Comparison of neoadjuvant adriamycin and docetaxel versus adriamycin, cyclophosphamide followed by paclitaxel in patients with operable breast cancer / 대한외과학회지

PURPOSE: Neoadjuvant chemotherapy is the standard treatment for patients with locally advanced breast cancer and is increasingly considered for patients with operable disease. Recently, as many clinical trials have demonstrated favorable outcomes of anthracycline-taxane based regimen, this approach has been widely used in the neoadjuvant setting. METHODS: We compared women who received adriamycine and docetaxel (AD) with adriamycin, cyclophosphamide followed by paclitaxel (AC-T) as neoadjuvant chemotherapy. The AD group was scheduled for six cycles of AD (50 mg/m2 and 75 mg/m2, respectively) at a 3-week interval. The AC-T group was scheduled for four cycles of adriamycin and cyclophosphamide (50 mg/m2 and 500 mg/m2, respectively) followed by four cycles of paclitaxel (175 mg/m2) at a 3-week interval. RESULTS: The responses of chemotherapy were equivalent (overall response rate [AD, 75.7% vs. AC-T, 80.9%; P = 0.566], pathologic complete response [pCR] rate [breast and axilla: AD, 10.8% vs. AC-T, 12.8%; P = 1.000; breast only: AD, 18.9% vs. AC-T, 14.9%, P = 0.623], breast conserving surgery rate [P = 0.487], and breast conserving surgery conversion rate [P = 0.562]). The pCR rate in the breast was higher in the human epidermal growth factor receptor 2 (HER2) positive cases (HER2 positive 33.3% vs. negative 10%, P = 0.002). Although nonhematologic toxicities were comparable, hematologic toxicities were more severe in the AD group. Most women in the AD group suffered from grade 3/4 neutropenia (P < 0.001) and neutropenic fever (P < 0.001). CONCLUSION: Tumor responses were not different in various variables between the two groups. However, AC-T was a more tolerable regimen than AD in patients with breast cancer receiving neoadjuvant chemotherapy.

Granulocytic Sarcoma in Breast after Bone Marrow Transplantation / 한국유방암학회지

Granulocytic sarcoma is a localized extramedullary solid tumor composed of immature myeloid cell and is usually associated with acute myeloid leukemia or myelodysplastic syndrome. Although it can involve any site, commonly in lymph nodes, skin, bone and soft tissue, the involvement of breast is unusual. Especially, the involvement of the breast as a pattern of relapse after bone marrow transplantation is extremely rare. We have experienced 2 cases of granulocytic sarcoma after bone marrow transplantation. One case was a 39-year-old woman with right breast mass diagnosed with granulocytic sarcoma. She had received an unrelated bone marrow transplantation due to biphenotype acute leukemia 3 years before our presentation. Another case was a 48-year-old woman with acute myeloid leukemia, who was diagnosed with granulocytic sarcoma on both breasts 8 months after allogenic bone marrow transplantation. We also discuss the clinicopathologic features of granulocytic sarcoma in breast after bone marrow transplantation.

Risk Reducing Surgery in Carriers with Double Heterozygosity for BRCA1 and BRCA2 Mutations

Among the treatment options for BRCA mutation carriers, risk reducing surgery is the most effective. However, this procedure has been rarely performed in Korea. Interestingly, our case showed double heterozygosity for BRCA1 and BRCA2 mutations. The patient was diagnosed with left renal cancer and left breast cancer at 45-years-of-age, 4 years before risk reducing surgery. The patient received left radical nephrectomy and left partial mastectomy with axillary lymph node dissection. After pretest counseling, the patient underwent genetic testing that identified BRCA1 and BRCA2 mutations. After post-test counseling, the patient decided on intensive surveillance. At 49-years-of-age, the patient was newly diagnosed with contralateral breast cancer. Treatment options were discussed once again. We performed bilateral total mastectomy with immediate reconstruction and prophylactic bilateral salpingo-oophorectomy after multidisciplinary discussion. The patient has been satisfied with the results of surgery. We think this procedure is a recommendable treatment option for BRCA mutation carriers.

An Ileocutaneous Fistula That Developed 12 Years after Repair of an Abdominal Wall Defect Using Intraperitoneal Placement of High-density Polypropylene Mesh (Marlex(R))

Although prosthetic materials are commonly used to repair abdominal wall defects, they are also associated with postoperative complications. These complications could be prevented by the adoption of uniform guidelines on surgical methods and materials, but the best anatomical position for placement of prosthetic meshes is unclear. We report a case of an enterocutaneous fistula that developed after an abdominal wall defect was repaired by intraperitoneal application of a prosthetic mesh (Marlex(R)) to raise awareness of the consequences of improper use of prosthetic materials.

The Clinical Implication of Intravesical Prostatic Protrusion to Lower Urinary Tract Symptoms in Patients of Prostatic Volume 30~50gm / 대한남성과학회지

PURPOSE: Intravesical prostatic protrusion (IPP) is a morphological change of prostate protruded into bladder and might be related to bladder outlet obstruction (BOO) depending on the extent of protrusion. There is a high possibility that lower urinary tract symptoms (LUTS) tends to get worse as IPP grows. Therefore, it is necessary to examine the effect of IPP on LUTS after revision of prostate volume in order to identify the direct effect of IPP on BOO and LUTS. MATERIALS AND METHODS: A retrospective study of 296 male patients diagnosed with benign prostate hyperplasia (BPH) between August 2006 and December 2008 were performed. The patients were evaluated with international prostate symptoms score (IPSS) and quality of life (QoL), uroflowmetry (UFR), post-void residual urine volume (PVR), prostate volume and IPP as measured by transurectal ultrasound (TRUS). The changes of IPSS after 8 weeks of medication treatment and the occurrence rates of transurethral resection of prostate (TURP) and acute urinary retention (AUR) were compared. By checking IPSS and UFR, the improvement of voiding symptom was evaluated. RESULTS: The population of patients with moderate enlargement (30-50gm) of prostate extent was 147 (49.6%) out of 296, the whole examined population. There were correlation between IPP and IPSS (p=0.002) and the storage symptoms score was significantly increased (p=0.014). After 8 weeks of medication treatment, both moderate BPH patients with IPP showed similar improvement in storage symptom compared to non-IPP groups. But, the TURP was significantly performed more with IPP (p=0.040) than non-IPP groups and more AUR has occurred (p=0.013). After TURP, IPP group resulted in improvement of IPSS, storage symptoms score and voiding symptoms score statistically compared to non-IPP group. As the change of UFR and IPSS after TURP had shown, the improvements of voiding volume, maximal flow rate (Qmax), and average flow rate (Qavg) in IPP groups were smaller however, it is no correlation in statistical view. CONCLUSIONS: Moderate BPH group with IPP has a higher possibility of having AUR and surgical treatment while showing significant correlation with storage symptoms. A further prospective study is necessary for identification of improvement of IPSS and UFR after TURP and IPP should be checked carefully during TRUS.

Posterior Surgery of Neurologically Compromised Osteoporotic Kyphosis: Posterolateral Decompression and Stabilization using Titanium Mesh / 대한정형외과학회잡지

PURPOSE: Several treatment options have been reported for post-traumatic kyphosis (PTK) and neurologically compromised osteoporotic fractures. However, there is no ideal surgical procedure. This study evaluated the effectiveness of posterolateral decompression and anterior support with a titanium mesh in PTK by posterior surgery. MATERIALS AND METHODS: Seventeen patients with PTK and neurologically compromised osteoporotic fractures underwent a single posterior approach. During posterior decompression, a titanium mesh was inserted through the posterior approach after a transpedicular intracorporeal corpectomy. Complications, operating time and blood loss were noted, and radiographic studies and neurological status were evaluated before surgery, after surgery, and at final follow-up. RESULTS: The mean kyphosis was 35+/-9.7degrees (range; 17-58degrees) before surgery, 3.2+/-1.8degrees after surgery (correction; 90.5%) and 5.5+/-3.2degrees at the final follow-up (correction; 85.5%). There was 29.6degrees correction of the kyphosis with a 6% loss of correction. Postoperative neurological improvement using the Frankel classification was demonstrated in all patients. There was no new onset or progressive neurological deterioration, additional surgery or extrusion of mesh. Three complications were encountered: one care each of pneumonia, prolonged ventilator support and distal adjacent vertebral fracture. CONCLUSION: The posterior insertion of a titanium mesh for anterior support appears to maintain the length of the anterior column, stabilize the injured vertebra and facilitate spinal fusion. Posterolateral decompression allows as direct a decompression as the anterior approach.

Usefulness of a Sonographic Bladder Scan for Uroflowmetry and the Evaluation of the Anxiety Level Associated with Uroflowmetry / 대한비뇨기과학회지

PURPOSE: Uroflowmetry (UFM) requires at least 125ml to 150ml of urine volume for an adequate interpretation. It is common to repeat UFM in clinical settings because of an insufficient voided volume, which may be induced by increased anxiety. To reduce performing repeated UFMs, we evaluate the usefulness of performing a prevoiding sonographic bladder scan and we determined the anxiety level before performing UFM. MATERIALS AND METHODS: We enrolled one hundred two patients (mean age: 62.6+/-15.0 years) who visited our clinic due to voiding dysfunction. The bladder volume prior to UFM was measured by an automated bladder scan (Biocon-500(TM), Mcube Technology) when the patients felt a strong fullness sensation. All the patients kept a voiding diary for 3 days, and they underwent the State-Trait Anxiety Inventory questionnaire, the fullness scale and UFM. RESULTS: The mean prevoiding volume was 307+/-124ml and the mean voided volume was 271+/-129ml. There was a correlation between the prevoiding scan volume and the voided volume: voided volume=17.502+(0.724xprevoiding volume) (r=0.851, p<0.001). Among the 333 patients without a bladder scan and who had UFM performed, 25.8% showed insufficient voided volumes of less than 125ml, and 32.4% showed voided volumes of less than 150ml. However, among the 102 patients who underwent a bladder scan, 9.8% showed insufficient voided volumes of less than 125ml and 12.7% showed voided volumes of less than 150ml (p<0.001). The patients who had a higher state of anxiety than trait anxiety before their UFM revealed a relatively decreased functional bladder capacity (p=0.013). CONCLUSIONS: Although UFM is simple, the patient may feel embarrassed before test. Anxiety can cause a decreased functional bladder capacity. A prevoiding sonographic bladder scan can reduce the incidence of insufficiently voided UFM.

Polypharmacy and Central Nervous System Adverse Effects of Anticholinergic Agents in the Men with Benign Prostate Hyperplasia

PURPOSE: Elderly patients commonly receive multiple drugs compared to young patients because of high comorbidity. Some common illnesses in the elderly with underlying diseases are complicated or aggravated by treatment with anticholinergic agents. We evaluated the use of anticholinergic agents and their adverse effects in the men with benign prostate hyperplasia. MATERIALS AND METHODS: One hundred-eighty four patients over 40 years-old who visited hospital for the treatment of benign prostate hyperplasia and prescribed more than one anticholinergic agent from January 2005 to June 2006 were enrolled. The patients who took anticholinergics during less than 2 months or suffered from psychiatric problems were excluded. One hundred-fifteen patients were included and all prescribed drugs were classified and counted. The number of anticholinomimetic agents and their 10 adverse effects were checked. RESULTS: Mean age was 67.0+/-10.6 years and mean cormobidity diseases counted 1.1+/-1.1. Mean pill and mean anticholinergic agents counted 7.3+/-4.3 and 1.8+/-1.1, respectively. Prescribed anticholinergic agents count increased with patient's age(p=0.401). As the patients took more medications, they had higher possibility to take anticholinergic agents. And as the patients took more anticholinergic agents, they showed more anticholinergic adverse effects(p<0.001). CONCLUSION: Elderly patients mistakenly tend to attribute drug-induced changes in memory and cognitive function to aging or comorbid conditions. Therefore prescribers should consider an anticholinergic agent's receptor selectivity, ability to cross the blood-brain barrier, and pateint's medical history in elderly patients. Additionally physicians can actively perform Mini-Mental Status Examination for evaluation of the patient's cognitive functions under anticholinergic medication.

The Effect of Basiliximab on the Incidence of Acute Renal Allograft Rejection within 1 Year Post-Transplantation

PURPOSE: Basiliximab has become widely used in clinical practice for initial immunosuppression in renal transplantation cases, to reduce the incidence of acute rejection without adverse events. Herein, we report the early outcomes of renal transplantation using basiliximab at a single center. METHODS: This retrospective study included 148 renal allograft recipients at a single center. All patients were followed for longer than 1 year after transplantation, and treated with a calcineurin inhibitor and steroids for maintenance immunosuppression. The use of basiliximab and mycophenolate mofetil (MMF) was optional. We compared the incidence of episodes of acute graft rejection in kidney recipients who were treated with basiliximab as an initial immunosuppressive therapy with those who were treated without basiliximab. RESULTS: Basiliximab was used for initial immunosuppression in 58 patients. Patients maintained immunosuppression with triple (n=69) or double (n=79) regimens including a calcineurin inhibitor (cyclosporine A (n=111) or tacrolimus (n=37)) and methylprednisolone with or without MMF. Thirty-six (24.3%) patients had a rejection episode within 1 year after transplantation and twenty-six (17.6%) patients had an episode of infection. The patients who were treated with basiliximab had fewer rejection episodes (n=11, 18.9%) within the first year after transplantation than the patients who did not take basiliximab (n=25, 27.7%); this difference was not statistically significant. (P=0.245). However, basiliximab significantly affected the number of rejection episodes in the double regimen group (P=0.006), but not the number of rejections in the triple regimen group (P=0.432) and did not affect the number of infection episodes in both groups (P value of double, triple=0.291, 0.772) within one year after transplantation. CONCLUSION: The results of this study suggest that basiliximab might be more useful for graft recipients who are treated with double immunosuppression with a calcineurin inhibitor and steroid than for the recipients with triple immunosuppression including MMF.

Factors Confluencing the Result of Percutaneous Balloon Kyphoplasty in Osteoporotic Thoracolumbar Compression Fracture

PURPOSE: We are to find the method to objectify postoperative prognosis, analyzing the factors confluencing the result of kyphoplasty in osteoporotic vertebral compression fracture (OVCF). MATERIALS AND METHODS: Our study included 50 patients (55 vertebral bodies) who have undergone kyphoplasty from Sep. 2004 until Oct. 2005. We divided in the group according to bone mineral density (BMD), compression rate, recovery rate and cement leakage. We verified the significance of each group, using independent t-test, and ANOVA test among observers. RESULTS: We performed kyphoplasty on 55 vertebral bodies, 12 cases with more than 0.4 g/cm2 in BMD (mean: 0.53 g/cm2) and their mean preoperative compression rate (CR), immediate postoperative recovery rate (RR-IPO), and recovery rate after 6 months (RR-6M) was each 30.58%, 12.35%P, 9.93%P. 15 cases under 0.4 g/cm2 (mean 0.31 g/cm2), and their CR, RR-IPO and RR-6M was 26.73%, 11.77%P, 5.26%P respectively. The p-value was 0.004. Another studies according to CR, RR-IPO and leakage of cement revealed the better results in the cases of the lower CR, the smaller reduction and abscecnce of cement leakage, but statistically insignificant (p=0.309, 0.069, 0.356). CONCLUSION: Preoperative BMD was most important factor that confluencing postoperative radiological result in OVCF. Other factors were also thought to be confluencing factors, but statistically insignificant..

The Effect of Patellar Position on the Flexion Gap in Total Knee Arthroplasty

PURPOSE: The aim of this study was to investigate the relationship between eversion or reduction of patella and the heights of the extension or flexion gaps. MATERIALS AND METHODS: Measurements of the heights of the extension and flexion gaps were obtained during 32 primary posterior-stabilized total knee arthroplasties in 25 osteoarthritic patients. A tensor device was introduced after femoral and tibial bony resections while putting the knees flat on the operating table to measure the extension gaps in the medial and lateral compartments, respectively. The knee was flexed 95 degrees, and the tensor was introduced to measure the flexion gaps in the same manner. A calibrated torque wrench permitted the application of the force of about 113.4N.cm both in extension and in flexion in right knee, and of about 152.4N.cm both in extension and in flexion in left knee. RESULTS: The average height of the extension gap with everted patella was 20.9+/-2.6mm medially and 23.6+/-2.5 mm laterally, respectively. The average height of the extension gap with reduced patella was 21.0+/-2.6mm medially and 23.7+/-2.4mm laterally, respectively. The average height of the flexion gap with everted patella was 20.7+/-2.5mm medially and 23.2+/-2.8mm laterally, respectively. The average height of the flexion gap with reduced patella was 22.1+/-2.3mm medially and 24.2+/-2.8mm laterally, respectively. After reducing the patella, the flexion gap height increased an average 1.4+/-1.1(range: 0~4)mm and 1.0+/-1.2(range: -1~3)mm in the medial and lateral compartments, respectively. CONCLUSION: The height of flexion gap would be increased by reducing the patella from everted position in posterior- stabilized total knee arthroplasty for the patient with good preoperative flexion. The flexion gap must be observed not with everted patella but with reduced patella to determine whether it appears symmetric and balanced.

Extraperitoneal Bladder Rupture following a Normal Spontaneous Vaginal Delivery / 대한비뇨기과학회지

The urinary bladder is seldom injured by external forces, as it is located in the pelvic cavity, behind the symphysis pubis, and protected by the bony pelvis. Gynecological procedures are a major cause of bladder injury. Herein, a case of extraperitoneal bladder rupture, identified 6 days after vaginal delivery in a 27-year-old woman, with no history of cesarean section or pelvic surgery, and who was cured of the bladder rupture using conservative treatment with the indwelling of a urethral Foley catheter, is reported.

Clinical Analysis of Gastric Carcinoma with Single Node Metastasis

PURPOSE: In order to examine the significance of a sentinel lymph node for gastric cancer, we investigated single node metastases that were hypothesized to represent the sentinel lymph node. METHODS: Of 2, 265 primary gastric cancers patients we experienced from 1994 to 2003, 140 patients having gastric carcinoma with a single node metastasis were enrolled in this study. The factors we studied including age, gender, tumor size, location, cellular differentiation, stage, and the patients' survival rate. RESULTS: Single node metastases were found in 30.7% of T1, 35.0% of T2, 29.3% of T3 and 5.0% of T4 staged tumor. Metastatic lymph nodes were mainly located near the tumor in 122 of 140 patients (87.1%). Skip metastases, which were defined as metastases that were found at more distant locations, were found in 18 patients (12.7%), and they were mainly located around the left gastric artery, the common hepatic artery, the proper hepatic artery and the splenic artery. The frequency of skip metastases significantly increased when the tumor was located upper part of the stomach, the tumor size was more than 5 cm in diameter and depth of tumor invasion was deeper (P<0.05). We found more frequent skip metastases in lymph nodes for the diffuse type of tumor infiltration than the macronodular type (P<0.05). The patients' overall 5 year survival was 76.9%, and skip metastasis did not affect on the survival rate. CONCLUSION: Our study supports the understanding of the biology of sentinel nodes. During gastrectomy in gastric cancer patients, great attention should be paid to remove the sentinel nodes and D2 dissection should be done when skip metastasis is suspected.