課程資訊

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課程資訊

  1. 1. 台灣顱底外科醫學會 97 年度夏季學術研討會 地點:羅東博愛醫院五樓國際會議中心 Scientific Program ( 97 年 07 月 12 日 星期六 ) 時間 議程 09:00~10:10 會員報到 10:10~10:30 潘宏基理事長 陳幸鴻院長 Opening remark 學術演講 座長 演講者 題目 10:30~10:50 施養性 杜永光 Skull Base Surgery for General Neurosurgeons 10:50~11:10 邱仲慶 郭萬祐 MR Diffusion Imaging of Brain Tumors 11:10~11:30 洪純隆 黃金山 Personal experience in surgical management of brainstem and Spinal Cord Hemangioblastomas 11:30~11:50 高明見 楊大羽 陳敏雄/ Ali F. Krisht M.D. Transcavernous approach to the disease of the anterior upper third of the posterior fossa 11:50~12:10 陳翰容 關皚麗 林子淦 Surgical Treatment of carotid stenosis 12:10~13:40 Lunch (理監事會議:第一會議室) 13:40~14:00 侯勝博 林凱南 曹中侃 Head and Neck Reconstruction 14:00~14:20 羅綸洲 沈炯祺 方谷豪/ 侯勝博 Endoscopic management of nasopharyngeal tumor 14:20~14:35 黃棣棟 任森利 黃祖源 Long-term survival of glioblastoma 14:35~14:50 馬辛一 Gene therapy ABC 14:50~15:05 黃勝雄 陳幸鴻 王文斌 Skull Base Approaches for Surgical Treatmentof CSF Leak …………Two Cases Report 15:05~15:20 蔣永孝 黃銘超 劉安祥 Olfactory groove meningiomas: visual field outcome 15:20~15:40 Coffee break 15:40~15:55 鄭宏志 黃文成 葉昭宏 Petrosal tumor: experience of middle fossa approach 15:55~16:10 許永信 劉康渡 蘇泉發 Petroclival Tumors: Multiple Modality Treatment and Outcomes – Tzu-Chi Experience 16:10~16:25 鍾文裕 廖漢文 黃全福 Diffusion Magnetic Resonance Imaging in the Evaluation of the Response of Meningioma and Metastatic Brain Tumor Treated by Gamma Knife Radiosurgery 16:25~16:40 曾漢民 邵國寧 鄭文郁 Multimodality Treatment of Acromegaly 16:40~16:55 葉致文 Expanded endonasal approach 16:55~17:10 許書雄 張承能 李旭東 Endoscopic endonasal transsphenoidal surgery for large multi-extension pituitary macroadenoma 17:10~18:10 林萍章 醫學與法律(醫學倫理醫療法規繼續教育積分) 18:30~ 晚宴(渡小月餐廳)
  2. 2. Skull base surgery for general neurosurgeons --- Keep it simple and straightforward Yong-Kwang Tu, M.D.,Ph.D. Department of Neurosurgery, College of Medicine and Hospitals National Taiwan University, Taipei, Taiwan The evolution of skull base surgery in the past two decades has developed many different approaches for lesions at the various locations of the skull base and its adjacent regions. Most of these approaches consisted complicate procedure and need a lot of knowledge of the skull base anatomy to perform it. For general neurosurgeons who are not devoted in skull base surgery do not have the need to master all these procedures, yet some basic skull base approaches are very useful for general neurosurgeons. The basic principle in skull base surgery is to remove the bony obstacles at the trajectory of the surgery to minimize the brain retraction, and enable a better viewing of the lesions. Accordingly, removal of the major ridges on the skull base, namely, the sphenoidal ridge, the petrous ridge and the rim of the foramen magnum including the occipital condyles become the most important procedure to achieve this goal. Therefore, extradural approach to remove the sphenoidal ridge and anterior clinoidectomy (Dolenc’s approach), presigmoidal approach with posterior petrosectomy, and far lateral approach with partial removal the occipital condyle are the three most important skull base approaches for general neurosurgeons in their daily practice. The Dolenc’s approach is not only applied for cavernous sinus lesions, but can also be used for all the complex aneurysm at the internal carotid artery, tumors at the sphenoidal ridge, the orbit and sellar region. This approach may also be combined with the fronto-orbito-zygomatic approach to reach many lesions at the anterior, middle, and upper posterior fossa. The presigmoid approach can be applied for pontine lesions, clival lesions, and aneurysm of the basilar trunk and anteroinferior cerebellar artery. With the division of the tentorium, this approach can reach a vast region at the middle and posterior fossa. The far lateral approach can be used for tumors at the anterior part of the foramen magnum, aneurysms of the vertebral artery and the posteroinferior cerebellar artery, and lesions at the lower clivus and the anterior part of the medulla. The details of the surgical technique and indication for the selection of these three basic approaches will be presented.
  3. 3. Diffusion MR Imaging of Brain Tumors: The imaging power in grading tumors WanYuo Guo, M.D., Ph.D. Department of Radiology, Taipei Veterans General Hospital School of Medicine, National Yang-Ming University The water molecules in brain white matter are inherited with anisotrophic diffusion due to the special internal arrangement of axon fibers in the brain. Brain tissue is the one among the body structures that harbor the unique physiological characters. The specific internal setting and water diffusion are feasibly demonstrated by MR imaging, namely diffusion weighted imaging (DWI) and diffusion tensor imaging (DTI). In current clinical practice, DWI has become the mandatory imaging tool for stroke patients. Both cytotoxic and vasogenic edemas, i.e. abnormal intercellular and intracellular water retention, occurred in the infracted brain tissues. Thereafter, the tissues lost their unique anisotropic diffusion in MR environment. The infracted tissues are simply illustrated as abnormal high signals on DWI and low signals on apparent diffusion coefficient (ADC) map. Moreover, DWI is also an imaging tool with high sensitivity and specificity in differentiating brain abscess and tumor necrosis with cystic changes, i.e. high signals of the former versus low signals of the later on DWI. The differences in water molecules diffusion are also applicable to tumor differentiation in clinical practice. It was reported that water molecules in high grade and high nucleus/cytoplasm (N/C) ratio brain tumors are more restricted than that in low grade and low N/C ration tumors. In the presentation, the study result based on a retrospective analysis of DWI and morphological MR imaging of 100 tissue-proved brain gliomas will be reported. A novel analysis technique by simply selecting region of interest (ROI) of tumor and taking the normal white matter in the contra-lateral hemisphere as the control was used (Figure). It was found that tumor grade of brain gliomas are
  4. 4. statistically significant related to the brightness of high signals depicted on DWI. The analysis technique provides a reliable and, most plausibly, easily conducted manner for clinical practice of brain tumor management.
  5. 5. 腦幹及脊髓血管母細胞瘤之手術經驗 黃金山 國泰綜合醫院 外科部 神經外科 Personal experience in surgical management of brainstem and Spinal Cord Hemangioblastomas Jing-Shan, Huang Division of Neurosurgery, Department of Surgery Cathay General Hospital, Taipei, Taiwan Hemangioblastomas are uncommon vascular tumors in the central nervous system that occur mainly in the cerebellum and spinal cord. They account for approximately 4 percent of all spinal cord tumors, and between 7 and 12 percent of all posterior fossa primary neoplasms in the adult. Hemangioblastomas occur sporadically and in patients with von Hippel-Lindau (VHL) disease, an autosomal dominant disorder in which affected individuals develop cerebellar and retinal hemangioblastomas, pancreatic or renal cysts, renal cell carcinoma or pheochromocytomas. Among patients with hemangioblastoma, 25 percent occur in those with VHL disease. On the other hand, hemangioblastomas are the most common lesions associated with VHL disease, affecting 60 to 80 percent of patients. Hemangioblastomas can cause local symptoms by compression of neural structures, bleeding, or paraneoplastic complications. Their management requires expertise in interventional neuroradiology, neurosurgery, radiation oncology, and medical genetics. Most hemangioblastomas are found in young adults and children; however, sporadic hemangioblastomas have been reported in adults in their 60s and 70s. Seventeen patients with brainstem or spinal cord hemangioblastomas were identified, accounting for 34% of all hemangioblastomas surgically treated from August 1992 to May 2008 in Cathay General Hospital. There were 7 males and 8 females. 7 cases are associate with Von- Hippel Lindau disease. The patients were aged from 8 to 56 years with an average age of 32 years. The clinical manifestations were nonspecific. Magnetic resonance imaging, CT scan and angiography were the major diagnostic modalities. Tumors were located in brainstem (5) and spinal cord (12). Tumors were solid in 8 cases, mainly cyst in 7 cases, and small size in 10 (≤2.5 cm), large size in 7 (>2.5 cm). Extra-brainstem (EBS) type (including the fourth-ventricle hemangioblastomas) was seen in 3
  6. 6. cases, intrabrainstem (IBS) type in 2 cases and spinal cord type in 12 cases. Preoperative embolization was not performed in our cases. Mild hypothermia with or without hypotension and high dose steroid was done during the operation. Total tumor removal was achieved in 15 patients (88.2%), and incomplete removal in 2 cases. No patients died after the operation. Follow-up study (range, 1-18years; mean, 6 years) was available in 15 patients. McCormick functional grade were gradeⅠin 13 patients (86.6%), and grade Ⅱ in 2 patients (13.4%). A combined strategy of preoperative studies, mild hypothermia with or without hypotension, high dose steroid, SSEP monitoring, microsurgical technique, special tumor dissection principles and intensive perioperative management are mandatory for removal of these kinds of tumors with successful results.
  7. 7. Transcavernous approach to disease of the anterior upper third of the posterior fossa Min-Hsiung Chen, MD., Ali F. Krisht, MD. The region in the upper anterior third of the posterior fossa is a surgically hidden, narrow corridor between the petroclival surface anteriorly and the surface of the brainstem posteriorly. Although several approaches have been described to help surgeons reach this region, few of them enable practitioners to reach the different corners of the area and provide as wide a view as the one achieved using the transcavernous route. A transcavernous approach can be used in those cases (complex upper basilar artery [BA] aneurysms, upper petroclival junction meningiomas, trigeminal nerve schwannomas, upper clival chordomas, and anterior pontine lesions), all involving the anterior upper third of the posterior fossa. The approach uses the pretemporal route with exposure of the lateral wall of the cavernous sinus. It entails removal of the anterior clinoid process. The posterior clinoid process is also removed when necessary. The approach leads to the upper basilar region. It is widened inferiorly to expose the anterior aspect by removal of the posterior clinoid process and the petroclival osseous and dural elements. Its lateral extension exposes the region of the Meckel cave and it can be widened by removal of the petrous apex. Seventy patients experienced new transient mild cranial neuropathies, 95% of whom recovered fully. Surgically related ischemic morbidities occurred in few patients with BA aneurysms (one small medial thalamic infarct, ataxia due to superior cerebellar artery ischemia, and distal middle cerebral artery embolus in a patient with atrial fibrillation in whom anticoagulation therapy was stopped). All the neuropathies in patients with BA aneurysms were oculomotor and recovery was the rule in all of them. Some new permanent cranial
  8. 8. neuropathies occurred in the patients with meningiomas. In seven patients with preoperative neuropathy, two had partial improvement. Five patients with atypical meningiomas were treated with postoperative radiation therapy. Progression occurred later in four patients who were treated with gamma knife surgery. There were no surgery-related deaths. The safety achieved with the transcavernous route allows surgeons to achieve wide exposures to lesions involving the anterior upper third of the posterior fossa. It is an approach that should be mastered by every neurosurgeon dealing with cranial lesions.
  9. 9. Surgical Treatment for Carotid Stenosis Tzu-Kang Lin, M.D. 長庚醫院 神經外科 Patients with significant carotid Stenosis are at increased risk of ischaemic stroke. The hazard is even greater for those patients with symptom. Successful carotid endarterectomy can effectively reduce the risk of stroke. Nevertheless, the benefits of carotid endarterectomy are easily overruled if the operative morbidity and mortality are high. In 1991, two important reports of large clinical trials (NASCET and ECST) confirmed the benefit of carotid endarterectomy in preventing stroke, if the operation is performed by experienced hands for selected cases. Furthermore, the newly developed treatment strategy of angioplasty and carotid stenting has been increasingly adopted in the past 10 years, mainly because it is less invasive, and initial therapeutic result is acceptable. Nevertheless, there still has been no strong evidence to demonstrate its superior to carotid endarterectomy, and takes place endarterectomy to be the golden standard treatment for carotid stenosis. Yet, some controversies still surround the issues of intraoperative shunt, patch angioplasty, monitoring, and the settings of bilateral stenosis, tandem stenosis, and contralateral occlusion. These will be discussed further. In my series of 165 carotid endarterectomy performed in 157patients, the ratio of male to female is 4.9:1.0 (83%:17%). The age ranged from 49 to 87 with the mean age of 68. The clinical presentations include TIA (31.4%), stroke (55.3%), and others (13.3%). There were two postoperative ICH (1.2%) and three perioperative ischaemic strokes (1.8%). One patient died from postoperative intracerebral hematoma due to hyperperfusion syndrome 11 days later, with the mortality of 0.7%. Our experiences and literatures show carotid endarterectomy is still the golden standard for carotid stenosis. Nevertheless, angioplasty with stenting has its increasing role in the future, and is a good alternative nowadays for certain situations such as poor medical condition, restenosis, and radiotherapy induced stenosis, et al.
  10. 10. Head and Neck Reconstruction 曹中侃 長庚醫院整形外科 Surgery remains the prime treatment for oral cancer. Reconstruction plays an important role in the return of quality of life. Progress of reconstructive surgery made it much easy to do an immediate reconstruction after ablative procedure, with micro-vascular transfer. This comprehensive course describes selection of free flaps to reconstruct defects to maximize functional outcome following cancer ablative surgery. Adequate choice of reconstructive method is of utmost importance to reduce morbidity, death and financial burden on the society. The presentation places emphasis on the reconstructive goals and the management of advanced head and neck cancer. Personal experience for management of extensive composite maxillo- oromandibular (ECMO) defects using anterolateral thigh (ALT) flap plus mandible reconstruction plate (MRP) will be discussed. The course also highlights some key procedures to reduce postoperative complications and improve the outcome.
  11. 11. Edoscopic Management of Nasopharyngeal Tumor Ku-Hao Fang, MD; Sheng-Po Hao, MD, FACS, FICS Chang Gung Memorial Hospital Background: Nasopharyngeal carcinoma (NPC) is treated with radiation therapy. Salvage surgery is justified for primary recurrence of NPC. With the advent of endoscopic powerful instrument, endoscopic skull base surgery is popular recently. However, the feasibility of endoscopic surgery for malignancies has been controversial. We evaluate the feasibility of endoscopic nasopharyngectomy for locally recurrent NPC, and compare the surgical results with open nasopharyngectomy. Study design: Five NPC patients who had nasopharyngeal mucosal recurrence underwent salvage endoscopic nasopharyngectomies between January 2006 and July 2007. Four were primary recurrence while one had secondary recurrence. The mucosal recurrences were located in the lateral wall:2, roof and lateral wall:2, and floor: one of the nasopharynx. All patients were reported to have negative surgical margins after endoscopic nasopharyngectomies. Results: The endoscopic nasopharyngectomy was completed in less than 3 hours in each patient without surgical mobility. The patients were followed up in the clinics from 9 to 27 months, mean 17.6 months. Though they all had negative surgical margins on intraoperative frozen sections, two recurred. These two patients subsequently underwent another course of concurrent chemoradiation therapy. All the 5 patients remained alive to date. Conclusion: Endoscopic nasopharyngectomy is feasible for mucosal recurrence of NPC.
  12. 12. Long term survival of glioblastoma 黃祖源 高雄醫學大學 神經外科 The behaviour of malignant glioma is expressed either by the invasiveness or by the capacity to replace the surrounding brain progressively. Glioblastoma multiforme (GBM) patients are generally associated with a poor prognosis, with median survival of 10~12 months. GBM with long term survival (LTS) of 5 years is rare. It is unsterstandable that no large series of LTS have been studied, the clinico-pathological factors that contribute to LTS are still not identified. We reviewed the GBM cases operated in our department from 1998 to 2008. We selected 3 cases with the following characters: 1) supratentorial glioblastoma; 2) tumor specimens reviewed by our pathologist confirming the diagnosis; 3) survival for more than 5 years after surgical diagnosis. A clinical and pathological study was conducted in our cases, including the pre-operative performance status, imaging findings, treatment, disease free interval, proliferating index, presence of giant cells and p53 expression. Our study indicate that LTS is rarely found in GBM patients. In our cases, LTS with GBM seems to be a good performance status who receives multimodal therapy including maximal tumor removal, adequate radiotherapy, chemotherapy with nitrosourea, vincristin or temozolomide and with long disease-free interval.
  13. 13. 基因治療 ABC 馬辛一 三軍總醫院神經外科部 1. 基因治療 (gene therapy) 的定義: 根據行政院衛生署於民國八十六年八月頒 的『基因治療人體試驗申請與操作規範』中開宗佈 明 義 就 提 出 基 因 治 療 (gene therapy) 的 定 義 是 指 : 「 利 用 分 子 生 物 學 中 DNA 重 組 (DNA recombination)以及轉殖的技術,把重組之 DNA 分子傳遞至一個或多個人體染色體內,將患有遺 傳性、新陳代謝或癌症等疾病患者細胞內的致病基因,加以修補或置換,使其恢復正常功能;或者 在已喪失功能的基因外,輸入額外的正常基因,以製造必要的産物,使病人得以恢復健康的現代 醫療科技。」 隨著分子生物學及細胞生物學的進步,我們瞭解到某些蛋白質在許多疾病過程中,扮演著重 要的角色,而去 核糖核酸氧 (DNA)技術的發展,更讓我們對控制這些蛋白質的基因,有更一步的 認識。但由於這些蛋白質的大小、複雜度、及無法達到特定細胞等問題,所以我們無法經由傳統藥理 學方法來傳送或修飾這些蛋白質。簡單來說,基因治療是取一段外來的去 核糖核酸氧 (DNA),利用 物 理 或 生 物 方 法 , 轉 植 入 有 基 因 缺 陷 或 突 變 所 引 起 的 先 天 性 代 謝 缺 陷 (inborn error of metabolism)或疾病病患體內,使人體合成具有生物活性的蛋白質,進而改變細胞的功能,以克 服傳統治療上的障礙的治療方式。最理想的方式是能針對標記(targeted)的基因彌補,並能使之恢 復正常(regulated)的功能;因此,重組 DNA 的傳送成爲所有基因治療策略的主要焦點。基因的移 植似魔術一樣的神秘,如能成功,將可造福患者終身;同時也因這種新治療方法的研究可促成生 技上的發展,未來將是一個商業上熱門的競爭物件。 2. 基因治療的範圍: 自從 Edward Tatum 在 1966 年最早提出治療性基因轉移 (therapeutic gene transfer)的觀 念後(Tatum et al., 1966),基因轉移在人類疾病的治療上,最初被視爲治療人類因爲單個基因變 化所引起的遺傳疾病。因爲基因的缺陷而引起的遺傳疾病約占新生兒的 4%,每 200 個嬰兒中會有 1 位患有染色體不正常,而 1~2%是由單一基因的不正常所引起的。人類的基因多包含在 23 對(46 條)染色體內,有 30 億( 3x10 9 )個 基配對堿 (base-pair),共約有 5 萬到 10 萬個基因,而約有 5,000 個人類的疾病是因爲單個基因變化所引起。遺傳性疾病都是由於基因的缺陷,使得某一個特 殊的蛋白質無法合成或合成異常所造成,缺乏此一特殊蛋白質,將依其在細胞中之結構或酵素催 化的角色,導致不同的臨床表徵,而這些遺傳疾病是傳統藥理學方法無法完全治療的;如常見的 sickle cell anemia 、 cystic fibrosis 、 Duchenne / Becker muscular dystrophy、thalassemia、phenylketonuria、色盲(color blindness)、血友病(hemophilia)、及囊性纖
  14. 14. 維化(cystic fibrosis)等,以及不常見的 severe combined immunodeficiency (SCID) syndromes、 Lesch-Nyhan syndrome、及不同的脂肪(lipid)及 水化碳 醣(carbohydrate)貯藏病。這些遺傳疾病中, 僅有一小部份可經由蛋白質的置換加以治療,例如:第八因數治療血友病、輸血以治療 刀型貧血鐮 等,而這些治療僅能減緩疾病表徵,卻伴隨嚴重的並發症。對大部份的遺傳疾病而言,由於蛋白質 的複雜度及需傳送蛋白質至特殊的細胞內位置,使得提供蛋白質以治療遺傳疾病是不可行的。過去 器官移植也被用於治療遺傳疾病,例如:骨髓移植治療 刀型貧血;肝臟移植治療高血脂症;但器鐮 官來源的問題及免疫抑制所引起之不良後果,均是其發展上的限制。 基因療法的觀念始於六零年代,當時有學者曾提出利用基因轉移方法,把正常基因送入帶 有基因缺陷的細胞內,使之正常化,以治療遺傳疾病。經過多年的努力,於 1990 年 9 月正式開始 世界第一位病人的基因治療,病人有先天性基因缺陷,無法産生 adenosine deaminase (ADA), 以致於體內堆積過多的 deoxyadenosine triphosphate,此物質對 T 細胞具毒殺作用,因此病患 的免疫力相當差,很容易因病菌感染而死亡。既然病人之病因是因缺乏 ADA 的基因,根本治療方 法就是將 ADA 基因轉染入 T 細胞內,使 T 細胞能産生 ADA,病患的 T 細胞就能存活,病人就具 免疫力了;此臨床試驗結果證實基因治療的確具臨床療效。如果對受遺傳疾病影響之組織轉移正常 的基因,由於蛋白質可經由正常的細胞途徑在細胞內合成,因此可克服傳送複雜蛋白質的問題。雖 然遺傳疾病所缺損的基因存在個體內的每一細胞,但僅有小部份的組織或器官需要表現此一缺陷 基因;如果此一缺陷基因在身體的每個細胞均需表現(如:housekeeping 基因),通常會引發嚴重的 異常,導致胚胎無法發育。而遺傳疾病在影響組織上的局限性,大大地簡化基因治療的難易程度, 因爲我們只需將正常的基因送到真正有需要的組織;因此,基因治療的目標只是改正部份身體組 織的基因缺損。由於基因治療並不用於改變生殖母細胞的基因結構,因此無法預防後代免于遺傳性 疾病,然而基因治療仍被視爲可減緩遺傳疾病表徵的有效工具。基因治療的應用上,最令人感到莫 大興趣的是針對特定組織找出治療的基因;如果基因轉移可以針對主要受影響的器官,則在非標 的細胞中,將可避免外來基因表現所引起的副作用。正如同其他藥物製劑,特殊的細胞專一特性可 大幅減少基因轉移製劑的劑量;雖然目前尚無細胞專一性的基因傳送系統,但隨著基因治療研究 的發展,將會設計出新的 DNA 傳送方法。 基因治療的範圍主要有二大部份 : 1.遺傳性疾病。 2.後天性疾病。 目前大部份有關基因治療的臨床試驗,主要是針對後天性疾病,如:後天性免疫缺乏症候群、惡性 腫瘤、及心血管疾病的治療,而非單一基因缺陷所造成的遺傳性疾病。最近 10 年來,漸漸證實了 所有腫瘤細胞的癌化也是由多種基因的突變、失落、轉移、或擴增而引起;既然是因爲基因的改變而 引起的病變,當然應該可由基因著手來對症治療。基因治療在後天性疾病的應用較單一基因缺陷所 造成的遺傳性疾病爲快的原因是:
  15. 15. 1.治療遺傳性疾病所需的長期基因表現,目前尚難達成。 2.後天性的疾病較易收集到足 的病人,以進行不同的臨床試驗。夠 而由這兩者之比較我們發現 : 單一基因缺陷疾病的病理機轉較爲明確,而大部份的後天性疾病的 基因治療,其分子機轉並不清楚;另外,後天性疾病常以加入新的分子功能做爲治療的途徑,如 改變疾病的過程或阻礙已存在的功能,而不是矯正潛在的缺乏。 3. 基因治療之管制: 爲了避免基因治療的濫用,1973 年美國國家衛生研究院組成了一個集團,專事推動基因治 療的臨床試驗及控制;1976 年成立 RAC(Recombinant DNA Advisory Committee)制定正式的管 制條例;1988 年正式有第一個合于規定的基因治療計畫開始進行;1990 年又進行了第二及第三 個臨床試驗。在美國,人體基因治療必須提報食品藥品管理局 FDA 核可;此外大部分的擬案也須 提報衛生署的 RAC (Recombinant DNA Advisory Committee)核可,RAC 核可的擬案並不意味 FDA 已經核可或是該擬案已經開始進行。最近,申請基因治療的案件大幅增加,光是 1995 年上半 年內,已有 24 個計畫被審核通過;至 1998 年 9 月,RAC 核可的臨床基因轉移計劃已超過 280 個,基因治療計劃有 248 個、gene marking 計劃有 30 個、及非治療計劃有 2 個。在基因治療計劃 中有 27 個是與 Human immunodeficiency virus(HIV)感染有關(占所有基因治療計劃的 10.9%)、 有 36 個是與 monogenic disease (mostly cystic fibrosis)有關(占所有基因治療計劃的 14.5%)、有 173 個是癌症有關(占所有基因治療計劃的 69.8%)、其中有有 12 個是與其他疾病有關(占所有基因 治療計劃的 4.8%)。至今已有超過 1000 個病人在美國接受基因治療。 在臺灣真正的臨床基因治療計劃並未進行,但預期是不久後的事。 4. 基因治療之發展方向及未來趨勢: 基因傳遞的方法也有多種,每次醫學治療上有突破的創舉時,就會帶來許多新的看法、新的 鼓勵與新的希望,但是在試驗進行中一定會遭遇很多困難及阻礙,致使計畫停滯不前;既然人類 絕大部分的疾病因基因而引起,理所當然地應先從基因治療方式來著手進行。1996 年十月份的 Time 雜誌指出,去年美國國家衛生研究院花費近 200 億的資金在基因治療上,而結果實在渺茫, 該院的院長 Dr. Harold Varmus 覺得大家應該徹底檢討一下,是否應重新回到實驗室裏找出有效 的步驟,以達到療效。讓我們大家齊爲西元 2000 年的來臨,作爲我們對基因治療的新期望。 基因療法目前仍有許多技術問題尚待解決,臨床測試由於可以累積經驗,對此醫療技術的發展 相當有助益,但所需經費十分龐大。以美國的研究情形爲例,政府所提供的經費大約只能進行初步 的安全測試 (每個有效測試約須七百萬至二仟萬台幣);而後期的基因臨床測試更爲昂貴,大都需 藥廠來支援,由於遺傳疾病的基因治療就算成功,報酬率也極低,藥廠贊助的興趣並不大。基因療 法目前也是國內生物醫學研究的一項重點,臺灣地窄人稠,生物技術的發展相當有潛力;但基因 療法由於發展過程中需要有足 的經費進行臨床測試,未來勢必結合政府及藥廠的力量共同開發夠 , 才有成功的可能,因此醫學和商業的因素都直接影響這項高科技的發展,宜在早期便做全面的規
  16. 16. 劃和評估。 Skull Base Approaches for Surgical Treatment of CSF Leaks-------- Two Cases Report Wen-Ping Wang, M.D., Hsiang-Wen Lin, M.D., Hsing-Hong Chen, M.D. Rotong Pohai General Hospital, Rotong, Yilan Persistent cerebrospinal fluid (CSF) leakage from the skull base is a troublesome problem and has the potential risks of ascending infection and rarely tension pneumocephalus. Surgical treatment for persistent CSF leak from the skull base defect is indicated to prevent the neurological complications. In recent one year, two cases of complicated CSF leaks from the skull bases were surgically treated in our hospital. Both cases were complicated with Streptococcal meningitis before the neurosurgical repairs. The first one was traumatic in etiology and had the skull base defect over tectum tympani of right petrosal bone and the second case was iatrogenic in origin with the CSF leakage and ascending bacterial meningitis following endonasal procedure for congenital nasal encephalocele. The skull base defect was located over the anterior part of left cribriform plate. Transcranial skull base approaches were performed to repair the CSF leaks successfully: Bifrontobasal craniotomy with division of the sac of nasal encephalocele above the skull base defect, primary repair of the dural opening and skull base reconstruction with the viable pericranial flap were done for the first case, For the second case, retromastoid trans-petrosal approach was adopted and the dural defect was repaired with the fascial graft of temporalis muscle. Effective surgical treatment of the skull base CSF leakage depends on the accurate localization of the skull base defect. Thin-cut high resolution CT study of the skull base provides the valuable information before the appropriate skull base approach
  17. 17. for repair is planned.
  18. 18. Olfactory groove meningiomas: visual field outcome 劉安祥 高雄醫學大學 神經外科 Objective Meningiomas account for approximately 20% of all primary intracranial tumors. Of all intracranial meningiomas, 10% arise from the olfactory groove. The most common presenting symptoms were mental disturbance, headache, visual disturbance, and anosmia. We reassessed a series of patients treated microsurgically for an olfactory groove meningioma in regard to clinical outcome, especially focus on visual field recovery. Methods A retrospective study was conducted by reviewing the charts of patients including clinical presentation, imaging studies, surgical results, complication and follow-up status. Results A total of 206 intracranial meningiomas were operated between 2000 October and 2007 June in our department. There were 10 patients with olfactory groove meningioma, including 7 women and 3 men with a mean age of 55.9 years (age range, 46-70 year). The presenting clinical symptoms were as following: ansomia (4), headache (2), visual disturbance (3), and personality change (1). Tumors were operated through the bifrontal (7) and pterional (3) approaches. Total tumor removal (simpson grade I or II) was achieved in eight cases. No complication directly due to the surgery occurred. In images study, all cases showed peritumoral edema. In three patients with one eye nearly total visual field defect via auto- perimetry examination. After operation, one patient showed 80% of recovery of visual field and one 60% recovery. Conclusions The olfactory groove meningiomas frequently compressed the optic nerve and visual field defect was noted. When clear dissecting arachnoid membrane fascilitated tumor removal from optic nerve, optic nerve can get good preservation. Then visual field defect can get good recovery.
  19. 19. Petroclival Tumor -- Preliminary experience via middle fossa approach 葉昭宏,葉聰志,王嘉聲,邱仲慶 奇美醫學中心 神經外科 Petroclival tumors are defined as arising from the upper two thirds of the clivus, at the petroclival junction. These tumors remain one of the most challenging intracranial lesions to treat surgically. The primary goal of surgery is brain stem decompression. Many skull base approaches with the advantages of a short trajectory and minimal brain retraction have been developed for these lesions. The retromastoid approach combined with middle fossa approach may be used to access this area. The middle fossa anterior petrosectomy provides adequate exposure and avoids the associated postoperative morbidities. Here we will present our little preliminary experience in Chi-mei Hospital.
  20. 20. Multiple modality treatment of cranial base meningiomas involving the cavernous sinus and petroclival region – Tzu-Chi experience 蘇泉發 駱子文 邱琮朗 Chain-Fa Su, Tzu-Wen Loh, Tsung-Lang Chiu Department of Neurosurgery, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan Objective: Surgical resection of cranial base meningiomas is often limited owing to involvement of crucial neurovascular structures. Within the last two decades Gamma Knife Radiosurgery (GKRS) has gained increasing importance as an adjunct treatment after the incomplete resection of tumor and as an alternative treatment to open surgery. We retrospectively analyzed our recent cases focusing on tumor control, clinical course and morbidity. Methods: Between 2002 and 2008, we treated 42 cases of cranial meningiomas involving the petroclival and/or cavernous sinus region of basal skull. (male:female ratio, 11:31, mean age: 55.6 yrs; range, 9-81 yrs). Seven patients were treated with surgical resection alone, 14 patients with a combination of surgery and GKRS and 21 patients received GKRS alone. Pterional, subtemporal, anterior or posterior petrosal approaches or a combination were used in the surgical approach depends on the tumor location. In group of 21 cases treated with GKRS alone, the mean tumor volume was 6 cc, mean marginal dose was 14 Gy and most cases of the iso-dose line was set at the 50% with a mean of 49.6 %. In group of 14 cases treated with surgery and combination of GKRS, 4 cases were huge extensive tumors (volume > 50 cc). These 4 patients were treated with volume-staged GKRS after operation and will be separately discussed. The rest 10 cases treated with GKRS had a mean tumor volume of 9.75 cc, range 1-28.3 cc by mean marginal dose 14.1 Gy, range, 12-18 Gy, at an iso-dose line of 50%. Results: One operative mortality was noted due to severe brain swelling. Most of the cases are kept in good Karnofsky Performance Status before and after the treatments and had an good quality of life. Conclusions: In this limited experience, we considered the urgent decompression effect from the open surgery is necessary in patients with basal meningiomas compressing the brain stem or optic apparatus. However, it is not necessary to eradicate the whole tumors whenever tumors involve the neurovascular structures because the excellent long term tumor control rate and the low morbidity rate associated with GKRS can be achieved.
  21. 21. Diffusion Magnetic Resonance Imaging in the Evaluation of the Response of Meningioma and Metastatic Brain Tumor Treated by Gamma Knife Radiosurgery 黃全福 中山醫學大學附設醫院 加馬刀中心主任 Background: Patients usually receive serial magnetic resonance imaging (MRI) examinations to assess stereotactic radiosurgery (SRS) effects. But loss of tumor cell after radiosurgical treatment results in a relative increase in extracellular space that may lead to alteration of apparent diffusion constant (ADC). Our hypothesis is to investigate if the ADC can be used, rather than with methods depending on changes in tumor size, to predict treatment success after treatment of meningioma and brain metastases with SRS. Methods: We conducted a prospective trial involving 6 patients with intracranial meningiomas and 21 patients with 32 solid or solid-dominated lesions treated by SRS with 201-source cobalt in our Gamma Knife center. Patients received complete diffusion MRI before treatment and at multiple intervals following SRS. We followed up MRI findings and clinical outcomes at 3 months, and thereafter in 3-month intervals. We detected the long-term results of diffusion MRI in 7 patients treated for at least 5 years. We calculated apparent diffusion coefficients (ADC) from echoplanar diffusion weighted imaging, and compared mean ADC values. Mean ADC values at the various time intervals were compared with each other to see whether or not the ADC might be used as an early indicator of treatment success or failure. Results: The ADC for meningioma was 0.55-0.64 x 10-3 mm2/s (mean  SD). We observed 2 ADC phase changes after SRS: a significant (p < 0.05) reduction phase beginning at 4 hours and lasting 4 days after SRS followed by an elevation phase to pseudonormalized values. ADC significantly increased 30 days after SRS, reaching a
  22. 22. plateau in 3 months. MRI follow-up at 3-month intervals showed stable tumor size in all patients, with 3 patients revealing evidence of tumor necrosis. The ADC value for the long-term group was 1.26 x 10-3 mm2/s. (p < 0.05); however, MRI follow-up showed tumor shrinkage in 3 patients. The mean pre-treatment value of the ADC in the metastatic tumors was 1.05  0.12 x10-3 mm2/s. This value for the tumors rose significantly (P=0.009) seven days after SRS and continued to rise with time. Magnetic resonance imaging (MRI) showed that 91% of these tumors had been controlled by the SRS. ADC values in cystic/necrotic tumor tissue (2.13  0.18 x 10-3 mm2/s) were significantly (P<0.001) higher than in non-central necrotic tumor tissue (1.61  0.14 x 10-3 mm2/s). Conclusion: Gamma knife treatment is efficacious for meningioma and metastatic brain tumors. Serial changes in ADC values might eventually be useful to evaluate treatment success and in some patients even detected at early time points, and to distinguish radiation-induced central necrosis from tumor re-growth in cases where other imagery is not definitive. Key words: brain metastasis; diffusion-weighted imaging; magnetic resonance imaging; radiosurgery; meningioma. Multimodality Treatment of Acromegaly 鄭文郁 台中榮民總醫院 神經外科 Acromegaly is caused by excessive secretion of growth hormone (GH). The average annual incidence of acromegaly is approximately 3.3 per million, and the prevalence is approximately 60 per million. GH-secreting adenomas account for 20% of functional adenomas, and 75% of GH adenomas are macroadenomas. Acromegaly is associated with significant morbidities and a 2- to 3-fold increase in mortality because of the excessive metabolic action of GH and IGF-I, a marker of GH output. Reductions in morbidity correspond with decreases in IGF-I, and mortality is lowered following normalization of IGF-I or GH levels. Therefore, this has become an important end point. The goals of these therapies for acromegaly are to normalize excessive hormone secretion, thus normalizing serum levels of growth hormone (GH) and of insulin-like growth factors (IGF-I), to reduce the
  23. 23. clinical symptoms and signs of acromegaly and to reduce tumor size in order to relieve any symptoms due to tumor mass effect. These goals should be accomplished while preserving pituitary function and with as few side effects as possible. Currently available e treatments include transsphenoidal surgery (TSS) or craniotomy; medical therapy with the dopamine agonists, somatostatin analogues and Pegvisomant; radiotherapy (RT) or radiosurgery (RS), or combination therapy. TSS, the initial choice of therapy in most patients, is the most effective therapy at reducing the signs and symptoms of mass effect such as visual or neurological compromise. TSS is potentially curative, but the outcome is highly dependent on the tumor size, the degree of tumor invasion and the expertise of the surgeon. Microadenomas have a very high cure rate (90% or more) but these are the minority of tumours. Intrasellar macroadenomas have a similar control rate and it is only when tumours are extrasellar that cure rates (control rates) fall to around 50 or 60%. Therefore, Medical therapy has assumed the major role as adjunctive therapy following surgery or as first-line therapy for nonresectable tumors. The dopamine agonists used for the therapy of acromegaly include bromocriptine, quinagolide and cabergoline. Cabergoline seems to be the most efficacious of the dopamine agonists for the treatment of acromegaly, with normalization of IGF-I being achieved in up to 35% of patients treated. Dopamine agonists are generally not effective at reducing the size of pure GH-secreting pituitary tumors. Somatostatin analogues are the most effective medical therapy currently available for acromegaly. The clinically available long-acting somatostatin analogues are longacting octreotide and slow-release lanreotide. Overall, IGF-I levels normalize in about 66% of patients treated with long-acting octreotide and in 48% of patients treated with lanreotide. About 30% of GH-secreting tumors treated with somatostatin analogues as adjunctive therapy will have some shrinkage, and the amount of shrinkage usually ranges between 20 and 50% of tumor size. Signs and symptoms of the disease improve in about two-thirds of patients treated with long- acting somatostatin analogues. Gastrointestinal side effects are common when initiating somatostatin analogue therapy, but these effects do not typically limit continued use. Pegvisomant, the newest therapeutic option, blocks GH action at peripheral receptors, normalizes IGF-I levels, reduces signs and symptoms, and corrects metabolic defects. Pegvisomant does not appear to affect tumor size and has few adverse effects. Liver function tests should be regularly followed on pegvisomant treatment. Pegvisomant is the most effective drug treatment for acromegaly in normalizing IGF-I and producing a clinical response; it is the preferred agent in patients resistant to or intolerant of somatostatin analogs. Multi-modality therapy for acromegaly is often needed to achieve disease control. However, even combinations of currently available surgical and medical therapies
  24. 24. cannot achieve all the goals of therapy in many patients with acromegaly. RT may be used as adjunctive therapy after unsuccessful surgery and medical treatment. RT can lower GH levels and normalize IGF-I levels, but there is a long lag time before this effect is achieved. Biochemical control is not achieved for 6-10 years after conventional fractionated RT; the time to clinical effect after gamma knife radiosurgery (RS) seems to be shorter. The most common complication after all forms of RT or RS for acromegaly is the development of new hypopituitarism. Conclusion: Acromegaly is a disease characterized by GH hypersecretion, and is associated with multiple medical comorbidities and premature mortality. Successfully treated, life expectancy in acromegaly can be restored to normal. There are several effective treatment modalities available, with evolving paradigms in their use. With recent advances in the management of acromegaly, disease control can be reasonably expected in the majority of patients. Keywords: Acromegaly, Transsphenoidal surgery (TSS), Dopamine agonists, Somatostatin analogues, Pegvisomant; Radiotherapy (RT), Radiosurgery (RS)
  25. 25. Expanded Endonasal Approach Yip, Chi-Man Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital Skull base surgery remains a challenge to the neurosurgeons. Because of the complex anatomy of the skull base and the critical structures within this area, sometimes it is quite difficult to approach the lesions in this unique area especially from above, since the cranial nerves and major vessels are on the way of exposure. The endoscope’s earliest application in neurosurgery was in its use within the ventricular system. With the advancement of the imaging techniques, neuronavigation devices and the development of novel instruments, and sphenoid sinus provides a natural space for the endoscope as well as the instruments and the pathway to the skull base, leading to the development of endoscopic endonasal approach which opens a new window to the skull base surgery. On the midline sagittal plane, from crista galli down to the odontoid process of C2 and on the coronal plane, from the infratemporal fossa of one side to that of the other side, these areas now can be approached through the nose. Reconstruction is a big issue in this field. Hence, with the development of Hadad-Bassagasteguy flap and the application of tissue glue, the post-operative CSF leakage rate is much lower. Encounter the lesion first, visualization of the perforators and the corners within the surgical field are the advantages of this kind of approach.
  26. 26. Endoscopic endonasal transsphenoidal surgery for large, multi-extension pituitary macroadenomas: experience with 34 patients 李旭東 台中榮總神經外科 Objective: Recent advances in endoscopic imaging have developed an endonasal route suitable for pituitary surgery that is safe and effective for a large portion of pituitary adenomas. However, there still are some limitations to surgery in large, multi-extension macroadenomas. The main goal of this study was to evaluate the benefits and limitations of endoscopic endonasal transsphenoidal surgery for these sellar lesions in 34 of 370 pituitary adenomas. Materials and Methods: We analyzed 34 patients who had multi-extension pituitary macroadenomas (modified Hardy grade IV) that were larger than 4 cm in size. They underwent a total of 45 procedures of endoscopic endonasal transsphenoidal surgery for these lesions from November 1997 to July 2004. Twenty-one patients were male and thirteen were female. Ages ranged from 15 to 78 years. Among the 34 patients, 22 patients had nonfunctioning adenomas, 8 patients had prolactin (PRL) secreting adenomas, 2 patients had growth hormone (GH) secreting adenomas, and 2 had PRL-GH secreting adenomas. Results: Among these patients, 10 patients were operated on twice; only 1 patient was operated on 3 times. Reoperation rate was 32.3% (11/34). Visual improvement in these cases was a satisfactory 87.5% (28/32). The gross total removal of tumor rate
  27. 27. was 51.1% (23/45) and the subtotal removal of tumor rate was 31.1% (14/45). The complications rate was 11.1% (5/45), including 2 cases of post-operative CSF leakages, 2 of sphenoidal sinusitis, and 1 of post-operative intrasellar hematoma. First operative time ranged from 2-9 hours with a mean of 4.2 hours and blood loss ranged from minimal to 2700cc with a mean of 494cc. Post-operative hospital stay ranged from 2-8 days with a mean of 4.6 days in patients without complications. Second operative time ranged from 1.5-3.5 hours with a mean of 2.9 hours and blood loss ranged from minimal to 250cc with a mean of 95cc. Post-operative hospital stay ranged from 2-7 days with a mean of 3.5 days in patients without complications. Recurrence rate was 20.5% (7/34). Sixty-six percent (8/12) of the patients with a functioning tumor received medical control of hormonal hyperactivity postoperatively. Conclusion: Endoscopic endonasal transsphenoidal surgery for large, multi-extension pituitary macroadenomas in our series demonstrated acceptable results. Adequate optic decompression and low complication rate were achieved, but tumor resection was more difficult with these tumors. Longer operative time and more blood loss were also observed. However, the procedure is still a safe and effective one for improving the vision of patients with sella lesions.
  28. 28. 醫師當然要 法律懂 林萍章教授 長庚大學醫學系教授 長庚紀念醫院胸腔及心臟血管外科系主任 近日來,法界與醫界討論醫療糾紛的報導不少。醫界認為法界不該以刑法處 罰醫師,甚至佔所有醫療糾紛案件的百分之八十,榮登“世界第一名”。從而, 台灣成為全世界經常以刑法嚴厲處罰醫師的唯一「文明」國家。法界則質疑醫 師為什麼會「犯法」?因此,建議醫師需要了解法律,以免暴露在「法律的危 險」之中。其實,法律人與醫師一樣,組成份子皆是社會的菁英。雖然醫師階 層生性保守,尤其臺灣醫師經由光復初期之政治洗禮,大多數醫師更主動與 政治法律絕緣。然而,臺灣醫師為何老是犯法?甚至成為全球犯罪率最高的 專業人士。為此,臺灣醫師當然需要了解法律。 保護自己是臺灣醫師了解法律之首要目的。我國醫療糾紛案件百分之八十以 「刑事訴訟」提出,企圖「以刑逼民」威脅醫師。這在世界各國是絕無僅有的 (世界各國多以民事訴訟處理醫療糾紛案件)。 我國刑法所要求的一般過失之 「注意義務」與法官採用的「相當因果關係」之「客觀說」,竟以近乎吹毛求疵地 「事後先見之明」來挑剔面對醫療不確定性,但出發點是善意的醫師。根據美 國哈佛大學研究,高達百分之三點七的醫療行為使病人病情更惡化。但其中 四分之三為非過失行為所造成的併發症、副作用、或醫療意外。法界認為醫師 須事先將可預知的併發症與副作用告知病人或其家屬,得其同意,並於醫療 行為時遵守「醫療常規」方能免責。因此,遵守「告知後同意法則」與「醫療常 規」是臺灣醫師自保的先決條件。
  29. 29. 正確解讀法律條文是臺灣醫師了解法律之次要目的。許多臺灣醫師,甚至社 會人士,都認為只要遵守倫理原則,就不會觸犯法律。其實,這是嚴重的錯 誤。許多醫療法律會使臺灣醫師踏入陷 而不自知:安寧緩和醫療條例、人工阱 生殖條例、器官移植條例等比比皆是。這些法條為堅持某種價 而與一般人的值 倫理原則相違背。例如,我國安寧緩和醫療條例所強調的是「自然死」,即不 縮短病人生命,並不是一般人所謂的「安樂死」。適用此法律的病人必須是「末 期病人」,其要件是病人所患疾病不可治癒,且近期死亡已不可避免(例如癌 症末期病人)。目前社會上為數 多的、消耗健保資源極高的植物人、漸凍人、慢眾 性呼吸衰竭病人、或長期臥床的腦中風病人並非「末期病人」。他們並不適用安 寧緩和醫療條例。即使他們早已自願地簽署「選擇安寧緩和醫療意願書」,醫 師仍然不能放棄治療,否則將觸犯刑法「加工自殺罪」。從而,臺灣醫師不可 「想當然爾」地解讀法律條文。 修正不合時宜之法律條文與批判錯誤的判決是臺灣醫師了解法律之最終目的。 前面提到醫療糾紛案件採用民事訴訟乃世界各國常態。臺灣法界採用“獨特”的 刑事訴訟並未對病家有利,反而因臺灣醫界受「被判有罪」之威脅而破壞醫病 關係,進而走上防禦性醫療。這種錯誤的制度只是造成病、法、醫三輸,並非 臺灣人民之福。從而,「去刑化」仍是臺灣醫界努力的方向。最有效率的修法是 修正醫療法第八十二條第二項為「醫療機構及其醫師因執行業務致生損害於 病人,以故意或過失為限,負損害賠償責任。除重大過失外,不受刑事上之 訴究。」。但為使臺灣人民安心,「去刑化」仍須在立法上進行下列配套措施: 一、比照交通事故的第三責任險,建立有強制性的「醫療責任險」,使病人家 屬獲得快速賠償。歐美日本各國多有此制度。二、醫療糾紛案件進入訴訟程序 前,應強制「調解」。因為此時醫病雙方較能心平氣和地坐下來談。三、縮短醫 療糾紛民事訴訟案件之處理流程,訴訟費用在判決前由醫療責任險成立的基
  30. 30. 金暫 。墊 四、引進「專家證人」制度或「專家參審制」配合「交互詰問」制度,取代 目前的不公開的醫療糾紛鑑定制度,以確保被告的「對質詰問權」,並避免法 官的「自由心證」被誤導,進而「發現真實」與「伸張正義」。此外,在醫師有罪 的案件中,鑑定錯誤的百分比不低。為追求被告醫師的清白,而非不堪訴訟 之累地屈服於緩刑或易科罰金(外加巨額賠償),批判錯誤的判決是絕對必要 的。未來,我國醫療糾紛的鑑定機構或法院宜確立鑑定標準,並建立鑑定人 鑑定意見的審 機制。法官論罪應以查 醫療錯誤有重大過失才負刑事責任,以 「折衷說」為「相當因果關係」之基準,並以「結果迴避可能性」為「客觀注意義 務」之審 標準。查 臺灣醫師從小就是學校的資優生,也是社會的菁英,但曾幾何時已成為高犯 罪率的行業。為求早日達到病、法、醫三贏的局面,臺灣醫師當然需要了解法 律。
  31. 31. Yong-Kwang Tu, M.D.,Ph.D. Birth Date: April 9, 1948 Marital Status: Married with 2 children (Spouse: Tso-Hsien Tu) Current position: Professor and Chairman, Department of Neurosurgery, College of Medicine and Hospitals, National Taiwan University, Taipei, Taiwan Medical education: 1976 M.D. School of Medicine, National Taiwan University, Taipei 1984 Ph.D. Institute of Clinical Medicine, National Taiwan University, Taipei Postdoctoral training: 1976-1977 Resident in Internal Medicine National Taiwan University Hospital, Taipei 1977-1980 Resident in Surgery (Neurosurgery) National Taiwan University Hospital, Taipei 1980-1981 Chief Resident in Neurosurgery National Taiwan University Hospital, Taipei 1984.1988 Fellow in Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, U.S.A. Academic Appointments 1987.1988 Instructor in Surgery (Neurosurgery), Harvard Medical School, Boston, U.S.A. 1989.1991 Associate Professor in Neurosurgery (Non-tenure), National Taiwan University 1991.1998 Associate Professor in Neurosurgery (Tenure), National Taiwan University 1998- Present Professor in Neurosurgery (Tenure), National Taiwan University 2004- Present Chairman, Department of Neurosurgery, National Taiwan University Other Appointments: 1982-1983 Chief, Department of Neurosurgery, King Fahd Hospital (Jeddah General Hospital), Kingdom of Saudi Arabia 1998.1999 Vice-President, Provincial Taoyuan Hospital, Taoyuan, Taiwan 1999-2000 President, Municipal Chung-Hsin Hospital of Taipei 2000-2001 Director, Taipei Stroke Center
  32. 32. Academic Societies: 2000-2002 Secretary General, International College of Surgeons 2001-2003 President, Taiwan Stroke Society 2001-2004 President, Asian-Oceanian Society for Skull Base Surgery 2003-2005 President, Taiwan Society for Skull Base Surgery 2005-2007 President, Taiwan Neurosurgical Society 2006-2009 President, International Congress on Cerebrovascular Surgery 2007-2011 President, Asian-Australasian Society of Neurological Surgeons 2009-2012 Second Vice President, World Federation of Neurosurgical Societies
  33. 33. 郭萬祐醫師履歷簡要 中文姓名(英文) 郭萬祐 (WanYuo Guo) EMAIL wyguo@vghtpe.gov.tw 通訊地址 台北市石牌路二段 201 號台北榮民總醫院放射線部 聯絡電話 02-28757481 傳真 02-28757612 現職 台北榮民總醫院放射線部神經放射科主任 國立陽明大學醫學院、中國醫藥大學兼任教授 (教字第 013996) *學歷 1. 瑞典卡洛林斯卡醫學院(Karolinska Institute) 醫學博 士 2. 中國醫藥學院 醫學士 *經歷(職務) 台北榮民總醫院放射線部住院醫師、總住院醫師、研究 醫師、主治醫師、磁振造影科主任 專長 一般放射線學、神經放射線學、磁振造影、立體定位術、 加馬刀放射手術、胎兒影像學、腦瘤影像學 榮譽 1. Derek Harwood-Nash Paediatric Neuroradiology Scholarship, The Hospital for Sick Children university of Toronto, Toronto, Canada, 1998 2. Visiting Professor, Division of Pediatric Neurosurgery, Department of Neurosurgery, Jikei University, School of Medicine, Tokyo, Japan, 2004 3. Member-at-Large, Executive Committee, World Federation of Neuroradiological Societies 受邀演講 國內、外醫學會議及國內、外醫學中心數百場演講 論文發表 逾百篇國內、外定期期刊論文
  34. 34. 簡式履歷 Curriculum Vitae 金山黃 Jing-Shan Huang 基本資料 住址: (公)臺北市仁愛路四段 280 號 電話: (02) 2708-2121ext 3300 傳真: (02) 2754-0222 電子信箱:surgery@cgh.org.tw 學歷:國立台灣大學醫學院醫學系(1974 年畢業) 現 職 1. 國泰綜合醫院外科部部長 2. 國泰綜合醫院神經外科主任 3. 台灣外科醫學會理事 4. 台灣神經外科醫學會理事 5. 台灣神經脊椎外科醫學會理事 6. 國際外科學院院士 7. 國際外科醫學會中華民國總會理事 8. 教育部部定師資 9. 台北醫學大學系臨床教授 10.陽明大學醫學系臨床副教授 11.輔仁大學醫學系專任教師 經 歷 1. 台灣外科醫學會理事 2. 台灣外科醫學會監事 3. 台灣神經外科醫學會常務理事、理事
  35. 35. 4. 台灣神經脊椎外科醫學會理事 5. 國泰綜合醫院外科部第二加護病房主任 6. 臺大醫院神經外科總住院醫師 7. 臺大醫院外科住院醫師三年 畢業後訓練 1. 美國辛辛那堤大學腦神經中心研究員 2. 日本美原腦血管中心研究員 專 長 1. 腦神經外科 2. 脊椎外科 3. von Hippel Lindau 基因研究 4. 腦瘤及脊髓腫瘤手術
  36. 36. MIN-HSIUNG CHEN Mhchen@vghtpe.gov.tw Director General of Neurosurgery Center of Neurosurgery Taipei Veterans' General Hospital +886-2-2875-7882 GENENERAL INFORMATION: Date of Birth: December 27th 1953 EDUCATION National Yan-Ming Medical University, Taipei, Taiwan Ph.D in Clinical Medicine, September 2005 Taipei Medical College, Taipei, Taiwan Medical Doctor, June 1980 LANGUAGES English (Proficient), Chinese (Fluent in Mandarin and Taiwanese) EXPERIENCES Taipei Veterans' General Hospital, Taipei, Taiwan Director General of Center of Neuroscience July 2003 – Present Taipei Veterans' General Hospital, Taipei, Taiwan Director of Intensive Care Unit of Center of Neuroscience January 2002 – July 2003 Taipei Veterans' General Hospital, Taipei, Taiwan Attending Neurosurgeon (主治醫師) January 1989 – December 2001 XXXX Hospital, Glasgow, Scotland, United Kingdom Visiting Neurosurgeon November 1988 – December 1989 Taipei Veterans' General Hospital, Taipei, Taiwan General Neurosurgeon (總醫師) June 1987 – December 1988 Taipei Veterans' General Hospital, Taipei, Taiwan Neurosurgeon July 1984 – May 1987 Taipei Veterans' General Hospital, Taipei, Taiwan Surgeon June 1982 – June 1984 TEACHING EXPERIENCES National Yan-Ming Medical University, Taipei, Taiwan Associate Professor of Clinical Neurosurgery June 1990 – Present Taipei College of Nursery, Taipei, Taiwan Lecturer June 1990 – Present June 1990
  37. 37. Name : Tzu-Kang Lin (林子淦) Sex: Male Birth date: October 12, 1955 Birthplace: Taichung, Taiwan. Citizenship: Taiwan Office address: (1) 199, Tung Hwa North Road, Taipei, Taiwan. (2) 5, Fu-Shing St. Kwei-Shan, Taoyuan County, 333 Taiwan. Office tel.: (03) 328-1200 ext. 2412 Fax: 886-3-328-5818 Language: Taiwanese, Chinese, and English Spouse: Miao-Hwa Lee Date of birth: January 3, 1956 Children: Che-Chung Lin Date of birth: October 15, 1986 Male Che-Yu Lin Date of birth: May 25, 1990 Male Education: China Medical College, Taichung, Taiwan September 1974 -- June 1981. Post-graduate education and training General Surgery: Department of Surgery Chang Gung Memorial Hospital, Taipei, Taiwan June 30, 1983 -- June 30, 1985 Neurosurgery: Division of Neurosurgery Chang Gung Memorial Hospital, Taipei, Taiwan July 1, 1985 -- June 30, 1989 Neurology: Department of Neurology Chang Gung Memorial Hospital, Taipei, Taiwan. November 1, 1986 -- January 31, 1987 Neuroradiology: Department of Radiology (Neuroradiology) Chang Gung Memorial Hospital, Taipei, Taiwan July 1, 1987 -- September 30, 1987 Neuropathology: Department of Pathology (Neuropathology) Massachusetts General Hospital, Boston, Massachusetts, U.S.A. April 1, 1988 -- June 31, 1988 Employment Record: 1. July 1, 1989 -- Present Full time Neurosurgery Attending Chang Gung Memorial Hospital, Taoyuan, Taiwan 2. July 1, 1994 – Present Assistant professor, Neurosurgery Chang Gung University and Chang Gung Memorial Hospital, Taoyuan, Taiwan
  38. 38. Name: 曹 中 侃 Tsao / Chung Kan Sex: Male Birth Date: 1969. 04. 13 Birth Place: Changhua, Taiwan, R.O.C. Citizenship: R.O.C Office Address: 5, Fu-Shing Street, Gueishan Shiang, Taoyuan 333, Taiwan, R.O.C. Office Tel.: 886-3-3281200 ext. 3221, 0968-371300 Language: Mandarin, English, Taiwanese Spouse: Yeh / Mei Hua, 1977, 05, 12 Education Background: 1988 ~ 1995 Medical department, Chung Shan Medical University, Taichung, Taiwan, R.O.C. Post-graduate Education: General surgery: Residency in Chang Gung Memorial Hospital, Taipei, Taiwan July 1997 ~ June 2000 Plastic surgery: Residency in Chang Gung Memorial Hospital, Taipei, Taiwan July 2000 ~ now Employment Record: Residence, Department of General Surgery, Chang Gung Memorial Hospital July 1997 ~ June 2000 Residence, Department of Plastic Surgery, Chang Gung Memorial Hospital July 2000 ~ now Board Certification: Physician Board of R.O.C. ( No. 027012 ) Nov. 1996, Surgeon Board of R.O.C. ( No. 004679 ) Dec. 2001, Plastic Board of R.O.C. (No. 0348) Dec.2003 Hand Surgeon Board of R.O.C. (No. 000588) May 2004 Licensers: License No 5907 Professional Affiliations: 1.Taiwan Surgical Association, Republic of China 2.Plastic Surgical Association, Republic of China 3.Hand Surgical Association, Republic of China Research Insterest: 1. Neuroma reuse as recipient nerve source 2. Using the rat heterotopic heart transplant model, TUNEL assay and DNA laddering can detect apoptosis expressions and correlate with rejection occurrence sequence and severity grading.
  39. 39. KU-HAO FANG, MD POSTGRADUATE TRAINING 2005-2007 Chief Resident of Otolaryngology Department Chang Gung Memorial Hospital, Linkou, Taiwan 2002-2005 Otolaryngology Residency Chang Gung Memorial Hospital, Linkou, Taiwan 2001-2002 Internship Taipei Medical University Hospital, Taipei, Taiwan Taipei Medical University- Wan Fang Hospital, Taipei, Taiwan EDUCATION 1995-2002 Taipei Medical University Doctor of Medicine HONORS AND AWARDS 2002 Outstanding College Youth of 2002 by the China Youth Corps (CYC) HOSPITALAPPOINTMENTS Chang Gung Memorial Hospital, Linkou and Taoyuan, Taiwan SOCIETIES Taiwan Otolaryngological Society
  40. 40. 姓名:黃祖源 性別:男 出生日期:39年1月20日      年齡:58歲 住址:(公) 高雄市自由一路100號 高雄醫學大學附設醫院外科 電話:(公) 07-3215049 現職: 高雄醫學大學外科學部定副教授 高雄醫學大學神經外科主任 高雄醫學大學實驗外科學主任 學歷: 1965~1968 省立台南一中畢業 1968~1975 高雄醫學大學醫學系畢業 1981~1988 日本國立大阪大學神經外科醫學博士 1989 高雄醫學大學外科學部定副教授 1997  日本國立熊本大學神經外科研究員 1997~1999 中山大學人力資源管理研究所「醫療管理碩士學分班」學員 經歷: 1977~1978 台北中心診所外科住院醫師 1978~1981 台北馬偕紀念醫院外科、神經外科住院醫師 1981~1982 日本國立大阪大學神經外科醫師、研究員 1983~1984 日本大阪勞災醫院神經外科主治醫師 1985~1986 日本神戶掖濟會醫院神經外科主治醫師 1987~1988 日本大阪行岡醫院神經外科主治醫師 1988~1989 台北馬偕紀念醫院神經外科主治醫師 1989~2002 高雄醫學大學神經外科主治醫師 1996~1998 高雄醫學大學神經外科加護病房主任 2000~2002 高雄醫學大學神經外科主任 2003~2005 高雄市立聯合醫院外科部長 高雄醫學大學臨床教授 2005~2006 高雄市立聯合醫院院長 2007~迄今 高雄醫學大學神經外科主治醫師,主任 高雄醫學大學實驗外科學主任
  41. 41. 1、 基本資料 中文姓名 馬辛一 英文姓名 Ma, Hsin-I (Last Name) (First Name) (Middle Name) 國籍 台灣 性別 ■男□女 出生日期 1961 年 8 月 31 日 聯絡/地址 114 台北市成功路二段 325 號 三軍總醫院 神經外科部 聯絡電話 (02)87927177 傳真號碼 (02)87927178 E-Mail uf004693@mail2000.com.tw 二、主要學歷 請填學士級以上之學歷或其他最高學歷均可,若仍在學者,請在學位欄填「肄業」。 畢/肄業學校 國別 主修學門系所 學位 起訖年月 國防醫學院 台灣 醫學系 醫學士 1979/08 至 1986/07 國防醫學院 台灣 醫學科學研究所 理學博士 1996/08 至 2001/12 三、現職及與專長相關之經歷 指與研究相關之專任職務,請依任職之時間先後順序由最近者往前追溯。 服務機關 服務部門/系所 職稱 起訖年月 現職:三軍總醫院 神經外科部腦腫瘤醫學科 科主任 2002/07 至迄今 國防醫學院 外科學系 助理教授 2003/01 迄今 經歷:美國匹茲堡大學 分子基因及生物化學研究 研究員 2000/05 至 2002/05 所基因治療中心 美國匹茲堡大學 癌症中心 研究員 2000/05 至 2002/05 三軍總醫院 神經外科部 主治醫師 2001/11 至 2002/07 三軍總醫院 外科部神經外科 主治醫師 1992/08 至 2001/11 三軍總醫院 外科部神經外科 住院總醫師 1991/08 至 1992/07 三軍總醫院 外科部 住院醫師 1986/08 至 1991/07 四、專長 請自行填寫與研究方向有關之專長學門。 分子生物學 基因治療學 細胞生物學 病毒載體學 外科學 神經腫瘤學 神經外科學 脊椎醫學
  42. 42. 王文斌 醫師 學歷 台灣大學醫學系 經歷 1. 前長庚醫院神經外科醫師 2. 中華民國神經外科專科醫師 3. 林口長庚醫院神經外科住院醫師 現職 1. 羅東博愛醫院外科系醫療副院長 2. 羅東博愛醫院神經外科主任醫師 3. 羅東博愛醫院神經外科主治醫師
  43. 43. 個人資料表 一、基本資料 中文姓名 劉安祥 英文姓名 Lieu Ann Shung 性別 男 出生年月日 51 年 8 月 21 日 地址 807 高雄市三民區自由一路 100 號外科 電話 07-3215049 傳真 07-3215039 E-mail L510821@pchome.com.tw 二、主要學歷 畢業學校 國別 主修學們系所 學位 起訖年月 高雄學大學 中華民國 醫學系 學士 1981/09~1988/06 三、現職及專長 服務機關 服務部門 職稱 起訖年月 現職: 高雄醫學大學附設醫院 神經外科加 護病房 主任 2006~迄今 高雄醫學大學附設醫院 神經外科 主治醫師 1998~迄今 高雄醫學大學 外科學 助理教授 2006/01~迄今 經歷: 美國維吉尼亞大學 神經外科 研究員 2003/08~2005/07 高雄醫學大學附設醫院 外科 住院醫師 1988/08~1994/07 高雄醫學大學附設醫院 神經外科 總醫師 1994/08~1996/07 高雄醫學大學 外科學 講師 2000/08~2005/12
  44. 44. 葉昭宏 Chao-hung Yeh, MD Place of birth: 台灣 Taiwan,R.O.C Date of birth: May 22, 1965 Graduate: 中國醫學大學 醫學系 學士 1984 年 9 月至 1991 年 6 月 China Medical College Sep 1, 1984 - June 31, 1991 Employment Records: 奇美醫學中心 外科部住院醫師 91.9—93.6 Resident R1-R2 Department of Surgery Sep, 1991 — 1993-June 奇美醫學中心 神經外科住院醫師 93.7—96.6 Chief Resident Department of Surgery July, 1996 - June 1997 奇美醫學中心 神經外科總醫師 96.7—97.6 Chief Resident Department of Neurosurgery July, 1997 - June 1998 奇美醫學中心 神經外科資深研究員 97.7—99.6 Fellow F1-F2 Department of Neurosurgery July, 1998 - June 2000 奇美醫學中心 神經外科主治醫師 99.7 — now Full time attending Department of Neurosurgery July, 1999 – Present Barrow neurological institute, AZ,USA 研究員 2002-2003.
  45. 45. 1、 基本資料                 中 文 姓 名 蘇 泉 發 英 文 姓 名 Su, Chain-Fa (Last Name) (First Name) (Middle Name) 國 籍 中 華 民 國 性 別  男 □ 女 出生日期 1955 年 12 月 6 日 聯 絡 地 址 □□□□□花蓮市中央路三段 707 號 聯 絡 電 話 (公).(03)8561825 ext 2215 (宅/手機).0935615995 傳 真 號 碼 (03)8564797 E-MAIL suchainfa@yahoo.com.tw 2、 主要學歷 由最高學歷依次填寫,若仍在學者,請在學位欄填「肄業」。 學校名稱 國別 主修學門系所 學位 起訖年月(西元年/月) 國防醫學院 中華民國 醫學系 醫學士 1973/ 9 至 1980 / 8   / 至  /    / 至  /    / 至  /  3、 現職及與專長相關之經歷 指與研究相關之專任職務,請依任職之時間先後順序由最 近者往前追溯。 服務機構 服務部門/系所 職稱 起訖年月(西元年/月) 現職:慈濟綜合醫院 神經外科 主任  1994 / 7 至今 慈濟醫學院 醫學系 副教授 1994/ 07 至今 經歷:三軍總醫院 神經外科 主治醫師 1986 / 7 至 1994 / 7 美辛辛那提大學 神經外科 臨床醫師 1989 / 7 至 1990 / 7 美密蘇里哥倫比亞大學醫學院 神經外科 研究員 1988 / 6 至 1989 / 6   / 至  /    / 至  /  四、專長 請自行填寫與研究方向有關之學門及次領域名稱。 1. 腦神經外科學 2. 腦立體定位手術 3. 神經生理 4. 心臟血管生理 9 7 0
  46. 46. 姓名 服務單位 職稱 學歷 經歷 黃全福 中山醫學大 學附設醫院 加馬刀中心主任, 神經外科主任,中 山醫學大學醫學系 醫學研究所助理暨 教授 國立陽明醫學院 美國匹茲堡醫學中心神經外 科臨床研究員,台中榮總神經 外科主治醫師,光田綜合醫院 大甲分院神經外科主任
  47. 47. Cheng Wen-Yu Education: China Medical University, Taichung, Taiwan. M.D. degree, 1998. Professional Affiliations: Member Neurosurgical Society, Taiwan (R.O.C.) ID 0348 Surgical Association, R.O.C. ID 2-4203 Experience: 02/04-present Attending Neurosurgeon, Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan. 04/05-09/06 Fellow, Department of Neurosurgery, Standford University Hospital 08/03-01/04 Fellow, Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan. 07/02-07/03 Chief Resident, Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan. 07/97-06/02 Resident, Department of Neurosurgery,, Taichung Veterans General Hospital, Taichung, Taiwan. 07/96-06/97 Intern, Taichung Veterans, General Hospital, Taichung, Taiwan.
  48. 48. CURRICULUM VITAE Name: Yip, Chi-Man Gender: Female Address: Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital 386, Ta-chung 1st Road, Kaohsiung 813-46, Taiwan Tel.: 886-7-3422121 ext. 3040 or 3017, Fax: 886-7-3455064 Education & Training: 1988 M.D., Taipei Medical College, Taipei, Taiwan 1987-1988 Internship, Taipei Medical College Hospital Taipei,Taiwan 1988-1991 Surgical Resident, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan 1991-1997 Neurosurgery Resident, Division of Neurosurgery,Department of Surgery, Kaohsiung Veterans General Hospital Kaohsiung, Taiwan 1994-1995 Chief Resident, Department of Surgery Kaohsiung Veterans General Hospital Kaohsiung, Taiwan 1997-Present Attending Neurosurgeon, Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital 2007-2008 Visiting Scholar Fellowship, Minimally Invasive Neurosurgery Center, Department of Neurological Surgery, University of Pittsburgh Medical Center, U.S.A. Present Position: Attending Neurosurgeon, Division of Neurosurgery,Department of Surgery Kaohsiung Veterans General Hospital Kaohsiung, Taiwan
  49. 49. Hsu-Tung Lee M.D. Attending Neurosurgeon Department of Neurosurgery. Taichung Veterans General Hospital, 160, Sec. 3, Taichung-Kang Road, Taichung (407), Taiwan, R.O.C. Tel: 886-4-23741218, Fax: 886-4-23741208 E-Mail: sdlee@vghtc.gov.tw leesd2001@hotmail.com Education: National Defense Medical Center, Taipei, Taiwan, R.O.C., M.D. degree, 1990 Experience: 08/01-present Attending Neurosurgeon, Department of Neurosurgery, Taichung Veteran General Hospital, Taichung, Taiwan 03/08 Assistant Professor, Jenteh Juinior College of Medicine,Nursing and Management 07/05-06/06 Faculty, Dept. of Neurosurgery, Johns Hopkins Hospital , Baltimore, MD, USA 07/05-06/06 Research Fellow, Lenz Functional Neurosurgery Lab. Johns Hopkins Hospital , Baltimore, MD, USA 08/01-present Lecturer, National Defense Medical Center, Taipei,Taiwan 08/01-present Lecturer, National Yang Ming University, Taipei, Taiwan. 07/00-07/01 Clinical fellow, Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan 07/99/-06/00 Chief Resident, Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan. 08/98-06/99 Resident, Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan. 07/98-07/98 Attending surgeon , Surgical department, Kaoshung Army General Hospital 07/97-06/98 Chief Resident, Surgical department, Kaoshung Army General Hospital 09/93-06/97 Resident, Surgical department, Kaoshung Army General Hospital
  50. 50. 林萍章履歷表 1. 姓名:林萍章 2. 性別:男性 3. 出生日期: 1954年8月14日 4. 通訊地址:333桃園縣龜山 復興街五號鄉 長庚紀念醫院 胸腔及心臟血管外科系 5. 現職: a. 長庚紀念醫院外科臨床教授 b. 長庚大學醫學院外科教授 c. 長庚紀念醫院胸腔及心臟血管外科系主任 6. 學歷: 1980 年 6 月:國立臺灣大學醫學院醫學系畢業 2005 年 7 月:東吳大學法律學院碩士班畢業 7. 經歷: a. 1987年7月至今: 長庚紀念醫院胸腔及心臟血管外科主治醫師 b. 1990年8月至1991年10月: 長庚醫學院外科講師 c. 1991年7月至2003年6月: 長庚紀念醫院胸腔及心臟血管外科系主任 d. 1991年7月至1993年6月: 長庚紀念醫院外科臨床講師 e. 1991年11月至1996年4月: 長庚醫學院外科副教授 f. 1993年7月至1997年6月: 長庚紀念醫院外科臨床副教授 g. 1996年5月至今: 長庚大學醫學院外科教授 h. 1997年7月至今: 長庚紀念醫院外科臨床教授 i. 2005年7月至今: 長庚紀念醫院胸腔及心臟血管外科系主任 8. 專長: a. 心臟外科手術 b. 微創心臟手術 c. 心臟移植手術 9. 榮譽: a. 長庚醫院最佳論文獎:1991 年 Lin PJ, Chang CH, Chu JJ, et al: Endothelium-dependent production of prostacyclin in human internal mammary artery. Chang Gung Med J 1991;14:222-9. b. 中華民國行政院國科會研究獎: (1) 乙等研究獎:1992 年 (2) 甲等研究獎:1993, 1994, 1996, 1997, 1998 年 (3) 優等研究獎:1995 年 c. 長庚紀念醫院研究獎:1993, 1994, 1995, 1996, 1997, 1998 年

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