POST-LUNG TRANSPLANT BIOPSIES - AN 8-YEAR LOYOLA EXPERIENCE

A total of 125 transplant procedures involving the lung have been perf ormed at Loyola University of Chicago in 120 patients. There were 67 s ingle (40 right, 27 left)) 44 bilateral single, 2 double lung, and 12 heart-lungs (HL) transplant procedures. This paper summarizes the path ologic findings in 565 transbronchial, 102 endobronchial, 20 open lung , and 92 endomyocardial biopsies and compares them with the recommenda tions in the published literature. The lung biopsies were evaluated ac cording to the Working Formulation, Lung Rejection Study Group, Intern ational Society of Heart Transplantation. In transbronchial biopsies, all of which were from the transplanted lungs, the number of alveolate d lung fragments ranged from 0 to 14 (mean, 5). Two hundred twelve bio psies showed no rejection, 113 had minimal rejection, 133 had mild rej ection, 34 had moderate rejection, and 1 had severe acute rejection. A ctive airway damage (Grade B) was seen in 48 biopsies, which were grad ed from minimal to severe based on the amount of inflammation. Chronic rejection (Grade C) was diagnosed in 23, chronic vascular rejection ( Grade D) in 8, and acute vasculitis (Grade E) in 9 biopsies. Routine t richrome and elastic van Gieson stains did not add to the diagnosis. A ll biopsies were routinely stained with immunoperoxidase for cytomegal ovirus. Cytomegalovirus was diagnosed in 84 biopsies, 54 by both H&E a nd immunoperoxidase, 23 immunoperoxidase alone, and 5 by H&E alone. Th e endobronchial biopsy of the anastomotic site had nonspecific inflamm ation in 46 biopsies. Twenty-nine had infection with a specific organi sm, Aspergillus and Candida in each of 8 biopsies by Gomori's methenam ine silver stain, cytomegalovirus in 7 (4 by H&E and immunoperoxidase; 3 by immunoperoxidase), bacteria in 4, and fungal hyphae in 2 biopsie s. In the 12 patients with heart-lung transplants, a total of 92 endom yocardial, 35 transbronchial, and 1 endobronchial biopies were obtaine d. Acute rejection was seen only in 2 endomyocardial biopsies, whereas the transbronchial biopsy showed acute mild or moderate rejection in 10, chronic rejection in 1, and cytomegalovirus infection in six biops ies. We conclude that: (a) all biopsies with alveolated lung parenchym a can be evaluated for rejection and infection yielding clinically sig nificant diagnoses; (b) sections from three levels stained by H&E are essential for evaluation; (c) routine Gomori's methenamine silver, ela stic van Gieson, and trichrome stains are not required for transbronch ial biopsy, however, routine Gomori's methenamine stain is recommended for all anastomotic site biopsies; (d) routine immunoperoxidase for c ytomegalovirus is extremely helpful; (e) Grade B rejection should be f urther graded; and (f) endomyocardial biopsy played no significant rol e in the management of heart-lung recipients.