A 35-year-old man with ulcerative colitis for 12 years undergoes surveillance colonoscopy. A raised, non-polypoid lesion (laterally spreading tumour) is found in the transverse colon. Biopsy shows high-grade dysplasia within the lesion. What is the definitive management?

• A Endoscopic mucosal resection of the lesion
• B Repeat colonoscopy in 3 months with targeted biopsies
• C Segmental colectomy with lymphadenectomy
• D Total proctocolectomy with ileal pouch-anal anastomosis ✓

Explanation

In long-standing ulcerative colitis, a raised dysplastic lesion (DALM, dysplasia-associated lesion or mass) carries a high risk of synchronous or metachronous carcinoma. Endoscopic resection is unreliable and total proctocolectomy is the standard recommendation. Flat high-grade dysplasia also mandates colectomy. Segmental colectomy is inadequate due to the field defect in colitis.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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