Section 8: Surveillance for Colorectal Cancer in Ulcerative Colitis
ECCO statement 8AThe risk of colorectal cancer in ulcerative colitis is increased compared with the general population. Risk is associated with disease duration [EL 2], extent [EL 2], and more severe or persistent inflammatory activity [EL 2]
ECCO statement 8BConcomitant primary sclerosing cholangitis [EL 2] and a family history of colorectal cancer [EL 3] confer an additional risk for colorectal cancer
ECCO statement 8CSurveillance colonoscopy may permit earlier detection of colorectal cancer with a corresponding improved prognosis [EL 3]
ECCO statement 8D [adapted from statement 13D in Annese et al.13]Screening colonoscopy should be offered over 8 years following the onset of symptoms to all patients to reassess disease extent and exclude dysplasia [EL 5]
ECCO statement 8EWhen disease activity is limited to the rectum without evidence of previous or current endoscopic and/or microscopic inflammation proximal to the rectum, inclusion in a regular surveillance colonoscopy programme is not necessary [EL2]
ECCO statement 8FIn patients with concurrent primary sclerosing cholangitis, annual surveillance colonoscopy should be performed following the diagnosis of primary sclerosing cholangitis, irrespective of disease activity, extent, and duration [EL3]
ECCO statement 8G [adapted from statement 13E in Annese et al.13]Ongoing surveillance should be performed in all patients apart from those with proctitis [EL3]. Patients with high-risk features [e.g. stricture or dysplasia detected within the past 5 years, primary sclerosing cholangitis, extensive colitis with severe active inflammation] should have their next surveillance colonoscopy scheduled for 1 year [EL4]. Patients with intermediate risk factors should have their next surveillance scheduled for 2 to 3 years. Intermediate risk factors include extensive colitis with mild or moderate active inflammation, post-inflammatory polyps, or a family history of colorectal cancer in a first-degree relative diagnosed at age 50 years and above [EL5]. Patients with neither intermediate nor high-risk features should have their next surveillance colonoscopy scheduled for 5 years [EL5]
ECCO statement 8HColonoscopic surveillance is best performed when ulcerative colitis is in remission, because it is otherwise difficult to discriminate between dysplasia and inflammation on mucosal biopsies [EL5]
ECCO statement 8ISurveillance colonoscopy should take into account local expertise. Chromoendoscopy with targeted biopsies has been shown to increase dysplasia detection rate [EL2]. Alternatively, random biopsies [quadrantic biopsies every 10 cm] and targeted biopsies of any visible lesion should be performed if white light endoscopy is used [EL3]. High-definition endoscopy should be used if available
ECCO statement 8JChemoprevention with mesalamine compounds may reduce the incidence of colorectal cancer in ulcerative colitis [EL2]. There is insufficient evidence to recommend for or against chemoprevention with thiopurines
8.4.3. Immunosuppressants
IMs [e.g. thiopurines and MTX] and biologics [anti-TNF] could theoretically either increase the risk of CRC via immunosuppression, or be chemopreventive via a reduction of chronic mucosal inflammation. There are no data for MTX or anti-TNF, and the data for thiopurines are conflicting.49–51,478,511,519,527–529
ECCO statement 8KPresence of low-grade or high-grade dysplasia should be confirmed by an independent gastrointestinal specialist pathologist [EL 5]
ECCO statement 8LPolypoid dysplasia can be adequately treated by polypectomy provided the lesion can be completely excised, and there is no evidence of non-polypoid or invisible dysplasia elsewhere in the colon [EL 2]
ECCO statement 8MNon-polypoid dysplastic lesions can be treated endoscopically in selected cases. If complete resection can be achieved, with no evidence of non-polypoid or invisible dysplasia elsewhere in the colon, continued surveillance colonoscopy is reasonable [EL 5]. Every other patient with non-polypoid dysplasia should undergo colectomy, regardless of the grade of dysplasia detected on biopsy analysis [EL 2]
ECCO statement 8NPolyps with dysplasia that arise proximal to segments with macroscopic or histological involvement are considered as sporadic adenomas and should be treated accordingly [EL 2]
