At the time, I was already back in my classroom, getting ready for a new school year. Demols A, Marchal R, Devire J, Van Laethem JL. My favorite book right now is Blind Your Ponies, by Stanley Gordon West. 71% of the patients had hilar tumor (Klatskin), 23% distal and 6% intrahepatic CCA (IH). I itched everywhere my arms, my legs, my hands, my feet, my chest. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. 2023 MJH Life Sciences and CURE - Oncology & Cancer News for Patients & Caregivers. Bookshelf What Is the Life Expectancy for Cholangiocarcinoma? It would wake me in the middle of the night,, Heidi Rhea is a long-term survivor. 8600 Rockville Pike I attended the American Society of Clinical Oncology (ASCO) Annual Meeting this year as a research advocate. She was the longest survivor of correctable biliary atresia in our series in the Tohoku University Hospital. For example, if the 5-year relative survival rate for a specific stage of bile duct cancer (cholangiocarcinoma) is 30%, it means that people who have that cancer are, on average, about 30% as likely as people who don't have that cancer to live for at least 5 years after being diagnosed. Photodynamic therapy for cholangiocarcinoma. Affected individuals can survive for several months to several years after diagnosis, depending on the location of the cancer and how advanced it is. The outcome of interest was postoperative long-term survival and outcome data collected was limited to overall survival . It's located in his main bile duct of the liver. Please enable it to take advantage of the complete set of features! Unable to load your collection due to an error, Unable to load your delegates due to an error. VINEYARDS; FARMING PRACTICES; WINES. Paik WH, Park YS, Hwang JH, Lee SH, Yoon CJ, Kang SG, Lee JK, Ryu JK, Kim YT, Yoon YB. Each year, an estimated 8,000 people in the United States are diagnosed with bile duct cancer. Epub 2016 Dec 16. This study has focused on the repeat surgery when analyzing the survival outcomes of recurrent ICC. Viewing 15 posts - 1 through 15 (of 25 total), This topic has 24 replies, 19 voices, and was last updated. sharing sensitive information, make sure youre on a federal 2023 Cholangiocarcinoma Foundation - All Rights Reserved - Disclaimer, Language, Translation & Accessibility Options, Staging Perihilar Extrahepatic Cholangiocarcinoma, Staging Distal Extrahepatic Cholangiocarcinoma, Understanding Your Clinical Trial Results. -, World J Surg. Just saw my GI doc today and he says Im doing remarkably well. Methods: Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Background. Following subtotal stomach-preserving pancreatoduodenectomy, multiple hepatic recurrences were identified 9 months later, and GC therapy was initiated. Unresectable cholangiocarcinoma: comparison of survival in biliary stenting alone versus stenting with photodynamic therapy. 2021 Oct 11;13(20):5074. doi: 10.3390/cancers13205074. Bethesda, MD 20894, Web Policies official website and that any information you provide is encrypted N Engl J Med. 2022 Oct 14;14(10):e30315. This thread is so encouraging. Not very comforting., although I love, love love the stories. The .gov means its official. We were told from his oncologist team that after 3 months of aggressive chemo that we are going 2 hve another CT scan 2 c if the tumor has shrunk. epson control dashboard. Thanks! Bethesda, MD 20894, Web Policies Where do these numbers come from? A 61-year-old man diagnosed with HCCA was referred to our hospital. The outlook (prognosis) for people with cholangiocarcinoma is usually poor. You have a bad weed and the medicines don't usually work.". It is the most common primary tumor of the liver after hepatocellular carcinoma (HCC). It is a book of hope, and not giving up, because miracles do happen. 2020 Dec;25(12):2083-2089. doi: 10.1007/s10147-020-01775-x. I am also in California. Had chemo and radiation afterwards and have been cancer free since. Although intrahepatic cholangiocarcinoma (ICC) is relatively rare, its incidence and mortality are increasing worldwide. I was quite passionate about chocolate and spent several years playing in kitchens. Following subtotal stomach-preserving pancreatoduodenectomy, multiple hepatic recurrences were identified 9 months later, and GC therapy was initiated. It has spread and pretty much covered his liver however his liver is functioning normally, he has no tumour markers in his blood tests and isnt jaundice. So in our case that would have made her worse. government site. Kahaleh M, Mishra R, Shami VM, Northup PG, Berg CL, Bashlor P, Jones P, Ellen K, Weiss GR, Brenin CM, Kurth BE, Rich TA, Adams RB, Yeaton P. Clin Gastroenterol Hepatol. He feels well but has clearly lost weight and looks very jaundiced. 1 In light of the . The surgeon shared that I was "lucky" as he was able to get all of the tumor. [A case report of combined hepatocellular-cholangiocarcinoma whose lymph node recurrence effectively treated with UFT]. -, Horgan AM, Amir E, Walter T, Knox JJ. doi: 10.7759/cureus.30315. 2022 Jun 23;12:896764. doi: 10.3389/fonc.2022.896764. Our research revealed 1- and 3-year survival rates of 75.2% and 37.1%, respectively. It's an 8 1/2 hr surgery with dire COMPLICATIONS. FOIA Many doctors recommend blood and/or imaging tests about every 6 months for at least the first couple of years after treatment. My son Matt and his wife, Corrina, added to the richness of our life with the birth of my first grandchild, Millicent Rae, in May. Background Because of its high rate of early recurrence and its poor prognosis, long-term survival after cholangiocarcinoma is rare; therefore, only limited information on patients surviving more than 5 years after surgical therapy is available. Method: 8600 Rockville Pike 2021 Oct 21;11:776863. doi: 10.3389/fonc.2021.776863. This time I thought, Okay God, I'm really done now, right? I refused to give up and had chemotherapy on and off for 2 years now. The outcome after surgery for intrahepatic cholangiocarcinoma (ICC) with lymph node (LN) metastasis is generally poor, [1][2][3][4] and there are very few reports of long-term survivors after surgery. They are all attending college. Epub 2019 Feb 12. MeSH and transmitted securely. It is only accessible by boat or plane, and it does not have any traffic lights. 2023 MJH Life Sciences and CURE - Oncology & Cancer News for Patients & Caregivers. Just FYI, drank very little and never in area of river flukes, so no idea how I got this. I will hit my eight year mark of stage IV Intrahepatic Cholangiocarcinoma on December 1st this year. My congratulations to all the long-term survivors! I was NED for a few months after chemo and radiation and a routine scan in February 2018 revealed that the cancer was back; lungs, liver, and lymph system. [A case report--intrahepatic arterial infusion with CDDP and S-1 administration can elicit long-term survival for the patient with recurrenced intrahepatic cholangiocarcinoma after resection]. Patient with advanced intrahepatic cholangiocarcinoma with long-term survival successfully treated with a combination of surgery and chemotherapy. The tumor stage was T2aN0M0, stage II, based on the TNM . Effectiveness of repeat hepatic resection for patients with recurrent intrahepatic cholangiocarcinoma: Factors associated with long-term outcomes. My excitement for sweets is balanced by my love of tennis and hiking. If the cancer has spread to the regional lymph nodes, the 5-year survival rate is 8%. Careers. Clipboard, Search History, and several other advanced features are temporarily unavailable. Federal government websites often end in .gov or .mil. doi: 10.1016/j.surg.2017.08.011. If the cancer has spread to the regional lymph nodes, the 5-year survival rate is 16%. It is only accessible by boat or plane, and it does not have any traffic lights. Epub 2008 Jul 26. Patients with the best prognosis may be seen every 2-3 months with periodic laboratory and. 2021 Dec 15;13(12):1939-1955. doi: 10.4251/wjgo.v13.i12.1939. government site. 1,2 In the United States, the age-adjusted incidence of ICC increased from 0.32 in 1975 to 0.85 per 100 000 population in 2000 and has yet to plateau. We report a 49-year-old man with unresectable intrahepatic cholangiocarcinoma (ICC) who was treated with oral tegafur-uracil (UFT) chemotherapy and survived for over a decade. External-beam radiotherapy (50.4 Gy) was performed, and the tumor's size decreased to 6.3 cm in diameter. Finally, I wanted to become a mentor for other people battling the same cancer. Hepatic resection and palliative surgery are the two most common surgical treatments for this illness. Conclusions: Repeat surgery for recurrent ICC with an appropriate selection can be associated with prolonged survival. Our family started Craine's Cholangiocarcinoma Crew, a 501c3 that raises funds for research on bile duct cancers. Eleven years have now passed since the laparotomy, and the patient continues to lead a normal daily life working as a banker. Cholangiocarcinoma, also known as bile duct cancer, occurs mostly in people older than age 50, though it can occur at any age. Overall median and 5-year survival of resected patients were 37 months and 43 %, respectively, as compared to 13 months and 7 % in unresectable patients. You will also read general information on surviving the disease. I started six months of chemotherapy, and upon completion I thought, I am done with this cancer, end of story! I really hope it continues. It has been a good 2 years, very little pain or nausea. But 51-year-old Nicholas Belluomini of Erie, PA, is optimistic about his prognosis. We came up with three ideas, and we have implemented all of them. these therapies only work for a finite amount of time without inducing long term remission. Tumor size decreased on CT, and fluorodeoxyglucose-positron emission tomography/CT revealed a decline in the standardized uptake value of the tumor after 2 months, with decreased DUPAN-2 levels. He had his first chemo lastweek and touchwood to date has had no side effects. With two daughters in college that were not too far off-major milestones and such. Accessibility Endoscopic biliary decompression improved the QoL faster than surgery. Moving forward in the treatment of cholangiocarcinoma. PMC Long-term outcomes after surgical resection of bile duct cancer remain unsatisfactory, and survival, particularly after tumor recurrence, is poor. Have recently been dealing with issues of scar tissue in the ducts of the left lobe causing blockages leading to recurring sepsis. The 1-year survival was significantly improved for patients who underwent surgery plus adjuvant chemotherapy. The patients receiving metallic stents had better survival than those receiving plastic stents (40.4% vs 12.5% at 1 year, 9.1% vs 5.0% at 2 years, respectively). She talks about cholangiocarcinoma at every opportunity. Before 2004 May;24(2):177-87. doi: 10.1055/s-2004-828894. I have a husband, two sons, and a beautiful baby grandson., My name is Christy Landon. Thirty-five patients with simultaneous or consequent intrahepatic recurrence and extrahepatic recurrence were not amenable to the repeat surgery. -, Ann Surg Oncol. | Find, read and cite all the research you . Our family started Craine's Cholangiocarcinoma Crew, a 501c3 that raises funds for research on bile duct cancers. The survival statistics of cholangiocarcinoma has been showing very pathetic figure over the decades. My surgery was a choledocojejunostomy (sp?). Bile ducts connect your liver to your gallbladder and to your small intestine. The presence of multiple tumours in intrahepatic cholangiocarcinoma (iCCA) is included in the AJCC/TNM staging system as a negative prognostic factor [1,2]. This diagnosis and understanding it more made me realize that it has probably been growing in the body for years before the official down on paper diagnosis. I have mentored over 100 patients through the Scott Hamilton 4th Angel program, and also through various other organizations. The 5-year survival rate for extrahepatic bile duct cancer is 10%. If the cancer has spread to a distant part of the body, the 5-year survival rate is 2%. For example, in northeast Thailand, cholangiocarcinoma occurs in about 110 per 100,000 people. Surgery for recurrent biliary carcinoma: results for 27 recurrent cases. Radical surgical resection remains the main curative option for pCCA. An official website of the United States government. Never give up hope, or you will lose the fight. In our case treatment was not an option, as my mom is getting the same side effects as if she were receiving the standard treatment. 2015 Feb 27;13:82. doi: 10.1186/s12957-015-0507-8. Federal government websites often end in .gov or .mil. All rights reserved. Not much energy but still functioning. I wanted my children to have a normal life, and I didnt want them to worry on a daily basis if their mother was going to live or die. 2008; 15:545-548. doi: 10.1007/s00534-007-1270-1. I live in Richmond, VA. Im a retired IT executive. How successful is high-dose (> or = 60 Gy) reirradiation using mainly external beams in salvaging local failures of nasopharyngeal carcinoma? My partner received similar news yesterday, inoperable, because of where it is and drainage and chemotherapy being the only treatment plan, Hes 56 and 3 weeks ago was leading a normal life, just went jaundiced over a couple of days. I don't put much money into retirement anymore and I truly live in the moment. We have four adult children: Conner, Alexis, Logan, and Alec. PDF | Background: This study aimed to determine the role of surgical treatment in patients with stage II intrahepatic cholangiocarcinoma (iCCA).. | Find, read and cite all the research you need . They want to share with other members that they found a great post that still applies to todays problems with CC. . eCollection 2022. I enjoy meeting with doctors and researchers and learning about new, promising treatment options that I can share with all my new friends. The tumors were no longer evident 18 months later, and GC therapy was discontinued at the patient's request. When the mass on my arm was biopsied, the results revealed just how rare my cancer was. Each anatomic subtype has distinct genetic. See theRisk Factorsand Prevention section for more information. Liver Int. My first thought was, What would my family do without me? Hi, I was diagnosed in Aug 2019 and at first given months then within a week was told I had weeks. [ 1] We have some information on our website on cholangiocarcinoma here which I hope you will find useful. Its about the town of Willow Creek, MT, whos high school basketball team hasnt won a game in 5 YEARS, yet they play every game like there was a chance, even though they many be down 50pts with one minute to go, they played just as hard, like they actually had a chance to win. PMC Careers. Clipboard, Search History, and several other advanced features are temporarily unavailable. If the cancer has spread to the regional lymph nodes, the 5-year survival rate is 16%. I had a liver resection, and I was diagnosed with Intrahepatic Cholangiocarcinoma. I quickly made a will and tried to write some letters to my boys and my parents. The .gov means its official. The rush-hour consists of ranchers moving their sheep from one farm to another. Phase I/II trial evaluating concurrent carbon-ion radiotherapy plus chemotherapy for salvage treatment of locally recurrent nasopharyngeal carcinoma. Tokuda K, Morine Y, Saito Y, Yamada S, Miyazaki K, Yamashita S, Okikawa S, Ikemoto T, Imura S, Shimada M. Int J Clin Oncol. Cancer of the bile duct, or cholangiocarcinoma, is extremely rare. My husband is tolerating chemo well afew months down the line from my original post ,,,hisLiverfunction and cancer markers are improved . The most important piece of advice I give patients is the minute your doctor take your hope away, find a new doctor. The whole way cc is treated is evolving and I am hopeful the numbers will continue to improve. The tumor was diagnosed as ICC, and a laparotomy was performed; however, the tumor was too advanced to perform a curative resection. eCollection 2022. He didn't sugarcoat my diagnosis, but he offered hope. Endoscopic palliative therapy allowed a faster community reintegration, but with variable evolution. I think it is possible to live a long full life after cholangiocarcinoma just like people without cancer. I didn't have time for cancer, but as we all know it doesn't take applications. 1989 Mar;16(3 Pt 1):411-4. Cholangiocarcinomas (CCAs) are tumors with a poor prognosis and a lower quality of life (QoL). The site is secure. Also, I am a Seattle native and still live in Seattle. We do go back 10 years but because of the rarity of CC quite a few posts from way back still apply today. The true incidence of bile duct cancer is unknown, however, because establishing an accurate diagnosis is difficult. Objective: Evaluation of the outcome after resection for distal bile duct cancer (DBC) with focus on the impact of microscopic histopathological resection . government site. The researchers calculated that the overall median survival of patients with primary ITP was reduced by 5.1 years while that of patients with secondary disease was reduced by 11.1 years compared to the general population. If the cancer has spread to a distant part of the body, the 5-year survival rate is 2%. The cancer had spread to the lymph nodes in the hepatoduodenal ligament and on the posterior surface of the pancreas head. Cholangiocarcinoma (CCA) is a highly lethal adenocarcinoma of the hepatobiliary system, which can be classified as intrahepatic, perihilar and distal. Somehow hope fuels a refusal to give up, even when your brain knows the harsher realities. Most people who develop cholangiocarcinoma are older than 65. Effectiveness of repeat surgery for recurrence after primary hepatectomy in patients with intrahepatic cholangiocarcinoma. I live in the Pacific Northwest on a remote island in the San Juan archipelago. Talk with your doctor if you have any questions about this information. [Google Scholar] If the cancer does come back (recur), further treatment will depend on where the cancer is, what treatments you've had before, and your overall health. On December 1, 2009 at age 41, I was diagnosed with Intrahepatic Cholangiocarcinoma, aka Bile Duct Cancera very rare, aggressive and difficult to treat type of cancer. Combined hepatocellularcholangiocarcinoma (CHC) is a rare subtype of primary liver cancer with biphenotypic characteristics of both hepatocytic and cholangiocytic differentiation, . Its reassuring to know people are living longer than the prognosis we were given. I am studying to be a research advocate so I can help patients navigate clinical trials, find second and third opinions and find the best possible treatment options. MeSH This means the estimate may not reflect the results of advancements in how bile duct cancer is diagnosed or treated from the last 5 years. PDF New Techniques of Resection and Long- Term Survival for . First, I knew that faith played a strong role in my life, and I knew that I needed to rely on my faith to get through this. The chemo stopped working a few months ago and I have been given a new chemo treatment which includes chemo tablets. Up to 40 percent of people who have their tumors removed will survive for five years or more. Effectiveness of surgery for recurrent cholangiocarcinoma: A single center experience and brief literature review. DUPAN-2, duke pancreatic monoclonal antigen type-2; CA19-9, carbohydrate antigen 19-9; GC, gemcitabine and cisplatin; CIRT, carbon ion radiotherapy; cCR, clinical complete response; Lt. Would you like email updates of new search results? Also, gallstones and inflammatory conditions of the digestive tract, such as ulcerative colitis or an associated condition called primary sclerosing cholangitis (PSC), increase the risk of bile duct cancer. If the cancer is diagnosed at an early stage, the 5-year survival rate is 25%. The mortality rate of HCC-CC was 79.2% (HCC, 77.5%; CC, 93.5%) and the local recurrence rate of HCC-CC was 65.3% (HCC, 74.6%; CC, 88.4%). official website and that any information you provide is encrypted Traditionally, bile duct tumors located within the liver were classified with hepatocellular carcinoma as primary liver tumors. 2007;21(6):1015-29. doi: 10.1016/j.bpg.2007.09.005. sharing sensitive information, make sure youre on a federal My name is Bekki. I was diagnosed with stage 4 non operable Cholangiocarcinoma in Sept 2017. Cholangiocarcinoma (bile duct cancer) is a rare cancer that occurs when cells in a bile duct grow abnormally and out of control. It is only accessible by boat or plane, and it does not have any traffic lights. Cholangiocarcinoma is a type of cancer that occurs in the bile ducts in the liver. Keywords: The 5-year survival rate for intrahepatic bile duct cancer is 9%. HOME; ABOUT. PMC and transmitted securely. The five-year survival rate for bile duct cancer that hasn't spread outside of the bile ducts is 10% to 15%. Gastrointest Endosc. Cholangiocarcinoma (CCA) Prognosis Cholangiocarcinoma (CCA) is a rare group of fatal malignancies that can develop in the biliary tract. I devoured every website, clinical trial database, and daily Google Scholar Alerts about this disease. I decided to increase my faith, and hopefully share my faith with others, helping them strengthen or return to their faith. My husband was diagnosed with bile duct cancer a couple of months ago. 1,2 It is also the second most common malignancy of the liver. Background: Intrahepatic Cholangiocarcinoma Survival Rate If it is possible to remove the tumor entirely, there is a possibility of being cured. J Gastroenterol Hepatol. Next May, my son, Danny, will be, Hello. The present report describes the long-term survival of a 65-year-old man with distal bile duct cancer of pathological stage IIA (T2N0M0; depth of invasion, 5.5 mm) following multimodal treatment. The procedure was scheduled for the next day. Please enable it to take advantage of the complete set of features! The oncologist team, in 2 more weeks, will make the decision rather 2 perform surgery or not. Accessibility I told him I provide compassion, love, hope and prayers. The overall median survival time was 31 months, and the 1- and 3-year survival rates were 89% and 40%, respectively. We recently treated a patient with native liver with correctable biliary atresia who developed cholangiocarcinoma and died at 63 years of age. I am so thankful for the clinical trial of Adoptive Cell Therapy with Dr. Rosenberg which has extended my life hopefully for many years to come! I used it as motivation to quit smoking and set the stage for the next chapter of my life. I also have three grandchildren. 2009 Nov;24(11):1745-52. doi: 10.1111/j.1440-1746.2009.05915.x. carbon ion radiotherapy; chemotherapy; cholangiocarcinoma; cisplatin; gemcitabine; hepatic recurrence. This site needs JavaScript to work properly. Even just reality n not fictional words. PDF | Background Although hilar cholangiocarcinoma (HCCA) has a very poor prognosis, there are cases in which long-term survival is rarely obtained by. I dont expect to be a longterm survivor but I have already survived two edcuated guess prognoses. 2022 Jun 7;22(1):620. doi: 10.1186/s12885-022-09665-3. He is 32 and we have a baby. The https:// ensures that you are connecting to the She is 58. Definitive guidelines for recurrent intrahepatic cholangiocarcinoma (ICC) do not exist. Souche R, Addeo P, Oussoultzoglou E, Herrero A, Rosso E, Navarro F, Fabre JM, Bachellier P. Am J Surg. I am incredibly lucky to be married to my best friend and love of my life, Jason, who is the pillar of our family. Biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma with jaundice. Take care. The present report describes the longterm survival of a 65yearold man with distal bile duct cancer of pathological stage IIA (T2N0M0; depth of invasion, 5.5 mm) following multimodal treatment. By Cholangiocarcinoma Foundation | December 7, 2021. I had molecular profiling and found that I had the FGFR mutation. Heidi Rhea is a long-term survivor. The https:// ensures that you are connecting to the Then your doctor will probably want to see you once a year. I think it is possible to live a long full life after cholangiocarcinoma just like people without cancer. Remember, survival rates depend on several factors. Results: 2010 Apr 8;362(14):1273-81 Heidi has always been a cancer advocate, especially with her family history of Lynch syndrome. It's located in his main bile duct of the liver. I was stage 2b and advised to follow the standard of care; six months of chemo with a cocktail of gemcitabine and cisplatin. This site needs JavaScript to work properly. He has been through 7 surgeries and 2 1/2 months of chemotherapy. I had a researcher ask me what I thought was the most important thing I did for the people I mentored. I know my body and don't think this chemo is working but I remain positive and will continue to fight. The average age at diagnosis for people with intrahepatic bile duct cancer is 70 years. Currently, Im a reading/math tutor for a public 3rd-5th grade elementary school in my area. I am 69 soon to be 70. We immediately started researching cholangiocarcinoma, and the information we discovered was limited, and dismal. Again, knowledge is power and that translates to hope in my mind. Some will do it and it is critical for patients facing this to know even stage 3 patients can be long term survivors if you pour through the statistics, so there is cause to remain hopeful. World J Gastroenterol. I had my second surgery removing 35 percent of my liver during an eight-and-a-half hour surgery, followed up by another six months of chemotherapy. Healing needs to be physical, spiritual and mental. Epub 2021 Apr 26. Currently, I have more than 30 survivors for whom I am a mentor from across the country. She and we are devastated. J Hepatobiliary Pancreat Surg. Bethesda, MD 20894, Web Policies In case 6, a 39-year-old male patient developed cholangiocarcinoma simultaneously combined with hepatocellular carcinoma. I am a 40-year-old mother of two children, Grace, 9, and Connor, 7. Post-operative Rehabilitation in Klatskin Tumor: A Rare Case Report. J Clin Oncol. doi: 10.1200/JCO.2011.40.5381. I am a patient and an advocate, but first, I am a mother to three amazing sons. It offers drawings of body parts often affected by bile duct cancer. Morise Z, Sugioka A, Hoshimoto S, Kato T, Tanahashi Y, Ikeda M, et al. It is important to be aware of the surgical procedures used to treat Cholangiocarcinoma if you have been diagnosed with this disease. Surgery for cholangiocarcinoma. FOIA The cumulative dose of UFT has reached 2511 g without any significant adverse effects. Now the emotional turmoil on the other hand there is a whole other topic. Looking back over the last six years, I reflect on the thought that cancer is not a blessing, but many blessings presented themselves during the rough ride, blessings in the way of all the beautiful friends I have made with the same cancer, and the blessing for the appreciation of life. Epub 2009 Sep 25. Its tough as all patients differ. After 19 months, CT revealed tumor regrowth and another new metastatic lesion was identified in the left kidney. Registration is now open for our 2023 Annual Conference, It started as an itch. The exact cause of cholangiocarcinoma (bile duct cancer) is unknown but it is believed to be due to genetic changes. We prospectively enrolled 133 patients diagnosed with CCA in the 3rd Medical Clinic, Cluj Napoca, over a 4-year period (2005-2009).