Giuseppe Belfiore

Percutaneous CT-guided irreversible electroporation followed by chemotherapy as a novel neoadjuvant protocol in locally advanced pancreatic cancer: Our preliminary experience

INTRODUCTION Irreversible electroporation (IRE) is a non-thermal ablation technique recently used in pancreatic cancer. In our prospective study we evaluated safety, feasibility and efficacy of a neoadjuvant protocol based on CT-guided percutaneous IRE followed by chemotherapy in patients with locally advanced pancreatic cancer (LAPC). METHODS We performed CT-guided percutaneous IRE in 20 patients with LAPC, followed by a combination of gemcitabine (1000 mg/mq) and oxaliplatin (100 mg/mq) biweekly. Imaging follow-up was performed by a contrast enhanced CT scan at 1, 3, 6 months and then every 3 months. RESULTS No major complications occurred. Two patients died 3 and 4 months after IRE because of rapidly progressive disease. In the remaining 18 patients 6-month imaging follow-up showed a mean lesions volumetric decrease percentage of 42.89% (95% Confidence Interval: 34.90-54.88%). Thanks to lesions downstaging, three patients underwent R0 resection. At last available follow-up (mean follow-up 91 months; range 6-14), imaging showed no disease progression or post-surgical relapse in all 18 cases. The mean estimated survival was 12,950 months (95% CI: 11,570-14,332). CONCLUSIONS Our preliminary study suggests that IRE followed by chemotherapy is safe, feasible and effective in producing local control of LAPC, with a possible downstaging effect to resectable lesions.

CT-Guided Radiofrequency Ablation in the Treatment of Recurrent Rectal Cancer

OBJECTIVE Locally recurrent rectal adenocarcinoma remains a therapeutic challenge that is unsatisfactorily managed by surgery and radiation therapy or chemotherapy. Palliative CT-guided radiofrequency ablation was used in 14 patients with recurrent rectal adenocarcinoma who had been previously treated with abdominoperineal resection and radiation therapy. Follow-up CT or MRI was performed at 3, 6, 12, and 24 months. Pain palliation was monitored by the brief pain inventory (BPI). CONCLUSION One month after radiofrequency ablation, 11 patients reported satisfactory BPI mean scores reduction compared to baseline (from 7.6 to 3.4 and from 5.1 to 1.6 for worst and average pain, respectively). In two unresponsive patients, retreatment was successfully performed at 3 months. After 24 months, worst and average pain scores further decreased (to 2.6 and 0.8, respectively) in 10 patients, who, at imaging, showed an ablation zone covering the entire original lesion in two patients and incomplete ablation in eight. In our experience, radiofrequency ablation is a safe and effective palliative treatment for patients with recurrent rectal adenocarcinoma.

Preliminary Results in Unresectable Head and Neck Cancer Treated by Radiofrequency and Microwave Ablation: Feasibility, Efficacy, and Safety

PURPOSE To retrospectively determine whether the application of thermal ablation to recurrent and advanced head and neck cancer (HNC) could allow for local tumor control. MATERIALS AND METHODS From 2002 to 2014, 22 patients (17 men and 5 women; mean age, 64 y; age range, 42-88 y) with unresectable HNC lesions treated with thermal ablation were evaluated. Patients were followed at 3 and 6 months after treatment, every 6 months for 5 years, and yearly thereafter with computed tomography and/or magnetic resonance imaging. The mean follow-up period was 32.2 months (range, 3-51 mo). RESULTS Three of 22 patients with primary lesions are still alive; two of these patients were treated with radiofrequency (RF) ablation and one was treated with microwave (MW) ablation. Of the 19 remaining patients, four were treated with MW ablation and 15 were treated with RF ablation. Imaging revealed partial response in eight patients, and complete response was observed in the remaining 14. There were two major complications after ablation treatment. The mean survival time was 32.9 months ± 3.205 (standard error; 95% confidence interval [CI], 26.6-39.2 mo). The survival time for MW ablation cases (36 mo ± 5.185; 95% CI, 25.8-46.16 mo) was longer than for RF ablation (32.2 mo ± 3.911; 95% CI, 24.5-39.8 mo), although the CI overlap between the groups is large. CONCLUSIONS Percutaneous thermal ablation is a promising alternative treatment for local control of incurable HNC.

Elipse Balloon: the Pitfalls of Excessive Simplicity

To the Editor, We read with great interest the manuscript by Genco et al. [1] describing their initial experience with 38 patients who successfully completed the therapy with Elipse intragastric balloon (IGB) (Allurion Technologies, Wellesley, MA, USA). After the scheduled 16 weeks of therapy, 37 balloons were spontaneously evacuated, and one balloon was endoscopically removed, without any complication. The authors concluded that Elipse balloon is a safe device that can be swallowed and excreted without serious adverse events, avoiding an upper gastrointestinal (UGI) endoscopy. Despite these interesting and encouraging results, we report different experience with this device. A 55-yearold man with a BMI of 33.3 kg/m (weight 102 kg) and hepatic steatosis underwent insertion of Elipse balloon under our care in October 2016. After 6 weeks, the patient was readmitted to the hospital complaining with severe abdominal pain, nausea, vomiting, and no bowel movement since 24 h. Weight loss was about 10 kg (body weight = 92 kg; BMI = 30.06 kg/m). Abdominal ultrasound was unremarkable, but x-ray examination showed gastric dilation, air-fluid levels in the small bowel, and a radiopaque imagine that raised the suspicion of Elipse balloon valve in the left side of the abdomen (Fig. 1a, b). A nasogastric tube was positioned, and intravenous fluids and antibiotic therapy were administered. Computed tomography (CT) confirmed small bowel obstruction due to the presence of a partially desufflated balloon in the jejunal tract. The day after, another CT demonstrated the progression of the balloon, closer to the anterior abdominal wall allowing a guided aspiration of 85 cm from the device. A small amount of liquid was left in the lumen of device in order to allow further radiological studies (Fig. 2a, b). Due to persistence of symptoms and deterioration of clinical conditions, a laparoscopic exploration was performed but the Elipse device was not found during the small bowel inspection from Treitz ligament to ileocecal valve. A Foley catheter was positioned in the rectum and contrast medium was administered revealing the presence of balloon in the descending colon. So the desufflated balloon was removed by colonoscopy. There were no perioperative complications and the patient was discharged on the second postoperative day. Unfortunately few months later, the patient regained weight. Recently, a similar episode of small bowel obstruction due to Elipse balloon migration has been reported in a woman with previous multiple cesarean sections. A surgical intervention was required. The authors hypothesized that the incomplete balloon filling or the premature catheter disconnection during balloon placement could have promoted the balloon migration [2]. Previously, Machytk et al. reported the mechanism underlying balloon desufflation. According to their explanation, the * Paola Iovino piovino@unisa.it

Long-term local disease control in a recurrent soft-tissue sarcoma of the thigh treated by radiofrequency ablation.

In 2008, we performed radiofrequency ablation (RFA) in an elderly patient with a large recurrent soft‐tissue sarcoma of the thigh, previously treated with surgery and radiotherapy. After ablation, a marked shrinkage of tumor was obtained. Further local recurrences occurred during follow‐up, all safely treated by RFA, with local control of the disease maintained until 6‐year follow‐up. RFA was safe, effective, and repeatable for soft‐tissue sarcoma recurrences, and allowed long‐term local control of the disease. J. Surg. Oncol. 2015 111:708–710.

MR-Cisternography with T2-Weighted Single-Shot Fast Spin Echo Sequence in the Diagnosis of a Spontaneous CSF Fistula of the Sphenoid Sinus Causing Massive Pneumocephalus

A spontaneous CSF fistula of the sphenoid sinus was preoperatively diagnosed in a young woman presenting with massive pneumocephalus and rhinorrhea. Diagnosis was established by MR cisternography using a heavily T2-weighted 3D single-shot FSE sequence with half-Fourier analysis (3D-EXPRESS®), originally developed for imaging the inner ear. While unenhanced CT failed to detect the site of the fistula, MR permitted complete evaluation of the sellar/sphenoid region and tracked the CSF signal down to the nasal cavity.