Dysplasia associated with Crohn's colitis: segmental colectomy or more extended resection?

There is limited data on the appropriate management of dysplasia in Crohn's colitis. An evidence-based surgical strategy is provided.

Patients with a pathologic diagnosis of dysplasia in Crohn's colitis from 1987 to 2009 were identified. Patients were classified by dysplasia grade (low grade or LGD, high grade or HGD). Clinical, endoscopic, operative, and pathologic data were retrieved. Factors associated with a final cancer diagnosis were analyzed. Survival data on patients undergoing limited versus radical resection for cancer and HGD was compared.

From 1987 to 2009, 50 patients underwent a colectomy for Crohn's colitis-associated dysplasia. The predictive value of HGD for a final HGD or cancer diagnosis was 73%. The predictive value of LGD on biopsy for HGD in the colectomy was 36%. Sixteen patients (44%) who underwent a total proctocolectomy (TPC) or subtotal colectomy (STC) had multifocal dysplasia. Four of 10 (40%) cancer patients had evidence of dysplasia remote from cancer site on pathologic examination. During follow-up, there were 3 cancer-related deaths. One patient died of metachronous cancer after STC.

The findings confirm the risk of cancer in patients with CD dysplasia. Because of the multifocal nature of dysplasia in Crohn's colitis, TPC is recommended in good-risk patients. In specific circumstances, such as poor-risk patients especially in the setting of LGD, close endoscopic surveillance or alternatively segmental or STC with close postoperative endoscopic surveillance, depending upon the individual circumstance, may be discussed.