Acute cholecystitis as a complication following percutaneous ethanol injection of a hepatocellular carcinoma.

Percutaneous ethanol injection is a useful option in the treatment of hepatocellular carcinoma which are not amenable to resection or transplantation. We describe a case of cholecystitis and tumour infiltration of the gallbladder after percutaneous ethanol injection, a complication not previously described in literature. The patient was a 70-year-old woman with a history of asymptomatic HCV+ hepatopathy and a 6 cm hepatocellular carcinoma nodule in segment V which had been treated two months before by percutaneous ethanol injection in another center. She attended our center due to febrile syndrome. Imaging studies suggested cholecystitis with an abscess on the wall of the gallbladder, purulent material obtained by means of a CT-guided puncture. Surgery revealed purulent and neoplasic material inside the gallbladder, with tumor invasion of the posterior wall; a partial cholecystectomy was therefore performed and a drainage inserted. The patient showed no post-operative complications and was discharged after seven days. CONCLUSION: we believe that the percutaneous ethanol injection of hepatocellular carcinomas located close to the gallbladder may occasionally lead to complications in the form of cholecystitis with neoplasic infiltration of the gallbladder. A case of cholecystitis secondary to radiofrequency treatment of a similarly-located tumor has previously been described and, therefore, the use of percutaneous local destructive treatments for tumors close to the gallbladder would seem unadvisable.     

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.     

CT-guided percutaneous ethanol injection therapy for ultrasonically invisible hepatocellular carcinoma

We report the case of a 75-year-old woman with hepatitis C virus-related cirrhosis and recurrent hepatocellular carcinoma located just beneath the diaphragm. Computed tomography-guided percutaneous ethanol injection therapy was performed, because images of the tumor were hard to obtain on ultrasonography. The angle and depth of needle insertion were determined by using the geometric relationship between the target lesion and the skin insertion site on computed tomography scans. A 22-gauge needle was inserted through the right 6th intercostal space under local anesthesia. Computed tomography scanning was repeated to verify the needle position. After entry of the needle into the target lesion was confirmed, 10 mL of absolute ethanol was injected. This procedure caused transient mild pain, but there were no serious adverse effects such as pneumothorax or hemothorax. Three months after treatment, the lesion was not enhanced on dynamic computed tomography scanning, suggesting complete tumor ablation. At present, the patient is doing well. In conclusion, computed tomography-guided percutaneous ethanol injection therapy was safe and accurately achieved the desired tumoricidal effect in a patient with ultrasonically invisible hepatocellular carcinoma.     

Long-term outcome of percutaneous ethanol injection therapy for minimum-sized hepatocellular carcinoma

AIM： To evaluate long-term follow-up of minimum-sized hepatocellular carcinoma （HCC） treated with percutaneous ethanol injection （PEI）. METHODS： PEI was applied to 42 lesions in 31 patients （23 male and eight female） with HCC 〈 15 mm in diameter, over the past 15 years. RESULTS： Overall survival rate was 74.1% at 3 years, 49.9% at 5 years, 27.2% at 7 years and 14.5% at 10 years. These results are superior to, or at least the same as those for hepatic resection and radiofrequency ablation. Survival was affected only by liver function, but not by sex, age, etiology of Hepatitis B virus or Hepatitis C virus, α-fetoprotein levels, arterial and portal blood flow, histological characteristics, and tumor multiplicity or size. Patients in Chiid-Pugh class A and B had 5-, 7- and 10-years survival rates of 76.0%, 42.2% and 15.8%, and 17.1%, 8.6% and 0%, respectively （P = 0.025）. CONCLUSION： Treatment with PEI is best indicated for patients with HCC 〈 15 mm in Child-Pugh class A.     

Portal vein thrombosis following percutaneous ethanol injection therapy for hepatocellular carcinoma.

Percutaneous ethanol injection therapy was performed in a 66-year-old woman with hepatocellular carcinoma. She developed portal vein thrombosis that on color Doppler revealed no tumor vascular signal, and so was diagnosed as non-tumor thrombus. The thrombus resolved over 3 months.     

Rapid intrahepatic tumor seeding after percutaneous ethanol injection therapy for hepatocellular carcinoma

A 73-year-old man with hepatocellular carcinoma (HCC) had been treated repeatedly with transcatheter arterial embolization (TAE) and percutaneous ethanol injection therapy (PEIT) since 2000. HCC recurrence near the intrahepatic left portal vein was treated by PEIT in 2004. The patient complained of fatigue and upper abdominal pain 28 days later. Abdominocentesis and abdominal computed tomography demonstrated rupture of the recurrent HCC and multiple intrahepatic recurrences. We successfully performed emergency TAE, but the patient died of liver failure. Rapid seeding of multiple intrahepatic tumors after PEIT is a rare event, but such a possibility must be kept in mind.     

Ultrasound guided percutaneous ethanol injection of hepatocellular carcinoma

Percutaneous ethanol injection (PEI), as the first minimally invasive ablation method, has now been in use for more than 20 years. Its main indication is the treatment of small hepatocellular carcinomas superimposed on liver cirrhosis. PEI is highly effective for small tumors (<3 cm) with a complete response in 80% of patients. The efficacy for larger tumors (3-5 cm) is lower, with a complete response in 50%. To increase the effect in larger tumors some special techniques have been developed: single session therapy in general anesthesia, "multiple needles insertion", injection in the feeding artery. PEI is a well tolerated therapy, with a very low complication rate. Recurrences, either local or distant, may occur after PEI and can be treated with new sessions. Although it is still considered the standard percutaneous technique in the treatment of hepatocellular carcinoma, its place is challenged by the new thermal ablative percutaneous techniques, especially radiofrequency ablation.     

Survival benefit of cirrhotic patients with hepatocellular carcinoma treated by percutaneous ethanol injection as a salvage therapy

BACKGROUND: The therapeutic strategy for cirrhotic patients with hepatocellular carcinoma (HCC) who cannot tolerate surgery or transcatheter arterial chemoembolization (TACE) is uncertain. The safety and efficacy of percutaneous ethanol injection (PEI) as a salvage therapy in such patients is not clear. METHODS: A total of 63 (49 men) HCC patients (mean age 67 +/- 11 years), for whom surgery or TACE was not indicated because of the coexistence of various medical conditions, were enrolled and prospectively studied. Fifty-six (89%) were treated with PEI and 7 were treated with conservative measures. The outcome and the factors that may affect survival were evaluated. RESULTS: During a mean follow-up period of 16 +/- 9 months, 17 (30%) of the patients treated with PEI and 5 (71%) of those treated with conservative measures died (P = 0.045). A total of 16 patient-related and tumor-related variables that may influence the outcome were analyzed. Survival analysis showed that female gender, small (< or = 3 cm) solitary tumor and PEI were associated with a better prognosis (P < 0.05). When using the Cox proportional hazard model, PEI was the only significant independent factor predicting survival (relative risk: 0.3, 95% confidence interval: 0.11-0.86, P = 0.024). The 1- and 2-year survival rates were 85% and 65% for patients treated with PEI compared to 57% and 29% for conservative measures (P = 0.016). CONCLUSIONS: PEI may be a treatment option for cirrhotic patients who have HCC and coexisting contraindications that preclude surgery and TACE. Careful pre-treatment patient selection may effectively prolong the survival.     

Successful treatment of hepatocellular carcinoma with percutaneous ethanol injection therapy and local hyperthermia

The patient K.I., a 72-year-old male, was admitted to Nishide Hospital in July 1999 for hemodialysis treatment of end-stage chronic renal failure. At the time of his admission, an ultrasound examination of the patient's liver revealed a large mass in the S5-S8 segment. A hepatocellular carcinoma was suspected from the characteristic mosaic pattern seen with ultrasound and the elevation of alpha-fetoprotein in the serum. The patient's condition was considered to be medically inoperable, due to the patient's adaptation to hemodialysis. Furthermore, transcatheter arterial embolization was not indicated due to the patient's history of hypersensitivity to roentgen-contrast materials. An attempt to palliate the malignancy was made with a combination of local hyperthermia and percutaneous ethanol injection therapy. Magnetic resonance imaging revealed that the tumor structure had changed after 10 days of percutaneous ethanol injection therapy and that 2 months later the tumor size had decreased by about 50%. Moreover, the alpha-fetoprotein level had returned to normal by that time. In addition, this treatment did not cause any disturbance in the liver function. The patient tolerated treatment well. A combined treatment of local hyperthermia with percutaneous ethanol injection therapy appears to be useful in the management of hepatocellular carcinomas, especially in cases in which more aggressive treatment is not acceptable.     

Liver atrophy after transcatheter arterial embolization and percutaneous ethanol injection therapy for a minute hepatocellular carcinoma.

A 63-year-old male patient with compensated cirrhosis underwent transcatheter arterial embolization (TAE) and percutaneous ethanol injection therapy (PEIT) for a minute hepatocellular carcinoma (HCC). Although the HCC was successfully treated, esophageal varices worsened and refractory ascites developed 3 months after the TAE and PEIT. Liver atrophy progressed rapidly compared to the natural course of liver cirrhosis.     

Liver perforation: a serious complication of percutaneous acetic acid injection for hepatocellular carcinoma

A 75-year-old cirrhotic man, after undergoing percutaneous acetic acid injection therapy for hepatocellular carcinoma, presented high fever and right hypochondralgia. Computed tomography disclosed an area of low attenuation in the liver and a crescent-shaped intraperitoneal lesion adjacent to it. We diagnosed liver perforation and localized peritonitis due to the leakage of acetic acid following acetic acid injection. It is important to consider this serious complication when evaluating the indications for percutaneous acetic acid injection for hepatocellular carcinoma.     

Standards for selecting percutaneous ethanol injection therapy or percutaneous microwave coagulation therapy for solitary small hepatocellular carcinoma: consideration of local recurrence

OBJECTIVE: Percutaneous ethanol injection therapy (PEIT) and percutaneous microwave coagulation therapy (PMCT) are effective treatments for small hepatocellular carcinoma (HCC). There are no clear standards, however, for the selection of PEIT or PMCT. We determined standards based on local recurrence. METHODS: The subjects were 88 patients with solitary HCC measuring < or = 30 mm in diameter, who were treated by PEIT (n = 45) or PMCT (n = 43) and judged to be cured using computerized tomography (CT) with contrast medium after treatment. Patient characteristics, including age, gender, viral markers, Child-Pugh classification, tumor size, tumor cell differentiation, and serum alpha-fetoprotein (AFP) concentration we analyzed, and the factors influencing the local recurrence in the PEIT and PMCT groups were determined, using univariate and multivariate analysis. RESULTS: Univariate analysis indicated that tumor cell differentiation and serum AFP concentration influenced local recurrence in the PEIT group, and tumor size did so in the PMCT group. Multivariate analysis revealed that tumor cell differentiation influenced local recurrence in the PEIT group, and tumor size did so in the PMCT group. PEIT was effective for treating well-differentiated HCC, and PMCT was effective for treating HCC measuring < or = 15 mm in diameter. PMCT was superior to PEIT for treating patients with HCC measuring < or = 15 mm in diameter. In such cases with well-differentiated HCC, PEIT was as effective as PMCT. CONCLUSIONS: The selection of PEIT or PMCT to treat patients with HCC should be based on tumor size and cell differentiation.