Ultrasonographic guideline for thyroid nodules cytology: single institute experience / 대한외과학회지

PURPOSE: The main issue with the current ultrasonography (US) guidelines is the overestimation of malignant and indeterminate nodules as they do not aid in making decisions to treat patients. To overcome this, new US guidelines for thyroid nodules that have been shown to be better correlated with cytologic results have been proposed. We also suggested specific indications for US-guided fine needle aspiration (FNA) using the new US guidelines. METHODS: Clinical and pathologic data from 925 patients and 1,419 thyroid nodules were retrospectively collected. All subjects underwent US- and US-guided FNA at Department of Surgery, Wonju Christian Hospital, between March 2010 and July 2011. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated for both the current guidelines and the new guidelines. RESULTS: The accuracy, sensitivity, specificity, PPV, and NPV for the current guidelines in predicting malignancy were 24.1%, 99.3%, 62.2%, 25.0%, and 99.8%, respectively. The accuracy, sensitivity, specificity, PPV, and NPV for the new guidelines in predicting malignancy were 66.0%, 96.0%, 86.7%, 47.7%, and 99.4%, respectively. CONCLUSION: The use of the new US guidelines allow for a more accurate and specific diagnosis and a better treatment plan than the current guidelines. Additionally, the use of the new FNA guidelines may help prevent unnecessary FNAs and promote cost-effective follow-up for patients.

Role of External Beam Radiotherapy in Patients with Locally Advanced Papillary Thyroid Cancer / 대한내분비외과학회지

PURPOSE: External beam radiotherapy (EBRT) plays a controversial role in the management of differentiated thyroid cancer. We reviewed the outcomes of patients at our institution who had been treated with EBRT for advanced differentiated thyroid cancer. METHODS: Subjects included 35 patients who received thyroidectomy and EBRT at Yonsei University Wonju College of Medicine, Wonju Christian Hospital under the diagnosis of papillary thyroid cancer from January 1989 to September 2011. RESULTS: The 5 year overall locoregional control rate was 74.4%. No significant differences were found in locoregional progression- free survival for patients with complete resection, microscopic residual disease, or gross residual disease. CONCLUSION: The results of our study have shown that EBRT is effective for locoregional control of selected locally advanced papillary thyroid cancer, even with gross residual disease.

Association of BRAF(V600E) Mutation with Poor Clinical Prognostic Factors and Ultrasonographic Findings in Cases of Papillary Thyroid Carcinoma / 대한내분비외과학회지

PURPOSE: This study evaluated the association of the BRAF(V600E) mutation with known prognostic factors and ultrasonographic characteristics in cases of papillary thyroid carcinoma. METHODS: Subjects included 169 patients who received thyroidectomy at Wonju Christian Hospital under the diagnosis of papillary thyroid cancer from February 2010 to October 2011. RESULTS: Of the total patients who received thyroidectomy, there were 128 cases (75,7%) of BRAF(V600E) mutation. Neither age nor sex were associated with the BRAF(V600E) mutation. Tumor size, shape, margin, extrathyroidal extension, central node metastasis and lateral node metastasis were found not to be associated with the BRAF(V600E) mutation. Tumor calcification, echogenicity and vascularity were also not associated with the mutation. CONCLUSION: As debate remains about the association between the BRAF(V600E) mutation and clincopathologic factors and ultrasonographic characteristics in cases of papillary thyroid carcinoma, further study is needed.

Neuron-Like Differentiation of Bone Marrow-Derived Mesenchymal Stem Cells

PURPOSE: Mesenchymal stem cells (MSCs) are multipotent and give rise to distinctly differentiated cells from all three germ layers. Neuronal differentiation of MSC has great potential for cellular therapy. We examined whether the cluster of mechanically made, not neurosphere, could be differentiated into neuron-like cells by growth factors, such as epidermal growth factor (EGF), hepatocyte growth factor (HGF), and vascular endothelial growth factor (VEGF). MATERIALS AND METHODS: BMSCs grown confluent were mechanically separated with cell scrapers and masses of separated cells were cultured to form cluster BMSCs. As described here cluster of BMSCs were differentiated into neuron-like cells by EGF, HGF, and VEGF. Differentiated cells were analyzed by means of phase-contrast inverted microscopy, reverse transcriptase-polymerase chain reaction (RT-PCR), immunofluorescence, and immunocytochemistry to identify the expression of neural specific markers. RESULTS: For the group with growth factors, the shapes of neuron-like cells was observable a week later, and two weeks later, most cells were similar in shape to neuron-like cells. Particularly, in the group with chemical addition, various shapes of filament structures were seen among the cells. These culture conditions induced MSCs to exhibit a neural cell phenotype, expressing several neuro-glial specific markers. CONCLUSION: bone marrow-derived mesenchymal stem cells (BMSCs) could be easily induced to form clusters using mechanical scraping, not neurospheres, which in turn could differentiate further into neuron-like cells and might open an attractive possibility for clinical cell therapy for neurodegenerative diseases. In the future, we consider that neuron-like cells differentiated from clusters of BMSCs are needed to be compared and analyzed on a physiological and molecular biological level with preexisting neuronal cells, and studies on the possibility of their transplantation and differentiation capability in animal models are further required.

Analysis of Clinicopathologic Factors Associated with Bilateral Thyroid Micro Papillary Carcinoma / 대한내분비외과학회지

PURPOSE: Papillary thyroid carcinoma is the most common malignant tumor originating from the thyroid. The recent increase in frequency of thyroid ultrasonography is increasing the diagnostic rate of thyroid cancer, especially of the small-sized cancer. The appropriate extent of surgery for thyroid micropapillary carcinoma is still under debate, and bilaterality of the tumor may be an important factor determining the extent. Therefore, this study analyzed the clinicopathologic factors related to tumor bilaterality in order to help decide the extent of treatment. METHODS: Subjects included 134 patients who received total thyroidectomy and central neck lymph node dissection at Wonju Christian Hospital under the diagnosis of thyroid micropapillary cancer from January 1(st), 1994 to December 31(st), 2009. The frequency of bilateral tumor among the subjects were studied, and the relationship between bilaterality and clinicopathologic factors, including patients' gender, age, tumor size, multiple mass in single lobe, capsule invasion, extrathyroidal extension, lymphovascular space invasion, central neck node invasion and lateral neck node invasion was analyzed. RESULTS: There were 32 cases (23.9%) of bilateral tumor. Statistically significant factors related to bilaterality included two or more mass in a single lobe, perithyroidal soft tissue invasion. CONCLUSION: When we plan thyroidectomy for thyroid micropapillary cancer, one cannot rule out the possibility of bilateral thyroid micropapillary cancer in patients with clinicopathologic factors related to bilaterality. Closer preoperative examination is thought to be required for such patients.

Sonographic Analysis of the Nodular Form of Hashimoto Thyroiditis / 대한내분비외과학회지

PURPOSE: There are relatively few results from studies on nodular Hashimoto's thyroiditis. In addition, some Hashimoto's thyroiditis patients present with irregular symptoms, making the distinction from malignant thyroid nodule difficult. Therefore, we performed analyses on ultrasonographic findings of nodular Hashimoto's thyroiditis. METHODS: A retrospective follow-up study was performed on 76 patients (88 nodules) diagnosed with Hashimoto's thyroiditis after undergoing fine needle aspiration biopsy from January 2009 to December 2010. A frequency analysis was performed to investigate the most common ultrasonographic findings of nodular Hashimoto's thyroiditis. In addition, patients were divided into two groups based on the presence or absence of extensive Hashimoto's thyroiditis on the parenchyma, and ultrasonographic findings were compared and analyzed for nodules in each group. RESULTS: The study was performed on 76 patients and 88 nodules. The majority of nodular Hashimoto's thyroiditis were found to be solid on ultrasonography, and echogenicity was mostly hypoechoic, with prominent hypoechoic findings being more common. Most nodules did not have a rim surrounding the margins, and absence of accompanying calcification was also noted. The comparison and analysis of ultrasonographic findings of two patient groups that were divided based on the presence or absence of Hashimoto's thyroiditis across the parenchyma, revealed no significant difference. CONCLUSION: Most nodular Hashimoto's thyroiditis cases do not present with calcification or rims and frequently present as solid and hypoechoic. It can be concluded that such findings are consistent regardless of whether there is accompanying extensive changes at the thyroid parenchyma associated with Hashimoto's thyroiditis.

Hungry bone syndrome after parathyroidectomy of a minimally invasive parathyroid carcinoma / 대한외과학회지

The prognosis of parathyroid carcinoma varies significantly between numerous studies. Therefore, many attempts have been made to grade the degree of parathyroid carcinoma, and recently, classifying parathyroid carcinomas into either minimally invasive or widely invasive carcinoma- similar to follicular carcinoma of the thyroid- has led to a more reliable prediction of the prognosis. Hungry bone syndrome can occur if parathyroidectomy is performed due to primary hyperparathyroidism regardless of the cause of the disease. Hungry bone syndrome is characterized by postoperative a hypocalcemic state due to remineralization of various minerals, including calcium, of the bone; this syndrome requires a long-term supplementation of calcium. The authors aim to report, along with a review of related literatures, 1 case of a 29-year-old female patient diagnosed with minimally invasive parathyroid carcinoma who fell into hungry bone syndrome after parathyroidectomy.

Hungry bone syndrome after parathyroidectomy of a minimally invasive parathyroid carcinoma / 대한외과학회지

The prognosis of parathyroid carcinoma varies significantly between numerous studies. Therefore, many attempts have been made to grade the degree of parathyroid carcinoma, and recently, classifying parathyroid carcinomas into either minimally invasive or widely invasive carcinoma- similar to follicular carcinoma of the thyroid- has led to a more reliable prediction of the prognosis. Hungry bone syndrome can occur if parathyroidectomy is performed due to primary hyperparathyroidism regardless of the cause of the disease. Hungry bone syndrome is characterized by postoperative a hypocalcemic state due to remineralization of various minerals, including calcium, of the bone; this syndrome requires a long-term supplementation of calcium. The authors aim to report, along with a review of related literatures, 1 case of a 29-year-old female patient diagnosed with minimally invasive parathyroid carcinoma who fell into hungry bone syndrome after parathyroidectomy.

Analysis of Cytopathology of Fine Needle Aspiration Biopsy of the Thyroid according to Bethesda Classification and Clinical Implication of Atypical Cells of Undetermined Significance / 대한내분비외과학회지

PURPOSE: The frequency of diagnosis of each nodule category under the Bethesda classification was studied, and the differences in the results between cytopathologic and histopathologic analyses of same patients were assessed. Special attention was paid to the atypical cells of undetermined significance (ACUS), which is an intermediate category. The histopathology of ACUS specimens was confirmed to examine the clinical implication. METHODS: Patients (n=417) who underwent thyroid ultrasonography and fine needle aspiration of the thyroid since the application of Bethesda classification (November 2009 to August 2010) in this institution was enrolled in the study. RESULTS: According to the Bethesda criteria, of the 640 nodules there were 56 cases (8.8%) of ACUS, 14 cases (2.2%) of follicular neoplasm, 13 cases (2.0%) were suspicious for malignancy, and 37 cases (5.8%) were positive of malignancy. A total of 102 surgically-excised specimens were obtained, of which 40 specimens were previously categorized cytopathologically as ACUS. Of these 40 specimens, 16 cases (40%) were found to be malignant. CONCLUSION: A precise understanding of each diagnostic category seems to be necessary, which may help with treatment of patients with thyroid mass. This is especially true for ACUS, which was previously understood as an intermediate specimen, but which is actually a heterogeneous mix of benign specimen, benign specimen with various atypia, and malignancy. In case of ACUS, an extensive and accurate diagnostic approach utilizing various examination methods may be beneficial for the patient treatment.

Clinical Analysis of Patients with Abdomen or Neck-penetrating Trauma

PURPOSE: Recently, the change to a more complex social structure has led to an increased frequency of traumas due to violence, accident and so on. In addition, the severity of the traumas and the frequency of penetrating injuries have also increased. Traumas to cervical and abdominal areas, what are commonly seen by general surgeons, can have mild to fatal consequences because in these areas, various organs that are vital to sustaining life are located. The exact location and characteristics of the injury are vital to treating patients with the trauma to these areas. Thus, with this background in mind, we studied, compared, and analyzed clinical manifestations of patients who were admitted to Wonju Christian hospital for penetrating injuries inflicted by themselves or others. METHODS: We selected and performed a retrospective study of 64 patients who had been admitted to Wonju Christian Hospital from January 2005 to December 2009 and who had cervical or abdominal penetrating injuries clearly inflicted by themselves or others. RESULTS: There were 51 male (79.7%) and 13 female (20.3%) patients, and the number of male patients was more dominant in this study, having a sex ratio of 3.9 to 1. The range of ages was between 20 and 86 years, and mean age was 43.2 years. There were 5 self-inflicted cervical injuries, and 19 self-inflicted abdominal injuries, making the total number of self-inflicted injury 24. Cervical and abdominal injuries caused by others were found in 11 and 29 patients, respectively. The most common area involved in self-inflicted injuries to the abdomen was the epigastric area, nine cases, and the right-side zone II was the most commonly involved area. On the other hand, in injuries inflicted by others, the left upper quadrant of the abdomen was the most common site of the injury, 14 cases. In the neck, the left-side zone II was the most injured site. In cases of self-inflicted neck injury, jugular vein damage and cervical muscle damage without deep organ injury were observed in two cases each, making them the most common. In cases with abdominal injuries, seven cases had limited abdominal wall injury, making it the most common injury. The most common deep organ injury was small bowel wounds, five cases. In patients with injuries caused by others, six had cervical muscle damage, making it the most common injury found in that area. In the abdomen, small bowel injury was found to be the most common injury, being evidenced in 13 cases. In self-inflicted injuries, a statistical analysis discovered that the total duration of admission and the number of patients admitted to the intensive care unit were significantly shorter and smaller, retrospectively, than in the patient group that had injuries caused by others. No statistically significant difference was found when the injury sequels were compared between the self-inflicted-injury and the injury-inflicted-by-others groups. CONCLUSION: This study revealed that, in self-inflicted abdominal injuries, injuries limited to the abdominal wall were found to be the most common, and in injuries to the cervical area inflicted by others, injuries restricted to the cervical muscle were found to be the most common. As a whole, the total duration of admission and the ICU admission time were significantly shorter in cases of self-inflicted injury. Especially, in cases of self inflicted injuries, abdominal injuries generally had a limited degree of injury. Thus, in our consideration, accurate injury assessment and an ideal treatment plan are necessary to treat these patients, and minimally invasive equipment, such as laparoscope, should be used. Also, further studies that persistently utilize aggressive surgical observations, such as abdominal ultrasound and computed tomography, for patients with penetrating injuries are needed.

Traumatic Liver Injury in Pediatric Patients

PURPOSE: Trauma is an important cause of death in children. In particular, the liver is the second most commonly organ injured by blunt abdominal trauma. Treatment of patients with liver injury is has changed, and non-operative treatment is the major treatment method at present. In this study, we reviewed traumatic liver injury in pediatric patients. METHODS: Seventy-seven patients younger than 16 years of age with traumatic liver injury were assessed for 10 years from July 1999 to June 2009 at Wonju Christian hospital. Records of the patients were reviewed retrospectively. Demographic and clinical data were analyzed. RESULTS: The median age was 6 years, and the male-to-female ratio was 1.2 : 1. The most common injury grade was grade I. The majority of injuries were caused by was traffic accidents, and the second most common cause of injuries was falls. Twenty-four patients had liver injuries alone, and the most common accopaning injury was a lung injury. The average hospital stay was 20.7 days, and the average ICU stay was 4.8 days. Four patients died (5.2%). There were 6 patients with under 10 points on the Glasgow coma scale (GCS). Among these patients, three died. All mortality cases had over 16 points on the Injury Severity Score (ISS). Two patients were treated surgically, one of whom died. Of the 75 patients with non-operative management, three died due to associated injuries. CONCLUSION: Most pediatric patients with liver injury have good results with non-operative management. Associated injuries and hemodynamic instability are predictive of patient outcome, and those with isolated liver injuries can be successfully managed non-operatively.

The Early Experience of Laparoscopic Sigmoid Colon and Rectal Cancer Resection

PURPOSE: The aim of this study is to assess the pathologic surgical outcome and short-term outcome of a laparoscopic colorectal resection at an early time on the learning curve in comparison with open surgery. METHODS: Retrospectively collected data were obtained on 49 patients who underrent a laparoscopic sigmoid colon and rectal cancer resection between May 2001 and January 2006. The compared factors were the clinicopathologic characteristics, the operation time, the postoperative recovery, and complications. RESULTS: There were no significant differences in age, sex, TNM stage, and tumor size between the laparoscopic and open-surgery groups. The operation time was significantly longer in the laparoscopic group (291.4 vs. 201.9 min P < 0.001). In the view point of postoperative recovery, the laparoscopic group showed a significant advantage in the passage of flatus. There were no significant differences in harvested LNs, proximal margin, and distal margin between the two groups. The complication rate was not significantly different, but anastomotic leakage was higher in the laparoscopic group (16.7% vs. 2%, P=0.02). CONCLUSIONS: There were no significant differences in harvested LNs, proximal margin, and distal margin between the two groups, but anastomotic leakage was higher in the laparoscopic group.

Effects of Glycopyrrolate or Atropine on Hemodynamic Responses during Anesthetic Induction with Remifentanil and Sevoflurane in Elderly Patients / 대한마취과학회지

BACKGROUND: This study was conducted to determine the effect of glycopyrrolate or atropine on attenuating hemodynamic responses such as bradycardia and hypotension during anesthetic induction with remifentanil and sevoflurane in elderly patients, in a randomized placebo-controlled double blinded manner. METHODS: 60 patients over 65 years with ASA physical status 1 or 2 were allocated to one of three groups of 20 each. Each group received saline placebo (group C) or glycopyrrolate 4microgram/kg (group G) or atropine 0.5 mg (group A) immediately after induction of anesthesia, and then remifentanil 1microgram/kg bolus was given over 30s. Mean arterial pressure (MAP) and heart rate (HR) were measured before anesthetic induction, before intubation, and during 5 minutes after intubation at 1 minute interval. RESULTS: MAP remained stable and HR increased significantly 1 min after intubation in all groups. MAP decreased significantly during 2-5 minute after intubation in all groups. HR decreased in the group C, remained stable in the group G, and increased in the group A significantly during 3-5 minute after intubation. Hypotension (systolic blood pressure < 90 mmHg checked twice) occurred in 8 patients in the group C, 1 patient in the group G, and none in the group A. CONCLUSIONS: Glycopyrrolate and atropine attenuated the hemodynamic responses to laryngoscropy and intubation during anesthetic induction with remifentanil 1microgram/kg bolus dose and sevoflurane.

Indication of Interventional Treatment in Abdominal and Pelvic Trauma

PURPOSE: The aim of this study was to evaluate and establish the indications of interventional artery embolization in patients with a traumatic liver, spleen and pelvis injury. METHODS: 91 patients with a traumatic liver, spleen and pelvis injury, who had been treated with interventional arterial embolization from April 1992 to April 2004, were included in this retrospective study. The abdominal pelvic injuries were classified according to the CT scan findings based on the injury scale of the American Association for the Surgery of Trauma. The mechanism of trauma, initial vital signs, initial hemoglobin, hospital length, transfusion amount, shock index and fluid resuscitation amount were surveyed. All the patients underwent angiography. If there was evidence of an active hemorrhage during angiography, interventional arterial embolization with Gelfoam or stainless coil was performed. RESULTS: Among the 91 patients with a traumatic liver, spleen and pelvis injury, 25 out of 30 patients treated by hepatic arterial embolization, 36 out of 42 patients by splenic artery embolization and 14 out of 19 patients by pelvic artery embolization showed successful outcomes that were supported by shock index improvement (P<0.05), less fluid resuscitation requirements (P<0.05) and less packed red blood cell (RBC) requirements (P<0.05). CONCLUSION: Interventional artery embolization is a preferable non-surgical management for patient with a traumatic liver, spleen and pelvis injury. These results suggests that the indications of interventional arterial embolization are a shock index <1, transfusion amount to maintain a Hg level of 10 g/dl <3 pint per day and fluid resuscitation amount <2,000 ml per 2 hours.