Experts Speak on Dysplasia in IBD

A panel moderated by Miguel Regueiro, MD, and Corey Siegel, MD, discussed surveillance strategies for patients with inflammatory bowel disease (IBD) with extensive polyposis, and reviewed management options for high-grade and low-grade colonic dysplasia at the Advances in Inflammatory Bowel Disease annual meeting in Orlando, Florida, on December 15.

The panel included Fernando Velayos, MD, Nayantara Coelho-Prabhu, MD, Remo Panaccione, MD, Sandra Quezada, MD, and Tracy Hull, MD.

Dr Regueiro is a professor of medicine and chair of the Digestive Disease and Surgery Institute at Cleveland Clinic in Ohio. Dr Siegel is the chief of the gastroenterology and hepatology section and codirector of the IBD Center at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, and the Constantine and Joyce Hampers Professor of Medicine at the Geisel School of Medicine at Dartmouth.

Dr Velayos is the chief of gastroenterology division at Kaiser Permanente San Francisco Medical Center. Dr Coelho-Prabhu is a gastroenterologist at Mayo Clinic School of Medicine. Dr Panaccione is a professor of medicine and the director of the IBD unit at the University of Calgary. Dr Quezada is a professor of medicine in the division of gastroenterology and hepatology at the University of Maryland School of Medicine. Dr Hull is a colorectal surgery specialist at the Cleveland Clinic Digestive Disease and Surgery Institute.

The first case study focused on a 28-year-old patient with diffuse pseudopolyposis who had moderate ulcerative colitis (UC) at the age of 15. His colonoscopy revealed dense pseudopolyposis, especially in transverse and descending colon. Pathology was consistent with pseudopolyps except 1 biopsy that came back as a tubular adenoma from the sigmoid colon. The panel agreed on repeat colonoscopy in 6 months followed another in 1 year.

Chromoendoscopy may not be entirely helpful, Dr Regueiro said. “While pseudopolyposis do not increase the risk of cancer themselves, they can hide other lesions,” he said. A careful follow-up surveillance colonoscopy or a segmental resection or even colectomy are all reasonable approaches, he added.

In the case of a 58-year-old patient with low-grade dysplasia with moderate UC at age 40, electronic chromoendoscopy revealed a 3 to 4mm, flat, low-grade dysplastic lesion in the ascending colon, which was thought to be removed entirely with a biopsy. Since the symptoms were not well controlled with mesalamine, the doctors added vedolizumab to the routine. The patient then demonstrated an increased control of symptoms and endoscopic healing.

The panel agreed that multifocal low-grade is different than a single site and that it is imperative to follow vigilantly and offer surgical consultation.

The final case study focused on a 55-year-old patient diagnosed with Crohn’s colitis for 20 years who presented with high-grade dysplasia and with patchy disease, but no perianal disease. Inflammation was not well controlled by infliximab, vedolizumab, or ustekinumab. Following directed and nondirected biopsies taken throughout the colon, chromoendoscopy did not seem to have positive effects either.

Among patients with high-grade dysplasia, surveillance is no longer an option, the panel clarified. Some patients, and even physicians, do not want to adhere to our guidelines, they noted. For patients with endoscopically resectable high-grade dysplasia, whether polypoid or nonpolypoid, continued colonoscopic surveillance after complete resection of the lesion is recommended rather than referral for colectomy.

“Persistence and clarity matter here,” the panel concluded.

Reference:
Regueiro M, Siegel C, Velayos F, Coelho-Prabhu N, Panaccione R, Quezada S, Hull T. Case: Dysplasia in IBD. Presented at: Advances in Inflammatory Bowel Disease Annual Meeting; December 15, 2023. Orlando, Florida.