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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 4  |  Issue : 3  |  Page : 98-100

Expanding role of radiation in pancreatic tumors – A rare case report and a new horizon


Department of Radiotherapy and Oncology, PGIMER, Chandigarh, India

Date of Web Publication27-Sep-2019

Correspondence Address:
Dr. G Y Srinivasa
Department of Radiotherapy and Oncology, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_4_19

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  Abstract 


Solid pseudopapillary tumors (SPTs) of the pancreas are neoplasms with low malignant potential. Surgical resection offers excellent survival. Adjuvant therapy can have an increased role. A 45-year-old female presented with pain abdomen. Contrast-enhanced computed tomography of the abdomen revealed a 6 cm × 6 cm × 6 cm lesion in the pancreas. Fine-needle aspiration from the mass revealed a neuroendocrine tumor, and she underwent distal pancreatectomy and splenectomy. The diagnosis of SPT was made on histopathology report. Subsequently, the patient received adjuvant radiotherapy. Adjuvant radiotherapy can be considered to decrease the risk of local recurrences in the presence of poor-risk features.

Keywords: Adjuvant radiotherapy, pancreas, solid pseudopapillary epithelial neoplasm


How to cite this article:
Kapoor R, Dracham CB, Srinivasa G Y, Gupta A. Expanding role of radiation in pancreatic tumors – A rare case report and a new horizon. Int J Non-Commun Dis 2019;4:98-100

How to cite this URL:
Kapoor R, Dracham CB, Srinivasa G Y, Gupta A. Expanding role of radiation in pancreatic tumors – A rare case report and a new horizon. Int J Non-Commun Dis [serial online] 2019 [cited 2019 Oct 16];4:98-100. Available from: http://www.ijncd.org/text.asp?2019/4/3/98/268140




  Introduction Top


Solid pseudopapillary tumors (SPTs) of the pancreas are neoplasms with low malignant potential that account for approximately 1% of pancreatic tumors.[1] SPT has a predilection for young women with a peak onset in the second to the third decade. Vague clinical presentation renders the diagnostic workup fairly challenging if incidentally discovered at early stages, as SPTs are frequently misdiagnosed with neuroendocrine tumors.[2] Surgical resection offers an excellent chance for long-term survival with overall 5-year survival is reportedly 97%. The WHO classification has recently recognized SPT as an indolent tumor with a potential malignant behavior. However, around 15% of resected cases show malignant features at pathological analysis.[2],[3] Adjuvant therapy can have an increased role in patients with a tumor having malignant potentials, but limited reports are available for the adjuvant treatment. We, here, present a case of solid pseudopapillary epithelial neoplasm (SPEN) of the pancreas with capsular invasion treated with adjuvant radiation.


  Case Report Top


A 45-year-old female presented with pain in the left hypochondrium for 6 months. There were no other associated complaints. Contrast-enhanced computed tomography of the abdomen revealed a 6 cm × 6 cm × 6 cm round lesion expanding the tail of the pancreas and the lesion was heterogeneous with hypodense areas within it, and the left adrenal was visualized separately from the mass.

Fine-needle aspiration from the mass revealed a neuroendocrine tumor (islet cell type). Distal pancreatectomy and splenectomy were done in May 5, 2005, for the same, and two lymph nodes were identified and removed. Detailed histopathology report revealed an encapsulated mass of 7 cm × 7 cm × 5 cm and one area of the capsular breach was present. On microscopic examination, the tumor cells were disposed in sheets with thin capillary network dividing the cells into nests and papillary arrangement and revealed a tumor at one end infiltrating the capsule [Figure 1]. Mitotic activity was low, and none of the two lymph nodes show metastasis; the final diagnosis of SPEN of the pancreas was made. Subsequently, the patient was referred to the radiotherapy department for adjuvant radiotherapy.
Figure 1: Tumor cells disposited in sheets with thin capillary network dividing the cells into nests and papillary arrangement. Tumor at one end infiltrating the capsule

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A total dose of 50 Gy in 25 fractions over 5 weeks was given by conventional planning using anteroposterior: posteroanterior field with the use of the posterior shield for kidney block. After that, the patient was kept on regular follow-up, and he has remained in clinical and radiological complete remission till June 2016.


  Discussion Top


SPTs are very uncommon low-grade tumors with low malignant potential and indolent behavior. The rate of recurrence after surgical resection is reported as ranging between 3% and 9%,[4],[5] and some specific pathological features are predicting the likelihood of postoperative recurrence, namely capsular breach, pancreatic tissue invasion, and size of the lesion.[2],[6] However, there is a scarcity of data regarding adjuvant treatment.

The patient in our case was older than the typical age group reported so far. The tumor was located in the tail of the pancreas which is a commonly reported location.[7] Similar to our case, SPTs are frequently misdiagnosed as neuroendocrine tumors.[2]

These tumors overall have excellent postoperative outcomes. However, there are certain risk factors which are supposed to increase the risk of local recurrence. Factors such as large tumor size and capsular or pancreatic parenchymal invasion and lymphovascular invasion, as found in the index case, confer a poor prognosis due to chances of local recurrence.[5] Arguably, adjuvant treatment becomes indispensable in such cases. Although there is no data yet available studying the role of adjuvant radiotherapy in such cases, the radiosensitive nature of SPTs has been reported in the literature,[1],[8] and therefore, our case was treated with postoperative radiotherapy owing to the presence of the features as mentioned above.

Most of the reported cases have documented the development of recurrent disease, predominantly local, within 5 years. Our case, after a follow-up of 12 years after adjuvant radiotherapy, has shown no evidence of clinical or radiological recurrence so far.


  Conclusion Top


SPTs are indolent tumors with low malignant potential. Surgical resection is the standard of care. Adjuvant radiotherapy can be considered to decrease, if not eliminate, the risk of local recurrences in the presence of such poor-risk features. Further reports/case series are needed to validate the role of adjuvant radiotherapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zauls JA, Dragun AE, Sharma AK. Intensity-modulated radiation therapy for unresectable solid pseudopapillary tumor of the pancreas. Am J Clin Oncol 2006;29:639-40.  Back to cited text no. 1
    
2.
Marchegiani G, Andrianello S, Massignani M, Malleo G, Maggino L, Paiella S, et al. Solid pseudopapillary tumors of the pancreas: Specific pathological features predict the likelihood of postoperative recurrence. J Surg Oncol 2016;114:597-601.  Back to cited text no. 2
    
3.
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. 3
    
4.
Dai G, Huang L, Du Y, Yang L, Yu P. Solid pseudopapillary neoplasms of the pancreas: Clinical analysis of 45 cases. Int J Clin Exp Pathol 2015;8:11400-6.  Back to cited text no. 4
    
5.
Kang CM, Choi SH, Kim SC, Lee WJ, Choi DW, Kim SW, et al. Predicting recurrence of pancreatic solid pseudopapillary tumors after surgical resection: A multicenter analysis in Korea. Ann Surg 2014;260:348-55.  Back to cited text no. 5
    
6.
Kang CM, Kim KS, Choi JS, Kim H, Lee WJ, Kim BR, et al. Solid pseudopapillary tumor of the pancreas suggesting malignant potential. Pancreas 2006;32:276-80.  Back to cited text no. 6
    
7.
Romics L Jr., Oláh A, Belágyi T, Hajdú N, Gyurus P, Ruszinkó V, et al. Solid pseudopapillary neoplasm of the pancreas – Proposed algorithms for diagnosis and surgical treatment. Langenbecks Arch Surg 2010;395:747-55.  Back to cited text no. 7
    
8.
Fried P, Cooper J, Balthazar E, Fazzini E, Newall J. A role for radiotherapy in the treatment of solid and papillary neoplasms of the pancreas. Cancer 1985;56:2783-5.  Back to cited text no. 8
    


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