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What are the guidelines for treating adenoma-like DALMs in UC?

There are 2 general patterns of growth of dysplasia in ulcerative colitis (UC), considered flat (endoscopically undetectable) or elevated (endoscopically detectable).1 Elevated lesions are referred to by the acronym DALM (dysplasia-associated lesion or mass). Since the original description by Blackstone et al in 1991,2 it has been recognized that DALMs represent a heterogeneous group of lesions with different natural histories and risks of malignancy.1 DALMs are further subclassified as adenoma-like or non-adenoma like, depending on the gross characteristics of the lesion. Grossly, adenoma-like DALMs represent well-circumscribed, smooth or papillary, nonnecrotic, sessile, or pedunculated polyps that are usually easily removed by routine endoscopic methods, similar to sporadic adenomas. Nonadenoma-like lesions include velvety patches, plaques, irregular bumps and nodules, wart-like thickenings, stricturing lesions, and broad-based masses. These lesions are not typically amenable to removal by colonoscopy. It is well known that nonadenoma-like DALMs have a high risk (36%–85%) of either synchronous or metachronous cancer.1–3 However, previous studies that evaluated the natural history and risk of malignancy in UC patients with a nonadenoma-like DALM included lesions in which biopsies were obtained from the surface of the mass and, despite the fact that the biopsy showed only dysplastic epithelium, the underlying carcinoma was either not sampled or not detected until a colonic resection was performed. In contrast, adenoma-like DALMs possess a low risk of malignancy and, as a result, may be treated conservatively by polypectomy and continued surveillance (see below). Adenoma-like DALMs in UC represent 2 types of lesions. The first are sporadic adenomas that occur coincidentally in patients with UC, and, thus, are etiologically unrelated to the underlying inflammatory disease. Sporadic adenomas may develop in both inflamed and noninflamed portions of the bowel. Adenoma-like lesions that occur within noninflamed portions of the bowel (i.e., proximal to areas of chronic colitis) are easy to diagnose as sporadic adenomas since dysplasia and cancer in UC is believed to develop as a direct result of the underlying inflammatory condition.4 Therefore, the risk of neoplasia is not increased in noninvolved portions of the colon. However, sporadic adenomas may also occur in areas involved by UC, in which case they are difficult to differentiate from UC-related adenoma-like polypoid dysplastic lesions, which may have a similar endoscopic and histologic appearance.1–4 A recent study suggested that a large proportion of “DALMs” in patients with UC are, in fact, adenoma-like polyps rather than nonadenoma-like DALMs.5