Solid pseudopapillary Tumor of the Pancreas: Radiological and surgical review

Rare pancreatic cystic neoplasms: A pictorial review

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

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

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

Solid pseudopapillary neoplasm of the pancreas 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.

Comparison between solid pseudopapillary neoplasms of the pancreas and pancreatic ductal adenocarcinoma with cystic changes using computed tomography

BACKGROUND

Solid pseudopapillary neoplasms of the pancreas (SPN) share similar imaging findings with pancreatic ductal adenocarcinoma with cystic changes (PDAC with cystic changes), which may result in unnecessary surgery.

AIM

To investigate the value of computed tomography (CT) in differentiation of SPN from PDAC with cystic changes.

METHODS

This study retrospectively analyzed the clinical and imaging findings of 32 patients diagnosed with SPN and 14 patients diagnosed with PDAC exhibiting cystic changes, confirmed through pathological diagnosis. Quantitative and qualitative analysis was performed, including assessment of age, sex, tumor size, shape, margin, density, enhancement pattern, CT values of tumors, CT contrast enhancement ratios, "floating cloud sign," calcification, main pancreatic duct dilatation, pancreatic atrophy, and peripancreatic invasion or distal metastasis. Multivariate logistic regression analysis was used to identify relevant features to differentiate between SPN and PDAC with cystic changes, and receiver operating characteristic curves were obtained to evaluate the diagnostic performance of each variable and their combination.

RESULTS

When compared to PDAC with cystic changes, SPN had a lower age (32 years vs 64 years, P < 0.05) and a slightly larger size (5.41 cm vs 3.90 cm, P < 0.05). SPN had a higher frequency of "floating cloud sign" and peripancreatic invasion or distal metastasis than PDAC with cystic changes (both P < 0.05). No significant difference was found with respect to sex, tumor location, shape, margin, density, main pancreatic duct dilatation, calcification, pancreatic atrophy, enhancement pattern, CT values of tumors, or CT contrast enhancement ratios between the two groups (all P > 0.05). The area under the receiver operating characteristic curve of the combination was 0.833 (95% confidence interval: 0.708-0.957) with 78.6% sensitivity, 81.3% specificity, and 80.4% accuracy in differentiation of SPN from PDAC with cystic changes.

CONCLUSION

A larger tumor size, "floating cloud sign," and peripancreatic invasion or distal metastasis are useful CT imaging features that are more common in SPN and may help discriminate SPN from PDAC with cystic changes.

Solid pseudopapillary neoplasms of the pancreas: Multicenter Vasepa study

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

A rare case of concurrent intrahepatic splenosis and pancreatic adenocarcinoma following splenectomy

We present an extremely rare case of intrahepatic splenosis (IHS). On admission and examination, the patient was diagnosed with hepatocellular carcinoma and postoperative injury or inflammatory lesions of the pancreas, based on image analysis. Postoperative histopathology showed that the lesions of the liver and diaphragm were of splenic origin, and the pancreatic lesion was identified as a moderately differentiated adenocarcinoma. The lesson of this case is that if there is a history of splenic rupture or splenectomy, even in the presence of hepatitis or cirrhosis, doctors should be alert to the possibility of IHS. Furthermore, splenectomy may affect the blood supply to the tail of the pancreas, so patients with a pancreatic tail mass following splenectomy need follow-up and biopsy, if necessary.

Pregnancy Complicated With a Giant Pancreatic Tumor and Decompensation of Liver Cirrhosis: A Case Report and Literature Review

Pregnancy with solid pseudopapillary tumor of the pancreas (SPTP) is rare. Because pregnancy hormones may cause tumor progression, the management and treatment of SPTP need to balance the safety of pregnant women and fetuses with surgical treatment. We reported a case of a giant pancreatic tumor diagnosed during pregnancy that was considered to be SPTP. Examinations also showed hepatitis B virus infection and severe decompensation of liver cirrhosis. Medical termination of pregnancy was performed. The patient has lived with the tumor until now without surgery. We retrieved the published case reports, summarized the clinical characteristics of pregnancy with SPTP, and explored its management during the perinatal period. Most patients with SPTP have a good prognosis with good maternal and fetal outcomes, and it is important to choose an appropriate treatment method and timing. However, pregnancy combined with decompensated liver cirrhosis needs to be terminated in a timely manner because of its high-risk status.

Pancreatic Cancer and Its Mimics

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

Solid pseudopapillary neoplasm of the pancreas mimicking gastrointestinal stromal tumour

Solid pseudopapillary neoplasm (SPN) of pancreas is an uncommon low-grade malignant tumour that has a remarkable postoperative cure rate. Improved awareness and widespread use of imaging have resulted in more frequent diagnosis of these tumours. We report a case of a woman in her 20s who had an abdominal lump identified as a gastrointestinal stromal tumour on imaging elsewhere. The patient was reevaluated in our hospital and given a provisional diagnosis of SPN on radiology, which was later confirmed on postoperative histopathology.

Solid Pseudopapillary Neoplasm of the Pancreas: Unraveling Insights from a Single Institutional Study Emphasizing Preoperative Diagnosis of a Rare Tumor

Aim

Solid pseudopapillary neoplasm (SPN), a slow-growing pancreatic tumor with a vague clinical presentation and non-specific radiological features, is rather uncommon. We share our experience emphasizing on preoperative diagnosis and the correlation with final histopathological examination.

Materials and methods

This is a retrospective analysis of the 468 patients who underwent pancreas-related surgery at our institution between January 2013 and July 2022. Demographic characteristics, symptoms at presentation, preoperative serum calcium carbohydrate antigen (CA 19-9), lesion characteristics on cross-sectional diagnostic imaging, surgical technique, complications in postoperative period, length of stay, histopathological features, and 3-year follow-up findings of the patients with SPN of pancreas were evaluated.

Results

The male-to-female ratio was 1:11 and the mean age at presentation was 33.3 ± 9.5 years. Upper abdomen discomfort was the most common presenting complaint (91%). And five patients had findings suggestive of SPN on preoperative CECT abdomen, and the remaining six individuals were diagnosed solely based on final histological examination. The tumor's median diameter was 5.6 cm (range, 4.1-7.9). The distal body and tail of pancreas was the most common location (63%), followed by the head (36%), and was managed with distal pancreatectomy with or without spleen preservation and Whipple's procedure, respectively. One patient developed grade III Clavien-Dindo complication. The average length of in-hospital stay was 8.27±2.72 days. None of the patients had recurrence on follow-up.

Conclusion

Solid pseudopapillary neoplasm of the pancreas is often misdiagnosed preoperatively. Endoscopic ultrasound-guided FNA with IHC will be beneficial to diagnose it preoperatively especially in small-sized tumors with atypical features. Complete surgical resection with adequate margins without routine lymphadenectomy is curative in resectable tumors.

How to cite this article

Jayapal L, Kumar SR, Jebakumar GS, et al. Solid Pseudopapillary Neoplasm of the Pancreas: Unraveling Insights from a Single Institutional Study Emphasizing Preoperative Diagnosis of a Rare Tumor. Euroasian J Hepato-Gastroenterol 2023;13(2):50-54.

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

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

Lower cyst fluid carcinoembryonic antigen cutoff is helpful in the differential diagnosis of mucinous versus non-mucinous pancreatic cysts

BACKGROUND AND AIM

Pancreatic cystic lesions (PCLs) are being diagnosed with increased frequency and have varying neoplastic potential. We conducted this multimodal, prospective study to evaluate  the role of tumor cytology and molecular markers to differentiate PCL subtypes.

METHODS

Consecutive undiagnosed patients with PCLs (n = 100, mean age: 50.37 years; 41% males) were prospectively studied. Cyst fluid carcinoembryonic antigen (CEA), CA19.9, CA125, CA72.4, and vascular endothelial growth factor-alpha (VEGF-α) levels were measured by quantitative enzyme-linked immunosorbent assay (ELISA) method. Mutational analysis of the KRAS gene (exon 2, Codon 12 and 13) and GNAS gene (Exon 8, Codon 201) were performed by Sanger's sequencing.

RESULTS

The mean cyst size was 4.32 ± 2.4 cm. Fluid cytology revealed definitive diagnosis in 21 (22.3%) patients. All malignant PCLs could be identified on cytology whereas 10/14 (71%) non-malignant mucinous PCLs could also be identified on cytology based on mucin staining. Among the tested tumor markers, cyst fluid CEA had the best diagnostic performance for differentiation between mucinous and non-mucinous PCLs (AUC 0.933 [95% CI 0.86-0.91]). At a cyst fluid CEA cutoff level of 45.0 ng/mL, the sensitivity, specificity, positive predictive value, and negative predictive value for differentiation between mucinous and non-mucinous cysts were 88.5%, 96.8%, 92.0%, and 95.3%, respectively (p &lt; 0.05). KRAS and GNAS mutation had no significant diagnostic benefit in comparison to fluid cytology and CEA levels.

CONCLUSIONS

Fluid CEA at a lower cutoff of 45 ng/mL is the most accurate marker to differentiate between mucinous and non-mucinous PCL. The KRAS and GNAS mutational analysis does not improve upon the diagnostic performance of fluid cytology and tumor markers.

Solid Pseudopapillary Neoplasm of the Pancreas: Unfolding an Intriguing Condition

Pancreatic cancer is one of the most lethal malignant neoplasms, with a 1-year survival rate after diagnosis of 24%, and a 5-year survival rate of only 9%. While this illustrates the behavior of its main histologic type - ductal adenocarcinoma, there are other histologic subtypes of pancreatic cancer that can harbor excellent prognosis. Solid pseudopapillary neoplasm, described as a rare low-grade malignant neoplasm by the World Health Organization, is the best example of that, having an overall 5-year survival rate of about 97%. Not only the prognosis, but everything about this entity is unique: its histogenesis, epidemiology, presentation, imaging characteristics, cytology features, immunohistochemical profile, and treatment. This explains the urge to improve our understanding about this entity and thus our ability to accurately recognize and manage it. Having this in mind, this article aims to summarize the most relevant topics regarding this entity.

Transabdominal ultrasonographic diagnosis of relatively rare pancreatic neoplasms

There are various types of pancreatic neoplasms, and their prognosis and treatment methods are different. Therefore, accurate diagnosis is important to determine the best treatment strategy. Transabdominal ultrasonography is frequently used as a screening examination for diagnostic imaging of pancreatic neoplasms. In this review, we have focused on the characteristics of ultrasonic findings for relatively rare pancreatic neoplasms.

Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma: Role of the Radiologist and Oncologist in the Era of Precision Medicine

The incidence and mortality of pancreatic ductal adenocarcinoma are growing over time. The management of patients with pancreatic ductal adenocarcinoma involves a multidisciplinary team, ideally involving experts from surgery, diagnostic imaging, interventional endoscopy, medical oncology, radiation oncology, pathology, geriatric medicine, and palliative care. An adequate staging of pancreatic ductal adenocarcinoma and re-assessment of the tumor after neoadjuvant therapy allows the multidisciplinary team to choose the most appropriate treatment for the patient. This review article discusses advancement in the molecular basis of pancreatic ductal adenocarcinoma, diagnostic tools available for staging and tumor response assessment, and management of resectable or borderline resectable pancreatic cancer.

Gruber-Frantz tumor: a rare pancreatic neoplasm

We present the case of a 37-year-old woman with abdominal pain in the epigastrium radiating to the right flank for a month of evolution. On physical examination, epigastric mass is palpated, firm and painless. Computed tomography (CT) showed a cystic tumor in the body and tail of the pancreas with solid areas and defined borders (12x10 cm), which displaces structures. Endoscopic ultrasound (EUS)-guided fine needle biopsy was taken, with consistent cytology of SPT. Subsequently, a distal pancreatectomy with tumor resection and nodal dissection was performed. Cytology reported discohesive cells, some arranged around capillaries, with small nuclei with clefts, CK7 negative and β-catenin positive. After 4 years of follow-up, there is no evidence of recurrence.

Frantz tumor in a 58 year old woman; case report and literature review

Introduction

Frantz tumor or solid pseudopapillary neoplasm is a very rare tumor with low malignant potential, it constitutes 1-2 % of exocrine tumors of the pancreas.

Description of the case

We present the case of a 58-year-old female patient with a 4-month history of occasional abdominal pain in the epigastrium, the tomography detected a distal tumor of the pancreas. Is taken to distal pancreatectomy.

Discussion

It was first described by Franz in 1959 as a papillary tumor of the pancreas, in 2010 it was reclassified as a solid pseudopapillary tumor of low grade of malignancy. They appear in 8-16.6 % in patients before 13 years of age, in young women they present between the second and fourth decade of life. The treatment for excellence is surgical resection.

Conclusion

Pancreatic tumors represent a surgical challenge in any place of presentation.

Large-duct pattern invasive adenocarcinoma of the pancreas-a variant mimicking pancreatic cystic neoplasms: A minireview

Pancreatic cancer currently has no subtypes that inform clinical decisions; hence, there exists an opportunity to rearrange the morphological and molecular taxonomy that guides a better understanding of tumor characteristics. Nonetheless, accumulating studies to date have revealed the large-duct type variant, a unique subtype of pancreatic ductal adenocarcinoma (PDA) with cystic features. This subtype often radiographically mimics intraductal papillary mucinous neoplasms (IPMNs) and involves multiple small cysts occasionally associated with solid masses. The "bunch-of-grapes" sign, an imaging characteristic of IPMNs, is absent in large-duct PDA. Large-duct PDA defines the mucin profile, and genetic alterations are useful in distinguishing large-duct PDA from IPMNs. Histologically, neoplastic ducts measure over 0.5 mm, forming large ductal elements. Similar to classic PDAs, this subtype is frequently accompanied by perineural invasion and abundant desmoplastic reactions, and KRAS mutations in codon 12 are nearly ubiquitous. Despite such morphological similarities with IPMNs, the prognosis of large-duct PDA is equivalent to that of classic PDA. Differential diagnosis is therefore essential.

Tunica vaginalis testis metastasis as the first clinical manifestation of pancreatic adenocarcinoma: A case report

BACKGROUND

Metastases from pancreas or ampullary malignancies are common, but the spread to testicle and paratesticular tissue is exceedingly rare. To the best of our knowledge, fewer than 30 cases have been reported in the literature. More rarely, metastasis to tunica vaginalis testis occurs without involvement of the testes and epididymis.

CASE SUMMARY

A 65-year-old male who complained of painless swelling of the left scrotum for over 1 wk was referred to the Department of Urology. Scrotal ultrasound showed left testicular hydrocele with paratesticular masses. Chest computed tomography revealed lung metastasis and enlarged left supraclavicular lymph node.The blood tumor markersalpha-fetoprotein, human chorionic gonadotropin, and serum lactate dehydrogenase were withinnormal limits.The preoperative diagnosis was left testicular tumor with lung metastasis. Then radical orchidectomy of the left testicle and high ligation of the spermatic cord were performed, and postoperative histopathology suggested metastatic tumors that was confirmed by an abdominal computed tomographic scan. The positive computed tomography findings, in conjunction with the expression of cytokeratin 7 (CK7), CK20, CK5/6, and absence of expression of Wilms’ tumor suppressor gene 1, calretinin, melanocyte, prostate-specific antigen, thyroid transcription factor-1, GATA binding protein 3, caudal type homeobox 2, and napsinA supported the diagnosis of pancreatic adenocarcinoma. The outcome of this patient was unsatisfactory, and he died 3 mo later.

CONCLUSION

This case suggests that pancreatic metastatic carcinoma must be considered in the differential diagnosis of scrotal enlargement. The advanced age of the patient wassuggestive of a secondary testicular tumor.In addition, careful physical examination and ultrasonography as well as radiological examination have become a standard modality.