistochemical studies demonstrated that most solid-pseudopapillary neoplasms were immunoreactive with antibodies directed against vimentin and neuron-specific enolase. Recently, expression of CD10 and CD56 in this tumor has been reported. In this report, we expanded the demographic profile, highlighting 3 cases of solid-pseudopapillary neoplasm of the pancreas that presented in an elderly woman, a young man, and a young woman and further characterized them histologically and immunophenotypically. Grossly, all 3 tumors were well circumscribed and had a variable degree of cystic formation, necrosis, and hemorrhage. Microscopically, these tumors were characterized by a pseudopapillary pattern of epithelioid cells arranged around a delicate fibrovascular core with sheets of bland epithelioid cells filling cystic spaces. Hyaline globules, cholesterol granulomas, and foamy cells were all seen to be common findings. Although these 3 tumors were strongly immunoreactive for vimentin, alpha-1-antitrypsin, alpha-1-antichymotrypsin, neuron-specific enolase, CD10, CD56, and progesterone receptor, they demonstrated only variable "positivity" for epithelial membrane antigen and broad-spectrum cytokeratin, but were being consistently nonreactive for synaptophysin, insulin, glucogon, chromogranin A, and estrogen receptor. Interestingly, 2 of the 3 tumors were S-100 protein and melanin A reactive but were nonreactive for HMB45.

Solid pseudopapillary tumor of the pancreas: a multicenter study of 23 pediatric cases

BACKGROUND/PURPOSE

Solid pseudopapillary tumor (SPT) is a very rare form of childhood pancreatic tumor. This study was intended to analyze the clinicopathologic characteristics of this tumor in childhood.

METHODS

We retrospectively reviewed the medical records of patients who were pathologically diagnosed with SPT between March 1991 and March 2005.

RESULTS

Twenty-three patients underwent an operation and were pathologically diagnosed with SPT. Five (22%) were male, with a male-to-female ratio of 1:3.6. The initial signs and symptoms were upper abdominal pain in 20 patients (87%), palpable abdominal mass in 8 (35%), and dyspepsia in 6 (26%). Four patients (17%) had a history of abdominal trauma. Tumors were located in the pancreatic head (30%), body (13%), tail (44%), and both body and tail (13%). Operative procedures performed were pylorus-preserving pancreaticoduodenectomy (n = 6, 26.1%), distal pancreatectomy (n = 7, 30.4%), distal pancreatectomy with splenectomy (n = 7, 30.4%). The median follow-up period was 62 months (range, 6-175 months). One patient showed multiple liver metastasis 3 months after the initial operation and required adjuvant chemotherapy. All other patients were alive at their most recent follow-up with no evidence of recurrence or distant metastasis.

CONCLUSIONS

Complete resection of an SPT is usually curative and patients can survive a long period after the operation.

Estrogen receptors in pancreatic tumors

OBJECTIVES

Although a potential role for estrogen receptors (ER) in pancreatic tumors has been debated for many years, the importance of the receptors in these neoplasms remains unknown. Even the expression of the 2 ER isoforms, ER-alpha and ER-beta, in histological subtypes of pancreatic neoplasms is controversial. The aim of the present study was to systematically review the available literature about ER expression in pancreatic tumors and to discuss the potential importance of estrogen signaling in them.

METHODS

We performed a comprehensive literature search and analyzed the results regarding ER expression in pancreatic tumors, with special emphasis on the specificity of the antibodies used for immunohistochemistry.

RESULTS

Many articles have been published investigating the expression of ERs in pancreatic tumors, but the results are inconsistent. Moreover, most studies used antibodies that detected only ER-alpha, not ER-beta. Thus, the expression pattern of ER-beta in pancreatic neoplasm remains especially unclear.

CONCLUSIONS

The lack of detailed studies evaluating the expression of both ER-alpha and ER-beta receptors using isoform-specific antibodies likely contributes to the inconsistency of published results concerning ER expression in pancreatic tumors. Available published evidence suggests that a thorough reexamination of the potential role of ERs in pancreatic neoplasms is warranted.

Solid-pseudopapillary neoplasms of the pancreas in men and women: do they differ?

Solid-pseudopapillary neoplasms (SPNs) of the pancreas are uncommon and occur preferentially in young women. The question whether the features of SPNs occurring in men differ from those in women has not yet been studied. For a better understanding of the clinicopathological features of SPNs of both sexes, we studied a series of 14 tumors surgically resected at a Japanese hospital within a period of 14 years. This series was composed of seven men and seven women. All these SPNs demonstrated nuclear and cytoplasmic accumulation of beta-catenin protein in immunohistochemistry and 86% of them had activating mutations of beta-catenin gene. No pancreatic neuroendocrine tumors showed such immunohistochemical findings and genetic alterations. In our series, most SPNs in women showed encapsulation by thick fibrous tissue and massive degenerative changes. Most SPNs in men exhibited solid components without prominent degenerative changes, even though they were of a similar size to those in women. These findings suggest that SPNs in men tend to be a solid mass with slower progression of degenerative changes during their growth compared to that in women. Nuclear accumulation of beta-catenin appears to be a useful marker of SPN, which allows male SPNs to be correctly diagnosed despite their less typical features.

A solid pseudopapillary tumor arising from the greater omentum followed by multiple metastases with increasing malignant potential

Solid pseudopapillary tumor is a rare, indolent neoplasm almost exclusively seen in the pancreas. We describe an unusual case of solid pseudopapillary tumor arising in the greater omentum of a 45-year-old man with subsequent multiple liver metastases and peritoneal dissemination. The patient underwent a total of ten laparotomies and died of unresectable disease 8 years after the initial presentation. Microscopically, the primary tumor and the relapsed tumors consistently exhibited identical growth patterns, which were characterized by solid sheets intermingling with pseudopapillary arrangements of uniformly small cells. Immunohistochemical staining was diffusely positive for vimentin and focally positive for alpha-1-antitrypsin. These features were compatible with those of conventional pancreatic solid pseudopapillary tumors. We also performed quantitative evaluation of Ki-67 immunoreactivity and mitotic figures, which indicated malignant transformation of this extremely rare tumor. This is the first detailed report of solid pseudopapillary tumor arising outside the pancreas complicated by repetitive liver metastases and peritoneal carcinomatosis, suggesting the existence of a more lethal subgroup of tumors.

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.

Metastatic Solid-pseudopapillary Tumour of the Pancreas: Clinico-biological Correlates and Management

Solid-pseudopapillary tumour of the pancreas is a rare neoplasm of young women, currently categorised in the World Health Organization classification under exocrine pancreatic tumours. Increased awareness of this condition correlated recently with an apparent rise in incidence as well as recognition of more aggressive clinical courses. We describe two patients with solid-pseudopapillary tumour of the pancreas. A smaller, localised tumour in an unusually young white man was surgically excised with no evidence of recurrence after 2 years. The other case also had an uncommon presentation, with an aggressive course resulting in vascular encasement of the superior mesenteric bundle and aorta, and local involvement of the mesenteric lymph nodes. A literature review was carried out, and the main clinico-pathological features and strategies of treatment of solid-pseudopapillary tumour of the pancreas are presented. Pathological, genetic and molecular features distinguish solid-pseudopapillary tumours from pancreatic ductal adenocarcinoma. Furthermore, neuroendocrine differentiation can be found focally in occasional cases of solid-pseudopapillary tumour. Patients with localised disease are usually cured by surgery. Prolonged survival can be seen in the presence of distant metastasis, if such lesions are resected surgically. Chemotherapy and radiation therapy are used in rare cases when resection is not possible. No current chemotherapy regimens are considered standard in the treatment of this tumour. A rational chemotherapy protocol for such a rare tumour needs to consider its origin and clinical behaviour. However, the indolent clinical progression of solid-pseudopapillary tumours is similar to that of pancreatic neuroendocrine tumour.

Solid-pseudopapill�re Neoplasien

Solid pseudopapillary neoplasms (SPN) of the pancreas represent a special tumor entity, both morphologically and biologically. They form large solitary tumors that occur predominantly in young women. Histologically, they show solid, pseudopapillary, and pseudocystic patterns. The tumor cells are monomorphous and typically express vimentin, neuron-specific enolase, nuclear beta-catenin, and the progesterone receptor. Complete resection cures the tumor in about 90% of the cases. However, because recurrences and even metastases may occur in a small number of cases, SPN are classified as low-grade malignant tumors. Predicting malignancy histologically is not yet possible. The most important differential diagnosis to consider is neuroendocrine tumor of the pancreas. The etiology and pathogenesis of SPN are obscure.

Therapeutic strategy of papillary cystic and solid neoplasm (PCSN): a rare non-endocrine tumor of the pancreas in children

Papillary-cystic and solid neoplasm (PCSN) are rare tumors. Two personal observations and a review of the literature are presented with a total of 44 pediatric patients in addition to a total of 67 published cases in the review of Cohen (Pediatr. Surg. Int. 6 (1991) 128) and Snadjauf (Eur. J. Pediatr. Surg. 9 (1999) 416). Overall, PCSN shows a clear predominance in females and only occasionally occurs in males. Typically they grow to a large tumor mass with minimal symptoms. Their histologic and immunocytologic characteristics cause diagnostic difficulties, especially on frozen sections of small biopsies. The tumors are assumed to origin from pluripotent stem cells and present as tumors of low malignancy with a favorable prognosis. Nevertheless 10 children have been reported to develop metastases, 5 have demonstrated an invasive growth pattern and 4 local recurrence. But only two of the 111 pediatric cases have died from their tumor burden. Treatment of choice is a complete surgical resection, which is true for the primary tumor and for metastases as well as local recurrences. In our 2 patients one had spleen-conserving left pancreatic resection and one mesopancreatectomy with roux-en-y-reconstruction leading to long-term cure. Adjuvant therapy in curative resected patients is unnecessary and does not appear to improve prognosis.

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.

Tumeurs pseudopapillaires et solides du pancréas : à propos de cinq cas et revue de la littérature

INTRODUCTION

Solid pseudopapillary tumors of the pancreas are rare and their origin is unknown. The aim of this work was to report five new cases.

MATERIAL AND METHODS

Retrospective study of data from patients operated on from 1983 to 2002 in a university hospital specialized in pancreatic surgery. Patients were identified in a prospectively constituted database of pathologic examinations.

RESULTS

Five patients (three men and two women, aged from 15 to 69 years) underwent pancreatectomy for a solid pseudopapillary tumor, which was discovered fortuitously by imaging in three cases. Tumor diameter ranged from 4 to 15 cm. Diagnosis was made preoperatively in only one patient. There were three pancreaticoduodenectomies and two left pancreatectomies, with extension to the transverse colon due to vascular reasons in two cases. Only one significant complication occurred (one colonic fistula). With a follow-up ranging from 6 months to 6 years, all patients are alive without recurrence.

CONCLUSIONS

Solid pseudopapillary tumors are not exceptional in men. Complete resection can need extension to neighboring organs but allows good long-term survival.

A case of solid pseudopapillary neoplasm of the pancreas and tumor doubling time

BACKGROUND

Solid pseudopapillary neoplasm of the pancreas is a rare tumor with unique clinicopathological features. Although it is considered to grow slowly, little is known about its doubling time.

METHOD

We encountered a young Japanese woman with a solid pseudopapillary neoplasm of the pancreas that had been detected at another hospital 5 years previously but was resected at our hospital. The tumor showed only a solid component without any cysts. Computed tomographic scans taken 5 years apart were compared to determine the tumor doubling time.

RESULT

The tumor doubling time according to the formula of Schwartz and co-workers was determined to be 765 days.

CONCLUSION

These findings confirm that this tumor grows quite slowly and also support long disease-free periods even in patients who have recurrence or metastases.

The beta form of the estrogen receptor is predominantly expressed in the papillary cystic neoplasm of the pancreas

INTRODUCTION

Papillary cystic neoplasm (PCN) of the pancreas is a low-malignancy tumor affecting predominantly young females. Sex steroid hormones have been involved in its development and/or growth. Estrogen receptor (ER) has been scarcely found in this tumor, although there is some evidence suggesting expression of the beta-isoform. Unlike ER, progesterone receptor (PR) expression has been consistently observed. Immunohistochemical analysis of the two isoforms of ER has not been performed in this tumor.

AIM

To characterize expression of ER isoforms with an immunohistochemical method.

METHODOLOGY

Expression of ER-alpha, ER-beta, and PR was analyzed by immunohistochemistry using isoform-specific ER and PR antibodies in paraffin-embedded tissue blocks from seven cases of PCN of the pancreas.

RESULTS

Most patients were young females. ER-alpha and ER-beta were present in two and six tumors, respectively. PR was identified in six tumors.

CONCLUSIONS

ER-beta expression predominates over the alpha-isoform in PCN of the pancreas. This finding supports the idea that previous negative results on ER expression were a consequence of the use of antibodies with no anti-beta activity. The role of ER-beta in the milieu of factors promoting the development and aggressiveness of PCN needs to be elucidated to address novel diagnostic and therapeutic approaches.

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.

Solid pseudopapillary neoplasm of the pancreas: report of a case after a 10-year follow-up and review of the literature

A solid pseudopapillary neoplasm (SPN) is an extremely rare tumour of the pancreas that frequently occurs in young females and is mostly benign. SPN is a low-grade malignant tumour that may evolve years before symptoms start. However, the pathogenesis of this tumour remains unclear and there are no adequate reports of long-term results to evaluate the management and the long-term surgical control. We describe a new case of SPN with a 10-year follow-up, and review the world literature that accounts for approximately 322 cases. Moreover, a review of the current management and surgical tendencies in the treatment of SPN is considered. An SPN pancreatic tumour occurred in a 24-year-old female who complained of episodic mild abdominal pain sustained by a palpable epigastric mass. The tumour mass was detected by ultrasound and computer tomography and was localised at the tail of the pancreas adherent to the spleen. The preoperative diagnosis was uncertain and en-block distal pancreatectomy and splenectomy were performed. The size of the mass which weighed 300 g was 11 x 12 x 8 cm, and the tumour was strictly adherent and invaded the splenic hilum. Histologic examination confirmed a complete resection of the primary SPN that locally invaded spleen. The postoperative period was uneventful and after a 10-year follow-up the patient is free of symptoms. SPN should be considered in the differential diagnosis of large pancreatic masses, especially in young females. Radical resection, where technically feasible, should be considered the therapy of choice as it is a safe and effective control of the disease.

Comparative study of non-functional islet cell tumors and pancreatic solid and papillary neoplasms: biological behavior and immunohistochemistry

Although non-functional islet cell tumor (NFICT) and solid and papillary neoplasm (SPN) share similar clinical and pathological features, the outcome of each is different. Because NFICT often follow a malignant course and SPN are usually benign, the correct differential diagnosis is very important. We investigated the clinical and pathological findings in 10 cases of NFICT and 12 cases of SPN, including immunohistochemical analysis for chromogranin, vimentin, neuron-specific enolase, somatostatin, alpha-1-antitrypsin, estrogen receptor, progesterone receptor, CD99, p21 and Ki-67. The current study shows that chromogranin is the most valuable marker in differentiating between the tumors (P < 0.01). In contrast to previous reports stating that SPN express the progesterone and/or estrogen receptors, which are absent in other pancreatic tumors, our results show that one-third of SPN were positive for the progesterone receptor. Downregulation of p21 was found more frequently in NFICT (40%) than SPN (17%). The mean value of the Ki-67 proliferation index for NFICT (2.77% +/- 2.53%) was significantly higher than that for SPN (0.94% +/- 0.89%; P = 0.043). These results are consistent with NFICT having more malignant behavior than SPN.

Pseudopapillary solid cystic tumor arising from an extrapancreatic site

A case of pseudopapillary solid cystic tumor arising in the omentum of a 46-year-old woman is presented. A well-defined, encapsulated tumor measuring 5.2 x 4.0 x 4.0 cm was histologically characterized by a combination of solid and pseudopapillary growth patterns of tumor cells with abundant pale-to-eosinophilic cytoplasm. No pancreatic tissue was observed within or adjacent to the tumor. Immunohistochemically, the tumor was positive for vimentin, epithelial membrane antigen, and alpha1-antichymotrypsin. Ultrastructurally, the tumor cells contained electron dense granules of variable sizes, most likely representing lysosomes. Flow cytometry showed a diploid DNA content with a high S-phase fraction. The patient was well without recurrence 3 months after diagnosis. It is important to include pseudopapillary solid cystic tumor in the differential diagnosis of omental tumors.

Solid-pseudopapillary tumor of the pancreas (Frantz tumor) in children: report of four cases and review of the literature

BACKGROUND

Solid-pseudopapillary tumor of the pancreas (SPT) is an exceptionally rare neoplasm in children. Its origin remains enigmatic. It is of low malignant potential and occurs most frequently in young females.

PATIENTS AND METHODS

A cumulative review of the tumor's clinicopathological characteristics from the world's literature is presented. The clinical course, pathohistologic data and outcome of surgery of four Austrian children treated at the general hospital of Vienna are analyzed.

RESULTS

Between 1987 and 1999, four girls (age: 12--16 years) with SPT were diagnosed at our institution. All patients presented with an abdominal mass and uncharacteristic abdominal pain. Two tumors were located in the tail, one in the body and tail and one in the head of the pancreas (diameter: 7--15 cm). Surgical procedures included three distal pancreatectomies and one partial duodenopancreatectomy (Whipple procedure). One patient had two recurrences with metastases that could only be partially resected. Chemotherapy was initiated for this patient. In the follow-up period (range: 6 months to 12 years) all patients are alive with no evidence of recurrence.

CONCLUSIONS

SPT is a rare differential diagnosis of a pancreatic mass in children. It is mandatory to establish this diagnosis since complete surgical removal of the tumor even in case of metastases or local invasion offers an excellent prognosis.

Solid-pseudopapillary tumor of the pancreas: immunohistochemical localization of neuroendocrine markers and CD10

To clarify the neuroendocrine differentiation and CD10 expression in solid-pseudopapillary tumors (SPTs) of the pancreas, we performed immunohistochemical analysis in 19 such tumors, including one solid-pseudopapillary carcinoma (SPC), along with 20 pancreatic neuroendocrine tumors (PNTs), six acinar cell carcinomas (ACCs), and one pancreatoblastoma (PB). We used antisera directed against CD56, synaptophysin, protein gene product 9.5, the alpha-subunit of Go protein, chromogranin A, CD10, trypsin, chymotrypsin, various cytokeratins (CKs), CA19-9, vimentin, and alpha-1-antitrypsin (AAT). All SPTs exhibited immunoreactivity for CD56 and CD10, and 15 expressed other neuroendocrine markers focally with the exception of chromogranin A. Frequent clustering of synaptophysin-positive cells was noted. Two cases contained a peculiar nodule that cytomorphologically and immunohistochemically resembled PNT. CD10-positive cells were scarce in one SPC. PNTs were CD56-positive, but often with faint intensity, and staining for other neuroendocrine markers, including chromogranin A, was diffusely positive. CD10 was detected, mostly in a focal pattern, in five PNTs. Pan-CK, CK8, CK18, and CK19 were more frequently demonstrated in PNT than SPT. Vimentin and AAT were often identified in PNT as well and were not specific for SPT. ACCs were CD56-negative, with the exception of one case designated as a mixed acinar-endocrine carcinoma. PB was focally positive for CD56 at the periphery of the tumor nests. Four ACCs and one PB exhibited focal CD10 reactivity. This study demonstrated the unique immunohistochemical features of SPT. Our results also suggest that SPT exhibits, at least focally, neuroendocrine differentiation, and that these neuroendocrine markers and CD10 are diagnostically useful.

Mucinous cystic tumors of the pancreas: clinicopathological features, prognosis, and relationship to other mucinous cystic tumors

The clinicopathological features of 56 patients with mucinous cystic tumors (MCTs) of the pancreas were studied. Particular attention was paid to the prognosis of MCTs and the relationship to their ovarian, hepatic, and retroperitoneal counterparts. To distinguish MCTs from pancreatic intraductal papillary-mucinous tumors, MCTs were defined as tumors lacking communication with the duct system and containing mucin-producing epithelium, usually supported by ovarian-like stroma. All 56 tumors occurred in women (mean age 48.2 years) and were preferentially (93%) located in the body and tail of the pancreas. In accordance with the WHO classification, MCTs were divided into adenomas (n = 22), borderline tumors (n= 12), and noninvasive and invasive carcinomas (n = 22). Survival analysis revealed the extent of invasion to be the most significant prognostic factor (p<0.0001). Malignancy correlated with multilocularity and presence of papillary projections or mural nodules, loss of ovarian-like stroma, and p53 immunoreactivity. Stromal luteinization with expression of tyrosine hydroxylase, calretinin, or alpha inhibin was found in 66% of the cases. We conclude that the biologic behavior of MCTs is predictable on the basis of the extent of invasion. The similarities (i.e. gender, morphology, stromal luteinization) between pancreatic MCT and its ovarian, hepatobiliary, and retroperitoneal counterparts suggest a common pathway for their development.