I talked about everything that I think I wanted to as far as what this looks like for U.S. guided ablation, what the indications are and contraindications. And if you remember, I had two slides that were highlighted by red lighting that said very important, and it was who's right for this, who's wrong, and what are the indications and contraindications. So, we're going to see who is listening, and we're even going to get the faculty involved in this a little bit. So, with the first case, now, before I kind of told you that I'm a little suspicious of cases sometimes when they look really great, or what I call conference bias, which is to show off your best cases, and so I had some cases to show, and my interventional fellow kind of busted me for that, said, you know, this looks like your best stuff. So, she went back and made me stick to cases that have come through the clinic in the last two months. So, this is like real life stuff here, not selected, and I hope that it's helpful. So, this is the Penn State Pancreatic Cyst Clinic, and we get a lot of referrals, not just for cysts, but to consider ablation. So, here is a case that came in in August. 76-year-old male, minimal medical history seen in the Penn State Pancreatic Cyst Clinic for consideration of EUS guided pancreatic cyst ablation. Okay. Let's play this video. We'll run through this enhanced MRI and see what you think you might want to do. Small cyst in the tail, non-dilated duct, I won't say anything else. Okay, you need to see that again. We'll see what people think. Okay, who wants to be bold and tell us what you think the next best step might be for this patient? Was it 23.8 largest? Yeah, the largest you saw was a very oblong dilated side branch that was very narrow, but in the other axis measured 2.3. What do you think? This gentleman says, no ablation. Other choices? I see Andy saying, yeah, I agree with that. No ablation. John says no ablation. Okay, let's see what the right answer is. Yes. Continue MRI surveillance per ACG or for Cougar guidelines. Great. This is not for, this is a low risk cyst. These are dilated side branches. These are low risk IPMS. This represents the majority of cases. No ablation is indicated here. You can only introduce risk into this person's life. Be reassuring to this patient. Explain the natural history. Explain the guidelines. Continue. Life goes on. All right. Next case. A little different, 75-year-old male seen in the clinic, history of low-grade CLL, a few other medical conditions, nothing severe, underwent EUSFNA in 2018 with a diagnosis of IPMN based on serologic radiographic FNA chemical and cytologic analysis. Now has two high-risk features, a size greater than three centimeters and progression in time of three millimeters over a calendar year. Let's see what this looks like and see what you might want to do. Okay a little different this time. What do you think? We have a three and a half centimeter cyst. Looks a little unilocular. There were smaller cysts throughout the pancreas, not uncommon. There's an IPMN field defect but the dominant lesion is greater than three centimeters and it's growing. Looks unilocular. What do you think? Patient is not a surgical candidate, right? This patient is a surgical candidate. Yeah, consistent with IPMN. Okay, went through the multidisciplinary opinion. They've heard all their options, sitting me in clinic discussing whether ablation is appropriate. What do you think? It's in the neck. Would that help? It's unilocular. Looks like unilocular. That's important. The size is more than three. I mean obviously based on your talk ablation, I mean you have to discuss. This is the discussion. Give them the option that it is an option. Are you going to offer it to them? Not me personally. I feel your reservation. Not me personally. Get out there, let them know. John? Yeah, you'd offer it to them. Yeah, you like that. He wants to enroll in CHARMP too. I like that. Okay, yeah, in fact that's what we did. We offered this patient. This is a good candidate. It fits the criteria we talked about previously. So let's see how we did. This is the US guy, chemo ablation of that case. We had a septation. Not really that apparent on MRI, was it? But we want to get both of those, both of those chambers access so we can chemo ablate both of them. My mouse is giving me a little problem, so want to make sure that we've gone back and forth through that septation, open both sides of the cyst. We're going to chemo ablate both, meaning we're going to aspirate both sides and then we're going to fill it with chemotherapy. If we do it right, we should totally aspirate this cyst and fill it with chemotherapy and we should have a complete what sign? Snow globe sign. And in fact that's what we do. We completely fill this lesion. He has a good ablation effect. He had two ablations separated by three months and let's see how we did. Here's his follow-up. Last month, came in for repeat MRI at one year after his first ablation. That's the small lesion you saw before. That's what's left, eight millimeters worth of cyst. That can be followed over time. That meets the criteria greater than 90% reduction, which is complete ablation. Let's see that again. I'm going to stop it at the ablation because somebody said hold it. He tried to get away with something there. It didn't show us everything. There it is. So actually my fellow, Nerose, measured everything here. Actually the residual cyst is right here. So that's eight millimeters. This is some sort of T2 artifact here, but the residual cyst is there. So he's had a nice complete ablation. One year, that would satisfy the definition. He goes into routine surveillance post ablation, which would be one year annual surveillance. Okay, here's another one. 76 years old male, significant comorbidities referred for consideration of US guided ablation. Okay, you're seeing a theme here. Let's take a look at him. Okay, you see this three and a half by two centimeter cyst What do you see that either makes us a good ablation candidate or something you want to be thoughtful about? Any ideas? Very good. So this is a three and a half centimeter by two centimeter cyst and It looks good for ablation. However, this is a enhanced MRI. I'm trying to get it to stop at the right place here there we go and You'll see right here It does not want to pause for me Let's try it again right here This mouse it's a little schizophrenic. There we go Now not in the right place. There we go. We're gonna we're gonna be satisfied with that right here You'll see that this area here, which is about About four millimeters by eight millimeters is enhancing see how they this is and this is actually a t2 sequence So the fluid filled part of the cyst is actually black, right? but it's an enhanced MRI and you that's important because Not only are you looking at t2? Images to describe the cyst and look to the ductal anatomy But you're switching over to t1 enhanced images to look at the quality of the tissue Around the cyst if you have thick enhanced quality of that cyst that's that's MRI High risk feature of a mural nodule and this fact this gentleman has such a thing Right here. And in fact, although this FNA showed no signs of dysplasia on FNA This is an enhancing mural nodule This should be considered for surgery first and ablation only if that's not an option or the patient refuses as a matter of fact He saw surgery because of comorbidities and his own wishes. We're moving forward with ablation, but this is a surgery first issue ablation second Okay Correct see the heart and the liver well enhanced and then you see that enhancing quality to the cyst Yeah So this is a this is a common misstep of MR Surveillance of pancreatic cysts people get used to seeing the t2 images and that's all they see There's an important correlate to that which is you asked for enhancement. You need to look at that enhanced phase The flare is often the best or the enhanced T1 images and you're looking at the entire cyst you're looking for a thick Enhancement that suggests that you have Some amount of dysplasia starting to pile up causing a so-called mural nodule. That's important Not every radiologist is really going to know to look for that So it's reticent on you that if you're in this business is to look at your own images Make sure is it there is it not if it is it changes management. It's a really important part of MRI surveillance Okay 84 85 years old comes in significant comorbidities referred to our clinic for consideration of us guided pancreatic cyst ablation All right, let's see what you want to do with this one Sorry, I had a question for clarification. Regarding the sizes of the cysts, because I think early in your lecture you mentioned 2 to 6 centimeters is what you go for. What's the concern if it's larger than 6 centimeters? I can understand if it's smaller than that, but what's the concern for the larger ones? That's just our standardization. To tell you the truth, I've treated cysts larger than that. But if you do the calculations for volume of a cyst, you know, a 5 centimeter cyst, you know, four-thirds pi r cubed, that calculation, it comes out to 53 cc's of fluid. I mean, you just get to be in a technically challenging position if you're expecting an 80 cc filled cyst to ablate with a maximum of 25 to 30 cc's of ablative cocktail. I mean, you really want to be thinking about a different approach in such a large lesion, surgically primarily. If that's not an option, we're willing to do anything, but that's surgery first, ablation later. Okay, what do you think about this? Let me just add one more thing. In studies that I published and then the Koreans published, one of the risk factors for lack of response is a size over 5 centimeters. So, for the reasons he mentioned, the larger you get, the less likely you are to have that contact with the lining of the cyst, which is really what your goal is. So, that's why I don't treat cysts over that size. Yeah. Okay. What did we see? Do we want to ablate it? Do we not? No ablation. Somebody thought they saw maybe a dilated main duct. Is that what you're hearing? No. Okay. Yeah. There it is. There it is again. Remember, in the Fukuoka and the ACG guidelines, in the setting by PMN, main duct of 5 millimeters or greater is considered a worrisome feature. One centimeter greater is stigmata of malignancy, right? That's what you're looking at here. Really, you're not going to be effectively ablating this cyst. You got to know what is not a good candidate, and remember, that's on the relative contraindications list for this reason. This is surgery first. Now, John and I have both ablated main ducts, but those are real case-by-case basis after a lot of thoughtful planning and without other treatment options, but generally, stay away from main duct dilation. That's the highest grade pathology you have, and technically, that is non-amendable to ablation in most cases. Okay? So, that's four cases. I think we all did pretty well there. Nobody made a huge mistake. We all stayed out of the problem. Thank you.

US-guided ablation

pancreatic cysts

patient selection

enhancing mural nodules

imaging findings