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• W1989215734 abstract "Background & Aims: Since 1980, we have followed 259 patients with chronic Crohn's colitis in a prospective colonoscopic surveillance program. Our initial results through August 1998 showed a 22% chance of developing definite dysplasia or cancer by the fourth surveillance examination. We now update the results of all examinations since September 1998 until April 2005. Methods: All patients had at least 7 years of Crohn's colitis affecting at least one third of the colon. Patients were recalled every 1 to 2 years or sooner if dysplasia was found. Pathology was classified as normal, dysplasia (indefinite, low-grade [LGD], or high-grade [HGD]), or carcinoma. Lesions were classified as flat, polyp, or mass. Results: A total of 1424 examinations were performed on 259 patients. Ninety percent had extensive colitis. The median age at diagnosis was 22 years (range, 2–61 y), and the median disease duration was 18 years (range, 7–49 y). On screening examination, definite dysplasia or cancer was found in 18 patients (7%). Thirteen had LGD, 2 had HGD, and 3 had cancer. On surveillance examinations, a first finding of definite dysplasia or cancer was found in an additional 30 patients (14%). Twenty-two had LGD, 4 had HGD, and 4 had cancer. The cumulative risk of detecting an initial finding of any definite dysplasia or cancer after a negative screening colonoscopy was 25% by the 10th surveillance examination. The cumulative risk of detecting an initial finding of flat HGD or cancer after a negative screening colonoscopy was 7% by the ninth surveillance examination. Conclusions: Periodic surveillance colonoscopy should be part of the routine management of chronic extensive Crohn's colitis. Background & Aims: Since 1980, we have followed 259 patients with chronic Crohn's colitis in a prospective colonoscopic surveillance program. Our initial results through August 1998 showed a 22% chance of developing definite dysplasia or cancer by the fourth surveillance examination. We now update the results of all examinations since September 1998 until April 2005. Methods: All patients had at least 7 years of Crohn's colitis affecting at least one third of the colon. Patients were recalled every 1 to 2 years or sooner if dysplasia was found. Pathology was classified as normal, dysplasia (indefinite, low-grade [LGD], or high-grade [HGD]), or carcinoma. Lesions were classified as flat, polyp, or mass. Results: A total of 1424 examinations were performed on 259 patients. Ninety percent had extensive colitis. The median age at diagnosis was 22 years (range, 2–61 y), and the median disease duration was 18 years (range, 7–49 y). On screening examination, definite dysplasia or cancer was found in 18 patients (7%). Thirteen had LGD, 2 had HGD, and 3 had cancer. On surveillance examinations, a first finding of definite dysplasia or cancer was found in an additional 30 patients (14%). Twenty-two had LGD, 4 had HGD, and 4 had cancer. The cumulative risk of detecting an initial finding of any definite dysplasia or cancer after a negative screening colonoscopy was 25% by the 10th surveillance examination. The cumulative risk of detecting an initial finding of flat HGD or cancer after a negative screening colonoscopy was 7% by the ninth surveillance examination. Conclusions: Periodic surveillance colonoscopy should be part of the routine management of chronic extensive Crohn's colitis. See CME exam on page 954.It is well established that patients with chronic, extensive ulcerative colitis have an increased risk of developing colonic epithelial dysplasia and carcinoma.1Dawson I.M. Pryse-Davies J. The development of carcinoma of the large intestine in ulcerative colitis.Br J Surg. 1959; 47: 113-128Crossref PubMed Scopus (88) Google Scholar, 2Lindberg B. Persson B. Veress B. et al.Twenty years' colonoscopic surveillance of patients with ulcerative colitis: detection of dysplastic and malignant transformation.Scand J Gastroenterol. 1996; 31: 1195-1204Crossref PubMed Scopus (88) Google Scholar, 3Brostrom O. Lofberg R. Nordenvall B. et al.The risk of colorectal cancer in ulcerative colitis: an epidemiologic study.Scand J Gastroenterol. 1987; 22: 1193-1199Crossref PubMed Scopus (132) Google Scholar, 4Gyde S.N. Prior P. Allan R.N. et al.Colorectal cancer in ulcerative colitis: a cohort study of primary referrals from three centers.Gut. 1988; 28: 206-217Crossref Scopus (434) Google Scholar, 5Lashner B.A. Silverstein M.D. Hanauer S.B. Hazard rates for dysplasia and cancer in ulcerative colitis: results from a surveillance program.Dig Dis Sci. 1989; 34: 1536-1541Crossref PubMed Scopus (131) Google Scholar, 6Lennard-Jones J.E. Melville D.M. Morson B.C. et al.Precancer and cancer in extensive ulcerative colitis: findings among 401 patients over 22 years.Gut. 1990; 31: 800-806Crossref PubMed Scopus (407) Google Scholar, 7Maratka Z. Nebdal J. Kocianova J. et al.Incidence of colorectal cancer in proctocolitis A retrospective study of 959 cases of over 40 years.Gut. 1985; 26: 43-49Crossref PubMed Scopus (71) Google Scholar, 8Sachar D.B. Cancer in ulcerative colitis: good news and bad news.Ann Intern Med. 1981; 95: 642-643Crossref PubMed Scopus (19) Google Scholar, 9Collins R.H. Feldman M. Fordtran J.S. Colon cancer, dysplasia, and surveillance in patients with ulcerative colitis: a critical review.N Engl J Med. 1987; 316: 1654-1658Crossref PubMed Scopus (285) Google Scholar, 10Katzka I. Brody R.S. Morris E. et al.Assessment of colorectal cancer risk in patients with ulcerative colitis: experience from a private practice.Gastroenterology. 1983; 85: 22-29Abstract Full Text PDF PubMed Scopus (114) Google Scholar Depending on the methods, referral base, and geographic distribution of each particular study, the risk of developing cancer is about 0.25% to 0.5% per year after 8 to 10 years of disease.11Lofberg R. Brostrom O. Karlen P. et al.Colonoscopic surveillance in long-standing total ulcerative colitis.Gastroenterology. 1990; 99: 1021-1031PubMed Google Scholar, 12Rozen P. Baratz M. Gilat T. Low incidence of significant dysplasia in a successful endoscopic surveillance program of patients with ulcerative colitis.Gastroenterology. 1995; 108: 1361-1370Abstract Full Text PDF PubMed Scopus (106) Google Scholar, 13Blackstone M.O. Riddell R.H. Rogers B.H. et al.Dysplasia-associated lesion or mass (DALM) detected by colonoscopy in longstanding ulcerative colitis: an indication for colectomy.Gastroenterology. 1981; 80: 366-374PubMed Scopus (477) Google Scholar, 14Rosenstock E. Farmer R. Petras R. et al.Surveillance for colon carcinoma in ulcerative colitis.Gastroenterology. 1985; 89: 1342-1346PubMed Google Scholar, 15Nugent F.W. Haggit R.C. Gilpin P.A. Cancer surveillance in ulcerative colitis.Gastroenterology. 1991; 100: 1241-1248PubMed Google Scholar, 16Choi P.M. Nugent F.W. Schoetz Jr, D.J. et al.Colonoscopic surveillance reduces mortality from colorectal cancer in ulcerative colitis.Gastroenterology. 1993; 105: 418-424Abstract PubMed Google Scholar, 17Koobatian G.J. Choi P.M. Safety of surveillance colonoscopy in long-standing ulcerative colitis.Am J Gastroenterol. 1994; 89: 1472-1475PubMed Google Scholar This increased risk has lead to the endorsement of surveillance colonoscopies with biopsies as the standard of care for patients with chronic ulcerative colitis.18Itzkowitz S.H. Present D.H. Colorectal cancer screening and surveillance in inflammatory bowel disease.Inflamm Bowel Dis. 2005; 11: 314-321Crossref PubMed Scopus (504) Google ScholarMuch less is known about the risk of colonic dysplasia and carcinoma in patients with long-standing Crohn's colitis. Many studies consider all patients with Crohn's disease together when assessing risk,19Jess T. Loftus E. Velayos F. et al.Risk of intestinal cancer in inflammatory bowel disease: a population-based study from Olmstead, Minnesota.Gastroenterology. 2006; 130: 1039-1046Abstract Full Text Full Text PDF PubMed Scopus (394) Google Scholar, 20Jess T. Winther K.V. Munkholm P. et al.Intestinal and extra-intestinal cancer in Crohn's disease: follow-up of a population-based cohort in Copenhagen County, Denmark.Aliment Pharmacol Ther. 2004; 19: 287-293Crossref PubMed Scopus (190) Google Scholar, 21Bernstein C.N. Blanchard J.F. Kliewer E. et al.Cancer risk in patients with inflammatory bowel disease: a population-based study.Cancer. 2001; 91: 854-862Crossref PubMed Scopus (1003) Google Scholar, 22Mellemkjaer L. Johansen C. Gridley G. et al.Crohn's disease and cancer risk (Denmark).Cancer Causes Control. 2000; 11: 145-150Crossref PubMed Scopus (82) Google Scholar, 23Persson P.G. Karlen P. Bernell O. et al.Crohn's disease and cancer: a population-based cohort study.Gastroenterology. 1994; 107: 1675-1679PubMed Google Scholar, 24Munkholm P. Langholz E. Davidsen M. et al.Intestinal cancer risk and mortality in patients with Crohn's disease.Gastroenterology. 1993; 105: 1716-1723Abstract PubMed Google Scholar, 25Fireman Z. Grossman A. Lilos P. et al.Intestinal cancer in patients with Crohn's disease A population study in central Israel.Scand J Gastroenterol. 1989; 24: 346-350Crossref PubMed Scopus (97) Google Scholar, 26Gollop J.H. Phillips S.F. Melton 3rd, L.J. et al.Epidemiologic aspects of Crohn's disease: a population based study in Olmsted County, Minnesota, 1943–1982.Gut. 1988; 29: 49-56Crossref PubMed Scopus (223) Google Scholar, 27Kvist N. Jacobsen O. Norgaard P. et al.Malignancy in Crohn's disease.Scand J Gastroenterol. 1986; 21: 82-86Crossref PubMed Scopus (68) Google Scholar not just those patients with extensive Crohn's colitis. The relative risk of cancer in Crohn's disease has been reported to be anywhere from 1.9 in patients with all kinds of Crohn's disease19Jess T. Loftus E. Velayos F. et al.Risk of intestinal cancer in inflammatory bowel disease: a population-based study from Olmstead, Minnesota.Gastroenterology. 2006; 130: 1039-1046Abstract Full Text Full Text PDF PubMed Scopus (394) Google Scholar to 23.828Gyde S.N. Prior P. Macartney J.C. et al.Malignancy in Crohn's disease.Gut. 1980; 21: 1024-1029Crossref PubMed Scopus (264) Google Scholar in patients with extensive Crohn's colitis.Since 1980, we have followed 259 patients with chronic Crohn's colitis in a prospective colonoscopic surveillance program. Our initial results through August 1998 showed a 22% chance of developing definite dysplasia or cancer by the fourth surveillance examination.29Friedman S. Rubin P. Bodian C. et al.Screening and surveillance colonoscopy in chronic Crohn's colitis.Gastroenterology. 2001; 120: 820-826Abstract Full Text Full Text PDF PubMed Google Scholar We now update the results of all examinations performed in our original cohort since September 1998 until April 2005.Materials and MethodsAfter a diagnosis of metastatic colon cancer in a patient with extensive Crohn's colitis, we embarked on a systematic practice of calling back patients with Crohn's colitis to examine for dysplasia and cancer. Since January 1980, all of one author's (D.H.P.) patients with Crohn's colitis diagnosed for 7 years or longer and with at least one third of the colon involved were offered the opportunity to undergo colonoscopic screening and surveillance; almost all patients accepted. Crohn's disease was diagnosed by standard radiographic, endoscopic, and/or pathologic criteria. These criteria included extensive ileal disease, perianal fistulae, skip lesions, and granulomas. Ileal involvement was quantified by small-bowel series and colonic involvement was quantified by barium enema or colonoscopy. Patients without colonic involvement or with inflammation limited to the cecal tip or rectum were excluded. This corresponds to the lack of increased cancer risk in patients with proctitis and the minimally increased risk in patients with proctosigmoiditis. Left-sided disease was defined as that distal to the splenic flexure. We now report on the 259 patients who participated.All patients underwent colonoscopy by the same endoscopist (P.H.R.). The colonoscopic technique was the same as that used for patients with chronic ulcerative colitis, namely 4 circumferential biopsies performed at approximately 10-cm intervals and additional biopsies if strictures or suspicious polypoid lesions were observed. Polypoid dysplastic lesions deemed adenoma-like were removed completely. The bases of all polyps underwent extensive biopsy examinations, as well as the areas of mucosa surrounding each polyp. All polypoid lesions in this study were located in areas of macroscopic or microscopic colitis. If complete colonoscopy was precluded by stricturing, a pediatric colonoscope was used. No colonoscopic balloon dilation was attempted.All biopsy specimens accessed after 1983, when the ulcerative colitis guidelines for histologic interpretation of dysplasia were written,30Riddell R.H. Goldman H. Ransohoff D.F. et al.Dysplasia in inflammatory bowel disease: standardized classification with provisional clinical applications.Hum Pathol. 1983; 14: 931-968Abstract Full Text PDF PubMed Scopus (1589) Google Scholar were classified as normal, indefinite for dysplasia (IND), low-grade dysplasia (LGD), high-grade dysplasia (HGD), or carcinoma (CA), and were read predominantly by one pathologist (N.H.). Lesions were classified as flat, polyp, or mass.Biopsy specimens read in 1983 or earlier were classified as mild, moderate, or severe dysplasia, or CA. All biopsy specimens that were positive for LGD, HGD, or CA were reviewed by a second pathologist before the patients were sent for surgery. This study was approved by the Mount Sinai Hospital Institutional Review Board.Surveillance ColonoscopyIf the results of the screening colonoscopy were negative for dysplasia or CA, the patient was contacted for a repeat examination in 2 years. Initially, a handwritten call-back list was maintained, but after 1992 the list was computerized. Some patients waited longer than 2 years to report for surveillance colonoscopy despite notification by telephone and mail.Patients with IND on any colonoscopy were contacted for extensive repeat biopsies within 1 year. Patients with 1 area of flat LGD were contacted for repeat endoscopy within 1 to 6 months. Patients with recurrent or multifocal flat LGD, HGD, or CA were referred for surgery. Patients with adenoma-like polypoid dysplastic lesions that had been removed were contacted for repeat endoscopy within 1 to 6 months.31Rubin P. Friedman S. Harpaz N. et al.Colonoscopic polypectomy in chronic colitis: conservative management after endoscopic resection of dysplastic polyps.Gastroenterology. 1999; 117: 1295-1300Abstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar, 32Odze R. Farraye F.A. Hecht J.L. et al.Long-term follow-up after polypectomy treatment for adenoma-like dysplastic lesions in ulcerative colitis.Clin Gastroenterol Hepatol. 2004; 2: 534-541Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar Data were gathered during the summer of 2005 and the cut-off date for the end of this study was April 30, 2005.Statistical MethodsScreening examinationContinuous variables such as age and disease duration were grouped, and the Fisher exact test was used to test for an association between each demographic variable and the chance of finding dysplasia or cancer.Surveillance examinationsAnalysis of a first positive finding of LGD, HGD, or CA on the surveillance examinations was conducted as for time-to-event data, with the consecutive surveillance examinations representing the time variable. The probability of discovering new dysplasia or CA on a surveillance examination was estimated by life-table analysis on all patients who had a negative screening examination result and at least 1 surveillance examination, with follow-up duration terminated at the earliest examination with a positive finding or, in the case of patients without dysplasia, at the last surveillance examination. We also used Cox regression analysis to look for factors associated with a first positive finding on surveillance. Significant factors were sought by a stepwise procedure, with age and disease duration updated as time-changing covariates. To evaluate the total number of cancers found either on a surveillance examination or at surgery among the patients in the surveillance program, we calculated the number that would have been expected based on applying age- and sex-specific incidence rates for CA of the colon and rectum from the Surveillance Epidemiology and End Results (SEER) cancer registries of 1997 (the midpoint of the colonoscopies in this study) to the corresponding person-years of exposure among the patients under surveillance.ResultsA total of 1424 examinations (screening and surveillance) were performed, with a median of 5 examinations per patient (range, 1–23).Screening ExaminationDemographics of the study population are reported in Table 1. This was a unique group of patients in that 90% had extensive colitis. Thirty-one percent had previously undergone segmental colon resection. Only 1 dysplasia or cancer was found between 1980 and 1983. It was classified initially as mild and then re-read after 1983 as indefinite. At the initial screening examination, definite dysplasia or cancer was found in 18 patients (7%) (Table 2). Thirteen patients had LGD (7 polyps, 6 flat), 2 had HGD (2 flat), and 3 had CA (3 masses). There were no colonoscopic complications.Table 1Demographics of Study Population: Screening ExaminationsDemographicNumberPercentageFemale13351Median age at diagnosis, y (range)22 (2–61)Median disease duration, y (range)18 (7–49)Anatomic extent Ileocolitis14656 Colitis11344Location Right-sided only125 Left-sided only145 Extensive colitis23390 Rectal sparing9340First-degree relative with IBD4618First-degree relative with colorectal cancer104Prior partial colon resection8131Clinical status at screening colonoscopy No change in symptoms21583 Increased symptoms4417Complete colonoscopies22587 Open table in a new tab Table 2First Positive Finding of Definite Dysplasia or Cancer Found at ColonoscopyLGD polypLGD flatHGD polypHGD flatCA polypCA massTotal examinationsScreening Surveillance760203259 1431010212 2210000172 3300001148 4320211116 500000090 610100073 700000057 800000042 901000027 1010000018 1101000010 120000006 130000003 140000002 150000001 160000001 Open table in a new tab IND is a controversial finding and is not included as definite dysplasia in most ulcerative colitis surveillance studies. To be certain that disregarding IND in our statistical analysis made no difference, we recalculated all of our statistical tables to include IND and found the same associations (data not shown).The prevalence of definite dysplasia or cancer on screening examinations was significantly higher in patients who were older than 45 years as compared with their younger counterparts (P = .01) (Table 3). The prevalence also was higher, but not enough to reach statistical significance, in those who had a change in inflammatory bowel disease (IBD) symptoms as the indication for colonoscopy (P = .09), and those with longer than 20 years' disease duration (P = .22) (Table 3). It is notable that the prevalence for patients older than 45 years did not vary with disease duration, whereas these data indicate the possibility (not statistically significant) of increased prevalence with long duration of disease in patients age 45 years or younger (Table 4).Table 3Age Older Than 45 Years and Increased IBD Symptoms Were Associated With a Finding of Definite Dysplasia or Cancer on Screening ExaminationFactorPositive for neoplasiaP valueNumber%Age, y ≤455/1503.3.01 >4513/10911.9Indication Routine12/2155.6.09 Change in IBD symptoms6/4413.6Duration, y ≤207/1434.9.22 >2011/1169.5 Open table in a new tab Table 4For Disease Duration of 7 to 20 Years, Age Older Than 45 Years Was Associated With Definite Dysplasia or Cancer on Screening Examinations7–20 y>20 yAge ≤45 y2.7% (3/110)5% (2/40)Age >45 y12.1% (4/33)11.8% (9/76)P value.050.33 Open table in a new tab Surveillance ExaminationsDemographics of the patients who underwent surveillance colonoscopy are reported in Table 5. On surveillance examinations, a first positive finding of definite dysplasia or cancer was found in 30 patients (LGD, 22 patients [14 polyps, 8 flat]; HGD, 4 patients [2 polyps, 2 flat]; CA, 4 patients [2 polyps (stage 0), 2 masses]). LGD, HGD, or CA was detected as late as the 11th surveillance examination (Table 2). The factors considered in the stepwise procedure were as follows: age at examination older than 45 years, disease duration at examination older than 20 years and an interaction effect for age and duration (these age and duration factors were modeled as time-changing covariates), age at diagnosis older than 15 years or as a continuous variable, family history of cancer, family history of IBD, complete examination, female sex, pancolitis (vs right-sided or left-sided), and prior resection, as predictors of an initial finding of any extent of dysplasia. This analysis did not identify any consistent risk factors over time for the risk of finding dysplasia or cancer, but indicated an increased risk among patients whose disease duration was less than 20 years at their first surveillance examination, but lower risk for short-duration patients thereafter. There were no colonoscopic complications.Table 5Characteristics of Surveillance Examinations Not Preceded by a Positive Finding of LGD, HGD, or CAMedian interval between examinations, mo (range)18 (1–165)Prior partial colonic resection47 (4.8%)Clinical status at surveillance colonoscopy No change in symptoms915 examinations (94%) Increased IBD symptoms63 examinations (6%)Complete colonoscopies909 examinations (93%)NOTE. There were 978 examinations in 212 patients. Open table in a new tab We used life-table analysis to estimate the cumulative yield achieved in succeeding examinations by instituting routine surveillance colonoscopy after a negative screening result in this referral practice. The cumulative risk of detecting an initial finding of any LGD, HGD, or CA after a negative screening colonoscopy was 25% by the 10th surveillance examination (95% confidence interval, 13%–34%). The cumulative risk of detecting an initial finding of flat HGD or CA after a negative screening colonoscopy was 7% by the 10th surveillance examination (95% confidence interval, 1%–13%; Figure 1).Patient Outcomes After a Finding of Dysplasia or CancerFlat low-grade dysplasiaLGD (flat) was found during screening or surveillance examinations in 14 patients (Table 6).Table 6Follow-Up Evaluation for Patients With Positive Examination Results: Worst Lesion Found on Colonic Resection or on Subsequent Examination if No ResectionInitial finding, nMean time interval, mo (range)Worst lesion found, nLGD flat (14) Surgery (8)32.5 (23–42)CA (2)0HGD flat (3)6 (0–12)LGD polyp (2)36NEG (1) Surveillance (6)132HGD polyp (1)76 (60–96)LGD polyp (3)62.5 (5–120)NEG (2)LGD polyp (21) Surgery (5)85.5 (81–90)CA (2)24IND (1)54 (24–84)NEG (2) Surveillance (16)180LGD flat (1)70.1 (6–156)LGD polyp (8)45.3 (5–84)NEG (7)HGD flat (4) Surgery (4)0CA (2) (1 died from pouch CA 10 y later)0HGD flat (1)0NEG (1)HGD polyp (2) Refused surgery (1)24CA (1) (died) Polypectomy (1)24NEG (1)CA (7) Surgery (5)0CA (4)0NEG (1) Polypectomy (2)145 (86–204)NEG (2)CA, carcinoma; HGD, high-grade dysplasia; NEG, negative. Open table in a new tab Surgical resectionEight patients underwent surgical resection for recurrent or multifocal flat LGD. Patient follow-up evaluation is detailed in Table 6. Two CAs were found at surgery, 1 a stage IIIB and 1 a stage IIA. The first patient received chemotherapy and has not had a recurrence and the second patient has had a metastatic recurrence despite chemotherapy.No surgical resection and continued surveillanceSix patients with unifocal flat LGD did not undergo surgical resection. Follow-up evaluation is indicated in Table 6. One HGD polyp was found on a surveillance colonoscopy after 132 months and was removed by snare cautery.Polypoid low-grade dysplasiaLGD (polyp) was found during screening or surveillance examinations in 21 patients (Table 6).Surgical resectionFive patients had surgical resection for multifocal or recurrent polypoid LGD. Two patients had CAs found at surgery. Both patients had stage I tumors without nodal involvement and did not receive chemotherapy. Both patients have had no recurrence a mean of 42 months later.Polypectomy and continued surveillanceSixteen patients had continued surveillance. The worst lesion found was a flat LGD in 1 patient after 180 months.Flat high-grade dysplasiaAll 4 patients with flat HGD underwent surgical resection (Table 6). Two patients had CA. The first patient had a subtotal colectomy for flat HGD that revealed a stage I CA. One year later, she underwent an ileal pouch–anal anastomosis for flat HGD found on surveillance colonoscopy. Despite surveillance pouchoscopies with extensive biopsies every 1 to 2 years, she developed pouch cancer 10 years later and died despite chemotherapy. The other patient had stage IIA cancer, received chemotherapy, and has had no recurrence 5 years later.Polypoid high-grade dysplasiaTwo patients had polypoid HGD (Table 6). One patient underwent polypectomy and has had no further dysplasia on surveillance colonoscopies (follow-up period, 24 mo). The other patient had recurrent polypoid LGD and HGD and was offered surgical resection. He refused surgery and died of metastatic colon cancer 24 months later.CancerThree patients had cancer identified on screening examination and 4 patients had cancer identified on surveillance examinations 1, 3, and 4 (Table 6).Surgical resectionFive patients with CA underwent surgical resection. All patients had surgical resections immediately after diagnosis. Two cancers were stage IIA, 1 was stage I, 1 was stage IIIB, and the last 1 was stage IV. Three of the patients received chemotherapy with no recurrence and another patient still is receiving chemotherapy. All are alive today a mean of 57 months laterPolypectomyTwo patients had stage 0 cancers in polyps removed endoscopically by snare cautery. One patient had a subsequent resection for symptoms 86 months later and there was no dysplasia in the surgical specimen. The other patient has had no recurrence of neoplasia after 204 months. All cancer stages, surgeries, and outcomes are detailed in Table 7.Table 7Stage of Cancer, Surgery, and OutcomeInitial stage (T, N, M)Cancer found atWorst lesion found on prior colonoscopyOutcomeIIIB (T3,N1,M0)Surgery (IPAA)Recurrent/multifocal flat LGDChemotherapy, no recurrenceIIA (T3,N0,MX)Surgery (TPC + ileostomy)Recurrent flat LGDChemotherapy, recurrent metastatic diseaseI (T1,N0,M0)Surgery (right ileocolic resection)Recurrent/multifocal polypoid LGDNo chemotherapy, no recurrenceI (T2,N0,M0)Surgery (right ileocolic resection)Recurrent/multifocal polypoid LGDNo chemotherapy, no recurrenceI (T1,N0,M0)Surgery (subtotal colectomy then IPAA 1 y later for flat HGD)Single flat HGDNo chemotherapy, died from metastatic pouch CAIIA (T3,N0,M0)Surgery (TPC + ileostomy)Single flat HGDChemotherapy, no recurrenceIV (T4,N2,M1)Colonoscopy (no surgery)Recurrent polypoid HGD/LGDRefused surgery for polypoid HGD, diedIIIB (T3,N1,M0)Colonoscopy (TPC + ileostomy)NegativeChemotherapy no recurrenceIV (T4,N1,M1)Colonoscopy (limited rectal resection)NegativeCurrent chemotherapyIIA (T3,N0,M0)Colonoscopy (right ileocolic resection)NegativeChemotherapy no recurrenceIIA (T3,N0,M0)Colonoscopy (right ileocolic resection)NegativeChemotherapy no recurrenceI (T2,N0,M0)Colonoscopy (TPC+ ileostomy)NegativeNo chemotherapy0 (Tis,N0,M0)Colonoscopy (polypectomy)NegativeNo chemotherapy0 (Tis,N0,M0)Colonoscopy (polypectomy)NegativeNo chemotherapyIPAA, ileal pouch–anal anastomosis; TPC, total proctocolectomy. Open table in a new tab Because there was no control group for this study, we used the SEER cancer registry to see how the number of patients who developed CA while under surveillance, recognized either on a surveillance examination or at surgery, compared with colon and rectal cancer rates in the general population.33Ries L.A.G. Melbert D. Krapcho M. SEER cancer statistics review, 1975-2004. National Cancer Institute, Bethesda, MD2007http://seer.cancer.gov/csr/1975_2004/Google Scholar We counted exposure time from the screening examination to a surveillance examination with CA, or to the last surveillance examination, whichever came first. The 11 cancers (2 of these were stage 0 cancer found in polyps) that were found are significantly more than the 1.13 cases expected, based on applying the age- and sex-specific incidence rates for cancer of the colon and rectum from the SEER cancer registries of 1997 (the midpoint of the colonoscopies in this study) to the corresponding person-years of exposure among the 212 patients under surveillance.DiscussionIn contrast to most other population- or hospital-based studies of colon cancer in Crohn's disease, our population was unique in that 90% of patients had extensive colitis. In our initial study reported in 2001, we found a cumulative risk of neoplasia of 22% by the fourth surveillance examination.29Friedman S. Rubin P. Bodian C. et al.Screening and surveillance colonoscopy in chronic Crohn's colitis.Gastroenterology. 2001; 120: 820-826Abstract Full Text Full Text PDF PubMed Google Scholar In this study, we report on a more extended period of surveillance and found a cumulative risk of 25% by the 10th surveillance examinatio" @default.
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• W1989215734 title "Screening and Surveillance Colonoscopy in Chronic Crohn's Colitis: Results of a Surveillance Program Spanning 25 Years" @default.
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