0:00

So this is another case of the pancreatic

0:01

carcinoma, and we can see some classical

0:04

findings: dilated duct, which shows abrupt

0:06

cutoff in the pancreatic head region or

0:08

neck region, and then the neck is usually

0:12

situated anterior to the SMV (Superior mesenteric vein) and SMA (Superior mesenteric artery).

0:15

So we are almost in the neck region here,

0:17

and we see some of the ductal dilatation

0:19

on the side branch; ductal dilatation here

0:22

and pancreatic parenchyma is really not

0:25

atrophic as the way it was in the last case.

0:28

So there's a possibility that the patient

0:30

actually had some background pancreatitis

0:31

and now developing the cancer.

0:34

Uh, it is tough to say here unless we have

0:36

previous study CT or MR to compare with.

0:39

But what we see here in the pancreatic head

0:42

and the neck region, there is some homogeneous

0:45

T2 intensity, iso-intensity I would, I would say,

0:48

and that is going all the way towards

0:50

the pancreatic head and uncinate process.

0:53

And the duct actually shows

0:55

abrupt cutoff in this region.

0:57

So that raises the suspicion

0:58

that this is a mass here.

1:01

And let's quickly look on the CBD (Common Bile Duct).

1:03

CBD is here, and that looks not dilated.

1:06

And let's confirm this finding

1:07

quickly on the coronal.

1:10

CBD is not that dilated, but it is

1:12

rather decompressed in this location.

1:14

So the patient might not be having obstructive

1:16

jaundice in this particular case.

1:18

But what we see on the coronal image

1:19

is there is an ill-defined mass in the

1:21

pancreatic head region which has involved

1:25

the pancreatic neck, and the duct shows abrupt

1:28

cutoff in the same region, that raises a

1:30

suspicion of pancreatic head or neck mass.

1:33

Let's go back to the axial images

1:35

quickly and see other structures.

1:38

And what we see here, anteriorly, along with

1:40

the pancreatic head region, there is some

1:42

soft tissue haziness along the posterior

1:43

aspect of the gastric antrum and the pylorus.

1:47

But there is a possibility that the lesion

1:48

has actually involved the posterior aspect

1:50

of the gastric wall.

1:54

Involvement of GDA (Gastroduodenal Artery) and duodenum

1:56

has no value because they are

1:58

going to be resected respectively.

2:00

So if they're involved, that's not

2:02

going to change the management at all.

2:04

And as we go downwards, we can see SMV and SMA.

2:09

But as we go further and follow

2:11

the SMV, that just disappears.

2:14

Here in this location, SMV is not even seen.

2:17

And if we go backwards,

2:19

it is significantly attenuated in caliber.

2:21

And going backwards, portal vein is still seen.

2:25

But what is important, if we pay attention

2:28

to this area, there's lots of soft

2:30

tissue present between these two vessels.

2:33

And as we go further,

2:35

the soft tissue is still seen involving

2:37

the bifurcation of the celiac trunk.

2:41

So how come we have a tissue,

2:42

soft tissue, in this area?

2:45

And then we see some haziness

2:47

along the posterior aspect of the

2:48

common hepatic artery as well.

2:50

So this appearance, whenever we see

2:52

surrounding a vessel, specifically aortic,

2:55

uh, celiac bifurcation, that raises the

2:58

suspicion that this patient possibly has PNI,

3:01

perineural invasion, which we discussed earlier.

3:04

And that is not a good sign.

3:05

Having a perineural invasion about 2.5 cm

3:07

in length only, that is more than sufficient

3:10

to cause significant issues with the prognosis.

3:13

And there will be recurrence

3:14

if they are not treated well.

3:17

So this is a very important

3:18

sign to pay attention for.

3:20

As we go further, the soft tissue

3:22

haziness is seen throughout here,

3:23

and that goes and involves the

3:25

mesenteric root at this location.

3:29

And just quickly find if we

3:30

see any lymph nodes anywhere.

3:33

And this is something we discussed before.

3:35

These are the locations of celiac plexuses.

3:37

So nothing is involved at least there,

3:39

but the plexus itself is mostly involved.

3:43

And if we pay attention to the splenic

3:45

artery, the bifurcation, that is also involved.

3:47

But as I mentioned earlier,

3:49

involvement of splenic artery or vein is

3:52

not a contraindication for resectability.

3:55

Let's see how it looks on pre-contrast images.

3:59

Pre-contrast T1-weighted images, we can

4:01

quickly scroll through and see how it

4:04

compares with the pancreatic parenchyma.

4:06

This region actually looks more or less

4:08

hypointense though heterogeneously

4:11

hypointense at certain locations it is showing

4:13

isointensity compared to the parenchyma, and we

4:15

can actually see the possible involvement of

4:17

the posterior wall of the stomach really well

4:19

here, and this is the wall of the duodenum.

4:24

As we come higher, we can see the same

4:27

ill-defined soft tissue surrounding

4:30

the vessels we discussed before.

4:32

So far, we know that this

4:34

patient actually has a likely

4:36

infiltrated tumor with perineural invasion,

4:39

which has reached to the celiac bifurcation

4:42

and it is involving the common hepatic artery

4:44

and proximal splenic artery, and it is possibly

4:48

involving the SMV or confluence, and then it is

4:51

possibly infiltrating along the mesenteric route.

4:53

Let's see if we can add more with the

4:55

post-contrast images. So just to have a quick

4:58

idea here. Quickly see the liver and rest of the

5:03

organs if something we are missing or ignoring,

5:06

which can happen sometimes in real life as well.

5:08

And see here, we can see the SMA, which is

5:14

slightly away and well maintained throughout,

5:17

but this is SMV, which we discussed before,

5:19

which will be seen better on the delayed images.

5:22

And then we are seeing some

5:24

of the tortuous vessels here.

5:26

This is how it looked on T2.

5:28

You can see the outline of the common

5:31

hepatic artery is very fuzzy and ill-defined,

5:36

specifically in this region where it is

5:37

surrounded by that ill-defined soft tissue. Okay?

5:41

This is all perineural invasion here.

5:45

This is the tumor.

5:46

This is the tumor, and this is the main tumor here.

5:49

Let's quickly go to the venous

5:51

phase and see the venous structure.

5:54

And as we see here, portal vein just disappears.

5:58

It is replaced by some of the colitis

5:59

in this region, some of the colitis on

6:01

the backside, and going downwards, it is

6:05

significantly attenuated in caliber, and then

6:08

it reforms with SMV and becomes just normal.

6:12

So what happens if the tumor was

6:14

present in the uncinate process?

6:15

It will possibly involve the SMV first.

6:17

And in that situation, this SMV will be distorted

6:21

and teardrop in appearance, like a distorted

6:24

teardrop appearance is very classical for the

6:26

pancreatic invasion by adenocarcinoma.

6:29

And sometimes what happens, because of

6:30

the fibrotic tissue or the tissue of the

6:33

pancreatic adenocarcinoma, which is mostly

6:35

fibrotic, the size of the SMV becomes smaller.

6:39

So ratio between the SMA and

6:41

SMV is kind of one only.

6:43

So SMA is usually smaller than SMV.

6:45

But once there is infiltration of SMV, SMV

6:48

becomes smaller and the ratio is almost like 1.

6:51

That is again not a good sign.

6:52

So we have dealt with some of

6:54

the important signs so far.

6:56

One is double duct sign, then abrupt cutoff

6:58

of the duct, then atrophy of the pancreas,

7:01

then invasion or perivascular abutment versus

7:05

encasement of the vessels, teardrop sign

7:07

which can be seen with SMV, and then SMA and

7:11

SMV ratio which is, if it is more than 1,

7:14

then it is going to be most likely cancer.

7:16

So these four or five signs can help

7:17

you to differentiate between a real

7:19

cancer versus pseudo-mass or a chronic

7:23

pancreatitis mimicking adenocarcinoma.

7:25

And we are going to see some of the

7:26

cases in our lecture subsequently.