Pankreasın neoplastik kistlerinde tanı parametreleri: Tek merkez deneyimi

Giriş ve Amaç: Pankreas kistlerinin teşhis sıklığı, günümüzde bilgisayarlı tomografi ve manyetik rezonans görüntüleme gibi kesitsel görüntüleme yöntemlerinin yaygın kullanımı nedeni ile giderek artmaktadır. Pankreas kistik lezyonlarının tedavisini yönetmek çoğu zaman klinisyen için zordur. Bu nedenle ayırıcı tanı yapılması için; öykü, klinik, laboratuvar, radyolojik görüntüleme, endoskopik ultrasonografi, endoskopik ultrasonografi eşliğinde ince iğne aspirasyon biyopsisi ile alınan kist sıvı analizi ve sitopatoloji verilerinin değerlendirilmesi önemlidir. Bu çalışmanın amacı; pankreasın neoplastik kistlerinde klinik, laboratuvar, radyolojik, endosonografik ve patolojik incelemelerin tanıya katkısının psödokistlerle karşılaştırılarak araştırılmasıdır. Gereç ve Yöntem: Çalışmaya Temmuz 2009-Ağustos 2017 tarihleri arasında Dokuz Eylül Üniversitesi Tıp Fakültesi Hastanesi İç Hastalıkları Anabilim Dalı Gastroenteroloji Kliniği Endoskopi ünitesinde pankreas kistik lezyonu nedenli endoskopik ultrasonografi eşliğinde ince iğne aspirasyon biyopsisi ile değerlendirildikten sonra cerrahi operasyon geçiren ve patoloji sonucu “neoplastik kist” olan 30 hasta ile akut pankreatit öyküsü olup pankreas kistik lezyon nedenli endoskopik ultrasonografi eşliğinde ince iğne aspirasyon biyopsisi değerlendirilmesi sonrası endoskopik ultrasonografi raporlarında “psödokist” tanısı konulan 46 hasta dahil edilmiştir. Hastaların; demografik verileri, klinik özellikleri, laboratuvar verileri, radyolojik/ endoskopik ultrasonografi görüntü raporları ve patolojik inceleme sonuçları retrospektif olarak değerlendirilmiştir. Bulgular: Pankreas kistik lezyonu nedenli kiste yönelik cerrahi operasyon geçiren 30 hastanın cerrahi patoloji sonuçları; 15 hastanın (%50) intraduktal papiller müsinöz neoplazi, 6 hastanın (%20) kistik adenokarsinom, 4 hastanın (%13.3) solid psödopapiller neoplazm, 3 hastanın (%10) müsinöz kistik neoplazi ve 2 hastanın (%6.7) seröz kistik neoplazi şeklinde idi. Endoskopik ultrasonografi incelemesinde; pankreasın ve kistlerin morfolojik özelliklerine bakıldığında; neoplastik kist grubunda 2 (%6.7) hastada kronik pankreatit bulguları, 6 (%20) hastada ana pankreas kanalında genişleme, 2 (%6.7) hastada yan dal pankreas kanallarında genişleme, 6 (%20) hastada kistin pankreatik kanal ile bağlantılı olduğu, 9 (%30) hastada septasyon, 5 (%16.7) hastada lobulasyon, 5 (%16.7) hastada kalsifikasyon, 4 (%13.3) hastada kist duvarında kalınlaşma mevcuttu. Psödokist grubunda ise 1 (%2.2) hastada septasyon, 1 (%2.2) hastada lobulasyon mevcuttu. Endoskopik ultrasonografi eşliğinde ince iğne aspirasyon biyopsisi ile alınan kist sıvısı analizinde; neoplastik kist grubunda kist analizinde bakılan amilaz ortalama değeri; 28808.8±60961.01 U/L ve karsinoembriyojenik antijen ortalama değeri: 1055.29±1548.14 ng/mL olarak; psödokist grubunun kist analizinde ise amilaz ortalama değeri: 28246.13±29858.56 U/L ve karsinoembriyojenik antijen ortalama değeri: 7.31±10.02 ng/mL olarak saptanmıştır. Endoskopik ultrasonografi; neoplastik kistlerin 13’ünü (%43.3) tanısal olarak doğru tanımlamıştı. Müsinöz kistlerde; endoskopik ultrasonografinin tanısal olarak ayırt ediciliğine endoskopik ultrasonografi eşliğinde ince iğne aspirasyon biyopsisi bulgularından (sitopatoloji, müsin, string sign ve karsinoembriyojenik antijen >192 ng/mL ) herhangi birinin veya hepsinin pozitif olmasını eklediğimizde; tanısal duyarlılık %88.9’a varan oranlara ulaşmaktadır. Sonuç: Pankreasın neoplastik kistlerinin tanısında endoskopik ultrasonografi ve endoskopik ultrasonografi eşliğinde ince iğne aspirasyon biyopsisi en yüksek tanısal duyarlılığa sahip yöntemdir. Buna rağmen %15’e varan oranda neoplastik/benign kist ayrımını yapmada yeterli olmamaktadır. Radyolojik yöntemlerle birlikte kullanımı tanısal doğruluğu arttırmaktadır. Pankreas kisti bulunan diyabetik hastalarda serum kanser antijen 19-9 düzeylerinin bakılması neoplastik kist tanısında yardımcı olabilir.

Anahtar Kelimeler:

Pankreas, psödokist, kist, neoplazi, tanı, endoskopik ultrasonografi

Diagnosis parameters in pancreatic cystic neoplasms: Single center experience

Background and aims: The identification frequency of pancreatic cystic lesions are increasing day by day due to the widespread use of cross-sectional imaging methods such as computed tomography and magnetic resonance imaging. Pancreatic cystic lesions are simply divided into two main classes: non-neoplastic (eg: pseudocysts) and neoplastic cysts. Managing the treatment of pancreatic cystic lesions is difficult for the clinician; therefore, in order to make differantial diagnosis; medical history, clinical, laboratory, radiological imaging, endoscopic ultrasonography, evaluation of cyst fluid analysis and cytopathology data obtained with endoscopic ultrasonography/endoscopic ultrasonography-fine needle aspiration is important. The objective of this study was to investigate clinical, laboratory, radiological, endoscopic ultrasound and pathological examinations of the pancreatic cystic neoplasms by comparing the diagnostic contribution with pseudocysts. Materials and Method: 30 patients who underwent surgical operation and were diagnosed pathologic "neoplastic cyst" of pancreatic cystic lesions with endoscopic ultrasonography/endoscopic ultrasonography-fine needle aspiration biopsy evaluation in the gastroenterology clinic of the Dokuz Eylül Medical Faculty between July 2009 and August 2017 with 46 patients who history of acute pancreatitis with a diagnosis of ‘’pseudocyst’’ were included in the endoscopic ultrasonography reports after evaluation of endoscopic ultrasonography/endoscopic ultrasonography-fine needle aspiration biopsy with pancreatic cystic lesions, were icluded in the study. The demographic characteristics of the patients, clinical features, laboratory data, radiological/endoscopic ultrasonography image reports and pathological examination results were investigated retrospectively. Results: Surgical pathology results of 30 patients for pancreatic cystic lesions were intraductal papillary mucinous neoplasm in 15 patients (%50), cystic adenocarcinoma in 6 patients (%13), Solid pseudopapillary neoplasm in 4 patients (%13.3), mucinous cystic neoplasm in 3 patients (10%) and serous cystic neoplasm in 2 patients (%6.7). In the endoscopic ultrasonography; when the morphological characteristics of the pancreas and cysts are examined; 2 patients (%6.7) in the neoplastic cyst group had chronic pancreatitis, 6 patients (%20) had expansion in main pancreatic duct, 2 patients (%6.7) had enlarged in the side branch pancreatic duct, 6 patients (%20) had cysts were associated with the pancreatic duct, 9 patients (%30) had septation, 5 patients (% 16.7) had lobularity, 5 patients (% 16.7) had calcification, 4 patients (%13.3) had thick of the cyst wall. As for in the pseudocyst group; 1 patient (%2.2) had septation and 1 patient (%2.2) had lobularity. In cyst fluid analysis with endoscopic ultrasonography-fine needle aspiration biopsy: in the cyst analysis of the neoplastic cyst group mean amylase was 28808.8±60961.01 U/L and mean Carcinoembryonic antigen value was 1055.29±1548.14 ng/mL; in the cyst analysis of the pseudocyst group mean amylase value was 28246.13±29858.56 U/L and mean Carcinoembryonic antigen value was 7.31±10.02 ng/mL. Endoscopic ultrasonography diagnosed 13 (%43.3) of the neoplastic cysts correctly. In mucinous cysts; when we add the diagnostic discrimination of endoscopic ultrasonography to any of the endoscopic ultrasonography-fine needle aspiration biopsyfindings (cytopathology, mucin, string sign and Carcinoembryonic antigen > 192 ng/mL) or all of them positive, the diagnostic sensitivity reaches up to %88.9. Conclusion: In the diagnosis of neoplastic cysts of the pancreas; endoscopic ultrasonography and endoscopic ultrasonography-fine needle aspiration biopsyare the method with the highest diagnostic sensitivity. However, up to %15 is not sufficient to distinguish neoplastic/benign cyst. Its use with radiological methods increases diagnostic accuracy. Serum cancer antigen19-9 levels in diabetic patients with pancreatic cysts may be helpful in diagnose neoplastic cyst.

Keywords:

Pancreas, pseudocyst, cyst, neoplasi, diagnosis, endoscopic ultrasonography,

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1. Jacobson BC, Baron TH, Adler DG, 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;61:363-70.
2. Spinelli KS, Fromwiller TE, Daniel RA, et al. Cystic pancreatic neoplasms. Ann Surg 2004;239:651-9.
3. Hamilton SR, Aaltonen LA, Pathology and Genetics of Tumours of the Digestive System. S.R. H, L.A. A. World Health Organization Classification of Tumours. IARC Press Lyon 2000. 2000;
4. Samarasena JB, Nakai Y, Chang KJ. Endoscopic ultrasonography-guided fine-needle aspiration of pancreatic cystic lesions: a practical approach to diagnosis and management. Gastrointest Endosc Clin N Am 2012;22:169-85.
5. Yoon WJ, Brugge WR. Pancreatic cystic neoplasms: Diagnosis and management. Gastroenterol Clin North Am 2012;41:103-18.
6. Attasaranya S, Pais S, LeBlanc J, et al. Endoscopic ultrasound-guided fine needle aspiration and cyst fluid analysis for pancreatic cysts. JOP 2007;8:553-63.
7. Senol K. AKgül Ö, Gündoğdu SB, et al. Can outcome of pancreatic pseudocysts be predicted? Proposal for a new scoring system. Turkish J Trauma Emerg Surg 2016;22:150-4.
8. Sakorafas GH, Sarr MG. Cystic neoplasms of the pancreas; what a clinician should know. Cancer Treat Rev 2005;31:507-35.
9. Toouli J, Brooke-Smith M, Bassi C, et al. Guidelines for the management of acute pancreatitis. J Gastroenterol Hepatol 2002;17(Suppl):S15-39.
10. Roch AM, Parikh JA, Al-Haddad MA, et al. Abnormal serum pancreatic enzymes, but not pancreatitis, are associated with an increased risk of malignancy in patients with intraductal papillary mucinous neoplasms. Surgery 2014;156:923-30.
11. Bünger S, Laubert T, Roblick UJ, Habermann JK. Serum biomarkers for improved diagnostic of pancreatic cancer: a current overview. J Cancer Res Clin Oncol 2011;137:375-89.
12. Sperti C, Pasquali C, Guolo P, et al. Serum tumor markers and cyst fluid analysis are useful for the diagnosis of pancreatic cystic tumors. Cancer 1996;78:237-43.
13. Cho CS, Russ AJ, Loeffler AG, et al. Preoperative classification of pancreatic cystic neoplasms: The clinical significance of diagnostic inaccuracy. Ann Surg Oncol 2013; 20:3112-9.
14. Koito K, Namieno T, Nagakawa T, et al. Solitary cystic tumor of the pancreas: EUS-pathologic correlation. Gastrointest Endosc 1997;45:268-76.
15. Bhosale P, Balachandran A, Tamm E. Imaging of benign and malignant cystic pancreatic lesions and a strategy for follow up. World J Radiol 2010;2:345-53.
16. Song SJ, Lee JM, Kim YJ, et al. Differentiation of intraductal papillary mucinous neoplasms from other pancreatic cystic masses: Comparison of multirow-detector CT and MR imaging using ROC analysis. J Magn Reson Imaging 2007;26:86-93.
17. 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;5:489-95.
18. Kubo H, Nakamura K, Itaba S, et al. Differential diagnosis of cystic tumors of the pancreas by endoscopic ultrasonography. Endoscopy 2009;41:684-9.
19. O’Toole D, Palazzo L, Hammel P, et al. Macrocystic pancreatic cystadenoma: The role of EUS and cyst fluid analysis in distinguishing mucinous and serous lesions. Gastrointest Endosc 2004;59:823-9.
20. Chung JW, Chung MJ, Park JY, et al. Clinicopathologic features and outcomes of pancreatic cysts during a 12-year period. Pancreas 2013;42:230-8.
21. Bai X, Zhang Q, Masood N, et al. Pancreatic cystic neoplasms: a review of preoperative diagnosis and management. J Zhejiang Univ Sci B 2013;14:185-94.
22. Demir A, Tanidir Y, Kaya H, Turkeri LN. A giant adrenal pseudocyst: Case report and review of the literature. Int Urol Nephrol 2006;38:167-9.
23. van der Waaij LA, van Dullemen HM, Porte RJ. Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis. Gastrointest Endosc 2005;62:383-9.
24. Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004;126:1330-6.
25. Gonzalez Obeso E, Murphy E, Brugge W, Deshpande V. Pseudocyst of the pancreas: the role of cytology and special stains for mucin. Cancer 2009;117:101-7.
26. Park WG-U, Mascarenhas R, Palaez-Luna M, et al. Diagnostic performance of cyst fluid carcinoembryonic antigen and amylase in histologically confirmed pancreatic cysts. Pancreas 2011;40:42-5.
27. Correa-Gallego C, Warshaw AL, Fernandez-del Castillo C. Fluid CEA in IPMNs: A useful test or the flip of a coin? Am J Gastroenterol 2009;104:796-7.
28. Chai SM, Herba K, Kumarasinghe MP, et al. Optimizing the multimodal approach to pancreatic cyst fluid diagnosis. Cancer Cytopathol 2013;121:86-100.
29. Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015;148:824-848.e22.
30. Goh BK. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2005;128:1529.
31. de Jong K, Poley J-W, van Hooft J, et al. Endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions provides inadequate material for cytology and laboratory analysis: initial results from a prospective study. Endoscopy 2011;43:585-90.
32. Thosani N, Thosani S, Qiao W, et al. Role of EUS-FNA-based cytology in the diagnosis of mucinous pancreatic cystic lesions: a systematic review and meta-analysis. Dig Dis Sci 2010;55:2756-66.
33. Bick B, Enders F, Levy M, et al. The string sign for diagnosis of mucinous pancreatic cysts. Endoscopy 2015;47:626-31.
34. Lewandrowski KB, Southern JF, Pins MR, Compton CC, Warshaw AL. Cyst fluid analysis in the differential diagnosis of pancreatic cysts, a comparison of pseudocysts, serous cystadenomas, mucinous cystic neoplasms, and mucinous cystadenocarcinoma. Ann Surg 1993;217:41-7.
35. Procacci C, Biasiutti C, Carbognin G, et al. Characterization of cystic tumors of the pancreas: CT accuracy. J Comput Assist Tomogr 1999;23:906-12.
36. Canto MI, Hruban RH, Fishman EK, et al. Frequent detection of pancreatic lesions in asymptomatic high-risk individuals. Gastroenterology 2012;142:796-804.
37. Canto MI, Goggins M, Hruban RH, et al. Screening for early pancreatic neoplasia in high-risk individuals: A prospective controlled study. Clin Gastroenterol Hepatol 2006;4:766-81.
38. 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;12:183-97.
39. Chari ST, Leibson CL, Rabe KG, et al. Probability of pancreatic cancer following diabetes: a population-based study. Gastroenterology 2005;129:504-11.
40. Mimura T, Masuda A, Matsumoto I, et al. Predictors of malignant intraductal papillary mucinous neoplasm of the pancreas. J Clin Gastroenterol 2010;44:e224-9.
41. Leal JN, Kingham TP, D’Angelica MI, et al. Intraductal papillary mucinous neoplasms and the risk of diabetes mellitus in patients undergoing resection versus observation. J Gastrointest Surg 2015;19:1974-81.

ISSN: 1302-5422
Başlangıç: 2010
Yayıncı: Türk Gastroenteroloji Vakfı

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