MRI Cystic Pancreatic Lesions

Introduction to MRI of Cystic Pancreatic Lesions

The next 30 minutes or so, we will discuss MRI
of cystic pancreatic lesions or tumors,
and we also talk a little bit about the
management of these lesions.

I'm gonna give you some background information,
and we'll go over the classification
of cystic pancreatic lesions
and then discuss with you
at least my MRI approach to those lesions,
including techniques, some of the pearls
that help you differentiate lesions from each other.

And as I said, talk about some
of the follow up guidelines that are out there.

This is an old subject, so to speak.
The first publication that I could date back was
published in 1830 when
a French Canadian surgeon wrote a case report on a cystic
pancreatic mass.

So you can think this is an old subject why he
and many other people so interested in
cystic pancreatic lesions today.

While we all, I think, experience in clinical practice that,
we've seen an incredible increase in the prevalence
of these lesions, and people talk about 20 fold increase
over the last couple of decades in our institution,
my prior institution, and we looked at the incidents
of cystic pancreatic lesions on ct.

We found them in 2.2% of all CT studies,
abdominal CT studies, and up to 15% of abdominal MRIs.

And these data kind
of have been confirmed in a large autopsy series.
Were up to a quarter of patients on autopsy,
actually have at least one cystic pancreatic lesion.

We are used to this concept.
We see cysts in the kidneys.
We see cysts in the liver,
and typically we dismiss them.
We say they're small DITs and
most of the cases we don't really care about them.

However, lots of big difference with the kidneys
and the liver versus the pancreas that the majority
of cyst in the pancreas are so-called pre-malignant
or even malignant at the time of diagnosis.

And you cannot just dismiss them.
You have to have some sort of a follow-up algorithm in place
that will deal with these patients.

There's also, I think, kind of in contrary
to my talk here, some resisting,
some persisting limitations, how
to characterize the cystic pancreatic lesions,
especially when they're small.

I think lesions less than a centimeter
or even two centimeters, sometimes very hard
to determine which lesion you're dealing with.

So that's adds to the problem here.

Also, some of the management pathways
and follow up guidelines out there are very problematic.

And my book, that's nice to have IPMN guidelines.
But first you have to know you're dealing with an IPMN
before you can apply an IPMN guideline.

And again, we will discuss this later in this talk.

Classification of Cystic Pancreatic Lesions

This is a very busy slide.
I don't want you to remember all of this,
but I just wanna show that I can discuss four cystic pancreatic lesions today in my talk.

The ones that I believe you have to be aware of,
that you're gonna see in clinical practice not infrequently, and also know how to manage these lesions.

We're gonna, of course talk about the intra ductal papular
mucinous tumor, which is the most common lesion
you see in clinical practice.

We'll talk about the serious tumors
because these are benign.
And once you make the diagnosis, you know how to manage
that patient because again, you're dealing
with the benign lesion, mu cystic neoplasms,
which have a specific characteristics.

And these are pre-malignant lesions that have
to be dealt with surgically.

And then also a very rare tumor,
although we see it pretty much once a month
or every two months, which is called a spin,
or SPT, the full term is solid
pseudo papular tumor of the pancreas.

And the only reason they wanna show it to you is
because it has extremely specific imaging characteristics.

So once you're gonna see one,
you're gonna make the right diagnosis.

Very small font here.
And again, I don't want you to read this,
but just to reemphasize a true cyst in the pancreas,
like we see them in the liver and pancreas are ex in the
liver, and kidneys are extremely uncommon.

And that pseudocysts,
although this paper, which is pretty recent, says
that they make up 75% of all cyst, is totally not true.

I mean, I think everybody in the audience here will
admit that most of the cysts
that we see in the pancreas are unrelated to pancreatitis.

The patient has no history of pancreatitis at all,
and we're just dealing with very small neoplastic lesions.

Serous Tumors

So let's start off with the serous tumors.
The reason I wanna do that is again,
when you diagnose a s tumor correctly, you're done
because it's a benign lesion.

Uh, so there's two subtypes.
The one you definitely wanna remember is the classic one, which is the serous
microcystic pancreatic adenoma.

And then this is kind of a confusing subtype,
which is in common,
but it's called Sears macrocystic or oligo cystic.

So the Sears Microcystic one is typically seen in elderly female patients.
And the easy way to remember is to call
as the grandmother tumor.

Again, you expect an elderly female patient
to get this type of tumor.

They can be throughout the pancreas,
but more commonly they will be in the pancreatic head.

The macrocystic subtype has the same demographics, again,
elderly female patients,
but they're confusing imaging features.
We which we will discuss in a second here.

Features of Serous Microcystic Pancreatic Adenoma

So what are the features
of a serious microcystic pancreatic adenoma?

They're typically large, they're solitary.
They have this classic comb appearance.

With that, I mean that they're composed of out
of innumerable small cyst, which are arranged
around the central studied scar.

The central state scar, which is shown here,
has radi septations into the mass.

And very typically, or classically,
you'll see puncti calcifications within that scar.

By definition, people feel that serious tumors have at least more than six cysts,
and the cyst are smaller than two centimeter in size.

They also very classically lobulated in appearance,
and I do believe very strongly in the contour
of a cystic pancreatic lesion
to differentiate them from each other.

And again, because of the largest cysts
that are sitting in the periphery of the lesion,
they will get this lo contour
because the peripheral cy bulging
out the contour of the lesion.

Again, remember the lo contour of a patient with a serous tumor.

Also very important is that serous tumors,
they're well defined, but they don't have a capsule.

Okay? So s serious tumor don't have a capsule.

A couple of examples here on Mr.
Again, of a serious tumor, multi lobulated, if you want,
multicystic central studied scar
and the largest cyst sitting in the periphery of the lesion.

Another example here, I showed this I think to yesterday, or maybe not,
where we have this large mass
that nearly looks like solid
because it's so hypervascular, but it has these ations.

And if you do TTU imaging, you see in five seconds
that this is a multicystic mass arranged
around the central study scar,
which is enhancing post contrast administration.

Unfortunately, sometimes the CY is so small
that you're thinking you're dealing with the solid mass.

And this is a very unfortunate case of a patient
with a serious macro microcystic pancreatic adenoma,
which is a benign tumor, which went for Whipple resection,
which should never have happened.

And the reason was that they thought this was an endocrine
tumor because they say solid,
well-defined mass in the pancreas.

So the message here is to always think you see a
hypovascular mass with maybe some hypodensities in it,
could it be a serious tumor?

And send the patient for MRI.
So you actually can see that this tumor is consisting
of multiple small little cysts.

And this is again, the pet specimen.

Very quick word about D effusion, MRI in the serious,
in the cystic pancreatic lesions, it doesn't work.

We thought we would be able to differentiate benign
for malignant lesions and mucinous from
non-use lesions.

But it turned out in many papers
that this is not really true.

Atypical Features of Serous Microcystic Tumors

One of the atypical features of serious microcystic tumors,
again, I really showed you they can appear solid
because the cysts are so small, they can be multifocal,
and especially in patients with from hippo limbo disease,
they can contain internal hemorrhage.

And that's kind of an important one
because very few cystic tumors in the pancreas bleed.

And the classic one is a spin
or SPT tumor, which we'll discuss later.

But also the second one on my list will be a serious tumor.

And then rarely you will get ductal obstruction.

Just an example here of a patient from hippo limbo.
We all recognize the multiple cystic renal cell carcinomas in the kidneys,
and also multiple serious microcystic pancreatic adenomas in
the pancreas.

And then some other epithelial non-plastic cysts,
also classically seen with from hippo limbo.

So very classic case of from hippo limbo.

This is just an example of a serious microcystic tumor,
very classic appearing in the tail of the pancreas.

And it has some internal hemorrhage in it, which again,
is a feature that can be seen in serious tumors.

Serous Macrocystic or Oligocystic Variant

Just to finish up serious tumors, unfortunately,
we have this atypical or uncommon variant,
which is called serious macrocystic or oligo cystic.

What are the imaging features?
They look completely different.

They're typically unilocular or bilocal cysts,
but very importantly, they don't, they're not encapsulated
because this, obviously, if you look at this,
that could look like a mu cystic neoplasm or a pseudocyst,
but the lack of a capsule would suggest
that you may be dealing with a serious macrocystic
pancreatic adenoma.

And this is a patient that unfortunately was not diagnosed
correctly and went to surgery.

This is another case
of a serious macrocystic pancreat anoma, where again,
you see these lobulated mass, which only is composed out
of two cyst if you want,
and again, is not encapsulated on imaging.

Cyst Fluid Analysis for Serous Tumors

A quick word about cyst fluid analysis.
If people ask you to aspirate these lesions, a lot
of these lesions now get aspirated
by US endoscopic ultrasound.

But maybe percutaneously can be approached too.

The bottom line with serious tumors is that only in the minority,
you will get actually a positive cytology
that will give you the diagnosis.

But you can use some of these biochemical analysis
or markers that are available, serious tumors,
because they don't communicate with the ductal system.

They have a low amylase, they're non-use,
so they have very low CEA
and they're not, they're benign, so they have a low tumor marker C 90.9.

So the message here is everything is very low.

Serious tumors is very high on
the differential diagnosis.

Mucinous Cystic Neoplasm

The second one second cystic tumor we wanna discuss is
muso cystic neoplasm.

It's completely different animal.
Here, as I mentioned already, we're dealing
with a pre-malignant lesion.

So at any time you make this diagnosis,
the patient will probably get surgery.

If the patient is a surgical candidate, they're exclusively seen,
exclusively seen,
which is very important in middle-aged female patients.

And there's a reason for that
because these are taught to arise from translocation of primordial gonadal cells
during emer life into the into the tail
and body of the pancreas.

And that's why there only a rise in the body
and tail of the pancreas.

And so we call this the mother tumor.

At any given time, if you have a hundred of these,
75% approximately will be benign at that point.

But if you leave the men, they will become malignant.

And around 15% are actually already fully malignant.

The re again, why is it only in female patients?
Again, because of these cells
that are translocating.

And as a result, a pathologist,
and that's how I remember it,
a pathologist will only make the diagnosis
of mu cystic tumor when they see this very classic ovarian
like str in the specimen.

And that's how I can remember
that these are only seen in female patients.

And these are these this is this ovarian like stroma
that has sex hormone receptors,
and that's why you see them in middle aged female
patients on imaging.

They also look completely different than serious tumors.

What is so different about it?

As I mentioned already, the body and tear of the pancreas.

The cysts are few in number,
typically less than six, and they're larger.

They're more than two centimeter in size,
extremely important.

Serous tumors are non encapsulated,
but mucinous cystic neoplasms have a capsule.

These tumors are true expansile lesions,
so they're round or oval.

They're not ated like a serous tumors,
as we we're talking about.

And they're also hypovascular.

And as again, it's a benign to malignant lesion.

And the more abnormal features you have, such
as mural nodules or papillary projections, or tick wall
or calcifications, statistically more likely you'll be
dealing with a dysplastic
or a malignant lesion at the time of diagnosis.

So this in one blink of the eye, very suggestive
for a benign muso cystic neoplasm,
because it's looks very uncomplicated.

It has a capsule as we see on T two imaging,
but no neur noes, no calcifications,
no palpatory projections.

It's in the body until of the pancreas.

This is a 50-year-old female.

There's gonna be a muso cystic neoplasm,
if the patient does have any history of pancreatitis on MRI,
and this came out, which it should be, right,
because it's a surgical lesion,
and this lesion, it's encapsulated.

The capsule is beautifully seen on tatu imaging
as shown here, but this lesion already has a neural nodule.

And of course, this was taken to surgery.

And I always like this case
because it's very humbling as a radiologist
to see all these nodules that we were missing on our state-of-the art Mr. images.

This is a more recent case of another classic muso cystic neola.

It's an encapsulated mass, which is round to oval in shape,
and the body tell the pancreas with few septations.

And again, this should come out
as it did in this patient.

Cyst Fluid Analysis for Mucinous Cystic Neoplasms

Same here with cyst fluid analysis.

Remember that only 50% of the time,
you'll have a positive answer.

These tumors are mucinous in nature,
so they will have a high CEA, they're not communicating,
so they have a low amylase.

And the more malignant the lesion will be,
the more likely you actually will be dealing with abnormal tumor markers in that lesion.

Solid Pseudopapillary Tumor (SPT)

The third lesion I wanna discuss is this uncommon tumor, which you probably think, what
is he talking about or why is he wanna discuss this?

Well, because these lesions are
so specific in their imaging appearances
that once you're gonna see them,
you will make the right diagnosis.

There are many names in literature,
but the current term that the A FIP use,
the solid pseudo papular tumor of the pancreas,

these are classically seen in very young female patients,
typically in their teens or twenties.

In contrast to prior reports, older reports that said
that these lesions are more typically seen in African American females in the body
and tear of the pancreas.

More recent studies really haven't confirmed
these observations.

So we call this the daughter tumor.

So remember, the serious tumor is the grandmother tumor,
the mu cystic neoplasm is the mother, and then the span,
or SPT is the daughter tumor.

So what's so classic about it?

Well, these are encapsulated lesions as you see here,
and they actually solid masses
that ultimate infarct and bleed inside.

So you will see a combination of a capsule,
but the features to look for is capsule
and internal hemorrhage,
and the typically larger diagnosis that do like
to live in the in the body and tell the pancreas,
but again, not maybe more than in the head of the pancreas.

A couple of examples here.

I'm never gonna forget this case either,
because this was a people that know the Bo Brigham Women's Hospital in Boston,
and they know that there's a seven 11 store next door.

And this females was 18 years old, came into the er,
because she was assaulted in the seven 11 store.

And the radiologist said, well, there's a lot
of abnormalities here, but it has nothing to do
with the trauma because there's calcium in the wall
of this lesion, and there seems to be some maybe blood products inside the lesion too.

So we decided to do an MRI,
and indeed, this was an encapsulated mass.

You see the capstone deterior imaging
with internal hemorrhage.

And as I mentioned to you,
once you see those two in a young female,
you should always make the diagnosis of a spin tumor
or SPT tumor.

And this patient indeed went to surgery, surgery,
because I forgot to mention, these lesions are benign
or borderline malignant neoplasms.

And since the patient's gonna live another, hopefully 70
or 80 years, you wanna take these out
and not wait until they become malignant.

So this patient went to surgery.

Here you see the normal pancreas.

Here you see the capsule, which is classic for these tumors
and the papillary architecture of the spin tumor.

Just one more example of this,
and they look very fleshy as you see here.

But they have always those two features
of internal hemorrhage.

This is a T one weighted image prior
to contrast administration.

And you see the very high signal intensity
due to the blood products.

And on the subtraction imaging,
you see the capsular enhancement of the lesion.

You also see the capsule much better
on the deteriorate images.

So again, young female with hemorrhagic mass with a capsule,
you should make the diagnosis of a spend tumor.

Intraductal Papillary Mucinous Neoplasm (IPMN)

The last 15 minutes I have here, I will spend a lot of time on, as I mentioned already,
the most common cystic neoplasm we see on a daily basis,
which is intraductal papillary mtus neoplasm.

It's I kept it for last
because I don't want it to confuse with the any
of the other tumors that we already discussed,
because it's completely different
than any of the other ones.

Number one, it's different
because it's the only one
that's more common in male patients.

All the other ones are very female predominant.

It's also the only one that arises from the ductal system.

Remember, all the other ones are extra ductal,
and they're not communicating with the ductal system.

This one is arising from the ductal cells.

Extremely important, I believe, is that
you don't actually see the tumor.

What you see is extensive mucin production
by the tumoral cells,
which are typically microscopic in nature.

So the tumor itself, in most cases, you don't see,
but you see the mucin that's produced
by these abnormal cells.

So I kind of try to remember this by using this erupting volcano concept where the tumor's a little crater.

And what you see in the images is actually the the lava
and the smoke when the volcano erupts.

And this is true in a case like this, where you have combined duct, IPMN, so to speak,
where you have massive dilation of the main duct
and some side bench abnormalities,
but the tumor itself, I don't see,

I don't know if somebody asked me, where's the
where's the true epithelial abnormality here?

I don't know. If you're lucky, you'll see some neural nodules and papillary projections, which yes, in part
or the tumor, but there could be tumor throughout this gland
that I don't see on my images.

And again, as we were talking about indirect MRI
and lymph nodes, you have to know your limitations
because people are gonna come down in the reading room
and say, this is dysplastic, IPMN.

This is a malignant IPMN.

And I always say, how do you want me to tell you?

I don't even know where the tumor is.
I don't see the tumor itself.

So but again, there are a couple of features
that you have to be aware of, shape, ipmn
or ducts that are dilated.

So they kind of keep the shape of the ducts, and
therefore they kind of play amorphic in shape.

They're not ated, as we see in serious tumors.

They're not drowned and oval, as we see in SPS
and muso cystic tumors.

They also don't have septations.

What we actually see is the wall
of AUC against another wall of abduct.

And so it's semantics, but I call them pseudo septations.

Very classic.

As I said, if you have main duct type,
you will see the mucin coming out of the ula so
to speak, an endoscopy.

And just to again, illustrate the fact of how hard it is
to determine the pathological subtype.

This is one section through the duct
with different histological subtyping from an adenoma all the way to an invasive cancer.

And so it's very hard as a radiologist to determine
where in the spectrum you actually are with this specific patient.

Another feature that's helpful to make the diagnosis
of IPMN is multifocality.

All the other lesions we discussed
before are typically solitary in nature except
of serious tumors and vulner limbo.

But if you've seen multiple lesions scattered throughout the
gland, statistically you're dealing with an IPMN.

So as I said, we we don't we are not able
to determine the pathological subtype,
but at least we can try to determine the imaging if you want, phenotype.

And why is that important? Well,
the prognosis is totally different.

If you're dealing with a one centimeter side bench lesion
versus a main duct type PMN
or combined duct type p mn,
that measures two centimeter in diameter.

The two centimeter diameter guy has more than
50% chance of malignancy.

The lesion of one or two centimeter has a very low chance
of malignancy, probably less than 1%.

So it is important
to differentiate those different imaging subtypes.

And so this is an example
of a very small sarre IPMN
communicating with the ductal system.

And just based on that communication,
I know this is an IPMN,
because all the other lesions are not communicating
with the ductal system.

Prediction of Malignancy in IPMN

What about prediction of malignancy?

As I already alluded to, it's extremely hard
by imaging alone because of the lack of visualization of the tumor, and
therefore the numbers are very inaccurate, so to speak.

And people have evaluated innumerable imaging features such
as presence of calcification, CBD dilation,
tick acceptations communication, et cetera to try
to determine the malignancy of these lesion.

And it's extremely hard of course, if you see
metastasis, you see retroperitoneal involvement, you see
vascular involvement, you know, you're dealing
with a malignant IPMN.

Just to kind of reemphasize the appearances of IPMN.

So this is a classic CY Branch lesion.

It lives in the incident process of the pancreas,
which is a very common location.

I have not met a person that could explain
to me why there's a
predominant location in the incident process.

But you see this very plainly shaped lesion, which is a duct
that's dilated, filled with mucin all the way to the imp,
through this connection with the
main pancreatic ducts here.

So this again, is a side branch type IPMN.

So this is the classic main duct type IPMN.

Another example here of a patient with a
a side branch type lesion communicating
with the ductal system, which is confirmed on the ERCP.

And if you don't look very carefully,
you may think this is a serious microcystic pancreat
adenoma, but again, the communication makes this an IPMN
and not a serious tumor.

Additional Cases and Concepts for IPMN

A final concept that,
and I don't know how well this presents,
but I will show you a couple of additional cases
that you should be aware of, is that if patient has a main duct combined duct, IPMN,
there's musing sitting there that will sit there forever.

And as a result, the outflow of the pancreas is diminished
or obstructed, and the patient will develop chronic
obstructive pancreatitis in the tail of the pancreas.

So it's kind of a snake if you want eating a mouse
or an egg obstructing the outflow
of the rest of the contents.

And this is another example
with a very severe combined duct type PMN.

And if you look at the tail and body of the pancreas,
it has duct ectasia, classically seen
as we see them always in chronic pancreatitis.

So I want you to remember that this very frequently happens
that the patient will present with symptoms
and imaging appearances of chronic pancreatitis,
including calcifications in the body until the pancreas.

So every time you make this diagnosis
of chronic pancreatitis, I want you
to exclude a main duct type P men as the cause
of the chronic pancreatitis,
because not infrequently you will find that.

So this patient went to surgery,
and actually the surgery specimen confirms the combination of both
combined duct IPMN shown here,
and the peritoneal chronic pancreatitis,
which you will see in many cases.

When you see main main duct, IPMN as shown here,
where you have the duct that's dilated
and the large side branch lesion,
and the main duct suddenly stops.

You should be extremely concerned for a neoplasm
or a malignancy degeneration of a combined with IPMN,
which was the case in this specific patient,
which was resected as you see here,
where there was a small adenocarcinoma complicating this
patient with combined duct IPMN.

Another example here of a patient combined with IPMN,
if this is a Monday morning or a Friday afternoon,
and they ask you to read this, I think it's very hard.

So we use diffusion rate imaging here to confirm
that this patient has an area of restricted diffusion,
which was consistent with a small adenocarcinoma, again,
complicating this patient with combined duct IPMN.

So although I mentioned
that the fusion imaging is not helpful
to differentiate MUS from non mucinous lesions,
it's extremely helpful to depict these very small areas
of cancer in those patients with a very cumbersome MR examination to evaluate.

Cyst Fluid Analysis for IPMN

So again, back to the cyst fluid analysis for IPMN.

If you stick a needle in there and get some fluid aspirate what you're gonna get around 50% chance,
you're gonna get a positive diagnosis on cytology.

And also the biochemical analysis will be helpful
because remember, IPN is the
IPN is the only cystic pancreatic tumor
communicating with the ductal system.

So the amylase will be very high.

All the older tumors, the AMS is very low,
it's a useless neoplasm.

So the patient will have high CEA in the sample,
and if it's a malignant IPMN,
there will be abnormal tumor markers.

Also, just wanna take a minute to discuss the possibility
or maybe near future possibility
of doing genetic analysis in those patients
that we aspirate and send some of the samples
to a lab in Pittsburgh where they actually will tell you
where exactly in this stage, from adenoma
to malignant invasive IPMN,
you are based on the specific genetic mutations
that they find along that pathway.

So this is probably the future
of personalized medicine where you will take a little sample
and send it to a lab that will tell you where exactly
the lesion is.

Other Lesions to Exclude

So I just wanna emphasize
before I finish up here, that I'm not a person
that told you that there are four cystic pancreatic lesions.

I had the time to discuss in detail
for very specific pancreatic cystic entities,
which I want you to remember
and know the imaging features about.

But unfortunately, as anything else,
we have many other lesions that you have to exclude
before making a final diagnosis.

Some of these are extremely hard
to make the right diagnosis.

For example, lympho patal cyst.
I think it's a heart entity to diagnose.

Some others are more easy, like a retention cyst
and a patient with cystic fibrosis.

One that I if I fail to make the right diagnosis,
it's very frequently is
because I didn't think about a cystic endocrine tumor to be the reason of the cystic mass.

And the features here, of course, are to looking
for the hyper vascularity of the wall, of the lesion,
even if it is cystic to think about a cystic endocrine tumor.

The patient has a primary malignancy such as a s cy,
as renal cell carcinoma,
or a melanoma, you should think about cystic metastasis,
lymphomas or perp pancreatic then is really in the pancreas,
but should think about it when you see an exophytic
pancreatic cystic mass.

And then unfortunately, every solid pancreatic mass known to men can appear cystic like
lymphoma, esner, cell carcinoma, et cetera.

Management Guidelines

So last couple of minutes here,
we're just gonna talk about some management guidelines.

And I just quickly wanna review in the next two slides
what I do think we know from literature.

Number one, we know that when we detect a incidental cystic
pancreatic lesion, that those stay stable
the majority of the time.

And there are many papers out there, I like to believe
what I find in my own practice.

And we looked at this and we found that 88%
of all cystic pancreatic lesions we diagnose state stable
for at least five years.

So that's a very favorable data point if you want.

We also found that of the ones that did progress of the 12%,
it takes a long time for them to progress.

It's not that they happen over three months
and suddenly become double the size, et cetera.

So I always try to compare this entity
with the whole history
of colonic adenomas becoming colonic cancer.

It takes a long time, as you know, it's up to 10 years
before they become cancer, et cetera.

So it's a very similar problem here.

We also know that initial size is extremely important to deal with, if you have the diagnosis
of a cystic pancreatic mass,
if the lesion is less than three centimeter,
whatever the histology is, if it's now an endocrine tumor
of a serious tumor or a muso cystic neola
or IPMN, if it's less than three centimeter, the chance
of being malignant is less than 3%, which is huge
because that's why, if you look at any literature on this,
they don't take patients
to surgery typically when they're less than three,
three centimeter, because the chance
of buying from a Whipple procedure
or a pancreatectomy is actually higher.

So you don't wanna send a patient
with the most likely benign lesion
for a very invasive surgery.

We also know that symptomatic lesions are more likely
to be malignant and asymptomatic ones,
and that's probably true, although I have huge issues
with the patient with right upper quadrant pain
that has an eight millimeter cystic
pancreatic lesion in the pancreas.

So I don't know if there's actually a relationship
between those two entities,
but just wanna show you an example here
that this lesion less than three centimeter,
and I may have showed this already before,
but if you look at this wall of the lesion,
it's very irregular, right?

On the medial aspect, and it the butts the vessel.

So clearly you can you can't be stuck in your thinking
that this is less than 3 cent.

It's gonna be benign. This
this is a very suspicious lesion,
and this turned out to be a malignant side bench IP men,
which was less than three centimeter in size.

So they do exist. This is another example here that if you close your eyes, you blink, you miss this lesion,
which may be a good thing you think.

But this patient came back
because we had seen this lesion.

We had put them in put the woman in the in the algorithm for follow up, and she came back one year later
and kind of doubled in size.

It was still very small. And then we said,
let's go back in six months.

And it needed tripled. And then she went to surgery.

It turned out to be a muso cystic neoplasm.

So they do grow, if you ever doubt, do they grow?

They do grow. So to finish up here,
I just wanna give you how we treat those lesions.

And I know there are many guidelines out there,
and some of them are very specific for certain entities,
which I have issues with
because you have to know you're dealing
with a specific entity before you can apply that guideline.

But that's what we use, and I think it works pretty
well in our institution.

This is the right from the fact that
that we published this in radiology, that
before we had this, it was a total lottery.

What happened with a patient, if I was on,
I would say do an MRI in six months,
if my colleague was on it would be do a CT in three months
or nine months, whatever, because there was no consensus.

So at least this may not be the holy grail,
but right now, when the patient comes,
we have have this ne next to every workstation and act.

We're working on an to implement this in a structured report
right now, but at least the patient get treated
very identically if they come
and whoever's is on will use the same guideline.

So what we do is if a lesion is symptomatic
and it's more than three centimeter,
and it's a surgical candidate, the lesion will go
for resection when the lesion is symptomatic,
but it's a small lesion.

Remember that problem of having very small lesions
with symptoms, we don't send them to surgery
as a lot of people do.

We actually do an FNA
and we look for the presence of mucin high ca
or not tumor markers.

Positive cytology, again, 50% chance for that.

And some of these are sent to
that special lab under the research protocol.

And based on that, we will put them in resection.

If it's an IPMN or immune cystic neoplasm,
or they will go to observation, I will tell you
how frequently we follow those.

When the region is asymptomatic and small, we observe them.

We don't even aspirate them when lesion is asymptomatic,
but it's larger than three centimeter.

In the past, they would be sent to surgery.

But how can you send an asymptomatic patient
for ripple procedure at something very hard?

And so we aspirate those lesions,
and again, best based on what we get, we differentiate
between resection and observation.

So the ones that are put in observation algorithm,
that's what we use when the lesion is small,
very small as than a centimeter.

We scan the patient every two years for a total
of two ti of four years.

So two times when they're stable, we stop.

There's no data for that.

I just wanna mention that there's no data to prove
that it's a safe thing to do.

But the a CR guidelines actually are even
they say lesion is than centimeter.

You scan them once after two years,
and if it's stable, you stop.

So it's a little bit less liberal than those When the lesion
is approaching two centimeter, one to two centimeter,
we scan 'em every year twice.

And then one more time after two years, when the region is approaching three
centimeter, we scan them more shorter time intervals
for six months, and then yearly for another three years.

And stable after four years,
automatically gets the patient out of the algorithm.

And also this comes up frequently.

We're actually doing a research protocol right now.

What do you want to use for follow up?

I believe an MRI because I think it's much better technique
for cystic pancreatic lesions.

But we do an express protocol.

We don't use gadolinium.

We just scan the patient with a few
T two edit sequences.

The research protocol we're doing right now,
we send every patient that we see on MR to ultrasound
to see if we can see the lesion,
because obviously if we can see the lesion,
why would you want to use high expensive long,
long tests if you can follow these patients with ultrasound.

So that's something we're looking into.

And also that's something I don't understand at all.

There are patients that it seems like they're going on
a trip on a field trip.

They're 92 years old,
they have a 8 million cystic pancreatic lesion,
and every year they come back to institution
to get their cyst reevaluated.

And even if a double in size,
nobody would take an eight 92-year-old
to get a whip resection.

So it's debatable if you should
follow those patients too.

Conclusion

So in conclusion,
cystic pancreatic tumors are extremely diverse.

Group of lesions and neoplasms especially.

A lot of these have
however, very specific imaging appearances
or r features, especially when they're larger.

Think about the presence of hemorrhage.

Think about the presence of a capsule,
think about the communication with the duct or not,
and use this together with your suggestive democratic data
to make the right diagnosis.

So people know that work with me.

You can never call immune cystic neoplasm in a
male patient when I'm around.

They don't believe it because it should be nearly
exclusively in female patients.

So and that's important thing to remember.

And then also these management strategies
and follow up guidelines that are extremely complex.

But the recommendation for me to you is to work
with your gastroenterologists
and pancreatic surgeons to come up with a system that works,
that you feel is accurate for your patient population.

At least you will treat your patients all in a very
similar matter.

Thank you very much for your time.