胰腺囊性肿瘤的诊疗

doi:10.3877/cma.j.issn.1674-6899.2022.01.009

图1 浆液性囊腺瘤影像学注：A.CT平扫下胰尾处呈分叶状囊性改变；B.CT增强后见囊壁、囊内分隔强化；C.MRI中T₂WI可见多个大小不等的高信号囊腔；D、E.T₁WI由动脉期到实质期，囊壁及囊内分隔逐渐强化；F.T₁WI示增强期冠状位；G.常规超声检查下胰尾处低-无回声病灶；H.造影动脉期囊壁及分隔均呈强化，边界清楚，呈分叶状。箭头所示囊腺瘤位置

图2 黏液性囊腺瘤影像检查注：A.CT平扫下胰尾处一囊性占位；B.CT增强后见囊壁明显强化；C.MRI中T₂WI可见一高信号影，边界清楚；D、E.T₁WI由动脉期到实质期，囊壁逐渐地强化较SCN囊壁增强明显；F.T₁WI示增强期冠状位；G.常规超声下胰尾处一囊性结构，囊壁增厚；H.造影后囊内未见增强，囊壁可见明显增强。箭头所示囊腺瘤位置

图3 胰腺实性假乳头状瘤影像学注：A.CT平扫下胰头囊实性占位；B.CT增强后见实性成分强化，囊性成分与实性成分相间分布；C.MRI中T₂WI可见一稍高低混杂信号影，边界清楚；D、E.T₁WI由动脉期到实质期，病灶逐渐强化，与正常胰腺实质存在差异；F.T₁WI示增强期冠状位；G.MRCP示囊实性病灶未与胰管相连。箭头所示胰腺实性假乳头状瘤位置

图4 主胰管型IPMN影像学注：A.MRI中T₂WI可见主胰管扩张，胰体部囊性病灶；B、C.T₁WI由动脉期到实质期，主胰管及囊性病灶未见明显强化；D.MRCP示主胰管全称囊性扩张。箭头所示扩张胰管位置

图5 分支胰管型IPMN影像学注：A、B.分支胰管型；C.混合型；A.MRCP中T₂WI可见胰腺钩突囊性病灶；B.囊性病灶成葡萄串样并与主胰管相连；C.胰腺钩突成葡萄串样囊性病灶与主胰管相连，胰尾部囊性病灶，主胰管扩张

表1 胰腺囊性肿瘤的分类及特征

分类	常见年龄(岁)	性别比	发病部位	影像学特征	主胰管关系
SCN	50~70	70%女性	50%胰体尾	多囊，"蜂窝状"，中央钙化或星状瘢痕为特征表现	不相通
MCN	50~70	90%~95%女性	80%~90%胰体尾	单囊，巨囊，"蛋壳样"钙化	不相通
MD/MT-IPMN	50~70	男女相当	主胰管	主胰管扩张伴(或不伴)侧支扩张	相通
BD-IPMN	50~70	男女相当	50%胰头、7%胰尾、4%钩突、其他部位39%	分支胰管扩张	相通
SPN	20~30	90%女性	头、体、尾比例相当	实性和(或)囊性混杂肿块	不相通

表1 胰腺囊性肿瘤的分类及特征

分类	常见年龄(岁)	性别比	发病部位	影像学特征	主胰管关系
SCN	50~70	70%女性	50%胰体尾	多囊，"蜂窝状"，中央钙化或星状瘢痕为特征表现	不相通
MCN	50~70	90%~95%女性	80%~90%胰体尾	单囊，巨囊，"蛋壳样"钙化	不相通
MD/MT-IPMN	50~70	男女相当	主胰管	主胰管扩张伴(或不伴)侧支扩张	相通
BD-IPMN	50~70	男女相当	50%胰头、7%胰尾、4%钩突、其他部位39%	分支胰管扩张	相通
SPN	20~30	90%女性	头、体、尾比例相当	实性和(或)囊性混杂肿块	不相通

图6 2015版胰腺外科学组常见胰腺囊性肿瘤的治疗策略注：^a出现相关症状(如腹痛、肿块压迫、黄疸、呕吐等)，肿瘤位于胰头部，无法完全排除恶变，出现侵袭性表现(如肿瘤侵犯周围组织等)；^b肿瘤直径>3 cm，有壁结节，主胰管扩张>10 mm，胰液细胞学检查发现高度异型细胞，引起相关症状，肿瘤快速生长≥2 mm/年，CAl9-9水平高于正常值

图7 2015版美国胃肠病学会胰腺囊性肿瘤的诊疗策略

图8 2017版国际胰腺病学协会关于分支胰管型诊疗策略注：^a合并胰腺炎时，手术能同时缓解胰腺炎；^b管壁增厚、导管内黏蛋白或壁结节均提示主管胰受累

图9 2018版欧洲指南的关于IPMN的诊疗策略

表2 胰腺囊性肿瘤手术适应证

指南	手术指征
2015版胰腺外科学组指南	SCN: ①≥6 cm；②<6 cm，出现相关症状(如黄疸、肿块压迫等)，位于胰头，恶性不除外，侵犯周围组织 MCN：全部的 SPN：全部的 MD-IPMN和MT-IPMN：全部的 BD-IPMN：>3 cm，有壁结节，胰管扩张≥10 mm，细胞学检测发现高度异型细胞，引起相关症状(如黄疸、胰腺炎等)，肿瘤快速生长≥2 mm/年，实验室检验CA19-9水平高于正常值
2015版AGA指南	针对所有的胰腺囊性肿瘤：出现实性肿块+胰管扩张≥5 mm，细胞学检测阳性
2017版IAP指南	MCN：所有的 MD-IPMN和MT-IPMN：所有的 BD-IPMN：①绝对指征，恶性肿瘤或细胞学检测发现高度异型细胞，黄疸，存在对比增强的附壁结节(≥5 mm)，胰管扩张≥10 mm；②相对指征，生长≥5 mm/2年，血清CA19-9水平增高，胰管扩张5.0~9.9 mm或胰管突然扩张伴远端胰腺萎缩，囊肿直径≥30 mm并且存在增厚或对比增强的囊壁，对比增强的附壁结节<5 mm，急性胰腺炎，周围淋巴结肿大
2018版欧洲指南	SCN：保守处理，当出现相关症状或恶性不除外进行手术。囊灶大小不再作为指标 MCN：≥40 mm，存在对比增强的附壁结节，出现引起的相关症状(黄疸、胰腺炎等) SPN：所有的 MD-IPMN和MT-IPMN：所有的 BD-IPMN：①绝对指征，恶性肿瘤或细胞学检测发现高度异型细胞，出现黄疸，实性肿块，存在对比增强的附壁结节(≥5 mm)，胰管扩张≥10 mm；②相对指征，生长≥5 mm/年，血清CA19-9水平增高(无黄疸时>37 U/ml)，胰管扩张5.0~9.9 mm，囊肿直径≥40 mm，对比增强的附壁结节<5 mm，出现引起的相关症状(急性胰腺炎、新发糖尿病等)

表2 胰腺囊性肿瘤手术适应证

指南	手术指征
2015版胰腺外科学组指南	SCN: ①≥6 cm；②<6 cm，出现相关症状(如黄疸、肿块压迫等)，位于胰头，恶性不除外，侵犯周围组织 MCN：全部的 SPN：全部的 MD-IPMN和MT-IPMN：全部的 BD-IPMN：>3 cm，有壁结节，胰管扩张≥10 mm，细胞学检测发现高度异型细胞，引起相关症状(如黄疸、胰腺炎等)，肿瘤快速生长≥2 mm/年，实验室检验CA19-9水平高于正常值
2015版AGA指南	针对所有的胰腺囊性肿瘤：出现实性肿块+胰管扩张≥5 mm，细胞学检测阳性
2017版IAP指南	MCN：所有的 MD-IPMN和MT-IPMN：所有的 BD-IPMN：①绝对指征，恶性肿瘤或细胞学检测发现高度异型细胞，黄疸，存在对比增强的附壁结节(≥5 mm)，胰管扩张≥10 mm；②相对指征，生长≥5 mm/2年，血清CA19-9水平增高，胰管扩张5.0~9.9 mm或胰管突然扩张伴远端胰腺萎缩，囊肿直径≥30 mm并且存在增厚或对比增强的囊壁，对比增强的附壁结节<5 mm，急性胰腺炎，周围淋巴结肿大
2018版欧洲指南	SCN：保守处理，当出现相关症状或恶性不除外进行手术。囊灶大小不再作为指标 MCN：≥40 mm，存在对比增强的附壁结节，出现引起的相关症状(黄疸、胰腺炎等) SPN：所有的 MD-IPMN和MT-IPMN：所有的 BD-IPMN：①绝对指征，恶性肿瘤或细胞学检测发现高度异型细胞，出现黄疸，实性肿块，存在对比增强的附壁结节(≥5 mm)，胰管扩张≥10 mm；②相对指征，生长≥5 mm/年，血清CA19-9水平增高(无黄疸时>37 U/ml)，胰管扩张5.0~9.9 mm，囊肿直径≥40 mm，对比增强的附壁结节<5 mm，出现引起的相关症状(急性胰腺炎、新发糖尿病等)

图10 胰腺钩突黏液性囊腺瘤局部切除+胰管修复手术步骤注：A.显露胰头后方，见肿瘤位于胰钩突；B.肿瘤切除后，主胰管断开；C.主胰管支撑管置入后修复；下腔静脉(inferior vena cava, IVC)；主胰管(main pancreatic duct，MPD)

图11 胰腺中段SPT切除、端-端吻合术手术步骤注：A.中段胰腺切除后；B.远近端主胰管内置入胰管支架；C.胰腺端-端对拢缝合；D.胰腺端-端吻合完成

图12 分支胰管型原位局部切除手术步骤注：A、B.胰腺钩突部的分支胰管型原位切除联合主胰管架桥修复术法；C、D.胰颈部分支胰管型原位切除联合齐根结扎法；A.原位切除病变后，远近端胰管置入支撑管；B.完成胰管对端吻合；C.分离病变与正常胰腺实质，直至分支胰管根部；D.齐根结扎病变处分支胰管，原位切除囊性病变区域

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Diagnosis and treatment of pancreatic cystic neoplasms

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Diagnosis and treatment of pancreatic cystic neoplasms