Mucinous Cystic Neoplasms of the Pancreas: Imaging Features and Diagnostic Difficulties

doi:10.1053/crad.1999.0341

Clinical Radiology

Volume 55, Issue 3, March 2000, Pages 187-192

https://doi.org/10.1053/crad.1999.0341 Get rights and content

Abstract

AIMS: To review the imaging features of mucinous cystic neoplasms (MCNs) of the pancreas and to highlight difficulties in differentiating these lesions from pancreatic pseudocysts.

MATERIALS AND METHODS: The imaging investigations, case notes and histopathology of 13 patients who underwent surgery for an MCN of the pancreas, were reviewed.

RESULTS: An erroneous diagnosis of a pancreatic pseudocyst had been made in five of the 13 cases and in two patients cystenterostomy had been performed. Only one patient had a documented history of acute pancreatitis although mildly elevated serum amylase levels were identified in a further five cases. CT and US correctly diagnosed a cystic pancreatic mass in all 13 patients, however cross-sectional imaging features of neoplasia, such as septae, cyst wall calcification, focal thickening of the cyst wall and papillary projections, were absent in five (38%) cases. Coexistent imaging features of chronic pancreatitis were present in five of the 13 patients and in six resected specimens. Cyst wall calcification occurred only in malignant lesions and there was no relationship between cyst size and the degree of malignancy. While ERCP, angiography, and percutaneous needle aspiration may provide additional information, the majority of these examinations were either unhelpful or even misleading.

CONCLUSION: MCNs of the pancreas are frequently diagnosed and mismanaged as pancreatic pseudocysts with an associated increase in patient morbidity and mortality. Diagnostic imaging can help to distinguish MCNs from pseudocysts when there are features of neoplasia present, however, no imaging investigation can reliably differentiate the two conditions in all cases. If clinical doubt remains, it is preferable to err on the side of safety and either employ a ‘wait and watch’ strategy or to resect a cystic pancreatic lesion rather than drain a potentially malignant MCN.Scott, J. (2000). Clinical Radiology55, 187–192.

References (17)

D Mathieu et al.
Pancreatic cystic neoplasms
Radiol Clin North Am
(1989)
K Yamaguchi et al.
Cystic neoplasms of the pancreas
Gastroenterology
(1987)
JA Sand et al.
Clinical assessment compared with cyst fluid analysis in the differential diagnosis of cystic lesions of the pancreas
Surgery
(1996)
AL Warshaw
Implications of peritoneal cytology for staging of early pancreatic cancer
Am J Surg
(1991)
C Fernandez-del Castillo et al.
Cystic tumours of the pancreas
Surg Clin North Am
(1995)
AL Warshaw et al.
Cystic tumours of the pancreas. New clinical, radiologic and pathologic observations in 67 patients
Ann Surg
(1990)
J Compagno et al.
Mucinous cystic neoplasms of the pancreas with overt and latent malignancy (cystadenoma and cystadenocarcinoma). A clinicopathological study of 41 cases
Am J Clin Pathol
(1978)
VR Tandan et al.
Management of cystic lesions of the tail of the pancreas
Can J Surg
(1995)

There are more references available in the full text version of this article.

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It is not necessary to resect all mucinous cystic neoplasms of the pancreas: current guidelines do not reflect the actual risk of malignancy
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A systematic review of eligible studies published between 2000 and 2021 was performed on PubMed and Embase. Primary outcome was rate of malignancy. Data regarding high-risk features, including cyst size and mural nodules, were collected and analyzed.
A total of 40 studies and 3292 patients with resected MCN were included in the final analysis. The pooled rate of malignancy was 16.1% (95%CI 13.1–19.0). The rate of malignant MCN in studies published before 2012 was significantly higher than that of studies published after recent guidelines were published (21.0% vs 14.9%, p < 0.001). Malignant MCN were larger than benign (mean difference 25.9 mm 95%CI 14.50–37.43, p < 0.001) with a direct correlation between size and presence of malignant MCN (R2 = 0.28, p = 0.020). A SROC identified a threshold of 65 mm to be associated with the diagnosis of malignant MCN. Presence of mural nodules was associated with the diagnosis of a malignant MCN (OR = 4.34, 95%CI 3.00–6.29, p < 0.001).
Whereas guidelines recommend resection of all MCN, the rate of malignancy in resected MCN is 16%, implying that surveillance has a role in most cases, and that surgical selection criteria are warranted. Size and presence of mural nodules are significantly associated with an increased risk of malignant degeneration, small MCN and without mural nodules can be considered for surveillance.
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It is important to identify features on computed tomography (CT) that can distinguish between benign and premalignant or malignant pancreatic cysts to avoid unnecessary surgeries. This study investigated the preoperative diagnostic evaluation of cystic pancreatic lesions to determine how advanced imaging and clinical factors should guide management.
In total, 53 patients with 27 benign and 26 premalignant or malignant cysts were enrolled. CT features of the cysts were compared using univariate and multivariate analyses.
On univariate analysis, a solid component (p < 0.01), septation (p < 0.01), location (p < 0.01), border (p < 0.01), wall enhancement (p = 0.01), lesion margins (p < 0.01), pancreatic atrophy (p = 0.04), and a cystic wall (p < 0.01) were all significantly different between benign and premalignant or malignant cysts. On multivariate analysis, only a solid component (p < 0.01) and septation (p < 0.01) were significant.
A thin cystic wall, uniform homogeneity, a clear border, the presence of septation, pancreatic atrophy, and the absence of both wall enhancements and solid components were more frequently seen in benign cysts. A thick wall, lack of homogeneity, the presence of wall enhancements and solid components, absence of septation, only a small degree of pancreatic atrophy, and unclear borders were more frequent among premalignant or malignant cysts. The only CT features to differentiate benign from premalignant or malignant cysts were a solid component and septation.
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The introduction of laparoscopy in the 1980s has revolutionized the field of complex abdominal surgery. Traditional operations for almost all pancreatic resections and reconstructions have been described and replicated through a laparoscopic approach. Minimally invasive pancreatic surgeries are now well integrated into routine pancreatic resections and reconstructions at high-volume centers, with equivalent rates of mortality compared with open procedures. With the advent of robotic assistance, patients benefit from less intraoperative blood loss, expedited functional recovery, and shorter hospital stays. Meanwhile, surgeons benefit from binocular three-dimensional vision, scaling, stabilization of tremor, reduced operator fatigue, and improved ergonomics from the console-surgeon interface. This chapter will focus on the robotic approach, summarizing the data on the safety, efficacy, and technique of robotic approaches to minimally invasive pancreas surgery for both benign and malignant indications, showcasing the diversity of the platform for complex pancreatic operations.
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Mucinous cystic neoplasms (MCN) are rare premalignant neoplasms of the pancreas that are typically found as single lesions in the pancreatic body and tail of women in the fifth and sixth decade of life, do not communicate with the pancreatic ductal system and are characterized by mucin-producing epithelium supported by ovarian-type stroma.
We present here a case of diffuse pancreatic involvement by MCN in a 64-year-old woman with chronic pancreatitis. Pre-operative suspicion for MCN was low due to the multi-centric nature of the lesions and imaging/biochemical fluid analysis demonstrating connection with the pancreatic ductal architecture. The patient underwent total pancreatectomy with pathology showing multiple cysts lined by flat epithelium with focal ovarian-type stroma, consistent with low-grade MCN.
The presence of ovarian stroma on histological analysis is one of the defining characteristics of MCNs per WHO guidelines, and is mandatory for its diagnosis. Only one case of diffuse MCN has been previously described in the literature; however, in this case the authors were not able to reach a definitive histological diagnosis based on WHO criteria.
To our knowledge, this is the first report of diffuse histology-proven MCN of the pancreas.
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RAMucinous Cystic Neoplasms of the Pancreas: Imaging Features and Diagnostic Difficulties

Abstract

Radiol Clin North Am

Gastroenterology

Surgery

Am J Surg

Cystic tumours of the pancreas

Surg Clin North Am

Cystic tumours of the pancreas. New clinical, radiologic and pathologic observations in 67 patients

Ann Surg

Mucinous cystic neoplasms of the pancreas with overt and latent malignancy (cystadenoma and cystadenocarcinoma). A clinicopathological study of 41 cases

Am J Clin Pathol

Management of cystic lesions of the tail of the pancreas

Can J Surg

RA
Mucinous Cystic Neoplasms of the Pancreas: Imaging Features and Diagnostic Difficulties