Clinical experiences of solid pseudopapillary tumors of the pancreas in China

Solid pseudopapillary neoplasm of the pancreas causing obstructive jaundice: Case report of a rare entity

INTRODUCTION

Solid pseudopapillary neoplasm (SPN) is an extremely rare, low-grade, malignant pancreatic tumour with an excellent prognosis. We describe a case of SPN causing obstructive jaundice in a young female, thus mimicking pancreatic adenocarcinoma clinically and radiologically.

CASE PRESENTATION

A 32-year-old female presented with abdominal pain for 12 h, icterus, and an epigastric mass measuring 3 × 3 cm. Imaging studies revealed features of pancreatic neoplasm in the head of pancreas, possibly pancreatic adenocarcinoma. However, ultrasound-guided fine-needle aspiration cytology of the lesion revealed were indicative of SPN. The patient was managed by biliary decompression and underwent Whipple procedure for complete tumour resection. Histopathological analysis of the resected specimen confirmed the diagnosis of SPN.

DISCUSSION

SPN commonly presents in young females with abdominal pain, nausea, and vomiting. Our patient presented with jaundice, which is a rare finding even for pancreatic head tumours. Her clinical and radiological findings indicated pancreatic adenocarcinoma, since it commonly presents with painless jaundice, abdominal pain, and abdominal mass. Diagnostic confirmation is achieved by tissue biopsy - the presence of pseudopapillary patterns is a characteristic feature of SPN. Contrary to pancreatic adenocarcinoma, SPN has an excellent prognosis. Complete tumour resection is the mainstay of treatment for SPN, even in cases of local invasion or metastasis.

CONCLUSION

SPN poses a diagnostic challenge due to its non-specific presentation. Clinicians should consider SPN as a differential in women presenting with abdominal mass and vague abdominal complaints. Complete surgical resection is the mainstay of treatment for SPN.

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.

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.

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.

A case of repeat hepatectomy for liver metastasis from solid pseudopapillary neoplasm of the pancreas: a case report

Background

Solid pseudopapillary neoplasm of the pancreas is a rare tumor in young women, metastasizing in only 5–15% of cases, and most commonly to the liver. Although treatment guidelines have not been established, surgical resection is usually performed. We report a rare case of repeat hepatectomy for liver metastases after distal pancreatectomy with solid pseudopapillary neoplasm.

Case presentation

The patient was a 71-year-old woman who underwent distal pancreatectomy for solid pseudopapillary neoplasm, and liver metastasis occurred 4 years after the first surgery. Partial liver resection was performed for four liver metastases, and histopathological examination revealed a diagnosis of liver metastasis from solid pseudopapillary neoplasm. However, 18 months later, liver metastases were detected again; three tumors were identified, and partial resection was performed, which has provided 18 months’ recurrence-free survival.

Conclusions

Long-term prognosis can be expected following R0 resection for resectable liver metastasis from solid pseudopapillary neoplasm.

Grading Solid Pseudopapillary Tumors of the Pancreas: the Fudan Prognostic Index

BACKGROUND

Ki-67 has been shown to predict outcome of patients with solid pseudopapillary tumor of the pancreas (SPTP) but has not been incorporated into a formal classification system to predict recurrence-free survival (RFS).

METHODS

This is a retrospective cohort study of patients with histologically confirmed diagnosis of SPTP who had at least 1 year of follow-up at two tertiary academic centers. Survival data were assessed by Kaplan-Meier method and multivariable Cox regression model. Prognostic performance was compared among various systems.

RESULTS

A total of 193 consecutive patients were included, ranging in age from 12 to 70 years (median 33 years). Seven patients (3.6%) developed tumor recurrence. The 3-, 5-, and 10-year RFS rates were estimated at 96.9%, 96.1%, and 94.8%, respectively. For the AJCC staging system, patients with stage I had similar prognosis to those with stage II. For the ENETS staging system, patients with stage I to III had similar prognosis. Grade based on Ki-67 was superior to both the AJCC and ENETS systems for predicting survival. Multivariate analysis revealed that large tumor size [> 10 cm; hazard ratio (HR), 6.177 95% confidence interval (CI), 1.289-29.603; P = 0.023] and Ki-67 (HR, 17.199 95% CI, 4.001-73.930; P < 0.001) were independent predictors for RFS. The Fudan Prognostic Index based on the combination of Ki-67 and tumor size showed excellent discrimination for RFS and was more accurate and informative than other grading/staging systems.

CONCLUSION

The Fudan Prognostic Index better predicts RFS compared with either Ki-67 alone or the current AJCC and ENETS TNM-based staging systems.

Solid pseudopapillary neoplasms of the pancreas: Case series with a review of the literature

BACKGROUND/AIMS

The solid pseudopapillary neoplasms are quite rare tumors of the pancreas, comprising roughly 1-2% of all pancreatic neoplasms. It has a low malignant potential and usually affects young females. Despite increasing number of articles in the last decade, there is still debate on the pathogenesis, malignant potential and optimal surgical strategy for the solid pseudopapillary neoplasms.

MATERIALS AND METHODS

Medical recordings of 326 patients who were operated due to pancreatic mass were retrospectively analyzed. Patient demographics, presenting symptoms, surgical and pathologic characteristics of the tumor, postsurgical course, long-term survival, and other relevant data were extracted from patients' charts.

RESULTS

Majority of the patients were female in consistency with the classic data in the literature. All the patients underwent curative intent resections. Tumors were commonly localized in the tail of the pancreas making distal pancreatectomy the most commonly performed surgical procedure. Mean tumor diameter was 5.8 centimeters with tumor sizes ranging from 1 to 19 cm.

CONCLUSION

The solid pseudopapillary neoplasms of the pancreas is a rare tumor with low malignant potential, which is more common in females of reproductive age, with abdominal pain being their most common presentation. The short-term outcomes in patients following surgical R0 resection are excellent. However, proximal placement of the tumor and female gender may have slightly worse prognosis. We hope that our findings from a series of patients represent a contribution to the existing literature on SPN, and authors declare their willingness to provide further details for future meta-analyses.

A Review of Clinicopathological Characteristics and Treatment of Solid Pseudopapillary Tumor of the Pancreas with 2450 Cases in Chinese Population

Background

Solid pseudopapillary tumor of the pancreas (SPTP) has been reported as a rare disease with low malignant potential. The aim of this study was to summarize experiences of the diagnosis and treatment for the patients reported in the Chinese population.

Method

2450 SPTP cases reported in English and Chinese literature before Jan 2020 were for our review and analysis retrospectively.

Result

There are 389 male cases and 2061 female cases, and the ratio of male/female was 1 : 5.3. The average age was 29.3 years. The main clinical symptoms were upper abdominal pain and bloating discomfort in 51.6% of the cases and epigastric mass. 38.6% of the tumor was located at the head of the pancreas and 55.4% at the body and tail of the pancreas. The most frequent operative styles were tumor enucleation (38.4%). Pathology showed that the average diameter of the tumor was 8.2 cm and 12.3% of SPTP was malignant. 98.3% of cases had favorable survival.

Conclusions

SPTP is a rare indolent tumor occurring mainly in young women, and the main clinical performances are abdominal mass and abdominal pain; most tumors are distributed at the head and the tail of the pancreas; the prognosis after complete resection is excellent.

Comparison of the clinicopathological features of pancreatic solid pseudopapillary neoplasms between males and females: gender does matter

BACKGROUND

Solid pseudopapillary neoplasms (SPN) of the pancreas are a rare and low-grade malignant entity with a female predominance. However, it also occurs in males, but the rarity and lack of concern makes its clinicopathological features unclarified.

METHODS

The morphological, immunohistochemical, prognostic features and CTNNB1 exon 3 mutation status of SPN were compared semi-quantitively between 9 male and 21 female patients.

RESULTS

SPN in males grew in a distinctive solid pattern, with abundant fibrotic stroma and clear cells. Collagen tended to be the main component of tumor stroma in males, while hyaluronan composed a considerable proportion in females. A much stronger expression of androgen receptor (AR) was found in males, and CD56 and/or synaptophysin (Syn) was expressed frequently in both genders. All patients survived. One male patient had post-operational liver nodules and accepted interventional therapy without biopsy. Mutations of CTNNB1 exon 3 were observed in all cases, distributed at codon 32, 33 and 37 in both genders, as well as 34, 41 and 62 in females.

CONCLUSION

SPN in males presented with significantly different morphological features from that in females, which might be helpful in differential diagnosis, especially when with extensive positivity for CD56 and/or Syn. The stronger expression of AR in males might be a clue to explore the underlying mechanism of the gender difference.

Preoperative neutrophil-to-lymphocyte ratio predicts malignancy and recurrence-free survival of solid pseudopapillary tumor of the pancreas

BACKGROUND

Systemic inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been shown to be prognostic for many types of pancreatic malignancy. The aim of this study was to evaluate the prognostic role of these markers in patients with solid pseudopapillary tumor of the pancreas (SPTP).

METHODS

Patients who underwent surgical resection for histologically confirmed SPTP were retrospectively reviewed in our institution. Preoperative NLR and PLR were calculated. Clinicopathologic data were correlated with the presence of malignant potential and recurrence-free survival (RFS).

RESULTS

A total of 113 patients with SPTP were included in this study. Of them, 23 were men and 90 were women, with a median age of 35 years (interquartile range, 25-44). The optimal cut-off values for malignant SPTP were 3.22 for NLR, and 75.5 for PLR, respectively. Univariate analysis showed that high NLR (>3.22) and white blood cell count more than 9.96 × 109 /L were predictive of a malignant SPTP. Meanwhile, high NLR (P = 0.001) and age more than 35 years (P = 0.026) were associated with worse RFS. On multivariable analyses, high NLR was the only independent predictor of malignant SPTP (odd ratio 6.871; 95% confidence interval [CI], 1.482-31.864; P = 0.014) and RFS (hazard ratio 12.633; 95% CI, 1.758-90.790; P = 0.012).

CONCLUSIONS

This study highlights the supportive role of preoperative NLR in predicting malignancy and RFS of SPTP patients. Further studies including a larger cohort of patients are needed to corroborate our findings.

Prediction of malignancy and adverse outcome of solid pseudopapillary tumor of the pancreas

Since solid pseudopapillary tumor of the pancreas (SPTP) was officially classified by the World Health Organization in 1996, SPTP has recently received special attention in the literature. Studies have shown that SPTP is a heterogeneous tumor, with a small percentage of patients harboring aggressive behaviors. However, criteria for malignancy grade in SPTP have not been well established. The prognosis of SPTP is generally good, with cases having a chance for long-term survival even with recurrence and/or metastasis after surgical resection. The current American Joint Committee on Cancer/Union for International Cancer Control tumor, node, metastasis staging system is not specific to SPTP. The lack of a predictive staging classification that accurately describes the heterogeneity of this disease hinders meaningful research into optimal individualized therapy. Here we summarize and discuss the associated factors proposed for appraisal of the malignant potential and adverse outcome of SPTP.

Tumor Location Correlates with Clinicopathological Features and Prognosis of the Solid Pseudopapillary Neoplasm

Background

Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare neoplasms with low malignant behavior. These neoplasms can be aggressive and cause bad ending of SPN patients. The purpose of this article is to identify certain prognostic factors.

Method

We retrospectively evaluated 196 patients from our hospital and SEER database. We identified that tumor location was an independent prognostic indicator of SPN patients.

Results

DSS and OS of pancreatic head SPNs (HOP) were significantly shorter than those of other locations (OOP). Operation methods and age were different between HOP and OOP groups. Compared to OOP group, patients in HOP group were younger. Operation time was longer, and hospital stays were longer.

Conclusion

This work suggests that pancreatic head SPNs have distinct clinicopathological features and clinical outcome. It is urgent to optimize the treatment of SPN patients and identify effective prognostic indicators of SPN.

Central pancreatectomy with external drainage of monolayer pancreaticojejunostomy for prevention of postoperative pancreatic fistula: A retrospective cohort study

OBJECTIVE

Postoperative pancreatic fistula (POPF) remains a common problem and leading cause of morbidity and mortality after central pancreatectomy (CP). The aim of this study was to present a technique of external drainage of monolayer pancreaticojejunostomy for prevention of POPF.

METHODS

Patients received elective CP with external drainage of monolayer pancreaticojejunostomy between January 2010 and December 2016 were retrospectively analyzed. The occurrence and severity of POPF, overall complications, reoperation rate, in-hospital mortality, and length of postoperative hospital stay were measured. The 2016 updated definition and classification system of the International Study Group of Pancreatic Surgery (ISGPS) was used for POPF. In addition, a matched-pairs comparison with internal drainage of pancreaticojejunostomy was made.

RESULTS

33 consecutive patients underwent CP with external drainage of monolayer pancreaticojejunostomy during this period. 4 (12.1%) cases developed grade B POPF, among which one patient was classified as having Clavien-Dindo classification IIIa complication. None of the patients developed grade C POPF, delayed gastric emptying, or postpancreatectomy hemorrhage. There was no reoperation or in-hospital mortality occurred. Matched-pairs comparison revealed that patients with external drainage of pancreaticojejunostomy had significantly lower incidence of POPF.

CONCLUSION

External drainage of monolayer pancreaticojejunostomy seems effective in prevention of POPF after CP.

Solid Pseudopapillary Neoplasms of the Pancreas: A Surgical and Genetic Enigma

Solid pseudopapillary neoplasms of the pancreas are rare tumors accounting for 1-2% of pancreatic exocrine neoplasms. This entity was first described by Dr. Frantz in 1959 and was defined by the World Health Organization in 1996 as "solid pseudopapillary tumor." It is most often a benign neoplasm, but 10-15% of the cases are malignant. Over the past decades, the incidence of this tumor is increasing. However, many surgeons are still unfamiliar with this neoplasm and its unique characteristics, which can lead to pitfalls in the diagnosis and treatment. The correct diagnosis of SPNP is of utmost importance since it has a low malignant potential and with the appropriate treatment, patients have a long life expectancy. There are many genetic alterations, involving various signaling pathways that have been associated with SPNP and are very important in diagnosing the tumor. The cornerstone of SPNP treatment includes surgical excision of the tumor, preserving as much pancreatic tissue as possible. We review the information in the literature regarding more organ-preserving techniques and possible clinical features that might indicate a malignant potential, thus demanding a more radical intraoperative excision.

Diagnosis and treatment of massive duodenal gastrointestinal stromal tumors: Our experience with 12 cases

AIM: To investigate the diagnosis and treatment of massive duodenal gastrointestinal stromal tumors.

METHODS: We retrospectively analyzed the diagnosis, treatment and follow-up data for 12 patients with massive duodenal gastrointestinal stromal tumors treated at our hospital since January 2000.

RESULTS: Among the 12 patients, 6 without any adjuvant therapy died of tumor recurrence and metastasis, whose survival time was 23 to 36 mo. One patient died of liver and abdominal metastases and intestinal obstruction at 13 mo, who developed intraoperative tumor rupture and refused reoperation and other therapies. The rest five patients are still alive, all of whom had received Gleevec treatment for 1-3 years; liver metastasis occurred in 3 cases and was controlled with Gleevec, and 1 case survived for 61 mo, who is still on Gleevec targeted therapy.

CONCLUSION: Massive tumor and nuclear division phase > 5/50 at high magnification are main risk factors for postoperative recurrence and metastasis in duodenal gastrointestinal stromal tumors. Complete resection, even combined with resection of other organs, is the only means to cure massive duodenal gastrointestinal stromal tumors, because it can achieve R₀ resection and avoid intraoperative tumor rupture. Gleevec targeted therapy of patients with risk factors for recurrence is an effective method of prevention and treatment of recurrence and metastasis.

Prognostic value of Ki-67 in solid pseudopapillary tumor of the pancreas: Huashan experience and systematic review of the literature

BACKGROUND

Solid pseudopapillary tumor of the pancreas (SPTP) is considered to have a low Ki-67 proliferation index, which may explain the generally good clinical outcome. The aim of our study was to evaluate whether Ki-67 has prognostic value in SPTP.

METHODS

A case series study of patients with SPTP treated in our institution from June 2002 to April 2014 was conducted. Prognostic factors for clinical outcomes were analyzed by the use of clinical decision and survival analysis. In addition, we performed a systematic review and pooled analysis to evaluate our results.

RESULTS

The institutional data included 71 patients (13 male and 58 female) ranging in age from 12 to 64 years (median, 31 years). Three patients developed local recurrence and/or liver metastasis after initial surgery. The 5-year recurrence-free survival rate was 93.6%. One patient died of disease, with the 5-year disease-specific survival rate of 98.5%. Ki-67 index ≥ 4% was found significantly associated with the survival of SPTP. Twenty-six studies comprising 163 patients were included in the pooled analysis based on our inclusion criteria. A total of 15 cases showed a Ki-67 index ≥ 4%. Kaplan-Meier survival analysis confirmed that Ki-67 index ≥ 4% was significantly associated with poorer recurrence-free survival and disease-specific survival (both P < .001).

CONCLUSION

This study highlighted a potential role of Ki-67 in predicting adverse outcome of patients with SPTP and should be considered as part of routine histological reporting of SPTP.

Less Aggressive Surgical Procedure for Treatment of Solid Pseudopapillary Tumor: Limited Experience from a Single Institute

Objectives

To evaluate the clinical characteristics and radiological features of solid pseudopapillary tumor (SPT) and assess surgical therapy strategy.

Methods

A retrospective review was performed in 62 patients pathologically confirmed of SPT treated between 2003 and 2014. The clinical features, radiological examinations and surgical strategies were analyzed.

Results

56 females and 6 males were included in this study, mean age was 26 years old (range: 8–66 years old) with mean size of the tumor was 7.2 cm (range: 3–15 cm), and most tumor were commonly located in the head of pancreas (n = 29). Among all the cases, 3 patients had liver metastasis and underwent resection of SPT and liver metastasis. Furthermore, we performed 29 cases of local tumor excision; other patients underwent pancreaticoduodenectomy, middle pancreatectomy, middle pancreatectomy with splenectomy, distal pancreatectomy with spleen preservation, distal pancreatectomy with splenectomy and duodenum-preserving pancreatic head resection. No patient suffered from lymph node metastases. After median follow-up of 46 months (range: 2–135 months), no mortality or local recurrence or distant metastasis was found.

Conclusions

Solid pseudopapillary tumor is a latent malignant tumor with excellent prognosis. If feasible, less aggressive resection without regular lymphadenectomy is recommended for treatment of patients with SPT.

Solid Pseudopapillary Neoplasms of the Pancreas: a 19-Year Multicenter Experience in China

AIM

The aim of this study was to determine the clinicopathological features, surgical management, and prognosis of solid pseudopapillary neoplasms (SPNs) of the pancreas.

METHODS

This study conducted a retrospective analysis of 97 patients who underwent surgery for a pathologically confirmed SPN in five hospitals between January 1996 and December 2014.

RESULTS

The 97 cases included 93 female and 4 male patients, and the average age was 31.2 years. The tumor was located in the body or tail (70.1%), the head (20.6%), and the neck (9.3%). All patients underwent surgical exploration, including distal pancreatectomy (63.9%), pancreaticoduodenectomy (20.6%) (partial portal vein or superior mesenteric vein resection and artificial vascular graft reconstruction performed in 4.1% of the patients), central pancreatectomy (10.3%), enucleation (5.2%), and liver resection (1.0%). 16.5% of the patients had malignant tumors. The positive rate of Ki-67 was 66.7% in patients diagnosed with a malignant neoplasm and was comparable to 8.4% of the patients diagnosed to have a benign neoplasm (p < 0.001). After a median follow-up of 70.1 months, three patients had recurrence and one patient died of liver metastasis.

CONCLUSIONS

SPN is a rare neoplasm with low malignant potential. Surgical resection is warranted even in the presence of local invasion or metastases as patients demonstrate excellent long-term survival. Positive immunoreactivity for Ki-67 may predict the malignant potential and poor outcome of SPNs.

The genetic classification of pancreatic neoplasia

Cancer is caused by the accumulation of inherited and/or acquired alterations in specific genes. The recent decline in the cost of DNA sequencing has allowed tumor sequencing to be conducted on a large scale, which, in turn, has led to an unprecedented understanding of the genetic events that drive neoplasia. This understanding, when integrated with meticulous histologic analyses and with clinical findings, has direct clinical implications. The recent sequencing of all of the major types of cystic and noncystic neoplasms of the pancreas has revealed opportunities for molecular diagnoses and for personalized treatment. This review summarizes the results from these recent studies focusing on the clinical relevance of genomic data.

Surgical treatment of solid pseudopapillary neoplasms of the pancreas and risk factors for malignancy

BACKGROUND

The aim of this study was to identify clinical predictors of malignancy and surgical strategies for pancreatic solid pseudopapillary neoplasm (SPN) by analysis of surgical outcomes at a single institution.

METHODS

All patients who underwent surgery for SPN between 1995 and 2010 were identified. Histopathology slides of all patients were reviewed by a specialized pathologist and the neoplasms were classified according to the criteria of the World Health Organization 2010.

RESULTS

Of the 106 patients identified, 85 (80·2 per cent) were female, and the median age was 36 (range 10-65) years. Median tumour size was 4·5 (range 1·0-15·0) cm. Some 17 patients (16·0 per cent) were classified as having a high-grade malignant SPN. Tumour size of at least 5 cm was associated with high-grade malignant potential (P = 0·022). Although lymph nodes were removed from 40 patients (37·7 per cent), there were no nodal metastases. A total of five patients underwent en bloc resection of adjacent structures, including two with portal vein involvement. After a median follow-up of 56·9 months, two patients with high-grade malignant SPN had evidence of tumour recurrence in the lymph nodes and liver.

CONCLUSION

SPN with a diameter of 5 cm or more is associated with a high-grade malignant phenotype. Complete surgical removal is associated with low recurrence rates.

Solid pseudopapillary tumor of the pancreas with liver metastasis: Clinical features and management

OBJECTIVE

To summarize the diagnosis and management of metastatic pancreatic solid pseudopapillary tumors (SPTs).

METHODS

We retrospectively analyzed the clinical data of patients with metastatic pancreatic SPTs who were admitted to Peking Union Medical College Hospital from November 2001 to September 2013.

RESULTS

A total of 187 patients with pancreatic SPTs were admitted. Four patients had liver metastasis, and all four were female patients aged 20-72 years old. Each patient with metastases underwent surgical resection with good postoperative recovery. The mean follow-up period was 30 months (range, 1-64 months). None of the patients had obvious recurrence or distant metastasis.

CONCLUSIONS

Pancreatic SPT with liver metastasis is very rare, and surgical resection is an effective treatment option. The principle of surgical treatment is to resect the primary and metastatic lesions as completely as possible. The affected patients require long-term postoperative follow-up.

Solid and cystic papillary neoplasm of pancreas: A clinic-pathological and immunohistochemical study: A tertiary care center experience

Background:

Solid pseudopapillary tumor of the pancreas (SPT) is a rare tumor of low malignant potential, mostly described in young women.

Materials and Methods:

In this retrospective study from January 2000 - December 2010, there were 50 pancreatic tumors. In this period, four SPTs were encountered, which were analyzed with respect to clinical, imaging, histopathological, and immunohistochemical findings.

Results:

There was a female preponderance with mean age of 22.2 years. Two of the tumors were located in head of the pancreas and two in the body and tail region. On imaging, majority were large cystic tumors. Histopathologically, they exhibited extensive necrosis and presence of pseudo papillae in viable areas. Immunohistochemically, they were positive for alpha-1-anti-trypsin, alpha-1-anti-chymotrypsin, vimentin, CD10, and CD99. Progesterone receptor and p53 exhibited mild positivity in all of the four cases, whereas neuron specific enolase (NSE), synaptophysin, and chromogranin showed focal positivity in one case.

Conclusion:

Despite its non-specific clinical, imaging, and even immunohistochemical features, characteristic gross and microscopic findings provide reliable diagnosis of SPTs.

Imaging features of pancreatic tumors in children: 13-year experience at a pediatric tertiary hospital

BACKGROUND

Pancreatic tumors are rare in children, resulting in limited information regarding their frequency and imaging appearances.

OBJECTIVE

To review all pancreatic tumors seen in children over a decade at a large tertiary pediatric institution and to describe multimodality imaging findings.

MATERIALS AND METHODS

We conducted a retrospective review of imaging studies performed in children with pancreatic tumors between January 2000 and December 2012, analyzing imaging features on available US, CT and MR examinations. We reviewed patient charts for clinical features, management and final diagnosis.

RESULTS

We included 23 children in this study. Of these, 12 had solid and papillary epithelial neoplasms (SPEN), 3 had neuroendocrine tumors, 3 had lymphoma, and 1 each had hemangioendothelioma, benign congenital cysts with adipose tissue, dendritic cell sarcoma, metastatic rhabdomyosarcoma, and lipoma. All children with SPEN were teenage girls. SPEN showed characteristic imaging features including well-defined margins with surrounding capsule, solid-cystic components and hemorrhage.

CONCLUSION

Pancreatic tumors are uncommon in children. SPEN is the most common tumor and is seen predominantly in teenage girls and shows characteristic imaging features.

Natural history and malignant risk factors of solid pseudopapillary tumors of the pancreas

BACKGROUND AND AIM

Solid pseudopapillary tumors (SPTs) of the pancreas are unusual neoplasms of uncertain prognosis. Most patients with SPTs have a good prognosis after undergoing surgical resection, but there are rare cases in which a locally infiltrative growth pattern and metastatic variety are exhibited, or recurrence of the disease after surgery occurs; these cases have been reported with very poor clinical outcomes. Our study investigated the natural history of SPTs and delineated the clinicopathologic features that may predict the malignancy potential of the disease.

METHODS

A total of 100 patients with suspected SPTs were enrolled in our study and 77 patients underwent surgical resection. A resulting 60 tumors were pathologically proven to be SPTs and the affected patients were followed-up regularly after surgery. Clinical and pathologic data for all 100 patients were analyzed.

RESULTS

Of the 60 total patients with histologically positive SPTs, 55 (92%) were women and 5 (8%) were men. The median patient age was 34 years (range, 13-77 years). Among the 60 patients, 9 had malignant SPTs and 51 had benign SPTs. Deep parenchymal invasion into the surrounding tissue was the most frequent pathologic feature suggesting malignancy (75%) among the 60 patients who underwent surgical resection. Patient clinicopathologic characteristics and demographic factors were compared between those who had benign SPTs and those who had malignant SPTs. There were no significant differences in the various patient features between the 2 groups, including age, sex, symptoms, tumor size, tumor location, internal tumor composition, pattern of tumor calcification, tumor necrosis, hemorrhage, and immunohistochemical tumor tissue patterns. There were 2 patients who had distant metastasis; 1 presented with distal metastasis in the liver and the other patient had recurrence of cancer with a peritoneal mass after surgery. Metastasectomy was performed on the 2 patients and there was no mortality or disease progression during the follow-up period (median, 143 months; range, 53-319 months).

CONCLUSION

Solid pseudopapillary tumors are low-grade tumors that have a generally good prognosis. However, the clinical development and malignancy potential of SPTs are neither fully understood nor predictable, even with histologically benign tumors. Further investigations in tumor biology, along with long-term patient follow-up, may provide insight into the disease process and clinical development of SPTs.

Duodenal gastrointestinal stromal tumor: clinicopathological characteristics, surgical outcomes, long term survival and predictors for adverse outcomes

BACKGROUND

Gastrointestinal stromal tumors (GISTs) occur rarely in the duodenum. Because of their low incidence, data on long-term survival and prognostic factors are limited. The aims of this study were to present the authors' experiences in the diagnosis and treatment of this disease and to evaluate long-term surgical outcomes.

METHODS

Clinical data from 22 consecutive patients with duodenal GISTs surgically managed from May 1999 to August 2011 were retrospectively studied. A pooled analysis was done by systematically reviewing other case series reported in the English literature. Recurrence-free survival and independent predictors of adverse outcomes were analyzed using the Kaplan-Meier method and multivariate Cox regression.

RESULTS

Duodenal GISTs had a mild male predominance (68.2%), occurring primarily in older adults (median age, 58 years), with a frequency of 7.49% among all GISTs. Clinical presentations were nonspecific, with gastrointestinal bleeding and abdominal pain or discomfort being the most common symptoms. The tumors were located mainly in the second portion of the duodenum, in 14 patients (63.6%), with a median size of 3.75 cm (range, 1.4 to 14). All patients underwent curative surgical resection, including 9 pancreaticoduodenectomy, 3 segmental duodenectomy, and 10 local resection. Eighteen patients were alive without evidence of recurrence after a median follow-up period of 67.5 months (range, 3 to 118). The 1-year, 2-year, and 3-year rates of recurrence-free survival were 95%, 89.5%, and 86.7%, respectively. Kaplan-Meier analysis and log-rank tests showed that surgical pattern, mitosis, and risk grade were significantly associated with recurrence-free survival (P < .05 for all). However, only high mitosis was a significant predictive factor for adverse outcomes on multivariate analysis (hazard ratio, 16.414; 95% confidence interval, 1.914 to 140.756; P = .011).

CONCLUSIONS

Duodenal GIST is an unusual neoplasm with favorable survival after curative resection. Mitotic activity was more influential than tumor size and risk grade in predicting adverse outcomes. All patients with duodenal GISTs require long-term follow-up, because late relapse can occur even if the tumor has low malignant potential.

Solid pseudopapillary tumour of the pancreas: Incidence, prognosis and outcome of surgery (single center experience)

BACKGROUND

Solid pseudopapillary tumour (SPT) of the pancreas is a rare neoplasm of low malignant potential. The pathogenesis and guidelines for its treatment remain unclear. This study was designed to evaluate the diagnosis, surgical treatment and prognosis of SPT.

STUDY DESIGN

A retrospective study during the period between January 1995 to October 2012.

PATIENTS AND METHOD

Cases with SPTs treated at our institution were reviewed. Demographic data, clinical manifestations, radiological, surgical, and pathological records were reviewed for patients with SPT.

RESULTS

Twenty four patients with SPT were identified (22 women and 2 men with a mean age 24.83 ± 8.66 (12-52 years). The tumour was located in the head in (50%) and in the body (8.3%) and in the tail (41.7%). The mean size was 9.2 ± 5.3 (3-25 cm). The main clinical presentation was abdominal pain in (83.3%). All 24 patients had curative resection including pancreaticoduodenectomy (50%), central pancreatectomy (8.3%) and distal pancreatectomy (41.7%). Sex, age, symptoms, tumour size, CT image and tumour markers were not significant clinical factors to predict SPT with malignant behavior. The recurrence rate was (8.3%) after 5 years postoperatively. No hospital mortality, all patients except 2 patients (8.3%) were alive at follow up period. The estimated 1, 3, and 5 year survival rate was 95%, 95%, and 88%.

CONCLUSION

SPT are rare neoplasms with malignant potential. Aggressive surgical resection is needed even in presence of local invasion, and also for recurrence as patients had a good long term survival.

Cystic neoplasms of the pancreas

Pancreatic cysts are being identified with increasing frequency due to a combination of increased awareness and more frequent use of cross sectional imaging. Cystic neoplasms of the pancreas range from completely benign to frankly malignant. Identifying pre-malignant cysts offers the opportunity to prevent the development of pancreatic cancer. This article reviews the presentation, workup, and non-operative and operative management of premalignant and malignant pancreatic cysts.

Multi-centric solid-pseudopapillary neoplasm of the pancreas

Multi-centric solid-pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor: only 4 cases are reported in the literature. The clinical and pathological features have not yet been fully clarified. We report 3 cases of multi-centric SPN and discuss their clinical presentations and histological and immunohistochemical features, comparing with solitary SPN. Among the total of 7 cases, 6 were female and 1 was male. Patients had nonspecific symptoms at presentation. Tumors were often large and well demarcated with cystic degeneration and clear margin between lumps. Histologically, characteristic pseudopapilla was formed with uniform cells surrounding the delicate blood vessels. Tumor cells were positive for vimentin, synaptophysin, progesterone receptor, and CD10 and demonstrated nuclear localization of β-catenin. The prognosis of patients was excellent after complete surgical resections. Multi-centric SPN shares similar clinical and pathological features to solitary SPN.

Clinicopathologic features and surgical outcome of solid pseudopapillary tumor of the pancreas: analysis of 17 cases

BACKGROUND

We summarize our experience of the diagnosis, surgical treatment, and prognosis of solid pseudopapillary tumors (SPTs).

METHODS

We carried out a retrospective study of clinical data from a series of 17 patients with SPT managed in two hospitals between October 2001 and November 2011.

RESULTS

All of the 17 patients were female and the average age at diagnosis was 26.6 years (range 11 years to 55 years). The tumor was located in the body or tail in ten patients, the head in five patients, and the neck in two patients. The median tumor size was 5.5 cm (range 2 cm to 10 cm). All 17 patients had curative resections, including seven distal pancreatectomies, five local resections, four pancreaticoduodenectomies, and one central pancreatectomy. Two patients required concomitant splenic vein resection due to local tumor invasion. All patients were alive and disease-free at a median follow-up of 48.2 months (range 2 to 90 months). There were no significant associations between clinicopathologic factors and malignant potential of SPT. Ki-67 was detected in three patients with pancreatic parenchyma invasion.

CONCLUSIONS

The SPT is an infrequent tumor, typically affecting young women without notable symptoms. Surgical resection is justified even in the presence of local invasion or metastases, as patients demonstrate excellent long-term survival. Positive immunoreactivity for Ki-67 may predict the malignant potential of SPTs.

Management of a malignant case of solid pseudopapillary tumor of pancreas: a case report and literature review

Solid pseudopapillary tumor of the pancreas is a rare neoplasm with low malignant potential, which affects predominantly young females. Only approximately 10% to 15% cases of solid pseudopapillary tumors (SPTs) are malignant. We present the case of a 57-year-old woman who developed malignant SPT of the pancreas. Meanwhile, a literature review was carried out. Some clinicopathological features and strategies of management of malignant SPT are presented. In general, surgical removal of the tumor even in case of metastases or recurrence offers an excellent prognosis. Chemotherapy and radiotherapy should be taken into consideration in patients with unresectable tumor.

Solid-pseudopapillary carcinoma: a case study and literature review

Solid-pseudopapillary tumour (SPT) is a rare exocrine tumour of the pancreas and is considered to have low malignant potential. Few morphological criteria are used to predict malignant behaviour such as equivocal perineural invasion, angioinvasion and invasion to surrounding tissue, and should be designated as solid-pseudopapillary carcinoma (SPC). We report a case of SPC. Clinical and radiological findings are typical for SPT with no metastatic disease. There is no tumour recurrence after 4 months postresection. Clinical history and radiological findings were retrieved from the patient's record sheet and Viarad system. H&E staining and few immunoproxidase staining were reviewed by several pathologists. The histological findings are typical for SPT, with additional perineural invasion. There is no angioinvasion or capsular invasion identified. This is our first experience in diagnosing and managing SPC. We look forward to seeing the patient's disease status during her next routine follow-up. We expect good disease-free survival and very low risk of tumour recurrence, in view of only one risk factor (perineural invasion) and uninvolved surgical margins by the tumour.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Immunohistochemical evaluation of solid pseudopapillary tumors of the pancreas: the expression pattern of CD99 is highly unique

The aim of this study was to investigate CD99 as a new marker to characterize solid pseudopapillary tumors (SPTs), and to determine a specific panel of markers to identify the disease. We analyzed the clinicopathological characteristics and immunohistochemical features of 37 patients with SPT. All 37 tumors displayed intracytoplasmic dot-like immunoreactivity of CD99 in contrast to membranous staining in all pancreatic endocrine tumors and most of acinar cell carcinomas, along with negative immunostaining in ductal carcinomas. In addition, we observed a loss of expression of E-cadherin in all SPTs as well as in some other pancreatic tumors, and aberrant nuclear expression of β-catenin in most SPTs. Our findings demonstrated for the first time that the pattern of CD99 expression was highly specific for distinguishing SPTs from other pancreatic tumors. CD99 combined with E-cadherin/β-catenin and CD10 can be used as a relatively specific expression profile of SPTs.

Solid pseudopapillary tumor of the pancreas: can malignancy be predicted?

BACKGROUND

The objective of this study was to examine the clinicopathologic characteristics of solid pseudopapillary tumors (SPTs) of the pancreas, including the risk factors for disease recurrence and their effects on survival.

METHODS

The medical records of 114 patients who underwent surgery for a pathologically confirmed SPT between January 1995 and December 2007 were reviewed retrospectively.

RESULTS

Of the 114 patients, 98 (86.9%) were female, and the median age was 36 years (range, 11-75). All 114 patients underwent curative intent surgery and 13 (11.4%) underwent laparoscopic surgery. Of the 114 patients, 26 (22.8%) had solid pseudopapillary carcinoma (SPC). There were no differences in any clinical factors between the benign SPT and SPC groups; however, the only 4 recurrences identified were in the SPC group. After follow-up ranging from 11 to 177 months, all 114 patients were alive, with only 4 showing evidence of recurrence. Recurrence was observed in young patients with metastasis at first operation, invasion of an adjacent organ, and a large mass (≥13 cm).

CONCLUSION

Adequate operative resection including laparoscopic surgery is the mainstay of treatment for SPT. Although statistically significant risk factors for recurrence cannot be determined, tumor metastasis at the first operation, invasion of adjacent organ, large tumor size, young patient age, tumor rupture, and inadequate resection may increase the risk of recurrence. Our results demonstrate that long-term survival could be achieved by aggressive operative resection and interventional treatment of recurrent disease.

Clinical strategy for the management of solid pseudopapillary tumor of the pancreas: aggressive or less?

OBJECTIVE

To further delineate the clinicopathological and radiological features of solid pseudopapillary tumor (SPT) of the pancreas and summarize the surgical therapy strategy for this tumor.

METHODS

A retrospective review of 18 pathologically confirmed cases of SPT was performed and the clinical and pathological features, radiological findings and surgical interventions were analyzed.

RESULTS

The patients included 17 females and 1 male with a median age of 23 years. The median diameter of the lesions was 8.0 cm. Abdominal pain was the predominant complaint (8/18). The rest of the patients were asymptomatic and presented with a pancreatic mass detected incidentally. Radiological study revealed a well-demarcated mass which was composed of a solid-cystic portion. On post-contrast CT, the solid portions could be enhanced whereas the cystic parts remained unenhanced. With the preoperative diagnosis of SPT in 11 patients and pancreatic cyst, benign or malignant pancreatic tumor in the rest, pancreatic tumor resection was successfully completed. Surgical exploration findings, pathological characteristics and good prognosis of the patients with SPT, indicated its low-grade malignant potential.

CONCLUSION

In combination with clinical findings, radiological features of SPT may help to make the correct diagnosis and differentiation from other pancreatic neoplasms. Once diagnosed, given the excellent prognosis and low-grade malignancy, less aggressive surgical resection of the primary lesion is proposed.

Solid pseudopapillary tumor of the pancreas: a case series of 26 consecutive patients

OBJECTIVE

Solid pseudopapillary tumor (SPT) of the pancreas, which predominantly affects young women, is a relatively indolent entity with favorable prognosis. The aim of this study is to describe the clinicopathologic features and surgical management of this disease in our institution.

METHODS

A retrospective study of clinical data from 26 consecutive patients with SPT managed in a tertiary academic center between January 2002 and December 2007 was performed. Clinicopathologic factors were compared between benign and malignant cases to determine what features of the tumor could suggest malignant potential.

RESULTS

The 26 cases included 22 female and 4 male patients, and the average age was 32.3 years (range 15 to 64). Clinical symptoms were nonspecific and included upper abdominal pain or discomfort, abdominal distention, and back pain. The neoplasm was localized in the pancreatic head/neck in 14 patients and in the body/tail in 12 patients. The median diameter of these lesions was 6.25 cm (range 2 to 15). All of the tumors-including 8 pancreaticoduodenectomies, 10 distal pancreatectomies, 6 local resections, 1 total pancreatectomy, and 1 central pancreatectomy-were resected successfully. No patient received chemotherapy or radiotherapy after surgery. All of the patients except 1 were alive at a median follow-up of 32.5 months (range 3 to 69). One of the 2 patients with malignant SPT, in whom Ki-67 immunoreactivity was >25%, developed local recurrence with liver metastasis 4 months and died 6 months after surgery. There were no significant associations between clinicopathologic factors and malignancy.

CONCLUSIONS

SPT is a rare neoplasm with low malignant potential. Characteristic computed axial tomography and magnetic resonance imaging scans combined with age and sex profile should be sufficient for the decision to operate. Patients with malignant SPT should have careful follow-up. The high proliferative index assessed by immunohistochemical staining for Ki-67 may predict poor outcome of malignant SPT.