• Journal of Korean Neurosurgical Society
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• 제30권sup2호
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• pp.221-227
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• 2001

Objective : The therapeutic impact of tumor resection in glioblastomas is poorly defined and still questionable. Therefore, we conducted the current study to verify the role of tumor resection in the treatment of these highly malignant tumors. Methods : A retrospective study was performed(1990-1999) to compare the treatment results of surgical resection plus radiotherapy(130 patients) with those of stereotactic biopsy plus radiotherapy(19 patients) in glioblastomas. Only adult patients with supratentorial, de novo glioblastoma located in one lobe were included. Survival time/rate was analysed with Kaplan-Meier method, and prognostic variables were obtained from the univariate log-rank test and the multivariate Cox's proportional hazards model. Results : The resection group and the biopsy group did not differ in terms of age, gender, duration of symptoms, presenting symptoms, tumor location, tumor side, tumor size, and the frequency of midline shift. Patients in the biopsy group more often were found to have worse preoperative Karnofsky performance status(KPS)(p=0.001). On univariate analysis, age, KPS, and tumor side were associated with survival(p=0.0053, 0.0001, and 0.0331 respectively). Median survival time and 1-year survival rate were also statistically improved by tumor resection ; resection group - 13 months and 61.2%, and biopsy group - 8 months and 19.7%, respectively(p=0.0001). In patients with midline shift of the tumor, resection was highly effective comparing to biopsy(p=0.0001), but in patients without midline shift, external beam radiation alone was as effective as tumor resection(p=0.0605). Other prognostic variables did not affect survival. On multivariate analysis after variable selection, survival was independently associated with KPS(p=0.001), but not the surgical resection(p=0.2837). Even in biopsy group with midline shift of the tumor, survival rate was not different from that seen after tumor resection(p=0.3505). Conclusions : Radiotherapy alone was as effective as tumor resection plus radiotherapy in patients without midline shift of the tumor. Although there was not statistically significant, tumor resection looked like effective in patients with midline shift. For supratentorial, lobar glioblastoma patients without mass effect of the tumor, biopsy with radiotherapy is one of rational treatment strategies. We consider that tumor resection should be performed in patients with pretreatment midline shift.

• Maxillofacial Plastic and Reconstructive Surgery
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• 제35권5호
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• pp.277-283
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• 2013

Purpose: Well vascularized pectoralis major myocutaneous flap (PMMF) had been a commonly used versatile flap in reconstructive oromaxillofacial surgery since the 1970s. However, after the advent of microvascular surgery in the 1980s, the PMMF was used less frequently. But, to date, PMMF has been useful and has some advantages such as covering wide defects, covering vital structures, back-up procedure in cases of free flap failure, and reconstruction for radiotherapy patients. The purpose of this study is to evaluate the role, indication, complications, functional, and aesthetic results of this flap in the era of free flap with a literature and chart review. Methods: A retrospective study was conducted of 16 oral cancer patients undergoing reconstructive surgery with PMMF for reconstruction of defects from 2001 to 2012 at Kyungpook National University Hospital. The male to female ratio was 10:6, with a mean age of 63 years (16~79 years). Basic demographic data, previous treatment history, indications, dimension of the flap, site of reconstruction, postoperative complications, and patients' final status were systemically analyzed from chart review. Results: The pathology of the disease included squamous cell carcinoma in the majority of cases (n=14). The remaining cases were fibrosarcoma and mucoepidermoid carcinoma. Of the 16 PMMF reconstructions, 13 flaps were applied as primary reconstructive procedures, whereas three flaps were; salvage; procedures (vascularized free flap failure). Twelve patients had complications such as wound dehiscence, infection, hematoma, fistula, flap bulkiness, and partial flap necrosis. The higher complication rates showed an association with utilization of the flap in preoperative radiotherapy cases. However, all patients were discharged without failure. Conclusion: In reconstructive oromaxillofacial surgery, the PMMF is still a useful flap for huge defects. In addition, the PMMF can be used as a salvage procedure after vascularized free flap failure and reconstruction for patients with a history of preoperative radiotherapy.

• Journal of Chest Surgery
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• 제33권8호
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• pp.662-668
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• 2000

Background: Many recent results of clinical trials show that pre-operative concurrent chemoradiotherapy and surgical resection could increase the survival of N2 positive stage IIIA non-small cell lung cancer. This study was performed to assess the feasibility, toxicity, and affect rates of concurrent chemoradiotherapy and surgical resection in N2 positive stage IIIA non-small cell lung cancer. Material and Method: Thirty-one patients who underwent preoperative concurrent chemoradiotherapy for N2 positive stage IIIA non-small-cell lung cancer from May 1997 to April 1999 were entered into the study. Mean age was 61 yrs(43∼70 yrs), There were 24 men and 7 women. The confirmation of N2 disease were achieved through mediastinoscopic biopsy(24) and CT scans(7). Induction was achieved by two cycles of cisplatin and etoposide(EP) plus concurrent chest radiotherapy to 45 Gy. Resections were done at 3 weeks after the complection of preoperative concurrent chemoradiotherapy. Resections were performed in 23 patients, excluding 5 refusals and 3 distant metastasis. Result: All patients were compled the thoracic radiotherapy except one who had distant metastasis. Twenty three patients were completed the planned 2 cycles of EP chemotherapy, and 8 patients were received only 1 cycle for severe side effects(6), refusal(1), and distant metastasis(1). There was one postoperative mortality, and the cause of death was ARDS. Three patients who had neutropenic fever and one patient who had radiation pneumonitis were required admission and treatment. Esophagitis was the most common acute side effect, but relatively well-tolerated in most patients. The complection rate of concurrent chemoradiotherapy was 74%, resection rate was 71%, pathologic complete remission rate was 13.6%, and pathologic down-staging rate was 68%. Conclusion: Morbidity related to each treatment was acceptable and many of the patients have benefited down staging of its disease. Further prospective, preferably randomized, clinical trials of larger scale may be warranted to confirm the actual benefit of preoperative concurrent chemoradiotherapy and surgical resection in N2-positive stage IIIA non-small cell lung cancer.

• Radiation Oncology Journal
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• 제15권1호
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• pp.49-56
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• 1997

목적 : 절제 가능한 직장암 환자에서 수술전 방사선 치료를 시행한 예들(대상군)과 동일한 임상병기에서 수술만을 시행했던 예들(대조군)사이의 수술후 병리 조직학적 소견들을 비교하여 수술전 방사선 치료의 효과에 대하여 알아보고자 하였다. 대상 및 방법 :1995년 7월부터 1996년 4월까지 가톨릭대학교 의과대학 성모병원 방사선종양 학과에서 수술전방사선치료를 받았던 19명의 환자중 수술을 시행받은 16명을 대상으로 하였으며, 이를 과거에 수술만을 시행했던 31명과 후향적분석을 통해 비교하였다. 진단 당시 이들의 임상병기 분류는 Thomas Jefferson(TJ) system을 이용하였다. 수술전 방사선 치료는 매일 180-200 cGy로 주 5회, 총 방사선 조사량 4500-5000cGy까지 시행하였으며, 방사선 치료가 끝나고 평균 4주후에 수술을 시행하였다. 수술후 병기 결정은 Modified Astler-Coiler(MAC) system을 이용하였다. 방사선 치료후 임상 병기에 따른 수술후 병리학적 병기와 소견을 관찰하고, 이 결과를 수술전 동일한 임상 병기를 지녔던 대조군의 병리학적 소견과 비교하였다 병리학적 소견으로는 종양세포의 혈관 침범, 림프관 침범및 신경조직주위 침범여부 등을 관찰하였다. 통계학적 방법으로는 chi-square test를 사용하였다. 결과 : 대상이 되었던 19명중 16명에서 종양의 위치에 관계없이 방사선 치료후 항문보존적 근치수술을 시행할수 있었으며, 방사선 치료후 1명$(6.3\%)$의 환자가 병리조직학적으로 완전반응을 보였다. 방사선 치료후에 항문보존적 근치수술을 시행했던 대상군과 수술만을 시행했던 대조군사 이의 임상적 병기와 수술후 병기를 비교해 보면 TJ stage III였던 경우, 9명의 대상군중에서는 완전반응을 보인 1명을 제외하고는, 8명 모두가 MAC stage B로 나타났으며$(88.9\%)$, 17명의 대조관에서는 B인 경우가 11명$(64.7\%)$, C인 경우가 6명$(35.3\%)$이었으며, TJ stage III였던 경우, 7명의 대상군에서는 MAC stage상 B인 경우가 4명$(57.1\%)$, C인 경우가 3명 $(42.9\%)$이었고, 14명의 대조관에서는 B인 경우가 4명$(28.6\%)$, C인 경우가 10명$(71.4\%)$이었다. 따라서 수술전 방사선 치료를 시행했던 예들에서 병리학적 병기가 낮은 경향을 보였으며, 특히 방사선 치료후 MAC stage C 소견의 급격한 감소가 보였다(p=0.049). 병리학적인 소견으로 종양세포의 혈관 침범, 림프관 침범과 신경조직 주위 침범등이 대상군에서 대조군에 비하여 모두가 감소하는 것으로 나타났다. 결론 : 동일한 임상 병기에서 수술전 방사선 치료를 시행한 군과 수술만을 시행한 군 사이의 수술후 병기는 수술전 방사선 치료를 시행한 경우에 비하여 병기가 감소되는 경향을 보였다. 특히 병리학적으로 종양세포의 림프관 침범 소견이 감소된 것은 방사선 치료군에서 수술후 MAC Stage C 소견이 감소된 것과 일치되는 소견을 보였다 이러한 결과를 통해 절제 가능한 직장암 환자에서 수술전 방사선 치료를 하는 것이 효과적일수 있다고 사료된다. 그러나, 좀 더 명확한 결론을 얻기 위해서는 더 많은 수의 환자들을 대상으로 장기적인 추적관찰을 하는 연구가 함께 이루어져야 할 것이라고 생각된다.

• Radiation Oncology Journal
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• 제35권2호
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• pp.121-128
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• 2017

Purpose: To report the results of a correlation analysis of skin dose assessed by in vivo dosimetry and the incidence of acute toxicity. This is a phase 2 trial evaluating the feasibility of intraoperative radiotherapy (IORT) as a boost for breast cancer patients. Materials and Methods: Eligible patients were treated with IORT of 20 Gy followed by whole breast irradiation (WBI) of 46 Gy. A total of 55 patients with a minimum follow-up of 1 month after WBI were evaluated. Optically stimulated luminescence dosimeter (OSLD) detected radiation dose delivered to the skin during IORT. Acute toxicity was recorded according to the Common Terminology Criteria for Adverse Events v4.0. Clinical parameters were correlated with seroma formation and maximum skin dose. Results: Median follow-up after IORT was 25.9 weeks (range, 12.7 to 50.3 weeks). Prior to WBI, only one patient developed acute toxicity. Following WBI, 30 patients experienced grade 1 skin toxicity and three patients had grade 2 skin toxicity. Skin dose during IORT exceeded 5 Gy in two patients: with grade 2 complications around the surgical scar in one patient who received 8.42 Gy. Breast volume on preoperative images (p = 0.001), ratio of applicator diameter and breast volume (p = 0.002), and distance between skin and tumor (p = 0.003) showed significant correlations with maximum skin dose. Conclusions: IORT as a boost was well-tolerated among Korean women without severe acute complication. In vivo dosimetry with OSLD can help ensure safe delivery of IORT as a boost.

• Journal of Korean Neurosurgical Society
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• 제58권5호
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• pp.448-453
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• 2015

Objective : Recently, the survival of patients with hepatocellular carcinoma (HCC) has been prolonged with improvements in various diagnostic tools and medical treatment modalities. Consequently, spine metastases from HCC are being diagnosed more frequently. The accurate prediction of prognosis plays a critical role in determining a patient's treatment plan, including surgery for patients with spinal metastases of HCC. We investigated the clinical features, surgical outcomes, and prognostic factors of HCC presenting with spine metastases, in patients who underwent surgery. Methods : A retrospective review was conducted on 33 HCC patients who underwent 36 operations (three patients underwent surgical treatment twice) from February 2006 to December 2013. The median age of the patients was 56 years old (range, 28 to 71; male : female=30 : 3). Results : Overall survival was not correlated with age, sex, level of metastases, preoperative Child-Pugh classification, preoperative ambulatory function, preoperative radiotherapy, type of operation, administration of Sorafenib, or the Tokuhashi scoring system. Only the Tomita scoring system was shown to be an independent prognostic factor for overall survival. Comparing the Child-Pugh classification and ambulatory ability, there were no statistically differences between patients pre- and post-operatively. Conclusion : The Tomita scoring system represents a practicable and highly predictive prognostic tool. Even though surgical intervention may not restore ambulatory function, it should be considered to prevent deterioration of the patient's overall condition. Additionally, aggressive management may be needed if there is any ambulatory ability remaining.

• Journal of Yeungnam Medical Science
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• 제20권2호
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• pp.117-128
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• 2003

Thallium-201 scintigraphy is used to discriminate the malignant bone tumor from the benign by qualitatively and quantitatively, and to predict the response of preoperative chemotherapy in osteosarcoma, by comparing the changes of thallium uptake ratio after chemotherapy to the tumor necrosis ratio. Thallium-201 scintigraphy scan should be done prior to surgical biopsy. PICKER Prism 2000 gamma camera with high resolution parallel hole collimator is usually used for scanning. The patient is injected with 2-3mCi of Tl-201 and the early phase is checked in 30 minutes and delayed phase in 3 hours. The scan images are visually evaluated by a blinded nuclear medicine physician. We could evaluate true positive, true negative, false positive and false negative by the comparison of results with those of biopsy, and calculate positive and negative predictive value(%), sensitivity(%), specificity(%) and diagnostic accuracy(%). For the quantitative analysis of thallium uptake, we drew the region of interest on the tumor side and contralateral normal side as mirror image, and calculated the uptake ratio with dividing the amount of gamma count in tumor side by normal side. We could calculate the percent changes of thallium uptake ratio in early and delayed phase, and compare them to the ratio of tumor necrosis. Thallium-201 scintigraphy proved as useful imaging study to discriminate malignant bone tumor from benign, but had exception in giant cell tumor and low grade malignant bone tumors. We can use T1-201 scan to differentiate the benign from the malignant tumor, and to evaluate the response of preoperative chemotherapy or radiotherapy, and to determine the residual tumor or local recurrence. For the better result, we need to have a more detail information about false positive cases and a more objective and quantitative reading technique.

• Radiation Oncology Journal
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• 제34권2호
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• pp.96-105
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• 2016

Purpose: The standard radiation dose for patients with locally rectal cancer treated with preoperative chemoradiotherapy is 45-50 Gy in 25-28 fractions. We aimed to assess whether a difference exists within this dose fractionation range. Materials and Methods: A retrospective analysis was performed to compare three dose fractionation schedules. Patients received 50 Gy in 25 fractions (group A), 50.4 Gy in 28 fractions (group B), or 45 Gy in 25 fractions (group C) to the whole pelvis, as well as concurrent 5-fluorouracil. Radical resection was scheduled for 8 weeks after concurrent chemoradiotherapy. Results: Between September 2010 and August 2013, 175 patients were treated with preoperative chemoradiotherapy at our institution. Among those patients, 154 were eligible for analysis (55, 50, and 49 patients in groups A, B, and C, respectively). After the median follow-up period of 29 months (range, 5 to 48 months), no differences were found between the 3 groups regarding pathologic complete remission rate, tumor regression grade, treatment-related toxicity, 2-year locoregional recurrence-free survival, distant metastasis-free survival, disease-free survival, or overall survival. The circumferential resection margin width was a prognostic factor for 2-year locoregional recurrence-free survival, whereas ypN category was associated with distant metastasis-free survival, disease-free survival, and overall survival. High tumor regression grading score was correlated with 2-year distant metastasis-free survival and disease-free survival in univariate analysis. Conclusion: Three different radiation dose fractionation schedules, within the dose range recommended by the National Comprehensive Cancer Network, had no impact on pathologic tumor regression and early clinical outcome for locally advanced rectal cancer.

• Radiation Oncology Journal
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• 제27권2호
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• pp.78-83
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• 2009

목 적: 직장암에서 수술 전 항암화학방사선치료는 수술 후 항암화학방사선치료에 비하여 치료 성적은 비슷하며 독성은 낮아 최근에 많이 시행되고 있다. 본 연구에서는 수술 전 항암화학방사선치료 시 병행한 항암화학요법 중 적정 요법과 적정 이하의 비적정 요법에 따른 치료 결과를 알아보고자 하였다. 대상 및 방법: 2003년 4월부터 2006년 4월까지 수술 전 항암화학방사선치료와 수술을 시행한 환자 중 수술 병리결과 확보가 가능하고 단일 제제 화학요법을 시행한 환자 43명을 대상으로 하였다. 방사선치료는 전 골반에 41.4~50.4 Gy (중앙값, 45 Gy), 종양에 추가조사 0~5.4 Gy (중앙값, 5.4 Gy), 총 41.4~50.4 Gy (중앙값, 50.4 Gy)를 시행하였다. 적정군은 5-fluorouracil (5-FU) 500 mg/$m^2$/day를 방사선치료 첫 3일 동안과 5주 후 3일 동안에 반복 급속 정주 한 6명과 경구 capecitabine을 방사선 치료일에 사용한 6명으로 총 12명이었다. 비적정군은 동일량의 5-FU를 방사선치료 첫 3일에만 급속 정주한 31명이었다. 수술은 방사선치료가 끝난 뒤 40~71일(중앙값, 58일)에 시행하였고 36명은 하전방절제술을, 7명은 복회음절제술을 시행하였다. 결 과: 적정군과 비적정군 사이에, 치료반응 등급 3 이상의 치료반응(83.3% vs. 67.7%, p=0.456), 수술 전과 비교한 수술 후의 병기하강(75.0% vs. 67.7%, p=0.727), 주변절제연 2 mm 초과의 획득(66.7% vs. 83.9%, p=0.237) 등에서 통계적으로 유의하게 차이를 보이지는 않았으나, 병변의 위치가 항문에서 5 cm 이내에 위치한 경우 비적정군에서 괄약근 보존 수술을 시행한 비율이 적정군에 비하여 더 낮은 경향을 보였다(75% vs. 100%, p=0.068). 모든 환자에서 3도 이상의 독성은 관찰되지 않았다. 결 론: 비적정군에서 치료에 수반되는 독성은 낮았으나 모두 2도 이하였고, 항문에서 5 cm 이내에 위치한 직장암의 수술 시 괄약근 보존 수술률이 더 낮은 경향을 보여 적정 화학요법의 병행을 시행하는 것이 바람직하겠다.

• Radiation Oncology Journal
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• 제25권1호
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• pp.34-42
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• 2007

목 적: 국소적으로 진행된 직장암환자에서 수술 전 동시화학방사선요법을 시행한 환자들의 항문 괄약근 보존율과 병기 강하율 등을 분석하고자 후향적 임상 연구를 시행하였다. 대상 및 방법: 2002년 1월부터 2005년 12월까지 조직학적으로 확진된 직장암 환자 중, 병기가 T2 이상이거나 림프절 전이가 있는 환자를 대상으로 하였다. 한림대학교 성심병원 방사선종양학과에서 수술 전 동시화학방사선요법을 시행 받은 36명 중, 본원에서 수술을 시행한 26명을 대상으로 연구를 시행하였다. 환자들은 수술 전 병기결정을 위한 검사를 시행하였고 방사선치료는 CT를 촬영하여 치료계획을 세웠으며 매일 1.8 Gy로 주 5회, 총 방사선 조사량 $45.0{\sim}52.2\;Gy$까지 3차원 방사선치료 방법으로 시행하였으며, 방사선치료 첫째 주와 다섯째 주에 5-FU와 leucovorine을 동시 투여하였다. 수술은 동시화학방사선요법 종료 후 약 $2{\sim}4$주경에 시행하였다. 결 과: 대상 환자의 연령 중앙값은 61.9세($34{\sim}78$)였으며, 남자가 21명, 여자가 5명이었고 추적 관찰 기간의 중앙값은 28개월($11{\sim}44$)이었다. 모든 환자에서 절제연 음성인 근치절제가 가능하였으나 병리적으로 완전 반응을 보인 경우는 없었다. 수술은 3예에서 복회음부 절제술을, 나머지 23예에서 하전방절제술이 시행되어 괄약근 보존율은 88.5% (23/26)였다. 수술 후 병기 강하는 12예로 병기 강하율은 46.2%였으며 19예에서 종양 크기가 감소되어 종양크기 감소율은 73%였다. 국소 재발이 1명, 원격 전이가 3명에서 관찰되었으며 3년 무재발 생존율은 96.7%, 3년 무전이 생존율은 87%, 그리고 3년 무진행 생존율은 83.1%였다. 치료와 관련된 급성 독성으로는 Grade 3 & 4 빈혈 각각 1예, Grade 3 백혈구 감소증 1예, Grade 3 장폐색 1예가 관찰되었다. 결 론: 직장암 환자들에서 수술 전 동시화학방사선요법은 근치적 수술을 시행한 경우 높은 괄약근보존율과 수술 후 병기감소율을 보였으며 치료에 따른 독성도 대부분 경미하고 높은 순응도를 보여 효과적인 방법으로 판단되며 앞으로 많은 환자들을 대상으로 장기간에 걸친 추적 관찰을 요한다.