0:01

This patient is a 65-year-old female and history

0:03

was provided was just to assess the gallbladder.

0:06

And so we got an MRI to further

0:10

evaluate the gallbladder.

0:12

And I'll start off with the

0:13

axial T2 non-fat saturated image.

0:17

I'll scroll through the image just to give

0:20

you a sense of sort of what's happening here.

0:22

Up and down.

0:24

And so lots of abnormalities

0:25

in the right upper quadrant.

0:26

So let's focus on that.

0:28

Let's maybe center this a little bit, zoom up

0:31

a little bit so we can really, really have a

0:32

good look and see what's happening over here.

0:37

So the first thing I noticed when I sort of

0:38

look at this case is that I really don't see

0:40

a normal-looking gallbladder at all, right?

0:43

And this is kind of what the gallbladder should be.

0:46

It looks like the shape of the gallbladder.

0:47

Its signal is not that bright T2 hyperintense signal.

0:51

Okay.

0:51

Nor do I see areas of layering T2 hypointense.

0:54

It just looks like intermediate T2 signal

0:56

that's replacing the whole gallbladder.

0:59

Maybe a small portion of the gallbladder has normal

1:01

signal over here, but the rest of it is very abnormal.

1:04

And associated with this, I see this sort

1:06

of intermediate signal and this bulge that's

1:09

going out into the liver parenchyma as well.

1:13

And so really a lot of this

1:15

is abnormal in this instance.

1:17

As we scroll through these images, we

1:18

can also see that there's a large node,

1:21

a lymph node in the porta hepatis.

1:23

And it has very heterogeneous signal intensity

1:26

and you can see that the signal intensity within

1:28

it is quite similar to the signal intensity of

1:31

what we're seeing in the gallbladder itself.

1:34

Of course, I'm going to evaluate the signal intensity

1:36

better on the T2 fat saturated images and the axial

1:39

plane, which is what I have up here. And we look at

1:42

it again, very tough to see a normal gallbladder.

1:46

It has that very intermediate T2 signal.

1:48

We again can see some of that signal

1:49

extending into the liver parenchyma, maybe

1:52

a normal, small amount of bile over here.

1:55

We can see that there is some adenopathy in

1:57

the porta hepatis system, noted here with,

1:59

again, very similar intensity to whatever

2:01

else is going on in the gallbladder.

2:05

The key then here is to see if

2:07

whatever's happening is enhancing.

2:09

I'm just looking at these images themselves.

2:11

I'm worried about a neoplasm, but I want to make sure

2:14

that there's some enhancement associated with it.

2:16

I'll start off by looking at the T1 axial fat

2:19

saturated images without contrast to make sure that

2:23

there's no hyperintense T1 content that I need to be

2:26

aware of prior to looking at the post-contrast sequences.

2:29

As you look at that location, everything looks

2:33

pretty hypointense in its signal intensity, so we

2:35

don't need to worry about hyperintense content.

2:38

I can move right along to my axial

2:41

T1 fat saturated post-contrast image.

2:44

We do them in three phases.

2:46

Up here I have the equilibrium

2:48

phase, more relatively more delayed phase.

2:54

I'll zoom up and as we scroll through these images

2:56

we can see that this gallbladder demonstrates

3:00

a very, very heterogeneous enhancement.

3:03

And all of it is really demonstrating

3:04

heterogeneous enhancement.

3:06

Certainly this portion over here, and

3:07

that little outpouching into the liver

3:09

as well, demonstrates enhancement.

3:11

Right, if it was not enhancing, you

3:13

would have a signal void, much like the

3:14

bile over here, which is not enhancing.

3:16

You're not seeing that level of hypointensity or

3:18

that blackness, you're seeing sort of gray signal.

3:20

And to me, that tells me that there is

3:21

some level of enhancement, albeit low

3:24

level enhancement, in that location.

3:26

The adenopathy as well demonstrates

3:28

similar enhancement in the porta hepatis.

3:32

This again is an example of an adenocarcinoma

3:34

of the gallbladder, and the reason I wanted

3:36

to show this case is that we talked a little

3:39

bit about the different appearances of

3:41

adenocarcinoma and that it could be focal wall

3:43

thickening, diffuse wall thickening, polyploid.

3:45

It can also be just a large mass that's

3:49

replacing the gallbladder and that's

3:50

essentially what we're seeing over here.

3:53

And oftentimes it's associated with liver

3:55

invasion, which is what we can see here, as

3:57

well as adenopathy in the porta hepatis in

3:59

particular, which is what we can see over here.

4:02

So this is another example of an

4:04

adenocarcinoma of the gallbladder.