Sclerotherapy with tetracycline hydrochloride (HCL) solution in treatment of solitary hepatic cyst in childhood

Transcription

1 Sclerotherapy with tetracycline hydrochloride (HCL) solution in treatment of solitary hepatic cyst in childhood Poster No.: C-1906 Congress: ECR 2010 Type: Educational Exhibit Topic: Interventional Radiology Authors: G. Fabrizzi, C. Lanza, V. Bolli, G. Pieroni; Ancona/IT Keywords: hepatic cyst, tetracycline, sclerotherapy DOI: /ecr2010/C-1906 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 8

2 Learning objectives To describe a new treatment of symptomatic hepatic cyst in childhood: sclerotherapy with tetracycline hydrochloride (HCL) solution. To outline the advantages of this technique. To describe results of the method based on a series of 11 patients. Background Simple cysts are formed from the biliary epithelium and do not communicate with the bile ducts. Their diameter varies from a few millimeters to several centimeters. Although they usually remain asymptomatic, their growth may induce clinical symptoms with local compression. The most frequent signs and symptoms in such cases are discomfort on pain and a palpable abdominal mass [1,3]. Patients may also develop dyspnea, early satiety, swelling of the lower limbs owing to caval compression, and portal hypertension on jaundice [4]. Treatment of symptomatic hepatic cyst is problematic and controversial [5,6]. Surgery has been the traditional therapy, but it carries a high morbidity rate [7-10]. Percutaneous aspiration alone is only transiently effective [11]. The combination of aspiration and sclerotherapy has provided good results [12-16]. A number of sclerosing agents have been used in the past. Recently, tetracycline was successfully tested by using the minocycline hydrochloride form in the treatment of a simple symptomatic biliary cyst in adult [17-18]. Imaging findings OR Procedure details We treated 11 children (4 girl and 7 boys; mean age 5 years old) with large solitary hepatic cyst with sclerotherapy by one-shot injection of tetracycline HCL solution. After antiseptic preparation of the skin and local anesthesia with lidocaine, the cyst was punctured with a 21-gauge Chiba needle. The puncture site, needle angle, and depth were chosen at real-time US imaging. After aspiration of 10 cc of the cyst content, the cyst was opacified by injecting the same volume of iopamidol, a non ionic contrast agent, under fluoroscopic guide to check (fig.3) for the absence of communication between the cyst and the biliary tree and to test for the absence of leak into the peritoneal cavity. After that 200 mg of tetracycline HCL solution (5%) was injected into the cystic cavity. Page 2 of 8

3 Although we traversed normal hepatic parenchyma en route to the cyst to avoid leakage of tetracycline HCL, we waited 5-10 minutes after tetracycline injection to remove the needle. The tetracycline HCL solution was not aspirated before needle removal and remained in the cyst. This injection was performed only once. Ultrasonography changes were assessed 1, 3, 6 and 12 months after the procedure. No complication was observed postoperatively. Patients were dismissed from hospital after 4 days. Complete regression was found at 3 months US and MR examination (fig.4). Images for this section: Fig. 1: Fig.1 Ultrasound image show a large hepatic cyst Page 3 of 8

4 Fig. 2: Fig 2: MR axial T2 image show a hyperintense hepatic lesion Page 4 of 8

5 Fig. 3: Fig.3: Fluoroscopic check Page 5 of 8

6 Fig. 4: Fig.4: MR T2 axial image:on MR examination complete regression was found at 3 months. Page 6 of 8

7 Conclusion Intracystic instillation of tetracycline HCL is an effective and safe technique and may become the first choice therapy for benign hepatic cysts. The one-shot technique under ultrasound guidance prevents the risk of major complications, reduces the likelihood of failure and is inexpensive; furthermore, it significantly reduces procedure time and is better tolerated by patients. On the basis of the clinical and dimensional results obtained, percutaneous sclerotherapy of hepatic cysts can be recommended as the treatment of choice and as a valid alternative to laparoscopy in pediatric patients. Personal Information References 1. Cellier CC, Cuenod CA, Deslandes P, Auroux J, Landi B, Siauve N, Barbier JP, Frija G. Symptomatic hepatic cysts: treatment with single-shot injection of minocycline hydrocloridre. Radiology 1998;206: Gaines PA, Sampson MA. The prevalence and characterization of simple hepatic cysts by ultrasound examination. Br J Radiol 1989; 62: Vauthey JN, Maddern GJ, Blumgant LH. Adult polycystic disease of the liver. Br J Sung 1991; 78: Lerner ME, Roshkow JE, Smithline A, Ng C. Polycystic liver disease with obstructive jaundice: treatment with ultrasound guided cyst aspiration. Gastnointest Radiol 1992; 17: Tunnage RH, Eckhausen FE, Knol JA, Thompson NW. Therapeutic dilemmas in patients with symptomatic polycystic liver disease. Am Sung 1988; 54: Furuta T, Yoshida Y, Saku M, et at. Treatment of symptomatic non-parasitic liver cyst: surgical treatment versus alcohol injection therapy. HPB Sung 1990; 2: Sanchez H, Gagner M, Rossi RL, et al. Surgical management of parasitic cystic liver disease. Am J Sung 1991# 161: Newman KD, Tomes ye, Rakela J, Nagonney DM. Treatment of highly symptomatic polycystic liver disease. Ann Sung 1990; 212: Starzl TE, ReyesJ, Tzakis A, Mieles L, Todo I, Gordon R. Liver transplantation for polycystic liver disease. Arch Sung 1990;125: Monino M, De Giuli M, Festa V, Ganrone C. Laparoscopic management of symptomatic nonparasitic cysts of the liver: indications and results. Ann Sung 1994; 219: Page 7 of 8

8 11. Saini S, Mueller PR, Fennucci. JTJn, Simeone JF, Wittembeng J, Butch RJ. Percutaneous aspiration of hepatic cysts does not provide definitive therapy. AJR 1983; 141: Bean WJ, Rodan BA. Hepatic cysts: treatment with alcohol. AJR 1985; 144: Goldstein HM, Carlyle DR, Nelson RS. Treatment of symptomatic hepatic cyst by percutaneous instillation of Pantopaque. AJR 1976; 127: vansonnenbeng E, WroblickaTh D'Agostino HB, et al. Symptomatic hepatic cysts: percutaneous drainage and sclerosis. Radiology 1994; 190: Kainaluoma MI, Leinonen A, Stahlberg M,Paivansalo M, Kiviniemi H, Siniluoto T. Percutaneous aspiration and alcohol sclerotherapy for symptomatic hepatic cysts. Ann Sung 1989; 210: Andersson R, Jeppsson B, Lundenquist A, Bengmank S. Alcohol sclerotherapy of nonparasitic cysts of the liver. Br J Sung 1989;76: Rubinson RM, Bolooki H. Intrapleural tetracicline for control of malignant pleural effusion. South MedJ 1972; 65: Hagiwara H, Kasahara A, Hayashi N, et al. Successful treatment of a hepatic cyst by one shot instillation of minocycline chloride. Gastroenterology 1992; 103: Page 8 of 8