Differenzialdiagnose und radiologisches Management von zystischen Tumoren des Pankreas

Zusammenfassung

Zystische Pankreasläsionen werden oftmals als asymptomatischer Zufallsbefund und in deutlich zunehmender Häufigkeit entdeckt. In den letzten Jahren hat sich ein deutlich differenzierteres Verständnis dieser Tumoren entwickelt Das Spektrum der relevanten Läsionen umfasst insbesondere die intraduktal papilläre muzinöse Neoplasie (IPMN), die seröse zystische Neoplasie (SZN) und die muzinöse zystische Neoplasie (MZN). Diese Tumoren lassen sich mit sicheren Kenntnissen über den histologischen und bildmorphologischen Aufbau sowie Lokalisations-, Alters- und Geschlechtsverteilung gut differenzieren und von der häufigen Pankreaspseudozyste abgrenzen. Dies schließt auch ein grundlegendes Verständnis komplementärer endoskopischer Verfahren wie der Endosonografie mit der Möglichkeit der Aspiration des Zysteninhalts ein. Viele der zystischen Pankreastumoren zeigen das Potenzial zur malignen Transformation entlang einer Adenom-Karzinom-Sequenz und erfordern deshalb eine differenzierte Betrachtungsweise des radiologischen Managements dieser Läsionen. Die vorliegende Übersicht soll ein breites Verständnis pathologischer und bildmorphologischer Charakteristika von zystischen Pankreastumoren entwickeln und gibt Empfehlungen zum Vorgehen insbesondere bei inzidentell detektierten Läsionen.

Abstract

Cystic pancreatic lesions are often discovered incidentally as an asymptomatic finding, at a rate which is increasing considerably. In recent years the understanding of such tumors has become clearly differentiated. The spectrum of relevant lesions includes in particular the intraductal papillary mucinous neoplasm (IPMN), serous cystic neoplasm (SCN) and mucinous cystic neoplasm (MCN). With certain knowledge of their histological and radiomorphological structure as well as their distribution in terms of location, age and sex, such tumors are easy to differentiate and demarcate from common pancreatic pseudocysts. This also implies the fundamental understanding of complementary endoscopic procedures such as endosonography, which enables aspiration of the content of the cyst. A number of cystic pancreatic lesions have the potential to undergo malignant transformation along the adenoma-carcinoma sequence and therefore necessitate a differentiated approach to their radiological management. This review aims to develop a broad understanding of the pathological and radiomorphological characteristics of cystic pancreatic lesions and provides advice regarding procedures, particularly with respect to incidentally detected lesions.

abdomen - pancreas - CT - MR imaging

Literatur

• 1 Brugge W R, Lauwers G Y, Sahani D et al. Cystic neoplasms of the pancreas.  N Engl J Med. 2004;  351 1218-1226
• 2 Nichols M T, Russ P D, Chen Y K. Pancreatic imaging: current and emerging technologies.  Pancreas. 2006;  33 211-220
• 3 Grenacher L, Klauss M, Dukic L et al. Hochauflösende Bildgebung beim Pankreaskarzinom: Prospektiver Vergleich von MRT und 4-Zeilen-Spiral-CT.  Fortschr Röntgenstr. 2004;  176 1624-1633
• 4 Mussig K, Bares R, Dudziak K et al. Multimodale Bildgebung von pankreatischen neuroendokrinen Tumoren (Multimodal imaging of pancreatic neuroendocrine tumors).  Fortschr Röntgenstr. 2008;  180 379
• 5 Otto S, Kuhn J P, Wallaschofski H et al. Neuroendokrine Tumoren des gastroenteropankreatischen Systems – auch extraluminal?.  Fortschr Röntgenstr. 2008;  180 1131-1133
• 6 Tschugunow A, Puesken M, Juergens K U et al. Bestimmung eines geeigneten Scandelays für die 64-Zeilen-CT des Abdomens mit gewichtsadaptierter Kontrastmittelgabe.  Fortschr Röntgenstr. 2009;  181 683-690
• 7 Brambs H J, Juchems M. Zystische Tumoren des Pankreas.  Radiologe. 2008;  48 740-751
• 8 Basturk O, Coban I, Adsay N V. Pancreatic cysts: pathologic classification, differential diagnosis, and clinical implications.  Arch Pathol Lab Med. 2009;  133 423-438
• 9 Hutchins G F, Draganov P V. Cystic neoplasms of the pancreas: a diagnostic challenge.  World J Gastroenterol. 2009;  15 48-54
• 10 Goh B K, Tan Y M, Thng C H et al. How useful are clinical, biochemical, and cross-sectional imaging features in predicting potentially malignant or malignant cystic lesions of the pancreas? Results from a single institution experience with 220 surgically treated patients.  J Am Coll Surg. 2008;  206 17-27
• 11 Fernandez-del Castillo C, Targarona J, Thayer S P et al. Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients.  Arch Surg. 2003;  138 427-423 ; discussion 433 – 424
• 12 Jacobson B C, Baron T H, Adler D G et al. ASGE guideline: The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory fluid collections of the pancreas.  Gastrointest Endosc. 2005;  61 363-370
• 13 Kloppel G, Kosmahl M, Luttges J. Intraduktale Pankreasneoplasien.  Pathologe. 2005;  26 31-36
• 14 Kosmahl M, Pauser U, Anlauf M et al. Zystische Pankreastumoren und ihre Klassifikation.  Pathologe. 2005;  26 22-30
• 15 Kosmahl M, Peters K, Anlauf M et al. Solid-pseudopapilläre Neoplasien.  Pathologe. 2005;  26 41-45
• 16 Laffan T A, Horton K M, Klein A P et al. Prevalence of unsuspected pancreatic cysts on MDCT.  Am J Roentgenol. 2008;  191 802-807
• 17 Kimura W, Nagai H, Kuroda A et al. Analysis of small cystic lesions of the pancreas.  Int J Pancreatol. 1995;  18 197-206
• 18 Pauls S, Sokiranski R, Schwarz M et al. Wertigkeit von Spiral-CT und MRT (1,5T) zur präoperativen Diagnostik von Pankreaskopftumoren.  Röntgenpraxis. 2003;  55 3-15
• 19 Kim Y H, Saini S, Sahani D et al. Imaging diagnosis of cystic pancreatic lesions: pseudocyst versus nonpseudocyst.  Radiographics. 2005;  25 671-685
• 20 Klimstra D S, Pitman M B, Hruban R H. An algorithmic approach to the diagnosis of pancreatic neoplasms.  Arch Pathol Lab Med. 2009;  133 454-464
• 21 Singhal D, Kakodkar R, Sud R et al. Issues in management of pancreatic pseudocysts.  Jop. 2006;  7 502-507
• 22 Kloppel G, Kosmahl M. Cystic lesions and neoplasms of the pancreas. The features are becoming clearer.  Pancreatology. 2001;  1 648-655
• 23 Strobel O, Z’Graggen K, Schmitz-Winnenthal F H et al. Risk of malignancy in serous cystic neoplasms of the pancreas.  Digestion. 2003;  68 24-33
• 24 Kim S Y, Lee J M, Kim S H et al. Macrocystic neoplasms of the pancreas: CT differentiation of serous oligocystic adenoma from mucinous cystadenoma and intraductal papillary mucinous tumor.  Am J Roentgenol. 2006;  187 1192-1198
• 25 Zamboni G, Scarpa A, Bogina G et al. Mucinous cystic tumors of the pancreas: clinicopathological features, prognosis, and relationship to other mucinous cystic tumors.  Am J Surg Pathol. 1999;  23 410-422
• 26 Kosmahl M, Pauser U, Peters K et al. Cystic neoplasms of the pancreas and tumor-like lesions with cystic features: a review of 418 cases and a classification proposal.  Virchows Arch. 2004;  445 168-178
• 27 Stamatakos M, Sargedi C, Angelousi A et al. Management of the rare entity of primary pancreatic cystic neoplasms.  J Gastroenterol Hepatol. 2009;  24 1203-1210
• 28 Crippa S, Salvia R, Warshaw A L et al. Mucinous cystic neoplasm of the pancreas is not an aggressive entity: lessons from 163 resected patients.  Ann Surg. 2008;  247 571-579
• 29 Adsay N V. Cystic lesions of the pancreas.  Mod Pathol. 2007;  20 S71-S93
• 30 Lim J H, Jang K T, Rhim H et al. Biliary cystic intraductal papillary mucinous tumor and cystadenoma/cystadenocarcinoma: differentiation by CT.  Abdom Imaging. 2007;  32 644-651
• 31 Rodriguez J R, Salvia R, Crippa S et al. Branch-duct intraductal papillary mucinous neoplasms: observations in 145 patients who underwent resection.  Gastroenterology. 2007;  133 72-79 9; quiz 309 – 310
• 32 Adsay N V, Conlon K C, Zee S Y et al. Intraductal papillary-mucinous neoplasms of the pancreas: an analysis of in situ and invasive carcinomas in 28 patients.  Cancer. 2002;  94 62-77
• 33 Yamaguchi K, Yokohata K, Noshiro H et al. Mucinous cystic neoplasm of the pancreas or intraductal papillary-mucinous tumour of the pancreas.  Eur J Surg. 2000;  166 141-148
• 34 Ohhashi K MF, Takekoshi T et al. Four cases of „mucin-producing” cancer of the pancreas on specific findings of the papilla of Vater (Japanese).  Proc Dig Endosc. 1982;  20 348
• 35 Kaneko T, Nakao A, Inoue S et al. Intraoperative ultrasonography by high-resolution annular array transducer for intraductal papillary mucinous tumors of the pancreas.  Surgery. 2001;  129 55-65
• 36 Kaneko T, Nakao A, Nomoto S et al. Intraoperative pancreatoscopy with the ultrathin pancreatoscope for mucin-producing tumors of the pancreas.  Arch Surg. 1998;  133 263-267
• 37 Salvia R, Festa L, Butturini G et al. Pancreatic cystic tumors.  Minerva Chir. 2004;  59 185-207
• 38 Kobari M, Egawa S, Shibuya K et al. Intraductal papillary mucinous tumors of the pancreas comprise 2 clinical subtypes: differences in clinical characteristics and surgical management.  Arch Surg. 1999;  134 1131-1136
• 39 Doi R, Fujimoto K, Wada M et al. Surgical management of intraductal papillary mucinous tumor of the pancreas.  Surgery. 2002;  132 80-85
• 40 Kitagawa Y, Unger T A, Taylor S et al. Mucus is a predictor of better prognosis and survival in patients with intraductal papillary mucinous tumor of the pancreas.  J Gastrointest Surg. 2003;  7 12-18 ; discussion 18 – 19
• 41 Sugiyama M, Izumisato Y, Abe N et al. Predictive factors for malignancy in intraductal papillary-mucinous tumours of the pancreas.  Br J Surg. 2003;  90 1244-1249
• 42 Lange S, Alzen G, Leder H et al. Solid-pseudopapillärer Pankreastumor im Kindesalter.  Fortschr Röntgenstr. 2002;  174 286-290
• 43 Goh B K, Tan Y M, Cheow P C et al. Solid pseudopapillary neoplasms of the pancreas: an updated experience.  J Surg Oncol. 2007;  95 640-644
• 44 Adsay N V. Centrally necrotic invasive ductal adenocarcinomas of the pancreas presenting clinically as macrocystic lesions.  Mod Pathol. 2001;  13 1125A
• 45 Bauer A, Kleeff J, Bier M et al. Identification of malignancy factors by analyzing cystic tumors of the pancreas.  Pancreatology. 2009;  9 34-44
• 46 Sahani D V, Kadavigere R, Saokar A et al. Cystic pancreatic lesions: a simple imaging-based classification system for guiding management.  Radiographics. 2005;  25 1471-1484
• 47 Chari S T, Yadav D, Smyrk T C et al. Study of recurrence after surgical resection of intraductal papillary mucinous neoplasm of the pancreas.  Gastroenterology. 2002;  123 1500-1507
• 48 Meier-Meitinger M, Nagel M, Kalender W et al. Computergestütztes Navigationssystem für CT-gesteuerte Interventionen: Ergebnisse am Phantom und im klinischen Einsatz.  Fortschr Röntgenstr. 2008;  180 310-317
• 49 Tseng J F, Warshaw A L, Sahani D V et al. Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment.  Ann Surg. 2005;  242 413-419 ; discussion 419 – 421
• 50 Isenmann R, Henne-Bruns D. Indikationen zur chirurgischen Therapie benigner Pankreastumoren.  Radiologe. 2008;  48 732, 734-739
• 51 Sarr M G, Carpenter H A, Prabhakar L P et al. Clinical and pathologic correlation of 84 mucinous cystic neoplasms of the pancreas: can one reliably differentiate benign from malignant (or premalignant) neoplasms?.  Ann Surg. 2000;  231 205-212
• 52 Wilentz R E, Albores-Saavedra J, Zahurak M et al. Pathologic examination accurately predicts prognosis in mucinous cystic neoplasms of the pancreas.  Am J Surg Pathol. 1999;  23 1320-1327
• 53 Choi B S, Kim T K, Kim A Y et al. Differential diagnosis of benign and malignant intraductal papillary mucinous tumors of the pancreas: MR cholangiopancreatography and MR angiography.  Korean J Radiol. 2003;  4 157-162
• 54 Sadakari Y, Ienaga J, Kobayashi K et al. Cyst Size Indicates Malignant Transformation in Branch Duct Intraductal Papillary Mucinous Neoplasm of the Pancreas Without Mural Nodules.  Pancreas. 2009; 
• 55 Spinelli K S, Fromwiller T E, Daniel R A et al. Cystic pancreatic neoplasms: observe or operate.  Ann Surg. 2004;  239 651-657 ; discussion 657 – 659
• 56 Sahani D V, Saokar A, Hahn P F et al. Pancreatic cysts 3 cm or smaller: how aggressive should treatment be?.  Radiology. 2006;  238 912-919
• 57 Allen P J, D’Angelica M, Gonen M et al. A selective approach to the resection of cystic lesions of the pancreas: results from 539 consecutive patients.  Ann Surg. 2006;  244 572-582
• 58 Garcea G, Dennison A R, Pattenden C J et al. Survival following curative resection for pancreatic ductal adenocarcinoma. A systematic review of the literature.  Jop. 2008;  9 99-132