Operationsindikationen bei zystischen Tumoren des Pankreas

Zusammenfassung

Eine stetige Verbesserung der modernen Bildgebung sowie ein steigendes Alter in der Gesellschaft haben dazu geführt, dass zunehmend häufiger zystische Pankreastumoren detektiert werden. Zystische Pankreasraumforderungen stellen eine klinisch herausfordernde Entität dar, da sie ein breites biologisches Spektrum umfassen und ihre Differenzierung untereinander vor allem bei kleinen Tumoren häufig schwierig ist. Sie bedingen daher eine differenzierte Operationsindikationsstellung. Zur Bestimmung von Empfehlungen zur Operationsindikation bei zystischen Tumoren des Pankreas wurde von einer Qualitätskommission für Pankreaserkrankungen der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie eine systematische Literaturrecherche durchgeführt und daraus resultierend folgende Übersichtsarbeit erstellt. Auf Grundlage der aktuellen Evidenz besteht bei Vorliegen von Malignitätszeichen oder Hochrisikokriterien (Ikterus bei Obstruktion des Ductus choledochus durch die zystische Pankreasläsion, kontrastmittelaufnehmende intramurale Knoten ≥ 5 mm oder solide Komponenten in der Zyste oder Pankreashauptgang ≥ 10 mm) sowie bei Symptomen unabhängig von der Zystenentität (ausgenommen Pankreaspseudozysten) eine Operationsindikation. Ist die Entität der Pankreaszyste mittels bildgebender Diagnostik eruierbar, so sollten alle intraduktalen papillär-muzinösen Neoplasien (IPMN) vom Hauptgang und vom Mischtyp, alle muzinös-zystischen Neoplasien (MCN) > 4 cm sowie alle soliden pseudopapillären Neoplasien (SPN) reseziert werden. Serös-zystische Neoplasien (SCN) und Seitengang-IPMN ohne Risikokriterien stellen primär keine Operationsindikation dar. Die Operationsindikationsstellung bei Seitengang-IPMN mit relativen Risikokriterien und MCN < 4 cm ist Gegenstand aktueller Diskussionen und sollte individuell erfolgen. Die vorliegende Arbeit soll durch ein Herausarbeiten von Indikationsempfehlungen helfen, die Indikationsqualität bei zystischen Pankreastumoren zu verbessern. Die letztendliche Operationsindikationsstellung sollte jedoch immer individualisiert unter Berücksichtigung von Alter, Komorbiditäten und Patientenwunsch erfolgen.

Abstract

A steady improvement in modern imaging as well as increasing age in society have led to an increasing number of cystic pancreatic tumours being detected. Pancreatic cysts are a clinically challenging entity because they span a broad biological spectrum and their differentiation is often difficult, especially in small tumours. Therefore, they require a differentiated indication for indication of surgery. To determine recommendations for the surgical indication in cystic tumours of the pancreas, a quality committee for pancreatic diseases of the German Society for General and Visceral Surgery performed a systematic literature search and created this review. Based on the current evidence, signs of malignancy and high-risk criteria (icterus due to cystic pancreatic duct obstruction in the bile duct, enhancing mural nodules ≥ 5 mm or solid components in the cyst or pancreatic duct ≥ 10 mm), as well as symptoms, are a surgical indication, independently of the cyst entity (except pseudocysts). If the entity of the pancreatic cyst is detectable by diagnostic imaging, all main duct IPMN and IPMN of the mixed type, all MCN > 4 cm and all SPN should be resected. SCN and branch-duct IPMN without worrisome features do not constitute an indication for surgery. The indication of operation in branch-duct IPMN with relative risk criteria and MCN < 4 cm is the subject of current discussions and should be individualised. By defining indication recommendations, the present work aims to improve the indication quality in cystic pancreatic tumours. However, the surgical indication should always be individualised, taking into account age, comorbidities and the patientʼs wishes.

Schlüsselwörter

Pankreaschirurgie - Pankreaszysten - Operationsindikation - zystische Pankreasneoplasie

Key words

pancreatic cysts - cystic pancreas neoplasm - indication for the surgical management - pancreatic surgery

Publication History

Article published online:
04 June 2020

• Literatur

• 1 Tanaka M, Fernández-del Castillo C, Adsay V. et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12: 183-197 doi:10.1016/j.pan.2012.04.004
• 2 Kromrey ML, Bülow R, Hübner J. et al. Prospective study on the incidence, prevalence and 5-year pancreatic-related mortality of pancreatic cysts in a population-based study. Gut 2018; 67: 138-145 doi:10.1136/gutjnl-2016-313127
• 3 de Jong K, Nio CY, Hermans JJ. et al. High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol 2010; 8: 806-811 doi:10.1016/j.cgh.2010.05.017
• 4 Laffan TA, Horton KM, Klein AP. et al. Prevalence of unsuspected pancreatic cysts on MDCT. AJR Am J Roentgenol 2008; 191: 802-807 doi:10.2214/AJR.07.3340
• 5 Zhang XM, Mitchell DG, Dohke M. et al. Pancreatic cysts: depiction on single-shot fast spin-echo MR images. Radiology 2002; 223: 547-553
• 6 Chang YR, Park JK, Jang JY. et al. Incidental pancreatic cystic neoplasms in an asymptomatic healthy population of 21,745 individuals: Large-scale, single-center cohort study. Medicine (Baltimore) 2016; 95: e5535 doi:10.1097/MD.0000000000005535
• 7 Lee KS, Sekhar A, Rofsky NM. et al. Prevalence of incidental pancreatic cysts in the adult population on MR imaging. Am J Gastroenterol 2010; 105: 2079-2084 doi:10.1038/ajg.2010.122
• 8 Girometti R, Intini S, Brondani G. et al. Incidental pancreatic cysts on 3D turbo spin echo magnetic resonance cholangiopancreatography: prevalence and relation with clinical and imaging features. Abdom Imaging 2011; 36: 196-205 doi:10.1007/s00261-010-9618-4
• 9 Ip IK, Mortele KJ, Prevedello LM. et al. Focal cystic pancreatic lesions: assessing variation in radiologistsʼ management recommendations. Radiology 2011; 259: 136-141 doi:10.1148/radiol.10100970
• 10 DʼHaese JG, Werner J. Surgery of cystic tumors of the pancreas – why, when, and how?. Visc Med 2018; 34: 206-210 doi:10.1159/000489234
• 11 Hruban RH, Kloeppel G, Bofetta P. et al. Tumours of the Pancreas. In: Bosman FT, Carneiro F, Hruban RH. eds. WHO Classification of Tumours of the digestive System, 4th ed. Lyon: International Agency for Research on Cancer; 2010: 280-330
• 12 Grützmann R, Post S, Saeger HD. et al. Intraductal papillary mucinous neoplasia (IPMN) of the pancreas: its diagnosis, treatment, and prognosis. Dtsch Arztebl Int 2011; 108: 788-794 doi:10.3238/arztebl.2011.0788
• 13 Distler M, Welsch T, Aust D. et al. [Intraductal papillary mucinous neoplasm of the pancreas (IPMN)–standards and new aspects]. Zentralbl Chir 2014; 139: 308-317 doi:10.1055/s-0033-1350892
• 14 Del Chiaro M, Segersvärd R, Pozzi Mucelli R. et al. Comparison of preoperative conference-based diagnosis with histology of cystic tumors of the pancreas. Ann Surg Oncol 2014; 21: 1539-1544 doi:10.1245/s10434-013-3465-9
• 15 Correa-Gallego C, Ferrone CR, Thayer SP. et al. Incidental pancreatic cysts: do we really know what we are watching?. Pancreatology 2010; 10: 144-150 doi:10.1159/000243733
• 16 Sahani DV, Sainani NI, Blake MA. et al. Prospective evaluation of reader performance on MDCT in characterization of cystic pancreatic lesions and prediction of cyst biologic aggressiveness. AJR Am J Roentgenol 2011; 197: W53-W61 doi:10.2214/AJR.10.5866
• 17 Del Chiaro M, Segersvärd R, Lohr M. et al. Early detection and prevention of pancreatic cancer: is it really possible today?. World J Gastroenterol 2014; 20: 12118-12131 doi:10.3748/wjg.v20.i34.12118
• 18 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin 2019; 69: 7-34 doi:10.3322/caac.21551
• 19 Nimptsch U, Krautz C, Weber GF. et al. Nationwide in-hospital mortality following pancreatic surgery in Germany is higher than anticipated. Ann Surg 2016; 264: 1082-1090
• 20 Crippa S, Capurso G, Cammà C. et al. Risk of pancreatic malignancy and mortality in branch-duct IPMNs undergoing surveillance: a systematic review and meta-analysis. Dig Liver Dis 2016; 48: 473-479 doi:10.1016/j.dld.2016.02.003
• 21 Del Chiaro M, Ateeb Z, Hansson MR. et al. Survival analysis and risk for progression of intraductal papillary mucinous neoplasia of the pancreas (IPMN) under surveillance: a single-institution experience. Ann Surg Oncol 2017; 24: 1120-1126 doi:10.1245/s10434-016-5661-x
• 22 Lafemina J, Katabi N, Klimstra D. et al. Malignant progression in IPMN: a cohort analysis of patients initially selected for resection or observation. Ann Surg Oncol 2013; 20: 440-447 doi:10.1245/s10434-012-2702-y
• 23 Cauley CE, Waters JA, Dumas RP. et al. Outcomes of primary surveillance for intraductal papillary mucinous neoplasm. J Gastrointest Surg 2012; 16: 258-267 doi:10.1007/s11605-011-1757-6
• 24 Krautz C, Nimptsch U, Weber GF. et al. Effect of hospital volume on in-hospital morbidity and mortality following pancreatic surgery in Germany. Ann Surg 2018; 267: 411-417 doi:10.1097/SLA.0000000000002248
• 25 European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67: 789-804 doi:10.1136/gutjnl-2018-316027
• 26 Tanaka M, Fernández-Del Castillo C, Kamisawa T. et al. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017; 17: 738-753 doi:10.1016/j.pan.2017.07.007
• 27 Vege SS, Ziring B, Jain R. et al. Clinical Guidelines Committee; American Gastroenterology Association. American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148: 819-822 doi:10.1053/j.gastro.2015.01.015
• 28 Sahora K, Mino-Kenudson M, Brugge W. et al. Branch duct intraductal papillary mucinous neoplasms: does cyst size change the tip of the scale? A critical analysis of the revised international consensus guidelines in a large single-institutional series. Ann Surg 2013; 258: 466-475 doi:10.1097/SLA.0b013e3182a18f48
• 29 Fritz S, Klauss M, Bergmann F. et al. Pancreatic main-duct involvement in branch-duct IPMNs: an underestimated risk. Ann Surg 2014; 260: 848-855 doi:10.1097/SLA.0000000000000980
• 30 Aso T, Ohtsuka T, Matsunaga T. et al. “High-risk stigmata” of the 2012 international consensus guidelines correlate with the malignant grade of branch duct intraductal papillary mucinous neoplasms of the pancreas. Pancreas 2014; 43: 1239-1243 doi:10.1097/MPA.0000000000000199
• 31 Nguyen AH, Toste PA, Farrell JJ. et al. Current recommendations for surveillance and surgery of intraductal papillary mucinous neoplasms may overlook some patients with cancer. J Gastrointest Surg 2015; 19: 258-265 doi:10.1007/s11605-014-2693-z
• 32 Roch AM, Ceppa EP, DeWitt JM. et al. International Consensus Guidelines parameters for the prediction of malignancy in intraductal papillary mucinous neoplasm are not properly weighted and are not cumulative. HPB (Oxford) 2014; 16: 929-935 doi:10.1111/hpb.12305
• 33 Goh BK, Thng CH, Tan DM. et al. Evaluation of the Sendai and 2012 International Consensus Guidelines based on cross-sectional imaging findings performed for the initial triage of mucinous cystic lesions of the pancreas: a single institution experience with 114 surgically treated patients. Am J Surg 2014; 208: 202-209 doi:10.1016/j.amjsurg.2013.09.031
• 34 Dortch JD, Stauffer JA, Asbun HJ. Pancreatic resection for side-branch intraductal papillary mucinous neoplasm (SB-IPMN): a contemporary single-institution experience. J Gastrointest Surg 2015; 19: 1603-1609 doi:10.1007/s11605-015-2851-y
• 35 Robles EP, Maire F, Cros J. et al. Accuracy of 2012 International Consensus Guidelines for the prediction of malignancy of branch-duct intraductal papillary mucinous neoplasms of the pancreas. United European Gastroenterol J 2016; 4: 580-586 doi:10.1177/2050640615623370
• 36 Seo N, Byun JH, Kim JH. et al. Validation of the 2012 International Consensus Guidelines using computed tomography and magnetic resonance imaging: branch duct and main duct intraductal papillary mucinous neoplasms of the pancreas. Ann Surg 2016; 263: 557-564 doi:10.1097/SLA.0000000000001217
• 37 Hackert T, Fritz S, Klauss M. et al. Main-duct intraductal papillary mucinous neoplasm: high cancer risk in duct diameter of 5 to 9 mm. Ann Surg 2015; 262: 875-880 doi:10.1097/SLA.0000000000001462
• 38 Abdeljawad K, Vemulapalli KC, Schmidt CM. et al. Prevalence of malignancy in patients with pure main duct intraductal papillary mucinous neoplasms. Gastrointest Endosc 2014; 79: 623-629 doi:10.1016/j.gie.2013.08.024
• 39 Hirono S, Tani M, Kawai M. et al. The carcinoembryonic antigen level in pancreatic juice and mural nodule size are predictors of malignancy for branch duct type intraductal papillary mucinous neoplasms of the pancreas. Ann Surg 2012; 255: 517-522 doi:10.1097/SLA.0b013e3182444231
• 40 Kawada N, Uehara H, Nagata S. et al. Mural nodule of 10 mm or larger as predictor of malignancy for intraductal papillary mucinous neoplasm of the pancreas: pathological and radiological evaluations. Pancreatology 2016; 16: 441-448 doi:10.1016/j.pan.2015.12.008
• 41 Kobayashi N, Sugimori K, Shimamura T. et al. Endoscopic ultrasonographic findings predict the risk of carcinoma in branch duct intraductal papillary mucinous neoplasms of the pancreas. Pancreatology 2012; 12: 141-145 doi:10.1016/j.pan.2011.12.008
• 42 Shimizu Y, Yamaue H, Maguchi H. et al. Predictors of malignancy in intraductal papillary mucinous neoplasm of the pancreas: analysis of 310 pancreatic resection patients at multiple high-volume centers. Pancreas 2013; 42: 883-888 doi:10.1097/MPA.0b013e31827a7b84
• 43 Crippa S, Bassi C, Salvia R. et al. Low progression of intraductal papillary mucinous neoplasms with worrisome features and high-risk stigmata undergoing non-operative management: a mid-term follow-up analysis. Gut 2017; 66: 495-506 doi:10.1136/gutjnl-2015-310162
• 44 Kang MJ, Jang JY, Kim SJ. et al. Cyst growth rate predicts malignancy in patients with branch duct intraductal papillary mucinous neoplasms. Clin Gastroenterol Hepatol 2011; 9: 87-93 doi:10.1016/j.cgh.2010.09.008
• 45 Kwong WT, Lawson RD, Hunt G. et al. Rapid growth rates of suspected pancreatic cyst branch duct intraductal papillary mucinous neoplasms predict malignancy. Dig Dis Sci 2015; 60: 2800-2806 doi:10.1007/s10620-015-3679-8
• 46 Tanaka M. Thirty years of experience with intraductal papillary mucinous neoplasm of the pancreas: from discovery to international consensus. Digestion 2014; 90: 265-272 doi:10.1159/000370111
• 47 Tian X, Gao H, Ma Y. et al. Surgical treatment and prognosis of 96 cases of intraductal papillary mucinous neoplasms of the pancreas: a retrospective cohort study. Int J Surg 2015; 13: 49-53 doi:10.1016/j.ijsu.2014.11.028
• 48 Brunner M, Weber GF, Kersting S. et al. [Branch duct intraductal papillary mucinous neoplasm – contra resection]. Chirurg 2017; 88: 918-926 doi:10.1007/s00104-017-0495-z
• 49 Malleo G, Marchegiani G, Borin A. et al. Observational study of the incidence of pancreatic and extrapancreatic malignancies during surveillance of patients with branch-duct intraductal papillary mucinous neoplasm. Ann Surg 2015; 261: 984-990 doi:10.1097/SLA.0000000000000884
• 50 Lévy P, Jouannaud V, OʼToole D. et al. Natural history of intraductal papillary mucinous tumors of the pancreas: actuarial risk of malignancy. Clin Gastroenterol Hepatol 2006; 4: 460-468
• 51 Tanno S, Nakano Y, Nishikawa T. et al. Natural history of branch duct intraductal papillary-mucinous neoplasms of the pancreas without mural nodules: long-term follow-up results. Gut 2008; 57: 339-343
• 52 Uehara H, Nakaizumi A, Ishikawa O. et al. Development of ductal carcinoma of the pancreas during follow-up of branch duct intraductal papillary mucinous neoplasm of the pancreas. Gut 2008; 57: 1561-1565 doi:10.1136/gut.2007.145631
• 53 Hu Y, Johnston LE, Shami VM. et al. Comparative effectiveness of resection vs. surveillance for pancreatic branch duct intraductal papillary mucinous neoplasms with worrisome features. JAMA Surg 2018; 153: 225-232 doi:10.1001/jamasurg.2017.4587
• 54 Schmidt CM, White PB, Waters JA. et al. Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann Surg 2007; 246: 644-651
• 55 Rodriguez JR, Salvia R, Crippa S. et al. Branch-duct intraductal papillary mucinous neoplasms: observations in 145 patients who underwent resection. Gastroenterology 2007; 133: 72-79
• 56 Keane MG, Shamali A, Nilsson LN. et al. Risk of malignancy in resected pancreatic mucinous cystic neoplasms. Br J Surg 2018; 105: 439-446 doi:10.1002/bjs.10787
• 57 Postlewait LM, Ethun CG, McInnis MR. et al. Association of preoperative risk factors with malignancy in pancreatic mucinous cystic neoplasms: a multicenter study. JAMA Surg 2017; 152: 19-25 doi:10.1001/jamasurg.2016.3598
• 58 Jais B, Rebours V, Malleo G. et al. Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). Gut 2016; 65: 305-312 doi:10.1136/gutjnl-2015-309638
• 59 Pelaez-Luna MC, Moctezuma-Velázquez C, Hernández-Calleros J. et al. Serous cystadenomas follow a benign and asymptomatic course and do not present a significant size change during follow-up. Rev Invest Clin 2015; 67: 344-349
• 60 Das A, Wells CD, Nguyen CC. Incidental cystic neoplasms of pancreas: what is the optimal interval of imaging surveillance?. Am J Gastroenterol 2008; 103: 1657-1662 doi:10.1111/j.1572-0241.2008.01893.x
• 61 Kim MJ, Choi DW, Choi SH. et al. Surgical treatment of solid pseudopapillary neoplasms of the pancreas and risk factors for malignancy. Br J Surg 2014; 101: 1266-1271 doi:10.1002/bjs.9577
• 62 Cai YQ, Xie SM, Ran X. et al. Solid pseudopapillary tumor of the pancreas in male patients: report of 16 cases. World J Gastroenterol 2014; 20: 6939-6945 doi:10.3748/wjg.v20.i22.6939
• 63 Liu M, Liu J, Hu Q. et al. Management of solid pseudopapillary neoplasms of pancreas: a single center experience of 243 consecutive patients. Pancreatology 2019; 19: 681-685 doi:10.1016/j.pan.2019.07.001
• 64 Cizginer S, Turner BG, Bilge AR. et al. Cyst fluid carcinoembryonic antigen is an accurate diagnostic marker of pancreatic mucinous cysts. Pancreas 2011; 40: 1024-1028 doi:10.1097/MPA.0b013e31821bd62f
• 65 Gaddam S, Ge PS, Keach JW. et al. Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study. Gastrointest Endosc 2015; 82: 1060-1069 doi:10.1016/j.gie.2015.04.040
• 66 Jin DX, Small AJ, Vollmer CM. et al. A lower cyst fluid CEA cut-off increases diagnostic accuracy in identifying mucinous pancreatic cystic lesions. Pancreas 2015; 16: 271-272
• 67 Werner J, Fritz S, Büchler MW. Intraductal papillary mucinous neoplasms of the pancreas–a surgical disease. Nat Rev Gastroenterol Hepatol 2012; 9: 253-259 doi:10.1038/nrgastro.2012.31
• 68 Zeh HJ, Zureikat AH, Secrest A. et al. Outcomes after robot-assisted pancreaticoduodenectomy for periampullary lesions. Ann Surg Oncol 2012; 19: 864-870 doi:10.1245/s10434-011-2045-0
• 69 Moekotte AL, Rawashdeh A, Asbun HJ. et al. Safe implementation of minimally invasive pancreas resection: a systematic review. HPB (Oxford) 2019;