Gallbladder polyps and neoplasia - SUNY Downstate … polyps.pdfB-GALLBLADDER: -CHRONIC...

Gallbladder polyps and neoplasia

Volodymyr Labinskyy MD, Brooklyn VA Hospital August 16, 2012

www.downstatesurgery.org

64 year old male referred for evaluation of incidentally found asymptomatic gallbladder polyp 1.1 cm on screening abdominal CT for HCC surveillance PMH: Obesity, GERD, Dislipidemia, Hep C, DM II, Hypothyroidism PSH: Vasectomy, TURP 4/2012 Home meds: Finasteride, metformin, omeprazole, levothyroxine, simvastatin, HTZ, gemfibrozil, orlistat Physical exam: BMI 35, liver 2+ cm below costal margin Labs: within normal limits


RUQ US


Abdominal CT


7/23/12 Lap cholecystectomy. Uneventful postoperative course.

7/24/12 Discharged home

Pathology: Specimen A is labeled as "gallbladder mass". It consists of multiple yellow soft stones in aggregate measuring 0.8 x 0.6 x 0.4 cm.

B-GALLBLADDER: -CHRONIC CHOLECYSTITIS WITH CHOLELITHIASIS.


Gallbladder polyps and neoplasia


Epidemiology The highest incidence of gallbladder cancer is found in women living in India, Pakistan, and Ecuador.

Approximately 9760 cases of gallbladder and other biliary cancers are diagnosed annually in the United States, with 3320 deaths annually

In North America, high incidence rates are found among Native Americans and Hispanic women

(Jemal et al, 2010). (Barakat et al, 2006)


Etiology

Cholelithiasis and chronic inflammation.

Calcification in the wall of the gallbladder otherwise known as porcelain gallbladder. Incidence of cancer <10%

Chronic inflammatory conditions of the gallbladder (cholecystoenteric fistula)

Anomalous Pancreatico-Biliary Duct Junction

Chemical carcinogens: methyldopa, isoniazid, occupational exposure in the rubber industry

8% incidence of gallbladder cancer in gallbladder specimens with polyps, all more than 1 cm in size.


Preneoplastic Lesions

Progression from dysplasia to carcinoma in situ to frank invasive carcinoma is seen in gallbladder epithelium

Progression of precursor lesions to invasive carcinoma was estimated to be approximately 15 years

Gallbladder polyps have been noted in 3% to 6% of patients undergoing ultrasonography (US).

(Albores-Saavedra et al, 1986) (Roa et al, 1996)

(Zielinski et al, 2009)


The incidence of carcinoma in nonadenomatous polyps—cholesterol polyps, inflammatory polyps, and hyperplastic polyps—is close to zero

Risk of malignancy was associated with: increasing age >50 size greater than 1 cm the presence of a single polyp

(Choi et al, 2008, Ito et al, 2009)


Frequency gallbladder polyps

Type Benign polyps

Cholesterol polyps Adenomyomas Inflammatory polyps Adenomas Miscellaneous:

Leiomyomas Fibromas Lipomas, etc. Malignant polyps

Adenocarcinoma Miscellaneous:

Mucinous cystadenomas Squamous cell carcinoma Adenoacanthomas

Frequency 60 percent 25 percent 10 percent 4 percent 1 percent 80 percent 20 percent

Weedon, D. Benign mucosal polyps. In pathology of the gallbladder, Mason, New York 1984


Classification of Malignant Tumors of the Gallbladder


Relative Incidence of Gallbladder Cancer by Histologic Type


Giant cell adenocarcinoma of the gallbladder. This

tumor has an infiltrative nature, but it fills most of the

lumen of the gallbladder.


Papillary adenocarcinoma of the gallbladder: this

tumor has a cauliflower-like appearance and protrudes into the lumen with minimal invasion of the

gallbladder wall.


Imaging Modalities Used to Diagnose Gallbladder Cancer


Benign Polyps

Some clinicians have recommended cholecystectomy for any patient with fewer than three polyps

Cholecystectomy recommended for any polyp greater than 1 cm

The exception to this recommendation is for those arising in the setting of primary sclerosing cholangitis

(Shinkai et al, 1998) (Ito et al, 2009) (Buckles et al, 2002)


A prevalence of gallbladder cancer with polypoid lesions of the gallbadder equal to 0.08% was reported in white patients

On periodic US 4 to 12 months after the original US, polyps grew 1.4 to 4 times larger

US follow-up at 6- to 12-month intervals for 2 years; if polyp size is stable, routine survelliance can be stopped

(Aldouri et al, 2009) (Kubota at al, 1995)


Incidentally Discovered Gallbladder Carcinoma During or After Routine

Cholecystectomy

Gallbladder cancer is found in 0.27% to 2.1% of all laparoscopic cholecystectomies

Outcomes after prior noncurative resection were similar to outcomes from primary curative resections

Re-resection is recommended for all patients who are medically fit with T1b or greater level of invasion

Resection of the bile duct required for a complete resection in cases with a positive cystic duct stump margin

(Darmas et al, 2007; Kwon et al, 2008). (Fong et al, 2000). (Pawlik et al, 2007)


AJCC Staging System for Gallbladder Cancer


Anatomic Stage and Prognostic Groups

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage II T2 N0 M0

Stage IIIA T3 N0 M0

Stage III B T1-3 N1 M0

Stage IVA T4 N0-1 M0

Stage IVB Any T N2 M0 Any T Any N M1

From Edge SB, Byrd DR, Compton CC, et al (eds): AJCC cancer staging manual, ed 7, New York, 2010, Springer, pp 213–214.


PORT SITE RECURRENCES There is a theoretical risk of port site seeding after

laparoscopic cholecystectomy for what is eventually diagnosed as gallbladder cancer

It is rare for port site recurrences to occur as the sole site of disease

General practice does not include empirically resecting prior port sites during reexploration for gallbladder cancer

(Winston et al, 1999) (Povoski et al, 2004; Shoup & Fong, 2002)


Algorithm gallbladder polyps

* Symptoms: Biliary type pain, common duct obstruction, cholangitis, or recurrent pancreatitis. Dyspepsia is not an indication for surgery.


Treatment Recommendations for Gallbladder Cancer Diagnosed After

Cholecystectomy


Observed survival rates for 10,705 gallbladder cancers. Data from the National Cancer Data Base (Commission on Cancer of the American College of Surgeons and the American Cancer Society) diagnosed in years 1989–1996.


Following cholecystectomy, an adenocarcinoma of the gallbladder extending into the subserosa

is discovered incidentally. The recommended treatment includes which of the following?

A. Nothing further at this time

B. External beam radiation therapy

C. Radiation therapy and chemotherapy

D. Reoperation for liver resection and lymphadenectomy

E. Reoperation for performance of pancreatoduodenectomy


Ultrasound imaging demonstrates a 15-mm polypoid lesion in the gallbladder of an

asymptomatic 60-year-old patient. Which of the following best describes the recommended

treatment?

A. Observation with repeat ultrasound studies in 6 months

B. Cholecysectomy

C. Cholecysectomy if the patient is female

D. Cholecysectomy only if symptoms develop

E. Cholecysectomyonly if the patient also has gallstones


Which of the following is a contraindication to resection of an adenocarcinoma of the bile duct?

A. Tumor location in the distal common bile duct

B. Tumor location at the bifurcation of the bile duct

C. Peritoneal metastases

D. Invasion of the right portal vein and right hepatic artery

E. None of above


Gallbladder polyps and neoplasia - SUNY Downstate … polyps.pdfB-GALLBLADDER: -CHRONIC...

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