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Predictors and Characteristics of Pouch Neoplasia

Summary and Comment |
January 23, 2014

Predictors and Characteristics of Pouch Neoplasia

  1. Douglas K. Rex, MD

Prior colorectal cancer and dysplasia were confirmed as risk factors, and the anal transition zone was identified as an area for special focus during surveillance.

  1. Douglas K. Rex, MD

Patients who undergo colectomy and ileal pouch anal anastomosis (IPAA) for chronic ulcerative colitis commonly undergo surveillance examinations of their pouch. Although we know that an indication of colorectal neoplasia (vs. active colitis) for colectomy is one risk factor for developing neoplasia in the pouch and the cuff, few others are established. Now, investigators in the Netherlands have retrospectively examined outcomes of 1200 patients with inflammatory bowel disease who underwent IPAA.

After a median follow-up of 6.5 years, findings included:

  • Twenty-five patients (1.83%) developed pouch neoplasia, including 16 adenocarcinomas.

  • Cumulative incidences at 5, 10, 15, and 20 years after IPAA were 1.0%, 2.0%, 3.7%, and 6.9%, respectively, for neoplasia and 0.6%, 1.4%, 2.1%, and 3.3% for pouch carcinoma.

  • Prior dysplasia (hazard ratio, 3.76) and prior carcinoma (HR, 24.69) were risk factors for developing neoplasia.

  • Ten of 16 pouch carcinomas and 3 of 8 cases of pouch dysplasia were located at the anal transition zone.

  • Dysplasia and cancer were identified in ulcerated lesions, polypoid lesions, and mass-like lesions.

  • Four of 16 patients with pouch carcinoma were reported to have no visible lesions on endoscopy.

  • Nine of 16 patients died; median survival was 11 months after diagnosis of pouch cancer.

Comment

The very high ratio of cancer to dysplasia suggests that many patients were either not followed carefully, or not examined and biopsied carefully and systematically during surveillance. In addition, the claim that no endoscopically visible lesions were present in four patients with cancer seems extremely unlikely, and I suspect that careful examination with a high-definition instrument would identify endoscopically visible lesions in all the patients with cancer. Nevertheless, some useful findings are present. Surveillance of the pouch should begin shortly after ileal pouch anal anastomosis when the indication for colectomy is dysplasia or cancer, and should continue on a long-term basis. Careful inspection of the anal transition zone and systematic biopsy of this area are appropriate, in addition to random biopsies of the pouch.

  • Disclosures for Douglas K. Rex, MD at time of publication Consultant / Advisory board Exact Sciences; Ferring Pharmaceuticals; Given Imaging; Olympus Speaker’s bureau Boston Scientific; Braintree; Ferring Pharmaceuticals Grant / research support Battelle; Braintree; Northwestern University; Olympus America Editorial boards Annals of Gastroenterology and Hepatology; Comparative Effectiveness Research; Expert Review of Gastroenterology and Hepatology; Gastroenterology; Gastroenterology and Hepatology News; Gastroenterology Report; Gastroenterology Research and Practice; Journal of Clinical Gastroenterology; Techniques in Gastrointestinal Endoscopy; World Journal of Gastroenterology; World Journal of Gastrointestinal Oncology; World Journal of Gastrointestinal Pathophysiology; World Journal of Gastrointestinal Pharmacology and Therapeutics

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