Medical treatment versus "Watch and Wait" in the clinical management of CE3b echinococcal cysts of the liver

Abstract

Background: Available treatments for uncomplicated hepatic cystic echinococcosis (CE) include surgery, medical therapy with albendazole (ABZ), percutaneous interventions and the watch-and-wait (WW) approach. Current guidelines indicate that patients with hepatic CE should be assigned to each option based on cyst stage and size, and patient characteristics. However, treatment indications for transitional CE3b cysts are still uncertain. These cysts are the least responsive to non-surgical treatment and often present as indolent, asymptomatic lesions that may not warrant surgery unless complicated. Evidence supporting indications for treatment of this stage is lacking. In the attempt to fill this gap before the implementation of randomized clinical trials, we compared the clinical behavior of single hepatic CE3b cysts in 60 patients followed at the WHO Collaborating Centre for Cystic Echinococcosis of the University of Pavia.

Methods: We analyzed retrospectively data of 60 patients with hepatic CE3b cysts seen at our clinic over 27 years, who either received ABZ or were monitored with WW. Univariate and multivariate analysis were performed to investigate the effect on outcome (inactivation or relapse) of variables such as age, sex, origin, treatment, cyst size and presence of other echinococcal hepatic cysts using a multiple failure Cox proportional hazard model.

Results: ABZ treatment was positively associated with inactivation (p < 0.001), but this was not permanent, and no association was found between therapeutic approach and relapse (p = 0.091). No difference was found in the rate of complications between groups.

Conclusions: In conclusion, our study shows that ABZ treatment induces temporary inactivation of CE3b cysts, while during WW cysts remain stable over time. As the rate of adverse events during periods of ABZ treatment and WW did not differ significantly in the follow-up period considered in this study (median 43 months, IQR 10.7-141.5), expectant management might represent a valuable option for asymptomatic CE3b cysts when strict indication for surgery is absent and patients comply with regular long-term follow-up.

Figure 1

Schematic representation of the natural history of hepatic CE and suggested treatments. Black arrows indicate proposed cyst natural history based on clinical observation (Brunetti E., unpublished). Solid black arrows indicate natural evolution toward inactivation; black dashed arrows indicate evolution of therapy-unresponsive chronic stages. US images: cyst ultrasound classifications according to WHO-IWGE (in bold) and Gharbi [9]. As WHO-IWGE stage CE3b had not been explicitly described by Gharbi it is generally considered type III [10]. Gray boxes: suggested stage-specific approach to uncomplicated hepatic CE [4, 11, 12]. ABZ = Albendazole; PAIR = Puncture, Aspiration, Injection of scolecidal agent, Re-aspiration; PC = Permanent Catheterization.

Figure 2

Patients grouped by clinical management.

Figure 3

Kaplan Meier survival curve of inactivation and relapse.