M. Mangini

Percutaneous imaging-guided ablation therapies in the treatment of symptomatic bone metastases: preliminary experience

PurposeThe treatment of pain in bone metastases is currently multidisciplinary. Among the various therapies, local radiotherapy is the gold standard for pain palliation from single metastasis, even though the maximum benefit is obtained between 12 and 20 weeks from initiation. In carefully selected patients, several ablation therapies achieve this objective in 4 weeks. The purpose of this study was to assess the technical success, effectiveness and possible complications of percutaneous ablation therapies in patients with symptomatic bone metastases.Materials and methodsFrom November 2003 to May 2008, ten ablation treatments were performed in ten patients with acute pain from metastatic bone lesions. Patient selection and choice of the most appropriate ablation treatment was made based on lesion characteristics. Three patients were treated with radiofrequency, one with plasma-mediated radiofrequency, two with plasma-mediated radiofrequency and cementoplasty, three with radiofrequency and cementoplasty and one with microwave.ResultsAssessments were based not only on imaging but also on the visual analogue scale (VAS) score for determining pain and on changes in morphine-equivalent doses. In both cases, 3-month follow-up showed a statistically significant reduction of pain. In no case did local complications occur either during or after treatment. Only one patient treated with radiofrequency (1/9, 11%) developed low-grade fever and general malaise during the 6 days following the procedure, compatible with a post-radiofrequency syndrome, which was treated with acetaminophen (paracetamol) only and resolved on day 7.ConclusionsPercutaneous ablation therapies represent a safe and valuable alternative for treating localised pain from single bone metastasis, providing rapid (4-week) relief of symptoms and a significant reduction in morphine doses. This contributes to improving the quality of life of patients with metastatic disease.RiassuntoObiettiviIl trattamento del dolore nelle metastasi ossee è attualmente multidisciplinare. Tra le varie terapie, la radioterapia locale è il gold-standard nella palliazione del dolore da metastasi singola, anche se il massimo beneficio si ottiene tra le 12 e le 20 settimane dall’inizio della terapia. In pazienti accuratamente selezionati, varie terapie ablative raggiungono quest’obiettivo in 4 settimane. Scopo di questo lavoro è valutare il successo tecnico, l’efficacia e le eventuali complicanze delle terapie ablative percutanee in pazienti affetti da metastasi ossee sintomatiche.Materiali e metodiDa novembre 2003 a maggio 2008 sono stati effettuati 10 trattamenti in 10 pazienti con dolore acuto da lesioni metastatiche ossee. La selezione dei pazienti e la scelta del trattamento ablativo più idoneo è stata fatta sulla base delle caratteristiche della lesione. Tre pazienti sono stati trattati con radiofrequenza, 1 con radiofrequenza plasma-mediata, 2 con radiofrequenza plasma mediata e cementoplastica, 3 con radiofrequenza e cementoplastica, 1 con microonde.RisultatiLa valutazione è stata effettuata non solo con imaging, ma anche con una VAS score (visual analoge scale) per la determinazione del dolore e con la variazione delle dose equivalenti di morfina. In entrambi i casi la riduzione è stata statisticamente significativa. In nessun caso si sono verificate complicanze locali sia durante che dopo il trattamento. Solamente in un paziente trattato con radiofrequenza (1/9, 11%) abbiamo riscontrato nei 6 giorni successivi al trattamento insorgenza di febbricola e malessere generale compatibile con la “sindrome post-radiofrequenza”, risoltasi poi al settimo giorno e trattata solo con acetaminofene (paracetamolo).ConclusioniLe tecniche ablative percutanee rappresentano una sicura e valida alternativa al trattamento del dolore localizzato da metastasi ossee singole, apportando in breve tempo (4 settimane) un miglioramento della sintomatologia e una sensibile riduzione delle dosi di morfina. Ciò concorre a migliorare la qualità della vita in pazienti affetti da malattia metastatica.

Percutaneous Treatment of Traumatic Upper-extremity Arterial Injuries: A Single-center Experience

PURPOSEnTo assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries.nnnMATERIALS AND METHODSnBetween January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly.nnnRESULTSnImmediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%.nnnCONCLUSIONSnPercutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.

Report of Four Simultaneous Pancreas–Kidney Transplants in HIV-Positive Recipients With Favorable Outcomes

The advent of combined antiretroviral therapy (cART) dramatically changed the view of human immunodeficiency virus (HIV) infection as an exclusion criterion for solid organ transplantation, resulting in worldwide reports of successful transplants in HIV‐infected individuals. However, there are few reports on simultaneous pancreas–kidney transplant in HIV‐positive recipients detailing poor outcomes. A series of four pancreas–kidney transplant performed on HIV‐infected individuals between 2006 and 2009 is presented. All recipients reached stably undetectable HIV‐RNA after transplantation. All patients experienced early posttransplant infections (median day 30, range 9–128) with urinary tract infections and bacteremia being most commonly observed. In all cases, surgical complications led to laparotomic revisions (median day 18, range 1–44); two patients underwent cholecystectomy. One steroid‐responsive acute renal rejection (day 79) and one pancreatic graft failure (month 64) occurred. Frequent dose adjustments were required due to interference between cART and immunosuppressants. At a median follow‐up of 45 months (range, 26–67) we observed 100% patient survival with CD4 cell count >300 cells/mm3 for all patients. Although limited by its small number, this case series represents the largest reported to date with encouraging long‐term outcomes in HIV‐positive pancreas–kidney transplant recipients.

Complications of percutaneous nephrostomy in the treatment of malignant ureteral obstructions: single-centre review.

Purpose.The purpose of this study was to evaluate the incidence and type of complications connected with percutaneous nephrostomy (PCN) deployment by comparing two different techniques.Materials and methods.In the last 3 years, 299 procedures of nephrostomy were performed on 201 patients (93 women, 108 men; mean age 65.7 years, range 32–102 years) at our Institute; all patients were affected by malignancy. In 44 cases (14.72%), patients presented grade IV hydronephrosis and in 255 cases (85.28%) grade II–III hydronephrosis. In 68 patients (23.07%), the procedure was carried out under emergency conditions because of the rapid worsening of renal function. All procedures were carried out in the angiography room, with the patient lying in a prone or prone–oblique position, under ultrasound and fluoroscopic guidance. Access to the pyelocalyceal system (intermediate or lower calices) was performed by using a Seldinger technique in 255/299 cases, or a one–step technique (OST) in 44 procedures when grade 4 hydronephrosis was present. Statistical analysis of results was performed using bilateral tests on proportions as well as χ2 test of independence for contingency tables.Results.We observed no major complications. All in all, the rate of minor complications was 3.01% (9/299 cases): 8/255 (3.13%) cases with the Seldinger technique; 1/44 (2.27%) with OST. We observed 43/299 (14.4%) dislodgements: 32/255 (10.70%) with the Seldinger technique and 11/44 (3,68%) with OST. In 4/299 (1.33%), rupture of the catheter occurred, and in 2/299 (0.67%), kinking occurred (in all cases with OST). From the statistical analysis, we conclude that the examination technique modifies the percentage of complications; in particular, it significantly (p<0.05) influences complications connected with the catheter but not minor complications. In addition, the system of fixing does not affect the percentage of dislodgements.Conclusions.PCN is a method with a high percentage of technical success with low rate of complications thanks to combined use of sonographic and fluoroscopic guidance for the procedure. The OST technique is indicated for a highly remarkable hydronephrosis and in cases where the catheter is only placed for a short period. The Seldinger technique is carried out in patients with grades II and III hydronephrosis and if the disease is predicted to have a long duration.

Initial experience with percutaneous biopsies of bone lesions using XperGuide cone-beam CT (CBCT): technical note

PurposeThis paper describes our preliminary experience with percutaneous bone biopsy under XperGuide conebeam computed tomography (CBCT) guidance.Materials and methodsSeventeen patients (11 men and 6 women; mean age 57.8; range 17–81) with 17 bone lesions underwent biopsy with XperGuide CBCT (Philips Medical System, Best, The Netherlands). The mean diameter of the lesions was 2.32 cm (range 1–8 cm). Technical success (defined as the correct positioning of the needle within the lesion), diagnostic accuracy, sensitivity and specificity were evaluated. Complication rate was also recorded.ResultsThe technical success rate was 100%. In 15 patients, a sample of adequate material for histopathological analysis to yield a definitive diagnosis was obtained; in two patients, the sample was inadequate for a definitive diagnosis. In one of these two cases, the lesion was closely followed up for 1 year, during which it remained stable in size, and as a result, it was considered a false positive; the other was considered a false negative. Diagnostic accuracy, sensitivity and specificity were 94.12%, 90.91% and 100%, respectively. No major complications were recorded; only one patient had slight bleeding, with a consequent small haematoma, which reabsorbed in about 15 days.ConclusionsBone biopsy under XperGuide CBCT guidance can be considered accurate as a result of the combination of real-time needle orientation and spatial resolution of CT fluoroscopy. Moreover, our results are encouraging in terms of complication rate, diagnostic accuracy, sensitivity, specificity and reduction of CT workload.RiassuntoObiettivoScopo del lavoro è descrivere la nostra esperienza preliminare delle biopsie ossee percutanee eseguite sotto guida XperGuide cone-beam (CBCT).Materiali e metodiDiciassette pazienti (11 maschi e 6 femmine; età media 57,8 anni, range 17–81) con 17 lesioni ossee sono stati sottoposti a biopsia percutanea con guida XperGuide CBCT. Il diametro medio delle lesioni era di 2,32 cm (range 1–8 cm). Sono stati valutati il successo tecnico (definito come il corretto posizionamento dell’ago all’interno della lesione), l’accuratezza diagnostica, la sensibilità e la specificità. è stata inoltre riportata la percentuale di complicanze.RisultatiIl successo tecnico è stato del 100%. In 15 pazienti, è stato ottenuto un campione di materiale adeguato per l’esame isto-patologico e per giungere ad una diagnosi definitiva; in 2 pazienti il campione è risultato inadeguato per giungere ad una diagnosi. In uno dei 2 casi, la lesione è stata seguita per un periodo di follow-up di 1 anno, durante il quale le sue dimensioni sono rimaste stabili; pertanto questa è stata considerata un falso positivo. L’altra è stata considerata un falso negativo. Accuratezza diagnostica, sensibilità e specificità erano rispettivamente del 94,12%, 90,91% e 100%. Non è stata registrata nessuna complicanza maggiore; solo un paziente ha presentato un lieve sanguinamento con un conseguente piccolo ematoma, assorbitosi spontaneamente in circa 15 giorni.ConclusioniLa biopsia ossea sotto guida XperGuide CBCT può essere considerata accurata grazie alla combinazione tra la possibilità di orientamento nello spazio real-time dell’ago e la risoluzione spaziale della fluoro-tomografia computerizzata (TC). Inoltre, i nostri risultati sono incoraggianti in termini di percentuale di complicanze, accuratezza diagnostica, sensibilità, specificità e non ultimo, riduzione del carico di lavoro del servizio TC.

Trattamento endovascolare di aneurismi dell'aorta addominale in rottura: Endoprotesi aorto-uniliaca o biforcata?

PurposeThis study evaluated the safety and technical and clinical success rates of positioning endovascular endografts (EG) in ruptured abdominal aneurysms.Materials and methodsPatients with a ruptured abdominal aortic aneurysm confirmed by contrastenhanced computed tomography angiography (CTA) were eligible for the analysis. Of 67 patients, 42 (62.7%) were treated with EG. Thirteen patients (30.9%) received an aorto-uni-iliac EG (group A) and 29 a bifurcated EG (group B). Patients were divided for comparative analysis according to the configuration of the EG implanted.ResultsThe primary technical success rate was 100%; the primary clinical success rate was 95% (40/42). There were two intraoperative deaths (4.7%) related to intractable shock. No patient required conversion to open repair. Overall, 12 patients (28.5%) died within 30 days. The inhospital death rate was 30.9% (13/42). Hospital mortality rate was statistically higher in group A; the type of EG and intensive care unit admission were the only independent predictors of hospital mortality.ConclusionsIn our experience, a higher mortality rate was observed for the aorto-uni-iliac configuration; shock at admission was confirmed as the most important factor for postoperative survival.RiassuntoObiettivoScopo del nostro lavoro è stato valutare sicurezza, successo tecnico e successo clinico nel posizionamento di endoprotesi (EP) con approccio endovascolare in pazienti con aneurisma dell’aorta addominale in rottura.Materiali e metodiSono stati valutati 67 pazienti con aneurisma dell’aorta addominale in rottura, confermato mediante esame angio-tomografia computerizzata (TC). In 42 casi (62,7%) è stata posizionata endoprotesi: aorto-uniiliaca in 13 pazienti (30,9%) (gruppo A), e biforcata in 29 (gruppo B).RisultatiNel 95% dei casi (40/42) è stato ottenuto il successo tecnico. Le morti intra-operatorie sono state 2 (4,7%). In nessun paziente l’intervento è stato convertito in open. Dodici pazienti (28,5%) sono morti entro 30 giorni. La percentuale di morti durante il ricovero è stata del 30,9% (13/42). Mediante una analisi uni- e multivariata, i due gruppi sono risultati ben ponderati; lo shock è risultato statisticamente più frequente nel gruppo A. La percentuale di morte intra-ospedaliera è risultata statisticamente più alta nel gruppo A e questa era correlata al tipo di endoprotesi e all’accesso nella unità di terapia intensiva.ConclusioniNella nostra esperienza, si è osservata una più alta mortalità nel gruppo in cui è stata posizionata una EP aorto-uni-iliaca; lo shock all’ingresso è risultato essere il fattore più importante da correlare con la sopravvivenza post-operatoria.

Usefulness and safety of biliary percutaneous transluminal forceps biopsy (PTFB): our experience.

Abstract Aim: To evaluate the usefulness and safety of percutaneous transluminal forceps biopsy in patients suspected of having a malignant biliary obstruction. Material and methods: Forty consecutive patients (21 men and 19 women; mean age, 71.9 years) underwent forceps biopsy through percutaneous transhepatic biliary access performed to drain bile. Lesions involved the common bile duct (n 8), common hepatic duct (n 18), hilum (n 6), ampullary segment of the common bile duct (n 8) and were biopsied with 7-F biopsy forceps. Final diagnosis was confirmed with pathologic findings at surgery, or clinical and radiologic follow-up. Results: Twenty-one of 40 biopsies resulted in correct diagnosis of malignancy. Thirteen biopsy diagnosis were proved to be true-negative. There were six false-negative and no false-positive diagnoses. Sensitivity, specificity and accuracy in aspecific biliary obstructions were 85%, 100% and 88,7% respectively. Sensitivity of biopsy in malignancies was higher than in benign obstructions (100% vs 68,4%, CI = 95%). Sensitivity was lower in the hilum tract and in the common bile duct than in other sites (CI = 95%). No major complications related to biopsy procedures occurred. Conclusions:Percutaneous transluminal forceps biopsy is a safe procedure, easy to perform through a transhepatic biliary drainage tract, providing high accuracy in the diagnosis of malignant biliary obstructions.

Percutaneous cholecystostomy as the sole treatment in critically ill and elderly patients

PurposeThis study was done to investigate the effectiveness and clinical outcome of percutaneous cholecystostomy (PC) of treating acute cholecystitis in critical ill and elderly patients.Materials and methodsIn the last 3 years, PC was performed on 30 elderly and critically ill patients (17 men, 13 women; mean age 78.6, range 57–97 years) with acute cholecystitis and comorbid diseases.ResultsTechnical success was 30/30 (100%). Clinical effectiveness was 30/30 (100%), with statistically significant reductions in while blood cell (WBC) count, C-reactive protein (CRP) and fever. Mean WBC upon admission (19.87×103±1.61×103 /μl), axillary temperature (38.2±0.11 °C), and CRP (248.7±4.76 mg/l) values were significantly decreased in the 72 h following PC [12.9×103 ± 1.05×103/μl (p≤0.0001), 37 ± 0.04 °C (p≤0.0001), 113.5 ± 3 mg/l (p≤0.0001), respectively]. Clinical and ultrasonographic (US) signs of acute cholecystitis decreased in all patients. There were no major complications or procedure-related deaths, and the morbidity rate was low (3/30; 10%).ConclusionsPC appears to be a fast, easy and effective treatment for the acute phase of cholecystitis in elderly and critically ill patients. Procedure-related morbidity and mortality rates are very low compared with surgery. Conservative treatment for patients who are not eligible for surgery is acceptable.RiassuntoObiettivoL’obiettivo del nostro lavoro è stato quello di dimostrare l’efficacia della colecistostomia percutanea nel trattamento della colecistite acuta nei malati critici e nei pazienti anziani non candidabili al trattamento chirurgico.Materiali e metodiNegli ultimi 3 anni abbiamo effettuato 30 colecistostomie percutanee in malati critici e pazienti anziani (17 uomini, 13 donne, età media 78 anni, range 57–97 anni) con colecistite acuta e associate comorbilità.RisultatiIl successo tecnico è stato ottenuto nel 100% dei casi (30 su 30). L’efficacia clinica si è avuta in 30 casi su 30 (100%) con una riduzione statisticamente significativa della leucocitosi (WBC),proteina C reattiva (CPR) e febbre. Il valore medio dei globuli bianchi al ricovero (19,87×103±1,61×103/μl), della febbre (38,2±0,11°C) e della CRP (248,7±4,76 mg/l) si sono significativamente ridotti nelle 72 ore successive al trattamento di colecistostomia percutanea [12,9×103±1,05×103/ μl (p≤0,0001), 37±0,04°C (p≤0,0001), 113,5±3 mg/l (p≤0,0001), rispettivamente]. I segni clinici ed ecografici di colecistite acuta sono migliorati in tutti i pazienti. Non ci sono stati complicanze maggiori o casi di morte periprocedurale. La morbilità collegata alla procedura è stata bassa 3/30 (10%).ConclusioniIn conclusione si dimostra che la colecistostomia percutanea, nonostante il numero limitato di pazienti del nostro campione, è un metodo di trattamento veloce, semplice ed efficace per la cura della colecistite acuta nei malati critici e nei pazienti anziani. La morbilità relativa alla procedura e la mortalità sono molto basse se comparate alla chirurgia tradizionale. Il trattamento conservativo per i pazienti per i quali è controindicato il trattamento chirurgico è ben tollerato.

Gross hematuria caused by a congenital intrarenal arteriovenous malformation: a case report.

IntroductionWe report the case of a woman who presented with gross hematuria and was treated with a percutaneous embolization.Case presentationA 48-year-old Caucasian woman presented with gross hematuria, left flank pain, and clot retention. The patient had no history of renal trauma, hypertension, urolithiasis, or recent medical intervention with percutaneous instrumentation. The patient did not report any bleeding disorder and was not taking any medication. Her systolic and diastolic blood pressure values were normal at presentation. The patient had anemia (8 mg/dL) and tachycardia (110 bpm). She underwent color and spectral Doppler sonography, multi-slice computed tomography, and angiography of the kidneys, which showed a renal arteriovenous malformation pole on top of the left kidney.ConclusionsThe feeding artery of the arteriovenous malformation was selectively embolized with a microcatheter introduced using a right transfemoral approach. By using this technique, we stopped the bleeding, preserved renal parenchymal function, and relieved the patients symptoms. The hemodynamic effects associated with the abnormality were also corrected.

Radiofrequency ablation for single lung tumours not suitable for surgery: seven years’ experience

PurposeThis study was done to review recurrence patterns in patients with lung cancer (primary or secondary) treated with percutaneous image-guided radiofrequency (RF) ablation.Materials and methodsFrom January 2003 to August 2010, 32 patients (24 with primary non-small-cell lung cancer and eight with metastases) with single lung cancer were treated with RF ablation. Post-treatment imaging results were available for each patient. Follow-up was performed using computed tomography (CT) scans at 1, 3, 6, 12, 18 and 24 months after the procedure and annually thereafter. Patterns of recurrence were classified as local, intrapulmonary, nodal, mixed and distant. We evaluated overall survival after RF ablation and the factors associated with recurrence.ResultsSeventeen (53.1%) patients showed no evidence of recurrence at follow-up imaging (range 12-72 months; mean, 32.5 months). Recurrence was seen in 15 (46.9 %) patients (range 6-36 months; mean 14.8 months). Local recurrence (40%) after RF ablation was the most frequent. Median disease-free survival was 20 months. Sex, tumour location, tumour size and tumour stage were not associated with a risk of recurrence. Patient age was related to the risk of recurrence (p<0.05).ConslucionsLocal recurrence is the most common pattern in our series. A more aggressive initial RF ablation might offer improvement in outcomes, but this hypothesis needs to be confirmed by larger studies involving a larger number of patients.RiassuntoObiettivoScopo del presente lavoro è stato analizzare i patterns di recidiva in pazienti con tumore polmonare (primitivo o secondario) trattato mediante termo-ablazione con radiofrequenza (RFA) per via percutanea.Materiali e metodiDa gennaio 2003 ad agosto 2010, sono stati trattati 32 pazienti [24 affetti da tumore polmonare non a piccole cellule (NSCLC) ed 8 da lesioni secondarie] con tumore polmonare singolo. I reperti di imaging post-trattamento sono disponibili per tutti i pazienti. Il follow-up è stato eseguito con la tomografia computerizzata (TC) a 1, 3, 6, 12, 18 e 24 mesi dopo la procedura, e poi annualmente. I patterns di recidiva sono stati classificati come locale, intra-polmonare, linfonodale, misto ed a distanza. Abbiamo valutato la sopravivenza globale dopo RFA ed i fattori associati con il rischio di recidiva.RisultatiDiciassette (53,1%) pazienti non hanno presentato recidiva durante il follow-up (range 12–72 mesi; media 32,5 mesi). La recidiva è stata vista in 15 (46,9%) pazienti (range 6–36 mesi; media 14,8 mesi). La recidiva locale (40%) dopo RFA è stata quella osservata più frequentemente. La sopravvivenza media libera da malattia è stata di 20 mesi. Il sesso, la localizzazione del tumore, le dimensioni e lo stadio del tumore non sono risultate associate con il rischio di recidiva. L’età del paziente è risultata essere correlata in maniera statisticamente significativa con il rischio di recidiva (p<0,05).ConclusioniLa recidiva locale è il pattern di recidiva più frequente nella nostra serie; probabilmente un trattamento iniziale con RFA più aggressivo potrebbe dare dei risultati migliori, ma in accordo con l’analisi della letteratura riportata, sono necessari un maggior numero di pazienti e di studi per confermare questa ipotesi.