0:01

Here we have a patient who is 78, and she's female.

0:07

78-year-old female.

0:08

Let me start showing you some of the images.

0:12

Start off with a T2 weighted image without fat sat.

0:18

Again, we're just going to focus on the pancreas over here.

0:23

This is a lesion over here,

0:29

rather a large lesion.

0:31

It can look a little bit complex.

0:36

This is a T2 fat-sat image, let's just have another look at it.

0:40

Scrolling all the way up and down through it.

0:46

T1 pre is what it looks like over here.

0:55

We have some post-contrast sequences I'd like to share with you.

0:58

Our arterial phase,

1:02

just going to pause here for a few seconds so you can have a look at it.

1:06

Portal venous phase,

1:13

delayed or equilibrium phase.

1:15

I'm going to scroll up and down through it

1:16

so you get a nice sense of the complexity of this lesion over here.

1:23

Finally, for completion's sake,

1:24

as we look at these MRs in- and out-of-phase, see the lesion here.

1:30

In the in-phase, it looks like this,

1:33

not much real objective change

1:35

between the two on the in- and out-of-phase.

1:38

That's the lesion.

1:40

There's DWI images as well over here if you want to look at it.

1:45

This is a higher b-value.

1:50

Once again, I'm going to finish off by showing you what I think are maybe

1:56

some of the more key images to evaluate this lesson, the T2

2:00

and the post-contrast over here.

2:05

This is a second unknown case.

2:08

We have the polling question to see what the group thinks.

2:11

The most likely diagnosis, I'm giving you some options here ranging

2:16

from a mucinous cystadenoma to a serous cystadenoma,

2:21

adenocarcinoma as well,

2:25

and then the SPEN tumor as well.

2:31

Whenever the moderator wants to close the pole,

2:33

we'll see what we think it is.

2:36

We're leading towards serous cystadenoma.

2:40

A few possibly thought it was a mucinous cystadenoma.

2:43

Nobody thought it's an adenocarcinoma, which is great,

2:44

and nobody thought it was just a SPEN, which is great.

2:46

We're really between those two.

2:48

Almost two-thirds thought it was serous, and one-third, mucinous.

2:52

That's great. Let's have a look at this lesion as well.

2:56

Here's the lesion on the T2 weighted images.

2:58

It's at the head of the pancreas, and geez, it's quite complex.

3:03

If you look at it, it looks like there's a small cyst here,

3:05

a small cyst here, a small cyst here, a small cyst here,

3:07

and there's just all clustered together to make up this large lesion.

3:12

Inside of it, it looks like centrally,

3:14

maybe there's a T2 hypointense focus.

3:16

I'm not sure if that'll be important, or not,

3:18

but that is certainly a part of the imaging appearance of this lesion.

3:22

T1 pres are not as useful.

3:24

They just show that there's no hyperintense

3:26

content necessarily within this.

3:28

The post-contrast sequence, it just showed to be quite a complex lesion.

3:32

I'll just go to the delayed phase images, I think,

3:35

which shows that the borders are somewhat lobulated.

3:38

If you were to take your finger and run

3:40

around the outer border, it wouldn't be smooth.

3:42

It would be sort of lumpy bumpy as you go around it.

3:44

Internally, it has these reticulations.

3:47

The reticulations may reflect the walls

3:51

of these small cysts that are making this lesion up.

3:54

It's located at the head of the pancreas.

3:55

This happens to be, as I said, a lady in her late 70s,

3:59

and so putting things together,

4:02

the best diagnosis would probably be a serous cystadenoma,

4:05

which is what this turned out to be.

4:07

I think it's really tough.

4:10

If you look at these pancreatic cystic lesions, in particular,

4:14

it's very tough to come up with a prospective diagnosis.

4:17

Even if you tell your providers, I think this is serous cystadenoma.

4:21

Well, guess what? They're probably,

4:23

particularly, at this size, they're probably going to have to do

4:25

an endoscopic ultrasound to get some sampling

4:27

to make sure that that's exactly what it is,

4:29

and it doesn't mimicking something else.

4:33

What do we need to know about serous cystadenoma as well?

4:36

Good news is that they're benign tumors.

4:39

This is a rather large tumor, maybe 4 centimeters in size,

4:42

but it's going to be, statistically speaking, a benign tumor.

4:46

Now, if you'll look at the literature,

4:48

there are always going to be case reports of malignant transformation,

4:50

but it's really, really rare such that people,

4:54

and we consider this a benign entity.

4:58

We know that it often arises in females.

5:00

About three-quarters of the cases are seen in females,

5:03

and those females tend to be over the age of 60.

5:06

That's a statistic that you may end up remembering.

5:08

You don't know if you can hang your hat on that,

5:12

but it's certainly something that we see more often than not.

5:17

Generally, the teaching was that it arises in the head of the pancreas,

5:21

but as it turns out, it can really arise anywhere.

5:22

I think remembering that it arises in the head

5:25

of the pancreas may actually hinder you at times,

5:28

because then you may not call it what it is

5:31

just because it doesn't arise in that location.

5:33

It can arise anywhere, but it likes the head of the pancreas.

5:36

It almost always is incidental.

5:37

Occasionally, can have pain or some pancreatic biliary symptoms.

5:41

On imaging, it has a variety of appearances.

5:44

Now, this appearance that we see here

5:45

is probably the most common is microcystic,

5:48

so-called honeycomb in appearance.

5:50

You have these innumerable tiny cysts that are together

5:54

and bunched up together.

5:56

The teaching is that you'll see more than six cyst, each

5:59

less than two centimeters, but I don't know, at least in my practice,

6:01

we don't measure any of these cysts.

6:03

I don't know if the group out here listening in the Zoom call does that.

6:06

We just sort of gestalt and have a look at it.

6:10

They're thin-enhancing septations, and occasionally,

6:13

you'll see a central scar, which is calcified.

6:16

I'm assuming, and I don't have a CT on this,

6:18

but I'm assuming that this T2 hypointense focus in the center

6:21

of it is as good a look for a central calcified scar as any is.

6:25

The borders tend to be multilobulated as well.

6:28

They don't have smooth borders.

6:29

They tend to be multilobulated because you got

6:30

all these cysts that are clustered together that make it up.

6:35

Unfortunately, you have different variants,

6:37

which are, luckily, I guess less common that can confuse things.

6:41

Some of you in the call may know the microcytic

6:43

or oligocystic variant seen in up to 25% of cases.

6:47

I have to say we really don't see this that often

6:49

in clinical practice where it doesn't look like this.

6:51

It looks like they're much more larger cysts that are making it up.

6:56

It often mimics some mucinous cystadenoma,

6:58

so you really can't differentiate that on imaging at all.

7:01

There's this "solid variant" where the cystic stuff is less apparent,

7:06

and you're really just seeing septations mainly.

7:09

When you give contrast, it looks like the whole thing

7:11

is enhancing and in those instances,

7:13

it may actually mimic a neuroendocrine tumor.

7:16

Not a cystic neuroendocrine tumor, but a solid neuroendocrine tumor.

7:20

Again, having an endoscopic ultrasound with sampling is key.

7:24

What do you do for this?

7:26

You need something to establish the diagnosis.

7:28

If you look at the literature,

7:29

there are different guidelines on what to do with these cases,

7:32

but most societies agree that if you see

7:34

something that looks like a serous cystadenoma,

7:36

you're going to want to get sampling

7:38

to make sure that's exactly what it is.

7:39

Now, if you establish the diagnosis,

7:43

then there's no real need for follow-up unless the patient has symptoms.

7:48

The only caveat to that is that the ACR guidelines suggest

7:51

that when it's above 4 centimeters or about this size,

7:54

you may want to get it resected, or at least get a surgical consult

7:56

because it's possible that if you had a sampling,

7:58

you may have undersampled this lesion.

8:01

Now, this happened to be a lady who was in her late 70s.

8:04

We've been following this.

8:06

She happened to have some ductal dilatation,

8:08

which was probably due to mass effect

8:11

from this lesion rather than concurrent IPMN or anything.

8:16

We've been following her for some time

8:18

and had been doing okay with no plans

8:21

of resection due to other comorbidities.

8:25

So this case was a serous cystadenoma.

8:28

Move on to our next case.