Useful endoscopic findings for early diagnosis of ulcerative colitis associated colorectal cancer

Ulcerative colitis is a chronic inflammatory bowel disorder associated with a high risk of colorectal cancer [1]. Endoscopic diagnosis of early ulcerative colitis-associated colorectal cancer or precancerous lesions is very difficult [2] [3] [4].

We report three cases with early-stage colorectal cancer or dysplasia examined with conventional endoscopy, magnified endoscopy and/or endoscopic ultrasonography (EUS).

Case 1 ([Fig. 1]) was a 48-year-old woman with the total colitis type ulcerative colitis; the disease duration was 29 years. Through conventional endoscopy, the cancerous lesion was detected as a villous, flat elevation. In the examination using EUS, the cancerous lesion was observed as a hypoechoic area. Because the hypoechoic area included the cancer itself and concomitant inflammatory cell invasions and fibrosis, the borderline between the neoplastic and non-neoplastic lesion was unclear, making it difficult to evaluate the invasion depth. Histopathologic diagnosis was well-to-moderately differentiated adenocarcinoma and the invasion extended to the muscularis propria.

Fig. 1 Conventional endoscopy (Indigo carmine dye spraying) in case 1. The cancer was located in the rectum. Through conventional endoscopy, the cancerous lesion was detected as a villous, flat elevation.

Case 2 ([Fig. 2 a – d]) was a 55-year-old man with the left-sided colitis type of ulcerative colitis; the disease duration was 20 years. Through conventional endoscopy, the cancerous lesion was detected as a flat elevation. Through magnified endoscopy, the V_N pit patterns [5] were mainly observed in the cancerous lesion and the capillarectasia was emphasized. In the examination with EUS, a hypoechoic area extending to the submucosa was observed. Histopathologic diagnosis was moderately to poorly differentiated adenocarcinoma, and invasion extended to the submucosa.

Fig. 2 Case 2 results. a Through conventional endoscopy, the cancerous lesion was detected as a flat elevation with capillarectasia; the cancer was located in the rectum. b, c Using magnified endoscopy, the V_N pit patterns in the Kudo classification were mainly observed in the cancerous lesion (c), and the capillarectasia was emphasized (b). d In the examination with endoscopic ultrasound, a hypoechoic area was observed.

Case 3 ([Fig. 3]) was a 67-year-old man with the total colitis type of ulcerative colitis; the disease duration was 9 years. Through conventional endoscopy, the lesion was detected as a flat elevation with remarkable redness. Through magnified endoscopy V_N or V_I pit patterns in the central area of the flat elevation and IV pit patterns in the surrounding area were observed. Histopathologic diagnosis was low-grade dysplasia.

Fig. 3 Conventional endoscopy in case 3 showed the cancer located in the descending colon. The cancerous lesion was detected as a flat elevation with redness.

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References

• 1 Eaden J A, Abrams K R, Mayberry J F. The risk of colorectal cancer in ulcerative colitis: a meta-analysis.  Gut. 2001;  48 526-535
• 2 Rutter M D, Saunders B P, Schofield G. et al . Pancolonic indigo carmine dye spraying for the detection of dysplasia in ulcerative colitis.  Gut. 2004;  53 256-260
• 3 Sada M, Igarashi M, Yoshizawa S. et al . Dye spraying and magnifying endoscopy for dysplasia and cancer surveillance in ulcerative colitis.  Dis Colon Rectum. 2004;  47 1816-1823
• 4 Shimizu S, Tomioka H, Watanabe M, Tada M. Possible roles of endoscopic ultrasonography in ulcerative colitis associated colorectal cancer.  Early Colorectal Cancer. 2005;  9 31-35
• 5 Kudo S, Rubio C A, Teixeira C R. et al . Pit pattern in colorectal neoplasia: endoscopic magnifying view.  Endoscopy. 2001;  33 367-373