0:01

So sometimes the cases are not easy,

0:03

they can be sometimes very challenging.

0:06

And this particular case, we are seeing

0:10

multiple cystic lesions in the pancreatic head.

0:14

They do not qualify to be called a bunch

0:16

of grapes, but they are multiple,

0:18

they're situated together, they are packed together

0:20

with each other and confined to the pancreatic head.

0:24

And then we see similar kinds of findings

0:25

along the uncinate process on the backside.

0:28

But in addition to that, we see a dilated

0:31

pancreatic duct, which shows kind of normal

0:35

tapering as we expect in the body and tail,

0:38

but it becomes more prominent in the pancreatic head.

0:41

And as we follow this particular pancreatic

0:44

duct in the pancreatic head towards the

0:47

major papilla, it becomes very small.

0:50

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

0:53

On the coronal, we follow this

0:54

pancreatic duct from the pancreatic tail.

0:57

It gradually increases in size as we

0:59

expect in a normal pancreas because the duct is

1:02

usually bigger in the pancreatic head and

1:03

becomes smaller as we go from body to tail.

1:06

So it shows normal tapering there, but as

1:09

we go forward towards the pancreatic head,

1:13

we see this duct just disappear or narrow.

1:17

And then it is associated with some more

1:20

cystic lesions in the pancreatic head.

1:23

One of them possibly has a communication

1:25

with the main pancreatic duct.

1:26

So it can be a mixed type of IPMN here,

1:29

but we don't know what exactly is going on.

1:31

Is it just an IPMN side branch or is it main

1:33

duct IPMN together with the side branch IPMN?

1:37

So the question is what else could it be.

1:39

Can this be a case of pancreatitis, which is

1:43

called obstructive chronic pancreatitis,

1:46

which is causing obstruction of the opening of

1:48

the main pancreatic duct near the major papilla?

1:51

That is another possibility here.

1:54

So let's see how it looks on the other images.

1:57

So remember one thing, the sign we have

2:00

discussed before, that is duct penetration sign.

2:02

If we see that penetrating duct through the area

2:05

of possible mass, then it's possibly benign.

2:09

So in this particular case.

2:11

On these thin images, we see the duct is present

2:14

here, and that drains towards the major papilla.

2:18

Let's see how it looks on post-contrast

2:19

images, because post-contrast images are

2:22

thin, three-millimeter images, and sometimes

2:24

the duct is better seen on those images.

2:27

And as we follow this up, we see the

2:29

duct actually, very clearly here.

2:32

So duct is opening and

2:36

communicating with the directed duct.

2:39

The lesion or pseudomass we have in

2:41

the pancreatic head is causing focal

2:43

stricture in the proximal pancreatic

2:45

head, leading to distal ductal dilatation.

2:48

This mimics like it is possibly mixed duct

2:51

IPMN, but seeing the entire duct passing

2:54

through the so-called lesion gives you a

2:57

confidence that it is not cancer at least.

3:00

And secondly, we do not have any other

3:01

signs of cancer here because we are

3:03

seeing the parenchyma is well-maintained.

3:06

We are not seeing any tissue going

3:08

outside the boundaries of the pancreas.

3:12

None of the vessels are involved, and there

3:14

is no haziness surrounding the vessels.

3:16

We can go back and look on arterial phase one

3:19

more time and find everything is okay there.

3:23

So all of the vessels are looking fine.

3:25

What about the SMV?

3:27

SMV is also well-maintained.

3:28

It is well-maintained throughout

3:30

in size and caliber and shape.

3:33

There is no distortion.

3:35

So this cannot be a mass, first of all.

3:36

It is not a pancreatic head mass.

3:38

The question whether it is Obstructive

3:40

chronic pancreatitis or it is an IPMN with

3:44

side branch IPMN coexisting with that.

3:47

So these are the two differentials here.

3:49

And the next step will be either follow

3:51

up with the MR surveillance or a biopsy.

3:55

So in this particular case,

3:56

I would not prefer biopsy because I do not

3:58

see any signs of cancer anywhere.

4:02

Follow-up is a good advice here.

4:03

Surveillance will be better.

4:04

Okay.

4:05

Because the chances that it's going to be most

4:07

likely chronic obstructive pancreatitis is

4:09

higher because of this duct penetration sign

4:11

which we have seen on post-contrast images.