Mucinous cystic neoplasm of the pancreas. Estimation of grade of malignancy with imaging techniques and its surgical implications.

The results of diagnostic imaging procedures, macroscopic and microscopic findings and clinical follow up data of 20 mucinous cystic neoplasms of the pancreas were retrospectively reviewed to determine the grade of malignancy and its surgical implications. The largest mean diameter was 8.9 cm for 10 malignant cases, 5.0 cm for two premalignant cases, and 3.1 cm for eight benign tumours. Ultrasonography or computed tomography or both, corresponded well with macroscopy. The 10 malignant and two premalignant lesions had intracystic mural nodules or extracystic solid components, while the eight benign specimens had neither nodules nor solid portions. Structural complexity seen on ultrasonography or computed tomography, which reflected the irregularity in size and shape of the cysts, internal septa, walls, and solid components, was severe in the 10 malignant and two borderline tumours and mild or moderate in the eight benign lesions. Angiography showed that five of the nine malignant tumours were hypervascular, while the two premalignant and four benign lesions were all avascular. Five of 10 patients with malignant tumours died of local recurrence or remote hematogenous metastases, and one with malignant disease was still alive with liver metastases at the time of writing. We propose that a careful preoperative estimate of the malignant potential of such cysts should be made based on the size of the tumour, the presence of mural nodules and solid areas, and the structural complexity on ultrasonography or computed tomography, as well as the amount of vascularity seen on angiography. Attention should be paid at follow up to the presence of local recurrence and haematogenous metastases in cases of malignant disease.