La maladie de Parkinson au Canada (serveur d'exploration)

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Evaluation of alpha-synuclein immunohistochemical methods for the detection of Lewy-type synucleinopathy in gastrointestinal biopsies

Identifieur interne : 000224 ( Pmc/Corpus ); précédent : 000223; suivant : 000225

Evaluation of alpha-synuclein immunohistochemical methods for the detection of Lewy-type synucleinopathy in gastrointestinal biopsies

Auteurs : Anne-Gaëlle Corbillé ; Franck Letournel ; Jeffrey H. Kordower ; John Lee ; Elisheva Shanes ; Michel Neunlist ; David G. Munoz ; Pascal Derkinderen ; Thomas G. Beach

Source :

RBID : PMC:4820972

Abstract

The observation showing that Lewy type synucleinopathy (LTS), the pathological hallmark of Parkinson’s disease (PD), is found in the gut of almost all PD subjects led to a substantial amount of research to develop a diagnostic procedure in living patients based on endoscopically obtained gastrointestinal biopsies. However, the existing studies have provided conflicting results regarding the sensitivity and specificity of gastrointestinal biopsies for the detection of LTS. We therefore undertook a multi-center staining and blinded judging of a common set of slides from colonic biopsies to determine the optimal protocol for the detection of LTS. Four different immunohistochemical methods, developed in four separate expert laboratories, were evaluated for their sensitivity and specificity to detect enteric LTS. Test sets of formalin-fixed, paraffin-embedded sections from biopsies of 9 PD subjects and 3 controls were stained with the 4 methods and graded by 4 different observers. Four types of staining morphology (granular staining in the lamina propria, perivascular/vascular wall staining in the submucosa, lacy-granular pattern in the submucosa and epithelial cell nuclear staining) were variably observed in the slides stained by the 4 methods. Positive alpha-synuclein staining was observed by all 5 judges in most of the slides from control cases, regardless of the staining methods that were used. Moreover, none of the tested method or staining pattern had a specificity and sensitivity more than 80 % regarding to PD. Overall, our study suggest that the tested methods are not adequate for the prediction of PD using gastrointestinal biopsies. Future studies are warranted to test new immunostaining methods.

Electronic supplementary material

The online version of this article (doi:10.1186/s40478-016-0305-8) contains supplementary material, which is available to authorized users.


Url:
DOI: 10.1186/s40478-016-0305-8
PubMed: 27044604
PubMed Central: 4820972

Links to Exploration step

PMC:4820972

Le document en format XML

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<p>The observation showing that Lewy type synucleinopathy (LTS), the pathological hallmark of Parkinson’s disease (PD), is found in the gut of almost all PD subjects led to a substantial amount of research to develop a diagnostic procedure in living patients based on endoscopically obtained gastrointestinal biopsies. However, the existing studies have provided conflicting results regarding the sensitivity and specificity of gastrointestinal biopsies for the detection of LTS. We therefore undertook a multi-center staining and blinded judging of a common set of slides from colonic biopsies to determine the optimal protocol for the detection of LTS. Four different immunohistochemical methods, developed in four separate expert laboratories, were evaluated for their sensitivity and specificity to detect enteric LTS. Test sets of formalin-fixed, paraffin-embedded sections from biopsies of 9 PD subjects and 3 controls were stained with the 4 methods and graded by 4 different observers. Four types of staining morphology (granular staining in the
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</listBibl>
</div1>
</back>
</TEI>
<pmc article-type="research-article">
<pmc-dir>properties open_access</pmc-dir>
<front>
<journal-meta>
<journal-id journal-id-type="nlm-ta">Acta Neuropathol Commun</journal-id>
<journal-id journal-id-type="iso-abbrev">Acta Neuropathol Commun</journal-id>
<journal-title-group>
<journal-title>Acta Neuropathologica Communications</journal-title>
</journal-title-group>
<issn pub-type="epub">2051-5960</issn>
<publisher>
<publisher-name>BioMed Central</publisher-name>
<publisher-loc>London</publisher-loc>
</publisher>
</journal-meta>
<article-meta>
<article-id pub-id-type="pmid">27044604</article-id>
<article-id pub-id-type="pmc">4820972</article-id>
<article-id pub-id-type="publisher-id">305</article-id>
<article-id pub-id-type="doi">10.1186/s40478-016-0305-8</article-id>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Research</subject>
</subj-group>
</article-categories>
<title-group>
<article-title>Evaluation of alpha-synuclein immunohistochemical methods for the detection of Lewy-type synucleinopathy in gastrointestinal biopsies</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname>Corbillé</surname>
<given-names>Anne-Gaëlle</given-names>
</name>
<xref ref-type="aff" rid="Aff1"></xref>
<xref ref-type="aff" rid="Aff2"></xref>
<xref ref-type="aff" rid="Aff3"></xref>
<xref ref-type="aff" rid="Aff4"></xref>
<xref ref-type="aff" rid="Aff5"></xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Letournel</surname>
<given-names>Franck</given-names>
</name>
<xref ref-type="aff" rid="Aff4"></xref>
<xref ref-type="aff" rid="Aff5"></xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Kordower</surname>
<given-names>Jeffrey H.</given-names>
</name>
<xref ref-type="aff" rid="Aff6"></xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Lee</surname>
<given-names>John</given-names>
</name>
<xref ref-type="aff" rid="Aff7"></xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Shanes</surname>
<given-names>Elisheva</given-names>
</name>
<xref ref-type="aff" rid="Aff7"></xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Neunlist</surname>
<given-names>Michel</given-names>
</name>
<xref ref-type="aff" rid="Aff1"></xref>
<xref ref-type="aff" rid="Aff2"></xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Munoz</surname>
<given-names>David G.</given-names>
</name>
<xref ref-type="aff" rid="Aff8"></xref>
</contrib>
<contrib contrib-type="author" corresp="yes">
<name>
<surname>Derkinderen</surname>
<given-names>Pascal</given-names>
</name>
<address>
<email>derkinderenp@yahoo.fr</email>
</address>
<xref ref-type="aff" rid="Aff1"></xref>
<xref ref-type="aff" rid="Aff2"></xref>
<xref ref-type="aff" rid="Aff3"></xref>
<xref ref-type="aff" rid="Aff10"></xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Beach</surname>
<given-names>Thomas G.</given-names>
</name>
<xref ref-type="aff" rid="Aff9"></xref>
</contrib>
<aff id="Aff1">
<label></label>
Inserm, U913, Nantes, F-44035 France</aff>
<aff id="Aff2">
<label></label>
Nantes University, Nantes, F-44035 France</aff>
<aff id="Aff3">
<label></label>
Department of Neurology, CHU Nantes, Nantes, F-44093 France</aff>
<aff id="Aff4">
<label></label>
CHU Angers, Neurobiology and Neuropathology Laboratory, Angers, F-49033 France</aff>
<aff id="Aff5">
<label></label>
Université of Angers, UPRES EA3143, Angers, F-49033 France</aff>
<aff id="Aff6">
<label></label>
Department of Center for Brain Repair, Department of Pathology, Rush Medical College, Chicago, IL USA</aff>
<aff id="Aff7">
<label></label>
Department of Pathology, NorthShore Medical Group, Evanston, IL 60201 USA</aff>
<aff id="Aff8">
<label></label>
Laboratory Medicine, St. Michael’s Hospital, University of Toronto & Li Ka Shing Knowledge Institute, Toronto, ON Canada</aff>
<aff id="Aff9">
<label></label>
Banner Sun Health Research Institute, Sun City, AZ USA</aff>
<aff id="Aff10">
<label></label>
Department of Neurology, CHU Nantes, 44093 Nantes, France</aff>
</contrib-group>
<pub-date pub-type="epub">
<day>4</day>
<month>4</month>
<year>2016</year>
</pub-date>
<pub-date pub-type="pmc-release">
<day>4</day>
<month>4</month>
<year>2016</year>
</pub-date>
<pub-date pub-type="collection">
<year>2016</year>
</pub-date>
<volume>4</volume>
<elocation-id>35</elocation-id>
<history>
<date date-type="received">
<day>22</day>
<month>2</month>
<year>2016</year>
</date>
<date date-type="accepted">
<day>19</day>
<month>3</month>
<year>2016</year>
</date>
</history>
<permissions>
<copyright-statement>© Corbillé et al. 2016</copyright-statement>
<license license-type="OpenAccess">
<license-p>
<bold>Open Access</bold>
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (
<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>
), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (
<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>
) applies to the data made available in this article, unless otherwise stated.</license-p>
</license>
</permissions>
<abstract id="Abs1">
<p>The observation showing that Lewy type synucleinopathy (LTS), the pathological hallmark of Parkinson’s disease (PD), is found in the gut of almost all PD subjects led to a substantial amount of research to develop a diagnostic procedure in living patients based on endoscopically obtained gastrointestinal biopsies. However, the existing studies have provided conflicting results regarding the sensitivity and specificity of gastrointestinal biopsies for the detection of LTS. We therefore undertook a multi-center staining and blinded judging of a common set of slides from colonic biopsies to determine the optimal protocol for the detection of LTS. Four different immunohistochemical methods, developed in four separate expert laboratories, were evaluated for their sensitivity and specificity to detect enteric LTS. Test sets of formalin-fixed, paraffin-embedded sections from biopsies of 9 PD subjects and 3 controls were stained with the 4 methods and graded by 4 different observers. Four types of staining morphology (granular staining in the
<italic>lamina propria</italic>
, perivascular/vascular wall staining in the submucosa, lacy-granular pattern in the submucosa and epithelial cell nuclear staining) were variably observed in the slides stained by the 4 methods. Positive alpha-synuclein staining was observed by all 5 judges in most of the slides from control cases, regardless of the staining methods that were used. Moreover, none of the tested method or staining pattern had a specificity and sensitivity more than 80 % regarding to PD. Overall, our study suggest that the tested methods are not adequate for the prediction of PD using gastrointestinal biopsies. Future studies are warranted to test new immunostaining methods.</p>
<sec>
<title>Electronic supplementary material</title>
<p>The online version of this article (doi:10.1186/s40478-016-0305-8) contains supplementary material, which is available to authorized users.</p>
</sec>
</abstract>
<kwd-group xml:lang="en">
<title>Keywords</title>
<kwd>Parkinson’s disease</kwd>
<kwd>Gastrointestinal biopsies</kwd>
<kwd>Alpha-synuclein</kwd>
<kwd>Biomarker</kwd>
</kwd-group>
<funding-group>
<award-group>
<funding-source>
<institution-wrap>
<institution-id institution-id-type="FundRef">http://dx.doi.org/10.13039/100000864</institution-id>
<institution>Michael J. Fox Foundation for Parkinson's Research</institution>
</institution-wrap>
</funding-source>
<award-id>Research Grant 2013</award-id>
<principal-award-recipient>
<name>
<surname>Derkinderen</surname>
<given-names>Pascal</given-names>
</name>
</principal-award-recipient>
</award-group>
</funding-group>
<custom-meta-group>
<custom-meta>
<meta-name>issue-copyright-statement</meta-name>
<meta-value>© The Author(s) 2016</meta-value>
</custom-meta>
</custom-meta-group>
</article-meta>
</front>
<body>
<sec id="Sec1">
<title>Introduction</title>
<p>Since the discovery of aggregated and phosphorylated alpha-synuclein as the primary component of Lewy pathology, immunohistochemistry for alpha-synuclein has become the histological technique of choice for the diagnosis of Parkinson’s disease (PD) [
<xref ref-type="bibr" rid="CR1">1</xref>
,
<xref ref-type="bibr" rid="CR2">2</xref>
]. Several autopsy studies, showed that the distribution of Lewy-type synucleinopathy (LTS) is much greater than formerly appreciated extending to peripheral autonomic neuronal circuits [
<xref ref-type="bibr" rid="CR2">2</xref>
,
<xref ref-type="bibr" rid="CR3">3</xref>
]. The presence of LTS in peripheral neuronal tissues accessible to biopsies provides new opportunities for the development of original biomarkers that will directly assess the pathological process in living patients [
<xref ref-type="bibr" rid="CR4">4</xref>
,
<xref ref-type="bibr" rid="CR5">5</xref>
]. Among these peripheral autonomic neuronal circuits, the enteric nervous system displays several specific features that make it a prime candidate tissue for being a histopathological marker of PD as (i) it is an integrative neuronal network whose organization and complexity closely resemble that of the central nervous system (ii) it has been shown to be affected by the pathological process in the vast majority of PD patients [
<xref ref-type="bibr" rid="CR3">3</xref>
,
<xref ref-type="bibr" rid="CR6">6</xref>
<xref ref-type="bibr" rid="CR9">9</xref>
] (iii) it is readily, repeatedly and safely accessible by endoscopic biopsies in living patients [
<xref ref-type="bibr" rid="CR10">10</xref>
,
<xref ref-type="bibr" rid="CR11">11</xref>
]. This logically led laboratories to develop specific methods for the detection of LTS in routine gastrointestinal biopsies. However, the diversity of methodology between studies, especially regarding the immunohistochemical methods used, has led to conflicting results and discrepancies regarding the sensitivity and specificity of gastrointestinal biopsies for the detection of LTS [
<xref ref-type="bibr" rid="CR12">12</xref>
<xref ref-type="bibr" rid="CR17">17</xref>
]. The aim of our research project was therefore to test several different immunohistochemical methods for the detection of LTS in colonic biopsy with the objective of identifying a highly sensitive and specific technique that might be widely and readily used in different laboratories. For this purpose, a panel of expert investigators have participated, based on their published work using alpha-synuclein immunohistochemistry [
<xref ref-type="bibr" rid="CR2">2</xref>
,
<xref ref-type="bibr" rid="CR13">13</xref>
,
<xref ref-type="bibr" rid="CR18">18</xref>
,
<xref ref-type="bibr" rid="CR19">19</xref>
] and were asked to stain identical sets of paraffin-embedded sections from colonic biopsies with their own optimized method.</p>
</sec>
<sec id="Sec2">
<title>Materials and methods</title>
<sec id="Sec3">
<title>Selection of subjects and formalin-fixed paraffin-embedded blocks</title>
<p>Nine PD patients were included in this study, chosen from among 29 subjects that had been recruited from the movement disorder clinic in Nantes University Hospital, France for a previously published study of enteric synucleinopathy in wholemount mucosal-submucosal biopsies [
<xref ref-type="bibr" rid="CR12">12</xref>
]. From the same study, a set of 3 subjects (out of 10 in the original study) requiring a total colonoscopy for colorectal cancer screening were included as controls. The clinical characteristics of study subjects are summarized in Table 
<xref rid="Tab1" ref-type="table">1</xref>
.
<table-wrap id="Tab1">
<label>Table 1</label>
<caption>
<p>Clinical and pathological characteristics of study subjects</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th>Diagnosis</th>
<th>Age Mean (range)</th>
<th>Gender M:F</th>
<th>Disease duration (y) mean (range)</th>
<th>Wholemount synucleinopathy density grade mean (range)</th>
<th>FFPE synucleinopathy density grade mean (range)</th>
</tr>
</thead>
<tbody>
<tr>
<td>Control (
<italic>n</italic>
 = 3)</td>
<td>64 (61–68)</td>
<td>2:1</td>
<td>N/A</td>
<td>0</td>
<td>0</td>
</tr>
<tr>
<td>PD (
<italic>n</italic>
 = 9)</td>
<td>66 (47–71)</td>
<td>8:1</td>
<td>12.2 (4–20)</td>
<td>1.6 (0–2)</td>
<td>1.9 (0.5–3)</td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<p>Presumptive synucleinopathy in the formalin-fixed, paraffin-embedded (FFPE) sections was graded on a 0–3 scale. Wholemount synucleinopathy scores shown are from the original published study [
<xref ref-type="bibr" rid="CR12">12</xref>
] and were graded as 0–2 based on the number of positive biopsies out of the 4 that were taken from each subject (the maximum assigned score was 2)</p>
</table-wrap-foot>
</table-wrap>
</p>
<p>The 3 control and 9 PD subjects were chosen after screening sections from their archived descending colon biopsies stored in formalin-fixed, paraffin-embedded (FFPE) blocks. Screening was performed by AGC and FL of the Neuropathology Laboratory in Angers, France. Tissue blocks were fixed in 10 % (v/v) formalin for 48 h, embedded in paraffin and cut at 4 μm using a Leica RM125 microtome. Sections were collected on slides (Superfrost Plus, VWR, Fontenay sous Bois, France) and stained with an immunoperoxidase method for the detection of phosphorylated alpha-synuclein (Table 
<xref rid="Tab2" ref-type="table">2</xref>
). Global grading of all staining, regardless of morphology, was assigned using a 0–3 semi-quantitative density scale. PD cases were divided into 3 groups with 3 subjects in each group, one group with sparse staining density (PD group 0), one with moderate staining density (PD group 1) and one with high staining density (PD group 2). Control subjects had minimal staining densities (Table 
<xref rid="Tab1" ref-type="table">1</xref>
)
<table-wrap id="Tab2">
<label>Table 2</label>
<caption>
<p>Immunoperoxidase methods used by the central laboratory (AGC/FL) and the three testing laboratories</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th></th>
<th>Primary antibody</th>
<th>Epitope exposure</th>
<th>Signal development</th>
</tr>
</thead>
<tbody>
<tr>
<td>AGC/FL (Angers, France)</td>
<td>p-synuclein, #64
<break></break>
WAKO, Osaka
<break></break>
1:30,000</td>
<td>Formic acid (80 %)
<break></break>
20 min</td>
<td>BOND MAX
<break></break>
Leica Biosystems, Newcastle Upon Tyne, U.K.</td>
</tr>
<tr>
<td>TB (Sun City, AZ)</td>
<td>p-synuclein, polyclonal
<break></break>
H. Akiyama, Tokyo
<break></break>
1:10,000</td>
<td>Proteinase K 1:100
<break></break>
37 ° C, 20 min</td>
<td>ABC, DAB
<break></break>
Vector Laboratories</td>
</tr>
<tr>
<td>JK (Chicago, IL)</td>
<td>Alpha-synuclein, LB509
<break></break>
Invitrogen
<break></break>
1:500</td>
<td>Formic acid (88 %)
<break></break>
20 min</td>
<td>ABC, DAB
<break></break>
Vector Laboratories</td>
</tr>
<tr>
<td>DM (Toronto, Canada)</td>
<td>p-synuclein, #64
<break></break>
WAKO, Osaka
<break></break>
1:12,000</td>
<td>Ventana Protease 2
<break></break>
72 ° C, 8 min
<break></break>
Citrate buffer, pH 6 4
<break></break>
90 ° C, 4 min</td>
<td>Ventana Benchmark Ultra,
<break></break>
Optiview multimer and amplifier</td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<p>p-synuclein = alpha-synuclein phosphorylated at serine 129; ABC = avidin-biotin peroxidase complex; DAB = 3, 3’ di-aminobenzidine</p>
</table-wrap-foot>
</table-wrap>
.</p>
<p>None of the control subjects had a history of neurological or psychiatric diseases, none had abnormalities on neurological examination and on telephone interviews done in 2014 none had subsequently developed parkinsonian signs or symptoms. The study protocol was approved by the local Committee on Ethics and Human Research (
<italic>Comité de Protection des Personnes Ouest VI</italic>
), and registered on ClinicalTrials.gov (identifier NCT00491062). Written informed consent was obtained from each patient and from each normal volunteer.</p>
</sec>
<sec id="Sec4">
<title>Preparation of test slides and distribution to participating labs</title>
<p>The design of the study is depicted diagrammatically in Fig. 
<xref rid="Fig1" ref-type="fig">1</xref>
. Four unstained sections (4 μm) from each block (each block containing one biopsy tissue fragment) were sent by the central laboratory (AGC and PD) along with a brief methods section describing how the tissue was sampled to the 3 other participating testing laboratories (48 slides per lab, 144 slides in all). Each participating lab (TB, DM and JK) including the central laboratory stained the full set of sections with their optimal immunoperoxidase method for enteric synucleinopathy (Table 
<xref rid="Tab2" ref-type="table">2</xref>
). Blocks were assigned a number from 1–12 using a random number generator in order to blind evaluators to diagnosis.
<fig id="Fig1">
<label>Fig. 1</label>
<caption>
<p>Design of the study</p>
</caption>
<graphic xlink:href="40478_2016_305_Fig1_HTML" id="MO1"></graphic>
</fig>
</p>
</sec>
<sec id="Sec5">
<title>Slides grading and statistical analysis</title>
<p>The stained slide sets were initially examined by TB, who then constructed four different semi-quantitative grading templates (Fig. 
<xref rid="Fig2" ref-type="fig">2</xref>
and Additional file
<xref rid="MOESM1" ref-type="media">1</xref>
: Figures S1 and S2) with associated scoring tables for each of the four major morphological staining types present. The four different staining patterns were: (1) granular staining in the
<italic>lamina propria</italic>
of the mucosa (2) perivascular/vascular wall staining with a fine dotted pattern, in the submucosa (3) lacy-granular pattern in the submucosa (4) epithelial cell nuclear staining. The photomicrographs in Fig. 
<xref rid="Fig2" ref-type="fig">2</xref>
illustrate each staining pattern. As some of the staining patterns (types 2 and 3) were present only in the submucosa, or depended on the presence of blood vessels in the submucosa, the presence or absence of submucosa or blood vessels was recorded for each biopsy. No assumptions were made as to whether any of the staining patterns seen might represent specific or non-specific staining of pathological alpha-synuclein deposits, and all slides were graded for each pattern by each participating test lab in turn (TB, JK, and DM and one additional judge: John Lee, MD, PhD, of the Department of Pathology, NorthShore University Health System, Evanston, IL). The slides as well as the scoring tables were then returned to PD at the central laboratory. Density scores of none, sparse, moderate and frequent were converted to numerical values (0–4) for statistical analysis. Sum and average score per biopsy were calculated. All labs submitted their grading to the project principal investigator and results were analyzed after unblinding.
<fig id="Fig2">
<label>Fig. 2</label>
<caption>
<p>Photomicrographs of LTS immunostaining in colonic biopsies sections, illustrating the 4 staining patterns that were graded.
<bold>a</bold>
<italic>lamina propria</italic>
granular pattern, Template 1;
<bold>b</bold>
perivascular/vascular pattern, Template 2;
<bold>c</bold>
lacy-granular pattern, Template 3;
<bold>d</bold>
epithelial nuclear pattern, Template 4. Scale bar: 50 μM</p>
</caption>
<graphic xlink:href="40478_2016_305_Fig2_HTML" id="MO2"></graphic>
</fig>
</p>
<p>Statistical analyses were performed using intraclass correlation coefficient for judge ratings of staining densities, for each laboratory (TB, JK, FL, DM) and staining template pattern (LP = 
<italic>lamina propria</italic>
granular pattern; EC = endothelial cell nuclear pattern; LG = lacy-granular pattern; PV = perivascular-vascular pattern) were determined. The diagnostic accuracy of each staining pattern, in terms of being able to predict a diagnosis of PD, was calculated from each individual judge’s results and for the average of all judge’s results, for all applicable staining patterns seen on slides from each testing laboratory as well as from the central laboratory.</p>
</sec>
</sec>
<sec id="Sec6">
<title>Results</title>
<sec id="Sec7">
<title>LTS staining pattern and density scores</title>
<p>The density scores of the 4 raters were averaged to obtain a mean score of LTS staining per biopsy. Figure 
<xref rid="Fig3" ref-type="fig">3</xref>
represents the mean of density score by groups (controls and PD groups) for each staining pattern. Additional file
<xref rid="MOESM1" ref-type="media">1</xref>
: Table S1 shows the results of individual judge scores for the staining done by each test laboratory as well as by the central laboratory, for each scoring template. The four types of staining morphology were variably present in the slides stained by the 4 methods. The granular
<italic>lamina propria</italic>
staining was seen to some extent in all slide sets. The perivascular-vascular pattern was seen in slides stained by two of the labs (DM, AGC/FL). The submucosa lacy-granular pattern was seen only in slides stained by one lab (JK). The epithelial cell nuclear staining pattern was seen in slides stained by two labs (TB, AGC/FL).
<fig id="Fig3">
<label>Fig. 3</label>
<caption>
<p>LTS immunostaining scores for each template. Bar graph represents the LTS mean score for each group for each template in all methods. Data correspond to mean ± SEM of the 3 cases per group. PD group 0, 1 and 2 correspond to PD cases with sparse, moderate and high presumed LTS staining. Note that some templates were not observed in some methods. Template 1 : lamina propria granular pattern; Template 2 : perivascular/vascular pattern; Template 3: lacy-granular pattern; Template 4 : epithelial nuclear pattern</p>
</caption>
<graphic xlink:href="40478_2016_305_Fig3_HTML" id="MO3"></graphic>
</fig>
</p>
</sec>
<sec id="Sec8">
<title>Interobserver reliability and intraclass correlation coefficient</title>
<p>Interobserver reliability was generally moderately acceptable except for some staining morphology types in two laboratories (TB and AGC/FL, Table 
<xref rid="Tab3" ref-type="table">3</xref>
). Judge’s results were excluded when submucosa was not present, for those staining morphologies dependent on the presence of submucosa (DM-PV, JK, AGC/FL-PV). Submucosa was not present in 6 out of 48 slides.
<table-wrap id="Tab3">
<label>Table 3</label>
<caption>
<p>Intraclass correlation coefficient (ICC) for judge ratings of staining densities, for each testing laboratory (DM, TB, JK) and the central laboratory (AGC/FL), of each staining morphology type (LP = lamina propria granular pattern; EC = epithelial cell nuclear pattern; LG = lacy-granular pattern; PV = perivascular-vascular pattern)</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th></th>
<th>Box 1 DM-LP</th>
<th>Box 2 TB-EC</th>
<th>Box 2 TB-LP</th>
<th>Box 3 JK-LG</th>
<th>Box 3 JK-LG
<sup>a</sup>
</th>
<th>Box 4 AGC/FL-EC</th>
<th>Box 4 AGC/FL-LP</th>
<th>Box 4 AGC/FL-PV</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<italic>n</italic>
</td>
<td>12</td>
<td>12</td>
<td>12</td>
<td>12</td>
<td>11</td>
<td>12</td>
<td>12</td>
<td>12</td>
</tr>
<tr>
<td colspan="9">Four Raters</td>
</tr>
<tr>
<td>ICC</td>
<td>0.73</td>
<td>−0.04</td>
<td>0.02</td>
<td>0.81</td>
<td>0.78</td>
<td>NA</td>
<td>0.53</td>
<td>NA</td>
</tr>
<tr>
<td colspan="9">Three Raters</td>
</tr>
<tr>
<td>ICC</td>
<td>0.88</td>
<td>−0.05</td>
<td>0.00</td>
<td>0.79</td>
<td>0.72</td>
<td>0.16</td>
<td>0.78</td>
<td>0.80</td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<p>Some judges did not rate some staining patterns for some laboratories; results are therefore given for four judges where all judge scores were available and for the three common judges when one or more judge scores were missing. Cases without submucosa in the slide were excluded from results for staining morphologies dependent on the presence of submucosa (Box 3, JK-LG)</p>
<p>
<sup>a</sup>
Excluding insufficient submucosa</p>
</table-wrap-foot>
</table-wrap>
</p>
<p>Intraclass correlation coefficient for judge ratings of staining densities, for each laboratory and staining morphology type is shown in Table 
<xref rid="Tab3" ref-type="table">3</xref>
. Some judges did not rate some staining patterns for some laboratories. Results are therefore given for four judges where all judge scores were available and for the three common judges when one or more judge scores were missing. Cases without submucosa in the slide were excluded from results for staining morphologies dependent on the presence of submucosa (DM-PV, AGC/FL-PV, JK-LG).</p>
<p>Diagnostic accuracy for identifying PD cases, of judge ratings of staining densities, for each laboratory and staining morphology type were calculated (Table 
<xref rid="Tab4" ref-type="table">4</xref>
). Cases without submucosa in the slide were excluded from results for staining morphologies. Sensitivity were often acceptable (>80 %) but specificity too weak. None of the tested method or staining pattern had a specificity and sensitivity more than 80 % regarding to PD.
<table-wrap id="Tab4">
<label>Table 4</label>
<caption>
<p>Diagnostic accuracy for identifying PD cases, of judge ratings of staining densities, for each laboratory (DM, TB, JK, AGC/FL) and staining morphology type (LP = 
<italic>lamina propria</italic>
granular pattern; EC = endothelial cell nuclear pattern; LG = lacy-granular pattern; PV = perivascular-vascular pattern). Results for the average of judge’s ratings as well as the “best” judge’s ratings are shown. Some judges did not rate some staining patterns for some laboratories; results are therefore given for four judges where all judge scores were available and for the three common judges when one or more judge scores were missing. Cases without submucosa in the slide were excluded from results for staining morphologies dependent on the presence of submucosa (DM-PV, AGC/FL-PV, JK-LG). AUC = area under curve</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th></th>
<th>Box 1 DM-LP</th>
<th>Box 1 DM-LP
<sup>a</sup>
</th>
<th>Box 2 TB-EC</th>
<th>Box 2 TB-LP</th>
<th>Box 3 JK-LG</th>
<th>Box 3 JK-LG
<sup>a</sup>
</th>
<th>Box 4 AGC/FL-EC</th>
<th>Box 4 AGC/FL-LP</th>
<th>Box 4 AGC/FL-LG</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<italic>N</italic>
</td>
<td>12</td>
<td>7</td>
<td>12</td>
<td>12</td>
<td>12</td>
<td>11</td>
<td>12</td>
<td>12</td>
<td>12</td>
</tr>
<tr>
<td colspan="10">Four Raters</td>
</tr>
<tr>
<td>AUC</td>
<td>0.63</td>
<td>0.65</td>
<td>NA</td>
<td>NA</td>
<td>0.58</td>
<td>0.53</td>
<td>NA</td>
<td>0.67</td>
<td>NA</td>
</tr>
<tr>
<td>Sensitivity</td>
<td>86 %</td>
<td>83 %</td>
<td>28 %</td>
<td>28 %</td>
<td>89 %</td>
<td>97 %</td>
<td>NA</td>
<td>81 %</td>
<td>NA</td>
</tr>
<tr>
<td>Specificity</td>
<td>25 %</td>
<td>0 %</td>
<td>75 %</td>
<td>83 %</td>
<td>17 %</td>
<td>17 %</td>
<td>NA</td>
<td>33 %</td>
<td>NA</td>
</tr>
<tr>
<td>Youden Index</td>
<td>0.11</td>
<td>−0.17</td>
<td>0.03</td>
<td>0.11</td>
<td>0.06</td>
<td>0.14</td>
<td>NA</td>
<td>0.14</td>
<td>NA</td>
</tr>
<tr>
<td colspan="10">Three Raters</td>
</tr>
<tr>
<td>AUC</td>
<td>0.62</td>
<td>0.53</td>
<td>NA</td>
<td>NA</td>
<td>0.58</td>
<td>0.51</td>
<td>0.71</td>
<td>0.67</td>
<td>0.69</td>
</tr>
<tr>
<td>Sensitivity</td>
<td>85 %</td>
<td>78 %</td>
<td>37 %</td>
<td>15 %</td>
<td>89 %</td>
<td>100 %</td>
<td>74 %</td>
<td>74 %</td>
<td>70 %</td>
</tr>
<tr>
<td>Specificity</td>
<td>33 %</td>
<td>0 %</td>
<td>67 %</td>
<td>100 %</td>
<td>11 %</td>
<td>11 %</td>
<td>56 %</td>
<td>22 %</td>
<td>44 %</td>
</tr>
<tr>
<td>Youden Index</td>
<td>0.19</td>
<td>−0.22</td>
<td>0.04</td>
<td>0.15</td>
<td>0.00</td>
<td>0.11</td>
<td>0.30</td>
<td>−0.04</td>
<td>0.15</td>
</tr>
<tr>
<td colspan="10">Best Rater</td>
</tr>
<tr>
<td>Rater</td>
<td>DM</td>
<td>JK</td>
<td>JL</td>
<td>JL</td>
<td>JK</td>
<td>DM</td>
<td>JL</td>
<td>JK</td>
<td>DM</td>
</tr>
<tr>
<td>AUC</td>
<td>0.61</td>
<td>1.00</td>
<td>0.50</td>
<td>0.72</td>
<td>0.59</td>
<td>0.46</td>
<td>0.83</td>
<td>0.67</td>
<td>0.80</td>
</tr>
<tr>
<td>Sensitivity</td>
<td>100 %</td>
<td>100 %</td>
<td>78 %</td>
<td>44 %</td>
<td>89 %</td>
<td>100 %</td>
<td>67 %</td>
<td>100 %</td>
<td>78 %</td>
</tr>
<tr>
<td>Specificity</td>
<td>33 %</td>
<td>0 %</td>
<td>33 %</td>
<td>100 %</td>
<td>33 %</td>
<td>33 %</td>
<td>100 %</td>
<td>67 %</td>
<td>67 %</td>
</tr>
<tr>
<td>Youden Index</td>
<td>0.33</td>
<td>0.00</td>
<td>0.11</td>
<td>0.44</td>
<td>0.22</td>
<td>0.33</td>
<td>0.67</td>
<td>0.67</td>
<td>0.44</td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<p>
<sup>a</sup>
Excluding insufficient submucosa</p>
</table-wrap-foot>
</table-wrap>
</p>
</sec>
</sec>
<sec id="Sec9">
<title>Discussion</title>
<p>The primary aim of this study was to evaluate and compare different IHC methods for the detection of LTS in colonic biopsies. Regarding the ability to discriminate between control and PD subjects, the overall impression is that this was not accomplished by any of the staining methods or morphologically-defined staining types.</p>
<p>One of the striking results of our study is that positive alpha-synuclein staining was observed by all 4 judges in most of the slides from control cases, regardless of the staining methods that were used. Although several studies showed a high sensitivity of FFPE gastrointestinal biopsies for the detection of LTS in PD patients [
<xref ref-type="bibr" rid="CR13">13</xref>
,
<xref ref-type="bibr" rid="CR15">15</xref>
], recent reports have raised concerns regarding the specificity of this approach because alpha-synuclein immunoreactivity was also observed in some healthy individuals without PD [
<xref ref-type="bibr" rid="CR17">17</xref>
,
<xref ref-type="bibr" rid="CR20">20</xref>
]. This lack of specificity may result from technical difficulties inherent in the use of FFPE gastrointestinal biopsies for the detection of alpha-synuclein. Besides neurons, alpha-synuclein is physiologically expressed by red blood cells and vascular endothelial cells [
<xref ref-type="bibr" rid="CR21">21</xref>
,
<xref ref-type="bibr" rid="CR22">22</xref>
], two cell types, which can be retrieved from a routine gastrointestinal biopsy and thus be detected by alpha-synuclein immunohistochemistry in both healthy subjects and PD patients. Moreover, the interpretation of alpha-synuclein immunostaining for the detection of enteric LTS in PD can be delicate because of the scarcity and the morphology of the lesions. Rare typical Lewy bodies have been reported in the outermost plexus of the gut, namely the myenteric plexus, which can not be reached with a routine gastrointestinal biopsy [
<xref ref-type="bibr" rid="CR8">8</xref>
,
<xref ref-type="bibr" rid="CR17">17</xref>
,
<xref ref-type="bibr" rid="CR20">20</xref>
]. By contrast, the mucosa and the submucosa, which are captured by the biopsy-forceps, primarily contain thread-like and dot-like alpha-synuclein deposits in nerve endings, reminiscent of the small-sized Lewy neurites observed in the brain [
<xref ref-type="bibr" rid="CR8">8</xref>
,
<xref ref-type="bibr" rid="CR12">12</xref>
,
<xref ref-type="bibr" rid="CR23">23</xref>
,
<xref ref-type="bibr" rid="CR24">24</xref>
]. Such a morphology of staining can make it difficult to differentiate between LTS and physiological and/or non-specific alpha-synuclein staining in endoscopy tissue samples.</p>
<p>The above-mentioned limitations outline the critical need to develop proper neuronal counterstaining for the analysis of LTS in gastrointestinal biopsies. Combining routine colonic biopsies and microdissection techniques, we have previously shown that collecting whole-mounts of submucosa and mucosa enable a comprehensive assessment of the neural networks of these two structures [
<xref ref-type="bibr" rid="CR11">11</xref>
,
<xref ref-type="bibr" rid="CR12">12</xref>
]. In such whole mount-preparations, immunohistochemical analysis with a general neuronal marker such as PGP9.5, NF220 and Hu revealed that a single standard colonic biopsy contains an average of 150 submucosal neurons and a dense network of nerve fibers in the mucosa [
<xref ref-type="bibr" rid="CR11">11</xref>
,
<xref ref-type="bibr" rid="CR24">24</xref>
]. Although this approach provides outstanding information on the morphology of enteric neurons and allows the detection of Lewy pathology in most PD subjects, it nonetheless has several limitations as it has to be performed quickly following the endoscopic procedure, requires an experienced technician and is not suitable for retrospective analysis. It is therefore unlikely that such a procedure will be used in large-scale multicenter studies and there is a clearly need for reliable ways to label neuronal structures in FFPE gastrointestinal biopsies. Most of the available studies performed on FFPE blocks did not use any neuronal markers and relied primarily on morphology to identify the neuronal processes [
<xref ref-type="bibr" rid="CR13">13</xref>
,
<xref ref-type="bibr" rid="CR16">16</xref>
,
<xref ref-type="bibr" rid="CR17">17</xref>
]. Only two studies used S100 staining to exclude a significant proportion of biopsies from analysis due to the lack or paucity of nerve fibers [
<xref ref-type="bibr" rid="CR14">14</xref>
,
<xref ref-type="bibr" rid="CR15">15</xref>
]. For specificity reason, we would however not recommend the use of S100 staining for the detection of the neuronal processes as this protein is widely expressed by enteric glial cells, which are found in routine gastrointestinal biopsies [
<xref ref-type="bibr" rid="CR25">25</xref>
]. Our preliminary observation suggests that immunostaining with the pan neuronal marker PGP9.5 is an efficient screening method to establish whether the tissue sample contains an adequate number of neuronal structures.</p>
<p>In the current study, 3 out of 4 participating laboratories used antibodies against alpha-synuclein phosphorylated at serine 129 to detect LTS. Since the discovery by Fujiwara and coworkers that this residue was selectively and extensively phosphorylated in synucleinopathy lesions [
<xref ref-type="bibr" rid="CR26">26</xref>
], antibodies for phosphorylated alpha-synuclein have been widely used to label LTS in the central nervous system as well as in peripheral autonomic networks including the enteric nervous system [
<xref ref-type="bibr" rid="CR3">3</xref>
,
<xref ref-type="bibr" rid="CR9">9</xref>
]. Regarding gastrointestinal biopsies, most of the existing studies have used phospho-alpha-synuclein rather than total alpha-synuclein antibodies for the detection of pathological alpha-synuclein. Although some studies reported that staining with phospho-alpha-synuclein antibodies to be more extensive to that obtained with total alpha-synuclein [
<xref ref-type="bibr" rid="CR14">14</xref>
,
<xref ref-type="bibr" rid="CR27">27</xref>
], other studies found the opposite [
<xref ref-type="bibr" rid="CR15">15</xref>
,
<xref ref-type="bibr" rid="CR16">16</xref>
]. This may be due to the fact that a small amount (around 4 %) of alpha-synuclein is physiologically phosphorylated at serine 129 [
<xref ref-type="bibr" rid="CR26">26</xref>
], implying that phospho-synuclein antibodies can detect physiologic non-aggregated protein when no pretreatment is used. In this context, Visanji et al. recently adapted the paraffin-embedded tissue (PET) blot method, which degrades physiologic nonaggregated proteins and has been demonstrated to have superior sensitivity in detecting aggregated protein, to the detection of LTS in gastrointestinal samples [
<xref ref-type="bibr" rid="CR16">16</xref>
]. Surprisingly, they observed phospho-alpha-synuclein immunostaining in the colonic mucosa of 11/11 of control subject, despite the use of the PET blot method. This strongly suggests that non specific staining occurs in the gastrointestinal mucosa when phospho-alpha-synuclein antibodies are used, thereby explaining the lack of specificity observed in our study.</p>
<p>One obvious limitation of our study is the small sample size of the control group and it is possible that if it was repeated with more controls, the diagnostic accuracy of some of the methods might be higher. Another limitation was the absence of submucosa, blood vessels or judge’s scores for most of the slides, and for two of three control cases, rated for the perivascular staining morphology produced by the one testing laboratory (DM). It is possible, if all three controls had been graded and the staining scores segregated with the appropriate diagnosis, that the results for this laboratory may have been in fact acceptably accurate. Arguing against this possibility, however, is the low accuracy for this same morphology as produced by the central laboratory.</p>
</sec>
<sec id="Sec10">
<title>Conclusions</title>
<p>In conclusion, although our study has produced results that are less than definitive but it suggests that the tested immunohistochemical methods are not adequate for the prediction of PD in endoscopically obtained gastroinestinal biopsies. This failure may be due to the relative rarity of neuronal synucleinopathy in the submucosa of the colon or to the lack of sensitivity and specificity of the methods tested. Future studies including more control subjects along with new staining methods and screening for neuronal markers are needed.</p>
</sec>
</body>
<back>
<app-group>
<app id="App1">
<sec id="Sec11">
<title>Additional file</title>
<p>
<media position="anchor" xlink:href="40478_2016_305_MOESM1_ESM.pdf" id="MOESM1">
<label>Additional file 1: Figure S1.</label>
<caption>
<p>Templates used for semi-quantitative grading of staining morphologies present in the test sections.
<bold>Figure S2.</bold>
Representative Hematoxylin and Eosin staining of a colonic biopsy defining the regions available for assessment (mucosa and submucosa). Scale bar 200 μM.
<bold>Table S1.</bold>
Results of individual judge scores for the staining done by each test laboratory as well as by the central laboratory, for each scoring template. (PDF 3317 kb)</p>
</caption>
</media>
</p>
</sec>
</app>
</app-group>
<fn-group>
<fn>
<p>
<bold>Competing interests</bold>
</p>
<p>The authors declare that they have no competing interests.</p>
</fn>
<fn>
<p>
<bold>Authors’ contribution</bold>
</p>
<p>AGC, JK, DM, PD and TB designed the study. AGC, FL, MN and PD selected the test slides and supervised the slides distribution. AGC, FL, JK, DM and TB stained and graded the slides. JL and ES graded the slides. PD and TB wrote the manuscript. All authors read and approved the final manuscript.</p>
</fn>
</fn-group>
<ack>
<title>Acknowledgements</title>
<p>This work was supported by a grant from the Michael J Fox foundation for Parkinson’s research to PD and TB. AGC is a recipient of a
<italic>poste d’accueil Inserm</italic>
.</p>
</ack>
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