Clinical Outcomes of Proton Beam Therapy for Choroidal Melanoma at a Single Institute in Korea / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study retrospectively evaluated the clinical outcomes and complications of proton beam therapy (PBT) in a single institution in Korea and quantitatively analyzed the change in tumor volume after PBT using magnetic resonance imaging (MRI). MATERIALS AND METHODS: Twenty-four treatment-naïve patients who underwent PBT for choroidal melanoma between 2009 and 2015 were reviewed. Dose fractionation was 60-70 cobalt gray equivalents over 5 fractions. Orbital MRIs were taken at baseline and 3, 6, and 12 months after PBT and annually thereafter. The tumor volume was reconstructed and evaluated by stacking the tumor boundary in each thin-sliced axial T1-weighted image using MIM software. RESULTS: The median follow-up duration was 36.5 months (range, 9 to 82 months). One patient had suspicious local progression and two patients had distant metastasis. The 3-year local progression-free survival, distant metastasis-free survival, and overall survival rates were 95.8%, 95.8%, and 100%,respectively. Five Common Terminology Criteria for Adverse Event ver. 4.03 grade 3-4 toxicities were observed in four patients (16.7%), including one with neovascular glaucoma. The mean tumor volume at the baseline MRI was 0.565±0.084 mL (range, 0.074 to 1.610 mL), and the ratios of the mean volume at 3, 6, and 12 months to that at baseline were 81.8%, 67.3%, and 60.4%, respectively. CONCLUSION: The local controlrate and complication profile after PBT in patientswith choroidal melanoma in Korea were comparable with those reported in a previous PBT series. The change in tumor volume after PBT exhibited a gradual regression pattern on MRI.

A Case of Sympathetic Ophthalmia due to Corneal Perforation in a Patient with Meningioma

PURPOSE: To describe a case of sympathetic ophthalmia due to corneal perforation caused by exposure keratitis in a patient with recurrent sphenoid wing meningioma. CASE SUMMARY: A 34-year-old female patient presented with proptosis in her left eye caused by left sphenoid greater wing meningioma despite tumor debulking surgery and radiation treatment. The cornea was perforated with prolapsed iris due to exposure keratitis, thus enucleation of the left eye was performed. After 2 weeks, an inflammatory reaction occurred in both eyes, keratic precipitates on corneal endothelium, exudative retinal detachment, and multiple granulomatous nodules on the right eye retina. The patient was diagnosed with sympathetic ophthalmia, thus enucleation of the left eye and debulking of the tumor were performed followed by a high-dose intravenous steroid therapy. At 5 months postoperatively, slit lamp biomicroscope showed no chamber reaction; improved disc swelling and exudative retinal detachment in the right eye were observed. CONCLUSIONS: Despite conservative treatment for exposure keratitis due to proptosis caused by malignant sphenoid meningioma, corneal perforation can develop. Because sympathetic ophthalmia can occur, the other eye should be monitored.

Long-term Surgical Outcomes of the Multi-purpose Conical Porous Synthetic Orbital Implant

PURPOSE: We present clinical results of the use of the multipurpose conical porous synthetic orbital implant (MCOI) in surgical procedures of evisceration, enucleation, and secondary enucleation in ophthalmology patients. METHODS: A retrospective review was performed of 59 eyes in which conical implants were used, including 36 cases of eviscerations, 11 enucleations, and 9 secondary enucleations. In all of the cases, the follow-up period was greater than six months between 2004 and 2013. The results focus on documenting surgical findings, as well as postoperative complications among patients. RESULTS: Superior sulcus deformities were found in six eyes (10.2% of conical implant patients), and two eyes received additional surgical interventions to correct the deformities (3.4%). Blepharoptosis was found in four eyes (6.8%), two of which received upper eyelid blepharoplasty (3.4%). Fornix shortening was reported in only one eye (1.7%). Forty-one eyes had a satisfactory cosmetic appearance after the final prosthetic fitting of conical implants (69.5%). The most frequent postoperative complication was orbital implant exposure, which seemed to occur when the preoperative status of the conjunctiva, Tenon's capsule, and sclera preservation were poor in the eyes of the patients. CONCLUSIONS: There was a lower incidence of blepharoptosis and fornix shortening with the MCOI in comparison to spherical implants, while the incidence of orbital implant exposure was similar with the MCOI in comparison to other types of orbital implants. In addition, the MCOI may have advantages with respect to postoperative cosmetic outcomes.

Comparative Study of Hugel-tox(R) versus Botox(R) for the Treatment of Essential Blepharospasm

PURPOSE: To compare clinical efficacy and duration of Hugel-tox(R) (also known as Botulax(R)) and Botox(R) for the treatment of essential blepharospasm. METHODS: A total of 48 patients who were injected with Hugel-tox(R) (17 females, 7 males) or Botox(R) (18 females, 6 males) from February 2013 to October 2013 were enrolled in the present study. Changes in eyelid closing force and Scott grade before and after injection were analyzed. Adverse events were also evaluated. RESULTS: There were no significant differences between the Hugel-tox(R) and Botox(R) groups in clinical efficacy and duration. Before and after injection, changes in Scott grade (Hugel-tox(R): -1.17 +/- 0.70, Botox(R): -1.21 +/- 0.72, p = 0.840), changes in eyelid closing force (Hugel-tox(R): -1.38 +/- 0.58, Botox(R): -1.17 +/- 0.56, p = 0.212) and duration (Hugel-tox(R): 116.08 +/- 22.12 days, Botox(R): 126.92 +/- 38.94 days, p = 0.242) were shown. No serious adverse events were found in either group. CONCLUSIONS: Hugel-tox(R) showed nearly equal efficacy and duration compared with Botox(R).

Outcomes of Endoscopic Dacryocystorhinostomy in Patients Receiving Radioactive Iodine Therapy for Thyroid Carcinoma

PURPOSE: To evaluate the outcomes of endonasal or external dacryocystorhinostomy in patients who underwent radioiodine therapy due to thyroid cancer. METHODS: We reviewed retrospectively clinical and microbiological records of patients who had endonasal or external dacryocystorhinostomy after taking radioiodine therapy for thyroid cancer between January 2006 and December 2012. RESULTS: Twenty-three female adult patients with an average age of 50 years (range, 25 to 72 years) were identified. Seven patients underwent unilateral surgery and 16 had bilateral surgery. Among 39 eyes, 1 eye had combined nasal septoplasty, 3 eyes had external dacryocystorhinostomy and 36 eyes had endonasal dacryocystorhinostomy. Dacryocystorhinostomy was performed within 12 months after the last 131I dose in 3 cases and 2 (5%) presented with the symptom of epiphora. The major cause of symptomatic recurrence was restenosis of the lacrimal nasal mucosa due to the formation of scar tissue, thus, the patients underwent revision surgeries. The remaining 37 of the 39 eyes (95%) showed improvement of symptoms. CONCLUSIONS: Most patients who underwent dacryocystorhinostomy after 131I therapy due to thyroid cancer showed successful outcomes, especially after more than 1 year post-operatively. The major cause of nasolacrimal duct obstruction was a scar tissue formation in the nasal cavity mucosa.

Clinicopathological Characteristics of Malignant Eyelid Tumor in Korea

PURPOSE: To determine the clinical characteristics of patients with malignant eyelid tumors in Korea. METHODS: We performed a retrospective review of the medical records of 73 patients with malignant eyelid tumors who were histologically diagnosed at Seoul St. Mary's hospital from April 2004 to September, 2012 and followed for 6 months or longer. RESULTS: Of 73 cases, 41 (56.2%) were diagnosed as basal cell carcinoma, 17 (23.3%) as squamous cell carcinoma, 11 (15.1%) as sebaceous gland carcinoma, 3 (4.1%) as malignant melanoma, and 1 (1.4%) as basosquamous cell carcinoma. The mean age at diagnosis was 68.4 +/- 11.5 years. Tumors developed more commonly on the lower lid (54.8%). Most cases were treated by complete resection of tumors and eyelid reconstruction (95.9%). The prognosis of patients with basal cell carcinoma and squamous cell carcinoma was good, while that of the other tumors was relatively poor. CONCLUSIONS: The most common diagnosis was basal cell carcinoma (56.2%). Recurrence after complete surgical excision and reconstruction was uncommon.

A Case of Huge Pilocytic Astrocytoma Causing Eyeball Subluxation

PURPOSE: To report a relatively rare case of huge pilocytic astrocytoma of the optic nerve and optic chiasm causing eyeball subluxation. CASE SUMMARY: An eight-year-old male presented with proptosis and visual loss in the left eye for one year. The radiological findings showed a 2.9 x 2.7 x 4.2-cm tumor on the left optic nerve and optic chiasm. For diagnosis and treatment, the patient underwent tumor resection and enucleation. Pathohistological analysis of the tumor specimen revealed pilocytic astrocytoma, which is classified by the World Health Organization as a grade I astrocytic tumor. CONCLUSIONS: Astrocytoma is a tumor of the brain that affects children more often than adults. In general, gross-total resection of pilocytic astrocytoma is expected to be curative due to the non-invasive feature of the tumor. Considering pilocytic astrocytoma as differential diagnosis of orbital tumor in children with symptoms of rapidly progressive proptosis and decreased visual acuity is important because occurrence in the optic nerve and optic chiasm is possible.

Clinical Analysis of Epithelial Tumors of the Lacrimal Gland

PURPOSE: To analyze the clinical and radiologic findings and to evaluate the treatment and prognosis of epithelial tumor patients. METHODS: We retrospectively reviewed clinical and radiologic findings of 36 patients who had been histopathologically diagnosed with epithelial tumors of the lacrimal gland after biopsy and surgery at Seoul St. Mary's Hospital from May 2005 to October 2012. RESULTS: Among the patients with epithelial tumors of the lacrimal gland based on histopathological findings, there were 21 cases of pleomorphic adenoma, seven cases of dacryops, four cases of adenoid cystic carcinoma, two cases of adenocarcinoma, one case of benign oncocytoma, and one case of mucoepidermoid carcinoma. The characteristic clinical finding of epithelial tumors of the lacrimal gland was proptosis (52.7%). In contrast with benign epithelial tumors of the lacrimal gland, the characteristic clinical findings of malignant epithelial tumors of the lacrimal gland were limitation of motion (57.1%), diplopia (57.1%), ocular pain (42.9%), and decreased visual acuity (42.9%). The mean duration of the symptoms of malignant epithelial tumors (5.0 +/- 4.2 months) was shorter than that of benign epithelial tumors (11.2 +/- 11.1 months) (t-test, p = 0.034). In radiologic CT and MRI findings, there was minimal bony destruction in two cases of pleomorphic adenoma and calcification in one case of pleomorphic adenoma. Malignant epithelial tumors of the lacrimal gland, in contrast to benign tumors, showed characteristic bony destruction (57.1%), poorly marginated tumor outline (42.9%) and calcification (14.3%). The 57.1% of patients in this study with malignant tumors were treated with chemotherapy and radiotherapy after surgical treatment, and there was one case (14.3%) of recurrence after treatment. CONCLUSIONS: Careful analysis of clinical and radiologic findings can lead to early diagnosis of malignant tumors.

A Case of Conjunctival Myxoma Invading the Caruncle

PURPOSE: To report a rare case of conjunctival myxoma invading the caruncle. CASE SUMMARY: A 46-year-old man presented with a medical canthal conjunctival mass in his left eye. The mass was a semi-transparent, yellowish, movable mass 10 mm x 6 mm in size in the subconjunctival space. There was no pain and no tenderness. Excisional biopsy of the mass was performed. Histopathologic examination revealed findings suggestive of myxoma. CONCLUSIONS: Relatively transparent, movable, yellowish to pinkish conjunctival masses at medial canthal area without pain or tenderness can be diagnosed as myxoma on biopsy and myxoma can be seen at caruncle.

A Case of Angiosarcoma Arising from the Eyelid

PURPOSE: To report a case of angiosarcoma arising from the eyelid. CASE SUMMARY: A 72-year-old male patient presented with swelling and erythema on the upper and lower eyelid of 10 months in duration. After the diagnosis of cutaneous angiosarcoma via tissue biopsy, no evidence of systemic metastasis was found. The right eyelid was treated with radiation therapy and a partial clinical response was achieved. After 4 months of follow-up, swelling and a red-purple plaque developed on the same (right) eyelid. Another biopsy was performed and the histological examination indicated a recurrence of angiosarcoma. Neither local nor distant metastases were observed. However, large-sized and ill-defined margins warranted size reduction by paclitaxel neoadjuvant chemotherapy, followed by surgical excision and eyelid reconstruction. CONCLUSIONS: Angiosarcoma commonly occurs on the face and scalp, but rarely occurs on the eyelids. Herein, the authors report a case of angiosarcoma arising from the eyelid.

The Keratometric and Refractive Value Change According to Trephine Size Difference after Keratoplasty in Keratoconus

PURPOSE: To investigate mean keratometric and refractive value after penetrating keratoplasty according to the difference between donor and recipient cornea size. METHODS: In a retrospective study, Keratoconus patients who underwent penetrating keratoplasty for keratoconus from January 2005 to July 2008 were examined. Preoperatively, axial length was measured using applanation ultrasonography and anterior chamber depth, white to white diameter were also measured using the corneal topography. The trephine size of donor and recipient during the surgery were recorded. Preoperatively, 6, 12, and 24 months postoperatively refraction and keratometric value were evaluated in groups divided according to corneal trephine size difference. RESULTS: Among the 41 eyes of 41 patients, there was a mean age at transplant of 26.4 years. After surgery, the decrease of anterior chamber depth could contribute to the decrease of myopic change. However, the differences between donor and recipient cornea size do not have a significant affect on postoperative keratometric or refractive value. CONCLUSIONS: There is no significant difference between the postoperative keratometric value and the corneal trephine size difference in keratoconus patients.

The Prophylactic Effect of 360 Degree Endolaser Photocoagulation for Prevention of Retinal Detachment

PURPOSE: To evaluate the effectiveness of prophylactic effect of 360 degree endolaser photocoagulation for prevention of retinal detachment after pars plana vitrectomy. METHODS: In a retrospective study, 53 patients who underwent pars plana vitrectomy by one surgeon from Jan 2008 to Dec 2008 were examined. We compared the visual acuity improvement and postoperative retinal detachment and other postoperative complications in the 28 patients who received the 360 degree endolaser photocoagulation during the pars plana vitrectomy and the 26 patients who did not receive the 360 degree endolaser photocoagulation during the pars plana vitrectomy. RESULTS: Two patients who did not receive 360 degree endolaser photocoagulation during the surgery got the postoperative retinal detachment. One of them got the only fluid gas exchange, but the other had to receive the reoperation. There was no statistically significant difference of visual acuity between the two groups (p > 0.05), and no surgical complication associated with endolaser photocoagulation. CONCLUSIONS: 360 degree endolaser photocoagulation for prevention of retinal detachment during the pars plana vitrectomy would be considerable for preventing the retinal detachment development.

Surgical Outcome of Levator Recession for Correction of Upper Eyelid Retraction

PURPOSE: To assess the efficacy of levator recession under local anesthesia to treat upper eyelid retraction. METHODS: Records of 12 patients (12 lids) were reviewed retrospectively. Postoperative cosmetic results were assessed as good, fair, or poor based on the upper lid height and symmetry. Preoperative and postoperative marginal reflex distance (MRD1, mm), upper eyelid asymmetry, lid lag, lagophthalmos, and ocular exposure symptoms were compared. The reoperation rate was also evaluated. RESULTS: Causes accounting for upper lid retraction were Graves ophthalmopathy (9 lids, 75.0%), orbital pseudotumor (2 lids, 16.7%), and hypercorrection from previous ptosis operation (1 lid, 8.3%). At a mean +/- standard deviation of 27.7 +/- 24.0 months follow-up (range, 5-60 months), 11 patients (91.7%) showed significantly better cosmetic results. MRD1 decreased an average of 3.1 +/- 1.3 mm from 6.3 +/- 1.5 mm preoperatively to 3.2 +/- 0.9 mm postoperatively (p < 0.001). Upper lid asymmetry, lagophthalmos, and lid lag were also reduced significantly (p < 0.001). Overcorrection occurred in 3 lids (25%) and required levator advancement. Eleven patients (91.7%) experienced complete resolution of dry eye symptoms following levator recession. CONCLUSIONS: Levator recession showed good cosmetic results up to 2 years after surgery for upper eyelid retraction.

The Use of Statistical Methodology in Articles in Medical Journals and Suggestions for the Quality Improvement of the Pediatric Allergy and Respiratory Disease / 소아알레르기및호흡기학회지

Statistical analysis is an essential component of all biomedical research. Use of descriptive and inferential analysis enables researchers to summarize findings and conduct generalizations from research findings. Physicians must keep current with clinical information to practice evidence-based medicine. In doing so, physicians need to access reports of original research. This requires the reader to critically appraise the design, conduct, and analysis of each study and subsequently interpret the results. However, many surveys reveal prevalent statistical errors in articles in medical journals, and it is also clear that many physicians are seriously unfamiliar with statistical methods. This constitutes a major barrier to the development of medical research. Given this situation, this review article discusses the use of statistical methods in medical journal articles, the status of statistical errors among them, and the results of evaluation of physicians' understanding of statistical methods. Moreover, this article introduces the current trend in statistical reviews to improve the quality of medical journal articles, and explains the uniform requirements for manuscripts submitted to medical journals. Finally, the article proposes several specific ways to improve the quality of the Pediatric Allergy and Respiratory Disease.

The Correlation between Organisms Cultured from the Lacrimal Sac and Lacrimal Punctum in Dacryocystitis

PURPOSE: To evaluate the correlation between organisms cultured from the lacrimal punctum and lacrimal sac in acute and chronic dacryocystitis during endonasal or external dacryocystorhinostomy. METHODS: Clinical and microbiological records of patients who received endonasal or external dacryocystorhinostomy diagnosed with chronic or acute dacryocystitis between January 2006 and July 2010 were reviewed for age, gender, and culture results from samples of the lacrimal punctum and the lacrimal sac. RESULTS: A total of 107 (93%) patients were positive for bacterial cultures from the lacrimal punctum or sac. The majority of microorganisms from the lacrimal punctum were Staphylococcus epidermidis (24%), and the majority of microorganisms from the lacrimal sac were Staphylococcus aureus (25%). When simultaneous positive culture results from the lacrimal punctum and lacrimal sac were observed, the microorganisms from the 2 areas were identical in 62% of the samples. Additionally, the majority of these organisms were S. aureus. CONCLUSIONS: A high rate of microorganism-positive cultures from the lacrimal sac or lacrimal punctum with a diagnosis of chronic or acute dacryocystitis was found. In addition, the culture results demonstrated that the cause of dacryocystitis was mostly conjunctival normal flora, with a high degree of similarity in organisms between the lacrimal sac and lacrimal punctum (61.7%).

Temporary Severe Neurogenic Blepharoptosis after Reconstruction of Orbital Medial Wall Fracture

PURPOSE: To report two cases of temporary severe neurogenic blepharoptosis after successful reconstruction of orbital medial wall fracture. CASE SUMMARY: A 36-year-old woman and a 52-year-old man received orbital medial wall reconstruction with Medpor(R) for large fractures. Before the operation, the patients had only moderate swelling of the lid and periorbital ecchymosis. There were no limitations of extraocular muscles or ptosis. The operations were successful, although the patients developed unilateral complete ptosis with totally impaired levetor muscle function immediately after recovering from anesthesia. There were no anisocoria or limitations of the extraocular muscles. After oral steroid therapy, the patients began to improve on postoperative day 4 and after one month, respectively, and recovered to normal lid height and levator function after two months. CONCLUSIONS: Blepharoptosis after orbital medial wall reconstruction may result from ischemic damage at the end of the superior branch of the oculomotor nerve in the orbit due to compressive and tractional manipulation. Although very rare and temporary, this complication should be considered important because the occurrence can be unpredictable and may cause dissatisfaction to the surgeon and the patient after a successful operation.

Viability and Colony Forming Capacity of Hematopoietic Stem Cells after Cryopreservation / 대한소아혈액종양학회지

PURPOSE: Cryopreservation of hematopoietic stem cells is one of the essential components in autologous and peripheral blood stem cell transplantation. Cryopreservation of hematopoietic stem cell, the conventional method involves controlled-rate freezing by a programmed freezer in medium that contains 10% dimethyl sulfoxide (DMSO) as cryoprotectant, followed by storage in liquid nitrogen freezer. We compared the differences between different methods of cryopreservation and cryoprotectants on viability and colony forming capacity of hematopoietic stem cells. METHODS: Mononuclear cells separated using Ficoll-Hypaque from cord blood, peripheral blood and bone marrow were frozen with programmed freezer at 196degrees C or placed in a 70degrees C freezer without programmed freezer in both 10% and 20% DMSO. We measured cell viability using trypan blue dye exclusion method and colony forming capacity with methyl cellulose media at 7, 30 and 90 days after thawing. RESULTS: Cell viability of cord blood, peripheral blood and bone marrow was higher in the groups with programmed freezer compared with rapid freezing and storing in a 70degrees C freezer. Also as the storage time passed, the decrease in viability of hematopoietic cells was much less in the groups of controlled-rate freezing by a programmed freezer. The number of colony in cord blood and bone marrow was higher with programmed freezer and that of peripheral blood was higher with rapid freezing and storage in a 70degrees C freezer. Comparing the differences between different concentraions of DMSO, cell viability was similar or slightly higher in 20% DMSO groups than 10% DMSO groups, but the number of colony was higher in 10% DMSO groups. CONCLUSION: These results suggested that conventional cryopreservation method using programmed freezer with 10% DMSO was more effective in the cryopreservation of hematopoietic stem cells.

Chemosensitivity Test of Childhood Leukemic Cells

PURPOSE: The purpose of the present study is to determine the relation between in vitro resistance to 9 drugs, measured with colorimetric methylthiazol tetrazolium(MTT) assay and prognostic factors. METHODS: Thirty children with leukemia were evaluated at the pediatric department of Dongsan Medical Center. All samples tested with the MTT assay contained 80% or more leukemic cells, which were isolated by Ficoll density gradient centrifugation, and were incubated with 9 drugs for 4 days. The optical density(OD) of the wells was measured with microplate spectrophotometer. Leukemic cell survival(LCS) was calculated by OD treated well/OD control wellsx100(%). LD50 was calculated from the dose-response curve and used as a measure of resistance. RESULTS: Among the 30 children with leukemia, 16 were ALL, 14 were AML. Seventeen boys and thirteen girls ranged in age from 9 months to 16 years. Comparing LD50 values according to leukemic type, AML revealed relatively high LD50 values for all drugs, except VCR. But there were no significant differences between ALL and AML(P>0.05). Male showed high LD50 values for ASP, DET, ARA-C, VP16, ADR and 6TG. Age10 years children showed high LD50 values for all drugs, except 6TG. Patients with a leukocyte count>100,000/mm3 at diagnosis showed high LD50 values for VCR, ASP, DET, MTX, ARA-C, ADR, and 6TG. Patients with normal chromosome showed higher LD50 values. CONCLUSION: Our study showed higher LD50 values at AML, male, ageyears old, leukocyte count>100,000/mm3, and normal karyotype. The MTT test may contribute to the selection of effective chemotherapeutic agent for children with acute leukemia.