To examine the association between mucosal healing in celiac disease and the risk for lymphoproliferative malignancy (LPM), investigators in Sweden conducted a retrospective, population-based cohort study of 7625 patients with celiac disease who had at least one follow-up biopsy taken after diagnosis. Biopsies were taken at least 6 months after initiation of a gluten-free diet and at a median of 1.3 years after diagnosis. LPM occurrence was determined using a nationwide cancer registry.

In multivariate analysis, patients with persistent villous atrophy on follow-up biopsy had a higher risk for LPM compared with the general population (standardized incidence ratio, 3.78; 95% confidence interval, 2.71–5.12) and compared with patients with mucosal healing (hazard ratio, 2.26; 95% CI, 1.18–4.34). The risk estimate was highest for T-cell lymphoma, though not statistically significant. Total or subtotal villous atrophy was more strongly associated with T-cell lymphoma (HR, 9.23) than partial or no villous atrophy (HR, 3.4).

COMMENT

This study confirms the increased risk for lymphoproliferative malignancy in patients with celiac disease. Further, it documents for the first time that the risk for LPM, particularly T-cell lymphoma, is predicted by the degree of mucosal healing on follow-up biopsy. These findings strongly suggest that, as in inflammatory bowel disease, mucosal healing is an important therapeutic goal. Follow-up biopsy at 6 to 12 months after initiation of a gluten-free diet should be considered, with the goal of achieving resolution of villous atrophy.