Flat High-grade Dysplasia Research Articles

Wide Area Transepithelial Sample Esophageal Biopsy Combined with Computer Assisted 3-Dimensional Tissue Analysis (Wats3d) for the Detection of Flat High Grade Dysplasia and Adenocarcinoma in Barrett: A Multi-Center, Prospective, Randomized, Tandem Study

Wide Area Transepithelial Sample Esophageal Biopsy Combined with Computer Assisted 3-Dimensional Tissue Analysis (Wats3d) for the Detection of Flat High Grade Dysplasia and Adenocarcinoma in Barrett: A Multi-Center, Prospective, Randomized, Tandem Study

Diagnostic Yield of Dysplasia in Polyp-adjacent Biopsies for Patients with Inflammatory Bowel Disease: A Cross-sectional Study.

Patients with inflammatory bowel disease (IBD) undergoing polypectomy are recommended by current guidelines to have biopsies taken from adjacent mucosa to determine whether there is dysplasia present. With improvements in endoscopic imaging, it is now possible to characterize colonic lesions with higher levels of confidence than previously. We have reviewed the diagnostic yield of polyp-adjacent biopsies in IBD. A systematic search of our histopathology database revealed cases in which polyps had been endoscopically resected or biopsied in patients with IBD. Endoscopy reports and medical records were reviewed, and patient demographic and disease-specific details were recorded, along with details of polyp characteristics and histopathology outcomes. Three hundred and two polyps were biopsied or resected in 131 patients undergoing 178 colonoscopies. The median polyp size was 4 mm (range 1-45), and the predominant morphology was Paris 0-Is (n = 98, 32%). The histology was tubular adenoma in 76 (25%), tubulovillous adenoma in 14 (5%), hyperplastic in 112 (37%), post-inflammatory in 32 (11%), sessile serrated polyp in 31 (10%), traditional serrated adenoma in 2 (0.7%), flat high-grade dysplasia or cancer in 2 (0.7%) and other in 33 (11%). Dysplasia in adjacent biopsies was detected in 2 patients (0.7%), and was endoscopically visible in both cases. The proportion of endoscopically unsuspected dysplasia was 0/300 (0%, 95% CI 0-1.6%). The diagnostic yield for polyp-adjacent biopsies in patients with IBD is negligible. With high-definition technology and chromoendoscopy, it may no longer be necessary to biopsy endoscopically normal adjacent tissue to detect invisible dysplasia.

Association of Aneuploidy and Flat Dysplasia With Development of High-Grade Dysplasia or Colorectal Cancer in Patients With Inflammatory Bowel Disease

There is controversy over how to best manage patients with inflammatory bowel disease and flat low-grade dysplasia (fLGD) in the colon. We performed a retrospective analysis of formalin-fixed paraffin-embedded colon tissues with fLGD from 37 patients undergoing surveillance colonoscopy for inflammatory bowel disease from 1990 to 2015 at the University of California at San Francisco Medical Center, to determine whether detection of aneuploidy is associated with later development of high-grade dysplasia (HGD) or colorectal cancer. Medical data were collected from the patients for a mean follow-up time of 37 months. Using flow cytometry analysis of paraffin-embedded colon tissue, we detected aneuploidy in 15 of 37 samples with fLGD (40.5%). By comparison, aneuploidy was detected in 14 of 15 samples with flat HGD (93.3%) and 2 of 45 samples that were negative for dysplasia (4.4%). The univariate hazard ratio for subsequent detection of HGD or colorectal cancer in patients with fLGD and aneuploidy was 5.3 (95% CI, 1.542-24.121) within a mean follow-up time of 37 months. The presence of aneuploidy therefore identifies patients with fLGD in colon tissue who have an increased risk for HGD or colorectal cancer and may provide supportive evidence to a morphologic impression or suspicion of flat HGD.

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.

Current and Future Status for Evaluation of Dysplasia and Carcinoma in IBD

Endoscopic surveillance is an important method to identify colorectal neoplasia in patients with inflammatory bowel disease. Advances in endoscopic techniques using pancolonic chromoendoscopy have improved the detection of dysplasia compared to white-light endoscopy, which has the potential to decrease the risk of colorectal cancer. Currently, pancolonic chromoendoscopy is readily available for use, and in the future, it will likely become the standard of care for endoscopic surveillance. Pancolonic chromoendoscopy followed by confocal laser endomicroscopy may further increase the yield on surveillance endoscopy, although confocal laser endomicroscopy is not readily available outside of a limited number of institutions. Other endoscopic tools such as narrow band imaging have not been shown to be beneficial over white-light endoscopy. Emerging tools such as stool DNA testing show promise as an adjunct to colonoscopy but are still in the early stages of development. For management, patients with well-demarcated circumscribed dysplastic lesions should be resected endoscopically, followed by a continued endoscopic surveillance program. Patients with lesions that cannot be resected completely or that have features suggestive of invasive carcinoma on either endoscopy or histology should undergo colectomy. Patients with flat high-grade dysplasia should undergo colectomy. Patients with flat low-grade dysplasia should have a discussion about the risks and benefits of undergoing colectomy versus continuing in an endoscopic surveillance program. If they opt for surveillance, these patients should have more frequent follow-up surveillance examinations (every 3 to 6months) with pancolonic chromoendoscopy.

Circumferential Radiofrequency Ablation of a Long-Segment Barrett's Esophagus with Flat High-Grade Dysplasia Using the HALO 360 System

Radiofrequency ablation (RFA) has become the first choice for treatment of dysplastic Barrett's. RFA is indicated for flat high-grade dysplasia and for eradication of residual Barrett's after endoscopic resection of any visible lesion containing high-grade dysplasia or an early mucosal cancer. RFA has a high success rate for eradication of dysplasia in 95% of patients. Eradication of intestinal metaplasia can be obtained in approximately 80% of patients. This article is part of an expert video encyclopedia.

Focal Radiofrequency Ablation of Barrett's Esophagus as Add-On Treatment After Endoscopic Resection and HALO 360 Treatment

Radiofrequency ablation (RFA) has become the first-choice treatment for dysplastic Barrett's esophagus. RFA is indicated for flat high-grade dysplasia and for eradication of residual Barrett's esophagus after endoscopic resection of any visible lesion containing high-grade dysplasia or an early mucosal cancer. RFA has a high success rate for eradication of dysplasia in 95% of patients. Eradication of intestinal metaplasia can be obtained in approximately 80% of patients. This result can, however, only be obtained by a multiple step therapy with circumferential and subsequent focal ablation (HALO 90). This article is part of an expert video encyclopedia.

Is the Diagnosis of Flat Low-Grade Dysplasia on Surveillance Biopsy for Inflammatory Bowel Disease an Indication for a Colectomy? The Hartford Hospital Experience, 1998-2010

In patients with chronic inflammatory bowel disease (IBD), the presence of flat high-grade dysplasia (fHGD) is a major risk factor for the development of adenocarcinoma and an indication for colectomy. However there is controversy regarding the appropriate management of patients with flat low-grade dysplasia (fLGD). The goal of our study is to assess whether the discovery of fLGD during colonoscopic …

OC-011 Endoscopic therapy in barrett's oesophagus (be) with HGD (high grade dysplasia) and early malignancy; a prospective, single centre experience

IntroductionThere is increasing evidence that endoscopic therapy in BE with a combination of endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) is an effective treatment of intramucosal cancer (IMC) and...

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.

Is surveillance of Barrett's oesophagus cost-effective when endotherapy is used to treat high grade dysplasia or early cancer in Barrett's oesophagus?

Introduction There is emerging interest in the role of endotherapy in the management of high grade dysplasia (HGD) and intra-mucosal cancer in Barrett9s oesophagus (BO). We have previously shown that stepwise endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) for visible HGD and RFA for flat HGD is cost-effective compared to photo-dynamic therapy or oesophagectomy.1 Aim To assess the cost-effectiveness of surveillance of Barrett9s oesophagus when EMR-RFA for visible HGD and RFA for flat HGD is used to treat HGD or intra-mucosal cancer in BO. Methods A Markov model was created using a base population of 1000 50-year-old Caucasian males with BO followed to 75 years of age. All patients were assumed to be fit for oesophagectomy. Surveillance intervals were compared with strategies of no surveillance and surveillance with oesophagectomy for HGD. Cost-effectiveness was expressed as net amount per quality adjusted life year (QALY) and base-costs for treatment were obtained from the Department of Health HRG tariffs for 2007/2008. Monte Carlo simulation and probabilistic sensitivity analysis were carried out. Results 2-yearly surveillance with endoscopic therapy to treat HGD/intra-mucosal cancer in BO was the most cost-effective option yielding an incremental cost-effectiveness ratio (ICER) of 13,447 compared to no surveillance and other surveillance intervals (1, 2, 3, 4 and 5-yearly) and when no endotherapy was used as a comparative strategy. It was also more cost effective than a strategy of oesophagectomy for HGD/intra-mucosal cancer. Conclusion 2-yearly surveillance of BO is cost-effective when endotherapy is used to treat HGD and intra-mucosal cancer in BO.

PP-018 What is the most cost-effective therapy for high-grade dysplasia in Barrett's oesophagus?: Abstract PP-018

<h3>Introduction</h3> High grade dysplasia (HGD) in Barrett9s oesophagus (BO) has been regarded as an indication for oesophagectomy. However, the introduction of endoscopic mucosal resection (EMR), radiofrequency ablation (RFA) and photodynamic therapy (PDT) is changing practice. The cost-effectiveness of these strategies was compared with oesophagectomy. <h3>Methods</h3> Decision analysis (Markov) models were developed to examine EMR, RFA and PDT in managing HGD in BO. Two separate models were developed for endoscopically visible HGD and flat HGD. The models assumed that HGD was present at two separate endoscopies, that intramucosal cancer had been excluded and that staging modalities (EUS and CT) had been performed. Competing clinical strategies included a baseline strategy of oesophagectomy and other strategies involving EMR only (up to two resections were modelled), EMR followed by RFA and EMR followed by PDT, respectively, for visible HGD and RFA or PDT for flat HGD. Cost-effectiveness was expressed as net amount per quality adjusted life year (QALY) and base-costs for treatment were obtained from the Department of Health HRG tariffs for 2007/8. A cohort of 1000 50-year-old Caucasian males with BO and HGD followed until 75 years old was modelled. All patients were assumed to be fit for oesophagectomy. Monte Carlo simulation and sensitivity analysis were carried out. <h3>Results</h3> Treatment of visible HGD utilising EMR followed by RFA to ablate residual BO yielded a total cost per patient of £12 424 for 26 QALYs and was the most cost-effective strategy (Abstract 018). The incremental cost-effectiveness ratio (ICER) for this strategy compared to oesophagectomy was £7554. A strategy of treating flat HGD with RFA was more cost-effective than PDT or oesophagectomy (Abstract 10) and yielded an ICER of £4596 compared to oesophagectomy. All variables in the model were tested in a one-way sensitivity analyses and strategies involving EMR and RFA for visible HGD and RFA for flat HGD remained superior to competing strategies in the model. <h3>Conclusion</h3> A combination of EMR and RFA to treat visible HGD and RFA for flat HGD appear to be the most cost-effective strategies to treat HGD due to lower mortality and morbidity than oesophagectomy and less morbidity than PDT. This combination remained more cost-effective even if mortality due to oesophagectomy were to fall from 5 to 0%.

AGA Medical Position Statement on the Diagnosis and Management of Colorectal Neoplasia in Inflammatory Bowel Disease

The AGA Institute Medical Position Panel consisted of the authors of the technical review, a community-based gastroenterologist (Robert P. McCabe, MD, Minnesota Gastroenterology), academic-based gastroenterologists (Themistocles Dassopoulos, MD, James D. Lewis, MD, and Thomas A. Ullman, MD), an insurance provider representative (Tom James III, MD Physician Advisor, Strategic Advisory Group, Humana), a colon and rectal surgeon (Robin McLeod, MD, Mount Sinai Hospital-Canada), a pathologist (Lawrence J. Burgart, MD, Minnesota Gastroenterology), chair of the AGA Institute Clinical Practice and Quality Management Committee (John Allen, MD, Minnesota Gastroenterology), and chair of the Practice Management and Economics Committee (Joel V. Brill, MD, Predictive Health, LLC) .

Is EUS Necessary in the Management of Patients with High Grade Dysplasia in Flat Barrett's Mucosa?

Introduction: The use of Endoscopic Ultrasound (EUS) in patients with high-grade dysplasia (HGD) in the setting of Barrett's esophagus is debatable. Even with high frequency probes, it is difficult to distinguish the subtleties of high-grade dysplasia (HGD) from intramucosal cancer (ICA) or even cancer invading the submucosa. Some patients with nodular Barrett's and HGD are found to have malignant lymph nodes by EUS-fine needle aspiration (FNA). However, there is very little reported on the use of EUS ± FNA in the setting of flat Barrett's with HGD. The aim of this study was to investigate the impact of EUS±FNA in this subset of patients. Methods: A total of 22 consecutive patients with flat HGD who were referred to the University of Virginia and the University of Chicago for EUS between Jan 2005 - June 2008 were retrospectively studied. All patients underwent conventional radial endosonography (frequency 5 MHz). Any suspicious appearing lymph nodes were sampled using a linear echoendoscope. Results: Twenty-two patients (Mean age 65 y; 82% Male) with HGD in flat Barrett's mucosa had EUS examination prior to referral for therapy. 13 (59%) patients had long segment Barrett's and 7 (32%) patients had multifocal HGD. In 2 patients the latter information was not available. EUS staging reported T0N0 in 20 patients. Two patients had detected lymphadenopathy, however FNA cytology in both patients was negative for malignancy. Of the 12 patients that underwent EMR, 8 had HGD on histological examination, 1 had low grade dysplasia and 2 had nondysplastic Barrett's. An additional 3 patients underwent esophagectomy, and the surgical pathology revealed HGD with negative LNs. 5 patients underwent radiofrequency ablation without EMR, while 2 patients returned to their primary gastroenterologists for management. Conclusion: Patients with HGD in flat Barrett's mucosa had no evidence of invasive disease or nodal involvement by conventional EUS ± FNA. These findings correlated with pathologic staging in the 15 patients that had surgery or EMR. This study suggests that in patients with flat Barrett's and HGD, EUS did not affect staging or management and may not be needed in the routine workup in this group of patients.

Endoscopic and Endosonographic Predictors of Cancer in Patients with Barrett's Esophagus and High Grade Dysplasia

Background: Barrett's esophagus (BE) with high grade dysplasia (HGD) may have co-existent esophageal carcinoma and as a result traditional treatment has been esophagectomy. There has been increasing interest in endoscopic therapy as a viable alternative to esophagectomy in the management of HGD but little data exists to correctly guide patients between these treatment options. Aim: We studied patients referred for Endoscopic Ultrasound (EUS)/EGD who had BE with HGD to evaluate the ability of EGD and EUS to determine the presence of co-existing malignancy in HGD before therapy is instituted. Methods: All patients referred for evaluation of HGD in BE from October 2001 to November 2008 for EUS were included. Patients with prior biopsy proven carcinoma were excluded. A total of 53 patients met the above entry criteria. Analysis was performed to see if the findings of endoscopic nodularity, ulcer, stricture, length of BE, focal vs. multifocal HGD, or lesion seen on EUS staging predicted the presence of cancer. Cancer diagnosis was determined by histologic specimen and/or follow-up without evidence of cancer development. Mortality was confirmed for all patients as of November 2008. Results: A total of 30 out of 53 (57%) underwent esophagectomy. 5 patients had continued surveillance, 6 underwent photodynamic therapy, 6 endoscopic mucosal resection, 5 radiofrequency ablation, and 1 chemotherapy and radiation. The average length of follow-up for patients was 43 months (range 1 month to 84 months) with no new cases of adenocarcinoma. 11 patients out of 53 (20%) with HGD had proven esophageal cancer by histology. The mortality rate for the cohort was 2/53 (3.77%), both patients with proven carcinoma. Endoscopic findings of nodularity (p=0.004) and ulceration (p=0.01) predicted the presence of carcinoma. Other findings on endoscopy did not predict carcinoma including stricture (p=0.79), length of BE (p=0.11) or multifocal HGD (p=0.36). EUS stage greater than T0N0 significantly predicted cancer with an odds ratio of 49.4 and p value <0.0000001. One patient with flat HGD and a normal EUS exam was found to have intramucosal carcinoma. Conclusion: 1. The findings of nodularity and ulceration in patients with BE and HGD significantly predicts a co-existent cancer diagnosis. 2. EUS stage is the greatest independent predictor of carcinoma in patients with BE/HGD 3. Patients with flat HGD and negative EUS exam are very unlikely to have invasive cancer present and are thus are the best candidates for endoscopic therapy.

The Detection of Flat and Depressed Colorectal Lesions: Which Endoscopic Imaging Approach?

The secondary prevention of colorectal cancer (CRC) assumes that early detection and resection of precursor lesions disrupts the adenoma– carcinoma sequence and halts progression to invasive neoplastic disease. The adenoma– carcinoma sequence has until now formed the rationale for endoscopic therapies directed at reducing the incidence of CRC. The fact that snare polypectomy of exophytic lesions fails to prevent progression to carcinoma in up to 24% of cases has prompted reevaluation of the prevalence and clinicopathologic significance of flat and depressed colorectal lesions in Western population cohorts. Such lesions, although well-described in the Japanese literature, have only recently been reported in Western population cohorts. Debate has continued regarding their prevalence, anatomic localization, histopathologic characteristics, and proposed imaging modality of choice. Within this perspective, we summarize the key data pertinent to recently described endoscopic diagnostic modalities and detail their clinical applicability both for the detection of flat neoplastic lesions occurring in the “sporadic” patient cohort, familial polyposis syndromes, and chronic ulcerative colitis.

M1603 Should Endoscopic Ultrasonography (EUS) Be Performed in Barrett's Esophagus (BE) Patients with Flat High Grade Dysplasia and/or Mucosal Adenocarcinoma?

M1603 Should Endoscopic Ultrasonography (EUS) Be Performed in Barrett's Esophagus (BE) Patients with Flat High Grade Dysplasia and/or Mucosal Adenocarcinoma?

Effective treatment of early Barrett’s neoplasia with stepwise circumferential and focal ablation using the HALO system

The aim of the current study was to evaluate the efficacy and safety of stepwise circumferential and focal ablation using the HALO system for Barrett's esophagus containing flat, high-grade dysplasia (HGD) or residual dysplasia after endoscopic resection for HGD or intramucosal cancer (IMC). Visible abnormalities were removed with endoscopic resection prior to ablation. Persistence of dysplasia and absence of IMC were confirmed with biopsy after endoscopic resection. A balloon-based electrode was used for primary circumferential ablation and an endoscope-mounted electrode was used for secondary focal ablation. Twelve patients (nine men; median age 70 years) were treated (median Barrett's length 7 cm). Visible abnormalities were removed by endoscopic resection in seven patients. The worst pathological grade of residual Barrett's esophagus after resection and prior to ablation was low-grade dysplasia (LGD) (n = 1) and HGD (n = 11). Patients underwent a median of one circumferential and two focal ablation sessions. Complete remission of dysplasia was achieved in 12/12 patients (100%). Complete endoscopic and histological removal of Barrett's esophagus was achieved in 12/12 patients (100%). There were no ablation-related stenoses, and no subsquamous Barrett's esophagus was observed in 363 biopsies obtained from post-ablation neo-squamous mucosa. Protocolized cleaning of the ablation zone and electrode in between ablations resulted in superior regression of Barrett's esophagus compared with previous studies. During a median follow-up of 14 months no recurrence of dysplasia or Barrett's esophagus was observed. Stepwise circumferential and focal ablation for Barrett's esophagus with flat HGD or for Barrett's with residual dysplasia after endoscopic resection for HGD/IMC is a safe and effective treatment modality. Its success rate and safety profile compare favorably with alternatives such as esophagectomy, widespread endoscopic resection or photodynamic therapy.

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.

Diagnostic Problems and Advances in Inflammatory Bowel Disease

This review summarizes current diagnostic problems and advances with regard to patterns of inflammation and dysplasia in ulcerative colitis and Crohn's disease. Ulcerative colitis and Crohn's disease have a variety of characteristic but non-specific pathologic features. In approximately 5% of inflammatory bowel disease cases, a definite diagnosis of ulcerative colitis or Crohn's disease cannot be established, in which case the term “indeterminate” colitis is used. Most cases of indeterminate colitis are related to fulminant colitis, a condition in which the classic features of ulcerative colitis or Crohn's disease may be obscured by severe ulceration with early superficial fissuring ulceration, transmural lymphoid aggregates, and relative rectal sparing. Approximately 20% of patients with indeterminate colitis develop severe pouch complications, which is intermediate in frequency between ulcerative colitis (8–10%) and Crohn's disease (30–40%). In order to establish a diagnosis of ulcerative colitis or Crohn's disease, it is important to evaluate pathologic material in conjunction with clinical, laboratory, radiologic, and endoscopic features and to recognize the variety of changes that may be seen in fulminant ulcerative colitis. There are a number of exceptions to the classic principles of inflammatory bowel disease pathology that may lead to diagnostic confusion. For instance, apparent skip lesions on biopsy analysis may occur in patients with ulcerative colitis in the following settings; long term oral or topical therapy, focal ascending colon, cecum and/or appendiceal involvement in patients with left sided ulcerative colitis, upper gastrointestinal involvement in patients with ulcerative colitis, and at initial presentation of ulcerative colitis in pediatric patients. In all of these circumstances, the finding of patchy disease and/or rectal sparing should not be misinterpreted as either evidence against a diagnosis of ulcerative colitis, or as representing skip areas characteristic of Crohn's disease. Patients with ulcerative colitis and Crohn's disease are at increased risk for the development of dysplasia and carcinoma. Recent studies suggest that given a similar duration and extent of disease, patients with Crohn's disease have a similar risk of dysplasia and cancer as patients with ulcerative colitis. Dysplasia in ulcerative colitis may be classified as flat or elevated (dysplasia associated lesion or mass [DALM]). Patients with flat high grade dysplasia are generally treated with colectomy. However, there is recent evidence to suggest that patients with flat low grade dysplasia, particularly if detected at the time of initial endoscopic exam, or if its multifocal or synchronous, should also be treated with colectomy. Elevated lesions in ulcerative colitis (DALM) are subdivided into “adenoma-like” and “non-adenoma-like” lesions based on their endoscopic appearance. Recent data suggests that adenoma-like lesions, regardless of the grade of dysplasia, or the location of the lesion (i.e., inside or outside areas of established colitis) may be treated adequately by polypectomy if there are no other areas of flat dysplasia in the patient. Although there are some histologic and molecular features that can help differentiate sporadic adenomas from adenoma-like polypoid dysplastic lesions related to ulcerative colitis, none of these adjunctive techniques can help distinguish these lesions definitively in any single patient. Patients with a non-adenoma-like DALM, (irregular, broad based, or strictured lesion) should be treated with colectomy because of the high probability of adenocarcinoma. The surveillance and treatment options for patients with flat and elevated dysplasia in ulcerative colitis are reviewed in detail.