0:01

This is another case here, and we start

0:03

as usual with axial T2s, and as we scroll

0:06

through the axial T2s, we find some of the

0:09

areas in the liver parenchyma, those are

0:13

looking suspicious, because if you see any

0:15

intensity in the liver, which is intermediate

0:18

or close to spleen, that is not a good sign.

0:21

So if you see a lesion with intermediate

0:22

intensity in the liver, that's going to be most

0:25

likely suspicious or worrisome, specifically

0:27

if you are dealing with the case of cancer.

0:30

And as soon as we reach the pancreas,

0:33

we see the same kind of appearance, a duct

0:36

which is abruptly cutting off, overlying

0:39

atrophy of the pancreatic parenchyma, and

0:44

a lesion in the pancreatic head, which is

0:46

encasing this SMV more than 180 degrees.

0:51

So this is what we call encasement,

0:53

once it is more than 180 degrees.

0:56

And if we pay attention, close attention

0:57

to the SMA, it is also closely abutting

1:01

the medial aspect of the mass, and it is

1:04

almost like 180 degrees somewhere here.

1:07

So it looks like based on T2,

1:09

both of SMV and SMA are encased.

1:12

An encasement more than 180 degrees with

1:16

presence of suspicious hepatic lesions

1:18

makes it unresectable, obviously.

1:20

But what else is this the only finding?

1:23

Let's pay attention here.

1:25

There are some intensities seen in the

1:27

peritoneum near the celiac trunk and the vessels.

1:32

See this haziness or intensity

1:34

surrounding the vessels in this location.

1:36

And, that does not look good because

1:37

it, these intensities are contiguous

1:40

with the region which we have seen.

1:43

So, this is SMA, as we saw earlier, as we reach

1:47

higher, we can see the celiac trunk, which is

1:51

also surrounded by ill-defined soft tissue.

1:54

Let us see how it looks on coronal.

1:57

So, as we go in the coronal, and this

1:59

is the celiac trunk, and this is SMA,

2:04

and we can see this ill-defined soft

2:06

tissue is actually encircling the entire.

2:09

origin of the celiac trunk as well

2:11

as the SMA, and then it reaches

2:13

laterally to involve the retroperitoneum.

2:17

So seeing this sign is very worrisome because

2:21

it is possibly perineural invasion as well.

2:24

And then we have some lymph nodes in the

2:26

retroperitoneum, and then we see the proximal

2:28

duct which is spared by the tumor is looking

2:31

normal in caliber, and then we see distal

2:34

CBD is also kind of spared by the tumor.

2:38

So overall, this cannot be

2:39

called a developed sign.

2:41

So you have a tumor, but you do not have any double

2:43

duct sign, so you can have a double

2:46

duct sign even without a tumor, as we discussed.

2:48

And then we see ductal dilatation,

2:51

which shows abrupt cut off at the

2:53

location of the tumor is present.

2:55

So this is again a case of pancreatic head

2:59

mass, let us see how it looks on axial images

3:02

and post-contrast arterial phase.

3:05

And here we see the mass, some ill-defined

3:09

hypointensity along with the posterior

3:11

aspect, some of the vessels, some collaterals.

3:14

And this duct is showing abrupt cut off, and the

3:17

soft tissue which we have seen surrounding the

3:20

celiac trunk, common hepatic, retroperitoneum,

3:25

some of the deposits like a lymph node here.

3:28

So whatever we have seen on T2 looks like

3:30

they are real findings based on post-contrast.

3:34

In this particular case, we have seen

3:36

some of the hepatic metastasis as well.

3:39

And let's quickly go to high B-value

3:42

DWI to make sure that if we are missing

3:45

a location of tumor which we have

3:47

otherwise not seen on other sequences.

3:51

So on DWI, we can clearly see

3:52

this tumor is situated in the

3:56

retroperitoneum and mesenteric root.

3:57

It is surrounding the vessels.

4:00

It goes higher to involve the origin of the

4:02

celiac trunk, and these lesions in the liver

4:06

are also looking suspicious, even on DWI,

4:09

and there are some deposits or lymph nodes

4:11

in the retroperitoneum, as we saw earlier.

4:13

All of the findings which we have seen

4:15

in other sequences are real findings.

4:17

Anytime you see a finding, you

4:18

should just be sure that you confirm

4:19

those findings on other sequences.

4:21

Specifically T2s and correlate them with

4:24

the DWI high B-value and post-contrast images.

4:27

So this turned out to be another tumor,

4:29

which is locally infiltrative leading

4:31

to involvement of encasement of SMA and

4:33

SMV and celiac bifurcation with PNI.

4:37

And there are deposits

4:38

in the retroperitoneum and there are

4:40

deposits in the liver.

4:42

So all of these are making it unresectable

4:44

case advanced in case of metastasis throughout.