Carlo Gazzera

Role of Interventional Radiology in the Treatment of Biliary Strictures Following Orthotopic Liver Transplantation

AbstractPurpose: To evaluate the efficacy and safety of percutaneous treatment of biliary strictures complicating orthotopic liver transplantation (OLT). Methods: Between October 1990 and May 2000, 619 patients underwent 678 liver transplants. Seventy of the 619 (11%) patients were found to be affected by biliary strictures by July 2000. Bilioplasty was performed in 51 of these 70 (73%) patients. A cohort of 33 of 51 (65%) patients were clinically followed for more than 12 months after the last percutaneous treatment and included in the survey results. Results: After one to three treatments 24 of 33 (73%) patients were stricture-free on ultrasound and MR cholangiography follow-up. A delayed stricture recurrence required a fourth percutaneous bilioplasty in two of 33 (6%) patients. A surgical bilioenteric anastomosis was performed in six of 33 (18%) patients. Retransplantation was performed due to ischemic damage in one of 33 (3%) patients. Conclusion: Interventional radiology is an effective therapeutic alternative for the treatment of most biliary strictures complicating OLT. It has a high success rate and should be considered before surgical interventions. Elective surgery may be necessary in a few failed cases or those with more severe and extensive biliary strictures.

Radiological treatment of male varicocele: technical, clinical, seminal and dosimetric aspects

Purpose.The purpose of this study was to present our experience with percutaneous treatment of male varicocele considering technical, clinical, seminal and dosimetric aspects.Materials and methods.At baseline and at 6 months’ follow–up, 290 male patients aged between 18 and 37 (average age 27.3 years) with left (266 cases) or bilateral (24 cases) varicocele underwent clinical assessment, Doppler ultrasonography (US), laboratory testing of free and total serum testosterone, leutenising hormone (LH) and follicle stimulating hormone (FSH) gonadotropins, inhibin B and spermiogram. In 223 cases, selective catheterisation of the spermatic vein was performed with a right transfemoral approach. Two hundred and six out of 223 underwent radiological treatment of varicocele; in 194, hydroxy–poliethoxydocanol (Aetoxysclerol) was used only whereas in 12 cases (5.8%), 5 ml of absolute alcohol and a Gianturco coil (0.038–in. Cook coil, 10 mmx50 mm) were also used. In 17/223 patients (7.6%), sclerotherapy was contraindicated or not technically feasible. Sixty–seven patients refused radiological treatment and were used as a control group. In 20 patients, the following parameters were measured: dose area product, entrance surface dose, effective dose and gonad dose.Results.Technical success was achieved in 206/223 cases; two phlebographic examinations (immediately following administration of the sclerosing agent and after 15–20 min) showed prethrombotic endoluminal alterations of the internal spermatic vein. At 6 months’ follow–up, 172/206 patients (83.49%) showed complete resolution of the varicocele whereas 34/206 (16.5%) had only partial disengorgement of the pampiniform plexus. In these 206 patients, the spermogram showed a significant increase in sperm concentration (52.1±4.1 vs. 44.2±3.6 million/ml, p=0.002) and motility (40.5±2.2 vs. 33.3±2.0%, p=0.0001), with negligible morphological changes. In the control group and in the other 17 untreated patients, no variations in seminal parameters were observed. The following minor procedural complications were recorded: two cases of acute abdominal pain, three of vagal crisis during administration of sclerosing agent that resolved spontaneously and two of spermatic cord inflammation that resolved within days after medical therapy. We recorded no statistically significant differences with regard to testicular volume or serum hormone levels between the treated and untreated groups. Maximum effective dose and maximum gonad dose equivalent were 6.9 mSv and 0.69 mSv, respectively.Discussion and conclusions.Percutaneous radiological treatment of varicocele is a minimally invasive technique, which is well tolerated by patients and able to significantly improve seminal parameters. The principal technical limitation to percutaneous treatment is related to difficult selective catheterisation of the spermatic vein due to anatomic alterations, spasms and intimal dissection of the vein. Moreover, when the cremasteric vein is incontinent, inguinal surgical ligation provides better results. In the majority of cases, administration of at least 3 ml sclerosing agent at 3% ensures occlusion of the gonadic vein above the abdominal collaterals, which are responsible for long–term recurrence if not treated. In the remaining cases, absolute alcohol and metallic coils can be used to complete the treatment. The positive results in seminal parameters do not, however, allow for reliable assessment of patients’ fertility. Finally, we believe that radiological procedures are not indicated or justified when prolonged catheterisation with elevated gonadic irradiation is needed.

Percutaneous implantation of a catheter with subcutaneous reservoir for intraarterial regional chemotherapy: technique and preliminary results.

Purpose: We present the technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir for prolonged regional chemotherapy of hepatic and extrahepatic tumors.Methods: Two hundred patients with primary or secondary hepatic neoplasms, pelvic, pancreatic, renal, lingual, and breast cancer underwent the procedure. The access was the left axillary artery (188 patients) and the femoral artery (12 patients). The catheter tip was placed in the hepatic (170 patients), hypogastric (18), splenic (4), internal thoracic (2), gastroduodenal (3), renal (2) or the external carotid artery (1). The catheter was connected to a subcutaneous reservoir and filled with heparin: chemotherapeutic infusion was subsequently started.Results: One hundred percent immediate technical success was obtained. Forty-three of 200 (21.5%) patients had a complication: 29 patients had a catheter dislodgment, nine had arterial thrombosis, three had a pseudoaneurysm of the left axillary artery and two had a port pocket hematoma. Most complications (37/43, 86%) were treated percutaneously without interruption of chemotherapy. In only six cases (3% of the total population) was chemotherapy discontinued due to the complication itself. The mean duration of catheter patency was 7.2 months.Conclusion: Percutaneous placement of an intraarterial catheter is feasible and causes less discomfort to the patient than the surgical approach. The technique has an acceptable complication rate (21.5%), similar to that for surgical implantation (17.8%), with the advantage that in most cases the complications can be resolved percutaneously. This technique represents an alternative to surgical implantation in the treatment of liver metastases from colorectal cancer and opens new therapeutic possibilities for the local prolonged treatment of other kinds of tumor, though its clinical efficacy must be assessed in selected trials.

Combined regional and systemic chemotherapy by a mini-invasive approach for the treatment of colorectal liver metastases.

&NA; From February 1996 to December 1998, 95 patients affected with colorectal liver metastases underwent the positioning of an intraarterial hepatic catheter by a transcutaneous subclavian access, under local anesthesia. All patients were evaluated for catheter implantation complications. Moreover, 61 patients of 95 treated at our center were retrospectively evaluated for results of chemotherapy performed with two different schedules of hepatic artery infusion (HAI) combined with systemic chemotherapy (SC). Eleven patients (group A) were treated with combined SC (5‐fluorouracil continuous infusion) and HAI (floxuridine). A subsequent 50 patients underwent HAI (floxuridine, 4 cycles) followed, if a response or stable disease were observed, by combined SC and HAI (group B). Three cases of aneurysm of subclavian artery occurred, which were treated by the positioning of a radiologic arterial stent and the reimplantation of the catheter by a femoral access. Thrombosis of the hepatic artery was registered in four cases. We observed 10.5% occurrence of dislocation of the catheter, which was always moved again in the hepatic artery. In group A, with 45% clinical objective response rate and 10% stable disease rate, median survival time and median time to extrahepatic progression were 9 and 6 months, respectively. In group B, we observed 44% clinical objective responses and 26% stable disease after HAI. Patients without disease progression and therefore submitted to sequential SC and HAI had a median survival time of 21 months and a median time to extrahepatic progression of 16 months. The development of the miniinvasive technique of implantation of an arterial port can avoid laparotomy for HAI. Percutaneous implantation of an arterial port has a low rate of technical complications. HAI followed by combined systemic and regional chemotherapy has good results in terms of survival and time to extrahepatic progression.

Long-term outcome of radiofrequency thermal ablation (RFA) of liver metastases from colorectal cancer (CRC): size as the leading prognostic factor for survival

PurposeThe aim of this study was to review some prognostic factors for survival after radiofrequency ablation (RFA) of metastases from colorectal cancer (CRC).Materials and methodsFrom 1996 to 2009, 262 patients with metastases from CRC were treated with RFA. Fourteen were lost to follow-up. The following predictors were analysed in the remaining 248: synchronous/metachronous metastases, single/multiple metastases, diameter of largest metastasis and absence/presence of extrahepatic metastases. Survival was measured from the date of metastasis diagnosis and from the date of RFA.ResultsSurvival at 1, 2, 3 and 5 years was 93%, 78%, 62% and 35% from metastasis diagnosis, and 84%, 59%, 43% and 23% from the date of RFA. Median survival was 41 months in patients with largest metastasis ≤3 cm and 21.7 months for those with metastases >3 cm (p=0.0001); survival increased to 45.2 months in patients with largest metastasis ≤2.5 cm and fell to 18.5 months in those with metastasis >3.5 cm. Median survival of patients with extrahepatic metastases was significantly lower than that of patients without extrahepatic disease (23.3 vs. 32.6 months, p=0.018).ConclusionsIn light of our long-term results obtained with commonly used equipment, small lesion size (diameter of largest lesion ≤3 or 2.5 cm) proved to be the most favourable prognostic factor for survival in patients with CRC metastases to the liver treated with RFA. This conclusion is probably related to the possibility of obtaining radical ablation and points to the usefulness of devices allowing ablation of larger volumes. In the presence of extrahepatic metastases, RFA has less impact on survival, even though it is potentially useful in patients at a higher risk of death due to hepatic rather than extrahepatic metastases.RiassuntoObiettivoScopo del nostro lavoro è stato rivalutare alcuni predittori di sopravvivenza nella termoablazione con radiofrequenze (RFA) delle metastasi da carcinoma colorettale (CRC).Materiali e metodiTra il 1996 e il 2009 abbiamo trattato con RFA 262 pazienti con metastasi da CRC. Quattordici sono stati persi al follow-up; in 248 sono stati analizzati i seguenti predittori: metastasi sincrone/metacrone, metastasi unica/multiple, diametro della metastasi principale, assenza/presenza di metastasi extraepatiche. Le sopravvivenze sono state calcolate dalla data di diagnosi di metastasi e da quella della RFA.RisultatiLa sopravvivenza a 1, 2, 3, 5 anni è stata 93%, 78%, 62%, 35% dalla diagnosi di metastasi, e 84%, 59%, 43%, 23% dalla RFA. Nei pazienti con metastasi principale ≤3 cm la sopravvivenza mediana è stata 41 mesi vs. 21,7 di quelli con >3 cm (p=0,0001), ma in quelli ≤2,5 cm è salita a 45,2 mesi e in quelli >3,5 cm è scesa a 18,5. La sopravvivenza mediana dei pazienti con metastasi extraepatiche è stata significativamente inferiore a quelli senza (23,3 vs. 32,6 mesi, p=0,018).ConclusioniAlla luce dei nostri risultati a lungo termine, ottenuti con le apparecchiature comunemente utilizzate negli ultimi anni, le piccole dimensioni (diametro della lesione principale ≤3 o 2,5 cm) si confermano il fattore prognostico più favorevole per la sopravvivenza dei pazienti con metastasi epatiche da CRC sottoposti a RFA. Questa conclusione è molto probabilmente riconducibile alla possibilità di un’ablazione radicale e induce a prospettare l’utilità di apparecchiature in grado di aumentare il volume di ablazione. La RFA in presenza di metastasi extraepatiche è meno efficace in termini di sopravvivenza, ma potenzialmente utile nei pazienti a minor rischio di decesso per le metastasi extra-epatiche rispetto a quelle epatiche.

Fifteen years’ experience with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents: retrospective review of clinical and technical aspects

PurposeThe authors present a retrospective analysis of a large series of patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement.Materials and methodsBetween March 1992 and December 2006, 658 patients were referred to our centre for TIPS placement. Indications for the procedure were digestive tract bleeding (52.8%), refractory ascites (35.3%), preservation of portal vein patency prior to liver transplantation (3.0%) and thrombosis of the suprahepatic veins (2.3%). Other indications (6.6%) included pleural ascites, portal thrombosis and hepatorenal and hepatopulmonary syndromes. All patients were evaluated with colour Doppler ultrasonography and in a few cases with computed tomography. The portal system was punctured under sonographic guidance. Wallstent, Palmaz and Nitinol thermosensitive stents were used. Embolisation of persistent varices was performed in 6.8% of cases.ResultsTechnical success was 98.9%. During a 1,500-day follow-up, the cumulative incidence of stent revision was 25.7% (Nitinol), 32.9% (Wallstent) and 1.8% (Palmaz). Mortality rates were 31.1%, 38.5% and 56.4%, respectively. The technical complications included six cases of heart failure, six of haematobilia, three of stent migration, two of intrahepatic haematoma and one of haemoperitoneum. Eight patients with severe portosystemic encephalopathy (PSE) were treated with a reduction stent.ConclusionsTIPS placement is safe and effective and may act as a bridge to liver transplantation. Ultrasonography plays a fundamental role in the preliminary assessment, in portal vein puncture and during the follow-up. Stent patency is satisfactory.RiassuntoObiettivoGli autori presentano un’analisi retrospettiva di un’ampia casistica di pazienti sottoposti a TIPS.Materiali e metodiSono giunti al nostro centro per la TIPS 658 pazienti tra il marzo 1992 e il dicembre 2006. Le indicazioni alla procedura erano: sanguinamento digestivo (52,8%), ascite refrattaria (35,3%), “tutela” della pervietà portale pre-trapianto epatico (3,0%), trombosi delle vene sovraepatiche (2,3%). Altre indicazioni (6,6%) erano ascite pleurica, trombosi portale, sindrome epato-renale ed epato-polmonare. I pazienti sono stati studiati con ecocolor doppler, raramente con tomografia computerizzata; la puntura portale è stata ecoguidata. Sono stati impiegati stent Palmaz, Wallstent e termoespandibili. Nel 6,8% dei casi sono state embolizzate varici persistenti.RisultatiIl successo tecnico è stato del 98,9%. Durante un follow-up di 1500 giorni, l’incidenza cumulativa di reintervento sugli stent è stata del 25,7% (Nitinol), 32,9% (Wallstent) e 1,8% (Palmaz); la mortalità è stata rispettivamente 31,1%, 38,5% e 56,4%. Le complicanze tecniche sono state: 6 insufficienze cardiache, 6 emobilie, 3 migrazioni di stent, 2 ematomi intraepatici ed 1 emoperitoneo. Otto pazienti con encefalopatia portosistemica (PSE) grave sono stati trattati con stent riduttore.ConclusioniLa TIPS è sicura ed efficace, può rappresentare un ponte all’OLT. L’ecografia ha un ruolo fondamentale nello studio preliminare, durante la puntura portale e nel follow-up. La pervietà degli stent è soddisfacente.

Image-guided microwave ablation of hepatic tumours: preliminary experience

PurposeMicrowave thermal ablation (MWA) opens up a new scenario in the field of image-guided tumour ablation thanks to its potential advantages over validated radiofrequency ablation (RFA). In this pilot study, we assessed the technical success, safety and efficacy of MWA in treating hepatic malignancies.Materials and methodsAfter obtaining informed consent, we enrolled 15 inoperable patients, for a total of 19 lesions (ten metastases, nine hepatocellular carcinoma) with a mean diameter of 47 mm (range 14–78 mm). Mean follow-up was 8 (range 1–14) months.ResultsTechnical success reached 100%. Complications (one major and one minor) occurred in two cases. Complete ablation, obtained in 68.4% of cases, showed no significant correlation with either cancer histological type or with lesion diameter. At follow-up, treatment failures occurred in 60% of cases; lesion diameter was the only prognostic factor for maintaining complete ablation.ConclusionsOur preliminary results should encourage further trials of this technique. MWA proved to be feasible and safe in treating advanced-stage liver tumours and represented an additional therapeutic attempt to be validated in further and larger efficacy studies.RiassuntoObiettivoLa termoablazione con microonde (MWA) prospetta un nuovo scenario nel campo delle ablazioni tumorali imaging-guidate per i potenziali vantaggi rispetto all’ormai validata termoablazione con radiofrequenze (RFA). Con questo studio pilota ne abbiamo valutato successo tecnico, sicurezza ed efficacia nel trattamento dei tumori epatici maligni.Materiali e metodiPrevio consenso informato, abbiamo arruolato 15 pazienti non operabili, portatori di 19 lesioni (10 metastasi [MTS], 9 carcinomi epatici [HCC]) con diametro medio di 47 mm (range 14–78 mm). Il follow-up medio è stato di 8 mesi (range 1–14 mesi).RisultatiIl successo tecnico è stato del 100%. In due casi sono state registrate complicanze (1 maggiore e 1 minore). L’ablazione completa (AC), ottenuta nel 68,4% dei casi, non ha dimostrato correlazioni statisticamente significativa né con l’istotipo, né con il diametro delle lesioni. Nel follow-up, il fallimento del trattamento (FT) si è verificato complessivamente nel 60% dei casi; il diametro delle lesioni è stato l’unico fattore prognostico per l’AC mantenuta nel tempo.ConclusioniI risultati preliminari del nostro studio incoraggiano la sperimentazione di questa tecnica. La MWA è stata fattibile e sicura nel trattamento di neoplasie epatiche avanzate, e ha costituito un tentativo terapeutico oltre i protocolli oncologici standard da sottoporre al vaglio di più ampi studi di efficacia.

Follow-up of varicocele treated with percutaneous retrograde sclerotherapy: Technical, clinical and seminal aspects

Varicocele is a common cause of male infertility; it can be treated by percutaneous retrograde embolization of the internal spermatic vein in order to improve sperm parameters and male fertility. The aim of this study was to verify the improvement of semen parameters after varicocele retrograde sclerotherapy. We evaluated 223 patients with left (206) or bilateral (17) varicocele (mean age±SD, 27.3±4.7 yr, range 18–37) by clinical, Doppler and seminal examinations; all the patients underwent phlebography, using 5F Cobra catheter from the right femoral vein access to the internal spermatic vein and varicocele sclerosing with Hydroxy-polyaethoxydodecanol. Doppler and seminal examinations 6 months after sclerotherapy were requested for the follow-up. Sixty-seven patients with left or bilateral varicocele who did not undergo sclerotherapy were studied as controls. Six months after sclerotherapy, a complete resolution of left varicocele was present in 172 patients (77.1%), while a partial improvement was obtained in 34 patients (15.3%). In these 206 patients seminal examination showed a significant improvement of sperm concentration (mean±SEM, 52.1±4.1 vs 44.2±3.6 million/ml, p=0.002) and progressive motility (40.5±2.2 vs 33.3±2.0%, p=0.0001), but not of normal sperm morphology (38.9±2.3 vs 37.4±2.1%, ns). In the control group no significant variations of seminal parameters were observed 6 months after the basal examination. In conclusion, varicocele retrograde sclerotherapy is a well-tolerated technique with a low cost-benefit ratio, able to improve semen parameters.

Image-guided microwave ablation of hepatic tumours: preliminary experience. Termoablazione imaging-guidata con microonde (MWA) di neoplasie

PurposeMicrowave thermal ablation (MWA) opens up a new scenario in the field of image-guided tumour ablation thanks to its potential advantages over validated radiofrequency ablation (RFA). In this pilot study, we assessed the technical success, safety and efficacy of MWA in treating hepatic malignancies.Materials and methodsAfter obtaining informed consent, we enrolled 15 inoperable patients, for a total of 19 lesions (ten metastases, nine hepatocellular carcinoma) with a mean diameter of 47 mm (range 14–78 mm). Mean follow-up was 8 (range 1–14) months.ResultsTechnical success reached 100%. Complications (one major and one minor) occurred in two cases. Complete ablation, obtained in 68.4% of cases, showed no significant correlation with either cancer histological type or with lesion diameter. At follow-up, treatment failures occurred in 60% of cases; lesion diameter was the only prognostic factor for maintaining complete ablation.ConclusionsOur preliminary results should encourage further trials of this technique. MWA proved to be feasible and safe in treating advanced-stage liver tumours and represented an additional therapeutic attempt to be validated in further and larger efficacy studies.RiassuntoObiettivoLa termoablazione con microonde (MWA) prospetta un nuovo scenario nel campo delle ablazioni tumorali imaging-guidate per i potenziali vantaggi rispetto all’ormai validata termoablazione con radiofrequenze (RFA). Con questo studio pilota ne abbiamo valutato successo tecnico, sicurezza ed efficacia nel trattamento dei tumori epatici maligni.Materiali e metodiPrevio consenso informato, abbiamo arruolato 15 pazienti non operabili, portatori di 19 lesioni (10 metastasi [MTS], 9 carcinomi epatici [HCC]) con diametro medio di 47 mm (range 14–78 mm). Il follow-up medio è stato di 8 mesi (range 1–14 mesi).RisultatiIl successo tecnico è stato del 100%. In due casi sono state registrate complicanze (1 maggiore e 1 minore). L’ablazione completa (AC), ottenuta nel 68,4% dei casi, non ha dimostrato correlazioni statisticamente significativa né con l’istotipo, né con il diametro delle lesioni. Nel follow-up, il fallimento del trattamento (FT) si è verificato complessivamente nel 60% dei casi; il diametro delle lesioni è stato l’unico fattore prognostico per l’AC mantenuta nel tempo.ConclusioniI risultati preliminari del nostro studio incoraggiano la sperimentazione di questa tecnica. La MWA è stata fattibile e sicura nel trattamento di neoplasie epatiche avanzate, e ha costituito un tentativo terapeutico oltre i protocolli oncologici standard da sottoporre al vaglio di più ampi studi di efficacia.

Utilility of flow cytometry as ancillary study to improve the cytologic diagnosis of thyroid lymphomas.

To evaluate the efficacy of the use of flow cytometry (FC) immunophenotyping together with fine‐needle aspiration cytology (FNAC) in the diagnosis of thyroid lymphoma.