The diagnosis and management of an expanding post-traumatic soft tissue cyst of the hip and groin.

A post-traumatic cyst is a rare complication of significant soft tissue trauma. It occurs at the junction between the subcutaneous fat and underlying fascia, when a large, subcutaneous haematoma fails to resolve, developing into a chronic, fluid-filled cyst, lined with fibrous tissue. This results in a swelling that persists for years, gradually increasing in size, often without causing significant discomfort to the patient. Clinically and radiologically these swellings may be mistaken for neoplastic lesions. They can be difficult to treat, are refractory to conservative management and have a high rate of recurrence following surgical excision. Careful monitoring and early treatment of persistent postoperative seroma is advocated.

Multiple malignant melanomas in association with neurofibromatosis type 1.

We present a case of multiple primary malignant melanomata occurring over a six year period in a 63-year-old Caucasian man with neurofibromatosis type 1. There is doubt regarding a definite association between these two diseases despite a number of case reports and clear, potential pathological mechanisms. This case not only strengthens support for an association but also highlights the great difficulties that arise in the management of cutaneous melanomata in patients with neurofibromatosis.

Quantification and cytokine production of circulating lymphoid and myeloid cells in acute myelogenous leukaemia.

A simple assay was developed to assess the potential of patients with acute myelogenous leukaemia (AML) to respond to immunotherapy. Lymphocytes, monocytes and leukaemic blasts with their corresponding intracellular cytokine profiles were evaluated by four-colour flow cytometry. In 50 microl samples of whole blood, surface labelling for CD45, CD8 and CD3 was used for cell identification prior to intracellular staining for interleukin (IL)-4, IL-10, IL-12 and interferon (IFN)-gamma. Absolute numbers of CD8(+) and CD8(-) (putative CD4(+)) T-cells, NK cells (CD8(+)/CD3(-)) and monocytes were determined by reference to a fixed number of added fluorescent beads. The absolute numbers of CD8(-) and CD8(+) T-cells in the blood of patients with AML were similar to those of normal controls. More of the lymphocytes in the blood of leukaemic patients spontaneously produced cytokines compared with those of controls. Furthermore, primary AML blasts secreted predominantly IFN-gamma. After recovery from chemotherapy, lymphocyte counts tended to be lower than in normals and reduction of NK cells reached significance after the second chemotherapy (P=0.01). A prominent CD8(lo)/CD3(lo-int) lymphocyte subset appeared after recovery in some patients. This laboratory application of the study of cell subsets and intracellular cytokines in patients undergoing treatment may be helpful in monitoring immunological responses in AML.

Malignancy: Case report: Myelodysplasia Following Treatment of Chronic Lymphocytic Leukaemia with Fludarabine.

Recently there has been an increased awareness of a possible link between the use of purine nucleoside analogues and myelodysplasia. We report the case of a patient who developed myelodysplasia with complex cytogenetic changes after receiving fludarabine. We review the literature, discuss the possible links between myelodysplasia and nucleoside analogues and putative mechanisms for secondary neoplasia.

Human peripheral blood contains two distinct lineages of dendritic cells.

Human peripheral blood contains two populations of dendritic cells (DC) but their developmental relationship has not been established. Freshly isolated CD11c- DC possessed a lymphoid morphology, lacked myeloid markers but expressed lymphoid markers (CD4+ CD10+) whilst the CD11c+ DC were monocytoid in appearance and expressed myeloid markers. Although both populations were allostimulatory, only the CD11c+ DC were able to take up antigen. Irrespective of the culture conditions the CD11c- cells developed into CD11c- CD13- CD33- CD4+ CD1a- CD83+/- DC. In contrast, cultured CD11c+ cells developed the phenotype CD11c+ CD13+ CD33+/- CD4- CD1a+ CD83+ CD9+. Only the CD11c+ DC expressed macrophage colony-stimulating factor (M-CSF) receptor and gave rise to CD14+, esterase+, phagocytic macrophages when cultured in M-CSF. These data suggest that these two populations of DC represent distinct lineages of antigen-presenting DC.

Role of beta-chemokines in HIV-1 infection of dendritic cells maturing from CD34+ stem cells.

OBJECTIVES: To study the susceptibility to infection by different strains of HIV-1 viruses and the roles of chemokines (macrophage inflammatory protein-1alpha [MIP-1alpha], MIP-1beta, and regulated-on-activation-T-expressed-and-secreted [RANTES]) in CD34+ stem cells maturing into dendritic cells (DC). DESIGN: It has been controversial whether CD34+ stem cells are susceptible to HIV-1 infection and whether high levels of beta-chemokines are beneficial for suppressing HIV-1 infection during DC maturation. These questions were addressed using different strains of HIV-1 and CD34+ stem cells taken from cord blood and cultured with granulocyte-macrophage colony stimulating factor (GM-CSF) and tumor necrosis factor-alpha (TNF-alpha) to generate mature DC. METHODS: CD34+ stem cells were exposed with M-tropic virus Ba-L or T-tropic viruses IIIB or Rut at day 1. Beta-chemokines were added to some cells before the virus and kept throughout the culture. Virus replication was measured throughout the maturation of these cells into CD1a+ DC and CD1a- CD14+ cells using enzyme-linked immunosorbent assay (ELISA) for p24, nested polymerase chain reaction (PCR) for env and intracellular p24 detection by flow cytometry. RESULTS: First, CD34+ stem cells acquired or were infected by live virus because maturing cells showed infection by both M- and T-tropic viruses. Second, the viruses replicated actively during the maturation of CD34+ stem cells toward CD1a+ DC and CD1a- CD14+ cells. Third, beta-chemokines suppressed infection by M-tropic virus Ba-L. And finally, beta-chemokines enhanced infection by T-tropic viruses IIIB and Rut. CONCLUSIONS: In addition to the initial anti-M-tropic virus effect by beta-chemokines, selective pressure on viruses may also result because of an increase in susceptibility to T-tropic virus. Caution should be taken when evaluating the effect of beta-chemokine receptor agonists in AIDS therapy.

Juvenile xanthogranuloma variant: a clinicopathological case report and review of the literature.

Juvenile xanthogranuloma is a relatively rare cutaneous lesion. In order to make an early diagnosis and be alert to the possibility of visceral complications and associated medical conditions, plastic surgeons should be aware of the entity. The classic presentation is that of successive eruptions in the head, neck and upper trunk of initially red papules or nodules which later become yellow and finally brown flattened plaques or macules. This report is of an unusual variant with atypical histology including frequent mitoses and a lack of Touton giant cells.

Myelodysplasia Following Treatment of Chronic Lymphocytic Leukaemia with Fludarabine.

Recently there has been an increased awareness of a possible link between the use of purine nucleoside analogues and myelodysplasia. We report the case of a patient who developed myelodysplasia with complex cytogenetic changes after receiving fludarabine. We review the literature, discuss the possible links between myelodysplasia and nucleoside analogues and putative mechanisms for secondary neoplasia.

The in-vitro generation of dendritic cells from blast cells in acute leukaemia.

Dendritic cells (DC) are potent antigen-presenting cells responsible for the initiation of primary antigen-specific immune responses. In chronic myeloid leukaemia DC have been generated from Ph+ cells and these Ph+ DC are capable of stimulating cytolytic T-cell responses against the parent leukaemia cells. The prevalence of this phenomenon in acute leukaemia (AL) is unknown and we have therefore studied a variety of acute leukaemias to determine their potential for DC development. Peripheral blood mononuclear cells (PBMC) from 21 cases of AL were cultured in GM-CSF + TNF alpha. Of these cases, 15 were viable in culture and cells with typical DC morphology were observed in 12 of these 15 cases. DC growing in culture expressed either CDla and/or CD83 and were HLA-DR+ CD40+ CD80+ CD86+ typical of mature DC. In 9/12 cases the cultured cells possessed potent antigen-presenting capacity as measured in the allo-MLR. The malignant origin of the cultured DC was confirmed by FISH analysis in two cases (one 5q- and one Ph+ AL) and by persistent aberrant expression of CD19 in two cases of biphenotypic leukaemia. Functional DC may be derived from AL blasts in a significant number of patients and such DC may be capable of inducing leukaemia-specific immune responses with potential for clinically beneficial effects.

The biology and clinical applications of dendritic cells.

Dendritic cells (DC) have an essential role in the induction of immune responses to antigen by naive T cells. As 'professional' antigen-presenting cells they are specialized to take up, process and present soluble antigens in complexes with either class I or class II MHC molecules. They are present in only trace numbers in most tissues and in a relatively immature state but, in the presence of inflammatory signals, they rapidly take up foreign antigens and undergo maturation into potent antigen-presenting cells that migrate to secondary lymphoid tissue where they initiate an immune response. It is now possible to expand populations of DC in vitro both from primitive haemopoietic progenitors as well as from more mature peripheral blood mononuclear cells. This has shed light on many developmental aspects of DC biology and furthered our knowledge of the mechanisms of antigen processing and presentation. It is clear that there is more than one pathway of DC differentiation and that some DC may actually induce immunological unresponsiveness--a possible mechanism for tolerance to self-antigens. For clinicians the most exciting prospect is of their use as cellular adjuvants to generate beneficial responses to antigens of low immunogenicity such as tumour antigens. This review outlines aspects of human DC development and the way in which a greater understanding of their biology may lead to promising clinical applications.

Developmental aspects of dendritic cells in vitro and in vivo.

Dendritic cells (DC) are potent antigen presenting cells that possess the unique ability to stimulate naive T-cells. By studying DC derived from various tissues it has been shown that the morphology, phenotype and function of DC alter as they undergo a complex process of maturation. DC are derived from bone marrow progenitors and circulate in the blood as immature precursors prior to migration into the peripheral tissues. Within tissues DC are specialised in the taking up and processing of antigen so that it may be presented on MHC class II molecules. Upon appropriate stimulation tissue DC undergo further maturation and migrate to secondary lymphoid tissue where they present antigen to T-cells and induce an immune response. Studies of DC maturation in vitro have defined the cytokines regulating their development from CD34+ myelomonocytic progenitors as well as from more mature peripheral blood precursors. An alternative pathway of differentiation from thymic precursors has also been described. As a result of these studies, DC may now be generated and manipulated ex-vivo for clinical applications in oncology, autoimmune disease and transplantation.

An extremely delayed cytogenetic response to interferon-alpha in a patient with chronic myeloid leukaemia.

In chronic myeloid leukaemia (CML), treatment with interferon alpha IFN-alpha results in loss of the Ph' chromosome in a significant proportion of patients. Most cytogenetic responses occur early at a median of 9 months after initiation of treatment and failure to detect a cytogenetic response within a predetermined period may be a reason for IFN-alpha withdrawal. We report a patient in whom IFN-alpha dosage was initially severely limited by bone marrow suppression but in whom continuing treatment led to a first cytogenetic response only after 53 months. Increasing Ph' negativity over a further 2 years was associated with improving haematological tolerance which permitted IFN-alpha dose escalation and complete cytogenetic remission was achieved at 7 years after diagnosis. This remission has been sustained and has thus followed the most delayed cytogenetic response to IFN-alpha so far reported.

Serotype-specific immunoglobulin G antibody responses to pneumococcal polysaccharide vaccine in children with sickle cell anemia: effects of continued penicillin prophylaxis.

OBJECTIVES: (1) To determine serotype-specific IgG antibody responses to reimmunization with pneumococcal polysaccharide vaccine at age 5 years in children with sickle cell anemia and (2) to determine whether continued penicillin prophylaxis had any adverse effects on these responses. STUDY DESIGN: Children with sickle cell anemia, who had been treated with prophylactic penicillin for at least 2 years before their fifth birthday, were randomly selected at age 5 years to continue penicillin prophylaxis or to receive placebo treatment. These children had been immunized once or twice in early childhood with pneumococcal polysaccharide vaccine and were reimmunized at the time of randomization. RESULTS: Serotype-specific IgG antibody responses to reimmunization varied according to pneumococcal serotype but in general were mediocre or poor; the poorest response was to serotype 6B. The antibody responses were similar in subjects with continued penicillin prophylaxis or placebo treatment, and in subjects who received one or two pneumococcal vaccinations before reimmunization. The occurrence of pneumococcal bacteremia was associated with low IgG antibody concentrations to the infecting serotype. CONCLUSIONS: Reimmunization of children with sickle cell anemia who received pneumococcal polysaccharide vaccine at age 5 years induces limited production of serotype-specific IgG antibodies, regardless of previous pneumococcal vaccine history. Continued penicillin prophylaxis does not interfere with serotype-specific IgG antibody responses to reimmunization.

Fluorescence in situ hybridization analysis of t(3; 12)(q26; p13): a recurring chromosomal abnormality involving the TEL gene (ETV6) in myelodysplastic syndromes.

We have identified a new recurrent reciprocal translocation between chromosome 3 and 12 with breakpoints at bands 3q26 and 12p13, t(3;12)(q26;p13) in the malignant cells from five patients with acute transformation of myelodysplastic syndrome or blast crisis of chronic myelogenous leukemia. t(3;12)(q26;p13) appears as a rare but nonrandom event present in various myeloid leukemia subtypes, which is frequently associated with dysplasia of megakaryocytes, multilineage involvement, short duration of any blastic phase, and a very poor prognosis. Here, we report the molecular cytogenetic analysis of the t(3;12). Fluorescence in situ hybridization results indicate that the 3q26 breakpoints are quite heterogeneous and occur 5' of MDS1, 3' of EVI1, or between MDS1 and EVI1. Our results are very similar to those observed in other 3q26 rearrangements in which breakpoints were shown to occur over considerable distances 5' and 3' of EVI1. Fluorescence in situ hybridization investigations proved that, in three myelodysplastic syndrome cases with t(3;12)(q26;p13), the 12p 13 breakpoint occurred within the TEL gene.

Composition of the intra-erythroblastic precipitates in thalassaemia and congenital dyserythropoietic anaemia (CDA): identification of a new type of CDA with intra-erythroblastic precipitates not reacting with monoclonal antibodies to alpha- and beta-globin chains.

Ultrathin sections of bone marrow cells from two patients with homozygous beta-thalassaemia, two patients with haemoglobin H (HbH) disease, a patient with congenital dyserythropoietic anaemia (CDA) type III and two patients with severe congenital dyserythropoietic anaemia of an unusual type were reacted with mouse monoclonal antibodies against various globin chains and the reaction visualized using a gold-labelled goat antibody against mouse IgG. The multiple rounded intra-erythroblastic inclusions found in homozygous beta-thalassaemia reacted with the monoclonal antibody against alpha-globin chains but not beta-globin chains, thus confirming that they consisted of precipitated alpha-globin chains. The branching intra-erythroblastic inclusions found in HbH disease and CDA type III reacted with the monoclonal antibody against beta-globin chains but not alpha-globin chains, indicating that they consisted of precipitated beta-globin chains. The two patients with severe CDA had been transfusion-dependent since infancy, had a normal alpha:beta globin chain synthesis ratio or parents with normal red cell indices, displayed prominent dysplastic changes in their erythroblasts, and had intra-erythroblastic inclusions resembling those seen in homozygous beta-thalassaemia. However, unlike those in beta-thalassaemia, the inclusions in these two patients did not react with the monoclonal antibody against either alpha- or beta-globin chains. The inclusions reacted with antibody against zeta-globin chains, but detailed studies in one of the patients indicated that the antigen involved was not zeta-globin. These patients have features not reported in the condition known as dominantly inherited inclusion body beta-thalassaemia and appear to suffer from a novel type of CDA in which the intra-erythroblastic inclusions may consist of some non-globin protein or structurally-abnormal alpha-globin chains.