Effects of alendronate and vitamin D in patients with normocalcemic primary hyperparathyroidism.

UNLABELLED: No data on the pharmacological treatment of normocalcemic hyperparathyroidism (NPHPT) are available. We treated 30 NPHPT postmenopausal women with alendronate/cholecalciferol (treated group) or vitamin D alone (control group). Over 1 year, bone mineral density (BMD) increased significantly in treated group, but not in control group. Both treatments did not affect serum or urinary calcium. INTRODUCTION: Normocalcemic primary hyperparathyroidism (NPHPT) is defined by normal serum calcium and consistently elevated PTH levels after ruling out the causes of secondary hyperparathyroidism. It is likely that subjects with NPHPT may develop kidney and bone disease. As no data on the pharmacological treatment of NPHPT are available, we aimed to investigate the effects of alendronate and cholecalciferol on both BMD and bone biochemical markers in postmenopausal women with NPHPT. Safety of vitamin D was evaluated as secondary endpoint. METHODS: The study was a prospective open label randomized trial comparing 15 postmenopausal women with NPHPT (PMW-NPHPT), treated with oral alendronate plus cholecalciferol (treated group) and 15 PMW-NPHPT treated only with cholecalciferol (control group). Blood samples were obtained at baseline and after 3, 6, and 12 months. Bone turnover markers (BTM) were measured at baseline, 3, and 6 months, respectively. BMD was assessed at baseline and after 12 months. RESULTS: After 1 year of treatment, BMD increased significantly at the lumbar, femoral neck, and hip level in the treated group, but not in the control group (p = 0.001). No differences were found between or within groups in serum calcium, PTH, and urinary calcium levels. BTM significantly decreased in the treated group but not in the control group, at 3 and 6 months (p < 0.001), respectively. No cases of hypercalcemia or hypercalciuria were detected during the study. CONCLUSION: The results of this study indicate that alendronate/cholecalciferol increases BMD in postmenopausal women with NPHPT. Alendronate/cholecalciferol or vitamin D alone does not affect serum or urinary calcium.

Radioembolisation with (90)Y-labelled resin microspheres in the treatment of liver metastasis from breast cancer.

OBJECTIVES: Metastatic breast cancer is a heterogeneous disease, commonly affecting the liver. We report our experience with (90)Y radioembolisation (RE) and its effects on the survival of patients with treatment-refractory breast cancer liver metastases. METHODS: A total of 77 female patients affected by breast cancer were accepted into our department for RE. Inclusion criteria were inoperable and chemotherapy-refractory hepatic metastases, acceptable performance status, sufficient residual liver, no significant hepato-pulmonary shunts. Patients were divided in two groups: group 1 (29 patients) included those with Eastern Cooperative Oncology Group (ECOG) score 0, liver involvement (0-25 %) and no extrahepatic disease (EHD); group 2 (23 patient) included patients with ECOG score 1-2, liver involvement (26-50 %) and evidence of EHD. RESULTS: A total of 25 patients were considered ineligible. The median age of the remaining 52 patients was 57.5 years. The median overall survival was 11.5 months and better in those whose performance status and liver function were preserved (14.3 versus 8.2 months). According to Response Evaluation Criteria in Solid Tumor (RECIST), partial response (PR) was achieved in 29 patients (56 %), stable disease (SD) was achieved in a further 18 patients (35 %) and 5 patients showed progressive disease (PD) (10 %). DISCUSSION: (90)Y RE is effective in the treatment of liver metastases from breast cancer. We demonstrated a relevant survival and encouragingly high response rate in patients with treatment-refractory disease.

Radioembolisation using yttrium 90 (Y-90) in patients affected by unresectable hepatic metastases.

PURPOSE: This study was done to evaluate the effectiveness of radioembolisation of liver metastases with yttrium 90 (Y-90) in patients with no response to chemotherapy. MATERIALS AND METHODS: From February 2005 to January 2008, we treated 110 patients affected by liver metastatic disease from colorectal, breast, gastric, pancreatic, pulmonary, oesophageal and pharyngeal cancers and from cholangiocarcinoma and melanoma. We excluded patients with bilirubin level >1.8 mg/dl and pulmonary shunt >20% but not patients with minor extrahepatic metastases. RESULTS: We obtained a complete /partial response in 45 patients, stable disease in 42 patients and progressive disease in 23 patients. In 90 cases, we obtained a decrease in specific tumour marker level. The technical success rate was 96%, and technical effectiveness estimated at 3 months after treatment was 83.6%. Side effects were grade 4 hepatic failure in one case, grade 2 gastritis in six cases and grade 2 cholecystitis in two cases. The median survival and progression-free survival calculated by Kaplan-Meier analysis were 323 days and 245 days, respectively. CONCLUSIONS: According to our 3-year experience, Y-90 radioembolisation (SIR-spheres) is a feasible and safe method to treat liver metastases with an acceptable level of complications and a good response rate.

[Massive haemoperitoneum due to traumatic rupture of multifocal hepatocarcinoma in the right hepatic lobe. Case report]. / Emoperitoneo massivo da rottura di epatocarcinoma multifocale del lobo destro. Case report.

UNLABELLED: Abdominal blunt trauma is the main cause of death in people younger than 40 years old. The liver injury still represents a challenging problem. Isolated hepatic injury is rare and it occurs more frequentely in polytraumatizated patients and causes massive haemoperitoneum. The Authors report a case of a 83 years-old woman admitted to Emergency Department for syncope due to an active bleeding arising from a rupture of a right hepatic lobe unsuspected tumor. The computer tomography (CT) scans showed a clear pattern of liver laceration of the VI segment with contrast enhancement spreading in the surrounding tissues, and detected a multifocal hepatocarcinoma located in the VI, VII and VIII segments. Patient's haemodinamically unstable conditions suggested an urgent laparotomy. An accurate perihepatic packing with sterile-drape were successfully employed to control liver hemorrage. Temporary abdominal closure, followed by hepatic arteriography and the right hepatic artery embolization, completed the damage control. Re-exploration laparotomy after 72 hours confirmed the definitive haemostasis and the pack removal was performed without complications. CONCLUSIONS: CT plays a leading role in the diagnosis of liver damage. The patient's haemodynamic status is the principal criterion determining conservative or operative therapy in blunt liver injury. The early perihepatic packing followed by artheriographic embolization to stop liver hemorrhage showed efficacy and safety for the patient. The packing performed with sterile-drape is able to avoid removal complications and 72 hours timing for the pack removal is effective to avoid re-bleeding.

[A case of arterial chemoembolization for hepatocellular carcinoma with 11 years of survival]. / Un caso di epatocarcinoma trattato con chemio-embolizzazione arteriosa transcatetere con sopravvivenza di 11 anni.

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and the third most common cause of cancer mortality worldwide. The major risk of developing HCC is associated with HBV and HCV hepatitis. Liver transplant (LT) is the gold standard for "small" HCC (HCCs) in Child-Pugh class A cirrhotic patients. However its use has been restricted by the severe shortage of donors, so that hepatic resection (HR) is often performed in these patients. In the last two decades image-guided interventional catheterization and ablative regional treatment procedures have revolutionized the therapy of unresectable primary and secondary liver tumors. The Authors present a case of a 61-years old man with Child-Pugh class A HCCs. The age and the previous history of bladder carcinoma made the patient not suitable for LT. The patient refused HR so that transarterial chemoembolization combined to thermo-ablation therapy and oral intake of tamoxifen were proposed. Patient's tolerance to the treatments has been good. During 11-year follow-up there was earlier intrahepatic progression of the tumor followed by reduction in size and number of the lesions. In spite of the scarce prognosis, chemoembolization and immunotherapy allowed to achieve a satisfactory local control of disease in our patient and guaranteed a good quality of life at long-term follow-up.

[Massive lower gastrointestinal bleeding due to diverticular disease during antiplatelet therapy. Case report]. / Enterorragia massiva da diverticolosi sigmoidea in corso di terapia antiaggregante. Caso clinico.

Diverticular disease is very frequent in Western countries; in 5% of the cases it is the cause of serious bleeding, haemodynamic instability and death. The authors report a case of 74 years old patient with severe lower gastrointestinal bleeding. She was in antiplatelet treatment with acetylsalicylic acid (100 mg/die) and clopidogrel (75 mg/die) for preventing the restenosis of medicated stents positioned to treat an acute coronary syndrome. At the same time the patient was under treatment for primary hypercholesterolemia with rosuvastatin (20 mg/die). The severe haemorrhage demanded haemodynamic stabilization, achieved by colloid infusion and blood transfusions. The bleeding continued; selective arteriography showed it's origin from the areas of the sigmoid and superior hemorrhoidal arteries. During the procedure, embolization of the inferior mesenteric artery using spiral type BALT was performed, with consequent bleeding interruption. Fifteen days after the embolization, a rectosigmoid colonoscopy showed a sigmoid diverticular disease. The treatment with acetylsalicylic acid and clopidogrel has surely contributed to the severity of the hemorrhage. Recent experimental and clinical evidence suggests a possible antiplatelet effect of the statins.

[Transjugular intrahepatic portosystemic shunt (TIPS)]. / Derivazione porto-sistemica intraepatica per via transgiugulare (TIPS).

Transjugular intrahepatic portosystemic (TIPS) is radiological technique that has opened up new therapeutic horizons in the treatment of portal hypertension. Technically, the procedure includes catheterizing of the suprahepatic veins, prevalently right or middle, by means of transjugular access, and the creation of an intrahepatic path with the main portal branch. Later dilatation of the path by angioplasty and the application of a metallic stent at the site of the shunt complete the operation. Personal experience of 43 TIPS in 42 patients with a follow-up of 24 months is reported.

Long-term survival after transarterial chemoembolization for hepatocellular carcinoma.

Hepatocellular carcinoma is a main challenge in oncologic care. Surgery is the mainstay of treatment. Transarterial chemoembolization is the most widely used palliative treatment for hepatocellular carcinoma. The Authors present a case report of a 61-year old man with hepatocellular carcinoma, belonging to Child-Pugh class A. The advanced age and the previous history of bladder carcinoma made the patient not suitable for liver transplantation. The patient refused hepatic resection so that transarterial chemoembolization was proposed. During 14-year follow-up there was intrahepatic progression of the tumor after the first treatment, followed by reduction in size and number of the lesions after subsequent treatments. In spite of the ominous prognosis of hepatocellular carcinoma, in this case-report transarterial chemoembolization allowed us to achieve a unique long-term survival.

[Malignant occlusion of the bile ducts. Treatment with metallic endoprosthesis: Wallstent vs Strecker's stent]. / Occlusioni maligne delle vie biliari. Trattamento mediante endoprotesi metalliche: Wallstent vs stent di Strecker.

Stenting is the method of choice to relieve jaundice in the patients with inoperable malignant obstructions of the biliary tree. Over the last fifteen years, thousands of patients have been treated, if endoscopy failed or was unfeasible, with percutaneous transhepatic procedures: despite this wide experience, the role of conventional plastic endoprostheses is still debated, because these devices exhibit major limitations. The main objection to the use of Carey-Coons endoprostheses is the fact that a high rate of early occlusions has always been observed with plastic stents with a wide outer diameter (12-16 F). Metallic stents (self-expandable, Wallstent balloon-expandable Strecker stents) might solve these problems, especially in high-risk patients. The authors report their experience in 50 patients with midterm follow-up, a comparison of the two types of stents and their technical features.

[Technical and methodologic considerations on a new approach to the transjugular intrahepatic portosystemic shunt]. / Considerazioni tecnico-metodologiche su un nuovo approccio alla derivazione porto-sistemica per via transgiugulare (TIPS).

The authors report their experience with 10 transjugular intrahepatic portosystemic shunts (TIPS) in nine patients with severe portal hypertension; indications were rebleeding after sclerosing treatment in 8 cases and unmanageable ascitis in one case. The passage of the needle from the hepatic venous system into the portal venous system during the procedure may be technically difficult with both skin markers and US guidance, and several passages through liver parenchyma may be needed: this step is certainly the most critical one, for maneuver duration--and therefore risks--depend on it. Thus, in the last 6 patients a new method was used to easily identify portal bifurcation: a thin stainless platinum-tip guide-wire (0.018-inch diameter) was inserted, by epigastric approach under US guidance, through a fine Chiba needle (22 G) in the left main portal branch, dramatically reducing the number of failed punctures and maneuver duration. Both the above goals are to be reached to make TIPS easier and therefore advantage both patients and interventional radiologists.

[The percutaneous treatment of purulent intrathoracic fluid collections in HIV+ patients]. / Trattamento percutaneo di raccolte purulente endotoraciche in pazienti HIV+.

Eighteen HIV+ patients with purulent fluid intrathoracic collections (16 pleural empyemas and 2 lung abscesses) and persistent sepsis were treated with percutaneous drainage; all patients had received antibiotics for 5-7 days at least. Empyemas and lung abscesses were cured (according to clinical and radiographic criteria) in all patients (100%). One major complication was successfully treated--i.e., a pneumothorax with a iatrogenic lesion of the internal mammary artery, requiring selective embolization. In our experience, CT is the method of choice to guide lesion puncture. Van Sonnenberg Sump catheters (12-16 F) have been inserted in the last six months with the Trocar technique. The maneuvers were successful in all cases, with good compliance and management of patients in a 9-25 days' period (mean: 14 days). In our experience, the percutaneous drainage of intrathoracic fluid collections in HIV+ patients should be considered the method of choice.

Malignant biliary obstruction treated by Wallstents and Strecker tantalum stents: a retrospective review.

PURPOSE: To evaluate retrospectively the role and the effectiveness of self-expandable Wallstents and balloon-expandable Strecker stents in patients with inoperable malignant obstruction of the biliary tree. METHODS: Fifty patients with malignant biliary obstruction were treated from August 1991 to August 1992 by percutaneous placement of 55 metallic endoprostheses (39 Wallstents, 16 Strecker stents). All patients were followed by clinical evaluation, laboratory data, and ultrasonographic examination until death. RESULTS: Wallstent placement was successful in 36 patients without procedure-related complications. One partial occlusion after 1 year was resolved by percutaneous balloon dilatation. Fourteen patients were treated with 16 Strecker stents. Stenting was unsuccessful in four cases; four occlusions (after 6 h, 48 h, 2 and 6 months) were encountered. CONCLUSION: Wallstent endoprostheses have good results and long-term patency. There were some problems with Strecker stents during the placement and there was a higher occlusion rate.

[Treatment of malignant occlusions of bile ducts by one-step technique using metallic endoprostheses. A multicenter study of 50 cases]. / Trattamento delle occlusioni maligne delle vie biliari mediante endoprotesi metalliche con tecnica "one-step". Studio policentrico di 50 casi.

Long-term patency and ease of insertion of self-expandable metallic stents seem to overcome the disadvantages of plastic stents, changing the therapeutic approach to unresectable biliary tree malignancies. Their high cost is the main problem of metallic stents and reducing hospitalization time is a real opportunity to overcome this problem. Self-expandable stents could be the turning point to reduce overall costs. Fifty patients with malignant biliary tree obstruction (Zubrod performance status < 3) were treated with percutaneous placement of 58 Wallstent endoprostheses by the one-step technique. All patients had undergone thorough diagnostic exams - i.e., US, CT, PTC, ERCP with biopsy or brushing. Two major complications occurred in this series: a iatrogenic pseudoaneurysm requiring selective catheterization and embolization with Gianturco coils and a hepatic abscess six months after stent placement. Late stent occlusion occurred in six patients (12%) and was resolved by balloon dilatations. All patients were followed-up with clinical examinations, US and laboratory tests until death; median survival after stent placement was 122 days (range: 70 to 510 days). Average hospitalization time was 7 days with an acceptable cost reduction.