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Resektion von Hauptgang- und Mischtyp-IPMN ≥5 mm

Resection of main duct and mixed type IPMN ≥5 mm

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Zusammenfassung

Durch den Fortschritt in der Bildgebung werden immer mehr zystische Pankreasläsionen zufällig diagnostiziert. Unter den zystischen Pankreasläsionen nehmen dabei intraduktale papillär-muzinöse Neoplasien (IPMN) aufgrund ihres malignen Entartungspotenzials immer mehr eine wichtigere Rolle ein und die weitere Therapie bzw. Resektion muss sorgfältig abgewogen werden. Für die Diagnostik sollte stets eine Schnittbildgebung wie Computertomographie (CT) und/oder Magnetresonanztomographie (MRT) mit MR-Cholangiopankreatikographie (MRCP) durchgeführt werden. Ergänzend sollte eine Endosonographie (EUS) mit Punktion der zystischen Raumforderung erfolgen. Die Punktionsanalyse von Biomarkern wie GNAS- sowie KRAS-Mutationen oder das Verhältnis von Neutrophilen zu Lymphozyten (NLR) kann zur Differenzialdiagnose eingesetzt werden; diese spielen beim Hauptgang- und Mischtyp-IPMN derzeit jedoch noch eine untergeordnete Rolle. Die aktuellen Leitlinien (Fukuoka- und EU-Leitlinie) empfehlen beim Hauptgang- und Mischtyp-IPMN eine Resektion nach onkologischen Standards. Der Cut-off der Hauptgangdilatation liegt derzeit zwischen 5–10 mm, wird jedoch in den neusten Studien auf ≥5 mm reduziert, um einer potenziellen malignen Transformation vorzugreifen. Patientenalter und Komorbiditäten sind wichtige Parameter, welche bei der Interventionsentscheidung eine gewichtige Rolle spielen. Bei der Resektion sollten intraoperative Schnellschnittuntersuchungen des Gangepithels durchgeführt werden, um im Falle einer High-grade-Dysplasie im Absetzungsrand eine Nachresektion durchzuführen. Die Überwachung sollte bei potenziellen Risikokandidaten in regelmäßigen Abständen von 6 bis 12 Monaten erfolgen. Patienten mit malignem IPMN sollten analog zum Pankreaskarzinom nachgesorgt werden. Ein Screening für extrapankreatische Karzinome ist beim IPMN nicht erforderlich.

Abstract

The incidence of cystic pancreatic lesions is steadily increasing due to the technical advances in imaging. Within the group of cystic pancreatic lesions intraductal papillary mucinous neoplasms (IPMNs) depict an important entity. Due to a possible progression to malignancy the clinical strategy has to be well chosen. For primary diagnostic work-up imaging by magnetic resonance imaging (MRI) with MR cholangiopancreatography (MRCP) and computed tomography (CT) scanning is recommended. Additional information can be gained by endosonography and a biopsy of the cystic lesion, allowing analysis of biomarkers, such as GNAS and KRAS mutation as wells as NLR. These can help to differentiate between IPMN and other cystic lesions although the clinical importance for the diagnosis of main duct (MD) and mixed IPMN is limited. The current guidelines (Fukuoka and EU guidelines) recommend resection of MD and mixed IPMN following oncological standards. For the definition of MD-IPMN, a duct dilatation between 5–10 mm is needed when following the current guidelines; however, current publications claim an even lower cut-off of ≥5 mm due to the risk of malignant progression. Intraoperative frozen sections are recommended to evaluate the margins status and extended resection is recommended for residual high-grade dysplasia. Surveillance of potentially at risk patients is recommended at regular intervals of 6–12 months while patients with malignant IPMN should be followed according to pancreatic cancer protocols. A screening for extrapancreatic malignancy is not indicated.

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Authors and Affiliations

  1. Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, Technischen Universität München, Ismaninger Str. 22, 81675, München, Deutschland

    G. O. Ceyhan, F. Scheufele &  H. Friess

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  1. G. O. Ceyhan
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  2. F. Scheufele
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  3. H. Friess
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Correspondence to H. Friess.

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G. O. Ceyhan, F. Scheufele und H. Friess geben an, dass kein Interessenkonflikt besteht.

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

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Ceyhan, G.O., Scheufele, F. & Friess, H. Resektion von Hauptgang- und Mischtyp-IPMN ≥5 mm. Chirurg 88, 913–917 (2017). https://doi.org/10.1007/s00104-017-0494-0

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