Jae-Heon Jeong

Comparative Study of Medial Opening-Wedge High Tibial Osteotomy Using 2 Different Implants

PURPOSE The purpose of this study was to perform a retrospective clinical and radiographic evaluation after opening-wedge high tibial osteotomy (HTO) using a short spacer plate (Aescula; B. Braun Korea, Seoul, South Korea) and rigid long plate (TomoFix plate; Mathys, Bettlach, Switzerland) at follow-up 2 years postoperatively. METHODS We performed 94 opening-wedge HTOs with the Aescula plate (group I) and 92 HTOs with the TomoFix plate (group II). Patients underwent clinical and radiographic evaluations preoperatively and at 2 years postoperatively. Clinical evaluations were performed with Knee Society scores. Radiographic analysis included the mechanical tibiofemoral angle (mTFA) and the slope of the tibia angle with preoperative and postoperative full weight-bearing anteroposterior whole-leg views, as well as anteroposterior, lateral, and Merchant views of the knee. We measured the mTFA. In addition, we evaluated the complications in each group. The follow-up period was 2 years. RESULTS At follow-up 2 years postoperatively, we observed an overall complication rate of 38% in group I and 26% in group II (P = .083). We found plate-related complication rates of 20% in group I and 9% in group II (P = .039). Plate-related complications included loss of correction, fracture of the tibial plateau, screw failure, malunion, and fracture of the lateral cortical bone. The mean mTFA was -6.0° ± 3.2° in group I and -4.6° ± 2.8° in group II preoperatively (P = .262). The mean mTFA was 1.0° ± 3.1° in group I and 1.5° ± 2.3° in group II at the latest follow-up (P = .034). In group I, the mean Knee Society knee score and function score were 60.0 ± 12.9 and 57.9 ± 26.8, respectively, preoperatively. They improved to 92.1 ± 8.1 and 89.0 ± 15.1, respectively, at follow-up (P = .001 and P = .001, respectively). In group II, the mean Knee Society knee score and function score were 57.5 ± 14.8 and 57.4 ± 22.1, respectively, preoperatively. They improved to 95.5 ± 5.4 and 95.0 ± 7.6, respectively, at follow-up (P = .001 and P = .001, respectively). In addition, the mean postoperative knee score and function score in group II were higher than those in group I (P = .001 and P = .001, respectively). CONCLUSIONS We have shown a high plate-related complication rate and a significant loss of correction during a short-term follow-up period (2 years) after opening-wedge HTO using the new short spacer HTO plate compared with the rigid long plate. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Transglutaminase 2 as an independent prognostic marker for survival of patients with non-adenocarcinoma subtype of non-small cell lung cancer

BackgroundExpression of transglutaminase 2 (TGase 2) is related to invasion and resistance to chemotherapeutic agents in several cancer cells. However, there has been only limited clinical validation of TGase 2 as an independent prognostic marker in cancer.MethodsThe significance of TGase 2 expression as an invasive/migratory factor was addressed by in vitro assays employing down-regulation of TGase 2. TGase 2 expression as a prognostic indicator was assessed in 429 Korean patients with early-stage non-small cell lung cancer (NSCLC) by immunohistochemical staining.ResultsTGase 2 expression increased the invasive and migratory properties of NSCLC cells in vitro, which might be related to the induction of MMP-9. In the analysis of the immunohistochemical staining, TGase 2 expression in tumors was significantly correlated with recurrence in NSCLC (p = 0.005) or in the non-adenocarcinoma subtype (p = 0.031). Additionally, a multivariate analysis also showed a significant correlation between strong TGase 2 expression and shorter disease-free survival (DFS) in NSCLC (p = 0.029 and HR = 1.554) and in the non-adenocarcinoma subtype (p = 0.030 and HR = 2.184). However, the correlation in the adenocarcinoma subtype was not significant.ConclusionsTGase 2 expression was significantly correlated with recurrence and shorter DFS in NSCLC, especially in the non-adenocarcinoma subtype including squamous cell carcinoma.

Arthroscopic, suture anchor repair through a novel medial quadriceptal portal for medial meniscal root tear

Current options for meniscal root repair include repair into trans-osseous bone tunnels, trans-osseous suture passage for surface fixation, and suture anchor fixation. Suture anchor repair techniques have been developed since it eliminates the issue of the suture abrasion, tunnel drilling, and distal fixation inherent to trans-osseous tunnel. We present a description of a new variation in the more vertical suture anchor repair technique for meniscal root tear using a novel medial quadriceptal portal. Level of evidence Therapeutic, Level V.

Predictive factors of pathologic complete response and clinical tumor progression after preoperative chemotherapy in patients with stage II and III breast cancer

SummaryBackground This study aimed to define predictive factors of pathologic complete response (pCR) and disease progression in stage II and III breast cancer patients. Patients and Methods Three hundred thirty-eight patients were included in the study. Patients had received preoperative chemotherapy as follows: 101 had doxorubicin plus cyclophosphamide (AC); 91 had doxorubicin plus docetaxel; 103 had docetaxel plus capecitabine; and 43 had paclitaxel plus gemcitabine. A pCR was defined as the absence of residual invasive carcinoma in the breast. Results The majority of patients (73%) were premenopausal with a median age of 44 (range, 21–76) years. Fifty-four patients (16%) achieved pCR and were distributed among the 4 breast cancer subtypes as follows: 10% of patients with –ER or PR+/HER2−, 13% with ER or PR+/HER2+, 33% with ER-/PR-/HER2+, and 19% with ER-/PR-/HER2−(p = 0.001). Taxane-containing regimen (p = 0.042) and Breast cancer subtype (p = 0.005) were significant predictive variables for pCR. On the other hand, significantly more patients who received non-taxane-containing regimen (AC) experienced no response (p = 0.001) or progression (p = 0.006). Conclusions Patients with ER-/PR-/HER2+ tumors and those who received taxane-containing regimen achieved a higher pCR rate, while significantly more patients developed tumor progression by preoperative non-taxane-containing regimen (AC) compared to those who received taxane-containing chemotherapy.

Second-line chemotherapy for advanced gastric cancer in Korea

Stomach cancer is still one of the most prevalent malignancies and is the main cause of cancer deaths worldwide. The outcome for patients with metastasis, as well as for those with tumor recurrence, is dismal, with median survival time not greater than a year. Patients with unresectable locally advanced or metastatic lesions have been treated with systemic chemotherapy, and several randomized studies have demonstrated the benefit of chemotherapy compared with best supportive care. Recently, randomized phase III trials have presented a benefit of second-line chemotherapy compared with supportive care alone. However, it is not known at present which drug is the most effective in this setting. In Korea, the practice of offering second-line treatment to patients with advanced gastric cancer (AGC) is common, and many prospective clinical trials investigating clinical outcomes of second-line chemotherapy have been reported. Therefore, to define the potential role of second-line chemotherapy and to help to select an effective regimen, we review the published Korean prospective data concerning the use of chemotherapy in the second-line setting for the treatment of AGC. No phase III trials but 20 phase II trials were identified. The benefit of second-line chemotherapy in AGC has indirect evidence considering prolongation of progression-free survival (PFS) and improvement of the response rate. Taxanes, irinotecan, and oxaliplatin have been studied much and might be promising drugs considering cross-resistance to a 5-fluorouracil and cisplatin combination (FP). A large, prospective, multicenter, randomized phase III study is warranted to select the most effective second-line chemotherapeutic agents.

Plasma Cell Myeloma Initially Presenting as Lung Cancer

Plasma cell myeloma (PCM) is a malignant hematologic disease characterized by the proliferation of neoplastic plasma cells, producing excessive amounts of monoclonal immunoglobulin (Ig) or light chain (LC) [1, 2]. Although plasma cells are widely distributed throughout the body, PCM is found most often within the bone and bone marrow (BM), while the dissemination of extramedullary plasmacytoma into the lung has been reported to be very rare [3]. Moreover, pleural effusion caused by myelomatous involvement such as myelomatous pleural effusion (MPE) occurs in less than 1% of PCM cases [4-6]. We report a case of PCM with a rare presentation of MPE and plasmacytoma mimicking lung cancer. This case is characterized by the presence of monoclonal Ig using electrophoresis and free light chain (FLC) assay in addition to cytologic examination of the pleural fluid [7]. A 59-yr-old Korean woman complaining of anorexia and weight loss for 6 weeks was referred to our hospital in order to evaluate an incidental finding of a lung mass during a routine check-up from a local clinic. The patient had no history of smoking and exposure to environmental asbestos. Results of routine blood tests were as follows: Hb, 8.9 g/dL; platelet count, 199×109/L; and white blood cell (WBC), 3.8×109/L (segmented neutrophil, 79%; lymphocyte, 18%; monocyte, 2%; and eosinophil, 1%); and approximately 1 nucleated red blood cell (RBC) per 100 WBCs. Results of biochemical tests were as follows: protein, 6.4 g/dL (reference range, 5.8-8.0 g/dL); albumin, 4.4 g/dL (reference range, 3.1-5.2 g/dL); creatinine, 0.4 mg/dL (reference range, 0.6-1.2 g/dL); and lactate dehydrogenase, 602 U/L (reference range, 218-472 U/L). The chest computed tomography (CT) examination presented a lung mass with a lobulated contour in the left lower lobe, a bony destructive soft tissue mass in the left ribs, and multifocal pre/paravertebral mass lesions, especially at the T9-L1 level, with pleural effusions (Fig. 1). Radiologic findings suggested lung cancer with pleural metastasis, or alternatively, a PCM. Positron emission tomography (PET)/CT and bone scintigraphy showed multiple hypermetabolic lesions in the lung adjacent to the left ribs, which suggested lung cancer with multiple bone metastases and a recommendation to rule out all metastases of unknown origin. Cytologic examination of the pleural fluid revealed a large number of plasma cells. In the FLC assay, serum lambda FLC increased to 183 mg/L (reference range, 5.71-26.3 mg/L), and the kappa/lambda FLC ratio (rFLC) was markedly reversed to 0.048 (reference range, 0.26-1.65). Capillary electrophoresis with serum and urine samples showed a discrete peak with a definite immunosubtraction in lambda LC, suggesting monoclonal gammopathy. In the pleural fluid, gel electrophoresis revealed a monoclonal band in lambda antisera and lambda FLC was measured at 14,000.0 mg/L. BM examination revealed 18.6% plasma cells with eccentric nuclei and basophilic cytoplasm, and biopsy sections showed a packed marrow (Fig. 2). Surgery was performed for excision of the pleural mass on the day after BM examination (Fig. 3). Immunohistochemical stains on sections from biopsy specimens from the left pleural mass were compatible with plasmacytoma as follows: cytokeratin (CK) (-),CD5 (-), CD45 (+), CD138 (+), kappa (-), and lambda (+).Based on these results, the patient was diagnosed as having PCM with extramedullary dissemination into the lung. The patient was referred to the hematology department for chemotherapy, and peripheral blood stem cells were collected for an autologous stem cell transplant thereafter. Fig. 1 Imaging studies. Computed tomography (CT) and positron emission tomography (PET)/CT findings showing the branching out lung mass (A), pleural nodules (B), and paraspinal lesions (C), which were initially interpreted to be suggestive of lung cancer with ... Fig. 2 Bone marrow findings. Plasma cells with eccentric nuclei and basophilic cytoplasm were predominantly observed in aspiration smears (A, Wright stain, ×1,000) and clot sections (B, H&E stain, ×1,000). The biopsy sections revealed ... Fig. 3 Examinations of the pleural fluid and biopsy. In the cytospin of pleural fluid, plasma cells characterized by basophilic cytoplasm, eccentric nucleus and perinuclear halo were predominantly observed (A, Wright stain, ×1,000). In the pleural biopsy, ... Classically, PCM occurs mainly in BM-rich bone [8]. Therefore, primary clinical presentation includes bone pain, pathological fractures, and anemia [5, 9]. Extramedullary plasmacytomas have been reported in 15-20% of patients at diagnosis and in an additional 15% during the course of PCM, and these patients are often associated with high-risk diseases like MPE [4]. Although hematopoietic neoplasms may frequently colonize the pleural tissue, such as malignant lymphoma, especially in the end stage of the disease, extramedullary existence of plasmacytoma is not common and the incidence of thoracic cases is low, especially in patients presenting with pulmonary plasmacytoma and MPE to simulate a pleural mesothelioma or lung cancer [8, 10-12]. This study is limited in that IgD and IgE were not measured in further tests, because this was a retrospective case review. We report here a unique presentation of PCM overlapping massive pleural effusion to include monoclonal components and pleural plasmacytoma as initially mistaken for lung cancer. When MPE and pleural involvement are concomitantly observed, as in this case, a precise diagnosis of PCM is difficult when only clinical and imaging studies are conducted. In order to discriminate extramedullary PCM from other malignancies, biochemical assays such as electrophoresis or FLC assay in body fluid are very helpful to confirm the presence of monoclonal components when performed along with cytologic examinations of the pleural fluid.

Early Detection of BCR-ABL Fusion Gene of Cerebrospinal Fluid (CSF) by RT-PCR in Relapsed Acute Lymphoblastic Leukemia with Philadelphia Chromosome

As polymerase chain reaction (PCR) is increasingly applied in clinical medicine, early detection and more accurate diagnosis is possible. Using molecular methods with cerebrospinal fluid (CSF) samples in addition to existing cytological methods is of value even if only occult malignant cells are present. We describe a case of central nervous system (CNS) leukemia in a patient with Philadelphia chromosome–positive acute lymphoblastic leukemia confirmed by reverse transcription PCR (RT-PCR) in a CSF specimen from a patient who was treated with chemotherapy (Hyper CVAD protocol, including cyclophosphamide, vincristine, adriamycin, prednisolone, and intrathecal methotrexate). Study of her CSF identified atypical lymphocytes. To ensure that the diagnosis was correct, we conducted a CSF exam using RT-PCR and confirmed CNS relapse by identifying the BCR-ABL gene. After remission, a CNS relapse occurred in the form of optic nerve involvement. Despite treatment, the patient died of leukemia progression and multiple organ failure with sepsis. We discuss the diagnostic role of RT-PCR with CSF samples for early and accurate detection of CNS relapse and review the relevant literature on this subject.

All-Trans Retinoic Acid–Induced Myositis and Retinoic Acid Syndrome in Microgranular-Variant Acute Promyelocytic Leukemia

Acute promyelocytic leukemia (APL) is a subtype of acute myelogenous leukemia (AML). All-trans retinoic acid (ATRA) is an effective drug in the treatment of APL by promoting the terminal differentiation of leukemic cells into phenotypically mature myeloid cells. The microgranular-variant APL counts for a quarter of APL and is similar to monocytic origin leukemia. The microgranular-variant type has no effect on APL treatment. ATRA is related with some serious side effects such as Sweet’s syndrome and retinoic acid syndrome (RAS). Histologic characteristics of RAS are seen in capillary leakage and infiltration of organs by mature myeloid cells. ATRA-induced myositis is rarely described in adults and rare in children with APL. There have been increasing reports of ATRA-induced myositis, with its frequent association with RAS and Sweet’s syndrome. We report a patient with ATRA-induced myositis and RAS in microgranular variant APL and review the previously reported cases in the literature of ATRA-induced myositis. * APL : acute promyelocytic leukemia; ATRA : all-trans retinoic acid; RAS : retinoic acid syndrome; FISH : fluorescence in situ hybridization; MRI : magnetic resonance imaging; CK : creatine kinase; ICU : intensive care unit; CT : computed tomography; WBC : white blood cell