Spotlight on the pancreas. Klinische les Hepato-bilio-pancreatische heelkunde, 16 januari 2019

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1 Spotlight on the pancreas Klinische les Hepato-bilio-pancreatische heelkunde, 16 januari 2019

2 Overzicht 1. Cystische pancreasneoplasieën / precursorletsels 2. Pancreasadenocarcinoma 3. Chirurgische aspecten 4. Post-pancreatectomy hemorrhage (PPH)

3 1. CYSTISCHE PANCREASNEOPLASIEËN A. Classificatie B. Diagnostiek C. Management BD-IPMN!

4 A. Classificatie Del Chiaro et al. European experts consensus statement on cystic tumours of the pancreas. Digestive and liver disease 2013.

5 1. Serous cystic neoplasm Vrouwen > 60 jaar oud Geen voorkeursplaats Microcystisch, central scar Laag CEA-gehalte in cystevocht = BENIGNE > Enkel resectie als symptomatisch! Del Chiaro et al. European experts consensus statement on cystic tumours of the pancreas. Digestive and liver disease 2013.

6 - Tanaka et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology Del Chiaro et al. European experts consensus statement on cystic tumours of the pancreas. Digestive and liver disease Mucinous cystic neoplasm Bijna uitsluitend bij vrouwen, leeftijd > 40 jaar Voorkeur voor pancreascorpus of staart Hoog CEA-gehalte in cystevocht Tekens van maligne ontaarding: - Murale nodules - Wandcalcificaties - Grootte Maligne potentieel > Resectie Indien benigne: geen follow-up nodig

7 3. Solid pseudopapillary neoplasm Jonge vrouwen < 35 jaar oud Meestal t.h.v. Corpus of staart Vaste én cystische componenten, soms calcificaties Maligne potentieel met uitstekende lange termijnsoverleving > RESECTIE Kan laattijdig recidiveren én metastaseren > Levenslange follow-up Del Chiaro et al. European experts consensus statement on cystic tumours of the pancreas. Digestive and liver disease 2013.

8 4. Intraductal Papillary Mucinous Neoplasm Man=vrouw, > 50 jaar oud Main duct IPMN Branch duct IPMN Mixed type IPMN 57-92% maligniteit 6-46% maligniteit ~MD-IPMN RESECTIE Variabel maligne potentieel RESECTIE - Tanaka et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas.

9 - Tanaka et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology Tanaka et al. International consensus guidelines 2012 for the management op IPMN and MCN of the pancreas. Pancreatology Del Chiaro et al. European experts consensus statement on cystic tumours of the pancreas. Digestive and liver disease B. Diagnostiek CT of MRI Voorkeur MRI: - Betere beoordeling betrokkenheid main duct bij side-branch letsels - Minder stralenbelasting (follow-up!) EUS-FNA - Cytologie: lage sensitiviteit - Analyse cystevocht: gehalte CEA NIET gelinkt met maligniteit! - Moleculaire merkers PET/CT

10 C. Management Resectie: - Alle SYMPTOMATISCHE letsels - MCN - SPN - MD- en MT-IPMN > Branch-duct IPMN? - Tanaka et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 2006.

11 Sendai consensus criteria: BD-IPMN Resectie indien 1 of meerdere kenmerken: - Cyste diameter > 3 cm - Aanwezigheid murale nodules - Positieve cytologie - Symptomen - Dilatatie d. Wirsung (>6 mm) - Tanaka et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology Heckler et al. The Sendai and Fukuoka consensus criteria for the management of branch duct IPMN- a meta-analysis on their accuracy. Pancreatology

12 Fukuoka consensus criteria: BD-IPMN Conservatiever t.a.v. BD-IPMN: Onderscheid tussen High risk en worrisome-risk features - Tanaka et al. International consensus guidelines 2012 for the management op IPMN and MCN of the pancreas. Pancreatology Heckler et al. The Sendai and Fukuoka consensus criteria for the management of branch duct IPMN- a meta-analysis on their accuracy. Pancreatology 2017.

13 - Swaroop Vege et al. American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology Heckler et al. The Sendai and Fukuoka consensus criteria for the management of branch duct IPMN- a meta-analysis on their accuracy. Pancreatology American Gastroenterology Association Conservatiever: - Min. 2 high-risk features op beeldvorming om EUS-FNA te ondergaan - Langere intervallen bij kleine cystes zonder verdachte kenmerken (= om de 2 jaar MRI en STOP surveillance na 5 jaar) - Restrictiever qua follow-up na resectie = (low) Evidence-baced in tegenstelling tot consensus guidelines!

14 4. European experts consensus statement on cystic tumours of the pancreas Del Chiaro et al, Digestive and liver disease 2013

15 Samenvatting Del Chiaro et al. Del Chiaro et al. European experts consensus statement on cystic tumours of the pancreas. Digestive and liver disease 2013.

16 Techniek Bij vermoeden maligniteit: formele oncologische resectie met lymfadenectomie Zoniet: miltsparend proberen Parenchymsparend: totale pancreatectomie te vermijden Vriescoupe to do IPMN: hooggradige dysplasie in snedevlak > recoupe! - Tanaka et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatologu 2006.

17 Samenvatting SCN: benigne, enkel resectie als symptomatisch MCN: maligne potentieel, dus resectie. Geen follow-up als benigne SPN: maligne potentieel, radicale resectie en levenslange follow-up MD- en MT-IPMN: resectie en follow-up BD-IPMN: zoek verdachte kenmerken! - Tanaka et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology Del Chiaro et al. European experts consensus statement on cystic tumours of the pancreas. Digestive and liver disease 2013