Introduction

Use of sedation is associated with a positive effect on endoscopists ADR and a higher proportion of colonoscopies with a withdrawal time > 10. However, the impact of sedation on the risk of post colonoscopy colorectal cancer (PCCRC)deaths remains unclear.

Aims & Methods

Retrospective cohort study within a large population based screening program database in Austria, the association of sedation in screening colonoscopy with post-colonoscopy colorectal cancer death was analysed. Logistic regression was used to estimate the effect of sedation on PCCRC-death.

Results

407.598 screening colonoscopies were analyzed. In 371.132 (91,1%) sedation was used. 46.8% of sedated patients were men compared to 68,2% in unsedated patients (HR 1.94 (1.60, 2.35), p<0,001). Coecum was reached in 97.3% of sedated and 95.5% of unsedated individuals. (HR 4.22 (3.06, 5.82) p<0,001).
Cumulative incidence of PCCRC in sedated individuals was 0.05 (95% CI 0.05-0.5) after 4 years, 0.07% (0.07-0.07) after 6 years, 0.11% (0.11-0.11) after 8 years, 0.14 (0.14-0.14) after 10 years, 0.18% (0.18-0.18) after 12 years. In unsedated patient, cumulative incidence was 0.1% (0-1-0-1) after 4 years, 0.15% (0.15-0.15) after 6 years, 0.22% (0.21-0.23) after 8 years, 0.25% (0.24-0.26%) after 10 years, 0.27% (0.26-0.28) after 12 years. Hazard ratio was 1.31 (0.94-1.83, p=0.1) for sedation in PCCRC-deaths.

Conclusion

Incidence of PCCRC-death was higher in unsedated patients, however this effect was not significant and probably an effect of lower cecal intubation rate within unsedated patients.

Introduction

Patients with inflammatory bowel disease (IBD) in clinical and endoscopic remission may still experience disease relapse. Therefore, there is an unmet need for reliable predictors of outcomes to enable a personalized therapeutic approach. Recently, a novel histological score has highlighted the pivotal role of neutrophils in predicting disease outcomes in Ulcerative Colitis (UC)¹. Furthermore, the impairment of the intestinal barrier plays a key role in forecasting disease outcomes in UC and Crohn’s disease (CD). Hence, this study aims to assess the predictive role of neutrophils according to their tissue localization and intestinal barrier protein expression in IBD patients.

Aims & Methods

IBD patients in clinical remission who underwent colonoscopy between January 2020 and June 2022 at two tertiary referral centres were enrolled. Patients with a Mayo Endoscopic Score ≤1 for UC and a Simple endoscopic score of ≤6 for CD were included. The histological activity was assessed using the Robarts Histopathology Index, Nancy Histological Index, and PICaSSO Histological Remission Index. Neutrophil localization in the epithelium and lamina propria was carefully evaluated by experienced pathologists. Additionally, the immunohistochemical expression of barrier proteins, such as Claudin-2 and JAM (junctional adhesion molecule)-A, was assessed to evaluate the integrity of the intestinal barrier.

Results

Out of 60 UC and 76 CD patients, 60% were in histological activity. 25.8% of patients developed an adverse outcome within 12 months. Only neutrophils in the epithelium and not in lamina propria could predict adverse outcomes for UC (HR 5.20, p=.01) and CD (HR 4.38, p=.03) patients in endoscopic remission. Moreover, epithelial Claudin-2 expression correlated with endoscopic and histological disease activity and predicted outcomes in UC. Combining neutrophils in the epithelium or Claudin-2 expression significantly predicted outcomes in UC patients (HR 3.23, p=.035). Similar results were found for JAM-A in CD despite this protein showing less specificity as a barrier predictor of outcome.

Conclusion

This multicentre study highlights the potential role of epithelial neutrophil localization and Claudin-2 ‘leaky gut’ protein expression as practical clinical tools for predicting outcomes in IBD and potentially guiding patient-tailored therapy.

References

¹Gui X et al., Gut. 2022;71(5):889-898.

Disclosure

None

Introduction

Colorectal cancer (CRC) can be divided into screen-detected and non-screen-detected CRC. Furthermore, based on the interval between CRC detection and a previous screening or examination, CRC can be classified into several groups, including interval cancer and post-colonoscopy CRC. The proportion and characteristics of each CRC need to be clarified to understand the usefulness and limitations of CRC screening; however, they have not been fully elucidated. Particularly, little data is available on interval cancer under the annual fecal immunochemical test (FIT) screening.

Aims & Methods

We aimed to examine the proportions and characteristics of CRC with different detection histories by conducting a multicenter prospective study in Japan (“C-DETECT study”). Consecutive adult patients with CRC were prospectively enrolled in four hub hospitals of cancer treatment. CRC detection methods and intervals from previous examinations were assessed using a questionnaire. Since the population-based CRC screening using an annual FIT is performed in Japan, FIT-interval cancer was defined as CRC detected within 1 year following a previous negative FIT. Three-year post-colonoscopy CRC (PCCRC-3yr), which was defined as CRC detected within 3 years after the previous colonoscopy with negative CRC, was also investigated. Differences in the lesion and patient characteristics were compared for patients with the following CRC using the chi-squared test: i) screen-detected and non-screen-detected CRC; ii) (a) FIT-interval cancer, (b) PCCRC-3yr, (c) CRC detected within 1 year after a positive FIT with noncompliance to colonoscopy, and (d) CRC other than (a), (b), and (c).

Results

Of 1,241 CRC patients (1064 with invasive and 177 with intramucosal CRC), 475 (38.3%) had screen-detected and 766 (61.7%) had non-screen-detected CRCs. Non-screen detected CRCs showed significantly higher proportions of presence of ≥T2 invasion, metastasis, worse histology (poorly differentiated adenocarcinoma, signet-ring cell, or mucinous carcinoma) and left-sided CRCs than screen-detected CRC (82.1% vs 52.8% (P<0.01); 52.0% vs 26.7% (P<0.01); 18.7% vs 11.4% (P<0.01); 71.1% vs 61.7% (P<0.01), respectively). FIT-interval cancer (a), PCCRC-3yr (b), and CRC detected within 1 year after a positive FIT with noncompliance to colonoscopy (c) accounted for 4.5%, 7.0%, and 3.9% of all CRCs, respectively, and for 3.9%, 5.4%, and 4.3% of invasive CRCs, respectively. The comparison among these three types (a, b, c) and the other (d) demonstrated a significant difference in the proportions of ≥T2 invasion ((a) 58.9%, (b) 44.8%, (c) 87.5%, and (d) 73.0%, respectively (P<0.01)), metastasis ((a) 33.9%, (b) 21.8%, (c) 54.2%, and (d) 43.9%, respectively (P<0.01)), right-sided CRC ((a) 42.9%, (b) 40.2%, (c) 18.8%, and (d) 28.6%, respectively (P<0.01)), and female patients ((a) 53.6%, (b) 49.4%, (c) 27.1%, and (d) 41.6% respectively (P=0.02)).

Conclusion

Non-screen-detected CRC accounted for a large proportion of patients and demonstrated advanced characteristics in terms of invasion depth and metastasis, as well as CRC detected shortly after a positive FIT with no colonoscopy. These findings emphasize the importance of screening and colonoscopy compliance following a positive FIT. Notably, FIT-interval cancer and PCCRC-3yr existed in non-negligible proportions even under the annual FIT screening system and were characterized by higher proportions of a right-sided location and female. This novel finding suggests that these two types of CRCs may have different biological features from the others.

Clinical Case Summary

About 1-2% of pancreatic tumors are neuroendocrine pancreatic tumors (NETs). They are often solid masses; rarely they appear as cystic lesions.
The authors report the clinical case of a 66-year-old woman with unspecific abdominal pain, who was referred to the Pancreato-biliary clinic for pancreatic cystic lesions. Magnetic resonance cholangiopancreatography and abdominal CT showed multiple cystic lesions in the distal body and a lesion of 26 mm in the anterior region of the body with diffusion restriction; the duct of Wirsung was dilated (8 mm). Endoscopy ultrasound showed: several hyperechoic foci in the pancreatic parenchyma; a nodular hyperechoic lesion measuring 9 mm in the pancreatic body; a cystic lesion measuring 6 mm in the body; and two cystic lesions measuring 38 and 25 mm in the tail. Fine needle biopsy of the nodular lesion and fine needle aspiration of the larger cystic lesions was performed; the aspiration punction showed amylase 33207 U/L and carcinoembryonic antigen 0.9 ng/mL; however, the cytology of both lesions was inconclusive. Somatostatin receptor scintigraphy showed uptake in the pancreatic body's anterior region and high somatostatin receptor expression, suggesting a neuroendocrine pancreatic tumor diagnosis. In the multidisciplinary team discussion, the decision was to perform total duodenopancreatectomy with splenectomy, which occurred without complications. Histological examination revealed several well-differentiated NETs, the largest of which measured 4 cm, with < 2 mitoses per 2 mm², a proliferation index of 3-20% and regional ganglionic metastasis (pT3(m)N1). At 2 years of follow-up, the patient remains clinically stable without evidence of recurrence of the disease.
This case report, while displaying remarkable images, intends to highlight the challenge of the differential diagnosis between cystic lesions and neuroendocrine tumors of the pancreas; both entities can coexist synchronously and they may share imagiological features.

References

Images list:

1. Multiple cystic pancreatic lesions and a pancreatic lesion in the anterior region of the body with diffusion restriction (Magnetic Resonance Cholangiopancreatography).
2. Multiple cystic lesions in the distal body and a pancreatic lesion in the anterior region of the body (Abdominal Computed Tomography).
3. Several hiperecoic foci in the pancreatic parenchyma; a nodular hiperecoic lesion measuring 9 mm in the pancreatic body; a cystic lesion measuring 6 mm in the body; and two cystic lesions measuring 38 and 25 mm in the tail (Endoscopy ultrasound).
4. Uptake in the pancreatic body's anterior region and high somatostatin receptor expression (Somatostatin receptor scintigraphy)