Ultrasound Elastography in Differential Diagnosis of Benign and Malignant Thyroid Nodules / 대한내분비외과학회지

PURPOSE: The study evaluated elastography, a technique that allows differentiation between pathological and normal tissue by determination of tissue hardness. METHODS: From March 2009 to April 2010, 25 consecutive patients with thyroid nodules who were referred for surgical treatment were examined in this prospective study. Thirty nodules in these patients were examined by conventional ultrasound, ultrasound elastography, and fine needle aspiration cytology. Lesions were scored (1~3) according to hardness based on the Ueno classification system. The final diagnosis was based on histopathologic results. RESULTS: Of the 30 thyroid nodules, four were classified as benign and 26 were malignant. Two of the nodules with an elastography score of 1 were benign and 17 nodules whose elastography score was 3 were malignant. Two benign nodules and nine malignant nodules had an elastography score of 2. Applying an elastography score exceeding 2 as a indicator for malignancy determined that the sensitivity and specificity of the ultrasound elastography was 100.0% and 50.0%, respectively, the positive and negativepredictive values were 92.9% and 100.0%, respectively, and the accuracy of the technique was 93.3%. CONCLUSION: Ultrasound elastography may be a useful adjunct to ultrasonography in the identification of indeterminate thyroid nodules for which tissue diagnosis is required.

Application of a Scoring System to the Diagnosis of Acute Appendicitis

PURPOSE: Acute appendicitis is one of the most common diseases requiring surgical treatment. Delayed diagnosis, which causes complications like perforation of the appendix, abscess formation, or misdiagnosis, leads to unnecessary surgery. Many scoring systems have been suggested for the diagnosis of acute appendicitis. This study aims to evaluate the clinical value of previous scoring systems. METHODS: This study was conducted with a total of 270 patients who had visited the National Police Hospital (NPH) Emergency Room for acute abdominal symptoms from January to June 2008. The Alvarado and the Ohmann scores were applied retrospectively based on the patients' records. We found 3 criteria which were relatively objective and clinically meaningful; then, we designed a new 10 points scoring system. RESULTS: The sensitivity and the specificity of the Alvarado scoring system were 83.23% and 64.42%, respectively, whereas those of the Ohmann scoring system were 74.85% and 66.35%, respectively. The sensitivity and the specificity of the NPH scoring system were found to be 78.4% and 68.9%, respectively. The Ohmann scoring system showed a little lower sensitivity, and the NPH scoring system showed a little higher specificity, but the differences were not statistically significant. CONCLUSION: Our study indicates that the scoring systems considered are not useful diagnostic methods for primary screening and diagnosis of acute appendicitis.

Comparative Study of the Clinical Features and Treatment for Right and Left Colonic Diverticulitis

PURPOSE: Colonic diverticulitis is an uncommon disease in Korea, but the incidence of the disease is increasing. The right colon is the more preferred site for diverticulitis in Korea, but the incidence of left diverticulitis is increasing. Therefore, comparing the clinical features and treatments for right diverticulitis with those for left diverticulitis may help us to treat the disease more properly. METHODS: This study was performed retrospectively by reviewing the medical records of 96 patients with colonic diverticulitis, in whom either conservative or operative treatments were performed. RESULTS: Eighty-six patients had right diverticulitis (RD), and 10 patients had left diverticulitis (LD). The mean age of the patients was older for LD. Sixteen patients (18.6%) with RD had complications, and 7 patients (8.1%) underwent operations. On the other hand, 4 patients (40%) with LD had complications, and 3 patients (30%) underwent operations. The rates of complications and operations among old-aged patients were higher. The operations for 7 patients with RD who underwent surgery were 6 ileocecectomies and 1 diverticulectomy. On the other hand, the operations for the 3 patients with LD who underwent surgery were 2 resections and anastomoses and 1 diverticulectomy. The reasons for the operations were abscess formation, recurrence, perforation, and development of generalized peritonitis without response to conservative treatment. CONCLUSION: The incidence of LD is lower than that of RD in Korea, but the rate of complications and operations seems higher in LD. Therefore, patients who complain of left lower abdominal pain need to be thoroughly examined for LD.

Comparison of Laparoscopy-assisted Total Gastrectomy with Conventional Open Total Gastrectomy for Treating Early Proximal Gastric Cancer

PURPOSE: The purpose of this study was to compare the short-term clinical outcomes of laparoscopy-assisted total gastrectomy (LATG) with conventional open total gastrectomy (OTG) for treating proximal early gastric cancer and to determine the usefulness of the LATG procedure. METHODS: The records of 21 patients who underwent LATG for proximal early gastric cancer from January 2004 to August 2006 were retrospectively reviewed and compared with those records of 20 patients who underwent OTG during the same period. RESULTS: The patient characteristics, including gender, age, body mass index and comorbidities, were similar between the two groups. Combined resections were more frequently done in the OTG group than in the LATG group. The blood loss in the LATG group was significantly less than that in the OTG group. The operating time, time to first flatus and initial oral intake and the postoperative hospital stay were significantly shorter in the LATG group. The number of resected lymph nodes, lymph node metastasis, histologic type, TNM stage, complications, leukocyte counts and serum lactic acid levels were not significantly different between the two groups. CONCLUSION: LATG is a technically safe and feasible procedure for treating proximal early gastric cancer. Prospective multi-center trials are necessary to establish LATG as the standard treatment for proximal early gastric cancer.

Influence of Bone Marrow Micrometastasis in Recurrence and Survival of Breast Cancer

PURPOSE: Breast cancers frequently develop distant metastasis in the early phase. The survival rate of patients depends on a distant metastasis. The occurrence of a micrometastasis has been related to the prognostic features of breast cancer, such as a lymph node metastasis and the presence of a vascular invasion. The aim of this study was to examine the presence of RNA from epithelial tumors in bone marrow from a series of breast cancer patients and its correlation with the tumor staging and disease free survival. METHODS: Bone marrow samples were obtained from 59 patients with breast cancer at the time of surgery. The mononuclear fraction was separated and a nested reverse transcriptase polymerase chain reaction (RT-PCR) was carried out for the detection of keratin-19 with different two pairs of primers. After surgery, the patients were followed up for a 3-month interval. Its correlation with the tumor size, nodal involvement, stage, and recurrence was investigated. RESULTS: A bone marrow micrometastasis was detected by nested RT-PCR for Keratin-19 mRNA in one case in 4 DCIS, 13 in 30 patients with T1, 11 in 20 patients with T2, and all 4 cases in patients with a T3 lesion. Recurrence was observed in 7 cases and all of them tested positive for a micrometastasis in the bone marrow. CONCLUSION: The nested RT-PCR for keratin-19 mRNA from the bone marrow in patients with breast cancer is sensitive and reliable. Moreover, early recurrence has been observed in patients with tumor mRNA present in the bone marrow. Additional studies with a large number of patients and a long term follow up are needed.

Review of Splenectomy, Pancreas-preserving Splenectomy, Pancreatosplenectomy for Combined Radical Total Gastrectomy

PURPOSE: Splenectomy, pancreas-preserving splenectomy, pancreato-splenectomy are common combined operations of a total gastrectomy for gastric cancer. We attempted to determine the efficacy of these procedures after comparing and analyzing the complication rate and the five-year survival rate from the gastric cancer patients. METHODS: 121 advanced gastric cancer patients, except T4 patients, underwent radical total gastrectomy accompanied with splenectomy. and analyzed the clinical findings eg. age, sex, location of tumor, histological differentiation, lymph node metastasis, number of dissected LN, complication and the 5-year survival rate. RESULTS: 44 out of 121 patients underwent a pancreato- splencetomy, 53 patients underwent a pancreas-preserving splenectomy, and 24 patients underwent a simple splenectomy. There were no statistical difference in the patient's age, sex, location of tumor, histological differentiation, lymph node metastasis, the number of dissected LN and the 5 year-survival rate in stage II, IV with each operation. However, a pancreas-preserving splenectomy showed a better 5-year survival rate (53.7%) than a simple splenectomy (25.0%) and pancreato-splenectomy (32.1%) in stage III. The complication rate was 25% in a simple splenectomy, 17% in a pancreas-preserving splenectomy, 30% in a pancreato- splenectomy. Diabetes mellitus occurred in 3 patients who underwent a pancreato-splenectomy, in 1 patient with an iatrogenic splenic vein excision during a pancreas-preserving splenectomy. CONCLUSION: A pancreas-preserving splenectomy is the best choice in stage IIIa total gastrectomy patients with the lowest complication rate.