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PURPOSE: Hand transplantations have been initiated and have been encouraged by promising results for more than 1 decade. The aim of this study was to present the first case of hand transplantation performed in Taiwan. MATERIALS AND METHODS: On September 3, 2014, we transplanted the left distal forearm and hand of a brain-dead managed 37 years to a man aged 45 years who had traumatic amputation of the distal third of his right forearm 30 years ago. The total ischemic time during the transplantation was 6 hours and 45 minutes. Immunosuppression included anti-thymocyte globulins, and methylprednisolone (Solumedrol) was used for the induction. Maintenance therapy included systemic tacrolimus, mycophenolic acid [mycophenolate mofetil (MMF)], and prednisone. A combination of systemic (tacrolimus/MMF/prednisolone) and topical immunosuppressant cream (clobetasol and tacrolimus) was applied if acute rejection occurred. Follow-up included routine posttransplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support. RESULTS: The initial postoperative course was uneventful. No surgical complications were observed. Immunosuppression was well tolerated using tacrolimus, MMF, and prednisone, except for some immune-related complications. One episode of mild clinical and histological signs of cutaneous rejection was seen at 105 days after surgery. These signs disappeared after pulse therapy with Solumedrol and the topical application of immunosuppressive creams (tacrolimus and clobetasol). One infection episode occurred due to local cellulitis and axillary lymphadenopathy on day 140 and was successfully treated with antibiotics. The patient developed cytomegalovirus infection at 7 months that responded to medication. Intensive physiotherapy led to satisfactory progress in motor functioning. Sensory progress (Tinel sign) was good and reached the wrist by 3 months for the median and ulnar nerves, and could be felt in the finger tip by 9 months in response to deep pressure and light touch sensations. The patient has a lateral pinch that allows him to pick up and grip objects during daily living, although his muscle power is still insufficient. CONCLUSIONS: Hand allotransplantation is technically feasible. Currently available immunosuppression methods seem to control vascularized composite tissue allotransplantation rejection. A combination of topical and systemic immunosuppressants is a useful method to prevent acute hand allotransplant rejection.
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Amputación Traumática/cirugía , Traumatismos del Brazo/cirugía , Brazo/trasplante , Trasplante de Mano , Humanos , Masculino , Persona de Mediana Edad , Taiwán , Trasplante HomólogoRESUMEN
BACKGROUND: There is growing evidence of clinical data recently for successful outcomes of non-operative management (NOM) for blunt hepatic and spleen injuries (BHSI). However, the effectiveness of NOM for high-grade BHSI remains undefined. The aim of the present study was to review our experience with NOM in high-grade BHSI and compare results with the existing related data worldwide. METHODS: In this retrospectively protocol-driven study, 150 patients with grade 3-5 BHSI were enrolled during a 3-year period. Patients were divided into immediate laparotomy (immediate OP) and initial non-operative (initial NOM) groups according to hemodynamic status judged by duty trauma surgeon. Patients who received initial NOM were divided into successful NOM (s-NOM) and failed NOM (f-NOM) subgroups according to conservative treatment failure. We analyzed the clinical characteristics and the outcomes of patients. RESULTS: Twenty-eight (18.7%) patients underwent immediate operations, and the remaining 122 (81.3%) were initially treated with NOM. Compared with the initial NOM group, the immediate OP group had significantly lower hemoglobin levels, a higher incidence of tube thoracostomy, contrast extravasation and large hemoperitoneum on computed tomography, a higher injury severity score, increased need for transfusions, and longer length of stay (LOS) in the intensive care unit (ICU) and hospitalization. Further analysis of the initial NOM group indicated that NOM had failed in 6 (4.9%) cases. Compared with the s-NOM subgroup, f-NOM patients had significantly lower hemoglobin levels, more hospitalized transfusions, and longer ICU LOS. CONCLUSIONS: NOM of high-grade BHSI in selected patients is a feasible strategy. Notwithstanding, patients with initial low hemoglobin level and a high number of blood transfusions in the ICU are associated with a high risk for NOM failure.
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BACKGROUND: Fatty acid-CoA ligase 4 (FACL4) has been detected in various types of tumors. However, there is still very limited information about the role of FACL4 in breast cancer. Tissue microarray (TMA) technique analyzes thousands of specimens in a parallel fashion with minimal damage to the original blocks. This study was designed with the application of TMA to analyze the FACL4 status in breast cancer. MATERIALS AND METHODS: Archival tissue specimens from 102 patients with primary invasive breast cancer were selected and FACL4 expression was analyzed by immunhistochemical staining with TMA. The data of primary tumor staging, age, estrogen receptor status, lymph node status, histological grading and TNM staging were also collected. RESULTS: As shown my multivariate analysis, TNM stage was significantly related to the overall five-year survival rate. Nevertheless, FACL4 expression failed to have any significant relationship to overall five-year survival. CONCLUSION: Immuno-histochemical staining with TMA was convenient and feasible for the analysis of FACL4 expression status in breast cancer. Our preliminary results showed that FACL4 expression had no significant prognostic value in breast cancer.
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Biomarcadores de Tumor/metabolismo , Neoplasias de la Mama/enzimología , Carcinoma Ductal de Mama/enzimología , Carcinoma Lobular/enzimología , Coenzima A Ligasas/metabolismo , Adulto , Anciano , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/patología , Carcinoma Lobular/patología , Femenino , Estudios de Seguimiento , Humanos , Técnicas para Inmunoenzimas , Persona de Mediana Edad , Clasificación del Tumor , Estadificación de Neoplasias , Pronóstico , Receptor ErbB-2/metabolismo , Receptores de Estrógenos/metabolismo , Receptores de Progesterona/metabolismo , Tasa de Supervivencia , Análisis de Matrices TisularesRESUMEN
BACKGROUND: Many studies have shown that focal adhesion kinase (FAK) is a positive regulator of tumor progression and invasion. However, there is still very limited information about the role of FAK in breast cancer. Tissue microarrays (TMA) can analyze thousands of tissue samples in a parallel fashion with minimal damage to the origin block. This study was designed with the application of TMA to analyze the FAK status in breast cancer. PATIENTS AND METHODS: Archival tissue specimens from 98 patients with primary invasive breast cancer were selected and FAK expression was analyzed by immunohistochemical staining with TMA. The data of primary tumor staging, age, estrogen receptor status, lymph node status, histological grading and TNM staging were also collected. RESULTS: There were four patients (4.0%) with grade 1 expression in FAK, 41 patients (41.8%) with grade 2 expression in FAK and 53 patients (54.2%) with grade 3 expression in FAK. There was no significant relationship between FAK expression and age, estrogen receptor status, histological grading, primary tumor staging, lymph node status and TNM stage. By multivariate analysis, the TNM stage was found to be significantly related to the overall five-year survival rate (p<0.00001). CONCLUSION: Immunohistochemical staining with TMA is a convenient and feasible method. Unfortunately, our preliminary results fail to show meaningful prognostic value of FAK in breast cancer. A larger prospective study is warranted for further evaluation.
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Neoplasias de la Mama/enzimología , Proteína-Tirosina Quinasas de Adhesión Focal/metabolismo , Análisis de Matrices Tisulares/métodos , Adulto , Anciano , Neoplasias de la Mama/mortalidad , Femenino , Humanos , Inmunohistoquímica , Persona de Mediana Edad , Tasa de SupervivenciaRESUMEN
OBJECTIVES: Combined chemoradiotherapy with or without surgery is frequently performed as a curative treatment in patients with T3-4 locally advanced oesophageal squamous cell carcinoma. Computed tomography (CT) is frequently performed before and after chemoradiotherapy. The aim of this study is to evaluate the utility of the oesophageal wall thickness on CT scans to predict the response to chemoradiotherapy and the treatment outcome in patients with T3-4 locally advanced oesophageal squamous cell carcinoma. METHODS: Ninety-six patients with T3-4 locally advanced oesophageal squamous cell carcinoma, who were treated with neoadjuvant chemoradiotherapy followed by surgery between 1998 and 2008 at the Kaohsiung Chang Gung Memorial Hospital, were retrospectively reviewed. CT scans before and after chemoradiotherapy were available for 93 patients. Of these 93 patients, 24% (22 of 93) achieved a pathologically complete response (pCR). The measurement of the maximal dimension of the oesophageal wall thickness on CT scans before (pre) and after (post) chemoradiotherapy was performed retrospectively, and correlated with the response to chemoradiotherapy and patients' outcome. The percentage decrease of maximal oesophageal wall thickness after chemoradiotherapy was determined by the formula: [(pre -post)/pre] 100. RESULTS: Pre- and post-chemoradiotherapy maximal oesophageal wall thicknesses were significantly correlated with pCR, but the percent decrease of oesophageal wall thickness after chemoradiothrapy was not. Logistic models showed that pre-chemoradiotherapy maximal oesophageal wall thickness ≥20 mm was independently associated with response to chemoradiotherapy. For patients with pre-chemoradiotherapy maximal oesophageal wall thickness ≥20 mm, 91% did not achieve pCR after chemoradiotherapy. Univariate analyses demonstrated that a pre-chemoradiotherapy maximal oesophageal wall thickness ≥20 mm, T4 disease and positive regional lymph nodes (N stage) were predictive of inferior disease-free survival. In a multivariate comparison, pre-chemoradiotherapy maximal oesophageal wall thickness ≥20 mm represented an independent adverse prognosticator for disease-specific survival and disease-free survival. CONCLUSIONS: Most of the T3-4 locally advanced oesophageal squamous cell carcinoma patients with pre-treatment maximal oesophageal wall thickness ≥20 mm did not achieve pCR after chemoradiotherapy. Thus, oesophgectomy may be considered in advance in this group of patients. Pre-treatment maximal oesophageal wall thickness is of independent prognostic value in patients with T3-4 locally advanced oesophageal squamous cell carcinoma who receive neoadjuvant chemotheradiotherapy.
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Carcinoma de Células Escamosas/terapia , Quimioradioterapia Adyuvante , Neoplasias Esofágicas/terapia , Esofagectomía , Esófago/diagnóstico por imagen , Tomografía Computarizada Multidetector , Terapia Neoadyuvante , Adulto , Anciano , Antineoplásicos/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Escamosas/diagnóstico por imagen , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Cisplatino/administración & dosificación , Neoplasias Esofágicas/diagnóstico por imagen , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/patología , Esófago/patología , Esófago/cirugía , Femenino , Fluorouracilo/administración & dosificación , Estudios de Seguimiento , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Radioterapia Conformacional , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
AIM: To compare clinical presentation and ultrasound (US) and computed tomography (CT) sensitivity between intraluminal and infiltrating gallbladder carcinoma (GBCA). METHODS: This retrospective study evaluated 65 cases of GBCA that were categorized morphologically into the intraluminal-GBCA (n = 37) and infiltrating-GBCA (n = 28) groups. The clinical and laboratory findings, presence of gallstones, gallbladder size, T-staging, nodal status, sensitivity of preoperative US and CT studies, and outcome were compared between the two groups. RESULTS: There were no significant differences between the two groups with respect to female predominance, presence of abdominal pain, serum aminotransferases level, T2-T4 staging, and regional metastatic nodes. Compared with the patients with intraluminal-GBCA, those with infiltrating-GBCA were significantly older (65.49 +/- 1.51 years vs 73.07 +/- 1.90 years), had a higher frequency of jaundice (3/37 patients vs 13/28 patients) and fever (3/37 patients vs 10/28 patients), higher alkaline phosphatase (119.36 +/- 87.80 IU/L vs 220.68 +/- 164.84 IU/L) and total bilirubin (1.74 +/- 2.87 mg/L vs 3.50 +/- 3.51 mg/L) levels, higher frequency of gallstones (12/37 patients vs 22/28 patients), smaller gallbladder size (length, 7.47 +/- 1.70 cm vs 6.47 +/- 1.83 cm; width, 4.21 +/- 1.43 cm vs 2.67 +/- 0.93 cm), and greater proportion of patients with < 12 mo survival (16/37 patients vs 18/28 patients). The sensitivity for diagnosing intraluminal-GBCA with and without gallstones was 63.6% and 91.3% by US, and 80% and 100% by CT, respectively. The sensitivity for diagnosing infiltrating-GBCA with and without gallstones was 12.5% and 25% by US, and 71.4% and 75% by CT, respectively. CONCLUSION: In elderly women exhibiting small gallbladder and gallstones on US, especially those with jaundice, fever, high alkaline phosphatase and bilirubin levels, CT may reveal concurrent infiltrating-GBCA.
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Neoplasias de la Vesícula Biliar/diagnóstico por imagen , Neoplasias de la Vesícula Biliar/patología , Anciano , Diagnóstico Diferencial , Femenino , Fiebre/etiología , Vesícula Biliar/patología , Neoplasias de la Vesícula Biliar/complicaciones , Cálculos Biliares/etiología , Cálculos Biliares/patología , Humanos , Ictericia/etiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
BACKGROUND: Gallbladder carcinoma is uncommon and may manifest as acute cholecystitis. An accurate diagnosis is helpful for operative planning and this study attempted to explore the distinctive clinical and computed tomographic (CT) features for differentiating acute cholecystitis alone from that with contemporaneous gallbladder carcinoma. METHODS: This 20-year, retrospective study evaluated the CT features of 26 patients with surgically proven gallbladder carcinoma with clinical presentations of acute cholecystitis (carcinoma group). Thirty elderly patients with surgically proven simple acute cholecystitis were enrolled as age-matched controls (cholecystitis group). The clinical, laboratory, and CT findings were compared between the 2 groups. RESULTS: The carcinoma and cholecystitis groups showed no significant differences with respect to clinical symptoms (abdominal pain, fever, and jaundice), serum total bilirubin level, leukocyte count, percentage of segmented leukocytes, presence of gallstones, and CT features of pericholecystic stranding/fluid and focally increased enhancement of adjacent liver. Fifteen of the 26 (57.6%) patients in the carcinoma group exhibited diffuse gallbladder wall thickening on CT and the other 11 exhibited focal thickening or intraluminal masses. Beside female predominance, the patients in the carcinoma group had significantly higher serum aspartate/alanine aminotransferase and alkaline phosphatase levels, a thicker gallbladder wall, smaller volume, lower frequency of triple-layer gallbladder wall enhancement pattern, and a higher frequency of enlarged regional lymph nodes than those in the cholecystitis group. CONCLUSION: For elderly patients, especially women, presenting with acute cholecystitis and abnormal liver function, CT demonstration of focal gallbladder wall thickening, intraluminal masses, small gallbladder with diffuse wall thickening, and enlarged regional lymph nodes are suggestive of concurrent gallbladder carcinoma. Triple-layer gallbladder wall enhancement is suggestive of simple acute cholecystitis.
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Carcinoma/diagnóstico por imagen , Colecistitis Aguda/diagnóstico por imagen , Neoplasias de la Vesícula Biliar/diagnóstico por imagen , Anciano , Anciano de 80 o más Años , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
AIM: To describe the radiological findings of a macro-regenerative nodule (MRN) in the liver of pre-transplantation biliary atresia (BA) patients and to correlate it with histological findings. METHODS: Between August 1990 and November 2007, 144 BA patients underwent liver transplantation (LT) at our institution. The pre-transplantation computer tomograghy (CT) and magnetic resonance imaging (MRI) findings were reviewed and correlated with the post-transplantation pathological findings. RESULTS: Nine tumor lesions in 7 patients were diagnosed in explanted livers. The post-transplantation pathological findings showed that all the lesions were MRNs without malignant features. No small nodule was detected by either MRI or CT. Of the 8 detectable lesions, 6 (75%) were in the central part of the liver, 5 (63%) were larger than 5 cm, 5 (63%) had intra-tumor tubular structures, 3 (38%) showed enhancing fibrous septa, 3 (38%) had arterial enhancement in CT, one (13%) showed enhancement in MRI, and one (13%) had internal calcifications. CONCLUSION: Although varied in radiological appearance, MRN can be differentiated from hepatocellular carcinoma (HCC) in most of BA patients awaiting LT. The presence of an arterial-enhancing nodule does not imply that LT is withheld solely on the basis of presumed malignancy by imaging studies. Liver biopsy may be required in aid of diagnostic imaging to exclude malignancy.