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 Table of Contents  
TECHNICAL ARTICLE
Year : 2013  |  Volume : 5  |  Issue : 12  |  Page : 716-720

Accuracy of endoscopic ultrasound-guided fine needle aspiration in diagnosing solid pseudopapillary tumor


Department of Gastroenterology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS-66106, USA

Date of Web Publication18-Dec-2013

Correspondence Address:
Mojtaba Olyaee
Professor of Medicine, Gastroenterology. University of Kansas School of Medicine, Kansas City, KS
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1947-2714.123270

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  Abstract 

Background: Solid pseudopapillary tumors are rare pancreatic tumors. Accurate preoperative diagnosis helps in planning of the surgery. Aim: This study was to evaluate accuracy of endoscopic ultrasound-guided fine needle aspiration and immunohistochemistry in diagnosing solid pseudopapillary tumors. Materials and Methods: A retrospective review was performed by reviewing medical records to identify patients treated for solid pseudopapillary tumors over a 5-year period. Patients who were noted to have pancreatic lesions by computer tomography abdomen underwent endoscopic ultrasound. Fine needle aspiration was obtained from each of these lesions and subjected to immunohistochemistry. Results: Five patients were identified. Endoscopic ultrasound was able to identify the pancreatic lesions in all five patients noted in computer tomography abdomen. Solid pseudopapillary tumors were diagnosed by immunohistochemistry. All five patients underwent surgery and the resected lesions confirmed solid pseudopapillary tumors in 80% patients. Conclusion: Endoscopic ultrasound-guided fine needle aspiration has a higher degree of accuracy in diagnosing solid pseudopapillary tumors.

Keywords: Endoscopic ultrasound, fine needle aspiration, immunohistochemistry, solid pseudopapillary tumor


How to cite this article:
Saligram S, Fan F, Oropeza-Vail M, Gholami P, Olyaee M. Accuracy of endoscopic ultrasound-guided fine needle aspiration in diagnosing solid pseudopapillary tumor. North Am J Med Sci 2013;5:716-20

How to cite this URL:
Saligram S, Fan F, Oropeza-Vail M, Gholami P, Olyaee M. Accuracy of endoscopic ultrasound-guided fine needle aspiration in diagnosing solid pseudopapillary tumor. North Am J Med Sci [serial online] 2013 [cited 2020 Oct 20];5:716-20. Available from: https://www.najms.org/text.asp?2013/5/12/716/123270


  Introduction Top


Solid pseudopapillary tumors (SPT) are extremely rare, indolent, and low grade tumors. It has an incidence of 1-2% of exocrine tumors. [1] The differential diagnosis of SPT of the pancreas includes all solid or cystic pancreatic lesions. They can be benign lesions like pseudocysts, serous cystadenoma, hemangioma, pseudotumor, cystic lymphangioma, and cystic teratoma or malignant lesions like adenocarcinoma, mucinous cystadenoma, cystadenocarcinoma, and pancreatic neuroendocrine tumors. Treatment and subsequent care varies based on the diagnosis and hence accurate diagnosis is important. Percutaneous biopsy was used traditionally to diagnose SPT, which has higher risks and lower accuracy. [2],[3]

A recent multicenter trial suggested that endoscopic ultrasound (EUS) is an emerging technique to diagnose SPT. [4] We looked at the accuracy of EUS in making a diagnosis of SPT in our tertiary care center. We perform about 800 EUS annually. We evaluated all cases of SPT, which were diagnosed by EUS in the last 5 years.


  Materials and Methods Top


A retrospective review was performed to identify patients with SPT of the pancreas treated by a single physician at our tertiary care hospital over a 5-year period. The electronic medical record system was searched using the physician's name and the key term "solid pseudopapillary tumor." Medical records of resultant patients were reviewed to collect pertinent information to include demographics, symptoms, EUS findings, fine needle aspiration (FNA), complications, and immunohistochemistry. Long-term response to surgical management postdiagnosis was assessed by review of clinical records. All patients were diagnosed with SPT after being confirmed by immunohistochemistry. All EUS were performed to evaluate patients suspected of pancreatic mass by computer tomography (CT) scan.

Endoscopy technique: All procedures were performed using monitored anesthesia care (MAC). EUS was used to identify the lesions noted by CT scan. The lesions were accurately measured and their morphology was noted. Lesions were described as hyper echoic, anechoic lesions, or mixed echoic based on hypo enhancement or hyper enhancement on the EUS.

Biopsy protocol: Two samples of FNA were taken from the suspected lesion and they were then subjected to immunohistochemistry and evaluated by a pathologist.

Surgical management: The standard surgical management followed in our institution after confirming the diagnosis. Lesions with head of pancreas underwent partial pancreatico-duodenectomy (Whipple's procedure) and lesions in body or tail of pancreas underwent partial pancreatectomy. The resected lesions were again evaluated by the pathologist to confirm the diagnosis of SPT.

Follow up: Patients were initially followed up in the clinic after their surgery in 1 month. They were assessed for recurrence of SPT in the form of symptoms like abdominal pain, weight loss, and jaundice. They also underwent repeat CT abdomen in 3 months to ensure there was no evidence of recurrence of the tumor.


  Results and Discussion Top


Five patients were identified. Abdominal pain was present in all. All five patients initially suspected to be having pancreatic lesions on CT abdomen underwent EUS. EUS was able to identify the pancreatic lesions noted in CT abdomen. Average size of the lesions was 2.9 cm. Specific patient characteristics and EUS findings are described in [Table 1]. [Figure 1], [Figure 2], [Figure 3], [Figure 4] to [Figure 5] depicts immunohistochemistry and EUS findings of all patients. Two patients had lesions in pancreatic head, two patients had in pancreatic body, and one patient had a lesion in pancreatic tail. Two FNAs were obtained from each of these lesions and subjected to immunohistochemistry [Table 2].
Table 1: Patient characteristics and EUS fi ndings

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Table 2: Th e immunohistochemical stains

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Figure 1: Case 1- The EUS-FNA smear shows a highly cellular specimen with branching papillary-like fronds lined by multiple layers of tumor cells. (Pap stain, ×400)

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Figure 2: (a) Case 2- EUS showing 3.3 × 2.8 cm anechoic lesion in pancreatic tail. (b) Case 2- Tumor cells are bland and uniform, forming gland-like acinar structures. (Pap stain, ×600)

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Figure 3: (a) Case 3-EUS showing 0.85 × 0.65 cm anechoic lesion in pancreatic body. (b) Case 3- EUS-FNA smear shows pseudopapillae structures lined by multiple layers of tumor cells. (Diff-Quik stain,
×400)


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Figure 4: (a) Case 4- EUS showing 3 × 2 cm mixed echoic lesion with specks of calcification in pancreatic tail. (b) Case 4- This high power image demonstrates tumor cells with round to oval nuclei, fine chromatin and nuclear grooves. (Pap stain, ×600)

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Figure 5: (a) Case 5- EUS showing 4.5 cm x 4.2 cm hypo echoic lesion in uncinate process. (b) Case 5- A. EUS-FNA smear shows a long pseudopapillary structure characteristic of solid-pseudopapillary neoplasm.(Pap stain, ×400) B. The cellblock section shows a tumor cell group in a cystic background. (H and E stain, ×400) C. Immunohistochemical (IHC) stain for synaptophysin is positive in the tumor cells (IHC stain, ×400). D. Immunohistochemical stain for beta-catenin shows positive nuclear staining in the tumor cells. (IHC stain, ×400)

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SPT was first described in 1959 by Frantz [5] and was known as Frantz tumor. It was renamed as SPT by World Health Organization in 1996. SPT is a rare pancreatic tumor of unknown origin. Santini et al. [6] described them as cells originating from multipotent primordial cells or from genital ridge-/ovarian anlage-related cells, which were adherent to pancreatic tissue during embryogenesis. SPT predominantly occurs in females (90%) with a mean age of 29.4 years. [7] The mean age of patients in our cohort was 27 years and all of them were females. They present with symptoms of acute or chronic abdominal pain, vague abdominal discomfort, nausea, vomiting, and jaundice. SPT is confined to pancreas in 85% of cases while 15% may have metastasis at the time of presentation. [7],[8] All our patients had lesions confined to pancreas with no metastases. Metastases can occur in older individuals (more than 36 years) at a mean interval of 8.5 years. [9]

SPT is usually an incidental finding on CT scan. Imaging studies will suggest a pancreatic mass, which needs a definitive diagnosis by accurate tissue diagnosis prior to further treatment. SPT can be predominantly solid, mixed solid-cystic, or cystic pancreatic lesions with hemorrhage in the imaging studies. [10] These features can mimic findings of other pancreatic neoplasm. Preoperative diagnosis is confirmed by cytology of the sampled lesions, which is obtained by less invasive methods like endoscopic ultrasound-fine needle aspiration (EUS-FNA), CT-guided percutaneous biopsy or laparoscopy. Traditionally, CT-guided percutaneous biopsy was used to obtain the biopsy for cytology. However, CT-guided biopsy can cause seeding of the tumor by peritoneal or cutaneous contamination during sampling. [3] The risk of needle tract seeding by EUS-FNA is negligible due to short needle path. [11] Laparoscopy can be tedious, as it requires operation rooms and is more invasive technique compared with the imaging-guided biopsy.

EUS-FNA was first described in 1994. [12] EUS is helpful in diagnosis, staging, and evaluating internal cyst structure. [13] It also gives us information like pancreatic or peri-pancreatic lesions, exact size of the tumor, locally advanced lesion, metastasis to liver, lymph nodes, and vascular invasion. All of this information is vital in planning for the surgery. The lesions can be accurately sampled as the location of the lesions will guide the route of FNA thereby enabling a short needle tract. [14],[15] Transgastric approach is adopted for lesions in tail or body of pancreas while head or uncinate process will be approached by duodenum. [14] The EUS will have a characteristic appearance of a heterogeneous solid, mixed solid, or cystic hypoechoic lesion. [16] All five patients underwent EUS-FNA. Three patients had anechoic lesions, one patient had hypo echoic lesion, and one patient had mixed echoic lesion findings in EUS. The EUS finding were even accurate in mentioning the size and the extent of the tumor spread, which was essential for planning of surgery. This was confirmed intraoperatively and subsequently by histology of postoperative surgical specimens. Nearly 80% of our patients had an accurate preoperative diagnosis of SPT by EUS-FNA. This was confirmed by comparing the histology of postoperative specimens. One patient had an accurate diagnosis with a lesion of less than 1 cm size suggesting the accuracy of EUS technique in diagnosing smaller lesions.

The aspirated fluid from FNA will have cytopathological features of branching papillae with myxoid stroma. [16] SPT is strongly immunoreactive for β-catenin vimentin, CD10, α1-antitrypsin, and progesterone receptor. [17],[18] Immunoreactivity to chromogranin A, synaptophysin, CD56, and progesterone receptor suggests pancreatic endocrine neoplasm. [11] All five patients had immunohistochemical studies of the resected specimen. We started to use immunostains for FNA in the last 3 years in our institution and hence, the first three patients were diagnosed preoperatively by cytopathological features of EUS-FNA findings alone.

Complete surgical resection of SPT is recommended. [19],[20] Surgical debulking can prolong survival even if there is metastasis at the time of presentation. [1] SPT has an excellent prognosis, with a 5-year survival of 95%. [2]

All patients in our cohort had complete surgical resections and have been followed up for a mean period of 46.2 months after surgical resection. None of them required chemotherapy or radiation therapy. There has been no evidence of recurrence. We had one patient who had a preoperative diagnosis of SPT but final diagnosis came back as mucinous cyst neoplasm. This was because immunostaining was not used for the cytology due to its unavailability. Based on our institutional experience, we conclude that EUS-FNA is a reliable means and has a higher degree of accuracy in diagnosing SPT. The accuracy tends to increase when combined with cytohistological FNA. Also, it gives vital information like accurate size and location of the lesion prior to surgery.

 
  References Top

1.Martin RC, Klimstra DS, Brennan MF, Conlon KC. Solid-pseudopapillary tumor of the pancreas: A surgical enigma? Ann Surg Oncol 2002;9:35-40.  Back to cited text no. 1
    
2.Papavramidis T, Papavramidis S. Solid pseudopapillary tumors of the pancreas: Review of 718 patients reported in English literature. J Am Coll Surg 2005;200:965-72.  Back to cited text no. 2
    
3.Kosugi C, Furuse J, Ishii H, Maru Y, Yoshino M, Kinoshita T, et al. Needle tract implantation of hepatocellular carcinoma and pancreatic carcinoma after ultrasound-guided percutaneous puncture: Clinical and pathologic characteristics and the treatment of needle tract implantation. World J Surg 2004;28:29-32.  Back to cited text no. 3
    
4.Jani N, Dewitt J, Eloubeidi M, Varadarajulu S, Appalaneni V, Hoffman B, et al. Endoscopic ultrasound-guided fine-needle aspiration for diagnosis of solid pseudopapillary tumors of the pancreas: A multicenter experience. Endoscopy 2008;40:200-3.  Back to cited text no. 4
    
5.Frantz VK. Tumors of the pancreas. Atlas of tumor Pathology, 1 st Series, Fascicles 27 and 28. In: Frantz VK, editor. Washington DC: Armed Forces Institute of Pathology; 1959. p. 32-3.  Back to cited text no. 5
    
6.Santini D, Poli F, Lega S. Solid-papillary tumors of the pancreas: Histopathology. JOP 2006;7:131-6.  Back to cited text no. 6
    
7.Mao C, Guvendi M, Domenico DR, Kim K, Thomford NR, Howard JM. Papillary cystic and solid tumors of the pancreas: A pancreatic embryonic tumor? Studies of three cases and cumulative review of the world›s literature. Surgery 1995;118:821-8.  Back to cited text no. 7
    
8.Yang F, Jin C, Long J, Yu XJ, Xu J, Di Y, et al. Solid pseudopapillary tumor of the pancreas: A case series of 26 consecutive patients. Am J Surg 2009;198:210-5.  Back to cited text no. 8
    
9.Gonzalez-Campora R, Rios Martin JJ, Villar Rodriguez JL, Otal Salaverri C, Hevia Vazquez A, Valladolid JM, et al. Papillary cystic neoplasm of the pancreas with liver metastasis coexisting with thyroid papillary carcinoma. Arch Pathol Lab Med 1995;119:268-73.  Back to cited text no. 9
    
10.Dong DJ, Zhang SZ. Solid-pseudopapillary tumor of the pancreas: CT and MRI features of 3 cases. Hepatobiliary Pancreat Dis Int 2006;5:300-4.  Back to cited text no. 10
    
11.Burford H, Baloch Z, Liu X, Jhala D, Siegal GP, Jhala N. E-cadherin/beta-catenin and CD10: A limited immunohistochemical panel to distinguish pancreatic endocrine neoplasm from solid pseudopapillary neoplasm of the pancreas on endoscopic ultrasound-guided fine-needle aspirates of the pancreas. Am J Clin Pathol 2009;132:831-9.  Back to cited text no. 11
    
12.Hirooka Y, Goto H, Itoh A, Hashimoto S, Niwa K, Ishikawa H, et al. Case of intraductal papillary mucinous tumor in which endosonography-guided fine-needle aspiration biopsy caused dissemination. J Gastroenterol Hepatol 2003;18:1323-4.  Back to cited text no. 12
    
13.Chang KJ, Albers CG, Erickson RA, Butler JA, Wuerker RB, Lin F. Endoscopic ultrasound-guided fine needle aspiration of pancreatic carcinoma. Am J Gastroenterol 1994;89:263-6.  Back to cited text no. 13
    
14.Horwhat JD, Gress FG. Defining the diagnostic algorithm in pancreatic cancer. JOP 2004;5:289-303.  Back to cited text no. 14
    
15.Gornals J, Varas M, Catala I, Maisterra S, Pons C, Bargallo D, et al. Definitive diagnosis of neuroendocrine tumors using fine-needle aspiration-puncture guided by endoscopic ultrasonography. Rev Esp Enferm Dig 2011;103:123-8.  Back to cited text no. 15
    
16.Bardales RH, Centeno B, Mallery JS, Lai R, Pochapin M, Guiter G, et al. Endoscopic ultrasound-guided fine-needle aspiration cytology diagnosis of solid-pseudopapillary tumor of the pancreas: A rare neoplasm of elusive origin but characteristic cytomorphologic features. Am J Clin Pathol 2004;121:654-62.  Back to cited text no. 16
    
17.Salla C, Chatzipantelis P, Konstantinou P, Karoumpalis I, Pantazopoulou A, Dappola V. Endoscopic ultrasound-guided fine-needle aspiration cytology diagnosis of solid pseudopapillary tumor of the pancreas: A case report and literature review. World J Gastroenterol 2007;13:5158-63.  Back to cited text no. 17
    
18.Liu BA, Li ZM, Su ZS, She XL. Pathological differential diagnosis of solid-pseudopapillary neoplasm and endocrine tumors of the pancreas. World J Gastroenterol 2010;16:1025-30.  Back to cited text no. 18
    
19.Guo N, Zhou QB, Chen RF, Zou SQ, Li ZH, Lin Q, et al. Diagnosis and surgical treatment of solid pseudopapillary neoplasm of the pancreas: Analysis of 24 cases. Can J Surg 2011;54:368-74.  Back to cited text no. 19
    
20.Salvia R, Bassi C, Festa L, Falconi M, Crippa S, Butturini G, et al. Clinical and biological behavior of pancreatic solid pseudopapillary tumors: Report on 31 consecutive patients. J Surg Oncol 2007;95:304-10.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]


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