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Resident Handout Resident Handout Division of Transplantation Pathology University of Pittsburgh Medical Center July 2005 for private use of residents only- not for public distribution Table of Contents Anatomic Transplantation Pathology Rotation Clinical Responsibilities of the Division ........................................................4 Categorizations of Specimens and Structure of Signout.............................…4 Resident Responsibilities.................................................................................5 Learning Resources.........................................................................................6 Transplantation Pathology on the World-Wide Web......................................6 Weekly Schedule ............................................................................................7 Staff Locations and Telephone Numbers........................................................8 Background Articles Landmarks in Transplantation ...................…..................................................9 History of Transplant Immunobiology Part 1....…..........................................19 History of Transplant Immunobiology Part 2....…..........................................25 Kidney Grading Systems Banff 97 Diagnostic Grades (IA, IB etc.) .............................….....................33 Banff 97 Components (I t v g etc.) ....................................…........................35 Readings Banff 97 Working Classification of Renal Allograft Pathology….................38 Role of Donor Kidney Biopsies in Renal Transplantation ..............…...........58 Polyomavirus Allograft Nephropathy ……………………….. .....….............63 Renal Transplant 2004- Where do we stand? ……………………….....……68 Liver Grading Systems Banff Schema for Acute Liver Allograft Rejection.................……...............79 Banff Rejection Activity Index................................................……...............80 Banff Schema for Chronic Liver Rejection ....................................…............82 Modified Hepatitis Activity Index ..................................................…............84 Autoimmune Hepatitis Scoring System 1999..................................……........86 Staging and Grading Disease Activity in Steatohepatitis ...............…….........89 Readings Banff Schema for Grading Liver Allograft Rejection ..................……...........91 Pathophysiology of Chronic Allograft Rejection .........................……...........97 Recurrent Hepatitis C in the Liver Allografts.............................…….............140 Heart Grading System Standardized Cardiac Biopsy Grading.......................................……..............152 Readings Working Formulation for Grading Cardiac Allograft Rejection .……...........154 Revisiting 1990 ISHLT Working Formulation................................…............161 Lung Grading System Revised Working Formulation for Lung Transplant Rejection .................174 Readings Working Formulation for Grading Lung Transplant Rejection..................176 Bronchiolitis obliterans update ..................................................................192 Pancreas Grading System Grading of Acute Pancreas Allograft Rejection ........................................206 Readings Evaluation of Pancreas Transplant Needle Biopsy.....................................207 Histology of Pancreas Allograft Loss ........................................................224 Intestine Readings Schema for Histologic Grading of Small Bowel Acute Rejection.............232 Posttransplant Lymphoproliferative Disorders and Neoplasia Grading Systems PTLD 2001 …………………………………………………………..…..240 PTLD 1997.................................................................................................242 PTLD 1995.................................................................................................244 PTLD 1988.................................................................................................245 PTLD 1981.................................................................................................246 Readings PTLD- Importance of a Standardized Histologic Approach......................247 Tumors and Solid Organ Transplantation………………………...……...256 Anatomic Transplantation Pathology Rotation Clinical Responsibilities of the Division The Division of Transplantation Pathology is responsible for pathology support for the Thomas E. Starzl Transplantation Institute. This includes evaluation of primary recipient disease, resected native organs, and resected allografts. Evaluation of post-transplant biopsies for rejection and other causes of graft dysfunction comprise the main daily workload. This Division also evaluates biopsies of potential donor organs and handles all native liver biopsy specimens. The Division conducts six separate weekly clinicopathologic conferences to ensure quality control of biopsy results and to keep an open channel of communication between the clinical physicians and transplantation pathologists. In addition, there are two intradivisional quality assurance slide review conferences per week, to ensure agreement among the pathologists in grading rejection and to discuss interesting and/or difficult cases. Categorization of Specimens and Structure of “Signout” Specimens that come to the Division for review fall into five categories. They include “Bigs,” of which the majority are diseased native organs removed at the time of transplantation; “Quicks,” mainly biopsies such as surveillance gastrointestinal biopsies; native liver biopsies; skin biopsies for GVHD; lymph node biopsies to evaluate for PTLD, etc.; “Stats,” mainly organ allografts biopsies used to monitor rejection; and “Consults” which consist of outside slides submitted for review. The Division also handles a portion of medical kidney biopsies and performs frozen sections by clinical request on a 24/7 basis. The priority ranking the specimens receive, the structure of signout and reporting of the results are designed to best serve the transplant patients and clinical physicians involved in their care. “Stat” specimens receive the highest priority. These biopsies are submitted to Pathology before 9:00 AM and permanent H&E slides are ready for review by 3:00-3:30 PM the same day. “Quicks” and “Consults” are next in priority, and have a one day or less turnaround whenever possible. “Bigs” receive the next highest priority, and are signed out as expeditiously as possible. Native kidney biopsy results are transmitted to physicians in a provisional manner and signed out as special studies become available. The staff service responsibilities are divided as follows: One staff pathologist takes weekly responsibility (Monday through Friday) for Stats and Quicks and handles all frozen sections between 7:30 AM and 5:00 PM. A second staff pathologist is on “Big” service, which runs from Monday through the following Sunday. This pathologist covers all Consults in the Division (except for consults that are specifically addressed to an individual pathologist), Big specimens and Native kidney specimens from Monday through Friday and covers Frozen sections from 5:01 PM to 7:29 AM the following morning. This pathologist also covers all specimens on the weekend, regardless of type, and is on call for frozen sections throughout the weekend. Holidays are treated like a weekend, in that the pathologist on “Bigs” covers all casework and has call responsibility. Page 4 Resident Responsibilities The level of resident responsibility depends upon three factors: the level of training, competence, and the desire to assume responsibility. PGY-1 level residents are generally responsible for all “big” cases, including gross evaluation, organization, and review of the slides and finally, signout with the pathologists. The gross processing of cases can usually be accomplished by mid-morning or early afternoon. It has been the experience of junior residents that attempting to sit in on all signouts of “Bigs”, “Quicks”, and “Stats” can be a bit overwhelming in light of the short (usually 3 weeks) rotation schedule. The purpose of the rotation is to give you hands on experience with grossing transplant specimens, and with interpreting both native and allograft- based pathology. You are not expected to workup every case that comes through during this time, and your particular schedule will be worked out with the staff at the beginning of the rotation. When more than one resident is on rotation, it is the residents’ responsibility to divide the workload between them. Residents >PGY-1 may want to assume more responsibility by reviewing “quicks” and “consults” to enhance learning opportunities. A satisfactory division of labor in the past has been for the PGY-1 to assume responsibilities for “bigs”and >PGY-1 to take “quicks” and “consults.” The cases are then shared at signout time. Unfortunately, because of the urgency of Stat specimens, it is often not possible for the residents to review the cases before the official signout. The pathologist and resident review the cases together on a daily basis, and the preliminary results are recorded daily in the “Stat Book,” immediately outside the signout room. A recent change has been to deliver the “quicks” at 9:00-9:30 AM. Depending upon the signout time, this may give the resident an opportunity to review these cases upon delivery. The “big” specimens offer excellent learning opportunities in inflammatory and neoplastic liver disease and cardiovascular pathology. Most renal disease
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