胆囊息肉的大小可以指导治疗

StephenW

Gallbladder Polyp Size Can Guide Treatment
By Nancy Walsh, Staff Writer, MedPage Today
Published: August 20, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points

    The follow-up strategy for patients with gallbladder polyps should be based on the size of the lesions, which can influence progression and malignancy potential.
    Point out that gallbladder polyps that are more than 10 mm or increase in size during surveillance predicted neoplastic potential, and that polyps with either of these criteria should be resected.

The follow-up strategy for patients with gallbladder polyps should be based on the size of the lesions, which can influence progression and malignancy potential, British researchers advised.

In a retrospective analysis done at a tertiary care hepatobiliary center, polyps that increased in size during surveillance were significantly larger at baseline than those that remained stable (7 mm versus 5 mm in diameter, P<0.05), according to Giuseppe Garcea, MD, and colleagues from University Hospitals of Leicester in Leicester, England.

And polyps greater than 10 mm at baseline were more likely to be malignant or potentially so, with an area under the curve of 0.81 (P<0.001), the researchers reported online in Archives of Surgery.

The rarity of gallbladder polyps and an incomplete understanding of their natural history -- coupled with the fact that the vast majority are benign and only a few are adenomatous -- has led to uncertainty as to the optimal therapeutic approach.

In addition, ultrasound evaluation of the gallbladder presents difficulties, and many purported polyps turn out to be stones on the gallbladder wall or cholesterol polyps.

Therefore, in an attempt to clarify which patients should undergo removal of the gallbladder, which need surveillance, and which require little or no follow-up, Garcea's group reviewed the case notes from 986 patients seen at their center between 2000 and 2011.

More than half were women, and the median age was slightly over 57 years.

A total of 69% of the polyps were smaller than 5 mm, 26.2% were 5 to 10 mm, and the remaining few were larger than 10 mm.

A single polyp was present in 62%, while more than three were detected in 24.4%.

Median follow-up was 39.3 months, but half of the patients received no subsequent surveillance or follow-up.

An increase in size was seen in only 6.6% of polyps during the surveillance period, while a decrease was seen in 25.7% and no change occurred in 67.7%.

Among patients who underwent cholecystectomy, the most common reasons were persistent pain and polyp size in excess of 10 mm.

Following gallbladder removal, only 3.7% turned out to be possibly malignant on histologic evaluation, and only one specimen showed actual malignant changes.

The researchers then considered the potential cost-effectiveness of surveillance in patients with these polyps.

In the U.S., the overall economic burden associated with gallbladder cancer is $78 million yearly, they calculated.

Given the median age of 57 at the time of polyp detection, and a 20-year subsequent life expectancy, ultrasound surveillance every 2 years could carry a price tag of $47,036 each year and $9.4 million over 2 decades.

They further determined that biannual surveillance could save 5.4 lives each year, if all potentially neoplastic polyps were assumed to become malignant.

And if 30% of patients undergoing surveillance had surgery, as was the case in this cohort, annual costs for surgery would be $253,115, rising to $310,167 when surveillance costs are also included.

With annual costs of $94,069 for a single patient with gallbladder cancer, the saving of surveillance would be approximately $207,839 per 1,000 patients each year, they estimated.

They suggested that surveillance might be more cost-effective if only done for polyps 5 mm or more, and among groups such as Asians who have higher risks for gallbladder malignancy.

In an invited critique, Jonathan Koea, MD, of North Shore Hospital in Auckland, New Zealand, noted a caveat to these findings.

"Surveillance is only cost-effective when there is a high prevalence of adenomatous lesions within the polyp population -- something with current imaging techniques we cannot yet be sure of," he observed.

Garcea and colleagues concluded that polyps smaller than 5 mm "can probably be ignored," while resection should be done for those larger than 10 mm or increasing in size, and surveillance is in order for those between 5 mm and 10 mm.

But they deemed their finding that almost half of patients had no further follow-up after the detection of a polyp as "perhaps alarming."

They suggested that for young patients, cholecystectomy might be considered even with polyps smaller than 10 mm, because of the lengthy and possibly "unsustainable" surveillance that would be needed.

Finally, "all gallbladder polyps represent potentially premalignant disease and require discussion at a hepatobiliary multidisciplinary team meeting because this would enhance and standardize the management of this condition," they cautioned.

The authors and commentator reported no conflicts of interest.

Primary source: Archives of Surgery
Source reference:
Cairns V, et al "Risk and cost-effectiveness of surveillance followed by cholecystectomy for gallbladder polyps" Arch Surg 2012; DOI:10.1001/archsurg.2012.1948.

Additional source: Archives of Surgery
Source reference:
Koea J "Finding'em? Following 'em? Fixing 'em?" Arch Surg 2012; DOI: 10.1001/archsurg.2012.1959.

StephenW

胆囊息肉的大小可以指导治疗
南希·沃尔什，员工的作家，MedPage今天
发布时间：2012年8月20号
的罗伯特·Jasmer，医师，医学院的助理临床教授，美国加州大学旧金山和多萝西·卡普托，MA，RN，BSN，护士规划

行动要点

    胆囊息肉患者的后续战略，应根据病变的大小，从而影响发展和恶性潜力。
    指出，胆囊息肉，为10毫米或以上的规模增长在监测期间预测肿瘤的潜力，而且，这些标准的息肉应手术切除。

胆囊息肉的患者，应根据病变的大小，从而影响发展和恶性潜力的后续战略，英国研究人员建议。

在肝胆三级保健中心做了回顾性分析，增加的大小的息肉，在监测期间为基线，而不是那些仍然稳定（7毫米和5毫米的直径，P <0.05），根据朱塞佩Garcea MD，和他的同事在莱斯特，英国莱斯特大学医院。

基线大于10毫米的息肉，更有可能是恶性的或潜在如此，曲线下面积为0.81（P <0.001），研究人员报道在网上档案手术。

胆囊息肉和不完全理解他们的自然历史罕见的 - 事实上，绝大多数是良性的，只有少数是腺瘤性加上 - 导致不确定性的最佳治疗方法。

此外，超声检查，胆囊有困难，和许多声称息肉的结石胆囊壁或胆固醇性息肉。

因此，在试图澄清哪些患者应该进行切除胆囊，这就需要监控，并要求很少或根本没有跟进，在其中心在2000年和2011年的986例患者看到Garcea的小组审查的情况说明。

超过一半为女性，年龄中位数为略超过57年。

总共有69％的息肉小于5毫米，26.2％为5至10毫米，其余几人大​​于10毫米。

一个单发息肉为62％，而超过3中检测到24.4％。

中位随访时间为39.3个月，但有一半的患者没有收到后续的监视或跟进。

尺寸的增加，只有6.6％的息肉在监察期间，减少25.7％，占67.7％，没有发生变化。

在接受胆囊切除术的患者中，最常见的原因是持续性疼痛和息肉的大小超过10毫米。

胆囊切除后，只有3.7％的横空出世可能是恶性的组织学评价，只有一个样本显示实际的恶性变化。

然后，研究人员认为潜在的成本效益在这些息肉患者的监测。

在美国，整体的经济负担与胆囊癌78000000美元每年的，他们计算。

由于息肉检出的时候，年龄中位数为57和20年以后的寿命，超声监测，每2年可以携带标价每年47036美元9400000美元超过20年。

他们进一步确定，一年两次的监控可以节省每年5.4生活，如果假设所有潜在的肿瘤性息肉变成恶性。

如果做了手术，30％的患者接受监督的情况一样，在这个世代，手术的年度费用将253115美元时，上升到310167美元的监督成本也包括在内。

他们估计，每年的费用为一个单一的胆囊癌患者94069美元，节能的监督将约为每年每1000名患者207839美元。

他们认为，监测可能更具成本效益的，如果只是做了5毫米或以上的息肉，亚洲人胆囊恶性肿瘤有较高的风险，如各组。

乔纳森Koea，医学博士，在新西兰的奥克兰，北岸医院，在邀请的批评，这些发现指出了需要注意的。

“监测是唯一符合成本效益的腺瘤性病变的息肉内人口时，有一个高发病率 - 与当前的成像技术的东西，我们还不能确定，”他说。

garcea和同事得出结论，小于5毫米的息肉“大概可以被忽略，而切除应做那些大于10毫米，或增加的大小，和监视是5毫米和10毫米之间，以便为那些。

但他们认为他们的发现，几乎一半的患者没有进一步的后续检测后的息肉“也许是惊人的。”

他们建议，对于年轻患者，胆囊切除术可能甚至小于10毫米的息肉，因为漫长的，并可能“不可持续”的监控，将需要。

最后，“所有的胆囊息肉是指潜在的癌前病变，并要求在肝胆的多学科团队会议讨论，因为这将加强和规范管理这种情况，”他们警告说。

作者和评论员报告没有利益冲突。

主要来源：外科
来源参考：
凯恩斯V，等“风险和成本效益的监视，然后由胆囊切除术，胆囊息肉”拱外科杂志2012年DOI：10.1001/archsurg.2012.1948。

其他来源：外科
来源参考：
Koea J“Finding'em继他们？固定他们吗？”凯旋门外科杂志2012年DOI：10.1001/archsurg.2012.1959。