0:00

So this is an 84-year-old male. And I'll show you these images first.

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Was getting abdominal pain.

0:16

It's a little bit choppy on my end,

0:17

which is why I'm scrolling a little bit funny, but I think it's settled down now.

0:20

This is the finding.

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Look at the pancreas. It looks pretty abnormal.

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I'll scroll through it a few times here, just so you can go up and down through it.

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Coronals may help you as well,

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just to get a sense of what's going on in this plane.

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Now, clearly there's ductal dilatation approaching the head and neck

0:45

of the pancreas, or something else going on as well, I think.

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So, 84-year-old male. Pain.

0:51

This is what we see.

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Let's pop up the question to the group. Most likely diagnosis?

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So it could be any number of things,

1:01

but what do we think is the best diagnosis given the appearance?

1:05

Is it Mucinous Cystadenocarcinoma?

1:06

We've seen what that looks like.

1:08

Could this be that?

1:10

Possibly.

1:10

Lymphoepithelial cyst?

1:12

Again, putting that there.

1:14

Talked a little bit about that on the first case.

1:17

Could this just be running the milk, chronic pancreatitis?

1:20

Would you just call this chronic pancreatitis,

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move on to your next case.

1:24

Or option three, Main Duct IPMN with adenocarcinoma.

1:31

Yeah, main IPMN.

1:33

So majority said that

1:35

once lymphoepithelial cyst. You know, what I'll say about Iymphoepithelial cyst is

1:38

I don't think I've ever seen a case of it.

1:40

And what I've seen in literature, they're just sort of simple appearing cyst.

1:42

You're seldom going to call it perspective.

1:45

Like, I suppose there are people out there who really know their lymphoepithelial cyst

1:48

and will call them correctly. But most of us, we're never going to call it correctly.

1:54

So it's always going to be a tough thing to say that

1:55

this is the most likely diagnosis.

1:57

But this is a main duct IPMN with adenocarcinoma.

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And I have to say, I haven't seen too many

2:01

really nice cases of it, at least at our place at Latham.

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And this was a really nice example of it.

2:06

So I wanted to share with the group.

2:08

So what are we really seeing here?

2:10

So I think, as you scroll down,

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the first thing I think most people may notice is the ductal dilatation

2:14

quite pronounced, really parenchymal,

2:16

thinning associated with it and it's quite diffused as well.

2:19

But really as you start to get to the neck

2:21

of the pancreas, it's more than just ductal dilatation.

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If you window it, geez, there's soft tissue components.

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There's something in those ducts.

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And as you come down here, there's more soft tissue.

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More soft tissue. And when you start to see that sort

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of stuff, you got to be worried that there's a tumor inside of it.

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Now, could all that be hemorrhage, proteinaceous debris?

2:38

Yeah, but it just doesn't look like it.

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It looks too nodular, looks too much like soft tissue.

2:42

So I think that would be the best diagnosis in this instance.

2:46

Certainly, doesn't look like a mucinous cystadenocarcinoma

2:48

which is more discrete mass with nodules

2:50

and enhancement associated with some of those nodules.

2:54

And chronic pancreatitis can have ductal dilatation

2:57

but you're going to see calcifications and you're certainly

3:00

not going to see soft tissue components like that

3:01

with chronic pancreatitis.

3:02

You're going to see lots of calcification, ductal dilatation and parenchymal atrophy.

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And you know, this is one of those cases

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that I wanted to share with the group because we happened to be following this

3:13

patient for a while for a variety of reasons.

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If you look back here, this is in 2015. And looks pretty good to me.

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I mean, I wouldn't call anything here.

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At most, I would call maybe something here and maybe call a side branch IPMN at most

3:27

over there. Follow it up in a little bit, see what happens over time.

3:31

But over time, two years later,

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started to look like this.

3:39

You start to see ductal dilatation just two years

3:42

And I think the soft tissue components are a little bit tougher

3:45

to see, but knowing that they're there, it's probably going to be this stuff.

3:48

So it's really sort of developing before our eyes.

3:53

And another CT in June of 2020,

3:56

you can start to see the ductal dilatation is even more pronounced.

3:59

And then the most recent CT that we saw was in August of 2020,

4:02

where you can see more ductal dilatation soft tissue components.

4:06

So this turned out to be, as I said, to be a main duct IPMN.

4:09

So if we talk about IPMNs in general,

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these are mucinous producing tumors and they have papillary projections on histology,

4:16

and they're different from mucinous cystadenomas.

4:19

We see them pretty equally in males and females.

4:21

Some people suggest more often seen in males,

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but we see them in all patients and generally in all ages, but tend to be

4:30

more often in the 5th to 7th decade of life.

4:32

But it is variable.

4:34

IPMNs will communicate with a duct.

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Sometimes it's difficult to demonstrate that communication on imaging.

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But if you can, then that's going to be a clue that's going to be an IPMN.

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And all IPMNs will have malignant potential.

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When you sample them, you can have different degrees

4:49

of dysplasia, whether it's low, intermediate or high grade.

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You can have frank invasive carcinoma. And those are true malignancies,

4:57

or the ones when you sample, the pathologists say there's invasive carcinoma

5:01

or that there's high grade dysplasia. Those are the ones we really worry about.

5:05

And as the group probably knows,

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this is...

5:12

They come in a variety of different types on imaging.

5:15

Side branch, main duct, mixed and

5:19

mixed have components both side branch and main duct IPMNs.

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And with a main duct, you're really going

5:25

to see this markedly dilated tortuous duct.

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And you don't really see a discrete obstructing mass,

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but you see these mural nodule associated with it, like you see in this case,

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you're going to be worried that there's an underlying malignancy associated with it.

5:41

If possible, you're going to have to try to resect this.

5:43

This is going to be an impossible

5:45

resection, really, in this instance, given that there's really no much

5:50

pancreatic parechymal associated with the remainder of the pancreas.

5:54

But in general, when you look at IPMNs, when do you want to consider resection?

5:58

Well, when they're associated with ductal

6:00

dilatation that's pronounced more than ten millimetres.

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When you see enhancing nodules, or,

6:05

and, or if you have any symptoms that are attributable to that.

6:07

So symptoms is not something we can necessarily see, but we can see ductal

6:11

dilatation, we can see enhancing nodules just when we get suspicious for it.

6:14

And there were some questions here.

6:18

Somebody asked, is this a main duct that developed from a side branch?

6:21

I always thought main duct developed without side branch proceeding it.

6:23

That's a great question.

6:25

I don't know if this was a main duct that developed from a side branch.

6:30

All I can say is that back in the day, in 2015, I would not have called much

6:35

except for potentially a cystic lesion in sort of the incident process.

6:40

And for all we know,

6:41

this was sort of a budding main duct arising from the ventral duct

6:47

of the pancreas, that then sort of took over and involved everything.

6:51

So I think your comment is well taken.

6:53

Usually, they don't develop in the context of the side-branch IPMN, but then I think this

6:57

probably developed independent of that, as you suggested.

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And somebody also asks, is it possible fracture in main duct IPMN

7:04

with ductal dilatation, simply to an obstruction caused by cancer?

7:07

I always think, this stuff is going to be challenging.

7:09

I think with a cancer, you're just going to see a more discrete

7:13

mass and then upstream from it, the duct will be dilated.

7:16

In this instance, you're not really seeing a discrete mass.

7:19

What you're seeing is the duct that's

7:20

dilated and sort of at the periphery of the duct, there's these soft tissue nodules.

7:25

These soft tissue mural nodules, wall based nodules.

7:28

When you see mural nodules associated

7:31

with ductal dilatation, then you kind of think of a malignant sort

7:33

of transformation of an IPMN. When you see a more discrete mass

7:37

without sort of portions of the duct going through it, then you're going to think

7:41

of an adenocarcinoma that's causing ductal obstruction.

7:44

So I think in this instance, it's probably reasonable to think it's

7:50

an invasive cancer rising in main duct IPMN.

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But I suppose if you didn't have this sort of appearance here,

7:55

where there was appearance of the duct going through and this was all soft

7:58

tissue, perhaps it would be harder to call that perspectively.

8:04

Great questions.

8:08

Hopefully sufficient answers.

8:09

I know it's never...

8:11

Don't have all the answers, but I'm trying my best to hopefully

8:17

satiate your thirst for knowledge and questions that you have.

8:21

And two more cases and we have about seven minutes,

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so let me go through them so we can get through the hour.