A Novel Histologic Scoring System to Evaluate Mucosal Biopsies From Patients With Eosinophilic Esophagitis

doi:10.1016/j.cgh.2009.03.022

Clinical Gastroenterology and Hepatology

Volume 7, Issue 7, July 2009, Pages 749-755.e11

https://doi.org/10.1016/j.cgh.2009.03.022 Get rights and content

Background & Aims

Eosinophilic esophagitis (EoE) is characterized by medically/surgically-resistant gastroesophageal reflux symptoms and dense squamous eosinophilia. Studies suggest that histologic assessment of esophageal eosinophilia alone cannot reliably separate patients with EoE from those with gastroesophageal reflux disease (GERD). Our goal was to develop an assay to identify EoE patients and perhaps differentiate EoE from other causes of esophageal eosinophilia.

Methods

A monoclonal antibody specific for an eosinophil secondary granule protein (eosinophil peroxidase [EPX]) was developed and shown to specifically identify intact eosinophils and detect eosinophil degranulation in formalin-fixed specimens. A histopathologic scoring algorithm was developed to analyze data from patient evaluations; the utility of this algorithm was assessed by using archived esophageal tissues from patients with known diagnoses of EoE and GERD as well as controls from 2 tertiary care centers.

Results

Intraobserver/interobserver blinded evaluations demonstrated a significant difference (P < .001) between scores of samples taken from control subjects, from patients with esophageal eosinophilia who had a diagnosis of EoE, and from patients with GERD (P < .001). This algorithm also was able to identify patients whose clinical course was suggestive of a diagnosis of EoE, but that nonetheless failed to reach the critical threshold number of ≥15 eosinophils in a high-power (40×) microscopy field.

Conclusions

A novel immunohistochemical scoring system was developed to address an unmet medical need to differentiate histologic specimens from patients with EoE relative to those with GERD. The availability of a unique anti-EPX–specific monoclonal antibody, combined with the ease/rapidity of this staining method and scoring system, will provide a valuable strategy for the assessment of esophageal eosinophilia.

Section snippets

Development of an Anti-Eosinophil Peroxidase Monoclonal Antibody and Diagnostic Scoring Algorithm to Evaluate Esophageal Patients

For a complete explanation of this process, see Supplementary Materials and Methods.

Human Subjects

Adult esophageal patients were identified retrospectively by gastroenterologists at Mayo Clinic Arizona. These patients were divided into 4 groups. Group I were patients diagnosed with EoE by virtue of (1) clinical symptoms at presentation (eg, dysphagia, vomiting, and/or food impaction); (2) GERD was ruled out with pretreatment with proton pump inhibition, a normal pH/impedance monitor, and/or response to

Anti-Eosinophil Peroxidase Monoclonal Antibody–Based Immunohistochemistry: Pathology Assessments of Eosinophilic Esophagitis Patients, Including the Detection of Eosinophil Activation (the Release of Granule Proteins [Degranulation])

EPX-mAb–based immunohistochemistry provided a strategy for the rapid detection of infiltrating eosinophils in esophageal biopsies. More important, this strategy also provided a method with which to identify quickly areas of biopsies that are likely to contain the focus of ≥15 eosinophils/40× HPF needed to meet the histologic guidelines for a diagnosis of EoE. The photomicrographs of Figure 1 demonstrated the ease of identifying eosinophils within tissue sections by using EPX-mAb–based

Discussion

The EPX-mAb–based immunohistochemical assay described in this report represents a novel tool and systematic method to assess esophageal tissues for evidence of eosinophilic inflammation in both children and adults. The previously limited availability of eosinophil-specific antibody staining options for immunohistochemical assays that are sensitive, reproducible, and useful in the most commonly available format (ie, archived formalin-fixed paraffin-embedded tissues) had prevented the development

Acknowledgments

The authors are grateful to all of their Mayo Clinic Arizona (MCA) and Children's Hospital Denver (CHD) clinical colleagues and their patients. The authors are grateful for the invaluable insight provided by their pathology colleagues, including Drs K. Leslie (MCA), R. Valdez (MCA), C. Conley (MCA), J. Sweeney (MCA), Mark Lovell (CHD), and Kelley Capocelli (CHD). The authors would also like to thank Wendy Moore (CHD), S. Montgomery (MCA), and C. Sinclair (MCA). The authors are indebted to Media

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: Conflicts of interest The authors disclose no conflicts.

: Funding The studies presented regarding the use of these antibodies in the diagnosis of human disease were supported by the Mayo Foundation and research grants from the NIH to J.J.L. (HL065228, CA112442, and K26-RR019709), N.A.L. (HL058723), and G.T.F. (DK62245 and CURED). The creation/production of EPX-reactive mouse monoclonal antibodies was supported in part by a sponsored research grant from Schering-Plough.

View full text

Original articles—alimentary tractA Novel Histologic Scoring System to Evaluate Mucosal Biopsies From Patients With Eosinophilic Esophagitis

Background & Aims

Methods

Results

Conclusions

Section snippets

Development of an Anti-Eosinophil Peroxidase Monoclonal Antibody and Diagnostic Scoring Algorithm to Evaluate Esophageal Patients

Human Subjects

Anti-Eosinophil Peroxidase Monoclonal Antibody–Based Immunohistochemistry: Pathology Assessments of Eosinophilic Esophagitis Patients, Including the Detection of Eosinophil Activation (the Release of Granule Proteins [Degranulation])

Discussion

Acknowledgments

Gastroenterology

Gastrointest Endosc Clin N Am

J Allergy Clin Immunol

J Biol Chem

High intraepithelial eosinophil counts in esophageal squamous epithelium are not specific for eosinophilic esophagitis in adults

Am J Gastroenterol

Pathology of eosinophilic esophagitis: what the clinician needs to know

Am J Gastroenterol

Original articles—alimentary tract
A Novel Histologic Scoring System to Evaluate Mucosal Biopsies From Patients With Eosinophilic Esophagitis