9569 Background: Neoadjuvant (NA) ICB is standard of care for resectable stage III melanoma, with major pathological (p) response (R) (MPR, ≤10% viable tumor) strongly predicting relapse free survival (RFS). Imaging biomarkers to predict MPR are lacking. We evaluated the outcomes of patients (pts) treated with NA pembrolizumab (Pem) or nivolumab (NIVO) + ipilimumab (IPI) therapy, focusing on pR and FDG PET/CT metabolic changes. Methods: We retrospectively analyzed pts with resectable stage IIIB-D melanoma treated with NA Pem or NIVO + IPI at Peter Mac from March 2022 to Dec 2025. Clinical characteristics, pR, RFS, and treatment-related adverse events (TRAEs) were analyzed. RFS was calculated from date of surgery until day of death, recurrence or last follow up. Maximum standardized uptake value (SUVmax) of the most avid lesion (lymph node (LN) or in-transit metastases (ITM)) at baseline and post NA ICB on FDG PET/CT scans were recorded. Results: Of the 130 pts, 100 had LN metastasis only, 19 ITM only and 11 LN + ITM. 77 (59.2%) received Pem and 53 (40.8%) received NIVO + IPI. 117 pts (90.0%) underwent surgery: LN dissection in 40, index LN (ILN) excision in 58, ITM excision in 18 and excision of ITM + ILN in 1. 13 pts did not have surgery, 10 due to progressive disease on FDG PET/CT, complete resolution of ITM in 2, and toxicity in 1. MPR was seen in 74 (63.2%), partial response (pPR) in 7 (6.0%) and pathological non-response (pNR) in 36 (30.8%) pts. A ∆SUVmax decline ≥50% post NA ICB was strongly predictive of MPR, whereas pts without significant metabolic response were more likely to have pNR (sensitivity 93.2%, specificity 60.0%, positive predictive value 71.9%, negative predictive value 88.9% and accuracy 77.4% p =0.005). In ILN disease, 40/43 pts (93.0%) with ≥50% drop in ∆SUVmax achieved MPR (p<0.0001). In ITMs, a decline in ∆SUVmax ≥50% resulted in MPR in all 10 pts (table 1). At 12 months (m) median follow up, 14 pts recurred including 4 after MPR. The estimated 12m RFS was 89.0% for Pem and 79.3% for NIVO + IPI. 12m RFS in pts with ∆SUVmax decline ≥50% for Pem was 97% and 82% for NIVO + IPI ( p =0.045). Grade ≥3 TRAEs occurred in 12 pts (7.5%), more frequently with NIVO + IPI. Conclusions: NA ICB yields high MPR rates in stage III melanoma. Early metabolic response on FDG PET/CT, defined as a ΔSUVmax ≥50% decline is a strong, readily implementable imaging biomarker for predicting MPR following NA ICB, enabling early treatment adaptation and personalized surgical decision-making. Pem (n=77) NIVO + IPI (n=53) Median age [range] 67 [41-92] 67 [20-82] BRAF mutant, n (%) 23 (29.9) 27 (50.9) Stage III B/C/D, n 26/50/1 20/33/0 Site of disease, neck/axilla/groin/ITM, n 23/28/13/13 18/20/12/6 MPR, n (%) 45 (65.2) 29 (60.4) MPR ∆SUVmax decline ≥50% 33/35 13/14 MPR ∆SUVmax decline <50% 12/34 7/22 12m RFS ∆SUVmax decline ≥50% (95% CI) 96% (89%-100%) 100% 12m RFS ∆SUVmax decline <50% (95% CI) 82% (67%-100%) 80% (59%-100%)

BACKGROUND:Ex vivo normothermic machine perfusion (NMP) is an organ preservation technique that enables an extended assessment of graft suitability before liver transplantation (LT). Established monitoring protocols used during NMP vary significantly in their assessment of transplant suitability when applied to the same grafts. Graft-derived cell-free DNA (gdcfDNA) analysis is an emerging tool for monitoring graft health post-transplantation. We investigated the feasibility of monitoring gdcfDNA during NMP for LT in a proof-of-concept, observational study. METHODS:Serial plasma and bile samples were collected during NMP for 10 consecutive grafts, at 15 min post-machine reperfusion and then 2-h intervals. Digital polymerase chain reaction was used to quantify gdcfDNA at each time point. RESULTS:Five grafts were suitable for LT, there were no cases of primary nonfunction or death in the recipients. gdcfDNA was quantified in all bile and plasma samples (n > 100). In plasma, gdcfDNA concentrations climbed post-machine reperfusion until 4.25 h (median 2.25 h = 15.98 × 10 6 copies/mL, 4.25 h = 40.21 × 10 6 copies/mL). gdcfDNA levels then diverged significantly when comparing the viable and non-viable graft groups (6.25 h, median viable: 117.15 × 10 6 copies/mL versus non-viable: 16.72 × 10 6 copies/mL, P  = 0.01). These opposing trends correlated in each graft and in all cases with the viable/non-viable outcome. There was a trend of gradual decline in bile gdcfDNA from viable grafts post-machine reperfusion; discarded grafts showed more variable patterns of release. CONCLUSIONS:gdcfDNA analysis during NMP is a feasible and potential tool to inform viability assessment during NMP for LT. Bile gdcfDNA monitoring offers the prospect of an objective means to assess the degree of biliary injury associated with organ procurement.

BACKGROUND:Breslow thickness (BT), ulceration, and microsatellitosis are critical prognostic parameters for cutaneous melanoma staging. These parameters can vary depending on the number of tissue levels examined from individual paraffin blocks. We sought to evaluate all prognostic histopathologic parameters in melanoma for their variations between levels, taken at regular intervals, in a single study. METHODS:We analyzed 40 consecutive cases of primary cutaneous (nonacral) melanoma through five hematoxylin and eosin sections, taken at 100 μm intervals, for staging and prognostic parameters. RESULTS:Examination of additional levels resulted in (a) an increase in BT in 47.5% (19 out of 40) of cases and (b) detection of ulceration in a further 5% (2/40). This resulted in upstaging for 20% (8 out of 40) of patients (15% because of BT, 2.5% because of ulceration, and 2.5% because of BT and ulceration). The upstaging effect was incremental, with approximately 5% of patients upstaged with each additional 100 μm interval (up to 400 μm). Incipient ulceration and epidermal consumption were infrequent (10% of cases); however, when present, ulceration was subsequently observed in half of cases. We encountered no cases where microsatellitosis was detected at deeper levels. CONCLUSION:The performance of additional tissue levels is a simple and inexpensive procedure that can improve the accuracy of staging for patients with thin (pT1) primary cutaneous melanomas. It may be pertinent for pathologists to consider additional levels for thin melanomas when a BT measurement is close to a staging threshold (e.g., within 0.1-0.3 mm for pT1a vs. pT1b, or pT1b vs. pT2a), or when incipient ulceration is encountered.

IntroductionWe report the partial regression of metastatic squamous cell carcinoma (SCC) after reduction of long-term azathioprine therapy while awaiting surgery. The patient was a 69-year-old man with a history of kidney transplantation. Moderately differentiated SCC arising in the anterior neck was initially diagnosed, followed later by poorly differentiated SCC metastases to cervical lymph nodes. Lymph node clearance was performed 28 days after a reduction in azathioprine dosage. The palpable lymph node lesion had noticeably decreased in size at the time of surgery, and subsequent histology only detected 7mm and 0.2mm deposits of poorly differentiated SCC in 2 of 5 level I nodes, and a further 10 reactive nodes from levels II and III. One positive level I and another benign level II/III node, demonstrated necrosis, histiocytic infiltration and fibrosis, interpreted as features of regression. Hence, we investigated the role of immune cells in the partial regression of metastatic SCC after reduction of long-term azathioprine therapy while awaiting surgery.MethodsMultispectral immunohistochemistry using custom markers was performed on regions of interest of excised cervical lymph nodes, encompassing the entire SCC deposit and the surrounding adjacent stroma to quantify to number and types of immune cells present.ResultsMultispectral immunohistochemistry revealed the heavy infiltration of activated T cells in the tumour, as well as PD-L1+ antigen-presenting cells in the surrounding adjacent stroma, suggesting an immunologically mediated partial regression.DiscussionWe hypothesize that this reaction was triggered by azathioprine dose reduction. Dose modification of long-term immunosuppressive medications in patients with a transplantation history who later develop SCCs warrants further investigation.

Best response according to histological grade

ANZ Journal of SurgeryEarly View IMAGES FOR SURGEONS An ear-piercing melanoma in situ Paul Machado MBBS, Paul Machado MBBS orcid.org/0000-0001-8913-1936 Plastic and Reconstructive Surgery Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: Data curation, Project administration, Writing - original draft, Writing - review & editingSearch for more papers by this authorSibon Fuzzard MBBS, Sibon Fuzzard MBBS orcid.org/0000-0002-3314-7709 Plastic and Reconstructive Surgery Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: Conceptualization, Project administration, Writing - review & editingSearch for more papers by this authorSam Hamilton MBBS, Sam Hamilton MBBS orcid.org/0000-0002-8400-9779 Plastic and Reconstructive Surgery Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: Methodology, Writing - original draft, Writing - review & editingSearch for more papers by this authorLouise Jackett FRCPA, Louise Jackett FRCPA Anatomical Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: Formal analysis, Writing - review & editingSearch for more papers by this authorCarly Fox FRACS (Plastic Surgery), Carly Fox FRACS (Plastic Surgery) Plastic and Reconstructive Surgery Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: SupervisionSearch for more papers by this author Paul Machado MBBS, Paul Machado MBBS orcid.org/0000-0001-8913-1936 Plastic and Reconstructive Surgery Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: Data curation, Project administration, Writing - original draft, Writing - review & editingSearch for more papers by this authorSibon Fuzzard MBBS, Sibon Fuzzard MBBS orcid.org/0000-0002-3314-7709 Plastic and Reconstructive Surgery Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: Conceptualization, Project administration, Writing - review & editingSearch for more papers by this authorSam Hamilton MBBS, Sam Hamilton MBBS orcid.org/0000-0002-8400-9779 Plastic and Reconstructive Surgery Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: Methodology, Writing - original draft, Writing - review & editingSearch for more papers by this authorLouise Jackett FRCPA, Louise Jackett FRCPA Anatomical Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: Formal analysis, Writing - review & editingSearch for more papers by this authorCarly Fox FRACS (Plastic Surgery), Carly Fox FRACS (Plastic Surgery) Plastic and Reconstructive Surgery Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia Contribution: SupervisionSearch for more papers by this author First published: 03 November 2023 https://doi.org/10.1111/ans.18758Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Arnold M, Singh D, Laversanne M et al. Global burden of cutaneous melanoma in 2020 and projections to 2040. JAMA Dermatol. 2022; 158: 495–503. 10.1001/jamadermatol.2022.0160 PubMedWeb of Science®Google Scholar 2Felton S, Taylor RS, Srivastava D. Excision margins for melanoma in situ on the head and neck. Dermatol. Surg. 2016; 42: 327–334. 10.1097/DSS.0000000000000648 CASPubMedWeb of Science®Google Scholar 3Moura FS, Homer LE, McKirdy SW. Histological peripheral margins and recurrence of melanoma in situ treated with wide local excision. J. Skin Cancer 2020; 2020: 8813050. 10.1155/2020/8813050 PubMedWeb of Science®Google Scholar 4Dreher K, Kern M, Rush L, Jennings T. Basal cell carcinoma invasion of an ear piercing. Dermatol. Online J. 2022; 28. 10.5070/D328157066 PubMedGoogle Scholar 5Khundkar R, Wilson PA. Basal cell carcinoma at the site of a nasal piercing. J. Plast. Reconstr. Aesthet. Surg. 2009; 62: 557–558. 10.1016/j.bjps.2008.06.083 CASPubMedWeb of Science®Google Scholar 6Ng MF, Clarkson JH, Hogg FJ. Basal cell carcinoma arising from nasal piercing: cause or coincidence. J. Plast. Reconstr. Aesthet. Surg. 2010; 63: e153–e154. 10.1016/j.bjps.2009.02.086 CASPubMedWeb of Science®Google Scholar Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

Cutaneous melanoma is the deadliest form of skin neoplasm and its high mortality rates could be averted by early accurate detection. While the detection of melanoma is currently reliant upon melanin visualisation, research into melanosome biogenesis, as a key driver of pathogenesis, has not yielded technology that can reliably distinguish between atypical benign, amelanotic and melanotic lesions. The endosomal-lysosomal system has important regulatory roles in cancer cell biology, including a specific functional role in melanosome biogenesis. Herein, the involvement of the endosomal-lysosomal system in melanoma was examined by pooled secondary analysis of existing gene expression datasets. A set of differentially expressed endosomal-lysosomal genes was identified in melanoma, which were interconnected by biological function. To illustrate the protein expression of the dysregulated genes, immunohistochemistry was performed on samples from patients with cutaneous melanoma to reveal candidate markers. This study demonstrated the dysregulation of Syntenin-1, Sortilin and Rab25 may provide a differentiating feature between cutaneous melanoma and squamous cell carcinoma, while IGF2R may indicate malignant propensity in these skin cancers.

ObjectiveAfter liver transplant (LT), many investigations are needed to evaluate abnormal liver function test (LFT), which has poor specificity for graft function and complication. A single center retrospective audit of all adult single organ LT from 1/1/2015 to 31/12/2017 was performed. Demographic, clinical and investigation data from the LT database and electronic medical records and cost data from the hospital's Business Intelligence Unit were analyzed. Patients were classified into uncomplicated or complicated LFT by 2 independent investigators and the number, type, and cost of investigations in the first 30 post-operative days were analyzed. Investigations prior to liver biopsy was sub-analyzed.ResultsThere was 170 LT with 87 cases of uncomplicated LFT (51.2%) and 83 cases of complicated LFT (48.8%). Most patients with complicated LFT had additional investigations (97.6%), most commonly cholangiogram (55.4%) and liver biopsy (LBx) (50.6%). The additional investigations cost was $1863.3 (95% CI 1289.0-2437.6). Although most LBx (73.8%) showed evidence of rejection, LBx was often not the initial investigation of choice. Current LFT based post-transplant monitoring is inefficient. It remains difficult to determine which patient will benefit from an early invasive procedure like LBx, using LFT alone without further imaging investigations.

Clinical diagnosis of fibrosis is currently reliant on conventional methods. The current "gold standard" for fibrosis diagnosis is histological examination of a biopsy, which is labour intensive and requires extensive sample preparation. Here we show that a portable handheld near-infrared spectrometer coupled with machine learning algorithms can discriminate between kidney and cardiac fibrosis in a rat model of kidney failure compared to healthy rats without kidney failure. The most significant changes in the spectra of fibrotic tissue included shifts in absorption bands at 1509, 1581, 1689 and 1725nm attributed to collagen components. The best discrimination of fibrosis was achieved in kidney tissue (AUC=0.962), which showed a higher level of fibrosis compared to cardiac tissue (AUC=0.882). The results show the potential of the NIR spectroscopy to detect and to quantify fibrosis in the heart and kidney that in the future could be applied as an intraoperative surgical tool to guide surgical procedures.

While women pathologists have made up over one-third of pathologists in the Australian workforce for over 15 years and at least 50% since 2019, they are under-represented in senior leadership roles, scientific publications, grant recipients, editorial boards, key presentations, and professional awards. This is not unique to pathology and is seen in the broader medical and academic community. Barriers to gender equity and equality in pathology, medicine and academia include gender stereotypes, gender-based discrimination, structural and organisational barriers as well as broader social and cultural barriers. A diverse leadership reflective of the whole professional body and the broader community is important for optimal health outcomes. It is the responsibility and moral duty of individuals and organisations to address any gender disparities, inequities, and inequalities by monitoring, identifying, and acting on gender biases and systemic barriers that hinder appropriate levels of representation by women.

Merkel cell carcinoma (MCC) is an uncommon cutaneous neuroendocrine carcinoma that requires confirmation by immunohistochemical stains to exclude histological mimics such as melanoma. Here we report a unique case of MCC that showed nuclear SOX10 staining, which, to the knowledge of the authors, is a phenomenon not previously described in the literature, and a potential diagnostic pitfall.

Non-melanocytic skin cancers (NMSCs) account for five times the incidence of all other cancers combined and cost US $6 billion annually. These are the most frequent specimens encountered in community pathology practice in many Western countries. Lack of standardised structured pathology reporting protocols (SPRPs) can result in omission of critical information or miscommunication leading to suboptimal patient management. The lack of standardised data has significant downstream public health implications, including insufficient data for reliable development of prognostic tools and health-economy planning.The Royal College of Pathologists of Australasia has developed an NMSC SPRP. A multidisciplinary expert committee including pathologists, surgeons, dermatologists, and radiation and medical oncologists from high volume cancer centres was convened. A systematic literature review was performed to identify evidence for including elements as mandatory standards or best practice guidelines. The SPRP and accompanying commentary of evidence, definitions and criteria was peer reviewed by external stakeholders. Finally, the protocol was revised following feedback and trialled in multiple centres prior to implementation.Some parameters utilised clinically for determining management and prognosis including tumour depth, lymphovascular invasion or distance to the margins lack high level evidence in NMSC. Dermatologists, surgeons, and radiation oncologists welcomed the SPRP. Pathologists indicated that the variety of NMSC specimens ranging from curettes to radical resections as well as significant differences in the biological behaviour of different tumours covered by the NMSC umbrella made use of a single protocol difficult. The feedback included that using a SPRP for low risk NMSC was neither clinically justified nor compensated adequately by the Australian Medicare Reimbursement Schedule. Following stakeholder feedback, the SPRP implementation was restricted to excision specimens of head and neck NMSC; and low-risk NMSC, such as superficial basal cell carcinoma, were excluded.Implementing NMSC SPRP fulfils an unmet clinical need. Unlike other cancers, NMSCs generate a range of specimen types and are reported in a wide range of pathology practices. Limiting use of SPRP to NMSC at higher risk of progression and providing formatted templates for easy incorporation into laboratory information systems were essential to successful deployment. In the future, further consideration should be given to implementing the SPRP to include all relevant specimens, including non-head and neck and low-risk NMSC specimens.

The cover picture shows a handheld near-infrared spectroscopic probe to detect fibrosis in real time using a murine model. The major differences between spectra of healthy and fibrotic tissue were seen in specific absorption bands, which were attributed to disruption in the collagen network. More information can be found in the Research Article by John A. Adegoke, Jaishankar Raman, Bayden R. Wood, and co-workers.

AbstractIntroductionVisual assessment and imaging of the donor liver are inaccurate in predicting fibrosis and remain surrogates for histopathology. We demonstrate that 3‐s scans using a handheld near‐infrared‐spectroscopy (NIRS) instrument can identify and quantify fibrosis in fresh human liver samples.MethodsWe undertook NIRS scans on 107 samples from 27 patients, 88 from 23 patients with liver disease, and 19 from four organ donors.ResultsLiver disease patients had a median immature fibrosis of 40% (interquartile range [IQR] 20–60) and mature fibrosis of 30% (10%–50%) on histopathology. The organ donor livers had a median fibrosis (both mature and immature) of 10% (IQR 5%–15%). Using machine learning, this study detected presence of cirrhosis and METAVIR grade of fibrosis with a classification accuracy of 96.3% and 97.2%, precision of 96.3% and 97.0%, recall of 96.3% and 97.2%, specificity of 95.4% and 98.0% and area under receiver operator curve of 0.977 and 0.999, respectively. Using partial‐least square regression machine learning, this study predicted the percentage of both immature (R2 = 0.842) and mature (R2 = 0.837) with a low margin of error (root mean square of error of 9.76% and 7.96%, respectively).ConclusionThis study demonstrates that a point‐of‐care NIRS instrument can accurately detect, quantify and classify liver fibrosis using machine learning.

Background: To avoid patient harm, laboratories require protocols to resolve identification and specimen handling errors.This case describes how correct diagnoses were conveyed to two patients after their

Transplant recipients are known to be at an elevated risk of mortality in the event of SARS-CoV-2 infection, and vaccination has been shown to improve survival.1 No studies have specifically assessed the immunogenic risk of SARS-CoV-2 vaccination for solid organ transplant recipients. To date, there has only been 1 case report of liver allograft rejection associated with a SARS-CoV-2 vaccine, although this was confounded by simultaneous withdrawal of low dose prednisolone.2 Three liver transplant recipients from a single quaternary center developed deranged liver function within 2 wks of receiving SARS-CoV-2 vaccination without any alternate identifiable precipitant for rejection (see Table 1). They were all diagnosed with moderate or severe liver allograft rejection, which was confirmed on histopathological examination of liver allograft biopsies following identification of abnormal liver function tests (see Figure 1). All 3 cases were treated with intravenous methylprednisolone (dose of 1 g daily initially) followed by a wean of oral prednisolone starting at 40 mg. TABLE 1. - Clinical parameters Age Gender Allograft (etiology of liver disease) Years posttransplant Immunosuppression at presentation (tacrolimus trough level) Pfizer-BioNTech dose Detection postvaccination (d) Peak LFT derangement (d postvaccination) RAI ALT (U/L) AST (U/L) GGT (U/L) ALP (U/L) Bilirubin (mmol/L) Case 1 48 Female Liver (cryptogenic cirrhosis) 3 Tacrolimus 1 mg BD (6 µg/L) First 14 1235 (14) 820 (14) 1468 (43) 419 (43) 409 (42) 6–7 Case 2 24 Female Liver-kidney a (Caroli’s disease, autosomal recessive polycystic kidney disease) 7 Tacrolimus extended release (6.5 µg/L)Mycophenolate mofetil 1 g BDPrednisolone 5 mg daily First 12 187 (12) 254 (12) 465 (36) 241 (36) 372 (27) 8 Case 3 20 Female Liver (biliary atresia) 17 Tacrolimus extended release 3 mg daily (5.4 µg/L) First 8 1674 (17) 530 (17) 992 (34) 200 (14) 91 (21) 5–6 b Case 3 had previously received the standard 2-dose regimen of the AstraZeneca vaccine 6 mo earlier.aNo renal allograft dysfunction was observed.bModified by pretreatment effect (4 d of oral prednisolone 40 mg daily).ALP, alkaline phosphatase; ALT, alanine transaminase; AST, aspartate aminotransferase; BD, twice daily; GGT, gamma-glutamyl transferase; LFT, liver function test; RAI, rejection avidity index. FIGURE 1.: Histopathological findings of liver allograft biopsies after SARS-CoV-2 mRNA vaccination (Pfizer-BioNTech) for case 1 (A, H&E ×400), case 2 (B, H&E ×100), and case 3 (C, H&E ×400; D, H&E ×400). A, Post vaccination biopsy for Case 1 showed moderate to severe T cell mediated rejection with all portal tracts infiltrated and expanded by activated lymphocytes, neutrophils and eosinophils. Endotheliitis (*) and lymphocytic bile duct injury (arrow) were present in most portal tracts. B, Post vaccination biopsy for Case 2 showed severe T cell mediated rejection with expansile portal infiltrates (*), marked cholestatic lobular injury (arrow) and central venule perivenulitis with hepatocyte drop-out (#).C and D, Case 3 showed typical rejection infiltrate with endotheliitis (arrows), lymphocytic cholangitis (*) and limited lymphocytic central perivenulitis with perivenular hepatocyte damage (#).Case 1 experienced a later relapse of rejection requiring retreatment with 2 courses of intravenous methylprednisolone. She remains on triple immunosuppression. Case 2 developed evolving liver allograft failure despite receiving empiric treatment for antibody-mediated rejection including plasma exchange, intravenous immunoglobulin, and rituximab. During workup for retransplantation, she contracted COVID-19 and ultimately died from its complications. Case 3 took a longer time to respond than is usually observed with typical rejection (post treatment peak gamma-glutamyl transferase at day 34, see Table 1). She was commenced on ursodeosxycholic acid (500 mg twice daily), which appeared to hasten the recovery of the gamma-glutamyl transferase. She remains on triple immunosuppression. This case series suggests that there may be a causal link between the Pfizer-BioNTech vaccine and allograft rejection in susceptible liver transplant recipients. The temporal relationship between receipt of the vaccine, onset of symptoms, and subsequent liver biochemistry derangement is highly suggestive that the vaccine was at least partially responsible for the onset of rejection. These cases also had particularly dramatic cholestasis with jaundice, poor initial treatment response, and slower recovery than what would usually be seen in a rejection episode, which may suggest a unique pathophysiological mechanism underlying the rejection. It is biologically plausible that an mRNA vaccination could precipitate acute cellular rejection of the liver in a predisposed individual. The mRNA vaccination induces the host to create the spike protein from the SARS-CoV-2, and it has been shown that recombinant antibodies to this spike protein can cross react with human tissue.3 There have also been case reports of de novo autoimmune hepatitis following the SARS-CoV-2 vaccine among individuals without preexisting liver disease.4,5 Among liver transplant recipients at our center, a total of 2332 SARS-CoV-2 vaccines (Pfizer, n = 1189; AstraZaneca, n = 1048; Moderna, n = 95) have been administered. Therefore, it is clear that, if this association is real, clinically significant rejection triggered by vaccination appears to be rare. Nevertheless, we suggest biochemical monitoring of liver function in the weeks following vaccination. Further observation and experience with these vaccines are needed to establish if a true causal link exists.

Targeted therapy (BRAF inhibitor plus MEK inhibitor) is now among the possible treatment options for patients with BRAF mutation-positive stage III or stage IV melanoma. This makes prompt BRAF mutation testing an important step in the management of patients diagnosed with stage III or IV melanoma; one that can help better ensure that the optimal choice of systemic treatment is initiated with minimal delay. This article offers guidance about when and how BRAF mutation testing should be conducted when patients are diagnosed with melanoma in Australia. Notably, it recommends that pathologists reflexively order BRAF mutation testing whenever a patient is found to have American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) stage III or IV melanoma (i.e., any metastatic spread beyond the primary tumour) and that patient's BRAF mutation status is hitherto unknown, even if BRAF mutation testing has not been specifically requested by the treating clinician (in Australia, Medicare-subsidised BRAF(V600) mutation testing does not need to be requested by the treating clinician). When performed in centres with appropriate expertise and experience, immunohistochemistry (I HC) using the anti-BRAF V600E monoclonal antibody (VE1) can be a highly sensitive and specific means of detecting BRAF(V600E) mutations, and may be used as a rapid and relatively inexpensive initial screening test. However, VE1 immunostaining can be technically challenging and difficult to interpret, particularly in heavily pigmented tumours; melanomas with weak, moderate or focal BRAF(V600E) immunostaining should be regarded as equivocal. It must also be remembered that other activating BRAF(V600) mutations (including BRAF(V600K)), which account for similar to 10-20% of BRAF(V600) mutations, are not detected with currently available IHC antibodies. For these reasons, if available and practicable, we recommend that DNA-based BRAF mutation testing always be performed, regardless of whether IHC-based testing is also conducted. Advice about tissue/specimen selection for BRAF mutation testing of patients diagnosed with stage III or IV melanoma is also offered in this article; and potential pitfalls when interpreting BRAF mutation tests are highlighted.