Asher Kornbluth, MD, on Dysplasia: Timing and Action

In this video, Dr Kornbluth reviews his presentation from AIBD 2020 on the importance of careful surveillance for dysplasia and follow-up with patients with inflammatory bowel disease. 

Asher Kornbluth, MD, is a clinical professor of medicine at the Icahn School of Medicine at Mount Sinai in New York.

TRANSCRIPT

Hi. My name is Asher Kornbluth from the Icahn School of Medicine at Mount Sinai. I am truly absolutely delighted to have this opportunity to participate in this meeting under these unusual circumstances. I have to say that at this AIBD meeting, the attendees are about the same huge numbers we usually see. The course content as you've seen probably by now is really superb.

I want to thank Steve Hanauer, Millie Long, and Miguel Regueiro for inviting me again to present at this meeting. Today I presented specifically, Dysplasia:  Timing and Action. It's really focused on not just the value of chromoendoscopy and how we do that. We've been talking about that for years now.

You'll probably be delighted to hear that I presented a meta-analysis that although chromoendoscopy is better than our standard, frankly old-fashioned-colonoscopy white light, that in a meta-analysis, it did no better on in balance, compared to high definition, a careful high definition colonoscopy surveillance. That's good news for everyone.

Most people have not really picked up on chromo, learned about pit patterns, and they have found it particularly cumbersome. In fact, when you look at this data, you can be reassured that doing a careful examination with high-def is usually provides a very adequate exam. We also talked about, in terms of timing, the kind of patients who might need more rigorous surveillance.

We all know about disease duration, disease extent, but also  particularly about patients who have had more active inflammation cumulatively over the years and other markers perhaps, of more severe phenotypes such as the  phenotype of a stricture in colon, a phenotype of a more tubular colon. We need to know that these patients need to be surveyed very carefully.

Very importantly, and we should all adopt this if we haven't already, is the important nomenclature. Now this is not just for academic reasons or writing papers, but we should be  doing away with the terms DALM, and frankly ALM too, which is a more recent,--- an “Adenoma-Like Mass one at a normal-like mass. What we really should focus on is the entire concept of whether a given lesion is resectable or unresectable endoscopically.

Most of those lesions, except the high-display, dysplastic high-grade lesions, can be removed, followed very closely, and not need colectomy--- with certain provisions. Obviously, that hopefully, this is not multifocal, not more than low-grade dysplasia, and. iIt is not seen on repeated exams whereby the progression to advanced neoplasia, i.e., high-grade dysplasia and outright colorectal cancer, which may even be advanced. is advanced.

It's important to think of the nomenclature in terms of, something first of all, is it  visible, or was it picked up on a random biopsy?. More and more, we're looking to do more focused, targeted biopsies. First of all, is it visible. The flat lesions might be more likely to progress simply by virtue of the fact that they're flat and more difficult to find on subsequent exams.

So first of all, is it visible? Is it polypoid or not polypoid? Is it flat? And is it perhaps depressed or ulcerated, which are particularly more worrisome lesions.? Remember that not all of these broader lesions can we do have a very thorough, satisfying, and an exam that would concern confirm that we are getting everything out.

There are people those  who are now doing interventional endoscopy, advanced endoscopy. They might be the people who need to see the patients for this very broad EMR type lesion, or even an endoscopic submucosal dissection. Again, this is often in the hands of the more advanced endoscopists.

Again, we need to make sure though that the margins are clean, that  the mucosa adjacent to these lesions are not dysplastic, and we have the patient under close follow-up. Again, making sure that we're not missing any flat lesions, which again are becoming increasingly visible. But we're still not infallible in this regard.

We've also come to recognize that indefinite dysplasia is an important marker. There was a very important paper out of Mount Sinai this year with over 400 patients who over the years had indefinite dysplasia. It was found that patients who had indefinite dysplasia compared to those who did not, had a greater likelihood of progressing to low-grade dysplasia or even advanced neoplasia, i.e., again, high-grade dysplasia or colorectal cancer, particularly if they had repeated indefinite dysplasia on follow-up exams.

So, the patient with indefinite dysplasia, these certainly need to be considered very carefully, and confirmed as with other dysplastic lesions by an expert IBD pathologist.

Furthermore, we have additional evidence about low-grade dysplasia and a meta-analysis that I described that also showed that there's a greater progression not surprisingly, to high-grade dysplasia or cancer. Again, much of that was before this age where we thought about doing resections of lesions that were otherwise flat appearing.

Now remember a lot of these definitions of “flat’ or ‘invisible’ were before the age of widespread use of high-def or chromoendoscopy. The key point to remember and the most important point I'll stress, is that we need to accurately define what the lesion is. It really comes down to, is the lesion resectable or unresectable. We obviously need to make sure obviously we have clean margins with that.

There's no real data on resecting high-grade dysplasia and following that patient. There are's some studies going on now, of courseat  multiple centers, but really we're talking about broad dissections with lesions that are not high grade dysplasia, that are cleared entirely and followed closely. Again, not only with low-grade dysplasia, but we're learning about indefinite dysplasia again.

Remember, we have to have humility about this, that even in the best hands, even with the best vision, even with the most experienced people doing surveillance, even with chromo ( if you believe that has advantages), we will miss lesions. We are not infallible, and we have to recognize that this is an inexact science.

Again, focusing that not all these patients require colectomy, patients should have adequate  endoscopic resections and, close follow-up. For many patients that will be the appropriate follow-up.

I want to thank you again for paying attention to this video. I know this is a particularly trying time historically. I want to thank you all. Again, I want to thank the course directors, Millie, Steve, and Miguel, for putting together this absolutely outstanding program. I'm grateful to be able to be part of it. Thanks everyone. Hope to see you soon live.