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Updated: Apr 26, 2026
Intravital Imaging of Intraepithelial Lymphocytes in Murine Small Intestine
Published on: June 24, 2019
Optimal strategies to identify aberrant intra-epithelial lymphocytes in refractory coeliac disease
R L J van Wanrooij1, D M J Müller, E A Neefjes-Borst
1Department of Gastroenterology and Hepatology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands, rl.vanwanrooij@vumc.nl.
Insights
Flow cytometry is the most reliable method for diagnosing refractory celiac disease (RCD). Immunohistochemistry and TCR-gamma tests miss half of RCD patients with moderately increased aberrant intra-epithelial lymphocytes.
Area of Science:
- Gastroenterology
- Immunology
- Oncology
Background:
- Refractory celiac disease (RCD) patients are at risk for enteropathy-associated T-cell lymphoma (EATL).
- Flow cytometry of intra-epithelial lymphocytes (IEL) with aberrant phenotype is the gold standard for RCD diagnosis.
- Immunohistochemistry (IHC) and T-cell receptor (TCR) rearrangement studies are common but less sensitive/specific.
Purpose of the Study:
- To compare the diagnostic accuracy of IHC and TCR-gamma analysis against flow cytometry for RCD.
- To evaluate the effectiveness of different methods in identifying RCD patients at risk for EATL.
Main Methods:
- Duodenal biopsies from control and RCD patients were analyzed.
- Patients were categorized by aberrant IEL percentages (20-50% and >50%) via flow cytometry.
- IHC and TCR-gamma rearrangement studies were performed, with slides scored by three pathologists.
Main Results:
- IHC and TCR-gamma showed 100% and 71% sensitivity for high aberrant IELs (>50%), respectively.
- However, IHC and TCR missed 50% and 57% of RCD patients with moderate aberrant IELs (25-50%).
- IHC exhibited significant inter-observer variability (Kappa coefficients 0.28-0.85).
Conclusions:
- IHC and TCR-gamma are sensitive for high aberrant IEL counts but miss RCD patients with moderate increases.
- IHC demonstrates high inter-observer variability, impacting diagnostic reliability.
- Flow cytometry is recommended for diagnosing patients suspected of RCD.
Introduction:
Different strategies have been developed to identify those refractory celiac disease (RCD) patients who are at risk to develop an enteropathy associated T-cell lymphoma (EATL). Flow cytometric analysis of intra-epithelial lymphocytes (IEL) with an aberrant phenotype is considered the golden standard but is not widely available. Immunohistochemistry (IHC) and T-cell receptor (TCR) rearrangement studies are commonly available but may lack sensitivity and specificity. Here, we compared the three different methods in the workup of patients suspected for RCD.
Methods:
Duodenal biopsies from control patient (n = 5), RCD patients with moderately increased aberrant IEL populations (20-50 %: n = 14), and RCD patients with high numbers of aberrant IEL (>50 %: n = 5) as determined by flow cytometry were analysed by IHC and TCR-γ chain rearrangement analysis. Three pathologists scored the slides independently.
Results:
Sensitivity of IHC and TCR-γ rearrangement analysis in RCD patients with high numbers of aberrant IELs was 100 and 71 %, respectively. RCD patients with aberrant cells between 25 and 50 % however, were missed by IHC and TCR in 50 and 57 % of cases, respectively. In addition, inter-rater reliability analysis of the IHC scoring revealed coder-pair Kappa coefficients between 0.28 and 0.85.
Conclusion:
Immunohistochemistry and to a lesser extent TCR-γ clonality analysis are sensitive in identifying patients with high numbers of aberrant IEL populations, yet miss half of RCD patients with moderately increased numbers. In addition, IHC has a high inter-observer variability. Therefore, patients suspected for RCD should undergo flow cytometric analysis of the duodenum.
