Management and follow‐up of gallbladder polyps: updated joint guidelines between the ESGAR, EAES, EFISDS and ESGE
Kieran G. Foley1 · Max J. Lahaye2 · Ruedi F. Thoeni3 · Marek Soltes4 · Catherine Dewhurst5 · Sorin Traian Barbu6 · Yogesh K. Vashist7 · Søren Rafael Rafaelsen8 · Marianna Arvanitakis9 · Julie Perinel10 · Rebecca Wiles11 · Stuart Ashley Roberts12
European Radiology volume 32, pages 3358–3368 (2022)
Incidental gallbladder polyps are a common sonographic finding, occurring in approximately 3–6% of the general population [1]. Although most are benign cholesterol polyps or inflammatory polyps, a small percentage of them are true neoplastic polyps. Despite gallbladder cancer being a relatively infrequent diagnosis [2], detection of malignancy at an early stage of disease is critical to improve survival rates because gallbladder cancer is associated with a poor prognosis [3].
The original guidelines for the management of gallbladder polyps were released in 2017. In this paper, the authors updated the European guidelines by incorporating new evidence regarding the management of gallbladder polyps into its recommendations. They made 8 recommendations that we will summarize. Recommendations 1 to 7 have changed from the previous guidance, whereas recommendation 8 is unchanged.
1. Primary investigation of polypoid lesions of the gallbladder should be with abdominal ultrasound. Routine use of other imaging modalities is not recommended presently, but further research is needed. In centers with appropriate expertise and resources, alternative imaging modalities (such as contrast-enhanced and endoscopic ultrasound) may be useful to aid decision-making in difficult cases.
Since the original guidelines, several studies have explored the potential of alternative modalities for detecting gallbladder polyps and differentiating dysplastic malignant from benign polyps. Although some techniques, like high-resolution ultrasound (HRUS), endoscopic ultrasound (EUS), contrast-enhanced ultrasound (CEUS), magnetic resonance imaging (MRI) and positron emission tomography (PET), tried to improve the detection of pre-malignant and malignant lesions, a size greater than 1 cm remained a factor independently associated with a neoplastic polyp [4; 5].
2. Cholecystectomy is recommended in patients with polypoid lesions of the gallbladder measuring 10 mm or more, providing the patient is fit for, and accepts, surgery. Multidisciplinary discussion may be employed to assess perceived individual risk of malignancy.
Several studies have investigated alternative size thresholds at which to intervene, but the overall quality of evidence remains low. In the absence of an alternative size threshold with better evidence, the group chose to leave the 10 mm threshold unchanged. Multidisciplinary team meetings were introduced in this update to discuss the best management of individual patients.
3. Cholecystectomy is suggested if no alternative cause for the patient’s symptoms is demonstrated and the patient is fit for, and accepts, surgery. The patient should be counseled about the benefit of cholecystectomy versus the risk of persistent symptoms. There was limited and low-quality evidence regarding the value of cholecystectomy, in patients with symptoms potentially attributable to the gallbladder. One study reported that 61% symptomatic patients reported ongoing pain after their cholecystectomy [6]. So, in this update the group emphasized that symptomatic patients with gallbladder polyps should be counseled about the potential benefits of cholecystectomy versus the risks of persistent pain.
4.If the patient has a 6–9 mm polypoid lesion of the gallbladder and one or more risk factors for malignancy, cholecystectomy is recommended if the patient is fit for, and accepts, surgery.
These risk factors are:
- Age more than 60 years old;
- History of primary sclerosing cholangitis (PSC);
- Asian ethnicity;
- Sessile polypoid lesion (including focal gallbladder wall thickening > 4 mm).
A systematic review [7], which included 5,482 gallbladder polyps, identified the age threshold of more than 60 years as a significant risk factor for malignancy, resulting in the update of the age threshold (vs 50 years in the 2017 guidelines). In previous recommendations, only Indian ethnicity was considered a risk factor, however more recent reviews [8] suggested that the entire Asian population is at increased risk.
5. If the patient has either:
- No risk factors for malignancy and a gallbladder polypoid lesion of 6–9 mm
- Risk factors for malignancy and a gallbladder polypoid lesion 5 mm or less
Follow-up ultrasound of the gallbladder is recommended at 6 months, 1 year and 2 years. Follow-up should be discontinued after 2 years in the absence of growth.
The preview guidelines suggested that follow-up ultrasound is recommended at 6 months, 1 year and then yearly up to 5 years in these cases. In this update, the authors suggested that a limited strategy of one or two follow-up ultrasound investigations in the subsequent 1–2 years is sufficient to provide adequate reassurance for patients and clinicians, emphasizing that monitoring should be reserved for those who are potentially fit for surgery.
6. If the patient has no risk factors for malignancy, and a gallbladder polypoid lesion of 5 mm or less, follow-up is not required.
Previously, it was suggested that these patients were re-evaluated by ultrasound at 1 year, 3 years and 5 years. Although a few cases of gallbladder cancer in polyps measuring 5 mm or less have been reported in the literature to date, the group felt that a pragmatic approach to small gallbladder polyps was necessary, and, as such, do not recommend follow up for gallbladder polyps measuring 5 mm or less. New data reported by Szpakowski and Tucker [9] was considered insufficient justification for follow-up.
7. If during follow-up the gallbladder polypoid lesion reaches 10 mm, then cholecystectomy is advised. If the polypoid lesion grows by 2 mm or more within the 2-year follow-up period, then the current size of the polypoid lesion should be considered along with patient risk factors. Multidisciplinary discussion may be employed to decide whether continuation of monitoring, or cholecystectomy, is necessary.
Szpakowski and Tucker [9] provided the best evidence to date that slow growth is part of the natural history of gallbladder polyps. Their study reported that the cumulative probability of a gall- bladder polyp growing by 2 mm or more at 10 years was small. For this reason, in these guidelines, this recommendation was changed, and cholecystectomy was not advised for all patients with polyp growth.
8. If during follow-up the gallbladder polypoid lesion disappears, then monitoring can be discontinued.
This recommendation is unchanged from the previous guidance.
Conclusion:
Systematic reviews and large observational studies described above have been published since the previous version of the guidelines, in an attempt to discover important answers to these challenging clinical questions.
The substantial knowledge gained over the past several years has shown that aggressive follow-up and treatment of incidentally identified small gallbladder polyps may be unwarranted.
These revised guidelines from the ESGAR, EAES, EFISDS and ESGE are very important because they allow radiologists to stay up to date, optimize the use of resources and to provide the best and most up-to-date care for their patients.
References:
1. Aldouri AQ, Malik HZ, Waytt J, et al. The risk of gallbladder cancer from polyps in a large multiethnic series. Eur J Surg Oncol 2009;35(1):48–51.
2. Sung H, Ferlay J, Siegel RL et al (2021) Global Cancer Statis- tics 2020: GLOBOCAN Estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 71(3):209–249
3. Misra MC, Guleria S (2006) Management of cancer gallbladder found as a surprise on a resected gallbladder specimen. J Surg Oncol 93(8):690–698
4. Kim JH, Lee JY, Baek JH et al (2015) High-resolution sonogra- phy for distinguishing neoplastic gallbladder polyps and staging gallbladder cancer. AJR Am J Roentgenol 204(2):W150-159
5. Zhang H-P, Bai M, Gu J-Y, He Y-Q, Qiao X-H, Du L-F (2018) Value of contrast-enhanced ultrasound in the differential diagnosis of gallbladder lesion. World J Gastroenterol 24(6):744–751
6. Aliyazicioglu T, Carilli S, Emre A et al (2017) Contribution of gallbladder polyp surgery to treatment. Eur Surg Acta Chirurgica Austriaca 49(1):23-26
7. Elmasry M, Lindop D, Dunne DFJ, Malik H, Poston GJ, Fenwick SW (2016) The risk of malignancy in ultrasound detected gallbladder polyps: a systematic review. Int J Surg 33(PtA):28-35
8. Babu BI, Dennison AR, Garcea G (2015) Management and diagnosis of gallbladder polyps: a systematic review. Langenbecks Arch Surg 400(4):455-462
9. Szpakowski J-L, Tucker L-Y (2020) Outcomes of gallbladder polyps and their association with gallbladder cancer in a 20-year cohort. JAMA Network Open 3(5):e205143
Dr. Pedro Maganinho is a third-year Radiology resident at the Centro Hospitalar Universitário do Porto, in Portugal. He has a wide range of interests in diagnostic imaging including abdominal and gastrointestinal radiology.
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