Predicting recurrence of pancreatic solid pseudopapillary tumors after surgical resection: a multicenter analysis in Korea

Solid pseudopapillary tumor of pancreas: A report of two cases and literature review

Solid pseudopapillary neoplasm of the pancreas is rarely encountered in clinical practice. It is a tumor with a good prognosis and overall curative rates. It primarily affects young females in their twenties. It has characteristic imaging appearances, but a definite diagnosis requires histopathological examination. The treatment goal of solid pseudopapillary neoplasm is almost always curative and aims for complete resection of the mass. Here, we present 2 cases of this rare neoplasm. The first case was managed by laparoscopic distal pancreatectomy, while the second underwent a Whipple procedure for pancreatic head involvement.

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 pancreas with liver metastasis, diagnosed on fine needle aspiration cytology (FNAC)

Solid pseudopapillary neoplasm of the pancreas is a rare tumour with distinct clinicopathological features. The tumour most commonly occurs in younger women and has low malignant potential with an excellent overall prognosis.

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.

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.

The diagnosis and management of solid pseudopapillary epithelial neoplasm of the pancreas in a resource-limited setting: two cases from Cameroon

Solid pseudopapillary epithelial neoplasm (SPEN) of the pancreas is a rare tumor of low malignant potential that occurs most often in young females. Imaging and histopathology are necessary to confirm the diagnosis as most have no symptoms. Lack of access to these technologies in sub-Saharan Africa contributes to the difficulty in making an early and accurate diagnosis, and hence, impedes treatment. We present two cases of SPEN of the pancreas in young female patients at a rural, teaching hospital in Cameroon. The diagnosis was made only with histopathology. Computed tomography scan with intravenous contrast was essential to planning a safe surgical resection. Both patients had complete surgical resection with good results.

Case report: Retroperitoneal solid pseudopapillary neoplasm associated with multiple hepatic metastases

Solid pseudopapillary neoplasm (SPN) is a rare tumor mostly occurring in the pancreas. They are low-grade malignant tumors of the exocrine pancreas that occasionally metastasize, usually to the liver or peritoneum. Additionally, multiple metastases of extrapancreatic SPN to the liver are extremely rare and have been reported before. This study presents a case of a 13-year-old male patient with retroperitoneal SPN and multiple hepatic metastases. The patient presented with abdominal trauma and underwent enhanced CT, which revealed upper pancreatic occupancy and three hypodense foci in the right lobe of the liver. Moreover, increased spleen size was noted. The patient's serum tumor marker CA125 was increased to 39.00 U/mL (N < 35.0 U/mL), and circulating tumor cells were elevated to 10.2 FU/3 mL (N < 8.7 FU/3 mL). The patient underwent retroperitoneal occupancy resection and splenectomy, followed by resection of liver metastases 7 months after the surgery. Furthermore, multiple liver metastases from retroperitoneal SPN were confirmed postoperatively. The patient recovered for 1 year without tumor recurrence. This case emphasizes the importance of evaluating serum tumor markers and medical imaging in young patients as well as the fact that surgery appears to be the preferred treatment option for multiple metastases in SPN.

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.

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.

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.

Case report of peritoneal carcinomatosis in the clinical course of pancreatic solid pseudopapillary neoplasm (Frantz's tumor) in a patient with a history of blunt abdominal trauma

INTRODUCTION

Pancreatic solid pseudopapillary neoplasm (SPN), or Frantz's tumor, is a rare tumor with low malignant potential and a high cure rate when treated by complete surgical resection. There have been few reports of metastatic disease as a result of blunt abdominal trauma.

PRESENTATION OF CASE

A 13-year-old female patient was a victim of blunt abdominal trauma in 2019. A computed tomography (CT) scan showed a voluminous hemoperitoneum associated with a tumor in the pancreatic tail whose characteristics suggested a pseudopapillary tumor. The patient remained hemodynamically stable and nonoperative treatment was chosen. Two months later, a CT scan showed resolution of the hemoperitoneum and delimitation of the neoplasm in the tail of the pancreas. Elective body and tail pancreatectomy with laparoscopic splenectomy was performed. The patient remained asymptomatic for 15 months until she developed abdominal pain and constipation. A CT scan suggested peritoneal carcinomatosis, which was confirmed by biopsy of the lesions.

CLINICAL DISCUSSION

A pancreatic SPN, in the context of an abdominal injury, can undergo metastatic progression despite surgical resection with curative intent and adherence to the precepts of minimally invasive oncological surgery. It is important to plan for the long-term follow-up of patients, as well as to understand the risk factors for recurrence.

CONCLUSION

Although pancreatic SPN has a good prognosis, rupture of its capsule due to external trauma, as reported in the present case, may be a mechanism for peritoneal dissemination of the tumor with a consequent reduction in the length of disease-free survival.

Solid Pseudopapillary Neoplasms of the Pancreas: Clinicopathologic Analysis and a Predictive Model

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare. They are considered low-grade malignancies, and a small percentage of patients experience recurrence or metastasis. It is critical to investigate associated biological behavior and identify patients at a risk of relapse. This was a retrospective study of 486 patients with SPNs who were diagnosed between 2000 and 2021. Their clinicopathologic features, including 23 parameters and prognoses were analyzed. Six patients (1.2%) presented with synchronous liver metastasis. A total of 21 patients experienced recurrence or metastasis postoperatively. The overall and disease-specific survival rates were 99.8% and 100%, respectively. The 5- and 10-year relapse-free survival (RFS) rates were 97.4% and 90.2%, respectively. Tumor size, lymphovascular invasion, and the Ki-67 index were independent predictors of relapse. Furthermore, a Peking Union Medical College Hospital-SPN risk model was built to evaluate the risk of relapse and compared it with the American Joint Committee on Cancer tumor staging system (eighth edition, 2017). Risk factors included 3 parameters: tumor size (>9 cm), lymphovascular invasion status (presence), and Ki-67 index (>1%). Risk grades were available for 345 patients, who were divided into 2 groups: (1) low risk (n = 124) and (2) high risk (n = 221). The group with no risk factors was designated as low risk and had a 10-year RFS of 100%. The group associated with 1 to 3 factors was designated as high risk, with a 10-year RFS of 75.3%. Receiver operating characteristic curves were generated, and the area under the curve was 0.791 for our model and 0.630 for the American Joint Committee on Cancer with respect to the cancer staging system. We validated our model in independent cohorts and demonstrated a sensitivity of 98.3%. In conclusion, SPNs are low-grade malignant neoplasms that rarely metastasize, and the 3 selected pathologic parameters can be used to predict their behavior. A novel Peking Union Medical College Hospital-SPN risk model was proposed for routine application to guide the patient counseling in clinical practice.

Perioperative safety and prognosis following parenchyma-preserving surgery for solid pseudopapillary neoplasm of the pancreas

BACKGROUND/OBJECTIVES

To evaluate perioperative safety and outcome of parenchyma-preserving pancreatectomy and risk factors of metastasis and recurrence for patients with solid pseudopapillary neoplasm (SPN).

METHODS

Demographic data, operative and pathological parameter, follow-up data of patients with SPN undergoing their first operation were collected in our single center from May 2016 to October 2021 and compared between regular pancreatectomy group and parenchyma-preserving surgery group. Risk factors for metastasis and recurrence were investigated.

RESULTS

A total of 194 patients were included, 154 of whom were female and the average age of all patients was 33 years old. Most patients were asymptomatic, with the most common complaint being abdominal pain or discomfort. Of them, 62 patients underwent parenchyma-preserving pancreatectomy including middle segment pancreatectomy and enucleation, and 132 patients underwent regular pancreatectomy including pancreaticoduodenectomy, distal pancreatectomy and total pancreatectomy. Patients in the parenchyma-preserving surgery group had a shorter duration of operation, less intraoperative bleeding, and decreased risk of combined organ removal and blood transfusion, with no statistical significance yet. The two groups exhibited a similar incidence of postoperative complications including grade B and C pancreatic fistula, delayed gastric emptying, postoperative pancreatic hemorrhage, and other complications, as well as radiological intervention, relaparotomy and the length of postoperative hospital stay. There were no perioperative deaths. All the patients, except 18 of those who discontinued follow-up, were alive with a median follow-up time of 31 months. Three patients in the regular pancreatectomy group were observed to have liver metastasis, and no metastasis was observed in the parenchyma-preserving surgery group. Significant risk factors for tumor metastasis and recurrence were tumor size, angioinvasion, and nerve infiltration.

CONCLUSIONS

Parenchyma-preserving surgery did not significantly increase the frequency of perioperative complications or recurrence and might be preferable if comprehensive conditions allow.

Solid Pseudopapillary Neoplasm of the Pancreas: A Multi-Institution Study of 118 Cases

OBJECTIVES

The aim of the study is to summary the clinicopathological characteristics and surgical outcomes of solid pseudopapillary neoplasm (SPN) of the pancreas.

METHODS

In this retrospective study, the information of 118 patients with SPN from 3 hospitals were analyzed.

RESULTS

A total of 118 patients. The mean age was 30.8 (standard deviation, 14.7) years and the majority were female (n = 95, 80.5%). Sixty-seven patients (56.8%) had clinical symptoms, of which the most common symptom was abdominal pain (49.6%). The mean tumor size was 5.9 (standard deviation, 2.9) cm. Pseudopapillary architecture was the commonest histologic feature, and β-catenin, CD56, vimentin, neuron-specific enolase, CD10, a1-antitrypsin, cytokeratins showed different degrees of positive expression in immunohistochemical staining. Fourteen patients (11.9%) presented aggressive pathologic behavior, which was correlated to the incomplete tumor capsule. At a median follow-up of 59.2 months, the recurrence rate was 1.8% and the overall 5-year survival rate was 97.7%.

CONCLUSIONS

Solid pseudopapillary neoplasm of the pancreas is a potentially low-grade malignant tumor that most frequently found in young females. Its clinical manifestations are nonspecific and the diagnosis mostly depends on pathological examination. Surgical resection is the first choice of treatment for SPN with a good prognosis.

Differential diagnosis between pancreatic solid pseudopapillary tumors and pancreatic neuroendocrine tumors based on contrast enhanced ultrasound imaging features

PURPOSES

To evaluate the application of contrast enhanced ultrasound (CEUS) in preoperatively differential diagnosis between pancreatic solid pseudopapillary tumors (SPTs) and pancreatic neuroendocrine tumors (pNETs).

PATIENTS AND METHODS

This retrospective study was approved by Institutional Review Board. Patients with surgical resection and histopathological diagnosis as SPTs and pNETs were included. All patients underwent B mode ultrasound (BMUS) and CEUS examinations within one week before surgical operation. On BMUS, the size, location, echogenicity, calcification, and margin of lesions were observed and recorded. On CEUS imaging, enhancement patterns, and enhancement degrees were recorded and analyzed. An independent t-test or Mann-Whitney U test was used for comparison between continuous variables. Chi-square test was used to compare the CEUS patterns.

RESULTS

From February 2017 to Dec 2022, patients diagnosed as SPTs (n = 39) and pNETs (n = 48) were retrospectively included. On BMUS, anechoic cystic changes (19/39, 48.72%) and hyperechoic calcification (14/39, 35.90%) are more commonly detected in SPTs (P = 0.000). On CEUS imaging, the majority of SPTs (27/39, 69.23%) showed hypo-enhancement in the arterial phase, while most of the pNETs (36/48, 75.00%) showed hyper- or iso-enhancement in the arterial phase (P = 0.000). In the venous phase, most of the SPTs (32/39, 82.05%) showed hypo-enhancement, while over half of pNETs (29/48, 60.42%) showed hyper- or iso-enhancement compared to pancreatic parenchyma (P = 0.001).

CONCLUSIONS

CEUS is a valuable and non-invasive imaging method to make preoperatively differential diagnoses between SPTs and pNETs.

Reporting a Case of Solid Pseudopapillary Neoplasm of the Pancreas in a 44-Year-Old Woman with Parallel Analysis of Literature

We present a distinctive case of solid pseudopapillary neoplasm as seen in a 44-year-old woman who presented with an abdominal mass but unremarkable labs with no elevation in any of the tumor markers. Her symptomatology ranged from typical symptoms suggestive of malignancy such as weight loss, lethargy, and anorexia to complaints like abdominal pain and jaundice. Prior to presenting at our center, she was given no hope or much in terms of treatment options. She was found to have a substantial mass over the body and tail of pancreas with characteristic and typical gross as well as histological features. Subsequently, she underwent a successful surgery and has found herself in remission since.

Solid Pseudopapillary Neoplasms of the Pancreas Across Races Demonstrate Disparities with Comparably Good Prognosis

BACKGROUND

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare with low-grade malignancy and unclarified clinicopathological features. This study aimed to examine their characteristics and re-evaluate current treatments.

METHODS

Databases from three sources were screened for patients with SPNs. We compared the perioperative variables, clinical data, overall survival (OS), and prognostic factors for recurrence among the three corresponding cohorts.

RESULTS

We identified 286 patients diagnosed with SPNs between 1988 and 2020. Patients were mostly women (81%; median age: 38 years), and peak incidence was observed in women of 20-29 years of age. SPNs had a peak incidence in Asian men at 50-59 years of age (p = 0.002) and a delayed peak incidence in Asian women at 30-39 years of age (p < 0.001). Treatment strategies differed significantly across the institutions and included variations in the number of harvested lymph nodes and rates of vascular resection. Lymph node positivity was the only predictor of postoperative recurrence (odds ratio, 2.2; 95% confidence interval, 1.38-2.99; p = 0.007). Higher rates of lymphovascular invasion (p = 0.02), perineural invasion (p < 0.001), and R1 margin involvement (p < 0.001), as seen in one institution, did not result in poorer long-term survival in terms of the overall (p = 0.43), SPN-specific (p = 0.69), and recurrence-free survivals (p = 0.067).

CONCLUSIONS

In contrast to previous findings that SPNs are prevalent in young women, a racial predilection for middle-aged Asian men and a delayed female peak incidence were noted. Parenchyma-preserving pancreatectomy may be an acceptable treatment. Non-radical surgery may be appropriate in patients with multiple comorbidities.

Prospects and applications of enucleation in solid pseudopapillary neoplasms of the pancreas

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare, low-grade, malignant neoplasms that are mostly seen in young women in the second and third decades of life and are quite uncommon in children. Standard resection for benign and borderline neoplasms of the pancreas is associated with a substantial risk of postoperative morbidity and long-term functional impairment, whereas enucleation leads to less morbidity and preserves healthy parenchyma as well as exocrine and endocrine function. Enucleation of SPNs has been increasingly reported to be feasible and safe for preserving the normal physiological function of the pancreas, especially in teenagers and children. This review summarizes findings published in recent years on the enucleation of SPNs as well as potential future developments and directions. Enucleation has undoubtedly come to stay as an alternative surgical procedure for SPNs. However, many questions remain unresolved, and future directions toward the best surgical indication, the prevention and intervention of complications, especially pancreatic fistula, intraoperative resection margin safety assessment, and long-term oncology prognosis remain to be evaluated and should be explored in future clinical trials.

Clinical profile and outcome of solid pseudopapillary neoplasm of the pancreas: A retrospective study on 28 patients

BACKGROUND

Solid pseudopapillary neoplasms (SPN) of the pancreas are rare tumors accounting for 0.9-2.7% of all exocrine pancreatic tumors. Very few studies comprising of more than 10 patients have been published. The aim of the present study is to report on our experience with SPNs over a period of 14 years from a tertiary center of Eastern India.

METHODOLOGY

Data of all patients whose histopathology reports of surgically resected specimen confirmed SPN were retrospectively reviewed in the present study.

RESULTS

Twenty-eight patients had a pathologically confirmed diagnosis of SPN. Twenty-five (89.3%) patients were females with a median age of 26 (15-45) years. Abdominal pain (89.2%) was the most common presenting symptom. Abdominal mass was palpable in 12 (42.8%) patients. The mean size of the tumor was 9.03 cm (range, 4-25 cm). The most common location of the tumor was in the body and tail of pancreas (35.7%). The most commonly performed operation was distal pancreaticosplenectomy (n = 17, 60.7%), followed by Whipple's procedure (n = 8, 28.5%). Thirty postoperative complications developed in 23 (82.1%) patients. The operative mortality was 3.5% (n = 1). The median hospital stay was 10 (5-25) days. Over a median follow-up period of 36 months (range), no patient developed recurrence.

CONCLUSION

Although the size of tumor was quite large at the time of initial presentation, complete surgical resection was possible in all the patients. In experienced hand, surgery can be performed with acceptable perioperative mortality and excellent long-term outcomes.

Solid Pseudopapillary Neoplasm of the Pancreas with Lymph Node Metastasis in a Young Male Patient

Solid pseudopapillary pancreatic neoplasms are rare. The male-to-female ratio is 1:9, and metastasis occurs only in a few cases. A 39-year-old male with a solid pseudopapillary neoplasm (SPN) with lymph node metastasis underwent ultrasonography, CT, and MRI, which revealed a mass (8 cm) in the pancreatic head. Fluorodeoxyglucose (FDG)-PET showed a hypermetabolic lymph node in the root area of the superior mesenteric artery (SMA). The patient underwent pylorus-preserving pancreaticoduodenectomy, which confirmed a peripancreatic lymph node metastasis. The lymph node of the SMA root area remained because of the encasing of the superior mesenteric artery. After 14 months of follow-up (with no adjuvant therapy initiated), the residual metastatic lymph nodes showed no change and no recurrence. In conclusion, surgery of the primary tumor for patients with SPN is recommended, even in cases with metastatic lymph nodes remaining.

Solid Pseudopapillary Tumor of Pancreas with Sinistral Portal Hypertension: A Rare Presentation

An elderly male presented with complaint of dull aching pain in left upper abdomen of 2 months' duration. He was well built, and on abdominal examination, a large lump was palpable in left lumbar region. His biochemical, hematological parameters and tumor markers including CA 19.9 were within prescribed normal limits. Contrast enhanced computed tomography (CT) of the abdomen revealed large, well-defined, mixed solid, and cystic lesion arising from distal body-tail of the pancreas extending up to splenic hilum. Chronic thrombosis involving retro pancreatic splenic vein with multiple perisplenic, peripancreatic, and perigastric collaterals were noted. Based on characteristic CT abdomen findings, a diagnosis of solid pseudopapillary tumor (SPT) of the pancreas with sinistral portal hypertension (SPH) was made. The patient was planned for open distal pancreatectomy with splenectomy. At surgery, splenic flexure of colon was densely adhered to the tumor, and hence en bloc resection of colon was also performed. Postoperative period was uneventful, and he was discharged from the hospital on postoperative day 6. Histopathology reported solid pseudopapillary tumor of the pancreas, 22 cm in the largest dimension. SPT of the pancreas rarely present with SPH. At 22-cm size, this may be one of the largest SPTs reported in the English literature to date.

Prognostic Enigma of Pancreatic Solid Pseudopapillary Neoplasm: A Single-Center Experience of 63 Patients

Background: Studies investigating prognostic factors of solid pseudopapillary neoplasm (SPN) have been published with conflicting findings.

Methods: Retrospective analysis of 63 consecutive cases of SPN in our institution from January 2010 to December 2019 was carried out. The clinicopathological features, treatment practices along with survival associations were collected and analyzed.

Results: Fifteen patients (23.8%) were male, and 48 (76.2%) were female, with a median age of 34.0 ± 14.5 years. The larger tumor size was correlated with the more mixed components (p = 0.000) and the higher Ki-67 index (p = 0.042). No recurrence was found in the nine patients whose tumors fulfilled the WHO criteria for malignancy due to the presence of at least perineural invasion (6.4%), angiovascular invasion (2.3%), and/or adjacent organ invasion (6.4%). Microscopic infiltrative growth was detected in 9 (14.3%) tumors, which was correlated significantly with the WHO criteria (p = 0.002), capsule invasion (p = 0.005), and pancreatic parenchyma invasion (p = 0.001), but not with disease-free survival (p = 0.13). CD99 was found to be positively expressed in 88.9% (40/45) of tumors and more likely to have depressed Ki-67 index (p = 0.016). After a median follow-up of 58 months, only two patients (3.2%) had a recurrence after their first operation outside of our hospital. No patient died due to tumor progression.

Conclusions: Although survival is favorable with aggressive surgery, it is actually difficult to assess the prognostic factors of resected SPNs. Future investigations into the role of clinicopathological evaluation will unveil the prognostic enigma of pancreatic SPN after resection.

Clinicopathological factors associated with recurrence in patients undergoing resection of pancreatic solid pseudopapillary neoplasm

PURPOSE

Solid pseudopapillary neoplasm (SPN) is an uncommon pathology with a low-grade malignancy. Surgery is the milestone treatment. Nevertheless, despite appropriate management, some patients present recurrence. Risk factors associated with recurrence are unclear. The objective was to identify the clinicopathological factors associated with recurrence in patients with SPN treated with pancreatic resection.

METHODS

Medical records of patients treated with pancreatic resection during 2006-2020 were evaluated. Patients with histological diagnosis of SPN were included. Survival analysis was performed to identify the clinicopathological factors related to recurrence.

RESULTS

Seventy-four patients were diagnosed with SPN; 70 (94.6%) patients were female, and the median age was 20 years old. The median tumor diameter was 7.9 cm. Multivisceral resection was performed in 9 (12.2%) patients. Four (5.4%) patients presented lymph node metastasis.R0 resection was achieved in all cases. Six (8%) patients presented recurrence and the liver was the most frequent recurrence site (n = 5).After a median follow-up of 40.2 months, 9 (12%) patients died. Five (6.8%) patients died of disease progression. The 1-3- and 5-year overall survival (OS) was 97.1%, 90.2% and 79.9%, respectively. The 1-3-and-5-year recurrence-free survival (RFS) was 98.4%, 89.9% and 87%, respectively. In the univariate Cox-regression analysis, age ≥ 28 years(HR = 8.61, 95% CI 1.1-73.8),tumor diameter ≥ 10 cm(HR = 9.3, 95% CI 1.12-79.6),invasion of adjacent organs (HR = 7.45, 95% CI 1.5-36.9), lymph node metastasis (pN +) (HR = 16.8, 95% CI 2.96-94.9) and, AJCC Stage III (HR = 10.1, 95% CI 1.2-90.9) were identified as predictors for recurrence.

CONCLUSIONS

SPN is more frequently diagnosed in young women with a good overall prognosis after an R0 surgical resection even with disease recurrence. Age ≥ 28 years, larger tumors ≥ 10 cm, invasion of adjacent organs, lymph node metastasis(pN +) and, AJCC Stage III were predictors factors of recurrence in resected SPN.

Case Report: Targeted Therapy for Metastatic Solid Pseudopapillary Neoplasm of the Pancreas With CTNNB1 and PTEN Mutations

Background

Solid pseudopapillary neoplasm (SPN) of the pancreas shows an indolent clinical behavior in cases undergoing surgical resection. The efficacy of combination therapy in the metastatic extrapancreatic SPN treatment remains largely unknown and a clinical challenge.

Case Presentation

We report a case of a metastatic pancreatic SPN in a 45-year-old woman who presented with an aggressive peritoneal dissemination and hepatic metastases and still showed an indolent clinical course with combination therapy with repeated surgery and targeted therapy. Although the follow-up effect remains to be seen, this is the first report of practical experience of the targeted agents sunitinib and everolimus in metastatic SPN tumors based on the mutation status of PTEN (c.379G>A; p.G127R) and CTNNB1 (c.98C>G; p.S33C). To our knowledge, the PTEN variant identified in this case has not been previously reported in SPN.

Conclusion

Evidence on variant genetics indicates that future molecular studies may not only help to explain the mechanism of SPN occurrence and development but are also more likely to direct to future precision treatments.

Molecular Alterations in Solid Pseudopapillary Neoplasm of the Pancreas: The Achilles Heel in Conquering Pancreatic Tumorigenesis

Solid pseudopapillary neoplasms of the pancreas are overwhelmingly benign tumors predominately observed in women in the third decade of life. However, their malignant potential, based on local recurrences and metastases, has brought into question the available evidence on their biological behavior. Solid pseudopapillary neoplasms have distanced themselves from other pancreatic tumors with varying morphological appearance, immune profile, and histogenesis. In review of the literature, PubMed was queried using search strings, including "solid pseudopapillary neoplasm" and "molecular," and "immunohistochemistry." Alternative searches were also conducted given the variability in tumor name, including "solid pseudopapillary tumor" and "Frantz tumor." This article provides an in-depth review into the molecular pathways that contribute to the pathogenesis of solid pseudopapillary neoplasms. It also discusses the implications of existing molecular pathways toward tumor aggressiveness and recurrence potential.

Prediction of Recurrence Risk in Solid Pseudopapillary Neoplasm of the Pancreas: Single-Institution Experience

BACKGROUND

Solid pseudopapillary neoplasm (SPN) of the pancreas is a low-grade malignant neoplasm with unpredictable behavior. Factors associated with recurrence were not conclusively identified. The aim of this study is to define the clinicopathological criteria for recurrence risk prediction in SPNs based on the most recent scientific evidence and to present our experience with SPNs.

METHODS

A retrospective review of patients with SPNs operated on in our institution from June 2012 to June 2018 was completed. Patient characteristics and clinical outcomes were analyzed. A detailed literature review was performed to evaluate the factors associated with the recurrence of SPNs.

RESULTS

The cohort consisted of 13 female patients with a median age of 24 years and a mean tumor size of 7.7 cm. Body and tail (53.8%) were the most common location, and distal pancreatectomy with splenectomy was the prevalent surgical procedure. One patient of SPN operated on for local recurrence after 11 years which had high-grade malignant histological features on the previously resected tumor. At a median follow-up of 42 months (range 36 to 108), all patients were disease free and alive. The proposed criteria for predicting recurrence in SPNs include tumor size >8 cm, synchronous metastasis, malignant SPN (according to 2000 or 2010 World Health Organization [WHO] criteria), lymphovascular invasion, pancreatic parenchymal invasion, and high Ki-67 index (>4%). All these are worse prognostic factors and should be considered as high-risk factors for postoperative relapse.

CONCLUSION

The above-mentioned criteria can better predict SPN recurrence. Patients with high-risk features should undergo an extended follow-up.

[Rare pancreatic tumors]

Beyond pancreatic ductal adenocarcinoma, which is by far the most frequent pancreatic neoplasm, a great variety of tumors occur in the pancreas. They include solid and cystic masses and epithelial and nonepithelial neoplasms, and they show a great diversity in their biological behavior, ranging from benign tumors to highly aggressive neoplasms. As examples of rare pancreatic tumors, clinical, morphological, and molecular aspects of acinar cell carcinoma, pancreatoblastoma, solid pseudopapillary neoplasm, and serous cystic neoplasms are presented and discussed.

Prediction of Recurrence of Completely Resected Pancreatic Solid Pseudopapillary Neoplasms in Pediatric Patients: A Single Center Analysis

Background: Many previous studies have investigated the risk factors for the recurrence of pancreatic solid pseudopapillary neoplasms (SPNs), although a consensus has not yet been reached, despite this effort. We aimed to identify the predictive factors for recurrence in patients with SPNs who underwent complete surgical resection of the tumor. Methods: We retrospectively analyzed the records of pediatric patients with SPNs who underwent surgical resection at a single center between 2001 and 2018. Results: During the study period, 47 patients with SPNs underwent radical resection of the tumor. The median age of the patients was 14 (8–18) years. R0 resection was confirmed in every case and none of the patients presented with systemic metastasis at the time of diagnosis. The median follow-up period was 53.1 (30.8–150.8) months. Of the 47 patients, only two (4.2%) experienced recurrence. Using comparative analysis, we found that some factors such as a large tumor size, peripancreatic tissue invasion, and capsule invasion did not increase the risk of recurrence of SPNs. Lymph node metastasis was the only significant factor for recurrence in our study (p = 0.043). Conclusion: During our single center analysis, we found that only lymph node metastasis was a predictive factor for recurrence of SPNs among patients who underwent complete tumor resection. Long-term follow-up is required to determine whether SPNs will recur if lymph node metastasis is observed after surgery. Furthermore, therapeutic benefits of routine lymphadenectomy or sentinel lymph node biopsy should be investigated in future studies to reduce the risk of recurrence in patients with SPNs.

Solid bifocal pseudopapillary neoplasm of the pancreas: A case report

INTRODUCTION

This neoplasm of the pancreas is an uncommon entity, with a frequency of 0.3-2.7% of all pancreatic tumors and even more so the finding of a synchronous lesion of the same histological lineage. For this reason, we report the atypical presentation of a SPNPs through a clinical case, review of the literature and a classification proposal, from the quantitative point of view.

CASE PRESENTATION

21-year-old patient, with incidental finding of two pancreatic tumors. Surgery included a pyloric preserving pancreatoduodenectomy with pancreatojejunostomy, distal pancreatectomy and central pancreas was preserved. The patient presents low output pancreatic fistula and nosocomial infection, treated with antibiotic therapy, being discharged 29 days after the intervention. Pathological and immunohistochemical analysis consistent with two SPNP.

DISCUSSION

Its diagnosis is confirmed with the histological study and two synchronic SPNP are a rare entity and for this, or multiple lesions, an attempt should be made of a conservative resection of the parenchyma to minimize pancreatic insufficiency in a frequently young population, and always look for R0 resection, due to its uncertain behavior.

CONCLUSION

Bifocal SPNP is rare and for this it is utility classify this entity -from the quantitative point of view- into unifocal, bifocal and multifocal for future medical research.

Yield of surgery in solid pseudopapillary neoplasms of the pancreas: A case series and literature review

BACKGROUND

Solid pseudopapillary neoplasms (SPN) of the pancreas represents approximately 2% of non-endocrine tumors of the pancreas. It is described in the literature as a rare and predominant tumor in young women.

AIM

To report a case series with SPN and analyzing clinical, surgical, anatomopathological characteristics, as well as the prognosis and review of literature.

METHODS

Retrospective analysis of patients undergoing surgery, with histological diagnosis of SPN between 1998 and 2018, using standardized and prospectively completed forms, performed at the Surgery Service of the Upper Digestive System at Hospital São Rafael/Rede D’Or in Salvador - BA. Review of literature through a database search in MEDLINE/PubMed of retrospective articles.

RESULTS

Fourteen female patients with the average age of 31.6 years (range min-max) were selected. Twelve patients (85.7%) were asymptomatic, being an incidental diagnosis or due to screening for other reasons. One patient had abdominal pain due to gastric compression and another patient had jaundice. The 14 patients were staged with computerized tomography or magnetic resonance imaging. None had evidence of metastasis. In 8 patients (57.1%), the tumor was in the tail and body. The average size was 6.7 cm (range min-18). The type of surgery was according to the anatomical location of the tumor. There was no lymph node involvement. In two cases, vascular resection with the use of a prosthesis was required for reconstruction. The surgical margins were free. In all cases, postoperative immunohistochemistry confirmed that it was a solid pseudo-papillary neoplasia of the pancreas. There has been no disease recurrence in any case so far.

CONCLUSION

The tumors had a benign, indolent and histopathological behavior compatible with the literature. Curative surgery is recommended in all cases.

Solid Pseudopapillary Neoplasm of the Uncinate Process of the Pancreas: A Case Report and Review of the Literature

Solid pseudopapillary neoplasm (SPN) is a rare pancreatic neoplasm that accounts for 1-3% of all pancreatic tumors. SPNs are most commonly found in females in their third and fourth decades of life. Even though the majority of the tumors are benign, malignant tumors have also been reported. Given its rare occurrence, it remains a clinical dilemma in gastroenterology, oncology, and pathology. It is critical to diagnose it early and differentiate it from other similar pancreatic tumors or cysts to ensure favorable patient outcomes. Advanced imaging techniques, characteristic histologic findings, and immunohistochemical analysis can help in diagnosing solid pseudopapillary tumors. Early diagnosis and surgical resection can result in a cure in most cases, and tumor recurrence is extremely rare. In this report, we present a case of a 40-year-old female patient who presented to the emergency room and was diagnosed with SPN of the pancreas.

Development of CT-Based Imaging Signature for Preoperative Prediction of Invasive Behavior in Pancreatic Solid Pseudopapillary Neoplasm

Purpose

It is challenging for traditional CT signs to predict invasiveness of pancreatic solid pseudopapillary neoplasm (pSPN). We aim to develop and evaluate CT-based radiomics signature to preoperatively predict invasive behavior in pSPN.

Methods

Eighty-five patients who had pathologically confirmed pSPN and preoperative contrasted-enhanced CT imaging in our hospital were retrospectively analyzed (invasive: 24; non-invasive: 61). 1316 radiomics features were separately extracted from delineated 2D or 3D ROIs in arterial and venous phases. 200% (SMOTE) was used to generate balanced dataset (invasive: 72, non-invasive: 96) for each phase, which was for feature selection and modeling. The model was internally validated in the original dataset. Inter-observer consistency analysis, spearman correlation, univariate analysis, LASSO regression and backward stepwise logical regression were mainly applied to screen the features, and 6 logistic regression models were established based on multi-phase features from 2D or 3D segmentations. The ROC analysis and Delong's test were mainly used for model assessment and AUC comparison.

Results

It retained 11, 8, 7 and 7 features to construct 3D-arterial, 3D-venous, 2D-arterial and 2D-venous model. Based on 3D ROIs, the arterial model (AUC: 0.914) performed better than venous (AUC: 0.815) and the arterial-venous combined model was slightly improved (AUC: 0.918). Based on 2D ROIs, the arterial model (AUC: 0.814) performed better than venous (AUC:0.768), while the arterial-venous combined model (AUC:0.893) performed better than any single-phase model. In addition, the 3D arterial model performed better than the best combined 2D model. The Delong's test showed that the significant difference of model AUC existed in arterial models in original dataset (p = 0.019) while not in arterial-venous combined model (p=0.49) as comparing 2D and 3D ROIs.

Conclusion

The arterial radiomics model constructed by 3D-ROI feature is potential to predict the invasiveness of pSPN preoperatively.

[Solid pseudopapillary neoplasms of the pancreas : Diagnostics, surgical treatment and postoperative outcome]

BACKGROUND

Malignant solid pseudopapillary neoplasms (SPN) are rare tumor entities of the pancreas. The prognosis for SPN is generally excellent, although some tumors have malignant potential and tend to metastasize or relapse.

OBJECTIVE

The aim was to investigate whether there are histopathological or surgical risk factors that enable the biological potential of SPN to be estimated.

PATIENTS AND METHODS

Data from patients with SPN treated in two large German pancreas centers from 2009 to 2018 were evaluated with respect to the occurrence of SPN, surgical management, histopathological tumor characteristics and the postoperative outcome.

RESULTS

A total of 22 patients with SPN (17 women, 5 men) were operated on. The median age of the patients was 37 years (range 19-69 years). At the time of surgery 20 patients showed tumor growth limited to the pancreas. A female patient with recurrence of an externally resected SPN had lymph node involvement. Another female patient had a hepatic metastatic recurrence (Union Internationale contre Cancer (UICC) stage IV) of an externally resected SPN. Although all patients survived recurrence-free during the follow-up, this patient developed liver metastases again. The survival rate up to the end of the follow-up (median 43 months; range 1-132 months) of this study was 100%.

CONCLUSION

There is a lack of knowledge of the possible parameters that can be used to predict the biological behavior of SPN. Apart from an increased likelihood of recurrence after resection of an SPN recurrence, no clear risk factors could be identified in the examined patient collective that could indicate an increased malignant potential and a possibly poorer outcome. Only a radical surgical resection with lymphadenectomy enables a reliable assessment of the tumor stage and the removal of possibly affected lymph nodes, which could be the cause of a recurrence if left intact.

Clinical Pattern of Preoperative Positron Emission Tomography/Computed Tomography (PET/CT) Can Predict the Aggressive Behavior of Resected Solid Pseudopapillary Neoplasm of the Pancreas

Simple Summary

Predicting the aggressiveness of solid pseudopapillary neoplasms (SPNs) remains a worthwhile goal. The present study aimed to identify perioperative factors that can predict patients who will develop clinically aggressive SPN. A total of 98 patients diagnosed with SPNs were analyzed retrospectively. We found that age (≥40 years; p = 0.039), symptomatic presentation (p = 0.001), tumor size (>10 cm; p < 0.001), positron emission tomography/computed tomography (PET/CT) classification (Type III; p < 0.001), and lymphovascular invasion (p = 0.003) were significantly correlated with aggressive behavior of SPNs. Among these, age ≥40 years, PET/CT Type III configuration, and lymphovascular invasion were independent factors associated with an aggressive SPN. This information can help clinicians develop individualized management and surveillance plans to manage patients more competently.

Abstract

Predicting the aggressiveness of solid pseudopapillary neoplasms (SPNs) remains an important goal. The present study aimed to identify perioperative factors that can predict patients who will develop clinically aggressive SPN. Records of individuals with pathologically confirmed SPN from 2006 to 2017 were obtained from the patient registry database of Yonsei University, Severance Hospital. For this study, aggressive behavior was defined as SPN that had recurred, metastasized, or involved adjacent organs. A total of 98 patients diagnosed with SPNs were analyzed retrospectively. Of these, 10 were reported to have SPNs with aggressive characteristics. We found that age (≥40 years; p = 0.039), symptomatic presentation (p = 0.001), tumor size (>10 cm; p < 0.001), positron emission tomography/computed tomography (PET/CT) classification (p < 0.001), and lymphovascular invasion (p = 0.003) were significantly correlated with aggressive behavior of SPNs. Multivariate analysis showed that PET/CT configuration (p = 0.002) (exp(β)111.353 (95% confidence interval (CI): 5.960–2081), age ≥40 years (p = 0.015) (exp(β) 23.242 (95% CI: 1.854–291.4)), and lymphovascular invasion (p = 0.021) (exp(β) 22.511 (95% CI: 1.595–317.6)) were the only independent factors associated with aggressive SPN. Our data suggest that age ≥40 years, PET/CT Type III configuration, and lymphovascular invasion are independent factors associated with aggressive SPN. This information can help clinicians develop individualized management and surveillance plans to manage patients more effectively.

Solid Pseudopapillary Neoplasms of the Pancreas: a Single-Center Experience and Review of the Literature

PURPOSE

Pancreatic solid pseudopapillary neoplasms (SPNs) are rare borderline tumours mainly affecting young female patients. The number of patients diagnosed with SPNs has increased significantly in the last decades owing to the increased use of cross-sectional imaging investigating different abdominal symptoms, whilst a significant proportion are incidentally discovered during the process of evaluating other pathologies. We herein present our institutional experience of patients with SPN who underwent curative resection focusing on clinical, pathological features, and the long-term outcomes.

METHODS

All patients undergoing pancreatectomy in our institution for SPN from January 2010 until December 2018 were included. Clinical, perioperative, histological, and long-term outcomes were collected and analysed.

RESULTS

During the inclusion period, a total of 19 patients had a pathological diagnosis of SPNs after surgical resection. Sixteen of them were female (84%), while the median patient age was 30 (range 16-66) years. Nine patients (47%) underwent distal pancreatectomy and splenectomy, 2 (11%) underwent spleen preserving distal pancreatectomy, 6 (32%) underwent pancreatoduodenectomy, one (5%) underwent total pancreatectomy, and one (5%) central pancreatectomy. Seventeen patients underwent R0 resection. During a median follow-up of 23 months, no tumour recurrence or death was recorded.

CONCLUSION

In our experience, SPNs are rare tumours with low malignant potentials. Surgical resection remains the gold standard treatment and is associated with good prognosis.

Solid-Pseudopapillary Neoplasm of the Pancreas: A 63-Case Analysis of Clinicopathologic and Immunohistochemical Features and Risk Factors of Malignancy

Purpose

Solid-pseudopapillary neoplasm (SPN) of the pancreas, a rare tumor, has low malignant potential. However, some patients develop metastasis and recurrence after resection, with aggressive biological behaviors. This study aimed to explore the features and risk factors associated with the aggressive biological behaviors of SPNs.

Patients and Methods

We retrospectively analyzed the clinicopathological and long-term follow-up data of 63 patients diagnosed with SPN at the First Affiliated Hospital of Bengbu Medical College between January 2007 and February 2019.

Results

Sixty-three patients presented atypical clinical symptoms. The median tumor size was 7.0 cm (range, 2.4–17 cm), and imaging features were solid and cystic or solid tumors with uneven density. Frequent and diffuse nuclear LEF1 protein expression (94.2%) was observed with LEF1 having a higher sensitivity and specificity. Overall survival significantly correlated with tumor size, Ki-67 index, and lymph node metastasis (P < 0.05).

Conclusion

SPN is a rare low-grade malignancy with a specific pseudopapillary structure. LEF1 is an effective biomarker of SPNs. Although SPNs generally display indolent biological behavior, a large tumor size, high proliferation index, and lymph node metastasis may be risk factors for the aggressive behavior and poor prognosis of SPN.

A case of solid pseudopapillary neoplasm preoperatively diagnosed as left renal tumor

Solid pseudopapillary neoplasm is a rare disease that accounts for approximately 2% of pancreatic neoplasms, and the treatment is complete resection of the tumor. We experienced a case preoperatively diagnosed as a left renal tumor with pancreatic invasion and histologically diagnosed with solid pseudopapillary neoplasm of the pancreas. The purpose of this case report is to illustrate the importance of differentiating solid pseudopapillary neoplasm in patients who present a left renal tumor with pancreatic invasion.

•

Solid pseudopapillary neoplasm (SPN) is a rare disease that accounts for approximately 2% of pancreatic neoplasms.

•

In SPN, adjacent organ invasion is reported in only 2.6% cases, and SPN patients who underwent a distal pancreatomy combined with left nephrectomy were rarely reported.

•

We report a case preoperatively diagnosed with left renal tumor with pancreatic invasion and histologically diagnosed with SPN of pancreas.

•

The purpose of this case report is to illustrate the importance to differentiate solid pseudopapillary neoplasm in patients present a left renal tumor with pancreatic invasion.

Solid pseudopapillary neoplasm-diagnostic approach and post-surgical follow up: Three case reports and review of literature

BACKGROUND

Solid pseudopapillary neoplasm (SPN) is a rare tumor that was first described by Frantz in 1959. Although this tumor is benign, some may have malignant potential that can be predicted based on demographics, imaging characteristics, and pathologic evaluation. This case series presents 3 SPN cases with discussion on gender differences, preoperative predictors of malignancy, and a suggested algorithm for diagnostic approach as well as post-surgical follow up.

CASE SUMMARY

Three adult patients in a tertiary hospital found to have SPN, one elderly male and two young females. Each of the cases presented with abdominal pain and were discovered incidentally. Two cases underwent endoscopic ultrasound with fine needle aspiration and biopsy to assess tumor markers and immuno-histochemical staining (which were consistent with SPN before undergoing surgery), and one case underwent surgery directly after imaging. The average tumor size was 5 cm. Diagnosis was confirmed by histology. Two patients had post-surgical complications requiring intervention.

CONCLUSION

Demographic and imaging characteristics can be sufficient to establish diagnosis for SPN, while malignant cases require pre-operative evaluation with endoscopic ultrasound fine needle aspiration/fine needle biopsy.

Large tumor size, lymphovascular invasion, and synchronous metastasis are associated with the recurrence of solid pseudopapillary neoplasms of the pancreas

BACKGROUND

Solid pseudopapillary neoplasms (SPNs) of the pancreas have low malignant potential. However, malignant SPNs are not fully understood.

METHODS

To evaluate risk factors affecting malignant potential, the clinicopathologic features of 375 surgically resected SPNs were compared.

RESULTS

Fifty (13.3%) had malignant histologic features. Twenty-seven and 22 had perineural and lymphovascular invasions, respectively. Adjacent organ invasion was noted in 9 cases. Recurrence occurred in 8 cases. The median recurrence time after surgical resection was 67 months and was associated with a higher pT category (P = 0.001), lymphovascular invasion (P < 0.001), and synchronous metastasis (P < 0.001). SPN patients with malignant histologic features had worse recurrence-free survival (RFS; 10-year survival rate, 73.2%) than those without malignant histologic features (96.3%; P = 0.01). Patients with a higher pT category (P = 0.04), synchronous metastasis (P < 0.01), and lymphovascular invasion (P < 0.01) had worse RFS. Lymphovascular invasion (P = 0.042) and a higher T category (P = 0.002) were poor prognostic factors for recurrence.

CONCLUSION

Lymphovascular invasion and a higher T category were worse prognostic factors for recurrence in SPN patients with malignant histologic features. For SPN patients with malignant histologic features, a longer follow-up may be required.

Management Algorithms for Pancreatic Cystic Neoplasms: The Surgeon's Perspective

CONTEXT.—

The detection of pancreatic cystic neoplasms (PCNs) has increased owing to the advancement and widespread use of imaging modalities, resulting in differences between past and current management methods for PCNs, including intraductal papillary mucinous neoplasms (IPMNs). Therefore, clinicians should accurately diagnose and determine appropriate treatment strategies. However, previously published treatment guidelines for IPMNs present different indications for treatment.

OBJECTIVE.—

To review the current status of PCNs, including epidemiologic change, malignancy risk, and factors for treatment, and to provide the optimal management algorithms for PCNs, including IPMNs, from the clinician's point of view.

DATA SOURCES.—

Literature review of published studies and the authors' own work.

CONCLUSIONS.—

The treatment of PCNs relies on the type of cyst that is present or suspected. Serous cystic neoplasms are usually benign, and observation is sufficient. However, surgical treatment is required for mucinous cystic neoplasms, and malignancy risk differs according to lesion size. Solid pseudopapillary neoplasms also require surgery. The detection of small IPMNs has been increasing, and most branch duct-type IPMNs are dormant. However, cysts 3 cm or larger or growing branch duct-type IPMNs must be carefully monitored because of the increasing risk of malignancy. Therefore, surveillance strategies should be different according to the size of the lesions. A tailored approach is needed for selecting surgery or surveillance, considering the malignancy potential of the lesion and patient-associated factors such as operative risks and life expectancy. Nomograms are valuable tools for selecting treatment methods as a customized approach for IPMNs.

A case of recurrence of a solid pseudopapillary neoplasm of the pancreas effectively treated with proton beam radiotherapy

We report a case of a male in his 50 s who underwent pancreaticoduodenectomy for solid pseudopapillary neoplasm (SPN) of the pancreas at 30 years. He developed a liver abscess 15 years after the surgery, and CT scan revealed a swollen retroperitoneum lymph node and a tumor in the liver. Symptoms, including abdominal distension, appetite loss, and epigastric pain, appeared due to lymph node metastasis. Endoscopic ultrasonography-guided fine-needle aspiration against the lymph node revealed SPN recurrence. The tumor had invaded the common hepatic artery, and surgery was not indicated. Chemotherapy of Gemcitabine/nab-Paclitaxel biweekly was performed 8 times; however, no reduction in tumor size was observed, and the patient's symptoms worsened. Proton beam therapy (67.5 GyE in 25 fractions) was subsequently performed for lymph node metastasis, and led to a gradual reduction in lymph node metastasis, and an improvement in symptoms. No re-expansion of lymph node metastasis has been observed 3 years after proton beam therapy. Since SPN is low malignancy and most cases can be expected to be cured by surgery, there is currently no standard treatment of unresectable SPN. This case is the first report of proton beam therapy for SPN, and was considered to be effective.

Investigation of Fluorodeoxyglucose Positron Emission Tomography for the Diagnosis of Solid Pseudopapillary Neoplasm of the Pancreas: A Study Associated With a National Survey of Solid Pseudopapillary Neoplasms

OBJECTIVES

This study aimed to investigate the utility of fluorodeoxyglucose (FDG) positron emission tomography for solid pseudopapillary neoplasm (SPN) diagnosis.

METHODS

The subjects included 53 cases of SPN. We compared the maximal standardized uptake volume (SUVmax) with those of 25 cases of pancreatic duct cancer and 18 cases of pancreatic neuroendocrine neoplasm. In addition, immunopathological testing for SPN with regard to FDG uptake was undertaken.

RESULTS

An increase in SUVmax was observed in all tumors with increased tumor diameter. Among tumors of 20 mm or smaller, the SUVmax of SPN was significantly higher than those of pancreatic duct cancer and pancreatic neuroendocrine neoplasm. The results of a pathological study of FDG uptake in SPN revealed increased glucose transporter protein type 1 expression with tumor enlargement. Furthermore, increased hypoxia-inducible factor-1 and vascular endothelial growth factor expression under hypoxic conditions were observed in the areas of necrosis.

CONCLUSIONS

In cases in which high FDG uptake is observed in small pancreatic tumors, FDG positron emission tomography is potentially useful for SPN differentiation. The factors involved in FDG uptake in SPN include cell density and glucose transporter protein expression, as well as hypoxia-inducible factor and vascular endothelia growth factor expression in the hypoxic environment of necrotic areas.

Malignant epithelial/exocrine tumors of the pancreas

Pancreatic malignant exocrine tumors represent the most important cause of cancer-related death for pancreatic neoplasms. The most common tumor type in this category is represented by pancreatic ductal adenocarcinoma (PDAC), an ill defined, stroma-rich, scirrhous neoplasm with glandular differentiation. Here we present the relevant characteristics of the most important PDAC variants, namely adenosquamous carcinoma, colloid carcinoma, undifferentiated carcinoma, undifferentiated carcinoma with osteoclast-like giant cells, signet ring carcinoma, medullary carcinoma and hepatoid carcinoma. The other categories of malignant exocrine tumors, characterized by fleshy, stroma-poor, circumscribed neoplasms, include acinar cell carcinoma (pure and mixed), pancreatoblastoma, and solid pseudopapillary neoplasms. The most important macroscopic, histologic, immunohistochemical and molecular hallmarks of all these tumors, highlighting their key diagnostic/pathological features are presented. Lastly, standardized indications regarding gross sampling and how to compile a formal pathology report for pancreatic malignant exocrine tumors will be provided.

An Atypical Presentation of Pancreatic Pseudocyst Masquerading as Solid Pseudopapillary Neoplasm of Pancreas

Pancreatic pseudocysts are the most common cystic lesions of the pancreas, and often present as a consequence of acute or chronic pancreatitis. On the other hand, cystic neoplasms of the pancreas are rare, but pose a significant diagnostic challenge. The differentiation between these entities often relies on the clinical features and characteristic radiological evidence. However, the diagnostic dilemma persists, leading to misdiagnosis and inappropriate treatment. We present a case of pancreatic pseudocyst in a 49-year-old male, which clinically and radiologically mimicked solid pseudopapillary neoplasm, a rare type of cystic neoplasm of the pancreas.

The Prognostic Factors of Preoperative Prognostic Nutritional Index and Radiological Findings of Solid Pseudopapillary Tumors of Pancreas: A Single-Center Experience of 14 Years

Introduction

Solid pseudopapillary tumors of pancreas (SPTP) is an indolent rare tumor with malignant potential. The prediction of malignancy is an enigma. The aim of this study is to explore the relationship between operative measurements and malignancy prognosis of SPTP patients.

Methods

A cohort of consecutive 102 patients were enrolled in this study. Preoperative measurements and clinical outcomes were analyzed.

Results

Eighteen patients (17.6%) were confirmed as malignant. The malignant SPTP of the optimal cut-off value was 47.9 (p=0.012) for prognostic nutritional index (PNI). The value of PNI≤47.9 and incomplete capsule were significantly correlated with malignancy. Univariate analysis showed that the PNI≤47.9 (p=0.013) and incomplete capsule (p<0.001) were predictors of disease-specific survival (DSS). Multivariate analysis identified the PNI≤47.9 (p=0.036) and incomplete capsule (p=0.023) as the independent prognostic factors of DSS. The new score of 0,1,2 based on PNI and capsule presence stratified the patients into 3 groups. The patients with low PNI and incomplete capsule achieved the worst prognosis.

Conclusion

The combination test of operative PNI and capsule presence would be a reliable indicator of the aggressive natural history of SPTP.

Synchronous solid pseudopapillary neoplasm and invasive ductal carcinoma of the pancreas: a case report

Background

Solid pseudopapillary neoplasm (SPN) of the pancreas is an extremely rare neoplasm with a favorable prognosis. On the other hand, pancreatic invasive ductal carcinoma (IDC) is known to be an aggressive malignancy. To the best of our knowledge, there is no report of SPN combined with IDC of the pancreas.

Case presentation

A 66-year-old woman presented with abnormal genital bleeding and was diagnosed with inoperable cervical cancer. During computed tomography for cancer staging, the patient was incidentally diagnosed with pancreatic cancer. After radiation therapy for the cervical cancer, distal pancreatectomy with D2 lymph node dissection was performed. A postoperative pathological examination revealed SPN with ossification and well-differentiated IDC in the pancreatic body. On immunohistochemical staining, SPN tumor cells showed positive β-catenin and CD10 staining, whereas IDC cells were negative for both. The tumor boundaries were clear. Accordingly, the final pathological diagnosis was synchronous SPN and IDC of the pancreas. Moreover, pathological findings such as the ossification and small number of SPN cells suggested that SPN may have existed long before IDC initiation.

Conclusions

Here, we report the first case of SPN combined with IDC of the pancreas. They may occur independently, and the long-term presence of SPN may lead to the development of IDC.