Added value of apparent diffusion coefficient in distinguishing between serous and mucin-producing pancreatic cystic neoplasms

  • Pallavi Pandey
  • Ankur Pandey
  • Nannan Shao
  • Farnaz Najmi Varzaneh
  • Mounes Aliyari Ghasabeh
  • Manijeh Zharghampour
  • Pegah Khoshpouri
  • Daniel Fouladi
  • John Eng
  • Anne Marie O’Broin-Lennon
  • Marcia Canto
  • Ralph H. Hruban
  • Ihab R. KamelEmail author
Magnetic Resonance



To evaluate the added value of diffusion-weighted imaging (DWI) on MRI in differentiating serous from mucin-producing pancreatic cystic neoplasms (PCNs).


One hundred seventeen patients with PCN measuring ≥ 10 mm were included. Three readers independently evaluated MRI with and without the use of apparent diffusion coefficient (ADC). Logistic regression was used to analyze whether confidence scores were different with the use of different image sets. Diagnostic performance with and without ADC was compared.


DWI/ADC improved confidence in 44.8%, 73.6%, and 78.2% of patients by the three readers in distinguishing serous from mucin-producing PCNs. The use of ADC increased the probability of a higher confidence in the differentiation as compared to morphological imaging for all three readers (p < 0.001). Odds ratio for increase in the diagnostic confidence with the use of ADC for the three readers with decreasing years of experience were 5.8, 6.8, and 12.7. The diagnostic accuracy of morphological MRI with ADC was higher than that without ADC for two of three readers with lesser experience (87.2% vs. 80.8%; 91.5% vs. 80.8%).


DWI may have added value as a complementary tool to conventional morphological MRI in differentiating between serous and mucin-producing PCNs with possibly greater value for readers with less experience in reading abdominal MRI.

Key Points

Optimal management of PCNs requires differentiation of serous from mucin-producing PCNs.

ADC measurements allow increased confidence in differentiating serous from mucin-producing PCNs.

ADC measurements increase the accuracy in diagnosing serous versus mucin-producing PCNs.


Magnetic resonance imaging Diffusion MRI Pancreas Cysts Mucin 



Apparent diffusion coefficient


Branch duct intraductal papillary mucinous neoplasm


Contrast-enhanced magnetic resonance imaging


Computed tomography


Diffusion-weighted imaging


Fine needle aspiration


Fat saturation


Gradient echo


Intraductal papillary mucinous neoplasm


Mucinous cystic neoplasm


Main duct intraductal papillary mucinous neoplasm


Magnetic resonance cholangiopancreatography


Magnetic resonance imaging


Pancreatic cystic neoplasm


Serous cystadenoma


Standard deviation



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Ihab R. Kamel.

Conflict of interest

The authors declare that they have no conflict of interest.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the institutional review board.

Ethical approval

Institutional review board approval was obtained.


• retrospective

• diagnostic study

• performed at one institution

Supplementary material

330_2019_6010_MOESM1_ESM.docx (668 kb)
ESM 1 (DOCX 667 kb)


  1. 1.
    Zhang XP, Yu ZX, Zhao YP, Dai MH (2016) Current perspectives on pancreatic serous cystic neoplasms: diagnosis, management and beyond. World J Gastrointest Surg 8:202–211CrossRefGoogle Scholar
  2. 2.
    Sahani DV, Kambadakone A, Macari M, Takahashi N, Chari S, Fernández-del Castillo C (2013) Diagnosis and management of cystic pancreatic lesions. AJR Am J Roentgenol 200:343–354CrossRefGoogle Scholar
  3. 3.
    Lennon AM, Manos LL, Hruban RH et al (2014) Role of a multidisciplinary clinic in the management of patients with pancreatic cysts: a single-center cohort study. Ann Surg Oncol 21:3668–3674CrossRefGoogle Scholar
  4. 4.
    Tanaka M, Fernández-del Castillo C, Adsay V et al (2012) International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 12:183–197CrossRefGoogle Scholar
  5. 5.
    Song SJ, Lee JM, Kim YJ et al (2007) Differentiation of intraductal papillary mucinous neoplasms from other pancreatic cystic masses: comparison of multirow-detector CT and MR imaging using ROC analysis. J Magn Reson Imaging 26:86–93CrossRefGoogle Scholar
  6. 6.
    Lauenstein TC, Sharma P, Hughes T, Heberlein K, Tudorascu D, Martin DR (2008) Evaluation of optimized inversion-recovery fat-suppression techniques for T2-weighted abdominal MR imaging. J Magn Reson Imaging 27:1448–1454CrossRefGoogle Scholar
  7. 7.
    Visser BC, Yeh BM, Qayyum A, Way LW, McCulloch CE, Coakley FV (2007) Characterization of cystic pancreatic masses: relative accuracy of CT and MRI. AJR Am J Roentgenol 189:648–656CrossRefGoogle Scholar
  8. 8.
    Do RK, Katz SS, Gollub MJ et al (2014) Interobserver agreement for detection of malignant features of intraductal papillary mucinous neoplasms of the pancreas on MDCT. AJR Am J Roentgenol 203:973–979CrossRefGoogle Scholar
  9. 9.
    Choi JY, Kim MJ, Lee JY et al (2009) Typical and atypical manifestations of serous cystadenoma of the pancreas: imaging findings with pathologic correlation. AJR Am J Roentgenol 193:136–142CrossRefGoogle Scholar
  10. 10.
    Sun HY, Kim SH, Kim MA, Lee JY, Han JK, Choi BI (2010) CT imaging spectrum of pancreatic serous tumors: based on new pathologic classification. Eur J Radiol 75:e45–e55CrossRefGoogle Scholar
  11. 11.
    de Jong K, Nio CY, Hermans JJ et al (2010) High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol 8:806–811CrossRefGoogle Scholar
  12. 12.
    Megibow AJ, Baker ME, Morgan DE et al (2017) Management of incidental pancreatic cysts: a white paper of the ACR Incidental Findings Committee. J Am Coll Radiol.
  13. 13.
    Correa-Gallego C, Ferrone CR, Thayer SP, Wargo JA, Warshaw AL, Fernández-Del Castillo C (2010) Incidental pancreatic cysts: do we really know what we are watching? Pancreatology 10:144–150CrossRefGoogle Scholar
  14. 14.
    Valsangkar NP, Morales-Oyarvide V, Thayer SP et al (2012) 851 resected cystic tumors of the pancreas: a 33-year experience at the Massachusetts General Hospital. Surgery 152:S4–S12CrossRefGoogle Scholar
  15. 15.
    Schraibman V, Goldman SM, Ardengh JC et al (2011) New trends in diffusion-weighted magnetic resonance imaging as a tool in differentiation of serous cystadenoma and mucinous cystic tumor: a prospective study. Pancreatology 11:43–51CrossRefGoogle Scholar
  16. 16.
    Le Bihan D, Turner R, Douek P, Patronas N (1992) Diffusion MR imaging: clinical applications. AJR Am J Roentgenol 159:591–599CrossRefGoogle Scholar
  17. 17.
    Pozzessere C, Castaños Gutiérrez SL, Corona-Villalobos CP et al (2016) Diffusion-weighted magnetic resonance imaging in distinguishing between mucin-producing and serous pancreatic cysts. J Comput Assist Tomogr 40:505–512CrossRefGoogle Scholar
  18. 18.
    Sandrasegaran K, Akisik FM, Patel AA et al (2011) Diffusion-weighted imaging in characterization of cystic pancreatic lesions. Clin Radiol 66:808–814CrossRefGoogle Scholar
  19. 19.
    Cicchetti DV (1994) Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess 6:284–290Google Scholar
  20. 20.
    Boraschi P, Donati F, Gigoni R, Salemi S, Bartolozzi C, Falaschi F (2010) Diffusion-weighted MRI in the characterization of cystic pancreatic lesions: usefulness of ADC values. Magn Reson Imaging 28:1447–1455CrossRefGoogle Scholar
  21. 21.
    Fatima Z, Ichikawa T, Motosugi U et al (2011) Magnetic resonance diffusion-weighted imaging in the characterization of pancreatic mucinous cystic lesions. Clin Radiol 66:108–111CrossRefGoogle Scholar
  22. 22.
    Irie H, Honda H, Kuroiwa T et al (2002) Measurement of the apparent diffusion coefficient in intraductal mucin-producing tumor of the pancreas by diffusion-weighted echo-planar MR imaging. Abdom Imaging 27:82–87CrossRefGoogle Scholar
  23. 23.
    Mottola JC, Sahni VA, Erturk SM, Swanson R, Banks PA, Mortele KJ (2012) Diffusion-weighted MRI of focal cystic pancreatic lesions at 3.0-tesla: preliminary results. Abdom Imaging 37:110–117CrossRefGoogle Scholar
  24. 24.
    Yamashita Y, Namimoto T, Mitsuzaki K et al (1998) Mucin-producing tumor of the pancreas: diagnostic value of diffusion-weighted echo-planar MR imaging. Radiology 208:605–609CrossRefGoogle Scholar
  25. 25.
    Khashab MA, Kim K, Lennon AM et al (2013) Should we do EUS/FNA on patients with pancreatic cysts? The incremental diagnostic yield of EUS over CT/MRI for prediction of cystic neoplasms. Pancreas 42:717–721CrossRefGoogle Scholar
  26. 26.
    Ngamruengphong S, Lennon AM (2016) Analysis of pancreatic cyst fluid. Surg Pathol Clin 9:677–684CrossRefGoogle Scholar
  27. 27.
    Sasaki M, Yamada K, Watanabe Y et al (2008) Variability in absolute apparent diffusion coefficient values across different platforms may be substantial: a multivendor, multi-institutional comparison study. Radiology 249:624–630CrossRefGoogle Scholar
  28. 28.
    Barral M, Sebbag-Sfez D, Hoeffel C et al (2013) Characterization of focal pancreatic lesions using normalized apparent diffusion coefficient at 1.5-tesla: preliminary experience. Diagn Interv Imaging 94:619–627CrossRefGoogle Scholar
  29. 29.
    Do RK, Chandarana H, Felker E et al (2010) Diagnosis of liver fibrosis and cirrhosis with diffusion-weighted imaging: value of normalized apparent diffusion coefficient using the spleen as reference organ. AJR Am J Roentgenol 195:671–676CrossRefGoogle Scholar
  30. 30.
    Grech-Sollars M, Hales PW, Miyazaki K et al (2015) Multi-centre reproducibility of diffusion MRI parameters for clinical sequences in the brain. NMR Biomed 28:468–485CrossRefGoogle Scholar
  31. 31.
    Ye XH, Gao JY, Yang ZH, Liu Y (2014) Apparent diffusion coefficient reproducibility of the pancreas measured at different MR scanners using diffusion-weighted imaging. J Magn Reson Imaging 40:1375–1381CrossRefGoogle Scholar
  32. 32.
    Pandey A, Pandey P, Ghasabeh MA et al (2018) Accuracy of apparent diffusion coefficient in differentiating pancreatic neuroendocrine tumour from intrapancreatic accessory spleen. Eur Radiol 28:1560–1567CrossRefGoogle Scholar
  33. 33.
    European Study Group on Cystic Tumours of the Pancreas (2018) European evidence-based guidelines on pancreatic cystic neoplasms. Gut 67:789–804CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  • Pallavi Pandey
    • 1
  • Ankur Pandey
    • 1
  • Nannan Shao
    • 1
  • Farnaz Najmi Varzaneh
    • 1
  • Mounes Aliyari Ghasabeh
    • 1
  • Manijeh Zharghampour
    • 1
  • Pegah Khoshpouri
    • 1
  • Daniel Fouladi
    • 1
  • John Eng
    • 1
  • Anne Marie O’Broin-Lennon
    • 2
  • Marcia Canto
    • 2
  • Ralph H. Hruban
    • 3
  • Ihab R. Kamel
    • 1
    Email author
  1. 1.Russell H. Morgan Department of Radiology and Radiological Sciences, Central RadiologyJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Division of GastroenterologyJohns Hopkins Medical InstitutionsBaltimoreUSA
  3. 3.Department of PathologyJohns Hopkins Medical InstitutionsBaltimoreUSA

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