SPTs are one of the most uncommon histotypes of all exocrine pancreatic neoplasms. They were first described by Frantz in 1959.19
Since then, various names have been used to describe this unusual lesion, such as Frantz tumor, solid and cystic tumor of the pancreas, papillary cystic tumor, solid and papillary epithelial neoplasm, and Hamoudi's tumor. However, according to the World Health Organization classification of exocrine pancreatic tumors, the appropriate terminology for this tumor is SPT of the pancreas.20
in a cumulative review of the literature, found that 90% of patients with SPT were females with a mean age of 23.9 y. In our group, 100% of the patients were female with a median age of 34 y, which is comparable to other findings reported in the United States, but older than several reported from Asia.21,22
Clinically, patients with pancreatic SPT may present with nonspecific symptoms, including vague abdominal pain, increasing abdominal girth, or a palpable mass, while 9% are described as asymptomatic.22
In our series, 2 patients were asymptomatic with SPT discovered incidentally, and 3 patients presented with atypical abdominal pain ultimately leading to the diagnosis of SPT. This nonspecific presentation might delay diagnosis and lead to relatively larger tumor size upon first clinical evaluation, although tumor size has not been shown to be a predictor of resectability.22
This was also demonstrated in our series, because SPT of up to 8cm could still be completely resected.
The differential diagnosis of pancreatic SPT includes any solid or cystic pancreatic disease entities. In our series, only 1 patient underwent an EUS with biopsy in the preoperative assessment. As a result, 2 SPTs were initially misdiagnosed as mucinous cystic tumors. This demonstrates the necessity to perform a systematic preoperative histologic diagnosis for all suspected SPTs.
Definitive treatment of pancreatic SPT is achieved by complete resection of the tumor, preserving as much pancreatic tissue as possible, with the surgical approach depending on both tumor location and size. The first surgical resection of a pancreatic SPT was performed by Grosfeld and described by Hamoudi in 1970.23
Thirty-three years later, Carricaburu4
reported the first case of laparoscopic SPT resection in a child. Since then, only a few similar case reports have been published.5–11
The first series of SPT managed using laparoscopy was recently published by Cavallini et al.12
but included a heterogeneous population of both adult and child, male and female patients. Based on a review of the medical literature, it has been demonstrated that SPTs in male patients have distinct patterns of onset and aggressiveness versus those in female patients and that SPTs in adults and children also differ with regard to clinical features.13,14
The present study is the first to focus solely on adult female patients, the typical population that is affected by SPT. We find that laparoscopic DP is particularly suitable for our patients given their relatively young age. First, from an esthetic point of view the laparoscopic approach avoids abdominal incision with the exception of the Pfannenstiel incision. Second, it has been documented that laparoscopy decreases the risk of long-term incisional hernia and postoperative adhesions associated with the open procedure.24,25
This benefit disappears when patients require a laparotomy in the postoperative period due to complications from the initial procedure (as demonstrated by 2 of the 5 patients in our series). Some authors have also reported that laparoscopy decreases postoperative stress, analgesia requirements, and shortens hospital duration.26
In our series, the median hospital length of stay was comparable to the series of open DP for SPT published in the medical literature ()27–34
and also to open DP performed at our institution. However, 3 of our patients had complications delaying hospital discharge. Correcting for these complications, the hospital length of stay was only 7 d.
Series of Open Surgery for Solid Pseudopapillary Tumor
From an oncological point of view, the low-grade malignancy of SPT generally results in an excellent prognosis following complete surgical resection. Although SPTs may have malignant characteristics, they are generally not characteristic. Specifically, extrapancreatic or vascular invasion by the tumor, cellular pleomorphism, and elevated mitotic rates do not seem to have a significant impact on the oncologic behavior of SPTs. The analysis of multiple series of SPT operated on via open resection, including all type of pancreatic resections, demonstrates excellent outcomes, even in the presence of recurrent disease ()
In our group, all the patients were alive and free of recurrence or metastasis at a median follow-up of 60 mo. These results correspond theoretically to a 100% overall and disease-free survival at 1 y and 5 y. Thus, our oncologic results are comparable to those in the series of open resection. This demonstrates that laparoscopic resection of SPT does not impact oncologic outcomes. Furthermore, no lymph node metastases and no perineural invasions were found on histological analysis of the specimens in our series. This demonstrates that SPT rarely has lymph node metastases. Consequently, extensive lymphadenectomy is not necessary and makes laparoscopy even more appropriate.
Three complications occurred after the laparoscopic procedure. This overall morbidity rate (60%) is relatively high in comparison with open DP for pancreatic SPT as presented in
but only 2 patients (40%) had serious complications requiring a relaparotomy (DINDO IV). One complication in our series was minor (pancreatic fistulas grade A). Such a result is not surprising, because SPT patients present with classic risk factors for postoperative pancreatic fistula including small duct size and soft gland texture. The 2 serious complications included 1 splenic infarction and 1 hemorrage of the inferior pancreatic artery. The splenic ischemia resulted from the division of the splenic vessels but not of the laparoscopic approach per se. The hemorrhage may be attributed to the use of a laparoscopic stapler resulting in inadequate hemostasis at the pancreatic incision site. Thus, the rate of relaparotomies decreased over time as the surgeons gained experience with the laparoscopic procedure. By 2011, it was only 5.6% in our institution. However given these issues, we recommend these laparoscopic approaches in specialized centers given their acknowledged expertise in handling these complications.
The comparison between the pre- and postoperative SF 36 score results did not reveal any significant differences based on the laparoscopic procedure used. It would have been particularly interesting to compare quality of life between our patients operated on with laparoscopy and other patients operated on with open laparotomy, but quality of life was not assessed in medical articles of open DP. Nonetheless, our results confirm that the quality of life of our patients was not significantly impacted by the laparoscopic DP.