Colonoscopic Surveillance in Inflammatory Bowel Disease

Thomas A Ullman


Curr Opin Gastroenterol. 2005;21(5):585-588. 

In This Article

Management of Flat Low-Grade Dysplasia

By definition, dysplasia is unequivocal neoplasia. Because this fact is not well-appreciated by gastroenterologists,[10] few have been offering surgery to patients found to have low-grade dysplasia, particularly when it is found in only one random biopsy in a system known for less than ideal levels of agreement between pathologists. This was especially true prior to 1983, when Riddell et al.[6] standardized the interpretation of surveillance specimens. Two publications a decade ago, however, necessitated a rethinking of the perception that low-grade dysplasia carried only a small risk for subsequent development of CRC in ulcerative colitis. Connell et al.[11] noted that reclassification of St. Mark's low-grade dysplasia cohort resulted in a dramatic increase in the 5-year probability of more advanced pathology to 54%. In a summary of previously published surveillance series, Bernstein et al.[12] noted that 19% of patients who underwent immediate colectomy for low-grade dysplasia (LGD) were found to have CRC. Despite these studies, however, many clinicians have continued to pursue a nonoperative strategy for their patients with LGD, hoping to limit the rate of unnecessary colectomies and believing that any progression to more advanced pathology could be detected with more rigorous and frequent surveillance prior to the development of advanced-stage cancer.

Three recent publications have addressed this issue, unfortunately with conflicting results. Concluding in favor of early colectomy for patients with flat LGD, Ullman et al.[13] followed the outcomes of 46 patients with flat LGD diagnosed at Mount Sinai Hospital in New York after 1994. They found that (1) 23.5% of patients who underwent colectomy for flat LGD harbored more advanced pathology; (2) the actuarial rate of progression to advanced neoplasia (high-grade dysplasia (HGD) or CRC) was 53%; (3) advanced-stage cancers occurred in three of the 46 patients, two of whom had dysplasia-free examinations within 12 months of their cancer diagnosis and none of whom had HGD prior to developing cancer; and (4) no clinical variables, including the number of biopsies positive for LGD, were predictive of progression.

Two other series, however, failed to show such a worrisome prognosis for LGD. Befrits et al.[14] followed 60 patients with flat LGD from a single center in Sweden and found that none developed cancer on follow-up. Although these results are drastically different from those of the series by Connell et al.[11] and Ullman et al.,[13] it must be noted that pathologists at their center did not include 'indefinite for dysplasia' in their coding scheme and that patients were included whose dysplasia was detected prior to the Riddell classification of 1983.[6] In the series by Lim et al.[15] from Leeds in the United Kingdom, no meaningful progression to cancer was detected, but it is again worth noting that patients whose dysplasia was diagnosed prior to 1983 were included.

Unfortunately, these recent publications have failed to achieve consensus on the proper management of flat LGD in ulcerative colitis. If the data from Connell et al.,[11] Bernstein et al.,[12] and Ullman et al.[13] are to be believed, surgery is the best option. If, however, a patient is willing to take some risk, then a nonsurgical approach should be entertained.


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