Introduction

Inflammatory bowel diseases (IBD) may impact the daily life in affected patients in various dimensions including quality of life and work productivity. Suboptimal disease management and limited efficacy of available treatment options can cause inadequate disease control (IDC) resulting in disease progression and negative long-term outcomes. Here, we aim to assess the rates of IDC in daily clinical practice and the related economic burden.

Aims & Methods

IBD-PODCAST is a global cross-sectional, multicenter, non-interventional study assessing signs of residual disease activity according to STRIDE II-criteria¹ in patients with ulcerative colitis (UC) or Crohn’s disease (CD). Analysis included patient- and physician-reported measures as well as retrospectively assessed components of the medical record of the last 12 months. In accordance with the recent STRIDE-II recommendations¹, pre-defined indicators (‘red flags’) of IDC were assessed incl. clinical parameters, biomarkers, endoscopy and imaging studies and patient questionnaires such as the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and the Work Productivity and Activity Impairment Questionnaire (WPAI)). In addition, reported Health care resource utilization (HCRU) was assessed.

Results

From 04/2022 to 11/2022, 438 patients with IBD (UC: n=228; CD: n=210) were included at 21 German IBD centers. Parameters of IDC were identified in 43.8% (92/210) CD patients and in 39.9% (91/228) UC patients. More specifically, impaired quality of life (SIBDQ <50) was identified as the most common indicator of IDC, followed by steroid overuse and failure to achieve clinically meaningful improvement (>50% reduction of symptoms since therapy initiation) across both indications. Patients with IDC showed substantial impairments in WPAI such as work time missed (CD: 13.4% IDC vs. 2.6% ADC (adequate disease control) and UC: 10.5% IDC vs. 3.0% ADC). HCRU was substantially increased in the IDC group reflected by increased ER visits, hospitalization and surgery rates.

Table 1. HCRU in patients with IBD according to disease control status

Conclusion

In a substantial proportion of patients with IBD, inadequate disease control was associated with impaired quality of life, lower work productivity and more frequent health care utilization. Our data underlines the continued need for improved disease management and more treatment options in IBD patients.

References

1. Turner D, et al.; International Organization for the Study of IBD. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD. Gastroenterology. 2021 Apr;160(5):1570-1583.

Disclosure

A. Dignass has received fees for participation in clinical trials and for review activities, such as data monitoring boards, statistical analysis and endpoint committees from Abivax, AbbVie, Arena, Celgene/Bristol Myers Squibb, Falk, Gilead, Janssen and Pfizer; consultancy fees from AbbVie, Amgen, Biogen, Boehringer-Ingelheim, Celgene/Bristol Myers Squibb, Celltrion, Falk, Ferring, Fresenius Kabi, Galapagos, Gilead, High5Immunology, Janssen, Lilly, MSD, Pfizer, Pharmacosmos, Roche/Genentech, Sandoz/Hexal, Takeda, Tillotts and Vifor; and payment for lectures including service on speaker bureaus from AbbVie, Amgen, Biogen, CED Service GmbH, Celltrion, Falk Foundation, Ferring, Gilead/Galapagos, Janssen, Lilly, MSD, Onkowissen, Pharmacosmos, Pfizer, Streamed-Up, Takeda, Tillotts and Vifor.
D. Bettenworth is on the advisory board or consultant for AbbVie, Amgen, Arena, Atheneum, BNG Service GmbH, Bristol Myers Squibb, CED-Service GmbH, Celltrion, DGVS, Diaplan, Doctorflix, Else Kröner-Fresenius Foundation, Falk Foundation, Galapagos, Guidepoint, Impulze, Ferring, Janssen Cilag, Lilly, Medical Tribune, MedTriX, MSD, Mylan, Onkowissen, Pharmacosmos, Pfizer, Roche, Sandoz, Takeda, Tetrameros, Thieme, Tillotts Pharma, UCB Biopharma, Viatris and Vifor Pharma.
C. Schmidt obtained consulting fees from AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Ewopharma, Galapagos, Janssen-Cilag, MSD Sharp & Dohme, Norgine, Pfizer, Shield Therapeutics, and Takeda, lecture fees and travel support AbbVie, Alanta Health Group, Berlin Chemie, Biogen, CED Service, Celltrion, Ewopharma, Dr. Falk, Ferring, Galapagos, Janssen-Cilag, med update, Merckle, MSD Sharp & Dohme, Norgine, Novartis, Olympus, Pentax, Pfizer, Shire, Shield Therapeutics, and Takeda, and research support from Abbvie, Pentax and Olympus.
A. Marek and S. Rath are AbbVie employees and may own AbbVie stock or options.
AbbVie sponsored the study; contributed to the design; participated in the collection, analysis, and interpretation of data; in writing, reviewing, and approval of the final version.
The data collection and statistical analysis was supported by Labcorp Drug Development, which was funded by AbbVie.
No honoraria or payments were made for authorship.

Clinical Case Summary

Colorectal lymphomas are a rare cause of colonic neoplasia (0.2-0.6% malignant neoplasms of large bowel). Approximately 10% are primary colorectal lymphomas, while the rest correspond to colonic extension of systemic lymphoproliferative diseases.
We present the case of a 66-year-old woman with a history of rectum and pancreas adenocarcinoma (both in remission). During a follow-up CT, a thickening of the cecal pole was identified, with no adenopathy or other relevant findings (Photo1). The patient had no abdominal pain or B symptoms (night sweats, weight loss or fever).
The diagnosis was completed with a PET-CT that showed pathological uptake in the cecum (Photo2), so a colonoscopy was performed, which revealed a large polypoid lesion (30 mm) at the ileocecal level, with nodular areas with small ulcerations and no clear loss of the glandular pattern (Photo 3), from which multiple biopsies were taken.
Biopsies showed lymphoid proliferation with a ‘starry sky’ pattern, mitosis and apoptosis, and positive immunohistochemistry for CD45, CD20, CD10, BCL6, BCL2 and C-MYC, together with a high proliferation index (Ki-67 > 95%), all compatible with high-grade B-lymphoproliferative syndrome with Burkitt morphology (Photo 4).
Burkitt's lymphoma is a rare B-cell lymphoma (15% of GI lymphomas), associated with chromosomal translocation (8:14, 8:22 and 2:8) and overexpression of c-myc oncogene.
There are three clinical variants: endemic (common in Africa and associated with EBV and malaria), HIV-associated and sporadic (20%).
It is common in children and its most frequent symptoms are abdominal pain and weight loss, so diagnosis is often delayed. Although the yield of endoscopic biopsies is low (<20%), it is a key tool in its diagnosis, along with targeted biopsy of abdominal adenopathies.
Despite its aggressiveness, treatment with targeted chemotherapy achieves rates of more than 90%, and early diagnosis is essential to avoid complications and ensure adequate medical treatment.

References

- Photo 1: Thickening of the cecal pole seen in CT-Scan.
- Photo 2: Pathological uptake in the caecal area as seen on PET-CT Scan.
- Photo 3: Polypoid lesion in ileocecal area at colonoscopy
- Photo 4: Pathological anatomy of endoscopic biopsies: starry sky imaging and immunohistochemistry of Bcl-2 and C-myc

Introduction

Esophageal cancer (EC) is the eight most common cancer worldwide and causes the sixth highest number of deaths per year. The incidence of EC in Norway has increased by over 20 % over the past two decades, and a similar increase is seen in other Western countries. The overall five-year survival is approximately 20 %, which makes it one of the most fatal malignancies. Tumour stage at diagnosis is the main prognostic factor, and an early diagnosis is of most importance to improve survival. Upper endoscopy (UE) with biopsies is the standard procedure for diagnosing EC. However, several studies have questioned the efficacy of UE for diagnosis of esophageal neoplasms. The rate of missed esophageal cancers (MEC) at UE is of concern in many Western countries which have been reported to account for 6.4 to 12.7 % of all ECs. We aimed to calculate the rate of MEC and identify factors associated with MEC in Central Norway.

Aims & Methods

Retrospective population-based cohort study including 625 patients diagnosed with esophageal cancer (EC) in Central Norway 2004-2021. EC cases were identified by a search in the Cancer Registry of Norway, using ICD-10 codes C15x, and contained information about histological diagnosis and tumour localization. The dataset was verified by manual review of electronic patient records. MEC was defined as EC diagnosed 6-36 months after a previous non-diagnostic upper endoscopy. Clinical and disease variables were extracted from patient records. The rate of MEC in Central Norway was calculated annually and for the study period overall. Factors possibly associated with MEC, including tumour localization, histological type, as well as symptoms and findings were recorded. The median time interval from prior UE to date of diagnosis was calculated, as well as biopsy rates of patients with Barrett´s esophagus (BE) and ulcers at the prior UE.

Results

There were 625 patients in the entire cohort. The majority (n=404, 64.6%) were localized in the lower third of the esophagus and were adenocarcinomas (n=356, 57.0%). Fifty-one (8.2%) cancers were MEC. There was a significant increase in annual numbers of EC (p=0.001) and MEC (p=0.007) over the study period, but no increase in MEC rate (p=0.393). MEC patients were older than controls (74.0 years vs. 70.2 years, p=0.038), whereas sex did not differ significantly between MEC and controls. MEC was not associated with localization, sex or histological type. The most common findings at the prior UE were hiatus hernia (n=27, 52.9%), BE (n=26, 51.0%) and esophagitis (n=10, 19.6%), while the most common alarm symptom was gastrointestinal bleeding (n=11, 21.6%). The median time from prior UE to MEC diagnosis was 23.0 (6.2-35.6) months. In all patients with histological dysplasia (n=10) at the prior UE the follow-up interval was longer than recommended in current guidelines. A total of 24% of patients with either BE or an ulceration were not biopsied at UE preceding the MEC diagnosis.

Conclusion

MEC accounted for 8.2% of esophageal cancer in Central Norway. MEC was associated with higher age at diagnosis. There was no association between MEC and histological type or localization and a thorough examination of the entire esophagus is necessary to reduce MEC rates. Inappropriate follow-up of endoscopic BE, histological dysplasia or ulcerations were identified as preventable causes. Awareness of MEC, and more consistent biopsies of ulcerations and BE could reduce the MEC rate.

Disclosure

No conflict of interest.

Introduction

Colorectal carcinoma (CRC) screening strategies traditionally focused on conventional adenomas, but reports have highlighted the significance of serrated polyps, particularly sessile serrated polyps (SSP), in CRC pathogenesis. This study aimed to assess the prevalence, characteristics, and clinical implications of serrated polyps and hyperplastic polyps in our practice.

Aims & Methods

A retrospective analysis covering a decade (2015-2023) of colonoscopy data from our Gastroenterology department was conducted. Inclusion criteria comprised individuals 18 years or older undergoing initial colonoscopies for multiple indications, excluding those with prior colectomies, personal CRC history, or other abdominal tumors. Detailed demographic, procedural, endoscopic, and pathological data were collected and analyzed. Polyp endoscopic characteristics were thoroughly documented, including size, location, type, and pathologic data thoroughly reviewed to identify polyp type and grade of dysplasia.

Results

Among 22,175 colonoscopies reviewed, 5,741 polypectomies with complete histologic and endoscopic data were included. Adenomas comprised the majority, with 3,297 tubular adenomas, 885 tubulo-villous, and 137 villous adenomas. Hyperplastic polyps totaled 1,343, while only 74 were recognized as serrated, primarily located in the proximal colon (90%). Serrated polyps were predominantly sessile (71.6%), flat (24.4%), and pedunculated (4%) in endoscopic report. Reviewing pathology reports revealed 14.6% of serrated polyps exhibiting high-grade dysplasia. Notably, 18% of hyperplastic polyps were proximal to the sigmoid colon, and upon pathological revision, 15.7% were reclassified as serrated polyps.

Conclusion

The prevalence and clinical insights provided shed light on the diagnostic challenges and underscore the importance of accurate identification and management of SSP lesions. Establishing standardized detection metrics for serrated polyps is imperative for enhancing CRC screening efficacy and patient outcomes.

References

1. US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965–1977.
2. Rex DK, Boland CR, Dominitz JA, et al. Colorectal Cancer Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2017; 112:1016.