linda cendales composite tissue graft summary banff 2013 meeting in brazil
DESCRIPTION
Composite tissue graft summary from 12th Banff Conference on Transplant Pathology from the meeting in Comandatuba-Bahia, Brazil on August 23rd, 2013 http://cybernephrology.ualberta.ca/banff/2013TRANSCRIPT
Composite Tissue Session(Vascularized composite allograft)
Banff 2013 Summary
Linda Cendales, M.D
VCA Banff 2013Summary
• Speakers– Cinthia Drachenberg– Anthony J. Demetris– Christina Kaufman– Norma Uribe
• Virtual Case Presentation– Chandra Smart, UCLA– Max Fischer, Johns Hopkins– Emmanuel Morelon, et al,
Lyon-Amiens VCA team– Vijay Gorantla, et al.
University of Pittsburgh
Chronic Rejection in Vascularized
Composite Allografts
Cinthia Drachenberg, M.D.Professor of Pathology
University of Maryland School of Medicine
Chronic rejection in CTA
• Overview of chronic changes reported in the literature– Pre-clinical and clinical
• CTA/VCA share many features with solid organ transplants but have also unique characteristics to be taken in account.
Unadkat et al. Vasculopathy at 90 days in rat hind limb model
Striking venous inflammation with thickening and occlusion not shown.
Synovial biopsy 18 months Sentinel graftl biopsy 36 months
Soft tissue biopsy 50 months Synovial biopsy 50 months
Pathogenesis: of vasculopathyNon-alloimmune factors: trauma. episodic intense or chronic low grade mechanical damage, thermal injury.
hyperplasia as well as remodeling .
Microsurgery 1996
Can we borrow knowledge from other organs?
Similarities:•Morphology, distribution, progression, unclear etiology•Variability of course•Potential association with AR
Differences: • Venous involvement•C4d distribution?•Role of trauma, need for other surgeries etc.
Histopathological Observations in CTA with Clinical Correlation
A.J. DemetrisThomas Starzl Transplant Institute
Dept. of PathologyDivision of Transplantation
University of Pittsburgh Medical CenterPittsburgh, PA
Cell-mediated InjuryCornell et al Annu. Rev. Pathol. Mech. Dis. 2008. 3:189–220
Antibody Mediated Injury
PMN
anti-HLA Abanti-HLA Ab
Fc ReceptorFc ReceptorMediated BindingMediated Binding
C’ ActivationC’ Activation
Donor HLADonor HLA MACMACPlatelet microthrombiPlatelet microthrombi
EndotheliumEndotheliumADCCADCC
CDCCDC
C4dC4d
C4a +C4bC4a +C4b
C4C4C1C1
Courtesy of Peter Nickerson
Differential diagnosis in skin allograft biopsies, other than acute cellular
rejection• Graft localized
– Trauma– Insect bites– Infections– Allergic or irritant contact dermatitis– Posttransplant lymphoproliferative disorder
(PTLD)/lymphoma• Systemic
– Drug reactions/toxicity– Eosinophilic dermatitis– Graft vs. host disease
• OtherCendales LC, Kanitakis J, Schneeberger S, Burns C, Ruiz P, Landin L, Remmelink M, Hewitt
CW, Landgren T, Lyons B, Drachenberg CB, Solez K, Kirk AD, Kleiner DE, Racusen L. The Banff 2007 working classification of skin-containing composite tissue allograft pathology. Am
J Transplant. 2008 Jul;8(7):1396-400.
Conclusions• CTA allografts are grossly visible allowing for closer and
perhaps novel methods of monitoring
• Unexpected development of obliterative arteriopathy is not uncommon in all solid organ allografts and arterial wall thickness monitoring is helpful
• Early experience suggests that chronic CTA rejection will be more similar than different from solid organ allografts
• Novel immunosuppressive and treatment strategies are needed.
Case Presentation
Graft Appearance, Clinical Course, Skin Biopsy Histology and Outcomes:
Five Cases in Hand Transplant Recipients
THE LOUISVILLE VCA PROGRAMTHE LOUISVILLE VCA PROGRAM
CL Kaufman, MR Marvin, R Ouseph, R Zaring, Y Manon-Matos, B Blair, JE Kutz
Case Description Overall Grade ActualTreatment
HindsightView
1 Patient with extensive rejection not equally reflected in biopsies – Grade 0 and Grade II
? Significant based on clinical symptoms
Solumedrol IV and steroid taper
Chronic rejection of skin?
2 Skin histology at year 6 does not seem to reflect chronic rejection
Grade I-II possible complications from chronic superficial venous thrombus
Year 6 Solumedrol IV and pred taper
Venous obstruction?
3 This patient routinely has Grade I infiltrates, showed a Grade 3 biopsy in the absence of clinical symptoms
Grade 3, no symptoms, Grade 0 in local area subsequently
No additional treatment
So far, fine.
4 Banff grade 2 in year 11 and year 12 skin biopsy
Year 11 –grade IIYear 12 –grade I-II
No additional treatment
Allograft seems finePt does have DSA (C1q-)
Summary of cases
Bilateral forearm transplantation (México)
Dr. Armando Gamboa HernándezDr. Martín Iglesias (corresponding author)Dra. Patricia Butrón GandarillasDra. Josefina Alberú GómezDr. Mario VilatobaDr. Luis Eduardo MoralesDra. Norma Bobadilla
Banff VCA GroupCase Discussion
August 22, 2013
Banff VCA GroupCase Discussion
August 22, 2013
Max K. Fischer, MD, MPHAssistant Professor
Division of DermatopathologyJohns Hopkins University
12th Banff Conference on Allograft Pathology:
Diagnostic challenges in diagnosing rejection in vascularized composite
allografts
Chandra Smart, MDScott Binder, MD
UCLA Department of Pathology and Laboratory Medicine
Section of DermatopathologyAugust 22, 2013
Pathological aspects suggestive of skin chronic rejection in a face transplant recipient after
reduction of immunosuppression
Banff-VCA conference 2013
Emmanuel Morelon, Sylvie Testelin, Palmina Petruzzo, Lionel Badet, Bernard Devauchelle, Jean Kanitakis
On behalf of the Lyon-Amiens VCA team
Composite Tissue Session(Vascularized composite allografts)
Discussion
No changes to the Classification System at this time