Wan Wook Kim

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 single surgeon's experience and surgical outcomes of 300 robotic thyroid surgeries using a bilateral axillo-breast approach.

We introduce surgical outcomes regarding 300 cases of robotic thyroidectomy using a bilateral axillo‐breast approach (BABA).

Oncoplastic Surgical Techniques for Personalized Breast Conserving Surgery in Breast Cancer Patient with Small to Moderate Sized Breast

Oncoplastic surgery has revolutionized the field of breast conserving surgery (BCS). The final aims of this technique are to obtain an adequate resection margin that will reduce the rate of local recurrence while simultaneously improving cosmetic outcomes. To obtain successful results after oncoplastic surgery, it is imperative that patients be risk-stratified based on risk factors associated with positive margins, that relevant imaging studies be reviewed, and that the confirmation of negative margins be confirmed during the initial operation. Patients who had small- to moderate-sized breasts are the most likely to be dissatisfied with the cosmetic outcome of surgery, even if the defect is small; therefore, oncoplastic surgery in this population is warranted. Reconstruction of the remaining breast tissue is divided into volume displacement and volume replacement techniques. The use of the various oncoplastic surgeries is based on tumor location and excised breast volume. If the excised volume is less than 100 g, the tumor location is used to determine which technique should be used, with the most commonly used technique being volume displacement. However, if the excised volume is greater than 100 g, the volume replacement method is generally used, and in cases where more than 150 g is excised, the latissimus dorsi myocutaneous flap may be used to obtain a pleasing cosmetic result. The local recurrence rate after oncoplastic surgery was lower than that of conventional BCS, as oncoplastic surgery reduced the rate of positive resection margins by resecting a wider section of glandular tissue. If the surgeon understands the advantages and disadvantages of oncoplastic surgery, and the multidisciplinary breast team is able to successfully collaborate, then the success rate of BCS with partial breast reconstruction can be increased while also yielding a cosmetically appealing outcome.

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.

Surgical extent of central lymph node dissection in clinically node‐negative papillary thyroid cancer

The indications for elective bilateral central node dissection for patients with unilateral papillary thyroid carcinoma (PTC) who are clinically node negative are still not verified. We investigated the predictive factors of lymph node metastasis and formulated guidelines for surgical extent.

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.