Colonoscopic surveillance for cancer in ulcerative colitis: a critical review

Clinical pattern and progression of ulcerative proctitis in the Japanese population: a retrospective study of incidence and risk factors influencing progression

AIM

The rate of extension of proctitis in Western countries has been reported, but no data regarding long-term follow-up have been described for the Japanese population. Additionally, patients with long-standing or extensive ulcerative colitis have an increased risk for developing colorectal cancer. This study evaluated both the rate of extension of the disease and the development of neoplasia among patients with an initial diagnosis of ulcerative proctitis.

METHOD

We retrospectively investigated the medical charts of patients with proctitis from 1979 to 2014. The primary focus of this research was the extension of the inflammatory area. The secondary focus included risk factors for disease extension and the development of neoplasia.

RESULTS

Sixty-six patients satisfied the inclusion criteria. Proximal extension of the disease occurred in 34 patients: 19 patients had left-sided colitis and 15 had pancolitis. According to a multivariate analysis, disease extension was significantly higher in patients with disease onset before 25 years of age (P-value = 0.043). The cumulative rates of disease extension at 10 and 20 years were 33.8% and 52.2%, respectively. Three patients were diagnosed with dysplasia during follow-up, all of whom experienced disease extension before the development of dysplasia.

CONCLUSION

The rate of extension of ulcerative colitis in the Japanese population was comparable to that in Western countries. A younger age of disease onset was associated with disease extension. Extension of proctitis may be associated with an increased risk of colorectal cancer.

Paediatric ulcerative colitis surgery: Italian survey

BACKGROUND AND AIMS

Recent epidemiological studies showed an increase in ulcerative colitis among children, especially in its aggressive form, requiring surgical treatment. Although medical therapeutic strategies are standardized, there is still no consensus regarding indications, timing and kind of surgery. This study aimed to define the surgical management of paediatric ulcerative colitis and describe attitudes to it among paediatric surgeons.

METHODS

This was a retrospective cohort study. All national gastroenterology units were invited to participate. From January 2009 to December 2013, data on paediatric patients diagnosed with ulcerative colitis that required surgery were collected.

RESULTS

Seven units participated in the study. Seventy-one colectomies were performed (77.3% laparoscopically). Main surgical indications were a severe ulcerative colitis attack (33.8%) and no response to medical therapies (56.3%). A three-stage strategy was chosen in 71% of cases. Straight anastomosis was performed in 14% and J-pouch anastomosis in 86% of cases. A reconstructive laparoscopic approach was used in 58% of patients. Ileo-anal anastomosis was performed by the Knight-Griffen technique in 85.4% and by the pull-through technique in 9.1% of patients. Complications after colectomy, after reconstruction and after stoma closure were reported in 12.7, 19.3 and 35% of cases, respectively.

CONCLUSIONS

This study shows that there is general consensus regarding indications for surgery. The ideal surgical technique remains under debate. Laparoscopy is a procedure widely adopted for colectomy but its use in reconstructive surgery remains limited. Longer follow-up must be planned to define the quality of life of these patients.

History of and current issues affecting surgery for pediatric ulcerative colitis

Pediatric ulcerative colitis (UC) is reportedly more extensive and progressive in its clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent colectomies are needed. When physicians treat pediatric UC, they must consider the therapeutic outcome as well as the child's physical and psychological development. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This procedure was developed 100 years after the first surgical therapy, which treated UC by colon irrigation through a temporary inguinal colostomy. Predecessors in the colorectal and pediatric surgical fields have struggled against several postoperative complications and have long sought a surgical procedure that is optimal for children. We herein describe the history of the development of surgical procedures and the current issues regarding the surgical indications for pediatric UC. These issues differ from those in adults, including the definition of toxic megacolon on plain X-rays, the incidence of colon carcinoma, preoperative and postoperative steroid complications, and future growth. Surgeons treating children with UC should consider the historical experiences of pioneer surgeons to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.

Efficacy and safety of mesalamine suppositories for treatment of ulcerative proctitis in children and adolescents

BACKGROUND

Treatment of ulcerative proctitis has not been well studied in pediatric populations. We conducted an open-label trial to evaluate the clinical efficacy of a mesalamine suppository (500 mg) to treat pediatric patients with mild to moderate ulcerative proctitis.

METHODS

Pediatric patients (5-17 years of age) with ulcerative proctitis were enrolled for baseline evaluations, including a flexible sigmoidoscopic (or colonoscopic) assessment with biopsies performed at study entry. Eligible patients were started on mesalamine suppositories (500 mg) at bedtime. Two follow-up visits were scheduled after 3 and 6 weeks of treatment. The dose could be increased to 500 mg twice daily at the week 3 follow-up visit if deemed appropriate by the investigator based on the Disease Activity Index (DAI) assessment. The primary outcome measure was a DAI derived from a composite score of stool frequency, urgency of defecation, rectal bleeding, and general well-being.

RESULTS

Forty-nine patients were included in the intent-to-treat analysis. The mean DAI value decreased from 5.5 at baseline to 1.6 and 1.5 at weeks 3 and 6, respectively (P < 0.0001). Only 4 patients had their dose increased to 500 mg twice daily at week 3. Forty-one patients experienced at least one adverse event, most of which were deemed mild and unrelated to study therapy. The most common treatment-emergent adverse events were gastrointestinal (n = 30, 61.2%).

CONCLUSIONS

This study showed that a daily bedtime dose of a 500 mg mesalamine suppository is safe and efficacious in children with ulcerative proctitis.

Colorectal cancer in inflammatory bowel disease

Patients with long-standing inflammatory bowel disease have an increased risk of developing colorectal cancer (CRC). CRC risk increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and severity of inflammation of the colon. Chemoprevention includes aminosalicylates, ursodeoxycholic acid, and possibly folic acid. To reduce CRC mortality in IBD, colonoscopic surveillance remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal-anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.

Cancer in inflammatory bowel disease

Patients with long-standing inflammatory bowel disease (IBD) have an increased risk of developing colorectal cancer (CRC). Many of the molecular alterations responsible for sporadic colorectal cancer, namely chromosomal instability, microsatellite instability, and hypermethylation, also play a role in colitis-associated colon carcinogenesis. Colon cancer risk in inflammatory bowel disease increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and degree of inflammation of the bowel. Chemoprevention includes aminosalicylates, ursodeoxycholic acid, and possibly folic acid and statins. To reduce CRC mortality in IBD, colonoscopic surveillance with random biopsies remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Patients with small intestinal Crohn's disease are at increased risk of small bowel adenocarcinoma. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal-anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. Other extra intestinal cancers, such as hepatobiliary and hematopoietic cancer, have shown variable incidence rates. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.

Altered expression of CK7 and CK20 in preneoplastic and neoplastic lesions in ulcerative colitis

This study is based on all patients with ulcerative colitis from a defined catchment area in Northern Sweden in a still ongoing colonoscopy surveillance programme, which started in 1977. From this material we selected tissue from eight groups of patients consisting of normal control biopsies (5), inactive colitis (10), active colitis (10), findings of low-grade dysplasia (10), high-grade dysplasia (6), aneuploidy (without dysplasia and with subsequent dysplasia) (10), and ulcerative colitis-associated cancers (5). The samples were evaluated according to immunohistochemical expression of CK7 and CK20. Colonic mucosa from normal controls and inactive colitis was found to be completely negative for CK7. In 9 out of 10 patients with active colitis, CK7 was sparsely expressed in a patchy manner and connected with active epithelial inflammatory areas. 7 out of 10 patients with low-grade dysplasia and 3 out of 6 with high-grade dysplasia were positive for CK7. Samples with aneuploidy without dysplasia were completely negative, while 2 out of 6 showing subsequent dysplasia were positive. Of the five cancers, two were positive for CK7. CK20 was expressed in nearly all samples but relatively more in the lower part of the crypts in neoplasia-associated lesions. Our results indicate a possible relationship between expression of CK7 and CK20 and neoplastic development of colorectal mucosa in patients with ulcerative colitis. Further studies are needed to elucidate whether these findings have clinical significance.

Cancer in inflammatory bowel disease

Patients with long-standing inflammatory bowel disease (IBD) have an increased risk of developing colorectal cancer (CRC). Many of the molecular alterations responsible for sporadic colorectal cancer, namely chromosomal instability, microsatellite instability, and hypermethylation, also play a role in colitis-associated colon carcinogenesis. Colon cancer risk in inflammatory bowel disease increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and degree of inflammation of the bowel. Chemoprevention includes aminosalicylates, ursodeoxycholic acid, and possibly folic acid and statins. To reduce CRC mortality in IBD, colonoscopic surveillance with random biopsies remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Patients with small intestinal Crohn’s disease are at increased risk of small bowel adenocarcinoma. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal-anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. Other extra intestinal cancers, such as hepatobiliary and hematopoietic cancer, have shown variable incidence rates. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.

Management of low and high-grade dysplasia in inflammatory bowel disease: the gastroenterologists' perspective and current practice in the United Kingdom

BACKGROUND

Colonic dysplasia is a precursor to colorectal cancer (CRC) in inflammatory bowel disease (IBD). There is a risk of progression of both low-grade dysplasia (LGD) and high-grade dysplasia (HGD) to CRC over 5 years. The current British Society of Gastroenterology guidelines advocate colectomy when possible or at least colonoscopic surveillance every 6 months.

AIM

To obtain an overview of the gastroenterologists' perspective on various aspects of colonic dysplasia in IBD and to understand current management practice in the UK.

METHODS

A national postal survey of 551 gastroenterologists listed in the British Society of Gastroenterology Handbook 2003.

RESULTS

Some 56% of questionnaires were returned; 255 out of 551 completed questionnaires were included in the final analysis. A total of 70% considered LGD to be premalignant, whereas all considered HGD to be premalignant. Only 13% offered routine colectomy for LGD compared with 84% for HGD. More than a third felt that flat LGD might not have concurrent CRC, of which 95% performed surveillance colonoscopies in this group. A small proportion of the remaining gastroenterologists treated flat LGD surgically (13%), whereas 85% considered that LGD with dysplasia-associated lesion or mass (DALM) constituted a high risk of concurrent CRC, but only 52.5% offered total colectomy to this group. There was a wide variation in the frequency of surveillance for LGD in flat mucosa and DALM. A majority agreed that LGD progressed to HGD (82%) and CRC (75%). However, their perception of the risk of progression to either HGD or CRC over 5 years varied widely. All agreed that HGD may have coexistent CRC, and 98% thought it progressed to CRC. Patients were more likely to be treated with colectomy for flat HGD (77%) and HGD in the presence DALM (86%); 38% of gastroenterologists felt that over 30% of patients have coexistent CRC in HGD, and 10% continued to manage them conservatively.

CONCLUSION

There are wide variations in the perceptions and management of LGD in IBD in the UK compared with HGD, in which there seems to be more uniform agreement. The need for more research in this area and a national agreement on management is paramount. Until this is reached gastroenterologists will remain open to criticism and litigation.

Optimizing therapy in patients with pancolitis

Pancolitis affects approximately 20% to 40% of the total ulcerative colitis population and remains a therapeutic challenge for clinicians. Practitioners must focus on pancolitis when evaluating a patient for ulcerative colitis, because pancolitis is associated with more severe and fulminant disease and a higher rate of colorectal cancer and colectomy. It is imperative for clinicians to be knowledgeable in the clinical course, medications, and appropriate manner to induce and maintain clinical remission to prevent serious sequelae of the disease. The purpose of this article is to provide a review of the treatment of pancolitis for general gastroenterologists, because medical management decisions have life-long effects for this subgroup of patients.

Specificities of inflammatory bowel disease in childhood

In parallel with overall population trends, the incidence of paediatric ulcerative colitis (UC) has remained stable, whereas that of paediatric Crohn's disease (CD) has increased in recent decades. Still rare among preschool children, the incidence of both UC and CD rises steadily from middle childhood through adolescence. There is an unexplained preponderance of males with early-onset CD, and an equal gender distribution in paediatric UC. Observations on the familiality of paediatric inflammatory bowel disease (IBD) suggest that genetic susceptibility is particularly important to disease pathogenesis in young patients. In comparison to adult-onset disease, childhood UC is usually extensive but the anatomic localization of paediatric CD varies, as in adults. UC manifests uniformly as bloody diarrhea whereas the symptomatology of paediatric CD is much more diverse. Linear growth impairment frequently complicates chronic intestinal inflammation in paediatric CD. Key contributing factors have been defined; better immunomodulatory therapy and emerging biologic agents will potentially reduce its prevalence.

Diagnosis and management of dysplasia in patients with inflammatory bowel diseases

Patients with ulcerative colitis and Crohn's colitis face an increased lifetime risk of developing colorectal cancer. Factors associated with increased risk include long duration of colitis, extensive colonic involvement, primary sclerosing cholangitis, a family history of colorectal cancer, and, according to some studies, early disease onset and more severely active inflammation. Although prophylactic proctocolectomy can essentially eliminate the risk of cancer, most patients and their physicians opt instead for a lifelong program of surveillance. This entails regular medical follow-up, management with antiinflammatory and putative chemopreventive agents, and periodic colonoscopic examinations combined with extensive biopsy sampling throughout the colon. The main objective of regular colonoscopy is to detect neoplasia at a surgically curative and preferably preinvasive stage, i.e., dysplasia. An initial screening colonoscopy should be performed 7-8 years from disease onset or immediately in patients with primary sclerosing cholangitis. Surveillance should then continue annually or biennially so long as no dysplasia is found or suspected. Biopsy specimens are graded pathologically as negative, indefinite for dysplasia, low-grade dysplasia, high-grade dysplasia, or invasive cancer. The diagnosis and grading of dysplasia can be very challenging and should be confirmed by an expert pathologist whenever intervention or a change in management is contemplated. If 1 or more biopsy specimens are indefinite for dysplasia, colonoscopy intervals should be reduced. A patient with low- or high-grade dysplasia found in a discrete adenoma-like polyp, but nowhere else, can be safely managed with polypectomy and accelerated surveillance. However, dysplasia of any grade found in an endoscopically nonresectable polyp and high-grade dysplasia found in flat mucosa are both strong indications for proctocolectomy. Evidence further suggests that the same may be true even of low-grade dysplasia in flat mucosa. Chromoendoscopy holds promise for facilitating the endoscopic detection of neoplasia. The clinical application of newer molecular methods to detect neoplasia, particularly gene microarrays and stool DNA testing, also deserve further study.

Screening for dysplasia and TP53 mutations in closed rectal stumps of patients with ulcerative colitis or Crohn disease

BACKGROUND

Patients who undergo colectomy due to intractable chronic inflammatory bowel disease (IBD) may keep a closed rectal stump for several years, which may be at increased risk of malignant transformation owing to residual inflammatory activity. We examined a hospital series of patients with ulcerative colitis or Crohn colitis to describe the clinical, endoscopical and histological features of the closed rectal stump and to screen for dysplasia and mutations in the TP53 tumour suppressor gene.

METHODS

During rigid proctoscopy, rectal mucosal biopsy specimens and rectal lavage fluid were collected from 42 patients. Biopsy specimens were examined histologically, and genomic DNA extracted from frozen biopsies and lavage fluid was analysed for mutations in TP53 exons 4-9.

RESULTS

The median disease duration was 8.5 years (range 1.3-34 years). No endoscopic or histological signs of dysplasia or carcinoma were seen and no mutations in the TP53 gene were detected in any biopsy or lavage fluid specimens. Histological moderate to severe mucosal inflammation was present in 78% (33/42) of the patients, however, and rectal stump involution was noted in 43% (18/42).

CONCLUSION

No signs of malignancy or premalignant degeneration were detected in this prospective series of IBD patients with a closed rectal stump. Although this is reassuring for patients, the presence of moderate to severe inflammation in the majority of rectal stumps indicates a role for adjuvant molecular markers to improve colorectal cancer surveillance on this subgroup of IBD patients.

Ulcerative colitis in children: medical management

Ulcerative colitis is a chronic relapsing inflammatory disorder of the colonic mucosa of unknown etiology. The inflammatory process involves the mucosa and submucosa in a continuous segment of bowel with rectal involvement in almost all cases. Since its etiology is unknown, therapy is directed at modulating the inflammatory response in order to control symptoms and to prevent relapses. 5-aminosalicylates and corticosteroids have been the most widely used therapeutic agents for treatment of ulcerative colitis. Recently, experience has been gained with the use of other immunomodulators, such as mercaptopurine, azathioprine, methotrexate, cyclosporine, and tacrolimus, in pediatric patients. Colectomy is indicated in patients with severe colitis who do not respond to intensive medical therapy. The care of children with ulcerative colitis not only involves control of symptoms from gastrointestinal and extraintestinal manifestations, but also optimizing growth and development. The complications of chronic inflammation and long-term medical therapy must be weighed against the risks and benefits of surgery for children and adolescents with this condition.

Cancer prevention in patients with inflammatory bowel disease

Colorectal cancer is an important, and often dreaded, consequence of long-standing UC and Crohn's colitis. Surveillance colonoscopy, despite its limitations, is beneficial for detecting earlier stage cancers and, probably, mortality reduction. Agents such as anti-inflammatory medications, folic acid, and ursodeoxycholic acid show promise for chemoprevention in this disease. Future research will help to define better the natural history of dysplasia in IBD, and to determine how molecular approaches may be integrated into surveillance programs to reduce CRC risk.

Colonic malignancy arising in colitis - a single unit experience

OBJECTIVES: Colorectal malignancy complicating inflammatory bowel disease constitutes 1% of all colorectal malignancies. Although its overall numbers are low it represents the greatest cause of colitis related mortality in these patients. This paper describes the management of 24 patients presenting to a single unit over a period of 10 years. METHODS: The names of patients were collected prospectively when they presented with malignancy. Clinical details were collected by retrospective review of charts. RESULTS: In all, 24 patients with 27 malignancies were identified. The median age of presentation with malignancy was 56 years. Most patients were treated with proctocolectomy. Other patients were treated with segmental colectomy. In these patients the surgical procedure was dictated by the stage of the cancer, the age and comorbid state of the patient and the severity of ongoing colitis. CONCLUSIONS: Malignancy arising in colitis will constitute only a small part of a colorectal practice. The optimum method for detecting early, and potentially curable, disease has not been defined. Surgery should be tailored to the individual needs of the patient.

DNA aneuploidy as a marker of premalignancy in surveillance of patients with ulcerative colitis

BACKGROUND

Patients with ulcerative colitis have an increased risk of developing colorectal cancer. Specific and sensitive markers for premalignancy are needed. The present study evaluates the status of DNA aneuploidy (abnormal stemlines) as such a marker.

METHODS

A prospective surveillance programme was conducted for all patients with ulcerative colitis from a defined area. Regular colonoscopy with mucosal sampling for histological evaluation and flow cytometric DNA analysis was performed. Some 147 patients were studied from 1984 to 1997.

RESULTS

DNA aneuploidy was found in 20 patients. All but one had total colitis. The time from onset of disease to aneuploidy ranged from 5 to 31 years. Fourteen of the patients developed morphological alterations. In the same interval 127 patients, of whom 75 had total colitis, did not develop aneuploidy. Among patients with morphological alterations and aneuploidy, aneuploidy preceded these alterations in four patients and was present at the same examination in three; in seven patients the morphological alterations preceded the aneuploidy. Aneuploidy was diagnosed before the appearance of a dysplasia- associated lesion or mass in four of five cases.

CONCLUSION

Flow cytometric DNA analysis has definite value as a complement to histological examinations in cancer surveillance of patients with ulcerative colitis. Aneuploidy indicates a high risk for developing severe premalignant changes. However, there is no evidence to support the use of DNA aneuploidy as a sole indication for prophylactic surgery against cancer.

Inflammatory bowel disease in pediatric and adolescent patients

IBD is a chronic pediatric disease that needs to be treated by a team of experts consisting of pediatricians, pediatric gastroenterologists, psychologists, nutritionists, social workers, and nurses. A critical factor in successful management of this disease is the willingness of the patient to participate and cooperate with the team. Parents and patients must be educated and supported to treat these disorders effectively. Much further research is necessary to understand the specific causative and therapeutic issues unique to young patients with IBD.

Outcome after ileoanal anastomosis in pediatric patients with ulcerative colitis

BACKGROUND

To review the outcome after restorative proctocolectomy among children and adolescents with ulcerative colitis at a pediatric inflammatory bowel disease center.

METHODS

The records of all patients with ulcerative colitis undergoing colectomy and ileoanal anastomosis at The Hospital for Sick Children, Toronto, Canada, were reviewed. Questionnaires concerning functional results were sent to patients with restored transanal defecation.

RESULTS

Seventy three patients (mean age, 13.2 years; range, 2.6-18.8 years) underwent ileoanal anastomosis (19 straight ileoanal anastomosis, 41 J pouch, 13 S pouch) between January 1980 and June 1995 and were observed 5.8+/-3.3 years. The ileoanal anastomosis is nonfunctional in 19 (26%) patients. Excision rates according to type of restorative procedure were J pouch, 7% (3 of 41); S pouch, 32% (4 of 13); and straight ileoanal anastomosis, 32% (6 of 19). Failure was usually attributable to intractable diarrhea among patients with straight ileoanal anastomosis but was caused by anastomotic leak or pelvic-perianal sepsis among patients with pouch procedures. Failure rates did not vary with age at ileoanal anastomosis. Among patients retaining ileoanal continuity, continence problems reported in the questionnaire were frequent and tended to be more extreme among younger patients. Overall, 90% of respondents reported satisfaction with the functional outcome of the restorative operation.

CONCLUSIONS

The success rate of the ileoanal anastomosis/J-pouch procedure is comparable to that in adult series. The ileoanal anastomosis/J-pouch procedure is the operation of choice for children and adolescents who want ileoanal continuity restored after colectomy for ulcerative colitis.