Liver Cancer

◎ Definition
Liver is the largest organ in our body located right epigastrium that formed in two parts. Liver filters harmful matters from the blood and creates and stores matters that are necessary to maintain life and process elements that are absorbed so it can be used to our body appropriately. Also, it purifies our body along with kidney by eliminate unnecessary matters from our body. But, liver cells get damage when excessive medicines and toxicants are taken and create hepatitis, fatty liver, liver cirrhosis and can grow to be liver cancer. Most of primary liver cancer begins at liver cell and these types of cancer are called hepatoma or malignant liver cancer. When liver cancer get out from liver and transfer, cancer cells spreads to surrounding lymph node, bone and lung and the newly created tumors at this stages are abnormal cells that are same with primary tumor that found in liver. Be contrary to that, cancer created due to cancer cell separated from the cancer that created from other organs spread through blood vessels or lymphatic vessel is called metastatic liver cancer. Due to liver’s characteristic, many numbers of cancers created in organs, especially organs in belly are transmitted to liver easily. Primary liver cancer is classified as hepatoma, bile duct cancer and combine of hepatoma and bile duct cancer and sarcoma depends on which cell the cancer is developed. The most common liver cancer is hepatoma followed by bile duct cancer and most frequent developed liver cancer in Korea is the hepatoma. Speed of liver cancer’s progress is very fast so it is known that people usually survives only 3~4 month after diagnosis if it is not treated.

◎ Symptom
Liver cancer is the one of diseases that hard to early diagnosis. It is because there are no clear subjective symptoms so many times patients don’t realize it till it is very much advanced. Even when symptoms are finally appeared and liver tissues are being destructed it usually doesn’t exhibit through liver function test so liver is called ‘silent organ’. So, when the size of liver cancer is small, it is hard to know existences of liver cancer just by symptoms. Even when there are some subjective symptoms, many times patients visit hospital after it gets worse just by taking medicines since it is hard to differentiate with benign liver diseases like liver cirrhosis or chronic hepatitis and other stomach related diseases.

General symptoms are the dull pain at right epigastrium, feeling of heavy stomach or swell, nausea, vomiting, diarrhea or constipation, enervation and feeling of tired, weight lose, hypertrophy of liver, jaundice and anemia, hypoglycemia, fever and abdominal bleeding etc and different symptoms appears depending on the organs it has spread. People can spit blood when it is spreads to stomach or esophagus and when it has spread to lung, symptoms like cough and hemoptysis can be presented and headache or palsy can be occur when it has spread to brain. In case of spreading to bone, paralysis of lower half of body can be occur. All these symptoms are common symptoms of lowered of liver functions and normally not occurs on certain kinds of liver cancer.

◎ Treatment
sic treatment of liver cancer is surgical resection. But with advanced liver cancer, over 80% of liver cancer patients receive non-surgical treatment even with small liver cancer of early stage due to conditions like age of patient, very bad functional liver due to intense liver cirrhosis or can not operate due to location of tumor or numbers of tumor and when patients refuse to have operation. These kinds of non-surgical treatments are continuously improved through technology development and with accumulating clinical demonstration sometimes it exhibits same results as the surgical operation treatments. Procedure with local anesthesia is possible since all these treatment methods are all minimal-invasive so there are no dangers due to general anesthesia or laparotomy and there are merit of fast recover and return to normal life since it is possible to receive treatment as the outpatient or only few days is enough in the case of need of hospitalization. There are Transcatheter Arterial Chemo Embolization, ethanol injection and radiofrequency, laser, microwave and High Intensity Focused Ultrasound applied treatments as for the non-surgical operation liver treatments.

Radiofrequency ablation of liver cencer (RF liver ablation) treatment has been in center of concern ever since it was first presented in 1990 and it is the RF liver cencer treatment method not only being used in Korea, but being used worldwide at present. Under the ultrasonic-guide, locate RF electrode in the tumor then creates radiofrequency by the RF generator, electric current is conducted to surrounding tissue from the end of electrode. This stimulates ion of cancer tissue around RF electrode and created friction heat, and when temperature rise over 50°C, cells get irreversible damage. Compare to ethanol injection method, it have advantage of high complete removing rate and number of medical treatment can be reduced and it exhibits excellent effect on metastatic tumors of the liver.

Hypertension

◎ Treatment
Lancet. 2010 Dec 4;376(9756):1903-9. Epub 2010 Nov 17. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Symplicity HTN-2 Investigators, Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Bohm M. Collaborators (44) Bohm M, Mahfoud F, Sievert H, Wunderlich N, Rump LC, Vonend O, Schmieder RE, Uder M, Lobo M, Caulfield M, Erglis A, Azizi M, Sapoval M, Thambar S, Persu A, Renkin J, Schunkert H, Weil J, Hoppe UC, Krum H, Walton T, Schlaich MP, Esler MD, Scheinert D, Binder T, Januszewicz A, Witkowski A, Ruilope LM, Whitbourn R, Bruck H, Downes M, Luscher TF, Jardine AG, Webster MW, Zeller T, Sadowski J, Bartus K, Sobotka PA, Straley CA, Barman NC, Lee DP, Witteles RM, Bhalla V, Massaro JM. Source Baker IDI Heart and Diabetes Institute, PO Box 6492, St Kilda Road, Central Melbourne, VIC 8008, Australia. murray.esler@bakeridi.edu.au Abstract BACKGROUND: Activation of renal sympathetic nerves is key to pathogenesis of essential hypertension. We aimed to assess effectiveness and safety of catheter-based renal denervation for reduction of blood pressure in patients with treatment-resistant hypertension. METHODS: In this multicentre, prospective, randomised trial, patients who had a baseline systolic blood pressure of 160 mm?Hg or more (≥150 mm?Hg for patients with type 2 diabetes), despite taking three or more antihypertensive drugs, were randomly allocated in a one-to-one ratio to undergo renal denervation with previous treatment or to maintain previous treatment alone (control group) at 24 participating centres. Randomisation was done with sealed envelopes. Data analysers were not masked to treatment assignment. The primary effectiveness endpoint was change in seated office-based measurement of systolic blood pressure at 6 months. Primary analysis included all patients remaining in follow-up at 6 months. This trial is registered with ClinicalTrials.gov, number NCT00888433. FINDINGS: 106 (56%) of 190 patients screened for eligibility were randomly allocated to renal denervation (n=52) or control (n=54) groups between June 9, 2009, and Jan 15, 2010. 49 (94%) of 52 patients who underwent renal denervation and 51 (94%) of 54 controls were assessed for the primary endpoint at 6 months. Office-based blood pressure measurements in the renal denervation group reduced by 32/12 mm?Hg (SD 23/11, baseline of 178/96 mm?Hg, p

Thyroid Nodules

◎ Definition
Thyroid Nodule is very common and many diseases like benign tumor, thyroiditis and thyroid cancer etc. are the reason. It is developed more among the women. In the case of middle age women, tuber can be found by touch in about 5% of patient and rate goes up to 50~60% with thyroid imaging with ultrasound.

Thyroid Nodule itself is not big of problem when it is benign tumor since it rarely develops symptoms itself. But about 5% of thyroid nodule is thyroid cancer so if tumor is founded, diagnosis of weather or not it is cancer is must. Surgical operation is necessary when it is diagnosed as thyroid cancer, and no need of operation in the case of benign tumor in most of cases. Thyroid nodule is tuber created by part of thyroid get enlarged abnormally. So, thyroid nodule is not the name of diagnosis but it is one of symptoms that appears due to many thyroid diseases and the cause of it can be benign tumor and chronic thyroiditis etc.

◎ Symptom
When size of thyroid nodule reaches about 0.5~1 cm, it is possible to examine by the hand of experienced doctors and patient can touch themselves when it grow to be larger size. When size gets even larger, it can be seen from outside that is bulged out and commonly, movement of up and down can be seen when swallow saliva. When the size of thyroid nodule is too big, it can press surrounding tissue to create uncomfortable food swallowing, causes coughing and uncomfortable breathing etc but those is rare cases and usually it created problem only for the beauty of appearance. There are only within 2% of chance of cancer with tuber less than 1 cm that can be found only through ultrasound exam and it almost never creates any problems. The most important thing to do when thyroid nodule is found is to confirm that weather or not it is cancer. About 5% of tuber that can be touched is thyroid cancer. There are no symptoms of thyroid cancer in most of cases. 

Generally, the tuber of thyroid cancer is very hard and does not move when touched since it is adhered with surrounding tissue, speed of growth is fast and hoarsen due to invasion to surrounding nerves or lymph node around tuber can get larger. All these symptoms indicate possibilities of thyroid cancer but, there are thyroid cancers without any of those symptoms so accurate diagnosis through exam is necessary. In most of cases, thyroid nodule doesn’t accompanying symptoms but rarely, it induces hyperthyroidism. At this point, all the symptoms of hyperthyroidism will be appears. Thyroid nodule is found in women more frequently. Normally, it is found in female 4-5 times more than in male and the reason of it is still not clear.

◎ Treatment
Even with confirmation of benign through fine needle aspiration cytology on thyroid nodule, positive immediate treatment is not necessary. Sometimes, thyroid hormone is injected depends on the doctors. When the size of nodule is big and suppress surrounding, nodule is removed by surgical resection. It is the most secure treatment but, in most of cases, it doesn’t create big enough problems that require surgeries. When it is cystic thyroid nodule, sometimes liquid is extracted with syringe and treatment of injecting matters like alcohol is practiced when it relapse.

When thyroid nodule is distinguished as benign, operation is given for the tuber size of over 3 cm and medicine treatment is given for the ones less than 3 cm with observation in 6 month terms but the effects of it is unclear. Therefore, there are no special treating methods for small sized benign nodule.

But lately, radiofrequency ablation system that is being used for liver cancer, uterine fibroid and lung cancer etc. is applied to thyroid benign nodule and exhibits excellent treatment effects.  Radiofrequency ablation is inserting RF electrode to center part of tumor and create radiofrequency by RF generator and burn to eliminate tumors using radiofrequency heat. The advantages of thyroid radiofrequency ablation (RF ablation) are

1.	Treat thyroid nodule without scars or surgical operation.
2.	Unlike operation, there is no side effect.
3.	One day of hospitalization is enough. (Generally, operation requires 5-7days)
4.	Treat with local anesthesia.
5.	In most of cases, procedure is done with just 1 treatment.
6.	Less pain and fast recovery compares to operation.

Bone Tumor

◎ Definition
Cancer that created at breast, lung, stomach, uterus, thyroid and prostate etc. transmitting to bone due to progress of disease is called bone metastasis. Sometimes, the cancer that are unclear of created area transmitted to bone and misconceived as primary bone tumor since it present symptoms only at the bone. The easiest cancer to be transmitted to bone is breast cancer and sometimes, it transmits to bone after 10 years of treatment. Most of transmitted area is spine and thoracic vertebrae and vertebrae lumbales are most common and other than that, it is transmitting to pelvis, skull, femur and upper bone of arm. But it is rare to be transmitted to small bones of hands and feet.

Bone is common place for malignant tumor, which is transmitted from other area and it depends on the types of cancer but about 50~60% of cancer patients have Bone Metastasis. In the past, treatments for bone metastasis due to idea of thinking that bone metastasis is end stage of the cancer, but lately, with newly developed treatment, life of patient have been extended and trend of thinking the quality of living while alive became important have been rise. Suitable treatment is needed when experiencing pain due to bone transmitting, difficulty of walking and development of pathological fracture.

◎ Symptom
Pain around transmitted area is the most main symptom of bone metastasis but there are swelling, pathological fracture and spinal paralysis due to spine transmitted etc. other than pain. In early stage, light symptoms are presented that are uncomfortable for general living like lose of appetite and insomnia etc.

1. Bone pain
- It is the most common symptom that appears to be localized and develops gradually through few weeks, and it gets worse mostly at night.

2. Fracture
- Cause severe pains and it can be symptom of early stage of bone metastasis.

3. Spinal compression
- If patient with lumbago presents neurological symptom, emergency examination is carried since there is chance of spinal compression.

4. Hypercalcemia of malignancy
- It appears due to bone destruction and induces symptoms like nausea, lose of appetite, thirst and great tiredness etc. Coma can be induced if don’t treat on time.

◎ Treatment
Treatment methods are surgical operation, chemotherapy, radiotherapy and hormone therapy, radiofrequency ablation (RF ablation) etc. and many treatment is carried depends on created area and transmitted area. Radiotherapy is carried to suppress transmitting focus and removing pain and treatment is done with 4000~5000 rad. Bone connecting operation is carried for pathological fracture of long bone if patient’s whole body condition permits but, many times bone cements are being used together. Some cases, spinal paralysis treatment due to transmitting to spine is done by laminectomy but recovery is very difficult once complete paralysis developed. Hormone therapy is carried when it is believed to have hormone dependency such as breast cancer, prostate cancer, kidney cancer and endometrial cancer etc.

Bone metastasis radiofrequency ablation is treatment that newly presented and by applying radiofrequency ablation that are being used for RF ablation of liver cancer, myoma of the uterus and lung cancer etc. and exhibits very excellent effects. Radiofrequency ablation is inserting RF electrode to center part of tumor and create radiofrequency by RF generator and burn to eliminate tumors using radiofrequency heat.

Varicose Vein

◎ Definition
Varicose veins are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg,[1]although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde flow or reflux).[2] Leg muscles pump the veins to return blood to the heart (the skeletal-muscle pump), against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work (valvular incompetence). This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing.

◎ Symptom
Besides being a cosmetic problem, varicose veins can be painful, especially when standing. Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening (lipodermatosclerosis) and ulceration. Life-threatening complications are uncommon, but varicose veins may be confused with deep vein thrombosis, which may be life-threatening.

◎ Treatment
Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10% of the total blood of the legs, can usually be removed or ablated without serious harm.

Treatment Modalities:
Endovenous Radio Frequency Ablation.
Surgical ligation
Surgical stripping
Sclerotherapy

Uterine Fibroid

◎ Definition
Uterine Fibroid is benign tumor commonly called myoma that is easy to find in over 20-40 % of fertile women. There are usually no symptoms being presented so many times it is found while giving medical examination or due to promotion of foreign substance from underbelly. It’s because people usually can not notice the problem since most of Uterine Fibroid exhibits no symptoms or unclear symptoms like uncomfortable pelvis, pressure, dyspareunia, lumbago and urinary disturbance. Uterine fibroid existence and sizes can be confirmed easily with simple ultrasound exam. It is unusual for uterine fibroid to grow as cancer but however 0.1~0.4% of uterine fibroid turns into cancer and sometimes it creates 2nd degeneration and cause great pelvis pain. Unless the size of uterine fibroid is too big or cause special symptoms, it is not must to treat. The reason of uterine fibroid creation and growth is unclear but it is inferred that female hormone, estrogen act greatly and Uterine myoma is generally classified into 3 types based on where the myoma is developed within the uterus.

1. Submucosal myoma
- This type develops in the substratum endometrium, with the worst prognosis and many complications. Even a small size can bring bleeding and causes abortion and infertility. The rate of changing to a sarcoma is large and easily becomes an infection, suppuration, and necrosis.
Incidence rate : about 5%

2. Intramural myoma
- Developing deeply within the myometrium, this myoma causes the uterus size to increase. The area of the endometrium increases which causes the amount of menstruation to increase, but the patient cannot feel any other symptoms.
Incidence rate : about 80%

3. Subserosal myoma
- This develops in the most outer layer of the uterus. The myoma itself does not have any subjective symptoms, but suppresses other surrounding organs and causes many kinds of symptoms.
Incidence rate : about 15%

◎ Symptom
As the uterine myoma increases, it suppresses many surrounding organs within the body and blocks the contraction and relaxation of the uterus which causes many symptoms. The representative symptoms are abnormal metrorrhagia, pelycalgia, menstrual cramps, dyspareunia, urinary frequency, etc. The possibility of early labor increases in the case of infertility, early abortion and pregnancy, and that of puerperium bleeding increases since the uterus does not contract well after giving birth.
1. Menorrhagia
As the most common symptom of uterine myoma, the amount of menstruation increases and presents the main reason for treatment or surgery. This naturally causes anemia and chronic fatigue, which is a syndrome of continuous tiredness. The menstruation period may increase or it happens abnormally not during the period.

2. Pelycalgia
It is classified into chronic pelycalgia and acute pelycalgia. Chronic pelycalgia occurs in a form of menstrual cramps, dyspareunia, pelvic compression, and acute pelycalgia may occur with necrosis or denaturation of the myoma. Pelycalgia shows severe difference between individuals, and has various cases from slight levels to unbearable severe pain.

3. Urinary frequency or micturition disorder
This occurs if the uterine myoma develops from the anterior direction of the uterus wall and suppresses the urinary bladder or ureter.

4. Constipation or defecation pain
This occurs if the uterine myoma develops from the posterior direction of the uterus wall and suppresses the rectum.

5. Digestion disorder or ileus
This occurs when the uterine myoma suppresses the intestines.

6. Infertility
The myoma causes infertility and abortion depending on its location.

◎ Treatment
About 3 methods are presented for treating uterine myoma- hormone therapy, extirpation, (hysterectomy, myomectomy) and radiofrequency myolysis. Extirpation is divided into laparotomy and endoscopic operation. Endoscopic operation is parted into colpolaparotomy and laparoscopy. As the most recently developed method, RF Myolysis is the most supported by uterine myoma patients and OBGYN doctors. The treatment mechanism is to insert a thin RF electrode into the myoma or adenomyoma and create radiofrequency by RF generator. Then the ions in the organs will vibrate, creating heat and protein degeneration. The tissue which protein was degenerated dies, changes into collagen, and is absorbed slowly into normal organs. Therefore, the myoma size begins to reduce. Not only the tissue is degenerated, but also many blood vessels and other factors related to the growth of the myoma that nutrients it also dies, reducing the myoma and preventing reproduction and redevelopment. This lowers the recurrence rate significantly. Also, factors causing bleeding and pain are also eliminated. At present, many university and specialized hospitals are using this method, and many studies are being presented on positive, epochal treatment effects. Since its priorities are to preserve the uterus while showing fast improvements of several symptoms caused by uterine myoma or uterine adenomyoma, young women, those who want to preserve the uterus although they do not have further plans of pregnancy, and women in their 40s close to menopause with severe symptoms due to the myoma should actively consider this method.

Advantages of RF Myolysis are as follow;

1.	Preserve uterus with minimal damage.
2.	Conscious sedation can be used which excludes the risk of general anesthesia.
3.	The procedure time is short, and the patient can admitted and departed on that day since there are not any sequelas.
4.	Symptoms such as excessive bleeding or pain are quickly improved.
5.	No pain due to procedure or bleeding and leaves no scars or wound.
6.	The redevelopment and recurrence are blocked by eliminating the growth factor of the myoma.
7.	In cases of uterine adenomyoma, preservation treatment without removing the uterus is possible.
8.	Re-operation is simple, in case symptom improvement effects are under expects.

Adenomyosis

◎ Definition
This is a disease of a part of the endometrium proliferating abnormally in the myometrium, usually found in women over 40 of age. Excessive amounts of menstruation and extension of menstruation period, menstrual cramps are the most common symptoms. Dyspareunia and pelycalgia also appear commonly. Menstrual cramps start a week before menstruation and may continue until menstruation stops. As the endometrium tissue proliferates in the myometrium abnormally, the whole uterus enlarges and becomes heavy. Generally, the uterus wall gets about 2-2.5cm thicker, but 20-25% shows normal uterus size. The endometrium tissue in the myometrium often is influenced by hormones and cause bleeding during the menstruation period. In this case, the lesion color is reddish brown. About 15% of the patients are accompanied with endometriosis and over 50% has uterine myoma. Based on ultrasound image, the anterior, posterior wall of the uterus get thicker and shows an asymmetric feature. The boundary within the myometrium is unclear and appears as a heterogeneous shadow. Definite diagnosis can be made through biopsy.

◎ Symptom
Symptoms of Adenomyosis are similar with uterine fibroid. Symptoms are functional disorder types of metrorrhagia, secondary menstrual pain and it can promote uterine with pain, dyspareunia and chronic pelvic pain etc. and about 35% of it creates no symptoms. About 2/3 of functional disorder type metrorrhagia exhibits menorrhagia and the rate of polymenorrhea is quite low. Reason of excessive bleeding during menstruation is increase of volumes in uterine cavity and it can be connected with role of prostaglandin and hyperestrogenemia, and dysmenorrhea seems to be connected with prostaglandin. Dyspareunia’s reason is unclear unless it accompany endometrial hyperplasia and in histological way, the symptoms can be even slight with acute adenomyosis patients and to be opposite, sometimes it exists in affected area or in many times patient with non-functional adenomyosis complain severe pain. It is rare that adenomyosis exist by itself and about 80% of it accompanying myoma, endometrial hyperplasia, endometriosis and endometrial cancer etc. Fact of all disease above is connected to long term estrogen expose suggest that adenomyosis is connected with hyperestrogenemia. Disease that most accompany with adenomyosis is myoma of the uterus and it is about 57%. Even with many similar point with adenomyosis, endometriosis is accompanies only about 27%.

◎ Treatment
In case of myoma, the boundary of normal myometrium is clear and divided, so it is possible to extract only the myoma. However, in cases of adenomyosis, the endometrium tissue is distributed evenly within the myometrium without any boundaries. It is impossible to selectively remove abnormally proliferated endometrium tissue. As for complete recovery, hysterectomy is considered as the only way. Recently, there is a movement to improve the quality of life of women by preserving the uterus than unconditionally removing it and as a result, Radiofrequency ablation (RF Myolysis) is being highlighted for uterus preservation treatment for adenomyosis. At present, many university and specialized hospitals enforce RF Myolysis to women who want to preserve the uterus. As the abnormally proliferated endometrium tissue is protein degenerated by radiofrequency heat, it goes through necrosis, absorption, and finally the enlarged uterus slowly reduces. Improvement effects of symptoms such as menstrual cramps are quite satisfying. Therefore, it is recommended to enforce RF Myolysis before reckless hysterectomy.