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Kabir M, Thomas-Gibson S, Ahmad A, Kader R, Al-Hillawi L, Mcguire J, David L, Shah K, Rao R, Vega R, East JE, Faiz OD, Hart AL, Wilson A. Cancer Biology or Ineffective Surveillance? A Multicentre Retrospective Analysis of Colitis-Associated Post-Colonoscopy Colorectal Cancers. J Crohns Colitis 2024; 18:686-694. [PMID: 37941424 DOI: 10.1093/ecco-jcc/jjad189] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease [IBD] is associated with high rates of post-colonoscopy colorectal cancer [PCCRC], but further in-depth qualitative analyses are required to determine whether they result from inadequate surveillance or aggressive IBD cancer evolution. METHODS All IBD patients who had a colorectal cancer [CRC] diagnosed between January 2015 and July 2019 and a recent [<4 years] surveillance colonoscopy at one of four English hospital trusts underwent root cause analyses as recommended by the World Endoscopy Organisation to identify plausible PCCRC causative factors. RESULTS In total, 61% [n = 22/36] of the included IBD CRCs were PCCRCs. They developed in patients with high cancer risk factors [77.8%; n = 28/36] requiring annual surveillance, yet 57.1% [n = 20/35] had inappropriately delayed surveillance. Most PCCRCs developed in situations where [i] an endoscopically unresectable lesion was detected [40.9%; n = 9/22], [ii] there was a deviation from the planned management pathway [40.9%; n = 9/22], such as service-, clinician- or patient-related delays in acting on a detected lesion, or [iii] lesions were potentially missed as they were typically located within areas of active inflammation or post-inflammatory change [36.4%; n = 8/22]. CONCLUSIONS IBD PCCRC prevention will require more proactive strategies to reduce endoscopic inflammatory burden, and to improve lesion optical characterization, adherence to recommended surveillance intervals, and patient acceptance of prophylactic colectomy. However, the significant proportion appearing to originate from non-adenomatous-looking mucosa which fail to yield neoplasia on biopsy yet display aggressive cancer evolution highlights the limitations of current surveillance. Emerging molecular biomarkers may play a role in enhancing cancer risk stratification in future clinical practice.
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Affiliation(s)
- Misha Kabir
- Division of GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
- Imperial College London, London, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- Wolfson Endoscopy Unit, St Mark's Hospital, London, UK
| | - Ahmir Ahmad
- Imperial College London, London, UK
- Wolfson Endoscopy Unit, St Mark's Hospital, London, UK
| | - Rawen Kader
- Division of GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lulia Al-Hillawi
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK
- University of Oxford, Oxford, UK
| | - Joshua Mcguire
- Blizard Institute, Queen Mary University of London, London, UK
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Lewis David
- Department of Gastroenterology, East and North Hertfordshire, Stevenage, UK
| | - Krishna Shah
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Rohit Rao
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Roser Vega
- Division of GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - James E East
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Omar D Faiz
- Imperial College London, London, UK
- Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Ailsa L Hart
- Imperial College London, London, UK
- IBD Unit, St Mark's Hospital, London, UK
| | - Ana Wilson
- Imperial College London, London, UK
- Wolfson Endoscopy Unit, St Mark's Hospital, London, UK
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Harpaz N, Itzkowitz SH. Pathology and Clinical Significance of Inflammatory Bowel Disease-Associated Colorectal Dysplastic Lesions. Gastroenterol Clin North Am 2024; 53:133-154. [PMID: 38280745 DOI: 10.1016/j.gtc.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Timely diagnosis and effective management of colorectal dysplasia play a vital role in preventing mortality from colorectal cancer in patients with chronic inflammatory bowel disease. This review provides a contemporary overview of the pathologic and endoscopic classification of dysplasia in inflammatory bowel disease, their roles in determining surveillance and management algorithms, and emerging diagnostic and therapeutic approaches that might further enhance patient management.
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Affiliation(s)
- Noam Harpaz
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai; Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Annenberg Building 5-12L, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Steven H Itzkowitz
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Annenberg Building 5-12L, 1468 Madison Avenue, New York, NY 10029, USA
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Stjärngrim J, Ekbom A, Widman L, Hultcrantz R, Forsberg A. Post-colonoscopy rectal cancer in Swedish patients with Crohn's disease 2001-2015: a population-based case review study. Eur J Gastroenterol Hepatol 2023; 35:1334-1340. [PMID: 37942755 DOI: 10.1097/meg.0000000000002658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
OBJECTIVE Post-colonoscopy colorectal cancer (PCCRC) is a key quality indicator of colonoscopy, and PCCRC rates are high in the IBD population. Rectal cancer, an important risk factor for PCCRC among patients with Crohn's disease (CD), has not previously been examined. METHODS Swedish adult patients with CD who underwent a colonoscopy within 36 months before a rectal cancer diagnosis between 2001 and 2015 were identified through the National Patient and Cancer registers. Their medical records were reviewed and a root-cause analysis and a sub-categorization according to the World Endoscopic Organization (WEO) were performed. RESULTS Of 24 patients with CD and PCCRC in the rectum, 79% were men and the median age was 50 (IQR 45-59) years. The median disease duration was 21.5 (IQR 19-30) years. The cancer was located in the distal 5 cm of the rectum in 63% of the cases. Retroversion in the rectum was reported in only one case. The most common plausible explanation for PCCRC was 'possible missed lesion, prior examination adequate' (63%); when adding retroversion in the rectum, instead 77% of examinations were considered negative but deemed as inadequate. The most common PCCRC sub-category was non-interval type C (54%) and B (37%). Among those with type C, 38% should have been included in surveillance according to present guidelines. CONCLUSION Better adherence to surveillance guidelines and more meticulous follow-up is warranted. The importance of performing rectal palpation and retroversion in the rectum is underscored and we suggest that this is included in the WEO algorithm.
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Affiliation(s)
- Jessica Stjärngrim
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet
| | - Anders Ekbom
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet
| | - Linnea Widman
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet
- Department of Medicine, Huddinge, Karolinska Institutet
| | - Rolf Hultcrantz
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anna Forsberg
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet
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Itzkowitz S, Farraye FA, Limburg PJ, Gagrat Z, Olson MC, Zella J, Kisiel JB. Assessment of Stool DNA Markers to Detect Colorectal Neoplasia in Patients with Inflammatory Bowel Disease: A Multi-site Case-control Study. J Crohns Colitis 2023; 17:1436-1444. [PMID: 37166153 PMCID: PMC10588779 DOI: 10.1093/ecco-jcc/jjad069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Indexed: 05/12/2023]
Abstract
BACKGROUND AND AIMS The FDA-approved multitarget stool-DNA [mt-sDNA] test is a successful colorectal cancer [CRC] screening tool in average-risk individuals but is not indicated for patients with inflammatory bowel disease [IBD]. We determined the performance of the mt-sDNA assay without the haemoglobin component [mt-sDNAHgb-] in patients with IBD, while measuring sensitivity for colorectal cancer and advanced colorectal neoplasia [ACRN]. METHODS This was a multi-centre, proof-of-concept investigation in persons aged 18-84 years with a diagnosis of IBD, or primary sclerosing cholangitis [PSC] with IBD. Enrolment occurred between March 2013 and May 2016. Stool was tested with the mt-sDNA molecular markers only, minus the immunochemical haemoglobin component. RESULTS The analysis set contained 355 samples. The median age was 52 [range 39-62] years, 45.6% were female and 93% were White. Two-thirds [63%] had ulcerative colitis [UC] and 10.1% had PSC/IBD. Colonoscopy revealed cancer in 8.5% [N = 30], advanced precancerous lesions [APLs] in 9.3% [N = 33] and non-advanced precancerous lesions in 7.6% [N = 27], and three-quarters [74.7%, N = 265] had negative findings. mt-sDNAHgb- sensitivity was 73.3% for any stage cancers, and 76.2% for ACRN. Sensitivity was highest for IBD-associated high-grade dysplasia at 100% and 84.6% for IBD-associated low-grade dysplasia ≥1 cm. The test showed higher sensitivity and lower specificity in UC than in Crohn's disease. Increasing inflammation score was associated with a significant decrease in mt-sDNAHgb- test score [ = 0.028] amongst neoplasia-negative individuals, but not in patients with ACRN. CONCLUSIONS These data highlight the potential of multitarget stool-DNA marker testing as an important addition to colorectal cancer surveillance by complementing colonoscopic evaluations in IBD patients.
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Affiliation(s)
| | | | | | | | | | - Julia Zella
- Exact Sciences Corporation, Madison, WI, USA
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Al Bakir I, Kabir M, Yalchin M, Hart A. Optimising inflammatory bowel disease surveillance and dysplasia management-Where do we stand? United European Gastroenterol J 2022; 10:1054-1062. [PMID: 36349435 PMCID: PMC9752268 DOI: 10.1002/ueg2.12330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/16/2022] [Indexed: 11/11/2022] Open
Abstract
Patients with longstanding extensive colitis are at an increased risk of developing colorectal cancer (CRC), and are therefore enrolled into colonoscopy screening programmes with the aim of detecting pre-cancerous dysplastic change. However, current surveillance programs face multiple limitations relating to low levels of patient enrolment, missed lesions resulting in interval cancers, and uncertainties in the management of dysplasia. Patient counselling regarding the endoscopic and surgical management options of dysplastic lesions can prove particularly challenging, due to the variable risk of progression to cancer. In this review, we discuss the histopathological diagnosis of inflammatory bowel disease (IBD)-associated dysplasia, describe the techniques to maximise dysplasia detection, and present a standardised multi-disciplinary approach to managing patients with dysplasia. The challenges presented by this patient cohort highlight the clear clinical need for further research into the development and validation of non-invasive markers of CRC risk in IBD patients undergoing surveillance.
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Affiliation(s)
- Ibrahim Al Bakir
- Gastroenterology DepartmentChelsea and Westminster HospitalLondonUK
| | - Misha Kabir
- Gastroenterology DepartmentUniversity College HospitalLondonUK
| | - Mehmet Yalchin
- Inflammatory Bowel Disease UnitSt Mark's Hospital and Academic InstituteHarrowMiddlesexUK
| | - Ailsa Hart
- Inflammatory Bowel Disease UnitSt Mark's Hospital and Academic InstituteHarrowMiddlesexUK
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