Objec-ve. Case Presenta-ons and Ques-ons to Panel. Dysplasia case 11/13/11

Transcription

1 Case Presenta-ons and Ques-ons to Panel UCSF IBD Symposium November 12, 2011 Moderator Fernando Velayos MD Panelists Brian Feagan, MD James Lewis, MD MSCE Robert Cima, MD Hueylan Chern, MD Sunanda Kane, MD Objec-ve Present 2 cases and obtain both medical and surgical perspec-ve from panel regarding approach to the cases Focus on a few ques-ons and data slides per case Plenty of -me for ques-ons from audience to the panel regarding their talks and issues raised by the cases Dysplasia case 54 year old man with a history of left-sided ulcerative colitis diagnosed at age 10 referred to UCSF for 2 nd opinion/management of dysplasia Prior treatments include prednisone, Azulfidine, Asacol; mild disease over life-time Colonoscopy Nov 2010 elsewhere 1cm flat polypoid lesion 30 cm anal verge (inflammatory polyp) 2cm flat lesion 15 cm anal verge (tubulovillous adenoma) Anal stricture (chronic active proctitis, negative dysplasia) 1-2 solid BM day, no blood PMH: UC as above MEDS: Asacol 400 mg bid SH: Single homosexual male FH: Father unspecified blood disorder, mother fibromyalgia Exam: Unremarkable Labs: None recent Patient says he does not want colon removed 1

2 FYI Mul-- Center Survey of 616 Pa-ents with UC Results - Pa-ents overes-mate risk of CRC - Even if dysplasia is found, pa-ents have a very high threshold for undergoing colectomy Colectomy after dysplasia diagnosis in large health-care maintenance organization Colonoscopy 2007 (elsewhere) Pancolitis Polyp at 30 cm (chronic active colitis) 7mm polyp sigmoid colon TI with focal/subacute inflammation Chronic active colitis throughout colon Inflammatory anal tags, focally eroded, negative for dysplasia Path reread at UCSF (low grade dysplasia) Colonoscopy UCSF Normal TI Mild colitis throughout No polyp at 30 seen Slightly raised 3 cm lesion at 15cm (low-grade dysplasia) Anal/rectal stricture (proctitis, no dysplasia) 2

3 Medical Discussion questions Do you recommend colectomy? Should we call this flat dysplasia vs. raised dysplasia vs. does it matter? Does the anal stricture need any additional work-up or treatment or play into the decision? Surgical Discussion questions Surgical options or pouch outcomes to discuss with patient? Does the anal stricture matter? Does his age matter? Location of dysplasia matter? Any options besides proctocolectomy in someone with mild disease? Farraye FA, Odze R, Eaden J, Itzkowitz S. Diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology 2010; 138: Follow-up Patient offered and does want proctocolectomy Anal/rectal stricture sent for further evaluation Intramural fatty replacement of bowel around sigmoid and rectum c/w long-standing inflammation; no masses LAN Proctoscope saw stricture and deemed anal/rectal junction/us further eval could not be performed Anal dysplasia clinic eval/ reactive changes Follow-up flex-sig to be performed to remove remaining dysplastic tissue 3

4 CCFA Prospec-ve Mul-- Center Registry Aim 1: To determine the prevalence of occult cancer in IBD pa-ents who undergo colectomy and define what was occult about the cancer (sampling error, dysplasia elsewhere in the colon) Aim 2. Determine the short- term (1- year incidence) of colorectal cancer in UC pa-ents with dysplasia who decide on ongoing surveillance Aim 3: Determine predictors of occult and short- term cancer and test whether this can be predicted based on the endoscopic appearance (flat, polypoid) method of detec-on (chromoendoscopy) and resected status of the dysplas-c lesion (can I see it- is it discreet- can I resect it) Case: Loss of response to an-- TNF 24 yo man with 7 year history of Crohn s ileocoli-s referred to UCSF for 2 nd opinion regarding medical op-ons Ongoing flares requiring prednisone Ini-ated IFX 5 years ago with excellent response Started to lose response over -me December 2010 colonoscopy elsewhere Ac-ve Ileal inflamma-on, colonic inflamma-on Therapeu-c IFX level, no HACA an-bodies IFX discon-nued Restaging at UCSF MRE: inflamma-on within the terminal ileum Moderate to severe Crohn s with narrowing of TI. Moderate to severe ulcera-on in the sigmoid and descending colon Ileum: Chronic ac-ve inflamma-on with ulcer Descending Chronic ac-ve inflamma-on with ulcer Nega-ve Cdiff, nega-ve CMV Labs: Hct 23.9, albumin 2.5, CRP 76 Responded to oral steroids with 2 BM/day Treatment algorithm in pa-ents with clinical symptoms Positive HACA Sub-therapeutic IFX concentration * Therapeutic IFX concentration change to another anti-tnf agent increase IFX dose increase infliximab dose or frequency change to different anti-tnf agent endoscopy/cte with active disease endoscopy/cte with inactive disease if no response, change to Rx with different mechanism of action (non anti-tnf agent) If no response, change to different an-- TNF agent if no response, change to Rx with different mechanism of action (non anti-tnf agent) change to Rx with different mechanism of action (non anti-tnf agent) investigate for alternate etiology of symptoms Afif. DDW 2009 #962; W/ Anti-TNF in IBD * Patients should have endoscopic or radiologic imaging 4

5 Medical Discussion ques-ons What to do next: Switch an-- TNF, change class, or surgery? Do you use this algorithm in prac-ce? Any role for combina-on therapy here? Surgical discussion ques-ons If surgery is required Which surgery (what about the anal stricture)? Do you modify surgery choice and -ming based on whether pa-ent is on an an-- TNF or steroids before surgery? Is this the same answer for UC vs. Crohn s? Con-nua-on Elected to switch to an alterna-ve an-- TNF agent Currently doing well on prednisone taper Await whether he can be tapered off of steroids and maintain durable response off steroids Ques-on re PML and NAT Incidence PML: 1.6:1000 (95%CI: ) Incidence up to 24 infusions: 0.4: infusions: 0.04 (95%CI: ) infusions: 0.5 (95%CI: ) New JC virus Ab (Quest) NOT JC virus DNA Risk based on JC Ab Posi-ve: 1:100 Nega-ve: 1:10,000 5

6 Ques-ons Is this data useful for risk stra-fying and management? How to use new Ab test Need more info test characteris-cs? Screen all old pa-ents? Check all new starts What to do with posi-ve/nega-ve results Will NAT ever be a first- line op-on with this test 6