Screening and surveillance colonoscopy in chronic Crohn's colitis

Personalized Treatment for Crohn's Disease: Current Approaches and Future Directions

Crohn's disease is a complex, relapsing and remitting inflammatory disorder of the gastrointestinal tract with a variable disease course. While the treatment options for Crohn's disease have dramatically increased over the past two decades, predicting individual patient response to treatment remains a challenge. As a result, patients often cycle through multiple different therapies before finding an effective treatment which can lead to disease complications, increased costs, and decreased quality of life. Recently, there has been increased emphasis on personalized medicine in Crohn's disease to identify individual patients who require early advanced therapy to prevent complications of their disease. In this review, we summarize our current approach to management of Crohn's disease by identifying risk factors for severe or disabling disease and tailoring individual treatments to patient-specific goals. Lastly, we outline our knowledge gaps in implementing personalized Crohn's disease treatment and describe the future directions in precision medicine.

Characteristics, Reporting, and Potential Clinical Significance of Nonconventional Dysplasia in Inflammatory Bowel Disease

The term nonconventional dysplasia has been coined to describe several underrecognized morphologic patterns of epithelial dysplasia in inflammatory bowel disease (IBD), but to date, the full recognition of these newly characterized lesions by pathologists is uneven. The identification of nonconventional dysplastic subtypes is becoming increasingly important, as they often present as invisible/flat dysplasia and are more frequently associated with advanced neoplasia than conventional dysplasia on follow-up. This review describes the morphologic, clinicopathologic, and molecular characteristics of seven nonconventional subtypes known to date, as well as their potential significance in the clinical management of IBD patients.

Robot-assisted laparoscopic abdominoperineal resection for anal canal cancer associated with Crohn's disease: A case report

A 37-year-old man with Crohn's disease (CD) and a history of abdominal surgery was diagnosed with anal canal cancer. Robot-assisted laparoscopic abdominoperineal resection was performed and the patient was discharged without any postoperative complications. Recently, minimally invasive surgery for CD patients has grown in popularity. However, there have been few studies of robotic surgery for CD patients with anal canal cancer. To the best of our knowledge, we present the first report of a patient with CD-associated anal canal cancer who underwent robot-assisted laparoscopic abdominoperineal resection.

High-Grade Dysplasia in Inflammatory Bowel Disease: Indication for Colectomy

BACKGROUND

Patients with inflammatory bowel disease have an increased risk of colorectal cancer and are recommended to undergo increased surveillance compared to the general population. Currently, inadequate evidence exists to guide management of colonic dysplasia discovered during screening of inflammatory bowel disease patients.

OBJECTIVE

The goal of this study was to determine the risk of colorectal cancer in patients with ulcerative colitis or Crohn's disease with dysplasia on colonoscopy.

DESIGN

This was a retrospective study.

SETTING

This study was conducted at a high-volume, quaternary referral center with an inflammatory bowel disease program.

PATIENTS

Patients with a diagnosis of inflammatory bowel disease with colonoscopy within 6 months of colectomy were included.

MAIN OUTCOME MEASURES

The primary outcome measures included finding of colorectal cancer at time of colectomy.

RESULTS

There were 621 patients, 233 with ulcerative colitis and 388 with Crohn's disease. Of ulcerative colitis patients, 25 had low-grade dysplasia on colonoscopy with 1 (4%) found to have colorectal cancer at colectomy. High-grade dysplasia was noted preoperatively in 14 and colorectal cancer was found in 4 (29%) after colectomy. Compared to no dysplasia, low-grade dysplasia did not increase the risk of colorectal cancer (OR 1.98, p = 0.47), but high-grade dysplasia had an increased risk (OR 19.0, p < 0.001) of colorectal cancer. For the 7 patients with Crohn's disease and low-grade dysplasia, colorectal cancer was found in 1 patient (14%) at colectomy. High-grade dysplasia was noted preoperatively in 4 patients with Crohn's Disease, and colorectal cancer was found in 3 patients (75%) after colectomy. Compared to no dysplasia, low-grade dysplasia did not increase the risk of colorectal cancer (OR 12.4, p = 0.88), but high-grade dysplasia did increase the risk of colorectal cancer (OR 223.2, p < 0.001).

LIMITATIONS

This study was limited by its retrospective review.

CONCLUSION

In both ulcerative colitis and Crohn's disease, low-grade dysplasia was not associated with colorectal cancer. High-grade dysplasia was associated with an increased risk of colorectal cancer at time of colectomy. While continued surveillance may be appropriate for low-grade dysplasia, high-grade dysplasia necessitates surgical resection given the high likelihood of colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B887 .

DISPLASIA DE ALTO GRADO EN LA ENFERMEDAD INFLAMATORIA INTESTINAL INDICACIN DE COLECTOMA

ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal tienen un mayor riesgo de cáncer colorrectal y se recomienda someterse a una mayor vigilancia en comparación con la población general. Actualmente, existe evidencia inadecuada para guiar el manejo de la displasia colónica descubierta durante la valoracion de pacientes con enfermedad inflamatoria intestinal.OBJETIVO:Determinar el riesgo de cáncer colorrectal en pacientes con colitis ulcerosa o enfermedad de Crohn con displasia en la colonoscopia.DISEÑO:Este fue un estudio retrospectivo.AJUSTE:Este estudio se llevó a cabo en un centro de referencia cuaternario de alto volumen con un programa de enfermedad inflamatoria intestinal.PACIENTES:Pacientes con diagnóstico de enfermedad inflamatoria intestinal con colonoscopia dentro de los 6 meses posteriores a la colectomía.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado incluyeron el hallazgo de cáncer colorrectal en el momento de la colectomía.RESULTADOS:Hubo 621 pacientes: 233 con colitis ulcerosa y 388 con enfermedad de Crohn. De los pacientes con colitis ulcerosa, 25 tenían displasia de bajo grado en la colonoscopia y 1 (4%) tenía cáncer colorrectal en la colectomía. Se observó displasia de alto grado antes de la operación en 14 y cáncer colorrectal en 4 (29%) después de la colectomía. En comparación con la ausencia de displasia, la displasia de bajo grado no aumentó el riesgo de cáncer colorrectal (Odds Ratio 1,98, p = 0,47), pero la displasia de alto grado tuvo un mayor riesgo (OR 19,0, p <0,001) de cáncer colorrectal. Para los 7 pacientes con enfermedad de Crohn y displasia de bajo grado, se encontró cáncer colorrectal en 1 (14%) en la colectomía. Se observó displasia de alto grado antes de la operación en 4 pacientes con enfermedad de Crohn y cáncer colorrectal en 3 pacientes (75%) después de la colectomía. En comparación con la ausencia de displasia, la displasia de bajo grado no aumentó el riesgo de cáncer colorrectal (Odds Ratio 12.4, p = 0.88), pero la displasia de alto grado sí aumentó el riesgo de cáncer colorrectal (Odds Ratio 223.2, p <.001).LIMITACIONES:Este estudio estuvo limitado por su revisión retrospectiva.

CONCLUSIN

Tanto en la colitis ulcerosa como en la enfermedad de Crohn, la displasia de bajo grado no se asoció con el cáncer colorrectal. La displasia de alto grado se asoció con un mayor riesgo de cáncer colorrectal en el momento de la colectomía. Si bien la vigilancia continua puede ser apropiada para la displasia de bajo grado, la displasia de alto grado requiere resección quirúrgica dada la alta probabilidad de cáncer colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B887 . (Traducción-Dr Yolanda Colorado ).

Intestinal Cancer and Dysplasia in Crohn's Disease

Crohn's disease is associated with an increased risk of adenocarcinoma of the involved portions of the small bowel and colorectum and has similar risk factors to those described in ulcerative colitis, most significantly, extent of bowel involvement, PSC, and duration of unresected disease. Prevention strategies include risk stratification and secondary prevention with colonoscopic screening and surveillance to identify dysplasia or early-stage cancers, with surgery when needed. There is emerging information to suggest that control of inflammation may provide primary prevention of neoplasia, but further studies are required to test this strategy.

Clinicopathologic Features of Undetected Dysplasia Found in Total Colectomy or Proctocolectomy Specimens of Patients with Inflammatory Bowel Disease

AIMS

It remains controversial as to whether targeted biopsies should completely replace random biopsies for dysplasia surveillance in patients with inflammatory bowel disease (IBD). Several histologic patterns of non-conventional dysplasia have been described in IBD. This study aimed to investigate the rate and clinicopathologic features of dysplastic lesions found in total colectomy or proctocolectomy specimens that were undetected on prior colonoscopy.

METHODS AND RESULTS

The study analyzed 207 consecutive IBD patients who underwent a total colectomy or proctocolectomy and had at least one high definition colonoscopy prior to colectomy. Dysplasia found in the colectomy specimens was classified as undetected, only when there was no corresponding site of dysplasia detected on previous colonoscopic biopsies. Twenty-seven (13%) patients had 49 undetected dysplastic lesions found only at colectomy, while 22 (11%) had 31 previously detected dysplastic lesions only. The remaining 158 (76%) patients had no dysplasia. A greater proportion of the undetected (19%) or previously detected (23%) dysplasia group had concurrent primary sclerosing cholangitis compared with only 3% in the group without dysplasia (p < 0.001). The undetected dysplastic lesions were more likely to have non-conventional dysplastic features (76%), low-grade dysplasia (94%), and a flat/invisible gross appearance (73%) compared with the previously detected dysplastic lesions (13%, 68%, and 48%, respectively) (p < 0.05). Almost all patients with undetected dysplasia (93%) had a colonoscopy within 1 year of colectomy.

CONCLUSIONS

The rate of undetected dysplasia is not insignificant (13%), suggesting that increased random biopsies may improve the rate of dysplasia detection, including non-conventional dysplasia.

Inflammatory bowel disease-related colorectal cancer: Past, present and future perspectives

Inflammatory bowel disease-related colorectal cancer (IBD-CRC) is one of the most serious complications of IBD contributing to significant mortality in this cohort of patients. IBD is often associated with diet and lifestyle-related gut microbial dysbiosis, the interaction of genetic and environmental factors, leading to chronic gut inflammation. According to the “common ground hypothesis”, microbial dysbiosis and intestinal barrier impairment are at the core of the chronic inflammatory process associated with IBD-CRC. Among the many underlying factors known to increase the risk of IBD-CRC, perhaps the most important factor is chronic persistent inflammation. The persistent inflammation in the colon results in increased proliferation of cells necessary for repair but this also increases the risk of dysplastic changes due to chromosomal and microsatellite instability. Multiple pathways have been identified, regulated by many positive and negative factors involved in the development of cancer, which in this case follows the ‘inflammation-dysplasia-carcinoma’ sequence. Strategies to lower this risk are extremely important to reduce morbidity and mortality due to IBD-CRC, among which colonoscopic surveillance is the most widely accepted and implemented modality, forming part of many national and international guidelines. However, the effectiveness of surveillance in IBD has been a topic of much debate in recent years for multiple reasons — cost-benefit to health systems, resource requirements, and also because of studies showing conflicting long-term data. Our review provides a comprehensive overview of past, present, and future perspectives of IBD-CRC. We explore and analyse evidence from studies over decades and current best practices followed globally. In the future directions section, we cover emerging novel endoscopic techniques and artificial intelligence that could play an important role in managing the risk of IBD-CRC.

Systematic review with meta-analysis: incidence and factors for progression to advanced neoplasia in inflammatory bowel disease patients with indefinite and low-grade dysplasia

BACKGROUND

Due to limited research on the natural history of indefinite for dysplasia (IND) and low-grade dysplasia (LGD) in inflammatory bowel disease (IBD), the management of these patients is controversial.

AIMS

This systematic review and meta-analysis aimed to estimate the incidence and identify the risk factors for advanced neoplasia in IBD patients with IND and LGD.

METHODS

PubMed, Embase and Cochrane Central Register of Controlled Trials were searched until 24 December, 2021, to identify studies that reported pathological results of follow-up colonoscopy or surgery in IBD patients with IND and LGD. The main outcomes were the incidence and risk factors for advanced neoplasia in IBD patients with IND and LGD.

RESULTS

Based on the analysis of 38 studies, the pooled incidences of advanced neoplasia in IBD patients with IND and LGD were 9.9% (95% CI 4.4%-15.4%) and 10.7% (95% CI 7.0%-14.4%) respectively. The risk factors for advanced neoplasia in IND patients were primary sclerosing cholangitis (PSC) and aneuploidy. The risk factors for advanced neoplasia in LGD patients included male, PSC, previous IND, colonic stricture, index lesion ≥1 cm, distal location, multifocal lesions, distal and flat lesions, nonpolypoid/flat lesions and invisible lesions.

CONCLUSIONS

The incidence of advanced neoplasia was similar between IND and LGD in IBD patients, as high as one in ten, so more rigorous surveillance is also suggested in IND patients. Since the effects of most factors were derived from the pooled results of only two to three studies, further research was needed to confirm our results.

Revisiting fibrosis in inflammatory bowel disease: the gut thickens

Intestinal fibrosis, which is usually the consequence of chronic inflammation, is a common complication of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. In the past few years, substantial advances have been made in the areas of pathogenesis, diagnosis and management of intestinal fibrosis. Of particular interest have been inflammation-independent mechanisms behind the gut fibrotic process, genetic and environmental risk factors (such as the role of the microbiota), and the generation of new in vitro and in vivo systems to study fibrogenesis in the gut. A huge amount of work has also been done in the area of biomarkers to predict or detect intestinal fibrosis, including novel cross-sectional imaging techniques. In parallel, researchers are embarking on developing and validating clinical trial end points and protocols to test novel antifibrotic agents, although no antifibrotic therapies are currently available. This Review presents the state of the art on the most recently identified pathogenic mechanisms of this serious IBD-related complication, focusing on possible targets of antifibrotic therapies, management strategies, and factors that might predict fibrosis progression or response to treatment.

The Significance of Flat/Invisible Dysplasia and Nonconventional Dysplastic Subtypes in Inflammatory Bowel Disease: A Review of Their Morphologic, Clinicopathologic, and Molecular Characteristics

Patients with inflammatory bowel disease are at significantly increased risk of dysplasia and colorectal cancer (CRC). The early detection, histologic grading, and removal of dysplasia plays a critical role in preventing the development of CRC. With advances in endoscopic visualization and resection techniques, colectomy is no longer recommended to manage dysplasia, unless surveillance colonoscopy detects flat/invisible dysplasia (either high-grade dysplasia or multifocal low-grade dysplasia) or an endoscopically unresectable lesion. Although there are numerous review articles and book chapters on the morphologic criteria of conventional (intestinal type) dysplasia, the most well-recognized form of dysplasia, at least 7 distinct nonconventional morphologic patterns of epithelial dysplasia have been recently described in inflammatory bowel disease. Most practicing pathologists are not familiar with these nonconventional subtypes and thus, may even overlook some of these dysplastic lesions as benign or reactive. However, the recognition of these subtypes is important, as some of them appear to have a high risk of developing advanced neoplasia (high-grade dysplasia or CRC) and often show molecular alterations characteristic of advanced neoplasia. This review briefly describes the morphologic criteria of conventional dysplasia but predominantly focuses on all 7 nonconventional subtypes as well as our understanding of their clinicopathologic and molecular features that can assist in their risk stratification.

Identification of potential biomarkers with colorectal cancer based on bioinformatics analysis and machine learning

Colorectal cancer (CRC) is one of the most common malignancies worldwide. Biomarker discovery is critical to improve CRC diagnosis, however, machine learning offers a new platform to study the etiology of CRC for this purpose. Therefore, the current study aimed to perform an integrated bioinformatics and machine learning analyses to explore novel biomarkers for CRC prognosis. In this study, we acquired gene expression microarray data from Gene Expression Omnibus (GEO) database. The microarray expressions GSE103512 dataset was downloaded and integrated. Subsequently, differentially expressed genes (DEGs) were identified and functionally analyzed via Gene Ontology (GO) and Kyoto Enrichment of Genes and Genomes (KEGG). Furthermore, protein protein interaction (PPI) network analysis was conducted using the STRING database and Cytoscape software to identify hub genes; however, the hub genes were subjected to Support Vector Machine (SVM), Receiver operating characteristic curve (ROC) and survival analyses to explore their diagnostic values. Meanwhile, TCGA transcriptomics data in Gene Expression Profiling Interactive Analysis (GEPIA) database and the pathology data presented by in the human protein atlas (HPA) database were used to verify our transcriptomic analyses. A total of 105 DEGs were identified in this study. Functional enrichment analysis showed that these genes were significantly enriched in biological processes related to cancer progression. Thereafter, PPI network explored a total of 10 significant hub genes. The ROC curve was used to predict the potential application of biomarkers in CRC diagnosis, with an area under ROC curve (AUC) of these genes exceeding 0.92 suggesting that this risk classifier can discriminate between CRC patients and normal controls. Moreover, the prognostic values of these hub genes were confirmed by survival analyses using different CRC patient cohorts. Our results demonstrated that these 10 differentially expressed hub genes could be used as potential biomarkers for CRC diagnosis.

Telenutrition for Inflammatory Bowel Disease: A Tipping Point for Dietary Wellness

Inflammatory bowel disease (IBD), Crohn’s disease and ulcerative colitis, cause inflammation of the digestive tract. It is estimated that about three million Americans and, globally, over six million individuals, suffer from IBD. While most physicians, especially gastroenterologists, are experts in the function and pathology of the gastrointestinal tract, factors such as nutrition science education and training, bandwidth, culture, language, and the longitudinal nature of dietary care, represent some of the barriers to receiving optimal nutritional guidance. Remote dietary expert counseling, an emerging solution that has been further highlighted by the COVID-19 pandemic, can improve IBD patients’ nutritional status, avoid food triggers, and reduce the frequency and severity of exacerbations.

Inflammatory bowel disease (IBD), Crohn’s disease and ulcerative colitis, causes inflammation of the digestive tract. Remote nutritional expert care can improve IBD patients’ nutritional status, avoid food triggers, and reduce the frequency and severity of exacerbations.

Biomolecular imaging of colorectal tumor lesions using a FITC-labeled scFv-Cκ fragment antibody

For the sensitive diagnosis of colorectal cancer lesions, advanced molecular imaging techniques using cancer-specific targets have emerged. However, issues regarding the clearance of unbound probes and immunogenicity remain unresolved. To overcome these limitations, we developed a small-sized scFv antibody fragment conjugated with FITC for the real-time detection of colorectal cancer by in vivo molecular endoscopy imaging. A small-sized scFv fragment can target colon cancer secreted protein-2 (CCSP-2), highly expressed in colorectal adenocarcinoma tissues; moreover, its full-length IgG probe has been used for molecular imaging previously. To assess the efficacy of anti-CCSP-2 scFv-FITC, surgical specimens were obtained from 21 patients with colorectal cancer for ex vivo molecular fluorescence analysis, histology, and immunohistochemistry. Orthotopic mice were administered with anti-CCSP-2 scFv-FITC topically and intravenously, and distinct tumor lesions were observed by real-time fluorescence colonoscopy. The fluorescence imaging of human colon cancer specimens allowed the differentiation of malignant tissues from non-malignant tissues (p < 0.05), and the CCSP-2 expression level was found to be correlated with the fluorescence intensity. Here, we demonstrated the feasibility and safety of anti-CCSP-2 scFv-FITC for molecular imaging as well as its potential in real-time fluorescence colonoscopy for the differential diagnosis of tumor lesions.

Colorectal cancer in Crohn's disease: a series of 6 cases

Background

Colorectal cancer (CRC) is the most malignant complication in patients with Crohn’s disease (CD). We report 6 cases of CD-related CRC treated surgically at our hospital.

Case presentation

From 2010 to 2016, six CD patients were diagnosed with CRC. All patients were diagnosed with CD at < 25 years old, and the interval from onset of CD to diagnosis of CRC was > 10 years (range, 15–42 years) in all patients. The histological type of cancer was mucinous carcinoma in two cases, well-differentiated tubular adenocarcinoma in two cases, and moderately differentiated tubular adenocarcinoma in two cases. CRC was detected by screening colonoscopy in three cases (50%), and from clinical symptoms in the remaining three cases (50%). Two cases underwent colonoscopy within 2 months after symptom onset, detecting CRC in the relatively early stage. However, one case was diagnosed with advanced-stage CRC by endoscopy 1 year after symptom onset, and experienced poor prognosis.

Conclusions

Regular surveillance colonoscopy is needed to detect early-stage CRC in CD patients. Clear surveillance methods need to be established based on evidence.

Clinicopathological and prognostic evaluations of anorectal cancer after fecal diversion for patients with Crohn's disease

PURPOSE

Colorectum diversion with a proximal stoma is often the preferred surgical approach in patients with Crohn's disease-related anorectal lesions or refractory colitis. To date, few studies have assessed the incidence and prognosis of cancer in the diverted anorectal segments. This study aimed to evaluate the clinical characteristics and prognosis of anorectal cancer associated with Crohn's disease following fecal diversion.

METHODS

This was a retrospective study based on medical records of patients diagnosed with Crohn's disease between 1999 and 2020. It was conducted at Yokohama Municipal Citizen's Hospital. Patients diagnosed with anorectal cancer following fecal diversion were identified, and their prognosis was the primary outcome measure.

RESULTS

Among 1615 patients, 232 patients (14%) underwent colorectum diversion. Of those 232 patients, 11 were diagnosed with anorectal cancer following fecal diversion, ten were diagnosed with advanced cancer, 10 underwent abdominoperineal resection, and eight died. 1 could not undergo resection due to multiple lung metastasis and died. The overall five-year survival rate in patients diagnosed with anorectal cancer following fecal diversion was 20%.

CONCLUSION

Crohn's disease-associated anorectal cancer following fecal diversion was challenging to diagnose early, and patients had a poor prognosis even after curative resection. Early abdominoperineal resection may be considered for patients with Crohn's disease who cannot benefit from cancer screening and surveillance due to difficulty accessing the anorectal stricture via endoscopy.

Non-conventional dysplastic subtypes in inflammatory bowel disease: a review of their diagnostic characteristics and potential clinical implications

The early detection and grading of dysplasia is the current standard of care to minimize mortality from colorectal cancer (CRC) in patients with inflammatory bowel disease. With the development of advanced endoscopic resection techniques, colectomy is now reserved for patients with invisible/flat dysplasia (either high-grade [HGD] or multifocal low-grade dysplasia) or endoscopically unresectable lesions. Although most pathologists are familiar with the morphologic criteria of conventional (intestinal type) dysplasia, the most well-recognized form of dysplasia, an increasing number of diagnostic material has led to the recognition of several different morphologic patterns of epithelial dysplasia. The term “non-conventional” dysplasia has been coined to describe these changes, but to date, the recognition and full appreciation of these novel forms of dysplasia by practicing pathologists is uneven. The recognition of these non-conventional subtypes is becoming increasingly important, as some of them appear to have a higher risk of developing HGD or CRC than conventional dysplasia or sporadic adenomas. This review describes the morphologic characteristics of all seven non-conventional subtypes that have been reported to date as well as our current understanding of their clinicopathologic and molecular features that distinguish them from conventional dysplasia or sporadic adenomas.

Colorectal cancer in Crohn's colitis is associated with advanced tumor invasion and a poorer survival compared with ulcerative colitis: a retrospective dual-center study

PURPOSE

Colorectal cancer is a well-recognized complication of inflammatory bowel diseases (IBD), such as ulcerative colitis (UC) and Crohn's colitis (CC). In this study, we assess the clinico-pathological features and outcomes of patients with colorectal cancer from UC in comparison with CC.

METHODS

Data of all patients with colitis-associated cancer (CAC) who underwent surgery at Erlangen or Würzburg University Clinic between 1995 and 2015 were selected. Clinical, histopathological, and survival data were analyzed retrospectively.

RESULTS

Of all 88 patients with CAC, 20 patients had Crohn's colitis and 68 patients had ulcerative colitis. We observed a young median age at tumor diagnosis (49.5 years UC; 45.5 years CC, p = 0.208) in both diseases and a long median disease duration before CAC (19 years UC; 18 years CC; p = 0.840). Patients with CC suffered more often from rectal cancer (14 (70.0%) in CC; 23 (33.8%) in UC; p = 0.005) and advanced tumor stages (8 (47.0%) pT4 in CC; 14 (25.0%) pT4/ypT4 in UC; p = 0.008). Five-year overall survival rate was 39.3% for CC and 67.1% for UC (p = 0.009 for difference between the groups). Survival did not differ significantly between UC and CC in the multivariate analysis after correction for UICC tumor stage.

CONCLUSION

CAC in CC showed advanced tumor stages associated with reduced survival compared with CAC in UC. This may be explained by less intense surveillance in patients with CC leading to delayed cancer diagnosis.

Anorectal Cancer in Crohn's Disease Has a Poor Prognosis Due to its Advanced Stage and Aggressive Histological Features: a Systematic Literature Review of Japanese Patients

BACKGROUND

Patients with Crohn's disease (CD) are generally known to be at an increased risk of cancer. The anorectal area is the most frequent cancer site in Japanese CD patients. However, the risks are not well defined. The aim of this study was to clarify the clinicopathological characteristics of Japanese CD-associated anorectal carcinoma patients and to explore screening methods for the detection of cancer at earlier stages.

METHODS

A systematic review of case series and reports of Japanese CD-associated anorectal cancer patients published between 1983 and 2016 was conducted.

RESULT

There were 144 cases of cancer arising from anorectal lesions of CD. The median duration from the onset of CD to the cancer diagnosis was approximately 17 (0-39) years. The most prevalent histological type of cancer was mucinous carcinoma (49.3%), and 82.1% of patients were over T3 invasion. There were only 15.6% cases with early stage disease. A total of 82% patients had enhanced symptoms, whereas 56.3% of the early cancer cases had no symptomatic changes. Approximately 90% of cases were diagnosed preoperatively, and almost all early cancer patients were diagnosed with colonoscopy. The 5-year overall survival rate was 35.8%.

CONCLUSION

CD-associated anorectal carcinoma had a poor prognosis due to the advanced stage of the cases and aggressive histological features. As earlier-stage cancer is associated with a better prognosis than advanced stage disease, and it is also typically diagnosed by colonoscopy, surveillance colonoscopy may therefore help to improve the prognosis in cases without any symptomatic changes.

Association between psoriasis, psoriatic arthritis and gastrointestinal disease : An exploratory nationwide inpatient sample analysis

BACKGROUND

Psoriasis is associated with cardiovascular disease, inflammatory bowel disease (IBD), metabolic syndrome, and psychiatric disease. Furthermore, psoriasis is associated with immune dysregulation and systemic inflammation.

OBJECTIVE

To determine the association of psoriasis and psoriatic arthritis with IBD and the association of the combination of psoriasis or psoriatic arthritis with IBD and other gastrointestinal illnesses.

METHODS

Discharge data from the 2000-2014 Nationwide Inpatient Sample, Healthcare Cost and Utilization Project (HCUP), which approximates a 20% stratified sample of all US hospitalizations, were analyzed. Multivariable logistic regression was used to examine the association between psoriasis and psoriatic arthritis with IBD and 23 gastrointestinal illnesses adjusting for sociodemographic characteristics.

RESULTS

Psoriasis was associated with IBD (Crohn's disease adjusted odds ratio (aOR) = 2.13, 95% confidence interval (CI) [2.0-2.3], p < 0.001). When adjusting for sociodemographics and IBD, psoriasis was associated with 21 of 23 gastrointestinal diseases examined, most notably celiac disease, autoimmune hepatitis, and non-alcoholic fatty liver disease. Psoriatic arthritis was also associated with IBD (Crohn's disease, aOR = 1.95, 95% CI [1.7-2.2], and ulcerative colitis, aOR = 2.66, 95% CI [2.4-2.9]).

CONCLUSION

Psoriasis and psoriatic arthritis inpatients have an associated increase in IBD and numerous other gastrointestinal illnesses.

Baicalein suppresses the proliferation and invasiveness of colorectal cancer cells by inhibiting Snail‑induced epithelial‑mesenchymal transition

Scutellaria baicalensis (S. baicalensis) is a plant that is widely used for medicinal purposes. Baicalein, one of the primary bioactive compounds found in S. baicalensis, is thought to possess antitumor activity, although the specific mechanisms remain unclear. Therefore, the present study aimed to evaluate the ability of baicalein to disrupt the proliferation and metastatic potential of colorectal cancer (CRC) cells; a rapid and sensitive ultra-high performance liquid chromatography-tandem mass spectrometric method was employed for the identification of baicalein in an S. baicalensis aqueous extract and in rat plasma. To investigate the effects of baicalein, Cell Counting Kit-8 (CCK-8), western blotting, wound-healing and Transwell assays were performed. The data indicated that baicalein was absorbed into the blood and was able to effectively disrupt the proliferation, migration and invasion abilities of CRC cells in a dose- and time-dependent manner. Baicalein treatment was also revealed to decrease the expression of epithelial-mesenchymal transition (EMT)-promoting factors including vimentin, Twist1, and Snail, but to upregulate the expression of E-cadherin in CRC cells. The expression levels of cell cycle inhibitory proteins p53 and p21 also increased following baicalein treatment. In addition, Snail-induced vimentin and Twist1 upregulation, as well as E-cadherin downregulation, were reversed following treatment with baicalein. In conclusion, the results of the present study indicate that baicalein may suppress EMT, at least in part, by decreasing Snail activity.

Can Nrf2 Modulate the Development of Intestinal Fibrosis and Cancer in Inflammatory Bowel Disease?

One of the main mechanisms carried out by the cells to counteract several forms of stress is the activation of the nuclear factor erythroid 2-related factor (Nrf2) signaling. Nrf2 signaling controls the expression of many genes through the binding of a specific cis-acting element known as the antioxidant response element (ARE). Activation of Nrf2/ARE signaling can mitigate several pathologic mechanisms associated with an autoimmune response, digestive and metabolic disorders, as well as respiratory, cardiovascular, and neurodegenerative diseases. Indeed, several studies have demonstrated that Nrf2 pathway plays a key role in inflammation and in cancer development in many organs, including the intestine. Nrf2 appears to be involved in inflammatory bowel disease (IBD), an immune-mediated chronic and disabling disease, with a high risk of developing intestinal fibrotic strictures and cancer. Currently, drugs able to increase cytoprotective Nrf2 function are in clinical trials or already being used in clinical practice to reduce the progression of some degenerative conditions. The role of Nrf2 in cancer development and progression is controversial, and drugs able to inhibit abnormal levels of Nrf2 are also under investigation. The goal of this review is to analyze and discuss Nrf2-dependent signals in the initiation and progression of intestinal fibrosis and cancers occurring in IBD.

Mkp-1 is required for chemopreventive activity of butylated hydroxyanisole and resveratrol against colitis-associated colon tumorigenesis

Many dietary compounds show promising protective activity against colon cancer by activating nuclear factor-erythroid 2 related factor 2 (Nrf2). Recently, we reported that mitogen-activated protein kinase phosphatase 1 (Mkp-1) exhibits crosstalk with the Nrf2 signaling pathway, protecting against intestinal inflammation. Here, we present evidence that Mkp-1 is required for the chemopreventive action of the Nrf2 activators butylated hydroxyanisole (BHA) and resveratrol (RSV). In an azoxymethane/dextran sulfate sodium model of colitis-associated tumorigenesis, Mkp-1^-/- mice exhibited a phenotype similar to Nrf2^-/- mice with significantly more tumors than WT mice. Tumors from Mkp-1^-/- mice exhibited higher levels of macrophage infiltration than those from WT mice. This was accompanied by increased expression of nitrotyrosine and p53BP1, markers of oxidative stress and DNA damage, respectively. Moreover, dietary suppression of tumorigenesis using BHA (0.5%) or RSV (300 ppm) supplementation was achieved in WT but not in Mkp-1^-/- mice. In adenomas from WT mice, the expression of Mkp-1 was markedly lower than in adjacent normal tissue, concomitant with the down-regulation of Nrf2 and its target genes. Our data revealed that Mkp-1 is required in the protective role of Nrf2 signaling against colitis-associated tumorigenesis.

Anorectal cancer surveillance in Crohn's disease

OBJECTIVES

One of the characteristics of colorectal cancer complicating Crohn's disease (CD) in the Japanese population is that it frequently occurs in the lower anorectal site. This study aimed to examine CD patients biopsied in the lower anorectal sites to investigate the significance and problems associated with this method of cancer surveillance.

METHODS

Among 116 patients with CD duration of ≥10 years, we examined patients diagnosed with cancer using histological examination of the lower anorectal site (287 times). We also evaluated the detection rates of cancer and atypical cells using this method.

RESULTS

Of the 116 patients, neoplastic lesions were detected through biopsy in 22 (19.0%), of which 18 had carcinomas and 4 had atypical cells. The clinicopathological traits of the cancer patients were early-age onset and chronic disease duration of CD before cancer diagnosis. Histologic findings were characterized by a high frequency of poorly differentiated adenocarcinoma and mucinous carcinoma. The 18 patients with cancer were assigned to groups A and B depending on the presence or absence of cancer-related symptoms, and their characteristics were compared. Of these, 5 patients whose cancer was detected without symptoms (group A) had better prognosis than those detected with symptoms (group B) based on survival curves. We next examined 103 patients for surveillance after excluding 13 patients who were diagnosed with cancer-related symptoms from the 116 patients and found a 5.8% (6 patients) detection rate of cancer and atypical cells.

CONCLUSIONS

Our results suggest the effectiveness of transanal histological testing for the surveillance of anorectal cancer with CD.

Mkp-1 cross-talks with Nrf2/Ho-1 pathway protecting against intestinal inflammation

Inflammatory bowel disease (IBD) is associated with intense oxidative stress, contributes to colonic damage and tumorigenesis. Mitogen-activated protein kinase phosphatase 1 (Mkp-1) is an essential negative regulator of the innate immune response. However, its role in colitis, and its association with the nuclear factor-erythroid 2 related factor 2 (Nrf2), a master regulator of cytoprotection program against oxidative stress, in inflammatory response, is elusive. In this study, we found that increased expression of Mkp-1, Nrf2, and heme oxygenase 1 (Ho-1) was correlated in colonic tissues in patients with ulcerative colitis and Crohn's disease, as well as wild-type mice with colitis induced by dextran sodium sulfate (DSS). Mkp-1^-/- mice were more susceptible to DSS-induced colitis with more severe crypt injury and inflammation. Mechanistically, directly interacting with the DIDLID motif of Nrf2, Mkp-1 increased Nrf2 stability and positively regulated the constitutive and lipopolysaccharide (LPS)-inducible Nrf2/Ho-1 expression. Conversely, upon exposure to LPS, Nrf2 activated Mkp-1 transcription through the antioxidant response elements in the promoter of Mkp-1. Our results revealed a novel link between Mkp-1 and Nrf2 signaling pathways in protecting against colonic inflammation. Mkp-1 might be a therapeutic target for IBD.

DALM, rest in peace: a pathologist's perspective on dysplasia in inflammatory bowel disease in the post-DALM era

There are few abbreviations in surgical pathology that are associated with as much immediate recognition, frustration, and confusion as DALM (dysplasia-associated lesion or mass). DALM is used to describe endoscopically visible dysplastic lesions in the surveillance of patients with inflammatory bowel disease. However, the diagnosis of DALM has been complicated by the inconsistent criteria and use of terminology for describing dysplasia in inflammatory bowel disease, and a tendency to relate DALM with the need for colectomy. Fortunately, advancements in both endoscopic visualization and local excision capability have allowed for a more defined management of dysplasia in inflammatory bowel disease. In 2015, the Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients International Consensus Recommendations (SCENIC) Development Panel, a panel of predominantly expert gastroenterologists and endoscopists in surveillance of inflammatory bowel disease, published a consensus statement. One recommendation was to abandon DALM-related terminology in favor of endoscopic descriptors modified from the Paris endoscopic classification. Recommendations on surveillance and management of dysplastic lesions were also provided. Nevertheless, interval carcinomas and metachronous neoplasia remain persistent issues. This review aims to provide an update on the post-DALM terminology and management recommendations for inflammatory bowel disease-associated dysplasia necessary for a meaningful communication between pathologists and clinicians.

Evidence-based clinical practice guidelines for inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn's disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.

Strategies for detecting colon cancer in patients with inflammatory bowel disease

BACKGROUND

Patients with longstanding ulcerative colitis and colonic Crohn's disease have an increased risk of colorectal cancer (CRC) compared with the general population. This review assessed the evidence that endoscopic surveillance may prolong life by allowing earlier detection of CRC or its pre-cursor lesion, dysplasia, in patients with inflammatory bowel disease (IBD).

OBJECTIVES

To assess the effectiveness of cancer surveillance programs for diagnosis of IBD-associated colorectal cancer and in reducing the mortality rate from colorectal cancer in patients with IBD.

SEARCH METHODS

We searched MEDLINE, EMBASE, CENTRAL and clinical clinicaltrials.gov from inception to 19 September 2016. We also searched conference abstracts and reference lists to identify additional studies.

SELECTION CRITERIA

Potentially relevant articles were reviewed independently and unblinded by two authors to determine eligibility. Randomised controlled trials (RCTs) or observational studies (cohort or case control) assessing any form of endoscopic surveillance aimed at early detection of CRC were considered for inclusion. Studies had to have a no surveillance comparison group to be eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Eligible studies were reviewed in duplicate and the results of the primary research trials were independently extracted by two authors. The primary outcome was detection of CRC. Secondary outcomes included death from CRC, time to cancer detection, time to death and adverse events. Deaths from CRC were derived from life tables, survival curves or where possible, by calculating life tables from the data provided. The presence of significant heterogeneity among studies was tested by the chi-square test. Because this is a relatively insensitive test, a P value of less than 0.1 was considered statistically significant. Provided statistical heterogeneity was not present, the fixed effects model was used for the pooling of data. The 2x2 tables were combined into a summary test statistic using the pooled odds ratio (OR) and 95% confidence intervals as described by Cochrane and Mantel and Haenszel. The methodological quality of the included studies was assessed using the Newcastle-Ottawa scale for non-randomised studies The overall quality of the evidence supporting the primary and selected secondary outcomes was assessed using the GRADE criteria.

MAIN RESULTS

No RCTs were identified. Five observational studies (N = 7199) met the inclusion criteria. The studies scored well on the Newcastle-Ottawa scale, but due to the nature of observational studies, a high risk of bias was assigned to all the studies. Three studies were pooled to assess the rate of cancer detected in the surveillance group compared to the non-surveillance group. The studies found a significantly higher rate of cancer detection in the non surveillance group compared to the surveillance group. CRC was detected in 1.83% (53/2895) of patients in the surveillance group compared to 3.17% (135/4256) of patients in the non-surveillance group (OR 0.58, 95% CI 0.42 to 0.80; P = 0.0009). Four studies were pooled to assess the death rate associated with CRC in patients who underwent surveillance compared to patients who did not undergo surveillance. There was a significantly lower death rate associated with CRC in the surveillance group compared to the non-surveillance group. Eight per cent (15/176) of patients in the surveillance group died from CRC compared to 22% (79/354) of patients in the non-surveillance group (OR 0.36, 95% CI 0.19 to 0.69, P=0.002). Data were pooled from two studies to examine the rate of early stage versus late stage colorectal cancer (Duke stages A & B compared to Duke stages C & D) in patients who underwent surveillance compared to patients who do not undergo surveillance. A significantly higher rate of early stage CRC (Duke A & B) was detected in the surveillance group compared to the non-surveillance group. Sixteen per cent (17/110) of patients in the surveillance group had early stage CRC compared to 8% (9/117) of patients in the non-surveillance group (OR 5.40, 95% CI 1.51 to 19.30; P = 0.009). A higher rate of late stage CRC (Duke C & D) was observed in the non-surveillance group compared to the surveillance group. Nine per cent (10/110) of patients in the surveillance group had late stage CRC compared to 16% (19/117) of patients in the non-surveillance group (OR 0.46, 95% CI 0.08 to 2.51; P = 0.37). A GRADE analysis indicated that the quality of the data was very low for all of these outcomes. The included studies did not report on the other pre-specified outcomes including time to cancer detection, time to death and adverse events.

AUTHORS' CONCLUSIONS

The current data suggest that colonoscopic surveillance in IBD may reduce the development of both CRC and the rate of CRC-associated death through early detection, although the quality of the evidence is very low. The detection of earlier stage CRC in the surveillance group may explain some of the survival benefit observed. RCTs assessing the efficacy of endoscopic surveillance in people with IBD are unlikely to be undertaken due to ethical considerations.

The role of Nrf2-Keap1 axis in colorectal cancer, progression, and chemoresistance

Colorectal cancer is the third common cancer after lung and genital cancers worldwide with more than 1.2 million new cases diagnosed annually. Although extensive progress has been made in the treatment of colorectal cancer, finding novel targets for early diagnosis and effective treatment of these patients is an urgent need. Nuclear factor-erythroid 2-kelch-like ECH-associated protein 1 signaling pathway plays a key role in protecting cells from the damage of intracellular oxidative stress and extracellular oxidizing agents. Nuclear factor-erythroid 2 is a transcription factor that creates intracellular redox homeostasis via transcriptional activity and interaction with kelch-like ECH-associated protein 1. Furthermore, it contributes to survival and chemoresistance of colorectal cancer cells which is mediated by overexpression of cytoprotective and multidrug resistance genes. In this review, the dual role of nuclear factor-erythroid 2 signaling in induction of colorectal cancer cell survival and death as well as the possibility of targeting nuclear factor-erythroid 2-kelch-like ECH-associated protein 1 axis as an advanced strategy in prevention and effective treatment of colorectal cancer patients have been discussed.

Minimally invasive screening for colitis using attenuated total internal reflectance fourier transform infrared spectroscopy

This article describes a rapid, simple and cost-effective technique that could lead to a screening method for colitis without the need for biopsies or in vivo measurements. This screening technique includes the testing of serum using Attenuated Total Reflectance Fourier Transform Infrared (ATR-FTIR) spectroscopy for the colitis-induced increased presence of mannose. Chronic (Interleukin 10 knockout) and acute (Dextran Sodium Sulphate-induced) models for colitis are tested using the ATR-FTIR technique. Arthritis (Collagen Antibody Induced Arthritis) and metabolic syndrome (Toll like receptor 5 knockout) models are also tested as controls. The marker identified as mannose uniquely screens and distinguishes the colitic from the non-colitic samples and the controls. The reference or the baseline spectrum could be the pooled and averaged spectra of non-colitic samples or the subject's previous sample spectrum. This shows the potential of having individualized route maps of disease status, leading to personalized diagnosis and drug management.

Mechanisms, Management, and Treatment of Fibrosis in Patients With Inflammatory Bowel Diseases

In the last 10 years, we have learned much about the pathogenesis, diagnosis, and management of intestinal fibrosis in patients with inflammatory bowel diseases. Just a decade ago, intestinal strictures were considered to be an inevitable consequence of long-term inflammation in patients who did not respond to anti-inflammatory therapies. Inflammatory bowel diseases-associated fibrosis was seen as an irreversible process that frequently led to intestinal obstructions requiring surgical intervention. This paradigm has changed rapidly, due to the antifibrotic approaches that may become available. We review the mechanisms and diagnosis of this serious complication of inflammatory bowel diseases, as well as factors that predict its progression and management strategies.

The First Endoscopy in Suspected Inflammatory Bowel Disease

In a patient presenting with suspected inflammatory bowel disease, the initial endoscopic evaluation is a valuable tool for determining the correct disease diagnosis and the extent and severity of disease. A full colonoscopy and ileoscopy should be performed when possible, with systematic biopsies from each segment. When a diagnosis of inflammatory bowel disease is established, it is possible to distinguish between Crohn disease and ulcerative colitis, and specific endoscopic features may assist in this categorization. Because patchy healing can occur with treatment, it is important to obtain a thorough and accurate assessment of disease characteristics and distribution before initiating therapy.

The importance of biopsy sampling practices in the pathologic evaluation of gastrointestinal disorders

PURPOSE OF REVIEW

To summarize the literature regarding appropriate endoscopic sampling and surveillance protocols for common inflammatory diseases of the digestive tract. Gastroenterologists increasingly use endoscopy with mucosal biopsy to detect inflammatory diseases, assess response to therapy, and monitor for progression to dysplasia.

RECENT FINDINGS

Many diseases show a patchy distribution in the digestive tract and there may be poor correlation between the endoscopic appearance and presence of histologic abnormalities. Indeed, a clinician's ability to render a diagnosis is limited by endoscopic mucosal sampling. The appropriate number of tissue samples and required biopsy sites are not established for many gastrointestinal disorders, and adherence to guidelines may not yield a reliable diagnosis in all cases.

SUMMARY

We discuss the evidence supporting current recommendations and emerging endoscopic techniques for the evaluation of eosinophilic esophagitis, Barrett esophagus, chronic gastritis, celiac disease, and inflammatory bowel disease.

European Crohn's and Colitis Organisation Topical Review on Prediction, Diagnosis and Management of Fibrostenosing Crohn's Disease

This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focused on prediction, diagnosis, and management of fibrostenosing Crohn's disease [CD]. The objective was to achieve evidence-supported, expert consensus that provides guidance for clinical practice.

Chromoendoscopy Is More Effective Than Standard Colonoscopy in Detecting Dysplasia During Long-term Surveillance of Patients With Colitis

BACKGROUND & AIMS

Patients with colitis have an increased risk of colorectal cancer, compared with persons without colitis. Many studies have shown chromoendoscopy (CE) to be superior to standard methods of detecting dysplasia in patients with colitis at index examination. We performed a prospective, longitudinal study to compare standard colonoscopy vs CE in detecting dysplasia in patients with inflammatory bowel diseases in a surveillance program.

METHODS

We analyzed data from 68 patients (44 men, 24 women) diagnosed with ulcerative colitis (n = 55) or Crohn's disease (n = 13) at Mount Sinai Medical Center from September 2005 through October 2011. The patients were followed from June 2006 through October 2011 (median, 27.8 months); each patient was analyzed by random biopsy, targeted white light examination (WLE), and CE. Specimens were reviewed by a single blinded pathologist. The 3 methods were compared by using the generalized estimating equations method, and the odds ratios (ORs) for detection of dysplasia were calculated (primary outcome). Time to colectomy was analyzed by using the Cox model.

RESULTS

In the 208 examinations conducted, 44 dysplastic lesions were identified in 24 patients; 6 were detected by random biopsy, 11 by WLE, and 27 by CE. Ten patients were referred for colectomy, and no carcinomas were found. At any time during the study period, CE (OR, 5.4; 95% confidence interval [CI], 2.9-9.9) and targeted WLE (OR, 2.3; 95% CI, 1.0-5.3) were more likely than random biopsy analysis to detect dysplasia. CE was superior to WLE (OR, 2.4; 95% CI, 1.4-4.0). Patients identified as positive for dysplasia were more likely to need colectomy (hazard ratio, 12.1; 95% CI, 3.2-46.2).

CONCLUSIONS

In a prospective study of 68 patients with inflammatory bowel diseases, CE was superior to random biopsy or WLE analyses in detecting dysplasia in patients with colitis during an almost 28-month period. A negative result from CE examination was the best indicator of a dysplasia-free outcome, whereas a positive result was associated with earlier referral for colectomy.

Synchronous colonic lymphoma and adenocarcinoma in a patient with Crohn's disease, treated with thiopurine therapy and a TNFα inhibitor: a challenge to Occam's razor

A 52-year-old man with Crohn's disease, treated with thiopurine therapy and a tumour necrosis factor (TNF) α inhibitor, attended for surveillance colonoscopy, which revealed a transverse colon mass. Biopsies of this lesion showed a diffuse large B-cell lymphoma. CT scan demonstrated this lesion, an additional caecal mass and multiple metastases. A supraclavicular lymph node was removed and demonstrated metastatic adenocarcinoma, consistent with a synchronous caecal primary. At multidisciplinary oncological, haematological, histopathological, gastroenterological, radiological and palliative care assessment, the metastatic adenocarcinoma was deemed to carry a grave prognosis. Following sensitive discussion, the patient opted for palliative care and died several weeks later. Occam's razor, the principle that 'complexity should not be assumed unnecessarily', is a medical school doctrine. Occasionally, however, dual diagnoses do arise. Recognition, as in this case, may prove critical in informed decision-making, both by doctors and, most importantly, by patients, about prognosis and optimal patient care, especially end-of-life care.

The role of endoscopy in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a group of chronic immune-mediated disorders of the gastrointestinal tract. It is often the result of the interaction of genetic and environmental factors. The role of endoscopy in disease surveillance is unprecedented. However, there is considerable debate in therapeutic goals in IBD patients, ranging from the resolution of clinical symptoms to mucosal healing. Furthermore, deep remission has recently been advocated for altering disease course in these patients. Additionally, neoplasia continues to be a significant cause of morbidity and mortality in IBD patients. This review discussed the role of several endoscopic techniques in assessing mucosal healing and neoplasia with emphasis on novel non-invasive endoscopic techniques.

Mesalamine, but Not Sulfasalazine, Reduces the Risk of Colorectal Neoplasia in Patients with Inflammatory Bowel Disease: An Agent-specific Systematic Review and Meta-analysis

BACKGROUND

In some studies, 5-aminosalicylates as a class have been associated with protective effects against colorectal cancer in inflammatory bowel disease. In practice, only mesalamine at doses greater than 1.2 g per day is currently widely in this setting. The specific impact of mesalamine at these doses has not has not previously been determined.

METHODS

We performed a systematic review and meta-analysis of the effect of mesalamine on risk of colorectal neoplasia (CRN) from prior cohort and case-control studies. Sensitivity analyses for study setting and case definition were performed. A quality assessment was made of all included studies.

RESULTS

Mesalamine was associated with a modest reduction in the odds ratio (OR) of CRN (OR = 0.6, 95% confidence interval, 0.4-0.9, P = 0.04). This effect was only noted in hospital-based studies and only in the reduction of all CRN (not cancers alone). Patients prescribed doses >1.2 g per day had a lower risk of CRN (OR = 0.5, 95% confidence interval, 0.3-0.9, P = 0.02) than lower doses. This effect was also only present in the hospital-based studies. In contrast, there was no reduction in the risk of CRN in patients prescribed sulfasalazine (OR = 0.8, 95% confidence interval, 0.5-1.2, P = 0.3), regardless of study setting.

CONCLUSIONS

Mesalamine, particularly at doses >1.2 g per day, produces a modest reduction in the risk of CRN in inflammatory bowel disease patient populations from referral centers. Sulfasalazine does not seem to reduce the risk. No benefit was noted in population-based studies.

Colorectal cancer in colitis: a relic of the past?

The incidence of dysplasia and colorectal cancer in patients with long-standing colitis seems to be decreasing and controversy surrounds our detection and management strategies. Dysplasia is rarer, flatter, and smaller than in previous decades. Current surveillance guidelines, onerous in terms of colonoscopic workload and an emphasis on random biopsies, have yet to be shown to prevent colon cancers and colon cancer death in these patients. The evidence base for adjunct techniques such as chromoendoscopy is strong but adoption has been slow. We need to better risk-stratify patients with colitis and direct diminishing medical resources accordingly. Modulating dysplasia and cancer risk will involve optimizing medical therapies and focusing our colonoscopic efforts on those who will most likely benefit.

Rectal cancer in inflammatory bowel diseases: MR imaging findings

PURPOSE

To retrospectively analyze the MR imaging features of rectal cancer in patients with inflammatory bowel diseases (IBD).

MATERIALS AND METHODS

The MR imaging examinations of 13 patients with IBD-related rectal cancer were retrospectively reviewed. MR imaging included T2-weighted, diffusion-weighted (DW), and gadolinium chelate-enhanced MR imaging. MR imaging findings were analyzed and compared with endoscopic and histopathological findings.

RESULTS

Eight patients (8/13; 62%) had active IBD and five (5/13; 38%) had quiescent IBD on MR imaging. Two different tumor patterns were individualized including clearly visible soft-tissue mass (4/13; 31%) (Type 1 tumor) and marked circumferential rectal wall thickening (9/13; 69%) (Type 2 tumor). Twelve tumors (12/13; 92%) showed high signal intensity on T2-weighted MR images. All six tumors studied with DW-MR imaging (6/6; 100%) showed high signal on DW-MR imaging with restricted diffusion on apparent diffusion coefficient (ADC) map. On gadolinium chelate-enhanced MR imaging, heterogeneous enhancement was observed in one tumor (1/13; 8%), whereas 12 tumors (12/13; 92%) showed homogeneous enhancement. MR imaging showed pelvic fistula and intrapelvic abscess in association with four (4/13; 31%) and two tumors (2/13; 15%), respectively.

CONCLUSION

Our limited retrospective study demonstrates that rectal cancer in IBD patients can present as a circumferential wall thickening resembling inflammation and can occur in the absence of fistula or abscess. The use of T2-weighted and DW-MR imaging is recommended to improve rectal cancer detection in patients with long-standing IBD.

Recent advancement in understanding colitis-associated tumorigenesis

Chronic inflammation predisposes patients with inflammatory bowel disease to the risk of developing colitis-associated cancer (CAC). Growing evidence strongly suggests that CAC development is multifactorial and is attributed to concurrent, dynamic dysregulations in host immunity, enteric microbiota, and epithelial restitution during the course of chronic inflammation. This article discusses the recent advances in understanding the different forms of CAC that may develop in patients with inflammatory bowel disease and animal models, as well as molecular alterations and other processes that orchestrate the development of CAC.

Surgical management of nonpolypoid colorectal lesions and strictures in colonic inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) and dysplasia have pathologic characteristics and risks different from those of patients with sporadic carcinomas. Therefore, surgical interventions need to be more aggressive than in sporadic cases. This article reviews the surgical management of nonpolypoid lesions, dysplasia, and strictures found in patients with IBD.