Effect of diarrhoea on Tacrolimus trough level in a post liver transplant patient.

Tacrolimus, which bonds to an immunophilin, FK506 binding protein (FKBP) has emerged as one of the most widely used immunosuppressant post solid organ transplantation. It offers excellent patient survival rates post-transplantation and a lesser number of acute rejections as compared to cyclosporine. Tacrolimus has a narrow therapeutic window with overexposure leading to acute and chronic forms of nephrotoxicity. Remarkably few data have been published on the overexposure to tacrolimus following mild diarrhoea in post-transplant patients who received treatment with tacrolimus. We observed a post-liver transplant patient with increased trough level of tacrolimus during severe diarrhoea with no complications following a timely adjustment on the dose of tacrolimus.

Cholangiocarcinoma: a 10-year experience of a single tertiary centre in the multi ethnicity-Malaysia.

Cholangiocarcinoma (CCA) is a rare biliary tract epithelial malignancy. We described the clinical features of CCA patients in our institution. A 10-year retrospective study of patients with cholangiocarcinoma in University Malaya Medical Centre was conducted. Clinical data and outcomes in relation to the three anatomical groups of CCA were collected and analysed. Of the 69 patients that were included 55% were male. Mean age was 61 years. Twelve (17%) had intrahepatic, 38 (55%) perihilar and 19 (28%) distal tumour. Mean age (p=0.043), median duration of symptoms (p=0.011), jaundice (p<0.001), total bilirubin level (p=0.003), INR (p=0.005) and mean tumour size (p=0.048) were significantly related to the site of tumour. Only 12 patients had curative resection with seven R0 resections. Cholangiocarcinoma is increasingly diagnosed in our population. Despite that, the diagnosis is still often late. Age, jaundice and tumour size may predict anatomical location of CCA.

Predictors of axillary lymph node metastases in breast cancer: is there a role for minimal axillary surgery?

INTRODUCTION: Axillary nodal status is one of the most important prognostic factors in breast cancer. In the present study we used it to determine the predictors of axillary lymph node metastases in breast cancer and to determine if there is a group of patients in whom minimal axillary surgery is indicated. METHODS: This article reports a retrospective study of 953 patients with T1 and T2 invasive breast carcinomas seen in the University Malaya Medical Centre between January 2001 and December 2005, where axillary dissection was done. RESULTS: Of the 953 patients, 283 (29.7%) had breast-conserving surgery, and the rest had mastectomies. In this series, 463 patients (48.6%) were younger than 50 years of age; 365 patients (38.3%) had lymph node involvement. The Malays tend to have more axillary node metastases (45.1%) than the Chinese (36.9%); however, there was no significant relationship between age and race and lymph node involvement. Some 23.9% of grade 1 cancers were node positive, compared to 42.9% of grade 2/3 cancers. Tumor size ranged from 0.2 cm to 5 cm; 55.5% of tumors were T2 (>2-5 cm). There were only 13 (1.4%) T1a tumors (>0.1-0.5 cm). Node involvement was documented in 7.7% of T1a tumors, 12.3% of T1b tumors (>0.5-1 cm), 29.2% of T1c tumors, and 48.2% of T2 tumors. In patients who had no lymphovascular invasion (LVI), 24.4% had axillary node metastases, compared with 52.2% of patients where LVI was reported. On univariate analysis, our study found that tumor diameter>2 cm, presence of lymphovascular invasion, and higher tumor grade (2&3) were factors significantly associated with a higher risk of nodal metastases. On multivariate analysis, however, only lymphovascular invasion and tumor size were independent predictors based on the logistic regression. CONCLUSIONS: In T1 tumors, axillary lymph node dissection will overtreat almost 75% of cases; therefore a sentinel lymph node biopsy is justified in these tumors. Sentinel lymph node biopsy has been shown to reduce the complications of formal axillary dissection, such as shoulder stiffness, pain, and lymphedema. In patients with T2 tumors, where almost 45% have lymph node involvement, sentinel node biopsy may not be cost effective.

Does the pre-operative value of serum CA15-3 correlate with survival in breast cancer?

INTRODUCTION: CA15-3 is a well-known tumour marker for breast cancer. Currently it is not recommended for screening or diagnosis of breast cancer and its main application is in monitoring response to treatment in women with metastatic breast cancer. The aim of this study was to correlate serum CA15-3 at presentation with the stage of disease and overall survival in women with breast cancer in the University Malaya Medical Centre. METHODS: This is a retrospective study of 437 women who had CA15-3 levels determined at initial presentation of breast cancer to UMMC between Jan 1999 and Oct 2003. RESULTS: Of those patients who were adequately staged, CA15-3 was found to be elevated (defined as >51 U/ml) in 0% of Stage 1, 7.9% of Stage 2, 36.7% of Stage 3 and 68.6% of Stage 4 cases. In a subset of 331 patients with survival data, patients with normal CA15-3 had a 85% five year overall survival rate compared to 38% in their counterparts with elevation of the tumor marker. The level of elevation was also significantly related to survival; patients with values more than 200 U/ml exhibited only a 28% five year survival. The association of elevated CA15-3 at initial presentation with poor outcome was maintained over univariate and multivariate analyses. CONCLUSION: Estimation of CA15-3 at presentation of breast cancer is important as it is an independent prognostic indicator and may prompt the physician to investigate for metastases if elevated.