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and previous noon conferences by creating a free account.

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Today we are honored to welcome Dr. Kevin Chang

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for a lecture entitled MRI of the Pancreas neoplasms.

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Dr. Chang currently serves as the section chief

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of abdominal imaging

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and director of MRI at Boston Medical Center

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and Associate Professor of Radiology at Boston University,

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Chian and Avedisian School of Medicine, as well

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as adjunct associate professor

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of diagnostic imaging at Brown

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University Alpert Medical School.

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Dr. Chang has worked across multiple practices,

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health systems and hospitals over the past 20 years in a

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wide variety of academic, private practice

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and hybrid clinical settings, caring for a wide variety

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of patient populations

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before dedicating his current practice to the care

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of the underserved.

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At the end of the lecture, please join Dr. Chang in a q

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and a session where he will address questions you

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may have on today's topic.

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Please remember to use the q

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

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture.

1:20

Dr. Chang, please take it from here.

1:23

Alright, great. Thank you very much

1:25

for the invitation today.

1:27

So this is, uh, part two of, um, of my pancreas r talk,

1:32

and most of these images are MRI,

1:33

but I'll, I'll include a few ultrasounds and cts as well.

1:37

Today we're gonna be talking about neoplasms.

1:39

Last time we talked about, um, anatomy anatomic variants

1:43

as well as pancreatitis.

1:45

And I believe we also talked about some of the, um,

1:47

pancreatitis related fluid collections like pseudocysts

1:50

and wall off necrosis.

1:52

So today we're gonna be talking about, uh,

1:54

the other flip side of, uh,

1:55

focal pancreatic findings, tumors.

2:00

These are my financial disclosures.

2:04

And the answer key for basically

2:05

what we are gonna be talking about today.

2:07

Um, we're not gonna get too much into, uh,

2:10

mass forming pancreatitis

2:12

or pancreatitis related fluid collections.

2:15

We will touch upon adenocarcinomas,

2:17

although that's a completely, uh, separate topic

2:19

that could take up multiple lectures if you want

2:22

to get into, into the real details of the, uh,

2:25

of a very common, uh, pancreatic, um, finding.

2:29

And then we'll spend a little more time in, uh,

2:31

all the various different kinds of cystic tumors such

2:34

as serous and muus cystic neoplasms, as well as, uh,

2:39

ipmn, you know, intraductal papillary muus neoplasms,

2:42

solid pseudo papillary tumors, as well as, uh,

2:45

neuroendocrine tumors.

2:46

And then a few other rare, uh, tumors like

2:49

anar cell carcinomas.

2:51

And then the amary carcinomas, which is kind

2:53

of a broad topic that covers multiple tissue types.

2:57

So the most common pancreatic cancer is gonna be a

3:01

pancreatic adenocarcinoma.

3:02

This represents about 75 to 90% of pancreatic cancers.

3:06

Uh, they're distributed all throughout the pancreas.

3:08

Uh, 70% are are described to be in the head,

3:11

20% in the body, 10% in the tail.

3:13

There are a bunch of signs that are associated with it.

3:16

Uh, although they may not be a hundred percent specific

3:20

for this diagnosis, they should at least raise your

3:22

suspicion for a focal finding.

3:24

Uh, a double duct sign is when you have dilatation

3:26

of both the common bowel duct

3:28

and the pancreatic duct upstream

3:30

from a pancreatic head mass.

3:31

But this can be, uh, related to a bunch

3:33

of different pathologies that, uh, could be associated

3:36

with strictures or extrinsic mass effect

3:39

upon the distal ducts.

3:40

Uh, in addition to pancreatic adenocarcinomas,

3:43

when the biliary tube is distended, uh,

3:45

to include the gallbladder, um, without, uh, gallbladder,

3:50

um, without a Murphy sign, that's been described

3:52

as a viser sign.

3:55

And then the appearance of the stricture itself,

3:57

which we did get into in the, uh,

3:59

in part in the part one talk was, uh,

4:01

the appearance of the stricture.

4:03

It should look a little more abrupt.

4:05

Uh, malignant appearing can be eccentric

4:08

and is associated with upstream ductal dilatation.

4:10

And, um, when it's, uh, involving the pancreatic ducts,

4:13

oftentimes, uh, it'll also involve, um, atrophy

4:16

of the parenchyma.

4:18

20% have been associated with common bile duct dilatation.

4:23

Um, and it may

4:24

or may not involve the pancreatic ducts, um,

4:26

when it's at the pancreatic head, depending on its location,

4:29

these tumors tend to be T one hypo intense can be variable,

4:33

uh, in T two signal, and they tend to show hypo enhancement.

4:37

And how they differ from a lot

4:39

of the other pancreatic tumors is they tend

4:41

to be more ill-defined and infiltrative.

4:43

So they may not have a very circumscribed margin.

4:46

They may only, um, be evidenced by a change in the texture

4:50

of the parenchyma, the, the loss

4:51

of the typical feathery mixed soft tissue

4:54

and fat appearance of the pancreas.

4:56

You may have more of a homogeneous, uh,

4:58

ill-defined look in the region of a tumor.

5:01

But the, the classic, um, trigger for looking for this, uh,

5:06

area is look for the upstream, uh,

5:08

pancreatic ductal prominence

5:10

or pancreatic ductal dilatation.

5:11

There's certainly some overlap between the appearance

5:14

of adenocarcinomas and, uh,

5:15

and chronic pancreatitis as well as, uh,

5:18

mass forming pancreatitis.

5:20

The, uh, appearance of the duct can differ, though, usually

5:23

with chronic pancreatitis.

5:25

While you may have a dilated duct, it tends

5:27

to look a lot more, uh, beaded

5:30

and, uh, irregular looking, uh,

5:32

and is often associated with calcification, uh,

5:35

which is better seen on CT than on MRI,

5:37

whereas adenocarcinoma, when it's causing a stricture,

5:41

there's more smooth and pronounced ductal dilatation

5:43

upstream from the mass.

5:45

And if you can see the duct extending through the area

5:49

that looks mass, like the duct penetrating sign

5:52

that favors a focal pancreatitis rather than adenocarcinoma.

5:57

And then the factors that you're gonna be looking for, uh,

6:00

to guide wh the surgeon and,

6:02

and the oncologist in terms of whether something is

6:05

surgically resectable primarily,

6:07

or may benefit from neoadjuvant therapy, um,

6:11

would be involvement of vascular structures in particular,

6:14

especially celiac axis, the hepatic arteries, uh,

6:18

portal vein, the splenic confluence, uh,

6:22

superior mesenteric artery and vein.

6:24

Um, uh, usually those are,

6:27

those structures are more critical than other tributary

6:30

structures like splenic artery

6:31

and vein, which are resectable at the time

6:32

of a distal pancreatectomy.

6:35

And the, you know, rather than trying to judge

6:38

what's resectable

6:39

or nonresectable based off imaging, we just,

6:42

I describe the vessels that are involved

6:43

and let the surgeons decide based on the vessel involvement,

6:47

whether they are, uh, willing

6:49

to do a vascular reconstruction

6:51

for certain vessels if there is, uh, uh,

6:54

a vessel involvement.

6:56

And then you're also looking for involvement

6:57

of adjacent structures other than just the duodenum,

6:59

other than, uh, the, just the duodenum as well

7:02

as the presence of, uh, distant metastases, whether it's

7:05

to the liver, whether there's any particularly lymph nodes

7:08

that are, are particularly enlarged.

7:10

Um, although our accuracy for nodal staging is not quite

7:15

as good as it is for, for our primary staging

7:17

and metastatic staging, you're also going to be looking

7:20

for any, uh, peritoneal disease and, uh, implants.

7:24

So some examples of pancreatic head adenocarcinomas,

7:27

and we're not gonna get into too much detail in terms of,

7:30

uh, uh, specific staging

7:32

and, uh, use of, um, structured templates,

7:34

which we do at our site.

7:36

Here's a CT showing a, uh, stent going

7:39

through the pancreatic head,

7:40

and, um, in the region of the pancreatic head,

7:44

there is some, uh, some ill-defined, uh, soft tissue.

7:47

The pancreatic duct itself shows some up diffuse upstream

7:51

dilatation here, especially here in the pancreatic neck.

7:54

On the M-R-I-M-R-C-P, uh,

7:57

the ducts are particularly well shown.

7:59

So, um, I think pancreatic head, uh,

8:03

pancreatic adenocarcinomas can benefit from both CT andm R

8:07

imaging because there's definitely strength, strengths

8:09

and, uh, weaknesses to both modalities.

8:11

I think CT and,

8:13

and the multi-phase pancreatic protocol,

8:15

cts in particular are, are probably superior

8:18

for vascular, uh, evaluation.

8:21

But, uh, the pancreatic, um, MRIs are,

8:25

are very good at depicting the, uh,

8:27

ductal dilatation in the areas of ductal narrowing, uh,

8:31

and are also, uh, decent for,

8:33

for vascular evaluation in patients that are, are good, um,

8:36

breath holders or are amenable to, uh, good quality MRI.

8:41

The coronal, uh,

8:42

single shot image here again shows you diffuse smooth

8:45

upstream pancreatic ductal dilatation with an ill-defined,

8:49

uh, heterogeneous looking, poorly defined mass

8:52

of the pancreatic head responsible

8:54

for the, uh, for that, that finding.

8:55

This is another patient with a double duct sign.

8:57

You can see the common bile duct

8:59

and intrahepatic biliary ductal dilatation upstream from the

9:02

pancreatic head, as well as pancreatic ductal dilatation

9:04

and some, some dilated side branches as well.

9:08

So this is a, a double duct sign related

9:11

to an ill-defined T two hypot intense mass in the pancreatic

9:14

head here, consistent with, uh,

9:16

pancreatic head adenocarcinoma.

9:19

And, uh, these are some more, uh, another patient with a,

9:23

a double duct sign, again here, CBD dilatation,

9:25

pancreatic ductal dilatation to the level of the pancreatic

9:28

head, and it may be very difficult to actually see, uh,

9:32

a discreet mass itself,

9:33

but the presence of the, the focal narrowing

9:36

of both these ducts in an, in an area that, uh,

9:40

looks like they, you can't exclude an infiltrative mass, uh,

9:43

would be signs that you'd be looking for

9:45

for a pancreatic head adenocarcinoma.

9:48

And then here is another image, yet again, this one's closer

9:51

to the pancreatic, uh, body tail area.

9:53

You can see pancreatic ductal dilatation at the pancreatic

9:55

tail narrowing at a focal point,

9:58

transition point at the body tail junction.

10:01

And this mass shows, uh, T two hypo intensity.

10:05

And again, on the, um, on the single shot images here, uh,

10:08

you can see the, the focal transition

10:10

point at the level of the mass.

10:16

This one's a little more, um, uh, locally invasive.

10:20

You can see in addition to the, to the loss

10:23

of the normal texture of the pancreatic,

10:25

the pancreas at the level of the pancreatic neck.

10:27

Here you have upstream pancreatic ductal

10:30

dilatation on the ct.

10:31

Um, more and more mass like focus here.

10:34

Uh, there's also some narrowing

10:35

of the adjacent vessels here.

10:37

The Porto splenic confluence is basically, uh, um,

10:40

involved in case and, uh, luminal and the lumin is narrowed.

10:45

In addition, there's soft tissue extending

10:47

around the celiac axis as well as at least 180 degrees

10:50

around the SMA origin, uh, suggesting

10:52

that there's celiac axis, uh,

10:54

and, uh, SMV as, as well as SMA involvement

10:58

and Porto spinal confluence involvement.

11:01

And in most cases, the, these, these, um,

11:04

tumors would not be deemed, uh, primarily resectable are

11:09

accuracy for restaging

11:10

after treatment is not anywhere near as good

11:12

as it is pre-treatment, though.

11:14

So, uh, oftentimes our, our job in restaging a tumor

11:19

after, um, uh,

11:20

after neoadjuvant therapy is

11:22

to judge whether there's been good disease response.

11:25

But whether there's residual scar versus

11:29

residual tumor is a much more difficult call for us to make.

11:32

Certainly if we do see, uh, residual findings,

11:35

we would describe them, but that doesn't necessarily mean

11:38

that a patient is, uh, nonresectable after treatment.

11:41

And oftentimes long as the patient is a surgical candidate,

11:45

they'll give the, uh, patient that benefit of the doubt.

11:47

And surgeons may often take a patient

11:50

that looks unresectable

11:51

and restaging imaging to, um, surgery, to,

11:55

to determine intraoperatively whether, um, a tumor is, um,

11:59

uh, completely resectable or not.

12:01

This is a MR from that same patient.

12:03

Showing you, again, a little bit

12:04

of pancreatic ductal dilatation

12:06

upstream from an ill-defined mass.

12:08

And the pancreatic, um, head with the same, uh,

12:12

soft tissue encasement, uh, this evil gray kind of T two,

12:16

uh, relatively hyperintense signal surrounding the celiac

12:19

axis on, uh, T two weighted images as well

12:22

as on your T one fat sat, uh, post contrast images, uh,

12:26

and also at the SMA.

12:30

All right. Next topic is going to be cystic neoplasms.

12:33

And here there's a bunch of different things

12:35

that can look cystic.

12:36

We, you know, pseudocyst and, uh,

12:39

and, uh, more complex pancreatitis related fluid collections

12:43

can look like cystic neoplasms.

12:45

However, the way you differentiate the pancreatitis related

12:48

fluid collections from cystic neoplasms is

12:51

using the test of time.

12:52

So they, the, the imaging appearance for a lot

12:55

of these cystic neoplasms can, can overlap

12:58

with each other at any single time point.

13:00

But the reason why a lot of these, um,

13:03

findings are followed up on follow-up imaging,

13:06

especially if there is a clinical history of pancreatitis,

13:10

um, is

13:11

because, uh, a pancreatitis related fluid collection should

13:15

change in appearance over time.

13:16

So if you give it enough time, uh, give it a couple weeks

13:19

or months, and,

13:20

and you reevaluate, uh,

13:22

oftentimes the pseudocyst will change in appearance,

13:24

whether usually it will resolve if the pancreatitis is

13:28

resolving or,

13:29

or it'll look different, uh, in some way or form.

13:32

Whereas the cystic neoplasms tend to be a little more, uh,

13:36

persistent in appearance,

13:37

and they may grow over time as well.

13:39

So, um, we've gone into

13:41

pancreatitis related flu collections.

13:43

In the last talk. We're gonna focus on, um, findings

13:46

that are more neoplastic this time,

13:48

including s cystic neoplasms, formerly known as, uh,

13:52

s cystadenomas,

13:53

or SS cystatin carcinomas, as well as mucinous tumors,

13:57

which include mucinous cystic neoplasms, formerly known

14:00

as mucinous cystadenomas

14:01

or cystatin, no carcinomas, as well

14:04

as intraductal papillary muus neoplasms

14:06

of which there can be, um, side branch and main duct types.

14:10

And then we'll also get into solid pseudo papillary tumors,

14:14

or solid pseudo papillary epithelial neoplasms.

14:16

There's a bunch of different names for this,

14:18

S-P-N-S-P-N-S-P-T,

14:21

and then there's also cystic variants of other tumors

14:24

as well, which can ma can masque create as cystic neoplasms.

14:27

But, um, but they tend to be, uh, more atypical appearances

14:31

for the, for neuroendocrine tumors,

14:34

cystic neuroendocrine tumor cystic adenocarcinomas, as well

14:37

as, um, metastases that can also become cystic.

14:40

But we're gonna focus on these main three types

14:43

of cystic neoplasms.

14:46

And you can see, uh, the illustration here from, um,

14:50

from radiology assistant, kinda showing you the,

14:53

the different, um, appearances of these different neoplasms.

14:56

The sistic neoplasms tend to look like that cluster

14:59

of grapes appearance, whereas mu cystic neoplasms tend

15:02

to be larger and, uh, fewer LOEs.

15:05

And then, uh, IPNs and pseudocysts will both involve

15:09

or extend from the pancreatic duct, uh,

15:12

which is different from there, cystic neoplasms or serous

15:15

and mis cystic neoplasms, which are typically, um,

15:19

separate from the pancreatic duct.

15:23

So our first entity is the Sero Cystic Neoplasms.

15:25

Uh, another name for them in the past was

15:28

and Microcystic, uh, cystic or microcystic cystadenoma.

15:33

These are the so-called grandmother lesions.

15:36

So we'll talk about grandmother, mother,

15:39

and daughter lesions.

15:40

You know, that's, that's been described as three, um,

15:43

various predominant age groups for, for these lesions,

15:48

which are tend to predominate in females.

15:51

Um, but these are, these affect middle age

15:53

to elderly females.

15:54

Um, they are often asymptomatic,

15:57

although they can be associated with abdominal pain.

15:59

They are multilocular cysts

16:01

that are usually smaller than than two centimeters in size,

16:04

and usually more than six in number.

16:07

So it looks like a cluster of grapes.

16:08

Small little cysts oftentimes, uh, range in a radial

16:12

or a spoke wheel arrangement.

16:14

Uh, with a, uh, when you're looking at it at least on ct,

16:17

oftentimes it's associated

16:18

with a central stellate calcified scar.

16:20

Um, or occasionally, not always, but, um,

16:23

but a very helpful feature when you do see it.

16:25

And then because of the, uh, cluster of grapes appearance,

16:28

it's got a sated contour, so it looks very, um,

16:30

lobular on the outer margin.

16:32

And if these do get worked up

16:34

with a endoscopic ultrasound guided aspiration, um,

16:37

they can yield glycogen.

16:39

But these are usually considered a benign tumor, such

16:42

that if you see a lesion that has this classic appearance,

16:45

they can be left alone

16:46

and, uh, don't necessarily need to follow up at all either.

16:49

Although the a CR, um, pancreatic cystic, um,

16:53

flow charts do, uh, allow for, for some follow up

16:57

for these just to, to show that they're stable,

16:59

but usually they don't necessitate follow up.

17:01

This is a typical sistic neoplasm here in the pancreatic,

17:04

um, uh, body area.

17:06

This cluster of grapes appearance,

17:08

you can see the small little cysts separated by

17:11

multiple little thin internal septations,

17:12

which may show enhancement following contrast

17:14

administration, but they tend to be very thin.

17:16

There should not be any, anything that looks more mass like,

17:19

uh, no, no enhancing neural nodules,

17:23

no particularly thick septations in, uh, axial images.

17:27

This is a T one showing you as T one dark T two fat

17:31

that shows T one hyperintensity same appearance,

17:33

this cluster of grapes with thin internal septations,

17:36

which may show some, some, uh, thin internal, uh,

17:39

post contrast enhancement.

17:41

Here's another sistic neoplasm, and

17:44

because this one is very close to the pancreatic duct,

17:47

it can look very, very similar to a, uh, a side branch

17:50

or a branch ducted, IPMN.

17:52

So there's definitely some room for overlap

17:54

between these two entities.

17:58

But again, um, multiple small little, uh, cysts,

18:03

mucinous tumors on the other hand, um, uh,

18:06

these tumors contain mucin.

18:08

So if, uh, if, uh,

18:10

a gastroenterologist aspirates mucin from a pancreatic

18:13

cystic, uh, finding, they're going

18:16

to be very worried about a potentially malignant tumor.

18:20

So this includes mucin, cystic neoplasms, as well as, uh,

18:23

your various types of intraductal papillary mucinous

18:26

neoplasms, whether it's main duct or side branch or both.

18:30

And then there's also another entity that's, uh,

18:32

technically non neoplastic called a muus

18:34

non neoplastic cyst.

18:35

I'm not gonna show you that, but it's gonna look very

18:38

similar to, um, to these other, uh,

18:40

kinds of cystic neoplasms.

18:42

And in fact, it can look very similar to a side branch, uh,

18:45

IPMN, but when you aspirate it, um, there's mucin

18:49

but no evidence

18:50

or ovarian stroma on, uh, cytology or, or histology.

18:54

And, uh, technically they do not have a neoplastic

18:56

potential, but I,

18:58

but, um, I, I think these would be, uh, diagnosis

19:01

that histology rather than at, uh, radiology.

19:05

And then there's the, uh, solid pseudo papillary tumors

19:08

or solid pseudo papillary epithelial neoplasms,

19:11

the so-called dotter lesion, uh,

19:13

which there's an currently an uncertain cellular lineage.

19:16

Last I checked. Alright,

19:20

so muno cystic neoplasms, half as common as s cystadenomas,

19:24

um, all are considered either malignant

19:26

or potentially malignant.

19:28

Uh, these tend to affect the mothers in a, you know,

19:31

these are the mother lesions, middle-aged women.

19:33

Uh, the tumors resemble ovarian

19:35

or biliary cystatin, no carcinomas, basically, um,

19:37

pathologically speaking, they, they are, um, indifferent,

19:41

not, you can't differentiate it from a,

19:43

from their cyst adenocarcinoma

19:44

or cystic neoplasm counterparts in the ovaries

19:47

or in the biliary tree, um,

19:49

often described in the body and tail.

19:52

They tend to be larger than the serious cystic neoplasms,

19:55

and they tend to show fewer than six cysts.

19:59

They may, oftentimes they're unilocular

20:01

or oligo, you know, ular

20:03

and the cysts tend to be, uh,

20:05

larger than two centimeters in size each.

20:08

They tend to have thicker walls.

20:10

And when there are calcifications on CT that tend

20:13

to be more thin and peripheral rather

20:14

than central and stellate.

20:15

So peripheral rim calcification is a,

20:19

is a suspicious feature.

20:20

And in addition to mucin on aspiration, the, um,

20:24

they also will show higher, um, elevated tumor markers, CE,

20:27

a, and ca 19 nine.

20:29

And treatment is, is, uh, typically surgical excision,

20:32

especially if there are some, uh, some, um,

20:35

malignant appearing features like abnormal

20:37

enhancement or nodularity.

20:39

And here's an example of a,

20:41

a mu cystic neoplasm on multiple modalities.

20:43

Here you can see a cystic mass, uh,

20:46

or cystic collection, uh,

20:48

looks largely anti coic in this particular, uh, case.

20:52

And this one is being identified at the pancreatic tail

20:55

on CT pre

20:56

and post contrast, you do see a non enhancing circumscribed

21:00

cyst at the pancreatic tail without, uh,

21:03

abnormal enhancement in this case.

21:04

On, on MRI, it looks T one hypo intense,

21:08

very well circumscribed and T two hyperintense,

21:12

and on the single shot coronal fixed lab image.

21:14

Here you see it, uh,

21:16

without any associated pancreatic ductal dilatation.

21:20

Here's another more ominous looking mucin cystic neoplasm on

21:25

ct, uh, pre and post contrast showing you there are some

21:28

areas of, uh, wispy non-central, um, calcifications

21:33

and following contrast administration,

21:35

there's definitely some, uh, some areas

21:37

of abnormal enhancement as well

21:39

as lower down in the abdomen, some implants, uh, potential,

21:43

uh, uh, omental, uh, implants in the anterior belly.

21:50

Our next muus, uh,

21:52

neoplasm is gonna be the intraductal papillary muus

21:55

neoplasm, formerly known

21:56

as the intraductal papillary mucinous tumor.

21:59

And, um, these tumors can range in histology from epithelial

22:03

hyperplasia through adenoma has change

22:05

through carcinoma in situ to outright invasive cancers.

22:08

So these are, this is a spectrum of disease.

22:12

Um, 23% of these tend to be multiple.

22:15

They all by definition communicate

22:16

with a pancreatic ductal tree.

22:19

Um, but so can pseudocysts, so there can be some overlap

22:22

between those two entities.

22:23

It's very common to see these, I would say, uh, uh,

22:28

on average, one in five, um, patients that ever get, uh,

22:32

an MRCP are shown to have, uh, some kind of, uh,

22:35

an IPMN of some sort.

22:37

So it's, it's a very common finding.

22:40

Uh, there are two main types, uh, main duct involvement,

22:43

which are more likely to be malignant

22:46

or side branch, um, involvement, which is, uh,

22:49

usually lower in the, um, the histological spectrum.

22:52

Uh, unless you see, um, funny features or,

22:54

or ductal main duct, um, communication,

22:58

when you do see main duct dilatation,

23:00

it can be either upstream or downstream.

23:02

But the classic appearance, though,

23:04

is the downstream ductile dilatation from mucinous

23:07

distension of the duct.

23:09

And it often can be so far downstream that it bulges the,

23:13

uh, the major or minor papilla at the, um, second portion

23:16

of the duodenum, the so-called, uh,

23:18

pseudo pseudo do choli doco seal,

23:21

pseudo choli doco seal sign,

23:23

and that, that bulging, um, cystic look, uh, at the time

23:26

of ERCP is a pathognomonic feature of these main induc IPNs.

23:30

Other malignant features include, um, uh, solid

23:34

or papillary enhancing neural nodules.

23:36

Um, a large size, um, with 83%

23:40

that are greater than four centimeters in size being

23:42

malignant, as well as, uh, correlating with a degree

23:45

of ductal dilatation, especially in the main duct.

23:49

And here's a, a typical example of a branch like IPMN.

23:53

You can see a small little, uh, cyst here.

23:56

Uh, you can see it's looks like it's very communicating

23:59

with a otherwise normal caliber main pancreatic duct in the

24:02

pancreatic head.

24:04

Here's your more typical branch duct appearance.

24:07

And you can see here how, how it can look similar to small

24:11

sistic neoplasms.

24:12

In this case, this is closer to the pancreatic tail

24:15

and very closer relation to the pancreatic duct.

24:18

Um, and you can't always see the, uh, communication

24:21

with the duct, but if it's right next door to the duct,

24:24

then uh, I-P-M-N-A branch duct IP MN is, uh, certainly, uh,

24:27

uh, gonna be high in your differential.

24:31

Here's another case from the literature showing a main duct,

24:35

uh, variant where you can see, uh, dilatation of the pan

24:37

of the pancreatic duct, um, in close association with, um,

24:43

the area that you're worried about

24:44

and, uh, ethic on the ERCP.

24:46

Here you can see some mural filling defects along the walls

24:49

here, which, uh, correlate with, um, little papillary, uh,

24:53

areas of abnormality.

24:54

Here's another main duct type in the background

24:57

of chronic pancreatitis.

24:58

So you can see here on ct, there's some, there's,

25:02

there's still some parenchyma mixed

25:05

with punctate calcifications in the pancreatic body

25:07

and tail, but the pancreatic duct in the neck

25:10

and the head look diffusely dilated all the way to the,

25:13

uh, level of the ula.

25:15

And this was proven to be, uh, a main induct, IPMN.

25:20

And then here's another, uh, malignant IPMN

25:23

with neural nodularity,

25:25

which I believe showed enhancement

25:27

following contrast administration.

25:29

So you could see here T one, T one, uh, in phase

25:34

and outer phase, and then T two, again,

25:36

showing you the complexity along that margin with mural, uh,

25:40

nodules and, and some peripheral septations.

25:48

And, uh, also the pancreatic parenchyma did not look

25:51

as atrophic as you'd typically expect if there was an

25:54

adenocarcinoma or other, um, uh,

25:57

tumor in the pancreatic head area.

25:59

And then following contrast administration, here's that, um,

26:02

the, the, where we're showing the abnormal enhancement

26:05

of those complex components along that,

26:07

uh, right lateral margin.

26:09

Um, and this is, uh,

26:10

ultrasound also showing you the similar, uh, complexity to

26:13

that cystic mass in the pancreatic head.

26:18

All right, next topic is gonna be, um,

26:20

solid pseudo papillary tumors, also known as, uh,

26:23

solid cystic papillary epithelial neoplasms.

26:26

This is their so-called daughter lesion, uh,

26:29

classically described in younger females.

26:32

Um, uh, it's been described as, uh,

26:35

predominating in the black population.

26:37

I've also seen it in, uh, in quite a few, um, Hispanic

26:41

and Asian patients as well.

26:43

Uh, relatively rare can pre present with abdominal pain

26:47

or a mass, and they tend to be larger, um, uh,

26:52

on average, uh, around 10 centimeters in size,

26:54

especially in the pancreatic tail.

26:55

They tend to be well circumscribed.

26:57

They are much more heterogeneous in appearance than,

27:01

than your typical cystic neoplasm.

27:03

So there's less, um, uh, you know, it's not

27:07

as often confused with the other cystic neoplasms.

27:10

Um, in the right age population, there can be he, uh,

27:14

components of hemorrhage.

27:15

There can be solid components,

27:16

there can be cystic components.

27:18

Some of them can calcify.

27:20

Um, some of them will, will have a thick enhancing capsule.

27:24

Uh, sometimes they can look completely solid without

27:26

a cystic component at all.

27:27

They are considered low grade malignancies

27:29

and are usually surgically resected,

27:31

but the prognosis is usually much better than it is for,

27:34

for other, um, pancreatic neoplasms.

27:39

And, uh, they tend to be, when they do enhance,

27:42

the enhancement is usually more gradual, so they're not

27:45

as hypervascular as you might expect

27:47

with a neuroendocrine tumor.

27:49

But, um, but sometimes it can be difficult

27:52

to differentiate these, these neoplasms from,

27:54

from other cystic neoplasms.

27:56

But, um, if you're worry

27:58

or your differential is gonna include mu cystic neoplasms

28:01

or cystic neuroendocrine tumors, you know, all three

28:04

of these entities are,

28:05

are typically surgically resected anyways.

28:07

So, um, it's not always, uh, critical to try

28:11

to get the histology correct at the time

28:12

of radiologic imaging.

28:16

I have a bunch of different, uh,

28:17

solid pseudo papillary tumors here.

28:19

This one's, uh, one in that, that, um,

28:21

you see in the pancreatic body here

28:23

with some calcifications.

28:25

There's another one here in the pancreatic head,

28:27

much larger in size, very T two heterogeneous

28:30

with some areas of T two hyperintensity, uh,

28:33

best seen on the coronal, um, single shot images here.

28:37

And notice that there's no pancreatic ductal dilatation

28:39

upstream from this mass.

28:42

And, uh, with contrast, you with, uh, with gadolinium,

28:45

you can see that there are some areas of delayed kinda, um,

28:49

wispy, uh, enhancement within the, uh, within the mass.

28:56

So we're gonna talk about the, the, your typical finding

29:00

for, for cystic lesions, because it's so common.

29:04

You know, we need to figure out what we're gonna be doing

29:06

for incidental pancreatic cystic lesions.

29:08

Definitely there's an increasing frequency of detection,

29:11

especially with, uh, our improving MR technology.

29:14

We're, we're seeing so many more of these now

29:16

that our MRS are,

29:18

are much better quality than they had been in the past.

29:21

They are described more commonly,

29:23

certainly on MRI than they are on other imaging, um, tests.

29:26

Because we're so good at detecting cystic lesions on our T

29:30

two weighted images, they actually are present in, uh,

29:35

in a quarter of auto autopsy.

29:36

So even in the general population, it's very, very common.

29:39

And, uh, most, uh,

29:42

small cystic lesions don't need workup.

29:45

But usually imaging follow-up is what is recommended

29:48

for most of the incidental ones.

29:49

And the small IPNs have low malignant potential.

29:53

Uh, so because of this, a lot of these are followed

29:56

until they certain meet certain criteria

29:58

or trigger points that would, um, trigger a follow-up.

30:02

Uh, oftentimes, uh, endoscopic ultrasound guided,

30:05

um, aspiration.

30:07

The other reason why many of these, um,

30:09

lesions are followed is

30:10

because of the, uh, the, the theory

30:13

that there's a field defect in the entire pancreas.

30:16

So it's not just the cystic lesion

30:20

of the pancreas itself, that's, um, uh, worry as much

30:24

as the increased risk

30:25

for adenocarcinoma somewhere else in the pancreas.

30:28

So there are, you know, there's a bunch

30:31

of different follow-up, uh, regimens, um,

30:34

typically involving M-R-I-M-R-C-P,

30:37

but, um, some institutions are doing them non-contrast

30:41

to follow up to cystic lesion, whereas other institutions,

30:44

like my own, will use contrast

30:46

because of this field defect theory, where, um, you may want

30:51

to give contrast to look

30:52

for the adenocarcinoma rather than the follow up.

30:55

Just that cystic lesion itself, um,

30:57

in the remainder of the pancreas.

30:59

So very, uh, much up to debate

31:01

and, uh, controversial what the best follow-up,

31:03

uh, protocol is at the moment.

31:05

But, uh, MRI tends to be the test of choice for follow-up,

31:08

and there's a whole bunch of different, um,

31:10

follow up intervals that are being recommended,

31:12

and there's just as many different, um,

31:15

societal recommendations.

31:16

But I would say the most important criteria that surgeons,

31:19

gastroenterologists, and radiologists can all agree on are

31:22

the Tanaka criteria,

31:24

or also known as the Fuca consensus guidelines from 2017.

31:28

I believe they were last updated in 2017.

31:30

They talk about high risk stigmata versus

31:33

worrisome features.

31:35

And what you're looking for in terms of things

31:38

that would make you more suspicious of a cystic neoplasm is,

31:42

um, abnormal enhancement as well as the, um, the degree

31:46

of ductal dilatation.

31:47

So the high risk features, the most, um,

31:50

suspicious features are going to be enhancing nodules

31:53

that are five millimeters or larger in size

31:55

or dilatation of the main pancreatic duct to 10 millimeters

31:58

or larger in diameter, as well as, uh,

32:01

clinical symptoms like jaundice.

32:03

Uh, worrisome features, features that would warrant, uh,

32:06

that might warrant, uh, either closer follow-up or,

32:10

or aspiration would be, um, smaller enhancing nodules,

32:14

less than five millimeters in thickness,

32:16

or, uh, thick enhancing wall, uh,

32:18

main pancreatic ductal dilatation between five

32:21

and nine millimeters in size, especially if it's associated

32:23

with parenchymal atrophy, as well as the presence of, uh,

32:26

lymphadenopathy, um,

32:29

or a cyst, single cyst that's larger,

32:32

that's three centimeters or larger in size,

32:34

or a change in the growth of a cyst

32:37

by at least five millimeters in diameter

32:40

over the course of two years.

32:42

High risk TOMA are all, um, indications for resection,

32:46

whereas worrisome features would typically, um, uh, go on

32:50

to EUS aspiration and if inconclusive, then a follow-up MRI

32:55

or a follow-up EOS.

32:59

So, um, in terms of what their recommendations were

33:03

for follow-up in, uh, branch duct to IPMN,

33:06

less than three centimeters in size,

33:09

the the recommendations were, uh, differ based off, um,

33:12

the size of the cyst.

33:14

Uh, and I'm not gonna go into too much detail here

33:16

because there's so much variability in

33:18

what the different societies recommend.

33:19

In terms of follow up, I would make sure you, um, meet

33:24

with your surgeons and, uh, gastroenterologists and,

33:27

and come up with some criteria that you'd, that you would,

33:31

uh, agree upon as a group, uh,

33:33

in your multidisciplinary conferences, um, to, to use

33:37

to, to, to guide the management.

33:40

In 2015, the American Gastroenterological Association came

33:43

up with these guidelines, which were largely, uh,

33:46

size based, um, again, using

33:48

that same three centimeter cutoff for somebody

33:51

that's presumably asymptomatic.

33:53

Um, and they recommended one, three

33:56

and five year follow-up very, um, relatively, uh, um,

34:01

more pragmatic follow-up criteria.

34:03

Although since these guidelines came out, um,

34:06

there have been other, uh, more long-term, uh, evaluations

34:10

of these cystic neoplasms showing that, uh,

34:13

you may need follow up for, for up to 10 years

34:16

to document true stability and benignity.

34:21

So, um, but these are, are very pragmatic ones,

34:23

and I hope at some point, um,

34:25

if these guidelines get revised in the future, we may come

34:29

to something closer to these guidelines again,

34:32

but the a CR guidelines from 2017 were much more complex

34:36

than the other guidelines

34:37

that I had shown you, uh, beforehand.

34:40

And there's other guidelines as well, but you can see here,

34:42

and I'm not gonna go into these in too much detail other

34:45

than to show you that they're largely based off

34:48

not just the size of the cyst,

34:49

but the pain students age as well.

34:53

And the bottom line being,

34:54

if a patient is not a surgical candidate, um,

34:59

then these lesions may not be deemed

35:01

to be very clinically relevant anyways,

35:03

because since the treatment for, for something that,

35:06

for cystic neoplasm that, that you're worried about is going

35:10

to be a, uh, pancreatectomy.

35:12

If the patient's never gonna be a con, uh, candidate

35:15

for pancreatectomy, I would argue a lot

35:18

of these lesions should just be left alone and not followed.

35:21

So I would only follow the, uh, the lesions

35:23

that are clinically relevant for a patient, given their age

35:27

and clinical status.

35:29

But just real quick, you know,

35:31

there's the one age cutoff is gonna be 65 years old in small

35:35

cysts that are less than one in 0.5 centimeters in size.

35:38

Um, various recommendations, uh, per the a CR

35:42

for annual follow up, uh,

35:44

or every other year, follow up until nine

35:47

or 10 years of stability are, are demonstrated, uh,

35:50

in the mid category, kind of one and a half to two

35:53

and a half centimeter size range.

35:54

Again, there's different, uh, intervals

35:56

and different, um, recommendations in terms of, uh,

35:58

intervals and follow ups, some of them being,

36:01

uh, every six months.

36:03

Um, and then E-U-S-F-N-A being, uh, there if, uh,

36:07

they meet criteria in terms of, uh, worrisome features.

36:13

And, uh, again, these two differ based on whether you can,

36:16

uh, confirm pancreatic ductal communication or not.

36:20

And then certainly for the larger ones,

36:22

if you can characterize them, then the, the, uh,

36:25

management's gonna differ on whether you can characterize it

36:28

as a tic neoplasm, if it's low risk

36:30

or high risk based off, uh, those, uh, those fuca features,

36:35

uh, or whether you're gonna go straight onto EUS.

36:39

And then for, there's a special category for patients

36:42

that are older than 80 years, uh, which are, uh, less, uh,

36:46

aggressive in terms of the degree of follow up.

36:48

So I would only follow patients

36:52

who are candidates for treatment.

36:53

Um, follow up can be for up to five to 10 years, uh,

36:57

with different intervals, uh, whether it's every six months,

37:01

every one year, every other year, or, uh, none at all.

37:08

Okay, our next topic is gonna be

37:09

pancreatic neuroendocrine tumors.

37:11

Um, there's a whole bunch of different kind

37:13

of neuroendocrine tumors.

37:14

They used to be called eyelet cell tumors

37:16

until it was disproven

37:18

that they actually arose from eyelet cells of langer hands.

37:21

They are, they actually arise from the, um,

37:25

pluripotent stem cells around the duct, kind

37:27

of per ductal pluripotent stem cells.

37:29

So tumors is the more accurate, uh, term for these.

37:32

Now, most of them are going to be, um,

37:35

or, you know, half of them are, are going to be insulinoma,

37:38

which are mostly benign, 90% benign.

37:40

They tend to be smaller, and they tend to, to present

37:43

because of the, uh, the syndromes associated with it,

37:46

uh, hyperinsulinemia.

37:49

And because of their small size, they size,

37:51

they can be difficult to localize preoperatively, uh,

37:55

gastros are gonna be your second most common,

37:57

and most of these tend to be malignant.

37:59

The, the vast majority of the rest

38:01

of these neuroendocrin tumors tend to be malignant.

38:04

Um, they are often showing slow

38:07

and progressive, um, uh, presentation.

38:09

These are the ones that are associated

38:10

with the Zoria Ellison syndrome.

38:13

So, um, so they, they can be associated

38:16

with peptic ulcer disease.

38:17

They tend to be larger around four centimeters in size,

38:21

and they are often,

38:22

more often actually extra pancreatic than intra pancreatic.

38:26

Um, they're described as being anywhere in the gastro

38:29

triangle, so kind of the, the periportal location.

38:32

So the gastro triangles between the, um, cystic duct

38:36

and CBD confluence, the, uh, second, third portion

38:40

of the duodenum and the pancreatic neck.

38:43

So anywhere in that location, especially in the duodenum,

38:46

uh, a a, a hyper enhancing tumor in, in, in the duodenum

38:49

around that location with those kind of symptoms is going

38:52

to, um, often be a gastro.

38:55

Uh, and these are the patients.

38:57

A lot of these patients have, um, uh, you know, a lot of,

39:00

uh, the multiple endocrin neoplasia type one patients are,

39:03

are going to develop these kind of gastros.

39:06

There are gonna be other functional

39:08

syngen neoplasms as well.

39:09

Much, uh, of the remainder of these are, are much rarer.

39:13

Uh, most of these are also malignant.

39:15

Um, they, they include glucans, uh, VI ps

39:20

as well as somatostatins.

39:22

And, um, and these are, are related to the, um, to the

39:27

hormones that are being secreted.

39:29

Uh, WD HHAs you can be your watery diarrhea

39:32

and your, um, your hypokalemia

39:36

and, uh, achlorhydria.

39:38

And, uh, and some of these are

39:40

associated with diabetes as well.

39:41

And then you have ones that are called non-functional

39:43

neoplasms or neoplasms that, uh, may not manifest

39:47

as symptoms, although they often will be, uh, uh, related

39:51

to some kind of a, a hormonal secretion that's,

39:54

that's subclinical.

39:56

These tend to be larger in the size of the six

39:59

to 10 centimeter size range.

40:00

They tend to present late,

40:01

and most of these are also malignant as well.

40:03

And they are usually more heterogeneous in appearance than

40:06

your typical hyper enhancing T two bright mass

40:09

that we are accustomed to seeing.

40:11

For some of these smaller neuroendocrine tumors,

40:13

they can show heterogeneity on T two,

40:15

they can show heterogeneous enhancement, uh,

40:18

and oftentimes they can be difficult

40:19

to differentiate from adenocarcinomas and mets

40:22

and others more complex cystic pancreatic neoplasms chasms.

40:28

And, uh, this was, uh, an insulinoma

40:31

that we couldn't see on an octreotide scan.

40:33

Certainly nowadays we have dotatate PET scans,

40:36

which have better, uh, spatial resolution than that, uh,

40:40

but on, uh, but oftentimes they're picked up best on your,

40:44

your studies

40:46

that have a higher spatial resolution 'cause of their small size.

40:49

So in this case, um, you know, in general,

40:52

nukes is last I checked about 65% sensitive

40:55

for the detection of these tumors.

40:58

So in this case, it was very difficult to see on ct,

41:01

but are on MRI.

41:02

You can see this faint T two hyperintense lesion in the

41:05

pancreatic tail, which show, which, uh,

41:09

you see here again on, uh, on axial T one

41:12

and, uh, axial T two weighted images.

41:15

And it showed, uh, hyper enhancement that was, uh, you know,

41:19

subtle, but, um,

41:20

but you could pick it up in the pancreatic tail here.

41:23

So this was an in insulinoma at the pancreatic tail.

41:27

Here's another insulinoma here, uh, similar location,

41:30

a little bit bigger in size,

41:31

showing the arterial hyper enhancement

41:34

and, uh, hyperinsulinemia on, um, on serum assay.

41:40

And then this one is a, uh,

41:44

pitfall of imaging.

41:46

So in this is an MRIT one weighted here,

41:50

T two weighted in the upper middle here.

41:52

This is a high B value diffusion weighted image, as well

41:56

as pre and post contrast T one fat saturated images along

41:58

the lo bottom row in the pancreatic tail.

42:01

You're seeing something that T one hypo intense T two

42:03

hyperintense diffusion restricting,

42:06

and it shows, uh, some arterial phase enhancement that

42:09

that persists on the venous phase here.

42:11

But it, you have

42:13

to be careful about this particular location when you're

42:15

looking around the pancreatic tail look

42:18

and compare it to the adjacent spleen, um,

42:21

when it's iso intense on T two T one, uh, diffusion,

42:26

even if it shows, especially if it shows a similar

42:28

enhancement pattern to that kind of the moray, um,

42:31

arterial phase pattern of the spleen.

42:33

And it, um, more homogeneously enhances

42:36

on the venous phases here.

42:37

If it follows splenic signal, it's gonna be a spleen.

42:41

This is an intra pancreatic accessory spleen,

42:43

which I have seen, um, mistake in

42:45

for neuroendocrine tumor in the pancreatic tail.

42:48

So just be careful. They don't have

42:49

to be in the pancreatic tail.

42:51

They can be often, more often

42:52

that times they're right adjacent

42:54

to the pancreatic tail in the, in the splenic hilum,

42:56

but in this particular case, it could look like it's

42:59

inside the pancreas.

43:03

I, uh, added this one, even though it's a very rare tumor,

43:06

super rare, uh, pancreatic in our cell carcinoma is a rare

43:10

epithelial tumor that represents one 1%

43:13

or less of all pancreatic neoplasms,

43:15

but they tend to have more aggressive, uh,

43:17

behavior than adenocarcinomas.

43:20

Uh, in contra dis contra distinction to our, to,

43:24

to our grandmother, mother

43:25

and daughter lesions, these cystic lesions

43:27

and the pancreas, these ones tend

43:29

to have a male predominance,

43:30

although it definitely affects both sexes.

43:33

And I believe there's a bimodal alum,

43:35

uh, age of presentation.

43:36

There have been some that present in the pediatric

43:38

population as well as in the 60-year-old plus population.

43:43

Um, symptoms tend to be non-specific,

43:46

but, uh, one characteristic is lipase hyper secretion, uh,

43:51

with, uh, serum lipase levels oftentimes greater than 10,000

43:54

units per deciliter.

43:56

Um, the small minority can present with a classic, um,

44:00

Schmidt triad, uh, presentation related

44:03

to the lipase hyper secretion resulting in, um, lipase,

44:08

basically subcutaneous fat necrosis,

44:10

whether it's in the skin

44:11

or if it's around joints, it can manifest

44:14

as a poly arthropathy.

44:16

And then, uh, there can also be a serum eosinophilia.

44:20

And, uh, here's an example of a pancreatic asar,

44:24

um, carcinoma.

44:26

In this particular case, it was in the pancreatic head.

44:28

This is another great example of a double duck sign

44:31

that's not related to adenocarcinoma.

44:34

Um, certainly there's, uh, extra hepatic

44:36

and intrahepatic, bili, red ductal dilatation, as well

44:38

as diffuse upstream, uh, main

44:41

and side branch, uh, pancreatic ductal dilatation.

44:44

And as you can see, there's also multiple liver masses in

44:46

this case, uh, which on, uh,

44:48

post contrast imaging showed the classic, um, pattern

44:51

for cavernous angio.

44:53

So these are red herrings.

44:55

The actual tumor itself is this one right here.

44:57

T two hyperintense very well circumscribed,

45:00

much more circumscribed than your typical

45:02

adenocarcinoma in this case.

45:03

There's some, uh, T two hyperintense, uh,

45:07

non enhancing areas centrally consistent with, uh,

45:09

central necrosis and or hemorrhage or protein.

45:13

Here are, uh, T one weighted images out of phase

45:15

and enphase, again, showing you it's mostly T one hypo

45:18

intense with some wispy areas of, uh,

45:20

T one hyperintensity, uh, centrally.

45:23

And then here you can see the T two, um, uh, signal

45:27

with upstream pancreatic ductal dilatation

45:29

and avid diffusion restriction as well

45:32

with a high signal on the, the high B value, uh, DWIs

45:37

and, uh, low, uh, signal on the a DC map.

45:40

And then pre

45:42

and post contrast, you can see the, the hemorrhage

45:44

or protein here with the areas of, uh, delayed enhancement,

45:48

uh, on the, um, on, on these images here.

45:51

And then also good to note that this is the proximal main,

45:55

um, uh, portal vein.

45:58

So there's enhancing tumor thrombus within the portal vein

46:00

as well, which you probably can see

46:03

right here on the coronal image, um, here,

46:09

as well as on the coronal image here.

46:11

So pancreatic asar carcinoma, uh, very, uh,

46:16

rare diagnosis, not often, uh, prospective made on imaging.

46:24

All right. And then the last topic that we'll we,

46:26

we will talk about is amary tumors.

46:28

You know, this, this actually encompasses a spectrum

46:31

of different kind of, uh, tumors in the same general origin

46:35

or same general location right at the ula,

46:37

because of the location of the ula, there are,

46:41

there are at least three possible tissue origins, um,

46:44

because of the different, um, uh, tissues in that location.

46:47

You've got the common bile duct,

46:49

you've got your pancreatic duct,

46:51

and you have your duodenal wall.

46:53

So that means a tumor in this location can, can be of, um,

46:56

biliary origin such as cholangiocarcinoma

47:00

or pancreatic ductal origin, like an adenocarcinoma

47:03

or duodenal origin, like a duodenal adenocarcinoma.

47:07

And, um, because of its location, they tend to present early

47:10

because they present with, um, with, um,

47:12

painless jaundice much earlier than, uh, other tumors.

47:16

And as a result, because of their early presentation,

47:18

they tend to have a better prognosis

47:20

with an 85% five year survival.

47:23

Uh, sometimes because of its location

47:26

and early presentation, they can be too small to really

47:30

visualize well by any kind of imaging,

47:32

whether it's CT or mr.

47:34

Um, but, um, what, again, if you see ductal

47:39

dilatation upstream from something

47:41

that you can't see on imaging,

47:43

and you don't have a, a, a better, uh, a good explanation

47:46

for having a benign stricture in that location,

47:49

at the very least, it should prompt a recommendation

47:52

for a GI consultation for consideration of ERCP,

47:55

because oftentimes they'll be able

47:57

to better visualize a tumor there endoscopically, uh,

48:01

than we can see in terms of cross-sectional imaging.

48:04

And this is an, an example, which I think we,

48:07

I also showed you in my first talk of on diffuse upstream,

48:12

um, biliary ductal dilatation proximal to a,

48:15

an eccentric abrupt narrowing of the, uh, distal CBD here

48:20

with eccentric, um, um, thickening here from,

48:24

uh, an ampullary tumor.

48:28

And, uh, here, uh, you can see that there's some,

48:30

some hyper enhancement

48:32

and nodularity along the medial wall of the duodenum

48:36

ampullary carcinoma.

48:38

So that's our whirlwind tour of, um, many, not all,

48:42

but many pancreatic neoplasms.

48:44

Um, the chief differential that you're gonna try

48:47

to make is differentiating from a, a mass woman pancreatitis

48:51

or a pancreatitis related fluid collection.

48:53

Uh, using you, you can use follow-up imaging

48:56

that differentiate those.

48:57

Um, adenocarcinomas tend

48:59

to be your infiltrated poorly marginated tumors that

49:03

will result in, in ductal dilatation, uh,

49:05

pancreatic neuro biliary.

49:08

Uh, we've got our, all our spectrum of cystic tumors,

49:11

of which most of them tend to be these little

49:13

incidental branch ducted IPMs, which we can follow

49:16

or leave alone or ignore,

49:19

depending on the patient's clinical status and age

49:22

and clinical relevance.

49:24

Um, and then we talked about serious cystic neoplasms versus

49:26

mucin cystic neoplasms.

49:28

We talked about solid and pseudo papillary tumors,

49:31

or solid pseudo papillary epithelial neoplasms

49:33

and your daughter lesions.

49:35

We talked about neuroendocrine tumors.

49:37

And, uh, in addition

49:39

to your classic T two hyperintense hyper enhancing nodule,

49:43

there can be, um, more heterogeneity and cystic

49:46

or necrotic changes as they get larger in size, um,

49:49

or more, uh,

49:51

latent presentation like from your quote unquote

49:53

non-functional neuroendocrin tumors.

49:55

We touched upon the rare in our cell carcinoma,

49:59

and we, we briefly talked about amary carcinomas.

50:02

And with that, I'm happy to take any questions.

50:07

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

50:10

That was great. And, uh, we already have a flood

50:12

of questions in the q

50:13

and a box already, if you're able to pull that up

50:16

and see those.

50:18

Okay. Okay. I'm looking at the chat first.

50:20

Somebody mentioned that the FUCO guidelines were updated in

50:22

2024, so that's great to know.

50:24

I'll have to look that up.

50:25

That sounds like it's fresh off the press.

50:28

Um, let's see what else I can see here.

50:33

Um,

50:45

I apologize if, uh, for those

50:46

of you that couldn't hear me.

50:48

Um,

50:52

So one question is, how do you differentiate main duct

50:55

from main duct?

50:58

IPMN from dilated main duct from chronic pancreatitis?

51:01

And that's an excellent question.

51:02

Um, I did touch upon that earlier in the talk.

51:05

Uh, basically, uh, chronic pancreatitis.

51:08

The ductal dilatation tends to look a lot more beaded

51:11

and irregular because of, uh,

51:12

multifocal strictures in the duct.

51:14

Whereas, uh, uh, IPMN tends

51:18

to look more smooth and, uh, and smoothly distended.

51:23

You can see that as well with, uh,

51:25

upstream dilatation from adenocarcinomas.

51:27

Um, but, um,

51:29

but the ductal dilatations tends to look more diffuse

51:33

and smooth rather than beaded in irregular.

51:41

And, uh, let me take a look at the q

51:45

and a box here.

51:51

Somebody asked about templated reporting for pancreas, MRI.

51:54

I think, uh, if you go to the s the Society

51:58

of Abdominal Radiology Disease Focus panel,

52:01

they probably have a template there that you could download,

52:05

um, and I'm sure there's other locations

52:07

where you can find the, the templates as well.

52:15

And in terms of q and a,

52:25

So one question was, um,

52:27

what do you recommend when you see small cystic lesions in

52:30

the pancreas, um,

52:32

in a patient without a history of pancreatitis?

52:34

Is it better to recommend CT or mr?

52:38

So for small cystic lesions,

52:40

I think MRI is preferred over CT

52:42

because we can see the cysts much better on MRI than on ct.

52:47

Um, also, CT tends to not be as sensitive

52:52

or specific in the smaller cystic lesions

52:54

because you can, there can be, uh,

52:56

an overlap in the CT appearance of a cystic

52:59

neoplasm versus an area of, um, of focal fat.

53:03

You know, they're both gonna look very hypo dense on ct,

53:06

but they're very easy to differentiate on mr.

53:08

So sometimes they'll, uh,

53:10

a small incidental cyst seen on CT is gonna get sent to MR

53:13

for further characterization,

53:14

and it ends up being, uh, uh, an area

53:16

of signal dropout on the out

53:18

of phase versus in Phase T one without TT hyperintensity.

53:21

So usually those are just, uh, areas of focal fat

53:24

or small lipomas and, and can be ignored.

53:27

Whereas, um, uh, if it's a cystic lesion, then uh,

53:30

it's gonna be much better seen as well as, um,

53:34

the number of cystic lesions.

53:35

It's gonna be better seen on MRI throughout

53:37

the remainder of the pancreas.

53:38

And then your, your, um,

53:41

management is gonna depend on the largest,

53:43

um, cystic lesion.

53:47

And then the next question is,

53:48

why is a serious cystic neoplasm terminology now being used

53:51

over serious cyst adenoma?

53:53

I'm not sure what the patho pathologic reason for that is.

53:56

I think, um, um,

54:00

because it's includes both,

54:03

it probably includes the entire spectrum of cystadenomas

54:06

and cystatin or carcinomas.

54:07

I think for the most part, serious cystic neoplasms are, uh,

54:10

benign serious cystadenomas.

54:12

But, uh, I'm not sure exactly why the pathologist changed

54:15

the, the naming for that.

54:16

But in general, the, the, this change in naming applies

54:20

to not just pancreatic cystic lesions, but, um,

54:23

but um, biliary, uh, hepatobilliary ones as well.

54:27

So, uh, the sero cystic versus mu cystic neoplasm

54:31

terminology change, uh,

54:32

I think applies across the board now.

54:36

Um, the next question was about perineural spread

54:41

from atherosclerosis versus fat stranding

54:44

or enhancement on mr.

54:45

I'm not sure I have a good answer for that.

54:49

I'm not sure I've ever, uh, uh, tried

54:52

to diagnose perineural spread based off of,

54:54

uh, imaging alone.

54:56

So, I'm sorry, I can't answer that one.

54:59

Um, any reliable MRCT features that differentiate

55:04

oligo cystic serous tumor from mu cystic neoplasms?

55:08

Uh, probably not.

55:09

Um, basically

55:11

that those two things can look just like each other,

55:14

you know, an oligo cystic serous tumor, um,

55:19

or can, can overlap in appearance of the mu cystic neoplasm.

55:23

Certainly the larger the cysts are,

55:25

the more likely I think they're going

55:26

to be a muno cystic neoplasm than, uh,

55:29

algo cystic serious neoplasm.

55:31

And certainly if there are, are, um,

55:32

worrisome features like enhancing mineral nodules

55:35

or thickened septations, uh, I would, um, work it up,

55:40

uh, either way.

55:41

And, uh, the differentiation would best be made in those

55:45

cases, probably by EUS, uh, with FNA aspiration.

55:51

Okay. Um, what is considered a thick wall?

55:56

Um, I know there are criteria for wall thickness

55:59

for other neo spasms and other, uh, tumors.

56:03

I'm not sure exactly what the, um, the,

56:07

the definition is here.

56:08

Lemme see if I have it in my, uh,

56:12

in the talk here.

56:15

I'm gonna go back to the FUCA guidelines

56:19

and see if I had mentioned the,

56:22

um, septal thickness.

56:25

I'm not a hundred percent sure if I, uh, if,

56:28

if it's been described, if it has, I would definitely, um,

56:32

consult those Kyoto guidelines from 2024, the updated ones,

56:35

and see if they describe that.

56:36

I have to, um, get up to speed on, on terms of the latest,

56:41

um, uh, um, guidelines.

56:45

But, um, but certainly, uh, the thicker they are,

56:48

the more worse they're going to be.

56:52

Uh, any more recent efforts in

56:54

consolidating these guidelines?

56:55

Um, not sure. I hope so.

56:57

Uh, I don't know exactly what's being worked on currently,

57:01

uh, in terms of either the S-A-R-D-F-P or, or,

57:04

or these, um, the, the QTA guidelines.

57:07

But, uh, certainly, uh, I think, uh,

57:09

there it's pretty widely understood

57:12

that there should be more uniform, um, guidelines with, um,

57:16

multi society consensus.

57:20

Okay. B values used for, for diffusion,

57:25

I think there's a bunch of different diffusion,

57:27

uh, B values being used.

57:28

There tends to be a, um, uh, uh,

57:32

move towards moving to, uh, higher B values.

57:36

I think ours are, are B uh, are high,

57:39

B value is in 800 right now,

57:41

but I've seen others use even B one thousands

57:43

or B 14 hundreds,

57:47

and I'm not aware of any specific a DC numbers being used.

57:51

I think a lot of the a DC numbers are, are vendor specific.

57:54

So, um, if you're going to use quantify, uh, you know, um,

57:58

quantification, um, parameters, I think you have to decide

58:01

that based on your particular, um, magnet.

58:06

What contrast do you use for neuroendocrine tumors?

58:09

Uh, gavis Prius, I, I would use, uh,

58:12

an extracellular contrast agent like Gavis or proh

58:16

or, you know, all the different kinds of, um,

58:18

extracellular contrast agents that we use

58:20

because, um, I wanna see the pancreatic enhancement

58:25

without early washout.

58:26

You know, we're not characterizing, uh,

58:28

hepatocellular tumor like we would with either prima vista

58:31

or vis, so, so we tend

58:33

to use the extracellular contrast agents for pancreatic, uh,

58:36

neuroendocrine tumors.

58:41

Okay. So the next question is, uh, pancreatic pseudocyst

58:44

and side branch IPNs, uh, duct involvement.

58:48

Uh, how I, I think the questions regarding how

58:53

to determine whether they involve their duct

58:55

or if they're just adjacent to the duct.

58:57

And I, I find, you know, it's a great question.

59:00

I have the same question oftentimes as well.

59:02

I don't think it's always that clear cut when there is, um,

59:06

ductal involvement

59:07

or not when they're right next door to the duct.

59:09

I think if it's near the duct,

59:11

but you don't definitively see the,

59:13

the communication on MRCP sequences,

59:17

then you don't know if you're dealing with a duct, uh,

59:20

communicating, uh, lesion or not.

59:22

So your differential in terms

59:24

of cystic neoplasms is just gonna include your,

59:27

your non duct, uh,

59:28

communicating cystic neoplasms in addition to your IPMN

59:31

and potentially pseudocysts

59:33

or, uh, pancreatitis related fluid collections, um,

59:36

with the differential being either clinical

59:39

or based on follow up.

59:41

But I agree it doesn't, it's not always that clear, uh,

59:44

whether there's duct involvement when the main

59:46

duct is not dilated.

59:50

Next question about is about pancreatitis and malignancies.

59:53

Um, can they be called per neoplastic

59:55

or can pancreatitis be a mimicker of pancreatic mets?

59:58

Um, you know,

60:00

definitely pancreatic neoplasms can be associated

60:04

with pancreatitis when there's ductal dilatation

60:06

or obstruction, right?

60:07

So there's certainly the presence

60:09

of pancreatitis doesn't exclude a pancreatic neoplasm,

60:12

which is why a lot of these, um,

60:13

lesions when you're entertaining the possibility of a,

60:17

of a pancreatitis, whether it's related

60:19

to a pancreatic neoplasm or whether it's, um, paraneoplastic

60:23

or, or, or, or, or unrelated to a neoplasm, uh, the test

60:27

of time I think is gonna be, uh, one

60:29

of the best ways to differentiate.

60:30

And obviously if something does not resolve over time

60:34

and with, uh, with, uh, medical treatment, then,

60:38

then you're probably gonna end up going to a biopsy

60:40

to differentiate in

60:45

terms of, um, whether chronic pancreatitis

60:48

or chronic alcohol consumption predisposes to IPNs.

60:51

I'm not sure about that, but, um,

60:55

but, uh, I don't, I'm not aware of a, of a predisposition

60:59

to an IPMN based off of alcohol use.

61:04

And, um, I think that's pretty much it.

61:09

Yeah. You got through a lot of, uh, questions, Dr. Chang.

61:11

Alright. Excellent work.

61:14

Thank you very much. Yes, thank you so much again

61:17

for sharing your lecture and taking the time

61:18

to answer so many questions.

61:21

And thanks to everyone

61:22

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61:24

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61:25

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61:27

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61:29

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61:31

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61:35

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61:37

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61:40

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61:42

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61:44

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61:50

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