The Journal of Heart and Lung Transplantation
Nodular Endocardial Infiltrates (Quilty Lesions) Cause Significant Variability in Diagnosis of ISHLT Grade 2 and 3A Rejection in Cardiac Allograft Recipients
Section snippets
Nodular endocardial infiltrates (Quilty lesions) and grade 2 rejection
In 1990, the Stanford group reported finding accumulations of lymphocytes with scattered plasma cells and prominent vascularity in the endocardium (Quilty A), which might extend into the subjacent myocardium (Quilty B).2 These were named after the first patient in whom they were recognized. These lesions are dense infiltrates, often without recognizable myocytes in their central portions, containing numerous capillary-sized vessels, and composed of plasma cells and central aggregates of B
The CARGO study
The Cardiac Allograft Rejection Gene Expression Observational Study (CARGO) was initiated in 2001 to explore the relationship between peripheral leukocyte gene expression and acute allograft rejection and other clinical outcomes. Through this work, gene expression patterns distinguishing acute cellular rejection from quiescence have been identified and are being validated for clinical use. Cardiac allograft recipients from 8 centers were enrolled and followed-up with blood sample and clinical
Clinical Study
Under institutional review board (IRB)-approved informed consent at each institution, patients enrolled in the CARGO study were enrolled at the time of transplantation and followed during their post-transplant course. At each biopsy encounter, clinical and pathologic data were recorded and a peripheral blood sample was obtained.
Cardiac Biopsy Pathology
For 562 patients from 8 centers, 3,968 biopsy encounters were recorded. A sub-set of 827 biopsies from 273 patients was identified; this sub-set included all biopsies
Distribution of ISHLT Grades According to Local Pathologists
Among the 3,968 biopsies from 562 patients read by local pathologists, the mean time from transplantation was 210.5 days (median 101 days, standard deviation 482.6 days). The clinical characteristics of the 273 patients who provided the 827 biopsies evaluated in the study are shown in Table 1. The distribution of ISHLT grades assigned by local pathologists at the 8 centers is shown in Table 2. Grade 3A and B rejection rates were very low (<3.8% of all biopsies). The vast majority of cases
Discussion
The variability between pathologists in assigning ISHLT biopsy grades to cardiac allograft biopsies has been noted previously.8, 9, 10 The contribution of the ISHLT Grade 2 histologic pattern to inter-observer variability in biopsy grading has also been recognized.3, 6, 11 There has also been, perhaps in response to this variability in diagnosis, a wide variety of clinical responses to asymptomatic Grade 2 biopsy.6, 12, 13, 14, 15 It is therefore important for those in clinical management to
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