CARCINOMA OF THE COLON IN ULCERATIVE COLITIS

Recent advances in surveillance colonoscopy for dysplasia in inflammatory bowel disease

Inflammatory bowel disease (IBD) has a global presence with rapidly increasing incidence and prevalence. Patients with IBD including those with ulcerative colitis and Crohn's disease have a higher risk of developing colorectal cancer (CRC) compared to the general population. Risk factors for CRC in patients with IBD include long disease duration, extensive colitis, primary sclerosing cholangitis, family history of CRC, stricture, and prior dysplasia. Surveillance colonoscopy for CRC in patients with IBD should be tailored to individualized risk factors and requires careful monitoring every year to every five years. The current surveillance techniques are based on several guidelines. Chromoendoscopy with targeted biopsy is being recommended increasingly, and high-definition colonoscopy is gradually replacing standard-definition colonoscopy. However, it remains unclear whether chromoendoscopy, virtual chromoendoscopy, or white-light endoscopy has better efficiency when a high-definition scope is used. With the development of new endoscopic instruments and techniques, the paradigm of surveillance strategy has gradually changed. In this review, we discuss cutting-edge surveillance colonoscopy in patients with IBD including a review of literature.

Preparation of Fraxetin Long Circulating Liposome and Its Anti-enteritis Effect

This study sought to improve the oral bioavailability and enhance the anti-enteritis effect of fraxetin by incorporating it into long circulating liposomes (F-LC-Lipo). The optimal formulation of F-LC-Lipo was obtained via orthogonal design. The particle size, morphology, encapsulation efficiency, stability, and anti-enteritis effect of F-LC-Lipo were evaluated. The particle size of F-LC-Lipo was 166.65 ± 8.75 nm with entrapment efficiency (EE) of 92.18 ± 0.17%. The release rate in different dissolution media (pH 1.2 HCl, DDW, and pH 7.4 PBS) was significantly higher than that of fraxetin solution. Compared with the free fraxetin solution, F-LC-Lipo increased oral bioavailability of fraxetin by 4.43 times (443%). More importantly, F-LC-Lipo could improve the levels of interleukin-1 beta (IL-1β), IL-6, malondialdehyde (MDA), superoxide dismutase (SOD), tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP), prostaglandin E2 (PEG2), and IL-10 in rats with enteritis. Overall, these results suggested that LC-Lipo may serve as a potential carrier for improving the solubility and oral bioavailability of fraxetin as well as improving its enteritis effect.

Tumor markers and rectal cancer: support for an inflammation-related pathway

Inflammation may be a key element in the etiology of colorectal cancer. In our study, we examine associations between factors related to inflammation and specific rectal cancer mutations. A population-based study of 750 rectal cancer cases with interview and tumor DNA were compared to 1,205 population-based controls. Study participants were from Utah and the Northern California Kaiser Permanente Medical Care Program. Tumor DNA was analyzed for TP53 and KRAS2 mutations and CpG Island methylator phenotype. We assessed how these tumor markers were associated with use of anti-inflammatory drugs, polymorphisms in the IL6 genes (rs1800795 and rs1800796) and dietary antioxidants. Ibuprofen-type drugs, IL6 polymorphisms (rs1800796) and dietary alpha-tocopherol and lycopene significantly altered likelihood of having a TP53 mutation. This was especially true for TP53 transversion mutations and dietary antioxidants (OR for beta-carotene 0.51 95% CI 0.27, 0.97, p trend 0.03; alpha-tocopherol 0.41 95% CI 0.20, 0.84, p trend 0.02) Beta-carotene and ibuprofen significantly altered risk of KRAS2 tumors. The associations between lutein and tocopherol and TP53 and KRAS2 mutations were modified by IL6 genotype. These results suggest that inflammation-related factors may have unique associations with various rectal tumor markers. Many factors involved in an inflammation-related pathway were associated with TP53 mutations and some dietary factors appeared to be modified by IL6 genotype.

Synchronous multifocal colorectal carcinoma in a patient with delayed diagnosis of ulcerative pancolitis

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.

IL6 genotypes and colon and rectal cancer

Inflammation appears to play a key role in the development of colorectal cancer (CRC). In this study we examine factors involved in the regulation of inflammation and risk of CRC. Data from a multi-center case-control study of colon (N = 1579 cases and N = 1977 controls) and rectal (N = 794 cases and N = 1005 controls) cancer were used to evaluate the association between the rs1800795 and rs1800796 IL6 polymorphisms and CRC. We evaluated the joint effects of IL6 single nucleotide polymorphisms and regular use of aspirin/NSAIDs and vitamin D receptor (VDR) genotype. Having a C allele of the rs1800796 IL6 polymorphisms and the GG genotype of the rs1800795 IL6 polymorphisms was associated with a statistically significantly reduced the risk of colon (OR 0.76 95% CI 0.57, 1.00), but not rectal (OR 1.49 95% CI 1.02,2.16) cancer. Both IL6 polymorphisms were associated with significant interaction with current use of aspirin/NSAIDs to alter risk of colon cancer: individuals with a C allele in either polymorphism who were current users of aspirin/NSAIDs had the lowest colon cancer risk. CRC risk also was associated with an interaction between VDR and IL6 genotypes that was modified by current use of aspirin/NSAIDs. This study provides further support for inflammation-related factors in the etiology of CRC. Other studies are needed to explore other genes in this and other inflammation-related pathways.

The risk of colorectal cancer in ulcerative colitis: a meta-analysis

BACKGROUND AND AIMS

Controversy surrounds the risk of colorectal cancer (CRC) in ulcerative colitis (UC). Many studies have investigated this risk and reported widely varying rates.

METHODS

A literature search using Medline with the explosion of references identified 194 studies. Of these, 116 met our inclusion criteria from which the number of patients and cancers detected could be extracted. Overall pooled estimates, with 95% confidence intervals (CI), of cancer prevalence and incidence were obtained using a random effects model on either the log odds or log incidence scale, as appropriate.

RESULTS

The overall prevalence of CRC in any UC patient, based on 116 studies, was estimated to be 3.7% (95% CI 3.2-4.2%). Of the 116 studies, 41 reported colitis duration. From these the overall incidence rate was 3/1000 person years duration (pyd), (95% CI 2/1000 to 4/1000). The overall incidence rate for any child was 6/1000 pyd (95% CI 3/1000 to 13/1000). Of the 41 studies, 19 reported results stratified into 10 year intervals of disease duration. For the first 10 years the incidence rate was 2/1000 pyd (95% CI 1/1000 to 2/1000), for the second decade the incidence rate was estimated to be 7/1000 pyd (95% CI 4/1000 to 12/1000), and in the third decade the incidence rate was 12/1000 pyd (95% CI 7/1000 to 19/1000). These incidence rates corresponded to cumulative probabilities of 2% by 10 years, 8% by 20 years, and 18% by 30 years. The worldwide cancer incidence rates varied geographically, being 5/1000 pyd in the USA, 4/1000 pyd in the UK, and 2/1000 pyd in Scandinavia and other countries. Over time the cancer risk has increased since 1955 but this finding was not significant (p=0.8).

CONCLUSIONS

Using new meta-analysis techniques we determined the risk of CRC in UC by decade of disease and defined the risk in pancolitics and children. We found a non-significant increase in risk over time and estimated how risk varies with geography.

Clinical significance of the preoperative plasma carcinoembryonic antigen (CEA) level in patients with carcinoma of the large bowel

Preoperative levels of perchloric acid extractable plasma CEA were measured in 911 patients with complaints of the digestive system. A final diagnosis of benign disease was made for 579 patients; 332 patients were found to have cancer. Data for the preoperative CEA values were examined for clinical significance as an aide to diagnosis, preoperative disease staging, and prognosis. The results of our analysis support the conclusions of many investigators that the CEA assay is not a clinically useful diagnostic test, but it shows limited value in preoperative staging and a somewhat stronger correlation with prognosis.

Multifocal neoplasia involving the colon and appendix in ulcerative colitis: pathological and molecular features

A patient with ulcerative colitis, extensive dysplasia, multifocal colon cancer, and an appendiceal cystadenoma is described. A 48-year-old man with a 26-year history of ulcerative colitis (UC) had extensive dysplasia involving nearly the entire colon and four dysplasia-associated mass lesions (DALMs). Four invasive adenocarcinomas were present. This case is the first documentation of a DALM (mucinous cystadenoma) arising in the appendix in the setting of UC. The genetic alterations present in the various lesions were analyzed. The molecular profiles of the neoplastic lesions differed. Mutations were found in p53 and ras genes, and one site showed microsatellite instability in a single genetic locus. These molecular abnormalities develop before invasive cancer develops, and may undergo clonal expansion to create large mucosal patches containing certain cells with genetic alterations. The diversity of the early changes suggests that the recurrent inflammation characteristic of long-standing UC randomly damages genes known to participate in colon carcinogenesis and that it affects multiple target genes. The findings also support a multiclonal origin of synchronous tumors because the molecular phenotypes of the preinvasive lesions differed at various sites.

Ulcerative colitis with overexpression of p53 preceding overt histological abnormalities of the epithelium

A 53-year-old man with a 22-year history of ulcerative colitis(UC) (pancolitis), had an ulcerating rectal tumor. Resection of the rectum and sigmoid colon was performed. Pathology showed an expansive ulcerating adenocarcinoma tumor (type 2) invading the adventitia against a background of UC in a resolving phase. Dysplasia was also found in granular and flat mucosa adjacent to the invading carcinoma. Immunostaining for p53 showed diffuse positivity in both the carcinoma and dysplasia, and also in the mucosa with indefinite dysplasia or no dysplasia neighboring the dysplasia and carcinoma. Mapping of neoplasms and the area with p53 protein overexpression showed that the grade of dysplasia increased as the lesion approached the invasive carcinoma and that the mucosa with dysplasia was surrounded by mucosa without dysplasia or indefinite for dysplasia, but with p53 protein overexpression. In some areas without dysplasia showing p53 overexpression, there was significant morphometric enlargement of the area and diameter of the nucleus p53 Immunostaining is a good marker for assessing the genetic alterations that precede histological abnormalities and for diagnosing carcinoma in UC. Objective findings such as p53-protein overexpression and morphometric values should be used to evaluate cytological abnormalities in UC, as well as in common colorectal cancer.

Premalignant changes in ulcerative colitis

Colitis-associated carcinoma is often associated with, or preceded by, noninvasive epithelial neoplastic changes termed dysplasia. Surveillance colonoscopy with biopsies looking for dysplasia is now standard practice in the management of the cancer problem in ulcerative colitis. However, this practice continues to have a number of limitations and problems that need to be understood by surgeons who may be referring such patients. A number of recent reports indicate that colitis associated carcinoma is predominantly left-sided and incorporation of this distribution in the surveillance methods merits consideration. The molecular and genetic abnormalities involved in the pathogenesis of colitis associated neoplasia are being actively investigated and may yield supplementary methods to better define individual patient risk.

Assessment of dysplasia, mucosal mucins, p53 protein expression, and DNA content in ulcerative colitis patients with colectomy and ileorectal anastomosis

BACKGROUND

Patients with ileorectal anastomosis after colectomy for ulcerative colitis remain at risk of developing rectal malignancy. Detection of mucosal dysplasia has been used for regular screening but is difficult in inflammatory mucosa, prompting the search for complementary markers.

METHODS

This prospective study aimed to assess the prevalence of dysplasia, the predominance of sialomucin, DNA aneuploidy, and p53 overexpression as possible predictors of colorectal tumourigenesis, in the rectal mucosa of an unselected group of 27 patients with ileorectal anastomosis performed for ulcerative colitis. Patients had neither neoplastic nor dysplastic lesions on the colectomy specimen and the retained rectum at the time of surgery. One biopsy specimen of each lateral rectal wall was studied, using routine histology, mucin histochemistry, DNA flow cytometry, and the streptavidin-biotin complex method with D07 monoclonal antibodies directed towards the p53 protein.

RESULTS

Seventeen, seven, and three patients showed inflammatory lesions of inactive, moderate, and severe active colitis, respectively. Dysplasia, sialomucin predominance, DNA aneuploidy, and p53 overexpression were not detected.

CONCLUSIONS

The risk of malignant transformation of the rectal mucosa after ileorectal anastomosis seemed to be low in this ulcerative colitis group without high-grade dysplasia or carcinoma in the previous colectomy specimen, carefully followed up endoscopically and histologically. It remains to be evaluated which of the methods studied above will optimize the histopathologic surveillance of the rectal mucosa of ulcerative colitis patients with ileorectal anastomosis.

Cancer in inflammatory bowel disease

Patients with inflammatory bowel disease, including both ulcerative colitis (UC) and Crohn's disease, are at increased risk for the development of gastrointestinal carcinoma, particularly colorectal adenocarcinoma. The current options to reduce this cancer risk include prophylactic colectomy, periodic endoscopic screening with colectomy performed in those patients found to have dysplastic colonic mucosa, or expectant management with no routine surveillance regimen. Despite the lack of data demonstrating effectiveness of surveillance colonoscopy, this approach has become the standard of care in most communities in the United States. Although it has fallen out of fashion in recent years, prophylactic colectomy remains a good option for reducing cancer risk for select patients with UC.

Clinicopathological characteristics of colorectal carcinoma complicating ulcerative colitis

This study examined three features associated with colorectal carcinoma complicating ulcerative colitis: (a) the distribution of 157 cancers in 120 patients with ulcerative colitis treated at St Mark's Hospital between 1947 and 1992; (b) the frequency at which dysplasia was found at a distance from the tumour in 50 total proctocolectomy specimens in which an average of 27 histology blocks were reviewed, and (c) the five year survival rate according to Dukes's stage and participation in a surveillance programme. Of 157 carcinomas, 88 (56%) occurred in the rectosigmoid, 19 (12%) in the descending colon or splenic flexure, and 50 (32%) in the proximal colon. Among the 120 patients, the rectum or sigmoid colon contained cancer in 81 (67.5%). Dysplasia was detected in 41 of 50 reviewed proctocolectomy specimens (82%). Dysplasia distant to a malignancy occurred in 37 (74%); two were classified indefinite, probably positive, 19 were low grade, and 16 were high grade; in 18 specimens there was an elevated dysplastic lesion. Survival was related to the Dukes's stage: about 90% of patients with Dukes's A or B cancer were alive at five years. The five year survival of 16 patients in whom cancer developed during surveillance was 87% compared with 55% of 104 patients who did not participate in surveillance (p = 0.024).

Mutations in the p53 gene: an early marker of neoplastic progression in ulcerative colitis

BACKGROUND/AIMS

In long-term extensive ulcerative colitis, aneuploidy occurs earlier and loss of heterozygosity for p53 (p53 LOH) later during histological progression towards carcinoma. This study determined the time of onset of p53 mutation in this progression.

METHODS

We developed a rapid, sensitive screening assay for p53 mutations at codon 248. The geographic distribution of this p53 mutation was mapped in two fresh colectomy specimens with mutations of codon 248 (1 cancer, 1 dysplasia) and correlated with patterns of clonal expansion, histological progression, and allelic loss. Numerous samples from throughout both colons were analyzed (216 for histology, 142 for DNA content, 104 for mutation, and 41 for p53 LOH).

RESULTS

p53 mutation correlated highly with histological grade and was distributed more extensively than p53 LOH. Mutation, but not LOH, was also found in diploid, nondysplastic colonic mucosa adjacent to dysplastic areas.

CONCLUSIONS

These findings suggest that p53 mutation appears to be an early genetic event that precedes p53 LOH. The very close correlation of p53 mutation with aneuploidy (P > 0.0001) emphasizes the role of normal p53 at the G1 checkpoint to help prevent entry of genetically damaged cells into the cell cycle.

Neoplastic progression in ulcerative colitis: histology, DNA content, and loss of a p53 allele

Neoplastic progression in patients with chronic ulcerative colitis (UC) is characterized by the development of epithelial dysplasia, which is accompanied by genetic abnormalities that can be detected by flow cytometric and molecular biologic methods. Distribution of and correlation between histologic abnormalities, DNA content, and loss of heterozygosity for a p53 allele (p53 LOH) in the colons of nine UC patients were analyzed. Loss of a p53 allele was found in 85% (22/26) of biopsy specimens classified histologically as carcinoma, 63% (25/40) of biopsy specimens with high grade dysplasia, and 33% (7/21) of biopsy specimens with low grade dysplasia. Loss of heterozygosity for p53 was also found in 9% (5/57) of biopsy specimens indefinite for dysplasia and in 1/18 biopsy specimens negative for dysplasia, showing that this genetic change may occur early in the histological progression towards carcinoma. Aneuploid DNA contents were more common than p53 LOH in regions with negative, indefinite or low grade dysplastic histology; moreover, p53 LOH was detected only in aneuploid cells and not in diploid epithelium. Aneuploidy alone was not as specific a marker for the concomitant presence of dysplasia or carcinoma in a biopsy sample as aneuploidy combined with p53 LOH. These findings show that aneuploidy may precede both p53 LOH and epithelial dysplasia. Two UC patients' colons contained geographically separated clones of cells with different aneuploidies that also showed loss of different p53 alleles, suggesting that neoplasia may arise within different populations of cells in separate areas of the same colon.

Sucrase-isomaltase expression in chronic ulcerative colitis and dysplasia

Sucrase-isomaltase (SI) is a mucosal disaccharidase that is present in normal small intestine and fetal colon. It also has been noted in colonic adenomas and adenocarcinomas. We used a polyclonal antibody to human SI to investigate enzyme presence and utility in detecting dysplastic changes in chronic ulcerative colitis. Sections from 32 cases were reviewed for the presence or absence of active colitis and dysplasia. Immunostaining of these cases for SI was performed and the results were reported based on location of immunoreactivity (ie, membrane and cytoplasmic staining in superficial and crypt epithelial cells) and percentage of positivity. Of 81 sections examined, 48 were rated negative for dysplasia (23 inactive colitis, 20 active, and five probably negative) and 28 were rated positive (eight low grade and 20 high grade). Surface membrane staining of epithelial cells was noted in all 28 dysplastic slides and positive cases (sensitivity, 100%) but also in 29 of 48 negative sections (P less than .001). In contrast, cytoplasmic positivity was present in 25 of 28 dysplastic and in only two of 48 negative slides (P less than .0001). The presence of cytoplasmic staining of SI in the superficial or crypt cells revealed a sensitivity of 92% and a specificity of 94%. There were five additional sections rated as indefinite for dysplasia (probably positive or unknown); two showed staining patterns typical of negative slides and three showed positive staining patterns. Of the 18 samples of transitional mucosa next to areas of dysplasia, surface membrane staining of SI was seen in all samples and cytoplasmic staining was seen in 15. We conclude that membrane staining of SI can be detected in inflammatory, regenerative, and dysplastic mucosa in ulcerative colitis. Cytoplasmic staining, however, correlates strongly with the presence of dysplastic change and may help in its detection.

Mucin abnormality of colonic mucosa in ulcerative colitis associated with carcinoma and/or dysplasia

Twenty cases of resected specimens of carcinoma and/or dysplasia complicating ulcerative colitis were histochemically investigated by the periodic acid-thionein Schiff/potassium hydroxide/periodic acid-Schiff (PAT/KOH/PAS) staining method to see mucin characteristics of carcinoma, dysplasia, and the background mucosa of these lesions. As a control, 11 resected specimens of ulcerative colitis without dysplastic changes and 26 specimens of colonic carcinoma were examined also. All dysplasia and carcinoma in ulcerative colitis stained blue, whereas normal colonic mucin stained red in 65 percent. In 14 of 20 specimens with carcinoma and/or dysplasia, the background mucosa appeared normal with hematoxylin and eosin staining, but showed a mosaic staining pattern with PAT/KOH/PAS. However, only two of 11 specimens of ulcerative colitis without dysplasia and none of 26 specimens of flat mucosa with colorectal carcinoma showed a mosaic staining pattern. From these observations it was concluded that the PAT/KOH/PAS staining method could be useful as a histochemical marker of premalignant change in longstanding ulcerative colitis.

Can histopathologists reliably assess dysplasia in chronic inflammatory bowel disease?

A copy of the standardised classification (SC) proposed for assessing dysplasia in inflammatory bowel disease was circulated to six histopathologists who were asked to apply it to 40 slides from 34 patients with ulcerative colitis to test its reproducibility. The slides were relabelled and recirculated to the pathologists at least one month later. Each was asked to state whether or not key diagnostic features were present before giving a final dysplasia score for the second assessment. Only minor interobserver and intraobserver disagreements were recorded. Pathologists were most consistent at recognising back to back glands, villous mucosal architecture, hyperchromatic nuclei, stratification of nuclei, regenerative nuclei and loss of nuclear polarity. There was poor interobserver agreement in assessing dystrophic goblet cells and columnar mucous cells. Back to back glands, hyperchromatic nuclei, loss of nuclear polarity, stratification of nuclei and columnar mucous cells were considered to be the most important features for determining the severity of dysplasia. As there was poor interobserver agreement in assessing columnar mucous cells and dystrophic goblet cells these features need to be more clearly defined or should be removed from the SC.

Colorectal and extracolonic malignancy in ulcerative colitis

In a review of 1248 cases of ulcerative colitis seen at the Cleveland Clinic that were followed up to 1984 (mean, 14.4 years), 82 patients (6.5%) were subsequently found to have colorectal cancer and 48 (3.8%) had extracolonic malignancy, 6 of them with associated colorectal cancer. Most patients with colorectal cancer were men (2:1), and had extensive (90%) and long-lasting colitis (10 years or more in 93% of cases; mean 18 years). Colitis was inactive before the diagnosis of cancer in 48%. Acute onset of the first attack was rare (7%), and the disease had a remittent course in 92%. The mean age at diagnosis of cancer was 43 years. The cumulative risk of colorectal cancer was significantly higher in patients with extensive colitis than in those with left-sided disease (P less than 0.0001: 11.9% vs. 1.8% at 20 years and 25.3% vs. 3.7% at 30 years). When comparing mean duration of disease, left-sided colitis (22 years) did not differ significantly from extensive disease. The tumor was multifocal in 13.5%, proximal to the splenic flexure in 44%, and poorly differentiated in 34% of the cases. The diagnosis was suspected clinically in 64% of cases. The prognosis of colorectal cancer in patients with ulcerative colitis appears to be similar to that in the general population. The cumulative 5-year survival rate was 54%. This study supports the concept that surveillance colonoscopy should be started after 8 to 10 years of extensive colitis and after 15 years of left-sided colitis. Among those with extracolonic malignancy, the incidence of bile duct carcinoma, leukemia, bone tumors, and endometrial cancer was significantly greater than expected (P less than 0.01), whereas that of lung cancer was significantly lower than expected (P less than 0.01).

A comparison of multiple synchronous colorectal cancer in ulcerative colitis, familial polyposis coli, and de novo cancer

Multiple synchronous colorectal cancer (MSCC) among 1537 patients (69 with familial polyposis coli (FPC), 780 with ulcerative colitis (UC), and 685 with de novo colorectal (DNC) cancers) admitted to The Mount Sinai Hospital between 1945 and 1981 was tabulated. MSCC occurred in five of 24 cancer patients with FPC (21%), in 12 of 65 cancer patients with UC (18%), but in only 17 of 685 DNC patients (2.5%). The proportions of MSCC cases with more than two synchronous tumors were also much greater in the former two groups (UC 6/12 = 50%, FPC 3/5 = 60%) than in DNC (0/17 = 0%). Multiplicity of cancers is thus a distinguishing feature of UC and FPC. MSCC differed from solitary cancers by association with older age and more advanced stage at diagnosis in patients with FPC and by a rightward shift in anatomic distribution in all patients, especially those with FPC and UC.

Study of the cell proliferation kinetics in ulcerative colitis, adenomatous polyps, and cancer

Cell proliferation kinetics, using autoradiography, was investigated in 4 specimens of normal colonic mucosa, 11 cases of ulcerative colitis, 15 adenomas, and 17 advanced cancers of the large intestine. In the normal mucosa, the labeled cells were located only in the lower three fifths of the crypts, the so-called proliferation zone, and their labeling index was 11.7 +/- 4.0%. In the ulcerative colitis, the proliferation zones were remarkably extended toward the upper part of the crypts, and the mean labeling index was 20.5 +/- 9.4%. In the adenomatous polyps, labeling was seen in any part of the crypts, and abnormal proliferation patterns such as denseness, stratification, expansion, and budding of the labeled cells tended to increase in accordance with the degree of the histologic atypism. Their mean labeling index was 22.2 +/- 8.6%. However each labeling index of the polyps increased proportionally to their histologic atypism, from 15.2 +/- 8.1% in grade II to 30.1 +/- 9.9% in grade V. The mean labeling index of the cancers was 23.3 +/- 9.6%, and there was little difference in the labeling patterns of the malignant polyps and cancers. The proliferation patterns of the polyp and cancer were qualitatively different from those of the normal mucosa and the ulcerative colitis.

Distribution of colorectal cancer in patients with and without ulcerative colitis

A comparison of the anatomic distribution of colorectal cancer in patients with and without CUC is difficult because of the unequal number of patients in each group and the changing epidemiologic parameters of colorectal cancer in general. In the present study, the distribution of colorectal tumors in patients with and without CUC was compared over two different time periods at a single hospital. In the early time period (1960 to 1975), there was a significantly higher percentage of proximal tumors in the group with cancer and CUC compared to the group with cancer alone. In the most recent time period (1975 to 1981), there was no difference in distribution of colorectal cancer regardless of whether the patient had CUC or not. We believe that the increased percentage of proximal tumors in patients with colorectal cancers and no CUC that has occurred in recent years has led to the present findings of a similar distribution of tumors in patients with and without CUC.

Dysplasia in inflammatory bowel disease: standardized classification with provisional clinical applications

Assessment of epithelial dysplasia in ulcerative colitis has been hindered by inconsistencies in and disagreements about nomenclature and interpretation. To resolve these issues, pathologists from ten institutions participated in three exchanges of multiple slides and, following each exchange, in discussions of the results. A classification system for the epithelial changes that occur in ulcerative colitis was developed, which should be applicable to other forms of inflammatory bowel disease as well. The classification makes use of standardized terminology, addresses specific problem areas, and offers practical solutions. The reproducibility of the system was studied by means of examinations of both inter- and intra-observer variations. The clinical implications of the findings were incorporated into suggestions for patient management. The basis of the classification is that the term "dysplasia" is reserved for epithelial changes that are unequivocally neoplastic and may therefore give rise directly to invasive carcinoma. Specimens are categorized as negative, indefinite, or positive for dysplasia. The negative category includes all inflammatory and regenerative lesions and indicates that only continued regular surveillance is required. The indefinite category is applied to epithelial changes that appear to exceed the limits of ordinary regeneration but are insufficient for an unequivocal diagnosis of dysplasia or are associated with other features that prevent such unequivocal diagnosis. Clinically, it indicates that early repeat biopsy is often required to assess the changes more accurately. The positive category is divided into two subcategories: 1) high-grade dysplasia, for which colectomy should be strongly considered after confirmation of the diagnosis, and 2) low-grade dysplasia, which also requires confirmation and early repeat biopsy or colectomy, depending on other findings.

Colorectal carcinoma in patients with ulcerative colitis

Analysis of a 30 year (1950 to 1979) series of colorectal carcinoma disclosed 29 patients with ulcerative colitis, who were compared in this retrospective study with 1,032 noncolitic patients. Colitic tumors were often multiple and had a predilection for the transverse colon. Nineteen patients were resected with the intention of cure, for a curability rate of 66 percent, which is comparable to the 69 percent rate in noncolitic patients. The 5 year survival rate was 31 percent overall and 47 percent in curable cases, rates similar to those in noncolitic patients (34 and 47 percent). All patients with Dukes' A lesions survived 5 years. A high incidence of Dukes' C lesions was observed; one third of these patients survived 5 years . Apart from the advanced stage, no signs of "aggressiveness" or particular virulence were demonstrated in colitic cancer. Results of procedures less than proctocolectomy in 13 patients were dismal: 4 died from cancer within 3 years, and 6 developed late carcinoma in the retained part of the bowel, with a fatal outcome in all.

Prognosis of carcinoma in ulcerative colitis

Between 1947 and 1980, 67 patients with carcinoma complicating ulcerative colitis were treated at St Mark's Hospital. The tumours in these patients were compared with those in 4817 patients without colitis seen over the same period. There was a higher proportion of inoperable and high grade tumours in the colitic group but the prognosis was found to be very similar in patients with and without colitis.

Clinical evaluation of the Makari Intradermal Test in patients with cancer of the colon and rectum

A clinical study to evaluate the Makari Intradermal Test (MIT) involved 180 patients seen with symptoms suggestive of malignant disease, 85 of whom were subsequently shown to have carcinoma of the large bowel, and 66 asymptomatic volunteers. The prognostic value of initial and serial studies relative to patient-survival rate and the efficacy of serial studies in detecting disease in long-term follow-up of patients with resected malignant lesions were evaluated. On the basis of this study, the MIT appears to merit further investigation, not as a definitive diagnostic procedure, but as a survey for identifying patients with early malignancy or individuals at high risk to malignant epigenesis.

Colonoscopy and the detection of dysplasia in patients with longstanding ulcerative colitis

The role of colonoscopy in the surveillance of patients with ulcerative colitis for dysplasia was investigated in 43 patients with longstanding disease extending proximally beyond the splenic flexure. The examination was well tolerated and no complications were recorded. Dysplasia was found in 9 patients in one or more biopsies and was severe in 2, moderate in 1, and mild in 6. Both the patients with severe dysplasia had a carcinoma at subsequent operation. Colonoscopy may allow complete examination of the colon and biopsy of suspicious lesions and, since dysplasia may spare the rectum, colonoscopy with biopsy is a desirable component of any surveillance programme of the at-risk colitic.

Carcinoma in the retained rectum after colectomy for ulcerative colitis

A carcinoma arising in an excluded rectal stump 18 years after ileostomy and 14 years after subtotal colectomy has been described. Extent of involvement of the colon, age of the patient at onset of colitis, and duration of symptomatology are factors whcih have been shown to influence the incidence of carcinoma complicating ulcerative colitis. Fifty-eight similar cases of carcinoma developing in a retained rectum were collected from the literature. The incidence of this complication is approximately 3 per cent. Rectum-sparing operations do not appear to decrease the incidence of malignant transformation in ulcerative colitis. A decision to retain the rectum after colonic resection for ulcerative colitis must take into account both the significant incidence of malignant transformation associated with all rectum-sparing procedures and also the significant incidence of recurrent symptoms following this procedure.

Precancerous lesions in the mucosa in ulcerative colitis. A radiographic, endoscopic, and histopathologic study

A series of 150 patients with ulcerative colitis, 100 of which had had the disease more than 10 years, underwent colonoscopy on at least one occasion. 4700 biopsies of the mucosa of the gut were taken and examined histopathologically. 148 of the colonoscopies were performed within 12 months of the radiographic examination of the colon. Precancerous lesions were detected in 12 patients and moderate to severe reactive inflammatory changes in 39. One of the 12 patients with precancerous lesions was found to have a carcinoma in the same region at surgery 18 months later. No further cases of carcinoma in the series have been observed at follow-up surgery. Radiography and endoscopy demonstrated a higher rate of certain features of inflammation in the parts of colon with precancerous lesions, but no particular feature could be taken to indicate the presence of such lesions. All patients with precancerous lesions had on some occasion been radiologically and/or endoscopically judged to have total colitis, compared with 75% in the whole series. Analysis of clinical data in patients with and without precancerous lesions revealed no significant difference between the groups.

Cancer of the rectum following colectomy and ileorectal anastomosis for ulcerative colitis

The case notes of all patients treated for ulcerative colitis by colectomy and ileorectal anastomosis at the Gordon Hospital under the care of Mr S. O. Aylett from 1952 to 1976 have been reviewed. Three hundred and seventy-four patients left hospital with an ileorectal anastomosis and have been followed for periods up to 23 years. Twenty-two patients are known to have developed a carcinoma of the rectum. Within 10 years of the onset of the disease, no rectal carcinoma was found in 3534 patient-years. The risk was 1 in 185 patient-years between the tenth and twentieth years and 1 in 115 patient-years between the twentieth and thirtieth years. The cumulative risk was 6 per cent (+/- 2 per cent) at 20 years and 15 per cent (+/- 4 per cent) at 30 years. The need for meticulous follow-up is emphasized. The finding of dysplasia in rectal mucosal biopsies will, it is hoped, identify the patient at particularly high risk and enable rectal excision to be undertaken before carcinoma develops.

Radiological detection of colonic dysplasia (precarcinoma) in chronic ulcerative colitis

Epithelial dysplasia occurring in long-standing ulcerative colitis is a precancerous lesion. Macroscopically it has a nodular or villous appearance or may be indistinguishable from the surrounding mucosa. An investigation into the radiological diagnosis of dysplasia, using in vivo and in vitro double-contrast examinations with magnification radiographic studies, correlated with the histological analysis, has been made in four patients. Characteristic radiological abnormalities have been identified in the areas of the mucosa associated with histologically proven dysplasia. These appearances include nodularity and irregular areas with sharply angulated edges which may represent enlarged areae colonicae. The demonstration of these changes is an indication for endoscopic examination and biopsy of the suspicious area.

Multicentric colonic lymphoma complicating ulcerative colitis

A 72-year-old female with ulcerative colitis of 30 years duration underwent total proctocolectomy for a cecal mass thought to be an adenocarcinoma. Pathologic examination of the colon revealed 22 tumors, all of which proved to be malignant lymphoma, histiocytic type. Thirteen cases of non-Hodgkins malignant lymphoma and 2 cases of Hodgkins disease of the colon arising in ulcerative colitis are reviewed and discussed.

[Malignant degeneration of experimental ulcerative colitis of the rat following s.c. injection of 1,2-dimethylhydrazine (author's transl)]

Animal experiments were performed to answer the question whether ulcerative colitis is predisposed to malignant degeneration. Male Wistar rats were given aqueous solutions of degraded Carrageenan (4%; w/v). After induction of ulcerative colitis, 1,2-Dimethylhydrazine (DMH; 132 mg/kg body weight) was applicated during a period of 7 weeks. 17 of 18 rats developed multiple adenocarcinomas in the distal colon 15 weeks after the last injection of DMH. The Carrageenan induced colitis was localized predominantly in the distal part of the large bowel. Only 3 rats of a control group of 18 animals exposed to DMH only showed carcinomas of the colon. The difference is proven significant (P less than 0.01). Carrageenan for itself caused no malignancy. The results of the experiments demonstrate that, during ulcerative colitis, the colon of the rat is more susceptible to induction of cancer than the intact one.

Cancer in chronic ulcerative colitis. Diagnostic role of segmental colonic lavage

Saline colonic lavage in 74 patients with chronic ulcerative colitis was performed utilizing a commercially available dental irrigating unit through a polyethylene catheter in the biopsy channel of a colonoscope or through a sigmoidoscope via a lavage-aspirating double-lumen probe. Six patients were found with colonic carcinoma. Two diagnoses of malignancy were established by cytologic smears and cell block alone. Two patients had positive mucosal biopsies and cell block. One patient with a hepatic flexure carcinoma and a second patient with a malignancy proximal to the left colon stricture were missed by these techniques. Considering the established proclivity for carcinoma in these patients, it is felt that segmental lavage in areas of stricutre, grossly dostorted mucosa, or endoscopically inaccessible areas represents a valuable adjunct in the diagnosis of carcinoma in chronic ulcerative colitis.

Cell cycle parameters in human colon: comparison between primary and recurrent adenocarcinomas, benign polyps and adjacent unaffected mucosa

The duration of S phase and the labeling index were measured in adenocarcinomas, in polyps and in adjacent unaffected mucosa of a same patient. The in vitro double labeling technique was employed. The S phase duration in tumors was significantly longer than in unaffected mucosa and polyps. This agrees with previously reported data on human skin, colon and rectum and supports the suggestion that a long S phase might correlated with carcinogenesis. The labeling index in the mucosa adjacent to the tumors is higher than previously measured in normal tissue. Following colectomy however, the labeling index in unaffected mucosa and tumor was lower than prior to surgery. This suggests the disappearance of a systemic factor (in the colon?) which positively regulates the proliferative activity in the rectal and colonic musoca. The maintainance of a lengthened S phase duration in the recurrent tumor where L.I. is lowered, indicates that the proliferation rate and the S phase duration are regulated by separate control factors.