151 Journal of Cytology / July 2013 / Volume 30 / Issue 3

RANAJOY GHOSH, SAUMYA R. MALLIK, SANDEEP R. MATHUR, VENKATESWARAN K. IYER

Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence: Dr. Sandeep R Mathur, Department of Pathology, 1
st
Floor Teaching Block, All India Institute of Medical Sciences,
New Delhi, India. E-mail: mathuraiims@gmail.com
ABSTRACT
Background: Solid pseudopapillary tumor of pancreas (SPTP) is a rare pancreatic tumor of uncertain histogenesis usually
affecting young women. Though these tumors have characteristic cytomorphology, it is sometimes diffcult to differentiate
them from neuroendocrine tumors of the pancreas. We reviewed cases of SPTP to delineate the diagnostic cytological
features and also observed utility of CD 99 (MIC 2) immunostaining to aid in the diagnosis of this tumor.
Aims: This study was designed to demonstrate the utility of CD 99 immunostaining along with cytological features for making
a pre-operative diagnosis and delineating it from the neuroendocrine tumor of pancreas which is a close mimic.
Materials and Methods: Cytomorphological features of 11 cases of solid pseudopapillary neoplasm diagnosed by
pre-operative fne-needle aspiration cytology (FNAC) at our institute were reviewed. Immunocytochemistry for CD 99 was
also performed on the smears.
Results: All the cases had cellular smears with monomorphic cells lying singly, as loosely cohesive clusters as well as
forming delicate pseudopapillae. Presence of intra and extra-cellular basement membrane material, background foamy
macrophages and nuclear grooves were the other salient features. Immunocytochemistry for CD 99 could be performed on
eight cases and demonstrated typical paranuclear dot-like positivity.
Conclusions: Pre-operative early diagnosis of SPTP can be made by FNAC which can further be aided by CD 99
immunocytochemistry.
Key words: CD 99; immunohistochemistry; solid pseudopapillary tumor of pancreas.
Introduction
Solid pseudopapillary tumor of the pancreas (SPTP) is a
rare neoplasm of unknown histogenesis and low malignant
potential first reported by Frantz in 1959.
[1]
The tumor was
known by various names like solid and cystic tumor, solid
cystic and papillary epithelial neoplasm, and solid and
papillary tumor before the present consensus name solid
pseudopapillary tumor of pancreas (SPTP).
[2]
SPTP is more
common in young females although cases in males are also
reported in the literature.
[3]
Early pre-operative diagnosis is
of paramount importance as adequate resection is usually
curative.
[4]
SPT constitutes approximately 3% of the cystic
lesions of pancreas
[5]
and about 60 cases diagnosed by
fine-needle aspiration cytology (FNAC) are reported in the
literature.
[6]
The cytomorphology of this tumor is highly
characteristic, with features that are distinctive from those
of other cystic and solid tumors of the pancreas. However,
monomorphic population of discohesive cells and eccentric
nuclei sometimes makes it difficult to differentiate from
some other pancreatic tumors like the neuroendocrine
tumors. It is very important to distinguish this tumor
from other pancreatic tumors as these may have similar
clinical presentation and radiologic appearance but with
different prognosis and treatment. Immunohistochemically
these tumors are usually positive for vimentin and -1
antitrypsins
[7]
but no specific immunocytochemical markers
CD99immunocytochemistryinsolidpseudopapillarytumorof
pancreas:Astudyonfne-needleaspirationcytologysmears
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DOI:
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152
Ghosh, et al.: CD 99 immunocytochemistry in solid pseudopapillary tumor of pancreas
Journal of Cytology / July 2013 / Volume 30 / Issue 3
are present which could be used to distinguish it from
other pancreatic tumors. Some other markers like CD56,
neurone-specific enolase, progesterone receptor and CD10
may be immunopositive in SPTP
[8]
but may also be positive
in various other tumors.
[9]
Here we have studied detailed cytomorphological features
of 11 cases of SPTP for accurate pre-operative diagnosis along
with use of immunocytochemical marker CD 99 as a specific
marker for SPTP with a unique staining pattern.
Materials and Methods
Eleven cases of SPTPs with pre-operative cytological
diagnosis were retrieved from the archives of the
cytopathology laboratory of our institute. FNAC was done
with 23G needle under ultrasound guidance and in one case
EUS-guided aspirate was done. Toluidine blue stain was
done for specimen adequacy assessment and preliminary
diagnostic interpretation on site. Smears were fixed in
95% alcohol for Papanicolaou stain and air dried for May
GrnwaldGiemsa staining. Detailed cytomorphological
evaluation was performed in each case. Alcohol-fixed
slides were also used for immunocytochemistry. In five
cases, spare alcohol-stained slides were available and
immunocytochemistry was done on them. In three cases,
a Papanicolaou-stained slide was destained by dipping
in xylene for 2-3 h followed by immersing in methanol
for 15 minutes. Immunohistochemical staining was
done with monoclonal antibody against CD 99 (Dako,
Mouse antihuman antibody clone 12E7) using a routine
streptavidin-biotin horseradish peroxidase detection system
with diaminobenzidine (DAB) as chromogen.
Results
During the period of 2005-2012, 11 patients of SPTP
presented to our institute, with age ranging from 13 to
40 years. Only one of the patients was male and rest were
all females. The clinical and radiological features of these
patients are summarized in Table 1.
Cytomorphology
The smears ranged from being moderately cellular to richly
cellular. A pseudopapillary pattern with a fibrovascular core
surrounded by two or more layers of cells was conspicuous
in all the cases [Figure 1a and d]. Pseudorosettes were
observed in four cases [Figure 1c]. There were also many
loosely cohesive cells and bare nuclei in the background.
Extra-cellular deposition eosinophilic material was another
finding observed in all the cases while intracellular
eosinophilic material was seen in two cases [Figure 1e and f].
Five of the cases had foamy macrophages in the background
[Figure 1c]. The cells were monomorphic with round to oval
nuclei and moderate to abundant amount of cytoplasm with
five of the cases showing fine sago grain like vacuoles. Mild
anisonucleosis was observed in the cases. Nuclear grooves
were seen in many of the cells. Most of the cells had one
to two inconspicuous nucleoli [Figure 1b]. Mitosis was not
observed in any of the case, while one of the cases had
necrosis.
Immunocytochemistry
Immunocytochemistry for CD 99 was performed in eight of
the cases where alcohol-fixed smears were available. All the
cases demonstrated dot-like paranuclear positivity [Figure 2].
Immunocytochemistry for CD 99 was also performed in two
cases of pancreatic neuroendocrine tumor which were negative.
Table 1: Clinicopathological features of patients
Case no. Age/Sex Presentation Site Radiology
1 35/F Epigastric lump Head Cystic SOL in head of pancreas on USG
2 40/F Epigastric pain and vomiting, weight loss Tail and body Cystic mass near tail of pancreas not encasing vessels
on CT scan and USG
3 20/F Pain in left flank lump in epigastrium Body CT scan showed solid mass in body of pancreas
suggestive of adencoarcinoma
4 32/F Pain, intestinal obstruction due to adhesion Head Multiple mixed echogenic intra-hepatic area
5 20/F Pain abdomen and vomiting Body SOL in head of pancreas suggestive of tuberculosis/
carcinoma
6 22/F Lump in left upper abdomen with restricted mobility Head Solid cystic mass in head
7 13/F Pain abdomen Neck Mass in neck of pancreas and multiple mesenteric
lymphadenopathy
8 20/F Pain abdomen, weight loss hard lump in left upper abdomen Head CT scan suggestive of solid and cystic neoplasm
9 31/M Lump abdomen Body Solid heteroechoic mass in pancreas on USG MRI/CT
Scan shows cyst in body of pancreas suggestive of
Serous cystadenoma
10 27/F Pain abdomen Body Cystic mass in CT scan
11 26/F Lump and pain abdomen Body Solid cystic mass
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Ghosh, et al.: CD 99 immunocytochemistry in solid pseudopapillary tumor of pancreas
Journal of Cytology / July 2013 / Volume 30 / Issue 3
Discussion
Solid pseudopapillary tumors account for 1% of all
pancreatic neoplasms.
[10]
Solid pseudopapillary neoplasm
mostly occurs in adolescent girls and young women
(mean age 25-35 years).
[11]
SPTP in men is very rare, and
accounts for about 7% of cases. In our case series, 1 of 11
patients was male and 1 case was a middle aged female.
All other cases occurred in young females ranging from
13 to 35 years. Histogenesis of this tumor is uncertain;
however, it is believed to arise from uncommitted
epithelial cells that can show both endocrine and
exocrine differentiation.
[12]
Clinically, SPTP usually presents with abdominal mass and
discomfort or pain, or it may be an incidental finding in
work-up for unrelated conditions.
[13]
In our series, all patients
had pain abdomen and four patients presented with lump in
upper abdomen. One of the patients presented with intestinal
obstruction due to adhesions.
Approximately 70% of SPTPs originate in the body and tail of
the pancreas and less frequently in the head.
[11]
In our series,
4 out of 11 cases had tumor in head of pancreas and 6 had
tumor in body and tail of pancreas, while 1 had in neck of
pancreas.
Correct diagnosis of SPTP is very important for proper
management of this tumor . Resection of tumor is curative
and no chemotherapy and radiotherapy is required unlike
many other malignant pancreatic tumors. Moreover, as
these tumors are very vascular, pre-operative correct
diagnosis helps in anticipating complications like intra-
operative hemorrhage, or hemoperitonium. Imaging-
guided FNA biopsy is the cardinal choice for pre-operative
pathological diagnosis as the tumor is of low malignant
potential. The cytomorphology of SPTP is classical and
usually different from other cystic lesions of pancreas.
[14]

The cytological findings in our case was similar to those
of earlier reports in the literature.
[4,6,15]
Numerous cellular
papillary fragments as previously described were seen
in our cases some having an irregular Chinese letter-like
pattern. Pseudorosettes described in some of the studies
were also seen in four of our cases.
[16]
The papillary
fragments composed of monomorphic bland round to oval
cells were seen in all our cases confirming with the earlier
studies.
[4]
Many cells in the tumor had fine vacuolation in
the cells as described by Pettinato et al.
[14]
Intra-cytoplasmic
inclusions were seen in our case similar to that by Jayram
et al.
[17]
Cappelari et al
[18]
described nuclear grooves as
one of the typical findings of this tumor which was seen
in our cases.
Although SPTP have these classical morphological
features, there is considerable overlap in cytomorphology
and immunocytochemistry with some other pancreatic
tumors specially the pancreatic endocrine tumors.
[19]

Many of the immunocytochemical markers of endocrine
tumors are also expressed in SPTP.
[20]
Moreover, some
other markers of SPTP like CD10 and CD56 are also
positive in tumors like pancreatoblastoma and acinic
cell carcinoma.
[20]
Staining of CD56 in SPTP is also
inconsistent. Beta Catenin and E-cadherin were previously
considered good markers for SPTP,
[21]
and Holly Burford
et al.
[22]
had proposed a short panel comprising of
CD10, E-cadherin and -catenin for diagnosis of SPTP;
however, these markers are also found to be positive in
tumors like intra-ductal papillary mucinous neoplasm,
Figure 1: (a and d) Pseudopapillae with a delicate fibrovascular core
(Pap, x100 and MGG x100 respectvely). (b) Round to oval cells with fne
chromatn and inconspicuous nucleoli (Pap, x200). (c) Pseudorosete with
foamy macrophages in the background (Pap, x400). (e) Nuclear overlapping
in pseudopapillae (MGG, x400). (f) Intra-cellular basement membrane-like
material (MGG, x400)
a b c
f e d
Figure 2: (a and b) Paranuclear dot-like positvity of CD 99 (ICC, x200 and
x100, respectvely)
a b
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154
Ghosh, et al.: CD 99 immunocytochemistry in solid pseudopapillary tumor of pancreas
Journal of Cytology / July 2013 / Volume 30 / Issue 3
pancreatoblatoma and acinic cell carcinoma.
[23-25]
To rule
out the other morphologic mimics of SPTPs, a relatively
specific and consistent marker which is expressed on FNA
smears should be used.
CD 99 immunoreactivity in SPTP has been reported
recently in two studies on histopathology sections. CD
99 was demonstrated to have a characteristic paranuclear
dot-like positivity in these studies.
[26,27]
They reported
that this positivity pattern was quite classical of SPTP
among the different pancreatic tumors as it was negative
in pancreatoblastoma, adenocarcinoma and acinic cell
carcinoma. In pancreatic endocrine tumors, it was either
negative or had a membranous pattern of positivity.
[28]

Similar to our study, the studies on tissue sections had
100% of the SPTP positive for CD 99 [Table 2]. There has
been no published study which has evaluated utility
of CD 99 on FNA smears. In our series, CD 99 staining
in cytology smears also demonstrated a similar result
with paranuclear dot-like positivity in the eight SPTP
cases while negative in two endocrine tumors. Though,
in this study we performed immunocytochemistry in
Papanicolaou-stained slide by de-staining. The cell
block is ideal as it gives better cellularity and allows
performance of more tests in the same sample. A major
limitation of this study is the number of cases especially
only two neuroendocrine tumors were included in the
study for comparison. Immunocytochemistry on larger
number of cases may have been better and helped to
establish predictive values, our study is thus mainly a
descriptive study of this unique immunocytochemical
property.
SPTP is a tumor of low malignant potential where early
diagnosis and resection is curative. This is the first study
to demonstrate the paranuclear dot-like expression of CD
99 on FNA smears. This may help especially to differentiate
from the other close cytological differential diagnosis like
pancreatic endocrine tumors. CD 99 immunocytochemistry
thus may be used as a good adjunct to cytomorphology
for diagnosis of SPTP where there is an overlap with other
entities on imaging and morphology. The pathophysiology
for this unique staining pattern however is still to be
established.
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Ghosh, et al.: CD 99 immunocytochemistry in solid pseudopapillary tumor of pancreas
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How to cite this article: Ghosh R, Mallik SR, Mathur SR, Iyer VK. CD
99 immunocytochemistry in solid pseudopapillary tumor of pancreas: A
study on fne-needle aspiration cytology smears. J Cytol 2013;30:151-5.
Source of Support: Nil, Confict of Interest: None declared.
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