经皮冷消融联合酒精注射治疗不能切除的肝细胞癌

目的：评价经皮冷消融联合经皮酒精注射(PEI)治疗不能切除的肝细胞癌(HCC)的有效性和安全性。方法：65例HCC患者共105个肿瘤块接受经皮冷消融治疗。冷消融采用cRYOCARE系统，氩气作为冷却剂，共给予2次冷却-复温循环，每次冷却时冷冻刀顶端温度为-180℃。其中36例瘤块直径大于6cm的患者，在冷消融治疗后1～2周接受PEI治疗，每周1次，连续4～6次。结果：在平均随访期为16个月(5～21个月)内，32例(49．2％)无瘤生存，22例(33．8％)生存但有肿瘤复发，其中2例骨转移，3例肺转移，其余17例为肝内复发，但仅有3例是原先冷消融部位复发。在随访1年以上的41例患者中，有32例(78％)迄今仍生存，包括无复发和有复发的病例。8例(12．3％)死于肿瘤复发，3例(4．6％)死于非癌性原因。有CT复查资料的43例中，38例(88．4％)显示肿瘤缩小。冷消融治疗后22例行瘤块活检，除1例外，均显示为坏死性疤痕组织。冷消融治疗前血清甲胎蛋白(AFP)升高的病例中，91．3％在治疗后3～6个月内AFP下降至正常或接近正常。冷消融并发症包括1例发生肝包膜开裂，4例发生一过性血小板降低，2例发生无症状性右侧胸腔积液，2例在原先冷消融部位发生肝脓肿。结论：经皮冷消融为不能手术切除的HCC提供了安全而有效的治疗手段。     

Percutaneous ethanol injection, radiofrequency and their combination in treatment of hepatocellular carcinoma

AIM: To evaluate the therapeutic effect and the indication of percutaneous ethanol injection (PEI),radiofrequency ablation (RFA) and their combination in treatment of hepatocellular carcinoma (HCC).METHODS: Two hundred and fifty-five patients with HCC received treatment of PEI, RFA or their combination.Group1 (＜ 3 cm in diameter, n=85) was treated with PEI,group2 (＜ 3 cm in diameter, n=153) with RFA. Group3(＞3 cm in diameter, n=86) was divided into two groups.Group 3a (n=34) was treated with RFA, while group 3b(n=52) was treated with RFA for 2 wk after transcatheter arterial chemoembolization or PEI. Contrast-enhanced sonography was performed for 61 patients before and after RFA. Liver function and serum alpha-fetoprotein (AFP) were measured for all patients. Changes of the lesions on ultrasound and contrast-enhanced CT/MRI were evaluated for assessing the therapeutic responses.The 1-, 2-, 3- and 5-year survival rates were recorded after treatment.RESULTS: In group 1, the complete necrosis rate of lesions after 1 mo was 77.6% (66/85). The level of AFP declined conspicuously after 1 mo. The 1-, 2-, 3- and 5-year survival rate after treatment was 80.0% (52/65),60.4% (32/53), 52.5% (21/40) and 33.3% (7/21),respectively. In group 2, the complete necrosis rate of lesions after 1 moh was 92.2% (141/153). The level of AFP decreased conspicuously after 1 mo. The 1-, 2-,3- and 5-year survival rate after treatment was 94.6%(88/93), 73.2% (52/71), 63.5% (33/52) and 46.4%(13/28), respectively. In group 3a, the complete necrosis rate of lesions after 1 mo was 23.5% (8/34). AFP dropped down to the normal level in only one patient after 1 mo. The 1-, 2- and 3-year survival rate after treatment was 47.6% (10/21), 42.9% (6/14) and 27.3%(3/11), respectively. Only one patient was still alive after 5 years. In group 3b, the complete necrosis rate of lesions after 1 mo was 57.7% (30/52). The level of AFP decreased after 1 mo. The 1-, 2-, 3- and 5-year survival rate after treatment was 68.6% (24/35), 46.2% (12/26),36.8% (7/19) and 27.3% (3/11), respectively.CONCLUSION: The therapeutic effect of RFA on small HCC is better than that of PEI. Small HCC is the optimal indication of RFA. For recurrent HCC (diameter＞3 cm),the combined treatment of RFA and PEI/ACE should be used.     

Percutaneous ethanol injection, radiofrequency and their combination in treatment of hepatocellular carcinoma

AIM: To evaluate the therapeutic effect and the indication of percutaneous ethanol injection (PEI), radiofrequency ablation (RFA) and their combination in treatment of hepatocellular carcinoma (HCC). METHODS: Two hundred and fifty-five patients with HCC received treatment of PEI, RFA or their combination. Groupl (< 3 cm in diameter, n=85) was treated with PEI, group2(< 3 cm in diameter, n=153) with RFA. Group3 (>3 cm in diameter, n=86) was divided into two groups. Group 3a (n=34) was treated with RFA, while group 3b (n=52) was treated with RFA for 2 wk after transcatheter arterial chemoembolization or PEI. Contrast-enhanced sonography was performed for 61 patients before and after RFA. Liver function and serum alpha-fetoprotein (AFP) were measured for all patients. Changes of the lesions on ultrasound and contrast-enhanced CT/MRI were evaluated for assessing the therapeutic responses. The 1-, 2-, 3- and 5-year survival rates were recorded after treatment. RESULTS: In group 1, the complete necrosis rate of lesions after 1 mo was 77.6% (66/85). The level of AFP declined conspicuously after 1 mo. The 1-, 2-, 3- and 5-year survival rate after treatment was 80.0% (52/65), 60.4% (32/53), 52.5% (21/40) and 33.3% (7/21), respectively. In group 2, the complete necrosis rate of lesions after 1 moh was 92.2% (141/153). The level of AFP decreased conspicuously after 1 mo. The 1-, 2-, 3- and 5-year survival rate after treatment was 94.6% (88/93), 73.2% (52/71), 63.5% (33/52) and 46.4% (13/28), respectively. In group 3a, the complete necrosis rate of lesions after 1 mo was 23.5% (8/34). AFP dropped down to the normal level in only one patient after 1 mo. The 1-, 2- and 3-year survival rate after treatment was 47.6% (10/21), 42.9% (6/14) and 27.3% (3/11), respectively. Only one patient was still alive after 5 years. In group 3b, the complete necrosis rate of lesions after 1 mo was 57.7% (30/52). The level of AFP decreased after 1 mo. The 1-, 2-, 3- and 5-year survival rate after treatment was 68.6% (24/35), 46.2% (12/26), 36.8% (7/19) and 27.3% (3/11), respectively. CONCLUSION: The therapeutic effect of RFA on small HCC is better than that of PEL Small HCC is the optimal indication of RFA. For recurrent HCC (diameter>3 cm), the combined treatment of RFA and PEI/ACE should be used.     

Percutaneous ethanol injection for hepatocellular carcinoma originating in the caudate lobe

BACKGROUND/AIMS: Hepatocellular carcinoma originating in the caudate lobe is rare and the treatments for caudate hepatocellular carcinoma were thought difficult, because of its unique location at hepatic resection, or because of complex arterial supply at transcatheter arterial embolization. Percutaneous ethanol injection is an effective treatment for small hepatocellular carcinoma. The aim of this study was to assess the efficacy of percutaneous ethanol injection for hepatocellular carcinoma originating in the caudate lobe. METHODOLOGY: During the past 4 years, 7 patients with 7 hepatocellular carcinomas originating in the caudate lobe underwent percutaneous ethanol injection as a curative treatment. The outcomes of percutaneous ethanol injection and the survival of the 7 patients were evaluated. RESULTS: Percutaneous ethanol injection was successfully carried out with no severe complications in all patients. During follow-up periods local recurrence was noticed in a patient, that was treated with percutaneous ethanol injection again. Four patients had recurrence in other parts of the liver, who were treated with percutaneous ethanol injection alone or percutaneous ethanol injection and transcatheter arterial embolization. Six patients were alive for 12-55 months after percutaneous ethanol injection and 1 patient died of hepatic failure 15 months after the procedure. CONCLUSIONS: Percutaneous ethanol injection was a safe and effective treatment, and it would be an alternative therapy for hepatocellular carcinoma originating in the caudate lobe.     

化学栓塞-冷消融-酒精注射序贯治疗不能手术切除的肝细胞癌

目的探讨肝动脉化学栓塞(TACE)-冷消融-经皮酒精注射(PEI)序贯治疗对不能手术切除性肝细胞癌(HCC)的治疗价值。方法51例HCC患者先作TACE，2-3周后，作冷消融，再2-3周后作PEI。冷消融治疗采用Cryocare冷冻外科系统完成。结果48例得到6-20个月的随访，有8l.3％的患者治疗后肝内肿瘤缩小，12．5％无变化，6．3％增大；85．3％的患者血清AFP下降，11．8％无明显改变，2．9％升高；87．5％的患者己生存6～20个月，12．5％，生存4～17个月。按Kaplan Meier法计算，半年生存率89．6％，1年生存率80％，1年半生存率66．6％。结论将TACE-冷消融-PEI序贯应用，有相辅相成作用，可作为治疗不能手术切除性HCC的可供选择的安全而有效的方法。     

Percutaneous ethanol injection before liver transplantation in the hepatocellular carcinoma

Background/objectives. The study evaluates the outcome of patients who performed orthotopic liver transplantation (LT) as treatment for hepatocellular carcinoma (HCC), with percutaneous ethanol injection (PEI) while on the waiting list, verifying the effectiveness of this treatment in producing tumor necrosis and avoiding dropout and identifying treatment-related complications.Material and methods.Medical records of 97 patients on the waiting list for LT at Hospital Clinic of Barcelona were examined. Sixty-two (56.3%) patients had been treated with PEI (group 1); 35 (31.8%) had not received any anti-tumor therapy before LT (group 2).Results.Complete necrosis of the tumor was observed in 38/59 (64.3%) patients. The presence of additional nodules in the explant and the diameter of the main tumor of group 1 was significantly lower than in group 2 (p = 0.002). Dropout related to tumor progression occurred in 4.8% and 8.5%, and tumor recurrence in 5% and 6.2% for groups 1 and 2, respectively. Major complications were not evidenced after 421 PEI sessions and there was no tumor implant in the needle traject.Conclusions. In conclusion, the percutaneous treatment of HCC with PEI is a safe and effective method before the LT.     

Percutaneous microwave coagulation therapy for unresectable hepatocellular carcinoma

BACKGROUND/AIMS: Percutaneous microwave coagulation therapy (PMCT) has recently been introduced as a new treatment for hepatocellular carcinoma (HCC) in Japan. This study was performed to evaluate its efficacy and safety. METHODOLOGY: Thirteen patients with 17 nodules of unresectable HCC were subjected to PMCT under ultrasonic guidance. The tumors ranged from 1.2-4.4 cm in size. Assessment of the efficacy of PMCT was made by follow-up with dynamic computed tomography (CT). RESULTS: In the patients with small HCC (< or = 2.0 cm), 8 of 10 nodules (80%) showed complete remission after PMCT. In small nodules located on the liver surface, 3 out of 4 nodules (75%) showed complete remission. However, in the patients with larger HCC (> or = 2.1 cm), 5 out of 7 nodules developed local recurrence after PMCT. Regarding assessment of the necrotic area after PMCT, dynamic CT revealed enhancement that was possibly caused by congestion of the liver parenchyma surrounding the area of necrosis due to PMCT in the early phase of the treatment. Therefore, the necrotic area must be assessed carefully. Although a slight heat sensation and/or pain during microwave irradiation (a common effect of PMCT) occurred in all patients, there were no serious adverse effects. CONCLUSIONS: Complete remission of small HCC (< or = 2 cm in diameter) can be achieved with PMCT alone, but there seem to be limitations to its effectiveness with larger HCC (> or = 2.1 cm). There were no serious adverse effects from PMCT and the therapy can be safely carried out even in patients with poor liver function.     

Percutaneous ethanol injection in the treatment of hepatocellular carcinoma in cirrhosis

BACKGROUND/AIMS: In this study we discuss and evaluate the use of percutaneous ethanol injection for the treatment of hepatocellular carcinoma in cirrhosis. METHODOLOGY: Percutaneous ethanol injection was performed under ultrasound guidance, with multiple sessions at an outpatient department or with "single-session" technique under general anesthesia, according to the size and number of the lesions. RESULTS: In our patients with Child A (293), B (149), or C (20) cirrhosis and single hepatocellular carcinoma 5 cm or smaller, the 1-, 3- and 5-year survival rates were 98, 79 and 47%, 93, 63 and 29%, and 64, 12 and 0%, respectively. In our 108 patients with larger hepatocellular carcinoma, 1- and 3-year survival rates were: 72 and 57% in single, encapsulated tumors, 73 and 42% in single infiltrating or multiple encapsulated tumors, and 46 and 0% in symptomatic or with advanced portal thrombosis tumors. CONCLUSIONS: Percutaneous ethanol injection proved to be a safe, effective, repeatable, easy and low-cost therapy for hepatocellular carcinoma. Survival after percutaneous ethanol injection was comparable to that after surgical resection, probably because of a balancing between greater complete ablation rate of surgery versus absence of early mortality and liver damage of percutaneous ethanol injection. On the basis of the percutaneous ethanol injection rationale, other ablation techniques were proposed using radiofrequency, laser or acetic acid. Their initial results are promising.     

经皮氩氦刀冷冻治疗肝细胞癌的安全性和疗效

肝细胞癌(hepatocellular carcinoma,HCC)居世界癌症死因第三位,在中国居第二位。手术切除率仅为20%～30%,因供体缺乏,肝移植术明显受限,因此多种局部消融术,如无水酒精、射频、激光、高强度聚集超声、微波和冷冻消融等在HCC治疗中发挥着重要作用。氩氦超导靶向手术系统(氩氦刀)冷冻治疗HCC是近年发展的一项局部消融术,尽管在中国经皮氩氦刀治疗HCC已有较多应用,但世界范围内对该技术尚存争议。与应用广泛的射频消融术及其他热消融技术相比,氩氦刀冷冻治疗有产生较大的毁损面积及更为清晰可辨的治疗区域等优势。本文对经皮氩氦刀冷冻治疗HCC的适应证、技术、患者管理、安全性及疗效进行评述。     

Percutaneous ethanol injection under CT fluoroscopy for hypervascular hepatocellular carcinoma following transcatheter arterial embolization

BACKGROUND/AIMS: The present study was conducted to accurately monitor the pattern of ethanol distribution during percutaneous ethanol injection by computed tomography fluoroscopy and to examine the relationship between the distribution pattern and therapeutic effect. METHODOLOGY: Twenty-five hypervascular hepatocellular carcinomas were studied. Each was treated with transcatheter arterial embolization. However, as residual parts were detected, percutaneous ethanol injection under real-time computed tomography fluoroscopy was performed. For analysis, ethanol distribution and local recurrence rate were compared. RESULTS: Ethanol distribution in a tumor was classifiable into 3 patterns. In pattern 1, ethanol solution was distributed spherically. In pattern 2, ethanol solution spread forming linear boundaries indicating interruption of distribution by septa. In pattern 3, ethanol spread circumferentially only along the periphery sparing the central part of a tumor. The 6-month recurrence rate of the tumors in which ethanol solution was distributed to the whole viable part was 25% (pattern 1), 100% (pattern 2) and 0% (pattern 3), respectively. CONCLUSIONS: In the tumors showing distribution pattern 3 by computed tomography fluoroscopy, a combination therapy of transcatheter arterial embolization and percutaneous ethanol injection was more effective than in other patterns. Computed tomography fluoroscopy was useful for accurate monitoring and predicting the therapeutic effect of percutaneous ethanol injection.     

Percutaneous ethanol injection for the treatment of small hepatocellular carcinoma. Study of 95 patients

Percutaneous ethanol injection (PEI) was applied to 120 lesions in 95 patients with hepatocellular carcinomas (HCC) smaller than 3 cm in the past 6 years. All main target tumours, in 67 patients who had been followed by sonography for more than 6 months after PEI, decreased in size; 28 tumours (41.8%) became undetectable and have remained so until now. The 1-, 2-, 3-, 4- and 5-year survival rates calculated by the Kaplan-Meier method were 93%, 81%, 65%, 52% and 28% respectively. These survival rates were better than those of patients with HCC smaller than 3 cm who did not receive anticancer treatment (P less than 0.01). The survival of patients of the Child's A or Child's B status was better than that of those with Child's C disease. Recurrence occurred in areas within the liver different from the original lesion in 34% in one year, 61% in two years and 66% in three years after PEI. PEI was then repeated in 61% of such patients.     

Percutaneous ethanol injection for small hepatocellular carcinoma: therapeutic efficacy based on 20-year observation

BACKGROUND/AIMS: To evaluate the therapeutic efficacy of percutaneous ethanol injection (PEI) for patients with < or = 3 lesions of small (< or = 3 cm diameter) hepatocellular carcinoma (HCC). METHODS: PEI was applied to 270 patients with small HCC as the first-line treatment option during a 20-year period. RESULTS: (1) There was no treatment-related deaths, and only 2.2% of severe complications; (2) PEI induced a complete response of all HCCs according to CT evaluation performed within one month after the procedure, and the local recurrence rate at 3 years was 10%; (3) the overall 3- and 5-year survival rates after treatment were 81.6 and 60.3%, respectively, but the rates were higher, 87.3 and 78.3%, in Child A patients with a solitary tumor < or = 2 cm in diameter; (4) factors significantly influencing survival were liver function (P = 0.0033) and serum alpha-fetoprotein level (P = 0.0014), and (5) the recurrence rate at remote sites in the liver was lower in patients with HCC < or = 2 cm (P = 0.0395) and in those with a solitary HCC (P < 0.0001) according to Cox's proportional hazard model. (6) Radiofrequency ablation would not have been performed in approximately 25% of these patients. CONCLUSIONS: PEI is considered a reliable treatment for small HCC in terms of safety and efficacy.     

Percutaneous injection therapy for hepatocellular carcinoma in patients with chronic renal insufficiency

OBJECTIVES: Percutaneous injection therapy using acetic acid or pure ethanol is effective for hepatocellular carcinoma (HCC). However, its efficacy in HCC patients with coexisting chronic renal insufficiency (CRI), defined as a serum creatinine level of 1.5 mg/dl or above, is not known. This study compared the survival in HCC patients with and without CRI undergoing percutaneous injection therapy. METHODS: A total of 172 patients (129 male; age 67 +/- 10 years) during a 4-year period were included. Thirty-five of these patients had CRI (creatinine level 2.7 +/- 1.8 mg/dl) before treatment Fourteen patient- and tumour-related parameters were included for survival analysis. RESULTS: The mean follow-up period was 24 +/- 9 (range 4-40) months. Seven (20%) and 39 (28%) patients in the groups with and without CRI, respectively, died. There was no significant survival difference in patients with and without CRI. The cause of death was related to renal failure in two (29%) patients in the former group and one (3%) patient in the latter group. For the patients with CRI, the presence of ascites and a serum creatinine level of 2.3 mg/dl or above were poor prognostic factors in the univariate analysis; the latter was the only independent factor predicting a poor survival by the Cox multivariate proportional model. CONCLUSIONS: CRI does not affect overall survival in HCC patients undergoing percutaneous injection therapy. However, a serum creatinine level of 2.3 mg/dl or above is an independent poor prognostic predictor among patients with existing CRI.     

Ultrasonically guided percutaneous ethanol injection therapy for hepatocellular carcinoma

Ultrasonically guided percutaneous ethanol injection therapy (US-PEIT) was performed in 26 patients with hepatocellular carcinomas (HCC) in whom neither surgery nor transcatheter arterial embolization (TAE) was indicated, or TAE had proved ineffective. Comparison of results by various diagnostic imaging techniques with histopathological findings revealed that tumor necrosis after US-PEIT was correlated with increased echogenicity of the tumor by US, decreased density of the tumor and disappearance of contrast enhancement by computed tomography (CT), and change to a lower signal in the tumor by magnetic resonance imaging [MRI, 0.15 T permanent magnet, spin-echo sequence, repetition time (TR)/echo time (TE) = 2000/80 ms]. Thus, findings by imaging are useful in evaluating the initial effect of US-PEIT. Of three specimens obtained by liver resection and three obtained at autopsy, four showed complete necrosis after US-PEIT (maximum tumor diameter, 3 cm). This method also appeared to be effective in cases of capsular invasion. In this study, the 2-yr survival rate of patients with HCC was 75%. Although this study was not a controlled clinical trial, we conclude that US-PEIT may be a potentially effective treatment for HCC.     

肝动脉化疗栓塞联合氩氦刀冷冻消融治疗对不能手术的中晚期肝癌疗效的临床观察

目的观察肝动脉化疗栓塞术(TACE)联合氩氦刀冷冻消融技术治疗不能手术的中晚期肝癌患者的有效性和安全性。方法对2008年5月-2010年6月郑州大学附属洛阳中心医院收治的35例肝癌患者首先行TACE治疗2~3周,然后行氩氦刀冷冻消融治疗,1~2周后再次进行TACE治疗,治疗结束后评价近期疗效,并随访生存情况。两组间数据比较采用t检验,生存曲线采用Kaplan-Meier法进行生存分析。结果 35例患者均可评价疗效,其中完全缓解7例,部分缓解21例,稳定4例,进展3例;临床治疗有效率为80.00%,疾病控制率为91.43%;2、3年生存率分别为45.6%、39.4%。35例患者治疗前甲胎蛋白(AFP)为(837.6±216.7)μg/L,治疗后AFP为(206.2±48.6)μg/L,差异有统计学意义(t=2.673,P0.05)。结论 TACE联合氩氦刀冷冻消融是治疗不能手术的中晚期肝癌患者的可靠方法,具有创伤小、恢复快、并发症少等特点。     

Early detection of haemobilia associated with percutaneous ethanol injection for hepatocellular carcinoma

OBJECTIVE: Haemobilia often results from iatrogenic injury caused by therapeutic procedures. The objective of this study was to evaluate the efficacy of early diagnosis of haemobilia based on ultrasonography in patients with hepatocellular carcinoma undergoing percutaneous ethanol injection. PATIENTS AND METHODS: A combination retrospective and prospective study on the early detection of haemobilia caused by percutaneous ethanol injection was conducted on 365 patients in 1995-1996. The retrospective study reviewed the clinical, laboratory and imaging data of 172 patients who had undergone ethanol injection therapy in 1995. The results showed that ultrasonographic changes in the gallbladder, namely the rapid appearance of echogenic material in the gallbladder lumen, are a useful early sign of haemobilia. Based on the results of the retrospective study, a prospective study on the early detection of haemobilia was carried out in 1996. In the prospective study, percutaneous ethanol injection was halted as soon as haemobilia was detected. RESULTS: The incidence of haemobilia in the prospective group (3.6%) was not different from that in the retrospective group (4.7%). However, the mean duration between percutaneous ethanol injection and diagnosis of haemobilia was only 0.3 +/- 0.2 days in the prospective group, compared with 2.8 +/- 2.1 days in the retrospective group (P < 0.001), and the mean duration of jaundice in the prospective group (4.3 days) was significantly shorter than in the retrospective group (40.0 days) (P< 0.05). CONCLUSION: Early diagnosis of haemobilia based on ultrasonographic findings of the gallbladder lumen effectively reduces the severity of haemobilia-related complications due to immediate interruption of the interventional procedure.     

Radiofrequency ablation combined with percutaneous ethanol injection in patients with hepatocellular carcinoma

Background and study aimsHepatocellular carcinoma (HCC) is a major burden on health-care systems worldwide. Although radiofrequency ablation (RFA) is currently considered the best technique for coagulative necrosis, the superiority of concomitant use of RFA and percutaneous ethanol injection (PEI) needs to be determined. The study was designed to compare efficacy, safety and rate of survival of patients with HCC assigned to receive combined PEI–RFA versus RFA alone and versus PEI alone.Patients and methodsThis 3-year study enrolled 90 cirrhotic patients with HCC (Child’s class A or B, but not class C). They were randomly assigned for either PEI–RFA (group I), RFA alone (group II) or PEI alone (group III). The primary end point was ablation of the tumour. The secondary end point was rate of survival and recurrence.ResultsAfter the first session, complete ablation was significantly higher in the combination group (87.9%) compared with the RFA group (54.54%). After the second session, complete ablation was achieved in 97.0% of the combination group and in 84.8% of the RFA group. Regarding the PEI group, 75% had complete ablation, whereas 25% had partial ablation after multiple sessions. The survival rate, 1.5 years later, was significantly higher in group I (86.7%) compared with group III (63.3%). The overall incidence of serious adverse events was nil.ConclusionCombined treatment is superior to RFA alone and to PEI alone, in safety and efficacy in patients with HCC.