Phenotypic characteristics of cells derived from precursors of human melanoma.

Of 66 specimens from benign melanocytic nevi, including common acquired and congenital nevi, Spitz tumors (epithelioid cell nevi), and melanocytic nevi with dysplasia, 57 could be grown in tissue culture. The cultured cells were identified as melanocytes by the presence of premelanosomes and melanosomes. Cells from 28 of 32 nevus cultures grew in an anchorage-independent way in soft agar with a colony-forming efficiency between 0.001 and 1%. Clones derived from single cells and soft agar-selected colonies showed marked phenotypic heterogeneity, but all had a limited life span and did not undergo transformation in culture. These cells were nontumorigenic in nude mice. Cultured nevus cells expressed antigens present on melanoma but absent on normal fibroblasts and/or melanocytes as tested with monoclonal anti-melanoma antibodies. The anti-melanoma antibodies bound equally well to dysplastic, congenital, and common acquired nevi. Antigens are released by nevus cells similar to melanoma cells.

Specific immunoreactivity of hybridoma-secreted monoclonal anti-melanoma antibodies to cultured cells and freshly derived human cells.

The specificities of monoclonal antibodies against melanoma cells were analyzed using radioimmunoassay, mixed-hemadsorption assay, and quantitative absorption on a variety of malignant and nonmalignant cells. Three of the six hybridoma-secreted antibodies bound to the majority of melanoma cell lines, melanoma tumors, and astrocytoma cell lines as well as to all normal and Epstein-Barr virus-transformed lymphocytes tested. The binding pattern coincides with the presence or absence of the DR antigen on human cells. Conversely, two other antibodies, 19-19 and Nu4B, detected two different antigens common to melanoma and astrocytoma cells only. Cloning of melanoma cells resulted in establishment of DR-positive and DR-negative clones, with the binding of Nu4B antibody retained in all.

Expression of major histocompatibility complex antigens on inflammatory peripheral nerve lesions.

The expression of major histocompatibility complex (MHC) antigens by cells of the rat peripheral nervous system (PNS) was studied using a model of peripheral nerve transplantation. Monoclonal antibodies to polymorphic determinants of MHC class I and class II (Ia) molecules were used to determine donor or recipient origin of MHC antigen-bearing cells in nerve allografts. The expression of class I and class II antigens by PNS parenchymal cells was modified during varying alloimmune conditions. Baseline, constitutive expression of class I antigens on endothelial and perivascular cells and class II antigens on interstitial cells were identified. Decreased MHC antigen expression was noted following in vitro culture of nerve allografts prior to implantation. After transplantation, enhanced donor-derived MHC antigen expression was demonstrated by both cultured and untreated allograft endothelial, perivascular and interstitial cells in a pattern which was distinct from isografts. This data supports a concept of perivascular monocytic and/or parenchymal cell (Schwann cell or resident macrophage-like cell) activity as the resident antigen-presenting cell for PNS immune processes.

Cognitive and behavior profile of preschool children with chromosome 22q11.2 deletion.

A microscopic deletion of chromosome 22q11.2 has been identified in most patients with the DiGeorge, velocardiofacial syndrome, conotruncal anomaly face syndrome, and in some patients with isolated conotruncal cardiac anomalies. This study presents the neurodevelopmental outcome, including cognitive development, language development, speech, neuromuscular development, and behavioral characteristics of 40 preschool children (ages 13 to 63 months) who have been diagnosed with the 22q11.2 deletion. The impact of cardiac disease, cardiac surgery, and the palatal anomalies on this population was also studied. In the preschool years, children with a 22q11.2 deletion are most commonly found to be developmentally delayed, have mild hypotonia, and language and speech delays. The more significantly delayed children are at high risk to be subsequently diagnosed with mild or moderate mental retardation. The global delays and the variations in intelligence found are directly associated with the 22q11.2 deletion and are not explained by physical anomalies such as palatal defects or cardiac defects, or therapeutic interventions such as cardiac surgery. Our findings demonstrate that there is a pattern of significant speech disorders within this population. All of the children had late onset of verbal speech. Behavioral outcomes included both inhibition and attention disorders. Early intervention services are strongly recommended beginning in infancy to address the delays in gross motor skills, speech and language, and global developmental delays.

Altered skin flap survival and fluorescein kinetics with hemodilution.

Isovolemic hemodilution is known to reduce blood viscosity. Reduction of either the blood cell concentration or the serum total protein has been found to improve blood flow and ultimate survival of skin flaps. Nutritive blood flow and tissue survival were examined in dorsal pedicle skin flaps in three groups of rats at three hematocrit levels--44% (controls), 31%, and 19%. After hemodilution by phlebotomy and crystalloid replacement, the dye kinetics of intravenously administered fluorescein were measured with the fiberoptic perfusion fluorometer. Skin flap survival at the different hematocrits were also examined. Hematocrits and serum total protein were measured before and after hemodilution and the elevation of the flap. The rate of fluorescein elimination and ultimate flap survival were significantly augmented in the two hemodiluted groups. The maximum benefit was seen in the group of animals hemodiluted to 19%. However, significant improvement in blood flow and skin flap survival was noted in the group of animals that were hemodiluted to a more clinically acceptable level (31%). The decreases in serum total protein following flap elevation did differ among the groups. This study supports the hypothesis that isovolemic hemodilution may be a valuable technique for salvaging marginally ischemic tissues.

Monitoring tissue elimination of fluorescein with the perfusion fluorometer: a new method to assess capillary blood flow.

Visual assessment of tissue staining after intravenous fluorescein is a common technique for predicting viability of questionably perfused tissue. The development of the perfusion fluorometer has permitted quantification of tissue fluorescein, providing increased precision. This study employed this instrument to calculate fluorescein elimination from rats with and without raised dorsal pedicle flaps. Control animals exhibited homogeneous patterns of fluorescein elimination consistent with first-order kinetics. Elimination in experimental animals was assessed after the animals received full back skin flaps with the cephalad pedicle remaining intact. Three distinct patterns of elimination were noted in each flap. In the cephalad portion, elimination was similar to control. At the caudad end, no elimination was noted. Midflap, fluorescein was eliminated slowly. These elimination patterns predicted ultimate viability 14 days postoperatively, as they correspond to viable, dystrophic, and transitional sections, respectively (P less than 0.001). We conclude that perfusion fluorometry can assess capillary flow in healthy and ischemic tissue by documenting elimination as well as delivery of fluorescein.

Long-term follow-up of ocular findings in children with Stickler's syndrome.

PURPOSE: To document the longitudinal changes in eye status of children diagnosed with Stickler's syndrome in the first decade of life. METHOD: All patients with cleft palate were referred for eye examination. Of these, patients with systemic findings of Stickler's syndrome were included in this report. RESULTS: Thirty-four eyes in 17 patients met inclusion criteria, with median best-corrected recognition acuity of 20/30. The mean cycloplegic refraction at presentation was -5.00 diopters, and the mean refraction at last visit was -5.50 diopters. CONCLUSIONS: Refractive errors, cataracts, and vitreoretinal abnormalities can be detected early in life in patients with Stickler's syndrome, and refractive error changed little during the follow-up period.

Wallerian degeneration and inflammation in rat peripheral nerve detected by in vivo MR imaging.

To investigate the role of MR imaging in wallerian degeneration, a series of animal models of increasingly complex peripheral nerve injury were studied by in vivo MR. Proximal tibial nerves in brown Norway rats were either crushed, transected (neurotomy), or transected and grafted with Lewis rat (allograft) or brown Norway (isograft) donor nerves. The nerves distal to the site of injury were imaged at intervals of 0-54 days after surgery. Subsequent histologic analysis was obtained and correlated with MR findings. Crush injury, neurotomy, and nerve grafting all resulted in high signal intensity along the course of the nerve observed on long TR/TE sequences, corresponding to edema and myelin breakdown from wallerian degeneration. The abnormal signal intensity resolved by 30 days after crush injury and by 45-54 days after neurotomy, when the active changes of wallerian degeneration had subsided. These changes were not seen in sham-operated rats. Our findings suggest that MR is capable of identifying traumatic neuropathy in a peripheral nerve undergoing active wallerian degeneration. The severity of injury may be reflected by the corresponding duration of signal abnormality. With the present methods, MR did not distinguish inflammatory from simple posttraumatic neuropathy.

Periauricular cysts and sinuses.

Periauricular cysts, sinuses, and fistulas occur commonly in the pediatric population. They arise from developmental defects of the first branchial cleft and first branchial arch. In most instances the diagnosis and management of these conditions are straightforward, but exceptional presentations sometimes occur. Failure to recognize these unusual cases may result in inadequate treatment and subsequent recurrence, and even if the correct diagnosis is made, surgical management of these lesions may be complicated. A series of 15 cases of periauricular congenital lesions is reviewed, of which three cases illustrating a diagnostic or surgical challenge are presented. The embryology, presentation, and management of these anomalies are discussed. This is one of the largest series of first branchial cleft anomalies reported in the literature, and our paper uniquely discusses first branchial cleft anomalies and preauricular sinuses together, with an emphasis on the surgical management of facial nerve, external ear, and middle ear involvement.

The 22q11.2 deletion: screening, diagnostic workup, and outcome of results; report on 181 patients.

A submicroscopic deletion of chromosome 22q11.2 has been identified in the majority of patients with the DiGeorge syndrome, velocardiofacial syndrome, conotruncal anomaly face syndrome, and in some patients with isolated conotruncal cardiac anomalies, Opitz G/BBB syndrome, and Cayler cardiofacial syndrome. We have evaluated 181 patients with this deletion. We describe our cohort of patients, how they presented, and what has been learned by having the same subspecialists evaluate all of the children. The results help define the extremely variable phenotype associated with this submicroscopic deletion and will assist clinicians in formulating a management plan based on these findings.

Dermatofibrosarcoma protuberans of the head and neck.

Dermatofibrosarcoma protuberans of the head and neck is an unusual, slowly growing malignant tumor of the dermis which is locally infiltrative and recurs persistently. Fifteen cases of dermatofibrosarcoma of the head and neck were studied in detail as to age and sex of patient, location of the tumor, clinical course, and ultimate outcome. Four tumors were of the forehead, four were of the scalp, three were of the chin, two were of the anterior neck, one was of the lateral face, and one was of the postauricular region. Initial diagnosis was sometimes inaccurate, and initial treatment was often inadequate. The treatment of choice following diagnosis is wide local excision and careful follow-up examination.

Primary nasoplasty in unilateral and bilateral cleft nasal deformity.

A six-step nasoplasty for the primary correction of the unilateral and bilateral cleft nasal deformity is presented. A review of the evolution of primary nasal reconstruction and preliminary results of the method are described and illustrated.

Autotransfusion and reduction mammaplasty: a reappraisal in the 1990s.

Since the first report of autotransfusion and blood loss in major anesthetic procedures by Noone et al. in 1972, much has changed. The single most significant event is the development of the AIDS epidemic. With today's stringent and precisely defined transfusion criteria, the current practice of routinely using autologous units for reduction mammaplasties has caused considerable controversy. This study reviews the mean estimated blood loss during reduction mammaplasty and the use of autologous transfusion during a 46-month period at the Hospital of the University of Pennsylvania ending in November of 1991. The need for red blood cell transfusion is retrospectively analyzed. One-hundred female patients were entered into the study. The results demonstrate a decrease in blood loss from an average of 865 ml in the 1970s to 385 ml in the 1990s and suggest that routine employment of autologous transfusion is no longer necessary.

Experience with the Furlow double-reversing Z-plasty for cleft palate repair.

One-hundred and six cases of soft palate closure using the Furlow double-reversing Z-plasty technique have been reported. Most of these patients have been done in the past 2 years. There seem to be a number of worthwhile advantages to this procedure, with few disadvantages or complications. The operation is adaptable for use in early soft palate closure (3 to 6 months) as well as late closure (12 to 14 months), in submucosal clefts, as well as in secondary palatal repair where lengthening and repositioning of the levator muscle is desired. With this type of palatoplasty, the need for raising or shifting large mucoperiosteal flaps from the hard palate has been completely avoided. The operation can be combined with a primary posterior pharyngeal flap if desired, although this is not advised if early palatal closure (3 to 6 months) is used because of a high incidence of sleep apnea. Preliminary speech results are very encouraging.

Acute monomyelocytic leukemia presenting as a felon. Case report.

We present a case of acute leukemic infiltration in the distal phalanx of the thumb, resulting in a chronic felon with bone involement.

Cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology, and surgical management.

A retrospective, multivariate statistical analysis of 129 consecutive nonsyndromic patients undergoing cleft palate repair was performed to document the incidence of postoperative fistulas, to determine their cause, and to review methods of surgical management. Nasal-alveolar fistulas and/or anterior palatal fistulas that were intentionally not repaired were excluded from study. Cleft palate fistulas (CPFs) occurred in 30 of 129 patients (23 percent), although nearly a half were 1 to 2 mm in size. Extent of clefting, as estimated by the Veau classification, was significantly more severe in those patients who developed cleft palate fistula. Type of palate closure also influenced the frequency of cleft palate fistula. Forty-three percent of patients undergoing Wardill-type closures developed cleft palate fistula versus 10, 22, and 0 percent for Furlow, von Langenbeck, and Dorrance style closures, respectively. The fistula rate was similar in patients with (30 percent) and without (25 percent) intravelar veloplasty. Age at palate closure did not significantly affect the rate of fistulization; however, the surgeon performing the initial closure did not have an effect. Thirty-seven percent of patients developed recurrent cleft palate fistulas following initial fistula repair. Recurrence of cleft palate fistulas was not influenced by severity of cleft or type of original palate repair. Following end-stage management, a second cleft palate fistula recurrence occurred in 25 percent of patients. Continued open discussion of results of cleft palate repair is recommended.

Application of magnetic resonance imaging technique in determining canine muscle and human free-flap viability.

Magnetic resonance imaging technique is an exciting, new, safe clinical tool that provides a noninvasive way to monitor free-tissue transfers. Magnetic resonance imaging (MRI) produces a cross-sectional tomographic image at higher resolution than conventional CAT scans and provides a dynamic and physiologic assessment of transferred tissue. We first studied ischemic muscle in the beagle hindlimb gracilis muscles and found an incremental and definitive increase in signal strength both over time and in comparing complete devascularization to partial devascularization. In the right hindlimb (partially devascularized), there was an average increase in T2 (measured in milliseconds) of 2.5 percent at 1 hour, 16.72 percent at 3 hours, and 16.45 percent at 12 hours as compared to normal undisturbed muscle. Similarly, the left hindlimb (completely devascularized) measurements increased from 10.97 percent at 1 hour to 24.02 percent at 3 hours to 47.75 percent at 12 hours. Possible explanations for T2 increases include an increase in intercellular and intracellular water, a change in pH, and possible protein metabolism changes. Clinical studies in seven patients with free flaps have shown "normal" T2 values in healthy tissue comparable to undisturbed canine gracilis muscle and the change in contour and composition of tissue over time. The clinical usefulness of these data is apparent.

A comparison of local recurrence and resection margins for stage I primary cutaneous malignant melanomas.

A retrospective review of 552 patients with clinical stage I primary cutaneous malignant melanomas was undertaken comparing margins of resection and local recurrence between 1966 and 1981. The overall local recurrence rate was 8 per 552 (1.45 percent). We observed no instances of local recurrence in lesions less than 1.40 mm thick with resection margins of at least 1 cm. A comparison of resection margins greater than 2 cm versus less than 2 cm for lesions less than 1.00 mm thick showed no difference at the 0.05 level of significance for local recurrence (0 per 228 versus 2 per 154; 1.3 percent) or survival. While narrower margins of resection for thinner, low-risk stage I malignant melanomas appear safe, the exact minimum margin of resection needed to satisfy both oncologic and cosmetic considerations, whether 1 or 2 cm, will need to be determined by a large prospective, randomized study.

A comparison of iliac and cranial bone in secondary grafting of alveolar clefts.

This retrospective study compares the success of iliac versus cranial bone autografts in the secondary grafting of alveolar clefts. The study group was 116 patients with complete records and radiographs from a pool of 186 consecutively grafted patients at Children's Hospital of Philadelphia. The quality of graft "take" was graded radiologically. Variables potentially influencing outcome were evaluated and included graft type (iliac versus cranial bone), cleft type (unilateral versus bilateral), cleft severity (complete unilateral or bilateral cleft lip and palate versus cleft of the alveolus only), age at grafting, and complications. Although graft "take" versus "nontake" seemed comparable in iliac and cranial bone graft groups, iliac bone showed a statistical superiority over cranial bone, with more radiologically excellent grades (p = 0.04) in all cleft types. Likewise, when the two graft types were compared in more severe clefts (complete unilateral and bilateral cleft lip and palate), iliac bone showed statistical superiority (p = 0.02) over cranial bone. However, they seemed comparable in less severe clefts of the alveolus only (p = 0.22). Recipient-site complications and their sequelae were comparable in iliac versus cranial graft groups, and no age-related differences were noted in children grafted above or below age 10.

Cleft palate closure at 3 to 7 months of age: a preliminary report.

The evolution and present criteria for early soft palate closure are reviewed. A definitive group of patients (operated on at 3 to 7 months of age) is reviewed at least 2 years following their surgery. They are compared with our general clinic population (operated on at 12 to 18 months of age) and had significantly fewer secondary operations for velopharyngeal incompetence. The possible advantages and disadvantages of early soft palate closure are discussed.