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Patients with inflammatory bowel disease (IBD) may develop a variety of neoplastic and nonneoplastic polyps. This review covers the pathology, pathogenesis, natural history, and treatment of polyps in IBD with special emphasis on dysplastic lesions. Elevated or polypoid dysplastic lesions in IBD patients are referred to by the acronym DALM (dyspasia-associated lesion or mass). DALMs are further categorized as adenoma-like (endoscopically resectable polypoid dysplasia) or non–adenoma-like (non–endoscopically resectable polypoid dysplasia) based on their endoscopic appearance. Colectomy is recommended for patients with a non–adenoma-like DALM because of the high risk of synchronous or metachronous adenocarcinoma. In contrast, adenoma-like DALMs can be safely treated by polypectomy and continued surveillance provided that the lesion is removed in total, with negative margins, and no flat dysplasia is identified in the colon adjacent to and distant from the polyp.

Management of squamous cell carcinoma of the anus (SCCA) is becoming more relevant, as its incidence continues to increase. The purpose of this study was to evaluate regional and national data to assess trends in epidemiology, access to cancer center care, and overall management strategies in SCCA.A review of available data from the American College of Surgeons Committee on Cancer National Cancer Data Base focused on incidence, sex, age, stage at diagnosis, distance traveled for care, and utilization of therapy as first course of treatment (FCT). The analysis included 40,817 patients treated for SCCA at 1513 cancer centers in the United States, of which 2347 patients were treated at 109 cancer centers in New England, between the years 2003 and 2013.Over the 11-year period, incidence of SCCA increased by 76% in the United States and by 83.8% in New England. Stage was unknown in 11.7% of all US cases, significantly higher than more common cancers, for example, breast (4.3%), prostate (6%), or colon (7.8%) (P0.001). Patients in southern New England, compared with northern New England, traveled10 miles more often (53.4% vs. 38.1%) (P0.001), and25 miles less often (14.3% vs. 28.7%) (P0.001). Cases of early stage SCCA (0, I) were more frequent in southern New England (29.2%) than northern New England (21.7%) (P=0.0025), whereas more advanced stage (II to IV) cases occurred less frequently in southern New England (60.1%) than northern New England (72%) (P0.001). Overall, the most common FCT was chemoradiotherapy, utilized in 49.3% of cases, followed by chemoradiotherapy plus surgery in 19.4% of cases. Stage unknown patients were treated with chemoradiotherapy in 34.6% of cases, with surgery alone in 20.2%, and with chemoradiotherapy plus surgery in 15.4% of cases.The incidence of SCCA is steadily increasing. Its frequency of stage unknown is significantly higher than other common cancer sites. Travel distance and stage at diagnosis data may reflect regional differences in cancer center care access. Although chemoradiotherapy remains the most commonly utilized FCT, challenges in accurate staging and inconsistent use of additional prognostic variables may affect optimal treatment.

i A72-year-old men presented to his primary care physician with a chief complaint of a painful left scrotal mass of 2 weeks’ duration. He had a medical history of noninvasive bladder cancer for which he had completed a 6-week induction course of bacille Calmette-Guerin (BCG) 5 months before his present presentation. During his treatment, other than mild dysuria, he did not recall any scrotal discomfort, fever, or chills. The urine cultures were negative; however, the patient was treated with a 2-week course of ciprofloxacin antibiotics and nonsteroidal anti-inflammatory drugs. During his urologic consultation, the left scrotum was erythrematous, and an indurated mass was palpable at the lower pole of the left testis involving the epididymis, which had not decreased in size. He denied dysuria, hematuria, fevers, chills, nausea, vomiting, weight loss, or changes in bowel movements. He denied any history of urinary tract infections or other genitourinary complaints. Recent routine blood test results, including hemoglobin, hematocrit, liver function tests, -fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase, were within normal limits. His urinalysis revealed microscopic hematuria and was otherwise unremarkable. The urine culture was negative. A testicular ultrasound scan was obtained and revealed a left 3.5 1.5 cm heterogenous, hypoechoic, lobulated mass originating from the epididymal tail, with a mass effect on the lower pole of the testis (Fig. 1). Definitive invasion into the left testis could not be excluded, and the scrotum appeared indurated, with increased echogenicity suggestive of an inflammatory reaction. The right testis and epididymis were normal in appearance. A computed tomography urogram was also obtained and revealed a mildly thickened bladder wall consistent with the known previous bladder cancer and was otherwise unremarkable.

Polypoid lesions are frequently encountered during IBD surveillance colonoscopy. Accurate endoscopic and pathologic classification of these lesions is essential for appropriate management. Of particular importance are polypoid dysplastic lesions, which have historically been referred to by the term DALM (dysplasia-associated-lesion or mass). This chapter provides a review of the endoscopic features, pathology, natural history, and management of DALMs. Based on endoscopic features, DALMs can be subclassified as adenoma-like (endoscopically resectable) and non-adenoma-like (non-endoscopically resectable). The presence of a non-adenoma-like DALM is an indication for colectomy. In contrast, adenoma-like DALMs can be treated conservatively by polypectomy and endoscopic surveillance provided the lesion is completely removed and no flat dysplasia is identified in the colon.