Hepatocellular carcinoma: treatment with percutaneous ethanol injection and transcatheter arterial embolization.

The therapeutic effectiveness of a new combination therapy--pretreatment with transcatheter arterial embolization (TAE) and subsequent percutaneous ethanol injection (PEI)--for solitary large (> 3.0 cm in diameter) primary hepatocellular carcinoma lesions was compared with that of TAE alone. With TAE alone, a partial response of the tumor was seen in only 10% of the patients, and the 1-, 2-, and 3-year survival rates were calculated to be 68%, 37%, and 0%, respectively. Histologic examination of specimens obtained at hepatectomy showed that TAE alone caused complete necrosis in only 20% of the tumors. In contrast, PEI combined with TAE significantly (P < .05) increased the partial response rate (45%) and significantly (P < .01) prolonged the 1-, 2-, and 3-year survival rates (100%, 85%, and 85%, respectively). Combination therapy caused complete histologic necrosis in 83% of the tumors. It also was significantly (P < .05) better than TAE alone in terms of rate of primary tumor recurrence during follow-up.     

Hepatocellular carcinoma with blood supply from omental branches: treatment with transcatheter arterial embolization

PURPOSE: To evaluate the usefulness of transcatheter arterial embolization (TAE) through the omental branch in the treatment of hepatocellular carcinoma (HCC) with blood supply from the omental branch. MATERIALS AND METHODS: Fifteen patients with HCC fed by the omental branch underwent TAE. All but one had previously undergone several therapies for HCC, including TAE. Three patients had intraperitoneal hemorrhage caused by ruptured HCC fed by the omental branch, and two necessitated emergency TAE. The technical success rate, therapeutic effect, and safety of TAE via the omental branch were evaluated. RESULTS: Twenty-six omental branches that fed HCC were observed angiographically. Attenuation or occlusion of the hepatic artery was observed in 80%. Nineteen omental branches (73%) could be successfully embolized. Hepatic hemostasis was achieved in all patients with ruptured HCC. Tumor recurred in 80% of patients who underwent successful TAE of the omental branch, and additional therapy was performed in six patients. Ten patients died after 2-26 months (mean, 8 mo). Five patients were alive for 3-13 months (mean, 7 mo). Severe complications were not observed in any patient. CONCLUSION: TAE of the omental branch is safe and has become technically feasible in almost all patients, but tumors frequently recur.     

Hepatocellular carcinoma: treatment with transcatheter arterial chemoembolization

This article presents a review of the literature regarding the use of transcatheter arterial chemoembolization (TACE) in the treatment of hepatocellular carcinoma (HCC). There have been two different approaches to the treatment: (a) percutaneous tumor ablation methods which can be divided into injectable and thermal methods; percutaneous ethanol injection (PEI) is the most widely used method, and (b) TACE. PEI is the treatment of choice for single HCCs smaller or equal to 3 cm in size. For patients with large HCCs combined TACE and PEI is probably the most effective nonsurgical treatment. In the presence of multiple HCC nodules, TACE remains the treatment of choice.     

Transcatheter arterial embolization followed by percutaneous ethanol injection in the treatment of hepatocellular carcinoma

Purpose The aim of this study was to evaluate the effectiveness of transcatheter arterial embolization (TAE) followed by percutaneous ethanol injection (PEI) in the treatment of large hepatocellular carcinoma (HCC) lesions.Methods Fifteen patients with HCC were treated by means of TAE followed by 6–16 ethanol injections. In 10 patients, the HCC was solitary (3–8 cm); 3 patients had 1, and 2 patients had 2 daughter nodules (3 cm or smaller) in addition. In 12 of 15 main tumors and in 4 of 7 daughter nodules, a tumor capsule was observed by computed tomography or magnetic resonance imaging.Results Combined treatment with TAE and PEI resulted in complete necrosis of 12 of 15 main tumors and 7 of 7 daughter nodules on biopsy. Treatment failure (incomplete necrosis) occurred in 3 unencapsulated main tumors. The 1-year survival rate in 10 patients was 100%.Conclusion The combination of TAE and PEI proved to be an effective treatment for large HCC, including those with 1–2 small daughter nodules. The presence of a tumor capsule significantly correlates (p < 0.05) with a favorable outcome of treatment.     

Power Doppler sonography: evaluation of hepatocellular carcinoma after treatment with transarterial embolization or percutaneous ethanol injection therapy

OBJECTIVE: The aim of this study was to compare tumor detectability by assessing the vascularity on power and color Doppler sonography and CT after transarterial embolization or percutaneous ethanol injection therapy or both in hepatocellular carcinoma. SUBJECTS AND METHODS: Forty-seven nodules of hepatocellular carcinoma (size, 28 +/- 7 mm [mean +/- standard deviation]; range, 20-40 mm) in 38 patients were treated with transarterial embolization (n = 6), percutaneous ethanol injection therapy (n = 23), and transarterial embolization plus percutaneous ethanol injection therapy (n = 9). Power Doppler sonography, color Doppler sonography, and CT were performed before and 2 weeks, 3 months, and 6 months after the treatments. The existence of hepatocellular carcinoma was confirmed by positive findings for color signals on both Doppler sonography techniques and for tumor stains on CT. All the tumors were determined to be malignant by microscopic examination of biopsy specimens. RESULTS: Before the treatments, power Doppler sonography (100%) and CT (100%) were significantly more effective than color Doppler sonography (61.7%) (p < 0.001, for both). Six months after the treatments, the sensitivity of power Doppler sonography (87.5%) was significantly better than that of color Doppler sonography (12.5%) but was not significant in comparison with CT (66.6%). However, power Doppler sonography detected color signals in two of three tumors in which iodized oil was accumulated and no tumor stain appeared on CT, and the two lesions detected with power Doppler sonography were carcinomas. CONCLUSION: Power Doppler sonography can be considered the most sensitive technique in assessing the viability of hepatocellular carcinoma treated with transarterial embolization or percutaneous ethanol injection therapy or both.     

比较肝动脉化疗栓塞联合经皮乙醇注射与联合冷循环微波刀治疗原发性肝癌的疗效

目的比较肝动脉化疗栓塞（TACE）联合经皮乙醇注射（PEI）与TACE联合冷循环微波刀术（PMCT）治疗原发性肝癌的效果。 方法150例患者接受TACE联合PEI,160例患者接受TACE联合PMCT治疗。术后4周复查动态增强CT,观察疗效。 结果TACE+PEI或TACE+PMCT后1个月,肿瘤一次消融率分别为70.00%和87.67%,TACE+PMCT组的疗效要优于TACE+PEI组（P<0.05）。 结论TACE+PMCT是原发性肝癌的有效治疗方法,是单纯TACE疗效不佳者的理想选择。     

Hepatocellular carcinoma not detected with plain US: treatment with percutaneous ethanol injection under guidance with enhanced US.

To evaluate the usefulness of contrast material-enhanced ultrasound (US) in detection and treatment of hepatocellular carcinoma (HCC), carbon dioxide was injected as a contrast agent into the hepatic artery in 22 patients with HCC. Plain US had enabled detection of 24 HCC nodules in these patients. Contrast material-enhanced US enabled detection of seven additional nodules, which were confirmed as HCC by means of fine-needle aspiration biopsy performed under guidance with contrast-enhanced US. Six of these seven nodules were detected incidentally during examination of other suspected HCC nodules. Five of the seven nodules were treated with percutaneous ethanol injection (PEI) performed under guidance with contrast-enhanced US; the two other nodules were resected. Contrast-enhanced US made the HCC lesions visible for 15-60 minutes, sufficient time to mark the nodule with an iodized oil-ethanol solution for PEI. Because contrast-enhanced US enabled detection of additional nodules and performance of PEI in lesions not detected with plain US, it may help improve the treatment of HCC.     

Hepatocellular carcinoma treated by transcatheter arterial embolization: progress evaluated by computed tomography

Computed tomography (CT) was performed after 65 transcatheter arterial embolizations (TAE) in 50 patients with hepatocellular carcinoma. Nonenhanced high-density areas were seen in the tumors within 3 days in 17/25 cases (though they soon disappeared) and low-density areas within 2 weeks in 62/65. Gas bubbles were seen in these areas within 2 weeks in 60% of embolizations. Within 3 to 6 months after the first TAE, enhanced lesions developed around or inside the low-density areas in 15/22 patients. Complications appearing within 2 weeks included non-enhanced low-density areas in the liver and spleen, gallbladder thickening, swelling of the head of the pancreas, contrast retention in the kidneys and gallbladder, ascites, and pleural effusion.     

Large infiltrative hepatocellular carcinomas: treatment with percutaneous intraarterial ethanol injection alone or in combination with conventional percutaneous ethanol injection

PURPOSE: To retrospectively evaluate patients' tolerance and the effectiveness of percutaneous intraarterial ethanol injection (PIAEI), alone or combined with conventional percutaneous ethanol injection (PEI), for treatment of advanced hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Neither institutional review board approval nor informed consent was required for this retrospective study; however, all patients had given their consent to be treated with PIAEI. Fourteen men and four women with cirrhosis and HCC who were ineligible for conventional curative treatment (largest tumor diameter, 35-90 mm; mean, 52 mm +/- 16 [standard deviation]) and whose supplying arteries were visible on computed tomographic (CT) and color Doppler ultrasonographic (US) images were treated with US-guided PIAEI-either alone or combined with PEI. Twelve patients had infiltrative tumors, and six had nodular tumors. Four patients had portal venous tumor involvement. Tumor necrosis and recurrence were evaluated with CT, and 1- and 2-year survival rates were evaluated with Kaplan-Meier analysis. RESULTS: In four patients, the main tumor was treated with PIAEI only, and in 14 patients, the main tumor was treated with combined PIAEI and PEI. One patient died of myocardial infarction before CT evaluation. Tumor necrosis was complete in 15 (88%) and incomplete in two (12%) of 17 patients. Results of subsequent surgery performed in three patients confirmed the radiologic findings: complete tumor necrosis in two patients and incomplete necrosis in one patient. Two severe PIAEI-related complications occurred: liver abscess, which resolved, and fatal acute pancreatitis. During the follow-up period (mean, 15 months +/- 6.7), six patients died owing to recurrent HCC, and 10 patients were alive with no detectable tumor after a mean follow-up period of 18 months +/- 11. One- and 2-year survival rates were 76.6% and 44.5%, respectively. CONCLUSION: For patients with advanced HCC who are ineligible for other curative options, PIAEI could be an effective treatment, despite the associated risk of severe complications.     

Combined transcatheter arterial chemoembolization and percutaneous ethanol injection for the treatment of large hepatocellular carcinoma: local therapeutic effect and long-term survival rate

The aim of our study was to investigate local therapeutic effects and long-term results of combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in the treatment of large hepatocellular carcinoma (HCC). Eight-six patients (67 males and 19 females, age range 48–75 years, mean age 65.1 years) with Child-Pugh class A (n = 48) or B (n = 38) liver cirrhosis and a large HCC (main tumor 3.1–8 cm in diameter with no more than two daughter nodules) were enrolled in a prospective study. All patients underwent a single TACE session followed by PEI. Follow-up ranged from 4 to 65 months (mean 27.8 months, median 26 months). No major complication occurred. The local therapeutic effect, as assessed on the basis of findings at CT and MR imaging, was complete response in 71 of 86 patients (82 %) and partial response in 15 of 86. Overall survival rates by the Kaplan-Meier method were 92 % at 1 year, 83 % at 2 years, 69 % at 3 years, 58 % at 4 years, and 47 % at 5 years. Survival of Child-Pugh A patients (75 % at 3 years and 59 % at 5 years) was significantly longer (p < 0.01) than that of Child-Pugh B patients (61 % at 3 years and 35 % at 5 years). Combined TACE and PEI is an effective treatment for large HCC. Received 10 June 1997; Revision received 28 August 1997; Accepted 2 September 1997     

肝动脉化疗栓塞及注射无水乙醇、~(32)P-玻璃微球治疗原发性肝癌的临床研究

目的评价肝动脉化疗栓塞（ＴＡＥ）结合Ｂ超引导下注射无水乙醇（ＰＥＩ）、３２Ｐ玻璃微球（３２ＰＧＭＳ）治疗原发性肝癌的临床价值。方法８３例中、晚期肝癌分为２组，４３例综合应用ＴＡＥ＋ＰＥＩ＋３２ＰＧＭＳ治疗，４０例单纯应用ＴＡＥ治疗。结果综合治疗组手术切除１４例（３３％），有９例肿瘤组织完全坏死，５例有残存的肿瘤细胞，单纯ＴＡＥ组手术切除４例（１０％），肿块及周边有肿瘤细胞，血清ＡＦＰ下降率及肿块缩小率两组比较有显著性差异（Ｐ＜０．０１），１、２、３年生存率综合治疗组分别为８４％，７２％，６７％，而ＴＡＥ组分别为５３％，１０％，０％。结论ＴＡＥ＋ＰＥＩ＋３２ＰＧＭＳ的综合应用，是提高中、晚期原发性肝癌患者存活率的有效方法。     

The percutaneous treatment of uterine fibromas by means of transcatheter arterial embolization

INTRODUCTION: We report our preliminary experience with arterial embolization of uterine fibroids in seven women, focusing on the technical aspects of the procedure and the clinical and morphological results during the follow-up. MATERIAL AND METHODS: February to December 1999 seven women (mean age 47) underwent transcatheter arterial embolization of both uterine arteries as a permanent treatment for fibroids. We included in this study single or multiple, bleeding and/or large fibroids, symptomatic on compression, contraindicated for myomectomy because of high surgical or anesthesiologic risks or myomata in which myomectomy could probably be converted into hysterectomy. Fibroids enlarging the uterus to the size of 25 weeks' pregnancy or more, pedunculated myomata or small submucous fibroids--smaller than 5 cm--were excluded. Uterine arterial embolization was performed bilaterally, till a total blockage of flow, by injecting permanent embolization material: polyvinyl-alcohol (PVA) particles of increasing size from 150 to 500 mu and in varying amounts from 10 to 24 mL, depending on fibroid size and degree of vascularization. RESULTS: A technical success was achieved in all cases and no late complications were seen. At 6-month clinical follow-up all compressive symptoms had disappeared; regular menses had returned in 57% of patients, milder hyper-dysmenorrhea was present in 28% compared to pretreatment symptoms; only in one case (14%) was permanent amenorrhea observed. The 3-month and 6-month US follow-up studies showed an average 40.7% (range 10-50%) and 51% (range 25-83%) reduction in the fibroid size, respectively. All the small myomata (about 2 cm in size) were unidentifiable at 6-month US follow-up. In no cases did new fibroids appear. DISCUSSION: Surgery is the traditional treatment for symptomatic uterine fibroids (hysterectomy, myomectomy). More recently, hormone therapy and operative endoscopy (laparoscopy and hysteroscopy) have been introduced as alternatives, together with uterine embolization previously applied preoperatively in extensive bleeding neoplasms or to control post-partum hemorrhage. Transcatheter embolization of the uterine arteries feeding large fibroids is a minimally invasive technique which could be safely used as an alternative to surgery, and a valuable in the definitive treatment of symptomatic, large or multiple, intramural or submucosal fibroids. In agreement with literature findings, in the present series symptoms resolved completely in over 85% of cases after embolization, with an average reduction in fibroid size over 50% at 6-month follow-up in large fibroids, whereas smaller size myomata were no longer detectable at US and no new fibroids had formed. CONCLUSIONS: Our preliminary experience confirms that arterial embolization is a promising alternative to surgery in the definitive treatment of fibroids, thanks to its high efficacy and safety, also reducing patient hospitalization and costs.