Introduction

The Ki-67 labeling index is a well-established marker of cellular proliferation and has been associated with worse disease-free and overall survival in gastrointestinal stromal tumors (GISTs). Recent evidence highlights its potential role in risk stratification, particularly when Ki-67 exceeds certain thresholds. However, current assessment relies on postoperative histopathology. Radiomics, by extracting quantitative features from computer tomography (CT) images, may offer a non-invasive method to predict Ki-67 expression preoperatively. This meta-analysis aimed to evaluate the diagnostic performance of CT-based radiomics for predicting Ki-67 status in GISTs.

Aims & Methods

A systematic review and meta-analysis were conducted according to PRISMA guidelines). Four electronic databases (PubMed, Scopus, Science Direct, Cochrane Library) were searched for relevant articles up to December 2024. Eligible studies assessed CT radiomics in predicting Ki-67 in histologically confirmed GISTs. Pooled sensitivity, specificity, and area under the curve (AUC) were calculated using a random-effects model. Subgroup analyses were performed based on cohort type, CT protocol, number of features, and Ki-67 cutoff values. Study quality was assessed using the QUADAS-2 tool.

Results

Six studies comprising 1,632 patients met the inclusion criteria. Pooled sensitivity and specificity were 0.71 (95% CI: 0.63–0.79) and 0.76 (95% CI: 0.73–0.78), respectively. The pooled AUC was 0.79 (95% CI: 0.74–0.84). Subgroup analyses showed consistent performance across imaging protocols and feature counts, while Ki-67 cutoffs (8% vs. 10%) significantly impacted diagnostic accuracy. Sensitivity analysis confirmed robustness of specificity estimates. Publication bias was detected for specificity (Egger’s test p = 0.006).

Conclusion

CT radiomics demonstrates moderate accuracy for non-invasively predicting Ki-67 expression in GISTs. Given Ki-67's prognostic significance, radiomics could support preoperative risk assessment and personalized treatment planning. Further prospective validation is warranted.

Disclosure

No Conflict of Interest ​

Introduction

​​​​​Concerns regarding colorectal cancer in short bowel syndrome (SBS) patients receiving teduglutide (TED) treatment have led to the recommendation of colonoscopy for screening and surveillance.^1,2 While there are reports of new small bowel polyps in TED patients, data on small bowel cancer risk and surveillance are lacking.^3,4 This study aims to evaluate the feasibility and effectiveness of using double-balloon enteroscopy (DBE) for surveillance in SBS patients undergoing TED treatment.

Aims & Methods

Data from patients with SBS in TED treatment who underwent DBE within a year of starting TED at a tertiary referral center for enteroscopy between December 2019 and October 2023 were collected. The primary endpoints were technical success, adverse events, and total enteroscopy rates. Secondary endpoints included the incidence of small bowel polyps and residual small bowel length measurement.

Results

Nine patients (7 female, median age 65.5, IQR 58-79) with SBS (22% type 1, 55.6% type 2, 22.2% type 3-SBS) underwent DBE (10 anterograde, 2 retrograde) under procedural sedation. Crohn’s disease (33.3%) and post-surgical complications (33.3%) were the most frequent causes of SBS. The median interval from TED prescription to DBE surveillance was 9.1 months (IQR 3.2-32.9). The median depth of maximal insertion was 85 cm (IQR 50-187). No adverse events occurred during all the procedures. The total enteroscopy rate was 75% (80% [8/10] of anterograde DBEs, 50% [1/2] of retrograde DBEs). Panenteric DBE allowed the estimation of small bowel residual length in all cases (2/2) where this important clinical information was unknown and revealed a different residual small bowel length compared to surgery in 44% of patients. No small bowel malignancies were detected during the study period.

Conclusion

DBE surveillance for small bowel malignancy in SBS patients undergoing TED treatment is feasible and effective. Total enteroscopy can be frequently achieved with a single endoscopy in these patients, allowing easy oncologic surveillance.

References

1. Revestive (teduglutide). Summary of product characteristics. Takeda; August 2022. Accessed 23 March 2024. https://www. medicines.org.uk/emc/product/3382/smpc
2. Pironi L, Allard JP, Joly F, et al. Use of teduglutide in adults with short bowel syndrome-associated intestinal failure. Nutr Clin Pract 2024;39:141-153.
3. Pevny S, Pape UF, Elezkurtaj S, et al. De Novo Development of Distal Jejunal and Duodenal Adenomas After 41 Months of Teduglutide Treatment in a Patient With Short-Bowel Syndrome: A Case Report. JPEN J Parenter Enteral Nutr 2021;45:652-656.
4. Ukleja A, Alkhairi B, Bejarano P, et al. De Novo Development of Hamartomatous Duodenal Polyps in a Patient With Short Bowel Syndrome During Teduglutide Therapy: A Case Report. JPEN J Parenter Enteral Nutr 2018;42:658-660.

Clinical Case Summary

Intestinal involvement in systemic lupus erythematosus (SLE) is usually due to vasculitis that predominantly affects the small bowel (1, 2). The coexistence of lupus and inflammatory bowel disease (IBD) is uncommon (1), with a prevalence of 0.4% in ulcerative colitis and even lower in Crohn's disease (2). Drug-induced lupus is more common than lupus associated with IBD itself (2). Moreover, when both conditions coexist, it usually involves systemic lupus rather than oligosymptomatic forms (2).
We present a 20-year-old female patient diagnosed with SLE at age 13 with only joint involvement and well-controlled with methotrexate, hydroxychloroquine and oral prednisone that was referred due to diarrhoea with mucus and blood, diffuse abdominal pain and weight loss. A colonoscopy revealed patchy mucosal involvement with deep, medium-sized ulcers in the cecum, left colon, and especially the rectum. The ileum was lesion-free. Histological analysis showed intense acute and chronic inflammatory processes in the colon mucosa, consistent with IBD (clinically suspected Crohn's disease). Signs of vasculitis were not observed. Treatment with oral Mesalamine 3600 mg/day, rectal Mesalamine suppositories and oral corticosteroids led to improved stools, abdominal pain and normalization of inflammatory markers. However, after three months, she was admitted to our hospital due to increased bloody diarrhoea and diffuse abdominal pain, so we decided to treated with infliximab (5 mg/kg). After six months, the patient was asymptomatic with normal laboratory parameters and no signs of inflammatory activity on follow-up colonoscopy.
This case is interesting due to its low prevalence and association with joint-dominant S.L.E. and colonic involvement. Management is similar to CD patients, with positive results seen with infliximab in corticosteroid non-responders (3). The coexistence of both diseases presents a diagnostic and therapeutic challenge that requires multidisciplinary management.

References

1. Jin X;Wang G;Xu X;Bai Y;An R;Jiang D; (2020) Coexistence of crohn's disease and systemic lupus erythematosus: A case report and literature review, European journal of gastroenterology & hepatology. Available at: https://pubmed.ncbi.nlm.nih.gov/32732809/
2. E.V.;, K.K.P. (2012) Inflammatory bowel disease and lupus: A systematic review of the literature, Journal of Crohn's & colitis. Available at: https://pubmed.ncbi.nlm.nih.gov/22504032/
3. Algassim, A. et al. (2021) Systemic lupus erythematosus with crohn's disease: A rare combination and unusual presentation, European Journal of Case Reports in Internal Medicine. Available at: https://www.ejcrim.com/index.php/EJCRIM/article/view/2678