Coeliac Disease: The Current Role Of Pathology (II .

Coeliac disease: the current role of pathology (II)Refractory coeliac diseaseLuigi Terracciano

What is Refractory coeliac disease ?Refractory sprue or refractory coeliac disease (RCD)is defined by: persistent malabsorptive symptoms and villousatrophy despite strict adherence to a gluten-freediet (GFD) for 6 -12 months

Refractory coeliac disease An high rate of progression to lymphoma ( EATL) Unique biochemical and immunologic features Heterogeneous group whereas collagenous sprueaccounts for 30-50% of cases Most patients with collagenous sprue die fromdisease or require corticosteroids, otherimmunsuppressive agents or total parenteralnutrition to survive High prevalence of autoimmune conditions (2-12 fold than coeliac disease)

Prevalence of refractory sprueamong patients with coeliac disease The real prevalence of RCD is unknown but isprobably rare 0.7% - 1.5% of patients with Coeliac Disease (nonreferral population-based cohorts) More common in women Most cases diagnosed after age 50West J. Celiac Disease and Its Complications: A Time Traveller’s Perspective Gastroenterology 2009 136: 32-4Rubio-Tapia A, Murray JA. Classification and management of refractory coeliac diseaseGut 2010 59: 547-557

Presentation of RefractorySprue/Refractory Coeliac Disease Persistent diarrhoea, abdominal pain, andinvoluntary weight loss Multiple vitamin deficiencies Anaemia, fatigue, malaise

Refractory Coeliac Disease Patients The majority of patients with RCD experienceinitial clinical improvement on a GFD, but, aftera period of remission, develop diseaserefractory to gluten abstinence (‘secondaryRCD’) Patients who have no initial response to a GFD(‘primary RCD’ or ‘unclassified sprue’)

The first step in the diagnosis of RCD is toconfirm the initial diagnosis of CD Confirm gluten abstinence Rule out other causes of villous atrophy

Response to GFD Clinically - a marked symptomaticimprovement may occur within several days ofstarting GFD Mucosal improvement may continue for 2years or more

Causes of Villous Atrophy Coeliac diseaseTropical sprueGiardiasisInfectious enteritisSmall bowel bacterialovergrowthMicroscopic colitisEosinophilic gastroenteritisGraft-versus-host diseaseCow's milk and soy proteinenteropathyAbetalipoproteinaemia Small bowel ischaemiaIntestinal lymphomaTuberculosisCrohn's diseaseParasitic infestationSevere malnutritionAdult onset autoimmuneenteropathyCommon VariableImmunodeficiencyHIV enteropathyChemotherapy and radiationenteritis

Pathology work-upAbnormal Intraepithelial LymphocyteDetection Double CD3/CD8 immunohistochemistry T cell receptor clonal rearrangement by PCR Immunophenotyping using flow cytometry

Refractory Coeliac DiseaseClonal intraepithelial lymphocytes? 50% IELs with abnormal immunophenotype (CD3 CD8-) byIHC 20% ‘aberrant’ IELS (express cytoplasmic CD3ε, but lacksurface expression CD3, CD4 and CD8) by flow cytometryClonal T cell receptor gene rearrangement by molecular analysisNoRefractory CoeliacDisease Type 1YesRefractory CoeliacDisease Type 2

NORMALCD3CD8ABNORMALCD3CD8From Cellier C et al. Refractory sprue, coeliac disease, and enteropathy-associated T-cell lymphoma. Lancet.2000;356:203

Gut, 2007; 56: 1373 - 1378. Five-year survival was higher in the type 1 group(96 vs 58 %). Most deaths (half) were due to development ofT-cell lymphoma No patient with type 1 disease developed type 2disease

Treatment Options RCD type 1 - prednisone, budesonide orcombination of prednisone and azathioprine arebeneficial No established treatments for RCD type 2 Chemotherapeutic drugs alone or high-dose chemofollowed by autologous stem cell transplantation forselected patients with RCD type 2 Future novel therapies, such as interleukin 15blockade ?Al-Toma A, Goerres MS, Meijer JW, et al. Cladribine therapy in refractory celiac disease with aberrant T cells. ClinGastroenterol Hepatol 2006;4:1322e7; quiz 1300.Al-toma A, Visser OJ, van Roessel HM, et al. Autologous hematopoietic stem cell transplantation in refractory celiac diseasewith aberrant T cells. Blood 2007;109:2243-9Al-Toma A, Verbeek WH, Visser OJ, et al. Disappointing outcome of autologous stem cell transplantation for enteropathyassociated T-cell lymphoma. Dig Liver Dis 2007;39:634-41Yokoyamaa S, Watanabea, Satob N et al. Antibody-mediated blockade of IL-15 reverses the autoimmune intestinal damage intransgenic mice that overexpress IL-15 in enterocytes. PNAS 2009:106:15849–15854

Common Variable ImmuneDeficiency CVID can display features similar to those ofcoeliac disease Villous atrophy in 24% to 53% of duodenalsamples from patients Increased IELs (53%). CVID patients often show markedly decreasedto absent plasma cells (CD 138 useful)Daniels JA et al. Gastrointestinal Tract Pathology in Patients with Common Variable Immune Deficiency(CVID) – A Clinicopathologic Study and Systematic Review Am J Surg Pathol 2007;31:1800–1812

Autoimmune Enteropathy Rare cause of intractable diarrhoea associated withcirculating gut autoantibodies and a predispositionto autoimmunity. Adults and children Histologically similar to coeliac disease withincreased IELs and villous blunting IgA and IgG anti-enterocyte antibodies Other organ-specific autoantibodies No coeliac-related autoantibodies Steroid responsive

From: Akram S, Murray JA, Pardi DS et al. Adult Autoimmune Enteropathy: Mayo Clinic Rochester Experience. ClinGastroenterol Hepatol 2007;5:1282–1290

Collagenous sprue Rare form of small bowel enteropathy. Pathologic lesion consists of subepithelialcollagen deposition associated with variablealterations in villous architecture. Characterised clinically by chronic diarrhoeaand progressive malabsorption. It has traditionally been associated withsignificant morbidity

AJSP 24(5):676-687,May 2000- 5 new cases of collagenous sprue andextensive literature review- 13/30 patients known to have died fromcomplications of disease- 7 cases of collagenous sprue.The Lancet - Vol. 356,Issue 9225, 15 July2000, P 203-208- Clonal TCR gamma configurations were found in 5/6- 3 of these patients died from malnutrition.

AJSP 2009;33:1440–1449 12 cases (4 males), 41-84 yrs 6 patients improved clinically with combination ofGFD and immunosuppressant drugs; histologicimprovement in 3/6. 1 patient died of another illness, 2 died of CScomplications. No lymphoma. 4 had CD

Collagenous sprueCoeliac sprueCollagenous sprue Flat or nearly flat mucosa with crypthyperplasia and increasedintraepithelial lymphocytes (IELs)CD3 CD8 Positive serologic tests : tTG,antiendomisial, antigliadin abs Flat or nearly flat mucosa with mildor absent crypt hyperplasia andincreased intraepitheliallymphocytes (IELs) CD3 CD8 /- DQw2 and DQ8 Serologic test negative Clinical, biochemical andmorphologic response to a glutenfree diet regimen Collagen bandno DQw2 Incomplete or absent response to agluten-free diet regimen (refractorysprue)

Masson’sTrichrome

Lamina propria cells and capillariesentrapped in collagen

Varying degrees ofvillous atrophy

Sirius Red subepithelial collagen deposition

Sirius Red subepithelial collagen deposition

CD3

CD8

CD8

Seminested multiplex-PCR for B- and T-cell rearrangementIgH-FR3TCRg RearrangementIgH-FR1Almost no B-cells450400339350300247200139150160Size (bp)100Beta-Globin QCPolyclonal TCR-g rearrangement

Collagenous sprueHistology Layer of subepithelial collagen thicker than 12mm into the lamina propria Entrapment of cellular elements is a mandatory diagnostic criterion Crypt atrophy more frequent than crypt hyperplasia Intraepithelial lymphocytosis may be absent ( 25 IELs per 100 epithelial cells) Hyperchromasia of the crypt epithelium Subcrypt inflammation and even crypt abscesses If collagen deposits are found in ther small bowel, similar deposity may beconcomitantly present in colonic (ie, collagenous colitis) and/or gastricmucosa: further endoscopic assessment and biopsy elsewhere in GI tractZhao X, Arch Pathol Lab Med, 2011

Small bowel histologyGastric histology (4/7 bx)Colonic histology (7/9 bx)Collagenous sprueCollagenous gastritisCollagenous colitisLymphocytic colitisCollagenous sprueChronic gastritisNo biopsyCollagenous sprueLymphocytic gastritisNormal colonic biopsyCollagenous sprueNo biopsyNormal colonic biopsyCollagenous sprueCollagenous gastritisCollagenous colitisCollagenous sprueNormal antral biopsyNo biopsyCollagenous sprueNo biopsyCollagenous colitisCollagenous sprueNo biopsyCollagenous colitisCollagenous sprueNo biopsyCollagenous colitisCollagenous sprueCollagenous gastritisCollagenous colitisCollagenous sprueReactive gastropathyCollagenous colitisCollagenous sprueUlcerative jejuno-ileitisNo biopsyNo biopsy

TAKE HOME When patients fail to respond to GFD revisit and confirm initial diagnosisof CDConfirm adherence to GFDRare causes of villous atrophy should also be considered and ruled out. Recognition of RCD, and discrimination between RCD type 1 and 2, isimportant for prognosis and treatment. RCD is a potentially treatable condition, particularly type 1 variant. RCD type 2 is associated with a poorer prognosis and patients have a highrisk of developing EATL.Collagenous sprue: may be a histological pattern associated with several different immunemediated GI diseases, most commonly CD may be associated with collagen deposition in other parts of GIT Most patients respond to a combination of GFD and immunosuppressivedrugs

TEMPLATE REPORTCLINICAL DETAILS SITE & NO. OF BIOPSIESCOMMENT ON ORIENTATIONVILLOUS/CRYPT RATIO – NORMAL (type 1)/PARTIAL ORSUBTOTAL (type 2) / OR TOTAL (type 3)INCREASED IELS –NORMAL/INCREASED ( 25)PRESENCE OF NEUTROPHILS, EOSINIPHILS, SUBEPITHELIALCOLLAGEN ( 10-20 micron and measure)

References1. Zhao X, Johnson RL, Collagenous sprue: a rare, severe small-bowel malabsorptivedisorder Arch Pathol Lab Med. 2011 Jun;135(6):803-92. WeinsteinWM, Saunders DR, Tytgat GN, et al. Collagenous sprue—anunrecognized type of malabsorption. N Engl J Med 1970;283:1297-301.1. Vakiani E, Arguelles-Grande C, Mansukhani MM, et al. Collagenous sprue is notalways associated with dismal outcomes: a clinicopathological study of 19patients. Mod Pathol. 2010;23(1):12–26.2. Bagdi E, Diss TC, Munson P, Isaacson PG. Mucosal intra-epithelial lymphocytes inenteropathy-associated T-cell lymphoma, ulcerative jejunitis, and refractory celiacdisease constitute a neoplastic population. Blood. 1999; 94(1):260–264.3. Cellier C, Delabesse E, Helmer C, et al. Refractory sprue, coeliac disease, andenteropathy-associated T-cell lymphoma. Lancet. 2000;356(9225):203–208.

CD8 Phenotype in Refractory sprueIEL phenotype is considered abnormal when the number of CD8 IEL /100 epithelial cells is less than 50% of CD3 IEL / 100 epithelial cellsCellier C, Lancet, 200023 complicated CD18 Refractory Sprue:CD3 CD8 in 12/18 (67%)CD3 CD8- in 6/18 (33%)5 EATLCD3 CD8- in 3/5 (60%)de Mascarel A, Am J Surg Pathol, 2008CD86/6RCDPatey-Mariaud de Serre N, Histopathology, 200015/15RCDVerkarre V, Gut, 200317/20RCDBagdi E, Blood, 1999

CD8 Phenotype in Refractory sprueRefractory SprueType 1 CD3 CD8 Type 2 CD3 CD8- with clonal intestinal TCR grearrangements andclonal dissemination into the blood. Worse prognosis and strongindicator for the development of overt T-cell lymphoma (cryptic T-celllymphoma, Green PH, N Engl J Med, 2007 )

What is Refractory coeliac disease ? Refractory sprue or refractory coeliac disease (RCD) is defined by: persistent malabsorptive symptoms and villous atrophy despite stri