Solid-pseudopapillary tumor of the pancreatic head causing marked distal atrophy: a tumor originated posterior to the main pancreatic duct

Exocrine pancreatic insufficiency in distal pancreatectomy: incidence and risk factors

BACKGROUND

Exocrine pancreatic insufficiency (EPI) is a known consequence of pancreatic resection; however, its incidence following distal pancreatectomy is not well defined. The aim of this study was to describe the prevalence of EPI in patients undergoing distal pancreatectomy and moreover identify risk factors for developing de-novo EPI after distal pancreatectomy.

METHODS

A prospectively maintained institutional pancreatic resection database was interrogated to identify patients who underwent distal pancreatectomy from 2005 to 2015. Pre- and post-operative exocrine function, histopathology, demographics and volume of pancreas resected were analyzed.

RESULTS

The cohort consisted of 324 patients, 22 (6.8%) presented with EPI pre-operatively. 38 (12.6%) patients developed new onset EPI requiring pancreatic enzyme replacement therapy. There was no relationship between patient demographics or diabetes status and requirement for pancreatic enzyme replacement therapy, and no significant effect of resection volume on the need for pancreatic enzyme replacement therapy post-operatively (p ≥ 0.05). Having an underlying obstructive pancreatic pathology (p = 0.002) or a presenting history of acute pancreatitis (p < 0.001) significantly predicted development of de-novo EPI.

CONCLUSION

These results indicate that pre-existing EPI at time of surgery is not uncommon. Patients presenting for distal pancreatectomy should be assessed pre-operatively for the need for pancreatic enzyme replacement therapy.

Solid pseudopapillary neoplasm of the pancreas showing marked distal atrophy: A case report

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Solid pseudopapillary neoplasm with marked parenchymal atrophy of the distal pancreas.

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No acinar cells were observed, indicating exocrine dysfunction of atrophic parenchyma.

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The vestige of main pancreatic duct was observed in the distal atrophic pancreas.

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Central pancreatectomy without anastomosis of distal side of pancreas was performed.

Introduction

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare neoplasm, affecting primarily young females. Because SPNs are of low-malignancy, they rarely obstruct the main pancreatic duct (MPD) and cause atrophy of the distal pancreas even if their tumor sizes are large.

Presentation of case

A 35-year-old female was referred to our hospital due to pancreatic tumor. Imaging findings showed the presence of well-defined round tumor in the body of the pancreas with 25-mm in diameter. The pancreas parenchyma distal to the tumor was markedly atrophic, and MPD dilatation was not observed. The lesion was diagnosed as SPN by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), and central pancreatectomy was performed. Intraoperative frozen section of the distal atrophic pancreas showed no evidence of acinar cells, indicating exocrine dysfunction. Therefore, we closed distal pancreas stump instead of reconstruction. In the distal atrophic parenchyma, scattered foci of islets of Langerhans and the vestige of dilated MPD were observed. She has shown neither endocrine nor exocrine insufficiency after surgery.

Discussion

SPNs are usually found without atrophic change of distal pancreas. To the best of our knowledge, this is the first report of SPN in which exocrine dysfunction of atrophic pancreas was demonstrated pathologically and central pancreatectomy without anastomosis of distal pancreas was chosen for the surgical treatment.

Conclusion

We reported a very rare case of SPN with marked distal parenchymal atrophy. We successfully performed central pancreatectomy without reconstruction.

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 neoplasm of the pancreas in children: can we predict malignancy?

PURPOSE

We aimed to review clinical and histologic findings of solid-pseudopapillary neoplasm (SPN) in children and determine the predictive factor of the malignancy.

METHOD

The records of 45 patients (9 males, 36 females) who underwent surgery for SPN in the Asan Medical Center from 1992 to 2012 were retrospectively analyzed. We analyzed the factors between histologic benign group (n=36) and malignant group (n=9).

RESULTS

The mean age of children was 14.9±3.15years (range 9-20years). Mean size of the tumor was 6.36±3.61cm, and most common site in the pancreas was the tail (n=23). Three patients had distant metastasis at initial diagnosis. The sites were the liver (n=2) and the omentum (n=1). All patients underwent complete resection, and the median follow up period was 34months. Recurrence (n=4) was more common in the malignant group (p<0.05). We calculated the proportion of solid component by manual volumetry with a CT scan. The median value was 41.5% in benign group and 88.4% in malignant group. On comparative analysis, the proportion of solid component was found to have significant association with malignancy (p<0.05).

CONCLUSION

Histologic malignant SPN has high risk of recurrence. We should consider more radical resection when finding a predominantly solid tumor in a CT scan.

Long-term follow-up after pancreatoduodenectomy with portal vein resection for a huge solid pseudopapillary neoplasm in an adolescent girl

A 16-year-old Japanese girl with a huge 13-cm-diameter tumor in the pancreas head presented with life-threatening symptoms and findings including severe anemia, obstructive jaundice, duodenal stenosis, and serious portal vein compression. She underwent a pancreatoduodenectomy with combined resection of the portal vein. Reconstruction of the portal vein was successfully performed using an external iliac vein graft and postoperative anticoagulant therapy. Pathological examination revealed a solid pseudopapillary neoplasm of the pancreas. The patient's postoperative course was uneventful, but her menstruation ceased for 14 months. She is now alive with no evidence of recurrence 100 months postoperatively and she suffers no impairments in daily activities of life. As a treatment of solid pseudopapillary neoplasms of the pancreas, pancreatoduodenectomy combined with portal vein resection is rarely performed in adolescent patients, but is reportedly successful, with patients tolerating the operation and surviving without recurrence. An aggressive surgical attitude is recommended when dealing with this tumor type with curative resection, even in adolescent patients.

[Duodenum-preserving total pancreatic head resection : an organ-sparing operation technique for cystic neoplasms and non-invasive malignant tumors]

Cystic neoplasms of the pancreas are being detected and surgically treated increasingly more frequently. Intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) are primary benign lesions; however, the 5-year risk for malignant transformation has been estimated to be 63 % and 15 %, respectively. Surgical extirpation of a benign cystic tumor of the pancreas is a cancer preventive measure. The duodenum-preserving total pancreatic head resection technique (DPPHRt) is being used more frequently for cystic neoplasms of the pancreatic head. The complete resection of the pancreatic head can be applied as a duodenum-preserving technique or with segmental resection of the peripapillary duodenum. Borderline lesions, carcinoma in situ or T1N0 cancer of the papilla and the peripapillary common bile duct are also considered to be indications for segmental resection of the peripapillary duodenum. A literature search for cystic neoplastic lesions and DPPHRt revealed the most frequent indications to be IPMN, MCN and SCA lesions and 28 % suffered from a cystic neoplasm with carcinoma in situ or a peripapillary malignoma. The hospital mortality rate was 0.52 %. Compared to the Whipple type resection the DPPHRt exhibits significant benefits with respect to a low risk for early postoperative complications and a low hospital mortality rate of < 1 %. Exocrine and endocrine pancreatic functions after DPPHR are not impaired compared to the Whipple type resection.

Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions

BACKGROUND

Cystic neoplasms of the pancreas are diagnosed frequently due to early use of abdominal imaging techniques. Intraductal papillary mucinous neoplasm, mucinous cystic neoplasm, and serous pseudopapillary neoplasia are considered pre-cancerous lesions because of frequent transformation to cancer. Complete surgical resection of the benign lesion is a pancreatic cancer preventive treatment.

OBJECTIVES

The application for a limited surgical resection for the benign lesions is increasingly used to reduce the surgical trauma with a short- and long-term benefit compared to major surgical procedures. Duodenum-preserving total pancreatic head resection introduced for inflammatory tumors in the pancreatic head transfers to the patient with a benign cystic lesion located in the pancreatic head, the advantages of a minimalized surgical treatment.

PATIENTS

Based on the experience of 17 patients treated for cystic neoplastic lesions with duodenum-preserving total pancreatic head resection, the surgical technique of total pancreatic head resection for adenoma, borderline tumors, and carcinoma in situ of cystic neoplasm is presented. A segmental resection of the peripapillary duodenum is recommended in case of suspected tissue ischemia of the peripapillary duodenum. In 305 patients, collected from the literature by PubMed search, in about 40% of the patients a segmental resection of the duodenum and 60% a duodenum and common bile duct-preserving total pancreatic head resection has been performed.

RESULTS

Hospital mortality of the 17 patients was 0%. In 305 patients collected, the hospital mortality was 0.65%, 13.2% experienced a delay of gastric emptying and a pancreatic fistula in 18.2%. Recurrence of the disease was 1.5%. Thirty-two of 175 patients had carcinoma in situ.

CONCLUSION

Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions is a safe surgical procedure with low post-operative morbidity and mortality.

Presentation and management of pancreatic cystic neoplasms

Pancreatic cystic neoplasms are less frequent than other pancreatic tumors, but because of the wide availability and improvement of modern imaging methods, these neoplasms are being recognized with increasing frequency and it is often possible to be differentiated preoperatively not only from other cystic pancreatic disorders but also from one another. Most patients have no symptoms while clinical signs are not really useful in the clinical work up, and when they are present, they never help us to identify the type of pathology. Treatment differs with the diagnosis. Serous cystic neoplasms are uniformly benign and usually do not mandate resection unless this lesion is symptomatic. In contrast, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms have a premalignant or malignant tendency, and therefore should be managed aggressively by pancreatic resection; in the absence of invasive disease, prognosis is excellent after appropriate surgery, but the presence of invasive malignancy signifies a poor prognosis. Solid pseudopapillary neoplasms have nonaggressive behavior and their management is related to the extension of the disease. The purpose of this article is to review the types of pancreatic cystic neoplasms, their diagnosis, indications for surgical treatment, and outcome.

Solid pseudopapillary tumor of the pancreas: a multicenter study of 23 pediatric cases

BACKGROUND/PURPOSE

Solid pseudopapillary tumor (SPT) is a very rare form of childhood pancreatic tumor. This study was intended to analyze the clinicopathologic characteristics of this tumor in childhood.

METHODS

We retrospectively reviewed the medical records of patients who were pathologically diagnosed with SPT between March 1991 and March 2005.

RESULTS

Twenty-three patients underwent an operation and were pathologically diagnosed with SPT. Five (22%) were male, with a male-to-female ratio of 1:3.6. The initial signs and symptoms were upper abdominal pain in 20 patients (87%), palpable abdominal mass in 8 (35%), and dyspepsia in 6 (26%). Four patients (17%) had a history of abdominal trauma. Tumors were located in the pancreatic head (30%), body (13%), tail (44%), and both body and tail (13%). Operative procedures performed were pylorus-preserving pancreaticoduodenectomy (n = 6, 26.1%), distal pancreatectomy (n = 7, 30.4%), distal pancreatectomy with splenectomy (n = 7, 30.4%). The median follow-up period was 62 months (range, 6-175 months). One patient showed multiple liver metastasis 3 months after the initial operation and required adjuvant chemotherapy. All other patients were alive at their most recent follow-up with no evidence of recurrence or distant metastasis.

CONCLUSIONS

Complete resection of an SPT is usually curative and patients can survive a long period after the operation.