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Endoscopic mucosal resection for flat neoplasia in chronic ulcerative colitis: can we change the endoscopic management paradigm?
  1. David Paul Hurlstone (p.hurlstone{at}shef.ac.uk)
  1. Royal Hallamshire Hospital, Sheffield, United Kingdom
    1. David S Sanders (david.sanders{at}sh.nhs.uk)
    1. Royal Hallamshire Hospital, Sheffield, United Kingdom
      1. Mike D Hunter (m.d.hunter{at}shef.ac.uk)
      1. SCAN-Lab, Sheffield, United Kingdom
        1. Robert Atkinson (rob.atkinson{at}sth.nhs.uk)
        1. Royal Hallamshire Hospital, Sheffield, United Kingdom
          1. Mark E McAlindon (mark.mcalindon{at}sth.nhs.uk)
          1. Royal Hallamshire Hospital, Sheffield, United Kingdom
            1. Alan J Lobo (alan.lobo{at}sh.nhs.uk)
            1. Royal Hallamshire Hospital, Sheffield, United Kingdom
              1. Simon S Cross (simon.cross{at}sth.nhs.uk)
              1. Academic Unit of Pathology, Section of Oncology and Pathology, Sheffield University Medical School, United Kingdom
                1. Mike Thomson (mike.thomson{at}scg.nhs.uk)
                1. Dept. Endoscopy, Sheffield Childrens Hospital, Sheffield, United Kingdom

                  Abstract

                  Background: No studies have addressed the potential of endoscopic mucosal resection for treating flat dysplastic lesions in chronic ulcerative colitis. Historically, such lesions were referred for colectomy. Furthermore, there is only limited data to support endoscopic resection of exophytic adenoma-like mass lesions in colitis.

                  Aims: The primary aim was to evaluate the safety and clinical outcomes of colitic patients undergoing EMR for Paris class 0-II and class I adenoma-like mass as compared to sporadic controls. Secondary aims were to re-evaluate the prevalence, anatomical 'mapping' and histopathological characteristics of both Paris class 0-II and class I lesions in the context of chronic ulcerative colitis.

                  Methods: Prospective clinical, pathological and outcome data of patients with colitis-associated Paris class 0-II and Paris class I adenoma-like mass treated with EMR (primary end-points being colorectal cancer development, resection efficacy, metachronous lesion rates and post-resection recurrence rates) were compared to sporadic controls.

                  Results: 204 lesions were diagnosed in 169 colitic patients throughout the study period (82% [167/204] diagnosed at 'entry' colonoscopy with 36/204 (18%) at follow-up. A total of 170 ALMs, 18 DALMs and 16 cancers were diagnosed. A total of 4316 colonoscopies were performed throughout the study period (median per patient 6; range 1-8). The median follow-up period for the complete cohort was 4.1 years (range 3.6-5.21). 1675 controls were taken from our prospective database of non-CUC patients who had undergone EMR of sporadic Paris class 0-II and snare polypectomy of Paris type I lesions from 1998 and considered to be at 'moderate' to 'high' lifetime risk of colorectal cancer. 3792 colonoscopies were performed throughout the study period in this group (median per patient 4; range 1-7), median follow-up period 4.8 years (range 2.9-5.2). There were no statistically significant differences observed between the CUC study group and controls with respect to age, sex, median number of colonoscopies per patient, median follow-up duration, post resection complications, median lesional diameter or interval cancer rates. However, there was a significant between-group difference regarding Paris class 0-II lesion prevalence in the chronic ulcerative colitis group (82/155 [61%]) as compared to controls (285/801 [35%]; χ2 = 31.13; p < 0.001). Furthermore, LST recurrence rates were higher in the colitis cohort (1/7 [14%]) compared to controls (0/10 [0%]; p=0.048).

                  Conclusions: Flat dysplastic ALM, similarly to Paris class I ALM, can be managed safely by EMR in chronic ulcerative colitis. A change in management paradigm to include EMR for the resection of flat dysplastic lesions in selected cases is proposed.

                  • colonoscopy
                  • dysplasia
                  • intraepithelial neoplasia
                  • ulcerative colitis

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