 Hello, my name is Dr. Bukhya Tejasvi and I'm a third year radiology decedent from TNMC and we're well-narrated hospital. And the topic for my paper is, Imaging of Extrapancreatic Neuroendocrine Cuminous. So, the introduction is, the gastroentropancreatic neuroendocrine cumulus are a heterogeneous group of neoplasms that arise from cells of the diffused neuroendocrine system. And these account for about 1.5 of all GI and pancreatic neoplasms. And coming to the GI tribe, the ileum is the most common site and the colon is the least common site. And it is can all can produce metabolically active hormones, amines, and clinical manifestation of these lesions can be due to their hypersecretions. The more non-functional tumors frequently manifest as locally advanced disease like bowel obstruction, mass effect, or with metastasis, especially to the liver. The aim of my study is to evaluate extrapancreatic GI neuroendocrine tumors using various imaging techniques. And I have taken three cases and we have performed various modalities on this patients, especially the ultrasonography, contrast enhance ultrasonography, CT, MRI, and also the BGM studies. And further, all these cases were subjected to EUS-guired biopsy and histopathological correlation was done for the formation of the diagnosis. And my first case is about a 15-year-old female who is not an on-case of any comorbiditis, came with complaints of epigastric region pain since two months, intermittent vomiting, episodes since 20 days, alloys discoloration of sclera since 15 days, and associated with on-and-off low-grade intermittent fever and generalized weakness. On general examination, there was itchress and pallor, the vitals were stable, systemic examination was normal. The blood investigations showed raised liver enzymes and also raised total and direct bilirubin. And first, primarily ultrason was done and it has revealed a well-defined lesion in the D2 segment of the deodorinum with mild internal vascularity. And here we can see it caused upstream dilatation of the CBD and also central and peripheral IHBRD. And immediately to this lesion, there were two lymph nodal masses adjacent to the D2 segment and it is inferior to the head of pancreas. And further, we have done a contrast in an ultrasonography and here we can say this is the lesion and to the right and to the left is the meds and further left is IOTA. And time-density curve was generated with the help of automatic software and we can see early arterial enhancement with delayed washout and this follows enhancement pattern similar to the abdominal IOTA. And here we can see on the left, on the right side, early arterial enhancement in early washout compared to the abdominal IOTA. And considering these features, a possible diagnosis of neuroendocrine tumor was made. And further, MRI was done for confirmation of the diagnosis and also for the better delineation of the biliary tract. Here we can see single-shot MRCP reveals a well-defined mass in the anvil of the waiter which caused upstream dilatation of CBD and also mild central and peripheral IHBRD. And this mass on T1 it appears hyper intense. And this mass also shows different restriction pattern on DWI ADC. And also this lymph nodes show this and it has homogenous mild post-contrast enhancement. And following this MRI, ERCP with standing was performed and scope was not able to pass beyond B2. Further, we have done medium studies to look for the integrity and involvement of the D3 segment. Here, as we can see, there is a well-defined radio-opacity bulging to the D2 segment of the deorinum, which causes mild narrowing. But however, the medium is seen to pass distally. And next to gallium, IOTA PET was also done which revealed areas of high SU in the cochlear region and also in the adjacent lymph nodes. And further, we have done an US-guided biopsy which has confirmed the diagnosis of the neuroendocrine tumor. And here in this patient, the KI67 was about 4 to 5 persons, which reveals that this is a moderately differentiated IOTA. And next, after the diagnosis of IOTA was made, the patient was given PRRT, namely Peptide receptor regionally therapy. And the patient responded well to this treatment. And also on the further scans and the follow-up scans, we have seen there is a reduction in the clinical symptoms and also a reduction in the size of the lesion as well as lymph nodes. And my next case would be of a 61-year-female who came with a complaint of pain and abdomen since one year. Pain was localized to epigastric region, intermittent aching and progress gradually. It was associated with multiple episodes of vomiting. And the patient was subjected to CECT. And here we can see a well-defined mass seemed to be arising from the second part of deorinum with suprapankitic extension and ill-defined papillons with the head of the pancreas. And the mass shows intense post-contrast enhancement. And the same thing is shown over here too. And there are few, like two sub-santimetric-sized hypoenzyme lesions seen in the segment 8 of the liver, and we suspected them to be hepatic metastasis. And considering these features, we are given a diagnosis of neoplastic etiology, likely NET more than adenocarcinoma. And then a U.S. ghetto biopsy was done and further confirmed that this is a NET. And my third case would be of a 71-year-old female who presented with a complaint of pain and abdomen, chronic diarrhea, blood in stools and weight loss in 10 months. And on CECT, we can see an ill-defined soft tissue density mass lesion seen in the right paracolic cutter on lateral aspect of the distal ascending colon, which is seen to displace the colon immediately. And we also can see it is seen to be supplied with dilated torches medlecolic artery and drained by medlecolic wing. And this mass shows homogenous post-contrast enhancement. And this is a sagittal image showing thombosis of the intratumoral draining wing. And in the coronal images, we can see multiple dilated collaterals with the peripancreatic lesion near the head of the pancreas and medial to the lesion. Considering all these features, we have given a possible diagnosis of neuroendocrine tumor. And later, we have done an EUS-grade biopsies in which this conformed NET. And on the high-power image, there was nuclear pleomorphism with xylbarin appearance. And next, we have also seen a Pneumonucleidine fibrin thrombus in an intratumoral vein. And my conclusion would be as follows. So in the first case, which is an ampillary NET, apart from the CT and MRI, the time intensity curves which were derived on CUS, it added as more in the diagnosis of the NET. And the CUS can also be further used in the follow-up of these patients, especially in this post-radiation therapy. So the changes in the time intensity curves can be compared and thus we can see the treatment or response to the treatment. And thus the patients will be excluded from this unnecessary radiation via CT or VET. And in my next case, that is the second case that is NET from B2 segment, apart from the enhancement characteristics, the supra pancreatic extension and loss of fat planes of the pancreas and also the hepatic metastasis indicated the aggressiveness of the tumor. And coming to the next one, Coulomb is a very uncommon site for NET. However, in my case, that is ascending Coulomb NET, the CT enhancement pattern and supply with the adjacent directed tortuous medial polyp artery added in the diagnosis of NET. NETs are usually known to be associated with major vessel thrombosis. But however, in my third case, which is ascending Coulomb NET, intratumoral vein thrombosis is seen both on CT and also HP images. So in all these cases, we have done HP conformation along with using some specific stains for NETs, namely synaptophycin and chromogram. So overall, neuroendocrine tumors are usually small in size, solid and hypervascular. If they're larger in size, that is, that we take the criteria as more than two centimeters, they're often heterogeneous and could have areas of necrosis and occasionally could be solid cystic or completely cystic. On CT and MRI, they appear hyper-enhancing in the arterial phase. So MR techniques such as DW and ADC, ADC mapping now serves a complementary role to other MRI sequences, particularly for localizing non-hypervascular tumors. So there is a study done by Wong Wai in 2011, and that showed an inverse correlation between tumor KI67 labeling index on pathology and ADC values, and thus supported the role of DW in helping predict tumor biology. There's also significant association between CUS, KI67 and grade of the tumor. So we can see low-grade tumors are homogeneously hypervascular in CUS, whereas high-grade tumors are inhomogeneous. Neuroendocrine tumors are associated with tumor rhombosis of vessels in 5% of cases, majorly involving major veins like IVC's pleniquine and hotel vein. These are my references. Thank you.