Sibley R K, Berry G J, Tazelaar H D, Kraemer M R, Theodore J, Marshall S E, Billingham M E, Starnes V A
Department of Pathology, Stanford University Medical Center, CA 94305.
J Heart Lung Transplant. 1993 Mar-Apr;12(2):308-24.
We examined the utility of the transbronchial biopsy in the management of 53 lung transplant patients. One hundred thirty-three protocol biopsies were performed to ascertain the frequency and nature of abnormalities in clinically stable or asymptomatic patients; 128 diagnostic biopsies were performed in clinically ill patients to assess the morphologic abnormalities before the institution of therapy, and 105 biopsies were performed to assess the response to therapy. Histologic evidence of acute rejection was found in 24% of the protocol biopsies, and infection was found in 17%. Twenty-five patients with grade 1 or grade 2 perivascular infiltrates in protocol biopsies did not receive antirejection therapy. Follow-up biopsy in these patients showed spontaneous resolution of the infiltrates in 19% and increased infiltrates in 6. Only two of these patients became clinically ill, representing "progression" to clinical rejection in only 8% of the nontreated patients. Forty percent of the biopsies performed to rule out acute rejection or infection had histologic features of acute rejection, and another 23% had features of infection. Treatment of patients with clinical and histologic evidence of rejection was associated with rapid resolution of clinical symptoms in nearly 90% of the patients, but follow-up biopsies showed residual infiltrates compatible with ongoing or resolving rejection in 52%. Despite repeat antirejection therapy in some patients, these infiltrates persisted for an average of 30 days after the diagnostic biopsy. Follow-up biopsies also showed asymptomatic infection, usually cytomegalovirus pneumonitis, which often persisted for weeks despite the lack of symptoms. Perivascular infiltrates compatible with acute rejection were also found in 38% of biopsy specimens with evidence of infection. These perivascular infiltrates resolved with antibiotic treatment alone in nearly 50% of the patients with these features. Although perivascular mononuclear cell infiltrates are the cardinal histologic feature of acute rejection, similar infiltrates occur in patients who apparently have infection alone and other patients who have both infection and rejection; infiltrates compatible with minimal, mild, and moderate acute rejection also occur in clinically asymptomatic patients. These histologic findings are a challenge to both the pathologists' and the clinicians' skills in the management of the lung transplant patient.
我们研究了经支气管活检在53例肺移植患者管理中的效用。进行了133次方案活检，以确定临床稳定或无症状患者异常的频率和性质；对临床患病患者进行了128次诊断性活检，以在治疗开始前评估形态学异常，还进行了105次活检以评估治疗反应。在方案活检中，24%发现有急性排斥的组织学证据，17%发现有感染。25例在方案活检中有1级或2级血管周围浸润的患者未接受抗排斥治疗。对这些患者的随访活检显示，19%的患者浸润自发消退，6%的患者浸润增加。这些患者中只有2例出现临床疾病，仅占未治疗患者中“进展”至临床排斥的8%。为排除急性排斥或感染而进行的活检中，40%具有急性排斥的组织学特征，另外23%具有感染特征。有临床和组织学排斥证据的患者接受治疗后，近90%的患者临床症状迅速缓解，但随访活检显示，52%的患者有与持续或正在消退的排斥相符的残留浸润。尽管一些患者重复进行了抗排斥治疗，但这些浸润在诊断性活检后平均持续30天。随访活检还显示有无症状感染，通常是巨细胞病毒性肺炎，尽管没有症状，但往往持续数周。在有感染证据的活检标本中，38%也发现有与急性排斥相符的血管周围浸润。在有这些特征的患者中，近50%仅通过抗生素治疗血管周围浸润就消退了。虽然血管周围单核细胞浸润是急性排斥的主要组织学特征，但在明显仅有感染以及同时有感染和排斥的患者中也会出现类似浸润；与轻度、中度急性排斥相符的浸润在临床无症状患者中也会出现。这些组织学发现对病理学家和临床医生管理肺移植患者的技能构成了挑战。
