Polypoid lesions of the gallbladder: report of 100 cases with special reference to operative indications

Recent Advances in Endoscopic Ultrasound for Gallbladder Disease Diagnosis

Gallbladder (GB) disease is classified into two broad categories: GB wall-thickening and protuberant lesions, which include various lesions, such as adenomyomatosis, cholecystitis, GB polyps, and GB carcinoma. This review summarizes recent advances in the differential diagnosis of GB lesions, focusing primarily on endoscopic ultrasound (EUS) and related technologies. Fundamental B-mode EUS and contrast-enhanced harmonic EUS (CH-EUS) have been reported to be useful for the diagnosis of GB diseases because they can evaluate the thickening of the GB wall and protuberant lesions in detail. We also outline the current status of EUS-guided fine-needle aspiration (EUS-FNA) for GB lesions, as there have been scattered reports on EUS-FNA in recent years. Furthermore, artificial intelligence (AI) technologies, ranging from machine learning to deep learning, have become popular in healthcare for disease diagnosis, drug discovery, drug development, and patient risk identification. In this review, we outline the current status of AI in the diagnosis of GB.

Advances in the Early Detection of Hepatobiliary Cancers

Hepatocellular cancer (HCC) and biliary tract cancers (BTCs) have poor survival rates and a low likelihood of a cure, especially in advanced-stage disease. Early diagnosis is crucial and can significantly improve survival rates through curative treatment approaches. Current guidelines recommend abdominal ultrasonography (USG) and alpha-fetoprotein (AFP) monitoring for HCC screening in high-risk groups, and abdominal USG, magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) monitoring for biliary tract cancer. However, despite this screening strategy, many high-risk individuals still develop advanced-stage HCC and BTC. Blood-based biomarkers are being developed for use in HCC or BTC high-risk groups. Studies on AFP, AFP-L3, des-gamma-carboxy prothrombin, glypican-3 (GPC3), osteopontin (OPN), midkine (MK), neopterin, squamous cell carcinoma antigen (SCCA), Mac-2-binding protein (M2BP), cyclic guanosine monophosphate (cGMP), and interleukin-6 biomarkers for HCC screening have shown promising results when evaluated individually or in combination. In the case of BTCs, the potential applications of circulating tumor DNA, circulating microRNA, and circulating tumor cells in diagnosis are also promising. These biomarkers have shown potential in detecting BTCs in early stages, which can significantly improve patient outcomes. Additionally, these biomarkers hold promise for monitoring disease progression and evaluating response to therapy in BTC patients. However, further research is necessary to fully understand the clinical utility of these biomarkers in the diagnosis and management of HCC and BTCs.

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.

A New Risk Scoring System to Predict Malignancy in Gallbladder Polyps: a Single-Center Study

OBJECTIVE

Ultrasonography (US) is the most commonly used radiological method in the diagnosis of gallbladder polyps (GBPs). Patients diagnosed with GBPs on US are operated on with risk factors that do not have a high level of evidence. Our aim in this study is to determine the sensitivity of US in diagnosis GBPs, to define risk factors for neoplastic (NP) polyps, and to develop the risk scoring system.

MATERIALS AND METHODS

Between July 2011 and July 2021, 173 patients who were found to have GBPs in the pathology specimens after cholecystectomy were included in the study. Patients were divided into two groups: nonneoplastic and NP groups.

RESULTS

GBPs in patients who underwent abdominal US for any reason was 4.5%. The sensitivity of US in the diagnosis of GBPs was 56.6%. Comparison between groups, age ≥50, presence of symptoms, polyp size >12.5mm, single polyp, concomitant gallstones, and gallbladder wall thickness ≥4mm were statistically in the NP group. A risk scoring system was developed using these values. If the risk score was <4, 0.6% of GBPs was NP polyps. If the risk score was ≥4, 63.2% of GBPs were NP polyps.

CONCLUSION

Our risk scoring system can prevent unnecessary choelcystectomy. Because the incidence of NP polyps in low-risk patients (risk score <4) is extremely rare.

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.

Longitudinal Ultrasound Assessment of Changes in Size and Number of Incidentally Detected Gallbladder Polyps

BACKGROUND. Previous European multisociety guidelines recommend routine follow-up imaging of gallbladder polyps (including polyps < 6 mm in patients without risk factors) and cholecystectomy for polyp size changes of 2 mm or more. OBJECTIVE. The purpose of this study was to assess longitudinal changes in the number and size of gallbladder polyps on serial ultrasound examinations. METHODS. This retrospective study included patients who underwent at least one ultrasound examination between January 1, 2010, and December 31, 2020 (as part of a hepatocellular carcinoma screening and surveillance program) that showed a gallbladder polyp. Number of polyps and size of largest polyp were recorded based primarily on review of examination reports. Longitudinal changes on serial examinations were summarized. Pathologic findings from cholecystectomy were reviewed. RESULTS. Among 9683 patients, 759 (8%) had at least one ultrasound examination showing a polyp. Of these, 434 patients (248 men, 186 women; mean age, 50.6 years) had multiple examinations (range, 2-19 examinations; mean, 4.8 examinations per patient; mean interval between first and last examinations, 3.6 ± 3.1 [SD] years; maximum interval, 11.0 years). Among these 434 patients, 257 had one polyp, 40 had two polyps, and 137 had more than two polyps. Polyp size was 6 mm or less in 368 patients, 7-9 mm in 52 patients, and 10 mm or more in 14 patients. Number of polyps increased in 9% of patients, decreased in 14%, both increased and decreased on serial examinations in 22%, and showed no change in 55%. Polyp size increased in 10% of patients, decreased in 16%, both increased and decreased on serial examinations in 18%, and showed no change in 56%. In 9% of patients, gallbladder polyps were not detected on follow-up imaging; in 6% of patients, gallbladder polyps were not detected on a follow-up examination but were then detected on later studies. No gallbladder carcinoma was identified in 19 patients who underwent cholecystectomy. CONCLUSION. Gallbladder polyps fluctuate in size, number, and visibility over serial examinations. Using a 2-mm threshold for growth, 10% increased in size. No carcinoma was identified. CLINICAL IMPACT. European multisociety guidelines that propose surveillance of essentially all polyps and a 2-mm size change as the basis for cholecystectomy are likely too conservative for clinical application.

The Role of Endoscopic Ultrasound in the Diagnosis of Gallbladder Lesions

Gallbladder (GB) diseases represent various lesions including gallstones, cholesterol polyps, adenomyomatosis, and GB carcinoma. This review aims to summarize the role of endoscopic ultrasound (EUS) in the diagnosis of GB lesions. EUS provides high-resolution images that can improve the diagnosis of GB polypoid lesions, GB wall thickness, and GB carcinoma staging. Contrast-enhancing agents may be useful for the differential diagnosis of GB lesions, but the evidence of their effectiveness is still limited. Thus, further studies are required in this area to establish its usefulness. EUS combined with fine-needle aspiration has played an increasing role in providing a histological diagnosis of GB tumors in addition to GB wall thickness.

Value of high frame rate contrast-enhanced ultrasound in distinguishing gallbladder adenoma from cholesterol polyp lesion

OBJECTIVES

To compare the diagnostic value of high frame rate contrast-enhanced ultrasound (H-CEUS) in distinguishing gallbladder adenomas from cholesterol polyp lesions with that of CEUS.

METHODS

This study enrolled 94 patients with gallbladder polyp lesions (GPLs) who underwent laparoscopic cholecystectomy. CEUS and H-CEUS were performed before surgery. The perfusion features of GPLs and the final diagnosis as determined by both technologies were compared.

RESULTS

There were differences in vascular types between gallbladder adenomas and cholesterol polyp lesions observed on H-CEUS (p < 0.05), while there were no differences in vascular types between gallbladder adenomas and cholesterol polyp lesions observed on CEUS (p > 0.05). In the cholesterol polyp lesion group, there were no differences in vascular types between CEUS and H-CEUS (p > 0.05), while the vascular types were different between CEUS and H-CEUS in the gallbladder adenoma group (p < 0.05). The diagnostic value of H-CEUS in distinguishing gallbladder adenomas from cholesterol polyp lesions was better than that of CEUS.

CONCLUSIONS

H-CEUS improved the time resolution by increasing the frame rate, which helped to accurately reflect the difference in the microcirculation of GPLs and improved the ability of a differential diagnosis between cholesterol polyp lesions and adenomas. H-CUES may provide an effective means of imaging for patients with GPLs regarding the choice of treatment options.

KEY POINTS

• High frame rate CEUS improves the time resolution of CEUS by increasing the frame rate. • High frame rate CEUS is helpful to accurately evaluate the microvascular morphology of a gallbladder polyp lesion in the arterial phase. • High frame rate CEUS helps patients with gallbladder polyp lesions to choose the appropriate treatment means.

Pyloric adenomatous carcinoma of the gallbladder following laparoscopic cholecystectomy: A case report

INTRODUCTION

Adenoma and intra-adenoma carcinoma of the gallbladder are relatively rare diseases, and the World Health Organization classification reports a frequency of 0.3% for gallbladder adenomas. Precise preoperative diagnosis of gallbladder cancer, especially in the early stages, is challenging. Herein, we report a case of pyloric adenomatous carcinoma of the gallbladder, diagnosed by laparoscopic cholecystectomy and pathology, along with a literature review. This case was reported in accordance with the SCARE 2020 Guideline (Ref).

PRESENTATION OF CASE

A 62-year-old woman was diagnosed with a 4-mm polypoid lesion in the gallbladder during a medical examination. The patient was followed-up by ultrasonography (US) once a year and was referred to our department because of an increase in size. Carcinoembryonic antigen and carbohydrate antigen 19-9 levels were within normal limits. Abdominal ultrasonography revealed a pedunculated polypoid lesion in the body of the gallbladder measuring 8 mm. Computed tomography demonstrated that the whole tumor was enhanced in the early phase without significant lymph node enlargement. Magnetic resonance cholangiopancreatography demonstrated a type Ip polypoid lesion located in the body of the gallbladder without pancreaticobiliary junctional abnormalities. Endoscopic ultrasound detected a superficial nodular-type Ip polypoid lesion in the gallbladder body with a parenchyma-like internal echogenic pattern.

DISCUSSION

Based on these findings, the patient was diagnosed with gallbladder adenoma, and laparoscopic cholecystectomy was performed. Histopathological examination revealed the tumor was a papillary growth of atypical high columnar epithelial cells. The final diagnosis was pyloric adenoma with high-grade dysplasia and intra-adenoma carcinoma. The patient is currently undergoing outpatient follow-up without recurrence for 1 year.

CONCLUSION

Early gallbladder carcinoma with adenoma should be considered in patients with small gallbladder polypoid lesions. Considering the surgical stress of cholecystectomy and the malignant potential of gallbladder cancer, preceding surgery would be acceptable.

Intracystic Papillary Neoplasm of Gallbladder Mimicking Metastatic Malignancy on PET/CT

ABSTRACT

Intracystic papillary neoplasm of the gallbladder is a rare preinvasive neoplastic lesion with similar characteristics as intraductal papillary mucinous neoplasm and other papillary neoplasms of pancreaticobiliary system. We report a case of 48-year-old woman with a history of recurrent right flank chondrosarcoma and gallbladder lesion on MRI and PET/CT interpreted as indeterminate for metastatic disease. Subsequent cholecystectomy showed intracystic papillary neoplasm. With gallbladder lesions being rare on PET/CT, this case illustrates the importance of considering both primary and secondary tumors in the differential diagnosis.

Surgical Choice for Different Types of Gallbladder Adenomyomatosis: An Initial Experience of 20 Years Laparoscopic Cholecystectomy

OBJECTIVES

The objective of this study was to compare the difference of clinical biochemical statistics in different types of gallbladder adenomyomatosis (GA). To investigate the different effects of patients between the 3 different types of GA.

MATERIALS AND METHODS

Retrospective analysis of the clinical data of the adenomyomatosis patients that come from our hospital between 2010 to 2018. According to the preoperative image (all cases are performed as elective surgery), it could be divided into 3 groups: group A: fundal (localized) type; group B: segmental type; group C: diffuse type. The number of each group is 136, 27, 17. We analyze the biochemical statistics (total bilirubin, direct bilirubin, serum bile acid, alanine aminotransferase, aspartate aminotransferase, cholinesterase, etc.) of the 3 groups to explore the difference in operative mode, operative time and prognosis between these 3 groups.

RESULTS

(1) In the liver function statistics, aspartate aminotransferase has the statistical significance (F=4.974, P=0.012); (2) And the diffuse adenomyomatosis might have a higher bile acid (F=6.048, P=0.005); (3) The segmental and diffuse adenomyomatosis is easier to be combined with stones (F=19.226, P<0.001); (4) The fundal adenomyomatosis seems to have a better prognosis: fewer hospital stay (F=4.519, P=0.018), fewer drainage time (F=6.575, P=0.004) and fewer complications (χ=29.429, P<0.001).

CONCLUSIONS

GA is a disease characterized by epithelial proliferation and hypertrophy of the muscles of the gallbladder wall with an outpouching of the mucosa into or through the thickened muscular layer and cannot be regarded as a precancerous lesion based on available evidence. As for asymptomatic GA, conservative treatment is recommended with ultrasound examinations twice a year. The fundal type GA can be treated by partial laparoscopic cholecystectomy. The segmental and diffuse-type should undergo a total laparoscopic cholecystectomy.

Imaging based flowchart for gallbladder polyp evaluation

BACKGROUND

Preoperative differentiation between neoplastic and nonneoplastic gallbladder polyps, and the subsequent indication for cholecystectomy remains a clinical dilemma. The current 1 cm size threshold for neoplasia is unspecific. The aim of this study was to improve diagnostic work-up for gallbladder polyps using sonographic and MRI characteristics of neoplastic and nonneoplastic polyps.

METHODS

A prospective, exploratory study including patients undergoing cholecystectomy for gallbladder polyp(s) was conducted. Patients underwent targeted transabdominal ultrasound (TAUS) and MRI. Outcomes were sensitivity and specificity for polyp diagnosis, and the radiological characteristics of neoplastic and nonneoplastic polyp types. Histopathology after cholecystectomy was used as reference standard.

RESULTS

Histopathology demonstrated gallbladder polyps in 20/27 patients (74%): 14 cholesterol polyps, three adenomyomatosis, two adenomas and one gastric heterotopia. Sensitivity of polyp identification were 72% (routine TAUS) and 86% (targeted TAUS and MRI). Both adenomas were identified as neoplastic on targeted TAUS and MRI. Sonographic presentation as multiple, pedunculated polyps, either heterogeneous or with hyperechoic foci, or as single polyps containing cysts were limited to nonneoplastic polyps. On MRI hyperintense polyps on T1-weighted image were cholesterol polyps. An adenoma with high-grade dysplasia showed foci of decreased ADC values. We propose a checklist for polyp evaluation by targeted TAUS and a flowchart for radiological work-up of gallbladder polyps.

CONCLUSIONS

The presented checklist and flowchart could aid diagnostic work-up for gallbladder polyps compared to current routine ultrasound, by elimination of nonneoplastic polyps and ultimately improve treatment decision for patients with gallbladder polyps.

Is contrast enhanced ultrasonography an accurate way to diagnose gallbladder adenoma? A systematic review and meta-analysis

INTRODUCTION

Gallbladder adenoma (GA) is a precancerous neoplasm and needs surgical resection. It is difficult to differentiate adenoma from other gallbladder polyps using imaging examinations. The aim of present systematic review and meta-analysis was to evaluate the diagnostic accuracy of contrast-enhanced ultrasound in the diagnosis of gallbladder adenoma.

METHODS

The searches were conducted by two independent researchers to find the relevant studies published from 1/1/2009 until end of 30/06/2019. The search included published literature in the English language in MEDLINE via PubMed, EMBASE via Ovid, The Cochrane Library, and Trip databases. For literature published in other languages, national databases (Magiran and SID), KoreaMed, and LILACS were searched. The risk of bias of every article was evaluated by using QUADAS-2. On the basis of the results from the 2 × 2 tables, pooled measures for sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curves (AUC) along with their 95% confidence intervals (CIs) were calculated using the DerSimonian Lair methodology.

RESULTS

Overall, 868 patients were studied in the 10 studies chosen for inclusion. Of these 10 studies, 5 (50%) were retrospective and 5 (50%) were prospective. The total prevalence of gallbladder adenoma in 10 studies was 16% (95% CI 13%, 18%). The sensitivity and specificity of contrast-enhanced ultrasound were 0.846 (95% CI 0.818-0.871) and 0.870 (95% CI: 0.844-0.894), respectively. The diagnostic odds ratio was 40.807 (95% CI 18.838-88.393).

CONCLUSION

CEUS is a reliable, non-invasive, and no-radiation-exposure imaging modality with a high sensitivity and specificity for detection of gallbladder adenoma. Nonetheless, it should be applied cautiously, and large scale, well-designed trials are necessary to assess its clinical value.

Role of endoscopic ultrasound for gallbladder disease

Endoscopic ultrasonography (EUS) has excellent spatial resolution and allows more detailed examination than abdominal ultrasonography (US) in terms of qualitative diagnosis of tumors and evaluation of tumor invasion depth. To understand the role of EUS in gallbladder disease, we need to understand the normal gallbladder wall structure and how to visualize it on EUS. In addition, gallbladder lesions can be classified into two broad categories: protuberant and wall-thickening lesions. Here, the features on EUS were outlined. We also outlined the current status of EUS-FNA for gallbladder lesions as there have been scattered reports of EUS-FNA in recent years.

[Surgical treatment of gallbladder polyps]

OBJECTIVE

To study the incidence of gallbladder polyps and the possibilities of modern methods of diagnosis and surgical treatment of this disease.

MATERIAL AND METHODS

There were 42 laparoscopic cholecystectomies in patients with diagnosed gallbladder polyps. The polyps were diagnosed preoperatively. Intraoperative diagnosis during surgery for gallstone disease was observed in 3 cases. A comparative analysis of preoperative examination did not reveal any advantages of certain diagnostic approach.

RESULTS

Hyperplastic polyp was the most common type (n=20, 47.6%), adenomatous polyps occurred in 19 (45.3%) cases, cholesteric polyps - in 3 (7.1%) patients. All patients had signs of chronic inflammation of the gallbladder wall with its infiltration by lymphocytes and histiocytes.

CONCLUSION

Further studies with clear criteria for the diagnosis of gallbladder polyps including ones for determining true polyps, precancerous and malignant polyps are required.

Clinical relevance of gallbladder polyps; is cholecystectomy always necessary?

BACKGROUND

Gallbladder polyps are common incidental findings during abdominal ultrasonography. Cholecystectomy is recommended for polyps equal or greater than 10 mm on ultrasound due to their malignant potential. However, the majority of lesions appear to be pseudopolyps with no malignant potential. Our aim was to determine the correlation between ultrasonographic findings and histopathological findings after cholecystectomy for gallbladder polyps in two institutions.

METHOD

A retrospective analysis was performed at two Dutch institutions of patients who underwent cholecystectomy. All cholecystectomies for suspected gallbladder polyps between January 2010 and August 2017 were included. Ultrasonographic and histopathological reports were analyzed.

RESULTS

A total of 108 patients underwent cholecystectomy for gallbladder polyps. At abdominal ultrasound sixty-five patients (60.2%) were diagnosed with multiple gallbladder polyps. The mean diameter of the polyps was 11 mm. On pathological examination after cholecystectomy, only three specimens harbored true polyps. No anomalies were found in 48 (44%) patients and 51 (47%) had cholesterolosis.

CONCLUSION

The prevalence of true gallbladder polyps was much lower in this study than reported in literature. After cholecystectomy for gallbladder polyps diagnosed by ultrasound, 97% of patients had non-neoplastic or not identifiable lesions in the gallbladder. These findings question the usefulness of current guidelines for management of suspected gallbladder polyps.

Gallbladder Polyps: Rare Lesions in Childhood

OBJECTIVE

Unlike adults, gallbladder polyps (GPs) are rare in childhood. The aim of this study was to evaluate patients with a GP diagnosis.

METHODS

Patients who were diagnosed with GP via ultrasonography from October 2012 to October 2017 were retrospectively evaluated in terms of sociodemographic characteristics and laboratory findings.

RESULTS

The study included 19 patients diagnosed with GP and followed up in our department. The patients comprised 14 (73.6%) girls with a mean age of 13.9 ± 4.1 years and a mean follow-up period of 10.2 ± 5.4 months (range, 3-26 months). The most common presenting symptom of the patients (n = 15, 78.9%) for ultrasonography was abdominal pain without biliary symptoms. Location of the polyps was in the corpus in 55% of patients, and either in the fundus (20%) or the neck of the gallbladder (25%). The average diameter of the polyps was 4.5 ± 1.6 mm (range, 2-9 mm). Multiple polyps were observed in 3 patients. No significant change in the number or size of polyps was noted at the end of the follow-up periods. Cholecystectomy was applied to 1 patient who had >5 polyps with a rapid increase in size, and the pathology report was hamartomatous polyp. There was no remarkable change in the clinical or laboratory findings of other patients during the follow-up period.

CONCLUSION

In this study, GPs could be seen in young children as young as 16 months of age and ultrasonography is sufficient for follow-up in stable and asymptomatic patients.

Neoplastic polyps in gallbladder: a retrospective study to determine risk factors and treatment strategy for gallbladder polyps

Background

Preoperative differentiation of malignant and premalignant gallbladder polyps (GBPs) from benign lesions is a key imperative to guide treatment decision-making. We aimed to characterize the various types of GBPs and sought to identify the risk factors for neoplastic polyps. Our findings may help optimize treatment strategy.

Methods

Retrospective analysis of 686 patients with post-cholecystectomy pathologically-proven GBPs between January 2003 and December 2016. The patients were classified into non-neoplastic polyp group, benign neoplastic polyp group, and adenoma canceration group. Clinical features, ultrasound findings, and results of laboratory investigations and histopathological examination were reviewed and compared between the groups.

Results

Out of 686 patients, 542 (79.0%) had non-neoplastic polyps, 134 (19.5%) had neoplastic polyps, and 10 (1.5%) had adenoma canceration. The mean age was 46.06±12.12 years; 383 (55.8%) patients were female. The median (25^th percentile, 75^th percentile) time between diagnosis and surgery in the cholesterol polyp group [24 (3.5, 60) months] was significantly longer than that in adenoma [12 (2, 60) months] and adenoma canceration [5 (0.475, 12) months] groups. The mean diameter was 1.14±0.61 cm (range, 0.5-8.4 cm). Three hundred twelve (45.5%) patients had solitary polyps and intralesional blood flow was observed in 41 (6.0%) patients. On univariate analysis, age >49.5 years, polyp size >1.15 cm, solitary polyp, intralesional blood flow, absence of symptoms, and lack of cholecystitis showed a significant association with adenoma. On multivariate analysis, polyp size (>1.15 cm), intralesional blood flow, and lack of cholecystitis were independent predictors of adenoma.

Conclusions

Polyp size >1.15 cm, intralesional blood flow, and lack of cholecystitis were predictors of neoplastic polyps. Malignant transformation of adenoma may occur over a relatively short time.

Quantitative contrast-enhanced US helps differentiating neoplastic vs non-neoplastic gallbladder polyps

OBJECTIVES

To differentiate between large (≥ 1 cm in diameter) gallbladder (GB) non-neoplastic and neoplastic polyps using quantitative analysis of contrast-enhanced ultrasound (CEUS) findings.

METHODS

From September 2017 to May 2018, 29 patients (10 males; median age, 63 years) with GB polyps of ≥ 1 cm in diameter who were undergoing cholecystectomy were consecutively enrolled. All patients underwent preoperative conventional US and CEUS examinations. Quantitative analysis of CEUS findings using time-intensity curves between the two groups was independently performed by two radiologists. The interobserver agreement for the quantitative analysis of the CEUS results was measured using the intraclass correlation coefficient. Receiver operating characteristic analysis was performed to evaluate the diagnostic performance of CEUS examination.

RESULTS

After the cholecystectomy, the patients were classified into the non-neoplastic polyp group (n = 12) and the neoplastic polyp group (n = 17) according to the pathological results. The interobserver agreement for quantitative assessment between the two radiologists was near perfect to substantial. Quantitative assessment of the CEUS findings revealed that the rise time, mean transit time, time to peak, and fall time of non-neoplastic GB polyps were significantly shorter than those of neoplastic polyps (p < 0.001, p = 0.008, p = 0.013, and p = 0.002, respectively). The sensitivity and specificity of the quantitative CEUS parameters for the differentiation between the two groups were 76.5-100% and 75%, respectively, with an area under the curve of 0.765-0.887.

CONCLUSIONS

Quantitative analysis of CEUS findings could be valuable in differentiating GB neoplastic polyps from non-neoplastic polyps.

KEY POINTS

• Quantitative analysis of CEUS findings could be valuable in differentiating gallbladder neoplastic polyps from non-neoplastic polyps. • Quantitative analysis of CEUS findings in gallbladder polyps provides cut-off values for differentiation between neoplastic polyps and non-neoplastic polyps with near-perfect to substantial interobserver agreement.

Gallbladder polypoid lesions are inaccurately reported and undermanaged: a retrospective study of the management of gallbladder polypoid lesions detected at ultrasound in symptomatic patients during a 36-month period

AIM

To investigate whether gallbladder polypoid lesions (GPL) are accurately reported and managed by radiologists, sonographers, general practitioners (GPs) and surgeons.

MATERIALS AND METHODS

Consecutive abdominal ultrasound examinations indicating GPL in symptomatic patients performed during 2011-2013 were captured and analysed. The study comprised 244 patients who satisfied the inclusion criteria.

RESULTS

Of the ultrasound reports retrieved, 238/244 reports (98%) erroneously described the polypoid lesions as polyps. One hundred and thirty-two of the 244 (54%) reports recommended follow-up, 5/244 (2%) recommended no follow-up, 35/244 (14%) deemed the findings insignificant, and 72/244 (30%) did not comment. Regarding GP referral, 57/184 (31%) patients were correctly referred to general surgeons, 20/184 (11%) to gastroenterologists, and 107/184 (58%) were not referred to secondary care. Forty-three of the 244 patients (18%) underwent cholecystectomy. Regarding subsequent biliary presentations, 63/244 patients (26%) presented at a later date with biliary symptoms; 13/63 (21%) of these eventually had cholecystectomies with 2/13 (15%) experiencing potentially life-threatening pancreatitis episodes. Regarding the surgical approach, differences were observed in the way individual surgeons managed polypoid lesions, with some veering towards cholecystectomy, others towards follow-up ultrasound, and some towards discharge.

CONCLUSION

GPL tend to be misreported by radiologists and sonographers, unappreciated by GPs, and variably managed by surgeons. These factors delay definitive therapy and seem to contribute to future biliary presentations. A fresh educational approach is required to raise awareness among radiologists, sonographers, and GPs regarding the clinical relevance and possible representations of GPL, and a uniform strategy is needed for managing GPL.

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%.

Diagnosis and Treatment of Gallbladder Polyps: Current Perspectives

INTRODUCTION

Gallbladder polyps (GBPs) are generally harmless, but the planning of diagnosis and treatment of the GBP is of clinical importance due to the high mortality risk of delays in the diagnosis of gallbladder carcinomas that show polypoid development.

MATERIALS AND METHODS

GBPs are usually incidentally detected during ultrasonographic (USG) examinations of the abdomen. The risk of carcinoma development from polypoid lesions in the literature is reported as 0-27%. There is no consensus about the management of the GBPs. Herein, we reviewed the contemporary data to update our knowledge about diagnosis and treatment of gallbladder polyps.

RESULTS

Polyps can be identified in five different groups, primarily as neoplastic and non-neoplastic. Cholesterol polyps account for 60% of all cases. The most common (25%) benign polypoid lesions after cholesterol polyps are adenomyomas.

CONCLUSION

Ultrasonography and endoscopic ultrasonography seems to be the most important tool in differential diagnosis and treatment. Ultrasonography should be repeated in every 3-12 months in cases that are thought to be risky. Nowadays, the most common treatment approach is to perform cholecystectomy in patients with polyps larger than 10 mm in diameter. Radical cholecystectomy and/or segmental liver resections should be planned in cases of malignancy.

HOW TO CITE THIS ARTICLE

Dilek ON, Karsu S, et al. Diagnosis and Treatment of Gallbladder Polyps: Current Perspectives. Euroasian J Hepatogastroenterol 2019;9(1):40-48.

Strategy for discriminating cholesterol and premalignancy in polypoid lesions of the gallbladder: a single-centre, retrospective cohort study

BACKGROUND

The present study aimed to assess the risk factors of cholesterol and premalignancy in polypoid lesions of the gallbladder (PLGs) and to establish an appropriate treatment strategy.

METHODS

Data from patients who underwent cholecystectomy at the First Affiliated Hospital, School of Medicine, Zhejiang University, between January 2011 and July 2017, were collected retrospectively.

RESULTS

A total of 1561 patients were included in the present study. The cohort comprised of 636 (40.7%) males and 925 (59.3%) females, with a mean age of 49.5 (range 16-88) years; 65.6% (1024/1561) demonstrated cholesterol lesions in this cohort, among which cholesterol polyps accounted for 81.0%. Age younger than 50 years and multiple number of polyps were found to be independent predictive variables for cholesterol lesions (odds ratio (OR) 3.461, 95% confidence interval (CI) 2.058-5.820, P < 0.001 and OR 3.321, 95% CI 1.988-5.547, P < 0.001, respectively). The presence of polyp growth was associated with premalignancy (OR 5.366, 95% CI 1.466-19.637, P = 0.011), and the presence of clinical symptoms indicated benign non-cholesterol lesions (OR 0.368, 95% CI 0.153-0.885, P = 0.026).

CONCLUSION

In the case of patients ≥50 years old with single asymptomatic polyp, cholecystectomy was recommended if the polyp presented growth at a rate above 3-4 mm within 6 months. If not, trimonthly ultrasound follow up was recommended, and clinicians should carefully assess the risk factors for premalignancy in PLGs.

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.

Transabdominal ultrasound and endoscopic ultrasound for diagnosis of gallbladder polyps

BACKGROUND

Approximately 0.6% to 4% of cholecystectomies are performed because of gallbladder polyps. The decision to perform cholecystectomy is based on presence of gallbladder polyp(s) on transabdominal ultrasound (TAUS) or endoscopic ultrasound (EUS), or both. These polyps are currently considered for surgery if they grow more than 1 cm. However, non-neoplastic polyps (pseudo polyps) do not need surgery, even when they are larger than 1 cm. True polyps are neoplastic, either benign (adenomas) or (pre)malignant (dysplastic polyps/carcinomas). True polyps need surgery, especially if they are premalignant or malignant. There has been no systematic review and meta-analysis on the accuracy of TAUS and EUS in the diagnosis of gallbladder polyps, true gallbladder polyps, and (pre)malignant polyps.

OBJECTIVES

To summarise and compare the accuracy of transabdominal ultrasound (TAUS) and endoscopic ultrasound (EUS) for the detection of gallbladder polyps, for differentiating between true and pseudo gallbladder polyps, and for differentiating between dysplastic polyps/carcinomas and adenomas/pseudo polyps of the gallbladder in adults.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and trial registrations (last date of search 09 July 2018). We had no restrictions regarding language, publication status, or prospective or retrospective nature of the studies.

SELECTION CRITERIA

Studies reporting on the diagnostic accuracy data (true positive, false positive, false negative and true negative) of the index test (TAUS or EUS or both) for detection of gallbladder polyps, differentiation between true and pseudo polyps, or differentiation between dysplastic polyps/carcinomas and adenomas/pseudo polyps. We only accepted histopathology after cholecystectomy as the reference standard, except for studies on diagnosis of gallbladder polyp. For the latter studies, we also accepted repeated imaging up to six months by TAUS or EUS as the reference standard.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, selected studies for inclusion, and collected data from each study. The quality of the studies was evaluated using the QUADAS-2 tool. The bivariate random-effects model was used to obtain summary estimates of sensitivity and specificity, to compare diagnostic performance of the index tests, and to assess heterogeneity.

MAIN RESULTS

A total of 16 studies were included. All studies reported on TAUS and EUS as separate tests and not as a combination of tests. All studies were at high or unclear risk of bias, ten studies had high applicability concerns in participant selection (because of inappropriate participant exclusions) or reference standards (because of lack of follow-up for non-operated polyps), and three studies had unclear applicability concerns in participant selection (because of high prevalence of gallbladder polyps) or index tests (because of lack of details on ultrasound equipment and performance). A meta-analysis directly comparing results of TAUS and EUS in the same population could not be performed because only limited studies executed both tests in the same participants. Therefore, the results below were obtained only from indirect test comparisons. There was significant heterogeneity amongst all comparisons (target conditions) on TAUS and amongst studies on EUS for differentiating true and pseudo polyps.Detection of gallbladder polyps: Six studies (16,260 participants) used TAUS. We found no studies on EUS. The summary sensitivity and specificity of TAUS for the detection of gallbladder polyps was 0.84 (95% CI 0.59 to 0.95) and 0.96 (95% CI 0.92 to 0.98), respectively. In a cohort of 1000 people, with a 6.4% prevalence of gallbladder polyps, this would result in 37 overdiagnosed and seven missed gallbladder polyps.Differentiation between true polyp and pseudo gallbladder polyp: Six studies (1078 participants) used TAUS; the summary sensitivity was 0.68 (95% CI 0.44 to 0.85) and the summary specificity was 0.79 (95% CI 0.57 to 0.91). Three studies (209 participants) used EUS; the summary sensitivity was 0.85 (95% CI 0.46 to 0.97) and the summary specificity was 0.90 (95% CI 0.78 to 0.96). In a cohort of 1000 participants with gallbladder polyps, with 10% having true polyps, this would result in 189 overdiagnosed and 32 missed true polyps by TAUS, and 90 overdiagnosed and 15 missed true polyps by EUS. There was no evidence of a difference between the diagnostic accuracy of TAUS and EUS (relative sensitivity 1.06, P = 0.70, relative specificity 1.15, P = 0.12).Differentiation between dysplastic polyps/carcinomas and adenomas/pseudo polyps of the gallbladder: Four studies (1,009 participants) used TAUS; the summary sensitivity was 0.79 (95% CI 0.62 to 0.90) and the summary specificity was 0.89 (95% CI 0.68 to 0.97). Three studies (351 participants) used EUS; the summary sensitivity was 0.86 (95% CI 0.76 to 0.92) and the summary specificity was 0.92 (95% CI 0.85 to 0.95). In a cohort of 1000 participants with gallbladder polyps, with 5% having a dysplastic polyp/carcinoma, this would result in 105 overdiagnosed and 11 missed dysplastic polyps/carcinomas by TAUS and 76 overdiagnosed and seven missed dysplastic polyps/carcinomas by EUS. There was no evidence of a difference between the diagnostic accuracy of TAUS and EUS (log likelihood test P = 0.74).

AUTHORS' CONCLUSIONS

Although TAUS seems quite good at discriminating between gallbladder polyps and no polyps, it is less accurate in detecting whether the polyp is a true or pseudo polyp and dysplastic polyp/carcinoma or adenoma/pseudo polyp. In practice, this would lead to both unnecessary surgeries for pseudo polyps and missed cases of true polyps, dysplastic polyps, and carcinomas. There was insufficient evidence that EUS is better compared to TAUS in differentiating between true and pseudo polyps and between dysplastic polyps/carcinomas and adenomas/pseudo polyps. The conclusions are based on heterogeneous studies with unclear criteria for diagnosis of the target conditions and studies at high or unclear risk of bias. Therefore, results should be interpreted with caution. Further studies of high methodological quality, with clearly stated criteria for diagnosis of gallbladder polyps, true polyps, and dysplastic polyps/carcinomas are needed to accurately determine diagnostic accuracy of EUS and TAUS.

Three cases of intracystic papillary neoplasm of gallbladder

Intracystic papillary neoplasm (ICPN) of gallbladder is a comparatively new concept and is described as pre-malignant lesions in Nakanuma et al. (In: Bosman et al. (eds) WHO Classification of Tumours of the Digestive System, World Health Organization of Tumours, IARC, Lyon, 2010). ICPN with high-grade intraepithelial neoplasia is understood to include intraepithelial carcinoma or noninvasive carcinoma. And lesions with invasive cancer components are classified as ICPN with an associated invasive carcinoma [1]. According to Adsay et al., more than half of patients diagnosed with ICPN have invasive cancer components (Adsay et al., Am J Surg Pathol 36:1279-1301, 2012).Polypoid masses in the gallbladder including benign, malignant, and non-neoplastic lesions have been called gallbladder polyps, and ICPN is also a polypoid lesion in the gallbladder. However, it is difficult to differentiate between them. In the literature, it is said that the possibility of malignancy is high in lesions exceeding 1 cm (Terzi et al., Surgery 127:622-627, 2000). And there are few reports on characteristic imaging findings of ICPN.We have experienced three cases (two females and one male) of ICPN and report our imaging findings. Contrast-enhanced computed tomography revealed large papillary polypoid lesions approximately 2-4 cm in size in the gallbladder. Findings suggestive of deformation of the gallbladder wall and extrinsic progression were absent in all cases. T2-weighted magnetic resonance imaging revealed intense signals and diffusion-weighted imaging showed high intensity. Expanding of the gallbladder was seen in case 1, and a tumor stalk-like appearance was seen in the papillary mass in cases 2 and 3. Surgery was performed in all three cases and ICPN was diagnosed pathologically. The cancer was localized to the mucosa, with no infiltration of surrounding tissue in all three cases.

Reasonable cholecystectomy of gallbladder polyp - 10 years of experience

BACKGROUND AND OBJECTIVE

Although the incidence of carcinoma is not high in gallbladder polyps, it is essential to diagnose gallbladder cancer at an early stage to achieve a good therapeutic outcome. Therefore, the aim of this study was to define the characteristics of gallbladder polyps to establish sound criteria for surgical indications.

METHODS

In the current study, data from 516 patients with gallbladder polyps who underwent cholecystectomy were reviewed to correlate clinical features with histopathologic findings and identify risk factors with receiver-operating characteristic curves (ROCs).

RESULTS

Among the 516 patients who underwent cholecystectomy, 24 patients (4.6%) had cancerous change. The cancer group was significantly older (65.5 years (median, range 35-85)) than the non-cancer group (42 years (median, range 23-82)) (p < 0.001). Among the cancer group, the preoperative polyp size on ultrasonography was significantly larger (14 mm (median, range 9-30)) than the polyps in the non-cancer group (10.4 mm (median, range 1.9-45)) (p < 0.001). Using the ROC curve and considering the sensitivity and specificity for predicting malignant polyps, 12 mm may be a reasonable cutoff for considering a malignant polyp.

CONCLUSIONS

Gallbladder polyps with 10-11 mm in asymptomatic young patients (less than 50 years old) have low risk of malignancy, and therefore, a careful "wait and see with follow up by using ultrasonography strategy" might be more appropriate than immediate cholecystectomy.

Pathogenesis of gallbladder adenomyomatosis and its relationship with early-stage gallbladder carcinoma: an overview

The exact pathogenesis of gallbladder adenomyomatosis is still lacking and some controversies over its diagnosis and treatment exist. Originally recognized as a precancerous lesion, adenomyomatosis is currently recognized by recent studies as a benign alteration of the gallbladder that is often associated with cholecystitis and cholecystolithiasis. Gallbladder carcinoma is an extremely malignant disease with a 5-year survival rate of less than 5%. Therefore, it is important to diagnose, differentiate, and confirm the relationship between adenomyomatosis and early-stage gallbladder carcinoma. However, the early clinical symptoms of adenomyomatosis are extremely similar to those of gallbladder stones and cholecystitis, increasing the difficulty to identify and treat this disease. This article summarizes the research progress on gallbladder adenomyomatosis, aiming to improve the understanding of the pathogenesis of adenomyomatosis and further provide insight for its clinical diagnosis and treatment.

Predictive Model for Neoplastic Potential of Gallbladder Polyp

GOAL

To provide the statistical predictive model for neoplastic potential of gallbladder polyp (GBP).

BACKGROUND

Many studies have attempted to define the risk factors for neoplastic potential of GBP. It remains difficult to precisely adapt the reported risk factors for the decision of surgery. Estimating the probability for neoplastic potential of GBP using a combination of several risk factors before surgical resection would be useful in patient consultation.

STUDY

We collected data of patients confirmed as GBP through cholecystectomy at Samsung Medical Center between January 1997 and March 2015. Those with a definite evidence for malignancy, such as adjacent organ invasion, metastasis on preoperative imaging studies, polyp >15 mm, and absence of proper preoperative ultrasonographic imaging were excluded. A total of 1976 patients were enrolled. To make and validate the predictive model, we divided the cohort into the modeling group (n=979) and validation group (n=997). Clinical information, ultrasonographic findings, and blood tests were retrospectively analyzed.

RESULTS

Clinical factors of older age, single lesion, sessile shape, and polyp size showed statistical significance for neoplastic potential of GBP in the modeling group. A predictive model for neoplastic potential of GBP was constructed utilizing the statistical outcome of the modeling group. Statistical validation was performed with the validation group to determine the optimal clinical sensitivity and specificity of the predictive model. Optimal cut-off value for neoplastic probability was 7.4%.

CONCLUSIONS

The predictive model for neoplastic potential of GBP may support clinical decisions before cholecystectomy.

Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of localized gallbladder lesions

BACKGROUND AND AIM

Differential diagnosis of localized gallbladder lesions is challenging. The aim of the present study was to evaluate the utility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for diagnosis of localized gallbladder lesions.

METHODS

One hundred and twenty-five patients with localized gallbladder lesions were evaluated by CH-EUS between March 2007 and February 2014. This was a single-center retrospective study. Utilities of fundamental B-mode EUS (FB-EUS) and CH-EUS in the differentiation of gallbladder lesions and sludge plug were initially compared. Thereafter, these two examinations were compared with respect to their accuracy in the diagnosis of malignant lesions. Five reviewers blinded to the clinicopathological results evaluated microcirculation patterns in the vascular and perfusion images.

RESULTS

In the differentiation between gallbladder lesions and sludge plug, FB-EUS had a sensitivity, specificity, and accuracy of 82%, 100%, and 95%, respectively, whereas CH-EUS had a sensitivity, specificity, and accuracy of 100%, 99%, and 99%, respectively. FB-EUS-based diagnosis of carcinomas based on tumor size and/or shape had a sensitivity, specificity, and accuracy of 61-87%, 71-88%, and 74-86%, respectively. Additional information regarding irregular vessel patterns in the vascular image and/or heterogeneous enhancement in the perfusion image on CH-EUS increased the sensitivity, specificity, and accuracy for the diagnosis of carcinomas to 90%, 98%, and 96%, respectively. There was a significant difference between FB-EUS and CH-EUS in terms of carcinoma diagnosis.

CONCLUSION

CH-EUS was useful for the evaluation of localized gallbladder lesions.

The efficacy of real-time colour Doppler flow imaging on endoscopic ultrasonography for differential diagnosis between neoplastic and non-neoplastic gallbladder polyps

OBJECTIVES

We evaluated the usefulness of real-time colour Doppler flow (CDF) endoscopic ultrasonography (EUS) for differentiating neoplastic gallbladder (GB) polyps from non-neoplastic polyps.

METHODS

Between August 2014 and December 2016, a total of 233 patients with GB polyps who underwent real-time CDF-EUS were consecutively enrolled in this prospective study. CDF imaging was subjectively categorized for each patient as: strong CDF pattern, weak CDF pattern and no CDF pattern.

RESULTS

Of the 233 patients, 115 underwent surgical resection. Of these, there were 90 cases of non-neoplastic GB polyps and 23 cases of neoplastic GB polyps. In a multivariate analysis, a strong CDF pattern was the most significant predictive factor for neoplastic polyps; sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 52.2 %, 79.4 %, 38.7 %, 86.9 % and 73.9 %, respectively. Solitary polyp and polyp size were associated with an increased risk of neoplasm.

CONCLUSIONS

The presence of a strong CDF pattern as well as solitary and larger polyps on EUS may be predictive of neoplastic GB polyps. As real-time CDF-EUS poses no danger to the patient and requires no additional equipment, it is likely to become a supplemental tool for the differential diagnosis of GB polyps.

KEY POINTS

• Differential diagnosis between neoplastic polyps and non-neoplastic polyps of GB is limited. • The use of real-time CDF-EUS was convenient, with high agreement between operators. • The real-time CDF-EUS is helpful in differential diagnosis of GB polyps.

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.

Risk stratification of gallbladder polyps larger than 10 mm using high-resolution ultrasonography and texture analysis

OBJECTIVES

To assess important features for risk stratification of gallbladder (GB) polyps >10 mm using high-resolution ultrasonography (HRUS) and texture analysis.

METHODS

We included 136 patients with GB polyps (>10 mm) who underwent both HRUS and cholecystectomy (non-neoplastic, n = 58; adenomatous, n = 32; and carcinoma, n = 46). Two radiologists retrospectively assessed HRUS findings and texture analysis. Multivariate analysis was performed to identify significant predictors for neoplastic polyps and carcinomas.

RESULTS

Single polyp (OR, 3.680-3.856) and larger size (OR, 1.450-1.477) were independently associated with neoplastic polyps (p < 0.05). In a single or polyp >14 mm, sensitivity for differentiating neoplastic from non-neoplastic polyps was 92.3%. To differentiate carcinoma from adenoma, sessile shape (OR, 9.485-41.257), larger size (OR, 1.267-1.303), higher skewness (OR, 6.382) and lower grey-level co-occurrence matrices (GLCM) contrast (OR, 0.963) were significant predictors (p < 0.05). In a polyp >22 mm or sessile, sensitivity for differentiating carcinomas from adenomas was 93.5-95.7%. If a polyp demonstrated at least one HRUS finding and at least one texture feature, the specificity for diagnosing carcinoma was increased to 90.6-93.8%.

CONCLUSION

In a GB polyp >10 mm, single and diameter >14 mm were useful for predicting neoplastic polyps. In neoplastic polyps, sessile shape, diameter >22 mm, higher skewness and lower GLCM contrast were useful for predicting carcinoma.

KEY POINTS

• Risk of neoplastic polyp is low in <14 mm and multiple polyps • A sessile polyp or >22 mm has increased risk for GB carcinomas • Higher skewness and lower GLCM contrast are predictors of GB carcinoma • HRUS is useful for risk stratification of GB polyps >1 cm.

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

[Hemoperitoneum from Spontaneous Rupture of a Metastatic Abdominal Lymph Node in Gallbladder Cancer: A Case Report]

Gallbladder (GB) cancer is asymptomatic in nature, making diagnosis and treatment difficult. The lymph node status is the strongest predictor of long-term survival for patients with GB cancer, and a complete removal of regional lymph nodes is important for patients undergoing radical resection of GB cancer. Unfortunately, lymph node metastases are common in the early stages of GB cancer. However, there have only been a few cases describing the symptoms or complications of metastatic lymph nodes in patients with GB cancer. Although hemoperitoneum caused by metastatic lymph nodes can occur with several cancers, it is very rare. To the best of our knowledge, hemoperitoneum from spontaneous ruptures of metastatic lymph nodes with GB cancer has not yet been reported. Herein, we describe such a case in a patient newly diagnosed with GB cancer.

Polypoid lesions of the gallbladder: analysis of 1204 patients with long-term follow-up

BACKGROUND

Polypoid lesions of the gallbladder (PLG) are common, and most are benign. Few lesions are found to be malignant, but are not preoperatively distinguished as such using common imaging modalities. Therefore, we compared characteristics of benign and malignant PLGs in depth.

METHODS

We enrolled 1204 consecutive patients diagnosed with PLG at Taipei Veterans General Hospital between January 2004 and December 2013. Patients underwent either surgery or regular follow-up with various imaging modalities for at least 24 months. The mean follow-up duration was 72 ± 32 months.

RESULTS

Of 1204 patients, 194 underwent surgical treatment and 1010, regular follow-up. In addition, 73 % patients were asymptomatic. The mean PLG size was 6.9 ± 7.7 (range 0.8-129) mm; the PLGs of 337 patients (28 %) grew during their follow-up periods. The majority of PLGs (90.4 %) were single lesions, and 10.5 % of patients had associated gallstones. The PLGs of 20.1 % of surgical patients were malignant. Malignant PLGs were found in 32.4 % of patients ≥50 years old and in 4.7 % of those <50 years old (p < 0.001). Right quadrant abdominal pain, epigastric pain, and body weight loss were the three most common symptoms associated with malignancy. Malignant PLGs were significantly larger than benign lesions (means: 27.5 ± 18.4 mm vs. 12.3 ± 12.3 mm, respectively, p < 0.001). Notably, the size of 5 % of malignant PLGs was 3-5 mm, and that of 8 % was 5-10 mm. The negative predictive value for gallbladder malignancy was 92.8 % based on a size ≥10 mm and 100 % based on a size ≥3 mm.

CONCLUSIONS

Our study reassesses the PLG size that warrants more aggressive intervention. Cholecystectomy remains mandatory for PLGs > 10 mm, but should also be considered a definitive diagnostic and treatment modality for PLGs with diameters of 3-10 mm.

Preoperative predictive factors for gallbladder cholesterol polyp diagnosed after laparoscopic cholecystectomy for polypoid lesions of gallbladder

BACKGROUNDS/AIMS

We investigated patients' clinical and radiological data to determine preoperative factors that predict cholesterol gallbladder (GB) polyps of large size, which can be helpful for decision on further diagnostic tools.

METHODS

In this study, we retrospectively analyzed 126 patients who underwent laparoscopic cholecystectomy for GB polyps >10 mm diagnosed preoperatively by abdominal ultrasonography between February 2002 and February 2016 in Department of Surgery, Sanggye Paik Hospital. Patients were divided into non-cholesterol polyps group and cholesterol polyps group, based on the postoperative pathologic diagnosis. Clinical and radiological data, such as gender, age, body weight, height, body mass index (BMI), laboratory findings, size, number and shape of the polypoid lesions, and presence of the concurrent GB stone were compared between the two groups.

RESULTS

Of the 126 cases, 73 had cholesterol polyps (57.9%) and 53 cases were non-cholesterol polyps (42.1%). The younger age (<48.5 years), size of polyp <13.25 mm and multiple polyps were independent predictive variables for cholesterol polyps, with odd ratios (OR) of 2.352 (p=0.045), 5.429 (p<0.001) and 0.472 (p<0.001), respectively.

CONCLUSIONS

Age, size and polyp number were used to predict cholesterol GB polyp among polypoid lesions of the gallbladder >10 mm. For cases in which these factors are not applicable, it is strongly recommended to evaluate further diagnostic tools, such as computed tomography, endoscopic ultrasonography and tumor markers.

The role of endoscopic ultrasound in the diagnosis of gallbladder diseases

Endoscopic ultrasound (EUS) has recently played an increasing role in the diagnosis of gallbladder diseases. This review aims to summarize the role of EUS in the diagnosis of gallbladder lesions. EUS provides high-resolution images that can improve the diagnosis of gallbladder polypoid lesions and microlithiasis, in addition to evaluating gallbladder thickness and staging of gallbladder carcinoma. Contrast-enhancing agents may be useful for the differential diagnosis of gallbladder lesions, but the evidence of their effectiveness is still limited and further studies are required in this area to establish its usefulness. Endoscopic ultrasound combined with fine needle aspiration has played an increasing role in providing histological diagnosis of gallbladder tumors in addition to gallbladder thickening.

Contrast-enhanced ultrasound may distinguish gallbladder adenoma from cholesterol polyps: a prospective case-control study

PURPOSE

The aim of this study was to find the independent risk factors related with gallbladder (GB) adenoma compared to cholesterol polyp by contrast-enhanced ultrasound (CEUS).

MATERIALS AND METHODS

Between January 2010 and September 2014, a total of 122 consecutive patients undergoing cholecystectomy for GB polypoid lesions were enrolled. Before cholecystectomy, each patient underwent conventional US and CEUS examination and all image features were documented. The patients were divided into adenoma group and cholesterol polyp group according to the pathological findings. All the image features between two groups were statistically compared.

RESULTS

There were differences in patient age, lesion size, echogenicity, and vascularity of lesion between two groups (P < 0.05). There were differences in stalk width and enhancement intensity between the two groups (P < 0.05). Multiple logistic regression analysis proved that enhancement intensity, stalk of lesion, and vascularity were the independent risk factors related with GB adenoma (P < 0.05).

CONCLUSIONS

CEUS could offer useful information to distinguish adenoma from cholesterol polyp. The treatment algorithm for gallbladder polyp lesions would likely benefit from CEUS as a routine imaging investigation, especially in cases where the polyp is larger than 1 cm.

Is it necessary to perform prophylactic cholecystectomy for all symptomatic gallbladder polyps diagnosed with ultrasound?

OBJECTIVE

The main aim of this study is to determine the necessity of cholecystectomy in patients with ultrasound diagnosed symptomatic polypoid lesions of the gallbladder.

MATERIAL AND METHODS

The data of 82 patients with polypoid lesions of the gallbladder who had cholecystectomy between 2000 and 2012 were analyzed retrospectively with preoperative ultrasound and histopathology results.

RESULTS

The mean age was 48.05±11.18 years (range 25-74 years). All patients underwent preoperative ultrasound examination. Eighteen (22%) of the 82 patients were asymptomatic; their polypoid lesions of the gallbladder were detected with ultrasound during a check-up or other reasons. In 45 (55%) of cases pathology reported no polypoid lesions of the gallbladder. Right upper quadrant or epigastric pain was the most common symptom (41.46%) that led to hepatobiliary ultrasound, the other symptom was dyspepsia (36.59%). On preoperative ultrasound evaluation, 22 patients had multiple polyps, and 9 of these 22 patients had at least 3 polyps.

CONCLUSION

There is an inaccuracy of ultrasound to detect polypoid lesions of the gallbladder. After diagnosing polypoid lesions of the gallbladder by using standard ultrasound, further pre-operative diagnostic tests are needed to help discriminating benign lesions from malignant ones, which may prevent unnecessary surgery regardless of symptoms.

Single-Port Laparoscopic Cholecystectomy for Gall Bladder Polyps

Background and Objectives:

Single-port laparoscopic cholecystectomy (SPLC) was introduced to improve patients' postoperative quality of life and cosmesis over the conventional approach (CLC). The purpose of this case–control study was to compare the outcome of SPLC with that of CLC in a specific disease: gall bladder (GB) polyps.

Methods:

Eligible for the study were all patients with GB polyps who underwent laparoscopic cholecystectomy between June 1, 2009, and June 30, 2011. The 112 patients studied (56 each for SPLC and CLC) were matched by using a propensity score that included gender, age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, history of previous abdominal operation, and pathology outcome. To avoid selection bias caused by the surgeon's choice (often dependent on the degree of inflammation) and to investigate the efficacy of SPLC for a single disease, GB polyps, we excluded patients with acute or chronic cholecystitis.

Results:

Characteristics of the patients matched by a propensity score between SPLC and CLC showed no significant difference. Incidentally detected malignancy was in postoperative pathology in cases in both groups. Although operative time was shorter for SPLC, there was no significant difference in time between the 2 groups. There were 3 open conversions in the CLC group, and an additional port was used in the SPLC group. There was no difference between the groups in hospital stay and postoperative complications.

Conclusion:

In the management of GB polyps, the operative results of SPLC are comparable to those of CLC. We conclude that SPLC is as safe as CLC and has the potential for greater cosmetic satisfaction for patients than CLC. Further trials for objective appraisal of cosmetic outcomes are needed.

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.