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Pancreatic Neoplasms: HELP
Articles by Roberto Girelli
Based on 22 articles published since 2010
(Why 22 articles?)
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Between 2010 and 2020, R. Girelli wrote the following 22 articles about Pancreatic Neoplasms.
 
+ Citations + Abstracts
1 Editorial Percutaneous ablation of pancreatic cancer. 2016

D'Onofrio, Mirko / Ciaravino, Valentina / De Robertis, Riccardo / Barbi, Emilio / Salvia, Roberto / Girelli, Roberto / Paiella, Salvatore / Gasparini, Camilla / Cardobi, Nicolò / Bassi, Claudio. ·Mirko D'Onofrio, Valentina Ciaravino, Riccardo De Robertis, Camilla Gasparini, Nicolò Cardobi, Department of Radiology, G.B. Rossi Hospital, University of Verona, 37134 Verona, Italy. ·World J Gastroenterol · Pubmed #27956791.

ABSTRACT: Pancreatic ductal adenocarcinoma is a highly aggressive tumor with an overall 5-year survival rate of less than 5%. Prognosis and treatment depend on whether the tumor is resectable or not, which mostly depends on how quickly the diagnosis is made. Chemotherapy and radiotherapy can be both used in cases of non-resectable pancreatic cancer. In cases of pancreatic neoplasm that is locally advanced, non-resectable, but non-metastatic, it is possible to apply percutaneous treatments that are able to induce tumor cytoreduction. The aim of this article will be to describe the multiple currently available treatment techniques (radiofrequency ablation, microwave ablation, cryoablation, and irreversible electroporation), their results, and their possible complications, with the aid of a literature review.

2 Editorial Radiofrequency ablation of locally advanced pancreatic adenocarcinoma: an overview. 2010

D'Onofrio, Mirko / Barbi, Emilio / Girelli, Roberto / Martone, Enrico / Gallotti, Anna / Salvia, Roberto / Martini, Paolo-Tinazzi / Bassi, Claudio / Pederzoli, Paolo / Pozzi Mucelli, Roberto. ·Department of Radiology, University Hospital G.B. Rossi, University of Verona, Piazzale L.A. Scuro 10, Verona 37134, Italy. mirko.donofrio@univr.it ·World J Gastroenterol · Pubmed #20653055.

ABSTRACT: Radiofrequency ablation (RFA) of pancreatic neoplasms is restricted to locally advanced, non-resectable but non-metastatic tumors. RFA of pancreatic tumors is nowadays an ultrasound-guided procedure performed during laparotomy in open surgery. Intraoperative ultrasound covers the mandatory role of staging, evaluation of feasibility, guidance and monitoring of the procedure. Different types of needle can be used. The first aim in the evaluation of RFA as a treatment for locally advanced pancreatic ductal adenocarcinoma, in order of evaluation but not of importance, is to determine the feasibility of the procedure. The second aim is to establish the effect of RFA on tumoral mass in terms of necrosis and cytoreduction. The most important aim, third in order of evaluation, is the potential improvement of quality of life and survival rate. Nowadays, only a few studies assess the feasibility of the procedure. The present paper is an overview of RFA for pancreatic adenocarcinoma.

3 Review Role of local ablative techniques (Radiofrequency ablation and Irreversible Electroporation) in the treatment of pancreatic cancer. 2016

Paiella, Salvatore / Salvia, Roberto / Girelli, Roberto / Frigerio, Isabella / Giardino, Alessandro / D'Onofrio, Mirko / De Marchi, Giulia / Bassi, Claudio. ·General and Pancreatic Surgery Department, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro 10, 37134, Verona, Italy. · Pancreatic Surgical Unit, Casa di Cura Pederzoli, Peschiera Del Garda, Verona, Italy. · Radiology Department, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy. · Gastroenterology B Department, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy. · General and Pancreatic Surgery Department, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro 10, 37134, Verona, Italy. Claudio.bassi@univr.it. ·Updates Surg · Pubmed #27535401.

ABSTRACT: Thanks to continuous research and investment in technology, the ablation of tumors has become common. Through the application of different types of energy is possible to induce cellular injury of the neoplastic tissue, leading to cellular death. Radiofrequency ablation (RFA) and irreversible electroporation (IRE) represent the most applied ablative techniques on pancreatic cancer. RFA and IRE, causing necrosis and apoptosis of neoplastic cells, are able to destroy neoplastic tissue, to drastically modify the neoplastic microenvironment and, possibly, to stimulate both directly and indirectly the anti-tumor immune system. This article provides part of our experience with the application of RFA and IRE on pancreatic adenocarcinoma (PDAC).

4 Review Uncommon presentations of common pancreatic neoplasms: a pictorial essay. 2015

D'Onofrio, Mirko / De Robertis, Riccardo / Capelli, Paola / Tinazzi Martini, Paolo / Crosara, Stefano / Gobbo, Stefano / Butturini, Giovanni / Salvia, Roberto / Barbi, Emilio / Girelli, Roberto / Bassi, Claudio / Pederzoli, Paolo. ·Department of Radiology, G.B. Rossi Hospital, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy, mirko.donofrio@univr.it. ·Abdom Imaging · Pubmed #25772002.

ABSTRACT: Pancreatic neoplasms are a wide group of solid and cystic lesions with different and often characteristic imaging features, clinical presentations, and management. Among solid tumors, ductal adenocarcinoma is the most common: it arises from exocrine pancreas, comprises about 90% of all pancreatic neoplasms, and generally has a bad prognosis; its therapeutic management must be multidisciplinary, involving surgeons, oncologists, gastroenterologists, radiologists, and radiotherapists. The second most common solid pancreatic neoplasms are neuroendocrine tumors: they can be divided into functioning or non-functioning and present different degrees of malignancy. Cystic pancreatic neoplasms comprise serous neoplasms, which are almost always benign, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms, which can vary from benign to frankly malignant lesions, and solid pseudopapillary tumors. Other pancreatic neoplasms, such as lymphoma, metastases, or pancreatoblastoma, are rarely seen in clinical practice and have different and sometimes controversial managements. Rare clinical presentations and imaging appearance of the most common pancreatic neoplasms, both solid and cystic, are more frequently seen and clinically relevant than rare pancreatic tumors; their pathologic and radiologic appearances must be known to improve their management. The purpose of this paper is to present some rare or uncommon clinical and radiological presentations of common pancreatic neoplasms providing examples of multi-modality imaging approach with pathologic correlations, thus describing the histopathological bases that can explain the peculiar imaging features, in order to avoid relevant misdiagnosis and to improve lesion management.

5 Review Pancreatic intraductal papillary mucinous neoplasm invading the duodenum: a case report and a review of the literature. 2014

DʼOnofrio, Mirko / Tinazzi Martini, Paolo / De Robertis, Riccardo / Pregarz, Massimo / Girelli, Roberto / Pederzoli, Paolo / Pozzi Mucelli, Roberto. ·Department of Radiology G.B. Rossi Hospital University of Verona Verona, Italy mirko.donofrio@univr.it Department of Radiology Casa di Cura Pederzoli Peschiera del Garda Verona, Italy Department of Radiology G.B. Rossi Hospital University of Verona Verona, Italy Department of Radiology Casa di Cura Pederzoli Peschiera del Garda Verona, Italy Department of Surgery Casa di Cura Pederzoli Peschiera del GardaVerona, Italy Department of Radiology G.B. Rossi Hospital University of Verona Verona, Italy. ·Pancreas · Pubmed #24622089.

ABSTRACT: -- No abstract --

6 Clinical Trial Feasibility and safety of radiofrequency ablation for locally advanced pancreatic cancer. 2010

Girelli, R / Frigerio, I / Salvia, R / Barbi, E / Tinazzi Martini, P / Bassi, C. ·Hepatopancreatobiliary Unit, University of Verona, Verona, Italy. ·Br J Surg · Pubmed #20069610.

ABSTRACT: BACKGROUND: : Radiofrequency ablation (RFA) may be a valuable treatment option for locally advanced pancreatic cancer. The present study examined its feasibility and safety. METHODS: : Fifty patients with locally advanced pancreatic cancer were studied prospectively. Ultrasound-guided RFA was performed during laparotomy. The main outcome measures were short-term morbidity and mortality. RESULTS: : The tumour was located in the pancreatic head or uncinate process in 34 patients and in the body or tail in 16; median diameter was 40 (interquartile range 30-50) mm. RFA was the only treatment in 19 patients. RFA was combined with biliary and gastric bypass in 19 patients, gastric bypass alone in eight, biliary bypass alone in three and pancreaticojejunostomy in one. The 30-day mortality rate was 2 per cent. Abdominal complications occurred in 24 per cent of patients; in half they were directly associated with RFA and treated conservatively. Three patients with surgery-related complications needed reoperation. Reduction of RFA temperature from 105 degrees C to 90 degrees C resulted in a significant reduction in complications (ten versus two of 25 patients; P = 0.028). Median postoperative hospital stay was 10 (range 7-31) days. CONCLUSION: : RFA of locally advanced pancreatic cancer is feasible and relatively well tolerated, with a 24 per cent complication rate.

7 Article Neoadjuvant Treatment in Locally Advanced Pancreatic Cancer (LAPC) Patients with FOLFIRINOX or Gemcitabine NabPaclitaxel: A Single-Center Experience and a Literature Review. 2019

Napolitano, Fabiana / Formisano, Luigi / Giardino, Alessandro / Girelli, Roberto / Servetto, Alberto / Santaniello, Antonio / Foschini, Francesca / Marciano, Roberta / Mozzillo, Eleonora / Carratù, Anna Chiara / Cascetta, Priscilla / De Placido, Pietro / De Placido, Sabino / Bianco, Roberto. ·Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy. · Pancreatic Surgery Unit, Pederzoli Hospital, Peschiera del Garda, 37019 Verona, Italy. · Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy. robianco@unina.it. ·Cancers (Basel) · Pubmed #31337045.

ABSTRACT: The optimal therapeutic strategy for locally advanced pancreatic cancer patients (LAPC) has not yet been established. Our aim is to evaluate how surgery after neoadjuvant treatment with either FOLFIRINOX (FFN) or Gemcitabine-NabPaclitaxel (GemNab) affects the clinical outcome in these patients. LAPC patients treated at our institution were retrospectively analysed to reach this goal. The group characteristics were similar: 35 patients were treated with the FOLFIRINOX regimen and 21 patients with Gemcitabine Nab-Paclitaxel. The number of patients undergoing surgery was 14 in the FFN group (40%) and six in the GemNab group (28.6%). The median Disease-Free Survival (DFS) was 77.10 weeks in the FFN group and 58.65 weeks in the Gem Nab group (

8 Article Technique, safety, and feasibility of EUS-guided radiofrequency ablation in unresectable pancreatic cancer. 2018

Scopelliti, Filippo / Pea, Antonio / Conigliaro, Rita / Butturini, Giovanni / Frigerio, Isabella / Regi, Paolo / Giardino, Alessandro / Bertani, Helga / Paini, Marina / Pederzoli, Paolo / Girelli, Roberto. ·Department of Hepato-Pancreato-Biliary Surgery, Pederzoli Hospital, via Monte Baldo 24, 37019, Peschiera del Garda, VR, Italy. fscopelliti@ospedalepederzoli.it. · Department of Pancreatic Surgery, University of Verona, Verona, Italy. · Gastroenterology and Digestive Endoscopy Unit, Baggiovara Hospital, Modena, Italy. · Department of Hepato-Pancreato-Biliary Surgery, Pederzoli Hospital, via Monte Baldo 24, 37019, Peschiera del Garda, VR, Italy. · Department of General Surgery, Pederzoli Hospital, Peschiera del Garda, Italy. ·Surg Endosc · Pubmed #29766302.

ABSTRACT: BACKGROUND AND AIMS: Radiofrequency ablation (RFA) is a well-recognized local ablative technique applied in the treatment of different solid tumors. Intraoperative RFA has been used for non-metastatic unresectable pancreatic ductal adenocarcinoma (PDAC), showing increased overall survival in retrospective studies. A novel RFA probe has recently been developed, allowing RFA under endoscopic ultrasound (EUS) guidance. Aim of the present study was to assess the feasibility and safety of EUS-guided RFA for unresectable PDACs. METHODS: Patients with unresectable non-metastatic PDAC were included in the study following neoadjuvant chemotherapy. EUS-guided RFA was performed using a novel monopolar 18-gauge electrode with a sharp conical 1 cm tip for energy delivery. Pre- and post-procedural clinical and radiological data were prospectively collected. RESULTS: Ten consecutive patients with unresectable PDAC were enrolled. The procedure was successful in all cases and no major adverse events were observed. A delineated hypodense ablated area within the tumor was observed at the 30-day CT scan in all cases. CONCLUSIONS: EUS-guided RFA is a feasible and safe minimally invasive procedure for patients with unresectable PDAC. Further studies are warranted to demonstrate the impact of EUS-guided RFA on disease progression and overall survival.

9 Article Radiofrequency ablation for locally advanced pancreatic cancer: SMAD4 analysis segregates a responsive subgroup of patients. 2018

Paiella, Salvatore / Malleo, Giuseppe / Cataldo, Ivana / Gasparini, Clizia / De Pastena, Matteo / De Marchi, Giulia / Marchegiani, Giovanni / Rusev, Borislav / Scarpa, Aldo / Girelli, Roberto / Giardino, Alessandro / Frigerio, Isabella / D'Onofrio, Mirko / Secchettin, Erica / Bassi, Claudio / Salvia, Roberto. ·General and Pancreatic Surgery Department, Pancreas Institute, University of Verona Hospital Trust, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134, Verona, Italy. salvatore.paiella@aovr.veneto.it. · General and Pancreatic Surgery Department, Pancreas Institute, University of Verona Hospital Trust, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134, Verona, Italy. · Department of Pathology and Diagnostics, University of Verona Hospital Trust, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134, Verona, Italy. · Gastroenterology B Department, Pancreas Institute, University of Verona Hospital Trust, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134, Verona, Italy. · ARC-Net Research Centre, University of Verona Hospital Trust, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134, Verona, Italy. · HPB Unit, Casa di Cura Pederzoli, Via Monte Baldo, Peschiera del Garda, Verona, Italy. · Department of Radiology, Pancreas Institute, University of Verona Hospital Trust, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134, Verona, Italy. ·Langenbecks Arch Surg · Pubmed #28983662.

ABSTRACT: PURPOSE: SMAD4 mutational status correlates with pancreatic ductal adenocarcinoma (PDAC) failure pattern. We investigated in a subset of locally advanced patients submitted to radiofrequency ablation (RFA) whether the assessment of SMAD4 status is a useful way to select the patients. METHODS: Clinical, radiological, and follow-up details of patients submitted to RFA for locally advanced pancreatic cancer (LAPC), in whom cytohistological material was available at our institution, were retrospectively retrieved. SMAD4 expression was evaluated by immunohistochemistry (IHC) and considered "negative" or "positive." The survival analysis was conducted using Kaplan-Meier and Cox proportional hazards models. RESULTS: The study population consisted of 30 patients. Thirteen patients (43.3%) received RFA upfront, whereas 17 (56.7%) after induction treatments. SMAD4 was mutant in 18 out of 30 patients (60%). The overall estimated post-RFA disease-specific survival (DSS) was 15 months (95% CI 11.64-18.35). The estimated post-RFA DSS of patients with wild-type and mutant SMAD4 was 22 and 12 months, respectively (log-rank p < 0.05). At the multivariate analysis, SMAD4 was the only independent predictor of survival (p = 0.05). The pattern of failure was not associated with SMAD4 status (p = 0.4). CONCLUSIONS: Within patients undergoing RFA for LAPC, SMAD4 analysis could segregate a subgroup of subjects with improved survival, who likely benefited from tumor ablation.

10 Article Immunomodulation after radiofrequency ablation of locally advanced pancreatic cancer by monitoring the immune response in 10 patients. 2017

Giardino, Alessandro / Innamorati, Giulio / Ugel, Stefano / Perbellini, Omar / Girelli, Roberto / Frigerio, Isabella / Regi, Paolo / Scopelliti, Filippo / Butturini, Giovanni / Paiella, Salvatore / Bacchion, Matilde / Bassi, Claudio. ·Hepato-Biliary and Pancreatic Unit, Ospedale Dott. Pederzoli, Peschiera del Garda, VR, Italy. Electronic address: giardinochir@gmail.com. · LURM - Research Laboratory, University of Verona, Italy. · Immunology, University of Verona, Italy. · Ematology Research Laboratory, Vicenza Hospital, VI, Italy. · Hepato-Biliary and Pancreatic Unit, Ospedale Dott. Pederzoli, Peschiera del Garda, VR, Italy. · Pancreas Institute, University of Verona, Italy. · General Surgery Department, Pederzoli Hospital, Peschiera del Garda, VR, Italy. ·Pancreatology · Pubmed #29037917.

ABSTRACT: OBJECTIVE/BACKGROUND: RFA of pancreatic cancer has been demonstrated to be feasible and safe with a positive impact on survival. The aim was to investigate whether an immune reaction is activated after locally advanced pancreatic cancer (LAPC) ablation. METHODS: Peripheral Blood samples were obtained preoperatively and on post-operative days 3-30. Evaluated parameters were: cells [CD4 RESULTS: Ten patients were enrolled. CD4 CONCLUSIONS: This study provides the first evidence of RFA-based immunomodulation in LAPC. We observed a general activation of adaptive response along with a decrease of immunosuppression. Furthermore, most cells showed prolonged activation some weeks after the procedure, suggesting true immunomodulation rather than a normal inflammatory response.

11 Article Downstaging in Stage IV Pancreatic Cancer: A New Population Eligible for Surgery? 2017

Frigerio, Isabella / Regi, Paolo / Giardino, Alessandro / Scopelliti, Filippo / Girelli, Roberto / Bassi, Claudio / Gobbo, Stefano / Martini, Paolo Tinazzi / Capelli, Paola / D'Onofrio, Mirko / Malleo, Giuseppe / Maggino, Laura / Viviani, Elena / Butturini, Giovanni. ·HPB Surgical Unit, Pederzoli Hospital, Verona, Italy. isifrigerio@yahoo.com. · HPB Surgical Unit, Pederzoli Hospital, Verona, Italy. · General Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy. · Department of Pathology, Pederzoli Hospital, Verona, Italy. · Department of Radiology, Pederzoli Hospital, Verona, Italy. · Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy. ·Ann Surg Oncol · Pubmed #28516291.

ABSTRACT: BACKGROUND: Recent papers consider surgery as an option for synchronous liver oligometastatic patients [metastatic pancreatic ductal adenocarcinoma (mPDAC)]. In this study, we present our series of resected mPDACs after neoadjuvant chemotherapy (nCT). PATIENTS AND METHODS: All patients resected after downstaging of mPDAC were included in this study. Downstaging criteria were disappearance of liver metastasis and a decrease in cancer antigen (CA) 19-9. The type and duration of nCT, last nCT surgery interval, histology, morbidity, and mortality were recorded, and overall survival (OS) and disease-free survival (DFS) were analyzed. RESULTS: Overall, 24 of 535 patients (4.5%) observed with mPDAC were included. These patients received gemcitabine alone (5/24), gemcitabine + nanoparticle albumin-bound (nab)-paclitaxel (3/24), and FOLFIRINOX (16/24). Primary tumor size decreased from 31 to 19 mm (p < 0.001), and serum CA19-9 decreased from 596 to 18 U/mL (p < 0.001). In 14/24 patients, the tumor was located in the head. Median interval nCT surgery was 2 months, there were no mortalities, and the postoperative course was uneventful in 34% of cases. Grade B/C pancreatic fistula, postoperative bleeding, and sepsis occurred in 17/4, 4, and 12% of cases, respectively, and reoperation rate was 4%. R0 resection was achieved in 88% of cases, with 17% complete pathological response. Positive nodes were found in 9/24 patients with a median node ratio of 0.37, and OS and DFS was 56 and 27 months, respectively. CONCLUSIONS: Patients with mPDAC who were fully responsive to nCT may be cautiously considered for surgery, with potential benefit in survival compared with palliative chemotherapy alone. This is supported by results of our retrospective study, which is the largest ever reported.

12 Article Pancreatic neuroendocrine neoplasms: Magnetic resonance imaging features according to grade and stage. 2017

De Robertis, Riccardo / Cingarlini, Sara / Tinazzi Martini, Paolo / Ortolani, Silvia / Butturini, Giovanni / Landoni, Luca / Regi, Paolo / Girelli, Roberto / Capelli, Paola / Gobbo, Stefano / Tortora, Giampaolo / Scarpa, Aldo / Pederzoli, Paolo / D'Onofrio, Mirko. ·Riccardo De Robertis, Department of Radiology, Casa di Cura Pederzoli, 37019 Peschiera del Garda, Italy. ·World J Gastroenterol · Pubmed #28127201.

ABSTRACT: AIM: To describe magnetic resonance (MR) imaging features of pancreatic neuroendocrine neoplasms (PanNENs) according to their grade and tumor-nodes-metastases stage by comparing them to histopathology and to determine the accuracy of MR imaging features in predicting their biological behavior. METHODS: This study was approved by our institutional review board; requirement for informed patient consent was waived due to the retrospective nature of the study. Preoperative MR examinations of 55 PanNEN patients (29 men, 26 women; mean age of 57.6 years, range 21-83 years) performed between June 2013 and December 2015 were reviewed. Qualitative and quantitative features were compared between tumor grades and stages determined by histopathological analysis. RESULTS: Ill defined margins were more common in G2-3 and stage III-IV PanNENs than in G1 and low-stage tumors ( CONCLUSION: MR features of PanNENs vary according to their grade of differentiation and their stage at diagnosis and could predict the biological behavior of these tumors.

13 Article Oncocytic Intraductal Papillary Mucinous Neoplasms of the Pancreas: Imaging and Histopathological Findings. 2016

D'Onofrio, Mirko / De Robertis, Riccardo / Tinazzi Martini, Paolo / Capelli, Paola / Gobbo, Stefano / Morana, Giovanni / Demozzi, Emanuele / Marchegiani, Giovanni / Girelli, Roberto / Salvia, Roberto / Bassi, Claudio / Pederzoli, Paolo. ·From the *Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona; †Department of Radiology, Casa di cura Pederzoli, Peschiera del Garda; ‡Department of Pathology, G.B. Rossi Hospital, University of Verona, Verona; §Department of Pathology, Casa di cura Pederzoli, Peschiera del Garda; ∥Department of Radiology, Ca' Foncello Hospital, Treviso; ¶Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona; and #Department of Surgery, Casa di cura Pederzoli, Peschiera del Garda, Italy. ·Pancreas · Pubmed #27518461.

ABSTRACT: OBJECTIVES: To evaluate and correlate computed tomography/magnetic resonance findings and histopathologic features of oncocytic intraductal papillary mucinous neoplasms (O-IPMNs). METHODS: Computed tomography/magnetic resonance examinations and resection specimens of 16 O-IPMNs were retrospectively reviewed. Qualitative and quantitative imaging features were analyzed according to "worrisome features" and "high risk stigmata." Correlations between radiological and histopathological findings were evaluated using Fisher test. RESULTS: Most O-IPMNs (75%) presented as large mixed- or main duct-type lesions (mean size, 56.9 mm; range, 20-180); all branch-duct type lesions were larger than 3 cm. Ten lesions presented main pancreatic duct dilation of 10 mm or greater. Solid enhancing nodules were found in 10 cases. Two lesions presented foci of invasion at histopathologic analysis, the remaining presented high-grade dysplasia. Neither invasive carcinoma nor nodal metastases were found. No significant correlations were found between radiological predictors of malignancy and histopathological features. CONCLUSIONS: Oncocytic tumors are rare subtypes of pancreatic IPMN, whose imaging features are similar to other IPMN subtypes. Imaging predictors of malignancy as large size and huge solid internal nodules are frequently encountered in O-IPMNs; despite this, these features are not correlated with histopathological findings, being probably inapplicable to O-IPMNs.

14 Article C-Reactive Protein and Procalcitonin as Predictors of Postoperative Inflammatory Complications After Pancreatic Surgery. 2016

Giardino, A / Spolverato, G / Regi, P / Frigerio, I / Scopelliti, F / Girelli, R / Pawlik, Z / Pederzoli, P / Bassi, C / Butturini, G. ·Hepato-Pancreato-Biliary Surgery Unit, Casa di Cura Pederzoli, Via Monte Baldo 24, 37019, Peschiera del Garda, VR, Italy. giardinochir@gmail.com. · Hepato-Pancreato-Biliary Surgery Unit, Casa di Cura Pederzoli, Via Monte Baldo 24, 37019, Peschiera del Garda, VR, Italy. · The Johns Hopkins University School of Medicine, Baltimore, MD, USA. · Department of Surgery - Pancreas Institute, University of Verona, Verona, Italy. ·J Gastrointest Surg · Pubmed #27206502.

ABSTRACT: BACKGROUND: The association between postoperative inflammatory markers and risk of complications after pancreaticoduodenectomy (PD) is controversial. We sought to assess the diagnostic value of perioperative C-reactive protein (CRP) and procalcitonin (PCT) levels in the early identification of patients at risk for complications after PD. METHODS: In 2014, 84 patients undergoing elective PD were enrolled in a prospective database. Clinicopathological characteristics, CRP and PCT, as well as short-term outcomes, such as complications and pancreatic fistula, were analyzed. Complications and pancreatic fistula were defined based on the Clavien-Dindo classification and the International Study Group on Pancreatic Fistula (ISGPF) classification, respectively. High CRP and PCT were classified using cut-off values based on ROC curve analysis. RESULTS: The majority (73.8 %) of patients had pancreatic adenocarcinoma. CRP and PCT levels over the first 5 postoperative days (POD) were higher among patients who experienced a complication versus those who did not (p < 0.001). Postoperative CRP and PCT levels were also higher among patients who developed a grade B or C pancreatic fistula (p < 0.05). A CRP concentration >84 mg/l on POD 1 (AUC 0.77) and >127 mg/l on POD 3 (AUC 0.79) was associated with the highest risk of overall complications (OR 6.86 and 9.0, respectively; both p < 0.001). Similarly patients with PCT >0.7 mg/dl on POD 1 (AUC 0.67) were at higher risk of developing a postoperative complication (OR 3.33; p = 0.024). On POD 1, a CRP >92 mg/l (AUC 0.72) and a PCT >0.4 mg/dl (AUC 0.70) were associated with the highest risk of pancreatic fistula (OR 5.63 and 5.62, respectively; both p < 0.05). CONCLUSIONS: CRP and PCT concentration were associated with an increased risk of developing complications and clinical relevant pancreatic fistula after PD. Use of these biomarkers may help identify those patients at highest risk for perioperative morbidity and help guide postoperative management of patients undergoing PD.

15 Article Variation of tumoral marker after radiofrequency ablation of pancreatic adenocarcinoma. 2016

D'Onofrio, Mirko / Barbi, Emilio / Girelli, Roberto / Tinazzi Martini, Paolo / De Robertis, Riccardo / Ciaravino, Valentina / Salvia, Roberto / Butturini, Giovanni / Frigerio, Isabella / Milazzo, Teresa / Crosara, Stefano / Paiella, Salvatore / Pederzoli, Paolo / Bassi, Claudio. ·1 Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy ; 2 Department of Radiology, 3 Department of Surgery, Casa di Cura Dott. Pederzoli, Peschiera del Garda, Verona, Italy ; 4 Department of Surgery, G.B. Rossi Hospital, University of Verona, Verona, Italy. ·J Gastrointest Oncol · Pubmed #27034788.

ABSTRACT: BACKGROUND: To evaluate the correlation between variations of CA 19.9 blood levels and the entity of necrosis at CT after radiofrequency ablation (RFA) of unresectable pancreatic adenocarcinoma. METHODS: In this study, from June 2010 to February 2014, patients with diagnosis of unresectable and not metastatic pancreatic ductal adenocarcinoma, expressing tumor marker CA 19.9, treated with RFA procedure were included. All these patients underwent RFA. CT study was performed 1 week after RFA. The dosage of CA 19.9 levels was performed 1 month after RFA. Features of necrosis at CT, as mean entity, density and necrosis percentages compared to the original lesion, were evaluated and compared by using t-test with CA 19.9 blood levels variations after RFA procedure. RESULTS: In this study were included 51 patients with diagnosis of unresectable and not metastatic pancreatic ductal adenocarcinoma, expressing tumor marker CA 19.9, treated with RFA procedure and with CT study and CA 19.9 available for analysis. After the procedure, CA 19.9 blood levels reduced in 24/51 (47%), remained stable in 10/51 (20%) and increased in 17/51 (33%). In patients with CA 19.9 levels reduced, the tumor marker were reduced less than 20% in 4/24 (17%) and more than 20% in 20/24 (83%); instead the tumor marker were reduced less than 30% in 8/24 (33%) and more than 30% in 16/24 (67%). At CT scan necrotic area density difference was not statistically significant. Also there was no statistically significant difference among the mean area, the mean volume and the mean ablation volume in percentage related to the treated tumor among the three different groups of patients divided depending on the CA 19.9 blood levels. But a tendency to a statistically significant difference was found in comparing the mean percentage of ablation volume between two subgroups of patients with a decrease of CA 19.9 levels with less or more than 20% reduction of tumor markers and between two subgroups with less or more than 30% reduction of CA 19.9 levels. CONCLUSIONS: RFA of unresectable pancreatic adenocarcinoma induces reduction of CA 19.9 blood levels in about half of the cases.

16 Article Pancreatic Neuroendocrine Neoplasms: Clinical Value of Diffusion-Weighted Imaging. 2016

De Robertis, Riccardo / D'Onofrio, Mirko / Zamboni, Giulia / Tinazzi Martini, Paolo / Gobbo, Stefano / Capelli, Paola / Butturini, Giovanni / Girelli, Roberto / Ortolani, Silvia / Cingarlini, Sara / Pederzoli, Paolo / Scarpa, Aldo. ·Department of Radiology, Casa di cura Pederzoli, Peschiera del Garda, Italy. ·Neuroendocrinology · Pubmed #26646652.

ABSTRACT: BACKGROUND/AIMS: Diffusion-weighted imaging (DWI) can depict random motions of water molecules in biological tissues during magnetic resonance (MR) examinations. Few papers have tested its application to pancreatic neuroendocrine neoplasms (PanNENs). The aim of this paper is to assess the clinical value of DWI regarding the identification and characterization of PanNENs and diagnosis of liver metastases. METHODS: Preoperative MR examinations of 30 PanNEN patients were retrospectively reviewed; 30 patients with pathologically proven pancreatic ductal adenocarcinoma (PDAC) were included to compare the imaging features. Qualitative and quantitative MR features were compared between histotypes. A blinded-reader comparison of diagnostic confidence for PanNENs and liver metastases was conducted on randomized image sets. All results were compared with pathological data. RESULTS: PanNEN conspicuity was higher on DW images compared to conventional MR sequences. DWI had higher detection rates for PanNENs than had conventional sequences (93.3 vs. 71.1%). Sharp margins and absence of main pancreatic duct/common bile duct dilation and chronic pancreatitis were more common among PanNENs as compared to PDACs. Arterial iso- or hyperenhancement and portal hyperenhancement were more frequent within PanNENs as compared to PDACs. No differences between histotypes were found for quantitative features. Arterial-phase images had the highest interobserver agreement for the diagnosis of PanNEN (Cohen's κ = 0.667). DWI provided the highest detection rate for liver metastases as well as excellent interobserver agreement for the diagnosis of liver metastases (κ = 0.932), with good accuracy (AUC = 0.879-0.869). CONCLUSION: DWI has clinical value regarding the identification of PanNENs and the diagnosis of liver metastases, while conventional MR sequences are fundamental for their characterization.

17 Article Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). 2016

Jais, B / Rebours, V / Malleo, G / Salvia, R / Fontana, M / Maggino, L / Bassi, C / Manfredi, R / Moran, R / Lennon, A M / Zaheer, A / Wolfgang, C / Hruban, R / Marchegiani, G / Fernández Del Castillo, C / Brugge, W / Ha, Y / Kim, M H / Oh, D / Hirai, I / Kimura, W / Jang, J Y / Kim, S W / Jung, W / Kang, H / Song, S Y / Kang, C M / Lee, W J / Crippa, S / Falconi, M / Gomatos, I / Neoptolemos, J / Milanetto, A C / Sperti, C / Ricci, C / Casadei, R / Bissolati, M / Balzano, G / Frigerio, I / Girelli, R / Delhaye, M / Bernier, B / Wang, H / Jang, K T / Song, D H / Huggett, M T / Oppong, K W / Pererva, L / Kopchak, K V / Del Chiaro, M / Segersvard, R / Lee, L S / Conwell, D / Osvaldt, A / Campos, V / Aguero Garcete, G / Napoleon, B / Matsumoto, I / Shinzeki, M / Bolado, F / Fernandez, J M Urman / Keane, M G / Pereira, S P / Acuna, I Araujo / Vaquero, E C / Angiolini, M R / Zerbi, A / Tang, J / Leong, R W / Faccinetto, A / Morana, G / Petrone, M C / Arcidiacono, P G / Moon, J H / Choi, H J / Gill, R S / Pavey, D / Ouaïssi, M / Sastre, B / Spandre, M / De Angelis, C G / Rios-Vives, M A / Concepcion-Martin, M / Ikeura, T / Okazaki, K / Frulloni, L / Messina, O / Lévy, P. ·Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, France. · The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy. · Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. · Departments of Surgery and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. · Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. · First Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan. · Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. · Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea. · Department of Surgery, Yonsei University College of Medicine, Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea. · Pancreatic Surgery Unit, Department of Surgery, Polytechnic University of Marche Region, Ancona-Torrette, Italy. · NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, UK. · Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, Padua, Italy. · Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy. · Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy. · Hepato-Pancreato-Biliary Unit, Pederzoli Hospital, Peschiera del Garda, Italy. · Department of Gastroenterology, Hepatopancreatology and GI Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium. · Institute of Hepatopancreatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China. · Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. · Department of Pathology, Gyeongsang National University School of Medicine, Jinju, Korea. · Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK. · National Institute of Surgery and Transplantology named after Shalimov, Kiev, Ukraine. · Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden. · Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA. · Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil. · Hôpital Privé Mermoz, Gastroentérologie, Lyon, France. · Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan. · Gastroenterology Department, Hospital de Navarra, Pamplona, Spain. · Department of Gastroenterology and Hepatology, University College Hospital, London, UK. · Department of Gastroenterology, Hospital Clinic, CIBEREHD, IDIBAPS, University of Barcelona, Barcelona, Spain. · Department of Pancreatic Surgery, Humanitas Research Hospital, Rozzano, Milan, Italy. · Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia. · Radiological Department, General Hospital Cá Foncello, Treviso, Italy. · Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute, Milan, Italy. · Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea. · Department of Gastroenterology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia. · Department of Digestive Surgery, Timone Hospital, Marseille, France. · Gastrohepatology Department, San Giovanni Battista Molinette Hospital, University of Turin, Turin, Italy. · Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca-IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain. · The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan. · Department of Medicine, Pancreas Center, University of Verona, Verona, Italy. ·Gut · Pubmed #26045140.

ABSTRACT: OBJECTIVES: Serous cystic neoplasm (SCN) is a cystic neoplasm of the pancreas whose natural history is poorly known. The purpose of the study was to attempt to describe the natural history of SCN, including the specific mortality. DESIGN: Retrospective multinational study including SCN diagnosed between 1990 and 2014. RESULTS: 2622 patients were included. Seventy-four per cent were women, and median age at diagnosis was 58 years (16-99). Patients presented with non-specific abdominal pain (27%), pancreaticobiliary symptoms (9%), diabetes mellitus (5%), other symptoms (4%) and/or were asymptomatic (61%). Fifty-two per cent of patients were operated on during the first year after diagnosis (median size: 40 mm (2-200)), 9% had resection beyond 1 year of follow-up (3 years (1-20), size at diagnosis: 25 mm (4-140)) and 39% had no surgery (3.6 years (1-23), 25.5 mm (1-200)). Surgical indications were (not exclusive) uncertain diagnosis (60%), symptoms (23%), size increase (12%), large size (6%) and adjacent organ compression (5%). In patients followed beyond 1 year (n=1271), size increased in 37% (growth rate: 4 mm/year), was stable in 57% and decreased in 6%. Three serous cystadenocarcinomas were recorded. Postoperative mortality was 0.6% (n=10), and SCN's related mortality was 0.1% (n=1). CONCLUSIONS: After a 3-year follow-up, clinical relevant symptoms occurred in a very small proportion of patients and size slowly increased in less than half. Surgical treatment should be proposed only for diagnosis remaining uncertain after complete workup, significant and related symptoms or exceptionally when exists concern with malignancy. This study supports an initial conservative management in the majority of patients with SCN. TRIAL REGISTRATION NUMBER: IRB 00006477.

18 Article Short term chemotherapy followed by radiofrequency ablation in stage III pancreatic cancer: results from a single center. 2013

Frigerio, Isabella / Girelli, Roberto / Giardino, Alessandro / Regi, Paolo / Salvia, Roberto / Bassi, Claudio. ·Hepato-Pancreato-Biliary Unit, Casa di Cura Pederzoli, Via Monte Baldo 24, Peschiera del Garda, 37019, Verona, Italy; Department of Surgery B, Pancreas Institute, GB Rossi Hospital, University of Verona, Verona, Italy. isifrigerio@yahoo.com. ·J Hepatobiliary Pancreat Sci · Pubmed #23591744.

ABSTRACT: BACKGROUND: Neo-adjuvant chemotherapy (CHT) has gained increasing importance in resectable and borderline resectable pancreatic cancer leading to a better performing surgery when we look at negative resection margins and selection of patients with less aggressive disease. We apply this principle to patients with Stage III (LAC) pancreatic cancer undergoing RFA and try to select patients who may benefit from a local treatment. METHODS: All patients affected by LAC were treated with RFA for a stable disease after a short CHT. Postoperative morbidity and mortality were evaluated together with overall survival (OS) and disease specific survival (DSS). RESULTS: We consecutively treated 57 patients affected by LAC. Median duration of CHT before RFA was 5 months. The postoperative mortality rate was zero. Overall morbidity was 14 % with RFA-related morbidity of 3.5 %. The OS and DSS were 19 months and when compared to a similar population who received RFA as up front treatment, there was no difference. CONCLUSIONS: Our results do not support the adoption of a short CHT as a way to identify patients to treat with RFA with the most benefit. Based on this and by knowing the role of immune modulation after RFA and its specific involvement in pancreatic carcinoma, we can propose RFA as upfront treatment.

19 Article Triple approach strategy for patients with locally advanced pancreatic carcinoma. 2013

Giardino, Alessandro / Girelli, Roberto / Frigerio, Isabella / Regi, Paolo / Cantore, Maurizio / Alessandra, Auriemma / Lusenti, Annita / Salvia, Roberto / Bassi, Claudio / Pederzoli, Paolo. ·Pancreatic Unit, Casa di Cura Pederzoli, Peschiera del Garda (VR), Italy. giardinoalessandro@gmail.com ·HPB (Oxford) · Pubmed #23458679.

ABSTRACT: BACKGROUND: Radiofrequency ablation (RFA) is a relatively new technique, applied to metastatic solid tumours which, in recent studies, has been shown to be feasible and safe on locally advanced pancreatic carcinoma (LAPC). RFA can be combined with radio-chemotherapy (RCT) and intra-arterial plus systemic chemotherapy (IASC). The aim of this study was to investigate the impact on the prognosis of a multimodal approach to LAPC and define the best timing of RFA. METHODS: This is a retrospective observational study of patients who have consecutively undergone RFA associated with multiple adjuvant approaches. RESULTS: Between February 2007 and December 2011, 168 consecutive patients were treated by RFA, of which 107 were eligible for at least 18 months of follow-up. Forty-seven patients (group 1) underwent RFA as an up-front treatment and 60 patients as second treatment (group 2) depending on clinician choice. The median overall survival (OS) of the whole series was 25.6 months: 14.7 months in the group 1 and 25.6 months in the group 2 (P = 0.004). Those patients who received the multimodal treatment (RFA, RCT and IASC-triple approach strategy) had an OS of 34.0 months. CONCLUSIONS: The multimodal approach seems to be feasible and associated with an improved longer survival rate.

20 Article Cystic "feminine" pancreatic neoplasms in men. Do any clinical alterations correlate with these uncommon entities? 2013

Regi, P / Salvia, R / Cena, C / Girelli, R / Frigerio, I / Bassi, C. ·Department of General Surgery, Pancreas Institute, University of Verona, Verona, Italy. paoloregi@tiscali.it ·Int J Surg · Pubmed #23274554.

ABSTRACT: INTRODUCTION: Mucinous cystic neoplasm (MCN) and solid pseudopapillary neoplasm (SPN) of the pancreas are uncommon hormone-related pancreatic tumors (HRPTs) with a clear predominance in young women. This trial aims to investigate the possible association between HRPTs development in males and phenotypic and sex hormone alterations. METHODS: We performed a retrospective analysis of our database between February 1990 and February 2012. Risk factors for sexual dysfunction were considered exclusion criteria. We investigated secondary sexual characteristics development, sex hormone level and overall sexual dysfunction degree according with the International Index of Erectile Function Questionnaire (IIEF). RESULTS: We initially identified 25 patients [(MCN: n = 16 (64%); SPN: n = 9 (36%)]. At follow-up, 5 patients were lost, 8 resulted dead and 3 were excluded according to exclusion criteria. We finally enrolled 9 patients (MCN: n = 5; SPN: n = 4). Puberty occurred within physiological age for 7 patients, whereas it was delayed in 2 cases. Three patients revealed mild to moderate sexual dysfunction, along with low testosterone level in two cases. One patient presented hormonal alteration with a normal IIEF score. DISCUSSION: In this study, the first in literature with similar aim, hormonal and/or sexual dysfunction was present in 4 out of 9 patients affected by HRPT. The rarity of these lesions makes further trials to be needed for reliable conclusions.

21 Article Results of 100 pancreatic radiofrequency ablations in the context of a multimodal strategy for stage III ductal adenocarcinoma. 2013

Girelli, Roberto / Frigerio, Isabella / Giardino, Alessandro / Regi, Paolo / Gobbo, Stefano / Malleo, Giuseppe / Salvia, Roberto / Bassi, Claudio. ·Hepato-Pancreato-Biliary Unit, Pederzoli Hospital, Via Monte Baldo 24, Peschiera del Garda, Italy. ·Langenbecks Arch Surg · Pubmed #23053459.

ABSTRACT: BACKGROUND: Stage III pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis, with the results of chemoradiation being disappointing. Radiofrequency is an ablation technique employed in many unresectable solid tumours, but its application to pancreatic cancer is limited. We report our experience of radiofrequency ablation (RFA) with cytoreductive intent in stage III PDAC. PATIENTS AND METHODS: One hundred consecutive patients affected by stage III PDAC received RFA combined with chemoradiotherapy. Follow-up was planned on a 3-month basis including clinical evaluation, serum markers and computed tomography scan or MRI. Short-term outcomes and survival data were evaluated. RESULTS: Forty-eight patients received upfront RFA, and 52 had associated palliative surgery. Abdominal complications occurred in 24 patients, and in 15 cases, they were related to RFA. The mortality rate was 3 %. At a median follow-up of 12 months, 55 patients had died of disease and four patients due to unknown causes. Nineteen patients are alive with disease progression, and 22 are alive and progression free. CONCLUSIONS: We presented the broadest experience of RFA in stage III PDAC, focusing on the rationale of its application and considering the advanced stage of disease and the cytoreductive purpose of the procedure. The critical aspects of the technique, along with the unexpected results in efficacy, were discussed.

22 Article Combined modality treatment for patients with locally advanced pancreatic adenocarcinoma. 2012

Cantore, M / Girelli, R / Mambrini, A / Frigerio, I / Boz, G / Salvia, R / Giardino, A / Orlandi, M / Auriemma, A / Bassi, C. ·Oncological Department, Carrara Hospital, Carrara, Italy. maurizio.cantore@usl1.toscana.it ·Br J Surg · Pubmed #22648697.

ABSTRACT: BACKGROUND: Radiofrequency ablation (RFA) is an emerging treatment for patients with locally advanced pancreatic carcinoma, and can be combined with radiochemotherapy and intra-arterial plus systemic chemotherapy. METHODS: This observational study compared two groups of patients with locally advanced pancreatic carcinoma treated with either primary RFA (group 1) or RFA following any other primary treatment (group 2). RESULTS: Between February 2007 and May 2010, 107 consecutive patients were treated with RFA. There were 47 patients in group 1 and 60 in group 2. Median overall survival was 25·6 months. Median overall survival was significantly shorter in group 1 than in group 2 (14·7 versus 25·6 months; P = 0·004) Patients treated with RFA, radiochemotherapy and intra-arterial plus systemic chemotherapy (triple-approach strategy) had a median overall survival of 34·0 months. CONCLUSION: RFA after alternative primary treatment was associated with prolonged survival. This was further extended by use of a triple-approach strategy in selected patients. Further evaluation of this approach seems warranted.