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Indikationsqualität bei zystischen Läsionen des Pankreas

Quality of indications in cystic lesions of the pancreas

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Zusammenfassung

Im aktuellen klinischen Alltag haben zystische Pankreasläsionen (PCNs) einen zunehmend relevanten Stellenwert, da sie aufgrund der sich stetig verbessernden Bildgebung häufig als Zufallsbefund diagnostiziert werden. Man unterscheidet zwischen nichtneoplastischen und neoplastischen Pankreaszysten, wobei letztere in unterschiedlicher Ausprägung zur malignen Entartung neigen und damit als Vorläuferläsionen des duktalen Adenokarzinoms des Pankreas (PDAC) gelten. Zur Differenzialdiagnose werden neben einer genauen Anamnese und Untersuchung vor allem bildgebende Verfahren wie die Computertomographie (CT) und Magnetresonanztomographie (MRT) sowie der endoskopische Ultraschall mit Feinnadelaspiration herangezogen. Die Indikationen zur chirurgischen Resektion dieser Läsionen richten sich nach den aktuellen europäischen Leitlinien, deren Inhalte sind jedoch nicht evidenzbasiert, sondern stützen sich auf Erkenntnisse und Empfehlungen von Experten. Gemäß den Konsensusempfehlungen kann die asymptomatische serös-zystische Neoplasie (SCN) als seröse Läsion mit niedriger Tendenz zur Entartung beobachtet werden. Im Gegensatz dazu sollten alle muzinös-zystischen Neoplasien (MCN) >4 cm sowie alle solid-pseudopapillären Neoplasien (SPN) reseziert werden. Intraduktal papillär-muzinöse Neoplasien (IPMNs), die aufgrund ihres Bezugs zum Pankreasgangsystem in Haupt(MD)- oder Seitengang(BD)-IPMNs unterteilt werden, sollten als MD-IPMN und als Mixed-type(MT)-IPMN reseziert werden. Das Entartungsrisiko der BD-IPMN ist variabler und abhängig von Risikofaktoren, die klinisch und bildmorphologisch definiert werden. Das therapeutische Management erfolgt daher individuell nach Risikoabschätzung. Um die Indikationsqualität bei PCNs quantifizieren zu können und damit auch zu einer optimierten Versorgung beizutragen, werden dringend prospektive Langzeitstudien benötigt.

Abstract

Cystic tumors of the pancreas (PCN) have increasingly gained importance in the clinical routine as they are frequently diagnosed as an incidental finding due to the continuous improvement in cross-sectional imaging. A differentiation is made between non-neoplastic and neoplastic cysts, whereby the latter has a tendency to malignant transformation to a varying extent. Therefore, they can be considered as precursor lesions of pancreatic cancer (PDAC). In addition to a detailed patient history and examination, imaging modalities, such as computed tomography (CT), magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) with fine needle aspiration (FNA) are used for the differential diagnosis. The indications for surgical resection of these lesions are based on the current European guidelines from 2018; however, the content is not evidence-based but relies on knowledge and recommendations from experts. According to these consensus recommendations asymptomatic serous cystic neoplasms (SCN) are serous lesions with a low tendency for malignant transformation and can be monitored. In contrast resection is warranted for all mucinous cystic neoplasms (MCN) >4 cm and all solid pseudopapillary neoplasms (SPN). Intraductal papillary mucinous neoplasms (IPMN), which are differentiated into main duct (MD-IPMN) and branch duct type (BD-IPMN) IPMN based on the position in the pancreatic duct system, should be resected as MD-IPMN and mixed type (MT)-IPMN. The risk of malignant transformation in BD-IPMN is variable and depends on risk factors, which are defined clinically and by imaging morphology. The treatment management is therefore carried out on an individual basis following risk estimation. In order to quantify the quality of indications in PCN and thereby also contributing to optimized medical care, prospective long-term studies are urgently needed.

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  1. Klinik für Allgemein, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Standort Großhadern, Marchioninistr. 15, 81377, München, Deutschland

    B. W. Renz, M. Ilmer, J. G. D’Haese &  J. Werner

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B. W. Renz, M. Ilmer, J. G. D’Haese und J. Werner geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Die Autoren B. W. Renz und M. Ilmer waren zu gleichen Teilen an der Erstellung des Manuskriptes beteiligt.

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Renz, B.W., Ilmer, M., D’Haese, J.G. et al. Indikationsqualität bei zystischen Läsionen des Pankreas. Chirurg 91, 736–742 (2020). https://doi.org/10.1007/s00104-020-01217-4

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