Ultrasound-guided percutaneous irreversible electroporation of hepatic and abdominal tumors not eligible for surgery or thermal ablation: a western report on safety and efficacy

PURPOSE

To report our first results on sixteen patients affected by liver and abdominal malignant tumors, unfit for surgery or thermal ablation, treated with US-guided percutaneous irreversible electroporation (IRE).

METHODS

From June 2014 to December 2016, all patients meeting the inclusion criteria (malignant hepatic or abdominal tumors not eligible for resection or thermal ablation) and not meeting the exclusion criteria (heart arrhythmia, pro-hemorrhagic hematological alterations, tumor size > 8 cm, presence of a biliary metallic stent) referred to our institutions were prospectively enrolled to undergo percutaneous US-guided irreversible electroporation (IRE). Sixteen patients (age range 59-68 years, mean 63; 7 females) with 18 tumors (diameter range 1.3-7.5 cm) fulfilled the inclusion criteria and were included in the study. Data concerning efficacy (tested by a 1-week CEUS and a 4-week enhanced CT and/or enhanced MRI) and safety were recorded during a 18-month follow up.

RESULTS

All patients completed a 35-50-min procedure without complications. One patient with 6 cm Klatskin tumor also underwent a second session for 1 month. A 1-week CEUS and a 4-week e-CT and/or e-MRI arterial phase contrast enhancement analysis showed an overall reduction of arterial flow with confirmation of unenhanced lesions for seven nodules. After 1-18 months of follow up, no major complications were recorded and no tumor-related death occurred. The lesions of two patients disappeared 3 and 6 months after their treatment, respectively.

CONCLUSIONS

IRE is a promising ablation modality in the treatment of malignant hepatic and abdominal tumors unsuitable for resection or thermal ablation.

Peak width of skeletonized mean diffusivity (PSMD) as marker of widespread white matter tissue damage in multiple sclerosis

BACKGROUND

Peak width of skeletonized mean diffusivity (PSMD) is a novel and fully automated, MRI biomarker, which has shown clinical relevance in cerebral small vessel diseases (SVD). We aimed here to assess PSMD levels across the brain of patients with multiple sclerosis (MS), in comparison to normal controls (NC) and patients with CADASIL, a genetically defined form of severe SVD.

METHODS

We assessed PSMD in relapsing-remitting (RR) MS patients (n = 47) in comparison to age-matched CADASIL patients (n = 25) and NC (n = 28). Diffusion Tensor Imaging data were acquired on 1.5T MR clinical scanner to automatically compute PSMD through "skeletonization" of WM tracts and diffusion histograms.

RESULTS

RRMS had lower WM lesion volume (LV) than CADASIL (8.6 ± 8.2 vs 24.4 ± 17.4 cm³, p < 0.001). After correction for LV, PSMD values in MS were higher than in CADASIL patients (adjusted mean values: 4.5 vs 3.9 × 10^-4 mm²/s, p = 0.03) and in both patient groups were higher than in NC (2.8 ± 0.3 × 10^-4 mm²/s, p < 0.001). PSMD values correlated with LV in both patient groups (r = 0.8, p < 0.001 in MS; r = 0.6, p = 0.002 in CADASIL).

CONCLUSIONS

In both patient groups, PSMD was higher than in NC and closely correlated with LV, suggesting sensitivity in assessing brain tissue damage in these disorders. In MS patients, PSMD levels were higher than in CADASIL patients, despite the lower LV. This might be related to more severe normal-appearing WM abnormalities occurring in the MS brains. This novel, fully automated, MRI metric may represent a useful marker for a robust quantification of the diffuse WM tissue damage in MS.

Subclinical motor impairment assessed with an engineered glove correlates with magnetic resonance imaging tissue damage in radiologically isolated syndrome

BACKGROUND

An engineered glove measuring finger motor performance previously showed ability to discriminate early-stage multiple sclerosis (MS) patients from healthy controls (HCs). Radiologically isolated syndrome (RIS) classifies asymptomatic subjects with brain magnetic resonance imaging (MRI) abnormalities suggestive of multiple sclerosis.

METHODS

Seventeen asymptomatic subjects with RIS and 17 HCs were assessed. They performed finger-to-thumb opposition sequences at their maximal velocity, metronome-paced bimanual movements and conventional and diffusion tensor MRI.

RESULTS

Subjects with RIS showed lower (P = 0.005) maximal velocity and higher (P = 0.006) bimanual coordination impairment than HCs. In RIS, bimanual coordination correlated with T2-lesion volume, fractional anisotropy and radial diffusivity in the white matter.

CONCLUSIONS

These findings point out the relevance of fine hand measures as a robust marker of subclinical disability.

Effects of ZnO nanoparticles in the Caspian roach (Rutilus rutilus caspicus)

Most studies investigating the toxicity of zinc oxide nanoparticles (ZnO NPs) focused on the effect of size, whereas exposure concentration and duration remained poorly understood. In this study, the effect of acute and sub-acute exposures of ZnO NPs on Zn compartmentalization and biomarkers' expression were investigated in Rutilus rutilus caspicus (Caspian roach) considering various exposure scenarios: i) the assessment of the concentration-response curves and median lethal concentration (LC₅₀); ii) the assessment of the effects of organisms exposed at LC₅₀ value and one tenth of LC₅₀ value of ZnO NPs suspensions for 4 d and 28 d, respectively; iii) the assessment of 14 d depuration period. The same concentrations of ZnSO₄ were investigated. The highest Zn accumulation was detected in gill after sub-acute exposure (4.8 mg/L; 28 d) followed by liver, kidney and muscle. In gill, liver and muscle, Zn from Zn NPs accumulated higher concentrations. Depuration (14 d) decreased Zn content in each organ, but no complete removal occurred except for muscle. Biomarkers' activity was significantly over expressed after treatments, but depuration brought back their values to background levels and most effects were related to acute concentrations (48 mg/L; 4 d) and in presence of ZnSO₄. Histopathological analyses showed that the exposure to ZnO NPs increased lesions in gill, liver and kidney, with a direct proportionality between alterations and Zn accumulated in the target organs. After depuration, lesions regressed for both ZnO NPs and ZnSO₄, but not in a complete way. These data could contribute to increase the knowledge about ZnO NPs risk assessment in aquatic vertebrates, suggesting that the size of ZnO NPs can influence biomarker and histopathological effects.

Role of contrast-enhanced ultrasound to define prognosis and predict response to biotherapy in pancreatic neuroendocrine tumors

PURPOSE

The incidence of neuroendocrine tumors (NETs) is progressively increasing. Most cases arise from the digestive system, where ileum, rectum and pancreas represent the commonest site of origin. Liver metastases are frequently detected at diagnosis or during the follow-up. Contrast-enhanced ultrasound (CEUS) is used in patients with pancreatic NETs (P-NETs) and liver metastases from P-NET but its role has not been standardized. The aim of this retrospective study was to investigate CEUS in patients with P-NETs and liver metastases from P-NET both as prognostic factor and predictor of response to therapy with somatostatin analogues (SSAs).

METHODS

CEUS was performed at the diagnosis of NET and 3, 6 and 12 months after the beginning of SSAs. CEUS pattern was compared with contrast-enhanced computed tomography (CT) pattern.

RESULTS

There was a significant association between CEUS and CT pattern (X ² = 79.0; p < 0.0001). A significant association was found between CEUS pattern and Ki-67 index (X ² = 24.6; p < 0.0001). The hypervascular homogeneous CEUS typical pattern was associated with low tumor grading (G1 or G2) (X ² = 24.0; p < 0.0001). CEUS pattern changed from hypervascular homogeneous in baseline to hypovascular/hypervascular inhomogeneous after SSA therapy, with a significant association between tumor response at CT scan and appearance of hypervascular inhomogeneous pattern at CEUS evaluation (6 months: X ² = 57.0; p < 0.0001; 12 months: X ² = 49.8; p < 0.0001).

CONCLUSIONS

In patients with P-NET, CEUS pattern correlates with tumor grading, being homogeneous in G1-G2 but not in G3 tumors. After therapy with SSAs, CEUS is predictive of response to SSAs. These findings seem to support a role of CEUS as prognostic and predictive factor of response.

Meningitis and Riga-Fede disease: an unusual condition

BACKGROUND

Riga-Fede disease (RFD) is a benign inflammatory disorder characterised by the appearance of a traumatic ulceration of the oral mucosa. Early detection of RFD and its adequate management are very important.

CASE REPORT

The authors present a an unusual case of RFD with concomitant Staphylococcus aureus meningitis. A 36-day-old female infant was referred to the emergency room of the Hospital of the University of Siena for a 4-day history of high fever. Clinical evaluation revealed the presence of lingual ulceration caused by natal tooth. Few hours later, clinical manifestations were overshadowed by neurological symptoms. The cerebrospinal fluid examination showed the presence of Staphylococcus aureus. The wound healing after extraction of the tooth and the antibiotic therapy have been important for the resolution of this case. A conservative approach is preferable for natal teeth, but in this case the extraction was suggested since a more radical treatment was more likely to avoid major complications.

Biofilms on tuff stones at historical sites: identification and removal by nonthermal effects of radiofrequencies

A methodology aiming at identifying and removing biofilms from cultural heritage was applied to stones from tuff walls in historical sites. Identification of phototrophic encrusting microorganisms was carried out by optical and electron microscopy, as well as by molecular techniques (DNA analyses and denaturing gradient gel electrophoresis (DGGE)). In all sites, the examination of microbial components of biofilms resulted in the identification of 17 species belonging to Cyanobacteria, Rhodophyta, Bacillariophyta and Chlorophyta, with Cyanobacteria being the dominant components in all biofilms. In order to remove the biofilms, an innovative technique based on the use of nonthermal effects of radiofrequencies was adopted. The source of the electromagnetic fields was a signal generator connected to a horn antenna through an amplifier to provide the power boost required to generate the target field amplitude. Seven days after exposure to radiofrequency electromagnetic field, about 50 % reduction of biofilm was observed; after 14 days, biofilm extension was reduced by about 90 %. DGGE analyses performed after 14 days confirmed these visual inspections. Also, DGGE analyses carried out before and 14 days after treatments showed that 12 out of 17 identified species disappeared. A complete visual disappearance of biofilms was observed a month after the beginning of treatments. DGGE repeated at this time confirmed the total disappearance of biofilm-forming species. Treated stones, when transferred back to their original sites, did not show any microorganism re-growing after 6 months. No alteration in the color and structural consistency of tuff substrata was observed after radiofrequency treatments.

Benefit of surgery in presence of orbital metastasis

PURPOSE

Malignant tumors metastatic to the orbit are rare and only about 5% of orbital tumors are metastasis. We report on orbital surgery in a patient with orbital metastasis from small cell lung carcinoma (SCLC).

METHODS

A 75-year-old man complained of pain in the left orbital region and proptosis. Head CT scan showed a left retrobulbar mass compressing the optical nerve. Chest and body CT scans showed a round-shaped mass at the apex of the left inferior lobule of the lung and widespread nodal involvement.

RESULTS

A surgical intervention on the left orbit through a lateral approach was performed, with complete removal of the mass. Histology showed features of a non-anaplastic SCLC. A complete restoration of visual acuity was obtained

CONCLUSIONS

A debulking orbital surgery, in order to relieve optic nerve compression, should be offered to the patients with orbital metastasis.

Association of MRI metrics and cognitive impairment in radiologically isolated syndromes

OBJECTIVE

To evaluate cognitive changes in a cohort of radiologically isolated syndromes (RIS) suggestive of multiple sclerosis (MS) and to assess their relationship with quantitative magnetic resonance (MR) measures such as white matter (WM), lesion loads, and cerebral atrophy.

METHODS

We assessed the cognitive performance in a group of 29 subjects with RIS recruited from 5 Italian MS centers and in a group of 26 patients with relapsing-remitting MS (RRMS). A subgroup of 19 subjects with RIS, 26 patients with RRMS, and 21 healthy control (HC) subjects also underwent quantitative MR assessments, which included WM T1 and T2 lesion volumes and global and cortical brain volumes.

RESULTS

Cognitive impairment of the same profile as that of RRMS was found in 27.6% of our subjects with RIS. On MR scans, we found comparable levels of lesion loads and brain atrophy in subjects with RIS and well-established RRMS. In subjects with RIS, high T1 lesion volume (ρ = 0.526, p = 0.025) and low cortical volume (ρ = -0.481, p = 0.043) were associated with worse cognitive performance.

CONCLUSIONS

These findings emphasize the importance of including accurate neuropsychological testing and quantitative MR metrics in subjects with RIS suggestive of MS. They can provide a better characterization of these asymptomatic subjects, potentially useful for diagnostic and therapeutic decisions.

Cortical lesions in radiologically isolated syndrome

OBJECTIVE

To assess the presence of cortical lesions (CLs) as detected by MRI in subjects with radiologically isolated syndrome (RIS).

METHODS

Fifteen subjects with RIS underwent an MRI examination, including a double inversion recovery sequence for CL assessment. T2-hyperintense white matter (WM) lesion volume (LV) and normalized volumes of brain and cortex were also obtained.

RESULTS

Thirty-four CLs were identified in 6 of 15 (40%) subjects with RIS and predominantly distributed in frontotemporal lobes. CLs were frequent in subjects with RIS with immunoglobulin G oligoclonal bands on CSF, cervical cord lesions, and dissemination in time on brain MRI. WM LV was higher in subjects with CLs than in those without CLs (11.5 ± 10.1 vs 3.9 ± 2.8 cm(3), p = 0.04). Indeed, CL number and volume correlated with WM LV (r = 0.57, p = 0.03 and r = 0.61, p = 0.01). All subjects with CLs were classified in a previous study as having a very high probability of having relapsing-remitting multiple sclerosis (MS) on a logistic regression analysis of quantitative MRI indices.

CONCLUSIONS

We found CLs in subjects with RIS, a condition characterized by the unanticipated MRI finding of WM lesions highly suggestive of MS in the absence of a clinical scenario. CLs were mainly localized to the frontotemporal lobes and were associated with important markers of evolution to MS.

Percutaneous radiofrequency ablation of hepatocellular carcinoma compared to percutaneous ethanol injection in treatment of cirrhotic patients: an Italian randomized controlled trial

AIM

To compare 5-year survival of patients with a single hepatocellular carcinoma≤3 cm randomly assigned to receive percutaneous ethanol injection or radiofrequency ablation.

PATIENTS AND METHODS

A total of 285 patients (192 males, mean age 70 years), with a single hepatocellular carcinoma (mean diameter 2.2 cm) were randomly assigned to receive percutaneous ethanol injection (n=143) or radiofrequency ablation (n=142). The primary endpoint of the study was 5-year survival.

RESULTS

Overall 143 patients underwent percutaneous ethanol injection and 128 radiofrequency ablation. In consideration of segmental location, in fact, 14 patients with 14 hepatocellular carcinomas could not be treated with established radiofrequency and were treated with percutaneous ethanol injection; these patients were not included in the survival evaluation. In the percutaneous ethanol injection and in the radiofrequency ablation groups, 3- and 5-year survival rates of 74% and 68%, and 78% and 68%, and 79% and 70% [corrected] respectively, were observed (p=n.s). In the percutaneous ethanol injection group, 3- and 5-year local recurrence rates were 9.4% and 12.8% respectively; in the radiofrequency group, the 3 and 5 years local recurrence rates were 7.8% and 11.7%, respectively (p=n.s.). The overall costs of percutaneous ethanol injection and radiofrequency ablation were 1359 Euros and 171.000 Euros, respectively (p<0.0001)

CONCLUSION

Percutaneous ethanol injection and radiofrequency ablation conferred similar 5-year survival. Feasibility is not the same for both procedures. Percutaneous ethanol injection is much cheaper than radiofrequency ablation and should be considered whether in poor and rich countries.

Protective wrapping of the ulnar nerve in severe cubital tunnel syndrome: treatment and long-term results

The authors report their surgical experience with 10 cases of anterior subcutaneous ulnar nerve transposition and coverage of the nerve with substitutive dural flap, performed between January and November 2008 at the Department of Neurosurgery ("Santa Maria alle Scotte" Hospital, Siena, Italy) in the treatment of severe cubital tunnel syndrome. Clinical long-term results are analyzed and the relevant literature is reviewed.

Amebic liver abscesses: a new epidemiological trend in a non-endemic area?

BACKGROUND

Amoebic liver abscess (ALA) is the most common extraintestinal complication of colonic amebiasis. In recent decades its incidence in developed European countries has significantly increased because of travel and immigration of individuals from highly endemic areas. We report our 29-year experience in echo-guided percutaneous needle/catheter drainage (EPND/EPCD) of ALA.

PATIENTS AND METHODS

From May 1979 to November 2007, 68 ALA corresponding to 56 patients were diagnosed at our Department. All patients were treated with a metronidazole plus EPND/EPCD approach.

RESULTS

The majority of the cases did not need more than two echo-guided punctures. Two patients, both male immigrants (HIV-negative), had unmodified lesions after two EPNDs: catheter drainage was performed. A quick worsening of their clinical conditions and onset of neurological symptoms occurred; in both patients, computed tomography (CT) revealed a brain abscess. Intravenous medical therapy was started, but both died 4 and 3 days, respectively, after the onset of neurological symptoms (overall mortality rate: 3.57%).

CONCLUSION

The unfavorable outcome of two cases is a rare example of failure of percutaneous therapy of ALA. Mortality is a possible event even in a non-endemic area such as Italy. More observational data are needed to confirm the possibility of a new epidemiological trend.

Radiofrequency ablation of hepatocellular carcinoma extended into the portal vein: Preliminary results

INTRODUCTION

We report our preliminary results of radiofrequency (RF) ablation of hepatocellular carcinoma (HCC) and neoplastic portal thrombus (NPT) in cirrhotic patients.

METHODS

Ten patients (7 males and 3 females; mean age 68 yrs) with 10 HCC nodules (37-49 mm) extended into the main portal vein (MPV) underwent RF ablation. Diagnosis of NPT was achieved by fine-needle biopsy. RF ablation was performed firstly on the NPT and then on the HCC. RF ablation was considered successful when complete necrosis of the HCC and complete recanalization of the MPV were achieved. HCC necrosis was evaluated using contrast-enhanced CT. Recanalization of the portal vessels (PV) was analyzed using Color Doppler (CD). RF ablation was performed under ultrasonographic (US) guidance using a perfused electrode needle.

RESULTS

Complete necrosis of the HCC with complete recanalization of the PV was observed in 7 patients (success rate: 70%). In the remaining 3, necrosis of the HCC ranged from 70% to 95%, and recanalization of the PV was not complete. No major complications occurred. In 2 cases, mild ascites and increased aspartate aminotransferase/alanine aminotransferase (AST/ALT) values were observed. The follow-up ranged from 4 to 24 months; 1 and 2-year survival rates were 77% and 77%, respectively. At the last follow-up, the 7 successful patients were alive and the portal system was still patent. The 3 unsuccessful patients died within 5 months due to progressive disease.

CONCLUSION

RF ablation can destroy HCC and NPT achieving a high rate of efficacy and low rate of complications. However, to confirm these results a control group and a longer follow-up are required.