Jun-Ho Choe

The prognoses of metaplastic breast cancer patients compared to those of triple-negative breast cancer patients

Metaplastic breast carcinoma (MBC) is a rare, heterogeneous breast cancer characterized by admixture of adenocarcinoma with metaplastic elements, low hormone receptor expression, and poor outcomes. The authors retrospectively reviewed the medical records of 47 MBC patients and 1,346 invasive ductal carcinoma (IDC) patients. Two hundred eighteen of the IDC patients were triple-negative (TN-IDC) for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor-2 (ER-/PR-/HER2-). Patients were surgically treated at the Samsung Medical Center between 2005 and 2009. The MBC patients presented with a larger tumor size, lower lymph node involvement, higher histological and nuclear grades, higher triple negativity (ER-/PR-/HER2-) and higher p53, CK5/6, and EGFR expressions compared with those of the IDC group. However, there were no significant differences in clinicopathological characteristics between MBC and TN-IDC. During the follow-up period (median duration of 30.3xa0months, range 2.6–56.3xa0months), seven (14.9%) MBC patients, and 98 (7.1%) IDC patients had disease recurrence. The three-year disease-free survival (DFS) rate was 78.1% in the MBC group and 91.1% in IDC group (Pxa0<xa00.001). The three-year DFS rate was not significantly different between the MBC and TN-IDC groups (78.1 vs. 84.9%, Pxa0=xa00.114). However, in patients with lymph node metastasis who underwent adjuvant chemotherapy, the three-year DFS rate was 44.4% in the MBC group and 72.5% in the TN-IDC group (Pxa0=xa00.025). The authors found that MBC had a poorer clinical outcome than did IDC. In breast cancer patients with nodal metastasis, MBC had a poorer prognosis than did TN-IDC, despite adjuvant chemotherapy.

Does pre-operative breast magnetic resonance imaging in addition to mammography and breast ultrasonography change the operative management of breast carcinoma?

Magnetic resonance imaging (MRI) has been used for the local staging of breast cancer, especially to determine the extent of multiple lesions and to identify occult malignancies. The aim of this study was to evaluate the effect of pre-operative MRI on the surgical treatment of breast cancer. Between January 2006 and May 2007, 535 newly diagnosed breast cancer patients who planned to undergo breast conserving surgery had clinical examinations, bilateral mammography, breast ultrasonography, and breast MRI. The radiologic findings and clinicopathologic data were reviewed retrospectively. Ninety-eight (18.3%) patients had additional lesions, shown as suspicious lesions on breast MRI, but not detected with conventional methods. Eighty-four (15.7%) of these patients had a change in surgical treatment plans based on the MRI results. Forty-seven (8.8%) of the 84 patients had additional malignancies; the other 37 patients (6.9%) had benign lesions. The positive predictive value for MRI-based surgery was 56.0% (47 of 84 patients). During the period of study, the use of pre-operative MRI was increased with time (OR 1.20; 95% CI 1.16–1.23; Pxa0<xa00.001), but the mastectomy rate did not change significantly (OR 0.98; 95% CI 0.95–1.00; Pxa0=xa00.059). Multiple factors were analyzed to identify the patients more likely to undergo appropriate and complete surgery based on the additional findings of the pre-operative MRI, but the results were not statistically significant. This research suggests that a pre-operative MRI can potentially lower the rate of incompletely excised malignancies by identifying additional occult cancer prior to surgery and does not lead to an increase in the mastectomy rate; however, because some benign lesions are indistinguishable from suspicious or malignant lesions, excessive surgical procedures are unnecessarily performed in a significant portion of patients. In the future, the criteria for the use of MRI in local staging of breast cancer should be established.

Right Paraesophageal Lymph Node Dissection in Papillary Thyroid Carcinoma

BackgroundThis study was designed to identify the patients with papillary thyroid carcinoma (PTC) who would benefit from RPELN dissection. Summary Background Data: The value of the right paraesophageal lymph nodes (RPELNs), which are located posterior to the right recurrent laryngeal nerve, may be underestimated. Although the RPELNs are common sites of nodal recurrence, few related studies have been reported.MethodsWe retrospectively reviewed the medical records of 369 patients (286 female, 83 male) who underwent total thyroidectomy (327 patients) or right lobectomy (42 patients) with therapeutic or prophylactic central lymph node dissection for primary PTC between August 2008 and January 2010 at the Department of Surgery, Samsung Medical Center.ResultsCentral lymph node (CLN) metastases were present in 51.2% (189 of 369) of the patients, and RPELN metastases were present in 12.2% (45 of 369) of the patients. The rate of RPELN metastasis was 19.6% (37 of 189) in patients with CLN metastases, but only 4.4% (8 of 180) in patients with no CLN metastases (Pxa0<xa0.001). A univariate analysis revealed that RPELN metastasis was significantly correlated with the size of the tumor, the perithyroidal extent (capsular invasion), CLN metastasis, and lateral lymph node metastases. There were no significant differences in terms of gender, mean age, or number of tumors between groups. A multivariate analysis revealed that tumor size (>1xa0cm) and number of CLN metastases (≥3) were significantly correlated with RPELN metastasis.ConclusionsRPELN dissection should be considered in patients with right thyroid cancer, tumors larger than 1xa0cm, or multiple CLN metastases.

The efficacy of lateral neck sentinel lymph node biopsy in papillary thyroid carcinoma.

BackgroundAlthough occult lymph node metastasis to the lateral neck compartment is common in papillary thyroid carcinoma, the incidence and patterns of lateral neck node metastasis in papillary carcinoma are not known. We hypothesized that sentinel lymph node biopsy (SLNB) with radioisotope in the detection of occult lateral neck node metastasis would be useful in characterizing metastasis in papillary carcinoma.MethodsNinety-four patients with papillary thyroid carcinoma were included from June 2009 to March 2010 for lateral neck SLNB. Preoperative lymphoscintigraphy was obtained after intratumoral injection of a 99mTc-tin colloid under ultrasound guidance. Total thyroidectomy or lobectomy preceded SLN detection to avoid radioactivity interference with the primary tumor, after which SLNB was performed in the lateral neck nodes. In the cases where metastasis was detected in SLNs upon frozen biopsy, an immediate modified radical neck node dissection was performed.ResultsA total of 174 SLNs were identified in 60 patients (63.8%). The identification rate of the SLNs with isotope increased with time. Sentinel lymph node metastasis was found in 19 patients (31.7%). This clinically occult metastasis was only related to the total number of metastatic LNs in the central compartment. Patient age, gender, tumor size, location, extent of tumor invasion, multiplicity, and presence of thyroiditis were not related to metastasis in the lateral compartment. Detection of lateral neck SLNs upon biopsy with radioisotope was also feasible in level II and contralateral neck.ConclusionsSentinel lymph node biopsy is a useful method for evaluating the occult lateral neck lymph node status in patients with papillary thyroid carcinoma, especially in the cases of central neck node metastasis.

Predictive Factors for Lymph Node Metastasis in Papillary Thyroid Microcarcinoma

BackgroundBecause lymph node (LN) metastasis has been proven to be a predictor for locoregional recurrence (LRR) in papillary thyroid microcarcinoma (PTMC), better knowledge about the predictors for LN metastasis in PTMC is required.MethodsWe retrospectively reviewed 5656 PTMC patients who underwent total thyroidectomy and central neck dissection and/or lateral neck dissection between January 1997 and June 2015.ResultsMale gender (adjusted odds ratio [OR] 2.332), conventional variant (adjusted OR 4.266), tumor size >0.5xa0cm (adjusted OR 1.753), multiplicity (adjusted OR 1.168), bilaterality (adjusted OR 1.177), and extrathyroidal extension (ETE) (adjusted OR 1.448) were independent predictors for high prevalence of central LN metastasis (CLNM), whereas per 10-year age increment (adjusted OR 0.760) and chronic lymphocytic thyroiditis (adjusted OR 0.791) were independent predictors for low prevalence of CLNM. In addition, male gender (adjusted OR 1.489), tumor size >0.5xa0cm (adjusted OR 1.295), multiplicity (adjusted OR 1.801), ETE (adjusted OR 1.659), and CLNM (adjusted OR 4.359) were independent predictors for high prevalence of lateral LN metastasis (LLNM), whereas per 10-year age increment (adjusted OR 0.838) was an independent predictor for low prevalence of LLNM. There was a statistically significant difference in LRR with regard to nodal stage (pxa0<xa00.001).ConclusionsMeticulous perioperative evaluation of LN metastasis is required for PTMC patients with the above predictors.

Propensity score-matched analysis of robotic versus endoscopic bilateral axillo-breast approach (BABA) thyroidectomy in papillary thyroid carcinoma

PurposeThe da Vinci surgical robot system was developed to overcome the weaknesses of endoscopic surgery. However, whether robotic surgery is superior to endoscopic surgery remains uncertain. Therefore, the purpose of this study was to compare the surgical and oncologic outcomes between endoscopic and robotic thyroidectomy using bilateral axillo-breast approach (BABA).MethodsBetween January 2008 and June 2015, papillary thyroid carcinoma patients who underwent thyroidectomy with central neck dissection using endoscopic (nxa0=xa0480) or robotic (nxa0=xa0705) BABA were primarily reviewed. We performed 1:1 propensity score matching and 289 matched pairs were yielded.ResultsOperation time was significantly longer in the robotic thyroidectomy than in the endoscopic thyroidectomy (184.9 vs. 128.9xa0min, Pxa0<xa00.001). A significantly higher number of central lymph nodes (CLNs) were resected in the robotic thyroidectomy than in the endoscopic thyroidectomy (5.3 vs. 4.4, Pxa0=xa00.003). However, the incidence of other outcomes including hospital stay, postoperative duration, thyroglobulin level, radioactive iodine ablation, hemorrhage, chyle leakage, wound infection, recurrent laryngeal nerve injury, and loco-regional recurrence did not significantly differ between the endoscopic thyroidectomy and the robotic thyroidectomy.ConclusionsEndoscopic thyroidectomy is comparable with robotic thyroidectomy in view of surgical complications and LRR. Because robotic thyroidectomy resected a larger number of CLNs than did endoscopic thyroidectomy, further long-term follow-up studies will be required to clarify the possible prognostic benefits of robotic thyroidectomy.

Computed Tomography-Detected Central Lymph Node Metastasis in Ultrasonography Node-Negative Papillary Thyroid Carcinoma: Is It Really Significant?

BackgroundBecause of the limitations in ultrasonography (US), the advantages of computed tomography (CT) for detecting central lymph node (LN) metastasis have been suggested in papillary thyroid carcinoma (PTC).MethodsFirst, we compared the diagnostic accuracy of US and CT for detecting central LN metastasis in 6577 central neck levels from 3668 PTC patients. Second, to examine the clinical impact of CT-detected central LN metastasis (CT cN1a) in PTC patients with clinically node negative in US (US cN0), we selected two groups: group I comprised 1245 USxa0cN0 PTC patients who did not have CT scans and did not undergo central neck dissection (CND), while group II comprised 348 US cN0 and CT cN1a PTC patients who underwent CND. After propensity score matching, 254 matched pairs were yielded.ResultsFor detecting central LN metastasis, CT showed significantly higher sensitivity (38.9 vs. 27.5xa0%; pxa0<xa00.001) and accuracy (66.1 vs. 63.2xa0%; pxa0<xa00.001) than US. Furthermore, USxa0+xa0CT showed significantly higher sensitivity (47.8 vs. 27.5xa0%; pxa0<xa00.001) and accuracy (69.0 vs. 63.2xa0%; pxa0<xa00.001) than US. After matching, radioactive iodine ablation (81.5 vs. 85.8xa0%; pxa0=xa00.235) and locoregional recurrence (pxa0=xa00.663) were not significantly different between groups I and II.ConclusionsDespite the diagnostic advantages of preoperative CT, ‘CT-based CND’ in US cN0xa0PTC patients did not significantly influence postoperative management and locoregional recurrence. The strategy for the management of central neck in PTC patients can be sufficiently determined by US only.

Ileal metastasis of breast cancer in a patient with a BRCA2 gene mutation: Report of a case

Breast cancer is the most common malignancy in females. Common sites of metastases include the liver, lung, bone, and brain, while metastases to the extrahepatic digestive system are very rare. This report presents a patient diagnosed with breast carcinoma metastasis in the terminal ileum. The patient underwent breast-conserving surgery on both breasts because of breast cancer at the age of 46 years. Both breast cancers were consistent with stage I invasive ductal carcinomas. Colonoscopy during an investigation for hematochezia revealed a 2-cm ulceration in the terminal ileum 22 months later, and microscopic examination of a biopsy specimen of the ulceration revealed a poorly differentiated mass that was strongly suggestive of metastatic adenocarcinoma with endolymphatic tumor emboli. She underwent hand-assisted laparoscopic ileocecectomy because of ileal metastasis. She had a family history of breast cancer (sister) and colon cancer (brother). She exhibited HER2/neu discordance and carried the BRCA2 gene mutation. Surgeons should remain aware that breast cancer can metastasize to the gastrointestinal tract.

Predictive Factors of Lymph Node Metastasis in Follicular Variant of Papillary Thyroid Carcinoma

BackgroundCompared with conventional papillary thyroid carcinoma (PTC), follicular variant of PTC (FV-PTC) shows less aggressive behavior and better prognosis. Nonetheless, regional lymph node (LN) metastasis was found in 22.8% of FV-PTC patients. Because LN metastasis is a proven predictor of recurrence in PTC, it is important to assess LN metastasis in FV-PTC patients.MethodsWe retrospectively reviewed 134 FV-PTC patients who underwent thyroidectomy with neck dissection.ResultsCentral LN metastasis (CLNM) and lateral LN metastasis (LLNM) were found in 50 (37.3%) and 16 (11.9%) patients, respectively. In the multivariate analysis for CLNM, male sex (adjusted OR 4.735, pxa0=xa00.001), nonencapsulated form (adjusted OR 2.863, pxa0=xa00.022), and tumor sizexa0>1.0xa0cm (adjusted OR 3.157, pxa0=xa00.008) were independent predictors of high prevalence of CLNM in FV-PTC patients. In the multivariate analysis for LLNM, microscopic extrathyroidal extension (ETE) (adjusted OR 3.939, pxa0=xa00.041) and CLNM (adjusted OR 13.340, pxa0=xa00.001) were independent predictors of high prevalence of LLNM in FV-PTC patients.ConclusionsMeticulous perioperative evaluation and prophylactic central neck dissection may be beneficial for FV-PTC patients with male sex, nonencapsulated form, and tumor sizexa0>1.0xa0cm. Moreover, cautious perioperative evaluation of lateral neck LN may be mandatory for FV-PTC patients with microscopic ETE and CLNM.

Patterns, Predictive Factors, and Prognostic Impact of Contralateral Lateral Lymph Node Metastasis in N1b Papillary Thyroid Carcinoma

BackgroundAlthough the incidence among patients with bilateral lateral lymph node metastasis (LLNM) in N1b papillary thyroid carcinoma (PTC) is reported to be as high as 40%, only a few reports have addressed the characteristics of contralateral LLNM. Therefore, this study aimed to investigate the characteristics of patients with contralateral LLNM in N1b PTC.MethodsThis study retrospectively reviewed 834 patients with N1b PTC who underwent modified radical neck dissection between January 1997 and June 2015.ResultsOf the 834 N1b PTC patients, unilateral LLNM was found in 728 patients (87.3%) and bilateral LLNM in 106 patients (12.7%). The independent predictors of contralateral LLNM in N1b PTC patients were male sex (adjusted odds ratio [OR], 1.647; pxa0=xa00.039), tumor larger than 4 cm (adjusted OR, 6.700; pxa0<xa00.001), multiplicity (adjusted OR, 1.754; pxa0=xa00.040), bilobar involvement (adjusted OR, 1.971; pxa0=xa00.010), and bilateral central LN metastasis (CLNM) (adjusted OR, 2.829; pxa0=xa00.025). Moreover, contralateral LLNM significantly increased the risk of overall (adjusted hazard ratio [HR], 1.943; pxa0=xa00.016) and lateral neck (adjusted HR, 2.246; pxa0=xa00.015) locoregional recurrence.ConclusionsIn the preoperative period, the meticulous evaluation of contralateral lateral neck may be required for male N1b PTC patients with tumor larger than 4xa0cm, multiplicity, bilobar involvement, and/or bilateral CLNM. In the postoperative period, N1b PTC patients may be re-stratified according to the contralateral LLNM, and meticulous follow-up assessment is required for N1b PTC patients with contralateral LLNM.