0:01

So, in this particular case, what we

0:02

see, there is a dilated pancreatic duct,

0:05

and as we see here, at this particular

0:08

location, the duct caliber is about

0:10

0.9 centimeters, but that duct becomes

0:13

slightly lesser in size as we move

0:15

further in the pancreatic tail.

0:18

And then we see another channel arising

0:21

from the top of this duct, anteriorly,

0:25

that joins with the main duct afterwards,

0:27

or it possibly blindly ends somewhere here.

0:30

Maybe it is joining here, tough to say.

0:33

But the main point here is, the duct is increased

0:35

in caliber at the midpoint in the body,

0:38

but it becomes smaller in the pancreatic head.

0:42

So in the head it is just

0:44

0.55 centimeters.

0:46

Usually, the duct should increase

0:47

in size from head to tail.

0:49

So, the duct should be, if it is

0:52

0.6 centimeters here, it should go smaller,

0:54

smaller as we move from body to tail.

0:57

In our case, the duct was bigger in the body.

1:00

Let's see in the coronal plane.

1:03

The duct is dilated here.

1:04

No significant side branches are prominent,

1:07

and as we move forward to the pancreatic head,

1:10

we see the entire course of the duct draining

1:13

towards the major papilla, and then we see the

1:15

second channel, which we have seen on the axial

1:17

plane, partly, here, and the duct becomes normal.

1:22

So, seeing this kind of appearance, without

1:23

any overlying pancreatic parenchymal pathology,

1:26

without side branch ductal dilatation,

1:28

isolated segment of duct which is dilated,

1:31

which can represent a main duct IPMN.

1:36

So once you have suspicion of a main

1:37

duct IPMN, the next point is, see the

1:41

iso-intense T2-weighted filling defect

1:43

inside, if we have any of those or not.

1:46

There are few tiny foci here, those are

1:50

T2-weighted iso-intense or hypo-intense within

1:51

the duct, and those can be mucin deposits.

1:55

But otherwise, we are not seeing any obstructing

1:57

stone, we are not seeing any obstructive

2:00

lesion, we are not having any sequelae of chronic

2:03

pancreatitis, and that duct is classically

2:06

showing a segment which is dilated in the body.

2:08

Everything else is tapering

2:09

down and looking normal.

2:11

So, in this particular case, we are going to

2:14

look on the venous phase specifically to see if

2:18

we see any enhancement in that area of subtle

2:21

nodular enhancements or subtle nodularity

2:24

which we have seen on T2 weighted images.

2:27

There is a faint enhancement going

2:28

on along with the wall of this duct.

2:31

The point is, if this is more than 5 mm or not.

2:35

For that, we can measure them and see if

2:38

they are more than 5 mm, and they are not.

2:41

So remember, based on our protocol,

2:43

we discussed, algorithm we discussed, if the

2:45

papillary projection is less than 5 mm, that is

2:48

suspicious, but that doesn't fall into malignancy.

2:52

But given, we are giving the diagnosis

2:53

of a main duct IPMN, that entire lesion

2:57

becomes suspicious because the chances of

2:58

developing cancer in these lesions are about

3:00

70 percent over the period of 10 years.

3:04

Let us see how it behaves on the delayed

3:05

phase, if something changes there.

3:08

We still see some kind of nodularity

3:09

along with the wall, but none of these

3:11

are looking very prominent and entire

3:15

duct otherwise looks very clean.

3:17

So this is, and again we, we can see that

3:20

extra duct, an accessory duct, better on

3:24

these images because they are thin images,

3:26

3 millimeter, and we can see actually a

3:28

drainage of that duct to the main duct.

3:31

So there is an accessory duct here, which is

3:33

possibly congenital, but what we are seeing is

3:36

a dilated duct which is consistent with IPMN.

3:41

And this patient is going to be operated by

3:43

the surgeon if the patient is otherwise fine.

3:45

There are no comorbidities.

3:47

Otherwise, we are going to

3:48

follow this up with the MR.