Pankreasın neoplastik kistlerinde tanı parametreleri: Tek merkez deneyimi

Yıl 2019, , 38 - 51, 18.09.2019

Ali İlter Göksel Bengi Müjde Soytürk

https://doi.org/10.17940/endoskopi.631784

Öz

 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

Öz

 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.

Anahtar Kelimeler

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

Kaynakça

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