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Rothenberg ME, Dellon ES, Collins MH, Bredenoord AJ, Hirano I, Peterson KA, Brooks L, Caldwell JM, Fjällbrant H, Grindebacke H, Ho CN, Keith M, McCrae C, Sinibaldi D, White WI, Datto CJ. Eosinophil Depletion with Benralizumab for Eosinophilic Esophagitis. N Engl J Med 2024; 390:2252-2263. [PMID: 38924732 DOI: 10.1056/nejmoa2313318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
BACKGROUND Benralizumab is an eosinophil-depleting anti-interleukin-5 receptor α monoclonal antibody. The efficacy and safety of benralizumab in patients with eosinophilic esophagitis are unclear. METHODS In a phase 3, multicenter, double-blind, randomized, placebo-controlled trial, we assigned patients 12 to 65 years of age with symptomatic and histologically active eosinophilic esophagitis in a 1:1 ratio to receive subcutaneous benralizumab (30 mg) or placebo every 4 weeks. The two primary efficacy end points were histologic response (≤6 eosinophils per high-power field) and the change from baseline in the score on the Dysphagia Symptom Questionnaire (DSQ; range, 0 to 84, with higher scores indicating more frequent or severe dysphagia) at week 24. RESULTS A total of 211 patients underwent randomization: 104 were assigned to receive benralizumab, and 107 were assigned to receive placebo. At week 24, more patients had a histologic response with benralizumab than with placebo (87.4% vs. 6.5%; difference, 80.8 percentage points; 95% confidence interval [CI], 72.9 to 88.8; P<0.001). However, the change from baseline in the DSQ score did not differ significantly between the two groups (difference in least-squares means, 3.0 points; 95% CI, -1.4 to 7.4; P = 0.18). There was no substantial between-group difference in the change from baseline in the Eosinophilic Esophagitis Endoscopic Reference Score, which reflects endoscopic abnormalities. Adverse events were reported in 64.1% of the patients in the benralizumab group and in 61.7% of those in the placebo group. No patients discontinued the trial because of adverse events. CONCLUSIONS In this trial involving patients 12 to 65 years of age with eosinophilic esophagitis, a histologic response (≤6 eosinophils per high-power field) occurred in significantly more patients in the benralizumab group than in the placebo group. However, treatment with benralizumab did not result in fewer or less severe dysphagia symptoms than placebo. (Funded by AstraZeneca; MESSINA ClinicalTrials.gov number, NCT04543409.).
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Affiliation(s)
- Marc E Rothenberg
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Evan S Dellon
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Margaret H Collins
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Albert J Bredenoord
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Ikuo Hirano
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Kathryn A Peterson
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Laura Brooks
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Julie M Caldwell
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Harald Fjällbrant
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Hanna Grindebacke
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Calvin N Ho
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Matthew Keith
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Christopher McCrae
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Dominic Sinibaldi
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Wendy I White
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
| | - Catherine J Datto
- From the Divisions of Allergy and Immunology (M.E.R., J.M.C.) and Pathology and Laboratory Medicine (M.H.C.), Department of Pediatrics, and the Department of Pathology and Laboratory Medicine (M.H.C.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (E.S.D.); the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (A.J.B.); the Kenneth C. Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); the Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City (K.A.P.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Cambridge, United Kingdom (L.B.); Late-Stage Respiratory and Immunology, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden (H.F., H.G.); and Patient Centered Science, BioPharmaceuticals Medical Evidence (C.N.H.), Late-stage Respiratory and Immunology (M.K., C.J.D.) and Translational Science and Experimental Medicine, Early Respiratory and Immunology (C.M.), BioPharmaceuticals Research and Development, and Data Sciences and AI (D.S.) and Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences (W.I.W.), Research and Development, AstraZeneca, Gaithersburg, MD
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Laky K, Frischmeyer-Guerrerio PA. Development and dysfunction of structural cells in eosinophilic esophagitis. J Allergy Clin Immunol 2024; 153:1485-1499. [PMID: 38849184 DOI: 10.1016/j.jaci.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 06/09/2024]
Abstract
Eosinophilic esophagitis (EoE) is a disorder characterized by dysfunction and chronic local inflammation of the esophagus. The incidence and prevalence of EoE are increasing worldwide. The mechanisms responsible are poorly understood, and effective treatment options are limited. From the lumen outward, the esophagus comprises stratified squamous epithelium, lamina propria, and muscle. The tissue-specific nature of EoE strongly suggests that structural cells in the esophagus are involved in the EoE diathesis. Epithelial basal cell hyperplasia and dilated intercellular spaces are cardinal features of EoE. Some patients with EoE develop lamina propria fibrosis, strictures, or esophageal muscle dysmotility. Clinical symptoms of EoE are only weakly correlated with peak eosinophil count, implying that other cell types contribute to EoE pathogenesis. Epithelial, endothelial, muscle, and fibroblast cells can each initiate inflammation and repair, regulate tissue resident immune cells, recruit peripheral leukocytes, and tailor adaptive immune cell responses. A better understanding of how structural cells maintain tissue homeostasis, respond to cell-intrinsic and cell-extrinsic stressors, and exacerbate and/or resolve inflammatory responses in the esophagus is needed. This knowledge will facilitate the development of more efficacious treatment strategies for EoE that can restore homeostasis of both hematopoietic and structural elements in the esophagus.
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Affiliation(s)
- Karen Laky
- Food Allergy Research Section, Laboratory of Allergic Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Pamela A Frischmeyer-Guerrerio
- Food Allergy Research Section, Laboratory of Allergic Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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Lopez-Nunez O, Bernieh A, Kliewer KL, Kemtur P, Bolton SM, Mukkada VA, Schablein R, Woods C, Rothenberg ME, Collins MH. Transnasal Endoscopy Acquires Esophageal Biopsies Adequate for Comprehensive Pathology Evaluation in Patients With Eosinophilic Esophagitis. Pediatr Dev Pathol 2024:10935266241255723. [PMID: 38794944 DOI: 10.1177/10935266241255723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
BACKGROUND Transnasal endoscopy (TNE) does not require general anesthesia, an attractive characteristic for monitoring eosinophilic esophagitis (EoE). We evaluated the adequacy of TNE-obtained esophageal biopsies using the EoE Histology Scoring System (EoEHSS). METHODS The Cincinnati Center for Eosinophilic Disorders database was searched for esophageal biopsies obtained by the same endoscopist, using either TNE or conventional endoscopy (CE). Whole-slide biopsy images were evaluated. The Mann-Whitney test was used for median (interquartile range) values and Fisher exact test for categorical variables. P ≤ .05 was considered significant. RESULTS Median age (P = .82) or height (P = .83) did not differ between TNE (n = 17) and CE (n = 17) groups. Although median largest piece size (mm2) differed between the groups (TNE: 0.59 (0.45, 0.86), CE: 2.24 (1.09, 2.82), P < .001), all 8 EoEHSS features were evaluated in each group; only 1 feature (lamina propria fibrosis) was missing in both groups (TNE: 19/34, CE: 11/34, P = .09). The median peak eosinophil count/high-power field differed (TNE: 3 (0, 29), CE: 16 (1, 66), P = .03), but overall grade (TNE: 0.17 (0.10, 0.29), CE: 0.22 (0.14, 0.46), P = .12), stage (TNE: 0.14 (0.10, 0.24), CE: 0.20 (0.10, 0.43), P = .15), and non-eosinophil-related individual EoEHSS scores did not differ. CONCLUSIONS TNE- and CE-obtained esophageal biopsies are similarly sufficient for evaluation of key pathological features in EoE.
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Affiliation(s)
- Oscar Lopez-Nunez
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Anas Bernieh
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kara L Kliewer
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Pratibha Kemtur
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott M Bolton
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ryan Schablein
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Christopher Woods
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Shimonosono M, Morimoto M, Hirose W, Tomita Y, Matsuura N, Flashner S, Ebadi MS, Okayasu EH, Lee CY, Britton WR, Martin C, Wuertz BR, Parikh AS, Sachdeva UM, Ondrey FG, Atigadda VR, Elmets CA, Abrams JA, Muir AB, Klein-Szanto AJ, Weinberg KI, Momen-Heravi F, Nakagawa H. Modeling epithelial homeostasis and perturbation in three-dimensional human esophageal organoids. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.20.595023. [PMID: 38826379 PMCID: PMC11142071 DOI: 10.1101/2024.05.20.595023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Background Esophageal organoids from a variety of pathologies including cancer are grown in Advanced Dulbecco's Modified Eagle Medium-Nutrient Mixture F12 (hereafter ADF). However, the currently available ADF-based formulations are suboptimal for normal human esophageal organoids, limiting the ability to compare normal esophageal organoids with those representing a given disease state. Methods We have utilized immortalized normal human esophageal epithelial cell (keratinocyte) lines EPC1 and EPC2 and endoscopic normal esophageal biopsies to generate three-dimensional (3D) organoids. To optimize ADF-based medium, we evaluated the requirement of exogenous epidermal growth factor (EGF) and inhibition of transforming growth factor-(TGF)-β receptor-mediated signaling, both key regulators of proliferation of human esophageal keratinocytes. We have modeled human esophageal epithelial pathology by stimulating esophageal 3D organoids with interleukin (IL)-13, an inflammatory cytokine, or UAB30, a novel pharmacological activator of retinoic acid signaling. Results The formation of normal human esophageal 3D organoids was limited by excessive EGF and intrinsic TGFβ receptor-mediated signaling. In optimized HOME0, normal human esophageal organoid formation was improved, whereas IL-13 and UAB30 induced epithelial changes reminiscent of basal cell hyperplasia, a common histopathologic feature in broad esophageal disease conditions including eosinophilic esophagitis. Conclusions: HOME0 allows modeling of the homeostatic differentiation gradient and perturbation of the human esophageal epithelium while permitting a comparison of organoids from mice and other organs grown in ADF-based media.
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Collins MH, Arva NC, Bernieh A, Lopez-Nunez O, Pletneva M, Yang GY. Histopathology of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:205-221. [PMID: 38575219 DOI: 10.1016/j.iac.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Microscopic examination of esophageal biopsies is essential to diagnose eosinophilic esophagitis (EoE). Eosinophil inflammation is the basis for the diagnosis, but additional abnormalities may contribute to persistent symptoms and epithelial barrier dysfunction. Both peak eosinophil count and assessments of additional features should be included in pre-therapy and post-therapy pathology reports. Pathologic abnormalities identified in esophageal biopsies of EoE are reversible in contrast to esophageal strictures.
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Affiliation(s)
- Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Pathology ML1035, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Nicoleta C Arva
- Department of Pathology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Anas Bernieh
- Pathology ML1035, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave.nue Cincinnati, OH 45229, USA
| | - Oscar Lopez-Nunez
- Pathology ML1035, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave.nue Cincinnati, OH 45229, USA
| | - Maria Pletneva
- Department of Pathology, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132, USA
| | - Guang-Yu Yang
- Department of Pathology, Ward Building Ward 4-115, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL. 60611, USA
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6
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Kennedy KV, Muir AB, Ruffner MA. Pathophysiology of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:119-128. [PMID: 38575212 DOI: 10.1016/j.iac.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, progressive immune-mediated disease associated with antigen-driven type 2 inflammation and symptoms of esophageal dysfunction. Research over the last 2 decades has dramatically furthered our understanding of the complex interplay between genetics, environmental exposures, and cellular and molecular interactions involved in EoE. This review provides an overview of our current understanding of EoE pathogenesis.
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Affiliation(s)
- Kanak V Kennedy
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Amanda B Muir
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Abramson Research Center 902E, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Melanie A Ruffner
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Abramson Research Center 902E, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA; Division of Pediatric Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia
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7
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Shaul E, Kennedy KV, Spergel ZC, Daneshdoost S, Mahon M, Thanawala S, Spergel JM, Wilkins B, Ryan MJ, Muir AB. Endoscopic and histologic utility of transnasal endoscopy in pediatric eosinophilic esophagitis. J Pediatr Gastroenterol Nutr 2024; 78:1155-1160. [PMID: 38482943 DOI: 10.1002/jpn3.12170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/12/2024] [Accepted: 02/03/2024] [Indexed: 05/03/2024]
Abstract
Unsedated transnasal endoscopy (TNE) is an alternative method of examining the esophageal mucosa in pediatric patients with eosinophilic esophagitis (EoE), reducing cost, time, and risk associated with frequent surveillance esophagogastroduodenoscopies (EGD). Adequacy of transnasal esophageal biopsies for the evaluation of eosinophilic esophagitis histologic scoring system (EoEHSS) has not yet been evaluated. We compared procedure times, endoscopic findings, and EoEHSS scoring for EoE patients undergoing TNE versus standard EGD. Sixty-six TNE patients and 132 EGD controls matched for age (mean age 14.0 years) and disease status (29.3% active) were included. Compared to patients undergoing standard EGD, patients undergoing TNE spent 1.94 h less in the GI suite (p < 0.0001), with comparable occurrence rates of all visual endoscopic findings and most EoEHSS components. TNE serves as a useful tool for long-term disease surveillance, and consideration should be given to its use in clinical trials for EoE.
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Affiliation(s)
- Eliana Shaul
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Kanak V Kennedy
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Zachary C Spergel
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shanaz Daneshdoost
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mark Mahon
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shivani Thanawala
- Department of Medicine, Perelman School of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan M Spergel
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin Wilkins
- Department of Pathology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Matthew J Ryan
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amanda B Muir
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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8
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Nader LS, Epifanio M, Coelho MG, Steinhaus C, Melere M, da Silva CS, Ferreira CT. High prevalence of response to PPI treatment in children and adolescents with eosinophilic esophagitis in southern Brazil. FRONTIERS IN ALLERGY 2024; 5:1346843. [PMID: 38650863 PMCID: PMC11033356 DOI: 10.3389/falgy.2024.1346843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/21/2024] [Indexed: 04/25/2024] Open
Abstract
Introduction Eosinophilic esophagitis is a newly recognized entity, in which there is significant evidence available that clearly demonstrates the positive impact of PPIs on reducing esophageal eosinophilia in individuals across different age groups, including children, adolescents, and adults. Multiple mechanisms have been proposed to explain how this treatment effect occurs. In Brazil, there seems to be a lack of studies that have prospectively assessed the clinical and therapeutic response rate in pediatric patients with EoE. The objective of this study was to prospectively evaluate the clinical and therapeutic response of pediatric patients with EoE in a medical center located in southern Brazil, by investigating the effectiveness of PPI treatment. Methods This study is a clinical, prospective, open trial that took place in a pediatric hospital located in southern Brazil. The focus of the study was on patients diagnosed with Eosinophilic Esophagitis (EoE) who were given treatment using omeprazole/esomeprazole at a dosage of 1 mg.kg per dose, twice daily, for a period of 8-12 weeks. Following the treatment period, the patients underwent another endoscopy. Patients who exhibited 15 or less eosinophils in the biopsy conducted after the treatment were considered as responders. Results A total of 27 patients was evaluated (74.1% boys). The average age (± standard deviation) was 8 years (±4). Nineteen patients (70.3%) were considered as responders to PPI treatment: 6 patients-22.2%-exhibited a complete response (defined as having 5 or fewer eosinophil per high power field. Additionally, 13 patients-48.1%-demonstrated a partial response, characterized by eosinophil counts exceeding 5 but less than 15 eos/hpf. When comparing the responder and non-responder groups at presentation, a statistical difference was observed in the prevalence of food refusal as a presenting symptom. Food refusal was found to be more prevalent in the non-responder group (87.5% vs. 26.3%, P = 0.008). No differences were observed in terms of atopy history and endoscopic scores. Upon comparing the histological findings from the post-treatment endoscopy of the two groups, it was observed that PPI responders exhibited a greater tendency to decrease basal cell hyperplasia (P = 0.06) and intercellular edema (P = 0.08). Conclusion In this group of pediatric patients with EoE in Southern Brazil most patients showed a high prevalence of histological, endoscopic, and clinical response to PPI treatment. PPIs showed efficacy in Brazilian patients with EoE, most of whom would probably not be able to adequately undergo other treatments. Clinical Trial Registration https://ensaiosclinicos.gov.br/rg/RBR-2ntbth9, identifier (U1111-1301-1842).
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Affiliation(s)
- Luiza Salgado Nader
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Matias Epifanio
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | | | - Cintia Steinhaus
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Melina Melere
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Carolina Soares da Silva
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Cristina Targa Ferreira
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
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9
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Ruffner MA, Shoda T, Lal M, Mrozek Z, Muir AB, Spergel JM, Dellon ES, Rothenberg ME. Persistent esophageal changes after histologic remission in eosinophilic esophagitis. J Allergy Clin Immunol 2024; 153:1063-1072. [PMID: 38154664 PMCID: PMC11151730 DOI: 10.1016/j.jaci.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/27/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is characterized by persistent or relapsing allergic inflammation, and both clinical and histologic features of esophageal inflammation persist over time in most individuals. Mechanisms contributing to EoE relapse are not understood, and chronic EoE-directed therapy is therefore required to prevent long-term sequelae. OBJECTIVE We investigated whether EoE patients in histologic remission have persistent dysregulation of esophageal gene expression. METHODS Esophageal biopsy samples from 51 pediatric and 52 adult subjects with EoE in histopathologic remission (<15 eosinophils per high-power field [eos/hpf]) and control (48 pediatric and 167 adult) subjects from multiple institutions were subjected to molecular profiling by the EoE diagnostic panel, which comprises a set of 94 esophageal transcripts differentially expressed in active EoE. RESULTS Defining remission as <15 eos/hpf, we identified 51 and 32 differentially expressed genes in pediatric and adult EoE patients compared to control individuals, respectively (false discovery rate < 0.05). Using the stringent definition of remission (0 eos/hpf), the adult and pediatric cohorts continued to have 18 and 25 differentially expressed genes (false discovery rate < 0.05). Among 6 shared genes between adults and children, CDH26 was upregulated in both children and adults; immunohistochemistry demonstrated increased cadherin 26 staining in the epithelium of EoE patients in remission compared to non-EoE controls. In the adult cohort, POSTN expression correlated with the endoscopic reference system score (Spearman r = 0.35, P = .011), specifically correlating with the rings' endoscopic reference system subscore (r = 0.53, P = .004). CONCLUSION We have identified persistent EoE-associated esophageal gene expression in patients with disease in deep remission. These data suggest potential inflammation-induced epigenetic mechanisms may influence gene expression during remission in EoE and provide insight into possible mechanisms that underlie relapse in EoE.
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Affiliation(s)
- Melanie A Ruffner
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy & Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Tetsuo Shoda
- Department of Pediatrics, Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Megha Lal
- Division of Allergy & Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Zoe Mrozek
- Division of Allergy & Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Amanda B Muir
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jonathan M Spergel
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy & Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Evan S Dellon
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Marc E Rothenberg
- Department of Pediatrics, Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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10
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Peterson K, Collins MH, Aceves SS, Chehade M, Gonsalves N. Concepts and Controversies in Eosinophilic Esophagitis: What's Coming Down the Pipe? Gastroenterology 2024; 166:382-395. [PMID: 38052335 DOI: 10.1053/j.gastro.2023.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/11/2023] [Accepted: 10/16/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Kathryn Peterson
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Seema S Aceves
- University of California San Diego School of Medicine, San Diego, Rady Children's Hospital, San Diego, California
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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11
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Sasaki M, Hara T, Wang JX, Zhou Y, Kennedy KV, Umeweni CN, Alston MA, Spergel ZC, Ishikawa S, Teranishi R, Nakagawa R, Mcmillan EA, Whelan KA, Karakasheva TA, Hamilton KE, Ruffner MA, Muir AB. Lysyl Oxidase Regulates Epithelial Differentiation and Barrier Integrity in Eosinophilic Esophagitis. Cell Mol Gastroenterol Hepatol 2024; 17:923-937. [PMID: 38340809 PMCID: PMC11026689 DOI: 10.1016/j.jcmgh.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND & AIMS Epithelial disruption in eosinophilic esophagitis (EoE) encompasses both impaired differentiation and diminished barrier integrity. We have shown that lysyl oxidase (LOX), a collagen cross-linking enzyme, is up-regulated in the esophageal epithelium in EoE. However, the functional roles of LOX in the esophageal epithelium remains unknown. METHODS We investigated roles for LOX in the human esophageal epithelium using 3-dimensional organoid and air-liquid interface cultures stimulated with interleukin (IL)13 to recapitulate the EoE inflammatory milieu, followed by single-cell RNA sequencing, quantitative reverse-transcription polymerase chain reaction, Western blot, histology, and functional analyses of barrier integrity. RESULTS Single-cell RNA sequencing analysis on patient-derived organoids revealed that LOX was induced by IL13 in differentiated cells. LOX-overexpressing organoids showed suppressed basal and up-regulated differentiation markers. In addition, LOX overexpression enhanced junctional protein genes and transepithelial electrical resistance. LOX overexpression restored the impaired differentiation and barrier function, including in the setting of IL13 stimulation. Transcriptome analyses on LOX-overexpressing organoids identified an enriched bone morphogenetic protein (BMP) signaling pathway compared with wild-type organoids. In particular, LOX overexpression increased BMP2 and decreased the BMP antagonist follistatin. Finally, we found that BMP2 treatment restored the balance of basal and differentiated cells. CONCLUSIONS Our data support a model whereby LOX exhibits noncanonical roles as a signaling molecule important for epithelial homeostasis in the setting of inflammation via activation of the BMP pathway in the esophagus. The LOX/BMP axis may be integral in esophageal epithelial differentiation and a promising target for future therapies.
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Affiliation(s)
- Masaru Sasaki
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Takeo Hara
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joshua X Wang
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yusen Zhou
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kanak V Kennedy
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chizoba N Umeweni
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maiya A Alston
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Zachary C Spergel
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Satoshi Ishikawa
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ryugo Teranishi
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ritsu Nakagawa
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emily A Mcmillan
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelly A Whelan
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania; Department of Cancer and Cellular Biology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Tatiana A Karakasheva
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kathryn E Hamilton
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melanie A Ruffner
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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12
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Dellon ES. Eosinophilic Esophagitis: What's in a Name? Dig Dis Sci 2024; 69:330-334. [PMID: 38060168 DOI: 10.1007/s10620-023-08205-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Evan S Dellon
- , CB #7080, Bioinformatics Bldg., 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA.
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13
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Maslenkina K, Mikhaleva L, Mikhalev A, Kaibysheva V, Atiakshin D, Motilev E, Buchwalow I, Tiemann M. Assessment of the Severity and the Remission Criteria in Eosinophilic Esophagitis. Biomedicines 2023; 11:3204. [PMID: 38137426 PMCID: PMC10740698 DOI: 10.3390/biomedicines11123204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/19/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is an immune-mediated disease that manifests with dysphagia and is characterized by the predominantly eosinophilic infiltration of the esophageal mucosa. Several instruments have been developed to assess the symptoms of EoE: the Daily Symptom Questionnaire (DSQ), EoE Activity Index (EEsAI), Pediatric EoE Symptom Severity (PEESSv2), etc. The use of the EREFS is a gold standard for endoscopic diagnosis. The EoE histologic scoring system (EoEHSS) was elaborated for the assessment of histological features in EoE. However, the remission criteria are not clearly defined and vary greatly in different studies. Gastroenterologists establish the severity of EoE mainly based on endoscopic findings. At the same time, EoE requires a multidisciplinary approach. The recently developed Index of Severity of Eosinophilic Esophagitis (I-SEE) that is built on symptoms, endoscopic findings, and histological features is promising.
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Affiliation(s)
- Ksenia Maslenkina
- A.P. Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119991 Moscow, Russia; (K.M.); (L.M.); (E.M.)
| | - Liudmila Mikhaleva
- A.P. Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119991 Moscow, Russia; (K.M.); (L.M.); (E.M.)
| | - Alexander Mikhalev
- Laboratory of Surgical Gastroenterology and Endoscopy, Pirogov Russian National Research University, 117997 Moscow, Russia; (A.M.); (V.K.)
| | - Valeria Kaibysheva
- Laboratory of Surgical Gastroenterology and Endoscopy, Pirogov Russian National Research University, 117997 Moscow, Russia; (A.M.); (V.K.)
| | - Dmitri Atiakshin
- Research and Educational Resource Center for Immunophenotyping, Digital Spatial Profiling and Ultrastructural Analysis Innovative Technologies, RUDN University, 6 Miklukho-Maklaya St., 117198 Moscow, Russia;
| | - Eugeny Motilev
- A.P. Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119991 Moscow, Russia; (K.M.); (L.M.); (E.M.)
| | - Igor Buchwalow
- Research and Educational Resource Center for Immunophenotyping, Digital Spatial Profiling and Ultrastructural Analysis Innovative Technologies, RUDN University, 6 Miklukho-Maklaya St., 117198 Moscow, Russia;
- Institute for Hematopathology, Fangdieckstr. 75a, 22547 Hamburg, Germany;
| | - Markus Tiemann
- Institute for Hematopathology, Fangdieckstr. 75a, 22547 Hamburg, Germany;
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14
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Chehade M, Wright BL, Atkins D, Aceves SS, Ackerman SJ, Assa'ad AH, Bauer M, Collins MH, Commins SP, Davis CM, Dellon ES, Doerfler B, Gleich GJ, Gupta SK, Hill DA, Jensen ET, Katzka D, Kliewer K, Kodroff E, Kottyan LC, Kyle S, Muir AB, Pesek RD, Peterson K, Shreffler WG, Spergel JM, Strobel MJ, Wechsler J, Zimmermann N, Furuta GT, Rothenberg ME. Breakthroughs in understanding and treating eosinophilic gastrointestinal diseases presented at the CEGIR/TIGERs Symposium at the 2022 American Academy of Allergy, Asthma & Immunology Meeting. J Allergy Clin Immunol 2023; 152:1382-1393. [PMID: 37660987 DOI: 10.1016/j.jaci.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 09/05/2023]
Abstract
The Consortium of Eosinophilic Gastrointestinal Diseases and The International Gastrointestinal Eosinophil Researchers organized a day-long symposium at the 2022 Annual Meeting of the American Academy of Allergy, Asthma & Immunology. The symposium featured a review of recent discoveries in the basic biology and pathogenesis of eosinophilic gastrointestinal diseases (EGIDs) in addition to advances in our understanding of the clinical features of EGIDs. Diagnostic and management approaches were reviewed and debated, and clinical trials of emerging therapies were highlighted. Herein, we briefly summarize the breakthrough discoveries in EGIDs.
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Affiliation(s)
- Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz; Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Dan Atkins
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Seema S Aceves
- Rady Children's Hospital, San Diego, Calif; Division of Allergy, Immunology, University of California-San Diego, San Diego, Calif
| | - Steven J Ackerman
- Department of Biochemistry and Molecular Genetics, College of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Amal H Assa'ad
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Maureen Bauer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Margaret H Collins
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Scott P Commins
- Division of Allergy & Immunology, Center for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Carla M Davis
- Division of Immunology, Allergy, and Retrovirology, Baylor College of Medicine, Houston, Tex; Texas Children's Hospital Food Allergy Program, Texas Children's Hospital, Houston, Tex
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Bethan Doerfler
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Chicago, Ill
| | - Gerald J Gleich
- Department of Dermatology, School of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Sandeep K Gupta
- Children's of Alabama, University of Alabama at Birmingham, Birmingham, Ala
| | - David A Hill
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | | | - David Katzka
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY
| | - Kara Kliewer
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ellyn Kodroff
- Campaign Urging Research for Eosinophilic Disease, Lincolnshire, Ill
| | - Leah C Kottyan
- Cincinnati Children's Research Foundation, Division of Human Genetics, Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Shay Kyle
- Campaign Urging Research for Eosinophilic Disease, Lincolnshire, Ill
| | - Amanda B Muir
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark
| | - Kathryn Peterson
- Division of Gastroenterology, University of Utah Health, Salt Lake City, Utah
| | - Wayne G Shreffler
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Massachusetts General Hospital, Boston, Mass; Food Allergy Center, Massachusetts General Hospital, Boston, Mass
| | - Jonathan M Spergel
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Mary Jo Strobel
- American Partnership for Eosinophilic Disorders, Atlanta, Ga
| | - Joshua Wechsler
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Nives Zimmermann
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Marc E Rothenberg
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
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15
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Clevenger MH, Karami AL, Carlson DA, Kahrilas PJ, Gonsalves N, Pandolfino JE, Winter DR, Whelan KA, Tétreault MP. Suprabasal cells retain progenitor cell identity programs in eosinophilic esophagitis-driven basal cell hyperplasia. JCI Insight 2023; 8:e171765. [PMID: 37672481 PMCID: PMC10619442 DOI: 10.1172/jci.insight.171765] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/29/2023] [Indexed: 09/08/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is an esophageal immune-mediated disease characterized by eosinophilic inflammation and epithelial remodeling, including basal cell hyperplasia (BCH). Although BCH is known to correlate with disease severity and with persistent symptoms in patients in histological remission, the molecular processes driving BCH remain poorly defined. Here, we demonstrate that BCH is predominantly characterized by an expansion of nonproliferative suprabasal cells that are still committed to early differentiation. Furthermore, we discovered that suprabasal and superficial esophageal epithelial cells retain progenitor identity programs in EoE, evidenced by increased quiescent cell identity scoring and the enrichment of signaling pathways regulating stem cell pluripotency. Enrichment and trajectory analyses identified SOX2 and KLF5 as potential drivers of the increased quiescent identity and epithelial remodeling observed in EoE. Notably, these alterations were not observed in gastroesophageal reflux disease. These findings provide additional insights into the differentiation process in EoE and highlight the distinct characteristics of suprabasal and superficial esophageal epithelial cells in the disease.
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Affiliation(s)
- Margarette H. Clevenger
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adam L. Karami
- Department of Cancer & Cellular Biology, Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dustin A. Carlson
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter J. Kahrilas
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nirmala Gonsalves
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John E. Pandolfino
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Deborah R. Winter
- Department of Medicine, Rheumatology Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kelly A. Whelan
- Department of Cancer & Cellular Biology, Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Marie-Pier Tétreault
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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16
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Hill DA, Muir AB. The immune-epithelial interface in eosinophilic esophagitis: a conversation. FRONTIERS IN ALLERGY 2023; 4:1270581. [PMID: 37854541 PMCID: PMC10579787 DOI: 10.3389/falgy.2023.1270581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/19/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- David A. Hill
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics and Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Amanda B. Muir
- Division of Gastroenterology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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17
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Ricaurte Archila L, Smith L, Sihvo HK, Koponen V, Jenkins SM, O'Sullivan DM, Cardenas Fernandez MC, Wang Y, Sivasubramaniam P, Patil A, Hopson PE, Absah I, Ravi K, Mounajjed T, Dellon ES, Bredenoord AJ, Pai R, Hartley CP, Graham RP, Moreira RK. Performance of an Artificial Intelligence Model for Recognition and Quantitation of Histologic Features of Eosinophilic Esophagitis on Biopsy Samples. Mod Pathol 2023; 36:100285. [PMID: 37474003 DOI: 10.1016/j.modpat.2023.100285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/20/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023]
Abstract
We have developed an artificial intelligence (AI)-based digital pathology model for the evaluation of histologic features related to eosinophilic esophagitis (EoE). In this study, we evaluated the performance of our AI model in a cohort of pediatric and adult patients for histologic features included in the Eosinophilic Esophagitis Histologic Scoring System (EoEHSS). We collected a total of 203 esophageal biopsy samples from patients with mucosal eosinophilia of any degree (91 adult and 112 pediatric patients) and 10 normal controls from a prospectively maintained database. All cases were assessed by a specialized gastrointestinal (GI) pathologist for features in the EoEHSS at the time of original diagnosis and rescored by a central GI pathologist (R.K.M.). We subsequently analyzed whole-slide image digital slides using a supervised AI model operating in a cloud-based, deep learning AI platform (Aiforia Technologies) for peak eosinophil count (PEC) and several histopathologic features in the EoEHSS. The correlation and interobserver agreement between the AI model and pathologists (Pearson correlation coefficient [rs] = 0.89 and intraclass correlation coefficient [ICC] = 0.87 vs original pathologist; rs = 0.91 and ICC = 0.83 vs central pathologist) were similar to the correlation and interobserver agreement between pathologists for PEC (rs = 0.88 and ICC = 0.91) and broadly similar to those for most other histologic features in the EoEHSS. The AI model also accurately identified PEC of >15 eosinophils/high-power field by the original pathologist (area under the curve [AUC] = 0.98) and central pathologist (AUC = 0.98) and had similar AUCs for the presence of EoE-related endoscopic features to pathologists' assessment. Average eosinophils per epithelial unit area had similar performance compared to AI high-power field-based analysis. Our newly developed AI model can accurately identify, quantify, and score several of the main histopathologic features in the EoE spectrum, with agreement regarding EoEHSS scoring which was similar to that seen among GI pathologists.
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Affiliation(s)
| | | | | | | | - Sarah M Jenkins
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Donnchadh M O'Sullivan
- Department of Pediatric and Adolescence Medicine, Mayo Clinic, Rochester, Minnesota; Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota
| | - Maria Camila Cardenas Fernandez
- Department of Pediatric and Adolescence Medicine, Mayo Clinic, Rochester, Minnesota; Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota
| | - Yaohong Wang
- Department of Pathology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Ameya Patil
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Puanani E Hopson
- Department of Pediatric and Adolescence Medicine, Mayo Clinic, Rochester, Minnesota; Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota
| | - Imad Absah
- Department of Pediatric and Adolescence Medicine, Mayo Clinic, Rochester, Minnesota; Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota
| | - Karthik Ravi
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota
| | - Taofic Mounajjed
- Department of Pathology, Allina Hospitals and Clinics, Minneapolis, Minnesota
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Rish Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona
| | | | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Roger K Moreira
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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18
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Hiremath G, Sun L, Collins MH, Bonis PA, Arva NC, Capocelli KE, Chehade M, Davis CM, Falk GW, Gonsalves N, Gupta SK, Hirano I, Leung J, Khoury P, Mukkada VA, Martin LJ, Spergel JM, Wechsler JB, Yang GY, Aceves SS, Furuta GT, Rothenberg ME, Koyama T, Dellon ES. Esophageal Epithelium and Lamina Propria Are Unevenly Involved in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2023; 21:2807-2816.e3. [PMID: 36967100 PMCID: PMC10518022 DOI: 10.1016/j.cgh.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/28/2023] [Accepted: 03/13/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND & AIMS The nature of the involvement of esophageal tissue in eosinophilic esophagitis (EoE) is unclear. We estimated the intrabiopsy site agreements of the EoE Histologic Scoring System (EoEHSS) scores for the grade (degree) and stage (extent) of involvement of the esophageal epithelial and lamina propria and examined if the EoE activity status influenced the intrabiopsy site agreement. METHODS Demographic, clinical, and EoEHSS scores collected as part of the prospective Outcome Measures for Eosinophilic Gastrointestinal Diseases Across Ages study were analyzed. A weighted Cohen's kappa agreement coefficient (k) was used to calculate the pairwise agreements for proximal:distal, proximal:middle, and middle:distal esophageal biopsy sites, separately for grade and stage scores, for each of the 8 components of EoEHSS. A k > 0.75 was considered uniform involvement. Inactive EoE was defined as fewer than 15 eosinophils per high-powered field. RESULTS EoEHSS scores from 1263 esophageal biopsy specimens were analyzed. The k for the stage of involvement of the dilated intercellular spaces across all 3 sites in inactive EoE was consistently greater than 0.75 (range, 0.87-0.99). The k for lamina propria fibrosis was greater than 0.75 across some of the biopsy sites but not across all 3. Otherwise, the k for all other features, for both grade and stage, irrespective of the disease activity status, was 0.75 or less (range, 0.00-0.74). CONCLUSIONS Except for the extent of involvement of dilated intercellular spaces in inactive EoE, the remaining epithelial features and lamina propria are involved unevenly across biopsy sites in EoE, irrespective of the disease activity status. This study enhances our understanding of the effects of EoE on esophageal tissue pathology.
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Affiliation(s)
- Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Lili Sun
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital at Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carla M Davis
- Immunology, Allergy, and Retrovirology Division, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Gary W Falk
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - John Leung
- Boston Specialists/Boston Food Allergy Center, Boston, Massachusetts
| | - Paneez Khoury
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Vincent A Mukkada
- Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine Department of Pediatrics, Cincinnati, Ohio
| | - Lisa J Martin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan M Spergel
- Division of Allergy-Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Pennsylvania
| | - Joshua B Wechsler
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Guang-Yu Yang
- Division of Anatomical Pathology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Seema S Aceves
- Division of Rheumatology, Allergy & Immunology, Rady Children's Hospital, San Diego, San Diego, California
| | - Glenn T Furuta
- Section of Pediatric Gastroenterology and Hepatology, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Colorado
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, University of Cincinnati College of Medicine, Ohio
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
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19
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Alexander RG, Ravi K, Collins MH, Lavey CJ, Snyder DL, Lennon RJ, Kassmeyer BA, Katzka DA, Alexander JA. Eosinophilic Esophagitis Histologic Scoring System: Correlation with Histologic, Endoscopic, and Symptomatic Disease and Clinical Use. Dig Dis Sci 2023; 68:3573-3583. [PMID: 37432533 DOI: 10.1007/s10620-023-08029-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/29/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND The eosinophilic esophagitis histologic scoring system (EoEHSS) was developed to enhance the diagnostic standard of peak eosinophil count (PEC) in evaluating disease activity in EoE. AIMS (1) Correlate the EoEHSS and PEC to measures of symptomatic and endoscopic disease activity, (2) Correlate EoEHSS grade and stage subcomponents to clinical, radiology, and endoscopic markers of fibrotic disease, (3) Evaluate EoEHSS remission in asymptomatic patients with PEC < 15 eosinophils per high powered field (eos/hpf). METHODS Secondary analysis of prospective cohort data of 22 patients with EoE that underwent dietary therapy and endoscopy at 3 time points. Active disease was defined by EoEHSS grade or stage > 0.125, symptomatic disease by EoE symptom activity index > 20, endoscopic disease by endoscopic reference score > 2, and histologic disease by PEC ≥ 15 eos/hpf. EoEHSS remission was defined by esophageal inflammation (EI) grade of 0-1, EI stage of 0, total grade ≤ 3, and total stage ≤ 3. RESULTS EoEHSS grade and stage did not correlate with symptomatic disease but did with endoscopic and histologic disease. PEC showed similar correlation pattern. Abnormal grade and stage had strong sensitivity (87-100%) but poor specificity (11-36%) to detect symptomatic, endoscopic, and histologic disease activity. Lamina propria fibrosis was evaluated in 36% of biopsies and did not correlate with minimum esophageal diameter. Out of 14 patients who were in complete symptomatic, endoscopic, and histologic remission, 8 met criteria for EoEHSS remission. CONCLUSION The positive and negative correlations of EoEHSS to specific measures of symptomatic, histologic, and endoscopic activity suggest that it provides complementary information in EoE.
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Affiliation(s)
- Ryan G Alexander
- Department of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Karthik Ravi
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Crystal J Lavey
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Diana L Snyder
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ryan J Lennon
- Department of Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | - David A Katzka
- Department of Gastroenterology, Columbia University Medical Center, New York, NY, USA
| | - Jeffrey A Alexander
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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20
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Dellon ES. A New Tool to Assess Disease Severity in Eosinophilic Esophagitis. Gastroenterol Hepatol (N Y) 2023; 19:457-462. [PMID: 37772158 PMCID: PMC10524433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
The presentation of eosinophilic esophagitis (EoE) is heterogeneous with varied clinical, endoscopic, and histologic features impacting the severity of the condition. Until recently, however, and in contrast with many other conditions, there has been no standardized way to measure disease severity in EoE. A clinically applicable method for assessing severity in routine practice has been recognized as necessary to standardize assessment and management of EoE. Therefore, the American Gastroenterological Association has sponsored a consensus conference to determine elements of severity in EoE and develop the first tool to measure severity. This article presents details of this severity metric, which is known as the Index of Severity in EoE (I-SEE), and outlines the elements within I-SEE and how to categorize EoE as mild, moderate, severe, or inactive. The domains of I-SEE include symptoms and complications, inflammatory features (both endoscopic and histologic), and fibrostenotic features (both endoscopic and histologic). The article also provides an update on emerging data related to I-SEE and discusses the future studies necessary to implement I-SEE as part of a treatment framework in EoE.
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Affiliation(s)
- Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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21
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Clevenger MH, Karami AL, Carlson DA, Kahrilas PJ, Gonsalves N, Pandolfino JE, Winter DR, Whelan KA, Tétreault MP. Suprabasal cells retaining stem cell identity programs drive basal cell hyperplasia in eosinophilic esophagitis. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.20.537495. [PMID: 37131652 PMCID: PMC10153277 DOI: 10.1101/2023.04.20.537495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Eosinophilic esophagitis (EoE) is an esophageal immune-mediated disease characterized by eosinophilic inflammation and epithelial remodeling, including basal cell hyperplasia (BCH) and loss of differentiation. Although BCH correlates with disease severity and with persistent symptoms in patients in histological remission, the molecular processes driving BCH remain poorly defined. Here, we demonstrate that despite the presence of BCH in all EoE patients examined, no increase in basal cell proportion was observed by scRNA-seq. Instead, EoE patients exhibited a reduced pool of KRT15+ COL17A1+ quiescent cells, a modest increase in KI67+ dividing epibasal cells, a substantial increase in KRT13+ IVL+ suprabasal cells, and a loss of differentiated identity in superficial cells. Suprabasal and superficial cell populations demonstrated increased quiescent cell identity scoring in EoE with the enrichment of signaling pathways regulating pluripotency of stem cells. However, this was not paired with increased proliferation. Enrichment and trajectory analyses identified SOX2 and KLF5 as potential drivers of the increased quiescent identity and epithelial remodeling observed in EoE. Notably, these findings were not observed in GERD. Thus, our study demonstrates that BCH in EoE results from an expansion of non-proliferative cells that retain stem-like transcriptional programs while remaining committed to early differentiation.
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Affiliation(s)
- Margarette H. Clevenger
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611-3010, USA
| | - Adam L. Karami
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Dustin A. Carlson
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611-3010, USA
| | - Peter J. Kahrilas
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611-3010, USA
| | - Nirmala Gonsalves
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611-3010, USA
| | - John E. Pandolfino
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611-3010, USA
| | - Deborah R. Winter
- Department of Medicine, Rheumatology Division, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611-3010, USA
| | - Kelly A. Whelan
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Marie-Pier Tétreault
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611-3010, USA
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22
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Fuller AD, Karami AL, Kabir MF, Klochkova A, Jackson JL, Mu A, Tan Y, Klein-Szanto AJ, Whelan KA. Eosinophilic esophagitis-associated epithelial remodeling may limit esophageal carcinogenesis. FRONTIERS IN ALLERGY 2023; 4:1086032. [PMID: 37064719 PMCID: PMC10090679 DOI: 10.3389/falgy.2023.1086032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/28/2023] [Indexed: 03/31/2023] Open
Abstract
Introduction Under homeostatic conditions, esophageal epithelium displays a proliferation/differentiation gradient that is generated as proliferative basal cells give rise to suprabasal cells then terminally differentiated superficial cells. This proliferation/differentiation gradient is often perturbed in esophageal pathologies. Basal cell hyperplasia may occur in patients with gastroesophageal reflux disease (GERD), a condition in which acid from the stomach enters the esophagus, or eosinophilic esophagitis (EoE), an emerging form of food allergy. While GERD is a primary risk factor for esophageal cancer, epidemiological data suggests that EoE patients do not develop esophageal cancer. Methods In order to investigate the impact of EoE and esophageal cancer specifically on the cellular landscape of esophageal epithelium, we perform single cell RNA-sequencing in murine models of EoE and esophageal cancer, specifically esophageal squamous cell carcinoma (ESCC). We further evaluate modules of co-expressed genes in EoE- and ESCC-enriched epithelial cell clusters. Finally, we pair EoE and ESCC murine models to examine the functional relationship between these pathologies. Results In mice with either EoE or ESCC, we find expansion of cell populations as compared to normal esophageal epithelium. In mice with EoE, we detect distinct expansion of 4 suprabasal populations coupled with depletion of 2 basal populations. By contrast, mice with ESCC display unique expansion of 2 basal populations and 1 suprabasal population, as well as depletion of 2 suprabasal populations. Senescence, glucocorticoid receptor signaling, and granulocyte-macrophage colony-stimulating factor pathways are associated with EoE-enriched clusters while pathways associated with cell proliferation and metabolism are identified in ESCC-enriched clusters. Finally, our in vivo data demonstrate that exposure to EoE inflammation limits tumor burden of esophageal carcinogenesis. Discussion Our findings provide the first functional investigation of the relationship between EoE and esophageal cancer and suggest that esophageal epithelial remodeling events occurring in response to EoE inflammation may limit esophageal carcinogenesis. This investigation may have future implications for leveraging allergic inflammation-associated alterations in epithelial biology to prevent and/or treat esophageal cancer.
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Affiliation(s)
- Annie D. Fuller
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Adam L. Karami
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Mohammad Faujul Kabir
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Alena Klochkova
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Jazmyne L. Jackson
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Anbin Mu
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Yinfei Tan
- Genomics Facility, Fox Chase Cancer Center, Philadelphia, PA, United States
| | | | - Kelly A. Whelan
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
- Department of Cancer & Cellular Biology, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
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23
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Sasaki M, Hara T, Wang JX, Zhou Y, Kennedy KV, Umeweni NN, Alston MA, Spergel ZC, Nakagawa R, Mcmillan EA, Whelan KA, Karakasheva TA, Hamilton KE, Ruffner MA, Muir AB. Lysyl oxidase regulates epithelial differentiation and barrier integrity in eosinophilic esophagitis. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.03.27.534387. [PMID: 37034590 PMCID: PMC10081173 DOI: 10.1101/2023.03.27.534387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Background & Aims Epithelial disruption in eosinophilic esophagitis (EoE) encompasses both impaired differentiation and diminished barrier integrity. We have shown that lysyl oxidase (LOX), a collagen cross-linking enzyme, is upregulated in the esophageal epithelium in EoE. However, the functional roles of LOX in the esophageal epithelium remains unknown. Methods We investigated roles for LOX in the human esophageal epithelium using 3-dimensional organoid and air-liquid interface cultures stimulated with interleukin (IL)-13 to recapitulate the EoE inflammatory milieu, followed by single-cell RNA sequencing, quantitative reverse transcription-polymerase chain reaction, western blot, histology, and functional analyses of barrier integrity. Results Single-cell RNA sequencing analysis on patient-derived organoids revealed that LOX was induced by IL-13 in differentiated cells. LOX-overexpressing organoids demonstrated suppressed basal and upregulated differentiation markers. Additionally, LOX overexpression enhanced junctional protein genes and transepithelial electrical resistance. LOX overexpression restored the impaired differentiation and barrier function, including in the setting of IL-13 stimulation. Transcriptome analyses on LOX-overexpressing organoids identified enriched bone morphogenetic protein (BMP) signaling pathway compared to wild type organoids. Particularly, LOX overexpression increased BMP2 and decreased BMP antagonist follistatin. Finally, we found that BMP2 treatment restored the balance of basal and differentiated cells. Conclusions Our data support a model whereby LOX exhibits non-canonical roles as a signaling molecule important for epithelial homeostasis in the setting of inflammation via activation of BMP pathway in esophagus. The LOX/BMP axis may be integral in esophageal epithelial differentiation and a promising target for future therapies.
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Affiliation(s)
- Masaru Sasaki
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Takeo Hara
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joshua X. Wang
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yusen Zhou
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kanak V. Kennedy
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nicole N. Umeweni
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maiya A. Alston
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Zachary C. Spergel
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ritsu Nakagawa
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Emily A. Mcmillan
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kelly A. Whelan
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Cancer & Cellular Biology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Tatiana A. Karakasheva
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathryn E. Hamilton
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melanie A. Ruffner
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Allergy and Immunology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amanda B. Muir
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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24
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Mechanisms and clinical management of eosinophilic oesophagitis: an overview. Nat Rev Gastroenterol Hepatol 2023; 20:101-119. [PMID: 36253463 DOI: 10.1038/s41575-022-00691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/03/2023]
Abstract
Since the first description of eosinophilic oesophagitis (EoE) less than three decades ago, we have observed a striking increase in the number of patients diagnosed with EoE and the understanding of its clinical and immunopathogenic background. Nonetheless, a plethora of open questions await elucidation. In this Review, we discuss the current state of knowledge regarding the underlying mechanisms, particularly environmental factors and their interaction with genetic susceptibility. Subsequently, we discuss how to translate these factors into the diagnostic and therapeutic management of this chronic, immune-mediated disorder. Finally, we dissect the still long list of unmet needs, such as reasons for and handling refractory EoE and atypical clinical presentations. These open questions can guide us through future research steps and potentially foster reconsideration of the diagnostic guidelines of EoE.
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25
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Kennedy KV, Umeweni CN, Ruffner M, Muir AB. Treatment goals in eosinophilic esophagitis: Looking beyond eosinophil count. Ann Allergy Asthma Immunol 2023; 130:11-12. [PMID: 35973654 DOI: 10.1016/j.anai.2022.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Kanak V Kennedy
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chizoba N Umeweni
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melanie Ruffner
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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26
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Assessment of Esophageal Motility in Patients With Eosinophilic Esophagitis: A Scoping Review. J Clin Gastroenterol 2023; 57:10-30. [PMID: 36504227 DOI: 10.1097/mcg.0000000000001792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/08/2022] [Indexed: 12/15/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated condition causing esophageal symptoms, particularly dysphagia. Despite the important progress in the treatment of EoE, a significant proportion of patients continue to report symptoms that negatively impact quality of life. Esophageal manometry is used to assess motility and function, but is not routinely used in EoE. We aimed to systematically review and describe current literature evaluating esophageal manometry in EoE. Forty-eight studies meeting the criteria were identified, describing 802 patients. Using standard water swallow protocols, the proportion of abnormalities detected was not dissimilar to other populations, apart from disorders of esophago-gastric outflow, which were found in 5%. Twelve studies described pretreatment and posttreatment manometry, with motility normalization after pharmacological therapy reported in 20%. Early, brief panesophageal pressurization was described in a number of studies and was more prevalent in the few studies utilizing additional provocation testing. Reports in the literature regarding temporal relationships between manometric findings and symptoms are variable. Esophageal manometry may be capable of detecting clinically relevant changes to esophageal function in EoE. Possible mechanisms are altered neuromuscular function because of secretory products of EoE and/or fibroinflammatory processes, manifesting as pressurization because of altered esophageal compliance. Some changes may be reversible with therapy. Drawing strong conclusions from the literature is difficult, with bias toward case reports and retrospective observation. Adaptations to assessment protocols to include provocation testing may provide more robust evaluation and detect clinically relevant, subtle changes in esophageal function, earlier within the patient pathway.
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27
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Dellon ES, Collins MH, Furuta GT, Aceves SS. Reply. Gastroenterology 2022; 163:1720-1721. [PMID: 36063963 DOI: 10.1053/j.gastro.2022.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/27/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, and, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Glenn T Furuta
- Gastrointestinal Eosinophilic Diseases Program, and, Mucosal Inflammation Program, Department of Pediatrics, University of Colorado School of Medicine, and, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Seema S Aceves
- Division of Allergy, Immunology, University of California, San Diego, California; Rady Children's Hospital, San Diego, California
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28
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Muir AB, Ackerman SJ, Pan Z, Benitez A, Burger C, Spergel JM, Furuta GT, Rothman J, Wilkins BJ, Arnold MA, Dolinsky L, Grozdanovic M, Menard-Katcher C. Esophageal remodeling in eosinophilic esophagitis: Relationships to luminal captured biomarkers of inflammation and periostin. J Allergy Clin Immunol 2022; 150:649-656.e5. [PMID: 35405206 PMCID: PMC10367933 DOI: 10.1016/j.jaci.2022.03.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Esophageal remodeling is a factor in disease progression and symptom severity for patients with eosinophilic esophagitis (EoE). Remodeling can begin early in children, resulting in stricture and food impaction. Detection of esophageal remodeling often depends on endoscopy and is appreciated only in its later stages. OBJECTIVE We sought to determine whether luminal eosinophil-associated and remodeling proteins captured by the esophageal string test (EST) correlate with measures of esophageal remodeling and biomarkers of the epithelial-mesenchymal transition (EMT). METHODS Patients with EoE (7-18 years old) were enrolled from 2 pediatric hospitals. Participants performed the EST and underwent endoscopy. Histology, distensibility measured by endoluminal functional lumen imaging probe, and symptoms were assessed. Protein quantitation by ELISA was performed on mucosal biopsy and EST samples. Tissue sections were evaluated for EMT. Outcome measures were summarized, and Spearman ρ was used to assess bivariate correlations. RESULTS Forty patients (68% male) were enrolled (mean age, 12.5 years). Twenty-four (60%) had active disease (≥15 eosinophils per high-power field). EST-captured eotaxin-3, major basic protein 1, EDN, eosinophil peroxidase, and Charcot-Leyden crystal protein/galectin-10 showed significant correlations with peak eosinophils per high-power field (ρ 0.53-0.68, P < .001). Luminal proteins positively correlated with endoscopic features and markers of EMT, and negatively with esophageal distensibility. Periostin was captured by the EST and correlated with eosinophil density, basal zone hyperplasia, endoscopic appearance, and markers of EMT. CONCLUSION Luminal markers of esophageal remodeling in addition to biomarkers of eosinophilic inflammation correlate with epithelial and functional remodeling in EoE.
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Affiliation(s)
- Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| | - Steven J Ackerman
- Departments of Biochemistry and Molecular Genetics, and Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Zhaoxing Pan
- Research Institute, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Alain Benitez
- Division of Gastroenterology, Hepatology, and Nutrition, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Cassandra Burger
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology & Nutrition, Gastrointestinal Eosinophilic Diseases Program, and the Digestive Health Institute; Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Jonathan M Spergel
- Division of Allergy and Immunology and Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Glenn T Furuta
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology & Nutrition, Gastrointestinal Eosinophilic Diseases Program, and the Digestive Health Institute; Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Joshua Rothman
- Division of Gastroenterology, Hepatology, and Nutrition, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Benjamin J Wilkins
- Department of Pathology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Michael A Arnold
- Department of Pathology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Lauren Dolinsky
- Division of Gastroenterology, Hepatology, and Nutrition, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Milica Grozdanovic
- Departments of Biochemistry and Molecular Genetics, and Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Calies Menard-Katcher
- Research Institute, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
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29
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Disease Burden and Unmet Need in Eosinophilic Esophagitis. Am J Gastroenterol 2022; 117:1231-1241. [PMID: 35417421 DOI: 10.14309/ajg.0000000000001777] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/04/2022] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory disease of increasing prevalence, characterized by symptoms of dysphagia and reduced quality of life. A dysregulated type 2 immune response to food and aeroallergen leads to barrier dysfunction, chronic esophageal inflammation, remodeling, and fibrosis. Patients with EoE have impaired quality of life because of dysphagia and other symptoms. They may also suffer social and psychological implications of food-related illness and expensive out-of-pocket costs associated with treatment. Disease burden in EoE is often compounded by the presence of comorbid type 2 inflammatory diseases. Current conventional treatments include elimination diet, proton pump inhibitors, and swallowed topical corticosteroids, as well as esophageal dilation in patients who have developed strictures. These treatments demonstrate variable response rates and may not always provide long-term disease control. There is an unmet need for long-term histologic, endoscopic, and symptomatic disease control; for targeted therapies that can normalize the immune response to triggers, reduce chronic inflammation, and limit or prevent remodeling and fibrosis; and for earlier diagnosis, defined treatment outcomes, and a greater understanding of patient perspectives on treatment. In addition, healthcare professionals need a better understanding of the patient perspective on disease burden, the disconnect between symptoms and disease activity, and the progressive nature of EoE and the need for continuous monitoring and maintenance treatment. In this review, we explore the progression of disease over the patient's lifespan, highlight the patient perspective on disease, and discuss the unmet need for effective long-term treatments.
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30
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. Gastroenterology 2022; 163:59-76. [PMID: 35606197 PMCID: PMC9233087 DOI: 10.1053/j.gastro.2022.03.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Bob Geng
- University of California San Diego, San Diego, California; Rady Children's Hospital, San Diego, California
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock, Arkansas; Arkansas Children's Hospital, Little Rock, Arkansas
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven, Connecticut; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden, Connecticut
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children, Indianapolis, Indiana; Community Health Network, Indianapolis, Indiana
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville, Virginia
| | - Fouad J Moawad
- Division of Gastroenterology, Scripps Clinic, La Jolla, California
| | - Kathryn A Peterson
- Division of Gastroenterology, University of Utah Health, Salt Lake City, Utah
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Rady Children's Hospital, San Diego, California; Division of Allergy, Immunology, University of California-San Diego, San Diego, California
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31
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. J Allergy Clin Immunol 2022; 150:33-47. [PMID: 35606166 PMCID: PMC9549868 DOI: 10.1016/j.jaci.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/13/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora; Children's Hospital Colorado, Aurora
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati; Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora; Digestive Health Institute, Children's Hospital Colorado, Aurora
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam
| | - Bob Geng
- University of California San Diego, San Diego; Rady Children's Hospital, San Diego
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock; Arkansas Children's Hospital, Little Rock
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis; Riley Hospital for Children, Indianapolis; Community Health Network, Indianapolis
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid; Instituto de Investigación Sanitaria La Princesa, Madrid
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville
| | | | | | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora
| | - Seema S Aceves
- Rady Children's Hospital, San Diego; Division of Allergy, Immunology, University of California-San Diego, San Diego
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Kuang FL, De Melo MS, Makiya M, Kumar S, Brown T, Wetzler L, Ware JM, Khoury P, Collins MH, Quezado M, Pittaluga S, Klion AD. Benralizumab Completely Depletes Gastrointestinal Tissue Eosinophils and Improves Symptoms in Eosinophilic Gastrointestinal Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1598-1605.e2. [PMID: 35283330 PMCID: PMC9210216 DOI: 10.1016/j.jaip.2022.02.037] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 05/02/2023]
Abstract
BACKGROUND Previous studies of targeted eosinophil biologics in eosinophilic esophagitis have yielded mixed results. Possible explanations include incomplete eosinophil depletion with anticytokine (anti-IL-5) treatments and/or irreversible fibrotic tissue changes contributing to symptomatology. OBJECTIVE To characterize the therapeutic effect of eosinophil depletion in patients with hypereosinophilic syndrome with varied eosinophilic gastrointestinal (GI) disorders. METHODS Hematologic, histologic, endoscopic, and clinical symptoms for a subset (n = 7) of hypereosinophilic syndrome patients with GI tissue eosinophilia enrolled in a phase 2 clinical trial of benralizumab (anti-IL-5RA) were assessed before and after treatment (NCT02130882). RESULTS Blood and GI tissue eosinophils were completely depleted in all segments of the GI tract, and all patients reported improved GI symptoms, in some cases as early as after the first monthly dose. Some patients had recurrent symptomatic flares without recurrent peripheral or tissue eosinophilia, in most cases after prolonged symptomatic remission and in the setting of liberalization of dietary restrictions and/or tapering of background therapy. Although eosinophil-associated histologic changes improved in all segments, epithelial changes persisted in the esophagus and stomach in patients with recurrent disease flares even after 1 year of treatment. Serum tryptase and GI mast cells were generally unchanged with treatment, and increases were not associated with disease flares. Serum levels of IL-4 and IL-5 increased with benralizumab treatment (both P < .05). CONCLUSIONS Benralizumab treatment completely depleted blood and GI tissue eosinophilia in patients with eosinophilic GI disorders, but clinical response, while encouraging, was heterogeneous. Residual symptoms in some patients may reflect persistent epithelial changes in the upper GI tract.
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Affiliation(s)
- Fei Li Kuang
- Division of Allergy Immunology, Northwestern University Feinberg School of Medicine, Chicago, Ill; Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Michelly Sampaio De Melo
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - Michelle Makiya
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Sheila Kumar
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md
| | - Thomas Brown
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Lauren Wetzler
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - JeanAnne M Ware
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Martha Quezado
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - Stefania Pittaluga
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - Amy D Klion
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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Responsiveness of a Histologic Scoring System Compared With Peak Eosinophil Count in Eosinophilic Esophagitis. Am J Gastroenterol 2022; 117:264-271. [PMID: 34797816 DOI: 10.14309/ajg.0000000000001571] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The optimal instrument for assessing histologic disease activity in patients with eosinophilic esophagitis (EoE) is unclear. We assessed the responsiveness of the EoE Histologic Scoring System (EoE-HSS) when compared with that of the peak eosinophil count (PEC). METHODS Histopathology slides were obtained from patients with EoE at baseline and after 8 weeks of treatment with swallowed topical budesonide or elimination diet. Two blinded gastrointestinal pathologists scored biopsies on the EoE-HSS, PEC, and 100-mm visual analog scale (VAS) of overall histologic severity. Change was defined as an improvement by ≥0.5 SD in baseline VAS. Responsiveness was quantified using the standardized effect size (SES) and the probability that the index distinguishes a patient with improvement from a patient without improvement, which is the area under the receiver operating characteristic curve (AUC). Longitudinal validity was assessed using Pearson correlations between changes in EoE-HSS and both PEC and VAS. RESULTS The EoE-HSS grade (SES 2.18 [95% confidence interval, CI: 1.46-2.88]; AUC 0.73 [95% CI: 0.57-0.84]) and stage (SES 2.07 [95% CI: 1.37-2.77]; AUC 0.73 [95% CI: 0.58-0.84]) were highly responsive, similar to PEC (SES 1.44 [95% CI: 0.80-2.07]; AUC 0.73 [95% CI: 0.58-0.84]). The EoE-HSS grade and stage were more highly correlated with changes in VAS (grade 0.92 [95% CI: 0.86-0.95]; stage 0.89 [95% CI: 0.81-0.94]) than with changes in PEC (grade 0.74 [95% CI: 0.58-0.85]; stage 0.66 [95% CI: 0.47-0.80]). DISCUSSION The EoE-HSS is highly responsive, performs similarly to PEC, and is better correlated with changes in overall histologic activity in patients with EoE.
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CD73 + Epithelial Progenitor Cells That Contribute to Homeostasis and Renewal Are Depleted in Eosinophilic Esophagitis. Cell Mol Gastroenterol Hepatol 2022; 13:1449-1467. [PMID: 35108658 PMCID: PMC8957025 DOI: 10.1016/j.jcmgh.2022.01.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND & AIMS Although basal cell hyperplasia is a histologic hallmark of eosinophilic esophagitis (EoE), little is known about the capabilities of epithelial renewal and differentiation in the EoE inflammatory milieu. In murine esophageal epithelium, there are self-renewing and slowly proliferating basal stem-like cells characterized by concurrent expression of CD73 (5'-nucleotidase ecto) and CD104 (integrin β4). Here, we investigated CD73+CD104+ cells within the basal population of human esophageal epithelium and clarified the biological significance of these cells in the EoE epithelium. METHODS We performed flow cytometry on esophageal biopsy samples from EoE and non-EoE patients to determine the quantity of CD73+CD104+ cells in the epithelium. Simulating the EoE milieu we stimulated primary patient-derived and immortalized cell line-derived esophageal organoids with interleukin (IL)4 and IL13 and analyzed by flow cytometry, immunohistochemistry, and quantitative reverse-transcription polymerase chain reaction. We performed single-cell RNA sequencing on primary organoids in the setting of IL13 stimulation and evaluated the CD73+CD104+ population. We performed fluorescent-activated cell sorting to purify CD73+CD104+ and CD73- CD104+ populations and seeded these groups in organoid culture to evaluate the organoid formation rate and organoid size. We used RNA interference to knock down CD73 in esophageal organoids to evaluate organoid formation rates and size. We evaluated the effects of signal transducer and activator of transcription 6 (STAT6) signaling inhibition by RNA interference, a STAT6 inhibitor, AS1517499, as well as the proton pump inhibitor omeprazole. RESULTS EoE patients showed decreased epithelial CD73+CD104+ cell content. IL4 and IL13 stimulation depleted this population in 3-dimensional organoids with a recapitulation of basal cell hyperplasia as corroborated by single-cell RNA sequencing of the organoids, which suggests depletion of CD73+CD104+ cells. The CD73+CD104+ population had enhanced organoid formation compared with the CD73-CD104+ population. Similarly, knock-down of CD73 resulted in decreased organoid formation rate. Genetic and pharmacologic inhibition of STAT6 prevented T helper 2 cytokine-induced depletion of CD73+CD104+ cells. Lastly, omeprazole treatment prevented the effects of IL4 and IL13 on the CD73+CD104+ population. CONCLUSIONS This study addressed the role of CD73+CD104+ cells in epithelial renewal and homeostasis in the context of EoE. The depletion of the CD73+CD104+ self-renewal population by helper T cell 2 cytokines in EoE milieu may be perpetuating epithelial injury. Future therapies targeting epithelial restitution in EoE could decrease the need for immune modulation and steroid therapy.
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Young E, Philpott H. Pathophysiology of Dysphagia in Eosinophilic Esophagitis: Causes, Consequences, and Management. Dig Dis Sci 2022; 67:1101-1115. [PMID: 35230577 PMCID: PMC8976791 DOI: 10.1007/s10620-022-07419-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/20/2022] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is a leading cause of food bolus impaction in children and adults. The mechanism of dysphagia in EoE, particularly non-obstructive dysphagia, remains incompletely understood. While fibrostenotic processes appear to be critical in the development of dysphagia, somatosensory dysfunction and dysmotility also contribute. This review considers potential mechanisms of dysphagia and evaluates the utility of current and future treatment strategies in this context.
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Affiliation(s)
- Edward Young
- grid.460761.20000 0001 0323 4206Department of Gastroenterology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5031 Australia ,grid.1010.00000 0004 1936 7304Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA Australia
| | - Hamish Philpott
- grid.460761.20000 0001 0323 4206Department of Gastroenterology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5031 Australia ,grid.1010.00000 0004 1936 7304Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA Australia
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Votto M, Naso M, Clemente AM, De Filippo M, Gargiulo G, Granone V, Siri G, Marseglia GL, Licari A. Eosinophilic esophagitis an update in children. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022034. [PMID: 35666120 PMCID: PMC9494178 DOI: 10.23750/abm.v93is3.13068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/23/2022]
Abstract
Eosinophilic esophagitis (EoE) is an emerging antigen-mediated, inflammatory disease of unknown etiology. EoE affects about 1/2,000 patients in the United States (US), with a higher prevalence rate in adults (43.4/100,000) than in children (29.5/100,000), prevailing in Caucasians and male sex. EoE is a multifactorial disease typically characterized by type 2 inflammation. Pathogenesis is not entirely understood and is likely non-IgE mediated. Food allergens trigger EoE, stimulating the dysregulated immune cells through an impaired esophageal epithelial barrier. Clinical presentation of EoE depends on age and mainly includes food refusal, vomiting, abdominal or chest pain, dysphagia, and food impaction. Endoscopy is the gold standard to diagnose EoE. The goal of EoE therapy is to achieve clinical and histological remission to prevent esophageal fibrosis and improve patients' quality of life (QoL). Cornerstones of therapy are PPIs, topical steroids, and elimination diets. Over recent decades, research progress has been made in terms of a greater understanding of the EoE pathogenesis and new therapeutic approaches. However, there are still several unmet needs, such as non-invasive tools and biomarkers for monitoring the disease.
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Affiliation(s)
- Martina Votto
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Matteo Naso
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Andrea Martina Clemente
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Maria De Filippo
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Ginevra Gargiulo
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Veronica Granone
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Giulia Siri
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Ruffner MA, Juste L, Muir AB. Medical Management of Eosinophilic Esophagitis in Pediatric Patients. Pediatr Clin North Am 2021; 68:1191-1204. [PMID: 34736584 DOI: 10.1016/j.pcl.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis is an immune-mediated allergic disease of the esophagus that affects pediatric patients of all ages. The diagnosis is made by esophagogastroduodenoscopy demonstrating eosinophilic infiltrate of the esophagus. Approaches to treatment involve proton pump inhibitors (PPIs), swallowed topical steroid preparations, as well as dietary elimination. In this review we discuss the evidence and efficacy of each of these approaches.
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Affiliation(s)
- Melanie A Ruffner
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th and Civic Center Boulevard, Wood Building 3rd Floor, Philadelphia, PA 19104, USA
| | - Linola Juste
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Abramson Research Center 902E, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Abramson Research Center 902E, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Barni S, Arasi S, Mastrorilli C, Pecoraro L, Giovannini M, Mori F, Liotti L, Saretta F, Castagnoli R, Caminiti L, Cianferoni A, Novembre E. Pediatric eosinophilic esophagitis: a review for the clinician. Ital J Pediatr 2021; 47:230. [PMID: 34809686 PMCID: PMC8609874 DOI: 10.1186/s13052-021-01178-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 10/27/2021] [Indexed: 12/16/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic clinical-pathologic disease characterized by eosinophilic infiltration of the esophageal epithelium with esophageal dysfunction symptoms.EoE can occur at any age and has different clinical manifestations depending on the age onset.To date, esophago-gastroduodenal endoscopy (EGD) with biopsy is the gold-standard for EoE diagnosis.According to the recent consensus guidelines, proton pump inhibitors, corticosteroids and elimination diets could be a first-line therapy option. The aim of the treatment is clinical and histological remission for preventing long-lasting untreatable fibrosis.A multidisciplinary approach (allergist, gastroenterology, dietitian, and pathologist) is recommended for managing patients affected by EoE, given the complexity of its treatment.This review will provide a practical guide to assist pediatricians treating children with EoE.Moreover, it highlights the unmet needs in diagnosis and treatment that require urgent attention from the scientific community in the aim of improving the management of patients with EoE.
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Affiliation(s)
- Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Stefania Arasi
- Predictive and Preventive Medicine Research Unit, Multifactorial and Systemic Diseases Research Area, Pediatric Allergy Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Carla Mastrorilli
- Pediatric Unit and Emergency, University Hospital Consortium Corporation Polyclinic of Bari, Pediatric Hospital Giovanni XXIII, Bari, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Luca Pecoraro
- Department of Medicine, University of Verona, Policlinico GB Rossi, Verona, Italy
- Pediatric Unit, ASST Mantua, Mantua, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Lucia Liotti
- Pediatric Unit, Senigallia Hospital, Senigallia, Italy
| | - Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Riccardo Castagnoli
- Department of Pediatrics, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Development Age “Gaetano Barresi”, Allergy Unit, Department of Pediatrics, AOU Policlinico Gaetano Martino, Messina, Italy
| | - Antonella Cianferoni
- Pediatrics Department, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Allergy and Immunology Division, The Children’s Hospital of Philadelphia, Philadelphia, USA
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
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Clinicopathologic Correlations in Eosinophilic Gastrointestinal Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3258-3266. [DOI: 10.1016/j.jaip.2021.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 12/17/2022]
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Image Analysis of Eosinophil Peroxidase Immunohistochemistry for Diagnosis of Eosinophilic Esophagitis. Dig Dis Sci 2021; 66:775-783. [PMID: 32248390 PMCID: PMC7541435 DOI: 10.1007/s10620-020-06230-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diagnosis of eosinophilic esophagitis (EoE) requires manual quantification of tissue eosinophils. Eosinophil peroxidase (EPX) is an eosinophil-specific, cytoplasmic granule protein released during degranulation. AIMS The objective of this study was to evaluate image analysis of EPX immunohistochemistry as an automated method for histologic diagnosis of EoE. METHODS We performed a secondary analysis of prospectively collected esophageal biopsies obtained from adult subjects with EoE and controls. Tissue sections were stained with hematoxylin and eosin (H&E) and evaluated for peak eosinophils per high power field (eos/hpf). The same slides were de-stained and re-stained to detect EPX for direct comparison. Slides were digitized, and EPX staining area/mm2 was quantified using image analysis. Paired samples were compared for changes in EPX staining in treatment responders and non-responders. RESULTS Thirty-eight EoE cases and 49 controls were analyzed. Among EoE subjects, matched post-treatment biopsies were available for 21 responders and 10 non-responders. Baseline EPX/mm2 was significantly increased in EoE subjects and decreased in treatment responders. EPX quantification correlated strongly with eos/hpf (r = 0.84, p < 0.0001) and identified EoE subjects with high diagnostic accuracy (AUC 0.95, p < 0.0001). The optimal diagnostic EPX-positive pixel/area threshold was 17,379 EPX/mm2. Several controls (5/49) with < 15 eos/hpf on H&E staining exceeded this cutoff. CONCLUSIONS EPX/mm2 correlates strongly with eos/hpf, accurately identifies subjects with EoE, and decreases in treatment responders. Automated quantification of intact eosinophils and their degranulation products may enhance pathologic assessment. Future studies are needed to correlate EPX/mm2 with symptoms, endoscopic findings, and esophageal distensibility.
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Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome. Dig Dis Sci 2020; 65:3434-3447. [PMID: 33052498 PMCID: PMC7669680 DOI: 10.1007/s10620-020-06642-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/09/2022]
Abstract
Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of esophageal dysfunction, including dysphagia. While EoE is still considered a rare disease, in practice it seems that more and more cases are diagnosed every week, research in the field is exploding, and the pipeline for treatments contains multiple agents, some of which are quite far along the development pathway. After only scattered cases and small series were published in the late 1970s and 1980, Stephen Attwood, Thomas Smyrk, Tom DeMeester, and James Jones, published in Digestive Diseases and Sciences in 1993 a seminal report that described a clinicopathologic syndrome of esophageal eosinophilia with dysphagia. This review details the origins of this paper and compares and contrast what was observed then and what is known now about multiple aspects of EoE, including the clinical presentation, diagnosis, epidemiology, natural history, and treatments and outcomes. Moreover, it will highlight how the paper presaged a number of controversies in the field that have yet to be resolved, as well as foreshadowed the collaborative, multidisciplinary approach that has led to rapid advances.
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Katzka DA. Eosinophilic esophagitis in children is about more than eosinophils. Gastrointest Endosc 2020; 91:795-796. [PMID: 32204814 DOI: 10.1016/j.gie.2019.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/10/2019] [Indexed: 12/11/2022]
Affiliation(s)
- David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Mast Cell Infiltration Is Associated With Persistent Symptoms and Endoscopic Abnormalities Despite Resolution of Eosinophilia in Pediatric Eosinophilic Esophagitis. Am J Gastroenterol 2020; 115:224-233. [PMID: 31913192 PMCID: PMC7491279 DOI: 10.14309/ajg.0000000000000474] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Mast cells (MCs) are increased in eosinophilic esophagitis (EoE). Endoscopic abnormalities, symptoms, and epithelial changes can persist after treatment despite a reduction of esophageal eosinophilia. It is unknown whether this could be due to persistent MC infiltration. We aimed to determine whether patients with histologically inactive (HI) EoE (defined as <15 eosinophils per high-powered field) with persistent symptoms, endoscopic, or epithelial abnormalities after treatment have increased MCs. METHODS Secondary analysis of prospective data from 93 children with EoE undergoing post-treatment endoscopy between 2011 and 2015. Thirty-five non-EoE controls were included. Immunohistochemistry for tryptase, an MC marker, was performed on mid and distal esophageal biopsies. Total and degranulated intraepithelial MCs per high-powered field (MC/hpf) were quantified. Symptoms and endoscopic findings were recorded at time of endoscopy. MC/hpf were compared between HI-EoE and control, and among HI-EoE based on endoscopic and histologic findings, and symptoms. Nine clinical remission (CR) patients were identified, with absence of endoscopic abnormalities and symptoms. RESULTS MC/hpf were increased in HI-EoE compared with control (17 ± 11 vs 8 ± 6, P < 0.0). Patients with persistent endoscopic abnormalities had increased total (20 ± 12 vs 13 ± 10, P = 0.001) and degranulated (8 ± 6 vs 5 ± 4, P = 0.002) MC/hpf, with no difference in eosinophils. MC/hpf predicted furrowing (odds ratio = 1.06, P = 0.01) and rings (odds ratio = 1.05, P = 0.03) after controlling for treatment type, proton-pump inhibitor, eosinophils, and duration of therapy. Patients with persistent basal zone hyperplasia and dilated intercellular spaces had increased MC/hpf. Eosinophils were weakly correlated with MC/hpf in the mid (r = 0.30, P < 0.001) and distal (r = 0.29, P < 0.001) esophagus. Clinical remission patients had lower MC/hpf compared with patients with persistent symptoms and/or endoscopic abnormalities. DISCUSSION MC density is increased in patients with endoscopic and epithelial abnormalities, as well as a few symptoms, despite resolution of esophageal eosinophilia after treatment. This association warrants further study to ascertain whether MCs play an eosinophil independent role in EoE.
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Godwin B, Wilkins B, Muir AB. EoE disease monitoring: Where we are and where we are going. Ann Allergy Asthma Immunol 2019; 124:240-247. [PMID: 31830586 DOI: 10.1016/j.anai.2019.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 11/24/2019] [Accepted: 12/02/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To review literature on various methods of monitoring and characterizing eosinophilic esophagitis (EoE) with respect to their validity as well as risk to the patient. DATA SOURCES A literature search was performed using PubMed with keyword combinations of EoE and monitoring as well as various techniques used for monitoring, including but not limited to, symptoms, endoscopy, histology, fluoroscopy, FLIP, noninvasive monitoring, and biomarkers. STUDY SELECTIONS Case-control studies, observational studies, peer-reviewed reviews and guidelines, and systematic reviews were selected, reviewed, and summarized here. RESULTS A wealth of research regarding monitoring of EoE is currently being undertaken and published. Our review highlights those that have been validated and are currently being used, as well as some that show promise for future monitoring and disease characterization. CONCLUSION Eosinophilic esophagitis is a chronic condition that at this time requires upper endoscopy as the gold standard of diagnosis and monitoring. There is a great need in the field for less invasive monitoring tools and better ways to characterize disease to allow for personalization of therapies.
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Affiliation(s)
- Bridget Godwin
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Wilkins
- Department of Pathology and Laboratory Medicine, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Aceves S, Collins MH, Rothenberg ME, Furuta GT, Gonsalves N. Advancing patient care through the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR). J Allergy Clin Immunol 2019; 145:28-37. [PMID: 31758958 PMCID: PMC6981250 DOI: 10.1016/j.jaci.2019.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/19/2022]
Abstract
Recent advances in rare disease research are accelerated by the work of consortia that have been supported by the National Institutes of Health. Development of such consortia rely on multidisciplinary relationships and engagement with patient advocacy groups, as well as the National Institutes of Health and industry and academic partners. In this rostrum we present the development of such a process that focuses on eosinophilic gastrointestinal diseases. Principal investigators, patient advocacy groups, research assistants, and trainees work together to perform natural history studies that promote clinical trial readiness tools, conduct clinical trials, train a new generation of investigators, and perform innovative pilot studies.
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Affiliation(s)
- Seema Aceves
- Division of Allergy Immunology, University of California, San Diego, and Rady Children's Hospital, San Diego, La Jolla, Calif
| | - Margaret H Collins
- Division of Pathology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colo.
| | - Nirmala Gonsalves
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Ill
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