Dysplasia-associated Lesion Or Mass Research Articles

Influence of SCENIC recommendations on terminology used for histopathologic diagnosis of inflammatory bowel disease-associated dysplasia.

BACKGROUNDPublished in 2015, the International Consensus Recommendations on Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients (SCENIC) recommended abandoning the use of diagnostic term “dysplasia-associated lesion or mass (DALM)” for polypoid dysplastic lesions detected in patients with inflammatory bowel disease (IBD). The aim of this study was to investigate whether this recommendation had any influence on diagnostic terminologies used by pathologists in their practice.METHODSWe retrospectively reviewed all pathology reports for surveillance colonoscopic biopsies from ulcerative colitis (UC) patients in our institution during 1/2012-12/2014 (pre-SCENIC) and 1/2016-12/2018 (post-SCENIC). These included 1203 biopsies from 901 UC patients during the pre-SCENIC period and 1273 biopsies from 977 UC patients during the post-SCENIC period. Their corresponding endoscopic findings and histopathologic diagnoses were recorded. Clinical indications for total colectomy for UC patients and corresponding histopathologic findings in colectomy specimens were also recorded and compared.RESULTSA total of 347 and 419 polyps/polypoid lesions were identified during the pre-SCENIC and post-SCENIC periods, among which 60 and 104 were dysplastic/adenomatous, respectively. More polypoid dysplastic lesions were simply diagnosed as “adenoma” during the post-SCENIC period in comparison with the pre-SCENIC period (97.1% vs 65.0%; P < 0.001). The number of cases with a comment in pathology reports regarding the distinction between DALM and sporadic adenoma was also significantly decreased during the post-SCENIC period (5.8% vs 38.3%; P < 0.001). In addition, the term “dysplasia” was more consistently used for random biopsies during the post-SCENIC period. Furthermore, the terms “sessile serrated adenoma/polyp” (SSA/P) and “serrated epithelial change” (SEC) were more consistently used for polypoid lesions and random biopsies, respectively, during the post-SCENIC period, although these were not specifically addressed in the SCENIC recommendations. The indications for colectomy remained unchanged, however, despite the standardization of diagnostic terminologies.CONCLUSIONThe SCENIC recommendations relieve pathologists from the burden of distinguishing DALM from sporadic adenoma in IBD patients, which helps the standardization of diagnostic terminologies used by pathologists. The consistent use of the diagnostic terminologies may help reduce potential confusions to clinicians and patients.

PTH-031 Knife Assisted Resection for Dysplasia Associated Lesion or Mass: A Video Abstract

Introduction The risk of colonic neoplasia is increased in inflammatory bowel disease. Dysplasia-associated lesion or mass (DALM) can be difficult to detect and challenging to resect endoscopically. Conventional endoscopic mucosal resection (EMR) has been used but as these lesions are often flat morphologically, the snare slips off. Endoscopic submucosal dissection (ESD) has been shown to be able to resect flat lesions, however, they carry a high perforation rate outside the rectum. Knife assisted snare resection (KAR) is a novel technique that combines the principles of EMR and ESD. We aim to evaluate the safety and efficacy of this technique in resecting DALMS as well as demonstrate the technique in the accompanying video abstract. Methods Data of all KARs undertaken by a single endoscopist in our institution from 2012 to 2014 were prospectively compiled in a pre-designed database. 2 independent researchers interrogated the database. Endoscopic follow-up was performed to identify recurrence. Results 9 patients underwent KAR during this period. 8 patients had ulcerative colitis and 1 had Crohn’s colitis. The mean polyp size was 29 mm (10–60 mm). Scarring was noted in 89% of resections despite no previous resection attempts. En-bloc resection was achieved in 7 patients (78%). Endoscopic curative resection was achieved in 7 patients and 1 patient is awaiting endoscopic follow-up. 1 patient experienced a delayed perforation, which was managed surgically. Histological assessment of the resected polyps revealed 8 adenomas with low grade dysplasia and 1 cancer. Conclusion DALMs are difficult to detect and challenging to resect endoscopically using conventional methods. We have demonstrated that KAR as a novel technique is safe and effective in resecting DALMs. As the learning curve of KAR is not as steep as ESD, we believe that is a viable endoscopic resection technique of DALMs in inflammatory bowel disease. Disclosure of Interest None Declared

Paradigm Shift in the Surveillance and Management of Dysplasia in Inflammatory Bowel Disease (West).

Patients with long-standing inflammatory bowel disease (IBD) colitis have a 2.4-fold higher risk of developing colorectal cancer (CRC) than the general population, for both ulcerative colitis (UC) and Crohn's disease (CD) colitis. Surveillance colonoscopy is recommended to detect early CRC and dysplasia. Most dysplasia discovered in patients with IBD is actually visible. Recently published SCENIC (Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations) consensus statements provide unifying recommendations for the optimal surveillance and management of dysplasia in IBD. SCENIC followed the prescribed processes for guideline development from the Institute of Medicine (USA), including systematic reviews, full synthesis of evidence and deliberations by panelists, and incorporation of the GRADE methodology. The new surveillance paradigm involves high-quality visual inspection of the mucosa, using chromoendoscopy and high-definition colonoscopy, with endoscopic recognition of colorectal dysplasia. Lesions are described according to a new classification, which replaces the term 'dysplasia associated lesion or mass (DALM)' and its derivatives. Targeted biopsies are subsequently done on areas suspicious for dysplasia, and resections are carried out for discrete, resectable lesions.

Histological evaluation in ulcerative colitis.

This review summarizes diagnostic problems, challenges and advances in ulcerative colitis (UC). It emphasizes that, although histopathological examination plays a major role in the diagnosis and management of UC, it should always be interpreted in the context of clinical, endoscopic, and radiological findings. Accurate diagnosis requires knowledge of the classic morphological features of UC, as well as a number of atypical pathological presentations that may cause mis-classification of the disease process, either in resection or biopsy specimens. These atypical pathological presentations include rectal sparing and patchiness of disease at initial presentation of UC in pediatric patients or in the setting of medically treated UC, cecal or ascending colon inflammation in left-sided UC, and backwash ileitis in patients with severe ulcerative pancolitis. Loosely formed microgranulomas, with pale foamy histiocytes adjacent to a damaged crypt or eroded surface, should not be interpreted as evidence of Crohn’s disease. Indeterminate colitis should only be used in colectomy specimens as a provisional pathological diagnosis. Patients with UC are at risk for the development of dysplasia and carcinoma; optimal outcomes in UC surveillance programs require familiarity with the diagnostic criteria and challenges relating to UC-associated dysplasia and malignancy. Colon biopsy from UC patients should always be evaluated for dysplasia based on cytological and architectural abnormalities. Accurate interpretation and classification of dysplasia in colon biopsy from UC patients as sporadic adenoma or UC-related dysplasia [flat, adenoma-like, or dysplasia-associated lesion or mass (DALM)] requires clinical and endoscopic correlation. Isolated polypoid dysplastic lesions are considered to be sporadic adenoma if occurring outside areas of histologically proven colitis, or adenoma-like dysplasia if occurring in the diseased segment. Recent data suggest that such lesions may be treated adequately by polypectomy in the absence of flat dysplasia in the patient. UC patients with DALM or flat high-grade dysplasia should be treated by colectomy because of the high probability of adenocarcinoma. The natural history of low-grade dysplasia (LGD) is more controversial: while multifocal LGD, particularly if detected at the time of initial endoscopic examination, is treated with colectomy, unifocal flat LGD detected during surveillance may be managed by close follow-up with increased surveillance. The surveillance interval and treatment options for UC patients with dysplasia are reviewed in detail.

Large serrated polyp with KRAS mutation in inflammatory bowel disease: a “nondysplastic dysplasia-associated lesion or mass (DALM)”?

Large serrated polyp with KRAS mutation in inflammatory bowel disease: a “nondysplastic dysplasia-associated lesion or mass (DALM)”?

Polypectomy is Adequate Treatment for Adenoma-like Dysplastic Lesions (DALMs) in Crohnʼs Disease

The purpose of this study was to reevaluate the clinical and pathologic features and outcomes in patients with Crohn's disease with an adenoma-like dysplasia-associated lesion or mass (DALMs) to determine if polypectomy is adequate treatment. The clinical, endoscopic and pathologic features, and outcomes of 50 patients with Crohn's disease, each with ≥1 adenoma-like DALM were evaluated. The median length of follow-up was 39 months (range: 0.5-156 months). Of the 50 patients with Crohn's disease (male to female ratio, 30:20; median age: 53 years; median duration of disease: 83 months), 11 had ileal disease, 26 had colonic disease, and 13 had both ileal and colonic disease. Approximately 43% of polyps occurred within areas of previous or concurrent colitis, whereas 57% occurred in areas not previously involved by colitis. Most polyps had tubular architecture and contained low-grade dysplasia. Of the patients who had polypectomy followed by surveillance, 45% developed new adenoma-like DALMs, but none developed flat dysplasia and only 1 had adenocarcinoma at the time of resection, which was within 3 months of polypectomy. There were no differences in the clinical or pathologic features or outcomes in patients who had adenoma-like DALMs within versus outside areas of previous or concurrent colitis, except that the former showed a higher risk of developing new polyps within areas of colitis and near the site of the original polyp compared with the latter. Patients with Crohn's disease who develop an adenoma-like DALM, regardless of its location in relationship to previous or concurrent colitis, may be treated safely with polypectomy and continued surveillance.

Adenoma‐like and non‐adenoma‐like dysplasia‐associated lesion or mass in ulcerative colitis

Ulcerative colitis (UC) patients have an increased risk of colorectal cancer. UC has two general patterns of dysplasia, which are commonly classified as adenoma-like dysplasia-associated lesion or mass (DALM) and non-adenoma-like DALM. The latter has a high risk of concurrent malignancy and often requires a colectomy. Unfortunately, non-adenoma-like DALMs sometimes have endoscopic features similar to those of adenoma-like DALMs. Therefore, new endoscopic techniques to distinguish between these two kinds of DALM have been proposed.

Colonic neoplasia in young patients with inflammatory bowel disease and primary sclerosing cholangitis

Current guidelines recommend annual surveillance for colorectal cancer (CRC) in all patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC). The aim of our study was to validate the need for annual surveillance for colon neoplasia in patients ≤45 of age with a combined diagnosis of PSC and IBD. We identified patients, ≤45 years of age with a combined diagnosis of PSC and IBD, who were seen at the Mayo Clinic between 1995 and 2010. We then reviewed the medical records of the patients who developed colonic neoplasia defined as cancer, high-grade dysplasia (HGD) or dysplasia-associated lesion or mass (DALM). In the population of 784 patients ≤45 years of age with a combined diagnosis of PSC and IBD, 10 (1.3%) of 784 developed colonic neoplasia during the follow-up period. Seven patients had colon cancer, one had HGD and two had a DALM. Colonic neoplasia is uncommon in young patients (≤45 years of age) with a combined diagnosis of PSC and IBD. We suggest delaying surveillance in young patients and propose that studies should be carried out to clarify the cost-effectiveness of annual or biannual surveillance colonoscopies according to patient age.

Dysplasia associated lesion or mass (DALM) in a patient with ulcerative colitis complicated with primary sclerosing cholangitis

The risk of developing neoplasia is significantly increased in patients with long-standing ulcerative colitis. Intraepithelial neoplasia might arise from flat, endoscopically invisible lesions or may appear as DALM. The latter should be separated from adenoma-like mass (ALM), since the two entities require different management.

Mo1705 Flat Serrated Change: Does it Predict the Development of Colonic Mucosal Dysplasia in Inflammatory Bowel Disease?

BACKGROUND: Patients with colonic inflammatory bowel disease (IBD) face an increased risk of developing colorectal cancer (CRC). As in the general population, these cancers may demonstrate either chromosomal instability or microsatellite instability (MSI). In the noncolitis population non-Lynch MSI related CRC is associated with precursor polypoid serrated lesions (sessile serrated adenomas/polyps), particularly in the proximal colon. Histologically,we have observed hyperplastic polyp like changes in biopsies of flat mucosa taken during routine IBD surveillance colonoscopy termed here “flat serrated change”(FSC). AIM: To determine if IBD associated flat serrated change predicts the development of dysplasia or CRC. METHODS: Medical records of 281 IBD patients having undergone at least two surveillance colonoscopies between 2007-2011 were reviewed. 94 patients had FSC. 187 had no-FSC. The primary end point measured was the subsequent development of dysplasia or CRC. Dysplasia was classified as adenoma like mass (ALM), dysplasia associated lesion or mass (DALM), flat low grade dysplasia (LGD) or flat high grade dysplasia (HGD). Tubular adenomas in non-involved colon were excluded. Disease duration, anatomic extent, disease severity, medications, family history of colorectal cancer, and number of biopsies taken in each surveillance colonoscopy were also measured. RESULTS: The FSC and no-FSC groups were 58.5% and 55.1% male, respectively, with mean (SD) age at index colonoscopy of 52.8 (12.3) and 52.9 (13.8). Among the FSC patients, 12 (12.8%) had subsequent dysplasia of some type (ALM, DALM, LGD, or HGD), while 8 (4.3%) patients developed dysplasia in the no-FSC group (some patients had > 1 type of dysplasia). The unadjusted odds ratio comparing FSC to No-FSC for any dysplasia was 3.26 (p = 0.013). From an adjusted comparison by logistic regression, accounting for possible confounding of FSC effect with different rates of surveillance between the two groups, as well as age at index colonoscopy, and sex, the odds ratio was found to be 2.53 (p = 0.081). Dysplasia type results were as follows: ALM: FSC 7 (7.4%), no-FSC 5 (2.7%); DALM: FSC 2 (2.1%), no-FSC 1 (0.5%); LGD: FSC 5 (5.3%), no-FSC 2(1.1%) and HGD: FSC 2 (2.1%), no-FSC 1 (0.5%). These differences did not reach statistical significance. One CRC was found in each group. CONCLUSION: Flat serrated change might be associated a higher risk of subsequent mucosal dysplasia. However, after multivariate analysis, no statistically significant increased risk was demonstrated. Further study of this histologic observation is warranted, but these findings do not justify any change in standard dysplasia surveillance practice at this time.

Cancer risk in IBD: how to diagnose and how to manage DALM and ALM.

The risk of developing neoplasia leading to colorectal cancer is significantly increased in ulcerative colitis (UC) and most likely in Crohn's disease. Several endoscopic surveillance strategies have been implemented to identify these lesions. The main issue is that colitis-associated neoplasms often occurs in flat mucosa, often being detected on taking random biopsies rather than by identification of these lesions via endoscopic imaging. The standard diagnostic procedure in long lasting UC is to take four biopsies every 10 cm. Image enhancement methods, such as chromoendoscopy and virtual histology using endomicroscopy, have greatly improved neoplasia detection rates and may contribute to reduced random biopsies by taking targeted "smart" biopsies. Chromoendoscopy may effectively be performed by experienced endoscopists for routine screening of UC patients. By contrast, endomicroscopy is often only available in selected specialized endoscopic centers. Importantly, advanced endoscopic imaging has the potential to increase the detection rate of neoplasia whereas the interplay between endoscopic experience and interpretation of histological biopsy evaluation allows the physician to make a proper diagnosis and to find the appropriate therapeutic approach. Colitis-associated intraepithelial neoplasms may occur in flat mucosa of endoscopically normal appearance or may arise as dysplasia-associated lesion or mass (DALM), which may be indistinguishable from sporadic adenomas in healthy or non-colitis mucosa [adenoma-like mass (ALM)]. The aim of this review was to summarize endoscopic and histological characteristics of DALM and ALM in the context of therapeutic procedures.

Dysplasia Associated Lesion or Mass (DALM) in a Hepatitis C Patient: a case report.

Dysplasia Associated Lesion or Mass (DALM) are rare but pre-malignant lesions found in Ulcerative Colitis. Their macroscopic appearance maybe mistaken for colorectal cancer. There are several well known malignant associations with Hepatitis C infection but not colorectal cancer. We report an unusual case of finding DALM’s in association with Hepatitis C, highlighting the possibility of a yet unidentified causal relationship.

Endoscopic and pathological aspects of colitis-associated dysplasia

The risk of developing colorectal cancer in patients with colitis-associated dysplasia is considerable. Surveillance programs in patients with ulcerative colitis and Crohn's disease aim to detect dysplastic lesions early and rely heavily on taking random biopsy samples along the length of the colon. Diagnosing dysplasia can be difficult because of the heterogeneous endoscopic appearance of dysplasia and the poor interobserver agreement among pathologists when grading dysplasia. Colitis-associated dysplasia may present as a dysplasia-associated lesion or mass (DALM), which may be indistinguishable from a sporadic adenoma in non-colitic tissue, or may arise in flat mucosa of endoscopically normal appearance. Information about the endoscopic appearance, the colonic distribution and the histopathological grade of colitis-associated dysplasia is required to define the optimal treatment. This Review summarizes the endoscopic and histopathological features of colitis-associated dysplasia and the requirements for optimal interaction between endoscopists and pathologists, with the aim of reducing the uncertainties in the diagnosis of dysplastic lesions and improving the management of colitis-associated dysplasia.

Adherence to surveillance guidelines for dysplasia and colorectal carcinoma in ulcerative and Crohn’s colitis patients in the Netherlands

To study adherence to the widely accepted surveillance guidelines for patients with long-standing colitis in The Netherlands. A questionnaire was sent to all 244 gastroenterologists in The Netherlands. The response rate was 63%. Of all gastroenterologists, 95% performed endoscopic surveillance in ulcerative colitis (UC) patients and 65% in patients with Crohn's colitis. The American Gastroenterological Association (AGA) guidelines were followed by 27%, while 27% and 46% followed their local hospital protocol or no specific protocol, respectively. The surveillance was correctly initiated in cases of pancolitis by 53%, and in cases of left-sided colitis by 44% of the gastroenterologists. Although guidelines recommend 4 biopsies every 10 cm, less than 30 biopsies per colonoscopy were taken by 73% of the responders. Only 31%, 68% and 58% of the gastroenterologists referred patients for colectomy when low-grade dysplasia, high-grade dysplasia (HGD) or Dysplasia Associated Lesion or Mass (DALM) was present, respectively. Most Dutch gastroenterologists perform endoscopic surveillance without following international recommended guidelines. This practice potentially leads to a decreased sensitivity for dysplasia, rendering screening for colorectal cancer in this population highly ineffective.

Intraepitheliale Neoplasie/Dysplasie – Diagnose bei Colitis ulcerosa

About 1-2% of all colorectal carcinomas (CRCs) arise from a background of chronic inflammatory bowel diseases (IBDs) such as ulcerative colitis (UC) or Crohn's disease, and around 15% of patients with IBD die from colorectal cancer. Intraepithelial neoplasia/dysplasia in the setting of IBD is considered a precancerous lesion by definition. Intraepithelial neoplasia may present itself either as a flat or polypoid mucosal lesion and is referred to as a dysplasia-associated lesion or mass (DALM) in the latter case. The therapeutic consequence of high-grade intraepithelial neoplasia/dysplasia and/or DALM is proctocolectomy in most centers because of the high risk of synchronous or metachronous CRC. The diagnosis of ulcerative colitis-related intraepithelial neoplasia and its distinction from regenerative changes and sporadic adenomas (ALMs) occurring in UC is still one of the greatest challenges in gastrointestinal pathology. Intra- and interobserver variability for the distinction between low-grade intraepithelial neoplasia and regenerative lesions tends to be quite high. This is partly due to the difficult histomorphology and partly due to the relative rareness of this diagnosis (approximately 10% of patients with IBD).

Retocolite ulcerativa (RCU): perfil evolutivo clínico endoscópico. Estudo retrospectivo

OBJETIVO: Analisar o perfil da RCU. CASUÍSTICA E MÉTODOS: Análise retrospectiva de pacientes acompanhados pelos autores de 1996 a 2006. Confrontamos topografia das lesões, colonoscopia / histopatologia com ênfase na displasia e CCR. Rastreamos displasia após 7 anos de doença. Teste t de Student foi usado para média e qui-quadrado para números absolutos. P&lt; 0,05 significativo. RESULTADOS: 127 pacientes, 40 homens e 87 mulheres. Média de idade 47±13 N=61 (48%) na pancolite e 45±15 na colite esquerda N=66 (52%) p&gt; 0,05 para idade. Displasia em 9 (7%), 8 (6%) na pancolite p&lt; 0,01. Dois (2%) em mucosa lisa e 7 (12,5%) em portadores de nodularidade e DALM (dysplasia associated lesion or mass) p&lt; 0,05. Pseudopólipos N=55 (43%). CCR em 7 (5,5%). 13 colectomizados (10%), 3 por intratabilidade, 3 por megacólon tóxico, 1 por displasia com tumor na peça e 6 com CCR. CCR tinham mais de 12 anos de doença. Em 3 (2,3%) com doença ativa à histopatologia não foi detectado sangue macroscópico nas fezes. CONCLUSÕES: Reafirmamos a necessidade de vigilância para displasia e CCR. Pancolite aumenta risco de displasia e CCR. A idade não interfere na extensão da doença. Sangue nas fezes é importante no diagnóstico.

Chromosomal and Microsatellite Instability of Adenocarcinomas and Dysplastic Lesions (DALM) in Ulcerative Colitis

Longstanding ulcerative colitis (UC) is associated with a high risk of developing UC-related colonic adenocarcinoma (UCC). These carcinomas originate from nonadenomatous dysplastic regions referred to as dysplasia associated lesion or mass (DALM). We evaluated chromosomal and microsatellite instability (MSI) in 21 DALM/UCCs. Chromosomal instability was determined by high-resolution array comparative genomic hybridization with a 3500-element BAC-PAC array. MSI was assessed with markers BAT25 and BAT26 and by immunohistochemical analysis of mismatch repair genes. Comparative genomic hybridization revealed frequent losses of array clones (>20% of tumors) at chromosome arms 4p, 5q, and 18q, frequent gains of array clones (>20% of tumors) were found at 1q, 5p, 6p, 7p, 7q, 8p, 8q, 11p, 11q, 12q, 14q, 17q, 19q, 20p, and 20q. The pattern of alterations is dominated by gains on 5p and 20q with loss of 4p, all of which were already present in a patient with carcinoma in situ. Immunohistochemical analysis of mismatch repair genes MLH1, PMS2, MSH2, and MSH6 showed negative immunostaining in 1 neoplasm (5%). MSI of BAT25 and BAT26 was seen in 3 tumors (14%) including the neoplasm with aberrant immunostaining. In conclusion, we constructed a genomic profile of DALM/UCC including several novel genetic alterations. Further, we found a low percentage of MSI. Thus, DALM/UCCs display profound chromosomal instability, but this is not associated with concurrent MSI.

Polypectomy versus proctocolectomy for adenoma patients with long-standing ulcerative colitis

The only thing we have to fear is fear itself V Franklin Delano Roosevelt. Colorectal cancer surveillance in inflammatory bowel disease provokes both a sense of urgency and dread in most gastroenterologists. We know that patients with Crohn’s colitis and ulcerative colitis are at increased risk for colorectal cancer, although some disagreement remains on the precise risk of developing colorectal cancer with either of these conditions. Added to this is the theoretical concern that the polyp to carcinoma sequence may be accelerated or less predictable in patients with ulcerative or Crohn’s colitis, thus leading to earlier or clinically more aggressive colorectal cancer in patients without inflammatory bowel disease. Finally, a general dissatisfaction with the current tools of surveillance pervades almost every discussion of this topic. The finding of a sporadic adenoma in this bleak landscape can greatly deepen the angst. It need not be so emotionally fraught. The current management of polyps that develop in patients with colitis is strongly influenced by fear and a failure to define what it is we are seeing during the pressured moments of a surveillance procedure. To better understand where we are now with sporadic adenoma in colitis, we have much to learn from the evolution of the management of sporadic adenomas in patients without colitis during the 1970s and 1980s. The evolution of the current management algorithm for sporadic adenomas benefited greatly from the hard work of many clinicians and scientists but more importantly from coolerheaded investigators who developed a pragmatic, descriptive terminology of what was being viewed through the scope. Polyps were catalogued and categorized by size, morphology, and histology, but ultimately the conservative management of these polyps hinged on resectability. Once consensus on the resectability of a lesion was achieved, other issues of surveillance frequency, cancer risk, and need for surgery could be discussed intelligently. None of these answers were obvious at first, but most were established with time, careful observation, and experience. The first formal attempts at consensus in defining a polyp in colitis were hampered by deviating from this paradigm of discovery and surrendering to the fear and uncertainty clouding cancer risk in inflammatory bowel disease. The current taxonomy of polyps in colitis is crowded with terms such as Bnon-adenoma-dysplasia-associated lesion or mass[. In this muddled terminology, we can find the source of our current confusion and fear. We are closer to consensus on terminology than 5 years ago, but much work remains. Any definition of a polyp must hinge on its resectability before a surveillance schedule is determined or a surgeon summoned. Starting with the example of the patient without colitis, I believe that we all agree that colonoscopic polypectomy is considered to be effective for preventing colorectal cancer in these patients. Recent studies have demonstrated that even patients without colitis who are enrolled in a colonoscopic surveillance program after the identification of an adenomatous polyp are still at risk of developing colorectal cancer. And even in this relatively low-risk population (at least when compared with patients with long-standing ulcerative or Crohn’s colitis), this approach remains imperfect. Still, nobody is suggesting that we remove the colons of everybody who has been identified as having a sporadic adenoma. When one encounters an adenomatous polyp in the setting of colitis, there are several strategies that can be used. One would be to refer the patient for a total proctocolectomy. This would likely be resisted by the patient. A second, popular approach would be to perform a polypectomy, biopsy around the site (although this has never been shown to increase the yield of dysplasia it may help define resectability), and finally perform random biopsies throughout the colon. An alternative approach would be to use chromoendoscopy to better define the polyps present and enhance the yield for finding any other dysplasia in the patient. The yield for dysplasia during colonoscopy can be tripled, or even quadrupled, if one is using chromo-endoscopy techniques at the same time. The lesions should be removed and defined by the resectability and histology. The clinical definition of a dysplasia-associated lesion or mass (DALM) may need to be CONTROVERSIES IN IBD

Surgery for neoplastic changes in ulcerative colitis – can limited resection be justified? Outcome for patients who underwent limited surgery

Patients with ulcerative colitis (UC) are at an increased risk of developing colorectal cancer (CRC). The aim of this study was to investigate the outcome for the patients who underwent limited resection of the colon and/or rectum instead of panproctocolectomy (PPC), with special attention to those with neoplastic changes. Since 1977, all known patients with UC from our catchment area have been included in our surveillance programme. A total of 210 patients with UC have been followed up with regular colonoscopies and biopsies. Indications for surgery were severe therapy-resistant disease (TRD), high-grade dysplasia (HGD), CRC or repeated findings of low-grade dysplasia (LGD). Patient compliance was excellent. Fifty-one patients were operated on. In 29 of these patients, PPC was performed initially. At the end-point of the study, additionally seven patients had been radically operated on and three more patients planned to undergo such an operation. Accordingly, 22 patients had their first operation performed as a resection of either a part of or the whole colon or rectum. In this group, there were four patients diagnosed with CRC and three with dysplasia-associated lesion or mass (DALM). One of them died 6 months after surgery because of disseminated CRC, whereas the other patients were alive at the end-point of the study. One of these seven patients with CRC or DALM had at end-point been radically operated on and two patients were awaiting such a procedure (in two patients because of LGD and in one patient because of TRD). Six of the patients who had a colorectal resection performed on the indication of TRD were radically operated later on, five of them because of relapsed TRD and one patient because of LGD in the remaining rectal mucosa. Twenty-one patients gained a mean of 9.4 years with presumably better bowel function, from undergoing a limited resection instead of PPC. None of the patients who underwent a colonic and/or rectal resection died because of CRC or metachronous cancer in their remaining colon or rectum. The results of this study indicate that a limited resection of the colon and/or rectum in patients with UC, which requires surgical intervention increases the time with presumably better bowel function and may therefore be an alternative to PPC without increased risk of dying from CRC. This is dependent on the flexibility of the medical service and patient compliance.

Management of low and high-grade dysplasia in inflammatory bowel disease: the gastroenterologists?? perspective and current practice in the United Kingdom

Colonic dysplasia is a precursor to colorectal cancer (CRC) in inflammatory bowel disease (IBD). There is a risk of progression of both low-grade dysplasia (LGD) and high-grade dysplasia (HGD) to CRC over 5 years. The current British Society of Gastroenterology guidelines advocate colectomy when possible or at least colonoscopic surveillance every 6 months. To obtain an overview of the gastroenterologists' perspective on various aspects of colonic dysplasia in IBD and to understand current management practice in the UK. A national postal survey of 551 gastroenterologists listed in the British Society of Gastroenterology Handbook 2003. Some 56% of questionnaires were returned; 255 out of 551 completed questionnaires were included in the final analysis. A total of 70% considered LGD to be premalignant, whereas all considered HGD to be premalignant. Only 13% offered routine colectomy for LGD compared with 84% for HGD. More than a third felt that flat LGD might not have concurrent CRC, of which 95% performed surveillance colonoscopies in this group. A small proportion of the remaining gastroenterologists treated flat LGD surgically (13%), whereas 85% considered that LGD with dysplasia-associated lesion or mass (DALM) constituted a high risk of concurrent CRC, but only 52.5% offered total colectomy to this group. There was a wide variation in the frequency of surveillance for LGD in flat mucosa and DALM. A majority agreed that LGD progressed to HGD (82%) and CRC (75%). However, their perception of the risk of progression to either HGD or CRC over 5 years varied widely. All agreed that HGD may have coexistent CRC, and 98% thought it progressed to CRC. Patients were more likely to be treated with colectomy for flat HGD (77%) and HGD in the presence DALM (86%); 38% of gastroenterologists felt that over 30% of patients have coexistent CRC in HGD, and 10% continued to manage them conservatively. There are wide variations in the perceptions and management of LGD in IBD in the UK compared with HGD, in which there seems to be more uniform agreement. The need for more research in this area and a national agreement on management is paramount. Until this is reached gastroenterologists will remain open to criticism and litigation.