Diagnostic Utility of Endoscopic Features and Endoscopic Ultrasonography for Ulcerative Colitis-Associated Neoplasia: A Retrospective Study on the Role of Endoscopic Submucosal Dissection as a Total Biopsy.

BACKGROUND/

OBJECTIVES

Ulcerative colitis (UC)-associated neoplasia (UCAN) often presents as flat lesions with indistinct margins, and biopsy sensitivity is limited. Therefore, we evaluated endoscopic criteria to distinguish UCAN from sporadic neoplasia, assessing the accuracy of endoscopic ultrasonography (EUS) for invasion depth and the role of endoscopic submucosal dissection (ESD) as a "total biopsy."

METHODS

We reviewed 212 endoscopically treated neoplastic lesions in UC-affected mucosa (April 2016-January 2025). We compared preoperative diagnoses using macroscopic type, pit pattern, and the Japan Narrow-Band Imaging Expert Team classification with final histology. We compared depth estimates with pathology in 10 UCAN-suspected lesions undergoing EUS. Lesions < 2 cm underwent conventional endoscopic resection, whereas those ≥ 2 cm underwent ESD.

RESULTS

No UCAN was found in 189 lesions < 2 cm. Among 23 ESD lesions, 8 suspected sporadic lesions were non-UCAN. Of 15 UCAN-suspected lesions, 8 were UCAN, 6 sporadic, and 1 inflammatory. For positive T1b or deeper invasion, the sensitivity, specificity, positive and negative predictive values, and overall accuracy of EUS were 50.0%, 100%, 100%, 88.9%, and 90.0%, respectively. EUS depth assessment agreed with pathology in 9/10 cases; nine lesions were T1a or shallower, and one was T1b. Third-layer thickening occurred in two lesions-both UCAN-including the T1b cancer. In ESD cases, redness and a VI pit pattern were independent predictors of UCAN.

CONCLUSIONS

EUS-based depth assessment is useful for determining optimal treatment strategies. Beyond therapy, ESD enables comprehensive histologic assessment of the entire lesion, functioning as a total biopsy to guide management while preserving bowel function.