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CT of Primary Cystic Pancreatic Neoplasms

Can CT be Used for Patient Triage and Treatment?

¹ All authors: Department of Radiology, The Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21287.

Received March 5, 1999; accepted after revision December 15, 1999.

 
Address correspondence to E. K. Fishman.

Abstract

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OBJECTIVE. The purpose of this study was to determine whether CT can be used to distinguish serous cystadenomas from mucinous cystadenomas or cystadenocarcinomas of the pancreas and play an enhanced role in patient triage and treatment.

MATERIALS AND METHODS. A blinded retrospective analysis of CT scans from 50 patients with pathologically proven primary cystic pancreatic neoplasms was performed independently by three radiologists. Using classic CT criteria as reported in the literature, each tumor was categorized as definitely serous, mucinous, or indeterminate. Tumor location, size, presence of calcification, and size of largest cyst were recorded. Data for each reviewer were analyzed independently. Consensus data were then subjected to multivariate logistic regression analysis.

RESULTS. The ability of our reviewers to diagnose serous neoplasms ranged from 23% to 41%. Eight mucinous neoplasms were mistaken for serous tumors by two of the three reviewers. When consensus between at least two of the three reviewers was used for diagnosis, 27% of serous neoplasms were correctly diagnosed and all of the mucinous tumors were correctly identified as uncertain or mucinous, yielding the same clinical end point. For multivariate logistic regression analysis, a cyst smaller than 2 cm had a statistically significant association (p=0.005) with serous tumors, and the presence of peripheral tumoral calcification had a statistically significant association (p=0.01) with mucinous tumors.

CONCLUSION. There is significant variability in the CT appearance of serous and mucinous neoplasms of the pancreas, making CT an insensitive tool for differentiating these tumors. All tumors with peripheral calcifications were identified as mucinous neoplasms.

Introduction

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With the advent of 1-sec and sub-second helical CT, the role of CT as the primary imaging study for a wide range of clinical symptoms and presentations has continued to expand. With its increased use it is not surprising that incidental, serendipitous, or iatrogenic conditions will be detected [1]. Numerous publications have addressed the incidental adrenal mass or renal cell carcinoma. Likewise, cystic pancreatic lesions are not infrequently found in asymptomatic patients who lack a history of current or prior pancreatic pathology [2,3].

By far, the most common cystic lesion of the pancreas is a pseudocyst. Although cystic pancreatic neoplasms can emulate pancreatic pseudocysts, a careful clinical history or correlation with laboratory values (amylase or lipase) will often enable a specific diagnosis. When the diagnosis of pancreatitis can be excluded, or is clinically unlikely, a primary cystic neoplasm must be considered. Traditionally, these tumors have been classified as cystadenomas or cystadenocarcinomas of the serous (microcystic) and mucinous (macrocystic) subtypes [4]. It is well documented that serous or microcystic neoplasms have no malignant potential and that the mucinous or macrocystic type may coexist with or become a cystadenocarcinoma [4, 5]. Early differentiation of primary cystic neoplasms from adenocarcinomas and other pancreatic malignancies is important because asymptomatic microcystic adenomas do not require surgical excision and macrocystic cystadenomas or cystadenocarcinomas require surgery [4,5,6,7,8]. In addition, even the overtly malignant mucinous cystadenocarcinomas carry a far better prognosis than solid ductal adenocarcinomas [4, 5, 9, 10].

The radiographic appearance of microcystadenomas and macrocystic adenomas or adenocarcinomas has been described in several small series [4, 6,7,8, 11,12,13]. The largest single-institution study to date, reported by Johnson et al. [8], includes CT findings in 35 patients with primary cystic pancreatic neoplasms. We present an analysis of the CT findings in 50 patients with cystic pancreatic masses examined at our institution to determine whether specific CT criteria permit the definitive diagnosis of these tumors and whether CT can play a role in patient triage to preclude unnecessary invasive procedures in patients with serous cystadenomas of the pancreas.

Materials and Methods

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Using surgicopathologic records at our institution spanning 1984-1998, 250 cases of proven primary cystic pancreatic neoplasms were identified. Neoplasms such as mucin-secreting duct-ectatic adenocarcinomas and solid and papillary epithelial tumors (Hamoudi tumor) that have cystic characteristics but are not included in the classic description of primary cystic tumors were excluded. From these cases, 50 patients with serous or mucinous cystadenomas or cystadenocarcinomas had preoperative CT scans available for analysis. CT scans were performed on a variety of scanners, although most were helical. Forty-four CT scans were obtained with and six without IV contrast material. Collimation ranged from 3 to 10 mm and interscan spacing ranged from 3 to 8 mm.

Sixteen mucinous cystadenomas and 12 mucinous cystadenocarcinomas were present in 28 patients (16 women, 12 men), ranging in age from 24 to 86 years with a median age of 64 years. Twenty-two serous cystadenomas were present in 22 patients (17 women, five men), ranging in age from 28 to 84 years with a median age of 64 years.

Blinded retrospective analysis was performed independently by three experienced radiologists who analyzed each tumor using established CT criteria (Table 1) and then identified the tumor as a definite serous cystadenoma, a definite mucinous cystadenoma or cystadenocarcinoma, or indeterminate [4]. The reviewers were instructed to make a diagnosis as if this were a true clinical situation with the knowledge that all tumors identified as serous would not undergo biopsy or surgical excision. In addition, independent observations regarding the presence or absence of calcification, size of the largest cyst and overall mass, and location were recorded. Results for individual reviewers and a consensus of their observations requiring agreement of at least two of the three reviewers were compiled.

Results

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Tumor Characteristics
Mucinous neoplasms.—Consensus data show tumoral calcification was present in eight mucinous neoplasms (29%), of which seven (88%) were peripheral in location (Table 2). Mucinous tumors ranged in greatest dimension from 1.5 to 15 cm. The largest cyst in each tumor was larger than 2 cm in 24 patients (86%). Tumors were septated in four patients (15%), and mural excrescences were seen in two patients (7%). One mucinous cystadenoma had aggressive characteristics with tumor extending into the adjacent psoas muscle and tracking into the patient's proximal thigh (Fig. 1A,1B).

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —34-year-old woman who presented to emergency department with abdominal pain. Contrast-enhanced CT scans show aggressive, atypical mucinous cystadenoma extending into iliopsoas muscle (arrows). All reviewers identified this tumor as either uncertain or definitely mucinous.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —34-year-old woman who presented to emergency department with abdominal pain. Contrast-enhanced CT scans show aggressive, atypical mucinous cystadenoma extending into iliopsoas muscle (arrows). All reviewers identified this tumor as either uncertain or definitely mucinous.

Serous neoplasms.—Calcification was present in four serous tumors (18%), all of which were centrally located. Tumors ranged in greatest dimension from 1.4 to 27 cm. The largest cyst in each tumor was smaller than 2 cm in 14 patients (64%) (Table 2). One tumor had a stellate appearance, but no tumors showed papillary excrescences or internal debris.

Reviewer Analysis
Reviewer 1 correctly identified 32%, reviewer 2 identified 23%, and reviewer 3 identified 41% of the serous cystadenomas (Table 3). Although the ability to definitively diagnose serous neoplasms was low for reviewers 1 and 2, only one mucinous neoplasm was mistaken for a serous tumor by reviewer 2, and reviewer 1 correctly identified all mucinous lesions as mucinous or uncertain, yielding the same clinical endpoint. Reviewer 3 correctly identified more serous neoplasms than the other two reviewers but erroneously diagnosed seven mucinous tumors as serous cystadenomas.

To determine whether the opinions of multiple radiologists has an impact on diagnosis, a consensus reading was held in which a diagnosis for each tumor was determined by agreement between at least two of the three reviewers (Table 4). Of the 22 serous tumors, only six were correctly diagnosed by at least two of the three reviewers and only one was identified as unanimously serous. For eight of the serous tumors, all three reviewers were unable to exclude the diagnosis of a mucinous neoplasm and answered mucinous or uncertain (Fig. 2A,2B). All mucinous neoplasms were correctly categorized as mucinous or uncertain (yielding the same clinical end point of biopsy or surgery).

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —Two typical serous cystadenomas, one correctly and one incorrectly diagnosed by reviewers. 74-year-old woman whose primary complaint was early satiety and abdominal bloating. Contrast-enhanced CT scan shows serous cystadenoma composed of many cysts smaller than 2 cm and central tumoral calcifications correctly diagnosed by all reviewers.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —Two typical serous cystadenomas, one correctly and one incorrectly diagnosed by reviewers. 71-year-old woman with incidental finding on CT performed for unrelated symptoms. Contrast-enhanced helical CT scan shows serous cystadenoma of head of pancreas (arrow) measuring 2.5 cm and composed of multiple subcentimeter cysts. Compare this benign lesion with mucinous neoplasm shown in Figure 6 and note similarities. All three reviewers mistook this lesion for mucinous neoplasm.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6. —Contrast-enhanced CT scan in 65-year-old woman shows atypical mucinous cystadenoma in head of pancreas. Mass (arrow) measures 1.8 cm and contains some small septations. Note similarities between this mucinous neoplasm and serous cystadenoma in Figure 2B. Two reviewers were uncertain of diagnosis and one reviewer mistakenly identified this neoplasm as serous.

Discussion

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Pancreatic cystadenomas and cystadenocarcinomas are often radiographically similar to other pancreatic processes such as benign pseudocysts or pancreatic tumors that have cystic changes (i.e., solid and papillary epithelial neoplasms, necrotic islet cell tumors, intraductal papillary mucinous tumors, and, occasionally, pancreatic ductal adenocarcinomas) [9, 14,15,16,17,18,19,20,21]. Early differentiation of cystic neoplasms from the previously mentioned entities and accurate classification as microcystic or macrocystic tumors are important because asymptomatic microcystic adenomas do not require surgical excision and macrocystic cystadenomas or cystadenocarcinomas do [4, 22, 23].

Preoperative attempts to definitively diagnose cystic tumors as serous or mucinous using invasive and noninvasive techniques have had limited success. Although CT has remained the primary imaging technique for evaluation of the pancreas, MR imaging and sonography are often useful in revealing and characterizing pancreatic lesions of all types but have not been successful at differentiating subtypes of cystic pancreatic masses [12, 13].

Cyst fluid aspiration with cytologic evaluation, measurement of viscosity, and analysis for tumor markers and enzymes has shown promise as an ancillary diagnostic tool [24,25,26]. A series of 18 patients with primary cystic pancreatic neoplasms who underwent a total of 23 fine needle aspiration biopsies using CT (n = 16), sonography (n = 3), or intraoperative (n = 4) guidance resulted in a definitive diagnosis in 50% of serous lesions and 75% of mucinous neoplasms [25]. However, complications such as inadvertent spillage of potentially malignant fluid into the peritoneum may occur. Additionally, aspiration of nonpancreatic cysts (i.e., mesenteric duplication cysts) or dilution of cyst fluid as a result of communication with the pancreatic duct or other structures may lead to false-positive or false-negative diagnoses. The retrospective study by Johnson et al. [8] evaluated 35 CT scans and 23 sonograms of 45 pathologically proven serous and mucinous pancreatic tumors. Unlike the study by Johnson et al., our reviewers were not as successful at differentiating a serous cystadenoma from a mucinous tumor in most cases. We were able to definitively diagnose serous tumors in 23-41% of serous cystadenomas by independent readings and 27% by consensus reading compared with 93% of serous tumors (14/15 tumors) seen on CT by Johnson's reviewers. This difference is, in part, a result of differences in study design. Although both studies used established CT characteristics to define serous and mucinous tumors, the study by Johnson et al. did not allow reviewers to defer a diagnosis if they believed they could not confidently exclude a mucinous tumor. The only deviation from serous cystadenoma or mucinous cystadenoma or cystadenocarcinoma allowed was to judge a mass "atypical" serous or "atypical" mucinous. By including an "uncertain or indeterminate" category, we believe this more closely simulates a true clinical situation in which the reviewers were asked to combine established criteria with their impression on the basis of their experiences and make a decision that would have a strong impact on patient treatment. The importance rests on whether one can preoperatively determine that the patient needs no further intervention, that is, to definitively diagnose a serous neoplasm with a high level of certainty. Despite more than 30 years of combined experience interpreting CT examinations, our reviewers were uncertain of the diagnosis in an average of 57% of patients.

It is important to identify when the radiographic findings are not specific enough to confidently exclude a mucinous lesion. Classically, microcystic adenomas are described as multilocular well-circumscribed masses that often contain a central stellate scar and calcifications. Innumerable small cysts ranging in size from 1 to 20 mm are filled with clear fluid and have a honeycombed appearance as a result of intervening connective tissue septa (Fig. 3A,3B). Mucinous cystadenomas and cystadenocarcinomas can be unilocular or multilocular masses filled with mucin, hemorrhage, and debris [4,5,6]. Cysts vary in size but are usually larger than 2 cm and frequently have internal papillary excrescences (Fig. 4). Based on our data, classic criteria were met by only a few primary cystic pancreatic neoplasms. Specifically, only three serous neoplasms had all of the typical characteristics that raise the possibility of a bias in case selection because a disproportionate number of "atypical" cystic neoplasms may have been referred for biopsy or surgical excision. However, other institutions have published similar experiences with "atypical" imaging features. In the study by Johnson et al. [8], 47% of serous lesions and 50% of mucinous cystadenocarcinomas were judged "atypical" on the basis of CT findings. More recently, a case series from the same institution described 10 of 18 primary cystic pancreatic neoplasms as atypical based on radiographic characteristics [25].

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —Classic microcystic adenomas in two patients. Contrast-enhanced helical CT scan in 50-year-old woman shows microcystic adenoma (arrowheads). Note multiple small (<1 cm) cysts with tumoral calcification (arrows) in center of mass.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —Classic microcystic adenomas in two patients. 76-year-old woman with serous cystadenoma (arrow) incidentally noted on helical CT scan performed for cholecystitis. Mass is well defined and composed of many small (<5 mm) cysts.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4. —Contrast-enhanced CT scan in 86-year-old man reveals classic appearance of mucinous cystad-enocarcinoma. Note multiple large cysts (>2 cm) with peripheral tumoral calcification (short arrow), solid components, and mural nodules (long arrow).

Our reviewers had greatest difficulty identifying serous tumors that contained cysts larger than 2 cm. Of the eight serous tumors with cysts larger than 2 cm, the consensus of the reviewers provided the correct diagnosis for only one. All reviewers answered uncertain or mucinous (Fig. 5) for five of the eight tumors. In addition, CT scans depicting tumors smaller than 3 cm were difficult to interpret. Twelve tumors (24%) (six mucinous and six serous) were 3 cm or smaller (Fig. 6). Two of three reviewers answered uncertain for the diagnosis of 10 of these tumors.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5. —Contrast-enhanced CT scan in 38-year-old woman shows atypical serous cystadenoma with single large cyst measuring 9 cm. Note that there are no internal septations or peripheral calcifications to suggest mucinous neoplasm. All three reviewers identified this tumor as mucinous or uncertain.

The presence and location of tumor calcification is an important characteristic that can be helpful in arriving at an accurate diagnosis. None of the serous neoplasms in our study had peripheral calcifications, but 25% of the mucinous tumors did. Additionally, central calcifications were present in 10% of all tumors in this study (5/50), of which 80% were serous neoplasms. A potential pitfall is misinterpretation of vascular or ductal calcifications as tumoral in origin. One reviewer mistook a serous cystadenoma with heavy splenic artery calcifications as a mucinous neoplasm with peripheral tumoral calcification (Fig. 7A,7B).

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A. —CT scans with IV contrast material in 77-year-old woman. Serous cystadenoma of tail of pancreas shows heavy splenic artery calcifications (arrow).

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B. —CT scans with IV contrast material in 77-year-old woman. Splenic artery calcifications may be confused with tumoral calcifications (arrow) at periphery of lesion.

It is clear that CT provides limited assistance in the differentiation between serous and mucinous neoplasms. Even when pseudocysts and other pancreatic pathology easily confused with serous and mucinous neoplasms were eliminated and reviewers were provided with this information, they had great difficulty distinguishing between the two groups. Because of the variability in the radiographic appearance of serous cystadenomas and overlap in CT characteristics with mucinous neoplasms, most serous neoplasms still require ancillary testing such as biopsy to reach a definitive diagnosis.

However, we have also verified the finding of Johnson et al. [8] that the combined opinion of three radiologists improves accuracy. Despite our low sensitivity for identifying serous tumors, no mucinous neoplasm would be left untreated as a result of the consensus interpretation, and invasive procedures may have been avoided in 27% of patients. Although more data is needed on a greater number of patients, this case series shows significant variability in the imaging characteristics of serous cystadenomas and mucinous neoplasms of the pancreas, showing CT to be an insensitive tool for differentiating these tumors.

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