The document summarizes discussions from a workshop on vascularized composite allotransplantation (VCA) pathology. It addresses several unanswered questions in the field and proposes updates to the Banff VCA classification system. Key points discussed include: - Reviewing the specificity and significance of isolated dyskeratotic/apoptotic cells in different skin structures for grading rejection. - Studying the roles of C4d staining, antibody functions, and chronic changes like vasculopathy. - Addressing questions from an AST working group on expanding grading criteria, differences between hand and face transplants, optimal biopsy size and location. - Proposing a standardized biopsy collection form and digital library to facilitate

1. Vascularized Composite Allotransplantation
Banff VCA
Linda C. Cendales, M.D.
Associate Professor of Surgery
Duke University Medical Center
on behalf of
The Banff VCA Working Group

2. < 250 VCA recipients worldwide

3. Congratulations
to the field of
Vascularized Composite
Allotransplantation
for organizing themselves
under the Banff Structure

4. Coming together and agreeing to
systematically study VCA pathology is
a significant step
But the hard work starts now

5. We started talking together in a
common language
We can now argue

6. The Towel of Babel
Painting by Peter Bruegel the Elder, 1583

7. We cannot have arguments and
organize ourselves until we have a
common language.

8. A common language facilitates
disagreement in a good way
A common language allows for
collaboration

9. Diagnosis of Transplant Rejection
in the 1980’s
Transplantation 1984 Dec;38(6):709-13.
Relationships among the histologic pattern, intensity, and
phenotypes of T cells infiltrating renal allografts.
Kolbeck PC, Tatum AH, Sanfilippo F.
Histopathology. 1980 Sep;4(5):517-32.
The relation of different inflammatory cell types to the
various parenchymal components of rejecting kidney
allografts.
Reitamo S, Konttinen YT, Ranki A, Häyry P.

10. Common Language

11. Vascularized Composite
Allotransplantation
Before 2007
Nothing

12. VCA Banff
Now

13. Keeping this group together under this
framework is how this is going to go
forward
We can now answer the questions

14. Unanswered Questions

15. Histologic Features of Antibody Mediated Rejection after
Face Transplantation
Anil Chandraker MD FASN FAST FRCP
Medical Director of Kidney and Pancreas Transplantation
Brigham and Women’s Hospital
Director, Schuster Family Transplantation Research Center
Brigham and Women's Hospital
Associate Professor of Medicine, Harvard Medical School

16. Pre-Sensitized Recipient of a Full-Face
Allotransplant

17. Acute Cellular Rejection

18. Complement Deposition (C4d)
Pre- cellular rejection Cellular rejection Post-
treatment
Pre-
sensitized
patient
Not pre-
sensitized
patient

19. Graft vasculopathy in the skin
in vascularized composite allografts
J. Kanitakis
Depts. of Dermatology/Pathology
Ed. Herriot Hospital, Lyon, France
BANFF‐CST Joint Scientific Meeting
October 8, 2015 Vancouver, British Columbia

20. Sudden necrotic ulcerationProgression to scaly
erythematous maculopapules
SSG
initial
aspect
SSGNovember 2014

21. ID Nov 2014
– 9 years postTx (face)
CD20
CD4
C4d
Banff grade III

22. thickening/luminal obstruction of the nutrient SSG artery
≈ graft vasculopathy
SSG ulceration ID Nov 2014 – 9 years postTx - SSG
C4d-
AR rejection on the face (Banff III)
Graft vasculopathy of the SSG

23. Cutaneous Changes among
Transplant Patients
Adela Rambi G. Cardones, M.D.
Immunodermatology, Chronic GVHD Clinic
Director, Inpatient Consult Service
Assistant Professor
Duke University Department of Dermatology

24. Atypical Acute Rejection After Hand Transplantation
Schneeberger S, et al. American Journal of Transplantation
Volume 8, Issue 3, pages 688-696, 5 FEB 2008 DOI: 10.1111/j.1600-6143.2007.02105.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2007.02105.x/full#f3

25. Nails
(Distinctive Signs)
Dystrophy, pterygium, longitudinal ridging.

26. VCA Research Laboratory - Mission
Expanding the Banff VCA Criteria
Gerald Brandacher, MD, FAST
Associate Professor or Surgery
Scientific Director
Reconstructive Transplantation Program
Johns Hopkins University School of Medicine
Baltimore, MD, USA
on behalf of the AST VCA Advisory Council Working Group

27. Question from the AST Working Group
Does biopsy site matter? The skin anatomy and characteristics differ
significantly depending where on the hand or face the biopsy is taken. Should
this be reflected in the Banff Criteria?
While 4 mm biopsies provide a great deal of information, many centers do not
feel a biopsy of this size is practical. Should this criteria be revisited?
Additionally would more information be gained from two smaller biopsies,
one taken from an area of involvement and one from a “normal” area?
There appears to be distinct differences between infiltrates and histology of skin
from hand vs. face transplants. Should these differences be reflected in the
histological grade of rejection?

28. Question from the AST Working Group
Specific criteria to be reconsidered
a.Is the PAS stain still relevant and routinely performed?
b.CD163 may be a preferable marker to CD68 for macrophages.
c.What is the rationale to include both CD19 and CD20?
d.Why is CMV proposed as a recommended immunohistological stain
(would be unusual in the differential of rejection).
e.Inclusion of additional immunohistochemistry markers e.g. FoxP3.

29. Question from the AST Working Group
Many centers continue to report histological grades of 0-I, I-II and II-III
from review of VCA skin biopsies. As it is still unclear what histology
that is less severe than a grade I means, should we expand the
criteria?
Is the granularity of the current criteria sufficient?

30. Discussion
• Unanswered questions collected over the
years by the Banff VCA group
• Reviewed results of Banff VCA survey
• Reviewed Proposal for collection data
form
• Reviewed AST VCA advisory council
questions
• VCA Working Group Workshop, May 21,
2016, Durham, NC

31. • Challenges grading Banff VCA 0-I-II
• Specificity of isolated dyskeratotic/apoptotic
keratinocytes
• Does location alter the specificity of isolated
dyskeratotic/apoptotic cells?
– Epidermis
– Follicular epithelium
– Sweat gland epithelium
– Basal vs. suprabasal/at all levels
• Analogy to GVHD
• Value of a numeric threshold
• Role of mast cells in chronic immune injury
• Role of C4d staining and/or DIF staining for C4d in the
management of rejection
Banff VCA – Unanswered Questions

32. Banff VCA – Unanswered Questions
• Significance of focal epidermal changes (i.e. spongiosis
and/or lymphocyte exocytosis) in Banff VCA grades
• Study of effector functions of antibody and its
manifestations in tissues (acute and chronic)
• Detection of antibody functions
– Biopsy: histology, genomics
– Blood: serological, cellular
• Chronic changes
• Relationship of graft function and rejection
– Acute and Chronic

33. Banff VCA – Unanswered Questions
•Interpretation of long-term changes and related
biomarkers
•Differential diagnosis of inflammation vs. rejection
•Scope of Disease - Antibody Mediated Rejection
•Significance of myointimal proliferation
•Vasculopathy, role of antibody

34. Banff VCA Survey

36. We translated these results into
a one-page form to standardize
the collection of data

37. Banff VCA Biopsy Form
CUTANEOUS
Patient’s Surgical Identification # (or Case #): ________________
Patient’s Transplant Type: Limb, face, abdominal wall, etc.
Physician / Clinician to contact with results: (If more than one person, please let us know)
Name: Specialty:
Address:
Telephone number: __________ Fax number: __________
Email Address:
----------------------------------------------------------------------------------------------------------------------------
Protocol Biopsy Other _________________
Clinical signs and symptoms at the time of the biopsy (check all that apply)
__ rash __ sclerosis __edema __ pain __ erythema __ scale____blister_____
Percentage of allograft involved: <10%, ________ 10-50% ___________ >50% __________
Immunosuppressive Therapy for the transplant:
Sample Type, Punch ____ ellipse ____other____
Other stains ___________
Epidermis
Thickness Normal Atrophic Hypertrophic
Basilar Vacuolopathy Yes No
Dyskeratotic cells Yes No
Spongiosis Yes No
Keratinocytic Atypia Yes No
Exocytosis
Lymphocytes Yes No
Other Inflam Cells Yes No
Follicular Sebaceous Unit
Extent of involvement Upper half Lower half
Basilar Vacuolopathy Yes No
Apoptosis Yes No
Exocytosis
Lymphocytes Yes No
Other Inflammatory Cells Yes No
Eccrine Glands
Extent of involvement Duct Gland Both
Basilar Vacuolopathy Yes No
Apoptosis Yes No
Exocytosis
Lymphocytes Yes No
Other Inflammatory Cells Yes No
Endothelialitis
VX Not sampled
V0 No endothelialitis
V1 Endothelialitis
Final Diagnosis _____________________________
Banff Score __________
Comments _________________________________
Dermis
Extent of Involvement
Papillary Dermis only Yes No
Reticular Dermis only Yes No
Both Yes No
Inflammation:
Cell Type:
Lymphocytes Yes No
Plasma Cells Yes No
Eosinophils Yes No
Neutrophils Yes No
Distribution:
Perivascular Yes No
Periadnexal Yes No
Interstitial Yes No
Band-like Yes No
Sclerosis
Papillary Dermis only Yes No
Reticular Dermis only Yes No
Both Yes No
Vascular Changes
Arteriopathy Yes No
% narrowing of the lumen __<25% ___25-50%, ___> 50%)
Immunohistochemistry
C4d immunohistochemistry
____Negative ____positive ____not done
Others:

38. Banff VCA Resource

39. Human and Animal Histology/Immunohistochemistry Core
• VCA clinical samples (>2000)
– Tissue samples: muscle, skin, tendon, nerve, artery, vein
• Histopathology Core
• Digital Library
– Digital slide scanning – Aperio AT [400 slide scan capability]
• Dedicated Lab Space
• Histology Staff
Digital Library

40. AST VCA advisory council
questions
• Many centers continue to report histological grades of 0-I, I-II and II-
III from review of VCA skin biopsies. As it is still unclear what
histology that is less severe than a grade I means, should we
expand the criteria?
• New information is accumulating regarding the importance of loss of
capillaries and importance of evaluating small vessel vasculopathy.
Should a grading scale for early signs of “chronic” rejection be
proposed?
• There appears to be distinct differences between infiltrates and
histology of skin from hand vs. face transplants. Should these
differences be reflected in the histological grade of rejection?

41. • While 4 mm biopsies provide a great deal of information, many
centers do not feel a biopsy of this size is practical. Should this
criteria be revisited? Additionally would more information be gained
from two smaller biopsies, one taken from an area of involvement
and one from a “normal” area?
• While the current criteria do note that the level of involvement in the
graft should be reported, this is not reflected in the histological
score. Practically, this histologic score is used interchangeable as
“Grade of Rejection”. Should the working group propose an actual
“Grade of Rejection” vs. “grade of histology” that would reflect
clinical parameters such as
a. level of involvement, b. Edema, c. Induration
• Does biopsy site matter? The skin anatomy and characteristics
differ significantly depending where on the hand or face the biopsy
is taken. Should this be reflected in the Banff Criteria?
AST VCA advisory council questions

42. Workshop on VCA Pathology
May 21, 2016
Durham, NC

43. Thank you