臨牀消化器内科 Vol.24 No.9(8)


特集名 膵管内乳頭粘液性腫瘍(IPMN)
題名 IPMN全国調査
発刊年月 2009年 08月
著者 鈴木 裕 杏林大学医学部外科
著者 杉山 政則 杏林大学医学部外科
著者 阿部 展次 杏林大学医学部外科
著者 柳田 修 杏林大学医学部外科
著者 正木 忠彦 杏林大学医学部外科
著者 森 俊幸 杏林大学医学部外科
著者 跡見 裕 杏林大学医学部外科
【 要旨 】 膵管内乳頭粘液性腫瘍（intraductal papillary mucinous neoplasm；IPMN）全国症例調査の結果をもとに，IPMNの臨床病理像，治療方針を検討した．主膵管型および複合型は分枝膵管型に比しいずれも有意に腺癌症例が多く(65％，60％ vs 29％)，複合型は主膵管型と同様に取り扱うべきと思われた．サブタイプ別の良悪性を比較検討すると主膵管型・複合型では女性例，膵全体病変，主膵管径8mm以上，乳頭開大例，壁在結節径3mm以上，分枝膵管型ではなんらかの膵疾患・異常所見を有する場合，膵頭部病変，囊胞径33mm以上，主膵管径5mm以上，乳頭開大例，壁在結節径2mm以上が有意に腺癌を多く認めた．19.0％にほかの悪性腫瘍を合併し，78.6％が消化器癌であった．術後遠隔成績に関しては腫瘍の進展に応じて生存率が低下する傾向にあった．IPMNの治療方針に関しては，主膵管型・複合型は60％以上が腺癌であり，原則として手術適応とすべきである．また，分枝膵管型は腺癌の危険因子を有する例に加え，有症状例は手術を念頭において取り扱うべきと思われた．しかしながら，膵頭部病変やなんらかの膵疾患・異常所見を有する場合，乳頭開大例に対する取り扱いは問題となる．現状では囊胞径や主膵管径，壁在結節径などによって決定すべきと思われるが，腺癌の危険性を念頭においてのフォローが必要である．また，他臓器癌を高率に合併するため，局所のみでなく他臓器の精査も重要である．
Theme Intraductal Papillary Mucinous Neoplasm (IPMN)
Title Japanese Multiinstitutional Study of Pancreatic Intraductal Papillary Mucinous Neoplasms
Author Yutaka Suzuki Department of Surgery, Kyorin University School of Medicine
Author Masanori Sugiyama Department of Surgery, Kyorin University School of Medicine
Author Nobutsugu Abe Department of Surgery, Kyorin University School of Medicine
Author Osamu Yanagida Department of Surgery, Kyorin University School of Medicine
Author Tadahiko Masaki Department of Surgery, Kyorin University School of Medicine
Author Toshiyuki Mori Department of Surgery, Kyorin University School of Medicine
Author Yutaka Atomi Department of Surgery, Kyorin University School of Medicine
[ Summary ] An analysis of management for intraductal papillary mucinous neoplasms (IPMN) was performed in relation to the results of a Japanese multiinstitutional retrospective study of IPMN. The main duct type and the combined type are more likely to be adenocarcinoma than the branch duct type, with significant ration exhibited (65%, 60% vs 29%) . Predictive factors for malignant IPMN were female gender, wide spread pancreatic lesions, main duct diameter 8mm or greater, enlarged papilla orifice or mural nodule size 3mm or greater in main duct type and combined type conditions. Predictive factors include other pancreatic disorders, lesions in the pancreatic head, main duct diameter 5mm or greater, cyst diameter 33mm or larger, enlarged papilla orifice and mural nodule size 2mm or more in the branch duct type. The five-year survival rate for IPMN patients was 98-100% with adenoma or noninvasive carcinoma. Survival rates were 89% for minimally invasive carcinoma, and 57.7% for invasive carcinoma. With main duct and combined type conditions, all cases require surgery because of high rates of adenocarcinoma.In patients with the branch duct type, IPMN requires resection if tumors present one or more features which are symptomatic and predictive factors for malignant IPMN are observed. However, in patients with small tumors located in the pancreatic head, small tumors with other pancreatic disorders or enlarged papilla orifices, follow ups can be performed without surgery. However, periodic check ups for changes in these tumors, employing regular diagnostic imaging, are necessary. Complete checks of other organs are needed because IPMN frequently associated with other malignant neoplasms.
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