Composite Tissue Session
(Vascularized composite allograft)
Banff 2013 Summary
Linda Cendales, M.D
VCA Banff 2013
Summary
• Speakers
– Cinthia Drachenberg
– Anthony J. Demetris
– Christina Kaufman
– Norma Uribe
• Virtual ...
Chronic Rejection in Vascularized
Composite Allografts
Cinthia Drachenberg, M.D.
Professor of Pathology
University of Mary...
Chronic rejection in CTA
• Overview of chronic changes reported in the
literature
– Pre-clinical and clinical
• CTA/VCA sh...
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 monthsSynovial biopsy 50 months
Pathogenesis: of vasculopathy
Non-alloimmune factors: trauma. episodic intense or chronic low
grade mechanical damage, the...
Can we borrow knowledge from other
organs?
Similarities:
•Morphology, distribution, progression, unclear
etiology
•Variabi...
Histopathological Observations in CTA
with Clinical Correlation
A.J. Demetris
Thomas Starzl Transplant Institute
Dept. of ...
Cell-mediated Injury
Cornell et al Annu. Rev. Pathol. Mech. Dis. 2008. 3:189–220
Antibody Mediated Injury
PMN
anti-HLA Abanti-HLA Ab
Fc ReceptorFc Receptor
Mediated BindingMediated Binding
C’ ActivationC...
Differential diagnosis in skin allograft
biopsies, other than acute cellular
rejection
• Graft localized
– Trauma
– Insect...
Conclusions
• CTA allografts are grossly visible allowing for closer and
perhaps novel methods of monitoring
• Unexpected ...
Case Presentation
Graft Appearance, Clinical Course,
Skin Biopsy Histology and Outcomes:
Five Cases in Hand Transplant Recipients
THE LOUISV...
Case Description Overall Grade Actual
Treatment
Hindsight
View
1 Patient with extensive rejection
not equally reflected in...
Bilateral forearm transplantation (México)
Dr. Armando Gamboa Hernández
Dr. Martín Iglesias (corresponding author)
Dra. Pa...
Banff VCA Group
Case Discussion
August 22, 2013
Max K. Fischer, MD, MPH
Assistant Professor
Division of Dermatopathology
J...
12th
Banff Conference on Allograft
Pathology:
Diagnostic challenges in diagnosing
rejection in vascularized composite
allo...
Pathological aspects suggestive of skin chronic
rejection in a face transplant recipient after
reduction of immunosuppress...
Composite Tissue Session
(Vascularized composite allografts)
Discussion
No changes to the Classification System at this ti...
Linda Cendales Composite Tissue Graft Summary Banff 2013 Meeting in Brazil
Linda Cendales Composite Tissue Graft Summary Banff 2013 Meeting in Brazil
Linda Cendales Composite Tissue Graft Summary Banff 2013 Meeting in Brazil
Linda Cendales Composite Tissue Graft Summary Banff 2013 Meeting in Brazil
Linda Cendales Composite Tissue Graft Summary Banff 2013 Meeting in Brazil
Linda Cendales Composite Tissue Graft Summary Banff 2013 Meeting in Brazil
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Linda Cendales Composite Tissue Graft Summary Banff 2013 Meeting in Brazil

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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/2013

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Linda Cendales Composite Tissue Graft Summary Banff 2013 Meeting in Brazil

  1. 1. Composite Tissue Session (Vascularized composite allograft) Banff 2013 Summary Linda Cendales, M.D
  2. 2. VCA Banff 2013 Summary • 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
  3. 3. Chronic Rejection in Vascularized Composite Allografts Cinthia Drachenberg, M.D. Professor of Pathology University of Maryland School of Medicine
  4. 4. 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.
  5. 5. Unadkat et al. Vasculopathy at 90 days in rat hind limb model
  6. 6. Striking venous inflammation with thickening and occlusion not shown.
  7. 7. Synovial biopsy 18 months Sentinel graftl biopsy 36 months Soft tissue biopsy 50 monthsSynovial biopsy 50 months
  8. 8. Pathogenesis: of vasculopathy Non-alloimmune factors: trauma. episodic intense or chronic low grade mechanical damage, thermal injury. hyperplasia as well as remodeling . Microsurgery 1996
  9. 9. 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.
  10. 10. Histopathological Observations in CTA with Clinical Correlation A.J. Demetris Thomas Starzl Transplant Institute Dept. of Pathology Division of Transplantation University of Pittsburgh Medical Center Pittsburgh, PA
  11. 11. Cell-mediated Injury Cornell et al Annu. Rev. Pathol. Mech. Dis. 2008. 3:189–220
  12. 12. Antibody Mediated Injury PMN anti-HLA Abanti-HLA Ab Fc ReceptorFc Receptor Mediated BindingMediated Binding C’ ActivationC’ Activation Donor HLADonor HLA MACMAC Platelet microthrombiPlatelet microthrombi EndotheliumEndothelium ADCCADCC CDCCDC C4dC4d C4a +C4bC4a +C4b C4C4 C1C1 Courtesy of Peter Nickerson
  13. 13. 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 • Other Cendales 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.
  14. 14. 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.
  15. 15. Case Presentation
  16. 16. 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
  17. 17. Case Description Overall Grade Actual Treatment Hindsight View 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 II Year 12 –grade I-II No additional treatment Allograft seems fine Pt does have DSA (C1q-) Summary of cases
  18. 18. Bilateral forearm transplantation (México) Dr. Armando Gamboa Hernández Dr. Martín Iglesias (corresponding author) Dra. Patricia Butrón Gandarillas Dra. Josefina Alberú Gómez Dr. Mario Vilatoba Dr. Luis Eduardo Morales Dra. Norma Bobadilla
  19. 19. Banff VCA Group Case Discussion August 22, 2013 Max K. Fischer, MD, MPH Assistant Professor Division of Dermatopathology Johns Hopkins University
  20. 20. 12th Banff Conference on Allograft Pathology: Diagnostic challenges in diagnosing rejection in vascularized composite allografts Chandra Smart, MD Scott Binder, MD UCLA Department of Pathology and Laboratory Medicine Section of Dermatopathology August 22, 2013
  21. 21. 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
  22. 22. Composite Tissue Session (Vascularized composite allografts) Discussion No changes to the Classification System at this time

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