Pancolonic Endoscopic and Histologic Evaluation for Relapse Prediction in Patients With Ulcerative Colitis in Clinical Remission

Miyuki Kaneshiro; Kento Takenaka; Kohei Suzuki; Toshimitsu Fujii; Shuji Hibiya; Ami Kawamoto; Maiko Motobayashi; Hiromichi Shimizu; Masakazu Nagahori; Eiko Saito; Ryuichi Okamoto; Kazuo Ohtsuka; Mamoru Watanabe

Disclosures

Aliment Pharmacol Ther. 2021;53(8):900-907. 

In This Article

Results

Patients and Endoscopic/Histological Findings

After excluding patients with proctitis (n = 35), medical treatment changes (n = 22), prior colon surgery (n = 1), unclassified inflammatory bowel disease (n = 9), colorectal neoplasia (n = 1), concomitant infectious colitis (n = 3), colonoscopy contraindication (n = 19), and biopsy contraindication (n = 5), we enrolled 325 consecutive patients. Table 1 summarises the clinical characteristics of the study population. The partial Mayo score was 0 in 67.4%, 1 in 16.9%, and 2 in 15.7% of patients. Concomitant treatment with immunomodulators and anti-TNF agents was administered in 36.3% and 16.0% of patients, respectively. One patient suffered from primary sclerosing cholangitis.

All patients completed total colonoscopy and had no missing data pertaining to the endoscopic/histological scoring and patient background. Amongst the endoscopists, the discrepancy rate for the UCEIS scores for each endoscopic image was 24.3%, and the ICC for scoring was 0.895. Meanwhile, the discrepancy rate amongst the pathologists was 14.4%, and the ICC for histological remission was 0.824. The median values were 1 (range: 0–6; interquartile range [IQR]: 0–2) for "original UCEIS," 1 (range: 0–6; IQR: 0–2) for "worst affected UCEIS," and 1 (range: 0–17; IQR: 0–4) for "pancolonic UCEIS." In addition, 12.9% (n = 42) showed no active lesions in the sigmoid colon and rectum but had an endoscopic activity in the proximal colon (ascending, transverse, or descending). In total, 62.5% of the patients (n = 203) achieved the Geboes score of ≤3.0, while ≤2.0 and ≤1.0 for 48.0% (n = 156) and 32.9% (n = 107), respectively.

Patient Clinical Course

A total of 59 patients (18.2%) experienced clinical relapse within 1 year after colonoscopy. For the relapse, most patients (56/59) received additional and/or alternative medications, which included topical therapy given to 13 patients. Corticosteroids, thiopurine, and biologics were also given to 32, 23, and 11 patients, respectively. Additionally, nine patients experienced UC-related hospitalisation, and two of those nine patients had acute severe UC; but no one needed colectomy within a year.

Each UCEIS for Relapse

The scoring that predicted relapse was evaluated and determined by ROC curve analysis (Figure 2). The AUC for original, worst affected, and pancolonic UCEIS was 0.755, 0.817, and 0.852, respectively. Thus, the pancolonic UCEIS had a significantly higher AUC than the original (P < 0.01) and worst affected (P = 0.04) UCEIS. The superiority of pancolonic UCEIS was similar in assessment by each endoscopist (Figure S1), and the pancolonic UCEIS was also superior in both patients with left-sided colitis and pancolitis (Figure S2). In the ROC curve analysis, the cutoff values for pancolonic, original, and worst affected UCEIS were 3, 1, and 1, with adjusted HRs for clinical relapse of 4.02, 1.67, and 3.67, respectively (Table 2 and Tables S1 and S2).

Figure 2.

ROC curve analysis of 1-year relapse for each endoscopic evaluation. The AUCs for the original, worst affected, and pancolonic UCEIS were 0.755, 0.817, and 0.852, respectively

In the Kaplan–Meier curve analysis, patients with a pancolonic UCEIS of >3 showed a significantly lower relapse-free rate than those with a score of ≤3 (Figure 3: P < 0.01). The predictive ability of endoscopic remission (pancolonic UCEIS ≤3) to avoid a 1-year relapse was 77.6% sensitive and 76.3% specific.

Figure 3.

Kaplan–Meier curve analysis for relapse stratified by endoscopic results. The relapse-free rate was significantly lower in patients with pancolonic UCEIS >3 than in those with a score ≤3 (P < 0.01)

Histology for Relapse

We then evaluated the impact of histological results on clinical relapse. The Geboes score could stratify patient prognosis (Figure 4A), and its cutoff was determined as 3.0 using ROC curve analysis (Figure 4B). Multiple regression analyses showed that the histological activity (Geboes >3.0) was an independent risk factor for relapse (Table 2; HR: 3.41).

Figure 4.

(A) Kaplan–Meier curve analysis for relapse stratified by the histologic results in patients. The Geboes score could stratify the relapse-free rate (P < 0.01). (B) ROC curve analysis of 1-year relapse on the Geboes score, with an AUC of 0.779

Combination of Pancolonic UCEIS and Histology for Predicting Prognosis

Figure 5 illustrates the Kaplan–Meier curve analysis of relapse, therapy escalation, and hospitalisation, stratified by endoscopic (pancolonic UCEIS) and histological results. The patients who achieved both of pancolonic UCEIS ≤3 and Geboes score ≤3.0 showed lower rates of relapse (2.2% vs 39.0%, P < 0.01), therapy escalation (0% vs 15.6%, P < 0.01), and hospitalisation need (0% vs 6.4%, P < 0.01) than those who did not achieve such values. The predictive ability of the combination of pancolonic UCEIS ≤3 and Geboes score ≤3.0 to avoid a one-year relapse was 92.0% sensitive and 97.0% specific.

Figure 5.

Kaplan–Meier curve analysis for patient prognosis stratified by the combination of endoscopic and histological findings. The patients who achieved pancolonic UCEIS ≤3 and Geboes ≤3.0 showed a better prognosis than who did not achieve such values [P < 0.01 for relapse (A), therapy escalation (B), and hospitalisation (C)]

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