0:01

So this patient is a seven-year-old female.

0:03

Got an ultrasound in which they saw an

0:05

indeterminate lesion in the gallbladder.

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They weren't sure whether it was a

0:09

tumor or potentially a tumor or a cyst.

0:12

Something we've talked about in one

0:13

of the prior clinical vignettes.

0:16

So we got an MRI with contrast

0:18

with and without contrast.

0:19

And we'll start off by looking at

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the T2 non-fat saturated images.

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I'll just window this a little bit

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so we can see some of the findings nicely.

0:29

We'll zoom up a little bit as well, and let's

0:30

just scroll through the gallbladder just to

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give you a sense of what's happening there.

0:36

And we'll stop about here.

0:37

So a bunch of things happening with this gallbladder.

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Certainly things that are, we know that are

0:45

going to be benign is sort of this layering

0:46

content within the gallbladder itself.

0:49

We've seen that to be sludge or

0:50

concentrated bile in the past.

0:51

We're not going to be worried about

0:52

any of that, but this is sort of the

0:54

abnormality that I'd like to focus on.

0:56

And you look at it, it looks like it has sort of

0:58

this intermediate signal on the T2-weighted images.

1:02

And maybe a portion of it is extending outside of

1:06

the gallbladder wall, certainly thinning it over

1:08

here, but nothing that's frankly invading the liver.

1:11

And so let's investigate that further, look at

1:12

the T2 fat saturated images to get a better sense

1:16

of what the signal of this lesion looks like.

1:21

And so we can see it over here, with pretty

1:24

intermediate signal and a signal that

1:26

should make one worried if you look at it.

1:29

Let's look at the pre-contrast T1 signal because

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the key here is, is this thing enhancing?

1:34

If it's not enhancing, think about things like

1:36

tumor or bile sludge. If it is enhancing,

1:38

you've got to be worried about a tumor.

1:41

And this is a signal here.

1:43

Maybe intermediate in its signal

1:45

intensity.

1:46

Stuff that's concentrated down

1:48

here is more hyperintense.

1:50

And let's look at the post-contrast images.

1:54

And so this is that post-contrast image.

1:56

And, you know, I have to say, I read

1:57

this case several years ago now.

1:59

And I was very, sort of, starting off as an

2:02

attending, and I really did struggle with this

2:04

case, and many of you may be looking at this case,

2:06

and it's clear-cut to you, and I think

2:08

that's terrific, but to any of those who are

2:10

still struggling, just to let you know, I struggled

2:12

a lot through this case, and my question really

2:15

was, you know, is there enhancement within this?

2:18

And I looked at the subtraction images and

2:21

you know, it just looks like a lot of it is

2:23

not enhancing, and so that was going to be the

2:25

key finding for me. If it was enhancing, it's

2:27

going to be a tumor. If it's not enhancing,

2:29

it's going to be bile sludge, and they

2:31

have radically different treatment options. So I'm

2:36

sort of looking at this on different sequences.

2:38

Is this enhancing or not?

2:39

I looked at the subtraction images, and

2:42

you know, it looks like a lot of it is not

2:43

enhancing, but some of it is enhancing.

2:45

So I really wasn't sure how to

2:47

sort of put all of this together.

2:50

And then, you know, this just obviously comes with

2:52

experience, and you realize that, and this was a

2:55

very instructive case for me. For this finding,

2:57

is that this is what non-enhancement looks like.

2:59

This is bile.

3:00

This has no enhancement.

3:01

It is jet black, hypointense, really dark.

3:06

Yes, this lesion here may not

3:08

be enhancing as briskly as, say, some of

3:11

the organs or other lesions we see, but it

3:13

certainly doesn't have that jet black signal.

3:16

And so what that tells me is

3:17

that this indeed is enhancing.

3:19

It may not be the most robust enhancement, it may

3:21

be low-level enhancement, but it is enhancing.

3:24

And things like bile sludge

3:26

or any other benign finding like

3:28

that should have no enhancement at all.

3:32

And so, given that finding, this was

3:35

interpreted, therefore, as a neoplasm.

3:36

And this did turn out to be a neoplasm.

3:39

And in fact, it was an unusual histology of

3:42

squamous cell carcinoma of the gallbladder.

3:45

If you look at all gallbladder primary neoplasms,

3:48

the vast majority will be adenocarcinomas.

3:51

A minority will be the squamous cell variety.

3:53

This happened to be one of those.

3:55

And one of the other findings to always look for,

3:57

something I've talked about with primary neoplasms

3:59

already, is the presence of liver invasion, which

4:01

this did not seem to have, but also for adenopathy.

4:05

And so if you look at this closely, you'll

4:07

see that there is a node in the porta hepatis

4:10

right over here that really cinches the

4:13

diagnosis of this being a gallbladder neoplasm.

4:16

In this instance, as I mentioned, a

4:18

squamous cell carcinoma of the gallbladder.