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Diagnostische Strategie und differenzialtherapeutisches Vorgehen bei zystischen Läsionen des Pankreas

Diagnostic strategy and differential therapeutic approach for cystic lesions of the pancreas

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Zusammenfassung

Klinisches/methodisches Problem

Zystische Pankreasläsionen (ZPL) werden zunehmend häufiger diagnostiziert. Da bis zu 60 % der ZPL als prämaligne oder maligne einzustufen sind, sollte jede ZPL diagnostisch abgeklärt werden. Seröse ZPL mit geringem Entartungsrisiko (serös zystische Neoplasien, SZN) müssen von muzinösen ZPL mit relevantem Malignitätspotenzial (intraduktale papillär-muzinöse Neoplasien [IPMN] und muzinös zystische Neoplasie [MZN]) und harmlosen Pseudozysten unterschieden werden.

Radiologische Standardverfahren

Die Schnittbildgebung mithilfe der CT und MRT spielt bei der Diagnostik von ZPL eine entscheidende Rolle.

Methodische Innovationen

Vorgestellt wird ein Algorithmus zur differenzialdiagnostischen Einordnung von ZPL.

Leistungsfähigkeit

Der Ganganschluss ist das entscheidende diagnostische Kriterium, um IPMN von den übrigen ZPL zu differenzieren. Eine Ausnahme stellt die Pseudozyste dar, die ebenfalls einen Ganganschluss aufweisen kann. ZPL ohne Ganganschluss lassen sich anhand morphologischer Kriterien und Korrelation des radiologischen Befundes mit Patientenalter, -geschlecht, Anamnese und klinischer Symptomatik weiter klassifizieren.

Empfehlung für die Praxis

Abhängig von der Diagnose und damit dem Malignitätsrisiko muss im interdisziplinären Konsens entschieden werden, ob die ZPL kontrolliert oder operiert werden sollte. Aufgrund ihres hervorragenden Weichteilkontrasts ist die MRT der CT bei der Abbildung morphologischer Eigenschaften von ZPL überlegen.

Abstract

Clinical/methodical issue

Cystic pancreatic lesions (CPL) are diagnosed with increasing frequency. Because up to 60 % of CPL are classified as malignant or premalignant, every CPL should be fully investigated and clarified. Serous CPL with low risk of malignancy must be differentiated from mucinous CPL with relevant potential malignancy (intraductal papillary mucinous neoplasm IPMN) and mucinous cystic neoplasm (MCN) as well as from harmless pseudocysts.

Standard radiological methods

Cross-sectional imaging with computed tomography (CT) and magnetic resonance imaging (MRI) plays a crucial role in the diagnostics of CPL.

Methodical innovations

An algorithm for the differential diagnostic classification of CPL is presented.

Performance

The connection to the pancreatic duct is the key diagnostic criterion to differentiate IPMN from all other CPL. An exception to this rule is that pseudocysts can also show a connection to the pancreatic duct. A further classification of CPL with no connection to the pancreatic duct can be made by morphological criteria and correlation of the radiological findings with patient age, sex, history and symptoms.

Practical recommendations

Depending on the diagnosis and hence the malignant potential the indications for surgery or watch and wait have to be discussed in an interdisciplinary cooperation. Due to its higher soft tissue contrast MRI is often superior to CT for depiction of CPL morphology.

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Abbreviations

CEA:

Karzinoembryonales Antigen

CP:

Chronische Pankreatitis

EUS:

Endoskopischer Ultraschall, Endosonographie

FNA:

Feinnadelaspiration

IPMN:

Intraduktal papillär muzinöse Neoplasien

MRCP:

Magnetresonanzcholangiopankreatikographie

MZ(C)N:

Muzinös zystische Neoplasie

NEPN:

Neuroendokrine Pankreasneoplasie

SPN:

Solide pseudopapilläre Neoplasie

SZN:

Serös zystische Neoplasie

VHL:

Von-Hippel-Lindau-Syndrom

ZPL:

Zystische Pankreasläsion

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Authors and Affiliations

  1. Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    P. Mayer &  M. Klauß

  2. Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    C. Tjaden

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  1. P. Mayer
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  2. C. Tjaden
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  3. M. Klauß
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Correspondence to M. Klauß.

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P. Mayer, C. Tjaden und M. Klauß geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren Studien an Menschen oder Tieren.

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Mayer, P., Tjaden, C. & Klauß, M. Diagnostische Strategie und differenzialtherapeutisches Vorgehen bei zystischen Läsionen des Pankreas. Radiologe 56, 338–347 (2016). https://doi.org/10.1007/s00117-016-0091-0

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  • DOI: https://doi.org/10.1007/s00117-016-0091-0

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