Survival of patients with early hepatocellular carcinoma treated by percutaneous alcohol injection.

BACKGROUND: Once small (<10 mm) nodules, suspicious for hepatocellular carcinoma, are detected in cirrhotics, the European Association for the Study of the Liver guidelines recommend to delay histological confirmation and treatment until they increase in size. AIM: To validate this policy by evaluating survival of 450 cirrhotics in Child-Pugh class A or B with unifocal 'early' hepatocellular carcinoma treated by percutaneous alcohol injection. METHODS: Patients were sorted by nodular size into three groups: < or =10 mm (n = 36, group A), >10 to < or = 20 mm (n = 142, group B) and >20 to < or = 30 mm (n = 272, group C). Overall and tumour-free survivals were estimated by Kaplan-Meier method. RESULTS: In groups A, B and C, mean follow-up was 33 +/- 26, 34 +/- 22 and 35 +/- 25 months (P = 0.89), mean survival time was 63 +/- 54, 57 +/- 48 and 62 +/- 66 months (P = 0.69) and mean tumour-free survival was 44 +/- 47, 46 +/- 58 and 41 +/- 68 months (P = 0.51), respectively. When patients were sorted by Child status, mean survival time was 76 +/- 82 and 38 +/- 29 months in Child A and B (P < 0.0001). CONCLUSIONS: The comparable survival of percutaneous alcohol injection-treated patients with single, early hepatocellular carcinoma sorted by nodular size supports the European Association for the Study of the Liver 'wait-and-see' policy for patients with lesions <10 mm, and suggests that allowing the nodules to grow prior to taking further diagnostic or therapeutic actions would not harm these patients.

Ultrasound guided fine needle biopsy of early hepatocellular carcinoma complicating liver cirrhosis: a multicentre study.

BACKGROUND: Because hepatic cirrhosis is a major risk factor for hepatocellular carcinoma, recent guidelines by the European Association for the Study of the Liver (EASL) on clinical management of hepatocellular carcinoma recommend periodic ultrasound surveillance of cirrhotic patients with immediate workup for nodules >1 cm; an increase in the frequency of screening is considered sufficient for smaller lesions. AIMS: To determine the actual risk of hepatocellular carcinoma associated with the latter lesions and to assess the role of ultrasound guided-fine needle biopsy in their diagnosis. PATIENTS AND METHODS: Data were analysed for 294 new nodular lesions <20 mm, including 48 that were <10 mm, detected during a prospective multicentre study involving ultrasound surveillance of 4375 patients with hepatic cirrhosis. In the absence of alpha fetoprotein (AFP) levels diagnostic of hepatocellular carcinoma, ultrasound guided-fine needle biopsy was performed (n = 274). AFP and fine needle biopsy diagnoses of malignancies (hepatocellular carcinoma and lymphoma) were considered definitive. Non-malignant fine needle biopsy diagnoses (dysplastic or regenerative nodule) were verified by a second imaging study. Diagnoses of hepatocellular carcinoma based on this study were considered definitive; non-malignant imaging diagnoses were considered definitive after at least one year of clinical and ultrasound follow up. RESULTS: Overall, 258/294 (87.6%) nodules proved to be hepatocellular carcinoma, including 33/48 (68.7%) of those < or =10 mm. Overall typing accuracy of ultrasound guided-fine needle biopsy was 89.4%, and 88.6% for lesions < or =10 mm. CONCLUSIONS: In a screening population, well over half of very small nodules arising in cirrhotic livers may prove to be hepatocellular carcinoma, and approximately 90% of these malignancies can be reliably identified with ultrasound guided-fine needle biopsy.

Value of splanchnic Doppler ultrasound in the diagnosis of portal hypertension.

The accuracy of various Doppler parameters of portal circulation in the diagnosis of relevant portal hypertension (presence of gastroesophageal varices) was prospectively validated. The following parameters were compared in 51 patients with chronic liver disease (40 with cirrhosis and 11 with chronic hepatitis): portal vein flow velocity and congestion index, hepatic and splenic arteries resistance indexes (RI), modified liver vascular index (portal flow velocity/hepatic artery RI) and portal hypertension index, a new index calculated as: [(hepatic artery RI x 0.69) x (splenic artery RI x 0.87)]/portal vein flow velocity. Highest accuracy was achieved by the splenic artery RI and the portal hypertension index (both around 75%) at cut-offs, respectively, of 0.60 and 12 cm/s(-1), which appeared to be, therefore, the most favorable parameters for the clinical practice. Their use may limit the need for endoscopy to search for varices.

Ultrasound-guided fine needle biopsy of pancreatic masses: results of a multicenter study.

OBJECTIVE: The aim of this study was to investigate the results of ultrasound-guided fine needle biopsy of pancreatic masses in a large multicenter series. METHODS: This study collected the data of 510 patients who had a final diagnosis available and who had undergone ultrasound-guided fine needle biopsy of the pancreas. Retrieval rate, sensitivity, specificity, and overall diagnostic accuracy of the whole series, by three different bioptic procedures (cytology, histology, and cytology plus histology) were evaluated. The reliability of ultrasound-guided fine needle biopsy to allow a correct diagnosis in the different pancreatic pathologies was calculated. Finally, any complications were collected. RESULTS: For cytology, histology, and cytology plus histology, retrieval rate values were: 94%, 96%, and 97%; sensitivity was: 87%, 94%, and 94%, specificity: 100%; and diagnostic accuracy: 91%, 90%, and 95%, respectively. Ultrasound-guided fine-needle biopsy correctly diagnosed all the cases of pancreatic metastases or non-Hodgkin's lymphoma (23 of 510 cases as 5%; in eight of 23 it led to the first diagnosis of the primary tumor) and all the cases of abscesses, 97% of the cases of pseudocysts, 86% of pancreatic adenocarcinomas, 62% of cystic neoplasms, 35% of the cases of chronic pancreatitis (in this case, the bioptic procedures were reviewed), and 33% of neuroendocrine tumors. There were complications in one case of asymptomatic peripancreatic hematoma, three cases of vaso-vagal reactions, and 21 cases of pain. CONCLUSION: Ultrasound-guided fine needle biopsy of the pancreas is efficacious, without any difference between the various bioptic modalities (with the exception of chronic pancreatitis, in which histology is better). The technique is safe. Moreover, the procedure allows the identification of patients affected by pancreatic tumors other than adenocarcinoma (in our survey 5% of the total); in about one third of these patients it leads to the diagnosis of the primary tumor, thus avoiding inappropriate treatments.

Endoscopic treatment of a case of obstructive jaundice secondary to portal cavernoma.

Biliary changes secondary to portal hypertension are uncommon. These patients do not usually present clinical or biochemical evidence of cholestasis. This report describes one case of obstructive jaundice due to portal cavernoma. The obstructive jaundice appeared in adulthood in a patient who had developed the portal cavernoma during childhood. Endoscopic retrograde cholangiography allowed both the diagnosis and the palliative treatment of the stenosis of the common bile duct, avoiding risky surgical treatment.

Extracorporeal lithotripsy of intrahepatic stones with associated strictures of intrahepatic biliary ducts.

BACKGROUND AND AIMS: Intrahepatic stones are a frequent disease in the Eastern world but rare in Western countries. Treatment is complex and often requires surgical intervention. Extracorporeal shock wave lithotripsy is a relatively recent technique, widely used in the treatment of stones in the gallbladder and common bile duct. It can also be used in the treatment of intrahepatic stones. The present study analyses the efficacy of extracorporeal shock wave lithotripsy in intrahepatic stones. PATIENTS AND METHODS: In our study, we used extracorporeal lithotripsy in six cases of intrahepatic stones (mean age 53 years). In five of these cases deformities of the intrahepatic bile ducts were also present: stenoses and angulated strictures. The stones were in the right lobe of the liver in 5 patients, and in both lobes in 1 patient. Four patients had multiple stones and 2 a single stone, all varying in diameter from 6 to 25 mm. The stones were localized radiologically with contrast medium through a drainage tube. The technique does not require anaesthesia. An average of three lithotripsy sessions were necessary, with a mean total of 8050 shock waves per patient. RESULTS: Successful fragmentation was obtained in 5 out of 6 patients, while the remaining subsequently underwent surgery. No complications were observed. CONCLUSIONS: Extracorporeal shock wave lithotripsy proved to be effective, easy to perform and safe for the treatment of intrahepatic stones.

Percutaneous ethanol injection in the treatment of hepatocellular carcinoma. A multicenter survey of evaluation practices and complication rates.

BACKGROUND: Percutaneous ethanol injection (PEI) has become a widely used procedure in the treatment of hepatocellular carcinoma (HCC). However, the criteria for selecting patients are not standardized, and little information is available about the complications of the procedure. METHODS: A questionnaire was sent to 11 experienced Italian centers. It investigated: the size and the number of HCC nodules suitable for treatment and the Child-Pugh risk class of the associated cirrhosis; the performance of the procedure; the number and characteristics of the patients treated; and, finally, any complications. RESULTS: Most of the centers performed PEI in single HCC nodules less than 5 cm in diameter or in multiple nodules if fewer than three, the larger being less than 3 cm. Patients in Child-Pugh's classes A, B, and C with single nodules were generally considered for PEI. A prothrombin time of less than 40% and a platelet count of less than 40,000/mm3 contraindicated PEI in most of the centers. PEI was generally performed on outpatients, using Chiba or spinal needles. One thousand and sixty-six patients (8118 sessions) were enrolled; 74% had a single HCC nodule and 26% multiple nodules. All except four had cirrhosis; 53% were in Child class A, 38% in class B, and 9% in class C. The mean number of sessions needed to destroy an HCC nodule was 6.7 (range, 2-14), with a mean alcohol injection volume of 5.0 ml per session (range, 2-20 ml). One death (0.09%) and 34 complications (3.2%) were reported. Among the complications we call attention to the hemorrhagic ones (eight cases) and tumoral seeding (seven cases). Severe pain experienced during the maneuver led to discontinuation of the procedure in 3.7% of the patients; 13.5% of the patients required analgesics and 24% had fever after PEI. CONCLUSIONS: Some procedural aspects of PEI treatment differ among the various centers a standardization is advisable. In the present survey PEI is a low-risk technique.

The role of ultrasound in the differential diagnosis of serous and mucinous cystic tumours of the pancreas.

OBJECTIVE: To evaluate the usefulness of a series of ultrasound parameters in the differential diagnosis between serous and mucinous forms of cystic tumours of the pancreas. SETTING: Retrospective comparative study between the histological analysis of surgical specimens from cystic tumours of the pancreas (4 serous cystadenomas, 6 mucinous cystadenomas and 11 mucinous cystadenocarcinomas) and ultrasound evaluation. METHODS: The ultrasound images of the 21 tumours were analysed by an operator who did not know the result of the histological diagnosis and were divided according to Johnson's criteria (number of cysts > 6 and diameter < 2 cm for serous tumours; number of cysts <6 and diameter >2cm for mucinous tumours) and according to other anatomicopathological parameters such as the presence of septae, endocystic projections, central scar, central calcification and/or in the tumour wall. RESULTS: The ultrasound study gave a correct diagnosis in two out of the four (50%) serous cystic tumours. A central scar and internal calcification was present in one of them. Fifteen (88.2%) of the 17 mucinous tumours were correctly diagnosed; one presented peripheral calcifications and three endocystic projections. CONCLUSION: Ultrasound has a high degree of sensitivity in the differential diagnosis of serous and mucinous cystic tumours of the pancreas if the ultrasound aspects corresponding to the anatomicopathological structure of the neoplasms are correctly evaluated.

Ultrasound follow-up of patients at risk for hepatocellular carcinoma: results of a prospective study on 360 cases.

OBJECTIVES: We performed a prospective study with ultrasound (US) follow-up on a population at risk for hepatocellular carcinoma (HCC) to evaluate the possibilities of diagnosis of HCC at an early stage. METHODS: We studied 360 patients; 254 of those patients had cirrhosis of the liver (of which 167 had HCV, 28 had HBV, 53 were alcoholic, and six had autoimmune disease), and the remaining 106 patients had chronic hepatitis. US scan was performed and alpha-fetoprotein was measured every 6 months. Mean duration of follow-up was 56 months (range 18-72). We compared the results of HCC detection with those of 2170 patients with cirrhosis or chronic hepatitis observed with US in the same period, outside the follow-up protocol. RESULTS: In 24 of the follow-up patients, hepatic lesions were detected with US and proved to be HCC with fine needle biopsy, with a cumulative incidence of 6.6% and an annual incidence of 1.4%. The HCC was unifocal in 18 patients, always with diameter < or = 3 cm (small HCC). All but one of the 24 patients who developed HCC had liver cirrhosis, and the remaining patient had HBV-correlated chronic hepatitis. In the group of 2170 patients without serial follow-up, the percentage of detected unifocal tumors with diameters < or = 3 cm was only 15.5%, compared with 75% in the patients with serial follow-up. CONCLUSIONS: The US follow-up of a population at risk for HCC, consisting of patients with chronic liver diseases, made it possible to diagnose tumor < or = 3 cm in a high percentage of cases, with a statistically highly significant difference (chi 2, p = 0.000) compared with the patients not in the follow-up. Follow-up could increase the percentage of HCCs detected at a potentially curable stage. Cirrhosis is confirmed as being the main risk cause, regardless of etiology.

Histiocytoid hemangioma with prominent fingernail involvement.

Only 2 cases of histiocytoid hemangioma localized in the nail apparatus have been reported in the literature. We describe here a patient affected by multiple histiocytoid hemangiomas involving the 3rd right digit and fingernail. The pathological features were typical for a diagnosis of histiocytoid hemangioma showing vascular proliferation characterized by enlarged endothelial cells associated with inflammatory cells. Phenotypic characterization of the proliferating cells confirmed their vascular origin.

Echo-guided percutaneous ethanol injection in small hepatocellular carcinoma: personal experience.

We performed echo-guided percutaneous ethanol injection of the lesion in 26 cirrhotic patients with 33 hepatocellular carcinomas measuring 3 cm in diameter or less. Post-treatment lesions had disappeared in 4 patients, while in the remaining 22 patients the echo pattern of the lesion had changed and biopsies were negative. Fifteen patients (follow-up 11-30 months) remain disease-free, while recurrence occurred between 3 and 36 months in 7 cases. Percutaneous ethanol injection was successfully repeated in 4 cases; 5 patients died, 1 of HCC, 2 of esophageal variceal bleeding, and 2 of liver failure; 3 of the last four patients had Child's C disease. Percutaneous ethanol injection is a valuable treatment for hepatocellular carcinomas measuring not more than 3 cm. It has yet to be established how far this treatment influences the survival rates of patients and the natural course of hepatocellular carcinoma.

Comparison between echo-guided fine-needle aspiration cytology and microhistology in diagnosing pancreatic masses.

Echo-guided fine-needle aspiration biopsy of pancreatic masses is a well-established diagnostic procedure. However, there is no consensus as to the superiority of cytology or microhistology. We compared the results of cytology and microhistology in 50 consecutive patients who underwent fine-needle aspiration biopsy for pancreatic masses. Aspirates were positive for malignant disease in 42 patients; the other eight had chronic focal pancreatitis. In the 42 cases of cancer, cytology provided conclusive results in 40 (95.2%); sampling was inadequate in two. Microhistology proved accurate in 30 cases (71.4%); insufficient tissue was obtained in 12, giving a statistically significant difference in favor of cytology (P < 0.01). In the eight patients with benign disease both techniques ruled out malignancy; in five microhistology gave further indications confirming suspected chronic pancreatitis (fibrosis, lymphocyte and histiocyte-cell infiltrate). Our results show that cytology is the method of choice in diagnosing pancreatic carcinoma. Microhistology can be a useful adjunct in patients with suspected chronic pancreatitis.

Natural history of hepatic haemangiomas: clinical and ultrasound study.

Hepatic haemangiomas are the most common benign tumours of the liver and commonly present as incidental findings on sonographic examination of the abdomen. Since little is known of the natural course of these tumours, we performed a clinical and sonographic follow up of 123 haemangioma patients. Our prospective study investigated clinical and sonographic findings in 158 haemangiomas for periods of 12 to 60 months. Ninety nine haemangiomas measured less than 2 cm and had an echogenic pattern; 40 were between 2 cm and 5 cm with a mainly echogenic structure; 19 measured greater than 5 cm and showed a mixed echo pattern. At the first examination only eight patients, all with giant haemangiomas, presented symptoms which could be attributed to the tumour. During follow up only one haemangioma changed in shape and size. One patient who was symptom free at the first examination experienced right upper abdominal quadrant pain during follow up. No deterioration occurred in any of the patients with symptoms at the first examination, and all had a satisfactory quality of life. No complications arose during the follow up period. This study shows that in adults haemangiomas remain stable in size and echo patterns rarely change. Only haemangiomas greater than 5 cm may cause symptoms. Prolonged clinical and sonographic follow up of small and medium sized haemangiomas is not warranted.

Laparoscopy compared with ultrasonography in the diagnosis of hepatocellular carcinoma.

In recent years, various newer imaging procedures have superseded laparoscopy in the detection of many diseases. The role of laparoscopy in the diagnosis of hepatocellular carcinoma is still subject to debate. To assess the value of laparoscopy compared with that of ultrasonography, we compared data obtained from a series of 54 patients with hepatocellular carcinoma, all of whom had both procedures performed at nearly the same time. In our study, ultrasonography proved superior to laparoscopy in detecting the presence and extent of the hepatocellular carcinoma. Supplemental findings attributable to laparoscopy did not alter management, whereas additional information obtained by ultrasonography often did influence the choice of treatment. We conclude that ultrasonography is the primary diagnostic method of choice in the assessment of hepatocellular carcinoma and that laparoscopy should be reserved for only selected cases.

Intratumoral echo-guided injection of interleukin-2 and lymphokine-activated killer cells in hepatocellular carcinoma.

Interleukin-2 has proved to be effective for the intralesional treatment of tumors of the bladder. There are examples in literature of hepatocellular carcinoma (HCC) treatment with lymphokine-activated killer (LAK) cells infused in the hepatic artery. We decided to check the effects of echo-guided intralesional injection of these cells in this disease. We treated 5 patients with inoperable hepatocellular carcinoma, following cirrhosis; in 4 cases the mass had a diameter less than 3 cm (small HCC) while in the remaining case it measured 7 cm. Tumor size remained unchanged in 3 of the 4 small HCC, and increased only slightly in the other (over a period of 10 months). This would appear to indicate that treatment halted neoplasm growth or at least slowed it down. The echo pattern of the lesions changed, with a constant reduction in echogenicity. Finally, in multiple control biopsies, fibrosis, present in only one case before treatment, was found fairly constantly after treatment. There were no significant side effects, apart from slight water retention in one patient. On the basis of our preliminary results, we consider it worthwhile continuing this study to establish the most suitable IL-2 doses and analyze in more detail the modifications induced in the neoplasm.

Comparison between the 21-gauge Urocut needle and the 21-gauge Surecut needle in echo-guided percutaneous biopsy of neoplastic liver lesions.

Fine cutting needles for histology are now widely used in echo-guided biopsies of various organs. In this study we compared the results obtained in the biopsy of neoplastic hepatic lesions using two different 21-gauge cutting needles: Trucut needle (Urocut) and a modified Menghini needle (Surecut). Eighty-five patients with primary or metastatic hepatic neoplasms were biopsied with a Urocut needle and a further 85 patients underwent biopsy with a Surecut needle. The two groups were comparable for size and nature of hepatic neoplasms. The Urocut needle provided a much higher percentage of diagnostic material than the Surecut needle (94.8% vs 70.5%) regardless of the primary or metastatic nature of the lesion or its size. The diagnostic accuracy was only identical for both needles (91.3% for Urocut vs 91.5% for Surecut) whenever the diagnostic material was compared in cases in which both types of needles had been used to take the biopsy specimens. There were no complications in either of the two groups studied. Given the smaller incidence of non-diagnostic biopsies with the Urocut needle, we consider that this needle should be preferred in echo-guided biopsies of neoplastic hepatic lesions.

Cancer of the gastric stump in Italy, 1979-1986.

Sixteen thousand fiberoptic endoscopies were reviewed. Gastric stump cancer was found in 24 patients of 368 who had had gastric resection for benign peptic disease. A direct relation between the percentage of patients with cancer of the gastric stump and the postsurgical interval was observed. Patients with partial gastrectomy who are 15 to 20 years postoperative should have an endoscopy irrespective of presence or lack of symptoms. Multiple biopsies should be taken in view of the multicentric growth pattern of early carcinoma.

Echo-guided fine-needle biopsy of pancreatic masses.

Aim of this study was the evaluation of percutaneous echo-guided fine-needle biopsy in the diagnosis of focal lesions of the pancreas. In patients with masses of the pancreas 43 echo-guided fine-needle punctures have been performed. In 27 of the 30 cases of cancer, echo-guided puncture allowed aspiration of cells revealing malignancy. In the remaining three cases the histology was normal. Malignancy was not detected in the aspirate of any of the 13 cases of benign solid masses. In one of these patients we failed to obtain sufficient material for the purpose of diagnosis. The sensitivity of the method was 90%, the specificity 100%, and the diagnostic accuracy 92.8%. Positive and negative predictive values were 100 and 75%, respectively. No complications worthy of note occurred.

Small hepatocellular carcinoma: an Italian experience.

Recent reports have demonstrated the possibility of using ultrasound to detect hepatocellular carcinomas under 3 cm (small HCC). Our aim was to assess the incidence of small HCC in an Italian ultrasonographic series. Among 17,133 scans of unselected patients, we detected 85 HCC, 9 of which were under 3 cm. All patients had cirrhosis and 6 were HBsAg positive. An echo-guided biopsy was performed in all cases, and the diagnosis was always correct. We conclude that echographic follow-up is warranted in Italy for cases at risk for HCC such as HBsAg+ cirrhotics and patients with chronic aggressive HBsAg+ hepatitis older than 35, in agreement with the reports of Far Eastern authors.