0:00

Now, I'll give you the history on this one.

0:02

Interestingly, it had pelvic pain and got an ultrasound and it was pretty

0:07

unremarkable, but the patient really had a lot of pain.

0:11

And so they went into the OR, they did a lap...

0:13

you know, exploratory laparoscopy to see

0:16

what was going on and didn't see much in the pelvis.

0:20

But as they were sort of exploring,

0:22

they saw something in the retroperitoneum.

0:24

And so they closed up, and then got this imaging study over here.

0:29

So just a CT scan, post-contrast.

0:32

This is sort of the only imaging that I have for you.

0:37

And this is the lesion that we see on imaging.

0:43

So, again...

0:45

Now, this is a pancreatic cystic tox,

0:47

so even though it's a large lesion and can arise on a bunch of areas,

0:50

let's assume it's arising from the pancreas.

0:53

Quite complex.

0:56

Certainly more complex in some of the stuff we've seen

0:59

in some of the other cases.

1:00

What it looks like in the coronal images.

1:04

Again, sort of in the body tail of the pancreas in terms of its locations.

1:11

This is what it is on the sagittals.

1:16

And for the moment,

1:17

this is all I have for you, just this large, complex lesion that was

1:21

sort of picked up in the context of a pelvic pain in an exploratory surgery.

1:27

And then we got this CT scan and are now sort of

1:31

asked to make a diagnosis and

1:35

let's see what the polling question is for this.

1:39

So this one I wanted to ask the group,

1:41

what the next best step is.

1:44

You've seen the lesion.

1:46

Probably come up with a top diagnosis,

1:47

and based on that, what do you want to do next?

1:49

MRI in six months?

1:51

Do you want get a PET-CT now?

1:53

Endoscopic ultrasound,

1:55

or do you think this is something benign

1:57

and requires no follow up, no further follow up?

2:03

Yeah, so the majority said endoscopic ultrasound.

2:05

And so I think that a...

2:07

is a...

2:08

is the right...

2:08

is what I would do as the next step, I would say.

2:11

Follow-up MRI in six months is a possibility.

2:13

But there's some features here that would

2:14

make me want to do something a little bit faster.

2:19

And the PET-CT may eventually have to be done.

2:23

However, it probably is not the best next step in this case.

2:29

So let's go through this lesion.

2:32

Large lesion, complex lesion,

2:35

body entailed the pancreas, is a 36-year-old female,

2:39

has some septations within it

2:41

has some peripheral calcifications within it as well.

2:44

And also has these nodules.

2:47

And granted I don't have a non-contrast CT

2:49

to show you that this is enhancement, but this just doesn't look good.

2:53

This doesn't look good in terms of its

2:55

appearance, its nodularity, and you can see multiple nodules on different planes.

2:59

And so, you know, these are probably going

3:01

to be a soft tissue nodules arising in this big cystic mass.

3:05

And so, you know, we can't afford to potentially wait

3:08

a couple of months to see what to do with this.

3:10

And we have to sort of do something now.

3:11

And so, you know, in most instances,

3:14

when you see these pancreatic cystic lesions and you want to know,

3:17

you really want to know what it is to establish what to do next.

3:19

And so an endoscopic ultrasound is the best next step to do.

3:23

And an endoscopic ultrasound was done in this instance.

3:28

However, my pacs just froze.

3:30

So if you don't mind, I'm going to stop sharing for one second

3:32

and restart. It will take exactly 30 seconds for me to do this.

3:35

I do apologize.

3:36

And I just want to show this to you because I don't see this too often

3:39

on endoscopic ultrasounds, but in this case, we actually ended up seeing it.

3:43

Pretty nicely to see how they look.

3:46

Look at that.

3:46

So this looks like a...

3:48

this really large cystic lesion complex.

3:50

Look at that neural nodule over there.

3:51

And so they're going to do their best

3:53

to try to sample some of the neural nodularity and really,

3:58

you know,

3:58

you can see the needle coming in here and that's what they're sampling.

4:00

And so, I think doing no follow up is the wrong answer.

4:03

I think doing an MRI in six months may be too late.

4:06

I think doing a PET-CT would probably have very little utility,

4:10

given that it's a mucinous cystadenocarcinoma.

4:12

This really needs to be resected.

4:14

And fortunately, as this patient course has turned out, this is a very aggressive

4:19

and has really metastasized to many places now, including the liver.

4:24

And so it's a pretty sad case, particularly for somebody so young.

4:28

So that was this case that I want to share.

4:33

And somebody had asked, could it be a solid pseudopapillary tumor?

4:37

You know, that's a possibility.

4:40

It would be the leading diagnosis for me.

4:43

And we'll talk perhaps a little bit about

4:46

some features that could help us call these things SPEN.

4:50

I think for this one,

4:51

the fact that it's body entail smooth borders,

4:55

soft tissue nodularity like that,

4:57

you know, discrete nodules that we see sort of these peripheral calcifications.

5:03

I think that would be more likely of the final diagnosis in this case,

5:09

which is a question that another one of your colleagues has asked,

5:11

the final diagnosis was a mucinous cystadenocarcinoma.

5:16

So mucinous cystadenocarcinoma.

5:20

Okay, perfect.

5:20

So let's go on to the next case before my computer dies on us.