Guido Bonomo

Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy: a randomized trial

BACKGROUND Central venous access is extensively used in oncology, though practical information from randomized trials on the most convenient insertion modality and site is unavailable. METHODS Four hundred and three patients eligible for receiving i.v. chemotherapy for solid tumors were randomly assigned to implantation of a single type of port (Bard Port, Bard Inc., Salt Lake City, UT), through a percutaneous landmark access to the internal jugular, a ultrasound (US)-guided access to the subclavian or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Early and late complications were prospectively recorded until removal of the device, patients death or ending of the study. RESULTS Four hundred and one patients (99.9%) were assessable: 132 with the internal jugular, 136 with the subclavian and 133 with the cephalic vein access. The median follow-up was 356.5 days (range 0-1087). No differences were found for early complication rate in the three groups {internal jugular: 0% [95% confidence interval (CI) 0.0% to 2.7%], subclavian: 0% (95% CI 0.0% to 2.7%), cephalic: 1.5% (95% CI 0.1% to 5.3%)}. US-guided subclavian insertion site had significantly lower failures (e.g. failed attempts to place the catheter in agreement with the original arm of randomization, P = 0.001). Infections occurred in one, three and one patients (internal jugular, subclavian and cephalic access, respectively, P = 0.464), whereas venous thrombosis was observed in 15, 8 and 11 patients (P = 0.272). CONCLUSIONS Central venous insertion modality and sites had no impact on either early or late complication rates, but US-guided subclavian insertion showed the lowest proportion of failures.

High-Intensity Focused Ultrasound Ablation: Effective and Safe Therapy for Solid Tumors in Difficult Locations

OBJECTIVE The aim of this study was to evaluate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound therapeutic ablation of solid tumors in difficult locations. SUBJECTS AND METHODS A procedure was performed with a focused ultrasound tumor therapeutic system which provides real-time ultrasound guidance. All patients underwent MDCT or MRI, and some patients underwent PET/CT. From November 2007 through April 2009, 31 patients with 38 lesions of the liver and pancreas in difficult locations were treated. Six patients had hepatocellular carcinoma, 13 patients had hepatic metastasis from colorectal cancer, two had hepatic metastases of breast cancer, two had hepatic metastasis of neuroendocrine tumors, one patient had lymph node metastasis of breast cancer at the hepatic hilum, six patients had pancreatic cancer, and one patient had a neuroendocrine tumor. Difficult location was defined as tumor adjacent to a main blood vessel, the heart, the gallbladder and bile ducts, the bowel, or the stomach. RESULTS The mean diameter of tumors was 2.7 +/- 1.4 cm. PET/CT, MDCT, or both on the day after one session of high-intensity focused ultrasound treatment showed complete response in all six patients with hepatocellular carcinoma, the patient with lymph node metastasis, and 22 of 24 patients with hepatic metastasis. The symptoms of all seven patients with pancreatic caner or neuroendocrine tumors were palliated, and PET/CT or MRI showed complete response of six of seven lesions. Portal vein thrombosis occurred after high-intensity focused ultrasound ablation in one patient with pancreatic cancer. No other side effects were detected in a median follow-up period of 12 months. CONCLUSION According to our short- and long-term follow-up results, ultrasound-guided high-intensity focused ultrasound ablation can be considered a safe and feasible approach to the management of solid tumors in difficult locations.

Radioembolization of Hepatic Lesions from a Radiobiology and Dosimetric Perspective

Radioembolization (RE) of liver cancer with 90Y-microspheres has been applied in the last two decades with notable responses and acceptable toxicity. Two types of microspheres are available, glass and resin, the main difference being the activity/sphere. Generally, administered activities are established by empirical methods and differ for the two types. Treatment planning based on dosimetry is a prerogative of few centers, but has notably gained interest, with evidence of predictive power of dosimetry on toxicity, lesion response, and overall survival (OS). Radiobiological correlations between absorbed doses and toxicity to organs at risk, and tumor response, have been obtained in many clinical studies. Dosimetry methods have evolved from the macroscopic approach at the organ level to voxel analysis, providing absorbed dose spatial distributions and dose–volume histograms (DVH). The well-known effects of the external beam radiation therapy (EBRT), such as the volume effect, underlying disease influence, cumulative damage in parallel organs, and different tolerability of re-treatment, have been observed also in RE, identifying in EBRT a foremost reference to compare with. The radiobiological models – normal tissue complication probability and tumor control probability – and/or the style (DVH concepts) used in EBRT are introduced in RE. Moreover, attention has been paid to the intrinsic different activity distribution of resin and glass spheres at the microscopic scale, with dosimetric and radiobiological consequences. Dedicated studies and mathematical models have developed this issue and explain some clinical evidences, e.g., the shift of dose to higher toxicity thresholds using glass as compared to resin spheres. This paper offers a comprehensive review of the literature incident to dosimetry and radiobiological issues in RE, with the aim to summarize the results and to identify the most useful methods and information that should accompany future studies.

High-intensity focused ultrasound (HIFU) in patients with solid malignancies: evaluation of feasibility, local tumour response and clinical results.

PurposeThe purpose of this study was to evaluate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for ablation of solid tumours without damaging the surrounding structures.Materials and methodsA specific written informed consent was obtained from every patient before treatment. From September 2008 to April 2009, 22 patients with 29 lesions were treated: nine patients with liver and/or soft-tissue metastases from colorectal carcinoma (CRC), six with pancreatic solid lesions, three with liver and/or bone metastases from breast cancer, one with osteosarcoma, one with muscle metastasis from lung cancer, one with iliac metastasis from multiple myeloma and one with abdominal liposarcoma. The mean diameter of tumours was 4.2 cm. All patients were evaluated 1 day, 1 month and 3 months after HIFU treatment by multidetector computed tomography (MDCT), positron-emission tomography (PET)-CT and clinical evaluation. The treatment time and adverse events were recorded.ResultsAll patients had one treatment. Average treatment and sonication times were, respectively, 162.7 and 37.4 min. PET-CT or/and MDCT showed complete response in 11/13 liver metastases; all bone, soft-tissue and pancreatic lesions were palliated in symptoms, with complete response to PET-CT, MDCT or magnetic resonance imaging (MRI); the liposarcoma was almost completely ablated at MRI. Local oedema was observed in three patients. No other side effects were observed. All patients were discharged 1–3 days after treatment.ConclusionsAccording to our preliminary experience in a small number of patients, we conclude that HIFU ablation is a safe and feasible technique for locoregional treatment and is effective in pain control.RiassuntoObiettivoL’obiettivo di questo studio è stato quello di valutare la sicurezza e l’efficacia dell’applicazione degli ultrasuoni focalizzati ad elevata intensità (USgHIFU) nell’ablazione terapeutica di tumori solidi senza danneggiare le strutture circostanti.Materiali e metodiUno specifico consenso informato scritto è stato ottenuto da tutti i pazienti prima del trattamento. Da settembre 2008 ad aprile 2009 sono stati trattati 22 pazienti con 29 lesioni: 9 pazienti con metastasi epatiche e/o dei tessuti molli da carcinoma del colon retto (CRC), sei pazienti con lesioni solide del pancreas, tre con metastasi epatiche e/o ossee da tumore mammario, uno con osteosarcoma, uno con metastasi muscolare da tumore del polmone, uno con lesione iliaca da mieloma multiplo ed uno con liposarcoma addominale. Il diametro medio era di 4,2 cm. Tutti i pazienti sono stati valutati ad 1 giorno, 1 mese e a 3 mesi di distanza dal trattamento HIFU con tomografia computerizzata multidetettore (MDCT), tomografia computerizzata con tomografia ad emissione di positroni (PET-CT) e valutazione clinica. La durata del trattamento e gli eventi avversi sono stati registrati.RisultatiTutti i pazienti sono stati trattati in una unica sessione. Il tempo medio di trattamento e di sonazione sono stati di 162,7 e 37,4 minuti, rispettivamente. PET-CT e/o MDCT hanno mostrato risposta completa in 11/13 metastasi epatiche; tutte le lesioni ossee, dei tessuti molli e le lesioni pancreatiche sono state palliate nei sintomi, con risposta completa all’esame PET-CT, MDCT o risonanza magnetica (RM); il liposarcoma ha mostrato una ablazione quasi completa all’esame RM. Edema locale è stato osservato in tre pazienti senza ulteriori eventi avversi. Tutti i pazienti sono stati dimessi da 1 a 3 giorni dopo il trattamento.ConclusioniSecondo la nostra esperienza preliminare da un limitato numero di pazienti, l’ablazione USgHIFU può essere considerata una metodica sicura e fattibile in assenza di alternative terapeutiche locoregionali e valida per il controllo del dolore.

Adrenocortical oncocytoma: case report.

We report the case of an adrenocortical oncocytoma of the left adrenal cortex in a young woman. Physical examination revealed a mass in the left upper quadrant of the abdomen using abdomen ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI), which allowed the identification of a large and inhomogeneous mass between the left kidney and the spleen. The lesion was not endowed of any specific radiologic characteristic nor bysided by any biochemical activity that could allow a radiological presurgical diagnosis. Surgical resection led to the diagnosis of adrenocortical oncocytoma, with no aspects revealing malignant potential.

Structural lung damage after chemotherapy fact or fiction

BACKGROUND The hypothesis that chemotherapy increases morbidity after pneumonectomy remains under debate, as the results of previous surgical series remain controversial. The hypothesis of the study is that patients who received preoperative chemotherapy may have subclinical parenchymal damage, increasing their risk of respiratory complications. METHODS The study population was composed of 10 patients who underwent pneumonectomy after chemotherapy for lung cancer (cisplatin+gemcitabine) randomly selected from our database and compared with 10 matched patients who underwent pneumonectomy without previous chemotherapy during the same period. Healthy lung tissue was obtained from surgical specimens, processed according to standard methods and evaluated on ematossilin and eosin-stained sections. Two pathologists without information on the preoperative treatment were asked to review the slides in order to reach a consensus on the type and extent of lung damage. Relevant information was then compared with functional tests and postoperative outcome. RESULTS Severe and diffuse (more than 50% of lung parenchyma) interstitial alterations were detected in the lungs of eight patients, seven of which belonged to the chemotherapy group (70%, p 0.02). Six of these patients developed postoperative respiratory complications. In the chemotherapy group, patterns of interstitial involvement were variable interstitial inflammation and fibrosis associated with obliterative bronchiolitis [Roberts JR, Eustis C, Devore R, et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung carcinoma. Ann Thorac Surg 2001;72:885-8], bronchiolitis obliterans-organizing pneumonia [Leo F, Solli P, Veronesi G, et al. Does chemotherapy increase the risk of respiratory complications after pneumonectomy? J Thorac Cardiovasc Surg 2006;132:519-23], diffuse alveolar damage [Novoa N, Varela G, Jimenez MF. Morbidity after surgery for non-small cell lung carcinoma is not related to neoadjuvant chemotherapy. Eur J Cardiothor Surg 2001;20:700-4], DIP (desquamative interstitial pneumonia)-like reaction [Roberts JR, Eustis C, Devore R, et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung carcinoma. Ann Thorac Surg 2001;72:885-8] and UIP (usual interstitial pneumonia)-like changes [Roberts JR, Eustis C, Devore R, et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung carcinoma. Ann Thorac Surg 2001;72:885-8]. The only preoperative clinical predictor of severe diffuse damage was preoperative diffusion by carbon monoxide (Dlco). CONCLUSIONS Preoperative chemotherapy is associated with an increased risk of severe and diffuse pulmonary disease even in the presence of normal spirometric parameters. These alterations may play an important role in the occurrence of postoperative respiratory complications.

Coagulation Disorders in Patients with Cancer: Nontunneled Central Venous Catheter Placement with US Guidance—A Single-Institution Retrospective Analysis

PURPOSE To assess the feasibility and safety of ultrasonographic (US) guidance in the placement of nontunneled central venous catheters (CVCs) in patients with cancer who had altered coagulation profiles. MATERIALS AND METHODS The study was approved by the institutional review board; informed consent was obtained. Medical charts of all patients with cancer who underwent nontunneled CVC placement at the European Institute of Oncology, Milan, from September 2001 to August 2008 were retrospectively reviewed. Patients were considered to have coagulation disorders or risk of bleeding when they had the following: prothrombin time more than 1.2 times normal or activated partial thromboplastin time more than 1.2 times normal and/or platelet count less than 150 x 10(9)/L. Patients with a prothrombin time and partial thromboplastin time more than 2.2 times normal and/or a platelet count less than 50,000/mm(3) were considered to be at high risk for bleeding. Two hundred thirty-nine nontunneled CVCs were placed with US guidance in 157 patients. RESULTS One hundred twenty-two (51%) of 239 nontunneled CVCs were inserted in patients with cancer who had hemostasic disorders. Forty-five (37%) of 122 nontunneled CVCs were implanted in patients considered to be at high risk for bleeding. All catheters were successfully placed at the first needle pass with no major complications such as bleeding or pneumothorax. Two hundred thirty-three (97%) nontunneled CVCs were placed in the subclavian vein, and six (3%) were placed in the internal jugular vein. No patient underwent any correction for an abnormal coagulation profile. CONCLUSION In patients with cancer who had coagulation disorders, nontunneled CVC placement with US guidance was feasible and safe and did not require correction of coagulation parameters.

High Intensity Focused Ultrasound Ablation of Pancreatic Neuroendocrine Tumours: Report of Two Cases

We describe the use of ultrasound-guided high-intensity focused ultrasound (HIFU) for ablation of two pancreatic neuroendocrine tumours (NETs; insulinomas) in two inoperable young female patients. Both suffered from episodes of severe nightly hypoglycemia that was not efficiently controlled by medical treatment. After HIFU ablation, local disease control and symptom relief were achieved without postinterventional complications. The patients remained free of symptoms during 9-month follow-up. The lesions appeared to be decreased in volume, and there was decreased enhancing pattern in the multidetector computed tomography control (MDCT). HIFU is likely to be a valid alternative for symptoms control in patients with pancreatic NETs. However, currently the procedure should be reserved for inoperable patients for whom symptoms cannot be controlled by medical therapy.

Percutaneous placement of peritoneal port-catheter in oncologic patients

The aim of this paper is to describe the technique of percutaneous ultrasound (US)-guided placement of a peritoneal port-catheter in an interventional radiological setting. Nineteen patients with peritoneal carcinomatosis were selected for intraperitoneal port-catheter placement in order to perform intracavitary receptor-immuno- or radio-immunotherapy with Ytrium-90. All the procedures were performed percutaneously under US and fluoro guidance; the insertion site for catheters was chosen according to abdominal conditions and US findings: all devices were implanted at the lower abdominal quadrants. All patients were followed up with CT and US according to the therapy protocol. The procedure was successfully completed in 15/19 patients, in 4 being contraindicated by peritoneal adhesions. No procedure-related complications and device occlusions during therapy were observed; one catheter displaced 7 months later the placement. In our experience, this procedure was feasible, reliable and easy to perform, allowing the correct administration of the planned intracavitary therapy. Peritoneal adhesions are the main limitation of peritoneal port placement.

Ultrasound guided high intensity focused ultrasound (USgHIFU) ablation for uterine fibroids: Do we need the microbubbles?

Abstract Purpose: The aim of this study was to assess the safety and effectiveness of contrast-enhanced ultrasound (CEUS) on ultrasound guided high intensity focused ultrasound (USgHIFU) ablation of uterine fibroids. Methods: Thirty-three patients (37 fibroids) were randomly assigned to two groups: group A (17 patients, 20 fibroids) in which CEUS was used before, during and after HIFU treatment, and group B (16 patients, 17 fibroids) in which CEUS was not administered at all. Follow-up including contrast-enhanced magnetic resonance imaging (MRI) and a clinical questionnaire was performed, and technical success, ablation efficacy, volume reduction and complications were assessed. Results: Technical success was 100% in both groups. CEUS revealed residual enhancement in 40% of the patients in group A and the treatment was continued until the completion of ablation. MRI at 1 month after treatment revealed significant difference in the relative fibroid volume reduction rate between the two groups: 16.1% in group A versus 4.8%, in group B (p = 0.01). There was no statistically significant relative volume reduction rate for the results at 3, 6 and 12 months and no significant changes in the quality of life results or the complication rate. Conclusions: CEUS was safe and effective in enhancing US guidance during HIFU ablation of uterine fibroids. Moreover, the use of CEUS during HIFU sonication increased the ablation efficacy, leading to a more relevant fibroid volume reduction at 1 and 3 months. This gap disappeared after 6 months, when there were no differences between the two groups of patients at MRI. However, in our experience, USgHIFU represented a very effective method for the treatment of uterine fibroids, and the use of CEUS during HIFU procedure reduced the treatment time and treatment repetitions for incomplete fibroid ablation.