Gallbladder polyps in primary sclerosing cholangitis: Indication for early intervention

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 the ...

Polyp on Ultrasound: Now What? The Association between Gallbladder Polyps and Cancer

“…It should be noted that polyps arising in the setting of the gallstones should be removed because these patients have an increased risk of GBC, [18][19][20] as should those occurring in primary sclerosing cholangitis for the same reason. 21,22 The majority of polyps are benign, including many in the intermediate size of 1 to 2 cm. The current guidelines, however, suggest cholecystectomy for polyps over 10 mm.…”

An update on cancer risk and surveillance in primary sclerosing cholangitis

“…More studies are required to clearly define predictors for the presence of malignancy in gallbladder lesions in the PSC population. Smaller lesions may be at lower risk for GBC, but some cases have also identified that gallbladder lesions can grow rapidly in PSC patients . Guidelines should be cautiously applied to individual circumstances, and risks to benefits always weighed.…”

“…Smaller lesions may be at lower risk for GBC, but some cases have also identified that gallbladder lesions can grow rapidly in PSC patients. 46 Guidelines should be cautiously applied to individual circumstances, and risks to benefits always weighed. However, most causes of cirrhosis are associated with a risk for HCC development and therefore it is probable that PSC patients are at increased risk once they develop end stage liver disease.…”