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PCLS generation
The generation of PCLS can be separated into four essential steps: surgical lung tissue resection, agarose filling, vibratome-based PCLS generation, and culture of PCLS. The resected lung tissue is filled with low-melting point agarose, which adds the required stiffness to the lung tissue for slicing and preserves the native lung structure and architecture. Of note, PCLS generation is highly time consuming, thus often overnight storage of the filled lung tissue in DMEM F-12 medium can be included as an additional step and PCLS generation is started on the next day. Depending on the following experimental setup, generated PCLS can be incubated overnight in standard cell culture medium containing 0.1% (w/v) fetal bovine serum, before experimental conditions are applied. 3D-LTCs were viable and exhibited cellular functionality (such as surfactant protein secretion) for up to 120 h22 in the culture conditions outlined in this protocol (Figure 1) and might be optimized upon further improvement thereof.
Agarose filling
For agarose filling of the tissue, a cannula of a peripheral venous catheter with a 1.3 mm diameter attached to the agarose-filled syringe was inserted into a bronchus at the surface of the cut tissue (Figure 2A). Bronchi are often localized near to a pulmonary artery. While the arteries have thinner walls and tend to collapse, bronchi exhibited a good visible lumen. Depending on the tissue's integrity, the catheter can be advanced through several generations of the respiratory tree into the periphery of the lung. The penetrated bronchus was sealed around the cannula by using tweezers (Figure 2B). The pulmonary artery can be clamped with the tweezers at the same time. Afterwards, the tissue is lifted up and liquid agarose is gently instilled into the airways.
Depending on the position of the catheter, a majority of the tissue can be filled with liquid agarose (Figure 2D). Optionally, cone like parts of the lung tissue, which reflect the lung's parenchyma ventilated by the penetrated bronchus, might get filled with the agarose (Figure 2C). In both scenarios, a characteristic pattern of solidly filled tissue regions can be observed: first, a major part of the tissue is filled in wedges (Figure 2D), or secondly, smaller protruding round areas of thoroughly filled tissue regions appear (Figure 2C). If parts of the airways obstruct due to agarose clots or other causes, parts of the tissue might not be properly filled with agarose. Thus, only parts of the tissue might be applicable for slicing. In case of leakages during the agarose filling procedure, parts of the filled respiratory tree might get perforated and filling of the lung tissue gets nearly impossible However, possible workarounds include the filling via a more peripheral bronchus, a deeper penetration of the cannula into the distal airways (Figure 2G), or potential clamping of the leakage area (Figure 2H).
Precision-cut lung slicing
Tissue blocks at a length and width of 1-1.5 cm were excised from tissue regions, which were completely filled with solidified agarose (Figure 3A-3B). Next, the individual tissue blocks were glued on the tissue holder of the vibratome (Figure 3C). 500 µm thick PCLS were generated, whereas the tissue block at the vibratome was advancing forward with speeds between 3-12 µm/s. (Figure 3D-3F). Finally, the PCLS were submerged in cell culture medium containing 0.1% (w/v) fetal bovine serum and cultured at standard cell culture conditions, as outlined step 7.
Experimental readouts of human 3D-LTC after 48h of culturing
A representative immunofluorescence staining, as previously described by Alsafadi et al.25, is shown in Figure 4A-4C. Immunolabeling of fibronectin (red) and cell nuclei (DAPI, blue), allowed for imaging of the preserved alveolar structure in the human 3D-LTC ex vivo. Treatment of the human PCLS punches with a profibrotic cytokine cocktail (including transforming growth factor beta 1, platelet derived growth factor AB, lipophosphatidyl acid, and tumor necrosis factor alpha) for 48 h resulted in fibrosis-like changes in human 3D-LTCs. By qPCR, a significant induction of the fibrosis-relevant extracellular matrix components collagen type 1 and fibronectin genes in 3D-LTC punches was observed upon treatment with the profibrotic cocktail (Figure 4D). Additionally, protein levels of the mesenchymal marker vimentin were found upregulated in 3 out of 4 patients after treatment of 3D-LTC punches (Figure 4E).

Figure 1: Workflow of PCLS generation. Tumor-free areas of lung resections are thoroughly inspected due to their tissue integrity. If the tissue is scored suitable for further use (scoring is explained in detail in the material and methods section), it is next filled with liquid agarose. Tissue blocks filled with solidified agarose are subsequently sliced with a vibratome. Submerged in cell culture medium, 3D-LTC are cultured up to 120 h after their generation. Downstream analyses of the 3D-LTCs involve protein- or RNA-expression, live-tissue fluorescence imaging, as well as immunofluorescence staining after fixation of the tissue. Please click here to view a larger version of this figure.

Figure 2: Filling the lung tissue with low-melting point agarose. The lung tissue is cannulated with a peripheral venous catheter which is inserted into a bronchus adjacent to the pulmonary artery (Figure 2A). Tweezers are used to fix the cannula in the bronchus and to clamp the pulmonary artery to avoid leaking of the liquid agarose. Liquid agarose at 42 °C is poured into the lung tissue with a 30 mL syringe (Figure 2B). A distal positioning of the cannula during filling will result in small areas of filled tissue (Figure 2C), while proximal positioning will ensure the filling of a larger tissue volume (Figure 2D). Any obstructions of the airways will reduce the amount of tissue volume that can be filled (Figure 2E). In case of agarose leaking, a distal cannula positioning and/or clamping of the leakage side enables proper agarose filling of the lung tissue (Figure 2F-2H). Please click here to view a larger version of this figure.

Figure 3: Precision-cut lung slicing. A successfully agarose-filled lung tissue is used to excise a piece of a tissue block (1 cm x 1.5 cm x 1 cm) with a scalpel (Figure 3A). Next the excised tissue block is glued to the tissue holder, scale bar indicates 1 cm (Figure 3B). Preferably, the tissue is glued with its pleural surface to the surface of the tissue holder as shown in Figure 3C. 500 µm thick slices are cut by the vibratome with a sapphire knife in a 10°-15° angle relative to the tissue (Figure 3D and 3E). The cutting procedure results in 2-3 cm3 large intact lung slices, Scale bar = 5 mm (Figure 3F). Additionally, by using a biopsy puncher, small reproducible punches with a diameter of 4 mm can be generated. Please click here to view a larger version of this figure.

Figure 4: Experimental readouts of human 3D-LTCs after 48h of culture. A human 3D-LTC punch of 4 mm diameter was immunostained for fibronectin (in red) and DAPI (in blue) (Figure 4A-4C). Scale bars = 1,000 µm. Figure 4C shows the merged image. RNA analysis of PCLS by quantitative RT-PCR shows significant increases of COL1A1 and FN1 gene expression by the profibrotic cocktail25. Figure 4E displays an immunoblot of whole protein lysates of PCLS, which were treated with a fibrotic cocktail25. Probing for Vimentin and β-Actin demonstrated an increased protein expression of the mesenchymal marker (vimentin) after treatment with profibrotic factors in patient samples 1, 3, and 4. Please click here to view a larger version of this figure.
| Criterion | Points |
| The tissue sample has intact pleural surface. | 20 |
| The tissue sample seems macroscopically intact, lacking incisions, squashing, ruptures and distortions. | 20 |
| The tissue sample contains at least one bronchus with a diameter >1mm. | 20 |
| The tissue sample contains no or only little amounts of blood. | 4 |
| The tissue sample was stored fully in medium and shows no obvious sign of atelectasis. | 4 |
| The tissue sample was resected within the last four hours. | 4 |
| The tissue sample is larger than 5cm in its largest diameter. | 4 |
| Score in sum: | |
Table 1: Lung Agarose Filling Score. The Lung Agarose Filling Score (LAFS) correlates with the success-rate to fill a tissue resection with agarose for its subsequent vibratome-based PCLS production. The score sums up all points of criteria met by the tissue. An LAFS equal or above 72 predicts good agarose filling properties, a score below 60 predicts a highly probable failure of agarose filling of the tissue.