[2103] The Effect of General Versus Sub-Specialty Sign-Out on the Reporting of Lung Transplant Biopsy Rejection

Kumaran Mudaliar, Vikas Mehta, Zhihong Hu, Maria M Picken. Loyola University Medical Center, Maywood, IL

Background: Lung transplantation is an established treatment modality for patients with end-stage lung disease. Surveillance for rejection is based on spirometry parameters and pathologic evaluation of protocol biopsies in stable grafts; additional biopsies are performed for clinical indications in failing grafts. However, the detection of rejection is dependent on the observer's experience in allograft pathology interpretation. We sought to compare the % of reporting of rejection by general surgical pathology versus sub-specialty sign-out.
Design: We reviewed all lung transplant biopsies performed at our institution between 2005 and 2010 for the reported degree of rejection, underlying lung pathology leading to transplantation, age at the time of biopsy and correlated the results with the type of sign-out (general versus subspecialty). 1034 lung biopsies from 224 patients were reviewed; 41 patients who were < 40 years old all suffered from cystic fibrosis while 183 patients who were > 40 years old suffered primarily from idiopathic pulmonary fibrosis and COPD. Prior to 2008, lung transplant biopsies were handled by general pathologists but since 2008 this is done by a sub-specialty sign-out.
Results: Among 1034 biopsies reviewed, 362 were performed during 2005-2007 and 672 were performed from 2008-2010. The reported % of rejection (see table) doubled with subspecialty sign-out: 10.5 versus 22.5%. While this was mainly due to increased reporting of A1, there was also a 70% increase in the reporting of clinically significant (A2) grades of rejection. Moreover, reporting of minimal rejection (A1) was clinically helpful in patient management and planning for a possible re-biopsy. There was no statistically significant difference in reporting rejections in different patient age-groups and underlying lung pathology.

2005-2007  2005-2007, <40  2005-2007, >40 
A0%89.5% A0%89.2% A0%89.6%
A1%6.1% A1%4.8% A1%6.5%
A2%3.6% A2%4.8% A2%3.2%
A3%0.8% A3%1.2% A3%0.7%
2008-2010  2008-2010, <40  2008-2010, >40 
A0%77.7% A0%76.5% A0%77.9%
A1%14.7% A1%13.9% A1%14.9%
A2%6.1% A2%6.1% A2%6.1%
A3%1.5% A3%3.5% A3%1.1%

Conclusions: Introduction of sub-specialty sign-out doubled the overall % of reported rejections and, most importantly, increased by 70% the reporting of clinically significant, A2, rejections. While the latter leads to an immediate change in clinical management, the reporting of minimal rejection (A1) has also been helpful in overall patient management. Our study further supports the advantages of sub-specialty sign-out as an important quality assurance measure in surgical pathology.
Category: Quality Assurance

Monday, March 19, 2012 9:30 AM

Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 304, Monday Morning


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