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Nonresectable Hepatocellular Carcinoma

Improved Percutaneous Ethanol Injection Therapy Guided by CO₂-Enhanced Sonography

¹ All authors: Third Department of Internal Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.

View larger version (40K): [in a new window]   Fig. 1. —Decision tree shows study design of percutaneous ethanol injection guided by CO2-enhanced sonography. We performed four examinations (marked with one asterisk) only for hypervascular hepatocellular carcinoma (HCC) lesions after initial treatment. We performed all four examinations (marked with two asterisks) in patients whose local treatment was incomplete and in cases of new HCC lesions. We performed percutaneous ethanol injection guided by CO2-enhanced sonography (•) in patients who had a hypervascular HCC lesion on CO2-enhanced sonography and who had poor liver function due to advanced cirrhosis; in patients who had a hypovascular or faint tumor stain on digital subtraction arteriography; and in patients in whom transcatheter arterial embolization would be difficult because of stenosis or occlusion of hepatic artery as a result of repeated transcatheter arterial embolization.

View larger version (177K): [in a new window]   Fig. 2A. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 64-year-old woman with Child's class C cirrhosis [9] and hepatocellular carcinoma with new lesion during follow-up period. Digital subtraction angiogram obtained via right hepatic artery shows tumor stain (arrowheads) in superior anterior segment. Stent of transjugular intrahepatic portosystemic shunt is also seen (arrow). Tumor was located anterior to stent of transjugular intrahepatic portosystemic shunt. Transcatheter arterial embolization is impossible because of difficulty in placing microcatheter into feeding artery and poor liver function resulting from advanced cirrhosis.

View larger version (141K): [in a new window]   Fig. 2B. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 64-year-old woman with Child's class C cirrhosis [9] and hepatocellular carcinoma with new lesion during follow-up period. Conventional sonogram fails to show tumor that was seen in A in anterior superior segment. Stent of transjugular intrahepatic portosystemic shunt is revealed as highly echoic area (arrow).

View larger version (131K): [in a new window]   Fig. 2C. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 64-year-old woman with Child's class C cirrhosis [9] and hepatocellular carcinoma with new lesion during follow-up period. CO2-enhanced sonogram with direct injection of carbon dioxide into proper hepatic artery shows 30-mm area of positive enhancement (arrowheads) that was seen in A and B in anterior superior segment. Injection of 6.0 mL of iodized oil-ethanol mixture (1:2) was guided by CO2-enhanced sonography.

View larger version (129K): [in a new window]   Fig. 2D. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 64-year-old woman with Child's class C cirrhosis [9] and hepatocellular carcinoma with new lesion during follow-up period. Conventional sonogram obtained 1 week after percutaneous ethanol injection guided by CO2-enhanced sonography shows lesion has changed from isoechoic to slightly hyperechoic (arrowheads), enabling it to be treated with conventional percutaneous ethanol injection.

View larger version (116K): [in a new window]   Fig. 2E. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 64-year-old woman with Child's class C cirrhosis [9] and hepatocellular carcinoma with new lesion during follow-up period. Digital subtraction angiogram obtained via right hepatic artery shows no tumor stain (arrowheads) after six sessions of additional percutaneous ethanol injection therapy.

View larger version (169K): [in a new window]   Fig. 2F. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 64-year-old woman with Child's class C cirrhosis [9] and hepatocellular carcinoma with new lesion during follow-up period. CO2-enhanced sonogram obtained with direct injection of carbon dioxide into proper hepatic artery shows 30-mm area of nonenhancement (arrowheads) in anterior superior segment as seen in C.

View larger version (148K): [in a new window]   Fig. 3A. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 52-year-old man with Child's class A cirrhosis [9] and hepatocellular carcinoma with small lesion not detected on conventional sonography. Contrast-enhanced CT scan during hepatic arteriography shows high-attenuation area in posterior superior segment (arrow). Digital subtraction angiogram obtained via right hepatic artery showed faint tumor stain.

View larger version (177K): [in a new window]   Fig. 3B. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 52-year-old man with Child's class A cirrhosis [9] and hepatocellular carcinoma with small lesion not detected on conventional sonography. Conventional sonogram fails to show tumor that was seen in A in posterior superior segment.

View larger version (153K): [in a new window]   Fig. 3C. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 52-year-old man with Child's class A cirrhosis [9] and hepatocellular carcinoma with small lesion not detected on conventional sonography. CO2-enhanced sonogram with direct injection of carbon dioxide into proper hepatic artery shows 15-mm area of positive enhancement (arrow) that was seen in A in posterior superior segment.

View larger version (176K): [in a new window]   Fig. 3D. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 52-year-old man with Child's class A cirrhosis [9] and hepatocellular carcinoma with small lesion not detected on conventional sonography. Contrast-enhanced helical CT scan performed after four sessions of percutaneous ethanol injection therapy shows necrotic area (arrow) that is larger than viable area depicted on CT during hepatic arteriography before treatment.

View larger version (157K): [in a new window]   Fig. 4A. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 67-year-old man with Child's class B cirrhosis [9] and large hepatocellular carcinoma (maximum diameter, 100 mm) in residual tumor after initial treatment. Conventional abdominal radiograph obtained after treatment with combined transcatheter arterial embolization and percutaneous ethanol injection therapy shows deposition of iodized oil (arrows).

View larger version (132K): [in a new window]   Fig. 4B. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 67-year-old man with Child's class B cirrhosis [9] and large hepatocellular carcinoma (maximum diameter, 100 mm) in residual tumor after initial treatment. Digital subtraction angiogram obtained via right inferior phrenic artery shows two tumor stains in superior portion (arrowhead) and inferior portion (arrow) of right lobe after initial treatment. Digital subtraction angiogram obtained via right hepatic artery showed no tumor stain.

View larger version (104K): [in a new window]   Fig. 4C. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 67-year-old man with Child's class B cirrhosis [9] and large hepatocellular carcinoma (maximum diameter, 100 mm) in residual tumor after initial treatment. Sonogram with direct injection of CO2 into right inferior phrenic artery shows 15-mm area of positive enhancement (arrowheads) that was seen in B in superior portion. This lesion was not detected with conventional sonography.

View larger version (134K): [in a new window]   Fig. 4D. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 67-year-old man with Child's class B cirrhosis [9] and large hepatocellular carcinoma (maximum diameter, 100 mm) in residual tumor after initial treatment. CO2-enhanced sonogram with direct injection of carbon dioxide into right inferior phrenic artery shows 30-mm area of positive enhancement (arrows) that was seen in B in inferior posterior segment. In this residual lesion, viable portion could not be differentiated from nonviable portion on conventional sonography. Injections of 1.0 and 6.0 mL of iodized oil-ethanol mixture (1:1 and 1:2, respectively) into tumor in superior anterior and inferior posterior segments were guided by CO2-enhanced sonography.

View larger version (127K): [in a new window]   Fig. 4E. —Percutaneous ethanol injection guided by CO2-enhanced sonography in 67-year-old man with Child's class B cirrhosis [9] and large hepatocellular carcinoma (maximum diameter, 100 mm) in residual tumor after initial treatment. Conventional abdominal radiograph shows tips of needles corresponding to tumor staining shown on digital subtraction angiogram (arrowhead and arrows). Additional percutaneous ethanol injection therapy was performed seven times after original injection guided by CO2-enhanced sonography.

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