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DYSPLASTIC POLYPS IN CHRONIC COLITIS: IS COLECTOMY NEEDED?

In inflammatory bowel disease (IBD) patients, sporadic adenomatous polyps found proximal to inflamed mucosa receive definitive treatment by endoscopic polypectomy. In general, colectomy is recommended when an area of flat high-grade dysplasia or a visible, discrete, dysplasia-associated lesion or mass (DALM) is seen in an area of colitis. In the latter case, colectomy is performed because of the high reported association with adenocarcinoma. Two recent studies challenge this blanket recommendation. Engelsgjerd et al. studied 34 patients with ulcerative colitis (UC) and well-defined sessile or pedunculated polypoid DALMs found during colonoscopy. In 24 patients, the lesion was located within a known area of colitis (“adenoma-like DALM’)), while in the other 10 the lesions were proximal to the area of known colitis (“sporadic adenomas”). All lesions were removed by endoscopic polypectomy, and the majority showed only low-grade dysplasia. Mean polyp size was 0.63-0.85 cm. Patients were followed for a mean of 3.5 years, and none developed adenocarcinoma. About one-half of the patients developed additional polyps, with significantly more polyps resected from colitic mucosa than from noninflamed mucosa. Pathologic characteristics of the polyps were similar in the two groups. Clinical characteristics between the two groups were also similar, although those with sporadic adenomas had a shorter mean duration of colitis. Only one patient, initially with an adenomalike DALM, developed flat dysplasia. Based on these findings, the authors conclude that patients with DALMs that grossly resemble adenomas can be managed with polypectomy and subsequent endoscopic surveillance and do not require colectomy. Rubin et al. studied 48 IBD patients, with chronic UC or Crohn’s colitis involving at least one-third of the colon, enrolled in a screening program. All had discrete dysplastic polyps that were resected endoscopically. Mean polyp size was l .2 cm. Seventy polypectomies were performed, with 10 polyps removed from noncolitic mucosa. These were all identified as 1 17: 1295-1 300. tubular adenomas. Most polyps from colitic mucosa showed only low-grade dysplasia; however, one did show invasive adenocarcinoma. Mean follow-up was 4.1 years, and no patients developed flat dysplasia or carcinoma in that interval. Recurrent polyps were found in 23 patients, and 6 underwent surgical resection because of polyp recurrence at the site of the initial polypectomy. In 71% of patients, polyps were found after an initial negative colonoscopy. The authors conclude that discrete dysplastic polyps arising from colitic mucosa can be removed safely with endoscopic polypectomy. In the absence of flat dysplasia adjacent to the polyp or anywhere in the colon, colectomy is not needed. Comment: Patients with UC and Crohn’s colitis are at increased risk of developing colorectal cancer. This risk increases with increasing duration of disease as well as extent of the disease within the colon. In sporadic colorectal cancer, tumors generally arise from adenomatous polyps. In colitis-associated cancer, the precursor lesion is dysplasia, which may appear endoscopically as a raised lesion, but may also appear endoscopically as normal tissue. The goal of surveillance programs is to detect these dysplastic lesions before they become cancerous. Raised dysplastic lesions in a patient with chronic colitis have generally been considered markers of colorectal cancer, and colectomy has been recommended whenever these highrisk lesions are identified (Gastroenterology 198 1;80366-74; Lancet 1994;343:71-4). However, in some cases these mass lesions appear endoscopically and pathologically identical to sporadic adenomas in the noncolitic colon. Earlier studies have suggested that the risk of colon cancer in these lesions may not be as high as previously reported. Is colectomy really necessary when no other dysplastic lesions, particularly flat dysplasia, are found? Rubin et al. and Engelsgjerd et al. attempt to answer this question in their thought-provoking papers. Both studies examine a specific subgroup of patients: those with discrete polypoid DALMs that are endoscopically similar in appearance to sporadic adenomas in a colon with no areas of flat dysplasia. They conclude that endoscopic polypectomy appears to be adequate therapy for these lesions, with no evidence of cancer development in their follow-up period. This conclusion supports the findings of several smaller studies with the same result. Unfortunately, questions still exist about optimal management of these lesions. First, follow-up in both of these studies was less than 5 years, and the total number of patients studied is relatively small (despite the fact that Rubin et al. enrolled 684 patients in their surveillance program). Since cancer risk increases with increased duration of disease, longer follow-up in this patient group will be helpful. Second, and more worrisome, is whether these findings may be generalized to clinical practice. Both of these studies were conducted at academic centers with much experience managing IBD patients. In a recent British survey of gastroenterologists, management of colitisassociated dysplasia was inconsistent with published recommendations in one-half of the cases, 16% of gastroenterologists were unaware of the significance of a DALM, and pathologists with expertise in gastrointestinal pathology reviewed only 45% of cases (Gastrointest Endosc 2000;51: 123-8). Third, are recurrent polyps at the same site a harbinger of more ominous lesions to come? One-half of all patients studied developed recurrent polyps during follow-up, and six patients in Rubin et al.’s group ultimately underwent surgery. In all six, no further