Similarity of pulmonary rejection patterns among heart-lung and double-lung transplant recipients

The transbronchial biopsy and clinical courses of 9 double-lung and 1 single-lung recipients surviving greater than 10 days were analyzed and compared to those of 15 heart-lung transplants performed during the same time period. Of these, 8 isolated lung (LT) and 11 heart-lung transplant (HLT) recipients survived greater than 50 days and were at risk of developing obliterative bronchiolitis believed to be a form of chronic rejection. Cyclosporine-based immunosuppression, in combination with azathioprine and steroids, was used for 22 of 25 patients. Two double-lung recipients and 1 heart-lung patient received FK506 as the sole immunosuppressive agent; 90% and 62% of LT, and 67% and 54% of HLT recipients developed acute and chronic rejection, respectively (P = NS). The average time to first episode of acute (30.2 days [LT] versus 21.5 days [HLT]) and chronic rejection (146 days [LT] versus 193.7 days [HLT]) was not different between groups (P = NS). Age (34.2 [LT] versus 29.1 [HLT]) and sex (M:F, 5:5 [LT] versus 5:10 [HLT]) were also not found to be discriminators. The histologic diagnosis of chronic rejection was associated with significant declines in FEV1.0 and FEF25-75 (P less than 0.02). There was only one instance of cardiac rejection among the heart-lung transplant recipients. Heart-lung and isolated lung transplant patients appear to be at similar risk for developing acute or chronic pulmonary rejection.

Bronchial cartilage alterations in lung transplantation

Changes in the hyaline cartilage of the proximal bronchial tree were investigated in a group of combined heart-lung and double-lung recipients with and without OB. Ossification, calcification and fibrovascular ingrowth into the normally avascular hyaline bronchial cartilage were observed in almost all patients and were independent of small or large airway inflammation. Alterations in the integrity of hyaline cartilage have been produced by others in animals by ligation of the blood supply. Finding similar changes in airway cartilage of all transplanted lungs argues that there is relatively poor perfusion to the proximal air-conducting passage. Such a mechanism may contribute to the development of OB, bronchiectasis and a predilection for infections following pulmonary transplantation.

Aerosolized cyclosporine as single-agent immunotherapy in canine lung allografts

Current systemic immunosuppressive regimens are unable to prevent lung allograft rejection consistently and are associated with significant morbidity and death. Acute rejection has occurred in 40% and chronic rejection in 50% of our lung recipients. We hypothesized that regional immunotherapy with aerosolized cyclosporine would prevent or reduce lung allograft rejection while allowing for low systemic drug delivery. In a canine model of unilateral lung allotransplantation, aerosolized cyclosporine was delivered directly to the allograft. Acute rejection was prevented or reduced in all treated recipients. All control animals had severe acute rejection. Intragraft cyclosporine concentration was high and systemic drug delivery was low, as evidenced by low whole-blood cyclosporine levels and low tissue cyclosporine levels in skeletal muscle. Ninety-five percent of whole-blood trough cyclosporine levels were less than 150 ng/ml. Aerosolized cyclosporine was able to prevent or reduce acute pulmonary rejection and resulted in minimal systemic drug delivery.

Typical and atypical carcinoid tumors of lung: a clinicopathologic and DNA analysis of 20 tumors

Twelve typical carcinoid tumors (TCT) and eight atypical (malignant) carcinoid tumors (ACT) of the lung were studied for quantitative DNA content by image analysis in order to identify prognostic features. No correlation of any histologic variables of the TCTs and ACTs with abnormal DNA content were noted. Furthermore, it was concluded that although abnormalities of DNA content, particularly aneuploidy, are common in ACTs, DNA ploidy cannot be used independently to assess malignant potential.

The effect of clinical history on chest radiograph interpretations in a PACS environment

The effect that accompanying patient information has on diagnostic accuracy in radiologic interpretation has been studied by many researchers but remains a matter of contention. Experiments in the past emphasized the chest film because this procedure is the one done most frequently in radiology. However, with the increasing importance of digital imaging, the role of patient history in these procedures should be assessed. The use of a model computerized patient history in the interpretation of digitized chest images that were displayed on a high-resolution workstation was studied. Two hundred forty-seven selected posteroanterior chest images that indicated disease and that indicated no disease were interpreted in random sequence by five board-certified radiologists, with and without accompanying patient histories. Readers were prompted by the response forms to evaluate images for the possible occurrence of interstitial diseases, nodules, or pneumothorax. No significant differences (P = .05) in the detection of these abnormalities were noted between case readings with and without history for any of the radiologists or for the group as a whole. However, this methodology reflects a direct interpretation approach. The results of this study may not necessarily be applicable to individual prompts, different imaging procedures, or other abnormalities.

HLA-class II antigen expression in human heart-lung allografts

Long-term survival in heart-lung transplantation has ben hindered by the development of bronchiolitis obliterans (OB), which is believed to be a manifestation of chronic rejection of the lung. Since HLA-class II antigens are involved in the rejection response, the distribution of the class II products HLA-DR, HLA-DQ, and HLA-DP were studied in normal lung, and in transplanted lung with and without OB, utilizing frozen-section immunohistochemical techniques. All three allelic products are usually expressed on the epithelial, endothelial, and mesenchymal components of the lung. Sequential transbronchial biopsies from 4 recipients before and concurrent with the diagnosis of OB were stained with serial dilutions of monoclonal antibodies to assess the level of expression of the above class II products. Increased levels of HLA-DR and HLA-DP antigens may be seen on the bronchial and bronchiolar epithelium during OB, but the changes are subtle and complicated by many other variables. Additional studies are needed to confirm these preliminary results.

The pulmonary pathologic manifestations of the CREST syndrome

This report evaluates the histopathologic alterations of a series of 17 patients with the CREST syndrome and relates these alterations to clinical and functional abnormalities. Histologic abnormalities were classified into the following four distinct patterns: pulmonary vascular changes, primarily intimal fibroelastosis, associated with and without pulmonary hypertension; a pattern of fibrosis indistinguishable from usual interstitital pneumonia (UIP); small airways disease; and mixtures of these three patterns. Five patients (29%) had clinical and morphologic pulmonary hypertension, while five others showed mild reductions in diffusing capacity, presumably due to vascular compromise. Five patients had UIP-like interstitial fibrosis, with vascular alterations and restrictive lung disease. Only one patient had small airways disease exclusively. Concentric fibrointimal proliferation and occlusion of arterioles was worse in patients with clinical pulmonary hypertension and interstitial fibrosis of the UIP type, and was not always associated with pulmonary fibrosis. Twenty-one percent of patients developed primary lung carcinomas. The CREST syndrome is unique in the spectrum of pulmonary alterations seen in progressive systemic sclerosis for its high incidence of clinical pulmonary hypertension and propensity for the development of pulmonary carcinomas.

Donor-specific cytotoxicity testing: an advance in detecting pulmonary allograft rejection

Ten beagle dogs underwent left unilateral lung transplantation and were treated with cyclosporine and azathioprine. After three days, cyclosporine administration was discontinued and azathioprine administration was maintained at a suboptimal dose to allow a graded response to the pulmonary allograft. Dogs were monitored by chest roentgenogram, bronchoalveolar lavage (BAL), and sampling of peripheral blood lymphocytes at weekly intervals. Open lung biopsies also were performed at weekly intervals in 5 of the dogs. Lymphocytes from the BAL and peripheral blood and those grown in culture from open and transbronchial biopsy specimens were tested for donor-specific cytotoxicity (DSC) by testing their responsiveness to lymphocytes from their donor. Rejection was confirmed in all animals. Donor-specific cytotoxicity became detectable in all animals in either the BAL fluid or biopsy specimens. An abnormal chest roentgenogram developed in 9 dogs, but not until after DSC was detected in the BAL in 7. In the open biopsy specimens tested for DSC, all exhibited DSC synchronous with the first changes noted on chest roentgenogram. Donor-specific cytotoxicity was sensitive for detecting rejection in 8 of 9 dogs in the BAL and in 5 of 5 dogs in the open biopsy specimens. Based on these results, 3 additional dogs were maintained on cyclosporine. Two of these dogs did not reject their transplants and had no evidence of DSC. We conclude that donor-specific functional assays provide an advance over less sensitive clinical techniques.

Clear cell tumor of the lung. A clinicopathologic, immunohistochemical, and ultrastructural study of eight cases

We studied eight clear cell tumors of the lung (CCTL) to better define their clinical, immunohistochemical, and ultrastructural features, and to clarify their distinction from other neoplasms, particularly metastatic renal cell carcinoma. Patients ranged in age from 31 to 67 years (mean, 51 years). Seven patients had clinically benign, asymptomatic lesions measuring less than 2 cm in diameter that were devoid of necrosis. The eighth patient had a symptomatic, partially necrotic CCTL 4.5 cm in diameter that metastasized to the liver and peritoneum; the patient died of tumor 17 years after diagnosis. Ultrastructural study of seven CCTL showed interdigitating cell processes (all cases), primitive cell junctions (five of seven cases), intracytoplasmic glycogen (all cases), and rare dense core granules (two of seven cases). Immunohistochemically, paraffin-embedded sections from all eight CCTL were negative for cytokeratin (CK), epithelial membrane antigen (EMA), chromogranin, and vimentin. Focal staining was seen for S-100 protein (three of eight cases), neuron-specific enolase (three cases), synaptophysin (one case), and Leu 7 (one case). Although these findings suggest that at least some CCTL exhibit neuroendocrine differentiation, the tumor's histogenesis remains uncertain. Of more practical importance, the combined absence of CK, EMA, and vimentin in formalin-fixed, paraffin-embedded CCTL virtually precludes confusion with renal cell carcinoma. Although traditionally considered benign, CCTL larger than 2 cm that are symptomatic, and focally necrotic should be regarded as potentially malignant neoplasms.

Potential role of dendritic cells in bronchiolitis obliterans in heart-lung transplantation

Dendritic cells are essential for the activation of the type IV immunological reactions that are intrinsic to rejection of transplanted organs. We evaluated the number of dendritic cells in the recipient and donor portions of the trachea and donor bronchi of 6 heart-lung transplant recipients, 3 of whom had evidence of bronchiolitis obliterans, a presumed manifestation of chronic rejection of the lung. As compared with recipients without bronchiolitis obliterans, patients with it showed a significant increase in the number of S100-protein-positive dendritic cells in the tracheal and bronchial epithelium and submucosa of the donor organs. This finding of increased accessory cells in the transplanted mucosa provides support for the belief that bronchiolitis obliterans is an immunologically mediated form of chronic rejection.

Pulmonary blastoma. An immunohistochemical analysis with comparison with fetal lung in its pseudoglandular stage

Pulmonary blastomas are believed to be mixed epithelial and mesenchymal tumors that recapitulate the developing lung at 10-16 weeks gestation. The authors compared nine blastomas with ten fetal lungs in the pseudoglandular stage of development with a panel of antibodies to various lung antigens to evaluate immunophenotypic homology. Both blastomas and embryonal lungs showed expression of cytokeratin, epithelial membrane antigen, and carcinoembryonic antigen in their epithelial elements, and both contained scattered chromogranin-positive neuroendocrine cells. Rare surfactant-producing and Clara cell antigen-elaborating cells were identified in both groups. The mesenchymal components of blastomas and fetal lung showed smooth muscle, myofibroblastic, and blastematous differentiation. The blastematous elements demonstrated vimentin and keratin coexpression in four cases, providing some support for the contention that pluripotential blastema may give rise to the epithelial and mesenchymal elements of the distal lobule.

Intravascular lymphomatosis presenting in the lung

We report four patients who had intravascular lymphomatosis (IVL) that presented as interstitial lung disease. All four patients had progressive shortness of breath, weight loss, fever, and diffuse interstitial infiltrates on chest radiographs. Open lung biopsy samples showed an interstitial pneumonia except for the intravascular proliferation of large lymphoid cells associated with irregular congestion, fibrin microthrombi, and intimal proliferation in vessels. This appearance corresponded to an intravascular large cell lymphoma (malignant angioendotheliomatosis [MAE], angiotropic lymphoma). The differential diagnosis of IVL with other pulmonary lymphoproliferations and intravascular malignancies is reported.

Proliferative responses of bronchoalveolar lavage lymphocytes from heart-lung transplant patients

Donor-specific alloreactivity of bronchoalveolar lavage (BAL) lymphocytes was evaluated in the immunologic monitoring of lung transplant patients. The study dealt with 161 BAL performed on 28 transplant recipients. Unseparated BAL cells, separated BAL lymphocytes, and PBL were tested for donor-specific proliferative responses in 3-day primed lymphocyte testing (PLT), and for nonspecific proliferative responsiveness to exogenous IL-2. The proliferation data were analyzed for correlation with the status of the lung allograft assessed clinically, histologically, and by pulmonary function testing. Positive PLT responses of BAL lymphocytes were observed in 20 of 22 acute rejection episodes (91%) and in 24 of 35 cases (69%) when chronic rejection was diagnosed. During clinical quiescence donor-specific proliferative activity was demonstrated in only 4 of 35 cases (11%). Thus, acute rejection and chronic rejection correlated significantly (P less than 0.001) with donor-specific PLT reactivity of BAL lymphocytes. Though significant association with rejection was observed for the alloreactivity of unseparated BAL cells and PBL, the sensitivity of the PLT test with these cells was significantly lower than that with BAL lymphocytes. Similarly, the IL-2 proliferative activity of BAL lymphocytes was significantly increased during acute and chronic rejection. However, this test had lower sensitivity and specificity than did the donor-specific PLT. These findings suggest the usefulness of the donor-specific PLT of BAL lymphocytes as a reliable method for monitoring pulmonary rejection.

Disruption of the aortic anastomosis after heart-lung transplantation

Disruption of the aorta at the anastomotic site occurred in 4 of 66 consecutive heart-lung transplant recipients and was associated with a 100% mortality. In 3 of these patients, Candida either was cultured from the suture line or was seen in the wall of the aorta at postmortem examination. In 2 of these 3 patients, cultures of material from the donor trachea taken at the time of explanation grew Candida species. Two patients were seen with sudden massive hemorrhage on postoperative day 26 and postoperative day 28. One patient experienced acute decompensation due to right ventricular outflow tract obstruction on postoperative day 30, and the remaining patient was seen 7 months postoperatively with obstruction of both the left main bronchus and the right pulmonary artery caused by extrinsic compression by an aortic pseudoaneurysm. A high index of suspicion should be maintained when transplanting lungs containing Candida species, as we believe there is substantial evidence of donor transmission of the fungal agents. We now include amphotericin B in our antibiotic prophylactic regimen in an attempt to prevent fungal infection because previous treatment has been uniformly unsuccessful. Furthermore, we wrap both the trachea and the aorta with omentum to lessen the likelihood of mediastinal spread of infection to the aortic suture line.

Epstein-Barr virus-associated lymphoproliferative disease in a heart-lung allograft. Demonstration of host origin by restriction fragment-length polymorphism analysis

An unusual posttransplant lymphoproliferative disorder is reported occurring within 6 weeks of a heart-lung transplantation, in a patient with primary exposure to the Epstein-Barr virus. The tumor presented primarily in the lung allograft as a rapidly fatal bronchopneumonia refractory to antimicrobial therapy. The viral genome was detected within the lesion by Southern blot analysis, and a primary infection was confirmed by serologic studies. Restriction fragment length polymorphism analysis using the LAM 4-1214 probe demonstrated that the tumor infiltrate in the allograft lung was derived not from the donor's bronchial-associated lymphoid tissue but from recipient lymphocytes trafficking through the allograft.

Respiratory bronchiolitis-associated interstitial lung disease and its relationship to desquamative interstitial pneumonia

Respiratory bronchiolitis is a mild inflammatory reaction commonly noted in asymptomatic cigarette smokers. We reviewed 18 cases of respiratory bronchiolitis-associated interstitial lung disease (RB/ILD), which had been diagnosed on the basis of clinical evaluation and open-lung biopsy. All patients were cigarette smokers. The sex distribution of the patients was approximately equal, and their mean age was 36 years. Chest roentgenograms showed reticular or reticulonodular infiltrates in 72% of the patients. Histologically, inflammation of the respiratory bronchioles, filling of the bronchiolar lumens and surrounding alveoli with finely pigmented macrophages, associated interstitial inflammation, and mild fibrosis were noted. In most patients, respiratory improvement ensued when they stopped smoking. Because of histologic similarities to desquamative interstitial pneumonia (DIP), the 18 cases of RB/ILD were compared with 36 cases of DIP. DIP tended to occur in older persons, caused more severe symptoms, displayed ground glass infiltrates on chest roentgenograms, was characterized by more severe interstitial disease on pulmonary function tests, and was often associated with progressive respiratory disease.

[New trends in combined transplantation of the heart and lungs]

Heart-lung transplantation is a surgical alternative for patients with end-stage lung disease with associated right heart failure. While the procedure is very promising, the morbidity and mortality remain high. The current understanding of the proper selection of candidates, procurement and preservation of donor organs, operative procedure and postoperative care continues to evolve. At the University of Pittsburgh, 70 heart-lung transplantations have been performed since 1982. Early infection and chronic rejection are the major factors influencing survival. Early (less than 2 weeks) intrathoracic infection occurred in 43% of heart-lung transplant recipients, with pneumonia being the most frequent infection. The incidence of pneumonia in heart-lung transplant recipients is twice that in a comparable group of heart recipients. Subclinical pneumonitis in the donor lung, abnormal muco-ciliary clearance and altered allogenic response in the transplanted lung are significant factors associated with the increased incidence of early infections. Chronic rejection, manifested as bronchiolitis obliterans, has occurred in 54% of heart-lung transplantation recipients. Infection caused by cytomegalovirus, Epstein-Barr virus and Pneumocystis carinii have been shown to increase the incidence of bronchiolitis obliterans, as have episodes of acute rejection. Recent reports of a 61% 2-year survival rate represent a substantial improvement over earlier trials. With a better understanding of the pathogenesis of infection in the transplanted lung as well as improved immunosuppressive agents, further improvements in survival can be expected.

Pulmonary capillary hemangiomatosis. A report of three cases and a review of the literature

Pulmonary capillary hemangiomatosis (PCH) is a rare cause of pulmonary hypertension. At present, only eleven cases have been reported. This report describes the clinical and pathologic findings in three additional cases who presented to the University of Pittsburgh for heart-lung transplantation and integrates the clinical features of all fourteen cases. Clinically, this disorder should be suspected in a patient who presents with pulmonary hypertension, hemoptysis, a reticulonodular infiltrate on chest radiograph, a lung scan showing inhomogeneously enhanced perfusion (particularly in the lower lobes), and pulmonary angiography showing increased peripheral vascularity corresponding to both the radiographic infiltrate and the areas of enhanced perfusion on lung scan. Histologic features consist of nodular proliferation of capillary-sized vessels that infiltrate the pulmonary interstitium, vascular walls, and lumens as well as the alveolar septa. The vascular invasion results in a secondary veno-occlusive phenomenon that explains the clinical confusion with pulmonary veno-occlusive disease.

Pulmonary adenosquamous carcinomas with amyloid-like stroma

Two unique cases of pulmonary carcinomas showing squamous and glandular differentiation and the production of excessive amounts of extracellular waxy eosinophilic material resembling amyloid are reported. Immunohistochemical studies showed strong staining of the neoplastic cells with antibodies directed at cytokeratin, epithelial membrane antigen, and carcinoembryonic antigen. Of particular interest was the simultaneous strong staining for S-100 protein and vimentin. The histology, ultrastructure, and immunohistochemical findings suggest focal myoepithelial differentiation in these mixed carcinomas and indicate an analogy to salivary gland neoplasms, particularly adenoid cystic carcinoma and dermal analog tumors.

Bronchiolitis obliterans in heart-lung transplantation patients: radiologic findings in 11 patients

Patients who survive the postoperative period after combined heart-lung transplantation are at risk for developing progressive airway damage consisting of central bronchiectasis and bronchiolitis obliterans. The cause of these abnormalities is uncertain, but they are thought to represent a form of chronic rejection. The chest radiographs and medical records of 11 transplantation patients with proved bronchiolitis obliterans were reviewed retrospectively. A pathologic diagnosis was made by open-lung biopsy (five patients), transbronchial biopsy (three patients), and autopsy (two patients). Clinical criteria alone were used for diagnosis in one patient. In all patients, the chest radiographs showed parenchymal abnormalities consisting of linear-nodular, nodular, confluent nodular, or diffuse alveolar opacities. Radiographic evidence of central bronchiectasis was present in nine of the 11 patients. This feature was not present on chest radiographs of five randomly selected asymptomatic transplant patients. We conclude that the parenchymal lung changes in bronchiolitis obliterans in transplant patients are nonspecific and are radiographically indistinguishable from other infectious and noninfectious complications. The presence of central bronchiectasis (nine of the 11 patients) may be a distinctive radiographic finding in this group of patients.

The clinical spectrum, pathology, and clonal analysis of Epstein-Barr virus-associated lymphoproliferative disorders in heart-lung transplant recipients

This study presents the clinical and laboratory observations on posttransplant lymphoproliferative disorders (PTLDs) occurring in 5 of 53 heart-lung transplantation recipients. Cervical lymph nodes, tonsils, lungs, and gastrointestinal tract were the common sites of involvement by PTLDs. The histopathologic findings showed a spectrum of lymphoid and immunoblastic proliferation ranging from diffuse hyperplasia to malignant lymphoma, immunoblastic or large cell type. All cases were associated with a primary Epstein-Barr virus infection, and viral DNA was demonstrated within the lesional tissue in three cases. Immunohistochemical and immunoglobulin gene rearrangement studies revealed a B-cell proliferation that was monoclonal in three cases and polyclonal in two cases. Compared with PTLDs arising in other organ transplant recipients, this series is remarkable for a high incidence of PTLDs (9.4%), a short interval to tumor diagnosis (2.2 months, mean), involvement of the primary allograft in three cases (60%), and the frequent development of bronchiolitis obliterans. Possible reasons for this distinct clinicopathologic profile are discussed.