Anti-Inflammatory Biologics and Anti-Tumoral Immune Therapies-Associated Colitis: A Focused Review of Literature

Histology of IBD and related colitides in the elderly

Inflammatory bowel disease (IBD) are chronic relapsing diseases, affecting both children and adults with a life-long duration. An increased co-morbidity gives raise to fragility in the elderly. In this regard it should consider that several non-IBD colitides may mimic both ulcerative colitis and Crohn's disease. Moreover, chronic diseases represent a clinical challenge, mostly about treatment effectiveness. Finally, it is worth noting that patients with long-standing diseases - and elderly patients among them - have an increased malignancy risk when compared to general (non-IBD) population. Our paper aims to review the three main histological topics that play a role in the clinical management of IBD in the elderly, namely differential diagnosis, mucosal healing and IBD-associated dysplasia.

Dasatinib-induced Crohn's-like colitis

Dasatinib is a second-generation multityrosine kinase inhibitor used in the first-line and second-line treatment of Philadelphia chromosome-positive leukaemia. The most frequent type of Dasatinib-induced intestinal injury is haemorrhagic colitis; other morphologic patterns include apoptotic colopathy, CD8+ T-cell-mediated colitis and non-specific colitis. Aim of this study is to describe a novel Crohn's-like histopathologic pattern of Dasatinib-induced colitis. Four patients developed diarrhoea during Dasatinib treatment; colonoscopy was performed and biopsy sets were taken for histological analysis. All patients showed patchy, chronic active inflammation with cryptitis and microgranulomas (two patients). Ileal and rectal biopsies showed either no or mild, focal inflammation. An increase in lamina propria eosinophils was seen (two patients) and apoptoses were seen (three patients). Complete remission was observed after interruption of treatment. Dasatinib-induced colitis and Crohn's disease may share histologic features including microgranulomas, which can potentially lead to misdiagnosis if no information on treatment is provided.

Gastrointestinal injury induced by immunomodulators: A review article

An increasing number of immunomodulators, either anti-inflammatory or immunity-enhancing, have brought about a revolutionary effect in the management of a variety of autoimmune disorders and malignancies. However, their ability to cause gastrointestinal (GI) injury and induce GI symptoms has been increasingly and unexpectedly recognized. GI injury associated with immunomodulators may demonstrate various histologic and endoscopic patterns. Optimal diagnosis and treatment require a multidisciplinary approach. This review aims to provide an overview of the literature on its pathogenesis, the clinical, endoscopic, and histologic features, and suggested approaches to manage these newly recognized immunomodulator-induced GI adverse effects (AEs). We also reviewed current biomarkers predictive of GI toxicity and potential risk factors to identify susceptible patients. In addition, these immune-mediated AEs were compared with inflammatory bowel disease, a well-documented form of inflammation-driven GI injury. We hope this review will raise awareness and vigilance among clinicians of these entities to increase early diagnosis and rapid referral to specialist care.

Perforating Colitis Secondary to Immune Checkpoint Inhibitor Use in a Patient With Pericolonic Involvement by Rosai-Dorfman Disease

Recently, the use of immunotherapy has increased substantially for the treatment of several malignancies. It is associated with several gastrointestinal adverse events; however, severe complications such as intestinal perforation are rare. We present a 75-year-old man with metastatic melanoma, presented with profuse diarrhea and abdominal pain, after ipilimumab and nivolumab administration. Shortly after, he developed fulminant colitis and intestinal perforation and was found to have concurrent Rosai-Dorfman disease of pericolonic lymph nodes. With the increasing use of immunotherapy, reporting of serious adverse events and their mimics is essential. In addition, further studies are required to investigate whether an association exists between Rosai-Dorfman disease and immunotherapy.

Crohn's disease induced by ocrelizumab in a patient with multiple sclerosis

Drug-induced inflammatory bowel disease (IBD) is a clinical entity on the rise due to the frequent use of immunomodulatory therapy. Here we report the case of Crohn's disease due to Ocrelizumab, a humanized anti-CD20 monoclonal antibody approved for the treatment of multiple sclerosis. The exact mechanism by which anti-CD20 antibodies can trigger IBD is unknown, but since IBD and multiple sclerosis are processes included within the spectrum of immunomediated diseases, we could suggest that Ocrelizumab could trigger IBD in genetically predisposed patients.

Immunotherapy-induced Colitis: A Comprehensive Review of Epidemiology, Clinical Presentation, Diagnostic Workup, and Management Plan

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of a variety of malignancies including advanced melanoma, non-small cell lung cancer, renal cell carcinoma, head and neck cancers among others. Since their introduction, there has been significant improvement in survival and prognosis in patients with advanced malignancies. Unfortunately, improved outcomes have come at a price of significant immune-related adverse events, with those of the gastrointestinal tract being the most common. Gastrointestinal immune-related adverse events frequently present as diarrhea and colitis, the severity of which can range from mild diarrhea to fulminant colitis with intestinal perforation. Currently, management of ICI-induced colitis is primarily guided by retrospective studies and expert opinion. A significant number of ICI-induced colitis responds to high-dose corticosteroids; however, some patients require further therapy with biologics. There is limited information on the factors which may predispose patients to ICI-induced colitis. Future research elucidating these risk factors along with development of a scoring system could allow for risk-stratification of patients before initiation of ICI therapy. Such a system may help clinicians and patients keep a high index of suspicion regarding ICI-induced colitis and could hopefully reduce the incidence of severe cases. Similarly, future studies should investigate protective factors against ICI-induced colitis, which could potentially allow more patients to safely benefit from ICI therapy.

Gut inflammation induced by drugs: Can pathology help to differentiate from inflammatory bowel disease?

Drug‐induced mucosal injury (DIMI) in the gastrointestinal tract is important to recognise, partly because cessation of the culprit agent alone may result in resolution of symptoms. An ever‐growing list of medications, including newer immunotherapeutic agents and targeted therapies, can cause gastrointestinal inflammation of varying severity. However, the diagnosis of DIMI is challenging, as a single drug can induce a variety of histopathological patterns of injury including acute colitis, chronic colitis, microscopic colitis, apoptotic colopathy, and ischaemic‐type colitis. An additional consideration is the potential clinical, endoscopic and histological overlap of DIMI with gastrointestinal mucosal injury secondary to other entities such as inflammatory bowel disease (IBD). We discuss DIMI of the gastrointestinal tract with an emphasis on histological patterns that mimic IBD, histological features which may distinguish the two entities, and the diagnostic role and limitations of the pathologist.

Granulomatous colitis in a patient with metastatic melanoma under immunotherapy: a case report and literature review

BACKGROUND

Immune checkpoint inhibitors (ICPIs) have changed the way advanced malignancies are currently confronted, improving cancer patients' outcomes but also generating distinct immune-related (ir) adverse events. ICPIs-induced colitis is a common complication showing different clinical and histological manifestations. In the literature review, 14 cases with ICPIs related colon granulomas have been reported in 5 studies with either limited or unavailable information regarding histology. Granulomatous reactions can be mistakenly perceived as disease recurrence or progression. Better understanding and identification of this infrequent histological display can help to avoid misdiagnosis and mismanagement.

CASE PRESENTATION

A 63-year-old female patient with metastatic melanoma was admitted to the hospital with symptoms of nausea, persistent diarrhea and shivering fever under consecutive treatments with ICPIs, initially pembrolizumab and subsequently ipilimumab. Sigmoidoscopy was performed revealing mucosal edema, hyperemia and erosions of the rectum and sigmoid colon. Histological evaluation of sigmoid colon mucosa biopsies revealed an unusual colitis pattern characterized by multiple intracryptal granulomas attributed to ICPIs therapy. Steroids were administered and the patient recovered. ICPIs treatment was discontinued. The patient was subsequently treated with chemotherapy but follow up radiology showed disease progression. A re-challenge with another ICPI regimen was decided and the patient is currently under immunotherapy with stable disease regarding melanoma status and without any sign of colitis recurrence.

CONCLUSIONS

The present report provides detailed histological description of a distinctive ICPIs-induced granulomatous colitis and highlights the need for awareness of the distinct adverse events and reaction patterns in the context of immunotherapy.

Immune Checkpoint Inhibitor-Induced Pancreatic Injury: Imaging Findings and Literature Review

The immunotherapy revolution in cancer treatment involves a variety of specialists, not only oncologists, but also internal medicine physicians, endocrinologists, dermatologists, gastroenterologists, rheumatologists, and radiologists, introducing new scenarios and novel challenges in the diagnosis and management of a number of novel immune-related adverse events. Among these, immune checkpoint inhibitor-induced pancreatic injury has been described (occurring in up to 4% of patients) and has been reported to be responsible for visits to the emergency departments in up to 1.9% of patients treated with immune checkpoint inhibitors. This side effect can be symptomatic or non-symptomatic, and can be associated with the development of long-term damage to the pancreas, requiring the involvement of different specialists, including radiologists and gastroenterologists in the multidisciplinary team that manages these patients. The aim of this narrative review is to provide a summary of the available literature related to immune checkpoint inhibitor-induced pancreatic injury including the epidemiology, the clinical findings, and the management algorithm for diagnosis with a detailed analysis of the differential diagnosis at imaging, and treatment. A more in-depth focus is dedicated to symptomatic acute pancreatitis with its peculiar findings at imaging (ultrasound, computed tomography, and magnetic resonance imaging).

Gastrointestinal and liver adverse effects of anti-tumoral immune therapy: from recognition to treatment

Anti-tumoral immune therapy consists of monoclonal antibodies that target intra-cellular immune checkpoints-which under normal circumstances, act as regulators of T-cell immunity. By serving as inhibitors of cellular checkpoints, monoclonal antibodies stimulate the immune system thus augmenting the body's response against cancer. These immune-enhancers or stimulators have revolutionized the treatment of malignancy as they continue to show improvement in the overall survival of cancer patients. Currently, in the United States, six immune checkpoint inhibitors are approved for the treatment of a variety of solid tumors (1). As these checkpoint inhibitors are relatively new, only a scant amount of literature is available regarding both their adverse effects and management thereof. In addition, as newer antibodies are being developed, and expected to be enlisted among the armamentarium of cancer chemotherapeutic agents-the need to understand their toxicity and adverse effects is of paramount importance. Herein, we review some of the gastrointestinal and liver sequelea secondary to the usage of immunotherapeutic checkpoint inhibitor agents in cancer chemotherapy, as well as present the diagnosis and recommended treatment strategies for their adverse effects.

Healthcare resource utilization and costs associated with inflammatory bowel disease among patients with chronic inflammatory diseases: a retrospective cohort study

Background

Chronic inflammatory diseases (CIDs; ankylosing spondylitis [AS], psoriatic arthritis [PsA], psoriasis [PsO], or rheumatoid arthritis [RA]) and inflammatory bowel disease (IBD; Crohn’s disease and ulcerative colitis) are associated with substantial economic burden. The relative increased costs among patients with CIDs and concomitant IBD compared to those without IBD is an important consideration when deciding on the clinical management of patient symptoms. Given the increasing use of novel agents for the treatment of CIDs, including those that may increase the risk of IBD in patients with CIDs, the objective of the study was to describe the incidence of IBD and to quantify healthcare resource utilization (HRU) and costs associated with IBD among patients with CIDs.

Methods

The IBM MarketScan® Research Databases (1/2010–7/2017) were used to identify adult patients with ≥2 claims with a diagnosis of either AS/PsA/PsO/RA (index date was a random claim for AS/PsA/PsO/RA). The one-year incidence rate of IBD was calculated following the index date. HRU and healthcare costs were compared between patients developing and not developing IBD in the year following the index date, adjusting for baseline characteristics.

Results

A total of 537,450 patients with CIDs (mean age = 54.0 years; 63.1% female) were included in the study. The 1-year incidence rate of IBD was 0.52% (range = 0.39% in patients with PsO but without PsA to 1.73% in patients with AS). Patients who developed IBD (N = 2778) had significantly higher rates of inpatient, outpatient, and emergency room visits (incidence rate ratios [IRR] = 2.91, 1.35, 1.81; all P < 0.0001), compared to patients without IBD (N = 534,672). Patients who developed IBD had $18,500 (P < 0.0001) higher total costs per year, including $15,121 (P < 0.0001) higher medical costs and $3380 higher pharmacy costs (P < 0.0001).

Conclusion

Higher HRU and costs were observed in patients with concomitant CID and IBD compared to patients with CID alone. Consideration should be given to treatment decisions that adequately manage CID and IBD to ensure optimal clinical and economic outcomes.

Immunotherapy-related adverse effects on 18F-FDG PET/CT imaging

¹⁸F-Fluorodeoxyglucose positron emission tomography/CT imaging plays a key role in oncological imaging including in staging, radiotherapy planning, treatment response and recurrence assessment. Immunotherapies represent a major advance in cancer therapy for a number of tumours with resulting survival benefit. However, a wide range of immune related adverse events (irAEs), some of which can be apparent on imaging, have been reported. These involve many organ systems but particularly endocrine, cutaneous and gastrointestinal systems. Early detection of irAEs is essential to aid diagnosis and management of patients and to reduce associated morbidity. In addition, it is important to not mistake treatment related effects for disease.This pictorial review aims to identify common irAEs and changes seen on ¹⁸F-fluorodeoxyglucose positron emission tomography/CT.

Prostate cancer and inflammation: A new molecular imaging challenge in the era of personalized medicine

The relationship between cancer and inflammation is one of the most important fields for both clinical and translational research. Despite numerous studies reported interesting and solid data about the prognostic value of the presence of inflammatory infiltrate in cancers, the biological role of inflammation in prostate cancer development is not yet fully clarified. The characterization of molecular pathways that connect altered inflammatory response and prostate cancer progression can provide the scientific rationale for the identification of new prognostic and predictive biomarkers. Specifically, the detection of infiltrating immune cells or related-cytokines by histology and/or by molecular imaging techniques could profoundly change the management of prostate cancer patients. In this context, the anatomic pathology and imaging diagnostic teamwork can provide a valuable support for the validation of new targets for diagnosis and therapy of prostate cancer lesions associated to the inflammatory infiltrate. The aim of this review is to summarize the current literature about the role of molecular imaging technique and anatomic pathology in the study of the mutual interaction occurring between prostate cancer and inflammation. Specifically, we reported the more recent advances in molecular imaging and histological methods for the early detection of prostate lesions associated to the inflammatory infiltrate.