0:01

So another case here with a pancreatic cystic

0:03

lesion, and in this particular case, what we are

0:06

seeing, the lesion is kind of enlarged, lobulated

0:09

in outline, and the fat along with this lesion is

0:12

kind of dirty, and some of the area at the center

0:16

is showing kind of necrosis, and that lesion

0:20

proximally is involving the pancreatic neck as

0:23

well, and there is possible exophytic component

0:27

and that dirtiness along with the periphery is

0:30

reaching along with the undersurface of the gastric wall.

0:33

And if we pay attention to the liver,

0:36

we do not see any significant lesions.

0:39

The gallbladder is dilated,

0:40

and the CBD is not dilated.

0:42

There are possible gallstones there,

0:45

and the spleen is enlarged here.

0:47

And this lesion which we have seen in the pancreas

0:49

is abutting closely to the vessel posteriorly.

0:53

This is the origin of the splenic artery, and it is

0:56

difficult to perceive where the common hepatic

0:58

artery is here, but it should be somewhere nearby.

1:01

And this is SMA, and this is SMV, which is

1:06

It's just lost in this location of the tumor.

1:09

The next question is, do we see any

1:13

encasement of any other vessels,

1:15

including the bifurcation of the celiac?

1:18

That will be answered on post-contrast images.

1:21

So on the T2-weighted images, we did not

1:24

see the common hepatic artery at all, but

1:26

as we go downwards on the post-contrast

1:28

images, we can see the SMA is giving

1:30

rise to the common hepatic artery.

1:33

It is arising from an aberrant location, and

1:37

then it is giving rise to two different branches,

1:40

left and right, and that lesion which is closely

1:43

abutting the bifurcation is reaching to this

1:46

level where we can see the common hepatic origin.

1:48

But the good thing is we do

1:49

not see the fat involved there.

1:52

The fat is in between the vessel and

1:55

this lesion is very well maintained.

1:57

And that we can confirm from the delayed phase.

2:00

As we go downwards, we can see SMA is there.

2:04

This is the common hepatic artery.

2:07

This is a reconstruction of the SMV here back

2:10

because of the collaterals are filling it backwards.

2:13

And as we go.

2:15

Superiorly, it is completely lost.

2:17

So this lesion is possibly involving or invading

2:21

the SMV, confluence, and splenic vein as well.

2:27

And that is why we are seeing so

2:28

many collaterals in the periphery.

2:30

These collaterals are taking care of the

2:31

blood supply or venous supply, which is going

2:34

backwards towards the different collaterals in

2:36

the mesentery as well as the perihepatic region.

2:39

And this is kind of dominant musculature here,

2:41

all collaterals draining towards this area in

2:44

the mesentery and the region of hepatic vein.

2:49

vein and then we see this,

2:52

this tumor which is lobulated in outline.

2:55

It is infiltrating throughout along with the

2:56

anterior aspect or under surface of the stomach.

3:00

So whatever it is, it is not looking,

3:02

it is a classical adenocarcinoma, but the

3:05

behavior shown by this tumor is malignant.

3:08

The way it is invading the SMV confluence

3:10

and it is infiltrating along with the under

3:12

surface of the stomach, that is very worrisome.

3:15

We do not see any, any metastatic lesion in

3:18

the liver at least, but behavior of this lesion

3:21

is malignant overall and very aggressive.

3:23

And if we go to DWI and see its behavior,

3:28

so it has diffusion restriction here throughout,

3:32

and we can see some of the deposits along

3:34

with the mesenteric root here and see

3:37

if there is ADC correlate there or not.

3:39

So we see there is ADC correlate as well.

3:42

So overall this lesion is malignant,

3:44

whatever it is, it doesn't fit classically

3:47

into adenocarcinoma. But it is a big

3:49

lesion, which is locally infiltrated.

3:52

And this was actually a case of

3:54

necrotic, uh, neuroendocrine tumor.

3:57

And if we go retrospectively and look

3:59

on this case, on T2-weighted images,

4:02

necrosis was present on T2-weighted images.

4:04

Remember, if it is present within

4:06

the adenocarcinoma, adenocarcinoma

4:09

will be more aggressive outside.

4:10

It will encase the vessels.

4:12

In this particular case, the tumor has gone

4:15

closer to that vessel, but never involved it.

4:19

It is kind of against adenocarcinoma,

4:21

but it is tough to tell whether

4:22

what kind of malignancy it is.

4:23

But overall the appearance is malignant,

4:25

and biopsy was conclusive in this

4:27

case; it was a neuroendocrine tumor.

4:30

Obviously this was non-functional neuroendocrine

4:32

tumor because it was grown before it was presented,

4:35

and as I said earlier, 50 percent of these tumors

4:38

once they present, they present with metastasis.

4:42

So in this case, we did not see metastasis,

4:43

but it is locally invasive along with

4:45

the undersurface of the stomach here.