Clinical outcomes of endovascular treatment for ruptured thoracic aortic disease

Background/Aims@#Untreated rupture of the thoracic aorta is associated with a high mortality rate. We aimed to review the clinical results of endovascular treatment for ruptured thoracic aortic disease. @*Methods@#We retrospectively reviewed data on 37 patients (mean age, 67.0 ± 15.18 years) treated for ruptured thoracic aortic disease from January 2005 to May 2016. The median follow-up duration was 308 days (interquartile range, 61 to 1,036.5). The primary end-point of the study was the composite of death, secondary intervention, endoleak, and major stroke/paraplegia after endovascular treatment. @*Results@#The etiologies of ruptured thoracic aortic disease were aortic dissection (n = 11, 29.7%), intramural hematoma (n = 7, 18.9%), thoracic aortic aneurysm (n = 14, 37.8%), and traumatic aortic transection (n = 5, 13.5%). Three patients died within 24 hours of thoracic endovascular aortic repair, and one showed type I endoleak. The technical success rate was 89.2% (33/37). The in-hospital mortality rate was 13.5% (5/37); no deaths occurred during follow-up. The composite outcome rate during follow-up was 37.8% (14/37), comprising death (n = 5, 13.5%), secondary intervention (n = 5, 13.5%), endoleak (n = 5, 13.5%), and major stroke/paraplegia (n = 3, 8.1%). Left subclavian artery revascularization and proximal landing zone were not associated with the composite outcome. Low mean arterial pressure (MAP; ≤ 60 mmHg, [hazard ratio, 13.018; 95% confidence interval, 2.435 to 69.583, p = 0.003]) was the most significant predictor and high transfusion requirement in the first 24 hours was associated with event-free survival (log rank p = 0.018). @*Conclusions@#Endovascular treatment achieves high technical success rates and acceptable clinical outcome. High transfusion volume and low MAP were associated with poor clinical outcomes.

Challenge for Diagnostic Assessment of Deep Learning Algorithm for Metastases Classification in Sentinel Lymph Nodes on Frozen Tissue Section Digital Slides in Women with Breast Cancer / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Assessing the status of metastasis in sentinel lymph nodes (SLNs) by pathologists is an essential task for the accurate staging of breast cancer. However, histopathological evaluation of sentinel lymph nodes by a pathologist is not easy and is a tedious and time-consuming task. The purpose of this study is to review a challenge competition (HeLP 2018) to develop automated solutions for the classification of metastases in hematoxylin and eosin–stained frozen tissue sections of SLNs in breast cancer patients. @*Materials and Methods@#A total of 297 digital slides were obtained from frozen SLN sections, which include post–neoadjuvant cases (n = 144, 48.5%) in Asan Medical Center, South Korea. The slides were divided into training, development, and validation sets. All of the imaging datasets have been manually segmented by expert pathologists. A total of 10 participants were allowed to use the Kakao challenge platform for six weeks with two P40 GPUs. The algorithms were assessed in terms of the AUC (area under receiver operating characteristic curve). @*Results@#The top three teams showed 0.986, 0.985, and 0.945 AUCs for the development set and 0.805, 0.776, and 0.765 AUCs for the validation set. Micrometastatic tumors, neoadjuvant systemic therapy, invasive lobular carcinoma, and histologic grade 3 were associated with lower diagnostic accuracy. @*Conclusion@#In a challenge competition, accurate deep learning algorithms have been developed, which can be helpful in making frozen diagnosis of intraoperative sentinel lymph node biopsy. Whether this approach has clinical utility will require evaluation in a clinical setting

Clinical Effectiveness of High-Flow Nasal Cannula in Hypoxaemic Patients during Bronchoscopic Procedures / 결핵및호흡기질환

BACKGROUND: Bronchoscopy is a useful diagnostic and therapeutic tool. However, the clinical use of high-flow nasal cannula (HFNC) in adults with acute respiratory failure for diagnostic and invasive procedures has not been well evaluated. We present our experiences of well-tolerated diagnostic bronchoscopy as well as cases of improved saturation in hypoxaemic patients after a therapeutic bronchoscopic procedure. METHODS: We retrospectively reviewed data of hypoxaemic patients who had undergone bronchoscopy for diagnostic or therapeutic purposes from October 2015 to February 2017. RESULTS: Ten patients (44–75 years of age) were enrolled. The clinical purposes of bronchoscopy were for diagnosis in seven patients and for intervention in three patients. For the diagnoses, we performed bronchoalveolar lavage in six patients. One patient underwent endobronchial ultrasonography with transbronchial needle aspiration of a lymph node to investigate tumour involvement. Patients who underwent bronchoscopy for therapeutic interventions had endobronchial mass or blood clot removal with cryotherapy for bleeding control. The mean saturation (SpO2) of pre-bronchoscopy in room air was 84.1%. The lowest and highest mean saturation with HFNC during the procedure was 95% and 99.4, respectively. The mean saturation in room air post-bronchoscopy was 87.4%, which was 3.3% higher than the mean room air SpO2 pre-bronchoscopy. Seven patients with diagnostic bronchoscopy had no hypoxic event. Three patients with interventional bronchoscopy showed improvement in saturation after the procedure. Bronchoscopy was well tolerated in all 10 cases. CONCLUSION: This study suggests that the use of HFNC in hypoxaemic patients during diagnostic and therapeutic bronchoscopy procedures has clinical effectiveness.

The Clinical Efficacy and Safety of Four-Weekly Docetaxel as First-Line Therapy in Elderly Lung Cancer Patients with Squamous Cell Carcinoma / 결핵

BACKGROUND: Docetaxel is one of the standard treatments for advanced non-small cell lung cancer. Docetaxel is usually administered in a 3-week schedule, but there is significant toxicity. In this phase II clinical study, we investigated the efficacy and safety of a 4-weekly schedule of docetaxel monotherapy, as first-line chemotherapy for advanced squamous cell carcinoma in elderly lung cancer patients. METHODS: Patients with stage IIIB/ IV lung squamous-cell carcinoma age 70 or older, that had not undergone cytotoxic chemotherapy were enrolled. Patients received docetaxel 25 mg/m2 on days 1, 8, and 15, every 4 weeks. Primary endpoint was the objective response rate (ORR). Secondary endpoints were progression-free survival (PFS), overall survival (OS), and toxicity profiles. RESULTS: A total of 19 patients were enrolled. Among 19 patients, 17 were for evaluated efficacy and safety. In the intent-to-treat population, ORR and disease control rate (DCR) were 11.8% and 47.1%, respectively. In the response evaluable population, ORR was 16.7% and DCR was 66.7%. Median PFS and OS were 3.1 months and 3.3 months, respectively. There were three adverse grade 3/4 events. Grade 1 neutropenia was reported in one patient. CONCLUSION: Our data failed to demonstrate efficacy of a 4-weekly docetaxel regimen, in elderly patients with a poor performance status. However, incidence of side effects, including neutropenia, was lower than with a 3-week docetaxel regimen, as previously reported.

Synchronous Primary Leiomyosarcoma in the Thoracic Vertebra and the Liver / 대한소화기학회지

This is a case report of simultaneous primary leiomyosarcomas in the spine and liver. A 64-year-old woman presented to the Seoul Paik Hospital with epigastric discomfort and constipation that she had experienced for two months. A physical examination revealed severe tenderness around the thoraco-lumbar junction. Esophagogastroduodenoscopy showed an ulceroinfiltrative lesion on the gastric angle. An abdominopelvic CT scan revealed two low attenuated lesions in the S4 and S8 regions of the liver, as well as a soft tissue mass at the T10 vertebra. Percutaneous ultrasonography-guided needle biopsy of the hepatic nodules revealed a leiomyosarcoma. The tumor at the T10 vertebra was removed to avoid spinal cord compression. The histology of this tumor was compatible with that of leiomyosarcoma. The potential primary sites for leiomyosarcoma, including the lung, thyroid, breast, kidney, genitourinary organs, and gastrointestinal tract, were subsequently investigated. No detectable abnormal findings that would suggest the origin of the tumor were found. Synchronous primary leiomyosarcomas in the spine and liver are quite rare and have a poor prognosis.

Synchronous Primary Leiomyosarcoma in the Thoracic Vertebra and the Liver / 대한소화기병학회잡지

This is a case report of simultaneous primary leiomyosarcomas in the spine and liver. A 64-year-old woman presented to the Seoul Paik Hospital with epigastric discomfort and constipation that she had experienced for two months. A physical examination revealed severe tenderness around the thoraco-lumbar junction. Esophagogastroduodenoscopy showed an ulceroinfiltrative lesion on the gastric angle. An abdominopelvic CT scan revealed two low attenuated lesions in the S4 and S8 regions of the liver, as well as a soft tissue mass at the T10 vertebra. Percutaneous ultrasonography-guided needle biopsy of the hepatic nodules revealed a leiomyosarcoma. The tumor at the T10 vertebra was removed to avoid spinal cord compression. The histology of this tumor was compatible with that of leiomyosarcoma. The potential primary sites for leiomyosarcoma, including the lung, thyroid, breast, kidney, genitourinary organs, and gastrointestinal tract, were subsequently investigated. No detectable abnormal findings that would suggest the origin of the tumor were found. Synchronous primary leiomyosarcomas in the spine and liver are quite rare and have a poor prognosis.

The Clinical Efficacy and Safety of Four-Weekly Docetaxel as First-Line Therapy in Elderly Lung Cancer Patients with Squamous Cell Carcinoma / 결핵및호흡기질환

BACKGROUND@#Docetaxel is one of the standard treatments for advanced non-small cell lung cancer. Docetaxel is usually administered in a 3-week schedule, but there is significant toxicity. In this phase II clinical study, we investigated the efficacy and safety of a 4-weekly schedule of docetaxel monotherapy, as first-line chemotherapy for advanced squamous cell carcinoma in elderly lung cancer patients.@*METHODS@#Patients with stage IIIB/ IV lung squamous-cell carcinoma age 70 or older, that had not undergone cytotoxic chemotherapy were enrolled. Patients received docetaxel 25 mg/m2 on days 1, 8, and 15, every 4 weeks. Primary endpoint was the objective response rate (ORR). Secondary endpoints were progression-free survival (PFS), overall survival (OS), and toxicity profiles.@*RESULTS@#A total of 19 patients were enrolled. Among 19 patients, 17 were for evaluated efficacy and safety. In the intent-to-treat population, ORR and disease control rate (DCR) were 11.8% and 47.1%, respectively. In the response evaluable population, ORR was 16.7% and DCR was 66.7%. Median PFS and OS were 3.1 months and 3.3 months, respectively. There were three adverse grade 3/4 events. Grade 1 neutropenia was reported in one patient.@*CONCLUSION@#Our data failed to demonstrate efficacy of a 4-weekly docetaxel regimen, in elderly patients with a poor performance status. However, incidence of side effects, including neutropenia, was lower than with a 3-week docetaxel regimen, as previously reported.

Clinical and molecular characteristics of pulmonary sarcomatoid carcinoma

BACKGROUND/AIMS: Pulmonary sarcomatoid carcinoma (PSC) is a poorly differentiated non-small cell lung cancer (NSCLC) that contains components of spindle or giant cells. Owing to its low prevalence, there are insufficient data regarding its clinical features, therapeutic strategies and prognosis. METHODS: The medical records of 26 patients diagnosed with PSC from January 2009 to June 2015 were reviewed and analyzed for clinicopathological characteristics, treatment modality, and outcomes. RESULTS: The median age was 69.5 years. Twenty-three patients (88%) were male. Twenty-four patients (92%) were smokers. The median time from symptom onset to diagnosis was one month. Eighteen patients (69%) were diagnosed at an advanced stage. Pleomorphic carcinoma was the most common subtype, and epidermal growth factor receptor (EGFR) mutation was positive in two of 11 patients. Among 13 patients tested for programmed death ligand 1 (PD-L1) immunohistochemistry assay, eight showed high expression of PD-L1. The median overall survival (OS) of all patients was 9.5 months. In total, 12 patients were treated with chemotherapy: nine with platinum-based doublet therapy, two with tyrosine kinase inhibitor, and one with docetaxel. Seven patients showed partial response or stable disease. The median OS and progression-free survival of patients who received chemotherapy were 8.7 and 2.8 months, respectively. CONCLUSIONS: PSC was more common in males, smokers, and the elderly, with worse prognosis than ordinary NSCLC; chemotherapy response was favorable, and EGFR mutation status and PD-L1 expression may offer more therapeutic options.

A New Skin Graft Donor Site Using the Abdominal Dog-Ear Deformity in Mastectomy Flap Necrosis

BACKGROUND: Mastectomy flap necrosis is a common complication after mastectomy and immediate reconstruction with a deep inferior epigastric perforator (DIEP) flap. After abdominal free flap breast reconstruction, the most common secondary procedure is dog-ear correction of both flanks. We introduce a treatment for skin necrosis with a full-thickness skin graft (FTSG) using the abdominal dog-ear deformity. METHODS: In patients with skin necrosis of a mastectomy flap, we debrided all necrotic tissue when the demarcation was complete. We then performed an FTSG using the skin from the dog-ear correction of both flank areas. We fixed the graft with a tie-over dressing, and it was then removed on postoperative day 5. RESULTS: Skin necrosis of the mastectomy flap and dog-ear deformity were treated without any complications. The color and texture of the breasts were satisfactory. CONCLUSIONS: If a patient experiences post-mastectomy skin flap necrosis and has a dog-ear deformity on both sides of the flank after a DIEP flap, a dog-ear skin flap can be a good alternative donor site for reconstruction.

Feasibility and Aesthetic Results of Small Bilateral V-Y Advancement Flaps in the Extremities and Back

BACKGROUND: Random type small V-Y advancement flap is widely used for facial reconstruction with advantages including good color and texture match. However, the flap is not as widely used in the extremities and back as in the face because of apprehension of the relatively poor vascularity as a risk factor of flap necrosis. We used a small bilateral V-Y advancement flap for the repair of extremity and back defects from various causes. Competent clinical outcomes are described. METHODS: Between 2007 and 2014, 24 patients (48 flaps) with skin defects in the upper or lower extremities and back were enrolled. The site of the defect was on back (n=6), forearm (n=7), upper arm (n=2), lower leg (n=5), thigh (n=3), and axilla (n=1). RESULTS: Among the 48 flaps, 47 survived (no event: 42 flaps, total necrosis: 1 flap, partial necrosis: 5 flaps). All partial necrotized flaps healed in 3–4 weeks with conservative care. However, debridement and skin grafting was required for the total necrosis flap. One total necrosis and two partial necroses occurred on the anterolateral side of the lower leg. Two partial necroses occurred on the paraspinal area. CONCLUSIONS: Contour deformities including central depression and the dog-ear deformity were not observed. Small bilateral V-Y advancement in the extremity and back could be a safe and useful flap, if thick subcutaneous fat and subcutaneous plexus were saved. But areas with thin subcutaneous fat layer, such as the anterolateral lower leg, are poor candidates and carry the increased risk of improper subcutaneous pedicle circulation.

An IgE-Mediated Allergic Reaction Caused by Mulberry Fruit

Mulberry (Morus spp.) is a widespread deciduous tree and its fruit is commonly eaten in Korea and eastern Asia. Some reports demonstrate that mulberry fruit is a food allergen in the Mediterranean area. However, there has been no report of systemic allergic reactions after ingesting mulberry fruit in Korea. An 18-year-old boy with a mulberry fruit allergy visited our allergy clinic. He had experienced generalized urticaria, chest tightness, breathing difficulty, and abdominal cramping after ingesting mulberry fruit. The patient had a positive skin reaction to mulberry fruit extract (mean wheal size, 5 mm). We performed an ELISA to detect specific IgE antibody (Ab) to mulberry fruit extract in the patient's serum compared to those of non-atopic healthy controls and birch-sensitized individuals. Specific IgE Ab to mulberry fruit extract was detected in the patient's serum, as compared to non-atopic healthy controls. Another subject, who was strongly sensitized to birch pollen, also had a positive serum-specific IgE Ab to mulberry fruit. We performed IgE immunoblot analysis using the patient's and the other subject's sera, who had serum-specific IgE to mulberry fruit, to identify the IgE-binding component. An identical IgE-binding component to mulberry extract was detected in the two subjects at around 17 kDa, and which might be PR 10 of Bet v 1. In conclusion, mulberry fruit could induce a systemic allergic reaction through an IgE-mediated mechanism, and cross-reactivity might occur between mulberry fruit and birch pollen.

Endometrial Stromal Sarcoma Presented as an Incidental Lung Mass with Multiple Pulmonary Nodules / 결핵및호흡기질환

Low-grade endometrial stromal sarcoma (ESS) is an uncommon gynecologic malignancy of mesodermal origin. Pulmonary metastasis of low-grade ESS can occur years and decades after the treatment of the primary disease. Low-grade ESS is frequently mistaken as benign uterine neoplasm like uterine leiomyoma, which can potentially lead to a misdiagnosis. We present a case of a 42-year-old woman with low-grade ESS, that initially presented as an incidental lung mass with multiple pulmonary nodules, seven years after an uterine myomectomy. A 6.9x5.8 cm-sized intrapelvic mass suspected of uterine origin was discovered while searching for potential extrathoracic primary origin. A pelviscopy and simultaneous thoracoscopic lung biopsy were conducted for pathologic diagnosis. Finally, the diagnosis was confirmed as low-grade ESS with lung metastasis based on the histopathologic examination with immunohistochemical stain, which was showed positive for CD10 and hormone receptor markers (estrogen and progesterone receptors) in both pelvic and lung specimens.

Two Cases of Diagnosis and Removal of Endobronchial Hamartoma by Cryotherapy via Flexible Bronchoscopy / 결핵및호흡기질환

Although endobronchial hamartoma is a rare benign tumor, most patients with endobronchial hamartoma have respiratory symptoms such as obstructive pneumonia, hemoptysis, cough, or dyspnea due to bronchial obstruction. It can cause irreversible post-obstructive pulmonary destruction, thus early diagnosis and treatment is very important. Recently, there have been cases of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser and electrocautery procedures for bronchoscopic treatment of malignant or benign central airway obstruction with comparable therapeutic efficacy and few complications. Bronchoscopic cryotherapy is a newly developed technique for management of central airway obstruction. Moreover, it provides diagnostic methods with improving diagnostic yield and safety. We report two cases of endobronchial hamartoma, each diagnosed and definitively treated with bronchoscopic techniques. Endobronchial biopsy and removal was successfully performed by cryotherapy via flexible bronchoscopy without notable complications. Follow-up bronchoscopic examinations excluded residual or recurrent disease.

Complicated Acute Aortic Dissection with Malperfusion of the Left Common Iliac Artery Treated with Thoracic Endovascular Aortic Repair / 대한내과학회지

Acute aortic dissection with malperfusion syndrome is associated with poor clinical outcomes, and surgical treatment for complicated descending aortic dissections is associated with a high risk of operative mortality. Endovascular repair is emerging as a good alternative to surgery. Endovascular repair for a descending aortic dissection with malperfusion syndrome offers good clinical outcomes because of technical and anatomical benefits. Here, we report a case of descending aortic dissection and malperfusion syndrome in the left common iliac artery that was successfully treated with an aortic stent graft and peripheral stent.

Hybrid Treatment of an Aortic Arch Aneurysm with an Aberrant Right Subclavian Artery / 대한내과학회지

Aberrant right subclavian artery (ARSA) is a rare congenital anomaly but is the most common of the congenital vascular anomalies of the aortic arch. We report the case of a 68-year-old female undergoing chemotherapy for multiple myeloma who had a large thoracic aortic aneurysm (7.4 cm) with ARSA. She was treated with a hybrid procedure that combined a left common carotid-to-subclavian artery bypass with a "thoracic endovascular aortic repair (TEVAR)" because of the risk associated with a thoracotomy. A stent graft was deployed in the proximal part of the descending aorta to cover the thoracic aortic aneurysm after a left common carotid-to-subclavian bypass was made to restore blood flow in the left arm. There was no endoleak on digital subtraction angiography. Hybrid therapy can be performed successfully for the treatment of thoracic aortic aneurysm with ARSA.

A Case of IgG4-Related Disease Presenting as Massive Pleural Effusion and Thrombophlebitis / 결핵및호흡기질환

Immunoglobulin (Ig) G4-related disease is a recently recognized systemic fibroinflammatory condition characterized by a lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells with elevated circulating levels of IgG4. The disease can either be localized to one or two organs, or present as diffuse multi-organ disease. Furthermore, lesions in different organs can present simultaneously or metachronously. In the pulmonary manefestations, lesions associated with IgG4-related disease have been described in the lung parenchyma, airways and pleura, as well as the mediastinum. We report a case of IgG4-related disease presenting as massive pleural effusion and thrombophlebitis.

A Case Report of Recurrent Malignant Paraganglioma with Lung and Spine Metastasis that Occurred Sixteen Years after Primary Tumor Excision / 대한내과학회지

Paragangliomas are rare tumors that arise from the extra-adrenal chromaffin cells, and malignancy is defined by the presence of metastases to sites that normally lack chromaffin tissue. The main therapeutic targets are tumor reduction and control of excessive catecholamine secretion. Currently, the adjuvant therapy to surgery is radiotherapy treatment using high-dose MIBG; chemotherapy is currently evolving. We report herein a case of malignant paraganglioma with lung and spine metastasis that occurred 16 years after primary tumor excision and was treated with high dose MIBG radiotherapy and chemotherapy.

Endovascular Treatment of an Abdominal Aortic Pseudoaneurysm in a Patient with Behcet's Disease / 대한내과학회지

Behcet's disease shows systemic involvement, including mucocutaneus, ophthalmical, neurological, pulmonary, gastrointestinal, urogenital, mucoskeletal, and cardiovascular disorders. Aneurysmal changes develop in 65% of patients with arterial involvement and are associated with a poor prognosis. Although many attempts have been made to surgically manage these serious arterial lesions, several reports have shown a high recurrence rate and operation-related complications. Stent-graft placement has been indicated for the treatment of pseudoaneurysms and aneurysms in patients with a high surgical risk, including those with Behcet's disease. We herein describe an abdominal aortic pseudoaneurysm in a patient with Behcet's disease that was successfully treated with stent-graft insertion without an endoleak after 36 months of follow-up.

A Case of Etanercept Treatment in a Patient with Ankylosing Spondylitis on Peritoneal Dialysis

Treatments for patient with ankylosing spondylitis (AS) include non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs) and anti-tumor necrosis factor-alpha (TNFalpha) agents. However, owing to the well-known nephrotoxicity of NSAIDs and some DMARDs, the use of these drugs is limited in AS patients with renal insufficiency. As the pharmacokinetics and metabolism of anti-TNFalpha agents in patients of end stage renal disease, especially those receiving peritoneal dialysis (PD), have not been investigated well, little is known about treating them with anti-TNFalpha agents. We described the safety and efficacy of etanercept, a soluble fusion protein comprising the TNF receptor 2 in linkage with the Fc portion of immunoglobulin G, in a 40-year-old male AS patient receiving PD.

Intermittent, Non Cyclic Severe Mechanical Aortic Valve Regurgitation

Mechanical aortic prosthesis dysfunction can result from thrombosis or pannus formation. We describe an unusual case of intermittent, non cyclic mechanical aortic prosthesis dysfunction due to pannus formation with thrombus in the absence of systolic restriction of disk excursion, that presented with intermittent severe aortic regurgitation.