Analysis of Tumor Size between Imaging of Preoperative Ultrasound, MRI and Pathologic Measurements in Early Breast Carcinoma

Purpose@#Preoperative tumor size is associated with clinical stage, treatment plan and even survival rate of patient. We investigated the accuracy of tumor size estimation between magnetic resonance imaging (MRI) and ultrasonography (US) findings, comparing these with pathologic tumor size in the diagnosis of early breast carcinoma. @*Methods@#Between 2011 and 2016, 136 patients with early breast cancer were analyzed and their tumor size on US and MRI findings were compared with their pathologic tumor size retrospectively. The background parenchymal enhancement of MRI was categorized as minimal, mild, moderate, and extreme. The patients who underwent neoadjuvant chemotherapy, had positive resection margins, underwent excisional biopsy for cancer diagnosis, and had non-mass lesions on MRI scans, were excluded. @*Results@#In all, 83.1% of the cases showed concordance between MRI findings and pathologic tumor size within 0.5cm. MRI overestimated the findings by 10.3% and underestimated them by 6.6%; 78.7% showed concordance between US findings and pathologic tumor size within 0.5cm. US overestimated the findings by 5.9% and underestimated them by 15.4%. The tumor size on MRI (r=0.87) showed a stronger correlation to the pathologic tumor size than that on US (r=0.64) in early breast cancer patients. US had a tendency to underestimate the tumor size. The degree of breast parenchyma did not affect the accuracy of the measurement of preoperative tumor size. @*Conclusion@#MRI is relatively more accurate than US for assessing preoperative tumor size in breast cancer patients. US tends to underestimate tumor size.

Results of Absorbable Mesh Insertion and Patient Satisfaction in Breast-Conserving Surgery

PURPOSE: Breast-conserving surgery (BCS) is a standard treatment for breast cancer. Occasionally, patients may be dissatisfied with the breast shape due to deformity after BCS. To ensure satisfactory cosmetic results, a procedure with absorbable mesh after BCS was introduced in 2005. The purpose of this study was to identify the safety and effectiveness of this procedure. METHODS: From November 2013 to December 2015, patients who underwent BCS for a malignant breast mass at Jeonju Presbyterian Medical Center were reviewed, and 63 patients were included in this study. Based on data collected from medical records and telephone interviews, the subjects were divided into two groups as follows and retrospectively compared and analyzed: BCS with absorbable mesh (n=31) and BCS without absorbable mesh (n=32). Patient data included age, body mass index, underlying disease, tumor location and size, specimen size, operative time, axillary dissection based on frozen biopsy results, postoperative wound infection, postoperative radiotherapy, adjuvant chemotherapy, and follow-up period. To compare patient satisfaction between the two groups, a brief questionnaire consisting of four items was administered. RESULTS: Infection occurred in six patients (19.4%) in the absorbable mesh group and one (3.1%) in the BCS only group; however, the difference was not significant (p=0.053). Overall satisfaction, postoperative pain and postoperative motion limitation between the two groups were also not statistically significantly different. However, patients who underwent BCS with absorbable mesh insertion were better satisfied with the breast shape than those who underwent BCS without mesh from 1 year after operation (p=0.011). CONCLUSION: BCS with absorbable mesh is a simple and easy method to improve patient satisfaction for breast shape.

A Multicenter Phase II Trial of Neoadjuvant Chemotherapy with Docetaxel and Gemcitabine in Locally Advanced Breast Cancer / 한국유방암학회지

PURPOSE: The current multicenter phase II study was conducted to evaluate the efficacy and safety of the combination of docetaxel and gemcitabine as neoadjuvant chemotherapy (NAC) for locally advanced breast cancer. METHODS: A total of 98 patients with stage II–III breast cancer were enrolled. The primary endpoint was pathological complete response (pCR) rate of invasive cancer after the completion of the fourth cycle of NAC. The secondary endpoints included response rate (RR), rate of breast-conserving surgery, toxicity, and disease-free survival (DFS). This study is registered with ClinicalTrials.gov (NCT01352494). RESULTS: pCR in the breast and the axillary lymph node was observed in seven of the 98 enrolled patients (7.1%). The overall clinical RR, including partial responses, was 65.3%. Breast-conserving surgery was performed in 75 of the 98 assessable patients (76.5%). Neutropenia was frequent and was observed in 92 of the 98 patients (93.9%), including grade 3 and 4 in 24 patients (24.5%) and 63 patients (64.3%), respectively. Dose reductions were required for 30 of the 92 patients (32.6%). After a median follow-up of 24 months, the overall DFS of the group was 86.7%. CONCLUSION: The combination of docetaxel and gemcitabine did not improve pCR. However, this regimen has shown potential as a NAC by producing a reasonable rate of breast-conserving surgery and favorable responses in patients with locally advanced breast cancer. The therapeutic efficacy of this regimen will be determined in additional trials to overcome the limitations of the current study.

Clinical Experience with a Hybrid Procedure Using the Adherent Clot Catheter for Salvage of Thrombosed Hemodialysis Access: A Comparison with the Standard Fogarty Balloon Catheter

PURPOSE: This study aimed to compare the efficacy of two different catheters in hybrid surgery for salvage of thrombosed hemodialysis accesses. MATERIALS AND METHODS: The hybrid salvage procedure (surgical thrombectomy followed by endovascular angioplasty) of the thrombosed hemodialysis access, was performed using adherent clot (AC) catheter in 140 cases and Fogarty balloon catheter in 68 cases. Procedure-related outcomes such as the clot removal status, clinical success, complications, and primary patency rates were analyzed retrospectively. RESULTS: The proportion of cases with good clot removal scores in the AC catheter and Fogarty balloon catheter groups was 77.9% and 91.2%, respectively (P=0.018). Clinical success was achieved in 90.7% of the cases in the AC catheter group and in 98.5% of the cases in the balloon catheter group (P=0.035). The mean patency rates of the two groups were 50.7% and 63.2% at 3 months, 40.7% and 47.1% at 6 months, and 17.9% and 19.1% at 12 months. The complication rates (12.1% and 5.9%) and primary patency rates between the two catheters were not statistically different (P=0.328). On the analysis of the patency rate on access type of autologous (P=0.169) and prothetic graft (P=0.423), there was no significant difference between the two catheter groups. CONCLUSION: In terms of clot removal and clinical success, the AC catheter did not demonstrate better outcomes than the Fogarty balloon catheter. However, primary patency was not related to the type of catheter. Adherent clot catheter can be a useful alternative to Fogarty balloon catheter for thrombosed hemodialysis access.

The Comparative Analysis between Surgical Thrombectomy and Hybrid Treatment in Salvage Operation / 대한혈관외과학회지

PURPOSE: Salvage operation is performed to improve the functional deficit of vascular access. This study is planned to evaluate the utility of the hybrid surgery through a comparative analysis between the results of surgical thrombectomy and those of hybrid surgery, combining surgical methods and endovascular treatments. METHODS: From January 2007 to December 2008, surgical thrombectomy had been done to 55 patients, whereas hybrid surgery had been done to 111 patients from January 2009 to December 2011. We have done a comparative analysis on the patency rate after the salvage operation for each group, retrospectively. Medical records were reviewed for patient information and radiographic data was used for checking the stenosis site in the hybrid surgery group. RESULTS: There were no statistically significant differences between the two groups, including age, gender, diabetes status, hypertension, and vascular access site or type. The primary patency rate was significantly higher in arteriovenous fistulas (65%) compared with arteriovenous grafts group (55%), at 12 months (P<0.01). At one year after the salvage operation, the secondary patency rate was higher in the hybrid surgery group compared to the surgical thrombectomy group (43.8% vs. 23.7%, P<0.01). CONCLUSION: This study shows that hybrid surgery combining surgical methods and endovascular treatments can be more useful for the salvaging of thrombosed vascular access than performing only surgical thrombectomy.

Radiofrequency Ablation for Benign Thyroid Nodules Performed by Surgeon / 대한내분비외과학회지

PURPOSE: The ability to apply radiofrequency ablation (RFA) has provided for a greater diversity of approaches for treatment of benign thyroid nodules. This study evaluated the efficacy and safety of RFA performed by a surgeon. METHODS: From January 2009 to November 2010, a total of 47 benign thyroid nodules were treated with RFA performed by one surgeon. Nodular patterns were divided into mainly cystic, mixed, and mainly solid (soft solid, hard solid) nodules, and ultrasonography was performed for assessment of the volume-reduction radio (VRR) of each nodule. Follow-up ultrasonography was performed three to 19 months after ablation. And complication was observed. One session of RFA was performed. RESULTS: The median volume before ablation was 7.8 cm³ (range 1.3~43.2 cm³). After ablation, the median volume was 0.9 cm³ (range 0.0-21.6 cm³) and VRR was 81.5±17.3%. RFA in mainly cystic nodules resulted in significant decreases in VRR (93.7±5.0%, P=0.009). It was the largest among the nodular types. VRR was 81.4±13.1% in mixed nodules, 77.2±19.2% in mainly solid nodules, 85.9±11.0% in soft solid nodules, and 54.2±17.3% in hard solid nodules 95.7% of nodules (45 nodules) showed more than 50% reduction, while the two remaining nodules, which were hard solid nodules, showed less than 50% reduction. Complications included pain, voice change, nausea, and transient voice change. CONCLUSION: Results of this study demonstrated the safety and effectiveness of RFA performed by a surgeon for reducing nodule volume.

Follicular Variant of Papillary Thyroid Carcinoma: Clinicopathological Features According to Histologic Subgroup / 대한내분비외과학회지

PURPOSE: The follicular variant of papillary thyroid carcinoma (FVPTC) is difficult to diagnose due to pathologic features. There is also debate on the optimal extent of surgery. We separated FVPTC into two groups and compared the clinical features in an attempt to apply the treatment. METHODS: All 40 patients with FVPTC who were diagnosed between 1990 and 2009 were reviewed and separated into two groups, an encapsulated group and an infiltrative group, based on whether a capsule was formed or infiltration occurred. These two different subtypes of FVPTC were compared on the traits of sensitivity of diagnosis and clinicopathologic features. RESULTS: After review by a pathologist, 21 of 40 patients (55%) were found to have encapsulated tumors, and 18 patients (45%) had infiltrative tumors. There was no difference in age, sex, or size. Patients with encapsulated FVPTC had a significantly lower rate of lymph node metastasis (4.5%), multicentric tumors (18.2%), and thyroid capsular invasion (9.1%) compared with the infiltrative tumor group (50%, 50% and 50%, P<0.05). There was no difference in FNA sensitivity between the two groups, but the sensitivity to frozen biopsy was higher in the infiltrative group. There was no recurrence in the encapsulated group, but 4 patients (22.2%) experienced recurrence in the infiltrative group. CONCLUSION: FVPTC can be separated into two subgroups by histologic features, and there are some clinicopathologic differences between the two groups. Patients who had encapsulated FVPTC had a lower rate of lymph node metastasis, multicentric tumors, and thyroid capsular invasion. They also showed a lower rate of recurrence than the infiltrative group. It is suggested that the encapsulated group can be treated with limited surgery and the infiltrative group needs aggressive treatment.

Fifteen Years or Greater Follow-Up of Pediatric Differentiated Thyroid Cancer / 대한내분비외과학회지

PURPOSE: Thyroid cancer is rare in childhood. Although thyroid cancer is biologically more aggressive in children because of the high incidence of lymph node metastasis and distant metastasis when compared with that of adults, the prognosis is better. This study investigated the prognosis of pediatric differentiated thyroid cancer with 15 years or greater follow-up and we consider the proper treatment of pediatric differentiated thyroid cancer. METHODS: From January, 1979 to December, 1994 during 16 years, 17 patients younger than 17 years old and who underwent thyroid surgery for well differentiated thyroid cancer at the Department of Surgery at Presbyterian Medical Center were retrospectively reviewed by the medical records and they were interviewed by telephone. RESULTS: Total thyroidectomy was performed in 4 patients (23.5%), subtotal thyroidectomy was performed in 10 patients (58.8%) and lobectomy was performed in 3 patients (17.7%). The mean follow-up period was 23.5 years (range: 15~28.2 years) and recurrence was found in 7 cases (41.3%). Five cases (29.5%) showed locoregional recurrence and 2 cases (11.8%) showed distant metastasis. Postoperative radioiodine (¹³¹I) therapy was done in 6 cases (35%) and 6 cases (35%) underwent radioiodine therapy as a therapeutic modality for metastasis. CONCLUSION: The pediatric well differentiated thyroid cancer in this study showed high rates of lymph node metastasis at the time of diagnosis and a high recurrence rate, but the prognosis was good (100% overall survival rate during the follow-up period). Therefore, total thyroidectomy, radical lymph node dissection and postoperative radioiodine therapy are considered the initial patient management. This aggressive therapeutic management can decrease of the recurrence rate and increase the therapeutic effect. A radioiodine scan and thyroglobulin can used for follow-up.

Initial Experience with an Endovascular Suite (A Hybrid Operating Room)

PURPOSE: Endovascular interventions have seen explosive growth over the last decade. One of the critical factors to perform safe and reliable endovascular procedures is the availability of a well-equipped endovascular suite. The aim of this study is to clarify the necessity and benefits of an endovascular suite through our initial experience. METHODS: We performed an overview of the basic equipment and the adjunctive hardware and software of an endovascular suite for performing open surgical exposures or/and endovascular procedures. We also conducted a review of the endovascular procedures that were performed for 2 months in a newly built endovascular suite. RESULTS: The endovascular suite should offer sterile conditions to provide the endovascular specialist a complete gamut of options to treat patients with complex vascular diseases. The number of vascular and endovascular treatments increased about two fold after the establishment of the endovascular suite. CONCLUSION: The establishment of a modern endovascular suite arranged in an ergonomically devised fashion is helpful to remain on the cutting edge of medical practice. A endovascular suite will undoubtedly enhance the ability of vascular surgeons to provide quality health care to the patients who have a variety of arterial and venous disorders.

Feasibility of Ultrasound-guided Fine Needle Aspiration Cytology Using Extended Tube for a Thyroid Mass / 대한내분비외과학회지

PURPOSE: Fine needle aspiration cytology (FNAC) is a very useful procedure for the diagnosis and management of thyroid disease. The use of FNAC has increased over the years. We determined the incidence of complications associated with ultrasound-guided FNAC using an extended tube for a thyroid mass and the factors that contribute to such complications. METHODS: A retrospective chart review was conducted to identify patients who underwent FNAC. Two hundred fifty-four patients underwent 325 procedures between July and September 2009. RESULTS: There were no major complications associated with ultrasound-guided FNAC using an extended tube for a thyroid mass. The most minor complication was neck pain, which occurred in 16.1% of the patients (41/254). Multiple FNACs, anti-coagulant medications, abnormal thyroid function tests, nature of the mass, and size of the mass did not contribute to the complications in this study. CONCLUSION: Using an extended tube during ultrasoundguided FNAC for a thyroid mass is safe and convenient.

The Diagnostic Value of High Resolution Ultrasonography as Examined by Surgeons for the Differentiation of Thyroid Nodules / 대한내분비외과학회지

PURPOSE: High resolution ultrasonography has recently become a useful tool to differentiate malignant thyroid nodules from benign thyroid nodules. We performed this study in order to determine the usefulness of an ultrasonography examination that's performed by endocrinologic surgeons through the analysis of the sonographic characteristics. METHODS: A retrospective review was undertaken for 312 patients who underwent surgery and a US examination by the operator before surgery due to thyroid nodules at Jesus Hospital from February 2006 to March 2008. The review consisted of the characteristics of the sonographic parameters, such as the margin, structure, shape, echogenicity, homogeneity, calcification, sponge sign and the width/height ratio. RESULTS: On univariate analysis of the non-follicular neoplasm, the significant parameters were the margin, structure, shape, echogeneity, homogeneity, calcification and the width/height ratio. On the logistic regression analysis, the margin, structure, shape and echogenecity were significant parameters. On a univariateanalysis of the follicular neoplasm, the significant parameters were the shape, echogenecity, homogeneity and calcification. On the logistic regression analysis of the total thyroid nodules, the margin, structure, shape and echogenecity were significant parameters. Especially, hypoechoic and solid structures are the most potent malignant characteristics. CONCLUSION: Among the ultrasonographic characteristics checked by surgeons before surgery, the hypoechogenecity and solid structures are the most useful ones when planning operative management of thyroid nodules.

Diagnostic Value of Ultrasound-guided Fine Needle Aspiration Cytology by a Endocrine Surgeon / 대한내분비외과학회지

PURPOSE: Fine needle aspiration is a safe and relatively accurate procedure for distinguishing benign and malignant lesions. We determined the diagnostic value of ultrasoundguided fine needle aspiration using an extension tube and examination by an endocrine surgeon. METHODS: We reviewed the medical records of 257 consecutive patients receiving surgery for thyroid nodules in the Department of Surgery, Jesus Hospital, from January, 2006, to August, 2008. All patients received ultrasound-guided fine needle aspiration with an extension tube. RESULTS: The male to female ratio was 1:5.5. Definitive histopathological diagnosis revealed benign lesions in 120 cases (47%) and malignant lesions in 137 cases (53%). Benign lesions were composed of nodular goiter (102 cases), follicular adenoma (13 cases), and Hashimoto thyroiditis (5 cases). Malignant lesions were composed of papillary carcinoma (131 cases) and follicular carcinoma (6 cases). Fine needle aspiration cytology revealed benign lesions in 103 cases and malignant lesions in 126 cases. The Overall results of ultrasound-guided FNA were: sensitivity, 94.5%, specificity, 95.0%, positive predictive value, 96.0%, negative predictive value, 93.2%, accuracy rate, 94.7%, false negative, 5.4%, and false positive, 4.9%. Most specimens (96.4%) were amenable for diagnosis. CONCLUSION: Fine needle aspiration is a good method for the differential diagnosis of thyroid nodules. High resolution ultrasound-guided FNA with an extension tube is helpful for obtaining good specimens.

Comparison of the Operative Methods for Varicose Veins in the Lower Extremities

PURPOSE: There are several new surgical techniques for varicose vein surgery. Transilluminated Powered Phlebectomy (TIPP) and Endovenous Laser Therapy (EVLT) are accepted as useful surgical procedures for varicose veins. However, these techniques have some associated problems such as complications, remnant varicosities and are relatively expensive. We compared some of the new techniques with conventional methods and introduce new technique called Transillumination assisted EVLT (T-EVLT). METHOD: We reviewed cases with primary varicose veins involving the lower extremity in 217 patients managed by TIPP, EVLT and T-EVLT in the department of Surgery, Presbyterian Medical Center, from January 2003 to January 2007. RESULT: The distribution of age was the fifth decade (38.4%), fourth (23.8%) and third (15.2%), in order frequency. The male to female ratio was 1:1.43. The TIPP procedure had the lowest frequency of remnant varicosities (6.0%) but the second highest complication rate (17.9%). The EVLT procedure had a relatively low complication rate (9.5%) and good cosmetic results but the longest operation time and the highest frequency of remnant varicosities (21.6%). The T-EVLT procedure had the shortest operation time and the lowest frequency of remnant varicosities (19.5%) compared to the EVLT. CONCLUSION: Each of the operation methods had risks and benefits. The EVLT procedure had good cosmetic results and was easy to learn. However, had a relatively long operation time and many remnant varicosities. These problems may be overcome by the T-EVLT.

The Use of Extension Tube in Sono-guide FNAC / 대한내분비외과학회지

PURPOSE: Sono-guided FNAC (fine needle aspiration cytology) is a safe and accurate diagnostic procedure for thyroid nodules. We examined the use of an extension tube in FNAC as useful. METHODS: We reviewed 175 cases of patients with thyroid nodules where an extension tube was used in sono-guide FNAC and 153 cases where a syringe holder was used in Jeonju Jesus hospital, from July 2005 to September 2006. RESULTS: For cases with an extension tube, tumor size was smaller than 1 cm (38%), from 1 cm to 2 cm (27%), or larger than 2 cm (35%), with cytology results of benign (73%), intermediate (8%), malignant (7%), or nondiagnostic (12%). In cases with a syringe holder, tumor size was smaller than 1 cm (40%), from 1 cm to 2 cm (40%), or larger than 2 cm (20%), with cytology results of benign (51%), intermediate (4%), malignant (3%), or nondiagnostic (42%). The nondiagnostic percentage in cases where an extension tube was used was lower than in cases using a syringe holder. However, the number of tumors larger than 2 cm was significantly larger in the syringe group than the extension tube group. CONCLUSION: The use of an extension tube or a syringe holder in FNAC produce similar results.

Male Polythelia

Supernumerary nipples or polythelia are developmental abnormalities located along the embryonic mammary lines. It occurs sporadically but familial aggregation was been reported. Polythelia has been reported in association with congenital malformations, in particular with renal anomalies. We report a case of polythelia.

Histologic Degree of Invasion and Prognosis in Follicular Thyroid Carcinoma / 대한내분비외과학회지

PURPOSE: Follicular thyroid carcinoma (FTC) is the second most common malignancy of the thyroid after papillary thyroid carcinoma, constituting about 10% of all thyroid malignancies. The objective of the current investigation was to determine whether there was a direct relationship between the histologic degree of invasion, tumor recurrence, and patient survival. METHODS: We retrospectively reviewed the records of 55 patients with a histologic diagnosis of pure follicular carcinoma of the thyroid who were treated from 1990 to 2003 at the Presbyterian Medical Center in Jeonju, Korea. Their mean follow-up period was 8.4 years (range, 1~15 years). The following criteria were used to histologically define malignant follicular neoplasms: 1) minimally invasive, tumor invasion through the entire thickness of the tumor capsule; 2) moderately invasive, tumor with angioinvasion (with or without capsular invasion); and 3) widely invasive, broad area or areas of transcapsular invasion of thyroid and extrathyroid tissue. RESULTS: Among 33 patients with capsular invasion only, 2 patients (6%) developed recurrent disease. Of the 16 patients who had angioinvasion with or without capsular invasion, 4 patients (25%) developed recurrent disease. Among 6 patients who had widely invasive FTC, 5 patients (83%) developed recurrent disease, and 2 of those 6 patients (33%) with widely invasive FTC died of the disease. Patients who had widely invasive FTC had greater recurrence rates than patients who had a capsular or angioinvasion (P<0.001). The overall death rate for patients with widely invasive FTC was 33%. CONCLUSION: This study shows that patients with widely invasive FTC had greater recurrence rates and poorer survival than patients who had capsular or angioinvasion; this difference was statistically significant. The authors conclude that patients who had widely invasive FTC need close follow-up and active treatment.

A Clinical Analysis of Intussusception in Adult

PURPOSE: Adult intussusception is relatively rare and it's course is subacute or chronic course. It usually occurs secondary to tumors or other underlying cause. Especially the incidence of associated malignancy is increasing compare to the past. Purpose of this study was review of adult intussusception, our comprehension of the disease improved by and helped to plan treatments METHODS: During the past 11 yeasrs, from January, 1987 to December, 1997, 27 cases of adult intussusception at Department of Surgery, Presbyterian Medical Center were analyzed retrospectively. RESULTS: The age incidence was variable. But it occurred more frequently at 4th decades. Useful radiologic diagnostic tools were CT, U/S as well as barium enema. Nineteen instances of intussusception originating in the small bowel and 8 instances originating in the colon. The etiologic factors were found in 22 cases (74%). Of the 19 small bowel intussusception, 5 cases were associated with malignancy and 3 out of 8 colon intussusception were result from the malignancy. The common malignancy in small bowel was lymphoma and that in colon was adenocarcinoma. Surgical intervention was carried out in all of these 27 cases: 20 cases underwent surgical resection and 7 cases were reduced manually after surgical exploration; Only manually reduction was performed in 4 cases, manually reduction and cecopexy in 2 cases and manually reduction and adhesiolysis in 1 case. CONCLUSION: The malignancy was the major cause of adult intussusception. Especially in colonic intussusception, occupational percentage of malignancy was higher. The common malignancy in small bowel was lymphoma and that in colon was adenocarcinoma. So, we cosidered plans of treatments according to location, etiology and bowel state.