0:01

Okay, this is the case of adenocarcinoma.

0:05

And we are going to deal with some

0:06

very specific points which can lead to

0:08

diagnosis of adenocarcinoma on imaging.

0:10

So, this is axial T2.

0:12

I usually start any case of abdomen

0:15

body with T2 axials just to see a

0:17

broad idea what's going on there.

0:19

So in our case, what we see basically, the

0:22

entire pancreas is just atrophic throughout.

0:25

See the ductal dilatation here?

0:26

And as we move further, this ductal

0:28

dilatation becomes more prominent and as

0:30

soon as we reach the pancreatic head,

0:32

the duct just disappears abruptly there.

0:35

And then we see an area of heterogeneity

0:39

to hyperintensity or intermediate

0:42

intensity in that region, which is closely

0:44

abutting the medial wall of the duodenum.

0:48

So as we discussed earlier,

0:49

this is a very important point.

0:52

So if you see a ductal dilatation and

0:53

overlying pancreatic parenchyma is

0:55

atrophic, that highly suggests that

0:58

this patient likely has adenocarcinoma.

1:00

So even if you don't see this mass here,

1:02

if there is no mass visualized, it

1:04

can happen that the mass is actually

1:06

iso-intense on MR or iso-dense on CT.

1:08

It's not seen at all.

1:10

It is possible in 10 percent case of

1:11

CTs and about 2 to 3 percent cases of

1:13

the MR that you do not see any mass.

1:16

But if you see indirect signs like this,

1:19

dilated duct with overlying atrophic

1:21

pancreas without side branch ductal

1:24

dilatation, that's the caveat here, okay?

1:26

If you have ductal dilatation, if

1:27

your side branches are dilated,

1:29

it will be a different diagnosis.

1:30

Okay.

1:30

But if you do not see much of the side branch

1:32

dilatation, only the duct is dilated, and

1:35

overlying parenchyma is significantly atrophic.

1:37

And if you have a ratio between the duct and

1:39

parenchyma, that will be, duct is more than 0.

1:42

5, so, duct versus parenchyma ratio, 0.

1:44

5 or more, that is very much

1:47

diagnostic of adenocarcinoma.

1:48

That is a very reliable sign of diagnostic,

1:51

reliable sign of adenocarcinoma.

1:53

And the second sign which can be very

1:55

reliable is infiltration of the tumor beyond

1:58

the pancreas and involvement of the vessel.

2:01

So in this case, fortunately, what we see

2:04

is the main pancreatic duct, main, uh, portal

2:06

vein here and then it becomes confluence

2:09

and then it continues with the SMV.

2:11

The only thing which we are seeing here is just

2:12

some dirtiness and haziness of the fat here.

2:15

Most of the fat planes are well

2:16

maintained and this SMV is well

2:18

maintained and rounded in structure.

2:21

The SMA is also very, very

2:23

far from the lesion.

2:24

So both of these vessels are

2:26

mostly spared, on T2 at least.

2:29

And then as we go further,

2:30

we can just quickly evaluate.

2:32

The celiac trunk and the common

2:34

hepatic artery and the bifurcation.

2:38

So nothing is looking very much suspicious

2:40

based on T2-weighted images here.

2:43

Let's move further and quickly

2:45

see these findings in the coronal.

2:48

Atrophic pancreas, same way, abrupt cutoff,

2:50

then a mass and then what we see, the CBD is

2:54

also showing some kind of narrowing corresponding

2:56

to that mass and the entire CBD is dilated.

2:59

So now we have double duct sign.

3:01

As I said earlier, double duct sign can be seen

3:04

in cancers about 72 percent or 80 percent of

3:07

the patients, and we should suspect anything

3:10

periampullary whenever we see double duct sign.

3:13

It can be a mass, it can be a lesion,

3:14

it can be a stricture, it can be

3:16

autoimmune pancreatitis sometime.

3:19

So after seeing the pancreas, just quickly look

3:21

on the liver, liver we are seeing some of the

3:23

lesions, those are slightly more hyperintense

3:25

than a mass should be, and then we are seeing the

3:28

spleen, which is looking mostly clear, and rest

3:31

of the abdomen is looking grossly unremarkable.

3:35

Then we can move to the. These are pre-contrast

3:36

T1-weighted images, and these are very important

3:40

images because sometime you can find a lesion

3:43

only on these images, specifically if the

3:45

lesion is isointense on other sequences.

3:48

Here we can see the lesion is actually slightly

3:50

hypointense compared to the pancreas, and we

3:54

can actually ascertain that all of the pancreatic

3:56

lesion in the pancreatic head is causing some

3:59

of the dirtiness in the fat here, so if there

4:01

is invasion of the mesenteric root here, we will

4:03

be seeing it better on these images as well.

4:06

And let's quickly move to the arterial phase.

4:08

It is taken at 15 seconds after

4:10

the contrast reaches the aorta.

4:13

And in this particular phase, we see

4:16

that lesion is absolutely hypointense.

4:18

Okay?

4:19

So we can see that duct is terminating

4:21

at the lesion, at the lesion, and then

4:24

the lesion itself appears hypointense.

4:26

And let's quickly move to the delayed

4:28

venous phase to find the relationship

4:30

of this lesion with the vessels.

4:33

And we can confirm here that SMV

4:35

is not distorted in the outline.

4:38

There is some haziness in the mesenteric

4:40

fat, SMA is also spared, and there is no

4:44

soft tissue which is enhancing in this area,

4:46

which can be seen with perineural invasion.

4:49

And just to give you a quick idea, where

4:51

the, the neural plexus are usually situated.

4:55

Have you ever paid attention to this area,

4:57

between the IVC and this diaphragmatic crest?

5:00

What is this line here?

5:02

This small line, thin, faintly enhancing

5:04

line is basically celiac plexus, right-sided.

5:07

And the line here, along with the medial aspect

5:11

of the adrenal gland and the diaphragmatic crux,

5:15

is basically the left-sided of celiac plexus.

5:17

If they're involved, they will be thickened

5:19

and there will be soft tissue in this area.

5:23

And let's quickly deal with ADC.

5:26

So that tumor area is showing some

5:28

of the areas of ADC hyperintensities.

5:31

That means some of the area of this lesion

5:33

is mostly necrotic, but some of the areas

5:36

are showing ADC blackness or hypointensity.

5:42

This is delayed image, and

5:45

the same kind of finding.

5:48

So given this, this, these images, we can

5:50

confidently say that this patient actually

5:52

has a pancreatic head tumor, which has not

5:55

invaded the vessels; most of the vessels are

5:57

not involved, and this tumor is resectable.

6:00

We do not see any lesion in the

6:03

liver, which looks like metastatic.

6:05

We saw initially some of the hyperintensities,

6:08

those were either cysts or hemangiomas.

6:11

So see this area, and if you see the

6:14

same area in the delayed phase, it

6:16

has filled in, so it was hemangioma.

6:19

So, nothing in the liver which

6:20

is looking like metastatic.

6:22

There is no lymphadenopathy in the

6:24

retroperitoneum which can be, which can make this

6:28

case unresectable and there is no involvement

6:30

of those five vessels which we have described.

6:33

If there is infiltration in the retroperitoneum

6:35

or the mesentery that is very subtle which can be

6:38

still dealt easily with the surgeon and this is

6:42

the resectable case of pancreatic head carcinoma.