Current considerations for the surgical management of gallbladder adenomas

Gallbladder adenomas are rare lesions(0.5%)associated with potential malignant transformation,particularly with gallbladder adenomas that are≥1 cm in size.Early detection and management are crucial for preventing lethal carcinoma de-velopment.These polyps can often be distinguished from the more often nonneo-plastic cholesterol pseudopolyps(5%-10%),which are benign.Ultrasonography is the first-line tool for initial diagnosis and follow-up when indicated.The question is whether cholecystectomy is always necessary for all adenomas.The manage-ment of gallbladder adenomas is determined according to the size of the tumor,the growth rate of the tumor,the patient’s symptoms and whether risk factors for malignancy are present.Adenomas≥1 cm in size,an age>50 years and a familial history of gallbladder carcinoma are indications for immediate laparoscopic chole-cystectomy.Otherwise,ultrasound follow-up is indicated.For adenomas 6-9 mm in size,the absence of≥2 mm growth at 6 months,one year,and two years,as well as an adenoma sized<5 mm without existing risk factors indicates that no further surveillance is required.However,it would be preferable to individualize the management in doubtful cases.Novel interventional modalities for preserving the gallbladder need further evaluation,especially to determine the long-term outcomes.

Contrast-enhanced ultrasound in diagnosis of gallbladder adenoma

BACKGROUND：Gallbladder adenoma is a pre-cancerous neoplasm and needs surgical resection.It is difficult to differentiate adenoma from other gallbladder polyps using imaging examinations.The study aimed to illustrate characteristics of contrast-enhanced ultrasound（CEUS）and its diagnostic value in gallbladder adenoma.METHODS： Thirty-seven patients with 39 gallbladder adenoma- toid lesions （maximal diameter _〉10 mm and without metastasis） were enrolled in this study. Lesion appearances in conventional ultrasound and CEUS were documented. The imaging features were compared individuaUy among gallbladder cholesterol polyp, gallbladder adenoma and malignant lesion. RESULTS： Adenoma lesions showed iso-echogenicity in ul- trasound, and an eccentric enhancement pattern, ＂fast-in and synchronous-out＂ contrast enhancement pattern and homo- geneous at peak-time enhancement in CEUS. The homogenic- ity at peak-time enhancement showed the highest diagnostic ability in differentiating gallbladder adenoma from cholesterol polyps. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy and Youden index were 100%, 90.9%, 92.9%, 100%, 95.8% and 0.91, respectively. The characteristic of continuous gallbladder wall shown by CEUS had the highest diagnostic ability in differentiating adenoma from malignant lesion （100%, 86.7%, 86.7%, 100%, 92.9% and 0.87, respectively）. The characteristic of the eccentric enhance- ment pattern had the highest diagnostic ability in differenti- ating adenoma from cholesterol polyp and malignant lesion, with corresponding indices of 69.2%, 88.5%, 75.0%, 85.2%, 82.1% and 0.58, respectively.CONCLUSIONS： CEUS is valuable in differentiating gallbladder adenoma from other gallbladder polyps （〉_10 mm in diameter）. Homogeneous echogenicity on peak-time enhancement, a continuous gallbladder wall, and the eccentric enhancement pattern are important indicators of gallbladder adenoma on CEUS.

Large and unusual presentation of gallbladder adenoma: A case report

BACKGROUND Gallbladder adenoma is a relatively rare benign tumor with a potential for malignant transformation if found to be greater than 1 cm in size.CASE SUMMARY Herein,we report a case of a 51-year-old female with large 3 cm×3 cm mass of gallbladder adenoma that was misdiagnosed as adenocarcinoma due to its clinical presentation.Computed tomography and magnetic resonance imaging scans showed an irregularly shaped cauliflower-like lump in the gallbladder measuring 38 mm×32 mm corresponding to a malignant tumor and several gallbladder stones with low diffusion-weighted imaging and equisignal of T1-weighted imaging and T2-weighted imaging;moreover,the CA 19-9 levels were very high(184.1 U/mL).Pathology reports after tumor resection showed adenoma with moderate epithelial atypia and moderate atypia in the focal area with fine pedicle and no clear infiltration.CONCLUSION Computed tomography and magnetic resonance imaging scans need to be carefully scrutinized in certain rare cases of adenomas with abnormal imaging features.

Benign gallbladder diseases:Imaging techniques and tips for differentiating with malignant gallbladder diseases

Benign gallbladder diseases usually present with intraluminal lesions and localized or diffuse wall thickening.Intraluminal lesions of the gallbladder include gallstones,cholesterol polyps,adenomas,or sludge and polypoid type of gallbladder cancer must subsequently be excluded.Polyp size,stalk width,and enhancement intensity on contrast-enhanced ultrasound and degree of diffusion restriction may help differentiate cholesterol polyps and adenomas from gallbladder cancer.Localized gallbladder wall thickening is largely due to segmental or focal gallbladder adenomyomatosis,although infiltrative cancer may present similarly.Identification of Rokitansky-Aschoff sinuses is pivotal in diagnosing adenomyomatosis.The layered pattern,degree of enhancement,and integrity of the wall are imaging clues that help discriminate innocuous thickening from gallbladder cancer.High-resolution ultrasound is especially useful for analyzing the layering of gallbladder wall.A diffusely thickened wall is frequently seen in inflammatory processes of the gallbladder.Nevertheless,it is important to check for coexistent cancer in instances of acute cholecystitis.Ultrasound used alone is limited in evaluating complicated cholecystitis and often requires complementary computed tomography.In chronic cholecystitis,preservation of a two-layered wall and weak wall enhancement are diagnostic clues for excluding malignancy.Magnetic resonance imaging in conjunction with diffusion-weighted imaging helps to differentiate xathogranulomatous cholecystitis from gallbladder cancer by identifying the presence of fat and degree of diffusion restriction.Such distinctions require a familiarity with typical imaging features of various gallbladder diseases and an understanding of the roles that assorted imaging modalities play in gallbladder evaluations.