Sang Ah Han

The Korean Hereditary Breast Cancer (KOHBRA) Study: Protocols and Interim Report

AIMS The primary aims of the Korean Hereditary Breast Cancer (KOHBRA) study are to estimate the prevalence of BRCA1/2 mutations and ovarian cancer among a high-risk group of patients with hereditary breast cancer and their families. MATERIALS AND METHODS The KOHBRA study is a prospective multicentre cohort identifying cases and their families. Between May 2007 and May 2010, the KOHBRA study enrolled up to 2000 subjects. All participants received genetic counselling and BRCA genetic testing; the clinical information and blood samples for blood banking were collected. An interim analysis of the prevalence of BRCA1/2 mutations and ovarian cancer in Korean subjects was determined from the initial 975 patients who presented to 33 centres. RESULTS By April 2009, a total of 167 mutation carriers among 853 probands were identified. The prevalence of the BRCA mutation was as follows: 24.8% (106/428) for breast cancer patients with a family history of breast/ovarian cancers; 11.3% (24/212) for patients with early-onset (<35 years) breast cancer without a family history; 22.1% (15/68) for patients with bilateral breast cancer; male breast cancer in 8.3% (1/12); and 33.4% (1/3) for patients with breast and ovarian cancer. CONCLUSIONS The results of this study suggest that the prevalence of BRCA mutations in Korean subjects is similar to the prevalence reported among Western cohorts. However, weak family history and non-familial early-onset of breast cancer were significant factors associated with carrying the BRCA mutation in Korean breast cancer patients. Completion of the KOHBRA study is needed to confirm these findings.

Complementary and alternative medicine use and assessment of quality of life in Korean breast cancer patients: a descriptive study

PurposeThe worldwide use of complementary and alternative medicine (CAM) among cancer patients has increased, with breast cancer patients being more likely to use CAM compared with any other cancer patients. However, few surveys have systematically described CAM use among Korean breast cancer patients. This study investigated the use of CAM among patients who were diagnosed with breast cancer, along with the relevant demographic and clinical factors related to CAM use. We also compared the difference in quality of life between CAM users and nonusers.MethodsA total of 661 patients were invited to participate in this study during routine clinic visits, with 425 patients ultimately participating. Three hundred ninety-nine questionnaires were completed and used in the final analysis. Quality of life was evaluated based on the Korean versions of the EORTC QLQ-C30 and EORTC QLQ-BR23.ResultsPrevious or current CAM usage was reported by 229 patients (57.4%). Independent factors related to CAM use were marital status, cancer stage, and coexisting illness. The common types of CAM use included exercise therapy (43.2%) and ingestion of vitamins and minerals (41.9%). The reasons for CAM use were to boost the immune system (53.2%), promote health (46.8%) and prevent recurrence (37.7%). Large proportions (70.4%) of CAM users did not discuss their CAM use with their physicians. Only a small number of CAM users (2.5%) answered that they were unsatisfied with their CAM use, with most CAM users reporting that they would continue their CAM use. Quality of life was not significantly different between CAM users and nonusers.ConclusionsA significant number of patients with breast cancer have used CAM, and health care providers should be aware of the variety of CAM methods and their patients’ CAM uses for the proper management of breast cancer.

Feasibility of Sentinel Lymph Node Biopsy in Breast Cancer Patients with Initial Axillary Lymph Node Metastasis after Primary Systemic Therapy

Purpose Primary systemic therapy (PST) downstages up to 40% of initial documented axillary lymph node (ALN) metastases in breast cancer. The current surgical treatment after PST consists of breast tumor resection and axillary lymph node dissection (ALND). This strategy, however, does not eliminate unnecessary ALND in patients with complete remission of axillary metastases. The aim of this study was to examine the accuracy of sentinel lymph node biopsy (SLNB) after PST among patients with documented ALN metastasis at presentation and to identify the rate of pathologic complete-remission (CR) with ALN after PST. Methods We analyzed 66 patients with ALN metastasis that was pathologically proven preoperatively who underwent SLNB and concomitant ALND after PST. Axillary ultrasound (AUS) was used to evaluate the clinical response of initially documented ALN metastasis after PST. Intraoperative lymphatic mapping was performed using blue dye with or without radioisotope. Results After PST, 34.8% of patients had clinical CR of ALN on AUS and 28.8% patients had pathologic CR of ALN. The overall success rate of SLNB after PST was 87.9%, and the sentinel lymph node identification rate in patients with clinical CR was 95.7%. In patients with successful lymphatic mapping, 70.7% of patients had residual axillary metastases. The overall accuracy and false-negative rate were 87.9% and 17.1% in all patients: 95.5% and 10.0% in patients with clinical CR of ALN, and 83.3% and 19.4% in patients with residual axillary disease after PST. Conclusion Our findings suggest that SLNB may be feasible in patients with initial documented ALN metastasis who have clinical CR for metastatic ALN after PST. Further investigation in a prospective setting should be performed to confirm our results.

Intraoperative indocyanine green angiography for the objective measurement of blood flow

Purpose Intraoperative assessment of tissue perfusion is important to predict wound healing or improvement of symptoms in patients with peripheral arterial disease (PAD) or vascular trauma. There is no widely accepted standard for intraoperative measurement of tissue perfusion. Here, we report the use of indocyanine green (ICG)-based angiography to determine the blood flow in patients with PAD and vascular trauma. Methods The SPY fluorescent imaging system was utilized. A dose of 3–5 mL of ICG (2.5 mg/mL) was injected intravenously followed by a 10 mL normal saline flush. The SPY imaging system was used to quantitatively assess perfusion. During the study period, the SPY imaging system was applied in 4 patients with PAD and one patient with vascular trauma. Results In 3 patients with PAD associated with an ischemic wound, complete wound healing was achieved with the indication of viable tissue by the SPY system. In one patient with severe claudication in both lower extremities, the ICG angiography was used to determine the increased blood flow after revascularization. In the case of vascular trauma, this imaging system enabled the delineation of viability of the injured tissue. Conclusion ICG angiography can determine the surface tissue viability in PAD patients. In cases of severe vascular trauma,the SPY system can be used to determine tissue perfusion. Further study is warranted to define the definite utility of this technology to assess perfusion, response to revascularization, and potentially, to predict the likelihood of wound healing.

Multiple Symmetric Lipomatosis (Madelung's Disease) Presenting as Bilateral Huge Gynecomastia.

Multiple symmetric lipomatosis (MSL), or Madelungs disease, is a rare disease of unknown etiology. It is characterized by the presence of loose adipose tissue deposits localized in the cervical region and upper body. MSL presenting as bilateral huge gynecomastia is an extremely rare phenomenon. The present report describes a case of MSL in a 66-year-old man. The patients presented with bilateral breast bulging. He had a history of cigarette and alcohol use. His condition was treated with a bilateral nipple-sparing mastectomy. MSL can present as a form of gynecomastia, for its accurate diagnosis and proper treatment of MSL, increasing awareness of the clinical characteristics of the disease is required, especially amongst breast surgeons. Herein, we review the literature and discuss the clinical characteristics, pathology, and surgical treatment of MSL.

National trends for the treatment of peripheral arterial disease in Korea between 2004 and 2013

Purpose Peripheral arterial disease (PAD) has been a major public health issue in the elderly. Advances in endovascular surgery have led to a substantial shift in the management of PAD. Although the nationwide trend of PAD treatment in the Western countries was reported, limited data have been available on this in Korea. This study examined the national trend in the treatment of PAD in Korea over the past decade. Methods Health Insurance Review and Assessment Service data were used. We sought to analyze trends in the open and endovascular surgery for the treatment of PAD in Medicare beneficiaries between 2004 and 2013. We also analyzed trends in each types of surgery in the lower extremity. A linear-by-linear association was performed to determine the changes of PAD treatment for this period. Results The rate of open surgery per 100,000 Medicare beneficiaries decreased significantly from 8 procedures in 2004 to 6 in 2013. At the same time, endovascular surgery increased from 23 procedures in 2004 to 59 in 2013. Endovascular surgery in the lower extremity increased more than twofold, while the open surgery decreased by 39%. The rate of balloon angioplasty among endovascular surgery was increased by almost threefold, while the bypass surgery using artificial graft decreased by half. Conclusion Endovascular surgery is now performed more commonly than open surgery for PAD treatment. Balloon angioplasty increased by almost threefold, while the bypass surgery using artificial graft decreased by about 50%.

BRAF mutation may predict higher necessity of postoperative radioactive iodine ablation in papillary thyroid cancer

Purpose The primary aim of the present study was to analyze the association between high-risk clinicopathologic characteristics and the BRAFV600E mutation. Methods From March 2010 to September 2012, we performed analysis of the BRAF mutation (assessing V600E point mutation of BRAF gene, exon 15, on chromosome 7q34 by real-time polymerase chain reaction kit) from 499 papillary thyroid carcinoma (PTC) patients who underwent thyroidectomy. We analyzed the relation between the mutation and known clinicopathologic risk factors of PTC. Results BRAF mutations were found in 353 of 499 patients (70.7%). On univariate analysis, BRAF mutations were more frequently detected in patients with central lymph node metastasis (78.5% vs. 66.7%, P = 0.007) and classic PTC type (71.3% vs. 16.7%, P = 0.011). Patients with one or more aggressive pathologic feature such as lymph node metastasis, multifocality, and extrathyroidal extension showed higher BRAF mutation rate (73.5% vs. 62.3%, P = 0.022). BRAF mutation group showed more aggressive pathologic features, which is considered as higher necessity of radioactive iodine ablation (relative risk, 1.617; P = 0.035). Conclusion This study found that BRAF mutation is associated with classic PTC and central lymph node metastasis and higher necessity of radioactive iodine ablation.

Ultrasound fusion imaging with real-time navigation for the surveillance after endovascular aortic aneurysm repair

Ultrasound can be an effective alternative to computed tomography for surveillance following endovascular aneurysm repair (EVAR). Recently, ultrasound fusion imaging with the real-time navigation system was introduced. Here we described 3 patients who underwent post-EVAR surveillance using this novel technique. Complete coregistration was achieved in all patients. The origin of left renal artery was selected for the target of coregistration. Ultrasound fusion imaging was useful to differentiate the confusing lesion and to evaluate the complete resolution of endoleak and newly developed delayed endoleak. Ultrasound fusion image with real-time navigation system can be a feasible imaging tool for post-EVAR surveillance.

Meeting Highlights: The Second Consensus Conference for Breast Cancer Treatment in Korea

The Korean clinical practice guideline recently developed by the Korean Breast Cancer Society to address the national clinical situation is currently under revision ahead of a seventh recommendation. A second consensus conference was held to further develop this guideline by soliciting opinions regarding important issues related to surgery, radiotherapy, and medical oncology. Several issues were discussed, and the discussion progressed to pros and cons in the context of cases in various clinical situations. The panels discussed and voted on issues regarding surgical treatment for non-axillary regional lymph nodes, regional nodal irradiation of pN1 disease, and ovarian functional suppression (OFS) as an adjuvant treatment in premenopausal patients with hormone receptor-positive breast cancer. Regarding the surgical treatment of non-axillary regional lymph node, most panelists agreed with the recommendation of preoperative chemotherapy and postoperative radiotherapy for patients with biopsy-diagnosed metastases, whereas surgery or radiotherapy of non-axillary regional lymph nodes was suggested for clinical partial responders. Discussions on radiotherapy addressed the need for adjuvant radiotherapy and radiation field of regional lymph node in the context of various N1 breast cancer cases. The participants reached a consensus to recommend that N1 patients should receive regional nodal irradiation for a large tumor burden (e.g., three positive nodes, perinodal extension, or large primary tumor). Finally, the panels favored OFS in addition to endocrine therapy for premenopausal women with high risk factors such as a large tumor size, involvement of more than three nodes, and a high histologic grade.