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Editor,—Moriguchi et al(Gut 1996; 39: 860–2) report that of 4343 patients, 109 had gall bladder polyps detected on ultrasound, most of which were benign. They follow this with an interesting brief review of the literature. From their comments and my own reading of the subject, the overwhelming majority of gall bladder polyps are benign, although one of the 109 patients was found to have gall bladder cancer histologically, and this ties in with previous reports.1Koga et al 1 found carcinoma of the gall bladder presenting as polypoid lesions in three of four cases on ultrasound in their study and, surprisingly, by gall bladder wall thickening in only one of the four cases. Although the numbers are small and gall bladder cancer is relatively rare, it still comprises 3% of all gastrointestinal malignancies and causes 6500 deaths annually in the USA.2 In addition, the spread and size of tumour are correlated.3 4 The patients who survive more than five years are those in whom the cancer is diagnosed histologically at cholecystectomy for presumed benign disease—that is early, with disease confined to the mucosa or submucosa. Disease beyond these limits is accompanied by a drastic drop in survival rates at five years from 64 to 44% and the overall five year prognosis is quoted as less than 5%.4 Gallstones have also been found commonly in association with both gall bladder polyps and gall bladder malignancy.2 4-6 In the light of these findings, early cholecystectomy in selected patients could reduce long term mortality. Preliminary histology at surgery could permit dissection of portal hepatic nodes, excision of the gall bladder bed, and right hepatic lobectomy at initial cholecystectomy, thus improving survival2 and reducing the costs of repeat operation.
What remains controversial and undecided, however, is how to select those patients who should have early cholecystectomy from those who should have six monthly follow up ultrasound. Certainly, rapidly enlarging lesions or those with areas of gall bladder wall thickening should be removed, including benign lesions in women, especially those over 60,3 and in patients with gallstones, even asymptomatic ones.7 In the study by Moriguchi et al the size of the polyps was not related to whether malignancy developed, extrapolating from the adenoma–carcinoma sequence in which gall bladder adenomas are premalignant lesions.6 Indeed in Moriguchi et al’s study it is interesting that the larger polyps were found in the younger age group.
Clearly, logistic reasons dictate that not every patient with polyps should have an instant cholecystectomy if asymptomatic, and there does have to be a process of sifting and selection, but, in my view, this should err towards the side of more frequent surgery in the fit patient for the reasons discussed above.
Editor,—We are grateful to Dr Kyriacou for her interest in our recent study. We agree with him that there is a small number of patients who are diagnosed with gall bladder carcinoma and that early detection of carcinoma would improve their prognosis. The study by Koga et al 1-1 cited by Dr Kyriacou, however, describes the prevalence of gall bladder carcinoma in patients who had undergone cholecystectomy. Therefore, it is difficult to draw any conclusion from this study in terms of the prognosis of polypoid lesions of the gall bladder.
Prospective studies are needed to determine whether polypoid lesions develop into gall bladder carcinoma. Progression from adenoma to carcinoma takes time, and therefore these patients should be followed long term.
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