These guidelines aim to establish the standard practice for diagnosing and treating patients with differentiated thyroid cancer (DTC). Based on the Korean Thyroid Association (KTA) Guidelines on DTC management, the “Treatment of Advanced DTC” section was revised in 2024 and has been provided through this chapter. Especially, this chapter covers surgical and nonsurgical treatments for the local (previous surgery site) or regional (cervical lymph node metastasis) recurrences. After drafting the guidelines, it was finalized by collecting opinions from KTA members and related societies. Surgical resection is the preferred treatment for local or regional recurrence of advanced DTC. If surgical resection is not possible, nonsurgical resection treatment under ultrasonography guidance may be considered as an alternative treatment for local or regional recurrence of DTC. Furthermore, if residual lesions are suspected even after surgical resection or respiratory-digestive organ invasion, additional radioactive iodine and external radiation treatments are considered.

Pediatric differentiated thyroid cancers (DTCs), mostly papillary thyroid cancer (PTC, 80-90%), are diagnosed at more advanced stages with larger tumor sizes and higher rates of locoregional and/or lung metastasis. Despite the higher recurrence rates of pediatric cancers than of adult thyroid cancers, pediatric patients demonstrate a lower mortality rate and more favorable prognosis. Considering the more advanced stage at diagnosis in pediatric patients, preoperative evaluation is crucial to determine the extent of surgery required. Furthermore, if hereditary tumor syndrome is suspected, genetic testing is required. Recommendations for pediatric DTCs focus on the surgical principles, radioiodine therapy according to the postoperative risk level, treatment and follow-up of recurrent or persistent diseases, and treatment of patients with radioiodine-refractory PTCs on the basis of genetic drivers that are unique to pediatric patients.

Differentiated thyroid cancer demonstrates a wide range of clinical presentations, from very indolent cases to those with an aggressive prognosis. Therefore, diagnosing and treating each cancer appropriately based on its risk status is important. The Korean Thyroid Association (KTA) has provided and amended the clinical guidelines for thyroid cancer management since 2007. The main changes in this revised 2024 guideline include 1) individualization of surgical extent according to pathological tests and clinical findings, 2) application of active surveillance in low-risk papillary thyroid microcarcinoma, 3) indications for minimally invasive surgery, 4) adoption of World Health Organization pathological diagnostic criteria and definition of terminology in Korean, 5) update on literature evidence of recurrence risk for initial risk stratification, 6) addition of the role of molecular testing, 7) addition of definition of initial risk stratification and targeting thyroid stimulating hormone (TSH) concentrations according to ongoing risk stratification (ORS), 8) addition of treatment of perioperative hypoparathyroidism, 9) update on systemic chemotherapy, and 10) addition of treatment for pediatric patients with thyroid cancer.

The primary objective of initial treatment for thyroid cancer is minimizing treatment-related side effects and unnecessary interventions while improving patients’ overall and disease-specific survival rates, reducing the risk of disease persistence or recurrence, and conducting accurate staging and recurrence risk analysis. Appropriate surgical treatment is the most important requirement for this purpose, and additional treatments including radioactive iodine therapy and thyroid-stimulating hormone suppression therapy are performed depending on the patients’ staging and recurrence risk. Diagnostic surgery may be considered when repeated pathologic tests yield nondiagnostic results (Bethesda category 1) or atypia of unknown significance (Bethesda category 3), depending on clinical risk factors, nodule size, ultrasound findings, and patient preference. If a follicular neoplasm (Bethesda category 4) is diagnosed pathologically, surgery is the preferred option. For suspicious papillary carcinoma (suspicious for malignancy, Bethesda category 5), surgery is considered similar to a diagnosis of malignancy (Bethesda category 6). As for the extent of surgery, if the cancer is ≤1 cm in size and clinically free of extrathyroidal extension (ETE) (cT1a), without evidence of cervical lymph node (LN) metastasis (cN0), and without obvious reason to resect the contralateral lobe, a lobectomy can be performed. If the cancer is 1-2 cm in size, clinically free of ETE (cT1b), and without evidence of cervical LN metastasis (cN0), lobectomy is the preferred option. For patients with clinically evident ETE to major organs (cT4) or with cervical LN metastasis (cN1) or distant metastasis (M1), regardless of the cancer size, total thyroidectomy and complete cancer removal should be performed at the time of initial surgery. Active surveillance may be considered for adult patients diagnosed with low-risk thyroid papillary microcarcinoma. Endoscopic and robotic thyroidectomy may be performed for low-risk differentiated thyroid cancer when indicated, based on patient preference.

Objective: Microsurgical treatment could be a good alternative for the treatment of recurrent cerebral aneurysm after coil embolization. The purpose of this study was to present our experience of microsurgical treatment for recurrent cerebral aneurysm previously treated using coil embolization. Methods: From June 2012 to May 2019, 34 patients consecutively received microsurgical treatment for a recurrent cerebral aneurysm previously treated using coil embolization after it ruptured. Results: Of the 34 patients with aneurysm, 33 had the aneurysm located in the anterior circulation. The most common location was the anterior communicating artery (13 cases). Immediate radiologic outcome at coil embolization was completed (n=6), residual neck (n=26), and residual sac (n=2). The reason for microsurgical treatment included rebleeding (n=12), persistent residual sac (n=1), and recurrence on follow-up study (n=21). Rebleeding occurred within 10 days after coil embolization in 10 cases, and the other 2 were due to regrowth. In the 20 recurred and saccular aneurysms, coil compaction was present in 11 aneurysms and regrowth in 9 aneurysms. Simple neck clipping (n=29) and clipping with coil mass extraction (n=3) was possible in the saccular aneurysms. The blood blister like aneurysm (n=2) were treated using bypass and endovascular internal carotid artery trapping. In the follow-up study group after microsurgical treatment there were no severe complications due to the treatment. Age, cause of retreatment, and modified Rankin Scale before microsurgery were associated with good outcome (p<0.001). Conclusions Microsurgical treatment may be a viable and effective option for treating recurrent aneurysms previously treated by endovascular techniques.

OBJECTIVE: Head circumference (HC) has been reported to be an index of cognitive functioning in the elderly and in Alzheimer's patients. The object of the study is to find the relationship between HC and cognition. METHODS: A total of 7,603 subjects over 60 years of age were analyzed from preliminary data of Gwangju Dementia and Mild Cognitive Impairment Study. HC was manually measured and cognitive functioning was assessed by the Korean version of the Mini Mental State Examination (K-MMSE). RESULTS: Correlational analysis showed that HC was associated with age (r=-0.14, p<0.01), education (r=0.33, p<0.01), height (r=0.26, p<0.01), and K-MMSE (r=0.28, p<0.01). Also, even after adjusting for confounding variables (age, education, height, gender) the positive association between HC and K-MMSE score remained significant (beta=0.18, p<0.001). CONCLUSION: The results suggest that HC may play an important role in predicting cognitive impairment in the elderly.
Aged* ; Cognition* ; Confounding Factors (Epidemiology) ; Dementia ; Education ; Gwangju ; Head* ; Humans ; Mild Cognitive Impairment

Gastric cavernous hemangioma is a relatively rare benign gastric disease. Gastric hemangiomas are most commonly encountered in adulthood, although they can occur in any age group. While surgical resection is the curative treatment, endoscopic resection can be performed for treatment of selected cases. The patient was a 53-year-old male who was referred for evaluation of incidentally detected gastric subepithelial tumor with dense vascularity and oozing on the apex of the lesion. An EUS revealed a homogenously hypoechoic mass confined to the submucosal layer that showed no continuity with adjacent vessels, and there was no regional lymphadenopathy. Endoscopic submucosal dissection was successfully performed with en bloc resection. The final diagnosis was benign cavernous hemangioma of the stomach.
Hemangioma ; Hemangioma, Cavernous ; Humans ; Male ; Middle Aged ; Stomach ; Stomach Diseases

PURPOSE: Bony resection of the proximal medial tibia, an alternative technique for soft tissue balancing in total knee arthroplasty (TKA), was compared to the conventional medial soft tissue release technique. MATERIALS AND METHODS: From June 2005 to June 2007, we performed 40 TKA in 27 patients with > or =10degrees tibio-femoral varus deformity. The conventional, medial soft tissue release technique was applied in 20 cases and bony resection of proximal medial tibia in the other 20 cases (vertical osteotomy group). Total operation time, knee range of motion (ROM), hospital for special surgery (HSS) scores, and tibio-femoral medial-lateral gap ratio in 0degrees, 90degrees, and 130degrees flexion at postoperative 6 months were compared between the groups. RESULTS: The total operation time was shorter in the vertical osteotomy group. Tibio-femoral medial-lateral gap ratio in 130degrees flexion was closer to 1 in the vertical osteotomy group (p=0.000). There was no significant difference in the ROM, HSS score, or tibio-femoral medial-lateral gap ratio in 0degrees and 90degrees flexion at postoperative 6 months. CONCLUSIONS: In severe varus knees, bony resection of proximal medial tibia can be considered as an alternative technique, in order to decrease total operation time and to obtain medial-lateral, soft-tissue balance in deep flexion.
Arthroplasty ; Congenital Abnormalities ; Humans ; Knee ; Ligaments ; Osteotomy ; Range of Motion, Articular ; Tibia

BACKGROUND: Diamond Blackfan anemia (DBA), characterized by impaired red cell production, is a rare condition that is usually symptomatic in early infancy. The purpose of this study was to assess nationwide experiences of DBA encountered over a period of 20 years. METHODS: The medical records of 56 patients diagnosed with DBA were retrospectively reviewed from November 1984 to July 2010. Fifteen institutions, including 13 university hospitals, participated in this study. RESULTS: The male-to-female ratio of patients with DBA was 1.67:1. The median age of diagnosis was 4 months, and 74.1% were diagnosed before 1 year of age. From 2000 to 2009, annual incidence was 6.6 cases per million. Excluding growth retardation, 38.2% showed congenital defects: thumb deformities, ptosis, coarctation of aorta, ventricular septal defect, strabismus, etc. The mean hemoglobin concentration was 5.1+/-1.9 g/dL, mean corpuscular volume was 93.4+/-11.6 fL, and mean number of reticulocytes was 19,700/mm3. The mean cellularity of bone marrow was 75%, with myeloid:erythroid ratio of 20.4:1. After remission, 48.9% of patients did not need further steroids. Five patients with DBA who received hematopoietic transplantation have survived. Cancer developed in 2 cases (3.6%). CONCLUSION: The incidence of DBA is similar to data already published, but our study had a male predilection. Although all patients responded to initial treatment with steroids, about half needed further steroids after remission. It is necessary to collect further data, including information regarding management pathways, from nationwide DBA registries, along with data on molecular analyses.
Anemia ; Anemia, Diamond-Blackfan ; Aortic Coarctation ; Bone Marrow ; Congenital Abnormalities ; Diamond ; Erythrocyte Indices ; Heart Septal Defects, Ventricular ; Hemoglobins ; Hospitals, University ; Humans ; Incidence ; Korea ; Male ; Medical Records ; Registries ; Reticulocytes ; Retrospective Studies ; Steroids ; Strabismus ; Thumb ; Transplants

PURPOSE: To assess the relationship between biochemical bone turnover marker and bone mineral density(BMD) and to evaluate the predictive role of biochemical bone marker in postmenopausal osteopenic woman. MATERIALS AND METHODS: Ninety two postmenopausal women (50-65 years old), who have the T-score from -1.0 to -2.5 by the dual-energy X-ray absorptiometry (DEXA), were examined consecutively with BMD of the lumbar spine and biochemical bone turnover marker including urine Cross-linked N-telopeptide of type I collagen (u-NTX), urine deoxy-pyridinoline (u-DPD), serum Cross-linked C-telopeptide of type I collagen (s-CTX), serum bone-specific alkaline phosphatase (s-BAP), serum osteocalcin (s-OC) for six months. We evaluated the relation between the changes in the biochemical markers and the rate of bone loss. RESULTS: Seventy four postmenopausal women completed this study. All biochemical bone turnover marker and BMD at one time point including the baseline and the end point did not show any significant correlation. Another longitudinal study found no significant correlation between the baseline biochemical bone turnover marker and the change in lumbar spine BMD. The other study showed significant correlation between the changes in s-CTX/s-OC and the change in lumbar spine BMD (p=0.04, 0.03). The changes of u-NTX and s-OC were larger in the group of aggravation in BMD (p=0.032, 0.041). CONCLUSION: The relationship between bone turnover marker and BMD at one time point was not clear. The predictive role of baseline bone turnover marker was limited to predict the magnitude of changes in lumbar BMD in untreated osteopenic individuals. The changes of s-OC showed significant predictive role in the bone loss in osteopenic postmenopausal women.
Absorptiometry, Photon ; Alkaline Phosphatase ; Biomarkers ; Bone Diseases, Metabolic ; Collagen Type I ; Female ; Humans ; Longitudinal Studies ; Osteocalcin ; Osteoporosis ; Peptides ; Spine