Radiation therapy for resistant sternal hydatid disease

An unusual manifestation of hydatid disease: A case in a 20-year old male patient

Echinococcosis is a re-emerging public health issue in developing countries as most communities are homes to dogs and other domesticated animals while cattle raising is a major habit of most sub-Saharan countries. The usual presentations include liver and lung cysts. While few documentations and publications have been made on extra-pulmonary intrathoracic hydatid cysts in other parts of the world, there has been no published document on extra-pulmonary intrathoracic hydatid cysts consisting of eighty or more cystic masses in a single patient in Ethiopia. We present a case of right sided extra-pulmonary intrathoracic hydatid cysts in a 20-year old Ethiopian male patient with compressive respiratory symptoms and significant social history of cohabiting with dogs throughout childhood. The patient was treated by surgery via a posterolateral thoracotomy and had a smooth Post-operative course and discharged home on postoperative day 15 on albendazole and analgesics. Intraoperative findings included approximately 1500 ml of cystic fluid, eighty cystic masses and collapsed lung.

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Echinococcosis is a re-emerging public health issue in developing countries.

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Echinococcosis is among the most neglected tropical diseases.

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Extrapulmonary hydatid cyst is rare entity and occurs in any part of thorax.

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We present a case of right sided extrapulmonary hydatid cysts in a 20-year male.

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We extracted eighty cystic masses intraoperatively, which is a rear discovery.

IJRadiation therapy for recurrent hydatid cyst of the pelvic bone: a case report

BACKGROUND

Hydatid disease usually affects the liver, but can also extend to other locations, such as the bones. In these cases, complete resection of the bone is considered the only curative approach. However, this is rarely feasible, and patients are left with benzimidazoles as their only option. In this context, there is an evident need for alternative treatments that can improve results. We present the case of a patient with a treatment-refractory hydatid cyst of the bone, who successfully underwent radiotherapy (RT).

CASE SUMMARY

A 64-year-old woman was diagnosed with a hydatid cyst of the bone in the sacroiliac joint that caused her sciatalgia and paresthesia. She underwent treatment with albendazole and surgery, and was treated with further doses of albendazole after relapsing six months later. After 2 years, she required a new resection, achieving a stable disease for 2 more years. At this point, she began to suffer from more intense pain (visual analogue scale 6/10). Given that further surgery was no longer feasible, she underwent radiotherapy (54 Gy in 27 fractions). No treatment-related toxicity was observed. At 1 month after radiotherapy, the pain had completely disappeared; 9 months later, the patient remains asymptomatic. The titer of anti-Echinococcus-granulosus antibodies and the absolute volume of eosinophils decreased after treatment with radiotherapy. The cyst remains radiologically stable.

CONCLUSION

Although further studies are needed, radiotherapy seems to be effective for hydatid cysts that are refractory to other treatments.

Effect of intensity-modulated radiation therapy on sciatic nerve injury caused by echinococcosis

Conventional radiotherapy has a good killing effect on femoral echinococcosis. However, the sciatic nerve around the lesion is irreversibly damaged owing to bystander effects. Although intensity-modulated radiation therapy shows great advantages for precise dose distribution into lesions, it is unknown whether intensity-modulated radiation therapy can perfectly protect the surrounding sciatic nerve on the basis of good killing of femoral echinococcosis foci. Therefore, this study comparatively analyzed differences between intensity-modulated radiation therapy and conventional radiotherapy on the basis of safety to peripheral nerves. Pure-breed Meriones meridiani with bilateral femoral echinococcosis were selected as the research object. Intensity-modulated radiation therapy was used to treat left femoral echinococcosis of Meriones meridianus, while conventional radiotherapy was used to treat right femoral echinococcosis of the same Meriones meridianus. The total radiation dose was 40 Gy. To understand whether intensity-modulated radiation therapy and conventional radiotherapy can kill femoral echinococcosis, trypan blue staining was used to detect pathological changes of bone Echinococcus granulosus and protoscolex death after radiotherapy. Additionally, enzyme histochemical staining was utilized to measure acid phosphatase activity in the protoscolex after radiotherapy. One week after radiotherapy, the overall structure of echinococcosis in bilateral femurs of Meriones meridiani treated by intensity-modulated radiation therapy disappeared. There was no significant difference in the mortality rate of protoscoleces of Echinococcus granulosus between the bilateral femurs of Meriones meridiani. Moreover, there was no significant difference in acid phosphatase activity in the protoscolex of Echinococcus granulosus between bilateral femurs. To understand the injury of sciatic nerve surrounding the foci of femoral echinococcosis caused by intensity-modulated radiation therapy and conventional radiotherapy, the ultrastructure of sciatic nerves after radiotherapy was observed by transmission electron microscopy. Additionally, apoptosis of neurons was examined using a terminal-deoxynucleotidyl transferase-mediated dUTP nick end labeling assay, and expression of Bcl-2 and Bax in sciatic nerve tissue was detected by immunohistochemical staining and western blot assay. Our results showed that most neurons in the left sciatic nerve of Meriones meridiani with echinococcosis treated by intensity-modulated radiation therapy had reversible injury, and there was no obvious apoptosis. Compared with conventional radiotherapy, the number of apoptotic cells and Bax expression in sciatic nerve treated by intensity-modulated radiation therapy were significantly decreased, while Bcl-2 expression was significantly increased. Our findings suggest that intensity-modulated radiation therapy has the same therapeutic effect on echinococcosis as conventional radiotherapy, and can reduce apoptosis of the sciatic nerve around foci caused by radiotherapy. Experiments were approved by the Animal Ethics Committee of People’s Hospital of Xinjiang Uygur Autonomous Region, China (Approval No. 20130301A41) on March 1, 2013.

Inhibitory Effect of Ionizing Radiation on Echinococcus granulosus Hydatid Cyst

BACKGROUND

Heavy ion radiation has more advantages than traditional radiation therapy in the treatment of cancer, mainly because of its superior biological effects. However, there is currently no reliable evidence that heavy ion radiation can induce cell death in hydatid cysts at the cellular and molecular level. In addition, we believe heavy ion therapy could be a potential alternative approach for the treatment of hydatid cysts.

METHODOLOGY/PRINCIPAL FINDING

The hydatid cysts and protoscolices were obtained from an experimentally infected KunMing mice. LD50 was used to evaluate the death of the protoscolex. The cellular and ultrastructure of the parasites were observed under light and electron microscopes, the damage and copy numbers of mitochondrial DNA (mtDNA) were decided by QPCR. The apoptosis was evaluated by the expression and activity of caspase3. Dose-dependent ionizing radiation induced damage to the initial mtDNA. Echinococcosis cyst after ionizing radiation showed sparse cytoplasm, disorganized and clumped organelles, huge vacuoles, and villus deletions. The kinetic of DNA repair activity after X-ray irradiation was faster than those after carbon-ion irradiation. High doses of carbon ion radiation caused irreversible attenuation of mitochondrial DNA. Cysts showed obvious reduction in size after radiation. Carbon ion radiation was more effective than X-ray radiation in inhibiting hydatid cysts.

CONCLUSIONS

These studies provide evidence that heavy-ion radiation can cause the extinction of hydatid cysts in vitro. The carbon-ion radiation is more advantageous than X-ray radiation in suppress hydatid cyst.

A case of Extrapulmonary intrathoracic hydatidosis with pseudochylothorax

Echinococcus is a great re-emerging public health issue. Intrathoracic and extra pulmonary hydatid cysts with pseudochylothorax are rare. There is no standard treatment in case of hydatidosis with pseudochylothorax. Pharmacotherapy approaches may be an option in case of long duration of disease and high risk for surgery.

Management of osseous cystic echinococcosis

INTRODUCTION

Osseous cystic echinococcosis (CE) is one of the most complicated and devastating conditions caused by Echinococcus granulosus. Its management is difficult and there is scant literature about it. Areas covered: A literature review was performed to provide an update on its diagnosis, treatment and follow-up. Expert commentary: In most cases diagnosis of osseous CE can only be confirmed by surgery. Osseous CE should be managed by experienced physicians and addressed as a chronic disease with therapies must be aimed at controlling the disease and its sequels or complications, rather than with a curative intent.

Effects of X-ray on the metacestodes of Echinococcus granulosus in vitro

Background

Radiotherapy may represent an alternative treatment modality for cystic echinococcosis (CE), but there is no adequate evidence for it up to now. In this study, we aim to investigate the parasiticidal effects of X-ray on the metacestodes of Echinococcus granulosus in vitro.

Methods

Protoscoleces obtained from sheep naturally infected with CE were cultivated in RPMI 1640 medium containing 10% fetal bovine serum (FBS) at 37 °C in 5% CO₂. Upon encystation on day 14, the metacestodes were subjected to various intensities of X-ray. Metacestode structures were observed using light microscope and transmission electron microscopy (TEM), and Real-Time PCR was carried out to determine the expression of EgTPX, EgHSP70, EgEPC1 and Caspase-3.

Results

On day 14, encystation was noticed in the majority of protoscoleces in the control group. In the X-ray groups, the encystation rate showed significant decrease compared with that of the control group (P < 0.05), especially the groups subjected to a dose of ≥40 Gy (P < 0.01). Light microscope findings indicated the hooklets on the rostellum were deranged in the irradiation group, and malformation was noticed in the suckers in a dose dependent manner. For the TEM findings, the cellular structure of the germinal layer of the cysts was completely interrupted by X-ray on day 7. The expression of EgTPX, EgHSP70, EgEPC1 and Caspase-3 was up-regulated after irradiation, especially at a dose of ≥45Gy (P < 0.05).

Conclusions

X-ray showed parasiticidal effects on the metacestodes of E. granulosus. Irradiation triggered increased expression of EgTPX, EgHSP70, EgEPC1 and Caspase-3.

Efficacy of radiotherapy for the treatment of cystic echinococcosis in naturally infected sheep

BACKGROUND

Radiotherapy is commonly used to treat cancers. To date, there has been no study focusing on the effects of radiotherapy on hydatid disease in large animals. In this study, we aim to investigate the efficiency and safety of radiotherapy for treating hydatid disease caused by Echinococcus granulosus in naturally infected sheep.

METHODS

Ultrasound was used to screen naturally infected sheep in an echinococcosis endemic area in Xinjiang, China. A computer tomography (CT) scan confirmed the presence of hydatid cysts. Twenty sheep naturally infected with E. granulosus in the liver and/or lungs were randomly assigned into four groups receiving no irradiation, or X-ray irradiation of low (30 Gy), medium (45 Gy), and high dose (60 Gy), respectively. After three months of radiotherapy, a CT scan was performed to measure the changes in the cysts. The hepatic parasite cysts and host tissues were collected for histology and gene expression analysis.

RESULTS

In the animals subject to irradiation, no significant differences were observed in their appetite, daily activities, and weight before and after radiotherapy. Severe calcification was noticed in the cysts subject to a high dose of radiation compared with the groups subject to low and medium doses. Hematoxylin and eosin staining showed that irradiation contributed to the damage of the cyst structure and nucleus in the germinal layers. Quantitative PCR demonstrated that expression of TPX and HSP70 significantly decreased in a dose-dependent manner (P < 0.05). The expression of the EPC1 decreased in the medium- and high-dose groups compared with the low-dose group (P < 0.05). Meanwhile, the expression of radiation-related apoptosis genes caspase-3 and Gadd45 decreased with an increase in the irradiation dose.

CONCLUSIONS

Radiotherapy is an option with satisfactory efficiency and safety for treating cystic echinococcosis in sheep with partial response or stable disease at month 3. In future, inhibition of cystic activity using radiotherapy may serve as a new regimen for treating hydatid disease.

Gamma-Ray Treatment of Echinococcus Protoscoleces prior to Implantation in Mice Reduces Echinococcosis

Echinococcosis is a serious parasitic disease caused by Echinococcus tapeworms. Protoscoleces are sometimes released during surgical treatment for hydatid cysts, causing the recurrence of echinococcosis. Protoscoleces may be susceptible to radiation therapy. In this study Echinococcus protoscoleces were cultured in vitro and then divided into four different γ-ray irradiation dose groups (10 Gy, 20 Gy, 40 Gy, and 80 Gy) and a blank group. The protoscoleces were then implanted into the abdominal cavity of mice. Four months later, we observed that the incidence and weight of cysts declined with the increase of irradiation dose. γ-ray irradiation can suppress the generation of Echinococcus originated from protoscolex, the reason of which is due to the damaging to the structure of Echinococcus. Irradiation may prevent echinococcosis recurrence after surgical removal of hydatid cysts.

Surgery or radiotherapy for the treatment of bone hydatid disease: a retrospective case series

BACKGROUND

Currently, there is no accepted treatment for inoperable bone hydatid disease where medical treatment has proved ineffective. Alternative treatment strategies are therefore urgently needed. Radiotherapy may constitute a treatment option, but there is currently a lack of adequate evidence. This study sought to retrospectively assess the efficacy and safety of surgery or radiotherapy in the treatment of bone hydatid disease in patients attending a single hospital in China.

METHODS

This was a retrospective case series analyzing clinical data from consecutive patients treated between January 2000 and December 2011. Patients with an Echinococcus sp infection were counselled about their disease and the potential treatment options, and made an informed decision between surgery and radiotherapy. All patients were followed up. The treatment outcome was observed in the two treatment groups based on the frequencies of relapse and complications, and self-evaluated patient satisfaction.

RESULTS

Of 40 patients (age range 25-57 years), 24 opted for surgery and 16 for radiotherapy. Relapse occurred in 14 patients (58%) post-surgery and in three patients (21%) post-radiotherapy. Bone defects, limb movement disorders, and pain were reported in seven patients (29%) post-surgery, while two patients (13%) reported hardening of the irradiated region or a limb after radiotherapy. Titres of parasite-specific antibodies decreased significantly after radiotherapy but not after surgical intervention. Patient satisfaction was significantly higher in the radiotherapy group.

CONCLUSION

This retrospective case series describes, for the first time, the clinical outcomes in a series of patients treated with radiotherapy for bone hydatid disease. Although no direct comparison between the treatment groups could be made due to methodological limitations of the study design, this study indicates that well-designed prospective randomized controlled clinical trials assessing radiotherapy may be warranted in patients with inoperable hydatid disease of the bones.

Non-surgical and non-chemical attempts to treat echinococcosis: do they work?

Cystic echinococcosis (CE) and alveolar echinococcosis (AE) are chronic, complex and neglected diseases. Their treatment depends on a number of factors related to the lesion, setting and patient. We performed a literature review of curative or palliative non-surgical, non-chemical interventions in CE and AE. In CE, some of these techniques, like radiofrequency thermal ablation (RFA), were shelved after initial attempts, while others, such as High-Intensity Focused Ultrasound, appear promising but are still in a pre-clinical phase. In AE, RFA has never been tested, however, radiotherapy or heavy-ion therapies have been attempted in experimental models. Still, application to humans is questionable. In CE, although prospective clinical studies are still lacking, therapeutic, non-surgical drainage techniques, such as PAIR (puncture, aspiration, injection, re-aspiration) and its derivatives, are now considered a useful option in selected cases. Finally, palliative, non-surgical drainage techniques such as US- or CT-guided percutaneous biliary drainage, centro-parasitic abscesses drainage, or vascular stenting were performed successfully. Recently, endoscopic retrograde cholangiopancreatography (ERCP)-associated techniques have become increasingly used to manage biliary fistulas in CE and biliary obstructions in AE. Development of pre-clinical animal models would allow testing for AE techniques developed for other indications, e.g. cancer. Prospective trials are required to determine the best use of PAIR, and associated procedures, and the indications and techniques of palliative drainage.

Assessment of the effect of Allium sativum on serum nitric oxide level and hepatic histopathology in experimental cystic echinococcosis in mice

The current study was carried out to evaluate the prophylactic and therapeutic effects of Allium sativum on experimental cystic echinococcosis by measuring the serum nitric oxide level and studying hepatic histopathological changes. The experimental animals were divided into five groups, ten mice in each, group (I): prophylactic; group (II): therapeutic; group (III): prophylactic and therapeutic; group (IV): infected nontreated; group (V): non infected non treated. The results showed that serum nitric oxide was significantly increased as a result of infection in all infected groups compared to group V. Statistical significant difference was noted in serum nitrate level in group I at 1st and 8th week post infection compared to the same time interval in group IV. In group II, statistical significance was noticed only at the 1st week post infection. Statistical significant difference was noted in serum nitrate level in group III at 1st, 4th, 6th and 8th week post infection compared to same time interval in group IV. Hydatid cysts developed in livers of mice of group IV as early as 4 weeks of infection while no cysts were found in groups I,II and III. Histopathologically there were moderate pathological changes in group I and group II as hepatocytes showed moderate steatosis, moderate venous congestion and inflammatory cellular infiltrate with foci of degeneration and necrosis. While livers of mice of group III showed mild steatosis, mild venous congestion, mild inflammatory cellular infiltrate, no necrosis and no biliary hyperplasia. Accordingly, that garlic (Allium sativum) may be a promising phototherapeutic agent for cystic echinococcosis.

Suppression of E. multilocularis hydatid cysts after ionizing radiation exposure

Background

Heavy-ion therapy has an advantage over conventional radiotherapy due to its superb biological effectiveness and dose conformity in cancer therapy. It could be a potential alternate approach for hydatid cyst treatment. However, there is no information currently available on the cellular and molecular basis for heavy-ion irradiation induced cell death in cystic echinococcosis.

Methododology/Principal Findings

LD50 was scored by protoscolex death. Cellular and ultrastructural changes within the parasite were studied by light and electron microscopy, mitochondrial DNA (mtDNA) damage and copy number were measured by QPCR, and apoptosis was determined by caspase 3 expression and caspase 3 activity. Ionizing radiation induced sparse cytoplasm, disorganized and clumped organelles, large vacuoles and devoid of villi. The initial mtDNA damage caused by ionizing radiation increased in a dose-dependent manner. The kinetic of DNA repair was slower after carbon-ion radiation than that after X-rays radiation. High dose carbon-ion radiation caused irreversible mtDNA degradation. Cysts apoptosis was pronounced after radiation. Carbon-ion radiation was more effective to suppress hydatid cysts than X-rays.

Conclusions

These studies provide a framework to the evaluation of attenuation effect of heavy-ion radiation on cystic echinococcosis in vitro. Carbon-ion radiation is more effective to suppress E. multilocularis than X-rays.

Surgical removal of cysts may be impractical in cases that cysts are in multiple organs or tissues, or in risky locations. In that case, alternative treatment should be employed. Heavy-ion radiation could be an effective way for treatment of hydatid cysts, taking its full advantage of well-defined range, small lateral beam spread and an enhanced biological effectiveness. In this study, we found that carbon-ion radiation could result in extensive mitochondrial DNA damage and apoptosis in hydatid cysts. Cellular and ultrastructural changes were observed after ionizing radiation, which were indicative of cysts growth inhibition. To our knowledge, this is the first study reporting the biological effect of carbon-ion radiation on E. multilocularis hydatid cysts.

Spinal cystic echinococcosis--a systematic analysis and review of the literature: part 2. Treatment, follow-up and outcome

Bone involvement in human cystic echinococcosis (CE) is rare, but affects the spine in approximately 50% of cases. Despite significant advances in diagnostic imaging techniques, surgical treatment and introduction of pharmacological therapy, spinal echinococcosis remains associated with a high degree of morbidity, disability and mortality. We systematically reviewed the published literature of the last five decades to update and summarize the currently existing data on treatment, follow-up and outcome of spinal CE.