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Margaret M Burke, FRCPath
I2C2 Pathology Council Representative

margaret burkeINTRODUCTION
You will have read in the May issue of ISHLT Links that during the 32nd meeting of ISHLT in Prague last April, the Board established a new Outreach Committee - the International and Inter-Societal Co-ordination Committee [known, thankfully, in its abbreviated form as I2C2!].1 I was honoured to be nominated by the incoming Chair of the Pathology Council, Patrick Bruneval (Paris, FR), as its representative on the I2C2 committee. While emerging international issues are of interest to us all, I consider that my main focus at this stage is on Inter-Societal and International Outreach as it applies to Pathology.

Cardiothoracic and transplant pathologists are a minority as members of ISHLT and of each country's community of pathologists. We report allograft biopsies as an extension of our specialty interest, but these form a small part of a large pathology workload for general pathologists who often report allograft biopsies from other organ and tissue recipients. Thus issues of communication, multidisciplinary working, subspecialty training, and reproducibility of biopsy interpretation become important for our "niche" subspecialty. Nowadays progress in digital technology allows us to digitize pathology glass slides and manipulate the images from our desktops in a way that simulates the controls of our microscopes. So, using web-based digital platforms to set up folders of digitized slides, accessible from the desktop globally, overcomes limitations imposed by geography and enables us to promote good practice in cardiothoracic transplant pathology through ongoing education, training, audit and, increasingly, diagnosis and case consultation.2

An example of the benefits of this approach is the ISHLT Board-sponsored initiative on cardiac antibody-mediated allograft rejection (AMR) which has evolved over the last three years. This initiative was informed from two sources:

1. In North America, the challenges of biopsy diagnosis of cardiac AMR were addressed in dedicated cardiac allograft sessions, organised by Rene Rodriguez (Cleveland, OH) at several Banff Conferences on Allograft Pathology. Work done at the 2001 session3 informed the ISHLT 2005 revision of the ISHLT 1990 Cardiac Allograft Biopsy Working Formulation, as part of which criteria for pathologic diagnosis of AMR were proposed.4 Subsequent transatlantic collaboration identified issues with biopsy detection of C4d, presented at Banff 20095 which was attended by ISHLT Board representative Lori West.

2. In Europe, members of the Association for European Cardiovascular Pathology (AECVP) formed a Transplant Working Group in January 2009 which networked widely throughout Europe in order to undertake two studies, both of which were presented at ISHLT's Chicago meeting in 2010. They highlighted concerns around poor reproducibility of biopsy diagnosis of cardiac AMR using the ISHLT 2005 Working Formulation and lack of standardization of C4d paraffin section immunostaining and interpretation.6,7

The data from all this work was fed into discussions at two very successful ISHLT-sponsored workshops held by the Pathology Council prior to the 2010 and 2011 annual meetings of our Society co-chaired by Gerry Berry (Stanford, CA) working with Annalisa Angelini (Padua, IT) and myself (London, UK).8 In this issue of the Links you will read an update by Patrick Bruneval following a third workshop held prior to this year's ISHLT meeting in Prague. It is clear to us that the use of web-based digital technology to assess pathology slides was key to the outcome of all this work. So successful were we that the Pathology Council's remit has now been extended to include pulmonary AMR - an altogether different challenge (!) which Gerry Berry addresses in this issue.

Networking between professional societies can bring considerable benefit, as shown by recent collaborative work by the AECVP and the North America-based Society for Cardiovascular Pathology.9,10 Both societies hold annual scientific meetings and have strong commitments to education, training and research. Multidisciplinary networking is also encouraged by the American Society of Transplantation (AST) which in 2010 established a Transplant Diagnostics Community of Practice, an educational and training resource open to all AST members of transplant teams who wish to develop best practice in transplant diagnostics. Non-AST members may participate for a one-year trial but thereafter must join the AST if they wish to continue to participate. Links to these societies with details of some of their meetings are given at the end of this article.

We heart and lung transplant pathologists should network globally, even if only informally at this stage. Then we can more easily share access to information about available teaching courses, scientific meetings of relevance and web-based tutorials as well as promoting collaborative research on topics of mutual interest in our "niche" subspecialty. If you—somewhere in the world—wish to link with us please contact me to discuss it (, especially if you have ideas as to how we can interact and develop as a global heart and lung transplant pathologist community to help keep our skills and knowledge up-to-date. I may not know the answer to any of your queries - but hopefully I will know someone who does!


Disclosure Statement: The author has no relevant financial relationship to declare.


  1. Clark Stephen, Zuckermann Andreas. I2C2 - bringing ISHLT to the world.
  2. Al-Janabi S, Huisman A, Van Diest PJ. Digital pathology: current status and future perspectives. Histopathology. 2012 Jul;61(1):1-9.
  3. Rodriguez ER. The pathology of heart transplant biopsy specimens: revisiting the 1990 ISHLT working formulation. J. Heart Lung Transplant. 2003 Jan;22(1):3-15.
  4. Stewart S, Winters GL, Fishbein MC, et al. Revision of the 1990 working formulation for the standardization of nomenclature in the diagnosis of heart rejection. J. Heart Lung Transplant. 2005 Nov;24(11):1710-20.
  5. Sis B, Mengel M, Haas M, et al. Banff '09 meeting report: antibody mediated graft deterioration and implementation of Banff working groups. Am.J.Transplant. 2010 Mar;10(3):464-71.
  6. Angelini A, Andersen CB, Bartoloni G, et al. A web-based pilot study of inter-pathologist reproducibility using the ISHLT 2004 working formulation for biopsy diagnosis of cardiac allograft rejection: the European experience. J. Heart Lung Transplant. 2011 Nov;30(11):1214-20.
  7. Burke M, Andersen CB, Ashworth M, et al. C4d methodology and interpretation in diagnosis of cardiac antibody-mediated rejection: a European survey from the Association for European Cardiovascular Pathology (AECVP). J. Heart Lung Transplant. 2010;29(2):S37-S38.
  8. Berry GJ, Angelini A, Burke MM, et al. The ISHLT working formulation for pathologic diagnosis of antibody-mediated rejection in heart transplantation: Evolution and current status (2005-2011). J. Heart Lung Transplant. 2011 Jun;30(6):601-11.
  9. Thiene G, Veinot JP, Angelini A, et al. AECVP and SCVP 2009 Recommendations for Training in Cardiovascular Pathology. Cardiovasc.Pathol. 2010 Jan 13.
  10. Leone O, Veinot JP, Angelini A, et al. 2011 Consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology. Cardiovasc.Pathol. 2012 Jul;21(4):245-74.