Clinical Analysis of Macrocalcifications Accompanying a Thyroid Nodule: A Comparative Study with Microcalcifications / 대한내분비외과학회지

PURPOSE: The clinical value of macrocalcifications as an indicator that predicts malignancy of thyroid nodules is controversial. The purpose of this study was to investigate additional ultrasonographic findings accompanying macrocalcifications for predicting malignancies in thyroid nodules. METHODS: Between January 2005 and April 2008, 315 patients who had thyroid nodules with FNAB resulting in suspicious malignancies underwent thyroidectomy at the Wallace Memorial Baptist Hospital. Three hundred fifteen nodules, which were confirmed to be papillary thyroid carcinoma, and 192 nodules, which were confirmed to be benign, were reviewed retrospectively. We analyzed the malignancy rates according to calcification patterns and US findings of the associated solid nodules. RESULTS: Among the 165 papillary thyroid carcinomas with microcalcifications, 161 accompanied solid nodules, and 4 were found with microcalcifications, but without solid nodules. Of the 161 papillary thyroid carcinomas with microcalcifications and solid nodules, 85.7% showed signs suggestive of malignancy. The remaining 14.3%, where only microcalcifications were present, showed indications of predicting malignancy. When solid nodules were found with macrocalcifications, there were indicators of predicting malignancy (100%). Also, for situations in which benign nodules were accompanied by solid nodules, 29% had signs of predicting malignancy. For situations in which benign nodules did not accompany solid nodules, 21% showed suspicious signs of predicting malignancy, but were all confirmed as benign. CONCLUSION: CFor nodules that accompany microcalcifications, there can be indicators that predict malignant conditions separate from other opinions that accompany microcalcifications. However, for macrocalcifications, it would be more effective to set up future treatment plans based on ultrasonographic features of solid nodules accompanying calcifications rather than the calcification itself.

The Experiences of Performing Sentinel Lymph Node Biopsies with the Use of Methylene Blue Dye in Patients with Invasive Breast Carcinoma / 한국유방암학회지

PURPOSE: Isosulfan blue has been traditionally used as a tracer to map the lymphatic system during identification of the sentinel lymph node (SLN). However, this vital dye is difficult to obtain in Korea. Radioisotopes such as technetiumlabeled sulfur colloid or albumin colloid are also expensive and complex to use. The purpose of this study is to evaluate usefulness of a sentinel lymph node biopsy (SLNB) using methylene blue dye in breast cancer patients. METHODS: We evaluated the sentinel node mapping experience using methylene blue dye from July 2003 to January 2007. Fifty-eight patients with clinical T1-T2 breast cancer without palpable axillary lymph nodes were enrolled. All SLNs were submitted for intraoperative frozen section and hematoxyline and eosin (H & E) stain analysis. For the negative SLNs, serial sections of each SLN specimen were examined by permanent H & E staining and by immunohistochemical techniques (IHC) using cytokeratin. Regardless of the results of a frozen section for the SLNs, a backup level II or III axillary lymph node dissections (ALND) was performed. RESULTS: Of the 58 patients that underwent a SLNB using methylene blue dye, an SLN was identified in 56 patients (96.6%), and metastatic SLNs were detected in 14 cases. Axillary lymph node metastasis found in 18 out of 58 patients. Thus, the false negative rate for a SLNB was 22.2% (4/18). Two patients had a micrometastasis (pN1mi) and two patients had clusters of isolated tumor cells (pN0[i+]) that were identified in the SLNs by IHC with the additional use of cytoketatin. The sensitivity, specificity, and accuracy of the SLNBs were 77.8%, 100%, and 92.9%, respectively. The false negative rate improved with the accumulation of experience for performing a SLNB (12.5% vs 30.0%). The sensitivity, specificity, positive predictive value, and accuracy of preoperative ultrasonography (USG) for an axillary lymph node metastsis were 50.0%, 95.5%, 81.8% and 81.0% respectively. CONCLUSION: Based on our initial experience, methylene blue dye is safe, inexpensive, and a readily available tracer for the SLN mapping, and it could be an effective alternative to the use of isosulfan blue dye for accurately identifying SLNs in early breast caner patients. We expected that the findings of preoperative USG could serve as useful adjuncts to a SLNB.

The Usefulness of Preoperative Ultrasonography on Decision of Operative Extent in Patients with Papillary Thyroid Microcarcinoma / 대한내분비외과학회지

PURPOSE: Usually papillary microcarcinoma (PMC) grows very slowly with a good prognosis, although it frequently metastasizes to regional lymph nodes and shows multiple tumor formation in the thyroid. Therefore, how to treat papillary microcarcinoma has been controversial. Recently several studies reported that some ultrasonographic features may potentially reflect the biological aggressiveness of a lesion. We investigated which ultrasonographic findings can reflect aggressive characteristics and whether US can helpful in selecting the appropriate surgical treatment of PMC. METHODS: We retrospectively reviewed the preoperative ultrasonographic findings and pathologic risk factors of 68 patients who had undergone surgical treatment for PMC at the Wallace Memorial Baptist Hospital from January 2004 to December 2005. RESULTS: The incidences of multifocality, extrathyroidal extension, and lymph node metastasis of PMC were 42.6%, 48.5% and 20.6%, respectively. The Mean sizes of PMC were no significant differences according to age, multifocality, extrathyroidal extension, lymph node metastasis, stage and AMES risk group, and tumor size more than 5 mm was not linked to pathologic prognostic factors. Cases demonstrating multiple nodules in the unilateral or bilateral lobes, as well as those with fine strong calcifications in the tumor on US, were directly linked to multifocality on pathologic finding. US is insensitive technique for detecting lymph node metastasis and it's sensitivity was only 14.3%, but it's positive predictive value and specificity were high (100%). CONCLUSION: The date suggested that complete surgery with appropriate nodal dissection should be performed in patients with PMC which their US demonstrating multiple nodules in the unilateral or bilateral lobes, fine strong calcifications echoes in tumor and US-detected node metastasis.

Combined Multimodality Treatment including Surgery / 한국유방암학회지

An ipsilateral supraclavicular lymph node recurrence of breast cancer after surgery has been considered a predecessor to distant metastases. There still is a debate as to whether breast carcinoma patients with the isolated supraclavicular lymph node recurrence should be considered to have disseminated disease or if aggressive treatment, with curative intent, is justified. We report two cases of an isolated ipsilateral supraclavicular lymph node recurrence following modified radical mastectomy, and multimodality treatments with modified radical neck dissection, systemic chemotherapy and involved field radiotherapy. These patients have lived without locoregional recurrence or distant metastases for 3 and 2 years, respectively. Conclusively, we recommend aggressive combined multimodality treatments, including surgery, such as modified radical neck dissection or complete excision of the involved lymph nodes, systemic chemotherapy, and involved field radiotherapy, in patients with isolated supraclavicular lymph node recurrence, but with no other evidence of distant metastases.

The Accuracy of the Physical Examination, Mammography, and Ultrasonography in the Assessment of Tumor Size and Axillary Lymph Node Metastasis in Breast Cancer Patient / 한국유방암학회지

PURPOSE: With the increasing use of neoadjuvant chemotherapy and minimally invasive therapy, the accuracy of preoperative determination of breast tumor size and axillary lymph node status become more important. The purpose of this study was to correlate physical examination, mammographic, and ultrasonographic measurements of tumor size and regional lymph node status with pathologic findings and to evaluate the accuracy of various preoperative examination methods. METHODS: Ninety patients presenting with palpable primary breast cancer treated with mastectomy or breast conserving surgery with axillary dissection were measured breast tumor size and axillary lymph node status by physical examination, mammography, and high resolution duplex ultrasonography, and correlated with the values obtained at pathologic examinations. RESULTS: The sensitivity of mammography and sonography for breast tumor were 82.5% and 90.8%, respectively. The average diameter of tumors was 3.39+/-1.77 cm on pathologic examination. Physical examination demonstrated the highest correlation coefficient (r=0.759) in measurement of the tumor size. The sensitivity of physical examination mammography, and sonography for axillary node involvement were 37.5%, 57.7%, and 73.9%, respectively, and with specificity of 98.1%, 86.5%, and 92.9%, respectively, and with positive predictive value of 93.8%, 75.0%, and 85.0%, respectively. CONCLUSION: Physical examination is the best non-invasive predictor of the real size of palpable primary breast cancer, whereas high resolution duplex ultrasonography is most sensitive assessment method of axillary lymph node status. The specificity of axillary nodal status can be increased by fine-needle biopsy under sonographic guidance and it can be serve as useful adjuncts to sentinel node biopsy.