F1000ResearchF1000Research2046-1402F1000 Research LimitedLondon, UK10.12688/f1000research.140561.3Case ReportArticlesCase Report: Solid pseudo-papillary tumor of the pancreas in a young woman: a rare pancreatic neoplasm with nonspecific presentation
[version 3; peer review: 1 approved, 1 approved with reservations]
GhanneyOlfaFunding AcquisitionWriting – Original Draft PreparationWriting – Review & Editinghttps://orcid.org/0000-0001-7896-9901a1SaadRimSoftware1Ben A morsoumayaSoftware1MayadaTrimechVisualization1
University of Monastir, Monastir, Monastir, Tunisiagounayolfa@gmail.com
Solid pseudopapillary tumors (SPT) of the pancreas are rare neoplasms, representing less than 2% of all pancreatic tumors, and predominantly affecting young women. Their clinical and radiological presentation is often heterogeneous, which may delay or complicate the diagnosis. Complete surgical resection is usually curative, provided that the diagnosis is established at an early stage. We report the case of a young woman who presented with a pancreatic mass revealed by vague non-specific abdominal pain. The diagnosis was confirmed by histopathological and immunohistochemical examination of the resected surgical specimen. This case highlights the diagnostic challenges associated with SPT and emphasizes the importance of considering this entity in the differential diagnosis of pancreatic tumors in young patients, even in the absence of specific biological abnormalities.
PancreasTumorsurgerySolid pseudopapillary neoplasm of the pancreasThe author(s) declared that no grants were involved in supporting this work.Amendments from Version 2
In this revised version, the manuscript has been substantially improved in terms of scientific clarity and structure. The Abstract and Introduction were refined to better highlight the clinical relevance of solid pseudopapillary tumors and to provide a more precise overview of current knowledge. The Case Presentation was edited for greater clarity and consistency, with improved description of clinical findings and imaging features. The Discussion was expanded to include a more comprehensive review of the recent literature, particularly regarding epidemiology, pathogenesis, radiological characteristics, and long-term outcomes. Overall, the language was revised to enhance readability and coherence, and minor inconsistencies were corrected.
Introduction
A solid pseudopapillary tumor (SPT) of the pancreas is a rare pathological entity accounting for approximately 2% of pancreatic exocrine tumors.
1,
2 It is characterized by low malignant potential and a strong predilection for young women.
Despite increasing recognition, its pathogenesis remains incompletely understood.
Hormonal and embryological hypotheses have been proposed, supported by female predominance and progesterone receptor expression. Clinically, SPT often presents with non-specific or minimal symptoms, and in many cases the tumor is discovered incidentally during imaging performed for unrelated reasons.
Because of this nonspecific presentation, diagnosis relies primarily on histopathological examination. Surgical resection remains the treatment of choice and is usually associated with an excellent prognosis, even in cases with large tumors or limited local invasion.
3
Observation
A 19-year-old woman of African origin, a high school student with no history of abdominal trauma, surgery or smoking was admitted for evaluation of chronic abdominal pain located in the epigastrium and the left hypochondrium. She also had no relevant family medical history. The pain had started six months before admission and had progressively worsened. It was associated with an deterioration of her general condition, and she reported an 11 kg weight loss during this period.
The physical examination was unremarkable,except for mild epigastric tenderness. Laboratory tests were within normal limits. Abdominal Doppler ultrasonography showed a round, well-defined vascular mass. It measured approximately 42 mm and extended from the retroperitoneum to the lower pole of the ipsilateral kidney. It was heterogeneous,predominantly cystic, with hyperechoic components.
Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 44 × 42 × 34 mm solid masslocated in the pancreatic tail. The lesion was isodense on non-contrast imaging, with moderate and heterogeneous enhancement after contrast administration, and contained scattered cystic areas. The mass had well-defined margins and extended inferiorly toward the descending colon without signs of compression or invasion. The peritoneal fat was normal in appearance (
Figure 1). Hepatic and pancreatic laboratory tests were normal. Endoscopic ultrasound-guided biopsy was not available in our hospital service; therefore, surgery was performed without a preoperative histological confirmation.
Abdominal magnetic resonance imaging showing a heterogeneous mass repulsing below the left kidney.
Intraoperatively a 5-cm exophytic tumor arising from the inferior border of the pancreatic tail was identified and completely resected by distal pancreatectomy. There was no locoregional invasion or distant metastasis. The tumor was completely resected by a distal pancreatectomy, and the postoperative course was uneventful. Histopathological examination revealed a solid pseudopapillary tumor of the pancreas. The cytoarchitectural features were consistent with this diagnosis, and immunohistochemical staining demonstrated CD10 positivity in tumor cells. The patient had a favorable postoperative course, with normal ultrasonographic follow-up at 3, 12, 24, and 48 months and CT scans at 12, 24, and 48 months, showing no evidence of recurrence or residual disease.
Discussion
Solid pseudo-papillary tumor (SPT) of the pancreas is a rare pathological entity first described by Frantz in 1959. It accounts for approximately 0.7 to 2.7% of all exocrine pancreatic tumors and less than 5% of cystic pancreatic neoplasms.
4 The rarity of this entity makeseach reported case valuable, particularly in improving diagnostic awareness and refining management strategies.
SPT predominantly affects young women, with more than 90–95% of cases occurring in females and a mean age at diagnosis of approximately 22 years.
5,
6 This epidemiological profile was consistent with our patient. Although rare cases in males and elderly patients have also been reported.
7 The etiopathogenesis of SPT remains unclear. Two main hypotheses have been proposed: a hormonal origin suggested by the female predominance and progesterone receptor expression, and an embryological origin involving totipotent pancreatic stem cells capable of multidirectional differentiation.
8
In most cases, SPT presents with non-specific symptoms. Abdominal pain is the most frequent mode of revelation, reported in nearly 50–60% of patients, while incidental discovery on imaging performed for unrelated reasons is increasingly common. In our patient, chronic non-specific abdominal pain was the only presenting symptom, and no specific biological abnormalities were observed. This reinforces the limited diagnostic value of laboratory investigations and highlights the central role of imaging in the diagnostic pathway.
SPT can arise in any part of the pancreas but shows a predilection for the body and tail, accounting for approximately 60–65% of cases. Rare extra-pancreatic localizations, including retroperitoneal, mesocolic, or hepatic sites, have been described and support the hypothesis of origin from ectopic pancreatic tissue or pluripotent stem cells. Macroscopically, SPT is usually a large, well-circumscribed mass, often exceeding 10 cm in diameter, with a fibrous capsule and mixed solid-cystic appearance.
9,
10
Radiologically, abdominal ultrasound typically reveals a well-defined heterogeneous mass. On computed tomography, SPT appears as a hypodense lesion with limited enhancement and mixed solid and cystic components. Magnetic resonance imaging often shows heterogeneous hyperintensity on both T1- and T2-weighted sequences, with a hypointense peripheral capsule. Although imaging findings are highly suggestive, they are not pathognomonic, as several cystic pancreatic lesions may mimic SPT. In resource-limited settings, the lack of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) may lead to upfront surgery, as in our case. Nevertheless, EUS-FNA currently represents a reliable diagnostic tool, with reported accuracy exceeding 80% for pancreatic tumors.
6,
11
Histological examination remains the gold standard for diagnosis. Typical microscopic features include uniform polygonal cells arranged in solid sheets and pseudopapillary structures surrounding a fibrovascular core. Immunohistochemistry plays a crucial role, with tumor cells classically expressing CD10, vimentin, alpha-1 antitrypsin, and β-catenin. Nuclear accumulation of β-catenin, reflecting activation of the Wnt signaling pathway, is currently considered one of the most specific hallmarks of SPT.
11
From a therapeutic perspective, surgery remains the cornerstone of treatment. Complete resection is associated with excellent outcomes, even in cases with local invasion or limited metastatic disease. Our patient underwent distal pancreatectomy with favorable postoperative evolution. Parenchyma-preserving procedures, such as enucleation or central pancreatectomy, are increasingly favored when feasible, as they reduce the risk of long-term endocrine and exocrine insufficiency while maintaining excellent oncological outcomes. Minimally invasive approaches, including laparoscopic and robotic surgery, have also demonstrated safety and efficacy.
Although SPT is generally considered a tumor with indolent behavior, it should not be regarded as strictly benign. Malignant features, including vascular invasion, perineural invasion, and distant metastases, are reported in approximately 10–15% of cases. The liver remains the most common metastatic site. Importantly, late recurrences have been described up to 10–15 years after initial surgery, emphasizing the need for long-term follow-up even in non-metastatic cases.
12
This case highlights three important clinical messages: (1) SPT should be considered in young women presenting with pancreatic masses; (2) the absence of EUS-FNA should not delay curative surgery when imaging is suggestive; and (3) long-term surveillance is mandatory despite excellent short-term prognosis. Further multicenter studies are required to define optimal follow-up strategies and to clarify the molecular determinants of malignant transformation in SPT.
Conclusions
Solid pseudopapillary neoplasm of the pancreas is a rare tumor with low malignant potential and excellent long-term prognosis after complete surgical resection. Diagnosis relies on histopathology and immunohistochemistry, as clinical and biological features are often non-specific. This case underlines the importance of considering SPT in young women presenting with pancreatic masses and supports early surgical management when imaging findings are suggestive. Long-term follow-up remains essential due to the risk of late recurrence.
Patient consent
We obtained written informed consent from the patient for the use and publication of their data.
Data availability
All data underlying the results are available as part of the article and no additional source data are required.
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Solid-Pseudopapillary Neoplasm of the Pancreas: A 63-Case Analysis of Clinicopathologic and Immunohistochemical Features and Risk Factors of Malignancy.Cancer Manag. Res.31 déc 2021;13:3335–3343.
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10.3390/cancers1713224040647537PMC1224943210.5256/f1000research.196753.r472507Reviewer response for version 3Fabregas MD MPHJesus C1Refereehttps://orcid.org/0000-0003-1120-1783
Memorial Healthcare System, Hollywood, USA
Competing interests: No competing interests were disclosed.
This is a great effort by the authors. They should be commended on the writing of this important topic. I have added some minor recommendations for the editor and author’s consideration.
This manuscript presents a case of SPT in a 19-year-old woman managed by distal pancreatectomy with favorable long-term follow-up. While the topic is clinically relevant and the case is well-documented, the manuscript in its current form requires minimal revision before it can be considered for indexing. The case itself does not offer substantial novelty beyond the existing literature, and the authors need to more clearly articulate what distinguishes this report from the many previously published SPT cases.
MINOR CONCERNS
Limited novelty and unclear contribution. SPT case reports are now abundant in the literature. The authors should explicitly state in the Introduction what unique aspect this case adds — whether it is the resource-limited setting (absence of EUS-FNA), the long 48-month follow-up, or the African demographic context. As written, the justification for indexing is insufficiently argued.
Several details are missing that would strengthen the report. What were the specific tumor markers tested (CA 19-9, CEA)?
The pathology findings are summarized in a single sentence. A case report of a rare tumor should provide a more detailed gross and microscopic description, ideally with representative histological images (H&E and immunohistochemistry). The absence of pathology figures is a significant gap.
Some minimal typographical and grammatical errors that should be corrected: "an deterioration" should read "a deterioration"; "solid masslocated" needs a space; "makeseach" should be "makes each." A thorough proofreading pass is needed.
Only one MRI image is provided. Additional imaging (CT with contrast, ultrasound) and pathology figures would substantially improve the manuscript.
The authors report 48 months of follow-up but also note that late recurrences can occur up to 10–15 years post-surgery. They should acknowledge this limitation — their follow-up, while reassuring, is not sufficient to declare the patient cured.
No mention is made of informed patient consent for publication or institutional ethics approval, which is a requirement for case reports in most journals.
Can you briefly juxtapose the striking differences in the prognosis of pancreatic ductal adenocarcinoma vs this specific histology subtype.
DECISION: Publish with some modifications
The case is clinically sound and the patient outcome is well-documented, but the manuscript needs to better justify its contribution, provide more complete pathological and surgical data, and improve its presentation before it meets the standard for indexing. I encourage the authors to revise and resubmit.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
No
Is the case presented with sufficient detail to be useful for other practitioners?
Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Yes
Is the background of the case’s history and progression described in sufficient detail?
Partly
Reviewer Expertise:
Gastrointestinal malignancies
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Ghanneyolfauniversity hospital Tahar Sfar, Not Applicable, Mahdia, Tunisia
Competing interests: no competing interests
1342026
Response to reviewer
Reviewer comment 1
Limited novelty and unclear contribution. SPT case reports are now abundant in the literature. The authors should explicitly state in the Introduction what unique aspect this case adds — whether it is the resource-limited setting (absence of EUS-FNA), the long 48-month follow-up, or the African demographic context. As written, the justification for indexing is insufficiently argued.
Response 1
We thank the reviewer for this insightful comment. We agree that solid pseudopapillary tumor (SPT) case reports are increasingly reported in the literature, and that clearly stating the added value of the present case is essential.
In response, we have revised the Introduction to better highlight the specific contributions of our report. In particular, we emphasize three key aspects: (1) the management in a resource-limited setting where endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was not available, leading to direct surgical management; (2) the relatively long-term follow-up of 48 months confirming the absence of recurrence; and (3) the epidemiological context of a young African patient, which remains underrepresented in published series.(Lines 20-28)
Reviewer comment 2
Several details are missing that would strengthen the report. What were the specific tumor markers tested (CA 19-9, CEA)?
Response 2
We thank the reviewer for this relevant comment. Additional details regarding tumor markers have now been included in the manuscript. Specifically, serum CA 19-9 and carcinoembryonic antigen (CEA) levels were assessed and found to be within normal limits. This information has been added to the Observation section to improve the completeness of the clinical description (Lines 37-38)
Reviewer comment 3
The pathology findings are summarized in a single sentence. A case report of a rare tumor should provide a more detailed gross and microscopic description, ideally with representative histological images (H&E and immunohistochemistry). The absence of pathology figures is a significant gap.
Response 3
We thank the reviewer for this valuable comment. We fully agree that a more detailed pathological description and the inclusion of representative histological images significantly strengthen the quality of the report.
Accordingly, the histopathological findings have been expanded to include both macroscopic and microscopic features of the tumor. In addition, representative histological images, including hematoxylin and eosin (H&E) staining as well as immunohistochemical staining, have now been included in the revised manuscript to better illustrate the characteristic features of solid pseudopapillary tumor.( Lines 59-66)
Reviewer comment4
Some minimal typographical and grammatical errors that should be corrected: "an deterioration" should read "a deterioration"; "solid masslocated" needs a space; "makeseach" should be "makes each." A thorough proofreading pass is needed.
Response 4
We thank the reviewer for this careful reading of the manuscript. The typographical and grammatical errors highlighted have been corrected accordingly. In addition, the manuscript has undergone a thorough proofreading to improve clarity, grammar, and overall readability.
Reviewer comment 5
Only one MRI image is provided. Additional imaging (CT with contrast, ultrasound) and pathology figures would substantially improve the manuscript.
Response:
We thank the reviewer for this valuable suggestion. In response, we have added additional imaging studies to strengthen the manuscript. Specifically, contrast-enhanced MRI image has been included alongside the previously provided CT images. In addition, representative histopathological figures have also been incorporated. These additions provide a more complete radiological and pathological illustration of the case and improve the overall clarity and educational value of the report.
Reviewer comment6 : The authors report 48 months of follow-up but also note that late recurrences can occur up to 10–15 years post-surgery. They should acknowledge this limitation their follow-up, while reassuring, is not sufficient to declare the patient cured.
Response 6 :
We sincerely thank the reviewer for this important and insightful comment. We fully agree that, although the 48-month follow-up in our case is reassuring, it remains insufficient to definitively exclude the possibility of late recurrence, which has been reported up to 10–15 years after surgical resection.
In response to this comment, we have revised the manuscript to explicitly acknowledge this limitation. We have clarified that, despite the absence of recurrence at 48 months, this duration of follow-up does not allow the patient to be considered definitively cured. We also emphasized the need for prolonged and careful surveillance.
These modifications have been incorporated into the Abstract, Discussion, and Conclusion sections to ensure consistency throughout the manuscript.(Line 23 -24-136-137-151-152)
Reviewer comment 7 No mention is made of informed patient consent for publication or institutional ethics approval, which is a requirement for case reports in most journals
Response 7 :
We thank the reviewer for highlighting this important point. We confirm that written informed consent for publication was obtained from the patient prior to submission of this case report.
In addition, we have clarified the ethical considerations in the revised manuscript. According to our institutional policy, ethical approval is not required for single case reports; however, all procedures were conducted in accordance with the principles of the Declaration of Helsinki.
This information has now been clearly stated in the “Patient consent” and “Ethics statement” sections of the manuscript. (Lines 157-164)
Reviewer comment 8 : Can you briefly juxtapose the striking differences in the prognosis of pancreatic ductal adenocarcinoma vs this specific histology subtype.
Response 8 :
We thank the reviewer for this valuable suggestion. We agree that highlighting the prognostic differences between solid pseudopapillary tumors and pancreatic ductal adenocarcinoma provides important clinical context.
Accordingly, we have revised the Discussion section to briefly compare these two entities. While pancreatic ductal adenocarcinoma is associated with a poor prognosis and a 5-year survival rate below 10% in most series, solid pseudopapillary tumors are characterized by an excellent prognosis, with reported 5-year survival rates exceeding 95% after complete surgical resection.
This comparison has been added to emphasize the distinct biological behavior and clinical outcomes of these two pancreatic neoplasms.(Lines 138-142)
10.5256/f1000research.168423.r298016Reviewer response for version 2CienfuegosJavier1Referee
Clínica Universidad de Navarra, Pamplona, Navarra, Spain
Competing interests: No competing interests were disclosed.
The authors have made corrections and improved the manuscript. The paper can be accepted for indexing.
Thank you very much for your confidence.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is the case presented with sufficient detail to be useful for other practitioners?
Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Partly
Is the background of the case’s history and progression described in sufficient detail?
Partly
Reviewer Expertise:
Gaatrintestinal Surgery, Laparoscopic surgery
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
10.5256/f1000research.153929.r280969Reviewer response for version 1CienfuegosJavier1Referee
Clínica Universidad de Navarra, Pamplona, Navarra, Spain
Competing interests: No competing interests were disclosed.
1.- The differential diagnosis of cystic lesions of the pancreas is a challenge given that in many cases they are discovered incidentally and due to the heterogeneity they display.
The authors present the case of a solid pseudopapillary tumor of the pancreas (SPT) in a 19-year-old patient. In spite of the correct description of the case, two aspects are worthy of comment.
Regarding the preoperative diagnosis, the authors are not in favor of performing a cytological analysis due to the risk of dissemination. Currently the cytologic characteristics of SPT are well established and the recommendation is to perform endoscopic ultrasound and fine needle aspiration (EUS-FNA).
SPTs have been reported to have cytoplasmic and nuclear expression of the Wnt pathway (ß-catenin and loss of E-cadherin) in 100% of cases, unlike endocrine tumors whether these be solid or cystic.
The other aspect worth mentioning is the surgical technique. Even though most SPTs have a benign behavior, an invasive and metastatic component affecting the lymph nodes has been reported in 10% of cases. As a result, “enucleation” should be avoided and pancreatic resection should be performed using oncologic criteria depending on the size and location of the lesion, using either an open or laparoscopic technique.
Major comments:
The patient was intervened without a precise diagnosis before surgery. Nowadays, in this type of lesion, the means are available so that the most accurate diagnosis possible can be made before surgery.
In this sense, the authors should comment on the case discussion, the opportunity to perform a fine needle puncture and cytological study.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Partly
Is the case presented with sufficient detail to be useful for other practitioners?
Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Partly
Is the background of the case’s history and progression described in sufficient detail?
Partly
Reviewer Expertise:
Gaatrintestinal Surgery, Laparoscopic surgery
I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
References:
The World Health Organization Reporting System for Pancreaticobiliary Cytopathology: Overview and Summary.Cancer Cytopathol.2024;
10.1002/cncy.228063870967010.1002/cncy.22806Ghanneyolfauniversity hospital Tahar Sfar, Not Applicable, Mahdia, Tunisia
Competing interests: No competing interests were disclosed.
1162024
Dear Reviewer
Thank you for taking the time to read our article and for your valuable feedback. Allow me to clarify a few points. Please know that we are open to discussion and look forward to your responses.
First Point :
It is well known currently that , Echo-endosonography gives the ability of fine-needle aspiration and biopsy and, therefore, setting a correct preoperative pathologic diagnosis of tumor with an accuracy of 97.2%. However, EUS-guided biopsy demands specialized endoscopic skills, and unfortunately, it is not available in our hospital service, That´s why our patient underwent surgery before establishing the diagnosis of solid pseudopapillary tumor of the pancreas .
In the discussion section, we mentioned that biopsy is not recommended. We were referring to abdominal CT-guided biopsy, not endoscopic ultrasound-guided biopsy. We did not specify this clearly, leading to confusion. We will rectify this in the manuscript.
Here is a paragraph that we will add to the discussion section for correction.
An unequivocal diagnosis remains histological. Endoscopic techniques offer ways to diagnose pseudopapillary solid tumor of pancreas(SPTP) before surgery. Like abdominal ultrasound, SPTP can appear as solid, cystic, or a combination of both on endoscopic ultrasound (EUS). EUS-guided fine needle aspiration (EUS-FNA) is now commonly used to diagnose pancreatic tumors, with high accuracy rates of over 80%. This technique not only allows for biopsy but also enables the minimally invasive collection of fluid samples, such as pancreatic juice and cyst fluid.(1)
Second Point :
Surgical technique
Regarding surgical technique, indeed Parenchyma-preserving pancreatectomies, such as enucleation, central pancreatectomy, and duodenum-preserving pancreatic head resection (DPPHR), are being performed more frequently(2) . Studies have shown that these procedures can lower the occurrence of pancreatic endocrine and exocrine insufficiencies while maintaining positive short- and long-term results (3) .
Enucleation, duodenum-preserving pancreatic head resection (DPPHR), and pancreaticoduodenectomy are options for SPTP located in the pancreatic(4). Enucleation, central pancreatectomy, and distal pancreatectomy (with or without splenectomy) are available for tumors in the pancreatic body and tail.(5)
Minimally invasive techniques, including laparoscopic and robotic surgery, can be suded in both traditional and parenchyma-preserving procedures.
To date, no consensus on the best approach for the treatment of SPTP metastasis has been established. Metastasis to lymph nodes is not common, occurring in only 1.0% to 7.9% of cases. Therefore, extended lymphadenectomy may not be needed for most patients (6).
References :
Antoniou EA, Damaskos C, Garmpis N, Salakos C, Margonis GA, Kontzoglou K, Lahanis S, Spartalis E, Patsouras D, Kykalos S, Garmpi A, Andreatos N, Pawlik TM, Kouraklis G. Solid Pseudopapillary Tumor of the Pancreas: A Single-center Experience and Review of the Literature. In Vivo. 2017 Jul-Aug;31(4):501-510. doi: 10.21873/invivo.11089. PMID: 28652415; PMCID: PMC5566898.
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Ghanneyolfauniversity hospital Tahar Sfar, Not Applicable, Mahdia, Tunisia
Competing interests: No competing interests were disclosed.
2562024
Cover Letter
[Ghannei Olfa]
[University of Monastir, Monastir, Tunisia]
[Email:
gounayolfa@gmail.com]
[25 june 2024]
[Javier Cienfuegos]
[Clínica Universidad de Navarra, Pamplona, Navarra, Spain]
Dear Javier Cienfuegos,
I hope this letter finds you well. I am writing to express my sincere gratitude for your thorough and insightful review of our manuscript titled "Solid pseudo-papillary tumor of the pancreas"
Your detailed comments and constructive feedback have been invaluable in enhancing the quality and clarity of our work.
We have carefully considered each of your remarks and have made the necessary revisions to address the concerns raised. Below, we provide a point-by-point response to each of your comments
Comment 1 : The patient was intervened without a precise diagnosis before surgery. Nowadays, in this type of lesion, the means are available so that the most accurate diagnosis possible can be made before surgery.
Response1: it is well known currently that , Echo-endosonography gives the ability of fine-needle aspiration and biopsy and, therefore, setting a correct preoperative pathologic diagnosis of tumor with an accuracy of 97.2%. However, EUS-guided biopsy demands specialized endoscopic skills, and unfortunately, it is not available in our hospital service, That´s why our patient underwent surgery before establishing the diagnosis of solid pseudopapillary tumor of the pancreas . I have included this remark in the manuscript
(Line22)
Comment 2 : Regarding the preoperative diagnosis, the authors are not in favor of performing a cytological analysis due to the risk of dissemination
Response2: In the discussion section, we mentioned that biopsy is not recommended. We were referring to abdominal CT-guided biopsy, not endoscopic ultrasound-guided biopsy. We did not specify this clearly, leading to confusion. Since this message is potentially confusing, we have removed it from the manuscript.
Comment 3 : The surgical technique.
Response3: We have revised the paragraph discussing the surgical treatment in the manuscript after consulting recent literature
Thank you once again for your constructive feedback and your contribution to the improvement of our manuscript. We look forward to your further comments and hope that our revisions meet your expectations.