Comparison of Single Incision Endoscopic Nipple-Sparing Mastectomy and Conventional NippleSparing Mastectomy for Breast Cancer Based on Initial Experience / 한국유방암학회지

Purpose@#Endoscopic breast surgery for patients with breast cancer was introduced for its superior cosmetic outcomes; it was initially studied in the field of breast-conserving surgery and, more recently, in robotic-assisted nipple-sparing mastectomy (NSM). The main purpose of this study was to investigate the feasibility and safety of endoscopic NSM (E-NSM) in patients with breast cancer by comparing E-NSM and conventional NSM (C-NSM). @*Methods@#Between May 2017 and October 2020, we retrieved the records of 45 patients who underwent NSM with permanent silicone implants and divided them into the E-NSM group (20 patients) and the C-NSM group (25 patients), depending on the use of the endoscopic device.We also analyzed demographic information, pathology, operative time, and complications. @*Results@#No significant differences were observed between the 2 groups based on demographic information, postoperative pathological data, mean length of hospital stay, and total number of complications. The mean preparation time for surgery was comparable between both groups. Compared to the C-NSM group, the E-NSM group had a significantly longer mean operative time and, subsequently, a significantly longer mean total operative time and number of complications. @*Conclusion@#The results showed that E-NSM was feasible and safe with a more inconspicuous incision in patients with breast cancer.

Comparison of Single Incision Endoscopic Nipple-Sparing Mastectomy and Conventional NippleSparing Mastectomy for Breast Cancer Based on Initial Experience / 한국유방암학회지

Purpose@#Endoscopic breast surgery for patients with breast cancer was introduced for its superior cosmetic outcomes; it was initially studied in the field of breast-conserving surgery and, more recently, in robotic-assisted nipple-sparing mastectomy (NSM). The main purpose of this study was to investigate the feasibility and safety of endoscopic NSM (E-NSM) in patients with breast cancer by comparing E-NSM and conventional NSM (C-NSM). @*Methods@#Between May 2017 and October 2020, we retrieved the records of 45 patients who underwent NSM with permanent silicone implants and divided them into the E-NSM group (20 patients) and the C-NSM group (25 patients), depending on the use of the endoscopic device.We also analyzed demographic information, pathology, operative time, and complications. @*Results@#No significant differences were observed between the 2 groups based on demographic information, postoperative pathological data, mean length of hospital stay, and total number of complications. The mean preparation time for surgery was comparable between both groups. Compared to the C-NSM group, the E-NSM group had a significantly longer mean operative time and, subsequently, a significantly longer mean total operative time and number of complications. @*Conclusion@#The results showed that E-NSM was feasible and safe with a more inconspicuous incision in patients with breast cancer.

Extent of central lymph node dissection for papillary thyroid carcinoma in the isthmus

PURPOSE: The incidence of papillary thyroid carcinoma (PTC) arising from the isthmus is low; however, these tumors have aggressive clinical and pathological features. Moreover, the existing guidelines regarding the extent of surgery for this type of tumor are unclear. METHODS: This study enrolled 282 patients who underwent total thyroidectomy with bilateral central lymph node dissection. The patients were divided into 2 groups based on the location of the median line of the PTC. Group I included patients in whom the median line was located between the lateral margins of the trachea; group II included all others. We compared the 2 groups and conducted a multivariate analysis to assess risk factors for contralateral node metastasis from a PTC arising from the isthmus. RESULTS: Patients in group I had significantly higher frequencies of extrathyroidal extension and central lymph node metastasis. Group I also had a higher frequency of contralateral node metastasis, and a tumor size >1.0 cm was identified as an independent risk factor for contralateral node metastasis among patients in this group. CONCLUSION: Bilateral central lymph node dissection could be considered for patients with isthmic PTCs >1.0 cm in size who have clinically suspicious node metastasis.

Significance of micrometastases in the calculation of the lymph node ratio for papillary thyroid cancer

PURPOSE: The lymph node ratio (LNR) is an important prognostic factor in papillary thyroid carcinoma (PTC), but micrometastases in cervical lymph nodes (LNs) are not of great clinical importance. In this study, we analyzed the accuracy of prediction of the prognosis depending on whether micrometastases were included in the number of metastatic LNs when calculating LNR. METHODS: The study included 353 PTC patients who underwent total thyroidectomy with neck LN dissection, and calculated LNR by 2 methods according to whether micrometastases were included in the number of metastatic LNs: Method 1 did not and method 2 did include. To compare the predictive values of LNR by the 2 methods, correlation coefficients and receiver operating characteristic (ROC) curves were analyzed. RESULTS: Positive correlations were found between LNR and preablation stimulated thyroglobulin (sTg) levels in both methods, but the correlation between method 1 LNR and preablation sTg level was significantly stronger than that for method 2 (Fisher z = 1.7, P = 0.045). The areas under these 2 independent ROC curves were analyzed; the prognostic efficacy of method 1 LNR was more accurate than that of method 2 LNR, and the difference was statistically significant (P = 0.0001). CONCLUSION: Regional recurrence of PTC can be predicted more accurately by not including micrometastases in the number of metastatic LNs when calculating LNR.

Evaluation of Prognostic Factors and Validation of Tumor Response Ratios after Neoadjuvant Chemotherapy in Patients with Breast Cancer

PURPOSE: In the treatment of breast cancer, neoadjuvant chemotherapy (NAC) is useful to reduce breast cancer size before surgical intervention. Patients who achieve a pathologic complete response (pCR) to NAC have improved overall survival (OS). However, the relationship between prognosis and partial response is yet unclear. In this study, we evaluated prognostic factors and the tumor response ratio (TRR) method among patients who received NAC. METHODS: Clinicopathologic factors were evaluated to predict OS. The TRR was calculated by dividing pathologic tumor size by clinical tumor size. TRRs were then categorized into four groups, and the survival times for the different TRR groups were compared using statistical evaluation. RESULTS: Clinical N stage (p=0.02), overall stage (p=0.04), pathologic N stage (p=0.03), hormone receptor status (p=0.01), and lymphovascular invasion (p=0.02) were significantly associated with OS. Pathologic overall stage and TRR did not correlate with OS. Patients with a pCR exhibited the best survival rates using the current staging system and the TRR method. CONCLUSION: Clinicopathologic factors can be easily applied to predict OS, and clinicians could use these parameters until an accurate, simple, and highly discriminatory methods is developed to assess breast cancer patients with a partial.

Minimally invasive parathyroidectomy with or without intraoperative parathyroid hormone for primary hyperparathyroidism

PURPOSE: The improvement of intraoperative parathyroid hormone (IOPTH) assay and localization studies has enabled a minimally invasive parathyroidectomy (MIP) in primary hyperparathyroidism (pHPT). The aim of this study is to analyze the demographics, clinical presentations, and surgical outcomes of the pHPT patients who received surgical management with versus without IOPTH. METHODS: Analysis of a database was performed on 53 patients who underwent parathyroidectomy for pHPT from 2004 to 2013. Preoperative localization was done by both sestamibi scan and ultrasonography. We divided the patients into two groups (without IOPTH versus with IOPTH) and analyzed the surgical outcomes statistically between two groups. RESULTS: The concordance rate of Technetium 99m sestamibi scan and ultrasonography was 73.6% and 90.6%, respectively. The overall cure rate of group 1 (without IOPTH) was 94.9% and that of group 2 (with IOPTH) was 100%. The decline of PTH at postoperative 5 minutes and 10 minutes was 75.2% +/- 14.9% and 84.9% +/- 8.6% in cured patients. On the other hand, that of noncured patients at 5 minutes and 10 minutes was 17.2% +/- 9.7% and 8.2% +/- 2.2%. There was a significant difference in the drop rate of IOPTH between cured and persistent patients (P < 0.01). Pathological examination showed adenoma in 41 of 53 patients (77.4%) and hyperplasia in 10 of 53 patients (18.9%). CONCLUSION: Even though the localization studies were successful, IOPTH monitoring is essential to avoid a surgical failure in MIP.

Predicting postoperative total calcium requirements after parathyroidectomy in secondary hyperparathyroidism

BACKGROUND/AIMS: To prevent hypocalcemia after parathyroidectomy (PTX), parenteral calcium is required in addition to oral calcitriol and calcium. After switching to oral calcium, patients can be discharged from the hospital. The aim of this study was to analyze the clinical characteristics and outcomes of PTX performed at a single Korean center and to investigate the associated laboratory factors used to analyze the total amount of postoperative calcium required. METHODS: We enrolled 91 hemodialysis patients undergoing PTX from November 2003 to December 2011. We collected clinical and laboratory data preoperatively, 12 and 48 hours postoperatively, at discharge, and 3 and 6 months postoperatively. RESULTS: In total, 59 patients underwent PTX with autotransplantation (AT), 6 underwent total PTX without AT, 11 underwent subtotal PTX, and 15 underwent limited PTX. Total PTX without AT showed the lowest recurrence rate. At all postoperative time points, the mean levels of serum calcium, phosphorus, and intact parathyroid hormone (iPTH) decreased significantly, compared with preoperative levels; however, alkaline phosphatase (ALP) increased significantly from 48 hours postoperatively to discharge (p < 0.001). On multiple linear regression analysis, the total amount of injected calcium during hospitalization showed a significant correlation with preoperative ALP (p < 0.001), preoperative iPTH (p = 0.037), and Deltaphosphorus at 48 hours (p < 0.001). We developed an equation for estimating the total calcium requirement after PTX. CONCLUSIONS: Preoperative ALP, preoperative iPTH, and Deltaphosphorus at 48 hours may be significant factors in estimating the postoperative calcium requirement. The formula for postoperative calcium requirement after PTX may help to predict the duration of postoperative hospitalization.

The role of preoperative ultrasonography, computed tomography, and sestamibi scintigraphy localization in secondary hyperparathyroidism

PURPOSE: The role of preoperative localization studies is controversial in surgery of secondary hyperparathyroidism (sHPT). The aim of study was to evaluate the accuracy of preoperative ultrasonography (USG), CT, and 99mTc sestamibi scintigraphy (MIBI) in localizing enlarged parathyroid glands and to find the impact of correct localization in successful parathyroidectomy. METHODS: We compared operative findings with the preoperative localization of ultrasonography, computerized tomography and sestamibi scintigraphy in 109 patients with sHPT and identified well-visualized locations of abnormal parathyroid glands by evaluating the sensitivity of each imaging study with regard to typical locations of glands. We investigated the effect of preoperative imaging localization on the surgical outcomes by measuring the intraoperative parathyroid hormone (ioPTH) decrement for positive or negative imaging localization. RESULTS: USG (91.5%) had the highest sensitivity and MIBI (56.1%) had the lowest among 3 modalities. The sensitivity of combined USG and CT (95.0%) was the highest among combined 2 modalities. The combination of all 3 modalities (95.4%) had the highest sensitivity among the combinations of modalities. The reduction of ioPTH in patients with positive imaging localization (86.6%) was greater than negative imaging localization (84.2%), with no significant difference (P = 0.586). The recurrence or persistence of sHPT was not correlated with preoperative imaging localization (19 patients in negative, 16 in positive; P = 0.14). CONCLUSION: Preoperative imaging localization contributed to surgical success but not to surgical outcomes. The combination of ioPTH measurement with imaging localization might be valuable for better surgical results in sHPT.

Tumor Sprouting in Papillary Thyroid Carcinoma Is Correlated with Lymph Node Metastasis and Recurrence

BACKGROUND: Identification of poor prognostic factors in papillary thyroid carcinoma (PTC) patients is important for the patients' care and follow-up. We can sometimes see small tumor clusters without desmoplasia and no evidence of lymphatic emboli around the main tumor mass of PTC. We termed this form of tumor clustering, 'tumor sprouting,' and determined whether these tumors correlate with lymphovascular invasion, lymph node metastasis, and recurrence. METHODS: We analyzed a total of 204 cases of papillary thyroid macrocarcinoma. Number, size and distance from the main tumor of the tumor sprouting were observed and analyzed with clinicopathologic characteristics. RESULTS: Tumor sprouting was observed in 101 patients. Presence of tumor sprouting was significantly associated with positive resection margin (p=.002), lymphovascular invasion (p=.001), lymph node metastasis (p<.001), and recurrence (p=.004). Univariate analysis of recurrence-free survival revealed that tumor multiplicity (p=.037), positive resection margin (p=.007), lymphovascular invasion (p=.004), lymph node metastasis (p<.001), and tumor sprouting (p=.004) were poor prognostic factors. In multivariate analysis, positive resection margin was an independent poor prognostic factor of recurrence. CONCLUSIONS: In conclusion, tumor sprouting is significantly correlated with lymph node metastasis and recurrence. Evaluation of tumor sprouting in PTC patients could be helpful in predicting tumor recurrence or lymph node metastasis.

Achievement of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative: recommended serum calcium, phosphate and parathyroid hormone values with parathyroidectomy in patients with secondary hyperparathyroidism / 대한외과학회지

PURPOSE: The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) 2003 has established guidelines for the treatment of secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease - minerals and bone disorder (CKD-MBD). This study evaluated parathyroidectomy in SHPT patients for the achievement of the NKF-K/DOQI-recommended values of serum calcium, phosphate, and parathyroid hormone (PTH). METHODS: Between January 2005 and December 2010, parathyroidectomy was performed as recommended by the NKF-K/DOQI guidelines in 81 patients with SHPT and CKD-MBD. Serum PTH, calcium, and phosphate levels were measured prior to and 6, 12, 36, and 60 months after parathyroidectomy. RESULTS: Calcium, phosphate, and PTH levels dropped shortly after parathyroidectomy; however, a slight increase showed in the long term. Calcium levels increased for up to 60 months. Phosphate and PTH levels increased for up to 36 months but tended to decrease slightly at 60 months. The mean values were within the target ranges, except for PTH at 36 months. The target parameters of serum phosphate (42.9-61.1% of patients) and serum calcium (a peak of 61.1% of patients at 36 months, but only 28.6% at 60 months) were achieved the most. Less than 34% of patients achieved the recommended range for PTH. CONCLUSION: Parathyroidectomy was not an optimal procedure for achieving all the biochemical parameters recommended by the NKF-K/DOQI. Although it was helpful in attaining the recommended values for serum calcium and phosphate in SHPT patients resistant to medical therapy, the PTH levels did not fall within the recommended range.

Robotic Adrenalectomy Using a Lateral Transperitoneal Approach: Initial Experience of Fifteen Consecutive Cases / 대한내분비외과학회지

PURPOSE: In this study, we report on our initial experience using the da Vinci-S® robotic surgical system in performance of laparoscopic adrenalectomy. METHODS: Fifteen patients, 11 with left adrenal tumors and four with right adrenal tumors, underwent robotic adrenalectomies using the lateral transperitoneal approach with the da Vinci-S® surgical system at the Korea University Anam Hospital, Seoul, Korea, between October 2009 and May 2012. RESULTS: The mean age of the patients was 45.5 (22~61) years, and the mean body mass index was 23.81 (18.0~28.57) kg/m². Eleven left adrenalectomies, four for primary aldosteronisms, four for pheochromocytomas, two for primary adrenal Cushing's adenoma, and one for myelolipoma, and four right adrenalectomies, two for the primary adrenal Cushing's adenomas, one for pheochromocytoma, and one for primary aldosteronism, were performed robotically. There was no conversion to traditional laparoscopic or open surgery. The mean size of the tumor was 2.54 (1.0~5.5) cm. The mean operative time was 208.2 (120~320) minutes, and the mean console time was 127.6 (75~212) minutes. No major postoperative morbidity was observed, and the mean length of hospital stay was 5.86 days. CONCLUSION: We found that the robotic systems, with magnified stereoscopic three-dimensional vision, elimination of tremor, and the ability to articulate and rotate the instruments, were ideal surgical tools for operation of adrenal lesion. Robotic adrenalectomy may be a safe and effective alternative to traditional laparoscopic adrenalectomy.

Disease of Parathyroid and Surgical Strategy / 대한내분비외과학회지

The role of surgery in parathyroid disease has shown a recent decrease with development of calcinomimetics such as cinacalcet. During thyroid surgery, every endocrine surgeon makes every effort to preserve the parathyroid gland. However, postoperative hypoparathyroidism cannot be completely prevented. Knowledge of the precise anatomy of the parathyroid, including embryological movement of parathyroid glands, is needed. Surgical indications of parathyroidectomy include primary hyperparathyroidism, secondary hyperparathyroidism, tertiary hyperparathyroidism and parathyroid carcinoma. Parathyroidectomy for primary hyperparathyroidism has shown a significant change due to introduction of the sestamibi scan, intraoperative PTH assay, and focused parathyroidectomy. Minimally invasive surgery has now become standard operation for primary hyperparathyroidism. However, focused unilateral parathyroid operation should be done very cautiously because you can lose the chance of cure. Recurrence rate after parathyroidectomy is approximately 5% and experience of a surgeon can only reduce this rate. Surgery for secondary hyperparathyroidismis performed in only 1~2% of CKD patients. Surgical methods include subtotal parathyroidectomy, total parathyroidectomy, and total parathyroidectomy with autotransplantation and the results of the operation are not different. With the introduction of cinacalcet, comparison between surgery and medication showed an effective drop down of serum PTH level and increase of BMD only in surgery. Cincalcet did not show improvement of mortality, vascular calcification, and nephrplithiasis. According to oneJapanese report, PTH more than 500 pg/ml, size larger than 1 cm, and more than two enlarged parathyroid favor parathyroidectomy in renal osteodystrophy. During parathyroid surgery, high suspicion for carcinoma gives the only chance for cure because en bloc resection is important. Parathyroid disease has evolved since introduction of Cinacalcet and endocrine surgeons should join with physicians as a team for development of a treatment plan.

Efficacy of intraoperative parathyroid hormone monitoring to predict success of parathyroidectomy for secondary hyperparathyroidism / 대한외과학회지

PURPOSE: In secondary hyperparathyroidism (sHPT), it is unclear which criterion for intraoperative parathyroid hormone (ioPTH) decline performs best and whether ioPTH monitoring is sufficiently efficacious in predicting postoperative surgical cure by retrospective review. METHODS: In 80 parathyroidectomies for sHPT, patients with ioPTH monitoring and follow-up PTH assay were categorized into physiologically accepted and failed groups. Receiver operating characteristic (ROC) curves were used to identify the criterion with the best performance and to determine the regression equation for prediction of surgical success. RESULTS: There was a statistically significant difference in the percentage reduction of ioPTHs between the two groups (P < 0.05). With our criterion, cure was predicted with a sensitivity of 86% and specificity that could be improved to 60% using an 85% ioPTH decrease as cut-off level when this value was compared to the Miami Criterion. There was a slightly negative correlation between the natural logarithm of percentage reduction of ioPTH and percentage reduction of PTH at follow-up (R2 = 0.109, P = 0.003). CONCLUSION: ioPTH measurements are a useful tool for improvement of the cure rate of operations for sHPT. Because this study aimed at 40 minutes (ioPTH3) as an optimal process in the operation, we recommend using a criterion of more than 85% ioPTH decline at 40 minutes by use of the ROC curve, and the use of the presently calculated regression equation may enable prediction of success.

Successful Localization of Distant Metastasis in Parathyroid Carcinoma Using Intraoperative Parathyroid Hormone Assay

Intra-operative parathyroid hormone (IOPTH) assay is a useful tool to confirm complete excision of all hyper-functioning parathyroid gland tissue. In this report, we describe a case with successful localization of distant metastasis in a patient with parathyroid carcinoma using the IOPTH assay. A 53-year-old man presented to our clinic with a serum calcium level of 11.8 mg/dL and an intact PTH level of 233.3 pg/mL. He had been treated for parathyroid carcinoma eleven years ago. Two suspected metastatic lesions were detected on the chest computed tomography. Due to the vastly different surgical field necessary to excise each lesion, we preferentially removed only one lesion and we monitored the other remaining suspected lesion without resection via IOPTH assay. Six months later, the patient's serum calcium and intact PTH levels remained within their normal ranges. To the best of our knowledge, this is the first case to effectively utilize IOPTH assay for the management of metastatic parathyroid carcinoma.

Surgical Treatment of Local Recurrence in Thyroid Cancer / 대한갑상선학회지

The diagnosis and treatment of recurrent or persistent thyroid cancer can pose significant clinical dilemmas. The tumor generally has a relatively indolent biology; however, recurrent or persistent disease is not uncommon, although tumor-specific mortality is infrequent. Treatment options include 131I, surgical resection, and ethanol or radiofrequency ablation. Neck recurrences are common in papillary thyroid carcinoma (PTC). Surgical removal decreases the need for additional therapy and can minimize complications from local recurrence. Therefore, any patient with a local recurrence should be offered surgical resection. Since reoperations in the central neck can be difficult, it is essential that a surgeon have accurate preoperative imaging and extensive experience in thyroid surgery.

Maxillofacial Enlargement in Secondary Hyperparathyroidism Successfully Treated by Limited Parathyroidectomy and Paricalcitol / 대한신장학회지

Maxillary enlargement is a rare complication of secondary hyperparathyroidism (SHPT). A 35-year-old Korean man undergoing chronic hemodialysis presented with a painless enlargement involving the maxilla and mandible. Plain radiography and CT scan showed bony expansion at the maxilla and mandible with multiple radiolucency. Serum intact parathyroid hormone (iPTH) was >1,600 pg/mL. Tc-99m sestamibi (MIBI) parathyroid scan and neck sonogram were compatible with SHPT. He underwent limited parathyroidectomy and commenced a course of paricalcitol. Fifteen months after surgery, maxillary enlargement and bony resorptions involving both hands markedly improved. Thirty-six months after the surgery, the serum iPTH level was 109.3 pg/mL. This is the first report in Korea documenting a patient with maxillary enlargement in SHPT who was successfully treated with limited parathyroidectomy and paricalcitol.

Preoperative Thyroid-stimulating Hormone Levels as a Predictor of Thyroid Carcinoma / 대한내분비외과학회지

PURPOSE: This study investigated the effects of serum thyroid-stimulating hormone (TSH) levels in predicting malignancy-associated differentiated thyroid cancer (DTC) and benign thyroid nodules. METHODS: Between January 2005 and December 2007, 346 patients underwent thyroid surgery at one hospital. Their records were retrospectively reviewed. RESULTS: Sixty-nine percent (237 of 346) of the patients had DTC. The mean preoperative TSH level was higher than in the malignant group (5 uIU/ml vs 0.4 uIU/ml). The rate of malignancy was the 71% in patients with TSH levels >5 uIU/ml. The TSH level of DTC with metastasis of the lymph node was higher than that with non-metastasis (3.08 uIU/ml vs 2.09 uIU/ml, P<0.01) CONCLUSION: The likelihood of DTC increases with higher serum TSH concentration. Serum TSH level might be useful in predicting malignant nodular thyroid lesion.

Mandibular Enlargement, Metastatic Pulmonary Calcification and Gastric Mucosal Calcinosis in a Patient with Chronic Kidney Disease-mineral Bone Disorder / 대한신장학회지

Secondary hyperparathyroidism is one of the most common complications of patients with chronic kidney disease (CKD). Mandibular enlargement, metastatic pulmonary calcification, and gastric mucosal calcinosis are rare complications in these patients. The defect of calcium and phosphorus metabolism may precipitate pathologic calcification at diverse organs and soft tissue, and change bone architecture. In case of involving periarticular area, patients usually present with localized swelling, pain, and reduced mobility in affected sites. However, in case of organ involvement, except in an advanced stage of disease, there are no specific symptoms. Among these patients, treatment strategies include tight control of calcium and phosphate levels, parathyroidectomy for hyperparathyroidism, renal transplantation, and local excision of calcific lesions. We report a case of mandibular enlargement, metastatic pulmonary calcification, and gastric mucosal calcinosis due to CKD with improvement 3 months after medical and surgical treatment.

Hormone Replacement Therapy and Breast Cancer: The Situation in Korea / 한국유방암학회지

No abstract available.

Molecular Targets for Treatment of Breast Cancer / 한국유방암학회지

Advances in molecular biology have made it possible to understand the tumor biology of breast cancer at the molecular level and have revealed molecular targets for the therapy of breast cancer. Nowadays, targeting agents are used as mono-therapy or as combined therapy with other anti-cancer drugs for the treatment of breast cancer. Much more efforts is also being made in the development of better therapeutic agents targeting molecules having an important role in tumor biology. In this article, promising molecules for targeted therapy are reviewed for their roles in the pathophysiology and the treatment of breast cancer. We also introduce and summarize new preclinical agents, developed or on developing, with preliminary results from clinical trials. Given the progress currently being made, targeted therapy could become a main strategy for the treatment of breast cancer in the near future.