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Zystische Raumforderungen des Pankreas

Differenzialdiagnostik und Therapie
  • J. RosendahlEmail author
  • P. Michl
Schwerpunkt: Erkrankungen des Pankreas
  • 91 Downloads

Zusammenfassung

Zystische Raumforderungen des Pankreas werden in den meisten Fällen als Zufallsbefund detektiert. Aufgrund des potenziellen Risikos einer malignen Transformation sind oft eine weiterführende Diagnostik und eine Überwachung der Patienten notwendig. Bevor die Patienten in ein Überwachungsprogramm aufgenommen werden, muss die klinische Gesamtsituation einschließlich des Alters, der Komorbiditäten und des Patientenwunschs nach ausführlicher Aufklärung berücksichtigt werden. Bisher gibt es keine zuverlässigen Biomarker, die das Risiko einer malignen Transformation sicher vorhersagen. Bei den bildgebenden Verfahren ist die Magnetresonanztomographie/Magnetresonanzcholangiopankreatikographie der Computertomographie hinsichtlich der Genauigkeit in der Darstellung von „besorgniserregenden“ Veränderungen überlegen. Der endoskopische Ultraschall wird komplementär eingesetzt und kann durch den Einsatz von Kontrastmittel bzw. durch eine diagnostische Punktion der zystischen Raumforderung zusätzliche Informationen liefern, die das therapeutische Vorgehen beeinflussen. Vor allem bei den häufigsten zystischen Neoplasien, den intraduktalen papillär-muzinösen Neoplasien (IPMN), existieren teilweise divergierende Empfehlungen und Strategien in Überwachung und Management. Unstrittig ist, dass IPMN vom Hauptgang- und gemischten Typ reseziert werden sollten. Zusätzlich bestehen relative Indikationen für eine operative Versorgung von IPMN bei Risikokonstellationen. Für alle zystischen Pankreasraumforderungen gilt, dass die Fälle in einer interdisziplinären Expertenrunde unter Beteiligung von Gastroenterologen, Viszeralchirurgen, Radiologen und Pathologen besprochen werden sollten, um die optimale patientenorientierte Therapiestrategie empfehlen zu können.

Schlüsselwörter

Zystische, muzinöse und seröse Neoplasien Chirurgische Onkologie Endosonographie Magnetresonanztomographie Computertomographie 

Cystic lesions of the pancreas

Differential diagnostics and treatment

Abstract

Cystic space-occupying lesions of the pancreas represent incidental findings in most cases. As there is a potential risk of malignant transformation further evaluation of the lesions as well as a follow-up of these patients is usually recommended. Before this work-up is initiated the clinical situation of the patient as a whole and comorbidities, age and personal preferences have to be taken into account. So far there are no biomarkers that reliably predict the risk of malignant transformation. Imaging by magnetic resonance tomography (MRI) in combination with magnetic resonance cholangiopancreatography (MRCP) is more accurate than computed tomography to identify worrisome features. During follow-up, endoscopic ultrasound (EUS) can be used as complementary method to MRI/MRCP. Using contrast enhancement or endoscopic fine needle aspiration (EUS-FNA) may influence the therapeutic strategy in some patients. Whereas for some cystic pancreatic lesions consensus has been reached, varying recommendations exist for intraductal papillary mucinous neoplasms (IPMN). There is consensus that in main-duct as well as in mixed-type IPMN surgery is recommended. The management of branch-duct type IPMN, however, remains controversial. A multidisciplinary expert panel including gastroenterologists, visceral surgeons, radiologists and pathologists is essential to discuss all cases of patients with cystic pancreatic lesions and to guarantee an optimal, patient-centered treatment recommendation.

Keywords

Neoplasms, cystic, mucinous, and serous Surgical oncology Endosonography Magnetic resonance imaging Tomography, x‑ray computed 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

J. Rosendahl und P. Michl geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Hruban RH, Kloeppel G, Bofetta P et al (2010) Tumours of the pancreas. In: Bosman FT, Carneiro F, Hruban RH (Hrsg) WHO classification of tumours of the digestive system, 4. Aufl. International Agency for Research on Cancer, Lyon, S 280–330Google Scholar
  2. 2.
    Girometti R, Intini S, Brondani G et al (2011) Incidental pancreatic cysts on 3D turbo spin echo magnetic resonance cholangiopancreatography: prevalence and relation with clinical and imaging features. Abdom Imaging 36:196–205CrossRefGoogle Scholar
  3. 3.
    Chang YR, Park JK, Jang JY et al (2016) Incidental pancreatic cystic neoplasms in an asymptomatic healthy population of 21,745 individuals: large-scale, single-center cohort study. Medicine (Baltimore) 95:e5535CrossRefGoogle Scholar
  4. 4.
    de Jong K, Nio CY, Hermans JJ et al (2010) High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol 8:806–811CrossRefGoogle Scholar
  5. 5.
    European Study Group on Cystic Tumours of the Pancreas (2018) European evidence-based guidelines on pancreatic cystic neoplasms. Gut 67:789–804CrossRefGoogle Scholar
  6. 6.
    Kim JR, Jang JY, Kang MJ et al (2015) Clinical implication of serum carcinoembryonic antigen and carbohydrate antigen 19-9 for the prediction of malignancy in intraductal papillary mucinous neoplasm of pancreas. J Hepatobiliary Pancreat Sci 22:699–707CrossRefGoogle Scholar
  7. 7.
    van der Waaij LA, van Dullemen HM, Porte RJ (2005) Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Gastrointest Endosc 62:383–389CrossRefGoogle Scholar
  8. 8.
    Jang DK, Song BJ, Ryu JK et al (2015) Preoperative diagnosis of pancreatic cystic lesions: the accuracy of endoscopic ultrasound and cross-sectional imaging. Pancreas 44:1329–1333CrossRefGoogle Scholar
  9. 9.
    Lee HJ, Kim MJ, Choi JY et al (2009) Relative accuracy of CT and MRI in the differentiation of benign from malignant pancreatic cystic lesions. Clin Radiol 66:315–321CrossRefGoogle Scholar
  10. 10.
    Sainani NI, Saokar A, Deshpande V et al (2009) Comparative performance of MDCT and MRI with MR cholangiopancreatography in characterizing small pancreatic cysts. AJR Am J Roentgenol 193:722–731CrossRefGoogle Scholar
  11. 11.
    Visser BC, Muthusamy VR, Yeh BM et al (2008) Diagnostic evaluation of cystic pancreatic lesions. HPB (Oxford) 10:63–69CrossRefGoogle Scholar
  12. 12.
    Song SJ, Lee JM, Kim YJ et al (2007) Differentiation of intraductal papillary mucinous neoplasms from other pancreatic cystic masses: comparison of multirow-detector CT and MR imaging using ROC analysis. J Magn Reson Imaging 26:86–93CrossRefGoogle Scholar
  13. 13.
    Donahue TR, Hines OJ, Farrell JJ et al (2010) Cystic neoplasms of the pancreas: results of 114 cases. Pancreas 39:1271–1276CrossRefGoogle Scholar
  14. 14.
    Kim JH, Eun HW, Park HJ et al (2012) Diagnostic performance of MRI and EUS in the differentiation of benign from malignant pancreatic cyst and cyst communication with the main duct. Eur J Radiol 81:2927–2935CrossRefGoogle Scholar
  15. 15.
    Gress F, Gottlieb K, Cummings O et al (2000) Endoscopic ultrasound characteristics of mucinous cystic neoplasms of the pancreas. Am J Gastroenterol 95:961–965CrossRefGoogle Scholar
  16. 16.
    Yamao K, Nakamura T, Suzuki T et al (2003) Endoscopic diagnosis and staging of mucinous cystic neoplasms and intraductal papillary-mucinous tumors. J Hepatobiliary Pancreat Surg 10:142–146CrossRefGoogle Scholar
  17. 17.
    Al-Haddad M, DeWitt J, Sherman S et al (2014) Performance characteristics of molecular (DNA) analysis for the diagnosis of mucinous pancreatic cysts. Gastrointest Endosc 79:79–87CrossRefGoogle Scholar
  18. 18.
    Brugge WR, Lewandrowski K, Lee-Lewandrowski E et al (2004) Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Baillieres Clin Gastroenterol 126:1330–1336Google Scholar
  19. 19.
    Cizginer S, Turner BG, Turner B, Bilge AR et al (2011) Cyst fluid carcinoembryonic antigen is an accurate diagnostic marker of pancreatic mucinous cysts. Pancreas 40:1024–1028CrossRefGoogle Scholar
  20. 20.
    Gaddam S, Ge PS, Keach JW et al (2015) Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study. Gastrointest Endosc 82:1060–1069CrossRefGoogle Scholar
  21. 21.
    Jin DX, Small AJ, Vollmer CM, Jhala N et al (2015) A lower cyst fluid CEA cut-off increases diagnostic accuracy in identifying mucinous pancreatic cystic lesions. J Pancreas 16:271–277Google Scholar
  22. 22.
    Kadayifci A, Al-Haddad M, Atar M et al (2016) The value of KRAS mutation testing with CEA for the diagnosis of pancreatic mucinous cysts. Endosc Int Open 4:E391–E396CrossRefGoogle Scholar
  23. 23.
    Khalid A, Zahid M, Finkelstein SD et al (2009) Pancreatic cyst fluid DNA analysis in evaluating pancreatic cysts: a report of the PANDA study. Gastrointest Endosc 69:1095–1102CrossRefGoogle Scholar
  24. 24.
    Winner M, Sethi A, Poneros JM et al (2015) The role of molecular analysis in the diagnosis and surveillance of pancreatic cystic neoplasms. JOP 16:143–149PubMedGoogle Scholar
  25. 25.
    Nilsson LN, Keane MG, Shamali A et al (2016) Nature and management of pancreatic mucinous cystic neoplasm (MCN): a systematic review of the literature. Pancreatology 16:1028–1036CrossRefGoogle Scholar
  26. 26.
    Jais B, Rebours V, Malleo G et al (2016) Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). Gut 65:305–312CrossRefGoogle Scholar
  27. 27.
    Reid MD, Choi HJ, Memis B et al (2015) Serous neoplasms of the pancreas: a clinicopathologic analysis of 193 cases and literature review with new insights on macrocystic and solid variants and critical reappraisal of so-called “serous cystadenocarcinoma”. Am J Surg Pathol 39:1597–1610CrossRefGoogle Scholar
  28. 28.
    Das A, Wells CD, Nguyen CC (2008) Incidental cystic neoplasms of pancreas: what is the optimal interval of imaging surveillance? Am J Gastroenterol 103:1657–1662CrossRefGoogle Scholar
  29. 29.
    Del Chiaro M, Ateeb Z, Hansson MR et al (2017) Survival analysis and risk for progression of intraductal papillary mucinous neoplasia of the pancreas (IPMN) under surveillance: a single-institution experience. Ann Surg Oncol 24:1120–1126CrossRefGoogle Scholar
  30. 30.
    Morris-Stiff G, Falk GA, Chalikonda S et al (2013) Natural history of asymptomatic pancreatic cystic neoplasms. HPB (Oxford) 15:175–181CrossRefGoogle Scholar
  31. 31.
    Rosendahl J, Mössner J (2014) Intraduktale papillär-muzinöse Neoplasien des Pankreas. Dtsch Med Wochenschr 139(17):894–897CrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019

Authors and Affiliations

  1. 1.Klinik für Innere Medizin IUniversitätsklinikum Halle (Saale)Halle (Saale)Deutschland

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