[Echo-guided fine-needle biopsy for the diagnosis of hepatic angioma. A report on 114 cases]. / La biopsia ecoguidata con ago sottile per la diagnosi di angioma epatico. Rapporto su 114 casi.

METHODS: Personal experience with fine-needle aspiration biopsy (FNAB) performed in 114 patients (42 males and 72 females) with hepatic angiomas, in whom imaging techniques did not allow a definite diagnosis, is reported. FNAB was made on 57.9% of the cases for atypical US pattern of the nodule, on 52.6% for a previous cancer history, with both conditions on 10.5%. The procedure was carried out by cyto-assistance for collecting material and a rapid stain diagnosis with an average of 2 biopsies per patient. Diagnostic accuracy was evaluated with following laparoscopy in 25 cases; surgery in 4 cases; angiography in 6 cases and US follow-up for 1 year at least in 78 cases (1 drop-out). RESULTS: One false-negative and 4 false-positives were detected with an overall accuracy of 96%. Two minor accidents were observed, due to a profuse bleeding of giant angiomas and resolved with medical care. CONCLUSIONS: Therefore, in case of angiomas larger than 5 cm, the use of laparoscopy after FNAB to control the bleeding and to confirm the diagnosis is suggested.

Ultrasound-guided fine needle biopsy and laparoscopy in the study of pancreatic masses: report on 136 cases.

The authors report their experience from 136 fine needle ultrasound (FN-US)-guided biopsies and laparoscopies. The pancreatic diseases considered by these methods were as follows: 9 cases of Pancreatitis, 11 cases of Pancreatic cysts, 5 cases of endocrine cancer, 109 cases of Exocrine cancer and 2 not conclusive cases. Diagnostic accuracy of FNB and laparoscopy was evaluated for each group and, in particular, for cancer patients. In the latter group, FNB helped to detect abdominal diffusion in 25 cases (33%) while laparoscopy, including laparoscopic washing, revealed a micro-diffusion in 31 cases (55%), the latter not shown previously by CT, RNM and US. The combination of these methods allows us to confirm the advanced stage of the majority of pancreatic cancers at onset. Furthermore, this seems to be a very reliable method to select resectable patients, thus avoiding useless, sometimes hazardous and expensive further investigation.

Implication of laparoscopy and peritoneal cytology in the staging of early pancreatic cancer.

Staging of pancreatic cancer still represents a challenge for surgeons involved in this field. Diagnostic methods of radiological imaging used routinely (CT, NMR, angiography) may understage this neoplasm. In fact, the presence of peritoneal or subglissonian hepatic micrometastases (< 2 cm) is a frequent surprise at laparotomy and forces the surgeon to use a palliative procedure. Actually this policy has not to be followed because the possibility to perform non-surgical palliation of jaundice or pain respectively by percutaneous radiological stent insertion and celiac alcoholization. In this viewpoint, preoperative staging has acquired an important role for a correct treatment, be it surgical or medical. Laparoscopy allows it to overcome the understaging produced by the more common diagnostic means, with the possibility to view directly the celomatic space and the surface of the abdominal viscera; moreover, during this procedure it is possible to perform a peritoneal washing to obtain other information about the cancer stage. In our experience, 56 patients were judged as resectable by radiologic methods; 31 were excluded from surgery by laparoscopy; 10 of the remaining 25 cases were submitted to radical resection. The operative resectability rate resulted in 40%, against 18% in cases where we submitted to surgery all the patients. Seven patients underwent peritoneal washing, always with a negative result; all were submitted to surgery and radically resected. In our opinion, laparoscopy and peritoneal washing represent useful tools in the staging of patients affected by pancreatic cancer.

[The role of laparoscopy and peritoneal cytology in the preoperative staging of pancreatic carcinoma]. / Il ruolo della laparoscopia e della citologia peritoneale nella stadiazione pre-operatoria del carcinoma pancreatico.

The staging of pancreatic cancer still represents a challenge for surgeons involved in this field; radiological diagnostic methods used routinely (CT, NMR, angiography) may under-estimate this neoplasm; in fact, the presence of peritoneal or subglissonian hepatic micrometastasis (< 2 cm) is a frequent surprise at laparotomy and force the surgeon to undertake a palliative procedure. This policy need not be followed because it is possible to perform non-surgical palliation of jaundice or pain respectively by percutaneous radiological stent insertion and coeliac alcoholisation. Pre-operative staging thus acquires an important role in the correct treatment, surgical or medical. Laparoscopy allows us to overcome the understaging of the more common diagnostic methods and view directly the coelomatic space and the surface of the abdominal viscera; moreover during this procedure it is possible to perform a peritoneal wash to obtain other information on the cancer stage. We judged 56 patients by radiological diagnosis; 31 were excluded from surgery by laparoscopy; 10 of the other 25 cases were submitted to radical resection. The resectability operative rate was 40%, compared with 18% if we had submitted patients to surgery. Several patients underwent peritoneal wash, always with negative results; all were submitted to surgery and radically resected. In our opinion, laparoscopy and peritoneal wash represent useful tools in the staging of patients affected with pancreatic cancer.

"Cyto-assisted", ultrasound-guided biopsy in the diagnosis of focal disease of the abdomen.

From May 1988 to June 1990, 260 patients with abdominal focal disease underwent ultrasonically guided percutaneous fine needle biopsy. The technique of so-called "FNAB-CYT" is described. The procedure entailed very few complications: the mortality rate was 0% and the morbidity rate was 1.5%. The specificity of the technique was 100%, and sensitivity was 93.43%. False-negative diagnoses were made in 8 cases, and in 5 patients the cytologic diagnoses were uncertain. There were no false-positives. The possibility of an immediate control of the collected material by the pathologist avoids the risk of inadequate samples and reduces the number of biopsies for the patient. Comparison among diagnoses on rapid and definitive preparations and histologic ones was carried out to evaluate the diagnostic efficiency of the cytologic procedure. In our experience, a rapid staining of the smears allowed a correct cytologic diagnosis in 87.7% of the cases within approximately 5 min of the biopsy. On the basis of our experience, the authors recommend FNAB-CYT as a routine first-level (less invasive) procedure for diagnosis of abdominal focal disease.

Progressive pneumoperitoneum in the management of giant incisional hernias: a study of 41 patients.

Forty-one patients (17 men and 24 women) were treated with progressive pneumoperitoneum before repair of giant incisional hernias. The pneumoperitoneum was induced using nitrous oxide gas and a laparoscopic insufflator, and was topped up every other day for a mean of 5.5 days with a total injection of 23.2 litres of nitrous oxide. The pneumoperitoneum was well tolerated in 30 patients, caused a mild temporary pain in 10 patients and a sharp pain in one patient; no serious side-effects occurred. All the patients underwent surgery to repair their hernias, 40 patients were available for follow-up for a mean of 25.3 months, only two hernias recurred both within 4 months of the operation.

Laparoscopy in the abdominal staging of melanoma.

A retrospective study on laparoscopic results in the abdominal staging of 297 patients with melanoma, is reported. In 195 (99.3%) of patients, laparoscopy was technically feasible, and in 10% the clinical stage was changed on the basis of the findings. In 34% of patients with metastasis of the liver and peritoneum, the tumor had a diameter of under 1 cm and therefore was not detectable with non-invasive techniques. In the light of these results laparoscopy is advisable in patients with Stage I melanoma at a high risk of metastatization (Clark IV-V; Breslow greater than 0.76 mm) and in Stage II patients. In Stage III patients, laparoscopy seems indicated for an evaluation of the efficacy of systemic treatment.

Malignant peritoneal mesothelioma. A clinical and laparoscopic study of ten cases.

A retrospective study of 10 cases of malignant peritoneal mesothelioma from two centers is reported. All cases were initially diagnosed between 1967 and 1986 utilizing laparoscopy and the histologic interpretation of laparoscopic biopsy samples. Subsequently, the original diagnosis was confirmed by two independent pathologists employing both histological and histochemical techniques. In five cases immunohistochemical studies were also performed. The clinical findings and course of the disease were similar to other reported series. Laparoscopic findings of mesothelioma were indistinguishable from metastatic peritoneal neoplasms. However, the presence of homogeneous spreading of nodules, plaques, or fleshy masses on both parietal and visceral peritoneum; the absence of direct or indirect signs of other abdominal neoplasms; and the absence of hepatic metastases or the possible presence of nodules or plaques on Glisson's capsule without any parenchymal involvement, when observed, allowed the laparoscopist to suspect the disease in four of 10 cases. Laparoscopy may be useful in detecting mesothelioma. The diagnosis is mainly morphological, but even morphology has its inherent limitations. Further studies are necessary to improve the diagnostic accuracy of this tumor.

Prelaparoscopic echography used to detect abdominal adhesions.

Through the use of echography after establishing the pneumoperitoneum, it is possible to recognize the presence of intra-abdominal adhesions and the distribution of gas. Using this method, the laparoscopist is able to form a picture of the intra-abdominal situation with regard to the site of the adhesions and the pneumoperitoneal chambers. This enables him to choose the best site for the insertion of the trocar both for the avoidance of possible incidents, and for optimal inspection. This method has been successfully employed in 39 patients with large abdominal surgical scars. Laparoscopy confirmed the echographic findings in almost all the cases. Thus, in 38% of cases the laparoscopic "inspection site" chosen was atypical with respect to the usual sites for the insertion of the laparoscope, but always proved to be the most suitable.

Laparoscopy in staging, follow-up, and restaging of ovarian carcinoma.

Laparoscopy was systematically employed for the study of 143 cases of primary ovarian tumor in the various phases of staging, treatment, follow-up, and restaging. We found that laparoscopy allowed a more precise staging if used before laparotomy. Verification of response at any time in the course of therapy was readily achieved by laparoscopy.

Laparoscopy in abdominal staging of esophageal carcinoma. Report of 369 cases.

Three hundred sixty-nine patients with cancer of the esophagus (280) and of the cardia (89) underwent laparoscopy, which revealed single or multiple metastases to the liver, peritoneum, omentum, stomach, and lymph nodes in 52 patients (14%) and a metastasis to the gastric wall or to the regional lymph nodes in 36 patients (9.7%). Laparoscopic false negative findings in our series of 250 cases submitted to laparotomy was only 4.4% (2.8% for the liver, 1.2% for the peritoneum, and 0.4% for the omentum). Cirrhosis was diagnosed in 14.3% and severe portal hypertension in 6.7% of our series. Laparoscopy is a very effective procedure in pretherapy staging of esophageal cancer.

Discriminant analysis in the clinical and biochemical diagnosis of primary liver cancer.

Discriminant analysis was used in evaluating the importance of clinical aspects and the value of routine and experimental biochemical markers in the differential diagnosis of primary liver cancer (PLC) and chronic, non-neoplastic, liver diseases. Our results show that: 1) Clinical signs, such as the presence of pain, weight loss or mass, correctly indicate the diagnosis in 76% of the cases; 2) The determination of alkaline phosphatase isoenzymes is shown by the computer to be the most useful marker and provides an overall diagnostic accuracy which is higher than that of alpha-fetoprotein. We also found that, by using these two markers together, "by intersection," the best overall accuracy (85%) is obtained. We, therefore, suggest determination of alkaline phosphatase isoenzymes and alpha-fetoprotein in screening the populations at risk for liver cancer.