Putting Evidence into Practice: IBD Surveillance, Chromoendoscopy and Future Directions

Quality of Surveillance Impacts the Colitis-Associated Advanced Neoplasia Risk: A Multicenter Case-Control Study

BACKGROUND AND AIMS

Although colorectal cancer (CRC) surveillance is embedded in clinical inflammatory bowel disease (IBD) practice, a subset of patients still develops advanced neoplasia (AN) (high-grade dysplasia [HGD] and/or CRC). We aimed to assess the impact of surveillance quality on AN risk in IBD.

METHODS

In this multicenter case-control study, we searched the Dutch nationwide pathology databank to identify IBD cases with AN and controls with indefinite or low-grade dysplasia. The surveillance colonoscopy preceding the index lesion (first indefinite for dysplasia [IND]/low-grade dysplasia [LGD] or AN) was used to assess the impact of surveillance quality. We assessed intervals, bowel preparation, cecal intubation, and absence of inflammation as primary quality indicators. In addition, we assessed chromoendoscopy, endoscopist expertise, hospital setting, and biopsy strategy. Associations of quality indicators with AN risk were determined with multivariable logistic regression analyses with Firth's correction.

RESULTS

We included 137 cases and 138 controls. Delayed intervals (58.2% vs 39.6%) and active inflammation (65.3% vs 41.8%) were frequently present in cases and controls and were associated with AN (delayed interval: adjusted odds ratio [aOR], 2.00; 95% confidence interval [CI], 1.07-3.81; P = .03; active inflammation: aOR, 2.46; 95% CI, 1.33-4.61; P < .01). Surveillance compliant with primary quality indicators was associated with a reduced AN risk (aOR, 0.43; 95% CI, 0.22-0.91; P = .03), similar to chromoendoscopy (OR, 0.11; 95% CI, 0.01-0.89; P = .01). Other indicators were not significantly associated with AN.

CONCLUSIONS

Surveillance compliant with primary quality indicators is associated with a reduced colitis-associated AN risk. Delayed surveillance intervals and active inflammation were associated with an increased AN risk. This underlines the importance of procedural quality, including endoscopic remission to optimize the effectiveness of endoscopic surveillance.

Colorectal Cancer Screening in Inflammatory Bowel Diseases-Can Characterization of GI Microbiome Signatures Enhance Neoplasia Detection?

Current noninvasive methods for colorectal cancer (CRC) screening are not optimized for persons with inflammatory bowel diseases (IBDs), requiring patients to undergo frequent interval screening via colonoscopy. Although colonoscopy-based screening reduces CRC incidence in IBD patients, rates of interval CRC remain relatively high, highlighting the need for more targeted approaches. In recent years, the discovery of disease-specific microbiome signatures for both IBD and CRC has begun to emerge, suggesting that stool-based biomarker detection using metagenomics and other culture-independent technologies may be useful for personalized, early, noninvasive CRC screening in IBD patients. Here we discuss the utility of the stool microbiome as a noninvasive CRC screening tool. Comparing the performance of multiple microbiome-based CRC classifiers, including several multi-cohort meta-analyses, we find that noninvasive detection of colorectal adenomas and carcinomas from microbial biomarkers is an active area of study with promising early results.

Colorectal Cancer Surveillance in Patients with Inflammatory Bowel Diseases: Chromoendoscopy or Non-Chromoendoscopy, That Is the Question

Subjects affected by ulcerative colitis and Crohn’s disease with colonic localization have an increased risk of colorectal cancer (CRC). Surveillance colonoscopy is recommended by international guidelines as it can detect early-stage CRC. Based on previous evidence, in 2015 the Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients International Consensus indicated dye chromoendoscopy (DCE) as the most effective technique for detecting dysplasia. However, advances in endoscopic technology such as high-definition colonoscopes and dye-less virtual chromoendoscopy (VCE) may change future practice. In this review, we summarize the available evidence on CRC surveillance in IBD, focusing on the emerging role of high-definition white light endoscopy (HD-WLE) and VCE over the standard DCE, and the current role of random biopsies.

Dysplasia Surveillance in Inflammatory Bowel Disease: A Cohort Study

Introduction

Patients with colonic inflammatory bowel disease (IBD) are at an increased risk for colorectal cancer (CRC), whereby surveillance colonoscopy is recommended.

Aim

To study the clinical and endoscopic variables associated with dysplasia in IBD patients.

Methods

A cohort study was conducted on IBD patients who were part of a colonoscopy surveillance program between 2011 and 2016.

Results

A total of 342 colonoscopies were performed on 162 patients (105 with ulcerative colitis [UC] and 57 with Crohn's disease). Random biopsies were performed at least once on 81.5% of patients; 33.3% of the patients underwent chromoendoscopy (CE) at least once. Endoscopically resectable lesions were detected in 55 patients (34%), and visible lesions deemed unfit for endoscopic resection were found in 5 patients (3.1%). Overall, 62 dysplastic visible lesions (58 with low-grade dysplasia and 3 with high-grade dysplasia) and 1 adenocarcinoma were found in 34 patients. Dysplasia in random biopsies was present in 3 patients, the yield of random biopsies for dysplasia being 1.85%/patient (3/162), 1.75%/colonoscopy (6/342), and 0.25%/biopsy (9/3,637). Dysplasia detected in random biopsies was significantly associated with a personal history of visible dysplasia (p = 0.006). Upon univariate analysis, dysplasia was significantly associated with the type of IBD, the performance of random biopsies, and CE (p = 0.016/0.009/0.05, respectively). On multivariate analysis, dysplasia was associated with duration of disease.

Conclusion

Our data confirm that patients with long-standing IBD, in particular UC, should be enrolled in dysplasia surveillance programs, and that performing CE and random biopsies seems to help in the detection of colonic neoplastic lesions.

Pediatric Colonoscopic Polypectomy Technique

Colonoscopy with polypectomy is frequently performed in pediatric patients based on symptoms, with the majority of polyps identified being benign juvenile pedunculated polyps with a vascular stalk. This is in distinction to adults where polypectomy is often performed as part of a colon cancer screening and prevention strategy and a higher fraction of polyps are sessile and or dysplastic. In adults, polypectomy techniques emphasize a need for deeper resection to ensure complete resection of adenomas or potential carcinoma in situ. Adenomatous polyps can occur in the pediatric age group and may be associated with an underlying polyposis, hereditary or chronic inflammatory conditions. Polypectomy techniques include use of cold biopsy forceps for very small polyps, cold snare polypectomy for small sessile polyps and hot snare polypectomy for the majority of polyps in the pediatric age group. Adjuvant techniques include epinephrine volume reduction, saline-assisted polypectomy and hemostatic techniques including injection, clip application and loop application to prevent or treat post-polypectomy bleeding. Electrosurgical principles guide the settings and type of current utilized during hot snare polypectomy. Polypectomy utilizing thermal techniques is associated with a higher risk of complications compared with diagnostic colonoscopy.

Effect of chromoendoscopy in the proximal colon on colorectal neoplasia detection in Lynch syndrome: a multicenter randomized controlled trial

BACKGROUND AND AIMS

Patients with Lynch syndrome (LS) undergo regular surveillance by colonoscopy because of an increased risk of colorectal neoplasia, particularly in the proximal colon. Chromoendoscopy (CE) has been reported to improve neoplasia detection compared with conventional white-light endoscopy (WLE), but evidence is limited. Our aim was to investigate the effect of CE in the proximal colon on detection of neoplastic lesions during surveillance in LS.

METHODS

This was a multicenter prospective randomized controlled trial of 246 patients with LS who were randomly assigned (1:1) to conventional WLE (n = 123) or colonoscopy with CE in the proximal colon (n = 123), stratified for previous colorectal adenomas and enrolling center. Two years after baseline colonoscopy, patients underwent colonoscopy with CE in the proximal colon. The primary outcome was the proportion of patients with at least one neoplastic lesion at baseline and after 2 years.

RESULTS

Neoplasia detection rates at baseline colonoscopy were 27% for WLE versus 30% for CE (odds ratio [OR], 1.23; 95% confidence interval [CI], 0.69-2.2; P = .56). In the proximal colon, neoplasia detection rates were 16% for WLE versus 24% for CE (OR, 1.6; 95% CI, 0.9-3.1; P = .13). Total procedure time was 9 minutes longer in the CE group. At follow-up after 2 years, neoplasia detection rates were similar in both groups: 26% for the original WLE group versus 28% for the CE group (OR, 1.1; P = .81).

CONCLUSIONS

CE in the proximal colon for LS surveillance was not superior to WLE with respect to the initial detection of neoplasia, and not associated with reduced neoplasia detection rates after 2 years. The value of CE remains to be established. (Clinical trial registration number: NCT00905710.).

Role of endoscopy in the surveillance and management of colorectal neoplasia in inflammatory bowel disease

Endoscopy has become increasingly fundamental in the management of patients with inflammatory bowel disease (IBD). It is required for diagnosis, assessment of therapeutic response, postoperative follow up and in the surveillance of dysplasia. With rapid advances in technology, including high definition colonoscopy and chromoendoscopy, questions have arisen regarding the most appropriate surveillance and management strategies of colorectal neoplasia in IBD. We aim to review current surveillance strategies, explore the utility of new technologies, and examine the role of endoscopic resection, with the aim of clarifying these questions.