S. Rossi

Complications of ultrasonically guided fine-needle abdominal biopsy: results of a multicenter Italian study and review of the literature

This report describes the complications following 10,766 ultrasonically guided fine-needle biopsies performed from 1979 to 1987 in 33 Italian echographic units. The mortality was 0.018%: the two reported deaths were due to hemoperitoneum and occurred in patients with hepatocellular carcinoma arising in a cirrhotic liver. Twenty patients (0.18%) had major complications. This series confirms that abdominal biopsy with fine needles is safe, even though our death rate was higher than in previous reports. Among the other nine fatalities following fine-needle abdominal biopsy reported in the literature, seven were secondary to hemorrhage. The biopsy of pancreatic carcinoma was more dangerous for needle-tract seeding (five of eight reported cases, including one in our series).

Ultrasonically guided percutaneous splenic tissue core biopsy in patients with malignant lymphomas.

Ultrasonically [US] guided percutaneous tissue core biopsy of the spleen was done on 46 patients with malignant lymphomas. The biopsies were undertaken as a staging procedure in 32 patients, as a restaging procedure in 7, during follow‐up in 2, and as a diagnostic step in 5 [previously undiagnosed cases with clinically and ultra‐sonographically suspected lymphoma]. In 45 patients, the tissue core specimens obtained by US‐guided biopsies were sufficient for a correct histologic examination; in one patient, the specimen was considered inadequate. The tissue core specimens showed splenic involvement in 12 patients and normal splenic tissue in the other 33. These latter cases were confirmed by splenectomy, by lap‐aroscopy with larger splenic biopsy needles, and by clinical and US follow‐up over a period of 6 to 30 months. In all previously undiagnosed patients [five], splenic biopsies allowed histologic subtyping. Additional immuno‐logic subclassification into B‐cell and T‐cell types of lymphomas was done in two instances. There were no complications in this series. These results suggest that percutaneous US‐guided splenic tissue core biopsy is a useful and safe technique for the diagnosis, staging, and follow‐up of malignant lymphoma.

Cirrhosis of the liver

An ultrasonographic study about the prevalence of cholelithiasis was performed in 410 cirrhotic patients and in 414 controls matched for age and sex. Gallstone disease was found more often in cirrhotic patients (31.9%) than in controls (20.7%) (P<0.001. The female-to-male ratio of gallstones prevalence in cirrhotic patients approached to 1∶1. Gallstone disease in cirrhotic patients vs controls was significantly higher (30.2% vs 16.5%) (P<0.001 in males only. No difference was found, for gallstone disease prevalence in cirrhosis of different etiology. The prevalence of cholelithiasis increased from Childs A to Childs C with a significant trend P<0.001; this difference was significant in males (12.3% vs 40.5%) P<0.001) but not in females. This study shows that cirrhosis represents a risk factor for the development of cholelithiasis in males. We suggest that high levels of estrogens could play a role in these patients, by an impairment of gallbladder emptying similar to that observed in pregnant women.An ultrasonographic study about the prevalence of cholelithiasis was performed in 410 cirrhotic patients and in 414 controls matched for age and sex. Gallstone disease was found more often in cirrhotic patients (31.9%) than in controls (20.7%) (P less than 0.001). The female-to-male ratio of gallstones prevalence in cirrhotic patients approached to 1:1. Gallstone disease in cirrhotic patients vs controls was significantly higher (30.2% vs 16.5%) (P less than 0.001) in males only. No difference was found, for gallstone disease prevalence in cirrhosis of different etiology. The prevalence of cholelithiasis increased from Childs A to Childs C with a significant trend (P less than 0.001); this difference was significant in males (12.3% vs 40.5%) (P less than 0.001) but not in females. This study shows that cirrhosis represents a risk factor for the development of cholelithiasis in males. We suggest that high levels of estrogens could play a role in these patients, by an impairment of gallbladder emptying similar to that observed in pregnant women.

Laparoscopic ultrasonography in the study of liver diseases

SummaryIn this report we present our preliminary experience using a recently developed sonolaparoscope. The 7.5 MHz rotating transducer, fixed to the tip of the laparoscope, produces a sector scan display of 180°. We have used this technique in nine patients: five with cirrhosis and four with focal lesions of the liver. Laparoscopic sonography (LS) visualized two small nodular lesions in two cases of cirrhosis that did not show up with conventional ultrasonography (US). In one case of small hepatocellular carcinoma (HCC) located in the seventh hepatic segment, the lesion was not revealed. The ultrasound patterns of cirrhosis, hepatic cyst, and hemangioma were typical. We also performed ultrasonically guided biopsies. We concluded that laparoscopic sonography may be useful in the study of cirrhosis and in oncological patients for the screening of small hepatic lesions and that it could, in future, represent a preoperative step for liver surgery.

Association of Non-Hodgkin’s Lymphoma and Hepatocellular Carcinoma

Four patients with hepatocellular carcinoma (HCC) out of a group of 132 with non-Hodgkins lymphoma (NHL) are described. HCC was the most common second neoplasm in this series; in contrast, only 2 cases of HCC associated with NHL have been reported in the English literature. The diagnosis of HCC was suggested by ultrasound (US) and confirmed by ultrasonically guided fine-needle biopsy (UG-FNB). The 4 cases of HCC arose from cirrhosis. In this series, 10 out of 132 patients (7.6%) presented cirrhosis. Some considerations concerning the possible role of NHL (and/or the related therapy) in promoting the development of HCC in cirrhotic patients are discussed. The usefulness of US and of UG-FNB in the management of the patient with NHL is emphasized.

Hepatocellular carcinoma associated with other primary malignancies

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Splenic lesions in Hodgkin's and non-Hodgkin's lymphomas. An ultrasonographic study

Abstract Objective: To reassess, in patients with lymphoma, the prevalence of splenic involvement by the disease, the ultrasound findings and the correlations with the histological data. Methods: A total of 342 consecutive patients, 56 with Hodgkins (HL) and 286 with non-Hodgkins lymphoma (NHL), were submitted to abdominal ultrasonography (US). The US-detected lymphomatous lesions were divided into: (1) small (less than 1 cm) and diffuse, producing a pattern of parenchymal infiltration; (2) focal. In the latter, the US patterns and the number and size of the lesions were registered. The lymphomatous nature of the splenic lesions was proved pathologically or by follow-up. Results: Fifty-four of the 342 patients showed splenic lesions; there were 9 56 patients with HL (16.1%) and 45 286 with NHL (15.7%); most of the lesions occurred at the initial staging and advanced stages of the diseases. Lesions of the diffuse type were found in 33% of the patients, both in HL and NHL; 67% of the patients had nodular lesions. Of the 54 spleens involved, 14 (26%) were normal-sized. In NHLs, the diffuse type lesions occurred mostly in low/intermediate grade and the nodular type in intermediate/high grade diseases. In total, 50% of all the nodular lesions were single and 50% were larger than 3 cm. In 67% of cases for HL and in 73% for NHL, the lesions were hypoechoic. Conclusions: US may reliably detect splenic involvement from lymphoma only if a modification of echo-texture is produced, as the size of the spleen is an insufficient criterion. The overall prevalence of splenic lesions in our series was 15.8%; it was higher than those previously reported. Lymphomatous lesions were confirmed to be mostly hypoechoic; only the correlations between diffuse lesions and low/intermediate grade NHLs and between nodular lesions and intermediate/high grade NHLs were confirmed.

Sclérothérapie prophylactique des varices œsophagiennes à haut risque de saignement etude prospective et randomisée, avec longue période de surveillance

RésuméLa présente étude contrôlée, prospective et randomisée, a évalué l’efficacité de la sclérothérapie prophylactique des varices œsophagiennes dans un groupe de patients à haut risque de saignement, mais présentant encore une hémostase conservée avant le premier épisode hémorragique sur varices.37 patients ont été inclus dans I’étude : 18 ont reçu une sclérothérapie prophylactique, 19 ont servi de cas-témoins. La durée moyenne de surveillance a été de 36,6 mois.Les taux de mortalité due au saignement au cours de la période complete d’observation ont été significativement inférieurs dans le groupe sclérothérapie par rapport au groupe témoin (P = 0.003)Les tables de survie montrent que la sclérothérapie prophylactique diminue significativement l’incidence des hémorragies sur varices (P = 0.02) et améliore de façon significative, la survie globale (P = 0.009).Les auteurs concluent que la sclérothérapie prophylactique est utile dans le traitement des patients cirrhotiques àa haut risque hémorragique avec une fonction hémostatique conservée.SummaryThe efficacy of prophylactic sclerotherapy of varices at high risk of bleeding in cirrhotic patients with spared clotting function before the first episode of variceal haemorrhage, was evaluated in a prospective, randomized, controlled trial.37 patients were treated as followed : 18 patients received prophylactic sclerotherapy and 19 served as controls. The median follow-up was 36.6 months.The mortality rate due to bleeding during the overall observation period was significantly lower in the sclerotherapy group versus control group (P = 0.003).Life table curves showed that prophylactic sclerotherapy significantly diminished the incidence of variceal haemorrhage (P = 0.02) and significantly improved overall survival (P = 0.009).We concluded that prophylactic sclerotherapy is useful in the treatment of cirrhotic patients with high-risk bleeding varices and spared clotting function.ResumenEl presente estudio controlado, prospectivo y randomisado, ha evaluado la eficacia de la escleroterapia profiláctica de várices esofágicas en un grupo de pacientes de alto riesgo hemorrágico, pero que — presentan aúm una hemostasis conservada antes del primer episodio — hemorrágico varicoso.37 pacientes han sido incluídos en el estudio: 18 han recibido una — escleroroterapia profiláctica, 19 han servido de casos testigos. La duración mediana de seguimiento ha sido de 36.6 meses.La tasa de hemorragia debido al sangramiento en el curso del período completo de observación ha sido significativamente inferior en el grupo de escleroterapia respecto al grupo testigo (P = 0.003).Las tablas de sobrevida muestran que la escleroterapia profiláctica disminuye significativamente la incidencia de hemorragia sobre várices (P = 0.02) y mejora de manera marcada la sobrevida global (P = 0.009).Los autores concluyen que la escleroterapia profiláctica es útil en el tratamiento de pacientes cirróticos de alto riesgo hemorrágico con una función de coagulación conservada.