PANKREASIN NEOPLASTİK KİSTİK TÜMÖRLERİNDE PRATİKLER, BİR EĞİTİM ve ARAŞTIRMA HASTANESİ DENEYİMİ

ÖZET Amaç: Çoğunlukla insidental olarak rastlanan ve malign olma ihtimalinden dolayı pankreasın neoplastik kistik lezyonlarının, Amerikan Gastroenteroloji Derneğinin 2015 kılavuzu örnekliğinde, pratik noktalarını ortaya koymayı amaçladık. Gereç ve Yöntem: Pankreas neoplastik kistik tümörlü 25 hasta retrospektif olarak incelendi. Hastaların yaşları, cinsiyetleri, ilk ön tanılarını aldıklarında insidental mi semptomatik mi olduğu, ilk yönlendirici radyolojik tetkikikin USG, BT, MR (+/- MRCP) veya diğer yönlendirici faktörler ve takiplerinde EUS bulguları ( aspirasyon sıvısında amilaz, CEA, CA 19-9, ince iğne hücre aspirasyon sonuçları) değerlendirildi. Tüm hastaların yönlendirme sonrası eksikleri giderilerek MR-MRCP ve EUS’ları tamamlandı. Hastaların takip ve cerrahisi değerlendirildi. Bulgular: 25 hastanın 18(%72)’si kadın, 7(%28)’i erkekti. Ortalama yaş 57,3 olup 30-77 aralığında değişmekteydi. Seröz kistik tümörlü 10(%40), Müsinöz kistik tümörlü 6(%24), intraduktal papiller müsinöz tümörlü 8(%32), solid psödopapiller tümörlü 1(%4) hasta değerlendirildi. MR-MRCP ve EUS bulguları tanı koymada uyumlu ve tamamlayıcıydı. Ameliyat edilen 7(%28) hastanın patoloji sonuçları uyumlu olup 1(%4) hastada invaziv kanser tesbit edildi. Sonuç: Pankreasın neoplastik kistik tümörleri çoğunlukla insidental olarak tesbit edilir. Malign potansiyel taşıyabileceğinden dolayı ileri tetkikler MR-MRCP ve EUS (sıvı ve hücre aspiratı incelemeleri dahil) ile yapılmalı; tanı, takip ve cerrahi kararı uygun ve pratik yönlendirmeleri nedeniyle AGA 2015 kılavuzuna göre verilmelidir.

Anahtar Kelimeler:

pankreas kistleri, MR-MRCP, EUS, AGA 2015 klavuzu

PRACTICES IN PANCREATIC NEOPLASTIC CYSTIC TUMORS, A TRAINING AND RESEARCH HOSPITAL EXPERIENCE

ABSTRACT Objective: Neoplastic cystic tumors of the pancreas are mostly incidentally detected and they carry risk of malignancy. We aimed to reveal practical points of the management according to 2015 guideline of the American Gastroenterology Association. Material and Method: Twenty-five patients with pancreatic neoplastic cystic tumors were retrospectively analyzed. Patients' ages, genders, whether they were incidental or symptomatic when they received their initial pre-diagnosis with USG, CT, MR (+/- MRCP) or other guiding factors and EUS findings (amylase, CEA, CA 19-9 in the aspiration fluid and cell aspiration results) were evaluated. MR-MRCP and EUSs of all patients were completed. The follow-up and surgery of the patients were evaluated. Results: Of the 25 patients, 18 (72%) were female and 7 (28%) were male. The average age was 57.3 and ranged from 30-77. Ten (40%) patients with serous cystic tumor, 6 (24%) with mucinous cystic tumor, 8 (32%) with intraductal papillary mucinous tumor, and 1 (4%) with solid pseudopapillary tumor were evaluated. MR-MRCP and EUS findings were compatible and complementary in diagnosis. Pathology results of 7 (28%) operated patients were compatible and 1 (4%) patient had invasive cancer. Conclusion: Neoplastic cystic tumors of the pancreas are mostly detected incidentally. Further investigations should be done with MR-MRCP and EUS (including fluid and cell aspirate examinations) as they may have malignant potential; The diagnosis, follow-up and surgical decision should be made according to the AGA 2015 guideline due to its appropriate and practical guidance.

Keywords:

Pankreatic cysts, MR-MRCP, Endoscopic Ultrasound,

PDF

___

1- Megibow AJ, Baker ME, Gore RM, Taylor A. The incidental pancreatic cyst. Radiol Clin North Am. 2011;49:349–359.
2- Lee KS, Sekhar A, Rofsky NM, Pedrosa I. Prevalence of incidental pancreatic cysts in the adult population on MR imaging. Am J Gastroenterol. 2010;105:2079–2084.
3- 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.
4- Zamboni G, Kloeppel G, Hruban RH, Klöppel G. Mucinous cystic neoplasms of the pancreas. In: Aaltonen LA, Hamilton SR, editors. World health organization classification of tumours. pathology and genetics of tumours of the digestive system. Lyon, France: IARC Press; 2000. p. 234.
5- Santhi Swaroop Vege, Barry Ziring, Rajeev Jain, Paul Moayyedi, and the Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts. Gastroenterology 2015;148:819–822.
6- Nakai Y, Isayama H, Itoi T, Yamamoto N, Kogure H, Sasaki T, et al. Role of endoscopic ultrasonography in pancreatic cystic neoplasms: where do we stand and where will we go? Dig Endosc. 2014;26(2):135-43.
7- Brugge WR, Lewandrowski K, Lee-Lewandrowski E, Centeno BA, Szydlo T, Regan S, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology. 2004;126(5):1330-6.
8- Springer S, Wang Y, Dal Molin M, Masica DL, Jiao Y, Kinde I, et al. A combination of molecular markers and clinical features improve the classification of pancreatic cysts. Gastroenterology. 2015;149(6):1501-10. doi: 10.1053/j.gastro.2015.07.041.
9- Bick BL, Enders FT, Levy MJ, Zhang L, Henry MR, Abu Dayyeh BK, Chari ST, Clain JE, Farnell MB, Gleeson FC, et al. The string sign for diagnosis of mucinous pancreatic cysts. Endoscopy. 2015;47:626–631.
10- Raquel Herranz Pérez, Felipe de la Morena López, Cecilio SantanderVaquero. Diagnostic Approach to Cystic Pancreatic Neoplasms. Rev Col Gastroenterol vol.34 no.1 Bogotá Jan./Mar. 2019.
11- Yunus Yavuz, Rıfat Yalın. Pankreasın kistik tümörleri: Ayırıcı tanının önemi. Turkish Journal of Surgery, 2020.
12- Austin L Chiang and Linda S Lee. Clinical approach to incidental pancreatic cysts. World J Gastroenterol. 2016 Jan 21; 22(3): 1236–1245.
13- Basar O, Brugge WR. Pancreatic cyst guidelines: Which one to live by? Gastrointest Endosc. 2017;85(5):1032-1035.
14- Miyasaka Y, Ohtsuka T, Tamura K, Mori Y, Shindo K, Yamada D, et al. Predictive Factors for the Metachronous Development of High-risk Lesions in the Remnant Pancreas After Partial Pancreatectomy for Intraductal Papillary Mucinous Neoplasm