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For medical professionals only
This article details the diagnosis and treatment process of a middle-aged and elderly male CD patient undergoing chemotherapy after gastric cancer surgery, which finally improved after 5 years of treatment, and once again confirmed that vedelizumab is at the top of
the safety pyramid of IBD treatment.
Inflammatory bowel disease (IBD) is a chronic inflammatory bowel disease that primarily affects the digestive system, with Crohn's disease (CD) and ulcerative colitis (UC) being the main types [1].
At present, the cause of CD is not clear, the symptoms of the lesion can invade the entire digestive tract, patients are mainly manifested as diarrhea, abdominal pain, fistula and perforating inflammation, mostly in segmental, asymmetric distribution, symptoms have the characteristics of repeated attacks and remission, and so far there is no treatment plan to completely cure the disease [2, 3].
In this issue, Dr.
Xu Xiaoyan, attending physician of the Department of Gastroenterology of Weihai Municipal Hospital, is invited to share a classic case of CD, and see how a CD patient can defeat nearly 5 years of stubborn Crohn's disease
through vedelizumab upgrade treatment.
About the author
Professor Xu Xiaoyan
Attending physician of the Department of Gastroenterology, Weihai Municipal Hospital, he is a doctoral candidate at Shandong University
In 2019, he studied in Qilu Hospital of Shandong University for half a year, mainly learning enteroscopy operation and IBD diagnosis and treatment
He is a member of the Inflammatory Enterology Group of the Gastroenterology Branch of Shandong Medical Association, a member of the Self-Exempt Hepatology Group of the Hepatology Branch of Shandong Medical Association, a member of the Enteroscopy Group of the Digestive Endoscopy Branch of Shandong Medical Association, and a youth member of
the Oncology Endoscopy Branch of the Shandong Anti-Cancer Association.
Typical case, male, 64 years old
.
He was hospitalized for the first time in 2017
Present medical history: admitted to hospital
for more than 2 months due to abdominal pain and diarrhea.
Anamnesis: The patient underwent radical gastric cancer surgery in 2015, and the postoperative pathology was gastric antral small curvature ulcer type poorly differentiated adenocarcinoma, a small number of mucinous adenocarcinoma, and three chemotherapy
sessions after surgery.
Auxiliary examination:
ESR: 31mm/h; CRP：23mg/L； TK-1: negative; T-spot: negative; Serum myeloma and lymphoma detection: negative
superficial lymph node ultrasound: bilateral neck and bilateral inguinal area lymph nodes are visible, the boundary is clear, and there are no obvious abnormal swollen lymph nodes
in bilateral axillary and bilateral supraclavicular areas.
Colonoscopy: through colonoscopy, it was found that the end of the ileum was about 20cm, multiple ulcers, about 0.
5cm in large cases, no abnormalities in the colorectal mucosa, pathology at the end of the ileum: chronic inflammation of the mucosa with acute inflammation, and a few inflammatory necrosis (Figure 1).
Figure 1 Diagnosis of colonoscopy
in 2017: terminal ileal ulcer, after
gastric cancer.
Treatment regimen: mesalazine sustained-release granules 1.
5 g / day, 3 times / day; Bifidobacterium triple viable capsule 2 capsules/time, 2 times/day
.
In 2018, the second admission changed the treatment plan
In 2018, the patient was readmitted to the hospital for re-examination
.
Auxiliary examinations: antinuclear antibody spectrum 18 items:
negative;
Anti-neutrophil antibody profile: negative
.
Colonoscopy: the terminal ileum was found to be about 20cm, scattered ulcers, surface white moss, biopsy 3 pieces, ileocecal valve and appendix mucosa were not abnormal, and 0.
3*0.
3cm flat polyps were seen in the ileocecal part, and forceps were given (Figure 2).
Fig.
2 Colonoscopy pathological
examination in 2018: chronic mucosal inflammation with acute inflammation and granulation tissue hyperplasia at the end of the ileum, and some inflammatory necrosis were seen; Chronic mucosal inflammation with acute inflammation
in the ileocecal region.
Treatment plan: out-of-hospital oral administration of Podesan 1.
5g / time 3 times; Clostridium caseinate tablets 2 tablets / time, 3 times / day treatment
.
In 2019, he was admitted to the hospital for the third time and was diagnosed with CD
.
Auxiliary examination: blood routine:
HB121g/L; Stool routine: yellow soft stool, positive OB; ESR: 21mm/h; CRP：9.
2mg/L； PCT：0.
023ng/ml； Six items: negative; Biochemistry: roughly normal; Complete set of swelling markings: negative; Infectious disease indexes: four tests of negative
EBVCA-IgG 78.
5U/ml; EBNA-IgG > 600U/ml, the rest are negative
.
TORCH infection screening: rubellavirus IgG 65 IU/ml (N: 9-11); CMV IgG 149U/ml (N: 12-14); Herpes simplex type I, II IgG>30Index, residual negative
.
ANCA vasculitis indicators: negative; Antinuclear antibody profile: positive ANA 1:320; TB infection T cell test: negative
.
PET-CT imaging diagnosis: more than 4 years after gastric cancer surgery and chemotherapy, no obvious signs of local tumor recurrence were found; Mild/mild uptake of FDG by multiple lymph nodes in the middle and lower abdominal cavity suggests a high likelihood of benign lesions; Bilateral fibrous foci; suggests multiple benign micro/small nodules in the wilderness of both lungs; mild benign thickening of bilateral pleura; diffuse decrease in liver density in both kidney cysts; F18-FDG PET-CT general examination (cranial to superior femoral segment) showed no other significant abnormalities
.
Transanoenteroscopy: continue to slide about 300cm through the ileocecal valve to reach the upper ileum, the ileum is scattered in the distribution of longitudinal ulcers, covered with yellow and white moss, part of the intestinal lumen can be seen annular stenosis, endoscopy can pass.
Fig.
3 Diagnosis of enteroscopy
in 2019: After multi-hospital consultation, the final diagnosis was Crohn's disease A3L1B1, CDAI score 5
.
Treatment regimen: the patient weighed 71 kg, and 60 mg methylprednisolone sodium succinate was used for × 7 days; Oral methylprednisolone tablets, the first dose of 48 mg, when decreasing by 4 mg to 20 mg per week, and decreasing by 2 mg per week; Oral methylprednisolone tablets were added 1 tablet (qd) after 20 days, and 2 tablets (qd) after half a month; Protective drug Naxin, Diqiao, calcitriol softgel 1 tablet / day
.
In mid-February 2020, hormones were discontinued, azathioprine 2 tablets/day were maintained for 1 year, and colonoscopy
was stopped for 1 week due to discomfort such as azathioprine fatigue.
Fourth escalation of vedelizumab in 2021
Present medical history: the patient's abdominal pain, abdominal distension and bowel movements were significantly improved, and after taking hormones in the morning, he felt abdominal discomfort, malaise, and soreness of the lower limbs, and the above symptoms improved
on their own after about 1 hour.
Ancillary examination: colonoscopy:
multiple flaky longitudinal ulcers at the end of the ileum, peripheral mucosal hyperemia and edema, biopsy toughness, no obvious abnormalities in the whole colon (Figure 4).
Fig.
4 CDST score of precolonoscopy
with vedelizumab in 2021 (Fig.
5): the total score was 19.
56, which predicted that the response rate of patients receiving vedelizumab was high
.
Fig.
5 CDST scoring
regimen: The patient started a single dose of 300mg of vedelizumab in 2021 for escalation
.
Colonoscopy
is repeated six months after the patient is treated with vedelizumab.
Colonoscopy: an ulcer scar at the end of the ileum shows that an ulcer is nearly healed and has improved significantly (Fig.
6).
Fig.
6 Summary of colonoscopy case after vedelizumab treatment, the patient is a middle-aged and elderly man, with a history of radical gastric cancer resection and 3 courses of chemotherapy after surgery 2 years before the onset of CD, and multiple colonoscopy
in the past 5 years of treatment showed terminal ileal ulcer, no abnormalities in the colorectum, and slightly improved symptoms after taking mesalazine.
However, the intestinal ulcer did not improve
.
After up to 5 years of treatment, the patient has significantly improved from a large number of ulcers distributed under small enteroscopy to only one ulcer scar and one healing, proving that vedelizumab can help early non-complicated CD patients achieve endoscopic remission, and the use of vedelizumab in postoperative patients with vedelizumab is safer, without serious adverse reactions and toxic side effects, bringing a new dawn to patients
.
Expert reviews
CD is a recurrent chronic non-specific intestinal inflammatory disease, and its onset site can widely involve the entire thickness of the digestive tract, mainly manifested as segmental chronic non-specific intestinal inflammation, and the main etiology and pathogenic mechanism are not clear
.
CD is characterized by chronic abdominal pain and diarrhea, and is often similar to the clinical manifestations of intestinal tuberculosis, lymphoma, intestinal Behcet, drug-induced intestinal mucosal injury and other diseases, and is not easy to identify
.
After nearly 5 years of treatment, the patient used a variety of drugs including mesalazine, and his symptoms improved slightly, but the intestinal ulcer did not improve
.
This dilemma
was reversed with an escalation of treatment with vedelizumab.
Not only did the patient's symptoms be significantly improved, but endoscopic healing
was achieved.
The use of V-CDST before treatment can provide an important reference
for clinical decision-making by CD doctors.
Studies have shown that patients with moderate CD with a moderate/high probability of clinical response predicted by V-CDST have a higher mucosal healing rate and a better prognosis [4].
In this case, the patient's V-CDST score greater than 19 showed a high response rate, suggesting that the use of vedelizumab may bring additional benefit
to the patient.
This case is characterized by postoperative cancer with CD, which has higher requirements
for drug safety and efficacy.
Available evidence suggests that vedelizumab is at the top of the safety pyramid for IBD treatments, the "safety pyramid" of inflammatory bowel disease treatments [5,6].
The GEMINI Long-Term Safety (LTS) study included more than 2000 IBD patients, some of whom received vedecrolizumab for more than 9 years
.
The final analysis demonstrated that vedecrolizumab has a good safety profile and tolerability and is suitable for long-term treatment in patients with moderate to severe CD, even at a long follow-up period [7].
The safety of vedelizumab in the treatment of IBD patients after bowel or parenteral surgery has been confirmed
by several studies.
In patients with IBD who have undergone bowel or parenteral surgery, vedelizumab does not increase the risk of postoperative infection or other complications [8,9]; In addition, vedelizumab can effectively prevent recurrence after CD surgery in CD patients, and the recurrence rate of endoscopic CD within one year is significantly lower than that of ustekinumab [10,11].
Therefore, the safety of vedelizumab in the treatment of gastric cancer postoperative CD in this case has sufficient evidence-based evidence
.
In terms of efficacy, vedelizumab has also been shown to have good CD endoscopic healing effect
.
VERSIFY, a Phase 3b prospective multicenter, open-label, single-arm study to evaluate the efficacy of vedecrolizumab in clinical and endoscopic remission in the treatment of active CD, showed that 11.
9% of all patients achieved endoscopic response at week 26 and 17.
9%
achieved endoscopic response at week 52.
Patients with CD who had not previously received antitumor necrosis factor-α (TNF-α) had better outcomes, with complete mucosal healing rates (visible ulcer disappearance) at weeks 26 and 52 of 19.
6 and 25 percent, respectively [12].
The real-world study of Victoria in the United States has also confirmed that vedelizumab has a higher rate of clinical remission and mucosal healing in patients with moderate CD [13].
It can be seen that for the treatment of CD patients after gastric cancer surgery in this case, the use of vedelizumab can balance safety and efficacy
.
At the same time, the V-CDST scoring tool used to evaluate it before treatment can predict the patient's response to vedelizumab and better guide clinical treatment
.
The current drug treatment methods of CD mainly include traditional drug treatment, biological agents, and traditional Chinese medicine compounds
.
In recent years, the study of vedelizumab has stood out [2], which has been shown to induce and maintain CD imaging improvement and healing, hoping to accumulate more clinical evidence to further support
drug decisions.
Review expert
, Professor Qiao Xiuli
Weihai Municipal Hospital, Chief Physician
Master tutor and adjunct professor of Binzhou Medical College
Member of the Integrative Medicine Committee of the China Alliance of Inflammatory Bowel Diseases
Member of Digestive Branch of Shandong Medical Association
Standing Committee Member of Endoscopy Branch of Shandong Medical Association
Visiting scholar at Emory University
Chairman of the Hepatology Branch of Weihai Medical Association
Where to see more clinical knowledge of digestive liver disease? Come to the "doctor's station" and take a look 👇
References:
[1] Liang Xiaonan, et al.
Clinical Convergence,2018,33(11):987-990.
[2] Wang Muling, et al.
Chinese Journal of Hospital Pharmacy,2020,40(17):1891-1895.
[3] HE Qiong, et al.
Journal of Practical Medicine,2019,35(18):2962-2966.
[4] Dulai PS,et al.
Aliment Pharmacol Ther.
2020; 51(5):553-564.
[5] B Click,et al.
Inflamm Bowel Dis.
2019,25(5):831-42.
[6] Gastroenterology.
2019,157(4):1007-1018.
e7.
[7] Aliment Pharmacol Ther.
2020 Sep 2
[8] Kotze PG,et al.
Therap Adv Gastroenterol.
2018 21,11:1756284818783614.
[9] Law CCY,et al.
J Crohns Colitis.
2018 Apr 27; 12(5):538-545.
[10] Journal of Crohn's and Colitis,Volume 15,Issue Supplement_1,May 2021,Page S320.
[11] Vermeire S,et al.
J Crohns Colitis.
2022 Jan 28; 16(1):27-38.
[12] Gastroenterology.
2019 Jul 4.
pii:S0016-5085(19)41080-9.
[13] Gastroenterology Vol.
162,No.
3S,S8
.
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.
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