0:01

So, before I move to the next few cases,

0:03

I'm going to deal with certain signs.

0:05

Those are very important once we are

0:06

trying to differentiate between the

0:07

chronic pancreatitis and adenocarcinoma.

0:10

So, it is possible that you develop

0:12

adenocarcinoma on the background of

0:13

chronic pancreatitis, but that happens

0:15

only in about 2 to 3 percent of the cases.

0:18

Usually, mass-forming chronic pancreatitis can

0:21

mimic adenocarcinoma, and we should know how

0:24

to differentiate those two together because

0:26

the management can be completely different.

0:29

So, let's deal with the first sign.

0:31

The penetrating duct sign.

0:33

So if we see this particular case, this is from

0:36

one of my papers, which I recently published in

0:39

radiographs, we can see on the coronal images,

0:42

the pancreatic duct is seen passing through

0:45

that soft tissue area in the pancreatic head.

0:48

So this looks like a mass there, and it can

0:50

be chronic pancreatitis or adenocarcinoma.

0:53

But if we see a penetrating duct passing through,

0:56

a mass, it's going to be most likely benign.

0:59

It cannot be cancer.

1:00

So, it has very high

1:01

specificity, high reliability.

1:03

So, if we see penetrated duct sign either

1:06

on MRCP or post-contrast images or coronal

1:10

T2 images, it's a sign suggesting that

1:12

this lesion is most likely going to be

1:13

chronic pancreatitis rather than cancer.

1:15

And if we have chronic pancreatitis that

1:17

will, that may also involve the lower end of

1:20

the CBD and may cause some stricturing there,

1:23

and that will lead to a directed CBD as well.

1:26

So, you can have double duct sign,

1:28

but the patient might not have cancer.

1:32

Next sign we should be aware of, we discussed

1:34

in some of the cases before, the atrophy of the

1:37

pancreas, pancreatic parenchyma, and dilated duct.

1:41

So, if we have duct versus

1:42

parenchyma ratio exceeding 0.05,

1:44

on EOS this number is 0.34, but on CD it should be 0.5,

1:48

so if we have atrophy of pancreas

1:51

with significantly dilated duct.

1:53

Without significant side branch ductal dilatation,

1:56

that's going to be most likely a case of cancer.

1:59

If we see a mass, which has displaced the

2:02

calcification at the periphery, so if we

2:04

have a comparison CT before, where these

2:07

calcifications were situated in the center,

2:09

and this mass has developed in between, and

2:11

then all the calcifications have been displaced

2:13

at the periphery, that is a sign of cancer.

2:17

But that will be seen better

2:18

on CT rather than on MR.

2:20

The bullet sign, classical one.

2:22

Described by one of my colleagues

2:24

from the University of Washington,

2:25

Dr. Freeney.

2:25

But this is not specific for cancer.

2:28

It is specific for a peridural or peri ampullary

2:31

lesion, but not specific for the cancer.

2:36

This is a classical sign of teardrop SMV.

2:40

Teardrop SMV or distorted SMV is

2:41

seen with infiltrative tumor only.

2:44

And only adenocarcinoma

2:45

infiltrates along with the vessel.

2:47

None of the other tumor can do that.

2:49

If you see infiltration or distorted

2:52

SMV, that's going to be cancer.

2:54

And the same thing here we can see, in

2:57

this particular case, infiltration has

2:59

involved the SMV and the size of SMV and

3:01

SMA are looking more or less similar.

3:03

So SMA versus SMV ratio or SMV versus SMA

3:06

ratio, to be very specific, is similar.

3:10

So usually the SMV is bigger, but once the

3:13

tumor infiltrates that, SMV becomes smaller.

3:16

And seeing the similar size of both

3:17

of the vessels is not a good sign.

3:18

It's most likely a cancer.