Growth rate and malignant potential of small gallbladder polyps--systematic review of evidence. Surgeon. 2014;12:221-226. [PMID: 24502936 DOI: 10.1016/j.surge.2014.01.003]

Perforated Calculous Cholecystitis and Incidental Squamous Cell Carcinoma of the Gallbladder-A Complex Relationship with a Difficult Management in the Acute Setting

The worldwide prevalence of gallstones (GSs) is estimated to be between 10% and 15% in the general population. Gallbladder carcinoma (GBC) is the most common biliary tract neoplasia, and it is characterized by highly aggressive behavior and poor overall prognosis. Long-standing GSs and chronic inflammatory state represent the most common risk factors for GBC, promoting a carcinogenic microenvironment. Long-standing GSs expose patients to potentially severe surgical and oncological complications. A 71-year-old gentleman, who had never experienced biliary symptoms and had diabetes mellitus (DM), presented with severe peritonitis due to perforated acute calculous cholecystitis. The patient underwent an emergent laparotomic cholecystectomy. Histopathology found a rare pT2b poorly differentiated squamocellular carcinoma of the gallbladder. Although more difficult due to the concomitant inflammatory context, it is critical to identify suspicious lesions during preoperative imaging in patients at high risk of malignancy presenting with complex acute gallbladder pathologies. A review of the literature was conducted to gain a deeper insight into the relationship between long-standing GSs and GBC, evaluating also the difficult diagnosis and management of malignancy in the acute setting. Considering the existing literature, the choice to pursue a prophylactic cholecystectomy may be justifiable in selected asymptomatic GS patients at high risk for GBC.

Use of peroral cholangiopancreatoscopy-assisted endoscopic mucosal resection for biliopancreatic intraductal lesions

BACKGROUND

This study aimed to assess the feasibility and safety of performing cholangiopancreatoscopy-assisted endoscopic mucosal resection (CA-EMR) for biliopancreatic intraductal lesions.

METHODS

Special electrocautery snares and injection needles that can pass through the working channel of a single-operator cholangiopancreatoscope were developed. Between November 2023 and April 2024, we performed CA-EMR for two patients with gallbladder polyps, one patient with a neoplastic lesion in the common bile duct (CBD), and one patient with a neoplastic lesion in the main pancreatic duct. The technical success rate and adverse events were recorded.

RESULTS

All four CA-EMR procedures were performed successfully. Postoperative pathology revealed inflammatory gallbladder polyps in two patients, low grade intraepithelial neoplasia of the CBD in one patient, and intraductal papillary mucinous neoplasm (IPMN) in one patient. The patient with IPMN experienced mild postoperative pancreatitis and recovered after conservative treatment. No adverse events were encountered in the other three CA-EMR procedures.

CONCLUSION

This study preliminarily confirmed the feasibility and safety of CA-EMR for treating biliopancreatic intraductal lesions.

Diagnostic performance of EUS-guided elastography for differential diagnosis of gallbladder polyp

BACKGROUND AND AIMS

It is difficult to differentiate between neoplastic and non-neoplastic gallbladder (GB) polyps before surgery. EUS-guided elastography (EUS-EG) is a noninvasive complementary diagnostic method. The utility of EUS-EG in the differential diagnosis of GB polyps has not been investigated. We investigated the diagnostic performance of EUS-EG for the differential diagnosis of GB polyps.

METHODS

Patients with GB polyps were prospectively enrolled from June 2020 until November 2022. EUS-EG and semiquantitative evaluation of the strain ratio (SR) were performed for differential diagnosis of GB polyps. Fifty-three eligible patients were divided into 2 groups based on the final diagnosis after surgery. Patient demographics, EUS characteristics, and SR values were compared. A receiver-operating characteristic curve analysis was performed to determine the optimal cutoff SR value that discriminates between neoplastic and non-neoplastic GB polyps.

RESULTS

The median SR value for neoplastic polyps (32.93 [interquartile range {IQR}, 22.37-69.02]) was significantly higher than for non-neoplastic polyps (5.40 [IQR, 2.36-14.44], P < .001). Significant differences were found in SR values between non-neoplastic, benign neoplastic (23.38 [IQR, 13.62-39.04]), and malignant polyps (49.25 [IQR, 27.90-82.00]). The optimal cutoff SR value to differentiate between neoplastic and non-neoplastic polyps was 18.4. In multivariable logistic regression, SR value >18.4 (odds ratio, 33.604; 95% confidence interval, 2.588-436.292) was an independent predictor of neoplastic polyps.

CONCLUSIONS

EUS-EG and SR values can be used as a supplementary method for evaluating GB polyps. (Clinical trial registration number: NCT04416763.).

Rapid Identification of Benign Gallbladder Diseases Using Serum Surface-Enhanced Raman Spectroscopy Combined with Multivariate Statistical Analysis

In this study, we looked at the viability of utilizing serum to differentiate between gallbladder (GB) stones and GB polyps using Surface-enhanced Raman spectroscopy (SERS), which has the potential to be a quick and accurate means of diagnosing benign GB diseases. Rapid and label-free SERS was used to conduct the tests on 148 serum samples, which included those from 51 patients with GB stones, 25 patients with GB polyps and 72 healthy persons. We used an Ag colloid as a Raman spectrum enhancement substrate. In addition, we employed orthogonal partial least squares discriminant analysis (OPLS-DA) and principal component linear discriminant analysis (PCA-LDA) to compare and diagnose the serum SERS spectra of GB stones and GB polyps. The diagnostic results showed that the sensitivity, specificity, and area under curve (AUC) values of the GB stones and GB polyps based on OPLS-DA algorithm reached 90.2%, 97.2%, 0.995 and 92.0%, 100%, 0.995, respectively. This study demonstrated an accurate and rapid means of combining serum SERS spectra with OPLS-DA to identify GB stones and GB polyps.

Spectrum of imaging findings in hyperplastic cholecystosis and potential mimics

Adenomyomatosis and cholesterolosis of the gallbladder, collectively termed hyperplastic cholecystosis, are commonly encountered incidental findings on imaging studies performed for a variety of indications including biliary colic or nonspecific abdominal pain. These pathologies are rarely the source of symptoms, generally considered benign and do not require further work-up. However, their imaging characteristics can overlap with more sinister conditions that should not be missed. In this review, the imaging findings of adenomyomatosis and cholesterolosis will be reviewed followed by other gallbladder pathologies that might mimic these conditions radiologically. Important differentiating factors will be discussed that can aid the radiologist in making a more confident imaging diagnosis.

GALLBLADDER POLYPS: CORRELATION AND AGREEMENT BETWEEN ULTRASONOGRAPHIC AND HISTOPATHOLOGICAL FINDINGS IN A POPULATION WITH HIGH INCIDENCE OF GALLBLADDER CANCER

BACKGROUND

Gallbladder polyps are becoming a common finding in ultrasound. The management has to consider the potential risk of malignant lesions.

AIMS

The aim of this study was to analyze the ultrasound findings in patients undergoing cholecystectomy due to gallbladder polyps and compare them for histopathological findings (HPs).

METHODS

Patients with an ultrasonographic diagnosis of gallbladder polyp and who underwent cholecystectomy from 2007 to 2020 were included in the study.

RESULTS

A total of 447 patients were included, of whom 58% were women. The mean age was 45±12 years. The mean size of polyps in US was 7.9±3.6 mm. Notably, 9% of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p=0.003). Histopathological findings confirmed the presence of polyps in 88.4%, with a mean size of 4.8±3.4 mm. In all, 16 cases were neoplastic polyps (4.1%), 4 of them being malignancies, and all were single and larger than 10 mm. We found a significant correlation between ultrasound and histopathological findings polyp size determination (r=0.44; p<0.001). The Bland-Altman analysis obtained an overestimation of the US size of 3.26 mm. The receiver operating characteristic (ROC) curve analysis between both measures obtained an area under the receiver operating characteristic curve (AUC) of 0.77 (95%CI 0.74-0.81). Ultrasound polyps size larger than 10 mm had an odds ratio (OR) of 8.147 (95%CI 2.56-23.40) for the presence of adenoma and malignancy, with a likelihood ratio of 2.78.

CONCLUSIONS

There is a positive correlation and appropriate diagnostic accuracy between ultrasound size of gallbladder polyps compared to histopathological records, with a trend to overestimate the size by about 3 mm. Neoplastic polyps are uncommon, and it correlates with size. Polyps larger than 10 mm were associated with adenoma and malignancy.

Incidental Findings of Gallbladder and Bile Ducts-Management Strategies: General Aspects, Gallbladder Polyps and Gallbladder Wall Thickening-A World Federation of Ultrasound in Medicine and Biology (WFUMB) Position Paper

The World Federation of Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings with a series of position papers to give advice on characterization and management. The biliary system (gallbladder and biliary tree) is the third most frequent site for incidental findings. This first part of the position paper on incidental findings of the biliary system is related to general aspects, gallbladder polyps and other incidental findings of the gallbladder wall. Available evidence on prevalence, diagnostic work-up, malignancy risk, follow-up and treatment is summarized with a special focus on ultrasound techniques. Multiparametric ultrasound features of gallbladder polyps and other incidentally detected gallbladder wall pathologies are described, and their inclusion in assessment of malignancy risk and decision- making on further management is suggested.

Value of Conventional Ultrasound-based Scoring System in Distinguishing Adenomatous Polyps From Cholesterol Polyps

BACKGROUND AND AIM

Ultrasound has increased the detection of gallbladder polyps, but it has limitations in evaluating the nature of gallbladder polyps, especially the maximum size of 1.0 to 1.5 cm. We assessed the value of ultrasound scoring system based on independent predictive parameters in distinguishing adenomatous polyps from cholesterol polyps with the maximum size of 1.0 to 1.5 cm.

MATERIALS AND METHODS

We enrolled 163 patients with gallbladder polyps (1.0 to 1.5 cm) who underwent ultrasonography and cholecystectomy. Ultrasound image characteristics were compared between cholesterol polyps and adenomatous polyps in the training cohort from April 2018 to January 2020. An ultrasound scoring system was constructed in the training cohort, and its diagnostic performance was evaluated in the validation cohort from February 2020 to February 2021.

RESULTS

Maximum size, height/width ratio, stone or sludge, vascularity, and hyperechoic spot were significantly different between cholesterol polyps and adenomatous polyps in the training cohort ( P <0.05). The independent predictive parameters for adenomatous polyps were lower height/width ratio, presence of vascularity and absence of hyperechoic spot. The total score was as follows: (height/width ratio, <0.9=4, ≥0.9=0) + (vascularity, present=3, absent=0) + (hyperechoic spot, absent=2, present=0). The sensitivity, specificity and accuracy of ultrasound scoring system ≥5 for diagnosis of adenomatous polyps in the validation cohort were 73.33%, 80.49%, and 78.57%, respectively.

CONCLUSIONS

The ultrasound scoring system aids in distinguishing adenomatous polyps from cholesterol polyps, and effectively decreasing unnecessary cholecystectomy.

Gallbladder polyps growth rate is an independent risk factor for neoplastic polyps

Background

The size of gallbladder (GB) polyps is a representative risk factor for neoplastic polyps. However, whether growth rate during follow‐up is associated with neoplastic polyps remains unclear.

Methods

From 2009 to 2019, a cohort of patients with GB polyps who underwent cholecystectomy was enrolled. We included only patients who underwent at least two abdominal ultrasonography procedures at least 6 months apart prior to cholecystectomy. Performance and optimal cutoff value of polyp growth rate for predicting neoplastic polyps were estimated using receiver operating characteristic (ROC) analysis. In addition to growth rate, several other variables considered suitable for predicting neoplastic polyps were also investigated. A nomogram was created to predict neoplastic polyps.

Results

A total of 239 patients with neoplastic polyps (n = 27, 11.3%) and non‐neoplastic polyps (n = 212, 88.7%) were included. The median follow‐up period was 28.5 months. The area under the ROC curve (AUROC) of polyp growth rate for neoplastic polyps was 0.66 (95% confidence interval, 0.59–0.72). The growth rate cutoff value for prediction of neoplastic polyps was 3 mm/year (sensitivity, 37.0%; specificity, 86.3%). Multivariate analysis identified several factors predicting neoplastic polyps: polyp size ≥10 mm (odds ratio [OR], 3.74, p = 0.041), solitary polyp (OR, 3.92, p = 0.004), and polyp growth rate ≥ 3 mm/year (OR, 2.75, p = 0.031). The AUROC of the nomogram using these three significant factors in multivariate analysis was 0.71.

Conclusion

GB polyps with a growth rate of over 3 mm per year on ultrasonography during follow‐up should be considered a risk factor for neoplastic polyps.

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 of Incidentally Detected Gallbladder Polyps: Society of Radiologists in Ultrasound Consensus Conference Recommendations

Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but are benign cholesterol polyps with no inherent risk of malignancy. In addition, recent studies have shown that the overall risk of gallbladder cancer is not increased in patients with small gallbladder polyps, calling into question the rationale for frequent and prolonged follow-up of these common lesions. In 2021, a Society of Radiologists in Ultrasound, or SRU, consensus conference was convened to provide recommendations for the management of incidentally detected gallbladder polyps at US. See also the editorial by Sidhu and Rafailidis in this issue.

Incidental finding of a large polypoidal gallbladder mass diagnosed as papillary adenocarcinoma – A case report

Introduction and importance

Case presentation

Clinical discussion

Conclusion

•

Polypoid lesions of gallbladder are discovered incidentally.

•

Presenting symptoms are mostly nonspecific.

•

Ultrasonography of abdomen on routine health check-up showed the lesion.

•

Most of the lesions are benign in nature but few present with malignant features.

•

Polyps larger than 1 cm in size have higher chance of malignancy.

Is there a role for growth status in distinguishing gallbladder adenomas from cholesterol polyps? - A retrospective study based on 520 cholecystectomy patients

INTRODUCTION

Gallbladder adenomas have cancerous potential and occur in 4-8.9% of gallbladder polyps. The growth status (size progression and growth rate during follow-up) of polyps and their effectiveness for predicting adenomas are poorly defined. Herein, we compared adenomas and cholesterol polyps based on the growth status and evaluated the reported risk factors in predicting neoplasm.

METHODS

We enrolled 520 patients who underwent preoperative ultrasonic follow-up more than 6 months with post-cholecystectomy pathologically confirmed gallbladder polyps. The patients were classified into adenoma and cholesterol polyp groups. Growth status, clinical characteristics, laboratory data, ultrasonic findings were reviewed and compared between the groups.

RESULTS

Seventy-nine adenomas and 441 cholesterol polyps were analyzed. The mean diameter of adenomas (cholesterol polyps) was 7.24 ± 4.36 mm (6.23 ± 2.88 mm) in the initial and 12.06 ± 4.61 mm (10.05 ± 2.95 mm) in the preoperative examination. The median size progression (range) of polyps in the cholesterol polyps [3 (0, 22)] mm was smaller than that in adenomas [4 (0, 21)] mm (p = .075). The mean growth rate of adenomas (1.07 ± 1.33 mm/6 months) was slightly faster than in cholesterol polyps (0.83 ± 1.04 mm/6 months) (p = .338). The indicators significantly associated with adenomas were age >49.5 years, lack of gallbladder polyps/cholelithiasis family history, polyp size >11.5 mm and solitary polyp (p = .005, p = .027, p = .001, and p = .021, respectively).

CONCLUSION

Growth status was not a valuable modality to distinguishing gallbladder adenomas from cholesterol polyps. Risk factors such as age, polyp size, and solitary polyp were effective in predicting adenomas.

How Can We Manage Gallbladder Lesions by Transabdominal Ultrasound?

The most important role of ultrasound (US) in the management of gallbladder (GB) lesions is to detect lesions earlier and differentiate them from GB carcinoma (GBC). To avoid overlooking lesions, postural changes and high-frequency transducers with magnified images should be employed. GB lesions are divided into polypoid lesions (GPLs) and wall thickening (GWT). For GPLs, classification into pedunculated and sessile types should be done first. This classification is useful not only for the differential diagnosis but also for the depth diagnosis, as pedunculated carcinomas are confined to the mucosa. Both rapid GB wall blood flow (GWBF) and the irregularity of color signal patterns on Doppler imaging, and heterogeneous enhancement in the venous phase on contrast-enhanced ultrasound (CEUS) suggest GBC. Since GWT occurs in various conditions, subdividing into diffuse and focal forms is important. Unlike diffuse GWT, focal GWT is specific for GB and has a higher incidence of GBC. The discontinuity and irregularity of the innermost hyperechoic layer and irregular or disrupted GB wall layer structure suggest GBC. Rapid GWBF is also useful for the diagnosis of wall-thickened type GBC and pancreaticobiliary maljunction. Detailed B-mode evaluation using high-frequency transducers, combined with Doppler imaging and CEUS, enables a more accurate diagnosis.

Routine examination of gallbladder specimens after cholecystectomy: a single-centre analysis of the incidence, clinical and histopathological aspects of incidental gallbladder carcinoma

BACKGROUND

Gallbladder carcinoma is often found incidentally on histopathologic examination after cholecystectomy-this is referred as incidental gallbladder carcinoma (IGC). Routine vs selective histopathological assessment of gallbladders is under debate and this study evaluates the role of regular specimens' examination, based on a single-centre analysis of incidence, clinical and histopathological aspects of IGC.

METHODS

Patients who underwent cholecystectomy, between July 2010 and January 2020, were considered. Exclusion criteria were age under 18 and preoperative diagnosis of GB carcinoma. Demographic, clinical and histopathological data were retrospectively collected, continuous variables with a normal distribution were evaluated with Student's t-test and ANOVA.

RESULTS

Some 5779 patients were included. The female/male ratio was 2.5:1. Chronic cholecystitis (CC) was the most common finding on specimens (99.3%), IGC was found in six cases (0.1%). In the latter group, there were 5 women and patients were older than those with benign disease-73.7 [Formula: see text] 5.38 years vs 55.8 [Formula: see text] 0.79 years (p < 0.05). In all the cases, the GB was abnormal on intraoperative inspection and beside cancer, histopathology showed associated CC and/or dysplasia. Upon diagnosis, disease was at advanced stage-one stage II, one stage IIIA, one stage IIIB, three stage IVA. Two patients are alive, three died of disease progression-median survival was 7 months (range 2-14).

CONCLUSIONS

In this series, ICG was rare, occurred most commonly in old adult women and was diagnosed at an advanced stage. In all the cases, the GB was abnormal intraoperatively, therefore macroscopic GB anomalies demand histopathological assessment of the specimen.

Gallbladder Disorders: A Comprehensive Review

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

Gallbladder Carcinoma and Its Differential Diagnosis at MRI: What Radiologists Should Know

Gallbladder carcinoma is the most common cancer of the biliary system. It is challenging to diagnose because patients are often asymptomatic or present with nonspecific symptoms that mimic common benign diseases. Surgical excision is the only curative therapy and is best accomplished at early non-locally advanced stages. Unfortunately, gallbladder cancer often manifests at late locally advanced stages, precluding cure. Early tumors are often incidentally detected at imaging or at cholecystectomy performed for another indication. Typical imaging features of localized disease include asymmetric gallbladder wall thickening, polyps larger than 1.0 cm, and a solid mass replacing the gallbladder lumen. Advanced tumors are often infiltrative and can be confusing at CT and MRI owing to their large size. Determination of the origin of the lesion is paramount to narrow the differential diagnosis but is often challenging. It is important to identify gallbladder cancer and distinguish it from other benign and malignant hepatobiliary processes. Since surgical resection is the only curative treatment option, radiologist understanding and interpretation of pathways of nodal and infiltrative tumor spread can direct surgery or preclude patients who may not benefit from surgery. While both CT and MRI are effective, MRI provides superior soft-tissue characterization of the gallbladder and biliary tree and is a useful imaging tool for diagnosis, staging, and evaluation of treatment response. ^©RSNA, 2020.

Ultrasound Radiomics Effective for Preoperative Identification of True and Pseudo Gallbladder Polyps Based on Spatial and Morphological Features

Purpose: To explore the value of ultrasound radiomics in the preoperative identification of true and pseudo gallbladder polyps and to evaluate the associated diagnostic accuracy.

Methods: Totally, 99 pathologically proven gallbladder polyps in 96 patients were enrolled, including 58 cholesterol polyps (55 patients) and 41 gallbladder tubular adenomas (41 patients). Features on preoperative ultrasound images, including spatial and morphological features, were acquired for each lesion. Following this, two-stage feature selection was adopted using Fisher's inter-intraclass variance ratios and Z-scores for the selection of intrinsic features important for differential diagnosis achievement with support vector machine use.

Results: Eighty radiomic features were extracted from each polyp. Eight intrinsic features were identified after two-stage selection. The contrast 14 (Cont14) and entropy 6 (Entr6) values in the cholesterol polyp group were significantly higher than those in the gallbladder adenoma group (4.063 ± 1.682 vs. 2.715 ± 1.867, p < 0.001 for Cont14; 4.712 ± 0.427 vs. 4.380 ± 0.720, p = 0.003 for Entr6); however, the homogeneity 13 (Homo13) and energy 8 (Ener8) values in the cholesterol polyp group were significantly lower (0.500 ± 0.069 vs. 0.572 ± 0.057, p < 0.001 for Homo13; 0.050 ± 0.023 vs. 0.068 ± 0.038, p = 0.002 for Ener8). These results indicate that the pixel distribution of cholesterol polyps was more uneven than that of gallbladder tubular adenomas. The dispersion degree was also significantly lower in the cholesterol polyp group than the gallbladder adenoma group (0.579 ± 0.054 vs. 0.608 ± 0.041, p = 0.005), indicating a lower dispersion of high-intensity areas in the cholesterol polyps. The long axis length of the fitting ellipse (Maj.Len), diameter of a circle equal to the lesion area (Eq.Dia) and perimeter (Per) values in the cholesterol polyp group were significantly lower than those in the gallbladder adenoma group (0.971 ± 0.485 vs. 1.738 ± 0.912, p < 0.001 for Maj.Len; 0.818 ± 0.393 vs. 1.438 ± 0.650, p < 0.001 for Eq.Dia; 2.637 ± 1.281 vs. 5.033 ± 2.353, p < 0.001 for Per), demonstrating that the cholesterol polyps were smaller and more regular in terms of morphology. The classification accuracy, sensitivity, specificity, and area under the curve values were 0.875, 0.885, 0.857, and 0.898, respectively.

Conclusions: Ultrasound radiomic analysis based on the spatial and morphological features extracted from ultrasound images effectively contributed to the preoperative diagnosis of true and pseudo gallbladder polyps and may be valuable in their clinical management.

Recommendations for the Management of Incidental Hepatobiliary Findings in Adults: Endorsement and Adaptation of the 2017 and 2013 ACR Incidental Findings Committee White Papers by the Canadian Association of Radiologists Incidental Findings Working Group

The Canadian Association of Radiologists Incidental Findings Working Group consists of both academic subspecialty and general radiologists and is tasked with adapting and expanding upon the American College of Radiology incidental findings white papers to more closely apply to Canadian practice patterns, particularly more comprehensively dealing with the role of ultrasound and pursuing more cost-effective approaches to the workup of incidental findings without compromising patient care. Presented here are the 2020 Canadian guidelines for the management of hepatobiliary incidental findings. Topics covered include initial assessment of hepatic steatosis and cirrhosis, the workup of incidental liver masses identified on ultrasound and computed tomography (with algorithms presented), incidental gallbladder findings (wall thickening, calcification, and polyps), and management of incidental biliary dilatation.

Epidemiology of gallbladder cancer

According to GLOBOCAN 2018 data, gallbladder cancer (GBC) accounts for 1.2% of all global cancer diagnoses, but 1.7% of all cancer deaths. Only 1 in 5 GBC cases in the United States is diagnosed at an early stage, and median survival for advanced stage cancer is no more than about a year. The incidence of the disease is increasing in the developed world. Gallstones, biliary cysts, carcinogen exposure, typhoid, and Helicobacter pylori infection, and abnormal pancreaticobiliary duct junctions are all risk factors, many of which account for its geographical, ethnic and sex distribution. Genetics also plays a strong role, as about a quarter of GBC cases are considered familial, and certain ethnicities, such as Native Americans, are at far higher risk for the neoplasm. Prevention includes weight loss, vaccination against and treatment of bacterial infections, early detection and elimination of polyps and cysts, and avoidance of oral estrogen replacement therapy.

Gallbladder polyps - a follow-up study after 11 years

Background

The aim of our study was to investigate the prevalence and natural long-term progression of gallbladder polyps in a random sample of the general population.

Methods

Four hundred and thirteen subjects (190 women, 223 men; aged 29–75 years) were studied first in 2002 and again eleven years later in 2013. All subjects were interviewed using a standardised questionnaire, anthropometric data were recorded, and an abdominal ultrasound scan was carried out.

Results

The prevalence of gallbladder polyps was 6.1% (115/1880) in the 2002 study and 12.1% (50/413) in the 2013 follow-up study. After eleven years, 36 subjects (8.7%, 36/413) had developed new polyps, thirteen subjects (48.1%, 13/27) no longer had gallbladder polyps, and 14 subjects (51.9%, 14/27) still had polyps. The number of polyps had increased in six of these subjects (43%, 6/14), decreased in a further six (43%, 6/14), and remained unchanged in two (14%, 2/14). The mean polyp size was 4.7 mm (± 2.2 mm, range 2–20 mm) in 2002 and 4.0 mm (± 1.9 mm, range 0.5–11 mm) at follow-up. A decrease in polyp size was noted in seven (50%) of the 14 subjects, an increase in size in five subjects (35.7%), and no change in two subjects (14.3%). The shape of the polyps had changed from pedunculated to sessile in two subjects (14.3%, 2/14) and from sessile to pedunculated in one subject (7.1%, 1/14).

Conclusions

In long-term follow-up, the prevalence of gallbladder polyps increased, with new lesions developing in 8.7% of the population. Polyps persisted in 51.9% of the subjects who had them in the original study and disappeared in the other 48.1%.

Frequency, Risk Factors, and Outcome of Gallbladder Polyps in Patients With Primary Sclerosing Cholangitis: A Case-Control Study

The prevalence polyps (GBPs) in the general population has been estimated to be approximately 5%, with up to 10% of these being dysplastic or malignant. Previous studies have suggested that patients with primary sclerosing cholangitis (PSC) have increased frequency of GBPs. However, data on the prevalence, risk factors, and outcome of GBPs in these patients are sparse. This case‐control study investigates the frequency, risk factors, and outcome of GBPs in patients with PSC. In this study, 363 patients with an established diagnosis of PSC based on magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), or liver biopsy were identified. Patients with at least one abdominal imaging and no history of cholecystectomy before the first available abdominal imaging were included. The presence of GBPs was confirmed by abdominal computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound. Patients with GBPs were compared to those without GBPs. Furthermore, patients with malignant/premalignant polyps were compared to those with benign polyps. The frequency of GBPs in patients with PSC was 10.6%. There was no significant difference in the frequency of inflammatory bowel disease (IBD) between the two groups. Of the 16 with GBPs who underwent cholecystectomy, 10 had malignant/premalignant lesions, of whom 6 had adenocarcinoma, and 4 had high‐grade dysplasia. Of the 6 patients with adenocarcinoma, 4 had lesions >10 mm, 1 had a lesion as small as 4 mm, and 1 had a 7‐mm lesion. Conclusion: GBPs may be frequently seen in patients with PSC. These lesions seem to occur independent of IBD. In patients with PSC, even small GBPs appear to have a risk of malignancy. These findings suggest that patients with PSC and GBPs may benefit from cholecystectomy, regardless of the size of the polyp.

Current practices and future prospects for the management of gallbladder polyps: A topical review

A gallbladder polyp is an elevation of the gallbladder mucosa that protrudes into the gallbladder lumen. Gallbladder polyps have an estimated prevalence in adults of between 0.3%-12.3%. However, only 5% of polyps are considered to be "true" gallbladder polyps, meaning that they are malignant or have malignant potential. The main radiological modality used for diagnosing and surveilling gallbladder polyps is transabdominal ultrasonography. However, evidence shows that other modalities such as endoscopic ultrasound may improve diagnostic accuracy. These are discussed in turn during the course of this review. Current guidelines recommend cholecystectomy for gallbladder polyps sized 10 mm and greater, although this threshold is lowered when other risk factors are identified. The evidence behind this practice is relatively low quality. This review identifies current gaps in the available evidence and highlights the necessity for further research to enable better decision making regarding which patients should undergo cholecystectomy, and/or radiological follow-up.

Trends of Gallbladder Cancer in Jordan Over 2 Decades: Where Are We?

Background and Study Aims:

The prevalence of gallbladder cancer (GBC) varies between different parts of the world. This study is a review of literature and an update of a previously published study conducted in our university and aims to reassess the incidence of GBC over the past 2 decades.

Patients and Methods:

We conducted a retrospective study between 2002 and 2016. Data regarding demographics, clinical presentation, risk factors, histopathology, investigations, and treatments were obtained. A diagnosis of GBC established during surgery or primarily detected in the surgical specimen was classified as incidental.

Results:

Of 11 391 cholecystectomies performed, 31 cases (0.27%) of GBC were found. The mean age of patients with GBC was 68 years (43-103 years), 74% were women. The annual incidence of GBC was 0.2/100 000 (men: 0.1/100 000; women: 0.3/100 000). Biliary colic and acute cholecystitis were the main presentations. Diagnosis of GBC was “incidental” in 67% of cases. About 75% of patients with GBC had gallstones, 13% had polyps, and 3% had porcelain gallbladder. Adenocarcinoma was the dominant (87%) histologic type.

Conclusions:

The GBC rate in our region, similar to others parts of the world, is still low and has not changed over the past 2 decades. This study consolidates the previously published recommendations regarding the high index of suspicion of GBC in elderly with cholelithiasis.

The gallbladder polypoid-lesions conundrum: moving forward with controversy by looking back

Gallbladder polypoid-lesions (GPs) are found in 5-10% of the general population. Although the majority of GPs are asymptomatic and benign in nature, some of them can develop into cancer, which carries a poor prognosis. Currently, the risk factors, natural history and classification of GPs remain unclear, differentiation of benign from malignant or premalignant GPs based on available diagnostic modalities and/or features of patients and GPs remain difficult, and there are still no evidence-based guidelines to dictate when and how GPs of varying sizes and subtypes should be managed. All of these facts have left GPs in uncertainty. Areas covered: A literature search was performed using the terms 'gallbladder polyps' AND 'polypoid lesion of gallbladder' in the PubMed database from January 2000 to September 2016. Original and review articles on almost all aspects of GPs in humans, especially diagnosis, treatment and surveillance, were reviewed and analyzed. Reference lists of reviews and original articles were also examined for relevant publications. Expert commentary: The present article summarizes almost all aspects of GPs, analyzes the controversies, and outlines our data and comments. It is the authors' purpose that this article be beneficial for scientific, accurate and appropriate management of GPs.

Gallbladder cancer epidemiology, pathogenesis and molecular genetics: Recent update

Gallbladder cancer is a malignancy of biliary tract which is infrequent in developed countries but common in some specific geographical regions of developing countries. Late diagnosis and deprived prognosis are major problems for treatment of gallbladder carcinoma. The dramatic associations of this orphan cancer with various genetic and environmental factors are responsible for its poorly defined pathogenesis. An understanding to the relationship between epidemiology, molecular genetics and pathogenesis of gallbladder cancer can add new insights to its undetermined pathophysiology. Present review article provides a recent update regarding epidemiology, pathogenesis, and molecular genetics of gallbladder cancer. We systematically reviewed published literature on gallbladder cancer from online search engine PubMed (http://www.ncbi.nlm.nih.gov/pubmed). Various keywords used for retrieval of articles were Gallbladder, cancer Epidemiology, molecular genetics and bullion operators like AND, OR, NOT. Cross references were manually searched from various online search engines (http://www.ncbi.nlm.nih.gov/pubmed,https://scholar.google.co.in/, http://www.medline.com/home.jsp). Most of the articles published from 1982 to 2015 in peer reviewed journals have been included in this review.

Management and follow-up of gallbladder polyps : Joint guidelines 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)

Objectives

The management of incidentally detected gallbladder polyps on radiological examinations is contentious. The incidental radiological finding of a gallbladder polyp can therefore be problematic for the radiologist and the clinician who referred the patient for the radiological examination. To address this a joint guideline was created by 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).

Methods

A targeted literature search was performed and consensus guidelines were created using a series of Delphi questionnaires and a seven-point Likert scale.

Results

A total of three Delphi rounds were performed. Consensus regarding which patients should have cholecystectomy, which patients should have ultrasound follow-up and the nature and duration of that follow-up was established. The full recommendations as well as a summary algorithm are provided.

Conclusions

These expert consensus recommendations can be used as guidance when a gallbladder polyp is encountered in clinical practice.

Key Points

• Management of gallbladder polyps is contentious

• Cholecystectomy is recommended for gallbladder polyps >10 mm

• Management of polyps <10 mm depends on patient and polyp characteristics

• Further research is required to determine optimal management of gallbladder polyps

Polypoid lesions of the gallbladder: disease spectrum with pathologic correlation

Gallbladder polyps are seen on as many as 7% of gallbladder ultrasonographic images. The differential diagnosis for a polypoid gallbladder mass is wide and includes pseudotumors, as well as benign and malignant tumors. Tumefactive sludge may be mistaken for a gallbladder polyp. Pseudotumors include cholesterol polyps, adenomyomatosis, and inflammatory polyps, and they occur in that order of frequency. The most common benign and malignant tumors are adenomas and primary adenocarcinoma, respectively. Polyp size, shape, and other ancillary imaging findings, such as a wide base, wall thickening, and coexistent gallstones, are pertinent items to report when gallbladder polyps are discovered. These findings, as well as patient age and risk factors for gallbladder cancer, guide clinical decision making. Symptomatic polyps without other cause for symptoms, an age over 50 years, and the presence of gallstones are generally considered indications for cholecystectomy. Incidentally noted pedunculated polyps smaller than 5 mm generally do not require follow-up. Polyps that are 6-10 mm require follow-up, although neither the frequency nor the length of follow-up has been established. Polyps that are larger than 10 mm are typically excised, although lower size thresholds for cholecystectomy may be considered for patients with increased risk for gallbladder carcinoma, such as patients with primary sclerosing cholangitis.

Gallbladder Cancer in the 21st Century

Gallbladder cancer (GBC) is an uncommon disease in the majority of the world despite being the most common and aggressive malignancy of the biliary tree. Early diagnosis is essential for improved prognosis; however, indolent and nonspecific clinical presentations with a paucity of pathognomonic/predictive radiological features often preclude accurate identification of GBC at an early stage. As such, GBC remains a highly lethal disease, with only 10% of all patients presenting at a stage amenable to surgical resection. Among this select population, continued improvements in survival during the 21st century are attributable to aggressive radical surgery with improved surgical techniques. This paper reviews the current available literature of the 21st century on PubMed and Medline to provide a detailed summary of the epidemiology and risk factors, pathogenesis, clinical presentation, radiology, pathology, management, and prognosis of GBC.