A systematic review of solid-pseudopapillary neoplasms: are these rare lesions?

Rare pancreatic cystic neoplasms: A pictorial review

Since rare pancreatic cystic tumors may differ from common pancreatic cystic neoplasms in terms of treatment plan and prognosis, the differential diagnosis of these diseases is clinically relevant. Various imaging tests play an important role in the differential diagnosis of rare cystic pancreatic tumors, but accurately distinguishing these diseases solely on the basis of imaging findings is challenging. The purpose of this pictorial review is to present CT and in particular MR imaging features of rare pancreatic cystic tumors and discuss potential elements for differential diagnosis.

Spontaneous rupture of solid pseudopapillary neoplasm (SPN) of the Pancreas - imaging insights and review of the literature

Solid pseudopapillary neoplasm (SPN) of the pancreas, are rare low-grade malignant pancreatic tumors, most commonly occurring in young women during their second or third decade of life. They can present with vague abdominal symptoms like pain, discomfort, and nausea, or it can be incidentally discovered on imaging studies. There has been limited literature on ruptured SPN, which can be spontaneous or traumatic. In this paper, we present three cases of ruptured SPN, one traumatic and two spontaneous, to add to the scarcity of knowledge regarding this condition and its radiologic features, along with a detailed review of current literature.

Solid pseudopapillary neoplasm of the pancreas in an adolescent: A case report and review of the literature

BACKGROUND

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare epithelial tumor that primarily affects young women. Since the condition is often asymptomatic or presents with non-specific symptoms, its diagnosis can be difficult.

CASE SUMMARY

This report details the case of a 15-year-old girl who presented with a 2-year history of abdominal pain, with no significant findings during physical examination. Abdominal ultrasound revealed a well-defined heterogeneous solid-cystic mass in the epigastric region, likely originating from the tail of the pancreas. A subsequent contrast-enhanced computed tomography scan indicated a well-defined cystic lesion with an enhancing solid component and capsule in the tail of the pancreas, suggestive of a cystic neoplasm. The patient underwent an open distal pancreatectomy with splenectomy, and histopathological analysis confirmed the diagnosis of SPN of the pancreas.

CONCLUSION

This case highlights the risk of SPN in adolescent girls and the necessity of early diagnosis and intervention for better outcomes.

A rare case of a large solid pseudopapillary neoplasm with extensive liver metastasis

Solid pseudopapillary neoplasms (SPNs) are uncommon pancreatic tumors that primarily affect young females. We report a case of a 24-year-old female diagnosed with SPN and liver metastasis during a routine examination. Imaging revealed an 8-cm pancreatic mass with multiple liver metastases. Histopathology confirmed SPN. Subsequent next-generation sequencing revealed a CTNNB1 mutation. The patient underwent a total pancreatectomy with splenectomy, right hemihepatectomy, and intraoperative radiofrequency ablation. Two years after the surgery, she remained complication-free. She is under regular surveillance. This case underscores the importance of early detection and comprehensive management of SPN.

An innovative surgical approach for solid pseudopapillary neoplasm with duodenal invasion in a pediatric patient: a case report

BACKGROUND

Pediatric pancreatic tumors, especially with duodenal invasion, are exceptionally rare and a strategy for their treatment has not been established. A pancreaticoduodenectomy is often the desired treatment, but may be over-invasive for solid pseudopapillary neoplasm (SPN). This study reports an innovative surgical approach for SPN with duodenal invasion using pancreatic enucleation and endoscopically guided partial duodenectomy.

CASE PRESENTATION

An 11-year-old girl complained of malaise and presented with severe anemia; imaging revealed a tumor of undetermined origin, involving the pancreatic head and descending duodenum. Intraoperative findings showed tumor adherence to the pancreatic head and endoscopy revealed invasion of the duodenum. The tumor was enucleated from the pancreatic head, and partial duodenectomy was performed under endoscopically guided direct visualization. Pathology confirmed SPN with duodenal invasion, and no residual tumor. Although a Grade B pancreatic fistula occurred postoperatively, it was managed conservatively. At the 15-month follow-up, no signs of tumor recurrence, duodenal stenosis, or pancreatic dysfunction were evident.

CONCLUSIONS

Given the good prognosis of SPN, we believe that enucleation from the pancreatic head combined with an endoscopically guided partial duodenectomy could be a useful and less invasive alternative to pancreaticoduodenectomy for cases with duodenal invasion.

A case of laparoscopic spleen-preserving distal pancreatectomy for small solid pseudopapillary neoplasm in an adult male with anomalous splenic vein confluence

Although anomalies of the celiac and/or superior mesenteric arteries are occasionally encountered during abdominal surgery, anomalous venous confluence is seldom reported during pancreatic surgery. Herein, we present a rare case of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for the treatment of a solid pseudopapillary neoplasm in an asymptomatic 37-year-old male with an anomalous splenic vein (SpV) confluence. Computed tomography angiography (CTA) revealed an anomaly of the SpV, which coursed transversely through the superior border of the pancreas, over the celiac artery and into the portal vein, along the superior line of the common hepatic artery. We successfully performed an LSPDP without peripancreatic vessel injury by exposing the SpV and splenic artery through an approach from the superior position of the pancreas. Preoperative imaging, especially CTA, is crucial to ensuring a safe, successful laparoscopic pancreatectomy.

Clinical Insights Into Pediatric Solid Pseudopapillary Neoplasms of the Pancreas

BACKGROUND

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare tumors with low malignant potential that usually occur in young girls and women. This study investigated the treatment experiences and outcomes after surgery for pediatric SPNs in our institutions as pediatric case series of solid SPNs are few, and long-term follow-up is also limited.

METHODS

We retrospectively reviewed the outcomes of nine patients diagnosed with SPNs who underwent surgery in our three hospitals (The Jikei University Hospital, The Jikei University Kashiwa Hospital, and Kawaguchi Municipal Medical Center) between 2001 and 2023.

RESULTS

All nine patients who underwent surgery were girls. Their ages ranged from 8 to 15 years (median: 10 years). The location of the tumor was at the pancreatic head, body, and tail in five, one, and three patients, respectively. Enucleation, pancreaticoduodenectomy, and laparoscopic distal pancreatectomy (LDP) were performed in four, two, and three patients, respectively. Regarding postoperative complications, a pancreatic fistula was detected in six patients, with three and three patients having grades A and B fistulas, respectively; two patients required percutaneous drainage, and one patient required endoscopic ultrasonography (EUS)-guided transgastric drainage. The follow-up period ranged from six to 261 months (median: 97 months). At the final follow-up, all nine patients were alive without recurrence.

CONCLUSION

SPNs of the pancreas are incidentally diagnosed by diagnostic workups following trauma in children more frequently compared to adults. Additionally, the tumor resection by minimally invasive approaches, such as enucleation, or laparoscopic procedures results in a good prognosis in some cases.

Solid pseudopapillary neoplasms of the pancreas (SPNs): diagnostic accuracy of CT and CT imaging features

PURPOSE

To summarize the abdominal computed tomography (CT) imaging and clinicopathological data of patients with SPNs of the pancreas and analyze the accuracy of preoperative CT diagnosis and features.

MATERIALS AND METHODS

Between June 2006 and June 2023, CT images of 120 histopathologically proven SPNs in the pancreas were retrospectively reviewed. Fifteen features, including age, sex, and CT-determined features, were included in a multiple stepwise regression analysis. The correlations between features and SPNs, including odds ratios (ORs) and 95% confidence intervals (CIs), were evaluated.

RESULTS

Among the 120 patients, the diagnostic accuracy of CT was 43.3%. The baseline CT results of patients with a correct diagnosis and misdiagnosis revealed significant differences in sex (P = 0.043), age (P = 0.004), boundary (P = 0.037) and encapsulation (P = 0.002) between the two groups. The preoperative imaging diagnostic accuracy was significantly greater in females than in males (47.9% vs. 25.0%, P = 0.043). The immunohistochemical indices did not significantly differ between the two groups. The results of univariate analysis revealed significant differences in sex (P = 0.048), age (P = 0.014), tumor length (P = 0.023), tumor boundaries (P = 0.039) and capsule type (P = 0.003). The results of multivariate analysis revealed that encapsulation was closely related to the diagnostic accuracy of CT (P = 0.04).

CONCLUSIONS

The accuracy of CT in the diagnosis of SPNs is low, but a length‒diameter ratio of the tumor approaching 1.0, encapsulation and clear boundaries are important CT-determined features. The capsule is an independent CT predictor in the diagnosis of SPNs.

Unresectable Metastatic Solid Pseudopapillary Pancreatic Neoplasm Treated With Liver Transplantation

We present a 49-year-old woman requiring living donor liver transplantation after liver metastasis from a pancreatic solid pseudopapillary tumor. After identifying a pancreatic mass and liver lesions, she underwent extensive surgical resection. Pathology revealed a solid pseudopapillary neoplasm of the head and body of the pancreas, extending into the peripancreatic soft tissues and confirmed to have spread to the liver. Subsequently, she underwent adjuvant chemotherapy and radiofrequency ablations of the new liver lesions. Despite immunotherapy and chemotherapy, there was a progression of the lesions. With interval growth of liver lesions, without evidence of extrahepatic disease, she underwent living donor liver transplantation.

Diagnosis and Management of Pancreatic Cysts

As pancreatic cyst incidence rises, likely due to the ubiquitous increase in cross-sectional imaging, their management presents multiple challenges for both the practitioner and patient. It is critical that all pancreatic cysts are appropriately characterized, as treatment decisions depend on an accurate diagnosis. Diagnostic modalities such as cytology, biopsy, and cyst fluid biomarkers allow for definitive diagnosis of virtually all lesions. Some cysts, such as intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, and cystic pancreatic endocrine neoplasms, have malignant potential and must be surveyed. Other cysts, such as serous cystadenomas and pancreatic fluid collections, do not have malignant potential. Surveillance strategies vary widely depending on cyst type and size and while multiple medical societies advocate surveillance, their published surveillance guidelines are heterogenous. Cysts with high-risk stigmata or worrisome features are usually resected, depending on the patient's surgical fitness. In patients unfit for resection, newer endoscopic ablative techniques are advocated. Controversial aspects regarding cyst management include whether surveillance can be stopped, how surveillance should be performed, and the extensive financial burden cyst management places on the health care system. Further study into the natural history of cystic lesions, including definitive determination of the rate of malignant transformation for each cyst type, is essential.

Triglyceride-glucose index and glycemic dynamics in pancreatic ductal adenocarcinoma: implications for disease progression and prognosis

BACKGROUND

To elucidate the relationship between the triglyceride-glycemic index (TyG) and clinical characteristics of pancreatic ductal adenocarcinoma (PDAC).

METHODS

A total of 1,594 individuals diagnosed with pancreatic and periampullary neoplasms were categorized into four groups: PDAC-early (n = 403), locally advanced PDAC (LAPC, n = 315), PDAC-late with distant metastasis (n = 371), and other tumor types (n = 505). TyG-high was defined as a TyG index greater than 8.81 in males and 8.73 in females.

RESULTS

The prevalence of TyG-high status was highest in PDAC-early (68.48%), followed by LAPC (53.33%), and lowest in PDAC-late (44.47%). TyG-high status significantly predicted worse PDAC prognosis (P = 0.0166), particularly in PDAC-late (P = 0.0420). Despite similar blood glucose levels across PDAC groups (P = 0.897), PDAC-early patients showed significantly higher rates of glycemic disturbances (56.33% vs. 32.28%) and TyG-high status (68.48% vs. 47.13%) compared to those with other tumors. Progressive increases in glycemic disturbances and TyG-high status were observed from benign to pre-malignant lesions and PDAC-early. PDAC-early patients at the pancreatic head exhibited higher rates of glycemic disturbances (58.12% vs. 33.33%, P < 0.0001), larger pancreatic duct diameters (0.4056 cm vs. 0.3398 cm, P = 0.0043), and poorer prognosis compared to periampullary cancers, although the TyG-high rate and body mass index were similar.

CONCLUSION

The TyG index exhibits a complex association with PDAC stages, profoundly shaping glycemic profiles. At the initial stages of PDAC, a notable elevation in TyG-high status and glycemic disturbances is observed. However, in advanced PDAC, while the TyG-high rate diminishes, abnormal glucose levels persist.

A narrative review on rare types of pancreatic cancer: should they be treated as pancreatic ductal adenocarcinomas?

Pancreatic cancer is one of the deadliest malignancies in humans and it is expected to play a bigger part in cancer burden in the years to come. Pancreatic ductal adenocarcinoma (PDAC) represents 85% of all primary pancreatic malignancies. Recently, much attention has been given to PDAC, with significant advances in the understanding of the mechanisms underpinning disease initiation and progression, along with noticeable improvements in overall survival in both localized and metastatic settings. However, given their rarity, rare histological subtypes of pancreatic cancer have been underappreciated and are frequently treated as PDAC, even though they might present non-overlapping molecular alterations and clinical behavior. While some of these rare histological subtypes are true variants of PDAC that should be treated likewise, others represent separate clinicopathological entities, warranting a different therapeutic approach. In this review, we highlight clinical, pathological, and molecular aspects of rare histological types of pancreatic cancer, along with the currently available data to guide treatment decisions.

Solid pseudopapillary neoplasm of the pancreas with hepatic metastases: problems and strategies

Background

Solid pseudopapillary neoplasms of the pancreas with hepatic metastases are infrequent and difficult to diagnose, and treatment is uncertain.

Methods

A retrospective analysis of clinical data from patients with pancreatic solid pseudopapillary neoplasm (SPN) hepatic metastases who underwent surgery at the First Hospital of Jilin University from January 2005 to December 2021 was conducted. A total of 287 patients with SPN were included in the study, of which 8 (3%) developed liver metastases, all of whom were treated surgically and recovered well after surgery. The clinical presentation, imaging features, surgical treatment, histopathological examination, and postoperative follow-up data (mean 70 months; range 28-138 months) of the patients were recorded and analyzed. Clinical response strategies can be derived by reviewing previous studies on hepatic metastases of SPNs.

Results

For resectable hepatic metastases from pancreatic solid pseudopapillary neoplasms, early surgery with total resection of the primary tumor and metastasis has shown great efficiency and is associated with patient good prognosis. In patients presenting unresectable hepatic metastases, aggressive tumor reduction surgery resulted in the alleviation of clinical symptoms and reduction of tumor burden while potentially achieving long-term survival.

Conclusion

For hepatic metastases of SPNs, a preoperative liver tissue biopsy is beneficial for a definitive diagnosis. Surgery demonstrates excellent therapeutic efficacy and is considered the preferred curative treatment approach. This paper presents clinical experiences with SPN-related hepatic metastases at the Affiliated Hospital of Jilin University, which can be used to guide patient counseling in clinical practice.

Rare case of solid pseudopapillary neoplasm of the pancreas with liver and splenic metastasis in a 19-year-old girl

INTRODUCTION

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare neoplasms, accounting for only 1 %-2 % of all pancreatic tumors, and predominantly affect female patients.

CASE PRESENTATION

The present case report details a patient presenting to the emergency department with abdominal pain for 3 days who ultimately received a diagnosis of SPNs in the pancreatic body and tail. A contrast-enhanced computed tomography (CT) scan revealed a sizable mass arising from the pancreas, featuring an enhancing cystic component with involvement of the liver and spleen. The patient underwent subsequent exploratory laparotomy, a distal pancreatectomy, splenectomy, and partial hepatectomy. SPN diagnosis was confirmed by histopathology and immunohistochemistry with negative resection margins.

CLINICAL DISCUSSION

Approximately 70 % of SPN cases are asymptomatic and are incidentally discovered. Despite advances in diagnostic modalities, preoperative diagnosis of SPNs remains a clinical challenge. Surgical management with negative resection margins remains the primary treatment approach. The recurrence rate after surgical resection has been reported to be 3 %-9 %. The prognosis for SPNs limited to the pancreas is generally favorable, with a cure rate exceeding 95 % after complete surgical resection.

CONCLUSION

An SPN of the pancreas is a rare tumor observed in young female patients. Although it is classified as a malignant tumor, SPN has low malignant potential. Aggressive surgical resection, however, has proven effective in curing SPN for the majority of patients.

Imaging differentiation of solid pseudopapillary neoplasms and neuroendocrine neoplasms of the pancreas

Purpose

The present study aimed to compare the computed tomography (CT) and magnetic resonance imaging (MRI) features of solid pseudopapillary neoplasms (SPNs) and pancreatic neuroendocrine neoplasms (pNENs).

Method

Lesion imaging features of 39 patients with SPNs and 127 patients with pNENs were retrospectively extracted from 104 CT and 91 MRI scans.

Results

Compared to pNEN patients, SPN patients were significantly younger (mean age 51.8 yrs versus 32.7 yrs) and more often female (female: male ratio, 5.50:1 versus 1.19:1). Most SPNs and pNENs presented as well-defined lesions with an expansive growth pattern. SPNs more often appeared as round or ovoid lesions, compared to pNENs which showed a lobulated or irregular shape in more than half of cases (p<0.01). A surrounding capsule was detected in the majority of SPNs, but only in a minority of pNENs (<0.01). Hemorrhage occurred non-significantly more often in SPNs (p=0.09). Signal inhomogeneity in T1-fat-saturated (p<0.01) and T2-weighted imaging (p=0.046) as well as cystic degeneration (p<0.01) were more often observed in SPNs. Hyperenhancement in the arterial and portal-venous phase was more common in pNENs (p<0.01). Enlargement of locoregional lymph nodes (p<0.01) and liver metastases (p=0.03) were observed in some pNEN patients, but not in SPN patients. Multivariate logistic regression identified the presence of a capsule (p<0.01), absence of arterial hyperenhancement (p<0.01), and low patient age (p<0.01), as independent predictors for SPN.

Conclusions

The present study provides three key features for differentiating SPNs from pNENs extracted from a large patient cohort: presence of a capsule, absence of arterial hyperenhancement, and low patient age.

Solid pseudopapillary neoplasms of the pancreas: Multicenter Vasepa study

INTRODUCTION

Solid pseudopapillary tumors (SPT) of the pancreas are rare exocrine neoplasms of the pancreas. Correct preoperative diagnosis is not always feasible. The treatment of choice is surgical excision. These tumors have a good prognosis with a high disease-free survival rate.

OBJECTIVE

To describe the clinicopathological and radiological characteristics as well as short- and long-term follow-up results of patients who have undergone SPT resection.

METHODS

Multicenter retrospective observational study in patients with SPT who had undergone surgery from January 2000-January 2022. We have studied preoperative, intraoperative, and postoperative variables as well as the follow-up results (mean 28 months).

RESULTS

20 patients with histological diagnosis of SPT in the surgical specimen were included. 90% were women; mean age was 33.5 years (13-67); 50% were asymptomatic. CT was the most used diagnostic test (90%). The most frequent location was body-tail (60%). Preoperative biopsy was performed in 13 patients (65%), which was correct in 8 patients. Surgeries performed: 7 distal pancreatectomies, 6 pancreaticoduodenectomies, 4 central pancreatectomies, 2 enucleations, and 1 total pancreatectomy. The R0 rate was 95%. Four patients presented major postoperative complications (Clavien-Dindo > II). Mean tumor size was 81 mm. Only one patient received adjuvant chemotherapy. With a mean follow-up of 28 months, 5-year disease-free survival was 95%.

CONCLUSION

SPT are large, usually located in the body-tail of the pancreas, and more frequent in women. The R0 rate obtained in our series is very high (95%). The oncological results are excellent.

Surgical Outcomes of Pancreatic Solid Pseudopapillary Neoplasm: Experiences of 24 Patients in a Single Institute

Background and Objectives: The pancreatic solid pseudopapillary neoplasm (SPN), a rare tumor predominantly affecting young women, has seen an increased incidence due to improved imaging and epidemiological knowledge. This study aimed to understand the outcomes of different interventions, possible complications, and associated risk factors. Materials and Methods: This study retrospectively analyzed 24 patients who underwent pancreatic surgery for SPNs between September 1998 and July 2020. Results: Surgical intervention, typically required for symptomatic cases or pathological confirmation, yielded favorable outcomes with a 5-year survival rate of up to 97%. Despite challenges in standardizing preoperative evaluation and follow-up protocols, aggressive complete resection showed promising long-term survival and good oncological outcomes. Notably, no significant differences were found between conventional and minimally invasive (MI) surgery in perioperative outcomes. Histopathological correlations were lacking in prognosis and locations. Among the patients, one developed diffuse liver metastases 41 months postoperatively but responded well to chemotherapy and transcatheter arterial chemoembolization, with disease stability observed at 159 postoperative months. Another patient developed nonalcoholic steatohepatitis after surgery and underwent liver transplantation, succumbing to poor medication adherence 115 months after surgery. Conclusions: These findings underscore the importance of surgical intervention in managing SPNs and suggest the MI approach as a viable option with comparable outcomes to conventional surgery.

Comments and illustrations of the European Federation of Societies for Ultrasound in Medicine contrast-enhanced ultrasound guidelines. Rare pancreatic tumors, imaging features on transabdominal ultrasound and EUS with contrast enhancement: Rare epithelial pancreatic tumors: solid pseudopapillary neoplasm, acinar cell carcinoma, mixed neuroendocrine-non-neuroendocrine neoplasms, some rare subtypes of pancreatic adenocarcinoma and pancreatoblastoma

Rare malignant pancreatic lesions are systematically reported in this review. The focus is on the imaging appearance of the rare epithelial pancreatic tumors such as the solid pseudopapillary neoplasm, acinar cell carcinoma, rare subtypes of adenocarcinoma, and pancreatoblastoma as seen on ultrasound, EUS, and contrast-enhanced ultrasound or EUS. The present overview summarizes the data and shows that not every pancreatic tumor is likely to be the most common entities of ductal adenocarcinoma or neuroendocrine tumor.

Outcome and survival were similar with laparoscopic and open pancreatectomy in 102 solid pseudopapillary neoplasms

BACKGROUND

Solid pseudopapillary neoplasms of the pancreas (SPNP) are rare tumors predominantly in young women. We report the largest single-center cohort study comparing resection of SPNP by laparoscopic approach (LA) and the open approach (OA).

METHOD

Between 2001 and 2021, 102 patients (84% women, median age: 30) underwent pancreatectomy for SPNP and were retrospectively studied. Demographic, perioperative, pathological, early and the long-term results were evaluated between patients operated by LA and those by OA.

RESULTS

Population included 40 LA and 62 OA. There were no significant differences in demographics data between the groups. A preoperative biopsy by endoscopic ultrasound was performed in 45 patients (44%) with no difference between the groups. Pancreatoduodenectomy (PD) was less frequently performed by LA (25 vs 53%, p = 0.004) and distal pancreatectomy (DP) was more frequently performed by LA (40 vs 16%, p = 0.003). In the subgroup analysis by surgical procedure, LA-PD was associated with one mortality, less median blood loss (180 vs 200 ml, p = 0.034) and fewer harvested lymph nodes (11 vs 15, p = 0.02). LA-DP was associated with smaller median tumor size on imaging (40 vs 80mm, p = 0.048), shorter surgery (135 vs 190 min, p = 0.028), and fewer complications according to the median comprehensive complication index score (0 vs 8.7, p = 0.048). LA-Central pancreatectomy was associated with shorter surgery (160 vs 240, p = 0.037), less median blood loss (60 vs 200, p = 0.043), and less harvested lymph nodes (5 vs 2, p = 0.025). After a median follow-up of 60 months, two recurrences (2%) were observed and were unrelated to the approach.

CONCLUSIONS

The LA for SPNP appears to be safe, should be applied cautiously in case of PD for large lesion, and was not associated with recurrence.

Solid pseudopapillary neoplasm (SPN) of the pancreas: current understanding on its malignant potential and management

Solid pseudopapillary neoplasms (SPN) of the pancreas are presently recognized as low-grade malignant tumors that are frequently observed in young females. This tumor has a low incidence and is associated with an excellent prognosis following surgical resection. Typical SPNs primarily affect the pancreas and tend to have moderate or asymptomatic manifestations. Based on retrospective research, it is anticipated that patients with SPN can achieve disease-free survival, even in cases when metastasis is detected during inspection. However, the incidence of malignant SPN has been consistently underestimated, as evidenced by recent research findings. Malignancy of SPN primarily encompasses invasion and infiltration, metastasis, and recurrence after R0 resection. Imaging technologies such as Ultrasound, Computed Tomography, Magnetic Resonance Imaging, and Position Emission Tomography are capable of preliminarily identifying malignant SPN, which is primarily based on its invasive clinical features. Research on risk factors of malignant SPN revealed that larger tumor size, Ki-67 index, and several other parameters had significant correlations with invasive tumor behavior. Pathologic features of malignant SPNs overlay other pancreatic tumors, nevertheless they can provide valuable assistance in the process of diagnosis. Several confirmed specific pathologic biomarkers are related to its cellular origin, characteristic gene mutation, and cell proliferation. Considering the invasiveness of malignant SPN, it is imperative to enhance the comprehensiveness of its therapy. Tumor resection remains a suggested course of action in line with typical SPN, and additional lymph node dissection is seen as reasonable. Compared to benign SPNs, malignant SPNs have worse prognosis, underscoring the necessity of early identification and treatment in comprehensive medical centers to get improved clinical outcomes.

Unraveling the enigma: A comprehensive review of solid pseudopapillary tumor of the pancreas

Solid pseudopapillary tumor of the pancreas (SPTP) is a rare neoplasm predominantly observed in young females. Pathologically, CTNNB1 mutations, β-catenin nuclear accumulation, and subsequent Wnt-signaling pathway activation are the leading molecular features. Accurate preoperative diagnosis often relies on imaging techniques and endoscopic biopsies. Surgical resection remains the mainstay treatment. Risk models, such as the Fudan Prognostic Index, show promise as predictive tools for assessing the prognosis of SPTP. Establishing three types of metachronous liver metastasis can be beneficial in tailoring individualized treatment and follow-up strategies. Despite advancements, challenges persist in understanding its etiology, establishing standardized treatments for unresectable or metastatic diseases, and developing a widely recognized grading system. This comprehensive review aims to elucidate the enigma by consolidating current knowledge on the epidemiology, clinical presentation, pathology, molecular characteristics, diagnostic methods, treatment options, and prognostic factors.

Twenty-one years of experience with resected solid pseudopapillary neoplasm: a retrospective single-institutional cohort study

BACKGROUND

Although the incidence of solid pseudopapillary neoplasm (SPN) is <2% of the incidence of pancreatic tumor, the prevalence seems to be increasing. SPNs are mostly benign. However, they also show malignant features. This study aimed to identify the clinical outcomes of patients who underwent surgery for SPN at a single center.

METHODS

Data on 217 patients with SPN who underwent surgery in Samsung Medical Center between 2000 and 2020 were retrospectively analyzed.

RESULTS

Herein, the mean age of the 217 patients was 40.0 ± 12.6 years, with a female predominance (80.6%). Most patients had no comorbidity. The mean tumor size was 4.4 ± 3.1 cm. The tumor was located at the pancreatic head in 36 patients (16.6%), the body of the pancreas in 69 patients (31.8%), and the pancreatic tail in 96 patients (44.2%). Of note, 35 patients (16.1%) underwent pancreaticoduodenectomies, 148 patients (68.2%) had distal pancreatectomies, and the other patients had subtotal /total pancreatectomy (9.7%) or enucleation/mass excision (6.0%). No patient had lymph node (LN) metastasis. Moreover, 6 patients (2.8%) had a recurrence in the liver or regional LNs. The 5-year recurrence-free survival rate was 96.8%. The only factor affecting recurrence was tumor size (P = .007).

CONCLUSION

Because SPN predominates in relatively young women, patients often hesitate to undergo surgery. Nevertheless, as size is the prognostic factor, early resection is recommended for a better prognosis in the case of surgically feasible, young age, and healthy patients.

Cinematic rendering of solid pseudopapillary tumors: Augmenting diagnostics of an increasingly encountered tumor

Pancreatic solid pseudopapillary tumors (SPTs) are a rare subset of pancreatic neoplasms, accounting for under 2 % of exocrine pancreatic tumors. The incidence of SPTs has shown a significant increase in the past two decades, attributed to heightened cross-sectional imaging utilization. These tumors often present with nonspecific clinical symptoms, making imaging a crucial tool in their detection and diagnosis. Cinematic rendering (CR) is an advanced 3D post-processing technique that generates highly photorealistic realistic images by accurately modeling the interaction of light within the imaged volume. This allows improved visualization of anatomic structures which holds potential to improve diagnostics. In this manuscript we present the first description of CR appearances of SPTs in the reported literature. Through showcasing a range of cases, we highlight the potential of CR in illustrating the diverse imaging characteristics of these unique neoplasms.

Solid pseudopapillary neoplasm of the pancreas: a retrospective study of 195 cases

Objective

Solid pseudopapillary neoplasm of the pancreas (SPN) is a rare exocrine tumor of the pancreas. The aim of our study is to summarize the clinical features of SPN and to analyze the risk factors for malignant SPN.

Methods

From May 2013 to September 2022, patients who were pathologically confirmed to have SPN were retrospectively reviewed. Demographic data, clinical and pathological features, follow-up data were collected and analyzed. To investigate the factors influencing the benign or malignant nature of SPN, we employed logistic regression. Additionally, we utilized Kaplan-Meier curves to depict and analyze the overall prognosis.

Results

A total of 195 patients were included, 163 of whom were female and the average age of all patients was 31.7 years old. Among 195 patients, 101 patients (51.8%) had no obvious clinical symptoms and their pancreatic lesions were detected during routine examination. The primary symptom was abdominal pain and distension in 64 cases (32.8%). The maximum diameter of SPN tumors ranged from 1-17 cm (mean 6.19 cm). Forty-eight postoperative complications developed in 43 (22.1%) patients. After a median follow-up duration of 44.5 months, the overall 5-year survival rate was 98.8% and the recurrence rate was 1.5%. Furthermore, we observed a statistically significant difference in the completeness of the tumor capsule between benign and malignant SPN.

Conclusion

SPN is associated with a favorable long-term survival after surgery in our large sample size cohort. For malignant SPN, tumor capsule incompleteness is an independent risk factor.

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.

Pathologic Features of Primary Pancreatic Malignancies

This chapter explores the pathologic features of benign and malignant lesions of the pancreas. As pathologic classifications evolve particularly for cystic lesions and neuroendocrine tumors, it is important for physicians who treat patients with gastrointestinal malignance to fully evaluate these pathologic classifications.

EUS-guided tissue acquisition in patients with solid pseudopapillary neoplasms of the pancreas

OBJECTIVES

Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has been the most common method used for the preoperative cytopathological diagnosis of solid tumors of the pancreas. There are only a few reported cases about the role of endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) in the pre-operative diagnosis of solid pseudopapillary neoplasms (SPN). This study aimed to evaluate the diagnostic yield of EUS-TA,including endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) andEUS-FNB, in patients with SPN.

METHODS

We performed a retrospective analysis of patients with EUS-TA for SPN diagnosis in 2 referral centers. The primary outcome was the diagnostic yield of EUS-TA compared to the surgical specimen.

RESULTS

Seventy-four patients with SPN of the pancreas were identified. Eighteen had a EUS-TA (10 EUS-FNB and 8 EUS-FNA). The median age of the patients was 31 years (IQR 21-38), and all patients were women. The most common presenting symptom was abdominal pain. Most of the tumors were in the head of the pancreas (9/18; 50%). The median tumor size by EUS was 4.5 cm (min-max 2-15 cm). The most common appearance on EUS was a solid lesion (n = 8/18, 44.4%). A definitive presurgical cytopathological diagnosis was obtained in 16/18 patients (88.8%) with EUS-TA. The sensitivity and positive predictive value of the EUS-TA were 94% each. One patient in the EUS-FNB group developed mild acute pancreatitis.

CONCLUSION

The diagnostic yield of the EUS-TA in SPN is high. In most cases, the diagnosis was obtained with the first procedure. No differences in the diagnostic yield or AEs between EUS-FNA vs. EUS-FNB needles were seen.

Rare Pancreatic/Peripancreatic Cystic Lesions Can Be Accurately Characterized by EUS with Through-the-Needle Biopsy-A Unique Pictorial Essay with Clinical and Histopathological Correlations

Due to their aspecific macroscopic appearance, uncommon pancreatic cystic lesions (PCLs) are often misdiagnosed as mucinous lesions and improperly resected. We aimed to evaluate the endoscopic ultrasound (EUS)-guided through-the-needle biopsy (TTNB) capacity of the preoperative diagnosis of uncommon PCLs. Overall, 136 patients with PCLs who underwent EUS-TTNB between 2016 and 2022 were retrospectively identified. Common histotypes (e.g., IPMN, serous cystadenoma, and mucinous cystadenoma) were excluded and 26 (19.1%) patients (15 female, mean age 52.9 ± 10.4) were analyzed. The EUS findings, adverse events (AEs), and TTNB outcomes in uncommon PCLs were evaluated. The cysts histotype was accurately diagnosed by TTNB in 24/26 (92.3%) cases (seven cystic neuroendocrine tumors, four squamoid cysts, three acinar cells cystadenomas, two lymphoepithelial cysts, two mucinous non-neoplastic cysts, two bronchogenic cysts, two cystic lymphangiomas, one solid-pseudopapillary neoplasm, and one schwannoma). In the remaining two cases, lymphangioma was eventually diagnosed after resection. Surgery was performed in 15/26 (57.7%) patients. The mean follow-up of non-surgical patients was 32.5 months. One severe acute case of pancreatitis (3.8%) that required surgery occurred after EUS-TTNB. Uncommon pancreatic/peripancreatic lesions represent the 19.1% of PCLs in our series, with mainly benign histotypes. TTNB demonstrated a high diagnostic performance with a low rate of AEs in this setting, representing a reliable tool with which to avoid useless surgery.

Local resection for solid pseudopapillary neoplasms of the pancreas shows improved postoperative gastrointestinal function and reduced mental stress: a multiquestionnaire survey from a large cohort

BACKGROUND

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare, low-grade malignant pancreatic tumor with a highly favorable prognosis. Most SPN patients are young and middle-aged women. The main controversial topic for SPN is local resection (LR) versus radical resection (RR). Theoretically, LR could lead to better gastrointestinal function (GIF) and less mental stress. However, no data is available to support this hypothesis.

METHODS

All SPN patients undergoing surgical treatment in Peking Union Medical College Hospital from 2001 to 2021 were included in the study. A cross-sectional online multiquestionnaire survey containing 110 questions was sent to them (Clinicaltrial.org, NCT05604716). This online multiquestionnaire survey focused on GIF and mental stress and consisted of eight questionnaires. Multiple linear regression analysis was conducted to identify independent factors impacting GIF and mental stress.

RESULTS

A total of 183 cases provided valid results. Among them, 46 patients (25.1%) underwent LR, and 137 (74.9%) underwent RR. Ninety-four cases (51.4%) underwent minimally invasive surgery (MIS), while 89 (48.6%) underwent open surgery. The average GSRS score of the patients was 1.9±0.7, indicating that most suffered from mild gastrointestinal dysfunction. The scores of PHQ-9 and GAD-7 in 16 patients (8.7%) and 27 (14.8%) patients, respectively, were beyond 10.0, which indicated clinical depression and anxiety. Additionally, 19 (10.4%) patients reported poor ability to work, and 31(16.9%) patients had significant body image concerns. Compared to other clinicopathological characteristics, LR (LR vs. RR: PHQ-9 score, P =0.018; WAI average score, P =0.010; EORTC QLQ-C30, nine subdomains, P <0.05; GSRS average score, P =0.006) and MIS (MIS vs. open surgery: EORTC QLQ-C30, three subdomains, P <0.05; GSRS average score, P =0.006) were the most significant factors predicting improved GIF and reduced mental stress.

CONCLUSIONS

This study systematically presents postoperative GIF and mental stress of SPN patients using validated multiquestionnaires for the first time. It provides solid evidence that LR and MIS can improve GIF and reduce mental stress after surgery for SPN patients, which could be helpful for the surgeons to make more personalized surgical plans for their patients.

Large Duct Pancreatic Ductal Adenocarcinoma: A Morphological Variant of Pancreatic Ductal Adenocarcinoma With Distinct CT and MRI Characteristics

OBJECTIVE

To investigate the imaging characteristics of large duct pancreatic ductal adenocarcinoma (LD-PDAC) on computed tomography (CT) and magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Thirty-five patients with LD-PDAC (63.2 ± 9.7 years) were retrospectively evaluated. Tumor morphology on CT and MRI (predominantly solid mass vs. solid mass with prominent cysts vs. predominantly cystic mass) was evaluated. Additionally, the visibility, quantity, shape (oval vs. branching vs. irregular), and MRI signal intensity of neoplastic cysts within the LD-PDAC were investigated. The radiological diagnoses rendered for LD-PDAC in radiology reports were reviewed.

RESULTS

LD-PDAC was more commonly observed as a solid mass with prominent cysts (45.7% [16/35] on CT and 37.1% [13/35] on MRI) or a predominantly cystic mass (20.0% [7/35] on CT and 40.0% [14/35] on MRI) and less commonly as a predominantly solid mass on CT (34.3% [12/35]) and MRI (22.9% [8/35]). The tumor morphology on imaging was significantly associated with the size of the cancer gland on histopathological examination (P = 0.020 [CT] and 0.013 [MRI]). Neoplastic cysts were visible in 88.6% (31/35) and 91.4% (32/35) of the LD-PDAC cases on CT and MRI, respectively. The cysts appeared as branching (51.6% [16/35] on CT and 59.4% [19/35] on MRI) or oval shapes (45.2% [14/35] on CT and 31.2% [10/35] on MRI) with fluid-like MRI signal intensity. In the radiology reports, 10 LD-PDAC cases (28.6%) were misinterpreted as diseases other than typical PDAC, particularly intraductal papillary mucinous neoplasms.

CONCLUSION

LD-PDAC frequently appears as a solid mass with prominent cysts or as a predominantly cystic mass on CT and MRI. Radiologists should be familiar with the imaging features of LD-PDAC to avoid misdiagnosis.

Long-term Survival, Quality of Life, and Molecular Features of the Patients With Solid Pseudopapillary Neoplasm of the Pancreas: A Retrospective Study of 454 Cases

OBJECTIVE

To present comprehensive information on the clinicopathological, molecular, survival characteristics, and quality of life (QOL) after surgery for solid pseudopapillary neoplasm (SPN) of the pancreas in a large cohort after long-term follow-up.

BACKGROUND

SPN is a rare tumor with an uncertain malignant potential, and solid information on long-term prognosis and QOL remains limited.

METHODS

All hospitalized patients with SPNs who underwent surgery between 2001 and 2021 at the Peking Union Medical College Hospital were retrospectively reviewed. The clinicopathological characteristics of the patients were retrieved. A cross-sectional telephone questionnaire was administered to inquire about the QOL. Molecular analyses were performed using whole-exome sequencing.

RESULTS

Exactly 454 patients with SPN were enrolled, of whom 18.5% were males and 81.5% were females. The mean patient age was 31 ± 12 years. In total, 61.3% of the patients had no symptoms. The size of the tumors was 5.38 ± 3.70 cm; 83.4% were solid cystic tumors, and 40.1% had calcifications. The proportions of local resection, distal pancreatectomy with or without splenectomy, and pancreaticoduodenectomy with or without pylorus preservation were 29.7%, 28.9% or 22.9%, and 11% or 6.8%, respectively. Over the years, there has been a significant shift from open to minimally invasive surgery. Among all surgical procedures, pylorus-preserving pancreaticoduodenectomy (PPPD) had the highest incidence of grade 2 to 4 complications (up to 32.3%), compared with 6.7% in distal pancreatectomy ( P < 0.001). Regarding histopathology, tissue invasion, perineural invasion, cancerous microvascular emboli, lymph node metastasis, and distant metastasis were present in 16.5%, 2.2%, 0.7%, 2.0%, and 3.1% of patients, respectively. Sixty patients were lost to follow-up. Sixteen of the 390 patients who underwent resection (4.1%) experienced local recurrence or distant metastasis after surgery. In total, 361 patients responded to the telephone survey. Nearly 80% of patients claimed their QOL was not significantly affected after surgery; however, the remaining 20% complained of lower QOL during 3 to 6 years of follow-up after surgery. No clinicopathological factor could reliably predict clinical recurrence or metastasis after resection. A total of 28 driver genes were detected with mutations in at least 2 tumor samples and the top 3 frequently mutated genes were CTNNB1 , ATRNL1 , and MUC16 .

CONCLUSIONS

This study presented the largest cohort of patients with SPN after surgery from a single center and reported the QOL of these patients. SPN is associated with extremely favorable long-term survival, even in patients with metastasis, and most patients have a good QOL after surgery.

Solid Pseudo-papillary Neoplasia: A Rare Malignancy of the Pancreas

Solid pseudopapillary neoplasms (SPNs) are exceedingly rare type of exocrine pancreatic malignancy, representing only 0.9%-2.7% of all exocrine pancreatic malignancies. They predominantly affect young women and unlike other pancreatic malignancies, they have excellent prognoses with 5-year survival following surgical resection approaching 97%. Given the rarity of the disease, little is known about their histopathogenesis as they do not harbor similar genetic mutational abnormalities like other pancreatic tumors. We describe a rare case of SPN in a young female who was found to have the rare diagnosis during the work up for deranged liver function tests.

Pancreatic Cancer and Its Mimics

Pancreatic ductal adenocarcinoma (PDAC) is the most common primary pancreatic malignancy, ranking fourth in cancer-related mortality in the United States. Typically, PDAC appears on images as a hypovascular mass with upstream pancreatic duct dilatation and abrupt duct cutoff, distal pancreatic atrophy, and vascular encasement, with metastatic involvement including lymphadenopathy. However, atypical manifestations that may limit detection of the underlying PDAC may also occur. Atypical PDAC features include findings related to associated conditions such as acute or chronic pancreatitis, a mass that is isointense to the parenchyma, multiplicity, diffuse tumor infiltration, associated calcifications, and cystic components. Several neoplastic and inflammatory conditions can mimic PDAC, such as paraduodenal "groove" pancreatitis, autoimmune pancreatitis, focal acute and chronic pancreatitis, neuroendocrine tumors, solid pseudopapillary neoplasms, metastases, and lymphoma. Differentiation of these conditions from PDAC can be challenging due to overlapping CT and MRI features; however, certain findings can help in differentiation. Diffusion-weighted MRI can be helpful but also can be nonspecific. Accurate diagnosis is pivotal for guiding therapeutic planning and potential outcomes in PDAC and avoiding biopsy or surgical treatment of some of these mimics. Biopsy may still be required for diagnosis in some cases. The authors describe the typical and atypical imaging findings of PDAC and features that may help to differentiate PDAC from its mimics. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Zins in this issue.

Multicenter Study on the Performance of Imaging Tests Compared to Endosonography-Guided Fine-Needle Aspiration in the Diagnosis of Solid Pseudopapillary Neoplasms of the Pancreas

Introduction

Imaging diagnosis of pancreatic solid-pseudopapillary neoplasms (SPNs) is difficult. Preoperative diagnosis by endosonography-guided fine-needle aspiration (EUS-FNA) is possible and has been reported in the literature in pancreatic tumors. However, its usefulness is still controversial. The aim of this study was to determine the accuracy of the EUS-FNA in the diagnosis of patients with SPN and describe the findings in computerized tomography (CT), magnetic resonance cholangiopancreatography imaging (MRI/MRCP), and EUS therefore comparing the imaging methods alone to the findings of microhistology (McH) obtained by EUS-FNA.

Materials and Methods

We retrospectively reviewed the medical records of patients undergoing EUS-FNA with suspected SPN in imaging studies in 5 Brazilian high-volume hospitals (two university hospitals and three private hospitals). The demographic data; findings in CT, MRI/MRCP, and EUS; and McH results obtained by EUS-FNA were noted prospectively. The final diagnosis was obtained after the anatomopathological examination of the surgical specimen in all patients (gold standard), and we compared the results of CT, MRI/MRCP, EUS, and the McH with the gold standard.

Results

Fifty-four patients were included in the study, of which 49 (90.7%) were women with an average age of 33.4 (range 11-78) years. The most common symptom presented was abdominal pain, present in 35.2% patients. SPN was detected incidentally in 32 (59%) patients. The average size of the tumors was 3.8 cm (SD: 2.26). The most common finding at EUS was a solid, solid/cystic, and cystic lesion in 52.9%, 41.1%, and 7.8% patients, respectively. The final diagnosis was 51 patients with SPN and 3 with nonfunctioning pancreatic neuroendocrine tumors (NF-NET). The correct diagnosis was made by CT, MRI/MRCP, EUS isolated, and EUS-FNA in 21.9%, 28.88%, 64.71%, and 88.24%, respectively. EUS-FNA associated with CT and MRI increased diagnostic performance from 22.72% to 94.11% and from 29.16% to 94.11%, respectively.

Conclusions

SPN are rare, incidentally identified in most cases, and affect young women. Differential diagnosis between SPN, NF-NET, and other types of tumors with imaging tests can be difficult. EUS-FNA increases preoperative diagnosis in case of diagnostic doubt and should be used whenever necessary to rule out NF-NET or other type of solid/cystic nodular lesion of the pancreas.

Frantz's Tumor in Focus: The Tale of a 34-Year-Old Yemeni Female Patient

A solid pseudopapillary tumor (SPT) of the pancreas, which mainly occurs in young women, is an uncommon pancreatic tumor that often presents diagnostic and therapeutic dilemmas. This case study discusses the symptoms and treatment approach for a 34-year-old woman from Yemen diagnosed with SPT. The patient was diagnosed through abdominal and pelvis CT scan, followed by ultrasound-guided biopsy confirming the presence of SPPT. Management through the Whipple procedure and portal vein reconstruction proved successful, with no recurrence or metastasis noted in a year-long follow-up. The importance of comprehensive understanding and surgical expertise in handling SPT is emphasized.

Rare Solid Pancreatic Lesions on Cross-Sectional Imaging

Several solid lesions can be found within the pancreas mainly arising from the exocrine and endocrine pancreatic tissue. Among all pancreatic malignancies, the most common subtype is pancreatic ductal adenocarcinoma (PDAC), to a point that pancreatic cancer and PDAC are used interchangeably. But, in addition to PDAC, and to the other most common and well-known solid lesions, either related to benign conditions, such as pancreatitis, or not so benign, such as pancreatic neuroendocrine neoplasms (pNENs), there are solid pancreatic lesions considered rare due to their low incidence. These lesions may originate from a cell line with a differentiation other than exocrine/endocrine, such as from the nerve sheath as for pancreatic schwannoma or from mesenchymal cells as for solitary fibrous tumour. These rare solid pancreatic lesions may show a behaviour that ranges in a benign to highly aggressive malignant spectrum. This review includes cases of an intrapancreatic accessory spleen, pancreatic tuberculosis, solid serous cystadenoma, solid pseudopapillary tumour, pancreatic schwannoma, purely intraductal neuroendocrine tumour, pancreatic fibrous solitary tumour, acinar cell carcinoma, undifferentiated carcinoma with osteoclastic-like giant cells, adenosquamous carcinoma, colloid carcinoma of the pancreas, primary leiomyosarcoma of the pancreas, primary and secondary pancreatic lymphoma and metastases within the pancreas. Therefore, it is important to determine the correct diagnosis to ensure optimal patient management. Because of their rarity, their existence is less well known and, when depicted, in most cases incidentally, the correct diagnosis remains challenging. However, there are some typical imaging features present on cross-sectional imaging modalities that, taken into account with the clinical and biological context, contribute substantially to achieve the correct diagnosis.

Potential Role for Observation in Small Solid Pseudopapillary Neoplasm (SPN)

BACKGROUND

Solid pseudopapillary neoplasms (SPN) are rare tumors of the pancreas, typically affecting young women. Resection is the mainstay of treatment but is associated with significant morbidity and potential mortality. We explore the idea that small, localized SPN could be safely observed.

METHODS

This retrospective review of the Pancreas National Cancer Database from 2004 to 2018 identified SPN via histology code 8452.

RESULTS

A total of 994 SPNs were identified. Mean age was 36.8 ± 0.5 years, 84.9% (n = 844) were female, and most had a Charlson-Deyo Comorbidity Coefficient (CDCC) of 0-1 (96.6%, n = 960). Patients were most often staged clinically as cT2 (69.5%, n = 457) followed by cT3 (17.6%, n = 116), cT1 (11.2%, n = 74), and cT4 (1.7%, n = 11). Clinical lymph node and distant metastasis rates were 3.0 and 4.0%, respectively. Surgical resection was performed in 96.6% of patients (n = 960), most commonly partial pancreatectomy (44.3%) followed by pancreatoduodenectomy (31.3%) and total pancreatectomy (8.1%). In patients clinically staged as node (N0) and distant metastasis (M0) negative, occult pathologic lymph node involvement was found in 0% (n = 28) of patients with stage cT1 and 0.5% (n = 185) of patients with cT2 disease. The risk of occult nodal metastasis significantly increased to 8.9% (n = 61) for patients with cT3 disease. The risk further increased to 50% (n = 2) in patients with cT4 disease.

CONCLUSIONS

Herein, the specificity of excluding nodal involvement clinically is 99.5% in tumors ≤ 4 cm and 100% in tumors ≤ 2 cm. Therefore, there may be a role for close observation in patients with cT1N0 lesions to mitigate morbidity from major pancreatic resection.

Cystic pancreatic neoplasms in a tertiary gastroenterologic referral center: Evaluation of the diagnostic accuracy of endoscopic ultrasound, progression rate and malignancy rate in a large unicentric cohort

INTRODUCTION

Cystic pancreatic neoplasms (CPN) are frequently diagnosed due to better diagnostic techniques and patients becoming older. However, diagnostic accuracy of endoscopic ultrasound (EUS) and value of follow-up are still unclear.

MATERIAL AND METHODS

The aim of our retrospective study was to investigate the frequency of different cystic pancreatic neoplasms (intraductal papillary mucinous neoplasm [IPMN], serous and mucinous cystadenoma, solid pseudopapillary neoplasia), diagnostic accuracy, size progression, and rate of malignancy using EUS in a tertiary reference center in Germany. Between January 1, 2012 and December 31, 2018, 455 patients were diagnosed with cystic pancreatic lesions (798 EUS examinations).

RESULTS

Endoscopic ultrasound diagnosed 223 patients with cystic pancreatic neoplasms, including 138 (61.9%) patients with branch duct IPMN, 16 (7.2%) with main duct IPMN, and five (2.2%) with mixed-type IPMN. In the largest subgroup of branch duct IPMN, cysts were size progressive in 20 patients (38.5%). Fine needle aspiration (FNA) was performed in 21 patients, and confirmed the suspected diagnosis in 12/21 patients. 28 surgical resections were performed, in 7/28 patients (25%), high-grade dysplasia or cancer was diagnosed. Endoscopic ultrasound diagnosis of serous and mucinous cystic pancreatic neoplasms was correct in 68.4%.

CONCLUSIONS

Endoscopic ultrasound differential diagnosis of CPNs is challenging. Even in a tertiary expert center, differentiation of serous and mucinous cystic neoplasia is not guaranteed. Relevant size progression of CPN, however, is rare, as is the rate of malignancy. The data of this study suggest that morphologic criteria to assess pancreatic cysts alone are not sufficient to allow a clear diagnosis. Hence, for the improved assessment of pancreatic cysts, EUS should be combined with additional tests and techniques such as MRT/MRCP, contrast-enhanced EUS, and/or FNA/fine needle biopsy including fluid analysis. The combination and correlation of imaging studies with EUS findings is mandatory.

Role of endoscopic ultrasound in the characterization of solid pseudopapillary neoplasm of the pancreas

BACKGROUND

Solid pseudopapillary neoplasm (SPN) is an uncommon pathology of the pancreas with unpredictable malignant potential. Endoscopic ultrasound (EUS) assessment plays a vital role in lesion characterization and confirmation of the tissue diagnosis. However, there is a paucity of data regarding the imaging assessment of these lesions.

AIM

To determine the characteristic EUS features of SPN and define its role in preoperative assessment.

METHODS

This was an international, multicenter, retrospective, observational study of prospective cohorts from 7 large hepatopancreaticobiliary centers. All cases with postoperative histology of SPN were included in the study. Data collected included clinical, biochemical, histological and EUS characteristics.

RESULTS

One hundred and six patients with the diagnosis of SPN were included. The mean age was 26 years (range 9 to 70 years), with female predominance (89.6%). The most frequent clinical presentation was abdominal pain (80/106; 75.5%). The mean diameter of the lesion was 53.7 mm (range 15 to 130 mm), with the slight predominant location in the head of the pancreas (44/106; 41.5%). The majority of lesions presented with solid imaging features (59/106; 55.7%) although 33.0% (35/106) had mixed solid/cystic characteristics and 11.3% (12/106) had cystic morphology. Calcification was observed in only 4 (3.8%) cases. Main pancreatic duct dilation was uncommon, evident in only 2 cases (1.9%), whilst common bile duct dilation was observed in 5 (11.3%) cases. One patient demonstrated a double duct sign at presentation. Elastography and Doppler evaluation demonstrated inconsistent appearances with no emergence of a predictable pattern. EUS guided biopsy was performed using three different types of needles: Fine needle aspiration (67/106; 63.2%), fine needle biopsy (37/106; 34.9%), and Sonar Trucut (2/106; 1.9%). The diagnosis was conclusive in 103 (97.2%) cases. Ninety-seven patients were treated surgically (91.5%) and the post-surgical SPN diagnosis was confirmed in all cases. During the 2-year follow-up period, no recurrence was observed.

CONCLUSION

SPN presented primarily as a solid lesion on endosonographic assessment. The lesion tended to be located in the head or body of the pancreas. There was no consistent characteristic pattern apparent on either elastography or Doppler assessment. Similarly SPN did not frequently cause stricture of the pancreatic duct or common bile duct. Importantly, we confirmed that EUS-guided biopsy was an efficient and safe diagnostic tool. The needle type used does not appear to have a significant impact on the diagnostic yield. Overall SPN remains a challenging diagnosis based on EUS imaging with no pathognomonic features. EUS guided biopsy remains the gold standard in establishing the diagnosis.

Solid Pseudopapillary Epithelial Neoplasm of the Pancreas: A Rare Entity with Diagnostic Dilemma

The solid pseudopapillary epithelial neoplasm (SPEN) of the pancreas is a relatively uncommon entity. The aim of the present study was to summarize our experiences with regard to diagnostic dilemma, surgery, postoperative follow-up, and management. This retrospective data were collected during the period from January 1, 2018 to December 31, 2020. A total of four patients (three females and one male) were identified within an age range of 13 to 25 years. All the patients were presented with nonspecific symptoms such as abdomen lumps, swelling in the abdomen, and abdominal pain. To reach a definite diagnosis, imaging studies were conducted along with endoscopic ultrasound fine-needle aspiration (EUS-FNA) and biopsy. After confirmation of SPEN on biopsy, all the patients underwent surgery without any complications. Patients are on follow-up, and to date, no metastasis has been detected. SPEN is a rare pancreatic tumor with unusual pathological features leading to a diagnostic dilemma. The pathologist should be familiar with SPEN and its salient histological characteristics that differentiate it from other look-alike pancreatic tumors and can help in timely surgery and management.

Diagnosis and surgical management of a rare neoplastic entity: Solid Pseudopapillary Neoplasm of the Pancreas

INTRODUCTION AND IMPORTANCE

Solid Pseudopapillary Tumors of the Pancreas is an extremely rare pancreatic neoplastic entity that makes up barely 3 % of all types of exocrine pancreatic neoplasia. Symptoms vary and none of them are specific or pathognomonic for the disease. Therefore, delayed treatment or misdiagnoses could be the result. In turn, patients' morbidity and mortality significantly rise. Diagnosing or suspecting this type of critical type of neoplasia in the preoperative phase is a key component to performing appropriate and curative surgical interventions that result in increased patient survivability.

CASE PRESENTATION

We hereby present the rare case of a previously healthy 20-year-old female whose chief complaints were chronic epigastric and left hypochondriac region pain and discomfort along with loss of appetite. During our preoperative radiological investigation, we found a cystic mass with well-defined borders located between the head of the pancreas and the second part of the duodenum. It measured (63 × 45 mm). No metastasis or lymph node involvement was elicited.

CLINICAL DISCUSSION

The tumor was utterly resected via a successful Whipple procedure. A definitive diagnosis of a Solid Pseudopapillary Tumor was reached following meticulous histopathological and immunohistochemical analysis of the resected specimens.

CONCLUSION

Based on our review of the published literature, no previously published cases from our country of pancreatic Solid Pseudopapillary Tumors exist. Documentation of this rare neoplasia is warranted to raise awareness and to establish the necessary clinical protocols to optimally diagnose, timely treat, and adequately follow up on patients who present with this malignancy.

Pancreatic solid pseudopapillary neoplasm with concomitant left unilateral renal agenesis and bicornuate uterus: a case report

A solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor of the pancreas. Concomitant SPN with urogenital anomalies is a very rare presentation.

Case Presentation

A 16-year-old female presented with a chief complaint of abdominal pain 30 days back. Solid pseudopapillary neoplasm (SPN) of the pancreas was diagnosed with the aid of ultrasonography and contrast-enhanced computed tomography of the abdomen and pelvis. Incidentally, concomitant left unilateral renal agenesis and bicornuate uterus were also detected in radiological findings. The patient underwent spleen-preserving distal pancreatectomy, and SPN was confirmed with the histopathological report.

Discussion

Symptomatic SPN patients present with an abdominal mass and pain or very rarely jaundice. Most of the SPNs are benign. Complete surgical excision results in more than 95% cure. SPN with concomitant urogenital anomalies is extremely rare, and their concurrent occurrence can be better attributed to Wnt signaling pathway owing to their similar pathogenic mechanism.

Conclusion

The solid pseudopapillary tumor has an excellent prognosis if timely resected. Proper evaluation of the patient with imaging is necessary to suspect and diagnose SPN who has urogenital anomalies and vice versa.

Clinical Characteristics of Patients With Surgically Resected Pancreatic Cysts: A Retrospective Analysis of 136 Patients

OBJECTIVES

To retrospectively analyze the characteristics of pancreatic cysts with respect to histopathological diagnosis and various diagnostic imaging tools.

METHODS

The clinical features of 136 patients and characteristics of histopathologically diagnosed cysts were retrospectively assessed. The diagnostic accuracy of endoscopic ultrasound (EUS), computed tomography (CT), and magnetic resonance imaging (MRI) for pancreatic cysts was compared. Risk factors for high-grade dysplasia/invasive cancer in patients with intraductal papillary mucinous neoplasms (IPMNs) were also determined.

RESULTS

The final analysis included 30 serous cystic neoplasms (SCNs) (21.6%), 13 mucinous cystic neoplasms (MCNs) (9.4%), 65 IPMNs (46.8%), and 13 solid pseudopapillary neoplasms (SPNs) (9.4%). The percentage of women with MCNs, SPNs, SCNs, and IPMNs was 100.0, 76.9, 73.3, and 47.7%, respectively (P < .001). The percentages of patients over 60 years of age with IPMNs, SCNs, MCNs, and SPNs were 73.9, 23.3, 0, and 0%, respectively (P < .001). The percentage of cysts located in the body and tail of the pancreas in MCNs, SCNs, SPNs, and IPMNs was 100, 70, 53.9, and 46.2%, respectively (P < .001). A unique honeycomb appearance was observed in 26.7% of SCNs. The overall diagnostic accuracy of EUS, CT, and MRI for pancreatic cysts was 82.6, 72.5, and 73.9%, respectively. Lesion size and presence of solid components were independent predictors of high-risk IPMNs.

CONCLUSIONS

Patient characteristics and cyst features can help to differentiate pancreatic cyst types and identify high-risk IPMNs. The diagnostic accuracy of EUS for pancreatic cysts is superior to that of CT and MRI.

The Role of MRI in the Diagnosis of Solid Pseudopapillary Neoplasm of the Pancreas and Its Mimickers: A Case-Based Review with Emphasis on Differential Diagnosis

Solid pseudopapillary neoplasm (SPN) is rare pancreatic tumor occurring most commonly in young females. The typical imaging appearance of SPN is of well-defined, encapsulated, and large heterogeneous tumors, consisting of solid and cystic components due to various degrees of intralesional hemorrhage and necrosis. However, atypical imaging presentation in the form of small solid tumors or uniformly cystic lesions might also be seen, which can be explained by specific pathological characteristics. Other imaging features such as a round shape, the absence of main pancreatic duct dilatation, and slow growth, in combination with vague symptoms, favor the diagnosis of SPNs. Nevertheless, the radiological findings of SPN might overlap with other solid and cystic pancreatic neoplasms, such as neuroendocrine tumors, serous and mucinous neoplasms, and even small pancreatic adenocarcinomas. In addition, a few benign non-tumorous conditions including walled-of-necrosis, and intrapancreatic accessory spleen may also pose diagnostic dilemmas simulating SPNs on imaging studies. The aim of this manuscript is to provide a comprehensive overview of the typical and atypical imaging features of SPNs and to describe useful tips for differential diagnosis with its potential mimickers.

Can solid pseudopapillary neoplasm of the pancreas without degeneration be diagnosed with imaging? a comparison study of the solid component of solid pseudopapillary neoplasm, neuroendocrine neoplasm, and ductal adenocarcinoma

PURPOSE

To investigate the MR findings of the solid components within pancreatic solid pseudopapillary neoplasms (SPNs) to characterize solid SPN without degeneration.

METHODS

After case matching, 23 patients with SPNs, 23 with pancreatic neuroendocrine neoplasms (PNENs), and 46 pancreatic ductal adenocarcinomas (PDACs) were included in this retrospective comparative study. The MR findings of the solid components within the pancreatic tumors were assessed qualitatively and semi-quantitatively.

RESULTS

In the qualitative assessment, significant differences were noted in T2-weighted imaging and MR cholangiopancreatography (MRCP). SPNs with a score of 4-5 (iso- to hyper-intense compared with the renal cortex) were observed in 18/19 (94.7%) by reader 1 and 15/19 (78.9%) by reader 2 (score 5, 52.6% and 47.4%) on fast spin-echo (FSE) T2-weighted imaging. On MRCP, the two readers identified 12 (63.2%) and 8 (42.1%) SPNs, respectively. The semi-quantitative signal-intensity ratio (SIR, signal intensity of tumor/signal intensity of the pancreatic parenchyma) of SPNs on FSE T2-weighted imaging was significantly higher (mean, 1.99-2.01) than that of PNENs (1.30-1.31) or PDACs (1.26-1.28). The sensitivity/specificity of 'hyper' on T2-weighted imaging (qualitative score of 4-5, or SIR of ≥ 1.5) were 78.9-100.0%/63.8-79.7%. The sensitivity/specificity of 'remarkably hyper' (score of 5, SIR of ≥ 2.0, or visible on MRCP) or salt-and-pepper pattern were 36.8-68.4%/85.5-98.6%.

CONCLUSION

T2-weighted imaging may be the key sequence for solid SPN. Solid tumors with hyper-intensity on T2-weighted imaging (especially, more hyper-intense than the renal cortex, more than twice the signal of the pancreatic parenchyma, depicted on MRCP, or salt-and-pepper appearance) may be suspected to be SPNs.

Role of Endoscopic Ultrasound in the Evaluation of Pancreatic Cystic Neoplasms: A Concise Review

Pancreatic cystic lesions are being discovered as incidental lesions during cross-sectional imaging studies of the abdomen with increasing frequency. Endoscopic ultrasound is an important diagnostic modality for managing pancreatic cystic lesions. There are various types of pancreatic cystic lesions, from benign to malignant. Endoscopic ultrasound has a multifactorial role in delineating the morphology of pancreatic cystic lesions, ranging from fluid and tissue acquisition for analysis-fine needle aspiration and through-the-needle biopsy, respectively-to advanced imaging techniques, such as contrast-harmonic mode endoscopic ultrasound and EUS-guided needle-based confocal laser endomicroscopy. In this review, we will summarize and provide an update on the specific role of EUS in the management of pancreatic cystic lesions.