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Chirurgische Therapie intraduktaler papillär muzinöser Neoplasien des Pankreas

Surgical therapy of intraductal papillary mucinous neoplasms of the pancreas

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Zusammenfassung

Intraduktale papillär muzinöse Neoplasien (IPMNs) des Pankreas werden heute in zunehmendem Maße diagnostiziert und zeichnen sich durch zystische Formationen, Produktion von Mukus und intraepithelialem Wachstum in den Pankreasgängen aus. IPMNs können eine Vielzahl von morphologischen Variationen aufweisen und gehen entweder vom Pankreashauptgang, von seinen größeren Seitenästen oder von beidem aus (sog. Mischtyp). Darüber hinaus werden IPMNs als Präkanzerosen angesehen, welche sich bis hin zum Pankreasadenokarzinom entwickeln können. Bis heute ist allerdings nicht bekannt, ob alle IPMNs das Potenzial zur neoplastischen Transformation besitzen und wie der zeitliche Ablauf einer solchen Entwicklung aussieht. Aufgrund der heute fehlenden sicheren Differenzierung zwischen benignen und malignen IPMNs ist für die Mehrzahl aller neu diagnostizierten Tumoren eine chirurgische Resektion indiziert. Gemäß den aktuellen Therapieempfehlungen (Sendai-Kriterien) sollten lediglich asymptomatische Seitengang-IPMNs mit weniger als 3 cm Durchmesser ohne radiologisch auffällige Merkmale wie beispielsweise Knoten, Wandverdickungen und ohne Anhalt für Größenprogression beobachtet, jedoch nicht reseziert werden. Allerdings sind diese Therapierichtlinien in den letzten Jahren zunehmend kritisch bewertet worden, da auch sog. „Sendai-negative“ IPMNs nach histologischer Aufarbeitung bereits in vielen Fällen Zeichen einer malignen Transformation aufweisen. Der vorliegende Bericht fasst die Indikation und die operative Therapie von IPMNs nach heutigem Kenntnisstand zusammen.

Abstract

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas constitute an increasingly recognized entity of cystic pancreatic tumors which are characterized by mucin production and epithelial growth within the pancreatic ducts and show a wide spectrum of morphologic variants. They may arise in the main pancreatic duct, its major side branches or in both (mixed type). Furthermore, IPMNs are considered as precursor lesions to pancreatic adenocarcinoma. However, it is not clear what the time course of such potential neoplastic transformation might be and whether all lesions progress to malignant tumors. As currently no diagnostic test can reliably differentiate between benign and malignant tumors the majority of newly diagnosed IPMNs should be surgically resected. According to current treatment guidelines (Sendai criteria), only asymptomatic side branch IPMNs of less than 3 cm in diameter without suspicious radiologic features, such as nodules, thickness of the cystic wall or size progression, should be treated conservatively without the need for surgical resection. Recently, this approach has become controversial due to a relevant number of reported Sendai negative IPMNs which revealed malignant transformation on final histological examination. The focus of this review is on the surgical treatment of IPMNs with regard to the current state of knowledge.

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  1. Abteilung für Allgemein-, Viszeral und Transplantationschirurgie, Universität Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    S. Fritz,  M.W. Büchler & J. Werner

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  1. S. Fritz
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  2. M.W. Büchler
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  3. J. Werner
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Correspondence to M.W. Büchler.

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Fritz, S., Büchler, M. & Werner, J. Chirurgische Therapie intraduktaler papillär muzinöser Neoplasien des Pankreas. Chirurg 83, 130–135 (2012). https://doi.org/10.1007/s00104-011-2184-7

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