0:01

So the next topic we are going to deal with is IPMN.

0:04

So, intraductal papillary mucinous neoplasm.

0:08

Usually hesitant to call it neoplasm because if

0:11

you call it neoplasm, people will be alarmed and they

0:13

will be thinking that they have developed cancer.

0:17

So, in the report, I would prefer to use the term

0:19

IPMN rather than the complete name of this tumor.

0:23

So, IPMN can be main duct when it involves

0:27

the main pancreatic duct, or it can be side

0:31

branch when it involves the side branches.

0:35

And usually, these side branch

0:37

tumors, they are multicellular and

0:40

they arise from the pancreatic head.

0:42

And they are usually seen in elderly

0:43

patients, more than 60 years of age.

0:47

So, side branch IPMNs can also

0:50

coexist with the main branch.

0:51

So, you can actually have a main

0:52

branch IPMN, and then you have

0:55

coexisting side branch IPMNs together.

0:58

So this is called a main branch, and this

1:01

is side branch, and this is mixed type.

1:05

Okay.

1:06

The point here is if we have

1:09

side branch IPMNs, the probability

1:11

that a patient can develop cancer in

1:14

10 years is just 20 to 30 percent.

1:19

But that probability goes high in 10

1:22

years for main branch to about 70 percent.

1:26

So having a main duct IPMN is a very

1:31

ominous sign, and that will lead to major

1:34

surgery, and the surgeon is going to remove that

1:36

entire pancreas or the segment of the pancreas

1:38

which is involved. So, low intensity seen

1:43

in the IPMNs are basically mucinous balls.

1:45

Most of them are, but the papillary

1:47

projections or mural nodule will also look

1:50

like low intensity on T2-weighted images.

1:53

And only the post-contrast image

1:54

is going to differentiate that.

1:56

But in real life, what is happening

1:59

nowadays, because the workload is

2:00

increased, and we need lesser table time,

2:03

we are using abbreviated protocols.

2:04

We are using just T2-weighted images

2:07

with MRCP images to follow up the IPMNs.

2:09

But if you see something concerning, if the size

2:12

of the IPMN is increased in a certain duration, or

2:16

if you see something looking like a papillary

2:17

projection or mural nodule which was not there on

2:19

the previous study, you can order a post-contrast

2:22

study and call the patient back if you are

2:24

doing an abbreviated protocol in your institution.

2:27

The point is, if you see any lesion which

2:29

shows more than three centimeters in size or

2:32

papillary projection or internal growth between

2:35

the two scans, which should be around five

2:37

millimeters in two years somewhere, and

2:40

if we see a size of pancreatic duct more than

2:42

5 mm, we should take it very suspiciously.

2:46

Side branch IPMN can sometimes mimic

2:47

a serious tumor because both of them are

2:49

smaller, multiloculated, multilobulated.

2:52

They mostly arise from the

2:53

pancreatic head or proximal pancreas.

2:56

But the only thing, if we can demonstrate

2:58

communication with the main pancreatic duct,

3:00

that is the diagnostic point, because that

3:04

clinches the diagnosis, because that will be IPMN.

3:07

And as I said earlier, 70 percent of main

3:10

branch IPMN can develop malignancy in 10 years.

3:13

So this is how the IPMN looks.

3:15

They arise from the side branches, they

3:17

are dilated, sometimes they are just

3:18

atrophic, but they are usually in bunch,

3:21

and they look like a bunch of grapes.

3:23

And these are usually situated in

3:25

the uncinate process of pancreatic

3:26

head once they are side branched.

3:29

But the main branch can develop

3:30

anywhere throughout the pancreatic

3:33

duct or a segment of pancreatic duct.

3:35

So whenever we are dealing with the case of

3:37

IPMN, we should go through this flowchart.

3:40

This is not from ACR.

3:42

This is described by the pancreatic

3:44

surgeons and it is published in 2017.

3:47

If I am not wrong, ACR published its last

3:50

update on IPMN management in 2017 itself.

3:53

At the same time, we had this update.

3:55

And surgeons do not like the

3:57

ACR protocol or algorithm.

4:00

So I'm going to deal with this particular

4:01

algorithm, which is very useful in real life.

4:03

Surgeons are going to love this one.

4:05

So whenever you deal with the case of

4:07

cystic lesion in the pancreatic head,

4:08

and the patient has obstructive jaundice,

4:11

that can be a case of surgery.

4:13

So you need a biopsy from there, irrespective.

4:17

If you see a mural nodule, which is more

4:19

than five millimeters in size or the duct

4:22

is more than 10 millimeters, all of these

4:25

are high risk of malignancy, and they

4:28

will go to surgery or biopsy directly.

4:32

But if these are not seen, which is the

4:33

common case in the real scenario, those are

4:35

the cases that are coming to radiology,

4:38

we are going to ask these eight questions.

4:40

If the size of the cyst, or the bunch of the

4:43

cysts together, is more than 3 cm, if we see a

4:47

nodule which is 5 mm or less in size, if we see

4:51

thickened enhancing cyst walls, or the septations,

4:55

if we see the size of the duct between 5 to 9 mm,

4:59

if the change of caliber of the duct is present

5:02

with distal pancreatic atrophy, which is a sign of

5:04

cancer, and if we see lymphadenopathy along with

5:08

the cystic lesion in the pancreas, if we see CA 99

5:11

level more than 40, and if the cystic lesion shows

5:15

growth of more than 5 mm in 2 years, all of these

5:19

are highly suspicious signs, and the patient should be

5:22

referred to endoscopic guided ultrasound biopsy.

5:25

Thank you.

5:26

And they will possibly undergo surgery based on

5:29

the findings, what they see on biopsy results.

5:32

But, if none of these are positive, or if the

5:35

biopsy is negative, they will come to radiology.

5:39

And then we are going to follow these up.

5:41

And we should know how to follow these up.

5:43

So size is the criteria.

5:45

If the size is more than 3 cm,

5:48

the first should be an MR or EUS.

5:52

If the EUS was negative, we are going to follow

5:54

these lesions every 3 to 6 months, forever.

5:58

And we have to be very cautious because

6:01

these lesions have high propensity to develop

6:03

cancers, and they can undergo surgery anytime.

6:06

If the patient is otherwise fine and there is no

6:09

underlying comorbidities, then possibly surgery

6:12

is the right way to deal with these cases.

6:14

But if you are going to follow this up, that

6:15

should be early, 3 to 6 months, alternatively

6:18

with EUS or MR as the surgeon wants.

6:23

The next category is between 2 to 3 centimeters.

6:25

These lesions will be again evaluated

6:27

first with EUS in the first 3 to 6 months.

6:30

And then you are going to follow these up with MR

6:33

or EUS.

6:33

Alternatively, in one year, the next

6:36

category is one to two centimeters.

6:38

Then here we are going to follow these lesions

6:41

with MR initially for six months and for

6:43

for one year, and then afterwards it'll be

6:46

every two years, and less than one centimeter

6:49

are the least possible malignant lesions.

6:51

Those are most likely going to be benign.

6:53

We are going to follow these up

6:54

for about six months in the first time

6:57

and then every two years afterwards.

6:59

So size is the criteria.

7:01

We have to be very cautious.

7:02

More than three centimeters, they

7:03

are very suspicious; less than one

7:05

centimeter, they are less suspicious.

7:07

In between, we are going to follow

7:09

them up with a CT, MR, or EUS

7:12

guided biopsy depending on the size.

7:14

And that follow-up will last up to

7:15

five years depending on whether they are

7:17

growing or not, and can be forever if

7:19

the size is more than three centimeters.