Multinucleated Giant Cell Reaction Research Articles

Spontaneous Hematoma of the Breast 30 Years after Augmentation

Sir: Delayed hematoma formation following augmentation mammaplasty is a rare complication.1–5 We encountered the largest hematoma ever reported, and the furthest from initial surgery, when a 56-year-old African American woman presented with a 3-month history of left breast swelling. The patient had subglandular silicone breast implants placed in the late 1970s and denied any recent trauma. On examination, the patient had extensive asymmetry, with a very large, firm left breast distended to approximately the size of a basketball (Fig. 1). Mammography and ultrasound showed evidence of implant rupture and a large fluid collection surrounding the implant. Computed tomography identified a well-defined fat plane between the fluid and the pectoralis major muscle (Fig. 2).Fig. 1.: The patient presented with a 3-month history of a slowly enlarging left breast.Fig. 2.: Computed tomographic scan of the chest reveals a large heterogeneous fluid collection within the left breast, a well-demarcated plane between this collection and the pectoralis major muscle, and bilateral implant rupture.During surgical exploration, the implant was found to be ruptured with silicone mixed within the hematoma fluid. In total, 4.5 liters of material was removed from the breast. Open periprosthetic capsulectomy was performed, and biopsy specimens were obtained from thickened areas of the capsule. Results of cultures were negative and pathologic evaluation revealed a ruptured silicone implant, with benign fibroadipose tissue and chronic inflammation. Within the specimen, silicone granulomas with multinucleated giant cell reaction and hemosiderin-laden macrophages were identified. The postoperative course was uneventful, and staged reconstruction is planned. In 1979, Georgiade et al. first reported a hematoma developing in a 25-year-old patient 2.5 years after breast augmentation using saline prostheses containing triamcinolone acetonide.1 During exploration, an eroded capsular artery was found to be actively bleeding, and this was ascribed to the steroid infusion. Follow-up reports attribute late hematoma formation to the erosion of vessels arising from the breast capsule, and various inciting factors have been described, including inflammation, microfracture of the capsule, friction of the implant against the capsule, and trauma.2–5 Our pathologic findings are consistent with inflammation contributing to the development of the hematoma, likely as a reaction to the ruptured silicone implant. Previous case reports describe chronic expanding hematomas developing around various types of implants after a period ranging from 5 months to 22 years; thus, this hematoma is the furthest from time of onset, developing 30 years after augmentation.4 Before this study, the largest hematoma evacuated was 500 ml, whereas in this case, 4.5 liters of fluid was removed, making this the largest collection to date.5 Described treatment of hematomas ranges from close observation to surgical management.2–5 In the setting of hematoma development many years after augmentation without an inciting event, other pathologic findings such as infection, inflammation, and malignancy should be considered. The hematoma requires drainage, and the capsule must be examined for any evidence of persistent bleeding. In addition, the breast and capsule must be inspected for any evidence of malignancy, especially in the setting of reconstruction and prior malignancy. In summary, hematoma formation is a rare complication of breast implantation. Patients presenting with sudden swelling of the breast should be evaluated for infection, malignancy, and late hematoma formation. Imaging studies are useful adjuncts to better characterize breast abnormality, but ultimately surgical exploration is the standard treatment. DISCLOSURE The authors have no financial interest to disclose in relation to the content of this article. Yvonne Rasko, M.D. Department of Surgery Division of Surgical Oncology Michel Saint-Cyr, M.D. Department of Plastic and Reconstructive Surgery Yan Peng, M.D. Department of Pathology Roshni Rao, M.D. Department of Surgery Division of Surgical Oncology University of Texas Southwestern Medical Center Dallas, Texas

Clinical and histological characteristics of renal AA amyloidosis: a retrospective study of 68 cases with a special interest to amyloid-associated inflammatory response

We retrospectively reviewed the clinicopathological features of a series of 68 renal AA amyloidosis observations collected between 1990 and 2005. The amyloidogenic disease was a chronic infection (40.8%), a chronic inflammation (38%), a tumor (9.9%), a hereditary disease (9.9%), or was undetermined in 1.4% of cases. Nephrotic syndrome and renal insufficiency were noted in 63.1% and 75% of patients, respectively. The distribution pattern of glomerular amyloid deposits was mesangial segmental (14.7%), mesangial nodular (26.5%), mesangiocapillary (32.3%), and hilar (26.5%). Glomerular form was observed in 80.9% of cases and vascular form in 19.1%. AA amyloidosis-related inflammation was noted in 30 patients (44.1%) and appeared as a multinucleated giant cell reaction (27.9%) or a glomerular inflammatory infiltrate (25%), including glomerular crescents (17.6%). At the end of follow-up, 26 patients (38.2%) showed end-stage renal disease. The clinical presentation of glomerular and vascular forms was distinct with a clear predominance of proteinuria in glomerular form. Inflammatory reaction was preferentially observed in biopsies with a codeposition of immunoglobulin chains and/or complement factors in AA amyloid deposits. The distribution pattern of glomerular amyloid deposits and glomerular inflammatory reaction were independent factors influencing proteinuria level. Tubular atrophy, abundance, and distribution pattern of glomerular amyloid deposits at the time of biopsy were independent predictors of renal outcome. In conclusion, the glomerular involvement appeared as the determining histological factor for clinical manifestations and outcome of renal AA amyloidosis. AA amyloidosis-related inflammation could partly result from an immune response directed against AA fibrils and could induce amyloid resolution and crescents.

Multinucleated Foreign Body Giant Cells in Placental Membrane

We report the pathologic finding of a multinucleated foreign body giant cell reaction to squames and fetal hair in the placental membranes in a 37-week 1-day intrauterine gestation. This reaction appeared to have developed in association with repeated intrauterine procedures performed in the third trimester, including cordocentesis for fetal blood sampling, intrauterine blood transfusion, and amnioreduction for polyhydramnios. This type of reaction most likely was directed to prolonged amniotic fluid leakage that occurred spontaneously or after intrauterine procedures in the second half of the second trimester and the third trimester. Careful examination of the placental membranes and recognition of the foreign body giant cell reaction may provide etiologic insight in cases of unexplained oligohydramnios.

The Pathology of Breast Biopsy Site Marking Devices

This report presents our experience with 54 cases of patients who had excision of breast lesions after deployment of radiographic biopsy site markers at the time of stereotactic biopsy. These were of two types: pellets of a resorbable copolymer of polylactic acid/polyglycolic acid (31 cases) and plugs of bovine collagen (23 cases), both containing embedded metallic clips for long-term radiographic marking. On gross examination, the pellets have a characteristic appearance similar to a soft grain of rice, whereas the collagen plugs are spongiform with variable hemorrhagic changes. Microscopically, there are distinct differences in the morphologic features of these two types of biopsy site markers and the associated tissue reactions. With the pellets, there is an initial cell-poor fibrotic reaction around empty spaces followed by a multinucleate giant cell reaction and penetration of the marker core by eosinophilic fibrinous material. The collagen plugs are recognized as eosinophilic, hyalinized, acellular material, accompanied by an inflammatory infiltrate composed predominantly of lymphocytes, plasma cells, eosinophils and, occasionally, neutrophils, which penetrate the core of the marker with time. The degradation of the collagen plug appears to be associated with infiltration of the marker by fibrovascular tissue and deposition of native collagen; of note is the absence of a significant multinucleate giant cell reaction. These novel breast biopsy site markers do not interfere with the histologic processing of the tissue or with their histopathologic interpretation.

Malignant Melanoma in a Burn Scar

Cancers of various sorts are occasionally encountered in burn scars. These lesions are usually squamous cell carcinomas, and the burn scars are usually old. Very rarely, malignant melanoma is encountered. An 87-year-old nursing home patient who had been burned by a lightening strike at age 16 was evaluated. She had sustained a wound covering 2% or 3% of her body surface involving her neck and the upper portion of her anterior trunk that had required several grafts. A lesion was noted over the suprasternal notch approximately 3 months before admission. The biopsy was reported as malignant melanoma. She was subsequently treated by wide reexcision with an associated Z-plasty for neck release. Because of the patient's age and the presence of four areas of regional lymph nodes nearby into which metastasis might spread, no lymph node dissections were carried out. The specimen from the reexcision was reported as squamous cell carcinoma in situ, melanoma in situ, and multinucleated giant cell reaction, acute and chronic infiltrates. The wound margins were clear.

Neuropathogenesis of chimeric simian/human immunodeficiency virus infection in pig-tailed and rhesus macaques.

We recently reported that a chimeric simian/human immunodeficiency virus (SHIVKU-1) developed in our laboratory caused progressive depletion of CD4+ T lymphocytes and AIDS within 6 months of inoculation into pig-tailed macaques (M. nemestrina). None of the pig-tailed macaques showed productive SHIV infection in the central nervous system (CNS). In this report, we show that by further passage of the pathogenic virus in rhesus macaques [M. mulatta], we have derived a new strain of SHIV (SHIVKU-2) that has caused AIDS and productive CNS infection in 3 of 5 rhesus macaques infected with the virus. Productive replication of SHIV in the CNS was clearly shown by high infectivity titers and p27 protein levels in brain homogenates, and in 2 of the 3 rhesus macaques this was associated with disseminated, nodular, demyelinating lesions, including focal multinucleated giant cell reaction, largely confined to the white matter. These findings were reminiscent of HIV-1 associated neurological disease, and our immunohistochemical and in situ hybridization data indicated that the neuropathological lesions were associated with the presence of SHIV-specific viral antigens and nucleic acid respectively. However, the concomitant reactivation of opportunistic infections in these macaques suggested that such pathogens may have influenced the replication of SHIV in the CNS, or modified the neuropathological sequelae of SHIV infection in the rhesus species, but not in pig-tailed macaques. Our findings in the two species of macaques highlight the complexities of lentiviral neuropathogenesis, the precise mechanisms of which are still elusive.

Primate Trabeculectomies With 5-Fluorouracil Collagen Implants

Bilateral trabeculectomies were performed on four normal cynomolgus monkeys. Highly purified bovine skin collagen implants with either 1 mg of 5-fluorouracil or physiologic saline (one each per monkey by randomized, masked assignment) were sutured under the scleral flaps. The randomization code was not broken until all clinical and histopathologic observations had been completed. Six weeks postoperatively, the 5-fluorouracil-treated eyes had more deeply open internal trabeculectomy ostia than the control eyes; however, the intraocular pressures were indistinguishable, the filtering blebs were only minimally different, and half of each group had trace or mild anterior subcapsular lenticular changes. Histologically, a multinucleated foreign body giant cell reaction was evident in all of the collagen implants, but the 5-fluorouracil-treated eyes had less vigorous or delayed reactions compared to the control eyes. The collagen implant appears to be a poor drug delivery system in this model of glaucoma filtering surgery, because it incites a granulomatous inflammatory reaction.

Sporadic cerebral amyloid angiopathy with giant cell reaction

We report a case of intracerebral hemorrhages due to sporadic cerebral amyloid angiopathy in a 43-year-old male with a luxuriant giant cell reaction. The amyloid was resistant to potassium permanganate-sulfuric acid oxidation and reacted with an antiserum to synthetic beta-protein. The distribution and histologic characteristics of the multinucleated giant cell reaction suggest that it represents a foreign-body reaction rather than giant cell arteritis.

Undifferentiated carcinoma of the maxillary sinus with osteoclast-like multinucleated giant cell reaction in the stroma Light microscopic and ultrastructural study.

A case of undifferentiated carcinoma originating from the maxillary sinus with osteoclast-like multinucleated giant cells resembling those of giant cell lesions of bone is presented. Although the histogenesis of the osteoclast-like multinucleated giant cells is not definitely established, it is proposed that the multinucleated giant cells are reactive in nature and histiocytic in origin because of their benign appearance, high level of acid-phosphatase activity and ultrastructural features, and that they arise from mononuclear histiocytic cells.F urthermore, histopathologic findings of the carcinoma that followed are reported.

Histology and fertility after microsurgical anastomosis of the rabbit fallopian tube with nylon and polyglactin sutures

Polyglactin and nylon suture material were compared in microsurgical anastomosis of oviduct of rabbits with regard to the histologic reaction, adhesion formation, and nidation index. Thirty days after surgery, the tissue inflammatory response was very similar in both groups. At 90 days, polyglactin had been totally absorbed in 80% of the cases, and no inflammatory reaction persisted at the site of the suture. At this time, multinucleated giant cell reaction to nylon sutures was persistent but minimal. The results reveal no significant functional differences between oviduct reanastomosed with nylon versus polyglactin suture. No significant difference in subsequent fertility due to suture selection was demonstrated.

Miescher's Granuloma of the Face

Thirteen patients had a distinctive annular, nonscarring granuloma affecting the forehead and face. The lesions appear predominantly in women in early middle life and are not frequently associated with clinical diabetes mellitus. Histopathologic changes reveal a granulomatous pattern with marked tendency toward multinucleated giant cell reaction and with no necrobiosis. The term ``Miescher's granuloma of the face" is proposed for the condition. We feel that Miescher's granuloma of the face is a clinically and histologically distinct entity within the spectrum of diseases that include necrobiosis lipoidica and granuloma annulare.

Turpentine-Induced Inflammation in the Chicken. A Light- and Electron-Microscope Study, with Emphasis on the Macrophage, Epithelioid Cell, and Multinucleated Giant Cell Reaction

Turpentine-Induced Inflammation in the Chicken. A Light- and Electron-Microscope Study, with Emphasis on the Macrophage, Epithelioid Cell, and Multinucleated Giant Cell Reaction