Download PDF
Zentralbl Chir 2014; 139(3): 308-317
DOI: 10.1055/s-0033-1350892
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Intraduktale papillär-muzinöse Neoplasien (IPMN) des Pankreas – Standards und neue Aspekte

Intraductal Papillary Mucinous Neoplasm of the Pancreas (IPMN) – Standards and New Aspects
M. Distler
1   Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Deutschland
,
T. Welsch
1   Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Deutschland
,
D. Aust
2   Institut für Pathologie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Deutschland
,
J. Weitz
1   Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Deutschland
,
R. Grützmann
1   Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der TU Dresden, Deutschland
› Author Affiliations
Further Information

Publication History

Publication Date:
15 November 2013 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Die intraduktalen papillär-muzinösen Neoplasien (IPMN) des Pankreas gehören zur heterogenen Gruppe der zystischen Pankreasläsionen und werden mit zunehmender Häufigkeit diagnostiziert. Die Diagnosesicherung und Abklärung der Differenzialdiagnosen (Pseudozysten, serös-zystische Neoplasien [SCN], muzinös-zystische Neoplasien [MCN], intraduktale papillär-muzinöse Neoplasien [IPMN] und solid-pseudopapilläre Neoplasien [SPN]) sind häufig nicht einfach. IPMN werden als Vorläuferläsionen für die Entstehung eines Pankreaskarzinoms angesehen, wobei sich je nach morphologischem (Hauptgang- oder Nebengang-IPMN) bzw. histologischem Typ (intestinal, pankreatobiliär, onkozytisch, gastrisch) ein unterschiedliches malignes Potenzial ergibt. Die frühzeitige Diagnose und die Wahl des geeigneten Therapieverfahrens sind entscheidend für die Heilung. Konsens besteht über die Indikation zur Resektion aller Hauptgang-IPMN, da die Rate an malignen Befunden sehr hoch ist. Eine Befundkontrolle und Beobachtung ist nur für kleine Nebengang-IPMN ohne Anzeichen für Malignität zu empfehlen. Das zunehmende Verständnis der Histopathologie und Tumorbiologie von IPMN hat zu einer Novellierung der 2006 von der International Association of Pancreatology (IAP) aufgestellten Leitlinie geführt. Empfehlungen bez. der Beobachtung oder Nachsorge von Nebengang-IPMN können anhand der aktuellen Datenlage nicht eindeutig gegeben werden.

Abstract

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas belong to the heterogeneous group of cystic pancreatic lesions and have been diagnosed more frequently in recent years. Diagnosis and differentiation from other cystic lesions (pseudocysts, serous-cystic neoplasias [SCN], mucinous-cystic neoplasias [MCN], intraductal papillary-mucinous neoplasias [IPMN] and solid pseudopapillary neoplasias [SPN]) is often challenging. IPMN of the pancreas are considered as precursor lesions for the development of invasive pancreatic cancer. However, depending on the morphological (MD-IPMN, BD-IPMN) and histological subtype (intestinal, pancreatobiliary, oncocytic or gastric) the malignant potential of IPMNs varies significantly. Hence, early diagnosis and selection of the appropriate therapeutic strategy is necessary for optimal outcome and cure. There is a strong consensus for the resection of all MD-IPMN. Small BD-IPMN without signs of malignancy can be followed by observation. The increasing understanding of the histopathology and tumour biology of IPMN has led to an amendment of the 2006 International Association of Pancreatology (IAP) guidelines for the treatment of cystic pancreatic tumours. In consideration of recent data, recommendations for observation and/or follow-up of IPMN cannot be given definitely.

Schlüsselwörter

IPMN - Pankreaskarzinom - Pankreaschirurgie - zystischer Pankreastumor - Prognose

Key words

IPMN - pancreatic cancer - pancreatic surgery - cystic pancreatic tumour - prognosis
 

  • Literatur

  • 1 Laffan TA, Horton KM, Klein AP et al. Prevalence of unsuspected pancreatic cysts on MDCT. Am J Roentgenol 2008; 191: 802-807
    CrossrefPubMedGoogle Scholar
  • 2 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
    CrossrefPubMedGoogle Scholar
  • 3 Kosmahl M, Pauser U, Anlauf M et al. Cystic pancreas tumors and their classification: features old and new. Pathologe 2005; 26: 22-30
    CrossrefPubMedGoogle Scholar
  • 4 Grützmann R, Saeger HD. Cystic tumors of the pancreas. Chirurg 2010; 81: 755-768
    CrossrefPubMedGoogle Scholar
  • 5 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
    PubMedGoogle Scholar
  • 6 Sohn TA, Yeo CJ, Cameron JL et al. Intraductal papillary mucinous neoplasms of the pancreas: an updated experience. Ann Surg 2004; 239: 788-797
    CrossrefPubMedGoogle Scholar
  • 7 Zhang XM, Mitchell DG, Dohke M et al. Pancreatic cysts: depiction on single-shot fast spin-echo MR images. Radiology 2002; 223: 547-553
    CrossrefPubMedGoogle Scholar
  • 8 Hackert T, Tjaden C, Büchler MW. [Developments in pancreatic surgery during the past ten years]. Zentralbl Chir 2013; Jul 3 [Epub ahead of print]
    PubMedGoogle Scholar
  • 9 Tanaka M, Chari S, Adsay V et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 2006; 6: 17-32
    CrossrefPubMedGoogle Scholar
  • 10 Hruban RH, Takaori K, Klimstra DS et al. An illustrated consensus on the classification of pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasms. Am J Surg Pathol 2004; 28: 977-987
    CrossrefPubMedGoogle Scholar
  • 11 Bosman FT, Carneiro F, Hruban RH et al., eds WHO Classification of Tumours of the digestive System. 4. Aufl. Lyon: IARC; 2010
    Google Scholar
  • 12 Lüttges J, Zamboni G, Longnecker D et al. The immunohistochemical mucin expression pattern distinguishes different types of intraductal papillary mucinous neoplasms of the pancreas and determines their relationship to mucinous noncystic carcinoma and ductal adenocarcinoma. Am J Surg Pathol 2001; 25: 942-948
    CrossrefPubMedGoogle Scholar
  • 13 Wada K, Kozarek RA, Traverso LW. Outcomes following resection of invasive and noninvasive intraductal papillary mucinous neoplasms of the pancreas. Am J Surg 2005; 189: 632-636
    CrossrefPubMedGoogle Scholar
  • 14 Nagai K, Doi R, Kida A et al. Intraductal papillary mucinous neoplasms of the pancreas: clinicopathologic characteristics and long-term follow-up after resection. World J Surg 2008; 32: 271-278
    CrossrefPubMedGoogle Scholar
  • 15 Niedergethmann M, Grützmann R, Hildenbrand R et al. Outcome of invasive and noninvasive intraductal papillary-mucinous neoplasms of the pancreas (IPMN): a 10-year experience. World J Surg 2008; 32: 2253-2260
    CrossrefPubMedGoogle Scholar
  • 16 Schmidt CM, White PB, Waters JA et al. Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann Surg 2007; 246: 644-651
    CrossrefPubMedGoogle Scholar
  • 17 Waters JA, Schmidt CM, Pinchot JW et al. CT vs. MRCP: optimal classification of IPMN type and extent. J Gastrointest Surg 2008; 12: 101-109
    CrossrefPubMedGoogle Scholar
  • 18 Yamao K, Nakamura T, Suzuki T et al. Endoscopic diagnosis and staging of mucinous cystic neoplasms and intraductal papillary-mucinous tumors. J Hepatobiliary Pancreat Surg 2003; 10: 142-146
    CrossrefPubMedGoogle Scholar
  • 19 Pais SA, Attasaranya S, Leblanc JK et al. Role of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms: correlation with surgical histopathology. Clin Gastroenterol Hepatol 2007; 5: 489-495
    CrossrefPubMedGoogle Scholar
  • 20 Kubo H, Chijiiwa Y, Akahoshi K et al. Intraductal papillary-mucinous tumors of the pancreas: differential diagnosis between benign and malignant tumors by endoscopic ultrasonography. Am J Gastroenterol 2001; 96: 1429-1434
    CrossrefPubMedGoogle Scholar
  • 21 Ohno E, Hirooka Y, Itoh A et al. Intraductal papillary mucinous neoplasms of the pancreas: differentiation of malignant and benign tumors by endoscopic ultrasound findings of mural nodules. Ann Surg 2009; 249: 628-634
    CrossrefPubMedGoogle Scholar
  • 22 Sedlack R, Affi A, Vazquez-Sequeiros E et al. Utility of EUS in the evaluation of cystic pancreatic lesions. Gastrointest Endosc 2002; 56: 543-547
    CrossrefPubMedGoogle Scholar
  • 23 Kersting S, Konopke R, Kersting F et al. Quantitative perfusion analysis of transabdominal contrast-enhanced ultrasonography of pancreatic masses and carcinomas. Gastroenterology 2009; 137: 1903-1911
    CrossrefPubMedGoogle Scholar
  • 24 Salvia R, Malleo G, Marchegiani G et al. Pancreatic resections for cystic neoplasms: from the surgeonʼs presumption to the pathologistʼs reality. Surgery 2012; 152: 135-142
    CrossrefPubMedGoogle Scholar
  • 25 Pitman MB, Genevay M, Yaeger K et al. High-grade atypical epithelial cells in pancreatic mucinous cysts are a more accurate predictor of malignancy than “positive” cytology. Cancer Cytopathol 2010; 118: 434-440
    CrossrefPubMedGoogle Scholar
  • 26 Park WG, Mascarenhas R, Palaez-Luna M et al. Diagnostic performance of cyst fluid carcinoembryonic antigen and amylase in histologically confirmed pancreatic cysts. Pancreas 2011; 40: 42-45
    CrossrefPubMedGoogle Scholar
  • 27 Pitman MB, Michaels PJ, Deshpande V et al. Cytological and cyst fluid analysis of small (< or = 3 cm) branch duct intraductal papillary mucinous neoplasms adds value to patient management decisions. Pancreatology 2008; 8: 277-284
    CrossrefPubMedGoogle Scholar
  • 28 Maker AV, Lee LS, Raut CP et al. Cytology from pancreatic cysts has marginal utility in surgical decision-making. Ann Surg Oncol 2008; 15: 3187-3192
    CrossrefPubMedGoogle Scholar
  • 29 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
    CrossrefPubMedGoogle Scholar
  • 30 Fritz S, Hackert T, Hinz U et al. Role of serum carbohydrate antigen 19-9 and carcinoembryonic antigen in distinguishing between benign and invasive intraductal papillary mucinous neoplasm of the pancreas. Br J Surg 2005; 92: 724-728
    CrossrefPubMedGoogle Scholar
  • 31 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
    CrossrefPubMedGoogle Scholar
  • 32 Schlitter AM, Esposito I, Klöppel G. Klassifikation und Diagnose zystischer Pankreastumoren. Viszeralmedizin 2011; 27: 182-188
    PubMedGoogle Scholar
  • 33 King JC, Ng TT, White SC et al. Pancreatic serous cystadenocarcinoma: a case report and review of the literature. J Gastrointest Surg 2009; 13: 1864-1868
    CrossrefPubMedGoogle Scholar
  • 34 Mukhopadhyay B, Sahdev A, Monson JP et al. Pancreatic lesions in von Hippel-Lindau disease. Clin Endocrinol (Oxf) 2002; 57: 603-608
    CrossrefPubMedGoogle Scholar
  • 35 Papavramidis T, Papavramidis S. Solid pseudopapillary tumors of the pancreas: review of 718 patients reported in English literature. J Am Coll Surg 2005; 200: 965-972
    CrossrefPubMedGoogle Scholar
  • 36 Spinelli KS, Fromwiller TE, Daniel RA et al. Cystic pancreatic neoplasms: observe or operate. Ann Surg 2004; 239: 651-657
    CrossrefPubMedGoogle Scholar
  • 37 Adsay NV, Klimstra DS, Compton CC. Cystic lesions of the pancreas. Introduction. Semin Diagn Pathol 2000; 17: 1-6
    PubMedGoogle Scholar
  • 38 Matos JM, Grützmann R, Agaram NP. Solid pseudopapillary neoplasms of the pancreas: a multi-institutional study of 21 patients. J Surg Res 2009; 157: 137-142
    CrossrefPubMedGoogle Scholar
  • 39 Basturk O, Coban I, Adsay NV. Pancreatic cysts: pathologic classification, differential diagnosis, and clinical implications. Arch Pathol Lab Med 2009; 133: 423-438
    PubMedGoogle Scholar
  • 40 Crippa S, Salvia R, Warshaw AL et al. Mucinous cystic neoplasm of the pancreas is not an aggressive entity: lessons from 163 resected patients. Ann Surg 2008; 247: 571-579
    CrossrefPubMedGoogle Scholar
  • 41 Crippa S, Fernández-Del Castillo C, Salvia R et al. Mucin-pruducing neoplasms of the pancreas: an analysis of distinguishing clinical and epidemiological characteristics. Clin Gastroenterol Hepatol 2010; 8: 213-219
    CrossrefPubMedGoogle Scholar
  • 42 Schnelldorfer T, Sarr MG, Nagorney DM et al. Experience with 208 resections for intraductal papillary mucinous neoplasm of the pancreas. Arch Surg 2008; 143: 639-646
    CrossrefPubMedGoogle Scholar
  • 43 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
    CrossrefPubMedGoogle Scholar
  • 44 Furukawa T, Klöppel G, Volkan Adsay N et al. Classification of types of intraductal papillary-mucinous neoplasm of the pancreas: a consensus study. Virchows Arch 2005; 447: 794-799
    CrossrefPubMedGoogle Scholar
  • 45 Distler M, Kersting S, Niedergethmann M et al. Pathohistological subtype predicts survival in patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Ann Surg 2013; 258: 324-330
    CrossrefPubMedGoogle Scholar
  • 46 Nakata K, Ohuchida K, Aishima S et al. Invasive carcinoma derived from intestinal-type intraductal papillary mucinous neoplasm is associated with minimal invasion, colloid carcinoma, and less invasive behavior, leading to a better prognosis. Pancreas 2011; 40: 581-587
    CrossrefPubMedGoogle Scholar
  • 47 Sadakari Y, Ohuchida K, Nakata K et al. Invasive carcinoma derived from the nonintestinal type intraductal papillary mucinous neoplasm of the pancreas has a poorer prognosis than that derived from the intestinal type. Surgery 2010; 147: 812-827
    CrossrefPubMedGoogle Scholar
  • 48 Furukawa T, Hatori T, Fujita I et al. Prognostic relevance of morphological types of intraductal papillary mucinous neoplasms of the pancreas. GUT 2011; 60: 509-516
    CrossrefPubMedGoogle Scholar
  • 49 Yopp AC, Katabi N, Janakos M et al. Invasive carcinoma arising in intraductal papillary mucinous neoplasms of the pancreas: a matched control study with conventional pancreatic ductal adenocarcinoma. Ann Surg 2011; 253: 968-974
    CrossrefPubMedGoogle Scholar
  • 50 Xiao HD, Yamaguchi H, Dias-Santagata D et al. Molecular characteristics and biological behaviours of the oncocytic and pancreatobiliary subtypes of intraductal papillary mucinous neoplasms. J Pathol 2011; 224: 508-516
    CrossrefPubMedGoogle Scholar
  • 51 Couvelard A, Sauvanet A, Kianmanesh R et al. Frozen sectioning of the pancreatic cut surface during resection of intraductal papillary mucinous neoplasms of the pancreas is useful and reliable: a prospective evaluation. Ann Surg 2005; 242: 774-778
    CrossrefPubMedGoogle Scholar
  • 52 Brune K, Abe T, Canto M et al. Multifocal neoplastic precursor lesions associated with lobular atrophy of the pancreas in patients having a strong family history of pancreatic cancer. Am J Surg Pathol 2006; 30: 1067-1076
    PubMedGoogle Scholar
  • 53 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
    CrossrefPubMedGoogle Scholar
  • 54 Fritz S, Klauss M, Bergmann F et al. Small (Sendai negative) branch-duct IPMNs: not harmless. Ann Surg 2012; 256: 313-320
    CrossrefPubMedGoogle Scholar
  • 55 Cauley CA, Waters JA, Dumas RP et al. Outcomes of primary surveillance for intraductal papillary mucinous neoplasm. J Gastrointest Surg 2012; 16: 258-267
    CrossrefPubMedGoogle Scholar
  • 56 Tanaka M, Fernandez-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
    CrossrefPubMedGoogle Scholar
  • 57 Distler M, Grützmann R. New aspects of surgery for pancreatic cancer. Principles, results and evidence. Pathologe 2012; 33 (Suppl. 02) S258-S265
    CrossrefPubMedGoogle Scholar
  • 58 Grützmann R, Distler M, Keck T et al. Pancreatic anastomosis – a video comparison of differrent techniques. Zentralbl Chir 2013; 138: 24-26
    Article in Thieme ConnectPubMedGoogle Scholar
  • 59 Salvia R, Crippa S, Falconi M et al. Branch-duct intraductal papillary mucinous neoplasms of the pancreas: to operate or not to operate?. Gut 2007; 56: 1086-1090
    CrossrefPubMedGoogle Scholar
  • 60 Walsh RM, Vogt DP, Henderson JM et al. Management of suspected pancreatic cystic neoplasms based on cyst size. Surgery 2008; 144: 677-684
    CrossrefPubMedGoogle Scholar
  • 61 Lee CJ, Scheiman J, Anderson MA et al. Risk of malignancy in resected cystic tumors of the pancreas < or = 3 cm in size: is it safe to observe asymptomatic patients? A multi-institutional report. J Gastrointest Surg 2008; 12: 234-242
    Google Scholar
  • 62 Genevay M, Mino-Kenudson M, Yaeger K et al. Cytology adds value to imaging studies for risk assessment of malignancy in pancreatic mucinous cysts. Ann Surg 2011; 254: 977-983
    CrossrefPubMedGoogle Scholar
  • 63 Levy 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
    CrossrefPubMedGoogle Scholar
  • 64 Rautou PE, Levy P, Vullierme MP et al. Morphologic changes in branch duct intraductal papillary mucinous neoplasms of the pancreas: a midterm follow-up study. Clin Gastroenterol Hepatol 2008; 6: 807-814
    CrossrefPubMedGoogle Scholar
  • 65 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
    CrossrefPubMedGoogle Scholar
  • 66 Cauley CE, Pitt HA, Ziegler KM et al. Pancreatic enucleation: improved outcomes compared to resection. J Gastrointest Surg 2012; 16: 1347-1355
    CrossrefPubMedGoogle Scholar
  • 67 Grützmann R, Ehehalt F, Saeger HD. Spezielle Situationen und taktische Vorgehensweise. In: Birth M, Ittel TH, Pereira PL, Hrsg. Hepatobiliäre und Pankreastumoren. Interdisziplinäres Vorgehen. 1st ed. Heidelberg: Springer; 2010: 297-299
    CrossrefGoogle Scholar
  • 68 Fritz S, Schirren M, Klauss M et al. Clinicopathologic characteristics of patients with resected multifocal intraductal papillary mucinous neoplasm of the pancreas. Surgery 2012; 152: 74-80
    CrossrefPubMedGoogle Scholar
  • 69 Poultsides GA, Reddy S, Cameron JL et al. Histopathologic basis for the favorable survival after resection of intraductal papillary mucinous neoplasm-associated invasive adenocarcinoma of the pancreas. Ann Surg 2010; 251: 470-476
    CrossrefPubMedGoogle Scholar
  • 70 Fernandez-del Castillo C, Adsay NV. Intraductal papillary mucinous neoplasms of the pancreas. Gastroenterology 2010; 139: 708-713
    CrossrefPubMedGoogle Scholar
  • 71 Distler M, Rückert F, Hunger M et al. Evaluation of survival in patients after pancreatic head resection for ductal adenocarcinoma. BMC Surg 2013; 13: 12
    CrossrefPubMedGoogle Scholar
  • 72 Bassi C, Sarr MG, Lillemoe KD et al. Natural history of intraductal papillary mucinous neoplasms (IPMN): current evidence and implications for management. J Gastrointest Surg 2008; 12: 645-650
    CrossrefPubMedGoogle Scholar
  • 73 Alexander BM, Fernandez-Del Castillo C, Ryan DP et al. Intraductal papillary mucinous adenocarcinoma of the pancreas: clinical outcomes, prognostic factors, and the role of adjuvant therapy. Gastrointest Cancer Res 2011; 4: 116-121
    PubMedGoogle Scholar
  • 74 Keck T. [Carcinoma of the pancreas: current status of multimodal therapy]. Zentralbl Chir 2011; 136: 352-358
    Article in Thieme ConnectPubMedGoogle Scholar
  • 75 Winter C, Kristiansen G, Kersting S et al. Google goes cancer: improving outcome prediction for cancer patients by network-based ranking of marker genes. PLoS Comput Biol 2012; 8: e1002511
    CrossrefPubMedGoogle Scholar
  • 76 Yamaguchi K, Kanemitsu S, Hatori T et al. Pancreatic ductal adenocarcinoma derived from IPMN and pancreatic ductal adenocarcinoma concomitant with IPMN. Pancreas 2011; 40: 571-580
    CrossrefPubMedGoogle Scholar
  • 77 Reid-Lombardo KM, Mathis KL, Wood CM et al. Frequency of extrapancreatic neoplasms in intraductal papillary mucinous neoplasm of the pancreas: implications for management. Ann Surg 2010; 251: 64-69
    CrossrefPubMedGoogle Scholar
  • 78 Benarroch-Gampel J, Riall TS. Extrapancreatic malignancies and intraductal papillary mucinous neoplasms of the pancreas. World J Gastrointest Surg 2010; 2: 363-367
    CrossrefPubMedGoogle Scholar