Cholesterosis of the Gallbladder is NOT a Premalignant Condition
Cholesterosis (cholesterolosis) of the gallbladder is a benign condition characterized by cholesterol ester deposition in the gallbladder wall and is not considered premalignant or associated with increased risk of gallbladder cancer. This is a distinct pathologic entity separate from conditions that do carry malignancy risk.
Key Distinguishing Features
Cholesterosis is Benign
- Cholesterosis represents lipid accumulation in the gallbladder mucosa without dysplastic changes or malignant potential 1, 2
- The condition occurs in approximately 13-14% of cholecystectomy specimens and shows no progression to malignancy 3
- Histologically, cholesterosis demonstrates cholesterol-laden macrophages in the lamina propria without epithelial atypia 2
Conditions That ARE Premalignant (For Contrast)
The following gallbladder conditions do carry malignancy risk and require different management:
- Gallbladder polyps ≥8 mm in PSC patients: These warrant cholecystectomy due to high risk of malignancy or dysplasia, with reported gallbladder cancer rates of 8.8 per 1,000 person-years 4
- Large gallstones (>3 cm): May carry increased risk for gallbladder cancer and prophylactic cholecystectomy may be advisable 4
- Calcified ("porcelain") gallbladder: Carries increased risk for gallbladder cancer 4
Clinical Management of Cholesterosis
When Symptomatic
- If cholesterosis causes biliary colic symptoms, laparoscopic cholecystectomy is the definitive treatment with excellent outcomes (95.9% completion rate, no complications in reported series) 3
- Medical therapy with ursodeoxycholic acid can achieve regression of cholesterol polyps in 56.5% of cases and improvement in gallbladder contractile function 5
When Asymptomatic
- Asymptomatic cholesterosis discovered incidentally requires no specific intervention beyond what would be indicated for any coexisting gallstones 4
- The presence of cholesterosis does not change management recommendations for asymptomatic gallstones, which favor expectant management 4
Common Clinical Pitfalls
Do not confuse cholesterosis with dysplasia or premalignant conditions. The key distinctions are:
- Cholesterosis shows lipid deposition without epithelial changes 2
- Biliary dysplasia/BilIN shows epithelial atypia and follows a metaplasia-dysplasia-carcinoma sequence in conditions like PSC 4
- Cholesterosis has no association with progression to malignancy in long-term follow-up 1, 2
Do not assume all gallbladder pathology carries cancer risk. While gallbladder cancer is discovered incidentally in 0.4-1.5% of cholecystectomy specimens overall 6, this reflects the background prevalence of occult cancer, not a causal relationship with cholesterosis specifically.
Cholesterosis does not require surveillance imaging or accelerated surgical intervention beyond what symptoms or coexisting conditions (like symptomatic gallstones) would otherwise dictate 4, 3.