Intestinal T-cell lymphoma: a reassessment of cytomorphological and phenotypic features in relation to patterns of small bowel remodelling

High Expression of Intestinal Homing Receptor CD103 in Adult T-Cell Leukemia/Lymphoma, Similar to 2 Other CD8+ T-Cell Lymphomas

We investigated the expression of the αEβ7 integrin (CD103)-intestinal homing receptor of T-intraepithelial lymphocytes (IELs) in 130 cases of adult T-cell leukemia/lymphoma (ATLL). We detected CD103 lymphoma cells in 55% (31/56) of mainly gastrointestinal (GI)-involved ATLL cases. Among them, lymphoma cells of 18 cases located in other involved organs had similar CD103 expression patterns. Histologically, we found (a) increased reactive IELs in non-neoplastic mucosal layers in 28% (5/18) of surgical and mucosal resection cases, (b) preserved epithelial glands, and (c) numerous small intraepithelial ATLL nests in involved lesions in 36 (69%) and 21 (40%), respectively, of the 52 examined cases. These 3 patterns were common in intestinal type II enteropathy-associated T-cell lymphoma but were rare in intestinal EBV nasal-type/like T/natural killer (NK)-cell lymphoma. We detected CD103 tumor cells in 41% (16/39) of lymph node-involved ATLL, in 31% (11/35) of skin-involved ATLL, in 68% (21/31) of type II CD4 enteropathy-associated T-cell lymphoma cases, in 36% (8/22) of primary gastric T/NK-cell lymphomas, and in 77% (7/9) of CD8 epidermotropic mycosis fungoides. CD103 ATLL prefers involving the GI tract over the skin (P<0.05). CD103 expression in GI-involved and/or total ATLL cases was significantly higher than in other 9 T/NK-cell lymphoma groups (P<0.05 or 0.01). Only ATLL cases were commonly CD103 in CD4 T/NK-cell lymphoma groups (P<0.05 or 0.01). Human T-lymphotropic virus-1-infected CD103 T-IELs and mucosal T cells may be important sources of ATLL.

Multiple lesions of gastrointestinal tract invasion by monomorphic epitheliotropic intestinal T-cell lymphoma, accompanied by duodenal and intestinal enteropathy-like lesions and microscopic lymphocytic proctocolitis: a case series

Background

In East Asia, monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL), previously known as type II enteropathy-associated T-cell lymphoma (EATL), occurs more frequently than type I EATL, and coeliac disease is rare.

Case presentation

Here we present four cases of MEITL in Japanese patients, including the endoscopic and pathological findings of their duodenal and colorectal lesions. Tumor specimens obtained from duodenal, intestinal, and colorectal biopsies in all four patients showed a diffuse intramucosal infiltration of small to/or medium-sized lymphoma cells and numerous atypical intraepithelial lymphocytes (IELs). These cells were immunohistologically positive for CD103, CD3, CD7, CD8, CD56, and T-cell intracellular antigen-1. Upper and lower gastrointestinal and antegrade double-balloon endoscopy revealed foci of edematous mucosa, with or without villous atrophy, in the non-neoplastic mucosa. Histological studies demonstrated duodenal and intestinal enteropathy-like lesions as well as microscopic (lymphocytic) proctocolitis with increased CD3- and CD8-positive and CD56-negative T-IELs in all four patients. The clinicopathological findings of the non-neoplastic lesions were similar to those characteristic of coeliac disease, suggesting that variants of coeliac disease may be present in the prodromal lesions of MEITL.

Conclusions

Our study supports the need for random gastrointestinal biopsies to determine tumor spread, the features of MEITL in the particular patients, and the presence of prodromal non-neoplastic lesions.

Is ALK-gene rearrangement overlooked in primary gastrointestinal T-cell lymphomas? About two cases

A 41-year-old male patient with a history of ankylosing spondylitis and Crohn disease, treated with immunomodulators and disease-modifying drugs, was diagnosed with a primary intestinal T-cell lymphoma that followed a 7.5-year-course. This transmural proliferation lacked cytological characteristics of anaplastic large cell lymphoma (ALCL), and was CD8-positive, and CD30- and anaplastic lymphoma kinase (ALK)-negative by immunohistochemistry (IHC). However, ALK-gene rearrangement (ALK-gr) was detected by fluorescence in situ hybridization (FISH) in both initial and persistent disease. The possibility of indolent T-cell lymphoproliferative disease of the gastrointestinal tract with atypical features (transmural involvement) related to ALK-gr was suggested. A previous case of aggressive 'enteropathy-associated ALCL' in the context of celiac disease was recently reported, which also lacked anaplastic morphology, and where CD30 and ALK expression was incidentally demonstrated by IHC, and ALK-gr subsequently confirmed by FISH. These two recent cases represent two distinct rare entities pertaining to the group of primary intestinal T-cell lymphomas, and they both show unexpected ALK-gr. This suggests that ALK-gr has been overlooked in the group of primary intestinal T-cell lymphomas. Performing IHC and FISH tests for ALK-gr in primary gastrointestinal T-cell lymphomas might be of importance, particularly with the advancement of targeted therapy that could impact treatment and prognosis.

Clinical prognostic analysis of 116 patients with primary intestinal non-Hodgkin lymphoma

The gastrointestinal tract is the most common extranodal invasion site of non-Hodgkin lymphoma (NHL). Primary gastrointestinal NHL is often discussed together in most survival analyses. Primary intestinal NHL is significantly different from primary gastric NHL with regard to clinical features, pathological subtype, treatment, and prognosis. In this article, we analyzed clinical and pathological characteristics of primary intestinal NHL, and we also explored prognostic factors for primary intestinal NHL. A retrospective analysis was carried out on clinical data from 116 cases of confirmed primary intestinal NHL. The Kaplan-Meier method was used for the survival analysis. A Cox model was used for a multivariate analysis. In 116 patients with primary intestinal NHL, 79 patients were men (68.1%) and 37 patients were women (31.9%). In the cases used in this study, 68 were B-cell NHL and 48 were T-cell NHL. The age, incidence of intestinal obstruction, B symptom and performance status (PS) were closely related with pathological subtype. One-year and two-year survival rates were 76.7 and 58.3%, respectively. The log-rank univariate analysis showed male patients, PS score greater than or equal to two, hypoproteinemia, intestinal perforation, T-cell type, late stage (III/IV), no radical surgery, and no chemotherapy had relatively poor prognoses. Cox multivariate analysis shown that gender (95.0% CI 0.218-0.721), pathological subtype (95.0% CI 1.484-4.179), and radical surgery (95.0% CI 0.110-0.394) were independent prognostic risk factor for primary intestinal NHL. Male patients, T-cell intestinal lymphoma, and no radical surgery had rapid clinical processes and poor prognoses.

The value of double-balloon enteroscopy in patients with refractory celiac disease

OBJECTIVE

Patients with refractory celiac disease can develop enteropathy-associated T-cell lymphoma (EATL) or ulcerative jejunitis. Double-balloon enteroscopy allows examination of the small bowel. We prospectively assessed the value of this technique in patients with refractory celiac disease in a tertiary referral center.

METHODS

Small bowel enteroscopy was performed in a total of 21 consecutive patients for lesions like ulcerations (high risk). Biopsy specimens were taken from such lesions and from examined small bowel at three different levels of scope insertion depth. Tissue specimens were evaluated for the modified Marsh classification and for the presence of EATL.

RESULTS

Twenty-four procedures were successfully performed without complications. EATL was found in five patients (24%, 95% CI 10-45%) as circumferential, discrete, or confluent ulcerations. In three of them, Marsh III was found while in the other two patients with EATL Marsh I was found. Another two patients (9%, 95% CI 2-28%) had ulcerative jejunitis in the absence of EATL and histology was compatible with Marsh III. In the remaining 14 patients (54%, 95% CI 35-73%), no high-risk lesions were found. Double-balloon enteroscopy could exclude the presence of EATL in four patients that was suggested by abdominal computerized tomography.

CONCLUSIONS

Complications of refractory celiac disease like ulcerative jejunitis or EATL could efficiently be detected or excluded by double-balloon enteroscopy. This technique should be reserved for patients with refractory celiac disease or patients with a past history of EATL.

Refractory coeliac disease

A small proportion of coeliac disease (CD) patients fail to improve after a gluten-free diet (GFD) and may be considered as atypical regarding their outcome (refractory coeliac disease). The aim of this study is to diagnose and manage patients with CD who fail to improve after a GFD. Refractory coeliac disease (RCD) is a malabsorption syndrome defined by persisting villous atrophy with, usually, an increase of intraepithelial lymphocytes (IELs) in the small bowel in spite of a strict GFD and comprises a heterogenous group of diseases. Some of these diseases have to be excluded and can be treated by specific therapies like antibiotics in tropical sprue and giardiasis and immune globulin substitution in common variable immunodeficiency, while other malabsorption syndromes are less well defined and may require immunosuppressive therapy. Standardized treatment, however, has not been evaluated in such patients so far. In a subgroup of patients with RCD, an abnormal intraepithelial lymphocyte (IEL) population may be observed with the lack of surface expression of usual T-cell markers (CD3-CD8 and/or the T-cell receptor (TCR)) on IELs associated with T-cell clonality pattern suggest the presence of an early enteropathy-associated T-cell lymphoma (EATL) in a subgroup of patients with RCD. This hypothesis has been supported by studies, which revealed progression into overt intestinal T-cell lymphomas in a subgroup of RCD. Steroid treatment has been reported effective even in patients with underlying early EATL. However, long-term results are unsatisfactory in most of these patients with RCD and parenteral nutrition has to be applied in some of these cases. First results with more aggressive chemotherapies and use of cytokines are under way. Due to the difficulty of diagnostic and therapeutic regimens patients should be referred to tertiary centres for coeliac disease.

Intestinal non-Hodgkin's lymphoma: a multicenter prospective clinical study from the German Study Group on Intestinal non-Hodgkin's Lymphoma

PURPOSE

Intestinal non-Hodgkin's lymphomas are not well characterized. We therefore studied prospectively their clinical features and response to standardized therapy.

PATIENTS AND METHODS

Fifty-six patients with primary intestinal lymphoma were included in a prospective, nonrandomized multicenter study. Lymphoma resection was recommended and staging was performed according to the Ann Arbor classification. Patients were scheduled to receive six cycles of cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) chemotherapy, and at stages EIII to EIV, they received additional involved-field radiotherapy. Corticosteroids were used in patients who could not receive chemotherapy.

RESULTS

Thirty-five patients had intestinal T-cell lymphoma (ITCL), 21 patients had intestinal B-cell lymphoma (IBCL; 18 diffuse large-cell lymphomas, two marginal-cell lymphomas, and one follicle-center lymphoma). Thirty-four patients at stages EI to EII (14 ITCL and 20 IBCL) and nine patients at stages EIII to EIV (all ITCL) received chemotherapy. No patient in stages EIII to EIV received radiotherapy, because death occurred in 12 of 14 patients. Two-year cumulative survival in patients with IBCL was 94% (95% CI, 82% to 100%) and higher than in patients with ITCL (28% [95% CI, 13% to 43%]; P <.0001), even when only stages EI to EII were considered (ITCL, 37.5% [95% CI, 16.5% to 58.5%]; P <.0001). IBCL patients compared with ITCL patients were at lower lymphoma stages (P <.01), had higher Karnofsky status (P <.005), had intestinal perforation less often (P <.05), required emergency operation less often (P <.05), received CHOP (P <.05) more often, and reached complete remission (P <.0005) more frequently.

CONCLUSION

IBCL patients at stages EI and EII respond well to chemotherapy, but the prognosis and treatment of ITCL patients is unsatisfactory.

Feline epitheliotropic intestinal malignant lymphoma: 10 cases (1997-2000)

The clinical, histopathologic, and immunohistochemical features of 10 cats with epitheliotropic intestinal malignant lymphoma (EIL) are described. Intestinal biopsy samples were reviewed by 3 pathologists to confirm the diagnosis of EIL. These samples (n = 10) were compared to the intestinal biopsies of normal cats (n = 11), cats with inflammatory bowel disease (IBD; n = 7), and cats with non-EIL (n = 9) for quantification and immunophenotyping of intraepithelial lymphocytes. Immunophenotypic studies were performed with CD3 and CD79a antibody stains to assess for T- and B-cell immunoreactivity, respectively. EIL biopsies had markedly more intraepithelial lymphocytes than normal intestine (NRL) and samples from cats with IBD. However, no marked difference was observed in the number of intraepithelial lymphocytes in cats with non-EIL compared to cats with EIL. Regardless of the histologic diagnosis, the intraepithelial lymphocytes in all cats were small- to intermediate-sized T cells. Clinical findings and imaging studies in the cats identified minimal or nonspecific findings in affected cats. Most cats fit the typical profile of cats with IBD or alimentary malignant lymphoma. Nine of 10 cats with EIL were treated with prednisone with or without additional chemotherapy. Four cats were refractory to chemotherapy and were euthanized within 3.5 months. The remaining 5 cats had long-term survival times of 11 months or greater. The median survival time was 11 months. Additional studies are warranted to better characterize EIL and its relationship to IBD in cats and non-EIL and to identify optimal treatment strategies for this disease.

Peripheral T/NK-cell lymphoma: a report of the IXth Workshop of the European Association for Haematopathology

AIMS

In April 1998, The European Association for Haematopathology organized the IXth workshop on peripheral T-cell and NK-cell lymphomas and leukaemias. The workshop focused on unusual subtypes of these rare malignancies, allowing evaluation of the recently published WHO classification of neoplastic diseases of the lymphoid tissues.

METHODS AND RESULTS

One-hundred and three cases were centrally immunophenotyped and hybridized for EBER1/2 of Epstein--Barr virus. All cases were reviewed by a panel of experienced haematopathologists and classified according to the new WHO classification for lymphoid neoplasms. Three cases were considered as precursor T-cell and 95 cases as peripheral T/NK-cell lymphoma/leukaemia. Although the cases represented a selected series of unusual cases, the following conclusions could be made: (i) Most lymphomas except the hepatosplenic gamma/delta T-cell lymphomas showed a rather broad morphological spectrum, with differences both between and within individual tumours. (ii) This heterogeneity was also reflected by the immunophenotype, for instance a variable expression of CD30 was found in many enteropathy type T-cell lymphomas. (iii) Exceptions in phenotype were regularly found in almost all categories, indicating that phenotype should not be the final determining factor in classification. (iv) The great majority of T-cell lymphomas expressed the alpha/beta T-cell receptor, with the exception of all but one hepatosplenic T-cell lymphomas and a few other extranodal peripheral T cell lymphomas. (v) Malignancies of precursor cells, blastic NK-cell lymphoma/leukaemia, adult T-cell lymphoma/leukaemia and most AIL-type T-cell lymphomas did not express cytotoxic molecules such as TIA1 and granzyme-B. In contrast, all five aggressive NK/T-cell lymphomas/leukaemias, a single case of large granular lymphocyte leukaemia and 40 of 47 primary extranodal lymphoma/leukaemias expressed these molecules. In hepatosplenic gamma/delta T-cell lymphoma, five of six cases showed expression of TIA1 but not of granzyme-B. (vi) Seven tumours developed after organ-transplant, four cases being EBV-positive. No distinct phenotype could be attributed to these cases.

CONCLUSIONS

Most peripheral T/NK cell lymphomas could be categorized as distinct entities as described in the recently proposed WHO classification for lymphoid neoplasms.

Pathology of intestinal lymphomas

The advent of immunohistological and molecular techniques has enabled the comprehensive characterization of many lymphoma entities. Furthermore, it has increased the consensus in lymphoma classification among pathologists. In this review we describe the pathological features of primary intestinal lymphomas classified according to the revised European-American classification of lymphoid neoplasms. The majority of primary intestinal lymphomas are of B-cell lineage and most of these are high-grade tumors. By morphology they may be classified as diffuse large B-cell lymphomas of centroblastic, immunoblastic or plasmablastic type and Burkitt lymphomas. The latter occur predominantly in the terminal ileum and affect children or young adults. Low-grade extra-nodal marginal-zone lymphoma of the mucosa-associated lymphoid tissue (MALT) type and, less frequently, follicular center-cell lymphomas are the low-grade B-cell lymphomas most commonly observed in this region. The first mentioned tumor and its specific intestinal variant, alpha-chain disease or immunoproliferative small intestinal disease are well known for their indolent clinical course. Primary intestinal mantle-cell lymphoma often presents as multiple lymphomatous polyposis and similarly to its node-based equivalent is associated with an unfavorable prognosis. Most primary intestinal T-cell lymphomas display a characteristic immunophenotype, particular histological features with prominent epitheliotropism and are often associated with celiac disease indicating that these tumors form a specific lymphoma type. It has been termed intestinal T-cell lymphoma or enteropathy-type T-cell lymphoma. Clinically, these are aggressive diseases with a high mortality rate. In summary, primary intestinal lymphomas consist of several entities which display distinct clinicopathological features thus confirming the relevance of lymphoma typing.

Epitheliotropic T-cell gastrointestinal tract lymphosarcoma with metastases to lung and skeletal muscle in a cat

An Abyssinian cat examined because of hypoproteinemia and weight loss was found to have epitheliotropic T-cell lymphosarcoma of the gastrointestinal tract. Neoplastic lymphocytes infiltrated the epithelium and lamina propria of the stomach, small intestine, and large intestine. Metastatic foci were found in the lungs and the musculature of the right hind limb. Chemotherapy resulted in transient shrinkage of the lung and limb masses; however, these masses grew to approximately their original size within 2 weeks after initiation of treatment, and the cat was euthanatized.

Spontaneously relapsing clonal, mucosal cytotoxic T-cell lymphoproliferative disorder: case report and review of the literature

Primary T-cell lymphoma of the gastrointestinal tract is a rare and usually aggressive disorder that may be associated with celiac disease. The authors describe a unique case of a clonal proliferation of CD8+ T cells involving the oral mucosa, ileum, and colon of a 35-year-old man that has regressed spontaneously and recurred numerous times over a 9-year period without treatment. The patient's symptoms were limited to occasional rectal bleeding and recurring painful oral ulcers. Within the intestine, these collections of small T cells induced minimal architectural distortions and did not show extensive epitheliotrophism. Polymerase chain reaction and sequencing analyses revealed that the identical T-cell clone has been present for more than 9 years and in different mucosal locations in this patient. This may represent a unique T-cell lymphoproliferative process akin to a mucosal counterpart of lymphomatoid papulosis of the skin.

[Radiotherapy for gastrointestinal lymphomas: indications and techniques]

Gastrointestinal lymphomas are almost exclusively of a non-Hodgkin's type. The Western form is characterized by a higher incidence of stomach location (50%), a MALT type (mucosa associated lymphoid tissue) (40%), a B-cell type (90%), and a high grade (55%). Chronic infection with Helicobacter pylori is an important risk factor. Mediterranean lymphomas form a particular clinical and pathological entity with diffuse involvement of the small bowel and are frequently being associated with a chronic malabsorption disorder. Eradication of Helicobacter pylori in early gastric lymphomas, and the use of tetracyclines in early Mediterranean lymphomas, have been shown to induce durable remissions. For more advanced gastric lymphomas, treatment usually consists of anthracyclin-based chemotherapy followed by involved field radiotherapy. Surgery is usually reserved for complications such as perforation or bleeding, or in some selected cases for salvage after failure of non-surgical therapy. For intestinal lymphomas, surgical resection whenever feasible, followed by anthracyclin-based chemotherapy is the most common treatment. Radiotherapy is usually reserved for consolidation in some clinical situations. The most commonly found prognostic factors are stage, grade, and tumor bulk. Treatment results vary with the presence of adverse prognostic factors and the used treatment combination. In general, patients with favorable disease receiving combined therapy have a 5-year relapse free survival (RFS) approaching 90%, whereas those with unfavorable disease have a RFS of 40-50%.

Origin of primary gastric T-cell lymphomas from intraepithelial T-lymphocytes: report of two cases

AIMS

The classification of primary gastric T-cell lymphomas is uncertain due to the exceeding rarity of these tumours; many of the reported cases were felt to be similar to node-based lymphomas. We describe two cases of primary gastric T-cell lymphoma with evidence of origination from intraepithelial T-lymphocytes.

METHODS AND RESULTS

Both tumours were restricted to the stomach; one displaying a large ulcerated mass, the other a widespread superficial tumour manifestation. Histologically the first tumour was composed of sheets of medium-sized lymphoid cells showing marked epitheliotropism at the edge of the ulcer, and a CD3+, CD4-, CD8-, CD20-, CD56-, CD103+, beta F1+ phenotype. The second case differed histologically and immunophenotypically from the first case. In addition to lamina propria and submucosal infiltration, the lymphoma contained an extensive intraepithelial component even in large areas without other evidence of tumour. The neoplastic cells ranged in size from small to medium and large. Immunohistology disclosed a CD3+, CD4+, CD8-, CD20-, CD56-, beta F1+ phenotype. Staining for CD103 could not be performed in this case since frozen material was not available.

CONCLUSIONS

The prominent epitheliotropism, the marked intraepithelial growth and the expression of CD103 strongly imply a derivation of these primary gastric lymphomas from intraepithelial T-lymphocytes. Additional studies of larger series will clarify whether the findings described here are typical of primary gastric T-cell lymphomas.

Most CD56+ intestinal lymphomas are CD8+CD5-T-cell lymphomas of monomorphic small to medium size histology

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.

Primary intestinal gamma-delta T-cell lymphoma with evidence of Epstein-Barr virus

AIMS

Primary intestinal T-cell lymphomas account for about 5% of all primary gastrointestinal lymphomas and are mostly associated with coeliac disease. They usually express the CD3-associated T-cell receptor alpha/beta heterodimer and HML1, and some are related with Epstein-Barr virus (EBV). As far as we know, the present report describes the first case of primary gamma-delta (gamma delta) EBV-associated intestinal T-cell lymphoma without enteropathy. Only hepatosplenic, nasal and cutaneous gamma delta T-cell lymphomas have previously been described.

METHODS AND RESULTS

Our case concerned a 43-year-old man with no history of coeliac disease, who presented with multifocal small bowel involvement showing high grade T-cell lymphoma with medium sized and large pleomorphic cells and a small pleomorphic T-cell component. Angioinvasion and angiocentricity were occasionally present. Immunohistochemical studies of lymphoma cells showed a T-cell gamma delta phenotype (CD3+, CD2+, TCR delta 1+, V delta 2+ and beta F1-) without expression of CD4, CD8, CD5, or HML1. Most tumour cells were positive for the cytotoxic granular proteins TiA1 and granzyme B. Rearrangement of the TCR gamma chain gene was demonstrated by polymerase chain reaction and in-situ hybridization with EBER probes revealed strong nuclear positivity in virtually all neoplastic cells.

CONCLUSION

We described the first case of primary intestinal gamma delta T-cell lymphoma without enteropathy in which EBV might fulfil a pathogenic role.

Abnormal intestinal intraepithelial lymphocytes in refractory sprue

BACKGROUND & AIMS

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Expression of cytotoxic molecules in intestinal T-cell lymphomas. The German Study Group on Intestinal Non-Hodgkin Lymphoma

Intestinal T-cell lymphoma (ITCL) represents a subgroup of peripheral T-cell lymphomas which is thought to arise from alpha beta intraepithelial T-lymphocytes. Since these lymphocytes may contain cytotoxic molecules, the question of whether this also holds true for ITCL arises. Twenty ITCL cases were examined for the presence of granzyme B, perforin, and T-cell-restricted intracellular antigen (TIA-1)/granule membrane protein of 17 kD (GMP-17). Two molecules with restricted expression in cytotoxic cells, granzyme B and perforin, were detected by immunocytochemistry and by in situ hybridization with an isotopically labelled RNA probe, respectively. Immunocytochemistry was also performed with the antibody 2G9, which recognizes two molecules, one expressed by cytotoxic cells (TIA-1) and the other found in granulocytes and cytotoxic cells (GMP-17). Granzyme B, TIA-1/GMP-17, and perforin were found in the neoplastic cells of 16/19 cases, 19/20 cases, and 16/17 cases, respectively, of ITCL, but not in the tumour cells of the control group, which consisted of intestinal B-cell lymphomas (five cases) and CD8-negative peripheral nodal T-cell lymphomas (six cases). At least one of these molecules was expressed in the tumour cells of all ITCL cases. 2G9 proved to be the most sensitive immunohistological marker, since reactivity with this antibody was not only observed in the highest number of cases, but also found in high numbers of neoplastic cells in positive cases. In conclusion, ITCL appears to show cytotoxic differentiation in all cases. In conjunction with immunophenotypic and genotypic data, our results support a uniform derivation of this tumour from intraepithelial alpha beta cytotoxic T-lymphocytes.