Non-polypoid colorectal neoplasms in ulcerative colitis

Modified Kudo classification can improve accuracy of virtual chromoendoscopy with FICE in endoscopic surveillance of ulcerative colitis

Background and study aims  Virtual chromoendoscopy with Fuji Intelligent Color Enhancement (FICE) has never been studied in prospective trials of endoscopic surveillance for ulcerative colitis (UC). We compared FICE and white light endoscopy (WLE) in differentiation of visible lesions in UC. Patients and methods  In a prospective parallel study, we compared consecutive outpatients with UC submitted to surveillance colonoscopy with FICE or WLE. At least one visible polypoid or non-polypoid lesion for each patient was required. Random biopsies from normal mucosa, targeted biopsies or removal of suspected neoplastic lesions and targeted biopsies of unsuspected lesions were performed. In the FICE arm, neoplasia was suspected according to a modified Kudo classification (FICE-KUDO/inflammatory bowel disease [IBD]). Sensitivity (SE), specificity (SP), positive and negative likelihood ratios (LR) and negative predictive value (NPV) were analyzed. Results  One hundred patients were submitted to FICE (n = 46) or WLE (n = 54). Twenty-two patients (11 in WLE, 11 in FICE) had a least one neoplastic lesion. No neoplasia was found in random biopsies. Among 275 lesions, 17 of 136 by FICE and 27 of 139 by WLE were suspected neoplasia, but 28 (14 in each arm) were true neoplastic lesions. The accuracy of FICE-KUDO/IBD vs WLE (per lesion) was: SE 93 % vs 64 % ( P  = 0.065), SP 97 % vs 86 % ( P  = 0.002), positive-LR 28.3 vs 4.5 ( P  = 0.001), negative-LR 0.07 vs 0.42 ( P  = 0.092), NPV 99 % vs 96 % ( P  = 0.083). FICE-KUDO/IBD detected more non-polypoid lesions than WLE ( P  = 0.016). Conclusions  Targeted biopsies of polypoid and non-polypoid lesions, using the modified Kudo classification with FICE are more accurate than WLE in UC surveillance.

Clinical usefulness of narrow band imaging magnifying colonoscopy for assessing ulcerative colitis-associated cancer/dysplasia

Background and study aims: Colitis-associated cancer/dysplasia (CC/D) can affect the life expectancy of patients with ulcerative colitis (UC). Although the utility of magnifying chromocolonoscopy has been shown, the use of optical magnification with narrow band imaging (NBI) for distinguishing CC/D from non-neoplastic lesions in patients with UC has not been reported. We evaluated whether endoscopic findings are distinguishing and thus assessed the clinical usefulness of NBI magnification for differentiating UC-associated lesions. Patients and methods: The study involved 27 patients diagnosed and treated at Hiroshima University Hospital between September 2005 and March 2015: a neoplasia group (16 lesions) and a non-neoplasia group (17 lesions). The neoplasias comprised 9 dysplastic lesions, 5 intramucosal carcinomas, and 2 submucosal carcinomas, and 17 non-neoplastic lesions. Targeted biopsy samples of suspicious lesions detected by conventional colonoscopy were classified pathologically as neoplastic or non-neoplastic, and NBI magnifying colonoscopy findings (i. e., the surface [unclear/regular/irregular/amorphous] and vascular [same as the background mucosa/regular/irregular/avascular] patterns) of the 2 lesion types were compared. Results: Irregular/amorphous surface patterns were significantly more common in neoplastic lesions than in non-neoplastic lesions (81 % [13/16] vs. 18 % [3/17], respectively, P < 0.001). Irregular/avascular vessel pattern tended to be more common in neoplastic lesions (75 % [12/16] vs. 41 % [7/17], respectively). The surface pattern correctly predicted 82 % of neoplastic lesions, and the vessel pattern correctly predicted 67 % of non-neoplastic lesions. The 2 endoscopic findings together correctly predicted 91 % of neoplastic lesions. Conclusion: Surface pattern, determined by magnifying colonoscopy with NBI, is useful for differenting between UC-associated neoplastic and non-neoplastic lesions.

Role of random biopsies in surveillance of dysplasia in ulcerative colitis patients with high risk of colorectal cancer

Background/Aims

Recent data suggest that the incidence of ulcerative colitis (UC) related colorectal cancer (CRC) in India is similar to that of West. The optimum method for surveillance is still a debate. Surveillance with random biopsies has been the standard of care, but is a tedious process. We therefore undertook this study to assess the yield of random biopsy in dysplasia surveillance.

Methods

Between March 2014 and July 2015, patients of UC attending the Inflammatory Bowel Disease clinic at the All India Institute of Medical Sciences with high risk factors for CRC like duration of disease >15 years and pancolitis, family history of CRC, primary sclerosing cholangitis underwent surveillance colonoscopy for dysplasia. Four quadrant random biopsies at 10 cm intervals were taken (33 biopsies). Two pathologists examined specimens for dysplasia, and the yield of dysplasia was calculated.

Results

Twenty-eight patients were included. Twenty-six of these had pancolitis with a duration of disease greater than 15 years, and two patients had associated primary sclerosing cholangis. No patient had a family history of CRC. The mean age at onset of disease was 28.89±8.73 years and the duration of disease was 19.00±8.78 years. Eighteen patients (64.28%) were males. A total of 924 biopsies were taken. None of the biopsies revealed any evidence of dysplasia, and 7/924 (0.7%) were indefinite for dysplasia.

Conclusions

Random biopsy for surveillance in longstanding extensive colitis has a low yield for dysplasia and does not suffice for screening. Newer techniques such as chromoendoscopy-guided biopsies need greater adoption.

Paradigm Shift in the Surveillance and Management of Dysplasia in Inflammatory Bowel Disease (West)

Patients with long-standing inflammatory bowel disease (IBD) colitis have a 2.4-fold higher risk of developing colorectal cancer (CRC) than the general population, for both ulcerative colitis (UC) and Crohn's disease (CD) colitis. Surveillance colonoscopy is recommended to detect early CRC and dysplasia. Most dysplasia discovered in patients with IBD is actually visible. Recently published SCENIC (Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations) consensus statements provide unifying recommendations for the optimal surveillance and management of dysplasia in IBD. SCENIC followed the prescribed processes for guideline development from the Institute of Medicine (USA), including systematic reviews, full synthesis of evidence and deliberations by panelists, and incorporation of the GRADE methodology. The new surveillance paradigm involves high-quality visual inspection of the mucosa, using chromoendoscopy and high-definition colonoscopy, with endoscopic recognition of colorectal dysplasia. Lesions are described according to a new classification, which replaces the term 'dysplasia associated lesion or mass (DALM)' and its derivatives. Targeted biopsies are subsequently done on areas suspicious for dysplasia, and resections are carried out for discrete, resectable lesions.

Clinical usefulness of endocytoscopy in the remission stage of ulcerative colitis: a pilot study

BACKGROUND

Histopathology can be used to detect ulcerative colitis (UC) relapse, but diagnosis of the disease activity by histopathology requires multiple biopsies to be taken. Magnifying endocytoscopy provides a method for real-time ultra-magnifying imaging. It was recently reported that the endocytoscopy system score (ECSS) correlates well with the histopathology of UC. Here we evaluated the clinical usefulness of endocytoscopy for accurately monitoring UC during remission.

METHODS

We performed endocytoscopy on 26 patients with UC in remission that had been diagnosed by conventional colonoscopy at our institution between January and April 2013. Endocytoscopy was performed at the area of the rectum where UC had been detected with conventional endoscopy. Biopsies were also taken from the same area and histopathology was evaluated by a single pathologist according to the Matts' grading system. The correlation between the relapse rate of UC and both the ECSS and the Matts' histopathological grade was evaluated.

RESULTS

The ECSS of the intestinal mucosa in UC showed a correlation with the Matts' histopathological grade (Spearman's |r| = 0.647). The patients were classified into two groups: those with an ECSS of 0-2 (Grade A, 12 cases) and those with an ECSS of 3-6 (Grade B, 10 cases). To date, three Grade B cases have relapsed and no Grade A cases have relapsed. The average post-endocytoscopy surveillance period was 446 ± 92 days.

CONCLUSIONS

The ECSS may be a predictive indicator for UC relapse since there was a correlation between the ECSS and the degree of inflammation as determined by histopathology.

Detection of nonpolypoid colorectal neoplasia using magnifying endoscopy in colonic inflammatory bowel disease

Patients with inflammatory bowel diseases (IBD) have a high risk of colitis-associated dysplasia and cancer. It is important that careful surveillance with colonoscopy is performed for all patients with IBD and, more frequently, for those considered to be at high risk. Traditionally, flat dysplasia in ulcerative colitis has been considered to be detectable only by using random biopsy specimens of mucosa that appeared unremarkable during endoscopy. However, recent studies have shown that most of them are visible; thus, their detection as nonpolypoid colorectal neoplasms is an integral component in the prevention of colitic cancer.

Is it possible to discriminate between neoplastic and nonneoplastic lesions in ulcerative colitis by magnifying colonoscopy?

BACKGROUND

Colitis-associated cancer/dysplasia is an intestinal tract condition that can affect the life expectancy of patients with ulcerative colitis. It is often difficult to detect neoplastic lesions. This study evaluated whether any endoscopic features are effective for distinguishing colitis-associated cancer/dysplasia from nonneoplastic lesions in patients with ulcerative colitis.

METHODS

The study involved 52 patients with 61 lesions treated at Hiroshima University Hospital between September 1999 and May 2012: 10 patients with 11 dysplastic lesions, 5 patients with 5 intramucosal carcinomas, 3 patients with 3 submucosal carcinomas, and 34 patients with 42 nonneoplastic lesions. All patients had undergone targeted biopsy. Endoscopic findings were compared between patients with biopsy-determined neoplasia and those with biopsy-determined nonneoplasia. Multivariate regression analysis was performed to identify magnifying chromocolonoscopy features predictive of neoplasia.

RESULTS

No significant difference was found in conventional endoscopy features between the neoplastic and nonneoplastic lesions. Under magnifying chromocolonoscopy, the pit density of the neoplastic lesions was found to be significantly greater than that of the nonneoplastic lesions (89% [17/19] versus 60% [25/42], respectively). Pit margins were more frequently irregular in the neoplastic lesions than in the nonneoplastic lesions (63% [12/19] versus 33% [14/42], respectively).

CONCLUSIONS

In differentiating between colitis-associated neoplastic and nonneoplastic lesions, focus should be on the high residual density of pits and irregular pit margins observed under magnifying chromocolonoscopy.