The clinical heterogeneity of IBD is reflected in the heterogeneity in the macro and microscopic feature and makes cancer surveillance in this population much more challenging than in the general population. IBD associated risk factors for colorectal cancer are well known and this is the reason why any patient with a history of extensive disease, whether UC or CD, of more than 10 years must undergo a complete colonoscopy with multiple biopsies every 2 years. Any dubious situation should be carefully discussed by the gastroenterologist, the surgeon and the pathologist and the maximal alert in case of dysplasia or cancer on flat inflamed mucosa should be given.
In the past, the more crucial issue was the signifi cance of dysplasia in endoscopically visible lesions (Dysplasia Associated Lesion or Mass) with high rates of carcinoma when these patients underwent colectomy. In more recent data, about 10 surveillance programs reported findings of carcinoma in 17 out of 40 (43%) colectomies performed with an indication of DALM . However, not all polypoid lesions with dysplasia carry the same significance for IBD patients. Some polyps can be snared like adenomas unrelated to colitis, particularly if they arise in a segment of the colon not involved in inflammation, and can be managed like polyps in the general population .
The dysplasia encountered in an adenoma or in chronic inflammation is quite identical and so we have no reliable means of differentiating between them in regards to our decision. A well-conducted study tried to answer this question and concluded that no adverse outcomes resulted after endoscopic removal of 70 polyps (three with high-grade non-invasive dysplasia) from 48 IBD patients in a mean follow-up time of 4.1 years .
The best way to manage dysplasia and colorectal cancer is via a surveillance program; however, in this case the patients have to be correctly and clearly informed that dysplasia and cancer can still arise despite the program of close observation and the skilfulness of the medical staff . In our opinion, the development of dysplasia itself in a surveillance program is not enough in itself to advise patients to undergo colectomy. Situations are different and, as mentioned before, even a severe dysplasia in an ade-nomatous polyp not related to inflammatory disease, could be optimally managed with a radical polypec-tomy. As always in this context, such a decision of course requires that the gastroenterologist, surgeon and pathologist develop a decision-making protocol through which information about the patient, specific literature data, personal experience and skills are clearly shared and accepted.
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