Subsequent pregnancy and long-term safety after breast cancer: a retrospective analysis of Korean health insurance data

Purpose@#Long-term safety of pregnancy after breast cancer (BC) remains controversial, especially with respect to BC biological subtypes. @*Methods@#We analyzed a population-based retrospective cohort with BC from 2002 to 2017. Patient-level 1:1 matching was performed between pregnant and nonpregnant women. The study population was categorized into 6 biological subtypes based on the combination of prescribed therapies. Subanalyses were performed considering the time to pregnancy after BC diagnosis, systemic therapy, and pregnancy outcomes. @*Results@#We identified 544 matched women with BC, who were assigned to the pregnant (cases, n = 272) or nonpregnant group (controls, n = 272) of similar characteristics, adjusted for guaranteed bias. These patients were followed up for 10 years, or disease and mortality occurrence after the diagnosis of BC. Survival estimates were calculated. The actuarial 10-year overall survival (OS) rates were 97.4% and 91.9% for pregnant and nonpregnant patients, respectively. The pregnant group showed significantly better OS (adjusted hazard ratio [aHR], 0.29; 95% confidence interval [CI], 0.12–0.68; P = 0.005) and did not have a significantly inferior disease-free survival (aHR, 1.10; 95% CI, 0.61–1.99; P = 0.760). @*Conclusion@#Consistent outcomes were observed in every subgroup analysis. Our observational data provides reassuring evidence on the long-term safety of pregnancy in young patients with BC regardless of the BC biological subtype.

An analysis of the outcomes of totally implantable access port implantation performed by surgical residents

Purpose@#This study aimed to investigate the clinical outcomes after totally implantable access port (TIAP) implantation performed by general surgery residents in patients with colorectal cancer. @*Methods@#A total of 291 consecutive patients who underwent TIAP implantations were evaluated. The patients were divided into threegroups: second-, third-, and fourth-grade residents. @*Results@#The mean follow-up was 22.1 months (range, 1–87 months). The total times of operation, puncture, and cannulation decreased as the resident grade increased (P<0.001). Early complications significantly decreased with higher resident grades (P=0.039). The non-use of ultrasonography and non-use of C-arm were identified as independent risk factors for complications. Resident grades between second and third (P=0.005) and between second and fourth (P=0.041) were identified as independent risk factors for optimal tip position. @*Conclusion@#TIAP implantation can be safely and effectively performed by residents. Low-grade residents were associated with early complications.

An analysis of the outcomes of totally implantable access port implantation performed by surgical residents

Purpose@#This study aimed to investigate the clinical outcomes after totally implantable access port (TIAP) implantation performed by general surgery residents in patients with colorectal cancer. @*Methods@#A total of 291 consecutive patients who underwent TIAP implantations were evaluated. The patients were divided into threegroups: second-, third-, and fourth-grade residents. @*Results@#The mean follow-up was 22.1 months (range, 1–87 months). The total times of operation, puncture, and cannulation decreased as the resident grade increased (P<0.001). Early complications significantly decreased with higher resident grades (P=0.039). The non-use of ultrasonography and non-use of C-arm were identified as independent risk factors for complications. Resident grades between second and third (P=0.005) and between second and fourth (P=0.041) were identified as independent risk factors for optimal tip position. @*Conclusion@#TIAP implantation can be safely and effectively performed by residents. Low-grade residents were associated with early complications.

Poorly differentiated thyroid carcinoma: An institutional experience

Purpose@#The incidence of poorly differentiated thyroid carcinoma (PDTC) is extremely low among thyroid cancers and there is no standardized treatment guideline for it. In this study, we have analyzed PDTC patients and reviewed their clinicopathological features. @*Methods@#Data of PDTC patients from our institution are collected through the electronic medical database. We analyzed them by several parameters such as basic demographics, presenting symptom, preoperative cytology results, associated pathology, surgical results, surgery type, and distant metastasis. @*Results@#We collected 23 cases in our institution. Apart from two patients who were transferred to another hospital upon diagnosis, all 21 operated cases are analyzed. The parameters we studied were age, sex, presenting symptoms, distant metastasis and pathological features such as tumor size, associated pathology, predominant pattern and so on. We also provided descriptive analyses according to the type of presentation and treatment; patients with distant metastasis, juvenile cancer, and concurrent hyperthyroidism. Furthermore, we provided different cases in which the initial surgical plans differed. @*Conclusion@#We present 21 cases of PDTC patients and clarify their clinicopathological features. Despite some limitations, this study may shed light for future research regarding treatment of PDTC patients.

A single-use negative-pressure wound therapy device can reduce mastectomy skin flap necrosis in direct-to-implant breast reconstruction

Background@#Mastectomy flap necrosis is a common and challenging complication of direct-to-implant (DTI) breast reconstruction. The PICO single-use negative-pressure wound therapy device may reduce the complications associated with skin flap necrosis. We evaluated the relationship between PICO use and the incidence of mild, moderate, and severe skin flap necrosis in patients at high risk of necrosis. @*Methods@#Using medical records from January 2015 to March 2019, we retrospectively analyzed patients who underwent DTI breast reconstruction after oncological breast surgery at a single institution and identified those at high risk for skin flap necrosis. During this period, PICO was used selectively for patients deemed to be at particularly high risk. Patient demographics, operative characteristics, and the degree of skin flap necrosis were compared according to whether PICO was used. @*Results@#Of 117 patients (122 breasts), 45 were deemed to be at high risk of skin flap necrosis. PICO was applied to 38 of these breasts, and seven breasts received a conventional dressing. Skin flap necrosis occurred in 30 breasts (24 in the PICO group [63.2%] vs. 6 in the no-PICO group [85.7%]). Significantly fewer cases of severe skin flap necrosis were observed in the PICO group (2/38 [5.3%]) than in the no-PICO group (3/7 [42.9%]) (P=0.004). There were no significant between-group differences in outcomes measured using BREAST-Q scores. @*Conclusions@#Use of a single-use negative-pressure wound therapy device can reduce the risk of severe skin flap necrosis in patients at high risk of skin flap complications associated with DTI breast reconstruction.

A comparative study of Watson for Oncology and tumor boards in breast cancer treatment

PURPOSE: Watson for Oncology (WFO) is a computing system for considering treatment option with patients. The aim of this study is to determine the concordance rate of WFO and tumor board in treatment options of breast cancer.METHODS: One hundred and seventy breast cancer patients who were treated at Gachon University Gil Medical Center (GMC) from December 2016 to March 2018 were investigated. “Concordance” is defined that treatment provided by GMC tumor board and WFO-provided treatments (Recommend or For Consideration) were coincide. “Discordance” is defined that treatment provided by GMC tumor board and WFO-provided treatments (Not Recommended or Not Available) were coincide.RESULTS: In chemotherapy, of the total 170 patients, 23 patients were excluded, and the concordance rate was compared in 147 patients. Concordance rate was 93% (136/147). In the 11 patients who were discordant, seven patients complied with the treatment proposed by GMC tumor board due to insurance problems and age, and two patients did not follow the treatment proposed by WFO due to pregnancy and patient's choice, and one patient chose a treatment determined by WFO, last one patient was not treated with chemotherapy because it was not considered to be clinically necessary. In radiotherapy, the overall agreement rate was as high as 99% (147/148).CONCLUSION: Through this study, we found that many of the treatment proposals provided by WFO are highly reliable. Although the overall agreement is high in the radiotherapy regimen, the indication for radiotherapy by WFO is more aggressive and hypofractionated high dose intensity radiotherapy is growing trend by WFO.

Stem cell analysis with intraductally treated mammary epithelial cells

PURPOSE: The activity of mammary stem cells (MaSCs) is essential to mammary growth, differentiation and regeneration in cycles of pregnancy, lactation, and involution. The capability to recruit the mammary gland through the cycles is attributed to stem cells. It was shown that the intraductal (i.duc) injection of pegylated liposomal doxorubicin (PLD) to multiparous FVB/N mice was associated with a significantly reduced outgrowth potential of mammary gland cells. We have explored i.duc PLD's effect on stem cell number and function in mouse mammary gland and aldehyde dehydrogenase (ALDH)'s availability as a mouse MaSC marker.METHODS: The total mammary epithelium was purified from 6 to 8-month-old FVB/N control and i.duc PLD-administered mice treated twice and analyzed by flow cytometry and limiting dilution cleared mammary fat pad transplants.RESULTS: There was no significant difference in the proportions of stem cell-enriched population (CD49(fhigh)CD24(med)) between control and i.duc PLD-treated groups. However, we found a significant reduction in the outgrowth potential of CD49(fhigh)CD24(med) and CD49(fhigh)CD24(med)ALDH(+) cells from i.duc PLD-treated mammary glands. We discovered that adding ALDH to CD49(fhigh)CD24(med) had the possibility of better marker selection for MaSC of mice.CONCLUSION: We present i.duc administration of PLD to reduce MaSC function, but not the number; and ALDH activity may add further selection of MaSCs to CD49f CD24 in mouse mammary glands. Screening of chemotherapeutic drugs or other natural products by this method of stem cell analysis may provide safe i.duc treatment in breast cancer.

A comparative study of the clinical characteristics of breast cancer patients less than 35 years old and older patients

PURPOSE: In Korea, the incidence of breast cancer peaks in the fifth decade, which is younger than that observed in the Western world. We conducted this study to compare the clinical characteristics and prognostic factors of breast cancer in women < 35 and ≥35 years old.METHODS: The medical records of 969 patients treated for breast cancer at the Gil Medical Center from 2008 through 2012 were reviewed. Tumor characteristics, surgical methods, and adjuvant therapies were compared in two groups.RESULTS: Number of childbirths, family history, the proportion of postmenopausal women were lower among those aged < 35 years. However, tumor size, number of metastatic lymph nodes, and surgical procedures were similar in two groups. The rate of triple negative status in younger patients was higher than in older patients. Adjuvant chemotherapy was effective in patients positive for hormone receptors and no lymph nodal invasion, and it was effective in patients negative for hormone receptors and lymph nodal invasion in patients aged >35 years old. Postoperative radiotherapy was statistically effective in patients aged < 35 and ≥35 years old that underwent breast-conserving surgery. Pregnancy were significantly associated with survival in younger patients. While lymph node stage, presence of progesterone receptor, and triple negative status were significantly associated with survival on older patients.CONCLUSION: The prognostic factors of breast cancer in patients younger than 35 years old were pregnancy. Triple negative status rate was higher in younger patients than in older patients. Adjuvant therapy had similar effects in patients aged < 35 or ≥35 years old.

Clinicopathological markers associated with recurrence in ductal carcinoma in situ of breast by age group

PURPOSE: In the present study, factors related to the recurrence of breast ductal carcinoma in situ (DCIS) in Korean patients were identified, and the prognostic factors for each age group were explored.METHODS: The subjects were 226 patients who were diagnosed with DCIS by histopathologic examination, and the effect of representative prognostic factors that are known already, including estrogen receptor (ER), progesterone receptor (PR) and the human epidermal growth factor receptor 2 (HER2) status, Ki-67 levels, and adjuvant therapy on the recurrence of DCIS was analyzed by using the Cox proportional hazard model.RESULTS: Among the 226 subjects, 11 patients underwent the recurrence of breast cancer. The average follow-up period was 52.7±23.5 months. The average age of the subjects was 50.6±9.3 years. Among the DCIS patients, the recurrence of breast cancer was significantly higher in the ER negative patients and those who have a Ki-67 level over 20%. However, the PR and HER2 status did not significantly affect breast cancer recurrence. The result also showed that only ER negative was a significant factor before the age of 50 years and that only the Ki-67 level over 20% was a significant factor to the patients 50 years of age or older.CONCLUSION: DCIS patients should be appropriately treated and managed depending on their age and clinicopathological factors to prevent the recurrence of DCIS.

Comparison of Outcomes of Hybrid and Surgical Correction for De Novo Arteriovenous Graft Occlusion

PURPOSE: This study aimed to compare surgical revisions and balloon angioplasty after surgical thrombectomy on thrombosed dialysis access as a first event. MATERIALS AND METHODS: Records of patients undergoing creation of arteriovenous grafts (AVGs) at the Gachon University Gil Medical Center between March 2008 and February 2016 were reviewed. Among them, patients who underwent treatment on first-time thrombotic occlusion after AVG creation were identified. Outcomes were primary, primary-assisted, and secondary patency. The patency was generated using the Kaplan-Meier method, and patency rates were compared by log-rank test. RESULTS: A total of 59 de novo interventions (n=26, hybrid interventions; n=33, surgical revisions) for occlusive AVGs were identified. The estimated 1-year primary patency rates were 47% and 30% in the surgery and hybrid groups, respectively. The estimated primary patency rates were not different between the two groups (log-rank test, P=0.73). The Kaplan-Meier estimates of 6 and 12 months for primary-assisted patency rates were 68% and 57% in the surgery group and 56% and 56% in the hybrid group. The Kaplan-Meier estimates of 12 and 24 months secondary patency rates were 90% and 71% in the surgery group and 79% and 62% in the hybrid group. There were no differences in the estimated primary-assisted and secondary patency rates between the two groups. CONCLUSION: Our results showed no significant difference between the two groups in terms of primary patency (P=0.73), primary-assisted patency (P=0.85), and secondary patency (P=0.78). However, percutaneous transluminal angioplasty can give more therapeutic options for both surgeons and patients.

Retrospective Analysis of Idiopathic Granulomatous Mastitis: Its Diagnosis and Treatment

PURPOSE: Idiopathic granulomatous mastitis (IGM) is a rare disease characterized by noncaseating granulomatous inflammation of unknown origin. Because its clinical features are similar to those of other type of mastitis or breast cancer, accurate diagnosis and adequate treatment are essential to ensuring a short symptom duration and improving the quality of life. METHODS: The clinical, radiologic, pathophysiologic, and treatment data for 43 patients diagnosed with IGM at the Breast Cancer Center of Gachon University Gil Medical Center between 2005 and 2016 were retrospectively reviewed. RESULTS: Forty-one patients (95.34%) were of childbearing age, seven (16.27%) had a history of lactation, and five (11.62%) had a history of oral contraceptive use. In terms of radiologic findings, 30 patients (69.77%) were diagnosed with Breast Imaging-Reporting and Data System category ≥4A lesions. Corticosteroid therapy was administered to 36 patients (83.72%); overall, 18 patients (41.86%) did not require surgery and 25 patients (58.13%) underwent partial or total mastectomy. Twelve patients (27.90%) developed recurrence. CONCLUSION: IGM is a benign disease that can be misdiagnosed as breast cancer because of its similar clinical and radiologic findings. Proper diagnosis and treatment can be difficult, but delays may lead to prolonged pain and cosmetic and socioeconomic problems. Efforts should be aimed at establishing the cause of IGM and developing efficient protocols for its diagnosis and treatment.

Prognostically Distinctive Subgroup in Pathologic N3 Breast Cancer / 한국유방암학회지

PURPOSE: The aim of this retrospective study was to investigate whether there are prognostically different subgroups among patients with pathologic N3 (pN3) breast cancer. METHODS: The records of 220 patients who underwent surgery for pN3 breast cancer from January 2006 to September 2012 were reviewed. All patients received adjuvant therapy according to standard protocols. The primary outcome was disease-free survival (DFS). RESULTS: Patients were followed for a median time of 68.3 months after their primary surgery (range, 10-122 months), during which time 75 patients (34.1%) had developed disease recurrence and 48 patients (21.8%) had died. The DFS and overall survival were 67.8% and 86.1%, respectively, at 5 years. Multiple logistic regression analysis showed that young age (3.0) (p=0.020), high nodal ratio (number of metastatic lymph nodes divided by number of removed nodes) (>0.65) (p=0.062), and molecular phenotype (p=0.012) were significantly associated with tumor recurrence. Tumor biological subtype was the most significant predictor of recurrence. The 5-year DFS rates in patients with hormone receptor (HR) positive and human epidermal growth factor receptor 2 (HER2) negative, HR+HER2+, HR-HER2+, and triple negative subtypes were 82%, 63%, 58%, and 37%, respectively. CONCLUSION: Clinical outcomes of patients with extensive nodal metastasis were heterogeneous in terms of prognosis. Tumor biological subtype was the most important prognostic factor for pN3 disease. The prognosis of patients with HR+HER2- subtype in pN3 breast cancer was similar to that of patients with stage II breast cancer.

Ki-67 as a Predictor of Response to Neoadjuvant Chemotherapy in Breast Cancer Patients / 한국유방암학회지

PURPOSE: The objectives of this study were to assess the potential value of Ki-67 in predicting response to neoadjuvant chemotherapy in breast cancer patients and to suggest a reasonable cutoff value for classifying Ki-67 expression. METHODS: This study included 74 breast cancer patients who underwent surgery after anthracycline-based neoadjuvant chemotherapy between 2007 and 2012. We analyzed the clinical and immunohistochemical characteristics using core biopsy specimens obtained before neoadjuvant chemotherapy to determine their correlations with the response to chemotherapy. RESULTS: A clinical complete response was observed in 6 patients (8.1%); a clinical partial response, in 44 patients (59.5%); and clinical stable disease, in 24 patients (32.4%). A pathologic complete response (pCR) was observed in 10 patients (13.5%). In univariate analysis, estrogen receptor (ER) negativity (p=0.031), human epidermal growth factor receptor 2 (HER2) positivity (p=0.040), and high Ki-67 expression (p=0.036) were predictive factors for a pCR. In multivariate analysis, Ki-67 was the only independent predictor of a pCR (p=0.049). The analysis of Ki-67 values revealed that 25% was a reasonable cutoff value for predicting the response to chemotherapy. In subgroup analysis, a higher Ki-67 value (> or =25%) was a significant predictive factor for the response to neoadjuvant chemotherapy, especially in ER-negative and HER2-positive breast cancer patients. CONCLUSION: Ki-67 expression in breast cancer tissue may be an effective factor for predicting the response to neoadjuvant chemotherapy. We suggest that a 25% level of Ki-67 expression is a reasonable cutoff value for predicting a response to chemotherapy. Moreover, Ki-67 is a useful predictive factor for pCR, especially in patients with ER-negative and HER2-positive breast cancer.

Lamellar Body Counts in Fetal Rabbits' Experimental Diaphragmatic Hernia and Tracheal Ligation

Experimental tracheal ligation (TL) has been shown to reverse the pulmonary hypoplasia associated with congenital diaphragmatic hernia (CDH) and to normalize gas exchange. The purpose of this study was to determine whether the TL would correct the surfactant deficiency present in the fetal rabbit model of CDH by using lamellar body count. Lamellar bodies are synthesized and secreted by the type II pneumocytes of fetal lung. The phospholipids present in these bodies constitute the major component of pulmonary surfactant. Twenty-one pregnant New Zealand rabbits underwent hysterotomy and fetal surgery on gestational day 24. Two fetuses of each pregnant rabbit were operated. In the fetus of one end of bicornuate uterus, left DH was created by excision of fetal diaphragm through open thoracotomy (DH Group). In the fetus of the other end of bicornuate uterus, left DH and TL were created (TL Group). The fetuses were delivered by Cesarean section on gestational day 31. Fourteen in control group, 12 in the DH group and 13 in TL group were born alive. En bloc excision of lungs, bronchi and trachea was done in all newborn rabbits. A five Fr catheter was inserted through trachea and repeated irrigations with 10 cc normal saline were done. The irrigated fluid was centrifuged at 280 xg for 5 minutes and the lamellar bodies were counted with the upper level fluid in platelet channel of electronic cell counter. The average lamellar body counts were 37.1 +/- 14.2 x 10(3)/microL in control group, 11.5 +/- 4.4 x 10(3)/microL in DH group, and 6.5+/- 0.9 x 10(3)/microL in TL group. Lamellar body count in DH group was lower than in control group and did not increase after TL. This study shows TL has no therapeutic effect on decreased surfactant level of CDH and the pregnant rabbit is appropriate for the animal model of CDH.

Induced pluripotent stem cells and personalized medicine: current progress and future perspectives / 대한해부학회지

Generation of induced pluripotent stem cells (iPSCs) has revolutionized the field of regenerative medicine by providing researchers with a unique tool to derive disease-specific stem cells for study. iPSCs can self-renew and can differentiate into many cell types, offering a potentially unlimited source of cells for targeted differentiation into somatic effector cells. Hence, iPSCs are likely to be invaluable for therapeutic applications and disease-related research. In this review, we summarize the recent progress of iPSC generation that has been made with an emphasis on both basic and clinical applications including disease modeling, drug toxicity screening/drug discovery and cell replacement therapy.

Clinical Study of Inguinal Hernia in Pediatric Patients

This study is a retrospective analysis of 1244 cases of the inguinal hernia in children under the age of fifteen years who were operated at the department of pediatric surgery, Inje University Busan Paik Hospital from March, 1997 to February, 2007. The ratio of male to female was 3.6:1. The type of hernia was indirect in all of the cases. The hernia was on the right side in 656 cases (53.9 %), left side in 467 cases (37.5 %), and bilateral in 121 cases (9.7 %). The hernia presented most frequently in infants under age 12 months; 364 cases (29.2 %). Fifty-nine cases (21.7 %) were in female and 305 cases (31.3 %) in male. There were 428 cases (33.6 %) in 1-3 years age group, 295 cases (23.7 %) in 4-6 years, 112 cases (9.0 %) in 7-9 years, 39 cases (3.1 %) in 10-12 years and 16 (1.2 %) in 13-15 years. The content of hernia sac was small bowel (59 %), omentum (31 %) in males and the ovary and tube (54 %) and small bowel (26 %) in female. The incidence of combined operation at the time was 3.2 %, and consisting of orchiopexy (67.5 %), frenulotomy (12.5 %), appendectomy (10 %), circumcision (5 %), and fistulotomy (5%). The incidence of combined disease was 2.8 % and consisting of undescended testis, Hirschsprung's disease, idiopathic hypertrophic pyloric stenosis, imperforate anus, and congenital heart disease. After unilateral inguinal hernia repairs, contralateral hernias developed in 34 patients. The laterality of the primary site of hernias were left in 19 cases (55.8 %), and right 15 cases (44.1 %). The 936 cases (75.2 %) were operated under general anesthesia; Mask bagging 663 cases (53.2 %), endotracheal intubation 257 cases (20.6 %), and laryngeal mask 16 cases (1.2 %). The remainder 308 cases (24.7 %) were operated under regional caudal anesthesia.

A Case Report of Accessory Cervical Thymus

Accessory cervical thymic tissue has been rarely reported. However, it should be included in the differential diagnosis of neck masses in children, along with branchial anomalies, lymph nodes and other tumors. This lesion occurs along the descending line of the thymus between the angle of mandible and superior mediastinum. A 2-month-old infant presented with an asymptomatic left sided neck mass. MRI revealed a well defined homogeneous mass in the deep lobe of left parotid gland. At operation, an easily identified soft tissue mass was found in the left submandibular area, measuring 3 x 1.5 cm. It was completely excised. Microscopic examination revealed normal thymic tissue.

Breast Cancer in Three Women Associated with Von Recklinghausen's Disease

Type 1 neurofibromatosis (NF1), also known as von Reck-linghausen's disease, is a common autosomal dominant neurocutaneous disorder. Persons with NF1 have an increased risk of malignancy compared with the general population, but there are few reports of neurofibromatosis combined with breast cancer. We report on three cases of breast cancer combined with NF1.

A Case Report of Chylous Mesenteric Cyst

Chylous mesenteric cyst is a rare variant of mesenteric cystic lesions. Pathologically there is lack of communication of the main lymphatic vessels, resulting in cystic mass formation. Clinical presentation is diverse and can range from an incidentally apparent abdominal mass to symptoms of an acute abdomen. A 5-year-old girl presented with abdominal distension without pain. CT scan showed a huge and thin-walled cystic mass without solid portion. Laparotomy showed a 20 x 18 cm sized huge mesenteric cyst containing chylous fluid. Pathological diagnosis was cystic lymphangioma.

Blunt Abdominal Trauma in Children

Trauma is one of the leading causes of death in children. Abdominal trauma is about 10% of all pediatric trauma. This study describes the sex and age distribution, injury mechanism, site of intraabdominal injury, management and mortality of children aged 16 years or less who suffered abdominal trauma. The hospital records of 63 patients treated for abdominal injury between March 1997 and February 2007 at the department of surgery, Inje University Pusan Paik Hospital, were analyzed retrospectively. The peak age of incidence was between 2 and 10 years (78%) and this report showed male predominance(2.7:1). The most common mechanism of blunt abdominal trauma was pedestrian traffic accident (49%). The most common injured organ was liver. More than Grade IV injury of liver and spleen comprised of 4(12%) and 5(24%), respectively. Fourteen cases (22%) had multiple organ injuries. Forty nine cases (78%) were managed nonoperatively. Three patients (4.8%) died, who had Grade IV liver injury, Grade IV spleen injury, and liver and spleen injury with combined inferior vena cava injury, respectively. All of the three mortality cases had operative management. In conclusion, the liver or spleen injury which was more than Grade 4 might lead to mortality in spite of operation, although many cases could be improved by nonoperative management.