GALLBLADDER POLYPS: WHEN TO CUT, WHEN TO CUT BAIT Kevin E. Behrns, M. D.

Hux Professor and Vice Chair Chief of General Surgery Department of Surgery University of Florida Gainesville, FL 32610 Type of Polyp Gallbladder polyps are a common clinical findings occurring in 5% of patients who often have cross-sectional imaging for non-specific abdominal symptoms. When encountering patients with gallbladder polyps, it is important to note what type of polyp is described. While true polyps are adenomatous, gallbladder polyps are often non-epithelial growths and, in fact, about 70% of polyps are cholesterol polyps that have no malignant potential. Adenomas are uncommon and constitute approximately 8% of all gallbladder polyps. Less common polypoid lesions include adenocarcinomas, inflammatory polyps, gallstones masquerading as polyps and heterotopic tissue. Risk Assessment After considering the type of polyps, the risk of development of cancer should be determined. Most demographic data suggest that men and women have an equal propensity to develop adenomatous polyps, however, one study found that men had an increased risk of polyp development. In addition, several studies have noted that patients with primary sclerosing cholangitis (PSC) that have polyps are more likely to develop adenocarcinoma. Finally, patients with advancing age may be predisposed to have cancer because some data suggests that gallbladder polyps, like colonic polyps, have an adenoma-to-carcinoma sequence and, therefore, advancing age would permit malignant transformation. Morphology and size have long been deemed important features of gallbladder polyps. A ten millimeter rule for gallbladder polyps is often cited as a reason for cholecystectomy because polyps larger than 10 mm have an increased risk of cancer. Several caveats should be kept in mind when considering the size and morphology of gallbladder polyps. First, polyps less than 5 mm rarely, if ever, harbor carcinoma. Conversely, polyps greater than 15 mm may have cancer cells in up to 70% of specimens. Thus, those polyps that are 5-15 mm must be carefully followed; with a risk of malignancy up to 22% in these patients. Finally, sessile polyps are more likely malignant than pedunculated polyps. Additional Investigation Gallbladder polyps are typically identified on ultrasonography, which has a sensitivity and specificity of over 90%. Contrast enhanced CT may aid in the diagnosis with an overall accuracy of 87% for cancer. FDG-PET adds little to the CT. Importantly,

endoscopic ultrasound, which permits detailed evaluation of the gallbladder wall, has excellent diagnostic capabilities and should be used for indeterminate polyps of 5-15 mm. Management Clinical decision-making for gallbladder polyps is rather straightforward since the options include surveillance versus cholecystectomy. Cholecystectomy should be considered in patients with polyps greater than 15 mm and smaller polyps that are sessile or found in patients with PSC. If the polyp is less than 15 mm and surveillance is the management of choice then re-evaluation should occur every 3-6 months because some studies suggest that polyps can increase in size 4-fold in 12 months. If the rate of growth is nil then surveillance can be stopped after 2 years. If cholecystectomy is the treatment plan then one should consider the benefits of open versus laparoscopic cholecystectomy. Sentiment exists that laparoscopic cholecystectomy should not be performed if there is evidence of cancer because laparoscopic gallbladder cancer surgery is often complicated by port-site recurrence. In one study, 16 patients with gallbladder polyps followed for 4 years had no recurrence. If the specimen demonstrates cancer that invades the muscular wall then radical cholecystectomy should be performed. In addition, when selecting cholecystectomy over surveillance, it is important to know the complications of cholecystectomy. In a large study of nearly 23,000 cholecystectomies, the local complication rate was 7%. Systemic complications were observed in 2.3% of patients. Bile duct injury occurred in 0.3% of patients. Factors important in the outcome include body mass index, male gender and surgeon experience. Conclusion When to cut? Patients with polyps greater than 15 mm should have their gallbladder removed as should patients with PSC and sessile polyps. When to cut bait? Those polyps ranging between 5-15 mm should be closely followed or, alternatively, the gallbladders removed. Patients with gallbladder polyps less than 5 mm should have surveillance and not undergo operation.

GALLBLADDER POLYPS: WHEN TO CUT, WHEN TO CUT BAIT

Kevin E. Behrns, M. D. Hux Professor and Vice Chairman Chief of General & GI Surgery University of Florida Gainesville, FL

GALLBLADDER POLYPS Learning Objectives To discuss the types of gallbladder polyps To identify factors that influence management of gallbladder polyps
Is this cancer?

To describe imaging studies that assist in the diagnosis of gallbladder To discuss the advantages and disadvantages of surveillance vs. cholecystectomy

GALLBLADDER POLYPS Case Presentation

61 y. o. man with left flank bulge and asymptomatic filling defect of GB
2.2 cm mass

GALLBLADDER POLYPS Clinical Question

IS THIS A TRUE GALLBLADDER POLYP?

CT c/w single adherent gallstone CA 19-9 normal Lap chole August 2007

GALLBLADDER POLYPS Types of Polyps

Prevalence 4%-9.5%

GALLBLADDER POLYPS Clinical Question

Cholesterol polyps70% Adenomas- 8% Adenocarcinoma5.6% Inflammatory polyps- 13% Gallstones Gastric heterotopia
Hepatobiliary Pancreat Dis Int 2004;3:591

IF THIS IS A POLYP, WHAT FACTORS INFLUENCE MANAGEMENT?

GALLBLADDER POLYPS Risk Assessment

Demographics
Males
11.3% vs. 7.2% Controversial

GALLBLADDER POLYPS Morphologic Factors- Size

Morphology
Size- 10 mm rule Rapid growth 61 patients followed with US for 48 months
29% had increased size or number of polyps

Indian Primary sclerosing cholangitis Hep B sAg+

11.4% vs. 9.1%

Study (yr) Koga

1988

N 40 172 72 67

%ACA <10 mm 3 0 6 5

%ACA >10 mm 78 38 39 29

Advancing age
Adenoma-to-carcinoma sequence Ann Surg 2001;234:657 Gastrointest Endosc 200;52:372 Eur J Surg Oncol 2008 J Gastroentrol & Hepatol 2007

48% of benign lesions exceed 10 mm Polyps less than 5 mm almost never malignant Polyps > 15 mm have increased risk of harboring malignancy
Up to 46-70% malignant

Yang
1992

Kubota
1995

Polyps 5-15 mm have 14%22% of malignancy Sessile polyps harbor malignancy in 33% versus 13% in pedunclulated polyps regardless of size

Sugiyama
1995

GALLBLADDER POLYPS Diagnostic Evaluation WHAT ADDITIONAL INORMATION MAY GUIDE MANAGEMENT? Surveillance vs. Cholecystectomy

GALLBLADDER POLYPS Imaging

Ultrasound
Sensitivity 90.1% Specificity 93.9% Gallstones accompany polyps in 40%+

EUS- preferred for polyps because of accuracy of GB wall imaging

Non-neoplastic lesions- aggregation of hyperechoic spots and multiple microcysts Scoring systems for neoplastic polypsMaximum diameter Internal echo pattern- heterogeneous vs. homogeneous Hyperechoic spots Sensitivity 78%, specificity 83%, accuracy 83% for neoplasia

Contrast enhanced CT
Sensitivity 88%, specificity 87%, positive predictive value 88%, negative predictive value 87%, overall acccuracy 87% for neoplastic lesions (Arch Surg 1998;133:735)

FDG-PET
1 false positive in 8 patients with benign gallbladder lesions

GALLBLADDER POLYPS Management

Surveillance
US 3-6 months to establish growth rate for 2 years Growth rate can be 4-fold within 12 months Little or slow growth- US 12 months Duration of follow-up unknown

GALLBLADDER POLYP Operative Procedure

Criteria for cholecystectomy:

Demographics Size Morphology
Neoplastic polyps see more frequently in patients with gallstones

SHOULD A LAPAROSCOPIC OR OPEN CHOLECYSTECTOMY BE PERFORMED?

Patient preference

GALLBLADDER POLYPS Operative Techniques

Should a laparoscopic cholecystectomy be performed? 16 patients with gallbladder adenoma
Follow-up 4 years No recurrence

GALLBLADDER POLYPS Cholecystectomy Risk

SALTS Study Group22,953 cholecystectomies
Mortality 0.3% Complications7% intraoperative 4% postoperative local 2.3% systemic 0.3 % bile duct injury

6 patients with malignant polyps

Follow-up 2-8 years 2 required radical cholecystectomy 1 recurrence with PT2

Factor associated with complications

Male gender, BMI, ASA, emergency operation, surgeon experience JACS 2006;203;723 Critical View of Safety of Triangle of Calot

Importance of full thickness resection without perforation Polyps > 18 mm should be removed by open cholecystectomy
Surg Laparosc Endosc Percutan Tech 2001;11:242

GALLBLADDER POLYPS Summary- Size

Polyps <5 mm
Surveillance No need for EUS

GALLBLADDER POLYPS Conclusions

WHEN TO CUT
Polyp >15 mm Sessile polyp Increasing in size between 5-15 mm Patient with PSC Patient preference

WHEN TO CUT BAIT

Polyp <5 mm Stable pedunculated polyp 5-15 mm Significant comorbidities At initial diagnosis all patients should be enrolled in surveillance program for at least 2 years

Polyps > 15 mm
Cholecystectomy

Polyps 5-15 mm
Surveillance
Growth rate Morphology Demographics

Histology of Case Presentation