Ultrasound-guided percutaneous ethanol injection under general anesthesia for the treatment of hepatocellular carcinoma on cirrhosis: long-term results in 268 patients.

OBJECTIVE: Percutaneous ethanol injection (PEI) under general anesthesia (One-shot PEI) is a therapy for large and multiple hepatocellular carcinoma (HCC) by the injection of a large amount of ethanol into the tumor. We report our results with 5-year survival rates in patients with HCC on cirrhosis treated with One-shot PEI. PATIENTS AND METHODS: From October 1992 to March 1998, 268 cirrhotic patients (age 42-82 years; 191 males; 95 Child-Pugh's A class, 150 B and 23 C class of cirrhosis) with 515 HCC nodules underwent One-shot PEI. Diameter of HCC nodules ranged from 0.6 to 14 cm (mean 5.02 +/- 2.2 cm; median: 4 cm). One hundred and thirty-eight patients had a single nodule (range 3.2-14 cm; mean 5.6 +/- 2.1 cm), 130 had multiple nodules, up to six nodules (mean 2.9 nodules) (range 0.6-11 cm; mean 4.8 +/- 2.1 cm) RESULTS: CT showed complete necrosis in 357/506 nodules (70%). Five patients (1.8%) with nine nodules died as a result of the procedure (variceal bleeding in three cases, liver failure in one and hemoperitoneum in one). The overall survival rates were 93, 83, 74, 65 and 59% at 1, 2, 3, 4 and 5 years, respectively. Survival rates were 90, 84, 82 and 82% at 12, 24, 36 and 48 months, respectively, in patients with a single nodule less than or = 5 cm, and 97, 71, 59, 59 and 59% at 12, 24, 36, 48 and 60 months, respectively, in patients with single nodule >5 cm. Patients with multiple nodules had survival rates of 97, 89, 75, 60 and 60% at 12, 24, 36, 48 and 60 months, respectively. CONCLUSION: PEI of large and multiple HCC showed survivals similar to conventional PEI for patients with smaller tumors.

[The echo-guided interstitial laser photocoagulation of malignant liver tumors. The authors' personal technic, immediate results and short-term complications in patients with normal and altered liver function]. / Fotocoagulazione laser-interstiziale ecoguidata dei tumori maligni del fegato. Tecnica personale, risultati immediati e complicanze a breve termine nei pazienti con funzionalità epatica normale e alterata.

PURPOSE: The literature studies about interstitial laser photocoagulation of liver tumors mainly deal with the treatment of liver metastasis in patients with normal liver function. We report our personal experience with interstitial laser photocoagulation in patients with liver tumors (mostly cirrhotics with hepatocellular carcinoma). Our aim was to evaluate the short term efficacy of percutaneous interstitial laser photocoagulation in inducing focal ablation of liver tumors and the possible complications in patients with normal and impaired liver function. MATERIAL AND METHODS: Sixty-six patients (52-80 years; 42 men), 47 with 51 hepatocellular carcinoma nodules (diameter = 1.6-6.6 cm; mean 3.1 cm) on cirrhosis (18 in Child-Pugh A class, 24 in B e 5 in C class) and 19 patients with single liver metastasis (17 from colon, 2 from lung carcinoma; diameter = 3.9 cm; mean: 4.5 cm) underwent interstitial laser photocoagulation under ultrasound guidance. Depending on tumor size up to four needles were inserted in the tumor and multiple laser illuminations were performed: in nodules < or = 2 cm a single optical fiber and a single needle insertion were used, in nodules > 2 < 3 cm, 2-3 fibers were used with a single laser illumination, in nodules > 3 < 4 cm, 4 fibers were inserted and two laser illuminations were performed in the same session after 1.5 cm withdrawal of all fibers in the tumor, in nodules > 4 cm 2 sessions with 2 laser illuminations per session were performed. Necrosis of the nodules was evaluated with triphasic Helical CT 7 days after treatment. Patients with incomplete necrosis at CT were treated with additional interstitial laser photocoagulation sessions to attain complete necrosis. RESULTS: Fifty-eight patients underwent a single interstitial laser photocoagulation session, 7 patients 2 session and 1 patient 3 sessions. The range of administered energy per patient was 1200-32,000 Joules (mean: 6700 J). CT showed complete necrosis of 47 nodules in 43 patients with hepatocellular carcinoma and in 15/18 patients with metastasis. Three Child C class patients with mild ascites and hyperbilirubinemia before procedure (nodules O: 1.9, 3.5 and 5.8 cm) dropped out of CT follow-up because of severe liver function impairment with increased ascites and hyperbilirubinemia, associated with transient ileum paraliticus in 1 case. One of these patients died two months after treatment. Two patients with metastasis dropped out of treatment because of complications occurred after the interstitial laser photocoagulation session (1 ileum paraliticus, 1 gastric hemorrhage) and another one refused to continue the treatment.

Interstitial laser photocoagulation under ultrasound guidance of liver tumors: results in 104 treated patients.

OBJECTIVE: To evaluate the efficacy and complications of interstitial laser photocoagulation (ILP) under ultrasound (US) guidance as a technique for focal ablation of liver tumors in patients with normal and impaired hepatic function. PATIENTS AND METHODS: A total of 104 patients, 77 with 85 nodules of hepatocellular carcinoma on cirrhosis (29 in Child-Pugh A class, 43 in B e 5 in C class) and 27 patients with hepatic metastases (25 from colon, two from lung carcinoma) underwent ILP under US guidance. Depending on tumor size up to four needles were inserted in the tumor and multiple laser illuminations were performed in one or multiple sessions. Necrosis of the nodules was evaluated with triphasic contrast-enhanced CT. RESULTS: Ninety-four patients underwent a single ILP session and nine patients two sessions. CT showed complete necrosis in 70 out of 85 HCC nodules in 65 treated patients and in 24 out of 31 patients with metastases. Three Child C class patients dropped out the control of efficacy by CT because of severe liver failure associated in one case with transient paralytic ileum. One of these patients died 2 months after treatment. Two patients with metastasis dropped the completion of the treatment because of complication occurred after the ILP session (one paralytic ileum, one gastric haemorrage). CONCLUSIONS: ILP under US guidance is effective in inducing complete necrosis in small and large liver tumors. Nevertheless, ILP can cause severe derangement of liver function in patients with advanced cirrhosis.

[Ultrasonography-guided percutaneous ethanol injection in large an/or multiple liver metastasis]. / Alcolizzazione percutanea ecoguidata delle metastasi epatiche con grandi dimensioni e/o multiple.

INTRODUCTION: Percutaneous ethanol injection (PEI) under sonographic guidance is an effective therapy for hepatocellular carcinoma on cirrhosis, while less favorable results have been reported for liver metastases. Surgery and/or other new treatments (i.e., interstitial thermotherapy) are indicated only for small metastases (< 3 cm) and surgeons no longer perform the palliative debulking of neoplastic masses. PATIENTS AND METHODS: From March, 1994, to December, 1997, thirty-three patients with 62 large (> 3.5 cm) and/or multiple liver metastases, who were not eligible for surgery nor thermotherapy, were treated with one-shot PEI under general anesthesia. The diameter of the nodules ranged 35-92 mm (mean: 39); the lesions were single in 15 patients and localized in both the right and the left lobe in 19 patients. 25-110 ml ethanol were injected per session. Post-treatment results were assessed with dynamic or dual-phase spiral CT; therapeutic success was defined as the absence of hyperdense lesion areas. RESULTS: Complete necrosis of the metastases was shown in 10 patients (30.3%). Necrosis rate ranged 70-90% in 21 patients (64%) and was 50% in 2 patients (5.7%). Survival rates were 94%, 80%, 80% and 44% at 12, 24, 36 and 44 months, respectively. No major complications were observed. Seeding of neoplastic cells along the needle tract has been never observed to date. DISCUSSION: Metastasis diameter and number impact on long-term survival. PEI under general anesthesia allows to treat also the patients who are not eligible for other treatments and to inject large amounts of ethanol per session in different tumor areas because metastases usually set on in an otherwise healthy liver. CONCLUSIONS: One-shot PEI can cause major, even complete, tumor necrosis in large and multiple liver metastases. The absence of any important complications and the survival rates in our series seem to indicate that one-shot PEI is effective for tumor debulking in patients not eligible for surgery and other alternative treatments.

Percutaneous ethanol injection under general anesthesia for hepatocellular carcinoma: 3 year survival in 112 patients.

OBJECTIVE: percutaneous ethanol injection (PEI) under general anesthesia (One Shot PEI) is a new therapy for large and multiple hepatocellular carcinoma (HCC) by the injection of large amount of ethanol in the tumor. We report our results with 3 years survival rates in patients with HCC on cirrhosis treated with One Shot PEI. PATIENTS AND METHODS: between October 1992 and July 1996, 112 cirrhotic patients (79 males; age: 45-80; mean: 64 years) with 215 HCC nodules (diameter 0.6-14 cm; mean 4.1 cm) underwent One Shot PEI. Fifty-three patients had a single nodule (diameter=3-14 cm; mean=4. 5 cm), 59 had two or more (two to five) nodules (diameter=0.6-13 cm; mean=4.9). Ethanol injected ranged between 16 and 120 ml per session. Survival rates were calculated according to Kaplan-Meier method and Wilcoxon test was used for statistical analysis. RESULTS: five patients died within 7 h-10 days after the treatment for rupture of esophageal varices in three cases, rupture of subcapsular HCC in one case and liver failure in one case. In the remaining 107 patients, dynamic CT or spiral CT, performed 72 h-1 month after the treatment, showed complete necrosis in 76 cases (71%) and incomplete necrosis (although always ?50%) in 31. Survival rates at 1, 2, 3 years in all 107 patients were 88, 76, and 76% respectively. Survival rates in Child A Class patients were 100, 92, 92% and in Class B patients were 84, 72, and 72% at 1, 2, 3 years respectively; in Class C were 70 and 40% at 1 and 2 years respectively (P=0.01). Survival rates in patients with single nodule were 95, 82 and 82% at 1, 2 and 3 years, while in patients with multiple nodules were 80, 68 and 58% at 1, 2 and 3 years respectively (P=n.s.). During the follow-up (6-46 months) 48 patients showed intrahepatic recurrences; 41 out of them were retreated with new sessions of One Shot PEI or traditional PEI. CONCLUSIONS: PEI One Shot is more aggressive than traditional PEI. Survival rates of PEI One Shot seems similar to those obtainable by conventional PEI and even better than surgery.