Gallbladder polypoid lesions >15mm as indicators of T1b gallbladder cancer risk

Diseases of the Gallbladder and Biliary Tree

Diseases of the gallbladder include a spectrum of gallstone diseases (cholelithiasis, cholecystitis, choledocholithiasis, and cholangitis), cysts, polyps, and malignancy. In this review, we present the incidence, risk factors, clinical presentation, diagnosis, and treatment of these various conditions. Importantly, we report when more urgent referral is indicated, as well as red flags that warrant further intervention and/or management.

A Bayesian network prediction model for gallbladder polyps with malignant potential based on preoperative ultrasound

BACKGROUND

It is important to identify gallbladder polyps (GPs) with malignant potential and avoid unnecessary cholecystectomy by constructing prediction model. The aim of the study is to develop a Bayesian network (BN) prediction model for GPs with malignant potential in a long diameter of 8-15 mm based on preoperative ultrasound.

METHODS

The independent risk factors for GPs with malignant potential were screened by χ² test and Logistic regression model. Prediction model was established and validated using data from 1296 patients with GPs who underwent cholecystectomy from January 2015 to December 2019 at 11 tertiary hospitals in China. A BN model was established based on the independent risk variables.

RESULTS

Independent risk factors for GPs with malignant potential included age, number of polyps, polyp size (long diameter), polyp size (short diameter), and fundus. The BN prediction model identified relationships between polyp size (long diameter) and three other variables [polyp size (short diameter), fundus and number of polyps]. Each variable was assigned scores under different status and the probabilities of GPs with malignant potential were classified as [0-0.2), [0.2-0.5), [0.5-0.8) and [0.8-1] according to the total points of [- 337, - 234], [- 197, - 145], [- 123, - 108], and [- 62,500], respectively. The AUC was 77.38% and 75.13%, and the model accuracy was 75.58% and 80.47% for the BN model in the training set and testing set, respectively.

CONCLUSION

A BN prediction model was accurate and practical for predicting GPs with malignant potential patients in a long diameter of 8-15 mm undergoing cholecystectomy based on preoperative ultrasound.

Value of prediction model in distinguishing gallbladder adenoma from cholesterol polyp

BACKGROUND AND AIM

Gallbladder adenomatous polyp is a pre-cancerous neoplasm, and it is difficult to classify from cholesterol polyps before cholecystectomy. The study aimed to clarify the risk characteristics of gallbladder adenomas and establish a prediction model to differentiate gallbladder adenomas from cholesterol polyp lesions.

METHODS

From May 2019 to December 2021, the patients underwent cholecystectomy in the Shanghai Eastern Hepatobiliary Surgery Hospital were retrospectively reviewed. According to the permanent pathology test, the patients were divided into adenomas and cholesterol polyps groups. All the included cases received ultrasound equipment examinations before cholecystectomy and their clinical information were completely recorded. Then the patients' baseline characteristics and ultrasound imaging variables were analyzed by logistic regression. Finally, a predictive model for gallbladder adenomas will be established and assessed based on the independent risk factors.

RESULTS

A total of 423 cases including 296 cholesterol polyps and 127 gallbladder adenomas were analyzed in detail. Multivariate logistic regression analysis revealed that solitary polyp lesion (OR = 2.954, 95% CI 1.759-4.960, P < 0.001), the maximal diameter of lesions (OR = 1.244, 95% CI 1.169-1.324, P < 0.001), and irregular shape of polyp lesions (OR = 5.549, 95% CI 1.979-15.560, P = 0.001) were the independent predictive factors of gallbladder adenomas. According to the results, regression equation of logit(P) = -3.828 + 1.083*number of gallbladder polyps lesions (GPLs) + 0.218*diameter of GPLs + 1.714*shape of GPLs was established. Area under the curve (AUC) was 0.828 (95% CI 0.782-0.874, P < 0.001). When logit P > 0.204, the sensitivity of estimating adenoma was 79.5%, the specificity of recognizing adenoma was 70.6%, and the whole correct ratio was 73.3%. While the AUC of diameter (10 mm) being a predictive factor in this study was only 0.790 (95% CI 0.741-0.839, P < 0.001). And the sensitivity and specificity of 10 mm as the optimal diagnostic cutoff value to diagnose adenomas were 74.8% and 65.9%, respectively.

CONCLUSIONS

The risk factors of solitary polyp lesion, larger diameter, and irregular morphology feature of polyp lesions were significantly related to gallbladder adenomas. And the predictive model established in the study can effectively identify adenomas from cholesterol polyps and help patients to select the optimal treatment protocol.

Risk of developing gallbladder cancer in patients with gallbladder polyps detected on transabdominal ultrasound: a systematic review and meta-analysis

OBJECTIVE

To estimate the risk of malignancy in gallbladder polyps of incremental sizes detected during transabdominal ultrasound (TAUS).

METHODS

We searched databases including MEDLINE, Embase, and Cochrane Library for eligible studies recording the polyp size from which gallbladder malignancy developed, confirmed following cholecystectomy, or by subsequent follow-up. Primary outcome was the risk of gallbladder cancer in patients with polyps. Secondary outcome was the effect of polyp size as a prognostic factor for cancer. Risk of bias was assessed using the Quality in Prognostic Factor Studies (QUIPS) tool. Bayesian meta-analysis estimated the median cancer risk according to polyp size. This study is registered with PROSPERO (CRD42020223629).

RESULTS

82 studies published since 1990 reported primary data for 67,837 patients. 67,774 gallbladder polyps and 889 cancers were reported. The cumulative median cancer risk of a polyp measuring 10 mm or less was 0.60% (99% credible range 0.30-1.16%). Substantial heterogeneity existed between studies (I2 = 99.95%, 95% credible interval 99.86-99.98%). Risk of bias was generally high and overall confidence in evidence was low. 13 studies (15.6%) were graded with very low certainty, 56 studies (68.3%) with low certainty, and 13 studies (15.6%) with moderate certainty. In studies considered moderate quality, TAUS monitoring detected 4.6 cancers per 10,000 patients with polyps less than 10 mm.

CONCLUSION

Malignant risk in gallbladder polyps is low, particularly in polyps less than 10 mm, however the data are heterogenous and generally low quality. International guidelines, which have not previously modelled size data, should be informed by these findings.

ADVANCES IN KNOWLEDGE

This large systematic review and meta-analysis has shown that the mean cumulative risk of small gallbladder polyps is low, but heterogeneity and missing data in larger polyp sizes (>10 mm) means the risk is uncertain and may be higher than estimated.Studies considered to have better methodological quality suggest that previous estimates of risk are likely to be inflated.

Management and follow-up of gallbladder polyps: updated joint guidelines between the ESGAR, EAES, EFISDS and ESGE

Abstract

Main recommendations

Primary investigation of polypoid lesions of the gallbladder should be with abdominal ultrasound. Routine use of other imaging modalities is not recommended presently, but further research is needed. In centres with appropriate expertise and resources, alternative imaging modalities (such as contrast-enhanced and endoscopic ultrasound) may be useful to aid decision-making in difficult cases. Strong recommendation, low–moderate quality evidence.

Cholecystectomy is recommended in patients with polypoid lesions of the gallbladder measuring 10 mm or more, providing the patient is fit for, and accepts, surgery. Multidisciplinary discussion may be employed to assess perceived individual risk of malignancy. Strong recommendation, low-quality evidence.

Cholecystectomy is suggested for patients with a polypoid lesion and symptoms potentially attributable to the gallbladder if no alternative cause for the patient’s symptoms is demonstrated and the patient is fit for, and accepts, surgery. The patient should be counselled regarding the benefit of cholecystectomy versus the risk of persistent symptoms. Strong recommendation, low-quality evidence.

If the patient has a 6–9 mm polypoid lesion of the gallbladder and one or more risk factors for malignancy, cholecystectomy is recommended if the patient is fit for, and accepts, surgery. These risk factors are as follows: age more than 60 years, history of primary sclerosing cholangitis (PSC), Asian ethnicity, sessile polypoid lesion (including focal gallbladder wall thickening > 4 mm). Strong recommendation, low–moderate quality evidence.

If the patient has either no risk factors for malignancy and a gallbladder polypoid lesion of 6–9 mm, or risk factors for malignancy and a gallbladder polypoid lesion 5 mm or less, follow-up ultrasound of the gallbladder is recommended at 6 months, 1 year and 2 years. Follow-up should be discontinued after 2 years in the absence of growth. Moderate strength recommendation, moderate-quality evidence.

If the patient has no risk factors for malignancy, and a gallbladder polypoid lesion of 5 mm or less, follow-up is not required. Strong recommendation, moderate-quality evidence.

If during follow-up the gallbladder polypoid lesion grows to 10 mm, then cholecystectomy is advised. If the polypoid lesion grows by 2 mm or more within the 2-year follow-up period, then the current size of the polypoid lesion should be considered along with patient risk factors. Multidisciplinary discussion may be employed to decide whether continuation of monitoring, or cholecystectomy, is necessary. Moderate strength recommendation, moderate-quality evidence.

If during follow-up the gallbladder polypoid lesion disappears, then monitoring can be discontinued. Strong recommendation, moderate-quality evidence.

Source and scope

These guidelines are an update of the 2017 recommendations developed between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery and other Interventional Techniques (EAES), International Society of Digestive Surgery–European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE). A targeted literature search was performed to discover recent evidence concerning the management and follow-up of gallbladder polyps. The changes within these updated guidelines were formulated after consideration of the latest evidence by a group of international experts. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence.

Key Point

• These recommendations update the 2017 European guidelines regarding the management and follow-up of gallbladder polyps.

Bilious mask: parasite masquerading as malignant gall bladder polyp

A 31-year-old woman, presenting with right upper quadrant pain, was suspected to have malignant gall bladder polyp based on MRI and CT scan findings. She underwent radical cholecystectomy with excision of bile duct and hepaticojejunostomy. Surprisingly, histology revealed parasitic remnants within the bile duct wall with no evidence of malignancy. A year later, this young woman suffers significant impairment of quality of life, perhaps an aftermath to the radicality of the surgery. Our case demonstrates a masquerade of 'malignant biliary polyp' by a parasite. This raises the need for extensive investigations such as endoscopic ultrasound guided biopsies, parasitic serology and positron emission tomography (PET) scans when patients present with probable malignant biliary lesions, even in difficult-to-access areas. A preoperative diagnosis might have averted an unnecessary major surgery in this young woman.

Scoring system for gallbladder polyps based on the cross-sectional area and patient characteristics

BACKGROUND

Current management guidelines for gallbladder polyps (GBPs) focus on a diameter more than 1 cm as an indication for cholecystectomy. Since most GBPs are not malignant, unnecessary cholecystectomies can lead to unnecessary complications and costs. We developed a score to identify true polyps focusing on their cross-sectional area (CSA).

METHODS

We retrospectively analyzed the demographic, clinical, laboratory, and sonographic characteristics of 522 patients with GBPs who had undergone cholecystectomy at our hospital between January 2010 and July 2020 (reference group). We used univariate analysis to compare these parameters between 88 true polyps and 434 pseudopolyps and multivariate logistic regression analysis to identify parameters to include in our scoring model. Receiver operating characteristics and area under the curve were used to identify cut-off values. The model was tested on a validation group of 98 patients.

RESULTS

In the multivariate analysis, a CSA >123 mm², positive blood flow signal, age >55.5 years, alanine aminotransferase (ALT) levels > 50 U/L, and an ALT/aspartate aminotransferase ratio > 0.77 were significantly associated with true polyps (odds ratio 6.528, 2.377, 2.617, 2.445, and -0.372, respectively). A prediction model based on cut-off values was used to distinguish a low-risk and high-risk GBP group; true polyps accounted for 6.54% and 58.72%, respectively (p < 0.001). In the low-risk and high-risk validation groups, true polyps comprised 12.35% and 82.35%, respectively (p < 0.001).

CONCLUSIONS

Our scoring system shows high accuracy and specificity in identifying true polyps and helps determine the need for surgical resection.

An Important Gallbladder Pathology Mimicking Gallbladder Carcinoma: Xanthogranulomatous Cholecystitis: A Single Tertiary Center Experience

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is an uncommon, focal, or diffuse destructive inflammatory disease of the gallbladder mimicking or being together with the gallbladder carcinoma. This study aimed to evaluate the diagnosis, treatment, and outcomes of patients with XGC as a single tertiary center experience in the light of literature.

MATERIALS AND METHODS

Data about 34 patients with XGC identified after evaluating 2212 cholecystectomy specimens between January 2013 and December 2018 in a single tertiary center were documented to determine demographics (sex, age), clinical symptoms and findings, biochemical and imaging clues and operative findings, duration of hospitalization, postoperative complications, and histopathologic results.

RESULTS

Thirty-four patients with XGC were evaluated (17 male and 17 female patients with a mean age of 53; range, 25 to 78). Preoperative diagnosis was chronic calculous cholecystitis in 5 patients, cholelithiasis in 12 cases, acute calculous cholecystitis in 16 and emphysematous cholecystitis in 1 patient. Ultrasound was performed in all patients, computerized tomography in 11, contrast-enhanced magnetic resonance imaging in 9, and magnetic resonance cholangiopancreatography in 7 patients. None of the patients were diagnosed preoperatively. All patients received laparoscopic cholecystectomy, among whom 9 were converted to open. Partial cholecystectomy was performed in 1 patient. One patient with gallbladder adenocarcinoma was treated with radical cholecystectomy. XGC has nonspecific clinical and radiologic findings; thus, preoperative diagnosis is generally absent. Open cholecystectomy is the recommended treatment modality. Conversion to open is frequently necessary after laparoscopy. Complete cholecystectomy is the ultimate goal; however, partial cholecystectomy may be preferred to protect the structures of the hepatic hilum. Preoperative imaging studies (ultrasound or computerized tomography) of 34 patients showed a gallbladder stone in 18 patients, microlithiazis in 12 patients, sludge in 10 patients, and gallbladder sclerosis in 5 patients.

CONCLUSIONS

Diagnosis of XGC and differentiation from gallbladder carcinoma may be difficult through preoperative or peroperative studies, even imaging is useful; the definitive diagnosis depends exclusively on pathologic examination. The surgeon should be prepared for every possibility.

The management of gallbladder polyps

Neoplastic gallbladder polyps (NGP) are rare; the prevalence in the overall population is less than 10%. NGP are associated with a risk of malignant degeneration and must be distinguished from other benign gallbladder polypoid lesions that occur more frequently. NGP are adenomas and the main risk associated with their management is to fail to detect their progression to gallbladder cancer, which is associated with a particular poor prognosis. The conclusions of the recent European recommendations have a low level of evidence, based essentially on retrospective small-volume studies. Abdominal sonography is the first line study for diagnosis and follow-up for NGP. To prevent the onset of gallbladder cancer, or treat malignant degeneration in its early phases, all NGP larger than 10mm, or symptomatic, or larger than 6mm with associated risk factors for cancer (age over 50, sessile polyp, Indian ethnicity, or patient with primary sclerosing cholangitis) are indications for cholecystectomy. Apart from these situations, simple sonographic surveillance is recommended for at least five years; if the NGP increases in size by more than 2mm in size, cholecystectomy is indicated. Laparoscopic cholecystectomy is possible but if the surgeon feels that the risk of intra-operative gallbladder perforation is high, conversion to laparotomy should be preferred to avoid potential intra-abdominal tumoral dissemination. When malignant NGP is suspected (size greater than 15mm, signs of locoregional extension on imaging), a comprehensive imaging workup should be performed to search for liver extension: in this setting, radical surgery should be considered.

Gallbladder Polyps Are Associated with Proximal Colon Polyps

Background

The association between gallbladder (GB) disease and colorectal precancerous lesions remains elusive. This study sought to explore the association between GB disease and colorectal neoplasms at different locations.

Methods

Patients who received general health checkup from January to December 2008 were included and subgrouped into three groups by polyp location: proximal, distal, and whole colon. GB disease and other known risk factors for colon cancer were compared and analyzed. Different types of polyps at different locations were further investigated.

Results

Of a total of 3136 patients (1776 men and 1360 women; mean age, 49.3 years) who had colon polyps, 212 (6.8%) had GB stone and 512 (16.3%) had GB polyps. Patients in the proximal colon polyp group had higher rates of GB polyps and stones. GB polyps were independently associated with proximal colon polyps, including both hyperplastic polyps (odds ratio, 1.523; P = 0.034) and adenomatous polyps (odds ratio, 1.351; P = 0.048). No relationship between GB polyps and distal or any colon polyps was observed. Irrespective of the polyp location (i.e., proximal, distal, or any part of the colon), GB stone did not show any association with colon polyp.

Conclusions

We suggested that GB polyps are associated with proximal colon polyps. Colonoscopy may be a more effective strategy for screening proximal precancerous lesions among patients with GB polyps. The association between GB disease and colon polyps demands further prospective investigation.

Polyp size of 1 cm is insufficient to discriminate neoplastic and non-neoplastic gallbladder polyps

Background

A significant proportion of gallbladder polyps are non-neoplastic, for which resection is not necessary. However, international guidelines advocate cholecystectomy for all polyps ≥ 1 cm. This study assessed a national cohort of histopathologically proven gallbladder polyps to distinguish neoplastic from non-neoplastic polyps.

Methods

PALGA, the nationwide network and registry of histo- and cytopathology, was searched to identify all histopathologically proven gallbladder polyps between 2003 and 2013. All polyps and (focal) wall thickenings > 5 mm were included, and classified as neoplastic or non-neoplastic. Polyp subtype, size, distribution, presentation as wall thickening or protruding polyp, and presence of gallstones were assessed for neoplastic and non-neoplastic polyps. A decision tree to distinguish neoplastic and non-neoplastic polyps was made and diagnostic accuracy of 1 cm surgical threshold was calculated.

Results

A total of 2085 out of 220,612 cholecystectomies contained a polyp (0.9%). Of these polyps, 56.4% were neoplastic (40.1% premalignant, 59.9% malignant) and 43.6% non-neoplastic (41.5% cholesterol polyp, 37.0% adenomyomatosis, 21.5% other). Polyp size, distribution, and presence of gallstones were reported in 1059, 1739 and 1143 pathology reports, respectively. Neoplastic polyps differed from non-neoplastic polyps in size (18.1 mm vs 7.5 mm, p < 0.001), singularity (88.2% vs 68.2%, p < 0.001), wall thickening (29.1% vs 15.6%, p < 0.001), and presence of gallstones (50.1% vs 40.4%, p = 0.001). However, adenomyomatosis presented with similar characteristics as neoplastic polyps. Fifty percent of polyps were ≥ 1 cm surgical threshold (optimal surgical threshold based on ROC-curve); sensitivity for indicating neoplastic polyps was 68.1%, specificity was 70.2%, and positive and negative predictive values were 72.9% and 65.1%.

Conclusions

The prevalence of gallbladder polyps on cholecystectomy is low and many of the polyps are non-neoplastic. Clinicopathological characteristics differ between neoplastic and non-neoplastic polyps in general, but these cannot properly indicate neoplasia. The 1 cm surgical threshold has moderate diagnostic accuracy and is insufficient to indicate surgery for neoplastic gallbladder polyps.

Pyloric Gland Adenoma of Gallbladder: A Review of Diagnosis and Management

Neoplastic polypoid mucosal lesions of the gallbladder are increasingly being reported in cholecystectomy specimens. However, due to the absence of unified terminology and reporting criteria, the body of scientific evidence on their classification, prognosis, and management is scarce and sometimes controversial. While they have different histomorphologic features (gastric foveolar, gastric pyloric gland, biliary, and intestinal), a significant immunohistochemical overlap exists which highlights their mixed cell lineage with a dominant cell type in each, establishing the subcategory. Because of many shared attributes, intracholecystic papillary-tubular neoplasm (ICPN) has been introduced as an umbrella terminology. ICPNs of the pyloric subtype are lesions larger than 1 cm, as most of the smaller ones are clinically insignificant and represent polypoid hyperplasia rather than a true neoplasm. In this review, we will focus on the pyloric gland adenomas as the most frequent histologic subtype of ICPNs.