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Ensari A, Marsh MN. Diagnosing celiac disease: A critical overview. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2019; 30:389-397. [PMID: 31060993 PMCID: PMC6505646 DOI: 10.5152/tjg.2018.18635] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 12/22/2018] [Indexed: 12/11/2022]
Abstract
The diagnosis of celiac disease (CD) no longer rests on a malabsorptive state or severe mucosal lesions. For the present, diagnosis will always require the gold-standard of a biopsy, interpreted through its progressive phases (Marsh classification). Marsh classification articulated the immunopathological spectrum of gluten-induced mucosal changes in association with the recognition of innate (Marsh I infiltration) and T cell-based adaptive (Marsh II, and the surface re-organisation typifying Marsh III lesions) responses. Through the Marsh classification the diagnostic goalposts were considerably widened thus, over its time-course, permitting countless patients to begin a gluten-free diet but who, on previous criteria, would have been denied such vital treatment. The revisions of this classification failed to provide additional insight in the interpretation of mucosal pathology. Morever, the subclassification of Marsh 3 imposed an enormous amount of extra work on pathologists with no aid in diagnosis, treatment, or prognosis. Therefore, it should now be apparent that if gastroenterologists ignore these sub-classifications in clinical decision-making, then on that basis alone, there is no need whatsoever for pathologists to persist in reporting them. Since new treatments are under critical assessment, we might have to consider use of some other higher level histological techniques sensitive enough to detect the changes sought. A promising alternative would be to hear more voices from imaginative histopathologists or morphologists together with some more insightful approaches, involving molecular-based techniques and stem cell research may be to evaluate mucosal pathology in CD.
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Affiliation(s)
- Arzu Ensari
- Department of Pathology, Ankara University School of Medicine, Ankara, Turkey
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Charlesworth RPG, Agnew LL, Scott DR, Andronicos NM. Celiac disease gene expression data can be used to classify biopsies along the Marsh score severity scale. J Gastroenterol Hepatol 2019; 34:169-177. [PMID: 29972865 DOI: 10.1111/jgh.14369] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM The diagnosis of celiac disease autoimmune pathology relies on the subjective histological assignment of biopsies into Marsh score categories. It is hypothesized that Marsh score categories have unique gene expression signatures. The aims were as follows: first, to develop a celiac disease quantitative reverse transcription-polymerase chain reaction (RT-PCR) array; second, define gene expression signatures associated with Marsh score categories; and third, develop equations that classify biopsies into Marsh score categories and to monitor the efficacy of patient treatment. METHODS Gene targets for inclusion in the celiac RT-PCR (qRT-PCR) array were identified using systematic analysis of published celiac transcriptomic data. The array was used to assess the gene expression associated with histological changes in duodenal biopsies obtained from adult patients. Finally, Marsh score classification equations were defined using discriminant analysis. RESULTS The array contained 87 genes. The expression of 26 genes were significantly (p < 0.06) associated with the discrete Marsh score categories. As the Marsh score pathology of biopsies increased, there was a progression of innate immune gene expression through adaptive Th1-specific gene expression with a concurrent decrease in intestinal structural gene expression in high Marsh score samples. These 26 genes were used to define classification equations that accounted for 99% of the observed experimental variation and which could classify biopsies into Marsh score categories and monitor patient treatment progression. CONCLUSIONS This proof-of-concept study successfully developed a celiac RT-PCR array and has provided evidence that discriminant equations defined using gene expression data can objectively and accurately classify duodenal biopsies into Marsh score categories.
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Affiliation(s)
- Richard P G Charlesworth
- Discipline of Biomedical Sciences, School of Science and Technology, University of New England, Armidale, New South Wales, Australia
| | - Linda L Agnew
- Discipline of Biomedical Sciences, School of Science and Technology, University of New England, Armidale, New South Wales, Australia
| | - David R Scott
- Hunter New England Area Health Service, Tamworth, New South Wales, Australia
| | - Nicholas M Andronicos
- Discipline of Biomedical Sciences, School of Science and Technology, University of New England, Armidale, New South Wales, Australia
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Charlesworth RPG, Agnew LL, Scott DR, Andronicos NM. Equations defined using gene expression and histological data resolve coeliac disease biopsies within the Marsh score continuum. Comput Biol Med 2018; 104:183-196. [PMID: 30500563 DOI: 10.1016/j.compbiomed.2018.10.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIM The gold standard diagnostic for coeliac disease (CD) is subjective histological assignment of biopsies into the Marsh score categories. It is hypothesized that discrete Marsh score categories can be quantitatively resolved into a continuum using discriminant equations defined using histological and gene expression data. Therefore, the aim of this study was to use a combination of histological and gene expression data to develop equations that classify CD patient biopsies into a quantitative Marsh score continuum which could be used by clinicians to monitor CD treatment efficacy. METHODS Both empirical and simulated gene expression and histological data were used to define predictive Marsh score equations. The distances of treated sample biopsies from the Marsh score standards were determined using the Mahalanobis distance calculation. RESULTS Three function, high resolution discriminant equations derived from simulated data were used to accurately classify 99.6% of simulated and empirically derived biopsy data. The first function resolved active (Marsh type 3) CD from mild (Marsh type 1) CD. The second function resolved normal (no specific pathology) biopsies from mild CD. The third function resolved active Marsh score 3 into a and b subcategories. Finally, measuring the Mahalanobis distance enabled the conversion of discrete Marsh score categories into a continuum. CONCLUSIONS This proof-of-concept study successfully demonstrated that the discrete Marsh score scale can be converted into a quantitative continuum capable of high resolution monitoring of patient treatment efficacy using equations defined by gene expression and histology data.
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Affiliation(s)
- Richard P G Charlesworth
- Discipline of Biomedical Sciences, School of Science and Technology, University of New England, Armidale, NSW, 2351, Australia.
| | - Linda L Agnew
- Discipline of Biomedical Sciences, School of Science and Technology, University of New England, Armidale, NSW, 2351, Australia
| | - David R Scott
- Gastroenterologist, Hunter New England Area Health Service, Tamworth, NSW, 2340, Australia
| | - Nicholas M Andronicos
- Discipline of Biomedical Sciences, School of Science and Technology, University of New England, Armidale, NSW, 2351, Australia
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Rostami K, Marsh MN, Johnson MW, Mohaghegh H, Heal C, Holmes G, Ensari A, Aldulaimi D, Bancel B, Bassotti G, Bateman A, Becheanu G, Bozzola A, Carroccio A, Catassi C, Ciacci C, Ciobanu A, Danciu M, Derakhshan MH, Elli L, Ferrero S, Fiorentino M, Fiorino M, Ganji A, Ghaffarzadehgan K, Going JJ, Ishaq S, Mandolesi A, Mathews S, Maxim R, Mulder CJ, Neefjes-Borst A, Robert M, Russo I, Rostami-Nejad M, Sidoni A, Sotoudeh M, Villanacci V, Volta U, Zali MR, Srivastava A. ROC-king onwards: intraepithelial lymphocyte counts, distribution & role in coeliac disease mucosal interpretation. Gut 2017; 66:2080-2086. [PMID: 28893865 PMCID: PMC5749338 DOI: 10.1136/gutjnl-2017-314297] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 06/17/2017] [Accepted: 06/22/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Counting intraepithelial lymphocytes (IEL) is central to the histological diagnosis of coeliac disease (CD), but no definitive 'normal' IEL range has ever been published. In this multicentre study, receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off between normal and CD (Marsh III lesion) duodenal mucosa, based on IEL counts on >400 mucosal biopsy specimens. DESIGN The study was designed at the International Meeting on Digestive Pathology, Bucharest 2015. Investigators from 19 centres, eight countries of three continents, recruited 198 patients with Marsh III histology and 203 controls and used one agreed protocol to count IEL/100 enterocytes in well-oriented duodenal biopsies. Demographic and serological data were also collected. RESULTS The mean ages of CD and control groups were 45.5 (neonate to 82) and 38.3 (2-88) years. Mean IEL count was 54±18/100 enterocytes in CD and 13±8 in normal controls (p=0.0001). ROC analysis indicated an optimal cut-off point of 25 IEL/100 enterocytes, with 99% sensitivity, 92% specificity and 99.5% area under the curve. Other cut-offs between 20 and 40 IEL were less discriminatory. Additionally, there was a sufficiently high number of biopsies to explore IEL counts across the subclassification of the Marsh III lesion. CONCLUSION Our ROC curve analyses demonstrate that for Marsh III lesions, a cut-off of 25 IEL/100 enterocytes optimises discrimination between normal control and CD biopsies. No differences in IEL counts were found between Marsh III a, b and c lesions. There was an indication of a continuously graded dose-response by IEL to environmental (gluten) antigenic influence.
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Affiliation(s)
- Kamran Rostami
- Department of Gastroenterology and Pathology, Milton Keynes University Hospital, Milton Keynes, UK
| | - Michael N Marsh
- Department of Gastroenterology, Luton and Dunstable University Hospital, Luton, UK,Wolfson College, University of Oxford, Oxford, UK
| | - Matt W Johnson
- Department of Gastroenterology, Luton and Dunstable University Hospital, Luton, UK
| | - Hamid Mohaghegh
- Gastroenterology and Liver Diseases Research Centre, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, The Islamic Republic of Iran
| | - Calvin Heal
- Centre for Biostatistics, Faculty of Biology, Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Geoffrey Holmes
- Department of Gastroenterology, Royal Derby Hospital, Derby, UK
| | - Arzu Ensari
- Department of Pathology, Ankara University Medical School, Ankara, Turkey
| | - David Aldulaimi
- Department of Gastroenterology, Warwick Hospital, Warwick, UK
| | - Brigitte Bancel
- Service de Pathologie, Centre de Biologie et Pathologie Groupe Hospitalier du Nord, Hospices Civils de Lyon, Lyon, France
| | | | - Adrian Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gabriel Becheanu
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Anna Bozzola
- Institute of Pathology Spedali Civili, Brescia, Italy
| | - Antonio Carroccio
- Internal Medicine and Pathology Unit, University of Palermo, Giovanni Paolo II Hospital, Sciacca, Italy
| | - Carlo Catassi
- Department of Pediatrics and Surgical Pathology, Università Politecnica delle Marche, Ancona, Italy
| | - Carolina Ciacci
- Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Alexandra Ciobanu
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mihai Danciu
- Departments of Gastroenterology and Pathology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Mohammad H Derakhshan
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK,Digestive Disease Research Center, Tehran University Medical Science, Tehran, Iran
| | - Luca Elli
- Center for Prevention and Diagnosis of Coeliac Disease and Pathology Unit, Fondazione IRCCS Ca’ granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Stefano Ferrero
- Center for Prevention and Diagnosis of Coeliac Disease and Pathology Unit, Fondazione IRCCS Ca’ granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Michelangelo Fiorentino
- Department of Medical and Surgical Sciences, University of Bologna and Diagnostic and Experimental, University of Bologna, Bologna, Italy
| | - Marilena Fiorino
- Internal Medicine and Pathology Unit, University of Palermo, Giovanni Paolo II Hospital, Sciacca, Italy
| | - Azita Ganji
- Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - James J Going
- Department of Pathology, Southern General Hospital, Lanarkshire, UK
| | - Sauid Ishaq
- Dudley group of Hospitals, Birmingham City University, Birmingham, UK
| | - Alessandra Mandolesi
- Department of Pediatrics and Surgical Pathology, Università Politecnica delle Marche, Ancona, Italy
| | - Sherly Mathews
- Department of Gastroenterology and Pathology, Milton Keynes University Hospital, Milton Keynes, UK
| | - Roxana Maxim
- Departments of Gastroenterology and Pathology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Chris J Mulder
- Department of Hepatogastroenterology and Pathology, Free University Medical Centre, Amsterdam, The Netherlands
| | - Andra Neefjes-Borst
- Department of Hepatogastroenterology and Pathology, Free University Medical Centre, Amsterdam, The Netherlands
| | - Marie Robert
- Department of Pathology and Medicine, Yale University School of Medicine, New Haven, USA
| | - Ilaria Russo
- Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Centre, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, The Islamic Republic of Iran
| | - Angelo Sidoni
- University of Perugia Medical School, Perugia, Italy
| | - Masoud Sotoudeh
- Digestive Disease Research Center, Tehran University Medical Science, Tehran, Iran
| | | | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna and Diagnostic and Experimental, University of Bologna, Bologna, Italy
| | - Mohammad R Zali
- Gastroenterology and Liver Diseases Research Centre, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, The Islamic Republic of Iran
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Evolutionary Developments in Interpreting the Gluten-Induced Mucosal Celiac Lesion: An Archimedian Heuristic. Nutrients 2017; 9:nu9030213. [PMID: 28264483 PMCID: PMC5372876 DOI: 10.3390/nu9030213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/22/2017] [Indexed: 02/07/2023] Open
Abstract
The evolving history of the small intestinal biopsy and its interpretation—and misinterpretations—are described in this paper. Certain interpretative errors in the technical approaches to histological assessment are highlighted—even though we may never be rid of them. For example, mucosal “flattening” does not reduce individual villi to their cores, as still seems to be widely believed. Neither is the mucosa undergoing an atrophic process—since it can recover structurally. Rather, the intestinal mucosa manifests a vast hypertrophic response resulting in the formation of large plateaus formed from partially reduced villi and their amalgamation with the now increased height and width of the inter-villous ridges: this is associated with considerable increases in crypt volumes. Sections through mosaic plateaus gives an erroneous impression of the presence of stunted, flat-topped villi which continues to encourage both the continued use of irrelevant “atrophy” terminologies and a marked failure to perceive what random sections through mosaic plateaus actually look like. While reviewing the extensive 40+ year literature on mucosal analysis, we extracted data on intraepithelial lymphocytes (IEL) counts from 607 biopsies, and applied receiver-operating characteristic (ROC)-curve analysis. From that perspective, it appears that counting IEL/100 enterocyte nuclei in routine haematoxylin and eosin (H&E) sections provides the most useful discriminator of celiac mucosae at histological level, with an effective cut-off of 27 IEL, and offering a very high sensitivity with few false negatives. ROC-curve analysis also revealed the somewhat lesser accuracies of either CD3+ or γδ+ IEL counts. Current official guidelines seem to be somewhat inadequate in clearly defining the spectrum of gluten-induced mucosal pathologies and how they could be optimally interpreted, as well as in promoting the ideal manner for physicians and pathologists to interact in interpreting intestinal mucosae submitted for analysis. Future trends should incorporate 3-D printing and computerised modelling in order to exemplify the subtle micro-anatomical features associated with the crypt-villus interzone. The latter needs precise delineation with use of mRNA in-section assays for brush border enzymes such as alkaline phosphate and esterase. Other additional approaches are needed to facilitate recognition and interpretation of the features of this important inter-zone, such as wells, basins and hypertrophic alterations in the size of inter-villous ridges. The 3-D computerised models could considerably expand our understandings of the microvasculature and its changes—in relation both to crypt hypertrophy, in addition to the partial attrition and subsequent regrowth of villi from the inter-villous ridges during the flattening and recovery processes, respectively.
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