Long-term Risk of Advanced Neoplasia After Colonic Low-grade Dysplasia in Patients With Inflammatory Bowel Disease: A Nationwide Cohort Study

Quality of Surveillance Impacts the Colitis-Associated Advanced Neoplasia Risk: A Multicenter Case-Control Study

BACKGROUND AND AIMS

Although colorectal cancer (CRC) surveillance is embedded in clinical inflammatory bowel disease (IBD) practice, a subset of patients still develops advanced neoplasia (AN) (high-grade dysplasia [HGD] and/or CRC). We aimed to assess the impact of surveillance quality on AN risk in IBD.

METHODS

In this multicenter case-control study, we searched the Dutch nationwide pathology databank to identify IBD cases with AN and controls with indefinite or low-grade dysplasia. The surveillance colonoscopy preceding the index lesion (first indefinite for dysplasia [IND]/low-grade dysplasia [LGD] or AN) was used to assess the impact of surveillance quality. We assessed intervals, bowel preparation, cecal intubation, and absence of inflammation as primary quality indicators. In addition, we assessed chromoendoscopy, endoscopist expertise, hospital setting, and biopsy strategy. Associations of quality indicators with AN risk were determined with multivariable logistic regression analyses with Firth's correction.

RESULTS

We included 137 cases and 138 controls. Delayed intervals (58.2% vs 39.6%) and active inflammation (65.3% vs 41.8%) were frequently present in cases and controls and were associated with AN (delayed interval: adjusted odds ratio [aOR], 2.00; 95% confidence interval [CI], 1.07-3.81; P = .03; active inflammation: aOR, 2.46; 95% CI, 1.33-4.61; P < .01). Surveillance compliant with primary quality indicators was associated with a reduced AN risk (aOR, 0.43; 95% CI, 0.22-0.91; P = .03), similar to chromoendoscopy (OR, 0.11; 95% CI, 0.01-0.89; P = .01). Other indicators were not significantly associated with AN.

CONCLUSIONS

Surveillance compliant with primary quality indicators is associated with a reduced colitis-associated AN risk. Delayed surveillance intervals and active inflammation were associated with an increased AN risk. This underlines the importance of procedural quality, including endoscopic remission to optimize the effectiveness of endoscopic surveillance.

Management of Dysplasia in Inflammatory Bowel Disease

Given the chronic nature of mucosal inflammation present in patients with inflammatory bowel disease (IBD), there is a high risk of dysplastic lesions progressing to cancer, in addition to a high risk of synchronous and/or metachronous cancers developing in those diagnosed with dysplasia. Due to this, consensus guidelines recommend regular surveillance. When visible dysplasia is encountered, options include endoscopic or surgical resection depending on characteristics of the lesion. Advancements in endoscopic tools increasingly allow for endoscopic removal when appropriate. Invisible dysplasia discovered on random biopsy should prompt referral to physicians who specialize in IBD. While surgical resection with proctocolectomy significantly decreases the risk of colorectal cancer, the risk must be balanced against the morbidity of surgery and quality-of-life concerns. Management of dysplasia in IBD patients requires complex decision-making that requires balance of patient values and goals of care with cancer-related risk factors.

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

BACKGROUND AND AIMS

Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients.

METHODS

Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement.

RESULTS

In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting.

CONCLUSIONS

By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.

Effectiveness of endoscopic resection for colorectal neoplasms in ulcerative colitis: a multicenter registration study

BACKGROUND AND AIMS

Patients with ulcerative colitis (UC) are at risk of developing colorectal cancer. The feasibility of endoscopic resection (ER) for UC-associated neoplasia has been suggested, but its efficacy and safety remain unclear. We aimed to assess the efficacy and safety of ER for colorectal neoplasms in patients with UC.

METHODS

This was a retrospective, multicenter cohort study of patients with UC who initially underwent ER or surgery for colorectal neoplasms between April 2015 and March 2021. Patients who had prior colorectal neoplastic lesions were excluded.

RESULTS

Among 213 men and 123 women analyzed, the mean age at UC onset was 41.6 years, and the mean age at neoplasia diagnosis was 56.1 years for 240 cases of total colitis, 59 cases of left-sided colitis, 31 cases of proctitis, and 6 cases of segmental colitis. EMR was performed for 142 lesions, and endoscopic submucosal dissection (ESD) was performed for 96 lesions. The perforation rate was 2.5% for all 238 lesions removed by ER and 6.3% for the 96 lesions removed by ESD. Among 146 ER lesions followed up with endoscopy, the local recurrence rate was 2.7%. The incidence of metachronous neoplasia after ER was 6.1%. All patients were followed a median of 34.7 months after initial treatment, and 5 died (all surgical cases). Overall survival was significantly higher in the ER group than in the surgery group (P = .0085).

CONCLUSIONS

ER for colorectal neoplasms in UC may be acceptable in selected cases, although follow-up for metachronous lesions is necessary.

Optimizing individualized management of patients with ulcerative colitis: Identification of risk factors predicting ulcerative colitis-associated neoplasia

The risk of developing colorectal neoplasia in patients with ulcerative colitis (UC) is increased. The purpose of this study is to analyze the risk factors of UC-associated neoplasia (UCAN) in UC patients and establish a clinical prediction model. 828 UC patients were included in this retrospective study. 602 patients were in discovery cohort and 226 patients were in validation cohort (internal validation cohort/external validation cohort: 120/106). Clinical and endoscopic data were collected. The discovery cohort was divided into UC group and UCAN group for univariate and multivariate binary logistic analyses. The UCAN clinical prediction model was established and verified. In the univariate analysis, 7 risk factors were related to UCAN. Multivariate logistic regression analysis showed that age at diagnosis of UC (OR: 1.018, 95% CI: 1.003-1.033), Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score (OR: 1.823, 95% CI: 1.562-2.128), and size of polyps (size1: OR: 6.297, 95% CI: 3.669-10.809; size2: OR: 12.014, 95% CI: 6.327-22.814) were independent risk factors of UCAN. A mathematical equation was established. The area under the ROC curve (AUC) of this model was calculated to be 0.845 (95%CI: 0.809-0.881). The sensitivity was 0.884 and the specificity was 0.688. The AUC of internal validation cohort was 0.901 (95%CI: 0.815, 0.988), sensitivity was 75.0% and specificity was 92.6%. The AUC of external validation cohort was 0.842 (95%CI: 0.709, 0.976), sensitivity was 62.5% and specificity was 93.9%. This prediction model is simple, practical, and effective for predicting the risk of UCAN, which is beneficial to the individualized management of patients with UC.

Low risk of new dysplastic lesions in an inflammatory bowel disease population study with dye chromoendoscopy

Background and study aims  Rates of new dysplastic lesions or cancer progression after first dye chromoendoscopy in the era of high-definition endoscopy have yet to be determined. Patients and methods  A multicenter, population-based, retrospective cohort study was performed in seven hospitals in Spain. Patients with inflammatory bowel disease and fully resected (R0) dysplastic colon lesions under surveillance with high-definition dye-based chromoendoscopy were sequentially enrolled between February 2011 and June 2017, with a minimum endoscopic follow-up of 36 months. The aim was to assess the incidence of developing more advanced metachronous neoplasia by analyzing possible associated risk factors. Results  The study sample included 99 patients and 148 index lesions (145 low-grade dysplasia lesions and three high-grade dysplasia [HGD] lesions with a mean follow-up of 48.76 months [IQR: 36.34-67.15]). The overall incidence of new dysplastic lesions was 0.23 per 100 patient-years, 1.15 per 100 patients at 5 years and 2.29 per 100 patients at 10 years. A history of dysplasia was associated with a higher risk of developing any grade of dysplasia during follow-up ( P  = 0.025), whereas left colon lesions were associated with a lower risk ( P  = 0.043). The incidence of more advanced lesions at 1 year and 10 years was 1 % and 14 % respectively, with lesion size > 1 cm being a risk factor ( P  = 0.041). One of the eight patients (13 %) with HGD lesions developed colorectal cancer during follow-up. Conclusions  The risk of dysplasia progressing to advanced neoplasia and, specifically, the risk of new neoplastic lesions after endoscopic resection of colitis-associated dysplasia, are both very low.

Image-Enhanced Endoscopy Surveillance of Colon and Pouch Dysplasia in IBD

BACKGROUND

Patients with longstanding ulcerative colitis and Crohn's colitis are at risk for developing colorectal cancer and need regular endoscopic surveillance to detect and remove precursor lesions. To do so, different technologies are available.

DATA SOURCES

The sources are observational and controlled studies, meta-analysis, and expert consensus articles available on PubMed.

STUDY SELECTION

The selected materials include articles reporting outcomes of and recommendations on endoscopic surveillance and resection of dysplasia in the gastrointestinal tract, including the ileoanal pouch and the anal transition zone, in patients with inflammatory bowel disease.

MAIN OUTCOME MEASURES

Incidence and detection rate of dysplasia and cancer with different endoscopic techniques in patients with inflammatory bowel disease.

RESULTS

Risk of cancer is proportional to the duration and extent of the disease, and surveillance interval should be tailored on the individual risk in a range of 1 to 5 years. High-definition imaging and virtual chromoendoscopy have improved the detection of dysplasia and are now comparable with conventional dye spray chromoendoscopy. After restorative proctocolectomy with ileoanal pouch, the risk of cancer is modest, but its high mortality warrants endoscopic surveillance. The evidence to guide pouch surveillance is limited, and recently, the first expert consensus provided a framework of recommendations, which include an initial assessment 1 year after surgery and follow-up depending on individual risk factors.

LIMITATIONS

The limitation includes scarcity of data on ileoanal pouch surveillance.

CONCLUSIONS

Virtual chromoendoscopy and high-definition imaging have improved endoscopic surveillance, and more progress is expected with the implementation of artificial intelligence systems.

Multicentre derivation and validation of a colitis-associated colorectal cancer risk prediction web tool

OBJECTIVE

Patients with ulcerative colitis (UC) diagnosed with low-grade dysplasia (LGD) have increased risk of developing advanced neoplasia (AN: high-grade dysplasia or colorectal cancer). We aimed to develop and validate a predictor of AN risk in patients with UC with LGD and create a visual web tool to effectively communicate the risk.

DESIGN

In our retrospective multicentre validated cohort study, adult patients with UC with an index diagnosis of LGD, identified from four UK centres between 2001 and 2019, were followed until progression to AN. In the discovery cohort (n=246), a multivariate risk prediction model was derived from clinicopathological features using Cox regression. Validation used data from three external centres (n=198). The validated model was embedded in a web tool to calculate patient-specific risk.

RESULTS

Four clinicopathological variables were significantly associated with AN progression in the discovery cohort: endoscopically visible LGD >1 cm (HR 2.7; 95% CI 1.2 to 5.9), unresectable or incomplete endoscopic resection (HR 3.4; 95% CI 1.6 to 7.4), moderate/severe histological inflammation within 5 years of LGD diagnosis (HR 3.1; 95% CI 1.5 to 6.7) and multifocality (HR 2.9; 95% CI 1.3 to 6.2). In the validation cohort, this four-variable model accurately predicted future AN cases with overall calibration Observed/Expected=1.01 (95% CI 0.64 to 1.52), and achieved 100% specificity for the lowest risk group over 13 years of available follow-up.

CONCLUSION

Multicohort validation confirms that patients with large, unresected, multifocal LGD and recent moderate/severe inflammation are at highest risk of developing AN. Personalised risk prediction provided via the Ulcerative Colitis-Cancer Risk Estimator ( www.UC-CaRE.uk ) can support treatment decision-making.

Systematic review with meta-analysis: incidence and factors for progression to advanced neoplasia in inflammatory bowel disease patients with indefinite and low-grade dysplasia

BACKGROUND

Due to limited research on the natural history of indefinite for dysplasia (IND) and low-grade dysplasia (LGD) in inflammatory bowel disease (IBD), the management of these patients is controversial.

AIMS

This systematic review and meta-analysis aimed to estimate the incidence and identify the risk factors for advanced neoplasia in IBD patients with IND and LGD.

METHODS

PubMed, Embase and Cochrane Central Register of Controlled Trials were searched until 24 December, 2021, to identify studies that reported pathological results of follow-up colonoscopy or surgery in IBD patients with IND and LGD. The main outcomes were the incidence and risk factors for advanced neoplasia in IBD patients with IND and LGD.

RESULTS

Based on the analysis of 38 studies, the pooled incidences of advanced neoplasia in IBD patients with IND and LGD were 9.9% (95% CI 4.4%-15.4%) and 10.7% (95% CI 7.0%-14.4%) respectively. The risk factors for advanced neoplasia in IND patients were primary sclerosing cholangitis (PSC) and aneuploidy. The risk factors for advanced neoplasia in LGD patients included male, PSC, previous IND, colonic stricture, index lesion ≥1 cm, distal location, multifocal lesions, distal and flat lesions, nonpolypoid/flat lesions and invisible lesions.

CONCLUSIONS

The incidence of advanced neoplasia was similar between IND and LGD in IBD patients, as high as one in ten, so more rigorous surveillance is also suggested in IND patients. Since the effects of most factors were derived from the pooled results of only two to three studies, further research was needed to confirm our results.

Endoscopic colorectal cancer surveillance in inflammatory bowel disease: Considerations that we must not forget

Inflammatory bowel disease (IBD), encompassing Crohn's disease and ulcerative colitis, is a chronic immune-mediated inflammatory disease that primarily affects the gastrointestinal tract and is characterized by periods of activity and remission. The inflammatory activity of the disease involving the colon and rectum increases the risk of colorectal cancer (CRC) over the years. Although prevention strategies are evolving, regular surveillance for early detection of neoplasia as a secondary prevention strategy is paramount in the care of IBD patients. In this review article, we discuss the current evidence of the risks of developing CRC and evaluate the best available strategies for screening and surveillance, as well as future opportunities for cancer prevention.

Increased Colorectal Neoplasia Risk in Patients with Inflammatory Bowel Disease and Serrated Polyps with Dysplasia

BACKGROUND

The impact of serrated polyps on the advanced colorectal neoplasia (CRN) risk in inflammatory bowel disease (IBD) patients is unknown. Serrated polyps are histologically categorized as hyperplastic polyps (HPs), sessile serrated lesions (SSLs), and traditional serrated adenomas (TSAs).

AIMS

We aimed (1) to characterize the serrated polyps in IBD patients, (2) to identify factors associated with the presence of serrated polyps in IBD, and (3) to assess the CRN risk in IBD patients with serrated polyps.

METHODS

We established a retrospective cohort of IBD patients with and without colonic serrated polyps. Cox-regression analysis with time-dependent variables was used to compare advanced CRN risk in IBD patients with and without serrated polyps.

RESULTS

Of the 621 enrolled IBD patients, 198 had a serrated polyp (92 HPs, 88 SSLs without dysplasia, 13 SSLs with dysplasia, and 5 TSAs). Independent factors associated with serrated polyps were ulcerative colitis (UC) (odds ratio (OR) 1.77, 95% confidence interval (CI) 1.19-2.62, p = 0.005), male gender (OR 1.63, 95% CI 1.11-2.40, p = 0.013), and older age (per year increase, OR 1.06, 95%CI 1.05-1.08, p < 0.001). TSAs and SSLs with dysplasia were risk factors for subsequent advanced CRN (HR 13.51, 95% CI 3.11-58.68, p < 0.001), while HPs (HR 1.98, 95% CI 0.46-8.60, p = 0.36) and SSLs without dysplasia (HR 0.87, 95% CI 0.11-6.88, p-0.89) did not impact the subsequent advanced CRN risk.

CONCLUSIONS

UC, male gender and older age were associated with the presence of serrated polyps. The majority of serrated polyps (91%) were HPs and SSL without dysplasia and did not affect the CRC risk. However TSAs and SSLs with dysplasia, representing a small subgroup of serrated polyps (9%), were associated with subsequent advanced CRN.

Colorectal Dysplasia and Cancer Surveillance in Ulcerative Colitis

Ulcerative colitis (UC) is a risk factor for the development of inflammation-associated dysplasia or colitis-associated neoplasia (CAN). This transformation results from chronic inflammation, which induces changes in epithelial proliferation, survival, and migration via the induction of chemokines and cytokines. There are notable differences in genetic mutation profiles between CAN in UC patients and sporadic colorectal cancer in the general population. Colonoscopy is the cornerstone for surveillance and management of dysplasia in these patients. There are several modalities to augment the quality of endoscopy for the better detection of dysplastic or neoplastic lesions, including the use of high-definition white-light exam and image-enhanced colonoscopy, which are described in this review. Clinical practice guidelines regarding surveillance strategies in UC have been put forth by various GI societies, and overall, there is agreement between them except for some differences, which we highlight in this article. These guidelines recommend that endoscopically detected dysplasia, if feasible, should be resected endoscopically. Advanced newer techniques, such as endoscopic mucosal resection and endoscopic submucosal dissection, have been utilized in the treatment of CAN. Surgery has traditionally been the mainstay of treating such advanced lesions, and in cases where endoscopic resection is not feasible, a proctocolectomy, followed by ileal pouch-anal anastomosis, is generally recommended. In this review we summarize the approach to surveillance for cancer and dysplasia in UC. We also highlight management strategies if dysplasia is detected.

The Fate of Unifocal Versus Multifocal Low-Grade Dysplasia at the Time of Colonoscopy in Patients With IBD

BACKGROUND

Recommendations regarding management of colorectal dysplasia in the setting of IBD continue to evolve.

OBJECTIVE

This study aimed to determine the rate of progression from dysplasia to adenocarcinoma, specifically focusing on the differences in unifocal and multifocal low-grade dysplasia and dysplasia found on random biopsy versus targeted biopsies.

DESIGN

This is a retrospective review.

SETTING

This study was conducted at an IBD referral center.

PATIENTS

All adult patients (≥18 years of age) with a known diagnosis of either ulcerative colitis or Crohn's disease, who underwent a surveillance colonoscopy between January 1, 2010 and January 1, 2019, were selected.

MAIN OUTCOMES MEASURES

The primary outcomes measured were the progression of dysplasia and the risk factors for progression.

RESULTS

A total of 23,751 surveillance colonoscopies were performed among 12,289 patients between January 1, 2010 and January 1, 2019. The mean age at colonoscopy was 52.1 years (SD 16.9 years), 307 patients (2.5%) had a history of primary sclerosing cholangitis, and 3887 (3.15%) had a family history of colorectal cancer. There was a total of 668 patients (5.4%) with low-grade dysplasia, 76 patients (0.62%) with high-grade dysplasia, and 68 patients (0.55%) with adenocarcinoma in the series. The 1-, 2-, and 5-year cumulative incidence rate of progressing from low-grade dysplasia to high-grade dysplasia were 1.6%, 4.8%, and 7.8%. The 1- and 2-year cumulative incidence rates of progressing from low-grade dysplasia to adenocarcinoma were 0.7% and 1.6%. There were no significant differences in unifocal and multifocal progression. Primary sclerosing cholangitis, ulcerative colitis, male sex, and advanced age were all found to be significant risk factors for neoplasia on multivariable analysis.

LIMITATIONS

A retrospective database was a source of information.

CONCLUSION

Progression of low-grade dysplasia to adenocarcinoma, regardless of its being unifocal or multifocal, remains very low in the setting of adequate surveillance and medical management. The presence of multifocal low-grade dysplasia should not change the decision making to pursue ongoing endoscopic surveillance versus proctocolectomy. Patients who had primary sclerosing cholangitis with dysplasia found on random biopsies may be at highest risk for dysplasia progression. See Video Abstract at http://links.lww.com/DCR/A649.

EL DESENLACE DE LA DISPLASIA DE BAJO GRADO UNIFOCAL VERSUS MULTIFOCAL DURANTE LA COLONOSCOPIA EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL

ANTECEDENTES:Las recomendaciones para el tratamiento de la displasia colorrectal en el contexto de la enfermedad inflamatoria intestinal siguen evolucionando.OBJETIVO:Determinar la tasa de progresión de displasia a adenocarcinoma, centrándose específicamente en las diferencias en displasia de bajo grado unifocal y multifocal, y displasia encontradas en biopsias aleatorias versus biopsias dirigidas.DISEÑO:Revisión retrospectiva.ÁMBITO:Centro de referencia de EII.PACIENTES:Todos los pacientes adultos (> 18 años) con un diagnóstico comprobado de colitis ulcerosa o enfermedad de Crohn que se sometieron a una colonoscopia de vigilancia entre el 1 de enero de 2010 y el 1 de enero de 2019.PRINCIPALES VARIABLES ANALIZADAS:Progresión de la displasia y factores de riesgo de progresión.RESULTADOS:Se realizaron un total de 23.751 colonoscopias de vigilancia en 12.289 pacientes entre el 1/1/2010 y el 1/1/2019. La edad media en el momento de la colonoscopia fue de 52,1 años (DE 16,9 años), 307 pacientes (2,5%) tenían antecedentes de colangitis esclerosante primaria y 3887 (3,15%) tenían antecedentes familiares de cáncer colorrectal. Hubo un total de 668 pacientes (5,4%) con displasia de bajo grado, 76 pacientes (0,62%) con displasia de alto grado y 68 pacientes (0,55%) con adenocarcinoma en la serie. La tasa de incidencia acumulada de 1, 2, 5 años de progresión de displasia de bajo grado a displasia de alto grado fue del 1,6%, 4,8% y 7,8%. Las tasas de incidencia acumulada de 1 y 2 años de progresión de displasia de bajo grado a adenocarcinoma fueron 0,7% y 1,6%, respectivamente. No hubo diferencias significativas en la progresión unifocal y multifocal. Se encontró que la colangitis esclerosante primaria, la colitis ulcerosa, el sexo masculino y la edad avanzada eran factores de riesgo significativos de neoplasia en el análisis multivariable.LIMITACIONES:Base de datos retrospectiva.CONCLUSIÓN:La progresión de la displasia de bajo grado a adenocarcinoma, independientemente de que sea unifocal o multifocal, sigue siendo muy baja en el contexto de una vigilancia y un tratamiento médico adecuados. La presencia de displasia multifocal de bajo grado no debería cambiar la toma de decisión para continuar con vigilancia endoscópica continua o realizar la proctocolectomía. Los pacientes con colangitis esclerosante primaria y displasia encontrada en biopsias aleatorias pueden tener una mayor progresión de la displasia. Consulte Video Resumen en http://links.lww.com/DCR/A649.

Predicting Colorectal Cancer Occurrence in IBD

Patients with colonic inflammatory bowel disease (IBD) are at an increased risk of developing colorectal cancer (CRC), and are therefore enrolled into a surveillance programme aimed at detecting dysplasia or early cancer. Current surveillance programmes are guided by clinical, endoscopic or histological predictors of colitis-associated CRC (CA-CRC). We have seen great progress in our understanding of these predictors of disease progression, and advances in endoscopic technique and management, along with improved medical care, has been mirrored by the falling incidence of CA-CRC over the last 50 years. However, more could be done to improve our molecular understanding of CA-CRC progression and enable better risk stratification for patients with IBD. This review summarises the known risk factors associated with CA-CRC and explores the molecular landscape that has the potential to complement and optimise the existing IBD surveillance programme.

Prognostic Factors for Advanced Colorectal Neoplasia in Inflammatory Bowel Disease: Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) have an increased risk of colorectal cancer (CRC). We performed a systematic review and meta-analysis to identify all prognostic factors for advanced colorectal neoplasia (aCRN, high-grade dysplasia, or CRC) in patients with IBD.

METHODS

A systematic literature search was conducted according to the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Risk of bias was assessed using the Quality in Prognostic Studies tool. Random-effects models were created separately for odds and hazard ratios, different study designs, and univariable or multivariable data. The evidence for all prognostic factors was categorized as "weak", "moderate", or "strong", based on estimate of effect sizes, heterogeneity, and risk of bias.

RESULTS

A total of 164 studies were included, allowing pooled analysis of 31 potential prognostic factors. In the univariable analysis, the evidence for extensive disease was classified as strong while evidence for low-grade dysplasia, strictures, primary sclerosing cholangitis, post-inflammatory polyps, family history of CRC, and ulcerative colitis versus Crohn's disease was considered moderate. Evidence for any dysplasia, colon segment resection, aneuploidy, male sex, and age was classified as weak. In addition, histologic inflammation was identified as a risk factor in multivariable analysis (weak evidence). The evidence for the protective factors colonoscopic surveillance, 5-Aminosalicylic Acid, thiopurines, and smoking was moderate in univariable analysis. Multivariable analysis provided weak evidence for statin use.

CONCLUSIONS

In this systematic review and meta-analysis, we identified 13 risk factors and 5 protective factors for aCRN in IBD patients, based on univariable and/or multivariable pooled analyses. These findings might lay the groundwork for an improved CRC risk stratification-based surveillance in IBD.

Dysplastic Progression to Adenocarcinoma is Equivalent in Ulcerative Colitis and Crohn's Disease

BACKGROUND

We sought to determine the rate of progression from dysplasia to adenocarcinoma in ulcerative colitis [UC] vs Crohn's diseases [CD] and describe the risk factors unique to each.

METHODS

All adult patients [≥18 years] with a known diagnosis of either UC or CD who underwent a surveillance colonoscopy between January 1, 2010 and January 1, 2020 were included.

RESULTS

A total of 23 751 surveillance colonoscopies were performed among 12 289 patients between January 1, 2010 and January 1, 2020; 6909 [56.2%] had a diagnosis of CD and 5380 [43.8%] had a diagnosis of UC. There were a total of 668 patients [5.4%] with low-grade dysplasia [LGD], 76 patients [0.62%] with high-grade dysplasia [HGD], and 68 patients [0.55%] with adenocarcinoma in the series; the majority of the dysplastic events were located in the right colon. Significantly more UC patients had a dysplastic event, but the rate of LGD and HGD dysplasia progression to adenocarcinoma was not significantly different in CD or UC [p = 0.682 and p = 1.0, respectively]. There was no significant difference in the rate of progression from LGD/HGD to adenocarcinoma based on random biopsies vs targeted biopsies of visible lesions [p = 0.37]. However, the rate of progression from LGD vs HGD to adenocarcinoma was significantly greater for HGD [p < 0.001].

CONCLUSION

While more UC patients were found to have neoplasia on colonoscopy, the rate of progression from LGD and HGD to adenocarcinoma was equivalent in UC and CD, suggesting that endoscopic surveillance strategies can remain consistent for all IBD patients.

Effects of 5-aminosalicylates or thiopurines on the progression of low-grade dysplasia in patients with inflammatory bowel disease: a systematic review and meta-analysis

PURPOSE

Although 5-aminosalicylates and thiopurines may have an antineoplastic effect on colorectal neoplasia in patients with inflammatory bowel disease (IBD), their impact on the progression of low-grade dysplasia (LGD) in IBD is uncertain. Therefore, we performed a systematic review and meta-analysis to evaluate whether 5-aminosalicylates or thiopurines can protect against the progression of LGD in patients with IBD.

METHODS

Systematic searches of PubMed, EMBASE, Cochrane Library databases, and major conference proceedings were conducted to identify all eligible studies through March 2020. Data were pooled using a random effects model. Study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Five studies comprising 776 IBD patients with LGD were included. Overall, 5-aminosalicylates (Hazard ratio (HR) = 0.91, 95% confidence interval (CI) 0.55-1.51) and thiopurines (HR = 0.64, 95% CI 0.23-1.79) did not significantly reduce the risk of advanced colorectal neoplasia (high-grade dysplasia/cancer) in IBD patients with LGD. Moreover, the effects of 5-aminosalicylates or thiopurines on risk of advanced colorectal neoplasia in IBD patients with LGD were not significant by different primary sclerosing cholangitis status, study quality, sample size, and IBD type.

CONCLUSIONS

In this study, we did not find a significant protective effect of 5-aminosalicylates or thiopurines on the progression of LGD in patients with IBD.

Solute carrier family 12 member 2 as a proteomic and histological biomarker of dysplasia and neoplasia in ulcerative colitis

BACKGROUND AND AIMS

Ulcerative colitis (UC) patients have a greater risk of developing colorectal cancer through inflammation-dysplasia-carcinoma sequence of transformation. The histopathological diagnosis of dysplasia is therefore of critical clinical relevance, but dysplasia may be difficult to distinguish from inflammatory changes.

METHODS

A proteomic pilot study on 5 UC colorectal dysplastic patients highlighted proteins differentially distributed between paired dysplastic, inflammatory and normal tissues. The best candidate marker was selected and immunohistochemistry confirmation was performed on AOM/DSS mouse model lesions, 37 UC dysplasia, 14 UC cancers, 23 longstanding UC, 35 sporadic conventional adenomas, 57 sporadic serrated lesions and 82 sporadic colorectal cancers.

RESULTS

Differential proteomics found 11 proteins significantly more abundant in dysplasia compared to inflammation, including Solute carrier family 12 member 2 (SLC12A2) which was confidently identified with 8 specific peptides and was below the limit of quantitation in both inflammatory and normal colon. SLC12A2 immunohistochemical analysis confirmed the discrimination of preneoplastic and neoplastic lesions from inflammatory lesions in mice, UC and in sporadic contexts. A specific SLC12A2 staining pattern termed "loss of gradient" reached 89% sensitivity, 95% specificity and 92% accuracy for UC-dysplasia diagnosis together with an inter-observer agreement of 95.24% (multirater κfree of 0.90; IC95%: 0.78 - 1.00). Such discrimination could not be obtained by Ki67 staining. This specific pattern was also associated with sporadic colorectal adenomas and cancers.

CONCLUSIONS

We found a specific SLC12A2 immunohistochemical staining pattern in precancerous and cancerous colonic UC-lesions which could be helpful for diagnosing dysplasia and cancer in UC and non-UC patients.

No Increased Risk of Colorectal Neoplasia in Patients With Inflammatory Bowel Disease and Postinflammatory Polyps

BACKGROUND

Patients with inflammatory bowel disease (IBD) who have postinflammatory polyps (PIPs) may have an increased risk of developing colorectal neoplasia. Current guidelines recommend an intensified surveillance strategy in these patients, although the evidence for this recommendation is conflicting. The aim of our study was to assess whether IBD patients with PIPs are at increased risk of colorectal neoplasia.

METHODS

We established a retrospective cohort in a tertiary IBD center with IBD patients undergoing colorectal cancer (CRC) surveillance in the current era. We compared cumulative incidences of colorectal neoplasia since IBD diagnosis between patients with and without PIPs and corrected for confounders. Second, we compared the risk of receiving a colectomy.

RESULTS

In our cohort with >22 years of median follow-up, 154 of 519 patients had PIPs. PIPs were associated with extensive disease (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.61-4.42; P < 0.001) and with more severe inflammation at colonoscopy (OR, 3.54; 95% CI, 2.28-5.50; P < 0.001). After correction for confounders, the presence of PIPs was not associated with development of colorectal neoplasia (hazard ratio [HR], 1.28; 95% CI, 0.85-1.93; P = 0.24) or with development of advanced neoplasia (HR, 1.38; 95% CI, 0.52-3.68; P = 0.52). There was a higher risk of colectomy in patients with PIPs (HR, 3.41; 95% CI, 1.55-7.54; P = 0.002).

CONCLUSION

In this cohort, PIPs were associated with disease extent, inflammation, and higher rates of colectomy. However, the presence of PIPs was not associated with the development of neoplasia. These findings suggest that patients with PIPs may not need an intensified surveillance strategy.

Increased risk of high-grade dysplasia and colorectal cancer in inflammatory bowel disease patients with recurrent low-grade dysplasia

BACKGROUND AND AIMS

The impact of recurrent low-grade dysplasia (LGD) on the risk of advanced neoplasia (high-grade dysplasia and colorectal cancer) in inflammatory bowel disease (IBD) patients is unknown. In addition, it is unclear how a neoplasia-free period after index LGD impacts this risk. We aimed to determine whether recurrent LGD is a risk factor for advanced neoplasia development and to evaluate the impact of a neoplasia-free time period after initial LGD diagnosis on the advanced neoplasia risk.

METHODS

This is a nationwide cohort study using data from the Dutch National Pathology Registry to identify all IBD patients with LGD and ≥1 follow-up colonoscopy between 1991 and 2010 in the Netherlands. Follow-up data were collected until January 2016. We compared the cumulative advanced neoplasia incidence between patients with and without recurrent LGD at first follow-up colonoscopy using log-rank analysis. We subsequently studied the impact of a neoplasia-free period after initial LGD on the advanced neoplasia incidence.

RESULTS

We identified 4284 IBD patients with colonic LGD with a median follow-up of 6.4 years. Recurrent LGD was a risk factor for advanced neoplasia (hazard ratio, 1.66; 95% confidence interval, 1.22-2.25; P = .001). A neoplasia-free period of at least 3 years after LGD protected against advanced neoplasia.

CONCLUSIONS

Recurrent LGD at follow-up colonoscopy after initial LGD was a risk factor for advanced neoplasia. A neoplasia-free period of at least 3 years after initial LGD was associated with a reduced subsequent risk of advanced neoplasia.

Early Surgery in Inflammatory Bowel Diseases Is a Better Option than Prolonged Conservative Treatment

Early surgery is a very important aspect of treatment of inflammatory bowel diseases. In Crohn's disease, early surgery should be performed in emergencies, in refractory courses, and in special cases at the beginning of the disease if there is a stenosis limited to the terminal ileum. In ulcerative colitis, prolonged therapy with extended application of all available substances should be avoided. Every therapy with more than 2 biologicals endangers the patient. Low-grade intraepithelial neoplasia (IEN) should also be resected earlier due to a 23% risk of synchronous and metachronous high-grade IEN or cancer.