0:01

So this is an interesting case because this

0:03

case was seen by radiology multiple times,

0:07

evaluated very closely in the duration of

0:09

six months, at least three to four times.

0:11

Every time we saw this case and we called

0:13

suspicious feature and advised EOS-guided

0:17

biopsy, and every time biopsy came,

0:21

non-conclusive, and this was discussed in one

0:24

of the tumor board with the surgeons,

0:27

and this was the last scan which I presented in

0:29

the tumor board, and I reported it myself.

0:31

So, see this, this particular case here,

0:33

I mean, see there is a lesion which is showing

0:35

T2-weighted hypointense luminal content.

0:39

On T1-weighted images, it appears T1-bright,

0:44

so whatever it has, it has mucin content inside

0:47

or hypotenuse content with some of the linear

0:51

ill-defined hypointensities along with the periphery.

0:55

But if we pay attention to the periphery

0:56

of this lesion on T2-weighted images,

0:59

we see the duct is situated along with

1:02

the periphery anteriorly and then,

1:05

along with the lateral edge of this lesion,

1:07

there is some thickened irregular tissue

1:12

which is showing different kind of intensity

1:14

compared to the rest of the pancreas.

1:16

It is slightly more intermediate to hyperintense.

1:20

See that area here.

1:22

So given this appearance, and then if we pay

1:24

attention to the duct, as the duct passes

1:26

through this area, that becomes narrow and

1:29

irregular, and duct distally is dilated.

1:32

So there is something which is causing obstruction

1:34

here in the duct, and it is causing narrowing.

1:37

And this infiltrative area here looks like

1:40

more suspicious along with the lateral edge.

1:43

So, despite this was non-conclusive or

1:46

benign biopsy three to four times,

1:48

we were calling it cancer again and again.

1:50

And this was the last scan.

1:51

But this was very unfortunate to see

1:53

that by this time, the patient developed

1:56

retroperitoneal lymphadenopathy.

1:59

So, we have more lymph nodes here.

2:02

And lymph nodes or some soft tissue

2:05

along with the posterior aspect within

2:07

the retroperitoneum and porta hepatis.

2:10

And see how impressive it looks

2:11

on diffusion-weighted images.

2:14

So if we go to the high B value and try to

2:17

see these areas, we see some of the lymph

2:21

nodes in the retroperitoneum and that area

2:25

of irregularity which we have seen previously

2:27

on T2 is also showing faint restriction.

2:32

And as we go to the

2:33

post-contrast in the arterial phase,

2:37

we are able to see that area is not enhancing.

2:39

Remember, adenocarcinoma contains

2:42

fibrotic component, so in the arterial

2:44

phase, it will look hypo-intense.

2:47

So periphery of this region was not enhancing

2:48

in the beginning in the arterial phase,

2:50

but as we go to the delayed venous phase, we see

2:55

some irregular enhancement going on there,

2:58

which is possibly seen better on venous phase.

3:03

So there is some irregular thickened

3:05

tissue here, which is enhancing on the

3:07

venous phase, and this is 35 seconds.

3:12

And we can see this faint

3:13

enhancement in this area much better.

3:16

And that is why 35 seconds to 45 second venous

3:19

phase is important for adenocarcinomas.

3:23

So this was actually a case of malignant

3:24

transformation of mucinous tumor.

3:27

This was possibly mucinous tumor

3:28

here because it has mucin content.

3:31

It has close relationship with that duct which is

3:33

possibly not communicating with the main lesion.

3:36

But what we saw along with the periphery of

3:38

this lesion, there is irregular enhancement

3:41

and expansion and on T2 it corresponds to

3:46

narrowing of the duct with soft tissue

3:48

surrounding it and overlying dilatation.

3:52

So we strongly said it is a case of adenocarcinoma,

3:56

malignant transformation from the mucinous

3:58

tumor pre-existing there, and there

4:01

are lots of retroperitoneal adenopathy.

4:04

So at this point, surgeons thought they should go

4:05

inside and evaluate this patient with laparoscopy.

4:08

And once they entered that, this was a

4:10

non-resectable adenocarcinoma arising from the

4:13

pancreas because of the lymph nodes there.

4:16

And just for curiosity, I will go back

4:18

to the arterial phase and see if we can find

4:21

anything wrong with the vessels and all the

4:23

vessels were well-maintained throughout.

4:25

So non-resectability was because of the presence

4:27

of lymph node in the retroperitoneum.