Shyr-Ming Sheen-Chen

Extracorporeal shock wave promotes growth and differentiation of bone-marrow stromal cells towards osteoprogenitors associated with induction of TGF-β1

Extracorporeal shock-wave (ESW) treatment hasbeen shown to be effective in promoting the healing of fractures. We aimed to determine whether ESW could enhance the growth of bone-marrow osteoprogenitor cells. We applied ESW to the left femur of rats 10 mm above the knee at 0.16 mJ/mm 2 in a range of between 250 and 2000 impulses. Bone-marrow cells were harvested after ESW for one day and subjected to assessment of colony-forming unit (CFU) granulocytes, monocytes, erythocytes, megakaryocytes (CFU-Mix), CFU-stromal cells (CFU-S) and CFU-osteoprogenitors (CFU-O). We found that the mean value for the CFU-O colonies after treatment with 500 impulses of ESW was 168.2 CFU-O/well (sem 11.3) compared with 88.2 CFU-O/well (sem 7.2) in the control group. By contrast, ESW treatment did not affect haematopoiesis as shown by the CFU-Mix (p = 0.557). Treatment with 250 and 500 impulses promoted CFU-O, but not CFU-Mix formations whereas treatment with more than 750 impulses had an inhibiting effect. Treatment with 500 impulses also enhanced the activity of bone alkaline phosphatase in the subculture of CFU-O (p Our findings suggest that optimal treatment with ESW could enhance rat bone-marrow stromal growth and differentiation towards osteoprogenitors presumably by induction of TGF-β1.

Superoxide Mediates Shock Wave Induction of ERK-dependent Osteogenic Transcription Factor (CBFA1) and Mesenchymal Cell Differentiation toward Osteoprogenitors

Extracorporeal shock wave (ESW) is an alternative non-invasive method for the promotion of bone growth and tendon repair. In an animal model, we have reported that ESW promoted bone marrow osteoprogenitor growth through transforming growth factor-β1 induction. We have further explored the mechanism for the ESW promotion of osteogenesis. Results showed that an optimal ESW treatment at 0.16 mJ/mm2 for 500 impulses rapidly induced a higher O 2 − and ONOO− production associated with a decrease of nitric oxide level in 1 h, and induced a higher transforming growth factor-β1 production in 24 h, and a higher colony-forming units-osteoprogenitor formation in 12 days. The colony-forming units-osteoprogenitor colonies revealed positive staining of bone alkaline phosphatase and turned into bone nodules in 21 days. Early scavenging of O 2 − but not Ca2+, H2O2, or prostaglandin E2 suppressed osteoprogenitor cell growth and maturation. Scavenging of O 2 − by superoxide dismutase raised the nitric oxide level back to the basal level and suppressed ESW-promoted osteoprogenitor cell growth, whereas inhibition of ONOO− by urate or NO byN-nitro-l-arginine methyl ester did not affect ESW promotion of osteogenesis, indicating that O 2 − acted as an early signal for ESW-induced cell growth. Further studies demonstrated that ESW induced ERK activation, and blockage of O 2 − production or inhibition of tyrosine kinase, but not protein kinase A and C inhibitors, suppressed ESW-induced ERK activation. In support that O 2 − mediated the ESW-induced ERK activation and osteogenic differentiation, we further demonstrated that scavenging of O 2 − by superoxide dismutase and inhibition of ERK activation by PD98059 decreased specific osteogenic transcription factor, core binding factor A1 activation, and decreased osteocalcin expression. Taken together, we showed that ESW-induced O 2 − production followed by tyrosine kinase-mediated ERK activation and core binding factor A1 activation resulted in osteogenic cell growth and maturation. Thus, an appropriate modulation of redox reaction by ESW may have some positive effect on the bone regeneration.

Single and multiple pyogenic liver abscesses: clinical course, etiology, and results of treatment.

Abstract. A total of 483 patients with pyogenic liver abscess during the years 1986 to June 1995 were studied at Chang Gung Memorial Hospital in Kaohsiung: 343 were a single abscess and 140 were multiple abscesses. Males were predominantly affected by this disease. Abdominal pain was more frequent with the single abscess than with multiple abscesses, and jaundice was more frequent with multiple abscesses. Blood levels of alkaline phosphatase, bilirubin, and creatinine and the white blood cell count were significantly higher in patients with multiple abscesses than in those with a single abscess; and the hemoglobin level was higher with single abscesses. The single abscess was usually larger than 5 cm, and the multiple abscesses were usually smaller than 5 cm. The single abscess was always located on the right side (72%) and the multiple abscesses always on the right or both sides. Single abscesses mainly had a cryptogenic origin (58.9%) and multiple abscesses a biliary origin (45.0%). Liver aspirates revealedKlebsiella pneumoniae, Escherichia coli, Streptococcus, Bacteroides,Enterococcus, among others. K. pneumoniae was more often found in a single abscess and E. coli more often in multiple abscesses. Percutaneous catheter drainage and aspiration comprised the main treatment initially, and the failure rate with multiple abscesses was higher than that with single abscesses. Surgical intervention should be considered for multiple abscesses because of the underlying disease. The overall mortality with multiple abscesses (22.1%) was higher than that with a single abscess (12.8%). Partial hepatectomy produced a low mortality rate for both single and multiple abscesses and should be considered in the presence of severe hepatic destruction by an abscess or a stone.

Temporal and spatial expression of bone morphogenetic proteins in extracorporeal shock wave-promoted healing of segmental defect

Extracorporeal shock wave (ESW) is a noninvasive acoustic wave, which has recently been demonstrated to promote bone repair. The actual healing mechanism triggered by ESW has not yet been identified. Bone morphogenetic proteins (BMP) have been implicated as playing an important role in bone development and fracture healing. In this study, we aimed to examine the involvement of BMP-2, BMP-3, BMP-4, and BMP-7 expression in ESW promotion of fracture healing. Rats with a 5-mm segmental femoral defect were given ESW treatment using 500 impulses at 0.16 mJ/mm(2). Femurs and calluses were subjected to immunohistochemistry and RT-PCR assay 1, 2, 4, and 8 weeks after treatment. Histological observation demonstrated that fractured femurs received ESW treatment underwent intensive mesenchymal cell aggregation, hypertrophic chondrogenesis, and endochondral/intramembrane ossification, resulting in the healing of segmental defect. Aggregated mesenchymal cells at the defect, chondrocytes at the hypertrophic cartilage, and osteoblasts adjunct to newly formed woven bone showed intensive proliferating cell nuclear antigen expression. ESW treatment significantly promoted BMP-2, BMP-3, BMP-4, and BMP-7 mRNA expression of callus as determined by RT-PCR, and BMP immunoreactivity appeared throughout the bone regeneration period. Mesenchymal cells and immature chondrocytes showed intensive BMP-2, BMP-3, and BMP-4 immunoreactivity. BMP-7 expression was evident on osteoblasts located at endochondral ossification junction. Our findings suggest that BMP play an important role in signaling ESW-activated cell proliferation and bone regeneration of segmental defect.

Smooth muscle tumors of the gastrointestinal tract: Analysis of prognostic factors

BACKGROUND The survival rates and therapeutic approaches to gastrointestinal leiomyoma and leiomyosarcoma vary widely. This review analyzes the clinical symptoms and signs, the results of the pathologic examination, and the DNA makeup of these tumors and determines the factors that affect the prognosis of patients who have leiomyosarcoma. METHODS Flow cytometric DNA analysis was performed in 80 patients with gastrointestinal smooth muscle tumors to establish the correlation of DNA ploidy with tumor size and stage and histologic grade. Using univariate and multivariate analyses, we investigated tumor size, histologic grade, association with gastrointestinal bleeding, DNA makeup, operative procedure, age, gender, and tumor necrosis as they affect the long-term survival of 45 patients with leiomyosarcoma. The Kaplan-Meier method was used to determine the survival rates and the log-rank method was used to compare survival rates between the two groups. RESULTS Between 1986 and 1992, operations were performed on the 80 gastrointestinal smooth muscle tumors--esophageal 1, stomach 32, intestinal 33, colonic 2, and rectal 12. The most common symptoms and signs were gastrointestinal bleeding (43.8%), abdominal mass (37.5%), and abdominal pain (21.3%), and the tumors were classified as leiomyoma 35, low-grade leiomyosarcoma 24, and high-grade leiomyosarcoma 21, according to the cellular atypia and mitotic rate. DNA ploidy correlated with histology grade (r = 0.70, p < 0.01) and tumor size (r = 0.31, p < 0.01) but not with localized or advanced tumors. Only one patient with leiomyoma died of liver metastasis during the follow-up period. In univariate analysis of the 45 patients with leiomyosarcoma, the survival rate was poor in men with tumor sizes greater than 5 cm, incomplete resections, advanced tumors, and high-grade tumors. With multivariate Cox regression analysis only advanced tumors (p < 0.01) and high-grade tumors (p < 0.01) were the independent factors that affected survival. CONCLUSIONS Leiomyosarcomas usually measure more than 10 cm. In univariate analysis the significant factors affecting the survival rate of patients with leiomyosarcoma are maleness, size greater than 5 cm, inadequate resection, and advanced-stage and high-grade disease. In multivariate Cox regression analysis advanced-stage and high-grade leiomyosarcoma are the only independent factors affecting survival. DNA ploidy correlates with the size and the grade of gastrointestinal smooth muscle tumors but not with tumor stage. DNA ploidy does not affect independently the survival of leiomyosarcoma.

Serum concentration of tumor necrosis factor in patients with breast cancer

Background: The outcome of breast cancer is usuallydetermined by multiple factors. Serum tumor necrosis factoralpha concentration has been found to be increasedin the circulation of patients with malignancy. Thisstudy was designed with the aim to investigateany correlation between the serum tumor necrosis factoralpha and the clinicopathological fetures and furthermore evaluatethe prognostic significance of serum tumor necrosis factoralpha concentration in breast cancer. Methods: Forty consecutivepatients with invasive breast cancer undergoing modified radicalmastectomy were prospectively included and evaluated. Venous bloodsamples were collected before the surgery. Sera wereobtained by centrifugation, and stored at − 70°C until assayed. The control group consisted 30healthy, age-matched subjects. Serum concentrations of tumor necrosisfactor alpha were measured by the quantitative sandwichenzyme immunoassay technique. The data on tumor size,age, estrogen receptor status, lymph node status andTNM staging were reviewed and recorded.Results: The mean value of serum tumor necrosis factor alphain patients with invasive breast cancer was 1.47± 0.58 pg/ml and that of the controlgroup was 0.98 ± 0.37 pg/ml, and thedifference was significant (P < 0.01). With univariableanalysis, patients with maximum tumor size of 5cm or larger (P=0.03), more advancedTNM staging (P < 0.01); and more advancedlymph node status (P < 0.01) were shownto have significantly higher serum concentrations of tumornecrosis factor alpha. However, with multivariable analysis, TNMstaging appeared as the only independent factor (P< 0.01) predicting the significant, higher serum concentrationsof tumor necrosis factor alpha. Conclusion: Preoperative evaluationof serum tumor necrosis factor alpha concentrations maybe a valuable parameter for reflecting the severityof staging for invasive breast cancer.

Synchronous and “early” metachronous colorectal adenocarcinoma

PURPOSE: We evaluated the accuracy of preoperative diagnostic examinations and determined whether patients with synchronous colorectal cancers differ from patients with a single colorectal malignancy in clinicopathologic factors, the possibility of early metachronous colorectal cancer, and postoperative outcome. METHODS: A retrospective evaluation of 1,780 patients with primary colorectal adenocarcinoma from 1987 to 1993 was performed. We divided patients into three groups: Group 1, single colorectal adenocarcinoma; Group 2, synchronous colorectal adenocarcinoma; and Group 3, early metachronous colorectal adenocarcinoma. RESULTS: There were 52 cases (3 percent) in Group 2 and 13 cases (1 percent) in Group 3 (<3 years from the index colorectal cancer operation). Differences in age, gender, and cancer-free rate among the three groups did not reached statistical significance. Compared with cancers in Group 1, significantly more proximal tumor locations and early cancer stage were noted for the second and third cancers in Group 2. In Group 3 a significantly more proximal tumor site was noted for the index colorectal cancer but cancer stage showed no significant difference from cancers in Group 1. Better histologic type was also noted in the index and second cancers in Group 2 than in cancers in Group 1. There was a higher incidence of associated benign adenoma in Group 2 (35vs. 15 percent in Group 1). The positivity rate of Group 2 was significantly higher by preoperative colonoscopy (71 percent) and incidental findings at surgery (58 percent) than barium enema examination (30 percent). CONCLUSION: Preoperative barium enema examination was an unsatisfactory tool for detecting synchronous tumors. Preoperative colonoscopy demonstrated a higher positivity rate, but it still failed to detect nearly 30 percent of cases with synchronous tumors. Intraoperative palpation of the whole colorectum could detect nearly 60 percent of unexpected synchronous tumors. We believe both colonoscopy and intraoperative palpation of the whole colorectum are crucial to the early detection of synchronous colorectal cancer.

A study on pruritus after parathyroidectomy for secondary hyperparathyroidism

BACKGROUND The effective therapy for uremic pruritus remains a clinical challenge, and the factors affecting the pruritus before and after parathyroidectomy have not been defined. STUDY DESIGN Thirty-seven patients were operated on for secondary hyperparathyroidism. Their ages ranged from 14 to 73 years, and the duration of dialysis from 12 to as long as 168 months. Indications for surgery were skin itch in 22 patients and other reasons in 15 patients. Serum levels of calcium, phosphorus, intact PTH (i-PTH), and alkaline phosphatase were checked at two different intervals-before surgery and 1 week after operation. Immunohistochemical stain of mast cells, antihuman macrophage (CD68), antihuman dendritic reticulum cell (CD35), and i-PTH (IHPTH) were performed on skin specimens. Skin samples were prepared into tissue homogenates and analyzed for concentrations of interleukin-2 (II-2) and tumor necrosis factor-alpha (TNF-alpha). II-2 and TNF-alpha were measured by sandwich enzyme-linked immunosorbent assay. The extent of pruritus was evaluated on a visual analog scale (VAS) ranging from 0 to 10 and a behavior rating scale (BRS) ranging from 0 to 5, at a preoperative stage and 1 week after operation. RESULTS Serum levels of calcium, phosphorus, the product of calcium and phosphorous (Ca x P), alkaline phosphatase, and i-PTH changed significantly after parathyroidectomy. The VAS decreased from 5.4 +/- 3.2 to 1.8 +/- 1.5 (p < 0.001). Significant improvement of BRS was achieved 1 week after surgery (p < 0.001), and in the followup period. Before surgery, there was no correlation between serum levels of calcium, phosphorus, Ca x P, alkaline phosphatase, i-PTH, number of mast cells, CD68, CD35, and IHPTH, and the scale of itch estimated with either VAS or BRS. The tissue levels of Il-2 and TNF-alpha were not detectable in any of them. We noted that high levels of phosphorus and Ca x P affected the postoperative extent of pruritus. But a linear regression test showed Ca x P was the only factor affecting postoperative itch. CONCLUSIONS Pruritus in patients with secondary hyperparathyroidism can be reduced by parathyroidectomy. Apparently, high-level Ca x P is the only factor that seems to affect the postoperative extent of pruritus.

Serum Levels of Hepatocyte Growth Factor in Patients with Breast Cancer

Objective: Hepatocyte growth factor (HGF) has been reported the cause of many biological events, including cell proliferation, movement, invasiveness, morphogenesis, and angiogenesis. Elevated hepatocyte growth factor content in tumor tissue was reported to predict a more aggressive biology in non–small cell lung cancer patients. However, there is still limited knowledge about the role of HGF in breast cancer. This study was designed with the aim to elucidate the possible relationship between the preoperative circulating soluble HGF and breast cancer. Materials and Methods: One hundred twenty-four consecutive patients with invasive breast cancer undergoing surgery were prospectively included and evaluated. Venous blood samples were collected before the surgery. Sera were obtained by centrifugation and stored at −70°C until assayed. The control group consisted of 35 patients with benign breast tumor (20 with fibrocystic disease and 15 with fibroadenoma). Serum concentrations of soluble HGF were measured by the quantitative sandwich enzyme immunoassay technique. The data on primary tumor staging, age, estrogen receptor status, lymph node status, distant metastases status, histologic grading, and tumor-node-metastasis (TNM) staging were reviewed and recorded. Results: The mean value of serum soluble HGF in patients with invasive breast cancer was 529.05 ± 123.33 pg/mL and that of control group was 343.00± 31.03 pg/mL and the difference was significant (P < 0.001). Furthermore, there were significantly higher serum levels of soluble HGF in patients with negative estrogen receptor (P = 0.035), in patients with poorer differentiated tumor (P < 0.001), in patients with more advanced primary tumor staging (P < 0.001), in patients with more advanced lymph node status (P < 0.001), in patients with distant metastases (P < 0.001), and in patients with more advanced TNM staging (P < 0.001). In multivariate analysis by the multiple linear regression method, TNM staging (P < 0.001) seemed an independent factor regarding the significant higher serum levels of soluble HGF. Conclusion: Patients with more advanced TNM staging were shown to have higher serum soluble HGF. Thus, preoperative serum soluble HGF levels might reflect the severity of invasive breast cancer and deserve further evaluation.

Serum levels of matrix metalloproteinase 2 in patients with breast cancer

Matrix metalloproteinases (MMPs) have been reported to be associated with invasive and metastatic behaviors of human malignant tumors. However, there is still limited knowledge about the role of matrix metalloproteinases-2 (MMP-2) in breast cancer. This study was designed with the aim to elucidate the possible relationship between the preoperative circulating MMP-2 and breast cancer. Fifty-seven consecutive patients with invasive breast cancer undergoing surgery were prospectively included and evaluated. Venous blood samples were collected before the surgery. Sera were obtained by centrifugation, and stored at -70 degrees C until assayed. The control group consisted of 12 patients with benign breast tumor (six with fibrocystic disease and six with fibroadenoma). Serum concentrations of MMP-2 were measured by the quantitative sandwich enzyme immunoassay technique. The data on primary tumor stage, age, estrogen receptor, lymph node status, and TNM staging were reviewed and recorded. The mean value of serum MMP-2 in patients with invasive breast cancer was 694.3+/-140.5 ng/ml and those of control group were 593.3+/-134.0 ng/ml and the difference was significant (P=0.026). Furthermore, there were significantly higher serum levels of MMP-2 in the patients with more advanced primary tumor staging (P=0.005), in the patients with more advanced lymph node status(P=0.011) and in the patients with more advanced TNM staging (P<0.001). In multivariate analysis, TNM staging (P<0.001) appeared as independent factor regarding the significant higher serum levels of MMP-2. Patients with more advanced TNM staging were shown to have higher serum MMP-2 levels. Thus preoperative serum MMP-2 levels might reflect the severity of invasive breast cancer and deserve further evaluation.