Pancreas: Tumor andI Inflammation - HD

Introduction

Thank you very much. We can start with the pancreas.

Thank you, Paul, for kind invitation.

Dear friends, dear colleagues, the title is two more and Inflammation.

I'd like to speak first if it's possible about inflammation, because I want to concentrate more on tumor of the pancreas.

Technique and Methods

This is first light dedicated to the technique and methods.

First of all, we need to have the best visualization of the gland.

The all the results that we show are after the visualization of the gland, obviously.

This is a very important thing because we use contrast for lesion characterization and not for detection.

If I see something during my examination, I can characterize a mass after the injection in the same section if I want.

The dose that I use, I prefer 2.4 because the examination is not dedicated only to the pancreas.

I use the first part of the dynamic phases of the dynamic study for lesion characterization.

After 120 seconds, there is no more information to continue to view again to see the lesion during contrast.

I mean, I have to move to the liver because information from the liver study in the late phase are more important.

I need to exclude the presence of metastatic lesion.

The complete examination of the pancreas is pancreatic study from zero to 120 seconds and then liver study to exclude metastatic lesion.

Some few important thing in my opinion to differentiate this examination from CT and MRI, we are injecting microbile.

Blood pool contrast agent, while the contrast agent on CT and MRI are molecular.

There is a interstitial phase in the late phase.

I mean, fibrosis will enhance in the late phase on ct.

This is impossible with ultrasound.

It is important, can be an advantage or disadvantage.

I don't know. I will show you some cases on that.

Temporal resolution is the best one in respect to MRI.

Spatial resolution is very good, and the contrast resolution is related to the fact that no re tissue is present.

I mean, when I inject contrast on a lesion in the pancreas on ct, I have to consider the basel density of this CT or this lesion on ct.

And then I inject contrast to view a lesion.

To understand the to view the vascularization of this lesion, I have to inject a lot of contrast.

First of all, 120, 100, and then I need to have a lot of vessels inside because otherwise there is no difference from the basel density and the dynamic phases.

I can have subtraction, but not in the routinely study.

I mean, in contrast to enhancement ultrasound, in every examination, we clean, we filtered everything, and then we inject.

What we'll see is only vessels is only contrast.

Inflammation: Acute Pancreatitis

Coming to inflammation, acute pancreatitis, I want to show you directly the grading.

This is very important to for a prognosis of the patient.

I want to know if the pancreas, I know that the patient has acute pancreatitis because it is not an imaging diagnosis.

What I want to know with the imaging is if the pancreas is normal, yet normal, perhaps the volume, if the pancreas en last diffusely or focal enlargement of the pancreas.

And so the the fluid collection, but what is very important is the necrosis, how much and where.

I have to be panoramic enough to exclude or to confirm the presence of two collections necrosis, two aerial necrosis and how many in respect to the gland.

The first example is an enlargement of the pancreas.

You can see also here enlargement of the pancreas that is only slightly hypo coic in respect to the rest of the pancreas.

If I ingest contrast, perhaps I can see necrosis here.

The prognosis of a patient can be changed.

Look here. How is easy to compare ultrasound and CT in this case where huge collection and more than half of the pancreas is gone all into necrosis.

I can inject contrast in this case, in example, you can see enlargement of pancreas and in homogeneity of the body and tail, body tail, you can see through collection in the ventral portion of the pancreas.

But when I inject contrast, this is not normal pancreas, inflammatory pancreas, this is necrosis.

There are no more vascularization of this portion.

My report, my examination, my information are completely different.

This is important paper in my opinion, in which you can see that com, the correlation between contra sensor ultrasound and CT was very good.

Contra sensor ultrasound is similar to CT in detecting necrosis.

And so we can use contra sensor ultrasound.

This is a comparison, but the problem in my opinion is that you can think about the extrusion criteria of this of this paper.

In example here in particular here, poor visualization of the pancreas and ultrasound.

In this paper, only patient in which all the pancreas is well visible are included.

And so these are results.

When you can see all the pancreas in acute pancreatitis patient, I think that all of you have the same experience for me is very different, difficult to see the pancreas in this patient for pain.

You are not able to compress a lot of mechanisms.

We are in the worst situation.

And so this is my idea in the use of contrast in acute pancreatitis.

We can use contrast to reduce CT in the follow-up of acute patient acute pancreatic patient.

This for sure, this is very important, but the CT at the beginning is mandatory in my opinion, to have an idea of the situation.

And so not at the beginning of the symptoms, but after 72 hours, this is my position.

Tumors

Ductal Adenocarcinoma

What about tumor? I want to speak first about Dr. OC carcinoma, and we can agree and is I want to show first ct then the results of contra science ultrasound, because we need to compare in this disease, in this tumor.

This is very frequent, this very aggressive.

We need to compare the results of contra science ultrasound with CT and MRI.

We need to know the results of CT in this kind of patient just to put contra sound ultrasound, if it's necessary in the right position.

CT is the best imaging modality for studying for diagnosis and staging pancreatic ductal lung carcinoma 2007.

We can agree on that, absolutely, yes.

But the problem is that very often the first examination is an ultrasound examination.

This is present in this paper.

You can see ultra sonography is frequently the first imaging modality.

Not only that pick up a PAA a problem without symptoms, an incidental finding, but also in patient with symptoms of suspicious symptoms for pancreatic malignancy.

The first examination is an ultrasound.

This is true in Italy, in Europe, is true also in Asia.

Just to prove that, let me show you.

This is our meeting, and from one year I review all the solid lesion in the pancreas discussed during the meeting.

And in 80% of the cases, we found an ultrasound examination at the beginning.

Really, believe me, if the first examination is more accurate, more precise, we can have faster diagnosis.

This means better prognosis for the patient if we are speaking about ductal ladoc carcinoma.

So we have guidelines, but not only the fum guidelines because the application to the pancreas is also present in the NS dedicated to the endocrine tumor, and also in Italian society guidelines for the management and diagnosis of cystic tumor of the pancreas.

Coming to our guidelines, however, the first indication is characterization of ductal dental carcinoma.

Let me show you first the typical features.

We have solid lesion.

The detection is without contrast.

This asymptomatic patient, so is an incidental finding.

No vessels co doppler.

When inject contrast, I can see the typical features of duct adenocarcinoma.

Contrast sensor ultrasound that is the de lesion is marked the hypovascular.

I can use this, but sorry, let me show you another important thing.

This is not a vascular pattern.

You can see carefully inside, and you can see few micro bubbles moving because this is a high desmoplastic lesion with a high amount of fibrosis.

And this is another case of ductal carcinoma, a mass in the pancreatic head.

Again, solid hypo coic hypovascular.

After romine injection, the lesion resected is fibrotic, so the fibrosis is visible here, and the mean vascular density is very low.

With the CD 34 marker, you can see that very few vessels are present in the lesion.

How accurate is this sign?

Ductal carcinoma is reported to be hypovascular in 73% to 93% of the case in this study.

We have immediate diagnosis of ductal carcinoma.

This is a multicenter study in 1,439 partic pathological approved lesion.

You can see again that duct carcinoma in 90% of the cases is marked three hypo.

This what I want to show you, if we detect an enlarged pancreatic body or hypo coic area in the body of the pancreas, for sure suspected because there is dilation of duct of stream.

It it's up to us what to put in our report.

We can see we can write the body is a little bit large, but also we can say why not Please sit in every cases, but this is not the solution.

And I will show you why.

If I can inject contrast immediately, let me show you that it is very easy to understand that all the pancreas is vascularized except this area that is a little bit smaller but markedly hypovascular.

I have to call this Dr. Adenocarcinoma.

And this patient was a symptomatic patient.

Incidental finding the lesion was perfectly inside the body received CT staging that proved the lesion, no metastatic spread.

And this is the resection look, the dral carcinoma in the pancreas is a T one and zero M zero with dilation of duct upstream.

The solution is not to send all the lesion to the CT because it is well known that ductal carcinoma can be isod dense, no lesion.

You perform ultrasound examination, you detect a lesion of two cm or 1.5 cm, you send the patient to ct, and CT is completely negative.

This first result is very heavy.

It's very important because the patient receives ct.

If it's negativity ct, everything is okay.

And if you look here in this paper published in radiology in 2011, you can see that the paper is focused on small under two cm DR carcinoma, and 30% of the patient of the lesion are isod dance, no lesion.

This is a patient that I was on CT this during this day.

You can see something here is not, there is nothing perhaps, but upstream you can see the the thickening of the the body is reduced.

So there is a perhaps initial chronic upstream chronic obstructive pancreatitis.

I said to the resident, please move the patient to ultrasound resident.

Why we are on ct, because is very easy to see ducto carcinoma or into the acoustic impotence is completely different.

I can see the lesion, I can jet contrast, I will prove, because the contrast is different to the the contrast of ct, I can prove the hypovascular pattern of ducto carcinoma very small.

This paper, in this paper, a comparison between contra ultrasound CT on ductal lung carcinoma.

You can see that there is no differential the statistical difference between the two image method for the diagnosis.

But let me show you, in this range, less than two cm, again, there is four false negative results for ct.

And the false negative results of COS is zero.

We have a very accurate method in the first line.

This is a good comparison, but if we move here, this lesion detect on ultrasound is very small in the medial portion, in the internal portion of a pancreatic head, no dilation of duct biliary is normal, no symptoms, nothing but lesion after contrast, media injection is markedly hypo and the lesion is invisible on ct.

Isod dance was a Dr. Carcinoma.

Contrast for the characterization for sure, but not for the staging.

I have to do the staging before before the injection because I want to see the contact, the relationship between the lesion to vessels.

Let me show you. This case is a a mass in the pancreatic head with involvement of snet process.

And in fact, you can see an infiltration small of the of the wall of the superior me vein.

And then I inject contrast for characterization ductal carcinoma.

I moved to liver to exclude metastatic lesion.

This is the complete examination to the pancreas for the study of ductal carcinoma, pancreatic tumor, generally speaking.

And the lesion, the infiltration was proved during the surgical resection.

Hypervascular Lesions: Endocrine Tumors

What about the hypervascular lesion such as endocrine tumor?

This is a small in insulinoma, you can see that is absolutely well visible on CT as hyperdense nodule in the neck of of the of the pancreas lesion is less than one cm, but the difference on conscience ultrasound is only that I can view dynamically the announcement of the lesion.

In big or in non-functioning endocrine tumor, the lesion can be big or small.

I can see vessels on doppler this predict the hyper vascularization, but only after the contrast media injection, I can be really sure that the lesion is hypervascular typical for endocrine tumor.

This is not an endocrine in duct endo carcinoma.

It this is an endocrine tumor.

I can suggest the diagnosis and also the management of these.

Patient is different.

Think about the the the the pet examination.

Very useful in endocrine tumor.

Mass Forming Pancreatitis

What about the logistic theology of mass in the pancreas?

This is an example how to immune mass forming pancreatitis is very typical.

The iso echogenicity after contrast injection, I don't have the final diagnosis here, but in mass, even if resectable, if there is no typical sign of ductal carcinoma, I can move to IF to move, to biopsy to prove that this lesion is of logistic theology.

I don't have the final diagnosis, but in this case, I can exclude the presence of a ductal carcinoma.

Summarizing, this is the pattern.

I show you the typical pattern of ductal carcinoma markedly hypo.

This is the part of an endocrine tumor moving to hyper genicity after contrast with the injection.

And when the lesion is iso to the rest of the pancreas, I can think about the ology of the lesion moving to cystic lesion in the pancreas.

Cystic Lesions

This is a very sorry for that, but very easy distinction between two completely separate wards the the scy are not so frequent.

And then we are cystic tumor of the pancreas.

I want to tell you that we can think about cell docetic lesion only if there is a story of acute pancreatitis or chronic pancreatitis.

Otherwise, there is no possibility to have acetic lesion in in this case.

Our diagnosis is more have to be more for a tumor of the pancreas.

And it's very easy to distinguish cystic tumor of the pancreas.

Based on morphology, we have the the ball and we have the the cloud.

I mean this microcystic lesion.

Speaking about the first, let me show you these two cases on ct.

I will tell you the story later on.

But first let we can comment the the lesion.

You can see a round lesion here.

And here is hypodense, hypodense, cystic, cystic, and you can see that there is something inside and the wall is not perfect.

Here is visible here, here is more sharp.

Perhaps there is something also here.

The diagnosis is not so easy. Seems to be the same.

Which of this two lesion is neoplastic?

The first or the other one? Both.

I don't know if I tell you the story.

You have the diagnosis, but not based on the imaging finding on ct.

I mean this patient status post acute pancreatitis, and this is the ct.

Cystic lesion, this patient, no symptoms.

This is an incidental finding, but let me show you the results.

Also contrast and enhance ultrasound.

This is the debris inside the ssis.

When I move to contrast and enhance ultrasound, everything is clear, is filtered.

There is nothing I inject.

The debris necrosis, no ance and so is very easy to say that this is not a tumor.

This is a cyto oma in which you can see the results of contra sensor ultrasound absolutely better than than density.

I can use contra sensor ultrasound for characterization of incidental finding, yes, in cystic case, also an incidental finding of cystic mass.

In this case, this is a macrocystic lesion in the body tail.

We know that there is a good correlation for the detection of septa and nodule with pathology.

Moving to to our contrast examination this case, you can see here a lot of septa not well visible or Basel because there is moine inside.

When I move to contrast, I filter ing and I'm in the the right situation.

Perfect situation to detect nodule or septa in this tumor for morphology is rounded again, is a mino cystadenoma that is a prial lesion and needs resection resection.

This is a typical aspect of macino cystadenoma.

Inside you have Mina that give us signal during ultrasound examination.

Inside homogeneous, also with doppler you have a lot of artifact and you are not in the best situation to detect a lesion inside.

And here when you move to contrast, you can see small septa inside.

These are the case of macino cystadenoma.

Contra ultrasound is better than basel ultrasound for the characterization of cystic pancreatic mass.

Yes. Also better in respect to CT for the definition of the septa because I am proving the vascularization.

This is another case.

Small mussino cystadenoma, this a ct and we be sure about the presence of announcement inside.

This is MRI. Once again, there is something here perhaps I'm not sure, but the results on contra sensor ultrasound is completely different for sure.

This is cystic tumor of the pancreas is rounded with SSA thick wall.

The septa are different with a are not so tiny, I mean, so is are not organized like in the sero cystadenoma.

This is very easy in this case to have the final diagnosis of ous tumor, eno, stem, plasma, cystic mucinous cystadenoma.

The diagnosis, the accuracy also, again in the in this paper is very high.

Microcystic Lesions

Moving to Microcystic the things are not so good.

As for Enos cyto adenoma eno cystic tumor, generally speaking because in this case I need to be sure about the relationship of this kind of lesion in respect to the ductal system.

This microcystic lesion for sure is a tumor is vascularized, but only with MRI or endoscopic ultrasound.

But here I am not invasive. I can see that.

I can say that there is no connection with the version duct.

And so this is a serious cystadenoma for sure is not an IPMN on of the branch duct.

In fact, in this case, why I have to inject contrast.

This is a small incidental finding.

Microcystic lesion, no history of acute pancreatitis, no history of chronic sign of chronic pancreatitis.

I want to save money. I do not inject contrast.

I directly suggest MRI, not CT, but MRI and so I can be sure prove, again, confirm the presence of a microcystic lesion and very easy to understand the connection.

We conduct this IPMN of the branch duct.

In this kind of lesion we can use CUS is working in this kind of lesion is better.

MRI absolutely what clinical application I'm finished.

Clinical Applications

Incidental finding and problem solving technique for sure, this is a very small lesion.

Incidentally detected is a one cm solid stupid nodule of the incident process of the pancreas.

I can send this patient to CT by is young.

If you want to send to other imaging modality, please MRI no C because in 30% of the cases, this lesion will be undetected with the fo false negative results of ct.

In this case, I prefer je contrast.

The lesion unfortunately is markedly hypo ductal adenocarcinoma.

Then the patient receive multi detector CT staging and you can see the results of one cm ductal Leno carcinoma of the pancreas.

Early diagnosis for a better prognosis is another case of small lesion hypovascular.

And this is the results.

The lesion is perfectly inside the pancreas.

Ductal Leno carcinoma, T one N zero M zero, sorry.

Okay, problem solving technique.

I can show you that in this clean cystic lesion of the tail, you can detect septa, you can prove vascularization in respect to MRI disease around lesion with thick septa announcing after contrast mineral injection.

Again, munos adenoma.

Perfect correlation, perfect diagnosis.

This is a paper, a meta-analysis proving us that sensitivity specificity in literature is very good for differentiated diagnosis of ductal carcinoma and non-action carcinoma.

No tumor, this is a multiparametric imaging of a pancreas because I have not only contrast on the machine, I can use elastography.

This is not course, but let me show you the results on this.

Not so easy lesion enlargement of the pancreatic head is in homogeneous.

You can see that lesion is stiff.

The normal pancreas is 1.4 in the body. So perfect.

And the lesion is stiff. Again, I can jet contrast.

And so this is the complete examination of the pancreas nowadays to the pancreas to for the study of a pancreatic lesion.

Conclusions

This conclusion, contrast sensor ultrasound is accurate image method in the characterization of the pancreatic masses.

And we can have immediate diagnosis of duct carcinoma.

This not perhaps a routine ultrasound, but this is better for us and for the patient.

Thank you.