Andrea Salmi

Percutaneous etharrol injection in the treatment of hepatocellular carcinoma in cirrhosis. A study on 207 patients

In 207 cirrhotic patient carriers of hepatocellular carcinoma (HCC), percutaneous ethanol injection (PEI) was administered with ultrasound guidance. The patients were classified as Childs Class A, 136; B, 54; and C, 17. Their mean age was 63.5 years, and the male‐female ratio was 3.5:1. There was a single HCC less than 5 cm in diameter in 162 patients; 45 had more than one HCC. The follow‐up ranged from 5 to 71 months (mean, 25 months). No noteworthy complications occurred during or after 2485 treatments. The 1‐year, 2‐year, and 3‐year survival percentages (by the Kaplan‐Meier method) for the patients with one HCC were 90%, 80%, and 63%, respectively. The corresponding percentages by Childs class were 97%, 92%, and 76% for Class A; 88%, 68%, and 42% for B; and 40%, 0%, and 0% for C. The 1‐year, 2‐year, and 3‐year survival rates for patients with more than one HCC were 90%, 67%, and 31%, respectively. These results were similar to those found by others and showed that PEI was a safe, reproducible, easy‐to‐do, and low‐cost therapeutic technique. In terms of survival, these PEI results were better than the published results of no treatment and equivalent to those of surgery. In uncontrolled series, bias can play an important role. Therefore, additional trials would be useful. Cancer 1992; 69: 925–929.

Ultrasound-guided fine-needle biopsy of focal liver lesions: techniques, diagnostic accuracy and complications: A retrospective study on 2091 biopsies

Two thousand and ninety-one ultrasound-guided fine-needle biopsies were performed in 1946 patients to diagnose focal liver lesions. The diagnostic accuracy of fine-needle biopsies is very high (only one false positive was observed), both for aspiration biopsy (93.4%) and for cutting biopsy (95.1%). The difference is not statistically significant. In cases of hepatocellular carcinoma (but not in cases of metastasis or hepatic lymphoma), double biopsy (aspiration and cutting) showed higher diagnostic sensitivity than single methods. A certain number of benign focal liver lesions were also diagnosed. In the present series, no case of death following liver puncture was observed. Intraperitoneal hemorrhage was the most common complication. The risk with a cutting needle being higher than with an aspirative needle.

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-Hodgkins 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 pseudocystes, 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.

Natural history of focal nodular hyperplasia of the liver : an ultrasound study

Sixteen cases of focal nodular hyperplasia (FNH) of the liver were followed by ultrasound (US) for a mean of 33 months (range 6–81). In 69% of the cases, the diagnosis was incidental. On US the lesions were single in 75% of the cases, localized in the right lobe in 75%, and subcapsular in 50%. No specific US‐pattern could be identified. A central scar was found in 19% of the patients. At the end of the follow‐up, the size was reduced in 7/16 cases, and in 1/16 the lesion disappeared. The spontaneous reduction of nodules in FNH must be considered in the management of this pseudotumor.

Diagnosis, treatment and survival of patients with hepatorenal syndrome: A survey on daily medical practice

BACKGROUND & AIMS Hepatorenal syndrome (HRS) is a severe complication of cirrhosis with ascites. The International Ascites Club recommended strict diagnostic criteria and treatment with vasoconstrictors and albumin. Aim of this prospective cohort study was to investigate the prevalence of HRS, diagnostic criteria, treatment and 3-month outcome in the daily-clinical-practice. METHODS Two-hundred-fifty-three patients with cirrhosis and renal failure consecutively admitted to 21 Italian hospitals were recruited. RESULTS The prevalence of HRS was 45.8% (30% type-1 and 15.8% type-2). In 36% of cases HRS was presumed because not all diagnostic criteria could be fulfilled. In 8% of cases HRS was superimposed on an organic nephropathy. Patients with HRS type-1 were younger and showed higher leukocyte count, higher respiratory rates, and worse liver function scores. Sixty-four patients with HRS type-1 received vasoconstrictors (40 terlipressin and 24 midodrine/octreotide). A complete response was obtained in 19 cases (30%) and a partial response in 13 (20%). Age was the only independent predictor of response (p=0.033). Three-month survival of patients with HRS type-1 was 19.7%. Survival was better in patients who responded to therapy. Age (p=0.017), bilirubin (p=0.012), and creatinine increase after diagnostic volume expansion (p=0.02) independently predicted death. The mortality rate was 97% among patients with at least two negative predictors. CONCLUSIONS The diagnostic criteria of HRS in our daily-clinical-practice could not be completely fulfilled in one third of cases. The treatment with vasoconstrictors and albumin was widely implemented. Mortality was strongly predicted by simple baseline variables.

Ultrasonography-Detected Macroregenerative Nodules in Cirrhosis: A Prospective Study

BACKGROUND & AIMS The preneoplastic role of macroregenerative nodules in cirrhosis is still debated. Thirty-two consecutive ultrasonography-detected macronodules were followed up to evaluate whether and which lesions are the actual precursors of hepatocellular carcinoma, if histology can identify preneoplastic macronodules, and whether additional parameters are related to neoplastic evolution. METHODS Macroregenerative nodule classification was based on recently proposed histological criteria. Extranodular liver cell dysplasia was also evaluated. The follow-up included ultrasonography and serum alpha-fetoprotein level determination every 3 months. RESULTS Twenty-two macronodules (78%) were classified as typical and 7 (22%) as atypical. Twenty-one were hypoechoic, and 11 were hyperechoic. Extranodular dysplasia was more frequently associated with atypical than typical macronodules (5 of 7 vs. 6 of 22). After 28 +/- 15 months, neoplastic transformation occurred in 8 macronodules (25%) and was more frequent in atypical than in typical (5 of 7 vs. 3 of 25), in hyperechoic than in hypoechoic (5 of 11 vs. 3 of 21), and in extranodular dysplasia-associated macronodules than in extranodular dysplasia-free macronodules (5 of 11 vs. 2 of 18). Five hepatocellular carcinomas appeared outside the original macronodule. CONCLUSIONS Atypical macroregenerative nodules can be considered precursors of hepatocellular carcinoma. Histology is useful in identifying preneoplastic macronodules, and hyperechoic pattern and extranodular dysplasia are additional risk factors for neoplastic transformation.

A randomised, open label, controlled trial on the effect of interferon plus amantadine compared with interferon alone for treatment of chronic hepatitis C

BACKGROUND: Combination of the antiviral drug amantadine with interferon (IFN) may be more effective than IFN monotherapy for treatment of chronic hepatitis C. METHODS: We randomised 93 patients with chronic hepatitis C to IFNIFN 6 MU 3 times/week for 24 weeks, followed by IFN 3 MU 3 times/week for further 24 weeks given in combination with amantadine 100 mg t.i.d. (regimen A, n=48) or as monotherapy (regimen B, n=45). Control liver biopsies were obtained 6 months post treatment. RESULTS: At the end of the trial a similar proportion of patients had normal serum ALT levels (35% for regimen A, and 44% for regimen B) as measured by intention to treat criteria. Sustained biochemical response at 6 months post treatment was 15 and 20%, and sustained virological response was 10 and 20% for regimen A and B, respectively. The effect on liver histology was also similar: the inflammatory components of the Knodell score decreased by 1.3+/-0.6 points for regimen A and by 1.6+/-0.6 for regimen B, and score for fibrosis remained unchanged with both regimens. CONCLUSIONS: Combination of IFN therapy with amantadine does not enhance the effect of IFN as shown by biochemical, virological and histological criteria.

P.1.48: EFFECTIVENESS AND SAFETY OF TENOFOVIR DISOPROXIL FUMARATE IN FIELD PRACTICE: A MULTICENTER EUROPEAN COHORT STUDY OF 737 PATIENTS WITH CHRONIC HEPATITIS B

A COLONIC SELF-EXPANDINGMETAL STENT PLACEMENT AS “BRIDGE TO SURGERY” IS THE SAFEST STRATEGY IN THE MANAGEMENT OF PATIENTS WITH LEFT-SIDED COLON CANCER OBSTRUCTION C. Vincenzo ∗ ,6, C. Luigiano7, L. Ansaloni8, F. Coccolini 8 , L. Fuccio6, C. Fabbri 7 , A. Mussetto 9, L. Ceroni 6, G. Manes 10, T. Casetti 9 , A.D. Pinna8, N. D’Imperio7, R.M. Zagari 6, F. Bazzoli 6 6Department of Internal Medicine and Gastroenterology, Bologna, Italy; 7Unit of Gastroenterology, Ausl Bologna Bellaria-Maggiore Hospital, Bologna, Italy; 8Department of General Surgery and Transplant, University of Bologna, Bologna, Italy; 9Unit of Gastroenterology, Ravenna Hospital, Ravenna, Italy; 10Unit of Gastroenterology, L. Sacco Hospital, Milano, Italy

Skin tags: Markers for colonic polyps?

In recent years skin tags have been proposed as a means to identify persons with colon polyps. The purpose of this study was to assess the association between skin tags and colon polyps and to determine whether this sign may represent an indication for total colonoscopy

External validation of the ITA.LI.CA prognostic system for patients with hepatocellular carcinoma: A multicenter cohort study

Several staging systems for hepatocellular carcinoma (HCC) have been developed. The Barcelona Clinic Liver Cancer staging system is considered the best in predicting survival, although limitations have emerged. Recently, the Italian Liver Cancer (ITA.LI.CA) prognostic system, integrating ITA.LI.CA tumor staging (stages 0, A, B1‐3, C) with the Child‐Turcotte‐Pugh score, Eastern Cooperative Oncology Group performance status, and alpha‐fetoprotein with a strong ability to predict survival, was proposed. The aim of our study was to provide an external validation of the ITA.LI.CA system in an independent real‐life occidental cohort of HCCs. From September 2008 to April 2016, 1,508 patients with cirrhosis and incident HCC were consecutively enrolled in 27 Italian institutions. Clinical, tumor, and treatment‐related variables were collected, and patients were stratified according to scores of the Barcelona Clinic Liver Cancer system, ITA.LI.CA prognostic system, Hong Kong Liver Cancer system, Cancer of the Liver Italian Program, Japanese Integrated System, and model to estimate survival in ambulatory patients with hepatocellular carcinoma. Harrells C‐index, Akaike information criterion, and likelihood‐ratio test were used to compare the predictive ability of the different systems. A subgroup analysis for treatment category (curative versus palliative) was performed. Median follow‐up was 44 months (interquartile range, 23‐63 months), and median overall survival was 34 months (interquartile range, 13‐82 months). Median age was 71 years, and patients were mainly male individuals and hepatitis C virus carriers. According to ITA.LI.CA tumor staging, 246 patients were in stage 0, 472 were in stage A, 657 were in stages B1/3, and 133 were in stage C. The ITA.LI.CA prognostic system showed the best discriminatory ability (C‐index = 0.77) and monotonicity of gradients compared to other systems, and its superiority was also confirmed after stratification for treatment strategy. Conclusion: This is the first study that independently validated the ITA.LI.CA prognostic system in a large cohort of Western patients with incident HCCs. The ITA.LI.CA system performed better than other multidimensional prognostic systems, even after stratification by curative or palliative treatment. This new system appears to be particularly useful for predicting individual HCC prognosis in clinical practice. (Hepatology 2018;67:2215‐2225)