The challenge of extraabdominal desmoid tumour management in patients with Gardner's syndrome: radiofrequency ablation, a promising option.

Desmoid tumours are benign, myofibroblastic stromal neoplasms common in Gardner's syndrome, which is a subtype of familial adenomatous polyposis characterized by colonic polyps, osteomas, thyroid cancer, epidermoid cysts, fibromas and sebaceous cysts. The primary treatment is surgery, followed by adjuvant radiotherapy, but the local recurrence rate is high, and wide resection can result in debilitating loss of function. We report the case of a 39-year-old man with Gardner's syndrome who had already undergone a total prophylactic colectomy. He developed desmoid tumours localized in the mesenteric root, abdominal wall and dorsal region, which were treated from 2003 through 2013 with several surgical procedures and percutaneous radiofrequency ablation. In 2008 and 2013, RFA was applied under ultrasonographic guidance to two desmoid tumours localized in the dorsal thoracic wall. The outcomes were low-grade pain and one case of superficial skin necrosis, but so far there has been no recurrence of desmoid tumours in these locations. Surgical resection remains the first-line therapy for patients with desmoid tumours, but wide resection may lead to a poor quality of life. Radiofrequency ablation is less invasive and expensive and is a possible therapeutic option for desmoid tumours in patients with Gardner's syndrome.

Ultrasound Patterns of Hepatocellular Carcinoma and Their Prognostic Impact: A Retrospective Study.

BACKGROUND: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death. Abdominal ultrasound (US) is by far the most widely used first-level exam for the diagnosis of HCC. We aimed to assess whether different ultrasound patterns were related to tumor prognosis. METHODS: We retrospectively reviewed all patients with a new diagnosis of HCC (single nodule) and undergoing radiofrequency thermal ablation (RFTA) at our clinic between January 2009 and December 2021. Patients were classified according to four HCC ultrasound patterns: 1A, single capsulated nodule; 1B, well capsulated intra-node nodule; 1C, cluster consisting of capsulated nodules; and 2, non-capsulated nodule. RESULTS: 149 patients were analysed; median follow-up time was 43 months. US patterns 1A (32.9%) and 1B (61.1%) were the most commonly seen. Median overall survival (OS) and recurrence-free survival (RFS) from RFTA were 54 months (95% CI, 42-66) and 22 months (95% CI, 12-32), respectively. Pattern 1A showed the best OS. Compared to pattern 1A, 1B was independently associated with worse OS (51 months (95% CI, 34-68) vs. 46 months (95% CI, 18-62)) and RFS (34 months (95% CI, 27-41) vs. 18 months (95% CI, 12-24)). Patterns 1C and 2 were associated with worse RFS compared to 1A, while no difference was seen for OS. Among baseline clinical variables, pattern 1B exhibited higher histological grade (p = 0.048) and tumor dimension (p = 0.034) compared to pattern 1A. CONCLUSIONS: Our findings demonstrate that different US patterns correlate with different survival outcomes and tumor behavior in patients with HCC. Prospective studies are needed to confirm these results.

Repeated radiofrequency ablation for management of patients with cirrhosis with small hepatocellular carcinomas: a long-term cohort study.

UNLABELLED: In most patients with cirrhosis, successful percutaneous ablation or surgical resection of hepatocellular carcinoma (HCC) is followed by recurrence. Radiofrequency ablation (RFA) has proven effective for treating HCC nodules, but its repeatability in managing recurrences and the impact of this approach on survival has not been evaluated. To this end, we retrospectively analyzed a prospective series of 706 patients with cirrhosis (Child-Pugh class ≤ B7) who underwent RFA for 859 HCC ≤ 35 mm in diameter (1-2 per patient). The results of RFA were classified as complete responses (CRs) or treatment failures. CRs were obtained in 849 nodules (98.8%) and 696 patients (98.5%). During follow-up (median, 29 months), 465 (66.8%) of the 696 patients with CRs experienced a first recurrence at an incidence rate of 41 per 100 person-years (local recurrence 6.2; nonlocal 35). Cumulative incidences of first recurrence at 3 and 5 years were 70.8% and 81.7%, respectively. RFA was repeated in 323 (69.4%) of the 465 patients with first recurrence, restoring disease-free status in 318 (98.4%) cases. Subsequently, RFA was repeated in 147 (65.9%) of the 223 patients who developed a second recurrence after CR of the first, restoring disease-free status in 145 (98.6%) cases. Overall, there were 877 episodes of recurrence (1-8 per patient); 577 (65.8%) of these underwent RFA that achieved CRs in 557 (96.5%) cases. No procedure-related deaths occurred in 1,921 RFA sessions. Estimated 3- and 5-year overall and disease-free (after repeated RFAs) survival rates were 67.0% and 40.1% and 68.0 and 38.0%, respectively. CONCLUSION: RFA is safe and effective for managing HCC in patients with cirrhosis, and its high repeatability makes it particularly valuable for controlling intrahepatic recurrences.

Increased CD8+ intraepithelial lymphocyte infiltration and reduced surface area to volume ratio in the duodenum of patients with ulcerative colitis.

OBJECTIVE: Recent evidence suggests the involvement of the upper gastrointestinal tract in ulcerative colitis (UC). By conducting a prospective controlled study, we explored the immunological abnormalities in the duodenal mucosa of UC patients. METHODS: Duodenal and colonic biopsies were collected from 24 corticosteroid-free UC patients and 21 controls. Colonization by Helicobacter pylori and positivity for anti-endomysial antibodies was an exclusion criteria. The severity of duodenal and colonic inflammation was determined by endoscopic and histologic scores. Morphometry was performed to measure the surface area to volume ratio (SV). Duodenal CD3(+) and CD8(+) intraepithelial lymphocytes (IELs) and lamina propria mononuclear cells (LPMCs) were detected by immunohistochemistry. RESULTS: Fifteen UC patients and 14 controls were Helicobacter pylori and anti-endomysial antibody negative and were thus included in the study. Microscopic duodenitis was reported in 4 of the 15 UC patients (26.6%), and in none of the controls. A significantly higher number of CD3(+) and CD8(+) IELs and LPMCs was found in UC patients than in controls. A significant positive correlation between the percentage of both CD3(+) and CD8(+) IELs and disease activity was found in UC patients. SV was significantly reduced in UC patients compared to controls, and inversely correlated with the percentage of CD8(+) IELs. CONCLUSIONS: The duodenum of UC patients is infiltrated by a higher number of CD8(+) IELs which correlates with the degree of villous flattening and disease activity, but not with extent of the colonic lesions. Further studies are needed to clarify whether the duodenum is a target organ in UC.

Intrabile duct metastasis from colonic adenocarcinoma without liver parenchyma involvement: contrast enhanced ultrasonography detection.

It is well-known that biliary duct invasion with intraluminal growth is one of the developmental patterns of primary liver tumors, and macroscopic intrabiliary growth of liver metastases in colorectal cancer is found with high frequency. Surgical treatment is the only potential curative therapy. However, many patients die of intrahepatic and/or extrahepatic recurrence after the resection. One of the causes of high recurrence rate after resective surgery, particularly surgical margin recurrences, is the invasion of biliary ducts mainly due to intraluminal tumor growth. We describe the first recorded case of a metastasis from colorectal cancer involving solely the common hepatic biliary duct, without invasion of contiguous liver parenchyma. A correct diagnosis was obtained by means of contrast enhanced ultrasound and ultrasound-guided fine needle aspiration biopsy.

Effect of hyperbarism on radiofrequency ablation outcome.

OBJECTIVE: Our objective was to investigate whether increases in atmospheric or local tissue pressure would affect the outcome of radiofrequency ablation procedures and the size of the created thermal lesions. MATERIALS AND METHODS: Thermal lesions were produced in specimens of explanted bovine liver inside a hyperbaric chamber at 101 (atmospheric), 141, 202, 273, and 364 kPa using radiofrequency power settings of 20, 30, 40, and 50 W. In subsequent in vivo experiments, thermal lesions were produced in the livers of anesthetized pigs with or without occlusion of the hepatic vein draining the ablation site. RESULTS: At each radiofrequency power setting, progressive increases in applied pressure were paralleled by decreases in minimum impedance and increases in maximum tissue temperatures at the electrode tip (reflecting tissue-fluid boiling points), delivery time, total energy delivered, and thermal lesion volumes. Similar increases were observed in radiofrequency ablation procedures performed in vivo under occlusion of the vein draining the ablation site. CONCLUSION: By elevating the tissue-fluid boiling point, increased pressure delays the desiccation of tissue in contact with the radiofrequency electrode tip and the related sharp increase in impedance. The result is prolonged delivery of larger amounts of radiofrequency energy and larger thermal lesions.

Portal hypertensive gastropathy in cirrhotics without varices: a case-control study.

OBJECTIVE: Information is lacking on portal hypertensive gastropathy (PHG) in cirrhotics without varices; our aim it is to evaluate whether clinical and sonographic parameters are associated with PHG and may provide information suitable for the management of these patients. PATIENTS AND METHODS: After endoscopic selection of 145 cirrhotics without varices, 75 with PHG and 70 without PHG, clinical and sonographic characteristics were assessed. RESULTS: Forty portosystemic shunts were present in 27 patients. The mean Child-Pugh score was 6.3±1.4 and 5.6±0.5 in patients with severe and mild PHG, respectively (P=0.004). The mean portal vein diameter was 10.4±1.7 and 11.6±2.0 mm in cirrhotics without and with PHG, respectively (P=0.0002). CONCLUSION: A link between the presence of PHG and a more advanced phase of cirrhosis was found. Duplex Doppler sonography was confirmed to be a valuable diagnostic method in monitoring cirrhosis. Management of these patients cannot be performed on the basis of a single diagnostic method, and a multimodal diagnostic approach is required.

Defining a proper setting for endoscopy in coeliac disease.

OBJECTIVE: As it has been demonstrated that a careful duodenal inspection during upper gastrointestinal endoscopy may be useful in predicting coeliac disease, we tried to define the usefulness of endoscopy in detecting unsuspected coeliac patients. DESIGN AND METHODS: We considered all the first diagnoses of coeliac disease from 1992 to 2001, i.e. 110 patients with a biopsy-proven diagnosis of coeliac disease. From 1992 to 1997, neither of the endoscopists paid careful attention to the endoscopic features of coeliac disease in the course of the examinations performed for indications other than coeliac disease. From 1998 to 2001, the same endoscopists looked very carefully at these endoscopic features, regardless of the indication for the procedure. RESULTS: Over the first period, 22/16,081 patients endoscoped for the first time had a histological diagnosis of coeliac disease, with a prevalence of 1/731. In all 22 patients the indication for the examination was the suspicion of coeliac disease. The endoscopic appearance of the duodenum was indicative in 16/22 (72.7%) patients. Over the second period, the diagnosis of coeliac disease was made in 88/10,410 patients endoscoped for the first time. The prevalence of the disease was 1/118 examinations performed. The endoscopic appearance of the duodenum was indicative in 70/88 (79.5%) patients. In 13/88 patients, the diagnosis of coeliac disease was presumed because of the macroscopic appearance of duodenum, lacking a past history suggestive of coeliac disease. CONCLUSIONS: Despite a still open controversy on the accuracy of endoscopic markers in the diagnosis of coeliac disease, we have found that in subjects not suspected for coeliac disease and undergoing an upper gastrointestinal endoscopy for other reasons, attention to the endoscopic pattern could facilitate the identification of a relevant number of cases.

Radiofrequency ablation of pancreatic neuroendocrine tumors: a pilot study of feasibility, efficacy, and safety.

OBJECTIVE: This study aimed to assess the feasibility, safety, and efficacy of radiofrequency ablation (RFA) of pancreatic neuroendocrine tumors (PNETs). METHODS: We performed RFA on 10 patients (7 women) aged 38 to 75 years with histologically diagnosed PNETs (secreting in 3 cases) who could not or would not undergo surgical resection. Tumor nodules (diameter, 0.9-2.9 cm; mean [SD], 1.6 [0.5] cm) were located in the head (n = 7) or body (n = 3) of the pancreas. Ultrasound-guided RFA was performed percutaneously (n = 7), endoscopically (n = 1), or intraoperatively (n = 2) using commercially available equipment. Complete ablation was defined as absence of enhancing tissue at the tumor site on contrast-enhanced imaging studies and normalization of previously elevated serum hormone levels. RESULTS: Complete ablation was achieved with 1 (n = 9) or 2 (n = 1) RFA procedures. All neuroendocrine syndromes regressed within 24 hours of treatment. No recurrences were observed during follow-up (range, 12-60 months; median [SD], 34 [14] months). No deaths occurred. Major complications included acute pancreatitis in 3 patients, 2 of whom developed pancreatic fluid collections that were successfully managed with ultrasound-guided drainage and endoscopy. CONCLUSIONS: Radiofrequency ablation is a feasible, safe, and effective option for patients with small PNETs who cannot or do not want to undergo surgical resection.