J.-C. Yu

The mechanisms of failure of totally implantable central venous access system: analysis of 73 cases with fracture of catheter.

BACKGROUNDnTotally implantable access ports are often used for the administration of chemotherapy or prolonged intravenous infusions in patients with cancer. The technique has been well described. However, some complications would happen. The pinch-off-syndrome is one of these complications. We report another presentation of pinch-off-syndrome and how to prevent.nnnMETHODSnFrom January 2005 to December 2007, 73 patients of catheter fracture were collected. The duration of Port-A implantation ranged from January 2003 to October 2007. During this period, 3358 port-catheters were implanted. There were three brands of Port-A implanted included 46% BardPort (Bard, Salt Lake City, UT, USA), 42% A Port (Arrow international, Reading, PA, USA) and 12% PORT-A CATH (Deltec, St. Paul, MN, USA).nnnRESULTSnThe most common clinical presentation was difficulty in injection in 32 cases (43.8%). The incidence of brand C was far lower than brand A and B. The most common site of fracture was at the proximal part (anastomosis between injection port and catheter) in 68 cases (93.2%). The incidence of fracture of Port-A was 6 in 738 (0.81%) in cut-down method; 67 in 2620 (2.56%) in percutaneous subclavian method. Most of the cases (34%) were no more than six months.nnnCONCLUSIONnThe most frequent location of fracture Port-A was in proximal part - anastomosis between injection port and catheter. The cause of easily fracture may be associated with pinch-off-syndrome and design of Port-A. This kind of fracture could be prevented by cut-down method and fixed one stitch in proximal part.

Papillary breast lesions diagnosed by core biopsy require complete excision

BACKGROUNDnSurgical excision of papillary breast lesions with atypia diagnosed using core needle biopsy (CNB) has been accepted; however, the management of benign papillary lesions (without atypia) has been controversial. The purpose of this study was to evaluate the surgical outcome of nonmalignant papillary lesions diagnosed by ultrasound-guided 14-gauge CNB, and to establish clear guidelines on management of these lesions.nnnMETHODSnWe retrospectively identified 268 nonmalignant papillary breast lesions, including 203 benign lesions and 65 atypical lesions, diagnosed by CNB and subsequently surgically excised in 250 women at our institution between July 2004 and October 2010. For each lesion, medical records and radiologic and pathologic reports were reviewed and coded. We compared the histological upgrade among the collected variables.nnnRESULTSnOn histological examination after surgical excision, 15.4% atypical papillary lesions and 5.9% benign lesions were upgraded to malignant, and 20.2% benign lesions were upgraded to atypical. Atypia (Pxa0=xa00.015) was significantly associated with malignant upgrade at excision. No clinical or radiologic variable was helpful in predicting the possibility of histological upgrade of CNB-diagnosed nonmalignant papillary lesions.nnnCONCLUSIONSnNonmalignant papillary lesions diagnosed with CNB showed an unacceptable pathological upgrade rate after excision. Therefore, surgical excision should be performed for all papillary lesions of the breast for definitive diagnosis.

Factors predictive of breast cancer in open biopsy in cases with atypical ductal hyperplasia diagnosed by ultrasound-guided core needle biopsy.

AIMSnThe purpose of the study was to explore factors predictive of breast cancer as diagnosed by excision biopsy in cases with a diagnosis of atypical ductal hyperplasia (ADH) on ultrasound-guided core needle biopsy (CNB).nnnPATIENTS AND METHODSnWe carried out diagnosis of breast lesions by ultrasound-guided CNB in a single hospital in Taiwan from November 2003 to October 2009. Patients who were diagnosed with ADH and subsequently underwent excision biopsy were included in this study (nxa0=xa0124).nnnRESULTSnFifty-six of the 124 patients who were included (45.2%) had cancer, and the remaining 68 had benign lesions. By multivariate analysis of all clinical characteristics and on the basis of the imaging features in these cases, older patient age (≥50xa0y/o, OR: 3.910, pxa0=xa00.005), larger tumour size (≥15xa0mm, OR: 3.398, pxa0=xa00.013), and the presence of architectural distortion by mammography (OR: 10.7, pxa0=xa00.036) were found likely to be associated with breast cancer.nnnCONCLUSIONSnOpen biopsy is necessary in patients who were diagnosed with ADH on CNB. Older patients (≥50xa0y/o), with a larger tumour size (≥15xa0mm) and an abnormal mammography are especially likely to have breast cancer.

Triptolide ameliorates autoimmune diabetes and prolongs islet graft survival in nonobese diabetic mice.

Objectives Triptolide (TPL) possesses profound immunosuppressive effects and has potential in allograft transplantation. We investigated whether TPL treatment prevents autoimmune diabetes in nonobese diabetic (NOD) mice and prolongs the survival of islet grafts against autoimmune attack or allograft rejection. Methods Diabetic incidence was monitored in TPL-treated NOD mice. Nonobese diabetic or BALB/c islets were transplanted into diabetic recipients treated with TPL. Different T-cell subsets in grafts or spleen were analyzed. The proliferation, apoptosis, cytokines, and activities of AKT, NF&kgr;B, and caspases 3, 8, and 9 of T cells were determined. Results Diabetic incidence was reduced and inflammatory cytokines were decreased in islets and spleen under TPL treatment. T-cell proliferation was reduced and the survival of syngeneic or allogeneic grafts was significantly increased in TPL-treated mice. The populations of CD4, CD8, CD4CD69, CD8CD69, and interferon-&ggr;–producing T cells in islet grafts and spleen were reduced. Triptolide treatment increased the apoptosis of T cells in the spleen of recipients. Levels of phosphorylated protein kinase B and phosphorylated inhibitor of kappa B in splenocytes were reduced and caspases 3, 8, and 9 were increased in TPL-treated mice. Conclusions Triptolide treatment not only reduced the diabetic incidence in NOD mice but also prolonged the survival of syngeneic or allogeneic grafts.

Advanced age is not a contraindication for liver resection in cases of large hepatocellular carcinoma

BACKGROUNDnThe role of surgery in the management of large hepatocellular carcinomas (HCCs) is controversial. Advanced age and comorbidities are taken into account when major surgery is considered.nnnPURPOSEnTo compare the outcomes of liver resection (LR) and transarterial chemoembolization (TACE) for resectable HCC in patients aged 70 years or older.nnnPATIENTS AND MATERIALSnThis study included 70 patients aged 70 years or older treated for large HCCs (≥5 cm) between January 2007 and December 2012: 37 underwent LR and 33 underwent TACE. The outcomes of these patients were retrospectively analyzed. Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and survival data were compared using the log-rank test.nnnRESULTSnHospital stay was significantly longer in the LR group than in the TACE group (10 days vs 8.5 days; P = 0.003). Treatment-related complications were more frequent in the TACE group, but this difference was not statistically significant. LR was associated with a better disease-free survival rate, median survival rate and cumulative overall survival rate.nnnCONCLUSIONnOur results showed that LR could be a safe and effective treatment option for HCC tumors ≥5 cm in patiets aged 70 years or older.

A paraduodenal hernia (Treitz's hernia) causing acute bowel obstruction

Paraduodenal hernias, also called Treitz’s hernia, are unusual causes of intestinal obstruction and account for 0.9% of all intestinal obstructions (1). Paraduodenal hernias constitute half of all internal abdominal hernias and occur when the small bowel herniates into the paraduodenal fossa with manifestation of intestinal obstruction (2). Specific clinical signs are often absent, leading to the frequent delay of correct diagnosis, with bowel necrosis resulting in up to 20% of patients (3). Herein, we present our case to increase the awareness of Treitz’s hernia and suggest the early CT scan intervention may be helpful to make the preoperative diagnosis of paraduodenal hernia.

Dimethyl sulfoxide inhibits spontaneous diabetes and autoimmune recurrence in non-obese diabetic mice by inducing differentiation of regulatory T cells.

Type 1 diabetes mellitus (T1D) is caused by the destruction of insulin-producing β cells in pancreatic islets by autoimmune T cells. Islet transplantation has been established as an effective therapeutic strategy for T1D. However, the survival of islet grafts can be disrupted by recurrent autoimmunity. Dimethyl sulfoxide (DMSO) is a solvent for organic and inorganic substances and an organ-conserving agent used in solid organ transplantations. DMSO also exerts anti-inflammatory, reactive oxygen species scavenger and immunomodulatory effects and therefore exhibits therapeutic potential for the treatment of several human inflammatory diseases. In this study, we investigated the therapeutic potential of DMSO in the inhibition of autoimmunity. We treated an animal model of islet transplantation (NOD mice) with DMSO. The survival of the syngeneic islet grafts was significantly prolonged. The population numbers of CD8, DC and Th1 cells were decreased, and regulatory T (Treg) cell numbers were increased in recipients. The expression levels of IFN-γ and proliferation of T cells were also reduced following DMSO treatment. Furthermore, the differentiation of Treg cells from naive CD4 T cells was significantly increased in the in vitro study. Our results demonstrate for the first time that in vivo DMSO treatment suppresses spontaneous diabetes and autoimmune recurrence in NOD mice by inhibiting the Th1 immune response and inducing the differentiation of Treg cells.

An unusual submucosal tumor of the cecum presenting a palpable abdominal mass: hepatoid carcinoma.

Hepatoid carcinoma is a special type of extrahepatic neoplasm presenting features of morphology, immunohistochemistry and biological behavior similar to hepatocellular carcinoma. It was first described in the stomach, which is the most common site and very rarely in the colon (1-2). The prognosis of hepatoid carcinoma is very poor compared with that of common types of adenocarcinoma. A prompt and accurate diagnosis of is important (3). We report here an unusual submucosal tumor of the cecum presenting a palpable abdominal mass, diagnosed as a hepatoid carcinoma by microscopic morphology and immunochemical staining. A 50-year-old woman developed presented with a palpable abdominal mass and intermittent diarrhea for 2 months associated with weakness and weight loss of 7 kilograms. Physical examination showed anemic conjunctiva and a 6-cm palpable, tender mass on right lower quadrant abdominal region. Laboratory data showed hemoglobin of 11.2 g/dl and normal values of tumor markers as carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 and alpha-fetoprotein (AFP). Computed tomography (CT) of abdomen revealed a 8 cm x7 cm× 7 cm het-

Association of estrogen receptor, progesterone receptor and HER2 following neoadjuvant systemic treatment in breast cancer patients undergoing surgery.

AimsThe aim of this study was to analyze the association between the status of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2) in breast cancer with neoadjuvant therapy by using tissue biopsy and surgical specimens.MethodsThis study included 78 patients with breast cancer, who presented to our hospital between June 1999 and June 2011, and were treated with neoadjuvant therapy and subsequent mastectomy or partial mastectomy. All clinicopathological data regarding pre-neoadjuvant biopsy and definitive surgical specimens were reviewed for accuracy. The status of ER, PR, and HER2 was determined by immunohistochemistry.ResultsPaired samples from 78 women (mean age 51.4xa0±xa011.7xa0years) were successfully analyzed. A switch in the status of ER was identified in 16 patients (20xa0%); PR, in 18 (23xa0%); and HER2, in 27 (35xa0%). There were no significant differences in the status of ER, PR, and HER2 between the primary tumor and the resected tumor after neoadjuvant therapy. Neoadjuvant therapy does not significantly influence the status of the steroid hormone receptors and the HER2 level in our study.ConclusionsInitial biopsy may be reliable for determining the appropriate adjuvant therapy, but final pathology are still needed to evaluate the prognosis and provided the alternative treatment when tumor recurrence. Further prospective study is needed to optimize the care available for breast cancer patients.

Recurrence of hepatocellular carcinoma after liver transplantation presenting as anastomotic biliary stricture

A 52-year-old man visited our hospital complaining of anorexia and fatigue two months after receiving orthotopic liver transplantation for hepatocellular carcinoma. A laboratory investigation demonstrated a clinical picture of obstructive jaundice. T-tube cholangiography showed biliary stricture over the anastomotic site. Percutaneous transluminal balloon dilatation and stenting was attempted but failed. Magnetic resonance cholangiography showed possible tumor recurrence over the site of the anastomotic biliary stricture. A biopsy sample was obtained via ultrasound-guided aspiration and histopathological study revealed inflammatory and fibrotic changes. With high suspicion of recurrence of the hepatocellular carcinoma, surgical exploration was performed and an intraoperative frozen section proved the recurrence. We thus diagnosed this case as a recurrence of hepatocellular carcinoma after liver transplantation. To our knowledge, there have been no previous reports of early tumor recurrence after liver transplantation being the cause of an anastomotic biliary stricture.