0:01

So this patient is a 50-year-old female who presents

0:04

with right upper quadrant pain and had got some prior

0:08

imaging that was concerning for findings in the gallbladder

0:10

and so wanted an MRI to really have a better look at it.

0:13

And so we'll start off this vignette by

0:15

looking at the T2 non-fat-saturated image.

0:19

Let's just scroll through this image to

0:21

start with to just get an appreciation of

0:23

really everything that's going on, because there's

0:25

a little bit, uh, things going on over here.

0:28

So up and down we've scrolled

0:29

through, and so what do we see?

0:31

Let's focus on the gallbladder to start with.

0:33

So I'm going to focus on this image.

0:35

We see quite a large gallstone.

0:38

We see some smaller gallstones within this.

0:40

We also see layering sludge within this gallbladder.

0:44

This gallbladder looks distended.

0:46

We can see the cystic duct beautifully here.

0:48

We can see some layering sludge within

0:49

the gallbladder neck there as well.

0:52

Those are all good things to see.

0:55

We've seen them before, but however, if you look at the

0:57

fundus of the gallbladder, this is very, very abnormal.

1:01

Up to about here is okay.

1:03

But after that, there is marked thickening

1:06

of the gallbladder fundus, and it has

1:10

that sort of T2 signal that is worrisome.

1:14

You know, that has that intermediate T2 signal that

1:16

would make me worried for an underlying neoplasm.

1:19

Whenever I want to evaluate, you know, the true T2

1:21

signal or a more accurate T2 signal of any lesion,

1:25

I look at the T2 fat-saturated images, which

1:27

I have up here now, and we'll ignore the other

1:30

findings in the gallbladder, and we can see this

1:32

sort of signal here.

1:33

That's a very worrisome signal that is often

1:36

indicative of an underlying neoplasm.

1:39

Look at the T2 coronal images, non-fat-saturated.

1:42

Again, you can see the gallstones, a lot of the

1:44

other benign findings that we saw, but also, as

1:47

you scroll in, if we were to window this

1:51

just a little bit, you can see marked, marked

1:54

thickening, really centered at the gallbladder fundus.

1:58

And that itself would be worrisome for a neoplasm.

2:02

But let's see what this looks like on our post-contrast

2:04

images because we want to make sure that if it indeed

2:07

is a neoplasm, it should have some degree of enhancement.

2:10

We'll start off by looking at the T1 axial

2:12

fat-saturated pre-contrast images to make

2:15

sure there's no internal hyperintense

2:17

content that we need to watch out for.

2:20

Let's just center this a little bit so we

2:23

can see the biliary sludge is hyperintense.

2:25

The actual mass itself really doesn't

2:28

have any hyperintense T1 content.

2:30

And then when we give contrast, we can see that

2:35

indeed there is enhancement associated with this mass.

2:39

It's not a lot of enhancement, but

2:42

it's not no enhancement, right?

2:44

So that has that sort of, it's brighter than

2:45

it is on the non-contrast image.

2:48

So that tells us that this is an enhancing mass, and

2:53

this turns out to be a gallbladder adenocarcinoma.

2:58

Primary neoplasm of the gallbladder. So if we

3:00

were to look at all the primary neoplasms of

3:03

the gallbladder, about 90 percent of them will be

3:05

adenocarcinomas. Epidemiologically, they're most

3:09

commonly found in females above the age of 60.

3:12

But, you know, these can occur

3:14

in sort of any patient.

3:16

And there are different appearances

3:17

that have been described for

3:20

this gallbladder adenocarcinoma.

3:23

You can certainly have masses that completely

3:26

replace the gallbladder, such that it's very

3:28

difficult to see even a normal gallbladder.

3:32

We can have irregular gallbladder wall

3:34

thickening, which can be focal, as

3:36

seen in this case, or quite diffuse.

3:38

You sometimes can even see it just as a polypoid

3:41

mass that's protruding into the gallbladder lumen.

3:44

Often, these are infiltrative masses with

3:47

invasion of the liver parenchyma, as well as

3:50

portal lymphadenopathy in the portal region.

3:54

This instance actually had large

3:55

nodes in the portal region.

3:57

You can see over here, at least one of

3:59

these nodes is probably causing some

4:00

mass effect upon the gallbladder lumen.

4:03

Bile ducts, or at least their soft tissue extending

4:05

from it, that's encircling the bile duct, resulting in

4:07

that marked biliary ductal dilatation that you see.

4:11

What are some risk factors that place

4:13

patients at increased risk for getting this?

4:16

There's a bunch of them that have been put out there.

4:18

Certainly, patients who have a history

4:21

of prolonged chronic cholecystitis,

4:23

this may be something that can develop in that setting.

4:27

We talked a little bit about polyps as well

4:30

and how some of them can be premalignant.

4:32

And so particularly polyps that are greater

4:34

than two centimeters, they can result

4:36

in having an adenocarcinoma develop.

4:40

And another risk factor that's been

4:42

associated with developing adenocarcinomas

4:45

is gallstones, but particularly not just

4:48

having gallstones, but having large gallstones

4:50

that are greater than three centimeters.

4:53

It's hard to know if that's really a risk factor, given

4:56

that so many of the patient population have gallstones.

4:59

So this just may, you know, gallstones may just be a

5:02

finding that you see, and adenocarcinomas are

5:05

something that happens to develop separate from that.

5:07

But there have been at least a couple of studies

5:09

that have shown that when you have large

5:10

gallstones, for example, like this one, greater

5:12

than three centimeters, that there may be an

5:14

increased risk for developing adenocarcinoma

5:17

in that setting.

5:19

However, I don't believe anyone is advocating

5:21

for taking out gallbladders prophylactically

5:24

on the basis of just having large gallstones.

5:27

But that is something that perhaps, as radiologists,

5:30

we can sort of pay close attention to the gallbladder

5:33

of those patients who have large gallstones to

5:35

make sure that the wall is regular and does not

5:38

develop any areas of thickening that can then develop

5:41

into a full-blown adenocarcinoma of the gallbladder.