 So let's go to pancreatic neuroendocrine tumors now pancreatic neuroendocrine tumors are not as common as pancreatic ductile adenocarcinoma but their numbers are increasing and one of the reason is we have now patients who have risk factors and you know especially MEN syndrome or VHL these you know incidents we are detecting more of these young adults and kids who are high risk of developing pancreatic neuroendocrine tumors and you know the most majority like 70% are sporadic so we don't know who to screen for but we can screen in this 10 to 30% of patient who might have high risk so that's where screening is currently offered the good news is with curative resection patient do very well more than 15% survival even with metastasis they do pretty well after a treatment so the biology is much more favorable and I think it comes back to why Steve Jobs did much better than Patrick Schwasey because the biology is more favorable now these are the two survival curves this is the data from my previous institution at MGH what you can see is there are clear 10 year overall survival benefit in patients who have been operated versus those who are not been operated so that tells you why we respect all neuroendocrine tumors if even if when they are asymptomatic if you incidentally detect which is majority of neuroendocrine tumor these days we detect them on imaging so tumor they are still resected but not the small one less than 2 centimeter size tumor don't have as much benefit survival benefits so in less than 2 centimeter tumor if incidentally detected in older adults those are ones that are followed now what are the imaging features now our traditional textbook have taught us that neuroendocrine tumors tend to be hyper vascular that is true in functioning tumors functioning tumors tend to be small they are hyper vascular and their metastasis are also hyper vascular so when you are detecting functioning tumor you need to be diligent both with your protocol as well as search pattern because they can be multifocal they are tiny they could be less than 1 centimeter and they can have symptoms so it's critical that you have a diligent search pattern in patients who have high risk for neuroendocrine tumor including VHL or MEN patients majority of patients actually are non-functioning I would say 60 to 70 percent of neuroendocrine tumors fall in a non-functioning category and these are either incidentally detected or due to the mass effect the large size or local invasion or metastasis we might see them and what you notice here is these tumors tend to be more heterogeneous they tend to be larger they need tend to have cystic changes or necrosis and some can masquerade as a primary cystic tumors of the pancreas now since they are malignant they are all resected whether you call them MCN or you call them neuroendocrine tumor they are taken out so as long as you don't call them pseudosist of the pancreas so that's majority are now they are locally invasive so vascular structure involvement they go to lymph nodes first and the metastasis can go to liver peritoneal meds or distant meds are otherwise uncommon in the non-functioning tumors now the question is does the benefit of surgery extend to all types of tumor because we are picking a lot of these and what we learn from the same data actually if the tumor is under one centimeter and patient has no symptoms the survival benefits between operated and non-operated is not much when we go to under two centimeters kind of a similar trend once the lesion go more than two centimeter and three centimeter then there is a differences in the survival so based on this the new guidelines suggest neuroendocrine tumor when incidentally detected and if they are less than two centimeter size they are biopsied initially because we can't say on imaging hundred percent they are neuroendocrine and then they are followed with imaging we don't reject them less than two centimeter tumor now our job is not only detecting these lesion but also making sure they we characterize the masquerading lesions one of the common area for neuroendocrine tumor incidental tumor is body and tail of the pancreas where we can have intra pancreatic spleen or splenium whatever we you want to call it they can be hyper vascular as we know splenic tissue can be and I think you need to always question yourself if this lesion is splenial or it's a neuroendocrine tumor you want to save patient biopsy because you know biopsying a tail lesion through endoscopy is not that easy and how do you characterize we all know it's plan you'll follow the enhancement pattern of spleen on CT this can be tougher on dual energy CT it's much easier on material density iodine you can see it's exactly similar distribution of iodine but MR is diagnostic we rarely do nuclear medicine studies to characterize splenial and MR you have all signal characteristics on all sequences splenial follows that of a spleen and I'm sure most of you will have no challenge in characterizing though but you need to be careful sometime in your mind you might think you are dealing with splenial and and taking a more diligent approach is important other lesion that can be hyper vascular or metastasis from needle cell carcinoma occasionally very small microcystic neoplasm or sponge variety of microcystic neoplasm can masquerade as a neuroendocrine tumor on and MR is pretty classic there especially the delayed phase images and T2 weighted images now this is what you need to be careful you know this is a patient who had some symptoms a lesion was detected in the tail of the pancreas it was considered like you know excessive spleen or intra pancreatic spleen because on CT it looks similar to spleen MR was done MR you can see the signal doesn't match that of a spleen even on T2 weighted images it doesn't match exactly there is more heterogeneity and on enhancement it enhances difference so MR is always much better than CT whenever in doubt you should get an MR and this is was indeed a neuroendocrine tumor of the pancreas so as long as you know that you need to categorize the lesion which might masquerade as a neuroendocrine tumor but also being delayed