No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Abstract
Clonal T cell receptor (TCR) gene rearrangements and loss of T cell antigens such as CD8 and TCR-beta in intraepithelial lymphocytes (IELs) may indicate the development of an enteropathy-type intestinal T cell lymphoma (EITCL) in patients with refractory sprue.
To define the diagnostic value of these markers in duodenal biopsies from patients with villous atrophy as a result of various underlying disorders.
Duodenal biopsies from eight patients with coeliac disease and five patients with villous atrophy caused by defined disorders were compared with three patients with refractory sprue evolving into overt EITCL, two patients with ulcerative jejunitis, and with eight patients with overt EITCL, for expression of CD3, CD4, CD8, and TCR-beta in IELs using immunohistochemistry and for clonal TCR-gamma gene rearrangements using polymerase chain reaction. In addition, biopsies from six consecutive patients with refractory sprue of uncertain cause were examined.
Clonal TCR-gamma gene rearrangements were found in all resected tumours of patients with EITCL, in 3/8 duodenal biopsies of patients with EITCL, in 2/2 patients with ulcerative jejunitis, in 2/3 patients with refractory sprue evolving into overt EITCL, and in 1/6 patients with refractory sprue. No rearrangements were found in biopsies from patients with refractory sprue caused by defined disorders or those with coeliac disease. Clonality in duodenal biopsies was associated with an abnormal phenotype of IELs in all cases and in all but one case in patients with evidence of underlying coeliac disease. Specificity for detection of an EITCL using immunohistology was 77% for CD8 and for TCR-beta staining, and 100% for detection of a clonal TCR-gamma gene rearrangement. Sensitivity was 62% for staining with CD8 and clonality investigation, while sensitivity reached 100% for TCR-beta staining in all investigated patients with EITCL.
Clonal proliferations of phenotypically abnormal IELs in refractory sprue represent an early manifestation of EITCL, for which the term "sprue-like intestinal T cell lymphoma" is proposed. This constellation is also found in duodenal biopsies from patients with an overt EITCL and is not related to other sprue syndromes, resulting in a high specificity for detection of an EITCL or refractory sprue evolving into EITCL. Overt EITCL may develop directly from coeliac disease without a precursor lesion (refractory sprue with clonal IELs) being demonstrable in duodenal biopsies or via a "sprue-like intestinal T cell lymphoma". This latter entity is a complication of coeliac disease.
... The absence and presence of phenotypically atypical IELs divides RCD into two phases, RCD1 and RCD2, respectively. About half of those with RCD2 will develop EATL [173][174][175], whilst progression to lymphoma in patients with RCD1 is exceptional [173,176,177]. The histological features of RCD are similar to that of celiac disease, but ulcerative jejunitis and lymphocytic gastritis tend to be more frequent in RCD2 [174]. ...
... There are significant differences between RCD1 and RCD2, which may even suggest different disease entities [197] and cellular origins. The prognosis is different with significantly inferior prognosis in RCD2 [177], whilst progression of RCD1 to RCD2 [177] and from RCD1 to EATL [174] is exceptional. ...
... There are significant differences between RCD1 and RCD2, which may even suggest different disease entities [197] and cellular origins. The prognosis is different with significantly inferior prognosis in RCD2 [177], whilst progression of RCD1 to RCD2 [177] and from RCD1 to EATL [174] is exceptional. ...
Simple Summary
Intestinal T- and NK-cell lymphoproliferative disorders are a group of rare gastrointestinal disorders that arise from immune cells in the intestinal mucosa that are also relatively unknown. Diseases such as indolent T-cell lymphoproliferative disorders of the gastrointestinal tract do not even require treatment, whereas others, such as monomorphic epitheliotropic intestinal T-cell lymphoma, will generally cause death within a year. No effective treatment is currently available, as little is known about how these tumours form or even what cells they arise from. This article summarizes the current state of knowledge about the main types of immune cells in the gastrointestinal mucosa and the processes by which they may transform into neoplasms. The clinical behaviour, pathological appearances and the molecular alterations that underlie these diseases are also discussed.
Abstract
The intestinal immune system, which must ensure appropriate immune responses to both pathogens and commensal microflora, comprises innate lymphoid cells and various T-cell subsets, including intra-epithelial lymphocytes (IELs). An example of innate lymphoid cells is natural killer cells, which may be classified into tissue-resident, CD56bright NK-cells that serve a regulatory function and more mature, circulating CD56dim NK-cells with effector cytolytic properties. CD56bright NK-cells in the gastrointestinal tract give rise to indolent NK-cell enteropathy and lymphomatoid gastropathy, as well as the aggressive extranodal NK/T cell lymphoma, the latter following activation by EBV infection and neoplastic transformation. Conventional CD4+ TCRαβ+ and CD8αβ+ TCRαβ+ T-cells are located in the lamina propria and the intraepithelial compartment of intestinal mucosa as type ‘a’ IELs. They are the putative cells of origin for CD4+ and CD8+ indolent T-cell lymphoproliferative disorders of the gastrointestinal tract and intestinal T-cell lymphoma, NOS. In addition to such conventional T-cells, there are non-conventional T-cells in the intra-epithelial compartment that express CD8αα and innate lymphoid cells that lack TCRs. The central feature of type ‘b’ IELs is the expression of CD8αα homodimers, seen in monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL), which primarily arises from both CD8αα+ TCRαβ+ and CD8αα+ TCRγδ+ IELs. EATL is the other epitheliotropic T-cell lymphoma in the GI tract, a subset of which arises from the expansion and reprograming of intracytoplasmic CD3+ innate lymphoid cells, driven by IL15 and mutations of the JAK-STAT pathway.
... It has been speculated that the clonal T-cell population found in the intestinal mucosa of RCD patients could be the precursor of overt EATL [64,119,120]. Indeed, Daum et al. [119] demonstrated that a clonal TCR-γ gene rearrangement could be found in 3/8 duodenal biopsies of patients with EATL, in 2/2 patients with UJI, in 2/3 patients with RCD evolving to EATL, and in 1/6 patient with RCD, whereas clonal rearrangements were present in all resected EATL. Although similar results were obtained by Verbeek et al. [121], these authors also demonstrated that flow cytometric determination of aberrant IELs could predict EATL development in RCD patients more accurately than T-cell clonality analysis with polymerase chain reaction (PCR). ...
... It has been speculated that the clonal T-cell population found in the intestinal mucosa of RCD patients could be the precursor of overt EATL [64,119,120]. Indeed, Daum et al. [119] demonstrated that a clonal TCR-γ gene rearrangement could be found in 3/8 duodenal biopsies of patients with EATL, in 2/2 patients with UJI, in 2/3 patients with RCD evolving to EATL, and in 1/6 patient with RCD, whereas clonal rearrangements were present in all resected EATL. Although similar results were obtained by Verbeek et al. [121], these authors also demonstrated that flow cytometric determination of aberrant IELs could predict EATL development in RCD patients more accurately than T-cell clonality analysis with polymerase chain reaction (PCR). ...
... Although similar results were obtained by Verbeek et al. [121], these authors also demonstrated that flow cytometric determination of aberrant IELs could predict EATL development in RCD patients more accurately than T-cell clonality analysis with polymerase chain reaction (PCR). The presence of TCR-γ clonal amplification in the duodenal biopsies of RCD-II and UJI patients, as well as in the subsequent tumor specimens [64,119], and the high predictive value of the quantification of aberrant T-cells for the identification of those RCD patients at risk of evolving in EATL [121], support the concept that these two conditions should be considered as "cryptic lymphomas" and should prompt an extensive diagnostic workup to exclude the presence of malignancy; however, the presence of clonal TCR-γ gene rearrangements is not infrequent, even in cases lacking features of RCD-II [122,123]. Hussein et al. demonstrated that TCR-γ clonal amplification was present not only in 67% of RCD-II, but also in 17% of patients with RCD-I and in 6% of CeD patients under GFD [122]. ...
Celiac disease (CeD) is an immune-mediated enteropathy precipitated by ingestion of gluten in genetically predisposed individuals. Considering that CeD affects approximately 1% of the Western population, it may be considered a global health problem. In the large majority of cases, CeD has a benign course, characterized by the complete resolution of symptoms and a normal life expectancy after the beginning of a gluten-free-diet (GFD); however, an increased risk of developing malignancies, such as lymphomas and small bowel carcinoma (SBC), has been reported. In particular, enteropathy-associated T-cell lymphoma (EATL), a peculiar type of T-cell lymphoma, is characteristically associated with CeD. Moreover, the possible association between CeD and several other malignancies has been also investigated in a considerable number of studies. In this paper, we aim to provide a comprehensive review of the current knowledge about the associations between CeD and cancer, focusing in particular on EATL and SBC, two rare but aggressive malignancies.
... 63,65,[76][77][78] Abnormal histological data should also lead us to discover other possible causes of RCD as microscopic colitis. [63][64][65]74 It is possible to classify the RCD in two distinct forms: i) the type 1 RCD, in which the infiltration of lymphocytes in the mucosa of the small intestine is similar to that of subjects not treated with CD and a normal IEL phenotype is found; 74,78,79 ii) the type 2 RCD, in which there is a clonal expansion of an aberrant IEL population: the CD3-positive lymphocytes intraepithelial exhibit an abnormal or atypical immunophenotype with the loss of normal expression of differentiation markers present on the cell surface as those of the CD 8. 78,79 Furthermore, the analysis of Tcell receptors may detect an oligoclonal expansion present in the entire surface of the intestinal mucosa. 67,74,78,79 The presence of these abnormalities in lymphocyte T cells in type 2 RCD is associated with a significantly worse prognosis than that estimated for patients with forms of RCD type 1. 74,75 The management of type 1 RCD includes the exclusion of an accidental ingestion of gluten, covering an evaluation and consequent possible treatment of any nutritional deficiency. ...
... 63,65,[76][77][78] Abnormal histological data should also lead us to discover other possible causes of RCD as microscopic colitis. [63][64][65]74 It is possible to classify the RCD in two distinct forms: i) the type 1 RCD, in which the infiltration of lymphocytes in the mucosa of the small intestine is similar to that of subjects not treated with CD and a normal IEL phenotype is found; 74,78,79 ii) the type 2 RCD, in which there is a clonal expansion of an aberrant IEL population: the CD3-positive lymphocytes intraepithelial exhibit an abnormal or atypical immunophenotype with the loss of normal expression of differentiation markers present on the cell surface as those of the CD 8. 78,79 Furthermore, the analysis of Tcell receptors may detect an oligoclonal expansion present in the entire surface of the intestinal mucosa. 67,74,78,79 The presence of these abnormalities in lymphocyte T cells in type 2 RCD is associated with a significantly worse prognosis than that estimated for patients with forms of RCD type 1. 74,75 The management of type 1 RCD includes the exclusion of an accidental ingestion of gluten, covering an evaluation and consequent possible treatment of any nutritional deficiency. ...
... [63][64][65]74 It is possible to classify the RCD in two distinct forms: i) the type 1 RCD, in which the infiltration of lymphocytes in the mucosa of the small intestine is similar to that of subjects not treated with CD and a normal IEL phenotype is found; 74,78,79 ii) the type 2 RCD, in which there is a clonal expansion of an aberrant IEL population: the CD3-positive lymphocytes intraepithelial exhibit an abnormal or atypical immunophenotype with the loss of normal expression of differentiation markers present on the cell surface as those of the CD 8. 78,79 Furthermore, the analysis of Tcell receptors may detect an oligoclonal expansion present in the entire surface of the intestinal mucosa. 67,74,78,79 The presence of these abnormalities in lymphocyte T cells in type 2 RCD is associated with a significantly worse prognosis than that estimated for patients with forms of RCD type 1. 74,75 The management of type 1 RCD includes the exclusion of an accidental ingestion of gluten, covering an evaluation and consequent possible treatment of any nutritional deficiency. 64,74,80 It is often necessary, the symptomatic treatment of diarrhea in order to reduce its impact on patients' quality of life and in extreme cases, the traditional medical treatment consists in the use of systemic steroids such as prednisone. ...
Celiac disease (CD) is a complex polygenic disorder, which involves genetic factors human leukocyte complex (HLA) and non-HLA genes, environmental factors, innate and adoptive immunity, and a robust chronic T-mediated autoimmune component. The main goal of the present monograph is to define a methodological approach for the disease, characterized by frequent late diagnosis, in order for the physician to become aware of the disease management, the diversity of the clinical presentation itself and in different patients. A unique attention is payed to the specific diagnostic tests to define a correct and accurate application of them, and in addition, to disease follow-up and possible complications. Moreover, a dedicated space is assigned to refractory CD, to potential CD and non-celiac gluten sensitivity. Legislative aspects of the celiac disease in Italy are addressed, too. The celiac disease guidelines and their evaluation by means of Appraisal of Guidelines, Research and Evaluation II instrument allow us to classify the different recommendations and to apply them according to the stakeholders’ involvement, pertinence, methodological accuracy, clarity and publishing independence. Finally, the most current scientific evidence is taken into account to create a complete updated monograph.
... Eight studies were identified that included data on diagnostic accuracy for RCeD subtype I or II [191][192][193][194][195][196][197][198] . However, none of these was designed as a prospective diagnostic study, recruiting patients affected by so-far unresolved enteropathies, including those with a prior diagnosis of CeD and following a strict, prospectively designed diagnostic trait. ...
... Although these ranges document a substantial scatter of data, the somewhat more stable sensitivities in analysing the T cell clonality and the more stable specificities in the IHC analysis would favour a sequential diagnostic process. Moreover, early studies have shown that patients with evident TCR clonality (RCeD type II), who present with small intestinal IELs that are CD8 − or TCRαβ − , are more prone to develop an enteropathy-associated T cell lymphoma, which might implicate a prognostic function of this marker 197 . ...
Coeliac disease (CeD) is an immunological disease triggered by the consumption of gluten contained in food in individuals with a genetic predisposition. Diagnosis is based on the presence of small bowel mucosal atrophy and circulating autoantibodies (anti-type 2 transglutaminase antibodies). After diagnosis, patients follow a strict, life-long gluten-free diet. Although the criteria for diagnosis of this disease are well defined, the monitoring phase has been studied less and there is a lack of specific guidelines for this phase. To develop a set of clinical guidelines for CeD monitoring, we followed the Grading of Recommendations Assessment, Development and Evaluation methodology. Statements and recommendations with the level of evidence were developed and approved by the working group, which comprised gastroenterologists, pathologists, dieticians and biostatisticians. The proposed guidelines, endorsed by the North American and European coeliac disease scientific societies, make recommendations for best practices in monitoring patients with CeD based on the available evidence. The evidence level is low for many topics, suggesting that further research in specific aspects of CeD would be valuable. In conclusion, the present guidelines support clinicians in improving CeD treatment and follow-up and highlight novel issues that should be considered in future studies.
... 102,115,116 Va precisato che sebbene non ci sono evidenze per ricercare in tutti i pazienti affetti da colite microscopica una MC, una diagnosi di celiachia deve essere considerata in tutti quei casi in cui la colite microscopica non risponde al trattamento instaurato o sia associata a sintomi che sono indipendenti da questa e fortemente suggestivi di MC. 123 In definitiva la MCR può essere definita come una condizione caratterizzata dalla persistenza o dalle frequenti recidive di sintomi o segni compatibili con malassorbimento, associate a dimostrazione istologica di atrofia dei villi intestinali, nonostante sia stata instaurata per più di 12 mesi una dieta priva di glutine ed in assenza di altri disordini, inclusi il linfoma intestinale. 16,124,125 È possibile classificare la MCR in due forme distinte: i) la MCR di tipo 1, in cui l'infiltrazione dei linfociti nella mucosa del piccolo intestino è simile a quella dei soggetti con MC non trattata; 126,127 ii) la MCR di tipo 2, in cui i linfociti T CD3-positive intrae-piteliali esibiscono un immunofenotipo anormale o atipico con la perdita dell'espressione dei normali markers di differenziazione presenti sulla superficie cellulare come quelli dei CD 8. 126,127 Inoltre, l'analisi dei recettori delle T-cellule potrebbero rilevare una espansione oligoclonale presente in tutta la superficie della mucosa intestinale. 126,127 La presenza di queste anormalità nelle cellule linfocitarie T nella MCR di tipo II è associata ad una prognosi nettamente sfavorevole rispetto a quella stimata per i pazienti con forme di MCR di tipo 1. 119,120 Il management della MCR di tipo 1 include l'esclusione di un'ingestione accidentale di glutine come causa di una non conosciuta attività della malattia ed include una valutazione e conseguente eventuale trattamento di eventuali deficit nutrizionali. ...
... 16,124,125 È possibile classificare la MCR in due forme distinte: i) la MCR di tipo 1, in cui l'infiltrazione dei linfociti nella mucosa del piccolo intestino è simile a quella dei soggetti con MC non trattata; 126,127 ii) la MCR di tipo 2, in cui i linfociti T CD3-positive intrae-piteliali esibiscono un immunofenotipo anormale o atipico con la perdita dell'espressione dei normali markers di differenziazione presenti sulla superficie cellulare come quelli dei CD 8. 126,127 Inoltre, l'analisi dei recettori delle T-cellule potrebbero rilevare una espansione oligoclonale presente in tutta la superficie della mucosa intestinale. 126,127 La presenza di queste anormalità nelle cellule linfocitarie T nella MCR di tipo II è associata ad una prognosi nettamente sfavorevole rispetto a quella stimata per i pazienti con forme di MCR di tipo 1. 119,120 Il management della MCR di tipo 1 include l'esclusione di un'ingestione accidentale di glutine come causa di una non conosciuta attività della malattia ed include una valutazione e conseguente eventuale trattamento di eventuali deficit nutrizionali. 115,119,128 Spesso è necessario un trattamento sintomatico della diarrea al fine di ridurne l'impatto sulla qualità di vita dei pazienti. ...
p class="titolo">
MANAGEMENT DEL PAZIENTE CON DIARREA, NAUSEA E VOMITO: DALLE EVIDENZE ALLA PRATICA CLINICA
La gestione del paziente con diarrea: razionale e obiettivi
T.M. Attardo, C. Quarneti, R. Menichella, E. Romualdi
La gestione del paziente con nausea e vomito : razionale e obiettivi
T.M. Attardo, R. Menichella, C. Quarneti, E. Romualdi
MALNUTRIZIONE E MALATTIA CELIACA: LO STATO DELL’ARTE
La gestione del paziente con malnutrizione: dalle evidenze alla pratica clinica
S. Ciarla, M. Poggiano, P. Gnerre, F. Risaliti, L. Magni, L. Morbidoni, A. Maffettone, A. Paradiso, M. Rondana, A. Schimizzi, R. Risicato
La gestione del paziente con malattia celiaca: razionale e obiettivi
T.M. Attardo, E. Magnani, C. Casati, D. Cavalieri, P. Crispino, F. Fascì Spurio, S. De Carli, D. Tirotta, P. Gnerre </p
... •Type I RCD •Histology reveals IEL with normal surface T-cell receptors and normal CD3 and CD 8 expression [71,[73][74][75] •Management includes avoidance of gluten exposure and repletion of nutritional deficiencies [61,64,70,71,73]. ...
... •Type II RCD •Histology reveals IEL with loss of surface T-cell receptors and abnormal phenotypic expression and differentiation of CD3 and CD8 positive intraepithelial T cells [73][74][75] •Management is similar to Type I RCD. Type II RCD is less likely to respond to treatment and carries a poorer prognosis; largely explained by its progression to enteropathy-associated T-cell lymphoma [70,71,73,[76][77][78] Prednisone is used in severe cases of RCD. ...
... This refractory state, earlier described by Marsh as an irreversible villous atrophy (or Marsh 4), affects around 2-10% of all patients with CD and is suggested to be the link between CD and overt lymphoma [239,252,253]. RCD can evolve into ulcerative jejunitis [254] or EATL [252,[255][256][257][258]. The latter is characterized by endoluminal small bowel ulcerations with histological evidence of lymphoma but also by the development of gross tumor mass in advanced stages. ...
... However, a minority of patients (2-10%) maintains persistent villous atrophy despite strict restriction of gluten and develops refractory disease [239]. RCD can evolve into ulcerative jejunitis or EATL [252,256]. The diagnosis of celiac associated lymphoma is often difficult and survival is generally poor [324,325]. ...
Celiac disease affects a great proportion of children and adults. Due to its protean manifestations the diagnosis is often missed. Thanks to the presence of serological and genetic tests as well the possibility to obtain small bowel biopsy specimens through endoscopy the diagnosis is relatively easy to make in the majority of patients with uncomplicated form of celiac disease. The prognosis of these patients is very good provided they follow a strict-gluten free diet. A different story is those patients with complicated forms of the disease and the so-called refractory celiac disease with a sombre prognosis that fails to respond to a gluten-free diet. In this section we review the current algorithms to reach a diagnosis in both the uncomplicated as well as the complicated forms using new technology and the knowledge derived from current etiopathogenetic concepts.
... DNA was extracted from paraffin-embedded duodenal specimens (Maxwell, Promega) and amplified by multiplex PCR using fluorescence-labeled primer sets binding to the Vand J-gene segments of the rearranged TCRγ (two primer pools) and TCRβ loci (three primer pools) employ-ing the BIOMED-2/EuroClonality protocols [15] . Assessment of the TCR rearrangement patterns was done via capillary electrophoresis (GeneScan; 3500 Genetic Analyzer, Thermo Fisher Scientific) of the fluorescence-labeled PCR products [16] . All assays were performed as independent duplicates. ...
Background
Flow cytometry of intestinal lymphocytes is discussed to be a stronger predictor of enteropathy-associated T-cell lymphoma development in refractory celiac disease than T-cell clonality analysis.
Aims
To investigate possible associations between clinical characteristics of refractory celiac disease patients and aberrant intraepithelial lymphocytes and to evaluate the accuracy of immunophenotyping for the identification of high-risk refractory celiac disease.
Methods
Flow cytometry of isolated lymphocytes from duodenal biopsies of controls and celiac disease patients was performed and results were compared to clinical data.
Results
Flow cytometry analysis was performed on 42 controls, 37 non-complicated celiac disease and 30 refractory celiac disease cases with or without T-cell receptor clonality. Elevated aberrant intraepithelial lymphocyte counts were significantly associated with severe malabsorption. A 15% cut-off (aberrant lymphocytes among all lymphocytes) had the best discriminatory ability to identify high-risk patients. However, this technique failed to identify some high-risk cases (sensitivity 63%, specificity 100%). The severity of malabsorption was added to the criteria for high-risk refractory celiac disease, improving the correct patients’ allocation (sensitivity 100%, specificity 96%).
Conclusion
Immunophenotyping of aberrant intraepithelial lymphocytes is a good predictor for high-risk refractory celiac disease. Furthermore, adding the evaluation of malabsorption to the diagnostic assessment of refractory celiac disease optimizes accuracy.
... 18 Surface TCRγδ 18 expression is rare, but cytoplasmic TCRβ chains can be observed in up to 50% of cases. 30,31 Surface TCRαβ expression, as noted in 2 of our RCD II cases, has not been described before. Detection of immunophenotypic abnormalities is facilitated by flow cytometry, which can detect low-level antigen expression and distinguish between cytoplasmic and surface antigen expression. ...
Refractory celiac disease type II (RCD II), also referred to as "cryptic" enteropathy-associated T-cell lymphoma (EATL) or "intraepithelial T-cell lymphoma," is a rare clonal lymphoproliferative disorder that arises from innate intraepithelial lymphocytes. RCD II has a poor prognosis and frequently evolves to EATL. The pathogenesis of RCD II is not well understood and data regarding the immunophenotypic spectrum of this disease and underlying genetic alterations are limited. To gain further biological insights, we performed comprehensive immunophenotypic, targeted next-generation sequencing, and chromosome microarray analyses of 11 RCD II cases: CD4/CD8 (n=6), CD8 (n=4), and CD4 (n=1), and 2 of 3 ensuing EATLs. Genetic alterations were identified in 9/11 (82%) of the RCD II cases. All 9 displayed mutations in members of the JAK-STAT signaling pathway, including frequent, recurrent STAT3 (7/9, 78%) and JAK1 (4/9, 44%) mutations, and 9/10 evaluable cases expressed phospho-STAT3. The mutated cases also harbored recurrent alterations in epigenetic regulators (TET2, n=5 and KMT2D, n=5), nuclear factor-κB (TNFAIP3, n=4), DNA damage repair (POT1, n=3), and immune evasion (CD58, n=2) pathway genes. The CD4/CD8 and other immunophenotypic subtypes of RCD II exhibited similar molecular features. Longitudinal genetic analyses of 4 RCD II cases revealed stable mutation profiles, however, additional mutations were detected in the EATLs, which occurred at extraintestinal sites and were clonally related to antecedent RCD II. Chromosome microarray analysis demonstrated copy number changes in 3/6 RCD II cases, and 1 transformed EATL with sufficient neoplastic burden for informative analysis. Our findings provide novel information about the immunophenotypic and genomic characteristics of RCD II, elucidate early genetic events in EATL pathogenesis, and reveal potential therapeutic targets.
... 18 Surface TCRγδ 18 expression is rare, but cytoplasmic TCRβ chains can be observed in up to 50% of cases. 30,31 Surface TCRαβ expression, as noted in 2 of our RCD II cases, has not been described before. Detection of immunophenotypic abnormalities is facilitated by flow cytometry, which can detect low-level antigen expression and distinguish between cytoplasmic and surface antigen expression. ...
Refractory celiac disease type II (RCD II), also referred to as "cryptic" enteropathy-associated T-cell lymphoma (EATL) or "intraepithelial T-cell lymphoma," is a rare clonal lymphoproliferative disorder that arises from innate intraepithelial lymphocytes. RCD II has a poor prognosis and frequently evolves to EATL. The pathogenesis of RCD II is not well understood and data regarding the immunophenotypic spectrum of this disease and underlying genetic alterations are limited. To gain further biological insights, we performed comprehensive immunophenotypic, targeted next-generation sequencing, and chromosome microarray analyses of 11 RCD II cases: CD4/CD8 (n=6), CD8 (n=4), and CD4 (n=1), and 2 of 3 ensuing EATLs. Genetic alterations were identified in 9/11 (82%) of the RCD II cases. All 9 displayed mutations in members of the JAK-STAT signaling pathway, including frequent, recurrent STAT3 (7/9, 78%) and JAK1 (4/9, 44%) mutations, and 9/10 evaluable cases expressed phospho-STAT3. The mutated cases also harbored recurrent alterations in epigenetic regulators (TET2, n=5 and KMT2D, n=5), nuclear factor-κB (TNFAIP3, n=4), DNA damage repair (POT1, n=3), and immune evasion (CD58, n=2) pathway genes. The CD4/CD8 and other immunophenotypic subtypes of RCD II exhibited similar molecular features. Longitudinal genetic analyses of 4 RCD II cases revealed stable mutation profiles, however, additional mutations were detected in the EATLs, which occurred at extraintestinal sites and were clonally related to antecedent RCD II. Chromosome microarray analysis demonstrated copy number changes in 3/6 RCD II cases, and 1 transformed EATL with sufficient neoplastic burden for informative analysis. Our findings provide novel information about the immunophenotypic and genomic characteristics of RCD II, elucidate early genetic events in EATL pathogenesis, and reveal potential therapeutic targets.
... 35,36 Interleukin 15 (IL-15) produced by enterocytes, in close contact with these IELs, appears to play a key role in the homeostasis of this lymphocyte populaton and in their potental transformaton in RCD and lymphoma development. 37,38 An increase in the monocytc and enterocytc IL-15 transcriptonal regulaton appears to be the basis for the development of RCD and especially for type II RCD. 39 In healthy subjects and uncomplicated celiac patents, IELs express the CD103 surface marker, which diferentates them from the lamina propria lymphocytes. ...
... The absence of (Type I) or presence (Type II) of abnormal intraepithelial lymphocytes on duodenal histology can distinguish between the 2 subtypes of RCD [9]. PCR gene amplification on cells can differentiate between polyclonal (Type I) T cell receptors and monoclonal T cell receptors (Type II) [10,11]. ...
BACKGROUND AND AIMS: There is no literature on the role of repeat small bowel capsule endoscopy (SBCE) in patients with refractory coeliac disease (RCD) following treatment with steroids +/- immunosuppressants. METHODS: The findings on SBCEs from a group of patients with histologically proven RCD (n=23) were compared to the findings from patients with uncomplicated coeliac disease (n=48). All patients had concurrent duodenal histology and serology taken at the time of SBCE. RESULTS: Patients with RCD had a greater extent of mucosal involvement on SBCE than patients with uncomplicated CD (42.4+/-34.1% vs 9.7+/-21.7%, p=0.0001). Following treatment with steroids and / or immunosuppressants, patients with RCD had an improvement in the extent of affected small bowel mucosa (42.4+/-34.1% vs 26.4+/-28.9% p=0.012). There was no statistical difference in histology and serology taken at the time of the first and second SBCE in patients with RCD. CONCLUSIONS: Our study suggests that SBCE is valuable in documenting the extent of mucosal involvement in patients with RCD. This is the first study that delineates the value of a second look SBCE to assess improvement in the extent of disease in the small bowel following treatment.
... Several groups have identified aberrant clonal T-cell populations among the IELs seen in RCDII; the aberrant populations commonly show absent surface lineage markers, but usually retain expression of intracellular CD3, as well as showing incomplete or out-of-frame TCR gene rearrangements. Additionally, some IELs demonstrate the characteristic immunophenotype of EATL, suggesting a pathogenic link between RCD and EATL [58][59][60][61][62]. Kooy-Winkelaar et al. demonstrated that the presence of gluten-specific CD4-positive T-cells perpetuated the proliferation and activation of lineage-negative IELs via the production of cytokines TNF, Il-2, and IL-21 [63]. ...
There are a number of rare T-cell lymphoma subtypes that may be encountered in clinical practice. In recent years, improved immunohistochemical techniques and molecular tumor profiling have permitted refinement of some of the diagnostic categories in this group, as well as the recognition of distinct conditions not previously well elucidated. In this chapter, we cover the diagnostic and clinical features of some of the more common of these conditions, including subcutaneous panniculitis-like T-cell lymphoma, cutaneous gamma-delta T-cell lymphoma, enteropathy-associated T-cell lymphoma, monomorphic epitheliotropic intestinal T-cell lymphoma, primary cutaneous CD8-positive aggressive epidermotropic cytotoxic T-cell lymphoma, CD4-positive small/medium T-cell lymphoproliferative disorder, and acral CD8-positive T-cell lymphoma. Given the rarity of these conditions, optimal treatments approaches are not always well established, not least as data from large-scale clinical trials are lacking. In this chapter, we aim to provide a summation of current thinking around best treatment, as well as highlighting some controversies in the management of these diagnoses.
... Alfsen et al. and Wright et al. were the first to suggest that some cases of adult-onset RCD, despite being morphologically indistinguishable from uncomplicated celiac disease, might represent "low-grade lymphomas" of IELs that could transform to EATL [47,48], and Isaacson and Wright described a relationship between ulcerative jejunitis and EATL [49]. Subsequent studies by a number of investigators confirmed these observations by documenting clonal IEL expansions in a proportion of RCD and ulcerative jejunitis cases and demonstrating identical clones in ulcerated and adjacent unaffected mucosa, as well as co-existent or subsequent EATL, which had an aberrant immunophenotype (similar to EATL) [50][51][52][53][54][55][56]. These findings indicated a multistep process of lymphomagenesis, at least in a proportion EATL (54% in one series) [ ...
Purpose of review:
To provide an update on the pathogenesis of enteropathy-associated T cell lymphoma (EATL) and its relationship with refractory celiac disease (RCD), in light of current knowledge of immune, genetic, and environmental factors that promote neoplastic transformation of intraepithelial lymphocytes (IELs).
Recent findings:
EATL frequently evolves from RCD type II (RCD II) but can occur "de novo" in individuals with celiac disease. Recurrent activating mutations in members of the JAK/STAT pathway have been recently described in EATL and RCD II, which suggests deregulation of cytokine signaling to be an early event in lymphomagenesis. Intraepithelial T cells are presumed to be the cell of origin of EATL (and RCD II). Recent in vitro molecular and phenotypic analyses and in vivo murine studies, however, suggest an origin of RCD II from innate IELs (NK/T cell precursors), which could also be the cell of origin of RCD II-derived EATL. The immune microenvironment of the small intestinal mucosa in celiac disease fosters the development of EATL, often in a multistep pathway.
... 12 18-20 However, data regarding the patterns of TCR-GR in different phases or clinical presentations of CD are limited and their clinical significance remains unclear. [11][12][13][14] Standardisation of multiplex PCR assays and optimisation of primers for TCR-GR studies has led to increased sensitivity in the detection of clonal T cell populations in T cell neoplasms. 10 In our study, we investigated the significance of the different TCR-GR patterns using the BIOMED-2 primers in different phases of CD, including RCD, and correlated these findings with the relevant clinical and pathological features. ...
Aims
Refractory coeliac disease type II (RCDII), a rare complication of coeliac disease (CD) associated with high morbidity, requires identification of a clonal population of phenotypically aberrant intraepithelial lymphocytes (IELs) for diagnosis. However, data regarding the frequency and significance of clonal T cell receptor (TCR) gene rearrangements (TCR-GRs) in small bowel (SB) biopsies of patients without RCDII are limited.
Methods
We analysed results of TCR-GR analyses performed on SB biopsies at our institution over a 3-year period, which were obtained from eight active CD, 172 CD on gluten-free diet (GFD), 33 RCDI, and three RCDII patients and 14 patients without CD. TCR-GR patterns were divided into clonal, polyclonal and prominent clonal peaks (PCPs) and these patterns were correlated with clinical and pathological features.
Results
Clonal TCR-GR products were detected in biopsies from 67% of patients with RCDII, 17% of patients with RCDI and 6% of patients with GFD. PCPs were observed in all disease phases (range 12%–33%). There was no significant difference in the TCR-GR patterns between the non-RCDII disease categories (p=0.39). A higher frequency of surface CD3(−) IELs was noted in cases with clonal TCR-GR, but the PCP pattern did not show associations with any clinical or pathological feature. Persistence of clonal or PCP pattern on repeat biopsy was seen for up to 2 years without evidence of RCDII.
Conclusions
Clonal TCR-GRs are not infrequent in cases lacking features of RCDII, while PCPs are frequent in all disease phases. TCR-GR results should be assessed in conjunction with immunophenotypic, histological and clinical findings for appropriate diagnosis and classification of RCD.
... 15 So far, it is well known that clonally expanded mucosal T-cells expressing the same CDR3 region are a hallmark of RCD type II. 9 Since it has been shown from early on that clones found in RCD type II were identical to the clonal structure of EATLs that later arose within the same individual, the assumption came up that RCD type II is a premalignant condition that might require an oncologic rather than an immunosuppressive treatment strategy. [16][17][18][19] However, the TCR repertoire in the duodenal mucosa in its molecular heterogeneity with respect to the number and frequency of co-existing clonally expanding T-cells in the healthy duodenum as well as in active CD and diseases with clonal expansion of T-cells as RCD type II needs further characterisation. ...
Objective:
Refractory coeliac disease (RCD) is a potentially hazardous complication of coeliac disease (CD). In contrast to RCD type I, RCD type II is a precursor entity of enteropathy-associated T-cell lymphoma (EATL), which is associated with clonally expanding T-cells that are also found in the sequentially developing EATL. Using high-throughput sequencing (HTS), we aimed to establish the small-intestinal T-cell repertoire (TCR) in CD and RCD to unravel the role of distinct T-cell clonotypes in RCD pathogenesis.
Design:
DNA extracted from duodenal mucosa specimens of controls (n=9), active coeliacs (n=10), coeliacs on a gluten-free diet (n=9), RCD type I (n=8), RCD type II (n=8) and unclassified Marsh I cases (n=3) collected from 2002 to 2013 was examined by TCRβ-complementarity-determining regions 3 (CDR3) multiplex PCR followed by HTS of the amplicons.
Results:
On average, 10(6) sequence reads per sample were generated consisting of up to 900 individual TCRβ rearrangements. In RCD type II, the most frequent clonotypes (ie, sequence reads with identical CDR3) represent in average 42.6% of all TCRβ rearrangements, which was significantly higher than in controls (6.8%; p<0.01) or RCD type I (6.7%; p<0.01). Repeat endoscopies in individual patients revealed stability of clonotypes for up to several years without clinical symptoms of EATL. Dominant clonotypes identified in individual patients with RCD type II were unique and not related between patients. CD-associated, gliadin-dependent CDR3 motifs were only detectable at low frequencies.
Conclusions:
TCRβ-HTS analysis unravels the TCR in CD and allows detailed analysis of individual TCRβ rearrangements. Dominant TCRβ sequences identified in patients with RCD type II are unique and not homologous to known gliadin-specific TCR sequences, supporting the assumption that these clonal T-cells expand independent of gluten stimulation.
... Haematoxylin was used as a counterstain. The density of the intraepithelial T-cell compartment and the ratios of CD8 þ to CD8 À T cells were determined using our published methods 69,70 . To identify neutrophils (Neutrophil elastase, Dako, clone NP57) and lymphocytes (CD3, Novocastra, clone LN10) 19 syCRCs (from Instituto Humanitas Milan, UCLH London, and Wellcome Trust Centre for Human Genetics, Oxford) and 14 soCRCs (from UCLH London) were stained on the bondmax system (http://www.vision-bio.com/). ...
Synchronous colorectal cancers (syCRCs) are physically separated tumours that develop simultaneously. To understand how the genetic and environmental background influences the development of multiple tumours, here we conduct a comparative analysis of 20 syCRCs from 10 patients. We show that syCRCs have independent genetic origins, acquire dissimilar somatic alterations, and have different clone composition. This inter- and intratumour heterogeneity must be considered in the selection of therapy and in the monitoring of resistance. SyCRC patients show a higher occurrence of inherited damaging mutations in immune-related genes compared to patients with solitary colorectal cancer and to healthy individuals from the 1,000 Genomes Project. Moreover, they have a different composition of immune cell populations in tumour and normal mucosa, and transcriptional differences in immune-related biological processes. This suggests an environmental field effect that promotes multiple tumours likely in the background of inflammation.
... A small group of celiac disease patients do not respond to strict gluten-free diet and present with large numbers of aberrant IEL in a type 2 refractory celiac disease [38] . The abnormal cell phenotype includes the loss of surface CD3 with preservation of cytoplasmic CD3ε [39,40] and rearranged TCRγ chains [38,41] . These abnormal and highly proliferative IEL are suggested to give rise to T-cell lymphoma [42] , while others suggest innate IEL giving rise to enteropathy-associated T-cell lymphoma (EATL) [26,43] . ...
Background:
Chronic intestinal inflammation due to noninfectious causes represents a growing health issue all over the world. Celiac disease as well as inflammatory bowel diseases (IBD) like Crohn's disease and ulcerative and microscopic colitis involve uncontrolled T-cell activation and T-cell-mediated damage as common denominators. Therefore, diagnosis and treatment decisions clearly benefit from the knowledge of the intricacies of the systemic and the local T-cell activity.
Summary:
Depending on the cytokine milieu, CD4+ T cells can differentiate into proinflammatory T helper 1 (Th1), anti-inflammatory Th2, antimicrobial Th17, pleiotropic Th9, tissue-instructing Th22 cells, and in the regulatory compartment forkhead box protein 3+ Treg, suppressive Tr1 or Th3 cells. Additionally, follicular Th cells provide B-cell help in antibody class switching; cytotoxic CD8+ T cells target virus-infected or tumor cells. This review discusses our current knowledge on the contribution of defined T-cell subpopulations to establishing and maintaining chronic intestinal inflammation in either of the above entities. It also puts emphasis on the differences in the prevalence of these diseases between Eastern and Western countries.
Key messages:
In celiac disease, the driving role of T cells in the lamina propria and in the epithelium mainly specific for two defined antigens is well established. Differences in genetics and lifestyle between Western and Eastern countries were instrumental in understanding underlying mechanisms. In IBD, the vast amount of potential antigens and the corresponding antigen-specific T cells makes it unlikely to find universal triggers. Increased mucosal CD4+ regulatory T cells in all four entities fail to control or abrogate local inflammatory processes. Thus, prevailing differences in the functional T-cell subtypes driving chronic intestinal inflammation in celiac disease and IBD at best allow some overlap in the treatment options for either disease.
... Increased population of IELs is one of the characteristic findings in CD but their role in the pathogenesis has not been fully identified. Few recent studies showed that IELs might be related to the development of refractory CD (RCD) and enteropathy-associated T cell lymphoma [79,80]. IELs may be involved in causing epithelial cell damage by conversion from antigen specific T cells to NK like cells that cause stress-induced damage to epithelial cells and this in turn, may be mediated by IL-15 [80]. ...
Celiac Disease is an autoimmune enteropathy with increasing incidence worldwide in both adults and children. It occurs as an inflammatory condition with destruction of the normal architecture of villi on consumption of gluten and related protein products found in wheat, barley and rye. However, the exact pathogenesis is not yet fully understood. A gluten-free diet remains the main modality of therapy to date. While some patients continue to have symptoms even on a gluten-free diet, adherence to this diet is also difficult, especially for the children. Hence, there is continued interest in novel methods of therapy and the current research focus is on the promising novel non-dietary modalities of treatment. Here, we critically reviewed the existing literature regarding the pathogenesis of celiac disease in children including the role of in-utero exposure leading to neonatal and infant sensitization and its application for the development of new therapeutic approaches for these patients.
... 15 So far, it is well known that clonally expanded mucosal T-cells expressing the same CDR3 region are a hallmark of RCD type II. 9 Since it has been shown from early on that clones found in RCD type II were identical to the clonal structure of EATLs that later arose within the same individual, the assumption came up that RCD type II is a premalignant condition that might require an oncologic rather than an immunosuppressive treatment strategy. [16][17][18][19] However, the TCR repertoire in the duodenal mucosa in its molecular heterogeneity with respect to the number and frequency of co-existing clonally expanding T-cells in the healthy duodenum as well as in active CD and diseases with clonal expansion of T-cells as RCD type II needs further characterisation. ...
... The type I refractory CD is characterized by IEL that have normal CD3 + /CD8 + phenotype and are polyclonal in the T-cell gene rearrangement studies. In contrast, majority of patients with either refractory CD or so called ulcerative jejunitis have clonal populations of IEL [36,37] and are now classified as type II refractory CD [35]. Although these phenotypically aberrant IEL are not morphologically recognizable as aberrant, nor they form tumor masses, they clearly represent risk and the first step in progression to the enteropathy-associated T-cell lymphoma (EATL) [36]. ...
Duodenal biopsy is an essential component in the diagnosis of celiac disease (CD). Although the classical findings of increased number of intraepithelial lymphocytes, crypt hyperplasia and villous atrophy are very characteristic, the diagnosis cannot be achieved on the basis of histopathology alone, as there are many entities that can mimic CD and a close collaboration of a pathologist and a clinician specialist is needed. In a patient with suspected CD, pathologist should describe essential histopathological findings and offer differential diagnosis when appropriate. The most important recent changes in the diagnostic criteria for CD include lower numbers of intraepithelial lymphocytes that are considered to be normal and recommendation to perform biopsies from the proximal part of the duodenum in addition to the distal duodenal biopsies.
Objectives
Children with coeliac disease (CD) have an increased number of chromosome aberrations in peripheral blood lymphocytes. Whether genetically determined or a secondary phenomenon in CD, chromosome abnormalities may be involved in the predisposition to cancer in CD patients. The aim of the study was to follow a group of children with CD in whom the initial frequency of chromosome aberrations at diagnosis was known and to measure the same variable after a minimum of 2 years on a gluten‐free diet.
Methods
Chromosome aberrations in peripheral blood lymphocytes were determined in 17 patients with CD, before and after at least 24 months of a gluten free diet (mean, 33 months), and in 15 healthy children. The differences in the frequency of aberrations were analyzed by Mann‐Whitney U test and Wilcoxon matched‐pairs signed‐ranks test.
Results
Twelve patients adhered to the diet and had a significantly lower frequency of chromosome aberrations than did 5 patients not following the diet (0.16% v 1.2%; P = 0.03), whereas at presentation there had been no difference (1.54% v 1.2%; P = 0.09). The frequency of aberrations at follow‐up in patients who were diet adherent was significantly lower than at presentation (1.54% v 0.16%; P = 0.02) and remained unchanged in patients who were not diet adherent (1.2% v 1.2%; P = 1). After at least 24 months of a gluten‐free diet, children with CD did not differ from healthy control subjects (0.16% v 0.27%; P = 0.54), whereas children not following the diet had an increased frequency of aberrations (1.2% v 0.27%; P = 0.05).
Conclusions
The frequency of chromosome aberrations in peripheral blood lymphocytes of patients with CD decreased significantly on a gluten‐free diet. We conclude that genomic instability is a secondary phenomenon, possibly caused by chronic intestinal inflammation.
Refractory Celiac Disease (RCD) develops in a small subset of celiac patients (CeD) who become refractory to gluten-free diet (GFD). Two forms of RCD can be distinguished based on the immunophenotype of intraepithelial lymphocytes (IEL) and the immunogenetic status of TCRγ. While RCDI is a benign condition, RCDII is a clonal lymphoproliferation that can evolve towards an aggressive enteropathy-associated T-cell lymphoma (EATL). RCDII and EATL display distinctive histological and immunohistochemical features. However, those features may lack sensitivity and specificity. In particular, malignant cells from RCDII consist of small cells that do not divide actively and have normal cytological appearance. Histological diagnosis is thus highly expert-dependent. This chapter describes how complementary cellular and molecular approaches enable accurate diagnosis of RCDII. Multiparameter immunophenotyping of lymphoid cells extracted from intestinal biopsies helps demonstrating the expansion of the abnormal/malignant IEL in RCDII. Molecular tools are useful to identify immunogenetic clonal hallmarks and characteristic oncogenetic somatic gain-of-function mutations.
Specimens from the gastrointestinal (GI) tract are among the most commonly encountered in routine pathology practice worldwide. It is well known that the luminal GI tract is home to various areas rich in mucosa-associated lymphoid tissue (MALT), whether native or acquired. The latter may be particularly problematic due to its well-known predisposing factors such as Helicobacter pylori infection and autoimmune conditions. Nevertheless, native GI structures are often the subject of query, particularly in conditions that may mimic lymphoproliferative conditions, including infectious and inflammatory diseases. Herein, we describe and share common clinicopathological findings in our daily practice that are challenging to distinguish from subtle low-grade neoplastic lymphoproliferative disorders.
Most gastrointestinal NK and T cell lymphomas are aggressive in behaviour, although in recent years a subset of indolent lymphoproliferative disorders have been described, which must be distinguished from their more malignant mimics. Intestinal T-cell lymphomas may arise from intra-epithelial lymphocytes and display epitheliotropism, such as enteropathy-associated T-cell lymphoma and monomorphic epitheliotropic intestinal T-cell lymphoma. They are both aggressive in behaviour but differ in their clinic-pathological features. On the other hand, intra-epithelial lymphocytes are not prominent in intestinal T-cell lymphoma, NOS, which is a diagnosis of exclusion and probably represents a heterogeneous group of entities. Indolent lymphoproliferative disorders of NK- and T-cells of both CD8 and CD4 subsets share a chronic, recurring clinical course but display differences from each other. CD8+ T-cell lymphoproliferative disorder of GI tract has a low proliferative fraction and does not progress nor undergo large cell transformation. Whilst NK-cell enteropathy runs an indolent clinical course, it may display a high proliferation fraction. On the other hand, CD4+ indolent T-cell lymphoproliferative disorder displays variable proliferation rates and may progress or transform after a number of years. In Asia and South America, it is not uncommon to see involvement of the gastrointestinal tract by EBV-associated extranodal NK/T cell lymphoma, nasal type, which must be distinguished from NK cell enteropathy and EBV-associated mucocutaneous ulcers.
Refractory celiac disease (RCD) encompasses biologically heterogeneous disorders that develop in a small proportion (0.3%) of individuals with celiac disease that are associated with high morbidity. Two broad categories are currently recognized, type I (RCD I) and type II (RCD II), based on immunophenotypic and molecular features of the intraepithelial lymphocytes (IELs). RCD I is characterized by a polyclonal expansion of IELs displaying a normal immunophenotype, while RCD II represents a clonal proliferation of immunophenotypically “aberrant” IELs, and is considered a low-grade lymphoproliferative disorder. The pathogenesis of RCD I has not been clarified, but limited studies suggest multifactorial etiology. On the other hand, recent immunologic, molecular and immunophenotypic analyses have proposed lineage-negative innate IELs to be the cell of origin of a proportion of RCD II cases. Furthermore, sequencing studies have identified frequent, recurrent, activating mutations in members of the JAK-STAT pathway in RCD II. This finding, in conjunction with prior in vitro experimental observations, suggests roles of deregulated cytokine signaling in disease pathogenesis. In this review, we describecurrent understanding of environmental, immune and genetic factors associated with the development of RCD and briefly discuss diagnostic and therapeutic considerations.
Celiac disease is a chronic, immune-mediated enteropathy driven by dietary gluten found in genetically susceptible hosts. It has a worldwide distribution, is one of the most common autoimmune disorders globally, and is the only autoimmune condition for which the trigger is known. Despite advances in characterizing mechanisms of disease, gaps in understanding of celiac disease pathogenesis remain. A "frontier" concept is considering what moves an HLA-DQ2 or DQ8-positive individual from asymptomatic gluten tolerance to celiac disease manifestation. In this arena, environmental triggers, including age at the time of initial gluten exposure, the occurrence of usual childhood viral infections, and microbiome alterations have emerged as key events in triggering the symptomatic disease. Pathologists play a major role in frontier aspects of celiac disease. This includes the discovery that duodenal mucosal histology in follow-up biopsies does not correlate with ongoing patient symptoms, antitissue transglutaminase antibody titers and diet adherence in celiac disease patients. Further, in light of recent evidence that the detection of monoclonal T-cell populations in formalin-fixed biopsies is not specific for type II refractory celiac disease, pathologists should resist performing such analyses until common causes of "apparent" refractoriness are excluded. The promise of therapies in celiac disease has led to clinical trials targeting many steps in the inflammatory cascade, which depend upon a pathologist's confirmation of the initial diagnosis and evaluation of responses to therapies. As pathologists continue to be active participants in celiac disease research, partnering with other stakeholders, we will continue to impact this important autoimmune disease.
Objective:
Causes of small-bowel villous atrophy (VA) include coeliac disease (CD), its complications and other rare non-coeliac enteropathies. However, forms of VA of unknown aetiology may also exist. We defined them as idiopathic VA (IVA). To retrospectively classify the largest cohort of IVA patients and compare their natural history with CD.
Methods:
Notes of 76 IVA patients attending two tertiary centres between January 2000 and March 2019 were retrospectively reviewed. CD, its complications and all the known causes of VA were excluded in all of them. Persistence of VA during follow-up and lymphoproliferative features were used to retrospectively classify IVA, as follows. Group 1: IVA with spontaneous histological recovery (50 patients). Group 2: persistent IVA without lymphoproliferative features (14 patients). Group 3: persistent IVA with lymphoproliferative features (12 patients). Survival was compared between IVA groups and 1114 coeliac patients. HLA was compared between IVA patients, coeliac patients and appropriate controls.
Results:
Five-year survival was 96% in IVA group 1, 100% in IVA group 2, 27% in IVA group 3 and 97% in CD. On a multivariate analysis hypoalbuminemia (P = 0.002) and age at diagnosis (P = 0.04) predicted mortality in IVA. Group 2 showed association with HLA DQB1*0301 and DQB1*06.
Conclusion:
IVA consists of three groups of enteropathies with distinct clinical phenotypes and prognoses. Mortality in IVA is higher than in CD and mainly due to lymphoproliferative conditions necessitating more aggressive therapies.
Celiac disease is a gluten-triggered immune-mediated disorder, characterized by inflammation of the enteric mucosa following lymphocytic infiltration and eventually resulting in villous blunting. There have been many developments in refining diagnostic laboratory tests for celiac disease in the last decade. Biopsy-sparing diagnostic guidelines have been proposed and validated in a few recent prospective studies. However, despite these developments, histologic evaluation of duodenal mucosa remains one of the most essential diagnostic tools as it helps in the diagnosis of celiac disease in individuals who do not fulfill the biopsy-sparing diagnostic criteria and in those not responding to a gluten-free diet. Histologic evaluation also allows for the assessment of mucosal recovery after treatment and in the identification of concurrent intestinal diseases. Therefore, pathologists should be familiar with the histologic spectrum of celiac disease and need to be aware of other disorders with similar symptoms and histopathology that may mimic celiac disease. This review aims to provide pathologists with updates on celiac laboratory testing, biopsy-sparing diagnostic criteria, histopathology, complications, and differential diagnoses of celiac disease.
Принят на 42-й научной сессии Центрального научно-исследовательского института гастроэнтерологии; Москва, 2–3 марта 2016 г. Консенсус разработан ведущими экспертами – гастроэнтерологами и педиатрами России, основан на методических рекомендациях «Глютеновая энтеропатия – междисциплинарная патология» (2006) и «Диагностика и лечение целиакии у детей» (2010), рекомендациях Общества детских гастроэнтерологов России «Диагностика и лечение целиакии у детей» (2010), Федеральных клинических рекомендациях по оказанию медицинской помощи детям с целиакией Союза педиатров России (2015), критериях диагностики целиакии Европейского общества детских гастроэнтерологов, гепатологов и нутрициологов («пересмотренные критерии» ESPGHAN, 1990), Рекомендациях по диагностике и лечению целиакии Американской коллегии гастроэнтерологов (Аmerican college of gastroenterology clinical guideline: diagnosis and management of celiac disease, 2013), Рекомендациях по лечению целиакии взрослых Британского общества гастроэнтерологов (Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology, 2014) и утвержден на 42-й научной сессии Центрального научно-исследовательского института гастроэнтерологии (ЦНИИГ) «Принципы доказательной медицины в клиническую практику» (Москва, 2–3 марта 2016 г.). Консенсус публикуется в сокращенном виде: представлены разделы документа по диагностике и лечению целиакии у взрослых.
Refractory celiac disease (RCD) is a rare condition, usually managed at specialized centers. However, gastroenterologists and pathologists in general practices are often the first to consider a diagnosis of RCD in celiac patients with persistent symptoms. The distinction between type I and type II RCD is crucial as patients with RCD II have a shortened life expectancy. The diagnosis of RCD II requires the demonstration of abnormal intraepithelial lymphocytes and/or monoclonal T-cell populations in duodenal biopsies, typically assessed in formalin-fixed paraffin-embedded tissue. We investigated the clinical significance of T-cell receptor gene rearrangements and CD3/CD8 staining in formalin-fixed paraffin-embedded biopsies from 32 patients with RCD I (4), RCD II (3), newly diagnosed celiac disease (CD) (10), established CD patients with follow-up biopsies (10), and Helicobacter pylori-associated lymphocytosis (5). Clonal T-cell populations were present in all lymphocytosis groups but not in normal controls. No difference in the frequency of clonal populations or persistence of identical clones was found between RCD I and II patients. The degree of villous blunting did not correlate with clonal status in any group. No difference in the number of CD3/CD8-positive intraepithelial lymphocytes per 100 enterocytes was found between groups. We suggest that clonal evaluation of T cells should not be employed routinely in the evaluation of CD patients with persistent symptoms until common causes of "apparent refractoriness" have been excluded. In addition, lymphocyte phenotyping and T-cell clonal analysis appear to be insufficient as stand-alone tests to reliably distinguish RCD I and II.
Celiac disease, celiac sprue, or gluten-sensitive enteropathy, is a generalized autoimmune disease characterized by chronic inflammation and atrophy of the small bowel mucosa. It is caused by dietary exposure to gluten and affects genetically predisposed individuals. In Mexico, at least 800,000 are estimated to possibly have the disease, prompting the Asociación Mexicana de Gastroenterología to summon a multidisciplinary group of experts to develop the “Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico” and establish recommendations for the medical community, its patients, and the general population. The participating medical professionals were divided into three working groups and were given the selected bibliographic material by the coordinators (ART, LUD, JMRT), who proposed the statements that were discussed and voted upon in three sessions: two voting rounds were carried out electronically and one at a face-to-face meeting. Thirty-nine statements were accepted, and once approved, were developed and revised by the coordinators, and their final version was approved by all the participants. It was emphasized in the document that epidemiology and risk factors associated with celiac disease (first-degree relatives, autoimmune diseases, high-risk populations) in Mexico are similar to those described in other parts of the world. Standards for diagnosing the disease and its appropriate treatment in the Mexican patient were established. The guidelines also highlighted the fact that a strict gluten-free diet is essential only in persons with confirmed celiac disease, and that the role of gluten is still a subject of debate in relation to nonceliac, gluten-sensitive patients. Resumen: La enfermedad celiaca (EC), esprúe celíaco o enteropatía sensible al gluten, es una enfermedad autoinmune generalizada que se caracteriza por inflamación crónica y atrofia de la mucosa del intestino delgado, causada por la exposición al gluten de la dieta que afecta a individuos genéticamente predispuestos. En México se estima que al menos 800,000 personas podrían padecerla, por lo que la Asociación Mexicana de Gastroenterología convocó a un grupo multidisciplinario de expertos para que realizaran la Guía clínica para diagnóstico y tratamiento de enfermedad celíaca en México, y se establecieran recomendaciones para la comunidad médica, sus enfermos y la población general. Los profesionistas participantes, divididos en 3 mesas de trabajo, recibieron material bibliográfico seleccionado por los coordinadores (ART, LUD, JMRT), quienes propusieron los enunciados que fueron discutidos y votados en 3 sesiones: 2 a través de medios electrónicos y una presencial. Al final se aceptaron 39 enunciados que, una vez aprobados, fueron desarrollados y revisados por los coordinadores hasta su versión final, que fue aprobada por todos los participantes. Dentro de estas se destaca que la epidemiología y factores de riesgo asociados (familiares de primer grado, enfermedades autoinmunes, poblaciones de alto riesgo) a EC en México son similares a los descritos en otras partes del mundo. Se establecen pautas para el diagnóstico y el tratamiento apropiado de los pacientes mexicanos que la padecen. Se insiste en que una dieta estricta libre de gluten es indispensable solo en las personas con EC confirmada, y que su papel en pacientes con sensibilidad al gluten sin EC es aún un tema de controversia. Keywords: Celiac disease, Mexico, Diagnosis, Gluten, Allergy, Sensitivity, Palabras clave: Enfermedad celíaca, México, Diagnóstico, Gluten, Alergia, Sensibilidad
Celiac disease, celiac sprue, or gluten-sensitive enteropathy, is a generalized autoimmune disease characterized by chronic inflammation and atrophy of the small bowel mucosa. It is caused by dietary exposure to gluten and affects genetically predisposed individuals. In Mexico, at least 800,000 are estimated to possibly have the disease, prompting the Asociación Mexicana de Gastroenterología to summon a multidisciplinary group of experts to develop the "Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico" and establish recommendations for the medical community, its patients, and the general population. The participating medical professionals were divided into three working groups and were given the selected bibliographic material by the coordinators (ART, LUD, JMRT), who proposed the statements that were discussed and voted upon in three sessions: two voting rounds were carried out electronically and one at a face-to-face meeting. Thirty-nine statements were accepted, and once approved, were developed and revised by the coordinators, and their final version was approved by all the participants. It was emphasized in the document that epidemiology and risk factors associated with celiac disease (first-degree relatives, autoimmune diseases, high-risk populations) in Mexico are similar to those described in other parts of the world. Standards for diagnosing the disease and its appropriate treatment in the Mexican patient were established. The guidelines also highlighted the fact that a strict gluten-free diet is essential only in persons with confirmed celiac disease, and that the role of gluten is still a subject of debate in relation to nonceliac, gluten-sensitive patients.
Copyright © 2018. Publicado por Masson Doyma México S.A.
The paper presents the All-Russian consensus on the diagnosis and treatment of celiac disease in children and adults, which has been elaborated by leading experts, such as gastroenterologists and pediatricians of Russia on the basis of the existing Russian and international guidelines. The consensus approved at the 42nd Annual Scientific Session of the Central Research Institute of Gastroenterology on Principles of Evidence-Based Medicine into Clinical Practice (March 2-3, 2016). The consensus is intended for practitioners engaged in the management and treatment of patients with celiac disease. Evidence for the main provisions of the consensus was sought in electronic databases. In making recommendations, the main source was the publications included in the Cochrane Library, EMBASE, MEDLINE, and PubMed. The search depth was 10 years. Recommendations in the preliminary version were reviewed by independent experts. Voting was done by the Delphic polling system.
The key principle of gastrointestinal (GI) biopsy interpretation is that the GI tract has a limited repertoire of responses to a host of injuries, and diagnosing the type of injury in any given biopsy often requires correlation with clinical details. Gastroesophageal reflux disease (GERD) is among the most common of gastrointestinal track disorders and many patients undergo endoscopic biopsies in the course of evaluation for reflux symptoms. Biopsies from patients with graft versus host disease (GVHD) in the esophagus show intraepithelial lymphocytosis, basilar vacuolization, epithelial apoptosis and necrosis in severe disease. High grade dysplastic lesions are typically managed with endoscopic mucosal resection (EMR) or surgical resection. Low-grade B-cell lymphomas of mucosa-associated lymphoid tissue (MALT) are believed to arise in organized lymphoid tissue in the gastric mucosa that is usually acquired in response to Helicobacter pylori infection. Rare high-grade neuroendocrine (small-cell) carcinomas can be encountered on anal biopsies.
Die Zöliakie ist eine häufige Erkrankung. Während man früher davon ausging, dass vor allem Kleinkinder von der Erkrankung betroffen sind, wissen wir heute, dass sie sich in allen Altersgruppen manifestieren kann. Entscheidend vor Beginn einer Therapie ist die sichere Diagnosestellung. Dies kann, da immer häufiger Menschen bereits vor Aufsuchen eines Arztes mit einer glutenfreien Diät beginnen, bisweilen in der Praxis Probleme bereiten. Die Übersichtsarbeit fokussiert auf das sich wandelnde klinische Bild der Zöliakie, möchte praktische Tipps bei der Diagnosestellung und beim Vorgehen bei fehlendem klinischen Ansprechen auf eine glutenfreie Diät geben und schärft den Blick für seltene, aber schwerwiegende Komplikationen der Erkrankung. Obwohl sich erste Medikamente in der Erprobung befinden, wird auf absehbare Zeit die glutenfreie Diät die Hauptsäule der Therapie bleiben.
Coeliac disease has a complex pathogenesis that results from the interaction between environmental (dietary exposure to gluten), genetic and immunologic factors. Gluten-free diet induces clinical and histological recovery in the majority of patients. However, a proportion of patients does not respond to a glutenfree diet and will be diagnosed as Refractory Coeliac Disease (RCD). RCD can be classified in type 1, characterized by polyclonal intraepithelial lymphocytes with a normal immune phenotype, and type 2, characterized by monoclonal intraepithelial lymphocytes with an aberrant immune phenotype. RCD is associated with a high risk of complications such as malnutrition, lymphocytic gastritis, ulcerative jejunitis and enteropathy-associated T-cell lymphoma, especially type 2. The prognosis is poor in RCD type 2, with a 5-year survival of approximately 50%. RCD can be considered a precursor of lymphoma. The treatment of RCD, mainly type 2, remains a clinical challenge.
Mature T- and NK-cell neoplasms represent a wide spectrum of lymphoid malignancies developed from the clonal proliferation of mature T- and NK-cells. These disorders may involve bone marrow and peripheral blood (leukemia), lymphoid or extramedullary tissues (lymphoma), or both. Mature T- and NK-cell neoplasms comprise <15% of all lymphoid tumors. They are divided into three major categories: leukemic or disseminated, nodal, and extranodal. T-cell prolymphocytic leukemia (T-PLL) is a sporadic and aggressive lymphoproliferative disorder of post-thymic T-cells characterized by a high peripheral blood lymphocyte count and infiltration of the bone marrow, spleen, liver, lymph nodes, and skin. A high frequency of ataxia-telangiectasia (. ATM) gene mutations suggests that ATM functions as a type of tumor suppressor gene. Most T-PLL cases also show an aberrant T-cell receptor alpha (T. CRA) gene rearrangement that activates TCL1 or MTCP1-B1 oncogenes.
A small proportion of patients with celiac disease continue to suffer from a malabsorption syndrome with intestinal villous atrophy typical for celiac disease despite a strict gluten-free diet. This clinical picture is known as refractory celiac disease. On the basis of the immunohistology and the clonal expansion of the T cell receptor gene it can be further classified into refractory celiac disease type 1 with an autoimmune character and refractory celiac disease type 2 with a prelymphoma character. These can be clearly distinguished from so-called sprue syndromes which completely or partially lack the typical characteristic features of celiac disease except for the morphological alterations of the intestinal mucosa. As a rule symptomatic refractory celiac disease type 1 is treated by immunosuppression, whereas this approach cannot be used for refractory celiac disease type 2. The risk of enteropathy-asssociated T cell lymphoma (EATL) developing from refractory celiac disease type 2 is massively increased so that a more extensive diagnostic procedure including cross-sectional imaging and if necessary bone marrow puncture must be carried out. When symptomatic refractory celiac disease type 2 should be aggressively treated in the sense of a lymphoma therapy; however, the prognosis for this clinical picture is still unsatisfactory and new therapy approaches are urgently needed.
About 30–40% of all malignant lymphomas arise primarily at extranodal sites. The incidence of extranodal lymphomas in different countries parallels that of nodal lymphomas, indicating that a high frequency of nodal lymphomas implies a high frequency of extranodal lymphomas as well (Newton et al. 1997). Beyond that, a dramatic increase of extranodal lymphomas has been observed due to AIDS. The most frequent sites of extranodal lymphomas in general are the gastrointestinal tract and the skin.
The diagnosis of canine intestinal lymphoma by morphological examination is challenging, especially when endoscopic tissue specimens are used. The utility of detection of antigen receptor gene rearrangement by polymerase chain reaction (PARR) in canine lymphoma has been well established, but its usefulness to distinguish enteritis and intestinal lymphoma remains unclear. In this retrospective study we assessed clonality of 29 primary canine intestinal lymphoma, 14 enteritis and 15 healthy control cases by PARR analysis, using formalin-fixed, paraffin-embedded full-thickness tissue specimens. We could detect monoclonal rearrangements in 22 of 29 canine intestinal lymphomas [76%; 95% confidence interval (CI) 56-90%] and polyclonal rearrangements in all of the enteritis and healthy control cases (100%; CI 88-100%). We revealed a predominance of T-cell phenotype compared to B-cell phenotype (85%; CI 65-96% and 15%; CI 4-35%, respectively). We showed that PARR analysis contributes to differentiation of canine intestinal lymphoma from enteritis and to phenotyping of lymphomas.
© 2015 John Wiley & Sons Ltd.
Two hundred and ten patients with coeliac disease previously reported from this unit were reviewed at the end of 1985 after a further 11 years of follow up. The initial review at the end of 1974 could not demonstrate that a gluten free diet (GFD) prevented these complications, probably because the time on diet was relatively short. The same series has therefore been kept under surveillance with the particular aim of assessing the effects of diet on malignancy after a further prolonged follow up period. Twelve new cancers have occurred: of which one was a carcinoma of the oesophagus and two lymphomas. Thirty nine cancers developed in 38 patients and of 69 deaths, 33 were the result of malignancy. A two-fold relative risk (RR) of cancer was found and was because of an increased risk of cancer of the mouth and pharynx (RR = 9.7, p less than 0.01, 95% confidence interval (CI) = 2.0-28.3), oesophagus (RR = 12.3, p less than 0.01, CI = 2.5-36.5), and of non-Hodgkin's lymphoma (RR = 42.7, p less than 0.001, CI = 19.6-81.4). The results indicate that for coeliac patients who have taken a GFD for five years or more the risk of developing cancer over all sites is not increased when compared with the general population. The risk is increased, however, in those taking a reduced gluten, or a normal diet, with an excess of cancers of the mouth, pharynx and oesophagus (RR = 22.7, p < 0.001), and also of lymphoma (RR = 77.8, p < 0.001). A significant decreasing trend in the excess morbidity rate over increasing use of a GFD was found. The results are suggestive of a protective role for a GFD against malignancy in coeliac disease and give further support for advising all patients to adhere to a strict GFD for life.
Studies of the morphologic and phenotypic diversity of intraepithelial T cells in human small intestine have shown them to be heterogeneous, yet distinct from most extra intestinal T cells. In this study sequential immunoenzymatic staining was used to define new intraepithelial lymphocyte subpopulations in man. In normal human jejunum approximately 6% of the intraepithelial T cells expressing CD3 (an antigen associated with the T cell receptor) do not express the T cell subset antigens CD4 or CD8. Approximately 20% of CD7+ cells (T cells and null cells) do not express CD4 or CD8 and 14% of the CD7+ cells do not express CD3 and are therefore not T cells. The CD7+, CD3+/-, CD4-, CD8- population is concentrated in the tips of the villi. In coeliac disease, the ratios of the subsets change significantly. The percentage of CD3+, 4-, 8- cells increases to 28%, the proportion of CD7+, 4-, 8- cells remains unchanged and the CD7+, CD3- (non-T cell) population is reduced to 1.4% of the CD7+ cells. In contrast, in patients with villous atrophy of uncertain aetiology, all CD4-, CD8- lymphocyte subsets are decreased compared with normal biopsies. Finally, in enteropathy associated T cell lymphoma (malignant histiocytosis of the intestine) in which the 'uninvolved mucosa' is histologically similar to untreated coeliac disease, the changes in the intraepithelial T cell sub-sets are indistinguishable from those in coeliac disease, suggesting that the lymphoma is a complication of coeliac disease.
Enteropathy-associated T cell lymphoma (EATCL; malignant histiocytosis of the intestine) arises in patients with enteropathy, which in some cases is known to be a result of gluten sensitivity. The lymphoma arises in the intestine, where it may remain localized, although eventual dissemination is the rule. Intraepithelial tumour cells often are seen at the mucosal tumor margin. These features suggest that EATCL may be a tumor of intraepithelial lymphocytes. A monoclonal antibody (HML-1) has been produced recently that recognizes the entire intraepithelial lymphocyte population and 50% of lamina propria T cells but very few cells outside the mucosa. Immunocytochemistry has shown that all cases of enteropathy-associated T cell lymphoma studied are HML-1 positive and all peripheral T cell lymphomas and mucosal B cell lymphomas are HML-1 negative. This suggests strongly that EATCL is a tumor of mucosal T cells, possibly the intraepithelial T cell component.
Ulcerative jejunitis (UJ) and enteropathy-associated T-cell lymphoma (EATL) are closely related conditions both associated with celiac disease. Benign-appearing inflammatory ulcers are seen in both, which has led to the suggestion that UJ is a manifestation of EATL. The aim of this study was to investigate this relationship using the polymerase chain reaction (PCR) to detect T-cell gene rearrangement. PCR amplification of the T-cell receptor gamma-chain gene was performed on DNA extracted from lymphoma, associated inflammatory ulcers, and intervening mucosa in six EATL cases and from ulcers and intervening mucosa of seven cases of UJ. In two of these cases, DNA from a subsequent lymphoma was also studied. The PCR products from the tumor and an ulcer from one EATL case, two ulcers from one case of UJ, and one ulcer and subsequent cutaneous lymphoma from one UJ case were sequenced. Twenty-five ulcers from twelve cases of Crohn's disease, twenty sections of normal bowel, and nine celiac biopsies were included as controls. A monoclonal T-cell population defined by a dominant band equal in size to that amplified from the lymphoma was identified in at least one ulcer from four informative EATL cases and from intervening mucosa in three. Monoclonality was demonstrated in at least one, and up to thirteen, ulcers from all seven cases of UJ, in intervening mucosa in five, and in the two subsequent lymphomas. Sequencing showed the same clone was present in the tumor and the ulcer in the EATL case, in two of three ulcers from the UJ case, and in an ulcer and subsequent cutaneous lymphoma in one UJ case. All Crohn's disease ulcers and all sections of normal bowel were polyclonal. One of nine celiac biopsies showed a dominant band. In conclusion, we have shown that T-cell monoclonality is a feature of the ulcers in both UJ and EATL and that the same clone is present in EATL and its associated inflammatory ulcers and in UJ and subsequently developing lymphoma.
We assessed the clonality of duodenal mucosal T cells in patients with celiac disease and controls. Fifteen adult patients were studied. Four patients had a complicated celiac disease, 3 did not respond to a gluten-free diet, and 2 had an ulcerative jejunitis (including 1 patient with nonresponsive celiac disease). Seven patients had an untreated celiac disease responsive to a gluten-free diet. Histological examination of duodenal biopsies of these 11 patients showed benign-appearing celiac disease without evidence of lymphoma. Four patients with nonulcer dyspepsia and normal duodenal biopsies served as controls. TCRγ gene rearrangements were analyzed by multiplex polymerase chain reaction on DNA extracted from duodenal biopsies. Major clonal rearrangements of the T-cell receptor were found in 4 cases, all with complicated celiac disease. Monoclonality was confirmed by DNA sequencing of the junctional region in 3 cases and by hybridization with clone-specific oligoprobes. Patients with celiac disease responsive to gluten-free diet had mainly a polyclonal pattern, with 1 of them having an oligoclonal rearrangement. An oligoclonal pattern was also observed in 2 control patients. Three patients with complicated celiac disease evolved to T-cell lymphoma with liver (n = 2) or bone marrow (n = 1) invasion. Identical clones were found in the enteropathic duodenojejunum and peripheral blood in the patient with large-cell lymphoma with bone marrow invasion. This study suggests that complicated celiac disease is a cryptic T-cell lymphoma.
Objective: To document the progressive phases in the evolution of a flat mucosa in treated gluten-sensitive patients. Design: Patients were challenged orally with a graded series of Frazer's peptic-tryptic digest of gluten (0.1, 0.5, 1.0, 1.5, 3, 6 and 12g). After a control jejunal biopsy, four post-challenge biopsy specimens were obtained 12, 36, 60 and 84 h later. These challenges were performed on outpatients in the Gastrointestinal Investigation Unit at Hope Hospital, Salford, UK. Mucosal specimens were measured by computer-assisted quantitative image analysis. Main outcome: The observations were consistent with earlier proposals for the sequence of changes inferred from static observations on coeliac and dermatitis herpetiformis patients, and their first-degree relatives. Results: There was a reproducible sequence of reactions which could be traced throughout the entire series of mucosal challenges which initially comprised lymphocytic infiltrates into villous epithelium (the 'infiltrative' lesion) followed by crypt epithelium, without accompanying architectural disturbances. Alterations in mucosal architecture first comprised enlargement of the crypts (the 'infiltrative-hyperplastic' lesion) followed, eventually, by the loss of villi (the 'flat-destructive' lesion). Lamina propria 'activation' and infiltration by neutrophils and basophils occurred with the infiltrative-hyperplastic lesion, and parallelled severer mucosal architectural disruption. Evidence of increases in the mitotic activity and size of intra-epithelial lymphocytes was a late phenomenon, as were reductions in enterocyte heights similar to the evolution of an intestinal experimental graft-versus-host reaction, and hence, with a presumed T cell-mediated process. Early changes in villi and enterocytes, followed by secondary crypt hypertrophy (the conventional 'haemolytic' model of flattening) were not seen. Conclusions: The data are similar to the evolution of an intestinal experimental graft-versus-host reaction, and hence, with a presumed T cell-mediated process. Early changes in villi and enterocytes, followed by secondary crypt hypertrophy (the convential 'haemolytic' model of flattening) were not seen.
Intestinal T-cell lymphoma (ITCL) is an uncommon entity among primary gastrointestinal lymphomas. In this study we evaluated tumours from 20 patients presenting with (n=8) or without (n=12) a history of coeliac disease (CD). Neoplastic lesions were composed of predominantly small (n=4), small-to-medium (n=2), medium/mixed-to-large (n=7) or large and anaplastic (n=7) cells. Different patterns of tumour growth and remodelling of the small bowel wall were observed. Pattern a (n=4) was characterized by an intramucosal spread of small tumour cells with a small growth fraction. This pattern resembles mucosal inflammation in CD. In pattern b (n=2), ulcerated solitary or multiple tumours composed of small to medium-sized cells were observed. The adjacent or distant mucosa showed a nearly normal architecture. In pattern c (n=7), ulcerated lesions were composed of medium-sized to large cells. Mucosal flattening occurred in all segments infiltrated by lymphoma. In pattern d (n=7), bowel remodelling was observed along the small intestine even at sites not affected by lymphoma. The main neoplastic lesions were composed of pleomorphic large or anaplastic cells frequently expressing the CD30 molecule. Intramucosal spread of a small epitheliotropic T-cell population was observed in the vicinity or even at distant segments of the small bowel. The demonstration of clonal rearrangements of T-cell receptor genes helped to trace widespread occurrence of this small intraepithelial neoplastic component. We suggest that different features of tumour cells such as the expression of activation antigens may contribute to the remodelling of small bowel mucosa. The addition of immunophenotyping data to macroscopic and microscopic features of specimens provided evidence that this uncommon lymphoma exhibits a spectrum in cytological composition and growth patterns. However, despite the considerable heterogeneity of the cases analysed, most of them shared a characteristic immunohistochemical profile (CD3+, CD8+/–, CD103+), further substantiating the view that ITCL is the neoplastic equivalent of an intraepithelial T-cell subset of the small intestine. This phenotype and the intraepithelial accumulation of lymphoma cells observed in the surviving mucosa are clues to the diagnosis of this clinicopathological lymphoma entity characterized by a broad range of morphological expressions.
Two hundred and two patients with coeliac disease or idiopathic steatorrhoea previously reported from this unit have been reviewed after a further 10 years of follow-up. Of 20 more deaths, 10 were due to malignancy. A separate study was made of all patients with histologically confirmed coeliac disease seen to the end of 1972 and followed up to the end of 1974. Twenty-one of the 43 deaths in this series were due to malignant tumours, of which 13 were reticulum cell sarcomas. There was no evidence that patients showing sub-optimal clinical response to gluten withdrawal or persisting falt jejunal biopsies were more prone to die of cancer. A gluten-free diet did not appear to be effective in preventing malignant complications, but a longer follow-up of patients will be necessary to provide a final answer to this question.
Twenty-seven cases of primary peripheral T-cell lymphomas of the intestine (PTLI) were investigated. Seven patients had histories of malabsorption. The most frequent symptoms at presentation were weight loss, abdominal pain, and acute abdomen. The jejunum was the most common site of lymphoma and multifocal disease was found in 72% of the cases. Twenty-two patients (92%) presented with localized disease confined to the intestine and abdominal lymph nodes, only two patients had generalized disease. According to the pattern of lymphoma infiltration and the morphology of the uninvolved small intestinal mucosa, 21 cases were separated histologically into three categories; 1) enteropathy-associated T-cell lymphoma (EATCL, n = 9) showing predominant intramucosal lymphoma spread and villous atrophy of uninvolved mucosa with high density of intraepithelial lymphocytes (IEL), 2) EATCL-like lymphoma without enteropathy (EATCL-LLWE, n = 5) but with an infiltration pattern similar to EATCL, and 3) T-cell lymphoma without features of EATCL (Non-EATCL, n = 7). Distinctive features of EATCL were the high incidence of malabsorption states, multifocal intestinal disease in all cases, and the high frequency of intestinal recurrences. On frozen sections four of eight PTLI showed the phenotype CD3+ CD4- CD8- HML-1+, which is also expressed on a small subset of normal IEL. The morphologic and immunomorphologic findings suggest that the majority of PTLI is derived from mucosal T lymphocytes. This derivation may be responsible for certain biologic features, such as the preferential spread to and relapse of PTLI at small intestinal sites.
Serum IgA antiendomysial antibodies (EmA) were found in 61 (87%) of 70 adults and children with untreated celiac disease, whereas IgA antigliadin antibodies (AGA) and IgA R1-antireticulin antibodies (R1-ARA) were positive in 71% and 47%, respectively, of the same patients. Two of the nine untreated celiacs negative for IgA EmA showed positivity for IgA AGA. While IgA AGA and R1-ARA disappeared in all the celiacs tested one year after gluten-free diet, IgA EmA persisted at low titer in seven (18%) of these 38 subjects, although the jejunal biopsy showed a complete regrowth of jejunal villi. All the disease control patients as well as the blood donors tested were always negative for the three IgA antibodies. Our results state that the search for both IgA EmA and AGA gives the best results in the screening of celiac disease, since the positivity for at least one of these two antibodies allows identification with a 100% specificity of the 90% of untreated celiac patients.
Expression of the gamma/delta T-cell receptor (TcR) for antigen on CD3+ intraepithelial lymphocytes (IEL) was studied in situ by two-colour immunofluorescence on jejunal tissue sections from 24 patients with coeliac disease and 17 controls. The proportion of intraepithelial TcR gamma/delta+ cells was significantly increased (P less than 0.002) in untreated (median 20%, range 11-53%) as well as in treated (gluten-free diet) coeliac disease (median 23%, range 16-55%) compared with controls (median 2%, range 0-39%). Although TcR alpha/beta+ IEL dominated both in controls and coeliac disease, T cells expressing the TcR gamma/delta were preferentially located within the epithelium rather than in the lamina propria. Paired staining for TcR gamma/delta and CD8 revealed that most (approximately 90%) intraepithelial TcR gamma/delta+ lymphocytes in coeliac disease were CD8-. A remarkably large fraction (median 67%, range 58-94%) of intraepithelial TcR gamma/delta+ cells expressed the V delta 1/J delta 1-encoded epitope revealed by monoclonal antibody delta TCS1. Our results suggested that increase of the intraepithelial TcR gamma/delta+ CD8- subset of T cells is particularly related to coeliac disease.
2 cases of precursor T cell lymphoma and 37 cases of peripheral T cell lymphoma were investigated for their reactivity with the monoclonal antibody (mAb) HML-1, which recognises human intestinal T lymphocytes but not lymph-node T cells. In all but one of the lymphomas studied, the tumour cells were unreactive with the mAb HML-1. The HML-1+ lymphoma was the only tumour that was primarily localised in the epithelium and lamina propria of the small intestine, and was associated with ulcerative jejunitis and coeliac disease. This result suggests that the HML-1+ lymphoma was derived from intestinal mucosa T lymphocytes and differs from precursor T cell lymphoblastic lymphomas and nodal and cutaneous peripheral T cell lymphomas.
Collagenous sprue is a distinctive lesion of the intestinal mucosa associated with progressive malabsorption. The intestinal pathology, as observed in a 51-year-old woman, was initially identical with the characteristic "flat" lesion of untreated celiac sprue. Thereafter, bands of eosinophilic hyaline material within the lamina propria became increasingly apparent. On electron microscopy this eosinophilic material was identified as collagen. As the disease progressed, the mucosa became progressively thinner. Nevertheless a few short segments of normal mucosa remained even at the time of death. Massive steatorrhea, water and electrolyte loss were the main problems. Corticosteroids reduced malabsorption somewhat but had deleterious side effects. All other therapy, including a gluten-free diet, failed. Extensive studies during life and careful post-mortem examination did not establish a known cause for collagenous sprue. Some cases currently designated "refractory" or "unclassified" sprue may prove ...
Specimens from 23 patients with enteropathy-associated T cell lymphoma were studied by immunohistochemistry after antigen retrieval. Specimens from 14 of these patients were investigated for the presence of clonal T cell gene rearrangements in both the tumor and the adjacent enteropathic intestine by the polymerase chain reaction. Primers for T cell receptor beta and gamma genes were used in a combination that permits the identification of approximately 90% of T cell receptor rearrangements. Clonal rearrangements of the T cell receptor were found in 13 of the 14 tumors studied. Specimens of enteropathic bowel resected with the tumor, but showing no morphological or immunohistochemical evidence of tumor involvement, showed clonal T cell receptor gene rearrangements in 11 cases. In 10 of these, the amplified DNA was of the same molecular weight in the enteropathic bowel as in the corresponding tumor. In 2 cases, sequencing the polymerase chain reaction product showed identical T cell receptor gene rearrangements in the tumor and in the adjacent intestine. Uniform staining for p53 was seen in 22 of the 23 tumors. In 9 of 19 cases studied, collections of small lymphocytes in the enteropathic bowel expressed p53. In all but one of these specimens, a clonal rearrangement of the T cell receptor genes was identified. We interpret these findings as support for the concept that enteropathy-associated T cell lymphoma arises on a background of gluten-sensitive enteropathy with evolution of neoplastic T cell clones from the reactive T cell population present in the enteropathic bowel.
Case History—An 85 yr old woman presenting with recent onset of abdominal swelling and back pain.
Primary gastrointestinal lymphoma, which is the commonest extranodal lymphoma and almost exclusively of non-Hodgkin’s type, is defined as lymphoma that has presented with the main bulk of disease in the gastrointestinal tract, with or without involvement of contiguous lymph nodes, and necessitating direction of treatment to that site....
Small bowel lymphomas account for 20 to 40% of primary gut lymphomas in Western populations and are among the most common malignant tumours of the small bowel. We studied 119 cases of primary small bowel lymphoma presenting over 4 decades. Two thirds of the patients were men with a peak age incidence in the 7th decade. Common presenting features included abdominal pain, weight loss, small bowel obstruction, and acute abdomen. Tumours were classified using the Kiel European Association for Haematopathology Geneva Workshop scheme and phenotyped on paraffin sections; 66% were B cells, and 34% were T cell. In all cases, the antibodies L26 and polyclonal CD3 reliably distinguished between B- and T-cell tumours. Of the B-cell lymphomas, 62% were diffuse high grade, 20% were low-grade lymphomas of mucosa-associated lymphoid tissue, 11% had both low- and high-grade components, and 7% were other low-grade types. Of the T-cell lymphomas, 83% were high grade, and 49% were enteropathy associated. Most T-cell lymphomas were ulcerated plaques or strictures in the proximal small bowel; B-cell lymphomas tended to be annular or polypoid masses in the distal and terminal ileum. Survival data showed that low-grade B-cell lymphomas had the best outcome and T-cell lymphomas the worst. Adverse prognostic features included perforation, high-grade histology, multiple tumours and advanced stage.
Differentiation between cutaneous pseudo-T-cell lymphomas and cutaneous T-cell lymphomas (CTCLs) may be extremely difficult. In this study, it was investigated whether demonstration of an aberrant phenotype and detection of clonal T-cell receptor gamma (TCR gamma) gene rearrangements can be used as additional differential diagnostic criteria. Immunohistochemical studies and TCR gamma gene rearrangement analysis using a polymerase chain reaction with primers specific for V gamma 1-8 and V gamma 9 gene segments in combination with denaturing gradient gel electrophoresis (PCR/ DGGE) were performed on frozen material of 11 pseudo-T-cell lymphomas and 17 CTCLs, including 9 cases of mycosis fungoides (MF) and 8 pleomorphic CTCLs. Clonal TCR gamma gene rearrangements were found in 66% of patch/plaque-stage MF and 100% of tumor-stage MF and pleomorphic CTCL, but not in any of 10 pseudo-T-cell lymphomas studied. Aberrant expression of CD2, CD3, and/or CD5 antigens was noted in 3 of 6 (50%) cases of patch/plaque-stage MF, all three cases of tumor-stage MF, and 5 of 8 (62%) pleomorphic CTCLs, but not in any of the 11 pseudo-T-cell lymphomas. Moreover, in pseudo-T-cell lymphomas exhibiting a nodular or diffuse growth pattern, a considerable admixture with reactive CD8+ T cells (15 to 60%), B cells (up to 20%), and macrophages was a characteristic finding. In conclusion, the results of this study suggest that demonstration of clonal TCR gene rearrangements and an aberrant phenotype, as well as demonstration of many admixed CD8+ T cells and B cells can be considered as useful additional criteria in the differentiation between pseudo-T-cell lymphomas and CTCLs.
The etiology of refractory sprue is unclear. To gain insight into its pathogenesis, the phenotype and T-cell receptor (TCR) gene rearrangement status of intestinal lymphocytes were analyzed in a group of patients with clinical or biological features of celiac disease but either initially or subsequently refractory to a gluten-free diet.
Intestinal biopsy specimens were obtained from 26 adults: 6 patients with refractory sprue, 7 patients with active celiac disease, and 13 normal controls. The phenotype of intestinal lymphocytes was studied by immunohistochemistry and, in 3 patients with refractory sprue, by cytometry of lymphocytes purified from intestinal biopsy specimens. TCR rearrangements were assessed by studying TCRgammaV-J junctional regions from DNA extracted from intestinal biopsy specimens and purified intestinal lymphocytes.
In the 6 patients with refractory sprue, but not in normal controls or patients with active celiac disease, the intestinal epithelium was massively infiltrated by small lymphocytes that lacked CD8, CD4, and TCR, contained intracytoplasmic but not surface CD3epsilon chains, and exhibited restricted TCRgamma gene rearrangements.
Refractory sprue is associated with an abnormal subset of intraepithelial lymphocytes containing CD3epsilon and restricted rearrangements of the TCRgamma chain but lacking surface expression of T-cell receptors.
We assessed the clonality of duodenal mucosal T cells in patients with celiac disease and controls. Fifteen adult patients were studied. Four patients had a complicated celiac disease, 3 did not respond to a gluten-free diet, and 2 had an ulcerative jejunitis (including 1 patient with nonresponsive celiac disease). Seven patients had an untreated celiac disease responsive to a gluten-free diet. Histological examination of duodenal biopsies of these 11 patients showed benign-appearing celiac disease without evidence of lymphoma. Four patients with nonulcer dyspepsia and normal duodenal biopsies served as controls. TCRgamma gene rearrangements were analyzed by multiplex polymerase chain reaction on DNA extracted from duodenal biopsies. Major clonal rearrangements of the T-cell receptor were found in 4 cases, all with complicated celiac disease. Monoclonality was confirmed by DNA sequencing of the junctional region in 3 cases and by hybridization with clone-specific oligoprobes. Patients with celiac disease responsive to gluten-free diet had mainly a polyclonal pattern, with 1 of them having an oligoclonal rearrangement. An oligoclonal pattern was also observed in 2 control patients. Three patients with complicated celiac disease evolved to T-cell lymphoma with liver (n = 2) or bone marrow (n = 1) invasion. Identical clones were found in the enteropathic duodenojejunum and peripheral blood in the patient with large-cell lymphoma with bone marrow invasion. This study suggests that complicated celiac disease is a cryptic T-cell lymphoma.
The expression of the natural killer (NK) cell marker CD56 has been reported to occur in NK cell lymphomas/leukemias and a small group of peripheral T-cell lymphomas but has not been studied extensively in primary intestinal non-B-cell lymphomas. Normal human jejunal intraepithelial lymphocytes (IELs) are mainly T-cell receptor (TCR)-alphabeta+CD3+CD8+CD5low and include an approximately 15% fraction of CD56+ cells that could be the cells of origin for CD56+ intestinal T-cell lymphoma (ITL). To test this hypothesis, 70 cases diagnosed as ITL were immunophenotyped, and 15 CD56+ cases (21%) were identified. The majority of the CD56+ lymphomas was of monomorphic small to medium-sized histology, shared the common phenotype betaF1+/-CD3epsilon/cyt+CD8+CD4-CD5-CD57-TIA-1+ and had clonally rearranged TCR gamma-chain genes. In contrast, the CD56- lymphomas were mainly composed of pleomorphic medium and large cells or had a morphology most consistent with anaplastic large-cell lymphoma and were mostly CD8-. These findings suggest that the majority of CD56+ intestinal lymphomas are morphologically and phenotypically distinct T-cell lymphomas most likely derived from activated cytotoxic CD56+CD8+ IELs. Some overlapping histological and clinical features between CD56+ and CD56- ITLs indicate that the former belong to the clinicopathological entity of ITL. The consistent expression of cytotoxic-granule-associated proteins introduces ITL (both CD56+ and CD56-) into the growing family of usually aggressive extranodal lymphomas of cytotoxic T-cell and NK-cell derivation. In contrast to putative NK-cell lymphoma of the sinonasal region, intestinal NK-cell lymphoma seems to be very rare.
Loss of response to a gluten-free diet (refractory sprue) and ulcerative jejunitis are complications of celiac disease that may progress to enteropathy-associated T-cell lymphoma (EATL). Both conditions are characterized by the presence of a nonlymphomatous monoclonal T-cell population in the enteropathic mucosa. In EATL, a similar monoclonal population that shows clonal identity with the lymphoma itself is also present in the enteropathic mucosa. In this study we show that in all three circumstances the monoclonal T-cell population is constituted by cytologically normal, noninvasive intraepithelial T lymphocytes that share an identical aberrant immunophenotype with EATL. Patients with refractory sprue and/or ulcerative jejunitis are, therefore, suffering from a neoplastic T-cell disorder for which hematological treatment strategies need to be devised.
Detection of clonal T-cell receptor gamma (TCRgamma)-chain gene rearrangement is a promising approach to distinguish between cutaneous T-cell lymphomas (CTCLs) and reactive T-cell infiltrates. Despite the improved sensitivity by using the polymerase chain reaction (PCR) rather than Southern blot analysis, monoclonality could be demonstrated in only 53-90 per cent of CTCL biopsies in recent studies. In the present study, formalin-fixed, paraffin-embedded specimens of 21 selected patients with clear-cut advanced-stage CTCL were analysed using a semi-nested TCRgamma PCR with newly developed consensus primer pairs. Detection of PCR products was done by GeneScan analysis (GSA); this technique is advantageous due to its sensitivity and accuracy in the detection and size determination of PCR products and it is easier to interpret than direct read-outs from TGGE or DGGE gels. In serial dilution experiments, TCRgamma-PCR-GSA allowed the detection of clonal, rearranged T-cells with a high in vitro sensitivity against a polyclonal background (1-6 per cent). Despite the selection of clear-cut, advanced-stage CTCL cases, however, dominant clonal TCRgamma-chain gene rearrangement was found in only 16 of the 21 patients analysed, indicating an overall clinical sensitivity of 76 per cent. Specificity was evaluated using biopsy specimens from 21 control patients suffering from long-standing psoriasis (n=13) and eczema (n=8). Surprisingly, GeneScan profiles showing apparently single dominant peaks were detected in 14 per cent of these skin lesions, but these profiles turned out to be pseudo-monoclonal by repeated determinations. In conclusion, TCRgamma-PCR-GSA does not suffice reliably to exclude malignancy, due to its limited clinical sensitivity, but with precautions taken to detect pseudo-monoclonality and to secure specificity, TCRgamma-PCR-GSA is a valuable instrument in the diagnosis of CTCL.
Recently, patients with refractory sprue have been shown to contain a clonal proliferation of phenotypically abnormal intraepithelial lymphocytes in their intestine. Whether this signifies early enteropathy-type intestinal T-cell lymphoma (EITCL) or a reactive condition is not clear. We report on a patient presenting with the findings of refractory sprue who subsequently developed overt EITCL.
Duodenal biopsies from 1997 (refractory sprue) and duodenal and jejunal biopsies from 1998 (intestinal T-cell lymphoma) were compared by immunohistochemistry and PCR for the detection of T-cell receptor (TCR)-gamma gene rearrangements. Clonal PCR products were sequenced.
The duodenal biopsies from both 1997 and 1998 and the jejunal tumor biopsy showed villus atrophy and an increase of intraepithelial lymphocytes with an abnormal immunophenotype (CD3+, CD4-, CD8- and TCR-beta-). In all duodenal specimens including the one from 1997, and the jenunal tumor biopsy, an identical clonal amplificate was detected by enzymatic amplification of the TCR-gamma gene.
These data suggest that refractory sprue containing a clonal proliferation of phenotypically abnormal intraepithelial lymphocytes may represent an early manifestation of EITCL. The detection of immunohistochemical negativity for several antigens normally found on intraepithelial lymphocytes such as CD8 or the TCR-beta chain in combination with clonal T-cell populations by PCR may be helpful in identifying refractory sprue with a malignant transformation.
- Pg Isaacson
- Gastrointestinal Lymphoma
Isaacson PG. Gastrointestinal lymphoma. Hum Pathol 1994;
25:1020–9.