Sensitivities of Biopsy Sites in the Endoscopic Evaluation of Graft-Versus-Host Disease: Retrospective Review from a Tertiary Center

Histological diagnosis of acute graft-versus-host disease in different sites of the upper gastrointestinal tract with correlation to endoscopic findings

Graft-versus-host disease (GvHD) involving the intestine is a threat to patients after allogeneic hematopoietic stem cell transplantation (alloHSCT). We evaluated biopsies from different sites of the upper gastrointestinal tract (GIT) of 97 patients after alloHSCT. Forty-six patients with clinical symptoms consistent with upper GI GvHD revealed histological features of GvHD in the esophagus, stomach, and/or duodenum. Biopsies of the duodenum and esophagus were significantly more sensitive for signs of GvHD than those of the gastric antrum or corpus. The histological features of GvHD were significantly correlated with the endoscopic findings of ulcers, erosion, atrophy, and white plaques; however, the sensitivity and specificity of the latter were low. In univariate analysis, overall mortality was significantly associated with histological GvHD signs in all four sites. Nonrelapse mortality was associated with histologic GvHD features in the antrum only. Regarding GvHD diagnosis, biopsies of the upper gastrointestinal tract should include the duodenum and/or esophagus.

An investigation of the diagnostic, predictive, and prognostic impacts of three colonic biopsy grading systems for acute graft versus host disease

Acute graft versus host disease (aGvHD) is an important, life-threatening complication after allogeneic hematopoietic stem cell transplantation (alloHSCT). To investigate the value of multiple simultaneous colon biopsies in improving diagnostic accuracy in patients with aGvHD, we retrospectively analyzed 157 patients after alloHSCT. The biopsies were evaluated individually using three established histological grading systems (Lerner, Sale, and Melson). The maximum, minimum, median, and mean histological aGvHD grades were calculated for each patient, and the results were correlated with the Glucksberg grade of clinical manifestation of GvHD, steroid therapy status, and outcome. We found that multiple colon biopsies enhanced diagnostic sensitivity. Moreover, higher histological grades correlated with steroid therapy initiation and refractoriness; the latter particularly occurred when advanced damage was present in all samples and healthy colon mucosa was reduced or absent. On multivariate analysis, the minimal Lerner and Glucksberg grades for intestinal aGvHD were significantly associated with steroid treatment failure. Ninety-nine patients died. The median survival was 285 days after the biopsies were taken. Fifteen patients died from relapse of their underling disorder and 84 from other causes, mostly infection (53 patients) and GvHD (14 patients). Multivariate analysis revealed a significant association between none-relapse mortality and the mean Lerner grade, minimum Melson grade, Glucksberg organ stage, and platelet counts. Thus, we found the Lerner system to be superior to the other grading methods in most instances and histologic evaluation of multiple simultaneously obtained biopsies from the colon to result in a higher diagnostic yield, which helps plan systemic steroid treatment while predicting treatment response and outcome.

Esophagitis in patients without gastroesophageal reflux disease or eosinophilic esophagitis: diagnostic considerations

PURPOSE OF REVIEW

A multitude of inflammatory diseases other than gastroesophageal reflux disease (GERD) and eosinophilic esophagitis can affect the esophagus. Despite the deceptively simple organization of squamous mucosa and its limited number of inflammatory responses, a wide array of histologic patterns can be seen in inflammatory disorders involving the esophagus. Each such histologic pattern is associated with a limited number of underlying conditions, and the clinician can use this information to narrow the differential diagnosis. The purpose of this review is to review and discuss the pathologic diagnosis of esophagitis caused by conditions other than GERD or eosinophilic esophagitis, with an emphasis on recent developments in the field.

RECENT FINDINGS

Recent studies suggest that lymphocytic esophagitis may be a histologic manifestation of esophageal motility disorders. Immunophenotypic features of infiltrating lymphocytes may be helpful in this scenario. immunoglobulin G4-related disease has been implicated as a cause of esophageal inflammation with ulceration, strictures, and mass-forming fibrosis, whereas epidermoid metaplasia has been linked molecularly to the squamous cell neoplasia pathway.

SUMMARY

Improved knowledge and appreciation of the pathology of esophageal inflammation are needed to better understand the pathogenesis of various types of esophagitis, and to inform new approaches to the therapy and management of inflammatory esophageal diseases.

Site specific diagnostic yield of endoscopic biopsies in Gastrointestinal Graft-versus-Host Disease: A tertiary care Center experience

BACKGROUND

Gastrointestinal (GI) graft versus host disease (GVHD) occurs in up to 40% of patients undergoing allogenic hematopoietic stem cell transplantation (HSCT). However, the optimal endoscopic approach is still unclear and the area of the GI tract with the highest diagnostic yield is still a topic of debate.

OBJECTIVE

We compared the diagnostic yield of different anatomic site biopsies in the diagnosis of GI GVHD and assessed the correlation of endoscopic findings with histopathology.

METHODS

All cases of biopsy proven GI GVHD were obtained from pathology database AUBMC between 1/1/2005 and 31/8/2017. We retrospectively analyzed the demographical, clinical and endoscopic data.

RESULTS

Nineteen patients were diagnosed with GI GVHD over 17.6 years. The most common presenting symptom was severe diarrhea (18 patients, 94.7%). Combining upper endoscopy and sigmoidoscopy with biopsies had the highest diagnostic yield of 90% in diagnosing GI GVHD compared to 63.6%, 78.6% and 77.8% for upper endoscopy, sigmoidoscopy and colonoscopy respectively. In macroscopically normal mucosa, the recto-sigmoid and duodenal biopsies had the highest diagnostic yield (75%). As for the macroscopically abnormal mucosa, the highest yield was for the recto-sigmoid biopsies (100%) in lower endoscopy and duodenal biopsies in the upper endoscopy (60%).

CONCLUSION

In a patient suspected to have GI GVHD, the best endoscopic approach is the combination of upper endoscopy and flexible sigmoidoscopy with biopsies of normal as well as abnormal mucosa. It should be emphasized that normal mucosa be biopsied especially in the duodenum and recto-sigmoid for a better diagnostic yield.

Upper gastrointestinal acute graft-versus-host disease adds minimal prognostic value in isolation or with other graft-versus-host disease symptoms as currently diagnosed and treated

Upper gastrointestinal acute graft-versus-host disease is reported in approximately 30% of hematopoietic stem cell transplant recipients developing acute graft-versus-host disease. Currently classified as Grade II in consensus criteria, upper gastrointestinal acute graft-versus-host disease is often treated with systemic immunosuppression. We reviewed the Center for International Blood and Marrow Transplant Research database to assess the prognostic implications of upper gastrointestinal acute graft-versus-host disease in isolation or with other acute graft-versus-host disease manifestations. 8567 adult recipients of myeloablative allogeneic hematopoietic stem cell transplant receiving T-cell replete grafts for acute leukemia, chronic myeloid leukemia or myelodysplastic syndrome between 2000 and 2012 were analyzed. 51% of transplants were from unrelated donors. Reported upper gastrointestinal acute graft-versus-host disease incidence was 12.1%; 2.7% of recipients had isolated upper gastrointestinal acute graft-versus-host disease, of whom 95% received systemic steroids. Patients with isolated upper gastrointestinal involvement had similar survival, disease-free survival, transplant-related mortality, and relapse as patients with Grades 0, I, or II acute graft-versus-host disease. Unrelated donor recipients with isolated upper gastrointestinal acute graft-versus-host disease had less subsequent chronic graft-versus-host disease than those with Grades I or II disease (P=0.016 and P=0.0004, respectively). Upper gastrointestinal involvement added no significant prognostic information when present in addition to other manifestations of Grades I or II acute graft-versus-host disease. If upper gastrointestinal symptoms were reclassified as Grade 0 or I, 425 of 2083 patients (20.4%) with Grade II disease would be downgraded, potentially impacting the interpretation of clinical trial outcomes. Defining upper gastrointestinal acute graft-versus-host disease as a Grade II entity, as it is currently diagnosed and treated, is not strongly supported by this analysis. The general approach to diagnosis, treatment and grading of upper gastrointestinal symptoms and their impact on subsequent acute graft-versus-host disease therapy warrants reevaluation.

Gastrointestinal Biopsies for Evaluation of Acute Graft-Versus-Host Disease in Allogeneic Hematopoietic Stem Cell Transplant Patients

Graft-versus-host disease (GVHD) is the major complication post hematopoeitic stem cell transplantation (HSCT) causing significant morbidity and mortality. Colonic biopsies were performed in 25 post HSCT patients presenting the diarrhea for diagnosis of acute graft versus host disease (A-GVHD). The present study was undertaken to evaluate and illustrate histomorphological features of A-GVHD in GI biopsies and to grade them. Histopathological features of gastrointestinal biopsies from 25 allogeneic HSCT patients having clinical suspicion of A-GVHD were evaluated and compared with colonic biopsies from negative controls. A-GVHD was observed in 17 cases, CMV colitis was present in 3 cases and one case had herpes simplex infection diagnosed in conjunction with serological findings. A-GVHD was graded as grade 1 and 2 in 10 cases and grade 3 and 4 in 7 cases. Apoptosis of crypt epithelial cells was the cardinal feature for diagnosis. Grade 1 and grade 2 A-GVHD cases showed crypt apoptosis in all cases as well as pericryptal apoptosis in lamina propria in many cases. Occasional crypt loss was seen in grade 2 GVHD. Inflammatory infiltrate was composed of lymphocytes and plasma cells. Neutrophils were inconspicuous. Grade 3 and grade 4 A-GVHD cases showed contiguous areas of multiple crypt loss and ulceration with inflammatory infiltrate predominantly composed of lymphocytes and plasma cells, but neutrophils were more prominent than in grade 1 and 2 A-GVHD. Apoptosis of crypt epithelial cells was present in all grade 3 &4 cases except one case. CMV cases were diagnosed by CMV inclusions and IHC stain. Several factors including drug-induced side effects and infections can cause difficulty in histologic interpretation of gastrointestinal biopsies for GVHD. Proper histomorphological interpretation of intestinal A-GVHD is critical for clinical management. A-GVHD is treated with immunosuppression which may worsen infective condition, if present.

Choice of Endoscopic Procedure in Children With Clinically Suspected Gastrointestinal Graft-versus-host Disease

OBJECTIVES

Gastrointestinal graft-versus-host disease (GI-GVHD) is a potentially life-threatening complication after hematopoietic stem cell transplantation. Symptoms indicating GI-GVHD motivates endoscopy with biopsy sampling and histopathological confirmation. Optimal extent of endoscopy in children is, however, presently unknown. Therefore, we aimed to evaluate whether biopsies from the rectosigmoid area versus the rest of the colon/ileocolon with or without biopsies from simultaneous upper endoscopy, were equally reliable for detection of GI-GVHD and relevant differential diagnoses.

METHODS

Retrospective multicenter study based on histopathological re-evaluation of biopsies and hospital record data, collected from children with suspected GI-GVHD.

RESULTS

Forty-four children with 51 endoscopic occasions (81 procedures) were included. Thirty-nine of 51 (76.5%) were diagnosed as GI-GVHD, 14 (27.4%) received a differential diagnosis and 7 (13.7%) had normal histology findings. Comorbidity, that is, simultaneous detection of a differential diagnosis and GI-GVHD, was observed in 9 (23.1%) cases. Cytomegalovirus infection was the most frequent differential diagnosis, 6 of 7 were detected in biopsies from rectosigmoid and esophagogastroduodenal areas. Sensitivity for detection of GI-GVHD in biopsies collected from rectosigmoid-ileocolonic-, rectosigmoid-, or esophagogastroduodenal areas were 97.4%, 84.6%, 83.3%, respectively, and 97.4% when the latter 2 were merged. The difference, nondetected GI-GVHD in the rectosigmoid area versus detected elsewhere in the GI tract, was statistically significant (P = 0.03).

CONCLUSIONS

Biopsies collected from the rectosigmoid area solely were not optimal for detection of pediatric GI-GVHD. When biopsy sampling from rectosigmoid and upper GI tract areas was combined, the sensitivity for GI-GVHD was, however, equally high as for ileocolonoscopy or full upper and lower endoscopy.

Cecum ulcer is a reliable endoscopic finding in cytomegalovirus colitis concomitant with graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

Although graft-versus-host disease (GVHD) is the major complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT), cytomegalovirus (CMV) reactivation also occurs in patients after allo-HSCT and these conditions often clinically overlap. The aim of this study was to determine reliable endoscopic findings of CMV colitis in patients with gastrointestinal graft-versus-host-disease (GI-GVHD). Patients after allo-HSCT who were histologically confirmed to have GI-GVHD with or without CMV colitis and patients with an immunosuppressive condition were retrospectively analyzed. We divided the patients into three groups: GI-GVHD with CMV colitis (group A), GI-GVHD without CMV colitis (group B), and CMV colitis without undergoing allo-HSCT (group C). From medical records, the involved colorectal areas and endoscopic findings according to the groups were compared. A total of 70 patients were divided into three groups (group A: n = 19, group B: n = 28, group C: n = 23). Mucosal injuries in groups A and C frequently occurred in the cecum including ileocecal valves. On the other hand, there were no abnormal lesions on ileocecal valves in group B. Furthermore, ulcer lesions were more frequently observed in groups A and C than in group B (p < 0.001). The sensitivity and specificity of mucosal injuries in the cecum for prediction of CMV colitis were 89.5 and 76.5%, respectively, and mucosal injuries in the cecum were more reliable findings than CMV antigenemia. Ulcer lesions in the cecum are reliable endoscopic findings for CMV colitis in patients with GI-GVHD after allo-HSCT.

Use of the National Institutes of Health Consensus Guidelines Improves the Diagnostic Sensitivity of Gastrointestinal Graft-Versus-Host Disease

CONTEXT

- Graft-versus-host disease of the gastrointestinal tract is a common complication of hematopoietic stem cell transplant associated with significant morbidity and mortality. Accurate diagnosis can be difficult and is a truly clinicopathologic endeavor.

OBJECTIVES

- To assess the diagnostic sensitivity of gastrointestinal graft-versus-host disease using the 2015 National Institutes of Health (NIH) histology consensus guidelines and to analyze histologic findings that support the guidelines.

DESIGN

- Patients with allogeneic hematopoietic stem cell transplants were identified via a retrospective search of our electronic medical records from January 1, 2005, to January 1, 2011. Endoscopies with available histology were reviewed by 2 pathologists using the 2015 NIH guidelines. The clinical diagnosis was used as the gold standard. A nontransplant set of endoscopic biopsies was used as a control.

RESULTS

- Of the 250 total endoscopies, 217 (87%) had a clinical diagnosis of gastrointestinal graft-versus-host disease. Use of the NIH consensus guidelines showed a sensitivity of 86% and a specificity of 65%. Thirty-seven of 58 (64%) cases with an initial false-negative histopathologic diagnosis were diagnosed as graft-versus-host disease on our review.

CONCLUSIONS

- Use of the NIH histology consensus guidelines results in a high sensitivity and specificity, thereby decreasing false-negatives. Additionally, use of the NIH guidelines aids in creating uniformity and diagnostic clarity. Correlation with clinical and laboratory findings is critical in evaluating the differential diagnosis and to avoid false-positives. As expected, increased apoptosis with decreased inflammation was associated with a pathologic diagnosis of graft-versus-host disease and supports the NIH guidelines.

Effective and less invasive diagnostic strategy for gastrointestinal GVHD

BACKGROUND AND STUDY AIMS

 Rectosigmoidoscopy with biopsy has been regarded to be a useful procedure to diagnose gastrointestinal graft-versus-host disease (GVHD). However, little is known about the specific colonoscopic features of gastrointestinal GVHD. In this study, we focused on the 4 unique colonoscopic findings - orange peel appearance, spotty redness, small mucosal sloughing, and diffuse mucosal defect - which are possible specific findings of gastrointestinal GVHD. We aimed to estimate the usefulness of these four unique colonoscopic findings in the rectosigmoid portion to diagnose gastrointestinal GVHD.

PATIENTS AND METHODS

 Seventy patients who were histologically diagnosed with gastrointestinal GVHD at our institute were retrospectively enrolled. Colonoscopic findings were reviewed, focusing on the four characteristic findings. The percentage of the positive cases for the characteristic findings was calculated. The final scoping portion and the number of cases showing any of the four characteristic findings in the rectosigmoid portion were also evaluated. The relationships between biopsy sites and the histological findings were also evaluated.

RESULTS

 Orange peel appearance was observed in 66 cases (94.3 %). Spotty redness was observed in 45 cases (64.3 %). Small mucosal sloughing was observed in 49 cases (70.0 %). Diffuse mucosal defect was observed in six cases (8.6 %). The number of cases that were concurrently positive for one, two, and three findings were 16 (20.8 %), 20 (26.0 %), and 34 (48.6 %), respectively. Fifty-eight cases (82.9 %) were investigated up to the rectosigmoid portion, and 12 (17.1 %) were investigated beyond the sigmoid colon. All of the cases showed at least 1 of the 4 characteristics in the rectosigmoid portion. The percentage of crypt apoptosis in the biopsy specimen from orange peel appearance, spotty redness, small mucosal sloughing, and diffuse mucosal defect were 87.5 %, 83.3 %, 87.2 %, and 88.9 %, respectively.

CONCLUSION

 Orange peel appearance, spotty redness, small mucosal sloughing, and diffuse mucosal defect are the characteristic colonoscopic findings useful for diagnosis of gastrointestinal GVHD. These findings are frequently observed in the rectosigmoid portion. The histological detection rates for crypt cell apoptosis from these findings are high. Identifying the four characteristic findings on rectosigmoidoscopy and taking biopsies from these areas could be essential for the diagnostic strategy for gastrointestinal GVHD.

Acute graft-versus-host disease of the gut: considerations for the gastroenterologist

Haematopoietic stem cell transplantation (HSCT) is central to the management of many haematological disorders. A frequent complication of HSCT is acute graft-versus-host disease (GVHD), a condition in which immune cells from the donor attack healthy recipient tissues. The gastrointestinal system is among the most common sites affected by acute GVHD, and severe manifestations of acute GVHD of the gut portends a poor prognosis in patients after HSCT. Acute GVHD of the gastrointestinal tract presents both diagnostic and therapeutic challenges. Although the clinical manifestations are nonspecific and overlap with those of infection and drug toxicity, diagnosis is ultimately based on clinical criteria. As reliable serum biomarkers have not yet been validated outside of clinical trials, endoscopic and histopathological evaluation continue to be utilized in diagnosis. Once a diagnosis of gastrointestinal acute GVHD is established, therapy with systemic corticosteroids is typically initiated, and non-responders can be treated with a wide range of second-line therapies. In addition to treating the underlying disease, the management of complications including profuse diarrhoea, severe malnutrition and gastrointestinal bleeding is paramount. In this Review, we discuss strategies for the diagnosis and management of acute GVHD of the gastrointestinal tract as they pertain to the practising gastroenterologist.

Upper Versus Lower Endoscopy in the Diagnosis of Graft-Versus-Host Disease

BACKGROUND AND AIM

The optimal endoscopic approach to patients with suspected gut graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation (HSCT) is uncertain. We aimed to assess the diagnostic yield of upper and lower endoscopies performed in patients post-HSCT.

METHODS

We identified a cohort post-HSCT with acute and chronic GVHD who underwent gastrointestinal endoscopies for GVHD diagnosis. Hospital charts were reviewed and results were stratified according to patients' symptoms.

RESULTS

From 1990 to 2013 433 HSCTs were performed. Fifty-six patients underwent 141 endoscopies, of which 117 were done to evaluate for GVHD or an alternative diagnosis. A total of 28/43 (65%) of the lower endoscopies and 41/74 (55%) of the upper endoscopies diagnosed GVHD or an alternative disease process on pathology. A total of 15/43 (35%) of lower endoscopies were flexible sigmoidoscopies, and 11/15 (73%) of these diagnosed GVHD or an alternative diagnosis. Upper endoscopy performed in patients with diarrhea as their only symptom diagnosed GVHD in 44% and an alternative diagnosis in 11%. In comparison, lower endoscopy in patients with only diarrhea diagnosed GVHD in 50%, and 18% offered an alternative diagnosis. Upper endoscopy provided a diagnosis of opportunistic viral and fungal infections of the upper gastrointestinal tract in 7 patients, while lower endoscopy diagnosed pseudomembranous colitis in 2.

CONCLUSIONS

Upper and lower endoscopy had a similar diagnostic yield in patients with known or suspected GVHD involving the gut, even for patients presenting only with diarrhea. Because of its ease and safety upper endoscopy is the preferred initial endoscopic approach in patients with suspected gut GVHD, however flexible sigmoidoscopy is a reasonable other option.

Graft-versus-Host Disease of the Gut: A Histologic Activity Grading System and Validation

The pathologic interpretation of gut biopsies in hematopoietic cell transplant recipients to assess graft-versus-host disease (GVHD) is well accepted and supplements clinical and endoscopic findings. However, the histologic activity grading of GVHD is controversial, with attempts to predict prognosis or response to treatment largely unsuccessful. GVHD is being diagnosed earlier in its course, raising the possibility that the pathologic grading system can be profitably modified. We developed a histologic activity grading system designed to replace the commonly used modified Lerner grading systems. Our system stratifies the low-level Lerner grade I category into 4 activity grade categories, based on the average frequency of apoptotic cells. The results are expressed as ordinal categories: GVHD of minimal, mild, moderate, severe histologic activity, or severe histologic activity with destruction (activity grades 1 to 5). In a retrospective study, we studied 87 consecutive cases with 201 post-transplantation specimens (median, 48 days; range, 18 to 1479 days) of stomach, duodenum, and colorectum, which had been activity graded at the time of the original diagnosis. Most of the biopsies diagnosed as GVHD were low grade-minimal (11%) or mild (71%) histologic activity. We hypothesized that the higher activity grades would be associated with more therapeutic intervention. The odds of increased therapy in the combined all-site specimens were increased as activity grade increased (odds ratio, 2.9 [95% confidence interval {CI}, 1.9 to 4.5]; P = < .0001). Thus, our grading system was validated. To investigate whether the activity grade was associated with therapy within the formerly undivided Lerner grade I category, the analysis was restricted to these 174 all-site specimens. The validation result was similar (odds ratio, 3.1 [95% CI, 1.3 to 7.2]; P = .009). This result interestingly suggests that there is useful information hidden in the Lerner grade I category, which could potentially guide immediately actionable treatment decisions. This histologic activity grade system has been in use at our institution for over 2 years with good acceptance.