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van Linschoten RCA, Jansen FM, Pauwels RWM, Smits LJT, Atsma F, Kievit W, de Jong DJ, de Vries AC, Boekema PJ, West RL, Bodelier AGL, Gisbertz IAM, Wolfhagen FHJ, Römkens TEH, Lutgens MWMD, van Bodegraven AA, Oldenburg B, Pierik MJ, Russel MGVM, de Boer NK, Mallant-Hent RC, Ter Borg PCJ, van der Meulen-de Jong AE, Jansen JM, Jansen SV, Tan ACITL, van der Woude CJ, Hoentjen F. A Prediction Model for Successful Increase of Adalimumab Dose Intervals in Patients with Crohn's Disease: Secondary Analysis of the Pragmatic Open-Label Randomised Controlled Non-inferiority LADI Trial. Dig Dis Sci 2024:10.1007/s10620-024-08410-z. [PMID: 38594435 DOI: 10.1007/s10620-024-08410-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/26/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND In the pragmatic open-label randomised controlled non-inferiority LADI trial we showed that increasing adalimumab (ADA) dose intervals was non-inferior to conventional dosing for persistent flares in patients with Crohn's disease (CD) in clinical and biochemical remission. AIMS To develop a prediction model to identify patients who can successfully increase their ADA dose interval based on secondary analysis of trial data. METHODS Patients in the intervention group of the LADI trial increased ADA intervals to 3 and then to 4 weeks. The dose interval increase was defined as successful when patients had no persistent flare (> 8 weeks), no intervention-related severe adverse events, no rescue medication use during the study, and were on an increased dose interval while in clinical and biochemical remission at week 48. Prediction models were based on logistic regression with relaxed LASSO. Models were internally validated using bootstrap optimism correction. RESULTS We included 109 patients, of which 60.6% successfully increased their dose interval. Patients that were active smokers (odds ratio [OR] 0.90), had previous CD-related intra-abdominal surgeries (OR 0.85), proximal small bowel disease (OR 0.92), an increased Harvey-Bradshaw Index (OR 0.99) or increased faecal calprotectin (OR 0.997) were less likely to successfully increase their dose interval. The model had fair discriminative ability (AUC = 0.63) and net benefit analysis showed that the model could be used to select patients who could increase their dose interval. CONCLUSION The final prediction model seems promising to select patients who could successfully increase their ADA dose interval. The model should be validated externally before it may be applied in clinical practice. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov, number NCT03172377.
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Affiliation(s)
- Reinier C A van Linschoten
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Fenna M Jansen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Renske W M Pauwels
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Lisa J T Smits
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Femke Atsma
- Scientific Center for Quality of Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Science, Nijmegen, The Netherlands
| | - Dirk J de Jong
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Paul J Boekema
- Department of Gastroenterology and Hepatology, Maxima Medical Center, Eindhoven, The Netherlands
| | - Rachel L West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | - Ingrid A M Gisbertz
- Department of Gastroenterology and Hepatology, Bernhoven Hospital, Uden, The Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 'S-Hertogenbosch, The Netherlands
| | - Maurice W M D Lutgens
- Department of Gastroenterology and Hepatology, Elisabeth Twee Steden Ziekenhuis, Tilburg, The Netherlands
| | - Adriaan A van Bodegraven
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Center, Sittard-Geleen/Heerlen, The Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | - Marieke J Pierik
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Maurice G V M Russel
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Twente, The Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Pieter C J Ter Borg
- Department of Gastroenterology and Hepatology, Ikazia Hospital, Rotterdam, The Netherlands
| | | | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, The Netherlands
| | - Sita V Jansen
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Adrianus C I T L Tan
- Department of Gastroenterology and Hepatology, CWZ Hospital, Nijmegen, The Netherlands
| | | | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
- Division of Gastroenterology, Department of Medicine, University of Alberta, 2-20A Zeidler Ledcor Centre, 8540-112 Street NW, Edmonton, AB, T6G 2P8, Canada.
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Fockens KN, Jong MR, Jukema JB, Boers TGW, Kusters CHJ, van der Putten JA, Pouw RE, Duits LC, Montazeri NSM, van Munster SN, Weusten BLAM, Alvarez Herrero L, Houben MHMG, Nagengast WB, Westerhof J, Alkhalaf A, Mallant-Hent RC, Scholten P, Ragunath K, Seewald S, Elbe P, Baldaque-Silva F, Barret M, Ortiz Fernández-Sordo J, Villarejo GM, Pech O, Beyna T, van der Sommen F, de With PH, de Groof AJ, Bergman JJ. A deep learning system for detection of early Barrett's neoplasia: a model development and validation study. Lancet Digit Health 2023; 5:e905-e916. [PMID: 38000874 DOI: 10.1016/s2589-7500(23)00199-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/22/2023] [Accepted: 09/18/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Computer-aided detection (CADe) systems could assist endoscopists in detecting early neoplasia in Barrett's oesophagus, which could be difficult to detect in endoscopic images. The aim of this study was to develop, test, and benchmark a CADe system for early neoplasia in Barrett's oesophagus. METHODS The CADe system was first pretrained with ImageNet followed by domain-specific pretraining with GastroNet. We trained the CADe system on a dataset of 14 046 images (2506 patients) of confirmed Barrett's oesophagus neoplasia and non-dysplastic Barrett's oesophagus from 15 centres. Neoplasia was delineated by 14 Barrett's oesophagus experts for all datasets. We tested the performance of the CADe system on two independent test sets. The all-comers test set comprised 327 (73 patients) non-dysplastic Barrett's oesophagus images, 82 (46 patients) neoplastic images, 180 (66 of the same patients) non-dysplastic Barrett's oesophagus videos, and 71 (45 of the same patients) neoplastic videos. The benchmarking test set comprised 100 (50 patients) neoplastic images, 300 (125 patients) non-dysplastic images, 47 (47 of the same patients) neoplastic videos, and 141 (82 of the same patients) non-dysplastic videos, and was enriched with subtle neoplasia cases. The benchmarking test set was evaluated by 112 endoscopists from six countries (first without CADe and, after 6 weeks, with CADe) and by 28 external international Barrett's oesophagus experts. The primary outcome was the sensitivity of Barrett's neoplasia detection by general endoscopists without CADe assistance versus with CADe assistance on the benchmarking test set. We compared sensitivity using a mixed-effects logistic regression model with conditional odds ratios (ORs; likelihood profile 95% CIs). FINDINGS Sensitivity for neoplasia detection among endoscopists increased from 74% to 88% with CADe assistance (OR 2·04; 95% CI 1·73-2·42; p<0·0001 for images and from 67% to 79% [2·35; 1·90-2·94; p<0·0001] for video) without compromising specificity (from 89% to 90% [1·07; 0·96-1·19; p=0·20] for images and from 96% to 94% [0·94; 0·79-1·11; ] for video; p=0·46). In the all-comers test set, CADe detected neoplastic lesions in 95% (88-98) of images and 97% (90-99) of videos. In the benchmarking test set, the CADe system was superior to endoscopists in detecting neoplasia (90% vs 74% [OR 3·75; 95% CI 1·93-8·05; p=0·0002] for images and 91% vs 67% [11·68; 3·85-47·53; p<0·0001] for video) and non-inferior to Barrett's oesophagus experts (90% vs 87% [OR 1·74; 95% CI 0·83-3·65] for images and 91% vs 86% [2·94; 0·99-11·40] for video). INTERPRETATION CADe outperformed endoscopists in detecting Barrett's oesophagus neoplasia and, when used as an assistive tool, it improved their detection rate. CADe detected virtually all neoplasia in a test set of consecutive cases. FUNDING Olympus.
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Affiliation(s)
- K N Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - M R Jong
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - J B Jukema
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - T G W Boers
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - C H J Kusters
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - J A van der Putten
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - L C Duits
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - N S M Montazeri
- Biostatistics Unit, Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - S N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - B L A M Weusten
- Department of Gastroenterology and Hepatology, UMC Utrecht, University of Utrecht, Utrecht, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - L Alvarez Herrero
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - M H M G Houben
- Department of Gastroenterology and Hepatology, HagaZiekenhuis Den Haag, Den Haag, Netherlands
| | - W B Nagengast
- Department of Gastroenterology and Hepatology, UMC Groningen, University of Groningen, Groningen, Netherlands
| | - J Westerhof
- Department of Gastroenterology and Hepatology, UMC Groningen, University of Groningen, Groningen, Netherlands
| | - A Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Hospital Zwolle, Zwolle, Netherlands
| | - R C Mallant-Hent
- Department of Gastroenterology and Hepatology, Flevoziekenhuis Almere, Almere, Netherlands
| | - P Scholten
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - K Ragunath
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Curtin University, Perth, WA, Australia
| | - S Seewald
- Department of Gastroenterology and Hepatology, Hirslanden Klinik, Zurich, Switzerland
| | - P Elbe
- Department of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - F Baldaque-Silva
- Department of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Center for Advanced Endoscopy Carlos Moreira da Silva, Gastroenterology Department, Pedro Hispano Hospital, Matosinhos, Portugal
| | - M Barret
- Department of Gastroenterology and Hepatology, Cochin Hospital Paris, Paris, France
| | - J Ortiz Fernández-Sordo
- Department of Gastroenterology and Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - G Moral Villarejo
- Department of Gastroenterology and Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - O Pech
- Department of Gastroenterology and Hepatology, St John of God Hospital, Regensburg, Germany
| | - T Beyna
- Department of Gastroenterology and Hepatology, Evangalisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - F van der Sommen
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - P H de With
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - A J de Groof
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - J J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
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3
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Jansen FM, van Linschoten RCA, Kievit W, Smits LJT, Pauwels RWM, de Jong DJ, de Vries AC, Boekema PJ, West RL, Bodelier AGL, Gisbertz IAM, Wolfhagen FHJ, Römkens TEH, Lutgens MWMD, van Bodegraven AA, Oldenburg B, Pierik MJ, Russel MGVM, de Boer NK, Mallant-Hent RC, ter Borg PCJ, van der Meulen-de Jong AE, Jansen JM, Jansen SV, Tan ACITL, Hoentjen F, van der Woude CJ. Cost-Effectiveness Analysis of Increased Adalimumab Dose Intervals in Crohn's Disease Patients in Stable Remission: The Randomized Controlled LADI Trial. J Crohns Colitis 2023; 17:1771-1780. [PMID: 37310877 PMCID: PMC10673815 DOI: 10.1093/ecco-jcc/jjad101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/30/2023] [Accepted: 06/10/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND AIMS We aimed to assess cost-effectiveness of increasing adalimumab dose intervals compared to the conventional dosing interval in patients with Crohn's disease [CD] in stable clinical and biochemical remission. DESIGN We conducted a pragmatic, open-label, randomized controlled non-inferiority trial, comparing increased adalimumab intervals with the 2-weekly interval in adult CD patients in clinical remission. Quality of life was measured with the EQ-5D-5L. Costs were measured from a societal perspective. Results are shown as differences and incremental net monetary benefit [iNMB] at relevant willingness to accept [WTA] levels. RESULTS We randomized 174 patients to the intervention [n = 113] and control [n = 61] groups. No difference was found in utility (difference: -0.017, 95% confidence interval [-0.044; 0.004]) and total costs (-€943, [-€2226; €1367]) over the 48-week study period between the two groups. Medication costs per patient were lower (-€2545, [-€2780; -€2192]) in the intervention group, but non-medication healthcare (+€474, [+€149; +€952]) and patient costs (+€365 [+€92; €1058]) were higher. Cost-utility analysis showed that the iNMB was €594 [-€2099; €2050], €69 [-€2908; €1965] and -€455 [-€4,096; €1984] at WTA levels of €20 000, €50 000 and €80 000, respectively. Increasing adalimumab dose intervals was more likely to be cost-effective at WTA levels below €53 960 per quality-adjusted life year. Above €53 960 continuing the conventional dose interval was more likely to be cost-effective. CONCLUSION When the loss of a quality-adjusted life year is valued at less than €53 960, increasing the adalimumab dose interval is a cost-effective strategy in CD patients in stable clinical and biochemical remission. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov, number NCT03172377.
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Affiliation(s)
- Fenna M Jansen
- Radboud University Medical Center, Department of Gastroenterology and Hepatology, Nijmegen, The Netherlands
| | - Reinier C A van Linschoten
- Erasmus MC, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
- Franciscus Gasthuis & Vlietland, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | - Wietske Kievit
- Radboud University Medical Center, Radboud Institute for Health Science, Department for Health Evidence, Nijmegen, The Netherlands
| | - Lisa J T Smits
- Radboud University Medical Center, Department of Gastroenterology and Hepatology, Nijmegen, The Netherlands
| | - Renske W M Pauwels
- Erasmus MC, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | - Dirk J de Jong
- Radboud University Medical Center, Department of Gastroenterology and Hepatology, Nijmegen, The Netherlands
| | - Annemarie C de Vries
- Erasmus MC, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | - Paul J Boekema
- Maxima Medical Center, Department of Gastroenterology and Hepatology, Eindhoven, The Netherlands
| | - Rachel L West
- Franciscus Gasthuis & Vlietland, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | | | - Ingrid A M Gisbertz
- Bernhoven Hospital, Department of Gastroenterology and Hepatology, Uden, The Netherlands
| | - Frank H J Wolfhagen
- Albert Schweitzer Hospital, Department of Gastroenterology and Hepatology, Dordrecht, The Netherlands
| | - Tessa E H Römkens
- Jeroen Bosch Hospital, Department of Gastroenterology and Hepatology, ‘s-Hertogenbosch, The Netherlands
| | - Maurice W M D Lutgens
- Elisabeth Tweesteden Ziekenhuis, Department of Gastroenterology and Hepatology, Tilburg, The Netherlands
| | - Adriaan A van Bodegraven
- Zuyderland Medical Center, Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Sittard-Geleen/Heerlen, The Netherlands
| | - Bas Oldenburg
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, The Netherlands
| | - Marieke J Pierik
- Maastricht University Medical Center+, Department of Gastroenterology and Hepatology, Maastricht, The Netherlands
| | - Maurice G V M Russel
- Medisch Spectrum Twente, Department of Gastroenterology and Hepatology, Twente, The Netherlands
| | - Nanne K de Boer
- Amsterdam University Medical Center, Vrije University Amsterdam, Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam, The Netherlands
| | | | - Pieter C J ter Borg
- Ikazia Hospital, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | | | - Jeroen M Jansen
- OLVG, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Sita V Jansen
- Reinier de Graaf Gasthuis, Department of Gastroenterology and Hepatology, Delft, The Netherlands
| | - Adrianus C I T L Tan
- Canisius Wilhelmina Hospital, Department of Gastroenterology and Hepatology, Nijmegen, The Netherlands
| | - Frank Hoentjen
- Radboud University Medical Center, Department of Gastroenterology and Hepatology, Nijmegen, The Netherlands
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
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4
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van Linschoten RCA, Jansen FM, Pauwels RWM, Smits LJT, Atsma F, Kievit W, de Jong DJ, de Vries AC, Boekema PJ, West RL, Bodelier AGL, Gisbertz IAM, Wolfhagen FHJ, Römkens TEH, Lutgens MWMD, van Bodegraven AA, Oldenburg B, Pierik MJ, Russel MGVM, de Boer NK, Mallant-Hent RC, Ter Borg PCJ, van der Meulen-de Jong AE, Jansen JM, Jansen SV, Tan ACITL, van der Woude CJ, Hoentjen F. Increased versus conventional adalimumab dose interval for patients with Crohn's disease in stable remission (LADI): a pragmatic, open-label, non-inferiority, randomised controlled trial. Lancet Gastroenterol Hepatol 2023; 8:343-355. [PMID: 36736339 DOI: 10.1016/s2468-1253(22)00434-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite its effectiveness in treating Crohn's disease, adalimumab is associated with an increased risk of infections and high health-care costs. We aimed to assess clinical outcomes of increased adalimumab dose intervals versus conventional dosing in patients with Crohn's disease in stable remission. METHODS The LADI study was a pragmatic, open-label, multicentre, non-inferiority, parallel, randomised controlled trial, done in six academic hospitals and 14 general hospitals in the Netherlands. Adults (aged ≥18 years) diagnosed with luminal Crohn's disease (with or without concomitant perianal disease) were eligible when in steroid-free clinical and biochemical remission (defined as Harvey-Bradshaw Index [HBI] score <5, faecal calprotectin <150 μg/g, and C-reactive protein <10 mg/L) for at least 9 months on a stable dose of 40 mg subcutaneous adalimumab every 2 weeks. Patients were randomly assigned (2:1) to the intervention group or control group by the coordinating investigator using a secure web-based system with variable block randomisation (block sizes of 6, 9, and 12). Randomisation was stratified on concomitant use of thiopurines and methotrexate. Patients and health-care providers were not masked to group assignment. Patients allocated to the intervention group increased adalimumab dose intervals to 40 mg every 3 weeks at baseline and further to every 4 weeks if they remained in clinical and biochemical remission at week 24. Patients in the control group continued their 2-weekly dose interval. The primary outcome was the cumulative incidence of persistent flares at week 48 defined as the presence of at least two of the following criteria: HBI score of 5 or more, C-reactive protein 10 mg/L or more, and faecal calprotectin more than 250 μg/g for more than 8 weeks and a concurrent decrease in the adalimumab dose interval or start of escape medication. The non-inferiority margin was 15% on a risk difference scale. All analyses were done in the intention-to-treat and per-protocol populations. This trial was registered at ClinicalTrials.gov, NCT03172377, and is not recruiting. FINDINGS Between May 3, 2017, and July 6, 2020, 174 patients were randomly assigned to the intervention group (n=113) or the control group (n=61). Four patients from the intervention group and one patient from the control group were excluded from the analysis for not meeting inclusion criteria. 85 (50%) of 169 participants were female and 84 (50%) were male. At week 48, the cumulative incidence of persistent flares in the intervention group (three [3%] of 109) was non-inferior compared with the control group (zero; pooled adjusted risk difference 1·86% [90% CI -0·35 to 4·07). Seven serious adverse events occurred, all in the intervention group, of which two (both patients with intestinal obstruction) were possibly related to the intervention. Per 100 person-years, 168·35 total adverse events, 59·99 infection-related adverse events, and 42·57 gastrointestinal adverse events occurred in the intervention group versus 134·67, 75·03, and 5·77 in the control group, respectively. INTERPRETATION The individual benefit of increasing adalimumab dose intervals versus the risk of disease recurrence is a trade-off that should take patient preferences regarding medication and the risk of a flare into account. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Reinier C A van Linschoten
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | - Fenna M Jansen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Renske W M Pauwels
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Lisa J T Smits
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Femke Atsma
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Wietske Kievit
- Radboud institute for Health Science, Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dirk J de Jong
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Paul J Boekema
- Department of Gastroenterology and Hepatology, Maxima Medical Center, Eindhoven, Netherlands
| | - Rachel L West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | | | - Ingrid A M Gisbertz
- Department of Gastroenterology and Hepatology, Bernhoven Hospital, Uden, Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Maurice W M D Lutgens
- Department of Gastroenterology and Hepatology, Elisabeth Twee Steden Ziekenhuis, Tilburg, Netherlands
| | - Adriaan A van Bodegraven
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Center, Sittard-Geleen/Heerlen, Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, UMC Utrecht, Utrecht, Netherlands
| | - Marieke J Pierik
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Maurice G V M Russel
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Twente, Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Pieter C J Ter Borg
- Department of Gastroenterology and Hepatology, Ikazia Hospital, Rotterdam, Netherlands
| | | | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Netherlands
| | - Sita V Jansen
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, Netherlands
| | - Adrianus C I T L Tan
- Department of Gastroenterology and Hepatology, CWZ Hospital, Nijmegen, Netherlands
| | | | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands; Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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5
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Kanis SL, Modderman S, Escher JC, Erler N, Beukers R, de Boer N, Bodelier A, Depla ACT, Dijkstra G, van Dijk ABRM, Gilissen L, Hoentjen F, Jansen JM, Kuyvenhoven J, Mahmmod N, Mallant-Hent RC, van der Meulen-de Jong AE, Noruzi A, Oldenburg B, Oostenbrug LE, Ter Borg PC, Pierik M, Romberg- Camps M, Thijs W, West R, de Lima A, van der Woude CJ. Health outcomes of 1000 children born to mothers with inflammatory bowel disease in their first 5 years of life. Gut 2021; 70:1266-1274. [PMID: 33046558 PMCID: PMC8223671 DOI: 10.1136/gutjnl-2019-319129] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to describe the long-term health outcomes of children born to mothers with inflammatory bowel disease (IBD) and to assess the impact of maternal IBD medication use on these outcomes. DESIGN We performed a multicentre retrospective study in The Netherlands. Women with IBD who gave birth between 1999 and 2018 were enrolled from 20 participating hospitals. Information regarding disease characteristics, medication use, lifestyle, pregnancy outcomes and long-term health outcomes of children was retrieved from mothers and medical charts. After consent of both parents, outcomes until 5 years were also collected from general practitioners. Our primary aim was to assess infection rate and our secondary aims were to assess adverse reactions to vaccinations, growth, autoimmune diseases and malignancies. RESULTS We included 1000 children born to 626 mothers (381 (61%) Crohn's disease, 225 (36%) ulcerative colitis and 20 (3%) IBD unclassified). In total, 196 (20%) had intrauterine exposure to anti-tumour necrosis factor-α (anti-TNF-α) (60 with concomitant thiopurine) and 240 (24%) were exposed to thiopurine monotherapy. The 564 children (56%) not exposed to anti-TNF-α and/or thiopurine served as control group. There was no association between adverse long-term health outcomes and in utero exposure to IBD treatment. We did find an increased rate of intrahepatic cholestasis of pregnancy (ICP) in case thiopurine was used during the pregnancy without affecting birth outcomes and long-term health outcomes of children. All outcomes correspond with the general age-adjusted population. CONCLUSION In our study, we found no association between in utero exposure to anti-TNF-α and/or thiopurine and the long-term outcomes antibiotic-treated infections, severe infections needing hospital admission, adverse reactions to vaccinations, growth failure, autoimmune diseases and malignancies.
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Affiliation(s)
- Shannon Linda Kanis
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sanne Modderman
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johanna C Escher
- Pediatric Gastroenterology, Erasmus MC Sophia Children Hospital, Rotterdam, The Netherlands
| | - Nicole Erler
- Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ruud Beukers
- Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | - Nanne de Boer
- Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Alexander Bodelier
- Gastroenterology and Hepatology, Amphia Hospital site Molengracht, Breda, The Netherlands
| | | | - Gerard Dijkstra
- Gastroenterology and Hepatology, University of Groningen, Groningen, The Netherlands
| | | | - Lennard Gilissen
- Gastroenterology and Hepatology, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Frank Hoentjen
- Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - Jeroen M Jansen
- Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Johan Kuyvenhoven
- Gastroenterology and Hepatology, Spaarne Hospital, Haarlem, The Netherlands
| | - Nofel Mahmmod
- Gastroenterology and Hepatology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | | | | | - Anahita Noruzi
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bas Oldenburg
- Gastroenterology and Hepatology, Utrecht Hospital, Utrecht, The Netherlands
| | - Liekele E Oostenbrug
- Gastroenterology and Hepatology, Zuyderland Medisch Centrum Heerlen, Heerlen, The Netherlands
| | | | - Marieke Pierik
- Gastroenterology and Hepatology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Mariëlle Romberg- Camps
- Gastroenterology and Hepatology, Zuyderland Medical Centre Sittard-Geleen, Sittard-Geleen, The Netherlands
| | - Willem Thijs
- Gastroenterology and Hepatology, Martini Hospital, Groningen, The Netherlands
| | - Rachel West
- Gastroenterology and Hepatology, Franciscus Gasthuis, Rotterdam, New Caledonia
| | - Alison de Lima
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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6
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Young GP, Symonds EL, Nielsen HJ, Ferm L, Christensen IJ, Dekker E, van der Vlugt M, Mallant-Hent RC, Boulter N, Yu B, Chan M, Tevz G, LaPointe LC, Pedersen SK. Evaluation of a panel of tumor-specific differentially-methylated DNA regions in IRF4, IKZF1 and BCAT1 for blood-based detection of colorectal cancer. Clin Epigenetics 2021; 13:14. [PMID: 33478584 PMCID: PMC7818774 DOI: 10.1186/s13148-020-00999-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/22/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Differentially-methylated regions (DMRs) are characteristic of colorectal cancer (CRC) and some occur more frequently than common mutations. This study aimed to evaluate the clinical utility of assaying circulating cell-free DNA for methylation in BCAT1, IKZF1 and IRF4 for detection of CRC. METHODS A multiplexed real-time PCR assay targeting DMRs in each of the three genes was developed. Assay accuracy was explored in plasma specimens banked from observational cross-sectional trials or from volunteers scheduled for colonoscopy or prior to CRC surgery. RESULTS 1620 specimens were suitable for study inclusion including 184 and 616 cases with CRC and adenomas, respectively, and 820 cases without neoplasia (overall median age, 63.0 years; 56% males). Combining the PCR signals for all targeted DMRs returned the best sensitivity for CRC (136/184, 73.9%, 95% CI 67.1-79.7), advanced adenomas (53/337, 15.7%, 95% CI 12.0-20.1) and high-grade dysplastic (HGD) adenomas (9/35, 25.7%, 95% CI 14.0-42.3) with a 90.1%, specificity for neoplasia (739/820, 95% CI 87.9-92.0, p < 0.01). Detection of methylation in all three genes were more likely in CRC cases than those without it (OR 28.5, 95% CI 7.3-121.2, p < 0.0001). Of the 81 positive cases without neoplasia, 62 (76.5%) were positive by a single PCR replicate only and predominantly due to detection of methylated BCAT1 (53.2%). Single replicate positivity was significantly higher than that in CRC (26/136, 19.1%, p < 0.0001), and single BCAT1 replicate positivity was more likely in cases without neoplasia than in CRC (OR 17.7, 95% CI 6.6-43.3, p < 0.0001). When a positive result was limited to those with ≥ 1 PCR replicate positive for either IKZF1 or IRF4, or at least two replicates positive for BCAT1, the multi-panel test maintained a high sensitivity for CRC (131/184, 71.2%, 95% CI 64.3-77.3) and HGD adenomas (8/35, 22.9%, 95% CI 11.8-39.3, p = 0.029) but improved specificity significantly (772/820, 94.1%, 95% CI 92.3-95.6, p < 0.0001 vs. any PCR replicate positive). CONCLUSION The multi-panel methylation assay differentiates cases with CRC from those without it and does so with high specificity when criteria for BCAT1 detection are applied. The marker panel is flexible and studies in those at average risk for CRC are now warranted to determine which panel configuration best suits screening goals. TRIAL REGISTRATION ACTRN12611000318987. Registered 25 March 2011, https://www.anzctr.org.au/ ACTRN12611000318987.
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Affiliation(s)
- Graeme P Young
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | - Erin L Symonds
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
- Bowel Health Service, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Hans Jørgen Nielsen
- Department of Surgical Gastroenterology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Linnea Ferm
- Department of Surgical Gastroenterology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Ib J Christensen
- Department of Surgical Gastroenterology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Manon van der Vlugt
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Nicky Boulter
- Clinical Genomics Pty Ltd, North Ryde, NSW, Australia
| | - Betty Yu
- Clinical Genomics Pty Ltd, North Ryde, NSW, Australia
| | - Michelle Chan
- Clinical Genomics Pty Ltd, North Ryde, NSW, Australia
| | - Gregor Tevz
- Clinical Genomics Pty Ltd, North Ryde, NSW, Australia
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7
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Frei NF, Konté K, Duits LC, Klaver E, Ten Kate FJ, Offerhaus GJ, Meijer SL, Visser M, Seldenrijk CA, Schoon EJ, Weusten BLAM, Schenk BE, Mallant-Hent RC, Bergman JJ, Pouw RE. The SpaTemp cohort: 168 nondysplastic Barrett's esophagus surveillance patients with and without progression to early neoplasia to evaluate the distribution of biomarkers over space and time. Dis Esophagus 2020; 34:5907935. [PMID: 32944737 PMCID: PMC9155949 DOI: 10.1093/dote/doaa095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
The ReBus cohort is a matched nested case-control cohort of patients with nondysplastic (ND) Barrett's esophagus (BE) at baseline who progressed (progressors) or did not progress (nonprogressors) to high-grade dysplasia (HGD) or cancer. This cohort is constructed using the most stringent inclusion criteria to optimize explorative studies on biomarkers predicting malignant progression in NDBE. These explorative studies may benefit from expanding the number of cases and by incorporating samples that allow assessment of the biomarker over space (spatial variability) and over time (temporal variability). To (i) update the ReBus cohort by identifying new progressors and (ii) identify progressors and nonprogressors within the updated ReBus cohort containing spatial and temporal information. The ReBus cohort was updated by identifying Barrett's patients referred for endoscopic work-up of neoplasia at 4 tertiary referral centers. Progressors and nonprogressors with a multilevel (spatial) endoscopy and additional prior (temporal) endoscopies were identified to evaluate biomarkers over space and over time. The original ReBus cohort consisted of 165 progressors and 723 nonprogressors. We identified 65 new progressors meeting the same strict selection criteria, resulting in a total number of 230 progressors and 723 matched nonprogressors in the updated ReBus cohort. Within the updated cohort, 61 progressors and 107 nonprogressors (mean age 61 ± 10 years) with a spatial endoscopy (median level 3 [2-4]) were identified. 33/61 progressors and 50/107 nonprogressors had a median of 3 (2-4) additional temporal endoscopies. Our updated ReBus cohort consists of 230 progressors and 723 matched nonprogressors using the most strict selection criteria. In a subgroup of 168 Barrett's patients (the SpaTemp cohort), multiple levels have been sampled at baseline and during follow-up providing a unique platform to study spatial and temporal distribution of biomarkers in BE.
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Affiliation(s)
- N F Frei
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - K Konté
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - L C Duits
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - E Klaver
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - F J Ten Kate
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - G J Offerhaus
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - S L Meijer
- Department of Pathology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - M Visser
- Department of Pathology, Symbiant BV, Zaans Medical Center, Zaandam, The Netherlands
| | - C A Seldenrijk
- Department of Pathology, Pathology-DNA BV, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - B L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - B E Schenk
- Department of Gastroenterology and Hepatology, Isala Klinieken, Zwolle, The Netherlands
| | - R C Mallant-Hent
- Department of Gastroenterology, Flevo Hospital, Almere, the Netherlands
| | - J J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - R E Pouw
- Address correspondence to: R. E. Pouw, MD, PhD, Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands.
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8
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Grobbee EJ, van der Vlugt M, van Vuuren AJ, Stroobants AK, Mallant-Hent RC, Lansdorp-Vogelaar I, Bossuyt PMM, Kuipers EJ, Dekker E, Spaander MCW. Diagnostic Yield of One-Time Colonoscopy vs One-Time Flexible Sigmoidoscopy vs Multiple Rounds of Mailed Fecal Immunohistochemical Tests in Colorectal Cancer Screening. Clin Gastroenterol Hepatol 2020; 18:667-675.e1. [PMID: 31419575 DOI: 10.1016/j.cgh.2019.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/23/2019] [Accepted: 08/02/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We compared the diagnostic yields of colonoscopy, flexible sigmoidoscopy, and fecal immunochemical tests (FITs) in colorectal cancer (CRC) screening. METHODS A total of 30,007 asymptomatic persons, 50-74 years old, were invited for CRC screening in the Netherlands. Participants were assigned to groups that received 4 rounds of FIT (mailed to 15,046 participants), once-only flexible sigmoidoscopy (n = 8407), or once-only colonoscopy (n = 6600). Patients with positive results from the FIT (≥10 μg Hb/g feces) were referred for colonoscopy. Patients who underwent flexible sigmoidoscopy were referred for colonoscopy if they had a polyp of ≥10 mm; adenoma with ≥25% villous histology or high-grade dysplasia; sessile serrated adenoma; ≥3 adenomas; ≥20 hyperplastic polyps; or invasive CRC. The primary outcome was number of advanced neoplasia detected (diagnostic yield) by each test. Secondary outcomes were number of colonoscopies needed to detect advanced neoplasia and number of interval CRCs found during each primary screening test. Patients with interval CRCs were found through linkage with Netherlands Cancer Registry. Advanced neoplasia were defined as CRC, adenomas ≥ 10 mm, adenomas with high-grade dysplasia, or adenomas with a villous component of at least 25%. RESULTS The cumulative participation rate was significantly higher for FIT screening (73%) than for flexible sigmoidoscopy (31%; P < .001) or colonoscopy (24%; P < .001). The percentage of colonoscopies among invitees was higher for colonoscopy (24%) compared to FIT (13%; P < .001) or flexible sigmoidoscopy (3%; P < .001). In the intention to screen analysis, the cumulative diagnostic yield of advanced neoplasia was higher with FIT screening (4.5%; 95% CI 4.2-4.9) than with colonoscopy (2.2%; 95% CI, 1.8-2.6) or flexible sigmoidoscopy (2.3%; 95% CI, 2.0-2.7). In the as-screened analysis, the cumulative yield of advanced neoplasia was higher for endoscopic screening with colonoscopy (9.1%; 95% CI, 7.7-10.7) or flexible sigmoidoscopy (7.4%; 95% CI, 6.5-8.5) than with the FIT (6.1%; 95% CI, 5.7-6.6). All 3 screening strategies detected a similar proportion of patients with CRC. Follow-up times differed for each test (median 8.3 years for FIT and flexible sigmoidoscopy and 5.8 years for colonoscopy). Proportions of patients that developed interval CRC were 0.13% for persons with a negative result from FIT, 0.09% for persons with a negative result from flexible sigmoidoscopy, and 0.01% for persons with a negative result from colonoscopy. CONCLUSIONS Mailed multiple-round FITs detect significantly more advanced neoplasia, on a population level, compared with once-only flexible sigmoidoscopy or colonoscopy screening. Significantly fewer colonoscopies are required by individuals screened by multiple FITs. Trialregister.nl numbers: first round, NTR1096; second round and additional invitees, NTR1512; fourth round, NTR5874; COCOS trial NTR1829.
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Affiliation(s)
- Esmée J Grobbee
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Manon van der Vlugt
- Department of Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Anneke J van Vuuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - An K Stroobants
- Clinical Chemistry, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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Duits LC, Klaver E, Bureo Gonzalez A, Boerwinkel DF, Ten Kate FJW, Offerhaus GJA, Meijer SL, Visser M, Seldenrijk CA, Krishnadath KK, Schoon EJ, Weusten BLAM, Mallant-Hent RC, Pouw RE, Bergman JJGHM. The Amsterdam ReBus progressor cohort: identification of 165 Barrett's surveillance patients who progressed to early neoplasia and 723 nonprogressor patients. Dis Esophagus 2019; 32:5032889. [PMID: 29873685 DOI: 10.1093/dote/doy037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 12/11/2022]
Abstract
Patient selection is suboptimal in most studies focused on identifying biological markers for neoplastic progression in Barrett's esophagus (BE). This study aims to describe a stringently selected community-based case-control cohort of non-dysplastic BE (NDBE) patients who progressed to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) and BE patients who never progressed to be used for future biomarker studies. We identified all patients referred for endoscopic work-up of BE neoplasia at three tertiary referral centers for treatment of BE neoplasia between 2000 and 2013. We performed a detailed registration of any endoscopic surveillance history before neoplastic progression. Controls were selected from a retrospective BE surveillance registration in 10 community hospitals. A total of 887 patients were referred for endoscopic work-up of BE neoplasia. Based on predefined selection criteria, we identified 165 progressor patients (82% men; mean age 55 years ± 10.4) with a baseline endoscopy demonstrating NDBE > 2 years before neoplastic progression. Using the same predefined selection criteria, 723 nonprogressor patients (67% men; mean age 57 years ± 11.3) with >2 years of endoscopic surveillance were identified. Median length of the BE segment was 5 cm (IQR 4-7) in progressors and 4 cm (IQR 2-6) in controls. Median duration of surveillance was 89 months (IQR 54-139) in progressors and 76 months (IQR 47-116) in nonprogressors. Paraffin embedded biopsies are available for biomarker research in all patients. Ethical approval was obtained and material transfer agreements were signed with all 58 contributing pathology labs. This is the largest community-based case-control cohort of BE patients with and without progression to early neoplasia. The stringent selection criteria and the availability of paraffin embedded biopsy specimens make this a unique cohort for biomarker studies.
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Affiliation(s)
- L C Duits
- Departments of Gastroenterology and Hepatology
| | - E Klaver
- Departments of Gastroenterology and Hepatology
| | | | | | - F J W Ten Kate
- Pathology, Academic Medical Center, Amsterdam.,Department of Pathology, University Medical Center, Utrecht
| | - G J A Offerhaus
- Pathology, Academic Medical Center, Amsterdam.,Department of Pathology, University Medical Center, Utrecht
| | - S L Meijer
- Pathology, Academic Medical Center, Amsterdam
| | - M Visser
- Pathology, Academic Medical Center, Amsterdam
| | | | | | - E J Schoon
- Gastroenterology, St Antonius Ziekenhuis, Nieuwegein
| | | | | | - Roos E Pouw
- Departments of Gastroenterology and Hepatology
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Nissen LHC, Derikx LAAP, Jacobs AME, van Herpen CM, Kievit W, Verhoeven R, van den Broek E, Bekers E, van den Heuvel T, Pierik M, Rahamat-Langendoen J, Takes RP, Melchers WJG, Nagtegaal ID, Hoentjen F, Peutz-Kootstra C, Roelofs JJTH, Willems SM, Willig AP, van Bodegraven AA, Tan ACITL, Meeuse JJ, van der Meulen–de Jong AE, Oldenburg B, Loffeld BCAJ, Durfeld BM, van der Woude CJ, Cahen DL, D’Haens G, Janik D, Mares WGM, Gilissen LPL, Wolters FL, Dijkstra G, Erkelens GW, Tang TJ, Breumelhof R, Smalbraak HJT, Thijs JC, Voskuil JH, Kuyvenhoven JP, Vecht J, Rijk MCM, Janssen JM, Sarneel JT, Tjhie-Wensing JWM, Lai JYL, Vlasveld LT, Oostenbrug LE, Gerretsen M, Van Herwaarden MA, Mahmmod N, Russel MGVM, Grubben MJAL, Vu MK, Verhulst ML, Dewint P, Stokkers PCF, Bus PJ, Wismans PJ, van der Haeck PWE, Stuyt RJL, Zeijen RNM, Dahlmans RPM, Vandebosch S, Romkens TEH, Moolenaar W, ten Hove WR, Boot H, van der Linde K, Wahab P, de Boer SY, Thurnau K, Thijs WJ, Josemanders DFGM, West RL, Pierik MJ, Depla ACTM, Keulen ETP, de Boer WA, Naber AHJ, Vermeijden JR, Mallant-Hent RC, Beukers R, Ter Borg PCJ, Halet ECR, Bruin KF, Linskens RK, Bruins Slot W. Risk Factors and Clinical Outcomes of Head and Neck Cancer in Inflammatory Bowel Disease: A Nationwide Cohort Study. Inflamm Bowel Dis 2018; 24:2015-2026. [PMID: 30759216 DOI: 10.1093/ibd/izy096] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunosuppressed inflammatory bowel disease (IBD) patients are at increased risk to develop extra-intestinal malignancies. Immunosuppressed transplant patients show increased incidence of head and neck cancer with impaired survival. This study aims to identify risk factors for oral cavity (OCC) and pharyngeal carcinoma (PC) development in IBD, to compare clinical characteristics in IBD with the general population, and to assess the influence of immunosuppressive medication on survival. METHODS We retrospectively searched the Dutch Pathology Database to identify all IBD patients with OCC and PC between 1993 and 2011. Two case-control studies were performed: We compared cases with the general IBD population to identify risk factors, and we compared cases with non-IBD cancer patients for outcome analyses. RESULTS We included 66 IBD patients and 2141 controls with OCC, 31 IBD patients and 1552 controls with PC, and 1800 IBD controls. Age at IBD diagnosis was a risk factor for OCC development, Crohn's disease (CD; odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.07), and ulcerative colitis (UC; OR, 1.03; 95% CI, 1.01-1.06). For PC, this applied to UC (OR, 1.05; 95% CI, 1.01-1.06). IBD OCC cases showed impaired survival (P = 0.018); in PC, survival was similar. There was no effect of immunosuppression on survival. Human papillomavirus (HPV) testing of IBD cases revealed 52.2% (12/23) HPV-positive oropharyngeal carcinomas (OPCs). CONCLUSION This study shows that IBD is associated with impaired OCC survival. Higher age at IBD diagnosis is a risk factor for OCC development. We found no influence of immunosuppression on survival; 52.2% of OPC in IBD contained HPV.
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Affiliation(s)
- Loes H C Nissen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology.,Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | | | - Anouk M E Jacobs
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology
| | - Carla M van Herpen
- Department of Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rob Verhoeven
- Netherlands Cancer Registry/Netherlands Comprehensive Cancer Organization
| | | | - Elise Bekers
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Tim van den Heuvel
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marieke Pierik
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Robert P Takes
- Department of Otorhinolaryngology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology
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Duits LC, van der Wel MJ, Cotton CC, Phoa KN, Ten Kate FJW, Seldenrijk CA, Offerhaus GJA, Visser M, Meijer SL, Mallant-Hent RC, Krishnadath KK, Pouw RE, Tijssen JGP, Shaheen NJ, Bergman JJGHM. Patients With Barrett's Esophagus and Confirmed Persistent Low-Grade Dysplasia Are at Increased Risk for Progression to Neoplasia. Gastroenterology 2017; 152:993-1001.e1. [PMID: 28012849 DOI: 10.1053/j.gastro.2016.12.008] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 12/01/2016] [Accepted: 12/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS For patients with Barrett's esophagus, the diagnosis of low-grade dysplasia (LGD) is subjective, and reported outcomes vary. We analyzed data from a multicenter study of endoscopic therapy to identify factors associated with progression to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in patients with LGD of the esophagus. METHODS We performed a retrospective analysis of data from 255 patients with a primary diagnosis of LGD (78% men; mean age, 63 years) who participated in a randomized controlled trial of surveillance vs radiofrequency ablation in Europe. Three expert pathologists independently reviewed baseline and subsequent LGD specimens. The presence and degree of dysplasia was separately recorded for each biopsy and classified according to the Vienna Classification system. The primary end point was development of HGD or EAC. We performed univariate logistic regression analyses to assess the association between outcomes and factors such as number of pathologists confirming LGD, multifocality of LGD, and persistence of LGD over time. RESULTS Of the 255 patients, 45 (18%) developed HGD or EAC during a median 42-month follow-up period (interquartile range, 25-61 months); patients were examined by a median 4 endoscopies (interquartile range, 3-6 endoscopies). The number of pathologists confirming LGD was strongly associated with progression to neoplasia; risk for progression increased greatly when all 3 pathologists agreed on LGD (odds ratio, 47.14; 95% confidence interval, 13.10-169.70). When LGD was detected at baseline and confirmed by a subsequent endoscopy, the odds for progression to neoplasia also increased greatly (odds ratio, 9.28; 95% confidence interval, 4.39-19.64). Multifocal LGD was not significantly associated with progression to neoplasia. CONCLUSIONS The number of pathologists confirming LGD and persistence of LGD over time increase risk for development of HGD or EAC in patients with Barrett's esophagus and LGD. These simple, readily available variables can help stratify risk and select patients for prophylactic ablation therapy.
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Affiliation(s)
- Lucas C Duits
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Myrtle J van der Wel
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands; Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Cary C Cotton
- Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - K Nadine Phoa
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Fiebo J W Ten Kate
- Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - Cees A Seldenrijk
- Department of Pathology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - G Johan A Offerhaus
- Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - Mike Visser
- Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sybren L Meijer
- Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Rosalie C Mallant-Hent
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, Flevoziekenhuis, Almere, The Netherlands
| | - Kausilia K Krishnadath
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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12
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van Doorn SC, van der Vlugt M, Depla A, Wientjes CA, Mallant-Hent RC, Siersema PD, Tytgat K, Tuynman H, Kuiken SD, Houben G, Stokkers P, Moons L, Bossuyt P, Fockens P, Mundt MW, Dekker E. Adenoma detection with Endocuff colonoscopy versus conventional colonoscopy: a multicentre randomised controlled trial. Gut 2017; 66:438-445. [PMID: 26674360 DOI: 10.1136/gutjnl-2015-310097] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/24/2015] [Accepted: 11/22/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Colonoscopy is the current reference standard for the detection of colorectal neoplasia, but nevertheless adenomas remain undetected. The Endocuff, an endoscopic cap with plastic projections, may improve colonic visualisation and adenoma detection. The aim of this study was to compare the mean number of adenomas per patient (MAP) and the adenoma detection rate (ADR) between Endocuff-assisted colonoscopy (EAC) and conventional colonoscopy (CC). METHODS We performed a multicentre, randomised controlled trial in five hospitals and included fecal immonochemical test (FIT)-positive screening participants as well as symptomatic patients (>45 years). Consenting patients were randomised 1:1 to EAC or CC. All colonoscopies were performed by experienced colonoscopists (≥500 colonoscopies) who were trained in EAC. All colonoscopy quality indicators were prospectively recorded. FINDINGS Of the 1063 included patients (52% male, median age 65 years), 530 were allocated to EAC and 533 to CC. More adenomas were detected with EAC, 722 vs 621, but the gain in MAP was not significant: on average 1.36 per patient in the EAC group versus 1.17 in the CC group (p=0.08). In a per-protocol analysis, the gain was 1.44 vs 1.19 (p=0.02), respectively. In the EAC group, 275 patients (52%) had one or more adenomas detected versus 278 in the CC group (52%; p=0.92). For advanced adenomas these numbers were 109 (21%) vs 117 (22%). The adjusted caecal intubation rate was lower with EAC (94% vs 99%; p<0.001), however when allowing crossover from EAC to CC, they were similar in both groups (98% vs 99%; p value=0.25). INTERPRETATION Though more adenomas are detected with EAC, the routine use of Endocuff does not translate in a higher number of patients with one or more adenomas detected. Whether increased detection ultimately results in a lower rate of interval carcinomas is not yet known. TRIAL REGISTRATION NUMBER http://www.trialregister.nl Dutch Trial Register: NTR3962.
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Affiliation(s)
- S C van Doorn
- Departments of Gastroenterology & Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M van der Vlugt
- Departments of Gastroenterology & Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Actm Depla
- Departments of Gastroenterology & Hepatology, Slotervaartziekenhuis, Amsterdam, The Netherlands
| | - C A Wientjes
- Departments of Gastroenterology & Hepatology, Sint Lucas Andreas Ziekenhuis, Amsterdam, The Netherlands
| | - R C Mallant-Hent
- Departments of Gastroenterology & Hepatology, Flevoziekenhuis, Almere, The Netherlands
| | - P D Siersema
- Departments of Gastroenterology & Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - H Tuynman
- Departments of Gastroenterology & Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Departments of Gastroenterology & Hepatology, Slotervaartziekenhuis, Amsterdam, The Netherlands
| | - S D Kuiken
- Departments of Gastroenterology & Hepatology, Sint Lucas Andreas Ziekenhuis, Amsterdam, The Netherlands
| | - Gmp Houben
- Departments of Gastroenterology & Hepatology, Slotervaartziekenhuis, Amsterdam, The Netherlands
| | - Pcf Stokkers
- Departments of Gastroenterology & Hepatology, Sint Lucas Andreas Ziekenhuis, Amsterdam, The Netherlands
| | - Lmg Moons
- Departments of Gastroenterology & Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Pmm Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - P Fockens
- Departments of Gastroenterology & Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Mundt
- Departments of Gastroenterology & Hepatology, Flevoziekenhuis, Almere, The Netherlands
| | - E Dekker
- Departments of Gastroenterology & Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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13
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Timmer MR, Martinez P, Lau CT, Westra WM, Calpe S, Rygiel AM, Rosmolen WD, Meijer SL, ten Kate FJ, Dijkgraaf MG, Mallant-Hent RC, Naber AH, van Oijen AH, Baak LC, Scholten P, Böhmer CJ, Fockens P, Maley CC, Graham TA, Bergman JJ, Krishnadath KK. Derivation of genetic biomarkers for cancer risk stratification in Barrett's oesophagus: a prospective cohort study. Gut 2016; 65:1602-10. [PMID: 26104750 PMCID: PMC4988941 DOI: 10.1136/gutjnl-2015-309642] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 06/06/2015] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The risk of developing adenocarcinoma in non-dysplastic Barrett's oesophagus is low and difficult to predict. Accurate tools for risk stratification are needed to increase the efficiency of surveillance. We aimed to develop a prediction model for progression using clinical variables and genetic markers. METHODS In a prospective cohort of patients with non-dysplastic Barrett's oesophagus, we evaluated six molecular markers: p16, p53, Her-2/neu, 20q, MYC and aneusomy by DNA fluorescence in situ hybridisation on brush cytology specimens. Primary study outcomes were the development of high-grade dysplasia or oesophageal adenocarcinoma. The most predictive clinical variables and markers were determined using Cox proportional-hazards models, receiver operating characteristic curves and a leave-one-out analysis. RESULTS A total of 428 patients participated (345 men; median age 60 years) with a cumulative follow-up of 2019 patient-years (median 45 months per patient). Of these patients, 22 progressed; nine developed high-grade dysplasia and 13 oesophageal adenocarcinoma. The clinical variables, age and circumferential Barrett's length, and the markers, p16 loss, MYC gain and aneusomy, were significantly associated with progression on univariate analysis. We defined an 'Abnormal Marker Count' that counted abnormalities in p16, MYC and aneusomy, which significantly improved risk prediction beyond using just age and Barrett's length. In multivariate analysis, these three factors identified a high-risk group with an 8.7-fold (95% CI 2.6 to 29.8) increased HR when compared with the low-risk group, with an area under the curve of 0.76 (95% CI 0.66 to 0.86). CONCLUSIONS A prediction model based on age, Barrett's length and the markers p16, MYC and aneusomy determines progression risk in non-dysplastic Barrett's oesophagus.
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Affiliation(s)
- Margriet R. Timmer
- Department of Gastroenterology and Hepatology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Pierre Martinez
- Evolution and Cancer Laboratory, Centre for Tumour Biology, Barts Cancer Institute, London, EC1M 6BQ, United Kingdom
| | - Chiu T. Lau
- Department of Gastroenterology and Hepatology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Wytske M. Westra
- Department of Gastroenterology and Hepatology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Silvia Calpe
- Department of Gastroenterology and Hepatology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Agnieszka M. Rygiel
- Department of Gastroenterology and Hepatology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Wilda D. Rosmolen
- Department of Gastroenterology and Hepatology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Sybren L. Meijer
- Department of Pathology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Fiebo J.W. ten Kate
- Department of Pathology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Marcel G.W. Dijkgraaf
- Clinical Research Unit, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | | | - Anton H.J. Naber
- Department of Gastroenterology, Tergooiziekenhuizen, 1213 XZ, Hilversum, The Netherlands
| | | | - Lubbertus C. Baak
- Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, 1091 AC, Amsterdam, The Netherlands
| | - Pieter Scholten
- Department of Gastroenterology, Sint Lucas Andreas Ziekenhuis, 1061 AE, Amsterdam, The Netherlands
| | - Clarisse J.M. Böhmer
- Department of Gastroenterology, Spaarne Ziekenhuis, 2134 TM, Hoofddorp, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Carlo C. Maley
- Centre for Evolution and Cancer, University of California at San Francisco, CA 94143-0128, USA
| | - Trevor A. Graham
- Evolution and Cancer Laboratory, Centre for Tumour Biology, Barts Cancer Institute, London, EC1M 6BQ, United Kingdom
| | - Jacques J.G.H.M. Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
| | - Kausilia K. Krishnadath
- Department of Gastroenterology and Hepatology, Academic Medical Centre – University of Amsterdam, 1011 AZ, Amsterdam, The Netherlands
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14
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Martinez P, Timmer MR, Lau CT, Calpe S, Sancho-Serra MDC, Straub D, Baker AM, Meijer SL, Kate FJWT, Mallant-Hent RC, Naber AHJ, van Oijen AHAM, Baak LC, Scholten P, Böhmer CJM, Fockens P, Bergman JJGHM, Maley CC, Graham TA, Krishnadath KK. Dynamic clonal equilibrium and predetermined cancer risk in Barrett's oesophagus. Nat Commun 2016; 7:12158. [PMID: 27538785 PMCID: PMC4992167 DOI: 10.1038/ncomms12158] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 06/06/2016] [Indexed: 12/24/2022] Open
Abstract
Surveillance of Barrett's oesophagus allows us to study the evolutionary dynamics of a human neoplasm over time. Here we use multicolour fluorescence in situ hybridization on brush cytology specimens, from two time points with a median interval of 37 months in 195 non-dysplastic Barrett's patients, and a third time point in a subset of 90 patients at a median interval of 36 months, to study clonal evolution at single-cell resolution. Baseline genetic diversity predicts progression and remains in a stable dynamic equilibrium over time. Clonal expansions are rare, being detected once every 36.8 patient years, and growing at an average rate of 1.58 cm(2) (95% CI: 0.09-4.06) per year, often involving the p16 locus. This suggests a lack of strong clonal selection in Barrett's and that the malignant potential of 'benign' Barrett's lesions is predetermined, with important implications for surveillance programs.
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Affiliation(s)
- Pierre Martinez
- Evolution and Cancer Laboratory, Centre for Tumour Biology, Barts Cancer Institute, Queen Mary University of London, EC1M 6BQ London, UK
| | - Margriet R. Timmer
- Department of Gastroenterology and Hepatology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Chiu T. Lau
- Department of Gastroenterology and Hepatology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Silvia Calpe
- Department of Gastroenterology and Hepatology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Maria del Carmen Sancho-Serra
- Department of Gastroenterology and Hepatology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Danielle Straub
- Department of Gastroenterology and Hepatology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Ann-Marie Baker
- Evolution and Cancer Laboratory, Centre for Tumour Biology, Barts Cancer Institute, Queen Mary University of London, EC1M 6BQ London, UK
| | - Sybren L. Meijer
- Department of Pathology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Fiebo J. W. ten Kate
- Department of Pathology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Rosalie C. Mallant-Hent
- Department of Gastroenterology and Hepatology, Flevoziekenhuis, 1300 EG Almere, The Netherlands
- Gastroenterological Association, 1006 AE Amsterdam, The Netherlands
| | - Anton H. J. Naber
- Gastroenterological Association, 1006 AE Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Tergooiziekenhuizen, 1201 DA Hilversum, The Netherlands
| | - Arnoud H. A. M. van Oijen
- Gastroenterological Association, 1006 AE Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Medisch Centrum, 1800 AM Alkmaar, The Netherlands
| | - Lubbertus C. Baak
- Gastroenterological Association, 1006 AE Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, 1091 AC Amsterdam, The Netherlands
| | - Pieter Scholten
- Gastroenterological Association, 1006 AE Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Sint Lucas Andreas Ziekenhuis, 1006 AE Amsterdam, The Netherlands
| | - Clarisse J. M. Böhmer
- Gastroenterological Association, 1006 AE Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Spaarne Ziekenhuis, 2134 TM Hoofddorp, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Jacques J. G. H. M. Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
- Gastroenterological Association, 1006 AE Amsterdam, The Netherlands
| | - Carlo C. Maley
- Biodesign Institute, School of Life Sciences, Arizona State University, Tempe, Arizona 85281, USA
| | - Trevor A. Graham
- Evolution and Cancer Laboratory, Centre for Tumour Biology, Barts Cancer Institute, Queen Mary University of London, EC1M 6BQ London, UK
| | - Kausilia K Krishnadath
- Department of Gastroenterology and Hepatology, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Academic Medical Center—University of Amsterdam, 1100 DD Amsterdam, The Netherlands
- Gastroenterological Association, 1006 AE Amsterdam, The Netherlands
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15
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Duits LC, Phoa KN, Curvers WL, Ten Kate FJW, Meijer GA, Seldenrijk CA, Offerhaus GJ, Visser M, Meijer SL, Krishnadath KK, Tijssen JGP, Mallant-Hent RC, Bergman JJGHM. Barrett's oesophagus patients with low-grade dysplasia can be accurately risk-stratified after histological review by an expert pathology panel. Gut 2015; 64:700-6. [PMID: 25034523 DOI: 10.1136/gutjnl-2014-307278] [Citation(s) in RCA: 194] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 06/28/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Reported malignant progression rates for low-grade dysplasia (LGD) in Barrett's oesophagus (BO) vary widely. Expert histological review of LGD is advised, but limited data are available on its clinical value. This retrospective cohort study aimed to determine the value of an expert pathology panel organised in the Dutch Barrett's Advisory Committee (BAC) by investigating the incidence rates of high-grade dysplasia (HGD) and oesophageal adenocarcinoma (OAC) after expert histological review of LGD. DESIGN We included all BO cases referred to the BAC for histological review of LGD diagnosed between 2000 and 2011. The diagnosis of the expert panel was related to the histological outcome during endoscopic follow-up. Primary endpoint was development of HGD or OAC. RESULTS 293 LGD patients (76% men; mean 63 years±11.9) were included. Following histological review, 73% was downstaged to non-dysplastic BO (NDBO) or indefinite for dysplasia (IND). In 27% the initial LGD diagnosis was confirmed. Endoscopic follow-up was performed in 264 patients (90%) with a median follow-up of 39 months (IQR 16-72). For confirmed LGD, the risk of HGD/OAC was 9.1% per patient-year. Patients downstaged to NDBO or IND had a malignant progression risk of 0.6% and 0.9% per patient-year, respectively. CONCLUSIONS Confirmed LGD in BO has a markedly increased risk of malignant progression. However, the vast majority of patients with community LGD will be downstaged after expert review and have a low progression risk. Therefore, all BO patients with LGD should undergo expert histological review of the diagnosis for adequate risk stratification.
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Affiliation(s)
- Lucas C Duits
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - K Nadine Phoa
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Fiebo J W Ten Kate
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands Department of Pathology, University Medical Centre, Utrecht, The Netherlands
| | - Gerrit A Meijer
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Cees A Seldenrijk
- Department of Pathology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - G Johan Offerhaus
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands Department of Pathology, University Medical Centre, Utrecht, The Netherlands
| | - Mike Visser
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Kausilia K Krishnadath
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Rosalie C Mallant-Hent
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands Department of Gastroenterology and Hepatology, Flevoziekenhuis, Almere, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
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16
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Gardenbroek TJ, Pinkney TD, Sahami S, Morton DG, Buskens CJ, Ponsioen CY, Tanis PJ, Löwenberg M, van den Brink GR, Broeders IA, Pullens PH, Seerden T, Boom MJ, Mallant-Hent RC, Pierik RE, Vecht J, Sosef MN, van Nunen AB, van Wagensveld BA, Stokkers PC, Gerhards MF, Jansen JM, Acherman Y, Depla AC, Mannaerts GH, West R, Iqbal T, Pathmakanthan S, Howard R, Magill L, Singh B, Htun Oo Y, Negpodiev D, Dijkgraaf MG, Ram D'Haens G, Bemelman WA. The ACCURE-trial: the effect of appendectomy on the clinical course of ulcerative colitis, a randomised international multicenter trial (NTR2883) and the ACCURE-UK trial: a randomised external pilot trial (ISRCTN56523019). BMC Surg 2015; 15:30. [PMID: 25887789 PMCID: PMC4393565 DOI: 10.1186/s12893-015-0017-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 02/26/2015] [Indexed: 12/18/2022] Open
Abstract
Background Over the past 20 years evidence has accumulated confirming the immunomodulatory role of the appendix in ulcerative colitis (UC). This led to the idea that appendectomy might alter the clinical course of established UC. The objective of this body of research is to evaluate the short-term and medium-term efficacy of appendectomy to maintain remission in patients with UC, and to establish the acceptability and cost-effectiveness of the intervention compared to standard treatment. Methods/Design These paired phase III multicenter prospective randomised studies will include patients over 18 years of age with an established diagnosis of ulcerative colitis and a disease relapse within 12 months prior to randomisation. Patients need to have been medically treated until complete clinical (Mayo score <3) and endoscopic (Mayo score 0 or 1) remission. Patients will then be randomised 1:1 to a control group (maintenance 5-ASA treatment, no appendectomy) or elective laparoscopic appendectomy plus maintenance treatment. The primary outcome measure is the one year cumulative UC relapse rate - defined both clinically and endoscopically as a total Mayo-score ≥5 with endoscopic subscore of 2 or 3. Secondary outcomes that will be assessed include the number of relapses per patient at 12 months, the time to first relapse, health related quality of life and treatment costs, and number of colectomies in each arm. Discussion The ACCURE and ACCURE-UK trials will provide evidence on the role and acceptability of appendectomy in the treatment of ulcerative colitis and the effects of appendectomy on the disease course. Trial registration NTR2883; ISRCTN56523019
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Affiliation(s)
- Tjibbe J Gardenbroek
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Thomas D Pinkney
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Saloomeh Sahami
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Dion G Morton
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Christianne J Buskens
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Gijs R van den Brink
- Department of Gastroenterology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Ivo Amj Broeders
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Paul Hjm Pullens
- Department of Gastroenterology, Meander Medical Center, Amersfoort, The Netherlands
| | - Tom Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, The Netherlands
| | - Maarten J Boom
- Department of Surgery, Flevo Hospital, Almere, The Netherlands
| | | | | | - Juda Vecht
- Department of Gastroenterology, Isala Hospital, Zwolle, The Netherlands
| | - Meindert N Sosef
- Department of Surgery, Atrium Medical Center, Heerlen, The Netherlands
| | - Annick B van Nunen
- Department of Gastroenterology, Atrium Medical Center, Heerlen, The Netherlands
| | | | - Pieter Cf Stokkers
- Department of Gastroenterology, Lucas Andreas Hospital, Amsterdam, The Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Hospital, Amsterdam, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, Onze Lieve Vrouwe Hospital, Amsterdam, The Netherlands
| | - Yair Acherman
- Department of Surgery, Slotervaart Hospital, Amsterdam, The Netherlands
| | | | - Guido Hh Mannaerts
- Department of Surgery, St. Franciscus Hospital, Rotterdam, The Netherlands
| | - Rachel West
- Department of Gastroenterology, St. Franciscus Hospital, Rotterdam, The Netherlands
| | - Tariq Iqbal
- Department of Gastroenterology, University Hospitals Birmingham, Birmingham, UK
| | | | - Rebecca Howard
- Birmingham Clinical Trials Unit, University Hospitals Birmingham, Birmingham, UK
| | - Laura Magill
- Birmingham Clinical Trials Unit, University Hospitals Birmingham, Birmingham, UK
| | - Baljit Singh
- Department of Surgery, University Hospitals Leicester, Leicester, UK
| | - Ye Htun Oo
- School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - Dmitri Negpodiev
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | | | - Geert Ram D'Haens
- Department of Gastroenterology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
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17
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Alvarez Herrero L, Curvers WL, van Vilsteren FGI, Wolfsen H, Ragunath K, Wong Kee Song LM, Mallant-Hent RC, van Oijen A, Scholten P, Schoon EJ, Schenk EBE, Weusten BLAM, Bergman JGHM. Validation of the Prague C&M classification of Barrett's esophagus in clinical practice. Endoscopy 2013; 45:876-82. [PMID: 24165812 DOI: 10.1055/s-0033-1344952] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS The Prague C&M classification for Barrett's esophagus has found widespread acceptance but has only been validated by Barrett's experts scoring video sequences. To date, validation has been lacking for its application in routine practice during real-time endoscopy. The aim of this study was to evaluate agreement between Barrett's experts and community hospital endoscopists when using this classification to describe Barrett's esophagus and hiatal hernia length during real-time endoscopy. PATIENTS AND METHODS Patients underwent two consecutive endoscopies performed by different endoscopists. The study was performed in two cohorts: one cohort was seen by Barrett's experts and the other cohort by community hospital endoscopists. Landmarks were recorded according to the Prague classification. Outcomes were interobserver agreement (assessed with intraclass correlation coefficient [ICC]), absolute agreement, and relative agreement. RESULTS A total of 187 patients were included, with median extent of C3M5 (IQR C1 - 7 M4 - 9) for Barrett's esophagus and 3 cm (IQR 2-5) for hiatal hernia length. ICC was 0.91 (95 % confidence interval [CI] 0.88-0.93) for maximum length, 0.92 (95% CI 0.90-0.94) for circumferential extent, and 0.59 (95% CI 0.49-0.68) for hiatal hernia length. Absolute agreement within ≤ 1 cm was 74% (95% CI 68-80) for circumference, 68% (95% CI 62-75) for length, and 63% (95% CI 56 - 70) for hiatal hernia length. Relative agreement was 91% for Barrett's esophagus and 80 % for hiatal hernia length. Barrett's experts and community hospital endoscopists showed no differences in agreement. Shorter Barrett's segments (≤ 5 cm) had lower agreement compared with longer segments (> 5 cm). CONCLUSIONS Agreement was good for Barrett's esophagus and reasonable for hiatal hernia length. These findings strengthen the value of the Prague C&M classification to describe Barrett's esophagus and hiatal hernia length. Although absolute agreement during real-time endoscopy was high, one should anticipate that Barrett's values may vary by 1 - 2 cm between two endoscopies.
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Affiliation(s)
- Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius hospital, Nieuwegein, The Netherlands
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18
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Phoa KN, Pouw RE, van Vilsteren FGI, Sondermeijer CMT, Ten Kate FJW, Visser M, Meijer SL, van Berge Henegouwen MI, Weusten BLAM, Schoon EJ, Mallant-Hent RC, Bergman JJGHM. Remission of Barrett's esophagus with early neoplasia 5 years after radiofrequency ablation with endoscopic resection: a Netherlands cohort study. Gastroenterology 2013; 145:96-104. [PMID: 23542068 DOI: 10.1053/j.gastro.2013.03.046] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 03/20/2013] [Accepted: 03/21/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND & AIMS Radiofrequency ablation (RFA), with or without endoscopic resection effectively eradicates Barrett's esophagus (BE) containing high-grade intraepithelial neoplasia and/or early-stage cancer. We followed patients who received RFA for BE containing high-grade intraepithelial neoplasia and/or early-stage cancer for 5 years to determine the durability of treatment response. METHODS We followed 54 patients with BE (2-12 cm), previously enrolled in 4 consecutive cohort studies in which they underwent focal endoscopic resection in case of visible lesions (n = 40 [72%]), followed by serial RFA every 3 months. Patients underwent high-resolution endoscopy with narrow-band imaging at 6 and 12 months after treatment and then annually for 5 years (median, 61 months; interquartile range, 53-65 months); random biopsy samples were collected from neosquamous epithelium and gastric cardia. After 5 years, endoscopic ultrasound and endoscopic resection of neosquamous epithelium were performed. Outcomes included sustained complete remission of neoplasia or intestinal metaplasia (IM), IM in gastric cardia, or buried glands in neosquamous epithelium. RESULTS After 5 years, Kaplan-Meier analysis showed sustained complete remission of neoplasia and intestinal metaplasia in 90% of patients; neoplasia recurred in 3 patients and was managed endoscopically. Focal IM in the cardia was found in 19 of 54 patients (35%), in 53 of 1143 gastric cardia biopsies (4.6%). The incidence of IM of the cardia did not increase over time; and IM was diagnosed based on only a single biopsy in 89% of patients. Buried glands were detected in 3 of 3543 neosquamous epithelium biopsies (0.08%, from 3 patients). No endoscopic resection samples had buried glands. CONCLUSIONS Among patients who have undergone RFA with or without endoscopic resection for neoplastic BE, 90% remain in remission at 5-year follow-up, with all recurrences managed endoscopically. This treatment approach is therefore an effective and durable alternative to esophagectomy; www.trialregister.nl number, NTR2938.
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Affiliation(s)
- K Nadine Phoa
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Fiebo J W Ten Kate
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mike Visser
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Bas L A M Weusten
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology, Catharina Hospital, Eindhoven, The Netherlands
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19
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Stegeman I, de Wijkerslooth TR, Mallant-Hent RC, de Groot K, Stroobants AK, Fockens P, Mundt M, Bossuyt PM, Dekker E. Implementation of population screening for colorectal cancer by repeated Fecal Immunochemical Test (FIT): third round. BMC Gastroenterol 2012; 12:73. [PMID: 22713100 PMCID: PMC3407009 DOI: 10.1186/1471-230x-12-73] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 06/19/2012] [Indexed: 12/15/2022] Open
Abstract
Background Colorectal cancer (CRC) is the most common cancer in Europe with a mortality rate of almost 50%. The prognosis of patients is largely determined by the clinical and pathological stage at the time of diagnosis. Population screening has been shown to reduce CRC-related mortality rate. Most screening programs worldwide rely on fecal immunochemical testing (FIT). The effectiveness of a FIT screening program is not only influenced by initial participation rate, but also by program adherence during consecutive screening rounds. We aim to evaluate the participation rate in and yield of a third CRC screening round using FIT. Methods and design Four years after the first screening round and two years after the second round, a total number of approximately 11,000 average risk individuals (50 to 75 years of age) will be invited to participate in a third round of FIT-based CRC screening. We will select individuals in the same target area as in the previous screening rounds, using the electronic database of the regional municipal administration registrations. We will invite all FIT-negatives and all non-participants in previous screening rounds, as well as eligible first time invitees who have moved into the area or have become 50 years of age. FITs will be analyzed in the special technique laboratory of the Academic Medical Center of the University of Amsterdam. All FIT-positives will be invited for a consultation at the outpatient clinic. In the absence of contra-indications, a colonoscopy will follow at the Academic Medical Center or at the Flevohospital. The primary outcome measures are the participation rate, defined as the proportion of invitees that return a FIT in this third round of FIT-screening, and the diagnostic yield of the program. Implications This study will provide precise data on the participation in later FIT screening rounds. This enables to estimate the effectiveness of CRC screening programs that rely on repeated FIT- screening, such as the one that will be implemented in the Netherlands in 2013.
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Affiliation(s)
- Inge Stegeman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands.
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20
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Curvers WL, van Vilsteren FG, Baak LC, Böhmer C, Mallant-Hent RC, Naber AH, van Oijen A, Ponsioen CY, Scholten P, Schenk E, Schoon E, Seldenrijk CA, Meijer GA, ten Kate FJ, Bergman JJ. Endoscopic trimodal imaging versus standard video endoscopy for detection of early Barrett's neoplasia: a multicenter, randomized, crossover study in general practice. Gastrointest Endosc 2011; 73:195-203. [PMID: 21168835 DOI: 10.1016/j.gie.2010.10.014] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 10/08/2010] [Indexed: 12/24/2022]
Abstract
BACKGROUND Endoscopic trimodal imaging (ETMI) may improve detection of early neoplasia in Barrett's esophagus (BE). Studies with ETMI so far have been performed in tertiary referral settings only. OBJECTIVE To compare ETMI with standard video endoscopy (SVE) for the detection of neoplasia in BE patients with an intermediate-risk profile. DESIGN Multicenter, randomized, crossover study. SETTING Community practice. PATIENTS AND METHODS BE patients with confirmed low-grade intraepithelial neoplasia (LGIN) underwent both ETMI and SVE in random order (interval 6-16 weeks). During ETMI, BE was inspected with high-resolution endoscopy followed by autofluorescence imaging (AFI). All visible lesions were then inspected with narrow-band imaging. During ETMI and SVE, visible lesions were sampled followed by 4-quadrant random biopsies every 2 cm. MAIN OUTCOME MEASUREMENTS Overall histological yield of ETMI and SVE and targeted histological yield of ETMI and SVE. RESULTS A total of 99 patients (79 men, 63±10 years) underwent both procedures. ETMI had a significantly higher targeted histological yield because of additional detection of 22 lesions with LGIN/high-grade intraepithelial neoplasia (HGIN)/carcinoma (Ca) by AFI. There was no significant difference in the overall histological yield (targeted+random) between ETMI and SVE. HGIN/Ca was diagnosed only by random biopsies in 6 of 24 patients and 7 of 24 patients, with ETMI and SVE, respectively. LIMITATIONS Inspection, with high-resolution endoscopy and AFI, was performed sequentially. CONCLUSION ETMI performed in a community-based setting did not improve the overall detection of dysplasia compared with SVE. The diagnosis of dysplasia is still being made in a significant number of patients by random biopsies. Patients with a confirmed diagnosis of LGIN have a significant risk of HGIN/Ca. ( CLINICAL TRIAL REGISTRATION NUMBER ISRCTN91816824; NTR867.).
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Affiliation(s)
- Wouter L Curvers
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands.
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21
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Curvers WL, ten Kate FJ, Krishnadath KK, Visser M, Elzer B, Baak LC, Bohmer C, Mallant-Hent RC, van Oijen A, Naber AH, Scholten P, Busch OR, Blaauwgeers HGT, Meijer GA, Bergman JJGHM. Low-grade dysplasia in Barrett's esophagus: overdiagnosed and underestimated. Am J Gastroenterol 2010; 105:1523-30. [PMID: 20461069 DOI: 10.1038/ajg.2010.171] [Citation(s) in RCA: 319] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Published data on the natural history of low-grade dysplasia (LGD) in Barrett's esophagus (BE) are inconsistent and difficult to interpret. We investigated the natural history of LGD in a large community-based cohort of BE patients after reviewing the original histological diagnosis by an expert panel of pathologists. METHODS Histopathology reports of all patients diagnosed with LGD between 2000 and 2006 in six non-university hospitals were reviewed by two expert pathologists. This panel diagnosis was subsequently compared with the histological outcome during prospective endoscopic follow-up. RESULTS A diagnosis of LGD was made in 147 patients. After pathology review, 85% of the patients were downstaged to non-dysplastic BE (NDBE) or to indefinite for dysplasia. In only 15% of the patients was the initial diagnosis LGD. Endoscopic follow-up was carried out in 83.6% of patients, with a mean follow-up of 51.1 months. For patients with a consensus diagnosis of LGD, the cumulative risk of progressing to high-grade dysplasia or carcinoma (HGD or Ca) was 85.0% in 109.1 months compared with 4.6% in 107.4 months for patients downstaged to NDBE (P<0.0001). The incidence rate of HGD or Ca was 13.4% per patient per year for patients in whom the diagnosis of LGD was confirmed. For patients downstaged to NDBE, the corresponding incidence rate was 0.49%. CONCLUSIONS LGD in BE is an overdiagnosed and yet underestimated entity in general practice. Patients diagnosed with LGD should undergo an expert pathology review to purify this group. In case the diagnosis of LGD is confirmed, patients should undergo strict endoscopic follow-up or should be considered for endoscopic ablation therapy.
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Affiliation(s)
- Wouter L Curvers
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9 , Amsterdam 1105 AZ , The Netherlands
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22
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Curvers WL, Bohmer CJ, Mallant-Hent RC, Naber AH, Ponsioen CI, Ragunath K, Singh R, Wallace MB, Wolfsen HC, Song LMWK, Lindeboom R, Fockens P, Bergman JJ. Mucosal morphology in Barrett's esophagus: interobserver agreement and role of narrow band imaging. Endoscopy 2008; 40:799-805. [PMID: 18828075 DOI: 10.1055/s-2008-1077596] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS We have recently proposed a classification of mucosal morphology in Barrett's esophagus based on three criteria: regularity of mucosal pattern, regularity of vascular pattern, and presence of abnormal blood vessels. We aimed to evaluate the interobserver agreement with the proposed mucosal morphology classification and to assess the additional value of narrow band imaging (NBI) over high resolution white light endoscopy (HR-WLE). PATIENTS AND METHODS Five international experts in the field of Barrett's imaging and seven community endoscopists with no expertise in this field independently evaluated magnified still images from 50 areas, obtained with HR-WLE and NBI, in Barrett's esophagus patients. Visual analogue scales (VAS) were used for scoring imaging quality. Interobserver agreement for mucosal morphology and yield for identifying early neoplasia were assessed. RESULTS Imaging qualities of NBI were rated more highly than HR-WLE, when evaluated separately as well as in a side-by-side comparison. The interobserver agreement ranged from 0.40 to 0.56 and did not significantly differ between expert and non-expert endoscopists. The overall yield for correctly identifying images of early neoplasia was 81 % for HR-WLE, 72 % for NBI and 83 % for HR-WLE + NBI, with no significant difference between experts and non-experts. CONCLUSION Interobserver agreement for the classification of mucosal morphology was moderate. Although NBI was rated more highly than HR-WLE for imaging quality, this did not result in improved interobserver agreement or increased yield for identifying early neoplasia in Barrett's esophagus. This applied to non-expert as well as expert endoscopists.
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Affiliation(s)
- W L Curvers
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
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23
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Linskens RK, Mallant-Hent RC, Murillo LS, von Blomberg BME, Alizadeh BZ, Peña AS. Genetic and serological markers to identify phenotypic subgroups in a Dutch Crohn' s disease population. Dig Liver Dis 2004; 36:29-34. [PMID: 14971813 DOI: 10.1016/j.dld.2003.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Both genetic and microbial factors seem to play a pivotal role in the aetiopathogenesis of Crohn's disease. The CARD15 frameshift mutation might link host genetic factors and the indigenous microbial flora, since CARD15 expression is stimulated by peptidoglycan, thereby activating NF-kappaB. It is hypothesised that CARD15 mutation carriers have defective anti-microbial reactions, resulting in more penetrating lesions and antibody responses, which are now being used as highly specific markers for Crohn's disease. The serological marker anti-Saccharomyces cerevisiae antibody directed against cell wall oligomannosidic epitopes has high specificity for Crohn's disease. Perinuclear anti-neutrophil cytoplasmic antibodies have been found in a subgroup of Crohn's disease patients, mostly with colonic involvement. METHODS We investigated the incidence of two CARD15 mutations (3020insC and 2722G>C), anti-S. cerevisiae antibody, and perinuclear anti-neutrophil cytoplasmic antibody in 108 (73F/35M) patients with Crohn's disease with a mean duration of disease since diagnosis of 16 (1-41) years in relation to their phenotype, according to the Vienna classification. RESULTS The prevalence of CARD15 frameshift mutation was 21%. Of all patients, 62% were anti-S. cerevisiae antibody positive, and 9% had perinuclear anti-neutrophil cytoplasmic antibodies. The prevalence of both anti-S. cerevisiae antibodies and perinuclear anti-neutrophil cytoplasmic antibodies was higher in the mutation carriers compared to non-carriers. Remarkably, all patients with a CARD15 mutation and positive anti-S. cerevisiae antibody had ileal disease. Carriership of the mutation was significantly associated with penetrating behaviour of the disease and weakly associated with stricturing behaviour. Furthermore, anti-S. cerevisiae antibody was associated with ileal disease involvement. Finally, most perinuclear anti-neutrophil cytoplasmic antibody positive patients showed ulcerative-like behaviour of disease (by means of colonic localisation). CONCLUSIONS Genetic and serologic markers might be useful in defining patient subgroups. This may result in a more accurate prediction of disease behaviour, prognosis and therapeutic approach.
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Affiliation(s)
- R K Linskens
- Department of Gastroenterology, VU Medical Center, Amsterdam, The Netherlands.
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24
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Linskens RK, Mallant-Hent RC, Groothuismink ZMA, Bakker-Jonges LE, van de Merwe JP, Hooijkaas H, von Blomberg BME, Meuwissen SGM. Evaluation of serological markers to differentiate between ulcerative colitis and Crohn's disease: pANCA, ASCA and agglutinating antibodies to anaerobic coccoid rods. Eur J Gastroenterol Hepatol 2002; 14:1013-8. [PMID: 12352222 DOI: 10.1097/00042737-200209000-00013] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Accurate diagnosis of inflammatory bowel disease, in particular the differentiation between ulcerative colitis and Crohn's disease, is important for treatment and prognosis. Several serological markers have been used as non-invasive diagnostic tools in inflammatory bowel disease patients both to differentiate ulcerative colitis from Crohn's disease and to define patient subgroups. AIM To evaluate the diagnostic accuracy of three serological tests in differentiating ulcerative colitis from Crohn's disease by single or combined use. METHODS Sera from 51 patients with clinically well-defined ulcerative colitis and 50 patients with clinically well-defined Crohn's disease were analysed. Detection assays for the presence of perinuclear anti-neutrophil cytoplasmatic antibodies (pANCA), antibodies against (ASCA) and serum agglutinating antibodies to anaerobic coccoid rods were studied. Sensitivity, specificity, predictive values and likelihood ratios of each of these serological tests were determined. RESULTS In supporting the diagnosis of ulcerative colitis, the sensitivity and specificity of the pANCA test were 63% and 86%, respectively. The ASCA test (immunoglobulin A or immunoglobulin G positive) for diagnosing Crohn's disease had a sensitivity of 72% and a specificity of 82%. The sensitivity of antibodies to anaerobic coccoid rods in diagnosing Crohn's disease was 52%, whereas specificity was 90%. A combination of pANCA-positive and ASCA-negative results in the case of ulcerative colitis showed a sensitivity and specificity of 51% and 94%, respectively. However, for ASCA-positive and pANCA-negative results in the case of Crohn's disease, sensitivity was 64% and specificity was 94%. The combination of all three tests increased positive predictive value and specificity to 100% for both ulcerative colitis and Crohn's disease. In Crohn's disease patients, positive pANCA was correlated with colonic involvement. No correlation was found between the presence of any of these antibodies and disease activity, duration and behaviour or medical treatment. CONCLUSIONS The value of these serological tests in differentiating ulcerative colitis from Crohn's disease is limited when used separately but, by combining two or more tests, the positive predictive value and specificity can be improved substantially. These tests might be of help in studying disease heterogeneity, and may contribute to defining various subgroups of patients with different pathogeneses.
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Affiliation(s)
- Ronald K Linskens
- Departments of Gastroenterology and Clinical Immunology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands.
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