Hyoung-Jin Moon

Surgical anatomy of the anterior ethmoidal canal in ethmoid roof

Objectives/Hypothesis This study was undertaken to examine three main relationships. First, the distance and angle from the anterior ethmoidal canal to the limen nasi and the sill were measured. Second, the location of the anterior ethmoidal canal was examined in relation to the lamellas and the skull base. Third, the existence of bony defects in the canal and the course of the canal through the anterior cranial fossa were studied.

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

Augmentation rhinoplasty of the Asian nose may be effectively accomplished with alloplastic materials. However, certain circumstances mandate the use of autologous grafts (e.g., dorsal augmentation that exceeds 8 mm and patient intolerance of alloplastic implants). Septal and auricular cartilages are inadequate for dorsal augmentation of the Asian nose. The use of costal cartilage for autologous augmentation in select Asian patients has proven to be a reliable method in more than 500 operative cases during a 10-year period. This study was designed to evaluate the ideal costal cartilage graft for augmentation rhinoplasty. Forty-two preserved cadavers were studied for the relationship of the individual rib cartilages to the surrounding tissue and for the length and caliber of each costal cartilage. The seventh rib was found to be the ideal rib graft by virtue of its safe location and overall size for grafting. The seventh rib is situated over the abdominal cavity, so the risk of pneumothorax is insignificant. The internal thoracic artery and vein descend in close apposition behind the first to sixth ribs but begin a course medial to the ribs inferior to this point, and therefore vascular injury during seventh-rib harvesting is unknown. The seventh rib also provides the greatest overall available length (90.7 mm, right; 89.6 mm, left) and thickness (17.6 mm, right; 17.5 mm, left). Despite the more conspicuous location of the incision required to harvest the seventh rib, the limited 3-cm incision that is used has healed favorably in almost all cases. The other major drawback for seventh-rib harvesting is the dissection required through the overlying rectus abdominis muscle, but little technical difficulty or postoperative morbidity is added with muscle dissection. The seventh rib is advocated as the ideal choice for augmentation rhinoplasty and potentially other recipient sites.

Comparison of the underestimation rate in cases with ductal carcinoma in situ at ultrasound-guided core biopsy: 14-gauge automated core-needle biopsy vs 8- or 11-gauge vacuum-assisted biopsy

OBJECTIVE The objective of this study was to compare the underestimation rate of invasive carcinoma in cases with ductal carcinoma in situ (DCIS) at percutaneous ultrasound-guided core biopsies of breast lesions between 14-gauge automated core-needle biopsy (ACNB) and 8- or 11-gauge vacuum-assisted biopsy (VAB), and to determine the relationship between the lesion type (mass or microcalcification on radiological findings) and the DCIS underestimation rate. METHODS We retrospectively reviewed imaging-guided biopsies of breast lesions performed from February 2003 to August 2008. 194 lesions were diagnosed as DCIS at ultrasound-guided core biopsy: 138 lesions in 132 patients by 14-gauge ACNB, and 56 lesions in 56 patients by 8- or 11-gauge VAB. The histological results of the core biopsy samples were correlated with surgical specimens. The clinical and radiological findings were also reviewed. The histological DCIS underestimation rates were compared between the two groups and were analysed for differences according to the clinical and radiological characteristics of the lesions. RESULTS The DCIS underestimation rate was 47.8% (66/138) for 14-gauge ACNB and 16.1% (9/56) for VAB (p<0.001). According to the lesion type on sonography, DCIS underestimation was 43.4% (63/145) in masses (47.6% using ACNB and 15.8% using VAB; p=0.012) and 24.5% (12/49) in microcalcifications (50.0% using ACNB and 16.2% using VAB; p=0.047). CONCLUSION The underestimation rate of invasive carcinoma in cases with DCIS at ultrasound-guided core biopsies was significantly higher for ACNB than for VAB. Furthermore, this difference does not change according to the lesion type on ultrasound. Therefore, ultrasound-guided VAB can be a useful method for the diagnosis of DCIS lesions presented as either mass or microcalcification.

Discordant elastography images of breast lesions: how various factors lead to discordant findings.

PURPOSE To evaluate the rate of the elastography-pathology discordance, and evaluate which various factors have an effect on discordant elastography images (DEI) of breast lesions. MATERIALS AND METHODS Elastography images of 284 pathologically confirmed breast lesions of 233 patients were evaluated. Elasticity scores were compared to pathology results, and lesions were divided into 4 groups: benign concordant/discordant, and malignant concordant/discordant. The rate of DEI among benign and malignant lesions was calculated and compared. Patient, lesion factors and image adequacy were compared among the concordant and discordant groups for analysis. RESULTS Among the 284 breast lesions, 225 (79.2%) were benign, and 59 (20.8%) were malignant. The rate of DEI among malignant lesions was significantly higher than in benign lesions, i. e., 52.5 vs. 3.1% (p < 0.001). Discordant images were more significantly seen in patients with extremely dense breasts on mammography in benign lesions, 42.9 vs. 11.9% (p = 0.034). Discordant images were more significantly seen in malignant lesions < 10 mm or ≥ 20 mm (p = 0.006), and those with inadequate images (64.5 vs. 35.5%, p < 0.001). CONCLUSION The rate of DEI was higher in malignant lesions than in benign lesions. Dense breast parenchyma, lesion size and image adequacy showed significance in discordant images of elastography which need consideration in image acquisition and interpretation.

Adding MRI to ultrasound and ultrasound-guided fine-needle aspiration reduces the false-negative rate of axillary lymph node metastasis diagnosis in breast cancer patients

AIM To evaluate whether adding magnetic resonance imaging (MRI) to ultrasound (US) and US-guided fine-needle aspiration (US-FNA) can reduce the false-negative rate (FNR) in the diagnosis of axillary lymph node metastasis (ALNM) in breast cancer patients, and to assess false-negative diagnosis of N2 and N3 disease when adding MRI to US and US-FNA. MATERIALS AND METHODS From March 2012 to February 2013, 497 breast cancer patients were included in the study. ALNM was evaluated according to US and US-FNA prior to MRI. Second-look US was performed when MRI showed positive findings of ALNM. If second-look US also revealed a positive finding, US-FNA was performed. Diagnostic performance, including FNR, was calculated for US and US-FNA with and without MRI. The negative predictive value (NPV) of N2 and N3 disease was evaluated in negative cases based on US and US-FNA with MRI. RESULTS A total of 159 of 497 (32.0%) patients were found to have ALNM. Among them, 92 patients were diagnosed with metastasis on US and US-FNA. When adding MRI to US and US-FNA, an additional six patients were diagnosed with metastasis. The FNR of diagnosis of ALNM was improved by the addition of MRI (42.1% versus 38.4%, p = 0.0143). The NPV for N2 and N3 disease was 98% (391/399) based on US and US-FNA with MRI. CONCLUSION Adding MRI to US and US-FNA could reduce the FNR of the diagnosis of ALNM. Furthermore, US and US-FNA with MRI may exclude 98% of N2 and N3 disease.

Endoscopic Frontal Sinusotomy Using the Suprainfundibular Plate as a Key Landmark

INTRODUCTION Since the introduction of an endoscopic intervention in the management of frontal sinusitis, endoscopy has become the first choice of treatment for patients who have a frontal sinus disease. Reports of endoscopic intervention for frontal sinus surgery have been on the rise, and a wide range of technically advanced operative instruments have become available. As a result, endoscopic frontal sinus surgery has evolved considerably. However, because the anatomical structure of the frontal sinus is extremely intricate and there are many critical structures such as the lamina papyracea and the cribriform plate in the area, endoscopic frontal sinus surgery remains technically difficult. Various endoscopic techniques of frontal sinus surgery have been suggested. In 1995, a study of the anatomical terminology and nomenclature of paranasal sinus structures was reported. Despite this information, during the approach to the frontal sinus the bony septa between the lamina papyracea and the middle turbinate have not yet been determined. Furthermore, a consensus on the surgical landmarks and terminology that should be adopted has not been reached and the operative techniques remain difficult to understand. As an example of indefinite terminology, “frontal recess” is a term currently being used for the structure that is seen after removal of the natural tract of the frontal sinus outflow. When the frontal sinus drains anterosuperiorly to the ethmoid infundibulum, which is the most common type of frontal sinus drainage, the superior end of the infundibulum has a dome-shaped appearance, which is called the terminal recess. The upper portion of the uncinate process and the anterior wall of bulla ethmoidalis always meet to form the superior end of the ethmoid infundibulum, and both are attached superiorly to the skull base as a plate. They are some portions of the ethmoid bone, and there is no definite landmark to distinguish one from the other. Therefore, we needed a new term, “suprainfundibular plate (SIP),” which indicates both the superior portion of the uncinate process and the superior portion of the bulla ethmoidalis. To perform endoscopic frontal sinusotomy, a complete knowledge of the structures that must be removed before the frontal ostium is in the endoscopic field of vision view is essential. To this end, we suggest a simplified surgical approach, which uses the SIP as a key landmark in identifying the frontal ostium.

Whole-breast US following mammography and breast MRI in newly diagnosed breast cancer patients: can it be more than just a guidance tool for biopsy?

AIM To evaluate the role of ultrasound (US) following magnetic resonance imaging (MRI) and mammography in patients with newly diagnosed breast cancers by assessing the additional cancer detection rate of US. MATERIAL AND METHODS Two hundred and twenty-five women who had undergone 225 MRI examinations followed by US were included. An US-detected additional cancer was defined as a lesion detected using breast US that had not been detected by MRI, and which was shown to be malignant at histopathology. The rate of additional cancer detection, incidence of additional malignancies, positive predictive value (PPV), and false-positive (FP) rate were analysed. Factors associated with an increase in the additional cancer detection rate were analysed. RESULTS The additional cancer detection rate was 0% (0/225) for the ipsilateral breast and 0.9% (2/225) for the contralateral breast, and the PPVs were 0% (0/5) and 100% (2/2), respectively. The overall TP:FP ratio was 0.4 (2:5). The additional cancer detection rate was higher for cases with moderate and severe background parenchymal enhancement than cases with minimal and mild background parenchymal enhancement (p=0.003). The additional cancer detection rate for cases with moderate and severe background parenchymal enhancement was 5.7% (2/35) for the contralateral breast (p=0.003). CONCLUSION Preoperative breast US following MRI and mammography can help clinicians screen for contralateral cancers with an additional detection rate of 0.9%. Moreover, whole-breast US might be a useful contralateral screening modality in cases with moderate or marked parenchymal enhancement on breast MRI.

Additional malignant breast lesions detected on second-look US after breast MRI vs. additional malignant lesions detected on initial US in breast cancer patients: comparison of US characteristics.

PURPOSE The purpose of our study was to review and compare the US findings of synchronous malignant breast lesions other than the index cancer additionally detected on second-look US with those detected on initial US, and therefore to determine differing characteristics that may aid in diagnosis and essentially improve the performance of the initial US examination. MATERIALS AND METHODS A retrospective review of 39 mammographically occult synchronous malignant lesions other than the index cancer from 38 patients was performed (21 lesions: detected on second-look US, 18 lesions: detected on initial US). All patients underwent initial mammography, bilateral whole breast US (BWBU) and breast MRI, and all lesions were confirmed pathologically by biopsy or preoperative localization. RESULTS Additional malignant breast lesions detected on both initial US and second-look US tended to be subtle and often did not show classic malignant findings. Second-look US lesions (median, 7.0 mm; range, 3 - 22 mm) tended to be smaller than initial US lesions (median, 9.0 mm; range 3 - 45 mm), although the difference was not statistically significant (p = 0.134). Second-look US lesions also showed no posterior acoustic features (p = 0.037) and a significantly higher proportion of lesions with circumscribed or indistinct margins compared to initial US lesions (p = 0.042). Second-look US lesions were significantly subareolar or relatively far (> 5 cm) from the nipple than initial US lesions (p = 0.048). CONCLUSION Second-look US lesions showed more subtle findings of posterior acoustic features and margins, and tended to be subareolar or relatively far from the nipple compared to initial US lesions. However, both groups showed subtle US findings and there was no significant difference in other features.