Diagnosis of chronic lung transplant rejection by transbronchial biopsy

Chronic rejection in the form of obliterative bronchiolitis (OB) associated with chronic inflammation and fibrosis of bronchi (CIB) is a significant cause of morbidity and mortality in long-term heart-lung and single-lung transplant recipients. To determine the utility of transbronchial biopsy in diagnosing chronic rejection, we reviewed 24 transbronchial biopsies (TBBs) performed at the time of, or subsequent to, a clinical diagnosis of OB of chronic rejection in eight heart-lung and single-lung transplant recipients at the Methodist Hospital, Houston, Texas. These were compared with 36 randomly selected control TBBs from 14 patients without a clinical or histopathologic diagnosis of OB of chronic rejection at any time in their course. In the former group of TBBs, nine (38%) were diagnostic of OB and seven (29%) showed CIB suspicious for chronic rejection. TBBs diagnosed as negative had significantly fewer samples of tissue (1.0 versus > 3) and significantly smaller size of tissue (1.44 mm versus > 4.5 mm) than did TBBs in the OB or CIB categories. When strict criteria were used, no false diagnoses of OB of chronic rejection were made on control TBBs. However, OB associated with bronchiolitis obliterans organizing pneumonia of viral pneumonitis was present in three (8%) and CIB in 15 (42%) of control TBB associated with acute rejection and infection. This finding emphasizes the nonspecificity of CIB. We conclude that TBB is potentially useful in diagnosing OB of chronic rejection in some cases and in suggesting chronic rejection in other cases. Inadequate sampling by the bronchoscopist was the major reason for a negative biopsy.

Significance of acute bronchitis/bronchiolitis in the lung transplant recipient

Acute bronchitis/bronchiolitis (ABB) in the lung allograft is characterized by a predominantly neutrophilic infiltrate in the small and large airways and accompanied by other features such as luminal dilatation, mucous plugging, and granulation tissue formation. The etiologies for ABB are varied and depend on the context in which this lesion is found. Fifty-nine biopsies from 49 patients were found to have these changes. By correlating the clinical and histopathologic features we found ABB in one of five clinico-pathologic categories: I) Harvest Injury (9 patients); II) Acute Cellular Rejection (7 patients); III) Bronchiolitis Obliterans Syndrome (14 patients); IV) Infection [prior to the development of bronchiolitis obliterans (OB)] (15 patients); and V) Other Manifestations of ABB (4 patients). In the context of early manifestations of harvest injury (Category I), ABB reflected severe ischemic lung injury with secondary acute inflammation of the airways. The prognosis was poor, with five patients dying and one requiring retransplantation because of irreversible harvest injury within 1 month of transplantation. When ABB was found in the setting of acute cellular rejection (Category II), it represented a severe manifestation of immunologic airway injury with a predominant lymphoplasmacytic response, and was followed by subsequent development of OB in five of seven patients. In those patients with histologically proven OB (Category III), the finding of ABB was present in a scarred or distorted airway and was a manifestation of airway rejection, infection, or both as demonstrated clinicopathologically, Infection-related ABB prior to the development of OB (Category IV) was managed as infection alone in 13 patients, but a coexistent perivascular lymphoplasmacytic infiltrate brought the concern for concurrent infection and rejection process in two patients. Since only two of the 15 patients in this category later developed OB, these patients with infectious ABB alone did not appear to be at a significant risk for the later development of OB. Finally, four patients demonstrated ABB without associated clinical manifestations and were placed in Category V (Other Manifestations of ABB). In this category, ABB was noted to be an indolent finding with all of the patients alive to date and none developing OB. Overall, the interpretation of ABB in the lung transplant setting depends on the recognition of the histologic clues and the clinical context in which one finds this airway lesion.

Ability to culture resectable non-small cell lung carcinomas is correlated with recurrence

Present clinicopathologic staging of non-small cell lung cancer is limited in its ability to provide more than a general prognostic estimate in patients with lung cancer who have resectable disease. This study was performed to identify whether the ability to adapt tumor tissue from resectable (stage I to IIIa) non-small cell lung cancer was associated with a poorer prognosis and an increased risk for early tumor recurrence. We attempted to culture a tumor specimen obtained from 90 patients with resectable non-small cell lung cancer. We used a culture medium conditioned by exposure to the lung cancer cell line A549-1, a known producer of autocrine lung cancer growth factors, and provided tumor colony scaffolding using a feeder layer of inactivated fibroblasts, and found these measures improved tumor culture yields. Twenty-two cell lines were obtained, a success rate of 24.4%. Tumor recurrences were more common (79%) among the culture-positive patients than among the culture-negative patients (37.5%; p < 0.002). For all patients, survival at 19 months in the culture-positive patients was 50.0%, compared with 83.6% in the culture-negative patients (p < 0.005). The median survival for the culture-positive patients was 15 months, versus 21.7 months for the culture-negative patients (p < 0.004). The establishment of a culture was a predictor of shortened survival for patients with stage I disease. In patients with stage I disease, survival at 19 months was 54.5% for the culture-positive patients, versus 89% for the culture-negative patients (p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Lymphangioleiomyomatosis: recurrence after lung transplantation

Pulmonary lymphangioleiomyomatosis is a disease principally affecting women during child-bearing years that eventually leads to respiratory failure. Recently, it has been listed as an indication for lung transplantation. To date, no cases of recurrent lymphangioleiomyomatosis after lung transplantation have been reported, unlike the experience with sarcoidosis and giant cell interstitial pneumonia. At the University of Pittsburgh Medical Center, four patients have undergone single-lung transplantation for lymphangioleiomyomatosis. We now report that one of these cases developed recurrent lymphangioleiomyomatosis in the allograft lung.

A comparison of ganciclovir and acyclovir to prevent cytomegalovirus after lung transplantation

In an attempt to modify the sequelae of cytomegalovirus (CMV) infections after lung transplantation, 25 allograft recipients were randomized to either ganciclovir 5 mg/kg once a day 5 d/wk (Group G) or acyclovir 800 mg four times a day (Group A). All subjects received ganciclovir during postoperative Weeks 1 through 3, and they were then given either A or G regimens until Day 90. At termination of study enrollment, the cumulative incidence of all CMV infections (including seroconversions) was increased in Group A compared with that in Group G (75% versus 15%, p < 0.01), as was the incidence of overt CMV shedding and/or pneumonitis (50% versus 15%, p < 0.043). In comparison with those in Group G, subjects in Group A were also afflicted with an increased prevalence of obliterative bronchiolitis (OB) during the first year after transplantation (54% versus 17%, p < 0.033). Intravenous catheters for ganciclovir administration resulted in four complications among three of the subjects in Group G (23%). The short-term benefits of ganciclovir were ultimately limited, moreover, in that cumulative rates of CMV and prevalence of OB are now similar in both treatment groups after approximately 2 yr of observation. We conclude that prolonged ganciclovir prophylaxis decreases the early incidence of CMV and OB among lung transplant recipients, but these effects are of finite duration. Although CMV prevention appears to have considerable potential value in this population, definitive viral prophylaxis will require development of protracted or repeated treatment regimens, or longer-acting agents.

Can immunohistological analysis of transbronchial biopsy specimens predict responder status in early acute rejection of lung allografts?

Acute cellular rejection (ACR) in the early posttransplant period is recognized as one predictor of the development of bronchiolitis obliterans in lung transplant recipients. Using an immunohistochemical panel of antibodies to CD3, L26, HLA-DR, collagenase IV, proliferating cell nuclear antigen (PCNA), KPI, and S100 antigens we analyzed cases of moderate ACR that did respond (n = 11) and that did not respond (n = 10) to bolus solumedrol therapy early in the postoperative period (< 100 days) to determine if we could identify predictors of histological response. Responders who had follow-up negative biopsies after therapy had biopsy specimens containing an average of 41.1% T cells (range, 15.1 to 69.8), 8.8% B cells (range, 0.6 to 20), 18.1% HLA-DR-positive cells (range, 3 to 29.6), 12.2% PCNA-positive cells (range, 2.7 to 22.6), 8.9% collagenase IV-positive cells (range, 0.7 to 20.9), and rare dendritic cells. Nonresponders who had follow-up biopsies that failed to show a significant change in rejection grade had biopsy specimens with the following average cell profiles: 35.8% T cells (range, 7 to 70.7), 21.6% B cells (range, 3.7 to 39.5), 14.2% HLA-DR-positive cells (range, 1.8 to 24.7), 11.4% PCNA-positive cells (range, 0.8 to 22), 12.6% collagenase IV-positive cells (range, 0.6 to 34.1), and occasional dendritic cells. Statistical analysis suggested that large numbers of B lymphocytes in early acute rejection predicts non-responsiveness to interventional immunosuppressive therapy and may indicate a significant role of humoral rejection in the behavior of early allograft rejection.

Deleterious effects of cardiopulmonary bypass on early graft function after single lung allotransplantation: evaluation of a heparin-coated bypass circuit

Clinical lung transplantation may necessitate the use of cardiopulmonary bypass during the procedure, resulting in increased morbidity with more severe early graft dysfunction and increased blood loss. A heparin surface-coated cardiopulmonary bypass circuit is now available with improved biocompatibility and reduced systemic heparin requirements and may offer advantages compared with standard uncoated cardiopulmonary bypass circuits. This study investigates in a canine model of single-lung allotransplantation whether cardiopulmonary bypass adversely affects early graft function and whether a heparin-coated cardiopulmonary bypass circuit with reduced systemic heparin dosage improves results compared with standard uncoated cardiopulmonary bypass systems. Fifteen dogs underwent left single-lung allotransplantation with occlusion of the contralateral pulmonary artery and bronchus 1 hour after reperfusion. In one group, five animals underwent the procedure without cardiopulmonary bypass. In the group with uncoated circuits, five animals underwent the procedure with the use of standard uncoated cardiopulmonary bypass circuits with full systemic heparin dosage. In the group with heparin-coated circuits, five animals underwent the procedure with the use of heparin-coated cardiopulmonary bypass circuits and reduced systemic heparin dosage. Early graft function was evaluated by arterial oxygenation, pulmonary mechanics, lung water measurements, and histologic analysis. Hemodynamics and postoperative blood loss were also measured. Two hours after reperfusion, partial pressure of oxygen in arterial blood on an inspired oxygen fraction = 1.0 was significantly greater (p < 0.001) in the group without cardiopulmonary bypass (467 +/- 58 mm Hg) than in the group with uncoated circuits (114 +/- 90 mm Hg) and the group with heparin-coated circuits (193 +/- 105 mm Hg), with no significant difference between the groups undergoing bypass procedures. Lung compliance decreased and lung water increased in all transplanted lungs without significant differences between groups. Histologic analysis did not differentiate between the groups. After reperfusion, cardiac index and mean arterial pressure were significantly reduced in the groups with uncoated circuits and with heparin-coated circuits compared with the group that did not undergo cardiopulmonary bypass (p < 0.001). Postoperative blood loss was significantly less (p < 0.002) in the group that did not undergo cardiopulmonary bypass (90 ml +/- 38 ml) compared with both the group with uncoated circuits (750 +/- 15 ml) and the group with heparin-coated circuits (690 +/- 387 ml), with no significant difference between the groups that underwent bypass. The use of cardiopulmonary bypass with systemic heparinization is detrimental to early graft function in this canine model of left single-lung allotransplantation.(ABSTRACT TRUNCATED AT 400 WORDS)

Case report: fluconazole therapy in histoplasma mediastinal granuloma

A 41-year-old man presented with night sweats, fever, and substernal chest pain approximately 5 months after being treated for community-acquired pneumonia. Chest radiograph revealed a mediastinal mass that was confirmed by computed tomography (CT) of the thorax. During surgery, enlarged paratracheal lymph nodes and a mass surrounding the right lower lobe bronchus and bronchus intermedius were found. Multiple biopsies from the mass showed that it consisted mainly of acellular fibrous tissue, but a small number of fungal forms typical of Histoplasma capsulatum were seen at the edged of the fibrotic reaction. The lymph nodes contained granulomatous inflammation and areas of necrosis, but no organisms were identified. The patient was treated with fluconazole for 6 weeks with resolution of symptoms. After completion of therapy, a follow-up CT scan of the thorax showed involution of the mediastinal mass. There has been no recurrence of symptoms or radiographic abnormalities for 24 months since cessation of fluconazole. This case illustrates isolated mediastinal involvement by histoplasmosis and suggests that therapy with fluconazole at this stage may prevent the often devastating late complications of mediastinal fibrosis.

Mixed allogeneic chimerism in lung allograft recipients

Microchimerism in lung allograft recipients was studied in the autopsies of nine female recipients of male lung grafts who had survived for more than 1 month after transplantation. Using a Y chromosome-specific probe tissues were studied for the presence of donor cells that had migrated beyond the graft itself. They were quantitated by cell counting to give absolute numbers of cells per organ volume. While donor cells were disseminated throughout the body, their numbers were small. These absolute numbers should be studied in a larger group of recipients to determine if they correlate with prognosis and the development of bronchiolitis obliterans.

A prospective randomized trial of FK506 versus cyclosporine after human pulmonary transplantation

We have conducted a unique prospective randomized study to compare the effect of FK506 and cyclosporine (CsA) as the principal immunosuppressive agents after pulmonary transplantation. Between October 1991 and March 1993, 74 lung transplants (35 single lung transplants [SLT], 39 bilateral lung transplant [BLT]) were performed on 74 recipients who were randomly assigned to receive either FK or CsA. Thirty-eight recipients (19 SLT, 19 BLT) received FK and 36 recipients (16 SLT, 20 BLT) received CsA. Recipients receiving FK or CsA were similar in age, gender, preoperative New York Heart Association functional class, and underlying disease. Acute rejection (ACR) was assessed by clinical, radiographic, and histologic criteria. ACR was treated with methylprednisolone, 1 g i.v./day, for three days or rabbit antithymocyte globulin if steroid-resistant. During the first 30 days after transplant, one patient in the FK group died of cerebral edema, while two recipients treated with CsA died of bacterial pneumonia (1) and cardiac arrest (1) (P = NS). Although one-year survival was similar between the groups, the number of recipients free from ACR in the FK group was significantly higher as compared with the CsA group (P < 0.05). Bacterial and viral pneumonias were the major causes of late graft failure in both groups. The mean number of episodes of ACR/100 patient days was significantly fewer in the FK group (1.2) as compared with the CsA group (2.0) (P < 0.05). While only one recipient (1/36 = 3%) in the group treated with CsA remained free from ACR within 120 days of transplantation, 13% (5/38) of the group treated with FK remained free from ACR during this interval (P < 0.05). The prevalence of bacterial infection in the CsA group was 1.5 episodes/100 patient days and 0.6 episodes/100 patient days in the FK group. The prevalence of cytomegaloviral and fungal infection was similar in both groups. Although the presence of bacterial, fungal, and viral infections was similar in the two groups, ACR occurred less frequently in the FK-treated group as compared with the CsA-treated group in the early postoperative period (< 90 days). Early graft survival at 30 days was similar in the two groups, but intermediate graft survival at 6 months was better in the FK group as compared with the CsA group.

Effect of cardiopulmonary bypass on early graft dysfunction in clinical lung transplantation

The records of 100 lung transplant recipients (13 heart-lungs, 45 double-lungs, and 42 single-lungs) from September 1990 through April 1992 were reviewed to determine the role of cardiopulmonary bypass (CPB) in early graft dysfunction. Fifty-five patients requiring CPB (CPB group) for 186 +/- 54 minutes were compared with the 45 patients without CPB (no-CPB group). All of the heart-lung and en-bloc double-lung transplantations were performed under CPB, with pulmonary vascular lung disease the principal diagnosis, resulting in a significantly younger age population in the CPB group. All other donor- and recipient-related factors matched well in both groups. Of 38 bilateral single-lung transplantations, CPB was used in 18. In double-lung and heart-lung recipients gas exchange of the allografts was evaluated by the arterial/alveolar oxygen tension ratios at nine intervals during the first 72 hours. The mean arterial/alveolar oxygen tension ratio in the CPB group was 0.48 +/- 0.19, significantly lower than in the no-CPB group with 0.60 +/- 0.22 (p = 0.025). All patients had radiographic interpretation and scoring of pulmonary infiltrates from chest roentgenograms taken within 12 hours after reperfusion. The CPB group had more severe pulmonary infiltrates than the no-CPB group (p = 0.034). Prolonged intubation defined as 7 days or longer occurred significantly more often (29/55) in the CPB group than in the no-CPB group (8/45) (p = 0.003). Actuarial graft and patient survival at 1 month was better in the no-CPB group than in the CPB group (42/45 versus 44/55 [p = 0.05] and 43/45 versus 45/55 [p = 0.033], respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of inhaled nitric oxide in a porcine model of adult respiratory distress syndrome

OBJECTIVE

To assess the efficacy of inhaled nitric oxide (NO) in reducing pulmonary hypertension in a porcine model of adult respiratory distress syndrome.

DESIGN

Nonrandomized, controlled experiment without blinding.

SETTING

Surgical research laboratory.

PARTICIPANTS

Twelve pigs, matched equally for body weight.

INTERVENTION

Acute lung injury was induced by intravenous injection of oleic acid. Animals were then divided into either a control group, for monitoring without any further intervention, or a NO-treatment group, in which NO was administered at concentrations of 10 to 80 ppm, with each step separated by a NO-free interval to assess duration of effect.

MAIN OUTCOME MEASURES

Pulmonary artery pressure, systemic blood pressure, PaO2, intrapulmonary shunt fraction, and extravascular lung water. Nitrosylated hemoglobin, arterial methemoglobin, and plasma nitrite and nitrate concentrations.

RESULTS

All animals responded to oleic acid injection with rapid development of pulmonary hypertension and deterioration of PaO2 and intrapulmonary shunt fraction. Inhaled NO reversed these changes in a concentration-dependent manner. Cessation of NO administration led to a prompt return of pulmonary hypertension. A small but significant drop in systemic blood pressure was observed only at the highest concentration of NO administered (80 ppm). Extravascular lung water almost doubled following oleic acid injury. This increase was sustained in all animals for the remainder of the experiment. Significant increases in circulating methemoglobin and plasma nitrite and nitrate concentrations were measured during NO inhalation.

CONCLUSION

Inhaled NO appears to be a selective pulmonary vasodilator and may prove to be useful in improving gas exchange in adult respiratory distress syndrome.

Diffuse pulmonary lymphangiomatosis

Angiomatous lesions of the lung are uncommon and not well characterized. We describe nine cases of a distinct lymphatic vascular lesion that we have termed "diffuse pulmonary lymphangiomatosis." Extrathoracic lymphangiomatous lesions were not identified. The patients comprised seven males and two females with a mean age at presentation of 10 years (age range, 1 month to 33 years). Six patients were younger than 10 years of age. Symptoms included "wheezing" or "asthma" (44%) and dyspnea (22%) present for 3 months to 20 years. Chest radiographs showed bilateral interstitial infiltrates, often greatest in the lower lobes. Pleural or pericardial effusions were present or developed in six patients. Pulmonary function tests showed in two patients and mixed obstruction and restriction in five patients. Open lung biopsies (nine patients) and autopsy (one patient) showed anastomosing endothelial lined spaces along pulmonary lymphatic routes (especially pleural and interlobular septal) accompanied by asymmetrically spaced bundles of spindle cells, which were prominent in six cases. Hemosiderin deposition often was present in the spindle cell areas and in the adjacent lung. The lining cells were positive for factor VIII-related antigen (eight cases) and Ulex europaeus I agglutinin (four cases). The spindle cells were reactive with antibodies to vimentin (nine cases), desmin (six cases), actin (seven cases), progesterone receptor (seven cases), and proliferating cell nuclear antigen (one case); they were negative for estrogen receptor (seven cases), keratin, (eight cases), and HMB-45 (eight cases). Diffuse pulmonary lymphangiomatosis was progressive in eight cases and was most aggressive in the youngest children. Two of the children have died, one of pulmonary hemorrhage and the other after heart-lung transplantation. Diffuse pulmonary lymphangiomatosis is distinct from lymphangiectasis, lymphangioleiomyomatosis, pulmonary capillary hemangiomatosis, Kaposi's sarcoma, and kaposiform hemangioendothelioma. Due to its distribution and histology, a lymphatic origin of the lesion is favored.

Recurrence of sarcoidosis in pulmonary allograft recipients

Lung transplantation is a potentially curative therapy for the end-stage pulmonary sequelae of sarcoidosis. We reviewed the course of five lung allograft recipients with underlying sarcoidosis (S) at the University of Pittsburgh Medical Center and compared them with a control group (C) of 44 contemporaneous transplant recipients with other respiratory diseases. Sarcoid granulomata have developed in the allografts of 4 S, although these lesions have not yet been demonstrated to result in clinically significant abnormalities. In comparison with C, sarcoidosis patients had significantly greater mean grades of acute rejection during the first 3 months after transplantation (2.1 +/- 0.3 versus 1.6 +/- 0.1, S and C, respectively, p < 0.042) and larger proportions of lung biopsies showing more than mild acute rejection (40 versus 18%, p < 0.012) and lymphocytic bronchitis (30 versus 13%, p = 0.02), as well as a greater percentage of polymorphonuclear leukocytes in BAL returns (34.9 +/- 5.4 versus 19.0 +/- 1.6, p < 0.01). The two groups did not differ, however, in frequency of obliterative bronchiolitis, survival, or pulmonary function. We conclude that lung transplant recipients with underlying sarcoidosis are very likely to develop recurrent disease in the allograft and have more severe acute rejection responses, especially in the first weeks after transplantation. Pulmonary transplantation appears to be an efficacious therapy for end-stage sarcoidosis, but the long-term sequelae of the increased acute rejection and recurrent sarcoidosis in the allograft remain to be determined.

Aspects of lung transplantation that contribute to increased severity of pneumonia. An experimental study

In lung or heart-lung transplant recipients, complications as a result of pulmonary infections continue to be the most frequent causes of morbidity and mortality. This study was undertaken to identify the contributions of (1) thoracotomy, (2) interruption of lymphatic vessels and bronchial arteries, (3) transplant procedure, (4) drug-induced immunosuppression, and (5) graft allogenicity to the increased risk of pneumonia in lung transplantation. Lewis rats were inoculated with 10(5) colony-forming units of Legionella pneumophila serogroup 1 by direct instillation into the trachea after one of the following: a general anesthetic with no operation; a left thoracotomy; a left thoracotomy with pulmonary hilar stripping; an isogeneic orthotopic left lung transplant with or without immunosuppression; or an allogeneic transplant with immunosuppression with Brown-Norway rats as donors. Immunosuppression was induced with an intramuscular injection of cyclosporine (25 mg/kg of body weight) from the inoculation day to day 3. All rats were killed on day 6, and severity of infection was determined by quantitative culture of Legionella organisms in the lungs and spleen, titer of Legionella urinary antigen, differential cell count in bronchoalveolar lavage fluid, body weight loss, and gross inspection of the lung. Significant increases in lung Legionella concentration occurred as a result of the addition of pulmonary hilar stripping (from 10(5.13 +/- 0.34) in the thoracotomy group to 10(5.66 +/- 0.25) in the thoracotomy with hilar stripping group, p = 0.013) and the addition of immunosuppression (from 10(5.47 +/- 0.47) in the isogeneic transplant group to 10(6.94 +/- 0.52) in the isogeneic transplant with immunosuppression group, p = 0.00016). Thoracotomy, transplant procedures, and allogenicity itself resulted in no significant increases. The results for all other indicators paralleled those for lung culture. We conclude that the combination of drug-induced immunosuppression with lung denervation and interruption of lymphatic vessels and bronchial arteries results in the early development and increased severity of pneumonia in lung transplantation.

An immunophenotypic study of the inflammatory cell populations in colon adenomas and carcinomas

There is increasing interest in the host immunologic response to colon carcinoma as immunotherapeutic techniques are being developed. We studied the inflammatory cells in 27 specimens of normal mucosa, 16 hyperplastic polyps, 21 tubular adenomas, 19 tubulovillous adenomas, 12 villous adenomas, and 17 invasive carcinomas using immunohistochemical techniques in paraffin-embedded tissue. UCHL-1-positive T-cells predominated in the lamina propria of all specimens. In polyps and carcinomas, reactive lymphoid follicles composed of L26-positive B-cells, and UCHL-1-positive T-cells were a prominent feature and UCHL-1-positive cells were increased in the epithelial compartment. Cells bearing surface immunoglobulins were widely distributed in all specimens, with IgA predominating. There was a relative increase in IgG-positive cells in the carcinomas. KP1-positive macrophages, S-100-positive dendritic cells, and HLA-DR-positive cells were oriented toward the lumenal surface in normal mucosa and hyperplastic polyps, suggesting a diffuse antigen presenting system. Macrophages and dendritic cells were increased and dispersed in the neoplasms. HLA-DR expression was increased in the neoplasms, mainly in the stromal cells. We conclude that there is an activated immune response in adenomas and carcinomas of the colon compared to normal mucosa. This is represented by expansion and reorganization of both the T- and B-cell compartments and the macrophage-cell systems.

Lymphocytic bronchitis/bronchiolitis in lung allograft recipients

Twenty-six cases of lymphocytic bronchitis/bronchiolitis (LBB) identified by transbronchial biopsy in 25 lung allograft recipients were studied to determine its relationships to acute rejection and bronchiolitis obliterans (OB). LBB occurred 355 days after transplantation on average (range, 15-2,118 days) and was manifested by a patchy or diffuse submucosal infiltrate of lymphocytes and plasma cells, which percolated deep to the smooth muscle layer of the bronchi in 15 cases. Submucosal granulation tissue and bronchiolitis were observed more frequently in patients who developed OB than in those who did not (44% and 88% vs 23% and 41%). Although 39% of patients progressed to OB overall, the majority of patients with LBB who received augmented immunosuppressive therapy (steroids, antithymocyte globulin, or both) improved or stabilized their pulmonary function abnormalities. Interestingly, LBB was preceded by acute rejection in 20 of 26 instances, and LBB frequently persisted as a histologic finding after the initial diagnostic transbronchial biopsy. LBB appears to be related to previous acute rejection episodes and responds to augmented immunosuppressive therapy.

Pediatric lung transplantation. The years 1985 to 1992 and the clinical trial of FK 506

The application of lung transplantation to the pediatric population was a natural extension of the success realized in our adult transplantation program, which began in 1982. Twenty pediatric patients (age range 3 to 18 years) have had heart-lung (n = 11), double lung (n = 8), and single lung (n = 1) transplantation procedures. The causes of end-stage lung disease were primary pulmonary hypertension (n = 7), congenital heart disease (n = 5), cystic fibrosis (n = 4), pulmonary arteriovenous malformation (n = 2), graft-versus-host disease (n = 1), and desquamative interstitial pneumonitis (n = 1). Four (20%) patients had thoracic surgical procedures before the transplantation operation. The survival was 80% at a mean follow-up of 2 years. Immunosuppressive drugs included cyclosporine (n = 9) or FK 506 (n = 11) based therapy with azathioprine and steroids. Children were followed up by means of spirometry, transbronchial biopsy, and primed lymphocyte testing of bronchoalveolar lavage fluid. The mean number of treated episodes of rejection was 1.4 at 30 days, 0.5 at 30 to 90 days, and 1.4 at more than 90 days, and the first treated rejection episode occurred on average 28 days after the operation. Obliterative bronchiolitis developed in four (25%) of 16 patients surviving more than 100 days. Results of pulmonary function tests have remained good in almost all recipients. The greatest infectious risk was that of cytomegalovirus: one death and one case of pneumonia. Posttransplantation lymphoproliferative disease was diagnosed in two (12.5%) patients; both recovered. The most common complications were hypertension (25%) and postoperative bleeding (15%). Early results indicate that lung transplantation is a most promising therapy for children with severe vascular and parenchymal lung disease.

Ameloblastoma of the maxilla: CT and MR appearance

This paper describes the CT and MR appearance of an ameloblastoma that involved the maxilla, infratemporal fossa, and adjacent structures. Although not pathognomonic, the multicystic appearance of an ameloblastoma may suggest the correct diagnosis.

Benefits of posttransplantation monitoring of interleukin 6 in lung transplantation

To determine the predictive diagnostic value of interleukin 6 (IL-6) monitoring in lung and heart-lung transplants, we measured posttransplantation serum IL-6 levels in 17 adult lung or heart-lung transplant recipients. Posttransplantation IL-6 elevation patterns were classified into 4 groups: serum IL-6 level remained negative throughout the monitoring period (group 1; n = 1; 6%); several sharp spikes with normal baseline (group 2; n = 9; 53%); persistently high level of serum IL-6 (group 3; n = 3; 18%); and several sharp spikes of serum IL-6 elevation with abnormally high baseline (group 4; n = 4; 24%). One patient without an elevation of IL-6 (group 1) did not experience any episodes of rejection or infection. Nine patients in group 2 had 19 IL-6 spikes, 13 of which were associated with histopathologically or clinically diagnosed rejection, 3 with acute bronchitis, and 1 with diffuse alveolar damage. Three patients in group 3 had persistent infections including cytomegalovirus infection, toxic megacolon, and repeated bacterial infection during the monitoring period, and 4 in group 4 died within 3 months after transplantation. From this study it appears that a spiked elevation of IL-6 could have a predictive value in diagnosing rejection, and persistently high levels of IL-6 indicate the presence of infection. Thus, IL-6 monitoring is beneficial for lung transplant recipients.

Multidrug resistance in lung allograft recipients: possible correlation with the development of acute and chronic rejection

The expression of drug resistance antigens in mononuclear inflammatory cells was studied in transbronchial lung biopsy specimens of lung allograft recipients who experienced steroid-sensitive and steroid-resistant bouts of acute rejection and bronchiolitis obliterans. Immunostains for C494 and C219 epitopes of p-glycoprotein and human metallothionein revealed that (1) mononuclear cells expressing these antigens are present in the lung allograft during rejection, (2) that steroid-resistant acute rejection is associated with increased percentages of C494 and metallothionein-positive cells as compared to steroid-sensitive cases, (3) that bronchiolitis obliterans was associated with a higher percentage of cells with drug-resistant antigen expression, and (4) that steroid-resistant bronchiolitis obliterans is associated with the highest percentage of C494 and metallothionein-positive cells in the five clinical situations studied. P-glycoprotein and metallothionein expression may be a marker of aggressive or persistent cases of acute rejection and bronchiolitis obliterans.

Sequelae of cytomegalovirus pulmonary infections in lung allograft recipients

Indirect effects of cytomegalovirus (CMV) infections in lung transplant recipients (LTX) have not previously been described in detail. We compared spirometric results, development of chronic rejection, rates of respiratory superinfections, and mortality as long as 2 yr after transplantation, between 62 LTX who never developed CMV (CMV-) and 56 LTX with a history of CMV pulmonary infections (CMV+). Initial spirometric parameters were near identical for both groups, but determinations > or = 6 months after transplantation showed that expiratory flows of the CMV+ were significantly reduced. Actuarial prevalences of chronic allograft rejection (CR) at 2 yr were highest among CMV+ with biopsy-proved pneumonitis (74%) compared with 22% among CMV- (p < 0.038). Bacterial or fungal pneumonias developed in 58.9% of the CMV+, whereas the rate among CMV- was 38.7% (p < 0.05). Only 36% of LTX with CMV pneumonitis lived 2 yr compared with 70% survival for CMV- (p < 0.016). Ganciclovir treatment of CMV infections decreased rates of respiratory superinfections and improved survival of patients, but it did not appear to affect subsequent development of CR. We conclude that CMV pulmonary infections among LTX result in serious late sequelae and that current treatment is ineffectual for prevention of viral-associated CR in these patients.