Chemoembolization Ethanol injection

For many patients suffering from liver tumors, surgery may represent the only curative approach for others only palliative, interventional techniques are available for local tumor control (e.g., cryotherapy, chemoembolization, ethanol injection, and radio frequency ablation). 

In an open trial, percutaneous ethanol injections into the liver improved prognosis compared with conservative treatment in 63 patients with cirrhosis and hepatocellular carcinoma who were not suitable for surgery or transcatheter arterial chemoembolization (16). Most of the patients had mild to moderate local pain during or immediately after injection and 29% developed fever. 

Kato T, Saito Y, Niwa M, Ishiguro J, Ogoshi K. Combination therapy of transcatheter chemoembolization and percutaneous ethanol injection therapy for imresectable hepatocellular carcinoma. Cancer Chemother Pharmacol 1994 33(Suppl) S115-18. 

Combination Therapy Chemoembolization and Transportal Ethanol Injection Yamakodo et al. (1999) reported the long-term efficacy of TACE combined with transportal ethanol injection (TPEl) in patients with HCC > 2 cm in diameter. Transhepatic portal access was performed 2-6 weeks subsequent to TACE and ethanol (10-65 ml) was injected into the portal vein branch supplying the involved segment. Technical success was achieved in all patients, but hepatic failure developed in two (8%) patients. The 1- to 6-year survival rates were 87%, 72%, 72%, 63%, 51%, and 51%, respectively. 

Bartolozzi C et al. (1995) Treatment of large HCC transcatheter arterial chemoembolization combined with percutaneous ethanol injection versus repeated transcatheter arterial chemoembolization. Radiology 197 812-8 Barton PP et al. (1996) Embolization of bone metastases. J Vase Intervent Radiol 7 81 8... 

Allgaier HP, Deibert P, Olschewski M, Spamer C, Blum U, Gerok W, Blum HE (1998) Survival benefit of patients with inoperable hepatocellular carcinoma treated by a combination of transarterial chemoembolization and percutaneous ethanol injection-a single-center analysis including 132 patients. Int J Cancer 79 601-605... 

Colella G, Bottelli R, De Carlis L et al (1998) Hepatocellular carcinoma comparison between liver transplantation, resective surgery, ethanol injection, and chemoembolization. Transpl Int 11 S193-196 Daniels JR, Sternlicht M, Daniels AM (1988) Collagen chemoembolization pharmacokinetics and tissue tolerance... 

Transarterial chemoembolization (TACE) has widely been proposed as the palliative treatment of choice. However, most data indicate a limited benefit from TACE in patients with advanced liver cirrhosis (Llovet et al. 2003). In the past percutaneous tumor ablation by radiofrequency (RFA) or laser-induced thermo therapy (LITT) has supplemented ethanol injection. Any of these methods has hmitations with respect to tumor size, perfusion and localization, as described above. 

Kirchhoff T, Chavan A, Galanski M (1998) Transarterial chemoembolization and percutaneous ethanol injection therapy in patients with hepatocellular carcinoma [comment]. Eur J Gastroenterol Hepatol 10 907-909 Kitamoto M, Imagawa M, Yamada H et al (2003) Radiofrequency ablation in the treatment of small hepatocellular carcinomas comparison of the radiofrequency effect with and without chemoembolization. AJR Am J Roentgenol 181 997-1003... 

Koda M, Murawaki Y, Mitsuda A, Oyama K, Okamoto K, Idobe Y, Suou T, Kawasaki H (2001) Combination therapy with transcatheter arterial chemoembolization and percutaneous ethanol injection compared with percutaneous ethanol injection alone for patients with small hepatocellular carcinoma a randomized control study. Cancer 92 1516-1524... 

Lubienski A, Bitsch RG, Schemmer P, Grenacher L, Diix M, Kauffmann GW (2004) Long-term results of interventional treatment of large unresectable hepatocellular carcinoma (HCC) significant survival benefit from combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) compared to TACE monotherapy. Fortschr ROntgenstr 176 1794-1802... 

Fig. 3.3.1. This flowchart illustrates the algorithm used for selecting the appropriate treatment option for patients with hepatocellular carcinoma (HCC) including surgical resection, transplantation, radiofrequency ablation RFA)y transarte-rial chemoembolization (TAC ), new agents such as selective internal radiation therapy (SIRT)y systemic therapy and best supportive care. RFA is offered to patients with early-stage HCC with a single tumor smaller than 5 cm or as many as three lesions, each smaller than 3 cm, good performance status and evidence for neither vascular invasion nor extrahepatic tumor spread based on clinical and imaging flndings. (M Metastases, N nodules, PEI percutaneous ethanol injection, PST performance status test.) "Cadaveric liver transplantation or living donor liver transplantation With permission from Llovet et al. (2003) Lancet 362 1907-1917...

De Cobelli F, Castrucci M, Sironi S et al (1994) Role of magnetic resonance in the follow-up of hepatocarcinoma treated with percutaneous ethanol injection (PEI) or transarterial chemoembolization (TACE). Radiol Med Torino 88 806-817... 

Table 8.1. HCC survival rates after PEI or a combination of PEI andTACE. (HD High density, PEIpercutaneous ethanol injection, RFA radiofrequency ablation, TACE transarterial chemoembolization)...

Yamamoto K, Masuzawa M, Kato M et al (1997) Evaluation of combined therapy with chemoembolization and ethanol injection for advanced hepatocellular carcinoma. Semin Oncol 24 S6-50-S56-55... 

It is our experience that the type of HCC seen at MDACC, and perhaps in the Western World, is different or at least more advanced from that more commonly treated by the interventional radiologist in Japan (Yamashita et al. 1993). Nodular HCC is seen in less than 25% of our patients, while it comprises 75% of the Japanese patient population. However, this is now changing due to the present influx of patients with positive hepatitis B and C. This type of tumor can be approached by surgery, by the direct injection of absolute ethanol, by direct percutaneous thermal ablation (radiofrequency or cryoablation), by chemoembolization, or the combination of these techniques (Figs. 9.4,9.5). 

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