Epidemiology, therapy and outcome of hepatocellular carcinoma between 2010 and 2019 in Piedmont, Italy

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and the second leading cause of cancer deaths worldwide. It is often diagnosed at an advanced stage and therefore its prognosis remains poor with a low 5-year survival rate. HCC patients have increasingly complex and constantly changing characteristics, thus up-to-date and comprehensive data are fundamental.

AIM

To analyze the epidemiology and main clinical characteristics of HCC patients in a referral center hospital in the northwest of Italy between 2010 and 2019.

METHODS

In this retrospective study, we analyzed the clinical data of all consecutive patients with a new diagnosis of HCC recorded at "Santa Croce e Carle" Hospital in Cuneo (Italy) between 1 January 2010 and 31 December 2019. To highlight possible changes in HCC patterns over the 10-year period, we split the population into two 5-year groups, according to the diagnosis period (2010-2014 and 2015-2019).

RESULTS

Of the 328 HCC patients who were included (M/F 255/73; mean age 68.9 ± 11.3 years), 154 in the first period, and 174 in the second. Hepatitis C virus infection was the most common HCC risk factor (41%, 135 patients). The alcoholic etiology rate was 18%, the hepatitis B virus infection etiology was 5%, and the non-viral/non-alcoholic etiology rate was 22%. The Child-Pugh score distribution of the patients was: class A 75%, class B 21% and class C 4%. The average Mayo end-stage liver disease score was 10.6 ± 3.7. A total of 55 patients (17%) were affected by portal vein thrombosis and 158 (48%) by portal hypertension. The average nodule size of the HCC was 4.6 ± 3.1 cm. A total of 204 patients (63%) had more than one nodule < 3, and 92% (305 patients) had a non-metastatic stage of the disease. The Barcelona Clinic Liver Cancer (BCLC) staging distribution of all patients was: 4% very early, 32% early, 23% intermediate, 34% advanced, and 7% terminal. Average survival rate was 1.6 ± 0.3 years. Only 20% of the patients underwent treatment. Age, presence of ascites, BCLC stage and therapy were predictors of a better prognosis (P < 0.01). A comparison of the two 5-year groups revealed a statistically significant difference only in global etiology (P < 0.05) and alpha-fetoprotein (AFP) levels (P < 0.01).

CONCLUSION

In this study analyzing patients with a new diagnosis of HCC between 2010-2019, hepatitis C virus infection was the most common etiology. Most patients presented with an advanced stage disease and a poor prognosis. When comparing the two 5-year groups, we observed a statistically significant difference only in global etiology (P < 0.05) and AFP levels (P < 0.01).

Multidrug-Resistant Bloodstream Infections in Internal Medicine: Results from a Single-Center Study

OBJECTIVES

Infections due to multidrug-resistant organisms (MDROs) are expanding globally and are associated with higher mortality rates and hospital-related costs. The objectives of this study were to analyze the trends of MDRO bacteremia and antimicrobial resistance rates in Internal Medicine wards of our hospital and to identify the variables associated with these infections.

METHODS

During a 6-year period (July 1, 2011-June 30, 2017), patients with positive blood culture isolates hospitalized in the Internal Medicine wards in the Santa Croce and Carle Hospital in Cuneo, Italy, were assessed. We performed an analysis taking into consideration the time trends and frequencies of MDRO infections, as well as a case-control study to identify clinical-demographic variables associated with MDRO bacteremias.

RESULTS

During the study period a total of 596 blood cultures were performed in 577 patients. The most frequently identified organism was Escherichia coli (33.7%), followed by Staphylococcus aureus (15.6%) and S epidermidis (7.4%). The percentage of resistance to methicillin among S aureus isolates showed a decreasing trend, whereas rates of extended-spectrum β-lactamase-producing Enterobacteriaceae and carbapenemase-producing Klebsiella pneumoniae increased during the study period. Multivariate analysis showed that the nosocomial origin of the infection, hospitalization during the previous 3 months, residence in long-term care facilities, presence of a device, antibiotic exposure during the previous 3 months, and cerebrovascular disease were independently associated with bacteremia by resistant microorganisms.

CONCLUSIONS

Our analysis reveals a concerning microbiological situation in an Internal Medicine setting, in line with other national and regional data. The risk variables for infection by MDRO identified in our study correspond to those reported in the literature, although studies focused on Internal Medicine settings appear to be limited.

RDW-based clinical score to predict long-term survival in community-acquired pneumonia: a European derivation and validation study

An excess long-term mortality has been observed in patients who were discharged after a community-acquired pneumonia (CAP), even after adjusting for age and comorbidities. We aimed to derive and validate a clinical score to predict long-term mortality in patients with CAP discharged from a general ward. In this retrospective observational study, we derived a clinical risk score from 315 CAP patients discharged from the Internal Medicine ward of Cuneo Hospital, Italy, in 2015-2016 (derivation cohort), which was validated in a cohort of 276 patients discharged from the pneumology service of the Barakaldo Hospital, Spain, from 2015 to 2017, and from two internal medicine wards at the Turin University and Cuneo Hospital, Italy, in 2017. The main outcome was the 18-month follow-up all-cause death. Cox multivariate analysis was used to identify the predictive variables and develop the clinical risk score in the derivation cohort, which we applied in the validation cohort. In the derivation cohort (median age: 79 years, 54% males, median CURB-65 = 2), 18-month mortality was 32%, and 18% in the validation cohort (median age 76 years, 55% males, median CURB-65 = 2). Cox multivariate analysis identified the red blood cell distribution width (RDW), temperature, altered mental status, and Charlson Comorbidity Index as independent predictors. The derived score showed good discrimination (c-index 0.76, 95% CI 0.70-0.81; and 0.83, 95% CI 0.78-0.87, in the derivation and validation cohort, respectively), and calibration. We derived and validated a simple clinical score including RDW, to predict long-term mortality in patients discharged for CAP from a general ward.

Red cell distribution width predicts mid-term prognosis in patients hospitalized with acute heart failure: the RDW in Acute Heart Failure (RE-AHF) study

The aim of the study was to evaluate the prognostic role of red cell distribution width (RDW) in a broad population of patients hospitalized for acute heart failure (AHF). In a retrospective cohort observational study, 451 consecutive patients discharged for AHF were categorized in patients with low RDW (≤ 14.8%) and high RDW (> 14.8%). The rates of death from all causes or of hospital readmission for worsening heart failure and death were determined after a median follow-up of 18 months. The overall population has a median age of 80 years (IQR 72-85), 235 patients (52%) were males. Patients with a higher RDW have more comorbidities and a higher Charlson Index. At follow-up, 200 patients (44%) had died and 247 (54%) had died or were readmitted for HF: in the cohort with low RDW, 70 patients (36.4%) had died, whereas in the cohort with high RDW, 165 patients (63.7%) had died: the unadjusted risk ratio of patients with high RDW was 2.03 (log-rank test: p < 0.0001). In a multivariate Cox regression model, the hazard ratio for death from any cause in the 'high RDW' cohort is 1.73 (95% confidence interval 1.2-2.48; p = 0.003); the RDW adds prognostic information beyond that provided by conventional predictors, including age; etiology of HF; anemia; hyponatremia; estimated glomerular filtration rate; NT-proBNP levels; Charlson comorbidity score, atrial fibrillation, functional status, therapy with renin-angiotensin-aldosterone system inhibitors, beta-blockers. RDW is a powerful marker of worse long-term outcomes in patients with AHF, and its prognostic value is maintained beyond that provided by other well-established risk factors or biomarkers.

Characteristics and management of pyogenic liver abscess: A European experience

Pyogenic liver abscess (PLA) are space-occupying lesions in the liver associated with high morbidity and mortality. The aim of this study is to review an Italian hospital experience in epidemiological, clinical patterns, and management of PLA.We performed a retrospective, descriptive case series at a single center assessing demographic characteristics, presentation patterns, etiological factors, microbiological etiology, and management for patients treated for PLA between 2000 and 2016.Around 109 patients were identified. The majority of patients presented with fever (73%); right upper abdominal pain in 63.3%, vomiting and nausea in 28.4%. The most common laboratory abnormality among included items was increased C-reactive protein and fibrinogen blood levels, respectively, in 98% and 93.9% of cases. Abdominal ultrasound was the diagnostic investigation in 42.4% of cases; CT scan and MR imaging were performed in 51.1% and 3.3% of cases respectively. We observed blood or pus culture study in 99 cases of which only 53.5% came with positive microbial reports. The most common organism identified was Escherichia coli (26.5%), followed by Streptococcus spp (13.2%). Early antibiotic treatment started on all patients and 66.7% of cases required different approaches, Ultrasound or CT-guided needle aspiration of PLA was performed in 13 patients (11%) and percutaneous abscess drainage was performed on 72 patients (67%).PLA is a diagnostically challenging problem due to nonspecific presenting characteristics. The microbiological yield identified was a typical European spectrum with a preponderance of Escherichia coli infections. Once recognized, percutaneous drainage and antibiotic treatment are the mainstay of management for PLA.

A complicated case of pulmonary embolism in a patient with renal failure

We describe a case of pulmonary embolism with instable hemodynamics in a patient with renal failure; the case is complicated by heparin-induced thrombocytopenia (HIT). Renal failure has a high prevalence in hospitalized patients and is a restriction on administration of low molecular weight heparins (LMWH) and fondaparinux. HIT is a potentially life-threatening complication, therefore a precocious diagnosis is essential. Therapy consists in the immediate stop of heparin’s administration and in the administration of non-heparin antithrombotic drugs.

Hepatitis C-associated osteosclerosis: a new case with long-term follow-up and a review of the literature

Hepatitis C-associated osteosclerosis (HCAO) is an uncommon condition characterized by increased bone density, skeletal pain and elevated bone formation markers. Since 1992, only 17 cases have been reported. We herein describe the case of a 61-year-old woman affected by severe pain involving the lower limbs. The laboratory data showed an elevated serum alkaline phosphatase level, and the patient was found to be seropositive for hepatitis C virus infection. In addition, an X-ray skeleton survey showed marked cortical thickening of both femurs and tibias, and a whole-body bone scan revealed an increased cortical radionuclide uptake in the involved bones. These findings were consistent with a diagnosis of HCAO. In this report, we discuss the patient's clinical course over 16 years and, for the first time, show a normalized radioisotope uptake on bone scanning 10 years after the diagnosis.

Epidemiology, clinical-treatment patterns and outcome in 256 hepatocellular carcinoma cases

AIM: To analyze the epidemiology, clinical characteristics, treatment patterns and outcome in hepatocellular carcinoma (HCC) patients.

METHODS: We analyzed clinical, pathological and therapeutic data from 256 consecutive patients, examined at S. Croce Hospital in Cuneo-Piedmont, with a diagnosis of HCC between 30^th June 2000 and 1^st July 2010. We analyzed the hospital imaging database and examined all medical records, including the diagnosis code for HCC (155.0 according to the ICD-9M classification system), both for inpatients and outpatients, and discovered 576 relevant clinical records. After the exclusion of reports relating to multiple admissions for the same patient, we identified 282 HCC patients. Moreover, from this HCC series, we excluded 26 patients: 1 patient because of an alternative final diagnosis, 8 patients because of a lack of complete clinical data in the medical record and 17 patients because they were admitted to different health care facilities, leaving 256 HCC patients. To highlight possible changes in HCC patterns over the ten-year period, we split the population into two five-year groups, according to the diagnosis period: 30^th June 2000-30^th June 2005 and 1^st July 2005-1^st July 2010. Patients underwent a 6-mo follow up.

RESULTS: Two hundred and fifty-six HCC patients were included (male/female 182/74; mean age 70 years), 133 in the first period and 123 in the second. Hepatitis C virus (HCV) infection was the most common HCC risk factor (54.1% in the first period, 50.4% in the second; P = 0.63); in the first period, 21.8% of patients were alcoholics and 15.5% were alcoholics in the second period (P > 0.05); the non-viral/non-alcoholic etiology rate was 3.7% in the first period and 20.3% in the second period (P < 0.001). Child class A patients increased significantly in the second period (P < 0.001). Adjusting for age, gender and etiology, there was a significant increase in HCC surveillance during the second period (P = 0.01). Differences between the two periods were seen in tumor parameters: there was an increase in the number of unifocal HCC patients, from 53 to 69 (P = 0.01), as well as an increase in the number of cases where the HCC was < 3 cm [from 22 to 37 (P = 0.01)]. The combined incidence of stage Barcelona Clinic Liver Cancer 0 (very-early) and A (early) HCC was 46 (34.6%) between 2000-2005, increasing to 62 (50.4%) between 2005-2010 (P = 0.01). Of the patients, 62.4% underwent specific treatment in the first group, which increased to 90.2% in the second group (P < 0.001). Diagnosis period (P < 0.01), Barcelona-Clinic Liver Cancer stage (P < 0.01) and treatment per se (P < 0.05) were predictors of better prognosis; surveillance was not related to survival (P = 0.20).

CONCLUSION: This study showed that, between 2000-2005 and 2005-2010, the number of HCV-related HCC decreased, non-viral/non alcoholic etiologies increased and of surveillance programs were more frequently applied.

Management of hepatocellular carcinoma: international guidelines

Hepatocellular carcinoma (HCC) is a major health problem worldwide. The incidence of HCC is increasing in Europe and in the United States. HCC is currently the leading cause of death among cirrhotic patients. Cirrhosis is the strongest and the most common risk factor for HCC. Surveillance for HCC is widely practiced and can be recommended for certain at-risk groups. Among serological screening test, alpha-fetoprotein (AFP) is the best known (cut-off 20 ng/mL, sensitivity 60%, specificity 91%). The radiological screening test most widely used is ultrasonography (sensitivity 65—80%, specificity >90%). The tests used to diagnose HCC include radiology, biopsy and AFP. Detection of hepatic mass within a cirrhotic liver is highly suspicious of HCC. If AFP is greater than 200 ng/mL and the radiological appearance of the mass is suggestive for HCC, the likelihood that the lesion is HCC is high. The Barcelona-Clinic-Liver-Cancer staging system identifies patients with early HCC who may benefit from curative therapies, those at intermediate or advanced disease stage who may benefit from palliative treatments, as well as those at end-stage with a very poor life expectancy. Today many patients are diagnosed at an early stage. The therapies that offer a high rate of complete responses and potential cure are surgical resection, transplantation and percutaneous ablation. Among non-curative therapies the only one that has been shown to positively impact survival is transarterial chemoembolization. Several steps have to be taken to improve effectiveness of HCC therapy. These include patient education on risk factors for HCC and implementation of screening programs, increasing the number of patients diagnosed in early stage.

Early stratification of patients with chest pain and suspected acute coronary syndrome in the Emergency Department

AIM

The aim of this study was to investigate the accuracy of a critical pathway in the early stratification and management of patients with chest pain and suspected acute coronary syndrome (ACS) in the Emergency Department (ED).

METHODS

An observational study was performed enrolling all patients with non-traumatic chest pain and suspected ACS who presented during a one-year period in the ED, where a critical pathway with five-level risk stratification, based on risk factors, characteristics of pain and ECG, was implemented. Patients were prospectively evaluated for rates of death, unstable angina, myocardial infarction or revascularization procedure occurring during admission or in the 30 days following discharge from the ED. Receiver-Operating Characteristics (ROC) curve was used to measure the accuracy of the stratification method.

RESULTS

Overall, 1813 patients were enrolled: 475 patients (26.1%, 95% CI: 24.0-28.1 ) were admitted and 1338 (73.8%, 95% CI: 71.7-75.8) were discharged. Main outcomes occurred in 233 (49.9%, 95% CI: 47.5-52.2) of patients admitted and in 6 (0.4%, 95% CI: 0.06-0.7) of those discharged. The risk stratification system showed a good accuracy with an AUC-ROC curve of 0.90 (95% CI: 0.88-0.93). A total of 1541 (85%) patients were managed according to critical pathway. Adverse events were significantly fewer in patients discharged according to pathway criteria than in those who were not (0.27% vs. 1.37%, difference: 1.1% CI 95%: 0.06-2.1), without significant increase of inappropriate admissions.

CONCLUSION

A critical pathway, based on clinical and ECG features, is a safe and accurate tool to stratify and manage the patients with non-traumatic chest pain and suspected ACS in the ED.

Primary hepatic carcinoid: A case report and literature review

Carcinoids are tumors derived from neuroendocrine cells and often produce functional peptide hormones. Approximately 54.5% arise in the gastrointestinal tract and frequently metastasize to the liver. Primary hepatic carcinoid tumors (PHCT) are extremely rare; only 95 cases have been reported. A 65-year-old man came to our attention due to occasional ultrasound findings in absence of clinical manifestations. His previous medical history, since 2003, included an echotomography of the dishomogeneous parenchymal area but no focal lesions. A computed tomography scan performed in 2005 showed an enhanced pseudonodular-like lesion of about 2 cm. Cholangio-magnetic resonance imaging identified the lesion as a possible cholangiocarcinoma. No positive findings were obtained with positron emission tomography. Histology suggested a secondary localization in the liver caused by a low-grade malignant neuroendocrine tumor. Immunohistochemistry was positive for anti chromogranin antibodies, Ki67 antibodies and synaptophysin. Octreoscan scintigraphy indicated intense activity in the lesion. Endoscopic investigations were performed to exclude the presence of extrahepatic neoplasms. Diagnosis of PHCT was established. The patient underwent left hepatectomy, followed by hormone therapy with sandostatine LAR. Two months after surgery he had a lymph nodal relapse along the celiac trunk and caudate lobe, which was histologically confirmed. The postoperative clinical course was uneventful, with a negative follow-up for hematochemical, clinical and radiological investigations at 18 mo post-surgery. Diagnosis of PHCT is based principally on the histopathological confirmation of a carcinoid tumor and the exclusion of a non-hepatic primary tumor. Surgical resection is the recommended primary treatment for PHCT. Recurrence rate and survival rate in patients treated with resection were 18% and 74%, respectively.

Vertebroplasty in the treatment of osteoporosis vertebral fractures: report on 52 cases

BACKGROUND

Percutaneous vertebroplasty (PV) is largely employed in vertebral body compression fractures (VCF).

PURPOSE

To evaluate the efficacy of PV on pain relief and functional status, and its complications rate.

MATERIALS AND METHODS

A prospective observational study was conducted by the Division of Internal Medicine of St. Croce and Carle Hospital.

INCLUSION CRITERIA

Diagnosis of osteoporosis, intense back pain, unresponsive to conservative treatment, associated with radiological evidence of recent VCF. Pain control and functional improvement were respectively assessed using Visual Analogue Scale (VAS) and Activity of Daily Living scale (ADL) on admission, 24 h after PV and at follow-up. PV complications were detected by an immediate computed tomography (CT) scan on the vertebra treated as well as the vertebrae above and below the treated level(s) and by CT chest scan to exclude pulmonary emboli. A magnetic resonance imaging (MRI) follow-up at 6 or 12 months was performed.

RESULTS

Fifty-two (46 with primary osteoporosis) patients were enrolled (mean age 73.18 yr, range 44-92). Median follow-up was 20.4 months (range 6-24). Treated vertebrae were 124. VAS, mean value was 9.05 (range 6-10) before treatment, 5.95 (range 2-8) at 24 h after PV and 4.94 (range 2-9) at follow-up (p<0.001). Before PV, 18 patients (34.6%) were functionally impaired vs 8 patients (15.3%) at follow-up (p<0.003). Control MRI evidenced 9 (17.3%) new VCF adjacent and 13 (25%) non-adjacent to treated vertebras. There was one case of discitis. Seven cases (13%) of cement leakage in para-vertebral space were observed.

CONCLUSION

PV is safe and effective in immediate pain reduction and functional improvement and at a median term follow-up.