Management of elevated dysplastic lesions in patients with IBD

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Background

Historically, an elevated lesion containing dysplasia in inflammatory bowel disease (IBDInflammatory bowel disease) was referred to as a dysplasia-associated lesion or mass (DALMDysplasia associated lesion mass). Such lesions were strongly associated with synchronous or metachronous colorectal cancer (CRCColorectal cancer).[1] A diagnosis of DALMDysplasia associated lesion mass was therefore an indication for colectomy. In the present era of high-definition colonoscopy where earlier detection of dysplasia is typical, the term DALMDysplasia associated lesion mass should no longer be used (see Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendation [SCENICSurveillance for colorectal endoscopic neoplasia detection and management in inflammatory bowel disease patients: International Consensus recommendations]).[2]

Visible dysplastic lesions that can often be resected endoscopically with clear resection margins can be followed by close surveillance colonoscopy with good outcomes.[3][4][5][6][7] Conversely, if the dysplastic lesion cannot be entirely removed or multifocal dysplasia is present (indicating a more widespread ‘field-effect’), referral for surgical management is recommended.

Elevated dysplastic lesions should be classified as either endoscopically-resectable or endoscopically non-resectable. Appropriate methods for managing endoscopically resectable lesions include conventional polypectomy and endoscopic mucosal resection. Endoscopic submucosal dissection or full-thickness resection might be possible in some situations. When lesions are removed endoscopically the absence of dysplasia in the surrounding flat mucosa should be assessed either by visualisation or by biopsies. Tattooing near the polypectomy site is recommended to permit easier identification for future surveillance colonoscopies.

Endoscopically non-resectable dysplastic lesions require surgical resection, typically by colectomy. Referral for discussion at an IBDInflammatory bowel disease multidisciplinary meeting involving an experienced colorectal surgeon is recommended.

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Evidence

What should be the protocol to manage elevated dysplasia in IBDInflammatory bowel disease? (MNG1)

Systematic review evidence

No studies published since 2010 were identified that compared management protocols for elevated dysplasia in those with IBDInflammatory bowel disease.

Overview of additional evidence (non-systematic literature review)

Long-term follow-up data provide reassurance that localised dysplastic lesions in IBDInflammatory bowel disease can be treated effectively by endoscopic means, followed by careful follow-up surveillance.[3][4][5][6][7]

A recent meta-analysis examining cancer risk after resection of polypoid dysplasia in patients with longstanding ulcerative colitis found the pooled incidence of CRCColorectal cancer to be 5.3 per 1000 years of patient follow-up (95% confidence interval [CI] 2.7–10.1).[8] The incidence of combined colorectal cancer/high grade dysplasia and all forms of dysplasia were 7.0 (95% CI 4.0–12.4) and 65 (95% CI 54–78) per 1000 years of patients follow up, respectively.[8]

Evidence summary and recommendations

Evidence summary Level References
No studies published since 2010 were identified that compared management protocols for elevated dysplastic lesions in patients with IBDInflammatory bowel disease. N/A
Evidence-based recommendationA recommendation formulated after a systematic review of the evidence, indicating supporting references.Question mark transparent.png Grade
Raised lesions containing dysplasia may be treated endoscopically provided that the entire lesion is removed and there is no dysplasia in flat mucosa elsewhere in the colon.
C
Evidence-based recommendationA recommendation formulated after a systematic review of the evidence, indicating supporting references.Question mark transparent.png Grade
If a raised dysplastic lesion cannot be completely removed, surgical intervention is strongly recommended.
D
Consensus-based recommendationA recommendation formulated in the absence of quality evidence, after a systematic review of the evidence was conducted and failed to identify admissible evidence on the clinical question.Question mark transparent.png

In the presence of multifocal low-grade dysplasia that cannot be removed endoscopically, at least frequent surveillance colonoscopy is required. Surgical management is an alternative based on case-by-case discussion.

Surveillance colonoscopy with chromoendoscopy within 3–12 months should be carried out after endoscopic resection of an elevated dysplastic lesion in inflammatory bowel disease.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

The important objective for the endoscopist performing surveillance procedures is to identify lesions that are safely and completely resectable endoscopically. This is based on endoscopic features of the identified lesion and elsewhere in the colon.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

Nomenclature should reflect the SCENICSurveillance for colorectal endoscopic neoplasia detection and management in inflammatory bowel disease patients: International Consensus recommendations international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. The term 'dysplasia associated lesion or mass (DALMDysplasia associated lesion mass)' should not be used.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

Consider referral to an experienced endoscopist to perform surveillance for inflammatory bowel disease using chromoendoscopy to exclude multi-focal dysplasia followed by endoscopic resection of the dysplastic lesion.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

Close colonoscopic surveillance is required following endoscopic resection of dysplasia given the risk of multifocal dysplasia and metachronous dysplasia.

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References

  1. Blackstone MO, Riddell RH, Rogers BH, Levin B. Dysplasia-associated lesion or mass (DALM) detected by colonoscopy in long-standing ulcerative colitis: an indication for colectomy. Gastroenterology 1981 Feb;80(2):366-74 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7450425.
  2. Laine L, Kaltenbach T, Barkun A, McQuaid KR, Subramanian V, Soetikno R, et al. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. Gastroenterology 2015 Mar;148(3):639-651.e28 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25702852.
  3. 3.03.1 Allen P, De Cruz P, Kamm MAMetachronous adenoma. Dysplastic lesions in ulcerative colitis: changing patadigms. Inflammatory Bowel Disease 2010.
  4. 4.04.1 Engelsgjerd M, Farraye FA, Odze RD. Polypectomy may be adequate treatment for adenoma-like dysplastic lesions in chronic ulcerative colitis. Gastroenterology 1999 Dec;117(6):1288-94; discussion 1488-91 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10579969.
  5. 5.05.1 Odze RD, Farraye FA, Hecht JL, Hornick JL. Long-term follow-up after polypectomy treatment for adenoma-like dysplastic lesions in ulcerative colitis. Clin Gastroenterol Hepatol 2004 Jul;2(7):534-41 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15224277.
  6. 6.06.1 Rubin PH, Friedman S, Harpaz N, Goldstein E, Weiser J, Schiller J, et al. Colonoscopic polypectomy in chronic colitis: conservative management after endoscopic resection of dysplastic polyps. Gastroenterology 1999 Dec;117(6):1295-300 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10579970.
  7. 7.07.1 Vieth M, Behrens H, Stolte M. Sporadic adenoma in ulcerative colitis: endoscopic resection is an adequate treatment. Gut 2006 Aug;55(8):1151-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16423892.
  8. 8.08.1 Wanders LK, Dekker E, Pullens B, Bassett P, Travis SPSerrated polyp, East JE. Cancer risk after resection of polypoid dysplasia in patients with longstanding ulcerative colitis: a meta-analysis. Clin Gastroenterol Hepatol 2014 May;12(5):756-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23920032.

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Appendices

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