Antonio Bianchini

Percutaneous Laser Ablation in the Treatment of Hepatocellular Carcinoma with Small Tumors: Analysis of Factors Affecting the Achievement of Tumor Necrosis

PURPOSE To identify the factors that affect the achievement of tumor necrosis with percutaneous laser ablation (PLA) in patients with hepatocellular carcinoma (HCC) and tumor size no larger than 4.0 cm. MATERIALS AND METHODS Ultrasound-guided biopsy results were retrospectively studied in 99 lesions (range, 0.5-4.0 cm; mean, 2.7 cm) from 82 patients (44 men, 38 women; age range, 50-80 years; median, 68 y) who had undergone PLA. RESULTS Complete tumor ablation was obtained in 90 lesions (90.9%). Of the nine cases in which complete tumor necrosis was not achieved, six had tumors located in sites that did not allow the optimal placement of fibers, and five of these had a tumor diameter greater than 3 cm. Early discontinuation of PLA as a result of decompensation of liver cirrhosis was the reason for not achieving a complete tumor ablation in three other cases. There was a clear relationship between the energy delivered and the volume of necrosis achieved (r = 0.56; P < .001) regardless of the initial size of HCC tumors. The number of illuminations required, and consequently the amount of energy delivered, was also affected by tumor location. In fact, lesions adjacent to large vessels (> or = 3 mm) required a greater number of illuminations than the other lesions to achieve complete ablation (2.9 +/- 1.4 vs 2.3 +/- 0.9; P = .043). The eight cases with undifferentiated histology required more illuminations than the cases with other histologic types (3.4 +/- 0.9 vs 2.2 +/- 0.9; P < .001). However, these cases were located in sites that did not allow the optimal placement of fibers, therefore requiring multiple treatments. CONCLUSION PLA is a highly effective treatment in HCC with a tumor size of 4.0 cm or smaller. In this setting, two variables, tumor size and tumor location, affect the achievement of complete tumor ablation and the number of treatments required to obtain tumor necrosis.

Percutaneous ultrasound-guided laser ablation is effective for treating selected nodal metastases in papillary thyroid cancer.

CONTEXT Mini-invasive procedures may be useful for control of local neck nodal metastases of papillary thyroid cancer (PTC) in high-risk patients. OBJECTIVE Our objective was to assess the effectiveness and safety of ultrasound (US)-guided laser ablation (LA) for nonsurgical treatment of small-size neck metastases of PTC. DESIGN AND SETTING We conducted a pilot study on a surgically controlled metastasis, followed by a prospective trial with a 12-month follow-up. PARTICIPANTS Participants included five patients with previous total thyroidectomy and neck dissection for PTC, with eight new lymph node metastases in an area already treated with surgical dissection and lymph node volume less than 2 ml and absent radioiodine uptake. OUTCOME MEASURES We evaluated thyroglobulin (Tg) and US changes of the lymph nodes 6 and 12 months after LA as well as tolerability and side effects of the procedure. RESULTS A single LA treatment induced progressive volume reduction of the eight metastatic lymph nodes. Mean baseline volume decreased from 0.64 ± 0.58 to 0.07 ± 0.06 ml at 12-month control. Mean volume reduction was 64.4 ± 0.19% at 6 months (P < 0.02 vs. baseline) and 87.7 ± 0.11% at 12 months (P < 0.01 vs. baseline). No regrowth was registered. Mean serum Tg on LT4 decreased from 8.0 ± 3.2 ng/ml to 2.0 ± 2.5 ng/ml at 12-month control (P < 0.02 vs baseline). In three patients (60%) Tg levels were undetectable at 12-month control. Pain was tolerable in two cases and mild in three cases. Transient dysphonia in one patient was the only complication. After 1 yr, no cancer seeding was present. CONCLUSION LA is a well-tolerated outpatient procedure that results in a rapid cytoreduction of cervical nodal metastases of PTC. Mini-invasive procedures may be used in lieu of surgery as an adjunctive therapy for small-burden local/regional disease recurrence. They are occasionally associated with an anatomical or biochemical cure, but long-term follow-up or controlled trials are needed.

Ultrasound-Guided Laser Ablation of Incidental Papillary Thyroid Microcarcinoma: A Potential Therapeutic Approach in Patients at Surgical Risk

BACKGROUND Incidental papillary thyroid microcarcinoma (PTMC), a frequent clinical problem, is usually associated with a favorable outcome. During long-term follow-up, only a minority of cases show aggressive behavior with either lymph node or distant metastases. Recently, we had an opportunity to evaluate the efficacy of nonsurgical, ultrasound (US)-guided percutaneous laser ablation (PLA) for local treatment of PTMC in an otherwise inoperable patient. PATIENT AND METHODS Neck US examination revealed an incidental, solitary, 8 × 7 × 7 mm hypoechoic nodule with microcalcifications of the right thyroid lobe. The patient suffered from decompensated liver cirrhosis, renal failure, and recent surgery followed by external beam radiation therapy for breast cancer. Cytologic diagnosis showed papillary thyroid carcinoma, but the patient declined surgery because of high risk of thyroid surgery. After local anesthesia with 2% xylocaine, PLA was performed according to the previously reported procedure with an Nd:YAG laser. SUMMARY The procedure was well tolerated, without side effects, and the patient required no analgesics. US-guided fine-needle aspiration biopsy and core-needle biopsy were performed at 1 and 12 months after PLA, which demonstrated necrotic material and inflammatory cells with no viable neoplastic cell. At the 24 months US follow-up examination, the area of necrosis further decreased, demonstrating a 4 × 4 mm hypoechoic zone and a small hyperechoic area due to fibrotic changes. A fine-needle aspiration biopsy confirmed the absence of malignant cells. CONCLUSIONS Laser-induced thermal ablation was a safe and effective ablative treatment for a patient with PTMC confined to the thyroid gland who was at high surgical risk. This approach should be considered only in elderly patients and/or in those with comorbidities that might expose the patients to an undue high surgical risk and only after the evaluation by neck US, computed tomography, magnetic resonance imaging, or positron emission tomography/computed tomography rules out lymph-node involvement or metastatic disease.

Laser Ablation and 131-Iodine: A 24-Month Pilot Study of Combined Treatment for Large Toxic Nodular Goiter

CONTEXT It is normally recognized that the preferred treatment in large toxic thyroid nodules should be thyroidectomy. OBJECTIVE The aim of the study was to assess the efficacy of combined laser ablation treatment (LAT) and radioiodine 131 (131I) treatment of large thyroid toxic nodules with respect to rapidity of control of local symptoms, of hyperthyroidism, and of reduction of administered 131I activity in patients at refusal or with contraindications to surgery. DESIGN AND SETTING We conducted a pilot study at a single center specializing in thyroid care. PATIENTS Fifteen patients were treated with LAT, followed by 131I (group A), and a series of matched consecutive patients were treated by 131I only (group B). INTERVENTION(S) Laser energy was delivered with an output power of 3 W (1800 J per fiber per treatment) through two 75-mm, 21-gauge spinal needles. Radioiodine activity was calculated to deliver 200 Gy to the hyperfunctioning nodule. MAIN OUTCOME MEASURE(S) Thyroid function, thyroid peroxidase antibody, thyroglobulin antibody, ultrasound, and local symptoms were measured at baseline and up to 24 months. RESULTS Nodule volume reduction at 24 months was: 71.3 ± 13.4 vs 47.4 ± 5.5%, group A (LAT+131I) vs group B (131I), respectively; P < .001). In group A (LAT+131I), a reduction in radioiodine-administered activity was obtained (-21.1 ± 8.1%). Local symptom score demonstrated a more rapid reduction in group A (LAT+131I). In three cases, no 131I treatment was needed after LAT. CONCLUSIONS In this pilot study, combined LAT/131I treatment induced faster and greater improvement of local and systemic symptoms compared to 131I only. This approach seems a possible alternative to thyroidectomy in patients at refusal of surgery.

Contrast-Enhanced Ultrasound in the Management of Thyroid Nodules

INTRODUCTION Thyroid nodules are discovered by palpation in 3–7% of subjects in the general population, but an epidemic of clinically unapparent thyroid lesions is detected by high-resolution ultrasonography (US) of the cervical region (1–3). The clinical importance of thyroid nodules, besides the infrequent local compressive symptoms or thyroid dysfunction, is the possibility of thyroid cancer, which occurs in about 5% of all thyroid nodules (4–5). Thus it is essential to improve our diagnostic tools to avoid the use of unnecessary diagnostic surgery. Brightness-mode US is currently the most accurate imaging test to evaluate solitary thyroid nodules or multinodular goiters (6–8). Thyroid US results in improved management for patients, with clinical findings suggestive of thyroid nodules (9). Many patients either have a palpable but not suspicious nodule, or have incidentally revealed but sonographically relevant nodules that warrant fine needle aspiration biopsy (10). Unfortunately, in most cases US characteristics cannot unequivocally distinguish benign and malignant lesions (10–12). Color Doppler US was proposed to evaluate nodule

Predictive Value of Malignancy of Thyroid Nodule Ultrasound Classification Systems: A Prospective Study

Context British Thyroid Association (BTA), American Thyroid Association (ATA), and American Association of Clinical Endocrinologists (AACE/ACE/AME) recommend for thyroid nodules an ultrasound (US)-based stratification of risk of malignancy. Aim of our study was to assess the diagnostic accuracy of US classification systems and their reliability for indication to fine-needle aspiration (FNA). Design Prospective study on 987 thyroid nodules consecutively referred for FNA. US images were independently reviewed by four experts for assignment of malignancy risk. Cytologically benign nodules had confirmation with a second FNA, whereas Bethesda class IV, V, and VI nodules were operated upon. Class III nodules had surgery or follow-up on the basis of clinical, immunocytochemical, and US features. Results BTA: Malignancy rate was 2.8% in benign, 10.0% in indeterminate, 51.3% in suspicion, and 80.9% in malignant US class. Sensitivity was 0.74, specificity was 0.92, and accuracy was 0.89. ATA: Malignancy rate was 0.0% in benign, 2.2% in very low suspicion, 3.0% in low suspicion, 5.8% in intermediate, and 55.0% in high suspicion US class. Sensitivity was 0.81, specificity was 0.87, and accuracy was 0.86. AACE/ACE/AME: Malignancy rate was 1.1% in low-risk, 4.4% in intermediate-risk, and 54.9% in high-risk US class. Sensitivity was 0.82, specificity was 0.87, and accuracy was 0.86. K correlation coefficient was 78.9%, 76.9%, and 82.0% for BTA, ATA, and AACE/ACE/AME classifications. Conclusions Classification systems had elevated predictive value of malignancy in high-risk classes. ATA and AACE/ACE/AME systems were effective for ruling out indication to FNA in low-US-risk nodules. A similar diagnostic accuracy and a substantial interobserver agreement was provided by the three- and the five-category classifications.

Minimally Invasive Treatments for Thyroid Nodules

The incidence of thyroid nodules, either solitary or within a multinodular goiter, is steadily increasing during the last decades, and new therapeutic tools, besides the current options of simple surveillance or surgery, would be profitable to attain a personalized management. Most thyroid nodules are asymptomatic and benign at cytological assessment, remain stable over the years, and do not warrant treatment. In other cases, however, the nodules grow progressively, become visible, and eventually cause local symptoms. As in these cases, a protracted clinical observation is frequently followed by surgical consultation; a well-timed use of minimally invasive procedures could reshape the progression of these benign thyroid lesions toward surgery.

Ultrasound-guided laser ablation for local control of neck recurrences of medullary thyroid cancer. A feasibility study

Abstract Background: Surgery is the standard treatment for cervical metastases of medullary thyroid cancer (MTC) diagnosed after initial surgical treatment. Repeated neck dissections, however, carry an elevated risk of complications, have an adverse impact on the quality of life, and sometimes do not achieve cure of the disease Clinical case: In a patient who had undergone two cervical neck dissections complicated by accessory nerve injury, an US-guided laser ablation (LA) of a lymph node metastasis of MTC was performed. LA was performed with two treatments during a five month period. The procedure was carried out with one optical fiber and an energy delivery of 3300 and 360 Joules. Treatments were well tolerated and resulted in complete structural and biochemical cure during a 12 month follow-up. No major complication was registered. Conclusions: LA is a promising tool for the management of relapsing cervical metastases that are localized in non- critical areas and are characterized by low progression rate. Advantages of LA are the outpatient setting, the absence of general anesthesia, the tolerability and the safety of the procedure. Thus, LA may be considered as an alternative approach to surgery or active surveillance for the management of local recurrences of MTC in selected patients.

Percutaneous Laser Thermal Ablation (LAT): Techniques, Indications, Experience and Complications

Thyroid nodules are a frequent clinical problem in endocrine practice [1, 2]. The majority of them are benign and asymptomatic but some steadily grow and may cause pressure symptoms or concern [1]. Surgical resection is the traditional approach to thyroid lesions that, even if benign at repeated fine-needle aspiration biopsy (FNA), are symptomatic or progressively enlarging [3]. Surgery, however, carries some problems: is expensive, is associated with a low but not negligible risk of cosmetic damage or complications, and is frequently followed by the need of a substitution therapy [3]. During the last years, non-surgical, minimally invasive procedures (MIT) have been investigated for the treatment of thyroid lesions when surgery is technically difficult or is refused by the patient [4]. Bown [5] first used laser energy for the debulking of hepatic tumours and later, in the year 2000, US-guided laser ablation (LAT) was proposed for the management of benign solid thyroid nodules [6]. Currently, the procedure is increasingly used for the treatment of selected patients with thyroid lesions and its principles, outcomes, side effects and indications will be reviewed in the following chapters.