Consensus statementSCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease
Introduction
Patients with ulcerative colitis or Crohn’s colitis have an increased risk of colorectal cancer (CRC). Most cases are believed to arise from dysplasia, and surveillance colonoscopy therefore is recommended to detect dysplasia. Detection of dysplasia traditionally has relied on both examination of the mucosa with targeted biopsies of visible lesions and extensive random biopsies to identify invisible dysplasia. Current U.S. guidelines recommend obtaining at least 32 random biopsy specimens from all segments of the colon as the foundation of endoscopic surveillance.1, 2, 3, 4
However, much of the evidence that provides a basis for these recommendations is from older literature, when most dysplasia was diagnosed on random biopsies of colon mucosa.5 With the advent of video endoscopy and newer endoscopic technologies, investigators now report that most dysplasia discovered in patients with inflammatory bowel disease (IBD) is visible.6, 7 Such a paradigm shift may have important implications for the surveillance and management of dysplasia.
The evolving evidence regarding newer endoscopic methods to detect dysplasia has resulted in variation among guideline recommendations from organizations around the world.1, 2, 3, 4, 8, 9, 10 We therefore sought to develop unifying consensus recommendations addressing 2 issues: (1) How should surveillance colonoscopy for detection of dysplasia be performed? (2) How should dysplasia identified at colonoscopy be managed?
Section snippets
Development process
An international multidisciplinary group representing a wide spectrum of stakeholders and attitudes regarding IBD surveillance (Appendix 1, available online at www.giejournal.org) developed these recommendations following a process that adhered to suggested standards for guideline development from the Institute of Medicine and others and that incorporated the GRADE methodology.11, 12, 13, 14 Details regarding the development process are provided in Figure 1 and Appendix 2. A systematic review
Terminology
A subgroup of panelists developed a set of terms for colonoscopic findings in IBD surveillance to establish uniformity in communication. Descriptive phrases, modified from the Paris Classification,15 were recommended for adoption (Table 1). Modifications included the addition of terms for ulceration and border of the lesion. It was agreed that the terms dysplasia-associated lesion or mass (DALM), adenoma-like, and non-adenoma-like should be abandoned. The term endoscopically resectable
Detection of dysplasia on surveillance colonoscopy
The goal of this section is to define the optimal method(s) of detecting colon dysplasia in patients with IBD. Detection of dysplasia, which is the immediate goal of surveillance colonoscopy, was chosen as the primary endpoint, with the understanding that detection of dysplasia is not clearly documented to improve clinical outcomes such as CRC incidence or mortality. Only histologic diagnoses of low-grade or high-grade dysplasia were considered; diagnoses of indefinite for dysplasia were
Implementation of high-quality endoscopic surveillance
Widespread implementation of high-quality endoscopic surveillance in patients with IBD will require a variety of initiatives, which will be discussed in a separate publication. Resources will be needed to train endoscopists in endoscopic surveillance and recognition of visible dysplasia with both white-light endoscopy and chromoendoscopy. These may include training courses, photographic atlases,64, 65, 66 and video repositories.67 Quality metrics and methods to document acceptable performance
Future research
The evidence currently available to inform decisions on appropriate colonoscopic surveillance methods to detect and manage dysplasia in patients with IBD is limited. Thus, further research would be of value for most of the issues addressed in this guideline. Suggested research includes the following: larger trials of chromoendoscopy using high-definition colonoscopy, comparison of different chromoendoscopy techniques (eg, indigo carmine vs methylene blue, concentration of dye, delivery of dye
Disclosure
Two non-profit charitable foundations, the Maxine and Jack Zarrow Family Foundation and the William K. Warren Foundation, provided unrestricted gifts supporting the guideline development process. The funding sources had no involvement at any stage of the development process, no representation at the consensus meeting, and no role in the drafting or approval of the manuscript. T. Kaltenbach is a consultant and has received research support from Olympus. A. Barkun is a consultant for Cook, is on
Acknowledgments
The SCENIC Consensus Group would like to thank Sarah McGill, MD, for taking notes during the face-to-face meeting, Paul Sinclair, MSc, for technical support related to the electronic platform used to provide evidence to panelists and for voting on statements, and Myriam Martel for her assistance in the additional literature searches from major scientific meetings for the systematic review.
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This document is a product of the Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations. This document was reviewed and approved by the Governing Boards of the American Society for Gastrointestinal Endoscopy and the American Gastroenterological Association. It appears simultaneously in Gastrointestinal Endoscopy and Gastroenterology.
The SCENIC international consensus statement also was reviewed and endorsed by the Asian Pacific Association of Gastroenterology, British Society of Gastroenterology, Canadian Association of Gastroenterology, European Society of Gastrointestinal Endoscopy, and Japan Gastroenterological Endoscopy Society.
Additional SCENIC (Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations) Development Panel Members: James E. East, BSc, MBChB, MD (Res), FRCP (John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom) Francis A. Farraye, MD, MSc (Boston University, Boston, Massachusetts, United States) Brian Feagan, MD, MSc (Roberts Research Institute, University of Western Ontario, Canada) John Ioannidis, MD, DSc (Stanford University, Palo Alto, California, United States) Ralf Kiesslich, MD, PhD (Johannes Gutenberg University, Mainz, Germany) Michael Krier, MD (Brooke Army Medical Center/San Antonio Military Medical Center, San Antonio, Texas, United States) Takayuki Matsumoto, MD (Iwate Medical University, Morioka, Japan) Robert P. McCabe, MD (Minnesota Gastroenterology, Minneapolis, Minnesota, United States) Klaus Mönkemüller, MD, PhD (University of Alabama, Birmingham, Alabama, United States) Robert Odze, MD (Brigham & Women's, Boston, Massachusetts, United States) Michael Picco, MD, PhD (Mayo Clinic, Jacksonville, Florida, United States) David T. Rubin, MD (University of Chicago Medicine, Chicago, Illinois, United States) Michele Rubin, RN (Society of Gastroenterology Nurses and Associates, University of Chicago Medicine, Chicago, Illinois, United States) Carlos A. Rubio, MD, PhD (Karolinska Institute and University Hospital, Stockholm, Sweden) Matthew D. Rutter, MBBS, MD, FRCP (University Hospital of North Tees, Teesside, United Kingdom) Andres Sanchez-Yague, MD (Hospital Costa del Sol, Marbella, Spain) Silvia Sanduleanu, MD, PhD (University of Maastricht, Maastricht, Netherlands) Amandeep Shergill, MD (Veterans Affairs San Francisco; University of California, San Francisco; San Francisco California, United States) Thomas Ullman, MD (Mount Sinai, New York, New York, United States) Fernando Velayos, MD (University of California, San Francisco; San Francisco, California, United States) Douglas Yakich (Crohn's and Colitis Foundation of America) Yu-Xiao Yang, MD, MSCE (University of Pennsylvania, Philadelphia, Pennsylvania, United States)