Review of dynamic contrast-enhanced ultrasound guidance in ablation therapy for hepatocellular carcinoma

Local ablative techniques-percutaneous ethanol injection, microwave coagulation therapy and radiofrequency ablation (RFA)-have been developed to treat unresectable hepatocellular carcinoma (HCC). The success rate of percutaneous ablation therapy for HCC depends on correct targeting of the tumor via an imaging technique. However, probe insertion often is not completely accurate for small HCC nodules, which are poorly def ined on conventional B-mode ultrasound (US) alone. Thus, multiple sessions of ablation therapy are frequently required in diffi cult cases. By means of two breakthroughs in US technology, harmonic imaging and the development of second-generation contrast agents, dynamic contrast-enhanced harmonic US imaging with an intravenous contrast agent can depict tumor vascularity sensitively and accurately, and is able to evaluate small hypervascular HCCs even when B-mode US cannot adequately characterize the tumors. Therefore, dynamic contrast-enhanced US can facilitate RFA electrode placement in hypervascular HCC, which is poorly depicted by B-mode US. The use of dynamic contrast-enhanced US guidance in ablation therapy for liver cancer is an effi cient approach. Here, we present an overview of the current status of dynamic contrast-enhanced US-guided ablation therapy, and summarize the current indications and outcomes of reported clinical use in comparison with that of other modalities.

Evidence based review of the impact of image enhanced endoscopy in the diagnosis of gastric disorders

Gastric cancer is the third most common cause of cancer-related death.Advanced stages of gastric cancersgenerally have grim prognosis.But,good prognosis can be achieved if such cancers are detected,diagnosed and resected at early stages.However,early gastric cancers and its precursors often produce only subtle mucosal changes and therefore quite commonly remain elusive at the conventional examination with white light endoscopy.Image-enhanced endoscopy makes mucosal lesions more conspicuous and can therefore potentially yield earlier and more accurate diagnoses.Recent years have seen growing work of research in support of various types of image enhanced endoscopy(IEE) techniques(e.g.,dye-chromoendoscopy;magnification endoscopy;narrow-band imaging;flexible spectral imaging color enhancement;and I-SCAN) for a variety of gastric pathologies.In this review,we will examine the evidence for the utilization of various IEE techniques in the diagnosis of gastric disorders.

Management of gastric mucosa-associated lymphoid tissue lymphoma in patients with extra copies of the MALT1 gene

AIM To identify the clinical features of gastric mucosaassociated lymphoid tissue(MALT) lymphoma with extra copies of MALT1.METHODS This is a multi-centered,retrospective study. We reviewed 146 patients with MALT lymphoma in the stomach who underwent fluorescence in situ hybridization analysis for t(11;18) translocation. Patients were subdivided into patients without t(11;18) translocation or extra copies of MALT1(Group A,n = 88),patients with t(11;18) translocation(Group B,n = 27),and patients with extra copies of MALT1(Group C,n = 31). The clinical background,treatment,and outcomes of each group were investigated.RESULTS Groups A and C showed slight female predominance,whereas Group B showed slight male predominance. Mean ages and clinical stages at lymphoma diagnosis were not different between groups. Complete response was obtained in 61 patients in Group A(69.3%),22 in Group B(81.5%),and 21 in Group C(67.7%). Helicobacter pylori(H. pylori) eradication alone resulted in complete remission in 44 patients in Group A and 13 in Group C. In Group B,14 patients underwent radiotherapy alone,which resulted in lymphoma disappearance. Although the difference was not statistically significant,event-free survival in Group C tended to be inferior to that in Group A(P = 0.10).CONCLUSION Patients with t(11;18) translocation should be treated differently from others. Patients with extra copies of MALT1 could be initially treated with H. pylori eradication,similar to patients without t(11;18) translocation or extra copies of MALT1.

Value of acoustic radiation force impulse elastography for the assessment of ascites syndrome

AIM:To assess the feasibility of performing acoustic radiation force impulse(ARFI) elastography in patients with ascites and its predictive value for the cirrhotic or non-cirrhotic etiology of ascites.METHODS:Our study included 153 patients with ascites,mean age 58.8 ± 13.1 years.One hundred and fifteen(75.2%) patients had ascites in the context of cirrhosis,29(18.9%) had non-cirrhotic ascites(diagnosed by clinical,ultrasound,endoscopic and/or laparoscopic criteria) and in 9(5.9%) cases we could not establish the etiology of ascites.We performed 10 ARFI measurements and the median value was calculated and expressed in meters/second(m/s).Among the 29 patients with non-cirrhotic ascites were included:20 laparoscopically demonstrated peritoneal carcinomatosis with histological confirmation,7 acute pancreatitis with ascites which later resolved,and one case each of lymphatic ascites and ascites in the context of a liver abscess.In 11 of the 20 patients with peritoneal carcinomatosis,the liver structure was homogenous in the ultrasound examination and in 9 patients the ultrasound exam revealed liver metastases.RESULTS:We could not obtain valid ARFI measurements in 5 patients(3.2%).The mean liver stiffness measurements by means of ARFI were statistically significantly higher in patients with cirrhotic ascites than in those with non-cirrhotic ascites:3.04 ± 0.70 vs 1.45 ± 0.59 m/s(P < 0.001).For a cut-off value of 1.8 m/s for predicting cirrhosis(and ascites in the context of cirrhosis),as obtained in a previous study,ARFI had 98.1% sensitivity,86.2% specificity,96.4% positive predictive value,92.5% negative predictive value and 95.6% accuracy for predicting cirrhotic ascites.For a cut-off value of 1.9 m/s the accuracy was 94.9% and for a 2 m/s cut-off value it was 92.8%.CONCLUSION:ARFI elastography is feasible in most patients with ascites and has a very good predictive value for the cirrhotic or non-cirrhotic etiology of ascites.

Robot-assisted surgery for gastric cancer

Minimally invasive surgery for gastric cancer is a rela-tively new research field, with convincing results mostly stemming from Asian countries. The use of the robotic surgery platform, thus far assessed as a safe procedure, which is also easier to learn, sets the background for a wider spread of minimally invasive technique in the treatment of gastric cancer. This review will cover the literature published so far, analyzing the pros and cons of robotic surgery and highlighting the remaining study questions.

Splenic artery aneurysm presenting as a submucosal gastric lesion: A case report

We are reporting the rare case of splenic artery aneurysm of 4 cm of diameter presenting as a sub mucosal lesion on gastro-duodenal endoscopy. This aneurysm was treated by endovascular coil embolization and stent graft implantation. The procedure was uneventful. On day 1, the patient presented an acute severe epigastric pain and cardiovascular arrest. Abdominal computed tomography scan showed an active leak of the intravenous contrast dye in the peritoneum from the splenic aneurysm. We performed an emergent resection of the aneurysm, and peritoneal lavage. Postoperatively, hemorrhagic choc was refractory to large volumes replacement, and intravenous vaso-active drugs. On day 2, he presented massive hematochezia. We performed a total colectomy with splenectomy and cholecystectomy for ischemic colitis, with spleen and gallbladder infarction. Despite vaso-active drugs and aggressive treatment with Factor VIIa, the patient died after uncontrolled disseminated intravascular coagulation.