Zusammenfassung
Zystische Läsionen des Pankreas werden heute aufgrund des steigenden Lebensalters und moderner Schnittbildverfahren zunehmend häufig diagnostiziert. Intraduktale papillär-muzinöse Neoplasien (IPMN), muzinöse zystische Neoplasien (MCN), solide pseudopapilläre Neoplasien (SPN) sowie seröse zystische Neoplasien (SCN) machen insgesamt über 90 % der zystischen Neoplasien aus. Während seröse Zysten ein geringes Malignitätspotenzial haben und somit nur bei Symptomen reseziert werden sollten, haben alle muzinösen Neoplasien ein erhöhtes Malignitätspotenzial, das eine Resektion in der Regel erforderlich macht. Nur bei IPMNs wird diese klare Indikation zur Resektion differenziert diskutiert. IPMNs können eine Vielzahl von morphologischen Variationen aufweisen und gehen entweder vom Pankreashauptgang, von seinen größeren Seitenästen oder von beidem aus (sog. Mischtyp). 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) kann jedoch bei asymptomatischen Seitengangs-IPMNs mit weniger als 2–3 cm Durchmesser ohne Risikofaktoren wie Knoten, Wandverdickungen und ohne Anhalt für Größenprogression beobachtet und auf eine Resektion verzichtet 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.
Abstract
Cystic tumors of the pancreas are diagnosed increasingly more due to increasing life expectancy and the moderate use of modern radiological diagnostics. Intraductal papillary mucinous neoplasms of the pancreas (IPMN), mucinous cystic neoplasms (MCN), solid pseudopapillary neoplasms (SPN) and serous cystic neoplasms (SCN) represent over 90 % of all cystic neoplasms of the pancreas. Although serous cystic lesions have a low or even no potential for malignant transformation, they are mostly resected when symptomatic. In contrast, mucinous lesions have an increased malignant potential and should therefore be resected in almost all cases. While this is true for all cases of MCNs and SPNs this is controversial for all IPMNs as they show a wide spectrum of morphological variants. The IPMNs may arise in the main pancreatic duct, major side branches or in both (mixed type). Although all IPMNs are considered to be precursor lesions to pancreatic adenocarcinomas it is not clear what the time course of such potential neoplastic transformation might be and whether all lesions progress to malignant tumors. As no currently used diagnostic test can reliably differentiate between benign and malignant tumors, the majority of newly diagnosed IPMNs should undergo surgical resection. According to current treatment guidelines (Sendai criteria), asymptomatic side branch IPMNs of less than 3 cm in diameter without suspicious radiological features, such as nodules, thickness of the cystic wall or size progression can be treated conservatively without the need for surgical resection. Recently, this approach has become controversial due to a relevant number of IPMNs reported as Sendai negative that showed malignant transformation on final histological examination.
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Interessenkonflikt. W. Hartwig und J. Werner geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Hartwig, W., Werner, J. Resektion zystischer Pankreastumoren. Gastroenterologe 9, 31–37 (2014). https://doi.org/10.1007/s11377-013-0821-z
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DOI: https://doi.org/10.1007/s11377-013-0821-z
Schlüsselwörter
- Intraduktale papillär-muzinöse Neoplasien
- Operationsindikationen
- Chirurgische Therapie
- Operationsstrategien
- Sendai-Kriterien