Peritoneal metastatic disease in a child after excision of a solid pseudopapillary tumour of the pancreas: a unique case

Late Recurrence of Pancreatic Solid Pseudopapillary Neoplasm With Peritoneal Carcinomatosis Treated With Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): A Case Report

Pancreatic solid pseudopapillary neoplasm (SPN) is a rare malignant tumour predominantly affecting young women. The occurrence of peritoneal carcinomatosis (PC) in this setting is an even rarer condition, usually related to perioperative tumour rupture. We present a case of a 43-year-old woman who previously underwent distal splenopancreatectomy after the diagnosis of a pancreatic SPN. Thirteen years later, the patient underwent a radical hysterectomy due to a uterine myoma. Intraoperatively, a peritoneal mass was additionally found and resected. Histological examination revealed an implant with morphology compatible with pancreatic SPN. The patient was then referred to our institution. Staging MRI and CT revealed multiple nodular lesions adjacent to the left colon, suggestive of peritoneal implants. The patient was then submitted to cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin and irinotecan. Histological examination confirmed peritoneal involvement by a pancreatic SPN. The postoperative course was unremarkable. Two years after surgery, the patient remains asymptomatic with no evidence of relapse. Despite SPN being cancer with a relatively indolent evolution, one needs to be aware of a possible recurrence several years after the primary resection, mainly in patients with evidence of intraoperative tumour rupture.

Features and Treatment of Peritoneal Metastases from Solid Pseudopapillary Neoplasms of the Pancreas

Background

Solid pseudopapillary neoplasms (SPNs) of the pancreas may present widespread peritoneal metastases, but the treatment of this malignancy has not been well described and requires further investigation.

Material/Methods

Four cases of SPN with significant peritoneal metastases in our department were operated and retrospectively summarized after long-term follow-up. Eight more cases of peritoneal metastatic SPN from the PubMed database were also included in the analysis.

Results

Peritoneal metastases of SPNs have different gross features. The benign nodules were tenacious and well encapsulated, while the malignant nodules were soft and prone to slow bleeding. However, neither of these nodules invaded the small intestines or mesentery. Of the 12 disseminated cases, 7 had history of primary tumor rupture, whereas the others had tumors malignant in nature. A total of 14 surgical events were documented, including 3 complete cytoreductive surgeries (CCRS), 9 cytoreductive surgeries (CRS), and 2 debulking surgeries. After follow-up ranging from 0.3 to 6.1 years, the results of the Fisher’s exact test showed no difference between CCRS and CRS in treating either low-grade or high-grade malignant SPNs (P=0.257 and P=0.203, respectively). For all cases of SPN with peritoneal metastases, the CCRS procedure could significantly improve tumor-free survival (TFS) compared to the CRS procedure (P=0.046).

Conclusions

SPN rupture could cause significant peritoneal metastases, and either disruption or biopsy of these lesions should be avoided. Peritoneal metastases from SPNs vary both in gross features and biological mechanisms. CCRS may offer optimal therapeutic outcomes and longer TFS for individuals with significant peritoneal metastases of SPNs.

Solid pseudopapillary tumour (Frantz's tumour) of the pancreas in childhood: successful management of late liver metastases with sunitinib and chemoembolisation

The patient is a girl aged 17 years who originally presented at age 11 years with a solid pseudopapillary tumour (SPT) in the head of the pancreas treated by an R0 pylorus-preserving Whipple procedure. The patient underwent surveillance CT every 3 months for the first year followed by MRI every 6 months. She was noted to have a new liver lesion in Couinaud segment VI highly suspicious for metastasis at 30 months. Liver wedge biopsy confirmed metastatic SPT. Two months later two new lesions were noted in Couinaud segment VII. The family preferred medical management to surgery resulting in a treatment combination of the tyrosine kinase inhibitor sunitinib and hepatic artery embolisation. The patient developed a hepatic abscess following embolisation but recovered with antibiotics. The patient has subsequently been followed with serial MRIs every 3 months, and 20 months following chemoembolisation, she has no evidence of recurrence of the metastases.

Recurrence of Solid Pseudopapillary Neoplasms of the Pancreas: Results of a Nationwide Study of Risk Factors and Treatment Modalities

BACKGROUND

Solid pseudopapillary neoplasms of the pancreas (SPPN) can relapse very late, but little is known about risk factors for recurrence and optimal treatment. We aimed to identify risk factors for recurrence and to analyze treatment modalities in all French pediatric cases of SPPN over the past 20 years.

MATERIAL AND METHODS

Data were collected from pediatric oncologists and surgeons, and also from adult pancreatic surgeons in order to identify late recurrences.

RESULTS

Fifty-one patients (41 girls) were identified. Median age at diagnosis was 13.1 years [8.7-17.9]. Abdominal pain was the commonest presenting symptom (32/49, 65%). The tumor was located in the pancreatic head in 24 patients (47%). Preoperative biopsy or cytology was performed in 14 cases (28%). All patients were operated with a median of 23 days [0-163] after diagnosis. The rate of postoperative morbidity was 29%. With a median follow-up of 65 months [0.3-221], the overall and event-free survival was 100% and 71%, respectively. Seven patients (13.7%) relapsed with a median of 43 months [33-94] after initial surgery. Six were treated surgically, either alone (n = 3) or with perioperative chemotherapy (n = 2) or hyperthermic intraperitoneal chemotherapy (n = 1). One patient in whom further treatment was not feasible was still alive at last news. Risk factors for recurrence were positive surgical margins (P = 0.03) and age less than 13.5 years at diagnosis (P = 0.03).

CONCLUSIONS

SPPN recurrence in this pediatric series was a rare and late event that did not undermine overall survival. Complete surgical removal of recurrent tumors appears to be the best option.

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.

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.

[The pseudopapillary tumor of the pancreas (or Frantz's tumor)]

The pseudopapillary tumor of the pancreas (or Frantz's tumor) is a rare exocrine pancreatic tumor with a low degree of malignancy. It occurs more frequently among women between 20 and 40 years of age and in the Asian population. This tumor is rarer in the pediatric population. The symptoms are subtle, the most striking being pain and an abdominal mass. Pathologically, the tumor is usually well circumscribed with regions of necrosis, hemorrhage and cystic degeneration. A thick, fibrous capsule is often present. The low grade of malignancy of this tumor with a fibrous capsule led to perform a surgical resection. The localization and local invasion determine the surgical technique. Despite its potential for local infiltration and metastatic disease (up to 15% confined often to the liver), the prognosis is favorable after a surgical resection with correct margins. Long follow-up is necessary to detect a possible recurrence, even late.

Is laparoscopic management suitable for solid pseudo-papillary tumors of the pancreas?

PURPOSE

Solid pseudo-papillary tumors (SPT) are rare pancreatic neoplasms of low-malignant potential occurring mainly in young women. The purpose of this report is to describe our experience with laparoscopic management of these tumors with 4-year follow-up.

METHODS

Three children with SPT were admitted to two hospitals in Paris, France, between February 2000 and December 2006. Diagnosis or treatment was carried out using laparoscopic techniques (biopsy and resection in one case and biopsy only in two). Long-term follow-up data were collected.

RESULTS

All three patients presented recurrences within 3 years after resection, i.e., disseminated peritoneal recurrence in two patients and local recurrence in one. The two patients with peritoneal recurrences were treated by surgical resection and chemotherapy. The patient with local recurrence could not be treated due to contraindicating local factors. All three patients were alive at the time of this writing.

CONCLUSION

This is the first report describing long-term follow-up after laparoscopic management of SPT. All three patients developed recurrences. These poor results contrast sharply with the low risk of local or disseminated recurrence after open laparotomy without chemotherapy that has been considered as the treatment of choice up to now. Recurrences after laparoscopic management may have been due to diffusion of tumor cells caused by gas insufflation especially during biopsy. Laparoscopic biopsy should not be performed in patients presenting SPT.

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.