• Journal of Chest Surgery
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• v.40 no.12
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• pp.817-824
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• 2007

Background: There are two choices for heart valve replacement-the use of a tissue valve and the use of a mechanical valve. Using a tissue valve, additional surgery will be problematic due to valve degeneration. If the risk of additional surgery could be reduced, the tissue valve could be more widely used. Therefore, we analyzed the risk factors and mortality of patients undergoing repeated heart valve replacement and primary replacement. Material and Method: We analyzed 25 consecutive patients who underwent repeated heart valve replacement and 158 patients who underwent primary heart valve replacement among 239 patients that underwent heart vale replacement in out hospital from January 1995 to December 2004. Result: There were no differences in age, sex, and preoperative ejection fraction between the repeated valve replacement group of patients and the primary valve replacement group of patients. In the repeated valve replacement group, the previously used artificial valves were 3 mechanical valves and 23 tissue valves. One of these cases had simultaneous replacement of the tricuspid and aortic valve with tissue valves. The mean duration after a previous operation was 92 months for the use of a mechanical valve and 160 months for the use of a tissue valve. The mean cardiopulmonary bypass time and aortic cross clamp time were 152 minutes and 108 minutes, respectively, for the repeated valve replacement group of patients and 130 minutes and 89 minutes, respectively, for the primary valve replacement group of patients. These results were statistically significant. The use of an intra aortic balloon pump (IABP) was required for 2 cases (8%) in the repeated valve replacement group of patients and 6 cases (3.8%) in the primary valve replacement group of patients. An operative death occurred in one case (4%) in the repeated valve replacement group of patients and occurred in nine cases (5.1%) in the primary valve replacement group of patients. Among postoperative complications, the need for mechanical ventilation over 48 hours was different between the two groups. The mean follow up period after surgery was $6.5{\pm}3.2$ years. The 5-year survival of patients in the repeated valve replacement group was 74% and the 5-year survival of patients in the primary valve replacement group was 95%. Conclusion: The risk was slightly increased, but there was little difference in mortality between the repeated and primary heart valve replacement group of patients. Therefore, it is necessary to reconsider the issue of avoiding the use of a tissue valve due to the risk of additional surgery, and it is encouraged to use the tissue valve selectively, which has several advantages over the use of a mechanical valve. In the case of a repeated replacement, however, the mortality rate was high for a patient whose preoperative status was not poor. A proper as sessment of cardiac function and patient status is required after the primary valve replacement. Subsequently, a secondary replacement could then be considered.

• Radiation Oncology Journal
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• v.17 no.1
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• pp.9-15
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• 1999

Purpose : This is a retrospective study to evaluate the response rate, acute toxicity, and survival rate of a combined chemotherapy and radiation therapy in limited disease small cell lung cancer, Materials and Methods : Firty-six patients with limited disease small-cell lung cancer who underwent combined chemotherapy and radiation therapy between October 1994 and April 1998 were evaluated. Six cycles of chemotherapy were planned either using a VIP regimen etoposide, ifosfamide, and cis-platin) or a EP regimen (etoposide and cis-platin). Thoracic radiation therapy was planned to deli- ver 44 Gy using 1 OMV X-ray, starting concurrently with chemotherapy. Response was evaluated 4 weeks after the completion of the planned chemotherapy and radiation therapy, and the prophylaetic cranial irradiation was planned only for the patients with complete responses. Acute toxicity was evaluated using the SWOG toxicity criteria, and the overall survival and disease-free survival were calculated using the Kaplan-Meier Method. Results : The median follow-up period was 16 months (range:2 to 41 months). Complete response was achieved En 30 (65$\%$) patients, of which 22 patients received prophylactic cranial irradiations. Acute toxicities over grade III were granulocytopenia in 23 (50$\%$), anemia in 17 (37$\%$), thrombo- cytopenia in nine (20$\%$), alopecia in nine (20$\%$), nausea/vomiting in five (11$\%$), and peripheral neuropathy in one (2$\%$). Chemotherapy was delayed in one patient, and the chemotherapy doses were reduced in 58 (24$\%$) out of the total 246 cycles. No radiation esophagitis over grade 111 was observed, while interruption during radiation therapy for a mean of 8.3 days occurred in 21 patients. The local recurrences were observed in 8 patients and local progressions were in 6 patients, and the distant metastases in 17 patients. Among these, four patients had both the local relapse and the distant metastasis. Brain was the most common metastatic site (10 patients), followed by the liver as the next common site (4 patients). The overall and progression-free survival rates were 79$\%$ and 55$\%$ in 1 year, and 45'/) and 32% in 2 years, respectively, and the median survival was 23 months. Conclusion : Relatively satisfactory local control and suwival rates were achieved after the combined chemotherapy and radiation therapy with mild to moderate acute morbidities in limited disease small cell lung cancer.

• Radiation Oncology Journal
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• v.18 no.3
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• pp.194-199
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• 2000

Purpose : Then determining the lower margin of post-operative pelvic radiation therapy field according to the traditional method (recommended by Gunderson), the organs located in the low pelvic cavity and the perineum are vulnerable to unnecessary radiation. This study evaluated the effect of individualized determination of the lower margin at 2 cm to 3 cm below the anastomotic site on the failure patterns. Materials and Methods . Authors included ぉ patients with modified Astler-Coiler (MAC) stages from B2 through C3, who received low anterior resection and post-operative pelvic radiation therapy from Sept. 1994 to May 1998 at Samsung Medical Center, Sungkyunkwan University. The numbers of male and female patients were 44 and 44, and the median age was 57 years (range: 32-81 years). Three field technique (posterior-anterior and bilateral portals) by 6, 10, 15 MV X-rays was used to deliver 4,500 cGy to the whole pelvis followed by Sn cGy's small field boost to the tumor bed over 5.5 weeks. Sixteen patients received radiation therapy by traditional field margin determination, and the lower margin was set either at the low margin of the obturator foramen or at 2 cm to 3 cm below the anastomotic site, whichever is lower. In 72 patients, the lower margin was set at 2 cm to 3 cm below the anastomotic site, irrespectively of the obturator foramen, by which the reduction of radiation volume was possible in 55 patients ($76\%$). Authors evaluated and compared survival, local control, and disease-free survival rates of these two groups. Results : The median follow-up period was 27 months (range : 7-58 months). MAC stages B2 in 32($36\%$), B3 in 2 ($2\%$), Cl in 2 ($2\%$), C2 in 50 ($57\%$), and C3 in 2 ($2\%$) Patients, respectively. The entire patients' overall survival rates at 2 and 4 years were $94\%$ and $68\%$, respectively, and disease-free survival rates at 2 and 4 years were $86\%$ and $58\%$, respectively. The first failure sites were local only in 4, distant only in 14, and combined local and distant in 1 patient, respectively. There was no significant difference with respect to local control and disease-free survival rates ( p=0.42, p=0.68) between two groups of different lower margin determination policies. Conclusion : The new concept in the individualized determination of the lower margin depending on the anastomotic site has led to the equivalent local control and disease-free survival rates, and is expected to contribute to the reduction of unnecessary radiation-related morbidity by reduction of radiation volume, compared with the traditional method of lower margin determination.

• Radiation Oncology Journal
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• v.21 no.4
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• pp.261-268
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• 2003

Purpose: To report the results of curative treatment for patients with tonsil cancer by retrospective analysis. Materials and Methods: From Jan. 1995 till Dec. 2000, 27 patients with squamous cell carcinoma of the tonsil received curative treatment at Samsung Medical Center. Therapeutic decision was made through multidisciplinary conference, and curative radiation therapy was favored when, (1) the patient's condition was not fit for general anesthesia and surgery, (2) the patient refused surgery, (3) complete resection was presumed impossible, or (4) too severe disability was expected after surgery. Surgery was the main local modality in 17 patients (S$\pm$RT group), and radiation therapy in 10 (RT$\pm$CT group). The median follow-up period was 41 months. Results: AJCC stages were I/II in four, III in two, and IV in 21 patients. The 5-year disease-free survival rate was 73.3$\%$ in all patients, 70.6$\%$ in the S$\pm$RT group, and 77.8$\%$ in the RT$\pm$CT group. Treatment failure occurred in seven patients, all with stage III/IV, and all the failures occurred within 24 months of the start of treatment. Five patients among the S$\pm$CT group developed treatment failures; 2 local, 2 regional, and 1 distant (crude rate=29.4$\%$). Two patients among the RT$\pm$CT group developed failures; 1 synchronous local and regional, and 1 distant (crude rate=20.0$\%$). The 5-year overall survival rate was 77.0$\%$ in all patients, 80.9$\%$ in the S$\pm$RT group, and 70.0$\%$ in the RT$\pm$CT group. Conclusion: We could achieve favorable results that were comparable to previously reported data with respect to both the rates of local control and of survival by applying S$\pm$RT and RT$\pm$CT. RT$\pm$CT is judged to be an alternative option that can avoid the functional disability after surgical resection.

• Radiation Oncology Journal
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• v.20 no.2
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• pp.139-146
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• 2002

Purpose : This study evaluated the treatment outcomes, patterns of failure, and treatment related complications of primary lymphoma patients who received definitive radiation therapy. Materials and Methods : A retrospective analysis was undertaken for 31 patients with primary orbital lymphoma at the Asan Medical Center between February 1991 and April 2001. There were 18 males and 13 females with ages ranging from 3 to 73 years (median, 44 years). The involved sites were 9 conjunctivae, 12 eyelids and 10 other orbits. The histological types were 28 MALT lymphomas (low-grade B-cell lymphoma of mucosa-associated lymphoid tissue type), 1 diffuse large B-cell lymphoma, 1 anaplastic large cell lymphoma and 1 lymphoblastic lymphoma. The Ann Arbor stages were all IE $(100\%)$. Ann Arbor stage III or IV patients were excluded from this study, Bilateral orbital involvement occurred in 6 cases. Radiation therapy was given with one anterior port of high energy electrons $(6\~16\;MeV)$ for the lesions located at the anterior structures like the conjunctivae or eyelids. Lesions with a posterior extension or other orbital lesions were treated with 4 or 6 MeV photons with appropriately arranged portals. In particular, lens blocks composed of lead alloy were used in conjunctival or eyelid lesions. Twelve patients received chemotherapy. The median follow-up period was 53 months. Results : The 5-year overall, cause-specific, and disease-free survival was $91\%,\;96\%,\;and\;80\%$, respectively. The complete response rate 6 months after radiation therapy was $100\%$. Local recurrences were observed in 2 patients at 16 and 18 months after completion of radiation treatment. They were salvaged with additional radiation therapy. Two patients developed distant metastases. A MALT lymphoma patient with a lung relapse was successfully salvaged with radiotherapy, but the other lymphoblastic lymphoma patient with bone marrow relapse expired. There were no severe complications but 5 patients developed radiation-induced cataracts and 2 patients developed dry eye. Conclusion : Most primary orbital lymphomas consisted of MALT lymphomas. Radiation therapy was a successful treatment modality for orbital lymphoma without any severe complications. In cases of local relapses, radiation therapy is also a very successful salvage treatment modality.

• Radiation Oncology Journal
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• v.14 no.1
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• pp.25-31
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• 1996

Purpose : To evaluate the potential advantage for 'sandwich' technique radiotherapy compared to Postoperative radiotherapy in resectable rectal cancer. Materials and Methods : Between January 1989 and Mar 1994, 60 patients with resectable rectal cancer were treated at Inje University Seoul and Sanggye Paik Hospital. Fifty one patients were available for analysis: 20 patients were treated with sandwich technique radiotherapy and 31 patients were treated with Postoperative radiotherapy. In sandwich technique radiotherapy(RT), Patients were treated with preoperative RT 1500 cGy/5fx, followed by immediate curative resection. Patients staged as Astler-Coiler B2, C were considered for postoperative RT with 2500-4500 cGy. in postoperative RT total radiation dose of 4500-6120 cGy, 180 cGy daily at 4-Sweets was delivered. Patients were followed for median period of 25 months. Results : The overall 5-year survival rates for sandwich RT group and postoperative RT group were $60\%$ and $71\%$, respectively(p>0.05). The 5-rear disease free survival rates for each group were $63\%$. There was no difference in local failure rate between two groups($11\%$ versus $7\%$) Incidence of distant metastasis was $11\%$(2/20) in the sandwich technique RT group and $20\%$(6/31) in the postoperative RT group(p>0.05). The frequencies of acute and chronic complications were comparable in both groups. Conclusion : The sandwich technique radiotherapy group shows local recurrence and survival similar to those of Postoperative RT alone group but reduced distant metastasis compared to Postoperative RT group. But long term follow-up and large number of patients is needed to make an any firm conclusion regarding the value of this sandwich technique RT.

• Radiation Oncology Journal
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• v.18 no.2
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• pp.92-100
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• 2000

Purpose :This study was performed to determine the optimal treatment velum of Patients treating with radiation therapy for intracranial germ cell tumor. Materials and Methods : From 1993 to 1998, 19 patients with intracranial germ cell tumors treated by gamma knife radiosurgery were analyzed. The location of tumor was as follows; 9 cases on pineal region, 1 case on suprasellar region, and 9 cases of multiple lesion. 7 patients were pathologically verified; 5 cases of germ cell tumor and 2 cases of non germinomatous germ cell tumor. Tumor volume was ranged from 2.4 cm$^{3}$ to 74 cm$^{3}$. Irradiation dose was 10 Gy to 20 Gy with 50% isodose curve. Follow up period was 10 months to 54 months. Results : Recurrences were observed in 14 cases among 19 (74%) patients. Complete remission and partial remission were achieved in 2 (11%) and 10 (53%) respectively. No response was observed in 7 (36%). 2 cases were recurred within original tumor bed. 6 cases were recurred beyond but contiguous with tumor bed. Ventricular relapses separated from pretreatment tumor bed were 3. Spinal recurrences were 4. Among 8 recurred cases of which tumor volume is smaller than 20 cm$^{3}$, 2 were recurred within original tumor bed, 4 were recurred beyond but contiguous with tumor bed, and 1 spinal recurrence. Meanwhile, 6 cases of which tumor volume larger than 20 cm3, 1 case was recurred beyond but contiguous with tumorbed, 2 ventricular recurrences separated with original tumor bed, and 3 spinal recurrences. 5 cases which did not show any recurrence sign showed characteristics of single lesion, tumor volume smaller than 20 cm$^{3}$ and normal tumor marker. All of 4 cases of spinal recurrences happened in the case having ventricular invasion or lesion. Among 9 cases having multiple lesion, only 3 cases recurred within original tumor bed or around tumor bed, the other 6 cases recurred separated from pretreatment tumor bed. Conclusion : Gamma knife radiosurgery is not recommended for the treatment of intracranial germ cell tumor. It is because of small treatment volume and inadequate radiation dose that are characteristics of gamma knife radiosurgery. Tumor volume, ventricular invasion or ventricular lesion in multiple lesion are important factors to be considered for the wide field radiation therapy Tumor volume smaller than 20 cm$^{3}$, single lesion, no ventricular lesion or invasion, and normal tumor marker are ideal indications for small involved field radiation therapy. Prophylactic spinal irradiation seems to be necessary when there is ventricular lesion, ventricular invasion, and multiple lesions. When the tumor volume is larger than 20 cm$^{3}$, multiple lesions, abnormal tumor marker, and whole ventricular irradiation or partial brain irradiation would be possible and neoadjuvant chemotherapy would be most beneficial in these group.

• Radiation Oncology Journal
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• v.27 no.4
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• pp.181-188
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• 2009

Purpose: The aim of this study was to evaluate the results of postoperative radiotherapy in a case of perihilar cholagiocarcinoma by analyzing overall survival rate, patterns of failure, prognostic factors for overall survival, and toxicity. Materials and Methods: Between January 1998 and March 2008, 38 patients with perihilar cholangiocarcinoma underwent a surgical resection and adjuvant radiotherapy. The median patient age was 59 years (range, 28 to 72 years), which included 23 men and 15 women. The extent of surgery was complete resection in 9 patients, microscopically positive margins in 25 patients, and a subtotal resection in 4 patients. The tumor bed and regional lymphatics initially received 45 Gy or 50 Gy, but was subsequently boosted to a total dose of 59.4 Gy or 60 Gy in incompletely resected patients. The median radiotherapy dose was 59.4 Gy. Concurrent chemotherapy was administered in 30 patients. The median follow-up period was 14 months (range, 6 to 45 months). Results: The 3-year overall survival and 3-year progression free survival rates were 30% and 8%, respectively. The median survival time was 28 months. A multivariate analysis showed that differentiation was the only significant factor for overall survival. The 3-year overall survival was 34% in R0 patients and 20% in R1 patients. No statistically significant differences in survival were found between the 2 groups (p=0.3067). The first site of failure was local in 18 patients (47%). No patient experienced grade 3 or higher acute toxicity and duodenal bleeding developed in 2 patients. Conclusion: Our results suggest that adjuvant RT might be a significant factor in patients with a positive margin following a radical resection. However, there was still a high locoregional recurrence rate following surgery and postoperative radiotherapy. Further study is necessary to enhance the effect of the adjuvant radiotherapy.

• Radiation Oncology Journal
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• v.26 no.1
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• pp.65-73
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• 2008

Purpose: Women with breast cancer diagnosed at an age of 40 years or younger have a greater prevalence of germline BRCA1 and BRCA2 mutations than the prevalence of women with breast cancer diagnosed at older ages. Several immunohistochemical characteristics have been identified in breast cancers from studies of Caucasian women with BRCA1/2 mutations having familial or early-onset breast cancers. The aim of this study is to determine whether early-onset breast cancer in BRCA1 or BRCA2 mutation carriers, who were not selected from a family history, could be distinguished by the use of immunohistochemical methods and could be distinguished from breast cancer in women of a similar age without a germline BRCA1 or BRCA2 mutation. We also analyzed the prognostic difference between BRCA1/2 related and BRCA1/2 non-related patients by the use of univariate and multivariate analysis. Materials and Methods: Breast cancer tissue specimens from Korean women with early-onset breast cancers were studied using a tumor tissue microarray. Immunohistochemical staining of estrogen receptor(ER), progesterone receptor(PR) and HER-2, as well as the histology and grade of these specimens, were compared. The prognostic impact of immunohistochemical and histological factors as well as the BRCA1/2 mutation status was investigated separately. Results: There were 14 cases and 16 deleterious BRCA1/2 mutations among 101 patients tested. A family history(4/14) and bilateral breast cancers(3/9) were high risk factors for BRCA1/2 mutations. BRCA1/2-associated cancers demonstrated more expression of ER-negative(19.4% versus 5.1%, p=0.038) and HER-2 negative than BRCA1/2 negative tumors, especially for tumors with BRCA1 tumors The BRCA1/2 mutation rate for patients with triple negative tumors(negative expression of ER, PR and HER-2) was 24.2%. Tumor size, nodal status, and HER-2 expression status were significantly associated with disease free survival, as determined by univariate and multivariate analysis, but the BRCA1/2 status was not a prognostic factor. Conclusion: Breast cancer that occurs in women with a germline BRCA1 or BRCA2 mutations have recognizable immunohistochemical features, which may be useful in identifying individuals that are more likely to carry germline mutations. Although the BRCA1/2 mutation status was not a prognostic factor in Korean women with early-onset breast cancer, more cases with a longer follow-up period are needed for further study.

• Radiation Oncology Journal
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• v.20 no.4
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• pp.316-322
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• 2002

Objective : A retrospective study was peformed to evaluate whether postoperative adjuvant radiotherapy can improve survival and decrease recurrence as compared with surgery alone in resected esophageal cancer. Materials and Methods : From Jan. 1985 to Dec. 1993, among 94 esophageal cancer Patients treated with surgery, fifty-one patients were included in this study. Transthoracic esophagectomy was peformed in 35 patients and transhiatal esophagectomy in 16. Postoperative adjuvant radiotherapy was peformed 4 weeks after surgery in 26 among 38 patients in stage II and III. A total dose of $30\~60\;Gy$ in 1.8 Gy daily fraction, median 54 Gy over 6 weeks, was delivered in the mediastinum+both supraclavicular lymph nodes or celiac lymph nodes according to the tumor location. Forty-seven patients$(92\%)$ had squamous histology. The median follow-up period was 38 months. Results : The overall 2-year and 5-year survival and median survival were $56.4\%,\;36.8\%$ and 45 months. Two-year and 5-year survival and median survival by stage were $92\%,\;60.3\%$ for stage I, $63\%,\;42\%$ and 51 months for stage II and $34\%,\;23\%$ and 19 months for stage III (p=0.04). For stage II and III patients, 5-year survival and median survival were $22.8\%$, 45 months for the surgery alone group and $37.8\%$, 22 months for the postoperative RT group (p=0.89). For stage III patients, 2-year survival and median survival were $0\%$, 11 months for the surgery alone group and $36.5\%$, 20 months for the postoperative RT group (p=0.14). Local and distant failure rates for stage II and III were $50\%,\;16\%$ for the surgery alone and $39\%,\;31\%$ for the postoperative RT group. For N1 patients, local failure rate was $71\%$ for the surgery alone group and $37\%$ for the postoperative RT group (p=0.19). Among 10 local failures in the postoperative RT group, in-field failures were 2, marginal failures 1, out-field 5 and anastomotic site failures 2. Conclusion : There were no statistically significant differences in either the overall survival or the patterns of failure between the surgery alone group and the postoperative RT group for resected stage II and III esophageal cancer. But this study showed a tendency of survival improvement and decrease in local failure when postoperative RT was peformed for stage III or N1 though statistically not significant. To decrease local failure, a more generous radiation field encompassing the supraclavicular, mediastinal, and celiac lymph nodes and anastomotic site in postoperative adjuvant treatment should be considered.