Now interestingly enough, the BSG is
about to come out with their guidelines,
and it's not yet, it's in press, and we couldn't put it
into our AGA document because GUT wouldn't allow us,
but we were able to comment in that article,
and this is in summary what the British
are gonna be doing as of 2010.
They're gonna start screening at 10 years,
and they are dividing up their population into risk groups.
Which we don't do here.
So the lower risk group are gonna get
colonoscopy every five years.
Who are the lower risk group?
Extensive Colitis but no active endoscopic
or histologic inflammation.
The colon that looks pretty healthy.
People who only had left sided colitis
or Crohn's colitis affecting less than 50% of the colon.
Okay, we can live with that.
Intermediate risk are gonna come back every three years.
Okay?
These are people with extensive colitis who have mild
active inflammation, or they have some pseudo polyps,
or they have a family history.
And the higher risk group, who are gonna
come back every year, have extensive disease with moderate
severe inflammation, strictures,
dysplasia in the past five years who declined surgery,
PSC, or a young relative with colon cancer.
So the BSG guidelines are gonna differ now.
I think in England, not I think,
they don't have as many healthcare dollars.
We think we have healthcare dollars,
maybe we don't have as much as we thought,
but they are gonna stratify patients.
It's kinda scary to me that they're gonna take some patients
and scope them every five years, or even every three years.
So, people sometimes say to me,
when do I recommend colectomy?
I sort of thought about it, and I put it all on one slide.
I would recommend colectomy if there's
an endoscopically non-resectable lesion,
whether its flat or raised if you can't get it out
endoscopically and regardless of the grade of dysplasia,
its gotta come out.
Think of a sporadic adenoma.
If you had a sporadic adenoma that you couldn't get out,
gotta go to surgery.
If there's high grade, or certainly cancer
in flat mucosa, that's colectomy.
Multifocal dysplasia I have respect for.
Repeated dysplasia on follow-up exams.
If there's a stricture in ulcerative colitis,
that's worrisome, especially if it's in the proximal colon,
and especially if it's causing symptoms.
With Crohn's it's a little more dicey, right,
Crohn's people, you often get strictures,
so we don't jump to colectomy for Crohn's certainly.
But for UC, be careful about a stricture in UC.
Inability to perform surveillance for whatever reason,
it could be a stricture, there could be a lot
of pseudo polyps, maybe the patient can't
prep themselves well, whatever it is,
if you can't perform adequate surveillance,
you might have to have that discussion about surgery.
And then patient's preference.
If they can't adhere to surveillance,
you know, if you look at all the surveillance studies,
the ones that get cancer, the people that didn't
show up for five years cause they put their head in the sand
so, in summary, patients with longstanding UC
and Crohn's have an increased risk for colon cancer.
The risk of dysplasia may be decreasing,
based on those population studies.
Polypoid dysplasia, assuming complete
endoscopic resection, can be followed with continued
surveillance.
A DALM or a high grade in flat mucosa, and anything
that's endoscopically unresectable should prompt
a colectomy, and flat low grade
has a variable biology that we're still learning about,
but deserves close surveillance.
If we have two minutes, not even two minutes,
maybe I could just share with you some of the data
that we're gonna present at DDW.
There's been no study to date that has looked at
progression of dysplasia based on the side
of the colon that it's sitting on.
We know from other diseases, like Lynch,
like even sporadic literature, people say
that the reason why right sided colon cancers
occur or progress is that they're not seen
by colonoscopists.
And in Lynch, proximal neoplasia progresses
more rapidly, so no one's ever looked at this
in IBD, so we took our population of patients,
and this was done by Robert Goldstone,
who's a Duke student with us this year
from Mount Cyanide, and what Robert did,
working with me and Tom and Noam Harpaz
was to take everybody in our database
who had pan colitis, so everybody had equal opportunity
to get neoplasia in an area that was inflamed.
And he looked at those who had low grade dysplasia
in the distal colon or the proximal colon.
Now, the only difference in these groups was that
the people with distal low grade dysplasia,
a lot of those lesions tended to be more flat
that polypoid compared to the proximal location,
but other than that, the groups were pretty comparable
in terms of their age, their duration of ulcerative colitis,
whether they had PSC, their exposure to 5-ASA,
their exposure to 6-MP.
And in this last slide, this is what we found.
The people who had proximal low grade dysplasia
did not progress very much to high grade,
in fact there were no cancers in this group,
whereas the people who had distal low grade dysplasia,
that's where we saw a progression.
13 out of the 70 progressed, there were 7 cancers
and 6 high grades.
So it looks as if maybe location of dysplasia in the colon,
left sided dysplasia, might, if this is reproduced
in other studies, maybe this goes on to cancer,
and maybe we have to intensify our biopsy-ing
of the rectal sigmoid.
The one thing we couldn't be sure of
in this study was whether someone might have had
a lot of years of left sided inflammation
before their extensive pan colitis.
It's very hard, impossible, to know that,
patients don't even know it a lot of times.
So it's conceivable that maybe
the people with distal LGD had many years
of inflammation before their pan colitis.
But nonetheless, that's the data,
we'll have to see whether it pans in other hands.
So I've said a lot, let me stop here
and entertain questions, and thank you for your attention.
(applause)
Theodore.
- [Theodore] This is really interesting data,
I'm stuck, if you can go back a slide to the table.
Is it the flatness or the distalness,
because it looks like the distal ones are more flat,
I'm imagining maybe the raised ones,
if you're able to resect them, you can see
when you resect them.
- Right, there is an interaction there, you're right.
And it is true that the flatness does contribute
to the progression, that is right.
And actually, we also looked at indefinite,
yeah I don't know if I have a slide here.
When we looked at indefinite dysplasia, we didn't
see any difference.
Now I don't know, again, what that means,
but there really was no significant difference.
It looked as if there might have been a little bit
less progression in the proximal, but you're right.
I think the morphology of dysplasia is still important.
Whether it's flat.
- [Theodore] If you kind of pool those and say,
if you just look at lesions that are both distal and flat,
are those even more significantly likely to progress?
- Yes, yes.
But again, is it the flatness that's weighing,
outweighing the distal?
Yeah, so yes, Grace.
- [Grace] So you talked about pseudo polyps
and when I think of pseudo polyps I think of two types,
there's sort of one for the one,
versus just the white scar ones.
Are you taking up all the white scar ones?
- We don't usually touch pseudo,
I mean anything that looks like an inflammatory
polyp, you know, it's got that white cap,
or it's just sort of erythematous,
we don't even touch those.
The number of cases where a cancer actually arises
in the pseudo polyp is, you can count on one hand.
I think we've seen one case of a high grade
or a cancer in a pseudo polyp in the last 10 years
at Mount Cyanide, so that's rare as hen's teeth.
The problem is, it's like a minefield,
you know, you have a thousand pseudo polyps,
how do you know there isn't an adenoma,
or a dysplastic, lurking in that field,
and you don't, and it's treacherous.
- [Grace] Especially what I call the inflammatory
mention of the red, angry ones.
- Ignore those.
- [Grace] Not the star ones, the star ones are really--
- I mean, if it looks like an inflammatory polyp,
you know, if you're at all concerned of course,
you take one or two out.
But it's treacherous, and that's where I think,
you know, even the British, who are pretty conservative,
if you have somebody with pseudo polyps,
you're gonna survey them a little bit more often.
The problem is, what does that mean.
So you look in, you could look in every day if you want,
I mean, it's still gonna be there,
and how do you know, you know, what you're gonna find,
so it's tough, it's tricky.
There are some people who have pseudo polyps
limited to one little area of the colon,
and believe it or not, it's almost heretical to say this,
but sometimes we're actually doing segmental resections
and people would have ulcerative colitis.
You didn't hear that from me.
Yeah, Juanita.
- [Juanita] What are your thoughts on,
I know it's early, vitamin D and calcium
in people growing, who need medical treatment,
and my second question, with the microbiome issue,
are people looking at the microbial, you know...