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

Frantz's tumor as incidental finding during Heller myotomy for achalasia: case report and review of literature

Introduction

Solid pseudopapillary tumor is a low-grade malignancy of the pancreas and predominantly affects young women. This neoplasm is a rare pancreatic entity with vague clinical presentation. Diagnosis is often incidental through imaging or even during surgical approach for another condition.

Case presentation

A 22-year-old Brazilian female with gastrointestinal symptoms was diagnosed with achalasia and underwent Heller myotomy. Intraoperatory findings included an enlarging mass in the distal pancreas. During follow-up for the surgical approach of achalasia, a hypothesis of Frantz's tumor was stated, and spleen-preserving distal pancreatectomy was performed.

Discussion

The pathological pathways of Frantz's tumor is still unclear, and its connection with chromosomal abnormalities is under investigation. Although the tumor has been reclassified over the years to solid pseudopapillary tumor, surgical resection remains the standard treatment.

Conclusion

Despite a surgical challenge, surgery presents a great prognosis in these patients and long-term survival. High suspicion and proper investigation are fundamental to diagnosis and early treatment.

Solid Pseudopapillary Neoplasm - Case Series and Review of Literature

Solid-pseudopapillary neoplasm (SPN) is a variety of solid and cystic tumors of the pancreas. It was first described by Frantz in 1959. It is an unusual form of pancreatic carcinoma, with unknown etiopathogenesis, which accounts for about 0.17 to 2.7% of all pancreatic tumors. Here, we are describing 5 cases of pancreatic solid pseudopapillary neoplasm, out of 180 pancreatic tumors, operated in our institution in the 5-year period (2015-2020). Also, we have reviewed all available case series (from 2006 to 2020) in the literature, of pancreatic pseudopapillary neoplasm, for demographic information, etiopathogenesis, diagnosis, and extent of operation to establish the optimal management of this condition. Retrospective analysis of pancreatic tumors was carried out from February 2015 to January 2020. A total of 180 patients underwent pancreatic resection in this period for pancreatic tumor, out of which, the solid pseudopapillary neoplasm was confirmed in 5 cases (2.76%). Among these 5 cases, 4 cases (80%) were female and one (20%) male, with age group range from 14 to 45 years (mean age - 28 years). Abdominal pain was the most frequent presenting symptom (60%). Mean tumor diameter was 6.9 cm (range, 2-18 cm). Two patients were diagnosed preoperatively by CECT and MRI findings, and three patients were diagnosed preoperatively by percutaneous/USG-guided and CT-guided FNA cytology. Two patients underwent pancreatoduodenectomy; one patient underwent enucleation; and two patients underwent spleen preserving distal pancreatectomy. Four patients are alive and on regular follow-up, while one patient died on the 5th post-operative day due to post-operative sepsis.

Clinical Course, Genetic, and Immunohistochemical Characterization of Solid Pseudopapillary Tumor of the Pancreas (Frantz Tumors) in a Brazilian Cohort

Frantz tumors or solid pseudopapillary pancreatic neoplasm (SPN) are rare exocrine neoplasms that carry a favorable prognosis; they represent up to 3% of all tumors located in the region of the pancreas and have specific age and gender predispositions. In recent years, the rising curve of diagnosis is entitled to the evolution and access of diagnostic imaging. In this paper, we have retrospectively reviewed and described the clinical course of 40 patients with SPN from three institutions in Brazil, who had their diagnosis between 2005 and 2020, and analyzed the clinicopathological, genetic, and surgical aspects of these individuals. In accordance with the literature, most patients were women, 60% with unspecified symptoms at diagnosis, with tumors mainly located in the body and tail of the pancreas, of whom 70% underwent a distal pancreatectomy with sparing splenectomy as a standard procedure, and none of the cases have experienced recurrence to date. Surgery still remains the mainstay of treatment given the low metastatic potential, but more conservative approaches as observed in this cohort are evolving to become the standard of care. Herein, we present an in-depth analysis of cases focusing on the latest literature and report some of the smallest tumor cases in the literature. To our knowledge, this is the first report evaluating germline genetic testing and presenting a case of detected Li-Fraumeni syndrome.

Resection of a recurrent solid pseudopapillary neoplasm of the pancreas after duodenal sparing pancreaticoduodenectomy: A case report

Introduction

Solid Pseudopapillary Neoplasm (SPN) is a rare pancreatic neoplasm with low malignant potential and a relative indolent course. Complete resection of the SPN is curative for most cases and has a high survival rate. Recurrences, though rare, can still occur despite adequate resection. Pancreaticoduodenectomy is commonly performed to treat pancreatic head SPNs. In recent years, duodenum-preserving pancreatic head resection (DPPHR) has been reported as a less radical and acceptable alternative.

Case presentation

We are reporting a case of 26-year old female who presented with a 7 month history of epigastric pain and increasing abdominal girth. She was diagnosed by MRI to have a huge but resectable pancreatic head mass and subsequently underwent duodenum-preserving pancreatic head resection (DPPHR) with pancreaticojejunostomy. Histopathologic examination revealed a solid pseudopapillary tumor (SPN) with lymphovascular invasion and negative margins of resection. The patient underwent hepaticojejunostomy 5 months after resection for biliary stricture. Surveillance imaging revealed tumor recurrence warranting re-exploration for recurrence 3 years after the initial surgery. Intraoperative findings revealed the mass at the distal pancreatic remnant, requiring distal pancreatectomy and splenectomy.

Discussion

Solid pseudopapillary neoplasms are rare pancreatic neoplasms. Surgical resection of SPNs affords long term cure with good 5-year survival rates for localized tumors Despite the low malignant potential of SPNs, relapse after resection can still occur.

Conclusion

Complete local resection of the tumor is the treatment of choice in SPNs. DPPHR should be considered as an alternative in young patients with a localized SPN in the pancreatic head.

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Solid pseudopapillary neoplasm (SPN) is a rare pancreatic neoplasm.

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Complete local resection of the tumor is the treatment of choice.

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Duodenum preserving pancreatic head resection should be considered as an alternative to pancreatoduodenectomy for SPN.

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Despite the low malignant potential, recurrences occur and complete resection of tumor recurrence is the ideal management.

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Large tumor size and lymphovascular invasion are notable risk factors for SPN recurrence.

Laparoscopic enucleation of Frantz's tumor of the pancreas: Case report and literature review

Introduction

Frantz's tumor of the pancreas is a rare phenomenon, and it accounts for 1-3% of all neoplasms of the pancreas. Its percentage is much higher in younger persons, especially in younger women, as compared to the rest of the population.

Presentation of case

The present study describes a 32-year-old female patient in whom a preoperative imaging diagnosis confirmed a mass in the junction of the pancreas' body and tail. Based on the anamnesis, the preoperative diagnosis, and the patient's general status, the decision was made to performed laparoscopic enucleation of the pancreatic tumor. The operation and postoperative recovery passed without complications. Definitive histopathological and immunohistochemical findings confirmed a solid pseudopapillary neoplasm of the pancreas.

Discussion

Depending on the localization and the size of the tumor, surgical options range from typical and atypical resections of the pancreas to minimally invasive surgical procedures, such as local excision and enucleation. Laparoscopic procedures have a comparative advantage in cases of enucleation and resection of the pancreas. The low frequency of recidivation and a favorable prognosis, even after repeated surgery, are additional reasons for favoring the laparoscopic approach over the classical surgical approach.

Conclusion

A minimally invasive surgical approach should be applied whenever the dimensions and the localization of the tumor permit it, bearing in mind all the benefits and advantages that this surgical technique offers.

Hepatic metastasis in Frantz's tumor: A case report

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This is a borderline tumor with indolent biological behavior.

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There are still multiple poorly understood factors that can dictate its malignant transformation and prognosis.

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Here, a rare tumor whose age and survival are tangent the literature reports describe.

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There is a need for a long and rigorous segment to identify possible long-term metastases.

Introduction

Frantz’s Tumor or Solid Pseudopapillary Neoplasm (SPN) is rare with a solid-cystic pattern, and most common in young women.

Presentation of case

This study based on guidelines for case reports (SCARE) reports a case of SPN in a teenager aged 13 years at the diagnosis time, attended at a teaching public hospital in Brazil, which evolved into liver metastases. Clinical, laboratory, therapeutic and imaging data were collected from the physical chart and analyzed in light of current publications on the topic. The first consultation occurred in January 2012, where weight loss, fever, vomiting, left-sided hypochondrium and epigastric pain were reported. Imaging exams evidenced an expansive heterogeneous process in the pancreatic tail; however, laboratory exams and tumor markers did not present alteration in relation to reference values. In March of 2012, she underwent caudal body pancreatectomy, splenectomy, segmental colectomy and colo-coloanastomosis as a function of the intraoperative findings. After 63 months, right-sided hepatectomy was performed to resect metastases. Currently, she is undergoing outpatient monitoring, without complaint or alterations in imaging and laboratory exams, totaling 100 months of global survival.

Discussion

This is an interesting case report of a rare tumor, in so far as without any adjuvant chemotherapies, an 8-year long survival time could be achieved in this particular type of tumor despite initially large tumor expansion and later liver metastases.

Conclusion

Additional epidemiological studies, molecular and clinical trials are required to increase knowledge on SPN.

Giant splenic cyst and solid pseudopapillary tumour of the pancreas managed with distal pancreatectomy and splenectomy

Solid pseudopapillary tumours of the pancreas and giant splenic cysts are very rare entities, and their coexistence in a young female patient has not been previously reported in the literature. We present the case of a 27-year-old woman who presented with abdominal pain and two masses on abdominal imaging. A mass located in the right upper quadrant was biopsied, and histological and immunohistochemical analysis showed a solid pseudopapillary tumour of the pancreas. A giant cystic splenic lesion was also noted. The patient underwent a distal pancreatectomy and splenectomy in our referral centre. Margins were negative on histopathological examination. Negative surgical margins were achieved with distal pancreatectomy and splenectomy despite the large size of the pancreatic tumour. The management of solid pseudopapillary tumours of the pancreas is often challenging and the concomitant presence of a giant splenic cyst poses additional challenges to the surgical management of such tumours.

Solid Pseudopapillary Neoplasm of the Pancreas in Children and Adults: A National Study of 369 Patients

BACKGROUND

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor in children, with current evidence limited to single-center studies. We examined treatment and clinical outcomes for pediatric and adult SPN with a national data set.

METHODS

The 2004 to 2013 National Cancer Data Base was queried to identify all patients diagnosed with SPN. The cohort was stratified by age (pediatric and adult) defined as below 18 years and 18 years and above, respectively. Baseline characteristics and unadjusted outcomes were compared.

RESULTS

We identified 21 pediatric and 348 adult patients with SPN. Both groups displayed similar demographic composition. Patients were commonly female (90.5% [pediatric] vs. 85.9% [adult], P=0.56) and white (66.7% vs. 68.3%, P=0.74). Tumor location was similar between adults and children. Median tumor size was similar between children and adults (5.9 vs. 4.9 cm, P=0.41). Treatment strategies did not vary between groups. Partial pancreatectomy was the most common resection strategy (71.4% vs. 53.1%, P=0.80). Both groups experienced low mortality (0.0% vs. 0.7% at 5 y, P=0.31).

CONCLUSIONS

This study provides the largest comparison of pediatric and adult SPN to date. Children with SPN have similar disease severity at presentation, receive similar treatments, and demonstrate equivalent postoperative outcomes compared with their adult counterparts.

The importance of endoscopic ultrasound fine-needle aspiration in the diagnosis of solid pseudopapillary tumor of the pancreas: two case reports

BACKGROUND

Solid pseudopapillary tumor of the pancreas, otherwise known as solid and cystic tumor or Frantz tumor, is an unusual form of pancreatic carcinoma, with unknown etiopathogenesis, that accounts for 0.2 to 2.7% of all pancreatic tumors. It is defined as an exocrine pancreatic neoplasia that mainly affects women between the second and third decade of life, and its management is not well defined. Endoscopic ultrasound offers a key anatomical advantage in accessing the pancreas and endoscopic ultrasound fine-needle aspiration has become the gold standard method for the diagnosis of pancreatic lesions.

CASE PRESENTATION

Case 1: A 31-year-old white Hispanic woman presented with epigastric pain for 5 months. An abdominal ultrasound revealed a single 2 cm nodule in the uncinate process of her pancreas. Endoscopic ultrasound showed a regular, well-defined solid lesion with alternating cystic areas at the uncinate process of her pancreas, measuring 1.7 × 1.4 cm; endoscopic ultrasound fine-needle aspiration was then performed with cytopathological analysis compatible with solid pseudopapillary tumor. Body computed tomography confirmed the absence of metastases and she underwent conventional duodenopancreatectomy. However, she died 4 days after surgery due to postoperative surgical complications. Case 2: A 35-year-old Hispanic woman presented with left upper quadrant abdominal pain for 3 months, associated with a palpable mass at this region. A computed tomography scan showed a solitary nodule in the pancreatic body. Endoscopic ultrasound showed a regular, well-defined, homogeneous lesion with small anechoic (cystic) areas, measuring 2 × 2 cm, in between the pancreatic body and neck. Endoscopic ultrasound fine-needle aspiration was performed and cytopathological analysis was suggestive of a pseudopapillary solid tumor. She underwent a body-tail laparoscopic pancreatectomy with splenectomy. Nine months after the diagnosis, she remains asymptomatic, continuing regular follow-up in the oncology out-patient clinic.

CONCLUSIONS

Solid pseudopapillary tumor is a rare pancreatic malignancy. Endoscopic ultrasound fine-needle aspiration is the gold standard method to characterize and diagnose this type of pancreatic lesion, making this an invaluable tool to help guide clinical management and improve the preoperative diagnostic yield.

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.

First robotic pylorus preserving pancreaticoduodenectomy for Frantz's tumour in an adolescent girl

Solid pseudopapillary tumour (SPT) is one of the uncommon benign cystic neoplasms of pancreas occurring predominantly in young females. Being benign in nature, surgical resection is the treatment of choice with excellent 5-year survival. A 14-year-old girl presented with pain abdomen for 1 week. On evaluation, she was found to have a large SPT involving head and uncinate process of Pancreas She underwent robotic pylorus preserving pancreaticoduodenectomy (R-PPPD) with da Vinci® Si Robotic System (Intuitive Surgical, Sunnyvale, CA, USA). The total operating time was 480 min. Her postoperative recovery was uneventful and she was discharged on postoperative day 6. In the era of minimally invasive surgery, robotic pancreatic resection and reconstruction are becoming more acceptable. Although the operating domain is small in younger age group, the precise movement of robotic arm and high quality magnified three-dimensional view allows the surgeons to perform PPPD on younger patients also. Young female patients suffering from SPTs can electively undergo R-PPPD with minimal morbidity and mortality. R-PPPD can become the treatment of choice for SPTs involving pancreatic head region even in paediatric and adolescent age group.

Solid pseudopapillary tumor of the pancreas: clinical features and imaging findings

This study aimed to report clinical features and CT, MRI, PET/CT findings of solid pseudopapillary tumor (SPT) of the pancreas. Thirty-four patients with pathologically proven SPT were retrospectively reviewed. Most patients were asymptomatic. SPTs in male patients mainly appeared as solid and near solid tumors. Mixed tumors and cystic tumors had larger size than solid and near solid tumors. Solid tumors and solid part of mixed tumors were T2 hyperintense and T1 hypointense and had progressive enhancement. Four tumors (80%) showed markedly even or uneven ¹⁸F-FDG uptake. These characteristic features can help differentiate SPT from other pancreatic neoplasms.

Solid pseudopapillary neoplasm-Case report of a rare pancreatic tumor

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Solid pseudopapillary neoplasm is a rare pancreatic tumor.

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Most patients are female and within the second or third decade of life.

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The radiologic features are crucial for an accurate diagnosis.

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Tumor size has not been shown to be a predictor of resectability.

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Surgical resection is the treatment of choice with an excellent long-term prognosis.

Introduction

Solid pseudopapillary neoplasm (SPN) is a rare pancreatic tumor. Most patients are female within the second or third decade of life with only a small minority concerning children. Frequently described as low malignant potential tumors, surgical resection remains the main treatment.

Presentation of case

The authors present a case of a SPN diagnosed in a 17-year-old Caucasian girl with vomiting and abdominal pain localized to the right upper quadrant. CT scans and MRI scans showed the presence of a well-defined tumor arising from the pancreatic head with 14 cm of greater diameter. Pylorus-preserving pancreatoduodenectomy was performed and histopathology confirmed a SPN with complete resection and no evidence of malignancy.

Discussion

SPN are usually found incidentally hence the importance of an accurate radiologic diagnosis. Symptoms may be present such as abdominal pain or vomiting due to compression, namely in large tumors. A surgical approach is usually indicated aiming complete resection, with tumor size not predicting resectability.

Conclusion

Solid pseudopapillary tumors of the pancreas are extremely rare and usually have an excellent long-term prognosis after surgical resection.