Endoscopic mucosal resection for flat neoplasia in chronic ulcerative colitis: can we change the endoscopic management paradigm?
Endoscopic mucosal resection for flat neoplasia in chronic ulcerative colitis: can we change the endoscopic management paradigm?
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DOI：
10.1136/gut.2006.106294
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发表时间：
2007-06-01
期刊：
影响因子：
24.5
通讯作者：
Thomson, Mike
中科院分区：
文献类型：
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作者：
Hurlstone, David P.;Sanders, David S.;Thomson, Mike
背景资料：内镜下黏膜切除术（EMR）治疗慢性溃疡性结肠炎（CUC）中扁平异型增生病变的潜力迄今尚未得到解决。历史上，这种病变被称为结肠切除术。此外，只有有限的数据，以支持内镜切除外生性腺瘤样肿块（ALM）病变colis.Aims：评价安全性和临床结果的结肠炎患者进行EMR巴黎0-II级和I级ALM与散发性对照组相比。次要目的是重新评估CUC背景下巴黎0-II级和I级病变的患病率、解剖“映射”和组织病理学特征。方法：接受EMR治疗的结肠炎相关巴黎0-II级和巴黎I级ALM患者的前瞻性临床、病理学和结局数据（主要终点是结直肠癌的发展、切除术的疗效、异时病变率和切除术后复发率）与散发对照组进行比较。在研究期间，169例患者诊断出204处病变：167例（82%）在“入口”结肠镜检查时诊断，36例（18%）在随访时诊断。诊断出170例ALMs、18例发育不良相关病变肿块（DALMs）和16例癌症。整个研究期间共进行了4316次结肠镜检查（每例患者的中位数：6;范围：1-8）。完整队列的中位随访期为4. 1年（范围：3. 6 - 5. 21）。从我们的前瞻性数据库中纳入了1675例对照，这些患者从1998年起接受了散发性巴黎0-II型病变EMR和巴黎I型病变圈套息肉切除术，并且被认为具有中度至高度的结直肠癌终身风险。在整个研究期间，该组进行了3792次结肠镜检查（每例患者的中位数：4;范围：1-7）。中位随访期为4.8年（范围：2.9-5.2年）。在年龄、性别、每例患者结肠镜检查的中位次数、中位随访时间、切除术后并发症、中位病灶直径或间隔癌症发生率方面，未观察到CUC研究组和对照组之间的统计学显著差异。然而，CUC组（82/155（61%））与对照组（285/801（35%）; chi（2）= 31.13; p < 0.001）相比，巴黎0-II级病变的患病率存在显著的组间差异。此外，结肠炎组侧向扩散性肿瘤的复发率（1/7（14%））高于对照组（0/10（0%）; p = 0.048（95%CI 11.64%至40.21%））。结论：扁平DALM，类似于巴黎I级ALM，可以通过EMR安全地管理CUC。在管理模式的变化，包括EMR切除扁平异型增生病变在选定的情况下，提出。
Background: The potential of endoscopic mucosal resection (EMR) for treating flat dysplastic lesions in chronic ulcerative colitis (CUC) has not been addressed so far. Historically, such lesions were referred for colectomy. Furthermore, there are only limited data to support endoscopic resection of exophytic adenoma-like mass (ALM) lesions in colitis.Aims: To evaluate the safety and clinical outcomes of patients with colitis undergoing EMR for Paris class 0-II and class I ALM compared with 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 CUC.Methods: Prospective clinical, pathological and outcome data of patients with colitis-associated Paris class 0-II and Paris class I ALM treated with EMR (primary end points being colorectal cancer development, resection efficacy, metachronous lesion rates and post-resection recurrence rates) were compared with those of sporadic controls.Results: 204 lesions were diagnosed in 169 patients during the study period: 167 (82%) diagnosed at "entry'' colonoscopy, and 36 (18%) diagnosed at follow- up. 170 ALMs, 18 dysplasia-associated lesion masses (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 included from our prospective database of patients without CUC who had undergone EMR for sporadic Paris class 0-II and snare polypectomy of Paris type I lesions from 1998 onwards, and were 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). The median follow- up period was 4.8 years (range: 2.9-5.2). No statistically significant differences were 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 the prevalence of Paris class 0-II lesions in the CUC group (82/155 (61%)) compared with controls (285/801 (35%); chi(2) = 31.13; p < 0.001). Furthermore, recurrence rates of lateral spreading tumours were higher in the colitis cohort (1/7 (14%)) than among controls (0/10 (0%); p = 0.048 (95% CI 11.64% to 40.21%)).Conclusions: Flat DALM, similarly to Paris class I ALM, can be managed safely by EMR in CUC. A change in management paradigm to include EMR for the resection of flat dysplastic lesions in selected cases is proposed.