0:01

So now we are going to deal with another

0:02

case where we have a question whether it

0:04

is a cancer or it is chronic pancreatitis.

0:07

In this particular case, on T2 axial fat

0:10

suppress images, we can see the duct is dilated.

0:13

The pancreatic duct is prominent.

0:15

But in addition to that,

0:16

what we see, there are side branches.

0:18

Those are also prominent.

0:20

So what happens?

0:21

Chronic pancreatitis is not going to be focal.

0:23

It's going to be a chronic process

0:24

involving the entire pancreas.

0:26

And that will cause fibrosis of

0:28

the entire pancreatic parenchyma.

0:30

And that will lead to traction

0:31

over the underlying ducts.

0:34

And that is why they are dilated.

0:37

So seeing side branch dilatation like

0:39

this, with maintained parenchyma, overlying

0:41

a dilated duct, may suggest that it is

0:44

possibly a case of chronic pancreatitis.

0:47

So seeing this particular image,

0:49

I am leaning towards chronic pancreatitis rather

0:50

than a mass, despite we see a mass-like

0:53

area within the pancreatic head region.

0:57

So let's see how it looks on coronal.

1:00

On the coronal images, we can see the CBD is

1:04

also prominent, there is some intrahepatic

1:08

And as we go downwards, we see there is some

1:11

smooth tapering or narrowing of the distal CBD.

1:15

See the caliber here, and it becomes

1:17

smaller, smaller with the, gradually.

1:19

It's not like an abrupt cutoff.

1:21

It's kind of chronic, benign-looking

1:24

stricture involving the lower end of CBD.

1:27

So if we see like chronic, uh, appearing benign

1:30

stricture involving CBD, along with dilated duct.

1:34

So next point is basically, we have to see how

1:37

this duct is behaving through the pancreatic head.

1:41

So, pancreatic duct, once we follow in the

1:43

coronal, we can see this duct is actually seen.

1:47

It is just narrowed in caliber, but it is

1:50

passing through the so-called pseudomass,

1:55

and that corresponds to the major papilla.

1:58

And as we go backwards, CBD is

2:00

also seen opening, opening there.

2:03

So it suggests that this area has undergone lots

2:05

of scarring and fibrosis, and that had led to

2:09

this narrowing of the proximal pancreatic duct,

2:14

as well as the CBD, and that is again suggesting.

2:18

Thank you.

2:19

Chronic pancreatitis.

2:21

As I mentioned in my previous talk, that

2:24

seeing a penetrating duct is a very reliable

2:26

sign of calling it chronic pancreatitis.

2:29

So given these signs, I am heavily leaning towards

2:32

the chronic pancreatitis rather than a mass.

2:34

And now, let's go back and look on T2.

2:39

We saw some of the cystic structures here.

2:42

Those were multiloculated, multiloculated,

2:45

situated in the pancreatic head.

2:46

And they can be just chronic pseudocyst there.

2:50

Sequelae of pancreatitis.

2:52

And let's go and see how

2:54

they look on pre-contrast T1.

2:58

On pre-contrast T1, that

2:59

entire area looks hypointense.

3:01

But remember, both adenocarcinoma

3:04

and chronic pancreatitis are composed

3:06

of heavily of fibrotic tissue.

3:09

So they can both look like hypointense.

3:11

So don't be fooled by that,

3:13

that it is just mass there.

3:15

Chronic pancreatitis can look like this.

3:19

And as I said earlier, if it is a cancer,

3:22

it has a tendency to cause infiltration

3:24

along with the mesenteric root.

3:26

The vessels.

3:28

So let's see how it looks there.

3:31

Do we see any significant infiltration of any

3:33

vessel, though this SMV or Confluence here is

3:39

kind of distorted, but it never changed its shape.

3:43

It is rounded throughout, and the size of

3:46

SMA and SMV looks more or less as normal.

3:49

SMV is bigger than SMA is, and there is some

3:51

dirtiness along with the little aspect of the

3:55

SMV, which can be seen with any pancreatitis,

3:58

whether it is autoimmune or chronic.

4:01

But that is not encasing tissue there.

4:05

It is just dirtiness or haziness

4:06

which can be inflammation only.

4:08

And then those cystic lesions are not

4:10

showing any significant enhancement,

4:13

or mural nodules, which can suggest that

4:15

it is arising on the background of IPMN.

4:18

So basically given this appearance, retained

4:20

parenchyma, side branch ductal dilatation,

4:22

and then penetrated duct sign, which we have seen

4:25

on coronal images on T2, and the structure

4:29

involving the lower CBD which is kind of

4:31

benign appearing, which shows gradual tapering.

4:35

Overall findings are suggestive of

4:36

chronic pancreatitis, rather than a mass.