The FDA and others have been interested in the role of histology for assessing “deeper” levels of disease control, with the premise that biopsy may reflect the state of the disease more accurately and perhaps more objectively than endoscopy, and certainly more than symptoms. This is a compelling consideration, but is limited by the reality that we don’t know many things about histological activity. A few examples: how it varies over time, whether it provides more predictive value than endoscopy, what the variation in pathologist readings may be, and whether it is patchy. We also don’t know the time course of histological healing (or activation) and therefore, how to consider when and where to obtain samples.
What we DO know, however is that when people have complete histological healing (normalized biopsies), they are less likely to relapse than histological quiescence (scarring) or histological inflammation. And, that histological activity is predictive of subsequent neoplasia in ulcerative colitis.
All that to say, we really do not know whether we should treat to histological healing (and therefore, it’s not recommended). We know that if you get it, histological healing is a good thing (that’s helpful for you as the doctor and for patients to know) and that if there is histological activity, the risk of cancer is higher, so stratifying endoscopic surveillance to be more frequent is reasonable.
Thoughts and comments are welcome.
David T. Rubin, MD
Professor of Medicine, University of Chicago Medicine