Systematic review: colitis associated with anti-CTLA-4 therapy

BACKGROUND

Cytotoxic T-lymphocyte-associated protein-4 (CTLA-4) has an important role in T-cell regulation, proliferation and tolerance. Anti-CTLA-4 agents, such as ipilimumab and tremelimumab, have been shown to prolong overall survival in patients with metastatic melanoma, and their use is being investigated in the treatment of other malignancies. Their novel immunostimulatory mechanism, however, predisposes patients to immune-related adverse effects, of which gastrointestinal effects such as diarrhoea and colitis are the most common.

AIMS

To discuss the existing literature and summarise the epidemiology, pathogenesis and clinical features of anti-CTLA-4-associated colitis, and to present a management algorithm for it.

METHODS

We searched PubMed for studies published through October 2014 using the terms 'anti-CTLA,' 'ipilimumab,' 'tremelimumab,' 'colitis,' 'gastrointestinal,' 'immune-related adverse effect,' 'immunotherapy,' 'melanoma,' and 'diarrhoea.'

RESULTS

Watery diarrhoea is commonly associated with anti-CTLA-4 therapy (27-54%), and symptoms occur within a few days to weeks of therapy. Diffuse acute and chronic colitis are the most common findings on endoscopy (8-22%). Concomitant infectious causes of diarrhoea must be evaluated. Most cases may be successfully managed with discontinuation of anti-CTLA-4 and conservative therapy. Those with persistent grade 2 and grade 3/4 diarrhoea should undergo endoscopic evaluation and require corticosteroid therapy. Corticosteroid-resistant cases may respond to anti-tumour necrosis factor-alpha therapy such as infliximab. Surgery is reserved for patients with bowel perforation or failure of medical therapy.

CONCLUSION

Given the increasing use of anti-CTLA-4 therapy, clinicians must be aware of related adverse events and their management.

Acute small intestinal obstruction-an unusual complication of capsule endoscopy

We report a case of endoscopic capsule impaction causing acute small intestinal obstruction in a patient with Crohn's disease (CD), having obscure gastrointestinal bleeding. A 57-year old female presented with features of acute small bowel obstruction 2 days after capsule endoscopy elsewhere for the evaluation of intermittent bleeding per rectum and iron deficiency anemia. Patient underwent an exploratory laparotomy with right hemicolectomy for the diseased ileocecal region which mimicked malignancy. The capsule was found to be impacted in the strictured lumen of the terminal ileum. Post operative histopathological examination revealed it to be Crohn's disease.

Detection rate and outcome of colonic serrated epithelial changes in patients with ulcerative colitis or Crohn's colitis

BACKGROUND

Chronic ulcerative colitis (CUC) and colonic Crohn's disease (CD) increase colorectal neoplasia (CRN) risk. While sessile serrated polyp (SSP) is a known cancer precursor, serrated epithelial changes (SEC) are of uncertain prevalence and neoplastic risk.

AIM

To assess the serrated lesion detection rates in CUC and CD and documented incidence of subsequent CRN in a retrospective, single-centre cohort study.

METHODS

Patients were identified by a central diagnostic index and pathology review confirmed SEC, SSP, CUC and CD diagnoses from 2006-12. Matched controls were identified from among all CUC and CD patients having colonoscopy during the second half of the time period. All were followed for incident CRN, estimated by the Kaplan-Meier method.

RESULTS

Between 2006 and 2012, 79 SEC and 10 SSP cases were identified. Detection rates were estimated to be 10/1000 and 2/1000 patients, for SEC and SSP respectively, among 4208 unique CUC or CD patients having colonoscopy from 2010-12. With only 10 cases, SSP patients were not further analysed. Cumulative incidence of subsequent CRN at 1 and 3 years was 12% (95% CI, 0-30%) and 30% (3-57%), respectively, in SEC patients compared to 4% (0-12%) and 9% (0-23%), respectively, in CUC or CD controls (P = 0.047, log-rank). However, this statistical difference was not significant after patients were stratified for history of prior or synchronous dysplasia (P = 0.09).

CONCLUSIONS

Serrated epithelial changes and sessile serrated polyps are uncommonly detected by colonoscopy in chronic ulcerative colitis and Crohn's disease patients. Histology with changes of serrated epithelium may be associated with risk of subsequent colorectal neoplasia, however further studies are needed to explore this relationship.

Abstract P2-04-04: Breast cancer risk reduction in high risk women identified at the time of screening mammography. Integrating data from an established high risk clinic

Background: At the time of screening mammography, patient data can be collected and entered into a Modified Gail Model Risk Assessment Tool to identify patients at increased risk of invasive breast cancer. In turn, these patients can be referred to high risk centers where risk reduction strategies and chemoprophylaxis can be considered. The objective of this study is to establish how many women are at high risk of invasive breast cancer in a screening population who should be referred to a high risk center for counseling.

Methods: This is an observational prospective study evaluating 1,000 women at a single institution presenting for mammographic screening or diagnostic evaluation. At the time of mammography, these women routinely complete a standard intake questionnaire addressing breast cancer risk factors put forward by the institutional clinic. Modified Gail model risk scores were calculated from these data sheets. Women with a 5 year risk of invasive breast cancer of 1.7% or greater were identified as well as women at particularly high risk (≥3.4% or double the 5-year risk). At the time of analysis patients with a history of breast cancer or who underwent diagnostic mammography were excluded. Retrospective data from our institutional high risk clinic from January 2007 to December 2009 was analyzed in respect to patient age at referral, Gail Model Score, personal history of breast cancer, history of benign breast biopsies, and recommendation for and acceptance of chemoprophylaxis.

Results: Of 1,000 women screened in the prospective analysis, 366 had ≥1.7% 5-year risk of invasive breast cancer. 26% (96) of these women were under 60 years old while 74% (270) were ≥60 years old. Among the latter group, 19.6% (53) were found to have ≥ 3.4% of developing invasive cancer. In these women with double the 5-year risk, 96.2% had a family history of breast cancer and 69.8% had a prior biopsy. Similarly, in women under 60, greater than half were high risk secondary to a prior biopsy or family history. In the retrospective analysis of 600 patients evaluated in the high risk clinic, 38.8% were eligible for chemoprevention based on age >35, Gail model risk score, and no contraindications to treatment. 45.7% accepted recommendation for chemoprophylaxis as opposed 54.3% who had declined. Age was not found to be a predictor of acceptance of treatment.

Conclusions: 1/3 of patients who receive annual screening are at high risk for breast cancer. These patients can be identified from data routinely obtained at the time of screening mammography. These women should be referred for high-risk counseling and consideration of chemoprevention at the time of screening mammography. Further prospective studies may be warranted to determine if this is an effective way to provide risk reduction strategies for high risk women.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-04-04.

Variables affecting the performance of galactomannan assay in high-risk patients at a tertiary care centre in India

BACKGROUND

Diagnosis of invasive aspergillosis (IA) in immunocompromised patients using galactomannan ELISA (GM-ELISA) has shown variable sensitivity and specificity.

OBJECTIVES

To assess the diagnostic performance of GM-ELISA and analyze the effect of decreasing the cut off value, neutropenia, antifungals and piperacillin-tazobactam (PTZ). Prognostic value using 30 day all-cause mortality was also determined.

MATERIALS AND METHODS

Serum samples from 81 patients categorized into "proven," "probable," and "possible," categories based on revised EORTC/MSG definitions were tested by GM-ELISA.

RESULTS

Sensitivity of GM-ELISA in proven, probable and possible cases was 91.7%, 84.6% and 83.3% respectively. At an index cut-off value of 0.5 an increased sensitivity with minimal loss of specificity was observed. Use of antifungals demonstrated a decrease in sensitivity in proven and possible cases whereas it remained unaffected in probable category. Specificity increased from 75% to 100% with a positivity criterion of >2 consecutive samples. Although an increase in specificity was observed in patients not receiving PTZ, it was not statistically significant. Serial GM index values increased significantly in neutropenic patients and were associated with a poor prognosis.

CONCLUSIONS

GM-ELISA may be a useful diagnostic and prognostic modality for the detection of IA in high risk patients.

A comparison of the effect of two types of vibration exercise on the endocrine and musculoskeletal system

BACKGROUND

Whole body vibration (WBV) is a novel training intervention but a comparison of different methods of WBV has rarely been performed.

AIM

To compare the short and medium term effects of two regimens of WBV on endocrine status, muscle function and markers of bone turnover.

PATIENTS AND METHODS

Over a period of 16 weeks, 10 men with a median age of 33 yrs (range, 29,49), were randomised to stand on the Galileo platform (GP) or Juvent1000 platform (JP) 3 times/wk. The total study duration was 16 weeks with measurements performed in a 4 week period of run-in, 8 weeks of WBV and a 4 week period of washout. These measurements included an assessment of anthropometry, body composition, muscle function and biochemical markers of endocrine status and bone turnover. To assess immediate effects of WBV, measurements were also performed at 60 mins before and 5, 30 and 60 mins after WBV. To assess immediate effects of WBV, measurements were also performed at 60 mins before and 5, 30 and 60 mins after WBV.

RESULTS

GP at 22 Hz was associated with an immediate increase in serum GH, rising from 0.07 μg/l (0.04,0.69) to 0.52 μg/l (0.06,2.4) (p=0.06), 0.63 μg/l (0.1,1.18) (p=0.03), 0.21 μg/l (0.07,0.65) (p=0.2) at 5 mins, 20 mins and 60 mins after WBV, respectively. An immediate effect was also observed in median serum cortisol which reduced from 316 nmol/l (247,442) before WBV to 173 nmol/l (123,245) (p=0.01),165 nmol/l (139,276) (p=0.02) and 198 nmol/l (106,294) (p=0.04) at 5 mins, 20 mins and 60 mins after WBV, respectively. Median serum CTX reduced significantly after 8 weeks of WBV training in the GP group from 0.42 ng/ml (0.29,0.90) pre-WBV to 0.29 ng/ml (0.18,0.44) at the end of WBV training (p=0.03). Over the 8 weeks, there was a reduction in median serum cortisol in the GP group from 333 nmol/l (242,445) (pre-WBV) to 270 nmol/l (115,323) (WBV) (p=0.04). None of the changes observed in the JP group reached statistical significance. Neither group showed any significant effect on muscle function, IGF-1, testosterone, leptin, CRP, creatine kinase, insulin or other markers of bone turnover.

CONCLUSION

WBV can stimulate GH secretion, reduce circulating cortisol and reduce bone resorption. These effects are independent of clear changes in muscle function and depend on the type of WBV that is administered.

Anaesthesia for Robotic Gynaecological Surgery

Robotic surgery is gaining widespread popularity due to advantages such as reduced blood loss, reduced postoperative pain, shorter hospital stay and better visualisation of fine structures. Robots are being used in urological, cardiac, thoracic, orthopaedic, gynaecological and general surgery. Robotic surgery received US Food and Drug Administration approval for use in gynaecological surgery in 2005.

The various gynaecological robotic operations being performed are myomectomy, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, tubal reanastomosis, lymph node dissection, surgery of retroperitoneal ectopic pregnancy, Moskowitz procedure and endometriosis surgery.

The anaesthetic considerations include difficult access to the patient intraoperatively, steep Trendelenburg position, long surgical duration and the impact of pneumoperitoneum. We highlight the complications encountered in these surgeries and methods to prevent these complications.

Robotic gynaecological surgery can be safely performed after considering the physiological effects of the steep Trendelenburg position and of pneumoperitoneum. The benefits of the surgical procedure should be weighed against the risks in patients with underlying cardiorespiratory problems.

A novel variant of esophageal atresia with tracheo-esophageal fistula with a crossed-over proximal esophageal pouch: a diagnostic dilemma

Diagnosis of esophageal atresia (EA) with tracheo-esophageal fistula (TEF) can be easily done in newborns with symptoms of excessive salivation and failure to pass infant-feeding tube (IFT) into the stomach. There are many reports in the literature which describe the diagnostic pitfall of this IFT test. We describe a case of a neonate with EA with TEF in which the upper atretic esophageal pouch had grown long enough to reach up to the level of diaphragm, thus allowing the IFT to go up to significant distance from the alveolus giving the radiograph as if the tube is in the upper part of stomach, thus creating a diagnostic dilemma.

228 DOMINANT FOLLICLE ABLATION IMPROVES SUPEROVULATORY RESPONSE AND EMBRYO YIELD IN BUFFALOES SUBJECTED TO INTEGRATED SINGLE-OVULATION EMBRYO TRANSFER - MULTIPLE-OVULATION EMBRYO TRANSFER PROGRAM

Effect of the removal of inhibitory consequences of a dominant follicle (DF) on the recruitment, growth and ovulation of follicles in cyclic buffaloes induced to superovulate, was evaluated. Eight elite, multiparous, donor Murrah buffaloes, 80 to 120 days postpartum, were included in an integrated single-ovulation embryo transfer–multiple-ovulation embryo transfer (SOET-MOET) schedule. Superovulation with FSH (Folltropin® NIH-FSH-P1, Bioniche Animal Health, Belleville, ON, Canada) was preceded by nonsurgical single embryo (SOET) recovery on Day 5 or 6 after prostaglandin F2α (Lutalyse®, Pfizer, Madison, NJ, USA)-induced oestrus and AI (Day 0). For MOET, Folltropin was administered from Day 9 p.m. through to Day 13 p.m. in a twice-daily descending dose schedule (0–5, 5–4, 4–3, 3–2, 2–1 mL; total dose of 580 mg of NIH-FSH-P1). A dose of 25 mg of Lutalyse was administered on Day 12 a.m. and p.m. Donors were inseminated with proven semen on Day 14 a.m. and p.m. and Day 15 a.m. Nonsurgical embryo collection was carried out on Day 19 or 20 followed by administration of Lutalyse on Day 25. Following sexual rest for one complete oestrous cycle, Day 5 or 6 SOET was repeated. On Day 9, ultrasound-guided follicle aspiration was used to ablate the DF and the second MOET treatment was initiated at the same time. Mean diameter of DF at the start of superovulation treatment on Day 9 was similar between the first (12.5 ± 0.66 mm) and second (12.2 ± 0.33 mm) MOET cycles. At AI, mean number (9.6 ± 1.43 vs 13.4 ± 1.87) of follicles >9 mm were higher (P < 0.05) in the second (ablation) MOET cycle, though their mean diameters were similar (11.7 ± 0.21 vs 12.3 ± 0.21 mm; P = 0.17). On the day of ova/embryo collection, almost similar numbers of large follicles (4.1 ± 0.93 and 4.4 ± 0.84), with mean diameters of 12.9 ± 0.74 and 13.4 ± 0.83 mm, were observed for the first and second MOET, respectively. Mean (± SEM) numbers of corpora lutea (3.9 ± 0.81 and 4.9 ± 0.61; P = 0.19) and transferable quality embryos (0.6 ± 0.37 and 1.6 ± 0.37; P = 0.077) were counted in the first and second (ablation) MOET cycles, respectively. These preliminary findings suggest that ablation of DF before start of superovulatory treatment may be beneficial in improving the yield of transferable embryos in a buffalo MOET program. Director, CIRB, is acknowledged for the experimental facilities.