Survival Improvement in Korean Breast Cancer Patients Due to Increases in Early-Stage Cancers and Hormone Receptor Positive/HER2 Negative Subtypes: A Nationwide Registry-Based Study / 한국유방암학회지

PURPOSE: The aim of this study was to investigate whether the observed changes over time in the survival rates vary according to the intrinsic subtypes of breast cancer diagnosed. METHODS: Data from 46,320 breast cancer patients in the Korean Breast Cancer Registry who underwent surgery between 1999 and 2006 were reviewed. Among them, results from 25,887 patients with available data about the status of estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) were analyzed. Patients were classified into two cohorts according to the year in which they underwent surgery: 1999-2002 and 2003-2006. RESULTS: The patients treated in the latter time period showed significantly better overall survival (OS) compared with those in the former period when adjusted for follow-up duration. The proportion of hormone receptor+/HER2-subtype and stage I breast cancer were significantly higher in the latter period (47.4% vs. 54.6%, p<0.001; 31.0% vs. 39.6%, p<0.001, respectively). Improvement in OS between the former and latter periods was seen in all subtypes of breast cancer, including triple-negative cancers (all p-values <0.001 in univariate and multivariate analyses). CONCLUSION: Improvement in survival in Korean breast cancer patients over the study years is being observed in all subtypes of breast cancer, implying that increases in both early-stage detection and the proportion of less aggressive cancers contribute to this improvement.

Axillary Lymph Node Metastasis of Papillary Thyroid Carcinoma: A Case Report / 대한갑상선학회지

We report a case of axillary lymph node metastasis (LNM) as a recurrence of papillary thyroid carcinoma (PTC) in a 68-year-old male. The patient initially presented in 2009 with a 3.4x5.4 cm sized neck swelling and left cervical lymphadenopathy. He underwent total thyroidectomy and central compartment neck dissection (CCND) with left modified radical neck dissection (MRND). The pathological report confirmed PTC with metastasis of neck lymph node. On a regular follow up of positron emission tomography (PET), LNM was found on the right supraclavicular area and on the left axillary area. It was 17 months after the initial thyroid cancer had been diagnosed. The right MRND and left axillary lymph node dissections were performed in April of 2012. Pathological result confirmed metastatic PTC of left axillary lymph nodes. After recovery from the surgery, the patient got radioactive iodine therapy with I-131 180 mCi.

Association of Human Epidermal Growth Factor Receptor 2 with Radiotherapy Resistance in Patients with T1N0M0 Breast Cancer / 한국유방암학회지

PURPOSE: Preclinical studies have shown that human epidermal growth factor receptor 2 (HER2) status is associated with resistance to radiotherapy (RT). In this study, we evaluated the overall survival of a T1N0M0 breast cancer cohort in Korea according to the use of RT and the HER2 status. METHODS: We analyzed data collected from 11,552 patients with invasive breast cancer who were enrolled in the Korean Breast Cancer Society Registration Program between 1999 and 2007. Data on the TNM stage, estrogen receptor status, progesterone receptor status, HER2 status, operation method, and the use of RT were analyzed. RESULTS: The median follow-up period was 51 months. A significant improvement in overall survival after RT was observed only in the HER2(-) group. In this group, the 10-year overall survival rate was 95.5% for patients who did not receive RT and 96.3% for patients who received RT (p=0.037). In contrast, in the HER2(+) group, RT was not associated with a survival benefit (p=0.887). Multivariate analysis showed that RT was significantly associated with a reduction in mortality in the HER2(-) group (hazard ratio, 0.738; 95% confidence interval, 0.549-0.993; p=0.045). CONCLUSION: We found that postoperative RT was not associated with a survival benefit in HER2(+) breast cancer patients, suggesting that HER2(+) breast cancers could be RT resistant.

Reliability of Reconstructed Breast Flap after Chemotherapy and Radiotherapy in Immediate Breast Reconstruction

BACKGROUND: Postmastectomy adjuvant therapy is used to prevent locoregional recurrence and improve overall breast cancer specific survival rates. However, it can adversely affect the cosmetic results of reconstruction. Therefore, the authors examined flap stability and patients' satisfaction with immediate breast reconstruction after adjuvant therapy. METHODS: We retrospectively reviewed the medical records of 204 patients from January 2006 to November 2011. For complication rates, the authors categorized the patients who underwent the immediate breast reconstruction into 4 groups: adjuvant chemotherapy and radiotherapy group, adjuvant chemotherapy only group, adjuvant radiotherapy only group, and the group that did not undergo adjuvant therapy. For comparison of patients' satisfaction, the study was performed with an additional 16 patients who had undergone delayed breast reconstruction. RESULTS: Regarding complication rates, the group that had undergone adjuvant therapy showed no significant difference compared to the group that did not undergo adjuvant therapy. In evaluating the patients' satisfaction, there was no significant difference. CONCLUSIONS: Even after adjuvant therapy, immediate breast reconstruction showed good results with respect to flap stability and patients' satisfaction. Immediate breast reconstruction and adjuvant therapy is a safe and useful option for breast cancer patients.

Laparoscopic splenectomy for sclerosing angiomatoid nodular transformation of the spleen / 대한외과학회지

Primary splenic tumors are rare and mainly found incidentally on radiologic studies. Among them, sclerosing angiomatoid nodular transformation (SANT) of the spleen is a new entity defined as a benign pathologic lesion. Most SANTs have no clinical symptoms and are occasionally accompanied by other splenic diseases such as malignancies. So, the exact diagnosis of the nature of the splenic tumor is mandatory for further treatment. But, preoperative diagnosis is not easy since it is difficult to obtain the tissue from the spleen for pathological study. Recently, laparoscopic splenectomy has become the more standard procedure for the spleen for diagnosis and treatment. Here, we report a rare case of SANT diagnosed following laparoscopic splenectomy.

Lessons learned from 100 initial cases of laparoscopic liver surgery / 대한외과학회지

PURPOSE: Laparoscopic liver resection (LLR) is now widely accepted and is being increasingly performed. The present study describes our experience with LLR at a single center over an eight-year period. METHODS: This retrospective study enrolled 100 patients between October 2002 and February 2010. Forty-six benign lesions and 54 malignant lesions were included. The LLR performed included 58 pure laparoscopy procedures, 18 hand-assisted laparoscopy procedures and 24 hybrid technique procedures. RESULTS: The mean age of the patients was 57 years; among these patients, 31 were over 65 years of age. The mean operation time was 220 minutes. The overall morbidity was 11% and the mortality was zero. Among the 20 patients with simple hepatic cysts, 50% unexpectedly recurred. Among the 41 patients with hepatocellular carcinoma, 21 patients (51%) underwent preoperative radiofrequency ablation therapy or transarterial chemoembolization. During parenchymal-transection, 11 received blood transfusion. The width of the resection margins was under 0.5 cm in 11 cases (27%); 0.5 to 1 cm in 22 cases (54%) and over 1 cm in eight cases (12%). There was no port site seeding, but argon beam coagulation-induced tumor dissemination was observed in two cases. The overall two-year survival rate was 75%. CONCLUSION: This study suggests that the applications for LLR can be gradually expanded when assuring that the safety and curability of LLR are equivalent to that of open liver resection.

Expanded Criteria Donors / 대한이식학회지

Due to an impressive reduction in traffic mortalities in recent years, stroke has replaced trauma as the main cause of brain death, and the mean age of donors has increased gradually. As an immediate consequence, donations are growing increasingly more complex and less effective in terms of the number of recipients transplanted, particularly with organs affected negatively by age. The huge regional variability in donation activity observed suggests that there is room for improvement. Generally, liver transplantation extended criteria donors (ECD) are divided by donor-specific characteristics: age >65 years, steatosis >30% of graft volume, long interval between brain death and procurement or graft infected by hepatitis B or C, cold ischemia >12 hours, living donor grafts, split liver grafts, and liver grafts from donors after cardiac death. Deceased donor kidneys are classified as ECD if they meet either of the following conditions: (1) Donor age more than or equal to 60-years or (2) donor age 50 to 59 years, with at least two of the following criteria: serum creatinine more than 1.5 mg/dL, death due to cerebrovascular accident, or history of hypertension. No guidelines exist for allocating an ECD organ. Accurate assessment of the relative risk of graft failure associated with various combinations of donor characteristics is an essential prerequisite for counseling patients, making the decision to accept a transplant offer, evaluating programs, and developing allocation policy.

Clinical Outcomes in Patients with Triple-negative Breast Cancer and Brain Metastases / 한국유방암학회지

PURPOSE: Patients with triple-negative breast cancer (TNBC) are known to carry an increased risk of distant metastasis and poor survival. The principal objective of this study was to investigate survival after brain metastases in patients with TNBC. METHODS: The authors retrospectively evaluated clinical data obtained from 66 patients who had been diagnosed with breast cancer and brain metastasis from 2003 to 2009. Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth receptor-2 (HER2) statuses were determined via immunohistochemical staining. TNBCs were defined as those that were ER-negative, PR-negative, and HER2-negative. The time interval from initial diagnosis to brain metastasis and overall survival after brain metastasis was evaluated via the Kaplan-Meier method. RESULTS: Twenty four (40.0%) of 60 patients were diagnosed with TNBC. The clinicopathologic characteristics did not differ between the TNBC and non-TNBC patients. The disease-free survival durations of the TNBC and non-TNBC subjects were 17.9 and 25.6 months, respectively (p=0.135). The time intervals from initial diagnosis to brain metastasis were 25.5 and 43.7 months, respectively (p=0.027). The time intervals from distant metastasis to brain metastasis were 8.4 and 19.5 months, respectively (p=0.006). Overall survival durations from brain metastasis to death were 4.3 and 7.6 months, respectively (p=0.046). CONCLUSION: Patients with TNBC were more likely to develop brain metastasis earlier, and exhibit poor overall survival. Triple receptor status may be utilized as a prognostic marker for breast cancer patients with brain metastasis.

Use of Antidepressants in Patients with Breast Cancer Taking Tamoxifen / 한국유방암학회지

Tamoxifen, a selective estrogen modulator has been used for more than three decades to treat all stages of estrogen receptor (ER)-positive breast cancer and to prevent the disease. Tamoxifen is a pro-drug that requires metabolic activation to 4-hydroxytamoxifen and 4-hydroxy-N-desmethyltamoxifen (endoxifen) to elicit its pharmacological activity. Endoxifen has identical properties and potency with 4-hydroxytamoxifen, but is present in concentrations up to 10-fold higher than 4-hydroxytamoxifen. The cytochrome P450 2D6 (CYP2D6) enzyme plays a key role in converting tamoxifen into its active metabolites with significantly greater affinity for the ER and greater ability to inhibit cell proliferation. Genetic variants in the CYP2D6 gene may result in CYP2D6 enzymes with reduced or null activity, thereby decreasing the anti-cancer effect. In addition to genetic inactivation of CYP2D6, inhibitors of CYP2D6, including some antidepressants to treat hot flashes or depression in patients with breast cancer, may also alter enzyme activity and negatively affect the outcomes of patients receiving adjuvant tamoxifen. This article reviews and discusses the following issues: tamoxifen metabolism, antiproliferative effects of tamoxifen and its metabolites, CYP2D6 genetic polymorphisms, treatment for hot flashes and depression in breast cancer, and the pharmacological interactions between tamoxifen and antidepressants via CYP2D6. Although routine CYP2D6 testing is not recommended yet, coadministration of potent or intermediate CYP2D6 inhibitors in women taking tamoxifen should be avoided.

Phase II Study of Vinorelbine Plus Ifosfamide in Patients with Taxane-resistant Metastatic Breast Cancer / 한국유방암학회지

PURPOSE: The patients with metastatic breast cancer are routinely exposed to taxane and anthracycline as neoadjuvant, adjuvant, and palliative chemotherapeutic agents. This study was designed to evaluate the efficacy and safety of using a vinorelbine and ifosfamide (VI) combination treatment in patients with taxane-resistant metastatic breast cancer. METHODS: We evaluated the use of a VI regimen (25 mg/m2 vinorelbine administered on days 1 and 8 plus 2,000 mg/m2 ifosfamide administered on day 1-3 every 3 weeks) for breast cancer patients who evidenced tumor progression after palliative taxane treatment. RESULTS: Overall, 35 patients were enrolled in this study: Their median age was 50 years (range, 38-72 years). The overall response rate was 40.0% (14 patients; 95% confidence interval [CI], 23-57%). The median time to progression was 4.5 months (95% CI, 3.5-5.4 months). The median overall survival was 18.3 months (95% CI, 12.9-23.6 months). In the 190 cycle of treatment, the incidence of grade > or =3 neutropenia, anemia, and thrombocytopenia was 29.3%, 4.2%, and 2.0%, respectively. Neutropenic fever was noted in 6 cycles (3.1%). The non-hematological toxicities were not severe: grade 1 or 2 vomiting was observed in 22.8% of the patients. CONCLUSION: Our results suggest that the use of vinorelbine and ifosfamide (VI) combination chemotherapy appears to be effective and it showed an acceptable toxicity profile in the patients with taxane-resistant metastatic breast cancer.

Early Experiences with Laparoscopic- assisted Colectomy: Retrospective Comparison with Open Colectomy (Case-control Study)

Purpose: The aim of this study was to review our experience with laparoscopic-assisted colectomy (LACs), and to evaluate its feasibility and safety for surgical treatment of colorectal diseases, including cancer. Methods: Between September 2002 and September 2005, a LAC was performed in 58 patients. Of these, 6 cases of conversion to open colectomy were excluded from the analysis. Fifty conventional open colectomy (OCs) with clinicopathologic characteristics comparable to those of the LACs were selected and matched as a control group for comparative analysis regarding short-term oncologic and perioperative outcomes. The mean follow-up period was 13.8 (2~37) months. Results: Thirteen complications, involving 11 patients, occurred. The mean operative time of the LAC was longer than that of the OC (215 min vs. 179 min; P<0.0001). However, earlier restoration of bowel function was achieved in the LAC as measured by postoperative first flatus (2.8 days vs. 3.8 days) and intake of a clear liquid diet (4.7 days vs. 5.8 days). There was no significant difference in hospital stay (LAC vs. OC, 10.2 days vs. 11.8 days). In patients with malignancy, the proximal resection margin in the LAC was significantly shorter than that in the OC (9.2 cm vs. 13.3 cm; P<0.0001). However, there were no significant differences in the mean numbers of harvested lymph nodes (LAC vs. OC, 16.6 vs. 19.3; P=0.4330) and the mean distal resection margins (LAC vs. OC, 6.9 cm vs. 6.0 cm; P=0.1359). There were 3 distant metastases and one local recurrence during follow-up in the LAC group, but no port-site recurrence. Conclusions: In this study, we could not receive an advantage of shorter hospital stay due to the relatively high complication rate for a LAC, which may reflect a learning curve. Earlier postoperative recovery of bowel function and equal pathologic extent of resection in the LAC suggest that the LAC is an acceptable alternative procedure in the treatment of colorectal diseases, including malignancy. More experience with the LAC is necessary to overcome the learning curve. Affirmative long-term oncologic outcomes of are expected for the LAC.

Continuous Ambulatory Peritoneal Dialysis (CAPD) Catheter Insertion Using the Fluoroscopy and Minimal Skin Incision

PURPOSE: Continuous ambulatory peritoneal dialysis (CAPD) is an important method of performing renal replacement therapy in patients with chronic renal failure. A significant number of complications and catheter failures in CAPD are due to mechanical pro-blems and peritonitis. We describe our experience with CAPD with using fluoroscopy and a minimal incision technique to reduce complications. METHODS: We reviewed 57 CAPD patients at Dong-A University Medical Center from June 2004 to March 2005. All the procedures were standardized and performed by a single surgeon with using a flexible guide wire under aseptic fluoroscopic control through a minimal incision. Antibiotic treatment was done for three days after the surgery. RESULTS: The patients consisted of 30 males and 27 females. The common reasons for CAPD insertion were diabetic nephropathy (25 patients) and hypertension (9 patients). The mean operation time was 52.2+/-15.8 minutes. All the initial procedures were carried out under local anesthesia. Four of the patients needed their catheter repositioned during their postoperative course, which was done under local anesthesia in three cases and under spinal anesthesia in one case. Catheter malfunction occurred in 4 patients, and peritonitis developed in 8 patients (for wound related peritonitis in 1 patient and for catheter related peritonitis in 7 patients). CONCLUSION: Making a minimum incision and catheter insertion under fluoroscopic control for CAPD is a safe and highly effective method to reduce the incidence of catheter related complications. Furthermore, strict patient education is crucial for optimum catheter care, which is closely associated with development of peritonitis in CAPD patients.