What is the role of histopathology in the evaluation of disease activity in Crohn's disease?

The CT findings of extranodal natural killer/T-cell lymphoma, nasal type involving the gastrointestinal tract

OBJECTIVES

To analyze the CT imaging features of extranodal natural killer/T (NK/T)-cell lymphoma, nasal type (ENKTCL-NT) involving the gastrointestinal tract (GI), and to compare them with those of Crohn's disease (CD) and diffuse large B-cell lymphoma (DLBCL).

MATERIALS AND METHODS

Data were retrospectively collected from 17 patients diagnosed with GI ENKTCL-NT, 68 patients with CD, and 47 patients with DLBCL. The CT findings of ENKTCL-NT were analyzed and compared with those of CD and DLBCL. Data were analyzed using SPSS (version 25.0) and MedCalc (version 18.2.1). p < 0.05 was considered statistically significant.

RESULTS

The 17 patients with ENKTCL-NT included 11 males (64.7%) and 6 females (35.3%) (mean age, 46.41 ± 4.12 years). The CT features of ENKTCL-NT included: circumferential symmetric thickening (100%), moderate thickening (70.6%), skip lesions (52.9%), contiguous lesion (47.1%), mucosal or layered enhancement (70.6%), moderate mural enhancement (64.7%) with non-enhanced regions (47.1%), absence of lymphadenopathy (76.5%), bowel perforation or fistula (17.6%), and peri-enteric blurred fat space (70.6%). The presence of circumferential symmetric thickening, moderate mural enhancement, and non-enhanced regions were more indicative of ENKTCL-NT than CD (17/17 vs. 17/68, 11/17 vs. 22/68, 8/17 vs. 0/68, p < 0.05). The presence of skip lesions, mucosal or layered enhancement, and absence of peri-enteric lymphadenopathy were more indicative of ENKTCL-NT than DLBCL (9/17 vs. 2/47, 12/17 vs. 1/37, 13/17 vs. 19/47, p < 0.05).

CONCLUSION

CT imaging features can provide useful information for the early diagnosis of ENKTCL-NT and effectively differentiate it from CD and DLBCL.

KEY POINTS

Question Extranodal natural killer/T-cell lymphoma, nasal type (ENKTCL-NT) involving the gastrointestinal tract (GI) is highly malignant but easily misdiagnosed by clinicians and endoscopic examination. Findings CT could provide useful information in the diagnosis of ENKTCL-NT involving GI and in differentiating it from Crohn's disease and diffuse large B-cell lymphoma. Clinical relevance This study will help improve the ability of radiologists to diagnose ENKTCL-NT involving GI, and a more predictive diagnosis will also alert clinicians to perform multiple deep endoscopic biopsies, which will contribute to the early diagnosis and treatment of ENKTCL-NT.

Histologic Activity From Neoterminal Ileal Biopsies in Patients With Crohn's Disease in Endoscopic Remission is Associated With Postoperative Recurrence

INTRODUCTION

Following ileocolic resection (ICR), the clinical importance and prognostic implications of histologic activity on biopsies in Crohn's disease (CD) patients with endoscopic remission are not well defined. The aim of this study was to determine if histologic activity in patients with endoscopic remission is associated with future risk of endoscopic and/or radiologic postoperative recurrence (POR).

METHODS

In this multicenter retrospective cohort study, adult patients with CD who underwent ICR between 2009 and 2020 with endoscopic biopsies of ileal mucosa from Rutgeerts i0 on index colonoscopy were included. The composite rate of endoscopic (Rutgeerts score ≥i2b) and radiologic (active inflammation on imaging) recurrence was compared in patients with and without histologic activity using a Kaplan-Meier survival analysis. A multivariable Cox proportional hazard regression model including clinically relevant risk factors of POR, postoperative biologic prophylaxis, and histology activity was designed.

RESULTS

A total of 113 patients with i0 disease on index colonoscopy after ICR were included. Of these, 42% had histologic activity. Time to POR was significantly earlier in the histologically active versus normal group ( P = 0.04). After adjusting for clinical risk factors of POR, histologic activity (HR 2.37, 95% CI 1.17-4.79; P = 0.02) and active smoking (HR 2.54, 95% CI 1.02-6.33; P = 0.05) were independently associated with subsequent composite POR risk.

DISCUSSION

In patients with postoperative CD, histologic activity despite complete endoscopic remission is associated with composite, endoscopic, and radiographic recurrence. Further understanding of the role of histologic activity in patients with Rutgeerts i0 disease may provide a novel target to reduce disease recurrence in this population.

Peak enhancement in contrast-enhanced ultrasound for assessing endoscopic disease activity in patients with Crohn's disease: a meta-analysis

BACKGROUND

Contrast-enhanced ultrasound (CEUS) has been proposed as a valuable tool for detecting disease activity in patients with Crohn's disease (CD). However, previous studies have utilized different parameters, leading to variation in clinical assessment of this technique.

PURPOSE

To assess the effectiveness of peak enhancement (PE) in CEUS for evaluating endoscopic disease activity in patients with CD.

MATERIAL AND METHODS

Articles were obtained by searching PubMed, Embase, Web of Science, Wanfang, and CNKI databases. Only studies that investigated the effectiveness of PE in CEUS to discriminate endoscopic disease activity in patients with CD were considered. Pooled sensitivity and specificity were then calculated using a random effects model.

RESULTS

Overall, seven studies were included. The endoscopic disease activity of CD was determined based on the simple endoscopic score for Crohn's disease and Crohn's Disease Endoscopic Index of Severity scores. Pooled results showed that a high PE was associated with increased detection efficacy for endoscopic disease activity in CD. Pooled sensitivity, specificity, and positive and negative likelihood ratios were 0.88 (95% confidence interval [CI] = 0.71-0.96), 0.88 (95% CI = 0.81-0.93), 7.60 (95% CI = 4.61-12.53), and 0.14 (95% CI = 0.05-0.35), respectively. The pooled receiver operating characteristic was 0.90 (95% CI = 0.87-0.92), suggesting a good discriminating efficacy of PE in CEUS for endoscopic disease activity of patients with CD.

CONCLUSIONS

A high PE in CEUS displayed substantial distinguishing accuracy for assessing endoscopic disease activity of patients with CD.

Evaluation of Disease Activity in Inflammatory Bowel Disease: Diagnostic Tools in the Assessment of Histological Healing

Inflammatory bowel disease (IBD) comprises two types of chronic intestinal disorders: Crohn's disease and ulcerative colitis. In long-standing ulcerative colitis disease activity, histological persistent inflammation has been linked to an increased risk of relapse, and long-term corticosteroid use, even when endoscopic remission is reached. In Crohn's disease, the discontinuous nature of lesions and transmural inflammation have limited the standardized histological assessment. The current evidence from research proposes that besides clinical and endoscopic healing, the achievement of histological healing constitutes an endpoint to assess disease activity and remission in IBD patients concerning better long-term disease outcomes. Histological alterations may persist even in the absence of endoscopic lesions. For these reasons, new advanced techniques promise to revolutionize the field of IBD by improving the endoscopic and histologic assessment, disease characterization, and ultimately patient care, with an established role in daily practice for objective assessment of lesions. This review outlines the importance of including microscopic evaluation in IBD, highlighting the clinical benefits of a deep state of disease remission using validated diagnostic methods and scoring systems for daily clinical practice.

Crohn's Disease: Basic Characteristics of the Disease, Diagnostic Methods, the Role of Biomarkers, and Analysis of Metalloproteinases: A Review

Crohn's disease is a chronic inflammatory bowel disease that affects the ileum and/or large intestine. At the same time, it can also affect any other part of the human body, i.e., from the mouth to the anus. In Crohn's disease, the physiology and functioning of the epithelial barrier are inhibited due to the correlation of various factors, such as the environment, genetic susceptibility or intestinal microbiota. The symptoms are very troublesome and cause a significant reduction in quality of life, sometimes occurring with paralyzing permanent damage to the digestive tract, requiring enteral or parenteral nutrition throughout life. In order to make a proper and accurate diagnosis, an appropriately selected diagnostic path in a given clinical entity is necessary. Standard diagnostic methods are: laboratory examination, histopathological examination, endoscopic examination, X-ray, computed tomography, ultrasound examination and magnetic resonance imaging. Medical biology and the analysis of metalloproteinases have also proved helpful in diagnosing changes occurring as a result of Crohn's disease. Here we provide a thorough review of the latest reports on Crohn's disease and its genetic conditions, symptoms, morphology, diagnosis (including the analysis of Crohn's disease biomarkers, i.e., metalloproteinases) and treatment.

The implication of mesenteric functions and the biological effects of nanomaterials on the mesentery

A growing number of nanomaterials are being broadly used in food-related fields as well as therapeutics. Oral exposure to these widespread nanomaterials is inevitable, with the intestine being a major target organ. Upon encountering the intestine, these nanoparticles can cross the intestinal barrier, either bypassing cells or via endocytosis pathways to enter the adjacent mesentery. The intricate structure of the mesentery and its entanglement with the abdominal digestive organs determine the final fate of nanomaterials in the human body. Importantly, mesentery-governed dynamic processes determine the distribution and subsequent biological effects of nanomaterials that cross the intestine, thus there is a need to understand how nanomaterials interact with the mesentery. This review presents the recent progress in understanding the mesenteric structure and function and highlights the importance of the mesentery in health and disease, with a focus on providing new insights and research directions around the biological effects of nanomaterials on the mesentery. A thorough comprehension of the interactions between nanomaterials and the mesentery will facilitate the design of safer nanomaterial-containing products and the development of more effective nanomedicines to combat intestinal disorders.

ECCO Position on Harmonisation of Crohn's Disease Mucosal Histopathology

In inflammatory bowel disease [IBD], mucosal healing is a major therapeutic target and a reliable predictor of clinical course. However, endoscopic mucosal healing is not synonymous with histological healing, and the additional benefits of including histological remission as a target are unclear. In Crohn´s disease [CD], there are few studies highlighting the value of histological remission as a therapeutic target. Histological activity can persist in CD patients who are in endoscopic remission, and the absence of histological activity may be associated with lower relapse rates. Therefore, standardisation of procedures to evaluate CD histological activity is desirable. Topics that would benefit from standardisation and harmonisation include biopsy procedures, biopsy processing techniques, the content of histological scores, and the definitions of histological remission, histological response, and histological activity. In line with these needs, the European Crohn's and Colitis Organisation [ECCO] assembled a consensus group with the objective of developing position statements on CD histology based on published evidence and expert consensus. There was agreement that definitions of histological remission should include absence of erosion, ulceration, and mucosal neutrophils; that the absence of neutrophilic inflammation is an appropriate histological target in CD; that CD histological scores, such as the Global Histological Disease Activity Score, lack formal validation; and that histological scoring systems for ulcerative colitis, including the Geboes Score, Robarts Histopathology Index, and Nancy Histological Index, can be used for scoring intestinal biopsies in CD patients.

The Role of the Gluten-Free Diet in the Management of Seronegative Enteropathy

The differential diagnosis and treatment of seronegative enteropathy, also termed seronegative villous atrophy (SNVA), is a clinical challenge. Although seronegative coeliac disease (CD) is a frequent cause of SNVA, the aetiology can include immune-mediated, inflammatory, infectious, and drug-related forms. As a misdiagnosis of SNVA can result in patients being unnecessarily placed on a lifelong strict gluten-free diet or even given incorrect immunosuppressive therapy, the aim of this paper is to provide an evidence-based and practical approach for the workup and management of SNVA.

Histologic Remission Is Associated With Lower Risk of Treatment Failure in Patients With Crohn Disease in Endoscopic Remission

BACKGROUND

Although achieving histologic remission in ulcerative colitis is established, the incremental benefit of achieving histologic remission in patients with Crohn disease (CD) treated to a target of endoscopic remission is unclear. We evaluated the risk of treatment failure in patients with CD in clinical and endoscopic remission by histologic activity status.

METHODS

In a single-center retrospective cohort study, we identified adults with active CD who achieved clinical and endoscopic remission through treatment optimization. We evaluated the risk of treatment failure (composite of clinical flare requiring treatment modification, hospitalization, and/or surgery) in patients who achieved histologic remission vs persistent histologic activity through Cox proportional hazard analysis.

RESULTS

Of 470 patients with active CD, 260 (55%) achieved clinical and endoscopic remission with treatment optimization; 215 patients with histology were included (median age, 33 years; 46% males). Overall, 132 patients (61%) achieved histologic remission. No baseline demographic, disease, or treatment factor was associated with achieving histologic remission. Over a 2-year follow-up, patients with CD in clinical and endoscopic remission who achieved histologic remission experienced a 43% lower risk of treatment failure (1-year cumulative risk: 12.9% vs 18.2%; adjusted hazard ratio, 0.57 [95% confidence interval, 0.35-0.94]) as compared with persistent histologic activity.

CONCLUSIONS

Approximately 61% of patients with active CD who achieved clinical and endoscopic remission with treatment optimization simultaneously achieved histologic remission, which was associated with a lower risk of treatment failure. Whether histologic remission should be a treatment target in CD requires evaluation in randomized trials.

Defining the Path Forward for Biomarkers to Address Unmet Needs in Inflammatory Bowel Diseases

Despite major advances in the inflammatory bowel diseases field, biomarkers to enable personalized and effective management are inadequate. Disease course and treatment response are highly variable, with some patients experiencing mild disease progression, whereas other patients experience severe or complicated disease. Periodic endoscopy is performed to assess disease activity; as a result, it takes months to ascertain whether a treatment is having a positive impact on disease progression. Minimally invasive biomarkers for prognosis of disease course, prediction of treatment response, monitoring of disease activity, and accurate diagnosis based on improved disease phenotyping and classification could improve outcomes and accelerate the development of novel therapeutics. Rapidly developing technologies have great potential in this regard; however, the discovery, validation, and qualification of biomarkers will require partnerships including academia, industry, funders, and regulators. The Crohn's & Colitis Foundation launched the IBD Biomarker Summit to bring together key stakeholders to identify and prioritize critical unmet needs; prioritize promising technologies and consortium approaches to address these needs; and propose harmonization approaches to improve comparability of data across studies. Here, we summarize the outcomes of the 2018 and 2019 meetings, including consensus-based unmet needs in the clinical and drug development context. We highlight ongoing consortium efforts and promising technologies with the potential to address these needs in the near term. Finally, we summarize actionable recommendations for harmonization, including data collection tools for improved consistency in disease phenotyping; standardization of informed consenting; and development of guidelines for sample management and assay validation. Taken together, these outcomes demonstrate that there is an exceptional alignment of priorities across stakeholders for a coordinated effort to address unmet needs of patients with inflammatory bowel diseases through biomarker science.

Mucosal healing in Crohn's disease: new insights

INTRODUCTION

Traditional management of patients with Crohn's disease includes symptoms and quality of life improvement. With the advent of biological agents, mucosal healing has become an achievable goal, documented through endoscopy. However, due to the transmural nature of inflammation, the prevention of bowel damage should be included in the aims of a targeted therapeutic strategy.

AREAS COVERED

Updated literature has been searched in PubMed from 2008 to 2020. This review focuses on the state of the art in the innovative therapeutic goals in Crohn's disease, also considering still controversial aspects and future research topics in the management of Crohn's disease.

EXPERT OPINION

Although a widely agreed view supports the notion that mucosal healing and bowel damage control may promote beneficial outcomes (i.e. reduction in hospitalization and surgical rates, avoidance of steroids), long-term robust data are still missing. On the other hand, the development of -omics techniques has expanded our knowledge of the pathogenetic mechanism underlying inflammatory bowel disease and opened up new horizons in precision or personalized medicine.