Friday, February 3, 2012

Seeking information.......Granulomas, histiocytosis, type IV immune response.... (part 1 of x in this series)

Hip revision patients: I would really appreciate any feedback you can provide.  I will have more for you on this in the next few days.

Thanks, Connie...

Has anyone  discovered "tumor" (not necessarily cancerous) like growths that have surfaced while getting CT scans for other reasons following thier revision surgery?

I am particulary interested in  Granulomas.

Granuloma is a medical term for a tiny collection of immune cells known as macrophages[1]. Granulomas form when the immune system attempts to wall off substances that it perceives as foreign but is unable to eliminate Chromium or Cobalt.

…… radiologists often use the term granuloma when they see a calcified nodule on X-ray or CT scan of the chest. They make this assumption since granulomas often contain calcium, although the cells that form a granuloma are too tiny to be seen by a radiologist. The most accurate use of the term "granuloma" requires a pathologist to examine surgically removed tissue under a microscope.

How about  Histocytosis? (they don't mean the same thing but have heard physcians refer to them interchangebly.)

medicine, histiocytosis refers to an excessive number of histiocytes,[1] (tissue macrophages), and is typically used to refer to a group of rare diseases which share this as a characteristic. Occasionally and confusingly, the term "histiocytosis" is sometimes used to refer to individual diseases.

The histiocytes may attack skin, bone, muscles, and other important organs, including the liver, lung, spleen, and hematopoietic system. The disease is somewhat similar to cancer, and treatment often involves radiation and chemotherapy.

A histiocyte is a type of immune cell that eats foreign substances in an effort to protect the body from infection (like toxic metal substances in the body.) 

Histiocytosis X has typically been thought of as a cancer-like condition. More recently researchers have begun to suspect that it is actually an autoimmune phenomenon, in which immune cells mistakenly attack the body, rather than fight infections. Extra immune cells may form tumors, which can affect various parts of the body including the bones, skull, and other areas.

Following  are a few  abstracts  which might put these concepts  into context.

Virchows Arch. 2008 Nov;453(5):529-34. Epub 2008 Sep 4.

Necrotic granulomatous pseudotumours in bilateral resurfacing hip arthoplasties: evidence for a type IV immune response.


Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.


Clinical, radiological and histological findings were analysed in four patients who developed bilateral pseudotumours following metal-on-metal (MoM) resurfacing arthroplasties of both hips. Using a panel of monoclonal antibodies directed against HLA-DR, macrophages (CD14, CD68), dendritic cells (DC-SIGN, S100, CD11c), B cells (CD20), and T cells (CD3, CD4, CD8), the nature of the heavy inflammatory response seen in these cases was examined. Bilateral masses developed in periprosthetic soft tissues following the second MoM arthroplasty; these were characterised histologically by extensive coagulative necrosis, a heavy macrophage infiltrate and the presence of granulomas containing macrophages and giant cells; there was also a diffuse lymphocyte and variable plasma cell and eosinophil polymorph infiltrate. Immunohistochemistry showed strong expression of HLA-DR, CD14 and CD68 in both granulomatous and necrotic areas; lymphocytes were predominantly CD3+/CD4+ T cells. The clinical, morphological and immunophenotypic features of these necrotic granulomatous pseudotumours, which in all cases develop following a second resurfacing hip arthroplasty, is suggestive of a type IV immune response, possibly to MoM metal alloy components.


Am J Surg Pathol. 1994 Jan;18(1):83-90.

Sinus histiocytosis of pelvic lymph nodes after hip replacement. A histiocytic proliferation induced by cobalt-chromium and titanium.


Department of Pathology, University of Texas Southwestern Medical Center, Texas, Dallas 75235-9072.

Six men who had undergone hip replacements for degenerative joint disease or trauma subsequently had radical prostatectomies or cystoprostatectomies with bilateral pelvic lymph node dissections for adenocarcinoma of the prostate or transitional cell carcinoma of the urinary bladder. The hip prostheses implanted in three patients were known to contain cobalt-chromium alloy and titanium. The pelvic lymph nodes ipsilateral to the hip prosthesis in five patients and the bilateral pelvic nodes in the only patient with bilateral hip prosthesis had dark brown or black cut surfaces. These lymph nodes did not contain carcinoma but showed florid sinus histiocytosis characterized by large polygonal histiocytes filling and expanding sinuses and interfollicular regions. The foamy histiocytes contained cobalt-chromium and titanium microparticles by light microscopy, ultrastructure, and energy-dispersive x-ray microanalysis. The lymph nodes uninvolved by the histiocytic reaction lacked the heavy metal microparticles. Four cases were found to have a small number of polyethylene particles, which might have contributed to the histiocytic response. By immunohistochemistry, the foamy cells displayed immunoreactivity for lysozyme, alpha-1-antitrypsin, alpha-1-antichymotrypsin, and cathepsin D, providing additional support for their histiocytic derivation. To our knowledge, this is the first time that microparticles of cobalt-chromium and titanium that migrate from hip prostheses to pelvic lymph nodes have been shown to elicit a distinctive type of florid sinus histiocytosis. Pathologists should be aware of this characteristic foreign-body tissue response to avoid confusion with other types of sinus histiocytosis or with metastatic carcinoma.

More over the next few days.....

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