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BACKGROUND: Liver resection (LR) of colorectal metastases is associated with high recurrence risk. Aggressive local retreatment is advocated, but further recurrences may occur. Poor is known about presentation, treatment, and outcome of iterative recurrences. METHODS: A series of 323 consecutive patients undergoing first LR in the period 2004-2013 was reviewed. Patients with recurrence were included. Any local treatment (surgery, radiofrequency ablation (RFA) and stereotactic body radiation therapy (SBRT)) was analyzed. If first recurrence (1st Rec) was treated, further recurrences and treatments were considered. RESULTS: Overall, 206 (63.8%) patients had 1st Rec; 105 (51.0%) were treated (72 surgery, 19 RFA, 14 SBRT). Among treated patients, 78.1% had 2nd Rec, 74.4% 3rd Rec, 72.2% 4th Rec. Liver involvement progressively decreased (from 81.6 to 30.8%), and pulmonary one increased (from 23.3 to 53.8%). The proportion of treated patients remained stable (1st Rec = 51%, 2nd Rec = 55%, 3rd Rec = 56.3%, 4th Rec = 69.2%): surgery and RFA decreased (from 35.4 to 23.1%; from 9.2 to 0%) and SBRT increased (from 6.8 to 46.2%). Overall, 105 patients received 205 treatments (133 operations in 80 patients). Surgery had the best local disease control: at 2 years 93.4% versus RFA 56.4% (p = 0.0008) and SBRT 74.0% (p = 0.051). In comparison with chemotherapy, recurrence treatment improved survival after 1st Rec (3-year survival 62.9 vs. 13.4%, p < 0.0001), 2nd Rec (61.3 vs. 22.5%, p < 0.0001), and 3rd Rec (2-year survival 88.9 vs. 30.8%, p = 0.005). CONCLUSIONS: Aggressive local treatment of recurrent metastases may improve survival, even in the case of iterative recurrences and extrahepatic lesions. Surgery is the standard, but a multidisciplinary approach should be adopted to enlarge the pool of treatable patients.
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Ablação por Cateter , Neoplasias Colorretais/patologia , Hepatectomia , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia/cirurgia , Radiocirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: The aim of this study is to report the results of transarterial embolization (TAE) in the setting of postoperative bleeding after hip surgery. METHODS: We retrospectively evaluated 40 patients (male:female = 15:25, median age = 68 years) who underwent TAE from 2006 to 2016: 77.5% underwent total hip arthroplasty, 20% open reduction internal fixation, and 2.5% external fixation. Preangiographic multidetector computed tomography angiography was performed in 20 (49%) cases, and 9 of them showed arterial extravasation. Twenty-seven TAEs were performed within a week from surgery; active bleeding was seen in 33 (80.5%) angiograms. Gelatin sponge, microparticles, coils, n-butyl cyanoacrylate, and combinations of them were used as embolic materials. RESULTS: Bleeding was controlled in all cases. The most frequently embolized arteries were branches of the deep femoral artery (n = 17). Permanent embolization agents (microparticles, coils, n-2-butyl-cyanoacrylate) were used in 88% of cases; temporary agents (gelfoam) in 12%. One procedure was complicated by arterial dissection. Hospital discharge averaged 20 days post-TAE (median = 17, range = 3-104). One-month survival rate was 97.5%. One patient died of ischemic bowel perforation. CONCLUSION: TAE is safe and effective in stopping the bleeding of the hip region and should be performed early, to avoid irreversible ischemic damage. Multidetector computed tomography angiography can be used to confirm doubtful evidence of ongoing bleeding. Several embolic materials can be used, each one offering different advantages. Low complication and mortality rates were observed. TAE seems to be the ideal first-line intervention when postoperative bleeding of the operated hip is detected.
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Artroplastia de Quadril/efeitos adversos , Embolização Terapêutica/estatística & dados numéricos , Hemorragia Pós-Operatória/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia , Embolização Terapêutica/métodos , Embucrilato , Feminino , Esponja de Gelatina Absorvível , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The impact of fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) for patients with colorectal liver metastases (CLM) still is debated. Its relevance could be enhanced in the case of recurrent disease. The current study aimed to elucidate the role of PET-CT in restaging and treatment planning for recurrent CLM. METHODS: A series of 352 consecutive patients undergoing their first liver resection for CLM between 2005 and 2014 was reviewed. Of these patients, 224 (63.6 %) had a recurrence. The 107 patients who had received PET-CT at diagnosis of recurrence before chemotherapy were analyzed. CT was available in all cases, and magnetic resonance imaging (MRI) was available in 64 cases. RESULTS: Extrahepatic lesions were found in 59 patients. Liver and lung recurrences were detected with excellent sensitivity by CT/MRI and PET-CT (liver: 100 vs. 96.7 %; lung: 95.8 vs. 95.8 %). In detecting other recurrence sites, PET-CT had higher sensitivity than CT/MRI (91.5 vs. 54.2 %, p < 0.01; lymph nodes: 93.5 vs. 64.5 %, p = 0.011; peritoneum: 80 vs. 20 %, p = 0.023; bones: 87.5 vs. 37.5 %, nonsignificant difference). For 28.8 % (17/59) of the patients, the diagnosis of extrahepatic disease was obtained thanks to PET-CT (39.5 % considering nonpulmonary lesions). PET-CT modified treatment strategy in 16 (14.9 %) patients, excluding from surgery 15 (20.3 %) of 74 patients resectable at CT/MRI. This latter subgroup had a lower survival rate than the patients resectable after PET-CT (2-year survival, 22.7 vs. 77.8 %; p = 0.004), similar to the patients unresectable at CT/MRI (57.6 %). CONCLUSIONS: In the authors' experience, PET-CT has offered a relevant contribution to restaging of recurrent CLM. It disclosed one fourth of extrahepatic lesions and prevented worthless surgery for about 20 % of patients.
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Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Colorretais/patologia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/terapia , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Peritoneais/diagnóstico por imagem , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Neoplasias Ósseas/secundário , Fluordesoxiglucose F18 , Humanos , Neoplasias Hepáticas/secundário , Neoplasias Pulmonares/secundário , Linfonodos/diagnóstico por imagem , Metástase Linfática , Imageamento por Ressonância Magnética , Estadiamento de Neoplasias , Planejamento de Assistência ao Paciente , Neoplasias Peritoneais/secundário , Compostos Radiofarmacêuticos , Recidiva , Sensibilidade e Especificidade , Taxa de SobrevidaRESUMO
OBJECTIVES: To present the results of our experience with cyanoacrylic glue percutaneous injection to treat post-surgical non-healing enteric fistulae after failure of standard treatments. METHODS: Eighteen patients (14 males; age range 33-84, mean 69 years) were treated for a non-healing post-surgical enteric fistula after failure of standard treatments. Under computed tomography and/or fluoroscopic guidance, a mixture of cyanoacrylic glue (Glubran 2, GEM, Viareggio, Italy) and ethiodized oil was injected at the site of the fistula. Fistula was considered healed when no material was drained by the percutaneous drainage and a subsequent computed tomography confirmed the disappearance of any fluid collection. RESULTS: In all cases, it was possible to reach the site of the fistula using a percutaneous access. A median of 1 injection (range 1-5) was performed. Fistula healing was achieved in 16/18 (89 %) patients. One patient died for other reasons before fistula healing. Median time for fistula healing was 0 days (mean 8, range 0-58 days). No complications occurred. Reoperation was needed in one patient. CONCLUSIONS: Percutaneous injection of cyanoacrylic glue is feasible, safe, and effective to treat non-healing post-surgical enteric fistulae. It may represent a further option to avoid surgical reoperation in frail patients.
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Cianoacrilatos/administração & dosagem , Fístula Intestinal/terapia , Radiografia Intervencionista , Adesivos Teciduais/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Injeções Intralesionais , Fístula Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/terapia , Radiografia Intervencionista/métodos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , CicatrizaçãoAssuntos
Abscesso Hepático Piogênico , Neoplasias Hepáticas , Bactérias , Farmacorresistência Bacteriana Múltipla , Humanos , Abscesso Hepático Piogênico/tratamento farmacológico , Abscesso Hepático Piogênico/epidemiologia , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/terapia , PrevalênciaRESUMO
OBJECTIVES: To assess mid-term outcome of biodegradable biliary stents (BBSs) to treat benign biliary strictures refractory to standard bilioplasty. METHODS: Institutional review board approval was obtained and patient consent was waived. 107 patients (61 males, 46 females, mean age 59 ± 16 years), were treated. Technical success and complications were recorded. Ninety-seven patients (55 males, 42 females, aged 57 ± 17 years) were considered for follow-up analysis (mean follow-up 23 ± 12 months). Fisher's exact test and Mann-Whitney U tests were used and a Kaplan-Meier curve was calculated. RESULTS: The procedure was always feasible. In 2/107 cases (2 %), stent migration occurred (technical success 98 %). 4/107 patients (4 %) experienced mild haemobilia. No major complications occurred. In 19/97 patients (18 %), stricture recurrence occurred. In this group, higher rate of subsequent cholangitis (84.2 % vs. 12.8 %, p = 0.001) and biliary stones (26.3 % vs. 2.5 %, p = 0.003) was noted. Estimated mean time to stricture recurrence was 38 months (95 % C.I 34-42 months). Estimated stricture recurrence rate at 1, 2, and 3 years was respectively 7.2 %, 26.4 %, and 29.4 %. CONCLUSION: Percutaneous placement of a BBS is a feasible and safe strategy to treat benign biliary strictures refractory to standard bilioplasty, with promising results in the mid-term period. KEY POINTS: ⢠Percutaneous placement of a BBS is 100 % feasible. ⢠The procedure appears free from major complications, with few minor complications. ⢠BBSs offer promising results in the mid-term period. ⢠With a BBS, external catheter/drainage can be removed early. ⢠BBSs represent a new option in treating benign biliary stenosis.
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Implantes Absorvíveis , Doenças Biliares/cirurgia , Implantação de Prótese , Stents , Sistema Biliar , Constrição Patológica/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: In recent decades, the use of radiopharmaceuticals in the assessment of hepatocellular carcinoma (HCC) has become established, and new findings indicate that radiolabelled choline has considerable potential in this setting. Therefore, in this study we aimed to assess the diagnostic role of (11)C-choline positron emission tomography (PET)/CT, compared with conventional imaging with CT/MRI, in patients with HCC. METHODS: The study population comprised 45 patients (male to female ratio = 37:8, median age 70.5 years) referred to our institution owing to HCC: 27 at initial diagnosis and 18 for restaging after recurrence. In all cases we performed whole-body (11)C-choline PET/CT and compared its findings with contrast-enhanced CT (n = 35) or MRI (n = 29) or both (n = 15) for a total of 50 paired scans. The reference standard was either histological proof (21 patients) or a multidisciplinary consensus. Diagnostic accuracy was then determined in a scan-based (SBA) and a lesion-based analysis (LBA). RESULTS: On SBA the sensitivity and specificity for PET were 88 and 90 %, respectively, whereas for CT/MRI they were 90 and 73 %, respectively (p > 0.05). On LBA the overall sensitivity and specificity were 78 and 86 %, respectively, for PET vs 65 and 55 % for CT/MRI. Overall we investigated 168 disease sites, of which 100 were in the liver and 68 were extrahepatic. When considering only liver lesions, (11)C-choline PET and CT/MRI showed an accuracy of 66 and 85 %, respectively, while for extrahepatic lesions PET showed an accuracy of 99 %, while the accuracy of CT/MRI was 32 %. In both cases, there was a statistically significant difference in accuracy between the two modalities (p < 0.01). Combination of the PET results with those of CT/MRI resulted in the highest diagnostic accuracy in both analyses, at 92 % for SBA and 96 % for LBA. In 11 patients (24 %) the PET findings modified the therapeutic strategy, the modification proving appropriate in 10 of them. CONCLUSION: (11)C-Choline PET showed good accuracy in investigating patients with HCC and prompted a change in treatment planning in almost one fourth of patients. The main strength of (11)C-choline PET/CT resides in its ability to detect extrahepatic HCC localizations, but the combination with conventional imaging modalities allowed for the highest diagnostic accuracy.
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Radioisótopos de Carbono , Carcinoma Hepatocelular/diagnóstico , Colina , Neoplasias Hepáticas/diagnóstico , Imagem Multimodal , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Hepatocelular/diagnóstico por imagem , Feminino , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
A systematic review of the clinical safety and efficacy of percutaneous breast cancer cryoablation was performed. Of 202 papers screened, seven matched the inclusion criteria. Cryoablation was mainly performed under ultrasound guidance, and on average two cryoprobes were used. Complete local tumor control was noted in 73% of patients (mean follow-up, 8 mo). No major complications were noted. The cosmetic outcome was satisfactory. Breast cancer cryoablation is safe, although local tumor control is suboptimal. The best results are achieved with small (<15 mm) ductal tumors treated by application of multiple cryoprobes.
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Neoplasias da Mama/epidemiologia , Neoplasias da Mama/cirurgia , Criocirurgia/estatística & dados numéricos , Mastectomia/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Cirurgia Assistida por Computador/estatística & dados numéricos , Neoplasias da Mama/diagnóstico , Feminino , Humanos , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
PURPOSE: This paper presents a new magnetic resonance angiography (MRA) protocol for the evaluation of thoracic outlet syndrome (TOS) that allows for a separate assessment of veins and arteries while using a single, simultaneous and bilateral (SB-MRA) single contrast injection, valid for both abduction and adduction acquisitions. MATERIALS AND METHODS: From 2009 to 2013 we performed 38 MRA studies for clinically suspected TOS (13 M, 25 F; mean age, 35.9 years; σ = 11.13). Twin peripheral 20G intravenous catheters were placed in a cubital vein in both arms and connected to a single power injector by two lines joined with a connector. A 3T MR system with a wide gantry was used. Two groups of four radiologists assessed all the images. Group A judged the full examinations, Group B had only the late acquisitions. Differences were evaluated using the Chi square test. TOS was confirmed only after integration with the clinical history. RESULTS: Seventeen (45 %) patients were diagnosed with predominant venous TOS (VTOS), nine (24 %) with predominant arterial TOS (ATOS) and 12 (32 %) had an indeterminate or nonvascular condition. Group A radiologists identified significantly more VTOS than group B (p = 0.049). Interobserver agreement was very high. CONCLUSIONS: SB-MRA is a safe and reliable protocol for the study of TOS. It provides a supplementary early acquisition that allows for separate assessment of veins and arteries, permits the investigation of the collateral venous flow with a single injection of contrast material and provides a higher diagnostic power for VTOS. SB-MRA is helpful for the diagnosis of TOS of vascular origin.
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Angiografia por Ressonância Magnética/métodos , Síndrome do Desfiladeiro Torácico/diagnóstico , Adulto , Meios de Contraste/administração & dosagem , Diagnóstico Diferencial , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Injeções Intravenosas , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Síndrome do Desfiladeiro Torácico/etiologiaRESUMO
BACKGROUND: Contrast-enhanced intra-operative ultrasound (CE-IOUS) for colorectal liver metastases (CLMs) has become a part of clinical practice. Whether it should be selectively or routinely applied remains unclear. The aim of this study was to define criteria for the use of CE-IOUS. METHODS: One-hundred and twenty-seven patients underwent a hepatectomy for CLMs using IOUS and CE-IOUS. All patients underwent computed tomography (CT) and/or magnetic resonance imaging (MRI) within 2 weeks prior to surgery. The reference was histology, and imaging at 6 months after surgery. Univariate and multivariate analyses were performed. Statistical significance was set at P = 0.05. RESULTS: Using IOUS an additional 172 lesions in 51 patients were found. CE-IOUS found 14 additional lesions in 6 patients. Seventy-eight CLMs in 38 patients appeared within 6 months after surgery. The sensitivity, specificity, positive- and negative-predictive value were 63%, 98%, 100% and 27% for pre-operative imaging, 87%, 100%, 100% and 52% for IOUS, and 89%, 100%, 100% and 56% for IOUS+CE-IOUS, respectively. CE-IOUS allowed better tumour margin definition in 23 patients (18%), thus assisting resection. Analyses indicated that the presence of multiple (P = 0.014), and isoechoic CLMs (P = 0.049) were independently correlated with new findings at CE-IOUS. CONCLUSIONS: Compared with IOUS, CE-IOUS improved detection and resection guidance. These additions are significant and demand its use in cases with multiple and isoechoic CLMs.
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Neoplasias Colorretais/patologia , Meios de Contraste , Hepatectomia/métodos , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Metastasectomia/métodos , Seleção de Pacientes , Ultrassonografia de Intervenção , Adulto , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Feminino , Hepatectomia/efeitos adversos , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Modelos Logísticos , Imageamento por Ressonância Magnética , Masculino , Metastasectomia/efeitos adversos , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
OBJECTIVES: To evaluate feasibility, safety, and outcome of patients treated with biodegradable biliary stents for benign biliary stenosis refractory to other treatments. METHODS: Between March 2011 and September 2012, ten patients (seven men, three women; age 59 ± 7 years) with recurrent cholangitis due to postsurgical biliary stricture, previous multiple unsuccessful (two to five) bilioplasties, and unsuitability for surgical/endoscopic repair underwent percutaneous implantation of a biodegradable biliary stent. Patients were followed-up clinically and with ultrasound at 1, 3 and 6 months, and then at 6-month intervals. RESULTS: Stent implantation was always feasible. No immediate major or minor complications occurred. In all patients, 48-h cholangiographic control demonstrated optimal stent positioning and stenosis resolution. In a median follow-up time of 16.5 months (25th-75th percentiles = 11-20.25 months) no further invasive treatment was needed. Three patients experienced transient episodes of cholangitis. Neither re-stenosis nor dilatation of the biliary tree was documented during follow-up. No stent was visible at the 6-month follow-up. CONCLUSIONS: Percutaneous placement of biodegradable biliary stents represents a new option in treating benign biliary stenoses refractory to treatment with bilioplasty. This technique seems to be feasible, effective and free from major complications. Further investigations are warranted to confirm our preliminary results.
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Implantes Absorvíveis , Colestase/terapia , Implantação de Prótese/métodos , Stents , Idoso , Anastomose Cirúrgica/efeitos adversos , Sistema Biliar , Colangite/etiologia , Colestase/complicações , Colestase/diagnóstico por imagem , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/terapia , Endoscopia , Estudos de Viabilidade , Feminino , Febre/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite Alcoólica/complicações , Recidiva , Estudos Retrospectivos , Stents/efeitos adversos , UltrassonografiaRESUMO
Pancreatic neuroendocrine tumor (PNET) behavior assessment is a daily challenge for physicians. Modern PNET management varies from a watch-and-wait strategy to surgery depending on tumor aggressiveness. Therefore, the aggressiveness definition plays a pivotal role in the PNET work-up. The aggressiveness of PNETs is mainly based on the dimensions and histological grading, with sometimes a lack of specificity and sensibility. In the last twenty years, EUS has become a cornerstone in the diagnostic phase of PNET management for its high diagnostic yield and the possibility of obtaining a histological specimen. The number of EUS applications in the PNET work-up has been rapidly increasing with new and powerful possibilities. The application of contrast has led to an important step in PNET detection; in recent years, it has been gaining interesting applications in aggressiveness assessment. In this review, we underline the latest experiences and opportunities in the behavior assessment of PNETs using contact-enhanced EUS and contested enhanced harmonic EUS with a particular focus on the future application and possibility that these techniques could provide.
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RECIST 1.1 criteria are commonly used with computed tomography (CT) to evaluate the efficacy of systemic treatments in patients with neuroendocrine tumors (NETs) and liver metastases (LMs), but their relevance is questioned in this setting. We aimed to explore alternative criteria using different numbers of measured LMs and thresholds of size and density variation. We retrospectively studied patients with advanced pancreatic or small intestine NETs with LMs, treated with systemic treatment in the first-and/or second-line, without early progression, in 14 European expert centers. We compared time to treatment failure (TTF) between responders and non-responders according to various criteria defined by 0%, 10%, 20% or 30% decrease in the sum of LM size, and/or by 10%, 15% or 20% decrease in LM density, measured on two, three or five LMs, on baseline (≤1 month before treatment initiation) and first revaluation (≤6 months) contrast-enhanced CT scans. Multivariable Cox proportional hazard models were performed to adjust the association between response criteria and TTF on prognostic factors. We included 129 systemic treatments (long-acting somatostatin analogs 41.9%, chemotherapy 26.4%, targeted therapies 31.8%), administered as first-line (53.5%) or second-line therapies (46.5%) in 91 patients. A decrease ≥10% in the size of three LMs was the response criterion that best predicted prolonged TTF, with significance at multivariable analysis (HR 1.90; 95% CI: 1.06-3.40; p = .03). Conversely, response defined by RECIST 1.1 did not predict prolonged TTF (p = .91), and neither did criteria based on changes in LM density. A ≥10% decrease in size of three LMs could be a more clinically relevant criterion than the current 30% threshold utilized by RECIST 1.1 for the evaluation of treatment efficacy in patients with advanced NETs. Its implementation in clinical trials is mandatory for prospective validation. Criteria based on changes in LM density were not predictive of treatment efficacy. CLINICAL TRIAL REGISTRATION: Registered at CNIL-CERB, Assistance publique hopitaux de Paris as "E-NETNET-L-E-CT" July 2018. No number was assigned. Approved by the Medical Ethics Review Board of University Medical Center Groningen.
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Neoplasias Hepáticas , Tumores Neuroendócrinos , Humanos , Critérios de Avaliação de Resposta em Tumores Sólidos , Tumores Neuroendócrinos/diagnóstico por imagem , Tumores Neuroendócrinos/tratamento farmacológico , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/tratamento farmacológicoRESUMO
BACKGROUND & AIMS: Tumor shrinkage has been considered a fundamental surrogate efficacy measure for new cancer treatments. However, in patients treated with sorafenib for advanced hepatocellular carcinoma (HCC), tumor shrinkage rarely accompanies increased survival, thereby questioning the prognostic value of imaging-based Response Evaluation Criteria in Solid Tumors (RECIST). We investigated the prognostic usefulness of a decrease in serum alpha-fetoprotein (AFP) and compared it to RECIST. METHODS: In HCC patients treated with sorafenib with baseline AFP >20 ng/ml, AFP response was defined as a >20% decrease in AFP during 8weeks of treatment. Patients were also assessed by RECIST and were categorized as having radiologically proven progressive disease or disease control (consisting of complete or partial responses and stable disease). Comparisons of survival by RECIST and AFP response were corrected for guarantee-time bias by the landmark method. RESULTS: We evaluated 85 patients for AFP response, among them, 82 were also evaluated by RECIST. In the analysis of AFP response, 32 out of 85 patients (37.6%) were responders, whereas 58 out of 82 patients (70.7%) achieved disease control. In landmark analysis, the hazard ratios (HR) for survival according to AFP response and disease control were 0.59 (p=0.040) and 1.03 (p=0.913), respectively. In multivariate analysis, only AFP response (HR=0.52; p=0.009) and Cancer of the Liver Italian Program dichotomized stage (HR=0.42; p=0.002) were prognostic factors of survival. CONCLUSIONS: Assessment of AFP response may be considered as an alternative to RECIST to capture sorafenib activity in HCC.
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Antineoplásicos/uso terapêutico , Benzenossulfonatos/uso terapêutico , Carcinoma Hepatocelular/tratamento farmacológico , Monitoramento de Medicamentos/métodos , Neoplasias Hepáticas/tratamento farmacológico , Piridinas/uso terapêutico , alfa-Fetoproteínas/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/metabolismo , Carcinoma Hepatocelular/metabolismo , Carcinoma Hepatocelular/mortalidade , Feminino , Humanos , Neoplasias Hepáticas/metabolismo , Neoplasias Hepáticas/mortalidade , Masculino , Pessoa de Meia-Idade , Niacinamida/análogos & derivados , Compostos de Fenilureia , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Sorafenibe , Resultado do TratamentoAssuntos
Falso Aneurisma/etiologia , Falso Aneurisma/terapia , Cianoacrilatos/uso terapêutico , Embolização Terapêutica/métodos , Artéria Pulmonar , Toracotomia/efeitos adversos , Idoso , Falso Aneurisma/diagnóstico por imagem , Angiografia , Meios de Contraste , Feminino , Fluoroscopia , Humanos , Doença Iatrogênica , Insuficiência da Valva Mitral/cirurgia , Tomografia Computadorizada por Raios XRESUMO
Background: The fourth type of multiple endocrine neoplasia (MEN) is known as a rare variant of MEN presenting a MEN1-like phenotype and originating from a germline mutation in CDKN1B. However, due to the small number of cases documented in the literature, the peculiar clinical features of MEN4 are still largely unknown, and clear indications about the clinical management of these patients are currently lacking. In order to widen our knowledge on MEN4 and to better typify the clinical features of this syndrome, we present two more cases of subjects with MEN4, and through a review of the current literature, we provide some possible indications on these patients' management. Case Presentation: The first report is about a man who was diagnosed with a metastatic ileal G2-NET at the age of 34. Genetic analysis revealed the mutation p.I119T (c.356T>C) of exon 1 of CDKN1B, a mutation already reported in the literature in association with early-onset pituitary adenomas. The second report is about a 76-year-old woman with a multifocal pancreatic G1-NET. Genetic analysis identified the CDKN1B mutation c.482C>G (p.S161C), described here for the first time in association with MEN4 and currently classified as a variant of uncertain significance. Both patients underwent biochemical and imaging screening for MEN1-related diseases without any pathological findings. Conclusions: According to the cases reported in the literature, hyperparathyroidism is the most common clinical feature of MEN4, followed by pituitary adenoma and neuroendocrine tumors. However, MEN4 appears to be a variant of MEN with milder clinical features and later onset. Therefore, these patients might need a different and personalized approach in clinical management and a peculiar screening and follow-up strategy.
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Adenoma , Neoplasia Endócrina Múltipla , Neoplasias Hipofisárias , Adenoma/genética , Inibidor de Quinase Dependente de Ciclina p27/genética , Mutação em Linhagem Germinativa , Humanos , Neoplasia Endócrina Múltipla/diagnóstico , Neoplasia Endócrina Múltipla/genética , Neoplasia Endócrina Múltipla/patologia , Mutação , Neoplasias Hipofisárias/patologiaRESUMO
Background: Over the last two decades, augmented reality (AR) has been used as a visualization tool in many medical fields in order to increase precision, limit the radiation dose, and decrease the variability among operators. Here, we report the first in vivo study of a novel AR system for the guidance of percutaneous interventional oncology procedures. Methods: Eight patients with 15 liver tumors (0.7−3.0 cm, mean 1.56 + 0.55) underwent percutaneous thermal ablations using AR guidance (i.e., the Endosight system). Prior to the intervention, the patients were evaluated with US and CT. The targeted nodules were segmented and three-dimensionally (3D) reconstructed from CT images, and the probe trajectory to the target was defined. The procedures were guided solely by AR, with the position of the probe tip was subsequently confirmed by conventional imaging. The primary endpoints were the targeting accuracy, the system setup time, and targeting time (i.e., from the target visualization to the correct needle insertion). The technical success was also evaluated and validated by co-registration software. Upon completion, the operators were assessed for cybersickness or other symptoms related to the use of AR. Results: Rapid system setup and procedural targeting times were noted (mean 14.3 min; 12.0−17.2 min; 4.3 min, 3.2−5.7 min, mean, respectively). The high targeting accuracy (3.4 mm; 2.6−4.2 mm, mean) was accompanied by technical success in all 15 lesions (i.e., the complete ablation of the tumor and 13/15 lesions with a >90% 5-mm periablational margin). No intra/periprocedural complications or operator cybersickness were observed. Conclusions: AR guidance is highly accurate, and allows for the confident performance of percutaneous thermal ablations.
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Background: Hepatocellular carcinoma (HCC) is the most frequent liver malignancy and a leading cause of cancer death in the world. In unresectable HCC patients, transcatheter arterial (chemo-) embolization (TAE/TACE) has shown a disease response in 15-55% of cases. Though multiple TAE/TACE courses can be administered in principle, Stereotactic Body Radiotherapy (SBRT) has emerged as an alternative option in the case of local relapse following multiple TAE/TACE courses. Methods: This is a single-center, prospective, randomized, controlled, parallel-group superiority trial of SBRT versus standard TAE/TACE for the curative treatment of the intermediate stage of HCC after an incomplete response following TAE/TACE (NCT02323360). The primary endpoint is 1-year local control (LC): 18 events were needed to assess a 45% difference (HR: 0.18) in favor of SBRT. The secondary endpoints are 1-year Progression-Free Survival (PFS), Distant Recurrence-Free Survival (DRFS), Overall Survival (OS) and the incidence of acute and late complications. Results: At the time of the final analysis, 40 patients were enrolled, 19 (49%) in the TAE/TACE arm and 21 (51%) in the SBRT arm. The trial was prematurely closed due to slow accrual. The 1- and 2-year LC rates were 57% and 36%. The use of SBRT resulted in superior LC as compared to TAE/TACE rechallenge (median not reached versus 8 months, p = 0.0002). PFS was 29% and 16% at 1 and 2 years, respectively. OS was 86% and 62% at 1 year and 2 years, respectively. In the TAE arm, PFS was 13% and 6% at 1 and 2 years, respectively. In the SBRT arm, at 1 and 2 years, PFS was 37% and 21%, respectively. OS at 1 and 2 years was 75% and 64% in the SBRT arm and 95% and 57% in the TACE arm, respectively. No grade >3 toxicity was recorded. Conclusions: SBRT is an effective treatment option in patients affected by inoperable HCC experiencing an incomplete response following ≥1 cycle of TAE/TAC.