Gall bladder polyps in primary sclerosing cholangitis: Adhere to the guidelines

Abstract

We congratulate the investigators for their comprehensive review on cancer surveillance in patients with primary sclerosing cholangitis (PSC). 1 Annual ultrasound (US) examinations have been proposed by the American 2 as well as European practice guidelines, 3 and cholecystectomy is recommended for gallbladder (GB) polyps detected independent of their size. In their current review, Razumilava et al. discuss an alternative strategy consisting of repeat imaging every 3-6 months for the surveillance of polyps of less than 8 mm in size. 1 This strategy is based on reports that most GB cancers detected in patients with PSC arise in polyps well above this size. 4,5 We here report on 2 of our patients with GB polyps detected by regular imaging surveillance within the last year. The first patient is a 38-year-old male with a 10-year history of PSC. A 6-mm GB polyp was detected on surveillance US. The patient was advised to have a follow up US within 3-4 months and actually presented 6 months later. The polyp had grown to a size of 4 Â 2 cm. Surgery revealed an advanced GB adenocarcinoma with multiple small bilobar liver metastases. The second patient is a 44-year-old male with a 6-year history of PSC. He presented with a 1.6-cm GB polyp 8 months after having received magnetic resonance imaging of his liver without any pathology of the GB. Cholecystectomy revealed a tubular adenoma with focal high-grade dysplasia.These 2 cases underline that GB polyps may grow rapidly in patients with PSC. The first patient might have been cured if immediate cholecystectomy had been performed, as recommended by our current guidelines. The second patient might have developed GB cancer if a longer surveillance interval had been chosen. Yearly surveillance examinations, as recommended by the current guidelines, may not be appropriate in this high-risk population.We now recommend for our patients surveillance intervals of 6 months. More important, we should be cautious not to delay cholecystectomy in a patient with PSC and a GB polyp independent of its size, unless surgical risk far outweighs the benefit of potentially preventing a deadly cancer. Gall Bladder Polyps in Primary Sclerosing Cholangitis: Adhere to the GuidelinesTo the Editor:We thank Dr. Schramm and Dr. Lohse for their generous comments regarding our review and for sharing their experience with malignant gallbladder disease in primary sclerosing cholangitis (PSC) patients. As noted, our recommendations do differ slightly from the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) guidelines, which recommend prompt cholecystectomy for gall bladder polyps of any size in PSC patients. Our review ( fig. 2) also recommends consideration of prompt cholecystectomy in PSC patients with gall bladder polyps of any size in patients with good liver function. However, in patients with impaired liver function there is a risk in performing a cholecystectomy, and using a polyp size cutoff of 0.8 cm adds specificity to th...

Primary Sclerosing Cholangitis and Cholangiocarcinoma: Pathogenesis and Modes of Diagnostics

“…It has been recently suggested that for gallbladder lesions less than 0.8 cm repeated imaging every 3-6 months is an alternative strategy because most cancers will arise from polyps well above that size [58]. Since in our experience gallbladder tumors in PSC patients may grow rapidly [59], we believe that cholecystectomy should not be delayed. Current guidelines suggesting annual surveillance may not be sufficient in this high-risk patient group and we now recommend ultrasound examinations in our center every 6 months [59].…”

“…Since in our experience gallbladder tumors in PSC patients may grow rapidly [59], we believe that cholecystectomy should not be delayed. Current guidelines suggesting annual surveillance may not be sufficient in this high-risk patient group and we now recommend ultrasound examinations in our center every 6 months [59]. Once a mass lesion of the gallbladder is diagnosed by cross-sectional imaging, we would adhere to the guidelines and recommend cholecystectomy, regardless of the size of the lesion unless the surgical risk outweighs the potential benefits.…”

How Should Cancer Surveillance in Primary Sclerosing Cholangitis Be Performed?

“…In this regard, a common scenario the clinician encounters is the question about the dignity of a stenosis within the context of cholestasis, jaundice, and pruritus. Dominant stenoses will develop in more than half of the patients during the course of the disease, and CCA not being associated with dominant strictures is rare [ 11 , 12 , 13 ]. Hence, most strictures are of benign nature, and the sensitivity to detect malignancy using the combination of imaging modalities including computed tomography (CT) and magnetic resonance imaging (MRI), endoscopy with biliary brush cytology or biopsy, and the analysis of tumor markers in the serum is below 50-60%.…”

“…It has been suggested that for gallbladder lesions below the size of 0.8 cm repeated imaging every 3-6 months is an alternative strategy because most cancers will arise from polyps well above that size [ 29 ]. In our experience, gallbladder tumors in PSC patients may grow rapidly [ 12 ], and we therefore believe that cholecystectomy should not be delayed. Annual surveillance as suggested in the current guidelines may not be sufficient in this high-risk patient group; thus, we would argue for ultrasound examinations every 6 months [ 12 ].…”

“…In our experience, gallbladder tumors in PSC patients may grow rapidly [ 12 ], and we therefore believe that cholecystectomy should not be delayed. Annual surveillance as suggested in the current guidelines may not be sufficient in this high-risk patient group; thus, we would argue for ultrasound examinations every 6 months [ 12 ]. Once a mass lesion of the gallbladder is diagnosed by cross-sectional imaging, we would adhere to the guidelines and recommend cholecystectomy – regardless of the size of the lesion unless the surgical risk outweighs potential benefits.…”