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Carbon Dioxide–Enhanced Sonographically Guided Percutaneous Ethanol Injection: Treatment of Patients with Viable and Recurrent Hepatocellular Carcinoma

¹ Department of Radiology, Taipei Municipal Jen-Ai Hospital, No. 10, Sec. 4, Jen-Ai Rd., Taipei 106, Taiwan.
² Department of Radiology, Taipei Medical University School of Medicine, Taipei 110, Taiwan.
³ Department of Gastroenterology, Taipei Municipal Jen-Ai Hospital, Taipei 106, Taiwan.

View larger version (122K): [in a new window]   Fig. 1A. —47-year-old man with hepatocellular carcinoma who had undergone three transcatheter arterial chemoembolizations. CT scan shows homogeneous iodized oil retention (arrow) in tumor.

View larger version (160K): [in a new window]   Fig. 1B. —47-year-old man with hepatocellular carcinoma who had undergone three transcatheter arterial chemoembolizations. Unenhanced sonogram shows hyperechoic tumor. Note posterior acoustic shadowing (arrow).

View larger version (136K): [in a new window]   Fig. 1C. —47-year-old man with hepatocellular carcinoma who had undergone three transcatheter arterial chemoembolizations. Carbon dioxide (CO2)–enhanced sonogram shows small viable portion (v) in peripheral region of tumor (arrow) that was not seen on A or B. Five years after patient underwent CO2-enhanced sonographically guided percutaneous ethanol injection, no evidence of either viable tumor portion or recurrent tumor has been seen. N = nonviable portion of tumor.

View larger version (146K): [in a new window]   Fig. 2A. —65-year-old woman with hepatocellular carcinoma who had undergone four transcatheter arterial chemoembolizations. Unenhanced sonogram shows tumor (arrows) with mixed echogenicity. It is hard to identify which portion of tumor is viable.

View larger version (140K): [in a new window]   Fig. 2B. —65-year-old woman with hepatocellular carcinoma who had undergone four transcatheter arterial chemoembolizations. Angiogram shows arterial occlusion (arrow) that made transcatheter arterial chemoembolization difficult.

View larger version (148K): [in a new window]   Fig. 2C. —65-year-old woman with hepatocellular carcinoma who had undergone four transcatheter arterial chemoembolizations. Carbon dioxide (CO2)-enhanced sonogram shows viable portion in anterosuperior portion of tumor (arrows).

View larger version (149K): [in a new window]   Fig. 2D. —65-year-old woman with hepatocellular carcinoma who had undergone four transcatheter arterial chemoembolizations. CO2-enhanced sonogram shows needle (black arrow) being inserted into enhanced tumor portion seen on C (white arrow).

View larger version (137K): [in a new window]   Fig. 2E. —65-year-old woman with hepatocellular carcinoma who had undergone four transcatheter arterial chemoembolizations. Sonogram obtained during CO2-enhanced sonographically guided percutaneous ethanol injection shows ethanol (arrow) being injected into same area as that shown in C.

View larger version (179K): [in a new window]   Fig. 3A. —51-year-old man with hepatocellular carcinoma who had undergone surgery and five transcatheter arterial chemoembolizations. Unenhanced sonogram shows treated hyperechoic tumor (arrow) in left lateral segment.

View larger version (171K): [in a new window]   Fig. 3B. —51-year-old man with hepatocellular carcinoma who had undergone surgery and five transcatheter arterial chemoembolizations. Tumor seen in A does not enhance on carbon dioxide (CO2)–enhanced sonogram.

View larger version (177K): [in a new window]   Fig. 3C. —51-year-old man with hepatocellular carcinoma who had undergone surgery and five transcatheter arterial chemoembolizations. CO2-enhanced sonogram reveals enhanced recurrent tumor (arrow) inferior relative to treated tumor (seen in A) that was visible only on CO2-enhanced sonography.

View larger version (168K): [in a new window]   Fig. 3D. —51-year-old man with hepatocellular carcinoma who had undergone surgery and five transcatheter arterial chemoembolizations. Tumor (arrow) is not seen on sonogram after CO2 washout.

View larger version (155K): [in a new window]   Fig. 3E. —51-year-old man with hepatocellular carcinoma who had undergone surgery and five transcatheter arterial chemoembolizations. CO2-enhanced sonogram (needle is interrupted white line) obtained during percutaneous ethanol injection shows enhanced tumor (arrow). After patient underwent CO2-enhanced sonographically guided percutaneous ethanol injection, tumor was completely necrotic, and no evidence of viable tumor portions or recurrent tumors has been seen for 18 months.

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