Parenchymal trafficking of pleural mesothelial cells in idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is characterised by myofibroblast proliferation leading to architectural destruction. Neither the origin nor the continued proliferation of myofibroblasts is well understood. Explanted human IPF lungs were stained by immunohistochemistry for calretinin, a marker of pleural mesothelial cells (PMCs). Chronic obstructive pulmonary disease (COPD) and cystic fibrosis (CF) lungs acted as controls. The number of PMCs per 100 nucleated cells and per photomicrograph was estimated along with the Ashcroft score of fibrosis. Mouse PMCs expressing green fluorescent protein (GFP) or labelled with nanoparticles were injected into the pleural space of mice given intranasal transforming growth factor (TGF)-ß1. Mouse lungs were lavaged and examined for the presence of GFP, smooth muscle α-actin (α-SMA) and calretinin. Calretinin-positive PMCs were found throughout IPF lungs, but not in COPD or CF lungs. The number of PMCs correlated with the Ashcroft score. In mice, nanoparticle-laden PMCs were recoverable by bronchoalveolar lavage, depending on the TGF-ß1 dose. Fluorescent staining showed α-SMA expression in GFP-expressing PMCs, with co-localisation of GFP and α-SMA. PMCs can traffic through the lung and show myofibroblast phenotypic markers. PMCs are present in IPF lungs, and their number correlates with IPF severity. Since IPF presumably begins subpleurally, PMCs could play a pathogenetic role via mesothelial-mesenchymal transition.

Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study.

PURPOSE: Previous studies demonstrate a positive correlation between postoperative survival and the extent of pelvic lymphadenectomies in patients with bladder cancer. However, the distribution of nodal metastases has not been examined in sufficient detail. Therefore, we conducted a comprehensive prospective analysis of lymph node metastases to obtain precise knowledge about the pattern of lymphatic tumor spread. MATERIALS AND METHODS: Between 1999 and 2002 we performed 290 radical cystectomies and extended lymphadenectomies. Cranial border of the lymphadenectomy was the level of the inferior mesenteric artery, lateral border was the genitofemoral nerve and caudal border was the pelvic floor. We made every effort to excise and examine microscopically all lymph nodes from 12 well-defined anatomical locations. RESULTS: Mean total number and standard deviation of lymph nodes removed was 43.1 +/- 16.1. Nodal metastases were present in 27.9% of patients. The percentage of metastases at different sites ranged from 14.1% (right obturator nodes) to 2.9% (right paracaval nodes above the aortic bifurcation). By studying cases of unilateral primary tumors or with only 1 metastasis we observed a preferred pattern of metastatic spread. However, there were many exceptions to the rule and we did not identify a well-defined sentinel lymph node. CONCLUSIONS: We strongly recommend extended radical lymphadenectomy to all patients undergoing radical cystectomy for bladder cancer to remove all metastatic tumor deposits completely. The operation can be conducted in routine clinical practice and our data may serve as a guideline for future standardization and quality control of the procedure.

Prostatic adenocarcinnoma in cysprostatectomy specimens remolved for bladder tumors in bilharzial patients

Objective To determine the incidence of prostatic adenocarcinoma in bilharzial patients who previously underwent radical cystoprostatectomy for bladder tumors. Patients and Methods From February 1997 to February 1999; 249 male patients with bladder cancer were screened for prostate cancer prior to cystectomy using DRE and total PSA assay; as well as transrectal ultrasound-guided prostatic biopsies. Then the cystoprostatectomy specimens were serially sectioned (every 3 mm) and histologically examined. Results Prostatic adenocarcinoma was detected by ultrasound-guided prostatic needle biopsies in 2 cases; while in 18 it was discovered incidentally after cystoprostatectomy (total 20 patients = 8). Gleason score was 6 in 16 patients; 7 in 3 patients and 8 in the remaining patient. Perineural lymphatic permeation was observed in 4 cases and extracapsular extension in one. Conclusion Compared to previous reports on non-bilharzial patients; the incidence of prostate cancer in the cystoprostatectomy specimens of bilharzial patients was low; and the tumors were clinically insignificant in most of the cases

Results of a randomized, prospective, multicenter trial of mycophenolate mofetil versus azathioprine in the prevention of acute lung allograft rejection.

BACKGROUND: Although the use of mycophenolate mofetil (MMF) has reduced the incidence of acute rejection in heart and kidney allograft recipients, its role in lung transplantation remains controversial. Therefore, we conducted a randomized, prospective, open-label, multicenter study in lung transplant recipients to determine whether MMF decreases episodes of acute allograft rejection when compared with azathioprine (AZA). METHODS: Between March of 1997 and January of 1999, 81 consecutive lung transplant recipients from two centers were prospectively randomized to receive cyclosporine, corticosteroids, and either 2 mg/kg per day of AZA or 1 g twice daily of MMF. The primary study endpoint was biopsy-proven acute allograft rejection over the first 6 months posttransplant. Secondary endpoints included clinical rejection, cytomegalovirus (CMV) infection, adverse events, and survival. Surveillance bronchoscopies were performed at 1, 3, and 6 months, or if clinically indicated. Pathologists interpreting the biopsy results were blinded to the randomization. Results were analyzed according to intention-to-treat. Between group comparisons of means and proportions were made by using two sample t tests and Fisher's exact tests, respectively. Six-month survival was calculated by the Kaplan-Meier method and compared by the log rank test. RESULTS: Thirty-eight patients were prospectively randomized to receive AZA, and 43 MMF. The incidence of biopsy proven grade II or greater acute allograft rejection at 6 months was 58% in the AZA group and 63% in the MMF group (P=0.82). The 6-month survival rates in the MMF and AZA groups were 86% and 82%, respectively (P=0.57). Rates of CMV infection and adverse events were not significantly different between the two groups. CONCLUSIONS: Acute rejection rates and overall survival at 6 months are similar in lung transplant recipients treated with either MMF- or AZA-based immunosuppression.

Analysis of early deaths after isolated lung transplantation.

STUDY OBJECTIVES: To determine the causes of death in patients dying within 30 days after lung transplantation at the University of Florida, to assess the importance of several diagnostic modalities for determining the causes of their decline, and to construct an algorithm for the evaluation of patients with severe respiratory compromise occurring early after lung transplantation. DESIGN: Retrospective review of medical records and pathology slides from all patients dying within 30 days after lung transplantation, and biopsy specimen diagnoses from all lung allograft recipients at the University of Florida. PATIENTS: Nine deaths occurred during the first 30 days after transplantation among 117 patients undergoing 123 isolated lung transplantation operations. RESULTS: Infections accounted for the greatest number of deaths (bacterial pneumonia, four patients; catheter-related bacteremia, one patient). Persistent pneumonia confirmed by biopsy specimen was usually accompanied by histologic manifestations of acute cellular rejection and was associated with poor patient outcome (ie, death or subsequent development of bronchiolitis obliterans syndrome). In two patients, antibody-mediated rejection either was the immediate cause of death (hyperacute rejection, one patient) or preceded a fatal case of pneumonia (accelerated antibody-mediated rejection, one patient). Other causes of death included hypoxic-ischemic encephalopathy secondary to an intraoperative cardiac arrest (one patient), pulmonary venous thrombosis with bacterial colonization of the thrombotic material (one patient), and ischemic reperfusion injury (one patient). In most patients, more than one type of diagnostic technique was needed to ascertain the cause of the catastrophic decline. CONCLUSIONS: The causes of early posttransplant death in our patient group included infections, antibody-mediated rejection, hypoxic-ischemic encephalopathy secondary to cardiac arrest, pulmonary venous thrombosis, and ischemic reperfusion injury. Because these processes often demonstrate overlapping clinical and morphologic features requiring multiple diagnostic techniques for resolution, a systematic multimodality approach to diagnosis is advantageous for determining the causes of decline in individual patients and for estimating the incidences of the different causes of early graft and patient loss in the lung transplant population.

Lung transplantation after long-term mechanical ventilation : results and 1-year follow-up.

BACKGROUND: Long-term mechanical ventilation is considered as a relative or absolute contraindication for lung transplantation by most centers. We report on the results of transplantation in nine patients requiring long-term mechanical ventilation at two lung transplant centers. METHODS: The study group (group 1) consisted of nine patients receiving mechanical ventilation who underwent lung transplantation at either Duke University Medical Center or the University of Florida between 1992 and 1997. Patients in group 1 met the following criteria: they underwent exercise therapy with a physical therapist, and they were without panresistant bacterial airway colonization. The study patients that met these criteria spent at least 13 days receiving mechanical ventilation prior to transplantation. The control population (group 2; n = 65) consisted of all patients who underwent transplantation at either center in the calendar year 1997 who were ventilator independent. The 1-year survival rates in each group were calculated by the Kaplan-Meier method. The number of days required for extubation in each group were compared by the nonparametric Wilcoxon rank sum test. The FEV(1) value at 1 year was reported in each group. RESULTS: The 1-year survival rates were 78% and 83% in group 1 and group 2, respectively. The mean number of days required until extubation were 41 days in group 1 and 9 days in group 2 (p < 0.01). The allograft function was comparable in the two groups at 1 year. CONCLUSIONS: In a select population of ventilator-dependent patients, the 1-year survival rate is comparable to the standard lung transplant population. However, these ventilator-dependent patients require a significantly longer time until extubation than other transplant recipients.

Paediatric lower urinary tract rhabdomyosarcoma: a single-centre experience of 30 patients.

OBJECTIVE: To retrospectively analyse the long-term outcome of children with bladder and/or prostate rhabdomyosarcoma who were diagnosed at the authors' institution over the last 17 years. PATIENTS AND METHODS: The study comprised 30 children (26 boys and four girls, mean age 5 years, range 15 days to 15 years); 23 had stage III and seven had stage II disease. The initial biopsy showed an embryonal variant in 27 and round-cell sarcoma in three patients. All patients received eight weekly doses of vincristine, actinomycin D and cyclophosphamide (VAC). Subsequent treatment depended upon the response to chemotherapy. RESULTS: Fourteen patients had a complete or partial response to chemotherapy (> 50% reduction in tumour size); they were maintained on VAC chemotherapy for 2 years. Twelve patients in this group survived with no evidence of disease for 7 months to 10 years. Additional therapies were used in three patients, i.e. radical cystectomy in one and external irradiation in two. Sixteen patients had a minimal response to chemotherapy; in six, radical cystectomy was feasible and was followed by one year of chemotherapy. All patients were free of disease for 4-11 years. Radiotherapy was given to the remaining 10 patients; thereafter radical cystectomy became feasible in five while partial cystectomy was possible in three. Only three of these 10 patients survived for 4-11 years. CONCLUSION: The tumour response to initial chemotherapy can be used to stratify patients into two risk-groups, i.e. low-risk patients with a complete or partial response in whom the bladder could be salvaged, and high-risk patients with a minimal response, in whom intensive treatment should be pursued, with no attempt at bladder salvage.

A predictive model of survival after radical cystectomy for carcinoma of the bladder.

OBJECTIVE: To evaluate the effect of patient and tumour characteristics on the disease-free survival after radical cystectomy for infiltrating bladder cancer, and to use these to help in constructing a meaningful prognostic index. METHODS: The disease-free survival was initially evaluated in 1026 patients (the reference series, 1969-1990). A multivariate analysis showed that the tumour P stage, grade and nodal involvement were the only factors which had an independent and significant association with survival. The computed regression coefficients were then used to classify patients into one of four risk categories and the results then validated by applying the model to a prospective test series (1991-1995). RESULTS: The 5-year disease-free survival of both groups was similar. When the results for the risk categories of the reference series were compared with those of the test series, there was no significant difference. CONCLUSION: This comprehensive prognostic model for the results of radical cystectomy was validated and verified in a prospective group of patients. Adjuvant therapies are indicated for patients with a high risk score.

Susceptibility of lung transplants to preformed donor-specific HLA antibodies as detected by flow cytometry.

BACKGROUND: Preformed anti-HLA antibodies are known to have the potential to induce early graft damage in organ transplant recipients. However, in lung transplant recipients, little information exists about the significance of preformed antibodies directed to either class I or class II HLA antigens. METHODS: A two-color flow cytometry cross-match was performed in 92 consecutive lung transplant recipients using serum obtained immediately before transplantation. The presence of preformed antibodies was correlated with the incidence of severe graft dysfunction manifested as pulmonary infiltrates and severe hypoxemia with onset in the first few hours after transplantation. RESULTS: Six patients (6.5%) had low-level anti-donor IgG antibodies detected by flow cytometry, four against T and two against B lymphocytes. Three patients (50%) developed severe graft dysfunction with pulmonary infiltrates and hypoxemia. Two patients responded to treatment, but the third, who had an antibody highly specific for HLA-DR11, died at 48 hr after transplant. Results of histopathologic studies in this patient are consistent with hyperacute rejection and support a pathogenic role of these antibodies. In contrast, of 86 (93.5%) cases with a negative flow cytometry cross-match, only 4 (5%) had severe but reversible early graft dysfunction with pulmonary infiltrates and hypoxemia, attributed to ischemia-reperfusion injury (P<0.005). CONCLUSIONS: Class II, and perhaps class I HLA antibodies at relatively low concentrations represent a risk factor for severe early pulmonary graft dysfunction, with the potential to progress to hyperacute rejection and death.

Patterns and significance of CD44 expression in lung allografts.

BACKGROUND: Lung allograft rejection involves the interplay of multiple cellular populations, soluble mediators, and extracellular matrix proteins. The CD44 family of cell surface glycoproteins mediates a variety of cell-cell and cell-matrix interactions including lymphocyte homing to sites of antigenic challenge and fibroblast migration and invasion into extracellular matrix, processes integral to lung allograft rejection. METHODS: We performed immunohistochemical staining for CD44 on biopsies from allograft recipients with differing rejection experiences: Group 1 (n = 5 patients/10 biopsies) never exceeded Grade A1 or B2 acute rejection (AR); Group 2 (n = 7 patients/26 biopsies) had 2 or more episodes of Grade A2 or higher AR and no obliterative bronchiolitis (OB); Group 3 (n = 6 patients/17 biopsies) had clinical and pathologic OB. Nine infected allograft biopsies, 8 near-normal lung sections (non-transplant controls), and 13 non-transplant biopsies showing bronchiolitis obliterans organizing pneumonia (BOOP), organizing diffuse alveolar damage (DAD), or usual interstitial pneumonia (UIP) were also studied. RESULTS: Allograft biopsies demonstrated significantly more CD44 staining among lymphocytes, macrophages, Type II pneumocytes, and respiratory epithelial cells than non-transplant controls, while staining of lymphocytes, macrophages, and Type II pneumocytes did not differ significantly between allograft groups. Fibroblast CD44 staining in Group 3 biopsies significantly exceeded that of controls and Groups 1 and 2, and biopsies with AR and/or OB showed more fibroblast staining than biopsies with BOOP, organizing DAD, or UIP. Alveolar CD44-positive fibroblasts did not predict development of OB, while bronchial CD44-positive fibroblasts were followed in one case by OB. CONCLUSIONS: These findings suggest that CD44 expression is characteristic of graft-infiltrating inflammatory cells and resident parenchymal cells, and may be related to the initiation and evolution of AR and OB.

Primary adenocarcinoma of the urinary bladder: a report of 185 cases.

OBJECTIVE: To evaluate the outcome after the treatment of primary non-urachal vesical adenocarcinoma and to determine the significant prognostic factors. PATIENTS AND METHODS: The records of 185 patients with vesical adenocarcinoma were reviewed. The pathological evaluation included the determination of pathological stage, tumour grade, presence or absence of mucin and its location, evidence of bilharzial infestation and flow-cytometric DNA analysis. The mean follow-up of the treated patients was 3.1 years. Disease-free survival was estimated and the results correlated with patient and tumour characteristics (univariate analysis). Cox's proportional hazards analysis was used to determine prognostic factors. RESULTS: The overall 5-year disease-free survival was 55%; only three factors had a significant impact on survival, the tumour pathological stage and grade, and lymph node involvement. CONCLUSIONS: Radical cystectomy remains the only satisfactory treatment option for primary vesical adenocarcinoma. Tumour stage, grade and lymph node involvement are the only significant prognostic factors.

Radical cystectomy for carcinoma of the bladder: critical evaluation of the results in 1,026 cases.

PURPOSE: We performed a critical analysis of the different prognostic factors affecting survival among patients with carcinoma of the bladder for whom cystectomy was indicated. The different patient and tumor characteristics were correlated to survival data by a univariate as well as multivariate analysis. MATERIALS AND METHODS: Between 1969 and 1990, 764 men and 262 women, average age plus or minus standard deviation 43 +/- 8 years, with invasive carcinoma of the bladder were eligible for 1-stage radical cystectomy and urinary diversion. Patients were followed regularly and examined signs for and location of treatment failure. Followup ranged from 0 to 24.2 years, with a median plus or minus standard deviation of 4.05 +/- 4.16 years. RESULTS: Postoperative mortality was 4%. Most of the patients presented with advanced stage (greater than P3) disease. Squamous tumors accounted for 59% of cases, transitional carcinoma 22% and adenocarcinoma 11%. Bilharzial eggs were seen in 85% of the specimens. Regional lymph nodes were involved in 18.3% of the cases. The 5-year survival rate was 48%. The survival estimate was correlated to patient and tumor characteristics by univariate and multivariate analyses. Only tumor stage and grade, and lymph node status had a significant impact on survival. CONCLUSIONS: Contemporary cystectomy with continent diversion for muscle invasive disease provides minimal morbidity, offers good locoregional disease control and results in acceptable quality of life. The presence of positive regional lymph nodes is not a contraindication to this therapy.

Iron accumulation in lung allografts after transplantation.

Lung transplantation has become a therapeutic option for end-stage pulmonary diseases, but after transplantation, infections and obliterative bronchiolitis (OB) are major causes of long-term morbidity and mortality. OB is a fibroproliferative disease, of poorly understood etiology, characterized by an irreversible decline in allograft function. Because diseases with tissue iron overload are characterized by fibrosis and end-organ failure, we studied the iron concentrations in BAL fluid and lung tissue in 10 lung allograft patients. BAL fluid revealed significantly elevated iron concentrations in allograft patients compared with five normal volunteers (135+/-16.54 micromol/L vs 33.65+/-7.48 micromol/L, respectively). Prussian blue staining of biopsy specimens of lung allograft tissue revealed an accumulation of iron primarily in alveolar macrophages. Immunohistochemical stains for ferritin revealed accumulation of the protein in macrophages, interstitium, vascular walls, and bronchiolar epithelium. Iron studies of the blood (serum ferritin and iron concentrations) revealed no evidence for systemic iron overload. In conclusion, patients with pulmonary allografts appear to have elevated concentrations of iron in lung tissue. This iron overload may place the allografts at increased risk of metal-mediated injury and fibrosis.

Diagnostic yield of bronchoscopies after isolated lung transplantation.

Lung transplantation has become an acceptable therapeutic option for end-stage pulmonary diseases. The most common causes of long-term mortality after transplantation are infections and obliterative bronchiolitis (OB). While acute rejection has been shown to be associated with an increased risk of development of OB, cytomegalovirus (CMV) pneumonitis is more controversial as a risk factor for OB. Surveillance bronchoscopies are therefore advocated as a method of detecting silent episodes of CMV pneumonitis or acute rejection. We performed 226 bronchoscopies in 43 lung transplant recipients over 34 months. One hundred fifty-seven of the 226 bronchoscopies were performed according to a surveillance protocol. Acute rejection was diagnosed if lung histologic study revealed grade 2 to 4 rejection or if prompt reversal of clinical deterioration occurred after initiation of pulse steroid therapy. CMV pneumonitis was diagnosed when transbronchial biopsy histologic specimens revealed evidence of CMV inclusion bodies, or when CMV was recovered on BAL fluid in the presence of allograft deterioration. The proportion of patients who were free from any episode of acute rejection or CMV pneumonitis after transplantation was determined by Kaplan-Meier analysis. Twenty-one percent of our transplant recipients were free from acute rejection or CMV pneumonitis after a mean follow-up of 13 months. All patients who had acute rejection or CMV pneumonitis had the initial episode in the first 4 months after transplantation. Patients free of acute rejection or CMV pneumonitis 4 months after transplantation continued to be event free for the duration of follow-up. Our data suggest that surveillance bronchoscopy can be aborted in patients who are free from acute rejection or CMV pneumonitis by 4 months after transplantation. The role of surveillance bronchoscopy in decreasing the incidence of OB or improving survival can be determined only by future randomized prospective trials.

Fungal infections in lung and heart-lung transplant recipients. Report of 9 cases and review of the literature.

We reviewed the pattern and incidence of fungal infections in patients undergoing lung and heart-lung transplantation at Duke University Medical Center from September 1992 until August 1995, and present here 9 illustrative cases. Of the 73 lung and heart-lung transplant recipients studied, 59 (81%) had positive fungal cultures at some point after transplantation. The cases presented here illustrate that lung transplant recipients are predisposed to a wide variety of fungal infections. The clinical pattern of these infections ranges from asymptomatic to rapidly progressive fatal disease. In addition to the reactivation of previous fungal infections and recent exposure to new environmental sources, the donor lung itself can be the source of fungal infection, as we showed by using molecular epidemiology techniques. Because of the associated morbidity and mortality, efforts should be directed at investigating prophylactic antifungal regimens in lung transplant recipients. Preliminary reports on the use of itraconazole and aerosolized amphotericin B have been encouraging. Prospective randomized studies are needed to assess the safety and cost effectiveness of different regimens. Fungal infections in patients after lung transplantation can significantly impede recovery and lead to substantial mortality.

Glutathione depletion in epithelial lining fluid of lung allograft patients.

The lower respiratory tract is protected against reactive oxygen species (ROS) by a complex antioxidant system. In the epithelial lining fluid (ELF), glutathione (L-alpha-glutamyl-L-cysteinylglycine, GSH) is essential for adequate protection of pneumocytes from potential toxicity mediated by extracellular hydrogen peroxide (H2O2). We assessed the concentration of total GSH in bronchoalveolar lavage fluid (BALF) in lung allograft patients in the absence and presence of acute rejection. Bronchoalveolar lavage (BAL) and biopsies were performed concurrently on 36 occasions in 17 patients who had undergone lung transplantation. BALF samples were divided into two groups on the basis of presence or absence of acute lung rejection on transbronchial biopsy. Seven BALF samples were obtained from control subjects for comparison. The BALF data demonstrated significantly lymphocyte recruitment and evidence of lung injury during acute rejection episodes. Transplant allografts without rejection showed significant depletion of total GSH in the ELF as compared with that of normal volunteers (94.0 +/- 9.7 microM versus 302.6 +/- 40.8 microM, p < 0.01). Transplant allografts with acute rejection had a slightly higher GSH concentration in their ELF (179.8 +/- 34.7), but this was still lower than control values. The deficiency of total GSH in the alveolar fluid may predispose lung allografts to extracellular H2O2-mediated toxicity.

Eversion meatoplasty in management of urethral meatal stenosis.

Urethral meatal stenosis is common, producing about 5 per cent of all new patients in paediatric urologist office [1]. It may be congenital or acquired. The acquired type can follow repeated urinary tract infection or urethral instrumentation. Herein we present an eversion meatoplasty which is a simple technique that can be done even under local infiltration anaesthesia especially in children older than 10 years. This technique was applied in 100 cases. The results were excellent, apart from urinary spraying in the first few days that was noticed in 13 cases and disappeared spontaneously. Restenosis was not encountered in any of our cases.