Surveillance of IBD Using High Definition Colonoscopes Does Not Miss Adenocarcinoma in Patients with Low-grade Dysplasia

Abstract

Background Historically, limits to the ability to detect dysplasia in chronic inflammatory bowel disease (IBD)-associated colitis resulted in the recommendation that neoplasia of any grade be treated by proctocolectomy. We hypothesized that with improved optical technologies, most neoplasia in colitis is now detectable and reassessed the prevalence of colitis-associated neoplasia. Methods We retrospectively reviewed all our patients with IBD who had pathologist-confirmed neoplasia on surveillance colonoscopy and underwent a subsequent colectomy. We included patients whose index lesions were found between 2005 and 2014 (the dates of our high definition equipment) and recorded the location and grade of these lesions. These findings were compared to the surgical specimens, and in patients with partial colectomies, included follow-up. Results Thirty-six patients with IBD (19 [53%] ulcerative colitis, 17 [47%] Crohn’s disease) were found to have neoplastic lesions on surveillance colonoscopy and underwent a subsequent partial colectomy or total proctocolectomy. Fourty-four index lesions were identified by colonoscopy (29 white light and 7 methylene blue chromoscopy): 30 low-grade dysplasia, 6 high-grade dysplasia, and 8 adenocarcinoma. None of the low-grade dysplasia or adenocarcinoma index lesions were associated with synchronous carcinoma at colectomy. One of the patients with high-grade dysplasia had adenocarcinoma of the appendix. Conclusions In this experience with high definition colonoscopes in chronic colitis, no synchronous adenocarcinomas were found when colectomy was performed for low grade dysplasia and only 1 adenocarcinoma in the appendix was found in the setting of high-grade dysplasia. These findings suggest that active surveillance or subtotal colectomy, may be safe options for patients with IBD and some grades of neoplasia.

Systematic review with meta‐analysis: IBD‐associated colonic dysplasia prognosis in the videoendoscopic era (1990 to present)

“…Two cohort studies and one case series reported on the rates of prevalent cancer found in the surgical colectomy specimen resected soon after a pre‐operative diagnosis of visible HGD where 94% 28 to 100% 29,30 had not been endoscopically resected pre‐operatively. The prevalent cancer rate varied from 0% (n = 0/26), 28 20% (n = 1/5) 30 to 35.8% (n = 34/95) 29 . The studies with the highest prevalent cancer rates only included cases where the dysplasia was located within the extent of inflamed mucosa, rather than proximal to it 29,30 .…”

“…The prevalent cancer rate varied from 0% (n = 0/26), 28 20% (n = 1/5) 30 to 35.8% (n = 34/95) 29 . The studies with the highest prevalent cancer rates only included cases where the dysplasia was located within the extent of inflamed mucosa, rather than proximal to it 29,30 . The pooled estimated cancer prevalence rate from all these studies was 13.7% (95% CI: 0.0%‐54.1%).…”

“…Two cohort studies and one case series reported prevalent cancer rates with a pre‐operative diagnosis of visible LGD of 0.0% (n = 0/24), 30 2.5% (n = 2/79) 28 and 7.1% (n = 3/42) 29 . Here, both the studies with the lowest and highest prevalence rates included cases where only dysplasia found within a colitis‐affected segment were included.…”

Nearly a Third of High-Grade Dysplasia and Colorectal Cancer Is Undetected in Patients with Inflammatory Bowel Disease

“…A recent study by Krugliak Cleveland et al [14] found no synchronous adenocarcinomas in patients who underwent colectomy for LGD at a single tertiary care center. In that study, only 1 out of 30 patients with LGD on colonoscopy was upstaged to HGD, and 3 additional patients were found to have one or more synchronous HGD lesions.…”

Histological inflammation increases the risk of colorectal neoplasia in ulcerative colitis: a systematic review

“…While studies included in this review lack specifics about the use of advanced surveillance (such as chromoendoscopy, narrow-band imaging or confocal endomicroscopy), the role of these and other visualization enhancement techniques should be explored to assess for a shift in colorectal neoplasia risks, with perhaps earlier detection and shortened inflammation exposure. 12 …”