Histologic Review of the First Near Total Face Transplant
JS Stratton, MZ Siemionow, A Klimczak, WF Bergfeld. Cleveland Clinic, Cleveland
Background: Recent advances in immunosuppression and surgical techniques have progressed to make a near total face transplant, like the one performed at the Cleveland Clinic in December of 2008, possible. Composite tissue grafts consist of skin, subcutaneous tissue, muscle, nerve, and bone. Accurate clinical and histologic rejection surveillance is vital to preserve the function of the graft. A histologic review of the first eight months following the first near total face transplant was conducted and is discussed below.
Design: Paired skin and mucosa biopsies were obtained with accompanying clinical photographs at weekly, then biweekly, then monthly intervals. Paraffin sections for H&E, PAS, immunoperoxidase, and unstained sections for the TUNEL assay were obtained. Biopsies were graded using the Banff 2007 working classification of skin-containing Composite Tissue Allograft (CTA) Pathology. Immunostaining for CD3, CD4, CD8, CD20, CD68, CD30, FoxP3, K167, HMB45, CD1a, S100, FactorXIIIA, CD31, and CD34 was performed. The TUNEL assay was also performed to assess apoptosis.
Results: No definitive evidence of rejection was seen clinically. Histologically, grade II rejection was identified on five different biopsy dates (days 20, 63, 77, 91, 209, 246) with grade III rejection on two occurrences (days 47 & 153-159) with apoptosis that was confirmed by TUNEL. Interestingly, significant perivascular inflammation was not identified, even in the cases of grade III rejection. However, the inflammation has been noted in multiple small to medium size foci of interface inflammation with apoptosis. Furthermore, the significant episode of histologic rejection was only present in the mucosal biopsies and was absent from the paired skin biopsy.
Conclusions: We reviewed the histology of the first near total face transplant and documented five episodes of grade II rejection and two episodes of grade III rejection. Histologic evidence of rejection was only identified in mucosal biopsies, and was absent from the paired skin biopsies. Despite the presence of interface inflammation with clumps of apoptotic cells, significant accompanying perivascular inflammation and clinical symptomatology were not identified. We believe that the Banff (CTA) 2007 classification system is the most accurate grading system for composite grafts involving the face at this time. As more face transplant procedures are preformed, the difference between histologic evidence of rejection in mucosal and skin biopsies may be further elucidated.
Wednesday, March 24, 2010 1:00 PM
Poster Session VI # 108, Wednesday Afternoon