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Gallbladder polyps: when to wait and when to act
THE LANCET
COMMENTARY 1
Furchgott RF, Zawadzki JV. The obligatory role of endothelial cells in the relaxation of arterial smooth muscle to acetylcholine. Nature 1980; 288: 373-76. Umans JG, Levi R. Nitric oxide in the regulation of blood flow and arterial pressure. Annu` Rev Physiol 1995; 57: 771-90. Garland CJ, Plane F, Kemp BK, Cocks TM. Endothelium dependent hyperpolarization: a role in the control of vascular tone. Trends Pharmacol Sci. 1995; 16: 23-30. Jia L, Bonaventura J, Stamler JS. S-nitrosohaemoglobin: a dynamic activity of blood involved in vascular control. Nature 1996; 380: 221-26.
Koga’s observation that gallstones mask the presence of polyps. Further significance is given to the presence of gallstones by Yang et al’s observation that seven cancers 2 were found in the 47 patients with concurrent gallstones, 3 whereas only six cancers were found in the 125 patients without stones. Both groups found that malignant lesions tended to be single and larger, and to occur in older 4 patients. The two groups of researchers made similar recommendations for managing patients with gallbladder Gallbladder polyps: when to wait and polyps (figure). Moriguchi et al recently tested such a when to act strategy by identifying 111 patients with gallbladder polyps detected by ultrasonography during 1988 and The advent of ultrasonography to investigate patients with monitoring this cohort prospectively by 6–12 monthly suspected gallstones has increased detection of other ultrasound examinations until 1994.6 Six patients were gallbladder lesions, particularly polyps, which are found in 1 withdrawn in the study period, two died of unrelated up to 4% of patients. The term polyp encompasses a causes, and four underwent cholecystectomy, one of heterogeneous group of abnormalities, including true whom, a 77-year-old woman, had a 24 mm gallbladder polyps, polypoid tumours such as adenomas, and adenocarcinoma arising from pseudotumours, which may be Strategies for managing gallbladder polyps mucosa away from the polyp. either inflammatory polyps or What became of the remaining epithelium-covered aggregates of *Complicting factors Gallbladder polypoid lesions? 84% –Age >50 years lipid-laden macrophages, also polyp –Presence of gall stones remained the same size, 3·8% termed cholesterol polyps. shrank or disappeared, and Although gallbladder cancers 11·7% enlarged. Nine of the can present as polypoid lesions, Symptomatic Symptomless 12 polyps that enlarged were the relation between gallbladder initially smaller than 5 mm in polyps and cancer is diameter. A disquieting feature controversial. Large polyp Small polyp of the study was the Aldridge and Bismuth argued >10 mm <10 mm development of a 24 mm for a polyp-to-cancer sequence gallbladder cancer despite in which some adenomas frequent examination by Complicating Complicating progress to adenocarcinoma.2 factors* absent factors* present ultrasonography. A similarly Others believe most gallbladder rapid growth rate was carcinomas arise in situ from described by Kubota et al, flat, dysplastic epithelium.3 Follow-up with repeat ultrasound Refer for who reported a 1·5 to 4-fold Carcinoma of the gallbladder every 3-6 months cholecystectomy increase in maximum polyp usually presents late and has diameter in 4 to 12 months in an appalling prognosis. For five patients with gallbladder cancer.7 prognosis to be improved lesions have to be detected early, It is still unclear whether adenomas do progress to when still confined to the mucosa. But how do clinicians carcinomas and whether the use of ultrasound for distinguish between the rare, early malignant lesions and monitoring gallbladder polyps will lead to the detection the common benign ones? and successful treatment of early gallbladder cancer. The Some clues can be gleaned from ultrasonographic available evidence suggests that a watch-and-wait strategy appearances. Cholesterol polyps, which are the based on repeated ultrasound examination should be commonest polypoid lesions and have no malignant implemented cautiously until more is known about the potential, are characteristically small, multiple, and natural history of gallbladder polyps and the pathogenesis hyperechoic on ultrasound because of their cholesterol of gallbladder cancer. content. Differentiating other benign polyps from malignant lesions is more difficult, but polyp size is a Ralph A Boulton, David H Adams useful discriminator. Koga et al found polypoid lesions in Liver Unit, Queen Elizabeth Hospital, Birmingham B15 2TH, UK 4 40 of 411 patients who underwent cholecystectomy. Of 1 Jorgensen T, Jensen KH. Polyps in the gallbladder. A prevalence 32 benign polyps, 30 were under 10 mm in diameter, study. Scand Gastroenterol 1990; 25: 281–86. whereas seven of eight malignant lesions were larger, and 2 Aldridge MC, Bismuth H. Gallbladder cancer: the polyp-cancer of these five had been correctly diagnosed preoperatively sequence. Br J Surg 1990; 77: 363–64. on the basis of size or ultrasonographic appearance. 3 Albores-Saavedra J, Vardaman CJ, Vuitch F. Non-neoplastic polypoid lesions and adenomas of the gallbladder. Path Ann Part 1993; 28: Similarly, Yang et al reviewed the clinicopathological 145–77. findings in 182 patients presenting with polypoid lesions 4 Koga A, Watanabe K, Fukuyama T, Takigushi S, Nakayama F. of the gallbladder and found that lesions smaller than Arch Surg 1988; 123: 26–29. 10 mm diameter were benign, whereas all those larger 5 Yang HL, Sun YG, Wang Z. Polypoid lesions of the gallbladder: diagnosis and indications for surgery. Br J Surg 1992; 79: 227–29. were malignant, and most of these (11/13) exceeded 15 6 Moriguchi H, Tazawa J, Hayashi Y, et al. Natural history of polypoid mm.5 Although ultrasonography correctly identified 155 of lesions in the gall bladder. Gut 1996; 39: 860–62. 172 patients with polyps, it gave 10 false-positive results, 7 Kubota K, Bandai Y, Noie T, Ishizaki Y, Teruya M, Makuuchi M. and in 17 patients polyps were missed. However, 16 of How should polypoid lesions of the gall bladder be treated in the era of laparoscopic cholecystectomy? Surgery 1995; 117: 481–87. these 17 patients had concurrent cholelithiasis, confirming
Vol 349 • March 22, 1997
817
COMMENTARY 1
Furchgott RF, Zawadzki JV. The obligatory role of endothelial cells in the relaxation of arterial smooth muscle to acetylcholine. Nature 1980; 288: 373-76. Umans JG, Levi R. Nitric oxide in the regulation of blood flow and arterial pressure. Annu` Rev Physiol 1995; 57: 771-90. Garland CJ, Plane F, Kemp BK, Cocks TM. Endothelium dependent hyperpolarization: a role in the control of vascular tone. Trends Pharmacol Sci. 1995; 16: 23-30. Jia L, Bonaventura J, Stamler JS. S-nitrosohaemoglobin: a dynamic activity of blood involved in vascular control. Nature 1996; 380: 221-26.
Koga’s observation that gallstones mask the presence of polyps. Further significance is given to the presence of gallstones by Yang et al’s observation that seven cancers 2 were found in the 47 patients with concurrent gallstones, 3 whereas only six cancers were found in the 125 patients without stones. Both groups found that malignant lesions tended to be single and larger, and to occur in older 4 patients. The two groups of researchers made similar recommendations for managing patients with gallbladder Gallbladder polyps: when to wait and polyps (figure). Moriguchi et al recently tested such a when to act strategy by identifying 111 patients with gallbladder polyps detected by ultrasonography during 1988 and The advent of ultrasonography to investigate patients with monitoring this cohort prospectively by 6–12 monthly suspected gallstones has increased detection of other ultrasound examinations until 1994.6 Six patients were gallbladder lesions, particularly polyps, which are found in 1 withdrawn in the study period, two died of unrelated up to 4% of patients. The term polyp encompasses a causes, and four underwent cholecystectomy, one of heterogeneous group of abnormalities, including true whom, a 77-year-old woman, had a 24 mm gallbladder polyps, polypoid tumours such as adenomas, and adenocarcinoma arising from pseudotumours, which may be Strategies for managing gallbladder polyps mucosa away from the polyp. either inflammatory polyps or What became of the remaining epithelium-covered aggregates of *Complicting factors Gallbladder polypoid lesions? 84% –Age >50 years lipid-laden macrophages, also polyp –Presence of gall stones remained the same size, 3·8% termed cholesterol polyps. shrank or disappeared, and Although gallbladder cancers 11·7% enlarged. Nine of the can present as polypoid lesions, Symptomatic Symptomless 12 polyps that enlarged were the relation between gallbladder initially smaller than 5 mm in polyps and cancer is diameter. A disquieting feature controversial. Large polyp Small polyp of the study was the Aldridge and Bismuth argued >10 mm <10 mm development of a 24 mm for a polyp-to-cancer sequence gallbladder cancer despite in which some adenomas frequent examination by Complicating Complicating progress to adenocarcinoma.2 factors* absent factors* present ultrasonography. A similarly Others believe most gallbladder rapid growth rate was carcinomas arise in situ from described by Kubota et al, flat, dysplastic epithelium.3 Follow-up with repeat ultrasound Refer for who reported a 1·5 to 4-fold Carcinoma of the gallbladder every 3-6 months cholecystectomy increase in maximum polyp usually presents late and has diameter in 4 to 12 months in an appalling prognosis. For five patients with gallbladder cancer.7 prognosis to be improved lesions have to be detected early, It is still unclear whether adenomas do progress to when still confined to the mucosa. But how do clinicians carcinomas and whether the use of ultrasound for distinguish between the rare, early malignant lesions and monitoring gallbladder polyps will lead to the detection the common benign ones? and successful treatment of early gallbladder cancer. The Some clues can be gleaned from ultrasonographic available evidence suggests that a watch-and-wait strategy appearances. Cholesterol polyps, which are the based on repeated ultrasound examination should be commonest polypoid lesions and have no malignant implemented cautiously until more is known about the potential, are characteristically small, multiple, and natural history of gallbladder polyps and the pathogenesis hyperechoic on ultrasound because of their cholesterol of gallbladder cancer. content. Differentiating other benign polyps from malignant lesions is more difficult, but polyp size is a Ralph A Boulton, David H Adams useful discriminator. Koga et al found polypoid lesions in Liver Unit, Queen Elizabeth Hospital, Birmingham B15 2TH, UK 4 40 of 411 patients who underwent cholecystectomy. Of 1 Jorgensen T, Jensen KH. Polyps in the gallbladder. A prevalence 32 benign polyps, 30 were under 10 mm in diameter, study. Scand Gastroenterol 1990; 25: 281–86. whereas seven of eight malignant lesions were larger, and 2 Aldridge MC, Bismuth H. Gallbladder cancer: the polyp-cancer of these five had been correctly diagnosed preoperatively sequence. Br J Surg 1990; 77: 363–64. on the basis of size or ultrasonographic appearance. 3 Albores-Saavedra J, Vardaman CJ, Vuitch F. Non-neoplastic polypoid lesions and adenomas of the gallbladder. Path Ann Part 1993; 28: Similarly, Yang et al reviewed the clinicopathological 145–77. findings in 182 patients presenting with polypoid lesions 4 Koga A, Watanabe K, Fukuyama T, Takigushi S, Nakayama F. of the gallbladder and found that lesions smaller than Arch Surg 1988; 123: 26–29. 10 mm diameter were benign, whereas all those larger 5 Yang HL, Sun YG, Wang Z. Polypoid lesions of the gallbladder: diagnosis and indications for surgery. Br J Surg 1992; 79: 227–29. were malignant, and most of these (11/13) exceeded 15 6 Moriguchi H, Tazawa J, Hayashi Y, et al. Natural history of polypoid mm.5 Although ultrasonography correctly identified 155 of lesions in the gall bladder. Gut 1996; 39: 860–62. 172 patients with polyps, it gave 10 false-positive results, 7 Kubota K, Bandai Y, Noie T, Ishizaki Y, Teruya M, Makuuchi M. and in 17 patients polyps were missed. However, 16 of How should polypoid lesions of the gall bladder be treated in the era of laparoscopic cholecystectomy? Surgery 1995; 117: 481–87. these 17 patients had concurrent cholelithiasis, confirming
Vol 349 • March 22, 1997
817