Is familial papillary thyroid microcarcinoma more aggressive than sporadic form?

PURPOSE: With the increasing incidence of papillary thyroid microcarcinoma (PTMC), familial papillary thyroid microcarcinoma (FPTMC) is now recognized more frequently. However, the biological behavior of FPTMC is poorly understood. The aim of this study was to investigate the prevalence of FPTMC and its biological aggressiveness. METHODS: Between March 2006 and July 2010, 2,414 patients underwent primary surgical therapy for PTMC and 149 (6.2%) were further classified as FPTMC. To determine the biological aggressiveness of FPTMC, we compared the clinicopathological features and prognosis between FPTMC and sporadic PTMC (SPTMC). RESULTS: The male-to-female ratio was higher in FPTMC than in sporadic papillary thyroid microcarcinoma (SPTMC: 1:4.5 vs. 1:7.2, P = 0.041). The central lymph node (LN) metastasis rate was significantly higher in FPTMC than in SPTMC (36.2% vs. 24.2%, P = 0.002). The local recurrence rate was also higher in FPTMC than in SPTMC (4.5% vs. 0.6%, P < 0.001). We identified familial occurrence in 6.2% of cases of PTMC. FPTMC is associated with a high rate of central LN metastasis and local recurrence. CONCLUSION: These findings suggest that close follow-up can be beneficial in FPTMC patients to detect local recurrence.

Primary Squamous Cell Carcinoma of the Remnant Stomach after Subtotal Gastrectomy.

Primary squamous cell carcinoma (SCC) of the stomach is a very rare disease. However, the pathogenesis, clinical characteristics, and prognosis of gastric SCC are controversial and remain to be elucidated. Herein, we report a case of primary gastric SCC of the remnant stomach after subtotal gastrectomy. A 65-year-old man was admitted to our hospital due to epigastric discomfort and dizziness. He had undergone subtotal gastrectomy 40 years previously for gastric ulcer perforation. Endoscopy revealed a normal esophagus and a large mass in the remnant stomach. Abdominal computed tomography revealed enhanced wall thickening of the anastomotic site and suspected metachronous gastric cancer. Endoscopic biopsy revealed SCC. Total gastrectomy was performed with Roux-en-Y esophagojejunostomy. A 10-cm tumor was located at the remnant stomach just proximal to the previous area of anastomosis. Pathologic examination showed well-differentiated SCC extended into the subserosa without lymph node involvement (T3N0M0). The patient received adjuvant systemic chemotherapy with 6 cycles of 5-FU and cisplatin regimen, and he is still alive at the 54-month follow-up. According to the treatment principles of gastric cancer, early detection and radical surgical resection can improve the prognosis.

Follicular variant of papillary thyroid carcinoma with B-type Raf(V600E) showing higher frequency of suspicious sonographic features and multifocality.

BACKGROUND: The purpose of this study was to investigate the correlation between B-type Raf (BRAF) kinase mutation and clinicopathological features of follicular variant of papillary thyroid carcinoma (PTC). METHODS: Eighty-four patients with pathologically confirmed follicular variant of PTC, who underwent a preoperative BRAF(V600E) study, were analyzed. Clinicopathological parameters and ultrasonographic features were compared between the BRAF(V600E) -positive and negative groups. RESULTS: A total of 41.7% of the patients showed BRAF(V600E) . The BRAF(V600E) -positive group showed the smaller tumor size (7.3 ± 3.6 mm vs 10.7 ± 8.9 mm; p = .018) and the more frequent multifocality (25.7% vs 8.2%; p = .028). Follicular variant of PTC with BRAF(V600E) showed suspicious ultrasonographic features (88.6% vs 57.1%; p = .002) more frequently. BRAF(V600E) positivity is associated with multifocality after adjusting for age, sex, the presence of suspicious ultrasonographic features, pathological tumor size, and thyrotropin level. CONCLUSION: BRAF(V600E) was correlated with smaller tumor size and suspicious ultrasonographic features in follicular variant of PTC. BRAF(V600E) was a significant parameter for predicting multifocality of follicular variant of PTC.

Comparison of the outcomes of laparoscopic and open approaches in the treatment of periappendiceal abscess diagnosed by radiologic investigation.

BACKGROUND: Although laparoscopic appendectomy (LA) has been performed widely, the role of LA for complicated appendicitis remains controversial, and its role for periappendiceal abscess (PA) remains undefined. This study compared the clinical outcomes of LA and open appendectomy (OA) for PA diagnosed by radiologic investigation. PATIENTS AND METHODS: We conducted a retrospective review of 84 patients who underwent surgery for PA diagnosed by radiologic investigation between 2010 and 2013. Twenty-five patients underwent LA, and the remaining patients underwent OA. Patient characteristics, operative outcomes, and surgical complications were compared between the two groups. RESULTS: Three patients required conversion from LA to OA (12%). There were no significant differences in the overall complication (28% versus 25.4%; P=.8), wound infection (15.3% versus 4%; P=.27), stump leakage (4% versus 1.7%; P=.51), and postoperative ileus (4% versus 8.5%; P=.66) rates between the groups. The incidence of intraabdominal abscess (IAA) was significantly higher in the LA group (20% versus 3.4%; P=.02). In multivariate analysis, the risk factors for IAA were duration of drainage (P=.04) and type of operation (P=.006). The major complications rate was 2.4% in the total cohort, and the rate was significantly higher in the LA group (8% versus 0%; P=.02). CONCLUSIONS: For patients with PA, the rates of overall complications, wound infection, stump leakage, and postoperative ileus were similar for both procedures. However, LA resulted in a significantly higher incidence of IAA and major complications than OA.

A prospective comparison of patient body image after robotic thyroidectomy and conventional open thyroidectomy in patients with papillary thyroid carcinoma.

BACKGROUND: Body image is associated with self-esteem and identity and has a close relationship with quality of life (QoL). We compared the impact of surgical scars on the patient's perception of body image between conventional open thyroidectomy (OT) and robotic thyroidectomy (RT) in female papillary thyroid carcinoma patients. METHODS: From October 2009 to December 2010, we enrolled prospectively 116 papillary thyroid carcinoma patients who underwent total thyroidectomy at the Yonsei University Health System (Seoul, Korea). Of these 116 patients, 56 had OT and 60 RT. Their scars were assessed using the Vancouver Scar Scale (VSS), and psychometric properties were evaluated using the Body Image Scale (BIS) questionnaire postoperatively. Both groups were compared using cross-sectional and time-series methods. RESULTS: Mean age was significantly younger in the RT group. Regarding scar quality, the OT group showed superiority in scar pigmentation and the total VSS score during the early postoperative period, but the VSS score improved over time and was similar between both groups at 9 months. The RT group had better scores regarding most of the BIS items, a trend that remained relatively constant over time. In patients with noticeable scars (VSS ≥ 2) at 9 months, the RT group had better BIS scores regarding almost all items, including "self-conscious," "physical attractiveness," "feeling of less feminine," "sexual attractiveness," "dissatisfaction with body, scar and appearance when dressed," and "avoidance of people due to appearance." CONCLUSION: RT provides a better self-body image and improves QoL compared with conventional OT by avoiding a noticeable cervical scar.

Factors contributing to surgical outcomes of transaxillary robotic thyroidectomy for papillary thyroid carcinoma.

INTRODUCTION: Transaxillary robotic thyroidectomy is considered a technically feasible and safe treatment option for patients with low-risk papillary thyroid carcinoma (PTC). The aim of the present study was to determine the factors that contribute to the perioperative surgical outcomes of robotic thyroidectomy and to suggest guidelines for patient selection to be used by surgeons inexperienced in the technique. METHOD: We reviewed the records of 275 patients with PTC who underwent robotic total thyroidectomy using a gasless, transaxillary single-incision approach at Yonsei University Health System, South Korea, between January 2011 and May 2012. The association between surgical outcomes and clinicopathologic factors was assessed using linear and logistic regression analysis. RESULTS: The contributing factors for surgical outcomes of robotic thyroidectomy were categorized as patient factors, including gender and body mass index (BMI), and thyroid-specific factors, including thyroid gland size, coexistent thyroiditis, tumor size, and serum anti-thyroglobulin antibody and anti-microsomal antibody titers. Of these, male gender, a large thyroid gland, and thyroiditis significantly increased the total operation time. Male gender, thyroiditis, and overweight BMI increased the working space time, and a large thyroid gland and overweight BMI affected the console time. A large thyroid gland and histological thyroiditis were associated with increased intraoperative blood loss. There was no association between postoperative complications and clinicopathologic parameters. CONCLUSION: Male gender, overweight BMI, a large thyroid gland, and coexistent thyroiditis adversely affected the surgical outcome of robotic thyroidectomy. Surgeons inexperienced in the technique should avoid or carefully approach individuals with these factors.

Surgical complications after robotic thyroidectomy for thyroid carcinoma: a single center experience with 3,000 patients.

BACKGROUND: Robotic thyroidectomy (RT), a new gasless, transaxillary approach developed by the Yonsei University group in Seoul, Korea, eliminates the need for a cervical incision. Since RT is technically complex and has a steep learning curve, the surgical complication rate may initially be higher than with conventional surgery. This study evaluated the complication rates of transaxillary RT and assessed ways to prevent surgical complications. METHODS: Between October 2007 and March 2013, 3,000 patients underwent RT for thyroid cancer in the Department of Surgery, Yonsei University College of Medicine at Severance Hospital, Seoul. The medical records of these patients were reviewed retrospectively, and surgical complications were assessed on the basis of clinical findings. RESULTS: The most common surgical complication was symptomatic hypocalcemia, of which 37.43 % cases were transient and 1.10 % permanent. Other surgical complications included recurrent laryngeal nerve injury (1.23 % transient, 0.27 % permanent), seroma (1.73 %), hematoma (0.37 %), chyle leakage (0.37 %), trachea injury (0.2 %), Horner's syndrome (0.03 %), carotid artery injury (0.03 %), and brachiocephalic vein injury (0.03 %). The technique-related complications, which were never seen in conventional open thyroidectomy, were axillary skin flap perforation (0.1 %), and traction injury of the arm on the side the lesion was located (0.13 %). CONCLUSIONS: Surgeons who have mastered standardized robotic surgical procedures and who understand potential complications and how to prevent them can perform RT safely.

Surgical completeness of robotic thyroidectomy: a prospective comparison with conventional open thyroidectomy in papillary thyroid carcinoma patients.

BACKGROUND: Using the da Vinci(®) robotic system, surgeons can complete secure thyroidectomy without noticeable neck scarring. This study compared the surgical completeness of transaxillary robotic thyroidectomy (RT) with conventional open procedures (OT) in treating papillary thyroid carcinoma (PTC) patients. MATERIALS AND METHODS: From April 2009 through February 2011, 94 PTC patients underwent total thyroidectomy with central compartment neck dissection (CCND) at Yonsei University College of Medicine. All patients received 1.1 GBq radioactive iodine (RAI) ablation, post-therapy whole-body scans (TxWBS), and diagnostic WBS (DxWBS) 1 year later. We prospectively compared patient clinicopathologic characteristics and surgical completeness between the two groups. RESULTS: Fifty-one patients underwent OT and 43 underwent RT. Mean age was significantly younger in the RT group. Tumor size, capsular-invasion frequency, multifocality, bilaterality, and central nodal metastasis were not different between the two groups. The number of retrieved nodes during CCND did not significantly differ between the groups. There was no significant difference between the OT and RT groups in stimulated thyroglobulin levels acquired during TxWBS and DxWBS. The RAI uptake ratios at TxWBS were significantly higher in the RT group compared with the OT group; however, follow-up DxWBS showed no difference in RAI uptake ratios. Also, the ablation success rate was similar between the two groups. There were no abnormal findings in follow-up neck ultrasonography in either group. CONCLUSION: Remnant thyroid tissue ablation after transaxillary RT was successfully managed by 1.1 GBq RAI. RT showed similar surgical completeness versus conventional OT, and provides a safe and feasible surgical option for PTC patients.

Initial experience with robotic gasless transaxillary thyroidectomy for the management of graves disease: comparison of conventional open versus robotic thyroidectomy.

PURPOSE: The aim of this study was to report on our initial experiences with robotic gasless transaxillary thyroidectomy for the management of Graves disease (GD). METHODS: Among 257 patients with benign thyroid diseases who underwent thyroidectomy, 16 patients who underwent thyroidectomy for GD were analyzed from January 2009 to December 2010. These patients included 7 individuals who underwent robotic gasless transaxillary thyroidectomy (robot group; RG) and 9 who underwent conventional open thyroidectomy (open group; OG). Regardless of the type of surgery, all patients underwent subtotal thyroidectomy. The clinical characteristics and surgical outcomes of the 2 groups were compared. RESULTS: Patients in the RG were significantly younger at the time of surgery compared with those in the OG (P=0.028). The mean operative time was 171.29±18.88 minutes for the RG and 89.44±7.08 minutes for the OG (P=0.001). The mean weight of the resected glands was 77.43±12.29 g for the RG and 85.56±20.37 g for the OG (P=0.896). The RG had a significantly shorter mean hospitalization period of 3.0±0 days compared with 3.78±0.22 days of the OG. The mean number of times analgesics were used for pain control were 2.43±0.29 for the RG and 4.0±0.52 for the OG (P=0.039). No cases in the RG were converted to open thyroidectomy. During a mean follow-up period of 14.43±1.49 months for the RG, no patients continued antithyroid drugs or developed recurrent GD. CONCLUSIONS: Robotic gasless transaxillary thyroidectomy is a technically feasible and safe procedure for the patients with GD that results in a scarless outcome on the neck. This procedure can be a promising alternative for endoscopic or conventional open thyroidectomy for the management of GD.

Differentiated thyroid carcinoma of children and adolescents: 27-year experience in the yonsei university health system.

Thyroid carcinomas are uncommon in childhood and adolescence. The aim of this study was to analyze clinical features and clinical outcomes of thyroid cancer in the pediatric population treated in the Yonsei University Health System. From September 1982 to June 2009, 90 patients (75 females, 15 males; female:male ratio of 5:1) with differentiated thyroid carcinoma were identified in our institute. The mean age at diagnosis was 15.8 yr old (range 4.8-19.9 yr). Cervical masses were most common clinical manifestations at diagnosis in 65 patients (72.2%). Forty-two patients underwent less than total thyroidectomy and 18 patients underwent total thyroidectomy. Thirty patients (33.3%) had lateral neck lymph node metastasis and seven patients (7.8%) had lung metastasis at the time of surgery. Among the 90 patients, recurrence occurred in 14 patients (15.5%). Mean follow-up period for patients with differentiated thyroid carcinoma was 81.6 months (13-324 months). No patients died of differentiated thyroid carcinoma. Patients with differentiated thyroid carcinoma who were < 20-yr-of-age were present with aggressive local disease and a high frequency of lymph node and distant metastasis. It is recommended that pediatric thyroid cancer should be managed mostly using proper surgical approach with thyroidectomy and lymph node dissection when indicated.

Robot-assisted posterior retroperitoneoscopic adrenalectomy using single-port access: technical feasibility and preliminary results.

BACKGROUND: Posterior retroperitoneoscopic adrenalectomy (PRA) has several benefits compared with transperitoneal adrenalectomy in that it is safe and has a short learning curve. In addition, it provides direct short access to the target organ, prevents irritation to the intraperitoneal space, and does not require retraction of adjacent organs.1 (-) 3 We have performed several cases of robot-assisted PRA using single-port access for small adrenal tumors. This multimedia article introduces the detailed methods and preliminary results of this procedure. METHODS: Five patients underwent single-port robot-assisted PRA between March 2010 and June 2011 at our institution. During the procedure, patients were placed in a prone jackknife position with their hip joints bent at a right angle (Fig. 1). A 3 cm transverse skin incision was made just below the lowest tip of the 12th rib (Fig. 2), and the Glove port (Nelis, Kyung-gi, Korea) was placed through the skin incision while maintaining pneumoretroperitoneum (Fig. 3). CO2 was then insufflated to a pressure of 18 mm Hg to create an adequate working space. A 10 mm robotic camera with a 30-degree up view was placed at the center of the incision through the most cephalic portion of the Glove port. A Maryland dissector or Prograsp forceps (Intuitive Surgical, Inc., Sunnyvale, CA) was placed on the medial side of the incision, and Harmonic curved shears (Intuitive Surgical) were placed on the lateral side of the incision (Fig. 4). Using the Maryland dissector and the harmonic curved shears, the Gerota fascia is opened, perinephric fat is dissected, and the kidney upper pole is mobilized to expose the adrenal gland (Fig. 5). Gland dissection starts with lower margin detachment from the upper kidney pole in a lateral to medial direction (Fig. 6). After dissecting the adrenal gland from surrounding adipose tissue and medial isolation of the adrenal central vein, the vessel is ligated with a 5 mm hemolock clip (Fig. 7). Patient clinicopathologic data were analyzed retrospectively. RESULTS: The mean patient age was 56.6 ± 8.7 (range, 47-69) years. Right and left side approaches were used in two and three patients, respectively. All cases were adrenal cortical adenoma. The mean tumor size was 1.48 ± 0.28 (range, 1.0-1.7) cm. The mean surgery duration (skin to skin) was 159.4 ± 57.6 (range, 103-245) minutes, and the mean estimated blood loss was 46.0 ± 56.8 (range, 5-120) ml. The average time to oral intake and postoperative hospital stay were 0.65 ± 0.11 (range, 0.54-0.79) days and 4.0 ± 2.23 (range, 3-8) days, respectively. There were no conversions to open surgery or postoperative compli- cations. DISCUSSION: Some trials of minimally invasive single-access surgery of the adrenal gland have recently been performed.4 (,) 5 However, these new techniques have several limitations as a result of restrictions on instrumentation movement because of the small access ports used and relatively low-quality images produced. The recent introduction of the da Vinci S surgical robot system (Intuitive Surgical) to endoscopic surgery has improved instrumental dexterity and provided the surgeon with an ergonomically designed operating system. This system is also potentially safer and more meticulous in performing operations than endoscopic procedures as a result of a 3-D, magnified, stable operative view.6 (,) 7 The advantages of the da Vinci S surgical robot system and the numerous benefits of the posterior retroperitoneal approach motivated us to utilize single-port robot-assisted PRA. The primary selection criteria were small tumor size and a minimal amount of periadrenal fatty tissue because robot-assisted PRA using single-port access provides a small operative space, which causes manipulation problems when tumors are large. To ensure the safe application of these new techniques, we recommend that novice surgeons begin using single-port robot-assisted PRA for smaller tumors < 2 cm in patients with a body mass index of < 30 kg/m(2), gradually extending the size and body mass index as they accumulate experience. Although robot-assisted PRA using single-port access could not be compared with the other robotic adrenalectomy techniques in this study, the potential advantages of this approach compared to conventional robot-assisted transperitoneal adrenalectomy include a reduction in postoperative ileus, bacterial contamination, and intestinal complications because the peritoneal cavity is not opened, in addition to a reduction in postoperative pain because of its minimally invasive nature. CONCLUSIONS: Our initial experiences with robot-assisted PRA using single-port access assured us of its safety and feasibility for the resection of small adrenal tumors. Although single-port robot-assisted PRA appears to be safe and feasible, further experience and research is required to optimize patient selection criteria and verify its advantages over the traditional three-incision PRA technique.

The impact of body habitus on the surgical outcomes of transaxillary single-incision robotic thyroidectomy in papillary thyroid carcinoma patients.

BACKGROUND: Robotic applications have achieved safe and precise thyroidectomy with notable cosmetic and functional benefits. This study was designed to document the influence of body habitus on robotic thyroidectomy in papillary thyroid carcinoma (PTC) patients. METHODS: From July 2009 to February 2010, 352 patients underwent robotic thyroidectomy using a gasless, transaxillary single-incision approach at Yonsei University Health System. Body habitus was described using body mass index category (normal weight, overweight, obese), neck length, shoulder width, and shoulder width to neck length ratios. The impact of body habitus on surgical outcomes was analyzed with respect to operation time, number of retrieved central nodes, bleeding amount, and postoperative complications. RESULTS: Of the 352 patients, 217 underwent less than total thyroidectomy and 135 underwent total thyroidectomy. Operative variables (i.e. operation times, bleeding amounts, and numbers of retrieved central nodes) showed no significant differences between three BMI groups for less than total thyroidectomy. However, total operation and working space times were longer for obese patients during total thyroidectomy. In particular, shoulder width was positively correlated with total operation time, working space time, console time, and number of retrieved central nodes. On the other hand, postoperative complications were not significantly different in the three BMI groups and showed no significant correlation with the other indices of body habitus. CONCLUSIONS: Standardized robotic thyroidectomy can be performed safely and feasibly in patients with a large body habitus despite longer operation times.

Study of peripheral BRAF(V600E) mutation as a possible novel marker for papillary thyroid carcinomas.

BACKGROUND: The BRAF(V600E) mutation can be detected peripherally in the serum of patients with thyroid cancer. The purpose of this study was to establish the value of detecting the peripheral BRAF(V600E) mutation as a serum tumor marker in this population. METHODS: In this study, we obtained 94 serum samples from patients with papillary thyroid cancer positive for the BRAF(V600E) mutation in the tumor itself. The serum samples were analyzed for BRAF(V600E) mutation using real-time polymerase chain reaction (PCR). RESULTS: Sixty-seven patients (71.3%) had papillary thyroid microcarcinoma and 26 patients (27.7%) had underlying lymphocytic thyroiditis. Forty-three patients (45.7%) were found to have stage III or stage IV thyroid cancer. None of the patients had a detectable serum BRAF(V600E) mutation. CONCLUSION: We were unable to identify peripheral BRAF(V600E) mutations in patients with papillary thyroid cancer using real-time PCR. Further studies will be needed to validate our results using various diagnostic methods.

Coexistence of chronic lymphocytic thyroiditis with papillary thyroid carcinoma: clinical manifestation and prognostic outcome.

The study aimed to identify the clinical characteristics of coexisting chronic lymphocytic thyroiditis (CLT) in papillary thyroid carcinoma (PTC) and to evaluate the influence on prognosis. A total of 1,357 patients who underwent thyroid surgery for PTC were included. The clinicopathological characteristics were identified. Patients who underwent total thyroidectomy (n = 597) were studied to evaluate the influence of coexistent CLT on prognosis. Among the total 1,357 patients, 359 (26.5%) had coexistent CLT. In the CLT group, the prevalence of females was higher than in the control group without CLT (P < 0.001). Mean tumor size and mean age in the patients with CLT were smaller than without CLT (P = 0.040, P = 0.047, respectively). Extrathyroidal extension in the patients with CLT was significantly lower than without CLT (P = 0.016). Among the subset of 597 patients, disease-free survival rate in the patients with CLT was significantly higher than without CLT (P = 0.042). However, the multivariate analysis did not reveal a negative association between CLT coexistence and recurrence. Patients with CLT display a greater female preponderance, smaller size, younger and lower extrathyroidal extension. CLT is not a significant independent negative predictive factor for recurrence, although presence of CLT indicates a reduced risk of recurrence.

A comparative study of the surgical outcomes of robotic and conventional open modified radical neck dissection for papillary thyroid carcinoma with lateral neck node metastasis.

BACKGROUND: Several endoscopic modified radical neck dissections (MRND) have been conducted since the introduction of the endoscopic technique to thyroid surgery with the aim of avoiding a long cervical scar. Furthermore, the recent introduction of surgical robotic systems has increased the precision of endoscopic techniques. The aim of this study was to evaluate and compare the early surgical outcomes of robotic and conventional open MRND for papillary thyroid carcinoma (PTC) with lateral neck node metastasis (LNM). METHODS: From January 2009 to May 2010, 165 patients with PTC underwent bilateral total thyroidectomy with central compartment neck dissection and ipsilateral MRND. Of these patients, 56 formed the robotic procedure group (RG) and 109 the conventional open procedure group. These two groups were retrospectively compared with respect to their clinicopathological characteristics, early surgical outcomes, and surgical completeness. RESULTS: The operative time was longer, mean tumor size was smaller, mean age was lower, and disease stage was earlier in the RG. However, mean numbers of retrieved lymph nodes were similar in the two groups, and mean hospital stay after surgery was shorter in the RG. Furthermore, complication rates were similar in the two groups, and there was no statistical difference in postoperative Tg levels between the groups. CONCLUSIONS: Robotic MRND was found to be similar to conventional open MRND in terms of early surgical outcomes and surgical completeness but leaves no scar on the neck area. Robotic MRND can be viewed as an acceptable alternative method in low-risk PTC with LNM.

A comparative study of the transperitoneal and posterior retroperitoneal approaches for laparoscopic adrenalectomy for adrenal tumors.

BACKGROUND: Laparoscopic adrenalectomy is considered the gold standard for the surgical treatment of small adrenal tumors. However, several approach routes, such as the transperitoneal (TP), lateral retroperitoneal, and the posterior retroperitoneal (PR) approaches are being used based on surgeon's preference. The PR approach has several benefits compared with the others. Recently, the authors used the PR approach to treat several adrenal tumors and here describe the methods used in detail and the preliminary results obtained. METHODS: From January 2009 to July 2010, 58 patients underwent adrenalectomy. Open adrenalectomy and robotic adrenalectomy were performed in 5 and 10 patients. Also, 43 patients underwent laparoscopic adrenalectomy, and the TP and PR approaches were used in 26 and 17 patients, respectively. Clinicopathologic data and surgical outcomes were evaluated and compared retrospectively. RESULTS: There were no significant differences between the TP and PR groups in terms of age, sex, BMI, lesion side, volume of blood loss, or tumor size (3.86 ± 3.83 in TP approach, 2.64 ± 1.61 in PR approach). Mean operative time and average oral intake time using the PR approach were shorter than for the TP approach. Less analgesia use was required in patients who underwent PR approach. CONCLUSIONS: This study shows that posterior retroperitoneoscopic adrenalectomy is a safe procedure and the operative time is comparable to transperitoneoscopic adrenalectomy. The use of the PR approach for small adrenal tumor can provide very favorable surgical outcomes compared with the TP approach.

Prospects of robotic thyroidectomy using a gasless, transaxillary approach for the management of thyroid carcinoma.

PURPOSE: Robotic surgical systems are among the most innovative surgical developments and have radically promoted the use of minimally invasive techniques. Robotic technologies using different approaches have also been applied to thyroid surgery. Recently, the authors described a novel robotic surgical method for thyroid surgery based on a gasless, transaxillary approach (TAA), and have since serially reported on its technical feasibility and safety. Here, the authors report their experience of a consecutive series of 1000 cases treated using robotic thyroidectomy, and demonstrate its use for the surgical management of thyroid cancer. PATIENTS AND METHODS: From October 2007 to November 2009, 1000 patients with thyroid cancer underwent robot-assisted endoscopic thyroid surgery using a gasless TAA. All patients were selected using predetermined inclusion criteria after considering surgical risk, and all procedures were completed successfully using the da Vinci S or Si surgical system (Intuitive Surgical, Sunnyvale, CA). Patient's clinicopathologic characteristics, operation types, operation times, numbers of retrieved lymph nodes (LNs), postoperative hospital stays, complications, and short-term follow-up results were analyzed. RESULTS: Mean patient age was 39.1 ± 9.6 years and the male-to-female ratio was 1:12.6 (73:927). Six hundred twenty-seven patients underwent less than total and 373 patients underwent bilateral total thyroidectomy. Ipsilateral central compartment node dissection was conducted in all 1000 cases and additional lateral neck node dissection was conducted in 36 of the 1000 patients. Mean operation time was 136.7 ± 44.4 minutes and mean postoperative hospital stay was 3.0 ± 0.45 days. No serious postoperative complication occurred, except 3 cases of recurrent laryngeal nerve injury, and 1 case of Horner syndrome. Mean tumor size was 0.79 ± 0.6 cm and papillary thyroid microcarcinoma was in 752 cases (75.5%). The mean number of retrieved central LNs per patient was 4.62 ± 3.14. Central neck LN metastasis occurred in 361(36.1%) and lateral neck LN metastasis in 36 cases (3.6%). According to tumor nodes metastasis staging, 847 patients (84.7%) were of stage I, 144 patients (14.4%) were of stage III, and 9 patients (0.9%) were of stage IVA. CONCLUSIONS: The authors conclude that robotic thyroidectomy using a gasless TAA is a feasible, safe, and promising surgical alternative for selected patients with low-risk thyroid cancer, and recommend that the inclusion criteria of this technique be gradually extended to advanced thyroid cancer given suitable operator experience and future developments in robotic systems and instrumentation.

In vitro adenosine triphosphate based chemotherapy response assay in gastric cancer.

PURPOSE: The purpose of this study was to investigate the reliability and the clinical applicability of the adenosine-triphosphate-based chemotherapy response assay (ATP-CRA) as a method of determining in vitro chemosensitivity in patients with gastric cancer. MATERIALS AND METHODS: A total of 243 gastric cancer tissue samples were obtained from gastrectomies performed between February 2007 and January 2010. We evaluated the effectiveness of the ATP-CRA assay in determining the chemosensitivity of gastric cancer specimens using eleven chemotherapeutic agents - etoposide, doxorubicin, epirubicin, mytomicin, 5-fluorouracil, oxaliplatin, irinotecan, docetaxel, paclitaxel, methotraxate, and cisplatin - for chemosensitivity studies using ATP-CRA. We assessed the failure rate, the cell death rate, and the chemosensitivity index. RESULTS: The failure rate of ATP-CRA was 1.6% (4/243). The mean coefficient of variation for triplicate ATP measurements was 6.5%. Etoposide showed the highest cell death rate (35.9%) while methotrexate showed the lowest (16.6%). The most active chemotherapeutic agent was etoposide, which most frequently ranked highest in the chemosensitivity test: 31.9% (51/160). Oxaliplatin was more active against early gastric cancers than advanced gastric cancers, whereas docetaxel was more active against advanced cancers. The lymph node negative group showed a significantly higher cell death rate than the lymph node positive group when treated with doxorubicin, epirubicin, and mitomycin. CONCLUSIONS: ATP-CRA is a stable and clinically applicable in vitro chemosensitivity test with a low failure rate. The clinical usefulness of ATP-CRA should be evaluated by prospective studies comparing the regimen guided by ATP-CRA with an empirical regimen.