title: Risk of lymphoproliferative malignancy in relation to small intestinal histopathology among patients with celiac disease.
abstract: BACKGROUND
  Celiac disease is associated with an increased risk of malignant lymphomas. The risk of lymphoproliferative malignancies in patients with small intestinal inflammation without villous atrophy and in patients with latent celiac disease is unknown.
  
  
  METHODS
  We performed a cohort study using duodenal and jejunal biopsy data that were collected from all 28 Swedish pathology departments (July 1969 to February 2008). We identified two population-based cohorts composed of 28,989 individuals with biopsy-verified celiac disease (villous atrophy, Marsh stage 3) and 13,140 individuals with small intestinal inflammation without villous atrophy (Marsh 1 + 2) and a regional cohort of 3711 individuals with latent celiac disease (positive celiac disease serology and normal mucosa). Cancer data were obtained by linkage to the National Cancer Registry. We used Cox regression to estimate hazard ratios (HRs) for lymphoproliferative malignancy and any solid cancer among the three cohorts compared with a total of 227,911 age- and sex-matched reference individuals.
  
  
  RESULTS
  Although biopsy-verified celiac disease and intestinal inflammation were associated with lymphoproliferative malignancy (for celiac disease, HR = 2.82; 95% confidence interval [CI] = 2.36 to 3.37, n = 193; for inflammation, HR = 1.81; 95% CI = 1.42 to 2.31, n = 89), latent celiac disease was not associated with lymphoproliferative malignancy (HR = 0.97; 95% CI = 0.44 to 2.14, n = 7). The absolute rates of lymphoproliferative malignancies among persons with celiac disease, small intestinal inflammation, and latent celiac disease were 70.3 per 100,000 person-years, 83.4 per 100,000 person-years, and 28.0 per 100,000 person-years, respectively. Compared with individuals with celiac disease, individuals with small intestinal inflammation or latent celiac disease were at a statistically significantly lower risk of lymphoproliferative malignancy. Risk of any solid cancer was not increased beyond the first year of follow-up in any cohort. Celiac disease was associated with Hodgkin lymphoma and both T-cell and B-cell non-Hodgkin lymphomas.
  
  
  CONCLUSIONS
  The risk of lymphoproliferative malignancy in celiac disease is dependent on small intestinal histopathology, with no increased risk in latent celiac disease.
authors.affiliation: Department of Pediatrics, Örebro University Hospital, Örebro, Sweden. pelfstrom@gmail.com
authors.forename: Peter
authors.initials: P
authors.lastname: Elfström
authors.forename: Fredrik
authors.initials: F
authors.lastname: Granath
authors.forename: Karin
authors.initials: K
authors.lastname: Ekström Smedby
authors.forename: Scott M
authors.initials: SM
authors.lastname: Montgomery
authors.forename: Johan
authors.initials: J
authors.lastname: Askling
authors.forename: Anders
authors.initials: A
authors.lastname: Ekbom
authors.forename: Jonas F
authors.initials: JF
authors.lastname: Ludvigsson
mesh_terms: D000328:Adult; D001706:Biopsy; D016022:Case-Control Studies; D002446:Celiac Disease / Q000150:complications* / Q000473:pathology*; D015331:Cohort Studies; D004379:Duodenal Neoplasms / Q000209:etiology* / Q000473:pathology; D004382:Duodenitis / Q000150:complications* / Q000473:pathology; D004751:Enteritis / Q000150:complications* / Q000473:pathology; D005260:Female; D006801:Humans; D015994:Incidence; D007579:Jejunal Diseases / Q000150:complications* / Q000473:pathology; D007580:Jejunal Neoplasms / Q000209:etiology* / Q000473:pathology; D008223:Lymphoma / Q000209:etiology* / Q000473:pathology; D008297:Male; D008498:Medical Record Linkage; D008875:Middle Aged; D016017:Odds Ratio; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013548:Sweden / Q000453:epidemiology; D055815:Young Adult