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Diagnostic Accuracy of Transabdominal Ultrasonography for Gallbladder Polyps: Systematic Review

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Diagnostic Accuracy of Transabdominal Ultrasonography for Gallbladder Polyps: Systematic Review REVIEW • REVUE Diagnostic accuracy of transabdominal ultrasonography for gallbladder polyps: systematic review Erin Martin, MD, MSc Background: Previous research has shown variable but generally poor accuracy of Richdeep Gill, MD transabdominal ultrasonography in the diagnosis of gallbladder polyps. We per- formed a systematic review of the literature with the aim of helping surgeons interpret Estifanos Debru, MD and apply these findings in the preoperative assessment and counselling of their patients. Accepted for publication Nov. 22, 2017 Methods: We searched PubMed, MEDLINE and the Cochrane database using the keywords “gallbladder,” “polyp,” “ultrasound,” “pathology” and “diagnosis” for Correspondence to: English-language articles published after 1990 with the full-text article available E. Martin Division of General Surgery through our institutional subscriptions. Polyps were defined as immobile features University of Calgary that on transabdominal ultrasonography appear to arise from the mucosa and that North Tower, Room 1006 lack an acoustic shadow, and pseudopolyps were defined as features such as inflam- 1403 29th Ave NW mation, hyperplasia, cholesterolosis and adenomyomatosis that convey no risk of Calgary AB T2N 2T9 malignant transformation. [email protected] Results: The search returned 1816 articles, which were narrowed down to 14 pri- mary sources involving 15 497 (range 23–13 703) patients who had preoperative DOI: 10.1503/cjs.011617 transabdominal ultrasonography, underwent cholecystectomy and had postoperative pathology results available. Among the 1259 patients in whom a gallbladder polyp was diagnosed on ultrasonography, 188 polyps were confirmed as true polyps on patho- logic examination, and 81 of these were found to be malignant. Of the 14 238 patients for whom a polyp was not seen on ultrasonography, 38 had a true polyp on pathologic examination, none of which were malignant. For true gallbladder polyps, transabdom- inal ultrasonography had a sensitivity of 83.1%, specificity of 96.3%, positive predic- tive value of 14.9% (7.0% for malignant polyps) and negative predictive value of 99.7%. Conclusion: Transabdominal ultrasonography has a high false-positive rate (85.1%) for the diagnosis of gallbladder polyps. Further study of alternative imaging modali- ties and reevaluation of existing management guidelines are warranted. Contexte : Des recherches antérieures ont montré la précision variable, mais géné- ralement médiocre, de l’échographie transabdominale pour le diagnostic des polypes de la vésicule biliaire. Nous avons procédé à une revue systématique de la littérature scientifique afin d’aider les chirurgiens à interpréter et à appliquer ces résultats lors de l’évaluation préopératoire, et à conseiller leurs patients. Méthodes : Nous avons interrogé les réseaux PubMed, MEDLINE et la base de données Cochrane à partir des mots clés « gallbladder », « polyp », « ultrasound », « pathology » et « diagnosis » (vésicule biliaire, polype, échographie, pathologie et diagnostic) pour recenser les articles en langue anglaise publiés après 1990, pour lesquels le texte intégral était accessible par abonnement institutionnel. À l’échogra- phie, les polypes étaient définis comme des structures fixes semblant émaner de la muqueuse et dépourvues d’ombre acoustique, et les pseudopolypes étaient définis par des caractéristiques telles que l’inflammation, l’hyperplasie, la cholestérolose et l’adé- nomyomatose ne comportant pas de risque de transformation maligne. Résultats : La recherche a généré 1816 articles qui ont été ramenés à 14 sources principales regroupant 15 497 (éventail, 23–13 703) patients ayant subi une écho- graphie transabdominale préopératoire et une cholécystectomie, et pour lesquels on disposait des résultats de l’examen anatomopathologique postopératoire. Sur les 1259 patients chez qui des polypes intravésiculaires ont été diagnostiqués à l’écho graphie, 188 polypes ont été jugés vrais à l’examen anatomopathologique, et 81 d’entre eux se sont révélés malins. Parmi les 14 238 patients chez lesquels 200 J can chir, Vol. 61, No 3, juin 2018 © 2018 Joule Inc. or its licensors REVIEW aucun polype n’avait été détecté à l’échographie, 38 étaient porteurs d’un vrai polype à l’examen anatomopathologique et aucun ne s’est révélé malin. En ce qui concerne les vrais polypes intravésiculaires, l’échographie transabdominale a une sensibilité de 83,1 %, une spécificité de 96,3 %, une valeur prédictive positive de 14,9 % (7,0 % dans le cas des polypes malins) et une valeur prédictive négative de 99,7 %. Conclusion : L’échographie transabdominale présente un taux de résultats faux positifs élevé (85,1 %) pour le diagnostic des polypes de la vésicule biliaire. Il faudra approfondir la recherche sur d’autres techniques d’imagerie et réévaluer les lignes directrices actuelles de prise en charge. allbladder cancer is a rare but serious disease. 2415 patients with a mean polyp size of 5.0 mm There were 500 new cases of gallbladder cancer (SD 2.1 mm) and found that there was no statistically sig- and 265 deaths from this disease in Canada in nificant change in mean size at 30 months (5 mm G1 2015. Gallbladder polyps are malignant or potentially [SD 2.8 mm]) or 84 months (4.0 mm [SD 2.3 mm]). Ito malignant exophytic mucosal lesions such as adenomas, and colleagues8 followed 417 patients with polyps measur- adenocarcinomas or carcinomas.2 Pseudopolyps are fea- ing less than 10 mm for a median of 17 months (range tures such as inflammation, hyperplasia, cholesterolosis 1–81 mo) and found growth greater than 3 mm in only 6% and adenomyomatosis that convey no risk of malignant of patients. High-risk features and malignant disease did transformation.2 On transabdominal ultrasonography, gall- not develop in any patient. Although these studies are bladder polyps are defined as immobile features that small, they indicate that gallbladder polyps may not follow appear to arise from the mucosa and that lack an acoustic the standard progression of adenoma to adenocarcinoma. shadow (which is typically seen with gallstones).3 Previous Previous studies have shown poor correlation between pathologic review showed that all malignant gallbladder ultrasonography diagnosis and final pathology,2–4 and an tumours are found in polyps larger than 6 mm, that polyps attempted meta-analysis was aborted owing to a lack of sat- 10–20 mm in size have a 43%–77% incidence of gallblad- isfactory research.2 This diagnostic uncertainty introduces der cancer, and that polyps larger than 20 mm are the potential for unnecessary imaging, unnecessary surgery “pathognomonic” for gallbladder cancer.2 As such, current and all the associated risks to patients and costs to the guidelines for management of gallbladder polyps are health care system. heavi ly focused on their size. Polyps measuring 10 mm or We performed a systemic review with the aim of help- less should be managed with watchful waiting (with uncer- ing surgeons interpret previous research and apply the tainty regarding the number or frequency of visits or ultra- findings in the preoperative assessment and counselling of sonography examinations required), those measuring their patients. 11–20 mm should be managed with close follow-up or cholecystectomy, and those larger than 20 mm require METHODS cholecystectomy.2,4 Transabdominal ultrasonography has been shown to be We studied transabdominal ultrasonography as it is the inaccurate in measuring the size of polypoid gallbladder most widely available and most commonly used imaging lesions. Choi and colleagues5 found a mean deviation of modality for biliary disease. We searched MEDLINE, only 0.89 mm for true polyps, but Guo and colleagues6 PubMed and the Cochrane database using the keywords reported that transabdominal ultrasonography universally “gallbladder,” “polyp,” “ultrasound,” “pathology” and overestimates polyp size by 4.24 mm (standard deviation “diagnosis.” The articles were screened for relevance and [SD] 0.19 mm). These variations are potentially important duplicates. We included articles for review if they contained when one considers that the suggested management of data for patients who had had preoperative transabdominal polyps changes substantially over a 10-mm range, and they ultrasonography and had undergone cholecystectomy, and could translate into patients’ being classified into a higher for whom postoperative pathology results were available. risk category and being offered more ultrasonography The search was limited to English-language articles pub- examinations and surgical procedures than is appropriate. lished after 1990 with the full-text article available through Guo and colleagues6 also found that transabdominal ultra- our institutional subscriptions. We used the year 1990 as a sonography overestimates the size of cholesterolosis by cut-off given the substantial improvement in transabdom- 5.12 mm (SD 0.21 mm), much of which may be inaccu- inal ultrasonography technique after that year.9,10 Articles rately labelled as true polyps. were excluded from review if they did not focus on gall- Transabdominal ultrasonography has also been shown bladder polyps, if transabdominal ultrasonography was not to be a flawed modality for serial monitoring of gallbladder used, if patients did not undergo cholecystectomy or if the polyps, as longitudinal studies have demonstrated minimal article did not contain complete pathologic data. We also to no progression in size. Kratzer and colleagues7 followed reviewed the references of screened
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