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0:29

Today we are honored to welcome Dr.

0:30

Atif Zahir for a lectured entitled Cystic

0:33

Lesions of the Pancreas.

0:35

Dr. Zahir is a professor of radiology

0:37

and radiological science at Johns Hopkins

0:39

University School of Medicine.

0:42

He earned his medical degree from the ACON University

0:45

and completed a residency in diagnostic radiology at Beth

0:48

Israel Deaconess Medical Center, Harvard Medical School,

0:51

and a fellowship in abdominal imaging

0:53

and interventional radiology at Brigham

0:55

and Women's Hospital, Harvard Medical School.

0:58

At the end of his lecture, please join Dr.

1:01

Zahir in a q and a session

1:02

where he will address questions you may

1:04

have on today's topic.

1:06

Please remember to use the q

1:07

and a feature to submit your questions so we can get to

1:09

as many as we can before our time is up.

1:12

And with that, we're ready to begin today's lecture. We, Dr.

1:15

Zahir, please take you from here.

1:17

Hello everyone. My name is Arthur Zahir,

1:19

and I'm going to be discussing a simple approach

1:22

to diagnosis of cystic lesions of the pancreas.

1:25

Um, as we all know that the, um, widespread use

1:28

of cross-sectional imaging has led to an increased detection

1:31

of these lesions, um, which has made the role

1:33

of radiologists very important in

1:35

the care of these patients.

1:36

Uh, not only to make the diagnosis,

1:39

but also for the risk stratification of patients

1:42

who are at an increased risk of malignancy.

1:45

The, um, overwhelming majority

1:47

of these pancreatic cysts are benign, uh,

1:49

but it is imperative that we distinguish the benign variety

1:51

from the non benign lesions, uh,

1:54

that may ultimately turn malignant.

1:56

Um, in addition, um,

1:57

among the precancerous mucin producing lesions,

2:00

there's the spectrum that encompasses lesions that, uh,

2:03

range from low grade to intermediate

2:05

and high grade dysplasias, as well as early invasive cancer.

2:13

I have no disclosures.

2:17

So here I provide a simple patent based approach

2:19

for classification of these cystic lesions.

2:22

Let's start with a dilated mean duct.

2:24

This may be due to a mean duct, IPMN

2:27

or a pancreatic cancer with upstream dilatation of the duct.

2:31

Next, a simple interocular cyst that communicates

2:34

with a side branch of the pancreatic duct.

2:36

The differential diagnosis of such a lesion is a pseudocyst

2:39

or an IPMN for the same kind of cyst

2:43

that does not have a clear communication with a side branch.

2:46

The differential diagnosis still includes a pseudos

2:48

and an IPMN, but also includes a mu cystic neoplasm.

2:54

Now, let's take this ocular cyst without side branch

2:57

communication and septation and or a solid component to it.

3:01

Now, our differential diagnosis would be walled off

3:04

pancreatic necrosis instead of a pseudos MCN

3:07

and IPMN, same as

3:09

before with the addition

3:10

of solid pseudo peppery lesion or spend to the mix.

3:14

Lastly, when you see a lesion which consists

3:16

of multiple hin cyst, which may have a central scar with

3:19

or without calcifications, you may think

3:21

of a ser cystadenoma

3:23

and IPMN with calcifications may all be cons,

3:26

may also be considered.

3:29

Now, let's look at the incidents in the general population.

3:31

About 1.2% of, um, all people, uh, have, uh,

3:36

some sort of a cystic lesion within their pancreas.

3:40

If you increase the age demographics to over 70 years,

3:43

then it increases to about 25%.

3:46

So 25% of patients have some sort

3:48

of a cystic lesion within their pancreas.

3:53

Now, on MRI, about 20%

3:55

of patients have a cystic lesion within the pancreas

3:58

as seen, um, on imaging

4:00

and most, uh, pronounced on the T two weight images,

4:03

but also seen on the other, uh, sequences.

4:07

If you resect all the suspicious cystic lesions, then

4:11

60% of these lesions, uh, tend to be IPMN

4:16

or MCNs.

4:20

What are the techniques in our armamentarium?

4:23

Well, we have CT and MRI. Let's talk about CT first.

4:28

CT is widely available. It's highly reproducible.

4:30

It helps us stage pancreatic adeno adenocarcinoma.

4:34

If present, we use the dual phase CT where we, uh, where we,

4:38

uh, image with in the arterial and portal venous phases.

4:41

We use a intravenous a contrast,

4:44

and we use a water as a negative or neutral contrast.

4:48

Comparison is easy if prior lesion is seen incidentally

4:52

on another ct.

4:53

Well, the downside of CT is

4:56

that it has decreased sensitivity for smaller cystic lesions

4:59

and increased sensitivity for calcifications.

5:03

Now, let's talk about MRI.

5:10

MRI and MRCP are separate

5:12

and complimentary aspects of the imaging.

5:14

While MRI provides liver

5:15

and pancreatic parenchymal evaluation, MRCP is good

5:18

with biliary tree and pancreatic deline at

5:20

anatomic evaluations.

5:22

It is a non-invasive, um, technique, uh, and

5:26

and employs fewer compared to ER CP examination.

5:30

It has increased sensitivity for smaller cystic lesions,

5:33

but it has decreased sensitivity for calcifications.

5:36

Uh, unlike ct.

5:40

As far as the MRI imaging protocol is concerned, um, uh,

5:44

you have to have at least 1.5 Tesla magnet for, um,

5:47

accurate visualization and

5:48

characterization of these lesions.

5:50

Um, one needs contrast, uh, at least

5:53

for the initial characterization.

5:54

You know, you can follow these up without contrast,

5:56

but, uh, at least for the first, uh,

5:59

first examination, contrast is important.

6:01

I, um, usually tend to find the coronal T two fats at, uh,

6:05

uh, uh, sorry, uh, fast spin echo images.

6:08

Uh, very useful. So these coronal, um, non-fat set, the, um,

6:12

uh, images are very, very useful.

6:14

And not just, uh, looking at the lay of the land,

6:17

but also, um, uh, the cystic lesion in, um, in relation

6:21

to the, uh, pancreatic duct are very well visualized on

6:24

these, uh, sequences.

6:25

Um, abbreviated protocol can be considered

6:29

and is considered a lot of institutions

6:30

because of the fact that this is, uh, it saves time

6:33

and a lot of these patients are getting MRIs.

6:35

So the abbreviated protocol should include at least, uh,

6:38

the T two, uh, fain echo sequence.

6:41

Uh, the MRCP sequence, diffusion weighted sequences,

6:44

and the diffusion weighted sequence is important

6:46

because the, not for so much for the cyst follow,

6:48

but, uh, for any, uh, other, uh,

6:50

mass lesions in the pancreas.

6:52

And then the, uh, the T one, uh,

6:54

gradient echo sequences just, uh, um, are important

6:57

because if there's a mass lesion rising anywhere,

7:00

you can see the loss of their normal T one signal.

7:02

Um, and so, so for follow-up,

7:04

one can consider these abbreviated protocols.

7:09

Now, let's, uh, compare C-T-N-M-R-I as, uh, far

7:13

as the accuracy for characterizing symptomatic

7:16

and aggressive cysts are concerned.

7:18

Uh, there is a tie between MRI

7:21

and CT scan for subtle findings, such

7:26

as main duct involvement, uh, side branch communication,

7:30

or a detection of small lesions.

7:33

Um, MRI is a clear winner, um, from ct,

7:38

um, for characterizing cyst and predicting malignancy.

7:42

Uh, when we compare MRI with the endoscopic ultrasound

7:45

and FNA, then it's a tie.

7:51

So what are the recommendations?

7:52

Well, MRI with MRCP is preferred for detecting,

7:56

characterizing and monitoring pancreatic cystic lesions.

7:59

The A GA guidelines encourage MRI for surveillance

8:02

of presumed ipmn.

8:04

The A SG, uh, is an, uh, recommends an alternate

8:09

of endoscopic ultrasound

8:11

and MRI, so alternating these two modalities.

8:14

Um, so for, um, ct, uh, as far as CT is concerned,

8:18

the pancreatic protocol CT with MultiPlan reformations, um,

8:22

is recommended, um, for, um, for a variety of reasons,

8:26

because it's kind of the workforce and, um,

8:29

and it's easier to obtain.

8:30

So, a CR recommends, um, uh, C CT as a is a,

8:35

as a tool, and international consensus guidelines also

8:38

suggest either MRI

8:39

or ct, uh, uh, as, uh, a surveillance tool for IPM.

8:44

And you obviously run the risk of, um, the, uh, radiation,

8:48

ionizing radiation with c.

8:50

Now, let's discuss the different morphological features

8:53

of cystic lesions of the pancreas.

8:54

Well, you can have a microcystic appearance

8:56

where you have a cluster of small cyst.

8:58

You may or may not have a central scar, which may

9:01

or may not be calcified.

9:02

You can have a unilocular cyst,

9:05

you can have a unilocular cyst with septations,

9:09

and you can have a unilocular cyst

9:11

with multiple enhancing nodules shown here.

9:16

Another variety is you have a dilated mean pancreatic duct,

9:20

which may be, um, associated with it cystic lesions

9:24

or ocular cystic lesion,

9:26

or multiple cystic lesions in the side branches

9:29

as seen in ipmn.

9:35

Now, let's discuss introductory pep mucinous neoplasm.

9:38

So there is a spectrum of pathology.

9:40

You go from low grade to high grade to carcinoma.

9:45

The Intraductal Peppe growth pattern is, um,

9:50

is seen in ipm.

9:52

Mens, you can have marked MU and secretion.

9:55

They constitute one to 2%

9:56

of all pancreatic tumors affect men more commonly

10:01

than women, about 70%.

10:03

Uh, the men are usually older,

10:05

and the median ages about 65 years,

10:07

and that gives us the name grandparent tumor

10:11

or grandfather tumor.

10:12

Sometimes the average age of patients with non-invasive,

10:16

IPMN is three to five years younger than

10:18

IPMN with associated cancer.

10:20

And thus, this shows that this is a pre malignant lesion.

10:27

On end the endoscopy, you can see there's mucus exuding out

10:30

of the papilla right here, and that's a hallmark of IPMN.

10:37

Now, let's discuss the imaging features of IPMN.

10:40

They can be the main duct variety side,

10:43

branch type or combined.

10:46

The main pancreatic duct has

10:48

to be dilated more than six millimeter for it

10:50

to be called IPMN.

10:52

Um, and it can be, uh, diffusely dilated

10:55

or segmentally dilated.

10:59

They can be solitary, multiple or diffuse societal tumors.

11:03

The side branch dilatation is mostly seen in the unseed

11:06

process of the pancreas.

11:08

They can be internal debris, calcifications

11:10

or ary nodules seen within the IPMS.

11:13

The, the features that are important for diagnosis include

11:17

SEPTA and neur nodules, communication

11:19

with the pancreatic duct, which serves as the hallmark

11:21

for the diagnosis of IPMN

11:23

and pancreatic ductal dilatation

11:25

for diagnosing main duct variety.

11:33

Now, the risk of malignancy at 10 years in main duct is 60

11:37

to 70%, much higher than the branch type

11:40

where it is 22% cent.

11:48

This is the garden variety I side branch IPMN.

11:51

So you can see the main pancreatic duct right here.

11:53

And then you have small DD side branches, which are, uh,

11:57

side branch IPNs.

12:05

Now, some of the suspicious features which, uh, raise, uh,

12:09

alarm for, uh, developing malignancy

12:12

or dilatation of the main pancreatic duct.

12:14

As you can see in this example right here,

12:16

that the main pancreatic duct is extremely dilated in this

12:19

mid region right there, uh, a bulging papilla, that means

12:24

that mucin is excluding out.

12:25

So you can see right there into the duodenum.

12:29

And then the presence of neural nodules right here.

12:31

That which means that this, uh, there's some growth

12:34

of the soft tissue, um,

12:36

soft tissues within the, within the duct.

12:38

So right here, right here, these are neural nodules.

12:44

This is a 58-year-old woman with side branch IPN

12:47

with low grade dysplasia.

12:48

So you can see there's a nice correlation between the CT MRI

12:52

and a, uh, surgical path image.

12:55

Uh, here you have a dilated side branch

12:57

with a cystic lesion right here in the tail of the pancreas.

13:00

That corresponds to a very similar looking lesion on MRCP,

13:05

which corresponds to this lesion on the surgical specimen.

13:14

This is a 65-year-old woman with IPM, with IPM

13:17

and with intermediate grade dysplasia.

13:19

You can see there are multiple lesions in the pancreatic

13:22

tail, you can see right here.

13:23

And these correspond to multiple lesions on the MRCP.

13:27

See how much, uh, more detail you can get on the, um,

13:30

on the fluid sensitive sequence.

13:32

And then these corresponds

13:33

to these lesion on in the side branches on the

13:36

surgical resected specimen.

13:42

Here's a case example of a 41-year-old wound

13:44

with side branch IPM and with high grade dysplasia.

13:47

Here is a cystic lesion in the pancreatic body right here

13:50

with some septations right here that corresponds

13:53

to the cystic lesion in the pancreatic body on post contrast

13:57

MRI and on MRCP image.

13:59

And then when this, um, lesion was resected,

14:02

you can see multiple septations within a cystic lesion, uh,

14:06

in the tail of the pancreas.

14:07

This corresponded to the high grade dysplasia

14:09

and within an IPMN,

14:13

this is an 83-year-old woman with main duct IPMN

14:16

with invasive adenocarcinoma.

14:18

Here you can see a very dilated duct right here.

14:21

And then you see these soft tissue nodules

14:24

growing right here.

14:26

And then you can appreciate

14:27

that on the coronal image as well.

14:29

Dilated duct with,

14:31

with multiple soft tissue nodules that are enhancing.

14:34

So this is invasive ENO carcinoma.

14:40

This is a 78-year-old man

14:42

with invasive adenocarcinoma in a side branch.

14:44

So you can see there are multiple cystic lesions in the

14:48

pancreatic tail here that correspond to these, uh,

14:51

multiple cystic lesion in the tail region on the,

14:54

uh, T two weighted image.

14:56

And that corresponds

14:57

to these multiple cystic lesions on the path image.

15:00

Now, keep in mind, if you have more than 10 cyst,

15:02

there's a greater chance of high grade dysplasia

15:04

or invasive carcinoma, um, as compared to low

15:08

or intermediate greater dysphasia patients.

15:11

So, um, the more cyst you have, the more problem there is.

15:17

This is a nice example of a main duct IPM,

15:20

and you can see that the whole duct is dilated right here

15:24

and, uh, all the way to the ula.

15:27

This is what it looks like on ct.

15:29

The duct is very dilated, um, all the way down to the ula.

15:33

When you see a dilated duct, you have

15:34

to make sure there's no obstructing mass.

15:36

But, but in this case, you can see

15:37

that the whole thing is dilated all the way through the ula,

15:40

and there's no mass lesion seen on the,

15:42

there was no mass lesion seen on the post contrast images.

15:46

Here's a 70-year-old man with main duct

15:48

and side branch IPMN with moderate dysplasia.

15:51

Here is a dilated duct right here.

15:55

And then you see the soft tissue component right there

15:57

that is very complex.

15:59

Here it is on the surgical path specimen, it's taken out,

16:03

and that patient had moderate dysplasia.

16:08

Here is a 61-year-old man with mean duct, IPM

16:10

and with adenocarcinoma.

16:13

Again, you can see a dilated duct right here.

16:16

And then you see a soft tissue mass in this region right

16:18

there on the Corona coronal MIP images.

16:21

You can see that there's a soft tissue mass right there

16:24

with dilated, um, main duct on both sides.

16:27

So this is a main duct, IPMN

16:30

with adenocarcinoma arising in it.

16:39

Now, this is a 54-year-old man with segmental main duct,

16:42

IPMN with low grade dysplasia.

16:44

So as you notice here on this chron image

16:46

that the main pancreatic duct is not dilated in this region,

16:49

but it is vocally dilated in this region right here.

16:54

This is what it looks like on an MRCP image.

16:56

Again, notice that there's segmental dilatation

16:58

of the main pancreatic duct.

17:00

Not the whole thing, just the main,

17:02

just the part, just part of it.

17:03

And this kind of reminds you of a mouse in a snake.

17:07

Uh, so it's kind of, so-called a mouse

17:09

in a snake appearance.

17:10

As you can see, the mouse is right here,

17:13

and the, uh, the snake's belly is, uh, segmentally dilated.

17:22

Now, let's look at the risk of malignancy at five years.

17:25

So for branch checked IPMN, it's about 3.3%.

17:30

Um, if you take that duration to 15 years, uh, then this,

17:34

uh, this risk increase increases to 15%, uh, in patients

17:38

with branch duct ipmn, uh, for main duct IPMN,

17:43

it's uh, 40%, about 40%.

17:46

And, um, um, it's much higher compared to the, uh,

17:51

side branch ipmn.

17:53

Now look at, let's look at this, uh, study

17:54

for branch checked IPM

17:56

and notice that the risk increases with increasing size.

17:59

So this is a much higher cumulative incidence

18:02

of malignancy in patients who have cystic lesions or,

18:06

or I branched IPMN that are greater than three centimeter

18:10

compared to the ones that have less than, uh,

18:12

one centimeter in size.

18:16

Uh, similarly from main duct IPNs.

18:19

The risk is high baseline.

18:21

But when you add other predictive factors, such

18:23

as elevated C 99 main ME pancreatic duct, uh,

18:27

more than 10 millimeter in size, neuro nodules,

18:30

thickened wall in distal atrophy, then the, um,

18:34

the malignancy, uh, the chance of malignancy increases

18:39

To further complicate things, uh, synchronous

18:42

or ous invasive pancreatic cancer can be seen in up

18:46

to 9% of patients.

18:48

And hence, the IPNs of the pancreas are sometimes referred

18:51

to as tears of the pancreas cry for help by the organ

18:55

to look for tumors outside of the cystic lesions.

18:58

A case in point here shows no discernible change in the

19:01

cystic lesions on the MRCP images in 15 months.

19:04

However, there is interval development

19:06

of a solid mass in the unseed process

19:09

away from the pancreatic cystic lesions consistent

19:11

with ductal adenocarcinoma.

19:14

There are multiple, uh, guidelines available

19:16

for the follow-up of these, uh, cystic lesions.

19:18

And each institution has its, uh, own preference.

19:23

Um, you have the American Gastroenterology Association,

19:26

which releases guidelines in 2015.

19:29

There is the American College of Gastroenterology, um,

19:32

with its guidelines, um, released in 2018.

19:35

Uh, we have our own radiology guidelines, uh, from the a CR,

19:39

um, and these were released in 2017.

19:42

There is the European evidence-based guidelines on

19:45

pancreatic cystic neoplasms.

19:47

That is a, um, that was released in 2018.

19:50

And it's a combination of, uh, gastroenterologists, uh,

19:53

radiologists and, uh, surgeons

19:55

who have provided this guideline.

19:57

Um, and most recently, in, um, 2024, March of 2024,

20:02

we have the International Consensus Guidelines, which have,

20:04

uh, um, released their, um, their, uh, updated version

20:09

of their previous paper.

20:13

So let's stratify these features, um, in two categories,

20:17

the high risk category and the worrisome category.

20:20

Um, and this will dictate what the future course

20:22

of action is gonna be.

20:23

So if there is a presence of a mass lesion, if there is a D

20:27

that is dilated to more than 10 millimeter,

20:30

if there is an enhancing nodule

20:31

that's greater than five millimeter size,

20:33

or if there is positive cytology,

20:36

then these patients go straight to surgery in the presence

20:40

of a cyst that is greater than three

20:42

centimeters in, in size.

20:44

Also with a thickened wall.

20:46

Um, if there is an enhancing nodule

20:48

that's less than five millimeter in size,

20:50

if the duct is dilated between five

20:52

and nine millimeters, if there is a growth of a cyst, uh,

20:57

of, uh, 2.5 millimeters per year,

20:59

more than 2.5 millimeters per year,

21:01

if there is glandular atrophy

21:03

and then there's duct dilatation, if there there's presence

21:06

of acute pancreatitis that is unexplained new diabetes, uh,

21:10

elevated CA 99

21:11

or lymphadenopathy, then these patients, um, uh,

21:15

should undergo endoscopic ultrasound first, uh, according

21:18

to the international consensus guidelines.

21:22

Now, let's discuss the unilocular cyst.

21:24

So first and foremost, if you have a unilocular cyst,

21:27

you have to exclude presence or history of acute

21:31

or chronic pancreatitis.

21:33

If that is excluded, then you have to,

21:36

then you can move on to other things.

21:38

But in a patient who has history of pancreatitis,

21:41

a unilocular cyst is usually a pseudocyst.

21:45

Now, you also have to look for ductal communication.

21:48

Again, ductal communication can be seen in both pseudocyst

21:51

and IPMN, so that doesn't really help us a whole lot.

21:55

If there is progressive resolution, that means

21:57

that this patient had acute pancreatitis

21:59

and the the resolve,

22:02

and, uh, sometimes you have to do endoscopic ultrasound

22:05

with, um, with cyst aspiration

22:07

or surgical resection to really make the diagnosis.

22:13

So the other things that can be, uh,

22:15

macrocystic are mucinous cystadenomas.

22:18

These are lined by ovarian str, like biliary cystadenomas,

22:22

and they constitute 10% of all pancreatic cystic neoplasm.

22:26

They occur mostly in women, 90%,

22:29

and they usually happen in the fifth decade.

22:31

And mean age is about 45 years.

22:33

And that's why it gets, this tumor gets its

22:35

name, the mother tumor.

22:40

There is a spectrum. They can be borderline tumors,

22:42

or they can be MCN with carcinoma in cyto

22:45

or mucin eno carcinoma in 30% of patients.

22:55

Now, MCNs are less common than ipmn,

22:58

and they constitute about 16% of the resect pancreatic cys,

23:02

as opposed to 50%.

23:04

For ipmn, they have genetic mutations, uh, including kras.

23:08

As we said earlier, that KRAS is common to all, uh, P 16 R,

23:13

NF 43, TP 53, and SMA four.

23:17

And these are common to IPMN as well.

23:20

However, they, they, they do not have GNAS, which is an,

23:25

which is a feature of ipmn.

23:28

So that's how you can distinguish IPMs from,

23:30

from mucin adenomas.

23:35

Now, if the imaging features of istic, uh, tumors include,

23:39

they usually are for focal mass.

23:41

They usually are large between six to 10 centimeters,

23:44

usually solitary.

23:46

Um, they occur in the body and tail of the pancreas.

23:49

The cysts are less than six in number

23:52

and greater than two centimeter in size.

23:54

They usually have a fibrous capsule.

23:56

Now, the, uh, this is the only lesion, uh, other than

24:00

a spin, which has a, uh, has a capsule.

24:03

So this is how you distinguish, uh,

24:05

an encapsulated lesion from a non encapsulated lesion and

24:08

or, or encapsulated pathology from

24:10

non encapsulated pathology.

24:12

So the fi, the fibrous capsule is present in the MCNs

24:15

and spends, uh, calcification

24:18

can happen in the periphery in 2020 to 5% of cases.

24:21

They can have mu nodules.

24:23

They are hypovascular

24:24

and not connected with the pancreatic duct.

24:32

And here's a nice path specimen of the mucin cystadenoma.

24:35

You can see multiple larger mucin fill cystic lesion,

24:41

um, within the specimen.

24:47

Now, here is a, an example of an MCN.

24:51

You can see that in the tail.

24:52

There's an encapsulated lesion right here.

24:55

You can appreciate the capsule in the lesion right there.

24:59

And then there's a cystic lesion.

25:01

This corresponds to this, uh, fluid fill lesion

25:05

or on the fluid sensitive sequence on T two weighted images

25:08

on the, on the left, uh, bottom image.

25:10

And then there is a similar appearance on the post contrast

25:14

images of the capsule and no evidence

25:16

of any neuro nodularity.

25:22

This is a 62-year-old woman with mc N

25:24

and low grade dysplasia.

25:25

Here, you can see that there's an encapsulated lesion right

25:28

here, but if you look closely,

25:30

you can also see some foci calcification, as we discussed.

25:33

These are a feature of MCN, uh,

25:36

calcifications in the capsule, uh,

25:39

but can also be seen with, with spin.

25:44

Here is a 39-year-old woman with MCN

25:46

with moderate dysplasia here.

25:48

Now you can start appreciating a little bit

25:50

of irregularity in the wall right there,

25:53

and then some tations as well in the cystic lesion on the,

25:57

on the T two weighted images.

25:59

So this is moderate dysplasia.

26:02

This is a 62-year-old wound with MCN

26:05

and low grade dysplasia.

26:06

Here is a in and out of phase image,

26:10

and there is CT image.

26:12

So notice that with the increasing te

26:14

you can see some blooming artifact around the lesion

26:17

that is indicative of calcification.

26:20

And this calcification can be confirmed on CT as well.

26:22

So capsular, nice example of capsular calcification.

26:26

In this MCN,

26:30

this is the 46-year-old bone with MCM

26:33

with high grade dysplasia.

26:34

As you can see, a large lesion in the pancreatic body

26:37

and tail with a septation right here, septation right here.

26:42

And then there are these few daughter cysts as well,

26:45

which is a feature of MCN.

26:47

When you take the sample out, you can see

26:50

that the daughter cysts are lying within the cyst itself.

26:56

This is a more obvious example, 30 5-year-old woman

26:59

with invasive adnocarcinoma rising in MCN, um,

27:02

with high grade dysplasias.

27:04

So here's a large cystic lesion,

27:07

and then you can see these multiple do cyst there.

27:10

And these are, um, these are, this is a, a feature, uh,

27:13

common to MCN.

27:16

Uh, the corresponding path image shows the same thing.

27:23

This is a 37-year-old woman

27:24

with microinvasive adenocarcinoma rising in MCN.

27:28

Again, a large cystic lesion, multiple do cysts.

27:32

And these correspond

27:33

to do cyst on the T two weight image as well.

27:41

Okay, so the next tumor is a solid pseudo papillary tumor.

27:44

It's a benign, a lower grade malignant lesion.

27:47

It usually affects women in their twenties and thirties.

27:50

Um, it's one to 2% of all pancreatic uh, tumors.

27:54

There's no race or location predilection.

27:57

And because of its age demographics, it is also known

28:00

as the do tumor.

28:05

The imaging features include that is usually a focal mass.

28:09

Um, there is gradual accumulation

28:11

of contrast, uh, in the lesion.

28:13

Uh, unlike endocrine tumors,

28:15

which show arterial enhancement, um,

28:18

it's usually large about eight to 10 centimeters.

28:21

It's well demarcated. It has a capsule very much like MCN.

28:25

Uh, you can have solid and cystic degeneration.

28:28

This lesions can also have hemorrhage and calcifications.

28:34

Here's a, an example of a 31-year-old woman

28:37

with solid pseudo pepin neoplasm.

28:40

You can see this because of the young age.

28:42

That is really the first thing you're gonna think

28:45

of when you see a lesion, which is both cystic and solid.

28:48

Within the pancreas

28:54

is a 49-year-old woman with solid pseudo prine neoplasm.

28:57

Here again, there's a lesion in the pancreatic tail.

29:00

It's got some calcification in the periphery.

29:03

You can see that on this volume rendered image as well.

29:05

There's some calcification.

29:07

And then on the T two weight images, you can see

29:09

that it's not just a cystic,

29:10

it's got some solid component as well.

29:13

All these soft tissue nodules there.

29:15

And it is, um, um, uh, it is, it is inha.

29:19

That solid component is enhancing,

29:21

as you can see right here on the post contrast MRI imaging.

29:26

Now this lesion can very much be an MCN, um,

29:30

as the imaging features, um, overlap, uh,

29:33

this lesion turned out to be a spin.

29:39

Uh, let's move to the microcystic lesions,

29:41

and I put the microcystic variety in the end

29:43

because these are usually benign lesions.

29:47

So the one lesion that you have

29:49

to remember is a sero cystic, uh, STIC tumors.

29:53

Uh, they are, they include sero cystadenoma,

29:55

which is also known as a microcystic adenoma.

29:59

These are glycogen rich

30:01

and constitute 2% of all pancreatic, uh, neoplasms.

30:05

They occur in women 70% of the times,

30:08

and they're usually elderly, mean ages about 65 years.

30:12

They usually happen in the pancreatic head,

30:14

but they can happen anywhere in the pancreatic,

30:16

uh, parenchyma.

30:18

And because of their age demographics, they're also known

30:20

as the grandmother tumor.

30:25

You have another variety, which is known as oligo cystic

30:28

or macrocystic adenoma,

30:29

which is very much like an MCN, and it's confusing.

30:33

Um, but this is another morphologic variety of, um, of, uh,

30:37

uh, sero cystadenoma.

30:39

And then sero cyst carcinoma is exceedingly rare,

30:43

and we almost, uh, almost always these lesions are benign.

30:50

So here are the imaging findings usually appears

30:54

as a focal mass.

30:56

Uh, it has a honeycomb pattern.

30:58

As we discussed earlier on this diagram.

31:00

You can see that there are multiple small cysts that it, um,

31:04

that are, that make a part of this lesion.

31:07

Uh, the cysts are greater than six in number

31:10

and less than two centimeter in size.

31:13

You can have a central delayed score,

31:15

which can calcify right here, as you can see,

31:18

and they can be hypervascular as well.

31:20

Because of these septations, these septations enhance.

31:23

So after contrast administration, there is hyper enhancement

31:26

of these, um, uh, of these septations.

31:29

Now, some of the secondary findings are

31:31

no ductal dilatation.

31:32

Now, again, please note that I have put inverted commas

31:35

around the ductal dilatation.

31:36

What that really means is

31:38

that if the lesion is large enough,

31:40

it can cause ductal dilatation

31:42

and it can cause atrophy as well.

31:45

Similarly, however,

31:46

does the classic teaching was there's no ductal dilatation.

31:49

We've seen enough cases that ductal dilatation can in fact

31:52

happen along with atrophy.

31:58

This is a 73-year-old man with cystatin.

32:01

Again, it's unusual for men to have it,

32:03

but this is a patient who had one.

32:05

You can see there, there is cystic lesion right here, which,

32:07

which is composed of multiple small cysts

32:10

and instead of a honeycomb pattern,

32:12

and there's a central scar there as well.

32:15

And then that can be appreciated.

32:16

Well, on the T two weighted images, multiple small cysts,

32:19

and with a central scar.

32:24

Now this is a tougher case.

32:26

You can see that on ct, it appears

32:28

as a single hypo dense lesion in the pancreatic tail.

32:31

But when you do an MRCP, you can see

32:34

that there are multiple small cysts here that constituted,

32:38

and then also a central scar right there.

32:41

This actually was resected

32:43

because of its confusing appearance on ct.

32:46

And this turned out to be a sero cystadenoma.

32:52

This is a larger sero cystadenoma

32:54

where you can see there's a large cystic lesion,

32:56

and it's, you can see

32:58

that there is an enhancement in within the lesion as well,

33:01

because of the multiple septations that are enhancing.

33:04

Uh, this is just an incidentally noted, uh, hemangioma.

33:07

So this is unrelated okay's.

33:11

Another example, um, of, uh, CT MRI correlation.

33:15

So this lesion actually looks like that on MRI

33:19

large lesion multiple small cysts

33:22

with a essential score right there.

33:27

Now, if you wanna look really smart, well then you look

33:31

for the essential score with calcification.

33:33

If you find that, then that is a very specific sign

33:36

for a sero cystadenoma.

33:42

So if you wanna boil down the unique, uh, genetic profile

33:46

of the cystic lesions, uh, let's start

33:49

with solid pseudo neoplasm.

33:50

You have beta cain, and that is a hundred percent sensitive

33:55

and specific for spend.

33:58

Now, for sero cystic neoplasms, the,

34:01

there is a gene called VHL,

34:03

which is a hundred percent sensitive,

34:05

and 91% specific for the, uh, diagnosis of that,

34:09

uh, uh, this entity.

34:11

Again, as you mentioned earlier,

34:12

there are these imaging features which are very suggestive

34:15

of istic, uh, neoplasms.

34:16

However, in there are problem cases

34:19

where you cannot really differentiate them from ipmn.

34:22

Now, IPMN and M MCN share some genes.

34:25

Uh, so the gene, uh, so the, uh, RNF 43

34:28

and KRAS is, uh, present in both, uh,

34:33

IPMN and mu cystic neoplasm.

34:36

Uh, but gene A is really unique to IPMN.

34:40

So if you were to remember one gene, uh,

34:42

I think it'll be gene S for IPMN,

34:44

because IPMN really is the bread

34:46

and butter of our, uh, precancerous lesions.

34:49

So that is something that can be remembered.

34:54

But then again, you have these, uh, imaging features

34:56

that are really helpful for the diagnosis of these entities.

34:59

Here's an example of an IPMN right here

35:03

where you can see a cystic lesion that is communicating

35:05

with the CY branch right there.

35:07

This is an example of a spin where there is a cystic

35:12

and solid lesion with some calcifications right here.

35:15

This is an example of an MCN,

35:18

where you can see a large cystic lesion

35:20

with multiple do cyst.

35:22

And this is an example of a sero cystadenoma where you can,

35:27

um, see a conglomeration

35:30

or a honeycomb appearing cystic lesion with a central score.

35:36

So if you see a pancreatic cyst, it can either be very low

35:41

or no malignant potential.

35:43

It can be malignant or it can have malignant potential.

35:47

So the ones with the very low

35:50

or no malignant potential are osis and cytomas.

35:54

The ones with a, uh, malignant potentials are

35:59

MCN and IPMN.

36:00

And then ones that are clearly malignant are neuroendocrin

36:03

tumors, ductal, adenocarcinomas, and span.

36:07

Now, you don't need any surveillance for the very low

36:10

or no malignant potential lesions.

36:12

You need surgery for the ones that are clearly malignant

36:16

and for the malignant potential ones, you need surveillance

36:18

or surgery depending on the size

36:21

and imaging, uh, features of the lesion.

36:27

This is kind of, uh, a nice, uh, algorithm of how to deal

36:31

with these lesions.

36:32

Uh, in a high risk patient

36:34

who has jaundice enhancing neuro nodules

36:37

or main pancreatic duct greater than 10 millimeters,

36:39

these patients can go directly to surgery.

36:43

Now, patients who have worrisome features,

36:45

meaning they have, uh, either pancreatitis, uh, as a lesion

36:48

that is greater than or equal to three centimeters, uh,

36:52

which, uh, lesions which have thick

36:53

and enhancing mirror wall, uh, non enhancing, uh,

36:57

neuro nodules, or a main pancreatic duct, which is five

37:00

to nine millimeters with an abrupt change or with

37:03

or without an abrupt change.

37:04

Now these patients can undergo an endoscopic ultrasound.

37:08

Now, if the endoscopic ultrasound shows involvement

37:12

of the main pancreatic duct, uh, definite neuro nodules

37:15

or suspicious cytology,

37:17

then these patients can go to surgery.

37:20

Now, the endoscopic ultrasound can also lead

37:23

to surveillance if the patients have

37:25

these following features.

37:26

If the size is greater than three centimeters,

37:28

then you can either go for surgery

37:31

or you can do surveillance depending on the

37:33

clinical status of the patients.

37:34

But you have to do it for a shorter month,

37:36

shorter time period, which is six months.

37:38

Now, surveillance for two

37:40

to three centimeter size lesions can be two to three,

37:43

um, can be six months.

37:45

Size of one to two centimeters are yearly

37:48

and size less than one centimeter can be two to three years.

37:51

So these are kind of the general guidelines.

37:54

Um, however, the bottom line is it really depends on how,

37:58

what your surgeons

37:59

and gastroenterologists feel comfortable with.

38:01

And this is really a combined decision for, uh, the whole,

38:06

uh, clinical team.

38:09

So in summary, a pattern based approach helps the

38:12

identification of certain key imaging findings

38:14

that confidently suggest the diagnosis.

38:17

Some of the key features to identify are a dilated, uh, duct

38:20

for main duct, I-P-M-N-A cystic lesion with the history

38:24

of pancreatitis for pseudocyst or chronic pseudocyst.

38:29

Um, then side branch communication for the diagnosis

38:32

of IPMN, um, body and tail location

38:35

and daughter cyst appearance for mu cystic neoplasms, solid

38:39

and cystic appearance for spent tumors

38:41

and microcystic morphology with a central scar

38:44

for sero cystadenomas.

38:47

So that's all I have.

38:48

Uh, thank you very much for your time and attention.

38:50

Thank you so much Dr. Sahir, for your lecture.

38:53

And at this time, we will open up the

38:56

floor for some questions.

38:58

You could put your questions in the q

39:00

and a feature that would help us get

39:03

through as many as we can.

39:04

Before we close today, Dr.

39:08

Zahir, if you are able to open up the q

39:12

and a box, there's a couple

39:13

questions in there for you already.

39:16

Let me know if you can find the questions.

39:18

If not, I can read them off to you.

39:19

Uh, no, I can see them here. Awesome.

39:21

So, um, so, um, the first question I have is

39:25

how can one confidently differentiate pancreatic pseudos

39:28

from mcn, especially the one

39:30

with atypical dysplasia and imaging?

39:32

So, um, MCN has a sort

39:34

of a typical appear when it has a typical appearance,

39:37

you know, the cyst with a capsule

39:39

and some daughter cyst appearance.

39:40

Then it's very, um, uh, those features are highly suggestive

39:44

of, uh, uh, of an CN Pseudocyst, again, you know,

39:49

is solely based on history.

39:51

Uh, if you have a history of acute pancreatitis,

39:54

then you know, there's a greater chance

39:56

that the lesion is going to be, uh, pseudocyst

39:59

as opposed to an M mcn.

40:01

Um, I don't know much, uh, many studies

40:05

that have showed that the, um,

40:08

the MCN caused acute pancreatitis,

40:10

and then there was a resulting osis.

40:12

That's, that's kind of a very rare phenomena if that occurs,

40:15

maybe this case reportable.

40:17

Um, so yeah, so, so that's, um, basically one way.

40:21

So if you, if you, you, you ask the person, you ask the

40:24

or for provider if there is a history of, uh,

40:27

acute pancreatitis or not, then you based your,

40:29

your assessment on that.

40:31

And if there are these, those, uh, very specific features

40:34

of m cn, uh, like do cysts

40:36

and neur nodules, then you go in that direction.

40:39

Um, so, uh, is there any value for adding SWI sequence

40:42

to identify calcification MRI?

40:44

You know, usually, um, uh, usually not

40:47

because, you know, calcification can be, um,

40:50

very obvious on ct.

40:51

So, you know, you don't want to be adding more, uh,

40:54

sequences, um, make the MRI more complicated.

40:57

I think, uh, even with the increasing te you can really see

41:00

if there's a, uh, fibrotic, uh,

41:02

and calcified, uh, capsule or not.

41:04

So, um, so that's, uh, usually not, uh, required.

41:08

Um, I have a question. Uh, thank you for your time. Okay.

41:12

Um, how to defer chodo cys type three from

41:15

cystic pancreatic antic lesion?

41:16

That's an excellent question,

41:18

and that's a very tough one sometimes, um,

41:21

because of the fact that, you know,

41:23

if it's really in close proximity, uh,

41:26

to the pancreatic duct

41:27

or to the c to the CBD, then it's,

41:29

it's really hard if it is a, a cyst

41:33

or a cystic, uh, IPMN.

41:36

Um, so, um, one thing that you, one can do is sometimes, um,

41:40

uh, you know, these, uh, vis scans,

41:42

so HEPA contrast agents can help.

41:45

If the contrast is filling up the, um, the cyst,

41:48

then you know that this is gonna be a corded docal cyst

41:51

as opposed to an IPM.

41:53

And ultimately, sometimes you end up with a, uh,

41:56

with an endoscopic ultrasound to really look at it closely

41:59

and to see if the communication, uh, exists between the CBD

42:03

and the, uh, and the cyst.

42:07

Um, how do, how do you handle, uh,

42:09

fo dilated main pancreatic duct with no evidence

42:11

of solid or cystic mass?

42:13

So, so Foley dilated main pancreatic duct, uh,

42:16

is treated the same way

42:18

as a diffusely dilated main pancreatic duct.

42:21

So it's a main DR main duct, IPMN.

42:23

So, uh, depending on the size of the main duct,

42:26

if it's greater than, uh, 10 millimeters, um, then you know,

42:30

you can go straight to, um, uh, sometimes, uh, um, you know,

42:34

depending on the patient's, uh, surgical condition, you,

42:36

you, I think probably in all, for all practical purposes,

42:40

if it's not diffusely dilated,

42:41

then pe people end up getting an endoscopic ultrasound,

42:44

get a fluid, uh, analysis, uh, FNA with that.

42:47

If it's less than, uh, you can easily watch it.

42:49

Sometimes you have to be careful

42:51

that there are these ectatic ducts that can also look, uh,

42:54

dilated, especially in older people.

42:56

So, um, you know, as just,

42:59

I guess conservative surveillance can be, can be,

43:01

uh, can be helpful.

43:03

Um, is there a role of dynamic contrast MRI

43:06

to guide about risk of no, well,

43:08

dynamic contrast enhanced imaging?

43:10

Uh, you know, I think the four phase MRI is is, uh,

43:14

I think is sufficient, uh,

43:16

because of the fact that, uh, you know, your, uh, it's,

43:20

it's not like liver lesions where you have

43:21

to see enhancement patterns of these lesions, you know,

43:24

it's really, is there enhancement

43:26

or not, uh, really, um, uh, that you really going after.

43:31

So, um, I think, um,

43:33

just the four phase MRI is usually enough.

43:36

Um, next question is, can different cystic neoplasms

43:40

of pancreas occur synchronously?

43:42

Well, um, that's a good question.

43:46

Um, I think, um, uh, sometimes there is a chance

43:50

of people developing IPMN in conjunction

43:53

with cystadenomas,

43:55

but those are not very, uh, common, not very common.

43:58

So usually when it's one lesion, it's usually

44:01

IPNs tend to be multiple.

44:03

So you know, when you see one more than one, uh,

44:05

then the other lesion, even if it's atypical,

44:07

I think I would go with IPMN as opposed to, um, uh,

44:11

as opposed to a, a different diagnosis.

44:14

Um, what can occur sometimes, uh, uh,

44:17

as multiple lesions other than IPMs is the spend can, uh,

44:21

happen sometimes, um, in, um, I, I've seen up to two spends,

44:26

uh, together in the patient, and these patients tend

44:28

to have, uh, some sort

44:29

of more syndromic when they have have, uh, Gardner syndrome

44:32

and, and desmoid tumors as well.

44:34

So, um, so that's the only thing.

44:36

But usually, um,

44:37

these patients' demographics are very helpful.

44:39

These are young women, uh,

44:41

and the diagnosis usually not very challenging.

44:44

Uh, the next question is, is this correct?

44:45

IPM can become into pancreatic

44:47

and nereus, sorry for obvious, I'm questioning myself.

44:49

If I have picked up correctly what IPMN differentiates?

44:52

Yes, that is correct.

44:53

So IPMN does turn into, um, uh, can turn into, uh,

44:58

a pancreatic articular adenocarcinoma,

44:59

and that's the reason we do the surveillance.

45:01

So pancreatic ductal adenocarcinoma, there is, um,

45:04

there's a chance the lower chance in the side branch,

45:06

but there is higher chance in the main duct.

45:09

Um, also you have to remember that these, uh,

45:11

lesions can be, um, uh, uh, can just be sort

45:14

of har heralding something, uh, more sinister underneath.

45:18

So the pancreatic parenchyma has to be evaluated really well

45:21

because you can have a, um, uh,

45:23

a pancreatic echo carcinoma arising, uh, outside of the IPM

45:28

and the IPMs may just be all stable,

45:30

but you may have a cancer rising seminar else, uh,

45:35

for whom you recommended do genetic mutations.

45:37

Then for, um, so, so for genetic mutations, uh, you know,

45:40

right now the, the way things are going, um,

45:44

whenever an FNA is, uh, is done, we are sending our fluid

45:48

for genetic mutation testing also

45:50

because, so that is really the most specific way of, um,

45:54

of knowing what lesion it is.

45:56

'cause sometimes it's kind of borderline, you know, your,

45:58

the ca your, your, um,

46:01

amylase lipase are not all lining up properly.

46:03

So, so the genetic really, uh, genetic testing really,

46:07

really helps, uh, what caused the mouse

46:10

and the snake, uh, configuration.

46:12

Um, so, so the mouse

46:14

and the snake configuration is, uh, i,

46:16

I know it seems bizarre,

46:17

but, um, it is basically, uh, the fact

46:20

that the main duct is not entirely involved.

46:22

It's just a part of the duct that is involved with the,

46:25

with the, with the IPM.

46:26

And so that's what gives it, uh, is, uh, a mouse

46:29

and a snake appearance

46:30

because that part of the duct is producing a lot

46:33

of nuisance, and that's why it just gets vocally dilated.

46:35

Um, and then that obviously that mucin just sort of, uh,

46:39

goes downstream and then, uh, uh, gets excreted out.

46:43

And ultimately, um, you know, main duct, uh,

46:46

IPMN can be diffusely involved.

46:49

Uh, can IPMN have positive acidic fluid for malignant cells?

46:54

Um, you know, we don't really normally test for that.

46:58

So, um, it's, um, I think it's a more

47:01

of a non-specific test.

47:02

So we don't really, we don't really do that.

47:04

It's usually looking for, um, uh, for the more obvious ones.

47:09

Uh, and, um, and some genetic testings, uh, mucin, uh, MLAs,

47:13

like their cea, you know, those are the more obvious ones.

47:17

Uh, is there a situation where screening

47:18

of pancreas should be performed?

47:20

Example, diabetic growth?

47:21

So new diabetes is usually raises the, the question of, uh,

47:25

pancreatic deno carcinoma.

47:27

So, um, so yes, in that case, you know, you have

47:30

to do some imaging tests

47:32

to make sure there is no pancreatic cancer.

47:34

Um, otherwise, um, you know, surveillance is, uh, um,

47:40

uh, screening is performed.

47:41

We have a screening program for pancreatic, uh, cancer,

47:43

and these patients usually have two first degree relatives

47:46

or some genetic, uh, genetic markers such as BRCA mutations.

47:50

And these are the patients who end up getting, uh, uh,

47:53

getting, uh, screened occurrence of cystic neoplasm

47:57

and chronic pancreatitis is chronic pancreatitis,

48:00

high risk of neoplasm.

48:01

The answer is yes, the chronic pancreatitis is a high risk

48:05

for pancreatic ductal adenocarcinoma, not so much

48:08

for the cystic lesions of the pancreas.

48:10

So the cystic lesions that you see in the setting

48:12

of chronic pancreatitis are usually chronic pseudocyst, um,

48:15

but they are at a higher risk of, uh,

48:18

developing pancreatic ductal adenocarcinoma,

48:20

which becomes very challenging when the patients pancreas is

48:22

very, uh, calcified

48:24

and, uh, has a lot of inflammatory changes there.

48:28

Um, the next question I had to come across a case

48:31

where CCL is partial of malignant emase was elevated

48:34

in CT ipn.

48:35

What to infer out of these findings?

48:36

Well, you know, there, there you go.

48:38

I mean, I guess that that sort of tells you

48:39

that there are malignant cells, then that means

48:41

that there is a ductal carcinoma that's brewing

48:44

underneath the IPM.

48:45

Then, um, how do you screen diabetic patient

48:48

by ultrasound or mr.

48:49

So, so the idea, ideally we would, um, screen them with MRI

48:54

and not with ultrasound.

48:55

Ultrasound, we don't really find very useful, um,

48:58

for pancreas, uh, especially

48:59

because, you know, you don't really see the tail very well,

49:01

uh, in most cases.

49:03

And, um, uh, so, uh, you know, we tend to do MRI,

49:07

but I think CT can be a good alternative as well.

49:11

I think you got all the questions.

49:13

Okay. Well, it was my pleasure. It was my pleasure.

49:15

Thank you very much for this thing, guys, and, uh,

49:18

and I hope, uh, to see you again

49:19

or, uh, bring your presence at cancer.

49:23

Yeah, and thank you so much for this presentation

49:25

and answering all those questions

49:26

and for everyone else

49:28

for participating in this NOOM conference.

49:30

Thank you. You can access the recording

49:32

of today's conference and all our previous noom conferences

49:35

by creating a free MRI online account.

49:38

Be sure to join us next week on Thursday,

49:40

April 4th at 12:00 PM Eastern, where Dr.

49:43

Rodrigo Aguiar will deliver a lectured entitled MRI

49:46

of ACL Tears.

49:48

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49:51

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49:52

for updates on future NOOM conferences.

49:55

Thanks again, and have a great day.