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Intraduktal papillär muzinöse Neoplasie: Welche Befunde sprechen für Beobachtung?

Intraductal papillary mucinous neoplasia: which findings support observation?

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Zusammenfassung

In 1–2% aller CT-Untersuchungen des Abdomens findet sich eine zystische Läsion des Pankreas als Zufallsbefund. Mehr als zwei Drittel dieser Läsionen sind dysontogenetische Zysten oder Pankreaspseudozysten. An echten zystischen Neoplasien finden sich, zumindest in den Resektionsstatistiken, 30% seröse Zystadenome, 45% muzinös zystische Tumoren und 25% intraduktale papillär muzinöse Neoplasien. Die Diagnose einer zystischen Läsion des Pankreas erfolgt meist bildgebend. Symptomatische Läsionen müssen nach entsprechender Diagnostik einer definitiven Therapie zugeführt werden. Zur Einordnung der Artdiagnose bei symptomlosen Patienten ist die Frage des Ganganschlusses der zystischen Läsion (intraduktal papillär muzinöse Neoplasie [IPMN] und Pankreaspseudozyste), die der Größe (Indikation zur Resektion bei IPMN oder Therapieindikation bei Pseudozyste) und vor allem eine wandständige Knotenbildung, die auf Malignität hinweist, wesentlich. Die diagnostische Punktion einer zystischen Läsion mittels Endosonographie hilft bei der Unterscheidung zwischen benignen, potenziell malignen und malignen zystischen Läsionen. In der durch Punktion gewonnenen Zystenflüssigkeit helfen die Bestimmung von Lipase, CEA, Viskosität und Muzingehalt sowie die zytologische Untersuchung bei der Differenzierung. Differenzialdiagnostik und therapeutische Konsequenz werden anhand eines Algorithmus skizziert, wobei der meisten zystischen Läsionen keiner operativen Therapie bedürfen.

Abstract

On abdominal CT scans asymptomatic cystic lesions of the pancreas are accidentally detected in 1–2% of patients. Congenital cysts and pancreatic pseudocysts account for two thirds of these lesions. Pancreatic pseudocysts are a frequent complication of acute and chronic pancreatitis. Among resected cystic neoplasms serous cystic adenoma accounts for 30%, mucinous cystic neoplasms for 45% and intraductal papillary mucinous neoplasms for 25%. The diagnosis of a cystic pancreatic lesion is usually made by diagnostic imaging. Symptomatic lesions require definitive therapeutic treatment after appropriate diagnostic work-up. In the diagnosis of asymptomatic cystic lesions several factors are important, among them whether the cyst is connected to the pancreatic duct (as in IPMN and pseudocysts), the size of lesion (for treatment indications) and whether nodules form in the wall of the cyst (a sign of potential malignancy). EUS-guided fine needle aspiration of the cyst fluid adds to the discrimination between benign, premalignant and malignant cystic lesions. Measuring lipase activity, CEA, viscosity and mucin as well as cytology can help in differentiating cystic lesions. An algorithm is discussed for the differential diagnosis and for selection of the appropriate treatment for pancreatic cystic lesions, most of which never require surgery.

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Authors and Affiliations

  1. Klinik für Innere Medizin A, Universitätsmedizin der Ernst-Moritz-Arndt-Universität, Friedrich-Loeffler-Str. 23a, 17475, Greifswald, Deutschland

    J. Mayerle, M. Kraft, P. Simon, J. Ringel &  M.M. Lerch

  2. Klinik für Allgemein-, Viszeral-, Thorax- und Gefässchirurgie, Universitätsmedizin der Ernst-Moritz-Arndt-Universität, Greifswald, Deutschland

    P. Menges, L.I. Partecke & C.D. Heidecke

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  1. J. Mayerle
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  2. M. Kraft
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  3. P. Menges
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  6. L.I. Partecke
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Correspondence to M.M. Lerch.

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Mayerle, J., Kraft, M., Menges, P. et al. Intraduktal papillär muzinöse Neoplasie: Welche Befunde sprechen für Beobachtung?. Chirurg 83, 123–129 (2012). https://doi.org/10.1007/s00104-011-2183-8

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