Digital transplantation pathology: combining whole slide imaging, multiplex staining and automated image analysis.

Conventional histopathology is the gold standard for allograft monitoring, but its value proposition is increasingly questioned. "-Omics" analysis of tissues, peripheral blood and fluids and targeted serologic studies provide mechanistic insights into allograft injury not currently provided by conventional histology. Microscopic biopsy analysis, however, provides valuable and unique information: (a) spatial-temporal relationships; (b) rare events/cells; (c) complex structural context; and (d) integration into a "systems" model. Nevertheless, except for immunostaining, no transformative advancements have "modernized" routine microscopy in over 100 years. Pathologists now team with hardware and software engineers to exploit remarkable developments in digital imaging, nanoparticle multiplex staining, and computational image analysis software to bridge the traditional histology-global "-omic" analyses gap. Included are side-by-side comparisons, objective biopsy finding quantification, multiplexing, automated image analysis, and electronic data and resource sharing. Current utilization for teaching, quality assurance, conferencing, consultations, research and clinical trials is evolving toward implementation for low-volume, high-complexity clinical services like transplantation pathology. Cost, complexities of implementation, fluid/evolving standards, and unsettled medical/legal and regulatory issues remain as challenges. Regardless, challenges will be overcome and these technologies will enable transplant pathologists to increase information extraction from tissue specimens and contribute to cross-platform biomarker discovery for improved outcomes.

Primary and reactivated HHV8 infection and disease after liver transplantation: a prospective study.

Human herpesvirus 8 (HHV8) is pathogenic in humans, especially in cases of immunosuppression. We evaluated the risk of HHV8 transmission from liver donors, and its clinical impact in southern Italy, where its seroprevalence in the general population is reported to be as high as 18.3%. We tested 179 liver transplant recipients and their donors for HHV8 antibodies at the time of transplantation, and implemented in all recipients a 12-month posttransplant surveillance program for HHV8 infection. Of the 179 liver transplant recipients enrolled, 10.6% were HHV8 seropositive before transplantation, whereas the organ donor's seroprevalence was 4.4%. Eight seronegative patients received a liver from a seropositive donor, and four of them developed primary HHV8 infection. Two of these patients had lethal nonmalignant illness with systemic involvement and multiorgan failure. Among the 19 HHV8 seropositive recipients, two had viral reactivation after liver transplantation. In addition, an HHV8 seronegative recipient of a seronegative donor developed primary HHV8 infection and multicentric Castleman's disease. In conclusion, primary HHV8 infection transmitted from a seropositive donor to a seronegative liver transplant recipient can cause a severe nonmalignant illness associated with high mortality. Donor screening for HHV8 should be considered in geographic areas with a high prevalence of such infection.

Postoperative hepatic artery aneurysms development and remodeling in Ehlers-Danlos syndrome type IV. Case report.

Patients affected by Ehlers-Danlos syndrome (EDS) type IV are at risk for aneurysm formation and rupture. This case report shows the extreme vascular fragility of these patients. We studied a 31-year-old man that developed hepatic artery aneurysms 3 weeks after splenectomy. Computed tomography angiography showed the extreme vascular remodeling of the aneurysms. We conclude that remote site complications should be kept in mind by all surgeons in vascular EDS patients even after general surgery operations.

Acute renal allograft rejection with severe tubulitis (Banff 1997 grade IB).

Recent studies have correlated renal allograft function with individual histologic lesions defined in the Banff schema of kidney transplantation pathology. The clinical significance of severe tubulitis (Banff 97 grade t3) has not been specifically examined. We compared the clinical course and response to antirejection therapy in 36 patients with t3 tubulitis, and 137 patients with milder grades of tubulitis and varying grades of intimal arteritis. Rejection associated with severe tubulitis (grade t3) was associated with graft outcome that was worse than mild to moderate tubulitis (grades t1 or t2) and approached that seen in grade v1 intimal arteritis. Rejection characterized by grade v2 or v3 intimal arteritis had worse prognosis than v1 intimal arteritis and all grades of tubulitis without coexisting intimal arteritis. These observations validate the Banff 97 recommendation that the severity of both tubulitis and intimal arteritis needs to be graded in renal allograft biopsies. In addition, grade t3 tubulitis is identified as a lesion which should be a cause for clinical concern.

Biopsy of marginal donor kidneys: correlation of histologic findings with graft dysfunction.

BACKGROUND: Kidney biopsies are being used to evaluate marginal donors, but rigorous statistical validation of this practice with multivariate analysis has not been performed. METHODS: To analyze histologic parameters in 78 donor biopsies for their ability to predict graft dysfunction, we used a proportional odds model that included both donor and recipient factors. Glomerulosclerosis was categorized into grades 0, 1, 2, and 3, corresponding to 0, 1-10%, 11-20%, and 21-30% global sclerosis, respectively. The degrees of interstitial fibrosis, tubular atrophy, arteriosclerosis, and arteriolar hyalinosis were graded from 0 to 3+, using definitions suggested by the Banff Schema of allograft pathology. RESULTS: Increasing donor age was associated with higher glomerulosclerosis, tubular atrophy, and arteriosclerosis. Kidneys with any degree of interstitial fibrosis were 2.6 times [odds ratio (OR)] more likely to experience a worse outcome at 6 months (P = 0.02). This association held up after correction for acute rejection (OR 2.5, P = 0.03) and high panel-reactive antibody (OR 3.4, P = 0.006), However, the OR was reduced to 1.9 (P = 0.15) after controlling for recipient age. With each increment in the grade of glomerulosclerosis, the odds for a worse outcome at 12 months increased to 2.3 (P = 0.005). The value for OR became 2.0 (P = 0.03) when controlling for recipient age (P = 0.01), 2.4 (P = 0.005), when controlling for acute rejection, and 2.3 (P = 0.006) when controlling for high panel-reactive antibody. CONCLUSIONS: Histopathological parameters present in donor biopsies can independently predict post-transplant graft function. Implications for the pool of donor organs available for transplantation are discussed.

Development and experience with an integrated system for transplantation telepathology.

Rapid and accurate interpretation of allograft biopsies influences the outcome after organ transplantation. Expert histopathologic interpretation can also determine whether a donor organ should be used for transplantation or disposed. These and similar considerations in the field of Transplantation Pathology prompted us to develop a static image, store-and-forward telepathology system capable of rendering accurate, robust, and confidential communication by using readily available equipment and bandwidth capabilities for interactive real-time second opinion consultation. Between July 1999 and October 2000, 102 cases were transmitted, including 78 for second opinion and 1 for primary diagnosis with 6 (5 real-time) frozen sections. Full agreement with the original diagnosis was obtained in 67 of 78 (86%) cases; in 11 (14%) cases, teleconsultation resulted in 8 minor and 3 clinically significant differences of opinion. This led to a change in therapy in 1 case and further evaluation in 2 other cases. We conclude that static image, store-and-forward telepathology can enhance the practice of transplantation pathology, but a multidisciplinary team for ongiong support and development is required. This technology has the potential to promote case sharing, conduct continuing education, build consensus, and standardize readings of biopsies in multicenter trials in which histopathologic findings represent important outcome measures.

Malignant fibrous histiocytoma of the gallbladder: case report and review of the literature.

Malignant fibrous histiocytoma is a soft tissue sarcoma of mesenchymal origin. It can rarely present as a primary gallbladder tumor with only five cases having been reported to date in the English literature. Here we report the sixth documented case of malignant fibrous histiocytoma of the gallbladder, and we review all other cases reported. The outcome of the visceral sarcomas is poor when compared with tumors arising from the soft tissues. The treatment of primary malignant fibrous histiocytomas of the gallbladder is surgery. However, tumor recurrence is the norm even if wide clean margins are obtained. In contrast to tumors arising from the extremities the role of adjuvant radiotherapy and chemotherapy is less clear in the case of retroperitoneal and visceral sarcomas. Our patient is still alive and free of disease 46 weeks after surgery. The fact that this is the longest survival reported to date underscores the dismal prognosis of this disease.

Development of a standardized model for liver failure in pigs: anatomopathophysiologic findings after extended liver resection.

Eighteen pigs weighing a mean 19 ± 4 kg, were divided into group 1 (n = 2), that underwent resection of the left lateral lobe, group 2 (n = 2), resection of the left median and right median lobes; and group 3 (n = 18), resection of the left lateral, left median, right median, and right lateral lobes. All animals were followed for 5 days. Liver failure (n = 8) leading to animal death within 3 days after surgery was observed in 65% of group 3, whereas no group 1 or 2 animal experienced liver insufficiency. Multivariate analysis revealed that the extent of liver resection expressed as a percentage of total body weight <2.3%, international normalized ratio > 1.6 as postoperative day 2, serum bilirubin > 4.2 on postoperative day 2, and serum lactates > 9 mmol/L after resection were independent predictors of liver failure (P < .05). The number of resected liver lobes was not a good predictor of liver failure in swine, whereas the extent of resection expressed as a percentage of total body weight was an independent predictor of early liver failure. A resected liver-to-body weight ratio >2.3% was associated with a 65% probability of developing liver insufficiency. This parameter may be useful when developing a model of liver failure after extended liver resection in swine.

A diagnostic trap for the dermatopathologist: granulomatous reactions from cutaneous microimplants for cosmetic purposes.

We present a case of late granulomatous reactions from silicone that first appeared in a site different from that of the injection causing an incorrect diagnosis of liposarcoma in the beginning. The histological picture was a cystic-macrophagic granuloma in both the injection site (upper lip) and the migrating site (paranasal regions). We think that the foreign body has undergone an antigravity migration from the upper lip to the right paranasal region. To our knowledge, such a phenomenon has not been yet reported in literature.

Investigation of the patterns of argyrophilic nucleolar organiser regions (AgNORs) in primary gastric lymphomas.

Eight cases of primary gastric lymphomas have been investigated by AgNORs method to individualize the patterns of distribution of NORs. Modifying and exemplifying the scheme of Nikicicz and Norback, previously applied to blood smears and bone marrow in patients affected by leukaemia, the authors found 8 principal distribution patterns of AgNORs. Recording the percentage of the single patterns in every case it was possible to individualize two quite homogeneous groups. The authors maintain that in this way, avoiding complex numerical evaluations and statistical analysis, it is possible to easily classify the gastric lymphomas. We suggest that an improvement of the results could be achieved by comparing the immunophenotype of the cellular lymphomatous populations, and the AgNORs pattern with patients survival.

Utilization of hepatocyte-specific antibody in the immunocytochemical evaluation of liver tumors.

A monoclonal antibody highly specific for benign and malignant hepatocytes (HepPar 1) was evaluated as part of an antibody panel used to differentiate hepatocellular from nonhepatocellular neoplasms. Sixty-five liver tumors and two extrahepatic tumors from patients with documented liver tumors were studied. Twenty-two neoplasms were of hepatocellular origin, three were combined hepatocellular/cholangiocarcinomas, and the remainder were of nonhepatocellular origin. HepPar 1 alone had an 82% sensitivity and 90% specificity for the detection of hepatocellular neoplasms. The corresponding values for alpha-fetoprotein were 57% and 97%. Polyclonal antibody to carcinoembryonic antigen (canalicular pattern) had a sensitivity of 79% and specificity of 97% for these tumors. The use of antibody panels provided superior results when compared with individual antibodies. In summary, HepPar 1 monoclonal antibody is a useful reagent for the differential diagnosis of hepatocellular tumors. Its utility is enhanced when it is used as part of a diagnostic antibody panel.