Gastroenterology

Gastroenterology

Volume 138, Issue 2, February 2010, Pages 746-774.e4
Gastroenterology

AGA
AGA Technical Review on the Diagnosis and Management of Colorectal Neoplasia in Inflammatory Bowel Disease

https://doi.org/10.1053/j.gastro.2009.12.035Get rights and content

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Learning Objectives

This article has an accompanying continuing medical education activity on page e12. Upon completetion of reading this article, successful learners will be able to:

  • 1

    Understand the predisposing and protective factors for the development of colorectal neoplasia in patients with IBD

  • 2

    Understand the natural history of flat and raised dysplasia

  • 3

    Review the indications for colectomy in patients with flat and raised dysplasia

  • 4

    Review surveillance guidelines in patients with IBD

  • 5

    Understand the role of

UC

Patients with long-term UC have an increased risk of CRC, but the magnitude has been difficult to estimate. A number of factors have rendered the magnitude difficult to assess. First, a direct comparison between studies is difficult because of inconsistent methods used to calculate risk. Some studies reported the cumulative risk of developing CRC in a given population of patients with IBD, but unfortunately, many assume that all subjects have the same risk. Other studies have calculated the

Disease Duration

The increasing risk of CRC with disease duration in patients with UC has been demonstrated in the meta-analysis and surveillance program data previously mentioned.3, 6 An elevated RR is appreciable after 8 to 10 years of disease, which is the time at which regular colonoscopic surveillance should commence. A recent study from The Netherlands has suggested that cancers will be missed if surveillance is commenced at 8 to 10 years for patients with pancolitis, and 15 to 20 years for patients with

Correct Interpretation of Dysplasia

To understand the natural history of dysplasia, the nuances involved in the correct interpretation of dysplasia must first be appreciated. In both CD and UC, carcinoma develops through an inflammation/dysplasia/carcinoma sequence.62, 63 At present, dysplasia, which is defined as unequivocal neoplastic epithelium confined to the basement membrane, is the best and most reliable marker of an increased risk of malignancy in patients with IBD.64, 65 Dysplasia is present in more than 90% of UC cases

Gross Features of Raised Dysplasia

There is lack of consistency in the literature with regard to the criteria and methods used to designate raised, endoscopically visible, dysplastic lesions as DALMs.60, 78, 79 For instance, some studies categorize dysplastic lesions as flat only if they are endoscopically undetectable, whereas others include visible plaque-like or velvety discolored areas of mucosa in this category as well. There is also discordance with regard to the definitions used (including the criteria for dysplasia), the

Should Colectomy Be Performed for Flat Dysplasia?

As mentioned in the previous section, if a raised dysplastic lesion can be resected endoscopically, regardless of whether the dysplasia is low or high grade, the patient can be managed with continued surveillance colonoscopy and does not necessarily require a colectomy. This management is therefore analogous to that of a sporadic adenoma in the general population. However, if flat dysplasia is encountered in colitic mucosa, especially if the lesion cannot be completely removed by endoscopy,

Is There Sufficient Rationale for Performing Surveillance Colonoscopy in Patients With IBD?

Randomized controlled trials have not been performed to prove that surveillance colonoscopy is effective. However, a large number of case series have suggested a benefit of surveillance colonoscopy.13, 72, 83, 113, 142 Three case-control studies have examined this issue. In a population-based, nested case-control study of 142 patients with UC (derived from a study population of 4664 patients with UC) from Stockholm, Sweden, 2 of 40 patients with UC and CRC and 18 of 102 controls had undergone

How Should Surveillance Colonoscopy Be Performed?

Patients with ulcerative proctitis or ulcerative proctosigmoiditis are not at increased risk for IBD-related CRC and thus may be managed on the basis of average-risk recommendations. However, all patients should undergo a screening colonoscopy 8 years after the onset of symptoms with multiple biopsies throughout the colon to assess the true microscopic extent of disease. When performing surveillance colonoscopy, the most proximal extent of disease detected histologically at any point in time

What Role Do the Newer Imaging Techniques Play in Identifying and Managing Dysplasia?

Newer techniques are needed to facilitate identification of neoplastic lesions in patients with IBD. Chromoendoscopy has been proposed as a method to increase the yield of detecting dysplasia on surveillance colonoscopy and is considered a technique easily applicable to clinical practice. Chromoendoscopy has been more commonly used in Europe and Asia than in the United States to identify nonpolypoid flat and depressed neoplastic lesions in the colon.159 Chromoendoscopy has 2 main advantages57:

Should Chemopreventive Agents Be Used to Lower the Risk of Developing Dysplasia or CRC in IBD?

In the general population without IBD, it is well established that chemoprevention can reduce the incidence of adenomas and CRC.171 The notion that chemoprevention might reduce the incidence of colorectal neoplasia in IBD is particularly attractive because even though surveillance colonoscopy affords relative protection, some patients still develop CRC despite seemingly optimal surveillance. Curiously, some of the most effective chemopreventive agents for sporadic CRC are anti-inflammatory

Should Molecular Markers Be Applied to Help Stratify Patients Into Low-Risk and High-Risk Groups?

Knowledge about the molecular pathogenesis of colitis-associated cancer has been derived from studies of sporadic colon carcinogenesis. Not surprisingly, many of the molecular alterations responsible for sporadic CRC also play a role in colitis-associated cancer. The 2 major genetic pathways, chromosomal instability and microsatellite instability (MSI), occur with, roughly, the same frequency in sporadic CRC and colitis-associated cancer (chromosomal instability, 80%; MSI, 20%).199, 200 In

Areas of Future Research

Research and patient care in the field of IBD-associated colorectal neoplasia has become more enlightened in the last decade. It has become clear that raised dysplasia may not be as ominous as previously believed, as long as complete endoscopic resection can be assured. It is also becoming apparent that dysplastic lesions in the colitic colon are, in fact, visible and that newer, more sensitive imaging methods such as chromoendoscopy can improve dysplasia detection rates. Just as the quality of

Acknowledgments

NOTE: Dr Robin McLeod, a member of the AGA Institute Medical Position Panel, believes that in view of the high-risk (19% to 27%) of underlying cancer, in most situations patients should be offered colectomy when there is flat LGD which has been confirmed by an experienced pathologist.

The authors would like to acknowledge the expert assistance of Sheila A. Agyeman.

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References (50)

  • K. Shetty et al.

    The risk for cancer or dysplasia in ulcerative colitis patients with primary sclerosing cholangitis

    Am J Gastroenterol

    (1999)
  • E.V. Loftus et al.

    Risk of colorectal neoplasia in patients with primary sclerosing cholangitis

    Gastroenterology

    (1996)
  • R.M. Soetikno et al.

    Increased risk of colorectal neoplasia in patients with primary sclerosing cholangitis and ulcerative colitis: a meta-analysis

    Gastrointest Endosc

    (2002)
  • K.W. Nuako et al.

    Familial predisposition for colorectal cancer in chronic ulcerative colitis: a case-control study

    Gastroenterology

    (1998)
  • J. Askling et al.

    Family history as a risk factor for colorectal cancer in inflammatory bowel disease

    Gastroenterology

    (2001)
  • J. Askling et al.

    Colorectal cancer rates among first-degree relatives of patients with inflammatory bowel disease: a population-based cohort study

    Lancet

    (2001)
  • S. Friedman et al.

    Screening and surveillance colonoscopy in chronic Crohn's colitis

    Gastroenterology

    (2001)
  • M. Rutter et al.

    Severity of inflammation is a risk factor for colorectal neoplasia in ulcerative colitis

    Gastroenterology

    (2004)
  • R.B. Gupta et al.

    Histologic inflammation is a risk factor for progression to colorectal neoplasia in ulcerative colitis: a cohort study

    Gastroenterology

    (2007)
  • B. Crohn et al.

    The sigmoidoscopic picture of chronic ulcerative colitis (non-specific)

    Am J Med Sci

    (1925)
  • S. Warren et al.

    Cicatrizing enteritis as a pathological entity

    Am J Pathol

    (1948)
  • J.A. Eaden et al.

    The risk of colorectal cancer in ulcerative colitis: a meta-analysis

    Gut

    (2001)
  • C. Hendriksen et al.

    Long term prognosis in ulcerative colitis—based on results from a regional patient group from the county of Copenhagen

    Gut

    (1985)
  • D.D. Weedon et al.

    Crohn's disease and cancer

    N Engl J Med

    (1973)
  • T. Jess et al.

    Intestinal and extra-intestinal cancer in Crohn's disease: follow-up of a population-based cohort in Copenhagen County, Denmark

    Aliment Pharmacol Ther

    (2004)
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    Reprint requests Address requests for reprints to: Chair, Clinical Practice and Quality Management Committee, AGA National Office, 4930 Del Ray Avenue, Bethesda, Maryland 20814. Phone: (301) 272-1189; e-mail: [email protected].

    Conflicts of interest The authors disclose the following: Dr Farraye has received research support from Prometheus Laboratories; is a consultant and a member of the speaker's bureau for Abbott, Centocor, Proctor & Gamble, Prometheus Laboratories, Salix, and Shire; and is a consultant for UCB. The remaining authors disclose no conflicts.

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