Decision making in the management of Gall Bladder Polyps

1. GB POLYPS
DR AMIT DANGI
DEPARTMENT OF SURGICAL GASTROENTEROLOGY
KING GEORGE MEDICAL UNIVERISTY
LUCKNOW

2. Outline
• Introduction
• Classification
• Investigations
• Treatment
• Conclusions

3. Introduction
• A gallbladder polyp (GBP) is an elevation of the GB mucosa that protrudes into
the gallbladder lumen
• 5% prevalence in the global adult population, only 5% of these are true polyps.
• Increased detection due to frequent use of abdominal imaging.
• Commonly detected on USG of the abdomen: Prevalence - 0.3 and 9.5%.
• Incidence in resected GB specimens - 0.004 to 13.8 %
• Prevalence of malignancy among GBPs varies from 0% to 27%.2
Eur Radiol (2017)
The surgeon 14 (2016)

4. Classification of GB polyps
Christensen AH, Ishak KG. Arch Pathol 1970;

6. TRUE POLYPS
• Approximately 5% of all GB polyps
• Malignant potential
• Adenoma–carcinoma sequence in the
GBPs is less well understood.
• Existence evidence suggests that at
least some GB adenocarcinomas have
arisen in pre-existing adenomas
• The adenoma–carcinoma sequence is
likely, at least for some cases.
Aldridge MC, et al. Br J Surg 1990;
Albores-Saavedra J, et al. Hum Pathol 2012;
Kozuka S, et al. Cancer 1982;
McCain RS et al. World J Gastroenterol 2018
Okamoto M, et al. . Am J Gastroenterol 1999;
Lin WR, et al. J Gastroenterol Hepatol 2008;
PSEUDOPOLYPS
• Majority (70% of suspected polyps)
• Cholesterol pseudopolyps, focal
adenomyomatosis, inflammatory.
• No malignant potential
• Donot require any follow up or
intevention
Elmasry M, et al. Int J Surg 2016:

7. Investigations
• TRANS-ABDOMINAL USG (TAUS)
• HRUS
• ENDOSCOPIC USG (EUS)
• COLOR DOPPLER ABDOMEN
• CECT ABDOMEN
• MRI ABDOMEN
ROUTINE
SPECIFIC

8. TAUS
• On USG : An elevation of the GB wall that
protrudes into the lumen.
• Immobile
• No posterior acoustic shadowing.
• No reverberation or comet tail artifacts (s/o focal
adenomyomatosis or a cholesterol polyp)
• Sessile or pedunculated.
• A clearly infiltrating or large mass should be
treated as a GB cancer rather than a polyp.
• Operator dependent.
Shapiro RS, Winsberg F (1990) Radiology 177:153–156

9. EUS
• Works at higher frequency (5-12 MHZ)
• Enables the transducer to be in closer proximity to the target tissue.
• No attenuation by subcutaneous fat or interference from intestinal gas.
• Greater sensitivity (67%-86%) and specificity (84%-91%) for diagnosing malignancy in polyps than
CUS.
Babu BI, et al. Langenbecks Arch Surg 2015;
• Sugiyama et al compared EUS and CUS in 58 patients who underwent cholecystectomy for GBP <
20 mm
• EUS was more accurate at differentiating b/w true and pseudopolyps than CUS (97% vs 76%),
• More accurate for polyps > 10 mm (less accurate for GBPs < 6 mm)
• May play a role in decreasing the number of unnecessary cholecystectomies in larger GBPs.
Sugiyama M, et al. Ann Surg 1999
McCain RS et al . World J Gastroenterol 2018

10. …….EUS
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.
Cochrane Database of Systematic Reviews 2018

11. CECT and MRI Abdomen
• CT: widely used in staging of Carcinoma GB
• Best used in staging larger, suspicious malignant polyp.
• Not modality of choice for diagnosis and follow up of GBPs (No
superiority to CUS till date)
• MRI: Diffusion weighted MRI may play a role in diagnosing benign vs
malignant polyps.
• Further research warranted.
• Other imaging modalities: PET, Percutaneous transhepatic
cholecystoscopy, iv cholcystography.
McCain RS et al . World J Gastroenterol 2018

12. INVESTIGATIONS: RECOMMENDATIONS
• Primary investigation should be with abdominal ultrasound.
• Routine use of other imaging modalities is not recommended.
• In some centres with appropriate expertise and resources, alternative
imaging modalities (such as EUS) may be useful to aid decision-
making in difficult cases (low quality evidence, 100% agreement)
ESGAR, EAES, EFISDS, ESGE. Eur Radiol (2017)

13. TREATMENT
• Excision or follow up
• “Contentious”---- fear of malignancy
• Cholecystectomy is recommended for polyps >10 mm
• Management of polyps <10 mm depends on patient, symptoms and
polyp characteristics
• Further research is required to determine optimal management of
gallbladder polyps < 6 mm.

14. Risk factors for malignancy
POLYP CHARACTERISTICS
1. Size: > 10 mm, Increase in size
2. Morphology : sessile, focal GB
wall thickening > 4mm.
3. Presence of symptoms or gall
stones : Relationship with
malignancy not well
established.
PATIENT CHARACTERISTICS
1. Age >50
2. History of primary sclerosing
cholangitis (PSC)
3. Indian ethnicity

15. Size > 10 mm
• GBPs > 10 mm—cholecystectomy is recommended (Level III studies)
• Moderate quality evidence
• Greater incidence of GB carcinoma (22.8-80%) in the larger polyps (>10 mm).
• Evidence suggests that pseudo polyps tend to be smaller than true polyps
The surgeon 14 (2016) 278-286
ESGAR, EAES, EFISDS, ESGE. Eur Radiol (2017)
• The probability of malignancy is nearly zero when the polyp < 4.15 mm
• Others recommend a size of > 8 mm or > 12 mm as cut off for cholecystectomy.
Chattopadhyay D et al. World J Gastroenterology 2005;11(14):2171e3.
Kozuka S, et al. Cancer 1982;50(10):2226e34.

16. a: Probability of malignancy by size bucket.
b: Probability of Malignancy by Cumulative
Size Analysis
Benign polyps were far more likely to be of
size <10 mm whereas adenomas and
malignant polyps were more frequently >10
mm in size.
In the group <10 mm, 15.3% were malignant.
It appears that the probability of malignancy
is approximately zero when the size of the
polyp < 4.15 mm
Evidence based management of polyps of
the gall bladder: A systematic review of the
risk factors of malignancy. The surgeon 14
(2016) 278e286

17. Symptomatic polyps
• Polypoid lesion of the GB with patient’s symptoms attributable to the
GB—cholecystectomy is suggested (if no alternative cause)
• Low quality evidence
• Relationship b/w symptoms and risk of malignancy is not established.
• Jones-Monahan et al. : demonstrated that of 45 symptomatic patients
with GB polyps and no calculi who underwent cholecystectomy, 93%
experienced relief of symptoms
Isolated small gallbladder polyps: an indication for cholecystecto-
my in symptomatic patients. Am Surg 66:716–719

18. Sessile polyp
(including focal GB wall thickening >4 mm)
• A sessile morphology in a gallbladder polyp is an independent risk factor for malignancy,
increasing the risk by a factor of 7.32 (95% CI 4.18–12.82).
Bhatt NR, et al. Surgeon 2017
Kwon W, et al. J Korean Med 2014
• GB wall thickening >5 mm and wall irregularity are independent risk factors for malignancy.
Aldouri AQ, et al. Eur J Surg Oncol 35:
Zhu J-Q, et al. Hepatobiliary Pancreat Dis Int 14:
• Focal wall thickening >4 mm should be treated the same as patients with sessile polyps.
ESGAR, EAES, EFISDS, ESGE. Eur Radiol (2017)
• Bhatt et al do not recommend cholecystectomy based on sessile morphology alone, the
most recent guidelines by the ESGAR group recommend cholecystectomy for all sessile
polyps under between 6 mm and 9 mm

19. Age
• Risk of malignancy increases with age.
• Age threshold variable across studies.
• Different threshold of age in different studies : 50 years, 57, 60 or 65 years.
• Insufficient data to determine the most appropriate threshold.
• European guidelines : 50 years based on consensus rather than conclusive scientific evidence.
• The ESGE group conclude that if patients are aged 50 and have polyps of 6-9 mm they should
undergo cholecystectomy.
Eur Radiol (2017)
• If the age of the patient is > 50 years, then the odds of malignancy increase by a factor of 11.83
(95% CI: 7.77-18 )
The surgeon 14 (2016)

20. PSC
• AASLD and EASLD : Recommend cholecystectomy for patients with
PSC and a gallbladder polyp, irrespective of size.
Chapman R, et al Hepatology (2010)
EASL clinical practice guidelines: J Hepatol (2009)
• These patients should undergo a more intensive follow-up and have a
lower threshold for cholecystectomy than non-PSC patients.
ESGAR, EAES, EFISDS, ESGE. Eur Radiol (2017)

21. Indian Ethnicity
• Indian ethnicity had a significantly
higher prevalence of gallbladder
cancer: 5.5% versus 0.08%.
• ESGAR felt the evidence was so
compelling that their guidelines
state that in patients of Indian
ethnicity and a polyp between 6-9
mm they should undergo
cholecystectomy.
ESGAR, EAES, EFISDS, ESGE. Eur Radiol (2017
Aldouri AQ, et al. Eur J Surg Oncol 35:48–51

22. Other risk factors: Solitary GB Polyps
• Solitary GB polyps are more likely to be malignant than multiple polyps.
Elmasry M, et al. Int J Surg
• Increased risk of malignancy in a recent systematic review was 2.05 (95% CI: 1.52-
2.75).
Bhatt NR, et al. Surgeon 2016
• Other studies, however, have shown this not to be significant on multivariate
analysis
Aldouri AQ, et al. Eur J Surg Oncol
• No robust data that suggest asymptomatic multiple polyps are less likely to be
malignant than asymptomatic solitary polyps.
• The probability of malignancy is not high enough to recommend cholecystectomy
in all solitary polyps.
McCain RS et al . Management of gallbladder polyps. World J Gastroenterol 2018 July

23. Presence of gallstones
• Presence of gallstones was an
independent risk factor for
malignancy but with borderline
significance.
Aldouri AQ, et al. Eur J Surg Oncol
• Some authors recommend
cholecystectomy, regardless of
polyp size or presence of
symptoms, since gallstones are a
risk factor for GB cancer in pts
with GB polyps.
Patiño JF, Quintero GA. World J Surg 1998.
Terzi C, et al. Surgery 2000;
• Other studies found that
gallstones were not an
independent risk factor on
multivariate analysis.
Park JK, et al. Gut Liver 2:88–94
• Again the evidence level in this
area is low.
• Insufficient evidence to
recommend cholecystectomy
in these asymptomatic
patients.
ESGAR, EAES, EFISDS, ESGE. Eur Radiol (2017)

24. Increase in size of polyp
• Rapid increase is associated with malignancy.
• Kubota et al. reported a rapid growth of cancerous lesions in their
study but no growth in the benign lesions.
• This is not supported by all authors as Ukai et al. reported a change in
size from 9 x 6 mm to 12 x 10 mm in 10 months in case of a benign
cholesterol polyp.
Moriguchi H, et al. Gut 1996
Koga A, et al. Archives Surg 1988
Ukai K, et al. Hepatogastroenterology 1992

25. Risk assessment when the size of the polyp is less
than 10 mm
The surgeon 14 (2016)
Bhat et al. devised a risk assessment for polyps <10 mm.
If the assessment yields a risk of equal to or >18% then the polyp should be excised

26. Tumour Markers
• Limited research regarding role for tumor markers in the preoperative
evaluation of GBPs.
• CEA and CA19.9 : No correlation b/w malignancy and elevated
markers.
• No sufficient evidence to show that tumor markers will assist in the
decision making process for GBPs.
Kwon W et al. J Korean Med Sci 2009

27. SUMMARY
If the patient has risk factors for gallbladder
malignancy and a polyp 6–9 mm.
Cholecystectomy is recommended
No risk factors for GB malignancy and a polyp of
6–9 mm
Follow-up ultrasound at 6 months, 1 year and
then yearly up to 5 years.
Risk factors for malignancy and a polyp < 5 mm Follow-up ultrasound at 1 , 3 and 5 years
If during follow-up, polyp increases by > 2 mm Cholecystectomy advised
If during follow-up, polyp reaches 10 mm Cholecystectomy advised
If during follow-up gallbladder polyp disappears Discontinue follow-up
ESGAR, EAES, EFISDS, ESGE. Eur Radiol (2017)

28. M. Elmasry et al. International Journal of Surgery 33 (2016)

29. Results of long term surveillance
M. Elmasry et al. International Journal of Surgery 33 (2016)