Long-term Sonographic and Serological Follow-up of Inactive Echinococcal Cysts of the Liver: Hints for a “Watch-and-Wait” Approach

Abstract

Human cystic echinococcosis is a chronic, complex and neglected infection. Its clinical management has evolved over decades without adequate evaluation of efficacy. Recent expert opinion recommends that uncomplicated inactive cysts of the liver should be left untreated and solely monitored over time (“watch-and-wait” approach). However, clinical data supporting this approach are still scant and published mostly as conference proceedings. In this study, we report our experience with long-term sonographic and serological follow-up of inactive cysts of the liver. From March 1994 to October 2013, 38 patients with 47 liver cysts, diagnosed as inactive without any previous treatment history, were followed with ultrasound and serology at 6–12 months intervals for a period of at least 24 months (median follow-up 51.95 months) in our outpatient clinic. In 97.4% of patients, the cysts remained inactive over time and in only one case was reactivation of the cyst detected. No complications occurred during the time of monitoring. During follow-up, serology tests for CE were negative at diagnosis or became negative in 74.1% and were positive or became positive in 25.9% of cases. Patients with inactive cysts on ultrasound but positive serological tests were also investigated by CT scan (chest and abdomen) to rule out extra-hepatic cyst localization. This study confirms the importance of a stage-specific approach to the management of cystic echinococcosis and supports the use of a monitoring-only approach to inactive, uncomplicated cysts of the liver. It also confirms that serology plays only an ancillary role in the clinical management of these patients, compared to ultrasound and other imaging techniques. The implications of these findings for clinical management and natural history of cystic echinococcosis are discussed.

Factors Influencing the Serological Response in Hepatic Echinococcus granulosus Infection

“…Specific antibodies may be detectable for years in the presence of stably inactive cysts and even after radical surgery and do not imply the presence of active infection. [16][17][18][19] As a result, clinicians with little experience with this disease infer that positive serology always means presence of active infection, a wrong assumption often resulting in unnecessary treatment, with attendant side effects, cost, and patient (and physician) anxiety. A good understanding of the behavior of serology and its influencing variables, beyond stage of cysts, is crucial for the diagnosis and clinical management of CE, and allows clinicians to evaluate serology results in the context of each patient's condition.…”

Treatment of Hepatic Cystic Echinococcosis in Patients from the Southeastern Rhodope Region of Bulgaria in 2004–2013: Comparison of Current Practices with Expert Recommendations

“…12,13 Uncomplicated inactive CE4 and CE5 cysts do not have to be treated but only followed over time with US. 2,14 Despite the availability of the WHO-IWGE classification as a guidance for treatment, allowing a rational, comparable, and safe approach to CE, an online survey conducted in 2014 on the treatment options that clinicians around the world would choose in five clinical cases of CE found not only extremely heterogeneous managements of the same cases but also a *Address correspondence to Marin Muhtarov, Gastroenterology Ward, Multi-Profile Hospital for Active Treatment "Kardzhali," 19 Trakya Boulevard, 6600 Kardzhali, Bulgaria. E-mail: mukhtarov@ abv.bg worrying number of practices that are either unsafe or not recommended.…”

Costs Associated with Surgically Treated Cases of Abdominal Cystic Echinococcosis: A Single Center's Experience from 2008 to 2014, Pavia, Italy

“…13 In the present study, considering the median values of each cost item (hospitalization, intervention, procedures, and administrative cost), the largest contributors to a patient's total cost were the duration of the hospital stay and the length of the surgical intervention, equating to 47% and 32% of the total cost, respectively. The patient with the highest overall cost had a prolonged hospital stay (25 days) due to the presence of extra-hepatic cysts and the need for a longer observation period.…”