Management of elevated dysplastic lesions in patients with IBD

From Clinical Guidelines Wiki


Background

Historically, an elevated lesion containing dysplasia in inflammatory bowel disease (IBD) was referred to as a dysplasia-associated lesion or mass (DALM). Such lesions were strongly associated with synchronous or metachronous colorectal cancer (CRC).[1] A diagnosis of DALM was therefore an indication for colectomyThe surgical removal of all or part of the colon.. In the present era of high-definition colonoscopy where earlier detection of dysplasia is typical, the term DALM should no longer be used (see Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendation [SCENIC]).[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 colectomyThe surgical removal of all or part of the colon.. Referral for discussion at an IBD multidisciplinary meeting involving an experienced colorectal surgeon is recommended.

Back to top

Evidence

What should be the protocol to manage elevated dysplasia in IBD? (MNG1)

Systematic review evidence

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

Overview of additional evidence (non-systematic literature review)

Long-term follow-up data provide reassurance that localised dysplastic lesions in IBD 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 CRC to be 5.3 per 1000 years of patient follow-up (95% confidence intervalA measure that quantifies the uncertainty in measurement. When reported as 95% CI, it is the range of values within which we can be 95% sure that the true value for the whole population lies. [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 IBD. N/A
Evidence-based recommendationQuestion 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 recommendationQuestion mark transparent.png Grade
If a raised dysplastic lesion cannot be completely removed, surgical intervention is strongly recommended.
D
Consensus-based recommendationQuestion 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 pointQuestion 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 pointQuestion mark transparent.png

Nomenclature should reflect the SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. The term 'dysplasia associated lesion or mass (DALM)' should not be used.

Practice pointQuestion 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 pointQuestion mark transparent.png

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

Back to top

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 MA. 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 SP, 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.

Back to top

Appendices

Jutta's magnifying glass icon.pngPICO question MNG1 View Evidence statement form MNG1Evidence statement form MNG1 View Systematic review report MNG1Systematic review report MNG1
Back to top