Young Jin Suh

Diffusion-weighted imaging of breast cancer: correlation of the apparent diffusion coefficient value with prognostic factors.

To evaluate the role of diffusion‐weighted imaging (DWI) in the detection of breast cancers, and to correlate the apparent diffusion coefficient (ADC) value with prognostic factors.

Multidimensional analysis of the learning curve for laparoscopic rectal cancer surgery.

BACKGROUND The need for an initial learning experience in laparoscopic colorectal cancer surgery has been well established. However, the inherent differences in the complexity and results of laparoscopic rectal cancer surgery, as compared to colon surgery, warrant a study to analyze the learning curve exclusively for rectal cancer resections. MATERIALS AND METHODS four hundred thirty-one patients operated on between April 1994 and March 2006 were analyzed retrospectively for changes in surgical outcomes according to case sequence. A multidimensional analysis was done, based on the following parameters: conversion to laparotomy, intraoperative complications, postoperative complications, reoperations, operative time, and transfusion volumes. Multiple statistical methods were used for evaluation of the learning curve, which included the cumulative sum (CUSUM) method, risk-adjusted CUSUM, moving average method, and analysis of variance (ANOVA). RESULTS The risk factors for conversion were prior abdominal surgery (hazard ratio, 2.52; 95% CI, 1.04-6.10; P = 0.04) and tumor size > or =3.5 cm (hazard ratio, 5.05; 95% CI, 1.95-13.08; P = 0.001). Risk-adjusted CUSUM analysis showed that case 61 was the peak change point for conversion. Postoperative complications occurred in 56 patients (13.0%), and the rate was associated significantly with case sequence (P < 0.001). The turning point in the CUSUM model occurred at case 79, and the complication rates decreased thereafter. Operative time and intraoperative transfusion volumes stabilized over cases 61-75 and declined thereafter. CONCLUSIONS Multidimensional analysis considering various surgical outcomes is necessary to evaluate the learning curve for laparoscopic rectal cancer surgery. The effective surgical learning curve was approximately 60-80 procedures in this series.

Hedgehog related protein expression in breast cancer: gli-2 is associated with poor overall survival.

Background The hedgehog (Hh) signaling pathway is known to play a critical role in various malignancies, but its clinicopathologic role in breast cancer is yet to be established. Methods Tissue microarray blocks from 334 cases of breast cancer were prepared. The expression of six Hh signaling proteins including sonic hedgehog (Shh), patched (Ptch), smoothened (Smo), and the glioma-associated oncogene (Gli)-1, Gli-2, and Gli-3 were analyzed immunohistochemically. Results The expression of Hh signaling proteins was significantly correlated with some prognostic factors including the correlation of lymph node metastasis with the expression of Shh (p=0.001) and Ptch (p=0.064), the correlation of the stages with Shh and Gli-3 expression (p=0.007 and p=0.024, respectively), the correlation of the nuclear grade with the Smo (p=0.004) and Gli-3 (p=0.000), and the correlation of the histologic grade with the Ptch (p=0.016), Smo (p=0.007), and Gli-3 (p=0.000). The Shh, Ptch, Smo, Gli-1, and Gli-2 expression was significantly different between the phenotypes (p=0.000, p=0.001, p=0.004, p=0.039, and p=0.031, respectively). Gli-2 expression was correlated with a worse overall survival outcome (p=0.012). Conclusions Hh pathway activation is correlated with a more aggressive clinical behavior in breast carcinomas. The comparison of phenotypes suggested that the Hh pathway may be a useful therapeutic target for breast carcinoma. Patients with Gli-2 expression had a significantly lower overall survival rate and, therefore, it showed promise as a prognostic marker.

Clinical Implication of p53 Overexpression in Breast Cancer Patients Younger than 50 Years with a Triple-negative Subtype Who Undergo a Modified Radical Mastectomy

OBJECTIVE The purpose of this study was to identify the clinicopathological characteristics and prognostic value of p53 overexpression in breast cancer patients treated with a modified radical mastectomy. METHODS The medical records of 197 patients who had undergone modified radical mastectomy between January 1991 and December 2008 were reviewed retrospectively. Breast cancer subtype and p53 overexpression were investigated using immunohistochemistry and/or fluorescent in situ hybridization analysis of surgical specimens. RESULTS The median follow-up after the modified radical mastectomy was 56.1 months (range, 14.7-232.7). The median age was 47 years (range, 31-72). p53 overexpression was noted in 73 patients (37.1%). Breast cancer-specific death rate (P = 0.011), cancer progression (P = 0.024), distant metastasis (P = 0.015), hormone receptor negativity (P < 0.001) and human epidermal growth factor receptor 2 positivity (P = 0.017) were detected more frequently in patients with p53 overexpression. The overall survival rates were significantly lower in the p53-overexpression group than in the non-p53-overexpression group (P = 0.021, log-rank test). In the multivariate analysis, p53 overexpression showed the strongest prognostic significance in patients aged <50 years (P = 0.039) and with the triple-negative subtype (P = 0.023). CONCLUSIONS p53 overexpression correlated with breast cancer-specific death rates and adverse prognostic factors in patients treated with modified radical mastectomy. p53 overexpression might be a more reliable prognosticator in patients aged <50 years and with the triple-negative subtype. More effective systemic treatments might be warranted for these patients exhibiting p53 overexpression. Further validation is required to make more definite conclusions.

Learning Curves in Laparoscopic Right-Sided Colon Cancer Surgery: A Comparison of First-Generation Colorectal Surgeon to Advance Laparoscopically Trained Surgeon

BACKGROUND We aimed to evaluate the learning curve (LC) for laparoscopic right-sided colon cancer surgery (LRCCS) by comparing the results between two surgeons (first-generation colorectal surgeon versus laparoscopically trained surgeon). METHODS The study was a retrospective analysis that evaluated 117 consecutive LRCCSs performed by two surgeons, the first-generation surgeon (Surgeon A) and laparoscopically trained surgeon (Surgeon B), from April 1995 to August 2006. Patients were divided into two groups; patients included in groups I and II received LRCCSs from surgeons A and B, respectively. RESULTS The moving average method revealed that the operation times of surgeons A and B began to shorten after the 9th case. The cumulative sum (CUSUM) analysis of group I data showed that the 24th case was the peak point of conversion. The 35th case was the peak for intraoperative complications, and the 17th case was the peak for postoperative complications. There was only one case of conversion in group II. The peak points for inadequate lymph node dissection were the 37th case in group I and the 8th case in group II. The CUSUM analysis for surgeons A and B showed that the 18th case and the 8th case, respectively, were the overall peak points in the failure of LRCCS. CONCLUSIONS We suggest that careful observation of a laparoscopic procedure, such as acting as the scope operator for a certain amount of time, may help in shortening the LC of the actual procedure.

Late Onset Iatrogenic Diaphragmatic Hernia after Laparoscopy-Assisted Total Gastrectomy for Gastric Cancer

Through the advent of surgical techniques and the improvement of laparoscopic tools including the ultrasonic activated scissor, laparoscopic gastrectomy has been increasingly used in far more cases of benign or malignant gastric lesions for the benefit of patients without compromising therapeutic outcomes. Even though possible complications provoked by the ultrasonic activated scissor can be prevented during the procedure with increasing advanced laparoscopic experience and supervision, unexpected late complications after the operations rarely occur. An extremely rare case of left incarcerated diaphragmatic hernia of the transverse colon developed in an 81-year-old female patient as a late complication, 8 months after laparoscopy-assisted total gastrectomy for gastric cancer, with laparoscopy successfully resumed and without the need to sacrifice any portion of the bowel.

Clinical Features of Male Breast Cancer: Experiences from Seven Institutions Over 20 Years.

Purpose Breast cancer treatment has progressed significantly over the past 20 years. However, knowledge regarding male breast cancer (MBC) is sparse because of its rarity. This study is an investigation of the clinicopathologic features, treatments, and clinical outcomes of MBC. Materials and Methods Clinical records of 59 MBC patients diagnosed during 1995-2014 from seven institutions in Korea were reviewed retrospectively. Results Over a 20-year period, MBC patients accounted for 0.98% among total breast cancer patients, and increased every 5 years. The median age of MBC patientswas 66 years (range, 24 to 87 years). Forty-three patients (73%) complained of a palpable breast mass initially. The median symptom duration was 5 months (range, 1 to 36 months). Mastectomy was performed in 96% of the patients. The most frequent histology was infiltrating ductal carcinoma (75%). Ninety-one percent of tumors (38/43) were estrogen receptor–positive, and 28% (11/40) showed epidermal growth factor receptor 2 (HER-2) overexpression. After curative surgery, 42% of patients (19/45) received adjuvant chemotherapy; 77% (27/35) received hormone therapy. Five out of ten patients with HER-2 overexpressing tumors did not receive adjuvant anti–HER-2 therapy, while two out of four patients with HER-2 overexpressing tumors received palliative trastuzumab for recurrent and metastatic disease. Letrozole was used for one patient in the palliative setting. The median overall survival durations were 7.2 years (range, 0.6 to 17.0 years) in patients with localized disease and 2.9 years (range, 0.6 to 4.3 years) in those with recurrent or metastatic disease. Conclusion Anti–HER-2 and hormonal therapy, except tamoxifen, have been underutilized in Korean MBC patients compared to female breast cancer patients. With the development of precision medicine, active treatment with targeted agents should be applied. Further investigation of the unique pathobiology of MBC is clinically warranted.

Impact of laparoscopic surgery on the long-term outcomes for patients with rectal cancer

Background:  This 20‐year retrospective study compared the results of laparoscopic surgery with open surgery for patients with rectal cancer to evaluate the impact of laparoscopic surgery on long‐term oncological outcomes for rectal cancer.

Setup Error and Effectiveness of Weekly Image-Guided Radiation Therapy of TomoDirect for Early Breast Cancer.

Purpose This study investigated setup error and effectiveness of weekly image-guided radiotherapy (IGRT) of TomoDirect for early breast cancer. Materials and Methods One hundred and fifty-one breasts of 147 consecutive patients who underwent breast conserving surgery followed by whole breast irradiation using TomoDirect in 2012 and 2013 were evaluated. All patients received weekly IGRT. The weekly setup errors from simulation to each treatment in reference to chest wall and surgical clips were measured. Random, systemic, and 3-dimensional setup errors were assessed. Extensive setup error was defined as 5 mm above the margin in any directions. Results All mean errors were within 3 mm of all directions. The mean angle of gantry shifts was 0.6°. The mean value of absolute 3-dimensional setup error was 4.67 mm. In multivariate analysis, breast size (odds ratio, 2.82; 95% confidence interval, 1.00 to 7.90) was a significant factor for extensive error. The largest significant deviation of setup error was observed in the first week of radiotherapy (p < 0.001) and the deviations gradually decreased with time. The deviation of setup error was 5.68 mm in the first week and within 5 mm after the second week. Conclusion In this study, there was a significant association between breast size and significant setup error in breast cancer patients who received TomoDirect. The largest deviation occurred in the first week of treatment. Therefore, patients with large breasts should be closely observed on every fraction and fastidious attention is required in the first fraction of IGRT.

Fine needle aspiration cytology of thyroid follicular neoplasm: cytohistologic correlation and accuracy.

Background This study evaluated the accuracy of fine needle aspiration cytology (FNAC) in cases of follicular neoplasm (FN) on the basis of histologic diagnosis, and reviewed the cytologic findings of FN according to the FNAC. Methods Among the 66 cases diagnosed with thyroid FN by FNAC during the 7-year period from 2003 to 2009, 36 cases that had undergone thyroid surgery were available for review. Cytologic diagnosis was compared with the histologic diagnosis of each case. Results Among the 36 cases with a cytologic diagnosis of thyroid FN, histologic diagnosis was as follows: 20 follicular adenomas (55.6%), 3 Hurthle cell adenomas (8.3%), 2 follicular carcinomas (5.6%), 8 nodular goiters (22.2%), 2 papillary carcinomas (5.6%), and 1 Hashimotos thyroiditis (2.8%), resulting in a diagnostic accuracy of FNAC for thyroid FN of 69.5%. Conclusions This study shows that FNAC for thyroid FN is a useful primary screening method because when FN is diagnosed by FNAC, the rate of FN histologic diagnosis is relatively high, however, adequate sampling and experience is a prerequisite for this procedure.