Diagnosis Of Enteropathy-associated T-cell Lymphoma Research Articles

Diagnosis of enteropathy-associated T-cell lymphoma (EATL) on peripheral blood: A pleiomorphic morphology and an unusual immunophenotype.

A 72-year-old woman known for coeliac disease for several years presented with abdominal pain and deterioration of the general status. Blood biochemistry revealed a significant tumor lysis syndrome which led to her transfer to the intensive care unit. Her full blood count showed anemia (haemoglobin concentration 107 g/L), and leucocytosis (WBC 156 × 109/L). Microscopic examination of the blood film showed 86% pleiomorphic lymphomatous cells (all images May–Grünwald–Giemsa, ×100 objective) which may have been underestimated because of many apoptotic or smudge cells. These cells formed a continuum from small elements with high nucleocytoplasmic ratio, irregular nucleus, decondensed chromatin, and hyperbasophilic cytoplasm to very large elements with low nucleocytoplasmic ratio, irregular nucleus, more immature chromatin with indistinct nucleoli, and abundant cytoplasm with similar hyperbasophilic appearance and sometimes small vacuoles. Flow cytometry immunophenotyping showed an atypical profile with a very strong CD45, membrane CD3m− but cytoplasmic CD3c+, CD2−, CD5−, CD7+/−, CD4−, CD8−, TCRαβ−, TCRγδ−, CD56−, CD103−, and CD30+. The complex and monosomal karyotype showed, among many abnormalities, deletion of the long arm of chromosome 16 between bands 16q11 and 16q13 as described in the literature. Next-generation sequencing showed TET2 and EP300 mutations of undetermined significance (VAF = 13.72% and 7.72%, respectively). Duodenal and stomach biopsy revealed slightly dystrophic mucosa with mild atrophy and a site of high-grade intestinal T-cell lymphoma infiltration. Tumor cells consisted of medium to large pleomorphic cells with prominent nucleoli. They were strongly CD3+ and negative for other T cell markers including TCR expression. They expressed cytotoxic markers (TIA1 and perforin), and some large cells were positive for CD30. The Ki67 index was around 95%. Diagnosis of enteropathy-associated T-cell lymphoma (EATL) was therefore confirmed. Despite all the care provided by the medical unit, the patient passed away 4 days later. The diagnosis of EATL is a challenging situation due to its rarity. Although the circulating form is even rarer, knowledge of these unusual morphological and immunophenotypic features can speed up diagnosis by directing the clinician to a histological examination of the digestive tract, and enable treatment to be initiated as early as possible. It is therefore important for biologists to know the association of adult-onset coeliac disease with these atypical circulating cells, both morphologically and immunophenotypically. The absence of CD3m and most T-lineage markers on lymphoma cells should lead to a search for CD3c and additional markers, such as CD30 in this case. Ousset, Vergez, and Canali wrote the paper. Ousset and Vergez performed the blood smear examination. Vergez and Canali performed flow cytometric studies. Canali took the pictures. Laurent performed histological and molecular studies. Oberic followed the patient. All authors contributed to the final manuscript. This study was funded by Centre Hospitalier Universitaire de Toulouse. The authors have no conflict of interest. This manuscript respects the ethic policy of CHU Toulouse for the treatment of human research participants. This manuscript respects the ethic policy of CHU Toulouse for the treatment of human research participants. The authors did not obtain written informed consent from the patient but the patient did not object to his data being used for research purposes (as required by ethic policy of CHU Toulouse). Written permission for reproduction from the copyright owners will be provided if the submission is accepted. Data sharing does not apply to this article as no new data were created or analyzed in this study.

Diffuse intestinal ulcerations: Diagnostic challenge in a patient with complicated celiac disease

A 48‐year‐old female patient presented with longstanding unrecognized celiac disease (CD), a family history of CD, and a short duration of alarming symptoms. The diagnostic evaluation revealed the concomitant presence of small and large bowel ulcers raised a dilemma about differential diagnosis in her case. Pathologic examination of tissue specimens from the jejunal ulcer led to the diagnosis of enteropathy‐associated T‐cell lymphoma. In recent years, the availability of modern cross‐sectional imaging and endoscopy modalities has dramatically improved the detection and characterization of small bowel lesions. Characterization of small bowel ulcers by endoscopy and radiology imaging in a patient with suspected complicated CD (CCD) needs to be made in conjunction with all clinical factors, as there is a wide overlap of the possible etiologic factors. Enteropathy‐associated T‐cell lymphoma is a highly aggressive T‐cell lymphoma with a poor prognosis, since early diagnosis and appropriate treatment may be delayed due to nonspecific clinical and endoscopic presentation. Therefore, it is crucial to timely recognize patients with suspected CCD and properly navigate diagnostic imaging tools, acquire adequate biopsy, and perform immunophenotyping to set early diagnosis in patients with diffuse intestinal ulcers and CD.

A Case of Enteropathy Associated T-Cell Lymphoma (EATL) with Aberrant Phenotype, CD8+, CD56+: From Diagnosis to Death

Abstract Introduction/Objective Enteropathy Associated T-Cell Lymphoma (EATL) is a rare and aggressive subtype of primary intestinal T cell lymphoma which occurs in patients with Celiac Disease (CD), most prevalent in the western world with an incidence rate of 0.22-1.9 cases per 100,000. The classic immophenotype of these neoplastic intestinal T cells show loss of CD8 and CD56. The adherence to gluten-free diet, markedly decreases the incidence of this complication. Methods The patient’s previous and current biopsies, autopsy and EMR were reviewed. The patient is 66-year female that was diagnosed with Celiac Disease in 2003 after duodenal biopsy showed features suggestive of CD with positive anti-endomysial IgA antibody serology. She presents currently with burning abdominal pain, with subsequent CT scan showing a mass in the small bowel with mid gut rotation and lesions in the lungs, liver and bladder. Endoscopy showed multiple lesions extending from the hypopharynx to the large bowel, which on biopsy showed CD3+ lymphocytes expanding the lamina propria and infiltrating the crypt epithelium. Given the patient’s clinical history a diagnosis of EATL was made. The patient passed 5 days after diagnosis due to small bowel perforation. Results The initial duodenal biopsy showed villous blunting and increased intraepithelial lymphocytes. The biopsies of the gastrointestinal lesions show abnormal infiltrate of pleomorphic, intermediate in size lymphocytes with round to irregular and occasionally cleaved nuclei with pale to clear cytoplasm. These cells infiltrate the crypt epithelium. The immophenotype of these neoplastic cells are positive for CD3, CD7, CD8, CD56, TIA-1 and BF1, while negative for CD4, CD5 and CD30. T cell clonality was also positive. In addition to the above lesions, autopsy revealed involvement of an area of small bowel perforation with full-thickness mucosal wall involvement by the neoplastic cells. In addition, there is widely dissemenated disease involving the lung, liver, bone marrow, spleen, mesenteric lymph nodes, omentum, bladder, ovaries and myometrium (first report of uterine involvement). Conclusion CD8 positive EATL may occur in 19-30% of cases, and increases up to 50% in refractory CD. The differential diagnosis of MEITL, which is typically CD8 positive, is important and most be distinguished on the basis of clinical setting in the presence of Celiac Disease.

Analysis of clinicopathological features of 21 patients with enteropathy-associated T-cell lymphoma

Objective To investigate the clinicopathological and prognosis features of enteropathy-associated T-cell lymphoma (EATL). Methods 21 cases of EATL, 6 cases of peripheral T-cell lymphoma (PTCL) and 11 cases of natural-killer/T-cell lymphoma (NKTCL) were collected from January 2008 to May 2015. The immunophenotype of the tumor cell was tested by EnVision and as well as EBV-EBER for EB virus. Some patients were performed with follow-up data. Results 21 EATL patients included 14 males, 7 females and the middle age was 55 years old (40-79 years old). 15 patients affected the small bowel, 4 cases affected colon, 2 cases affected more than one site. 18 cases were mono-morpholohic EATL while 3 cases were classical EATL. The expression rates of neoplastic cells for CD3e, CD4, CD8, CD56, Granzyme B, TIA-1 were 95.24 % (20/21), 20.00 % (3/15), 73.68 % (14/19), 85.71 % (18/21), 64.71 % (11/17), 88.89 % (16/18) respectively. The expression of EBER in EATL patients (0, 0/21) was obviously lower than that in NKTCL patients (100 %, 11/11). 17 EATL patients had follow-up data, and the middle survival time was 15 months. No different prognosis was found in the three kinds of T-NHL (P = 0.697). Conclusions EATL usually occurs in elder male and jejunum. The diagnosis of EATL needs a lot of information, including clinical history, endoscopy, histomorphology, immunophenotype and EBV-EBER result. EATL has low mobidity and high malignancy, it still lacks impactful therapeutic regimen. Key words: Enteropathy-associated T-cell lymphoma; Pathology, clinical; Immunophenotype; Natural-killer/T-cell lymphoma

A case of enteropathy-associated T-cell lymphoma: diagnosis by flow cytometric immunophenotyping and genome analysis using ascitic fluid

Enteropathy-associated T-cell lymphoma (ETCL) is a primary extranodal T-cell lymphoma arising in the gastrointestinal tract, and is known as a rare and highly aggressive disease with a poor prognosis. The diagnosis of ETCL is usually established by histological examination using resected tumors or biopsy specimens during endoscopic studies. If tumor specimens for histopathological investigation are not available, then such a case might be difficult to accurately diagnose. We report here a case of ETCL which was diagnosed by cytopathology and flow cytometric immunophenotyping using paracentesis fluid without tumor specimens. Immunophenotyping by flow cytometry (FCM) of the ascitic fluid (AF) was invaluable in the final diagnosis of ETCL. Moreover, genetic alterations in the current case were also demonstrated. We emphasize the usefulness of effusion cytology for the expeditious diagnosis of ETCL. In particular, even in cases without tumor specimens, immunophenotyping by FCM using AF can play an important role in the diagnosis of ETCL, and simultaneous genome analysis may be useful to elucidate the biological characteristics of ETCL.

Enteropathy Associated T-Cell Lymphoma in a Young Patient with No Prior History of Celiac Disease

Purpose: Enteropathy associated T cell lymphoma (EATL) is a malignancy of the small intestine typically affecting the jejunum. It is a rare form of high grade non-Hodgkin lymphoma arising from T cells in the intra-epithelial mucosa of the small bowel with an annual incidence of 0.5-1 per million people in Western countries. Atypical cell lines arise as a consequence of longstanding celiac disease in genetically susceptible individuals. EATL presents commonly in the 3rd or 4th decade of life with a peak incidence in the 6th decade of life. Presenting symptoms typically include abdominal pain, malaise, anorexia, weight loss, and diarrhea. Approximately 50% of patients require exploratory laparotomy for complications of perforation, hemorrhage, or obstruction. A 27-year-old female presents with intermittent epigastric abdominal pain, nausea, vomiting, diarrhea, and weakness. Her past medical history was notable for sickle cell trait and iron deficiency anemia. Initial CT imaging revealed circumferential duodenal thickening. An initial endoscopy with mucosal biopsy revealed only nonspecific inflammatory changes. She was started on a proton pump inhibitor. Serologic workup for celiac disease was negative. Serologic testing for HTLV-1 was also negative. A repeat EGD performed 2 months later due to persistent symptoms showed diffuse ulceration starting in the second portion of the duodenum with mild circumferential narrowing. Biopsies were consistent with EATL. One month later she presented with peritonitis and suspected small bowel perforation requiring small bowel resection. Surgical specimens confirmed EATL. Her postoperative course was unremarkable until several days after initiating chemotherapy. She developed septic shock and hypoxemic respiratory failure requiring intubation. Her abdomen became increasingly distended. After a prolonged course in the ICU, the patient ultimately died. The suspicion of EATL warrants an extensive work-up including endoscopy, CT/PET, and capsule endoscopy. If an initial biopsy is negative, the patient should proceed with full thickness biopsy. If the clinical suspicion remains high, small bowel resection for pathologic examination should be considered. The diagnosis of EATL is typically ominous. The 5 year survival rate is 10-20%, mostly due to patients having advanced disease and severe malnutrition at the time of diagnosis. Treatment consists of chemotherapy (usually anthracyline based) and possibly hematopoietic stem cell transplant. Surgery is indicated only for complications of therapy such as obstruction or perforation. As EATL is a histologically high grade lymphoma, early diagnosis and treatment is crucial to overall survival.

Sequential Evaluation of Outcome in Enteropathy Associated T Cell Lymphoma Comparing Standard Therapeutic Approaches – Surgery or CHOP-Like Chemotherapy with a New High Dose Ifosfamide/Methotrexate and Autologous Stem Cell Transplant Regimen: A Prospective Study of Scotland and Newcastle Lymphoma Group

Enteropathy associated T-cell lymphoma (EATL) is a rare disease with dismal prognosis. At present there are no standardised diagnostic or treatment protocols. The SNLG collected 5yrs of prospective data which uniquely enables us to describe the disease in a population-based setting. Additionally, we introduce results from a novel approach with aggressive chemotherapy (CT) and autologous stem cell transplantation (ASCT). From 1994 – 1998 all pts diagnosed with lymphoma in Scotland and the Northern region of England were prospectively registered. Pts with a diagnosis of EATL were evaluated for clinical features, treatment and outcome. The novel regimen was piloted from 1997 for new pts eligible for intensive treatment. This therapy delivers one cycle of CHOP, followed by 3 courses of IVE (ifosfamide, etoposide, epirubicin), alternating with intermediate dose methotrexate (MTX). Stem cells are harvested after IVE and complete remissions (CR) are consolidated with myeloablative ASCT. During the study period, 4542 pts were diagnosed with non-Hodgkin-lymphoma and of these 54 pts (1.2%) had features of EATL. In the population of 7.6 million, this equates to an overall incidence of 0.14/100,000 per yr. The median age at diagnosis was 57 yrs, 61% of pts were male. 40% of pts presented with Lugano clinical stage (CS) IIE (serosal penetration involving adjacent organs and tissues), 17% CS IV (disseminated extranodal involvement or supradiaphragmatic nodal involvement), 15% CS I (confined to GI-tract), 15% CS II1 (local abdominal involvement) and 12% CS II2 (distant abdominal involvement). Two pts had bone marrow involvement. Diagnosis of EATL was made at laparotomy in 91% of pts. Tumour was arising from the small bowel in 96% of pts; in one case involved the duodenum and in another the iliocaecal region. Pain was the most common presenting symptom (81%), followed by weight loss, visceral perforation, nausea/vomiting, bowel upset and subacute obstruction. Symptoms were present less than a month before diagnosis in 33% of pts and between 1–6 months in 55%. 92% of pts had co-existing coeliac disease (diagnosed prior to diagnosis of EATL in 35% of pts and co-incidently in 58%). 30 pts (56%) were treated with surgery and CT, 19 pts (35%) with surgery alone and 5 pts (9%) with CT alone. Of those pts treated with CT the majority (31/35) received CHOP-like regimens. There were no statistically significant differences between treatment groups with the exception of higher number of elderly pts treated with surgery alone. 44 pts died, mostly due to lymphoma or complications. For all pts, median progression free survival (PFS) was 3.4 months and overall survival (OS) 7 months. 5yr PFS and OS for pts treated with CHOP-like CT was 20% and 22%, respectively and no pts treated with surgery alone survived. 18 pts were subsequently treated with the new regimen. The median age was 52.5 yrs, 67% of pts were male, 39% presented with Lugano CS II1, 22% CS I, 22% CS IV, 11% CS IIE, 6% CS II2+E. The bone marrow was involved in one pt. Site of disease was small bowel in 83% of pts and two patients had involvement of stomach and duodenum and one of small bowel and colon. In all except one pt the diagnosis was made at laparotomy. 12 pts (67%) completed all planned treatment, 3 pts had progressing disease during treatment, two other did not received ASCT due to poor general condition and one pt declined further treatment. Most common severe toxicities were pancytopenia, infection, nausea/vomiting and obstruction/perforation. Treatment results were compared with historical control group treated with CHOP-like CT. There was no difference between the groups according to age, sex and features at presentation. Compared to pts treated with CHOP-like CT, those in the IVE/MTX group had improved CR at final evaluation (42% vs 72%), 5yr PFS (20% vs 56%; p=0.008) and 5yr OS (22% vs 67%; p=0.001). Additionally, in the IVE/MTX group fewer patients died than in the CHOP-like CT group (33% vs 81%; p=0.002). There were no treatment related deaths. In a population-based study of EATL we describe the natural history of the disease in the context of current treatments. We propose a new protocol with significantly improved outcome and acceptable toxicities. In conclusion, pts with EATL should be treated with systemic CT and where feasible an aggressive treatment like IVE/MTX – ASCT. We recommend patients should be entered into national studies such as (NCRI 1418) to evaluate this approach further.

Isolation of human small bowel intraepithelial lymphocytes by Annexin V-coated magnetic beads

Human intestinal intraepithelial lymphocytes (IEL) are important effector cells of the mucosal immune system and their study is hampered by the difficulty of their isolation. The molecular study of enriched samples of IEL is mandatory in the diagnosis of enteropathy-associated T-cell lymphoma and refractory celiac sprue. In order to isolate human small bowel IEL, we took advantage of the stress that intestinal epithelial cells (IEC) suffer during the conventional initial steps of IEL isolation, which induces their apoptosis but not that of IEL. After cell individualization by dithiothreitol and ethylenediamine tetraacetic acid, two-thirds of human IEC can be stained with Annexin-V due to their surface exposure of phosphatidyl serine, a sign of apoptosis. This percentage increases to 95% after performing a density gradient to enrich for IEL. This allows for the use of Annexin-V-coated magnetic beads, originally designed for the removal of dead cells from cell cultures, to obtain >95% pure, 99% viable and untouched IEL after two rounds of depletion. This simple procedure has proven useful for the isolation of human IEL for functional and molecular studies and can conceivably facilitate the diagnosis of intestinal lymphoid malignancies that rely upon the study of pure IEL preparations.