Diagnosis of solid-pseudopapillary neoplasm of the pancreas by EUS-guided FNA

Solid pseudopapillary neoplasm of the pancreas: A case report with a brief literature review

INTRODUCTION

Solid pseudopapillary neoplasm (SPN) of the pancreas, representing only 1 % of pancreatic cancers, was identified by Virginia Frantz in 1959. Predominantly affecting young females, it often remains asymptomatic, posing diagnostic challenges due to slow growth. This paper emphasizes SPN's rarity and associated diagnostic complexities.

CASE PRESENTATION

In a specific case, a 17-year-old female with post-traumatic right flank pain underwent an enhanced CT scan, revealing a well-defined, hypodense mass in the pancreatic head. With normal laboratory results, a diagnostic laparotomy exposed a sizable solid cystic mass. A Whipple procedure unveiled a predominantly cystic mass enveloped by a well-developed capsule.

DISCUSSION

SPN appears as a distinct mixed solid and cystic lesion on imaging, necessitating confirmation through core biopsy. Surgical resection, the primary treatment, ensures a positive overall prognosis, despite rare recurrence and metastases. Microscopic examination reveals pseudopapillae, and immunohistochemistry aids diagnosis with positive staining for estrogen receptor, progesterone receptor, CD10, and CD99.

CONCLUSION

SPN, a rare pancreatic neoplasm predominantly affecting young females, may present with abdominal pain or palpable mass despite its usual asymptomatic nature. Diagnosis involves imaging and biopsy confirmation, with surgical resection as the curative treatment. While prognosis is generally favorable, comprehensive understanding and improved management require further research for this uncommon pancreatic neoplasm.

Atypical solid pseudopapillary tumor of the pancreas in a 14-year-old

Diagnostic approach can be difficult in pediatric pancreatic masses. Our case shows that even though radiologic appearance was not conclusive, surgery remains the main treatment in resectable masses especially in children.

Clinical and Pathological Features of Solid Pseudopapillary Neoplasms of the Pancreas: A Nationwide Multicenter Study in Japan

OBJECTIVE

The aim of this study was to evaluate the clinicopathological features of solid pseudopapillary neoplasms (SPNs).

METHODS

In this retrospective study, 288 SPNs were analyzed.

RESULTS

Overall, 214 patients (74%) were female. Distant metastases occurred in 4 patients, and splenic vein tumor thrombus occurred in 1 patient. Although imaging findings showed large (>2.0 cm) SPNs with clear, regular border, and heterogeneous internal structure, small SPNs appeared as almost entirely solid. Surgical resection was performed in 278 cases. The 5-year survival rate was 98.8%. Six patients had tumor recurrence after the initial resection. The detection rate in typical pathological findings was low for small SPNs. Tumor extension to the pancreatic parenchyma was detected in greater than 70% of the cases. Tumor invasion to adjacent organs was detected in 13 cases. One was given a diagnosis of apparent high-grade malignant transformation.

CONCLUSIONS

The proportion of male cases was higher than that in previous studies, and there were statistically significant differences in the onset age and tumor diameter between male and female patients. Therefore, women seemed to have an early occurrence of SPNs, suggesting a difference in the developmental stage between men and women. Images and pathological findings of SPNs varied according to tumor size. Our findings indicated that SPN patients have excellent survival after margin-negative surgical resection.

Cystic lesions of the pancreas

Different types of benign or malignant cystic lesions can be observed in the pancreas. Pancreatic cystic lesions are classified under pathology terms into simple retention cysts, pseudocysts and cystic neoplasms. Mucinous cystic neoplasm is a frequent type of cystic neoplasm and has a malignant potential. Serous cystadenoma follows in frequency and is usually benign. Intraductal papillary mucinous neoplasms are the most commonly resected cystic pancreatic neoplasms characterized by dilated segments of the main pancreatic duct and/or side branches, the wall of which is covered by mucus secreting cells. These neoplasms can occupy the pancreatic head or any part of the organ. Solid pseudopapillary tumor is rare, has a low tendency for malignancy, and is usually located in the pancreatic body or tail. Endoscopic ultrasound with the use of fine-needle aspiration and cytology permits discrimination of those lesions. In this review, the main characteristics of those lesions are presented, as well as recommendations regarding their follow up and management according to recent guidelines.

Solid pseudopapillary tumor of the pancreas (Frantz's tumor): two case reports and a review of the literature

Introduction

Solid pseudopapillary tumor of the pancreas is extremely rare in children; it usually occurs in young women between 18 and 35 years of age. It comprises less than 3 % of pancreatic tumors. It is of low malignancy; however, it may be locally aggressive. Surgical resection is the treatment of choice and its prognosis is excellent.

Case presentation

Two Caucasian girls, 15 and 12 years of age were diagnosed with tumor of the pancreas. The first patient had severe abdominal pain. In the second case the tumor was asymptomatic, detected incidentally during ultrasound. Computed tomography confirmed pancreatic mass. In the first case, apart from the tumor located in the head and the body of her pancreas, focal change in her right kidney was found, which was an indication to biopsy that confirmed solid pseudopapillary tumor. In the second patient the tumor was located in the body of her pancreas, with portal vein occlusion and well-developed collateral circulation. In the first patient a pancreatoduodenectomy (Traverso-Longmire) was performed; there was no mass in her right kidney. In the second case, distal pancreatectomy and splenectomy were performed. In both cases histopathology revealed solid pseudopapillary tumor resected radically. Our first patient’s postoperative course was uneventful. In the second case, her postoperative course was complicated by necrosis of the remaining pancreatic head that needed pancreatoduodenectomy. Follow-up at 28 and 26 months revealed no evidence of tumor recurrence or metastases on magnetic resonance imaging.

Conclusions

Typical radiological appearance of solid pseudopapillary tumor is an indication for surgery. The treatment of choice is tumor resection with sparing of pancreatic tissue. In one of our two cases we performed a preoperative biopsy because of an uncharacteristic mass in her right kidney. In our second patient, necrosis of her spared pancreatic head meant that we could not preserve pancreatic tissue. Our whole diagnostic process, treatment and possible complications analysis should be of interest and noteworthy not only to surgeons as the treatment of choice is radical resection, but also to pediatric oncologists because of differentiation from other pancreatic tumors in children.

CTNNB1 mutational analysis of solid-pseudopapillary neoplasms of the pancreas using endoscopic ultrasound-guided fine-needle aspiration and next-generation deep sequencing

BACKGROUND

Solid-pseudopapillary neoplasm (SPN), a rare neoplasm of the pancreas, frequently harbors mutations in exon 3 of the cadherin-associated protein beta 1 (CTNNB1) gene. Here, we analyzed SPN tissue for CTNNB1 mutations by deep sequencing using next-generation sequencing (NGS).

METHODS

Tissue samples from 7 SPNs and 31 other pancreatic lesions (16 pancreatic ductal adenocarcinomas (PDAC), 11 pancreatic neuroendocrine tumors (PNET), 1 acinar cell carcinoma, 1 autoimmune pancreatitis lesion, and 2 focal pancreatitis lesions) were analyzed by NGS for mutations in exon 3 of CTNNB1.

RESULTS

A single-base-pair missense mutations in exon 3 of CTNNB1 was observed in all 7 SPNs and in 1 of 11 PNET samples. However, mutations were not observed in the tissue samples of any of the 16 PDAC or other four pancreatic disease cases. The variant frequency of CTNNB1 ranged from 5.4 to 48.8 %.

CONCLUSIONS

Mutational analysis of CTNNB1 by NGS is feasible and was achieved using SPN samples obtained by endoscopic ultrasound-guided fine needle aspiration.

Endoscopic ultrasound-guided fine needle aspiration improves the pre-operative diagnostic yield of solid-pseudopapillary neoplasm of the pancreas: an international multicenter case series (with video)

BACKGROUND/OBJECTIVES

Solid-pseudopapillary neoplasms (SPNs) are rare pancreatic tumors, which occur most frequently in young women and are associated with an excellent prognosis. Computed tomography (CT) is used most commonly to identify these lesions, but there are few studies evaluating the role of endoscopic ultrasound (EUS) and fine needle aspiration (EUS-FNA) in the assessment of SPN. The aim of the study was to determine the incremental diagnostic yield of EUS-FNA compared with CT or EUS in the evaluation of patients with SPN.

METHODS

A retrospective chart review of consecutive patients diagnosed with SPN who underwent CT, EUS, and EUS-FNA at five centers from three countries from 1998 to 2013. Patient demographics, imaging, endoscopic studies, cytopathology, and histology were reviewed.

RESULTS

Thirty-four patients were identified with SPN. There were 31 (91.2 %) females, with a mean age at diagnosis of 37 years (range 16-81). The most common presenting symptom was abdominal pain which was present in 59 %. SPNs were incidentally detected in 14 (41.2 %) of the patients. The median tumor size was 4.2 cm (range 1.9-9.4). No patient had evidence of local or distant metastases. The most common appearance on EUS was of a mixed solid-cystic lesion (67.6 %). The diagnostic yield of CT and EUS alone was 23.5 and 41.2 %, respectively. CT and EUS combined had a diagnostic yield of 52.9 %. The addition of EUS-FNA significantly increased the diagnostic yield to 82.4 % compared with either CT or CT and EUS (p < 0.005). There were no reported adverse events reported.

CONCLUSIONS

SPNs are rare pancreatic tumors primarily affecting young women. The addition of EUS-FNA significantly increased the pre-operative diagnostic yield of SPN to 82.4 %.

Clinical presentation and comparison of surgical outcome for segmental resection vs. Whipple's procedure for solid pseudopapillary tumor: Report of six new cases & literature review of 321 cases

AIM

Report 6 new cases of solid-pseudopapillary-pancreatic-tumor, comprehensively review 321 cases reported in American literature, and compare outcomes for segmental resection vs.. Whipple's procedure.

METHODS

Cases of solid-pseudopapillary-tumor at William Beaumont Hospital, 1999-2011, identified by computerized analysis of pathology reports. Comprehensive review of all American cases identified by computerized literature review. Segmental resection includes open/laparoscopic central pancreatectomy and anatomic distal pancreatectomy, but excludes enucleation.

RESULTS

Six cases of solid-pseudopapillary-pancreatic-tumors (0.5% of all solid pancreatic lesions), occurred during 1999-2011 at the hospital. Mean age at diagnosis = 27.7 years. All 6 were female. All patients had abdominal pain. Mean symptom duration = 10.0 days. All patients had normal routine blood tests. Mean APACHE II score at diagnosis = 1.8. All six patients had single heterogeneous lesions, with cystic/solid components. All patients underwent surgery: segmental resection-4, Whipple's procedure-2. Tumors were uniformly diagnosed by surgically resected tissue. Mean tumor size = 5.7 cm. Mean postoperative length of stay = 4.0 days for segmental resection (N = 4) vs. 14.0 days for Whipple's procedure (N = 2). All 6 patients are alive and well to-date, without evident local recurrence or metastasis. In a literature review, 45 patients undergoing Whipple's procedure versus 34 patients undergoing segmental resection, had significantly longer mean postoperative hospitalization (16.4 vs. 4.3 days, p = 0.01), and had increased unadjusted mortality (20.2% vs. 2.2%, p = 0.018). However, this mortality difference became insignificant when adjusting for longer mean follow-up of Whipple's procedure patients (Kaplan-Meier-survival-curve, p = 0.75).

CONCLUSIONS

This work suggests segmental resection of these pancreatic tumors localized to the body/tail may have a better surgical outcome than Whipple's procedure for tumors localized to the pancreatic head. Further studies are necessary.

Solid pseudopapillary neoplasm of the pancreas

Solid pseudopapillary neoplasms (SPNs) are rare entities accounting for between 0.13 and 2.7 per cent of pancreatic tumours. This neoplasm has a predilection for females under the age of 35. The authors report this case of a SPN incidentally discovered when a 59-year-old female underwent a chest x-ray to investigate a wheeze. A subsequent CT abdomen revealed a 10 cm well-circumscribed mass adjacent to the tail of the pancreas. This mass was successfully resected. Immunohistochemical markers established the diagnosis of a SPN. The wheeze associated with the presentation of this case was unrelated to the tumour which was an incidental finding. These neoplasms are largely asymptomatic and indolent reaching a large size before detection. Diagnosis is confirmed on histology and in this case surgical resection was curative and there was no metastasis at presentation.

Pancreatic solid pseudopapillary tumours - EUS FNA is the ideal tool for diagnosis

BACKGROUND

Solid pseudopapillary tumour (SPT) is a rare tumour of the pancreas with low malignant potential affecting mainly young women difficult to diagnose preoperatively. The aim of this study is to describe the endoscopic ultrasound (EUS) features and utility of EUS-guided fine needle aspiration (FNA) in diagnosing these tumours.

METHODS

A retrospective analysis of SPTs identified in a tertiary institution EUS database between April 2002 and April 2009 was performed. Medical records, imaging, EUS features, cytology and histology specimens were reviewed. Patients were followed up until April 2009.

RESULTS

Seven cases of SPTs were indentified out of 2400 EUS performed. All patients were females with a mean age of 41 years (range 22-69). The tumours were solitary with a mean diameter of 2.9 cm (range 2-4.3 cm). Five tumours were located in the body and tail of the pancreas and two in the neck. All lesions were hypoechoic, heterogenous and well circumscribed, with five having a cystic component and two having a calcified rim. FNA using a 22-gauge needle was performed in six cases with no complications. A preoperative diagnosis of SPT based on cytology was obtained in 5/6 cases (83%). Surgical resection was done in six cases with confirmation of SPT and no metastatic disease.

CONCLUSION

EUS-guided FNA is a minimally invasive, safe and reliable way of diagnosing SPT by providing characteristic cytological specimens. Definitive preoperative diagnosis leads to targeted and minimally invasive surgical resection.

Solid pseudopapillary neoplasms of the pancreas

SPN is a rare neoplasm that affects mainly young women. Despite this feature, SPN have been seen in both genders, multiple races, and at a wide range of ages. The genetic mechanism behind the development of SPN is distinct from the more lethal ductal carcinoma of the pancreas. This difference is reflected in the favorable outcome for patients with SPN. Surgery is typically curative in patents with localized disease and possibly in patients with limited metastasis or local extension. No consensus exists on an effective systemic therapy. There are no reliable predictors for disease-specific mortality or recurrence in the minority of patients who develop aggressive disease.

Role of endosocopic ultrasound in the diagnosis of cystic tumours of the pancreas

With the increased use of sophisticated imaging, cystic lesions in the pancreas are being recognized with greater frequency. Although imaging alone may not provide a specific diagnosis in many cases, a combination of imaging characteristics, clinical presentation, and additional procedures such as endoscopic ultrasound guided fine needle aspiration of cystic lesion, allows appropriate management. Cystic lesions in the pancreas can be divided pathologically into congenital cysts, pseudocysts and cystic neoplasm. At least four different types of cystic neoplasm have been described: mucinous neoplasms, intraductal papillary mucinous neoplasms, serous neoplasms and papillary cystic neoplasms The most important diagnosis is differentiating between mucinous and non-mucinous cystic lesion because of their different potential of malignancy. Endoscopic ultrasound provides the highest resolution of the pancreas and endoscopic ultrasound-fine needle aspiration can supply further diagnostic information on the basis of cytology, fluid viscosity, concentration of tumour glycoproteins, amylase level, molecular analysis that may contribute to the better clinical outcome of these neoplasms.

ACG practice guidelines for the diagnosis and management of neoplastic pancreatic cysts

The diagnosis and management of pancreatic cystic lesions is a common problem. At least 1% of hospitalized patients at major medical centers will have a pancreatic cystic lesion on cross sectional imaging. Up to a quarter of all pancreata examined in an autopsy series contained a pancreatic cyst, 16% of which were lined by an "atypical" epithelium and 3% of which had progressed to carcinoma-in-situ (high grade dysplasia). in the past, it was thought these cystic lesions were benign, but increasing evidence points to the cystic lesions as being the origin of some pancreatic malignancies. The most important clinical tools in the diagnosis and management of pancreatic cystic lesions are cross sectional imaging, endoscopic ultrasound, and cyst fluid analysis. The most important differential diagnosis is distinguishing mucinous (pre-malignant) and non-mucinous cystic lesions. The findings of a macrocystic lesion containing viscous fluid rich in CEA are supportive of a diagnosis of a mucinous lesion. Serous lesion are the most common non-mucinous cyst and are characterized by a microcystic morphology, non-viscous fluid and a low concentration of CEA in the cyst fluid. The following document includes a description of neoplastic pancreatic cysts, a critical review of relevant diagnostic tests, and a discussion of treatment options. We have proposed a set of guidelines for the diagnosis and management of patients with neoplastic pancreatic cysts. The guidelines are based on published data backed by an analysis of the quality of the data and are designed to address the most frequent and important clinical scenarios. In addition to providing a summary of the diagnostic data, we offer diagnostic and management suggestions based on 13 common clinical problems. Although the field is rapidly evolving, a set of core principles is provided based on a balance between the risk of malignancy and the benefit of pancreatic resection.