BACKGROUND AND PURPOSE: To compare the efficacy and safety of antiplatelet agents for the secondary prevention of ischemic stroke based on cytochrome P450 2C19 (CYP2C19) polymorphisms. METHODS: This study was a prospective, multicenter, randomized, parallel-group, open-label, blind genotype trial. First time non-cardiogenic ischemic stroke patients were enrolled and screened within 30 days. Participants were randomized to receive either triflusal or clopidogrel for secondary stroke prevention. The primary outcome was the time from randomization to first recurrent ischemic stroke or hemorrhagic stroke. RESULTS: The required sample size was 1,080 but only 784 (73%) participants were recruited. In patients with a poor CYP2C19 genotype for clopidogrel metabolism (n=484), the risk of recurrent stroke among those who received triflusal treatment was 2.9% per year, which was not significantly different from those who received clopidogrel treatment (2.2% per year; hazard ratio [HR], 1.23; 95% confidence interval [CI], 0.60–2.53). In the clopidogrel treatment group (n=393), 38% had good genotypes and 62% poor genotypes for clopidogrel metabolism. The risk of recurrent stroke in patients with a good CYP2C19 genotype was 1.6% per year, which was not significantly different from those with a poor genotype (2.2% per year; HR, 0.69; 95% CI, 0.26–1.79). CONCLUSIONS: Whilst there were no significant differences between the treatment groups in the rates of stroke recurrence, major vascular events, or coronary revascularization, the efficacy of antiplatelet agents for the secondary prevention of stroke according to CYP2C19 genotype status remains unclear.
Cytochrome P-450 CYP2C19 ; Cytochrome P-450 Enzyme System* ; Cytochromes* ; Genotype ; Humans ; Metabolism ; Platelet Aggregation Inhibitors ; Prospective Studies ; Random Allocation ; Recurrence ; Sample Size ; Secondary Prevention* ; Stroke*

OBJECTIVE: Chest pain is one of the most common complaints in the emergency department (ED). Cardiac computed tomography angiography (CCTA) is a frequently used tool for the early triage of patients with low- to intermediate-risk acute chest pain. We present a study protocol for a multicenter prospective randomized controlled clinical trial testing the hypothesis that a low-dose CCTA protocol using prospective electrocardiogram (ECG)-triggering and limited-scan range can provide sufficient diagnostic safety for early triage of patients with acute chest pain. METHODS: The trial will include 681 younger adult (aged 20 to 55) patients visiting EDs of three academic hospitals for acute chest pain or equivalent symptoms who require further evaluation to rule out acute coronary syndrome. Participants will be randomly allocated to either low-dose or conventional CCTA protocol at a 2:1 ratio. The low-dose group will undergo CCTA with prospective ECG-triggering and restricted scan range from sub-carina to heart base. The conventional protocol group will undergo CCTA with retrospective ECG-gating covering the entire chest. Patient disposition is determined based on computed tomography findings and clinical progression and all patients are followed for a month. The primary objective is to prove that the chance of experiencing any hard event within 30 days after a negative low-dose CCTA is less than 1%. The secondary objectives are comparisons of the amount of radiation exposure, ED length of stay and overall cost. RESULTS AND CONCLUSION: Our low-dose protocol is readily applicable to current multi-detector computed tomography devices. If this study proves its safety and efficacy, dose-reduction without purchasing of expensive newer devices would be possible.
Acute Coronary Syndrome ; Adult ; Angiography* ; Chest Pain ; Coronary Angiography ; Electrocardiography ; Emergencies* ; Emergency Service, Hospital ; Heart ; Humans ; Length of Stay ; Prospective Studies ; Radiation Exposure ; Retrospective Studies ; Thorax ; Triage

PURPOSE: This study evaluates the BRAF(V600E) test with fine-needle aspiration cytology (FNAC) for lateral lymph node (LN) metastasis in papillary thyroid carcinoma (PTC). METHODS: Ninety-one patients, including 95 lateral LNs with possible PTC metastasis, were consecutively entered into the study. We analyzed the accuracy of results for the BRAF(V600E) test and FNAC for lateral LN metastasis in PTC. RESULTS: Modified radical neck dissection was performed for 34 cases due to lateral LN metastasis. The sensitivity of FNAC was 88.2% , and the LN-BRAF(V600E) test 64.7%. The specificity and positive predictive value (PPV) were 100% for both tests. The negative predictive values (NPV) were FNAC, 93.8%, and LN-BRAF(V600E), 83.6%. For samples positive with either the BRAF(V600E) test or FNAC, the sensitivity was 94.1%, specificity 100%, PPV value 100%, and NPV 96.8%. CONCLUSION: This study suggests that the complementary LN-BRAF(V600E) test with FNAC is a supportive diagnostic method for PTC patients with indeterminate or non-diagnostic suspicious lateral LNs.
Biopsy, Fine-Needle ; Humans ; Lymph Nodes* ; Methods ; Neck Dissection ; Neoplasm Metastasis ; Sensitivity and Specificity ; Thyroid Gland* ; Thyroid Neoplasms*

PURPOSE: The aims of this study were to investigate whether parathyroid score can predict hypocalcemia after total thyroidectomy with central lymph node dissection (CLND) and to determine clinical value of parathyroid score for treatment of hypocalcemia. METHODS: A prospective review of 209 patients who underwent total thyroidectomy with CLND for papillary thyroid cancer from January to December 2012 was conducted. Parathyroid score was designed based on the number and color of parathyroid preservation (Save and intact color of a parathyroid was 2; Save but mild discoloration was 1.5; Not identification was 1.2; Autotransplantation was 1.0; Sacrifice was -1). RESULTS: The mean numbers of parathyroid glands were as follows: save & intact color was 2.0; save & mild discoloration was 0.8; not identification was 0.8; autotransplantation was 0.4. The average parathyroid score was 6.54+/-0.69 (range 3.4~8.0). The average PTH was 16.3 at the 1st POD. Transient and permanent hypocalcemia were 33.4% (70/209) and 0.9% (2/209), respectively. Parathyroid score was 6.78+/-0.54 in patients without transient hypocalcemia, 5.93+/-0.67 with hypocalcemia, parathyroid score was significantly lower in transient hypocalcemia, abnormal PTH at the 1st POD (P<0.001, P<0.001). CONCLUSION: Parathyroid score may predict patients at risk of developing transient hypocalcemia after total thyroidectomy with CLND.
Autografts ; Humans ; Hypocalcemia* ; Lymph Node Excision ; Parathyroid Glands ; Parathyroid Hormone ; Prospective Studies ; Thyroid Neoplasms ; Thyroidectomy*

PURPOSE: Papillary thyroid carcinoma (PTC) is the most common malignant tumor of the thyroid and BRAFV600E mutation is the most frequent genetic alteration in PTC. BRAFV600E mutation has been demonstrated as a prognostic biomarker for prediction of poor clinicopathological outcomes, such as increased incidence of extrathyroidal extension, lymph node metastasis, and advanced stage. However, there is conflicting literature regarding the association of BRAFV600E mutation and aggressive clinicopathological features. In this study, we investigated the prevalence of BRAFV600E mutation in PTC and determined the association of BRAF mutation with indicators of poor prognosis for PTC. METHODS: We reviewed 1009 patients with PTC, who underwent thyroid surgery at Kyungpook National University Hospital between January 2013 and March 2014. BRAFV600E mutation analysis was performed using real-time polymerase chain reaction based amplification of DNA extracted from paraffin-embedded tumor specimens. RESULTS: BRAFV600E mutation was detected in 863 (85.5%) patients. In univariate analysis, histologic subtype, extrathyroidal extension, and advanced stage showed significant association with BRAFV600E mutation. In addition, concurrent Hashimoto's thyroiditis showed an association with low prevalence of BRAFV600E mutation. However, no statistically significant association was observed for age, gender, multifocal or bilateral tumor, and lymph node metastasis. Multivariate analysis showed an independent association of extrathyroidal extension with BRAFV600E mutation. CONCLUSION: In this study, extrathyroidal extension of PTC is an independent prognostic factor associated with BRAFV600E mutation status. However, conduct of further large scale studies with long term follow up is required before the BRAF mutation can be conclusively recommended as a prognostic biomarker.
DNA ; Gyeongsangbuk-do ; Humans ; Incidence ; Lymph Nodes ; Multivariate Analysis ; Neoplasm Metastasis ; Prevalence ; Prognosis ; Real-Time Polymerase Chain Reaction ; Thyroid Gland ; Thyroid Neoplasms* ; Thyroiditis

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.
Breast Neoplasms ; Breast* ; Carcinoma, Ductal* ; Choristoma ; Diagnosis ; Mammography* ; Mass Screening* ; Nipples

Chyle leakage is a rare complication of surgery for thyroid cancer that generally develops after lateral neck dissection. Here, we describe chyle leakages experienced after central neck dissection (CND). A total of 615 patients with thyroid cancer were treated by total thyroidectomy with CND between Jan 2012 and Dec 2012 at our facility, and three (0.49%) developed chyle leakages. The amounts of leakage were all less than 100 ml/day. One patient was resolved with conservative management, while the others were treated with conservative treatment and fibrin glue injection in chylous lymphocele. Chyle leakage after CND is very uncommon, and most cases involve minor leakage. Fibrin glue could be a treatment option for chyle leakage following CND.
Chyle* ; Fibrin Tissue Adhesive ; Humans ; Lymphocele ; Neck Dissection* ; Neck* ; Thyroid Neoplasms ; Thyroidectomy*

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.
Axilla ; Breast ; Breast Neoplasms ; Diagnostic Imaging ; Electrons ; Fluorodeoxyglucose F18 ; Humans ; Lymph Node Excision ; Lymph Nodes ; Magnetic Resonance Imaging ; Neoplasm Metastasis ; Nitriles ; Pyrethrins ; Retrospective Studies ; Sensitivity and Specificity ; Sentinel Lymph Node Biopsy

Oncoplastic breast surgery has become a popular choice of treatment for breast reconstruction after mastectomy. There are two different techniques in oncoplastic surgery depending on the volume of the excised breast tissue. One is the volume displacement procedure, which combines resection with a variety of different breast-reshaping and breast-reduction techniques; the other is the volume replacement procedure in which the volume of excised breast tissue is replaced with autologous tissue. In this study, current authors performed various volume replacement techniques based on the weight of the excised tumor and its margin of resection. We used a latissimus dorsi myocutaneous flap for cases in which the resection mass was greater than 150 g, and for cases in which the resection mass was less than 150 g, we used a regional flap, such as a lateral thoracodorsal flap, a thoracoepigastric flap, or perforator flaps, such as an intercostal artery perforator flap or a thoracodorsal artery perforator flap. In the patients with small to moderate-sized breasts, when a postoperative deformity is expected due to a large-volume tumor resection, the replacement of non-breast tissue is required. Many of whom have small breasts, oncoplastic volume replacement techniques in breast-conserving surgery allow an extensive tumor excision without concern of compromising the cosmetic outcome and can be reliable and useful techniques with satisfactory aesthetic results.
Arteries ; Breast ; Breast Neoplasms ; Congenital Abnormalities ; Cosmetics ; Displacement (Psychology) ; Female ; Humans ; Mammaplasty ; Mastectomy ; Mastectomy, Segmental ; Perforator Flap

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 patient's 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.
Breast ; Breast Neoplasms ; Cosmetics ; Displacement (Psychology) ; Female ; Humans ; Mammaplasty ; Mastectomy, Segmental ; Surgery, Plastic