Genetics of familial amyloidotic polyneuropathy in a Hong Kong Chinese kindred

Familial amyloidotic polyneuropathy type 1 (FAP1, MIM176300) is an autosomal dominant disease caused by mutations in the transthyretin (TTR) gene. An extended Chinese kindred of FAP1 was first reported in Hong Kong in 1989, three of the four histologically proven subjects have deceased. TTR gene mutations were not studied then. A DNA-based diagnosis was performed on FAP1 by restriction analysis and direct DNA sequencing was carried out on a symptomatic member of this family who had undergone a liver transplantation. It showed a substitution of thymine by cytosine in the second base of codon 30 in exon 2 of the TTR gene, with the creation of a novel HhaI restriction endonuclease site. Valine is substituted by alanine (V30A) in the mutant TTR. Both restriction analysis and direct sequencing revealed the same mutation in one of the two asymptomatic siblings. This mutation was first reported in a FAP1 family of German descent.

Emergency living related liver transplantation for fulminant reactivation of hepatitis B virus after unrelated marrow transplantation

We report a unique case of emergency living related donor orthotopic liver transplantation (OLT) for late fulminant reactivation of hepatitis B virus (HBV) after matched unrelated bone marrow transplantation (BMT) for chronic myeloid leukemia (CML). Cessation of lamivudine after BMT for HBV positive patients may carry risks of late fatal HBV reactivation. Similar to fulminant HBV reactivation in the general population, OLT under resumption of lamivudine can be life saving. In our case, concomitantly molecular relapse of CML at the time of liver failure was also cleared by OLT, possibly via a 'liver-graft vs. leukemia' effect. Liver rejection (graft vs. graft disease) was mild due to inherent immunocompromise of the marrow graft. Hence BMT recipients in stable remission should not be denied the opportunity for life-saving solid organ transplantation. A choice of marrow and liver donors with innate HBV immunity may be needed to give the additional advantage of long-term HBV clearance.

Immunoprofile of cervical and endometrial adenocarcinomas using a tissue microarray

Adenocarcinomas of the uterine cervix show a wide range of morphological features, and can be confused with endometrial adenocarcinoma in biopsy or curetting specimens. The objective of this study was to use tissue microarray technology to evaluate the immunoprofile of a large set of uterine adenocarcinomas with an extended panel of antibodies, comparing the profile of primary cervical and endometrial adenocarcinomas. A tissue microarray was constructed using paraffin-embedded, formalin-fixed tissues from 141 hysterectomy specimens. Duplicate 0.6-mm cores were obtained from 57 cervical adenocarcinomas (16 in situ and 41 invasive) and 84 endometrial adenocarcinomas. Tissue array sections were immunostained with 21 commercially available antibodies [B72.3, CD 99, carcinoembryonic antigen (CEA), c-kit, pancytokeratin, CK 5/6, CK 7, CK8/18, CK19, CK 20, CK 22, EMA, estrogen receptor (ER), KP-1, melan-A, p53, PLAP, S-100, synaptophysin, TTF-1, and vimentin] utilizing the avidin-biotin (ABC) technique. Hierarchical clustering analysis of the tumors was done based on the immunostaining results. Only ER ( P<0.001), CEA ( P=0.04), vimentin ( P<0.001), and CK 8/18 ( P=0.002) showed a significantly different frequency of positivity in endometrial relative to cervical adenocarcinomas. ER, vimentin, and CK 8/18 were more likely to be expressed in endometrial adenocarcinomas, while cervical adenocarcinomas more frequently expressed CEA. We were able to identify immunoprofiles that were highly specific for endocervical adenocarcinoma (ER(-), vimentin(-), CK 8/18(-), CEA(+)) or endometrial adenocarcinoma (ER(+), vimentin(+), CK 8/18(+), CEA(-)), but most tumors showed an intermediate, non-specific immunophenotype. Hierarchical clustering analysis was useful in the interpretation of these intermediate immunophenotypes. Papillary serous adenocarcinoma of the endometrium was less likely to express vimentin ( P=0.002) than endometrioid carcinoma of the endometrium.

Solid-phase microextraction from small volumes of sample in a glass capillary

A new sampling method is proposed for solid-phase microextraction (SPME), in which the extraction is carried out in a glass capillary containing a few microliters of sample. When an adsorption-type fiber is used for SPME, the equilibrium between aqueous sample and coating can be described by a Langmuir isotherm. Since the total amount of analytes and coexisting substances stays at a low level in a small volume of sample, the linear concentration range of analytes will be extended for SPME to be applied in quantification and the interference caused by sample matrix will be reduced. In addition, sampling in a capillary has a short diffusion distance and extraction equilibrium is established in 5-10 min. It is important in clinical analysis and therapeutic drug monitoring to be able to analyse sample volumes of samples. The feasibility of the new sampling method is demonstrated by the extractions of p-hydroxybenzaldehyde and a synthetic solution containing 1-naphthol, paeonol and 1-naphthylamine.

A simple method for DNA extraction from marine bacteria that produce extracellular materials

We present a simple method for extracting DNA from the marine bacteria Hahella chejuensis, a Streptomyces sp., and a Cytophaga sp. Previously, DNA purification from these strains was hindered by the presence of extracellular materials. In our extraction method, the marine bacteria are lysed by freezing and grinding in liquid nitrogen, and treated with SDS. The extracted DNA is purified using a phenol/chloroform mixture, and precipitated in isopropanol. The extracted DNA is of high quality and suitable for molecular analyses, such as PCR, restriction enzyme digestion, genomic DNA blot hybridization, and genomic DNA library construction. We used this method to extract genomic DNA from several other marine bacteria. Our method is a reproducible, simple, and rapid technique for routine DNA extractions from marine bacteria. Furthermore, the low cost of this method makes it attractive for large-scale studies.

Right lobe living donor liver transplantation with or without venovenous bypass

BACKGROUND

Venovenous bypass was considered necessary to maintain haemodynamic stability and avoid splanchnic and retroperitoneal congestion during the anhepatic phase of liver transplantation. It was essential for right lobe living donor liver transplantation (LDLT) in which the inferior vena cava needed to be cross-clamped to construct wide and short hepatic vein anastomoses. However, many complications related to venovenous bypass have been reported. This study aimed to determine whether venovenous bypass was necessary for right lobe LDLT.

METHODS

Between June 1996 and June 2001, 72 patients underwent right lobe LDLT. The outcomes for the first 29 patients who had venovenous bypass during the operation were compared with those of the remaining 43 patients who did not have venovenous bypass. In patients without bypass, blood pressure was maintained during the anhepatic phase by boluses of fluid infusion and vasopressors.

RESULTS

Compared with patients undergoing operation without venovenous bypass, patients who had venovenous bypass required significantly more blood, fresh frozen plasma and platelet infusion, and had a lower body temperature; their postoperative hepatic and renal function in the first week was worse than that in patients who did not have a bypass. The time to tracheal extubation was longer and the incidence of reintubation for ventilatory support was higher with venovenous bypass. Six of the 29 patients with venovenous bypass died in hospital, compared with two of the 43 patients without a bypass (P = 0.05). By multivariate analysis, the lowest body temperature during the transplant operation was the most significant factor that determined hospital death.

CONCLUSION

Venovenous bypass is not necessary and is probably harmful to patients undergoing right lobe LDLT, and should therefore be avoided.

Hepatic resection for colorectal liver metastases: prospective study

OBJECTIVE

To assess the operative and long-term survival outcomes of hepatic resection for colorectal liver metastases during an 11-year period in a tertiary referral centre in Hong Kong.

DESIGN

Prospective study.

SETTING

University teaching hospital, Hong Kong.

SUBJECTS AND METHODS

Between January 1989 and December 1999, 72 patients underwent hepatic resection for colorectal liver metastases. Clinical, pathological, and outcome data were prospectively collected and analysed. Factors affecting long-term survival were also evaluated.

RESULTS

Twenty-five (34.7%) patients were found to have synchronous hepatic metastasis at the time of colorectal resection. Fifty-two (72.2%) patients underwent major hepatic resection. The operative morbidity and hospital mortality rates were 19% and 4%, respectively. The 5-year survival rate after hepatectomy was 31.9%. The median disease-free survival and median overall cumulative survival were 18.5 months and 30.8 months, respectively. On multivariate analysis, a high preoperative serum carcinoembryonic antigen level (>200 ng/mL) and tumour involvement of the resection margin at histology were the two independent risk factors that adversely affected survival outcome.

CONCLUSION

Hepatic resection for colorectal liver metastases can be performed safely, with minimal operative mortality and acceptable morbidity, and results in satisfactory survival. High preoperative serum carcinoembryonic antigen level and histological involvement of resection margin by cancer adversely affect the survival outcome.

Ten-year experience with liver transplantation at Queen Mary Hospital: retrospective study

OBJECTIVE

To report the experience with liver transplantation at the Queen Mary Hospital from 1991 to 2000.

DESIGN

Retrospective study.

SETTING

Liver transplant centre of a University teaching hospital, Hong Kong.

PATIENTS

One hundred and forty-eight patients (127 adults and 21 children) who underwent a total of 155 liver transplants using 75 cadaver grafts (full-size, 67; reduced-size, 5; split, 3) and 80 living donor grafts (left lateral segment, 15; left lobe, 6; right lobe, 59) from October 1991 to December 2000 were reviewed.

MAIN OUTCOME MEASURES

Graft and patient survival rate.

RESULTS

The most common disease indications for liver transplantation were chronic hepatitis B-related liver disease (n=74) in adults and biliary atresia (n=14) in children. Eighteen patients had hepatocellular carcinoma. Forty-eight (31%) liver transplants (three ABO-incompatible) were performed in high-urgency situations for patients requiring intensive care. The proportion of living donor liver transplants was 47.7% in adults and 73.9% in children. The overall 1-year and 5-year patient survival rates were 82% and 77%, respectively. The survival of high-risk recipients, such as those with fulminant hepatic failure (80%), chronic hepatitis B (81%), or hepatocellular carcinoma (94%), was not inferior to that of other patients.

CONCLUSION

Over the last decade, the promotion of (cadaver) organ donation through public education coupled with innovative techniques in living donor liver transplantation have enabled a liver transplantation programme to be established in Hong Kong with gratifying results.

Post-transplantation lymphoproliferative disease in Chinese: the Queen Mary Hospital experience in Hong Kong

Post-transplantation lymphoproliferative disease (PTLD) is an unique iatrogenic complication after bone marrow transplantation (BMT) and solid organ transplantation (SOTx). The pattern of EBV related lymphoma in Chinese is different from Caucasians. We surveyed the incidence, clinical and pathological spectrum of PTLD among 541 cases of allogeneic BMT, 145 cases of renal transplant, 35 cases of heart/lung transplantation and 146 cases of orthotopic liver transplantation (OLT). From 1994 to 2001, 13 consecutive cases of PTLD were diagnosed, ranging from disseminated NK cell lymphoma to localized plasmacytoma. Both donor and recipient derived PTLD was documented. Disease was often heralded by cytomegaloviral disease and antithymocyte globulin (ATG) usage. Two cases were diagnosed post-mortem, and six patients died of PTLD at a median of 3 months. Complete and partial remission was only achieved in 3 and 2 cases, respectively, despite a range of treatment (reduced immunosuppression, explantation, radiotherapy, combination chemotherapy, donor lymphocytes, autologous marrow infusion and rituximab). Most responding patients died subsequently of rejection, infection and graft versus host disease (GVHD). The incidence of PTLD is not increased in Chinese patients. However, some patients may be at increased risk, especially mismatched allogeneic BMT, parental OLT (especially involving young infants) and heavy ATG exposure.

Living donor liver transplantation without the use of blood products

We report on two patients who presented with unresectable hepatocellular carcinoma complicating hepatitis B liver cirrhosis. After evaluation, both patients were accepted for liver transplantation. Being aware of the scarce availability of cadaveric liver grafts and the long waiting time, family members volunteered to be donors for the two patients. Living donor liver transplantation using right lobe liver grafts, including the middle hepatic vein, was subsequently performed without the use of blood products in both the donors and recipients. All involved recovered uneventfully from their respective operations.

Right-lobe live donor liver transplantation improves survival of patients with acute liver failure

BACKGROUND

Right-lobe live donor liver transplantation (LDLT) is used by many liver transplant centres for treating adult patients with terminal liver disease, but its incremental benefit for the intended recipient over cadaveric liver graft transplantation has not been determined. The impact of LDLT as a proactive approach on the outcome of patients with acute liver failure was analysed.

METHODS

From January 1999 to March 2001, right-lobe LDLT was offered proactively to 50 consecutive patients with acute liver failure and their families. The outcome of those who opted for right-lobe LDLT (n = 34) was compared with that of those who did not opt for LDLT (n = 16).

RESULTS

In the group that opted for right-lobe LDLT, 16 patients eventually received a live donor right-lobe graft (14 patients survived) and three patients received a cadaveric liver graft that became available while the potential live donor was undergoing evaluation (all three patients survived). Among the group who did not opt for LDLT, only one patient received a cadaveric liver graft and survived. The former group had a higher overall survival rate (17 of 34 versus one of 16). With a proactive approach, the overall transplant rate was increased from four of 50 to 20 of 50. The morbidity rate among donors was low and none died.

CONCLUSION

Right-lobe LDLT improves the overall survival rate of patients with acute liver failure and should be considered as one of the treatment options for adult patients with acute liver failure.

Aggressive hepatocellular carcinoma complicating pregnancy after autologous bone marrow transplantation for non-Hodgkin's lymphoma

In the Asia-Pacific region, autologous and allogeneic bone marrow transplantation (BMT) in patients infected with the hepatitis B virus (HBV) may be complicated by fatal hepatic failure due to viral reactivation. Survivors may suffer from accelerated hepatitis and cirrhosis. We report the first case of hepatocellular carcinoma (HCC) after autologous BMT for mediastinal B cell lymphoma. The tumor developed rampantly during a planned pregnancy 5 years after BMT. Less than 40 cases of HCC complicating pregnancy have been reported, and outcome is invariably poor. Immunosuppression and HBV reactivation after autologous BMT, as well as immune tolerance and hormonal changes associated with pregnancy may contribute to the rapid tumor growth. Biochemical and radiological surveillance for HCC should be strengthened in HBV carriers after BMT, especially in patients with the histology of chronic liver disease, or biochemical/ virological evidence of increased HBV activity.

Efficient homolactic fermentation by Kluyveromyces lactis strains defective in pyruvate utilization and transformed with the heterologous LDH gene

A high yield of lactic acid per gram of glucose consumed and the absence of additional metabolites in the fermentation broth are two important goals of lactic acid production by microrganisms. Both purposes have been previously approached by using a Kluyveromyces lactis yeast strain lacking the single pyruvate decarboxylase gene (KlPDC1) and transformed with the heterologous lactate dehydrogenase gene (LDH). The LDH gene was placed under the control the KlPDC1 promoter, which has allowed very high levels of lactate dehydrogenase (LDH) activity, due to the absence of autoregulation by KlPdc1p. The maximal yield obtained was 0.58 g g(-1), suggesting that a large fraction of the glucose consumed was not converted into pyruvate. In a different attempt to redirect pyruvate flux toward homolactic fermentation, we used K. lactis LDH transformant strains deleted of the pyruvate dehydrogenase (PDH) E1alpha subunit gene. A great process improvement was obtained by the use of producing strains lacking both PDH and pyruvate decarboxylase activities, which showed yield levels of as high as 0.85 g g(-1) (maximum theoretical yield, 1 g g(-1)), and with high LDH activity.

Biliary complications during liver resection

Biliary complications after hepatectomy may lead to sepsis, liver failure, and death. Measures to detect biliary injury after liver transection may reduce such morbidity. The aim of this study was to investigate the trend of biliary complications after hepatectomy during the last 10 years and assess the efficacy of intraoperative measures (methylene blue test, cholangiography, fibrin glue application) for reducing postoperative biliary complications. This is a retrospective study of 616 consecutive patients who underwent hepatectomy in our institution from January 1989 to September 1998. The study period was divided into the first 5 years and the second 5 years for comparison. The hospital mortality rate was 6%. It was significantly reduced during the second 5-year period (3.3% vs. 10.6%; p = 0.0002). The postoperative biliary leakage rate was 5.5% and was also reduced during the second 5-year period (3.5% vs. 9.8%; p = 0.004). Postresection methylene blue tests were performed more frequently during the second 5-year period than the first (63% vs. 28%; p = 0.0001). The postoperative biliary leakage rate was reduced by the methylene blue test (3.6% vs. 7.3%; p < 0.05) but not by application of fibrin glue (7.2% vs. 4.2%) or postresection cholangiography. However, among the 60 patients with a positive methylene blue test, postoperative biliary leakage still occurred in 10% of them after the leakage sites were sutured. In conclusion, the biliary complication rate is decreasing. Only the postresection methylene blue test, but not postresection cholangiography or application of fibrin glue, helps to reduce the postoperative biliary leakage rate.

Endoscopic stenting for malignant biliary obstruction

Use of endoscopic stents to manage patients with malignant obstructive jaundice is a well accepted measure. Interpretation of the results of endoscopic stenting must be made with reference to the level of the bile duct obstruction. Results were generally unsatisfactory for hilar lesions, especially when the intrahepatic ducts were segregated into multiple isolated systems. After deployment, stent dysfunction due to clogging by biliary sludge is apparently an inevitable process for the conventional plastic stent. Considerable efforts had been made to prolong the stent patency by changing its physical configuration, coating the inner lumen, and the choice of material but with little success. The development of a self-expandable metal stent is a major advance, but the benefits derived from a larger stent lumen are compromised by the initial expense and the tumor ingrowth through the wires for all models available commercially. Current data failed to substantiate the value of routine preoperative biliary decompression, as there is no reduction in the morbidity and mortality rates after surgery. Although biased patient selection may have resulted in the negative observations made, repeated clinical trials should probably focus on patients with distal bile duct tumors who are preparing for a major pancreatic resection. As a definitive palliative measure, endoscopic stenting is a more cost-effective option than surgery for patients with limited life expectancy based on data regarding plastic stents. The recommendations are evolving however, as there is progressive refinement of laparoscopic surgery techniques and designs of endoscopic stents.

Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients

BACKGROUND

ERCP is the standard for detection of choledocholithiasis in patients with acute biliary pancreatitis, and, if performed early, ERCP decreases morbidity. However, there are procedure-related complications. The aim of the present prospective study was to evaluate the ability of EUS to detect choledocholithiasis in patients presenting with acute pancreatitis.

METHODS

The study group comprised 100 consecutive patients who presented with acute pancreatitis. EUS, and immediately thereafter, ERCP were performed by separate blinded examiners within 24 hours of admission. The diagnostic accuracy of EUS in identifying gallbladder stones was compared with that of transcutaneous US. The diagnostic accuracy of EUS in detecting choledocholithiasis was then compared with that of US and ERCP based on the results of endoscopic instrumentation of the bile duct after sphincterotomy.

RESULTS

EUS was more sensitive than US in detecting gallbladder stones (100% vs. 84%, p < 0.005). The sensitivities of ERCP and EUS for choledocholithiasis were both 97%, and the overall accuracies were 96% and 98%, respectively, with no significant difference. EUS detected the absence of choledocholithiasis in 65 of 66 patients (specificity = 98%). Endosonographic examination was successful in all patients, whereas ERCP was unsuccessful in 5 patients (p > 0.05). Post-endoscopic sphincterotomy bleeding developed in 4 patients; there was no EUS-related morbidity (p > 0.05).

CONCLUSION

EUS is more sensitive than US in detecting biliary stones in patients with acute pancreatitis. It is as accurate as ERCP in detecting choledocholithiasis. EUS can be used to select patients with acute pancreatitis who require therapeutic ERCP, thus avoiding diagnostic ERCP and its associated potential for complications in the majority of patients.

Stress analysis of the disc adjacent to interbody fusion in lumbar spine

After anterior interbody fusion in the lumbar spine, the accelerated degeneration of the disc adjacent to the fusion levels was clinically observed. To understand the stress distribution of the adjacent disc, this study created a finite element model of the lumbar spine from L1-L5 vertebral body. The fusion model modified from the intact model was used to simulate the anterior interbody fusion. Various loading conditions, which included flexion, extension, lateral bending, and torsion, were applied to the finite element model to study the corresponding stress distribution. From the finite element model calculation, at a lower fusion site or more fusion levels, the stress of the disc adjacent to interbody fusion increased more than upper fusion site or single fusion level under flexion, torsion and lateral bending. Larger stress increase was estimated at the upper disc adjacent to interbody fusion than the lower disc adjacent to interbody fusion. In stress distribution, the upper disc adjacent to interbody fusion had a little alteration under torsion.

Management of spontaneous rupture of hepatocellular carcinoma: single-center experience

PURPOSE

To report the management of patients with spontaneous rupture of hepatocellular carcinoma (HCC) in a single center over a 10-year period and to evaluate a two-stage therapeutic approach.

PATIENTS AND METHODS

A retrospective study was performed on all 1,716 patients with HCC who presented from 1989 to 1998. The two-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, hemostasis by transarterial embolization (TAE) or surgical means, followed by second-stage hepatic resection or transarterial oily chemoembolization (TOCE). Results of definitive treatment were compared with patients with no history of rupture during the same study period.

RESULTS

During the study period, 154 patients (9%) had spontaneous HCC rupture. Initial intervention to control bleeding included TAE in 42 patients, surgical hemostasis in 35 patients, and conservative management only in 53 patients. The 30-day mortality rate was 38%. Independent factors on presentation affecting 30-day mortality were shock on admission, hemoglobin, serum total bilirubin, and known diagnosis of inoperable tumor. After initial stabilization and clinical evaluation, 33 patients underwent hepatic resection and 30 patients received TOCE. Median survival of the hepatectomy patients was 25.7 months; that of the TOCE patients was 9.7 months. Compared with patients with no rupture, survival after hepatectomy (25.7 months v 49.2 months, P =.003) was inferior but still substantially long, whereas survival after TOCE was comparable (9.7 months v 8.7 months, P =.904).

CONCLUSION

Early mortality of spontaneous rupture of HCC was dependent on prerupture disease state, liver function, and severity of bleeding. Although it was a catastrophic presentation, prolonged survival could be achieved in selected patients with second-stage hepatic resection or TOCE.

[Clinical observation on treatment of non-small cell lung cancer with Chinese herbal medicine combined with bronchial arterial infusion chemotherapy]

OBJECTIVE

To explore the effect of treatment for non-small cell lung cancer (NSCLC) with Chinese herbal medicine (CHM) combined with bronchial arterial infusion chemotherapy (BAIC).

METHODS

Patients with moderate or advanced NSCLC were randomly divided into two groups, the 39 patients in the treated group treated with CHM plus BAIC therapy and 37 in the control group treated with BAIC alone. The short-term therapeutic effect, long-term survival rate, changes of clinical principal symptoms, quality of life and peripheral blood pictures in the two groups were observed and compared.

RESULTS

After treatment the rate of CR + PR + NC in the treated and the control group was 92.31% and 70.27% respectively, the inter-group comparison showed a significant difference (P < 0.05). The 0.5-, 1- and 2-year survival rate in the treated group was 79.49%, 56.41% and 51.28% respectively and in the control group, 72.97%, 51.35% and 24.32% respectively. The 2-year survival rate in the former was better than that in the latter (P < 0.05). Moreover, the improvement of clinical symptoms, Karnofsky scoring, body weight and peripheral blood picture in the treated group was superior to that in the control group.

CONCLUSION

Therapeutic effect of BAIC could be enhanced by combining it with CHM.

Protein aggregation after focal brain ischemia and reperfusion

Two hours of transient focal brain ischemia causes acute neuronal death in the striatal core region and a somewhat more delayed type of neuronal death in neocortex. The objective of the current study was to investigate protein aggregation and neuronal death after focal brain ischemia in rats. Brain ischemia was induced by 2 hours of middle cerebral artery occlusion. Protein aggregation was analyzed by electron microscopy, laser-scanning confocal microscopy, and Western blotting. Two hours of focal brain ischemia induced protein aggregation in ischemic neocortical neurons at 1 hour of reperfusion, and protein aggregation persisted until neuronal death at 24 hours of reperfusion. Protein aggregates were found in the neuronal soma, dendrites, and axons, and they were associated with intracellular membranous structures during the postischemic phase. High-resolution confocal microscopy showed that clumped protein aggregates surrounding nuclei and along dendrites were formed after brain ischemia. On Western blots, ubiquitinated proteins (ubi-proteins) were dramatically increased in neocortical tissues in the postischemic phase. The ubi-proteins were Triton-insoluble, indicating that they might be irreversibly aggregated. The formation of ubi-protein aggregates after ischemia correlated well with the observed decrease in free ubiquitin and neuronal death. The authors concluded that proteins are severely damaged and aggregated in neurons after focal ischemia. The authors propose that protein damage or aggregation may contribute to ischemic neuronal death.

Improving survival results after resection of hepatocellular carcinoma: a prospective study of 377 patients over 10 years

OBJECTIVE

To investigate whether the survival results after resection of hepatocellular carcinoma (HCC) have improved within the past decade by an analysis of a prospective cohort of patients over a 10-year period.

SUMMARY BACKGROUND DATA

The surgical death rate after resection of HCC has greatly improved in recent years, but the long-term prognosis remains unsatisfactory. It remains unknown whether the survival results after resection of HCC have improved within the past decade.

METHODS

The clinicopathologic and follow-up data of 377 patients who underwent curative resection of HCC between January 1989 and January 1999 were prospectively collected. These patients were categorized according to two time periods: before 1994 (group 1, n = 136) and after 1994 (group 2, n = 241). The two groups were compared for clinicopathologic data and survival results. The prognostic factors for disease-free survival were further analyzed to identify the factors that might have led to improved survival outcomes.

RESULTS

The overall and disease-free survival results were significantly better in group 2 compared with group 1. Patients in group 2 had significantly higher proportions of subclinical presentation, small tumors, and tumors of early pTNM stage. There were also significantly lower frequencies of histologic margin involvement, less intraoperative blood loss, and a lower transfusion rate in group 2. By multivariate analysis, early pTNM stage, subclinical HCC, and no perioperative transfusion were independent favorable prognostic factors for disease-free survival.

CONCLUSIONS

Significant improvement of overall and disease-free survival results after resection of HCC has been achieved within the past decade as a result of advances in the diagnosis and surgical management of HCC. Earlier diagnosis of HCC by better imaging modalities, increased detection of subclinical HCC by screening of high-risk patients, and a reduced perioperative transfusion rate were identified as the major contributory factors for the improved outcomes.

Clinicopathologic features of long-term survivors and disease-free survivors after resection of hepatocellular carcinoma: a study of a prospective cohort

PURPOSE

This study aims to clarify the clinicopathologic features of long-term survivors and disease-free survivors after resection of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

The clinicopathologic features of 5-year survivors and disease-free survivors were elucidated in a cohort of 230 patients prospectively observed for > 5 years (64 to 192 months) after curative resection of HCC.

RESULTS

The incidence of 5-year overall and disease-free survivors were 37% (85 of 230) and 20% (45 of 230), respectively. Clinicopathologic features associated with 5-year survivors included female sex (P =.024), preoperative serum albumin > or= 40 g/L (P =.033), AST < 50 u/L (P =.001), tumor < 5 cm (P =.001), solitary tumor (P =.035), encapsulated tumor (P =.021), no venous invasion (P =.001), no microsatellite nodule (P =.001), and early pathologic tumor-node-metastasis (pTNM) stage (I or II, P <.001). Features favoring 5-year disease-free survivors were preoperative serum AST < 50 u/L (P =.007), tumor < 5 cm (P =.005), encapsulated tumor (P =.007), no venous invasion (P <.001), no microsatellite nodule (P =.001), and early pTNM stage (I or II, P <.001). By multivariate analysis, pTNM stage was the only significant predictive factor for both overall and disease-free survival.

CONCLUSION

This study shows that long-term disease-free survival > 5 years after resection of HCC can be achieved in patients with favorable tumor characteristics. Early pTNM stage was the most reliable predictor of both long-term overall and disease-free survivors.

The management of gingival and esthetic problems: a clinical case

The coordinated management of gingival and esthetic problems is important in dentistry. In addition, the most difficult variable to control in the treatment of anterior esthetics is the soft tissue. This article discusses the relationship between the surrounding soft tissue and the emerging crown form. The authors introduce a soft-tissue index model technique that will help the technician in fabricating the final crown with a form similar to the provisional. In this case report, provisional crowns are fabricated with enough tissue support to provide for an optimal crown-gingival interface. The present case demonstrates how to manage the gingival margin in the provisional stage and how to transfer the provisional and soft tissue to the laboratory model.