胰腺囊性肿瘤的诊断与治疗

Diagnosis and treatment of pancreatic cystic neoplasms

    摘要
  • 摘要: 目的:探讨胰腺囊性肿瘤的临床特点以及诊断与治疗。
    方法:回顾性分析2010年1月至2014年12月安徽医科大学第一附属医院收治的62例胰腺囊性肿瘤患者的临床资料。良性黏液性囊腺瘤(MCN)、浆液性囊腺瘤(SCN)、良性实性假乳头状瘤(SPN)、导管内乳头状黏液瘤(IPMN)设为良性肿瘤患者，交界性或恶性 MCN、交界性或恶性IPMN设为恶性肿瘤患者。分析患者性别、年龄、临床症状、影像学检查结果、实验室检查结果、手术方式、手术时间、术中出血量、围术期并发症、病理学检查结果和随访结果等指标。采用电话及门诊复查相结合的方式随访，随访时间截至2014年12月31日或患者死亡。正态分布的计量资料以±s表示，非正态分布的计量资料以M(范围)表示，计数资料采用χ2检验或Fisher确切概率法进行单因素分析，采用Logistic回归模型进行多因素分析。
    结果:62例患者中，31例因上消化道不适症状等就诊，10例无特异性表现，在健康体检时发现，10例近2～3个月出现体质量明显减轻，9例可触及腹部包块，2例因梗阻性黄疸入院。62例患者影像学检查发现肿瘤直径为(60±35)mm；肿瘤位于头颈部11例，胰体尾部51例。其中33例患者发现囊内结节或实性成分，6例发现主胰管扩张。患者B超、 CT、MRI、超声内镜(EUS)及PET/CT检查的诊断阳性率分别为85.5%(53/62)、93.2%(55/59)、94.1%(16/17)、100.0%(3/3)及100.0%(2/2)。62例患者术前CEA为1.22 μg/L(0.20~12.98 μg/L)， CA19-9为10.85 U/mL(0.60~1 000.00 U/mL)；CEA升高者仅占4.8%(3/62)，CA19-9升高者仅占14.5%(9/62)。62例患者均行手术治疗，其中联合脾脏切除的胰体尾切除术36例，胰十二指肠切除术10例，胰腺部分切除术7例，保留脾脏的胰体尾切除术6例，单纯囊肿切除术2例，姑息性胆肠RouxenY吻合术1例。手术切除率为98.4%(61/62)，手术时间为(219±79)min，术中出血量为(299±296)mL。术后13例患者出现不同程度的并发症，经过禁食、止血、抗感染等对症支持处理均好转。病理学检查结果：MCN 27例(恶性或交界性MCN 11例)，SCN 18例，SPN 11例，IPMN 6例(恶性或交界性IPMN 3例)。62例患者获得随访，随访时间为3～63个月，2例恶性肿瘤患者死亡，其余患者预后良好。单因素分析结果：发病年龄、肿瘤直径、术前CEA、术前CA19-9是影响患者肿瘤恶性程度的相关因素(χ2=18.798，12.335，7.281，10.073，P< 0.05)。多因素分析结果：年龄≥65岁、术前CA19-9≥34.00 U/mL是影响患者肿瘤恶性程度的独立危险因素(RR=0.923，0.994；95%可信区间：0.863～0.987，0.988～0.999，P<0.05)。
    结论:胰腺囊性肿瘤无特异性临床表现；B超、CT和MRI检查是胰腺囊性肿瘤的主要检查方法；胰腺囊性肿瘤患者术后总体预后较好；年龄≥65岁和术前CA19-9≥34.00 U/mL是胰腺囊性肿瘤恶性程度的独立危险因素。

     

    Abstract: Objective:To investigate the clinical features, diagnosis and treatment  of pancreatic cystic neoplasms.
    Methods:The clinical data of 62 patients with pancreatic cystic neoplasms who were admitted to the First Affiliated Hospital of Anhui Medical University from January 2010 to December 2014 were retrospectively analyzed. Benign neoplasms included benign mucinous cystic neoplasm (MCN), serous cystic neoplasm (SCN), solid pesudopapillary neoplasm (SPN) and intraductal papillary mucinous neoplasm (IPMN) and malignant neoplasms included borderline or malignant MCN and borderline or malignant IPMN. The sex, age, clinical symptoms, imaging features, laboratory results, surgical method, operation time, volume of intraoperative blood loss,perioperative complications, result of pathological examination and followup were analyzed. Patients were followed up by telephone interview and outpatient examination up to 31, December 2014 or death. Measurement data with normal distribution were presented by ±s, while measurement data with nonnormal distribution were presented by M (range). Univariate analysis of count data was done by chisquare test or Fisher exact probability. Multivariate analysis was done by Logistic regression model.
    Results:Of the 62 patients with pancreatic cystic neoplasms, 31 were retreated due to upper digestive discomfort, 10 without specific features were found during the health examinations, 10 due to weight loss in near 2-3 months, 9 due to abdominal masses and 2 due to obstructive jaundice. Results of radiographic examinations showed that the diameter of the tumor is (60±35)mm, 11 of tumors located in the head and neck of pancreas and 51 located in the body and tail of pancreas. The cystic nodule or solid ingredients were detected in 33 patients and main pancreatic duct dilation in 6 patients. The positive diagnostic rates of B ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasonography (EUS) and positron emission tomographycomputed tomography (PET/CT) were 85.5%(53/62), 93.2%(55/59), 94.1%(16/17), 100.0%(3/3) and 100.0%(2/2). Preoperative serum CEA and serum CA19-9 were 1.22 μg/L(0.20-12.98 μg/L) and 10.85 U/mL (0.60-1 000.00 U/mL), while the percentage of patients with increasing CEA and CA19-9 were 4.8%(3/62) and 14.5%(9/62), respectively. All the 62 patients received surgery, distal pancreatectomy (DP) combined with splenectomy were performed on 36 patients, pancreatoduodenectomy on 10 patients, partial pancreatic resection on 7 patients, spleenpreserving DP on 6 patients, cystresection on 2 patients and palliative RouxenY anastomosis on 1 patient. The rate of surgical resection, operation time and volume of blood loss were 98.4%(61/62), (219±79)minutes and (299±296)mL. After operation, 13 patients had different degrees of complication, and were improved by symptomatic treatment such as jejunitas, hemostasis and antiinfection. The results of pathological examination showed that 27 patients were with MCN (11 with malignant or borderline MCN), 18 with SCN, 11 with SPN and 6 with IPMN (3 with malignant or borderline IPMN). All the patients were followed up for 3-63 months with good prognoses, except for the death of 2 patients. The results of univariate analysis showed that age of onset, tumor diameter, preoperative serum CEA and preoperative serum CA19-9 were related factors affecting diagnosis of malignant tumor (χ2=18.798, 12.335, 7.281, 10.073, P<0.05). The results of multivariate analysis showed that age≥65 years and preoperative serum CA19-9≥34.00 U/mL were independent risk factors affecting diagnosis of malignant tumor (RR=0.923, 0.994; 95% confidence interval: 0.863-0.987, 0.988-0.999; P<0.05).
    Conclusions:B ultrasound, CT and MRI are the main diagnostic methods for pancreatic cystic neoplasms without specific clinical features. Patients with pancreatic cystic neoplasms have overall good prognosis. The results of multivariate analysis showed that age≥ 65 years and preoperative serum CA19-9≥34.00 U/mL are independent risk factors affecting tumor malignancy.

     

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