Diagnosis and management of dysplasia in patients with inflammatory bowel diseases
Diagnosis and management of dysplasia in patients with inflammatory bowel diseases
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DOI：
10.1053/j.gastro.2004.03.025
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发表时间：
2004-05-01
期刊：
影响因子：
29.4
通讯作者：
Harpaz, N
中科院分区：
文献类型：
--
作者：
Itzkowitz, SH;Harpaz, N
溃疡性结肠炎和克罗恩氏结肠炎患者一生中患结直肠癌的风险增加。与风险增加相关的因素包括结肠炎持续时间长，广泛的结肠受累，原发性硬化性胆管炎，结直肠癌家族史，以及根据一些研究，早期疾病发作和更严重的活动性炎症。虽然预防性直肠结肠切除术可以基本上消除癌症的风险，但大多数患者和他们的医生选择终身监测计划。这需要定期的医疗随访，使用抗生素和假定的化学预防剂进行管理，以及定期的结肠镜检查结合整个结肠的广泛活检取样。常规结肠镜检查的主要目的是在手术治愈和最好是侵入前阶段检测瘤形成，即，发育不良原发性硬化性胆管炎患者应在发病后7 - 8年或立即进行结肠镜检查。只要没有发现或怀疑发育异常，就应每年或每两年继续监测。活检标本的病理分级为阴性，不确定的异型增生，低度异型增生，高度异型增生，或浸润性癌。异型增生的诊断和分级可能非常具有挑战性，无论何时考虑干预或改变管理，都应由专家病理学家确认。如果一个或多个活检标本不确定为异型增生，则应缩短结肠镜检查间隔。在分离的腺瘤样息肉中发现低度或高度异型增生的患者，但在其他地方，可以通过息肉切除术和加速监测进行安全管理。然而，在内镜下不可切除的息肉中发现的任何级别的异型增生和在平坦粘膜中发现的高度异型增生都是直肠结肠切除术的强烈适应症。有证据进一步表明，即使是平坦粘膜中的低度异型增生也可能是如此。色素内镜有望促进内镜检查肿瘤。检测肿瘤的新分子方法的临床应用，特别是基因微阵列和粪便DNA检测，也值得进一步研究。
Patients with ulcerative colitis and Crohn's colitis face an increased lifetime risk of developing colorectal cancer. Factors associated with increased risk include long duration of colitis, extensive colonic involvement, primary sclerosing cholangitis, a family history of colorectal cancer, and, according to some studies, early disease onset and more severly active inflammation. Although prophylactic proctocolectomy can essentially eliminate the risk of cancer, most patients and their physicians opt instead for a lifelong program of surveillance. This entails regular medical follow-up, management with antiinflammatory and putative chemopreventive agents, and periodic colonoscopic examinations combined with extensive biopsy sampling throughout the colon. The main objective of regular colonoscopy is to detect neoplasia at a surgically curative and preferably preinvasive stage, i.e., dysplasia. An initial screening colonoscopy should be performed 7-8 years from disease onset or immediately in patients with primary sclerosing cholangitis. Surveillance should then continue annually or biennially so long as no dysplasia is found or suspected. Biopsy specimens are graded pathologically as negative, indefinite for dysplasia, low-grade dysplasia, high-grade dysplasia, or invasive cancer. The diagnosis and grading of dysplasia can be very challenging and should be confirmed by an expert pathologist whenever intervention or a change in management is contemplated. If I or more biopsy specimens are indefinite for dysplasia, colonoscopy intervals should be reduced. A patient with low- or high-grade dysplasia found in a discrete adenoma-like polyp, but nowhere else, can be safely managed with polypectomy and accelerated surveillance. However, dysplasia of any grade found in an endoscopically nonresectable polyp and high-grade dysplasia found in flat mucosa are both strong indications for proctocolectomy. Evidence further suggests that the same may be true even of low-grade dysplasia in flat mucosa. Chromoendoscopy holds promise for facilitating the endoscopic detection of neoplasia. The clinical application of newer molecular methods to detect neoplasia, particularly gene microarrays and stool DNA testing, also deserve further study.