Indigo Carmine-Assisted High-Magnification Chromoscopic Colonoscopy for the Detection and Characterisation of Intraepithelial Neoplasia in Ulcerative Colitis: A Prospective Evaluation

Background and Study Aims: Recent data suggest that panchromoscopy using methylene blue can improve the detection of intraepithelial neoplastic lesions in the context of surveillance colonoscopy for patients with chronic ulcerative colitis. This method has also been shown to provide a more accurate diagnosis of the extent of disease and inflammatory activity. Interval cancers are known to occur in patients with chronic ulcerative colitis despite the adoption of currently accepted surveillance biopsy protocols. We hypothesised that targeted chromoscopy alone, with high-magnification imaging, may increase the total number of intraepithelial neoplastic lesions detected, compared with conventional colonoscopy and biopsy surveillance according to current protocols.
Patients and Methods: A total of 350 patients with long-standing ulcerative colitis (≥ 8 years) underwent surveillance colonoscopy using high-magnification chromoscopic colonoscopy (HMCC). Quadrantic biopsies at 10-cm intervals were taken on extubation in addition to targeted biopsies of abnormal mucosal areas. Defined lesions were further evaluated using modified Kudo crypt pattern analysis. These data were compared with data from 350 disease duration- and disease extent-matched control patients who had undergone conventional colonoscopic surveillance between January 2001 and April 2005.
Results: Significantly more intraepithelial neoplastic lesions were detected in the magnification chromoscopy group compared with controls (69 vs. 24, P < 0.0001). Intraepithelial neoplasia was observed in 67 lesions, of which 53 (79 %) were detected using magnification chromoscopy alone. Chromoscopy increased the number of flat lesions with intraepithelial neoplasia detected compared with controls (P < 0.001). Twenty intraepithelial neoplastic lesions were detected from 12 850 non-targeted biopsies in the HMCC group (0.16 %), while 49 intraepithelial neoplastic lesions were detected from the 644 targeted biopsies in the HMCC group (8 %). From 12 482 non-targeted biopsies taken in the control group patients, 18 (0.14 %) showed intraepithelial neoplasia. The yield of intraepithelial neoplastic lesions from targeted biopsies in the control group (i. e. without HMCC imaging), however, was only modestly improved at 1.6 % (6/369). Using modified Kudo criteria, the sensitivity and specificity for differentiating neoplastic from non-neoplastic lesions using HMCC were 93 % and 88 % respectively. The total procedure time was significantly longer in the HMCC group compared with controls (P < 0.02).
Conclusions: Magnification chromoscopy improves the detection of intraepithelial neoplasia in the endoscopic screening of patients with chronic ulcerative colitis. Neoplastic and non-neoplastic mucosal change can be predicted with a high overall accuracy using magnification techniques. These adjunctive endoscopic techniques have important clinical implications and may lead to changes in current practice guidelines.

References

• 1 Goldmann H. Significance and detection of dysplasia in chronic colitis.  Cancer. 1996;  78 2261-2263
• 2 Riddell R H, Goldman H, Ransohoff D F. et al . Dysplasia in inflammatory bowel disease: standardized classification with provisional clinical implications.  Hum Pathol. 1983;  14 931-968
• 3 Shelton A A, Lehman R E, Schrosck T R, Welton M L. Retrospective review of colorectal cancer in ulcerative colitis at a tertiary centre.  Arch Surg. 1996;  131 806-810
• 4 Eaden J A, Mayberry J F. Colorectal cancer complicating ulcerative colitis: a review.  Am J Gastroenterol. 2000;  95 2710-2719
• 5 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
• 6 Ekbom A, Helmick C, Zack M, Adami H O. Ulcerative colitis and colorectal cancer: a population-based study.  N Engl J Med. 1990;  323 1228-1233
• 7 Rubin C E, Haggit R C, Burmer G C. et al . DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis.  Gastroenterology. 1992;  103 1611-1620
• 8 Brooker J C, Saunders B P, Shah S G. et al . Total colonic dye-spray increases the detection of diminutive adenomas during routine colonoscopy: a randomized controlled trial.  Gastrointest Endosc. 2002;  56 333-338
• 9 Kiesslich R, Fritsch J, Holtmann M. et al . Methylene blue-aided chromoendoscopy for the detection of intraepitheial neoplasia and colon cancer in ulcerative colitis.  Gastroenterology. 2003;  124 880-888
• 10 Hurlstone D P, McAlindon M E, Sanders D S, Lobo A J. Further validation of high-magnification chromoscopic colonoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis.  Gastroenterology. 2004;  36 194
• 11 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
• 12 Hurlstone D P. Is there a role for high-magnification chromoendoscopy in the endoscopic diagnosis of dysplasia-associated lesion or mass and adenoma in patients with ulcerative colitis? [Review].  Hepatogastroenterology. 2003;  50 31-32
• 13 Hurlstone D P, Fujii T, Lobo A J. Early detection of colorectal cancer using high-magnification chromoscopic colonoscopy.  Br J Surg. 2002;  89 272-282
• 14 Paris Workshop Participants . The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach and colon.  Gastrointest Endosc. 2002;  58 S3-S43
• 15 Kudo S, Rubio C A, Teixeira C R. et al . Pit pattern in colorectal neoplasia: endoscopic magnifying view.  Endoscopy. 2001;  33 367-373
• 16 Japanese Research Society for Cancer of the Colon and Rectum . General rules for clinical and pathological studies on cancer of the colon, rectum and anus. Part I: clinical classification.  Jpn J Surg. 1983;  13 557-573
• 17 Japanese Research Society for Cancer of the Colon and Rectum . General rules for clinical and pathological studies on cancer of the colon, rectum and anus. Part II: histopathological classification.  Jpn J Surg. 1983;  13 574-598
• 18 Schlemper R J, Riddell R H, Kato Y. et al . The Vienna classification of gastrointestinal neoplasia.  Gut. 2000;  47 251-255
• 19 Crohn B, Rosenberg H. The sigmoidoscopic picure of chronic ulcerative colitis (non-specific).  Am J Med Sci. 1925;  170 220-228
• 20 Gyde S N, Prior P, Allan R N. et al . Colorectal cancer in ulcerative colitis: a cohort study of primary referrals from three centres.  Gut. 1988;  29 206-217
• 21 Brostrom M O, Lofberg R, Ost A. Cancer surveillance of patients with longstanding ulcerative colitis: a clinical and endoscopical and histological study.  Gut. 1986;  27 1408-1413
• 22 Lashner 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 1536-1541
• 23 Leidenius M, Kellokumpu I, Husa A. et al . Dysplasia and carcinoma in longstanding ulcerative colitis: an endoscopic and histological surveillance programme.  Gut. 1991;  32 1521-1525
• 24 Collins 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 1654-1658
• 25 Ransohoff D F, Riddell R H, Levin B. Ulcerative colitis and colonic cancer: problems in assessing the diagnostic usefulness of mucosal dysplasia.  Dis Colon Rectum. 1985;  28 383-388
• 26 Bernstein C N. ALMs versus DALMs in ulcerative colitis: polypectomy or colectomy?.  Gastroenterology. 1999;  117 1488-1492
• 27 Tanaka S, Haruma K, Ito M. et al . Detailed colonoscopy for detecting early superficial carcinoma: recent developments.  J Gastroenterol. 2000;  35 Suppl 12 121-125
• 28 Kudo S, Kashida H, Tamura T. et al . Colonoscopic diagnosis and management of nonpolypoid early colorectal cancer.  World J Surg. 2000;  24 1081-1090
• 29 Fujii T, Nagata K, Saito Y. The correspondence of magnifying endoscopic diagnosis and pathological diagnosis.  Stomach Intest. 1999;  34 1653-1664
• 30 Hurlstone D P, Cross S S, Drew K. et al . An evaluation of colorectal endoscopic mucosal resection using high-magnification chromoscopic colonoscopy: a prospective study of 1000 colonoscopies.  Endoscopy. 2004;  36 491-498
• 31 Hurlstone D P, Cross S S, Adam I. et al . Efficacy of high magnification chromoscopic colonoscopy for the diagnosis of neoplasia in flat and depressed lesions of the colorectum: a prospective analysis.  Gut. 2004;  53 284-290
• 32 Tung S Y, Wu C S, Su M Y. Magnifying colonoscopy in differentiating neoplastic from nonneoplastic colorectal lesions.  Am J Gastroenterol. 2001;  96 2628-2632
• 33 Konishi K, Kaneko K, Kurahashi T. et al . A comparison of magnifying and nonmagnifying colonoscopy for diagnosis of colorectal polyps: a prospective study.  Gastrointest Endosc. 2003;  57 48-53