Abstract
Background
Polypoid lesions of the gallbladder (PLG) have been a common finding on ultrasound examinations of the abdomen and are more prevalent since our use of equipment incorporating pulse shaping increased bandwidth, and enhanced phase use for image reconstruction began in 1996. Our study correlates the pre-operative ultrasonographic findings of these lesions to the surgically resected specimen with specific regard to identifying neoplastic polyps.
Methods
A retrospective review was performed of 130 patients who had a pre-operative ultrasound of the gallbladder and subsequently underwent cholecystectomy between August 1996 and July 2007 at the Mayo Clinic Rochester.
Results
Seventy-nine pseudopolyps (cholesterol polyps, inflammatory polyps, and adenomyomas) and 15 neoplastic polyps were identified on histopathologic analysis. However, 36 patients (27%) did not have a PLG upon histopathologic analysis. Thirty-one polyps had suspicious ultrasonographic characteristics for neoplastic changes. Twenty-nine were ≥10 mm, 12 had vascularity, and one demonstrated invasion. Of these, there were 23 pseudopolyps and six true polyps with neoplastic changes on final pathology (four dysplastic adenomas and two adenocarcinomas). Three asymptomatic polyps ≤10 mm (4%) in maximum diameter based on pre-operative ultrasound imaging (US) had neoplastic changes at pathology (two dysplastic adenomas and one adenocarcinoma). Several statistically significant risk factors were identified that increased the likelihood for malignancy in a PLG: history of primary sclerosing cholangitis (PSC), local invasion, vascularity, and ≥6 mm maximum diameter based on pre-operative US. Of PLGs ≤10 mm, 7.4% were neoplastic. Twenty-five patients were followed up with at least two serial ultrasound examinations. Of these, seven demonstrated polyp growth. None of these specimens demonstrated neoplastic changes. The positive predictive value (PPV) and negative predictive value (NPV) for ultrasound diagnosing neoplastic changes based on current criteria was 28.5% and 93.1%, respectively, with a false negative rate of 5.0%. Expanding the criteria to include cholecystectomy for PLGs ≥ 6 mm changes the positive predictive value and negative predictive value to 18.5% and 100%, respectively, with a false negative rate of 0%.
Conclusion
Histopathologic analysis of polypoid lesions of the gallbladder continues to be the gold standard to identify malignancy. Ultrasound has been used extensively in the pre-operative management of these lesions, but modern ultrasound techniques are unable to differentiate between benign and malignant PLGs with any certainty. We recommend that strong consideration be given to surgical resection of PLGs ≥ 6 mm based on pre-operative US due to the significant risk of neoplasm. Additionally, PLGs in all patients with PSC, any patient in whom diligent long-term follow-up cannot be completed, and lesions that demonstrate growth, vascularity, invasion, or are symptomatic require cholecystectomy.
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References
Bergdahl L. Gallbladder carcinoma first diagnosed at microscopic examinations of gallbladders removed for presumed benign disease. Ann Surg. 1980;191:19–22. doi:10.1097/00000658-198001000-00004.
Yamaguchi K, Enjoji M. Carcinoma of the gallbladder: a clinicopathology of 103 patients and a newly proposed staging. Cancer. 1988;62:1425–1432. doi:10.1002/1097-0142(19881001)62:7<1425::AID-CNCR2820620730>3.0.CO;2-T.
Shirai Y, Yoshida K, Tsukada K, Muto T. Inapparent carcinoma of the gallbladder: an appraisal of a radical second look operation after simple cholecystectomy. Ann Surg. 1992;215:326–331. doi:10.1097/00000658-199204000-00004.
Bivins BA, Meeker WA, Weiss DL, Griffen WO. Carcinoma is situ of the gallbladder: a dilemma. Soutern Med J. 1975;68:297–300.
Okamoto M, Okamoto H, Kitahara F, Kobayashi K, Karikome K, Miura K et al. Ultrasonographic evidence of association of polyps and stones with gallbladder cancer. Am J Gastroenterol. 1999;94(2):446–450. doi:10.1111/j.1572-0241.1999.875_d.x.
Kozuka S, Tsubone M, Yasui A, Hachisuka K. Relation of adenoma to carcinoma in the gallbladder. Cancer. 1982;50:2226–2234. doi:10.1002/1097-0142(19821115)50:10<2226::AID-CNCR2820501043>3.0.CO;2-3.
Aldridge MC, Bismuth H. Gallbladder cancer: the polyp-cancer sequence. Br J Surg. 1990;77(4):363–364. doi:10.1002/bjs.1800770403.
Meyers RP, Shaffer EA, Beck PL. Gallbaldder polyps: epidemiology, natural history and management. Can J Gastroenterol. 2002;16:187–194.
Terzi C, Sokmen S, Seckin S, Albayrak L, Ugurlu M. Polypoid lesions of the gallbladder: report of 100 cases with special reference to operative indications. Surgery. 2000;127:622–627. doi:10.1067/msy.2000.105870.
Chattopadhyay D, Lochan R, Gopinath BR, Wynne KS. Outcome of gallbladder polypoidal lesions detected by transabdominal ultrasound scanning: a nine year experience. World J Gastroenterol. 2005;11(14):2171–2173.
Sadamoto Y, Oda S, Tanaka M, Harada N, Kubo H, Eguchi T et al. A useful approach to the differential diagnosis of small polypoid lesions pf the gallbladder, utilizing an endoscopic ultrasound scoring system. Endoscopy. 2002;34(12):959–965. doi:10.1055/s-2002-35859.
Akatsu T, Aiura K, Shimazu M, Ueda M, Wakabyashi G, Tanabe M et al. Can endoscopic ultrasonography differentiate non lastic from neoplastic gallbladder polyps? Dig Dis Sci. 2006;51(2):416–421. doi:10.1007/s10620-006-3146-7.
Choi WB, Lee SK, Kim MH, Seo DW, Kim HJ, Kim DI et al. A new strategy to predict the neoplastic polyps of the gallbladder based on a scoring system using EUS. Gastrointest Endosc. 2000;52:372–379. doi:10.1067/mge.2000.108041.
Numata K, Oka H, Morimoto M, Sugimori K, Kunisaki R, Nihonmatsu H et al. Differential diagnosis of gallbladder diseases with contrast-enhanced harmonic gray scale ultrasonography. J Ultrasound Med. 2007;26:763–774.
Koga A, Watanabe K, Fukuyama T, Takiguchi S, Nakayama F. Diagnosis and operative indications for polypoid lesions of the gallbladder. Arch Surg. 1988;123(1):26–29.
Yang HL, Sun YG, Wang Z. Polypoid lesions of the gallbladder: diagnosis and indications for surgery. Br J Surg. 1992;79:227–229. doi:10.1002/bjs.1800790312.
Kubota K, Bandai Y, Noie T, Ishizaki Y, Masanori T, Makuuchi M. How should polypoid lesions of the gallbladder be treated in the era of laparoscopic cholecystectomy? Surgery. 1995;117(5):481–487. doi:10.1016/S0039-6060(05)80245-4.
Ishikawa O, Ohhigashi H, Imaoka S et al. The difference in malignancy between pedunculated and sessile polypoid lesions of the gallbladder. Am J Gastroenterol. 1988;84:1386–1390.
Sugiyama M, Atomi Y, Kuroda A, Muto T, Wada N. Large cholesterol polyps of the gallbladder: diagnosis by means of US and endoscopic US. Radiology. 1995;196:493–497.
Moriguchi H, Tazawa J, Hayashi Y, Takenawa H, Nakayama E, Marumo F et al. Natural history of polypoid lesions in the gall bladder. Gut. 1996;39:860–862. doi:10.1136/gut.39.6.860.
Csendes A, Burgos AM, Csendes P, Smok G, Rojas J. Late follow-up of polypoid lesions of the gallbladder smaller than 10 mm. Ann Surg. 2004;234(5):657–660. doi:10.1097/00000658-200111000-00011.
Collett JA, Allan RB, Chisholm RJ, Wilson IR, Burt MJ, Chapman BA. Gallbladder polyps: prospective study. J Ultrasound Med. 1998;17:207–211.
Tsuchiya Y, Uchimura M. collective review of 503 cases of small polypoid lesions (less than 20 mm in maximum diameter) of the gallbladder: size distribution in various diseases and the depth of carcinomatous invasion. Jpn J Gastroenterol. 1986;83:2086–2087. Japanese.
Sun XJ, Shi JS, Han Y, Wang JS, Ren H. Diagnosis and treatment of polypoid lesions of the gallbladder: report of 194 cases. Hepatobiliary Pancreat Dis Int. 2004;3:591–594.
Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P. Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg. 1997;184(6):571–578.
Tublin ME. Question and answer. AJR. 2001;177:467.
Mangel AW. Management of gallbladder polyps. South Med J. 1997;90(5):481–483.
Inoue T, Kitano M, Kudo M, Sakamoto H, Kawasaki T, Maekawa YC. Diagnosis of gallbladder diseases by contrast-enhanced phase-inversion harmonic ultrasonography. US Med Biol. 2007;33:353–361. doi:10.1016/j.ultrasmedbio.2006.09.003.
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Zielinski, M.D., Atwell, T.D., Davis, P.W. et al. Comparison of Surgically Resected Polypoid Lesions of the Gallbladder to their Pre-operative Ultrasound Characteristics. J Gastrointest Surg 13, 19–25 (2009). https://doi.org/10.1007/s11605-008-0725-2
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DOI: https://doi.org/10.1007/s11605-008-0725-2