Sara Pacella

Percutaneous Laser Ablation in the Treatment of Hepatocellular Carcinoma with Small Tumors: Analysis of Factors Affecting the Achievement of Tumor Necrosis

PURPOSE To identify the factors that affect the achievement of tumor necrosis with percutaneous laser ablation (PLA) in patients with hepatocellular carcinoma (HCC) and tumor size no larger than 4.0 cm. MATERIALS AND METHODS Ultrasound-guided biopsy results were retrospectively studied in 99 lesions (range, 0.5-4.0 cm; mean, 2.7 cm) from 82 patients (44 men, 38 women; age range, 50-80 years; median, 68 y) who had undergone PLA. RESULTS Complete tumor ablation was obtained in 90 lesions (90.9%). Of the nine cases in which complete tumor necrosis was not achieved, six had tumors located in sites that did not allow the optimal placement of fibers, and five of these had a tumor diameter greater than 3 cm. Early discontinuation of PLA as a result of decompensation of liver cirrhosis was the reason for not achieving a complete tumor ablation in three other cases. There was a clear relationship between the energy delivered and the volume of necrosis achieved (r = 0.56; P < .001) regardless of the initial size of HCC tumors. The number of illuminations required, and consequently the amount of energy delivered, was also affected by tumor location. In fact, lesions adjacent to large vessels (> or = 3 mm) required a greater number of illuminations than the other lesions to achieve complete ablation (2.9 +/- 1.4 vs 2.3 +/- 0.9; P = .043). The eight cases with undifferentiated histology required more illuminations than the cases with other histologic types (3.4 +/- 0.9 vs 2.2 +/- 0.9; P < .001). However, these cases were located in sites that did not allow the optimal placement of fibers, therefore requiring multiple treatments. CONCLUSION PLA is a highly effective treatment in HCC with a tumor size of 4.0 cm or smaller. In this setting, two variables, tumor size and tumor location, affect the achievement of complete tumor ablation and the number of treatments required to obtain tumor necrosis.

Percutaneous laser ablation in patients with isolated unresectable liver metastases from colorectal cancer: Results of a phase II study

We prospectively evaluated the safety, local tumor control, and impact on survival parameters of percutaneous laser ablation (PLA) in patients with colorectal liver metastases not amenable to surgical resection. The study included 44 individuals with 75 unresectable liver metastases and no known extrahepatic disease. The median number of metastases treated for each patient was one, with a range of 1–4. Metastases had a median diameter of 3.4 cm (range 0.5–9 cm), and a median volume of 16.8 cm3 (range 0.4–176.4 cm3). All patients also received systemic chemotherapy with modalities that differed according to the type of response to PLA. After treatment, 61% (46/75) of the tumors were ablated completely. The likelihood of achieving a complete ablation was significantly higher when metastases had a diameter <3.0 cm (p = 0.004). Overall survival was 30.0±12.7 months in patients with a complete ablation, and 20.2±10.2 months in those with a partial ablation (p = 0.002). There were no major complications during or after PLA, the most frequent side effect being abdominal pain that required analgesics. These findings indicate that PLA can be safely used as an adjunct to chemotherapy in unresectable colorectal liver metastases, and may have a positive impact on survival.

Effectiveness, Safety, and Local Progression After Percutaneous Laser Ablation for Hepatocellular Carcinoma Nodules up to 4 cm Are Not Affected by Tumor Location

OBJECTIVE A high-risk location--defined as the tumor margin being less than 5 mm from large vessels or vital structures--represents a well-known limitation and contraindication for radiofrequency ablation of hepatocellular carcinoma (HCC) nodules. The aim of this study was to verify whether HCC nodule location negatively affected the outcome of percutaneous laser ablation in terms of its primary effectiveness, safety, and ability to prevent local tumor progression. MATERIALS AND METHODS The medical records and radiologic examinations of 164 cirrhotic patients (90 men, 74 women; mean age ± SD, 68.6 ± 8.3 years) with 182 HCC nodules 4 cm or smaller (mean diameter ± SD, 2.7 ± 0.78 cm) that had been treated by laser ablation between 1996 and 2008 were retrospectively analyzed. One hundred six patients had 116 nodules in high-risk sites (high-risk group), whereas 58 patients had 66 tumors located elsewhere (standard-risk group). RESULTS The overall median follow-up was 81 months (range, 6-144 months). The initial complete ablation rate per nodule did not significantly differ between the high-risk group and the standard-risk group (92.2% vs 95.5%, respectively; p = 0.2711). Rates of major complications (high-risk group vs standard-risk group, 1.9% [including one death] vs 0%) and minor complications (5.6% vs 1.0%) were not statistically different between the two groups. Only side effects were recorded significantly more often in high-risk patients than in standard-risk patients (31.5% vs 19.8%; p = 0.049). There was no significant difference in either cumulative incidence of local tumor progression (p = 0.499) or local tumor progression-free survival (p = 0.499, log rank test) between the high-risk group and the standard-risk group. CONCLUSION When laser ablation is used to treat small HCC nodules, tumor location does not have a significant negative impact on the techniques primary effectiveness or safety or on its ability to achieve local control of disease.

Stent Repair of Bilateral Post-Traumatic Dissections of the Internal Carotid Artery

Purpose: To report endovascular repair of bilateral internal carotid arteries (ICAs) in a youth following an accident. Case Report: A 17-year-old boy presented with dissection of both ICAs after a motorcycle accident. The lesions started 2 cm above the bifurcation and continued upward to the siphon, with normal flow into the circle of Willis. Surgical repair was excluded due to the critical clinical condition of the patient and owing to the anatomical extent of the dissection. Carotid Wallstent endoprostheses were deployed bilaterally to repair the dissected segments of the ICAs. After 13 months, the patient is in good health, with complete patency of both arteries. Conclusions: The good result we experienced in this case indicates that stents may be a safe and effective treatment for traumatic bilateral carotid dissections. However, the long-term durability of these devices in a young patient remains to be determined.

Influence of ablative margin on local tumor progression and survival in patients with HCC ≤4 cm after laser ablation

Background Ablation of the normal hepatic parenchyma surrounding the tumor (ablative margin [AM]) is necessary to prevent local tumor progression. Purpose To assess the prognostic value of the ablative margin in patients with HCC ≤4 cm treated with US-guided laser ablation. Material and Methods A cohort of 116 patients (53 women and 63 men, age range 42–82 years) with 132 HCC nodules ≤4 cm completely ablated by US-guided laser ablation was retrospectively analyzed. Rates of local tumor progression were compared using different ablative margin cut-offs (≥2.5, 5.0, 7.5, and 10.0 mm). Survival probability curves were obtained with the Kaplan-Meier method. Results The mean period of follow-up was 42 months (range 3–114 months). Local tumor progression was identified in 24 out of 132 lesions (18%), with an average time to progression of 24 months (range 6–36 months). A significant difference in local tumor progression was observed only if the ablative margin was ≥7.5 mm (7% vs. 23%, P = 0.020). Survival curves of patients with or without an ablative margin ≥7.5 mm were not different (P = 0.665; mean survival time 43.8 ± 3.1 and 46.8 ± 6.1 for an AM < or ≥7.5 mm, respectively). Conclusion An ablative margin ≥7.5 mm turned out to be useful in preventing local tumor progression but did not affect long-term survival in patients with HCC ≤4 cm treated with laser ablation.

Contrast-Enhanced Ultrasound in the Management of Thyroid Nodules

INTRODUCTION Thyroid nodules are discovered by palpation in 3–7% of subjects in the general population, but an epidemic of clinically unapparent thyroid lesions is detected by high-resolution ultrasonography (US) of the cervical region (1–3). The clinical importance of thyroid nodules, besides the infrequent local compressive symptoms or thyroid dysfunction, is the possibility of thyroid cancer, which occurs in about 5% of all thyroid nodules (4–5). Thus it is essential to improve our diagnostic tools to avoid the use of unnecessary diagnostic surgery. Brightness-mode US is currently the most accurate imaging test to evaluate solitary thyroid nodules or multinodular goiters (6–8). Thyroid US results in improved management for patients, with clinical findings suggestive of thyroid nodules (9). Many patients either have a palpable but not suspicious nodule, or have incidentally revealed but sonographically relevant nodules that warrant fine needle aspiration biopsy (10). Unfortunately, in most cases US characteristics cannot unequivocally distinguish benign and malignant lesions (10–12). Color Doppler US was proposed to evaluate nodule