Long-term in vitro maintenance of clonal abundance and leukaemia-initiating potential in acute lymphoblastic leukaemia.

Lack of suitable in vitro culture conditions for primary acute lymphoblastic leukaemia (ALL) cells severely impairs their experimental accessibility and the testing of new drugs on cell material reflecting clonal heterogeneity in patients. We show that Nestin-positive human mesenchymal stem cells (MSCs) support expansion of a range of biologically and clinically distinct patient-derived ALL samples. Adherent ALL cells showed an increased accumulation in the S phase of the cell cycle and diminished apoptosis when compared with cells in the suspension fraction. Moreover, surface expression of adhesion molecules CD34, CDH2 and CD10 increased several fold. Approximately 20% of the ALL cells were in G0 phase of the cell cycle, suggesting that MSCs may support quiescent ALL cells. Cellular barcoding demonstrated long-term preservation of clonal abundance. Expansion of ALL cells for >3 months compromised neither feeder dependence nor cancer initiating ability as judged by their engraftment potential in immunocompromised mice. Finally, we demonstrate the suitability of this co-culture approach for the investigation of drug combinations with luciferase-expressing primograft ALL cells. Taken together, we have developed a preclinical platform with patient-derived material that will facilitate the development of clinically effective combination therapies for ALL.

Ductal carcinoma in situ of the male breast presenting as adolescent unilateral gynaecomastia.

A 17 year old male patient was referred to the breast surgery service with a unilateral swelling of the left breast. Subsequent evaluation led to discharge with a diagnosis of adolescent gynaecomastia. Four years later the same patient was referred back to the breast surgery service and the referral was turned down without a consultation as the surgical treatment of gynaecomastia was not funded by the local Primary Care Trust (PCT). Three years following, this now 24 year old gentleman was referred to the Plastic surgery service at the Hospital Trust where he had been initially referred as a 17 year old. He underwent a nipple sparing mastectomy through a peri-areolar incision. The histology amounted to a diagnosis of ductal carcinoma in situ (DCIS). A literature review revealed the rarity of pure DCIS in the adolescent male. The variation in availability of treatments across the National Health Service in England has lead to a "postcode lottery" due to "rationing" decisions being made by individual Primary Care Trusts. "Action on Plastic Surgery", an NHS Modernisation Agency document, was designed as an aid to PCT's making funding decisions on Plastic Surgery patients in 2005. The case described in this report illustrates the difficulty in clinical diagnosis of a male breast lump. This persistent lesion was sampled on 2 separate occasions with fine needle aspiration, neither aspirate raising the possibility of DCIS. In conclusion this case describes a rare pre-malignant condition of the male breast. Complete histology of such a lump is the only conclusive investigation necessary and the limitations put upon the surgeon by the "rationing" of such treatment must be overcome on clinical grounds.

Randomized controlled trial of fibrin sealant to reduce postoperative drainage following elective lymph node dissection.

BACKGROUND: Excessive postoperative drainage following groin and axillary lymphadenectomy may be associated with a prolonged hospital stay and an increased complication rate. The use of fibrin sealant before wound closure may reduce postoperative wound drainage. METHODS: Consecutive patients undergoing elective groin or axillary lymphadenectomy were randomized to standard wound closure or to having fibrin sealant sprayed on to the wound bed before closure. Postoperative wound drainage, duration of drainage and complications were recorded, as were locoregional recurrence, distant metastasis and mortality. RESULTS: A total of 74 patients requiring 38 groin and 36 axillary dissections were randomized. The median postoperative wound drainage volume for the groin dissection cohort was 762 (range 25-3255) ml in the control group and 892 (265-2895) ml in the treatment group (P = 0·704). Drainage volumes in the axillary cohort were 590 (230-9605) and 565 (30-1835) ml in the control and treatment groups respectively (P = 0·217). There was no difference in the duration of drainage or postoperative complication rate between the treatment groups in both the axillary and groin cohorts. Local recurrence, distant metastasis and mortality rates did not differ between the treatment groups. CONCLUSION: There was no advantage in using fibrin sealant during elective lymphadenectomy in terms of reducing drainage output or postoperative complication rate.

Fine needle aspiration in plastic surgery outpatients: a retrospective study.

A survey suggested that fine needle aspiration cytology of masses in plastic surgery outpatient clinics was suboptimal. A cytopathologist gave training in the technique and the effectiveness of this intervention was audited. A total of 236 aspirates were taken from 147 patients in the earlier time period and 215 from 149 in the later period. The overall inadequate aspirate rate remained constant at 43%. The most common reasons for poor aspirates were excess blood, unrepresentative adipose tissue and insufficient cellular material. When the specimen was adequate after training, the sensitivity and specificity of the investigation were 96% and 100%, respectively. We present methods for sample optimization. Alternative strategies may be to limit aspiration to one clinician or to refer the patient to a cytopathologist experienced in the technique.

Tissue expansion in the limbs: a comparative analysis of limb and non-limb sites.

We present an 8 year retrospective case-note study of 88 patients, who underwent 113 episodes of tissue expansion for a variety of indications. Overall, 31 patients underwent 42 episodes of tissue expansion in the limbs, and 57 patients underwent 71 expansions at other sites. Although the incidence of complications was higher in the limb group (43%) than in the group undergoing expansion at other sites (27%), the overall success in completing expansion was remarkably similar in both groups (86% and 83%, respectively). The indications and contraindications for tissue expansion in our cases are presented, as is the specific management in the presence of infection or exposure. Careful case selection, proper planning and meticulous surgical technique are important in minimising complication rates and ensuring both success and salvage in the case of any mishaps.

Arc-scanning very high-frequency digital ultrasound for 3D pachymetric mapping of the corneal epithelium and stroma in laser in situ keratomileusis.

PURPOSE: To test and demonstrate measurement precision, imaging resolution, 3D thickness mapping, and clinical utility of a new prototype 3D very high-frequency (VHF) (50 MHz) digital ultrasound scanning system for corneal epithelium, flap, and residual stromal thickness after laser in situ keratomileusis (LASIK). METHODS: VHF ultrasonic 3D data was acquired by arc-motion, meridional scanning within a 10-mm zone. Digital signal processing techniques provided high-resolution B-scan imaging, and I-scan traces for high-precision pachymetry in 4 eyes. Thickness maps of individual corneal layers were constructed. Reproducibility of epithelial, flap, and full corneal pachymetry was assessed for single-point and 3D thickness mapping by repeated measures. Thickness mapping of the epithelium, stroma, flap, and full cornea were determined before and after LASIK. Preoperative to postoperative difference maps for epithelium, flap, and stroma were produced to demonstrate anatomical changes in the thickness profile of each layer. RESULTS: Surface localization precision was 0.87 microm. Central reproducibility for single-point pachymetry of epithelium was 0.61 microm; flap, 1.14 microm; and full cornea, 0.74 microm. Reproducibility for central pachymetry on 3D thickness mapping was 0.5 microm for epithelium and 1.5-microm for full cornea. B-scans and 3D thickness maps after LASIK demonstrated resolution of epithelial, stromal component of the flap, and residual stromal layers. Large epithelial profile changes were demonstrated after LASIK. Topographic variability of flap thickness and residual stromal thickness were significant. CONCLUSIONS: VHF digital ultrasound arc-B scanning provides high-resolution imaging and high-precision three-dimensional thickness mapping of corneal layers, enabling accurate anatomical evaluation of the changes induced in the cornea by LASIK.

High-resolution ultrasonic imaging of blood flow in the anterior segment of the eye.

PURPOSE: To develop a noninvasive technique to visualize and measure blood flow in the iris and ciliary body. METHODS: Echo data from 50-MHz ultrasound scans of the iris and ciliary body of rabbits were digitized using a new "swept scan" modality. The method makes use of spatial oversampling to identify regions with scatterers whose range changes with time. The data allowed construction of high-resolution B-mode images with embedded flow information. Pulsatility over the cardiac cycle was evaluated by sending a series of pulses along a single line of sight containing a vessel of interest. Local blood flow and changes over the cardiac cycle before and after application of atropine were quantified. RESULTS: Flow was identified in the radial vessels and major arterial circle of the iris. Vessels with lumens as small as 40 microm in diameter and flow velocities as low as 0.6 mm/sec were measured. Change in blood velocity over the cardiac cycle was determined to be approximately 27%. Peak systolic velocity after administration of topical atropine increased by 72%. CONCLUSIONS: This technique allowed visualization of flow using the same type of very-high-frequency transducer now widely used for imaging the anterior segment. The technique can also be used at lower frequencies for more posterior tissues with similar improvement of resolution over Doppler. The ability to examine flow in the anterior segment of the eye offers a new tool for study of glaucoma, hypotony, tumors, and other disorders.

A comparison of ultrasonic beams for thermal treatment of ocular tumors.

OBJECTIVE: This study examined the relative merits of different ultrasonic beams and exposure modalities for treating ocular melanomas. METHODS: Simulations were conducted to evaluate temperature patterns and lesion shapes induced by intense-ultrasound treatment of ocular tumors. In-vitro insonification experiments were conducted in bovine lenses. RESULTS: Simulated hyperthermia exposures did not effectively treat tumor margins because of thermal conduction into nearby fluid-like media. Standard high-intensity focused beams produced narrow lesions during 2-s exposures. A high-intensity, multi-lobed beam, produced by a transducer with strip electrodes, generated asymmetric lesions with a single large dimension; this lesion shape could expedite the production of lesion matrices within large tumors. In-vitro cataract shapes were consistent with simulation results for focused high-intensity beams. CONCLUSIONS: Thermal conduction and perfusion can cause underheating of tumor margins during hyperthermia unless special beam designs are used. The strip-electrode transducer configuration promises to expedite treatment of extended tumor volumes.

Very high-frequency ultrasound corneal analysis identifies anatomic correlates of optical complications of lamellar refractive surgery: anatomic diagnosis in lamellar surgery.

OBJECTIVE: To examine the utility of very high-frequency (VHF) ultrasound scanning in determining the anatomic changes and correlates of optical complications in lamellar refractive surgery. STUDY DESIGN: Case series. PARTICIPANTS: Cases analyzed included marked asymmetric astigmatism postautomated lamellar keratoplasty (ALK), image ghosting despite normal videokeratography post-ALK, uncomplicated myopic laser in situ keratomileusis (LASIK), and hyperopic LASIK with regression. METHODS: A prototype VHF ultrasound scanner (50 MHz) was used to obtain sequences of parallel B-scans of the cornea. Digital signal processing techniques were used to measure epithelial, stromal, and flap thickness values in a grid encompassing the central 4 to 5 mm of the cornea, enabling pachymetric mapping of each layer with 2-micron precision. MAIN OUTCOME MEASURE: The appearance of the corneas in VHF ultrasound images and thickness values of individual corneal layers determined from VHF ultrasound data. RESULTS: VHF ultrasound resolved the epithelial, stromal cap, or flap and residual stromal layers 1 year after lamellar surgery. Asymmetric stromal tissue removal was differentiated from stromal cap irregularity. Epithelium acted to compensate for asymmetry of the stromal surface about the visual axis and for localized surface irregularities. Irregularities in the epithelial-stromal interface accounted for image ghosting present despite apparently normal videokeratography. Epithelial thickening was shown after uncomplicated myopic LASIK. Hyperopic LASIK demonstrated relative epithelial thickening localized to the region of ablation accounting for refractive regression. CONCLUSIONS: VHF ultrasound shows promise as a sensitive method of determining the anatomic correlates of optical complications in lamellar refractive surgery.

The shape of Bowman's layer in the human cornea.

PURPOSE: The aim of this investigation was to derive a mathematical model for Bowman's layer, the interface between the epithelium and stroma, in the human cornea. METHODS: The central epithelial thickness distribution within 14 normal human corneas was measured in vivo using high frequency ultrasonic digital signal processing with a measurement precision of 2 microns. The results per eye were averaged and incorporated into existing algorithms for the estimation of the shape of the anterior surface of Bowman's layer using terminology in accordance with Baker's equation. RESULTS: The average radius of Bowman's layer was 7.34 mm (SE +/- 0.17 mm). Descriptions of this boundary ranged from a steepening or prolate ellipse to a hyperbola. However, the typical Bowman's layer is hyperbolic with a shape factor, p = -0.22 (SE +/- 1.81). CONCLUSION: The results support previous cadaver studies where Bowman's layer was found to be steeper than the anterior corneal surface but disagree with the concept that the average Bowman's layer is akin to a prolate ellipse. The hyperbolic nature of the average Bowman's layer has the potential to influence the optical performance of the eye.

The selective use of a single-stage and a two-stage technique for hypospadias correction in 157 consecutive cases with the aim of normal appearance and function.

This paper establishes the aim of normal function and appearance in hypospadias surgery. In order to meet this aim we have used a combination of a single-stage and a two-stage repair, both incorporating foreskin reconstruction. The technique of single-stage repair is illustrated using operative photographs. Our experience with 157 repairs in a 3-year period is described. Thirty-five single-stage repairs were completed with no complications; 122 two-stage repairs were carried out, in which a 5% fistula rate was achieved in primary cases. Salvage reconstruction had a higher incidence of complications.

Correlation of high-frequency ultrasound backscatter with tumor microstructure in iris melanoma.

OBJECTIVE: This study aimed to correlate histologic characteristics with high-frequency ultrasound backscatter spectra in malignant melanomas of the iris. DESIGN: The study design was a cohort (case series) study of patients diagnosed with iris melanoma in the authors' clinic. PARTICIPANTS: Sixteen patients with iris melanoma participated. INTERVENTION: The patients were scanned with a 50-MHz ultrasound unit equipped for digitization of raw echo data. Spectral parameter images representing the spatial distribution of size and concentration of tissue inhomogeneities were produced. MAIN OUTCOME MEASURES: The variation of spectral properties within and between tumors was determined. In the two tumors in this series for which histologic material was available, the authors compared scatterer concentration and size with histology and mathematically modeled the effect of melanocyte distribution on spectra. RESULTS: Ultrasound scattering characteristics differed considerably among tumors. Where histology was available, acoustic parameters correlated with the size and number of melanocytes present. CONCLUSIONS: Iris melanomas exhibited a wide range in acoustic backscatter properties. Whereas characteristics such as vascularity and necrosis might contribute to this, in the two cases examined here, backscatter characteristics could be largely accounted for by melanocyte distribution. A better understanding of the relationship of histology to noninvasive ultrasound data will enhance the diagnostic utility of this technique.

Three-dimensional ultrasound imaging. Clinical applications.

OBJECTIVE: The aim of this report is to describe the technology of three-dimensional (3-D) ultrasonic imaging and its impact on improved diagnosis and monitoring of ocular disease. DESIGN: The authors reviewed techniques for acquiring and displaying 3-D ultrasound data of the eye. PARTICIPANTS: The authors applied these techniques to representative individual cases, including a choroidal hemorrhage, a ciliary body melanoma, a ciliary body detachment, a displaced posterior chamber intraocular lens, and topographic analysis of a normal cornea. INTERVENTION: A computer-controlled motion system was used to perform very high-frequency (VHF) (50-MHz) and conventional (10-MHz) digital 3-D ultrasound data collection. The scanning system allowed digitization of ultrasound data from a series of parallel planes. The 3-D data could be manipulated interactively to obtain two-dimensional images in any plane through the scan volume. The 3-D images were constructed by volume rendering and could be positioned for viewing from a variety of perspectives. The 3-D ultrasound parameter images representing acoustic scatterer properties were generated by spectrum analysis of digitized echo data. Color maps representing the contour and thickness of the epithelium and stroma of the central corneal were generated by digital signal processing of 3-D echo data. RESULTS: Quantitative volume measurement and biometric techniques enhanced the diagnostic and treatment planning information content in 3-D ultrasound images. The location and extent of hemorrhage and clots within the suprachoroidal space were shown with solid modeling. Volume changes in ciliary body melanoma over time were documented and 3-D ultrasound parameter image changes associated with radiation therapy observed. In ciliary body detachment, the extent of the detachment was shown. Solid modeling of a posterior chamber intraocular lens showed misplacement of the haptic in relation to the lens capsule remnants. Keratopachymetric maps showed the range and variance of thickness and local radius of curvature measurements in the cornea. CONCLUSIONS: Quantitative volume measurement and biometric tools combined with segmentation of 3-D ultrasound images improve diagnostic and treatment planning informational content of 3-D ultrasound images through improved localization of tissue structures.

Ultrasonic evaluation of the vitreous and retina.

Ultrasonic evaluation of the vitreous body augments and complements visual and clinical assessment in any condition in which some form of media opacity exists, eg, cornea, lens, hemorrhage, or subretinal mass. The appearance of the eye in hypotony, the presence of foreign material, the pattern of hemorrhage, and the presence of a detached retina or choroid are all identifiable and their diagnosis may be of critical importance to patient management. Patterns of diabetic retinopathy and ocular tumors are usually characteristic using conventional 10 MHz ultrasound. The use of Very High Frequency (VHF or UBM) ultrasound can identify ciliary body detachment or other retroiridal pathology, such as tumors and cysts.

Textured or smooth implants for breast augmentation? Three year follow-up of a prospective randomised controlled trial.

Silicone breast implant surface texturing has been shown to reduce the short-term incidence of adverse (Baker III/IV) capsular contracture in augmentation mammaplasty in double-blind randomised controlled trials. It is, however, undetermined whether the textured surface merely delays the onset of severe contracture or its effect on capsular contraction is persistent. The current study reviewed, after three years, 49 of the 53 patients who had undergone subglandular breast augmentation mammaplasty in a randomised double-blind study with textured or smooth silicone gel-filled implants in 1989. The incidence of adverse capsular contracture was 59% for smooth implants and 11% for textured ones (P = 0.001; chi 2 = 10.60). Eight patients (31%) with smooth prostheses underwent breast implant exchange for severe capsular contracture between the one and three year assessments, compared with a revisional surgery rate of only 7.4% (2/27 patients) for the textured group (P < 0.04). These adverse capsular contracture and revisional breast implant surgery rates clearly demonstrate that the effect of textured implants in reducing capsular contracture in augmentation mammaplasty found at one year is maintained at three years, and suggest that it may be long lasting.

Ultrasonically induced hyperthermia for adjunctive treatment of intraocular malignant melanoma.

PURPOSE: This report describes results of a prospective pilot trial to evaluate the safety and efficacy of hyperthermia as an adjunct to enucleation or brachytherapy in the treatment of patients with intraocular malignant melanoma. METHODS: Twenty-five patients with intraocular malignant melanomas were treated with ultrasonically induced hyperthermia. In 14 patients, hyperthermia was administered before enucleation (median follow-up period, 44 months), and in 11 patients, hyperthermia was used as an adjunct to brachytherapy (median follow-up period, 79 months). RESULTS: Patient survival in each group was compared with that of a control group treated with enucleation or brachytherapy alone, using Kaplan-Meier and Cox analysis. Taking into account the simultaneous effects of tumor size and location, the relative risk ratios and 95% confidence bounds associated with adjunctive hyperthermia were 1.68 (range, 0.60-4.72) and 0.68 (range, 0.16-2.89) for the enucleation and brachytherapy groups, respectively. CONCLUSIONS: Patients receiving adjunctive hyperthermia with brachytherapy showed increased survival, whereas those receiving hyperthermia before enucleation showed decreased survival. Neither trend was statistically significant in this small series. The synergism of hyperthermia with radiation may offer the possibility of improved tumor management.

Ophthalmic, ultrasonographic findings in primary central nervous system lymphoma with ocular involvement.

PURPOSE: To describe and classify ophthalmic, ultrasonographic findings in patients with primary central nervous system lymphoma with ocular involvement. METHODS: B- and A-scan ultrasonography was performed on the eyes of 13 patients with primary central nervous system lymphoma with ocular involvement. RESULTS: In seven patients, the eyes were the site of initial involvement. In the other six patients, both ocular and central nervous system disease were present at the initial evaluation. All patients had abnormal ultrasonographic findings. The most common were vitreous debris (n = 10), choroidal-scleral thickening (n = 6), and widening of the optic nerve (n = 4). Elevated chorioretinal lesions (n = 3) and retinal detachment (n = 2) were also found. CONCLUSION: Ophthalmic ultrasonography is a useful adjunctive diagnostic technique for characterizing ocular involvement in lymphoma. Ocular lymphoma may present as chorioretinitis, vitreitis and nonspecific uveitis; it produces characteristic, but nonspecific findings on ultrasonography. The diagnosis of ocular involvement is an important factor in determining treatment.

Correlation of ultrasound parameter imaging with microcirculatory patterns in uveal melanomas.

Previous studies demonstrated a correlation between acoustic backscatter parameters and survival in ocular melanoma. The histologic presence of microvascular networks in ocular melanoma is also associated with death from metastases. This study tests the hypothesis that melanomas grouped on the basis of these microvascular patterns are separable by ultrasound spectrum analysis. We scanned 40 melanomas using a 10-MHz ultrasound unit equipped for digitization of radio frequency data. After enucleation, tumors were sectioned in planes corresponding to the ultrasonographic examination and stained to demonstrate microcirculation. Acoustic spectral parameters were compared between 14 melanomas with a nevuslike microcirculation and 26 with foci of high-risk microvascular structures. Smaller scatterer size, lower acoustic concentration and greater spatial variability were found to correlate with high-risk microvascular patterns and areas of cystic degeneration. We suggest that nonvascular extracellular matrix components associated with microvessels may be responsible for the correlation of acoustic parameters with microvascular pattern and distribution.

Iridoschisis: high frequency ultrasound imaging. Evidence for a genetic defect?

AIMS: To elucidate changes in the anatomy of the anterior chamber associated with iridoschisis, a rare form of iris atrophy, and their potential contribution to angle closure glaucoma. METHODS: Both eyes of a 71-year-old woman with bilateral iridoschisis and fibrous dysplasia and her asymptomatic 50-year-old daughter were scanned with a very high frequency (50 MHz) ultrasound system. RESULTS: The symptomatic patient exhibited diffuse changes in the iris stoma with an intact posterior iris pigmented layer in both eyes. These changes were clinically compatible with the lack of iris transillumination defects. Additionally, iris bowing with a resultant narrowing of the angle occurred. The asymptomatic daughter showed discrete, but less severe iris stromal changes. CONCLUSION: This is the first detailed study of high frequency ultrasonic imaging of the iris in iridoschisis. The observed structural changes suggest angle narrowing by forward bowing of the anterior iris stroma may be a mechanism of IOP elevation in this condition. The ultrasonic detection of iris changes in the asymptomatic daughter of the symptomatic patient and the association of iridoschisis with fibrous dysplasia suggest a possible genetic component in the pathogenesis of this condition.