Solid Pseudopapillary Tumors of the Pancreas
Radical surgical resection should be performed for all solid pseudopapillary neoplasms (SPNs) of the pancreas, regardless of size or symptoms, as complete excision is curative and associated with excellent long-term survival. 1
Primary Treatment Approach
Standard Resection Strategy
- All SPNs require complete surgical resection with negative margins (R0 resection), as this is the only curative treatment and yields 5-year survival rates of 88-95% 1, 2, 3
- The specific surgical procedure depends on tumor location 3, 4:
Aggressive Surgical Approach for Advanced Disease
Even in cases of locally advanced, metastatic, or recurrent SPNs, an aggressive surgical approach with complete resection is indicated 1. This recommendation is critical because:
- SPNs have low-grade malignant potential with indolent behavior, making even advanced disease potentially curable with complete resection 5
- Patients with local invasion, capsule invasion, or even tumor rupture during surgery still achieve excellent outcomes without recurrence when complete resection is achieved 2, 4
- Recurrent disease should be re-resected aggressively, as demonstrated by cases requiring completion pancreatectomy years after initial surgery 6
Surgical Technique Considerations
Laparoscopic vs. Open Approach
- Laparoscopic distal pancreatectomy is feasible for body/tail tumors, particularly smaller lesions 4
- Critical caveat: Laparoscopic resection should only be performed by experienced surgeons due to risk of tumor rupture during manipulation of large masses 4
- Tumor rupture during laparoscopic resection does not necessarily preclude good outcomes if complete resection is still achieved, though it should be avoided 4
Spleen Preservation
- For benign or low-grade malignant distal pancreatic tumors like SPNs, spleen-preserving distal pancreatectomy should be attempted when technically feasible, particularly for smaller tumors not involving splenic vessels 7
- However, splenectomy is acceptable and commonly performed (41.7% of cases) without adverse impact on outcomes 2
Expected Outcomes and Prognosis
Survival and Recurrence
- Recurrence rate is low (8.3%) even at 5 years post-resection 2
- 1-year, 3-year, and 5-year survival rates are 95%, 95%, and 88% respectively 2
- No mortality should be expected with modern surgical techniques at experienced centers 2, 3
- Mean hospital stay is approximately 10 days 3
Postoperative Complications
- Pancreatic fistula is the most common complication, occurring in approximately 37.5% of cases after pancreatoduodenectomy 3
- Overall morbidity is low with no mortality in contemporary series 3, 4
Critical Clinical Pitfalls to Avoid
Do Not Delay Surgery
- No role exists for neoadjuvant chemotherapy or radiation - proceed directly to surgical resection 3
- Preoperative biopsy is not mandatory when imaging is characteristic of SPN 1
- Clinical factors including sex, age, symptoms, tumor size, CT appearance, and tumor markers cannot reliably predict malignant behavior, so all SPNs warrant resection 2
Do Not Refuse Surgery for Advanced Features
- Local invasion into adjacent structures is not a contraindication to resection 2
- Synchronous or metachronous metastases should still be resected when complete excision is achievable 1
- The only contraindication to resection is unresectable vascular invasion (mesenteric vessels) combined with distant metastases 4
Surveillance After Resection
- Long-term follow-up is essential as recurrence can occur years after initial resection 6
- Follow-up should include imaging at 3-12 months post-resection, then every 6-12 months thereafter with CT/MRI as clinically indicated 1
- Recurrent disease warrants aggressive re-resection, including completion pancreatectomy if necessary 6