Atypia of undetermined significance on thyroid fine needle aspiration: surgical outcome and risk factors for malignancy

PURPOSE: This study was performed to analyze the surgical pathology results of the "atypia of undetermined significance" (AUS) category from thyroid fine needle aspiration (FNA) and to describe the characteristics to distinguish a malignant from a benign nodule. METHODS: A retrospective analysis was done on 116 patients who underwent thyroid surgery from December 2008 to December 2012, following a diagnosis of AUS from preoperative thyroid FNA. We investigated the age, gender, size and site of the nodules, ultrasonographic criteria, cytological features, the number of atypia results after repeated FNAs, surgical method, and final pathologic results. RESULTS: Sixty-five out of 116 patients underwent total thyroidectomy and the rest had partial thyroidectomy. The final pathologic results were 41 malignancies (35.3%) and 75 benign diseases (64.7%). AUS was divided into group 1: 'cannot rule out malignancy' or group 2: 'cannot rule out follicular neoplasm'. After surgery, group 1 revealed papillary thyroid cancer in most cases and group 2 revealed follicular adenoma in most cases. Age over 40 years, ultrasonographic findings suggestive of malignancy, more than 2 results of atypia from repeated FNAs and nodules less than 2 centimeters were risk factors for malignancy on univariate analysis. Multivariate analysis showed that ultrasonographic findings suggestive of malignancy was a significant risk factor for malignancy. CONCLUSION: For proper evaluation of the risk for malignancy in thyroid AUS patients, the ultrasonographic criteria should be considered along with other clinicopathological findings such as age, nodule size, number of atypia, cytologic features.

Generalized peritonitis arising from small bowel metastasis in a lung cancer patient / 대한외과학회지

Symptomatic gastrointestinal metastasis from lung malignancy is rarely reported. In this report, we present a case of lung adenocarcinoma with acute abdominal pain from small bowel perforation. The patient underwent small bowel resection and the final diagnosis was metastatic adenocarcinoma originating from lung. Immunohistochemistry was positive for thyroid transcription factor-1 and cytokeratin 7 (CK7), and negative for CK20. We present this rare case and briefly review the literature.

Observational study of central metastases following thyroid lobectomy without a completion thyroidectomy for papillary carcinoma / 대한외과학회지

PURPOSE: There are no guidelines for the optimal timing of the decision of when to perform completion thyroidectomy, and controversy exists regarding how the timing of completion thyroidectomy impacts survival patterns. We investigated the legitimacy of an observational strategy in central node metastasis after thyroid lobectomy for papillary thyroid cancer (PTC). METHODS: We retrospectively evaluated 522 consecutive patients who underwent thyroid lobectomy. Of the 69 patients with central metastasis, 61 patients (88.4%) were included in an observational study under cautious evaluation with informed consent by the patients, and compared with an observation arm of 180 postlobectomy N0 (node negative proven) patients. RESULTS: Of the 522 patients, six (1.1%) thyroid, five (0.9%) central, and two (0.4%) lateral recurrences were observed. Lateral recurrences occurred in the immediate completion N0 and Nx groups but not in the N1a observation arms. There were two (3.3%) central recurrences without thyroid or lateral recurrence on the observation arm of N1a observation patients. But two (1.1%) thyroid and three (1.7%) central recurrences were on the observation arm of N0 patients. In Kaplan-Meier survival curves for central or lateral recurrences between observation arms for the N1a and N0 groups, no significant difference was found between the N1a and N0 observation arms (P = 0.365). CONCLUSION: The timing of when to perform completion thyroidectomy in central metastases-proven patients after lobectomy for PTC should be based on the patient's risk category.

Erratum: Analysis of Infections Occurring in Breast Cancer Patients after Breast Conserving Surgery Using Mesh / 한국유방암학회지

No abstract available.

Age and prognosis of papillary thyroid carcinoma: retrospective stratification into three groups / 대한외과학회지

PURPOSE: We investigated the prognosis according to age in papillary thyroid carcinoma (PTC) patients. METHODS: We retrospectively evaluated 2,890 patients who underwent thyroidectomy due to PTC between May 2004 and Aug 2008. We divided patients into 3 groups: young ( or =55 years old). RESULTS: Median age was 47.0 years old (range, 15 to 82 years). Within a follow-up period median of 50 months, there were 148 (5.1%) locoregional recurrences, 6 (0.2%) PTC-related deaths, and 18 (0.6%) PTC-unrelated deaths. Outcomes were more favorable in the young group, with no PTC-related death despite the frequent locoregional recurrence. In the old group compared to the middle, there was a higher proportion of male, and more aggressive types as T3 or N1b, higher mean tumor number, more multiplicity, and bilaterality. The old group of > or =55 years did not show a significant difference in PTC-related deaths than other age groups in Cox analysis (OR, 0.9; P = 0.677), but a significant cutoff age in PTC-related deaths at 62.5 years was determined in ROC analysis (area under curve = 0.912). CONCLUSION: We showed that the or =62.5 years group shows a poor prognosis regardless of other factors such as male sex or tumor aggressiveness. Further multiinstitutional studies are needed to elucidate the prognosis according to patient's age.

Recurrence Pattern of Intrathyroidal Papillary Carcinoma / 대한내분비외과학회지

PURPOSE: We investigated the pattern of regional recurrence pattern of intrathyroidal node negative - T1N0 or T2N0 - papillary carcinoma, focusing on skip versus continuous central and lateral lymph node metastasis. Most lymph node metastasis of papillary thyroid carcinoma appear in a step-wise sequential pattern, but discontinuous lymph node metastasis may occur in 11.1~37.5% in node positive papillary cancer. While skip metastasis has been studied on the synchronous central and lateral lymphatic clearance, it has not been studied in reoperative settings on lateral recurrence. METHODS: From January 2000 to December 2005, Two hundred and seventy-five T1/T2 N0 patients underwent reoperative lymphatic clearance after total thyroidectomy and clinical - not prophylactic - central neck dissection in Gwangju and Hwasoon Chonnam National University Hospitals. We enrolled 210 patients who showed central and lateral neck metastasis as the continuous recurrence group and 65 patients who showed lateral metastasis without central lymph node metastasis as the skip recurrence group. RESULTS: Skip metastasis occurred in 17.6% (9/27 patients), and skip recurrence was in 23.6% (65/275 patients). In univariate analysis, in case of a single lesion, the skip recurrence was more prone to occur than multiple (P=0.026) and bilateral (P=0.048) papillary carcinoma. Multivariate analysis showed that tumor less than 1 cm (OR=2.24, P=0.009), single lesion (OR=3.23, P=0.019) for multiple lesion, and (OR=2.22, P=0.025) for bilateral lesion. CONCLUSION: Skip metastases were found in 17.6% (9 out of 27) of patients, and skip recurrence in reoperative surgery was found in 23.6% (65 out of 275) of patients. Careful follow-up and low dose radioiodine therapy may be considered in T1N0 or T2N0 papillary carcinoma in selected patients.

Risk Factor of Invasive Breast Cancer in Patients with Preoperative Diagnosis of Ductal Carcinoma in Situ

PURPOSE: Ductal carcinoma in situ (DCIS), unlike invasive ductal carcinoma, does not require sentinel lymph node biopsy or axillary lymph node dissection because the possibility of axillary lymph node metastasis is low. However, occasionally, despite preoperative diagnosis of DCIS, invasive ductal carcinoma can be diagnosed by postoperative biopsy. Therefore, a study of the associated risk factors is necessary. METHODS: 198 patients with an initial diagnosis of DCIS, treated between February 2005 and December 2009, were retrospectively analyzed. Associations between clinical and pathologic factors were analyzed for significance using univariate and multivariate analyses. RESULTS: Of the 198 patients, 57 (28.8%) were found to have invasive disease on final pathology. Multivariate analysis revealed 4 independent predictors of invasive cancer upon final pathology: diagnosis by needle biopsy (OR, 3.165; P=0.008), positive p53 on preoperative biopsy (OR, 2.494; P=0.019) DCIS size (>2 cm) on microscopic finding (OR, 2.683; P=0.014), and relatively young age (OR, 0.958, P=0.046). Of the 13 patients with positive axillary lymph nodes, 11 (84.6%) were shown to have invasive cancer on final pathology (P<0.001). CONCLUSION: In cases of preoperative diagnosis based on needle biopsy, positive p53, large tumor, and relatively young age, an SLNB procedure can be considered because in almost 30% of the patients an invasive carcinoma is found after surgery.

Is it possible to predict hypothyroidism after thyroid lobectomy through thyrotropin, thyroglobulin, anti-thyroglobulin, and anti-microsomal antibody? / 대한외과학회지

PURPOSE: We investigated the incidence and risk factors of hypothyroidism after thyroid lobectomy, and evaluated the possibility to predict hypothyroidism preoperatively with serologic markers, such as thyrotropin (TSH), thyroglobulin (TG), anti-thyroglobulin (ATA), and anti-microsomal antibody (AMA). METHODS: We enrolled 123 consecutive patients who underwent thyroid lobectomy due to benign conditions between May 2004 and April 2008. Only preoperative euthyroid patients were included. Patients were divided into two groups by postoperative thyroid function outcomes, into hypothyroid (n = 97) and euthyroid groups (n = 26), and analyzed specially for the preoperative levels of TSH, TG, ATA, and AMA. RESULTS: Twenty-six (21.1%) patients developed hypothyroidism following thyroid lobectomy within 35.7 months of follow-up. The proportion of post-lobectomy hypothyroidism was high in patients with high-normal preoperative TSH level, and the cut-off value was 2.0 mIU/L, with 67% sensitivity and 75% specificity. The quantitative titer of preoperative TG, ATA, and AMA was not significant, but the outcome of categorical analysis of two or more positivities on these three markers was significantly higher in hypothyroid patients than in euthyroid patients (28.6% vs. 3.9%, P = 0.024). The combined positivity of preoperative TSH and two or more positivities of TG, ATA, and AMA possess 100% positive predictive value and 81% negative predictive value. CONCLUSION: The incidence of hypothyroidism following thyroid lobectomy was 21.1%. High-normal preoperative TSH and two or more positivities for TG, ATA, and AMA are good pre-operative predictive markers. Such high-risk patients need close TSH monitoring before the onset of clinical hypothyroidism.

Primary papillary carcinoma originated from a branchial cleft cyst / 대한외과학회지

Although branchial cleft cysts are common, papillary carcinomas arising from them are rare. Here we report a 41-year-old woman with papillary carcinoma originating from a right lateral branchial cleft cyst without any evidence of a papillary carcinoma in the thyroid gland. The patient underwent right lateral neck dissection followed by total thyroidectomy. We then confirmed papillary carcinoma arising from the branchial cleft cyst through microscopic and immunohistochemical staining with thyroglobulin (TG), thyroid-associated transcription factor-1 (TTF-1) and p63. It is the 10th case worldwide describing papillary carcinoma in a branchial cleft cyst with a review of the literature on the features of the disease and discussion of the role of immunohistochemical staining with TG, TTF -1 and p63. In conclusion, it should be emphasized that the surgeon must be cautioned of the possibility of primary papillary carcinoma in the branchial cleft cyst.

Analysis of Infections Occurring in Breast Cancer Patients after Breast Conserving Surgery Using Mesh / 한국유방암학회지

PURPOSE: Breast conserving surgery using mesh can effectively fill the defective space, but there is the risk of infection. METHODS: From June 2007 to August 2010, 243 patients who underwent breast conserving surgery with polyglactin 910 mesh insert for breast cancer at our institution were retrospectively studied. RESULTS: Infection occurred in 25 (10.3%) of 243 patients. When comparing the infection and non-infection groups in multivariate analysis, there was no significant difference in age, underlying disease, preoperative biopsy methods, mass location, axillary lymph node dissection, operative methods, neoadjuvant or adjuvant chemotherapy use, mass size and removed breast volume. The infection appeared more common only in patients with body mass index (BMI) greater than 25. Infection symptoms occurred, on average, 119.5 days after surgery, and the average duration of the required treatment was 34.4 days. Out of 25 patients with postoperative infection complications, 16 (64%) patients underwent incision and drainage with mesh removal, whereas the remaining 9 (36%) only required conservative treatment. CONCLUSION: During breast conserving surgery, the risk of infection is increased in patients with high BMI, and should be taken into account when considering insertion of a polyglactin 910 mesh. Patient's age, underlying disease and perioperative treatment methods were not significant risk factors for developing mesh infection. Given that most infections seem to develop symptoms one month after surgery, a long enough observation period should be initiated. Early detection and appropriate conservative treatments may effectively address infections, thus reducing the need for more invasive therapies.

The Role of Lymphovascular Invasion as a Prognostic Factor in Patients with Lymph Node-Positive Operable Invasive Breast Cancer / 한국유방암학회지

PURPOSE: Lymphovascular invasion (LVI) is an important prognostic factor in patients with lymph node-negative patients with invasive breast cancer. However, the prognostic value of LVI it is unclear and controversial about its prognostic value in patients with lymph node-positive breast cancer patients. So, we report the an analysis of the prognostic significance of LVI in a large cohort study of patients with lymph node-positive patients with invasive breast cancer. METHODS: We retrospectively reviewed 967 patients with invasive breast cancer that had undergone surgical treatment at our hospital, from January 2004 to December 2007. Among these thempatients, 349 patients with lymph node-positive breast cancer patients are were included in this study. We evaluated clinical and pathological data in these patients, we compared with 5-year overall survival and disease-free survival between an LVI-present group and an LVI-absent group. RESULTS: The median follow-up was 48 months (range, 12-78 months), and the mean age of the patients was 48 years (range, 23-78 years). LVI was present in 192 patients (55%) of with tumors and was associated with age or =2 cm (p or =4; p=0.005), and high histological grade (II and III; p=0.02) was were an independent significant predictors of disease-free survival and overall survival in the whole group of patients. CONCLUSION: In this case, we demonstrated that LVI is a significant predictor of poor prognosis in patients with lymph node-positive patients with primary invasive breast cancer, LVI is a significant predictive predictor value of poor prognosis. So, LVI should be considered in the therapeutic strategy as a decision making tool in the adjuvant chemotherapy setting.

Bilaterality of Inguinal Hernia in Adult Patients: Synchronous Bilateral and Metachronous Contralateral Hernia

PURPOSE: We are to describe the incidence and accordance rate of hernia type in synchronous bilateral and metachronous contralateral inguinal hernia. METHODS: We retrospectively reviewed the medical records of 625 adult patients who underwent inguinal hernia repair by a single surgeon at our institute between November 2001 and October 2008. We divided the patients into 3 groups; Synchronous bilateral inguinal hernia group (SH), Metachronous contralateral inguinal hernia group (MH) and Unilateral inguinal hernia group (UH) and analyzed patients' general clinical features and outcomes. RESULTS: Male patients numbered 578 (92.5%) and female patients numbered 47 (7.5%), so the male to female ratio was 12.3:1. Each number of SH and MH were 49 (7.8%) and 59 (9.4%). In MH, the mean interval of counterlateral hernia development following ipsilateral hernia repair was 8.9 years and 20 (33.9%) were developed in a 3-year period. And the incidence of right hernia development after repair of left hernia predominated over left hernia development after repair of right hernia by a ratio of 1.27:1. Accordance rate of hernia type in both sides was 83.8% in SH and 91.2% in MH. CONCLUSION: The incidence of SH and MH were each 7.8% and 9.4% and accordance rate of hernia type is very high in SH and MH. In MH, many patients (33.9%) developed in 3 years after ipsilateral hernia repair. In this study, patients have high accordance rate of hernia type in both sides and indirect type is dominant, especially in MH.