What is the management for a gallbladder (cholecystic) polyp with significant size increase?

From the Guidelines

Surgical consultation is recommended for gallbladder polyps with significant size increase, particularly those that have grown by 4 mm or more within a 12-month period or have reached a size of 15 mm or larger 1.

Key Considerations

• The risk of malignancy increases with polyp size, and polyps larger than 10 mm have a higher risk of gallbladder cancer (GBC) 1.
• The SRU consensus conference committee recommends surgical consultation for polyps of 15 mm or greater, and for polyps measuring 10-14 mm, the decision for surgical consultation may be made depending on patient factors or evidence of growth at follow-up imaging 1.
• Rapid sustained growth of a polyp is conceptually concerning, and growth of 4 mm or more within 1 year constitutes rapid growth 1.
• Patient selection for surgery is multifactorial, requiring shared decision-making, and must take into account patient health status as well as risk profiles of imaging findings 1.

Special Considerations

• In people with primary sclerosing cholangitis (PSC), cholecystectomy is recommended for gallbladder polyps greater than or equal to 8 mm in size and smaller polyps growing in size, due to the high risk of malignancy or dysplasia 1.
• A careful risk-benefit assessment is required for patients with PSC at severe disease stages with liver decompensation, and prophylactic cholecystectomy cannot be recommended in all patients 1.

Management Approach

• For polyps with significant size increase, surgical consultation is recommended to discuss the risks and benefits of cholecystectomy 1.
• The decision to proceed with surgery should be based on individual patient factors, including the size and growth rate of the polyp, as well as the patient's overall health status and risk profile 1.

From the Research

Management of Gallbladder Polyps

The management of gallbladder polyps depends on various factors, including the size of the polyp, the presence of symptoms, and the patient's risk factors for malignancy.

• According to the guidelines updated by 2, cholecystectomy is recommended for patients with polypoid lesions of the gallbladder measuring 10 mm or more.
• For patients with a polypoid lesion and symptoms potentially attributable to the gallbladder, cholecystectomy is suggested if no alternative cause for the patient's symptoms is demonstrated and the patient is fit for, and accepts, surgery 2.
• 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 2.
• Risk factors for malignancy include age more than 60 years, history of primary sclerosing cholangitis (PSC), Asian ethnicity, and sessile polypoid lesion (including focal gallbladder wall thickening >4 mm) 2, 3, 4.

Follow-up of Gallbladder Polyps

For patients with gallbladder polyps that do not meet the criteria for cholecystectomy, follow-up ultrasound is recommended.

• Follow-up ultrasound of the gallbladder is recommended at 6 months, 1 year, and 2 years for polyps measuring 6-9 mm in patients without risk factors for malignancy, and for polyps less than 5 mm in patients with one or more risk factors for malignancy 2, 3.
• If the patient has no risk factors for malignancy, and a gallbladder polypoid lesion of 5 mm or less, follow-up is not required 2.
• If during follow-up the gallbladder polypoid lesion grows to 10 mm, then cholecystectomy is advised 2.
• 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, and multidisciplinary discussion may be employed to decide whether continuation of monitoring, or cholecystectomy, is necessary 2.

Size and Malignancy Risk

The size of the gallbladder polyp is an important factor in determining the risk of malignancy.

• Polyps ≥1 cm are more likely to be neoplastic, with a positive predictive value of 94.3% and a negative predictive value of 85% 5.
• However, 14% of polyps <1 cm were also neoplastic, highlighting the need for close monitoring of small polyps, especially in older patients 5.
• The cancer detection rate increases significantly with an increase in the lesion size, with rates of 16.4% for lesions ≥10 mm, 55.9% for lesions ≥15 mm, and 94.1% for lesions ≥20 mm 6.