STUDY OF PATTERNS OF DYSPLASIA IN INFLAMMATORY BOWEL DISEASES

Background: Inflammatory bowel disease (IBD) comprises of Ulcerative colitis, Crohn’s disease and colitis of indeterminate type. Patients with long established IBD are at a greater risk for development of colorectal carcinoma (CRC). The best marker for cancer risk in IBD is dysplasia. IBD on biopsy can show low grade dysplasia (LGD) or high grade dysplasia (HGD) or histological features indefinite for dysplasia. Aims: 1) Determination of the incidence of LGD, HGD and CRC in IBD patients. 2) Evaluation of presence of any correlation between duration of IBD and extent of intestinal involvement by IBD and between duration of IBD and multifocality of dysplasia. Materials and Method: 393 patients with clinical suspicion of IBD were enrolled in this study. During surveillance endoscopy number of biopsy samples taken from each case were 10-15. Histopathological examination of these biopsy samples was done. Results: Out of 266 patients of IBD who turned up for surveillance endoscopy, the incidences of LGD, HGD, CRC and IBD indeterminate for dysplasia were found to be 10.90%, 4.51%, 4.51% and 2.63% respectively. On statistical analysis it was discovered that in both UC and CD the extent of intestinal involvement was directly proportional to the duration of the disease. In both UC and CD, longer disease durations were linked to more foci of dysplasia. Conclusion: In both UC and CD, longer disease durations is linked to the extent of intestinal involvement and number of foci of dysplasia while type of dysplasia (LGD/HGD) is not related to duration of IBD. In IBD with UC incidence of PSC is linked with the extent of intestinal involvement.

Novel Pathologic Factors for Risk Stratification of Gastric “Indefinite for Dysplasia” Lesions

Background/Aims. “Indefinite for dysplasia” (IND) conditions of the stomach have high malignancy rates (22.6%–75.0%). Endoscopic resection is sometimes used for follow-up, but criteria for selecting this follow-up method are not established. We investigated pathologic factors to subclassify the IND of the stomach and select appropriate follow-up methods. Methods. In total, 123 IND cases with final diagnoses of cancer (29.3%), high-grade dysplasia (6.5%), low-grade dysplasia (11.4%), and nonneoplasm (52.8%) were randomly divided into test set ( n = 27 ) and validation set ( n = 96 ). By the image analysis, size, pleomorphism, hyperchromasia, irregularity of nuclei, and ratios of structural atypia area (SAA) to total IND area were measured in the test set. Using the validation set, consensus meetings were held for the evaluation of pathologic factors that predict the final diagnosis. Results. By image analysis, the only ratio of SAA to total IND area was associated with the final diagnosis ( p < 0.001 ). In the consensus meeting for validation, the nuclear factors, except loss of nuclear polarity ( p = 0.004 – 0.026 ), could not predict the final diagnosis. Conversely, most structural factors could predict the final diagnosis. In particular, SAA > 25 % was the most powerful predictive factor. We proposed criteria of risk stratification by using SAA > 25 % , loss of surface maturation (LOSM), and loss of nuclear polarity (LONP) (Malignancy rate; Category 0: SAA ≤ 25 % without LOSM and LONP; 0%, Category 1: SAA ≤ 25 % with any of LOSM or LONP; 15.2%–16.7%, Category 2: SAA > 25 % without LOSM and LONP; 44.4%–50.0%, Category 3: SAA > 25 % with any of LOSM or LONP 54.5%–55.6%). Conclusions. Structural atypia was more helpful than nuclear atypia and SAA > 25 % was the most powerful predictor for the diagnosis of INDs of the stomach. We propose shortening the follow-up period to six months for Category 1, endoscopic resection for Category 2 and 3, postresection follow-up periods of one year for Category 2, and six months for Category 3.

516 THE CHARACTERIZATION OF DYSPLASIA IN BARRETT’S ESOPHAGUS—A PROSPECTIVE NATIONWIDE REGISTRY FROM THE RIBBON NETWORK

Barrett’s Esophagus is the main pathological precursor to esophageal adenocarcinoma (EAC), dysplasia is known to be one of the principal predictors of progression to malignancy. The RIBBON Registry was established with six academic medical centers in the Republic of Ireland to identify and manage high risk Barrett’s Esophagus (BE) patients. From our database of over 4,000 patients our aim was to establish characteristics of those patients who progressed to dysplasia and furthermore to malignancy. Methods Data was gathered prospectively from December 2007—December 2019. Ethical approval was sought for the database at the time of establishment. Detailed endoscopic, pathological and clinical data was collected via a web-based data capture system at time of initial diagnosis and at each subsequent encounter. A data manager was appointed at each site and a national lead coordinating the project. The Vienna Grading system was used to grade histology. Patients were included if they had an initial or subsequent diagnosis of Specialized intestinal metaplasia (SIM), Indefinite for dysplasia (IND) or Low-Grade Dysplasia (LGD). Results 860 patients were included with a total of 3792 patient years, a male to female ratio of 2.9:1 and a median age at diagnosis of 63. 50 patients had an initial diagnosis of SIM with subsequent episodes of dysplasia while 510 patients had IND or LGD at diagnosis. 158 (18.37%) progressed to High grade dysplasia (HGD) and EAC. The overall incidence of EAC was 1.7% per year, HGD 2.4% per year and a combined rate of 4.2% per year. Median time to progression in SIM was 4.7 years, 1.1 years for IND and 9 months for LGD. Conclusion The overall progression of the group was much higher compared to looking at those who had SIM alone without dysplasia from the same registry (0.9% per year). Time to progression was significantly faster in the groups with initial dysplasia be that IND or LGD. In our centers those patients were followed up with repeat endoscopy as per international guidelines, the above results highlight the importance of this practice given the potential for malignancy.

Persistent indefinite for dysplasia in Barrett’s esophagus is a risk factor for dysplastic progression to low-grade dysplasia

Summary Patients with Barrett’s esophagus (BE) are at increased risk of esophageal adenocarcinoma (EAC). The risk is largely based on the degree of dysplasia. Dysplasia cannot always be differentiated from inflammatory changes, and therefore may be classified as indefinite for dysplasia (IND). The risk of progressive dysplasia in patients with IND is unclear. Our aim is to characterize the risk of progression in US veterans with BE-IND. We performed a single-center retrospective cohort study of patients with BE-IND between 2006 and 2016. All IND was diagnosed by consensus conference with an expert gastrointestinal (GI) pathologist or review by an expert GI pathologist and persistence was defined as IND present on subsequent endoscopic biopsy. The primary outcome was the incidence rate of high-grade dysplasia (HGD)/EAC. Secondary outcomes included any progression including incident low-grade dysplasia (LGD), any prevalent dysplasia and risk factors for dysplastic progression, namely persistent IND. Risk factors for progression were assessed using univariate and multivariate analysis with logistic regression. Among 107 patients with BE-IND, there were no incident cases of HGD/EAC. Twenty patients (18.7%) developed incident LGD during a median follow-up of 2.39 years (interquartile range, 1.13–5.17). The annual rate of progression to LGD was 5.95 per 100 patient-years (95% CI, 3.73–9.02). Prevalent dysplasia was common (9.3%). Eight patients had prevalent LGD, one patient had prevalent HGD and one patient had prevalent EAC. Twenty-eight patients (30.1%) were found to have persistent IND. Among those with persistent IND, 10 (36%) patients progressed to LGD (none to HGD/EAC). The progression rate to LGD for patients with persistent IND was 7.86 (95% CI, 3.99–14.02) cases per 100 patient-years versus 4.78 (95% CI, 2.48–8.52) for nonpersistent IND (P = 0.036). The odds ratio for progression to LGD in persistent IND was 3.06 (95% CI, 1.08–8.64). In multivariate analysis adjusting for age, smoking history, presence of hiatal hernia and BMI &gt; 30, persistent IND remained significant (OR 3.23; 95% CI, 1.04–9.98). Regression to nondysplastic BE was very common. Seventy-one (61%) patients developed complete and sustained regression of all dysplastic changes at last follow-up. Persistent IND, present in one-third of patients with IND, is an independent risk factor for progression to LGD. Although no patients in this cohort developed HGD/EAC, prevalent dysplasia was common (9.3%). Taken together, patients with IND should receive close surveillance for both prevalent and incident dysplasia especially if IND is persistent.