Seung Ook Hwang

Surgical techniques for personalized oncoplastic surgery in breast cancer patients with small- to moderate-sized breasts (part 1): volume displacement.

Despite the popularity of breast-conserving surgery (BCS), which constitutes 50-60% of all breast cancer surgeries, discussions regarding cosmetic results after BCS are not specifically conducted. The simple conservation of breast tissue is no longer adequate to qualify for BCS completion. The incorporation of oncological and plastic surgery techniques allows for the complete resection of local disease while achieving superior cosmetic outcome. Oncoplastic BCS can be performed in one of the following two ways: 1) volume displacement techniques and 2) volume replacement techniques. This study reports volume displacement surgical techniques, which allow the use of remaining breast tissue after BCS by glandular reshaping or reduction techniques for better cosmetic results. Thorough understanding of these procedures and careful consideration of the patients breast size, tumor location, excised volume, and volume of the remaining breast tissue during the surgery in choosing appropriate patient and surgical techniques will result in good cosmetic results. Surgery of the contralateral breast may be requested to improve symmetry and may take the form of a reduction mammoplasty or mastopexy. The timing of such surgery and the merits of synchronous versus delayed approaches should be discussed in full with the patients. Because Korean women have relatively small breast sizes compared to Western women, it is not very easy to apply the oncoplastic volume displacement technique to cover defects. However, we have performed various types of oncoplastic volume displacement techniques on Korean women, and based on our experience, we report a number of oncoplastic volume displacement techniques that are applicable to Korean women with small- to moderate-sized breasts.

The Comparative Study of Ultrasonography, Contrast-Enhanced MRI, and 18F-FDG PET/CT for Detecting Axillary Lymph Node Metastasis in T1 Breast Cancer

Purpose A more noninvasive evaluation of axillary lymph node in breast cancer is one of the principal challenges of breast cancer treatment. To detect axillary lymph node metastasis (ALNM) in T1 breast cancer, we have compared the axillary ultrasonography (AUS), contrast-enhanced magnetic resonance imaging (cMRI), and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) to determine the most adequate test or a combination of tests. Methods Retrospectively, 349 T1 breast cancer patients who were preoperatively examined using AUS, cMRI, and PET/CT between 2008 and 2011 and whom underwent pathological evaluations of axillary lymph nodes were reviewed and analyzed. Results In total, 26.4% (92/349) of patients exhibited ALNM. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of AUS for determining ALNM were 44.6%, 88.7%, 58.6%, 81.7%, and 77.1%, respectively. cMRI was similar to AUS. The sensitivity, specificity, PPV, NPV, and accuracy of PET/CT were 44.5%, 94.2%, 73.2%, 82.6%, and 81.1%, respectively. The combination including cMRI and PET/CT was the most accurate with sensitivity, specificity, PPV, NPV, and accuracy values of 39.1%, 98.8%, 92.3%, 81.9%, and 83.1%, respectively. The mean number (3.5±4.2) of ALNMs in the patients who were positive based on cMRI and PET/CT and also pathologically proven to exhibit ALNM was significantly larger than the number (2.16±2.26) in other patients who exhibited ALNM (p=0.035). Conclusion There are no definitive modalities for detecting ALNM in T1 breast cancers to replace sentinel lymph node biopsy (SLNB). If ALNM is suspected based on cMRI and PET/CT, the axillary dissection without SLNB might be a better option because it is related to high possibilities of ALNM and large axillary metastatic volumes.

A Prospective, Randomized Study between the Small Jaw® and the Harmonic Focus® in Open Thyroidectomy

Objectives LigaSure Small Jaw® (LSJ) was recently developed and applied to thyroid surgery along with Harmonic Focus® (HF). We compared the 2 devices in open total thyroidectomy for papillary thyroid carcinoma (PTC). Study Design A prospective, randomized study. Setting Tertiary care center. Methods This prospective, randomized study included 126 patients enrolled between December 2011 and June 2012. The numbers of patients in the LSJ group and the HF group were 64 and 62, respectively. Operative times, drain output, parathyroid status, complications, laboratory data, hospital stay, and analgesia requirements were analyzed. Results Operation time, parathyroid status, postoperative complications including hypocalcemia, oral calcium supplement, calcium, parathyroid hormone, usage count of painkiller, and hospital stay were not different among the 2 groups. Ionized calcium on postoperative days 1, 2, and 10 was higher in the LSJ group (P = .04, P = .04, P = .01), and drain output was lower in the LSJ group (106.8 vs 123.6 mL, P = .01). Conclusions Open thyroidectomy for PTC using the HF or the LSJ was safe and effective and was not associated with any increase in complications. Surgical outcomes and operative morbidity were equivalent between the 2 groups.

Clinical Value of Visually Identifiable 18F-fluorodeoxyglucose Uptake in Primary Papillary Thyroid Microcarcinoma

Objective This study evaluates the relationship between visually identifiable 18F-fluorodeoxyglucose (FDG) uptake in primary papillary thyroid microcarcinoma (PTMC) and tumor aggressiveness. Study Design Historical cohort study. Setting Tertiary care center. Methods Clinicopathological factors and PET/CT findings of 219 PTMC surgical patients who underwent preoperative 18F-FDG positron emission tomography/computed tomography (PET/CT) were retrospectively reviewed. Results 18F-FDG uptake was observed in the tumors of 124 (56.6%) patients. Tumor size (odds ratio [OR] = 1.774; 95% confidence interval [CI], 1.416-2.223; P < .0001) and Hashimoto thyroiditis (OR = 2.815; CI, 1.237-6.404; P = .014) independently predicted 18F-FDG uptake. Tumor size (OR = 1.495; CI, 1.217-1.835; P < .0001) and BRAFV600E mutation (OR = 3.320; CI, 1.056-10.432; P = .040) independently predicted extrathyroidal invasion. Multiplicity (OR = 2.375; CI, 1.278-4.415; P = .006) independently predicted central lymph node metastasis. Conclusion 18F-FDG uptake in PTMC depends on tumor size and Hashimoto thyroiditis. Therefore, preoperative PET/CT for PTMC may not help in evaluating tumor aggressiveness.

Oncologic outcomes of volume replacement technique after partial mastectomy for breast cancer: A single center analysis

BACKGROUND AND OBJECTIVES Volume replacement technique is a good option for Asian women with small to moderate-sized breasts undergoing partial mastectomy for breast cancer. We analyzed the oncologic outcomes of this procedure in a single center. METHODS Seventy-two patients with breast cancer underwent partial mastectomy with volume replacement technique in this prospective study. Volume replacement techniques were tailored individually according to the volume of excised breast and tumor location. The mean duration of follow-up was 40.9 months. We analyzed association between various clinicopathologic factors and locoregional recurrence, distant metastasis and assessed cosmetic outcomes. RESULTS The incidences of locoregional recurrence and distant metastasis were 2.8% and 5.6%, respectively. According to multivariate analysis, history of contralateral breast cancer (P < 0.001) and fat necrosis (P = 0.002) significantly associated with incidence of locoregional recurrence and pathologic tumor size (P = 0.037) and stage (P = 0.048) significantly influenced the incidence of distant metastasis. CONCLUSION From an oncologic perspective, volume replacement procedures after partial mastectomy are an appropriate form of surgical management of breast cancer.

Comparison of Laser Ablation Using Multidirectional and Forward-Firing Fiber in Human Thyroid Gland Experimental Study

The aim of this study is to evaluate the differences between forward-firing and multidirectional lasers and to evaluate the effects of exposure times and power on laser ablation of thyroid tissue. This is an experimental, ex vivo study. The experiments were conducted on 3 thyroid glands using 2 power levels (3 and 5 W) and exposure times (3 and 5 minutes) with forward-firing and multidirectional lasers. The length and width of the demarcated zone were measured to assess the size of thermal effect. NADPH staining was performed to determine tissue viability. Thermal transformation caused by the forward-firing laser produced oval necrotic zones, whereas thermal transformation caused by the multidirectional-firing laser produced clear round necrotic zones, which clearly demarcated in both hematoxylin and eosin staining and NADH staining.

Ultrasound-Guided Laser Ablation Using Multidirectional-Firing Fiber for Papillary Thyroid Carcinoma: An Ex Vivo Study with Evaluation of Tumor Cell Viability.

OBJECTIVE The objective of this study was to evaluate the viability of tumor cells after laser ablation for papillary thyroid carcinoma and to determine if the laser ablation procedure using multidirectional-firing fiber had a therapeutic effect. BACKGROUND DATA Many noninvasive techniques have been introduced for the treatment of thyroid cancer. Among them, the laser ablation technique has been proven its therapeutic effect for large benign thyroid nodules. MATERIALS AND METHODS Three patients who were diagnosed with papillary thyroid carcinoma using fine-needle aspiration cytology were enrolled. All of the selected tumors were >2 cm in size and there was no case of extrathyroidal extension. A laser fiber was inserted into the tumor by means of ultrasound guidance and ablation was performed for 3 min at 7 W of output power. The specimens were stained using hematoxylin and eosin (H&E) and nicotinamide adenine dinucleotide (NADH), and were evaluated by a pathologist. RESULTS The specimen showed three clearly distinct zones: zone 1, carbonized zone; zone 2, coagulated zone; and zone 3, normal thyroid tissue. No remaining thyroid tissue was visible in zone 1 after staining, because of complete necrosis of the tumor cells. Although thyroid tissue remained in zone 2, no viable tumor cells were detected using NADH staining. CONCLUSIONS It was found that laser ablation using multidirectional-firing fiber could be an effective treatment technique for papillary thyroid carcinoma. This technique enables not only direct cancer treatment with cell necrosis but also the securement of a tumor safety margin in a similar manner to surgery.

The role of preoperative breast magnetic resonance (MR) imaging for surgical decision in patients with triple-negative breast cancer

Several reliable randomized studies do not recommend routine preoperative breast MR imaging for patients with breast cancer. However, because the principle of MR imaging is based on the dynamics of contrast enhancement, a specific biologic subgroup of tumors should sensitively respond to the imaging process.

Ductal Carcinoma Arising from Ectopic Breast Tissue Following Microcalcification Observed on Screening Mammography: A Case Report and Review of the Literature

Ectopic breast tissue can occur anywhere along the incompletely regressed mammary ridge. Among the various types of breast choristoma, ectopic breast tissue, which has only glandular tissue without a nipple or areola, is most commonly detected in axillary areas. However, ectopic breast cancer is often not detected until significant clinical symptoms have been revealed, or diagnosis is delayed. Furthermore, an examination of ectopic breast tissue tends to be omitted from a screening mammography. Especially, the microcalcifications of ectopic breast tissue are difficult to delineate on mammography. Herein, the authors report a case of ectopic breast carcinoma that showed clustered microcalcifications on screening mammography, and discuss the interpretation and implications of microcalcification in ectopic breast tissue.

Five-Year Oncologic Outcomes of Volume Displacement Procedures After Partial Mastectomy for Breast Cancer.

Micro‐Abstract Although volume displacement procedures after partial mastectomy for breast cancer are increasingly being performed, few studies have comprehensively reported the oncologic outcomes of these procedures and the associations of those outcomes with clinicopathological variables. This study addresses that deficit in part and presents data concerning the efficacy of these procedures. Background: Volume displacement techniques that use remnant breast tissue are useful in reconstructive procedures after partial mastectomy. The authors analyzed the oncologic results of volume displacement surgery after partial mastectomy and their associations with various clinicopathologic factors. Patients and Methods: One hundred fifty‐eight eligible patients with breast cancer who underwent volume displacement procedures after partial mastectomy were included in this prospective study, in which associations between clinicopathologic factors and locoregional recurrence, distant metastasis, and death were analyzed. Results: During a mean follow‐up of 60.8 months, locoregional recurrence occurred in 3 cases (1.9%) and distant metastasis in 4 (2.5%). According to multivariate analysis, bilaterality of breast cancer (P = .035) and adjuvant chemotherapy (P = .042) were associated with distant metastasis. Conclusion: Volume displacement procedures after partial mastectomy have good oncologic results and are acceptable procedures for patients with breast cancer.