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Shamsiddinova A, Burch J, Deputy M, Rao C, Worley G, Dean H, Thomas-Gibson S, Faiz O. Oncological outcomes of patients with inflammatory bowel disease undergoing segmental colonic resection for colorectal cancer and dysplasia: systematic review. BJS Open 2024; 8:zrae052. [PMID: 38822726 PMCID: PMC11143477 DOI: 10.1093/bjsopen/zrae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/26/2024] [Accepted: 04/07/2024] [Indexed: 06/03/2024] Open
Affiliation(s)
- Amira Shamsiddinova
- Department of Surgery and Gastroenterology, St Mark’s Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jennie Burch
- Department of Surgery and Gastroenterology, St Mark’s Hospital and Academic Institute, London, UK
| | - Mohammed Deputy
- Department of Surgery and Gastroenterology, St Mark’s Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Christopher Rao
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, North Cumbria Integrated Care NHS Foundation Trust, Cumberland Infirmary, Carlisle, UK
| | - Guy Worley
- Department of Surgery and Gastroenterology, St Mark’s Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Harry Dean
- Department of Surgery and Gastroenterology, St Mark’s Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Siwan Thomas-Gibson
- Department of Surgery and Gastroenterology, St Mark’s Hospital and Academic Institute, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Omar Faiz
- Department of Surgery and Gastroenterology, St Mark’s Hospital and Academic Institute, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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2
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Kabir M, Thomas-Gibson S, Tozer PJ, Warusavitarne J, Faiz O, Hart A, Allison L, Acheson AG, Atici SD, Avery P, Brar M, Carvello M, Choy MC, Dart RJ, Davies J, Dhar A, Din S, Hayee B, Kandiah K, Katsanos KH, Lamb CA, Limdi JK, Lovegrove RE, Myrelid P, Noor N, Papaconstantinou I, Petrova D, Pavlidis P, Pinkney T, Proud D, Radford S, Rao R, Sebastian S, Segal JP, Selinger C, Spinelli A, Thomas K, Wolthuis A, Wilson A. DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making. J Crohns Colitis 2023; 17:1652-1671. [PMID: 37171140 DOI: 10.1093/ecco-jcc/jjad083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients. METHODS Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement. RESULTS In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting. CONCLUSIONS By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.
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Affiliation(s)
- Misha Kabir
- Division of GI Services, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
| | - Siwan Thomas-Gibson
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Phil J Tozer
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Omar Faiz
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Ailsa Hart
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Lisa Allison
- Department of Gastroenterology, Royal Free Hospital, London, UK
| | - Austin G Acheson
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Semra Demirli Atici
- Department of Surgery, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Pearl Avery
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Mantaj Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Division of Medicine, Dentistry and Health Sciences, University of Melbourne, Austin Academic Centre, Melbourne, VIC, Australia
| | - Robin J Dart
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Justin Davies
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Anjan Dhar
- Department of Gastroenterology, Darlington Memorial Hospital, County Durham & Darlington NHS Foundation Trust, Darlington, UK
- Department of Gastroenterology, Teesside University, UK, Middlesbrough, UK
| | - Shahida Din
- Edinburgh IBD Unit, NHS Lothian, Western General Hospital, Edinburgh, UK
| | - Bu'Hussain Hayee
- Department of Gastroenterology, King's College Hospital, London, UK
| | - Kesavan Kandiah
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Christopher Andrew Lamb
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Royal Victoria Infirmary, Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Jimmy K Limdi
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Greater Manchester, UK
- Department of Gastroenterology, University of Manchester , Manchester, UK
| | - Richard E Lovegrove
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust , Worcester, UK
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nurulamin Noor
- Department of Gastroenterology, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Ioannis Papaconstantinou
- Department of Surgery, Aretaieion Hospital, National and Kapodistrian University of Athens, A thens, Greece
| | - Dafina Petrova
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- Escuela Andaluza de Salud Pública [EASP], Granada, Spain
- CIBER of Epidemiology and Public Health [CIBERESP], Madrid, Spain
| | - Polychronis Pavlidis
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Thomas Pinkney
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - David Proud
- Department of Surgery, Austin Health, Heidelberg Victoria, VIC, Australia
| | - Shellie Radford
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rohit Rao
- Department of Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Jonathan P Segal
- Department of Gastroenterology, Northern Hospital Epping, University of Melbourne, Melbourne, VIC, Australia
| | - Christian Selinger
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Antonino Spinelli
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Kathryn Thomas
- Department of Surgery, Nottingham University Hospitals, UK
| | - Albert Wolthuis
- Department of Surgery, University Hospital Leuven, The Netherlands
| | - Ana Wilson
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
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3
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Coelho-Prabhu N, Lewis JD. Update on Endoscopic Dysplasia Surveillance in Inflammatory Bowel Disease. Am J Gastroenterol 2023; 118:1748-1755. [PMID: 37543741 DOI: 10.14309/ajg.0000000000002460] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/02/2023] [Indexed: 08/07/2023]
Abstract
As medical management of inflammatory bowel disease makes great advances, most patients with inflammatory bowel disease will have long life expectancies without need for total colectomy. With prolonged disease duration, however, there is increased risk of dysplasia leading to colorectal cancer. Multiple consensus and guideline documents have been published over the last decade with recommendations to optimize early detection and management of dysplastic lesions. Endoscopic technology has improved tremendously, even over the past few years. Previously invisible dysplasia has become visible in most cases with advanced imaging technologies that now allow for much clearer and more detailed mucosal inspection. New tools to facilitate endoscopic resection of visible lesions have also enabled patients to avoid colectomy, with resulting need to continue colon surveillance. There are limited or conflicting data leading to inconsistent recommendations regarding the need for random biopsies, the preferred endoscopic imaging technique, and surveillance intervals after resection of dysplasia. Similarly, there remains significant variability in the application of guidelines into daily practice and availability of and training with advanced imaging technologies. Here, we present a narrative review of which patients are at highest risk for dysplasia, the current guidelines on surveillance colonoscopy, factors affecting optimal mucosal visualization, enhanced imaging techniques, standardized reporting terminologies for surveillance colonoscopy, endoscopic management of dysplasia, indications for colectomy, and briefly on future potential technologies to assist in dysplasia detection.
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Affiliation(s)
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Jamil OK, Shaw D, Deng Z, Dinardi N, Fillman N, Khanna S, Krugliak Cleveland N, Sakuraba A, Weber CR, Cohen RD, Dalal S, Jabri B, Rubin DT, Pekow J. Inflammation in the proximal colon is a risk factor for the development of colorectal neoplasia in inflammatory bowel disease patients with primary sclerosing cholangitis. Therap Adv Gastroenterol 2023; 16:17562848231184985. [PMID: 37692199 PMCID: PMC10486214 DOI: 10.1177/17562848231184985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 06/12/2023] [Indexed: 09/12/2023] Open
Abstract
Background Patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) have an increased risk of developing colorectal neoplasia (CRN) in the proximal colon. Objectives To evaluate whether duration and severity of inflammation are linked to the development of CRN in this population. Design Retrospective, case-control chart review of patients with PSC and IBD at a tertiary care center. Methods Disease activity was scored per colonic segment at each colonoscopy prior to the first instance of observed CRN using a modified Mayo endoscopic sub-score and histologic assessment. Patients in the CRN-positive group were compared to controls that did not. Results In all, 72 PSC-IBD patients with no history of CRN were identified, 13 of whom developed CRN after at least one colonoscopy at our institution. Patients in the CRN-positive group had significantly more endoscopic (p < 0.01) and histologic (p < 0.01) inflammation in the right compared to the control group prior to the development of dysplasia. There was significantly greater endoscopic inflammation in the segment of the colon with a dysplastic lesion than other segments of the colon (p = 0.018). Patients with moderate/severe lifetime endoscopic (p = 0.02) or histologic inflammation (p = 0.04) score had a lower probability of remaining free of dysplasia during follow-up. Nearly half of the patients with dysplasia had invisible lesions found on random biopsy. Conclusions Endoscopic and histologic inflammation in the proximal colon are risk factors for CRN in patients with PSC-IBD. PSC-IBD patients frequently have subclinical inflammation, and these findings support the practice of regular assessment of disease activity and random biopsy of inflamed and uninflamed areas in patients with PSC with the goal of reducing inflammation to prevent the development of CRN.
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Affiliation(s)
- Omar K. Jamil
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Dustin Shaw
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA Digestive Diseases Research Core Center, University of Chicago Medicine, Chicago, IL, USA
| | - Zifeng Deng
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Nicholas Dinardi
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Natalie Fillman
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Shivani Khanna
- Department of Allergy and Immunology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | | | - Russell D. Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Sushila Dalal
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Bana Jabri
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA Digestive Diseases Research Core Center, University of Chicago Medicine, Chicago, IL, USA
| | - David T. Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Joel Pekow
- Inflammatory Bowel Disease Center, University of Chicago Medicine, 900 East 57th Street, MB #9, Chicago, IL 60637, USA
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Olecki EJ, Perez Hoguin RA, King S, Razavi NC, Scow JS. High-Grade Dysplasia in Inflammatory Bowel Disease: Indication for Colectomy. Dis Colon Rectum 2023; 66:262-268. [PMID: 35714339 DOI: 10.1097/dcr.0000000000002242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease have an increased risk of colorectal cancer and are recommended to undergo increased surveillance compared to the general population. Currently, inadequate evidence exists to guide management of colonic dysplasia discovered during screening of inflammatory bowel disease patients. OBJECTIVE The goal of this study was to determine the risk of colorectal cancer in patients with ulcerative colitis or Crohn's disease with dysplasia on colonoscopy. DESIGN This was a retrospective study. SETTING This study was conducted at a high-volume, quaternary referral center with an inflammatory bowel disease program. PATIENTS Patients with a diagnosis of inflammatory bowel disease with colonoscopy within 6 months of colectomy were included. MAIN OUTCOME MEASURES The primary outcome measures included finding of colorectal cancer at time of colectomy. RESULTS There were 621 patients, 233 with ulcerative colitis and 388 with Crohn's disease. Of ulcerative colitis patients, 25 had low-grade dysplasia on colonoscopy with 1 (4%) found to have colorectal cancer at colectomy. High-grade dysplasia was noted preoperatively in 14 and colorectal cancer was found in 4 (29%) after colectomy. Compared to no dysplasia, low-grade dysplasia did not increase the risk of colorectal cancer (OR 1.98, p = 0.47), but high-grade dysplasia had an increased risk (OR 19.0, p < 0.001) of colorectal cancer. For the 7 patients with Crohn's disease and low-grade dysplasia, colorectal cancer was found in 1 patient (14%) at colectomy. High-grade dysplasia was noted preoperatively in 4 patients with Crohn's Disease, and colorectal cancer was found in 3 patients (75%) after colectomy. Compared to no dysplasia, low-grade dysplasia did not increase the risk of colorectal cancer (OR 12.4, p = 0.88), but high-grade dysplasia did increase the risk of colorectal cancer (OR 223.2, p < 0.001). LIMITATIONS This study was limited by its retrospective review. CONCLUSION In both ulcerative colitis and Crohn's disease, low-grade dysplasia was not associated with colorectal cancer. High-grade dysplasia was associated with an increased risk of colorectal cancer at time of colectomy. While continued surveillance may be appropriate for low-grade dysplasia, high-grade dysplasia necessitates surgical resection given the high likelihood of colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B887 . DISPLASIA DE ALTO GRADO EN LA ENFERMEDAD INFLAMATORIA INTESTINAL INDICACIN DE COLECTOMA ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal tienen un mayor riesgo de cáncer colorrectal y se recomienda someterse a una mayor vigilancia en comparación con la población general. Actualmente, existe evidencia inadecuada para guiar el manejo de la displasia colónica descubierta durante la valoracion de pacientes con enfermedad inflamatoria intestinal.OBJETIVO:Determinar el riesgo de cáncer colorrectal en pacientes con colitis ulcerosa o enfermedad de Crohn con displasia en la colonoscopia.DISEÑO:Este fue un estudio retrospectivo.AJUSTE:Este estudio se llevó a cabo en un centro de referencia cuaternario de alto volumen con un programa de enfermedad inflamatoria intestinal.PACIENTES:Pacientes con diagnóstico de enfermedad inflamatoria intestinal con colonoscopia dentro de los 6 meses posteriores a la colectomía.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado incluyeron el hallazgo de cáncer colorrectal en el momento de la colectomía.RESULTADOS:Hubo 621 pacientes: 233 con colitis ulcerosa y 388 con enfermedad de Crohn. De los pacientes con colitis ulcerosa, 25 tenían displasia de bajo grado en la colonoscopia y 1 (4%) tenía cáncer colorrectal en la colectomía. Se observó displasia de alto grado antes de la operación en 14 y cáncer colorrectal en 4 (29%) después de la colectomía. En comparación con la ausencia de displasia, la displasia de bajo grado no aumentó el riesgo de cáncer colorrectal (Odds Ratio 1,98, p = 0,47), pero la displasia de alto grado tuvo un mayor riesgo (OR 19,0, p <0,001) de cáncer colorrectal. Para los 7 pacientes con enfermedad de Crohn y displasia de bajo grado, se encontró cáncer colorrectal en 1 (14%) en la colectomía. Se observó displasia de alto grado antes de la operación en 4 pacientes con enfermedad de Crohn y cáncer colorrectal en 3 pacientes (75%) después de la colectomía. En comparación con la ausencia de displasia, la displasia de bajo grado no aumentó el riesgo de cáncer colorrectal (Odds Ratio 12.4, p = 0.88), pero la displasia de alto grado sí aumentó el riesgo de cáncer colorrectal (Odds Ratio 223.2, p <.001).LIMITACIONES:Este estudio estuvo limitado por su revisión retrospectiva. CONCLUSIN Tanto en la colitis ulcerosa como en la enfermedad de Crohn, la displasia de bajo grado no se asoció con el cáncer colorrectal. La displasia de alto grado se asoció con un mayor riesgo de cáncer colorrectal en el momento de la colectomía. Si bien la vigilancia continua puede ser apropiada para la displasia de bajo grado, la displasia de alto grado requiere resección quirúrgica dada la alta probabilidad de cáncer colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B887 . (Traducción-Dr Yolanda Colorado ).
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Affiliation(s)
- Elizabeth J Olecki
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsyvlania
| | - Rolfy A Perez Hoguin
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsyvlania
| | - Steven King
- The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Nina C Razavi
- The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Jeffery S Scow
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
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Young EJ, Rajandran A, Philpott HL, Sathananthan D, Hoile SF, Singh R. Mucosal imaging in colon polyps: New advances and what the future may hold. World J Gastroenterol 2022; 28:6632-6661. [PMID: 36620337 PMCID: PMC9813932 DOI: 10.3748/wjg.v28.i47.6632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/23/2022] [Accepted: 11/22/2022] [Indexed: 12/19/2022] Open
Abstract
An expanding range of advanced mucosal imaging technologies have been developed with the goal of improving the detection and characterization of lesions in the gastrointestinal tract. Many technologies have targeted colorectal neoplasia given the potential for intervention prior to the development of invasive cancer in the setting of widespread surveillance programs. Improvement in adenoma detection reduces miss rates and prevents interval cancer development. Advanced imaging technologies aim to enhance detection without significantly increasing procedural time. Accurate polyp characterisation guides resection techniques for larger polyps, as well as providing the platform for the "resect and discard" and "do not resect" strategies for small and diminutive polyps. This review aims to collate and summarise the evidence regarding these technologies to guide colonoscopic practice in both interventional and non-interventional endoscopists.
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Affiliation(s)
- Edward John Young
- Department of Gastroenterology, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Elizabeth Vale 5031, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, South Australia, Australia
| | - Arvinf Rajandran
- Department of Gastroenterology, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Elizabeth Vale 5031, South Australia, Australia
| | - Hamish Lachlan Philpott
- Department of Gastroenterology, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Elizabeth Vale 5031, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, South Australia, Australia
| | - Dharshan Sathananthan
- Department of Gastroenterology, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Elizabeth Vale 5031, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, South Australia, Australia
| | - Sophie Fenella Hoile
- Department of Gastroenterology, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Elizabeth Vale 5031, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, South Australia, Australia
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Elizabeth Vale 5031, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, South Australia, Australia
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7
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Friedberg S, Rubin DT. Intestinal Cancer and Dysplasia in Crohn's Disease. Gastroenterol Clin North Am 2022; 51:369-379. [PMID: 35595420 DOI: 10.1016/j.gtc.2021.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Crohn's disease is associated with an increased risk of adenocarcinoma of the involved portions of the small bowel and colorectum and has similar risk factors to those described in ulcerative colitis, most significantly, extent of bowel involvement, PSC, and duration of unresected disease. Prevention strategies include risk stratification and secondary prevention with colonoscopic screening and surveillance to identify dysplasia or early-stage cancers, with surgery when needed. There is emerging information to suggest that control of inflammation may provide primary prevention of neoplasia, but further studies are required to test this strategy.
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Affiliation(s)
- Scott Friedberg
- University of Chicago Medicine Inflammatory Bowel Disease Center
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center.
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8
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Krugliak Cleveland N, Torres J, Rubin DT. What Does Disease Progression Look Like in Ulcerative Colitis, and How Might It Be Prevented? Gastroenterology 2022; 162:1396-1408. [PMID: 35101421 DOI: 10.1053/j.gastro.2022.01.023] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 02/08/2023]
Abstract
Ulcerative colitis (UC) has been characterized by inflammation limited to the mucosa. Although sustained and durable remission has been associated with mucosal healing, the recurrent phenomenon of persistent clinical disease activity despite mucosal healing has been observed in clinical practice and across pivotal trials. Over time, UC appears to confer an increased risk of progression, defined as changes of disease phenotype; adverse transmural effects on the bowel wall; increased risk of neoplasia development; worsening colorectal function; and increased risk of colectomy, hospitalizations, and other extraintestinal comorbidities. Although the treatment paradigm for Crohn's disease has shifted toward early aggressive intervention to prevent disease progression and irreversible bowel damage, such urgency in efforts to halt disease progression in UC have been largely overlooked. This review summarizes the multiple facets of UC contributing to a modified perception of the disease as a progressive one. We propose further study of the natural history and priorities for further treatment goals that include these considerations.
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Affiliation(s)
| | - Joana Torres
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Lisbon, Portugal; Division of Gastroenterology, Hospital da Luz, Lisbon, Portugal
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois.
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9
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Murthy SK, Feuerstein JD, Nguyen GC, Velayos FS. AGA Clinical Practice Update on Endoscopic Surveillance and Management of Colorectal Dysplasia in Inflammatory Bowel Diseases: Expert Review. Gastroenterology 2021; 161:1043-1051.e4. [PMID: 34416977 DOI: 10.1053/j.gastro.2021.05.063] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 04/19/2021] [Accepted: 05/21/2021] [Indexed: 02/08/2023]
Abstract
Improvements in disease management, as well as endoscopic technology and quality, have dramatically changed the way in which we conceptualize and manage inflammatory bowel disease-related dysplasia over the past 20 years. Based on evolving literature, we propose a conceptual model and best practice advice statements for the prevention, detection, and management of colorectal dysplasia in people with inflammatory bowel disease. This expert review was commissioned and approved by the American Gastroenterological Association Institute Clinical Practice Updates Committee and the American Gastroenterological Association Governing Board to provide timely guidance on a topic of high clinical importance to the American Gastroenterological Association membership. It underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology.
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Affiliation(s)
- Sanjay K Murthy
- The Ottawa Hospital Inflammatory Bowel Disease Centre, Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Joseph D Feuerstein
- Center for Inflammatory Bowel Disease Beth Israel Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Ontario, Canada
| | - Fernando S Velayos
- Division of Gastroenterology and Hepatology, The Permanente Medical Group, San Francisco, California.
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10
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Cleveland NK, Rubin DT. CANCER PREVENTION IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE. PRACTICAL GASTROENTEROLOGY 2021; 45:12-28. [PMID: 34707325 PMCID: PMC8547793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Inflammatory bowel disease (IBD) is associated with increased rates of malignancies; some are disease-related (like colorectal cancer) and some are primarily associated with therapy exposures. Although there may be an overlap between disease- and therapy-related cancers, the general strategy for prevention of cancer in patients with IBD lies in understanding the risk factors for these malignancies, educating patients about the recommended screening and surveillance practices, and incorporating general screening recommendations into routine IBD care. An important limitation to our understanding of the effectiveness of our intervention and prevention strategies is the lack of studies assessing mortality benefit, but in part also a reflection of the low mortality in our IBD population. In practice, it is imperative to weigh the risks of cancer or other treatment-related complications in the context of disease progression as a result of lack of or ineffective treatment for IBD when tailoring a management plan for each patient.
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Affiliation(s)
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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11
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Kabir M, Fofaria R, Arebi N, Bassett P, Tozer PJ, Hart AL, Thomas-Gibson S, Humphries A, Suzuki N, Saunders B, Warusavitarne J, Faiz O, Wilson A. Systematic review with meta-analysis: IBD-associated colonic dysplasia prognosis in the videoendoscopic era (1990 to present). Aliment Pharmacol Ther 2020; 52:5-19. [PMID: 32432797 DOI: 10.1111/apt.15778] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/02/2020] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The prognosis of dysplasia in patients with IBD is largely determined from observational studies from the pre-videoendoscopic era (pre-1990s) that does not reflect recent advances in endoscopic imaging and resection. AIMS To better understand the risk of synchronous colorectal cancer and metachronous advanced neoplasia (ie high-grade dysplasia or cancer) associated with dysplasia diagnosed in the videoendoscopic era, and to stratify risk according to a lesion's morphology, endoscopic resection status or whether it was incidentally detected on biopsy of macroscopically normal colonic mucosa (ie invisible). METHODS A systematic search of original articles published between 1990 and February 2020 was performed. Eligible studies reported on incidence of advanced neoplasia at follow-up colectomy or colonoscopy for IBD-dysplasia patients. Quantitative and qualitative analyses were performed. RESULTS Thirty-three studies were eligible for qualitative analysis (five for the meta-analysis). Pooled estimated proportions of incidental synchronous cancers found at colectomy performed for a pre-operative diagnosis of visible high-grade dysplasia, invisible high-grade dysplasia, visible low-grade dysplasia and invisible low-grade dysplasia were 13.7% (95% CI 0.0-54.1), 11.4% (95% CI 4.6-20.3), 2.7% (95% CI 0.0-7.1) and 2.4% (95% CI 0.0-8.5) respectively. The lowest incidences of metachronous advanced neoplasia, for dysplasia not managed with immediate colectomy but followed up with surveillance, tended to be reported by the studies where high definition imaging and/or chromoendoscopy was used and endoscopic resection of visible dysplasia was histologically confirmed. CONCLUSIONS The prognosis of IBD-dysplasia diagnosed in the videoendoscopic era appears to have been improved but the quality of evidence remains low. Larger, prospective studies are needed to guide management. PROSPERO registration no: CRD42019105736.
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Affiliation(s)
- Misha Kabir
- St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | | | - Naila Arebi
- St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | | | - Phil J Tozer
- St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | - Ailsa L Hart
- St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | | | - Adam Humphries
- St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | - Noriko Suzuki
- St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | - Brian Saunders
- St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | | | - Omar Faiz
- St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
| | - Ana Wilson
- St Mark's Hospital, Harrow, UK.,Imperial College London, London, UK
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12
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Feuerstein JD, Rakowsky S, Sattler L, Yadav A, Foromera J, Grossberg L, Cheifetz AS. Meta-analysis of dye-based chromoendoscopy compared with standard- and high-definition white-light endoscopy in patients with inflammatory bowel disease at increased risk of colon cancer. Gastrointest Endosc 2019; 90:186-195.e1. [PMID: 31009609 DOI: 10.1016/j.gie.2019.04.219] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/10/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with ulcerative colitis have an increased risk of colorectal cancer. We sought to assess the comparative efficacy of standard white-light endoscopy (SDWLE) or high-definition white-light endoscopy (HDWLE) versus dye-based chromoendoscopy through a meta-analysis and rate the quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. METHODS A systematic review of the literature in PubMed, EMBASE, and Web of Science was performed in April 2018. The primary outcome was the number of patients in whom dysplasia was identified using a per patient analysis in randomized controlled trials (RCT) and analyzed separately for non-RCTs. Analysis was performed using RevMan 5.3 reporting random-effects risk ratios. RESULTS Of the 27,904 studies identified, 10 studies were included 6 of which were RCTs (3 SDWLE and 3 HDWLE). Seventeen percent (84/494) of patients were noted to have dysplasia using chromoendoscopy compared with 11% (55/496) with white-light endoscopy (relative risk [RR] 1.50; 95% confidence interval [CI], 1.08-2.10). When analyzed separately, chromoendoscopy (n = 249) was more effective at identifying dysplasia than SDWLE (n = 248) (RR, 2.12; 95% CI, 1.15-3.91), but chromoendoscopy (n = 245) was not more effective compared with HDWLE (n = 248) (RR, 1.36; 95% CI, 0.84-2.18). The quality of evidence was moderate. In non-RCTs, dysplasia was identified in 16% (114/698) of patients with chromoendoscopy compared with 6% (62/1069) with white-light endoscopy (RR, 3.41; 95% CI, 2.13-5.47). Chromoendoscopy (n = 58) was more effective than SDWLE (n = 141) for identification of dysplasia (RR, 3.52; 95% CI, 1.38-8.99), and chromoendoscopy (n = 113) was also more effective than HDWLE (n = 257) (RR, 3.15; 95% CI, 1.62-6.13). The quality of the evidence was very low. CONCLUSION Based on this meta-analysis, non-RCTs demonstrate a benefit of chromoendoscopy over SDWLE and HDWLE, whereas RCTs only show a small benefit of chromoendoscopy over SDWLE, but not over HDWLE.
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Affiliation(s)
- Joseph D Feuerstein
- Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Shana Rakowsky
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lindsey Sattler
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Abhijeet Yadav
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Foromera
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Laurie Grossberg
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam S Cheifetz
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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13
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Surveillance Colonoscopy for Ulcerative Colitis-Associated Colorectal Cancer Offers Better Overall Survival in Real-World Surgically Resected Cases. Am J Gastroenterol 2019; 114:483-489. [PMID: 30747769 DOI: 10.14309/ajg.0000000000000117] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the effectiveness of surveillance colonoscopy (SC) and optimize its use by assessing real-world surgically resected cases of ulcerative colitis (UC)-associated colorectal cancer (CRC) and dysplasia. METHODS Clinicopathological data of 406 (238 CRC and 168 dysplasia) patients who underwent surgical resection in 10 UC specialized institutions were retrospectively reviewed. The overall survival (OS) rates were compared between the SC and non-SC groups. The incidence of and risk factors for early-onset CRC (<8 years after UC onset) were identified. The distribution of CRC lesions was also assessed. RESULTS Cancer stages were significantly more advanced in the non-SC group than in the SC group (P < 0.001). The patients in the SC group showed significantly better OS than those in the non-SC group (5-year OS: 89% vs 70%; log-rank test: P = 0.001). Seventeen percent of patients developed CRC within 8 years after UC onset. The age at UC onset was a risk factor and a good predictor of early-onset CRC (<8 years) (P < 0.01; AUC: 0.85). The most common sites of CRC were the rectum (51%) and sigmoid colon (20%). Multiple CRC was identified in 16% of patients. CONCLUSIONS Surveillance colonoscopy was effective and improved the OS in patients with UC. We recommend that patients with late-onset UC (>40 years) undergo SCs earlier because of the high incidence of CRC within 8 years of UC onset. Moreover, the rectum and sigmoid colon should be more thoroughly examined.
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14
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Cleveland NK, Ollech JE, Colman RJ, Rodriquez D, Hirsch A, Cohen RD, Hanauer SB, Hart J, Hurst R, Rubin DT. Efficacy and Follow-up of Segmental or Subtotal Colectomy in Patients With Colitis-Associated Neoplasia. Clin Gastroenterol Hepatol 2019; 17:205-206. [PMID: 29751167 PMCID: PMC7034413 DOI: 10.1016/j.cgh.2018.04.061] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/24/2018] [Accepted: 04/29/2018] [Indexed: 02/07/2023]
Abstract
The historical approach to neoplasia in the setting of chronic colitis was to perform a total proctocolectomy. Recent consensus and society guidelines1-3 suggest that when dysplastic lesions can be removed endoscopically, continued surveillance is appropriate. This is based on improvements in optical technologies and the low risk of metachronous colorectal carcinoma in these patients.4-6 We hypothesized that if a lesion was completely removed surgically and followed up endoscopically, metachronous colorectal carcinoma would be a rare occurrence. Thus, segmental resection may be offered as a definitive surgery in patients with chronic colitis and localized colorectal neoplasia in whom endoscopic resection is not feasible. Retention of the distal colon/rectum is expected to result in an overall improved quality of life compared with permanent ileostomy or an ileoanal J-pouch. Here, we report our experience and follow-up evaluation of segmental resections for preoperative neoplasia in patients with Crohn's disease (CD) or ulcerative colitis (UC).
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Affiliation(s)
| | - Jacob E. Ollech
- University of Chicago Medicine, Inflammatory Bowel Disease Center
| | - Ruben J. Colman
- University of Chicago Medicine, Inflammatory Bowel Disease Center
| | - Dylan Rodriquez
- University of Chicago Medicine, Inflammatory Bowel Disease Center
| | - Ayal Hirsch
- University of Chicago Medicine, Inflammatory Bowel Disease Center
| | - Russel D. Cohen
- University of Chicago Medicine, Inflammatory Bowel Disease Center
| | | | - John Hart
- University of Chicago Medicine, Inflammatory Bowel Disease Center
| | - Roger Hurst
- University of Chicago Medicine, Inflammatory Bowel Disease Center
| | - David T. Rubin
- University of Chicago Medicine, Inflammatory Bowel Disease Center
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15
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Chiu K, Riddell RH, Schaeffer DF. DALM, rest in peace: a pathologist's perspective on dysplasia in inflammatory bowel disease in the post-DALM era. Mod Pathol 2018; 31:1180-1190. [PMID: 29789648 DOI: 10.1038/s41379-018-0068-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/30/2018] [Accepted: 04/01/2018] [Indexed: 02/07/2023]
Abstract
There are few abbreviations in surgical pathology that are associated with as much immediate recognition, frustration, and confusion as DALM (dysplasia-associated lesion or mass). DALM is used to describe endoscopically visible dysplastic lesions in the surveillance of patients with inflammatory bowel disease. However, the diagnosis of DALM has been complicated by the inconsistent criteria and use of terminology for describing dysplasia in inflammatory bowel disease, and a tendency to relate DALM with the need for colectomy. Fortunately, advancements in both endoscopic visualization and local excision capability have allowed for a more defined management of dysplasia in inflammatory bowel disease. In 2015, the Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients International Consensus Recommendations (SCENIC) Development Panel, a panel of predominantly expert gastroenterologists and endoscopists in surveillance of inflammatory bowel disease, published a consensus statement. One recommendation was to abandon DALM-related terminology in favor of endoscopic descriptors modified from the Paris endoscopic classification. Recommendations on surveillance and management of dysplastic lesions were also provided. Nevertheless, interval carcinomas and metachronous neoplasia remain persistent issues. This review aims to provide an update on the post-DALM terminology and management recommendations for inflammatory bowel disease-associated dysplasia necessary for a meaningful communication between pathologists and clinicians.
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Affiliation(s)
- Kenrry Chiu
- Division of Anatomic Pathology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Robert H Riddell
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - David F Schaeffer
- Division of Anatomic Pathology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
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16
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Shibuya K, Homma S, Yoshida T, Ohno Y, Ichikawa N, Kawamura H, Imamoto T, Matsuno Y, Taketomi A. Carcinoma in the residual rectum of a long-standing Crohn's disease patient following subtotal colectomy: A case report. Mol Clin Oncol 2018; 9:50-53. [PMID: 29896400 DOI: 10.3892/mco.2018.1626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 04/24/2018] [Indexed: 01/28/2023] Open
Abstract
The development of colorectal cancer in long-standing Crohn's disease (CD) patients has become a major complication. Therapeutic guidelines for CD-associated cancer (CDAC) have already been established in Western countries; however, specific guidelines are not currently available in Japan. Surveillance of the residual intestine for cancer screening is important for long-standing CD patients. The present case report describes the occurrence of rectal carcinoma in a patient with a 25-year history of CD. A 37-year-old male with a 17-year history of CD underwent semi-emergent subtotal colectomy and ileostomy for bowel obstruction secondary to the transverse colon stenosis, and multiple severe stenosis and inflammation. Postoperatively, the patient resumed pharmacological treatment and underwent follow-up colonoscopies at ~1-2-year intervals. Despite continued pharmacological treatment, inflammation continued in the residual rectum. A total of 8 years following the primary operation, colonoscopy revealed inflammatory polyposis at the remnant rectum, which was diagnosed as adenocarcinoma. The interval between the last colonoscopy was 16 months. The patient then underwent laparoscopic abdominoperineal resection, and remained without recurrence for 12 months following resection. Thus, in long-standing CD patients, annual colonoscopy of the residual intestine may be considered for cancer screening, and specific surveillance guidelines for CDAC should be established.
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Affiliation(s)
- Kazuaki Shibuya
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Shigenori Homma
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Tadashi Yoshida
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Yosuke Ohno
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Hideki Kawamura
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Teppei Imamoto
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido 060-8648, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido 060-8648, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
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17
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Assessment of peri-polyp biopsy specimens of flat mucosa in patients with inflammatory bowel disease. Gastrointest Endosc 2018; 87:1304-1309. [PMID: 29307473 PMCID: PMC9646239 DOI: 10.1016/j.gie.2017.12.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 12/03/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS When colon polyps are removed in the setting of inflammatory bowel disease (IBD) involving the large intestine, biopsy sampling of the flat mucosa surrounding such polyps have been recommended, but there are no data to support this practice. METHODS We reviewed endoscopic and pathologic findings in IBD patients who had dysplastic polyps removed and biopsy sampling of the adjacent flat mucosa. We assessed risk for subsequent neoplasia based on the presence or absence of dysplasia in the peri-polyp flat mucosa and based on number and grade of index polypoid lesions. Kaplan-Meier survival analysis was performed. RESULTS Fifty-six IBD patients (68% ulcerative colitis [UC]) underwent 102 colonoscopies, in which 129 dysplastic polyps were resected. Five hundred three biopsy procedures of the surrounding flat mucosa were performed (mean, 3.9 biopsy samples per polyp), of which 16 (3.2%) were dysplastic. Thirty-four patients (21 UC) had follow-up in a median of 1.7 years (range, .02-15) and 147 colonoscopies. The presence of dysplasia in peri-polyp biopsy specimens during index colonoscopy was not associated with risk of developing high-grade dysplasia (HGD) or cancer (Pearson χ2 test = .19). The size and number of dysplastic polyps were not predictive of neoplastic outcomes, but the probability of developing subsequent advanced neoplasia for polypoid low-grade dysplasia was 18%, 29%, and 40% by 1, 3, and 5 years, respectively, and for polypoid HGD was 50%, 60%, and 70% by 1, 3, and 5 years, respectively (hazard ratio, 7.0; standard error, 4.8). CONCLUSIONS In patients with IBD-associated colitis, biopsy sampling of the mucosa adjacent to discrete dysplastic polypoid lesions are low yield and do not predict findings in follow-up examinations. However, the grade of dysplasia of the polyp itself is predictive of subsequent advanced neoplasia.
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Abstract
PURPOSE OF REVIEW Patients with long-standing ulcerative colitis have an increased risk for the development of colorectal cancer (CRC). Colitis-related dysplasia appears to confer the greatest risk. Colonoscopic surveillance to detect dysplasia has been advocated by gastrointestinal societies. The aim of surveillance is the reduction of mortality and morbidity of CRC through detection and resection of dysplasia or detecting CRC at an earlier and potentially curable stage. Traditional surveillance has relied on mucosal assessment with targeted biopsy of visible lesions and random biopsy sampling on the premise that dysplasia was not visible at endoscopy. Advances in optical technology permitting increased detection of dysplasia and evidence that most dysplasia is visible has had practice-changing implications. RECENT FINDINGS Emerging evidence favours chromoendoscopy (CE) for dysplasia detection and is gaining wider acceptance through recent international (International Consensus Statement on Surveillance and Management of Dysplasia in Inflammatory Bowel Disease (SCENIC)) recommendations and endorsed by many gastrointestinal societies. Adoption of CE as the gold standard of surveillance has been met with by scepticism, from conflicting data, operational barriers and the need to understand the true impact of increasingly higher dysplasia detection on overall CRC mortality. Valid debate notwithstanding, implementation of a risk stratification protocol that includes CE is an effective approach allowing earlier detection of dysplasia and colorectal neoplasia, determination of surveillance intervals with appropriate allocation of resources and limiting morbidity from CRC and colonoscopy itself. Further prospective data should define the true and long-term impact of dysplasia detection with modern techniques.
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19
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The Role of Chromoendoscopy and Enhanced Imaging Techniques in Inflammatory Bowel Disease Colorectal Cancer Colonoscopy Surveillance. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/978-3-319-62993-3_25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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20
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Eluri S, Parian AM, Limketkai BN, Ha CY, Brant SR, Dudley-Brown S, Efron JE, Fang SG, Gearhart SL, Marohn MR, Meltzer SJ, Bashar S, Truta B, Montgomery EA, Lazarev MG. Nearly a Third of High-Grade Dysplasia and Colorectal Cancer Is Undetected in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2017. [PMID: 28631086 PMCID: PMC6435268 DOI: 10.1007/s10620-017-4652-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is unclear whether intensive surveillance protocols have resulted in a decreased incidence of colorectal cancer (CRC) in inflammatory bowel disease (IBD). AIMS To determine the prevalence and characteristics of IBD associated high-grade dysplasia (HGD) or CRC that was undetected on prior colonoscopy. METHODS This is a single-center, retrospective study from 1994 to 2013. All participants had a confirmed IBD diagnosis and underwent a colectomy with either HGD or CRC found in the colectomy specimen.The undetected group had no HGD or CRC on prior colonoscopies. The detected group had HGD or CRC identified on previous biopsies. RESULTS Of 70 participants, with ulcerative colitis (UC) (n = 47), Crohn's disease (CD) (n = 21), and indeterminate colitis (n = 2), 29% (n = 20) had undetected HGD/CRC at colectomy (15 HGD and 5 CRC). In the undetected group, 75% had prior LGD, 15% had indefinite dysplasia, and 10% had no dysplasia (HGD was found in colonic strictures). Patients in the undetected group were more likely to have pancolitis (55 vs. 20%) and multifocal dysplasia (35 vs. 8%). The undetected group was less likely to have CRC at colectomy (25 vs. 62%). There was a trend toward right-sided HGD/CRC at colectomy (40 vs. 20%; p = 0.08). In addition, 84% of the lesions found in the rectum at colectomy were not seen on prior colonoscopy in the undetected group. CONCLUSIONS The prevalence of previously undetected HGD/CRC in IBD found at colectomy was 29%. The high proportion of undetected rectal and right-sided HGD/CRC suggests that these areas may need greater attention during surveillance.
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Affiliation(s)
- Swathi Eluri
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA.
- Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
| | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Berkeley N Limketkai
- Stanford University School of Medicine, Stanford, CA, USA
- Digestive Health Liver Clinic, 900 Blake Wilbur Dr, MC 5355, Palo Alto, CA, 94304, USA
| | - Christina Y Ha
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Steven R Brant
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Sharon Dudley-Brown
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Jonathan E Efron
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Sandy G Fang
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Susan L Gearhart
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Michael R Marohn
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Stephen J Meltzer
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Safar Bashar
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Brindusa Truta
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Elizabeth A Montgomery
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Mark G Lazarev
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
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Getting a Low Grade for Missing High-Grade Dysplasia and Colorectal Cancer in IBD. Dig Dis Sci 2017; 62:3594-3595. [PMID: 29052819 DOI: 10.1007/s10620-017-4795-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/07/2017] [Indexed: 12/09/2022]
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Tontini GE, Rath T, Pastorelli L, Vecchi M, Neumann H. Surveillance strategies for colitis-associated cancer: state of the art and future perspectives. Expert Rev Gastroenterol Hepatol 2017; 11:427-437. [PMID: 28276810 DOI: 10.1080/17474124.2017.1297705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Colitis-associated cancer (CAC) represents a concrete risk of morbidity and mortality in patients with long lasting inflammatory bowel diseases. Surveillance colonoscopy is a rapidly evolving research field with profound changes from the traditional approach based on scheduled controls and random biopsy protocols. Areas covered: A literature search was performed using PubMed/Embase to review the latest evidence supporting the need for surveillance colonoscopy. By focusing on the most promising recent advances in this field, we provide a state-of-the-art overview of the current gold standards for the diagnosis and management of colitis-associated dysplasia. Expert commentary: Evidence-based and emerging data have questioned the efficacy and effectiveness of both standard surveillance colonoscopy and random biopsy protocols. The latest guidelines endorse early initiation of surveillance programs, risk-profiling assessment of colonoscopy intervals and standardized use of advanced imaging modalities to detect early dysplasia. Current trends clearly reveal increased attention to direct visualization and endoscopic management of visible dysplastic lesions, even in patients with longstanding colitis. Emerging technological advances in gastrointestinal endoscopy are expected to change the endoscopic surveillance protocols in the near future.
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Affiliation(s)
- Gian Eugenio Tontini
- a Gastroenterology and Digestive Endoscopy Unit , IRCCS Policlinico San Donato , San Donato Milanese , Italy
| | - Timo Rath
- b Department of Medicine I , University of Erlangen-Nuremberg , Erlangen , Germany
| | - Luca Pastorelli
- a Gastroenterology and Digestive Endoscopy Unit , IRCCS Policlinico San Donato , San Donato Milanese , Italy
- c Department of Biomedical Sciences for Health , University of Milan , Milano , Italy
| | - Maurizio Vecchi
- a Gastroenterology and Digestive Endoscopy Unit , IRCCS Policlinico San Donato , San Donato Milanese , Italy
- c Department of Biomedical Sciences for Health , University of Milan , Milano , Italy
| | - Helmut Neumann
- b Department of Medicine I , University of Erlangen-Nuremberg , Erlangen , Germany
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Colman RJ, Rubin DT. Histological inflammation increases the risk of colorectal neoplasia in ulcerative colitis: a systematic review. Intest Res 2016; 14:202-10. [PMID: 27433141 PMCID: PMC4945523 DOI: 10.5217/ir.2016.14.3.202] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 05/30/2016] [Accepted: 05/30/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND/AIMS Ulcerative colitis (UC) patients are at greater risk for the development of colorectal neoplasia. Several individual studies have demonstrated associations between severity of histologic inflammation and colorectal neoplasia. However, a comprehensive systematic review has not been completed. We performed a systematic review and meta-analysis to explore the relationship between histologic inflammation and risk for neoplasia among available observational studies. METHODS Three databases (EMBASE, MEDLINE and the Cochrane Library) were systematically searched. Studies were included if they included UC patients who underwent colonoscopic assessment and when histologic inflammation and colorectal neoplasia were both reported. Colorectal neoplasia rates were compared. Quantitative meta-analysis was attempted. RESULTS Four of 1,422 records found were eligible. Results from 2 case-control studies reported a 3.5-fold increased risk for colorectal neoplasia associated with a single point increase in histologic inflammation. This result was further corroborated by one cohort study that demonstrated increased hazard ratios. The second cohort study reported outcomes for patients with normal gross endoscopy, but had increased histological inflammation when neoplasia was assessed. Finally, this study reported increased risk for neoplastic progression by histological inflammation among patients who were normal by gross endoscopic evaluation. Quantitative meta-analysis was unsuccessful due to heterogeneity between study measures. CONCLUSIONS There is strong evidence that histologic inflammation among patients with UC increases the risk of colorectal neoplasia. The depth and nature of assessment of additional clinical variables was varied and may have resulted in greater outcome discrepancy. Additional study related to mechanisms of inflammation-related neoplasia and therapeutic modification is needed.
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Affiliation(s)
- Ruben J Colman
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA.; St. Barnabas Hospital Health System, The Bronx, NY, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
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