A Randomized Controlled Trial for Doing vs. Omitting Intraoperative Frozen Section Biopsy for Resection Margin Status in Selected Patients Undergoing Breast-Conserving Surgery (OFF-MAP Trial) / 한국유방암학회지

Purpose@#Intraoperative frozen section biopsy is used to reduce the margin positive rate and re-excision rate and has been reported to have high diagnostic accuracy. A majority of breast surgeons in the Republic of Korea routinely perform frozen section biopsy to assess margins intraoperatively, despite its long turnaround time and high resource requirements. This study aims to determine whether omitting frozen section biopsy for intraoperative margin evaluation in selected patients is non-inferior to performing frozen section biopsy in terms of resection margin positivity rate. @*Methods@#This study is a phase III, randomized controlled, parallel-group, multicenter non-inferiority clinical trial. Patients meeting the inclusion criteria and providing written informed consent will be randomized to the “frozen section biopsy” or “frozen section biopsy omission” group after lumpectomy. Patients with clinical stage T1–T3 disease who are diagnosed with invasive breast cancer by core-needle biopsy and plan to undergo breast-conserving surgery will be included in this study. If a daughter nodule, non-mass enhancement, or microcalcification is identified on preoperative imaging, these features must be within 1 cm of the main mass for inclusion in the trial. The target sample size is 646 patients per arm. The primary endpoint will be the resection margin positive rate, and the secondary endpoints include the reoperation rate, operating time, residual cancer after reoperation, residual cancer after re-excision according to the frozen section biopsy result, resection volume, patient quality of life, and cost-effectiveness.Discussion: This is the first randomized clinical trial utilizing frozen section biopsy for intraoperative margin evaluation and aims to determine the non-inferiority of omitting frozen section biopsy in selected patients compared to performing frozen section biopsy.We expect that this trial will help surgeons perform the procedure more efficiently while ensuring patient safety.

Impact of the COVID-19 Pandemic on the Diagnosis and Surgery of Breast Cancer: A Multi-Institutional Study / 한국유방암학회지

Purpose@#The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the rates of screening, case identification, and referral for cancer diagnosis. We investigated the diagnosis and surgery status of breast cancer before and after the COVID-19 pandemic at a multi-institutional level. @*Methods@#We collected breast cancer data from the clinical data warehouse which contained the medical records of patients from six academic institutions in South Korea. Patients were divided into two groups: February to April (period A) and May to July (period B). The data from the two groups were then compared against the same periods in 2019 and 2020. The primary objective was to investigate the differences in breast cancer stages before and after the COVID-19 pandemic. @*Results@#Among 3,038 patients, there was a 9.9% reduction in the number of diagnoses in 2020. This decrease was more significant during period A than period B. The breast cancer stage was not statistically different in period A (p = 0.115), but it was in period B (p = 0.001). In the subset analysis according to age, there was a statistical difference between 2019 and 2020 in period B for patients under the age of 65 years (p = 0.002), but no difference was observed in the other groups. @*Conclusion@#The number of breast cancer cases declined during the pandemic, and the staging distribution has changed after the pandemic peak.

Delayed contralateral traumatic carotid cavernous fistula after craniomaxillofacial fractures

A carotid-cavernous sinus fistula is a rare condition in which an abnormal communication exists between the internal or external carotid artery and the cavernous sinus. It typically occurs within a few weeks after craniomaxillofacial trauma. In most cases, the carotid-cavernous sinus fistula occurs on the same side as the craniomaxillofacial fracture. We report a case of delayed carotidcavernous sinus fistula that developed symptoms 7 months after the craniomaxillofacial fracture. The fistula developed on the side opposite to that of the craniomaxillofacial fracture. Based on our experience with this case, we recommend a long follow-up period of 7–8 months after the occurrence of a craniomaxillofacial fracture. We also recommend that the follow-up should include consideration of the side contralateral to the injury.

Skeletal cavernous hemangiomas of the frontal bone with orbital roof and rim involvement

Skeletal cavernous hemangiomas are rare, benign tumors that may involve the supraorbital rim and orbital roof. However, such involvement is extremely rare. We report a case of skeletal cavernous hemangioma of the frontal bone involving the orbital roof and rim. En bloc excision and reconstruction, using a calvarial bone graft for the orbital roof and rim defect, was performed. It is important not only to perform total excision of skeletal cavernous hemangiomas, but to properly reconstruct the defects after the total excision since several complications can arise from an orbital roof and rim defect.

Feature Analysis of Burn Patients in Korea Using National Health Insurance Database

PURPOSE: Investigating epidemiological features of burn victims from a national frame has not been attempted recently. METHODS: South Korean National Health Insurance System (NHIS) provides a vast array of feature data on common diseases. A database search from January 2013 to December 2017 was undertaken with disease codes related to burn injuries and burn dressing procedures. After data cleaning, feature analysis was done with final dataset of 1,800 records. RESULTS: Demographic analysis showed gender preference to woman by 6:4. Age distribution showed bimodal peaks at 0~9 years and 40~60 years. Burns to the lower extremity seemed to increase with burn depth. Marked decrease in duration of hospitalization for first- and second-degree burns were noted over five years. CONCLUSION: Incidence to age analysis showed bimodal peaks in pediatric (age 0~9) and middle-aged (age 40~60) individuals. A decreasing trend towards shorter hospitalization is noted in mild to moderate burns. Further attention is needed to prevent third-degree burns to the elderly.

Crohn's disease and smoldering multiple myeloma: a case report and literature review

Crohn's disease (CD) is a chronic inflammatory bowel disease (IBD) that presents with abdominal pain, weight loss, and diarrhea. Although the etiology has not been fully elucidated, both environmental and genetic causes are known to be involved. In chronic inflammatory conditions such as IBD, B lymphocytes are chronically stimulated, and they induce monoclonal expansion of plasma cells, sometimes resulting in monoclonal gammopathy of undetermined significance. Immunomodulators that are commonly used to control inflammation, such as tumor necrosis factor-α (TNF-α) blockers could increase the possibility of hematologic malignancy. The pathogenesis of multiple myeloma in association with TNF-α inhibitor therapy is attributed to decreased apoptosis of plasma cell populations. Here, we describe a case of a 36-year-old male patient who was diagnosed with immunoglobulin A subtype smoldering multiple myeloma during the treatment for CD with infliximab and adalimumab. We report this case along with a review of the literature on cases of multiple myeloma that occurred in conjunction with CD.

The Effect of Reproductive Factors on Breast Cancer Presentation in Women Who Are BRCA Mutation Carrier / 한국유방암학회지

PURPOSE: Germline mutations in the BRCA1 and BRCA2 genes confer increased risks for breast cancers. However, the clinical presentation of breast cancer among women who are carriers of the BRCA1 or BRCA2 (BRCA1/2 carriers) mutations is heterogenous. We aimed to identify the effects of the reproductive histories of women with the BRCA1/2 mutations on the clinical presentation of breast cancer. METHODS: We retrospectively analyzed clinical data on women with proven BRCA1 and BRCA2 mutations who were recruited to the Korean Hereditary Breast Cancer study, from 2007 to 2014. RESULTS: Among the 736 women who were BRCA1/2 mutation carriers, a total of 483 women had breast cancers. Breast cancer diagnosis occurred at significantly younger ages in women who experienced menarche at ≤14 years of age, compared to those who experienced menarche at >14 years of age (37.38±7.60 and 43.30±10.11, respectively, p<0.001). Additionally, the number of full-term pregnancies was significantly associated with the age of diagnosis, especially in women with the BRCA2 mutation. The prevalence of advanced stages (stage II or III vs. stage I) of disease in parous women was higher than in nulliparous women (68.5% vs. 55.2%, p=0.043). This association was more pronounced in women with the BRCA2 mutation (hazard ratio, 2.67; p=0.014). CONCLUSION: Our results suggest that reproductive factors, such as the age of onset of menarche and the presence of parity, are associated with the clinical presentation patterns of breast cancer in BRCA1/2 mutation carriers.

Can We Skip Intraoperative Evaluation of Sentinel Lymph Nodes? Nomogram Predicting Involvement of Three or More Axillary Lymph Nodes before Breast Cancer Surgery / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The American College of Surgeons Oncology Group Z0011 trial reported that complete dissection of axillary lymph nodes (ALNs) may not be warranted in women with clinical T1-T2 tumors and one or two involved ALNs who were undergoing lumpectomy plus radiation followed by systemic therapy. The present study was conducted to identify preoperative imaging predictors of ≥ 3 ALNs. MATERIALS AND METHODS: The training set consisted of 1,917 patients with clinical T1-T2 and node negative invasive breast cancer. Factors associated with ≥ 3 involved ALNs were evaluated by logistic regression analysis. The validation set consisted of 378 independent patients. The nomogram was applied prospectively to 512 patients who met the Z0011 criteria. RESULTS: Of the 1,917 patients, 204 (10.6%) had ≥ 3 positive nodes. Multivariate analysis showed that involvement of ≥ 3 nodes was significantly associated with ultrasonographic and chest computed tomography findings of suspicious ALNs (p < 0.001 each). These two imaging criteria, plus patient age, were used to develop a nomogram calculating the probability of involvement of ≥ 3 ALNs. The areas under the receiver operating characteristic curve of the nomogram were 0.852 (95% confidence interval [CI], 0.820 to 0.883) for the training set and 0.896 (95% CI, 0.836 to 0.957) for the validation set. Prospective application of the nomogram showed that 60 of 512 patients (11.7%) had scores above the cut-off. Application of the nomogram reduced operation time and cost, with a very low re-operation rate (1.6%). CONCLUSION: Patients likely to have ≥ 3 positive ALNs could be identified by preoperative imaging. The nomogram was helpful in selective intraoperative examination of sentinel lymph nodes.

Prosthetic Valve Endocarditis caused by HACEK Organisms: a Case Report and Systematic Review of the Literature / 감염과화학요법

HACEK is a rare cause of prosthetic valve endocarditis (PVE). We describe 42-year-old male patient who presented with Aggregatibacter aphrophilus PVE and cerebral infarct. A. aphrophilus was isolated from his blood cultures as the sole pathogen, which was confirmed by subsequent 16S rRNA sequencing. He was treated with valve replacement surgery and an 8 week course of pathogen-directed antibiotic therapy and followed for 20 months without recurrence.

Comparison of Injury Patterns between All-terrain Vehicles and Motorbike Riders in Jeju Island

PURPOSE: As the usage rate of all-terrain vehicles (ATV) the number of injuries caused by ATVs is also surging. This has led to an increase in social attention to the safety of ATVs and the law for ATV safety standards was revised in 2009 and 2011. The purpose of this study was to evaluate the characteristics of ATV injury compared with motorbike injury after implementation of the ATV safety policy. METHODS: A retrospective cross-sectional observation study was conducted using emergent department (ED)-based indepth injury surveillance system data from 2011 January to 2014 December. Demographics, injury-related characteristics, injury severity, and outcomes of patients related to ATV and motorbike injury visiting our ED were analyzed. Multivariate logistic regression was used for major adverse event (MAE), which was defined as any intensive care, emergent operation, or death between ATV and motorbike related injury adjusted for covariates. RESULTS: During the study period, there were 101 ATV- and 584 motorbike-related injuries. Females had more ATV-related injuries (63.4% vs 32.9%, p<0.001) during leisure activities (93.1%) with higher helmet usage (73.3% vs 62.0%, p=0.01) and lower usage in terms of emergency medical service (23.8% vs 46.4%, p<0.001), automobile insurance (10.9% vs 54.1%, p<0.001) compared with motorbike-related injuries. MAE in ATV-related injuries was less likely in a univariate logistic model (unadjusted odd ratios [ORs] 0.489, 95% confidential intervals [Cis] 0.282 to 0.848), but the multivariate logistic model showed no significant difference (adjusted ORs 1.018, 95% CIs 0.376 to 1.414). CONCLUSION: Results of this study showed no significant difference in occurrence of clinical major adverse events between motorbikes and ATVs-related injury on Jeju Island. However, considering the high injury prevalence in young age, female, and passengers during leisure activities, development of an education and injury prevention program will be needed for this vulnerable population.

Poorly Differentiated Thyroid Carcinoma with Gross Internal Jugular Vein Invasion and Multiple Lung Metastases / 대한갑상선학회지

A rare case of poorly differentiated thyroid carcinoma (PDTC) with gross intraluminal invasion to the internal jugular vein whose clinical manifestation was multiple lung metastases is described. A 66-year-old man was referred to the outpatient clinic of the Department of Internal Medicine, hemato-oncology subdivision for multiple lung nodules found by his regular health check-up. These lung nodules showed variable sizes with irregular shapes, and typical distributions throughout the parenchyma, which were consistent with metastatic nodules. Ultrasonography revealed a 4.5 cm sized hypoechoic mass with irregular shape in his left thyroid lobe and a huge thrombus in the left internal jugular vein. PDTCs associated with gross intraluminal invasion to the great cervical vein and multiple lung nodules as their first clinical manifestation are extremely rare. We would emphasize the importance of preoperative detailed evaluation of the disseminated disease by ultrasonography in suspected patients.

Risk Factors Associated with Distant Metastasis and Survival Outcomes in Breast Cancer Patients with Locoregional Recurrence / 한국유방암학회지

PURPOSE: To decide the optimal treatment for breast cancer patients with locoregional recurrence (LRR), it is important to determine which group has the highest risk of subsequent distant metastasis (DM). We aimed to investigate the factors associated with DM in patients with LRR. METHODS: We reviewed the data of 208 patients with LRR as the first event after primary surgery for breast cancer at our institution between 1997 and 2010, to identify significant factors associated with DM. Subsequently, Kaplan-Meier curves and the Cox regression method were used to analyze the correlation between clinical factors and survival. RESULTS: DM occurred in 33.2% (68/208) of LRR patients. The median DM-free interval was 23 months. Some clinical factors were associated with DM in univariate analysis, including the type of primary surgery (p=0.026), tumor size (p=0.005), nodal status (p=0.011), and administration of initial adjuvant chemotherapy (p=0.001). In addition, regional rather than local recurrence and a disease-free interval (DFI; duration between primary surgery and LRR) < or =30 months were also significant (p<0.001 for both). However, only a shorter DFI reached significance in multiple logistic regression analysis. Cox regression analysis of DM-free survival showed that both a shorter DFI and regional recurrence were significant factors with hazard ratios of 2.1 (95% confidence interval [CI], 1.21-3.65) and 1.85 (95% CI, 1.04-3.28), respectively. CONCLUSION: DFI was the most important factor associated with subsequent DM in patients with LRR as a first event of failure.

A Case Report of Familial Renal Hypouricemia Confirmed by Genotyping of SLC22A12, and a Literature Review

A 24-year-old male visited our hospital because of pain in both flanks. His biochemistry profile showed an elevated serum creatinine level and low serum uric acid level. History taking revealed that he had undertaken exercise prior to the acute kidney injury (AKI) event, and he stated that family members had a history of urolithiasis. His renal profile improved after hydration and supportive care during hospitalization. Although the patient was subsequently admitted again due to AKI, his status recovered with similar treatment. Since the diagnosis of the patient was familial renal hypouricemia with exercise-induced AKI, we performed genotyping of SLC22A12, which encodes human urate transporter 1. The diagnosis was confirmed by the detection of a homozygous mutation of W258X. We herein, report a case of familial renal hypouricemia confirmed by genotyping of SLC22A12, and review the relevant literature.

A Case of Pulmonary Cryptococcosis in an Immunocompetent Male Patient Diagnosed by a Percutaneous Supraclavicular Lymph Node Biopsy / 결핵및호흡기질환

Cryptococcal pneumonia usually occurs in immunocompromised patients with malignancy, acquired immune deficiency syndrome, organ transplantations, immunosuppressive chemotherapies, catheter insertion, or dialysis. It can be diagnosed by gaining tissues in lung parenchyma or detecting antigen in blood or bronchoalveolar lavage fluid. Here we report an immunocompetent 32-year-old male patient with diabetes mellitus diagnosed with cryptococcal pneumonia after a ultrasound-guided percutaneous supraclavicular lymph node core needle biopsy. We treated him with fluconazole at 400 mg/day for 9 months according to the guideline. This is the first case that cryptococcal pneumonia was diagnosed from a percutaneous lymph node biopsy in South Korea.

A Case of Type 2 Diabetes Mellitus with Severe Insulin Resistance and Dumping Syndrome after Bariatric Surgery

Patients with diabetes undergo bariatric surgery to improve sugar metabolism and to achieve weight loss. However, possible complications after bariatric surgery must be carefully considered. We report a case of uncontrolled blood sugar after bariatric surgery despite weight loss in a severely obese patient with diabetes. The patient underwent bariatric surgery in 2009 in order to lose weight and improve glycemic control. Six months after the surgery, the patient experienced dumping syndrome. The patient did actually lose weight; however, as the visceral fat/subcutaneous fat+visceral fat ratio increased, insulin resistance was not improved, and glycemic control was aggravated. The patient received proper medication for dumping syndrome including nutritional support and exercise education. Due to these efforts, the patient has maintained her weight loss, and her blood sugar level was controlled within the target range.

Bone mineral density and bone turnover markers in patients on long-term suppressive levothyroxine therapy for differentiated thyroid cancer

PURPOSE: Current management for patients with differentiated thyroid cancer includes near total thyroidectomy and radioactive iodine therapy followed by administration of supraphysiological doses of levothyroxine (L-T4). Although hyperthyroidism is a well known risk factor for osteoporosis, the effects of L-T4 treatment on bone mineral density (BMD) in patients with thyroid cancer do not appear to be as significant as with endogenous hyperthyroidism. In this study, we evaluated the impact of long-term suppressive therapy with L-T4 on BMD and bone turn over markers in Korean female patients receiving L-T4 suppressive therapy. METHODS: We enrolled 94 female subjects (mean age, 50.84 +/- 11.43 years) receiving L-T4 after total or near total thyroidectomy and radioactive iodine therapy for thyroid cancer (mean follow-up period, 12.17 +/- 4.27 years). The subjects were divided into three groups by thyroid stimulating hormone (TSH) level (group 1 with TSH level 0.17 microIU/mL) and four groups by quartile of free T4 level. L-T4 dosage, BMD (examined by dual-energy x-ray absorptiometry), and bone turnover markers were evaluated according to TSH and free T4 levels. RESULTS: No significant decrease was detected in BMD or bone turnover markers according to TSH level or free T4 level. Also, the prevalence of osteoporosis and osteopenia was not different among groups. CONCLUSION: Long-term L-T4 suppressive therapy after thyroid cancer management did not affect bone density or increase the prevalence of osteoporosis even though TSH levels were supraphysiologically suppressed.

Regional Lymph Node Metastasis in Papillary Thyroid Cancer / 대한갑상선학회지

Papillary thyroid cancer is a common endocrine cancer and commonly presents with lymph node metastases. It has been generally accepted that lymphatic drainage occurs from the thyroid primarily to the central lymphatic compartment and secondarily to the lateral compartment nodes. Recently, improvements in the resolution of imaging studies and the availability of highly sensitive thyroglobulin assays have highlighted the importance of identifying disease in the pre-operative assessment and dealing effectively with metastatic regional disease in order to prevent recurrence. However, there are limitations to diagnosing central lymph node metastases. With unreliable imaging modalities, prophylactic central lymph node dissection should be performed on all patients with papillary thyroid cancer. In comparison with the central compartment, prophylactic lateral node dissection has little or no effect on improving the prognosis of patients with papillary thyroid cancer. Therefore, lateral node dissection is recommended only as a part of the therapeutic procedure. The extension of lateral neck dissection is recommended a comprehensive selective neck dissection of levels IIa, III, IV, and Vb. The rich lymphatic supply of the thyroid gland coupled with the propensity for nodal metastases in papillary thyroid cancer require the modern thyroid surgeon to be familiar with the indications for and techniques of regional lymph node dissection.

The Demand and Causes of Emergency Medical Service Utilization of Visitors on Jeju Island, South Korea

PURPOSE: Providing proper emergency medical services (EMS) for domestic or international visitors to popular destinations is becoming increasingly important. Jeju Island is the most visited spot in South Korea. The number of people visiting Jeju Island has increased every year, and this was over ten times the registered population on Jeju Island. The purpose of this study was to describe EMS use behavior and to estimate demand for EMS for visitors on Jeju Island. METHODS: A retrospective observational study was conducted on Jeju Island, with 580,000 citizens. EMS is a fire-based system with a single tiered intermediate service level by a single centralized dispatch center, 29 ambulances, and approximately 130 EMS providers. We collected all ambulance run-sheet data, which included comprehensive information as well as patients' address identification, monthly number of visitors, and census data of Jeju Island from January, 2010 to December, 2012. RESULTS: Among 90,674 EMS transports, 7,209 (8%) were excluded because of unknown address of patients, and of all 83,456 (100%) patients using EMS, 9,733 (12%) were visitors and 73,732 (88%) were residents. The percentage of females was higher for visitors than residents (45% vs. 43%, p<0.001) and the mean age was younger in visitors (38+/-19 vs. 54+/-22, p<0.001). Injury was much higher for visitors than residents (63% vs. 38%, p<0.001). The estimated monthly number of EMS use per 10,000 people was 3.7 (95% CI 3.5 to 3.9) in visitors and 35.7 (95% CI 34.9 to 36.5) in residents, with a ratio of 0.104 (95% CI 0.099 to 0.108). The trend of ratio by year was not significant (p=0.630). The correlation between monthly EMS use in visitors and monthly number of unregistered population was significant (Pearson's correlation 0.844). CONCLUSION: Determining EMS use behavior and the demand of EMS in visitors is a critical task. Our results are of interest in preparing and providing the provision of EMS for visitors.

High serum C-reactive protein level predicts mortality in patients with stage 3 chronic kidney disease or higher and diabetic foot infections

BACKGROUND: Diabetic patients are predisposed to foot infections because of vascular insufficiency and peripheral neuropathy. Diabetic foot infection is a common cause of mortality and lower extremity amputations (LEAs) in patients with chronic kidney disease (CKD). We evaluated the risk factors for mortality and LEAs in patients with stage 3 CKD or higher with diabetic foot infections. METHODS: We retrospectively evaluated a cohort of 105 CKD patients with diabetic foot infections between July 1998 and December 2011. We reviewed their demographic characteristics and laboratory parameters to evaluate the risk factors for mortality and amputations at 24 weeks after diagnosis of a diabetic foot infection. RESULTS: The mortality of the 105 enrolled CKD patients was 21% at 24 weeks after the diagnosis of a diabetic foot infection. Cox proportional regression analyses revealed that age 60 years or older [odds ratio (OR) 3.03, 95% confidence interval (CI) = 1.02-9.02, P = 0.047] and initial serum C-reactive protein (CRP) level > or = 3 mg/dL (OR 3.97, 95%CI = 1.17-13.43, P = 0.027) were independent risk factors for mortality at 24 weeks.Twenty-four patients (23%) underwent LEAs. On Cox proportional regression analyses, peripheral vascular disease (OR=4.49,95% CI=1.98-10.17, P=0.01) and cerebrovascular accident (OR 2.42, 95%CI=1.09-5.39, P=0.03) were independently associated with LEAs. CONCLUSION: This study showed that age and serum CRP level, were independent risk factors for mortality at 24 weeks in patients with stage 3-5 CKD with diabetic foot infections. Peripheral vascular disease and cerebrovascular accident were significantly associated with LEAs.

Correction of Congenital Metacarpal Synostosis with Polypropylene Mesh as an Interpositional Material / 대한정형외과학회잡지

Metacarpal synostosis is an uncommon congenital hand malformation characterized by the coalescence of two or more adjacent metacarpals. Patients visit the hospital due to abduction deformity, which is usually a mild deformity or a minor functional deficit. This is one of the reasons why the patient goes to the hospital late and foregoes proper management with early detection and treatment. A number of surgical procedures ranging from simple to complex have been employed for treatment of this deformity. We describe our experience with a longitudinal osteotomy, realignment of component metacarpals with the metacarpophalangeal joint, and interposition of a non-absorbable polypropylene mesh used for inguinal hernia for correction of the abducted deformity and prevention of recurrence of synostosis while minimizing morbidity.