Pankreasın Kistik Lezyonlarında Radyolojik Görüntüleme
Özet
Kistik pankreas lezyonları (KPL), görülme sıklığı %2,4 ila %24,3 arasında değişen, yaşla birlikte boyutu ve sayısı artan yaygın lezyonlardır. Farklı histolojik alt tiplerinin benzersiz prognozlar ve tedavi seçenekleri gerektirmesi nedeniyle bu lezyonların doğru karakterizasyonu hayati önem taşır. Görüntülemenin temel amacı, benign kitleleri malign olanlardan ayırt etmek, gereksiz cerrahi müdahaleleri önlemek ve malign dönüşümleri erken evrede yakalamaktır. KPL'lerin radyolojik olarak sınıflandırılmasındaki temel kriter, lezyonun ana pankreatik kanalla (APK) ilişkisidir. APK ile ilişkisiz grupta seröz kistik neoplazi (SKN), müsinöz kistik neoplazi (MKN) ve solid psödopapiller neoplazi (SPN) gibi neoplastik lezyonlar ile konjenital veya retansiyon kistleri yer alırken; APK ile ilişkili grupta en sık intraduktal papiller müsinöz neoplazi (IPMN) izlenir. Tanı sürecinde multidedektör bilgisayarlı tomografi (MDBT) ve manyetik rezonans görüntüleme (MRG) kritik öneme sahiptir. MRG ve MRKP, kanal ilişkisini belirlemede en hassas modalite iken, MDBT kalsifikasyon varlığını saptamada en iyi tekniktir. Bu lezyonların ayırıcı tanısı; morfolojik özellikler, yerleşim yeri, klinik öykü ve demografik veriler ışığında yapılarak hastaya özgü en doğru takip ve tedavi stratejisi belirlenir.
Pancreatic cystic lesions (PCLs) are common lesions with a detection prevalence ranging from 2.4% to 24.3%, and their size, number, and incidence increase with age. Accurate characterization of these lesions is essential because different histological subtypes possess distinct prognoses and require diverse therapeutic approaches. The primary objective of imaging is to differentiate benign masses from malignant ones, prevent unnecessary surgical interventions, and ensure the early detection of malignant transformation. The fundamental factor in the radiological classification of PCLs is whether the lesion is associated with the main pancreatic duct (MPD). While the MPD-unrelated group includes neoplastic lesions such as serous cystic neoplasia (SCN), mucinous cystic neoplasia (MCN), and solid pseudopapillary neoplasia (SPN), as well as congenital or retention cysts; the MPD-related group most commonly features intraductal papillary mucinous neoplasia (IPMN). Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) are required for accurate characterization. MRI combined with MRCP is the best modality for evaluating MPD communication due to its high contrast resolution, whereas MDCT is the superior technique for demonstrating the presence of calcification. Consequently, the differential diagnosis of these lesions is performed based on ductal communication, morphological features, localization, clinical history, and demographic data to determine the most accurate patient-specific follow-up and treatment strategy.
Referanslar
de Jong K, Nio CY, Hermans JJ et al (2010) High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol 8:806–811. https://doi.org/10. 1016/j.cgh.2010.05.017
Lee KS, Sekhar A, Rofsky NM, Pedrosa I (2010) Prevalence of incidental pancreatic cysts in the adult population on MR imaging. Am J Gastroenterol 105(9):2079–2084
Brugge WR (2015) Diagnosis and management of cystic lesions of the pancreas. J Gastrointest Oncol 6:375–388. https://doi.org/10.3978/j.issn. 2078-6891.2015.057
Lanke G, Lee JH (2020) Similarities and diferences in guidelines for the management of pancreatic cysts. World J Gastroenterol 26:1128–1141. https://doi.org/10.3748/wjg.v26.i11.1128
Nougaret S, Mannelli L, Pierredon MA, Schembri V, Guiu B (2016) Cystic pancreatic lesions: from increased diagnosis rate to new dilemmas. Diagn Interv Imaging 97:1275–1285. https://doi.org/10.1016/j.diii.2016. 08.017
Adler DG, Siddiqui AA (2016) What’s in a name? Pancreatic pseudocysts, walled-of necrosis, and pancreatic fuid collections. Endosc Ultrasound 5:215–217. https://doi.org/10.4103/2303-9027.187837
Lee HJ, Kim MJ, Choi JY, Hong HS, Kim KA (2011) Relative accuracy of CT and MRI in the diferentiation of benign from malignant pancreatic cystic lesions. Clin Radiol. https://pubmed.ncbi.nlm.nih.gov/21356393/. Accessed 8 Feb 2021
Kim JH, Eun HW, Park HJ, Hong SS, Kim YJ (2012) Diagnostic performance of MRI and EUS in the diferentiation of benign from malignant pancreatic cyst and cyst communication with the main duct. Eur J Radiol. https://pubmed.ncbi.nlm.nih.gov/22227264/. Accessed 8 Feb 2021
Sahani DV, Sainani NI, Blake MA, Crippa S, Mino-Kenudson M, delCastillo CF (2011) Prospective evaluation of reader performance on MDCT in characterization of cystic pancreatic lesions and prediction of cyst biologic aggressiveness. AJR Am J Roentgenol 197:W53-61. https:// doi.org/10.2214/AJR.10.5866
Banks PA, Bollen TL, Dervenis C et al (2013) Classifcation of acute pancreatitis–2012: revision of the Atlanta classifcation and defnitions by international consensus. Gut 62:102–111. https://doi.org/10.1136/ gutjnl-2012-302779 18. Fernández-del Castillo C
Bluth EI. Ultrasound, a practical approach to clinical problems. George Thieme Verlag. (2000) ISBN:0865778612
Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology. 2012;262 (3): 751-64. doi:10.1148/radiol.11110947
Fernández-del Castillo C, Targarona J, Thayer SP, Rattner DW, Brugge WR, Warshaw AL (2003) Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg Chic Ill 1960 138:427–423; discussion 433–434. https://doi.org/10.1001/ archsurg.138.4.427
Banks PA, Bollen TL, Dervenis C et al (2013) Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut 62:102–111. https://doi.org/10.1136/ gutjnl-2012-302779
Takahashi N, Papachristou GI, Schmit GD et-al. CT findings of walled-off pancreatic necrosis (WOPN): differentiation from pseudocyst and prediction of outcome after endoscopic therapy. Eur Radiol. 2008;18 (11): 2522-9. doi:10.1007/s00330-008-1039-1
Cui ML, Kim KH, Kim HG et al (2014) Incidence, risk factors and clinical course of pancreatic fuid collections in acute pancreatitis. Dig Dis Sci 59:1055–1062. https://doi.org/10.1007/s10620-013-2967-4
Macari M, Finn ME, Bennett GL et al (2009) Diferentiating pancreatic cystic neoplasms from pancreatic pseudocysts at MR imaging: value of perceived internal debris. Radiology 251:77–84. https://doi.org/10. 1148/radiol.2511081286
Ren F, Zuo C, Chen G et al (2013) Pancreatic retention cyst: multimodality imaging fndings and review of the literature. Abdom Imaging 38:818–826. https://doi.org/10.1007/s00261-012-9976-1
Megibow AJ, Baker ME, Morgan DE et al (2017) Management of incidental pancreatic cysts: a white paper of the ACR incidental fndings committee. J Am Coll Radiol 14:911–923. https://doi.org/10.1016/j. jacr.2017.03.010
Al-Salem AH (2014) Congenital pancreatic cysts. In: Al-Salem AH (ed) An illustrated guide to pediatric surgery. Springer, Cham, pp 309–313
Del Chiaro M, Verbeke C, Salvia R et al (2013) European experts consensus statement on cystic tumors of the pancreas. Dig Liver Dis 45:703–711. https://doi.org/10.1016/j.dld.2013.01.010
Buck J & Hayes W. From the Archives of the AFIP. Microcystic Adenoma of the Pancreas. Radiographics. 1990;10(2):313-22. doi:10.1148/radiographics.10.2.2183300
Ishigami K, Nishie A, Asayama Y, Ushijima Y, Takayama Y, Fujita N, Takahata S, Ohtsuka T, Ito T, Igarashi H, Ikari S, Metz CM, Honda H. Imaging pitfalls of pancreatic serous cystic neoplasm and its potential mimickers. World J Radiol. 2014 Mar 28;6(3):36-47. doi: 10.4329/wjr.v6.i3.36
Neumann HP, Dinkel E, Brambs H et al (1991) Pancreatic lesions in the von Hippel-Lindau syndrome. Gastroenterology 101:465–471
Jais B, Rebours V, Malleo G et al (2016) Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). Gut 65:305–312. https://doi.org/10.1136/gutjnl-2015-309638
Buetow PC, Rao P, Thompson LD (1998) From the archives of the AFIP. Mucinous cystic neoplasms of the pancreas: radiologic-pathologic correlation. Radiographics 18:433–449. https://doi.org/10.1148/radiograph ics.18.2.9536488
Zamboni G, Scarpa A, Bogina G et al (1999) Mucinous cystic tumors of the pancreas: clinicopathological features, prognosis, and relationship to other mucinous cystic tumors. Am J Surg Pathol 23:410–422
Goh BKP, Tan Y-M, Chung Y-FA et al (2006) A review of mucinous cystic neoplasms of the pancreas defined by ovarian-type stroma: clinicopathological features of 344 patients. World J Surg 30:2236–2245. https://doi.org/10.1007/s00268-006-0126-1
2. Lv P, Mahyoub R, Lin X et-al. Differentiating pancreatic ductal adenocarcinoma from pancreatic serous cystadenoma, mucinous cystadenoma, and a pseudocyst with detailed analysis of cystic features on CT scans: a preliminary study. Korean J Radiol. 12 (2): 187-95. doi:10.3348/kjr.2011.12.2.187
Buetow PC, Rao P, Thompson LD (1998) From the archives of the AFIP. Mucinous cystic neoplasms of the pancreas: radiologic-pathologic correlation. Radiographics 18:433–449. https://doi.org/10.1148/radiograph ics.18.2.9536488
Di Paola V, Manfredi R, Mehrabi S et al (2016) Pancreatic mucinous cystadenomas and cystadenocarcinoma: differential diagnosis by means of MRI. Br J Radiol. https://doi.org/10.1259/bjr.20150536
Coleman KM, Doherty MC, Bigler SA (2003) Solid-pseudopapillary tumor of the pancreas. Radiographics 23:1644–1648. https:// doi. org/ 10. 1148/ rg. 23603 5006
Buetow PC, Buck JL, Pantongrag-Brown L, Beck KG, Ros PR, Adair CF (1996) Solid and papillary epithelial neoplasm of the pancreas: imaging-pathologic correlation on 56 cases. Radiology 199:707–711. https:// doi. org/ 10. 1148/ radiology. 199.3. 86379 92
Anil G, Zhang J, Al Hamar NE, Nga ME. Solid pseudopapillary neoplasm of the pancreas: CT imaging features and radiologic-pathologic correlation. Diagn Interv Radiol. 2017 Mar-Apr;23(2):94-99. doi: 10.5152/dir.2016.16104
Zhu J-K, Wu D, Xu J-W et al (2019) Cystic pancreatic neuroendocrine tumors: a distinctive subgroup with indolent biological behavior? A systematic review and meta-analysis. Pancreatology 19:738–750. https://doi.org/10.1016/j.pan.2019.05.462
Singhi AD, Chu LC, Tatsas AD et al (2012) Cystic pancreatic neuroendocrine tumors: a clinicopathologic study. Am J Surg Pathol 36:1666–1673. https://doi.org/10.1097/PAS.0b013e31826a0048
Machado NO, Al Qadhi H, Al Wahibi K(2015) Intraductal papillary mucinous neoplasm of pancreas. North Am J Med Sci 7:160–175. https://doi. org/10.4103/1947-2714.157477
Tanaka M, Fernández-del Castillo C, Adsay V et al (2012) International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 12:183–197. https://doi.org/10.1016/j.pan. 2012.04.004
Pilleul F, Rochette A, Partensky C, Scoazec JY, Bernard P, Valette PJ (2005) Preoperative evaluation of intraductal papillary mucinous tumors performed by pancreatic magnetic resonance imaging and correlated with surgical and histopathologic fndings. J Magn Reson Imaging JMRI 21:237–244. https://doi.org/10.1002/jmri.20254
