BRAF(V600E) Test for Suspicious Lateral Lymph Nodes in Papillary Thyroid Cancer / 대한내분비외과학회지

PURPOSE: This study evaluates the BRAF(V600E) test with fine-needle aspiration cytology (FNAC) for lateral lymph node (LN) metastasis in papillary thyroid carcinoma (PTC). METHODS: Ninety-one patients, including 95 lateral LNs with possible PTC metastasis, were consecutively entered into the study. We analyzed the accuracy of results for the BRAF(V600E) test and FNAC for lateral LN metastasis in PTC. RESULTS: Modified radical neck dissection was performed for 34 cases due to lateral LN metastasis. The sensitivity of FNAC was 88.2% , and the LN-BRAF(V600E) test 64.7%. The specificity and positive predictive value (PPV) were 100% for both tests. The negative predictive values (NPV) were FNAC, 93.8%, and LN-BRAF(V600E), 83.6%. For samples positive with either the BRAF(V600E) test or FNAC, the sensitivity was 94.1%, specificity 100%, PPV value 100%, and NPV 96.8%. CONCLUSION: This study suggests that the complementary LN-BRAF(V600E) test with FNAC is a supportive diagnostic method for PTC patients with indeterminate or non-diagnostic suspicious lateral LNs.

Can Parathyroid Score Expect Hypocalcemia after Total Thyroidectomy? / 대한내분비외과학회지

PURPOSE: The aims of this study were to investigate whether parathyroid score can predict hypocalcemia after total thyroidectomy with central lymph node dissection (CLND) and to determine clinical value of parathyroid score for treatment of hypocalcemia. METHODS: A prospective review of 209 patients who underwent total thyroidectomy with CLND for papillary thyroid cancer from January to December 2012 was conducted. Parathyroid score was designed based on the number and color of parathyroid preservation (Save and intact color of a parathyroid was 2; Save but mild discoloration was 1.5; Not identification was 1.2; Autotransplantation was 1.0; Sacrifice was -1). RESULTS: The mean numbers of parathyroid glands were as follows: save & intact color was 2.0; save & mild discoloration was 0.8; not identification was 0.8; autotransplantation was 0.4. The average parathyroid score was 6.54+/-0.69 (range 3.4~8.0). The average PTH was 16.3 at the 1st POD. Transient and permanent hypocalcemia were 33.4% (70/209) and 0.9% (2/209), respectively. Parathyroid score was 6.78+/-0.54 in patients without transient hypocalcemia, 5.93+/-0.67 with hypocalcemia, parathyroid score was significantly lower in transient hypocalcemia, abnormal PTH at the 1st POD (P<0.001, P<0.001). CONCLUSION: Parathyroid score may predict patients at risk of developing transient hypocalcemia after total thyroidectomy with CLND.

Ductal Carcinoma Arising from Ectopic Breast Tissue Following Microcalcification Observed on Screening Mammography: A Case Report and Review of the Literature / 한국유방암학회지

Ectopic breast tissue can occur anywhere along the incompletely regressed mammary ridge. Among the various types of breast choristoma, ectopic breast tissue, which has only glandular tissue without a nipple or areola, is most commonly detected in axillary areas. However, ectopic breast cancer is often not detected until significant clinical symptoms have been revealed, or diagnosis is delayed. Furthermore, an examination of ectopic breast tissue tends to be omitted from a screening mammography. Especially, the microcalcifications of ectopic breast tissue are difficult to delineate on mammography. Herein, the authors report a case of ectopic breast carcinoma that showed clustered microcalcifications on screening mammography, and discuss the interpretation and implications of microcalcification in ectopic breast tissue.

Role of BRAFV600E Mutation as a Marker for Prognostic Stratification of Papillary Thyroid Carcinoma / 대한내분비외과학회지

PURPOSE: Papillary thyroid carcinoma (PTC) is the most common malignant tumor of the thyroid and BRAFV600E mutation is the most frequent genetic alteration in PTC. BRAFV600E mutation has been demonstrated as a prognostic biomarker for prediction of poor clinicopathological outcomes, such as increased incidence of extrathyroidal extension, lymph node metastasis, and advanced stage. However, there is conflicting literature regarding the association of BRAFV600E mutation and aggressive clinicopathological features. In this study, we investigated the prevalence of BRAFV600E mutation in PTC and determined the association of BRAF mutation with indicators of poor prognosis for PTC. METHODS: We reviewed 1009 patients with PTC, who underwent thyroid surgery at Kyungpook National University Hospital between January 2013 and March 2014. BRAFV600E mutation analysis was performed using real-time polymerase chain reaction based amplification of DNA extracted from paraffin-embedded tumor specimens. RESULTS: BRAFV600E mutation was detected in 863 (85.5%) patients. In univariate analysis, histologic subtype, extrathyroidal extension, and advanced stage showed significant association with BRAFV600E mutation. In addition, concurrent Hashimoto's thyroiditis showed an association with low prevalence of BRAFV600E mutation. However, no statistically significant association was observed for age, gender, multifocal or bilateral tumor, and lymph node metastasis. Multivariate analysis showed an independent association of extrathyroidal extension with BRAFV600E mutation. CONCLUSION: In this study, extrathyroidal extension of PTC is an independent prognostic factor associated with BRAFV600E mutation status. However, conduct of further large scale studies with long term follow up is required before the BRAF mutation can be conclusively recommended as a prognostic biomarker.

The Comparative Study of Ultrasonography, Contrast-Enhanced MRI, and 18F-FDG PET/CT for Detecting Axillary Lymph Node Metastasis in T1 Breast Cancer / 한국유방암학회지

PURPOSE: A more noninvasive evaluation of axillary lymph node in breast cancer is one of the principal challenges of breast cancer treatment. To detect axillary lymph node metastasis (ALNM) in T1 breast cancer, we have compared the axillary ultrasonography (AUS), contrast-enhanced magnetic resonance imaging (cMRI), and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) to determine the most adequate test or a combination of tests. METHODS: Retrospectively, 349 T1 breast cancer patients who were preoperatively examined using AUS, cMRI, and PET/CT between 2008 and 2011 and whom underwent pathological evaluations of axillary lymph nodes were reviewed and analyzed. RESULTS: In total, 26.4% (92/349) of patients exhibited ALNM. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of AUS for determining ALNM were 44.6%, 88.7%, 58.6%, 81.7%, and 77.1%, respectively. cMRI was similar to AUS. The sensitivity, specificity, PPV, NPV, and accuracy of PET/CT were 44.5%, 94.2%, 73.2%, 82.6%, and 81.1%, respectively. The combination including cMRI and PET/CT was the most accurate with sensitivity, specificity, PPV, NPV, and accuracy values of 39.1%, 98.8%, 92.3%, 81.9%, and 83.1%, respectively. The mean number (3.5+/-4.2) of ALNMs in the patients who were positive based on cMRI and PET/CT and also pathologically proven to exhibit ALNM was significantly larger than the number (2.16+/-2.26) in other patients who exhibited ALNM (p=0.035). CONCLUSION: There are no definitive modalities for detecting ALNM in T1 breast cancers to replace sentinel lymph node biopsy (SLNB). If ALNM is suspected based on cMRI and PET/CT, the axillary dissection without SLNB might be a better option because it is related to high possibilities of ALNM and large axillary metastatic volumes.

Chyle Leakage after Total Thyroidectomy and Central Neck Dissection: Report of Three Cases / 대한내분비외과학회지

Chyle leakage is a rare complication of surgery for thyroid cancer that generally develops after lateral neck dissection. Here, we describe chyle leakages experienced after central neck dissection (CND). A total of 615 patients with thyroid cancer were treated by total thyroidectomy with CND between Jan 2012 and Dec 2012 at our facility, and three (0.49%) developed chyle leakages. The amounts of leakage were all less than 100 ml/day. One patient was resolved with conservative management, while the others were treated with conservative treatment and fibrin glue injection in chylous lymphocele. Chyle leakage after CND is very uncommon, and most cases involve minor leakage. Fibrin glue could be a treatment option for chyle leakage following CND.

Surgical Techniques for Personalized Oncoplastic Surgery in Breast Cancer Patients with Small- to Moderate-Sized Breasts (Part 1): Volume Displacement / 한국유방암학회지

Despite the popularity of breast-conserving surgery (BCS), which constitutes 50-60% of all breast cancer surgeries, discussions regarding cosmetic results after BCS are not specifically conducted. The simple conservation of breast tissue is no longer adequate to qualify for BCS completion. The incorporation of oncological and plastic surgery techniques allows for the complete resection of local disease while achieving superior cosmetic outcome. Oncoplastic BCS can be performed in one of the following two ways: 1) volume displacement techniques and 2) volume replacement techniques. This study reports volume displacement surgical techniques, which allow the use of remaining breast tissue after BCS by glandular reshaping or reduction techniques for better cosmetic results. Thorough understanding of these procedures and careful consideration of the patient's breast size, tumor location, excised volume, and volume of the remaining breast tissue during the surgery in choosing appropriate patient and surgical techniques will result in good cosmetic results. Surgery of the contralateral breast may be requested to improve symmetry and may take the form of a reduction mammoplasty or mastopexy. The timing of such surgery and the merits of synchronous versus delayed approaches should be discussed in full with the patients. Because Korean women have relatively small breast sizes compared to Western women, it is not very easy to apply the oncoplastic volume displacement technique to cover defects. However, we have performed various types of oncoplastic volume displacement techniques on Korean women, and based on our experience, we report a number of oncoplastic volume displacement techniques that are applicable to Korean women with small- to moderate-sized breasts.

Surgical Techniques for Personalized Oncoplastic Surgery in Breast Cancer Patients with Small- to Moderate-Sized Breasts (Part 2): Volume Replacement / 한국유방암학회지

Oncoplastic breast surgery has become a popular choice of treatment for breast reconstruction after mastectomy. There are two different techniques in oncoplastic surgery depending on the volume of the excised breast tissue. One is the volume displacement procedure, which combines resection with a variety of different breast-reshaping and breast-reduction techniques; the other is the volume replacement procedure in which the volume of excised breast tissue is replaced with autologous tissue. In this study, current authors performed various volume replacement techniques based on the weight of the excised tumor and its margin of resection. We used a latissimus dorsi myocutaneous flap for cases in which the resection mass was greater than 150 g, and for cases in which the resection mass was less than 150 g, we used a regional flap, such as a lateral thoracodorsal flap, a thoracoepigastric flap, or perforator flaps, such as an intercostal artery perforator flap or a thoracodorsal artery perforator flap. In the patients with small to moderate-sized breasts, when a postoperative deformity is expected due to a large-volume tumor resection, the replacement of non-breast tissue is required. Many of whom have small breasts, oncoplastic volume replacement techniques in breast-conserving surgery allow an extensive tumor excision without concern of compromising the cosmetic outcome and can be reliable and useful techniques with satisfactory aesthetic results.

Surgical Techniques for Personalized Oncoplastic Surgery in Breast Cancer Patients with Small- to Moderate-Sized Breasts (Part 1): Volume Displacement / 한국유방암학회지

Despite the popularity of breast-conserving surgery (BCS), which constitutes 50-60% of all breast cancer surgeries, discussions regarding cosmetic results after BCS are not specifically conducted. The simple conservation of breast tissue is no longer adequate to qualify for BCS completion. The incorporation of oncological and plastic surgery techniques allows for the complete resection of local disease while achieving superior cosmetic outcome. Oncoplastic BCS can be performed in one of the following two ways: 1) volume displacement techniques and 2) volume replacement techniques. This study reports volume displacement surgical techniques, which allow the use of remaining breast tissue after BCS by glandular reshaping or reduction techniques for better cosmetic results. Thorough understanding of these procedures and careful consideration of the patient's breast size, tumor location, excised volume, and volume of the remaining breast tissue during the surgery in choosing appropriate patient and surgical techniques will result in good cosmetic results. Surgery of the contralateral breast may be requested to improve symmetry and may take the form of a reduction mammoplasty or mastopexy. The timing of such surgery and the merits of synchronous versus delayed approaches should be discussed in full with the patients. Because Korean women have relatively small breast sizes compared to Western women, it is not very easy to apply the oncoplastic volume displacement technique to cover defects. However, we have performed various types of oncoplastic volume displacement techniques on Korean women, and based on our experience, we report a number of oncoplastic volume displacement techniques that are applicable to Korean women with small- to moderate-sized breasts.

Surgical Techniques for Personalized Oncoplastic Surgery in Breast Cancer Patients with Small- to Moderate-Sized Breasts (Part 2): Volume Replacement / 한국유방암학회지

Oncoplastic breast surgery has become a popular choice of treatment for breast reconstruction after mastectomy. There are two different techniques in oncoplastic surgery depending on the volume of the excised breast tissue. One is the volume displacement procedure, which combines resection with a variety of different breast-reshaping and breast-reduction techniques; the other is the volume replacement procedure in which the volume of excised breast tissue is replaced with autologous tissue. In this study, current authors performed various volume replacement techniques based on the weight of the excised tumor and its margin of resection. We used a latissimus dorsi myocutaneous flap for cases in which the resection mass was greater than 150 g, and for cases in which the resection mass was less than 150 g, we used a regional flap, such as a lateral thoracodorsal flap, a thoracoepigastric flap, or perforator flaps, such as an intercostal artery perforator flap or a thoracodorsal artery perforator flap. In the patients with small to moderate-sized breasts, when a postoperative deformity is expected due to a large-volume tumor resection, the replacement of non-breast tissue is required. Many of whom have small breasts, oncoplastic volume replacement techniques in breast-conserving surgery allow an extensive tumor excision without concern of compromising the cosmetic outcome and can be reliable and useful techniques with satisfactory aesthetic results.

The Predictors of Tumor Invasion for Patients with an Initial Diagnosis of Ductal Carcinoma in situ and the Indications for Performing Sentinel Lymph Node Biopsy

PURPOSE: The diagnostic methods for examining suspicious lesions in the breast are becoming less invasive, like core-needle biopsy. Yet, the risk of invasion has been reported to be up to 47% for patients with ductal carcinoma in situ (DCIS) initially diagnosed by core-needle biopsy. The value of sentinel lymph node biopsy (SLNB) for DCIS has not been clearly proved. We searched for the factors associated with invasiveness of preoperatively diagnosed DCIS, and we determined the indications for performing SLNB for patients with preoperatively diagnosed DCIS. METHODS: Between October 1997 and December 2008, we retrospectively reviewed 135 patients with DCIS that was initially diagnosed by core-needle biopsy or other biopsy methods. We compared the invasive breast cancer group, which was finally diagnosed with the pure DCIS group in regards to clinical, radiological, and pathological factors. RESULTS: 21.5% of the patients with initial diagnosis of DCIS were finally diagnosed with invasive breast cancer. On univariate analysis, the statistically meaningful factors for invasiveness were palpable lesion (P<0.0001), core-needle diagnosis (P=0.007), large tumor size (P=0.028), high nuclear grade (P=0.002), and negative estrogen receptor (P=0.005). On multivariate analysis, a palpable lesion was the only independent risk factor (odds ratio 3.9 (1.1 to 13.8); P=0.035). Axillar lymph node metastases were found in three patients in the invasive cancer group. There was no lymph node metastasis in the DCIS group. CONCLUSION: We recommend that SLNB be considered in initially diagnosed DCIS with palpable lesion or high nuclear grade due to the high risk of invasiveness.