0:02

Hello, and welcome to Noon Conference, hosted by MRI Online.

0:03

3 00:00:06,090 --> 00:00:07,950 In response to the changes happening around the

0:07

world right now and the shutting down of in-person

0:10

events, we have decided to provide free daily

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noon conferences to all radiologists worldwide.

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Today, we are joined by Dr. David Sarkany.

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Dr. Sarkany is a fellowship-trained body

0:22

imaging radiologist and Program Director

0:24

of the Radiology Residency Program

0:27

at Staten Island University Hospital.

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In addition, he graduated from MGH with a Master

0:33

of Science in Health Professions Education.

0:37

Since this Noon Conference is recorded,

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unfortunately we will not be able to have our

0:42

typical Q and A session after the presentation.

0:45

However, the doctor has been kind enough to provide

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his email address and welcomes all of you to email

0:51

him afterwards if you have any follow-up questions.

0:54

That being said, thank you all

0:55

for joining us today. Dr. Sarkany,

0:58

I'll let you take it from here.

1:00

Hi everyone.

1:01

My name is David Sarkany.

1:03

I'm the Program Director of the Radiology

1:05

Residency at Staten Island University Hospital.

1:09

And, uh, I'm really excited to, to give

1:12

this talk on pancreatic cystic lesions.

1:14

Uh, I definitely wanna, uh, thank MRI Online and

1:19

Dr. Collins for reaching out to me, um, and giving

1:22

me this opportunity to, to speak to everyone.

1:25

Um, the way I'm approaching this topic of pancreatic

1:31

cystic lesions, and by the way, I have no financial

1:34

disclosures, is, you know, I always had trouble when I

1:38

was a, a resident with pancreatic, uh, cystic lesions.

1:42

Um, so I always found that, you know,

1:46

after reviewing the topic many, many times.

1:49

It's nice to just have, like, bullet points

1:51

and examples of the, the various lesions.

1:54

You can write chapters, uh, on this information.

1:58

But I think, especially for a resident,

2:00

for quick diagnosis purposes and even for

2:04

studying for the boards, it's nice to have

2:06

some, you know, bullet point, uh, things to

2:09

look for and some familiarity of the way.

2:12

Uh, these processes will look

2:15

on CT or MR, or ultrasound.

2:19

Okay, so let's get started.

2:21

So my objectives of this talk for you guys is,

2:25

um, describe important facts of the various

2:29

pancreatic cystic lesions that I will talk about.

2:32

Uh, identify important imaging findings.

2:36

Um, and finally outline the differential

2:38

diagnosis for pancreatic duct dilatation.

2:40

And the reason why I throw

2:42

pancreatic duct dilatation in.

2:44

Is 'cause there's a lot of cystic-type of

2:46

lesions that can be associated with it.

2:49

Um, so I think it's, uh, important to

2:51

include it when we talk about cystic lesions.

2:58

So before we start, uh, I just want to introduce

3:01

you to, uh, the ACR Appropriateness Criteria.

3:04

Um, so many of you may know what this is,

3:07

and it's, it's essentially, uh, a, a joint.

3:13

Um, collaboration of different, uh,

3:18

kinds of physicians getting together to

3:20

try to understand what would be the best

3:23

imaging modality for a disease process.

3:26

So I think it's very helpful for residents

3:28

to look at this because it can tell you what

3:30

is the best, uh, initial course of action

3:33

for imaging, but I think it's also important.

3:36

As you're developing as a resident and will become

3:40

an attending, to let your referring physicians

3:42

and colleagues know about this process because

3:46

this may help them order the right, uh, study.

3:49

So I just want to quickly just go over it.

3:53

Um, this is an example of right upper quadrant pain.

3:56

So what the ACR Appropriateness Criteria does.

3:59

Is, you know, as of the last time I checked in 2015,

4:04

there was a little over 200 kinds of, uh, uh, cases.

4:08

And, uh, they'll evaluate the cases based on the

4:11

literature to see what the best imaging modality is.

4:14

So this was an example of right upper quadrant pain.

4:17

The person had fever, a white count,

4:19

and a positive sonographic Murphy sign.

4:21

The best imaging, as most of us would know, would be a

4:25

right upper quadrant ultrasound or abdominal ultrasound.

4:28

So if you look to the, you know, the, the left

4:32

of the screen, we have a listing of all the

4:36

different kinds of modalities, and there's a

4:38

rating scale that's going from nine to three.

4:42

So if it's seven, eight, or nine, then.

4:46

It's good.

4:47

It's usually appropriate.

4:48

Four, five, or six.

4:50

It depends.

4:51

So that's when you have to take into account the

4:53

patient's clinical situation and the broader picture.

4:56

It may be a useful technique, and one,

4:59

two, and three is usually not appropriate.

5:02

And you'll see throughout your career, you're gonna

5:04

have people who are gonna be ordering studies that

5:07

are not so appropriate, and you wanna be able to help

5:10

them and educate them on what's the best thing to do,

5:14

if you look all the way to the right of the screen.

5:17

There's these circles, or little radiation circles,

5:21

and that's to tell you how much radiation dose, uh,

5:26

that's associated with, uh, the different modalities.

5:29

So clearly.

5:29

So this is, uh, a table describing

5:32

the relative radiation levels.

5:33

I'm not gonna get into any physics here.

5:35

Um, again, it's just so you're aware.

5:38

Um, so the zero means no radiation — ultrasound,

5:42

MRI — and then the more circles, the more radiation.

5:46

So clearly we have five circles here — C,

5:49

T, A, chest, A, and pelvis with contrast.

5:52

There's a lot of radiation that

5:53

will, uh, go along with that.

5:56

So it's also just an important thing to know,

5:58

because if there are modalities that will provide

6:02

the same answer, then we want to try to give the

6:05

least amount of radiation possible.

6:08

Um, clearly if the modality

6:10

requires it, it's necessary.

6:12

You have to do a CTA to rule out a GI bleed.

6:15

It is what it is then, you know, that's what we do.

6:20

Okay, so the topics I'm gonna talk about,

6:26

um, pancreatic cystic lesions are the, the

6:29

following: pseudocyst, serous cystadenoma, mucinous

6:33

cystadenoma, intraductal papillary mucinous tumor,

6:38

a simple pancreatic cyst. And I just want you to

6:41

know there are other cystic lesions, uh, not as

6:45

common, um, including cystic degeneration of adenocarcinoma.

6:50

So I'm not going to give a broad conversation

6:55

of every single possible pancreatic cystic lesion.

6:58

I want to hit on the, uh, the biggest

7:00

ones, or what I consider the biggest ones.

7:06

So let's start off with a pseudocyst.

7:08

So, um, many medical students and residents know

7:12

that pseudocysts usually occur due to pancreatitis,

7:15

and most often it could be alcoholic pancreatitis

7:19

or other various causes of pancreatitis.

7:22

Um, but occasionally it can be, um, due to trauma.

7:26

So if there's someone who was in a

7:27

car accident, or iatrogenic — you'll see

7:30

it sometimes with ERCP, for example.

7:33

Um, so those are, uh, causes of possible

7:37

pancreatitis that could at least lead to pseudocyst.

7:40

The actual concept of pancreatitis and

7:43

different terminology that's used with

7:45

pancreatitis is pretty extensive, and you could

7:48

probably, uh, write a book even about that.

7:50

So I'm not gonna get into pancreatitis itself,

7:52

'cause we're talking about cystic lesions, but

7:54

pseudocyst is a secondary, uh, complication.

7:58

So with pseudocysts, many of 'em can be

8:01

asymptomatic, but depending on the size and the,

8:05

the placement of the pseudocyst, sometimes it

8:08

can have mass effect and it can get infected.

8:12

Um, so important fact to know when

8:18

you're reading pancreatic CT or, uh,

8:20

MRI and you find a fluid collection.

8:22

Is that pseudocysts develop

8:24

after about four to six weeks.

8:26

So if you have day two of pancreatitis,

8:29

and you have a fluid collection, then

8:31

that's just a pancreatic fluid collection.

8:33

It's not a pseudocyst yet. It may develop into

8:36

a pseudocyst, um, but it's not a pseudocyst yet.

8:39

And it's a pseudocyst.

8:41

It's not a true cyst 'cause it actually has a fibrous

8:43

capsule as, uh, what, uh, contains the collection.

8:48

Interestingly enough, pseudocysts can be in any

8:52

part of the body. So clearly, most often it's

8:54

associated with the pancreas, but it can

8:57

be really in, uh, any portion of the body.

9:00

Um, and that's because the fluid can

9:01

track into different, uh, different areas.

9:07

So I just wanted to show, uh, a nice, uh,

9:10

CT example of just simple pancreatitis.

9:13

So here we have, uh, a pancreas.

9:15

Where the borders are, uh, kind of

9:18

obscured; it's kind of amorphous.

9:20

There's infiltrative changes around the pancreas.

9:24

So if you look, um, you know, higher up anterior

9:28

to the abdomen, the subcutaneous fat or the

9:30

intraperitoneal fat is very dark, but around the

9:34

pancreas, it's all kind of a, a whitish gray.

9:38

Um, so it's a perfect example of the way,

9:41

uh, acute pancreatitis would look like.

9:47

So this will be our first case, and this case

9:52

itself could be day two of pancreatitis, or it

9:55

could be, uh, the sixth week of pancreatitis.

9:58

And again, depending on the timing,

10:01

that will determine if it's pseudocyst.

10:03

But what we can say for sure is

10:05

that there are fluid collections

10:07

that are rim enhancing.

10:09

There are tons of inflammatory

10:10

changes around the pancreas.

10:11

And again, I'm only showing one image.

10:13

So you're not getting a, a great picture of the,

10:17

of the whole process, but you get a basic idea, and,

10:22

um, you know, if it's after four to six weeks, this

10:25

is a perfect example of a pancreatic pseudocyst.

10:32

So this is the same patient that they're following

10:35

up to see if the pancreatitis is, uh, improving.

10:39

This is one month later, so

10:40

we're at the four-week, uh, mark.

10:43

So these are definitely, uh, pseudocysts,

10:46

the rim-enhancing fluid collections.

10:48

Um, and there's actually two of 'em, and you

10:51

can see with the one that's larger that it is

10:55

really kind of smushing that, uh, left kidney.

10:58

And, um, it wouldn't be shocking if the patient's

11:01

having symptoms related to the, the left renal, uh,

11:05

system — UTIs, or hydro, or things of that nature.

11:10

And that's what I mean is sometimes it

11:12

can be asymptomatic, so that probably

11:14

smaller one is kind of asymptomatic.

11:16

The larger one is

11:18

causing mass effect.

11:19

It could cause mass effect on the stomach

11:21

and cause gastric outlet obstruction.

11:23

It can cause mass effect on the biliary ducts

11:26

and cause biliary duct dilatation, elevated bilirubin.

11:29

Um, so it could definitely have a, a lot of effects.

11:37

This is another case, um, it's an

11:39

example of chronic pancreatitis, and

11:41

we'll talk about a couple things here.

11:43

So the big arrow pointing to a

11:45

rim-enhancing fluid collection.

11:48

A pseudocyst.

11:49

Um, but what I'm pointing at with the pancreas

11:52

is there's a nice tubular hypodensity within the

11:55

pancreas, and that's a dilated pancreatic duct.

11:59

So going

12:00

back to, uh, my objectives, you

12:03

know, dilated pancreatic duct many times is

12:05

associated with some kind of cystic process,

12:08

and that's why I'm including it in this talk.

12:11

And then you also see white little

12:12

dots throughout the pancreas.

12:14

Those are calcifications.

12:16

So in chronic pancreatitis, um, and I'll show you

12:20

the next case that I show you, uh, will be a,

12:23

a more extreme example of chronic pancreatitis.

12:27

Um, we'll have calcifications in the pancreas, and

12:30

typically you'll have pancreatic duct dilatation.

12:33

Um, but the pseudocyst will not be communicating,

12:36

uh, will not be obviously communicating

12:39

with the, with the pancreatic duct.

12:41

Although the pseudocyst does form from,

12:45

uh, injury to the, to the pancreatic

12:48

duct or leaking of, uh, of fluid.

12:51

Um, so it's important to know for chronic

12:55

pancreatitis that you have pancreatic duct dilatation.

12:57

You'll have calcifications, um, and you may or may

13:02

not have cysts, uh, that depends on the patient.

13:09

So.

13:10

Okay, with pseudocyst treatment, um, many of 'em we can

13:15

treat conservatively, they'll regress on their own.

13:18

However, if they're symptomatic or they're getting

13:20

bigger, or they're coming back again, you

13:23

can either do surgery or endoscopic drainage.

13:27

And a lot of GI docs will stick a drain between

13:31

the pseudocyst into the stomach so that the

13:34

collection drains into, uh, the stomach.

13:36

So I've seen that a lot more recently.

13:39

Um, and I think it's a pretty, uh, easy

13:41

way to, uh, help that pseudocyst resolve.

13:49

So, previously I had mentioned that I'm

13:51

gonna give you a more complicated chronic

13:53

pancreatitis that's a little bit later on, and,

13:55

uh, when we get to it, I'll show it to you.

13:57

Okay.

13:58

Let's talk about serous cystadenomas.

14:01

Um, so this one was always, you know, a hard

14:04

one for me because they're just, they don't

14:06

occur in practice that common.

14:09

Um, so, but a few important points.

14:13

Number one, it's benign.

14:14

So that's, uh, a very important,

14:17

uh, thing to keep in mind.

14:20

More often in females, more often elderly; it

14:23

can be middle-aged, but for, you know, test

14:26

purposes or, uh, for general, trying to remember

14:31

purposes, it occurs in elderly people.

14:34

Tends to be in the head or uncinate process, and as

14:37

an aside, it can be associated with Von Hippel–Lindau.

14:44

So serous cystadenomas, the majority of them are

14:48

many tiny cysts between one to 20 millimeters,

14:51

and it's called the polycystic, uh, category.

14:54

That's the majority of them.

14:56

Um, there's a honeycomb pattern,

14:59

and there's an oligocystic.

15:00

The honeycomb pattern is the cysts are, uh, uh,

15:04

a lot smaller, and the fibrous septa are a

15:07

little bit more prominent.

15:10

The oligocystic, the cysts are

15:13

bigger than 20 millimeters.

15:16

Um, again, those two are not nearly as common.

15:20

Um, in general, serous cystadenoma was.

15:23

The cysts are separated by septa, fibrous

15:25

septa that are radiating from a central

15:27

scar, and that central scar can be calcified.

15:30

It doesn't have to be, though.

15:35

So this is not a great CT example.

15:39

Um, I'm gonna give you a sagittal image

15:41

where you see the septa a little bit more.

15:43

The arrow is kind of pointing towards a septa.

15:46

So this is a loculated fluid collection with septa.

15:49

It looks like a bunch of grapes.

15:51

Um, but I'll show you other examples

15:53

that are a little bit more obvious.

15:54

And this isn't, uh, in the head.

15:59

So here's a sagittal image.

16:00

Again, you can, you know, faintly see, faintly see,

16:04

um, you know, linear septa where a little bit more

16:08

high density than the actual cystic, uh, component.

16:12

So.

16:14

So I'm gonna show you some MRIs, but before I show

16:18

it to you, let's just, for those who don't know too

16:20

much about MRI, let's just go over two basic concepts.

16:23

Um, in the, you know, in the good old days,

16:27

um, when MRI first began, we essentially

16:30

had two sequences, T1 and T2.

16:32

Nowadays, we have tons and tons of different

16:34

sequences depending on the, uh, area of concern.

16:38

Um.

16:40

But originally, T1 was essentially kind

16:42

of like an anatomical, uh, sequence so you

16:46

can kind of get a lay of the land, know

16:49

what's going on with the general anatomy.

16:51

And T2 was more of a pathology type of sequence,

16:55

where things that are slightly bright were pathologic.

16:58

Now, if something was extremely bright,

17:01

like let's say a cyst, it's still pathologic.

17:04

It's just not malignant.

17:05

Um, so that was the purpose, uh, or

17:08

that's what T2 ended up showing us.

17:11

So again, so for the purposes of this talk,

17:13

um, T1 bright, uh, objects tend to

17:19

be fat or blood products, and T2 bright

17:23

tends to be simple fluid or blood products.

17:26

So they both can be blood products,

17:27

depending on the age of the hemorrhage,

17:30

if it's acute, or chronic, or subacute.

17:33

There will be, uh, different

17:34

kinds of signal intensities.

17:40

So this is a coronal single-shot

17:43

MRI, uh, gave a small field

17:48

of view and a larger field of view.

17:49

Um, and what I'm trying to show you here is the

17:54

serous cystadenoma right next to the stomach, and you

17:58

can kind of see a lot of little black lines in it.

18:01

It may be a little bit better on the smaller image.

18:04

Um, and again, so nowadays with MRI, there's a lot of,

18:10

uh, what I've noticed, a lot of mixing of the signals.

18:14

So here we have the stomach, which is bright.

18:17

You have the cystadenoma, which is

18:19

bright, both are fluid type of, uh.

18:22

Uh, areas, but the subcutaneous or intraperitoneal

18:25

fat is bright, so that's kind of confusing based on

18:28

what I just explained to you with T1 and T2.

18:32

The way I tell, uh, my students or residents to look

18:36

at it is, look at the fluid-based, um, structures.

18:41

If they're bright on T2, the ones that

18:44

should be bright — the gallbladder, fluid

18:46

in the bowel loops, in the bladder, if

18:49

there's no ovarian cyst or a renal cyst.

18:51

Then that sequence is a primarily

18:53

T2-weighted sequence.

18:55

So this is a — I will view this when I read

18:59

it as a primarily T2-weighted sequence.

19:02

Yes, it has some T1 components to it, um,

19:05

but it's a primarily T2-weighted sequence.

19:11

So to me, this is a much nicer picture where

19:14

you kind of get all these kind of little septations.

19:16

It really looks like a bunch of grapes.

19:18

This is, uh, a thick-slab MRCP image.

19:22

Um, and here is, uh, an axial T2 fat-sat image.

19:29

So again, T2 I know because the CSF is bright,

19:33

the stomach is bright, our cystadenoma is bright.

19:37

Um, it's fat-saturated.

19:39

So all the fat — intraperitoneal

19:41

and subcutaneous — is, uh, is black.

19:47

Just another example, again, I think you — this is

19:50

probably my best example of showing the fibrous septa,

19:53

um, and how it really looks like a, a bunch of grapes.

19:57

So this would be a classic, a no-brainer,

19:59

serous cystadenoma.

20:02

And it's important to know that,

20:03

because if you're gonna just

20:05

diagnose, you're gonna say there's

20:06

a cystic neoplasm in the pancreas.

20:09

They're gonna wanna rush to surgery.

20:11

And this is a non-surgical, uh, entity,

20:15

unless maybe it gets too big or there's,

20:18

you know, some secondary type of things.

20:20

But in and of itself, it's a benign lesion.

20:22

So just like you wouldn't remove a renal cyst,

20:24

you don't need to remove this lesion.

20:30

Just another example of those bunch of

20:32

grapes. On the right, there's an image,

20:34

it's a post-contrast T1 with fat sat.

20:38

I know it's T1 because the CSF is dark, fat sat.

20:42

The fat is dark.

20:44

And I'm telling you, there's contrast.

20:46

It's contrast in the aorta and the venous system.

20:48

You can see how the septa are enhancing.

20:52

Um, so that's a, a post-contrast.

20:59

Okay, so let's talk about

21:02

intraductal papillary mucinous tumor.

21:04

So, so far we hit on pseudocyst

21:06

and a serous cystadenoma.

21:09

So there are three different types of

21:11

intraductal papillary mucinous tumors.

21:14

Main duct, branch duct type, or what I call side branch,

21:19

or mixed, where it could be main duct and side branch.

21:25

So main duct intraductal papillary mucinous tumors

21:29

can be diffuse, involving the whole pancreatic duct.

21:31

Segmental, maybe just the body, maybe just the tail,

21:35

and it has malignant potential, some say up to 60%.

21:38

So this is a surgical, uh, lesion.

21:42

So if you diagnose, uh, main duct IPMN, then

21:47

uh, the patient will have, uh, that part of

21:49

the pancreas removed, if not the whole thing.

21:54

So this is a, a nice example where

21:56

they didn't actually do anything

21:58

for the main ducts and it got worse.

22:00

Um, it didn't get malignant in this person, but the,

22:05

the pancreatic duct dilatation, uh, got a lot worse.

22:08

I don't know if they ended up operating on this

22:10

person, but at year one, there was definitely a dilated

22:13

tubular hypodense structure involving most of the

22:16

pancreas, and that was a dilated, uh, pancreatic duct.

22:20

Now.

22:21

It's so dilated and lobulated that I had to show

22:25

it on three, uh, essentially different images.

22:27

So this is a coronal image of a

22:29

CT without IV contrast, and this

22:32

whole cystic thing is the main duct.

22:36

It's become extremely lobulated.

22:39

The, the bottom left, um, shows the

22:43

region — the pancreatic tail completely

22:46

replaced by a dilated pancreatic duct.

22:49

And then I showed another coronal because this is

22:51

the, the most, uh, distant part of the pancreas,

22:55

um, where again, the pancreatic parenchyma is

22:58

virtually all gone and it's just a, a dilated duct.

23:02

So this kind of person, the pancreas, uh, should

23:05

be removed because there is malignant potential.

23:09

So I'm gonna show a couple, uh, smaller ones.

23:14

Here's an example, um, on the left where we're

23:16

near the pancreatic body where there's a dilated

23:19

duct, and then I'm showing as it goes into the

23:21

head of the pancreas, it's a, it's a dilated duct.

23:29

This is an MRI, so this is

23:32

a UTE T2-weighted sequence.

23:35

Um, I'm showing, uh, on the

23:38

left I'm showing a white arrow.

23:40

That white arrow is supposed to be the CBD, and

23:44

the yellow arrow is a dilated pancreatic duct.

23:47

So remember, it's coronal, which means that, um,

23:51

the pancreatic tail is gonna be up in this corner.

23:54

Um, and the pancreatic head

23:56

is in, in this location here.

23:59

Um, and this is just a little bit more,

24:03

uh, distal to the pancreatic head.

24:04

We're in the pancreatic neck region where

24:08

uh, we still have that dilated, uh, duct.

24:11

We know, again, this is T2

24:13

'cause our gallbladder is bright.

24:14

We have hepatic cysts that are bright.

24:16

So even though the fat is kind of bright, we know

24:19

that this is a predominantly T2-weighted sequence.

24:26

So this goes, uh, we're right at

24:29

the point of that second chronic

24:30

pancreatitis, which is kind of complicated.

24:33

So, but it, it goes back to that dilated pancreatic

24:35

duct dilatation or, uh, discussion where, um.

24:40

It's important to keep that in mind when

24:42

you're dealing with, uh, cystic, uh, lesions.

24:45

So there is a differential diagnosis for pancreatic

24:49

duct dilatation, which we will, uh, we will get to.

24:51

But so far we've seen chronic pancreatitis

24:54

that can cause it and main duct IPMN.

24:58

So this is the chronic pancreatitis case

25:00

that I recently, uh, you know, was seeing.

25:05

I never saw anything really like this.

25:07

There's a huge pseudo mass.

25:10

Involving the pancreatic head.

25:11

Now we have tons of pancreatic calcifications,

25:14

there's pancreatic duct dilatation, and then

25:16

we got this big mass-like process here.

25:20

And let me show you on an axial image.

25:23

So this whole thing over here is a pancreatic

25:27

head lesion, and this area here might

25:31

be a pancreatic duct or a side branch.

25:33

I have no idea.

25:33

Again, I'm only showing you on one image.

25:36

I circled this area just so you know

25:37

what the SMV and the SMA are in relation

25:40

to this, uh, pancreatic lesion.

25:44

And, um, I — it's not what an adenocarcinoma would look like.

25:50

An adenocarcinoma that's this big would

25:52

probably have metastatic disease.

25:54

And commonly with chronic pancreatitis,

25:56

you can get pseudomasses that occur.

25:58

And it's not always an easy diagnosis.

26:01

It's not a, a slam dunk that it's a, it's a

26:04

pseudocyst. It's likely a pseudomass, but, you know,

26:08

follow-up and further evaluation has to be

26:10

performed just to make sure it's not an adenocarcinoma.

26:13

Um, but again, something this big would be,

26:16

uh, more likely a pseudomass.

26:20

And this person had no lymphadenopathy.

26:23

Uh, there were no liver lesions, no pulmonary nodules.

26:26

It was just the pancreas that was, uh, diseased.

26:31

So again, so here on the coronal, we're seeing

26:35

a nice dilated pancreatic duct, and as we

26:37

were talking about pancreatic duct dilatation,

26:39

chronic pancreatitis can cause it, and.

26:41

As we discussed, also main duct IPMNs can cause it.

26:48

And finally, for

26:50

pancreatic duct dilatation.

26:52

You can have a pancreatic,

26:53

adenocarcinoma, and this is an example.

26:56

The yellow circle shows a hypodense

26:58

structure within the head of the pancreas.

27:00

These are coronal images, and it's causing

27:03

distal pancreatic duct dilatation because

27:05

it's obstructing the pancreatic duct.

27:08

So now we have three things that

27:09

can cause pancreatic duct dilatation.

27:12

A central obstructing lesion,

27:14

such as an adenocarcinoma.

27:16

Um, another example could be an ampullary carcinoma,

27:20

uh, or even a, uh, a common bile duct cancer.

27:24

Um, those things can cause,

27:26

uh, pancreatic duct dilatation.

27:28

We have chronic pancreatitis, so that kind of

27:30

pancreatic duct dilatation is not malignant.

27:32

And then we have main duct IPMNs, which

27:34

are, uh, premalignant slash malignant.

27:41

This is that same case, I'm just showing, uh,

27:44

an axial image of what the body looks like.

27:47

The body is totally filled with a dilated

27:50

duct and atrophy of the parenchyma.

27:52

So a classic finding with pancreatic adenocarcinoma is

27:57

dilatation of the pancreatic duct, uh, distally.

28:00

And, um.

28:02

Atrophy of the, uh, associated pancreas.

28:05

And this person happens to have

28:06

a lot of liver hypodensities.

28:08

This is all metastatic disease to the, to the liver.

28:17

So branch duct or side branch, uh,

28:20

intraductal papillary mucinous tumors.

28:22

Um, these tend to be, uh, small cysts.

28:26

Um, and they communicate with the main

28:28

pancreatic duct and what they tend to look like.

28:31

Are, uh, berries hanging from a twig.

28:35

Um, these are usually benign.

28:36

There's a tiny percentage that, uh, can be malignant,

28:40

and there's various recommendations for follow-up.

28:42

I wasn't gonna get into, uh, all of that,

28:45

but, but we do follow these to make sure they

28:48

stay stable and they don't become, uh, worrisome.

28:54

So this is to me what a classic,

28:56

uh, side branch IPMN looks like.

28:58

So this is a single, uh, image

29:01

of a thick-slab, uh, MRCP.

29:05

Um, and we have these tiny little, uh, cystic foci

29:11

that are communicating with the pancreatic duct.

29:13

I have maybe 1, 2, 3, 4.

29:16

Um, it's a nice — the MRCPs, um, are very heavily

29:22

T2-weighted, meaning that only fluid-filled

29:24

structures are really well seen, and we see a

29:26

nice CBD that will branch into the biliary tree.

29:29

We actually see a nice cystic

29:30

duct into the, uh, gallbladder.

29:34

And then we have the nice pancreatic duct,

29:36

um, with these little tiny cystic, uh, areas.

29:41

This over here is probably a duodenal diverticulum.

29:45

So as an aside, sometimes you'll see these air

29:48

fluid collections that will be associated with the

29:51

pancreatic head, and you might think it's an abscess.

29:54

More often than not, it's just

29:56

a, uh, duodenal diverticulum.

29:59

They can be small, they can be very big.

30:02

Um, but if they don't have any, you know,

30:07

anti-inflammatory changes, it's probably just

30:09

a duodenal diverticulum, and those are benign.

30:13

Nothing to worry about.

30:17

So this is going back to, um, one of the examples of

30:21

the, the main duct IPMN that, that I was showing you,

30:25

because there was, uh, uh, a mixed component to it.

30:29

So here we have, we're in the head of the pancreas.

30:32

Again, this is a T2 fat-sat image.

30:36

CSF is bright.

30:37

Renal cyst is bright, gallbladder is bright.

30:41

Um, fat is dark because we fat-saturated it.

30:45

So in the pancreatic head we

30:46

have a very dilated, uh, duct.

30:49

And if you just look a little anterior

30:51

to it, it is a little tiny cyst.

30:53

And on the image on the right, you

30:55

can see there's a communication.

30:56

So this is what a side branch, uh.

31:01

IPMN would look like.

31:03

And it's in, uh, conjunction

31:05

with the, with the main duct.

31:11

And this is, uh, the, the same patient.

31:14

Uh, these are coronal images.

31:16

These are also a single shot.

31:18

They're, uh, again, predominantly

31:21

a T2-weighted sequence.

31:22

And that's the way we, uh, should look at it.

31:25

Yes, there's some bright in the intraperitoneal fat.

31:30

We see, uh, we see a CBD, we see a gallbladder,

31:34

we see a dilated main pancreatic duct.

31:37

We see this little cystic lesion on

31:39

the left below the pancreatic, uh, duct.

31:42

And then on the image on the right, we

31:44

see that there's some communication.

31:53

Okay, so now mucinous cystadenomas.

31:57

So these are important because these are premalignant

32:00

or malignant. Again, they're more often in females.

32:05

Um, they tend to be middle-aged.

32:07

So as opposed to those serous cystadenomas,

32:09

which tend to be more elderly, um, mucinous

32:13

tend to occur in the tail of the body. Again,

32:17

unlike serous, which tends to be in the head.

32:20

And these are macrocystic.

32:22

Sometimes they're just one.

32:23

They're a big cyst.

32:24

And that's it.

32:25

Again, different than the serous, which is

32:27

usually a lot of tiny cysts with fibrosepta.

32:30

And remember, the serous are benign, so it's important.

32:34

Serous, benign.

32:35

We're not gonna operate.

32:36

Mucinous is premalignant or malignant,

32:38

and we're gonna operate to take it out.

32:44

So before we get into, um.

32:47

Uh, mucinous.

32:48

Let's just talk a little bit

32:49

about ultrasound for some of you.

32:50

As a quick reminder, um, a simple cyst needs to be

32:55

anechoic, meaning it should be black on ultrasound.

33:00

Um, it should have a thin wall that you can't see,

33:03

and it should have posterior acoustic enhancement.

33:06

Um, I wouldn't say this is the best

33:07

example of posterior acoustic enhancement.

33:09

You can kind of see some linear black lines.

33:13

The yellow arrows point to, and then

33:15

it's kind of white, uh, centrally.

33:18

Um, so those are the three things

33:20

you want for a simple cyst.

33:23

Uh, and this structure happens to be an

33:24

ovary, but it was just a good example

33:26

of what a, a simple cyst looks like.

33:28

You can have a simple renal

33:29

cyst, a simple hepatic cyst, um.

33:35

So this is a patient who came in who I think she was

33:38

trying to get pregnant and was having abdominal pain.

33:41

We did a sono first thing.

33:44

So on the right, it's a transverse

33:46

image of the left upper quadrant.

33:48

On the left is a sagittal image, so just to

33:51

orient yourselves. On the sagittal image, the

33:55

top part is the anterior portion of the body.

33:58

The.

34:00

Back part or the, the bottom

34:01

part is the posterior portion.

34:03

And if you look, there's a, a nice kidney

34:07

that's, uh, right behind, uh, the big pseudocyst.

34:11

And this is an example of, yes, we have

34:13

the posterior acoustic enhancement.

34:15

It's very, very white over here.

34:17

But it's not really completely black.

34:20

There's a lot of little white, gray dots in it.

34:22

And that means this is a complex cyst.

34:24

Maybe there's some hemorrhage in it,

34:26

maybe there's some proteinaceous material.

34:28

Theoretically it could be infected,

34:30

um, but it's, or it could be mucin.

34:33

Um, and so it's not a typical simple cyst.

34:36

The, the image on the right is a transverse image.

34:39

So again, just to orient you, um.

34:43

The bottom over here, you kind of have a round

34:45

black structure that's your vertebral body.

34:48

Uh, a little bit further up, you have an axial image

34:52

of the left kidney, and then you have a little piece

34:55

of the spleen, and then you have this big pancreatic,

35:00

or let's say left upper quadrant cystic, uh, lesion.

35:03

At this time, it's kind of hard to

35:05

say where it's originating from, so we

35:07

ended up getting, uh, uh, a CT scan.

35:14

So here is an axial and a coronal post-contrast

35:18

CT scan showing that same big cystic lesion.

35:22

And here we actually see it's kind of nice where,

35:25

um, there's something called the claw sign where the,

35:29

uh, the parenchyma is surrounding, um, the cyst and.

35:35

When you see things like that, then you know

35:38

that that cyst originates from that structure.

35:40

So you might see it in a renal cyst,

35:43

you know, ovarian cyst, a hepatic cyst,

35:45

um, and you actually could see it displacing

35:47

the splenic vein, uh, posteriorly.

35:51

I'm showing this coronal image because again, you

35:53

see part of the splenic vein wrapping around it.

35:57

This is an artery up here.

35:59

Um, just to get you, uh, a

36:01

little bit, uh, better situated.

36:05

So then we did an MRI to try

36:08

to further characterize it.

36:11

So I had three different sequences here.

36:13

So let's just go over a little bit.

36:15

T1, T2.

36:16

So all the way on the left, the cyst is dark.

36:20

So we said that, uh, the only thing bright,

36:23

uh, on T1 would be fat or blood products.

36:27

So, um, a cyst should be dark.

36:31

On, um, on a T1.

36:32

So this is a T1-weighted sequence,

36:34

again, if we look at the CSF, it's dark.

36:37

Now, you may argue with me, well the

36:39

gallbladder looks kind of bright.

36:40

Well, first of all, the gallbladder

36:42

should look light bulb bright.

36:44

And this one looks like, you know, maybe

36:46

the top of the gallbladder is a little bit

36:48

darker and, uh, a little bit amorphous.

36:51

So this is actually a gallbladder

36:53

that has sludge in it.

36:54

So sludge in a gallbladder, 'cause

36:55

it's kind of like this proteinaceous type of

36:58

material will be, uh, bright on, uh, on T1.

37:04

Also as an aside, um, the pancreatic parenchyma is

37:07

very, uh, nice to look at on T1-weighted imaging.

37:11

The pancreatic parenchyma tends to be kind of bright.

37:14

So if you're looking for a subtle lesion, an adenocarcinoma

37:17

or something of that nature, it will be, uh, lower

37:20

in signal than the normal pancreatic parenchyma.

37:23

And sometimes that might be the

37:25

easiest way to pick up a pancreatic

37:27

adenocarcinoma.

37:29

On the right side, uh, the top right,

37:34

we have a T2-weighted sequence.

37:36

Um, again, there is a T1 component

37:39

'cause we see the fat is bright, but

37:40

that cyst is completely, uh, bright.

37:44

And finally the bottom is, again, if we look at

37:47

the CSF or the gallbladder, they're kind of dark.

37:51

Um, and the fat is dark.

37:53

This one is a T1 post-contrast with fat-sat,

37:57

and we see that the cyst remains black, that there's

38:01

no enhancement, so there is no enhancing component.

38:05

Again, that doesn't mean it's not

38:07

premalignant, it's still premalignant,

38:10

um, and still would need to be, uh, removed.

38:18

So I just like this picture

38:20

'cause it's pretty impressive.

38:21

Uh, it's a, a coronal, uh, thick slab,

38:25

MRCP, just showing this big cystic lesion, um,

38:30

you know, in the, in the left upper quadrant.

38:32

Now keep in mind, if you just had

38:35

this picture, there's a differential.

38:36

It could just be a renal cyst, it could

38:38

be a peritoneal inclusion cyst.

38:41

It could be, uh, you know, uh, other different things.

38:46

And, um.

38:47

So I'm, I'm showing this picture in context of the,

38:51

the other pictures that, that we had just gone over.

38:57

And this patient, again, a young patient, um,

39:01

had, uh, that portion of the pancreas removed.

39:03

So this was a post-op, uh, follow-up picture.

39:06

Um, that little white dense structure with a

39:09

yellow line it points to is a surgical clip.

39:12

And if you were to scroll up and down,

39:15

there's no pancreas distal to, uh, that

39:17

little piece in the pancreatic head.

39:20

Um, so just an example of what

39:22

surgery, uh, you know, will do.

39:29

So finally we'll talk about simple cyst.

39:33

Now, a simple cyst, there's no way to know

39:35

something is a simple cyst unless you actually

39:38

take it out and do histology and pathology.

39:41

Um, they're rare.

39:43

They have a true epithelial layer

39:45

as opposed to remember a pseudocyst

39:46

which will have a fibrous capsule.

39:49

And again, we won't know if it's a true simple

39:52

cyst unless you actually surgically remove it,

39:53

which we're not gonna do because they're benign.

39:56

They're common in children.

39:58

You can see them in autosomal dominant polycystic

40:01

kidney disease or Von Hippel–Lindau. Important.

40:05

They're asymptomatic, and, uh, and they're benign.

40:09

Um, so many times when we do

40:11

MRIs, we might see a cystic.

40:14

A cystic focus, and we can't definitely

40:17

say it communicates with the pancreatic duct.

40:19

Um, and so all we can do at that

40:22

point is, is give a differential.

40:24

It could be a side branch IPMN.

40:27

It could be a simple cyst.

40:28

In any case, as I had mentioned to

40:30

you earlier, side branch IPMNs

40:34

have a very tiny percentage of, uh, malignancies.

40:37

So we follow these.

40:39

Um, and there are different guidelines of sizes and

40:43

when to follow, um, and, and for how long to follow.

40:47

But keep in mind, so I'm not gonna actually

40:49

show you a, a picture of a cyst because

40:51

I can't prove it'll be a simple cyst.

40:53

Um, these are benign processes.

40:59

So just a, a, a quick review

41:02

of, uh, these general ideas.

41:06

Um, if you see a cyst in the pancreas, the

41:09

general differential diagnosis is gonna

41:12

be a pseudocyst versus a cystic neoplasm.

41:15

Again, cystic neoplasm can be serous.

41:19

It could be a mucinous cystadenoma.

41:20

It could be a degenerating adenoma.

41:22

It could be a side branch IPMN.

41:25

Um.

41:26

It could be a simple cyst.

41:29

Um, so it's important, number one, to

41:31

have some history and also to see how

41:35

it associates with the pancreatic duct.

41:37

So if you have a small cyst that's communicating with

41:40

the pancreatic duct, then it's a side branch IPMN,

41:43

and as I just mentioned, we're gonna follow those.

41:46

They don't need to be operated on, but

41:48

we follow 'em just because there's a

41:50

chance that they can become aggressive.

41:54

If it's not communicating with the

41:55

pancreatic duct, then history is pretty

41:59

important in the setting of pancreatitis.

42:03

If we have a fluid collection,

42:04

it's less than four weeks.

42:06

We're just gonna call it a peri-

42:07

pancreatic fluid collection.

42:09

Still have to follow it, still

42:10

have to see if it gets better.

42:12

These can get infected, um, and

42:15

can cause mass effect as well.

42:17

If it's greater than four

42:18

weeks, then it's a pseudocyst.

42:20

They'll have a fibrous capsule.

42:22

And again, these, uh, may regress over time or may

42:27

require surgical or, uh, endoscopic, uh, intervention.

42:31

And like I had mentioned earlier, I definitely

42:34

have seen a lot more, uh, endoscopic GI, uh,

42:38

doctors putting in, uh, little stents that

42:41

drain the cyst into the, into the stomach.

42:45

Um.

42:47

If you see something that looks like a bunch of

42:49

grapes, a lot of tiny cysts there together with a lot

42:52

of fibro septa, and we're talking about an elderly

42:55

female, and especially if it's in the head or uncinate

42:58

process, it's a serous cystadenoma, and these are

43:02

benign lesions and they do not require any surgery.

43:08

A unilocular tail lesion in a middle-aged

43:11

female will be a mucinous cystadenoma.

43:14

Um, and these are malignant, so

43:17

they're gonna require, um, uh, surgery.

43:25

And just finally, let's touch on

43:27

a dilated main pancreatic duct.

43:30

The differential diagnosis for a dilated

43:32

main pancreatic duct will be a main duct

43:34

IPMN.

43:36

Chronic pancreatitis, or obstructing pancreatic adenocarcinoma.

43:40

So main duct IPMN will essentially be

43:43

just an isolated dilated pancreatic duct.

43:46

There won't be any signs of pancreatitis.

43:48

There will not be any signs of chronic pancreatitis.

43:50

There won't be calcifications.

43:52

There, uh, won't be atrophy of, of the pancreas.

43:56

And there won't be this pseudo mass, which I had,

43:59

uh,

44:00

shown you.

44:01

And finally, with an obstructing pancreatic adenocarcinoma,

44:03

depending on where the adenocarcinoma is, and

44:06

most commonly they're in the head of the pancreas,

44:08

everything distal to that mass will be dilated.

44:13

And many times, uh, pancreatic adenocarcinomas will

44:16

cause, uh, common bile duct dilatation.

44:19

So there's something called a double

44:20

duct sign, which is a dilated common

44:22

bile duct and a dilated pancreatic duct.

44:25

Um.

44:26

So we have three different, uh, entities

44:29

that will cause a dilated main

44:31

pancreatic duct, two of which are malignant

44:34

and one of which is, uh, not malignant.

44:37

And an important thing to keep in mind with pancreatic

44:40

adenocarcinoma is its relationship to the SMA and SMV.

44:44

Way back when I showed you that

44:46

pseudomass, the mass was not.

44:48

Touching the SMA or SMV. If the mass touches,

44:51

if it's an adenocarcinoma and the mass touches the SMA

44:55

and SMV, it will affect surgical planning.

44:57

Many times they can't operate in, in, in that case.

45:01

Um, if however, there's a nice fat plane between

45:04

the SMV and SMA and the pancreatic mass,

45:07

then a Whipple procedure can be performed.

45:11

So, uh, I want to thank everybody.

45:13

Uh, it was great, uh, giving you a talk.

45:16

Uh, my name is David Sarnia again.

45:18

Uh, my email is d.sarnia@northwell.edu

45:22

or my personal one is ids1@hotmail.com.

45:27

My cell number is 9 1 7.

45:29

6 4 5 2 4 7 3. And my Twitter

45:33

handle is David Sarney one.

45:35

And really, if you have any questions, uh, or you just

45:39

want to talk about residency, or if medical students

45:41

are listening to this and they are interested in

45:44

radiology, please feel free to, to reach out to me.

45:47

Radiology is a great field, and I'm

45:49

happy to, uh, to, to talk to anybody.

45:52

And again, thank you MRI Online and Dr. Collins

45:55

for inviting me for this, uh, exciting talk.

45:59

As we bring this to a close, I want to thank

46:01

Dr. Sarkany for this lecture, and thanks to all of

46:03

you for participating in our Noon Conference.

46:06

A reminder that this conference is

46:07

available on demand on MRIO nline.com.

46:11

In addition to all previous Noon Conferences, be sure

46:13

to join us again on Friday for a lecture from

46:16

Dr. Lori Deitte on ultrasound.

46:18

Can't-Miss Diagnosis.

46:21

You can register for that at MRIO nline.com and follow

46:24

us on social media at the MRI Online for updates

46:28

and reminders on upcoming Noon Conferences.

46:30

Thanks again, and have a great day.