Hepatocellular carcinoma tumor thrombus entering the inferior vena cava treated with percutaneous RF ablation: a case report.

PURPOSE: Hepatocellular carcinoma (HCC) is the most common form of liver cancer. In advanced cancer stages (metastatic disease and/or vascular invasion), the generally accepted standard of care is systemic therapy using sorafenib as first-line treatment and, recently, regorafenib and nivolumab as second-line treatment, but the quality of life and the prognosis of patients remain very poor. Our paper reports a case of US-guided radiofrequency ablation (RFA) of both intraparenchymal HCC and inferior vena cava tumor thrombus. METHODS: We treated a patient with HCC associated with tumor thrombus extending into vena cava after failure of sorafenib therapy using US-guided radiofrequency ablation (RFA). RESULTS: A good radiological and clinical response was observed in association with excellent tolerability. The patient has been followed up for 15 months from the ablation, is alive, and is in a good clinical condition without evidence of tumor recurrence. CONCLUSION: This is the first case in which this minimally invasive percutaneous procedure has been successfully used to treat an HCC thrombus entering the vena cava.

Intrahepatic Cholangiocarcinoma and Thermal Ablation: Long-term Results of An Italian Retrospective Multicenter Study.

Background and Aims: Despite resection being considered the treatment of choice for intrahepatic cholangiocarcinoma (ICC), percutaneous thermal ablation can be an alternative treatment for patients unfit for surgery. Our aim was to compare long-term results of percutaneous sonographically-guided radiofrequency ablation (RFA) with high-powered microwave ablation (MWSA) in treatment of ICC. Methods: Results of 71 ICC patients with 98 nodules treated with RFA (36 patients) or MWSA (35 patients) between January 2008 and June 2018 in 5 Interventional Ultrasound centers of Southern Italy were retrospectively reviewed. Cumulative overall survival curves were calculated with the Kaplan-Meyer method and differences with the log-rank test. Eleven possible factors affecting survival were analyzed. Results: Overall survival of the entire series was 88%, 65%, 45% and 34% at 12, 36, 60 and 80 months, respectively. Patients treated with MWSA survived longer than patients treated with RFA (p < 0.005). The MWSA group with ICC nodules ≤3 cm or nodules up to 4 cm survived longer than the RFA group (p < 0.0005). In patients with nodules >4 cm, no significant difference was found. Disease-free survival and progression-free survival were better in the MWSA group compared to the RFA group (p < 0.005). Diameter of nodules and MWSA were independent factors predicting a better survival. No major complications were observed. Conclusions: MWSA is superior to RFA in treating ICC unfit for surgery, achieving better long-term survival in small (≤3 cm) ICC nodules as well as nodules up to 4 cm of neoplastic tumors and should replace RFA.

Microwave Ablation in Intermediate Hepatocellular Carcinoma in Cirrhosis: An Italian Multicenter Prospective Study.

Background and Aims: To report long-term results in treatment of intermediate hepatocellular carcinoma (HCC) in cirrhotics using new high-powered microwaves (MWS) ablation alone. Methods: This multicenter study included 215 cirrhotics (age range: 67-84 years; 137 males; 149 Child A, 66 Child B) who underwent percutaneous ultrasound-guided high-powered MWS ablation instead of transarterial chemoembolization. Among the patient population, 109 had a single nodule (Ø 5.3-8 cm) [group A], 70 had 2 nodules (Ø 3-6 cm) [group B] and 36 had 3-5 nodules (Ø 1.5-6.8 cm) [group C]. MWS ablation efficacy was evaluated using enhanced-computed tomography and/or magnetic resonance imaging. Primary end-point was 5-year cumulative overall survival (OS). Results: On enhanced-computed tomography and/or magnetic resonance imaging, complete ablation rates were 100% for 1.5-3.5 cm nodules. In nodules >3.5-5 cm, it was 89% for the first ablation and 100% for the second. For lesions >5-8 cm, ablation was up to 92%. Overall, 1-, 3- and 5-year survival rates were 89, 60, and 21%, respectively. The cumulative OS rate of group A was 89%, 66% and 34% at 1, 3 and 5 years. The cumulative OS rate of group B was 88%, 60% and 11% at 1, 3 and 5 years. The cumulative OS rate of group C was 86%, 55% and 0%. The 5-year survival rate was significantly different among the groups (p <0.001). One patient died from rupture of HCC. Upon multivariate analysis, preablation total bilirubin >1.5 mg/dL was an independent factor for predicting lower survival. Conclusions: Percutaneous MWS ablation of intermediate HCC is safe and effective in inducing large volume of necrosis in intermediate HCC nodules, providing long-term survival rates similar to transarterial chemoembolization. Preablation total bilirubin >1.5 mg/dL as expression of liver function reserve is the main factor predicting a worse outcome.

Goals defining therapy for primary immune thrombocytopenia in adults.

: Discordances existing between the two most influential guidelines on the treatment of immune thrombocytopenia, the 2010 International Consensus Report and the 2011 America Society of Hematology guideline, continue to be reflected by the heterogeneity of clinical practice of the physicians who treat this disease. Aimed at overcoming these discordances, we hypothesized that they could be ascribed to nonshared treatment goals. We classify the indications for and goals of the various possible treatments available for adults with primary immune thrombocytopenia according to the line of treatment and the phase of disease. The resulting classification is useful for recognizing the appropriateness of a chosen treatment in individual patients. The classification proposed here could constitute the basis for greater agreement among future guidelines and, in the meanwhile, could help less expert physicians recognize the appropriateness of a treatment to choose in the single patient.

Biological therapies for inflammatory bowel disease: research drives clinics.

The better understanding of the mechanisms of inflammatory bowel disease has driven our progress into the development of new biological therapies targeting specific molecules. Anti-TNF-alpha biologic compounds have shown great efficacy particularly in Crohn's disease. Infliximab (an IgG1 mouse/human chimeric monoclonal anti-TNF-alpha antibody fragment) is the most efficacious compound in induction and maintenance therapy of active and fistulizing Crohn's disease, being at present the only biological compound approved for therapy, but with the limit of the immunogenicity; CDP-571 (a humanized anti-TNF-alpha antibody) and CDP-870 (a PEGylated anti-TNF-alpha antibody) are less immunogenic, showed some efficacy in induction therapy in Crohn's disease but a rapid loss of response in maintenance therapy. Etanercept and onercept (soluble human recombinant TNF-alpha receptors fusion proteins) seem not to be efficacious in Crohn's disease demonstrating no class-effect for anti-TNF-alpha compounds. In preliminary study, adalimumab (an IgG1 humanized monoclonal anti-TNF-alpha antibody) offers good perspective of efficacy and safety also in infliximab-resistant or allergic patients. Inhibition of lymphocyte trafficking to the gut, through anti-adhesion molecules specific therapies (natalizumab, MLN-02, alicaforsen), has shown promising results: unfortunately, natalizumab, the most effective drug of this class, has recently been suspected to favour serious neurological complications. Other biologic therapies are under evaluation but at present seem to be less promising than infliximab; they consist of antiinflammatory cytokines, inhibitors of proinflammatory cytokines, hormones and growth factors: anti-IL12-antibody, interferon-alpha, interferon-beta, G-CSF, GM-CSF, EGF, growth hormone, anti-interferon-gamma, anti-IL-18, anti-IL-2-receptor and anti-CD3 antibodies. The evaluation of other biological drugs has been suspended for severe side effects as happened for anti-CD40L antibody causing thromboembolism and anti-CD4 antibody causing ly.mphopenia. Other compounds as IL-10 and IL-11 have been proven to be ineffective even if an oral formulation of IL-11 is under evaluation. Among the MAP kinases inhibitors BIRB-796 and RDP58 showed to be ineffective while CNI-1493 is under evaluation. The effort in identifying specific patients features predicting therapy response and the possible combination of different biological therapies represent undoubtedly a very promising perspective. Aim of this article is to review the biological compounds and their efficacy in IBD.

Effect of different bur grinding on the bond strength of self-etching adhesives.

This study compared the microtensile bond strength (MTBS) of three all-in-one adhesive systems and a two-step system using two types of burs to prepare the dentin surfaces. Flat coronal surfaces of 24 extracted human molars were produced using either regular-grit or superfine-grit diamond burs. Resin composite was then bonded to equal numbers of these surfaces using one of the four adhesives: Clearfil SE Bond (CSE), G-Bond (GB), SSB-200 (SSB) or Prompt L-Pop (PLP). After storage for 24 hours in 37 degrees C distilled water, the bonded teeth were sectioned into slices (0.7-mm thick) perpendicular to the bonded surface. The specimens were then subjected to microtensile testing and the bond strengths were calculated at failure. Bond strength data were analyzed by two-way ANOVA and the GamesHowell test for interaction between adhesive and type of cut dentin. The fractured surfaces were observed by SEM to determine the failure mode. In addition, to observe the effect of conditioning, equal numbers of the two bur-cut dentin surfaces of eight additional teeth were conditioned with the adhesives and observed by SEM. Based on the results, when CSE and SSB were bonded to dentin cut with a regular-grit diamond bur, the MTBS values were significantly lower than that of superfine bur-cut dentin; whereas, GB and PLP showed no significant differences in MTBS between the two differently cut surfaces. SEM observation of the fractured surfaces revealed a mixed mode (adhesive in some areas and cohesive in others in the same sample) of failure in all specimens except PLP, which showed cohesive failure within the adhesive for both types of bur preparation. Generally, SEMs of the conditioned surfaces using both types of burs showed partial removal of the smear layer for CSE, minimal for GB and SSB and complete removal for PLP. In conclusion, when cutting dentin, selecting the proper bur type is important for improving the bond strength of some self-etching adhesive systems.

The effect of the air-blowing step on the technique sensitivity of four different adhesive systems.

PURPOSE: To evaluate the technique sensitivity of four different adhesive systems using different air-blowing pressure. METHODS: Four adhesive systems were employed: Clearfil SE Bond [SE] (Kuraray, Japan), G-Bond [GB] (GC Corporation, Japan), Adper Prompt L-Pop [LP] (3M ESPE, USA) and an experimental adhesive, SSB-200 [SSB] (Kuraray, Japan). Twenty-four extracted molars were used. After grinding the coronal enamel surface, the teeth were divided into two equal groups. The first group's teeth were randomly assigned for bonding with the different adhesives using gentle air-blowing (g). For the teeth of the second group, the four adhesive systems were applied using strong air-blowing (s). After storage overnight in 37 degrees C water, the bonded specimens were sectioned into sticks (1 mm x 1 mm wide), which were subjected to microtensile bond strength testing (microTBS) at a crosshead speed of 1 mm/min. The load at failure of each specimen was recorded and the data were analyzed by one-way ANOVA and Tukey HSD tests. The surfaces of the fractured specimens were observed using SEM to determine the failure mode. RESULTS: The results of the microTBS test showed that the highest bond strengths tended to be with SE for both gentle and strong air-blowing, and the significantly lowest for SSB with strong air streaming. Comparing the two techniques, significant differences were noted only for SSB-200 (P < 0.05). For each material, the SEM evaluation did not show distinct differences in the nature of the fractures between the two techniques, except for SSB-200. CONCLUSIONS: The adhesives tested are not technique sensitive, except SSB-200, with regards to the air-blowing step.

Extraintestinal manifestations in inflammatory bowel disease.

Inflammatory bowel diseases (IBD) can be really considered to be systemic diseases since they are often associated with extraintestinal manifestations, complications, and other autoimmune disorders. Indeed, physicians who care for patients with ulcerative colitis and Crohn's disease, the two major forms of IBD, face a new clinical challenge every day, worsened by the very frequent rate of extraintestinal complications. The goal of this review is to provide an overview and an update on the extraintestinal complications occurring in IBD. Indeed, this paper highlights how virtually almost every organ system can be involved, principally eyes, skin, joints, kidneys, liver and biliary tracts, and vasculature (or vascular system) are the most common sites of systemic IBD and their involvement is dependent on different mechanisms.