PURPOSE: The American College of Surgeons Oncology Group Z0011 trial reported that complete dissection of axillary lymph nodes (ALNs) may not be warranted in women with clinical T1-T2 tumors and one or two involved ALNs who were undergoing lumpectomy plus radiation followed by systemic therapy. The present study was conducted to identify preoperative imaging predictors of ≥ 3 ALNs. MATERIALS AND METHODS: The training set consisted of 1,917 patients with clinical T1-T2 and node negative invasive breast cancer. Factors associated with ≥ 3 involved ALNs were evaluated by logistic regression analysis. The validation set consisted of 378 independent patients. The nomogram was applied prospectively to 512 patients who met the Z0011 criteria. RESULTS: Of the 1,917 patients, 204 (10.6%) had ≥ 3 positive nodes. Multivariate analysis showed that involvement of ≥ 3 nodes was significantly associated with ultrasonographic and chest computed tomography findings of suspicious ALNs (p < 0.001 each). These two imaging criteria, plus patient age, were used to develop a nomogram calculating the probability of involvement of ≥ 3 ALNs. The areas under the receiver operating characteristic curve of the nomogram were 0.852 (95% confidence interval [CI], 0.820 to 0.883) for the training set and 0.896 (95% CI, 0.836 to 0.957) for the validation set. Prospective application of the nomogram showed that 60 of 512 patients (11.7%) had scores above the cut-off. Application of the nomogram reduced operation time and cost, with a very low re-operation rate (1.6%). CONCLUSION: Patients likely to have ≥ 3 positive ALNs could be identified by preoperative imaging. The nomogram was helpful in selective intraoperative examination of sentinel lymph nodes.
Breast Neoplasms* ; Breast* ; Female ; Humans ; Logistic Models ; Lymph Nodes* ; Mastectomy, Segmental ; Multivariate Analysis ; Nomograms* ; Prospective Studies ; ROC Curve ; Surgeons ; Thorax

This is a study on the dose-decreasing effect of the first reversed laser beam collimator (RLBC) for C-arm type angiographic equipment. A laser beam was located at the center of each plane at an oblique angle to the angiographic equipment detector. A field of view, which could be seen with the naked eye, was made by focusing the laser beam in the direction of the X-ray source. The height of the table was fixed at 75 cm and the iron balls were located within 2 mm of the top, bottom, left, and right edges of the output image. The time needed for location fixing, fluoroscopy, and measurement of dose area product (DAP) were compared by having 30 radiologists perform location fixing by looking at the fluoroscopic image while performing location fixing (no radiation) and while the RLBC was turned on. In the next test, the time needed for location fixing, fluoroscopy, and DAP were compared when varying the location of the iron balls from 2 to 10 mm from the edges of the output image. The results showed that the time needed for location fixing, the time needed for fluoroscopy, and DAP decreased, both in the first test and the second test. This study confirmed that the use of a RLBC for C-arm type angiographic equipment decreases both the time needed to perform the procedure and the radiation dose received. It is expected that continuous advancement of RLBC technology will contribute greatly to decreasing the dose of radiation needed and improving convenience during angiography.
Angiography ; Fluoroscopy ; Iron

PURPOSE: Previous studies examining the relationship between time to treatment and survival outcome in breast cancer have shown inconsistent results. The aim of this study was to analyze the overall impact of delay of treatment initiation on patient survival and to determine whether certain subgroups require more prompt initiation of treatment. MATERIALS AND METHODS: This study is a retrospective analysis of stage I-III patients who were treated in a single tertiary institution between 2005 and 2008. Kaplan-Meier survival analysis and Cox proportional hazards regression model were used to evaluate the impact of interval between diagnosis and treatment initiation in breast cancer and various subgroups. RESULTS: A total of 1,702 patients were included. Factors associated with longer delay of treatment initiation were diagnosis at another hospital, medical comorbidities, and procedures performed before admission for surgery. An interval between diagnosis and treatment initiation as a continuous variable or with a cutoff value of 15, 30, 45, and 60 days had no impact on disease-free survival (DFS). Subgroup analyses for hormone-responsiveness, triple-negative breast cancer, young age, clinical stage, and type of initial treatment showed no significant association between longer delay of treatment initiation and DFS. CONCLUSION: Our results show that an interval between diagnosis and treatment initiation of 60 days or shorter does not appear to adversely affect DFS in breast cancer.
Breast Neoplasms* ; Breast* ; Comorbidity ; Diagnosis ; Disease-Free Survival ; Humans ; Retrospective Studies ; Survival Rate ; Time-to-Treatment ; Triple Negative Breast Neoplasms

PURPOSE: To decide the optimal treatment for breast cancer patients with locoregional recurrence (LRR), it is important to determine which group has the highest risk of subsequent distant metastasis (DM). We aimed to investigate the factors associated with DM in patients with LRR. METHODS: We reviewed the data of 208 patients with LRR as the first event after primary surgery for breast cancer at our institution between 1997 and 2010, to identify significant factors associated with DM. Subsequently, Kaplan-Meier curves and the Cox regression method were used to analyze the correlation between clinical factors and survival. RESULTS: DM occurred in 33.2% (68/208) of LRR patients. The median DM-free interval was 23 months. Some clinical factors were associated with DM in univariate analysis, including the type of primary surgery (p=0.026), tumor size (p=0.005), nodal status (p=0.011), and administration of initial adjuvant chemotherapy (p=0.001). In addition, regional rather than local recurrence and a disease-free interval (DFI; duration between primary surgery and LRR) < or =30 months were also significant (p<0.001 for both). However, only a shorter DFI reached significance in multiple logistic regression analysis. Cox regression analysis of DM-free survival showed that both a shorter DFI and regional recurrence were significant factors with hazard ratios of 2.1 (95% confidence interval [CI], 1.21-3.65) and 1.85 (95% CI, 1.04-3.28), respectively. CONCLUSION: DFI was the most important factor associated with subsequent DM in patients with LRR as a first event of failure.
Breast Neoplasms* ; Chemotherapy, Adjuvant ; Humans ; Logistic Models ; Neoplasm Metastasis* ; Neoplasm Recurrence, Local ; Prognosis ; Recurrence* ; Risk Factors*

PURPOSE: The ability to accurately predict the likelihood of achieving breast conservation surgery (BCS) after neoadjuvant chemotherapy (NCT) is important in deciding whether NCT or surgery should be the first-line treatment in patients with operable breast cancers. MATERIALS AND METHODS: We reviewed the data of 513 women, who had stage II or III breast cancer and received NCT and surgery from a single institution. The ability of various clinicopathologic factors to predict the achievement of BCS and tumor size reduction to < or = 3 cm was assessed. Nomograms were built and validated in an independent cohort. RESULTS: BCS was performed in 50.1% of patients, with 42.2% of tumors reduced to < or = 3 cm after NCT. A multivariate logistic regression analysis showed that smaller initial tumor size, longer distance between the lesion and the nipple, absence of suspicious calcifications on mammography, and a single tumor were associated with BCS rather than mastectomy (p < 0.05). Negative estrogen receptor, smaller initial tumor size, higher Ki-67 level, and absence of in situ component were associated with residual tumor size < or = 3 cm (p < 0.05). Two nomograms were developed using these factors. The areas under the receiver operating characteristic curves for nomograms predicting BCS and residual tumor < or = 3 cm were 0.800 and 0.777, respectively. The calibration plots showed good agreement between the predicted and actual probabilities. CONCLUSION: We have established a model with novel factors that predicts BCS and residual tumor size after NCT. This model can help in making treatment decisions for patients who are candidates for NCT.
Breast Neoplasms ; Breast* ; Calibration ; Cohort Studies ; Drug Therapy* ; Estrogens ; Female ; Humans ; Logistic Models ; Mammography ; Mastectomy ; Mastectomy, Segmental ; Neoadjuvant Therapy ; Neoplasm, Residual ; Nipples ; Nomograms* ; ROC Curve

PURPOSE: Patients with triple-negative breast cancer (TNBC) with pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) have superior survival outcomes compared to those with residual disease after NAC. This study investigated the value of three biomarkers, p53, Ki-67, and Bcl-2 for predicting pCR in NAC-treated patients with TNBC. METHODS: Between 2003 and 2012, 198 patients with pathologically confirmed primary TNBC were treated with two different taxane-based chemotherapeutic regimens prior to surgery. Before NAC, expression of p53 (cutoff 25%), Ki-67 (cutoff 10%), and Bcl-2 (cutoff 10%) was assessed immunohistochemically in core biopsy specimens. The incidence of pCR was correlated with the expression of these biomarkers. RESULTS: Overall, pCR occurred in 37 of the 198 patients (18.7%). A significant association was observed between the pCR rate and overexpression of the p53 and Ki-67 biomarkers. Multivariate analysis showed that only p53 expression was independently associated with pCR to NAC (odds ratio, 3.961; p=0.003). The sensitivity, specificity, positive predictive value, and negative predictive value of p53 expression for predicting pCR were 77.8%, 50.3%, 26.2%, and 90.9%, respectively. The pCR rate was the lowest (5.2%) in patients with low expression of both p53 and Ki-67, and it was the highest (25.8%) when both biomarkers showed high expression. CONCLUSION: Expression of p53 was significantly associated with pCR after NAC in patients with TNBC, suggesting that this biomarker might be particularly valuable in identifying TNBC patients prone to have residual disease after NAC.
Biomarkers ; Biopsy ; Drug Therapy* ; Humans ; Incidence ; Multivariate Analysis ; Neoadjuvant Therapy ; Polymerase Chain Reaction ; Sensitivity and Specificity ; Triple Negative Breast Neoplasms* ; Tumor Suppressor Protein p53

PURPOSE: The aim of this study is to report on the results and discuss the role of free flap followed by ipsilateral vascularized fibular transposition (IVFT) for reconstruction of large bone and soft tissue defect combined with infection by open tibia fracture. MATERIALS AND METHODS: During the research period, lasting from December 2002 to June 2008 (Kyung Hee University Medical Center), data were collected from three patients who underwent IVFT after free flap. We analyzed the successiveness and persistency of the infection using free flapping, bone union, and hypertrophy between transposed fibula and tibia. RESULTS: Regarding free flap, successive results were observed in all examples. In the final follow-up results, transposed fibulas all survived, having hypertrophy similar to that of adjacent tibia. CONCLUSION: Reconstruction of tibia defect with free flap followed by IVTF is a useful and safe method for avoidance of the potential risk of infection for patients with a large tibial bone defect and soft tissue defect associated with infection.
Fibula ; Follow-Up Studies ; Free Tissue Flaps* ; Humans ; Hypertrophy ; Lower Extremity* ; Methods ; Tibia

The purpose of this study was to compare the image between DSA and MDCT Angiography and to examine whether MDCT Angiography could be useful as a screening test for the diagnosis of cerebral aneurysm in patients who were diagnosed with cerebral aneurysm on DSA. Of patients who were diagnosed with cerebral aneurysm DSA at University Hospital, 194 patients who concomitantly underwent MDCT Angiography were enrolled in the current retrospective study. The methods for analyzing cerebral aneurysm were to analyze the presence of cerebral aneurysm on DSA and MDCT Angiography. In cases in which it exceeded 1, the corresponding cases were classified as narrow-neck aneurysms. In otherwise cases, they were classified as wide-neck aneurysms. Thus, a comparative analysis could be performed to ascertain if cases were narrow-neck or wide-neck aneurysms. As compared with DSA, the sensitivity of MDCT Angiography for cerebral aneurysm was measured to be 97.4%. The degree of consistency between narrow-neck and wide-neck aneurysms was 90.2% and the proportion of undetectable an at MDCT Angiography was 2.54%. mean size was 2.4 mm. It is expected that a non-invasive diagnostic modality for a screening test for cerebral aneurysm, MDCT Angiography might be a very useful regimen as compared with an invasive one, DSA.
Aneurysm ; Angiography ; Humans ; Intracranial Aneurysm ; Mass Screening ; Retrospective Studies

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.
Adenocarcinoma, Mucinous/*pathology ; Adult ; Aged ; Aged, 80 and over ; Carcinoembryonic Antigen/blood ; Carcinoma, Pancreatic Ductal/*pathology ; Carcinoma, Papillary/*pathology ; Female ; Humans ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Invasiveness ; Neoplasm Staging ; Pancreatic Neoplasms/*pathology ; Predictive Value of Tests ; ROC Curve ; Tomography, X-Ray Computed

BACKGROUND: This study compared the bronchodilator efficacy and safety of tiotropium inhalation capsules (18microgram once daily) with a ipratropium metered dose inhaler (2 puffs of 20microgram q.i.d.) in patients with chronic obstructive pulmonary disease (COPD). METHOD: After the initial screening assessment and a two-week run-in period, patients received either tiotropium 18microgram once daily or ipratropium 40microgram four times daily over a period of 4 weeks in a double blind, double dummy, parallel group study. The outcome measures were the lung function, the daily records of the peak expiratory flow rate (PEFR), the patients' questionnaire, and the use of concomitant salbutamol. The forced expiratory volume in one second (FEV1) and the forced vital capacity (FVC) were measured 5 minutes before inhalation, and 0.5, 1, 2 and 3 hours after inhaling the study drug on days 0, 14 and 28. RESULT: In 16 centers, 134 patients with a mean (SD) age of 66 (7) years and a predicted FEV1 of 42 (12)% were analyzed. The trough FEV1 response was significantly higher in the tiotropium group than in the ipratropium group after a four-week treatment period. The weekly mean morning PEFR of the tiotropium group was consistently higher than that of the ipratropium group during the 4-week treatment period with differences ranging from 12.52 to 13.88 l/min, which were statistically significant. Tiotropium was well tolerated by the COPD patients during the 4-week treatment period and had a similar safety profile to ipratropium. CONCLUSION: This study shows that tiotropium administrated once daily has a superior bronchodilator effect with a similar safety profile in treating COPD patients compared with ipratropium, inhaled four times daily.
Adult* ; Albuterol ; Bronchodilator Agents ; Capsules ; Forced Expiratory Volume ; Humans ; Inhalation ; Ipratropium* ; Lung ; Mass Screening ; Metered Dose Inhalers ; Outcome Assessment (Health Care) ; Peak Expiratory Flow Rate ; Pulmonary Disease, Chronic Obstructive* ; Surveys and Questionnaires ; Vital Capacity ; Tiotropium Bromide