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Allen PB, Kamm MA, De Cruz P, Desmond PV. Dysplastic lesions in ulcerative colitis: changing paradigms. Inflamm Bowel Dis 2010; 16:1978-83. [PMID: 20803510 DOI: 10.1002/ibd.21227] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Crohn and Rosenberg first highlighted the increased risk of colorectal cancer in ulcerative colitis in 1925. Cancer rates as high as 34 percent after 30 yrs of disease have been reported in several population-based studies, although the reported risk varies substantially. Lower rates have been reported in: population-versus specialist centre-cohorts, local practices with a high colectomy rate and high 5-aminosalicylate usage, and more recent as opposed to older reports. Despite this variation in reported risk, and lack of controlled evidence for cancer reduction, colonoscopic surveillance programmes are a routine part of care in many centres. Cancer is believed to arise most commonly in dysplastic epithelium, and the detection of either dysplasia or early cancer forms the basis of such programmes. Further confusion stems from the variety of terms used to describe dysplastic change.
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Affiliation(s)
- Patrick B Allen
- St Vincent's Hospital, Department of Gastroenterology, Melbourne, Australia
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102
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Rutter MD. A practical guide and review of colonoscopic surveillance and chromoendoscopy in patients with colitis. Frontline Gastroenterol 2010; 1:126-130. [PMID: 28839562 PMCID: PMC5517179 DOI: 10.1136/fg.2010.001438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2010] [Indexed: 02/04/2023] Open
Abstract
Patients with longstanding extensive colitis have an increased risk of developing colorectal cancer. The British Society of Gastroenterology has recently published revised guidelines for colitis surveillance, taking into account new evidence supporting chromoendoscopy and the endoscopic resection of certain neoplastic lesions. This article reviews some of the evidence behind this paradigm shift and gives a practical guide to chromoendoscopy.
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Affiliation(s)
- Matthew D Rutter
- University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK
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103
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Pekow JR, Hetzel JT, Rothe JA, Hanauer SB, Turner JR, Hart J, Noffsinger A, Huo D, Rubin DT. Outcome after surveillance of low-grade and indefinite dysplasia in patients with ulcerative colitis. Inflamm Bowel Dis 2010; 16:1352-6. [PMID: 20027656 PMCID: PMC3046461 DOI: 10.1002/ibd.21184] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The management of low-grade (LGD) and indefinite dysplasia (IND) in patients with ulcerative colitis (UC) remains controversial, as outcomes after a diagnosis of LGD or IND in previous studies vary widely. METHODS All patients evaluated were from a single institution referral center who had a history of UC and a diagnosis of either LGD or IND between 1994 and 2008 as confirmed by 2 expert gastrointestinal (GI) pathologists. Data were collected by chart review of electronic and paper medical records. All patients who did not undergo a colectomy within 90 days of their dysplasia diagnosis were included in the final analysis. Hazard ratios for risk factors as well as incidence rates and Kaplan-Meier estimates were used to calculate the progression to high-grade dysplasia (HGD) or colorectal cancer (CRC). RESULTS Thirty-five patients were included in the analysis, of whom 2 patients with IND and 2 patients with LGD developed HGD or CRC over a mean duration of 49.8 months. In total, the incident rate for advanced neoplasia for all patients was 2.7 cases of HGD or CRC per 100 person-years at risk. For flat and polypoid LGD the incident rate of advanced neoplasia was 4.3 and 1.5 cases per 100 person-years at risk, respectively. Patients with primary sclerosing cholangitis (PSC) had an incident rate of 10.5 cases per 100 years of patient follow-up. CONCLUSIONS We report a low rate of progression to HGD or CRC in patients who underwent surveillance for LGD or IND; polypoid dysplasia showed less risk of progression than flat dysplasia.
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Affiliation(s)
- Joel R. Pekow
- University of Chicago, Section of Gastroenterology, Hepatology, and Nutrition, Chicago, Illinois
| | - Jeremy T. Hetzel
- University of Chicago, Section of Gastroenterology, Hepatology, and Nutrition, Chicago, Illinois
| | - Jami A. Rothe
- University of Chicago, Section of Gastroenterology, Hepatology, and Nutrition, Chicago, Illinois
| | - Stephen B. Hanauer
- University of Chicago, Section of Gastroenterology, Hepatology, and Nutrition, Chicago, Illinois
| | | | - John Hart
- University of Chicago, Department of Pathology, Chicago, Illinois
| | - Amy Noffsinger
- University of Chicago, Department of Pathology, Chicago, Illinois
| | - Dezheng Huo
- University of Chicago, Department of Health Studies, Chicago, Illinois
| | - David T. Rubin
- University of Chicago, Section of Gastroenterology, Hepatology, and Nutrition, Chicago, Illinois
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104
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Harpaz N, Polydorides AD. Colorectal dysplasia in chronic inflammatory bowel disease: pathology, clinical implications, and pathogenesis. Arch Pathol Lab Med 2010; 134:876-95. [PMID: 20524866 DOI: 10.5858/134.6.876] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
CONTEXT Colorectal cancer, the most lethal long-term complication of chronic inflammatory bowel disease (IBD), is the culmination of a complex sequence of molecular and histologic derangements of the intestinal epithelium that are initiated and at least partially sustained by chronic inflammation. Dysplasia, the earliest histologic manifestation of this process, plays an important role in cancer prevention by providing the first clinical alert that this sequence is underway and serving as an endpoint in colonoscopic surveillance of patients at high risk for colorectal cancer. OBJECTIVE To review the histology, nomenclature, clinical implications, and molecular pathogenesis of dysplasia in IBD. DATA SOURCE Literature review and illustrations from case material. CONCLUSIONS The diagnosis and grading of dysplasia in endoscopic surveillance biopsies play a decisive role in the management of patients with IBD. Although interpathologist variation, endoscopic sampling problems, and incomplete information regarding the natural history of dysplastic lesions are important limiting factors, indirect evidence that surveillance may be an effective means of reducing cancer-related mortality in the population with IBD has helped validate the histologic criteria, nomenclature, and clinical recommendations that are the basis of current practice among pathologists and clinicians. Emerging technologic advances in endoscopy may permit more effective surveillance, but ultimately the greatest promise for cancer prevention in IBD lies in expanding our thus far limited understanding of the molecular pathogenetic relationships between neoplasia and chronic inflammation.
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Affiliation(s)
- Noam Harpaz
- Department of Pathology, The Mount Sinai School of Medicine, New York, New York 10092, USA.
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105
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Ueno Y, Tanaka S, Chayama K. Non-polypoid colorectal neoplasms in ulcerative colitis. Gastrointest Endosc Clin N Am 2010; 20:525-42. [PMID: 20656250 DOI: 10.1016/j.giec.2010.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The incidence of colorectal cancer associated with ulcerative colitis (UC) increases with time. It is imperative to identify dysplasia-associated lesions or masses (DALM) and non-polypoid colorectal neoplasms (NP-CRN) to reduce the morbidity and mortality from colorectal cancer associated with UC. Recent findings suggest most dysplastic lesions in UC can be considered as visible under careful endoscopic observation. To find NP-CRN in UC, the careful examination of well-prepared mucosa and noting subtle differences is necessary. Magnifying chromoendoscopy, therefore, can be useful to endoscopically diagnose these subtle findings. The authors believe that targeted biopsies during chromoendoscopy will increasingly be used and replace random biopsies in the future.
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Affiliation(s)
- Yoshitaka Ueno
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
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106
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Abstract
Ileal pouch-anal anastomosis has clearly diminished the role of colectomy and ileorectal anastomosis (IRA) in the management of patients with ulcerative colitis. Nonetheless, IRA probably still has an appropriate place in highly selected patients, and many others maintain an "out of circuit" rectal remnant after subtotal colectomy. Although symptomatic proctitis is the most common reason for completion proctectomy, these patients are also at a significant risk to develop rectal cancer. Routine surveillance appears to be warranted.
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Affiliation(s)
- Adam Juviler
- Department of Surgery, University of Vermont College of Medicine, Burlington, VT 05401, USA
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107
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Abstract
Patients with ulcerative colitis (UC) are at an increased risk for the development of colorectal cancer (CRC). Unlike sporadic CRC, the cancer in UC patients arises from a focal or multifocal dysplastic mucosa in areas of inflammation. The clinical features of UC-associated cancer are similar to those found in patients with hereditary non-polyposis colorectal cancer. As with other varieties of CRC, UC-associated cancer exhibits a variety of genetic and molecular changes/abnormalities. These abnormalities are however clustered in areas of mucosae with histological abnormalities. The magnitude and timing of these changes are however significantly different. Surveillance and identification of patients at risk for cancer are a challenging problem.
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Affiliation(s)
- Mahmoud N Kulaylat
- Department of Surgery, State University of New York-Buffalo, Kaleida Health, Buffalo General Hospital, Buffalo, New York 14203, USA.
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108
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Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 2010; 105:501-23; quiz 524. [PMID: 20068560 DOI: 10.1038/ajg.2009.727] [Citation(s) in RCA: 903] [Impact Index Per Article: 64.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.
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Affiliation(s)
- Asher Kornbluth
- Samuel Bronfman Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA.
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109
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Farraye FA, Odze RD, Eaden J, Itzkowitz SH. AGA technical review on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology 2010; 138:746-74, 774.e1-4; quiz e12-3. [PMID: 20141809 DOI: 10.1053/j.gastro.2009.12.035] [Citation(s) in RCA: 321] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Francis A Farraye
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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110
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Lübbers H, Mahlke R, Lankisch PG, Stolte M. Follow-up endoscopy in gastroenterology: when is it helpful? DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:30-9. [PMID: 20140171 PMCID: PMC2816788 DOI: 10.3238/aerztebl.2010.0030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 05/26/2009] [Indexed: 01/07/2023]
Abstract
BACKGROUND The indications for follow-up endoscopy have not been established in all diseases that can be diagnosed by endoscopy. METHODS Selective review of the literature and a survey of national guidelines. RESULTS In confirmed erosive or non-erosive reflux disease, follow-up endoscopy is indicated only in the presence of complications or Barrett's esophagus. In the case of gastric ulcer or complicated duodenal ulcer, monitoring by endoscopy is mandatory. There is no consensus regarding the indication for follow-up biopsy in confirmed endemic sprue. In an acute episode of confirmed ulcerative colitis, endoscopy is indicated only if the treatment depends on the findings. In confirmed Crohn's disease, this procedure is indicated only in the presence of complications, if the findings are unclear, and before elective intestinal surgery. Those at risk of hereditary colorectal carcinoma without polyposis should undergo colonoscopy annually, starting 5 years before the youngest age of occurrence in their family or at the age of 25 years, whichever comes first. CONCLUSIONS With particular reference to further gastrointestinal diseases discussed in the main text, this review unfortunately shows that many of the indications for follow-up endoscopy remain to be ascertained. Controlled studies are needed to establish with sufficient certainty what really helps our patients.
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Affiliation(s)
- Heiko Lübbers
- Allgemeine Innere Medizin, Städtisches Klinikum Lüneburg, Lüneburg
| | - Reiner Mahlke
- Allgemeine Innere Medizin, Städtisches Klinikum Lüneburg, Lüneburg
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Abstract
The risk of developing colorectal cancer in patients with colitis-associated dysplasia is considerable. Surveillance programs in patients with ulcerative colitis and Crohn's disease aim to detect dysplastic lesions early and rely heavily on taking random biopsy samples along the length of the colon. Diagnosing dysplasia can be difficult because of the heterogeneous endoscopic appearance of dysplasia and the poor interobserver agreement among pathologists when grading dysplasia. Colitis-associated dysplasia may present as a dysplasia-associated lesion or mass (DALM), which may be indistinguishable from a sporadic adenoma in non-colitic tissue, or may arise in flat mucosa of endoscopically normal appearance. Information about the endoscopic appearance, the colonic distribution and the histopathological grade of colitis-associated dysplasia is required to define the optimal treatment. This Review summarizes the endoscopic and histopathological features of colitis-associated dysplasia and the requirements for optimal interaction between endoscopists and pathologists, with the aim of reducing the uncertainties in the diagnosis of dysplastic lesions and improving the management of colitis-associated dysplasia.
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112
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Adherence to guidelines for surveillance colonoscopy in patients with ulcerative colitis at a Canadian quaternary care hospital. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:613-7. [PMID: 19816624 DOI: 10.1155/2009/691850] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with ulcerative colitis (UC) are at high risk of colonic dysplasia. Therefore, surveillance colonoscopy to detect early dysplasia has been endorsed by many professional organizations. OBJECTIVES To determine whether gastroenterologists at Hamilton Health Sciences (Hamilton, Ontario) adhere to recommendations for UC surveillance issued by the Canadian Association of Gastroenterology and to retrospectively assess the incidence and type of dysplasia found and the subsequent outcome of patients with dysplasia (ie, colorectal cancer [CRC], colectomy, dysplasia recurrence). METHODS A retrospective chart review of all patients with UC undergoing colonoscopy screening at Hamilton Health Sciences from January 1980 to January 2005, was performed. Patients were classified by the extent of colonic disease: limited left-sided colitis (LSC), pancolitis and any disease extent with concurrent primary sclerosing cholangitis. RESULTS A total of 141 patients fulfilled eligibility criteria. They underwent 921 endoscopies, including 453 for surveillance, which were performed by 20 endoscopists. Overall, screening was performed on 90% of patients, and surveillance at the appropriate time in 74%. There was a statistically significant increase in the mean number of biopsies per colonoscopy after the guidelines were published (P<0.01 for all categories). Colonic dysplasia was detected in 24 of 141 patients (17.0%), with 17 of 24 (70.8%) found at surveillance. Two patients (8.3%) had CRC successfully treated. The average age of patients with dysplasia was 56.1 years, with a mean disease duration of 10.9 years in LSC versus 11.8 years in pancolitis (P not significant). Colectomy was not recommended for any patient with flat dysplasia. No patients progressed to high-grade dysplasia or CRC. Patients with pancolitis had a higher incidence of neoplasia (21% [18 of 86]) than patients with LSC (12% [6 of 49]; P=0.24). Forty-one patients (29.5%) had at least one hyperplastic or inflammatory polyp. CONCLUSIONS For the majority of patients who underwent surveillance colonoscopies, their procedures were performed within the recommended time intervals, and biopsy compliance has improved. Dysplasia tended to arise after approximately 10 years of disease duration and in middle age, with flat dysplasia being rare. Interventions resulted in no dysplasia progressing to CRC, implying successful prevention.
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113
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Barthet M, Desjeux A, Grimaud JC. [Chromoendoscopy in inflammatory bowel disease]. ACTA ACUST UNITED AC 2009; 33:F7-11. [PMID: 19762184 DOI: 10.1016/j.gcb.2009.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The risk of colorectal cancer in case of IBD-related pancolitis reaches 2% after 10 years follow-up, 8% after 20 years up to 18% at 30 years, and was probably over-estimated in the first series. Chromoendoscopy appears to be helpful in the surveillance of IBD, and moreover recommended, using carmine indigo or methylene blue with a well-standardized procedure. Its place regarding other techniques like virtual coloration has to be clarified with randomized studies. The chromoendoscopy allows the operator to perform targeted biopsies, which appear to be more efficient for the detection of dysplasia than systematic biopsies performed every 10 cm. Nevertheless, it is too soon to remove systematic biopsies from scientific recommendations.
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Affiliation(s)
- M Barthet
- Service de gastroentérologie, hôpital Nord, chemin des Bourrely, Marseille cedex 20, France.
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114
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Nguyen GC, Frick KD, Dassopoulos T. Medical decision analysis for the management of unifocal, flat, low-grade dysplasia in ulcerative colitis. Gastrointest Endosc 2009; 69:1299-310. [PMID: 19249771 DOI: 10.1016/j.gie.2008.08.042] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 08/29/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Management of unifocal, flat, low-grade dysplasia (LGD) in ulcerative colitis (UC) remains controversial. OBJECTIVE To compare the relative costs and effectiveness of immediate colectomy and enhanced colonoscopic surveillance for the management of LGD. DESIGN AND SETTING Medical decision analysis by using state-transition Markov models. Transition probabilities and health utilities were derived from the literature, and costs were derived from national hospital data sets and Medicare and/or Medicaid reimbursement schedules. PATIENTS Two simulated cohorts of 10,000 patients with longstanding UC who were newly diagnosed with unifocal, flat LGD on initial surveillance colonoscopy. INTERVENTIONS Immediate colectomy or enhanced surveillance (repeated colonoscopy at 3, 6, and 12 months, and then annually). MAIN OUTCOME MEASUREMENTS Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. RESULTS Immediate colectomy dominated over enhanced surveillance and yielded higher QALYs (20.1 vs 19.9 years) and lower costs ($75,900 vs $83,900). These findings were robust to variations in model parameters, with immediate colectomy remaining dominant in 90% of simulations in sensitivity analysis. Varying postcolectomy health utility outside the range in the probabilistic sensitivity analysis rendered enhanced surveillance cost effective. When the health utility was below 0.77, the incremental cost-effectiveness ratio was $50,000 per QALY. LIMITATIONS Data based on observational studies and analyses rely on model assumptions. CONCLUSIONS Our analysis showed that immediate colectomy was preferable to enhanced surveillance. Health preference toward the postcolectomy state is, however, an influential factor. This decision analysis model provides a conceptual framework for physicians and patients to understand the relative benefits and costs of both interventions.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital IBD Centre, University of Toronto, Toronto, Ontario, Canada.
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115
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Campbell F, Maxwell R. Rationale for cancer prevention strategies in high-risk ulcerative colitis. Surgeon 2009; 7:96-100. [DOI: 10.1016/s1479-666x(09)80024-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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116
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Ullman T, Odze R, Farraye FA. Diagnosis and management of dysplasia in patients with ulcerative colitis and Crohn's disease of the colon. Inflamm Bowel Dis 2009; 15:630-8. [PMID: 18942763 PMCID: PMC2753500 DOI: 10.1002/ibd.20766] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
To minimize the possibility of developing lethal colorectal cancer (CRC) in ulcerative colitis (UC) and Crohn's colitis, patients are usually enrolled in a program of dysplasia surveillance. The success of a surveillance program depends on the identification of patients with dysplasia and timely referral for colectomy. While a number of issues might stand in the way of a surveillance system achieving its maximal effect (less than ideal agreement in the interpretation of biopsy specimens, sampling error by endoscopists, delays in referral to surgery, and patient drop-out among others), circumstantial evidence supports the concept that colonoscopic dysplasia surveillance is an effective means of reducing CRC mortality and morbidity while minimizing the application of colectomy for cancer prevention. This review critically appraises key issues in the diagnosis and management of dysplasia in UC and Crohn's disease as well as adjunct efforts to prevent CRC in inflammatory bowel disease.
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Affiliation(s)
- Thomas Ullman
- Mount Sinai School of Medicine, New York, New York, USA
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117
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Abstract
The risk of developing colorectal cancer (CRC) is influenced by several acquired risk factors, including environmental exposures and comorbid medical conditions that are partially genetic in nature. These risk factors are based on data almost exclusively derived from observational studies. Because of the possibility of bias due to confounding, these acquired risk factors should not be automatically assumed to be causative, and in fact some may not be truly independent risk factors. Acquired risk factors include the following categories: 1) dietary factors, 2) lifestyle factors, 3) side-effects of medical interventions, and 4) comorbid medical conditions. Dietary factors that potentially increase the risk of CRC include low fruit, vegetable, or fiber intake, high red meat or saturated fat consumption, and exposure to caffeine or alcohol. Of these factors, the significance of low fruit, vegetable, and fiber intake has been called into question because of contradictory results from large observational studies and negative results from randomized trials. The association of high red meat or saturated fat consumption with increased CRC risk is supported by the preponderance of observational data. Lifestyle factors include lack of exercise and smoking. These risk factors are supported by observational data of moderate quality. Medical interventions that may increase the risk of CRC include pelvic irradiation, cholecystectomy, and ureterocolic anastomosis after major surgery of the urinary and intestinal tracts. Aside from cholecystectomy, these risk factors are supported by observational data from small studies only, therefore their validity is not well established. Finally, comorbid medical conditions that are associated with increased risk of CRC include Barrett's esophagus, human immunodeficiency virus infection, acromegaly, and inflammatory bowel disease. The association between inflammatory bowel disease and CRC is well established and it forms the basis for widely adopted colonoscopic surveillance recommendations from national medical organizations. The other factors are supported by limited observational data only and are still controversial.
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Affiliation(s)
- Otto S Lin
- Virginia Mason Medical Center, Digestive Diseases Institute, Seattle, WA, USA
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118
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Ahmadi A, Polyak S, Draganov PV. Colorectal cancer surveillance in inflammatory bowel disease: The search continues. World J Gastroenterol 2009; 15:61-6. [PMID: 19115469 PMCID: PMC2653296 DOI: 10.3748/wjg.15.61] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with inflammatory bowel disease (IBD) are at increased risk for colorectal cancer (CRC). Risk factors for the development of CRC in the setting of IBD include disease duration, anatomic extent of disease, age at time of diagnosis, severity of inflammation, family history of colon cancer, and concomitant primary sclerosing cholangitis. The current surveillance strategy of surveillance colonoscopy with multiple random biopsies most likely reduces morbidity and mortality associated with IBD-related CRC. Unfortunately, surveillance colonoscopy also has severe limitations including high cost, sampling error at time of biopsy, and interobserver disagreement in histologically grading dysplasia. Furthermore, once dysplasia is detected there is disagreement about its management. Advances in endoscopic imaging techniques are already underway, and may potentially aid in dysplasia detection and improve overall surveillance outcomes. Management of dysplasia depends predominantly on the degree and focality of dysplasia, with the mainstay of management involving either proctocolectomy or continued colonoscopic surveillance. Lastly, continued research into additional chemopreventive agents may increase our arsenal in attempting to reduce the incidence of IBD-associated CRC.
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120
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Shin US, Yu CS, Kim CW, Park JS, Jeong KY, Yoon SN, Lim SB, Song JS, Kim JC. Malignancy Associated with Inflammatory Bowel Disease. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2009. [DOI: 10.3393/jksc.2009.25.3.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ui Sup Shin
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chan Wook Kim
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Seok Park
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kwang Yong Jeong
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Nam Yoon
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seok-byung Lim
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Joon Seon Song
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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121
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Velayos F. Colon cancer surveillance in inflammatory bowel disease patients: current and emerging practices. Expert Rev Gastroenterol Hepatol 2008; 2:817-25. [PMID: 19090741 DOI: 10.1586/17474124.2.6.817] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Colorectal cancer (CRC) is a feared complication of inflammatory bowel disease (IBD). The cumulative probability of developing this malignancy is significantly higher than in the general population, making IBD the third highest risk condition for CRC. Since CRC is such a concerning complication, it should be no surprise that patients and physicians want to know what the most important risk factors are for its development, as well as potential strategies for reducing these risks. This article reviews the current practice and emerging technologies for detecting and preventing colon cancer in patients with IBD.
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Affiliation(s)
- Fernando Velayos
- University of California, San Francisco, Center for Crohn's and Colitis, 2330 Post Street, Suite 610, San Francisco, CA 94116, USA.
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122
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Hirata I. The present status and problems with diagnosis and management of dysplasia/colitic cancer in ulcerative colitis. Clin J Gastroenterol 2008; 1:139-144. [DOI: 10.1007/s12328-008-0043-y] [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: 10/06/2008] [Accepted: 10/08/2008] [Indexed: 01/07/2023]
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123
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Kuester D, Dalicho S, Mönkemüller K, Benedix F, Lippert H, Guenther T, Roessner A, Meyer F. Synchronous multifocal colorectal carcinoma in a patient with delayed diagnosis of ulcerative pancolitis. Pathol Res Pract 2008; 204:905-10. [PMID: 18842350 DOI: 10.1016/j.prp.2008.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 07/07/2008] [Indexed: 01/04/2023]
Abstract
Patients with ulcerative colitis face an increased lifetime risk of developing colorectal cancer. Relatively often, the patients present with multiple synchronous or metachronous tumors. Here, we report a case of ulcerative colitis-associated synchronous multifocal colorectal carcinomas. A 36-year-old male presented with symptoms of persisting abdominal pain that had lasted for several months. Histology of the colonic biopsies showed active ulcerative pancolitis with extensive multifocal low- and high-grade dysplasia. Regardless of the diagnosis and medical advice, the patient initially refused therapy, and proctocolectomy was delayed for 12 months. In the resection specimen, four clinically unsuspected, partly mucinous adenocarcinomas accompanied by several foci of low- and high-grade dysplasia were found in the left colon and rectum. At the time of colectomy, advanced tumor stage was diagnosed and classified as pT3c(4) pN1(2/120) M0 V1 R0, UICC stage IIIB, G2. Furthermore, a mucinous cystadenoma was found in the appendix in the setting of ulcerative colitis. We discuss the neoplastic transformation, current surveillance guidelines, and the therapeutic management in ulcerative colitis.
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Affiliation(s)
- Doerthe Kuester
- Department of Pathology, Otto-von-Guericke University, Leipziger Strasse 44, 39120 Magdeburg, Germany.
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124
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Smith LA, Baraza W, Tiffin N, Cross SS, Hurlstone DP. Endoscopic resection of adenoma-like mass in chronic ulcerative colitis using a combined endoscopic mucosal resection and cap assisted submucosal dissection technique. Inflamm Bowel Dis 2008; 14:1380-6. [PMID: 18465807 DOI: 10.1002/ibd.20497] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Resection of an adenoma-like mass (ALM) in chronic ulcerative colitis (CUC) complicated by mucosal fibrosis has historically not been technically feasible. Endoscopic submucosal dissection techniques may now provide a therapeutic tool enabling the division of submucosal fibrotic scarring, hence enabling endoluminal resection for the first time in this select patient group. The aim was prospective evaluation of endoscopic submucosal dissection-assisted (ESD) resection of flat, sessile, and lateral spreading tumors in CUC complicated by submucosal desmoplasis. Clinical endpoints were postresection recurrence rates, R0 resection status, and complications. METHODS ESD-assisted endoscopic mucosal resection (EMR) using the Olympus KD-630L insulation-tipped knife was performed on selected lesions. RESULTS Sixty-nine patients met inclusion criteria, of which 2 were excluded due to follow-up default. En bloc resection was performed in 52/67 (78%) cases with 15/67 (7%) requiring a piecemeal approach. R0 resection was achieved in 49/52 (94%) of lesions undergoing en bloc resection (perforation rate 2/67 [3%]). Bleeding complications occurred in 7/67 (10%) of cases. No metachronous circumscribed intraepithelial neoplastic lesions or cancer was detected at follow-up. At a median of 18 months follow-up, overall cure rates for the ESD-assisted EMR cohort was 66/67 (98%). CONCLUSIONS We have shown for the first time that endoscopic resection of ALM even in the presence of complicating mucosal fibrosis is technically achievable using a combined ESD-assisted EMR technique. In an appropriately selected cohort, this technique may provide a technically feasible and clinically acceptable therapy where otherwise colectomy would be required.
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Affiliation(s)
- Lesley-Ann Smith
- Department of Gastroenterology, General Infirmary at Leeds, Leeds, UK
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125
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Dhir M, Montgomery EA, Glöckner SC, Schuebel KE, Hooker CM, Herman JG, Baylin SB, Gearhart SL, Ahuja N. Epigenetic regulation of WNT signaling pathway genes in inflammatory bowel disease (IBD) associated neoplasia. J Gastrointest Surg 2008; 12:1745-53. [PMID: 18716850 PMCID: PMC3976145 DOI: 10.1007/s11605-008-0633-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 07/16/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION WNT signaling pathway dysregulation is an important event in the pathogenesis of colorectal cancer (CRC) with APC mutations seen in more than 80% of sporadic CRC. However, such mutations in the WNT signaling pathway genes are rare in inflammatory bowel disease (IBD) associated neoplasia (dysplasia and cancer). This study examined the role of epigenetic silencing of WNT signaling pathway genes in the pathogenesis of IBD-associated neoplasia. METHODS Paraffin-embedded tissue samples were obtained and methylation of ten WNT signaling pathway genes, including APC1A, APC2, SFRP1, SFRP2, SFRP4, SFRP5, DKK1, DKK3, WIF1 and LKB1, was analyzed. Methylation analysis was performed on 41 IBD samples, 27 normal colon samples (NCs), and 24 sporadic CRC samples. RESULTS Methylation of WNT signaling pathway genes is a frequent and early event in IBD and IBD-associated neoplasia. A progressive increase in the percentage of methylated genes in the WNT signaling pathway from NCs (4.2%) to IBD colitis (39.7%) to IBD-associated neoplasia (63.4%) was seen (NCs vs. IBD colitis, p < 0.01; IBD colitis vs. IBD-associated neoplasia, p = 0.01). In the univariate logistic regression model, methylation of APC2 (OR 4.7, 95% CI: 1.1-20.63, p = 0.04), SFRP1 (OR 5.1, 95% CI: 1.1-31.9, p = 0.04), and SFRP2 (OR 5.1, 95% CI: 1.1-32.3, p = 0.04) was associated with progression from IBD colitis to IBD-associated neoplasia, while APC1A methylation was borderline significant (OR 4.1, 95% CI: 0.95-17.5, p = 0.06). In the multivariate logistic regression model, methylation of APC1A and APC2 was more likely to be associated with IBD-associated neoplasia than IBD colitis. (OR APC1A: 6.4, 95% CI: 1.1-37.7 p = 0.04; OR APC2 9.1, 95% CI: 1.3-61.7, p = 0.02). SUMMARY Methylation of the WNT signaling genes is an early event seen in patients with IBD colitis and there is a progressive increase in methylation of the WNT signaling genes during development of IBD-associated neoplasia. Moreover, methylation of APC1A, APC2, SFRP1, and SFRP2 appears to mark progression from IBD colitis to IBD-associated neoplasia, and these genes may serve as biomarkers for IBD-associated neoplasia.
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Affiliation(s)
- Mashaal Dhir
- Department of Surgery, Johns Hopkins University, Baltimore, MD 21231, USA
| | | | - Sabine C. Glöckner
- Department of Surgery, Johns Hopkins University, Baltimore, MD 21231, USA
| | - Kornel E. Schuebel
- Department of Oncology, Johns Hopkins University, Baltimore, MD 21231, USA
| | - Craig M. Hooker
- Department of Oncology, Johns Hopkins University, Baltimore, MD 21231, USA
| | - James G. Herman
- Department of Oncology, Johns Hopkins University, Baltimore, MD 21231, USA
| | - Stephen B. Baylin
- Department of Oncology, Johns Hopkins University, Baltimore, MD 21231, USA
| | - Susan L. Gearhart
- Department of Surgery, Johns Hopkins University, Baltimore, MD 21231, USA. Blalock 658, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Nita Ahuja
- Department of Surgery, Johns Hopkins University, Baltimore, MD 21231, USA. Department of Oncology, Johns Hopkins University, Baltimore, MD 21231, USA. 1650 Orleans Street, CRB 1 Room 342, Baltimore, MD 21287, USA
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126
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Potack J, Itzkowitz SH. Colorectal cancer in inflammatory bowel disease. Gut Liver 2008; 2:61-73. [PMID: 20485613 DOI: 10.5009/gnl.2008.2.2.61] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 08/27/2008] [Indexed: 12/14/2022] Open
Abstract
Patients with long-standing inflammatory bowel disease have an increased risk of developing colorectal cancer (CRC). CRC risk increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and severity of inflammation of the colon. Chemoprevention includes aminosalicylates, ursodeoxycholic acid, and possibly folic acid. To reduce CRC mortality in IBD, colonoscopic surveillance remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal-anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.
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Affiliation(s)
- Jonathan Potack
- Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, New York City, United States
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127
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Intraepitheliale Neoplasie/Dysplasie – Diagnose bei Colitis ulcerosa. DER PATHOLOGE 2008; 29 Suppl 2:280-5. [DOI: 10.1007/s00292-008-1057-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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128
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Simpson P, Papadakis KA. Endoscopic evaluation of patients with inflammatory bowel disease. Inflamm Bowel Dis 2008; 14:1287-97. [PMID: 18300282 DOI: 10.1002/ibd.20398] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Endoscopy plays a critical role in the diagnosis and management of inflammatory bowel disease (IBD). This article reviews the utility of endoscopy in the diagnosis of ulcerative colitis (UC) and Crohn's disease (CD), recommendations for cancer surveillance, and the use of newer techniques for the enhanced detection of dysplasia in chronic UC. Finally, the use of endoscopy for the management of certain complications of IBD is also discussed.
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Affiliation(s)
- Peter Simpson
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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129
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Abstract
Patients with long-standing inflammatory bowel disease (IBD) have an increased risk of developing colorectal cancer (CRC). Many of the molecular alterations responsible for sporadic colorectal cancer, namely chromosomal instability, microsatellite instability, and hypermethylation, also play a role in colitis-associated colon carcinogenesis. Colon cancer risk in inflammatory bowel disease increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and degree of inflammation of the bowel. Chemoprevention includes aminosalicylates, ursodeoxycholic acid, and possibly folic acid and statins. To reduce CRC mortality in IBD, colonoscopic surveillance with random biopsies remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Patients with small intestinal Crohn's disease are at increased risk of small bowel adenocarcinoma. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal-anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. Other extra intestinal cancers, such as hepatobiliary and hematopoietic cancer, have shown variable incidence rates. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.
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Affiliation(s)
- Jianlin Xie
- GI Division, Mount Sinai School of Medicine, One Gustave Levy Place, New York City, NY 10029, USA
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130
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Abstract
Both ulcerative colitis and Crohn’s disease carry an increased risk of developing colorectal cancer. Established risk factors for cancer among patients with inflammatory bowel disease (IBD) include the younger age at diagnosis, greater extent and duration of disease, increased severity of inflammation, family history of colorectal cancer and coexisting primary sclerosing cholangitis. Recent evidence suggests that current medical therapies and surgical techniques for inflammatory bowel disease may be reducing the incidence of this complication. Nonetheless heightened vigilance and a careful, comprehensive approach to prevent or minimize the complications of invasive cancer are warranted in this unique cohort of patients. Current guidelines for the prevention and early detection of cancer in this high risk population are grounded in the concept of an inflammation-dysplasia-carcinoma sequence. A thorough understanding of the definition and natural history of dysplasia in IBD, as well as the challenges associated with detection and interpretation of dysplasia are fundamental to developing an effective strategy for surveillance and prevention, and understanding the limitations of the current approach to prevention. This article reviews the current consensus guidelines for screening and surveillance of cancer in IBD, as well as presenting the evidence and rationale for chemoprevention of cancer and a discussion of emerging technologies for the detection of dysplasia.
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131
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Stenling R, Lindberg J, Rutegård J, Palmqvist R. Altered expression of CK7 and CK20 in preneoplastic and neoplastic lesions in ulcerative colitis. APMIS 2008; 115:1219-26. [PMID: 18092953 DOI: 10.1111/j.1600-0643.2007.00664.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study is based on all patients with ulcerative colitis from a defined catchment area in Northern Sweden in a still ongoing colonoscopy surveillance programme, which started in 1977. From this material we selected tissue from eight groups of patients consisting of normal control biopsies (5), inactive colitis (10), active colitis (10), findings of low-grade dysplasia (10), high-grade dysplasia (6), aneuploidy (without dysplasia and with subsequent dysplasia) (10), and ulcerative colitis-associated cancers (5). The samples were evaluated according to immunohistochemical expression of CK7 and CK20. Colonic mucosa from normal controls and inactive colitis was found to be completely negative for CK7. In 9 out of 10 patients with active colitis, CK7 was sparsely expressed in a patchy manner and connected with active epithelial inflammatory areas. 7 out of 10 patients with low-grade dysplasia and 3 out of 6 with high-grade dysplasia were positive for CK7. Samples with aneuploidy without dysplasia were completely negative, while 2 out of 6 showing subsequent dysplasia were positive. Of the five cancers, two were positive for CK7. CK20 was expressed in nearly all samples but relatively more in the lower part of the crypts in neoplasia-associated lesions. Our results indicate a possible relationship between expression of CK7 and CK20 and neoplastic development of colorectal mucosa in patients with ulcerative colitis. Further studies are needed to elucidate whether these findings have clinical significance.
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Affiliation(s)
- Roger Stenling
- Dept. of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden.
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132
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Biancone L, Michetti P, Travis S, Escher JC, Moser G, Forbes A, Hoffmann JC, Dignass A, Gionchetti P, Jantschek G, Kiesslich R, Kolacek S, Mitchell R, Panes J, Soderholm J, Vucelic B, Stange E. European evidence-based Consensus on the management of ulcerative colitis: Special situations. J Crohns Colitis 2008; 2:63-92. [PMID: 21172196 DOI: 10.1016/j.crohns.2007.12.001] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2007] [Accepted: 12/30/2007] [Indexed: 02/08/2023]
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133
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Konda A, Duffy MC. Surveillance of patients at increased risk of colon cancer: inflammatory bowel disease and other conditions. Gastroenterol Clin North Am 2008; 37:191-213, viii. [PMID: 18313546 DOI: 10.1016/j.gtc.2007.12.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Colorectal cancer (CRC) is the second most common cause of cancer-related mortality in the United States. Colonoscopic screening with removal of adenomatous polyps in individuals at average risk is known to decrease the incidence and associated mortality from colon cancer. Certain conditions, notably inflammatory bowel disease involving the colon, a family history of polyps or cancer, a personal history of colon cancer or polyps, and other conditions such as acromegaly, ureterosigmoidostomy, and Streptococcus bovis bacteremia are associated with an increased risk of colonic neoplasia. This article reviews the CRC risks associated with these conditions and the currently recommended surveillance strategies.
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Affiliation(s)
- Amulya Konda
- Division of Gastroenterology, William Beaumont Hospital, 3535 West 13 Mile Road, Royal Oak, MI 48076, USA
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134
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Abstract
Inflammatory bowel disease (IBD) in elderly individuals is associated with a unique set of challenges, some of which are related to age. This article examines the diagnosis and management of IBD in the context of recent advances in the understanding of its pathogenesis, and newer therapeutic modalities that have been possible from these advances.
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Affiliation(s)
- Prabhakar P Swaroop
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8887, USA.
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135
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Phelip JM, Ducros V, Faucheron JL, Flourie B, Roblin X. Association of hyperhomocysteinemia and folate deficiency with colon tumors in patients with inflammatory bowel disease. Inflamm Bowel Dis 2008; 14:242-8. [PMID: 17941074 DOI: 10.1002/ibd.20309] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Folate deficiency associated with hyperhomocysteinemia might increase the risk of developing colorectal cancer. The aim of this study was to evaluate factors associated with colonic carcinogenesis, in particular, folate and homocysteinemia levels, in a cross-sectional study of patients with inflammatory bowel disease (IBD). METHODS IBD patients with carcinogenic lesions discovered during colonoscopy [dysplasia-associated lesion or masses (DALM), colorectal cancer] were included and compared with the whole population of IBD patients with a normal colonoscopy performed during the same period. The following parameters were collected at the time of colonoscopy: age, sex, type, duration, activity, and extent of the disease, treatment, smoking status, and vitamin B12, folate, and homocysteinemia levels. Univariate and multivariate analyses were performed after adjusting for the main parameters. RESULTS One hundred and fourteen patients [41 with ulcerative colitis (UC), 73 with Crohn's disease (CD)] were included. Twenty-six carcinogenic lesions were isolated: 18 DALM (7 high-grade and 11 low-grade dysplasia) and 8 colorectal cancers. In univariate analysis, the factors associated with carcinogenesis were: active smoking (P = 0.03), folate level < 145 pmol/L (P = 0.02), hyperhomocysteinemia > 15 micromol/L (P = 0.003), duration of disease > 10 years (P = 0.006), and UC (P = 0.02). In multivariate analysis, patients with hyperhomocysteinemia associated with folate deficiency had 17 times as many carcinogenic lesions as patients with normal homocysteinemia whatever the folate status and duration of the disease (P = 0.01). Patients with hyperhomocysteinemia without folate deficiency had 2.5 times as many carcinogenic lesions as patients with normal homocysteinemia (P = 0.08). CONCLUSIONS Our data suggest that in IBD patients with normal homocysteinemia, the increase in carcinogenic risk is negligible. Conversely, in patients with hyperhomocysteinemia, folate deficiency may be associated with increased colorectal carcinogenesis in IBD patients.
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Affiliation(s)
- Jean Marc Phelip
- Department of Gastroenterology, University Hospital of Grenoble, France.
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136
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Stephens JH, Moore JWE. Can targeted intervention in CRC patients' relatives influence screening behaviour? A pilot study. Colorectal Dis 2008; 10:179-86. [PMID: 17459064 DOI: 10.1111/j.1463-1318.2007.01258.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This study aimed to assess the utility of a standardised risk information tool with respect to the uptake of screening activities administered to an accessible population of first-degree relatives of patients with sporadic colorectal cancer. METHOD Patients admitted for colorectal cancer resection were invited to enroll their family unit in the study. Families were randomised either to receive standard care or the intervention tool. The intervention group received a structured one page pamphlet outlining the risk associated with a family history of colorectal cancer, and the availability of and potential benefits from screening. Three months after the initial contact with the index patient, family members were invited to participate in a telephone interview. Primary end-points were both intention to screen and uptake of screening activities. RESULTS Forty-seven families had 156 eligible first degree relatives. Ninety-one consented to participate and were enrolled: 59 received standard care, 32 received the intervention. Age and sex were similar between groups. There was no significant difference in previous screening activities. The intervention tool had no influence on perceived self-risk of developing colorectal cancer or uptake of screening activities within the study period. CONCLUSION This study suggests that the provision of targeted risk information to first-degree relatives is not likely to positively influence screening behaviour. Health care providers need to find alternative methods of disseminating information to this high-risk group.
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Affiliation(s)
- J H Stephens
- Colorectal Surgical Unit, Gastrointestinal Services, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia.
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137
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Nathanson JW, Yadron NE, Farnan J, Kinnear S, Hart J, Rubin DT. p53 mutations are associated with dysplasia and progression of dysplasia in patients with Crohn's disease. Dig Dis Sci 2008; 53:474-80. [PMID: 17676397 DOI: 10.1007/s10620-007-9886-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2006] [Accepted: 05/21/2007] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mutations in the tumor suppressor gene p53 are associated with neoplasia in ulcerative colitis, but little is understood of their significance in Crohn's disease (CD). PURPOSE To explore p53 expression as a marker of neoplasia in CD patients. METHODS This is a retrospective review of CD patients who underwent p53 IHC staining in our center between 1995 and 2003. The p53 status was correlated to the presence and grade of neoplasia at the time of staining and in subsequent follow-up. RESULTS Fourteen CD patients had p53 assessment: eight were p53 positive and six were p53 negative. Seven of eight p53+ had dysplasia (six LGD, one HGD); one of six p53-had dysplasia (LGD) (P = 0.03). Four p53+ patients with follow-up had persistent dysplasia and two had progression to a higher grade. Three p53- patients with follow-up remained free of dysplasia. CONCLUSIONS This limited study shows that p53 over expression in CD patients is associated with dysplasia that may progress to a higher grade of neoplasia over time.
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Affiliation(s)
- Jeffrey W Nathanson
- Reva and David Logan Gastrointestinal Clinical Research Center at the University of Chicago, Chicago, IL, USA
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138
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Rubin DT, Cruz-Correa MR, Gasche C, Jass JR, Lichtenstein GR, Montgomery EA, Riddell RH, Rutter MD, Ullman TA, Velayos FS, Itzkowitz S. Colorectal cancer prevention in inflammatory bowel disease and the role of 5-aminosalicylic acid: a clinical review and update. Inflamm Bowel Dis 2008; 14:265-74. [PMID: 17932965 DOI: 10.1002/ibd.20297] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A roundtable consensus meeting was held to consolidate current knowledge on the etiology of colorectal cancer in patients with inflammatory bowel disease and to review current strategies, both diagnostic and preventive, specifically addressing the role of 5-aminosalicylic acid. Specific topics that were addressed included: the epidemiology of colorectal cancer, including an assessment of risk factors and the impact of colonoscopy on colorectal cancer incidence and mortality; the origin and evolution of dysplasia nomenclature and the natural history of dysplasia; review of the experience of St. Mark's Hospital (London) as gleaned from its surveillance database; mechanisms by which 5-aminosalicylic acid is thought to exert a chemopreventive effect; the potential future role of 5-aminosalicylic acid in chemopreventive strategies; chemoprevention in familial adenomatous polyposis; and other future research directions. This article provides a comprehensive overview of the issues discussed and should act as a guide to shaping the design of future studies in this area.
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Affiliation(s)
- David T Rubin
- University of Chicago Medical Center, Chicago, IL 60637, USA.
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139
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Abstract
Patients with long-standing inflammatory bowel disease (IBD) have an increased risk of developing colorectal cancer (CRC). Many of the molecular alterations responsible for sporadic colorectal cancer, namely chromosomal instability, microsatellite instability, and hypermethylation, also play a role in colitis-associated colon carcinogenesis. Colon cancer risk in inflammatory bowel disease increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and degree of inflammation of the bowel. Chemoprevention includes aminosalicylates, ursodeoxycholic acid, and possibly folic acid and statins. To reduce CRC mortality in IBD, colonoscopic surveillance with random biopsies remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Patients with small intestinal Crohn’s disease are at increased risk of small bowel adenocarcinoma. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal-anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. Other extra intestinal cancers, such as hepatobiliary and hematopoietic cancer, have shown variable incidence rates. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.
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140
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HIBI T, IWAO Y, YOSHIOKA M. Preventive Medical Examinations for Colorectal Cancer in Japan to Reduce Mortality from Colorectal Cancer. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1997.tb00451.x] [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] [Indexed: 02/23/2023]
Affiliation(s)
- Toshifumi HIBI
- Keio Cancer Center and Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Yasushi IWAO
- Keio Cancer Center and Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Masahiro YOSHIOKA
- Department of Gastroenterology, National Health Insurance Minamitama Hospital, Tokyo, Japan
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141
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Harpaz N. Neoplastic precursor lesions related to the development of cancer in inflammatory bowel disease. Gastroenterol Clin North Am 2007; 36:901-26, vii-viii. [PMID: 17996797 DOI: 10.1016/j.gtc.2007.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Dysplasia is an intermediate stage in the progression from inflammation to cancer in patients with inflammatory bowel disease. Clinically, dysplasia is used to define appropriate endpoints for colectomy in high-risk patients undergoing endoscopic surveillance. Surveillance is currently the only credible alternative to prophylactic colectomy for high-risk patients. The success of surveillance can be maximized by adherence of gastroenterologists to recommended procedural guidelines, adherence of pathologists to standardized histological criteria and nomenclature, and a joint commitment to close clinical-pathological communication. Technical enhancements to conventional endoscopy hold promise of improved efficiency and accuracy. Molecular-based testing may have a future role for risk stratification and early detection of neoplasia in inflammatory bowel disease.
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Affiliation(s)
- Noam Harpaz
- Division of Gastrointestinal Pathology, Department of Pathology, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA.
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142
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Vleggaar FP, Lutgens MWMD, Claessen MMH. Review article: The relevance of surveillance endoscopy in long-lasting inflammatory bowel disease. Aliment Pharmacol Ther 2007; 26 Suppl 2:47-52. [PMID: 18081648 DOI: 10.1111/j.1365-2036.2007.03487.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Development of colitis-associated colorectal cancer is an important clinical problem in patients with colonic inflammatory bowel disease (IBD). British and American guidelines recommend to start surveillance after a disease duration of 8-10 or 15-20 years for patients with extensive or left-sided colitis, respectively. AIM To assess the evidence level of current surveillance strategies. METHODS A PubMed-based literature search using the search terms inflammatory bowel disease, ulcerative colitis, Crohn's disease, dysplasia, colorectal cancer and surveillance was performed. RESULTS Low-grade and high-grade dysplastic lesions progress to cancer in a high percentage of patients. Furthermore, concurrent cancer is found in approximately one-third of the patients with colonic dysplasia. Low-level evidence showing reduced colorectal cancer-related mortality in patients who were undergoing surveillance is available. Patients with concomitant primary sclerosing cholangitis form a subgroup of IBD patients with an even higher risk of colorectal neoplasia. CONCLUSIONS Colonic surveillance prolongs life expectancy of patients with long-lasting IBD.
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Affiliation(s)
- F P Vleggaar
- Department of Gastroenterology, University Medical Center Utrecht, The Netherlands.
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143
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Inflammatory bowel disease: the problems of dysplasia and surveillance. Tech Coloproctol 2007; 11:299-309. [DOI: 10.1007/s10151-007-0386-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2006] [Accepted: 02/04/2007] [Indexed: 01/07/2023]
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144
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Salas Caudevilla A. [Evaluation of dysplasia in gastrointestinal diseases]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:602-11. [PMID: 18028857 DOI: 10.1157/13112598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Dysplasia, or intraepithelial neoplasia, consists of noninvasive neoplastic cellular proliferation that may precede or accompany invasive neoplasia. Diagnosis is mainly based on histological criteria, which include cytological and structural alterations, since macroscopically identifiable lesions often do not occur. In all current classifications, dysplasia is divided in two categories, low- and high-grade, with the aim of attempting to evaluate risk and guide the therapeutic approach. The classification of the Vienna consensus aims to unity criteria and decrease interobserver variability in diagnosis. In the digestive tract, evaluation of epithelial dysplasia is especially important in four entities: Barrett's esophagus, chronic gastritis, inflammatory bowel disease, and colorectal adenomas. The criteria for diagnosis and dysplasia staging are the same in all these entities, but the therapeutic approach may vary according to the affected organ and the clinico-pathological context.
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145
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Abstract
Patients with longstanding chronic ulcerative colitis are "at risk" of developing colorectal cancer. Approximately 1 in 6 patients will die as a result of colorectal malignancy, which can often be difficult to detect using conventional "white light" colonoscopy. New endoscopic techniques and technologies including the use of dye sprays, "chromoendoscopy", high magnification chromoscopic colonoscopy and recently chromoscopic assisted confocal laser scanning in vivo endomicroscopy have now been introduced to improve the diagnostic yield of intraepithelial neoplasia at screening colonoscopy. This review details the true "risk" of colorectal cancer complicating ulcerative colitis, discusses the objective evidence to support current endoscopic screening guidelines, and describes the imminent technological paradigm shift about to occur in the endoscopic management and detection of intraepithelial neoplasia.
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146
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Gupta RB, Harpaz N, Itzkowitz S, Hossain S, Matula S, Kornbluth A, Bodian C, Ullman T. Histologic inflammation is a risk factor for progression to colorectal neoplasia in ulcerative colitis: a cohort study. Gastroenterology 2007; 133:1099-105; quiz 1340-1. [PMID: 17919486 PMCID: PMC2175077 DOI: 10.1053/j.gastro.2007.08.001] [Citation(s) in RCA: 538] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 06/14/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although inflammation is presumed to contribute to colonic neoplasia in ulcerative colitis (UC), few studies have directly examined this relationship. Our aim was to determine whether severity of microscopic inflammation over time is an independent risk factor for neoplastic progression in UC. METHODS A cohort of patients with UC undergoing regular endoscopic surveillance for dysplasia was studied. Degree of inflammation at each biopsy site had been graded as part of routine clinical care using a highly reproducible histologic activity index. Progression to neoplasia was analyzed in proportional hazards models with inflammation summarized in 3 different ways and each included as a time-changing covariate: (1) mean inflammatory score (IS-mean), (2) binary inflammatory score (IS-bin), and (3) maximum inflammatory score (IS-max). Potential confounders were analyzed in univariate testing and, when significant, in a multivariable model. RESULTS Of 418 patients who met inclusion criteria, 15 progressed to advanced neoplasia (high-grade dysplasia or colorectal cancer), and 65 progressed to any neoplasia (low-grade dysplasia, high-grade dysplasia, or colorectal cancer). Univariate analysis demonstrated significant relationships between histologic inflammation over time and progression to advanced neoplasia (hazard ration (HR), 3.0; 95% CI: 1.4-6.3 for IS-mean; HR, 3.4; 95% CI: 1.1-10.4 for IS-bin; and HR, 2.2; 95% CI: 1.2-4.2 for IS-max). This association was maintained in multivariable proportional hazards analysis. CONCLUSIONS The severity of microscopic inflammation over time is an independent risk factor for developing advanced colorectal neoplasia among patients with long-standing UC.
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147
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Abstract
Patients with chronic colitis from inflammatory bowel disease (IBD) have an increased risk of colorectal cancer (CRC). Previously, to ameliorate this, prophylactic total colectomy was offered to patients who had chronic ulcerative colitis (UC); however, research has identified less invasive management options through better understanding of the pathogenesis of cancer in chronic inflammation, a more uniform histologic diagnosis by pathologists, and proper surveillance colonoscopy techniques. This article reviews the pathogenesis of neoplasia in IBD, and then reviews the risk factors for CRC in IBD, surveillance guidelines and their limitations, surveillance techniques, ileal pouch dysplasia, and chemoprevention. Although data for CRC risk in Crohn's disease (CD) are not as extensive, it has been suggested that the risks are comparable to UC.
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Affiliation(s)
- Anis A Ahmadi
- Inflammatory Bowel Diseases Program, Division of Gastroenterology, Department of Medicine, University of Florida, 1600 SW Archer Road, Box 100214, Gainesville, FL 32610, USA
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148
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Haruta I, Shibata N, Kato Y, Tanaka M, Kobayashi M, Oguma H, Shiratori K. Apoptosis Inhibitor Expressed by Macrophages Tempers Autoimmune Colitis and the Risk of Colitis-Based Carcinogenesis in TCRα−/− Mice. J Clin Immunol 2007; 27:549-56. [PMID: 17619226 DOI: 10.1007/s10875-007-9110-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Accepted: 06/06/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's disease and ulcerative colitis (UC) are the two main entities involved in human inflammatory bowel disease (IBD). However, their precise etiologies remain unclear. To study the development of mucosal inflammation, and chronic inflammation-based dysplasia and carcinoma formation, we examined possible roles of the apoptosis inhibitor expressed by macrophages (AIM) in an experimental IBD model. METHODS In this study, we used T cell receptor alpha deficient (TCRalpha(-/-)) mice, a known UC-like colitis model. We generated TCRalpha(-/-) x AIM(-/-) double knockout mice by crossbreeding TCRalpha(-/-) with AIM(-/-) mice. At 24 weeks of age, mice were killed to obtain colon tissues for pathological examinations. TCRalpha(-/-) x AIM(+/-) mice, heterozygous littermates of TCRalpha(-/-) x AIM(-/-) mice, were used as controls. RESULTS Severe colitis was observed in TCRalpha(-/-) x AIM(-/-) mice, when compared with TCRalpha(-/-) x AIM(+/-) mice. Dysplasia was detected in TCRalpha(-/-) x AIM(-/-) mice, but not in TCRalpha(-/-) x AIM(+/-) mice. Adenocarcinoma formation was observed from dysplasia only in TCRalpha(-/-) x AIM(-/-) mice. CONCLUSION Not only a high incidence of severe colitis but also dysplasia and adenocarcinoma formation were observed in TCRalpha(-/-) x AIM(-/-) mice only. AIM have some regulatory roles in inflammation and progression of dysplasia to carcinoma in TCRalpha(-/-) mice.
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MESH Headings
- Animals
- Autoimmune Diseases/metabolism
- Autoimmune Diseases/pathology
- CHO Cells
- Cell Line, Tumor
- Cell Transformation, Neoplastic/immunology
- Cell Transformation, Neoplastic/metabolism
- Colitis, Ulcerative/immunology
- Colitis, Ulcerative/metabolism
- Colitis, Ulcerative/pathology
- Cricetinae
- Cricetulus
- Female
- Inhibitor of Apoptosis Proteins/deficiency
- Inhibitor of Apoptosis Proteins/genetics
- Inhibitor of Apoptosis Proteins/physiology
- Macrophages/immunology
- Macrophages/metabolism
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Receptors, Antigen, T-Cell, alpha-beta/deficiency
- Receptors, Antigen, T-Cell, alpha-beta/genetics
- Risk Factors
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Affiliation(s)
- Ikuko Haruta
- Department of Medicine and Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
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149
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Kornbluth A. Visible dysplasia: what you see is most of what you get. Gastrointest Endosc 2007; 65:1005-6. [PMID: 17531634 DOI: 10.1016/j.gie.2007.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2006] [Accepted: 02/01/2007] [Indexed: 02/08/2023]
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150
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Abstract
The development of intestinal carcinoma in the setting of inflammatory bowel disease (IBD) has been recognized as an unsavory outcome of chronic inflammation of the bowel. Numerous studies have recently documented the clinical and morphologic features of malignant transformation in this closely-followed group of patients. This article highlights the recent findings of these population-based studies with specific attention to surgical concepts and frames these data in the context of surgical approaches to cancer arising in inflammatory disease. Specifically, the authors address the pathobiology of malignant transformation, the management of colorectal cancer in inflammatory bowel disease, the development of dysplasia in ulcerative colitis, surveillance of patients who have IBD, chemoprevention of cancer, and special features of surgical oncologic management.
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Affiliation(s)
- Juan C Cendan
- Department of Surgery, Division of General and GI Surgery, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA
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