Gallbladder polyps in primary sclerosing cholangitis: Indication for early intervention

Authors


  • Potential conflict of interest: Nothing to report.

To the Editor:

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 American2 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 × 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.

Christoph Schramm M.D.*, Ansgar W. Lohse M.D.*, * Department of Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

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