Marco Busso

Diagnostic accuracy and clinical impact of imaging-guided needle biopsy of renal masses. Retrospective analysis on 150 cases.

ObjectiveTo review our method of perform needle biopsies of renal masses.MethodsWe analysed 150 consecutive imaging-guided percutaneous biopsies. The pathological diagnosis was verified on clinical outcome in 129 cases (40 surgical resection, 53 thermal ablation, two medical treatment and 34 watchful waiting). Twenty-six patients underwent fine-needle aspiration biopsy (FNAB), 45 core-needle biopsy (CB) and 58 FNAB + CB. After review by two expert pathologists, cumulative accuracy of all FNAB (84) and all CB (103) was calculated. The rate of complications and mass management other than surgery was estimated.ResultsThe final diagnosis was malignancy in 97 cases (benign mass in 32). FNAB correctly diagnosed 64/84 masses (76.2%), CB 96/103 (93.2%). Of 58 masses submitted for both FNAB and CB, CB provided a 22.5% accuracy improvement. Major and minor complications occurred in 0% and 5.3%. Renal biopsy altered clinical management in 89/129 cases (68.9%), in terms of choosing therapeutic options other than surgery.ConclusionCB is more accurate than FNAB and should be preferred in renal mass biopsy. FNAB may precede CB when an expert pathologist can immediately evaluate the samples. Renal biopsy influences renal mass management.

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.

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.

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.

Radiofrequency thermal ablation (RFA) of hepatic metastases (METS) from breast cancer (BC): an adjunctive tool in the multimodal treatment of advanced disease

PurposeThe study was done to analyse the results of a series of radiofrequency ablation (RFA) procedures performed on hepatic metastases (METS) from breast cancer in order to evaluate the clinical impact of this therapy.Materials and methodsWe analysed 45 patients (mean age 55xa0years) with 87 METS (mean size 23xa0mm), in terms of adverse events (AE), complete ablation (CA) at initial follow-up assessment and during the subsequent follow-up (mean 30xa0months), time to progression, and survival. The correlation between local effectiveness and METS size was investigated. Possible predictors of 3-year survival, including the local effectiveness of RFA (complete ablation maintained at 1-year versus treatment failure) were analysed.ResultsNine AE occurred (two major complications, 2.3xa0%). CA at initial follow-up was obtained in 90xa0%; 19.7xa0% CA relapsed, with a time to progression of 8xa0months. The difference between the mean diameter of maintained CA (22xa0mm) and that of the treatment failures (30xa0mm) was highly significant (pxa0=xa00.0005), as was the 30xa0mm threshold (pxa0=xa00.0062). Overall survival at 1–3xa0years was 90, 58 and 44xa0%. At univariate analysis, the local effectiveness of RFA did not reach statistical significance.ConclusionRFA of hepatic METS from breast cancer has high local effectiveness in tumours up to 30xa0mm, but it is not relevant in determining survival.

Molecular and Histological Changes in Post-Treatment Biopsies of Non-Squamous Non-Small Cell Lung Cancer: A Retrospective Study.

BackgroundRecently, in advanced non-small cell lung cancer (NSCLC), standard chemotherapy was flanked by biological agents directed against genomic abnormalities, including EGFR and ALK alterations, that significantly improved patient outcome. Despite these achievements, tumour progression almost always occurs and a reassessment of the tumour genetic profile may contribute to modulating the therapeutic regimen. Resampling may provide tissue for additional tests to detect acquired resistance and/or new genetic alterations, but the currently available information is limited.Patients and MethodsHistological and genetic reassessments of biopsy or surgical tissue samples from 50 non-squamous NSCLC patients before and after at least one systemic treatment were performed. EGFR, KRAS, BRAF, PIK3CA and HER2 mutations were sequenced, p.T790M was identified with real-time PCR, and ALK and MET genomic alterations by fluorescence in situ hybridization.ResultsOverall in baseline biopsies, 37/50 (74xa0%) tumours had genetic alterations, either single (52xa0%) or multiple (22xa0%). Among them, 16 were EGFR mutations and 6 ALK rearrangements. In the second tissue sampling, 54xa0% of cases had additional genomic changes, including newly acquired alterations (81xa0%) or losses (18xa0%). The commonest changes were MET amplification and p.T790M mutation. One case had a histological shift from adenocarcinoma to small cell carcinoma.ConclusionsThe remarkable number of molecular changes following systemic therapy and the genetic complexity of some cases underline the value of histological and molecular re-evaluation of lung cancer to tailor the most appropriate therapy during disease progression.

Radiofrequency ablation of thoracic tumours: lessons learned with ablation of 100 lesions.

PurposeOur aim was to analyse the results of our first 100 radiofrequency ablation (RFA) procedures, of primary (nonsmall-cell lung cancers, NSCLC) and secondary (MTS) lung cancers to assess what lessons could be learned from our experience.Materials and methodsWe analysed 100 lesions (mean size 23xa0mm) in 81 patients (25 NSCLC/56 MTS). On the basis of the clinical–radiological evolution, we analysed complete ablation (CA) versus partial ablation (PA) at the first computed tomography (CT) scan and during the follow-up (mean 23xa0months), time to progression (TTP) and survival. Possible predictive factors for local effectiveness and survival were sought.ResultsAt the first CT scan CA was obtained in 88xa0%; the difference between the mean diameter of lesions achieving CA and PA was significant (20 versus 38xa0mm; pxa0=xa00.0001). A threshold of 30xa0mm (pxa0=xa00.0030) and the histological type (NSCLC 75xa0%/MTS 94xa0%; pxa0=xa00.0305) were also predictive of CA. A total of 18.4xa0% of the CA recurred (average TTP 19xa0months). Survival at 1, 2 and 3xa0years was 84.5, 65.4 and 51.5xa0%, respectively. The predictors of survival at 3xa0years were the coexistence of other MTS (pxa0=xa00.0422) and a diameter <20xa0mm (pxa0=xa00.0323), but not the local effectiveness of RFA.ConclusionRFA for thoracic malignancies is accurate for lesions up to 30xa0mm, especially if metastatic; survival is more closely related to staging factors than to the local effectiveness of RFA.

Long-term follow-up of ultrasound-guided botulinum toxin-A injections for sialorrhea in neurological dysphagia

Literature provides reports only of a limited follow-up single injection of botulinum toxin-A (BoNT-A) in patients with sialorrhea. The aim of our study is to evaluate the long-lasting efficacy and safety of ultrasound-guided BoNT-A injections for severe sialorrhea secondary to neurological dysphagia. We enrolled 38 severe adult sialorrhea patients referred consecutively to the neurology unit and performed bilateral parotid and submandibular gland BoNT-A injections under ultrasound guidance. The outcomes of the study were reduction of sialorrhea, duration of therapeutic effect, and subjective patient- and caregiver-reported satisfaction. A total of 113 BoNT-A administrations were given during the study period with a mean duration of follow-up of 20.2xa0±xa04.4xa0months. We observed a significant decrease from baseline in mean number of daily aspirations and a significant improvement in patient- and caregiver-reported outcomes following ultrasound-guided BoNT-A injections (pxa0<xa00.001 vs baseline for all comparisons) and the mean duration of the efficacy was 5.6xa0±xa01xa0months. No major treatment-related adverse events occurred and a low incidence of minor adverse events was reported. This study confirms the long-lasting efficacy and safety of ultrasound-guided BoNT-A injections for sialorrhea, regardless of the causative neurological disorder. These results should encourage the use of BoNT-A in the treatment of severe sialorrhea and highlight the role of ultrasound guidance to obtain optimal results in terms of safety and reproducible outcomes.

Detection and management of retroperitoneal cystic lesions: A case report and review of the literature

The identification of cystic lesions within the retroperitoneal space is a rare event that poses clinicians the challenge of a difficult diagnosis and disease management. Retroperitoneal cystic lesions account for a group of lesions that range from common benign lesions (e.g., lymphoceles developing as a surgical complication) to rare aggressive malignant neoplasms. Currently, in the majority of cases, image-guided procedures allow for a pathological diagnosis to be achieved in these challenging lesions, thus offering the chance of an appropriate treatment; however, the overall clinical assessment of retroperitoneal cysts is highly demanding. The present study reports the management of a representative clinical case, presenting with a voluminous cystic mass able to dislocate cave vein, whose diagnosis was preceded by a deep vein thrombosis. Computed tomography-scan and ultrasound guided percutaneous drainage were performed to achieve the diagnosis. Following the discussion of the current case report, a review of the pathological and radiological characteristics of retroperitoneal cystic lesions is presented.

Helical-Tip Needle for Transthoracic Percutaneous Image-Guided Biopsy of Lung Tumors: Results of a Pilot Prospective Comparative Study with a Standard Tru-Cut Needle

PurposeTo prospectively evaluate feasibility and diagnostic performance of the 14-gauge helical-tip (Spirotome™, Cook® Medical, Bloomington, USA) needle in transthoracic needle biopsy (TTNB) of lung lesions, compared to a conventional 18-gauge Tru-Cut needle.Materials and MethodsStudy was institutional review board approved, with informed consent obtained. Data from synchronous Spirotome and Tru-Cut image-guided TTNB of 20 consecutive patients with malignant peripheral lung tumors larger than 3xa0cm were enrolled for pathologic characterization and mutational analysis. Samples obtained with Spirotome and Tru-Cut needle were compared for fragmentation, length, weight, morphologic and immunohistochemistry typifying, tumor cellularity (TC) and DNA concentration.ResultsThe technical success rate for TTNB with Spirotome was 100%, and no major complications occurred. Less fragmentation (mean 2 vs. 3 fragments, Pxa0=xa0.418), greater weight (mean 13 vs. 8.5xa0mg, Pxa0=xa0.027) and lower length (mean 10.2 vs. 12.6xa0mm, Pxa0=xa0.174) were observed with Spirotome compared to Tru-Cut needle. Accuracy of Spirotome and Tru-Cut needle in defining cancer histotype was similar (90%). Absolute and relative TC (mean 42 vs. 38, 124 vs. 108/10HPF), and DNA concentration (mean 49.6 vs. 39.0xa0ng/μl) were higher with Spirotome compared to Tru-Cut needle, with no statistical significance (Pxa0=xa0.787 and Pxa0=xa0.140, respectively).Conclusions Percutaneous 14-gauge Spirotome TTNB of selected lesions is feasible and accurate. It provides adequate samples for diagnosis, comparable to 18-gauge Tru-Cut needle, with a higher amount of tumor tissue (weight, TC, DNA concentration) even in shorter samples.