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    2 Comments for this article
    RE: Outcomes of gallbladder polyps and their association with gallbladder cancer in a 20-year cohort
    Tomoyuki Kawada, MD | Nippon Medical School
    Szpakowski et al. determined the growth pattern of gallbladder polyps (GPs) and their association with gallbladder cancer (GBC) (1). The authors concluded that GBC rates were low and similar among patients with and without GPs, and here is a need of setting effective strategy of proactively following GPs to detect GBC. I greatly agree with their opinion of revising traditional approach for GBC screening by GPs information, and present data of related papers as follows.

    First, van Erp et al. conducted a retrospective cohort study to evaluate the malignant risk of gallbladder polyps in patients with primary sclerosing cholangitis
    (PSC) (2). GBC was significantly associated with polyps >10 mm, interval growth or mass-like lesions on pre-operative imaging. The majority of gallbladder polyps were benign and did not show significant growth over time, presenting 0.041 mm/year (95% CI: -0.017 to 0.249), and they concluded that immediate cholecystectomy was not recommended in patients with PSC without high-risk imaging features. They presented the same opinion with Szpakowski et al., even in patients with PSC, and intensive follow-up of patients with GPs should be limited to specific clinical findings.

    Second, Elmasry et al. conducted a systematic review to assess the natural history of ultrasonographically diagnosed GPs and their malignant potential (3). Risk factors of malignancy were GP >6mm, single GP, symptomatic GPs, age >60 years, Indian ethnicity, gallstones and cholecystitis. The incidence of GP malignancy was just 0.57%, and additional approach such as endoscopic ultrasound could be adopted for risk cases. They handled limited papers for their review, and a meta-analysis of randomized controlled studies would present stable information.

    1. Szpakowski JL, Tucker LY. Outcomes of gallbladder polyps and their association with gallbladder cancer in a 20-year cohort. JAMA Netw Open. 2020;3(5):e205143. Published 2020 May 1. doi:10.1001/jamanetworkopen.2020.5143
    2. van Erp LW, Cunningham M, Narasimman M, et al. Risk of gallbladder cancer in patients with primary sclerosing cholangitis and radiographically detected gallbladder polyps. Liver Int. 2020;40(2):382-392. doi:10.1111/liv.14326
    3. Elmasry M, Lindop D, Dunne DF, et al. The risk of malignancy in ultrasound detected gallbladder polyps: A systematic review. Int J Surg. 2016;33 Pt A:28‐35. doi:10.1016/j.ijsu.2016.07.061
    RE: Outcomes of gallbladder polyps and their association with gallbladder cancer in a 20-year cohort
    Rebecca Wiles, SA Roberts | Liverpool University Hospitals NHS Foundation Trust, UK
    As co-authors of the European Gallbladder Polyp Guidelines (1) we would like to congratulate the Authors on the excellent recent publication in JAMA Network Open (2). This is just the type of study we have been waiting for.

    In producing our guidelines in 2017, we recognised the evidence base was limited and we were clear our guidelines should not be a barrier to future research.

    This informative research has now been published, and we agree that current guidelines should be reviewed.

    We do seek one important point of clarity. In producing our guidelines, we were at pains
    to specify that some apparent polyps can be categorised as pseudopolyps and as such do not require follow up . It would be valuable for the authors to specify whether their cohort included both of these groups, or if ultrasonographers were clearly making a distinction between the two and therefore only apparent true gallbladder polyps were included.

    Congratulations to the authors!

    R. Wiles, SA Roberts

    (1) Wiles R, Thoeni R, Barbu S et al. Management and Follow-Up of Gallbladder Polyps : Joint Guidelines Between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery and Other Interventional Techniques (EAES), International Society of Digestive Surgery - European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE)
    Eur Radiol 2017 Sep;27(9):3856-3866

    (2) Szpakowski J, Tucker L. Outcomes of Gallbladder Polyps and Their Association With Gallbladder Cancer in a 20-Year Cohort. JAMA Netw Open. 2020;3(5):e205143. doi:10.1001/jamanetworkopen.2020.5143
    Original Investigation
    Gastroenterology and Hepatology
    May 18, 2020

    Outcomes of Gallbladder Polyps and Their Association With Gallbladder Cancer in a 20-Year Cohort

    Author Affiliations
    • 1Department of Gastroenterology, Kaiser Permanente, Fremont, California
    • 2Division of Research, Kaiser Permanente, Oakland, California
    JAMA Netw Open. 2020;3(5):e205143. doi:10.1001/jamanetworkopen.2020.5143
    Key Points español 中文 (chinese)

    Question  How often do gallbladder polyps grow, and are they associated with gallbladder cancer?

    Findings  In this cohort study with 622 227 participants aged 18 years or older, growth of gallbladder polyps was common, occurring in 66% of polyps sized less than 6 mm and in 53% sized 6 mm to less than 10 mm. Despite this, gallbladder cancer rarely occurred in those with gallbladder polyps, with an overall rate of 11.3 per 100 000 person-years and, among patients observed for at least 1 year, a rate of 3.6 per 100 000 person-years.

    Meaning  The findings of this study suggest that current guidelines recommending periodic ultrasonography of gallbladder polyps to proactively detect gallbladder cancer may need to be revised.


    Importance  Gallbladder polyps (GP) are found in more than 4% of adult abdominal ultrasonographs. Their growth pattern and association with gallbladder cancer (GBC) are poorly defined.

    Objective  To determine the growth pattern of GPs and their association with GBC.

    Design, Setting, and Participants  This cohort study included 622 227 adult members (ie, aged 18 years or older) of Kaiser Permanente Northern California, an integrated health care delivery system, enrolled between January 1, 1995, and December 31, 2014. The GBC cohort comprised a total of 365 adults with GBC and prior ultrasonography, and the GP cohort comprised 35 970 adults with GPs present on ultrasonography. Data analysis was performed from March 2016 to November 2019.

    Exposures  Gallbladder polyps (quantitative size, <6 mm, 6 to <10 mm, and ≥10 mm or qualitative size [ie, tiny, small, moderate, and large]).

    Main Outcomes and Measures  For the GBC cohort, proportion of patients with GBC with polyps identified on preceding ultrasonograph. For the GP cohort, rates of GBC among those with polyps according to size and rate of GP growth of at least 2 mm over time.

    Results  The GBC cohort comprised 365 individuals (267 [73.1%] women; 173 [47.4%] white patients; median [interquartile range] age, 71 [61-79] years). After excluding 14 patients who did not have evaluation of polyp size, the final GP cohort comprised 35 856 adults, with 18 645 (52.0%) women, a median (interquartile range) age 50 (40-60) years, and 15 573 (43.3%) white patients. Gallbladder polyps were found in 22 patients (6.0%) in the GBC cohort and in 35 870 of 622 227 adults (5.8%) who underwent abdominal ultrasonography. Of these, 19 (0.053%) were diagnosed with GBC, similar to those without GP (316 of 586 357 [0.054%]). The unadjusted GBC rate per 100 000 person-years was 11.3 (95% CI, 6.2-16.3) overall and increased with polyp size, from 1.3 (95% CI, 0-4.0) with initial size of less than 6 mm (n = 17 531) to 128.2 (95% CI, 39.4-217.0) with initial size of 10 mm or larger (n = 2055). In those observed for at least 1 year, the rate was 3.6 (95% CI, 0.7-6.5) per 100 000 person-years. In 6359 patients with evaluable follow-up, unadjusted cumulative probabilities of polyp growth of at least 2 mm at 10 years were 66.2% (95% CI, 62.3%-70.0%) in polyps initially less than 6 mm and 52.9% (95% CI, 47.1%-59.0%) in polyps initially 6 mm to less than 10 mm.

    Conclusions and Relevance  In this study, GBC rates were low and similar among patients with and without GPs. Growth of 2 mm or more appeared to be part of GP natural history. The results call into question the strategy of proactively following GP to detect GBC.