Surveillance and its Limitations

Mucosal dysplasia documented by surveillance colonoscopy used clinically to identify the "high risk" patients has proven to have significant limitations. Sampling error, presence of acute mucosal inflammation, differences in pathological interpretation (observer variations) and variable patient compliance are factors that might interfere with the diagnostic accuracy.

The reliability of dysplasia as a precursor of cancer is poor [22]. The histological interpretation is often subjective and of doubtful diagnostic value and the decision making resulting from its discovery will, therefore, often be doubtful. The grading of dyspla-sia, differentiation between true dysplastic changes and active inflammatory changes and differentiation between DALM and "sporadic" adenomas constitute the dilemma for the pathologist. Moreover, an important obstacle to an accurate assessment of dysplasia is an active mucosal inflammation that may result in cytological changes that are hard to distinguish from dysplasia.

Because dysplasia is focal and patchy, it may not even be detected by extensive colonoscopic biopsies, and established cancers may be missed entirely. Thus, there is evidence showing that a significant fraction of patients may have colorectal cancer in the absence of dysplasia at the colonoscopic surveillance, although this may at least in part be attributable to inadequate surveillance [26]. Based on such observations, the authors claimed that if proctocolectomy is recommended only upon detection of either high-grade dysplasia or dysplasia of any grade, a large proportion of patients may already have an established cancer at the time of surgery. It is obvious that there are practical limitations to the theoretical concept that dysplasia surveillance can reliably serve as a marker for malignant degeneration. The authors also emphasised that failure to operate on high-risk patients - i.e. those with pancolitis, those with duration of disease more than 10 years and those with disease presenting during childhood - while waiting for dysplasia to be discovered by surveillance colonoscopy will invite a high risk of developing concomitant colorectal cancer.

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