0:01

This is another case of cystic lesion in the

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pancreas, and here what we see in the pancreatic

0:06

tail, we have a lesion, which demonstrates

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multiloculated, multiloculated appearance.

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There are septations, and if we pay attention

0:16

here carefully, there is a duct here,

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which possibly communicates with one of these

0:22

extensions, and the duct otherwise looks just

0:25

normal, and we see a little bit fused cystic

0:29

structures in the pancreatic head here.

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And let's see how it looks on the coronal.

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There are a few more here, subcentimeter.

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On the coronal, if we see this classical

0:39

appearance of rosette-petal-like distribution

0:42

of lesions, and they are meeting at the

0:45

center somewhere, and there are septations.

0:48

So here it can mimic like a serous tumor.

0:50

It looks like a serous tumor.

0:51

But remember, it doesn't meet

0:53

the criteria of honeycombing.

0:56

The size of these cysts are bigger, first of all.

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So these are not less than 2-centimeter cysts.

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And see the number of cysts.

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They are not more than six,

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like almost six are there.

1:08

There are a few more in the background.

1:10

So size of the cyst is more important

1:12

than the number of cysts here.

1:14

And if we pay attention to the duct,

1:17

it is difficult to predict whether it is

1:19

communicating with this lesion or not.

1:21

So that can be easily solved on post-contrast

1:23

images sometime because we have better evaluation

1:26

there because of the thin slices, and we see

1:29

some more cystic lesions in the pancreatic head.

1:31

Those are most likely side

1:33

branch IPMNs (Intraductal Papillary Mucinous Neoplasm) or ectasia.

1:36

So, let us move to the post-contrast images.

1:40

So far our differential is IPMN/mucinous

1:42

tumor or less likely serous tumor.

1:46

But we have to demonstrate

1:48

communication with the main duct.

1:51

So, here we have that lesion on this

1:55

particular sequence, difficult to evaluate.

1:58

Let us go to the other sequence, tough to

2:01

predict, but there is possibly this duct

2:03

here coming and joining with this lesion.

2:06

This is the non-enhancing lesion

2:07

here, septations are not enhancing.

2:10

Let us try venous phase here.

2:12

Maybe it might help.

2:14

So there is a possibility that this

2:15

is the duct here, which is possibly

2:19

communicating with this particular area.

2:22

So this extension of this, this cystic lesion,

2:25

which is multiloculated, we can see this

2:27

extension towards the duct, and we can demonstrate

2:31

that the duct is possibly communicating as we

2:33

thought in the beginning on T2-weighted images.

2:36

So given this appearance of multiple cysts,

2:39

bigger in size, more than 2 centimeters

2:42

not enhancing with some septations,

2:45

coexisting some more IPMNs in the pancreatic

2:48

head, that it is possibly a case of IPMN rather

2:52

than serous tumor, but they can sometime mimic,

2:55

as in this case, this give rise to a classical

2:58

appearance that it is possibly serous but

3:00

it is not because of the size of the cyst.

3:03

Usually it should be honeycombed in appearance,

3:06

which we do not see in this particular case.

3:08

It was tough to demonstrate the communication

3:09

with the duct, which is possibly there or may

3:11

not be there given how you interpret the images.

3:14

But given the size and appearance,

3:16

it is leaning towards the IPMN.

3:19

Remember, both side branch IPMNs and mucinous

3:22

tumor have malignant potential, and they should

3:24

be further evaluated with endoscopic ultrasound

3:27

guided FNA (Fine needle aspiration), and see whether they draw serous fluid

3:31

out of this or it is mucinous fluid out of this.

3:33

And usually what happens if there is

3:35

a mucinous fluid, this will be taken

3:37

care of by the surgeon very quickly.